2020.09.15 FINAL 737 MAX Report For Public Release

F I N AL C O M M I T T E E R E P O R T
THE DESIGN, DEVELOPMENT & CERTIFICATION OF THE
BOEING 737 MAX
SEPTEMBER 2020
PREPARED FOR:
CHAIR OF THE COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE

PETER A. DEFAZIO
AND
CHAIR OF THE SUBCOMMITTEE ON AVIATION

RICK LARSEN

BY MAJORITY STAFF OF THE COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE
-FINAL COMMITTEE REPORT: BOEING 737 MAX-
Contents
Contents
Report
1. Introduction 1
2. Executive Summary 4
The Max Crashes
Investigative Themes
Investigative Findings
3. Boeing History and 737 MAX Background 34

Merging Companies – Changing Cultures
Competitive Pressure
From Marketing Marvel to Financial Burden
Certifying the 737 MAX
Changed Product Rule
Exceptions to the Rule
Engine Indicating and Crew Alerting System (EICAS)
Human Factors
A Holistic Review Process?
Trouble from the Start
Boeing-FAA Settlement Agreement
FAA’s Organization Designation Authorization Program
4. FAA Oversight and Delegation of Authority 56

Delegation Authority Background
ODA Program Effectiveness and Concerns
Boeing Aviation Safety Oversight Office Concerns and
Issues
Conflicts of Interest
Certification Process Affected by Mismanaged
Communications
History of FAA Bias Favoring Boeing
Effectiveness of Compliance and Enforcement Actions
5. Maneuvering Characteristics Augmentation System 85

New Larger Engines Resulted in Aerodynamic Instability
in Critical Situations
What is Angle-of-Attack (AOA)?
Boeing Rejected the Idea of an MCAS Indicator Light
A Plan to Downplay MCAS
Effect of MCAS on Pilot Differences Training
How MCAS was Presented to Regulators
i
Contents
Fragmented Oversight of MCAS
Military MCAS vs. Commercial 737 MAX MCAS
Redesigning MCAS
Communication Issues
MCAS was Vulnerable to Single AOA Sensor Failure
Squawk and Repetitive MCAS Activation
Faulty Assumptions, Fatal Timing
Catastrophic Consequences
737 MAX Chief Project Engineer Approved MCAS
Without Fully Understanding It
Pilots Uninformed About MCAS, References
Removed
MCAS Did Not Meet Its Own Design Requirements
6. AOA Disagree Alert 122

Angle of Attack (AOA) Disagree Alert and AOA
Indicator
How the AOA Disagree Alert Became Non-Functioning
on the 737 MAX
Discovering the Non-Functioning AOA Disagree Alert
Boeing’s Lack of Transparency Regarding the AOA
Disagree Alert
A Missed Opportunity with Lion Air
A Missed Opportunity at Xtra Aerospace
At Least Three Missed Opportunities to Catch Faulty
AOA Sensor
Culture of Omission
7. Boeing 737 MAX Pilot Training 138

Faulty Assumptions
Design Objective: 737 MAX Level B Training
Marketing the MAX
Gambling on Level B
Level B Implications to MCAS and other MAX Systems
Pushing Back on Level B
Safety and Commonality
Boeing Will Not Allow That to Happen
Pressuring Airlines
737 MAX Simulator Discrepancy Reports and Schedule
Pressure
Reverse Course
8. Production Pressure 163

737 MAX Production Line
Countdown Clock
Synthetic Airspeed
Loss of Control
The Renton Plant Production Line
ii
Contents
Production Pressure
No Slowing Down – Production Goes On
Renton Review
Undue Influence Pressure 2016 Survey
9. Post-Accident Response 189

Post-Accident Response
The Pilot Response Blame Game
The Startle Effect
FAA’s Emergency Airworthiness Directive
Predicting Problems
Omitting MCAS
Boeing Multi Operator Message (MOM)
MCAS Pilot Blowback
A 10-Second “Catastrophic” MCAS Test Scenario by
Boeing’s Own Test Pilot
Red Flags
Risk Analysis: Gambling with the Public’s Safety
Analyzing the TARAM Analysis
TARAM Risk Analysis: Who Knew?
The BASOO’s Post-Lion Air MCAS System
Oversight Report
Grounding the 737 MAX
10. New Issues Emerge 222

New Issues
11. Final Observations 228

Observations on Boeing
Observations on the Federal Aviation Administration
(FAA)
Improving Safety Cultures
FAA’s Cooperation with the Committee
Time for a Culture Change
Do Things Right and Do the Right Thing
The Once Great Engineering Firm
Figures Maneuvering Characteristics Augmentation System (MCAS)

– Timeline 100
Angle of Attack (AOA) Disagree Alert – Timeline 129
Related Documents Transcripts of the transcribed interviews and other

documents referenced in this report can be accessed here:
https://transportation.house.gov/committee-
activity/boeing-737-max-investigation
iii
Contents
References to Senior During design, development, and certification of the 737
Boeing Officials MAX, the following individuals held senior positions at
Boeing and are referred to in Boeing documents that are
linked to this report by their titles.
• Keith Leverkuhn served as Vice President (VP) and

General Manager (GM) of the 737 MAX Program from
April 2013 to April 2018. In Boeing documents,
references to “Former 737 MAX VP/GM” are
references to Mr. Leverkuhn.
• Michael Teal served as Vice President and 737 Chief

Project Engineer from August 2011 to March 2017. In
Boeing documents, references to “Former 737 MAX
Chief Project Engineer” are references to Mr. Teal.
• Mark Forkner served as 737 Technical Pilot from 2011

to 2015 and as 737 Chief Technical Pilot from 2015
until 2018 when he left Boeing to work at Southwest
Airlines. In Boeing documents, references to “Former
737 Chief Technical Pilot” are references to Mr.
Forkner.
• Elizabeth “Beth” Pasztor served as Vice President (VP)

of Boeing Commercial Airplanes (BCA) Safety, Security
and Compliance and in this role was the ODA Lead
Administrator. In Fall 2019, Ms. Pasztor became Vice
President and General Manager of Product & Services
Safety. In Boeing documents, references to “VP BCA
Safety, Security and Compliance” are references to Ms.
Pasztor.
Abbreviations 737 NG Boeing 737 Next Generation Airplane

AAR Airplane Assessment Report
ACO Aircraft Certification Office
AD Airworthiness Directive
AEG Aircraft Evaluation Group
AFSCME American Federation of State, County and Municipal
Employees
AIA Aerospace Industries Association
AIR Aircraft Certification Service
AR Authorized Representative
APA Allied Pilots Association
ATC Amended Type Certificate
ATP Airline Transport Pilot
AVS Aviation Safety Organization
BASOO Boeing Aviation Safety Oversight Office
iv
Contents
BCA Boeing Commercial Airplanes
CARB Corrective Action Review Board
CAS Commercial Aviation Services
CBT Computer Based Training
CEO Chief Executive Officer
DER Designated Engineering Representative
DOT Department of Transportation
DR Deficiency Report
EASA European Union Aviation Safety Agency
EBAW Enhanced Bank Angle Warning
ECS Environmental Control System
EDFCS Enhanced Digital Flight Control System
EICAS Engine Indicating and Crew Alerting System
EU European Union
FAA Federal Aviation Administration
FBW Fly-by-wire
FCC Flight Control Computer
FCOM Flight Crew Operations Manual
FSB Flight Standardization Board
FTD Fleet Team Digest
GAO Government Accountability Office
GM General Manager
IEEE Institute of Electrical and Electronics Engineers
IPT Integrated Product Team
ISS International Space Station
JATR Joint Authorities Technical Review
LAM Landing Attitude Modifier
LGW London Gatwick Airport
MCAS Maneuvering Characteristics Augmentation System
MOM Multi Operator Message
NASA National Aeronautics and Space Administration
NATCA National Air Traffic Controllers Association
NNC Non-normal Checklist
NTSB National Transportation Safety Board
ODA Organization Designation Authorization
OIG Office of Inspector General
OMB Operations Manual Bulletin
PASS Professional Aviation Safety Specialists
PSSA Preliminary System Safety Assessment
QFR Questions for the Record
RCAS Roll Command Alerting System
R-TARA Random Transport Airplane Risk Analysis
SCD Specification Control Drawing
SME Subject Matter Expert
SSA System Description and Safety Analysis
STC Supplemental Type Certificate
STS Speed Trim System
v
Contents
SWA Southwest Airlines
TARAM Transport Airplane Risk Assessment Methodology
TCBI Tutorial Computer-Based Instruction
TIA Type Inspection Authorization
VP Vice President
vi
1. Introduction
1. Introduction
-Introduction-
On the evening of March 9, 2019, Paul Njoroge was up late, tracking a flight from Toronto,
Canada to Addis Ababa, Ethiopia. It was the first leg of his family’s journey to visit relatives in
Kenya for what was to be the trip of their lifetimes. After his family arrived safely at their layover in
Addis Ababa, Mr. Njoroge went to bed, expecting to check in again the next day.
As he slept, his wife Carolyne, their three children—6-year-old Ryan, 4-year-old Kelli, and 9-
month-old Rubi—and his mother-in-law, Ann, continued their journey by boarding Ethiopian
Airlines flight 302 from Addis Ababa, Ethiopia, to Nairobi, Kenya. It was a crystal-clear day, but
within minutes of take-off the unthinkable happened: the Boeing 737 MAX, a brand new aircraft
with 157 passengers and crew members on board, began to dive back towards the ground as the
pilots fought to force the plane’s nose back up toward the sky. The battle did not last long. Six
minutes after take-off, Ethiopian Airlines flight 302 crashed. The jet’s impact left a massive crater in
a field just a few miles from the airport. Not a single soul survived.
Over one year later, Mr. Njoroge testified before the U.S. House Committee on
Transportation and Infrastructure that he is still haunted by the image of his young children’s final
moments. “I have nightmares about how they must have clung to their mother, crying, seeing the
fright in her eyes as they sat there helplessly. And there was nothing I could do to save them,” he
said. “I miss their laughter, their playfulness, their touch.”
Mr. Njoroge would soon learn that his family members were the victims of not the first, but
the second Boeing 737 MAX aircraft that was involved in a catastrophic, fatal crash killing everyone
on board—an extraordinary fact given the significant advances in aviation safety over the last two
decades, and the fact that the 737 MAX was a newly certified aircraft.
The story of the Boeing 737 MAX was never expected to be associated with catastrophe. It
was supposed to be a story of American ingenuity and technological success—a modern, more fuel-
efficient airplane that had already become the manufacturing giant’s best-selling jet in its storied
history prior to the first MAX crash of Lion Air flight 610 in Indonesia on October 28, 2018.
Ethiopian Airlines flight 302 crashed on March 10, 2019, just two years and two days after the
Federal Aviation Administration (FAA) had certified the new 737 derivative aircraft as safe to fly.
Clearly it was not.
The Boeing 737 MAX is now the subject of multiple investigations and lawsuits around the
world and will be forever associated with the tragic deaths of 346 people killed in two separate
crashes within five months of each other, as well as one rescue diver who died attempting to recover
bodies from the Lion Air crash in the Java Sea.
2
1. Introduction
This report concludes the U.S. House Committee on Transportation and Infrastructure’s 18-
month long investigation of the design, development, and certification of the 737 MAX aircraft, and
related matters. The Committee’s investigation has revealed multiple missed opportunities that could
have turned the trajectory of the MAX’s design and development toward a safer course due to
flawed technical design criteria, faulty assumptions about pilot response times, and production
pressures. The FAA also missed its own opportunities to change the direction of the 737 MAX
based on its aviation safety mission. Boeing failed in its design and development of the MAX, and
the FAA failed in its oversight of Boeing and its certification of the aircraft.
At the direction of Committee Chair Peter DeFazio and Subcommittee on Aviation Chair
Rick Larsen, this report is being released to help inform the public’s understanding of what went so
horrifically wrong and why. Despite the sweeping and substantive problems that have been
identified by this Committee’s investigation as well as various other investigations, both Boeing and
the FAA have suggested that the certification of the 737 MAX was compliant with FAA regulations.
The fact that a compliant airplane suffered from two deadly crashes in less than five months is clear
evidence that the current regulatory system is fundamentally flawed and needs to be repaired.
3
2. Executive Summary
-Executive Summary-
Technical design flaws, faulty assumptions about pilot responses, and management failures
by both The Boeing Company (Boeing) and the Federal Aviation Administration (FAA) played
instrumental and causative roles in the chain of errors that led to the crashes of Lion Air flight 610
in October 2018, 1 and Ethiopian Airlines flight 302 in March 2019, 2 that resulted in the tragic and
preventable deaths of 346 people. Both crashes involved Boeing 737 MAX airplanes.
On March 8, 2017, the FAA granted an amended type certificate to Boeing for the 737-8
aircraft, the first of the 737 MAX family. 3 The MAX is the 4th generation 737 model airplane 4 and is
the successor to the company’s 737 Next Generation (NG) family of aircraft. 5 The 737 MAX was
the 12th derivative model of the 737 aircraft, 6 which was first certified half a century earlier in 1967. 7
In May 2017, the 737 MAX first entered revenue passenger service with Malindo Air, a Malaysian air
carrier, two months after its FAA certification. 8 Seventeen months later the 737 MAX suffered its
first fatal crash. 9
On October 29, 2018, Lion Air flight 610 flying from Soekarno–Hatta International Airport
in Jakarta, Indonesia, to Depati Amir Airport in Pangkal Pinang, Indonesia, crashed into the Java Sea
13 minutes after takeoff, killing all 189 passengers and crew. 10 One Indonesian rescue diver also died
1 Barbara S. Peterson, “How Could a Brand New Boeing Jet Crash Without Warning?,” Popular Mechanics, October 31,
2018, accessed here: https://www.popularmechanics.com/flight/airlines/a24405573/indonesia-boeing-737-max-jet-
crash
2 Hadra Ahmed, Norimitsu Onishi, Dionne Searcey and Hannah Beech, “Ethiopian Airlines Plane Is the 2nd Boeing
Max 8 to Crash in Months,” New York Times, March 10, 2019, accessed here:
https://www.nytimes.com/2019/03/10/world/africa/ethiopian-airlines-plane-crash.html
3 “Type Certificate Data Sheet A16WE,” Federal Aviation Administration, Department of Transportation, March 8,
2017, accessed here:

https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/$FI
LE/A16WE_Rev_58.pdf
4 “Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8 Aircraft and Actions Taken After the
October 2018 Lion Air Accident,” Office of Inspector General (OIG), Department of Transportation (DOT), Report
No. AV2020037, June 29, 2020, p. 5, accessed here:
https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%
20Timeline%20Final%20Report.pdf

LE/A16WE_Rev_58.pdf
6 The 737 MAX was the 12th “derivative” of the original 737-100 aircraft certified in 1967, making it the 13th 737 model
produced by Boeing. See: “Type Certificate Data Sheet A16WE,” Federal Aviation Administration, Department of
Transportation, March 8, 2017, accessed here:
LE/A16WE_Rev_58.pdf
7 Ibid.
8 Firdaus Hashim, “Malindo operates world’s first 737 Max flight,” FlightGlobal, May 22, 2017, accessed here:
https://www.flightglobal.com/orders-and-deliveries/malindo-operates-worlds-first-737-max-flight/124109.article
9 James Griffiths, Steve George, Kathy Quiano and Helen Regan, “Lion Air crash: Indonesia to inspect all Boeing 737
Max 8 planes,” CNN, November 1, 2018, accessed here: https://www.cnn.com/2018/10/30/asia/lion-air-plane-crash-

intl/index.html
10 “Final KNKT.18.10.35.04 Aircraft Accident Investigation Report, PT. Lion Mentari Airlines, Boeing 737-8 (MAX);
PKLQP, Tanjung Karawang, West Java, Republic of Indonesia, 29 October 2018,” Komite Nasional Keselamatan
Transportasi (KNKT), Republic of Indonesia, issued October 25, 2019, pp. 19-27 (hereafter referred to as: “Lion Air
5
during recovery efforts. 11 Less than five months later, on March 10, 2019, in strikingly similar
circumstances, Ethiopian Airlines flight 302 crashed six minutes after takeoff on a flight from Addis
Ababa, Ethiopia, to Nairobi, Kenya, killing all 157 passengers and crew, including eight U.S.
citizens. 12
In March 2019, within days of the crash of Ethiopian Airlines flight 302, the House
Committee on Transportation and Infrastructure (Committee), under the leadership of Chair Peter
A. DeFazio and Subcommittee on Aviation Chair Rick Larsen, launched an investigation into the
design, development, and certification of the 737 MAX aircraft and related matters that led to these
crashes. 13 Since then, the Committee has held five hearings on issues related to the 737 MAX
program; 14 written 23 oversight letters, including 12 records request letters; received an estimated
600,000 pages of records from Boeing, the FAA, airlines, and others; and conducted two dozen
official interviews with current Boeing and FAA employees and others. This included transcribed
interviews with Michael Teal, former vice president, chief project engineer and deputy program
manager of the 737 MAX program; 15 Keith Leverkuhn, former vice president and former general
manager of Boeing’s 737 MAX program; 16 and Ali Bahrami, the FAA’s current Associate
Administrator for Aviation Safety. Committee staff have also spoken with a wide range of aviation
experts, engineers, software developers, and former FAA and Boeing employees. In addition, the
Committee’s investigation has been informed by records and information provided by numerous
whistleblowers who have contacted the Committee directly with their concerns.
This report was produced by Democratic staff of the Committee and is the culmination of
the Committee’s investigative efforts assessing the costs, consequences, and lessons from the design,
development, and certification of Boeing’s 737 MAX aircraft. The report reveals several
unmistakable facts. The MAX crashes were not the result of a singular failure, technical mistake, or
mismanaged event. They were the horrific culmination of a series of faulty technical assumptions by
Boeing’s engineers, a lack of transparency on the part of Boeing’s management, and grossly
insufficient oversight by the FAA—the pernicious result of regulatory capture on the part of the
FAA with respect to its responsibilities to perform robust oversight of Boeing and to ensure the
safety of the flying public. The facts laid out in this report document a disturbing pattern of
Flight 610 Final Aircraft Accident Investigation Report”), accessed here: https://aviation-is.better-
than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf
11 “Lion Air: Indonesian rescue diver dies while searching for victims of jet crash near Jakarta,” ABC Australia,
November 3, 2018, accessed here: https://www.abc.net.au/news/2018-11-03/indonesian-rescue-diver-dies-in-lion-air-

jet-crash-search/10463266
12 “Interim Investigation Report on Accident to the B737-8(MAX) Registered ET-AVJ operated by Ethiopian Airlines
on 10 March 2019,” Federal Democratic Republic of Ethiopia, Ministry of Transport, Aircraft Accident Investigation
Bureau, released March 9, 2020, pp. 11-18 (hereafter referred to as: “Ethiopian Airlines Flight 302 Interim Investigation
Report”), accessed here: http://www.aib.gov.et/wp-content/uploads/2020/documents/accident/ET-
302%20%20Interim%20Investigation%20%20Report%20March%209%202020.pdf
13 “As Part of Investigation into Boeing 737 MAX Certification Process, Committee Sends Records Requests to FAA,
Boeing,” Press Release, Committee on Transportation and Infrastructure, U.S. House of Representatives, April 1, 2019,
accessed here: https://transportation.house.gov/news/press-releases/as-part-of-investigation-into-boeing-737-max-
certification-process-committee-sends-records-requests-to-faa-boeing
14 See: “Boeing 737 MAX Investigation,” Committee on Transportation and Infrastructure, U.S. House of
Representatives, accessed here: https://transportation.house.gov/committee-activity/boeing-737-max-investigation

15 In November 2017, Mr. Teal was named to the position of vice president and chief project engineer for the Boeing
777X program.
16 In July 2018, Mr. Leverkuhn was named to the position of vice president of Supply Chain Propulsion for Boeing
Commercial Airplanes. He retired from Boeing this year.
6
technical miscalculations and troubling management misjudgments made by Boeing. It also
illuminates numerous oversight lapses and accountability gaps by the FAA that played a significant
role in the 737 MAX crashes.
-The MAX Crashes-
Ethiopian Airlines, which is wholly owned by the government of Ethiopia, 17 has flourished
over the last two decades as it has capitalized on a strategy to connect primary and secondary
markets across the African continent with North American, European, and Asian destinations via its
hub in Addis Ababa. 18 The carrier’s pilot training programs and facilities have garnered praise from
seasoned American pilots. 19 Before the crash of flight 302, Ethiopian Airlines’ last major accident
occurred in January 2010 and involved a Boeing 737-800 departing Beirut at night bound for Addis
Ababa; it was determined that the flight crew likely experienced spatial disorientation during climb
out over the Mediterranean Sea in the darkness, and that the crew failed to manage the flight path of
the airplane and lost control, leading to an impact with the sea. All 90 passengers and crew died. 20
Lion Air is an Indonesian airline which provides fast, inexpensive travel across the massive
Indonesian archipelago. 21 Unfortunately, Lion Air has a checkered safety record and has earned a
reputation among some observers of hiring inexperienced pilots and working them hard. 22 For
example, before the crash of flight 610, Lion Air airplanes had been involved in 10 accidents that led
to the death of 25 people since the company’s founding in 1999. 23 Moreover, between 2007 and
2016, the European Union (EU) blacklisted the carrier, prohibiting it from operating into EU
member states. 24
In November 2011, Lion Air signed a $22 billion order with Boeing for 230 units of the
737—including 201 737 MAX aircraft—the largest single order in Boeing’s history. 25 However,
while Lion Air’s business model was built around the use of the Boeing 737 and its pilots were used
17 “Corporate Overview,” Ethiopian Airlines, accessed here:
https://corporate.ethiopianairlines.com/AboutEthiopian/Overview
18 Omar Mohammed and Maggie Fick, “Ethiopian Airlines steps up hunt for African connections,” Reuters, November
23, 2018, accessed here: https://www.reuters.com/article/us-ethiopia-airlines-africa/ethiopian-airlines-steps-up-hunt-

for-african-connections-idUSKCN1NS0X3
19 Prepared statement of Captain Daniel F. Carey, President, Allied Pilots Association, Hearing titled, “Status of the
Boeing 737 MAX: Stakeholder Perspectives,” Subcommittee on Aviation of the Committee on Transportation and
Infrastructure, U.S. House of Representatives, 116th Congress, First Session, June 19, 2019, accessed here:
https://transportation.house.gov/imo/media/doc/CA%20Carey%20Hearing%20testimony%20.pdf
20 See: “ASN Accident Database: ET409,” Flight Safety Foundation Aviation Safety Network, accessed here:
https://aviation-safety.net/database/record.php?id=20100125-0
21 William Langewiesche, “What Really Brought Down the Boeing 737 MAX?,” The New York Times Magazine, September
18, 2019, accessed here: https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-

crashes.html?action=click&module=Top%20Stories&pgtype=Homepage
22 Ibid.
23 “ASN Aviation Safety Database: Lion Air accidents and incidents,” Flight Safety Foundation Aviation Safety Network,
accessed here: https://aviation-

safety.net/database/dblist.php?sorteer=datekey_desc&kind=%&cat=%&page=1&field=Operatorkey&var=5758
24 “Lion Air,” Flight Safety Foundation Aviation Safety Network, accessed here: https://aviation-
safety.net/database/operator/airline.php?var=5758
25 “Boeing, Lion Air Announce Historic Commitment for up to 380 737s,” Boeing Press Release, November 17, 2011,
accessed here: https://boeing.mediaroom.com/2011-11-17-Boeing-Lion-Air-Announce-Historic-Commitment-for-up-

to-380-737s and Kevin Voight, “Lion Who? What record Boeing-Indonesia deal means,” CNN Business, November 18,
2011, accessed here: https://www.cnn.com/2011/11/18/business/boeing-lion-air-indonesia-analysis/index.html
7
to flying the airplane, the 737 MAX contained a new feature in its flight control computer—the
Maneuvering Characteristics Augmentation System (MCAS)—that has become the center of
scrutiny for both MAX crashes. 26 The new system had the ability to trigger non-pilot-commanded
flight control movements that could place the airplane into a dangerous nose-down attitude that
challenged the pilots’ ability to control the aircraft. 27 In addition, the MCAS software operated on
input from one of the two angle-of-attack (AOA) sensors 28 externally mounted on the fuselage on
either side of the airplane. 29
The day before the crash of Lion Air flight 610, a mechanic in Denpasar, Indonesia, replaced
the AOA sensor on the left side of the accident airplane, prior to its 90-minute flight from Denpasar
to Jakarta. 30 The mechanic used a refurbished AOA sensor that had previously been used on a
Boeing 737-900ER (NG) aircraft operated by Lion Air’s Malaysian sister company, Malindo Air, 31
and rebuilt in late 2017 by Xtra Aerospace in Miramar, Florida. 32
On the flight to Jakarta, MCAS activated based on an erroneous reading from the newly
installed AOA sensor and commanded the airplane’s horizontal stabilizer 33 to push the nose down
while the pilots struggled against it to stabilize the airplane. 34 In this case, a third “deadheading” pilot
who occupied the jump seat inside the flight deck 35 recognized what was occurring and provided
26 Chris Brady, “Maneuvering Characteristics Augmentation System (MCAS),” The Boeing 737 Technical Guide,
Updated April 18, 2020, accessed here: http://www.b737.org.uk/mcas.htm
27 Ibid.
28 Angle of Attack (AOA) sensors are sometimes referred to as AOA vanes. Throughout this report we refer to them as
AOA sensors. See: “Angle of Attack (AOA) Systems,” UTC Aerospace Systems, accessed here:
https://utcaerospacesystems.com/wp-content/uploads/2018/04/Angle-of-Attack-AOA-Systems.pdf and “Angle of
Attack Vane,” Basic Air Data, accessed here: https://www.basicairdata.eu/knowledge-center/design/angle-of-attack-
vane
29 Ibid.
30 “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” pp. 36, 174, accessed here: https://aviation-
is.better-than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf
31 Ibid., pp. 37-38.
32 In October 2019, the FAA issued an order revoking Xtra Aerospace, LLC’s repair station certificate. According to the
FAA, which launched an investigation of the company after the Lion Air crash, it “determined that from November
2009 until May 2019, Xtra failed to complete and retain records in accordance with procedures in its repair station
manual to support parts on its capability list. The company also did not substantiate that it had adequate facilities, tools,
test equipment, technical publications, and trained and qualified employees to repair parts on its capability list.” See:
“FAA Revokes Repair Station Certificate of Xtra Aerospace of South Florida,” Press Release, Federal Aviation
Administration (FAA), October 25, 2019, accessed here:
https://www.faa.gov/news/press_releases/news_story.cfm?newsId=24314 and Dominic Gates, “FAA shuts down
Florida repair firm that supplied faulty Lion Air sensor on Boeing 737 MAX,” Seattle Times, October 25, 2019, accessed
here: https://www.seattletimes.com/business/boeing-aerospace/faa-shuts-down-revokes-certificate-of-florida-repair-
firm-that-supplied-faulty-lion-air-sensor/
33 The horizontal stabilizer is a movable part at the back of the aircraft that provides stability for the aircraft by pitching
the plane up or down, to keep it flying straight. Because of the faulty AOA readings MCAS erroneously tried to push the
nose of the aircraft down. See: https://howthingsfly.si.edu/ask-an-explainer/what-horizontal-stabilizer-modern-
commercialairplanes#:~:text=What%20is%20a%20horizontal%20stabilizer%20in%20modern%20commercial%20airpla
nes%3F,-A%3A&text=A%20horizontal%20stabilizer%20is%20a,down%20motion%2C%20of%20the%20aircraft.
34 “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” pp. 174-176, accessed here: https://aviation-
35 Throughout this report we use the term “flight deck” instead of “cockpit” in regard to the 737 MAX. According to
Aviation Stack Exchange, “A cockpit is a hole with a seat that you strap into for the entire flight. A flight deck is a larger
version of a cockpit, where you can at least leave your seat and walk behind it.” Access here:
8
instructions to the two active pilots that enabled them to regain control of the airplane and fly it
safely to Jakarta by depressing two “stabilizer trim cutout” switches, thereby removing electrical
power from the flight control that MCAS was erroneously activating. 36
Upon landing in Jakarta, the captain made entries in the airplane’s maintenance log about
cautions and warnings that appeared during the flight. However, he did not report the flight crew’s
use of the stabilizer trim cutout switches to address the unexpected horizontal stabilizer
movement. 37
On the following day, October 29, 2018, Lion Air flight 610 departed Jakarta. Again, the
AOA sensor provided inaccurate information to the flight control computer which triggered MCAS
to move the horizontal stabilizer which pushed the airplane’s nose down. 38 This occurred more than
20 times as the pilots fought MCAS while struggling to maintain control of the aircraft. 39
Unfortunately, because the previous flight crew did not document its use of the stabilizer trim
cutout switches to address the same condition, the new flight crew did not have an important piece
of information that could have helped them to identify and respond to the problem. 40 Amid a
cacophony of confusing warnings and alerts on the flight deck, the horizontal stabilizer ultimately
forced the airplane into a nose-down attitude from which the pilots were unable to recover. 41
Nearly five months later, on March 10, 2019, once again a faulty AOA sensor and
subsequent triggering of MCAS led to the downing of Ethiopian Airlines flight 302. As opposed to
the Lion Air accident airplane on which cautions and warnings on its earlier flights had given some
indication of a problem, the 737 MAX operated by Ethiopian Airlines had no known technical
troubles. 42 However, after a normal takeoff, the left AOA sensor began producing erroneous
readings. 43 Over the approximately six minutes that Ethiopian Airlines flight 302 was airborne
following its departure from Addis Ababa, Ethiopia, MCAS triggered four times as a result of the
false AOA readings and caused the airplane’s horizontal stabilizer to force the airplane into a nose-
https://aviation.stackexchange.com/questions/66094/cockpit-vs-flight-
deck#:~:text=A%20cockpit%20is%20a%20hole,the%20top%20of%20the%20ship
36 Ibid.
37 According to the “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” p. 176, the captain reported
problems experienced during the flight that had been displayed in messages on the Primary Flight Display and overhead
flight controls panel. These problems were the IAS DISAGREE (indicated airspeed disagree) and ALT DISAGREE
(altitude disagree) warnings and the illumination of the FEEL DIFF PRESS (feel differential pressure) light. The captain
did not mention the activation of the stick shaker or the runaway stabilizer and the use of the STAB TRIM CUTOUT
guarded switches that disabled MCAS and caused the flight crew to use manual trim for the majority of the flight and the
landing.
38 “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” p. xviii, accessed here: https://aviation-is.better-
39 Ibid., pp. 19-28, accessed here: https://aviation-is.better-than.tv/737%20MAX%202018%20-%20035%20-%20PK-
LQP%20Final%20Report.pdf and Sinead Baker, “This timeline shows exactly what happened on board the Lion Air
Boeing 737 Max that crashed in less than 13 minutes, killing 189 people,” Business Insider, October 29, 2019, accessed
here: https://www.businessinsider.com/lion-air-crash-timeline-boeing-737-max-disaster-killed-189-2019-10
40 Ibid.
41 Ibid.
42 “Ethiopian Airlines Flight 302 Interim Investigation Report,” pp. 130-132, accessed here: http://www.aib.gov.et/wp-
content/uploads/2020/documents/accident/ET-
43 Ibid.
9
down attitude from which the pilots were unable to recover. 44 Faulty AOA data that erroneously
triggered MCAS to repeatedly activate played critical roles in both MAX crashes.
There have been some allegations made against both Lion Air and Ethiopian Airlines
regarding poor maintenance and even cover-ups. For example, investigators determined that photos
provided by the Lion Air mechanic that purported to document the AOA sensor repair on the
accident airplane depicted a different airplane and dismissed the photos as invalid evidence. 45 In
addition, a whistleblower with knowledge of Ethiopian Airlines’ actions in the aftermath of the
March 2019 crash alleged that staff of the carrier accessed the airplane’s maintenance records the day
after the accident. 46 Such action is contrary to protocols that call for records to be immediately
sealed following a crash. 47 However, while it is not known how, if at all, the records were altered, the
whistleblower contends that this action was part of a pattern of faulty repairs and erroneous records
that call into question the reliability of Ethiopian Airlines’ maintenance practices. 48
In addition to maintenance concerns, some negative aspersions have arisen about the
abilities of the pilots who commanded the ill-fated Lion Air and Ethiopian Airlines flights. While
Lion Air has a reputation for hiring inexperienced pilots and quickly promoting them, the 31-year-
old captain of Lion Air flight 610 had accumulated over 5,100 hours of flight time on Boeing 737
airplanes, and the 41-year-old first officer had more than 4,200 hours on Boeing 737 models,
indicating that they were seasoned pilots. 49 Further, while the 29-year-old captain of Ethiopian
Airlines flight 302 had reportedly not received training on the airline’s 737 MAX simulator—even
though Ethiopian Airlines was one of the first airlines worldwide to purchase a 737 MAX specific
simulator 50—the young pilot had amassed over 5,500 flying hours on Boeing 737 airplanes,
including 103 hours on the 737 MAX. 51 Even the 25-year-old first officer of flight 302—who was
the least experienced of the pilots—had accumulated 207 hours flying Boeing 737 airplanes since
obtaining his commercial pilot’s license in December 2018, just three months before the fatal
crash. 52
44 Ibid.
45 “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” p. 185, accessed here: https://aviation-is.better-
46 Bernard Condon, “Whistleblower complaint alleges corruption in Ethiopian Airlines,” USA Today, October 7, 2019,
accessed here: https://www.usatoday.com/story/news/2019/10/07/ethiopian-airlines-whistleblower-alleges-

corruption-after-737-crash/3898991002
47 Ibid.
48 Ibid.
49 William Langewiesche, “What Really Brought Down the Boeing 737 MAX?” The New York Times Magazine, September
18, 2019, accessed here: https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-

crashes.html?action=click&module=Top%20Stories&pgtype=Homepage and “Lion Air Flight 610 Final Aircraft
Accident Investigation Report,” pp. 28-30, accessed here: https://aviation-is.better-
50 Selam Gebrekidan, “Ethiopian Airlines Had a Max 8 Simulator, but Pilot on Doomed Flight Didn’t Receive Training
On It,” New York Times, March 20, 2019, accessed here:

https://www.nytimes.com/2019/03/20/world/africa/ethiopian-airlines-boeing.html
51 “Ethiopian Airlines Flight 302 Interim Investigation Report,” pp. 18-21, accessed here: http://www.aib.gov.et/wp-
52 Ibid.
10
Addressing the qualifications of these pilots at a June 2019 Subcommittee on Aviation
hearing, Captain Dan Carey, a 35-year career pilot and then president of the Allied Pilots
Association, which represents 15,000 American Airlines pilots, said in his written statement:
To make the claim that these accidents would not happen to U.S.-
trained pilots is presumptuous and not supported by fact. Vilifying
non-U.S. pilots is disrespectful and not solution-based, nor is it in line
with a sorely needed global safety culture that delivers one standard of
safety and training. Simply put, Boeing does not produce aircraft for
U.S. pilots vs. pilots from the rest of the world. 53
Retired airline captain Chesley B. “Sully” Sullenberger III, who landed U.S. Airways flight
1549 on the Hudson River in 2009 saving all 155 people on board in what came to be known as the
“Miracle on the Hudson,” also testified at that hearing. He offered similar sentiments about the
qualifications of these pilots as part of his remarks about the two crashes. 54 In his prepared
testimony Captain Sullenberger wrote:
These crashes are demonstrable evidence that our current system of

aircraft design and certification has failed us… It is obvious that grave
errors were made that have had grave consequences, claiming 346
lives… Accidents are the end result of a causal chain of events, and in
the case of the Boeing 737 MAX, the chain began with decisions that
had been made years before, to update a half-century-old design… We
owe it to everyone who flies, passengers and crews alike, to do much
better than to design aircraft with inherent flaws that we intend pilots
will have to compensate for and overcome. Pilots must be able to
handle an unexpected emergency and still keep their passengers and
crew safe, but we should first design aircraft for them to fly that do not
have inadvertent traps set for them. 55
For two brand-new airplanes, of a brand-new derivative model, to crash within five months
of each other was extraordinary given significant advances in aviation safety over the last two
decades. 56 While certain facts and circumstances surrounding the accidents differed, a common
53 Prepared statement of Captain Daniel F. Carey, President, Allied Pilots Association, Hearing titled, “Status of the
Boeing 737 MAX: Stakeholder Perspectives,” Subcommittee on Aviation of the Committee on Transportation and
Infrastructure, U.S. House of Representatives, 116th Congress, First Session, June 19, 2019, accessed here:
https://transportation.house.gov/imo/media/doc/CA%20Carey%20Hearing%20testimony%20.pdf
54 Robert D. McFadden, “Pilot Is Hailed After Jetliner’s Icy Plunge,” New York Times, January 15, 2009, accessed here:
https://www.nytimes.com/2009/01/16/nyregion/16crash.html and Hearing titled, “Status of the Boeing 737 MAX:

Stakeholder Perspectives,” Subcommittee on Aviation, Committee on Transportation and Infrastructure, U.S. House of
Representatives, 116th Congress, First Session, June 19, 2019, accessed here:
https://transportation.house.gov/committee-activity/hearings/status-of-the-boeing-737-max-stakeholder-perspectives
55 Prepared statement of Chesley B. “Sully” Sullenberger III, Hearing titled, “Status of the Boeing 737 MAX:
Stakeholder Perspectives,” Subcommittee on Aviation of the Committee on Transportation and Infrastructure, U.S.
House of Representatives, 116th Congress, First Session, June 19, 2019, accessed here:
https://transportation.house.gov/imo/media/doc/Sully%20Sullenberger%20Testimony.pdf
56 See: “Fact Sheet – Out Front on Airline Safety: Two Decades of Continuous Evolution,” Federal Aviation
Administration, August 2, 2018, accessed here: https://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=22975;

“Safety Record of U.S. Air Carriers,” Airlines for America, accessed here: https://www.airlines.org/dataset/safety-
11
component in both of the accident airplanes was the new flight control feature: MCAS. Boeing
developed MCAS to address stability issues in certain flight conditions induced by the plane’s new,
larger engines, and their relative placement on the 737 MAX aircraft compared to the engines’
placement on the 737 NG. 57 On March 13, 2019, the FAA grounded the 737 MAX three days after
the Ethiopian Airlines crash, following similar actions taken by China, the EU, and Canada, among
others. 58 Despite optimistic predictions at the time—that a simple software fix for MCAS would
allow the 737 MAX to return quickly to service 59 —the aircraft has been grounded for 18 months,
with even more, newly discovered safety issues emerging since. 60 (See “New Issues Emerge” below).
This report identifies the key technical flaws and management failures the Committee has
discovered at both Boeing and the FAA during its investigation of the design, development, and
certification of the 737 MAX, and related issues. We anticipate that the factual evidence our
investigation has uncovered and the findings we present in this report will help the Members of the
Committee as they consider legislative actions to (1) rectify the problems our investigation has
revealed, (2) create a more robust FAA oversight structure and improved certification process, and
(3) enhance the safety of the flying public.
-Investigative Themes-
The Committee’s investigative findings identify five central themes that affected the design,
development, and certification of the 737 MAX and FAA’s oversight of Boeing. Acts, omissions,
and errors occurred across multiple stages and areas of the development and certification process of
the 737 MAX. These themes are present throughout this report. They include:
1) Production Pressures. There was tremendous financial pressure on Boeing and the 737 MAX
program to compete with Airbus’ new A320neo aircraft. 61 Among other things, this pressure
resulted in extensive efforts to cut costs, maintain the 737 MAX program schedule, and avoid
record-of-u-s-air-carriers; and “Air Traffic By the Numbers,” (Commercial Flight and Available Seat Mile (ASM)
Trends), Federal Aviation Administration, June 2019, accessed here:
https://www.faa.gov/air_traffic/by_the_numbers/media/Air_Traffic_by_the_Numbers_2019.pdf
57 Ralph Vertabedian, “How a 50-year-old design came back to haunt Boeing with its troubled 737 MAX jet,” Los Angeles
Times, March 15, 2019, accessed here: https://www.latimes.com/local/california/la-fi-boeing-max-design-20190315-

story.html
58 “Emergency Order of Prohibition: Operators of Boeing Company Model 737-8 and Boeing Company Model 737-9
Airplanes,” Federal Aviation Administration, Department of Transportation, March 13, 2019, accessed here:
https://www.faa.gov/news/updates/media/Emergency_Order.pdf and Luz Lazo, Michael Laris, Lori Arantani and
Damian Paletta, “FAA’s emergency order grounding Boeing jets came after the agency identified similarities between
crashes in Ethiopia, Indonesia,” Washington Post, March 13, 2019, accessed here:
https://www.washingtonpost.com/local/trafficandcommuting/canada-grounds-boeing-737-max-8-leaving-us-as-last-
major-user-of-plane/2019/03/13/25ac2414-459d-11e9-90f0-0ccfeec87a61_story.html
59 See: Dawn Gilbertson, “Boeing 737 MAX: How will airlines convince skittish passengers it’s safe to fly again,” USA
Today, April 7, 2019, accessed here: https://www.usatoday.com/story/travel/flights/2019/04/06/boeing-737-max-8-

passengers-return-airlines-safety-crashes-fix-airplanes/3376865002/ and Sam Roecker, “Boeing 737 MAX MCAS
Update Ready For Certification,” Simple Flying, April 18, 2019, accessed here: https://simpleflying.com/boeing-737-max-
update-complete
60 Natalie Kitroeff and David Gelles, “It’s Not Just Software: New Safety Risks Under Scrutiny on Boeing’s 737 Max,”
New York Times, January 29, 2020, accessed here: https://www.nytimes.com/2020/01/05/business/boeing-737-

max.html
61 David Gelles, Natalie Kitroeff, Jack Nicas, and Rebecca R. Ruiz, “Boeing Was ‘Go, Go, Go’ to Beat Airbus With the
737 MAX,” New York Times, March 29, 2019, accessed here: https://www.nytimes.com/2019/03/23/business/boeing-
737-max-crash.html
12
slowing the 737 MAX production line. The Committee’s investigation has identified several
instances where the desire to meet these goals and expectations jeopardized the safety of the flying
public.
2) Faulty Design and Performance Assumptions. Boeing made fundamentally faulty

assumptions about critical technologies on the 737 MAX, most notably with MCAS. Based on these
faulty assumptions, Boeing permitted MCAS—software designed to automatically push the
airplane’s nose down in certain conditions—to activate on input from a single angle of attack (AOA)
sensor. It also expected that pilots, who were largely unaware that the system existed, would be able
to mitigate any potential malfunction. Boeing also failed to classify MCAS as a safety-critical system,
which would have attracted greater FAA scrutiny during the certification process. The operation of
MCAS also violated Boeing’s own internal design guidelines related to the 737 MAX’s development
which stated that the system should “not have any objectionable interaction with the piloting of the
airplane” and “not interfere with dive recovery.” 62
3) Culture of Concealment. In several critical instances, Boeing withheld crucial information from
the FAA, its customers, and 737 MAX pilots. This included concealing the very existence of MCAS
from 737 MAX pilots 63 and failing to disclose that the AOA Disagree alert was inoperable on the
vast majority of the 737 MAX fleet, 64 despite having been certified as a standard aircraft feature. 65
The AOA Disagree alert is intended to notify the crew if the aircraft’s two AOA sensor readings
disagree, an event that can occur if one sensor is malfunctioning or providing faulty AOA data.
Boeing not only concealed this information from both the FAA and pilots, but also continued to
deliver MAX aircraft to its customers knowing that the AOA Disagree alert was inoperable on most
of these aircraft. Further, Boeing concealed internal test data it had that revealed it took a Boeing
test pilot more than 10 seconds to diagnose and respond to uncommanded MCAS activation66 in a
flight simulator, a condition the pilot found to be “catastrophic[.]” 67 While it was not required to
share this information with the FAA or Boeing customers, it is inconceivable and inexcusable that
62 Boeing Coordination Sheet, Revision G, June 11, 2018, TBC-T&I 30584 – 30592 at TBC-T&I 30588, at p. 170,
accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf

63 Benjamin Shang, “Boeing’s CEO explains why the company didn’t tell 737 Max pilots about the software system that
contributed to 2 fatal crashes,” Business Insider, April 29, 2019, accessed here: https://www.businessinsider.com/boeings-
ceo-on-why-737-max-pilots-not-told-of-mcas-2019-4
64 Alan Levin, “Boeing Failure to Fix 737 Max Warning Light May Draw FAA Penalty,” Bloomberg, February 21, 2020,
accessed here: https://www.bloomberg.com/news/articles/2020-02-21/boeing-failure-to-fix-737-max-cockpit-light-

may-draw-faa-penalty
65 See: Letter from then-Acting FAA Administrator Dan Elwell to Chair Peter DeFazio, July 11, 2019, (On file with the
Committee), and Julie Johnsson, Ryan Beene and Mary Schlangenstein, “Boeing Held Off for Months on Disclosing
Faulty Alert on 737 Max,” Bloomberg, May 5, 2019, accessed here: https://www.bloomberg.com/news/articles/2019-05-
05/boeing-left-airlines-faa-in-dark-on-737-alert-linked-to-crash
66 The Maneuvering Characteristics Augmentation System (MCAS) was designed to activate automatically without any
pilot command. To the extent this report uses the term “uncommanded” in connection with MCAS activation, it is for
consistency with Boeing’s own Functional Hazard Assessments which measured “Uncommanded MCAS function
operation to pilot reaction[,]” and determined that a pilot reaction time of greater than 10 seconds could be
“catastrophic[.]”
67 “Coordination Sheet, Subject: 737 MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-B-
BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision D, March 30, 2016, BATES Number TBC-T&I 29160 – 29166 at
p. 164, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf
13
Boeing withheld this information from them. It also argues strongly for a disclosure requirement.
Federal guidelines assume pilots will respond to this condition within four seconds. 68
4) Conflicted Representation. The Committee found that the FAA’s current oversight structure
with respect to Boeing creates inherent conflicts of interest that have jeopardized the safety of the
flying public. The Committee’s investigation documented several instances where Boeing
Authorized Representatives (ARs)—Boeing employees who are granted special permission to
represent the interests of the FAA and to act on the agency’s behalf in validating aircraft systems
and designs’ compliance with FAA requirements—failed to disclose important information to the
FAA that could have enhanced the safety of the 737 MAX aircraft. 69 In some instances, a Boeing
AR raised concerns internally in 2016 but did not relay these issues to the FAA, and the concerns
failed to result in adequate design changes. Some of the issues that were raised by the AR and not
thoroughly investigated or dismissed by his Boeing employees, such as concerns about repetitive
MCAS activation and the impact of faulty AOA data on MCAS, were the core contributing factors
that led to the Lion Air and Ethiopian Airlines crashes more than two years later.
5) Boeing’s Influence Over the FAA’s Oversight Structure. Multiple career FAA officials have
documented examples where FAA management overruled a determination of the FAA’s own
technical experts at the behest of Boeing. In these cases, FAA technical and safety experts
determined that certain Boeing design approaches on its transport category aircraft were potentially
unsafe and failed to comply with FAA regulations, only to have FAA management overrule them
and side with Boeing instead. 70 These incidents have had a detrimental impact on the morale of
FAA’s technical and subject matter experts that compromises the integrity and independence of the
FAA’s oversight abilities and the safety of airline passengers. A recent draft internal FAA “safety
culture survey” of employees in the agency’s Aviation Safety Organization (AVS) drew similar
conclusions. “Many believe that AVS senior leaders are overly concerned with achieving the
business-oriented outcomes of industry stakeholders and are not held accountable for safety-related
decisions,” the survey observed. 71
These five recurring themes point to a troubling pattern of problems that affected Boeing’s
development and production of the 737 MAX and the FAA’s ability to provide appropriate
68 JATR Report p.14, accessed here:

https://www.faa.gov/news/media/attachments/Final_JATR_Submittal_to_FAA_Oct_2019.pdf and FAA Advisory
Circular 25.1329-1C, October 27, 2014, p. 78, accessed here:
https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_25_1329-1C.pdf
69 For example, a June 7, 2013, email described an internal Boeing meeting that showed an AR concurred with Boeing’s
plan to describe MCAS as part of the speed trim function to avoid greater FAA certification requirements and pilot
training impacts. See: Boeing internal email, “Subject: PRG – 37MAXFCI-PDR_AI22 – MCAS/Speed Trim,” June 7,
2013, at p. 93, accessed here:
https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.
pdf
70 “Amid Committee’s Ongoing Investigation into the Certification of the 737 MAX, Chairs DeFazio and Larsen Raise
New and Serious Concerns to FAA About Other Safety-related Issues,” Press Release, Committee on Transportation
and Infrastructure, U.S. House of Representatives, November 7, 2019, (hereafter referenced as T&I Committee Press
Release, November 7, 2019) accessed here: https://transportation.house.gov/news/press-releases/amid-committees-
ongoing-investigation-into-the-certification-of-the-737-max-chairs-defazio-and-larsen-raise-new-and-serious-concerns-
to-faa-about-other-safety-related-issues-
71 “Safety Culture Assessment Report,” Federal Aviation Administration, Aviation Safety Organization (AVS),
conducted and prepared by The MITRE Corporation, (DRAFT) February 28, 2020, (Hereafter referred to as “FAA
Safety Culture Survey”). (On file with the Committee).
14
oversight of Boeing and the agency’s certification process. These issues must be addressed by both
Boeing and the FAA in order to correct poor certification practices that have emerged, reassess key
assumptions that affect safety, and enhance transparency to enable more effective oversight.
-Investigative Findings-
Listed below are the Committee’s investigative findings grouped into six distinct categories:
1) FAA oversight, 2) Boeing production pressures, 3) Maneuvering Characteristics Augmentation
System (MCAS), 4) AOA Disagree alert, 5) 737 MAX pilot training, and 6) Post-accident responses
by Boeing and the FAA.
FAA Oversight –The FAA failed to ensure the safety of the traveling public.
 The FAA’s recent draft “safety culture survey” has made it clear that the agency is struggling
to effectively fulfill its core regulatory and oversight mission to enhance aviation safety.
According to the survey results, 49 percent of the FAA employees responding said they
believe “safety concerns/incidents” will not be addressed, 43 percent believe the FAA
delegates too many certification activities to industry and 34 percent said “fear of
retribution” is one reason employees don’t report safety issues. 72 These results correspond
with many of the Committee’s own investigative findings.
 Excessive FAA delegation to Boeing has eroded FAA’s oversight capabilities.
 Boeing’s Authorized Representatives (ARs) may be impaired from acting independently.
 A 2016 Boeing internal survey of its ARs, who are supposed to represent the interests of the
FAA, conducted at the height of the 737 MAX’s certification activities, and provided to the
Committee from a whistleblower, found that 39 percent of Boeing ARs that responded
perceived “undue pressure” and 29 percent were concerned about consequences if they
reported potential “undue pressure.” 73
 The Committee has documented four instances in Boeing’s 737 MAX program where
Boeing ARs failed to represent the interests of the FAA in carrying out their FAA-delegated
functions. In one instance, in 2013, an AR concurred on a decision not to emphasize MCAS
as a “new function” because of Boeing’s fears that doing so would increase “costs” 74 and
lead to “a greater certification and training impact” on the 737 MAX program. 75 The
Committee has no evidence that the AR shared this information with the FAA. In addition,
the Committee found no evidence that any of the four Boeing ARs who knew that Boeing
72 Ibid.
73 “Undue Pressure: Key Learnings and Next Steps,” Boeing Commercial Airplanes, November 2016, at p. 145, accessed
here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf
74 Boeing “ITRACS” report, “Title: MCAS/Speed Trim,” 37MAXFCI-PDR_AI22, Item entered: May 21, 2013, Item
closed: June 27, 2013, BATES Number TBC-T&I 549172 – 548173. (On file with the Committee).
75 Boeing internal email, “Subject: PRG – 37MAXFCI-PDR_AI22 – MCAS/Speed Trim,” Sent: June 7, 2013, at p. 93,
accessed here:
pdf (The issues surrounding this June 2013 meeting regarding MCAS, and Boeing’s position on it, are discussed at length
in the MCAS section of this report).
15
had evidence demonstrating that in 2012 it took a Boeing test pilot more than 10 seconds to
respond to uncommanded MCAS activation in a flight simulator, a condition the pilot found
to be “catastrophic[,]” informed the FAA of this critical information. In 2016, a Boeing AR
also raised concerns regarding the ability of MAX pilots to respond to repetitive MCAS
activation and the impact of faulty AOA data on MCAS. Those concerns were not properly
addressed, and the AR did not inform the FAA of the concerns. The Committee also
discovered that one AR who was aware that Boeing knowingly delivered aircraft with
inoperable AOA Disagree alerts to its customers in 2017 and 2018 took no action to inform
the FAA.
 Not all of these instances violated FAA regulations or guidance. However, every one of
them indicates that Boeing ARs are not communicating fundamentally important
information about safety, certification or conformity-related issues to the FAA that could
drastically enhance the agency’s oversight functions and greatly improve its understanding of
potential safety issues on aircraft it is obligated to certify as safe.
 FAA management has undercut the authority and judgment of its own technical experts and
sided with Boeing on design issues that failed to adequately address safety issues and appear
to have violated FAA regulations or guidance, in some instances. These issues go beyond the
737 MAX program. The Committee is aware of at least one example where FAA technical
experts were overruled by FAA management regarding a lightning protection safety feature
on another Boeing aircraft, the 787 Dreamliner. 76
 The FAA’s oversight was hampered by poor, disjointed FAA communication among the
agency’s own internal offices responsible for certifying new critical 737 MAX systems, such
as MCAS. This lack of information impeded the ability of FAA employees to make fully
informed decisions about the MAX. From FAA leadership down, ineffective
communication and lack of coordination on key certification and safety issues jeopardized
the safety of the flying public.
 The FAA failed to fully exercise its oversight authority and this failure adversely affected
safety. The agency did not ask enough questions or sufficiently scrutinize Boeing responses
regarding critical certification-related issues involving pilot training and technical design.
 The FAA has, for instance, as of the publishing of this report, failed in its duty to hold
Boeing accountable for delivering airplanes with non-functioning AOA Disagree alerts that
Boeing knew were inoperable. 77 According to then-Acting FAA Administrator Dan Elwell,
Boeing was required to deliver airplanes with functioning AOA Disagree alerts because they
were part of the 737 MAX’s approved type design. 78
76 T&I Committee Press Release, November 7, 2019, accessed here: https://transportation.house.gov/news/press-

releases/amid-committees-ongoing-investigation-into-the-certification-of-the-737-max-chairs-defazio-and-larsen-raise-
new-and-serious-concerns-to-faa-about-other-safety-related-issues-
77 Letter from then-Acting FAA Administrator Dan Elwell to Chair Peter DeFazio, July 11, 2019, (On file with the
Committee).
78 Ibid.
16
 Boeing received an FAA exception to allow the company to not install on the 737 MAX an
Engine Indicating and Crew Alerting System (EICAS)—a system common in newly type
certificated aircraft since 1982 that displays for pilots aircraft system faults and failures and
helps pilots prioritize their response to multiple or simultaneous indications, warnings, and
alerts. The FAA accepted Boeing’s argument about the impracticality and the economic
expense of installing EICAS on the 737 MAX. 79 The 737 family, including the 737 MAX, is
the only Boeing commercial aircraft line that does not have an EICAS installed, which may
have helped to alleviate pilot confusion in both the Lion Air and Ethiopian Airlines
accidents. 80
Boeing Production Pressure – Costs, schedule, and production pressures at Boeing

undermined safety of the 737 MAX.
 Schedule pressure was visible to all Boeing employees working on the 737 MAX program.
 To emphasize the significance of the 737 MAX program’s schedule to Boeing employees,
the Committee learned that senior program officials kept a “countdown clock” in their
conference room. Keith Leverkuhn, the former Vice President and General Manager of the
MAX program, described the clock as an “excitement generator” for Boeing’s staff. But he
also acknowledged it was to remind staff about the MAX’s schedule. “One of the mantras
that we had was the value of a day,” he said, “and making sure that we were being prudent
with our time, that we were being thorough, but yet, that there was a schedule that needed to
be met….” 81 He said the countdown clock was used to mark two major milestones: power
on, when the MAX was powered up for the first time in the factory, and first flight. 82
 In 2012, in order to lower costs of the 737 MAX program, Boeing reduced the work hours
involved in avionics regression testing on the 737 MAX by 2,000 hours. It also examined
other reductions to save costs, including a reduction to flight test support by 3,000 hours
and a reduction to the engineering flight deck simulator (E-CAB) by 8,000 hours. 83
79 See: “Safety Recommendation Report: Assumptions Used in the Safety Assessment Process and the Effects of
Multiple Alerts and Indications on Pilot Performance,” National Transportation Safety Board (NTSB), September 19,
2019, accessed here: https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf; Boeing slide
presentation to FAA, “BCA Airplane Programs Organization Designation Authorization (ODA) Technical Review
Board 737 MAX Impractical Exception Proposal – Flight Crew Alerting, 25.1322(b)(2), (b)(3), (c)(2), (d)(1), and (d)(2),”
June 7, 2013, FAA-DEFAZIO-000032891 (On file with the Committee); and Dominic Gates, Steve Miletich, & Lewis
Kamb, “Boeing pushed FAA to relax 737 MAX certification requirements for crew alerts,” Seattle Times, October 2,
2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/boeing-pushed-faa-to-arelax-737-max-
certification-requirements-for-crew-alerts
80 Dominic Gates, Steve Miletich, & Lewis Kamb, “Boeing pushed FAA to relax 737 MAX certification requirements
for crew alerts,” Seattle Times, October 2, 2019, accessed here: https://www.seattletimes.com/business/boeing-
aerospace/boeing-pushed-faa-to-arelax-737-max-certification-requirements-for-crew-alerts
81 Committee staff transcribed interview of Keith Leverkuhn, former Vice President and General Manager of the 737
MAX program, Boeing Commercial Airplanes, May 19, 2020, accessed here:
https://transportation.house.gov/committee-activity/boeing-737-max-investigation
82 Ibid.
83 Boeing internal power-point presentation, “FCOI Model Leads Meeting – 737 MAX,” July 12, 2012, TBC-T&I
011072 - 011073 (On file with the Committee).
17
 In 2013, a Boeing engineer raised the issue of installing on the 737 MAX a synthetic airspeed
indicator—a computer-based indicator of speed that can be compared to actual airspeed
measures—as had been done on the 787 Dreamliner. However, this request was rejected by
Boeing management due to cost concerns and because adding synthetic airspeed could have
jeopardized the 737 MAX program’s directive to avoid pilot simulator training
requirements. 84
 The Committee has learned that to thank him for keeping to the MAX’s production
schedule, Boeing gave Michael Teal, the former Chief Project Engineer on the 737 MAX
program, restricted stock options after the airplane’s first flight in 2016 to show its
appreciation for his work. 85
 In June 2018, Ed Pierson, a senior Boeing plant supervisor at the company’s Renton,
Washington 737 MAX production factory, emailed Scott Campbell, the 737 General
Manager, requesting a meeting about “safety concerns.” 86 Mr. Pierson described multiple
concerns about production and schedule pressures that were impacting quality control and
safety issues. “As a retired Naval Officer and former Squadron Commanding Officer,”
wrote Pierson, “I know how dangerous even the smallest of defects can be to the safety of
an airplane. Frankly right now all my internal warning bells are going off. And for the first
time in my life, I’m sorry to say that I’m hesitant about putting my family on a Boeing
airplane.” 87
 In July 2018, five weeks after Mr. Pierson’s email, he finally met with Mr. Campbell in Mr.
Campbell’s office. According to Mr. Pierson’s testimony to the Committee, he told Mr.
Campbell that in the military they would temporarily halt production if they had the kinds of
safety problems that Mr. Pierson was seeing on the MAX factory floor. Mr. Campbell
allegedly responded: ‘‘The military is not a profit-making organization.’’ 88 Rather than
heeding Mr. Pierson’s dire warnings and thoroughly evaluating his safety concerns, Boeing
continued to ramp up production on the 737 MAX 89 and rehired retired Boeing employees
84 See: Boeing internal emails, “Subject: Synthetic Airspeed,” February 26, 2013, at p. 1, accessed here:
pdf, Natalie Kitroeff, David Gelles and Jack Nicas, “Boeing 737 Max Safety System Was Vetoed, Engineer Says,” New
York Times, October 2, 2019, (Updated 29, 2019), accessed here:
https://www.nytimes.com/2019/10/02/business/boeing-737-max-crashes.html and Dominic Gates, Steve Miletich
and Lewis Kamb, “Boeing rejected 737 MAX safety upgrades before fatal crashes, whistleblower says,” Seattle Times,
October 2, 2019 (Updated October 3, 2019), accessed here: https://www.seattletimes.com/business/boeing-
aerospace/boeing-whistleblowers-complaint-says-737-max-safety-upgrades-were-rejected-over-cost
85 Committee staff interview of Michael Teal, former Vice President, Chief Project Engineer and Deputy Program
Manager of the 737 MAX Program, Boeing Commercial Airplanes, May 11, 2020, accessed here:
86 Email from Ed Pierson to Scott A. Campbell, “Subject: Recovery Operations & Safety Concerns,” Saturday, June 9,
2018 1:32 PM.

87 Ibid.
88 Hearing titled, “The Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight of the Aircraft’s
Certification,” House Committee on Transportation and Infrastructure, 116th Congress, First Session, U.S. House of
Representatives, December 11, 2019, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
116hhrg40697/pdf/CHRG-116hhrg40697.pdf
89 The Boeing Company, Q2 2018 Earnings Call, July 25, 2018, p. 6, accessed here:
https://s2.q4cdn.com/661678649/files/doc_financials/quarterly/2018/q2/2Q18-Earnings-Call-Transcript-Final.pdf
18
to keep the production lines moving at the Renton plant. 90 Lion Air flight 610 crashed three
months later in October 2018.
Maneuvering Characteristics Augmentation System (MCAS) – Boeing failed to

appropriately classify MCAS as a safety-critical system, concealed critical information about
MCAS from pilots, and sought to diminish focus on MCAS as a “new function” in order to
avoid increased costs, and “greater certification and training impact.”
 Both Boeing and the FAA failed to appropriately designate MCAS a safety-critical system. In
May 2019, then-Acting FAA Administrator Dan Elwell acknowledged this point at a hearing
before the Committee. 91
 In 2012, Boeing developed initial concepts for an MCAS annunciator to inform pilots when
MCAS failed to activate, but never implemented it. 92 Instead, Boeing designed the “speed
trim fail” alert to incorporate the MCAS failure functionality. 93 Human factors experts have
argued that an MCAS-specific display that went beyond just indicating MCAS’s “failure”
could have helped to negate pilot confusion in the MAX accidents. 94
 In June 2013, Boeing employees formulated a plan to help avoid increased “cost,” 95 and
“greater certification and training impact” for the 737 MAX by describing MCAS as “an
addition to [the existing] Speed Trim [system].” 96 The Boeing meeting minutes warned: “If
we emphasize MCAS is a new function there may be a greater certification and training
90 “Boeing 737 MAX: Retired former employees come back to help with production,” Traveller, September 12, 2018,
accessed here: https://www.traveller.com.au/boeing-737-max-retired-former-employees-come-back-to-help-with-
production-h157in
91 Hearing titled, “Status of the Boeing 737 MAX: Stakeholder Perspectives,” Subcommittee on Aviation, Committee on
Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, May 15, 2019, pp. 28-
29, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg37277/pdf/CHRG-116hhrg37277.pdf
92 “Preliminary Design Decision Memo,” High Speed Pitch-Up, Revision A, November 8, 2012, BATES Number TBC-
T&I 010920, TBC-T&I 010926, accessed at p. 119 here: https://www.govinfo.gov/content/pkg/CHRG-

93 Hearing titled, “The Boeing 737 MAX: Examining the Design, Development, and Marketing of the Aircraft,”
Committee on Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, October
30, 2019, p. 20, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-
116hhrg38282.pdf
94 Dr. Mica Endsley, a Committee Chair at the Human Factors and Ergonomics Society and a former Chief Scientist of
the U.S. Air Force testified before the Transportation and Infrastructure Committee in December 2019. She pointed
out: “It is critical that the automation mode and status be clearly and saliently displayed. In this case a display showing
that the MCAS was on and each time it engaged, as well as its effect on aircraft trim, would have provided key input to
the pilots as to what the system was doing. If the MCAS is overridden by the pilot and turned off, this should be
displayed as well to provide clear feedback to the pilots on its state.” See: Dr. Mica R. Endsley, Prepared Testimony,
“The Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight of the Aircraft’s Certification,”
Committee on Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session,
December 11, 2019, accessed here: https://transportation.house.gov/committee-activity/hearings/the-boeing-737-max-
examining-the-federal-aviation-administrations-oversight-of-the-aircrafts-certification
95 Boeing ITRACS Item, “MCAS/Speed Trim,” 37MAXFCI-PDR AI22, BATES Number TBC T&I 549172-549173.
(On file with the Committee).

96 Boeing internal email, “Subject: PRG – 37MAXFCI-PDR_AI22 – MCAS/Speed Trim,” June 7, 2013, at p. 93,
accessed here:
pdf
19
impact.” 97 According to the email that summarized the meeting minutes, a Boeing AR
concurred with this plan. 98
 In 2015, a Boeing AR raised the question of whether MCAS was “vulnerable to single AOA
sensor failures….” 99 Despite this, the aircraft was delivered with MCAS dependent on a
single AOA sensor. Boeing’s decision to allow MCAS to operate off of a single AOA sensor
has been roundly criticized by a wide range of aviation safety experts. 100
 In March 2016, the General Manager of Boeing’s 737 MAX program, Keith Leverkuhn, and
Michael Teal, the former Chief Project Engineer on the 737 MAX program, both approved a
redesign of MCAS to increase its authority to move the aircraft’s stabilizer at low speed, in
order to address “stall characteristics” requirements necessary for FAA certification. 101
 Just hours after the approval for MCAS’s redesign was granted, Boeing sought, and the FAA
approved, the removal of references to MCAS from Boeing’s Flight Crew Operations
Manual (FCOM) 102—a document that provides procedures, performance, and systems
information to flight crews to enable their safe and efficient operation of the airplane. 103 As a
result, 737 MAX pilots were precluded from knowing of the existence of MCAS and its
potential effect on aircraft handling without pilot command. Meanwhile, the FAA officials
who authorized this request remained unaware of the redesign of MCAS until after the crash
of the Lion Air flight. Although Boeing’s approval of the redesign of MCAS and its efforts
to remove references to MCAS from pilot training material occurred nearly simultaneously it
is unclear if these actions were coordinated.
97 Ibid.
98 Ibid. (The issue regarding this June 2013 meeting, and Boeing’s response to it, are discussed at length in the MCAS
section of this report.)
99 See Boeing internal email, AOA Sensor email string – TBC-T&I 10584-10585, December 17, 2015, p. 121, accessed
100 See: Peter Cohan, “MIT Expert Highlights 'Divergent Condition' Caused By 737 MAX Engine Placement,” Forbes,
April 2, 2019, accessed here: https://www.forbes.com/sites/petercohan/2019/04/02/mit-expert-highlights-divergent-

condition-caused-by-737-max-engine-placement/#7c4f24d040aa; Jack Nicas, Natalie Kitroeff, David Gelles, & James
Glanz, “Boeing Built Deadly Assumptions Into 737 Max, Blind to a Late Design Change,” New York Times, June 1, 2019,
accessed here: https://www.nytimes.com/2019/06/01/business/boeing-737-max-crash.html?searchResultPosition=1;
and Gregory Travis, “How the Boeing 737 Max Disaster Looks to a Software Developer,” IEEE Spectrum, April 18,
2019, accessed here: https://spectrum.ieee.org/aerospace/aviation/how-the-boeing-737-max-disaster-looks-to-a-
software-developer
101 See: Boeing presentation, “737 MAX: SMYD (EFS) & FCC (MCAS) FT Validation, Basic Stall Characteristics,”
Compilation of previous presentations S&C, April 7, 2016, BATES Number TBC T&I 257428-257439, at TBC T&I
257430 (On file with Committee); Boeing presentation, “737 MAX / Stall Characteristics – Mitigation,” Aero S&C,
March 30, 2016, BATES Number TBC T&I 046618-046682 (On file with the Committee); and Boeing internal email,
“Subject: FW: 737MAX Stall Chars Meeting Summary 3-30-16,” Sent: March 30, 2016, 12:46:55 PM, BATES Number
TBC T&I 257421-257422 (On file with the Committee). See also, Committee staff transcribed interview of Keith
Leverkuhn, former Vice President and General Manager of the 737 MAX program, Boeing Commercial Airplanes, May
19, 2020 and Committee staff interview of Michael Teal, former Vice President, Chief Project Engineer and Deputy
Program Manager of the 737 MAX Program, Boeing Commercial Airplanes, May 11, 2020.
102 Email from Mark Forkner to FAA, “Subject: MCAS lives in both FCCs,” Sent: March 30, 2016 11:16:45 (On file with
the Committee).
103 “Development of Aircraft Operating Manuals,” SKYbrary, accessed here:
https://www.skybrary.aero/index.php/Development_of_Aircraft_Operating_Manuals
20
 After Boeing redesigned MCAS in 2016 to increase its authority to move the aircraft’s
stabilizer at lower speeds, Boeing failed to reevaluate the system or perform single- or
multiple-failure analyses of MCAS. 104
 In June 2016, a Boeing AR raised concerns following a test flight of the 737 MAX during
which MCAS countered the pilot’s attempts to trim the airplane, including concerns related
to the vulnerability caused by faulty AOA readings. 105 These concerns were discounted by
the AR’s Boeing colleagues, particularly Boeing’s test pilots. 106 However, faulty AOA data
that resulted in uncommanded MCAS activation was a significant contributing factor in the
crashes of both the Lion Air and Ethiopian Airlines flights. 107
 Following the same test flight, another Boeing engineer asked if repetitive MCAS activation
was a safety issue. 108 A colleague responded: “I don’t think this is safety, other then (sic) the
pilot could fight the MCAS input and over time find themselves in a large mistrim.” 109 In
both the Lion Air and Ethiopian Airlines flights, the pilots struggled to overcome MCAS,
partly because of MCAS’s repetitive activations that forced the airplanes into a nose-down
configuration from which the pilots were unable to recover. 110
 In a transcribed interview with Committee staff, Michael Teal, the former Chief Project
Engineer on the 737 MAX program, acknowledged that when he approved the MCAS
redesign in March 2016 he was unaware: 1) that MCAS operated from a single AOA sensor,
2) that MCAS could activate repeatedly, or 3) that Boeing had internal test data showing that
one of its own test pilots took more than 10 seconds to react to uncommanded MCAS
activation in a flight simulator, and described the results as “catastrophic.” 111
104 See Boeing presentation to FAA, “MCAS Development and Certification Overview,” December 17, 2018, (updated
and transmitted to FAA on March 1, 2019), TBC-T&I130073, TBC-T&I130111, pp. 178 - 201 at p. 198, accessed here:
https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf
105 Boeing internal email, “Subject: RE: S&C Brief Summary: 1A001, Test 009-25 6/13/16 [BLOCK 2],” Sent:
Wednesday, June 15, 2016, 10:23 AM, BATES Number TBC-T&I 246488 – TBC-T&I 246493 at TBC-T&I 246490 and
Boeing internal email, “Subject: RE: S&C Brief Summary: 1A001, Test 009-25 6/13/16 [BLOCK 2],” Sent: Wednesday,
June 15, 2016, 1:01 PM, BATES Number TBC-T&I 246488 – TBC-T&I 246493 at TBC-T&I 246489.
106 Boeing internal email, “Subject: RE: S&C Brief Summary: 1A001, Test 009-25 6/13/16 [BLOCK 2],” Sent:
Wednesday, June 15, 2016, 1:43 PM, BATES Number TBC-T&I 246488 – 246493 at TBC-T&I 246489 and Boeing
internal email, “Subject: RE: Discussion of MCAS Characteristics,” Sent: June 22, 2016, 1:59 PM, BATES Number
TBC-T&I 292457 – 292458. (On file with the Committee).
107 See: “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” accessed here: https://aviation-is.better-
than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf and “Ethiopian Airlines Flight

302 Interim Investigation Report,” accessed here: http://www.aib.gov.et/wp-
108 Boeing internal email, “Subject: RE: Squawk for MCAS trim Event,” Sent: Thursday, June 16, 2016, 2:49 PM,
BATES Number TBC-T&I 220826 (On file with the Committee).

109 Boeing internal email, “Subject: RE: Squawk for MCAS trim Event,” Sent: June 20, 2016, 6:38:08 AM, BATES
Number TBC-T&I 220826 (On file with the Committee).

110 See: “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” accessed here: https://aviation-is.better-
than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf and “Ethiopian Airlines Flight

302 Interim Investigation Report,” accessed here: http://www.aib.gov.et/wp-
Manager of the 737 MAX Program, Boeing Commercial Airplanes, May 11, 2020.
21
 Mr. Teal defended his lack of awareness of these key attributes on a system he approved
saying he relied on the advice of the engineers on the MAX program. Although Mr. Teal was
the program’s Chief Project Engineer responsible for signing off and approving of key
design decisions on the MAX, he did not actually supervise any engineers. “[Y]ou could say
that none of them worked for me but all of them worked for me,” he said. 112 This reporting
structure contributed to an overall lack of accountability on the MAX program.
 The operating parameters of the MCAS system eventually placed on the 737 MAX aircraft
violated Boeing’s own internal design requirements which demanded that MCAS “not have
any objectionable interaction with the piloting of the airplane” and “not interfere with dive
recovery,” which occurred in both 737 MAX crashes. 113
AOA Disagree Alert – Boeing concealed information from the FAA, its customers, and
pilots that the AOA Disagree alerts were inoperable on most of the 737 MAX fleet, despite
their operation being “mandatory” on all 737 MAX aircraft. To date, FAA has failed to hold
Boeing accountable for these actions.
 Boeing has publicly blamed its software supplier for an issue that tied the AOA Disagree
alert, which was supposed to be standard on all 737 MAX aircraft, to an optional AOA
Indicator display, 114 the result of which was to render the AOA Disagree alert inoperable on
more than 80 percent of the MAX aircraft. However, the Committee has learned that in July
2015, Boeing tested this software and failed to detect the problem. 115
 In August 2017, five months after the 737 MAX was certified by the FAA and three months
after it entered revenue service, Boeing issued a problem report to its supplier complaining
that the 737 MAX’s AOA Disagree alert was tied to the optional AOA Indicator and
therefore was not functioning on the vast majority of the 737 MAX fleet worldwide. 116 Yet
Boeing had previously approved of the version of the software that tied the AOA Disagree
alert to the optional AOA Indicator display in July 2015. 117
 Rather than immediately informing the FAA and Boeing customers about this issue when it
was discovered in August 2017, and advising Boeing to fix the problem via a software update
as soon as possible, a Boeing AR consented to Boeing’s plan to postpone the software
112 Ibid.
113 Boeing Coordination Sheet, Revision G, June 11, 2018, TBC-T&I 30584 – 30592 at TBC-T&I 30588, at p. 170,
accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf.
114 “Boeing Statement on AOA Disagree Alert,” Press Release, The Boeing Company, May 5, 2019, accessed here:
https://boeing.mediaroom.com/news-releases-statements?item=130431
115 “AOA DISAGREE Displayed with AOA Fail Flag,” Problem Report (PR) 195, PR opened: May 14, 2015, PR
closed: July 29, 2015, BATES Number TBC T&I TBC 267345-267346. (On file with the Committee). (Hereafter
referred to as “AOA Disagree Alert Problem Report #195”).
116 See: Boeing AOA Disagree Alert Narrative. TBC-T&I 267826 – TBC-T&I 267833, at TBC-T&I 267830 (On file
with the Committee). and Alan Levin, “Boeing Failure to Fix 737 MAX Warning Light May Draw FAA Penalty,”
Bloomberg, February 21, 2020, accessed here: https://www.bloomberg.com/news/articles/2020-02-21/boeing-failure-to-
fix-737-max-cockpit-light-may-draw-faa-penalty
117 Letter to Chair DeFazio and Subcommittee on Aviation Chair Larsen from attorney for Rockwell Collins, June 20,
2019, p. 9. (On file with the Committee).
22
update until 2020, three years later, so it could be done in conjunction with the rollout of
Boeing’s planned 737 MAX-10 aircraft. 118
 Although Boeing prepared a “Fleet Team Digest” to inform its customers about the
inoperable AOA Disagree alert, Boeing never sent it, keeping Boeing’s customers in the dark
about the inoperable alert until after the Lion Air crash. 119
 Boeing’s software supplier, Collins Aerospace, also falsely believed that Boeing had
communicated the AOA Disagree alert issue to its 737 MAX customers. 120
 Boeing provided Lion Air with a Flight Crew Operations Manual (FCOM) for its 737-8
MAX aircraft dated August 16, 2018, one year after learning that the AOA Disagree alert
was not functioning on most 737 MAX aircraft, including those operated by Lion Air. The
FCOM explained how the AOA Disagree alert was intended to work and provided
absolutely no indication that Boeing was fully aware that the AOA Disagree alert on the
Lion Air 737 MAX aircraft was not operational. 121 As a result, Lion Air pilots who
referenced Boeing’s FCOM would have falsely believed that the AOA Disagree alert was
functioning properly and would reliably warn them of a malfunctioning AOA sensor. Boeing
knowingly deceived these pilots and its customer airlines.
 Boeing did not acknowledge that the AOA Disagree alerts on more than 80 percent of the
737 MAX fleet were inoperative until after the Lion Air crash in October 2018. 122
 By the time of the Lion Air crash, Boeing had knowingly delivered approximately 200 MAX
aircraft to customers around the world with non-functioning AOA Disagree alerts. 123
 In July 2019, then-Acting FAA Administrator Dan Elwell informed the Committee that
“[a]lthough an AOA Disagree message was not necessary to meet FAA safety regulations,
once it was made part of the approved type design, it was required to be installed and
functional on all 737 MAX airplanes Boeing produced.” 124
 Although the AOA Disagree alert was not considered a safety critical component, Boeing
knowingly delivered 737 MAX aircraft to its customers with inoperable AOA Disagree alerts
that did not conform to the airplane’s amended type certificate. As far as the Committee
understands, the FAA has failed to take any measures whatsoever to hold Boeing
118 Boeing AOA Disagree Alert Narrative, TBC-T&I 267826 – TBC-T&I 267833, at TBC-T&I 267830 - TBC-T&I
267831. (On file with the Committee).

119 Boeing AOA Disagree Alert Narrative, TBC-T&I 267826 – TBC-T&I 267833, at TBC-T&I 267831. (On file with the
Committee).
120 Committee staff interview with Rockwell Collins employee, September 11, 2019.
121 Lion Air Flight Crew Operations Manual, August 16, 2018, accessed at pp. 175-177 here:
122 Alan Levin, “Boeing Failure to Fix 737 MAX Warning Light May Draw FAA Penalty,” Bloomberg, February 21, 2020,

may-draw-faa-penalty
123 “737 MAX: Deliveries Report,” The Boeing Company, accessed here:
http://www.boeing.com/commercial/#/orders-deliveries
124 Letter from then-Acting FAA Administrator Dan Elwell to Chair Peter DeFazio, regarding the mandatory installation
of functional AOA Disagree alerts on all Boeing 737 MAX aircraft, July 11, 2019. (On file with the Committee).
23
accountable for knowingly delivering aircraft with non-functioning AOA Disagree alerts to
their customer airlines and failing to inform MAX pilots or the FAA that an item that was
supposed to be a standard feature in the cockpit was inoperable.
737 MAX Pilot Training – Boeing’s economic incentives led the company to a significant
lack of transparency with the FAA, its customers, and 737 MAX pilots regarding pilot
training requirements and negatively compromised safety.
 Boeing had tremendous financial incentive to ensure that no regulatory determination

requiring pilot simulator training for the 737 MAX was made. Under a contract signed in
December 2011 with Southwest Airlines, the U.S. launch customer for the 737 MAX,
Boeing was financially obligated to have discounted the price of each MAX airplane it
delivered to Southwest by at least $1 million if the FAA had required simulator training for
pilots transitioning from the 737 NG to the 737 MAX. 125
 Southwest had 200 firm orders for the MAX with the option to purchase an additional 191
MAX aircraft. 126 Thus, if Boeing failed to obtain Level B (non-simulator) training
requirements or less from the FAA it would have owed Southwest between $200 to nearly
$400 million. 127 This helped incentivize Boeing and its leadership to forestall any simulator
training for 737 MAX pilots. This had the impact of evading and averting the inclusion of at
least one technology that could have affected Boeing’s directive to avoid simulator training.
 In November 2012, for instance, it took a Boeing test pilot more than 10 seconds to respond
to uncommanded MCAS activation during a flight simulator test, a condition the pilot found
to be “catastrophic[.]” 128 The FAA has provided guidance that pilots should be able to
respond to this condition within four seconds. 129 This event should have focused Boeing’s
attention on the need for enhanced pilot training for MAX pilots. It didn’t.
125 See: Letter from Southwest Airlines’ Drew Richardson to Chair DeFazio and Subcommittee on Aviation Chair Rick
Larsen, July 26, 2019, (On file with the Committee), and David Shepardson and Tracy Rucinski, “U.S. lawmakers
question Boeing’s $1 mln rebate clause for Southwest 737 MAX orders,” Reuters, October 30, 2019, accessed here:
https://www.reuters.com/article/us-boeing-airplane-southwest/u-s-lawmakers-question-boeings-1-mln-rebate-clause-
for-southwest-737-max-orders-idUSKBN1X92D4
126 “Southwest Airlines Reports Fourth Quarter And Record Annual Profit; 44th Consecutive Year Of Profitability,”
Southwest Airlines Company, January 26, 2017, accessed here:

http://www.southwestairlinesinvestorrelations.com/tools/viewpdf.aspx?page={55E44CBF-22E3-41F5-84EF-
B3EDAB030B07}
127 In January 2017, Southwest had 200 firm 737 MAX orders with the option to purchase 191 additional MAX aircraft.
In October 2019, one year after the Lion Air crash, Southwest had 246 firm MAX orders, 34 of its MAX aircraft were
grounded and it had the option to purchase 115 additional MAX aircraft. See: “Southwest Airlines Reports Fourth
Quarter And Record Annual Profit; 44th Consecutive Year Of Profitability,” Southwest Airlines Company, January 26,
2017, accessed here: http://www.southwestairlinesinvestorrelations.com/tools/viewpdf.aspx?page={55E44CBF-22E3-
41F5-84EF-B3EDAB030B07}; “Southwest Corporate Fact Sheet,” Southwest Airlines Company, 2020, accessed here:
https://www.swamedia.com/pages/corporate-fact-sheet#fleet and “Southwest Reports Record Third Quarter Net
Income And Earnings Per Share,” Southwest Airlines Company, October 24, 2019, accessed here:
http://www.southwestairlinesinvestorrelations.com/news-and-events/news-releases/2019/10-24-2019-112936719
128 Internal email from Boeing engineer to two Boeing test pilots, “Subject: MCAS Hazard Assessment,” Sent:
November 1, 2012, 2:40 PM, BATES Number TBC T&I 131226 – 131227 (On file with the Committee).
129 See: JATR Report p.14 and FAA Advisory Circular 25.1329-1C, October 27, 2014, p. 78, accessed here:
https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_25_1329-1C.pdf
24
 From 2015 to 2018, the information regarding the fact that Boeing’s own test pilot took
more than 10 seconds to respond to uncommanded MCAS activation in a flight simulator
leading to potentially “catastrophic” consequences was included in at least six separate
internal Boeing Coordination Sheets on MCAS’s requirements. 130 This indicates Boeing’s
keen awareness of the importance of this information.
 The Committee has found no evidence that Boeing shared this information with the FAA,
its customers, or 737 MAX pilots and Boeing has confirmed to the Committee that it found
no record showing it shared any of these MCAS Coordination Sheets with the FAA because
they were not required to do so.
 At least four Boeing ARs were aware of these findings and never reported them to the FAA.
 One of Boeing’s key goals for the 737 MAX program was that simulator-based training
would not be required for pilots transitioning to the 737 MAX from the 737 NG. 131 That
goal undermined appropriate pilot training requirements, hampered the development of
safety features that conflicted with that goal and created management incentives to downplay
the risks of technologies that jeopardized that goal. 132
 Early in the 737 MAX program, for instance, Boeing recognized that the addition of MCAS
to the pilot’s flight controls system posed a risk to qualifying for Level B (non-simulator)
training. 133
 However, the chief project engineer on the MAX program told Committee staff that
obtaining Level B (non-simulator) pilot training requirements from the FAA was a “design
objective” of the MAX program. 134 That directive demanded that differences training for
130 See: Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-
B-BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision B, July 8, 2015, TBC T&I 191227 – TBC T&I 191232 at TBC
T&I 191231 (On file with the Committee); Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim
(MCAS) Requirements,” No. Aero-B-BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision C, October 19, 2015, TBC
T&I 253262 - TBC T&I 253268 at TBC T&I 253267 (On file with the Committee); Boeing Coordination Sheet,
“737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-B-BBA8-C12-0159, Model: 737-
MAX (-7/8/9), Revision D, March 30, 2016, accessed at p. 164 here: https://www.govinfo.gov/content/pkg/CHRG-
116hhrg38282/pdf/CHRG-116hhrg38282.pdf; Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer
Trim (MCAS) Requirements,” No. Aero-B-BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision E, July 5, 2016, TBC
MAX (-7/8/9), Revision F, December 20, 2017, TBC T&I 037449 - TBC T&I 037457 at TBC T&I 037457 (On file with
the Committee); Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,”
No. Aero-B-BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June, 11 2018, accessed at p. 174 here:
131 Boeing internal email, “Subject: 737 MAX Firm Configuration Status/Help Needed,” Sent: May 4, 2013 11:35 AM,
BATES Number TBC-T&I 048706 – 048707, at pp. 128-129 accessed here:

132 Ibid.
133 Ibid.
Manager of the 737 MAX Program, Boeing Commercial Airplanes, May 11, 2020.
25
pilots transitioning from the 737 NG to the 737 MAX would be limited to 16 hours—or
less—of computer based training requirements. 135
 In July 2014, two years before the FAA made a determination regarding pilot training
requirements for the 737 MAX, and at a time when the FAA was actively questioning
Boeing on its presumption that no simulator training would be required, Boeing issued a
press release asserting: “Pilots already certified on the Next-Generation 737 will not require a
simulator course to transition to the 737 MAX.” 136 Boeing made similar claims in marketing
materials it provided to potential customers. 137
 In February 2015, Boeing’s 737 Chief Technical Pilot wrote that MAX simulator training
would be “unrecoverable” for some Boeing customers due to the lack of simulators. 138
 In August 2016, the FAA granted provisional approval for Level B (non-simulator)
differences training requirements for pilots transitioning between the 737 NG and the 737
MAX. 139 The FAA estimated that its approved computer-based training for the MAX could
be completed in approximately two hours, a drastic reduction from the 16 hours Boeing was
anticipating. 140
 The following month, in September 2016, Boeing granted its team of technical pilots the
company’s Commercial Aviation Services (CAS) Service Excellence Award for their role in
“developing the MAX Level B [non-simulator] differences training....” 141
 In March 2017, the month the 737 MAX was certified by the FAA, Boeing’s 737 Chief
Technical Pilot responded to colleagues about the prospects of 737 MAX simulator training,
writing: “Boeing will not allow that to happen. We’ll go face to face with any regulator who
tries to make that a requirement.” 142
 In May and June 2017, as some foreign carriers asked Boeing about providing simulator
training for their pilots transitioning to the 737 MAX from the 737 NG, emails show
135 Boeing internal email, “Subject: 737MAX Firm Configuration Status/Help Needed,” May 4, 2013, (see “Differences
Pilot Training” section), TBC-T&I 048706-048708, at pp. 128-130, accessed here:
136 “Boeing Selects Supplier for 737 MAX Full-Flight Simulator,” Boeing Press Release, July 11, 2014, accessed here:
https://boeing.mediaroom.com/2014-07-11-Boeing-Selects-Supplier-for-737-MAX-Full-Flight-Simulator
137 Slide presentation to Ethiopian Airlines—TBC-T&I 001999– TBC T&I 002000 at TBC T&I 002018, at pp. 124-126,

138 Boeing internal email from 737 Chief Technical Pilot to Former 737 MAX VP/GM, Former 737 MAX Chief Project
Engineer and others, “Subject: HELP NEEDED Request: 737 CL Program decision, RCAS/MAX training,” Friday,
February 27, 2015, 3:29 PM, BATES Number TBC T&I 552664-552666 (On file with the Committee).
139 FAA letter to The Boeing Company, “Subject: Boeing 737 MAX Pilot Qualification Plan (PQP) Gate 4,” August 17,
2016, BATES Number TBC-T&I 010895. (On file with the Committee).
140 See: “FAA Responses to Follow-Up Questions from House T&I Staff,” Sent: September 6, 2019, BATES Number
FAA-T&I-000031938 – 000031939 (On file with the Committee).

