Can't help fucking up, over and over and over and over and over again...

Boeing blames missing paperwork for Alaska Air incident, prompting rebuke from safety regulators

By Gregory Wallace and Chris Isidore

For months, missing paperwork has hindered the investigation into how a door plug blew off a 737 Max on an Alaska Airlines flight in January, making it difficult to find out who made the near tragic mistake. This week, Boeing disclosed that the paperwork may have caused the problem in the first place.

It was already well known that no documentation was found to show who worked on the door plug, which came off the plane after it had reached around 16,000 feet in the air causing an uncontrolled decompression, which injured a few passengers and even tore one’s shirt off.

But at a briefing for journalists at Boeing’s 737 Max factory in Renton, Washington, Boeing said that the lack of paperwork is why the four bolts needed to hold the door plug in place were never installed before the plane left the factory in October. The workers who needed to reinstall the bolts never had the work order telling them the work needed to be done.

Without the bolts, the door plug incident was pretty much inevitable. Luckily, it wasn’t fatal.

It’s a sign of the problems with the quality of work along the Boeing assembly lines. Those problems have become the focus of multiple federal investigations and whistleblower revelations, and the cause of delays in jet deliveries that are causing headaches for airlines and passengers around the globe.

Boeing may have stepped in it… again

But Boeing may have landed itself in even more trouble with regulators for divulging the details at this stage. The National Transportation Safety Board (NTSB) reprimanded Boeing Thursday for releasing “non-public investigative information” to the media. It said in a statement that the company had “blatantly violated” the agency’s rules.

“During a media briefing Tuesday about quality improvements… a Boeing executive provided investigative information and gave an analysis of factual information previously released. Both of these actions are prohibited,” the NTSB said.

Boeing will no longer have access to information generated by the NTSB during its investigation, the agency said, adding it was referring Boeing’s conduct to the Department of Justice.

“As a party to many NTSB investigations over the past decades, few entities know the rules better than Boeing,” the NTSB said.

Boeing responded that it held the briefing in an effort to “take responsibility” and be transparent for its role in the incident. It saidit “shared context on the lessons we have learned from the January 5 accident.”

“We deeply regret that some of our comments, intended to make clear our responsibility in the accident and explain the actions we are taking, overstepped the NTSB’s role as the source of investigative information,” said Boeing’s statement. “We apologize to the NTSB and stand ready to answer any questions as the agency continues its investigation.”

Bad paperwork trail

Boeing said during the Tuesday briefing that the reason the Alaska Air door plug was not probably secured in the first place was because two different groups of employees at the plant were charged with doing the work, with one removing and the other reinstalling the door plug as the plane was passing along the assembly line.

The first group of employees removed the door plug to address problems with some rivets that were made by a supplier, Spirit AeroSystems. But they didn’t generate the paperwork indicating they had removed the door plug, along with the four bolts necessary to hold it in place, in order to do that work.

When a different group of employees put the plug back in place, Boeing says the employees didn’t think the plane would actually fly in that condition.

Instead, they were just blocking the hole with the plug to protect the inside of the fuselage from weather as the plane moved outside to a different area of the factory compound. That group of employees often makes those kind of temporary fixes.

“The doors team closes up the aircraft before it is moved outside, but it’s not their responsibility to install the pins,” said Elizabeth Lund, senior vice president of quality for Boeing’s commercial airplane unit.

Those employees likely assumed paperwork existed showing that the plug and bolts had been removed, and that paperwork would prompt someone else along the line to install the bolts.

But without the paperwork, no one on the assembly line knew that the door plug had ever been removed, or that its bolts were missing, Lund said. Removing a door plug after a plane arrives from Spirit AeroSystems rarely happens, Lund added, so no one was aware the door plug needed attention.

“(Permanent) reinstallation is done by another team based on the paperwork showing what jobs are unfinished,” Lund said. “But there was no paperwork, so nobody knew to follow up.”

