NTSB released its preliminary report on the Alaska Airlines 737 MAX 9 incident

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A door panel that flew off a Boeing 737 MAX 9 jet mid-flight on Jan. 5 appeared to be missing four key bolts, according to a preliminary report from U.S. investigators that provided the first official look into how the frightening mishap took shape.

“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,” said Boeing President and CEO Dave Calhoun.

The U.S. National Transportation Safety Board report released on Tuesday focused on how the panel – fitted into this MAX 9 model in place of an optional exit – could have detached from the plane. The plug is held down by four bolts and then secured by “stop fittings” at 12 different locations along the side of the plug and the door frame.

The plug was manufactured by Spirit AeroSystems the a former subsidiary of Boeing. The part was produced at its facilities in Malaysia and delivered to Spirit’s Wichita, Kansas, facility in May 2023. It arrived in Renton on Aug. 31.

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The report shows the panel had to be removed at Boeing’s Renton, Washington, factory before being reinstalled. The initial findings released on Tuesday include photo evidence that the bolts required to hold the plug in place appeared to be missing.

The report found the panel was first removed to repair rivet damage logged by Boeing workers on Sept. 1, 2023, a day after the panel arrived in Renton. Investigators are still trying to determine what documentation was used to authorize the opening and closing of the plug during the rivet repair.

The report raises questions about who initially installed the bolts and why the door’s opening at Renton to correct the rivets was not properly documented, said U.S. aviation safety expert John Cox.

“When was the last time those bolts were installed? Did Spirit not install them and then when Boeing opened it the guys didn’t realize that they didn’t have the bolts? Or did Boeing not install them? That is something that I don’t think we have an answer for yet.”

Boeing said it has “implemented a control plan to ensure all 737-9 mid-exit door plugs are installed according to specifications.”

A photo in the report shows three visible locations where bolts are missing, with the fourth location covered by insulation.

“Photo documentation obtained from Boeing shows evidence of the left-hand MED plug closed with no retention hardware (bolts) in the three visible locations,” the report says.

With information from Reuters