The Boeing 737 MAX: Examining the Design, Development, and Marketing of the Aircraft
2167 Rayburn House Office Building
This is a hearing of the full Committee on Transportation and Infrastructure.
Mr. Dennis A. Muilenburg, President and CEO, The Boeing Company | Written Testimony
Accompanied by, Mr. John Hamilton, Vice President and Chief Engineer, Boeing Commercial Airplanes, The Boeing Company | Written Testimony
Opening remarks, as prepared, of Committee on Transportation and Infrastructure Ranking Member Sam Graves (R-MO) and Subcommittee on Aviation Ranking Member Garret Graves (R-LA):
Committee on Transportation and Infrastructure Ranking Member Sam Graves (R-MO):
Thank you, Mr. Chairman. I want to extend my condolences to the families and friends of the accident victims.
It is my hope that Mr. Muilenberg’s testimony today will help us understand decisions Boeing made between 2009 and 2017 regarding the design and certification of the 737 MAX. For example, as a pilot, I would also be concerned about having a piece of equipment or software in my cockpit that I didn’t know about.
Some of Boeing’s decisions were reviewed and approved by the Boeing Organization Designation Authorization, or ODA, Office on behalf of the FAA. While the Boeing ODA was authorized to act for the FAA, as the regulator the FAA retained ultimate responsibility for overseeing compliance with safety regulations.
Mr. Chairman, today we are hearing from Boeing leadership involved at the time of these decisions, but to get a complete picture I hope I can get your commitment to hold a Committee hearing in the near future to receive testimony from the FAA officials in charge between 2012 and 2017 when decisions related to the 737 MAX certification were made and approvals granted.
As I’ve said before, if the various investigations reveal problems with the certification, Congress should act to fix those specific, identifiable problems. But, in the aftermath of these accidents, we can’t address the safety of the aviation system by focusing on a single possible cause.
Safety experts often refer to the “Swiss Cheese Model of Accident Causation.” In this model, layers of accident protection are visualized as slices of cheese, with holes representing weaknesses. Some weaknesses are due to existing conditions, and others are due to active failures. An accident occurs when holes or weaknesses in the many layers all line up.
In the context of the 737 MAX, we must consider all layers of protection and address all weaknesses discovered. As an investigator for the Indonesian government said about the Lion Air accident, “If one of the nine contributing factors did not happen, the crash would not have happened.”
One particular layer – the design and certification of the 737 MAX – is the focus of a number of investigations. Earlier this year, Boeing took responsibility for MCAS design weaknesses and has been working on a software fix. Other weaknesses Boeing, with the FAA’s oversight, will address include pilot displays, operation manuals, and crew training. Today, I look forward to hearing about the status of those efforts.
I also want to hear about how these efforts line up with the recommendations of the Joint Authorities Technical Review (JATR) – the first completed review of the MAX’s certification by individuals with vast aviation and technical expertise.
While the JATR did not call for an end to the FAA’s delegation programs, it did highlight “bureaucratic inefficiencies” in the relationship between Boeing and the FAA. The FAA concurred with the JATR’s report and has committed to working on the recommendations.
Lastly, Mr. Muilenburg, I want to hear about recently shared documents related to Boeing’s former Chief Technical Pilot for the 737.
Other investigations are also moving forward, and last month the National Transportation Safety Board (NTSB) issued a Recommendation Report, which largely focused on assumptions made during the design and certification process related to human factors. But, design and certification cannot be the sole focus of our efforts. That’s only one layer of the cheese.
In the last few months, other weaknesses that appear to have played a role in the accidents have surfaced.
Reports earlier this month called into question evidence submitted to the Lion Air investigation related to the installation, calibration, and testing of a faulty angle of attack sensor. There have also been whistleblower statements and other reports raising significant concerns with Lion Air and Ethiopian Airlines’ operations and maintenance programs. The former chief engineer for Ethiopian Airlines filed a whistleblower complaint alleging significant problems with that airline’s maintenance, training, and recordkeeping. He also alleges that the air carrier went into the maintenance records of the 737 MAX a day after it crashed.
Unfortunately, operational pressures and lack of a robust safety culture can negatively impact aviation safety – another layer of the cheese. The NTSB has confirmed that, along with certification, operational factors will be a focus of its accident investigations.