141 Boeing internal email, “Subject: RE: Weekly inputs,” September 21, 2016, 4:26 PM, BATES Number TBC T&I TBC-
T&I 552192. (On file with the Committee).

142 Boeing internal email, “Subject: RE: Flight Transition costs,” Sent: March 28, 2017, 9:00:58 AM, accessed at p. 28
here:
pdf
26
Boeing’s 737 Chief Technical Pilot strongly opposed such training, and in one case even
successfully talked a carrier out of using such training for its pilots on the 737 MAX. 143
 In December 2017, the Chief Technical Pilot referring to his efforts to talk airlines out of the
need for simulator training wrote to a Boeing colleague: “I save this company a sick amount
of $$$$.” 144
 Even after the fatal Lion Air crash, Boeing maintained that its “rationale” for removing
references to MCAS from the 737 MAX training manual was still “valid,” 145 and Boeing
asserted that the addition of MCAS on the 737 MAX did “not affect pilot knowledge, skills,
abilities, or flight safety.” 146
 After the Lion Air crash, Boeing also recommended that FAA only require Level A training
on MCAS. 147 This is the training level with the fewest obligations, and would only require
pilots to review printed materials that described MCAS as part of their transition from the
737 NG to the 737 MAX. 148
 On March 1, 2019, the FAA reminded Boeing that the original level of differences training
proposed in 2016 by Boeing—before the Lion Air crash—was Level B. 149 The FAA
informed Boeing that the software changes to MCAS “may not meet the definition of Level
143 See: Boeing internal email, “Subject: RE: 737 MAX ATB/RTL FOTB” Sent: Monday, June 5, 2018, 8:01 PM (p. 14);
Boeing Email to airline customer, “Subject: RE: MAX LEVEL B DIFFERENCES SOLUTION,” Sent: Tuesday, June
6, 2017 11:01:40 AM (p. 34); Airline customer Email to Boeing, “Subject: RE: MAX LEVEL B DIFFERENCES
SOLUTION,” Sent: Wednesday, June 7, 2017, 12:12 AM (p. 32); and Boeing internal email, “Subject: FW: MAX
LEVEL B DIFFERENCES SOLUTION,” Sent: Wednesday, June 7, 2017, 10:01:41 AM (p. 32); accessed here (at page
numbers indicated in parenthesis):
pdf
144 Boeing internal instant message, December 12, 2017, at p. 87, accessed here:
pdf
145 Boeing Letter to FAA’s Seattle Aviation Evaluation Group (AEG), January 30, 2019—TBC-T&I 297017–297018, at
pp. 134-135, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-

116hhrg38282.pdf
146 Ibid.
147 Ibid. FAA has defined five training levels, in order of increasing requirements identified as A through E, that describe
acceptable training and checking methods that are appropriate to the degree of difference between the base aircraft and
the variations. See: FAA Flight Standards Information Management System, 8900.1 Contents, Volume 3 General
Technical Administration, Chapter 19 Flightcrew Member Training and Qualification Programs, Section 9 Safety
Assurance System: Differences Training—All Training Categories, accessed here:
http://fsims.faa.gov/wdocs/8900.1/v03%20tech%20admin/chapter%2019/03_019_009.htm
148 FAA Flight Standards Information Management System, 8900.1 Contents, Volume 3 General Technical
Administration, Chapter 19 Flightcrew Member Training and Qualification Programs, Section 9 Safety Assurance
System: Differences Training—All Training Categories, accessed here:
http://fsims.faa.gov/wdocs/8900.1/v03%20tech%20admin/chapter%2019/03_019_009.htm
149 FAA letter to Boeing 737 Chief Technical Pilot, “Subject: Boeing 737-8 Maneuver Characteristic Augmentation
System (MCAS) Evaluation Letter of Proposal RA-19-0029 FAA Response Letter,” March 1, 2019, BATES Number
TBC-T&I 297019 – 297020, at pp. 136-137, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
27
A differences” training and advised Boeing that the company’s “evaluation is proceeding at
risk.” 150 Nine days later, Ethiopian Airlines flight 302 crashed.
Post-Accident Response - Both Boeing and the FAA gambled with the public’s safety in the
aftermath of the Lion Air crash, resulting in the death of 157 more individuals on Ethiopian
Airlines flight 302, less than five months later.
 After the Lion Air crash, Boeing and the FAA failed to take the actions needed to avert a
second crash. In November 2018, days after the Lion Air crash, both Boeing and the FAA
issued advisories for 737 MAX pilots that failed to even mention the existence of MCAS by
name. 151 Only after receiving inquiries about MCAS from airlines did Boeing describe MCAS
in a Multi Operator Message (MOM), on November 10, 2018, that went to Boeing’s MAX
customers but was not otherwise made public. 152
 The FAA acknowledged to the Committee that it had drafted—and then deleted—reference
to MCAS that had originally appeared in a draft of its Emergency Airworthiness Directive
(AD). 153
 There were multiple red flags and clear data points that should have informed the FAA’s
decision-making after the Lion Air crash. The FAA learned, for instance, that not only had
Boeing failed to fix an inoperable AOA Disagree alert on more than 80 percent of the 737
MAX fleet, but that it had also decided not to inform the FAA or its customers about the
non-functioning alert for more than 14 months – until after the Lion Air crash. 154
 Moreover, in December 2018, the FAA received a briefing from Boeing in which the
company acknowledged that prior to certification, Boeing had not evaluated the effects of a
combination of failures leading to unintended MCAS activation in simulator tests nor their
combined flight deck effects on pilots. 155 Boeing also acknowledged that it did not reevaluate
150 Ibid.
151 Flight Crew Operations Manual Bulletin for the Boeing Company, Number TBC-19, 737-8/-9, Uncommanded Nose
Down Stabilizer Trim Due To Erroneous Angle of Attack (AOA) During Manual Flight Only, November 6, 2018,
accessed here at pp. 95-96: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-
116hhrg38282.pdf and FAA Emergency Airworthiness Directive # 2018-23-51, November 7, 2018, accessed here:
https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/83ec7f95f3e5bfbd8625833e0070a070/$FILE/2018-
23-51_Emergency.pdf
152 The Boeing Company Multi Operator Message (MOM), Subject: Information – Multi-Modal Stall Warning and Pitch
Augmentation Operation, MOM-MOM-18-0655-01B, November 10, 2018, p. 290, accessed here: https://aviation-
153 Questions from Hon. Peter A. DeFazio for Hon. Stephen M. Dickson, Administrator, Federal Aviation
Administration, Hearing titled: “The Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight of
the Aircraft’s Certification,” Committee on Transportation and Infrastructure, U.S. House of Representatives, 116th
Congress, First Session, December 11, 2019, accessed here at pp. 243-244:

may-draw-faa-penalty and “Boeing Statement on AOA Disagree Alert,” Press Release, The Boeing Company, accessed
here: https://boeing.mediaroom.com/news-releases-statements?item=130431
155 MCAS Development and Certification Overview—TBC-T&I 130073–130074; 130075–130117, at pp. 178-179, 180-
201, at p. 185, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-

116hhrg38282.pdf
28
its single- and multiple-failure assessments of MCAS after its engineers made design changes
to the MCAS software in 2016. 156 Further, because Boeing determined that the loss of one
AOA sensor followed by erroneous readings from the other AOA sensor to be extremely
improbable, it did not analyze this failure scenario even though it had determined that
delayed pilot reaction in this situation was “potentially catastrophic.” 157
 These issues should have raised warning signs for the FAA, but none of these issues were
deemed noncompliant with FAA regulations by the FAA. 158
 In December 2018, the FAA conducted a risk assessment based on its Transport Aircraft
Risk Assessment Methodology (TARAM) and estimated that without a fix to MCAS, during
the lifetime of the 737 MAX fleet, there could potentially be 15 additional fatal crashes
resulting in over 2,900 deaths. 159
 Despite that assessment, the FAA permitted the 737 MAX to continue flying while Boeing
and the FAA worked on designing and validating, respectively, a fix to the MCAS software.
During the period between the crashes, the FAA repeatedly justified its decision not to
ground the 737 MAX saying that it did not have appropriate data to make that
determination. 160 That judgment proved tragically wrong.
 In December 2019, in a transcribed interview with Committee staff, Ali Bahrami, the FAA’s
Associate Administrator for Aviation Safety, seemed unaware of key issues related to the 737
MAX accidents. 161 For instance, he said he had not seen Boeing’s November 6, 2018 Flight
Crew Operations Manual Bulletin that Boeing had provided as an update to flight crews
following the Lion Air crash. He said he was not familiar with the details of FAA’s post Lion
Air TARAM analysis that predicted 15 more fatal accidents without a fix to MCAS over the
lifetime of the MAX fleet. He was also unaware of the fact that Boeing had conducted its
own tests that showed it took a Boeing test pilot 10 seconds to respond to uncommanded
MCAS activation in a flight simulator, which the pilot described as “catastrophic,” despite
156 Ibid., p. 191

157 Ibid., pp. 191-192.
158 “737-8 MAX Maneuvering Characteristics Augmentation System Oversight Report” February 8, 2019, Prepared by:
FAA AIR-860 BASOO, (Draft), Boeing Aviation Safety Oversight Office (BASOO), Federal Aviation Administration
(FAA) (Hereafter referred to as “FAA MCAS Oversight Report (draft).”) This document was reviewed remotely by
Committee staff on May 1, 2020.
159 “Quantitative Risk Assessment, Random Transport Airplane Risk Analysis (R-TARA) Version 2.42,” Aircraft
Certification Service, Transport Airplane Directorate (TAD), Federal Aviation Administration (FAA), FAA-DEFAZIO-
000028836, part of TAD Corrective Action Review Board (CARB) Presentation Form: CARB 1- Unsafe Condition
Determination,” December 11, 2018, see: page 167, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
160 Robert Wall, Andrew Tangel, and Andy Pasztor, “The FAA Has No Current Plans to Ground Boeing’s 737 MAX
After Deadly Crash,” Wall Street Journal, March 11, 2019, accessed here: https://www.wsj.com/articles/the-faa-has-no-
current-plans-to-ground-boeings-737-max-11552341654 and Prepared Statement of Daniel K. Elwell, Acting
Administrator, Federal Aviation Administration (FAA), Hearing before the Subcommittee on Aviation of the House
Committee on Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, May 15,
2019, p. 24, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg37277/pdf/CHRG-
116hhrg37277.pdf
161 Committee staff transcribed interview of Ali Bahrami, Associate Administrator for Aviation Safety, Federal Aviation
Administration (FAA), December 5, 2019, accessed here: https://transportation.house.gov/committee-activity/boeing-

737-max-investigation
29
the fact that this information had been made public at a high profile Committee hearing on
the 737 MAX on October 30, 2019, and widely covered by the media. 162
 Separately, Mr. Bahrami claimed he could not recall a single conversation with Boeing
officials about the MAX in between the Lion Air and Ethiopian Airlines crashes. The FAA’s
head of aviation safety said, “I don't recall a conversation about that between the two
accidents.” 163
 Despite that, documents Boeing provided to the Committee show that recollection was not
accurate. On January 24, 2019, Elizabeth (“Beth”) Pasztor, Boeing’s ODA Lead
Administrator, and one of Boeing’s most senior officials regarding FAA regulatory
compliance, emailed Mr. Bahrami about setting up a phone call. 164 “I would appreciate a few
minutes of your time, the topic is Lion Air,” wrote Pasztor. 165 According to Mr. Bahrami’s
response, the two planned to speak the following day. 166 It is unclear if the call ultimately
took place and if it did, what was discussed, and who else, if anyone from FAA or Boeing
was on the call. However, one week after that email requesting the call with Mr. Bahrami,
Ms. Pasztor’s deputy wrote to the FAA’s Aircraft Evaluation Group (AEG) on Ms. Pasztor’s
Boeing letterhead arguing that the FAA should grant Boeing Level A training for MCAS in
its post Lion Air evaluation. 167
 The Department of Transportation (DOT) has provided the Committee with substantial
FAA records in response to Chair DeFazio and Subcommittee Chair Larsen’s original April
2019 records request. 168 However, this process has been inexplicably slow, seemingly
incomplete and it is still unclear to the Committee—17 months later—where the agency is in
its response since it has repeatedly and consistently refused to provide the Committee with
clear updates on the status of these requests. 169 The Senate Committee on Commerce,
30, 2019, at p. 22, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-
116hhrg38282.pdf
163 Committee staff transcribed interview of Ali Bahrami, Associate Administrator for Aviation Safety, Federal Aviation
Administration, December 5, 2019.

164 Email from Vice President, Boeing Commercial Airplanes Safety, Security, and Compliance to FAA Associate
Administrator for Aviation Safety, Sent: January 24, 2019, 3:48 PM, BATES Number TBC-T&I 552822. (On file with
the Committee).
165 Ibid.
166 Email from FAA Associate Administrator for Aviation Safety to Vice President, Boeing Commercial Airplanes
Safety, Security, and Compliance, “Subject: Re: Request for brief phone call,” Sent: January 24, 2019, 1:01 PM, Bates
Number TBC-T&I 552822. (On file with the Committee).
167 Boeing letter from ODA Deputy Lead Administrator to FAA SEA AEG, “Subject: Boeing Response to Transport
AEG letter,” RA-19-00269, January 30, 2019, TBC-T&I 297017 – 297018 (On file with the Committee).
168 See: “As Part of Investigation into Boeing 737 MAX Certification Process, Committee Sends Records Requests to
FAA, Boeing,” Press Release, Committee on Transportation and Infrastructure, U.S. House of Representatives, April 1,
2019, accessed here: https://transportation.house.gov/news/press-releases/as-part-of-investigation-into-boeing-737-
max-certification-process-committee-sends-records-requests-to-faa-boeing
169 In June 2019, DOT/FAA informed the House Committee on Transportation and Infrastructure that, regarding the
Committee’s investigation of the 737 MAX, it had between 592,915 and 92,265 potentially responsive emails to just a
few of the Committee’s April 1, 2019, records requests. The FAA acknowledged they had 592,915 emails with the term
“MCAS” or “AOA Sensors,” for instance, between March 2014 and April 25, 2019. This included 338,074 emails with
the terms “MCAS” or “AOA Sensors” and the terms “development” or “testing” or “fielding” or “certification.” For
the period between March 2014 and October 29, 2018 the number of emails that the FAA identified with the term
30
Science, and Transportation has experienced remarkably similar problems according to
public statements from that Committee’s Chairman, Senator Wicker. 170
 After the Lion Air crash, the FAA’s Boeing Aviation Safety Oversight Office (BASOO)
started an internal review of its MCAS certification process on the 737 MAX. The review
was the first time FAA performed its own detailed analysis of MCAS and the first time FAA
received a complete picture of how MCAS operated, according to the Department of
Transportation Office of Inspector General (DOT OIG). 171
 The draft report, titled, “737-8 MAX Maneuvering Characteristics Augmentation System
Oversight Report,” concluded that Boeing was compliant with FAA regulations in the
certification of the 737 MAX aircraft. “The oversight activity did not reveal any
noncompliances,” the report said, “but did observe some assumptions used by the Applicant
and accepted by the FAA.” 172 The report implied that these “assumptions” by both Boeing
and the FAA regarding pilot reaction time, for instance, were faulty. The FAA review also
found that there was nothing discovered that required “corrective action,” although they
cited some areas for potential “improvement.” 173 The draft report’s analysis showed that the
MAX was compliant with FAA regulations, raising serious questions about the FAA
certification process and its oversight of Boeing.
 This internal FAA review of MCAS began on January 9, 2019, 174 and the last version of the
draft report was dated February 8, 2019. 175 The FAA never finalized this report. The FAA
told the DOT OIG that the report was going through management review at the time of the
Ethiopian Airlines accident and that it was simply overtaken by events. 176
“MCAS” or “AOA Sensors” was 234,425. In relation to the terms “MCAS” or “AOA Sensors” and the terms
“development” or “testing” or “fielding” or “certification,” for that same time period, the FAA had identified 92,265
emails. See: “FAA Responses to Follow-Up Questions from House T&I Staff,” June 7, 2019, BATES Number FAA-
T&I-000192. In addition, in November 2019, in order to help DOT manage the scope of the Committee’s requests and
at the specific suggestion of DOT, the Committee provided DOT with a list of 13 specific searches of 27 current and
former FAA officials. The Committee has received several productions of records related to this request. However,
DOT has been unable or unwilling to inform the Committee which of these 13 searches have been performed or which
of the 27 individuals’ records have been searched.
170 Prepared Statement, Chairman Roger Wicker, Hearing titled, “Examining the Federal Aviation Administration’s
Oversight of Aircraft Certification,” Senate Committee on Commerce, Science & Transportation, June 17, 2020,
accessed here: https://www.commerce.senate.gov/2020/6/examining-the-federal-aviation-administration-s-oversight-
of-aircraft-certification
172 “FAA MCAS Oversight Report (draft).” This document was reviewed remotely by Committee staff on May 1, 2020.
173 Ibid.
175 FAA MCAS Oversight Report (draft), February 8, 2019.
31
 The metadata of this report showed that the report was accessed and printed by an FAA
employee on March 11, 2019, the day after Ethiopian Airlines flight 302 crashed.
 Because this report was a “draft” and a final copy was never produced the DOT refused to
provide a copy to the Committee. However, Committee staff were given the opportunity to
review the document.
-Investigative Findings Conclusion-
Boeing’s design and development of the 737 MAX was marred by technical design failures,
lack of transparency with both regulators and customers, and efforts to downplay or disregard
concerns about the operation of the aircraft. During development of the 737 MAX, a Boeing
engineer raised safety concerns about MCAS being tied to a single AOA sensor. 177 Another Boeing
engineer raised concerns about not having a synthetic airspeed system on the 737 MAX. 178 Concerns
were also raised about the impact of faulty AOA data on MCAS 179 and repetitive MCAS activations
on the ability of 737 MAX pilots to maintain control of the aircraft. 180 Ultimately, all of those safety
concerns were either inadequately addressed or simply dismissed by Boeing.
In the wake of the Lion Air and Ethiopian Airlines tragedies, Boeing has now acknowledged
some of these issues through its actions. For instance, Boeing now plans to have two AOA sensors
feed into MCAS. 181 Boeing has also said that MCAS will no longer activate repeatedly. 182 In January
2020, Boeing dramatically reversed course yet again, by recommending that pilots undergo simulator
training on the 737 MAX once the airplane returns to service. 183 That decision violated one of the
premier principles of the MAX program, to avoid pilot simulator training. Unfortunately, Boeing’s
responses to safety issues raised in the 737 MAX program have consistently been too late.

177 Boeing employee email, “MCAS Stab Rapid Reversal on PSIM Model,” December 17, 2015, BATES Number TBC-
T&I 010584 - TBC-T&I 010586 at TBC-T&I 010584, released at Hearing before the House Committee on
Transportation & Infrastructure, U.S. House of Representatives, 116th Congress, First Session, October 30, 2019, p.
178 Boeing internal emails, “Subject: Synthetic Airspeed,” February 26, 2013, at p. 1, accessed here:
pdf
179 Boeing internal email, “Subject: RE: S&C Brief Summary: 1A001, Test 009-25 6/13/16 [BLOC 2],” Wednesday, June
15, 2016, 1:01 PM, BATES Number TBC T&I 246488 – T&I 246493 at T&I 246489. (On file with Committee) .
180 Boeing internal email, “Subject: RE: Squawk for MCAS trim Event,” June 20, 2016, BATES Number TBC T&I
220826 - TBC T&I 220827 at TBC T&I 220826. (On file with the Committee).
181 “737 MAX Software Update,” The Boeing Company, accessed here:
https://www.boeing.com/commercial/737max/737-max-software-updates.page
182 Ibid.
183 “Boeing Statement on 737 MAX Simulator Training,” The Boeing Company, January 7, 2020, accessed here:
https://boeing.mediaroom.com/news-releases-statements?item=130596 and Natalie Kitroeff and David Gelles, “In

Reversal, Boeing Recommends 737 MAX Simulator Training for Pilots,” New York Times, January 8, 2020, accessed here:
https://www.nytimes.com/2020/01/07/business/boeing-737-max-simulator-training.html
32
The Committee’s investigation has also found that the FAA’s certification review of Boeing’s
737 MAX was grossly insufficient and that the FAA failed in its duty to identify key safety problems
and to ensure that they were adequately addressed during the certification process. The combination
of these problems doomed the Lion Air and Ethiopian Airlines flights.
The following pages detail the factual evidence gathered by the Committee during its
investigation that highlight the actions and events that undermined the design, development, and
certification of the 737 MAX aircraft and led to the tragic death of 346 people.
33
3. Brief Boeing History
and 737 MAX
Background
3. Brief Boeing History and 737 MAX Background
-Brief Boeing History and 737 MAX Background-
The Boeing Company was founded more than 100 years ago by William Edward Boeing. Mr.
Boeing was born in 1881 in Detroit, Michigan, and attended Yale University prior to leaving in 1903
before graduating to start a lumber company in Washington State. 184 He saw his first airplane in
1909, soon became a pilot, and went into business with U.S. Navy Commander George Conrad
Westervelt with the intent of building better airplanes. 185 In 1916, Boeing and Westervelt founded
the Pacific Aero Products Company. 186 The company’s first airplane, the Boeing Model 1 (B&W
Seaplane) flew in June 1916. 187 Less than one year later, soon after the United States entered World
War I, the company’s name was changed to the Boeing Airplane Company, and it quickly obtained
orders from the U.S. Navy to build Navy aircraft trainers. 188 Boeing soon also obtained an airmail
route from Chicago to San Francisco that required Boeing to deliver 26 airmail airplanes by July 1,
1927. 189
William Boeing was known as a stickler for accuracy, facts, and quality. He reportedly kept a
placard outside his office quoting from Hippocrates 190 that facts are the foundation of truth and
accurate observations. 191 Soon after he established his airplane company in 1916, he noticed
improperly cut wooden planks called “spruce ribs” in his airplane factory and walked all over them
until they broke, remarking that he would rather close down his shop than send out inferior work of
that kind. 192 As his biography states: “He believed in details and told his managers that many a
wrong decision stemmed from a detail overlooked or incorrectly interpreted.” 193
The Boeing Company has been a pioneer in aircraft and aviation related technology ever
since. In 1928, the company had 1,000 employees. 194 Today it employs more than 150,000 people
engaged in producing commercial and military airplanes and spacecraft in more than 150
countries. 195 The company produced the first modern passenger aircraft in 1933, the B-52 Bomber
in 1952, the Lunar Rover used to explore the moon in 1971, and large portions of the International
184 “Biography of William E. Boeing,” The Boeing Company, accessed here:

https://www.boeing.com/history/pioneers/william-e-boeing.page
185 Ibid.
186 “Pacific Aero Products Company: July 15, 1916,” This Day in Aviation, accessed here:
https://www.thisdayinaviation.com/tag/pacific-aero-products-company
188 Ibid. (Boeing’s name was changed to “The Boeing Company” in 1961. See: Stanley I. Weiss and Amir R. Amir, “The
Boeing Company,” Encyclopedia Britannica, accessed here: https://www.britannica.com/topic/Boeing-Company)

190 Hippocrates was a Greek physician born in 460 BC who is credited with writing the Hippocratic Oath that pledged to
help others and do no harm. The Hippocratic Oath is attributed with being a pillar of modern medical ethics today. See:
Wesley D. Smith, “Hippocrates: Greek physician,” Encyclopedia Britannica, (last updated) May 18, 2020, accessed here:
https://www.britannica.com/biography/Hippocrates and “Greek Medicine: The Hippocratic Oath,” History of
Medicine Division, National Library of Medicine, National Institutes of Health (NIH), accessed here:
https://www.britannica.com/biography/Hippocrates
192 Ibid.
193 Ibid.
194 Ibid.
195 “Boeing in Brief,” The Boeing Company, accessed here: https://www.boeing.com/company/general-info/
35
Space Station (ISS). 196 It has also built some of the world’s most well-known modern commercial
passenger airplanes, including the 707 that entered commercial service in 1958, followed by the 727
in 1964, the 737 in 1968, the 747 in 1970, and the 767 in 1981, as well as many other aircraft. 197
Merging Companies – Changing Cultures
In 1997, Boeing merged with McDonnell Douglas 198 and four years later, moved its
headquarters from Seattle to Chicago. 199 That merger and the move of Boeing’s headquarters has
been widely reported to have dramatically shifted the emphasis at Boeing from one devoted to
solving difficult engineering problems to one dedicated to enhancing and expanding Boeing’s
financial profits. 200
After the merger, Harry Stonecipher, the Chief Executive Officer (CEO) of McDonnell
Douglas became the President and Chief
Harry Stonecipher, former President Operating Officer of Boeing. 201 In 2004 he told
and Chief Operating Officer of the Chicago Tribune: “When people say I changed
Boeing (as quoted in the Chicago the culture of Boeing, that was the intent, so it’s
Tribune ) February 29, 2004 run like a business rather than a great engineering
firm. It is a great engineering firm, but people
invest in a company because they want to make
“WHEN PEOPLE SAY I CHANGED
money.” 202 Those sentiments, according to many
THE CULTURE AT BOEING, THAT observers and current and former Boeing
WAS THE INTENT, SO IT’S RUN employees, infected the company. They point to
LIKE A BUSINESS RATHER THAN that philosophy, which focused on financial
A GREAT ENGINEERING FIRM…” benefit rather than technical solutions and
innovation, as setting the stage for many of the
issues that ultimately contributed to the crashes of the two 737 MAX aircraft.
For the past century, Boeing has been a tremendously successful and innovative company,
admired for its achievements and singular importance to the U.S. economy. However, critics
contend that the company’s rising stock value over the past two decades was not directly correlated
to any technical success. 203 Some, in fact, have argued that recent fixation within the company on
196 Dragan Radovanovic and Benjamin Zhang, “Here are some of the most important moments from Boeing's 100 years
of business,” Business Insider, August 8, 2016, accessed here: https://www.businessinsider.com/boeing-100-years-
business-2016-7
197 Stanley I. Weiss and Amir R. Amir, “The Boeing Company,” Encyclopedia Britannica, accessed here:
https://www.britannica.com/topic/Boeing-Company
198 Ibid.
199 Ibid.
200 Natasha Frost, “How the McDonnell Douglas-Boeing merger led to the 737 MAX crisis,” Quartz, January 3, 2020,
accessed here: https://qz.com/1776080/how-the-mcdonnell-douglas-boeing-merger-led-to-the-737-max-crisis

201 “The Boeing Logbook 1997-2001,” The Boeing Company, accessed here:
https://web.archive.org/web/20130102173045/http://www.boeing.com/history/chronology/chron16.html
202 Patricia Callahan, “So why does Harry Stonecipher think he can turn around Boeing?” Chicago Tribune, February 29,
2004, accessed here: https://www.chicagotribune.com/chi-0402290256feb29-story.html

203 When Boeing and McDonnell Douglas merged together in August 1997 Boeing’s stock was $58 per share. On
October 8, 2018, just weeks before the Lion Air crash, Boeing’s stock was $383 per share. Despite the crash, Boeing’s
stock price continued to rise. On March 1, 2019, nine days before the Ethiopian Airlines crash, Boeing’s stock price
stood at $440 per share. On December 2, 2019, before the COVID-19 (coronavirus) crisis dramatically impacted the
aviation industry, Boeing’s stock price was $355 per share. Largely due to the fallout of the coronavirus on the entire
36
Boeing’s stock price and financial success undermined the emphasis on technical achievements and
innovation. William Lazonick, a Professor in Economics and Co-Director of the Center for
Industrial Competitiveness at the University of Massachusetts in Lowell, Massachusetts, has written
that Boeing’s attempts to profit undermined its efforts to protect the flying public. 204 Lazonick’s
research highlighted the fact that between 2013 and 2019, during the critical 737 MAX design,
development, and certification process, Boeing spent $17.4 billion on stock dividends and an
additional $43.1 billion on stock buybacks. 205 Lazonick wrote that these investment strategies may
have played key roles in Boeing not spending enough money on issues critical to the safe design and
development of the MAX, including adequate testing and safety analyses. 206
Financial and economic competitiveness also played a key role in Boeing’s eventual decision
to re-engine an existing airplane rather than design a new airplane in choosing its next product. In
2011, the estimated cost of building a brand-new airplane hovered around $10 billion while the cost
of re-engining the existing 737 NG to develop the new 737 MAX airplane was only about $3 billion,
according to Richard Aboulafia with the aviation industry market analysis firm, the Teal Group. 207
Multiple current and former Boeing employees who have contacted the Committee since our
investigation began have relayed dismay at the path they believe Boeing has taken since its merger
with McDonnell Douglas. They have described their excitement and enthusiasm at joining one of
the world’s most esteemed companies decades ago. They were thrilled to be working with smart,
intelligent, and dedicated colleagues. They viewed Boeing as an engineer’s paradise where they could
innovate and create leading edge technologies where safety was always at the forefront of
engineering decisions that were part and parcel of the business development process.
However, that emphasis changed slowly, but dramatically, over the years, according to these
employees. The prowess of the engineers’ technical designs and innovative diagrams were replaced
by the accounting acumen and financial decisions of business executives. Production schedules and
monetary costs, not technical specifications and safety considerations, began to drive Boeing’s
commercial aircraft programs, they say. These individuals were disturbed, but not surprised, by the
tragic consequences that have since been revealed regarding the technical missteps and misguided
judgments that impacted the design, development, and certification of Boeing’s 737 MAX aircraft.
aviation industry, on May 1, 2020, Boeing’s stock price had dropped to $133 per share. “The Boeing Company,”
MarketWatch, accessed here: https://www.marketwatch.com/investing/stock/BA/historical
204 William Lazonick and Mustafa Erdem Sakinc, “Make Passengers Safer? Boeing Just Made Shareholders Richer,” The
American Prospect, May 31, 2019, accessed here: https://prospect.org/environment/make-passengers-safer-boeing-just-

made-shareholders-richer
205 Ibid.
206 Ibid.
207 Steve Wilhelm, “What's the ROI for Boeing 737 replacement?,” Puget Sound Business Journal, July 5, 2011, accessed
here: https://www.bizjournals.com/seattle/blog/2011/07/whats-the-roi-for-boeing-737.html
37
Competitive Pressure
In December 2010, Boeing’s chief competitor in the civil airplane market—the European
consortium Airbus—launched the A320neo family of aircraft. 208 The term “neo” stood for new
engine option and was powered by new fuel-efficient engines that promised up to 15-percent greater
fuel efficiency over previous aircraft. 209 This translated into significant cost savings for airlines and
potentially passengers, and created a competitive advantage for Airbus. But Boeing initially
downplayed this competitive threat.
At a Boeing Commercial Airplanes (BCA) employee meeting on January 14, 2011, James
Albaugh, BCA’s CEO, said: “I think Airbus will find re-engining the A320 more challenging than
they think it will be.” 210 He did not think
the new Airbus could compete with James Albaugh
Boeing’s 737 NG aircraft. “At the same former Boeing Commercial Airplanes
time, while we haven’t made a firm Chief Executive Officer
decision,” said Albaugh, “I don’t think we
will re-engine the 737. It’s really hard to January 14, 2011
come up with a compelling business case to
do that,” he said. “We think the right answer
“EVERY CUSTOMER I TALK TO HAS A
[is] to probably do a new small airplane that REAL HARD TIME UNDERSTANDING
might come out toward the end of this WHY A RE-ENGINED AIRPLANE
decade.” Albaugh added: “Every customer I MAKES SENSE.”
talk to has a real hard time understanding
why a re-engined airplane makes sense.” 211 But a call to Albaugh’s boss changed that position.
According to the New York Times, in the spring of 2011, the CEO of The Boeing Company,
Jim McNerney, received a call from Gerard Arpey, the CEO of American Airlines. The call was
reportedly serious and the conversation frank. Boeing was told that American Airlines was about to
close a deal to purchase hundreds of A320-family airplanes from Airbus. If Boeing wanted to
maintain its business with American Airlines, Boeing would need to step up soon and offer a similar
alternative aircraft or lose out on maintaining American as a customer. 212
The call reportedly rattled Boeing’s executives. For more than a decade, American Airlines
had exclusively purchased Boeing aircraft. 213 The announcement that the airline planned to purchase
aircraft from Airbus was a huge strategic blow to Boeing. The company had been planning to
208 “Airbus offers new fuel saving engine options for A320 Family,” Airbus, December 1, 2010, accessed here:
https://www.airbus.com/newsroom/press-releases/en/2010/12/airbus-offers-new-fuel-saving-engine-options-for-
a320-family.html
209 Ibid.
210 “Boeing didn’t want to re-engine the 737–but had design standing by,” Leeham News and Analysis, March 20, 2019,
accessed here: https://leehamnews.com/2019/03/20/boeing-didnt-want-to-re-engine-the-737-but-had-design-standing-

by
211 Ibid.
212 David Gelles, Natalie Kitroeff, Jack Nicas and Rebecca R. Ruiz, “Boeing Was ‘Go, Go, Go’ to Beat Airbus With the
737 Max,” New York Times, March 23, 2019, accessed here: https://www.nytimes.com/2019/03/23/business/boeing-
737-max-crash.html
213 Ibid.
38
develop a completely new airplane. 214 Since 2005, Boeing had been toying with the idea of
developing a brand-new “clean sheet” commercial airplane. Boeing dubbed these efforts to design a
new commercial aircraft to replace the 737 NG “Project Yellowstone.” 215
However, the phone call between the two CEOs at American Airlines and Boeing changed
all that. Rather than endeavoring to develop a “clean sheet” airplane that would apply the lessons
learned from Boeing’s other commercial aircraft, including the 737, Boeing instead decided to
remodel its existing 737 NG aircraft so the company would not have to start from scratch, saving
time, resources, and costs in the process.
On July 20, 2011, Airbus announced that American Airlines had placed an order for 260
A320 family aircraft, including 130 of its new A320neo aircraft. 216 But given Boeing’s reversal and
commitment to re-engining the 737 NG, American Airlines also pledged to purchase 100 737-800s
and 100 737 MAX airplanes. 217 The airline
Boeing Press Release said it was “pleased to be the first airline to
August 30, 2011 commit to Boeing’s new 737 family offering,
which [was] expected to provide a new level
“THE RE-ENGINED 737 WILL ALLOW of economic efficiency and operational
BOEING TO CONTINUE TO performance, pending final confirmation of
the program by Boeing.” 218
DELIVER THE MOST FUEL
EFFICIENT, MOST CAPABLE The following month, Boeing
AIRPLANE WITH THE LOWEST announced its intent to develop a new
OPERATING COSTS IN THE SINGLE- commercial aircraft. In stark contrast to what
AISLE MARKET.” Albaugh told Boeing’s employees just seven
months earlier, Boeing issued an August 2011
press release that quoted Albaugh as saying: “The re-engined 737 will allow Boeing to continue to
deliver the most fuel efficient, most capable airplane with the lowest operating costs in the single-
aisle market.” 219 The press release noted that Boeing had already secured commitments from five
customers for 496 of the new airplanes. 220 Ignoring the statements that Albaugh had made to Boeing
employees earlier in the year, the press release asserted: “Customers expressing overwhelming
acceptance for new airplane.” 221
214 “Boeing didn’t want to re-engine the 737–but had design standing by,” Leeham News and Analysis, March 20, 2019,
accessed here: https://leehamnews.com/2019/03/20/boeing-didnt-want-to-re-engine-the-737-but-had-design-standing-
by
215 “Countdown to Launch: The Boeing 737 MAX Timeline,” Airways, January 27, 2016, accessed here:
https://airwaysmag.com/industry/boeing-737-max-timeline
216 “American Airlines acquires 260 Airbus A320 Family aircraft,” Airbus, July 20, 2011, accessed here:
https://www.airbus.com/newsroom/press-releases/en/2011/07/american-airlines-acquires-260-airbus-a320-family-
aircraft.html
217 Ibid.
218 “AMR Corporation Announces Largest Aircraft Order in History with Boeing and Airbus,” Press Release, American
Airlines, July 20, 2011, accessed here:

https://www.sec.gov/Archives/edgar/data/4515/000119312511191876/dex992.htm
219 “Boeing Launches 737 New Engine Family with Commitments for 496 Airplanes from Five Airlines,” Press Release,
The Boeing Company, August 30, 2011, accessed here: https://boeing.mediaroom.com/2011-08-30-Boeing-Launches-

