An Aviation Whistleblower report issued Tuesday by a US Senate committee cites numerous oversight gaps within the government and the aviation industry.
The report [PDF] was produced at the behest of the Senate Committee on Commerce, Science, and Transportation in response to two Boeing 737 MAX crashes in 2018 and 2019 that killed 346 people. It is based on testimony from seven industry whistleblowers from Boeing, GE, and the Federal Aviation Administration (FAA).
Boeing designed the 737 Max to compete against the Airbus A320neo. In order to achieve comparable fuel efficiency, Boeing basically put new engines on the existing 737 air frame, which allowed the passenger jet to avoid going through a new regulatory approval process.
Boeing 737 Max chief technical pilot charged with deceiving US aviation regulators over MCASREAD MORE
The resulting 737 Max, however, had different handling characteristics from the 737, and Boeing attempted to compensate by adding a software layer called MCAS, the Maneuvering Characteristics Augmentation System.
MCAS adjusts the aircraft's trim, setting plane control surfaces to maintain a set attitude. It was designed to do so based on input from a single angle-of-attack sensor, compared to three sensors in the comparable Airbus model. And it proved to be disastrous.
In 2018, Lion Air Flight 610, a 737 Max, crashed near Jakarta, Indonesia, due to false sensor readings that MCAS used to put the plane in full nose-down trim, from which the crew did not have time to recover.
In 2019, the pilots of Ethiopian Airlines Flight 302, also a 737 Max, attempted to counteract the effects of MCAS but could not physically move the mechanical trim wheel due to the aerodynamic force from plunging toward the ground.
Boeing in January agreed to pay $2.5bn to settle criminal charges arising from the two fatal 737 Max crashes. The manufacturer did not admit guilt, however, which would have prevented it from receiving future government contracts. Instead, it entered into a deferred prosecution agreement.
No company executive faces imprisonment for the misconduct that the biz has acknowledged. Boeing fired CEO Dennis Muilenburg in late 2019 over the 737 Max accidents and he departed with $62m in compensation.
The Justice Department in October indicted Mark A. Forkner, a former Boeing 737 MAX chief technical pilot, for fraud. The government contends Forkner provided the FAA with false, inaccurate, and incomplete information about MCAS and that led to the misunderstandings that contributed to the two crashes.
The Senate's Aviation Whistleblower report follows on the heels of the Aircraft Certification, Safety, and Accountability Act, an aviation safety reform law enacted in December, 2020, to address the problems that led to the two crashes.
It details testimony from Ed Pierson, a former Boeing senior manager, who described 13 other reported safety incidents with the 737 Max that did not result in any loss of life. He observed:
Most shocking of all, 11 of these 13 safety incidents occurred in the five months between the Lion Air crash and the Ethiopian Airlines crash. Thus 2 safety incidents per month. So at a time when Boeing and the FAA should have been operating at an extremely heightened sense of awareness after the Lion Air crash, the MAX continued to average two safety incidents per month for the five months leading up to the Ethiopian Airlines crash. At this rate, if the MAX had not been grounded in March 2019, there could have been another 42 safety incidents involving airplane systems (other than MCAS) by December 2020—which means a correspondingly higher probability of another fatal accident.
The report has found that the FAA certification process places aviation personnel under undue pressure.
For example, Richard Kucera, a former GE Aviation engineer, recounted "being placed in an untenable position where he was responsible for conducting engine conformity tests on behalf of [the] FAA, while also being charged with preparing GE engines to pass these same tests." And Boeing personnel, it's said, faced "relentless" schedule pressure with regard to the 737 Max.
The FAA, whistleblowers said, had too few safety engineers in its Seattle office overseeing Boeing, and had certification processes that did not reflect current airworthiness standards.
Not only that, senior FAA engineers who raised safety concerns "were sidelined during the 737 Max certification," the report states.
The FAA and the aviation industry, according to the report, also faces a challenge certifying and operating complex technical systems that involve the interaction of both people and automated systems, compounded by the scarcity of experts who truly understand these systems.
While automated flight control systems can enhance safety, increased reliance on automation creates new safety challenges
"While automated flight control systems can enhance safety, increased reliance on automation creates new safety challenges," the report says.
"These range from failure of pilots to correctly operate automated flight systems, to software malfunctions that generate faulty data, to the degradation of manual piloting skills."
The report makes numerous recommendations to augment the FAA's oversight capabilities, particularly with regard to its Organization Designation Authorization (ODA) program – by which the US aviation watchdog delegates its watching duties to workers at companies it's supposed to watch.
This practice of letting employees of aviation firms act on behalf of FAA personnel, as the report notes, has led to the approval of systems that should not have been approved.
For example, Michael Collins, a former FAA engineer, testified that FAA managers delegated 95 per cent of the certification of the Boeing 787 Dreamliner to Boeing personnel.
"This delegation decision included the certification of new high-risk battery installation technology, a decision made against the recommendation of a technical specialist who identified the system’s safety critical design flaw," the report stated.
"In the absence of FAA technical and safety engineer oversight, Boeing’s ODA found the lithium battery system design to be compliant. Later on, this exact design flaw led to dangerous 787 fire incidents and the eventual FAA grounding of the 787 Dreamliner." ®