Final report on Alaska Airlines Flight 1282 in-flight exit door plug separation

> We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled.

A bit OT, but what a gorgeous whale of a sentence! As always, the literary prowess of NTSB writers does not disappoint.

Looking forward to the length of the sentence the NTSB uses for Air India flight 171. Gonna be a doozy

AKA Boeing did not train, guide or oversee its people well → Workers skipped the process meant to keep track of bolts and hardware → The bolts for the mid-exit door were never put back → At 14K feet, the door blew free.

At school (Polish class in Poland) we were always taught to prefer complex and compound sentences over simple ones, because it's more elegant and speaks well the speaker/writer.

Reading aviation-related NTSB final reports is kind of a hobby of mine, and I must say, the NTSB is generally a treasure! Sure, you can find issues with some of their investigations, roads they might not have probed down as far as they could, but their culture of root causing and transparently reporting should be emulated across the government. I really hope they don't fall victim to the casual, random destruction our current administration is inflicting on broad swaths of the government.

Wouldn't it be the Indian authorities who issue a report?

Same happening in Hispanic school systems could explain the sentences in some of the Spanish Wikipedia articles.

It doesn't, though. It's pretentious and educated people will see through it. If the goal is to inform, then you should do the opposite.

The current aims of the executive branch are neither casual nor random, and I doubt the NTSB is in their crosshairs.

The goals are both obvious and specific; it’s a culture war being fought at the funding level.

Also, I really appreciate the way they put blame where it belongs. They don't say "manufacturing personnel failed to ...", they say "Boeing failed to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly ...".

Yes, but as the country of manufacture of the incident aircraft, NTSB is absolutely consulting on that report.

There is the culture war but don't ignore the dealmaking and profiteering. This can create the appearance of randomness because any entity can appeal to the executive for favor.

Sounds like in this case either Boeing didn't donate enough or, more likely, nobody wants to f with airliner safety.

Well that’s one source (of many) where the problem is coming from.

i imagine the language may change that though. With Polish having nominally 300k-400k words compared to English's >1m, i'd guess that it's a lot easier to misdirect and fluff up your writing in English.

They know their business. The goal is safety, not punishment. Blaming workers is great if you're after revenge or a scapegoat, but generally doesn't improve safety.

This sentence isn't written for elegance but for meaning. The formal cause of the accident was the mechanical separation, but that happened for a reason, either mechanical failure (which means a failure in the engineering of the aircraft, which would have to be remedied by new engineering processes) or an assembly failure (which would have to be remedied by new assembly processes). In one sentence, the author drills down to exactly what went wrong that enabled the accident to happen. Identifying that is the first step to remedying it.

"or, more likely, nobody wants to f with airliner safety"

If that would be more likely, Boeing wouldn't be, where it is.

To me it seems more likely Boeing has now too much attention on them, making fraud here even more dangerous/expensive.

Agreed about properly assigning the root cause to inadequate training but the sentence was unnecessarily complex in not making the first order cause clear until the end. I'd prefer stating up front that the first order cause was "securing bolts and hardware that were removed to facilitate rework" were not reinstalled - and then stating the root cause leading to that being inadequate training.

In the context of a summary I just expect the core sentence to take events in order from the headline failure ("in-flight exit door plug separation") and then work back to the root cause.

Right, Alaska didn't buy an aeroplane from "manufacturing personnel" they bought it from Boeing. If Boeing don't want to sell aeroplanes that's cool, bye-bye Boeing, but if they want to sell aeroplanes then it's their responsibility to ensure those planes are safe and it cannot somehow be a transferable responsibility.

My favorite NTSB-ism is "controlled flight into terrain", which means "crashed". This is as opposed to "uncontrolled flight into terrain", which means "fell from the sky".

In the end - action matters. Somebody didn’t put the bolts back in.

Yes - zooming out it important and ultimately where actionable remediation can be applied - but blame is due where blame is due: somebody fucked up at work and it almost brought down a plane.

