A sweeping congressional inquiry into the development and certification of Boeing's troubled 737 Max airplane finds damning evidence of failures at both Boeing and the Federal Aviation Administration that "played instrumental and causative roles" in two fatal crashes that killed a total of 346 people.
The House Transportation Committee released an investigative report produced by Democratic staff on Wednesday morning. It documents what it says is "a disturbing pattern of technical miscalculations and troubling management misjudgments" by Boeing, combined with "numerous oversight lapses and accountability gaps by the FAA."
Lion Air Flight 610 crashed in October 2018, and Ethiopian Airlines Flight 302 crashed in March 2019, both Boeing 737 Max aircraft.
"The Max crashes were not the result of a singular failure, technical mistake, or mismanaged event," the committee report says. Instead, "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 report is the latest of many investigations into the 737 Max crashes and includes little new information. But it appears to be the most comprehensive in analyzing both Boeing's and the FAA's roles in developing and certifying an ultimately flawed commercial passenger jet.
House Transportation Committee Chairman Peter DeFazio, D-Ore., says one of the most startling revelations uncovered by the investigation is that "both FAA and Boeing came to the conclusion that the certification of the Max was compliant" with FAA regulations. He calls that "mind-boggling."
"The problem is it was compliant and not safe. And people died," DeFazio said, adding that it's "clear evidence that the current regulatory system is fundamentally flawed and needs to be repaired."
"This is a tragedy that never should have happened," DeFazio added. "It could have been prevented and we're going to take steps in our legislation to see that it never happens again as we reform the system."
DeFazio's committee is drafting legislation that would overhaul the aircraft certification process and strengthen the FAA's oversight of airplane manufacturers. The Senate Commerce Committee is expected to take up similar, but somewhat weaker, legislation on Wednesday.
Failures of design, management and regulation
The House committee's report examines Boeing's engineering and technical design flaws, especially in developing a new flight control system called the Maneuvering Characteristics Augmentation System, or MCAS.
Earlier investigations found that in both the Lion Air and Ethiopian Airlines crashes, faulty data from a single angle-of-attack sensor caused MCAS to force the planes into repeated nosedives that the pilots eventually could not pull out of.
The report also details the faulty and outdated assumptions engineers made about how pilots would react in such a crisis and how Boeing failed to install an alert system that could have warned the crew, among other technical failures.
The investigative report outlines the intense pressure Boeing employees were under to keep costs down and the plane's development on schedule, as the company rushed development of the 737 Max to compete with the new Airbus A320neo.
Democratic Rep. Rick Larsen of Washington, whose Seattle-area district includes Boeing factories and thousands of company employees, chairs the House Aviation Subcommittee. He says misguided priorities of senior management drove a number of troubling decisions that put profits ahead of safety.
"In one case, senior management went as far as installing countdown clocks in conference rooms," said Larsen, "making clear to Max employees that meeting production timelines rather than safety was the top priority."
Another troubling finding is what the report calls the "culture of concealment." It documents several critical instances in which Boeing withheld crucial information from the FAA, its customers and 737 Max pilots.
This included concealing the very existence of the MCAS system from 737 Max pilots and failing to disclose that a warning signal to alert pilots of problems with critical sensors was inoperable on the vast majority of the 737 Max fleet.
Dissenters existed but were not heeded
Some Boeing pilots, engineers and other employees did raise safety concerns about the 737 Max, but those concerns were either inadequately addressed or dismissed by Boeing and never reached the FAA.
Aviation journalist Christine Negroni, author of The Crash Detectives: Investigating the World's Most Mysterious Air Disasters,notes that the investigators found substantial evidence that significant red flags were raised.
"As you go through and see the number of people who reported things, the number of emails in which MCAS is discussed," she says, "that tells you that people were concerned. And yet it never saw the light of day until after the first airline crashes."
Negroni says MCAS appeared a half-million times in emails and other internal documents, yet Boeing was able to keep airlines and pilots from knowing the flight control system even existed, as any mention of MCAS was kept out of pilot training and flight manuals.
Negroni says there isn't much new information in the congressional investigative report.
"But in the whole, what is to me astonishing about the report is the depth, the thickness and the deep history of both FAA and Boeing knowing that there were problems with the redesign of this airliner and the obliviousness of both parties in recognizing that this was a problem that needed to be addressed."
The mounting evidence that the plane crashes were preventable is an especially painful realization for the families of those who died in the Max plane crashes.
"It angers us to see how much Boeing did to cover this up and how much FAA has done to help them cover it up," said Michael Stumo. His 24-year-old daughter, Samya Rose Stumo, was on the fatal Ethiopian Airlines flight.
"The Lion Air crash in October of 2018, we now see should not have happened," Stumo said. "But then, the covering up to keep the Max in the air after the Lion Air crash, so that it crashed again in Ethiopia and killed my daughter, was unforgivable."
In a statement, a Boeing spokesman says the company has "learned many hard lessons" from the crashes "and from the mistakes we have made." The statement adds that Boeing has "made fundamental changes to our company as a result, and continue[s] to look for ways to improve."
The FAA says it "is committed to continually advancing aviation safety and looks forward to working with the Committee to implement improvements identified in its report." The aviation regulatory agency says in a statement that it is already implementing initiatives aimed at "improving our organization, processes, and culture." The FAA is also mandating "a number of design changes to the Boeing 737 Max before it returns to passenger service."
The House Transportation Committee is now drafting legislation to improve FAA oversight in the airplane certification process.
Republicans on the committee did not endorse the investigative report. A statement from ranking member Sam Graves of Missouri says "if aviation and safety experts determine that areas in the FAA's processes for certifying aircraft and equipment can be improved, then Congress will act." But he criticized Democrats for an investigation that "began by concluding that our system was broken and worked backwards from there."
Chairman DeFazio says "aviation safety should not be partisan," adding that he is optimistic that the parties can work out differences on FAA reforms.
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