NTSB Chair: Alaska 1282 investigation is like ‘peeling an onion’

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In an exclusive interview with The Air Current, National Transportation Safety Board Chair Jennifer Homendy said Friday the safety watchdog is planning a public investigative hearing into the Jan. 5 accident aboard Alaska Airlines 1282.

Homendy said the board and its investigators are in the middle of a “process of elimination” to piece together what happened in the factory as the 737 Max that lost a door plug shortly after departure was being assembled by Boeing. Homendy and Boeing have sparred publicly over claims of Boeing’s disclosure of specific information that would aid the investigation. 

Homendy told TAC that the hearing will occur towards the end of the summer. “When we feel like we need more — we need to uncover more — that’s when we have an investigative hearing, and staff has recommended to the board that there be an investigative hearing.” 

According to the board’s website, investigative hearings are primarily fact-finding in nature — collecting more testimony while simultaneously allowing the public to “observe the progress of the investigation.” Unlike a full board meeting, no deliberation or discussion takes place during a hearing.  

Boeing’s own “air safety investigators that are … parties to the investigation and their specific team have been cooperative with what they are able to provide,” Homendy noted. “However … there’s a lot we don’t know here, and there’s a lot of records that we are still obtaining and looking for and requesting.”

Related: 127 Days: The anatomy of a Boeing quality failure

Speaking to TAC, Homendy detailed a timeline of requests that culminated in her Senate testimony on March 6 in which she said that “Boeing has not provided us with the documents and information that we have requested numerous times over the past few months.”

Homendy said that on Feb. 6 she had invited leaders of the Senate Commerce Committee and the House Transportation & Infrastructure Committee as well as U.S. Secretary of Transportation Pete Buttigieg and Federal Aviation Administration leadership including Administrator Mike Whitaker to the NTSB laboratory in Washington, D.C. where the Max 9’s exit plug has been undergoing examination. 

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During a briefing and tour with members of Congress, Senate leadership asked if the NTSB investigator heading the maintenance records and human performance team knew “who did the work to open, close or secure the door plug? Have you been able to meet with them? What have you learned? And do you have records corresponding to the work that was done with the door plug, and the rivets?”

“We informed them at that time that we had not been able to identify the door crew that worked on the door with respect … to the Boeing employees that were responsible for opening, moving, closing and securing the door plug itself,” said Homendy. “We did not yet have the names from Boeing. And even though we had asked for them, we did not have any documentation, which sparked some surprise among the Senators.” Boeing has supplied some documentation and photograms related to the exit plug, some of which was included in the NTSB’s preliminary report, which concluded four key retaining bolts for the plug were not present when the aircraft left the factory.

 

“We know who the door manager is, the manager of the group that whoever did the work reports to,” said Homendy, noting that person is on medical leave “and is unable to be interviewed.” 

“The only thing we had from Boeing regarding the Boeing employees … was names of individuals who may have been on the floor during that time doing work that we could use to try to figure out who did the work.”

With its factory interviews upcoming as a part of the ongoing investigation, Homendy said Boeing was “still not responsive, not what we need” on the morning of Saturday, March 2.

“We said fine, you can’t provide us with the names. We would like … the names of everyone that reports to the door crew manager or reported to the door crew manager in September of 2023, that is what we asked for Saturday morning, because we couldn’t get the other information we’ve been asking for for quite some time.” 

Homendy said she was given a heads up in the days ahead of the hearing by senators that the same Feb. 6 question would be asked during her testimony and she would be prompted to provide an update. She said the full list “of everyone that reports to the door manager” was provided by Boeing at 2 p.m. on Wednesday, March 6, several hours after her testimony.

“So now we have to interview everybody to try to figure out, OK, who did the work so we can understand what processes there are in place? What records are kept? What checks and balances are in place? What’s the procedure? What occurred that day in particular, or a couple of days? … What day the work occurred, what shift it occurred, that’s still information we have not had.”

Related: The fallout for Boeing will extend far beyond the 737 Max 9 grounding

Homendy said that she and the NTSB had received non-public information from whistleblowers “directly related” to the investigation into Alaska 1282 and “some of the information that we will or have already sought” without saying specifically to what it was pertaining.

Boeing declined to speak to the specifics of the investigation, citing ICAO Annex 13 restrictions that limit what information parties to an investigation may disclose. Boeing said it will defer to the NTSB and is unable to discuss its own internal process around determining what happened on N704AL, the aircraft involved in Alaska 1282.

The company, however, pointed to a Feb. 6 statement from CEO David Calhoun when the NTSB’s preliminary report was published. “Whatever final conclusions are reached, Boeing is accountable for what happened. An event like this must not happen on an airplane that leaves our factory. We simply must do better for our customers and their passengers. We are implementing a comprehensive plan to strengthen quality and the confidence of our stakeholders. It will take significant, demonstrated action and transparency at every turn — and that is where we are squarely focused.”

Following Wednesday’s testimony, Sen. Maria Cantwell (D-Wash.), chair of the Senate Commerce Committee, requested more information from Calhoun “demanding their cooperation” within 48 hours to provide the NTSB with the documents that Homendy discussed, or providing more details as to why they couldn’t produce the records.

