One year later: The blowout from Boeing and the door-bolt blowout

Shortly after takeoff on January 5, 2024, a door plug on the Boeing 737 MAX 9 aircraft blew out, causing an uncontrolled decompression of the aircraft during Alaska Airlines Flight 1282.

Aircraft doors are built to remain closed during pressurised flight.

In the year since, the repercussions have impacted international aviation severely, shaken public confidence in air safety, and slowed down to a trickle deliveries of new airraft to customers such as Ryanair.

Boeing has outlined the steps it has taken to remedy the failures that caused the door bolt blowout in January 2024.

The company identified eight overarching issues and four basic areas to address: workforce training, simplifying plans, eliminating defects, and elevating safety culture.

Throughout the stand-downs, Boeing received over 30,000 ideas and pain points to improve operations and processes.

The FAA conducted a six-week audit of Boeing and a three-week audit at Spirit, providing important feedback that has been taken seriously.

The company said that, in 2023, with the introduction of thousands of new employees, Boeing recognised struggles on the factory floor, particularly addressing mistakes related to the MAX crash and reaffirming its commitment to air transportation safety.

Elizabeth Lund, what went wrong

A detailed explanation of events was delivered to select aviation media by Boeing senior vice president of quality Elizabeth Lund:

The fuselage came in from our supplier, and when it was initially loaded into the factory, it was discovered that there were five non-conforming rivets. These non-conforming rivets did not create a safety hazard, but they needed to be addressed. A defect arrived from our supplier, and the airplane then traveled throughout the factory. It moved to the end of the line while we discussed with our supplier whether the rivets were acceptable, whether they needed to be fixed, and if they could be fixed in that way. By the time we reached an agreement that the rivets needed to be removed and replaced, the airplane was already at the end of the line.

At that point, we believed there was a non-compliance with our process. In order to remove and replace these rivets, the mid-exit door plug had to be opened to gain access to drill out the rivets and replace them. We believe that the plug was opened without the correct paperwork. You may have read about this, as it was referenced in the NTSB report. We believe there was a non-compliance with our processes at that stage due to opening the plug without proper documentation.

There was documentation on the actual rivets, and those were removed and replaced appropriately, with the necessary stamps. However, by the time everything was signed off and the airplane was ready to move outside, we had a team called the move crew. Before an airplane rolls out of the factory on line move night, they come in to secure the airplane against the weather by closing doors and ensuring that any open holes are covered. In this case, they closed the plug but did not reinstall the retaining pins. That is not their responsibility; their job is simply to close it, and they rely on existing paperwork. The paperwork travels with the airplane, and all jobs are processed accordingly. Unfortunately, in this case, we believe the paperwork was never created, resulting in no open paperwork accompanying the airplane.

The last step was what we call an “OK to close.” Typically, people come in and look for two main things: is everything clean and are we good to go? This was the picture taken during the “OK to close.” You can see three out of the four locations where the pins are missing. After that, we received the OK to close, and the blankets came down. At that point, it was not visible that the plug had an interference fit, which is how it was able to fly for roughly 150 cycles without being identified. This snug fit allowed it to pass our flight tests, but it is not a permanent fit.

A defect entered our system from our supply chain and traveled throughout our final assembly, leading to a lack of compliance with our processes due to missing documentation. That is the background of what happened, and it will inform the rest of our system and processes.

Reaction to the blow-out

Step One involved immediate actions taken in phases. Our first phase was to ensure that no airplane ever leaves our factory in a condition that could cause an accident. I can say transparently that the fact one employee’s failure to fill out one piece of paperwork could lead to an accident was shocking to all of us. We have a series of redundancies throughout our process and recognized that this must never happen again.

It may not have been just one employee responsible for the earlier mentioned issue. The NTSB investigation is still ongoing but at this point we identify there was a lack of compliance in our processes.

We immediately had engineering conduct a review of our critical systems, identifying areas that could potentially cause an accident, such as rapid decompression or major structural issues. We compiled a list of these critical systems and implemented end-of-line inspections out of an abundance of caution. Most of these inspections were completed after our first flight, before entering the delivery process, to ensure that no other non-conformance existed in our system for anything critical. This was applied across all airplane programs.

