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“Technical design flaws, lack of transparency and failed oversight” led to two 737 MAX crashes

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Last week saw the publication of the damning final US House Committee on Transport & Infrastructure report on the ‘Design, Development & Certification of the Boeing 737MAX,’ and it doesn’t take any prisoners.

The results of the report suggest that the deaths of 346 people on Lion Air 610 and Ethiopian Airlines 302 were avoidable had Boeing not downplayed the differences between the MAX and previous generation 737s.

The Federal Aviation Administration also gets its share of the blame. It is criticised for delegating its oversight abilities to Boeing itself and even overruling its own experts at Boeing’s request:

“The MAX crashes were not the result of a singular failure, technical mistake, or mismanaged event. 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 pernicious result of regulatory capture on the part of the FAA with respect to its responsibilities to perform robust oversight of Boeing and to ensure the safety of the flying public.”

Five fundamental flaws

The investigation found five central themes that occurred across the design, development and certification of the fourth generation of the Boeing 737, first introduced in 1968.

Production pressures‘ and a focus on cutting costs in order to compete with Airbus on the A320neo. This included the desire to avoid greater FAA certification, additional pilot simulator training and consequently increased costs.

Faulty design and performance assumptions‘, in particular with MCAS, the Maneuvering Characteristics Augmentation System that was implemented to compensate for the unbalanced physical characteristics of the aircraft thanks to its engines. The aerodynamic effect of the heavier, larger LEAP-1B engines meant that the 737 MAX would tend to ‘pitch up’ with its nose. MCAS was designed to reduce this effect in manual flight by forcing the nose down. Furthermore, MCAS was not based on a redundant system but could be caused by a single point of failure.

A ‘culture of concealment’ which meant that neither flight manuals nor pilot training mentioned the introduction of MCAS on the 737 MAX or how to mitigate its effects in the event of a sensor failure. Boeing also concealed internal test data which revealed that it took Boeing’s own test pilot more than ten seconds to identify and respond to MCAS activation and which the pilot found ‘catastrophic’.

Conflicted representation‘ in which Boeing’s own employees, acting on behalf of the FAA during the certification process, failed to make the FAA aware of important information that could have improved the safety of the 737 MAX. In some cases, the ‘authorised representatives’ at Boeing raised concerns internally but were dismissed by other Boeing employees, resulting in no design changes.

Boeing’s influence over the FAA oversight structures‘ meant that FAA management sided with Boeing executives over the FAA’s own safety experts.

Boeing 737 MAX scimitar wingtip

Boeing executive still thinks the 737 MAX is a success

Even more worryingly, former Vice President and General Manger of the 737 MAX program, who stepped down in April 2018, still considers the 737 MAX a successful program despite 346 avoidable deaths:

T&I Committee staff: In light of the two crashes and the fact that the MAX has been grounded for more than a year, would you consider the development of the MAX a success?

Keith Leverkuhn: Yes, I would. …. I do challenge the suggestion that the development [of the 737 MAX] was a failure.

Not a particularly good look.

Conclusion

For many years, the phrase ‘if it ain’t Boeing, I ain’t going’ was a boon for Boeing’s marketing teams, implying that Boeing had a superior safety culture.

The final committee report suggests a complete reversal of the sentiment:

The Boeing Company needs to restore its reputation as a company focused squarely on safety and quality as Mr. Boeing envisioned and demanded. By heeding the horrific lessons from the MAX accidents, Boeing can and must take significant steps to create and maintain an effective, fulsome, and forthright safety culture. This would help to reinvigorate its workers’ morale and public confidence that Boeing is on the road to recovery stemming from the flaws that have been exposed as a result of the MAX crashes.

However, the Committee’s investigation raises questions regarding Boeing’s commitment to doing that or even to simply acknowledging that it made mistakes in the design, development, and certification of the 737 MAX aircraft.

The only silver lining is that the 737 MAX is likely to be the most-scrutinised aircraft on the market once it completes re-certification by the FAA, European Union Safety Agency and Transport Canada. Any future 737 MAX deliveries should be extremely safe, although the report doesn’t instil confidence for Boeing’s other aircraft programs.

It will be interesting to see what happens with IAG’s Letter Of Intent for 200 737 MAX aircraft, with BA’s share originally due to be deployed at London Gatwick. This is likely to be the cheapest short-haul aircraft deal negotiated in the last decade – Willie Walsh always envied how Ryanair achieved substantial discounts on large orders after 9/11 – but it seems unlikely at present that it will become a firm order.