In addition, along with its own MAX certification review, the Department of Transportation Inspector General, at the request of this Committee’s leadership, will soon begin a review of international training standards and the impact of automation.
I want to be crystal clear that reviewing these areas is not an effort to blame pilots or absolve Boeing of its responsibility.
A September New York Times Magazine article describes the changing nature of the airline industry and its impact on airmanship. The article refers to “a decades-long transformation of the whole business of flying, in which airplanes became so automated and accidents so rare that a cheap air-travel boom was able to take root around the world.” The boom in air travel resulted in a need for more and more pilots, but the pool of experienced pilots couldn’t keep up with demand. In fact, I’ve gotten letters from airlines offering me jobs because my license has an ATP (airline transport pilot) on it.
I’ll continue to repeat this: pilots can master cockpit technology, but when that technology fails, they must be able to fly the plane – not just fly a computer.
To be clear, none of this is a reflection on the Lion Air and Ethiopian pilots’ professionalism or character. Instead, it’s a reflection on the broader pressures present in today’s global aviation economy.
But it is incumbent on the airline whose name is on the side of that airplane to ensure their pilots are properly trained and not rushed into the cockpit to meet those demands.
So, in line with the “Swiss cheese model,” other layers of protection – such as pilot actions, airline operations, maintenance, and training programs – must also be explored and any weaknesses must be addressed.
I still believe that the FAA remains the gold standard for safety, and once the agency certifies the fixes to the MAX, I would gladly volunteer to be on the first flight alongside Administrator Dickson.
In regard to the two 737 MAX accidents, any issues should be addressed, but only after we have the benefit of various investigative work yet to be completed. Jumping to conclusions before that work is complete risks doing more harm than good.
Bottom line: the safety record speaks for itself – the FAA’s proven system has made air travel the safest mode of transportation in history.
Subcommittee on Aviation Ranking Member Garret Graves (R-LA):
Thank you, Mr. Chairman.
Yesterday was the anniversary of the Lion Air tragedy, and I want to let the families of those lost in that incident and in the Ethiopian crash know that I’m keeping their loved ones in mind as I sit here today.
Here in Washington, we all regularly talk about budgets in the billions of dollars, and a soup of acronyms, processes, and programs. Sometimes it can be easy to forget why we’re really here – what all these processes and programs are for. This is about people. That’s truly why we are here, and we can’t lose sight of that throughout this process.
So it’s thinking of those we lost that motivates me to ensure that we, as Members of both this committee and of the Congress, are thoughtful about our role in the aftermath of these incidents.
I’m pleased that Boeing is here today to tell us how the development of MCAS evolved, and the flaws in that process. We know from NTSB’s preliminary recommendations that certain incorrect assumptions and incomplete reviews of how multiple systems interact allowed those flaws to become fatal. We know this from the results of some of the expert investigative work that has been completed to date.
In air travel, there is no room for error, and that’s why it’s critical to have safety redundancies. We are closely reviewing the results and recommendations from the investigations which have already wrapped: FAA’s Joint Authorities Technical Review (JATR); NTSB’s, which has issued preliminary recommendations; Boeing’s internal review, which yielded recommendations that are already being implemented; and the Indonesian accident report, released late last week.
It’s my hope that the committee will hear from and consider the findings of the yet-to-be-concluded certification and accident investigations so that we can make sure we know what went wrong and leverage those findings and recommendations to ensure something like this doesn’t happen again.
I also hope we hear from FAA officials who were in charge of the agency when the certification process for this aircraft was conducted and its type certificate approved. This information will crucially inform the Committee on our next steps.
We certainly need to extract every single lesson learned so far, but it’s critical that we also take into consideration the many ongoing investigations into these accidents when we have their results: the Ethiopian accident report, Secretary Chao’s special committee, the DOT Inspector General’s reports, and several other international reviews.
It is very important that we wait for these experts to complete their work and carefully review their findings and recommendations. Once we have a better understanding of what happened and all the factors involved, we will ask ourselves: what changes do we need to make to ensure the highest levels of safety and prevent future accidents?
As Congress, we have to act on facts – not on emotion – to address every single problem identified so that this doesn’t happen again. But acting before we know the whole picture is both a disservice to those we lost and dangerous to those who will fly in the future.