737-New-Engine-Family-with-Commitments-for-496-Airplanes-from-Five-Airlines
220 Ibid.
221 Ibid.
39
Boeing’s 737 aircraft had been a dependable and successful aircraft since its development
five decades earlier. For Boeing, it was hard to let go of a good thing and gamble on developing a
brand-new aircraft. At the time of Boeing’s announcement to develop the new 737 MAX, Boeing
had delivered more than 9,000 of the 737 aircraft, in their various derivative models, since the first
737 had come off Boeing’s assembly line in 1967. 222 Producing a brand new aircraft would have
been technically exciting and challenging, but the costs and time involved in doing so made Boeing’s
executives anxious that they would lose out in competition to Airbus. Even once a decision was
made to update the 737, then known as the 737 NG (Next Generation), and replace it with the new
737 MAX aircraft, an aggressive production schedule and cost-conscious measures aimed at
competing with Airbus played a paramount role in the program.
Schedule and production pressures impacted the 737 MAX program throughout its design
and certification process. But these pressures were not unique to the MAX program. Boeing’s other
primary commercial aircraft program, the 787 Dreamliner, was reportedly losing tens of millions of
dollars on each 787 it built. In June 2015, a Forbes magazine contributor wrote: “These recurring
production losses (on top of 787 development costs) stood at over $26 billion in January and will
likely reach $30 billion, and possibly beyond.” 223 Boeing needed a competitive profit-making
commercial aircraft, and the company believed the 737 MAX was the answer.
Further, design issues that affected safety of the 787 Dreamliner foreshadowed eventual
problems that emerged in the 737 MAX program. In January 2013, the newly certified 787 was
grounded globally after two auxiliary power lithium ion battery fire incidents. 224 In November 2014,
after an almost two-year investigation, the National Transportation Safety Board (NTSB) released its
results and identified numerous issues in the design and certification of the 787 Dreamliner’s new
lithium batteries. 225 The report identified issues that, in many cases, parallel the findings of the
Committee’s investigation of the 737 MAX. Among its findings, NTSB found inadequate FAA
oversight, a failure by both FAA and Boeing’s Authorized Representatives (ARs) to identify critical
deficiencies, and flawed safety assumptions by Boeing that it made into the airplane’s System Safety
Assessment. 226 One year before the 787’s grounding, Boeing’s efforts to develop the 737 MAX were
already underway.
222 See: “Boeing Launches 737 New Engine Family with Commitments for 496 Airplanes from Five Airlines,” Press
Release, The Boeing Company, August 30, 2011, accessed here: https://boeing.mediaroom.com/2011-08-30-Boeing-
Launches-737-New-Engine-Family-with-Commitments-for-496-Airplanes-from-Five-Airlines and Natasha Frost, “How
the McDonnell Douglas-Boeing merger led to the 737 MAX crisis,” Quartz, January 3, 2020, accessed here:
https://qz.com/1776080/how-the-mcdonnell-douglas-boeing-merger-led-to-the-737-max-crisis
223 Richard Aboulafia, “Boeing Will Pay High Price For McNerney’s Mistake Of Treating Aviation Like It Was Any
Other Industry,” Forbes, June 24, 2015, accessed here:

https://www.forbes.com/sites/richardaboulafia/2015/06/24/boeing-mcnerney-and-the-high-price-of-treating-aircraft-
like-it-was-any-other-industry/#3a2aec3b579c
224 Jad Mouawad, “Report on Boeing 737 Dreamliner Battery Flaws Finds Lapses at Multiple Points,” New York Times,
December 1, 2014, accessed here: https://www.nytimes.com/2014/12/02/business/report-on-boeing-787-dreamliner-

batteries-assigns-some-blame-for-flaws.html
225 “Aviation Incident Report: Auxiliary Power Unit Battery Fire Japan Airlines Boeing 787-8, JA829J, Boston
Massachusetts,” January 7, 2013, NTSB/AIR-14/01, National Transportation Safety Board (NTSB), November 21,
2014, accessed here: https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR1401.pdf
226 Ibid.
40
From Marketing Marvel to Financial Burden
On January 27, 2012, Boeing initially submitted its proposal for an Amended Type
Certificate to develop the 737 MAX aircraft to the FAA. 227 The 737 MAX ultimately became
Boeing’s fastest-selling airplane ever produced. 228 When the 737 MAX was granted its Amended
Type Certificate from the FAA on March 9, 2017, 229 Boeing had already acquired more than 3,600
orders for the 737 MAX airplane from 83 customers worldwide. 230 The following month the
company obtained orders for 42 more aircraft from airlines in Mongolia, Iran, and Azerbaijan. 231 At
the time of its certification, Keith Leverkuhn, former Vice President and General Manager of the
737 MAX program, said: “This certification is a true testament to the dedication and commitment of
our entire MAX team throughout the process, from airplane design to flight testing.” 232
Boeing was making substantial profit on each 737 MAX it delivered prior to the Lion Air
and Ethiopian Airlines crashes. Moody’s credit-rating agency estimated that Boeing was making on
average between $12 and $15 million on each 737 MAX it delivered. 233 But the two MAX crashes
have taken a tremendous financial toll on the company costing Boeing nearly $19 billion so far, and
problems on the MAX have continued to mount as more issues have been discovered since the
aircraft was grounded. 234
Southwest Airlines, the U.S. launch customer for the 737 MAX, was reportedly losing
$67,000 per day, per airplane since the 737 MAX groundings in the days after the Ethiopian Airlines
crash (prior to the COVID-19 impact on the airline industry). 235 Southwest had 34 737 MAX aircraft
in its fleet when the MAX was grounded. 236 American Airlines was also losing an estimated $50,000
227 G-1 Issue Paper, Project: Boeing Commercial Airplanes, Model 737-8, Project No. PS12-0038, June 30, 2012,
BATES Number FAA-DeFazio 200-277. (Hereafter referred to as “G-1 Issue Paper.”) (On file with the Committee).
228 “Boeing, Malindo Air Celebrate First 737 MAX Delivery,” Press Release, Boeing Commercial Airplanes, May 16,
2017, accessed here: https://boeing.mediaroom.com/news-releases-statements?item=129894

229 “Boeing 737 MAX 8 Earns FAA Certification,” Press Release, The Boeing Company, March 9, 2017, accessed here:
https://boeing.mediaroom.com/2017-03-09-Boeing-737-MAX-8-Earns-FAA-Certification
230 Ibid.
231 See: “Boeing 737 MAX to Join MIAT Mongolian Airlines Fleet,” Press Release, Boeing Commercial Airplanes, April
3, 2017, accessed here: https://boeing.mediaroom.com/news-releases-statements?item=129875 and “Boeing

Announces Agreement with Iran Aseman Airlines for 30 737 MAXs,” Press Release, Boeing Commercial Airplanes,
April 4, 2017, accessed here: https://boeing.mediaroom.com/2017-03-17-Boeing-Announces-Agreement-with-Iran-
Aseman-Airlines-for-30-737-MAXs; and “Boeing, Silk Way Announce Order for Ten 737 MAX 8 airplanes,” Press
Release, Boeing Commercial Airplanes, April 14, 2017, accessed here: https://boeing.mediaroom.com/news-releases-
statements?item=129883
232 Ibid.
233 Benjamin Zhang, “Here's how much Boeing is estimated to make on each 737 MAX 8 plane,” Business Insider, March
13, 2019, accessed here: https://www.businessinsider.in/heres-how-much-boeing-is-estimated-to-make-on-each-737-

max-8-plane/articleshow/68399220.cms
234 Dominic Rushe, “Boeing puts cost of 737 Max crashes at $19bn as it slumps to annual loss,” The Guardian, January
29, 2020, accessed here: https://www.theguardian.com/business/2020/jan/29/boeing-puts-cost-of-737-max-crashes-at-

19bn-as-it-slumps-to-annual-loss
235 Darryl Campbell, “The 737 Built Southwest, and the 737 MAX Could Be its Undoing,” The Verge, October 23, 2019,
accessed here: https://www.theverge.com/2019/10/23/20927213/boeing-737-max-southwest-planes-crash-budget-

airlines-grounded-cost-maintenance
236 David Slotnick and Reuters, “Boeing is compensating Southwest for the 737 Max grounding, and the airline is sharing
$125 million of the agreed total with employees,” Business Insider, December 12, 2019, accessed here:
https://www.businessinsider.com/southwest-airlines-reaches-compensation-agreement-with-boeing-2019-12
41
per day, per airplane 237 following the grounding and had 24 MAX aircraft in its fleet at the time of
the grounding. 238
Certifying the 737 MAX
The 737 MAX is the 12th derivative aircraft of the 737 since it received its original FAA
certification in December 1967. 239 Over its lifespan, 737 derivatives have been classified into three
major categories, the 737 Classic, the 737 NG (Next Generation) and the 737 MAX. 240 Each new
category of aircraft included a new engine, improved range, greater fuel efficiency, and less noise. 241
There were significant modifications to the 737 MAX version compared to the 737 NG. 242
Most dramatically and significantly, this included the addition of new larger CFM LEAP-1B engines.
Since the engines on 737s sit below the wings, and the 737 sits relatively low to the ground, the
larger engines had to be mounted further forward and higher up on the wings in order to maintain
sufficient ground clearance. 243 To prevent the larger engines from dragging on the ground, the 737
MAX’s nose gear was extended by about 8 inches. 244 Additionally, when compared to the 737 NG,
its weight increased by more than 6,500 pounds, the tail cone was extended by 43 inches, and its
flight deck was modernized. 245 Importantly, these changes altered the aerodynamics of the aircraft,
237 Darryl Campbell, “The 737 Built Southwest, and the 737 MAX Could Be its Undoing,” The Verge, October 23, 2019,
accessed here: https://www.theverge.com/2019/10/23/20927213/boeing-737-max-southwest-planes-crash-budget-
airlines-grounded-cost-maintenance
238 David Slotnick and Reuters, “Boeing is compensating Southwest for the 737 Max grounding, and the airline is sharing
$125 million of the agreed total with employees,” Business Insider, December 12, 2019, accessed here:
https://www.businessinsider.com/southwest-airlines-reaches-compensation-agreement-with-boeing-2019-12
239 The 737 MAX was the 12th “derivative” of the original 737-100 aircraft certified in 1967, making it the 13th 737 model
aircraft produced by Boeing. See: “Type Certificate Data Sheet A16WE,” Federal Aviation Administration, Department
of Transportation, March 8, 2017, accessed here:
LE/A16WE_Rev_58.pdf.
240 While there are three major categories of 737 derivative aircraft (the 737 Classic, 737 NG and 737 MAX), the Boeing
737 MAX series is the fourth-generation model of Boeing’s 737 aircraft. These four generations include the 737-100, 737
Classic, 737 NG and 737 MAX. See: “Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8
Aircraft and Actions Taken After the October 2018 Lion Air Accident,” Office of Inspector General (OIG),
Department of Transportation (DOT), Report No. AV2020037, June 29, 2020, p. 5, accessed here:
241 “Official Report of the Special Committee to review the Federal Aviation Administration’s Aircraft Certification
Process,” Department of Transportation, January 16, 2020, (Hereafter referred to as the DOT Special Committee
report), p. 5, accessed here: https://www.transportation.gov/sites/dot.gov/files/2020-01/scc-final-report.pdf.
242 Chris Brady, “Boeing 737 MAX – Differences,” The Boeing 737 Technical Guide, Updated April 19, 2019, accessed
here: http://www.b737.org.uk/737maxdiffs.htm
243 Ralph Vartabedian, “How a 50-year-old design came back to haunt Boeing with its troubled 737 Max jet,” Los Angeles

story.html
244 Ibid.
245 Chris Brady, “Boeing 737 MAX – Differences,” The Boeing 737 Technical Guide, Updated April 19, 2019, accessed
here: http://www.b737.org.uk/737maxdiffs.htm
42
making it more likely to pitch upward 246 during certain flight conditions, putting it at risk of entering
a potentially dangerous stall. 247
However, one of the most significant changes to the aircraft could not be seen. This
included the changes to the flight control software that incorporated the addition of the
Maneuvering Characteristics Augmentation System (MCAS) to help counter the tendency of the
aircraft to pitch up. This addition would prove fatal as the installation of MCAS on the aircraft
played a critical role in the two 737 MAX crashes.
Changed Product Rule
On June 30, 2012, Boeing submitted its G-1 Issue Paper to the FAA’s Boeing Aviation
Safety Oversight Office (BASOO)―the central FAA office designated to oversee Boeing’s designee
authority and the certification process of the company’s aircraft―that highlighted the differences
between the 737-800 NG and Boeing’s proposed 737-8 MAX aircraft. 248 The G-1 Issue Paper was
used to form the “certification basis” for the 737 MAX and “to record issues and resolution for
changes to the certification basis.” 249
In all, the issue paper listed 201 distinct “significant changes” between the two aircraft. 250
This included 56 airframe changes, 94 system changes (including 15 avionics changes and 13 flight
control changes), 36 propulsion changes, and 15 payload related changes. 251 The G-1 Issue Paper
briefly cited MCAS as one of the software changes that resulted in modifications to the Enhanced
Digital Flight Control System (EDFCS). 252
As part of the FAA’s certification process, aircraft must comply with procedures detailed in
14 CFR part 21 (“Certification Procedures for Products and Articles”). Within these FAA
regulations is the “Changed Product Rule,” 253 which may apply when an applicant seeks certification
of a previously approved design to which the applicant is making changes. Changes can be made
through an amended type certificate (ATC), a supplemental type certificate (STC), or an amended
story.html
247 Peter Cohan, “MIT Expert Highlights 'Divergent Condition' Caused By 737 MAX Engine Placement,” Forbes, April
2, 2019, accessed here: https://www.forbes.com/sites/petercohan/2019/04/02/mit-expert-highlights-divergent-

condition-caused-by-737-max-engine-placement/#7c4f24d040aa; see Andy Pazstor, Andrew Tangel, and Alison Sider,
“Between two deadly crashes Boeing moved haltingly to make 737 MAX fixes,” Wall Street Journal, April 1, 2019,
accessed here: https://www.wsj.com/articles/between-two-deadly-crashes-boeing-moved-haltingly-to-make-737-max-
fixes-11554164171?mod=hp_lead_pos1
248 G-1 Issue Paper.
249 “How to Establish the Certification Basis for Changed Aeronautical Products,” FAA ORDER 8110.48, Federal
Aviation Administration (FAA), April 25, 2013, p. 5, accessed here:

https://www.faa.gov/documentLibrary/media/Order/ORDER_8110_48.pdf
253 14 CFR § 21.101 – “Designation of applicable regulations,” Code of Federal Regulations (CFR), as published in the
Federal Register, January 21, 2011, accessed here: https://www.govinfo.gov/app/details/CFR-2011-title14-vol1/CFR-

2011-title14-vol1-sec21-101 (The rule was originally issued in 2000 and has been amended several times since then.)
43
STC. 254 The “Changed Product Rule” process determines whether previous FAA regulatory
amendments, rather than the newest or latest amendments, may be applied in certifying an
applicant’s changed product. 255 Applicants for amended type certificates for derivative airplanes that
are versions of already-certificated airplanes must show that
FAA’s G-1 Issue Paper the change or any areas affected by the change comply with
on the 737 MAX, all applicable FAA airworthiness requirements. 256 There were
FAA Position on significant changes to the 737 MAX compared to the 737
July 21, 2012 NG aircraft.
“’[T]HE FAA HAS FOUND In 2012, the FAA raised numerous certification-
THAT THE PROPOSED related matters surrounding the 737 MAX. On July 21, 2012,
MODEL 737-8 [MAX for instance, the FAA declared: “[T]he FAA has found that
the proposed Model 737-8 is a significant product level
AIRCRAFT] IS A
change. Thus, the changed product must comply with the
SIGNIFICANT PRODUCT regulations in effect on the date of application for the change
LEVEL CHANGE.” unless an exception given in § 21.101(b) applies,” the FAA
wrote. 257 The applicant, however, may propose exceptions under these regulations if the area is not
affected, the change does not contribute materially to the level of safety, and/or if the changes are
impractical. 258 “When the applicant proposes exceptions, the FAA engineer must review data
submitted and make a finding,” according to the FAA. 259
The Joint Authorities Technical Review (JATR) panel, established by the FAA’s Associate
Administrator for Aviation Safety in June 2019 as a direct result of the MAX crashes, and comprised
of technical representatives from the FAA, National Aeronautics and Space Administration (NASA),
and civil aviation authorities from Australia, Brazil, Canada, China, Europe, Indonesia, Japan,
Singapore, and the United Arab Emirates, issued its final report in October 2019. 260 As part of its
review, the JATR panel evaluated how the Changed Product Rule was applied to the certification of
the MAX’s flight control system:
The JATR team determined that the Changed Product Rule process was
followed and that the process was effective for addressing discrete
changes. However, the team determined that the process did not
adequately address cumulative effects, system integration, and human
factors issues. The Changed Product Rule process allows the applicant
to only address in a limited way changed aspects (and areas affected by
254 “Joint Authorities Technical Review (JATR) - Boeing 737 MAX Flight Control System: Observations, Findings, and
Recommendations” Submitted to the Associate Administrator for Aviation Safety, U.S. Federal Aviation Administration
(FAA), October 11, 2019, (Hereafter referred to as “JATR Report”), p. III, accessed here:
https://www.faa.gov/news/media/attachments/Final_JATR_Submittal_to_FAA_Oct_2019.pdf
255 Ibid.
256 Ibid.
257 See: G-1 Issue Paper, p. 20 [FAA Position: July 21, 2012].
258 “How to Establish the Certification Basis for Changed Aeronautical Products,” FAA ORDER 8110.48, Federal
Aviation Administration (FAA), April 25, 2013, p. 3, accessed here:

https://www.faa.gov/documentLibrary/media/Order/ORDER_8110_48.pdf
259 Ibid. at p. 5.
260 JATR Report.
44
the change) and does not require analysis of all interactions at the
aircraft level. 261
The current Changed Product Rule process lacks an adequate

assessment of how proposed design changes integrate with existing
systems and the associated impact of this interaction at the aircraft level.
A more fulsome assessment process would apply to establishing the
certification basis as well as to finding compliance throughout the
certification process. 262
Since the MAX accidents, however,

the FAA has attempted to downplay the FAA’s G-1 Issue Paper on the 737 MAX,
differences between the 737 MAX and the FAA Position on July 21, 2012
737 NG aircraft. The FAA’s web-page on
“Airworthiness Certification,” that was last “BOEING STATED THAT A MAJOR
modified in December 2019, claimed, for REASON FOR NOT STEPPING UP TO
instance, “The Boeing 737-8/9 Max design
THE LATEST AMENDMENT IS TO
had minor changes to the 737 Next
Generation (NG) design. 263 For this reason, MINIMIZE THE IMPACT OF
the FAA issued an Amended Type Certificate CHANGES IN THE FLIGHT DECK
to the Max airplane, which was based on the AND MAINTAIN A COMMON FLIGHT
Type Certificate of the 737NG.” 264 Yet, the DECK PHILOSOPHY WITH THE 737
JATR pointed out that changes made under FLEET OF AIRPLANES.”
the Changed Product Rule could have
cumulative effects and impact system integration and human factors. 265
Exceptions to the Rule
In order to comply with the FAA certification requirements and to preserve commonality
between the 737 MAX and the prior model 737 NG airplane, Boeing applied for several exceptions
from FAA design regulations promulgated after the original 737 type certificate was issued in
1967. 266
On February 6, 2014, the FAA cited one issue -related to this topic. “Within the Boeing
proposed exceptions, there may be differences of opinion between the FAA and Boeing with
regards to the supporting rationale,” the FAA declared. 267 “For example, Boeing stated that a major
reason for not stepping up to the latest amendment is to minimize the impact of changes in the
261 JATR Report, p. IV.

263 “Airworthiness Certification,” Federal Aviation Administration (FAA), accessed here:
https://www.faa.gov/aircraft/air_cert/airworthiness_certification
264 Ibid.
266 “Dominic Gates, Steve Miletich and Lewis Kamb, “Boeing pushed FAA to relax 737 MAX certification requirements
for crew alerts,” Seattle Times, October 2, 2019 (Updated: October 3, 2019), accessed here:
https://www.seattletimes.com/business/boeing-aerospace/boeing-pushed-faa-to-arelax-737-max-certification-
requirements-for-crew-alerts
267 See G-1 Issue Paper, p. 26 [FAA Position: (February 6, 2014)].
45
flight deck and maintain a common flight deck philosophy with the 737 fleet of airplanes. Boeing
also asserted that updating the 737-8 with an engine-indicating and crew alerting system [EICAS]
type system will have a major impact on the type rating and training difference level between the
737-8 and the rest of the 737NG family.” 268
Engine Indicating and Crew Alerting System (EICAS)
Boeing obtained an FAA exception to allow the company to not install an Engine Indicating
and Crew Alerting System (EICAS) on the 737 MAX. 269 Since 1982, an EICAS or its equivalent
among Airbus airplanes has been common in
“737 MAX Certification Basis newly certificated transport aircraft. It displays
Risk Review - EICAS” aircraft system faults and failures in the cockpit
The Boeing Company and helps pilots prioritize responding to multiple
or simultaneous indications and alerts, which are
June 14, 2012 often accompanied by aural alerts specific to the
“IF WE HAD TO COMPLY level of severity of a particular fault. 270 But the
OUTRIGHT WITH REGULATION: exception from FAA relieved Boeing of the
requirement that the 737 MAX must be equipped
CONSIDERABLE PROGRAM COST
with a caution, alert, and advisory system that
AND SCHEDULE RISK [AND] “[p]rovide[s] timely attention-getting cues through
SIGNIFICANT [PILOT TRAINING] at least two different senses by a combination of
IMPACT TO OPERATORS WITH A aural, visual, or tactile indications” and that
FAMILY OF 737S.” “[p]revent[s] the presentation of an alert that is
inappropriate or unnecessary.” 271 Instead, the 737
MAX largely uses legacy cautions, warnings, alerts, and advisories from the previous generation of
the 737 aircraft. 272
Boeing was well aware early on of the risk posed to the 737 MAX program if it was required
to implement an EICAS on the MAX. In June 2012, a Boeing employee gave a presentation titled:
“737 MAX Certification Basis Risk Review: EICAS.” 273 The presentation defined the issue this way:
“Numerous crew alerts on the 737Max are new or revised and per changed product regulation are
required to meet latest amendment level. Current 737 flight crew alerting methods won’t comply
with latest regulation.” 274 The presentation went on to say that a “compliant design would be similar
to the 787 or 767 tanker and include” EICAS as well as other features. 275 Significantly, the
268 Ibid.
269 Ibid.
270 Ibid.
271 See: 14 CFR § 25.1322 – “Flightcrew alerting,” Code of Federal Regulations, as published in the Federal Register,
January 1, 2016, accessed here: https://www.govinfo.gov/app/details/CFR-2016-title14-vol1/CFR-2016-title14-vol1-

sec25-1322 and Dominic Gates, “Boeing pushed FAA to relax 737 MAX certification requirements for crew alerts,”
Seattle Times, October 2, 2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/boeing-pushed-
faa-to-arelax-737-max-certification-requirements-for-crew-alerts
272 Chris Brady, ““The 737-MAX Flightdeck,” The Boeing 737 Technical Guide, Updated April 19, 2019, accessed here:
http://www.b737.org.uk/flightdeck737max.htm
273 “737 MAX Certification Basis Risk Review: EICAS,” The Boeing Company, June 14, 2012, BATES Number TBC
T&I 014213-014230 at TBC-T&I 014215 - 014230. (On file with the Committee).
274 Ibid. at TBC-T&I 014216.
275 Ibid. at TBC-T&I 014216.
46
presentation noted: “IF we had to comply outright with regulation: Considerable program cost and
schedule risk,” it asserted, and “significant impact” on pilot training requirements. 276
The presentation also specifically cited the FAA’s regulation regarding flightcrew alerting
requirements (14 CFR § 25.1322). “Current 737 method of alerting will not comply with latest
amendment level of [section] 25.1322,” one of the slides noted, and it warned that the FAA and the
European Union Aviation Safety Agency (EASA) “may not agree with our proposal to get an
exception from the latest amendment.” 277 But it also noted, “Based on recent program experience,
we might be successful convincing the regulators to accept an exception to latest amendment level
of 25.1322.” 278
The presentation laid out a plan to do just that. “Change Product Rule allows for an
‘exception’ to meeting the latest regulations,” the presentation said. “Boeing’s exception proposal
will be based on compliance with the regulation being “impractical.” 279 The “cost of complying not
commensurate with degree of safety improvement,” the presentation suggested. 280
The presentation also cited “elements of [the] cost story” and said: “Also depends on
convincing the FAA that the safety improvement of complying with the new rule is not
overwhelming.” 281 The presentation said the MAX program would need “help” from Boeing
“finance” personnel regarding “how to structure our cost story,” and it said that they needed “buy-in
to [such an] exception proposal” from Boeing’s Authorized Representatives (ARs), who are
supposed to represent the interests of the FAA. 282 The presentation ended with the following
warning if the 737 MAX was driven to include EICAS in the aircraft – “This would have cascading
effects on flight deck design and other systems.”. 283
In the end, the FAA accepted Boeing’s argument about the impracticality and the economic
expense of installing EICAS on the 737 MAX. 284 This meant that the 737 aircraft family, including
the 737 MAX, would continue to be the only presently available Boeing commercial aircraft line that
did not have an EICAS installed. 285 Unfortunately, had the EICAS been installed on the Lion Air or
Ethiopian Airlines flights, some experts believe it may have helped to alleviate pilot confusion—a
contributing factor in both of those accidents. 286
276 Ibid. at TBC-T&I 014216.

277 Ibid. at TBC-T&I 014228.
278 Ibid. at TBC-T&I 014228.
279 Ibid. at TBC-T&I 014223.
280 Ibid. at TBC-T&I 014223.
281 Ibid. at TBC-T&I 014223.
282 Ibid. at TBC-T&I 014225.
283 Ibid. at TBC-T&I 014228.
284 Dominic Gates, “Boeing pushed FAA to relax 737 MAX certification requirements for crew alerts,” Seattle Times,
October 2, 2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/boeing-pushed-faa-to-

arelax-737-max-certification-requirements-for-crew-alerts
285 Ibid.
286 “Boeing pushed FAA to relax 737 MAX certification requirements for crew alerts,” Dominic Gates, Steve Miletich
and Lewis Kamb, Seattle Times, October 2, 2019 (Updated: October 3, 2019), accessed here,
https://www.seattletimes.com/business/boeing-aerospace/boeing-pushed-faa-to-arelax-737-max-certification-
requirements-for-crew-alerts
47
Human Factors
The National Transportation Safety Board (NTSB) emphasized the need for warning
systems like EICAS in a report it issued in response to the Lion Air and Ethiopian Airlines crashes
in September 2019, writing:
Multiple alerts and indications in the cockpit can increase pilots’

workload and can also make it more difficult to identify which
procedure the pilots should conduct. …
Human factors research has identified that, for non-normal

conditions, such as those involving a system failure with multiple
alerts, where there may be multiple flight crew actions required,
providing pilots with understanding as to which actions must take
priority is a critical need. 287
In addition, the NTSB has also pointed out that critical human factors considerations were
lacking during the certification of the 737 MAX but did not specifically distinguish between the
different types of certification processes. 288 According to its September 2019 report:
The NTSB notes that a number of human performance research

studies have been conducted in the years since the certification
guidance contained in AC 25.1309-1A was put in place (in 1988) ….
[I]t is likely that more rigorous, validated methodologies exist today
to assess error tolerance with regard to pilot recognition and response
to failure conditions. The NTSB also believes that the use of
validated methods and tools to assess pilot performance in dealing
with failure conditions and emergencies would result in more
effective requirements for flight deck interface design, pilot
procedures, and training strategies. However, we are concerned that
such tools and methods are still not commonplace or required as part
of the design certification process for functions such as MCAS on
newly certified type designs. 289
A Holistic Review Process?
Both the JATR and the NTSB analyses found room for substantial improvement in how
commercial transport aircraft are certified. Even the Special Committee, established by the Secretary
of Transportation to review the FAA’s certification process following the MAX crashes, which took
a somewhat different view regarding the thoroughness of the amended type certification (ATC)
process, conceded there is opportunity for improvement regarding this certification process on
“assumptions related to pilot performance and training, clarification and implementation of human
287 “Safety Recommendation Report: Assumptions Used in the Safety Assessment Process and the Effects of Multiple
Alerts and Indications on Pilot Performance,” National Transportation Safety Board (NTSB), September 19, 2019,
(Hereafter referred to as “NTSB Safety Recommendation Report”), pp. 10-11, accessed here:
https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf
288 Ibid., p. 9.
289 Ibid.
48
factors assessments, review of the cumulative effect of multiple changes to aircraft design, providing
of a holistic system operational risk assessment, and internal communication and communication
between Boeing and FAA.” 290
While some have questioned whether the use of an ATC process is problematic and not as
thorough as a new Type Certificate (TC) process, the Special Committee took a different view. “In
nearly all its interviews, the Committee asked a wide range of stakeholders the same two questions,”
the report said. “‘If Boeing had applied for a new type certificate for the 737 MAX 8, would it have
made a difference to the level of scrutiny of the aircraft during certification?’ and ‘Would seeking
certification via a new TC [Type Certificate] have produced a safer aircraft?’ The answer from the
experts was consistent; each said a new TC would not have produced more rigorous scrutiny of the
737 MAX 8 and would not have produced a safer airplane,” the Special Committee wrote. 291
That conclusion appears to be at odds with the position of some aviation experts. One
current Boeing aerospace engineer, who worked on the 737 MAX, wrote to the Senate Committee
on Commerce, Science, and Transportation in June 2020 regarding his observations about safety
concerns on the MAX and the certification process that permitted the MAX to be certified by the
FAA. He specifically cited the DOT Special Committee’s claim that a new type certification would
not have produced a “safer airplane.” “This conclusion is utterly incorrect,” he wrote. Because the
MAX was certified under an “Amended Type Certification,” it was not required to meet many of the
safety regulations that had emerged since the plane’s original certification back in 1967 and therefore
avoided installing some modern safety features on the airplane, such as various crew alerting
systems. 292 He also alleged that the MAX’s certification “was accomplished with hand-waving and
deception to hide the numerous ways the 1960s-era design of the 737 does not meet current
regulatory standards or a modern concept of aviation safety” and that going through the ATC
process “severely limited the range of human factors evaluation of 737 MAX systems.” 293
Separately, Professor Ronnie Gipson, an aviation attorney at the Cecil C. Humphreys School
of Law at the University of Memphis, recently wrote about the MAX crashes. “It is clear that there
needs to be a change in the way amended type certificates for design changes are approved. 294 The
current process is a remnant of the FAA’s bipartite mandate by Congress to promote air travel,” he
wrote. 295 Professor Gipson focused on flight testing issues, “but the lesson learned from the
737MAX debacle for the aviation industry and the FAA,” he argued, “is that the current certification
system for changes to aircraft design is inadequate.” 296
290 DOT Special Committee, p.8, accessed here: https://www.transportation.gov/sites/dot.gov/files/2020-01/scc-final-

report.pdf
291 Ibid.
292 See: Dominic Gates, “Boeing whistleblower alleges systemic problems with 737 MAX,” Seattle Times, June 18, 2020,
accessed here: https://www.seattletimes.com/business/boeing-aerospace/boeing-whistleblower-alleges-systemic-

problems-with-737-max and Letter to U.S. Senate Committee on Commerce, Science, and Transportation from Boeing
employee, June 5, 2020. (On file with the Committee).
293 Ibid.
294 Ronnie R. Gipson, Jr., “The FAA's Aircraft Design Approval Process Must be Overhauled,” Empire Bar Review, Issue
20, Federal Bar Association, Spring 2019, p. 11, accessed here:

https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3373387
295 Ibid.
296 Ibid.
49
In addition, despite the responses the DOT Special Committee received suggesting that
there were no fundamental differences regarding safety in an ATC review or a new TC review, it
appeared to acknowledge that a much broader holistic review was necessary in order to identify
potential safety issues, particularly regarding human factors. “However, the [DOT Special]
Committee concluded that additional consideration of the interface between the changed item and
the rest of the [airplane] system, as well and the impact of multiple changes over time, should be
required,” they wrote. 297 “This includes assessment of their combined effect on the flight crew’s
ability to safely manage operational tasks.” 298
The FAA’s JATR, which focused on the MAX’s flight control system, also observed: “There
are no criteria for determining when the core attributes of an existing design make it fundamentally
incapable of supporting the safety advancements introduced by the latest amendments to
airworthiness standards.” 299 Furthermore, the report found: “The requirements of an amended type
certificate certification process to focus only on “change and areas affected by the change” may fail
to recognize that the whole aircraft system (including the flight crew) could be affected by seemingly
small changes.” 300
While certification guidance does not incorporate the more rigorous methodologies that
have been developed since FAA Advisory Circular 25.1309-1A on “System Design and Analysis”
was issued in 1988, it is reasonable to think that certifying the 737 MAX as a new aircraft, rather
than a 737-derivative model, under the ATC process, may have helped to identify the potential
safety implications of new technologies that were incorporated into the 737 MAX. This would have
allowed for a more holistic assessment of all of the functions of all of the plane’s systems.
In contrast, certifying the 737 MAX as a derivative model led Boeing’s engineers and
managers to think about how to minimize the impact of new features, such as MCAS, on older,
established technologies that had already been certified on previous 737 aircraft. As a result,
designers thought narrowly about MCAS as a discrete addition. This also limited their evaluation of
how MCAS would function along with, or at the same time as, other, seemingly unrelated systems.
Efforts to access the potential cascading effects MCAS could have on these other systems and on
the pilots’ ability to control the aircraft as a result of an MCAS malfunction or design flaw were not
evaluated thoroughly enough. 301 Not adequately assessing the unintended consequences of new
technologies, or new functions or applications of existing technologies, on older components of the
737 MAX led to missed opportunities to identify potential safety risks to the aircraft, passengers, and
crew.
Trouble from the Start
Despite the promise of a technically improved, energy efficient, and financially competitive
aircraft that could compete with the Airbus A320neo aircraft, there was trouble on the 737 MAX
from the very start. Boeing’s 737 MAX aircraft had technical and operational issues that should have
297 DOT Special Committee, p.7, accessed here: https://www.transportation.gov/sites/dot.gov/files/2020-01/scc-final-

report.pdf
298 Ibid..
299 JATR Report, p. 7.
300 Ibid., p. 10.
301 See JATR, p. IV, recommending Change Product Rules and associated guidance be revised, “to require a top-down
approach whereby every change is evaluated from an integrated whole aircraft system perspective.”
50
served as an early warning sign of bigger troubles yet to come. In March 2016, during one of the
aircraft’s first test flights, the switch that regulates fuel flow to the engines on the MAX was
unintentionally and unknowingly triggered by the Boeing test pilot flying the aircraft by shutting off
fuel to the number one engine, the Committee has learned 302 The engine shut down. 303 Fortunately,
the aircraft returned safely without incident. The episode was the result of a design issue in the fuel
valve switch manufactured by a Boeing subcontractor. 304 Although there was reluctance on the part
of some senior Boeing officials to address and adequately fix this issue at the time, according to one
former Boeing employee, they eventually did. 305 The details of this episode were confirmed by the
former 737 MAX General Manager Keith Leverkuhn in a transcribed interview with Committee
staff. 306 One year after the “engine out” incident, in March 2017, the 737 MAX received its
airworthiness certificate from the FAA. 307
In May 2017, two months after it received its airworthiness certificate from the FAA and just
weeks before its first 737 MAX delivery, Boeing halted the test flights of the 737 MAX, effectively
grounding the entire fleet, which at the time numbered just 21 aircraft. 308 The manufacturer of its
new engines, CFM International, reported that its supplier for low pressure turbine rotor discs may
have delivered a batch of defective parts to Boeing. 309 In a statement, Boeing said: “Out of an
abundance of caution, we decided to temporarily suspend MAX flights. The step is consistent with
our priority focus on safety for all who use and fly our products.” 310 Boeing sent an estimated 30
engines back to CFM International, a joint venture between General Electric and Safran, a French
manufacturer, for inspection. 311 The temporary grounding was short lived. 312 On May 16, 2017, less
than one week after the MAX was grounded, Boeing made its first delivery of the new 737 MAX
aircraft to Malindo Air. 313
These two incidents show that Boeing did take appropriate steps in some cases, even if it did
so reluctantly. However, the 737 MAX program was not the only Boeing commercial aircraft
program suffering from technical and safety related issues. While many of the problems discovered
on the 737 MAX program were design related issues, years before the 737 MAX program started,
there were numerous warning signs about the quality and safety of Boeing’s production and
302 Confidential conversation with former Boeing employee and Democratic Committee staff, April 29, 2019.
303 Ibid.
304 Ibid.
305 Ibid
MAX program, Boeing Commercial Airplanes, May 19, 2020.

307 “Boeing 737 MAX 8 Earns FAA Certification,” Press Release, Boeing Commercial Airplanes, March 9, 2017, accessed
here: https://boeing.mediaroom.com/2017-03-09-Boeing-737-MAX-8-Earns-FAA-Certification
308 Alwyn Scott, “Boeing suspends 737 MAX flights due to engine issue,” Reuters,, May 10, 2017, accessed here:
https://www.reuters.com/article/us-boeing-737max-engine-idUSKBN1862O9
309 See: Stephen Trimble, “Boeing delivers first 737 Max,” FlightGlobal, May 16, 2017, accessed here:
https://www.flightglobal.com/systems-and-interiors/boeing-delivers-first-737-max-/124050.article and Alwyn Scott,

“Boeing suspends 737 MAX flights due to engine issue,” Reuters,, May 10, 2017, accessed here:
https://www.reuters.com/article/us-boeing-737max-engine-idUSKBN1862O9
310 Jon Ostrower, “Boeing grounds 737 MAX flights for engine inspections,” CNN Business, May 10, 2017, accessed
here: https://money.cnn.com/2017/05/10/news/companies/boeing-halts-737-max-flying-engine-issue/index.html
311 Ibid.
312 Jon Ostrower, “Boeing cleared to fly the 737 Max, delivers first jet,” CNN Business, May 17, 2017, accessed here:
https://money.cnn.com/2017/05/16/news/companies/boeing-737-max-first-delivery/index.html
313 “Boeing, Malindo Air Celebrate First 737 MAX Delivery,” Press Release, Boeing Commercial Airplanes, May 16,
2017, accessed here: https://boeing.mediaroom.com/news-releases-statements?item=129894
51
manufacturing processes across multiple Boeing Commercial Airplanes (BCA) programs. Beginning
in 2010, for example, the FAA discovered 193 instances of faulty wiring installation on Boeing’s 787
Dreamliner. 314 Additional inspections found 149 more instances of faulty wiring in addition to fuel
leaks caused by the improper installation of “lock wires.” 315 Wiring harnesses were also discovered
to have been installed incorrectly. 316
And then the 787 was grounded worldwide in 2013 after the airplane’s lithium battery—a
key part of the 787 electrical system—self-ignited on two separate occasions, creating an
unacceptable risk that a lithium-battery-fed fire would consume a 787 in flight before the crew could
land and evacuate the airplane. 317 The grounding would last for three and a half months, until
Boeing decided to enclose the airplane battery in a titanium box that would contain any fire. 318
Investigating the 787 battery incident that occurred in the United States—a fire on board a Japan
Airlines 787-8 after landing in Boston—the National Transportation Safety Board concluded Boeing
performed an incomplete system safety assessment that failed to consider the most severe effects of
a battery fire and that the FAA’s review of the assessment failed to identify this shortcoming. 319 The
Safety Board found that “[t]he [Japan Airlines] incident resulted from Boeing’s failure to incorporate
design requirements to mitigate the most severe effects of an internal short circuit within [a] battery
cell and the Federal Aviation Administration’s failure to identify this design deficiency during the
type design certification process.” 320
While these issues occurred on a different Boeing model airplane, the Committee’s
investigation found that in multiple other instances over the lifetime of the 737 MAX program—
and even beyond the 737 MAX program—Boeing engaged in conduct that ran contrary to sound
aviation engineering practices and in several cases attempted to shield critical information from
Federal regulators, Boeing’s customers, and 737 MAX pilots, jeopardizing the safety of the flying
public.
Boeing-FAA Settlement Agreement
By 2015, the FAA was pursuing 13 separate enforcement investigations against Boeing
related to multiple BCA programs, including the 737 program. 321 Most of these cases involved
failures by Boeing to take corrective actions to known problems, to take appropriate actions to
314 Committee staff briefing by the Federal Aviation Administration (FAA), July 12, 2019.
315 Ibid.
316 Ibid.
317 See: Emergency Airworthiness Directive, No. 2013-02-51, Federal Aviation Administration, January 16, 2013,
accessed here:
https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/0/8a1a8dc3135b60dd86257af60004cf4a/%24FILE/2
013-02-51_Emergency.pdf and Christopher Drew, Jad Mouawad, and Matthew L. Wald, “F.A.A. Grounds U.S.-
Operated Boeing 787s,” New York Times, January 16, 2013, accessed here:
https://www.nytimes.com/2013/01/17/business/faa-orders-grounding-of-us-operated-boeing-787s.html
318 “FAA Order Formally Lifts Boeing 787 Dreamliner Grounding,” The Associated Press, April 25, 2013, accessed here:
https://www.usatoday.com/story/travel/flights/2013/04/25/faa-boeing-787-dreamliner/2113463/
319 “Aircraft Incident Report: Auxiliary Power Unit Battery Fire, Japan Airlines Boeing 787-8, JA829J, Boston,
Massachusetts, January 7, 2013,” Incident Report, NTSB/AIR-14/01, National Transportation Safety Board (NTSB),
November 21, 2014, at 78-79, accessed here: https://www.ntsb.gov/investigations/accidentreports/reports/air1401.pdf
320 Ibid., p. 79.
321 Andy Pasztor and Robert Wall, “Boeing Accepts FAA Penalties Over Quality Control,” Wall Street Journal, December
22, 20015, accessed here: https://www.wsj.com/articles/boeing-faa-reach-settlement-over-safety-compliance-concerns-

1450794214
52
prevent known problems from reoccurring, and being tardy in its communications with the FAA
once Boeing learned these issues existed. 322 These problems affected multiple BCA programs
spanning multiple years and involving issues related to fuel tank flammability, millions of incorrectly
shaped fasteners, improperly installed decompression panels, tools being left inside airplanes (known
as foreign object debris or “FOD”), inappropriate installation of cargo doors on Boeing 777 aircraft,
and Boeing subcontractors falsifying certification records, among other issues. 323
In an attempt to resolve the “multiple pending and potential enforcement cases,” Boeing
and the FAA entered into a settlement agreement that went into effect on January 1, 2016. 324 The
agreement implemented corrective actions to ensure the issues identified by the FAA were corrected
and that systemic changes were instituted so that they would not emerge again. The agreement
settled two civil enforcement cases that the FAA had initiated and the 11 other enforcement
investigations that the FAA had been pursuing against Boeing. 325 As part of the agreement, Boeing
was obligated to implement various procedures to help improve the quality of its production and
manufacturing processes. This included implementing a Safety Management Systems (SMS) plan
that BCA developed to meet internationally accepted standards throughout the company’s
activities. 326 The FAA Administrator at the time, Michael Huerta responded by saying: “Boeing has
agreed to implement improvements in its design, planning, production and maintenance planning
processes and has already implemented several of these improvements.” 327
As part of the settlement agreement, Boeing initially paid $12 million and faces the potential
for an additional $24 million in penalties through the life of the five-year settlement agreement that
is set to conclude in December 2020. 328 Boeing, however, accumulated more than $80 billion in
gross profits during the five-year period in which most of these violations occurred, from 2010 to
2015. 329 Considering that Boeing’s gross profits peaked in 2018, reaching nearly $20 billion in that
year alone, the $12 million fine and the proposed potential future fines of $24 million—
characterized by the FAA as “stiff penalties” —appear insignificant. 330
322 Michael Laris, “Long before the Max disasters, Boeing had a history of failing to fix safety problems,” Washington Post,
June 17, 2019, accessed here: https://www.washingtonpost.com/local/trafficandcommuting/long-before-the-max-

disasters-boeing-had-a-history-of-failing-to-fix-safety-problems/2019/06/26/b4f5f720-86ee-11e9-a870-
b9c411dc4312_story.html
324 See: FAA-Boeing Settlement Agreement (Redacted Version), Signed by Reginald C. Govan, Chief Counsel, Federal
Aviation Administration (FAA) and Brett Gerry, Vice President and Assistant General Counsel, Boeing Commercial
Airplanes (BCA), December 2015, BATES Number: FAA T&I 6902-6930 (On file with the Committee), and “Boeing
Agrees to Pay $12 Million and Enhance its Compliance Systems to Settle Enforcement Cases” Press Release, Federal
Aviation Administration (FAA), Dec. 22, 2015, accessed here:
https://www.faa.gov/news/press_releases/news_story.cfm?newsId=19875
326 “Boeing Agrees to Pay $12 Million and Enhance its Compliance Systems to Settle Enforcement Cases” Press Release,
Federal Aviation Administration, Dec. 22, 2015, accessed here:

