Remarks as prepared for delivery.
Good morning and welcome to the National Transportation Safety Board.
I’m Jennifer Homendy and I’m honored to serve as Chairwoman of the NTSB.
With me today are my Board colleagues: Member Michael Graham, Member Tom Chapman, and Member Todd Inman.
Today’s meeting is open to the public, in accordance with the Government in the Sunshine Act.
On January 5, 2024, at about 5:13 p.m. Pacific Standard Time, Alaska Airlines flight 1282, a Boeing 737-9 airplane, experienced an in-flight separation of the left mid-exit door plug and rapid depressurization during climb after takeoff from Portland International Airport.
One flight attendant and seven passengers received minor injuries. The captain, the first officer, three flight attendants, and 164 passengers were uninjured, and the airplane sustained substantial damage.
I know I speak for the entire agency when I say how tremendously grateful we are that no one lost their life or was seriously injured in this accident.
At the same time, I cannot overstate the seriousness of this event, which jeopardized the lives of all 177 souls onboard and, perhaps, countless others on the ground.
I was the Board Member on scene for this accident. I walked through the aircraft with our investigators and saw the damage up close. And I spoke with a few of the flight attendants in the aftermath of what was clearly a terrifying event.
Frankly, it’s nothing short of a miracle that no one died or sustained serious physical injuries. But — as with any tragedy we investigate — there are injuries we can’t see…injuries that can have a profound impact on people’s lives and livelihoods.
There’s no doubt that Alaska Airlines, as a whole — from its executives toits safety leadership and those on the front line — the flight attendants, who I spoke with on my flight home — were shaken; devastated.
Alaska Airlines was the first airline to implement a safety management system, so it’s not surprising they have a strong safety record.
I want to commend the entire Alaska Airlines team for working with us throughout this investigation, particularly Max Tidwell and his safety team.
For those in the room, Elias Kontanis from our Transportation Disaster Assistance Division is here, and will be here throughout the Board meeting, to provide support to anyone who may need it.
I firmly believe there’s one reason flight 1282 averted catastrophe, and one reason only: The crew.
The actions of the captain, the first officer, four flight attendants, and air traffic controllers on duty that day were nothing short of heroic.
While climbing through about 14,830 feet, the cabin pressure dropped and the cabin altitude warning activated, followed one second later by the master caution alert.
According to the captain, he heard a loud bang, his ears popped, his head was pushed forward, and headset was pushed nearly off.
The first officer’s ears popped and, simultaneously, the flight deck door blew open and her headset blew off.
The captain and first officer immediately retrieved their emergency oxygen masks and put them on, as they were trained to do.
The first officer could see in her peripheral view through the open flight deck door that the cabin oxygen masks had dropped. She later saw the hand of a flight attendant shut the flight deck door.
From that flight attendant:
“The flight door flung open and hit me and hit the bathroom, and I flew. […] All I could think about was trying to close the door. I wasn’t buckled in but I had them around my arm, so I was at least attached to the airplane and I remember trying to close it and my upper back hurt so bad, with all my might trying to close that flight deck door, I even used my feet. I was trying to kick it closed and it would not close.”
Back on the flight deck, the captain asked the first officer to declare an emergency with air traffic control and request a lower altitude.
According to the first officer, she used the audio control panel to select the overhead speaker, turned up the volume, and contacted air traffic control to declare an emergency.
Both pilots said it was very loud, making it difficult for them to hear each other and the air traffic controller.
Communications issues persisted throughout the remainder of the flight. In fact, the first officer said, at one point, she and the captain had to communicate using hand signals and by yelling to each other.
The first officer pushed the altitude warning horn cutout switch to stop the continuous audible warning. She reached to the top of the glareshield panel to retrieve the quick reference checklist from its holder, but it wasn’t there.
She later found it behind her seat. The captain grabbed the quick reference handbook and the first officer used it to start going through their emergency procedures.
At some point, the captain said he heard the flight attendants over the cabin interphone talking about a hole in the cabin. He tried to communicate with them multiple times to no avail; he wasn’t sure whether they were okay and whether they could even hear him.
Meanwhile, the flight attendants were trying to communicate with the pilots, but the noise was so loud in the cabin that they didn’t know whether the pilots answered or if they were even okay.
The pilots had no idea what was happening in the cabin, and the flight attendants had no idea what was happening on the flight deck.
To quote the captain — it was “an explosive experience.”
The first officer said, “it was chaos.”
Back in the cabin, the flight attendants saw five empty seats next to a gaping hole in row 26 and believed multiple passengers had been lost.
From an interview:
“I looked down the aisle and I see […] the mom of the child by the window. The mom was on the floor just screaming, like agony, and she was shaking. […] I was holding her, I said what's going on, what's happening and she just says, ‘I was holding my son and I think my son blew out’ […] [T]hat's when I lift up my head and I saw the hole and I just started shaking.”
It wasn’t until the crew deplaned that they learned they didn’t lose a single passenger; that all crewmembers were accounted for.
