Here I share Final Committee Report – The Design, Development and Certification of the Boeing B737 Max from MAJORITY STAFF OF THE COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE (The House Committee on Transportation and Infrastucture), USA Congress
A committee’s Democrats say two fatal crashes were a “horrific culmination” of engineering flaws, mismanagement and oversight lapses.
The two crashes that killed 346 people aboard Boeing’s 737 Max and led to the worldwide grounding of the plane were the “horrific culmination” of engineering flaws, mismanagement and a severe lack of federal oversight, the Democratic majority on the House Transportation and Infrastructure Committee said in a report on Wednesday.
The report, which condemns both Boeing and the Federal Aviation Administration for safety failures, concludes an 18-month investigation based on interviews with two dozen Boeing and agency employees and an estimated 600,000 pages of records. The report argues that Boeing emphasized profits over safety and that the agency granted the company too much sway over its own oversight.
“This is a tragedy that never should have happened,” said Representative Peter A. DeFazio of Oregon, the committee chairman. “It could have been prevented, and we’re going to take steps in our legislation to see that it never happens again.”
Republicans on the committee, without issuing their own report, also called for safety improvements. But Representative Sam Graves of Missouri, the committee’s top Republican, said that while change was needed, congressional action should be based on expert recommendations, “not a partisan investigative report.”
The report was issued as the F.A.A. appeared close to lifting its March 2019 grounding order for the Max after evaluating data from test flights this summer and proposing changes to the jet. F.A.A. clearance could lead aviation authorities elsewhere to follow suit and allow the plane to fly again as soon as this winter.
Even as it strives to get the Max back into service, Boeing is contending with other challenges, including the deep downturn in air travel because of the coronavirus pandemic, and quality concerns about its 787 Dreamliner.
The congressional report on the Max identified five broad problems with the plane’s design, construction and certification. First, the race to compete with the European rival Airbus and its new A320neo led Boeing to make production goals and cost-cutting a higher priority than safety, the Democrats argued. Second, the company made deadly assumptions about software known as MCAS, which was blamed for sending the planes into nose dives. Third, Boeing withheld critical information from the F.A.A. Fourth, the agency’s practice of delegating oversight authority to Boeing employees left it in the dark. And finally, the Democrats accused F.A.A. management of siding with Boeing and dismissing its own experts.
“These issues must be addressed by both Boeing and the F.A.A. in order to correct poor certification practices that have emerged, reassess key assumptions that affect safety and enhance transparency to enable more effective oversight,” the Democrats said in the report.
The findings are largely in line with an abundance of information uncovered by federal investigators, news reporters and the committee’s preliminary work after the crashes in Indonesia in October 2018 and Ethiopia in March 2019.
Those crashes were caused in part by the MCAS system. Because the engines are larger and placed higher than those on the plane’s predecessor, they can cause the jet’s nose to push upward. MCAS was designed to push the nose back down. In both crashes, the software was activated by faulty sensors, sending the planes toward the ground as the pilots struggled to pull them back up.
The deaths could have been avoided if not for a series of safety lapses at Boeing and “grossly insufficient” oversight at the F.A.A., the Democrats argued. Internal communications at Boeing showed that several employees raised concerns about MCAS over the years, but their concerns were either dismissed or inadequately addressed, the House report said. It also accused Boeing of intentionally misleading the F.A.A., echoing a July report from the Transportation Department’s inspector general.
That report found that Boeing had failed to share critical information with regulators about important changes to MCAS and had been slow to share a formal safety risk assessment with the agency. The inspector general also said that Boeing had chosen to portray the MCAS software as a modification to an existing system rather than a new one, in part to ease the certification process, a decision that an authorized F.A.A. representative at the company agreed with, according to the congressional report.
Under federal law, the agency is allowed to delegate some oversight to manufacturers, but that practice backfired at Boeing, the congressional report found.
In 2012, for example, a Boeing test pilot took more than 10 seconds to reverse an MCAS activation, a response time that he later described as “catastrophic.” Boeing cited that finding several times over the years in internal documents, but the House report found no evidence that any of the four F.A.A. representatives at the company who knew of the finding ever passed it on to the agency. Sharing the information was not required, but the failure to do so was “inconceivable and inexcusable,” the report said.
F.A.A. management came in for severe criticism over its response to the crashes. In December, the report said, Ali Bahrami, the F.A.A.’s associate administrator for aviation safety, told committee staff members that he was unaware of an internal assessment produced after the first crash that had predicted 15 more over the lifetime of the Max fleet if MCAS was not fixed.
The report also said the agency was “inexplicably slow” in turning over records.
“The F.A.A. was actually more frustrating” than Boeing, Mr. DeFazio said on a call with reporters. “I’m not sure that we ever got all of the email chains we wanted. They claimed to have a very primitive old computer system.”
The report faulted Boeing for a lack of transparency, driven in part by a desire to play down the need for simulator training for pilots. Under a 2011 contract with Southwest Airlines, for example, Boeing had promised to discount each of the 200 planes in the airline’s order by $1 million if the F.A.A. required such simulator training for pilots moving from an earlier version of the aircraft, the 737NG, to the Max. That, the committee argued, created an incentive for Boeing to withhold critical safety information from the agency.
“This report lays bare the lie that Boeing cares about safety or the hundreds of lives they have ruined,” said Yalena Lopez-Lewis, whose husband, Army Capt. Antoine Lewis, died in the Ethiopian Airlines crash. “Boeing cut corners, lied to regulators, and simply considers this the cost of doing business.”
Democrats declined to provide details of prospective legislation, but said they were working on bipartisan reforms that could be passed before the end of the year.
“We are working closely with Republicans in the hope of coming to an agreement on a reform proposal in the very near future,” Representative Rick Larsen of Washington, the chairman of the aviation subcommittee, told reporters.
In a statement, Boeing said it had learned lessons from the crashes and had started to act on the recommendations of experts and government authorities.
“Boeing cooperated fully and extensively with the committee’s inquiry since it began in early 2019,” the company said. “We have been hard at work strengthening our safety culture and rebuilding trust with our customers, regulators and the flying public.”
The revised Max design has received extensive review, the company said, arguing that once the plane is ready to fly again, “it will be one of the most thoroughly scrutinized aircraft in history.”
The F.A.A. said in a statement that it would work with the committee to carry out any recommended changes and was already making some of its own.
“These initiatives are focused on advancing overall aviation safety by improving our organization, processes and culture,” it said.
Last month, the agency announced plans to require a number of design changes to the Max before it can fly again, including updating MCAS and rerouting some internal wiring. The proposed rule is open for public comment until next week. Barring major obstacles, the agency could lift its grounding order on the plane in the weeks or months to come, allowing Boeing to prepare the planes to fly as soon as this winter.
While hundreds of orders for the jet have been canceled, several thousand remain. In some cases, customers cannot break contracts or are otherwise deeply entwined with Boeing. Many also still want to add the Max to their fleet. A new plane can last a generation and typically requires little maintenance in the first few years of use. The Max promises substantial fuel savings, too, which can add up over several decades.
Still, Boeing warned in January that the grounding would cost more than $18 billion. And that was before the severe downturn in travel caused by the pandemic. Last month, Boeing said it would expand the 10 percent cut to its work force announced in April. And the company said last week that deliveries of its 787 Dreamliner, a large twin-aisle jet used for long-distance flights, had been slowed by new quality concerns.