National Transportation Safety Board (NTSB) Chair Jennifer Homendy on March 6 testified that Boeing failed to provide access to key protocols, documents and personnel necessary for NTSB’s investigation into the cause of the Jan. 5 Boeing 737 MAX-9 door plug incident, Homendy provided testimony during a Senate Committee on Commerce, Science and Transportation hearing on NTSB’s ongoing investigations.
In response, Boeing issued this statement on March 6:
“We have deep respect for the NTSB and the critical role they play in aviation safety. Since the first moments following the Alaska Airlines Flight 1282 accident, we have worked proactively and transparently to fully support the NTSB’s investigation. Our team works tirelessly with the NTSB team to respond comprehensively to all NTSB information requests and bring information to them that would be relevant to their investigation. Early in the investigation, we provided the NTSB with names of Boeing employees, including door specialists, who we believed would have relevant information. We have now provided the full list of individuals on the 737 door team, in response to a recent request. With respect to documentation, if the door plug removal was undocumented there would be no documentation to share. We will continue to cooperate fully and transparently with the NTSB’s investigation.”
After the hearing titled “National Transportation Safety Board Investigations Report,” U.S. Sen. Maria Cantwell, D-Washington, who chairs the committee, had sent a letter to Boeing CEO Dave Calhoun, demanding that the company provide NTSB with the requested information – including documentation of the door plug removal and reinstallation, and the names of the 25 persons assigned to the door plug team – within 48 hours.
“…every shift is documented, you know the workers that were involved in this particular area, you can get their names, you can ask for interviews with those individuals. And you're saying that that hasn't happened?” Cantwell asked Homendy during the hearing.
“We have gone through emails, we've gone through texts, we've looked at pictures to begin to get a picture of the date in mid-September, the two dates in mid-September that we believe the work occurred,” Homendy responded. “We haven't received that information directly from Boeing. We also believe we know what shift it occurred on. But we still -- there is one team … that deals with the doors, of 25 people. Why we don't have those names today, two months later, is really disappointing.”
“Well, it's beyond disappointing,” Cantwell said. “We have an entire economy that depends on people getting this right. And I thought that the CEO said that they would cooperate to the fullest. So, it seems like this information is now stymieing your investigation, and it seems that it's knowable, and that you should at least be able to talk to the individuals there.”
In her letter to Calhoun, Cantwell wrote if Boeing cannot provide the investigative information to the NTSB within 48 hours, Boeing should provide a thorough explanation of why not within the same time period.
"We cannot delay the important work of federal safety investigators," Cantwell wrote.
Excerpts from Opening Statement by Cantwell
"...Serious questions remain unanswered about the door plug accident on Alaska Airlines Flight 1282. We need to be satisfied that manufacturers have strong quality controls and FAA oversight is robust.
"The FAA and manufacturers, in my opinion, should listen to machinists and professional engineers who are asking for a stronger safety culture to improve certification and production quality. And we need to do everything to make sure they are not intimidated on the job to just keep the line moving.
"Members have been briefed about the accident and this committee will continue to do its oversight role.
"On February 6, 2024, the NTSB released its preliminary report regarding the Flight 1282. I appreciate its prompt investigation of the accident and its preliminary findings. The committee continues to be concerned about the deficiencies in safety culture. I think probably also, articulated or illuminated by the individual report that was required by our ACSAA [Aircraft Certification, Safety, and Accountability Act] bill and was delivered just a few weeks ago.
"The report implies that the Boeing facilities have significant, now I’m saying your report, to be clear, implies that Boeing facilities may have significant deficiencies in record keeping and the investigation continues to determine what manufacturer documentations were used to authorize the opening and closing of the left mid-exit door plug during rework. In particular, we want to know about the disclosure of records that may show why or how it was improperly installed and what caused the accident 1282. Which raises questions that we’ll ask in the Q&A period, whether the documents even exist.
"These are important issues that we need to get to the bottom of. There are lots of people in the Northwest, not just those who work at Boeing, but those who are involved in an aviation culture around our state. We want to get this right."
Question and Answer Segment
Ranking Member U.S. Sen. Ted Cruz, R-Texas, asked how cooperative the parties to the investigation have been with the NTSB.
“Have you gotten timely access to the documents, the information and the witnesses you need?” he asked.
Homendy: “There are a number of parties to the investigation and some parties have been very cooperative. For example, the Federal Aviation Administration. Boeing has not provided us with the documents and information that we have requested numerous times over the past few months, specifically with respect to opening, closing and removal of the door and the team that does that work at the Renton facility [in the state of Washington]."
Cruz: “Wow. Are you telling us that even two months later you still do not know who actually opened the door plug?”
Homendy: "That’s correct, senator. We don’t know. And it’s not for lack of trying. It’s not unsual that we don’t get information immediately in an investigation. I can point to numerous investigations where this occurs and it takes months and months to get information. But for this one it’s two months later.
"We know for a fact that there is a team that deals with the doors in Renton. There’s an entire team of 25 people and a manager. The manager has been out on medical leave. We have not been able to interview that individual. We’ve asked for the names of the other 25 people, have not received the names.
"We’ve asked for the records with respect to what occurred. We’ve asked for what shift it occurred on. We think we know what days the work occurred on. But that’s only because of our investigators work looking at pictures in emails to try to get to the bottom of that information.
"We don’t have the records. We don’t have the names of the 25 people that is in charge of doing that work in that facility. It is absurd that two months later we don’t have that. Our investigators right now are at the Renton facility and they are conducting interviews... [from Sunday through the rest of the week].
