Two plane crashes in 2018 and 2019 involving the new Boeing 737 Max aircraft weren’t a result of one single issue, but instead were caused by the failures of Boeing staff, Boeing management, and the Federal Aviation Administration, according to a new 245-page report released Wednesday by the U.S. House Transportation and Infrastructure Committee. In short: It was a perfect storm of shit where everyone made deadly mistakes.
Lion Air Flight 610 crashed near Indonesia on October 29, 2018, killing all 189 people on board, and Ethiopian Airlines Flight 302 crashed in Ethiopia on March 10, 2019, killing all 157 people on board.
The two crashes were just five months apart and led to several countries immediately grounding their 737 Maxes for safety assessments. The planes were eventually pulled from service indefinitely, worldwide. The U.S. was the last country to ground the new aircraft model, but has acted as the lead investigator into its failings, if only because Boeing is an American company.
“The MAX crashes were not the result of a singular failure, technical mistake, or mismanaged event,” the new report, which was posted online Wednesday morning, reads.
“They were the horrific culmination of a series of faulty technical assumptions by Boeing’s engineers, a lack of transparency on the part of Boeing’s management, and grossly insufficient oversight by the FAA—the pernicious result of regulatory capture on the part of the FAA with respect to its responsibilities to perform robust oversight of Boeing and to ensure the safety of the flying public.”
The report, written by Democrats in the House, is the culmination of 18 months of investigation to identify the primary cause of the crashes. Early reports suggested that technical failures involving the Maneuvering Characteristics Augmentation System (MCAS) in the planes were to blame.
From the new report:
Boeing made fundamentally faulty assumptions about critical technologies on the 737 MAX, 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.”
While it’s true that the MCAS system incorrectly believing the plane was stalling out forcing the nose down unnecessarily during the aforementioned fatal crashes, there were a lot of other issues involved, according to Congressional investigators. Not only did regulators at FAA have conflicts of interest that would potentially give Boeing more leeway, the race to compete with Airbus contributed to Boeing taking more shortcuts than it should have.
There’s been a slow drip of information ever since the crash in March 2019 that made people believe there might be systemic problems with the relatively new planes. Internal emails obtained by the Congressional committee even revealed that Boeing employees had doubts about the approval process for the Max series. In one particularly damning email from April of 2017, a Boeing employee wrote, “this airplane is designed by clowns, who in turn are supervised by monkeys.”
Other documents obtained by the committee revealed that Boeing obtained a special exemption from the FAA allowing the aviation company to not install an Engine Indicating and Crew Alerting System (EICAS) that may have allowed pilots to better prioritize problems from the cockpit. Boeing even gave an internal presentation in 2012 noting that if the company had to install EICAS in its latest model it would create new financials costs.
From the report:
Boeing was well aware early on of the risk posed to the 737 MAX program if it was required to implement an EICAS on the MAX. In June 2012, a Boeing employee gave a presentation titled: “737 MAX Certification Basis Risk Review: EICAS.” The presentation defined the issue this way: “Numerous crew alerts on the 737 Max are new or revised and per changed product regulation are required to meet latest amendment level. Current 737 flight crew alerting methods won’t comply with latest regulation.”274 The presentation went on to say that a “compliant design would be similar to the 787 or 767 tanker and include” EICAS as well as other features. Significantly, the schedule risk,” it asserted, and “significant impact” on pilot training requirements.
It was also revealed early on that the FAA allowed Boeing to do a lot of the certification of its own new aircraft, “delegating” oversight that should have been done by proper government authorities.
“Our report lays out disturbing revelations about how Boeing—under pressure to compete with Airbus and deliver profits for Wall Street—escaped scrutiny from the FAA, withheld critical information from pilots, and ultimately put planes into service that killed 346 innocent people. What’s particularly infuriating is how Boeing and FAA both gambled with public safety in the critical time period between the two crashes,” Rep. Peter DeFazio, the chairman of the committee, said in a statement posted online.
Boeing apologized to the families of the victims in an unsigned statement published Wednesday morning, but sought to assure the public that when the Max is allowed to fly again it will be “one of the most thoroughly scrutinized aircraft in history.”
An excerpt from Boeing’s statement:
The revised design of the MAX has received intensive internal and regulatory review, including more than 375,000 engineering and test hours and 1,300 test flights. Once the FAA and other regulators have determined the MAX can safely return to service, it will be one of the most thoroughly scrutinized aircraft in history, and we have full confidence in its safety. We have also taken steps to bolster safety across our company, consulting outside experts and learning from best practices in other industries. We have set up a new safety organization to enhance and standardize safety practices, restructured our engineering organization to give engineers a stronger voice and a more direct line to share concerns with top management, created a permanent Aerospace Safety Committee of our Board of Directors as well as expanded the role of the Safety Promotion Center.
But this new report has identified many problems that seem to be cultural rather than technical, including damning allegations that, “Boeing withheld crucial information from the FAA, its customers, and 737 MAX pilots.”
Democrats stressed that getting this full report out to the public was important in the name of transparency and making consumers feel safe as they venture out into the world again.
“On behalf of the families of the victims of both crashes, as well as anyone who steps on a plane expecting to arrive at their destination safely, we are making this report public to put a spotlight not only on the broken safety culture at Boeing but also the gaps in the regulatory system at the FAA that allowed this fatally-flawed plane into service,” De Fazio said.
“Critically, our report gives Congress a roadmap on the steps we must take to reinforce aviation safety and regulatory transparency, increase Federal oversight, and improve corporate accountability to help ensure the story of the Boeing 737 MAX is never, ever repeated.”
The FAA is reportedly planning on allowing the Max to fly again soon, but we’ll see whether this report gives the agency any pause about moving too quickly. Boeing has previously said that it might change the name of the Max, but if that’s the plan, it hasn’t been made public yet.
Back in 2019, there may have been skepticism from the U.S. public about getting on an airplane associated with two back-to-back crashes. Travel booking websites like Kayak even started to allow passengers to filter out specific planes, including the 737 Max, after the second Max crash in March 2019. But here in 2020, covid might make consumers more hesitant than anything to get on a passenger aircraft.