A “culture of concealment” at Boeing and “grossly insufficient” federal oversight of the 737 Max jets contributed to two crashes within months of each other that killed 346 people, according to a report released Friday by House Democrats.
In the report, leaders on the House Transportation Committee concluded a half a dozen ways in which Boeing and the FAA failed the public.
Reps. Peter A. DeFazio (D-Ore.) and Rick Larsen (D-Wash.) have said for months that the oversight system for airplane safety is badly broken. They will use the findings to help bolster their case that significant reform is needed to strengthen the government’s hand in dealing with Boeing, one of the nation’s biggest companies.
The report concludes that the FAA’s initial certification review of the plane was “grossly insufficient” and the agency “failed in its duty” to uncover critical safety problems and make sure Boeing fixed them.
“The combination of these problems doomed the Lion Air and Ethiopian Airlines flights,” the report found.
The FAA declined to address the findings but said it is open to outside recommendations.
“Today’s unprecedented U.S. safety record was built on the willingness of aviation professionals to embrace hard lessons and to seek continuous improvement,” the agency said in a statement. “While the FAA’s certification processes are well-established and have consistently produced safe aircraft designs, we are a learning agency and welcome the scrutiny.”
In recent months, the FAA has taken public steps to demonstrate that it is holding Boeing accountable and on Friday the agency announced new action against the company. The FAA said it was proposing to penalize Boeing $19.7 million for installing improper sensors on almost 800 of its Max 737 jets.
Boeing said in a statement that the company’s thoughts were with the crash victims’ families and that it would review the House report. The company said the sensors did not present a safety risk and that it had implemented changes to address the FAA’s concerns.
Tuesday will mark the anniversary of the second crash, which killed 157 people aboard Ethiopian Airlines Flight 302 when it plunged into the ground shortly after leaving Addis Ababa. That crash followed a similar one that killed 189 people on Oct. 29, 2018, in Indonesia, which the report calls “extraordinary and unprecedented in modern times.”
The report concluded that the FAA didn’t do enough to sharpen its oversight following the first crash and it wasn’t until after the second that agency officials joined international aviation regulators in grounding the Max 737 jets.
The aircraft remains grounded, and the decision has rocked Boeing, leading to the ouster of its chief executive in December and the halting of production of new Max jets earlier this year.
The report traces the origins of the crashes back years, to Boeing’s desire to compete with a new plane being developed by European manufacturer Airbus. That led to efforts to cut costs, follow a strict schedule and maintain high production numbers, even after a factory manager warned of problems on the shop floor, according to the report.
“The desire to meet these goals and expectations jeopardized the safety of the flying public,” the report concludes.
In an interview with the New York Times published this week, Boeing’s new chief executive, David Calhoun, sought to push the responsibility onto predecessor Dennis Muilenburg.
“We supported a C.E.O. who was willing and whose history would suggest that he might be really good at taking a few more risks,” said Calhoun, who was a member of Boeing’s board.
The planes that were coming off the production line in Renton, Wash., contained hidden flaws in a new feature called the maneuvering characteristics augmentation system, or MCAS, which was implicated in both crashes because of its power to drive the planes’ noses down in ways pilots struggled to counteract. Boeing made poor assumptions about how the feature would work — something company leaders now acknowledge — that led to it receiving a less thorough safety review, according to the report.
In other instances, the report concludes, Boeing concealed “crucial information” from its customers, pilots and the FAA — including not telling pilots about the existence of MCAS.
The FAA, for its part, did too little to scrutinize Boeing’s work and operated under a safety system that the report found set up “inherent conflicts of interest.”
That system, known as the organization designation authorization, or ODA, gives Boeing the power to name engineers who conduct safety work on behalf of the FAA. And it is the focus of legislative efforts to prevent crashes.
A trio of Democratic senators introduced legislation last week that would make changes to the system, giving the FAA’s leaders new authority, but family members of the crash victims say they want it replaced altogether.
“The ODA system killed my daughter,” said Michael Stumo, whose daughter Samya was on the Ethiopian Airlines flight. “We’re all unified that ODA has to go.”
Republican leaders in Congress have shown less appetite for sweeping changes, and a report compiled for Transportation Secretary Elaine Chao explicitly warned against overhauling the safety review system.
Reps. Sam Graves (Mo.) and Garret Graves (La.), Republican leaders on the House committee, said in a statement Friday that any legislation should be grounded in the “unbiased findings” of the safety experts who have reviewed the crashes.
“None of these expert reviews or investigations have come to the conclusion that our safety certification system is broken or in need of wholesale dismantlement,” they said.
The Democrats’ report points to recurring problems with FAA oversight that continued even after the Indonesia crash.
Following the Lion Air crash, the FAA missed the critical importance of information it was seeing about the Max and that Boeing was telling it privately, the report said.
The FAA learned, for example, that Boeing had not fixed an alert that didn’t work on roughly 80 percent of the Max fleet, and the company failed to tell the agency or airlines about the problem for more than 14 months, “which should have raised concerns about Boeing’s transparency with the FAA.”
The report also cites a briefing Boeing gave FAA officials in December 2018. The company acknowledged during that session that its simulator tests didn’t evaluate what would happen if “a combination of failures” caused MCAS to malfunction or how pilots would react in the cockpit when faced with multiple problems at once, the report said.
That should have raised “additional red flags,” investigators said. But the FAA failed to act swiftly or decisively enough.
“The FAA permitted the 737 MAX to continue flying anyway while Boeing and the FAA worked on designing and validating a fix to the MCAS software,” the report found. “That judgment proved tragically wrong.”