National Transportation Safety Board Chair Jennifer Homendy said Tuesday that the heroic actions of the crew aboard Alaska Airlines flight 1282 ensured everyone survived the terrifying incident last year when a door plug panel flew off the plane shortly after takeoff in January 2024.

Homendy said “the crew shouldn’t have had to be heroes, because this accident never should have happened.”

She noted that it wouldn’t have if Boeing and the Federal Aviation Administration had done enough to ensure the safety of the Boeing 737 Max plane.

An NTSB investigation over the past 17 months found that bolts securing what is known as the door plug panel were removed and never replaced during a repair. And the board found bigger problems too.

“An accident like this only happens when there are multiple system failures,” Homendy said.

She said Boeing’s new CEO, Kelly Ortberg, has made many safety improvements since taking the job last summer, but more needs to be done.

The blowout aboard Alaska Airlines flight 1282 occurred minutes after it took off from Portland, Oregon, and created a roaring air vacuum that sucked objects out of the cabin and scattered them on the ground below along with debris from the fuselage. Seven passengers and one flight attended sustained minor injuries, but no one was killed. Pilots were able to land the plane safely back at the airport.

The accident occurred as the plane flew at 16,000 feet. The Boeing 737 Max 9 was about halfway to its cruising altitude and traveling at more than 400 mph when passengers described a loud boom and wind so strong it ripped the shirt off someone’s back.

The 2-foot-by-4-foot fuselage panel covering an inoperative emergency exit behind the left wing had blown out. Only seven seats on the flight were unoccupied, including the two seats closest to the opening.

The panel that blew off was made and installed by a supplier, Spirit AeroSystems. It was removed at a Boeing factory so workers could repair damaged rivets, but bolts that help secure the door plug were not replaced. It’s not clear who removed the panel.

The NTSB said in a preliminary report that four bolts were not replaced after a repair job in a Boeing factory, but the company has said the work was not documented.

Investigators determined the door plug was gradually moving upward over the 154 flights prior to this incident before it ultimately flew off.

Boeing factory workers told NTSB investigators they felt pressured to work too fast and were asked to perform jobs they weren’t qualified for, including opening and closing the door plug on the particular plane involved. Only one of the 24 people on the door team had ever removed one of these plugs before and that person was on vacation when it was done on the plane.

A Boeing door installer told investigators everyone faced pressure to keep the assembly line moving.