The new finding from federal investigators comes one month and a day after the January 5 incident that triggered a 19-day emergency grounding of all Max 9s, and re-ignited scrutiny of Boeing following the fatal Max 8 crashes of 2018 and 2019.
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Boeing acknowledged its responsibility for the blowout in a statement issued after the NTSB report and said it is working to make sure incidents like this do not reoccur.
"Whatever final conclusions are reached, Boeing is accountable for what happened," said Boeing CEO Dave Calhoun in a statement. "An event like this must not happen on an airplane that leaves our factory. We simply must do better for our customers and their passengers."
Boeing said it was taking new actions to improve the way it makes the 737 Max 9 planes. That includes more inspections, giving the 737 teams more time "to focus on and implement quality improvements," and bringing in outside safety experts to assess its operations.
Evidence points to missing bolts
In their 19-page preliminary report released Tuesday, NTSB investigators included observations from a laboratory disassembly of Alaska 1282's door plug, which fell 16,000 feet into an Oregon backyard. It said the lack of damage to the plug where the bolts were supposed to attach it to the fuselage of the plane pointed to the conclusion that the bolts were missing at the time of the flight.
"Overall, the observed damage patterns and absence of contact damage or deformation around holes associated with the vertical movement arrestor bolts and upper guide track bolts in the upper guide fittings, hinge fittings, and recovered aft lower hinge guide fitting indicate that the four bolts that prevent upward movement of the MED plug were missing before the MED (mid exit door) plug moved upward off the stop pads," the report said referring to the mid exit door.
The report included a photo taken in September, more than a month before the plane was delivered to Alaska Air, that show the bolts missing during work on the aircraft, taken from a text message between two Boeing employees obtained by NTSB investigators. It means that the plane flew for a couple of months before the January 5 blowout with the bolts missing.
RELATED: Alaska, United Airlines say loose bolts found on Boeing Max 9s during inspections after door blowout
The report was only the preliminary finding and did not assess blame or cause of the incident. That could come in a final report that could be more than a year away.
In a statement, the Federal Aviation Administration said Wednesday: "This incident should have never happened and it cannot happen again. The FAA is continuing to support the National Transportation Safety Board's investigation into the Jan. 5 door plug incident."
The NTSB is in charge of the investigation and will provide any updates.
A bigger problem than one incident
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The fact that no one was sitting in the seat next to the gaping hole that appeared in the side of the plane is a key reason there was not a fatality on the flight.
Six crew and 171 passengers were on board the flight, which returned safely to Portland International Airport. Nobody was seriously hurt in the incident.
The missing bolts are apparently not the only problem. Both Alaska Airlines and United Airlines said last month that inspections of their fleets that took place after the January 5 incident revealed loose bolts.
"This is a somewhat complex issue with a lot of parts," NTSB Chair Jennifer Homendy told CNN in the week leading up to the release of the preliminary report. Even still, Homendy stressed that she "would have no problem getting on a Max 9 tomorrow and flying."
Boeing's history of quality lapses
The release of the report comes as Boeing's quality control is under intense scrutiny. During a House subcommittee hearing Tuesday, FAA Administrator Mike Whitaker said there are now two dozen FAA inspectors on location at Boeing's Renton, Washington plant as part of an agency audit.
Late Sunday, Boeing disclosed that it would need to "rework" improperly drilled holes discovered on 50 incomplete 737 Max planes still on the production line, causing a slowdown in deliveries.
Later, Boeing fuselage contractor Spirit AeroSystems said it had caused that more recent problem.
A Spirit spokesman said the company is working on "continuous improvement."
"As we review the NTSB's preliminary report, we remain focused on working closely with Boeing and our regulators on continuous improvement in our processes and meeting the highest standards of safety, quality and reliability," spokesman Joe Buccino said in a statement.
What happened onboard
The report also details the shock of the blowout, which caught passengers and crew by surprise.
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"The captain said that, while climbing through about 16,000 ft, there was a loud bang," the report said.
"The flight crew said their ears popped, and the captain said his head was pushed into the heads-up display (HUD) and his headset was pushed up, nearly falling off his head. The FO (first officer) said her headset was completely removed due to the rapid outflow of air from the flight deck."
CNN has reported that NTSB investigators have been closely scrutinizing the door plug and whether crucial bolts that hold it in place were properly installed when the incident occurred.
FAA is involved in the probe
Meanwhile, the head of the Federal Aviation Administration told House lawmakers Tuesday that his agency is "closely scrutinizing" Boeing after last month's door plug blowout.
"Going forward, we will have more boots on the ground closely scrutinizing and monitoring production and manufacturing activities," FAA Administrator Mike Whitaker said in prepared remarks.
The Federal Aviation Administration failed to properly scrutinize Boeing after two fatal crashes of 737 Max aircraft killed 346 people more than four years ago, the agency's new chief said.
"I wasn't there at the time as you noted. I guess I would say in retrospect and given what happened with the plug door, it's hard to call that oversight sufficient," Whitaker told Congress on Tuesday. "So, we're looking at that process and what additional steps need to be taken to make sure that oversight is sufficient."
Whitaker was sworn in late last year and was not at the FAA at the time of those crashes in 2018 and 2019. He was previously the second-ranking FAA official from 2013 to 2016. Whitaker appeared before the House aviation subcommittee, his first congressional testimony since being confirmed to the post little more than three months ago.
His agency is currently overhauling how it scrutinizes plane manufacturers, including Boeing, after a hole blew open in the side of a 737 Max 9 last month.
"I certainly agree that the current system is not working cause it is not delivering safe aircraft," Whitaker said. "We have to make some changes to that. And I think we also have to look at the culture."
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