A “spectacular” regulatory failure by the Federal Aviation Administration and a Boeing culture that prioritized profit over safety contributed to the two crashes of the 737 Max passenger jet that killed 346 people, a damning congressional report concludes.

The 238-page report, released by the House Transportation and Infrastructure Committee majority on Wednesday, found that while the Lion Air Flight 610 crash on Oct. 29, 2018, and the Ethiopian Airlines Flight 302 crash on March 10, 2019, were nominally caused by the failure of a new steering system in the Boeing 737 aircraft, that system was enabled by a toothless regulatory environment and a company where the desire for profit skewed its prioritization of safety.

“This is a tragedy that never should’ve happened,” said Chairman Peter A. DeFazio, D-Ore.

The committee Democrats’ report, based on an 18-month investigation, reaches conclusions that are thematically similar to the myriad investigations that have occurred since the two accidents: that the certification of the aircraft was fundamentally flawed, that the company was more motivated by profits than safety and that concerns raised by Boeing employees were often ignored.

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The report was released on the same day that the Senate Committee on Commerce, Science and Transportation is scheduled to take up a bill introduced by Commerce Chairman Roger Wicker, R-Miss., and ranking member Maria Cantwell, D-Wash., that would overhaul the FAA’s aircraft certification process by, in part, giving the agency authority to hire or remove Boeing employees tasked with FAA certification duties. 

Ranking member Sam Graves, R-Mo., and Aviation Subcommittee ranking member Garret Graves, R-La., said they will listen to nonpartisan reports and investigations as they work to address the accidents but said the Democratic staff’s investigation “began by concluding that our system was broken and worked backwards from there.”

“We continue to focus squarely on the nonpartisan reports and investigations and the improvements they have identified, and none of them have concluded that the U.S. certification system is fundamentally broken or in need of wholesale reform,” they said.

Still, DeFazio on Tuesday said he is working with Republicans to craft legislation responding to the report’s findings. He said the legislation would examine an FAA process that allows Boeing employees to certify parts of its aircraft, but he does not plan to “scrap” the process altogether. 

The 737 Max has been grounded since March 2019, and Chicago-based Boeing, which faces lawsuits and a criminal investigation, has reeled in the aftermath of the crisis, which has been worsened by the steep drop in airline ridership caused by the coronavirus pandemic. 

‘Hard lessons’

Boeing, in a statement, said it cooperated “fully and extensively” with the committee and is working to strengthen its safety culture. It said it has incorporated many recommendations from experts, committees and governmental authorities into the 737 Max and the overall design process and the revised airplane “has received intensive internal and regulatory review, including more than 375,000 engineering and test hours and 1,300 test flights.”

“We have learned many hard lessons as a company from the accidents of Lion Air Flight 610 and Ethiopian Flight 302, and from the mistakes we have made,” the company said. “Change is always hard and requires daily commitment but we as a company are dedicated to doing the work.”

The report released Wednesday describes the Max as the product of competitive worries. The company had initially sought to create a new aircraft but instead opted to upgrade the existing 737 in 2011, after European competitor Airbus released its new, more fuel efficient A320neo aircraft. A key goal of that new Boeing aircraft was that it not require simulator training, which would’ve provided the company with a competitive disadvantage. 

The upgraded Boeing aircraft, rigged with larger and more fuel efficient engines, had some aerodynamic complications. As a result, the plane could pitch up too high on ascent, creating an increased risk of engine failure. To rectify this, the company added the so-called Maneuvering Characteristics Augmentation System to help prevent the plane from ascending at a risky angle. 

The automated system was designed to push the plane’s nose downward if the plane was ascending at too steep an angle. But in both the Lion Air and the Ethiopian Air accidents, the sensor tasked with detecting that angle failed and the MCAS system repeatedly pushed the nose of the aircraft down, causing dives from which the pilots were ultimately unable to recover. 

Hidden system

“MCAS,” the report read, “was poorly designed, not adequately tested and received flawed oversight by the FAA.”

The Democrats’ report found that pilots of both planes had no reason to be aware that the MCAS system existed.

Boeing rejected a plan to use an indicator light to show when the MCAS system was activated. It downplayed the impact of the new system in order to evade further regulatory scrutiny, according to the report.

The company also sought and received FAA approval to remove references to the system from the airplane’s flight crew operations manual and training materials — part of a larger cost-saving effort to ensure that pilots did not require enhanced training to fly the new aircraft.

Production pressure on Boeing staff was intense, according to the report, which noted that management installed “countdown clocks” to remind workers of the pressure to deliver. 

“Meeting production deadlines rather than safety was a top priority,” said Rep. Rick Larsen, D-Wash., chairman of the committee’s Aviation Subcommittee.

The report was particularly damning to 737 Max leadership, singling out Michael Teal, vice president, chief project engineer and deputy program manager for the 737 Max program, for approving the design of MCAS “despite being unaware of basic facts about the system.” 

Teal, they wrote, was not aware that the system relied on a single sensor, nor was he aware that the system would activate repeatedly. He also did not know that a test pilot who tried to respond to the new system took 10 seconds to do so — a response time that the test pilot called “catastrophic.”

Instead, Teal said none of the employees on the project reported to him, and were instead aligned with different teams. 

Still, Teal nonetheless received a bonus in the form of restricted Boeing stock shares in January 2016. He now serves as vice president and chief project engineer of Boeing’s 777X program. In interviews with committee staff, he defended the aircraft, telling investigators that “we believed that we have a safe aircraft as designed, as intended, and put out with the designs and training associated with it.” 

A second senior official with the Max program, Keith Leverkuhn, now vice president of supply chain propulsion for Boeing Commercial Airplanes, echoed that sentiment. Asked by House investigators if he would consider the development of the Max a success despite the two crashes and the aircraft being grounded for a year, Leverkuhn replied, “Yes, I would.”

Staff members on the committee said they were shocked by the reluctance of company officials to admit a problem.

Committee Democrats also concluded that a cozy regulatory environment contributed to the development of the troubled aircraft, finding the FAA repeatedly opted to side with Boeing over its own technical experts.

The report pointed out the inherent conflict of interest in the so-called Organization Designation Authorization Program, which allowed Boeing employees to certify parts of the aircraft, finding problems with the program “significant.” When those employees questioned the operability of the MCAS system, the report found, Boeing was at times dismissive and often failed to share those concerns with the FAA.

The committee’s investigation admitted it “leaves open” the question of whether Boeing is committed to learning from mistakes made during the development of the Max.

“Boeing has gone from being a great engineering company to being a big business focused on financial success,” it said.