Boeing and US regulator made series of mistakes before 737 Max crashes: congressional report


A House of Representatives committee released a scathing report on Wednesday asking whether Boeing and government regulators have acknowledged the issues that have caused two fatal crashes of a 737 Max and whether either will be willing to make changes important to resolve them.Staff of the Democratic-controlled transport committee blamed the crashes that killed 346 people on the “horrific climax” of government oversight failure, design flaws and lack of action at Boeing despite knowledge of the issues.

The committee identified many gaps in the Federal Aviation Administration’s approval process for new airliners. But the agency and Boeing said the Max’s certification complied with FAA regulations, according to the 246-page report.

“The fact that a compliant aircraft has suffered two fatal crashes in less than five months is clear evidence that the current regulatory system is fundamentally flawed and needs to be fixed,” the staff wrote in the report released Wednesday morning.

The report underscores the need for legislation to fix the approval process and address the delegation of certain oversight duties by the FAA to employees of aircraft manufacturers, said committee chair Peter DeFazio, an Oregon Democrat. .

“Obviously, the system is inadequate,” DeFazio said. “We will adopt important reforms. ”

He would not give details of possible changes, saying committee heads were in talks with Republicans over the legislation. He said the committee will not abandon the delegation program and hopes to reach agreement on the reforms before the end of the year.

Several Canadians are shown in Addis Ababa in March 2019 participating in the planting of memorial trees for the victims of the crash of Ethiopian Airlines Flight 302. (Status check / Reuters)

The House report stems from an 18-month investigation into the October 2018 crash of Lion Air Flight 610 in Indonesia and the crash of Ethiopian Airlines Flight 302 in March 2019. The Max was stranded in the around the world shortly after the crash in Ethiopia that killed 18 Canadians. citizens.

Regulators are testing planes with revamped flight control software, and Boeing hopes to fly the Max again later this year or early 2021, although the pandemic has complicated prospects for the aviation industry.

Poorly communicated software flaw

Investigators mainly focused on why Boeing was able to get the jet approved with minimal pilot training: It convinced the FAA that the Max was an updated version of the previous generation 737s.

In fact, Boeing equipped the aircraft with software called MCAS, an acronym for Maneuvering Characteristics Augmentation System, which automatically lowers the nose of the aircraft to prevent an aerodynamic stall. Initially, pilots around the world were not made aware of the system, which Boeing said was necessary because the Max had bigger, more powerful engines that were placed further forward on the wings than the older 737s. .

In both crashes, the MCAS repeatedly pointed its nose down, forcing the pilots to fight unsuccessfully to keep the planes in the air.

Committee investigators said they found several instances in which Boeing withheld information about MCAS from the FAA and airlines.

Read the Congress report:

Boeing, which is headquartered in Chicago and has production facilities in Washington state, did not disclose that MCAS operates from a single sensor called an “angle of attack,” which measures the pitch of an plane. He also did not reveal that a gauge that would have alerted pilots to a faulty sensor was not working on the vast majority of jets.

Boeing also concealed that it took more than 10 seconds for a company test pilot to determine that MCAS was working and respond to it, a condition the pilot deemed “catastrophic,” according to the report. Federal guidelines assume that pilots will meet this condition within four seconds.

Four Boeing employees working as “authorized representatives” with permission to act on behalf of the FAA to validate the aircraft’s systems were aware of the slow response from the test pilot. But there was no evidence that they reported this to the FAA, according to the report.

Another authorized representative expressed concern in 2016 about the dangers of MCAS repeatedly pointing the nose down, but the concerns were never conveyed to the FAA.

The repeated activation of MCAS and the faulty sensors “were the main factors that led to the accidents at Lion Air and Ethiopian Airlines more than two years later,” the report said.

Additional training would have reduced the cost of the aircraft

According to the report, Boeing wanted to keep the details of the FAA MCAS so that it did not require additional pilot training. It would ruin Boeing’s sales pitch for the Max – that pilots of older 737s wouldn’t have to undergo extensive simulator training to fly the new planes.

Investigators found that Boeing had a financial incentive to avoid more pilot training. Under a 2011 contract with Southwest Airlines, Boeing would have had to reduce the price of each Max by US $ 1 million if simulator training was required.

“It has led to a lot of really bad decisions internally at Boeing, and the FAA hasn’t picked up on these things either,” DeFazio said.

He added that Boeing had an internal meeting in 2013 and agreed to never talk about MCAS outside the company. At one point, MCAS was listed in pilot training manuals, but an authorized representative approved its removal, he said.

In a statement, Boeing said it has worked to strengthen its safety culture and cooperated with the committee. The company incorporated many recommendations from committees and experts who looked into Max’s issues.

‘Change is always difficult’

Boeing said it learned from the mistakes.

“Change is always difficult and requires daily commitment, but we, as a company, are determined to get the job done,” the statement said.

The FAA said in a statement it looks forward to working with the committee to make improvements and is already making changes based on internal and independent reviews.

“These initiatives aim to advance overall aviation safety by improving our organization, processes and culture,” the FAA said, adding that it required a number of design changes to the Max before it could fly at new.

Regarding FAA oversight, investigators said they found numerous examples of agency officials canceling technical and safety experts at Boeing’s request.

In an interview with investigators, Keith Leverkuhn, former CEO of Boeing for the Max who was promoted at the company, said he viewed the Max’s development as a success despite the crashes.

“I dispute the suggestion that the development has been a failure,” according to the report.

The Senate Commerce Committee postponed a meeting scheduled for Wednesday to follow up on changes to a bipartisan bill introduced in June, giving the FAA more control over the selection of company employees who approve security decisions . One envisioned improvement could be that an aircraft with significant changes from previous models would need further review by the FAA.


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