Additionally, we conducted checks on all airplanes in the fleet and have confidence that no other airplane was delivered in a similar condition based on the comprehensive fleet check we performed. We also reached out to all our employees and implemented a system we called “read and sign.” This involved sending out a clear statement regarding the removal process, asking all production and manufacturing employees to read this statement and sign it, confirming their understanding. We achieved a 100% signature rate to ensure that everyone involved in the production system is reminded of and understands this process moving forward.

Review of the mid-exit plug

We conducted a comprehensive review of the mid-exit plug to ensure that any changes or potentially unclear aspects were addressed. Starting at Spirit, we worked our way through the entire system, clarifying any documentation that needed it, as well as any confusing parts that employees expressed uncertainty about. We cleaned up and clarified everything, ensuring that the entire process is crystal clear.

Additionally, we looked at other areas, particularly doors, to assess any possibility of similar issues occurring in other structures. We performed full inspections to ensure we had a thorough understanding of potential risks. We consulted with our customers, took best practices into account, and implemented these actions promptly. This was our immediate response to the question of how we can be completely sure that the airplanes we are delivering today are safe. We acted decisively and quickly, and we are confident in the outcome.

Next, we recognised this as a moment to step back and conduct a holistic review of our processes, asking what else we could do to ensure that our system is as robust as possible. We began collecting input from various sources, prioritising our employees. We implemented what we called quality stand-downs at every major manufacturing site within Boeing Commercial Airplanes. We held these stand-downs at 20 locations, bringing together cross-functional groups of employees from engineering, manufacturing, supply chain, quality, finance, HR, and more.

Briefing 70,000 employees

Over 70,000 employees in Boeing Commercial Airplanes participated in these quality stand-downs, which involved gathering everyone in the morning to discuss the importance of the initiative and have conversations with leadership. We then took employees to the manufacturing areas, allowing them to collaborate with teams they worked with, such as the landing gear group. This included individuals who design, purchase, install, and service landing gear, facilitating cross-functional teamwork.

We guided everyone on the manufacturing floor through safety and compliance walks, demonstrating how the factory operates. For those who may not be familiar with the environment, we provided a clear overview. We also shared a list of defects that had been identified, whether created by their teams or discovered in the field, and asked them to provide ideas and insights on how to produce a defect-free product.

As most of you will remember, this discussion overlaps with the time of the MAX grounding, during which our production rates significantly decreased for both the MAX and the 787. During that period, we experienced attrition and, although we did not conduct involuntary layoffs, we also didn’t backfill positions. When the MAX grounding was lifted and we resumed flying, the market rebounded incredibly fast, leading us to hire a large number of people.

To summarise, we brought in a substantial quantity of employees in a short timeframe, many of whom had varying levels of baseline expertise. For years, we have sourced many of our employees from the airline industry, technical schools, and maintenance, repair, and operations (MRO) sectors. We are actively assessing whether our supply chain can keep up with the current demands.

Total rework hours

This metric reflects the total rework effort across manufacturing. If the rework hours significantly exceed nominal levels, it serves as a warning flag that we need to take a closer look at the situation. We will address controls shortly. We also monitor how many jobs are open at the time of what we call “master schedule rollouts,” ensuring we remain within our nominal limits. Finally, our output measure at the end of the line evaluates how ready the airplane is right before it goes into service.

To monitor these metrics, we established control limits: a yellow control limit and a red control limit. Our commitment is to evaluate the situation and take action whenever we cross the red control limit. This triggers an entry into our safety management system, prompting a risk assessment that determines what actions are necessary to bring the metrics back within acceptable limits. We have implemented this framework across all programs in collaboration with the FAA, which has full access to our data and reviews it with us regularly.

So far, I think this system has been helpful as an indicator of our operational health. We have integrated it into our operating rhythms, ensuring its linkage to our overall goals. Our primary focuses are to ensure safe, quality airplanes and to strengthen our workforce and culture to support changeability. This approach is critical to our success.

We are a storied engineering powerhouse, and there’s a good reason for that. I entered this company in engineering, and I am proud to have done so. When I joined, safety was drilled into my DNA, and I believe it still is. We have a strong foundation of caring deeply about safety. However, I also know that we must continually improve, and this is a chance for us to do so.

