Boeing’s manufacturing woes long preceded door-panel blowout

By Ian Duncan and Lori Aratani / The Washington Post

Details that emerged from last week’s Boeing hearings have made at least one thing clear: The company’s manufacturing problems persisted for years despite many warning signs.

Hours of testimony over two days of National Transportation Safety Board sessions, along with thousands of pages of newly published documents, show that Boeing struggled with its 737 Max assembly process long before a midair blowout left a hole in the fuselage of an Alaska Airlines flight in January.

Transcripts of interviews with Boeing workers and federal inspectors indicate that the circumstances that led to the Alaska Airlines incident did not stem simply from a single failure to reinstall a door plug’s bolts, but also reflect a flawed system.

Instructions for some processes were so convoluted that even the head of quality control found them confusing. Supply-chain issues forced workarounds such as reusing engines to transfer planes. Employees feared harsh penalties such as being reassigned to work in a “cage” over perceived missteps.

“Is it just me or are we seeing a game of whack-a-mole every five to 10 years on safety?” said board member J. Todd Inman, referring to previous instances where Boeing pledged to address its shortcomings. “What do you think will be different this time?”

Here are some key takeaways from the NTSB hearings and accompanying documents.

Boeing’s problems are systemic

Boeing failed to ensure that removed parts were properly tracked, a topic that was the subject of repeated internal audits, employee complaints and FAA reviews.

FAA audits turned up examples where workers failed to follow Boeing’s written procedures. In some instances, federal inspectors said, the directions conflicted with what employees were taught during on-the-job training.

In one example, Boeing employees and FAA inspectors described the 50-plus pages of instructions for removing parts as long and confusing. The document had been revised 11 times since 2013, according to the NTSB, but never streamlined.

Even Elizabeth Lund, Boeing’s senior vice president for quality, struggled with it. “It was one of these things where I had to sort of go in a quiet room and read it to myself several times,” she told investigators.

The large number of removed parts in combination with burdensome instructions risked creating a conflict between what’s supposed to be done and what actually happens on the factory floor, said Katie Ringgold, a vice president for the 737 program.

“Our call to action is make it easy, make it clear, make it simple, and expect it and hold people accountable to it,” Ringgold said.

One FAA inspector believes Boeing is sincere in its desire to improve. But that inspector also doubted the company’s ability to actually do it.

“From what I’ve seen is Boeing is very willing to get these issues addressed,” the inspector told investigators. “The ‘able’ part I think is the one that’s in question because [of] the constant cycle of the repeated issues.”

Workers worry about speaking up

Aviation safety is built on the idea that people who make errors should be able to come forward without facing punishment so that problems can be fixed, an idea known as “just culture.” Despite a company policy that prohibits retaliation against employees who raise concerns, many workers say individuals are afraid to speak out or report safety concerns.

After the Alaska Airlines incident, two factory workers were shifted into jobs off the main production line. Lund described it as being transferred to a “lateral position.” The workers compared it to incarceration.

One of the reassigned workers told investigators in March that he had been put “literally in a jail, in a cage.”

“That’s where I’ve been the last 10 weeks and a half for eight hours a day,” he said.

It’s not clear that the workers were responsible for any of the problems that led up to the blowout. NTSB leaders during the hearing questioned the treatment of Boeing employees.

“What sort of impression does that give your employees if you sideline them?” asked NTSB Chair Jennifer Homendy.

Company executive Paul J. Wright said he was not directly involved in the situation but that good faith mistakes should be addressed without imposing punishment. But Lloyd Catlin, a representative of the factory workers union, said the tactic was commonplace.

“It sends a very clear message to the entire workforce,” Catlin said. “You mess up, you get moved.”

Production has seen repeated disruptions

According to a former FAA manager who spoke to investigators, when 737 Max production outpaced the engine supplier’s ability to meet demand five years ago, Boeing built planes without the engines and parked them at the factory until the missing components were available.

The factory ran out of space at one point. The solution? Fly extra planes to another facility, take the engines out and send them back on a truck for the next aircraft. “It was just ridiculous how bad it was,” the former manager said.

After two deadly crashes of 737 Max jets in 2018 and 2019, that model was grounded worldwide and aircraft piled up in storage. Production slowed and then the coronavirus pandemic took hold. The result, according to multiple witnesses, was a huge turnover in the company’s workforce.

Lund said employees the company hired as it tried to increase production in recent years often did not have previous aviation experience. One Boeing employee who leads production teams during the final stage of 737 Max assembly traced the problem to the company’s elimination of pensions for nonunion employees, which happened in the 2010s.

“A lot of the seasoned, experienced people retired when we got rid of our pension,” the employee told investigators. “Trying to retain or bring back that knowledge well … now we’re trying to build up our forces again, and I think that our past experiences still kind of haunt us.”

Boeing increased the amount of formal training new employees receive, enhanced on-the-job training and matched new workers with mentors, but managers said it’s not enough.

“We were hearing from the floor, particularly some of the experienced employees, these employees just don’t know enough coming out of training,” Lund said.

Checking on Boeing is hard

During the safety board’s two-day hearing, the FAA also faced questions about its oversight of Boeing, which increased following the Alaska Airlines accident.

But FAA officials told NTSB members that even as they ramp up their efforts to monitor Boeing, the complexity of its manufacturing system makes it hard to ensure that corrective actions solve problems at all facilities.

While inspectors said their relationship with Boeing was generally good, one FAA employee told NTSB investigators there were sometimes issues with access: “I don’t know if [it’s] my schedule, [but] just lately when we show up to do [an] audit and say you want to look at a specific thing, you are told ‘Oh, this is a non-workday’ and ‘They’re not working that job today,’ or ‘That’s only done on the second shift, or that’s done on the third shift.’”

One FAA inspector said he wished the agency had more people. “The biggest challenge about my job is just right now, the sheer amount of work at the plant,” the inspector told investigators. “It’s a juggling act.”

What’s next?

The NTSB’s final report on the Alaska Airlines blowout is expected to take a year to 18 months to complete.

As for Boeing, newly installed CEO Robert “Kelly” Ortberg sent a message to employees on Thursday, his first official day on the job, about the importance of restoring trust in the company’s work. “People’s lives depend on what we do every day and we must keep that top of mind with every decision we make,” he wrote.

Citing the importance of being close to production lines and the commercial airplane programs, Ortberg said he will be based in Seattle, rather than at Boeing’s corporate headquarters in Arlington, Virginia.

He already faces several urgent tasks. The company is awaiting word on whether a federal judge will sign off on the plea agreement it reached with the Justice Department in connection with fatal crashes of 737 Max jets that killed 346 people in 2018 and 2019. As part of the deal, Boeing has agreed to plead guilty to one felony fraud charge.

Meanwhile, the company is at odds with NASA over whether its Starliner spacecraft is safe enough to carry two astronauts back home from the International Space Station. Last week, the space agency said it might need to turn to Boeing rival SpaceX to help get the pair back home.

Boeing also is in negotiations with its largest labor union, the International Association of Machinists and Aerospace Workers District 751, whose contract expires in September. In July, union members, who play key roles in assembling and inspecting 737 Max and 777 aircraft, voted overwhelmingly to authorize a strike if their demands for higher wages and better working conditions are not met.

But Ortberg’s biggest task will be convincing federal regulators that Boeing can build safe airplanes so that limits on 737 Max production can be lifted.