In the United States, the House of Representatives has published their report On the flight safety of Boeing 737 MAX aircraft. The planning and regulatory process, which led to two accidents that claimed a total of 346 lives and a ban on a type of aircraft that has been going on for a year and a half, receives a strong verdict from the House Transport Committee.
“The design and development process for the 737 MAX was plagued by design flaws, a lack of transparency for both authorities and customers, and attempts to downplay or ignore concerns about the machine.”
According to the committee, the U.S. Aviation Authority’s FAA type approval process for the 737 MAX was also “severely deficient” and the authority “failed in its duty to identify safety factors and ensure that they are corrected during the certification process.”
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According to the committee, Boeing was under significant financial pressure to have a serious competitor to the 737 MAX aircraft for the Airbus A320neo series
As a result, production was focused on cutting costs and staying on schedule, with devastating consequences.
This pressure was reflected in the design of the fatal MCAS safety system. As early as 2015 – three years before the first accident – the company was considering whether MCAS was vulnerable in a situation where a single angle of attack sensor would fail. Despite the discussion, Boeing decided that MCAS would operate on the basis of data from only one angle of attack sensor.
The following year, the managers of the 737 MAX project approved a redesign that gave the MCAS system greater authority to intervene in the control of the machine. Just hours after the decision, Boeing applied to the FAA for permission to remove all MCAS references from the aircraft’s official manual — in other words, aircraft-type pilots no longer had access to the system’s existence and the way it affected the aircraft’s flight.
The FAA granted the permit without knowing that the MCAS was to be redesigned.
Boeing had already conducted an internal simulator test at this point, revealing that it even took more than ten seconds for the company’s own test pilot to intervene in the MCAS system, which in turn led to catastrophic results.
Even the chief engineer of the 737 MAX project testified that he was unaware of this, and other critical details, when approving the redesign of the MCAS.
Only after the accident
The new aircraft were equipped with a warning system designed to inform pilots of a situation in which the aircraft’s angle of attack sensors would provide conflicting data.
Three months after the aircraft type had started commercial traffic, Boeing discovered a technical failure that caused this so-called AOA (angle-of-attack) Disagree warning system to fail in about 80 percent of the aircraft individuals.
The company ended up postponing a remedial software update until 2020 to implement it when the largest machine version, the 737 MAX 10, was completed. Boeing had also written a technical bulletin about the system failure, which it did not send to the 737 MAX operators.
A year later, Boeing sent a manual to Lion Air, an Indonesian operating another aircraft that would be involved in an accident in the future, in which it accurately described the operation of the AOA Disagree alarm without any indication in the documentation that the alarm system was malfunctioning.
“Boeing knowingly betrayed the pilots and the airlines that were their customers,” Congress notes.
The system fault was only reported after the first accident.
Not mentioned in the release
Even in this situation, a few days after the crash, Boeing and the FAA sent a bulletin to the 737 MAX operators not even mentioning the MCAS system.
It was not until some airlines specifically inquired about the operation of the system from Boeing that the company informed its customer companies.
In December 2018, the FAA conducted an internal risk assessment, based on which it estimated that without a redesign of the MCAS system for the 737 MAX fleet, up to 15 airplane accidents could occur over its lifecycle, resulting in 2,900 deaths.
Despite this, and other cautionary examples, the authority did not ban the aircraft until another devastating accident occurred in March 2019.
Endangered flight safety
According to the Committee, the FAA’s approach has also jeopardized aviation safety. In several cases, FAA management has overridden the views of its agency’s technical experts to make decisions in favor of Boeing.
Indeed, many FAA employees believed that the agency’s management was too concerned about the success of the aircraft industry at the expense of safety.
According to the committee, “the main findings of the report reflect a corporate culture that is in dire need of reform in its relationship with security. Boeing has transformed from a fine engineering company into a business giant focused on financial success. If it continues with its old ways, the company risks repeating the mistakes made with the 737 MAX and suffering further reputational and financial losses. ”
In its concluding opinion, the committee states that it leaves open whether Boeing is really willing to admit and learn from the mistakes it has made.
The aircraft manufacturer commented on the report in a press release in which it emphasized that it had made significant changes to the 737 MAX aircraft. According to Boeing, it has full confidence in the safety of the aircraft type.
“Change is always difficult and requires daily commitment, but our company is dedicated to doing the necessary work.”
The story was originally published In Tekniikka & Talous magazine.