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On Aug. 6 and 7, the National Transportation Safety Board held an investigative hearing into the incident aboard Alaska 1282, where a mid-aft exit door plug departed a Boeing 737 Max 9 while in flight over Portland, Oregon. The investigative hearing is a proceeding that brings all parties involved in an effort to gather and discuss information for investigators to review.
The NTSB does not hold these hearings for all investigations, and no safety recommendations or final reports will be issued at its conclusion. See below for live updates on the 20 hours of proceedings from Editor-in-Chief Jon Ostrower and Staff Reporter Will Guisbond. The complete docket was published as part of the first day of the hearings.
Wednesday, Aug. 7:
7:04: The final panel has concluded. With that, day two — and the hearing — have come to an end.
6:55 pm: FAA production oversight witnesses say that the agency currently has 16 open enforcement actions with Boeing, eight of which are within a time frame from 2020 until now. — WG
6:04 pm: The investigative spokesperson for the Association of Flight Attendants began a question by commenting that the FAA has a dual mandate to both regulate and promote the aviation industry, and went on to ask how the agency witnesses balance those two things. This is incorrect. The agency’s mandate to “promote” the industry was removed by title IV of the FAA Reauthorization Act of 1996 following the high-profile crash of ValuJet flight 592 in the Florida Everglades. Following the incident, questions arose about the agency’s ability to both regulate a then-growing industry while also promoting its commercial interests, which was particularly relevant in the case of ValuJet’s low-cost airline business model, one of the first of its kind. However, some within the industry still believe that the formal removal of a word in the agency’s mandate hasn’t actually changed that day-to-day reality. — WG
5:43 pm: When asked by NTSB investigators what keeps them up at night, FAA personnel said that the utter complexity of the system, in combination with the unique systemic challenges at the country’s largest plane maker pose a particularly difficult landscape for regulators. “The biggest question I have of late, especially considering all that has happened since January 5th, is why is it so difficult to sustain a corrective action for the long-term? And sustain compliance to a process or a work instruction?” said Brian Kilgroe, FAA designated principal inspector for Boeing’s PC. — WG
3:47 pm: Chair Homendy reveals that the NTSB will conduct a safety culture survey of Boeing’s employees at their Renton, WA facility. She specifically made a point of asking Boeing witnesses to commit to aiding the board in this effort. — WG
3:33 pm: Resuming after a break for lunch, we are still finishing panel 3. In a brief moment of confusion among the witnesses, it appears there isn’t total clarity for how — and to whom — contract employees are able to submit safety reports. Boeing’s head of SMS confirmed that contract employees working on behalf of Spirit AeroSystems located at Boeing’s Renton, WA facility do not have access to the plane maker’s Speak Up system, which has been a major topic of the last five hours of questioning. Spirit senior quality advisor William Brown did note that one of these contract employees has historically submitted through the Speak Up system, although others alluded that this was submitted on that individual’s behalf by Boeing for this reason. — WG
1:38 pm: As an observation of much of the documentation being shown as part of the docket, we see Boeing’s instructions for insulation blanket installation written in all caps. One of the tenets of designing for readability is around specific typeface to foster ease of comprehension. “Readability is reduced with all caps because all words have a uniform rectangular shape, meaning readers can’t identify words by their shape,” according to the Harvard University design guide. Human factors teams and technical writers, take note. — JO
12:03 pm: When asked about the ability of front-line Boeing employees to recognize what a positive safety culture is and how to maintain it, the plane maker’s head of SMS said that “This is a new space for us,” a glaringly brazen indicator of the company’s past efforts to establish that atmosphere. “I think what it will take is employees seeing repetition,” he added, noting the importance of making sure employees feel empowered to speak up. “I think we are at the beginning of that journey.” — WG
