DCA24MA063

NTSB accident investigation · Boeing 737-9 · Portland, OR · January 6, 2024

Accident · Minor injuriesClass 1 · MajorFinal report
Date
January 5, 2024, 17:14 local (Jan 6, 2024, 01:14 UTC)
Place
Portland, OR
Injuries
8 minor, 172 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N704ALBoeing 737-9
Defining event
Enroute-climb to cruise: Part(s) separation from AC
Weather
Visual (VMC) · Night
Status
Completed · report June 24, 2025
Report
Board-adopted at Board Meeting · Board meeting June 24, 2025
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
International Association of Machinists and Aerospace Workers Union (IAM), FAA/ Federal Aviation Administration AVP-100, ALPA, AFA, Boeing, Spirit AeroSystems, Alaska Airlines
Safety recommendations
Yes
FAA report
20240105001319A
Case key
193617

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

the in-flight separation of the left mid exit door (MED) plug due to Boeing Commercial Airplanes’ 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 from the left MED plug to facilitate rework during the manufacturing process were reinstalled. Contributing to the accident was the Federal Aviation Administration’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.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fuselage: equip attach fittings (on fus)Aircraft › Aircraft structures · Not installed/availableBoeing 737-9: 1 caseAll aircraft: 3 casesProbable cause
TrainingOrganizational issues › Support/oversight/monitoring · ManufacturerBoeing 737-9: 1 caseAll aircraft: 26 casesProbable cause
Oversight: oversight of personnelOrganizational issues › Support/oversight/monitoring · ManufacturerBoeing 737-9: 1 caseAll aircraft: 26 casesProbable cause
Enforcement: company/organization policyOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBoeing 737-9: 1 caseAll aircraft: 4 casesProbable cause
Safety programs: adequacy of safety programOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBoeing 737-9: 1 caseAll aircraft: 24 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

On January 5, 2024, about 1713 Pacific standard time, Alaska Airlines flight 1282, a Boeing 737-9 airplane, N704AL, experienced an in-flight separation of the left mid exit door plug and rapid depressurization during climb after takeoff from Portland International Airport, Portland, Oregon. One flight attendant and 7 passengers received minor injuries; the captain, the first officer, 3 flight attendants, and 164 passengers were uninjured; and the airplane sustained substantial damage. The scheduled domestic passenger flight was operated under Title 14 Code of Federal Regulations Part 121 and departed PDX about 1707 with a planned destination of Ontario International Airport, Ontario, California.

Aircraft

Registration
N704AL
Reported as
Boeing 737-9
Category
Airplane
Serial number
67501
Built
2023
Airframe hours
510
Engines
CFM Intl LEAP-1B28 SER, 29,317 lbs thrust, turbo fanCFM Intl LEAP-1B28 SER, 29,317 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Alaska Airlines Inc
Registered owner
Alaska Airlines Inc
Airworthiness certificate
Standard, Transport
Departed
PDX · Portland, OR
Destination
ONT · Ontario, CA
Flight plan
IFR
Equipment
Heads up display, Data recorder

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
48
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
5-point
Flight hours
12,500 total · 6,500 in this make and model
Role
Co-pilot
Age
36
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Restraint
5-point
Flight hours
8,300 total · 1,500 in this make and model

Weather

Conditions
Visual (VMC) · Night
Wind
160° at 11 knots
Visibility
10 statute miles
Lowest ceiling
6,000 ft overcast
Temperature
50 °F, dew point 39 °F
Altimeter
30.23 inHg
Observed at
PDX, 12 nm away

Docket · 102

The files NTSB released with the investigation on August 9, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.5 GB in all.

