'Grossly insufficient': House report excoriates
Boeing, FAA over mistakes that led to 737 Max crashes
A cascade of false assumptions, mismanagement,
rushed deadlines, miscommunication and outright deception led to the
failure to catch the design flaws that led to two deadly crashes of
Boeing's now-grounded 737 Max jetliner, finds a congressional report
released Wednesday.
"Boeing failed in its design and development
of the Max, and the Federal Aviation Agency failed in its oversight of
Boeing and its certification of the aircraft," concludes the House
Transportation and Infrastructure Committee's 238-page report on the jetliner.
The report pinpoints multiple times engineers
questioned the safety of features that went into the jet, only to have
their concerns dismissed as lacking importance or jeopardizing the
development timeline or budget, the report finds. Employees charged with
keeping the FAA informed about those debates didn't pass on that
information to the agency.
Despite ample opportunities to have realized the
plane's deadly shortcomings, the 737 Max passed muster with both Boeing and
the FAA, which labeled it "compliant" in certifying it as safe to
go into service with many airlines in the U.S. and abroad.
"The problem is it was 'compliant' and not
safe – and people died," Rep. Peter DeFazio, D-Ore., the committee's
chairman, said in a brief statement to reporters.
A 737 Max operated by Lion Air plunged into the
Java Sea 13 minutes after takeoff in Indonesia in October 2018, taking 189
lives. Five months later, an Ethiopian Airlines jet with 157 passengers and
crew augered into the earth six minutes into its flight from Addis Ababa.
As similar circumstances in both crashes came to
light, the 737 Max has remained grounded worldwide. The FAA and other
global aviation safety agencies are reviewing Boeing's improvements to
decide whether to allow it to fly again.
Those improvements focus primarily on software
changes in a new system added to the jet and blamed for the crashes. In
both the fatal Lion Air and Ethiopian Airlines flights, pilots wrestled
with the new computer system, the Maneuvering Characteristics Augmentation
System, or MCAS, that wasn't on previous versions of the 737.
MCAS was added in the Max to try to make the
jetliner feel the same to pilots as previous generations of the workhorse
737, which first flew in the 1960s. The 737 Max has larger, heavier
engines, which could make it fly differently under some conditions.
The committee's report dwells on how, at multiple
points in the development of the Max, engineers and test pilots noted
problems in MCAS that would later prove to be at the root of the crashes.
As early as 2012, a Boeing test pilot found it
took 10 seconds to deal with an uncommanded activation of the MCAS system,
which was deemed to be "catastrophic," the report discloses.
Engineers questioned why the system was triggered
on data from a single angle-of-attack sensor when it has two. The AOA
sensors, as they are called, long predate MCAS and inform pilots whether
the plane's nose is pointed up or down.
More: Boeing 737 Max recertification: Europe's
flight safety agency completes first tests following deadly crashes
A test pilot noted that the MCAS system could kick
in multiple times, leaving the plane's ability to stay aloft badly
hindered, which is what sealed the fate of the Lion Air and Ethiopian
flights, according to the report.
The 737 Max's chief engineer said he approved MCAS
without really understanding it, the report states, a reflection of a
management system in which he had overall authority, but most of the
engineers on the project reported directly to others.
MCAS was so flawed that the FAA did an assessment
after the Lion Air crash – and months before the 737 Max would be grounded
– and estimated that it could account for 15 additional crashes over the
worldwide Max fleet's lifetime, with 2,900 deaths.
Despite that prediction, the FAA permitted the 737
MAX to continue flying while a fix to the MCAS software was contemplated,
the report said.
"During the period between the crashes, the
FAA repeatedly justified its decision not to ground the 737 MAX saying that
it did not have appropriate data to make that determination. That judgment
proved tragically wrong," the report states.
The FAA brushed off a Boeing disclosure that a key
indicator light that possibly could have saved the doomed jetliners wasn't
working on 80% of the 737 Max jets then in service. The light tells pilots
when one of the AOA sensors appears to be malfunctioning.
About a year later, the report says, the FAA's
associate administrator for aviation safety was interviewed by committee
staff and seemed unaware of many of the key issues that had come to light
about the jet.
On four occasions that the committee found, the
Boeing workers charged with informing the FAA of any issues that cropped up
in the development of the new jetliner failed to pass on the information to
the agency, raising questions about whether employees charged with such
duties have a conflict of interest.
It was easy to see why: The 737 Max development
team faced intense pressure to get their plane to customers without incurring
heavy additional costs as they tried to fend off competition from Europe's
Airbus, which had a similar fuel-saving jetliner in the works. The report
notes that Boeing senior managers had a "countdown clock"
installed in a meeting room, ticking down the minutes as the project was
supposed to meet key deadlines.
Boeing, in a statement, said it has learned
"hard lessons" in the wake of the crashes as it as struggled to
come up with fixes to the jet that will satisfy regulators.
"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," it said.
Yet Boeing executives pushed to make sure airlines
wouldn't have to include simulator training for pilots on the Max despite
the inclusion of MCAS. Instead, they were allowed to learn about the new
cockpit system from a tutorial on their laptops. Simulator training would
have cost more. Similarly, mention of MCAS was kept out of pilot manuals.
It was supposed to work seamlessly in the background.
The committee also found fault with the FAA. Its
actions involving the plane's certification to fly were "grossly
insufficient" and that it "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," the report states.
The report gives new ammunition to families of
victims who feel that Boeing isn't going far enough or that 737 Max remains
inherently unsafe.
Michael Stumo, whose daughter Samya, 24, died on
the Ethiopian flight, called for the FAA to halt the recertification
process.
"The FAA and Boeing hid information before
and are doing it again," he said in a statement provided through a
spokesman, Gary Hanauer. "Both Boeing and the FAA have refused to
provide their data that support their efforts to unground the plan. The Max
should not fly until Boeing and the FAA provide this data, so independent
experts and the public can confirm the aircraft is safe."
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