327 “Boeing Agrees to Pay $12 Million and Enhance its Compliance Systems to Settle Enforcement Cases,” Press
Release, Federal Aviation Administration, December 22, 2018, accessed here:

328 Ibid.
329 “Boeing Gross Profit 2006-2019,” Macrotrends, accessed here:
https://www.macrotrends.net/stocks/charts/BA/boeing/gross-profit
330 “Boeing Agrees to Pay $12 Million and Enhance its Compliance Systems to Settle Enforcement Cases,” Press
Release, Federal Aviation Administration, December 22, 2018, accessed here:

53
Moreover, in June 2019, the Washington Post reported that Boeing had failed to meet some of
its obligations under the settlement agreement in the previous
three and a half years and that the FAA has so far chosen not to The Washington Post
invoke enforcement provisions against Boeing that could
June 17, 2019
subject the company to the additional $24 million in penalties. 331
“[T]OP BOEING
In addition, since Boeing signed the settlement EMPLOYEES WHO
agreement with FAA, it has repeated some of the same WERE SUPPOSED TO
problems that the FAA agreement sought to force the company
to correct. Last year, for instance, the U.S. Air Force temporarily
BE REPRESENTING
halted deliveries of Boeing’s KC-46 Pegasus tanker twice THE FAA AT TIMES
because of foreign object debris found in the aircraft as a result AGGRESSIVELY
of deficiencies in the manufacturing process. The KC-46
332 CHAMPIONED THE
tanker is based on the Boeing 767 aircraft. In February 2020, it COMPANY’S
was reported that foreign object debris was also found in the fuel INTERESTS INSTEAD.”
tanks of dozens of undelivered 737 MAX aircraft. 333 Boeing’s
inability to correct such critical systematic manufacturing failures is extremely troubling.
FAA’s Organization Designation Authorization Program
The noted decline in product quality and safety culture at Boeing outlined above coincided
with the evolution in the FAA’s oversight structure of the aviation industry. In 2005, the FAA
restructured its decades old designee program and implemented a new designee oversight program
known as the Organization Designation Authorization (ODA) program that enhanced the authority
that FAA granted to aircraft manufacturers, such as Boeing, to perform FAA mandated certification
activities. It is worth noting that as part of the Committee’s 737 MAX investigation the Committee
has only investigated Boeing’s ODA program and not those of other aircraft manufacturers.
However, the problems with Boeing’s ODA program are clearly significant. The
enforcement issues investigated by the FAA that resulted in the 2015 settlement agreement, for
instance, found that Boeing employees who were supposed to be representing the interests of the
FAA under the ODA program were instead representing the interests of Boeing. As part of the
settlement agreement the FAA mandated that the individuals holding the top two positions in the
Boeing ODA program “will not advocate” for Boeing “to avoid any potential conflicts.” 334 As the
332 Stephen Losey, “Air Force again halts KC-46 deliveries after more debris found,” Air Force Times, April 2, 2019,
accessed here: https://www.airforcetimes.com/news/your-air-force/2019/04/02/air-force-again-halts-kc-46-deliveries-

after-more-debris-found
333 Kanishka Singh and Eric M. Johnson, “Boeing finds debris in fuel tanks of many undelivered 737 MAX jets,” Reuters,
February 22, 2020, accessed here: https://www.reuters.com/article/us-boeing-737max-debris/boeing-finds-debris-in-

fuel-tanks-of-many-undelivered-737-max-jets-idUSKCN20G08X
334 FAA-Boeing Settlement Agreement (Redacted Version), Signed by Reginald C. Govan, Chief Counsel, Federal
Aviation Administration (FAA) and Brett Gerry, Vice President and Assistant General Counsel, Boeing Commercial
Airplanes (BCA), December 2015, p. 6, BATES Number: FAA T&I 6902-6930. (On file with the Committee).
54
Washington Post observed: “[T]op Boeing employees who were supposed to be representing the FAA
at times aggressively championed the company’s interests instead.” 335
In addition, the Committee’s own investigation has revealed that Boeing designees involved
in critical issues regarding the certification of the 737 MAX program failed to keep the FAA
adequately informed of key issues, although these same designees did attempt to raise these issues
internally at Boeing.
The Committee’s investigation has shown that these and other significant and systemic
issues still exist at Boeing and were prevalent during a critical period of the MAX’s certification
process. These production and manufacturing issues, taken together with the aforementioned
design, development, and certification issues paint a deeply disturbing picture of cultural issues at
Boeing regarding safety, quality control, and transparency that will take a long time and serious
efforts to thoroughly resolve.
In many cases, the FAA designee structure under the ODA program has also led to
dwindling effectiveness of the FAA’s oversight authority that has adversely impacted safety. These
are not just the findings of the Committee’s investigation but have been clearly identified by the
FAA’s recent “safety culture” survey of its own Aviation Safety (AVS) employees. 336 In that survey,
for instance, 43 percent of AVS-wide respondents said the FAA does not appropriately delegate
certification activities to external FAA designees and 54 percent of FAA employees in the Aircraft
Certification Service (AIR) —a part of AVS—felt the same way. 337 In addition, 56 percent of AIR
employees believed there was too much external influence on the agency and that it was having an
impact on safety. 338
These and other issues at the FAA have hampered the agency’s ability to identify and
effectively correct quality and safety issues at Boeing. It is important to understand these issues and
the changes in the FAA’s designee oversight structure to grasp the full extent of the problems that
emerged in the 737 MAX program and that the Committee has uncovered during its investigation.
337 Ibid.
338 Ibid.
55
4. FAA Oversight and
Delegation of
Authority
4. FAA Oversight and Delegation of Authority
-FAA Oversight and Delegation of Authority-
INVESTIGATIVE FINDINGS
 Excessive FAA delegation of certification functions to Boeing on the 737 MAX eroded
FAA’s oversight effectiveness and the safety of the public.
 Boeing Authorized Representatives (ARs)—Boeing employees acting as representatives of

the FAA or performing certification functions on behalf of the FAA—were impaired from
acting independently of the company in regard to the certification of the 737 MAX.
 The Committee identified multiple cases where Boeing ARs did not relay important safety-
related information to the FAA because there was no requirement to do so, hindering a
more comprehensive FAA review of the 737 MAX which may have improved the safety of
the airplane and potentially prevented the two fatal MAX accidents.
 In some cases, FAA senior managers acted against the safety recommendations from FAA’s
own technical experts to support Boeing’s business interests. This included a rudder cable
issue on the 737 MAX and a lightning protection issue on the 787 Dreamliner. 339
 In November 2016, an internal Boeing survey found that a full 39 percent of Boeing ARs
said they had experienced “undue pressure,” pointing to disturbing cultural issues that
Boeing must confront to eradicate conditions that undermine safety. 340
 In February 2020, an FAA contractor published the results of FAA’s own (draft) “safety
culture survey” of employees in its Aviation Safety Organization (AVS). The results point to
an institution in dire need of immediate repair. The “key takeaway” from the survey and the
contractor’s interviews with AVS executives, employees, and other stakeholders was that
“AVS senior leadership’s response to and management of industry pressure is at the heart of
the organization’s core safety culture challenges: lack of trust, inconsistent accountability,
FAA role confusion, and the perception that AVS is moving further away from its safety
mission.” 341 Nearly half of the “survey respondents disagreed that FAA makes data-driven
decisions about safety regardless of external pressure.” 342 These findings mirror the
Committee’s own revelations in this report.
 The Committee’s investigation has identified sweeping and systemic problems revolving
around the ability of the FAA to effectively engage in regulatory activity and robust oversight
of Boeing to ensure the safety of the flying public and the aviation community.
339 Letter from Chair DeFazio and Subcommittee on Aviation Chair Larsen to FAA Administrator Dickson regarding
737 MAX Rudder Cable Issue and 787 Dreamliner Lightning Protection Issues, November 7, 2019, accessed here:
https://transportation.house.gov/imo/media/doc/DeFazio,%20Larsen%20Letter%20to%20FAA%20re%20rudder%2
0cables,%20lightning%20covers.pdf
340 “Undue Pressure: Key Learnings and Next Steps,” Boeing Commercial Airplanes (BCA), November 2016, pp. 144-

342 Ibid.
57
Delegation Authority Background
All U.S. manufactured aircraft and aviation products are subject to certification by the FAA
prior to their sale and use in the United States. 343 The FAA is responsible for regulating aviation
safety, which includes approving the design and manufacture of new aircraft and aviation products
before they enter air commerce. 344 To leverage its significant but limited staff resources, the FAA is
authorized by statute to delegate certification and other functions of the agency to qualified
individuals, 345 including through the Organization Designation Authorization (ODA) program. 346 An
Organization Designation Authorization includes both an ODA Holder—the parent organization to
which the FAA grants an ODA Letter of Designation—and an ODA unit that consists of
individuals within the ODA Holder’s organization who perform the FAA-authorized functions. 347
Individuals granted this specific designee authority are referred to throughout this report as
authorized representatives or ARs. 348
Civil aviation authorities worldwide—not just the FAA—administer delegation programs to

leverage the product-specific knowledge of manufacturers’ qualified employees to determine a
product’s compliance with government regulations. The FAA has relied on delegation authority for
more than 50 years. However, it has come to be more heavily used over time as airplanes, engines,
and their constituent systems have become increasingly complex. Figure 1 below illustrates the
development and evolution of FAA’s organizational delegation since the inception of FAA
delegation authority to industry.
343 49 U.S.C. § 44702, “Issuance of certificates,” accessed here: https://www.govinfo.gov/app/details/USCODE-2011-

title49/USCODE-2011-title49-subtitleVII-partA-subpartiii-chap447-sec44702/summary
344 See: 49 U.S.C. § 44702, “Issuance of certificates,” accessed here: https://www.govinfo.gov/app/details/USCODE-
2011-title49/USCODE-2011-title49-subtitleVII-partA-subpartiii-chap447-sec44702/summary; 49 U.S.C. § 44704, “Type

certificates, production certificates, airworthiness certificates, and design and production organization certificates,”
accessed here: https://www.govinfo.gov/app/details/USCODE-2015-title49/USCODE-2015-title49-subtitleVII-
partA-subpartiii-chap447-sec44704; and “Aviation Manufacturing: Status of FAA’s Efforts to Improve Certification and
Regulatory Consistency,” U.S. Government Accountability Office (GAO), GAO-14-829T, July 31, 2014, (Hereafter
referred to as GAO-14-829T), accessed here: https://www.gao.gov/assets/670/665131.pdf
345 49 U.S.C. § 44702(d).
346 The regulations addressing the ODA program are found in Title 14 of the Code of Federal Regulations (14 CFR) part
183, subpart D, sections 183.41 through 183.67. See: 14 CFR 183, “Representatives of the Administrator,” Subpart D,
“Organization Designation Authorization,” accessed here: https://www.govinfo.gov/app/details/CFR-2011-title14-
vol3/CFR-2011-title14-vol3-part183 and “Delegated Organizations,” Federal Aviation Administration (FAA), accessed
here: https://www.faa.gov/other_visit/aviation_industry/designees_delegations/delegated_organizations
347 Ibid.
348 The FAA’s designees had been termed designated engineering representatives (DERs), but during the years the 737
MAX underwent certification they were called authorized representatives (ARs). Most recently, the term used to describe
these designees has changed to engineering unit members (E-UMs). Throughout this report, these designees are referred
to as authorized representatives (ARs), since that was the term used for these designees during the certification of the
737 MAX.
58
Development of Organizational Delegation
Source: Department of Transportation, Office of Inspector General, Audit Report AV-2016-001 349
The current iteration of the ODA program was established in November 2005 and fully
implemented four years later as the means by which FAA grants designee authority to organizations
or companies to perform certain functions on its behalf. 350 This includes determining whether an
aircraft, engine, or component meets applicable requirements for issuance of an FAA certificate. 351
The ODA program combined various FAA delegation authorities to standardize the FAA’s
oversight of ODA designees. 352 In particular, the ODA program (1) expanded the scope of
approved tasks available to organizational designees; (2) increased the number of organizations
eligible for organizational designee authorizations; and (3) established a more comprehensive,
systems-based approach to managing designated organizations. 353
The ODA program was intended to allow the FAA to delegate certification of well-
understood, non-critical, or low-risk designs so that the FAA can remain directly involved in review
and approval of higher-risk items, such as safety-critical or “new and novel” designs. 354 This has
349 “FAA Lacks an Effective Staffing Model and Risk-Based Oversight Process for Organization Designation
Authorization,” Audit Report, Report Number: AV-2016-001, U.S. Department of Transportation (DOT), Office of
Inspector General (OIG), October 15, 2015 (Hereafter referred to as “DOT OIG Audit Report AV-2016-001”),
accessed here:
https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20ODA%20Final%20Report%5E10-15-
15.pdf
350 “Establishment of Organization Designation Authorization Program,” Federal Aviation Administration (FAA), Final
Rule, Federal Register, Vol. 70, No. 197, 70 FR 59931, October 13, 2005, (Hereafter referred to as “Establishment of
ODA Program,” 70 FR 59931), accessed here: https://www.federalregister.gov/documents/2005/10/13/05-
20470/establishment-of-organization-designation-authorization-program and DOT OIG Audit Report AV-2016-001.
351 See GAO-14-829T, p. 5, for a description of the types of certifications that FAA oversees.
352 DOT OIG Audit Report AV-2016-001.
353 “Establishment of ODA Program,” 70 FR 59931.
354 See Prepared Statement of Daniel K. Elwell, FAA Acting Administrator, Hearing titled, “Status of the Boeing 737
MAX,” Subcommittee on Aviation of the Committee on Transportation and Infrastructure, U.S. House of
Representatives, 116th Congress, First Session, May 15, 2019, and Daniel K. Elwell response to questions from Hon.
Henry C. “Hank” Johnson , p. 21 and p. 85, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
59
allowed FAA designees to engage in a broad range of actions performing more than 90 percent of
the total scope of FAA certification activities in many instances. 355 However, various investigations
of the 737 MAX, including the Committee’s own investigation, have concluded that FAA delegated
some certification activities to Boeing that it should have retained. In the case of the 737 MAX, in
2013, the FAA originally delegated 28 of 87 tasks to Boeing. 356 However, this number rose to 79 of
91 activities by November 2016, four months prior to final certification of the 737 MAX aircraft. 357
Once a designee establishes through inspections and tests that an aviation product comports
with FAA standards, the FAA is supposed to conduct a risk-based review of the designee’s work
and issue a type certificate if the product meets minimum safety standards. 358 As the Special
Committee to Review the Federal Aviation Administration’s Aircraft Certification Process,
established by the Secretary of Transportation in response to the MAX crashes, wrote: “Regardless
of whether it is FAA staff or FAA-authorized designees responsible for certain aspects of a
certification program, the applicant is always required to show compliance, while the FAA is
responsible to find compliance.” 359 The FAA further acknowledges that, “[They're] responsible for
the safety of civil aviation.” 360 In summary, the FAA bears ultimate responsibility for ensuring new
aircraft designs are safe and comply with airworthiness standards.
ODA Program Effectiveness and Concerns
Two months before the Lion Air crash, the FAA touted the aviation industry’s impressive
safety record over the preceding decade in a fact sheet that boasted: “The commercial aviation
system in the United States operates at an unprecedented level of safety. During the past 20 years,
commercial aviation fatalities in the U.S. have decreased by 95 percent as measured by fatalities per
100 million passengers.” 361
October 2018 Lion Air Accident,” Department of Transportation (DOT), Office of Inspector General (OIG), Report
No. AV2020037, June 29, 2020, p. 3, (Hereafter referred to as DOT OIG Report No. AV2020037), accessed here:
20Timeline%20Final%20Report.pdf. The DOT OIG wrote, “Designees can perform a substantial amount of critical
certification work on FAA’s behalf. For example, according to FAA data, in 2018 four U.S. aircraft manufacturers
approved about 94 percent of the certification activities for their own aircraft.”
356 DOT OIG Report No. AV2020037, p. 15.
357 Ibid.
358 FAA issues a type certificate that approves a product’s design when an applicant has demonstrated that the product
complies with applicable standards defined in 14 CFR. The type certificate is the foundation for other FAA approvals,
including production and airworthiness approvals. See “Type Certification,” FAA Order 8110.4C, CHG 6, Federal
Aviation Administration (FAA), Department of Transportation (DOT), March 6, 2017, accessed here:
https://www.faa.gov/documentLibrary/media/Order/FAA_Order_8110_4C_Chg_6.pdf and “Establishment of
Organization Designation Authorization Procedures,” Notice of proposed rulemaking (NPRM), Federal Register, Vol.
69, No. 13, 69 FR 2969, Federal Aviation Administration (FAA), January 21, 2004, accessed here:
https://www.federalregister.gov/d/04-1133/p-101
359 “Official Report of the Special Committee to Review the Federal Aviation Administration’s Aircraft Certification
Process,” Department of Transportation (DOT), January 16, 2020, (Hereafter referred to as “DOT Special Committee
Report”), p. 22., accessed here: https://www.transportation.gov/sites/dot.gov/files/2020-01/scc-final-report.pdf
360 “What we do,” Federal Aviation Administration, accessed here: https://www.faa.gov/about/mission/activities
361 “Fact Sheet – Out Front on Airline Safety: Two Decades of Continuous Evolution,” Federal Aviation
Administration, August 2, 2018, accessed here: https://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=22975
60
From 2010 to 2018, U.S. air carriers suffered just one passenger fatality. 362 The number of
commercial flights flown annually in the U.S. over this time period ranged between about 10.5
million and 11 million. 363 In 2019 alone, more than 811 million passengers boarded domestic flights
on U.S. airlines, continuing a decade-long trend of annual increases. 364 Even after the Lion Air and
Ethiopian Airlines crashes, the FAA repeatedly took the opportunity to focus on this past safety
record while reluctantly acknowledging problems in the certification of the 737 MAX. In May 2019,
for example, Dan Elwell, the then-Acting FAA Administrator, told an audience of international
aviation authorities in Texas: “One fatality in 10 years. I’ll say it again: 90 million flights, 7 billion
passengers. We’ve had one fatality.” 365
Unfortunately, the nation’s successful past aviation safety record eventually led to
complacency by both Boeing and the FAA. This was one factor that contributed to an
overconfidence in the certification system that promulgated a culture that equated compliance to
safety.
The Committee’s investigation found fundamental flaws in the implementation and

operation of the ODA program under which the FAA designated Boeing to act on its behalf. In
several cases, FAA provided inadequate oversight and instead deferred to Boeing, leading to the
production of airplanes with significant safety problems. These included the 737 MAX with its new
Maneuvering Characteristics Augmentation System (MCAS) feature as well as the 787 Dreamliner,
which in January 2013, experienced problems with on-board fires caused by the airplane’s new
lithium batteries. Both of these aircraft models—developed under the ODA program—were
grounded because of safety concerns. 366 Not all of the issues with the 787 Dreamliner or 737 MAX
can be attributed to the ODA program. However, the lack of robust FAA oversight certainly
contributed to the problems that resulted in both the 787 Dreamliner incidents and 737 MAX
crashes.
The Department of Transportation (DOT) Office of Inspector General (OIG) recognized

this as early as 2012, in its Fiscal Year 2012 Top Management Challenges report, where it found
significant weaknesses in the FAA’s ODA program. Among the key findings:
FAA has not adequately trained engineers on their new enforcement

responsibilities under ODA, and some FAA certification offices have
not effectively tracked or addressed poorly performing ODA
362 “Safety Record of U.S. Air Carriers,” Airlines for America, accessed here: https://www.airlines.org/dataset/safety-
record-of-u-s-air-carriers
363 “Air Traffic By the Numbers,” Federal Aviation Administration, June 2019, p.6, accessed here:
https://www.faa.gov/air_traffic/by_the_numbers/media/Air_Traffic_by_the_Numbers_2019.pdf
364 See “Passengers: All Carriers - All Airports,” Bureau of Transportation Statistics, U.S. Department of Transportation,
accessed here: https://www.transtats.bts.gov/Data_Elements.aspx?Data=1

365 Michael Laris, “Long before the Max disasters, Boeing had a history of failing to fix safety problems,” The Washington
Post, June 27, 2019, accessed here: https://www.washingtonpost.com/local/trafficandcommuting/long-before-the-max-

366 Gwyn Topham, “Boeing Dreamliner: US joins Japan in grounding 787s,” The Guardian, January 17, 2013, accessed
here: https://www.theguardian.com/business/2013/jan/16/japanese-carriers-ground-24-boeing-787s
61
personnel. In addition, ODA significantly reduced FAA’s role in

approving individuals who perform work on FAA’s behalf. 367
Studies from government and industry stakeholders have long raised questions about the
effectiveness of FAA’s certification process in making compliance decisions during certification. 368
The 2012 FAA Modernization and Reform Act, for instance, required FAA to work with industry to
resolve numerous issues related to its certification processes and varying interpretations and
applications of its regulations. 369 In response, the FAA chartered a rulemaking committee in April
2012 to address this requirement. 370 Based on the committee’s recommendations, the FAA developed
initiatives that included improving and expanding its ODA program and rolled implementation of
these initiatives into a larger organizational transformation of its Aircraft Certification Service
(AIR). 371
As part of this transformation, AIR sought to advance its safety mission and related
outcomes by interrelated means such as enhancing the accountability framework, adopting risk-
based decision making, implementing an information management strategy, and strengthening
industry partnerships, among other initiatives. 372 AIR anticipated that the successful implementation
of its transformation would enable it to better manage operational safety risk, reduce the time for
approval decisions, increase the schedule predictability of approval decisions, and increase AIR’s
productivity. 373 The FAA implemented the AIR reorganization in July 2017, which included the
establishment of the Systems Oversight Division (AIR-800) that is responsible for managing FAA’s
367 “Top Management Challenges for Fiscal Year 2012,” Report Number: PT-2012-006, Department of Transportation
(DOT), Office of Inspector General (OIG), November 15, 2011, p. 7, accessed here:
https://www.faa.gov/about/plans_reports/media/FY12TopMgmtChallengesFINAL.pdf
368 “Aviation Certification: Issues Related to Domestic and Foreign Approval of U.S. Aviation Products,” GAO-15-
550T, Government Accountability Office (GAO), April, 21, 2015, (Hereafter referred to as GAO-15-550T), accessed
here: https://www.gao.gov/products/gao-15-550t; and “Aviation Certification: FAA Has Made Continued Progress in
Improving Its Processes for U.S. Aviation Products,” GAO-17-508T, Government Accountability Office (GAO),
March, 23, 2017, accessed here: https://www.gao.gov/products/GAO-17-508T
369 FAA Modernization and Reform Act of 2012, Pub. L. No. 112-95, §§ 312 and 313, 126 Stat. 11, 66, 67 (2012).
370 See Ali Bahrami, Manager, FAA Transport Airplane Directorate, and Christine Thompson, Lead ODA Project
Administrator Advisor, Boeing Commercial Airplanes; Aircraft Certification Process Review and Reform Aviation
Rulemaking Committee Co-Chairs; “A Report from the Aircraft Certification Process Review and Reform Aviation
Rulemaking Committee to the Federal Aviation Administration: Recommendations on the Assessment of the
Certification and Approval Process,” Department of Transportation (DOT), Federal Aviation Administration (FAA),
May 22, 2012, accessed here:
https://www.faa.gov/regulations_policies/rulemaking/committees/documents/media/acprrarc-4202012.pdf
371 See “DOT Special Committee Report,” pp. 27-28 and GAO-17-508T.
372 “Comprehensive Strategic Plan for AIR Transformation,” Federal Aviation Administration (FAA), July 2018, p. 4,
accessed here:
https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/air/transformation/media/comprehensive_s
trategic_plan.pdf
373 Ibid., p. 6.
62
designees. 374 This implementation occurred four months after the FAA’s certification of the 737
MAX. 375
However, the FAA’s recent safety culture survey points to continuing problems with the
FAA’s management of designees and its ability to ensure the FAA’s fundamental mission of aviation
safety is being duly and fully met. “Many focus group participants,” the survey found, “believe that
the Organization Designation Authorization (ODA) Model is causing FAA to move further away
from its safety mission and results in confusion about the FAA’s roles.” 376 Furthermore, the survey
found that there was “a general concern that the FAA” … “has delegated too much authority to
industry which negatively impacts the safety of the National Airspace.” 377
In 2015, as FAA proceeded to make operational and organizational changes affecting its
expanding ODA program, GAO reported that while industry stakeholders emphasized the need for
FAA to expand its ODA program, industry union representatives expressed concerns about FAA’s
lack of resources to effectively do so. 378 Specifically, union representatives said that FAA already did
not have enough inspectors and engineers to provide the proper surveillance of existing designees. 379
Further, the DOT OIG found that FAA lacked a comprehensive process for determining
adequate staffing levels for effective ODA oversight and that inspectors and engineers were not fully
performing risk-based oversight due to the lack of adequate guidance, risk-based tools, and robust
data analysis. 380 As a result, FAA’s ODA oversight findings were often not related to issues that
could directly impact the potential loss of critical systems or other safety concerns, but rather
focused on minor issues such as paperwork errors. 381
Related to these issues, the unions representing aviation engineers, safety specialists, and
other personnel had deep concerns about the reorganization of the AIR and the impact it would
have on the FAA’s ability to conduct thorough oversight of Boeing. In February 2017, the National
Air Traffic Controllers Association (NATCA), the Professional Aviation Safety Specialists (PASS),
and the American Federation of State, County & Municipal Employees (AFSCME) published a
report titled: “Aircraft Certification “Transformation” Pre-Decisional Involvement Report: Union
Recommendations and Dissenting Opinion.” 382 Among its observations, the report noted: “Today
374 “Air Transformation Timeline,” Federal Aviation Administration (FAA), May 15, 2018, accessed here:
https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/air/transformation/media/AIR_transformati
on_timeline.pdf. For additional information on AIR transformation see “Aircraft Certification Service (AIR)
Transformation,” Federal Aviation Administration, accessed here:
https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/air/transformation/

LE/A16WE_Rev_58.pdf
376 FAA Safety Culture Survey.
377 Ibid.
378 GAO-15-550T, pp. 7-8.
379 Ibid.
380 DOT OIG Audit Report AV-2016-001, pp. 4-6.
381 Ibid., p.6.
382 “Aircraft Certification “Transformation” Pre-Decisional Involvement Report: Union Recommendations and
Dissenting Opinion,” National Air Traffic Controllers Association (NATCA), the Professional Aviation Safety
63
the Boeing Aviation Safety Oversight Office (BASOO) is focused on meeting Boeing certification
needs and does not allocate significant resources to oversight.” The report said the FAA plan
proposed “a 60 percent reduction in engineering involvement in certification oversight.” 383
Furthermore, the report found:
The shifting of resources from direct up front oversight at the high

risk point in the certification, to post certification audits and
correcting unsafe conditions that are discovered on in-service aircraft
is a fundamentally flawed concept and is not based upon data or risk
analysis. This concept is based on the premise the ODA will
independently make correct compliance findings without
involvement of the second set of eyes provided by FAA engineers
and inspectors. The assumption a “for profit” company that is faced
with significant financial incentive will always make appropriate
compliance findings contradicts human nature, and is not supported
by experience in other industries and the performance of the Boeing
ODA. The consequences of ODA approval of noncompliant or
unsafe designs would result in introduction of large numbers of
airplanes in passenger carrying service, resulting in exposure of the
public to a lower level of safety and the need for expensive retrofit of
the fleet. 384
The report also questioned FAA’s ability to identify unsafe conditions through the use of
oversight audits and “spot check compliance” conducted months or years after compliance findings
had been made. “The likelihood of finding the non-compliant or unsafe features using post
certification audits is low,” the report warned, “resulting in a lower level of safety than required by
the regulations that brought us today’s high safety level.” 385
The union representatives sent the report to Dorenda Baker, then-Director of the FAA’s
Aircraft Certification Service, with a cover letter that explained:
Unions remain concerned that the current AIR approach to

delegation, as well as the AIR Transformation concept, has some
fundamental flaws due to a lack of data substantiating the arguments
for changes in the FAA’s certification process. Unions are concerned
that deficiencies in the current and planned organization have a high
likelihood of reducing safety. 386
Specialists (PASS) and the American Federation of State, County & Municipal Employees (AFSCME), February 6, 2017.
383 Ibid.
384 Ibid.
385 Ibid.
386 Letter from the National Air Traffic Controllers Association (NATCA), the Professional Aviation Safety Specialists
(PASS) and the American Federation of State, County & Municipal Employees (AFSCME) to Ms. Dorenda Baker,
Director, Aircraft Certification Service, Federal Aviation Administration, regarding “Union Dissenting Opinion report,”
undated. (On file with the Committee).
64
In March 2019, as directed by the FAA Reauthorization Act of 2018 (Act), FAA established
an ODA Office within its Aviation Safety Organization to lead efforts to improve ODA program
performance, standardize application of policy, and ensure consistency in delegation decisions. 387 In
addition, FAA initiated an expert panel of ODA holders, aviation manufacturers, safety experts, and
FAA labor organizations as directed by the Act to survey existing ODAs and make
recommendations to enhance the oversight process and to improve ODA program effectiveness. 388
Boeing Aviation Safety Oversight Office Concerns and Issues
The FAA’s staffing challenges persisted even as delegation authority to ODA holders
expanded. These challenges were particularly evident in the FAA’s largest ODA oversight office,
which is dedicated to overseeing Boeing. In October 2019, the Joint Authorities Technical Review
(JATR) commissioned by the FAA to review the 737 MAX certification process reported that the
Seattle-based Boeing Aviation Safety Oversight Office (BASOO), under the AIR Systems Oversight
Division, was comprised of 45 FAA employees, including 24 total engineers, only 6 of whom were
senior engineers, who oversaw the 1,500 Boeing-designated ODA unit members, or authorized
representatives. 389 The DOT OIG, which released a report on the 737 MAX in June 2020, cited
slightly different numbers regarding the BASOO’s staffing levels. It said the BASOO was comprised
of 42 FAA employees overseeing approximately 1,500 Boeing-designated ODA representatives that
“includes 23 engineers who perform both certification work as well as oversight, 3 inspectors that
perform oversight, and additional project manager engineers and support staff.” 390
Regardless of the specific numbers of BASOO staff, the FAA appears to lack the staffing
levels required to provide effective and comprehensive oversight of the certification of safety-critical
and other components that they have been tasked with overseeing. In recognition of the disparity
between the number of FAA BASOO staff and Boeing ODA unit members, JATR said that:
• “The allocated staffing levels of 24 BASOO engineers may not be sufficient to carry
out the work associated with retained items and with the conduct of oversight
duties.” 391
• “There may be a lack of capacity and depth of experience of BASOO engineering

members to approve and make findings of compliance for retained items.” 392
387 See FAA Reauthorization Act of 2018, Sec. 212, accessed here:
https://www.congress.gov/115/plaws/publ254/PLAW-115publ254.pdf and FAA Response to Questions for the
Record submitted by Chairman DeFazio in reference to the Hearing titled, “The Boeing 737 MAX: Examining the
Federal Aviation Administration’s Oversight of the Aircraft’s Certification,” Committee on Transportation and
Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, p. 243, accessed here:
388 Ibid.
389 “Boeing 737 MAX Flight Control System: Observations, Findings, and Recommendations,” Joint Authorities
Technical Review (JATR), October 11, 2019, p. 27, (Hereafter referred to as “JATR Report”), accessed here:
392 Ibid.
65
• “Depending on the number of entry-level engineers in the BASOO, there could be

an imbalance of working-level engineers in relation to the number of senior
engineers reasonably expected to be required given the complexity of work by
Boeing.” 393
• “The BASOO may not be sufficiently staffed to review all the Boeing programs
(737, 747, 767, 777, and 787). There are two technical staff assigned per Boeing
program. Some of the technical staff are new engineers with limited airworthiness
experience.” 394
• “BASOO engineers [reviewing the 737 MAX] may not have had the technical
insight, due to lack of involvement, to assess compliance.” 395
• “The FAA extensively delegated compliance findings on the B737-8 MAX project to
the Boeing ODA. Safety critical areas, including system safety documents related to
MCAS, were initially retained by the FAA and then delegated to the Boeing
ODA.” 396
• “The FAA initially delegated acceptance of approximately 40% of the B737 MAX
project’s certification plans to the Boeing ODA. Additional certification plans that
were originally retained for acceptance by the FAA were later delegated to the
Boeing ODA as the certification project progressed. While the JATR team did not
conduct an exhaustive review of other ODAs, the team observed that delegating the
acceptance of certification plans does not appear to be a widespread practice for the
FAA.” 397
• “The FAA should identify and implement procedures for increased direct FAA
involvement in safety critical areas of ODA certification projects.” 398
The JATR’s key findings mirror many of the Committee’s own findings regarding
weaknesses in the BASOO’s ability to provide adequate oversight of Boeing and gaps in its
monitoring of certification activities at Boeing that contributed to safety issues on the 737 MAX
aircraft.
As a result of the inadequate number of FAA staff involved, the 737 MAX certification
process was extensively delegated to Boeing. This, combined with poor internal FAA
communication practices, meant that FAA specialists were not sufficiently aware of safety-critical
issues, including many system safety documents related to MCAS. In its report, JATR said that FAA
was unable to independently assess the adequacy of Boeing’s exercise of its ODA with respect to
MCAS, which was a new and novel feature that should have been closely scrutinized. 399 Had FAA
393 Ibid.
394 Ibid.
395 Ibid., p. 28.
396 Ibid., p. 26.
397 Ibid.
398 Ibid.
399 Ibid., pp. VII and 13-14.
66
technical staff been fully aware of the details of MCAS, they would have likely identified the
potential for the system to overpower other flight controls, which was a major contributing factor
leading to the two MAX crashes. 400
In addition, organizational and operational issues further precluded the BASOO’s ability to
fully understand the scale, scope, and complexity of work that had been delegated to Boeing. For
example, JATR found that Boeing internal procedural layers hindered ARs from directly
communicating with BASOO staff. Instead, ARs were allowed to contact the BASOO for technical-
only communication to better understand a documented FAA method of compliance, which JATR
said prevented the “free communication of issues/concerns to the FAA.” 401
Conflicts of Interest
Authorized representatives (ARs) play a critical role in helping to oversee aircraft and
aviation product manufacturers for the FAA under the ODA program. Within the aviation industry,
ARs have been described as the eyes and ears of the FAA. However, while acting on behalf of the
FAA, ARs are still employees of the organization for which they work, receiving their salary,
benefits, and supervision from the entities the FAA is responsible for overseeing. This creates
inherent conflicts-of-interest for the ARs and places them at risk of experiencing undue influence
from their supervisors or other company officials. In the case of the 737 MAX, the Committee’s
investigation revealed that on several occasions involving separate incidents, multiple Boeing-
designated ARs failed to properly inform the FAA of critical information that would have enhanced
the FAA’s knowledge of key issues and may have altered their certification decisions. In these
instances, the ARs exhibited a too-narrow view of compliance requirements that had profound
safety implications.
In establishing the ODA program, the FAA anticipated that a significant number of
individual designees who worked for larger organizations such as Boeing would become members of
an ODA unit and give up their individual designee status. 402 This represented a key change to the
FAA delegation structure. Prior to the establishment of the ODA program, FAA used “designated
engineering representatives” (DERs)—private individuals appointed by the FAA who acted on its
behalf either as company employees or as independent consultants who may have worked for any
client—in performing examinations, inspections, and tests in support of airplane certifications. 403
The DERs who were subsumed into the ODA program faced a significantly altered organizational
and communications structure. 404 DERs regularly coordinate with an FAA point-of-contact who
provides oversight of the designee’s activities. 405 However, under the ODA program, FAA
designates an ODA Holder to act as its representative and allows ODA Holders that have had
significant experience as a delegated organization to appoint ODA unit members with a minimum
400 Ibid., pp. 13-14.

401 Ibid., pp. 28-29.
403 See 14 CFR Part 183.
404 Designated Engineering Representatives (DER), Federal Aviation Administration,
https://www.faa.gov/other_visit/aviation_industry/designees_delegations/individual_designees/der/
405 In addition to designated engineering representatives, FAA also uses individual designees in roles such as pilot
examiners, mechanic examiners, and training center evaluators. For additional information, see “Individual Designees,”
Federal Aviation Administration, accessed here:
https://www.faa.gov/other_visit/aviation_industry/designees_delegations/individual_designees
67
level of FAA involvement. 406 In the case of Boeing, because of its significant experience as a
delegated organization, it appoints and manages the ODA unit comprising its cadre of
approximately 1,500 ARs.
This fundamental change was partly intended to help the FAA more effectively manage its
oversight resources by limiting the number of inquiries FAA technical experts were receiving from
Boeing ARs, for instance. 407 Under the new ODA program, Boeing management and AR Advisors
serve as a buffer between the ARs and FAA technical experts to help funnel information regarding
certification issues to the FAA in a more effective and efficient manner.
While this change relieved FAA of an administrative burden, it limited the interactions
between ARs and FAA staff, which as the JATR report noted, prevented the free communication of
issues and concerns. 408 As a result, these procedural changes have had the unintended and
deleterious effect of hindering the FAA’s oversight of Boeing and may have undermined the FAA’s
ability to be more fully aware of safety issues and concerns that Boeing ARs may have had regarding
the 737 MAX. The JATR report recommended that the FAA review whether engineering unit
members or ARs “are working without any undue
Anonymous FAA Employee pressure when they are making decisions on
FAA Safety Culture Assessment behalf of the FAA. This review should include
(Draft) February 28, 2020 ensuring the [engineering unit members] have
open lines of communication to FAA certification
“IT FEELS LIKE WE ARE engineers without fear of punitive action or
SHOWING UP TO A KNIFE FIGHT process violation.” 409
WITH NERF WEAPONS. IT IS A
To its credit, even before that
CHALLENGE TO BE AN EQUAL recommendation was made, the FAA’s Aviation
MATCH WITH BOEING IN THE Safety Organization (AVS) had initiated a large
MEETINGS/CONVERSATIONS.” scale “safety culture survey” that was conducted
from October 2019 to February 2020. The survey
was conducted by The MITRE Corporation and included all 7,147 AVS members, but only 25
410
percent, or 1,814 individuals, responded. 411 Still, the survey was comprehensive, including 17
interviews with AVS executives and labor leaders and 25 separate focus groups in six separate cities,
including Atlanta, Dallas, Seattle, New York, Boston, and Washington, D.C. 412 On the positive side,
71 percent believe their front-line manager supports safety and 69 percent agreed that they are
comfortable reporting safety issues/concerns. 413

407 Ibid.
408 JATR Report, pp. 28-29.
409 Ibid., p. 26.
410 The MITRE Corporation is an independent, non-profit organization that operates multiple federally-funded research
and development centers, including the Center for Advanced Aviation Systems Development sponsored by the FAA.
“Center for Advanced Aviation System Development,” The MITRE Corporation, accessed here:
https://www.mitre.org/sites/default/files/publications/caasd-03-2015.pdf
412 Ibid.
413 Ibid.
68
However, many of the other survey statistics were disheartening. A full 56 percent of those
who responded in the Aircraft Certification Service (AIR) believed “external pressures (e.g.,
industry) is perceived to get in the way of safety decisions.” 414 Within AVS overall, 52 percent did
not believe they had enough resources and manpower dedicated to safety, 49 percent believed that
safety concerns/incidents will not be addressed so they don’t report them, and 43 percent do not
believe the FAA appropriately delegates certification activities to organizational and individual
designees. 415
The gist of many of the anonymous responses to the survey questions mimicked what the
Committee has heard from numerous whistleblowers over the past 18 months. Among the
responses listed in the survey report:
• “It feels like we are showing up to a knife fight with Nerf weapons. It is a challenge
to be an equal match with Boeing in the meetings/conversations.” 416
• “They [industry] just keep going up the chain until they get the answers they
want.” 417
• “There is no respect for an expert culture that has existed through years of
experience. There is no acknowledgement of recommendations made by experts or
an explanation about why a different decision was made.” 418
• “There is a fallout of us not being able to do our job. Accidents happen and people
get killed.” 419
• “It is common for people to be selected based on managerial skills only regardless of
their technical expertise…they don’t understand the true risks of the decisions they
are making; they are making decisions that they don’t have a clue about.” 420
• “There is the perception that technical skills don’t matter for managers and they are
selected based on their ability to be molded and compliant with upper management’s
direction.” 421
Further, the adoption of an ODA organizational structure exposed Boeing-appointed ARs

to greater risks of undue influence from managers. For example, the JATR reported signs of undue
pressure on ARs who perform delegated functions “which may be attributed to conflicting priorities
and an environment that does not support FAA requirements.” 422 This is consistent with Boeing’s
own internal survey, conducted in 2016, at the height of the 737 MAX’s certification activities and
414 Ibid.
415 Ibid.
416 Ibid.
417 Ibid.
418 Ibid.
419 Ibid.
420 Ibid.
421 Ibid.
69
provided to the Committee from a whistleblower, which found that 39 percent of Boeing ARs that
responded perceived potential “undue pressure” and 29 percent were concerned about
consequences if they reported potential undue pressure. 423 Both Michael Teal, the former Chief
Project Engineer on the 737 MAX program, and Keith Leverkuhn, the former Program Manager of
the 737 MAX program, acknowledged in transcribed interviews with Committee staff that they were
aware of this internal Boeing survey, but dismissed undue pressure as a significant issue. 424
Moreover, some FAA officials believe the new ODA system limits the information they
receive in negative ways and that they are not always provided with a clear or complete view of
issues that could inform and potentially alter their position on certification related issues. According
to a story in The Seattle Times, a former Boeing aviation-safety engineer who worked as a designated
engineering representative under the old designee oversight system and as an AR under the newer
system, indicated that there was a dramatic difference between the implied obligations at the core of
each system. Under the old system, this engineer said “we knew we’d lose our livelihood if we didn’t
maintain the integrity of making decisions the way the FAA would do it. That check is no longer
there.” 425
Similarly, the Committee found in its investigation that the FAA was not able to check key
decisions because ARs never raised issues with the FAA that arguably should have been
communicated to the regulatory body charged with overseeing Boeing’s work. If these issues had
been raised, they may have impacted the FAA’s certification decisions regarding the 737 MAX and
ultimately improved the safety of the airplane. The Committee’s investigation revealed that, in
multiple incidents related to the development and certification of the 737 MAX, the Boeing ARs
that were supposed to serve as the eyes and ears of the FAA on the ground at Boeing, instead left
the FAA largely in the dark about issues that impacted certification, conformity and safety-related
matters. These include the following examples which are described in greater detail in the
“Maneuvering Characteristics Augmentation System (MCAS)” and “AOA Disagree Alert” sections
of this report:
• MCAS Description – In 2013, a Boeing AR approved Boeing’s actions to describe

MCAS externally as an addition to the “speed trim” system as opposed to a “new
function” due to Boeing’s fears that, “If we emphasize MCAS is a new function there
may be a greater certification and training impact.” 426
423 “Undue Pressure: Key Learnings and Next Steps,” Boeing Commercial Airplanes (BCA), November 2016, pp. 144-
151, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf.