An accident waiting to happen

The plane actually flew for about two months with the door plug in place despite the lack of bolts. But minutes after the Alaska Airlines flight took off from Portland, Oregon, on January 5, the door plug blew out, leaving a gaping hole in the side of the plane. Passengers’ clothing and phones were ripped away from them and sent hurtling into the night sky. But fortunately no passengers were seriously injured, and the crew was able to land the plane safely.

The missing bolts had been identified in preliminary findings of the National Transportation Safety Board, but that report did not assess blame for the accident. And a final report is not expected for about a year or more. A spokesperson for the NTSB said that the safety agency is continuing its investigation and will not comment on Boeing’s explanation for how the mistake was made.

Prosecutors urge Justice Department to file criminal charges against Boeing over 737 Max

The board released a preliminary report in February that said it had found the bolts were missing when it left the Boeing factory, but it did not assess blame. A final report is not expected for a year or more.

NTSB Chair Jennifer Homendy has testified about the missing paperwork at Congressional hearings since the preliminary report was released.

Boeing is addressing the problem by slowing down its assembly lines, and making sure that planes don’t advance with problems under the assumption that those problems will be dealt with later in the assembly process, Lund said.

“We have slowed down our factories to make sure this is under control,” she said.

“I am extremely confident that the actions that we took,” will ensure every airplane leaving this factory is safe, she added.

Key moments in Boeing's recent history:

OCTOBER 29, 2018

Lion Air Flight 610 crashes into the Java Sea soon after taking off from Jakarta, Indonesia, killing all 189 people on board.

JANUARY 30, 2019

Boeing reports record earnings, revenue tops $100 billion for the first time and the company forecasts better times ahead.

MARCH 10, 2019

Ethiopian Airlines Flight 302 crashes soon after taking off from Addis Ababa, Ethiopia, bound for Nairobi, Kenya, killing all 157 people on board.

MARCH 11, 2019

China grounds all of its 737 Max planes in wake of second crash. Many countries follow with their own groundings in the days ahead.

MARCH 15, 2019

The US Federal Aviation Administration orders a grounding of all 737 Max jets, making it one of the last aviation authorities in the world to do so. Its grounding will stay in effect for 20 months.

APRIL 4, 2019

Boeing for first time acknowledges that a feature on the 737 Max put in place to prevent the plane from climbing too fast and stalling "played a role" in the two fatal crashes. Investigators later attribute the two crashes to the feature, known as MCAS.

JULY 24, 2019

Boeing reports a $3.7 billion loss in the second quarter, its first loss following the Max grounding and what, at that point, was a record loss for the company. Its adjusted losses would reach $31.5 billion through the end of 2023, with no end to the losses in sight.

OCTOBER 29, 2019

On the anniversary of the first fatal crash, Boeing CEO Dennis Muilenburg testifies before a Senate committee, apologizing to the families and saying the company “understands and deserves” the scrutiny it had received. He meets with family members after the hearing.

DECEMBER 20, 2019

An uncrewed test flight by Boeing's Starliner spacecraft is unable to reach the International Space Station as planned and is forced to return to earth. It is the latest in a series of delays and setbacks that forced it to fall far behind SpaceX in its effort to carry astronauts for NASA.

DECEMBER 23, 2019

CEO Dennis Muilenburg is fired at the end of a disastrous year for Boeing. He is replaced by David Calhoun, who had been serving as chairman of the company. Muilenburg leaves the company with stock options and other assets valued at $80 million at that time, but with no severance.

JANUARY 9, 2020

Boeing releases a flood of internal communication between its employees showing many expressing doubts about the safety of the 737 Max before it is certified to fly passengers. In one famous April 2017 message, an employee described the plane as "designed by clowns, who in turn are supervised by monkeys."

JANUARY 21, 2020

Boeing, which continued to build the 737 Max during the grounding in hopes flights would resume soon, halts production of the plane, an acknowledgement that the fix would not come as soon as hoped.

MARCH 4, 2020

United Airlines and JetBlue Airways become the first US airlines to slash their flight schedules as the outbreak of the Covid-19 pandemic prompts passengers to stop flying. By the middle of the month US air travel would be down 96% compared to a year earlier, and US airlines will have cut scheduled flights by 71%. Deep financial losses by airlines around the world would cause massive order cancellations for the 737 Max. Normally canceling orders come with heavy penalties but the prolonged grounding of the jet allowed the orders to be canceled without penalty, further hitting Boeing.