Throughout this meeting, you’ll hear more about what it was like onboard flight 1282 that day.
I think what’s most inspiring to me is — amid absolute chaos and, I imagine, fear — the crewmembers were laser-focused on the safety of their passengers.
Using supplemental oxygen, the flight attendants ran up and down the aisle to check on passengers, never forgetting the most vulnerable on board: three lap children and four unaccompanied minors — one of whom was just six years old. It was his first time flying.
I hope everyone in the room or watching online takes away a new-found appreciation and respect for the men and women who protect us in the air and on the ground. Above all, these highly trained professionals are there for our safety.
Safety. That’s a promise the Flight 1282 crew delivered on.
Despite the harrowing circumstances, every single crewmember performed their safety duties with the highest degree of professionalism and competence, remaining calm in the most turbulent of times.
They are why all 177 souls onboard Alaska Airlines flight 1282 deplaned safely at the gate.
This doesn’t just “happen.” Every single crewmember we interviewed credited their training.
We at the NTSB examine training in every accident we investigate, in every transportation mode.
Why? Because it can, and often does, make the difference between life and death.
When every second counts, as it did on flight 1282, training to the point of muscle memory is paramount.
In this case, the crew knew precisely what to do — they acted without hesitation. It saved lives.
And yet, the crew shouldn’t have had to be heroes.
Because this accident never should have happened.
Since this accident occurred, there’s been a lot of focus on human error — on the actions of one or two individual Boeing employees.
Let me be clear: An accident like this does not happen because of an individual, or even a group of individuals.
Aviation is much more resilient than that.
An accident like this only happens when there are multiple system failures.
This is from the draft NTSB report we will soon discuss:
“[W]ithin a robust system, the introduction of a single error is almost never the only cause of an accident. Rather, several barriers of defense must fail for the error to lead to an accident.”
Several barriers of defense.
The truth is, there was a long chain of events that led to the door plug departure.
Problems were identified in numerous Boeing internal audits across production lines, employee Speak Up reports, quality alerts, and regulatory compliance issues.
In other words: The safety deficiencies that led to this accident should have been evident…to Boeing and to the FAA…and were therefore preventable.
This time, it was missing bolts securing the door plug. But the same safety deficiencies that led to this accident could just as easily have led to other manufacturing quality escapes and, perhaps, other accidents.
Which leads me to the ultimate purpose of our investigation: To inform safety recommendations that, once implemented, will help Boeing close the systemic gaps that led to this accident…help strengthen each “barrier of defense” against quality escapes…so that every airplane leaving a Boeing factory is safe to transport the most precious thing imaginable: human life.
Our job is to make recommendations to prevent accidents like this from recurring.
Following the accident, Boeing rolled out its Safety & Quality Plan, which has the same goal.
Will Boeing’s plan, in fact, prevent accidents like this from recurring?
Are there still gaps?
We discussed some of those gaps at the hearing last August, including the need for continued development of Boeing’s safety management system and improved safety culture, which they themselves recognize and have done a lot of work.
How do Boeing and FAA know the Key Performance Indicators to measure the health of Boeing's production lines are the right ones for safety?
Before the accident, multiple tiers of Boeing leadership routinely assessed quality-control metrics, such as nonconformances, quality escapes, and regulatory compliance issues.
What’s changed?
Are the processes they developed since the accident going to prevent or, at a minimum, detect the next manufacturing issue before the airplane leaves the factory — before there’s an accident?
I do want to take a moment to thank Kelly Ortberg for his safety leadership. We’ve had several great discussions focused on safety since he came onboard. He has his work cut out for him, a lot of challenges to address, and that’s going to take time.
I visited Boeing and Spirit AeroSystems just a few weeks ago to see some of the changes they’ve made since this accident occurred; I’m thankful for their progress, but you’ll hear today that more can and should be done.
When it comes to safety, the NTSB sets a “high bar.”
We’ve been unequivocal when it comes to demanding excellence in transportation safety…in demanding excellence from Boeing.
Lives depend on it.
Boeing is a cornerstone of American aviation. It is a pillar of American manufacturing, supporting more than 170,000 direct jobs and an estimated 1.6 million indirect jobs around the globe.
I believe Boeing, Spirit, and the FAA will take the lessons learned from this accident to heart and — once again — become a world leader in aviation safety.
Please know that I…and the entire NTSB…are here as a resource to help you not just meet the high expectations we all have for you, but exceed them.
With that said, this isn’t all on Boeing or Spirit.
I have lots of questions about where FAA was during all of this.
The FAA is the absolute last “barrier of defense” when it comes to ensuring aviation safety, protecting the more than one billion passengers and crewmembers who fly on U.S. and foreign airlines annually.
Appropriate oversight of those they are charged with regulating is critical and I am hopeful that — with new leadership at DOT and at FAA — that will occur.
I believe change brings about new opportunities for much-needed reform and a renewed commitment to safety, something we’ve seen from Secretary Duffy since “day one.”
Let’s now turn to today’s meeting.