Only if you're using technical writing in a situation where you shouldn't be.

Problem is the state of most English education doesn't even teach enough for people to recognize proper unambiguous technical writing, let alone appreciate it or attempt to compose it.

Reading NTSB reports themselves isn't for me, but I really enjoy reading this blog that does excellent write-ups of past plane crashes. It's really well written, easy to follow, and fascinating: https://admiralcloudberg.medium.com

Modern safety analysis acknowledges that humans are fallible, and they are generally acting in a good faith way to try and do their jobs correctly within a given system they are operating in.

That's why these reports tend to suggest corrective actions to the parts of the system that didn't work properly. Even in a perfectly functioning safety culture, an employee can make a mistake and forget to install the bolts. A functioning safety system has safeguards in place to ensure that mistake is found and corrected.

A culture war on poor people who need Medicaid? That doesn’t seem like class war to you?

> We determined that the probable cause of this accident was the in-flight separation of the left MED plug

I find this very strangely worded. It was an "incident", not an "accident"; and "the in-flight separation of the left MED plug" was the incident, not the cause of a non-existent accident.

The actual cause of the incident (as determined by the NTSB) is what follows all that unnecessary verbage.

In the end, identifying where you can usefully take action to reduce the chances of something similar happen in the future is far more useful than assigning blame.

Assigning blame is often the antithesis of safety.

In aviation and other safety-critical fields, we use a just culture approach — not to avoid accountability, but to ensure that learning and prevention come first.

https://en.wikipedia.org/wiki/Just_culture

Super underrated point - and one that I am not sure the general public always keeps top-of-mind, as human imperfection should be the default assumption. The whole system of air travel is designed so that wherever possible, multiple f*ck-ups can occur and not result in a catastrophe. The success of people involved with anything touching on aviation safety is best measured as in "how many f*ck-ups can occur in the same episode and have everyone still walk away alive?" If you can get that number up to 3, 4 complete idiotic screw-ups one after the other, and the people still live, you've really achieved something great.

I think CFIT is appropriate. There’s loads of cases where pilots flew into a mountain due to lack of environmental awareness. Here’s a bizarre example: https://admiralcloudberg.medium.com/lost-and-confused-the-cr...

Both result in a crash – the first due to pilot error, the second due to mechanical failure.

Yes! It's basically better to take all screw-up(s) and make their recurrence the assumption. 'Given people will forget to replace bolts how can we best make it so the plane cannot exit the factory without the bolts in place?'

Physics question: why do I know (maybe wrongly) that in flight the doors are sealed shut by the difference in pressure ? And if so, why did it not work in this case ?

There's a reason why Murphy's Law is so commonly acknowledged, though. When you've got a process like this that gets repeated over and over by a bunch of different people, you simply must recognize that that, if it's possible for someone to fuck up, then somebody will fuck up.

And a relatively straightforward corollary of that reality is that, when somebody fucks up, putting too much personal blame on them is pointless. If it weren't them, it would have been somebody else.

In other words, this "blame is due where blame is due" framing is mostly useful as a cop-out excuse that helps incompetent managers who've been skimping on quality controls and failsafes to shift the blame away from where it really belongs.

I don't know the answer for this specific case, but the pressure is high on the inside and low on the outside. If you have a hinted door that opens inward, then pressure will keep it shut. If you install the door wrong and forget to attach the hinge properly, it could be blown outward.

> They don't say "manufacturing personnel failed to ...", they say "Boeing failed to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly ...".

Doesn't this mean it should happen a lot more?

Can you point out what aspects of the bill relating to Medicaid are most concerning? I don't just mean the DNC talking points, but rather specific provisions. When I read through the actual provisions[1] they are far less scary than what I hear being used as DNC fundraising fodder. For instance, I can't just show up in the UK without any legal status and automatically have all free healthcare from the NHS[2]. But the provisions removing federal tax money support to provide free healthcare to the undocumented is one of the things being pointed to by opponents of the bill as being especially evil. If you feel that way, why is the US the only country that ought to do that?