1-A order of hearingItem 1 · PDF · 2 pages · 102 KB1-B designation of chair of board of inquiryItem 2 · PDF · 2 pages · 121 KB1-C designation of hearing officerItem 3 · PDF · 2 pages · 119 KB1-D designation of parties to the hearingItem 4 · PDF · 2 pages · 120 KB1-E notice of investigative hearingItem 5 · PDF · 2 pages · 106 KB1-F statement of purposeItem 6 · PDF · 3 pages · 351 KB1-G witness listItem 7 · PDF · 9 pages · 225 KB1-H witnesses professional biographiesItem 8 · PDF · 15 pages · 498 KB1-I exhibit listItem 9 · PDF · 4 pages · 50 KB1-J board of inquiry and technical panel professional biographiesItem 10 · PDF · 15 pages · 536 KB2-A operational factors - group chairman factual reportItem 11 · PDF · 36 pages · 1.9 MBOperational factors - errata 1 to group chairman's factual reportItem 12 · PDF · 15 pages · 5.6 MBOperational factors - errata 2 to group chairman's factual reportItem 13 · PDF · 2 pages · 72 KB2-B operational factors - attachment 1 - crew interview transcripts and statement - crew names redactedItem 14 · PDF · 84 pages · 3.6 MB2-C operational factors - attachment 2 - Alaska personnel interview transcriptsItem 15 · PDF · 97 pages · 896 KB2-D operational factors - attachment 3 - flight crew training records - flight crew names redactedItem 16 · PDF · 4 pages · 1.3 MB2-D operational factors - attachment 3 - flight crew training recordsItem 17 · PDF · 4 pages · 1.1 MB2-E operational factors -attachment 4 - Alaska airlines checklistItem 18 · PDF · 9 pages · 672 KB2-F operational factors - attachment 5 - simulator evaluationItem 19 · PDF · 21 pages · 2.3 MB2-G operational factors - attachment 6 - sequence of eventsItem 20 · PDF · 5 pages · 142 KB2-H operational factors - attachment 7 - continuing qualification quarterly training rotation scheduleItem 21 · PDF · 3 pages · 191 KB2-I operational factors - attachment 8 - cbt training modules [excerpts]Item 22 · PDF · 11 pages · 1.1 MB2-J operational factors - attachment 9 - continuous qualification 2025 loft simulator profileItem 23 · PDF · 3 pages · 161 KB2-K operational factors - 10 - weight and balance - name redactedItem 24 · PDF · 5 pages · 1.2 MB2-L operational factors - attachment 11 - Boeing response to flight deck door information requestItem 25 · PDF · 3 pages · 267 KB2-M operational factors - attachment 12 - NASA ASRS database query resultsItem 26 · PDF · 8 pages · 2.3 MB2-N operational factors - attachment 13 - flight ops training bulletin (postaccident)Item 27 · PDF · 5 pages · 1.2 MB2-O operational factors - attachment 14 - Alaska airlines cabin altitude warning and emergency descent training video (postaccident)Item 28 · M4V · 442 MBOperational factors - attachment 15 - maintenance and engineering checklist (postaccident)Item 29 · PDF · 6 pages · 649 KBOperational factors - attachment 16 - maintenance control checklist (postaccident)Item 30 · PDF · 3 pages · 281 KBOperational factors - attachment 17 - flight operations checklist (postaccident)Item 31 · PDF · 10 pages · 896 KB6-A survival factors group chair's factual reportItem 32 · PDF · 57 pages · 6.5 MB6B - survival factors attachment 1 flight attendants interview transcripts redacted - with fa names redactedItem 33 · PDF · 264 pages · 7.4 MB6-C survival factors - attachment 2 passenger interview summariesItem 34 · PDF · 15 pages · 211 KB7 Structures group chair's factual reportItem 35 · PDF · 16 pages · 2.0 MBStructures group chair's factual report - supplementItem 36 · PDF · 7 pages · 146 KBStructures group - explanation of AD compliance in productionItem 37 · PDF · 4 pages · 420 KBBoeing med plug design enhancementsItem 38 · PDF · 1 page · 338 KB9-A systems group chair's factual reportItem 39 · PDF · 31 pages · 2 photos · 1.5 MB9-B systems factual report attachment 1Item 40 · PDF · 50 pages · 49 photos · 169 MB9-C systems factual report attachment 2Item 41 · XLSX · 21 KB9-D systems factual report attachment 3Item 42 · XLSX · 19 KB9-E Boeing 737-7/8/8200/9/10 aircraft maintenance manual part I a�� system description section a�� mid cabin exit door plug temporary revision 52- 1001Item 43 · PDF · 4 pages · 1.1 MBSystems group - party representative formsItem 44 · PDF · 3 pages · 532 KB10-A flight data recorder - specialist's factual reportItem 45 · PDF · 27 pages · 15 photos · 6.5 MB10-B flight data recorder - specialist's factual report - ATTACHMENT1 - FDR tabular dataItem 46 · CSV · 6.8 MB10-C flight data recorder - specialist's factual report - ATTACHMENT2 - qar tabular dataItem 47 · CSV · 2.1 MB10-D flight data recorder - specialist's factual report - ATTACHMENT3 - FDR tabular dataItem 48 · CSV · 26.6 MB10-E flight data recorder - specialist's factual report - ATTACHMENT4 - qar tabular dataItem 49 · CSV · 8.2 MB10-F flight data recorder - specialist's factual report - ATTACHMENT5 - FDR tabular dataItem 50 · CSV · 104 MB10-G flight data recorder - specialist's factual report - ATTACHMENT6 - qar tabular dataItem 51 · CSV · 28.0 MB11-A manufacturing records and human performance factual reportItem 52 · PDF · 57 pages · 1.7 MBManufacturing records and human performance factual report addendumItem 53 · PDF · 31 pages · 2.2 MB11-B manufacturing records and human performance attachment 1 - ncr N1450292531 and nco 145-8789-rshk-1296-002NCItem 54 · PDF · 21 pages · 822 KB11-C manufacturing records and human performance attachment 2 - ncr N1450293199 and nco 145-8789-rgen-rshk-001NCItem 55 · PDF · 17 pages · 852 KB11-D manufacturing records and human performance attachment 3 - shipside action tracker (sat) 4650723Item 56 · PDF · 7 pages · 871 KB11-E manufacturing records and human performance attachment 4 - previous med plug removalsItem 57 · PDF · 3 pages · 343 KB11-F manufacturing records and human performance attachment 5 - Boeing quality alert 2023-0056-ARItem 58 · PDF · 3 pages · 1.2 MB11-G manufacturing records and human performance attachment 6 - bca qms document control excerptItem 59 · PDF · 5 pages · 2.1 MB11-H manufacturing records and human performance attachment 7 - bca qms supplier control excerptItem 60 · PDF · 5 pages · 2.4 MB
All 102 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.