[HN Gopher] Final report on Alaska Airlines Flight 1282 in-fligh...
___________________________________________________________________
Final report on Alaska Airlines Flight 1282 in-flight exit door
plug separation
Author : starkparker
Score : 94 points
Date : 2025-07-10 20:51 UTC (2 hours ago)
(HTM) web link (www.ntsb.gov)
(TXT) w3m dump (www.ntsb.gov)
| supportengineer wrote:
| The accident happened because a piece on the airplane wasn't put
| back on the right way. The company that made the plane didn't
| teach the workers well enough or check their work carefully.
| Also, the people in charge of making sure planes are safe didn't
| do a good job checking on things.
| heywoods wrote:
| What Boeing plant was the aircraft assembled at where this
| failure occurred?
| bboygravity wrote:
| And the whistleblower trying to warn people about this and
| other issues was potentially executed by the company.
| tptacek wrote:
| No he wasn't, and he wasn't.
| user3939382 wrote:
| Right because you're the source of authority on how and why
| these people died.
| HeyLaughingBoy wrote:
| Don't know why I'm bothering, but here:
| https://www.cnn.com/2024/05/17/business/boeing-
| whistleblower...
|
| If you have evidence to the contrary, by all means let us
| know.
| rcxdude wrote:
| About as much so as the person they were replying to, who
| was speculating with a similar lack of evidence.
| RandomBacon wrote:
| If I was determined to commit suicide, I'd probably try
| to accomplish other goals with it if I could. For that
| person, FUD might have been his secondary goal.
|
| I imagine if someone is contemplating suicide, they are
| not in a good place. Trying to sow FUD would be in line
| with that.
|
| A tragedy begetting more tragedy.
| BolexNOLA wrote:
| I see this conspiracy theory hasn't died yet
| CGMthrowaway wrote:
| Are we still talking about John Barnett? This guy's been
| talked about for years. You're asking -- we have Texas, we
| have this, we have all of the things. And are people still
| talking about this guy? That is unbelievable
| MrZongle2 wrote:
| Well done. No notes.
| kevin_thibedeau wrote:
| Then let's talk about why the weapons shipments were
| suspended.
| user3939382 wrote:
| https://www.bbc.com/news/business-68534703.amp
|
| This is one of two. As theories go conspiracy is pretty
| plausible in this case. Unless you're just naive about how
| the world works.
| vel0city wrote:
| There's supposedly video evidence of him parking his
| truck and nobody approaching it at all until people were
| there discovering the body. He had his personal firearm
| in his hand, ballistics suggest the bullet came from his
| gun, and it followed a path that made sense with him
| holding it and using it on himself.
|
| But hey I guess they did some kind of mind control on
| him.
| duk3luk3 wrote:
| > There's supposedly video evidence
|
| That statement is so weak it's better at inflaming the
| conspiracy theory than quelling it.
| almosthere wrote:
| These days, I only trust the conspiracy theories. Did you
| hear about Mike Lynch and the HP acquisition. Shady af
| BolexNOLA wrote:
| While you're bound to be right occasionally I would
| suggest maybe rethinking how open minded you should be
| almosthere wrote:
| lately it's 100%
|
| Aliens are visiting and/or we have electro-gravitics
| (which would likely imply visitors too)
|
| 9/11 - the story we were told isn't true - building 7?
| passports found?
|
| there are 2 dead Boeing whistleblowers
|
| the openai whistleblower
| BolexNOLA wrote:
| Yeah I'm out man. Not touching this
| lukan wrote:
| Well, a broken watch is still right 2 times a day.
| ryandrake wrote:
| At the risk of overgeneralizing, more and more in modern life
| it feels as though we are all surrounded by people who are
| supposed to do their jobs right who don't, and people who are
| supposed to inspect their work who aren't inspecting, and
| people who are supposed to check the inspection process who
| aren't checking, and a legislative body who's supposed to
| regulate all the checking and double checking who aren't doing
| anything at all!
|
| It's like vast swaths of people are just fooling around,
| collecting a paycheck, but aren't doing what they're supposed
| to be doing, and we're all just miraculously surviving our day-
| to-day because a bunch of denominators are very large numbers!
| pishpash wrote:
| No, because some people still care and clean up enough after
| the slackers. The slackers also realize this and slack just
| enough for nothing major to happen often.
