In a 69-page summary report, the Joint Authorities Technical Review (JATR) concludes that the Federal Aviation Administration failed to properly assess the risks of design changes to Boeing’s 737 Max. Those design changes are now widely considered to have been faulty, but the FAA approved them in 2017.
The panel of global aviation experts determined that the FAA failed to assign sufficient specialists to the 737 Max project, and those who were assigned “had inadequate awareness” of the complex system. In other words, the FAA failed to allocate appropriate resources and expertise to vetting the design changes.
The JATR panel includes experts from the FAA, NASA, the European Aviation Safety Agency and other worldwide regulatory agencies, along with representatives from numerous interested countries.
Additionally, the JATR found that the FAA sometimes failed to follow its own rules or used out-of-date procedures. Furthermore, the panel discovered evidence that some Boeing employees with FAA authority to approved design changes were unduly pressured by the company. Overall, the FAA oversaw the 737 Max’s design changes “in a way that failed to achieve the full safety benefit.”
Finally, the JATR reported that “the design assumptions were not adequately reviewed, updated, or validated; possible flight deck effects were not evaluated.” Moreover, ongoing safety assessments weren’t always performed on time.
Design change was confusing, poorly documented
The JATR was established shortly after the March 10 downing of an Ethiopian Airlines 737 Max which killed all 157 people on board. Previously, a 737 Max owned by Lion Air crashed off the coast of Indonesia, killing all 189 people aboard. The Ethiopian Airlines crash prompted a worldwide grounding of the jet that still remains in effect.
In both crashes, the flight control system apparently malfunctioned and allowed the aircraft to stall. The system, called MCAS, is programmed to automatically lower the plane’s nose when it is pointed too high. The system malfunctioned and repeatedly attempted to send the aircraft into a nose-dive. Chaotic alarms in the cockpit, missing documentation in the manual and failure by pilots to follow Boeing’s recovery procedure contributed to the problem and the pilots lost control.
Specifically, Boeing allegedly failed to incorporate the MCAS into the 737’s flight manuals and, where information was available, didn’t include the “non-normal” and emergency procedures required by regulations.
As we’ve discussed on this blog, the National Transportation Safety Board recently issued new safety recommendations. Since the JATR review, Boeing and the FAA have already begun making some changes that reflect the JATR’s findings. For example, the FAA will now require a panel of airline pilots, rather than test pilots, to test design changes.