424 Committee staff transcribed interview of Michael Teal, former Vice President, Chief Project Engineer and Deputy
Program Manager of the 737 MAX program, Boeing Commercial Airplanes, May 11, 2020; and Committee staff
transcribed interview of Keith Leverkuhn, former Boeing Vice President and General Manager of the 737 MAX
program, Boeing Commercial Airplanes, May 19, 2020.
425 Dominic Gates and Mike Baker, “Engineers say Boeing pushed to limit safety testing in race to certify planes,
including 737 MAX,” Seattle Times, May 5, 2019, accessed here: https://www.seattletimes.com/business/boeing-
aerospace/engineers-say-boeing-pushed-to-limit-safety-testing-in-race-to-certify-planes-including-737-max
426 Internal Boeing email, “PRG – 37MAXFCI-PDR_AI22 – MCAS/Speed Trim,” Sent: June 7, 2013, 9:10 PM,
accessed at p. 93 here:
pdf. This issue is discussed in more depth in the MCAS section. However, in a letter to the Committee on September 3,
2020, Boeing’s Chief Counsel for Regulatory and Legislative Affairs, wrote that the 2013 meeting about MCAS showed
that the Boeing participants agreed “’on keeping MCAS nomenclature.’” “The item was then closed,” he wrote. “In
other words, after reviewing the issue, the team recommended, and their manager agreed, to continue to refer to MCAS
70
• MCAS Repetitive Activation – In 2016, a Boeing AR questioned the ability of MCAS

to activate repeatedly and its impact on 737 MAX pilots to counteract MCAS’s response
after a Boeing test pilot had trouble “trimming” the aircraft due to MCAS’s repetitive
activation during a test flight. 427 The concern was reviewed by Boeing. It determined
there was “No real requirement violation,” although Boeing did make minor adjustments
to MCAS in response. The AR’s concerns were never shared with the FAA. 428
• MCAS Functional Hazard Assessment – From 2015 to 2018, multiple Boeing ARs
failed to inform the FAA that Boeing had discovered early on in the MAX program that
it took one of its own test pilots more than 10 seconds to respond to an uncommanded
activation of MCAS in a flight simulator, a condition the pilot found to be
“catastrophic[.]” 429 This should have called into question Boeing’s assumptions about
pilot response times. It did not. Multiple Boeing ARs were aware of this critical Boeing
test data and never shared it with the FAA, because there was no specific requirement to
do so.
• AOA Disagree Alert – In 2017, a Boeing AR failed to inform the FAA that the AOA
Disagree Alert feature on a majority of the 737 MAX fleet were inoperative and that
Boeing was aware of this condition. Moreover, Boeing continued to manufacture and
deliver airplanes with the nonfunctioning alert to customers without informing them or
the FAA that the alert was not operating. Although this feature was not a “safety critical”
component, it was still required to be functional on all 737 MAX delivered aircraft in
order to conform to the aircraft’s FAA type certification requirements. 430
These four incidents illustrate an ODA system that failed to inform the FAA of important
information the agency should have been made aware of and, in most cases, exposed the flying
public to potential safety dangers.
In another case, a Boeing AR raised a concern about the impact of erroneous AOA data on
MCAS, but his query was largely dismissed by his Boeing colleagues, and the concern about this
issue was not shared with the FAA. While there is no specific requirement for ARs to report
concerns to the FAA, their potential to do so was further precluded from being shared with the
FAA in the cases cited above when their Boeing colleagues explained away the concerns. If there
had been more fluid and frequent communication between Boeing’s ARs and FAA officials in the
BASOO and other FAA offices overseeing the certification of the 737 MAX, knowledge of these
by that name.” The letter neglected to cite the rest of this record which indicated Boeing would “continue using the
acronym MCAS” internally, however, “[e]xternally we would communicate it is an addition to Speed Trim.”
427 Boeing internal email, “Subject: S&C Brief Summary: 1A001, Test 009-25 6/13/16 [BLOCK 2],” Monday, June 13,
2016, 6:17 PM, BATES Number TBC-T&I246488 – TBC-T&I246493. (On file with the Committee).
428 Boeing internal email, “Subject: RE: Discussion of MCAS Characteristics,” Wednesday, June 22, 2016 1:59 PM,
BATES Number TBC T&I 292457-29258. (On file with the Committee).
B-BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision D, March 30, 2016, accessed at p. 164 here:
https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf and Email from Boeing
counsel to T&I Committee Staff, “Subject: proposed email searches,” Sent: Monday, February 10, 2020, 10:42 PM. (On
file with the Committee).
of functional AOA Disagree alerts on all Boeing 737 MAX aircraft, July 11, 2019. (On file with the Committee).
71
issues by the FAA may have dramatically improved safety of the airplane and enhanced FAA’s
certification scrutiny of the MAX.
Boeing’s ARs are supposed to represent the interests of the FAA and not the company.
While the FAA can impose consequences on ARs that fail in their duties, the Committee’s
investigation has shown that in addition to punitive threats, it is critical for the FAA to also establish
a structure that emboldens ARs to willingly report issues of concern or worries about technical
design shortcomings to the FAA. If there had been a clear communications vehicle for Boeing’s
ARs who had concerns about the 737 MAX program to go directly to the FAA and they were
encouraged to do so, it may have dramatically improved the FAA’s oversight of the program and the
ultimate safety of the aircraft.
In situations that warrant the revocation of an AR’s designee status, the FAA Administrator
may remove a designee if the person “has not properly performed [his or her] duties under the
designation.” 431 Details regarding these removal procedures are laid out in the ODA procedures
order. 432 However, designees seldom have their status revoked, which can be a difficult and long
process.
In one case, it took more than three years from when the FAA became concerned about the
work of a DER in 1997 to when it decided to decline the designee’s renewal request, effective
January 1, 2001, after the agency found that the designee had exceeded his authorization in
approving repairs on an aircraft and performed poor quality work in other instances. 433 In another
case, in February 2003, the U.S. Court of Appeals, District of Columbia Circuit, ruled in favor of the
FAA three years after the agency’s decision to deny a designee’s renewal based on actions the
designee made to approve engineering data, find compliance with FAA regulations outside his
delegated authority, and perform work on aircraft outside the United States without obtaining
authorization from the certification office. 434 In a third example, in June 2014, the same court upheld
FAA’s action 18 months earlier to terminate the appointment of a designated pilot examiner after an
FAA investigation found he had given test applicants the answers on tests, accepted incorrect
answers, failed to cover mandatory subjects, and failed to test mandatory maneuvers during test
rides. 435 Removing designees, as happened in these cases, however, is very rare.
431 See 14 CFR 183.15, “Duration of certificates,” Federal Aviation Administration, accessed here:
https://www.govinfo.gov/app/details/CFR-2003-title14-vol3/CFR-2003-title14-vol3-sec183-15
432 “Organization Designation Authorization Procedures,” National Policy, Order 8100.15, Federal
Aviation Administration (FAA), Department of Transportation (DOT), June 15, 2018, accessed here:
https://rgl.faa.gov/regulatory_and_guidance_library/rgorders.nsf/0/f8e0e1795804a25086257b6d005db348/$FILE/81
00.15B_CHG3_Incorporated.pdf
433 Randy Steenholdt, Petitioner, vs. Federal Aviation Administration, Respondent. No. 01-1331, 314 F. 3d 633, United
States Court of Appeals, District of Columbia, Circuit Court, Argued: October 7, 2002, Decided: January 10, 2003,
accessed here:
https://scholar.google.com/scholar_case?case=3215188119166900298&q=Randy+Steenholdt,+Petitioner,+vs.+Federa
l+Aviation+Administration,+Respondent.+No.+01-1331,+&hl=en&as_sdt=20006
434 Carlos Lopez, Petitioner, vs. Federal Aviation Administration, Respondent. No. 01-1427, 318 F. 3d 242, United States
Court of Appeals, District of Columbia, Circuit Court, February 11, 2003, Rehearing Denied March 5, 2003, accessed
here:
https://scholar.google.com/scholar_case?case=10150991282292631381&q=%22carlos+lopez%22+AND+FAA&hl=e
n&as_sdt=20006
435 Joseph F. Sheble, III, Petitioner v. Michael P. Huerta, et al., Respondents. No. 13-1136, 755 F. 3d 954, United States
Court of Appeals, District of Columbia, Circuit Court, Argued: January 9, 2014, Decided: June 24, 2014, accessed here:
72
Taking steps to better train ARs, significantly enhance FAA oversight of Boeing’s ODA
designees, and enable the FAA to take swift action when it is clear an AR is serving the interests of
the ODA Holder and not the interests of the FAA would help dramatically improve oversight of the
ODA program and the safety of the flying public. In addition, avenues for ARs to share concerns
they may have about technical design features or the path of a specific aircraft program must be
expanded and improved to help encourage ARs to report these issues to the Federal regulatory
agency that is tasked with overseeing Boeing and ensuring that the aircraft it certifies are safe.
Certification Process Affected by Mismanaged Communications
The Committee’s investigation found that fragmented communication between Boeing and
the FAA, as well as among FAA’s own internal offices, hindered the exchange of information. In
July 2017, for instance, a member of the FAA’s BASOO sent an email to colleagues in the FAA’s
Aircraft Evaluation Group (AEG) that referenced an Airplane Assessment Report (AAR) on the
737 MAX. The author of the email wrote, “It was the intent to coordinate all changes to the
approved validation plan task list with the FAA-AEG office, however due to schedule/availability
disconnects a small number of changes were not formally coordinated.” 436 In some cases,
coordination was not simply delayed but never actually occurred. This lack of clear and consistent
coordination on key issues regarding the certification of the 737 MAX had significant consequences
depriving essential FAA experts of information that may have altered some of their decisions
regarding the certification of the 737 MAX.
Most notably, the certification of MCAS illustrates how fragmented communications

resulted in information gaps within the FAA concerning this critical system. These information gaps
precluded key FAA employees from developing a full understanding of MCAS, its operational
performance characteristics, and the safety risks it presented. Furthermore, Boeing failed to
communicate fundamental information to all of the FAA offices that should have been aware of key
data related to the certification of the 737 MAX. For example:
• Aircraft Evaluation Group (AEG) – The Seattle AEG was responsible for
coordinating and managing proposed pilot training requirements on the 737 MAX. 437
Boeing requested—and the AEG permitted—the removal of reference to MCAS from
Boeing’s Flight Crew Operations Manual (FCOM) at the time Boeing was re-designing
the system to operate with greater authority. 438 However, the AEG staff remained
unaware of the MCAS re-design until after the crash of Lion Air flight 610.
https://scholar.google.com/scholar_case?case=7646547281908654251&q=sheble+vs.+faa+and+huerta&hl=en&as_sd
t=20006
436 FAA internal email, “Subject: RE: 737-8 ETOPS Airplane Assessment Report (AAR),” July 12, 2017, 9:38 a.m.,
BATES Number, FAA-T&I 00041270-41271 (On file with the Committee).

437 The AEG is part of the Aircraft Evaluation Division which helps to coordinate and assist with aircraft certification
and continued airworthiness programs. The AEG also plays a pivotal role establishing and managing the Flight
Standardization Board that determines requirements for pilot type ratings, develops training objectives, and conducts
initial training for both the manufacturer’s pilots and FAA inspectors to ensure initial competency of flight crews. See
“Aircraft Evaluation Division (AED),” Federal Aviation Administration, accessed here:
https://www.faa.gov/about/office_org/field_offices/aed/ and “Flight Standardization Board (FSB),” Federal Aviation
Administration, accessed here: https://www.faa.gov/aircraft/air_cert/airworthiness_certification/fsb
438 The AEG uses the FSB report as the basis for the approval of pilot training and qualification necessary for the
operation of aircraft. See “Subject: Guidance for Conducting and Use of Flight Standardization Board Evaluations,”
73
• Boeing Aviation Safety Oversight Office (BASOO) – The BASOO had delegated to
Boeing the certification actions that pertained to MCAS; however, Boeing failed to
update the affected certification plans and notify the BASOO when it re-designed MCAS
in March 2016. 439 As a result, the BASOO employees that should have been informed of
this significant change by Boeing did not learn of it until after the Lion Air crash. 440
• Aircraft Certification Office (ACO) – FAA test pilots in the Seattle ACO supported
the 737 MAX’s certification by ensuring through test flight procedures that the airplane
complied with regulations concerning its handling. The ACO worked with Boeing’s test
pilots to develop flight test certification plans and approved reports that documented the
performance of the 737 MAX during flight tests. 441 ACO staff were aware of the MCAS
re-design that occurred in 2016 because it affected tests that they participated in, but they
failed to share information about the re-design of MCAS with other FAA offices. 442
Collectively, the MCAS re-design illustrates a situation where knowledge of the change
existed in at least one FAA office but not others, and where effective information exchanges
between offices did not occur. Boeing’s failure to more fully communicate information about the
system’s re-design compounded the problem with siloed information. As the JATR observed,
fragmented communications made it more challenging for the FAA to recognize the impacts and
implications that MCAS posed to the airplane and to 737 MAX pilots. 443 Had the information
pertaining to the MCAS re-design been shared with a greater number of FAA experts, it would have
likely impacted the decisions they made regarding certification of the MAX.
While FAA’s organizational entities are responsible for performing their assigned roles and
not every FAA official can know of everything, the MCAS re-design example shows that FAA
officials could have and should have been more cognizant of critical issues affecting the certification
of the 737 MAX. The lack of a centralized FAA authority overseeing the entire 737 MAX
certification process contributed to the communication lapses that ultimately affected safety and
played a significant role in the 737 MAX crashes.
Advisory Circular, AC No: 120-53B, Federal Aviation Administration (FAA), Department of Transportation (DOT),
October 24, 2016, accessed here:
https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_120-53B_Chg_1.pdf. The AEG does not
technically approve the FCOM; however, it is customarily involved in its review as the FCOM may be referenced in
training materials. As related to the AEG permitting the removal of references to MCAS in the FCOM, see: Email from
737 Chief Technical Pilot to FAA, “Subject: MCAS lives in both FCCs,” Sent: Wednesday, March 30, 2016, 11:16:45.
441 See Flight Test Certification Report, Airplane Model 737-8, Title: 737-8 Control System Malfunctions, Boeing Test &
Evaluation, Seattle, Washington, August 21, 2017, TBC-T&I056097, 056102-056104, 056107-056108, and 056123.
442 “Response to Question 7 and Related Questions,” (Informally referred to as the “Boeing MCAS Narrative”), The
Boeing Company, response to the Committee on Transportation and Infrastructure, BATES Number TBC T&I
372821-372832 at TBC T&I 372825 (On file with the Committee), and Committee staff transcribed interview of Michael
Teal, former Vice President, Chief Project Engineer and Deputy Program Manager of the 737 MAX program, Boeing
Commercial Airplanes, May 11, 2020.
443 JATR, p. 13.
74
This negligent breakdown in communications did not start and stop at the FAA’s door,
however. One Boeing AR graphically described disjointed communications and varied
interpretations of FAA policies and procedures among different Boeing technical groups involved in
the 737 MAX program. In a February 2016 email, this AR included references to Type Inspection
Authorization (TIA) procedures used to authorize “official conformity, airworthiness inspections,
and flight tests necessary to fulfill certain
requirements” for aircraft type certifications. 444 The Boeing Authorized Representative
AR observed that some Boeing groups provided (AR) Internal Email
great detail on their plans for progressing through February 25, 2016
testing to eventual certification while other groups
provided no detail at all. 445 As a result of these
“[T]HERE IS NO CONFIDENCE
differences, the FAA lacked sufficient basis for
understanding what ARs were approving and had an THAT THE FAA IS
overall incomplete picture of key certification plans. UNDERSTANDING WHAT
“Thus there is no confidence that the FAA is THEY ARE ACCEPTING (OR
understanding what they are accepting (or rejecting),” REJECTING).”
the AR wrote. “No confidence in how to interpret
what is acceptable and not acceptable for post TIA configuration changes and thus no confidence
that ARs are doing the right thing in ‘concurring.’” The AR described the situation as a “crisis in
confidence,” clearly expressing worry about what ARs were agreeing to or concurring with in regard
to Boeing’s actions. 446
History of FAA Bias Favoring Boeing
Aside from issues specifically revolving around the ODA system, the Committee has
discovered multiple cases where FAA’s senior leaders have made certification decisions that were
biased towards Boeing’s own business interests and that undermined the safety concerns of the
FAA’s own experts. The FAA’s own internal survey of Aviation Safety (AVS) staff documented
widespread and similar concerns. According to the survey results, “Many believe that AVS senior
leaders are overly concerned with achieving the business-oriented outcomes of industry stakeholders
and are not held accountable for safety-related decisions.” 447 It also found that, “Employees and
managers reported that external pressure from industry is strong and is impacting the AVS safety
culture.” 448 The Committee’s own investigation was made aware of several examples of such
decisions by FAA that illustrate this bias. These examples go beyond the 737 MAX program and
have affected other Boeing programs as well.
444 See “Type Inspection Authorization, FAA Form 8110-1,” Federal Aviation Administration (FAA), Department of
Transportation (DOT), accessed here:
https://www.faa.gov/other_visit/aviation_industry/designees_delegations/resources/forms/media/FAA_Form_8110-
1.pdf. The TIA is an internal FAA document that authorizes the ACO employees to begin the test program, usually the
flight test portion. Official FAA flight testing begins only after the FAA issues a TIA. However, the applicant conducts
the tests and inspections to demonstrate that the test article to be submitted for FAA certification ground and flight tests
meets the minimum requirements for quality, conforms to the design data, and is safe for the planned tests.
445 Internal Boeing email, “Subject: RE: For 2pm,” Sent: February 25, 2016, 7:57:28 AM, accessed at p. 89 here:
pdf
446 Ibid.
448 Ibid.
75
787 Dreamliner Lithium Batteries
In 2011, Boeing’s 787 Dreamliner was certified by the FAA 449 and entered commercial
revenue service that same year. 450 The airplane incorporated many advanced technologies such as
fuel-efficient engines, a body fabricated primarily from composite materials, and lithium batteries in
its electrical system. 451 However, these lithium batteries had a history of being significantly more
susceptible to fire than other types of batteries. 452 The risk of transporting lithium batteries on cargo
airplanes was known prior to the 787 Dreamliner’s certification. A 2011 FAA analysis that examined
five cargo fires on U.S. registered airplanes from 1973 through 2010 predicted that as many as 4 to 5
additional cargo fires involving lithium batteries could occur by 2020. 453 Separately, in 2006, a
lithium battery exploded at the Tucson, Arizona, site of Securaplane Technologies, Inc., burning the
facility to the ground. 454 Securaplane is one of the Boeing suppliers of the charging system for the
Dreamliner’s lithium batteries—the system that was being tested when the battery fire occurred. 455
To ensure the safety of the 787 Dreamliner, its passengers, and crew, Boeing and the FAA
established design protections to prevent the batteries from overcharging and to reduce the risk of
fire. 456 Further, in 2007 the FAA set nine “special conditions” for the containment or venting of any
hazardous materials that Boeing was required to meet related to the installation of lithium batteries
on the 787 Dreamliner because regulations concerning use of lithium batteries did not exist. 457
Despite that, in the first few weeks of January 2013, two lithium battery incidents involving fire and
smoke from the batteries occurred on separate 787 Dreamliners. 458 This led the FAA to ground all
787 Dreamliner airplanes on January 16, 2013. 459
449 “Boeing 787 Dreamliner Receives FAA, EASA Certification,” Boeing Press Release, August 26, 2011, accessed here:
https://boeing.mediaroom.com/2011-08-26-Boeing-787-Dreamliner-Receives-FAA-EASA-Certification
450 “Boeing, ANA Complete Contractual Delivery of First 787 Dreamliner,” Boeing Press Release, September 25, 2011,
accessed here: https://boeing.mediaroom.com/2011-09-25-Boeing-ANA-Complete-Contractual-Delivery-of-First-787-

Dreamliner
451 Lithium-ion batteries weigh less than the nickel-cadmium batteries that had been traditionally used on board
airplanes. Batteries on airplanes are used pre-flight for purposes such as powering the flight control computer and
starting the engines. See Thom Patterson, “Dreamliner battery probe ends: 8 questions and answers,” CNN, December
12, 2014, accessed here: https://www.cnn.com/travel/article/boeing-787-dreamliner-investigation-report/index.html
452 Alwyn Scott and Mari Saito, “Boeing 787 battery woes put FAA approval under scrutiny,” Reuters, January 22, 2013,
accessed here: https://www.reuters.com/article/us-boeing-787-faa/insight-boeing-787-battery-woes-put-faa-approval-

under-scrutiny-idUSBRE90M04620130123
453 “Freighter Airplane Cargo Fire Risk Model,” DOT/FAA/AR-11/18, Federal Aviation Administration (FAA),
Department of Transportation (DOT), September 2011, accessed here: https://www.fire.tc.faa.gov/pdf/11-18.pdf; and

“2011 FAA Fire Safety Highlights,” Federal Aviation Administration, Undated, accessed here:
https://www.fire.tc.faa.gov/pdf/2011Highlights.pdf
454 Bob Brewin, “A 2006 battery fire destroyed Boeing 787 supplier’s facility,” Nextgov, January 22, 2013, accessed here:
https://www.nextgov.com/emerging-tech/2013/01/2006-battery-fire-destroyed-boeing-787-suppliers-facility/60809
455 Carli Brosseau, “NTSB to test 787's charger system here: Its maker, Securaplane, and US officials meet today in
safety inquiry,” Arizona Daily Star, January 22, 2013, accessed here: https://tucson.com/business/local/ntsb-to-test-s-
charger-system-here/article_37204df6-1064-59d5-9855-651a4b9d7e1b.html
456 Alwyn Scott and Mari Saito, “Boeing 787 battery woes put FAA approval under scrutiny,” Reuters, January 22, 2013,
accessed here: https://www.reuters.com/article/us-boeing-787-faa/insight-boeing-787-battery-woes-put-faa-approval-

under-scrutiny-idUSBRE90M04620130123
457 Ibid.
458 “FAA Statement on Grounding of 787 Dreamliner Fleet,” Press Release, Federal Aviation Administration, January
16, 2013, accessed here: https://www.faa.gov/news/press_releases/news_story.cfm?newsId=14233

459 Ibid.
76
“We were focused on the hazards of the battery,” explained Ali Bahrami, then Director of the
FAA’s Transport Airplanes Directorate that was in charge of the 787 Dreamliner’s certification, at
an April 2013 National Transportation Safety Board (NTSB) hearing describing how the batteries
were approved for use on the then-grounded airplane. “We knew the hazards were always there. The
awareness was always there. We did the best we could under the circumstances, and the knowledge
that existed then, to come up with standards that address the requirements for this particular
battery.” 460 At the same hearing, Mike Sinnett, Boeing’s chief engineer on the 787 Dreamliner, said
that the airplane’s certification by the FAA took 200,000 hours and was the most “extensive in our
company’s history,” adding that the battery’s certification was “very rigorous and subject to close
scrutiny by the FAA.” 461
But in November 2014, the NTSB released the results of its final report on the 787
Dreamliner’s lithium battery fires and indicated numerous problems with Boeing’s design and testing
and with FAA’s oversight of Boeing. 462 Problems that the NTSB identified included “insufficient
guidance for manufacturers to use in determining and justifying key assumptions in safety
assessments,” and insufficient guidance for FAA “certification engineers to use during the type
certification process to ensure compliance with applicable” FAA requirements. 463 The NTSB also
identified inadequate FAA oversight, a failure by both FAA and Boeing to identify critical
deficiencies, and flawed assumptions by Boeing. 464 These same problems were plainly evident on the
development and certification of the 737 MAX as well.
The battery issues and subsequent grounding of the 787 Dreamliner may have been avoided
had FAA officials acted on the recommendation of one of its own engineers who reviewed the
design of the batteries as part of the airplane’s certification. In testimony to the Committee in
December 2019, G. Michael Collins, a former FAA engineer with three decades of experience at the
agency, who had knowledge of the Dreamliner’s battery issues, said that during the airplane’s
certification process, an FAA engineer had proposed the use of a steel container to enclose the
lithium batteries and prevent an uncontrolled fire should the batteries ignite. 465 However, Mr. Collins
said FAA managers did not support the engineer’s proposal and left the certification decision about
the batteries’ installation to be made by the Boeing ODA instead. The ODA ultimately decided that
installing the batteries free of an enclosure would comply with the special conditions that had been
established for use of lithium batteries. It was only after the grounding of the Dreamliner as a result
of the extremely dangerous battery fires that the FAA mandated use of a steel container vented to
the outside of the airplane—as originally recommended by its own engineer. 466
460 Matthew L. Wald and Jad Mouawad, “Boeing Acknowledges Tests Underestimated 787 Battery Risks,” New York
Times, April 23, 2013, accessed here: https://www.nytimes.com/2013/04/24/business/safety-board-examines-787-

battery-approval.html
461 Ibid.
462 “Aircraft Incident Report: Auxiliary Power Unit Battery Fire, Japan Airlines Boeing 787-8, JA829J,” Boston
Massachusetts, January 7, 2013, NTSB/AIR-14/01, National Transportation Safety Board, November 21, 2014,
accessed here: https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR1401.pdf
463 Ibid. p. ix.
464 Ibid. pp. viii, x, and 70.
465 Prepared Statement of G. Michael Collins, Former Aerospace Engineer, Federal Aviation Administration, Hearing
titled, “The Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight of the Aircraft’s
Certification,” Committee on Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First
Session, December 11, 2019, accessed here: https://transportation.house.gov/committee-activity/hearings/the-boeing-
737-max-examining-the-federal-aviation-administrations-oversight-of-the-aircrafts-certification
466 Ibid.
77
In the case involving new lithium batteries on the 787 Dreamliner, as well as in the case of
MCAS on the 737 MAX, the FAA and Boeing downplayed, ignored, or did not adequately
understand or address the safety issues presented
Anonymous FAA Employee by these new features during the development and
FAA Safety Culture Assessment certification of those airplanes. Neither the lithium
Report (Draft) February 28, 2020 batteries nor MCAS were considered ‘safety critical’
systems and yet they led to safety incidents on the
“THERE IS NO RESPECT FOR AN 787 Dreamliner and two fatal accidents of the 737
EXPERT CULTURE THAT HAS MAX aircraft. As reported by CNN in its analysis
EXISTED THROUGH YEARS OF of NTSB’s November 2014 report on the 787
Dreamliner battery incidents, “any new piece of
EXPERIENCE. THERE IS NO
equipment can pose dangerous problems, even a
ACKNOWLEDGEMENT OF noncritical piece of equipment like batteries.” 467 The
RECOMMENDATIONS MADE BY combination of problems, identified by the NTSB
EXPERTS OR AN EXPLANATION in the 787 Dreamliner battery incidents and the
ABOUT WHY A DIFFERENT issues identified by the Committee’s investigation of
DECISION WAS MADE.” the 737 MAX crashes, points to the need for
fundamental changes to strengthen FAA’s oversight
of manufacturers so that critical safety deficiencies can be better identified and flawed assumptions
biased toward industry interests can be avoided.
737 MAX Rudder Cable
During the design of the 737 MAX, FAA bias toward Boeing was also shown in the
handling of technical concerns regarding the airplane’s rudder cable design. Federal regulation
requires design precautions be taken to minimize risks posed by uncontained engine failures, events
in which fragments from the damaged engine can penetrate parts of the airplane and cause
additional damage to its fuselage, fuel tanks, and other systems. 468 These requirements are based on a
history of related incidents and the resultant inability of pilots to safely control the impacted
airplanes. For example, on July 18, 1989, a McDonnell Douglas DC-10 operating United Airlines
flight 232, en-route from Denver to Chicago, attempted to make an emergency landing in Sioux
City, Iowa, after the airplane suffered an uncontained failure of its tail engine in which engine
fragments severed the hydraulic lines used to move the rudder and other control surfaces on the
plane’s aft stabilizer. 469 The flight crew’s ability to control the airplane was severely impaired as a
result of this damage, and it crash landed at the Sioux City Gateway Airport killing 112 people.
Miraculously 184 others survived. 470
467 Thom Patterson, “Dreamliner battery probe ends: 8 questions and answers,” CNN, December 12, 2014, accessed
here: https://www.cnn.com/travel/article/boeing-787-dreamliner-investigation-report/index.html and “NTSB

Recommends Process Improvements for Certifying Lithium-ion Batteries as it Concludes its Investigation of the 787
Boston Battery Fire Incident,” National Transportation Safety Board (NTSB), December 1, 2014, accessed here:
https://www.ntsb.gov/news/press-releases/Pages/PR20141201.aspx
468 14 C.F.R. § 25.903(d)(1).
469 Katie Peikes, “30 Years Since Flight 232 Crash-Landed In Sioux City,” Iowa Public Radio, July 19, 2019, accessed here:
https://www.iowapublicradio.org/post/30-years-flight-232-crash-landed-sioux-city#stream/0
470 Gary Washburn, “Simulator Pilot Says DC-10 Had No Chance,” Chicago Tribune, November 1, 1989, accessed here:
https://www.chicagotribune.com/news/ct-xpm-1989-11-01-8901270267-story.html
78
In 1997, mindful of the 1989 crash in which fragments from the DC-10’s exploded engine
shred the airplane’s hydraulic lines and disabled the rudder controls, the FAA issued an Advisory
Circular that recommended design precautions be taken to minimize risks posed by uncontained
engine failures. 471 These issues were further clarified in the Code of Federal Regulations, which
mandated “[d]esign precautions must be taken to minimize the hazards to the airplane in the event
of an engine rotor failure or of a fire originating within the engine which burns through the engine
case.” 472 Further, also in 1997, when FAA was considering the safety of the rudder cable on the 737
NG, it promulgated an issue paper that concluded:
Boeing should be aware that further increase in thrust, introduction

of new engines, or changes to the structure or flight control system
will necessitate a review of the FAA position and the requirements
for redundancy and separation in the flight control systems. In
anticipation of a long life for the new Model 737 derivative airplanes
and the potential for changes, in particular growth in engine power or
new engines, the FAA believes greater redundancy and separation in
the design of the flight control systems in the vicinity of the rotor
burst zone should be incorporated, although such improvements are
not required at this time. In addition, it should be noted that for
future certification programs, a greater level of minimization would
be expected for a new type certificated aircraft. 473
Despite that, three decades after the DC-10 crash, senior FAA management overruled both
the professional judgement of a large group of FAA technical specialists and the recommendations
of a safety review panel to permit the 737 MAX to be certified despite a design vulnerability that
exposed the airplane’s rudder cable to damage during an uncontained engine failure.
Chair DeFazio and Subcommittee on Aviation Chair Larsen expressed their ongoing
concerns about the 737 rudder cable issue in a November 2019 letter they sent to the FAA. 474 These
concerns stemmed from FAA’s action in 2016 to offer Boeing a chance to establish compliance with
the regulation to minimize the hazards to the airplane from uncontained engine failure without
implementing a design change. At least six FAA specialists refused to concur with the issue paper
that described the proposed method of compliance resulting in the empanelment of an oversight
board in accordance with FAA’s safety review process. 475
471 “Design Considerations for Minimizing Hazards Caused by Uncontained Turbine Engine and Auxiliary Power Unit
Rotor Failure,” Advisory Circular 20-128A, Federal Aviation Administration, Department of Transportation, March 25,
1997, accessed here: https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_20-128A.pdf
472 14 C.F.R. § 25.903(d)(1) – “Engines,” Federal Aviation Administration, Department of Transportation, accessed here:
https://www.govinfo.gov/app/details/CFR-2011-title14-vol1/CFR-2011-title14-vol1-sec25-903
473 “Issue Paper,” Project: Boeing Commercial Airplane Group 737-600/-700/-800 AT0328SE-T, Subject: Engine Rotor
Non-Containment and Critical Flight Controls, March 21, 1997, accessed at pp. 157-161 at p. 161 here:
474 Letter from Chair DeFazio and Subcommittee on Aviation Chair Larsen to FAA Administrator Dickson citing FAA
Issue Paper: Engine Rotor Burst and Rudder Mechanical Flight Control Cables, November 7, 2019, accessed here:
https://transportation.house.gov/imo/media/doc/DeFazio,%20Larsen%20Letter%20to%20FAA%20re%20rudder%2
0cables,%20lightning%20covers.pdf
475 Ibid. See also: “Issue Paper of March 21, 2016, on rudder cable – FAA-DeFazio 28872-28888” in Hearing before the
Committee on Transportation & Infrastructure, U.S. House of Representatives, 116th Congress, First Session, October
79
In his December 2019 testimony to the Committee, Mr. Collins, the former FAA engineer
who was one of four members of the oversight board, further described the review process. 476 Due
to the technical nature of the issue, Mr. Collins explained that the oversight board convened an
expert panel comprised of four additional FAA engineers and two FAA managers to investigate
whether the 737 MAX’s design was compliant with the requirement to minimize the hazards from
an uncontained engine failure. 477
In January 2017, the expert panel determined that the method of compliance offered by
FAA management in its issue paper did not meet the minimum level of safety required by the
regulations. 478 The oversight board concurred with the panel’s recommendation and forwarded the
panel’s report to FAA’s Aircraft Certification Service (AIR) for the responsible manager to decide
on the outcome of the issue. Ultimately, the AIR manager responded that the deciding authority had
considered the board’s recommendations but determined that all rules, orders, and procedures had
been followed with regards to the airplane’s certification. 479 This effectively closed the issue with
FAA finding that the airplane was compliant with the requirement to minimize the risk of
uncontained engine failure, despite the fact that a group of at least 18 FAA officials, including 13
FAA technical experts, four FAA managers and one FAA pilot had all recommended otherwise. 480
FAA management has the right to overrule the Agency’s technical experts. This does
happen. However, FAA management overruling 18 of its own technical experts without a
substantive and persuasive rebuttal to their concerns is extraordinarily unusual and highly troubling.
In his testimony to the Committee, Mr. Collins recounted how during his early years at the
FAA, he experienced a much different safety culture where managers and designated engineering
representatives worked collaboratively with an applicant to resolve design deficiencies. 481 More
recently, according to Mr. Collins, FAA’s safety culture has been negatively transformed. Today,
FAA’s management has permitted manufacturers to produce airplanes that do not comply with
safety standards, according to Mr. Collins. This has jeopardized aviation safety and demoralized
FAA’s critically important technical workforce that has strongly opposed those decisions. 482
30, 2019, pp. 241 – 257, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-

116hhrg38282.pdf
737-max-examining-the-federal-aviation-administrations-oversight-of-the-aircrafts-certification; see also “Safety Review
Program Findings and Recommendations – FAA-DeFazio 28922-28937” in Hearing before the Committee on
Transportation & Infrastructure, U.S. House of Representatives, 116th Congress, First Session, October 30, 2019, pp.
258 - 273, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-
116hhrg38282.pdf
477 Ibid.
478 Ibid.
479 Ibid.
480 Ibid.
737-max-examining-the-federal-aviation-administrations-oversight-of-the-aircrafts-certification
482 Ibid.
80
787 Dreamliner Lightning Protection
In addition to the safety hazard presented by an uncontained engine failure on the 737
MAX, the 787 Dreamliner was exposed to greater risk when FAA management sided with Boeing
over the advice of its technical experts in the case of its
FAA Employee fuel tank lightning protection.
Internal FAA Email
June 14, 2019 Because the 787 Dreamliner consists of more
than 50 percent carbon fiber composites that are not
“THIS IS CLEARLY A inherently conductive, it is at greater risk to damage
CONTENTIOUS ISSUE AND from lightning strikes compared to other aircraft. 483 To
mitigate this risk, Boeing designed and initially
BOEING IS RUSHING THE
produced aircraft with copper foil on a portion of the
CERTIFICATION SO THEY wing. The foil served to rapidly dissipate excessive
CAN DELIVER AIPLANES.” electric current and heat from a lightning strike to help
prevent the fuel contained within the airplane’s wings from potentially igniting. However, in late
2018, Boeing decided that the foil was not needed and eliminated its use in production. 484
In particular, as part of its investigation, the Committee learned that Boeing removed the
protective foil on an estimated 40 ‘wing sets’ on the 787 Dreamliner before seeking or receiving
FAA approval. 485 On February 22, 2019, FAA’s BASOO formally rejected Boeing’s design change
based on experts’ concerns that removing the copper foil on the wings created a greater risk of fuel
tank ignition. 486 However, Boeing appealed this decision. Exactly one week later, on March 1, 2019,
FAA management overturned the BASOO’s decision and allowed Boeing to continue producing the
787 Dreamliner without the copper foil to the dismay of FAA’s technical experts. 487 In short,
following Boeing’s appeal, the FAA reversed its decision, rejecting the safety concerns of its own
technical experts.
The issue, however, continued to concern FAA technical experts even after the FAA’s
official ruling. As one FAA expert wrote in an email on June 14, 2019, to seven of his colleagues,
“This is clearly a contentious issue and Boeing is rushing the certification so they can deliver
483 Jennifer Segui, "Protecting Aircraft Composites from Lightning Strike Damage," COMSOL Blog, June 11, 2015,
accessed here: https://www.comsol.com/blogs/protecting-aircraft-composites-from-lightning-strike-damage
484 Internal FAA email, “Subject: RE: Cu Foil Removal from 787 composite wings- Making it hard for us to do our job!”
Sent: January 31, 2019, 4:03:00 PM (On file with the Committee).
485 FAA Memorandum, “Subject: Article 65 Difference in Professional Opinion, Removal of lighting protection features
(Copper Foil and Dielectric Cap) From 787 Fuel Tanks,” April 2, 2019 (On file with the Committee), and Dominic
Gates, “FAA engineers objected to Boeing’s removal of some 787 lightning protection measures,” The Seattle Times,
December 10, 2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/faa-engineers-objected-
to-boeings-removal-of-some-787-lightning-protection-measures
486 FAA letter to Boeing, “Subject: The Boeing Company (TBC) Regulatory Administration (RA) Project Number PS16-
0765, “Recommend Approval of 787 Fuel Tank Structural Lightning Protection System Safety Assessment,” Deliverable
Number 4 and Deliverable Number 5 for Certification Plan (CP) Number 20595,” Reference 860-19-0120, February 22,
2019, accessed at p. 152 here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-
116hhrg38282.pdf
487 FAA letter to Boeing, “Subject: BASOO and Organization Management Team (OMT) Response to Boeing Appeal
related to Boeing Commercial Airplanes (BCA) Regulatory Administration (RA) Project Number PS16-0765, and 787
Lightning Zone 3 Compliance to Special Condition 25-414-SC,” Reference 860-19-0149, March 1, 2019, accessed at p.
157 here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf
81
airplanes.” 488 In a separate memo to FAA management on June 27, 2019, an FAA employee wrote
of his concerns that FAA management was delegating the System Safety Assessment to Boeing
simply because the FAA could not “support the airplane delivery schedule.” 489 He went on to say, “I
do not agree that delivery schedules should influence our safety decisions and areas of safety critical
findings, nor is this consistent with our safety principles.” 490
He concluded that he believed the FAA was “allowing Boeing to further erode the level of
safety of the airplane without the ability to assess the residual risk.” 491 While none of these altered
787 Dreamliner aircraft were delivered to Boeing’s customers prior to FAA’s approval of the design
change, one FAA official involved in this issue told Committee staff that he believed this was a way
for Boeing to game the system. 492 By the time Boeing alerted the FAA about the changes, it had
proceeded so far into production that it could claim that making a change was untenable in view of a
tight delivery schedule and argue that it would lose millions of dollars if it was forced to scrap the
wing sets it had already produced. As a result, FAA managers were under tremendous pressure to
approve Boeing’s design changes, this FAA official observed. 493
In an interview with Committee staff in December 2019, Ali Bahrami, the FAA’s Associate
Administrator for Aviation Safety, said he was completely unaware of the 787 Dreamliner lightning
protection issues until it was raised with the FAA by the Committee in November 2019. 494 He also
suggested that there was nothing wrong with Boeing making these changes prior to FAA approval,
but that Boeing was at financial risk if the FAA did not approve of Boeing’s redesign. 495 While Mr.
Bahrami pointed out that “manufacturers can produce anything they want,” he clarified that “they
cannot deliver” anything that FAA does not approve. 496 As previously stated however, some FAA
officials believed Boeing was betting on the fact that they would be able to persuade FAA
management to side with them regarding the removal of the 787’s lightning protection features,
which they ultimately did.
While issues of “non-concurrence,” such as with the 737 MAX’s rudder cable and the 787
Dreamliner’s lightning protection, do occur, they are relatively infrequent and are often viewed as a
last-ditch method of raising safety issues that the FAA’s technical staff believe are of significant
importance. FAA managers have the right to overrule their technical staff on these and other safety-
related matters. However, these instances of FAA technical experts being overruled to allow the
production of airplanes that lack arguably important safety features raise serious questions about 1)
how FAA manages safety and 2) how powerful corporations such as Boeing exert influence over
FAA to act in the company’s interests, often at the expense of safety.
488 Internal FAA Email, “Subject: 787 lightning protection,” Sent: Friday, June 14, 2019 7:46 AM. (On file with the
Committee).
489 Internal FAA memorandum of non-concurrence regarding lightning protection requirements on the 787 Dreamliner,
June 27, 2019. (On file with the Committee).

