House Democrats issued a sharply worded report revealing new details of how the combination of
design errors, lax government oversight and lack of transparency by the plane maker and regulators set the stage for two fatal 737 MAX crashes.
The 238-page document, written by the majority staff of the House Transportation Committee, calls into question whether the plane maker or the Federal Aviation Administration has fully incorporated essential safety lessons, despite a global grounding of the MAX fleet since March 2019.
After an 18-month investigation, the report, released Wednesday, concludes that Boeing’s travails stemmed partly from a reluctance to admit mistakes and “point to a company culture that is in serious need of a safety reset.”
“We have learned many hard lessons as a company from the accidents of Lion Air Flight 610 and Ethiopian Flight 302, and from the mistakes we have made,” Boeing said in a written response to the report, referring to the two fatal MAX crashes. The Chicago-based aerospace giant added: “We have been hard at work strengthening our safety culture and rebuilding trust with our customers, regulators, and the flying public.”
The findings released Wednesday also questioned whether pending changes inside the FAA would be sufficient to end what the report describes as fundamentally inadequate government reviews of new aircraft designs. Engineering and management errors on the MAX, according to the report, reflect a flawed approval process in which agency managers often undercut the authority of lower-level FAA engineers, giving industry undue influence over the process.
More on Boeing
- Former Top Boeing 737 MAX Officials Defend Design Process (Sept. 12, 2020)
- Congressional Report Faults Boeing on MAX Design, FAA for Lax Oversight (March 6, 2020)
- Boeing Employees Flagged Concerns About 737 MAX, Production Pressures (Oct. 30, 2019)
- ‘Why Is This Airplane Still Flying?’ The FAA Missteps That Kept Boeing’s MAX Aloft (Oct. 28, 2019)
- The Four-Second Catastrophe: How Boeing Doomed the 737 MAX (Aug. 16, 2019)
The report blames “grossly insufficient oversight by the FAA,” leaving the agency unable to appropriately meet its responsibilities and ensure passenger safety.
Rep. Peter DeFazio, the Oregon Democrat who is the committee’s chairman, said the 737 MAX saga highlights the need for major changes to U.S. air-safety regulation. “The problem is: It was compliant and not safe, and people died,” Mr. DeFazio said of the aircraft in a press briefing Tuesday. “Obviously, the system is inadequate.”
Responding to the report, the FAA said it is “committed to continually advancing aviation safety and looks forward to working with the committee to implement improvements identified in its report,” adding that voluntary initiatives already are under way based on lessons learned. The statement added that its focus is on “improving our organization, processes and culture.” The agency reiterated that it has mandated design changes to the MAX and “continues to follow a thorough process, not a prescribed timeline, for returning the aircraft to service.”
The report provides more specifics, in sometimes-blistering language, backing up preliminary findings the panel’s Democrats released six months ago, which laid out a pattern of mistakes and missed opportunities to correct them. Misfires of an automated flight-control system, called MCAS, overpowered pilots and led to two MAX crashes in less than five months that took 346 lives.
Fresh details in the report, however, show that various Boeing employees recognized and repeatedly flagged some of those hazards years before the FAA in 2017 certified the MAX as safe to carry passengers, though their warnings failed to prompt high-priority reviews by either the company or the agency.
Republican staffers participated in some interviews, including with two high-ranking Boeing executives who defended the plane maker’s design process. But none of the panel’s GOP members signed off on the report.
Senior Republicans on the committee disputed the Democrats’ call for an overhaul of U.S. aircraft certification, dismissing the report as partisan. “Expert recommendations have already led to changes and reforms, with more to come,” they said in a statement setting the stage for debate over an air-safety bill the committee’s Democrats are expected to introduce in coming weeks.
In one section, the Democrats’ report faults Boeing for what it calls “inconceivable and inexcusable” actions to withhold crucial information from airlines about one cockpit-warning system, related to but not part of MCAS, that didn’t operate as required on 80% of MAX jets. Other portions highlight instances when Boeing officials, acting in their capacity as designated FAA representatives, part of a widely used system of delegating oversight authority to company employees, failed to alert agency managers about various safety matters.
