NTSB: Boeing Failed to Provide Training or Oversight to Prevent Midair Incident on 737 MAX 9
The U.S. National Transportation Safety Board (NTSB) has concluded that Boeing did not provide the necessary training, guidance, or oversight to prevent the January 2024 incident in which a door panel detached midair from an Alaska Airlines-operated 737 MAX 9. The report, published this Tuesday, highlights a chain of oversights that, if addressed in time, would have entirely prevented the emergency.
Systemic Failures in Safety and Oversight
During the investigation, the NTSB determined that the manufacturer failed to install four key bolts in the affected aircraft. This production error was described as an “obvious” safety failure for both Boeing and the Federal Aviation Administration (FAA), according to NTSB Chair Jennifer Homendy.
“It’s a miracle no one died or suffered serious injuries,” Homendy stated during the report’s presentation.
A Safety Culture Under Scrutiny
The report’s most scathing criticism targets Boeing’s internal culture. The document notes that the manufacturer had identified unauthorized production issues for at least a decade through internal audits, reports, and other channels, yet failed to take effective corrective action.
Additionally, the company created no documentation for the removal or reinstallation of the door plug—a component covering an unused emergency exit—on the involved MAX 9. To date, Boeing has been unable to identify the employees responsible for this operation.
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Regulatory Response and Consequences for Boeing
In June 2024, the FAA acknowledged that its approach to Boeing had been “too hands-off,” in the words of then-Administrator Michael Whitaker. Since then, the agency has increased the presence of inspectors at both Boeing’s facilities and those of its supplier, Spirit AeroSystems.
The midair emergency led to the grounding of all MAX 9 aircraft for two weeks and the imposition of a monthly production cap of 38 units—a restriction that remains in place.
Legal Ramifications and Leadership Crisis
The incident also reignited legal pressure on Boeing. The Department of Justice (DOJ) opened a criminal investigation and stated that the company violated a deferred prosecution agreement signed in 2021 following the two fatal 737 MAX crashes in Indonesia and Ethiopia.
Although Boeing agreed in July 2023 to plead guilty to conspiracy to defraud, it recently reached a deal with the DOJ allowing it to avoid a formal guilty plea and external monitoring. Judicial approval of this agreement is still pending.
Following the crisis, CEO Dave Calhoun announced he would step down in the coming months. His successor, Kelly Ortberg, was praised by Homendy, though she cautioned that “he has a lot of work ahead and many challenges to address.”
Corrective Measures Underway
In response to the incident, Boeing is developing a design enhancement to ensure the door plug cannot be closed unless properly secured. However, the NTSB questioned the effectiveness of the company’s “on-the-job” training system, deeming it insufficient to guarantee operational safety.
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