A federal investigation has intensified after Boeing failed product audits and has not provided documentation on the removal and subsequent reinstallation of a door plug that failed on a Alaska Airlines Boeing 737 Max 9 flight in January.
According to the preliminary report by the Nation Transportation Safety Board (NTSB), the four bolts that were supposed to hold the door plug in place were not installed. The investigation revealed the door plug had been removed for maintenance because of improperly installed rivets.
In a Senate hearing Wednesday, NTSB Chair Jennifer Homendy said Boeing had stonewalled the safety agency’s request for documentation.
Since the door plug blowout, the FAA has increased its oversight of Boeing and its contractor, Spirit AeroSystems, which makes the fuselage of the Boeing 737 Max.
“As part of its aggressive oversight of Boeing and its suppliers in the wake of the January 5th plug door incident involving a Boeing 737 max 9, the FAA recently concluded an audit of Boeing’s production line that went above and beyond FAA’s standard inspection process,” the FAA told FLYING. “The FAA identified noncompliance issues in Boeing’s manufacturing process control, parts handling and storage, and product control.”
The audit of Boeing noted the manufacturer failed 33 of 89 product audits, while Spirit underwent 13 audits and failed six.
One area of audit failure was related to the door plug.
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According to The New York Times, among the issues noted by auditors included failure to follow “approved manufacturing process, procedure, or instruction,” as well documenting the order the work was done and subsequent quality control.
According to the report, at one point auditors observed technicians at Spirit using a hotel key card to check a door seal, an action that was not “identified/documented/called out in the production order.” Dawn dish soap was also used as a lubricant in the door seal fit- process, for which the instructions were “vague and unclear on what specifications/actions are to be followed or recorded by the mechanic.”
“We have received preliminary findings from the FAA’s special audit of 737 production, on which we will work with our customer to address and incorporate lessons identified through the process,” a spokesperson from Spirit AeroSpace Systems told FLYING. “Meanwhile, we continue multiple efforts undertaken to improve our safety and quality programs. These improvements focus on human factors and other steps to minimize nonconformities. We recognize there is more to do, and any findings from the FAA will serve as a guide as we pursue additional opportunities to increase our precision and reduce opportunities for error. In so doing, as we have stated, our goal is zero defects.”
Following the January 5 incident, the FAA halted production expansion of the Boeing 737 Max and is exploring the use of a third party to conduct independent reviews of quality systems.
- READ MORE: Boeing Changes Leadership of 737 Program
The FAA on-site presence at Boeing’s facility in Renton, Washington, and Spirit AeroSystems’ facility in Wichita, Kansas, will continue, the agency said. The FAA has also mandated a comprehensive action plan from Boeing to address its production issues, giving the company 90 days to complete this critical plan.
In a press conference Monday, FAA Administrator Mike Whitaker noted that the agency expects Boeing to have a plan in place in 30 days that will list milestones to strive for on the path to achieving better quality control. Whitaker has stated that Boeing “must commit to real and profound improvements. Making foundational change will require a sustained effort from Boeing’s leadership, and we are going to hold them accountable every step of the way.”
Boeing said it is on track to do that.
“Based on the FAA audit, our quality stand-downs and the recent expert panel report, we continue to implement immediate changes and develop a comprehensive action plan to strengthen safety and quality, and build the confidence of our customers and their passengers,” a Boeing spokesperson told FLYING. “We are squarely focused on taking significant, demonstrated action with transparency at every turn.”
In addition, at a press conference Monday Whitaker noted “the FAA has issued a letter of investigation (to Boeing) over the incident.” One of the questions being raised by federal agencies is if the failure to reinstall the door plug with the required bolts was a one-off event or symptom of a larger problem.
Door Plug Blowout
Several passengers aboard Alaska Airlines Flight 1282 were injured in the sudden decompression. The oxygen masks dropped from the ceiling, parts of the seats and interior cabin directly adjacent to the hole, and loose objects, including cellphones, were sucked out into the night sky.
The flight crew declared an emergency and returned for landing at Portland International Airport (KPDX) in Oregon. Within hours Alaska Airlines and the FAA grounded all 737 Max 9s.
The door plug and debris from the cabin were found on the ground in a Portland neighborhood.
For the better part of two weeks the aircraft remained grounded until they could undergo detailed inspections to check the security of the door plugs.
The NTSB investigation noted there had been three warnings of pressurization issues with the jet that had been documented by other flight crews prior to the accident. But since pressurization is a triple-redundant system, it was determined that the aircraft could remain in operation but was restricted from flying over the ocean.
Since the accident there have been multiple lawsuits filed against Alaska Airlines and Boeing on behalf of the passengers on board, and the Department of Justice is investigating Boeing.
In a press conference Monday, U.S. Transportation Secretary Pete Buttigeig said “we expect Boeing to fully cooperate with the NTSB and DOJ.”
