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

Part of me wonders if the plug could be designed such that it's obvious when the bolts are missing. Would this have happened if it were impossible to assemble without them, or if it were easy to verify their presence?

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.

The plugs are designed to be semi-permanent because they are only for emergency exits on certain high-capacity seat layouts not used by most US airlines (or any airline that has first class seats I believe). When you have more seats you need more exits.

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.