| almosthere wrote:
| This is not true, when that many people stop doing their
| job it spreads like a virus and the ones that still stand
| for good either a) leave companies or b) become infected
| also.
|
| They don't go against the grain. The people that do would
| have to have a constitution like no one you've met. Those
| people quit the moment covid-19 hit and they have since
| died or are just permanently retired.
| metabagel wrote:
| The issue at Boeing wasn't due to slackers. It was a
| process issue due to cutting corners (management issue).
| HeyLaughingBoy wrote:
| I have worked in the medical devices industry as a software
| engineer for about 20 years at this point. As you would
| expect, it's a very process-heavy field. I've generally
| worked with careful, competent people who want to do a good
| job and process goes a long way towards facilitating that.
|
| Every time I think about process though, I remember an
| editorial I read a long time ago about an engineer's
| experience in the aviation industry. He wasn't too thrilled
| about process. Instead, in his own words, "we were motivated
| by a very sincere desire to not kill anyone.
| tiahura wrote:
| The counter-culture successfully demonized concepts like
| duty, personal accountability, and shame. A boy scout was to
| be mocked.
| cosmicgadget wrote:
| Don't worry, the mainstream does this too while pretending
| to honor those values.
| metabagel wrote:
| It's nothing to do with the counter culture. Boeing cut
| corners in order to save money. That's the long and the
| short of it.
| renewiltord wrote:
| It's because we are very good at getting smart people into
| high comp jobs so all these low remuneration jobs are pretty
| much idiots.
|
| If they can avoid weed long enough to pass the drug tests,
| they'll be playing Candy Crush on their phone when
| inspecting.
|
| They just don't have the mental horsepower. Like being upset
| a jellyfish didn't discover calculus.
|
| Patio11 calls this The Sort. I thought it was good name.
| mschuster91 wrote:
| pay peanuts, get monkeys.
|
| when you pay utter shit but the c-level earns many 100x the
| salary of the workers, of course they don't give a fuck.
| visarga wrote:
| > At the risk of overgeneralizing, more and more in modern
| life it feels as though we are all surrounded by people who
| are supposed to do their jobs right who don't
|
| Meta observation - human society works by abstraction -
| leaky, and functional - not genuine understanding. Searle was
| wrong. There is no genuine understanding, only a web of
| abstractions that sometimes break.
| metabagel wrote:
| In general, people do what the organization providing their
| paycheck asks them to do. If their manager tells them to cut
| corners, they'll likely cut corners.
|
| Some people are opposed to bureaucracy and will tend to try
| to undermine processes which are designed to prevent errors
| in production and execution. Organizational culture needs to
| be established and maintained, which aligns everyone toward
| the processes needed to maintain required standards.
| pulse7 wrote:
| "What We Found
|
| We determined that the probable cause of this accident was the
| in-flight separation of the left MED plug due to Boeing's failure
| to provide adequate training, guidance, and oversight necessary
| to ensure that manufacturing personnel could consistently and
| correctly comply with its parts removal process, which was
| intended to document and ensure that the securing bolts and
| hardware that were removed to facilitate rework during the
| manufacturing process were properly reinstalled. Contributing to
| the accident was the FAA's ineffective compliance enforcement
| surveillance and audit planning activities, which failed to
| adequately identify and ensure that Boeing addressed the
| repetitive and systemic nonconformance issues associated with its
| parts removal process."
| pulse7 wrote:
| Somehow Boeing is happening to the whole IT industry at the
| moment where AI is forced upon programmers instead of "properly
| developing software" ...
| thewebguyd wrote:
| It's a byproduct of unchecked capitalism. This behavior will
| continue as long as there are no real consequences for those
| in charge.
| jiggawatts wrote:
| There's always consequences for people in charge! It's just
| that all of the consequences are related to not-enough-
| profit, which explains everything you need to know.
| thomascountz wrote:
| > We determined that the probable cause of this accident was the
| in-flight separation of the left MED plug due to Boeing's failure
| to provide adequate training, guidance, and oversight necessary
| to ensure that manufacturing personnel could consistently and
| correctly comply with its parts removal process, which was
| intended to document and ensure that the securing bolts and
| hardware that were removed to facilitate rework during the
| manufacturing process were properly reinstalled.
