NTSB faults Boeing manufacturing oversight in Alaska Airlines Flight 1282 door incident

Investigators found that four bolts meant to secure the left MED plug were missing before delivery of the new aircraft. This allowed gradual upward displacement of the plug over several flights until it detached completely during Flight 1282. The missing bolts would not have been detected during routine preflight inspections.

During manufacturing, Boeing personnel opened the left MED plug for rivet rework but did not generate a required removal record or conduct a quality assurance inspection upon closure. The NTSB noted deficiencies in Boeing’s Business Process Instruction (BPI) for parts removals—describing it as lacking clarity and ease of use—and found evidence of compliance issues spanning at least ten years. Efforts by Boeing and accepted by FAA had failed to address these persistent problems.

Additionally, Boeing’s on-the-job training regarding removal records was deemed insufficient. The FAA’s audit planning procedures also fell short in identifying ongoing discrepancies related to these processes.

The flight crew described immediate effects following decompression: their ears popped; headsets were dislodged; communication became difficult due to noise after the flight deck door blew open. Both pilots donned oxygen masks quickly, declared an emergency with air traffic control, descended safely back to Portland, and landed without further incident.

Sharon Petersen, CEO of AirlineRatings.com, commented: “This had the potential to be an absolute disaster. This accident, in the hands of a highly professional and safety-focused airline like Alaska Airlines, has without doubt prevented another accident or potential catastrophe. This occurrence, in the hands of an airline with sub-par onboard safety practices and less experienced pilots, could have potentially ended in tragedy. This is a perfect example of why Alaska Airlines features in our World's Safest Airlines list time and time again. We absolutely applaud their safety culture and adherence to protocol in the toughest of situations.”

The NTSB executive report also recommended improvements including better operator procedures for preserving cockpit voice recorder data after incidents; upgrades from two-hour audio recordings to 25-hour capabilities; review of design standards for portable oxygen bottles; enhanced hands-on training for using oxygen systems; more effective child restraint system usage for young children; and accurate ongoing assessment of safety culture as part of regulatory safety management systems.

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