The United States Congressional House Committee on Transportation and Infrastructure has released its final report on the two accidents involving Boeing 737 Max aircraft (Lion Air flight 610 in October 2018, and Ethiopian Airlines flight 302 in March 2019) that killed 346 people and led to the grounding of the aircraft worldwide.
The committee launched the investigation to ensure accountability, transparency and public safety. It is to be noted that further manufacturing defects have been identified, and the 737 Max remains grounded. The investigation took 18 months, concluding that Boeing failed in its design, and that the Federal Aviation Administration (FAA) failed in its oversight.
The committee found that: “The Max crashes were not the result of a singular failure, technical mistake, or mismanaged event. They were the 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 – the pernicious result of regulatory capture on the part of the FAA with respect to its responsibilities to perform robust oversight of Boeing and to ensure the safety of the flying public.”
Attempts to shift blame
Negative aspersions were made about the abilities of the pilots of the ill-fated flights, but the committee found that they were seasoned professionals.
Retired airline captain Chesley B ‘Sully’ Sullenberger III, who landed the US Airways flight on the Hudson River in 2009, saving all 155 people on board, summed it up in his testimony by pointing out that pilots should not have to “compensate for and overcome” inherent flaws in the design of aircraft.
Both flights used the new Manoeuvring Characteristics Augmentation System (MCAS) flight control feature that was developed to deal with stability issues, and which became central to the investigation.
The investigation into the design, development and certification of the 737 Max, and the FAA’s oversight of Boeing, identified and focused on five particular themes:
- Tremendous financial pressure placed on production;
- Faulty design and performance assumptions were made (most notably with regards to the MCAS software);
- Boeing withheld crucial information from the FAA, customers, and the 737 Max pilots (termed ‘culture of concealment’);
- Inherent conflicts of interest in the FAA’s current oversight structure with respect to Boeing; and
- Boeing exercised undue influence over the FAA’s oversight structure, which resulted in sub-standard certification practices.
The FAA failed to ensure the safety of the traveling public
The litany of failures includes the fear of retribution if employees reported safety issues; oversight capabilities eroded by excessive FAA delegation to Boeing; Boeing’s authorised representatives (ARs) may be impaired from acting independently; Boeing ARs were not communicating fundamentally important information about safety, certification or conformity-related issues to the FAA; and FAA technical experts were overruled or undercut by FAA management when noting safety concerns.
Boeing production pressure
The costs, schedule, and production pressures at Boeing undermined the safety of the 737 Max. Employees were put under tremendous pressure to meet the production schedule, with Boeing reducing the work hours on avionics regression testing by 2 000 hours, the flight test simulator by 3 000 hours, and the engineering flight deck simulator by 8 000 hours.
Boeing failed to classify MCAS as a safety-critical system, concealed critical information on the system from pilots, and didn’t point out to the FAA that MCAS was a “new function”.
Boeing concealed the fact that the angle-of-attack (AOA) disagree alert was inoperable
Boeing has publicly blamed its software supplier for this fault, even though it failed to detect the problem when it tested this software in 2015.
Boeing then postponed the software update to 2020 so it could be done in conjunction with the rollout of its planned 737 Max 10 aircraft.
Boeing’s economic incentives led to a significant lack of transparency
Boeing had entered into various contracts in which it had agreed to discount the price of the Max aeroplane if the FAA did not require simulator training for all pilots transitioning to the 737 Max. Boeing gave assurance to airlines that pilots qualified to fly a different 737 variant (the 737 Next Generation) need not undergo simulator training to fly the 737 Max. This placed a financial incentive on ensuring that no regulatory training was required (and meant that pilots needing simulator training on the new aircraft did not receive it).
Boeing and the FAA gambled with the public’s safety
Both Boeing and the FAA gambled with the public’s safety after the Lion Air crash which resulted in the deaths of 157 individuals on Ethiopian Airlines flight 302. Boeing did not mention the MCAS in advisories to pilots, and deleted the mention of MCAS in its Emergency Airworthiness Directive.
Unforgivable inconceivable and inexcusable transgressions
Among the worst transgressions:
- Boeing failed to classify MCAS as a ‘safety-critical system’ which would have attracted greater FAA scrutiny. The MCAS also flouted Boeing’s guidelines which stipulated that the system should not interfere with the piloting of the aeroplane.
- Boeing continued to deliver Max aircraft to its customers knowing that the ‘AOA disagree alert’ was inoperable on most of these aircraft. “By the time of the Lion Air crash, Boeing had knowingly delivered approximately 200 Max aircraft to customers around the world with non-functioning AOA disagree alerts.”
- Boeing concealed the result of an internal test in a flight simulator, in which the test pilot found the interference by the MCAS software to be catastrophic.
- The FAA, as at the date of the publishing of the report, has not held Boeing accountable for delivering aeroplanes with the non-functioning AOA disagree alerts that Boeing knew were inoperable.
The report concluded: “Boeing’s design and development of the 737 Max was marred by technical design failures, lack of transparency with both regulators and customers, and efforts to downplay or disregard concerns about the operation of the aircraft”, and that the “FAA’s certification review of Boeing’s 737 Max was grossly insufficient and that the FAA 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.”
Despite what the investigation found, Boeing and the FAA have suggested that the certification of the 737 Max was compliant with FAA regulations.
Whatever the results of the legislative actions that follow, this will be scant comfort for the families of the 346 people killed in the two accidents.
If Boeing and the FAA were effective in one thing, it was in swatting down the multiple red flags that kept on popping up.
But it is the fact that these transgressions occurred within a huge and until-then highly well-regarded multinational operating in a sector where safety is mission-critical – and, as so tragically evident, could not be hidden – that is alarming.
May this whole sorry story be a lesson for all companies, whether big or small, local or global.
Profit matters, but never to such an extent.
* Comair, which is under business rescue, took delivery of its first 737 Max 8 on February 27, 2019. This aircraft has however been grounded under the worldwide grounding order. Comair expects to resume operations by November 1, 2020.