Boeing blames missing documents for Alaska Air door stop incident

CNN — Renton, Washington (CNN) — Missing documentation on the 737 Max that lost a door latch on an Alaska Airlines flight in January is not only making it harder to determine the near-tragic failure, it may have caused the problem in the first place, Boeing said this week.

It was already known that no records were found showing who had worked on the door stopper. What was revealed this week at a press conference at Boeing’s 737 Max factory in Renton, Washington, is that missing records are the reason the four screws needed to secure the door stopper were never installed before the plane left the factory in October. The workers who had to reinstall the screws never had a work order telling them what work had to be done.

Without the screws, the door stop incident was almost unavoidable. Fortunately, it was not fatal.

This is a sign of the problems with the quality of work on Boeing’s assembly lines. These problems have become the focus of several federal investigations and whistleblower revelations and are the cause of delays in aircraft deliveries that are causing headaches for airlines and passengers around the world.

Boeing explained that this particular Alaska Air door plug issue was due to the fact that two different groups of workers were assigned to the job at the factory. One group removed the door plug while the other reinstalled it as the plane passed along the assembly line.

The first group of workers removed the door plug to fix problems with some rivets manufactured by a supplier, Spirit AeroSystems, but they did not produce any documentation showing that they had removed the door plug, along with the four screws needed to secure it, to perform this work.

When another group of employees reconnected the plug, Boeing said they did not believe the plane would actually fly in that condition.

Instead, they simply plugged the hole to protect the interior of the fuselage from the elements while the plane was being driven outside. This group of workers often makes such temporary repairs.

“The door team locks the airplane before it’s taken outside, but it’s not their job to install the pins,” says Elizabeth Lund, senior vice president of quality for Boeing’s commercial aircraft division.

These employees probably assumed that there was documentation showing that the plug and screws had been removed and that this documentation would prompt someone else on the production line to install the screws.

But without the records, no one else on the assembly line knew the door stopper had ever been removed or that its screws were missing, Lund said. Removing a door stopper after a Spirit AeroSystems aircraft arrives is rare, Lund added, so no one knew the door stopper needed to be repaired.

“The (permanent) reinstallation will be done by another team based on the documentation showing what work is not yet completed,” Lund said. “But there was no documentation, so no one knew what to do.”

In fact, the plane flew with the door plug in place for about two months, despite the lack of screws. 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 had their clothes and phones ripped off and thrown into the night sky. Fortunately, however, none of the passengers were seriously injured and the crew was able to land the plane safely.

The missing bolts were identified in a preliminary investigation by the National Transportation Safety Board (NTSB), but that report did not determine who was responsible for the accident, and a final report is not expected for about a year. An NTSB spokesman said the safety agency is continuing its investigation and would not comment on Boeing’s explanation of how the error occurred.

The committee released a preliminary report in February saying the missing screws left the Boeing factory but did not assign blame. A final report is not expected for a year or more.

NTSB Chair Jennifer Homendy has since testified about the missing documents at congressional hearings.

Boeing is addressing the problem by slowing the speed at which planes move down assembly lines and by ensuring that planes with problems are not moved forward on the assumption that those problems will be fixed later in the assembly process, Lund said.

“We have slowed down production in our factories to ensure the situation remains under control,” she said.

“I am extremely confident that the measures we have taken will ensure the safety of all aircraft leaving this plant,” she added.

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