[1] https://www.kff.org/tracking-the-medicaid-provisions-in-the-...

[2] https://www.nhs.uk/nhs-services/visiting-or-moving-to-englan...

If I remember right: during the checks before they were allowed to fly again after being grounded after this incident, multiple operators found issues with the bolts for these door plugs on their planes.

It’s a bit more nuanced than that. CFIT is intended to classify accidents where the aircraft itself was not causal. In any other case, it is assumed that there were mechanical or other aircraft-related factors that were contributory or causal.

This is absolutely incorrect. It runs counter to every high functioning safety culture I've ever encountered.

The system allowed the human to take the incorrect action. If your intern destroys your prod database, it's because you failed to restrict access to the prod database. The remediation to "my intern is capable of destroying my prod database" is not "fire the intern" it's "restrict access to the prod db".

Even the best trained humans will make errors. They will make errors stochastically. Your systemic safety checks will guard against those errors becoming problems. If your safety culture requires all humans to be flawless 100% of the time, your safety culture sucks.

So no, this isn't a fault with a human. Because this was a possible error, it was inevitable that at some point a human would make that error. Because humans never operate without errors for extended periods of time.

It seems pretty clearly describing a state + an outcome.

"(pilot control state) flight into (outcome of flight)"

One of those pieces of jargon that feels silly until you go, "Oh, actually, this makes a lot of sense when you deconstruct it."

> There's a reason why Murphy's Law is so commonly acknowledged, though.

In particular, the original formulation of Murphy's Law. The folk version has morphed into "anything that can go wrong, will go wrong". But the original was "If there are two or more ways to do something and one of those results in a catastrophe, then someone will do it that way".

The work requirements force people to file paperwork proving 80 hours of work monthly, and Arkansas showed this paperwork maze caused 18,000+ people to lose coverage even though 95% already met the requirements or qualified for exemptions. Arkansas spent $26.1 million just on administration with no increase in employment, and Georgia has spent over $40 million with 80% going to bureaucracy, not healthcare.

For rural hospitals, the bill cuts $58 billion in Medicaid funding over 10 years but only provides a $25 billion rural fund that covers less than half the losses. This puts 300+ rural hospitals at immediate risk of closure since they're already operating on thin margins.

For elderly people, the bill blocks nursing home staffing rules until 2034 and freezes home equity limits at $1 million permanently, plus adds more verification requirements.

The evidence shows these aren't about efficiency. They're about creating barriers that cost more money to administer than they save, while cutting care for people who already qualify.

Could've been worse. In Korean schools they somehow find the worst, most meandering and pointless examples of English prose and shove them at poor students at exam time to test their "English comprehension" skills, when any reasonable native speaker would've said "Who the fuck writes like this?"

don't all doors open outwards on airplanes ?

These investigations are about identifying root causes, not assigning blame.

Others already said it but since I'm the person you responded to, I'll reiterate that my suggestion was only about reordering the sequence of that sentence for better clarity, not about placing blame on individuals over process. When a failure can cause serious consequences including killing people, proper system design should never even permit a single point of failure to exist, especially one relying on humans to always perform correctly and completely. Even well-trained, highly-conscientious humans can make a mistake. While these people should have received better training as well as comprehensive sequential checklists, a good system design will have critical failure points such as this each verified and signed off by a separate inspector.

The problem with a culture which prioritizes "blame is due where blame is due" is it can cause people to not report near-misses and other gaps as well as cover-up actual mistakes. The shift in the U.S. from blaming (and penalizing) occasional pilot lapses to a more 'blameless' default mode was controversial but has now clearly demonstrated that it nets better overall safety.

Have you read Donald Norman's Design of Everyday Things?

