Internal FAA Review Saw High Risk of 737 MAX Crashes

Date : 12/11/2019 @ 6:47PM
Source : Dow Jones News
Stock : Boeing Co (BA)
Quote : 306.2719  -17.8781 (-5.52%) @ 7:14PM

Internal FAA Review Saw High Risk of 737 MAX Crashes

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By Andy Pasztor and Andrew Tangel 

U.S. regulators decided to allow Boeing Co.'s 737 MAX jet to keep flying after its first fatal crash last fall even after their own analysis indicated it could become one of the most accident-prone airliners in decades without design changes.

The November 2018 internal Federal Aviation Administration analysis, released during a House committee hearing Wednesday, reveals that without agency intervention, the MAX could have averaged one fatal crash about every two or three years. That amounts to a substantially greater safety risk than either Boeing or the agency indicated publicly at the time.

The assessment, which came the month after a Lion Air crash in Indonesia, raises new questions about the FAA's decision-making in the wake of that disaster, along with what turned out to be faulty agency assumptions on ways to alleviate hazards.

In the wake of the analysis, the FAA took steps to put short-term and permanent measures in place to combat hazards, but Wednesday's hearing started off with challenges to some of those decisions.

"Despite its own calculations, the FAA rolled the dice on the safety of the traveling public and let the 737 MAX continue to fly," said Rep. Peter DeFazio (D., Ore.), chairman of the House Transportation Committee.

The FAA's intervention proved inadequate after a second fatal MAX crash, in Ethiopia in March, led to the global grounding of the fleet and sparked an international controversy over the agency's safety oversight.

Mr. DeFazio said more than 500,000 documents gathered by his panel from the FAA and Boeing, combined with emails and interviews, have "uncovered a broken safety culture within" the company and the agency. The FAA "was unknowing, unable or unwilling to step up, regulate and provide appropriate oversight of Boeing," he said. "The FAA failed to ask the right questions and failed to adequately question the answers that agency staff received from Boeing."

FAA chief Steve Dickson said he would review the procedures used to certify the MAX and left open the possibility of further enforcement actions holding Boeing accountable for ongoing production errors and inadequate information-sharing related to design decisions.

"I reserve the right to take further action," he said.

But he defended FAA personnel while acknowledging agency missteps.

"The system is not broken," he told the panel.

An FAA spokesman said Tuesday: "It was clear from the beginning that an unsafe condition existed," adding that the analysis "provided additional context in helping determine the mitigation action." In an email, the spokesman said such analyses tend to overstate risk because they take the most conservative approach and because specifically identified problems likely appear more serious than they do in the operating fleet.

A Boeing spokesman declined to comment.

Mr. DeFazio's opening line of questioning also examined the FAA's overall safety oversight strategy, including designs of other models. "Our investigation has revealed that many of the FAA's own technical experts and safety inspectors believe FAA's management often sides with Boeing rather than standing up for the safety of the public," he said.

The FAA's analysis projected as many as 15 similar catastrophic accidents globally over the life of the MAX fleet -- spanning 30 to 45 years -- unless fixes were made to a particular automated flight-control system.

The conclusion of the risk assessment, according to a Wall Street Journal analysis, characterized the MAX, before software changes, as potentially more prone to crash than several earlier Boeing models.

The projected crash total, according to the Journal's analysis, was roughly comparable to all fatal passenger accidents over the previous three decades -- from any cause -- involving Boeing's 757, 767, 777, 787 and the latest 747 models combined. The MAX fleet was eventually anticipated to be nearly 5,000 jets world-wide, while the other fleets together total slightly more than 3,800 aircraft.

The potential for 15 projected crashes "would be an unacceptable number in the modern aviation-safety world," said Alan Diehl, a retired FAA and Pentagon air-safety official, who hasn't had any involvement in the MAX crisis.

The FAA's analysis relied on technical and statistical principles widely used by the agency after airliner crashes or serious incidents, and it was only part of the process of deciding whether to let the MAX keep flying. In addition to the statistical projection, the FAA conducted a subjective analysis of factors ranging from pilots' emergency-reaction times to how quickly design changes could be implemented. Both industry and government safety experts have described the numerical risk assessment as a core element of the FAA's deliberations.