Shortly after the initial publication of this article, Cantwell’s office released correspondence she received on March 8 from Ziad Ojakli, Boeing’s executive vice president of government operations. “With respect to documentation of the opening and closing of the door plug, our team has shared multiple times with the NTSB that we have looked extensively and have not found any such documentation. We likewise have shared with the NTSB what became our working hypothesis: that the documents required by our processes were not created when the door plug was opened. If that hypothesis is correct, there would be no documentation to produce,” Ojakli wrote, noting that “Boeing was not aware of any complaints or concerns about a lack of collaboration” prior to the Wednesday hearing.

TAC on Jan. 24 reported that only if the door plug had been removed fully would it have required documentation that cataloged this move, but not if it was cracked open in a standard maintenance mode. Boeing on Wednesday alluded to that fact, stating, “With respect to documentation, if the door plug removal was undocumented there would be no documentation to share” — which prompted more concerns from the board about the company’s broader safety culture and record-keeping. 

In the midst of this public sparring, The Seattle Times reported that Jack Kingston, a contracted Boeing lobbyist and former U.S. Representative, sent an email to Republican members of Congress trying to “discredit” Homendy’s testimony following the hearing. In this email, Kingston said that the information the NTSB had originally requested was indeed sent by Boeing. He told the Times: “unfortunately, the email inadvertently was sent out by my office without my knowledge (or Boeing’s) and it should not have been sent.”

In her interview with TAC, Homendy said, “March 8 at 3:15 [p.m. Eastern time], I can tell you … we still don’t know who did the work on the door plug.”

Painted rivets

Homendy wouldn’t specifically confirm that the board through its investigation had learned that the discrepant rivets that prompted the door plug opening had been originally painted over before being discovered by Boeing quality teams in the factory, a fact confirmed by TAC. She said, “Right now, we are collecting records.” It remains unclear if the painting over was done by Spirit AeroSystems contractors or Boeing personnel.

Homendy said NTSB teams are still conducting interviews with personnel in Renton, and “we try to not interrupt what they’re doing, so what came out of those interviews I don’t have a read back on those. But that work would be discussed with them in the interviews, and then we correlate that to the records that we receive. So still to be determined.”

Homendy likened the investigation to “peeling an onion” with each layer revealing another that requires seeking more information. “It’s very meticulous work … we have requested documents, we continue to request documents, and we will in the future, but it is a lot of fact-finding.”

“In this case, I think [the U.S. Department of Justice] is already doing whatever they are doing separate from us,” said Homendy, offering the first semi-official acknowledgement of a DOJ inquiry. “If it became ‘this was something criminal’, then we certainly could and would refer it [to the FBI]. But right now, we don’t have any evidence of that at this time.” Homendy said the NTSB has a Memorandum of Agreement with the FBI for such referrals.

Homendy has been an outspoken advocate for taking a “safe systems approach” to transportation accident investigation, and she emphasized that the NTSB’s interest in speaking to the individuals involved with the opening of the door plug is not to pin responsibility on any of them.

“I think we have to understand that the NTSB is not interested in … blaming this person, these personnel. What I’m interested in right now, the questions in my mind as the chair of the NTSB [are] why don’t we know who did the work? Is there a process in place to document when work is done, to assure that it’s inspected? And does that process exist right now in Boeing as a safety process, and is it carried out consistently for all situations where a door plug might have to be opened, removed, closed and secured?” Homendy said. 

Given its findings to date, Homendy said the investigation is taking a broad look at the safety culture surrounding Boeing. Alaska 1282 Investigator in charge John Lovell was the NTSB representative assigned to the 2018 Lion Air 610 and 2019 Ethiopian Airlines 302 crashes.

Related: Report: Decades of corporate decision making eroded Boeing safety culture

Homendy said Lovell has “a couple of people that are really focused on the human performance, safety culture, quality assurance, quality management piece of this, and they will look more broadly at the company as a whole, where they are today, and how their quality assurance, quality management and safety management system has come about, where it stands today, and where it needs to go. That’ll be the focus.”

Homendy said that the determination of how far back its examination with Boeing would go would be up to the investigative team and “as a board member and chair, I let them do the work they need to.”

As the NTSB was seeking records from Boeing, a Congressionally mandated report on the plane maker’s Organization Designation Authorization was released on Feb. 26, painting a deeply unsettling picture of Boeing’s safety culture and its long-term erosion at the hands of its corporate decision making. Homendy confirmed that the NTSB’s investigation will pick up some of the same strands of inquiry.

“Part of this is safety culture,” she said. “Do you feel that you are free to stop something that is unsafe? Do you feel you can speak up? Do you feel when you speak up that your issues are taken seriously? That’s all part of what went on here.”

Editor’s Note: This story has been updated to include statements from Boeing’s Ziad Ojakli.

Write to Jon Ostrower at jon@theaircurrent.com, Elan Head at elan@theaircurrent.com, and Will Guisbond at will@theaircurrent.com