Call it “ideological” instead of “culture” if you prefer. The goal is the same — defund the opposition.

Yes and, IMHO: docs, procedures, checklists, etc. strive to mitigate the challenge of assumed knowledge. It's a wicked hard problem.

It's a legitimate distinction, "they were in control" and "they weren't in control". If the pilots are on a collision course with a mountain, but are happily sitting there thinking they're going the other way, there's nothing wrong with the plane, and the pilots are in control of the plane. In contrast to a horizontal stabilizer failure, where the pilots aren't in control, and instead say their goodbyes for the cockpit voice recording.

Why frame it as ideological though? That doesn't explain which agencies get protected and which get cut. The NTSB stays funded because rich people fly on planes too. But Medicaid gets cut because wealthy people don't need it.

Look at weather service cuts. They're gutting the National Weather Service while Trump's appointees have ties to companies like AccuWeather and Satellogic that would profit from privatizing weather data.

It's about class interests. Agencies that serve everyone or that rich people depend on stay funded. Programs that only help poor people get cut, or get privatized to benefit specific wealthy interests. Make the wealthy better off through tax cuts and new business opportunities, make poor people worse off through service cuts.

Why can't people without disabilities or dependents work 20 hours a week?

CFIT is not necessarily pilot error. For example, if ATC vectored a plane without ground proximity warnings into the side of a mountain, that would also be CFIT.

It's not about whether they can work 20 hours. Most already do. Arkansas found 95% of people either met the requirements or qualified for exemptions, but 18,000+ still lost coverage due to the paperwork maze.

The requirements are designed to create barriers through bureaucracy. You have to report every month through a specific online portal, track your hours precisely, navigate exemption processes. Miss one monthly filing deadline and you lose healthcare. It's the most socially acceptable way to kick people off coverage without saying "we don't want poor people to have healthcare."

And it's not just work requirements. The bill also adds income verification twice a year instead of once, more asset checks, and cuts the actual funding. Each new hoop is another chance for eligible people to fall through the cracks. The goal is reducing enrollment through administrative friction, not promoting work.

English has over 1 million words? No way. Except for pronunciation, it is relatively simple language.

The reporting requirements don’t seem particularly onerous.

It’s on those individuals to not “fall through the cracks” if they truly need our money to fund their healthcare — I don’t see the problem.

"Identify and publicly anounce" vs "assign blame", what's the difference?

The cuts seem to be about defunding work around climate change.

You're right that a lot of the NOAA cuts target climate research specifically. But think about who benefits from attacking climate science. Oil companies and existing wealth structures that profit from fossil fuels. Climate research threatens those business models, so gutting it protects those interests.

The cuts go way beyond climate though. They're cutting 107,000 federal jobs across agencies while defense spending increases 13%. Framing this as ideological makes it sound like an abstract battle of ideas, but it's not abstract at all. Real people are losing health insurance, real hospitals are closing, real communities are losing weather warnings. Meanwhile wealthy people get tax cuts and connected companies get business opportunities. It's about material interests, not ideology.

What's the point of making requirements even stricter if they cost more to administer than they save and don't increase employment? The Congressional Budget Office estimates 5.2 million people would lose coverage by 2034, with savings primarily coming from eligible people losing coverage due to paperwork barriers rather than increased employment.[1]

The new bill allows states to verify monthly instead of every three months, so people lose coverage faster. Even working people get tripped up because 43% of workers would fail to meet 80 hours in at least one month due to variable schedules common in low-wage jobs.[2] People with multiple jobs have to submit paystubs from each employer monthly. Seasonal workers and food service workers are especially vulnerable because their hours swing wildly due to factors beyond their control.

[1] https://ccf.georgetown.edu/2025/05/27/medicaid-and-chip-cuts...

[2] https://www.cbpp.org/research/health/medicaid-work-requireme...