For mature companies, it is important to remain humble and seek out opportunities for improvement. We need to step back and identify areas where we are not as strong as we would like to be. It is crucial to be transparent about this and acknowledge our shortcomings. Bringing our employees along with us is essential as we rededicate ourselves to our commitment to safety.

This is a great and important opportunity for us to reflect on where we can make improvements and where we need to focus our efforts. Let’s be open and honest about it, take ownership of the issues, and go all in on our commitment to safety. This won’t be the last time we engage in this process; some may wonder if this will be a final effort, but I can assure you it will not be. We operate in an industry of continuous improvement, and to stay where we want to be, we will keep improving and doubling down on safety. This is the essence of what this plan is about.

AS9100, question

On the question of AS9100, we do require AS9100 compliance for our suppliers. While we are compliant with AS9100 at the Boeing Company, we are not AS9100 certified. I can tell you that since I’ve come into this role, we’ve had numerous discussions about this, and we are willing and prepared to pursue certification. I believe AS9100 is currently undergoing a revision, and we are in discussions with the FAA about whether we should seek certification now or wait until after the new revision is released.

The reason I ask about this is that we genuinely believe we are compliant; we built our systems to meet compliance standards, and we are audited as if we were certified. We simply haven’t gone through the certification process yet, and there is no aversion to doing so. We will pursue certification at some point; the question is whether we should do it before the new AS9100 revision comes out or afterward.

The essence of it seems to be why we didn’t have sufficient control last year or the year before while going through this process. I would say this is a journey. As I mentioned, we did overhaul training last year because we recognised the need for enhancements and made changes to foundational training. What we didn’t fully realise at the time was the necessity to significantly enhance on-the-job training.

Part of this is a learning process; as we lower the water line, we discover the next issue. When it comes to our processes and procedures, we were actively simplifying and strengthening them but doing so incrementally. We would identify a problem, fix it, and find the next issue—this pace wasn’t keeping up with our goals or needs.

Now, this is an opportunity for us to position ourselves firmly for the future, aiming for a state where we can operate effectively without disruption. Instead of continuously reacting to individual problems, let’s step back and evaluate everything comprehensively, addressing all the issues we’ve identified. It’s always better to uncover these issues sooner rather than later. I believe that some initiatives were underway, but not as comprehensively or rapidly as what we’re pursuing now.

Leadership owns culture

Ultimately, leadership owns culture, and we understand that. We have many new supervisors and managers, just as we do employees. We are launching a holistic process that includes intensive training for our managers covering everything from the technical details of their jobs to the processes they need to know.

We are ensuring that they understand standard work for effective leadership. We are actively working to keep them off the floor less frequently; we want to avoid having them sit in offices or meetings all day long, ensuring they can remain on the floor to support employees. We are training them on many aspects of the work their employees are doing that they may not be familiar with, such as the correct way to torque a bolt and how to verify that their employees are executing tasks correctly.

Additionally, we are focusing on leadership development, discussing the attributes of both weak and strong safety cultures. We are documenting these attributes to ensure that supervisors understand and can identify the culture we are striving for—one that prioritises a robust safety management system, a just culture, and encourages open communication. We want a culture where safety and quality always come first, even as we deliver airplanes, never sacrificing safety or quality for production pressures. We are thoroughly guiding them through this comprehensive leadership development process, and we are excited about it. We believe this will be one of the most powerful changes we make.

Our primary regulator under the bilaterals is the FAA, and they have been our main interface. Yes, we are briefing other regulators as well. We have an upcoming briefing scheduled. We have already briefed the layers below the top leadership level of EASA, and we have a meeting with the top level of EASA coming up, where the FAA will also participate. We will ensure they are fully aware of all the steps we are taking as we move forward.

I had a brief meeting with EASA where we provided a high-level overview of what we are working on with the FAA. They requested that once we complete our 90-day agreement with the FAA, we come back and give them a full briefing, which we will do. This is part of our approach to engage with regulators and explain our progress, as well as to explain our initiatives to our customers. We are open to feedback from everyone, genuinely committed to being as good as we can be in every aspect. We are receptive to any input that can help us improve.

After the MAX crashes, we took many incredibly positive steps. However, I understand the skepticism, especially with Boeing facing potential criminal prosecution.