490 Ibid.
491 Ibid.
492 Confidential conversation between Democratic Committee staff with FAA whistleblower, August 29, 2019.
493 Ibid.
494 Committee staff transcribed interview of Ali Bahrami, FAA Associate Administrator for Aviation Safety, December
5, 2019.
495 Ibid.
496 Ibid.
82
Reports of undue influence by Boeing continue to emerge, highlighting attempts to thwart

potential safety measures, appropriate accountability and effective oversight. According to the DOT
OIG, in November 2018 the FAA initiated a formal compliance action against Boeing related to the
ODA program shortly after the Lion Air accident, but unrelated to the accident. 497 These actions
revolved around “undue pressure” by Boeing on ODA unit members. These incidents in and of
themselves are troubling. However, Boeing’s response to the FAA raises additional disturbing issues
regarding Boeing’s efforts to acknowledge and correct its blatant ODA oversight deficiencies.
According to the DOT OIG, which recently released a report on the 737 MAX certification efforts
that mentioned the FAA’s November 2018 compliance action against Boeing:
In subsequent months, Boeing requested three extensions from FAA

before providing its response to the compliance action, including a
corrective action plan. FAA did not accept Boeing’s response to this
compliance action. FAA also issued two separate letters of
investigation in June 2019 and March 2020 against Boeing, related to
potential undue pressure of unit members. FAA did not accept
Boeing’s response to the June 2019 letter of investigation and is
currently evaluating that letter of investigation and the formal
compliance action together. The Agency is still awaiting Boeing’s
response to the more recent March 2020 letter of investigation. 498
Effectiveness of Compliance and Enforcement Actions
The FAA’s administration of the ODA program rests on its ability to implement compliance
and enforcement actions to ensure that designees meet their responsibilities. In June 2015, FAA
announced a new enforcement policy with a more collaborative and problem-solving approach
called the Compliance Program. 499 As a result of this change, FAA has increasingly used compliance
actions, such as counseling or training, rather than enforcement actions, such as civil penalties, to
address violations of safety standards. 500 The Government Accountability Office (GAO) recently
investigated the changes to these policies and their implications for FAA oversight. The GAO
released their evaluation in August 2020 and reported a 90 percent decrease in the number of
enforcement actions undertaken by the FAA’s Aircraft Certification Office from 2012 to 2019. 501
While FAA expects that this new approach will allow it to address the root cause of safety
standard violations upfront, GAO found that the FAA’s tracking of actions is less centralized and
No. AV2020037, June 29, 2020, accessed here:
498 Ibid.
499 Initially known as the Compliance Philosophy, FAA renamed this change to its enforcement and compliance policy
to the Compliance Program in 2018. See FAA Order 8000.373A, “SUBJ: Federal Aviation Administration Compliance
Program,” October 31, 2018, accessed here:
https://www.faa.gov/documentLibrary/media/Order/FAA_Order_8000.373A.pdf
500 “Aviation Safety: Actions Needed to Evaluate Changes to FAA’s Enforcement Policy on Safety Standards,” GAO-
20-642, Government Accountability Office (GAO), August 18, 2020, accessed here:
https://www.gao.gov/assets/710/708877.pdf
501 Ibid., p. 19.
83
takes place more in individual program offices than what had previously occurred when FAA’s
Enforcement Division tracked all administrative and enforcement actions. 502 Importantly, the GAO
found that the FAA “has not taken steps to evaluate if or determine how the program
accomplishes” its goals. 503 “Key considerations for agency enforcement decisions state than an
agency should establish an evaluation plan to determine if its enforcement policy achieves desired
goals. Three of eight FAA offices have started to evaluate the effects of the Compliance Program,
but two offices have not yet started,” according to the GAO. “Three other offices do not plan to do
so—in one case, because FAA has not told the office to,” the GAO wrote. 504
Without a central authority to oversee the Compliance Program’s use across the agency,
GAO concluded that FAA lacks controls to ensure that the program is working as intended. 505 To
remedy this deficiency, GAO recommended that the FAA assign authority to an office to oversee
the Compliance Program across program offices. 506 Such an office would then be able to collect and
analyze data to monitor use of the Compliance Program and to assess the effectiveness of the
program in meeting its goals. 507 The GAO concluded, “[W]ithout an evaluation, FAA will not know
if the Compliance Program is improving safety or having other effects—intended or unintended.” 508
As a regulatory agency, the FAA must be able to effectively regulate Boeing and provide
appropriate—and at times aggressive—oversight of Boeing. The public’s safety depends on it, and
the detailed investigative findings in this report makes that clear. Understanding the FAA’s oversight
structure, as well as the many problems it has recently encountered and the oversight challenges it
still needs to confront, is important to understanding why the U.S. aviation regulatory system failed
in such spectacular fashion with the certification of the 737 MAX aircraft and the FAA’s actions
after the crash of Lion Air flight 610.
502 Ibid., pp. 25-26.

503 Ibid, (“GAO Highlights” page).
504 Ibid., (“GAO Highlights” page).
505 Ibid., p. 34.
506 Ibid.
507 Ibid.
508 Ibid., (“GAO Highlights” page).
84
5. Maneuvering
Characteristics
Augmentation
System (MCAS)
5. Maneuvering Characteristics Augmentation System (MCAS)
-Maneuvering Characteristics Augmentation System (MCAS)-
 Early in the MAX program, in 2013, Boeing intentionally sought to ensure MCAS was not
defined as a new function in order to avoid increased costs and greater certification and pilot
training impact. 509
 Boeing engineers and an Authorized Representative (AR) raised concerns about MCAS
relying on a single AOA sensor in 2015, 510 and the impact to MCAS from erroneous AOA
data 511 and a pilot’s ability to counteract repetitive MCAS activation in 2016. 512 These
concerns were not investigated thoroughly enough and, in some cases, dismissed by other
Boeing colleagues. Because there was no specific regulatory requirement to share these
concerns with the FAA, Boeing and the AR chose not to inform the agency about these
issues.
 Boeing sought to acquire internal approval to redesign MCAS and to obtain FAA approval
to remove references to MCAS from pilot training material near simultaneously. On March
30, 2016, hours after the MCAS redesign was approved by the 737 MAX’s senior program
leadership, 513 Boeing sought, and the FAA separately approved, the removal of any
references to MCAS from Boeing’s Flight Crew Operations Manual (FCOM). 514
 Boeing’s Chief Project Engineer on the 737 MAX program was unfamiliar with key design
aspects of MCAS when he approved of its design, including its reliance on a single AOA
sensor and its ability to activate repeatedly. 515
 Boeing’s design of MCAS violated its own internal design requirements, which demanded
that the system “not have any objectionable interaction with the piloting of the airplane” and
“not interfere with dive recovery,” which occurred in both 737 MAX crashes. 516
509 See: Internal Boeing email, “PRG – 37MAXFCI-PDR_AI22 – MCAS/Speed Trim,” June 7, 2013, 9:10 PM, accessed
at p. 93 here:
pdf and Boeing ITRACS Item, “MCAS/Speed Trim,” 37MAXFCI-PDR AI22, BATES Number TBC T&I 549172-
T&I 010584 - TBC-T&I 010586 at TBC-T&I 010584, released at Hearing before the House Committee on
Transportation & Infrastructure, U.S. House of Representatives, 116th Congress, First Session, October 30, 2019, p. 121,
15, 2016, 1:01 PM, BATES Number TBC T&I 246488 – T&I 246493 at T&I 246489. (On file with the Committee).
512 Ibid. at TBC-T&I24690.
513 Internal Boeing email, “Subject: 5-15 update,” April 1, 2016, 3:28 p.m., BATES Number TBC T&I 255562. (On file
with the Committee).

514 Email from Mark Forkner to FAA, “Subject: MCAS lives in both FCCs,” March 3, 2016 (On file with Committee).
Program Manager of the 737 MAX program, Boeing Commercial Airplanes (BCA), May 11, 2020.
516 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-B-
BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June 11, 2018, accessed at p. 170 here:
86
INVESTIGATIVE FINDINGS - Continued
 In 2012, at the start of the 737 MAX program, it took a Boeing test pilot more than 10
seconds to respond to uncommanded517 MCAS activation in a flight simulator, which the
pilot found to be “catastrophic[.]” 518 Boeing never shared this information with the FAA, its
MAX customers, or MAX pilots.
New Larger Engines Resulted in Aerodynamic Instability in Critical Situations
In 2011, facing a competitive threat from Airbus’s new, more fuel efficient, single-aisle A320
aircraft, Boeing believed it did not have time to create a new plane from scratch. 519 Instead, it opted
to modify its existing 737 NG aircraft to make it more fuel efficient. 520 To help accomplish this,
Boeing installed, larger, more fuel efficient engines on this new 737 derivative airplane model
dubbed the 737 MAX aircraft. 521
The existing engines on the 737 NG aircraft were located under the wings and already hung
relatively low to the ground, a vestige of the 737’s original 1967 design—a time when stairs were
more commonly used by passengers to board planes than jetways, and ground crews more
commonly hand-lifted luggage into cargo holds, as opposed to using motorized belt loaders. 522 As a
result, there was not enough ground clearance to simply swap out the old engines and replace them
with new, larger, more efficient ones. 523
The engines on the 737 NG have a ground clearance of 17 inches. 524 By comparison,
Boeing’s 757 model aircraft has a minimum clearance of 29 inches and Boeing’s 787 Dreamliner has
a minimum clearance of 28 inches. 525 The 737 NG engine hangs so low that the otherwise circular
casing around it, known as a nacelle, is flattened at the bottom – giving it a look that some pilots
have dubbed the “hamster pouch.” 526
517 MCAS was designed to activate automatically without any pilot command. Use of the term “uncommanded” in
connection with MCAS activation here is for consistency with Boeing’s own Functional Hazard Assessments which
measured, “Uncommanded MCAS function operation to pilot reaction[,]” and observed that a “slow reaction time
scenario (> 10 seconds) found the failure to be catastrophic due to the inability to arrest the airplane overspeed.”
See Hearing titled, “The Boeing 737 MAX: Examining the Design, Development, and Marketing of the Aircraft,”
October 30, 2019, pp. 163-164 and 173-174, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
518 Boeing internal email from Boeing engineer to two Boeing test pilots, “Subject: MCAS Hazard Assessment,”
November 1, 2012, BATES Number TBC T&I 131226-131227. (On file with the Committee).
519 David Gelles, Natalie Kitroeff, Jack Nicas and Rebecca Ruiz, “Boeing Was ‘Go, Go, Go’ to Beat Airbus With the 737
Max,” New York Times, March 23, 2019, accessed here: https://www.nytimes.com/2019/03/23/business/boeing-737-
max-crash.html
520 Ibid.
521 Ibid.

story.html
523 Ibid.
524 Ibid.
525 Ibid.
526 Ibid.
87
What is Angle-of-Attack (AOA)?
Early in the development of the 737 MAX program, in order to help maintain enough
ground clearance on the 737 MAX, Boeing mounted the new engines further forward on the wings
and higher up on the aircraft. 527 This subsequently altered the plane’s aerodynamics during certain
flight maneuvers, especially
during high angles of attack
(AOA). 528 “Angle of attack is the
angle between the oncoming air
or relative wind and a reference
line on the airplane or wing,”
according to a Boeing article
from October 2000. 529 When the
airplane was pitched up at a high
AOA and pilots applied engine
thrust, that thrust caused the
airplane to pitch up even more,
creating a risk that the airplane
could enter a dangerous
condition known as an
aerodynamic stall, which is a loss
of lift under the wings and
causes the airplane to essentially
Source: “What is Angle of Attack?” AERO Magazine, fall out of the sky absent
The Boeing Company, October 2000.
appropriate corrective action by
the pilots, which in most cases would involve pushing the nose down so that air can flow across the
wings and the airplane can regain lift. 530
In addition, when piloting the 737 MAX during a test maneuver known as a high speed
wind-up turn, which is required for FAA certification and involves flying the plane at a high AOA,
the force that pilots felt on the control column was not as smooth as required. 531 As pilots pulled
back on the column during the maneuver, they could feel a slackening of resistance. 532 Conversely,
527 Ibid.
528 Ibid.
529 “What is Angle of Attack?” AERO Magazine, The Boeing Company, October 2000, accessed here:
https://www.boeing.com/commercial/aeromagazine/aero_12/attack_whatisaoa.html
530 See: “Maneuvering Characteristics Augmentation System (MCAS),” SKYbrary, Flight Safety Foundation, accessed
here: https://www.skybrary.aero/index.php/Maneuvering_Characteristics_Augmentation_System_(MCAS) and

“Aerodynamic Stall Awareness and Avoidance,” SKYbrary, Flight Safety Foundation, accessed here:
https://www.skybrary.aero/index.php/Aerodynamic_Stall_Awareness_and_Avoidance and Andy Pazstor, Andrew
Tangel, Alison Sider, “Between two deadly crashes Boeing moved haltingly to make 737 MAX fixes,” Wall Street Journal
April 1, 2019, accessed here: https://www.wsj.com/articles/between-two-deadly-crashes-boeing-moved-haltingly-to-
make-737-max-fixes-11554164171?mod=hp_lead_pos1
531 Dominic Gates & Mike Baker, “The inside story of MCAS: How Boeing’s 737 MAX system gained power and lost
safeguards,” Seattle Times, June 22, 2019, accessed here: https://www.seattletimes.com/seattle-news/times-

watchdog/the-inside-story-of-mcas-how-boeings-737-max-system-gained-power-and-lost-safeguards
532 Ibid.
88
the FAA mandates that airplanes handle this maneuver with a smooth transition. 533 To address this,
Boeing’s engineers initially considered adding small metal vanes known as vortex generators on the
wings. 534 This proposed fix did not prove to be satisfactory to address the issue, however.
Ultimately, Boeing decided to add the Maneuvering Characteristics Augmentation System (MCAS)
to the 737 MAX to help the aircraft compensate for those flight conditions. 535
Source: Dominic Gates and Mike Baker, “The inside story of MCAS: How Boeing’s 737 MAX
system gained power and lost safeguards,” The Seattle Times, June 22, 2019 (Updated: June 24, 2019).
As described in more detail above, MCAS is an automated system designed to activate if and
when the 737 MAX reached, among other things, a high AOA. In such an event, MCAS would
move the plane’s horizontal stabilizer to push the plane’s nose in a downward direction, to reduce
533 14 Code of Federal Regulations (CFR) § 25.203 “Stall characteristics,” Federal Aviation Administration (FAA),
Department of Transportation (DOT), January 1, 2011, accessed here: https://www.govinfo.gov/app/details/CFR-
2011-title14-vol1/CFR-2011-title14-vol1-sec25-203
534 See: Dominic Gates & Mike Baker, “The inside story of MCAS: How Boeing’s 737 MAX system gained power and
lost safeguards,” Seattle Times, June 22, 2019, accessed here: https://www.seattletimes.com/seattle-news/times-
watchdog/the-inside-story-of-mcas-how-boeings-737-max-system-gained-power-and-lost-safeguards and Jack Nicas,
Natalie Kitroeff, David Gelles, and James Glanz, “Boeing Built Deadly Assumptions Into 737 Max, Blind to a Late
Design Change,” New York Times, June 1, 2019, accessed here:
https://www.nytimes.com/2019/06/01/business/boeing-737-max-crash.html?searchResultPosition=1
535 Dominic Gates & Mike Baker, “The inside story of MCAS: How Boeing’s 737 MAX system gained power and lost
safeguards,” Seattle Times, June 22, 2019, accessed here: https://www.seattletimes.com/seattle-news/times-

watchdog/the-inside-story-of-mcas-how-boeings-737-max-system-gained-power-and-lost-safeguards
89
the angle of attack. 536 In both the Lion Air and Ethiopian Airlines crashes, erroneously high AOA
data from faulty AOA sensors caused MCAS to keep pushing the plane’s nose downward based on
faulty data, which led to catastrophic consequences. 537 While every 737 MAX aircraft has two AOA
sensors positioned on each side of the front of the aircraft, pre-crash versions of MCAS relied on
AOA data from only a single AOA sensor at a time. 538 The MCAS software system, embedded in
the airplane’s flight control computer, would end up playing a central role in the MAX crashes.
Boeing Rejected the Idea of an MCAS Indicator Light
Boeing initially considered adding an MCAS light on the flight control panel that would have
illuminated in the event that MCAS failed to activate The presence of an MCAS fail light on the
flight control panel would have notified pilots of the presence of MCAS on the 737 MAX.
Ultimately, however, Boeing rejected that idea. A mock-up of the MCAS indicator light was
displayed in a November 8, 2012, “Preliminary Design Decision Memo,” that was publicly released
at the Committee’s October 30, 2019, hearing on the 737 MAX. 539
John Hamilton, then-Chief Engineer for the Boeing Commercial Airplanes (BCA) division
of The Boeing Company, testified at that hearing and explained why Boeing decided to delete the
MCAS indicator light saying, “[I]t was deleted … because the functionality was incorporated into the
speed trim fail light.” 540 In response to Questions for the Record (QFRs) from that hearing, then-
Boeing Chief Executive Officer (CEO), Dennis Muilenburg, confirmed this line of thinking writing,
“MCAS is an extension of the pre-existing Speed Trim function….” 541
A May 2014 internal Boeing email also provides a summary of a “737 MAX Flight
Controls/Pilots Meeting” that raised questions about how to annunciate an MCAS failure. 542 “With
annunciation, failure is minor,” the email said. 543 “Without annunciation, failure is major.” 544 “Is it
536 “Maneuvering Characteristics Augmentation System (MCAS),” SKYbrary, Flight Safety Foundation, accessed here:
https://www.skybrary.aero/index.php/Maneuvering_Characteristics_Augmentation_System_(MCAS)
537 Final KNKT.18.10.35.04 Aircraft Accident Investigation Report, PT. Lion Mentari Airlines, Boeing 737-8 (MAX);
Transportasi (KNKT), Republic of Indonesia, issued October 25, 2019, (hereafter referred to as: Lion Air Flight 610
Final Aircraft Accident Investigation Report,”) accessed here: https://aviation-is.better-
than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf and Interim Investigation
Report on Accident to the B737-8(MAX) Registered ET-AVJ operated by Ethiopian Airlines on 10 March 2019,”
Federal Democratic Republic of Ethiopia, Ministry of Transport, Aircraft Accident Investigation Bureau, released March
9, 2020, (hereafter referred to as: “Ethiopian Airlines Flight 302 Interim Investigation Report,”) accessed here:
http://www.aib.gov.et/wp-content/uploads/2020/documents/accident/ET-
538 Curt Devine and Drew Griffin, “Boeing relied on single sensor for 737 Max that had been flagged 216 times to
FAA,” CNN, April 30, 2019, accessed here: https://www.cnn.com/2019/04/30/politics/boeing-sensor-737-max-

faa/index.html
October 30, 2019, pp. 119-120, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
540 Ibid., p. 20.
541 Ibid., p. 277.
542 Internal Boeing Email, “Subject: 737 MAX Flight Controls/Pilots Meeting,” Sent: Tuesday, May 27, 2014, 11:53 AM,
(Notes: “Meeting Date 5/27/2014 11:00 AM (recurring),” TBC-T&I 181331-181333 (On file with the Committee).
543 Ibid.
544 Ibid.
90
okay to not annunciate it, after all, what would the crew do? Should it be annunciated with the
existing SPEED TRIM FAIL light,” the email said. But it added, “The speed trim system is not all
that reliable.” 545
The notion that MCAS was simply an extension of the speed trim system was a central tenet
from Boeing during its certification. Technically, MCAS is part of the speed trim system. 546
However, many aviation experts have expressed concerns that this narrow definition was a strategy
to muddy the waters around MCAS so that Boeing could claim that MCAS was not new or novel
and therefore should not be subjected to greater scrutiny during certification. Greg Travis, a
software expert and private pilot, published one of the first detailed articles on MCAS in the
Institute of Electrical and Electronics Engineers’ (IEEE’s) magazine SPECTRUM in April 2019. 547
According to Travis, Boeing’s efforts to describe MCAS as simply an extension of the MAX’s
“speed trim system” was an effort to “give shade and cover to the notion that MCAS in the 737
MAX was not new.” 548
545 Ibid.
546 “Preliminary Summary of the FAA’s Review of the Boeing 737 MAX: Return to Service of the Boeing 737 MAX
Aircraft, Version 1,” Federal Aviation Administration, August 3, 2020, p. 23., accessed here:
https://www.faa.gov/news/media/attachments/737-MAX-RTS-Preliminary-Sum11:53 amary-v-1.pdf
547 Gregory Travis, “How the Boeing 737 Max Disaster Looks to a Software Developer,” IEEE Spectrum, April 18, 2019,
accessed here: https://spectrum.ieee.org/aerospace/aviation/how-the-boeing-737-max-disaster-looks-to-a-software-

developer
548 T&I Democratic staff email exchange with Gregory Travis, April 20, 2020.
91
A Plan to Downplay MCAS
Regardless of the technical merits of Boeing’s argument that MCAS should be characterized
as an extension of the speed trim system, Boeing also had other motivations to describe MCAS that
way. In May 2013, a group of Boeing employees working on the 737 MAX met to address another
concern: “If we emphasize MCAS is a new function there may be greater certification and training
impact,” one Boeing employee wrote in a June 7, 2013, email summarizing the minutes of that
meeting. 549
While Boeing did not hide MCAS from regulators, or even some airlines, it appears Boeing
took efforts over the lifespan of the MAX program to downplay and deflect attention away from
MCAS even after the Lion Air crash. 550
Boeing has claimed it provided clear indications to both foreign and domestic regulators
about MCAS. In a letter to the Committee on September 3, 2020, Boeing’s Chief Counsel for
Regulatory and Legislative Affairs wrote:
These facts make it clear that Boeing did not hide MCAS from the
FAA in connection with the 737 MAX’s certification or its
customers. Boeing employees repeatedly disclosed the existence of
MCAS, over many years, during their communications with the FAA,
foreign regulators, and customers. Their communications identified
MCAS by name and stated expressly that it was a “new” system that
was being added to the 737 MAX. 551
549 Internal Boeing email, “PRG – 37MAXFCI-PDR_AI22 – MCAS/Speed Trim,” June 7, 2013, 9:10 PM, accessed at p.
93 here:
pdf
550 See: Three months after the Lion Air crash Boeing was still arguing that its “rationale” to remove reference to MCAS
from 737 MAX pilot training manuals “remains valid” and it still argued that differences “between the 737 NG and 737
MAX relating to the MCAS flight control law do not affect pilot knowledge, skills, abilities, or flight safety.” See: Letter
from Boeing ODA Deputy Lead Administrator to FAA Aircraft Evaluation Group, January 30, 2019, BATES Number
TBC-T&I 297017 - TBC-T&I 297018, accessed at pp. 134-135 here: https://www.govinfo.gov/content/pkg/CHRG-
116hhrg38282/pdf/CHRG-116hhrg38282.pdf; and Letter from FAA B-737 FSB Chair to Boeing, December 13, 2018,
BATES Number TBC-T&I 297016, accessed here, at p. 133: https://www.govinfo.gov/content/pkg/CHRG-
551 Letter from Boeing Chief Counsel for Regulatory and Legislative Affairs to Committee on Transportation and
Infrastructure, September 3, 2020. (On file with the Committee). As noted later in this section, in March of 2016, Boeing
requested permission from the FAA to remove MCAS from the Flight Crew Operations Training Manual (FCOM),
telling the FAA that MCAS, “only operates WAY outside of the normal operating envelope.” See Internal Boeing email,
“Subject: 5-15 update,” April 1, 2016, 3:28 p.m., BATES Number TBC T&I 255562. (On file with the Committee). In
January 2017 Boeing also asked the FAA to remove references to MCAS from the pilot differences tables for the 737
MAX. Email from Mark Forkner, former Chief Technical Pilot, The Boeing Company, to FAA employee, Subject: “a
few DT updates please,” Tuesday, January 17, 2017 19:00:58 (On file with the Committee). On November 6, 2018,
Boeing issued an Operations Manual Bulletin (OMB) for that manual to provide pilots with critical information
following the Lion Air crash, but that bulletin did not mention MCAS. See Lion Air Flight 610 Final Aircraft Accident
Investigation Report, pp. 288-289. The next day FAA issued an Emergency Airworthiness Directive (AD) that, like
Boeing’s bulletin, did not mention MCAS. See FAA Emergency Airworthiness Directive (AD) 2018-23-51, November 7,
2018, accessed at:
23-51_Emergency.pdf. Boeing finally issued a Multi Operator Message (MOM) to 737 fleet operators regarding MCAS
92
However, the issue at the Boeing employee meeting was not about whether Boeing should
provide information about MCAS to the FAA. Rather, it was about how the information about
MCAS should be communicated to the FAA. In this regard, multiple investigations have found that
communication was problematic. For example, the Joint Authorities Technical Review (JATR)
found:
• “[T]he content of certification deliverables would not have provided

FAA technical staff with awareness of key details of the MCAS
function on the B737 MAX, including architecture, signal inputs, and
limits of authority.” 552
• “MCAS should have been considered a novelty (and therefore clearly

highlighted to the FAA technical staff) owing to the important
differences in function and implementation it has on the B737 MAX
compared with the previous MCAS installed on the B767-C2
(tanker).” 553
• “The FAA was not completely unaware of MCAS; however, because

the information and discussions about MCAS were so fragmented
and were delivered to disconnected groups within the process, it was
difficult to recognize the impacts and implications of this system. If
the FAA technical staff had been fully aware of the details of MCAS
function, the JATR team believes the agency likely would have
required an issue paper for using the stabilizer in a way that it had not
previously been used. MCAS used the stabilizer to change the
column force feel, not trim the aircraft . . . If an issue paper had been
required, the JATR team believes it would have likely identified the
potential for the stabilizer to overpower the elevator.” 554
According to the Department of Transportation Office of Inspector General (DOT OIG):
Early in the process, Boeing included limited information in initial

briefings to FAA on the MAX’s flight control software, MCAS,
which subsequently has been cited as a contributing or potentially
contributing factor in both accidents. However, Boeing presented the
software as a modification to the existing speed trim system that
would only activate under certain limited conditions. As such, MCAS
was not an area of emphasis in FAA’s certification efforts and
on November 10, 2018. According to Boeing, it did so, “responding to operator requests for additional information
about the subject matter of the OMB and AD . . . [that] provided technical details and operational information regarding
the MCAS function.” See Boeing’s response to Chair DeFazio’s question for the hearing record, Hearing titled, “The
Boeing 737 MAX: Examining the Design, Development, and Marketing of the Aircraft,” House Committee on
Transportation & Infrastructure, U.S. House of Representatives, 116th Congress, First Session, October 30, 2019, p. 276,
552 See Joint Authorities Technical Review (JATR), October 11, 2019 (hereinafter referred to as “JATR Report”), p. 24,
accessed here: https://www.faa.gov/news/media/attachments/Final_JATR_Submittal_to_FAA_Oct_2019.pdf

553 JATR Report p. 23.
554 JATR Report pp. 13-14.
93
therefore did not receive a more detailed review or discussion
between FAA engineers and Boeing. 555
In addition, a draft review of the MCAS certification process undertaken by the FAA
following the Lion Air crash, “noted Boeing’s document traceability and clarity of explanations were
lacking in its revisions to MCAS and other system certification documents. FAA’s post-accident
review determined that an independent reviewer would not have been able to effectively review the
safety assessment as a standalone compliance document or understand the full system functionality
and linkage with other systems and functions.” 556
This makes it even more notable that Boeing employees were worried – in June of 2013 –
that, “If we emphasize MCAS is a new function there may be greater certification and training
impact[,]” and were crafting a plan to try to make sure that didn’t happen. 557 Specifically, they
planned to, “Treat [MCAS] as an addition to Speed Trim . . . Externally we would communicate it as
an addition to Speed Trim. Internally continue using the acronym MCAS. … 558
They agreed to run the strategy by an Authorized Representative (AR) in Boeing’s Autoflight
group “to ensure this strategy is acceptable.” 559 An AR, as described previously, is a Boeing
employee authorized to conduct certification work on behalf of the FAA, and is supposed to work
to uphold the interests of the FAA and the flying public, not the company’s private commercial
interests. The Boeing employees also agreed to make sure that their technical familiarity presentation
to the European Union Aviation Safety Agency (EASA) “is consistent with the intent that MCAS is
an addition to Speed Trim.” 560
The Boeing AR concurred with Boeing’s plan regarding its description of MCAS. 561 As
stated in the summary of the meeting, “This will allow us to maintain the MCAS nomenclature while
not driving additional work due to training impacts and maintenance manual expansions.” 562
555 DOT Office of Inspector General, “Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8
Aircraft and Actions Taken After the October 2018 Lion Air Accident,” Report No. AV2020037, June 29, 2020, p. 15,
accessed here:
556 Ibid. at pp. 32-33.
93 here:
93 here:
pdf
559 Ibid.
560 Ibid.

93 here:
pdf
94
The intent of this plan was clear. It was not to avoid confusion about MCAS by regulators or
737 MAX pilots. The purpose of characterizing MCAS as an addition to speed trim was to avoid
“greater certification and training impact.”
Boeing’s item tracking compliance system database, called ITRACS, that documented this
decision suggested that “cost” was also a factor in the plan to downplay MCAS and to describe it as
merely an addition to the Speed Trim System. 563 On May 21, 2013, as part of that strategy meeting,
the issue was presented this way in Boeing’s ITRACS database:
Problem Statement: Every new buzzword represents a company and

airline cost via changed manuals, changed training, changed
maintenance manuals.
Recommended Action: Investigate deletion of MCAS nomenclature

and cover under the umbrella of ‘revised speed trim’. 564
In Boeing’s recent letter to the Committee they have claimed that the records they have
provided to the Committee regarding this May 2013 meeting shows that the team’s manager
accepted the “team analysis on keeping MCAS nomenclature.” “The item was then closed,” Boeing
wrote. “In other words, after reviewing the issue, the team recommended, and their manager agreed,
to continue to refer to MCAS by that name.” 565
What the letter did not indicate is that it seems both the Boeing AR and the team manager
accepted all of the team’s recommendations, which included referring to MCAS by name internally,
and “Externally we would communicate it as an addition to Speed Trim.” Since then, Boeing has, in
fact, repeatedly characterized MCAS as an addition to speed trim. For example, in response to
questions for the record from Chair DeFazio from the Committee’s October 2019 hearing on the
737 MAX, Mr. Muilenburg, the then-CEO of Boeing, wrote: “MCAS is an extension of the pre-
existing Speed Trim function….” 566
In isolation, perhaps this “[t]reat as an addition to Speed Trim” strategy could be dismissed.
The meeting, for instance, did not include senior Boeing officials. However, this was also not a
simple ad hoc email exchange between a few Boeing colleagues. The meeting, which was officially
documented in Boeing’s compliance database, was focused on strategizing about how to describe
MCAS to avoid greater certification and training impact for the 737 MAX.
564 Ibid.
565 Letter from Boeing Chief Counsel for Regulatory and Legislative Affairs to Committee on Transportation and
Infrastructure, September 3, 2020. (On file with the Committee).

566 Mr. Muilenburg QFR responses, Hearing titled, “The Boeing 737 MAX: Examining the Design, Development, and
Marketing of the Aircraft,” Committee on Transportation and Infrastructure, U.S. House of Representatives, 116th
Congress, First Session, October 30, 2019, p. 277, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
95
May/June 2013
MCAS/Speed Trim - Strategy Meeting Data
96
Effect of MCAS on Pilot Differences Training
The Boeing employees that devised the MCAS strategy were not the only Boeing employees
that appeared to worry about the consequences that MCAS could cause to the 737 MAX’s
certification and pilot training requirements There are five distinct levels of pilot “differences
training” that the FAA may require for new or derivative aircraft. They are labelled “Level A”
through “Level E” differences training requirements, and the requirements increase with each level
of training. 567
“Level A differences are those differences of which the flightcrew member needs to be
aware, but which have little effect on systems operations,” for instance. 568 The methods used for this
level of training can include reading highlighted pages of operating manuals or training bulletins and
no checking is required for whether or not the pilot has absorbed or retained this information. 569
According to the FAA, “Level B differences are those differences in systems, controls, and
indicators that have only minor procedural differences.” 570 “Appropriate instructional methods for
Level B differences include, but are not limited to, audiovisual presentations, lectures, and tutorial
computer-based instruction (TCBI). A task or systems check for Level B differences must be
conducted after training. Appropriate methods include an oral or written exam or TCBI self-test.” 571
Level E contains the highest training requirements, which require training in a full flight
simulator or an aircraft in order “to attain or maintain [specific] knowledge, skills, or abilities.” 572
One of the principal goals of the 737 MAX program was that it would require no greater
than Level B differences training for pilots to transition from flying the 737 NG to flying the 737
MAX aircraft. Even before an AR approved of the Boeing employee plan to describe MCAS as
merely an addition to the speed trim system, efforts to avoid increased pilot training requirements
were already well underway throughout the 737 MAX program.
On Saturday, May 4, 2013, several weeks before the MCAS strategy meeting referenced
above, Michael Teal, the former Chief Project Engineer on the 737 MAX program, sent an email to
senior chiefs and functional leaders on the MAX program and listed “14 open significant trade
studies/risk issues.” One of them specifically addressed the concern that MCAS could increase pilot
training requirements:
Differences Pilot Training: Ensuring that the level of change on

the MAX keeps the Differences training to 16 hours or less of Level
B training. Concerns include the impact of the resolution of 25.1322
567 FAA Order 8900.1, Volume 3. General Technical Administration, Chapter 19. Flightcrew Member Training and
Qualification Programs, Section 9. Safety Assurance System: Differences Training—All Training Categories, Flight
Standards Information Management System (FSIMS), Federal Aviation Administration (FAA), accessed here,
https://fsims.faa.gov/PICResults.aspx?mode=EBookContents&restricttocategory=all~menu
568 Ibid.
569 Ibid.
570 Ibid.
571 Ibid.
572 Ibid.
97
trade 573 and the Autopilot roll saturation change driven by the
addition of MCAS to the flight controls system. 574
In a transcribed interview with Committee staff, Mr. Teal acknowledged that obtaining Level
B training on the 737 MAX “was a design objective” 575 of the MAX program and that he had a role
in ensuring that design objective was being met. “I think it’s fair to say my job is to ensure that the
airplane meets all of its requirements -- the regulatory requirements, the Boeing requirements, the
customer requirements. And the differences training for an NG pilot to fly common with the MAX
was a part of that, the requirements that we set out to meet as a team,” he said. 576
How MCAS was Presented to Regulators
Boeing engaged in multiple efforts to downplay the role and potential safety implications of
MCAS on the MAX and attempted to abolish any reference to MCAS from various Boeing
documents. 577 In March 2016, Boeing sought and received approval from the FAA to remove
references to MCAS from the airplane’s flight crew operations manual (FCOM) and training
materials. 578 Boeing also failed to share critical information with the FAA or MAX customers
regarding the fact that the company knew that it had taken one of Boeing’s own test pilots more
than 10 seconds to respond to uncommanded MCAS activation in a flight simulator test, and the
pilot found the condition to be “catastrophic[.]” 579
Asked about why Boeing removed references to MCAS from pilot training documents at the
Committee’s October 2019 hearing , Dennis Muilenburg, then- CEO of Boeing, said: “[T]he intent
was to provide the training materials that the pilots would need to fly the airplane, rather than try to
educate them on the system details.” 580 Muilenburg explained, “Again, our goal is to optimize what
is in the training manual, so we don’t add more information than what is useful for the pilots.” 581
That explanation, however, does not comport with the rationale provided in the June 2013
meeting minutes for not referencing MCAS externally. As the MCAS strategy made clear, it was
573 This is a reference to the Federal Aviation Administration’s (FAA’s) Advisory Circular number 25.1322-1 on
“Flightcrew Alerting” that provides guidance for showing compliance with certain requirements of Title 14 of the Code
of Federal Regulations (14 CFR), part 25, for the design approval of flightcrew-alerting functions. See Advisory Circular
(AC), 25.1322-1 - Flightcrew Alerting, Federal Aviation Administration (FAA), December 13, 2010, accessed here:
https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_25.1322-1.pdf
574 Boeing internal email from Former 737 MAX Chief Project Engineer to Boeing Commercial Airplanes (BCA) Senior
Chiefs and Functional Leaders, “Subject: 737MAX Firm Configuration Status/Help Needed,” Saturday, May 4, 2013,
BATES Number TBC T&I 049683 - 49684. (On file with the Committee).
575 Committee staff Transcribed Interview of Michael Teal, former Vice President, Chief Project Engineer and Deputy
Program Manager for the 737 MAX program, Boeing Commercial Airplanes (BCA), May 11, 2020.
576 Ibid.
577 Email from Mark Forkner to FAA, “MCAS Lives in Both FCCs,” Mar. 30, 2016.
578 Ibid.
BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision D, March 30, 2016, accessed at p. 164 here:
580 Hearing titled, “The Boeing 737 MAX: Examining the Design, Development, and Marketing of the Aircraft,” House
116hhrg38282.pdf
581 Ibid at p. 97.
98
important to Boeing to limit any impact on increased certification and pilot training. Increases in
either would have increased the cost of the 737 MAX program. Three key concerns: 1) that MCAS
had the potential to increase certification scrutiny; 2) that MCAS could have led to greater pilot
training requirements; and 3) that references to MCAS in training and other manuals could increase
costs to both Boeing and its customer airlines, appear to have driven Boeing’s efforts to downplay
MCAS as much as possible.
To achieve those objectives, Boeing appears to have pushed the idea that MCAS was simply
an extension of the Speed Trim System. While technically this is accurate, describing MCAS that way
helped to obscure the fact that MCAS was a new function on commercial aircraft. To be clear,
Boeing provided information to the FAA about MCAS, including some in which MCAS was
characterized as new. However, the rationale for describing MCAS that way was clearly laid out in
the meeting minutes referenced above that approved a strategy to help Boeing attempt to shield
itself against greater certification and training impact. This strategy ran its course, promulgating the
idea within Boeing that there was no need to overload pilots with information about MCAS. In the
wake of the Lion Air and Ethiopian Airlines accidents, however, those arguments have been
strongly condemned by the pilot community. 582 In addition, the Lion Air final accident investigation
report pointed out the faulty logic in Boeing’s rationale to omit information about MCAS from
MAX pilots’ training manuals.
Without the awareness of the MCAS function, the flight crew would
possibly recognize an MCAS activation as Speed Trim System (STS)
input. MCAS behaves differently than the STS, it moves the
horizontal stabilizer at a faster rate. 583
Boeing has now reversed course on this issue. In October 2019, in testimony before the
Committee, John Hamilton, then-Chief Project Engineer for Boeing Commercial Airplanes
acknowledged this fact, stating, “I would say, since these accidents, we understand that pilots do
want more information, and we are going to incorporate that in our flight crew training manual and
flight crew operations manual.” 584
Whether Boeing’s actions to remove references to MCAS from training manuals and its’ lack
of transparency regarding test data it had regarding the impact MCAS could have on a pilot’s ability
to maintain effective control of the 737 MAX airplane were intentionally deceptive, or represented
unintentionally poor judgement, is difficult to know, but the result was the same. Boeing shielded
references to MCAS and important information about MCAS from 737 MAX pilots. 585
582 Benjamin Zhang, “Boeing's CEO explains why the company didn't tell 737 Max pilots about the software system that
contributed to 2 fatal crashes,” Business Insider, April 29, 2019, accessed here: https://www.businessinsider.com/boeings-
ceo-on-why-737-max-pilots-not-told-of-mcas-2019-4
583 Lion Air Flight 610 Final Aircraft Accident Investigation Report,” p.196, accessed here: https://aviation-is.better-
116hhrg38282.pdf
585 Email from Mark Forkner to FAA, “MCAS Lives in Both FCCs,” Mar. 30, 2016.
99
Maneuvering Characteristics Augmentation System (MCAS) – Timeline