The cost of government subsidies isn’t in just the subsidies or the administrative overhead alone. It’s in training people to rely on the government, in effectively subsidizing employers that pay less than a living wage, etc.

You're right that Medicaid subsidizes employers who pay poverty wages rely on taxpayers to provide healthcare for their workers instead of paying living wages themselves. But the solution isn't to eliminate Medicaid and leave workers with nothing. The solution is to raise the minimum wage or have universal healthcare so employers actually have to provide real benefits.

Most Medicaid recipients already work. They're not choosing dependency, they're working jobs that don't pay enough to afford healthcare. Taking away their healthcare doesn't suddenly make employers pay more, it just leaves workers desperate, which is exactly what those employers want.

You're essentially arguing we should eliminate the safety net that keeps our low-wage economy functioning. That would either force employers to pay living wages (unlikely) or create mass suffering among workers (more likely). Which outcome are you hoping for? Because right now it sounds like you'd rather have sick, desperate workers than challenge the employers who created this system.

It's not pretentious and there's nothing to see through here. This is the preferred style in Poland and it's widely used, especially by the educated people. Just because the sentences aren't simple, doesn't mean they're not informative.

Also, we were taught to prefer compound and complex sentences over simple ones where applicable, not at all costs. For instance, the quoted sentence from NTSB report is a bit too long in my opinion.

It can if you count all the different forms of each word and proper nouns. But this way Polish may have even more words than english, given multitude of different forms. I've never checked that, though.

There's also the tendency in English to make new words out of existing ones to create new meanings, while in Polish we often use multiple separate existing words to create new meanings.

All in all, I believe English has more base forms than Polish.

It has words of both Germanic and Latin origin, that's why it has so many. The fancy words are usually the Latin ones.

You could write the same thing using multiple sentences no problem, without affecting the meaning.

What problem? To make sentences like the one from NTSB report quoted here? Well, personally I would've split it and I'm pretty sure my teacher would've asked me to do it too if I were the author. ;)

I remember an anecdote from my English teacher where a student went to London, and a taxi driver told her (the student) something along "What a lovely English! It's a shame nobody speaks like that anymore." ;)

That's true for fusional languages. English isn't one.

The problem of writing to look smart rather than communicate vital information.

> the sentence was unnecessarily complex

I don’t see it that way. It’s designed for consumption by educated readers. A press release can dumb it down to middle-school reading level so the media can dumb it down to grade-school level for the masses.

Identify root causes so they can be prevented or mitigated in the future.

vs.

Figure out who to sue.

How come? A more fusional language is one where a single word can carry more forms of information where English would need more words (e.g. "my book"). This isn't directly related to how much information you should put in a sentence. OTOH, all languages are recursive which means you can construct arbitrarily long sentences - but you shouldn't, because human cognition has its limits.

In my experience as a speaker of a more fusional language, the sentences are shorter than in English, not longer.

"a complex writing style preferred by educated people" - how is that not pretentious?

You started by saying complex sentences should always be preferred, but now you ended by saying "only where applicable" and the sentence under discussion was "too long".

How about like this? "We determined the accident's probable cause: The in-flight separation of the left MED plug happened because Boeing had failed to provide adequate training, guidance, and oversight. These would have been necessary to ensure that manufacturing personnel could consistently and correctly comply with Boeing's parts removal process. The securing bolts and hardware had been removed during manufacturing to facilitate rework, and the process intended to document and ensure proper reinstallation."

> Most Medicaid recipients already work.

And most who don't can't. You included them earlier but they're worthy to keep in mind.

> "a complex writing style preferred by educated people"

This is not a quote of me. Nor is it an honest summary of what I wrote. It also completely ignores the context: the "educated people" were supposed to "see through" - the same people who predominantly prefer the same style. I have also never claimed the style is not used by other people. Quite the opposite. Not to mention, that education until 18 years of age is mandatory in Poland anyway.

> how is that not pretentious?

