Two Boeing plane crashes that killed 346 people in five months were the “horrific culmination” of design flaws, poor government oversight and lack of action by the planners, US researchers said.
Boeing and the Federal Aviation Administration were both criticized in a damning report by the House Transportation Committee following the crashes in Indonesia in October 2018 and Ethiopia in March 2019.
Both planes affected were Boeing 737 Max 8 jets – a model that met FAA requirements but was grounded around the world after the second disaster 18 months ago.
“The fact that a compliant plane has suffered two fatal crashes in less than five months is clear evidence that the current regulatory system is fundamentally flawed and needs to be fixed,” said the report released Wednesday.
Boeing was criticized in a house committee report after two crashes in 2018 and 2019 (photo, the jet that crashed in Ethiopia last March)
Regulators are testing aircraft with updated flight control software, and Boeing hopes the Max will be able to fly again by the end of this year or early 2021.
The researchers mainly focused on why Boeing was able to get the jet approved with minimal pilot training: It convinced the FAA that the Max was an updated version of the previous generation of 737s.
In fact, Boeing equipped the plane with software called MCAS, short for Maneuvering Characteristics Augmentation System, that automatically lowers the plane’s nose to prevent an aerodynamic blockage.
Initially, pilots around the world were not told about the system, which Boeing said was necessary because the Max had larger, more powerful engines.
In both crashes, MCAS repeatedly pointed the nose down, forcing pilots into unsuccessful struggles to keep the planes in the air.
The commission’s investigators said they had found several cases where Boeing had hidden information about MCAS from the FAA and airlines.
The Chicago-based company has not disclosed that MCAS was working with a single sensor called ‘angle of attack’, which measures the height of an aircraft.
It also didn’t reveal that a gauge that would have warned pilots of a faulty sensor wasn’t working on the vast majority of jets.
Boeing also hid that it took a company’s test pilot more than 10 seconds to determine that MCAS was working and responding to it, a condition the pilot found “ catastrophic, ” according to the report.
Federal guidelines assume that pilots will respond to this condition within four seconds.
Ethiopian emergency services are working on the site of the crash near Addis Ababa on March 10, 2019
Four Boeing employees authorized to act on behalf of the FAA to validate aircraft systems were aware of the test pilot’s slow response, the report said, but there was no evidence they had reported it to the FAA, the report said.
Another representative expressed concern in 2016 about the dangers of MCAS by repeatedly pointing the aircraft’s nose down, but the concerns never reached the FAA.
Repeated MCAS activation and faulty sensors “were the main factors leading to the Lion Air and Ethiopian Airlines crashes more than two years later,” the report said.
The committee has identified many shortcomings in the FAA approval process for new jetliners.
The report highlights the need for legislation to secure approval, said committee chairman Peter DeFazio.
“The system is clearly inadequate,” said DeFazio, a Democrat. “We are going to implement important reforms.”
DeFazio would not provide details on possible changes, saying the committee leaders are in talks with Republicans about legislation.
Senators today are considering a bill filed in June that would give the FAA more control over selecting company employees who sign their security decisions.
An improvement may be that an aircraft with significant changes from previous models would require more FAA rating.
According to the report, Boeing wanted to keep details about MCAS from the FAA so that no additional pilot training was required.
Additional training would have ruined Boeing’s sales pitch for the Max, that pilots of older 737s wouldn’t have to undergo extensive simulator training to fly the new planes.
Researchers found that Boeing had a financial incentive to avoid more pilot training. Under a 2011 contract with Southwest Airlines, Boeing should have gotten a $ 1 million discount on the price of each Max if simulator training had been necessary.
“That resulted in a lot of really bad decisions internally at Boeing, and the FAA didn’t include these things,” DeFazio said.
He added that Boeing had an internal meeting in 2013 and agreed never to talk about MCAS outside the company.
At one point, MCAS was listed in pilot manuals, but an authorized representative signed off to remove it, he said.
An Indonesian officer holds the Lion Air JT610 flight data recorder shortly after it was found underwater in November 2018
In a statement, Boeing said it has been working to strengthen its safety culture and has worked with the committee. The company has taken many recommendations from committees and experts who have researched Max issues.
Boeing said it has learned from mistakes.
“Change is always difficult and requires daily commitment, but we as a company are committed to doing the work,” the statement said.
The FAA said in a statement that it looks forward to working with the committee to make improvements, and is already making changes based on internal and independent reviews.
“These initiatives are aimed at improving overall aviation safety by improving our organization, processes and culture,” said the FAA, adding that some design changes are required to the Max before it can fly again.
When it came to FAA oversight, researchers said they had found multiple examples of agency managers overruling technical and safety experts on behalf of Boeing.
A draft FAA poll said many in the FAA believe aviation officials are “ too concerned about achieving the business-focused results of industry stakeholders and not held accountable for safety-related decisions, ” the report said.
In an interview with investigators, Keith Leverkuhn, former Boeing general manager for the Max who received his PhD in the company, said he considered the development of the Max a success despite the crashes.
“I dispute the suggestion that the development was a failure,” the report quotes him.
Researchers wrote that this raised doubts about Boeing’s ability to change.
Only a genuine, holistic and assertive commitment to changing the cultural issues exposed in the commission’s investigation … can improve aviation safety and really help both Boeing and the FAA learn from the terrible lessons. of the 737 Max tragedies, ”the report said.
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