MAY 27, 2020

Boeing announces it is laying off nearly 7,000 workers, after only just 5,500 employees took voluntary buyout packages. The 16,000 job cuts caused by the sharp drop in demand for planes during the pandemic is followed by another 7,000-job reduction announced later in the year.

AUGUST 28, 2020

The FAA orders the grounding of eight 787 Dreamliners due to questions about its manufacturing process. While the grounding is brief, it is the start of a series of delivery halts over two years due to questions about whether work was done to specifications.

NOVEMBER 18, 2020

The FAA announces it is ending the 20-month grounding of the 737 Max, clearing the way for it to again carry passengers. But the grounding has cost Boeing an estimated $20 billion to date, a cost that would creep higher in the following years.

SEPTEMBER 20, 2021

Boeing discloses it found empty tequila bottles inside one of the two 747 jets being refurbished for use as the next generation of Air Force One.

APRIL 27, 2022

Boeing announces it is delaying the launch of its next generation jet, the 777X, as well as taking a $660 million charge related to increased costs to deliver the two new jets that are to be used as Air Force One. The losses for the Air Force One jets will eventually top $2 billion.

SEPTEMBER 20, 2021

Boeing discloses it found empty tequila bottles inside one of the two 747 jets being refurbished for use as the next generation of Air Force One.

APRIL 27, 2022

Boeing announces it is delaying the launch of its next generation jet, the 777X, as well as taking a $660 million charge related to increased costs to deliver the two new jets that are to be used as Air Force One. The losses for the Air Force One jets will eventually top $2 billion.

JANUARY 5, 2024

An Alaska Airlines 737 Max 9 flight has a door plug blow out minutes into the flight, causing a gaping hole in the side of the plane. Clothing and phones rip away from passengers and are sent hurtling out of the plane. Fortunately, what could have been a catastrophic accident was avoided with no one sitting next to the hole, and no one was seriously injured.

FEBRUARY 6, 2024

A preliminary investigation by the National Transportation Safety Board finds that the Alaska Air plane left a Boeing factory in October missing the four bolts needed to secure the door.

FEBRUARY 26, 2024

The FAA issues a report sharply critical of the culture at Boeing, citing "gaps in Boeing's safety journey." The next day it announces it is giving Boeing 90 days to come up with a plan to fix problems. Subsequent FAA reports find multiple problems with Boeing's production practices following a six-week audit.

MARCH 1, 2024

The FAA flags more potential safety issues with the engines of the 737 Max and 787 Dreamliner, although it does not ground either aircraft. Also on March 1 the State Department fines Boeing $51 million for violating the arms export control act, allowing employees in China and other countries to download sensitive data from numerous defense aircraft and missiles.

MARCH 11, 2024

A LATAM Airlines Boeing 787 flight from Sydney, Australia to Auckland, New Zealand experiences a sharp drop in altitude, sending several passengers flying to the ceiling of the cabin, injuring dozens. A few days after the incident Boeing sent a notice to airlines with the 787 warning them to look at a switch on pilots' seats that, if accidentally triggered, can throw a pilot forward into the controls of the plane, which could possibly cause a nose dive. But it would not comment on whether that was the cause of this incident. Fortunately, the plane was able to land without any further incident.

MARCH 25, 2024

Boeing announces that CEO Dave Calhoun will leave the company at the end of the year as it begins a search for his successor. Stan Deal, CEO of the Boeing Commercial Airplane unit, also announces his retirement, effective immediately.

APRIL 9, 2024

The FAA announced an investigation into a whistleblower's complaint that the company took shortcuts when manufacturing its 777 and 787 Dreamliner jets, and that those risks could become catastrophic as the airplanes age. In a statement, the company disputed the complaint and said the engineer's concerns don't "represent the comprehensive work Boeing has done to ensure the quality and long-term safety of the aircraft."