Maybe it doesn't matter if a better design is possible - if adequate procedures exist and weren't followed, and oversight fails to catch instances of that, then anything could go wrong.
Every critical step should be as "idiot-proof" as possible, until better idiots are created who hammer structural parts into position to meet management-mandated arbitrary deadlines.
> The fix also includes adding lanyards atop the door-plug bolts to “permanently secure the bolts to the plug” and “provide a visual indication”, says Crookshanks. “They’ll hang there and be visible to a mechanic that had taken the bolts out.”
[1] https://www.flightglobal.com/safety/details-emerge-about-boe...
It sounds like Boeing is currently working on designing and certifying a design enhancement to the MED plug to make it obvious if one is not closed properly. Not sure where to find the details on it though.
"To the Federal Aviation Administration:" " Once you complete the certification of Boeing Commercial Airplanes’ design enhancement for ensuring the complete closure of Boeing 737 mid exit door (MED) plugs following opening or removal, issue an airworthiness directive to require that all in-service MED plug-equipped airplanes be retrofitted with the design enhancement. (A-25-15)"
This article: https://aerospaceglobalnews.com/news/boeing-completes-design..., suggests that the design enhancement will add "secondary retention devices" that "prevent installation of the cabin sidewall panels unless they are properly engaged." The article indicates that the existing bolts will also get lanyards that will "'permanently secure the bolts to the plug' and provide a visual indication' of whether they have been installed correctly."
Apparently, if only one of the four bolts was installed, it may have been sufficient to prevent the accident, according to: https://www.nytimes.com/2025/06/24/us/politics/boeing-alaska...
Given their nature the original intent was probably that they were secured at the factory and never touched. But because they are convenient for access during maintenance/inspection they get used more often.
This issue, the oxygen mask, and the child restraint issue are the NTSB doing the proper "what if things had been slightly different" calculation.
Airline maintenance removes and reinstalls these doors. They could accidentally commit the same error so Boeing should change the design such that the door will not stay in-place when the bolts are removed. Could be as simple as springs that force the plug open without the bolts. If the door won't stay closed without the bolts like a light switch it will be forced to clearly show when it is safe vs not.
Child restraints were mentioned partially because if a lap child had been in that row they'd have been sucked out by the decompression and free-fallen 14000 ft. It was entirely luck that it didn't happen.
Oxygen masks mentioned because the pilots had some trouble getting them on in a timely manner. If the incident had been sudden onset of thick toxic smoke one or both could have passed out before getting the mask on and oxygen flowing. That's like a fire extinguisher with a complicated pin mechanism. Adrenaline dump during emergencies ruins fine motor control, critical thinking, etc. The worst possible time to have something be fiddly and complicated. You want it to be muscle memory. So trivial a 5 year old child could do it without being taught.
And the CVR issue is just the NTSB mentioning that yet again for like the 100th time the CVR circuit breaker was not pulled so we lost the recording and any potential learnings to be had from examining them. This is a problem that just keeps happening over and over. Because it relies on pilots, after a huge emergency, to remember to pull a circuit breaker when they have a thousand far more important things to worry about (not to mention coming down from the adrenaline high) and the thing only keeps the last two hours... which was a standard set when they were continuous loops of wire before the switch to magnetic tape. All the new ones are little computers and flash chips.
Pinpoint "seems reasonable" changes like that without regard for the whole system of interactions are what sank Thresher.
The "sudden onset of thick toxic smoke" is rare. It's either not that toxic or the onset isn't that sudden. You can't just design the system based on assumptions of needing to cover a rare corner case without taking a look at the whole general thing and the frequency of various anomalies and crunching the numbers to see if you're not actually making it worse. I agree that the masks should be simple and reflexive but you absolutely could compromise the whole system if you prioritize reflexive over other attributes without actually taking a full stack look at the tradeoffs in all areas. Aircraft manufactures employ people to think about this stuff and they're frequently why "seems reasonable" changes don't get made.
Specifically in this case, that factory being Spirit Aerosystems in Wichita where the 737 fuselage is manufactured. Part of the problem here is that Boeing in Renton didn't have processes for removing the MED when necessary on the final assembly line (in this case to rework rivets near the door). Without processes, there was one senior guy on the door team who taught himself how to do it, this was only needed a few times a year, but he was on vacation when this airframe needed the MED removed. Someone else did it (the NTSB couldn't determine who), the work wasn't tracked, and a separate team (the team literally sealing it up so it could be moved outside) put the MED back in but didn't install the bolts (which were gone).
That sort of thing is also one of the legitimate reasons the FAA can have for not adopting an NTSB recommendation. Requiring a seat for small children is one of those calculations. The FAA ran the numbers and assumed some portion of those parents wouldn't fly and of that portion some would drive. Some portion of flights are for physical or emotional health that would not be handled (you can calculate the increase in suicides from things like missing a loved one's dying moments). And of course driving is way way more lethal. So you have to weigh the deaths from not flying plus deaths from driving against deaths avoided if lap children were prohibited.
[1] https://en.wikipedia.org/wiki/Proton-M#Notable_launch_failur...
Clearly, relying on people to do this after the incident doesn't work, but.. shouldn't this be in like the post-incident checklist?
Either a checklist for the pilot, or an incident manager... there's got to be a list of things to do, and pull the breaker on the recorder isn't going to be high on the list, but I would think it would be on it.
Hammering structural parts which don't want to go is hard work and if your workers have union protection you can bet they'll say "No". So what you need are strong union protections so that they feel able to say "No" when asked to do unreasonable things. Does that mean they're going to be a little harder to manage? Maybe, but mostly it means "Rule by fear" doesn't work and leadership might need to learn to inspire not threaten.
Union protections help in one place you're already familiar with. If your pilot says "No, I don't like those clouds at all" and won't fly, the airline can't fire them for that. That's their judgement, if you fire pilots who you feel aren't risking passengers necks to make the line go up you're not going to have any pilots at all.
Historically it helped for traffic control, but that's OK our old friend, Cowboy Actor and Friend of the Working Billionaire, Ronald Reagan smashed that, so now traffic control has the shocking poor working conditions Corporate America loves.