"While we were out there, we investigated both the Spirit [AeroSystems] employees that did the work on the rivets. Well, we don’t know who did the work on the door plug. For the Spirit [AeroSystems] employees, we were just informed last week, they’re actually not Spirit [AeroSystems] employees, they’re contractors. They work for three different contracting firms: Aerotek, Strom Aviation and Launch, all three are in the state of Washington. All three people work for three different entities for Spirit [AeroSystems]. Those were not told to us by Spirit [AeroSystems]. That information was told to us through the individuals who were being interviewed that contacted us directly. We have engaged our attorney on this matter, just so you’re aware."
Cruz: "I will say that is utterly unacceptable and the parties who are being investigated by NTSB need to cooperate fully…”
Cruz asked Homendy to inform the committee in writing one week from March 6 as to whether or not Boeing has cooperated.
”I expect you to have that list of 25 names,” he said.
Homendy added it’s not just the 25 names. She said NTSB has repeatedly requested from Boeing the documentation that went along with the work of opening the door plug, closing the door plug or any sort of removal if that exists.
Cruz said, “Please include that as well.”
Cantwell: "Following on, the expert review panel found that Boeing employees are still afraid to speak up and report safety issues. There is a way for employees to speak directly to the FAA, is there a way for people to speak directly to NTSB to aid in this investigation?"
Homendy: "Yes, in fact, I received a whistleblower report myself. Anonymously, we received some information that I made sure our team has, it also went to our team. So, we do have a couple of ways. The best way is for people to reach out to us at the website of [email protected]. And we'll make sure to follow up on that information."
Cantwell: "Were you able to get from the company what specific procedures that they have for identifying, storing, protecting, retrieving, and retaining quality records? Were they forthcoming on that?"
Homendy: "We have not received that information."
Cantwell: "Does the fact that Boeing has not produced these documents or that NTSB investigators have not been able to retrieve them indicate that they do not exist or ever existed?"
Homendy: "They may not. There are two options. Either they exist, and we don't have them, or they do not exist, which raises two very different questions -- several different questions depending on which one is the right answer."
Cantwell: "If you don't have that documentation, what does it say about the quality assurance program?"
Homendy: "We have been told…. let me back up on that. We have been informed that they have a procedure to maintain documents on when work is performed, including when door plugs are open, closed or removed. We have not been able to verify that. And without that information that raises concerns about quality assurance, quality management, safety management systems within Boeing."
Cantwell: "So that's why I asked that first question about procedures for identifying, storing, and protecting. Everybody knows out at Boeing that the workers think that the plane will fly when the paperwork weighs more than the plane. That is their way of saying a lot of paperwork exists. People know that you don't move the line without paperwork. That's just part of the process. So, the question is, are you looking at those procedures, and you're saying they're not forthcoming, even on the procedures?"
Homendy: "That's correct. But we are looking at those procedures, we go very in depth and very broad. We'll look at the procedures, policies, we will also look at other work that was done around the same time or within the last several years to see if there are concerns with other work or records that may be missing. So we go in depth, and we are also going in depth on safety culture, safety promotion, safety management as a whole."
Cantwell: "Okay, and so is the FAA in there? [Are] aviation safety investigators helpful in this or not helpful?"
Homendy: "FAA has been very cooperative and very helpful to us in the investigation, and we appreciate them. They've been a partner throughout this from the very beginning."
Cantwell: "I'm saying do any of their aviation inspectors on site have data or information about what processes and procedures may have existed or didn't exist?"
Homendy: "That is something that I would like to follow up with our team and get back to you on."
Cantwell: "Okay. And then back to this point, every shift is documented, you know the workers that were involved in this particular area, you can get their names, you can ask for interviews with those individuals. And you're saying that that hasn't happened?"
Homendy: "Correct. We have gone through emails, we've gone through texts, we've looked at pictures to begin to get a picture of the date in mid-September, the two dates in mid-September that we believe the work occurred.
"We haven't received that information directly from Boeing. We also believe we know what shift it occurred on. But we still there is one team, one team that deals with the doors of 25 people. Why we don't have those names today, two months later, is really disappointing."
Cantwell: "Well, it's beyond disappointing. We have an entire economy that depends on people getting this right. And I thought that the CEO said that they would cooperate to the fullest. So, it seems like this information is now stymieing your investigation, and it seems that it's knowable, and that you should at least be able to talk to the individuals there.
"Do you have any concerns, there was a report about, there could be an additional, because there was a consent decree that was about to expire, that any kind of other investigation by Department of Justice would impact your investigation?"
Homendy: "I do have concerns, our attorneys also have concerns. Only from the aspect, we don't want to tell any other agency what they should or should not do. Where it becomes a concern for us - we'll get the information at some point.
"Where it becomes a concern for us is when employees and others don't feel safe to speak to us."
Cantwell: "Well, that is occurring now. And so, what do we need to do to make sure that people feel safe and secure? That's part of the expert report. It's part of why we passed ACSSA [Aircraft Certification, Safety, and Accountability Act] to make sure there was no retaliation. What else can we do?
"And we can't have a viewpoint that, 'I just had to keep the line moving.' That's not the viewpoint we want. We want employees who are saying, 'I have a concern about this,' to be listened to, and to be backed up by those FAA ASIs [aviation safety inspectors]. That's what we want. And so, in this case, we want to understand whether that kind of retaliation still exists, and what we can do to make sure that these people feel free to speak to you, and to others who are investigating."
Homendy: "I completely agree with that.
"The aviation industry is so safe because we do encourage, the industry has encouraged, anonymous reporting, and through anonymous reporting addressed risk proactively and encouraged employees to speak up. That's how we have addressed safety and gotten to our excellent gold standard safety record we are in today in the aviation industry. Without that there is a significant concern.
"I am aware of the concerns with Boeing, which is why we are delving into safety culture and safety management."
