A damning report launched Friday offered the primary detailed account of how federal regulators licensed Boeing’s 737 Max jet and not using a clear understanding of a vital new system on the aircraft, a failure that contributed to 2 lethal accidents.
The report was produced by a multiagency activity power which included officers from the Federal Aviation Administration, NASA and 9 worldwide regulators, and was convened to scrutinize the plane’s certification course of after two 737 Max planes crashed in lower than 5 months, killing 346 folks. Lawmakers and federal investigators are nonetheless conducting their very own probes of the design and approval of the plane.
Among the report’s findings had been that Boeing didn’t clearly clarify to regulators a brand new automated system that contributed to the 2 crashes, and that the F.A.A. lacked the potential to successfully analyze a lot of what Boeing did share in regards to the new aircraft.
The F.A.A. relied closely on Boeing workers to approve the protection of the Max, utilizing a system of delegation that’s being scrutinized by lawmakers in the wake of the tragedies. The report discovered that Boeing workers who labored on behalf of the F.A.A. had at occasions confronted “undue pressures” in the course of the aircraft’s growth.
“This report confirms our very worst fears about a broken system,” Senator Richard Blumenthal, Democrat of Connecticut, stated in an interview. “To put the fox in charge of the henhouse never made any sense, and now we see the deeply tragic consequences.”
The assessment scrutinized the F.A.A.’s certification of the Max’s flight control system, including the new automated system, MCAS, which played a role in both crashes, in Indonesia last October and in Ethiopia in March.
In each crash, pilots struggled as a single damaged sensor sent the plane into an irrecoverable nose-dive within minutes of takeoff. Regulators around the world grounded the Max after the second accident. The plane remains grounded while Boeing works on a software fix. There is no timetable for when regulators will allow it to return to service.
The crisis is the worst in Boeing’s 103-year history and has already cost the company billions of dollars, hurt airlines and caused thousands of flights around the world to be canceled.
The report found that while the F.A.A. had been made aware of MCAS, “the information and discussions about MCAS were so fragmented and were delivered to disconnected groups” that it “was difficult to recognize the impacts and implications of this system.”
The task force said it believed that if F.A.A. technical staff had been fully aware of the details of MCAS, the agency would probably have required additional scrutiny of the system that might have identified its flaws.
It recommended that the F.A.A. review staffing levels at its Boeing office in Seattle, and that the agency review the Boeing office that allows company employees to perform certification work.
The F.A.A.’s administrator, Steve Dickson, said in a statement that he would “review every recommendation and take appropriate action.”
“We welcome this scrutiny and are confident that our openness to these efforts will further bolster aviation safety worldwide,” he added.
In a statement, the Boeing spokesman Gordon Johndroe said “safety is a core value for everyone at Boeing,” and that the company “is committed to working with the F.A.A. in reviewing the recommendations and helping to continuously improve the process and approach used to validate and certify airplanes going forward.”
The Joint Authorities Technical Review, which produced the report, was led by Chris Hart, a former chairman of the National Transportation Safety Board, and included aviation regulators from Europe, as well as China, Brazil and other countries. To conduct the review, Mr. Hart and his team were briefed by F.A.A. officials and Boeing executives, and they scrutinized extensive documentation on the certification of the Max.
A broad theme of the report is that the F.A.A. was too focused on the specifics of the new system and did not put sufficient effort into understanding its overall impact on the plane. In certification documents that Boeing submitted to the F.A.A., MCAS was not evaluated as “a complete and integrated function” on the new plane.
The report also said Boeing had failed to inform the F.A.A. as the design of MCAS changed during the plane’s development. A New York Times investigation revealed that the system changed dramatically during that process, making MCAS riskier and more powerful, and that key F.A.A. officials in charge of reviewing the system were inexperienced or unaware of the overhaul.
The task force said the certification documents that Boeing provided to the F.A.A. “were not updated during the certification program to reflect the changes” made to MCAS. It added that two critical documents that describe the potential dangers of a system like MCAS, the system safety assessment and the functional hazard assessment, “were not consistently updated.”
Boeing also failed to thoroughly stress-test the design of MCAS, according to the report, which found that “the design assumptions were not adequately reviewed, updated or validated.”
In addition, the report criticized Boeing for not adequately assessing the extra effort pilots might have to make to deal with MCAS, and it noted that Boeing had removed mention of MCAS from a draft of the pilot’s manual. As a result of that decision, some key F.A.A. officials were not fully aware of MCAS and were “not in a position to adequately assess training needs,” the report found.
To address some of these shortcomings, the report recommends that the F.A.A. update the certification process to allow the agency to be more involved in the design process early on.
The Max was certified in 2017 as the latest version of the 737 family. Because it was based on a well-known design, the F.A.A. allowed it to undergo a less thorough certification process than if it were an entirely new plane.
“Some elements of the design and certification remain rooted in the original 1967 certification of the B737-100,” the review found. But while some modern safety tools have been incorporated into new versions of the 737, others were not included in the Max because they were deemed “impractical,” the review found.
Over all, the report found fault with the process for certifying a new plane based on an old design, saying that it “lacks an adequate assessment of how proposed design changes integrate with existing systems.”
It recommended that the F.A.A. confirm that the Max is in fact compliant with regulations having to do with the plane’s flight guidance system, flight manual and stall demonstration.
Those recommendations, which could affect whether the plane is allowed back into service, have already been addressed by the F.A.A., according to a person familiar with the process. The effort to address those issues has contributed to the prolonged grounding of the Max.
In both of the flights that crashed, the pilots had a hard time identifying the cause of the problems and were unable to bring the planes under control.
The review found that the F.A.A. certification process had failed to adequately consider “pilot recognition time and pilot reaction time to failures.” In particular, the review suggested that the F.A.A. question Boeing’s assumption that pilots could react to a malfunction similar to the one caused by MCAS in just four seconds.
One source of the problems with the certification of the Max was the F.A.A. office in Seattle that oversees Boeing, according to the report. It found that the Boeing office had “limited experience and knowledge of key technical aspects” of the Max.
In the end, the F.A.A. was simply unable to effectively assess MCAS, the review found.
“The F.A.A. had inadequate awareness of the MCAS function,” which meant that the agency could not adequately assess Boeing’s certification of the system, the report found.
Get more stuff like this
Subscribe to our mailing list and get interesting stuff and updates to your email inbox.
Thank you for subscribing.
Something went wrong.