Four steps to safety

To the flying public, I would say that our foundational training was not as effective as it needed to be. When an employee completed foundational training and came to the floor, the support system in place wasn’t strong enough to help them with their jobs. The previous relationship wasn’t structured enough to ensure that new employees had someone to ask questions of or seek help from while trying to perform their tasks on the floor.

To address this, we have strengthened our mentorship program. Now, no employee leaves foundational training without being assigned a specific peer mentor, a named individual responsible for helping them with on-the-job training. In the past, the system was more informal, expecting managers or team leads to assist them, but this was insufficient given the unprecedented number of new employees entering at once.

We learned we needed to implement more structure in this process. Now, we have aligned our system so that every employee has a designated mentor to ensure they have the support and guidance they need as they start their roles.

I am extremely confident that the actions we took have ensured that every airplane leaving this factory is safe. I feel very confident that it will not happen again.

During this time, we were bringing in people who often had less experience, in many cases no aerospace experience, and there were so many new employees at once that we realized we needed to address this issue. The next couple of issues stem from that first one and are compounded by it.

I will just say the sheer complexity of our systems, processes, procedures, and build plans has been a challenge. We have been operating under the same foundational elements of many of our processes and procedures for 50, 60, or even 70 years. While we have updated them over time, we primarily added to them, addressing gaps and issues by clarifying procedures. As a result, we now have a deep and broad list of command media that is particularly difficult for new employees to grasp and ensure compliance with.

The second issue relates to our build plans, which can also be complicated, especially for new employees with no aerospace experience who may speak English as a second language. This situation further complicates their understanding.

The third issue we wanted to address is minimizing or eliminating defects coming into our factory from our supply chain. We need to be as close to perfect with the products coming in as we want to be with those going out. Additionally, findings from FAA audits provide us with a crucial opportunity for improvement. When we receive audit findings and feedback, we conduct root cause analyses and implement systemic changes. What we found is that some issues we had previously fixed had resurfaced. We are committed to ensuring these processes are robust enough to be sustainable long-term.

Lastly, the safety culture is paramount. One of the major findings from the AXA panel was that Boeing was and continues to be in the early stages of deploying our safety management system. We began deploying our safety management system earnestly from a voluntary standpoint in 2019, starting with a focus on the fleet and then moving on to our development programs. However, we had not fully deployed it across all areas of our production system, which the panel identified as an area for rapid improvement.

Another issue concerns how we manage work that is not completed as planned and how to effectively manage that work going forward. Lastly, we identified limited employee engagement. Our employees expressed a need for more time to participate in solutions for ensuring we create the perfect airplane.

Thus, while there are many issues, we can categorize them into eight overarching issues. We have identified four basic areas to address them: 1) investing in workforce training, 2) simplifying plans and processes, 3) eliminating defects both incoming and those we create, and 4) elevating our safety and quality culture.

30,000 ideas for change

Our airplanes are perfect every time, and throughout these stand-downs, we have received over 30,000 ideas, pain points, and areas for improvement. This has really formed the primary foundation of this plan, but it came from other sources as well. The FAA sent many auditors in here; they were with us at Boeing for six weeks across all three shifts. They also went to Spirit and spent three weeks there across all three shifts. We took all of the feedback from those audits seriously.

Our airline customers also came in and provided us with feedback, suggesting areas we might want to examine. We took all of that into account and looked at our own data to identify trends, assess risks, and pinpoint areas with defects. This helped us determine where we need to focus our attention.

In addition, there was AXA legislation, specifically AX 103, created by Congress that required an expert panel to evaluate Boeing’s safety culture and the deployment of our safety management system. This panel was convened well before the January 5th accident, but the report came out within that timeframe. They provided us with 52 recommendations, 48 of which were directed at Boeing, and we have accepted every one of those recommendations. We have incorporated this feedback into our plan.

Lastly, Boeing’s Board of Directors hired an independent assessor, Admiral Kirkland Donald. Admiral Donald leads a group that we affectionately call “the Admirals,” who have come in and spent time across our supply chain. They have visited multiple suppliers and all of our major locations. They have engaged in cross-talks with our unions, employees, and leaders, observing how we work and providing us with suggestions. We have incorporated their insights as well.

We compiled all of this input and developed the basis for our plan. Next chart, please. When we organized the information, we identified eight basic systemic issues or problem areas and created four solution sets, into which we have rolled this data. There is much more to cover.

