The FAA blamed Boeing for a deficient safety culture in a 50-page report issued on Monday following a public outcry over several safety lapses before the January 5 incident in which a door plug “blew out” from an Alaska Airlines 737 Max 9 in mid-flight.

In a review of the employment culture at the company, an expert panel found what it called gaps in Boeing’s safety journey and that a majority of employees did not show “skillful awareness” of the concepts of just culture and reporting culture.

The panel further reported that it could not find a “consistent and clear” safety reporting channel or process within the business unit. It also noted that employees do not understand how to use the different reporting systems and which reporting system to use and when. The panel expressed concern that the confusion might discourage employees from reporting what they see as safety problems.

The report concluded that, although Boeing previously provided a roadmap to implement an Organization Designation Authorization (ODA) and safety management systems (SMS), the airframer still hadn’t completed the changes described in the roadmap.

The report recommended that Boeing develop an action plan that includes a “milestone-based” approach to address each recommendation and share the results with the FAA.