By The Washington Post · Ian Duncan, Michael laris, Lori Aratani · NATIONAL, BUSINESS, CONGRESS, TRANSPORTATION
The watchdog's review concluded that Boeing decided as early as 2013 to portray the new automated feature as simply a modification of the plane's existing controls - a decision in keeping with the company's goal of minimizing the new training pilots would need on the aircraft, saving its customers money.
But the feature, known as the Maneuvering Characteristics Augmentation System (MCAS), continued to evolve during the plane's development, becoming more powerful, and staff members with the Federal Aviation Administration told auditors that they made key decisions about the feature without knowing that it had been altered. What's more, the final flight tests of the Max's control systems in late 2016, just a few months before the FAA granted the plane its final blessing, included some tests using the old, less powerful, version of the feature because Boeing was continuing to update it.
The result of those and other decisions meant FAA officials signed off on a system without a clear sense of how it worked and instead chose to focus on other areas regulators deemed high risk during the certification process, including the aircraft's larger engines and changes to its landing gear, the inspector general wrote.
The core of the inspector general's interim report was a detailed timeline that reads like a compendium of missed opportunities that resulted in tragedy.
In response, the FAA pointed to a letter from the Department of Transportation outlining several improvements that are being made in the agency's policies and procedures.
Boeing, in a statement, said: "We appreciate the Inspector General's efforts in reviewing the 737 MAX design and certification process, with which we have cooperated fully and extensively."
"Since the accidents, multiple committees and governmental authorities have examined issues related to the MAX, and in response to their findings and our own internal reviews, we have made substantial changes within our company to further enhance our commitment to safety. We are committed to transparency with the FAA during all aspects of the airplane certification process, and have made significant changes to improve our support to that regulatory process," the company said.
The release of the report comes the same week that FAA pilots and staff from Boeing completed a series of test flights on the Max, which has been grounded worldwide since March 2019 following the two crashes. The flights are seen as a key step for Boeing to win certification of the aircraft, but a number of other requirements must be met, including the evaluation of data gathered from the three days of testing.
The inspector general offered no recommendations, saying those may be included in future reviews of pilot training requirements, the FAA's oversight of the certification process and other related matters.
The inspector general reviews also chronicled the FAA's oversight of Boeing under a system known as Organization Designation Authorization, which gives manufacturers such as Boeing broad powers to perform much of the certification work for their own aircraft. The inspector general had, before the two Max crashes, identified deficiencies in the FAA's oversight of its delegation system, and the details outlined in its latest report point to additional shortcomings. For example, the report notes that the FAA's Boeing Aviation Safety Oversight Office has just 42 employees to oversee Boeing's 1,500 representatives.
The two fatal 737 Max crashes happened less than five months apart - the first on Oct. 29, 2018, off the coast of Indonesia, and the second March 10, 2019, in Ethiopia - killing a total of 346 passengers and crew members. Crash investigators say a faulty reading from one of the planes' sensors caused the MCAS to repeatedly activate, pushing the planes' noses down and making it virtually impossible for the pilots in both incidents to regain control.
The tragedies damaged the reputation of one of the United States' leading manufacturers and led to the ouster of its chief executive, Dennis Muilenburg, in December, as well as several other key company officials. It also led to scrutiny of the relationship between the FAA and the companies it is supposed to regulate.
Company emails uncovered as part of a separate congressional investigation showed several instances in which employees bragged about "Jedi mind tricking" regulators and showed contempt for their own internal process. In one 2017 exchange, a Boeing employee wrote, "this airplane is designed by clowns who are in turn supervised by monkeys."
Boeing's new leader, Dave Calhoun, has pledged to rebuild trust in the company, which has lost billions in revenue because of the Max crisis.
Some of the concerns raised by the nonpartisan inspector general have been raised in other reports, but this latest examination offers the clearest summary of the actions taken by Boeing and the FAA throughout the certification process and in the aftermath of the two crashes.