New employees

We knew we brought in thousands of new employees, and in 2023, we recognized that our employees were struggling on the floor. Certainly, there are areas where we acknowledged mistakes—specifically related to the MAX crash. We own up to this: Did this airplane leave our factory in what we believe is a non-conforming condition that led to the accident? Yes, it did.

What I will also say is that we have been, and will continue to be, dedicated to making air transportation as safe as humanly possible. The actions we have taken over many years have contributed to making air transportation the safest means of transportation available. Our safety record continues to improve. Are those improvements owned by us? Yes. Have we taken steps to address the issues? I believe we have, and I believe we are continuing to do so.

The steps we are taking will make us an even better company, and we are committed to ensuring that air transportation remains the safest means of travel. There is ample data supporting the safety of air transport; a large portion of the airplanes flying today are ours. How we manage that and our commitment to that is part of our overall mission. This is essential to our commitment to continuous improvement and to staying on that journey, because that’s what we’re about. 

Mike Whittaker, the FAA view

Mike Whittaker, FAA Administrator, received news of an incident involving an Alaska Airlines Boeing 737 MAX.

Mike Whittaker shared: One year ago, a little over two months into my tenure as FAA Administrator, a mid-cabin door plug blew out of an Alaska Airlines Boeing 737 MAX after it departed from Portland, Oregon. I was at home when I got the news — it was a Friday evening and I had just spent the day at the FAA Command Center in Virginia. Aircraft doors are designed so they cannot be opened during pressurized flight. Was there an external event — such as an incendiary device — that caused this event? If not, there was potentially a serious problem with this aircraft that needed to be addressed immediately.

I spoke with our safety experts and Transportation Secretary Pete Buttigieg to get all the facts and inputs before making the decision to issue an emergency airworthiness directive grounding all MAX aircraft built with this type of plug door. That soon led to a series of unprecedented steps that dramatically transformed how we oversee Boeing.

We put more inspectors on the factory floors. We capped production levels of the 737 MAX. We conducted an in-depth audit of the production line. And most significantly, we required Boeing to develop a comprehensive plan to fix its systemic production quality problems.

In addition to multiple meetings with Boeing’s leadership at FAA’s offices in Washington, I visited Boeing’s facilities several times in 2024 to engage directly with their workforce and get their feedback on company policies and safety culture. Employee safety reporting is a key element of a healthy safety culture, and I directly communicated the importance of a robust whistleblowing reporting program with Boeing’s CEO and ensured the independent FAA safety hotline information has been shared with all Boeing employees. Because of our work, we received a surge in employee safety reports during the past year, and that’s encouraging.n increase in reports — whether at a manufacturer, an airline or at the FAA — can be one sign of a healthy safety culture.

The recent machinists’ strike halted production for several weeks, but FAA inspectors remained in the factory and focused on issues like training and making sure aircraft were safely stored. As the strike ended, I spoke directly with the CEO about the importance of adhering to safety-management principles as Boeing resumed production. It’s clear that message hit home, as Boeing spent a full month post-strike making sure the necessary safety steps were taken before restarting production.

Boeing is working to make progress executing its comprehensive plan in the areas of safety, quality improvement and effective employee engagement and training. We’re actively monitoring the results and keeping a close eye on work at key Boeing facilities. FAA safety experts continually review the effectiveness of the changes; senior FAA leaders meet with Boeing weekly to review their performance metrics, progress, and any challenges they’re facing; we have conducted an unprecedented number of unannounced audits; and we conduct monthly status reviews with Boeing executives to monitor progress. Our enhanced oversight is here to stay.

But this is not a one-year project. What’s needed is a fundamental cultural shift at Boeing that’s oriented around safety and quality above profits. That will require sustained effort and commitment from Boeing, and unwavering scrutiny on our part.

We are looking at all aspects of our oversight and we continue to support the NTSB’s investigation of the door-plug accident. We will review any recommendations the NTSB provides, as well as any other recommendations from other parties, including the Office of Inspector General, to improve our internal processes. Our goal is to develop even more dynamic oversight protocols that enable us to anticipate and identify risks before incidents occur..

I have the utmost confidence that the agency’s highly skilled and deeply committed team of safety professionals will continue to apply the rigorous oversight required to make sure this happens after my tenure as Administrator ends.