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removals and its inadequate training of manufacturing personnel; Boeing's ineffective change management related to workforce experience level decreases; Boeing's ineffective corrective actions and the Federal Aviation Administration's (FAA) ineffective oversight that allOpen official document at PDF page 1NTSB AIR-25-04: In-Flight Separation of Left Mid Exit Door Plug, Alaska Airlines Flight 1282
Printed page label not indexed. PDF page 3.
Oversight Deficiencies................................ 92 2.4.1 Workforce Experience Change Management ........................................... 93 2.4.2 Persistence of Issues with Business Process Instruction “Remove Part or Assembly” ................................Open official document at PDF page 3NTSB AIR-25-04: In-Flight Separation of Left Mid Exit Door Plug, Alaska Airlines Flight 1282
Printed page 1. PDF page 15.
The term “depressurization,” which refers to a loss of cabin pressure, is used interchangeably with the term “decompression” in transport-category airplane regulations and Alaska Airlines' procedures. For consistency, this report uses the term “depressurization,” unlesOpen official document at PDF page 15NTSB AIR-25-04: In-Flight Separation of Left Mid Exit Door Plug, Alaska Airlines Flight 1282
Printed page 3. PDF page 17.
after the cabin pressure had dropped), and at 1713:56, the airplane's selected altitude changed from 23,000 ft to 10,000 ft. As the airplane descended, the cabin pressure increased.9 The first officer stated that she pushed the altitude warning horn cutoutOpen official document at PDF page 17NTSB AIR-25-04: In-Flight Separation of Left Mid Exit Door Plug, Alaska Airlines Flight 1282
Printed page 11. PDF page 25.
a cabin pressure controller; power loss; excessive cabin altitude or cabin altitude change rate (and the outflow valve is not in the correct position); or failures with the selector panel, wiring, or outflow valve components. According to the captain ofOpen official document at PDF page 25NTSB AIR-25-04: In-Flight Separation of Left Mid Exit Door Plug, Alaska Airlines Flight 1282
Printed page 18. PDF page 32.
pressurization control system adjusts the position of the outflow valve gates, which changes the rate of air released from the cabin. A flight crew can control cabin pressure using one of three modes: automatic, alternate, and manual. The cabin pressurizationOpen official document at PDF page 32NTSB AIR-25-04: In-Flight Separation of Left Mid Exit Door Plug, Alaska Airlines Flight 1282