Boeing senior VP of quality says missing paperwork hindered door plug blowout investigation

Good morning. How are you? Welcome to Renton, WA. We are thrilled to have you here today. So I am incredibly honored and excited to kick off this morning's briefing with an update of our comprehensive safety and quality plan. I suspect all of you have heard about it and read about it. Most of you have probably read the executive summary that we released. And we are excited to take this chance to be able to talk about it a little bit, take Q&A, give you a little bit more insights and discuss our plan. So with that, we will jump in and get started. Next slide please. So I think it's important to understand the plan to briefly understand what happened on Flight 1282 on January 5th, Alaska flight 1282 in the accident. And so we won't spend a ton of time here, but I want to level set so that when we talk about the plan, you'll know where some of the context for the plan came from. So when the fuselage arrived for the airplane that later flew flight 1282, the fuselage came in from our supplier and when the fuselage came in, it was discovered upon load in the factory, initial load in the factory, that there were five non conforming rivets. These non conforming rivets in and of themselves did not create a safety hazard, but they were non conforming and they needed to be fixed. So a defect arrived from our supplier. The airplane then traveled throughout the factory. You'll see the line with Katie in a little bit. It moved to the end of the line while we discussed with our supplier back and forth. Are the rivets OK? Are they not OK? Do they need to be fixed? Can you fix them this way? No, you can't. And the airplane was at the end of line. By the time we all reached agreement that the rivets needed to be removed and replaced at the end of line, we reached the point where we had a what we believe is a non compliance to our process. In order to remove and replace these rivets, the mid exit door plug needed to be opened in order to get access to drill out the rivets, replace them and we believe that plug was opened without the correct paperwork. You guys have read about it. It was referenced in the NTSB report which is up there. So we believe there was a non compliance to our processes at that point by having the plug opened without the correct documentation and paperwork. There was documentation and paperwork on the actual rivets. Those got removed and replaced. That was stamped off. That was appropriate. But by the time all of that got bought off and we were ready to go, the airplane was ready to move outside. We have a team that we call the move crew. Before an airplane rolls out of the factory on line, move night, they come in and they just button the airplane up for the weather. They close the doors. In this case, they closed the plug. They ensure that any open holes on the airplane are covered so that it's in good condition to go out in the weather. We believe the move crew. We know the move crew closed plug. They did not reinstall the retaining pins. That is not their job. Their job is to just close it and they count on existing paperwork. The paperwork goes with the airplane. All of the jobs are worked. Any open job gets worked later in the process. And in this case, because we believe the paperwork was never created, there was no open paperwork that traveled with the airplane. This actually is a photo of the actual airplane that you're working here. Looking at here. The last step is what we call an OK to close. And for an OK to close, typically people come in and look for really fought. Is everything clean? Are we good to go? This was the picture that was taken during the OK to close. You can see three out of the four locations. We can see there are no pins in there. After that, we were given the OK to close. The blankets came down and at that point it was not visible. The the plug has a little bit of an interference fit. That's how it was able to fly for roughly 150 cycles without being identified. That's how it passed our flight test because it's a, it's a snug fit, but not a not a permanent fit. So that's what happened. A defect entered our system from our supply chain. The defect traveled throughout our final assembly and then there was a lack of compliance to our processes by the correct documentation, using the correct documentation. And that's the background of what happened and that will feed the rest of our system and the rest of our processes in our proposal. Next chart please.