|
| A bit OT, but what a gorgeous whale of a sentence! As always, the
| literary prowess of NTSB writers does not disappoint.
| pj_mukh wrote:
| Looking forward to the length of the sentence the NTSB uses for
| Air India flight 171. Gonna be a doozy
| JSteph22 wrote:
| Wouldn't it be the Indian authorities who issue a report?
| twexler wrote:
| Yes, but as the country of manufacture of the incident
| aircraft, NTSB is absolutely consulting on that report.
| CGMthrowaway wrote:
| AKA Boeing did not train, guide or oversee its people well -
| Workers skipped the process meant to keep track of bolts and
| hardware - The bolts for the mid-exit door were never put back
| - At 14K feet, the door blew free.
| 0rzech wrote:
| At school (Polish class in Poland) we were always taught to
| prefer complex and compound sentences over simple ones, because
| it's more elegant and speaks well the speaker/writer.
| tuukkah wrote:
| Same happening in Hispanic school systems could explain the
| sentences in some of the Spanish Wikipedia articles.
| ecb_penguin wrote:
| It doesn't, though. It's pretentious and educated people will
| see through it. If the goal is to inform, then you should do
| the opposite.
| GuinansEyebrows wrote:
| i imagine the language may change that though. With Polish
| having nominally 300k-400k words compared to English's >1m,
| i'd guess that it's a lot easier to misdirect and fluff up
| your writing in English.
| beerandt wrote:
| Only if you're using technical writing in a situation where
| you shouldn't be.
|
| Problem is the state of most English education doesn't even
| teach enough for people to recognize proper unambiguous
| technical writing, let alone appreciate it or attempt to
| compose it.
| SilasX wrote:
| Well that's one source (of many) where the problem is coming
| from.
| Telemakhos wrote:
| This sentence isn't written for elegance but for meaning. The
| formal cause of the accident was the mechanical separation,
| but that happened for a reason, either mechanical failure
| (which means a failure in the engineering of the aircraft,
| which would have to be remedied by new engineering processes)
| or an assembly failure (which would have to be remedied by
| new assembly processes). In one sentence, the author drills
| down to exactly what went wrong that enabled the accident to
| happen. Identifying that is the first step to remedying it.
| ryandrake wrote:
| Reading aviation-related NTSB final reports is kind of a hobby
| of mine, and I must say, the NTSB is generally a treasure!
| Sure, you can find issues with some of their investigations,
| roads they might not have probed down as far as they could, but
| their culture of root causing and transparently reporting
| should be emulated across the government. I really hope they
| don't fall victim to the casual, random destruction our current
| administration is inflicting on broad swaths of the government.
| frumplestlatz wrote:
| The current aims of the executive branch are neither casual
| nor random, and I doubt the NTSB is in their crosshairs.
|
| The goals are both obvious and specific; it's a culture war
| being fought at the funding level.
| cosmicgadget wrote:
| There is the culture war but don't ignore the dealmaking
| and profiteering. This can create the appearance of
| randomness because any entity can appeal to the executive
| for favor.
|
| Sounds like in this case either Boeing didn't donate enough
| or, more likely, nobody wants to f with airliner safety.
| lukan wrote:
| "or, more likely, nobody wants to f with airliner safety"
|
| If that would be more likely, Boeing wouldn't be, where
| it is.
|
| To me it seems more likely Boeing has now too much
| attention on them, making fraud here even more
| dangerous/expensive.
| postpawl wrote:
| A culture war on poor people who need Medicaid? That
| doesn't seem like class war to you?
| lemoncucumber wrote:
| Reading NTSB reports themselves isn't for me, but I really
| enjoy reading this blog that does excellent write-ups of past
| plane crashes. It's really well written, easy to follow, and
| fascinating: https://admiralcloudberg.medium.com
| JoshTriplett wrote:
| Also, I really appreciate the way they put blame where it
| belongs. They don't say "manufacturing personnel failed to
| ...", they say "Boeing failed to provide adequate training,
| guidance, and oversight necessary to ensure that manufacturing
| personnel could consistently and correctly ...".
| wat10000 wrote:
| They know their business. The goal is safety, not punishment.
