The crashes of two Boeing 737 MAX aircraft that killed a total of 346 people were “a horrific culmination” of missteps by both Boeing and the U.S. Federal Aviation Administration (FAA), a U.S. House of Representatives committee report says.
The report, released Sept. 16 by Rep. Peter DeFazio (D-Oregon), chairman of the House Committee on Transportation and Infrastructure, and Rep. Rick Larsen (D-Washington), chairman of the panel’s Subcommittee on Aviation, describes a collection of “serious flaws and missteps in the design, development and certification” of the MAX, which entered commercial service in 2017.
The first of two fatal MAX accidents occurred the following year, on Oct. 29, 2018, when Lion Air Flight 610 crashed into the Java Sea after takeoff from Jakarta, Indonesia, killing all 189 passengers and crew. Five months later, on March 10, 2019, Ethiopian Airlines Flight 302 crashed after takeoff from Addis Ababa, Ethiopia, killing all 157 occupants.
MAX aircraft were subsequently grounded globally, and Boeing has since been working to correct problems that were blamed for the accidents. It is seeking FAA re-certification of the aircraft by the end of this year, and has expressed confidence it will receive the FAA’s stamp of approval.
However, regulators around the world have said they will not merely follow FAA’s lead and will determine for themselves whether the MAX is ready to return to service. The European Aviation Safety Agency (EASA) announced last week that it had completed 737 MAX test flights out of Vancouver, citing COVID-19 restrictions for why the test flights occurred in Canada instead of the U.S. The approval of the EASA and other global regulators will go a long way in deciding whether the MAX can return to service around the world in 2021.
After the issuance of House report, the FAA released the following statement. “The FAA is committed to continually advancing aviation safety and looks forward to working with the Committee to implement improvements identified in its report. We are already undertaking important initiatives based on what we have learned from our own internal reviews as well as independent reviews of the Lion Air and Ethiopian Airlines accidents. These initiatives are focused on advancing overall aviation safety by improving our organization, processes, and culture. Last month, the FAA published a notice of proposed rulemaking (NPRM) for an airworthiness directive (AD) that will mandate a number of design changes to the 737 MAX before it returns to passenger service. The FAA continues to follow a thorough process, not a prescribed timeline, for returning the aircraft to service.”
The committee report and associated documents, compiled by Democratic staff members, describe “serious flaws and missteps in the design, development and certification of the aircraft.”
The report says the two crashes were “a horrific culmination of a series of faulty technical assumptions by Boeing’s engineers, a lack of transparency on the part of Boeing’s management and grossly insufficient oversight by the FAA.”
After the House report was released, Boeing issued the following response. “Boeing cooperated fully and extensively with the Committee’s inquiry since it began in early 2019. We have been hard at work strengthening our safety culture and rebuilding trust with our customers, regulators, and the flying public. The passengers and crew on board Lion Air Flight 610 and Ethiopian Airlines Flight 302, as well as their loved ones, continue to be in our thoughts and prayers.
“Multiple committees, experts, and governmental authorities have examined issues related to the MAX, and we have incorporated many of their recommendations, as well as the results of our own internal reviews, into the 737 MAX and the overall airplane design process. The revised design of the MAX has received intensive internal and regulatory review, including more than 375,000 engineering and test hours and 1,300 test flights. Once the FAA and other regulators have determined the MAX can safely return to service, it will be one of the most thoroughly scrutinized aircraft in history, and we have full confidence in its safety. We have also taken steps to bolster safety across our company, consulting outside experts and learning from best practices in other industries. We have set up a new safety organization to enhance and standardize safety practices, restructured our engineering organization to give engineers a stronger voice and a more direct line to share concerns with top management, created a permanent Aerospace Safety Committee of our Board of Directors as well as expanded the role of the Safety Promotion Center.
“We have learned many hard lessons as a company from the accidents of Lion Air Flight 610 and Ethiopian Airlines Flight 302, and from the mistakes we have made. As this report recognizes, we have made fundamental changes to our company as a result, and continue to look for ways to improve. Change is always hard and requires daily commitment, but we as a company are dedicated to doing the work.”
Report’s Five Themes
The House committee report focuses on five central themes, including the “tremendous financial pressure” on Boeing to cut costs and maintain the 737 MAX production schedule to ensure that the MAX would be ready to compete with the new Airbus A320neo.
The report also cited Boeing’s faulty assumptions about MAX technologies, especially the maneuvering characteristics augmentation system (MCAS), which contained software designed to automatically push the airplane’s nose down under specific conditions. The manufacturer “expected that pilots, who were largely unaware that MCAS existed, would be able to mitigate any potential malfunction,” the committee said.
In addition, the report faulted Boeing’s “culture of concealment,” and said that it withheld information on the MAX from the FAA, its customers and MAX pilots. Among the items withheld were test data that showed “it took a Boeing test pilot more than 10 seconds to diagnose and respond to uncommanded MCAS activation in a flight simulator, a condition the pilot described as ‘catastrophic,’” the committee said. Guidelines assume that a pilot should be able to respond within four seconds.
The committee also cited the FAA’s oversight structure, which creates “inherent conflicts of interest that have jeopardized the safety of the flying public.” The report documented a number of instances in which Boeing employees who were authorized to perform work on the FAA’s behalf did not notify the FAA about potential safety issues.
The committee criticized Boeing’s influence over the FAA oversight structure, singling out examples in which FAA management “overruled a determination of the FAA’s own technical experts at the behest of Boeing.” These examples are “consistent with results of a recent draft FAA employee ‘safety culture’ survey that showed many FAA employees believed its senior leaders are more concerned with helping industry achieve its goals and are not held accountable for safety-related decisions,” the committee said.
In releasing the report, DeFazio said, “What’s particularly infuriating is how Boeing and FAA both gambled with public safety in the critical time period between the two crashes. … [W]e are making this report public to put a spotlight not only on the broken safety culture at Boeing but also the gaps in the regulatory system at the FAA that allowed this fatally flawed plane into service.”