11:38 am: One item that came up on day one of the hearing (and spawned reporting) was a previously undisclosed design change planned to the 737 Max mid-exit door to notify crews in case it is not fully closed. That is not accurate. Boeing is planning changes, but Elizabeth Lund’s comments Tuesday indicated that “upon my conversations with our engineering experts…they have looked at activating the sensor for the plug. They don’t think that will work necessarily as we would want.” Instead, because the MED only intended to be moved during heavy maintenance, Lund outlined changes that “will allow the door, the plug, to not be closed if there’s any issue until it’s firmly secure that would hold it securely in, as well as simple changes to make sure things like that the fasteners are lanyarded on.” She said she expected the design to be certified and implemented “with the year” and then available for retrofit on the fleet. — JO
10:47 am: We’re now deep into discussing SMS, where the technical panel has turned to questioning surrounding Boeing’s previously-implemented voluntary system (something that is now required by FAA for manufacturers). As a part of this line of questioning, the FAA gave a brief presentation on the history of SMS implementation. Long story short, it’s complicated. — WG
8:45 am: Good morning from day two in the NTSB board room. Today is largely expected to be even more intense than yesterday, with an outsize focus on safety culture at Boeing and oversight lapses at the FAA. We will see our first witnesses from the agency take the stand during panel three, which will focus on SMS, while the afternoon will turn generally to regulatory oversight. — WG
Tuesday, Aug. 6:
6:40 pm: Day one concludes. Investigative board reconvenes at 9 am on Wednesday.
6:26 pm: Repeatedly throughout the second panel we seen the intense strategic and cultural tension between Boeing and Spirit contractors fixing fuselage structural issues inside Renton on the assembly line. That was evident in TAC’s reporting from January when dissecting the timeline that led to the Flight 1282 accident and the eventual push to re-acquire Spirit. Homendy, reading from one interview transcript, “I don’t think the [Boeing] frontline loves supplier assist. I think the fundamental position that I hear from them is we should not need supplier assist because they should send these perfect fuselages regardless and you cannot argue with that.” — JO
6:16 pm: The Board has now turned its focus to safety management systems (SMS), where Member Inman references an interview with a Boeing employee who has worked on the floor for years. When asked by investigators what SMS means to them, this employee responded with “Safety management system would just be something to — for me, a safety management system looks more like a system to — for safety, as in the airplane in regards to — I don’t know, actually, I don’t even know that word…. I think it’s just what they have like on the walls…” — WG
6:14 pm: Referencing another interview transcript, board member J. Todd Inman cites the view of the Spirit contractors and their role within the Renton plan. “Well, basically, we’re the cockroaches of the factory.” “They understand their role is between them and Boeing completing the work,” said Riney, who noted he had not seen contractors treated as an underclass within the Boeing production system. — JO
6:05 pm: Chair Homendy, asking Spirit AeroSystems’ Michael Riney about pressure the supplier’s contractors were under to perform rework, references interview transcripts that quoted those inside the factory saying “It’s always go, go, go” and a push to remedy JBS (jobs behind schedule). “The pressure is there, it does get heavy.” Riney responded “our entire job is to get out of Boeing’s way…they understand their role,” which is to remedy any issues stopping Boeing work on the airplane. — JO
5:03 pm: In a moment of confusion and clarification at the hearing, Boeing’s Elizabeth Lund talked about the role of the “move team” having pushed the mid-exit door plug closed. The NTSB technical panel explicitly said that the action of pushing the door closed to move the aircraft and put weight on wheels happened on Sept. 18. The rework on the five discrepant rivets came the following day and the door was again opened after the move team’s actions. This commentary from Lund about the move team is what got Boeing in trouble following its pre-Farnborough Airshow briefings in late June. — JO
