Two views emerged of the pilots and flight attendants on Alaska Airlines Flight 1282, the 737 Max that made an emergency return to Portland International Airport eighteen months ago. As the plane ascended to about 15-thousand feet headed for California, an improperly installed door plug in the cabin blew out with a sudden bang, followed by a cacophony of wind and deafening noise.

In their description of the events on the evening of January 5, 2024, the National Transportation Safety Board described the two pilots and the four cabin attendants in near-heroic terms, praising their professionalism and care for the 171 terrified passengers, including 4 unaccompanied children, the youngest, just six years old.

“I’m terribly impressed by the crews’ excellent work to get the airplane safely on the ground,” said board member Thomas Chapman.  “The flight attendants made sure (the passengers) were secured and used portable oxygen to check on the minors, a great example of how they ensure safety in an emergency.”

On the lengthy list of safety recommendations emerging from the NTSB’s Tuesday hearing into the near disaster are several that highlight just how many hurdles the crew had to overcome.

Photo for illustration only. Not from Alaska Airlines flight.

As the plane lost pressurization, it triggered the automatic opening of the normally locked door to the flight deck. This alarmed the pilots, coming immediately after the unexplained boom of the depressurization. They were unaware that the door was designed to function this way. They may have wondered if an attempt to breach the cockpit was underway.

Their concern had to be heightened because they did not know what was going on in the cabin. A persistent squeal in their headphones made it impossible to communicate with the flight attendants. The pilots could not activate the microphones in their oxygen masks because in the 737 Max, the mics operated differently than in the earlier version of the 737.

Cabin attendants were having their own difficulties amid the unrelenting noise. Some passengers could not reach the drop-down oxygen masks which are set farther apart in the 737 Max. Then, two crew members with portable oxygen masks that enabled them to move about untethered, tried to attend to the children, but they could not open the portable oxygen bottles, which were sealed in plastic.

“The crew shouldn’t have had to be heroes,” NTSB Chair Jennifer Homendy said in reviewing all that went on and explaining the safety recommendations made by the board that call for “hands-on, aircraft-specific training and procedures for the use of each type of oxygen system in an operator’s fleet.” The Federal Aviation Administration also needs to “review the design standards for portable oxygen bottles to ensure that they adequately address ease of use,” the NTSB explained in a summary of its actions.

The 737 Max that flew as Flight 1282 left the Boeing assembly plant in Renton, Washington with the hidden door plug unbolted and unsecured. It came free after the plane took off from Portland, triggering an event that traumatized everyone on board, passengers and flight crew members alike.

The gaping deficiencies in Boeing manufacturing and FAA oversight have been the subject of much-deserved attention and now, dozens of safety recommendations you can read about here.

But stay with me as I keep the focus on the “what happened” to Flight 1282, not the “why it happened” because the lurking threat of loss of cabin pressure is much larger than you know. It is a contributing factor in at least a dozen air accidents and incidents each year.

A loss of cabin pressure can come on in a way that is dramatic and fraught, as it did with Alaska Airlines flight 1218. Other times, the onset is deceptively benign. The lack of oxygen to the brain at higher altitudes, called hypoxia, starves the mind, leading to deadly pairing; a loss of cognitive function and a feeling of well-being.

This is what happened in 2005. Two pilots in command of a Boeing 737 flying from Cyprus to Athens failed to notice the pressurization system was not set correctly. As the plane ascended and the altitude in the cabin passed 18-thousand feet, the oxygen masks dropped. While the passengers likely put on their masks, neither pilot did, instead trying to diagnose the problem as the plane continued to climb. Both fell unconscious

Despite a last-minute attempt to save the day by a flight attendant who was also a student pilot, all 121 aboard died when the plane ran out of fuel and hit a mountain near Athens. (Read more here.)

Loss of aircraft pressurization occurs somewhere in the world more than once a month, leading to emergency landings at best or injuries and deaths. A few are highlighted below.

An emergency descent over the Pacific by an All Nippon Airlines Dreamliner in 2019.

A near collision during an emergency descent over the Swiss Alps between a Ryanair 737 and another airliner in 2012.

Pilots of a Swedish airline failed to pressurize the RJ Avro 100 aircraft on takeoff in 2007 and did not become aware of it until after the passenger oxygen masks activated. The situation got worse when 20 of the mask compartments failed to open, leaving passengers at risk of hypoxia at 19-thousand feet.

A Viking Airlines 737 flight from Sharm el-Sheik to the UK declared a Mayday when it lost pressurization and diverted to Vienna in 2010.

In 2008, the crew of  Qantas 747 declared a Mayday over the Pacific near the Philippines when one of the emergency oxygen cylinders burst, blowing a hole in the fuselage and triggering a rapid loss of cabin pressurization.

The captain of a SpiceJet 737 operating in India temporarily lost consciousness after failing to put on his oxygen mask. Investigators found the pilots did not respond correctly to a failure alert from the automatic pressurisation system and inadvertently depressurized the airplane at 36-thousand feet.

So you can see that when a plane loses pressure, pilots may struggle, encountering tremendous stress, sometimes on a plane that is new to them and facing the possibility of an oxygen-depleted mind when they need every brain cell to be firing at one hundred percent.

Away from the stress of the moment, and on an airplane with which this Airbus test pilot was thoroughly familiar, the procedure looks like this.

That it so often does not, has captured the attention of safety specialists. In a conference room slightly less than 500 feet above sea level the fully oxygenated members of the safety board have made their position clear. The worst time to make things complicated for flight crews is when the air is thin and every second counts.