| Blaming workers is great if you're after revenge or a
| scapegoat, but generally doesn't improve safety.
| mrandish wrote:
| Agreed about properly assigning the root cause to inadequate
| training but the sentence was unnecessarily complex in not
| making the first order cause clear until the end. I'd prefer
| stating up front that the first order cause was "securing
| bolts and hardware that were removed to facilitate rework"
| were not reinstalled - and then stating the root cause
| leading to that being inadequate training.
|
| In the context of a summary I just expect the core sentence
| to take events in order from the headline failure ("in-flight
| exit door plug separation") and then work back to the root
| cause.
| lobochrome wrote:
| In the end - action matters. Somebody didn't put the bolts
| back in.
|
| Yes - zooming out it important and ultimately where
| actionable remediation can be applied - but blame is due
| where blame is due: somebody fucked up at work and it
| almost brought down a plane.
| bobsomers wrote:
| Modern safety analysis acknowledges that humans are
| fallible, and they are generally acting in a good faith
| way to try and do their jobs correctly within a given
| system they are operating in.
|
| That's why these reports tend to suggest corrective
| actions to the parts of the system that didn't work
| properly. Even in a perfectly functioning safety culture,
| an employee can make a mistake and forget to install the
| bolts. A functioning safety system has safeguards in
| place to ensure that mistake is found and corrected.
| calfuris wrote:
| In the end, identifying where you can usefully take
| action to reduce the chances of something similar happen
| in the future is _far more useful_ than assigning blame.
| tialaramex wrote:
| Right, Alaska didn't buy an aeroplane from "manufacturing
| personnel" they bought it from Boeing. If Boeing don't want
| to sell aeroplanes that's cool, bye-bye Boeing, but if they
| want to sell aeroplanes then it's _their_ responsibility to
| ensure those planes are safe and it cannot somehow be a
| transferable responsibility.
| dlcarrier wrote:
| My favorite NTSB-ism is "controlled flight into terrain", which
| means "crashed". This is as opposed to "uncontrolled flight
| into terrain", which means "fell from the sky".
| scoot wrote:
| > We determined that the probable cause of this accident was
| the in-flight separation of the left MED plug
|
| I find it very strangely worded. It was an "incident", not an
| "accident"; and "the in-flight separation of the left MED plug"
| _was_ the incident, not the cause of a non-existent accident.
|
| The actual cause of the incident (as determined by the NTSB) is
| what follows all that unnecessary verbage.
| colechristensen wrote:
| The NTSB remains very good at its job and should serve as a model
| for government. A beacon of hope.
| CamperBob2 wrote:
| Consequently, I'm sure they're being defunded even as we speak,
| like the US Chemical Safety Board already has been.
|
| Are we great again yet?
| Alupis wrote:
| Imagine _actually believing_ some mid-level bureaucrats are
| the only thing standing between normal operations and planes
| falling out of the sky...
| cosmicgadget wrote:
| Are you saying no one important is being DOGEs or that they
| can all be and the industry will self-police?
|
| It is tough to understand your snark.
| CamperBob2 wrote:
| Not worth feeding the troll. Starve him out and he'll
| find his way back to Reddit.
| aredox wrote:
| Don't worry, as a consequence , Boeing is being awarded contract
| after contract by the current administration.
| hughes wrote:
| Part of me wonders if the plug could be designed such that it's
| obvious when the bolts are missing. Would this have happened if
| it were impossible to assemble without them, or if it were easy
| to verify their presence?
|
| Maybe it doesn't matter if a better design is possible - if
| adequate procedures exist and weren't followed, and oversight
| fails to catch instances of that, then anything could go wrong.
| burnt-resistor wrote:
| The general principle would be making other parts with
| interference fit such that it or they visibly do not align
| without properly tightening/attaching parts below/about them.
| For example, the door plug should not sit in the correct
| position unless door plug bolts are all tightened and
| untightened door plug bolts shouldn't allow installing other
| parts like trim pieces to be flush.
|
| Every critical step should be as "idiot-proof" as possible,
| until better idiots are created who hammer structural parts
| into position to meet management-mandated arbitrary deadlines.