You can read the full 245 page report here.

Comments (70)

  • Doug M says:

    I wonder what if any progress Boeing have made towards a new single aisle plane without all the problems of the 50+ year old design.

  • AndyC says:

    “…lead to the two 737 MAX crashes…”. “Led”??

  • George K says:

    As long as Boeing is in a state of denial over its responsibilities, the Max does not deserve to return to the skies. I would argue that its flawed design would alone be a good reason to scrap it, but no, this is so much more than that.

    Quite worryingly, some Max designers who still assert that there is nothing fundamentally wrong with their work, have gone on to work on the 777X, which is something of a reward rather than any form of punishment..

    https://www.wsj.com/articles/former-top-boeing-737-max-officials-defend-design-process-11599959139

    • Alex W says:

      @george K Boeing’s state of denial does appear to be a serious issue and contrary to safety culture. However with 400 new or nearly new MAX’s out there, it would make sense to fix rather than scrap them all.

  • Novice says:

    I remember when I read about the crashes I was touring Argentina and had a lot of domestic flights and for the first time ever I was fretting about which planes were being used. Honestly, I’m not nervous on planes. So, this is not good for them at all. Especially if any ppl who are nervous on planes read this report.

  • Mark says:

    I have to say that I won’t be rushing to get on a Max when they do return. I wouldn’t be particularly keen to get on a 777X until they’ve been flying for a while either. I no longer assume that Boeing can be relied on to design or manufacture safe aircraft and I’ve yet to see anything in Beoing’s response to the crisis that persuades me that they have adequately learned from it.

    I’d much rather fly on an Airbus right now, or something that has a good few thousand flight hours minimum.

    • AJA says:

      I’m with you, I am not inclined to fly on the 737Max or whatever it gets renamed anytime soon. Is the 777X the one with the folding wing tips? Not sure I want that either. Mind you I have yet to fly on an A380 and at this rate given that it looks like that isn’t going to be around for much longer I may well never get to do that.

      The issues with the design of the 737Max seem problematic and all to do with the bigger Leap engine being mounted further forward and closer to the fuselage disrupting the balance and aerodynamics requiring the MCAS to compensate. That sounds in retrospect like a disaster that was waiting to happen.

  • Tocsin says:

    There may also be a “devil’s halo” effect: “Boeing, don’t they have safety problems?” irrespective of the actual type to be flown…

  • BJ says:

    A great articles from Rhys today accompanied by an interesting discussion so thanks to all. Given that, the limited number of readers contributing is perhaps a little disappointing IMO and quite telling I think. If even HFP readers are not that interested then clearly the public at large don’t give a toss what they are flying in as was discussed earlier.

    • Peter K says:

      Just because we are not all replying doesn’t mean we’re not interested. Just that we have nothing to add.

      • BJ says:

        Good point 🙂 Maybe Rhys or Rob could share page views with us, or at least whether they are above or below average? It would be interesting to shed some light on HFP readers reaction to safety articles.

      • BSI1978 says:

        +1.

        Absolutely interested in this, but the discussion became much more technical which is great, but absolutely nothing I can add on that front. Suffice it to write that I will however be keeping an eye on whatever name designation they give this going forward.

        Boeing’s response to this so far has been shameful.

  • yorkieflyer says:

    We have flown the MAX from Edinburgh to Stewart and I rather wish it was an experience we won’t repeat. Obviously we had no idea as to the flaws of the design and obviously neither did the pilots….I can’t say I’m keen on any civil airliner being aerodynamically unstable and a software fix being required, whether or not disclosed. There have been a number of badly designed aircraft over the years, the DC10 and its successor the MD11 spring to mind, flown both.
    I rather thought/hoped that the years that have passed and the undoubted improvement in air safety was partly due to better design, obviously not in the case of Boeing.
    This just follows on from the Dreamliner issues, largely stemming from the Charleston plant, so it’s not a one off…
    I’m a little worried as being from the north we’re a little dependent on Ryanair who still seem dead bent on the MAX?

    • Alex W says:

      The MAX (or whatever it will end up being called) is not aerodynamically unstable. True, it does use software to improve handling qualities in some areas of the flight envelope, but then so do all modern airliners. Given the level of scrutiny the fixed MAX will be very safe.