The design of the Boeing 737 MAX was marred by technical design failures, lack of transparency with both regulators and customers, and efforts to downplay or disregard concerns about the operation of the aircraft. Concerns about the safety of the MCAS system from within Boeing were either inadequately addressed or simply dismissed by Boeing. Oversight by the FAA during the certification review of the MAX was grossly insufficient. The combination of these problems doomed the Lion Air and Ethiopian Airlines flights.
That is the conclusion of the final committee report by the House Committee on Transportation and Infrastructure, which was released on September 16. The report concludes an 18-month investigation on the design, development, and certification of the MAX that included numerous hearings and analyses of documents, transcripts and other relevant sources. Many details have already emerged from the hearings themselves as well as from numerous publications, both from the media and from investigators that studied the crashes of the Lion Air MAX in September 2018 and the Ethiopian MAX in March 2019 which resulted in the grounding of the type.
Where the report is valuable is in its analyses of how a culture of concealment within Boeing and between the airframer and the FAA contributed to how the Maneuvering Characteristics Augmentation System (MCAS) was conceived. And changed the reputation of Boeing’s bestseller and that of the company: “The story of the Boeing 737 MAX was never expected to be associated with catastrophe. It was supposed to be a story of American ingenuity and technological success—a modern, more fuel-efficient airplane that had already become the manufacturing giant’s best-selling jet.”
Production issues and cost pressures
The Committee’s report identifies five themes that have contributed to the problems. It cites production pressures as the first, with huge pressure on Boeing to respond to the Airbus A320neo and produce a new 737-version in time and at reduced costs, for example by reducing designated hours for testing cockpit systems. Concerns of production and schedule pressures affecting safety were waved in 2018.
Faulty design assumptions
When it designed the MAX, Boeing made “fundamentally faulty assumptions about critical technologies, most notably with MCAS. Based on these faulty assumptions, Boeing permitted MCAS—software designed to automatically push the airplane’s nose down in certain conditions—to activate on input from a single angle of attack (AOA) sensor. It also expected that pilots, who were largely unaware that the system existed, would be able to mitigate any potential malfunction. Boeing also failed to classify MCAS as a safety-critical system, which would have attracted greater FAA scrutiny during the certification process. The operation of MCAS also violated Boeing’s own internal design guidelines related to the 737 MAX’s development which stated that the system should “not have any objectionable interaction with the piloting of the airplane” and “not interfere with dive recovery.”
From 2013, Boeing did everything to avoid increased costs for training and certification if MCAS was to be designated as a new feature. It kept saying the system was added to the existing speed trim system but did hide a redesign in 2016 that expanded its functionality to low speeds as well. “Just hours after the approval for MCAS’s redesign was granted, Boeing sought, and the FAA approved, the removal of references to MCAS from Boeing’s Flight Crew Operations Manual (FCOM) As a result, 737 MAX pilots were precluded from knowing of the existence of MCAS and its potential effect on aircraft handling without pilot command.” Boeing even failed to reevaluate the redesigned system.
Boeing had every reason to prevent additional costs because of MCAS training, the report says: “Under a contract signed in December 2011 with Southwest Airlines, the U.S. launch customer for the 737 MAX, Boeing was financially obligated to have discounted the price of each MAX airplane it delivered to Southwest by at least $1 million if the FAA had required simulator training for pilots transitioning from the 737NG to the 737 MAX.”
Culture of concealment
In this culture of concealment, Boeing withheld details of MCAS to the FAA, customers, and pilots. It failed to disclose the existence of the AOA Disagree alert to most operators and kept delivering aircraft to airlines on which the ‘option’ was still inoperable.
The report also concludes that “Boeing concealed internal test data it had that revealed it took a Boeing test pilot more than ten seconds to diagnose and respond to uncommanded MCAS activation in a flight simulator, a condition the pilot found to be “catastrophic.” While it was not required to share this information with the FAA or Boeing customers, it is inconceivable and inexcusable that Boeing withheld this information from them.” The ten seconds-issue was mentioned in at least six internal documents but not shared with the FAA and customers.