| toast0 wrote:
| It sounds like Boeing is doing a design enhancement. I found
| this article [1] that describes features for the bolts as:
|
| > The fix also includes adding lanyards atop the door-plug
| bolts to "permanently secure the bolts to the plug" and
| "provide a visual indication", says Crookshanks. "They'll hang
| there and be visible to a mechanic that had taken the bolts
| out."
|
| [1] https://www.flightglobal.com/safety/details-emerge-about-
| boe...
| gavinsyancey wrote:
| > Once you complete the certification of Boeing Commercial
| Airplanes' design enhancement for ensuring the complete closure
| of Boeing 737 mid exit door (MED) plugs following opening or
| removal, issue an airworthiness directive to require that all
| in-service MED plug-equipped airplanes be retrofitted with the
| design enhancement. (A-25-15)
|
| It sounds like Boeing is currently working on designing and
| certifying a design enhancement to the MED plug to make it
| obvious if one is not closed properly. Not sure where to find
| the details on it though.
| lyrrad wrote:
| I believe that's what this directive is for:
|
| "To the Federal Aviation Administration:" " Once you complete
| the certification of Boeing Commercial Airplanes' design
| enhancement for ensuring the complete closure of Boeing 737 mid
| exit door (MED) plugs following opening or removal, issue an
| airworthiness directive to require that all in-service MED
| plug-equipped airplanes be retrofitted with the design
| enhancement. (A-25-15)"
|
| This article: https://aerospaceglobalnews.com/news/boeing-
| completes-design..., suggests that the design enhancement will
| add "secondary retention devices" that "prevent installation of
| the cabin sidewall panels unless they are properly engaged."
| The article indicates that the existing bolts will also get
| lanyards that will "'permanently secure the bolts to the plug'
| and provide a visual indication' of whether they have been
| installed correctly."
|
| Apparently, if only one of the four bolts was installed, it may
| have been sufficient to prevent the accident, according to:
| https://www.nytimes.com/2025/06/24/us/politics/boeing-alaska...
| xenadu02 wrote:
| The plugs are designed to be semi-permanent because they are
| only for emergency exits on certain high-capacity seat layouts
| not used by most US airlines (or any airline that has first
| class seats I believe). When you have more seats you need more
| exits.
|
| Given their nature the original intent was probably that they
| were secured at the factory and never touched. But because they
| are convenient for access during maintenance/inspection they
| get used more often.
|
| This issue, the oxygen mask, and the child restraint issue are
| the NTSB doing the proper "what if things had been slightly
| different" calculation.
|
| Airline maintenance removes and reinstalls these doors. They
| could accidentally commit the same error so Boeing should
| change the design such that the door will not stay in-place
| when the bolts are removed. Could be as simple as springs that
| force the plug open without the bolts. If the door won't stay
| closed without the bolts like a light switch it will be forced
| to clearly show when it is safe vs not.
|
| Child restraints were mentioned partially because if a lap
| child had been in that row they'd have been sucked out by the
| decompression and free-fallen 14000 ft. It was entirely luck
| that it didn't happen.
|
| Oxygen masks mentioned because the pilots had some trouble
| getting them on in a timely manner. If the incident had been
| sudden onset of thick toxic smoke one or both could have passed
| out before getting the mask on and oxygen flowing. That's like
| a fire extinguisher with a complicated pin mechanism.
| Adrenaline dump during emergencies ruins fine motor control,
| critical thinking, etc. The worst possible time to have
| something be fiddly and complicated. You want it to be muscle
| memory. So trivial a 5 year old child could do it without being
| taught.
|
| And the CVR issue is just the NTSB mentioning that _yet again
| for like the 100th time_ the CVR circuit breaker was not pulled
| so we lost the recording and any potential learnings to be had
| from examining them. This is a problem that just keeps
| happening over and over. Because it relies on pilots, after a
| huge emergency, to remember to pull a circuit breaker when they
| have a thousand far more important things to worry about (not
| to mention coming down from the adrenaline high) and the thing
| only keeps the last two hours... which was a standard set when
| they were continuous loops of wire before the switch to
| magnetic tape. All the new ones are little computers and flash
| chips.
| ratdoctor wrote:
| There are a couple of typos on the page
|
| > dDevelop guidance for Federal Aviation Administration managers
| and inspectors
|
| > <strike>P</strike>rovide Federal Aviation Administration
| managers
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