After completing the risk assessment, FAA leaders decided to permit the MAX to remain in service with two important safeguards, according to the 2018 agency document, interviews with FAA officials and information the agency recently provided to the House Transportation Committee.

The FAA document anticipated that in roughly seven months, Boeing would devise, test and with the FAA's approval install revised software for MCAS, the suspect stall-prevention system that led to the Indonesia crash. Meanwhile, the FAA also concluded that it could buy time to prevent another accident by reiterating to airline crews world-wide how to respond in the event of a similar MCAS misfire. If crews were aware of the risk and knew how to respond, the FAA determined it was acceptable to let the planes continue carrying passengers until a permanent design change was in place. That fix is still in progress.

Boeing previously said it and the FAA "both agreed, based on the results of their respective rigorous safety processes, that the initial action of reinforcing existing pilot procedures...and then the development and fielding of a software update, were the appropriate actions."

The assumptions by Boeing and the FAA fell apart in less than five months, when a MAX operated by Ethiopian Airlines crashed as a result of an MCAS problem similar to the one that caused the earlier Lion Air crash. The dual tragedies, which took 346 lives, have sparked the biggest corporate crisis in Boeing's modern history.

Now, as the House panel conducts another hearing partly focusing on FAA and Boeing actions between the two crashes, lawmakers are expected to highlight the extent of the risk initially identified by the 2018 assessment, known as a Taram, which stands for Transport Airplane Risk Assessment Methodology.

The document was drafted during "an incredibly important period," Mr. DeFazio said in an interview before the hearing.

But inside the FAA, he said, "it has been pretty hard to identify exactly who was in charge of what, and who knew whatever" about MCAS and details of the risk analysis.

At Wednesday's hearing, Mr. DeFazio said the committee's staff previously spent some seven hours questioning Ali Bahrami, the FAA's top safety official, regarding details of the MAX risk assessment. According to Mr. DeFazio, Mr. Bahrami said he wasn't familiar with or involved with drafting the risk analysis and more broadly wasn't aware of what was going on when the agency studied options after the Lion Air crash.

Some aspects of the Taram were reported by the Journal in July. The new information gathered by House investigators has increased the document's significance for the committee and others investigating the accidents and their causes.

The MAX's safety record when it was grounded, after two years in service, roughly amounted to two catastrophic accidents for every one million flights, according to estimates by industry officials relying on unofficial data. By contrast, the model of 737 that came before the MAX has suffered one fatal crash for every 10 million flights, according to data from Boeing.

The 2018 global accident rate for all scheduled Western-built jetliners -- including those made by Europe's Airbus SE as well as regional passenger planes from Canadian, Brazilian and other manufacturers -- was one fatal crash per approximately three million flights.

The MAX's projected accident rate was far above FAA safety limits, according to a veteran FAA engineer familiar with risk-analysis methods. "It's something you couldn't live with," this engineer said.

Reminding pilots about an existing emergency procedure to turn off MCAS was intended to alleviate the short-term risk. A December 2018 report from the FAA shared with Boeing said the agency's analysis found the "risk is sufficiently low to allow continued growth of the fleet and operations until the changes to the system are retrofitted," according to a person close to the manufacturer.

Pressed on whether the FAA took sufficient action following the risk analysis, Mr. Dickson said Wednesday that was "something that we need to look at very closely," adding the "result is not satisfactory."

Mr. Dickson said, based on what he knows today, he would have grounded the aircraft after the first accident, though he didn't want to second-guess decisions made at the time.

The FAA and foreign regulators are testing changes to the MAX's flight-control computers intended to eliminate design problems that led to the crashes. Weeks of additional tests will be necessary, and the planes aren't expected to return to service until the first quarter of next year.

Write to Andy Pasztor at and Andrew Tangel at


(END) Dow Jones Newswires

December 11, 2019 13:32 ET (18:32 GMT)

Copyright (c) 2019 Dow Jones & Company, Inc.

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