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 despite their own
analysis indicating 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."
In response, FAA chief Steve Dickson promised the panel he will
review the procedures used to certify the MAX.
"The system is not broken," he told the panel. He didn't
elaborate on what actions he is weighing.
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.
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 andy.pasztor@wsj.com and Andrew Tangel
at Andrew.Tangel@wsj.com
(END) Dow Jones Newswires
December 11, 2019 12:16 ET (17:16 GMT)
Copyright (c) 2019 Dow Jones & Company, Inc.
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