By Andy Pasztor and Andrew Tangel
Inadequate U.S. safety oversight, combined with Boeing Co.'s
failures to properly assess and communicate important design
changes, contributed to two fatal 737 MAX crashes, according to the
most comprehensive outside review of the plane's approval
process.
The findings released Friday, assembled by a panel of U.S.
safety experts and nine foreign aviation regulators, criticized the
Federal Aviation Administration on a range of issues, including
relying on outdated certification procedures, maintaining
insufficient technical staff and failing to fully incorporate human
factors in approving automated cockpit systems.
According to the panel, the FAA should consider fundamental
changes to its longstanding oversight and engineering principles
because aircraft designs have become more complex, with different
systems interacting in unforeseeable ways. Because traditional
"regulations and standards will not address every conceivable
scenario," according to the nearly 70-page document, the new focus
should be on more flexible agency responses, particularly earlier
and deeper involvement of FAA experts in reviewing important design
decisions.
The FAA also should rely less on pilot reactions as fail-safe
protections in emergencies and incorporate likely real-world
cockpit responses -- instead of those expected from highly skilled
test pilots -- as part of formal risk analyses, the group
determined.
In the case of the 737 MAX, the panel found the FAA fell short
in many of those areas.
FAA chief Steve Dickson said in a statement, "I will review
every recommendation and take appropriate action." He added that
"we welcome this scrutiny and are confident that our openness to
these efforts will further bolster aviation safety world-wide."
Overall, the findings paint a picture of an FAA certification
process lacking predictability, needing updated technical guidance
and prone to inadequate communication between industry and
government participants. In addition to broad policy
recommendations, the report is filled with dozens of findings and
observations targeting specific phases of the certification
process.
The outside experts -- who included representatives from Europe,
Canada, China, Indonesia and Brazil -- were equally critical of
lapses by the Chicago plane maker in devising an automated
stall-protection system, called MCAS, which misfired to bring down
the two jets, taking 346 lives. In crashes five months apart, the
planes nosedived in Indonesia and Ethiopia after faulty sensor data
prompted MCAS to similarly push down the noses of the aircraft
despite efforts by pilots to pull out of steep dives.
Boeing, among other missteps, failed to update its own safety
analyses or inform the FAA about the extent of design changes that
made MCAS more powerful, according to the document. "The
information and discussions about MCAS were so fragmented and were
delivered to disconnected groups, " according to the panel, meaning
that relevant FAA officials didn't have a complete sense of the
automated flight-control feature's operation, fully recognize its
potential hazards or conduct a truly independent assessment of
whether it met safety requirements.
In addition, the report noted there was an indication of "undue
pressure" on some Boeing engineers working on the system as
designated FAA representatives. Such an indication, according to
the outside experts, "further erodes the level of assurance in this
system of delegation."
A Boeing spokesperson said the company is "committed to working
with the FAA in reviewing the recommendations and helping to
continuously improve the process and approach used to validate and
certify airplanes going forward."
The panel criticized Boeing's own process for designing MCAS,
saying it failed to identify the system's potential hazards. The
group said the plane maker also should have highlighted MCAS to
federal regulators given its important differences compared with a
military refueling tanker's version of the system that included key
safeguards.
Making MCAS for the 737 MAX rely on pilot action as a primary
backstop, before dealing with the system's potential hazards, "is
not in accordance with Boeing's process instructions for safe
design," according to the findings.
The report follows comments by Boeing Chief Executive Dennis
Muilenburg, who has defended the company's development of the 737
MAX. In April, Mr. Muilenburg said there had been "no technical
slip," adding in a call with investors: "There was no surprise or
gap or unknown here or something that somehow slipped through a
certification process."
In Washington, D.C., the report fueled criticism of the FAA and
Boeing.
The report raises concerns "that undue pressure may have been
placed on individuals at the FAA and Boeing to get the MAX into
service as quickly as possible," said Rep. Peter DeFazio of Oregon,
the Democratic chairman of the House Infrastructure and
Transportation Committee, who is heading up another review of the
jet's approval. Mr. Muilenburg is scheduled to testify before Mr.
DeFazio's committee Oct. 30.
U.S. Sen. Richard Blumenthal (D., Conn.) said the report's
"absolutely scathing portrait of systemic failure" called for an
independent review of the FAA's efforts to allow the MAX to again
carry passengers. The aircraft has been grounded by world
regulators since the second crash in March.
"We need to be sure that the system really works and that the
FAA gets it right this time," Mr. Blumenthal said in an
interview.
The safety panel's recommendations, as reported earlier by The
Wall Street Journal, also touched on inadequate data sharing by the
FAA with international authorities.
Some of the recommended changes were previously outlined by the
U.S. National Transportation Safety Board in a separate move, while
others already have been embraced by the FAA's leadership.
The panel, called the Joint Authorities Technical Review,
originally was assembled by the FAA as part of a strategy to
promote international consensus and pave the way for speedy return
of the MAX fleet to commercial service. But as the study group
delved into the missteps that beset the troubled jet -- and
Boeing's effort to devise software fixes lagged many months behind
schedule -- the report turned into a pointed, sometimes harshly
worded critique of the FAA's current system for approving new
airplane designs.
Write to Andy Pasztor at andy.pasztor@wsj.com and Andrew Tangel
at Andrew.Tangel@wsj.com
(END) Dow Jones Newswires
October 11, 2019 18:29 ET (22:29 GMT)
Copyright (c) 2019 Dow Jones & Company, Inc.
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