The longest portion of the document details previously undisclosed safety concerns raised inside Boeing by lower-level employees about the design and vulnerabilities of MCAS itself, concluding those questions “were inadequately resolved or dismissed.”
In June of 2016, about a year before the FAA certified the MAX’s safety, a Boeing engineer sent a colleague an email that referred to a company test pilot’s difficulty leveling the plane’s nose due to repetitive MCAS activations.
After the engineer questioned whether the pilot’s maneuvering difficulty amounted to a safety issue, the colleague responded it didn’t, but noted that in such a situation, pilots could “find themselves in a large mistrim,” meaning the plane’s nose could be sharply pointed down. That was exactly the scenario that played out in each MAX crash, with cockpit crews unable to regain control after the planes’ noses were forced downward by repeated, erroneous MCAS activations.
In another exchange, a Boeing employee asked how MCAS would react to faulty sensor data—which accident investigators would later identify as a precipitating factor in both fatal crashes—but the issue was dismissed by a colleague.
The report said the internal Boeing design concerns weren’t sufficiently resolved or addressed.
The House panel also highlighted internal Boeing documents spanning 2015 to 2018 that noted a company test pilot’s finding that a slow reaction to an MCAS misfire—one taking longer than 10 seconds—could result in catastrophe.
The report said several Boeing employees working on behalf of the FAA didn’t share the test pilot’s finding with the agency. Boeing has said it relied on industrywide safety principles to assume pilots would be able to respond appropriately to an MCAS misfire in four seconds.
In its statement responding to the report, Boeing highlighted steps it has taken in the wake of the MAX saga, which has cost it billions of dollars, on top of lost revenue and a drop in stock-market value, and significantly damaged its reputation. “We have made fundamental changes to our company,” Boeing said, noting “change is always hard and requires commitment” and adding it is dedicated to doing that work.
Delving into the period between the two crashes, the report said both the FAA and Boeing “seemed more intent on justifying their previous mistakes than in fully confronting the safety issues.” And committee investigators presented a picture of the FAA’s safety chief, Ali Bahrami, as divorced from day-to-day concerns about the MAX. According to the report, Mr. Bahrami told the investigators in an interview that he hadn’t seen Boeing’s bulletin reminding pilots of an emergency procedure days after the first MAX accident in October 2018.
Mr. Bahrami also told House staffers he wasn’t familiar with an internal FAA risk assessment after the first crash, which projected 15 more fatal crashes over the decadeslong lifetime of the MAX fleet if Boeing didn’t add safeguards to MCAS, the report said.
“I’m not familiar with the details of it,” Mr. Bahrami told the committee’s investigators in a December 2019 interview, according to the report. Mr. Bahrami acknowledged he decided fixes to MCAS could wait while the plane kept flying, because he and other FAA officials believed pilots would be able to intervene to avoid a crash. Echoing Boeing’s initial defense of its MCAS design after the first crash, the FAA official said “pilots are part of the system, and we rely on pilots to do certain things.”
The transcript of Mr. Bahrami’s interview with House investigators shows he said he didn’t recall any conversations with Boeing counterparts in the nearly five months between the two accidents. The report, however, cites emails showing he scheduled a call with a high-ranking Boeing executive to discuss the crash in Indonesia, though it wasn’t clear to the committee’s investigators whether the conversation took place. The FAA had no specific comment on Mr. Bahrami’s testimony.
But in a message sent to FAA staff Tuesday, which was reviewed by The Wall Street Journal, Mr. Bahrami alerted them to the House panel’s findings. “While the report is critical of both Boeing and the FAA, it offers valuable insights into how we can improve,” according to the message. After reiterating agency initiatives he supports, Mr. Bahrami’s message also urged employees to “work together to further enhance our safety processes.”
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