Flight-certification testing for Boeing’s 737 Max, which has been grounded since March 2019 after two deadly crashes, began Monday, the company said. A 737 Max flew from Seattle’s Boeing Field to Moses Lake in central Washington on Monday. (June 30)

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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 ‘complaint’ 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.

More: Boeing may be tackling 737 Max’s PR problem with a new name

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 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. 

More: Boeing finds new problem with 787 that will delay deliveries

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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