Wednesday, 16 September 2020

Boeing's ‘culture of concealment’ and a 'horrific' string of 'faulty technical assumptions' lead to the two fatal crashes of 737 MAX aircraft, report finds.

Grounded 737 MAX aircraft

The U.S. House of Representatives' Transportation and Infrastructure Committee has finally released its report on The Design, Development & Certification of the Boeing 737 MAX, following two crashes that caused the death of 346 people.

The report took 18 months to investigate and produce and has been damming on both the manufacture, Boeing and the US regulator, the FAA  citing a "horrific culmination" of failures which culminated in the Lion Air and Ethiopian Airlines crashes.

The Committee’s investigation has revealed multiple missed opportunities that could have turned the trajectory of the MAX’s design and development toward a safer course due to flawed technical design criteria, faulty assumptions about pilot response times, and production pressures. The FAA also missed its own opportunities to change the direction of the 737 MAX based on its aviation safety mission. Boeing failed in its design and development of the MAX, and the FAA failed in its oversight of Boeing and its certification of the aircraft. 

The full report details that the two fatal crashes were not a result of "a singular failure, technical mistake, or mismanaged event," but on a "horrific" culmination of "faulty technical assumptions by Boeing’s engineers", a lack of transparency across Boeing’s management, and "grossly insufficient oversight by the FAA."

Boeing was engaged in a massive cost-cutting exercise at the time of the MAX's introduction to operational service with airlines,  mainly so the model could compete with European rival Airbus over its latest incantation of the A320 and ensure more profit for shareholders. 

The Committee’s investigative findings have identified five central themes that affected the design,
development, and certification of the 737 MAX and FAA’s oversight of Boeing that are contributory factors in the disasters.

 1) Production Pressures.  The report states there was tremendous financial pressure to compete with Airbus which resulted in extensive efforts to cut costs, maintain the 737 MAX production schedule at all costs. The investigation has identified several instances where the desire to meet these goals and expectations jeopardized the safety of the flying public. Senior programme officials kept a “countdown clock” in their meeting room, whilst they said it was to keep up excitement to the types launch, it function also reminded staff of the tight deadlines they were forced to work to. 

 2) Faulty Design and Performance Assumptions.  The committee found that Boeing made fundamentally faulty assumptions about critical systems on the aircraft, especially the 'Maneuvering Characteristics Augmentation System' -  MCAS. Based on these faulty assumptions, Boeing permitted MCAS—software designed to automatically push the aircraft’s nose down in certain conditions, designed to activate on input from a single angle of attack (AOA) sensor. Boeing also assumed that pilots, who were largely unaware that the system even existed, would be able to mitigate any potential malfunction. Perhaps even more importantly,  the report states that Boeing failed to advise that MCAS was a safety-critical system, if it had been, the FAA would have put the system under greater scrutiny during the certification process. The committee also state in the report that the operation of  MCAS 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.”. It also beggas belief that such a safety critical system would operate from a feed of a single sensor. 

4) Conflicted Representation. Tis part of the report speculates on the integrity and impartiality of Boeing staff being given the responsibility of self certification at various points in the 737 MAX development by the FAA. Leading to confusion and critical information not being disclosed to the FAA.

5) Boeing’s Influence Over the FAA’s Oversight Structure.   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.

During the course of its investigations the committee found a number of incidents of information related to the safe operation fo the 737 MAX aircraft was not passed on to the FAA,  including details of when a test pilot took around 10 seconds to recover from an uncommanded acctivation of the MCAS system whilst in a flight simulator, which according to the pilot, would have been 'Catastrophic '.   The Committee also discovered that one Boeing employee who was also an FAA authorised representative, who was aware that Boeing knowingly delivered aircraft with inoperable AOA Disagree alerts to its customers in 2017 and 2018 but took no action to inform the FAA. 

Boeing did not acknowledge that the AOA Disagree alerts on more than 80 percent of the 737 MAX fleet were inoperative until after the Lion Air crash in October 2018. By the time of the Lion Air crash, Boeing had knowingly delivered approximately 200 MAX aircraft to customers around the world with non-functioning AOA Disagree alerts.


Another key part of the report details how Boeing wanted to avoid the need for mandatory simulator training for pilots of the 737 MAX for financial reasons.  In December of 2011 the manufacturer has signed a deal with launch customer Southwest Airlines that it would discount the price of each MAX aircraft it delivered to the budget airline by at least $1 million if the FAA had required simulator training for pilots transitioning from the 737 NG to the 737 MAX.

As Southwest had 200 firm orders for the MAX with further options to buy 191 more of the MAX jets, Boeing would owe the airline at least $200 million and possibly $400 million if it failed to get Level B (non-simulator) training requirement from the FAA.  The impact of this lead, according to the report, to Boeing 2evading and averting the inclusion of at least one technology [MCAS] that could have affected Boeing’s directive to avoid simulator training."


A number of experts have given evidence and submissions to the committee,  including Chesley B. “Sully” Sullenberger, the pilot of the US Air aircraft that landed on the River Hudson in New York in 2009.   He wrote:
"These crashes are demonstrable evidence that our current system of aircraft design and certification has failed us… It is obvious that grave errors were made that have had grave consequences, claiming 346 lives… 
Accidents are the end result of a causal chain of events, and in the case of the Boeing 737 MAX, the chain began with decisions that had been made years before, to update a half-century-old design… 
We owe it to everyone who flies, passengers and crews alike, to do much better than to design aircraft with inherent flaws that we intend pilots will have to compensate for and overcome. Pilots must be able to handle an unexpected emergency and still keep their passengers and crew safe, but we should first design aircraft for them to fly that do not have inadvertent traps set for them."


Boeing's statement in full:

Boeing cooperated fully and extensively with the Committee’s inquiry since it began in early 2019. We have been hard at work strengthening our safety culture and rebuilding trust with our customers, regulators, and the flying public. The passengers and crew on board Lion Air Flight 610 and Ethiopian Airlines Flight 302, as well as their loved ones, continue to be in our thoughts and prayers.

Multiple committees, experts, and governmental authorities have examined issues related to the MAX, and we have incorporated many of their recommendations, as well as the results of our own internal reviews, into the 737 MAX and the overall airplane design process. 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.

We have learned many hard lessons as a company from the accidents of Lion Air Flight 610 and Ethiopian Airlines Flight 302, and from the mistakes, we have made.  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."









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