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There it is, the probable answer to why the exit door plug on the Boeing 737 Max Alaska Airlines flight blew out in the air. A National Transportation Safety Board preliminary report on the incident, released today, says that four bolts on the door plug were missing.

Those four bolts, which prevent the door from sliding up, are removed on purpose when mechanics have to take the door off for maintenance or inspection, as was done last September, according to the report. But somehow, when the installation was over, they weren’t there. No bolts — nothing to stop the door from sliding up and then off.

Preliminary N.T.S.B. reports like this one focus on establishing facts rather than spelling out who was at fault, which will wait for the final report. But this plane was practically new, and the Boeing chief executive, David Calhoun, has already acknowledged that it was a “quality escape” that caused the blowout.

Everything so far indicates that Boeing is a company plagued by shoddy quality control. Just yesterday, it disclosed that a supplier had found “two holes may not have been drilled exactly to our requirements” on about 50 unfinished Boeing 737 Max planes, requiring more work on the planes and delaying their delivery.

How could all this happen?

This morning, before heading to Capitol Hill to testify before the House Transportation Committee, the F.A.A. administrator Mike Whitaker stopped by CNBC to discuss everything the agency has done to try to get ahead of this: slowing Boeing production lines, revoking certain exemptions, getting more inspectors on the ground, etc.

But he also said something that really goes to the heart of the matter. Pressed by the host about the root causes, Whitaker said, “The system is designed really as an audit system, and I think that hasn’t worked well enough.”

Our airline safety system assumes that airplane manufacturers are also deeply invested in upholding safety standards, so the F.A.A. oversight focuses on identifying new problems, improving existing systems and auditing to make sure existing standards are properly upheld.

What happens if a company instead focuses more on what it could get away with in terms of cost-cutting?

That’s how we get to a world where audits alone will not have “worked well enough.” The missing bolts may have caused the door to blow out, but it’s the missing corporate ethos that we should examine to understand the root cause.



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