"I commend the DOT Office of the Inspector General for agreeing to take on this critically important examination of the FAA's certification of the Boeing 737 MAX," said Rep. Peter DeFazio, D-Ore., chairman of the House Transportation and Infrastructure Committee, which has conducted five hearings on the Max. "This IG report reinforces some of the findings of our Committee's ongoing investigation, which has revealed a number of disturbing patterns, including Boeing's efforts to conceal critical information from regulators in its rush to get the MAX to market."
DeFazio said his committee will release additional findings from its investigation.
In a joint statement, Reps. Sam Graves, R-Mo., and Garret Graves, R- La., minority leaders on the committee, said it is critical that lawmakers use the inspector general's work and findings from other groups as Congress moves forward on possible changes.
"This is just the first step in the OIG's process, but this report shows the FAA's certification process at the time was followed and decisions made were based upon certain assumptions that we now know must be reevaluated by the FAA and Boeing," the lawmakers said. "In particular, we are very interested in the OIG's continuing review of FAA's processes for determining the certification basis, assessing pilot training needs, and conducting risk analyses."
The inspector general's report showed that the FAA did not sufficiently require complete, timely and trustworthy information from Boeing.
Boeing did not communicate its own formal risk assessment to the FAA regarding the automated feature until a few months before the FAA certified the Max, the report found.
"According to FAA management, it is not unusual for manufacturers to complete and submit the safety assessments toward the end of the certification process," according to the report.
And even then, the FAA relied on flawed Boeing findings. The company did not anticipate "catastrophic" results from a failure of the automated feature, the report said. As a consequence, neither Boeing nor the FAA called for installing key safety redundancies, which experts say could have saved the planes.
An FAA spokesman declined to respond directly, referring instead to a response from a deputy to Transportation Secretary Elaine Chao.
The report points to "some strengths in FAA's aircraft certification process, as well as areas for improvement," General Counsel Steven Bradbury told the inspector general in a letter last month.
Bradbury said the "FAA anticipates strengthening coordination" among agency officials responsible for certification, "as well as enhancing its human factors, flight controls, and system safety expertise to address weaknesses that led to an incomplete understanding of MCAS prior to certification."
Sen. Roger Wicker, R-Miss., chairman of the Senate Commerce Committee, which oversees aviation, and ranking Democrat Sen. Maria Cantwell of Washington state, have jointly introduced legislation that would strengthen the FAA's oversight of Boeing employees who conduct safety work on behalf of the agency and ensure that government and company employees are free to communicate with one another. The bill would also require the FAA to rethink its approach to evaluating the risks posed when automated flight systems and human pilots have to work together.
Previous reviews of the Max crashes have concluded that the agency and Boeing did not anticipate the difficulty some pilots would have overriding the MCAS if it failed.
House Democrats also are expected to introduce legislation following an extensive investigation into Boeing and the FAA. An interim report they released branded the agency as "grossly insufficient" in its initial review of the Max and blamed Boeing for having a "culture of concealment."
Meanwhile, the FAA continues to move forward with test flights in the Seattle area. The flights are an important step toward approving the Max to resume flying. The planes are being put through a set of maneuvers and emergency procedures to test whether changes Boeing made after the crashes meet the FAA's standards.
FAA Administrator Steve Dickson has said that the coronavirus pandemic has not slowed the agency's work in reviewing the Max. But he told members of Congress recently that convening a panel involving pilots from around the world, another important step in the process, could be challenging. Dickson has said he will personally fly a Max before signing off on ungrounding it.
"The report reinforces concerns that have been raised by the Commerce Committee, including Boeing's lack of candor during the certification process, FAA's questionable oversight of critical safety systems, and the FAA's response after the Lion Air crash," Wicker said. "Although the IG report does not include recommendations, it does provide a factual basis for further consideration of bipartisan aviation safety legislation that Senator Cantwell and I have introduced."