FAA lacking oversight structure
In its fourth and fifth conclusions, the House Committee points its fingers to the FAA, criticizing the regulator’s oversight structure with respect to Boeing. This “creates inherent conflicts of interest that have jeopardized the safety of the flying public. The Committee’s investigation documented several instances where Boeing Authorized Representatives (ARs)—Boeing employees who are granted special permission to represent the interests of the FAA and to act on the agency’s behalf in validating aircraft systems and designs’ compliance with FAA requirements—failed to disclose important information to the FAA that could have enhanced the safety of the 737 MAX aircraft. In some instances, a Boeing AR raised concerns internally in 2016 but did not relay these issues to the FAA, and the concerns failed to result in adequate design changes. Some of the issues that were raised by the AR and not thoroughly investigated or dismissed by his Boeing employees, such as concerns about repetitive MCAS activation and the impact of faulty AOA data on MCAS, were the core contributing factors that led to the Lion Air and Ethiopian Airlines crashes more than two years later.”
Boeing had gained excessive delegation of FAA oversight and too much influence over the regulatory body: “Multiple career FAA officials have documented examples where FAA management overruled a determination of the FAA’s own technical experts at the behest of Boeing. In these cases, FAA technical and safety experts determined that certain Boeing design approaches on its transport category aircraft were potentially unsafe and failed to comply with FAA regulations, only to have FAA management overrule them and side with Boeing instead.”
The Committee has identified at least four examples of this behavior: “In one instance, in 2013, an AR concurred on a decision not to emphasize MCAS as a “new function” because of Boeing’s fears that doing so would increase “costs” and lead to “a greater certification and training impact” on the 737 MAX program.”
“In addition, the Committee found no evidence that any of the four Boeing ARs who knew that Boeing had evidence demonstrating that in 2012 it took a Boeing test pilot more than ten seconds to respond to uncommanded MCAS activation in a flight simulator, a condition the pilot found to be “catastrophic” informed the FAA of this critical information.”
The report says: “These incidents have had a detrimental impact on the morale of FAA’s technical and subject matter experts that compromises the integrity and independence of the FAA’s oversight abilities and the safety of airline passengers.” It adds: “A recent draft internal FAA “safety culture survey” of employees in the agency’s Aviation Safety Organization (AVS) drew similar conclusions. “Many believe that AVS senior leaders are overly concerned with achieving the business-oriented outcomes of industry stakeholders and are not held accountable for safety-related decisions,” the survey observed.”
Lack of oversight also on 787
While the FAA has failed to exercise its oversight authority on various occasions, not all instances have violated FAA regulations. Yet, the Committee concludes that the five themes it had identified “point to a troubling pattern of problems that affected Boeing’s development and production of the 737 MAX and the FAA’s ability to provide appropriate oversight of Boeing and the agency’s certification process.” The Committee knows of at least one similar issue on another Boeing type: that of a lightning protection feature on the 787, in which FAA management overruled the judgment of an FAA expert.
Even after the Lion Air crash in 2018, Boeing and the FAA failed to take appropriate action that could have prevented the Ethiopian crash six months later: “There were multiple red flags and clear data points that should have informed the FAA’s decision-making after the Lion Air crash. The FAA learned, for instance, that not only had Boeing failed to fix an inoperable AOA Disagree alert on more than eighty percent of the 737 MAX fleet but that it had also decided not to inform the FAA or its customers about the non-functioning alert for more than 14 months – until after the Lion Air crash.”
Additional information did not trigger an alert within the FAA. Actually, its associate administrator for safety seemed unaware of the key issues related to the MAX accidents when asked in December 2019.
The Committee concludes: “These issues must be addressed by both Boeing and the FAA in order to correct poor certification practices that have emerged, reassess key assumptions that affect safety, and enhance transparency to enable more effective oversight.” These are the key issues that need to be addressed. That the pilots involved in the two MAX crashes lacked experience and abilities, as was said shortly after the accidents, is a conclusion not shared by the committee. Even the youngest pilot on the Ethiopian flight still had 207 hours of experience on a 737.
Active as journalist since 1987, starting with regional newspaper Zwolse Courant. Grand Prix reporter in 1997 at Dutch monthly Formule 1, general reporter Lelystad/Flevoland at De Stentor/Dagblad Flevoland, from 2002 until June 2021 radio/tv reporter/presentor with Omroep Flevoland.
Since mid-2016 freelance aviation journalist, since June 2021 fully dedicated to aviation. Reporter/editor AirInsight since December 2018. Contributor to Airliner World, Piloot & Vliegtuig. Twitter: @rschuur_aero.