A harshly worded preliminary congressional report Friday said Boeing’s development of the 737 MAX “was marred by technical design failures, lack of transparency with both regulators and customers, and efforts to obfuscate information about the operation of the aircraft.”
It also sharply criticized the oversight of the Federal Aviation Administration (FAA), calling its review of the MAX “grossly insufficient” and charging that the regulatory agency “failed in its duty to identify key safety problems and to ensure that they were adequately addressed during the certification process.”
“The combination of these problems doomed the Lion Air and Ethiopian Airlines flights,” said the preliminary investigative report by the staff of the Democratic majority on the U.S. House Committee on Transportation and Infrastructure.
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The report comes just days ahead of the one-year anniversary of the fatal crash of Ethiopian Airlines Flight 302 on March 10, 2019. That tragedy, following the Lion Air Flight 610 crash, brought the death toll to 346 people and led to the grounding of the MAX that is still in place.
The committee’s extensive investigation, which included interviews with Boeing whistleblowers and revelations of internal company documents, issued findings in five main areas. It concluded that:
- Extensive efforts at Boeing to cut costs, maintain the MAX program schedule, and not slow down the MAX production line undermined the safety of the jet.
- Faulty assumptions led Boeing to fail to classify new flight control software on the MAX called the Maneuvering Characteristics Augmentation System, or MCAS, as a safety-critical technology that demanded more scrutiny.
- In order to avoid greater FAA scrutiny and increased pilot training requirements, Boeing practiced a “culture of concealment” that withheld crucial information from the FAA, its airline customers, and pilots.
- Inherent conflicts of interest among authorized representatives of the FAA, who are Boeing employees authorized to perform certification work on behalf of the FAA, ” jeopardized the safety of the flying public.”
- Boeing’s influence over the FAA’s oversight resulted in FAA management rejecting safety concerns raised by the agency’s own technical experts at the behest of Boeing.
Boeing responded with a statement that it has “cooperated extensively for the past year with the Committee’s investigation” and that it will review the report.
The FAA in a statement said that “we are a learning agency and welcome the scrutiny.”
“The lessons learned from the investigations into the tragic accidents of Lion Air Flight 610 and Ethiopian Airlines Flight 302 will be a springboard to an even greater level of safety,” the statement added.
The ranking Republican members of the committee, Sam Graves, R-Mo., and Garret Graves, R-La., issued a statement Friday seeming to distance themselves from the report.
Citing various federal and international investigations into the crashes, they stated that “none of these expert reviews or investigations have come to the conclusion that our safety certification system is broken or in need of wholesale dismantlement.”
“We must ensure that we fix the problems that need to be fixed,” the Republican statement added.
Flawed design
The report criticizes the design of MCAS, finding that Boeing permitted the software to “rely on a single angle of attack (AOA) sensor for automatic activation, and assumed pilots, who were unaware of the system’s existence in most cases, would be able to mitigate any malfunction.”
“Partly based on those assumptions, Boeing failed to classify MCAS as a safety-critical system, which would have offered greater scrutiny during its certification,” the report adds. “The operation of MCAS also violated Boeing’s own internal design guidelines established during development.”
The report points out that though some Boeing engineers flagged potential safety problems with the design of the MAX flight controls, they were ignored.
“During development of the 737 MAX, Boeing engineers raised safety concerns about MCAS being tied to a single AOA sensor,” the report notes. “Another Boeing engineer raised concerns about not having a synthetic airspeed sensor on the 737 MAX.”
The latter is a reference to engineer Curtis Ewbank, who in an internal ethics complaint sent to Boeing headquarters in Chicago after the second crash documented his failed efforts in 2014 to add better safety controls on the MAX.
Aside from design mistakes, the report is also critical of how Boeing’s economic considerations affected the company’s transparency with the FAA, airlines and 737 MAX pilots regarding pilot training requirements.
“Boeing’s own analysis showed that if pilots took more than 10 seconds to identify and respond to a ‘stabilizer runaway’ condition caused by uncommanded MCAS activation the result could be catastrophic,” the report states.
This was discovered early on in the development of the 737 MAX program, and multiple Boeing authorized representatives “were aware of these findings and never reported them to the FAA.”
The House committee also concluded that “Boeing and the FAA gambled with the public’s safety in the aftermath of the Lion Air crash, resulting in the death of 157 more individuals on Ethiopian Airlines flight 302 less than five months later.”
In the aftermath of the Lion Air crash, the FAA conducted a risk assessment which calculated that without a fix to MCAS, during the lifetime of the 737 MAX fleet, there would be an estimated 15 more fatal, catastrophic accidents.
“However, the FAA permitted the 737 MAX to continue flying anyway while Boeing and the FAA worked on designing and validating a fix to the MCAS software,” the report states. “That judgment proved tragically wrong.”
The report calls for both congressional legislative reforms to improve FAA oversight of aviation safety, and action within Boeing to restore a culture that prioritizes safety over business considerations.
The development of a commercial jet “that is compliant with FAA regulations but fundamentally flawed and unsafe highlights an aviation oversight system in desperate need of repair,” the report concluded. “The fact that multiple technical design missteps or certification blunders were deemed ‘compliant’ by the FAA points to a critical need for legislative and regulatory reforms.”
“The FAA must develop a more aggressive certification and oversight structure to ensure safe aircraft designs and to regain the confidence of the flying public,” it adds.
Boeing, the report states, needs to “create and maintain an effective and vigorous safety culture.”
The report cites an internal Boeing survey conducted in 2016 at the height of the 737 MAX’s certification activities, which “found that 39% of Boeing employees that responded perceived ‘undue pressure’ and 29 percent were concerned about consequences if they reported potential undue pressure.”
The report interprets this as “painting a disturbing picture of cultural issues at Boeing that can undermine safety and oversight.”
“We hope these preliminary findings will help pave the way for legislative reforms as the committee’s investigation continues,” the report states.
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