4:28 pm: Boeing’s Elizabeth Lund explains that, as a part of the assembly process, a “move team” is responsible for getting ready to move an air frame outside once it has completed assembly. As a part of this process, the aircraft is readied for exposure to the elements, a process that involves closing all aircraft doors. Lund said that “the plan would have been to have a door member stay over [with the move team], as I mentioned. That was not done.” It is unclear if this occurred on the air frame that eventually became N704AL. — WG
4:06 pm: Chair Homendy brought up a specific remark from an interview between The Air Current and FAA Deputy Administrator Katie Thomson in a gaggle with reporters just now. Thomson said “we will provide ongoing oversight, but at the end of the day, it will be up to Boeing to decide whether it wants to produce a product that people have confidence in,” referencing the agency’s work beyond KPI’s issued in the quality and safety plan it delivered to the FAA earlier this year. Homendy responded with: “It’s not up to Boeing. It’s up to us, collectively… collectively to ensure safety. And FAA has a major role. So I was very disappointed in that remark.” — WG
4:02 pm: Spirit’s Michael Riney said Spirit contractors doing work inside Boeing’s Renton factory do not have access to the plane maker’s shipside action tracker (SAT), instead the contractors receive an excel spreadsheet that is checked for updates from prior versions. The SAT is a tool that tracks tasks that need additional manufacturing support. It’s been likened to Slack, but for building airplanes. — JO
2:20 pm: The NTSB board members are digging into the idea of Boeing’s durable level of change and historical back sliding on manufacturing quality, which it says has been a repeated theme through its AS1282 interviews. — JO
2:18 pm: In a back and forth between Jennifer Homendy & Boeing’s Elizabeth Lund, the NTSB chair asks on the new quality and production health KPIs: “How do we know these are the right numbers if they were available to you for years?” — JO
1:18 pm: One longstanding question just got an answer: Boeing’s fired 737 VP/GM Ed Clark has not been interviewed by the NTSB as part of the investigation into Flight 1282. — JO
12:38 pm: Stepping back for a moment, this NTSB hearing is such a granular display of the massive rift that has long existed between Boeing and its unionized machinists. You can’t point all the fingers you want, but Boeing won’t ever be healthy unless this relationship hugely improves. — JO
12:38 pm: Boeing’s Elizabeth Lund reveals that the company did receive several “Speak Up” reports from employees about removal work (like that done on the door plug) prior to AS1282. A review process was started, but “we did not get the elements and implemented prior to the accident.” — WG
12:01 pm: After Boeing’s Lund offers long explainer about changes to production, Jennifer Homendy says: “I just want a word of caution here, this is not a PR campaign for Boeing. What I want to know, what we want to know is what happened in March, April, May, June, July, August, September leading up to this.” — JO
11:23 am: Major demographic shift: Spirit’s Terry George says that 5 years ago 95% of Spirit assemblers had sheet metal experience. Today that number stands at 5%. Shifted from a 2 week training to a 6-8 week training. — JO
10:19 am: Boeing’s VP Quality Elizabeth Lund says the 737 line today is running “still in the 20s” and are not approved to exceed 38 per month. Renton was running “upper 20s, low 30s” when N704AL was being built in September 2023. — JO
10:12 am: The 4 minute window surrounding the depressurization of #AS1282, as seen from the flight data recorder. — WG
10:02 am: On disagreement with Boeing on increasing 737 rate with Spirit, George says: “They have the authority, but obviously we’re going to fall in line on whatever the rate increase.” Notes strong discussions between the companies on rate increases, especially post-COVID. — JO
9:19 am: Good morning, all. I’m with Will Guisbond at the NTSB hearing on Alaska Airlines flight 1282. Some background on the January accident aboard a 737 Max 9, which lost a door plug over Oregon. Here’s our reporting from The Air Current, all available today without a subscription. — JO
Related Reading:
- 127 Days: The anatomy of a Boeing quality failure
- NTSB Chair: Alaska 1282 investigation is like ‘peeling an onion’
- NTSB sanctions Boeing for sharing unauthorized Alaska 1282 information during media briefing
9:15 am: Good morning from the NTSB AS1282 investigative hearing. Jennifer Homendy kicks off her remarks by seemingly correcting herself that the Board and Boeing have a “collective duty” to rather than a “shared goal” of safety. — WG
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