A report released Wednesday on a U.S. congressional committee’s investigation into the 737 Max lambasted the manufacturer and the Federal Aviation Administration for a series of engineering lapses, management missteps, and oversight failures leading to the twin crashes that killed 346 people.
The report concluded that the crashes—the first involving a Lion Air Max 8 in October 2018 and the second an Ethiopian Airlines Max 8 in March 2019—did not result from a singular failure, technical mistake, or mismanaged event, but rather 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.
Issued by the House Transportation and Infrastructure Committee, the 238-page report revealed “multiple missed opportunities that could have turned the trajectory of the Max’s design and development toward a safer course” due to flawed technical design criteria, faulty assumptions about pilot response times, and production pressures.
“The FAA also missed its own opportunities to change the direction of the 737 Max based on its aviation safety mission,” said the report. “Boeing failed in its design and development of the Max, and the FAA failed in its oversight of Boeing and its certification of the aircraft.”
The conclusion of faulty design assumptions on the part of Boeing centered on the airplane’s Maneuvering Characteristics Augmentation System (MCAS) and its intent to activate based on readings from a single angle of attack (AOA) sensor. Boeing incorrectly assumed that pilots, largely unaware of the system, would be able to overcome any malfunction, said the report. It also failed to classify MCAS as a safety-critical system, which would have drawn further scrutiny from the FAA during the certification process. Finally, the report said that operation of MCAS violated Boeing’s own internal design guidelines calling for no “objectionable interaction with the piloting of the airplane” and neglected the principle that it “not interfere with dive recovery.”
In supporting its claims of a culture of concealment, the report said Boeing withheld crucial information from the FAA, its customers, and 737 Max pilots in several critical instances, including the very existence of MCAS. It also concluded that the company failed to disclose that the AOA disagree alert did not operate on some 80 percent of the 737 Max fleet, despite its certification as a standard aircraft feature. Meanwhile, Boeing concealed internal test data that revealed it took a company test pilot more than 10 seconds to diagnose and respond to uncommanded MCAS activation in a flight simulator. “While it was not required to share this information with the FAA or Boeing customers, it is inconceivable and inexcusable that Boeing withheld this information from them,” said the report. “It also argues strongly for a disclosure requirement. Federal guidelines assume pilots will respond to this condition within four seconds.”
The committee also found “inherent conflicts of interest” between Boeing and the FAA that jeopardized safety and documented several cases in which Boeing authorized representatives (ARs) failed to disclose information to the FAA that could have enhanced the safety of the Max. In some instances, a Boeing AR raised concerns internally in 2016 but did not relay them to the FAA, and the concerns failed to result in adequate design changes, said the report. The committee cited as “core contributing factors” to the crash the company’s failure to address the issues raised by the AR, including concerns about repetitive MCAS activation and the effects of faulty AOA data on the system.
Finally, the report cited documentation by “multiple career FAA officials” of cases where FAA management overruled a determination of the agency’s own technical experts at the behest of Boeing.
“In these cases, FAA technical and safety experts determined that certain Boeing design approaches on its transport category aircraft were potentially unsafe and failed to comply with FAA regulations, only to have FAA management overrule them and side with Boeing instead,” concluded the report. “These incidents have had a detrimental impact on the morale of FAA’s technical and subject matter experts that compromises the integrity and independence of the FAA’s oversight abilities and the safety of airline passengers.”
For its part, Boeing noted the report’s acknowledgment that since the accidents, the company has instituted several organizational and process changes to advance its safety culture, including creating a permanent safety committee within its board of directors, forming a product and services safety organization to review all aspects of product safety, and realigning its engineering function to require direct reporting to the chief engineer.
“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,” said Boeing in a statement. “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.”