The straw man you made up definitely is.

> You started by saying complex sentences should always be preferred

I wrote that we were always taught to prefer one over another (there were multiple teachers along the way), not that we were taught to always prefer one over another.

> but now you ended by saying "only where applicable"

There is no "but now".

> and the sentence under discussion was "too long".

I believe it is indeed.

This is not about "writing to look smart". It's about using elegant style and using the language to it's full potential. There were multiple attempts to strip Polish people of their mother tongue and identity throughout the history, so we were taught to treasure both and use language's full richness. It's also simply nicer to listen to or read richer forms. These are the reasons for why we were told it speaks well of the speaker/writer. Also, elegance does not contradict communicating vital information. It's a false dilemma.

> saying "we don't want poor people to have healthcare."

I don't really think it's about 'poor people' at all. I think most people agree with me that poor people who do their best deserve plenty of help.

From ABC News: "Pew found that around half of Americans would favor creating work requirements for Medicaid, with 32% opposed." [1]

Polling shows (and Trump's popular vote victory also suggests, arguably) that American voters largely are not in favor of freeloaders who don't work and rely on government benefits paid for by those who do work. Given that this country still operates on democratic principles, it's a democratic move to give those voters what they want, even if it isn't the most efficient. I think if you asked those voters why, they'd say that they're concerned that training people to expect a welfare program to pay for you without you having any obligation back is bad for us as a society, and could encourage more and more 'dropping out' leaving a larger burden for those who work, who our society does need to keep working.

If you want universal healthcare, tell the DNC to run on a platform that includes that instead of running a terrible candidate and a bunch of culture-war stuff that's deeply unpopular with moderates. Or abandon that worthless party and start one that can win.

[1] https://www.msn.com/en-us/news/politics/polls-show-americans...

Seasonal workers are explicitly protected in the final bill as long as their average amount of work makes sense, so that argument is out.

Also, this "verify monthly" sounds like fearmongering. All I see is "requires individuals who are enrolled meet requirements for 1 or more months between the most recent eligibility redeterminations (at least twice per year)." Also: "Requires states to conduct eligibility redeterminations at least every 6 months for Medicaid expansion adults."

The Medicaid expansion is not everyone on Medicaid, just a subset who before expansion were presumed not to be entitled to a government subsidy since they don't have any dependents or any disability and could just work.

I do think it's probably not the worst thing if people who have no dependents or disability are motivated to go get a full-time job because it's kind of a hassle to have to prove eligibility.

The DNC is now advocating that taxpayers not only must pay for all the healthcare of people who don't want to work at all, but we also need to make it a maximally convenient experience. The reason Democrats keep losing elections is that they can't read the room -- most people who work and are not upper-middle-class levels of comfort don't like the emphasis on maximizing the comfort and convenience of groups like the voluntarily unemployed and undocumented immigrants when it comes at the expense of working taxpayers who follow the rules. This is why the Big Beautiful Bill passed: It actually throws a bone to people who work via things like tax breaks on overtime pay and tips, and via restoring the SALT exemption. Between these 3 policies, you can see a benefit to people across the wealth spectrum who share one thing in common: people who work hard. I know the Dems are still doing fine in rich areas, but there are two problems which are intertwined:

1. There aren't enough of those rich Democrats who just want to open the tax money spigot, the ones who wouldn't mind paying an extra $30,000 in taxes next year to put their money where their mouth is.

2. Even when there are enough to win, the rest of the population still pays most of the actual tax dollars and they are increasingly resentful of what they see as rich Democrats helping themselves (via the government) to everybody's money to bestow as favors on people who don't seem to need it. I know your heart is in the right place, but the policies are not connecting with the people, as evidenced by the fact that the Democrats keep losing ground among the non-wealthy working demographic (which, in the Democrat narrative, ought to be their strongest base).

Note: I certainly don't agree with everything in the "OBBB," but there are some good ideas in there.