Sunday, December 20, 2020

Senate Panel Rebukes Federal Aviation Administration in Wake of Boeing 737 MAX Tragedies

Commerce committee details agency lapses policing airlines and pilots, retaliation against those raising safety concerns

The Wall Street Journal
By Andy Pasztor
Updated December 20, 2020 12:45 pm ET

A congressional panel issued a report documenting what it determined were safety-oversight lapses by the Federal Aviation Administration, from agency intimidation of federally protected whistleblowers to lax policing of maintenance errors.

The 101-page document, released Friday by the Senate Commerce committee, is sharply critical of Federal Aviation Administration leadership’s handling of numerous matters over several years. The findings stem from the broadest review of agency enforcement efforts conducted in the wake of two fatal crashes of Boeing Co.’s 737 MAX jets.

Concluding that systemic Federal Aviation Administration deficiencies pose an “unnecessary risk to the flying public,” the report cited a pattern of agency managers avoiding responsibility for failures to ensure proper staff training. Managers also undermined or overruled enforcement decisions of some inspectors, investigators determined.

“When inspectors pushed back,” according to the report, “they were investigated and in some cases reassigned.”

After examining some 13,000 pages of documents and interviewing dozens of agency employees, investigators described a “failed Federal Aviation Administration safety management culture” tending to favor companies over Federal Aviation Administration staff and “often accompanied by retaliation against those who report safety violations.”

Specifics raised in the report pertain to two major United States passenger carriers, a number of big cargo airlines and smaller commercial-aircraft and helicopter operators.

The Federal Aviation Administration said it was reviewing the information, but sounded a skeptical note. The committee, according to the Federal Aviation Administration, acknowledges its report contains a number of unsubstantiated allegations.

A string of earlier reports by House lawmakers, accident investigators and independent safety experts focused on the MAX’s flawed flight-control system, which led to 346 fatalities and a nearly two-year global grounding of the fleet.

The strongest and newest details in the latest safety review, however, related to other aspects of the Federal Aviation Administration dealings with the industry. Investigators found what they described as agency abuses of voluntary disclosure practices the Federal Aviation Administration routinely relies on to learn of hazards discovered by carriers, pilots and mechanics.

Federal Aviation Administration inspectors “were pressured or coerced by Federal Aviation Administration managers” to accept such voluntary disclosures even though they clearly fell outside the bounds of program procedures and requirements, according to the report.

The report lays out instances of Southwest Airlines exerting “improper influence on the Federal Aviation Administration to gain favorable treatment.”

Early this year, a Federal Aviation Administration inspector reported that after pilots on a Southwest flight experienced persistent flight-control problems during takeoff, cruise and descent, the crew opted to fly another leg with the malfunctioning plane instead of alerting maintenance personnel. The second flight was beset by the same handling difficulties.

“Despite the intentional nature of the event” which should have precluded protections under voluntary disclosures, according to the report, Southwest successfully argued the behavior of the crew fit the program’s guidelines and they shouldn’t be subject to punishment.

An improperly done previous repair turned out to be the root cause of the control issue, which could have resulted in a crash, according to the report. But the inspector who originally investigated the flights and the flawed repair, according to the report, told the committee he was convinced Southwest was gaming the system and provided misleading information to the Federal Aviation Administration.

The same inspector, who refused to accept another voluntary disclosure from Southwest, in that case told investigators maintenance tape had been mistakenly left on a sensor of a Southwest jet but the captain failed to investigate the discrepancy or note it in the logbook before conducting two flights. A subsequent crew, according to the report, did note it in the logbook as required.

Federal Aviation Administration whistleblowers told investigators the tape was placed there for calibration purposes and “the result could have been catastrophic.” The report indicates Southwest refused to permit pilots to be interviewed unless their information was accepted unconditionally as a voluntary disclosure and any type of punishment was precluded.

Southwest said it was aware of the report and has used earlier discussion of some issues to improve internal practices, adding the carrier “maintains a culture of compliance” and recognizes “the safety of our operation as the most important thing we do.” A spokeswoman added “we absolutely disagree with allegations of improper influence,” because Southwest didn’t “inhibit or interfere with the Federal Aviation Administration ability to exercise oversight and investigative responsibilities.”

In another section, the Senate report indicated Boeing officials tried to skew Federal Aviation Administration ground-simulator tests in their favor in July 2019, months after the second 737 MAX accident. These officials, according to investigators, “inappropriately coached” Federal Aviation Administration pilots on how to respond swiftly to simulated emergencies. According to the report, Federal Aviation Administration and Boeing officials “had established a predetermined outcome to reaffirm” Boeing’s initial design assumptions and “were attempting to cover up important information that may have contributed to the 737 MAX tragedies.”

Boeing’s activities failed to persuade the  Federal Aviation Administration to quickly return the MAX to service,  Federal Aviation Administration officials have told House and Senate investigators. Ground-simulator testing later the same day by a more-senior Federal Aviation Administration pilot eventually led the agency to demand major software and training fixes that ended up delaying resumption of flights for more than a year.

The Senate probe also highlighted long-standing assertions by a Federal Aviation Administration whistleblower that when the MAX initially got the green light to fly passengers, some of the agency officials who vetted pilot-training requirements didn’t have the required experience and training for the job. In the past, the Federal Aviation Administration repeatedly denied those accusations.

The Federal Aviation Administration statement said the agency “conducted a thorough and deliberate review of the 737 MAX” before lifting the grounding order last month. The Federal Aviation Administration added all safety issues have been fully addressed “through the design changes required and independently approved by the Federal Aviation Administration,” along with foreign regulators.

Boeing said lessons from the dual MAX crashes “have reshaped our company and further focused our attention on our core values of safety, quality and integrity.”

Following a 20-month probe, Senate investigators mentioned persistent difficulties getting access to government documents and interviewing Federal Aviation Administration employees. The report described some testimony as conflicting and misleading. “The level of cooperation by the Federal Aviation Administration” and its parent agency, the Department of Transportation “has been unacceptable and at times has bordered on obstructive,” according to the committee.


  1. I did not read, yet suspect the report void of naming specific individuals. If past reports are a guide, it is 'Boeing' or 'FAA' this and that .. no personal responsibility attributed to these failures.

  2. Hurray! Congress created this mess by instituting the Organization Delegation Authorization system in which Boeing, not the FAA, chose and managed the people at Boeing authorized to make certification findings for the FAA. Good to see that they had the courage to admit their mistake and reverse it. A rare thing indeed.


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