November 1, 2012 November 8, 2102 May 4, 2103
A Boeing test pilot takes more than A Boeing Preliminary Design Michael Teal, former Chief Project
10 seconds to respond to Decision Memo shows plans for an Engineer on the 737 MAX program,
uncommanded MCAS activation in MCAS annunciator on the flight sends an email to senior Boeing
a flight simulator and finds the deck of the 737 MAX to indicate if managers indicating “concerns”
condition “catastrophic.” Boeing MCAS fails to activate. However, about the addition of MCAS to the
repeatedly referred to that test data the annunciator was not ultimately flight controls system and its impact
in internal documents but never included on the aircraft. on Boeing’s ability to obtain Level B
relayed that information to the FAA (non-simulator) pilot differences
or to MAX pilots because there was training for 737 MAX pilots.
no specific requirement to share it.
May-June 2013 July 8, 2015 December 17, 2015
Boeing employees devised a strategy Boeing notes its test pilot’s slow, A Boeing AR asked in an email, “Are
on June 7, 2013, to treat MCAS as an “catastrophic” reaction time to we vulnerable to single AOA sensor
“addition to Speed Trim” to help uncommanded MCAS activation in failures with the MCAS
prevent increased “cost” due to its Coordination Sheet for the first implementation or is there some
changed manuals. The strategy, time, saying, “A typical reaction time checking that occurs?” In the end,
approved by a Boeing Authorized was observed to be approximately 4 MCAS was certified with a single
Representative (AR), is outlined in an seconds. A slow reaction time AOA sensor and erroneous AOA
email, saying: “If we emphasize scenario (> 10 seconds) found the data contributed to both 737 MAX
MCAS is a new function there may failure to be catastrophic due to the accidents. Boeing is now
be greater certification and training inability to arrest the airplane implementing changes in the wake of
impact.” overspeed.” Boeing updated this both MAX crashes so that MCAS
record, citing this same information, relies on two AOA sensors.
six times from 2015 to 2018 but
never shared this data with the FAA.
March 30, 2016 (8:00 am) March 30, 2016 (11:16 am) June 15, 2016
Keith Leverkuhn, Boeing’s former Mark Forkner, former 737 Chief A Boeing AR Advisor emailed a
737 MAX program General Technical Pilot, emails an FAA colleague and asked, “What happens
Manager, and Michael Teal, former official in the Seattle AEG at 11:16 when we have faulty AOA or Mach
Chief Project Engineer on the MAX a.m. requesting permission to remove number?” The colleague responds,
program, approve the redesign of references to MCAS from the MAX’s “As for faulty AOA and/or Mach
MCAS that enables it to activate at Flight Crew Operations Manual and number…if they are faulty then
lower speeds. training material. Unaware of the MCAS shuts down immediately.”
MCAS redesign, the FAA official Faulty AOA data was a major
grants this request. The Committee contributing factor in both MAX
has been unable to determine if Mr. crashes and MCAS did not shut
Forkner was aware that Boeing had down in either of those accidents.
approved a design change to MCAS
at the time he emailed FAA.
June 16, 2016 October 29, 2018 March 10, 2019
Referring to a Boeing test pilot’s Lion Air flight 610 crashes 13 Ethiopian Airlines flight 302 crashes
problem trimming the MAX due to minutes after takeoff killing 189 six minutes after takeoff killing all
repetitive MCAS activations, a people. MCAS is quickly determined 157 passengers and crew. The FAA
Boeing engineer asks, “Is this to be a major factor in the crash. is the last civil aviation authority to
considered a safety or cert[ification] Faulty AOA data erroneously caused ground the 737 MAX on March 13,
issue?” On June 20, 2016, a colleague MCAS to repetitively activate more 2020, three days after the Ethiopian
responds, “I don’t think this is safety, than 20 times as the pilots battled crash. The 737 MAX aircraft has
other then [sic] the pilot could fight MCAS for control of the aircraft. been grounded worldwide ever since.
the MCAS input and over time find These safety issues were identified by
themselves in a large mistrim.” This Boeing’s engineers years before the
is exactly what happened on both Lion Air crash, but they were not
MAX aircraft that crashed. appropriately addressed or dismissed.
100
Fragmented Oversight of MCAS
Throughout the certification process, oversight of MCAS was fragmented and marred by
confusion. Various references to MCAS were included in multiple FAA-related records, but FAA
did not have a holistic understanding of MCAS or the potential implications of its operations on the
aircraft or the flight crew. 586
As noted previously, by November 2016, four months prior to FAA certification of the 737
MAX, the FAA had delegated 79 of 91 certification plans to Boeing, nearly 90 percent of its
certification related tasks. 587
The certification documents related to MCAS were contained in two primary certification
plans (CP). These plans both dealt with the aircraft’s flight controls systems. One was dubbed:
“Flight Controls – Primary, Elevator and Stabilizer Control” or Stabilizer CP #13471. 588 The other
was named: “Flight Controls – Autoflight (EDFCS/FCC) & Autothrottle,” or EDFCS Certification
Plan CP #13474. 589 The acronym EDFCS/FCC stands for Enhanced Digital Flight Control
System/Flight Control Computer.
According to the National Transportation Safety Board (NTSB), the first of the certification
plans, the Stabilizer CP, proposed that the FAA delegate all Flight Controls Primary & Secondary
related compliance findings to Boeing. 590 “On April 14, 2015, the FAA approved the delegation of
several deliverables; however, they indicated that the deliverable titled ‘737 Stabilizer System
Description and Safety Analysis’ (SSA)[,]” which was the deliverable related to MCAS, would be
retained by the FAA and would not be proposed for delegation. 591 “In November 2016, Boeing
submitted the 737 Stabilizer System Description and Safety Analysis (SSA), revision F, to the FAA
for acceptance,” the NTSB wrote. 592 “In December 2016, the FAA’s response to Boeing was to
‘accept’ the submittal and with notation ‘delegated SSA approval to ODA.’” 593
586 “Boeing 737 MAX Flight Control System: Observations, Findings, and Recommendations,” Joint Authorities
Technical Review (JATR), October 11, 2019 (hereinafter referred to as “JATR Report”), pp 13-14, accessed here:
accessed here:
588 See: FAA Certification Plans for the 737 MAX-8, Federal Aviation Administration (FAA), BATES FAA-T&I
000194-000196 (On file with Committee), and “NTSB System Safety and Certification Specialist’s Report,” ID No.
DCA19RA017, Office of Aviation Safety, National Transportation Safety Board (NTSB), August 21, 2019, see p. 260 in
Lion Air Flight 610 Final Aircraft Accident Investigation Report,” accessed here: https://aviation-is.better-
589 Ibid.
590 “NTSB System Safety and Certification Specialist’s Report,” ID No. DCA19RA017, Office of Aviation Safety,
National Transportation Safety Board (NTSB), August 21, 2019, (included in Lion Air Flight 610 Final Aircraft Accident
Investigation Report,) at p. 262, accessed here: https://aviation-is.better-than.tv/737%20MAX%202018%20-
%20035%20-%20PK-LQP%20Final%20Report.pdf
591 Ibid., pp. 262-263.
592 Ibid.
593 Ibid., p. 263.
101
The NTSB also noted that the second certification plan, the EDFCS CP, “indicated that
approval of the EDFCS System Safety Analysis would be retained by the FAA and would not be
proposed to be delegated to the Boeing ODA. The FAA retained approval of the SSA until revision
K, submitted in January 2017. At that time, the FAA stamped the revision as ‘rejected’ due to the
need to correct some information and simultaneously delegated approval of the SSA once the final
edits were complete.” 594 The EDFCS System Safety Analysis was one of three deliverables within the
certification plan that the NTSB found were directly related to MCAS. 595 In March 2017, two
months after this System Safety Analysis was delegated to Boeing, the 737 MAX achieved final FAA
certification approval. 596
Moreover, the Joint Authorities Technical Review (JATR) also found that MCAS should
have been presented to the FAA as a novel system. If MCAS had been presented as a new and novel
aviation technology, the 737 MAX would have been subjected to far greater FAA regulatory scrutiny
and a more thorough technical assessment. The JATR noted that:
The FAA was not completely unaware of MCAS; however, because

the information and discussions about MCAS were so fragmented and
were delivered to disconnected groups within the process, it was
difficult to recognize the impacts and implications of this system. If
the FAA technical staff had been fully aware of the details of MCAS
function, the JATR team believes the agency likely would have
required an issue paper for using the stabilizer in a way that it had not
previously been used. MCAS used the stabilizer to change the column
force feel, not trim the aircraft . . . If an issue paper had been required,
the JATR team believes it would have likely identified the potential for
the stabilizer to overpower the elevator. 597
A total of 88 “issue papers” were written on the 737 MAX aircraft as part of the certification
process—which described various features on the airplane. 598 This included eight issue papers
addressing “systems avionics,” four on “systems flight controls” and two addressing “systems
software.” 599 But none were written specifically to address MCAS.
Military MCAS vs. Commercial 737 MAX MCAS
The first time Boeing added MCAS to a commercial aircraft was on the 737 MAX. However,
Boeing had previously added MCAS to the U.S. Air Force’s KC-46A Pegasus refueling tanker, which
was a derivative of Boeing’s commercial 767 airplane. 600 But there are significant differences between
594 Ibid, p.265.
595 Ibid, pp.265-266.
596 “Boeing 737 MAX 8 Earns FAA Certification,” Press Release, The Boeing Company, March 9, 2017, accessed here:
https://boeing.mediaroom.com/2017-03-09-Boeing-737-MAX-8-Earns-FAA-Certification
597 JATR Report, pp 13-14.
598 737 MAX Issue Papers, Federal Aviation Administration (FAA), BATES Number FAA-T&I 000197-000199. (On file
with Committee).
599 Ibid.
600 See: John A. Tirpak and Brian W. Everstine, “USAF Reviewing Training After MAX 8 Crashes; KC-46 Uses Similar
MCAS,” Air Force Magazine, March 22, 2019, accessed here: https://www.airforcemag.com/usaf-reviewing-training-
after-max-8-crashes-kc-46-uses-similar-mcas-system; Alison Sider and Andrew Tangel, “Before 737 MAX, Boeing’s
Flight-Control System Included Key Safeguards,” Wall Street Journal, September 29, 2019, accessed here:
102
the operational design of MCAS on the KC-46 tanker and on the 737 MAX. On the KC-46 tanker,
MCAS was given authority to move the plane’s horizontal stabilizer only once per activation, not
repeatedly as it was able to do on the 737 MAX. It was also given only limited power to push the
plane’s nose downward on the KC-46 tanker, which made it easier for pilots to counteract MCAS if
necessary. 601 Importantly, the KC-46 tanker has at least two AOA sensors feeding data into MCAS,
as opposed to a single AOA sensor like on the pre-crash design of the 737 MAX’s version of
MCAS. Finally, on the KC-46 tanker pilots could deactivate MCAS by simply pulling back on the
stick, as opposed to having to perform a runaway stabilizer trim procedure. 602
Initially, MCAS on the MAX was designed to activate only at higher speeds and in
conditions not normally experienced in commercial flight. MCAS was only authorized to activate
above a certain G-force and above a certain AOA. 603 As originally designed, MCAS was only capable
of moving the horizontal stabilizer a maximum of 0.6 degrees. 604
However, in March 2016, one year prior to the FAA’s certification of the 737 MAX, when
Boeing test pilots found the MAX was not handling well when nearing stalls at lower speeds, Boeing
redesigned MCAS to enable it to activate at lower speeds. 605 Moreover, the new version of MCAS
was capable of moving the horizontal stabilizer a maximum of 2.5 degrees (as opposed to 0.6
degrees as originally designed). 606 This was a significant technical change with dramatic operational
implications. Repeated bursts of the MAX’s horizontal stabilizer due to the activation of MCAS
placed both Lion Air flight 610 and Ethiopian Airlines flight 302 into unrecoverable dives, which
violated Boeing’s own internal MCAS design requirements. 607
https://www.wsj.com/articles/before-737-max-boeings-flight-control-system-included-key-safeguards-11569754800;
and “KC-46/737 MAX MCAS,” Media Factsheet, U.S. Air Force, March 21, 2019. (On file with the Committee).
601 Ibid.
602 Ibid.
603 Jack Nicas, Natalie Kitroeff, David Gelles, and James Glanz, “Boeing Built Deadly Assumptions Into 737 Max, Blind
to a Late Design Change,” New York Times, June 1, 2019, accessed here;
BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision B, July 8, 2015, TBC T&I 191227 - TBC T&I 191232 at TBC
T&I 191229 (On file with Committee); See also Jack Nicas, Natalie Kitroeff, David Gelles, and James Glanz, “Boeing
Built Deadly Assumptions Into 737 Max, Blind to a Late Design Change,” New York Times, June 1, 2019, accessed here;
605 Jack Nicas, Natalie Kitroeff, David Gelles, and James Glanz, “Boeing Built Deadly Assumptions Into 737 Max, Blind
to a Late Design Change,” New York Times, June 1, 2019, accessed here;
B-BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision D, March 30, 2016, accessed at p. 161 here:
https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf and Jack Nicas, Natalie
Kitroeff, David Gelles, and James Glanz, “Boeing Built Deadly Assumptions Into 737 Max, Blind to a Late Design
Change,” New York Times, June 1, 2019, accessed here: https://www.nytimes.com/2019/06/01/business/boeing-737-
max-crash.html?searchResultPosition=1
607 See: Lion Air Flight 610 Final Aircraft Accident Investigation Report, p. 196, accessed here: https://aviation-is.better-
than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf; Ethiopian Airlines Flight 302

Interim Investigation Report, p. 131, accessed here: http://www.aib.gov.et/wp-
302%20%20Interim%20Investigation%20%20Report%20March%209%202020.pdf; Boeing Coordination Sheet,
MAX (-7/8/9), Revision D, March 30, 2016, accessed at pp. 161-162 here:
https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf and Boeing
Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-B-BBA8-C12-
103
Redesigning MCAS
On Wednesday, March 30, 2016, Boeing held a “737MAX Leadership Review” meeting in a
4th floor conference room on its Everett, Washington, campus. Senior leaders on the MAX program
were given a presentation by Boeing’s engineers regarding the proposed redesign of MCAS. 608 The
presentation was titled: “737 MAX / Stall Characteristics – Mitigation” and it included a “Stall
Characteristics Go-Forward Plan.” 609
The approval of the redesign of the MCAS software was noted in an internal Boeing email
on April 1, 2016, from a manager in the Aerodynamics Stability & Control group. 610 Under a
heading titled “737MAX: Basic stall characteristics,” the manager wrote that in a meeting with Keith
Leverkuhn “on 3/30, the FC [Flight Control] configuration was approved as the mitigation for basic
stall characteristics.” 611 “Additionally, an update to the MCAS control law was approved to address a
special case of high altitude, flaps up stall characteristics.” 612
Boeing’s presentation regarding MCAS’s redesign suggested that they had an “FAA
Communication Plan,” 613 which indicated Boeing and FAA pilots would test the redesigned MCAS
software in the E-Cab simulator 614 around June 13, 2016, and that Boeing and FAA pilots would fly
the redesigned MCAS software around July 11, 2016, to test “maneuver procedures and stall
characteristics[.]” 615
In response to questions from Chair DeFazio and Subcommittee on Aviation Chair Larsen,
Boeing stated, “On numerous occasions, Boeing shared with the FAA and international regulators
that MCAS’s final design had changed from its earlier parameters, and that its operating range had
expanded to include low-speed conditions.” 616 Boeing also noted that, “FAA personnel also
observed the operation of the expanded MCAS during certification flight testing.” 617
While the new operating range of MCAS was included in certain communications with FAA,
MCAS, in general, was not an area of particular emphasis.
0159, Model: 737-MAX (-7/8/9), Revision G, June, 11/2018, accessed at p. 170 here:
608 “737 MAX / Stall Characteristics – Mitigation,” Aero S&C, March 30, 2016, BATES Number TBC-T&I 214928-
214941 (On file with Committee).

609 Ibid.
with Committee).
611 Ibid.
612 Ibid.
214941 at p.3, TBC-T&I 214930 and p. 6, TBC-T&I 214933 (On file with Committee).
614 An E-Cab is an “Engineering” flight simulator. See: “The “e-cab” – A Test Flight Deck,” The Boeing Company,
accessed here: http://www.boeing.com/commercial/737max/news/the-e-cab-a-test-flight-deck.page

214941 at p. 6, TBC-T&I 214933 (On file with Committee).

372821-372832 at TBC T&I 372825 (On file with the Committee).
617 Ibid.
104
According to the Department of Transportation’s Office of Inspector General:
Early in the process, Boeing included limited information in initial

briefings to FAA on the MAX’s flight control software, MCAS, which
subsequently has been cited as a contributing or potentially
contributing factor in both accidents. However, Boeing presented the
software as a modification to the existing speed trim system that
would only activate under certain limited conditions. As such, MCAS
was not an area of emphasis in FAA’s certification efforts and
therefore did not receive a more detailed review or discussion between
FAA engineers and Boeing. 618
When responding to a question from committee staff about whose job it would be at Boeing
to inform the FAA about a change to MCAS, Mr. Teal noted, “…the certification plans would have
to be updated . . .” 619 However, “[T]he JATR team found that the certification plans and some
certification deliverables (e.g., the preliminary system safety assessment (PSSA)) were not updated to
describe the expansion of the MCAS function for the low Mach portion of the flight envelope and
for compliance with stall-related requirements.” 620
Through its investigation, the Committee also learned that the FAA—in its own review of
MCAS in the wake of the Lion Air crash—determined that although there were gaps in the
information that Boeing provided to FAA about MCAS they did not identify any
“noncompliances.” 621 The FAA’s determination was listed in a draft report that they never finalized,
but that was reviewed by the Committee. That report and its conclusion, that there were no
“noncompliances” despite the fact Boeing did not share all critical and current certification records
with the FAA, highlights significant regulatory and oversight gaps at the FAA and the lack of an
effective regulatory aviation certification process. (See Post-Accident Response section for more details on this
report and its findings).
Communication Issues
Overall, the Committee’s investigation found extraordinarily poor communication between

Boeing and the FAA, in addition to fragmented and ad hoc communication within FAA offices that
played critical roles in the certification process. Other investigative bodies have reached similar
conclusions. 622 These communications failures prevented a full view of vitally important technical
issues that were central to the certification process.
accessed here:
620 JATR Report.
621 “737-8 MAX Maneuvering Characteristics Augmentation System Oversight Report,” Prepared by: FAA AIR-860
BASOO, Boeing Aviation Safety Oversight Office (BASOO), Federal Aviation Administration (FAA), February 8, 2019
(Draft). (Reviewed remotely “in camera” via access to FAA website by Committee Staff on May 1, 2020).
622 JATR report, pp. 13-14, and DOT Office of Inspector General, “Timeline of Activities Leading to the Certification
of the Boeing 737 MAX 8 Aircraft and Actions Taken After the October 2018 Lion Air Accident,” Report No.
105
According to the JATR report, for instance, “The [FAA’s Aircraft Evaluation Group] AEG
should have deeper involvement during the certification process and collaborate closely with FAA’s
Aircraft Certification Service (AIR) to ensure they have the proper knowledge to make informed
decisions about operational suitability issues that may be affected by certification details . . . Pilots
working in the certification process may not have complete knowledge of operational issues, while
pilots working in the operational evaluation process may not have complete knowledge of
certification issues. This may contribute to a lack of communication between the two processes.” 623
In addition, the DOT Special Committee noted that the “complexity” of merging older and
newer technologies on the 737 MAX meant that “in some cases, communications were fragmented.
No holistic assessment of total system operational safety risk was required, or presented, that might
have provided a broader review of safety risk to various management levels in the Boeing and FAA
organizations. This holistic assessment would also serve to enhance communication of assumptions
and feedback of data across the global aviation system,” the report concluded. 624
If the FAA had had a more comprehensive understanding of MCAS at the time the 737
MAX was undergoing certification, it is likely that it would have been classified as a “safety critical
system” and would have resulted in much greater FAA scrutiny. At a Committee hearing in May
2019, Chair DeFazio raised this question with then-Acting FAA Administrator Dan Elwell:
Mr. DEFAZIO. OK. Then is the MCAS a safety critical system, in

your opinion?
Mr. ELWELL. I didn’t make that designation, but it seems to me

that, yes, it is. 625
The issues highlighted above had a serious impact on FAA’s ability to have a clear and
complete picture of the potential technical and operational impacts of MCAS on the 737 MAX
aircraft. While Boeing couched MCAS as simply an extension to the previously existing Speed Trim
System, MCAS had never been previously incorporated onto a commercial airplane. It was also
fundamentally different than Boeing’s design of the MCAS system incorporated onto the U.S. Air
Force’s KC-46 tanker and it should have been designated a safety critical system, which would have
mandated a more thorough review.
AV2020037, June 29, 2020, p. 15, accessed here:

623 JATR report, pp. 44-45.
624 Official Report of the Special Committee to Review the Federal Aviation Administration’s Aircraft Certification
Process, DOT Special Committee Report, pp. 36-37, accessed here: https://cms8.dot.gov/sites/dot.gov/files/2020-
01/scc-final-report.pdf
625 Hearing titled, “Status of the Boeing 737 MAX,” House Committee on Transportation and Infrastructure,
Subcommittee on Aviation, 116th Congress, First Session, May 15, 2019, pp. 28-29 accessed here:
106
MCAS was Vulnerable to Single AOA Sensor Failure
In order to determine when to activate, MCAS relies on data from AOA sensors on the
aircraft. Each 737 MAX is equipped with two AOA sensors, one on each side of the aircraft. 626
However, MCAS was designed to rely on data from only one AOA sensor at a time to determine
whether to push the plane’s nose downward. 627 MCAS alternated which individual AOA sensor it
relied upon on each flight, from the left AOA sensor to the right AOA sensor and vice versa. 628
Because MCAS relied upon only one AOA sensor input at a time, this meant that, if the AOA
sensor upon which MCAS was depending malfunctioned, and erroneously indicated a high AOA,
MCAS would activate repeatedly and keep pushing the nose of the plane down unless the pilot knew
how to effectively deactivate MCAS.
The fact that the 737 MAX’s MCAS relied upon a single AOA sensor was problematic and
has been widely criticized. 629 As the American Society for Engineering Education reported: “That
MCAS apparently was vulnerable to a single point of failure ‘should never have been permitted,’ says
Guy Gratton, an aeronautical engineer and visiting professor at Cranfield University in the United
Kingdom. ‘Redundancy is a core idea, especially in a complicated system where lives are at stake,’
adds Karl Smith, cooperative learning professor of engineering education at Purdue University.” 630
The MCAS system on the U.S. Air Force’s KC-46 tanker, for instance, relies on two AOA
sensors. 631
The Lion Air final accident report also observed: “[T]he design of MCAS relying on input
from a single AOA sensor, made [the 737 MAX’s] Flight Control System susceptible to a single
failure of AOA malfunction. During the accident flight, the scenario was initiated by a single failure,
a high bias in AOA sensor. This high bias resulted in several aircraft level effects including stick
shaker, erroneous airspeed and altitude displays and MCAS after the flaps were retracted.” 632
Boeing’s Functional Hazard Assessment regarding pilot reaction to uncommanded MCAS

function did not rate the system as being hazardous enough to require redundant features, such as
multiple AOA sensors. 633 However, in its “analysis of hazardous and catastrophic failure conditions”
generally, the FAA has written:
626 Dominic Gates, “FAA cautions airlines on maintenance of sensors that were key to 737 MAX crashes,” Seattle Times,
August 20, 2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/faa-cautions-airlines-on-
maintenance-of-sensors-that-were-key-to-737-max-crashes
627 Ibid.
628 Ibid.
FAA,” CNN, April 30, 2019, accessed here: https://www.cnn.com/2019/04/30/politics/boeing-sensor-737-max-

faa/index.html
630 Mark Matthews and Charles Q. Choi, “Compass Course,” PRISM, American Society for Engineering Education
(ASEE), December 2019, accessed here: http://www.asee-prism.org/compass-course

631 “KC-46/737 MAX MCAS,” Media Factsheet, U.S. Air Force, March 21, 2019. (On file with Committee).
632 “NTSB System Safety and Certification Specialist’s Report,” ID No. DCA19RA017, Office of Aviation Safety,
National Transportation and Safety Board (NTSB), August 21, 2019, p. 194, (included in Lion Air Flight 610 Final
Aircraft Accident Investigation Report,) accessed here: https://aviation-is.better-than.tv/737%20MAX%202018%20-
%20035%20-%20PK-LQP%20Final%20Report.pdf
BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June, 11 2018, accessed at p. 163 here:
107
No catastrophic failure condition . . . should result from the failure of
a single component, part, or element of a system. Experienced
engineering judgment and service history should show that a
catastrophic failure condition by a single failure mode is not a
practical possibility. The logic and rationale used in the assessment
should be so straightforward and obvious that the failure mode
simply would not occur unless it is associated with an unrelated
failure condition that would, in itself, be catastrophic. 634
The frailty of AOA sensors was well known to the FAA prior to the certification of the 737
MAX. They are mounted on the plane’s fuselage near the nose and have a long history of known
635
risks of damage and failure. According to a 2019 analysis by Bloomberg, “There are at least 140
instances since the early 1990s of [AOA] sensors on
U.S. planes being damaged by jetways and other Boeing Internal Email
equipment on the ground, or striking birds in flight. In December 17, 2015
at least 25 cases in the U.S., Canada and Europe, the
damage triggered cockpit alerts or emergencies.” 636 In a “ARE WE VULNERABLE TO
slightly different analysis, CNN identified “at least 216
SINGLE AOA SENSOR
reports of AOA sensors failing or having to be repaired,
replaced or adjusted since 2004,” according to data from FAILURES WITH THE MCAS
the FAA’s Service Difficulty Reporting website. 637 IMPLEMENTATION OR IS
THERE SOME CHECKING
Fifteen months prior to the FAA’s certification of THAT OCCURS?”
the MAX, in March 2017, a Boeing engineer raised a
question about leaving MCAS dependent upon just one AOA sensor. In a December 17, 2015,
internal Boeing email, the Boeing engineer who was also an AR, asked, “Are we vulnerable to single
AOA sensor failures with the MCAS implementation or is there some checking that occurs?” 638 The
AR’s concern proved remarkably prophetic as it was erroneous AOA data on both Lion Air flight
610 and Ethiopian Airlines flight 302 that caused MCAS to activate leading to those crashes. 639
634 “System Safety Analysis and Assessment for Part 23 Airplanes,” Advisory Circular, AC No: 23 .1309-1E, Federal
Aviation Administration (FAA), November 17, 2011, accessed here:

https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC%2023.1309-1E.pdf
635 “Airworthiness Directive, Airbus Airplanes, Federal Aviation Administration (FAA), Notice of Proposed Rulemaking
(NPRM), 14 CFR Part 39, [Docket No. FAA–2015–4810; Directorate Identifier 2015–NM–090–AD], Federal Register /
Vol. 80, No. 218 / Thursday, November 12, 2015 / Proposed Rules, accessed here:
https://www.govinfo.gov/content/pkg/FR-2015-11-12/pdf/2015-28559.pdf
636 Alan Levin and Ryan Beene, “Sensors Linked to Boeing 737 Crashes Vulnerable to Failure,” Bloomberg, April 10, 2019,
accessed here: https://www.bloomberg.com/news/articles/2019-04-11/sensors-linked-to-737-crashes-vulnerable-to-

failure-data-show
FAA,” CNN Investigates, April 30, 2019, accessed here: https://www.cnn.com/2019/04/30/politics/boeing-sensor-737-

max-faa/index.html
T&I 010584 - TBC-T&I 010586 at TBC-T&I 010584, released at Hearing titled, “The Boeing 737 MAX: Examining the
Design, Development, and Marketing of the Aircraft,” House Committee on Transportation and Infrastructure, U.S.
House of Representatives, 116th Congress, First Session, October 30, 2019, p. 121, accessed here:
639 Lion Air Flight 610 Final Aircraft Accident Investigation Report, p. 195, accessed here: https://aviation-is.better-
108
Squawk and Repetitive MCAS Activation
On June 13, 2016, a few months after Boeing redesigned MCAS to give it more authority a
Boeing test pilot observed that MCAS countered his attempts to trim the plane while flying a low-
speed maneuver. 640 This situation raised concern with the same engineer who had previously asked
about the single AOA sensor vulnerability. 641 In reviewing a plot of the test flight data, this engineer
noted that the “ratchiness” of MCAS was causing the airplane to oscillate and recommended that
the issue be further examined via Boeing’s “squawk” process. 642
A squawk is the term used to describe a problem with an airplane. 643 Following the June 13,
2016, flight, one of the test pilots entered the problem into Boeing’s reporting system where
squawks are tracked until they are resolved. 644
This concern regarding the ability of pilots to effectively counteract repetitive MCAS
activations was incredibly prescient as both the Lion Air and Ethiopian Airlines flights experienced
uncontrolled oscillations from MCAS activations that led to catastrophic loss of command of the
MAX aircrafts. 645 Unfortunately, like the engineer’s previous question about MCAS relying on a
single AOA sensor, the new concerns were ultimately dismissed. 646
In a written response to the Committee about MCAS, Boeing said:
The technical discussions of MCAS also included the possibility of a

faulty angle of attack sensor potentially leading to repeated MCAS
activation. After evaluating the issue, the group of technical experts
and pilots involved in this discussion determined, based on their
collective expertise, that there was no need to redesign MCAS to
address this possibility because the flight crew would be able to
manage the condition using … well-understood piloting techniques
and procedures …. 647
640 Boeing internal email, “Subject: S&C Brief Summary: 1A001, Test 009-25 6/13/16 [BLOCK 2],” Monday, June 13,
2016, 6:17 PM, BATES Number TBC-T&I246488 – TBC-T&I246493 at TBC-T&I246492. (On file with Committee).
641 Ibid at TBC-T&I246490, TBC-T&I246491, and TBC-T&I246492.
642 Ibid at TBC-T&I246490.
643 Rod Machado, “Using the Airplane Squawk Sheet and Squawk Etiquette,” Disciplines of Flight, May 25, 2017, accessed
here: https://disciplesofflight.com/airplane-squawk-sheet/ 644 Boeing internal email, Subject: “Squawk for MCAS trim
Event,” Thursday, June 16, 2016 1:07 PM; TBC-T&I220826 – TBC-T&I220827 at TBC-T&I220826 (On file with the
Committee).
644 Boeing internal email, Subject: “Squawk for MCAS trim Event,” Thursday, June 16, 2016 1:07 PM; TBC-T&I220826
– TBC-T&I220827 at TBC-T&I220826 (On file with the Committee).

645 See: Lion Air Flight 610 Final Aircraft Accident Investigation Report, p. 78, accessed here: https://aviation-is.better-
than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf and Ethiopian Airlines Flight

302 Interim Investigation Report, pp. 10-11, accessed here: http://www.aib.gov.et/wp-
646 Boeing internal email, Subject “RE: Discussion of MCAS Characteristics,” Wednesday, June 22, 2016 1:59 PM; TBC-
T&I292457 – TBC-T&I292458 at TBC-T&I292457.

372821-372832 at TBC T&I 372829 (On file with the Committee).
109
On June 15, 2016, a Boeing engineer emailed several colleagues in reference to this issue and
asked: “What happens when we have faulty AOA or Mach number?” 648 Another Boeing engineer
responded, “As for faulty AOA and/or Mach
number … if they are faulty then MCAS shuts Boeing Internal Email
down immediately.” That may have been the
649
June 16, 2016
planned intent, but that did not happen on either
the Lion Air or Ethiopian Airlines flights. In both
“I DON’T THINK IT IS SAFETY,
cases faulty AOA data played critical roles in the
crashes, and MCAS did not shut down due to OTHER THAN THE PILOT COULD
erroneous AOA data received by MCAS. FIGHT MCAS INPUT AND OVER
TIME FIND THEMSELVES IN A
Further, another engineer who raised LARGE MISTRIM.”
questions in a June 16, 2016, email to colleagues
about these new concerns with MCAS was advised that the issue was not safety-related. 650 On June
20, 2016, the engineer who responded to this second engineer, said that the concern was about
meeting technical certification requirements and wrote, “I don’t think it is safety, other than the pilot
could fight the MCAS input and over time find themselves in a large mistrim.” 651
Two days later, on June 22, 2016, an “MCAS Review” meeting was held to resolve the issue.
Meeting participants largely supported the prevailing narrative in the email exchanges that preceded
the meeting suggesting the observed issue with MCAS’s
Boeing Internal Email “ratchiness” (or repetitive activation) was not a significant
June 15, 2016 concern. 652 Rather, as indicated in the notes from the meeting
that are depicted below, the effort needed to address the MCAS
issue was described as an “easy fix” and that the problem itself
“WHAT HAPPENS posed “no real requirement violation.” 653
WHEN WE HAVE
FAULTY AOA OR Further, in reference to the concern about “fail high AOA
MACH NUMBER?” or fail high Mach resulting in MCAS motion”—in other words,
that a false reading of a high AOA or a false reading of high
airspeed—meeting participants determined that other systems would be reacting to the failure and
that there was “[n]o need to redesign to address this issue.” 654
15, 2016, 1:01 PM, BATES Number TBC T&I 246488 – T&I 246493 at T&I 246489. (On file with Committee).
649 Ibid.
650 Boeing internal email, “Subject: RE: Squawk for MCAS trim Event,” June 20, 2016, BATES Number TBC T&I
220826 - TBC T&I 220827 at TBC T&I 220826. (On file with the Committee).
651 Ibid.
652 Boeing internal email, “Subject: RE: Discussion of MCAS Characteristics,” Wednesday, June 22, 2016 1:59 PM,
BATES Number TBC T&I 292457. (On file with the Committee).
653 Ibid.
654 Ibid.
110
The meeting minutes of the June 22, 2016, MCAS Review state:
1. Trim Capability – Squawked

MCAS was not allowing pilot to trim at 1.13Vsr (would take out
whatever trim was input). Resolution: move AOA trip higher to
avoid low Mach 1.13Vs trims, easy fix / small work statement. No
real requirement violation, however it will reduce the work load when
demonstrating cert conditions.
Some discussion on fail high AOA or fail high Mach resulting in
MCAS motion. Conclusion: other systems will be reacting to the
failure such as March trim or stick shaker, MCAS is small in
comparison. No need to redesign to address this. 655
The bottom of the email describing the meeting minutes stated: “All changes are minimal /
low collateral damage, therefore no additional flight testing.” 656 The reference to “1.13Vs trims” in
the email was a reference to the stalling speed. The stalling speed (Vs) is the minimum steady flight
speed at which the airplane is controllable. 657 The nomenclature “Vsr” is the reference to stall
speed. 658
Faulty Assumptions, Fatal Timing
Aside from the concerns raised by Boeing engineers about the impact of faulty AOA data on
MCAS and the ability of MAX pilots to be able to counteract repetitive MCAS activation, Boeing
also had evidence from its own test results showing that a test pilot took more than 10 seconds to
respond to uncommanded MCAS activation, a condition the pilot found to be “catastrophic[.]” In
the event that MCAS activated unexpectedly Boeing assumed that such a situation would look and
feel to pilots like a condition known as runaway stabilizer trim—a condition that involves the
electric trim motor suddenly moving the horizontal stabilizer toward the full nose-up or nose-down
stop. Stabilizer trim runaway is well known to pilots, and FAA guidance presumes pilots will
recognize the condition and complete the procedure to counteract it within four seconds.. 659 But
stabilizer trim runaway does not provoke the multitude of simultaneous and seemingly unrelated
cautions and warnings that accompany erroneous MCAS activation when triggered by a failure of an
AOA sensor. 660 Yet, Boeing assumed that pilots would respond to an unexpected MCAS activation
as it if were a runaway stabilizer trim event, within four seconds. 661
655 Ibid.
656 Ibid.
657 Susan Parson, “A Finesse for Vitesse: Mastering the Maze of V-speeds,” FAA Safety Briefing, May/June 2015,
accessed here: https://www.faasafety.gov/files/notices/2015/Nov/V_Speed_Review.pdf

658 Ibid.
659 “Approval of Flight Guidance Systems,” Advisory Circular (AC) 25.1329-1C, Federal Aviation Administration (FAA),
U.S. Department of Transportation (DOT), October 27, 2014, accessed here:

https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_25_1329-1C_CHG_1_.pdf
660 JATR Report, p. 16 and p. 27.
661 Ibid.
111
The National Transportation Safety Board found that Boeing, in making this assumption:
….did not evaluate all the potential alerts and indications that
could accompany a failure that also resulted in uncommanded
MCAS operation. Therefore, neither Boeing’s system safety
assessment nor its simulator tests evaluated how the
combined effect of alerts and indications might impact pilots’
recognition of which procedure(s) to prioritize in responding
to an unintended MCAS operation caused by an erroneous
AOA input. 662
However, according to the JATR “[n]o studies were found that substantiate the FAA
guidance concerning pilot recognition time and pilot reaction time . . . . It is not clear on what the
FAA guidance concerning pilot recognition
time and pilot reaction time was based.” 663 National Transportation Safety Board
September 18, 2019
The JATR also noted that “[a]nalysis
of aviation accidents demonstrates that pilots “WHILE BOEING CONSIDERED THE
may take a significantly longer time to POSSIBILITY OF UNCOMMANDED MCAS
recognize a malfunction and respond to it OPERATION AS PART OF ITS
than the test flight guidance suggests” and FUNCTIONAL HAZARD ASSESSMENT, IT
that “[t]he FAA’s guidance concerning pilot
reaction time of 3 seconds may not be DID NOT EVALUATE ALL THE
appropriate[.]” 664 POTENTIAL ALERTS AND INDICATIONS
THAT COULD ACCOMPANY A FAILURE
In addition, according to the NTSB, THAT ALSO RESULTED IN
“Multiple alerts and indications can increase UNCOMMANDED MCAS OPERATION.”
pilots’ workload, and the combination of the
alerts and indications did not trigger the accident pilots to immediately perform the runaway
stabilizer procedure during the initial automatic AND stabilizer trim input.” 665 The NTSB examined
the two accident flights on Lion Air and Ethiopian Airlines as well as the pre-accident flight on Lion
Air when MCAS activated, but the plane landed safely. According to the NTSB:
In all three flights, the pilot responses differed and did not match the
assumptions of pilot responses to unintended MCAS operation on
which Boeing based its hazard classifications within the safety
assessment and that the FAA approved and used to ensure the design
safely accommodates failures. Although a number of factors,
including system design, training, operation, and the pilots’ previous
experiences, can affect a human’s ability to recognize and take
Alerts and Indications on Pilot Performance,” National Transportation Safety Board (NTSB), September 19, 2019,
accessed https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf.
664 JATR Report, pp. 15-16.
Alerts and Indications on Pilot Performance,” National Transportation Safety Board (NTSB), September 19, 2019, p. 7,
accessed here: https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf
112
immediate, appropriate corrective actions for failure conditions,
industry experts generally recognize that an aircraft system should be
designed such that the consequences of any human error are
limited. 666
The NTSB report also found: “While Boeing considered the possibility of uncommanded
MCAS operation as part of its functional hazard assessment, it did not evaluate all the potential
alerts and indications that could accompany a failure that also resulted in uncommanded MCAS
operation. Therefore, neither Boeing’s system safety assessment nor its simulator tests evaluated
how the combined effect of alerts and indications might impact pilots’ recognition of which
procedure(s) to prioritize in responding to an unintended MCAS operation caused by an erroneous
AOA input.” 667 NTSB pointed out that according to Federal regulations under 14 CFR
25.1309(d)(4), “compliance demonstration as part of aircraft certification must include analysis that
considers the crew warning cues, corrective action required, and the capability of detecting faults.” 668
Catastrophic Consequences
Despite that, the Committee’s investigation also discovered that Boeing was aware, early on
in the 737 MAX program, that it could take some pilots 10 seconds or longer to respond to runaway
stabilizer trim or uncommanded MCAS activation. Boeing also knew that its own test pilot who
took more than 10 seconds to respond to an uncommanded MCAS activation in a fight simulator
and found the condition “catastrophic[.]” 669 The FAA defines catastrophic as, “Failure conditions
that are expected to result in multiple fatalities of the occupants, or incapacitation or fatal injury to a
flight crewmember normally with the loss of the airplane.” 670
The first reference the Committee found to the catastrophic consequences of the Boeing test
pilot’s 10 second reaction time dates to November 1, 2012, when a Boeing engineer in the 737 MAX
Aerodynamic Stability & Control Group emailed his colleagues to discuss recent simulator
assessments regarding a stab trim runaway during a wind up turn. 671 In the simulator tests one
Boeing pilot, with the assistance of “teamwork,” was able to recognize and react to this condition in
approximately four seconds. 672 The other pilot, however, found the condition “catastrophic.” 673
“The reaction time was long (>10 second) to use the aislestand (sic) stab cutout switch and there
was less teamwork with applying the nose up mechanical trim,” wrote the engineer. 674
666 Ibid.
667 Ibid. at p. 8.
668 Ibid. at p. 8.
670 “System Safety Analysis and Assessments for Part 23 Airplanes,” FAA Advisory Circular, AC No: 23 .1309-1E,
Federal Aviation Administration, November 17, 2011,at p. 11, accessed here:

https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC%2023.1309-1E.pdf
671 Boeing internal email from Boeing engineer to two Boeing test pilots, Subject: MCAS Hazard Assessment, November
1, 2012, BATES Number TBC T&I 131226-131227(On file with the Committee).
672 Ibid.
673 Ibid.
674 Boeing internal email from Boeing engineer to two Boeing test pilots, Subject: MCAS Hazard Assessment, November
1, 2012, BATES Number TBC T&I 131226-131227 (On file with the Committee).
113
The Boeing engineer asked a series of questions in the email that became extremely relevant
after the Lion Air and Ethiopian Airlines crashes. As in several other cases, the Committee found
Boeing engineers asked the right questions concerning key details, but they were inadequately
resolved or dismissed by some of their colleagues. If these crucial questions had been more
thoroughly addressed at the time, they could have helped, in some cases potentially dramatically, to
improve the safety of the 737 MAX.
Specifically, the Boeing employee asked his colleagues:
Do you think that with pilot training/knowledge of the [MCAS]

system there will be a sufficiently quick response to the stab runaway
during the windup turn/recovery and that it is appropriate to deem it
hazardous and have the MCAS system designed to meet this? Or
should we step up to catastrophic with the assumption that not all
pilots will recognize it quickly enough? 675
That was a revelatory observation. On each of the doomed MAX flights a cacophony of
alerts and warnings were erupting on the flight deck in the minutes prior to the crashes. A
combination of issues led to the Lion Air and Ethiopian Airlines crashes, but confusion on the flight
deck played a key factor in both accidents. 676
Despite the fact that Boeing knew that the consequences could be “catastrophic” if a pilot
did not react quickly enough to uncommanded MCAS activation, and the fact that Boeing cited this
fact repeatedly over the years in their internal coordination sheets on MCAS, based on their own
internal test data, no one at Boeing apparently informed the FAA about this critical data. 677 Between
2015 and 2018 Boeing issued six separate coordination sheets on MCAS that referenced the
“catastrophic” consequences of a greater than 10-second pilot response time. 678 At least four Boeing
675 Ibid.
Alerts and Indications on Pilot Performance,” National Transportation Safety Board (NTSB), September 19, 2019, p. 8,
accessed here: https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf
677 Email from Boeing attorney to Committee staff, February 10, 2020, 10:42 PM (On file with the Committee).
B-BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision B, July 8, 2015, TBC T&I 191227 - TBC T&I 191232 at TBC
T&I 191231 (On file with the Committee); Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim
114
ARs, reviewed, prepared, approved and/or were copied on these coordination sheets. 679 The
Committee has been unable to find any indication that any of these ARs informed the FAA about
this critical test data. Moreover, Boeing has informed the Committee that it has been unable to
locate any record showing that any of these coordination sheets were shared with the FAA. 680
The language throughout the years in the Boeing coordination sheets remained virtually
unchanged regarding the consequences of the 10-second pilot reaction time. It said:
Stabilizer runaways to pilot reaction (item D) were performed. These

failures were arrested by use of the aisle stand cutout switch when the
pilot recognized and reacted to the runaway. Assessments were done
during WUTs only i.e. within the operational flight envelope, but not
assessed by mistrim trim dive recoveries (normal operating envelope).
With pilot training to recognize the runaway and use of teamwork,
the failure was found Hazardous, which is the same as the item C
finding. A typical reaction time was observed to be approximately 4
seconds. A slow reaction time scenario (>10 seconds) found the
failure to be catastrophic due to the inability to arrest the airplane
overspeed. 681
Boeing MCAS Coordination Sheets Boeing produced two of these coordination sheets
2015-2018 in 2015, two in 2016, and one in 2017. It is notable
that Boeing also produced an updated coordination
“A SLOW REACTION TIME sheet on June 11, 2018, more than one year after the
737 MAX had been certified by the FAA and was
SCENARIO (>10 SECONDS) already flying in commercial service, and the
FOUND THE FAILURE TO BE assessment of a pilot taking more than 10-seconds
CATASTROPHIC DUE TO THE to react to uncommanded MCAS activation
INABILITY TO ARREST THE remained unchanged. 682 Yet the FAA, as well as
AIRPLANE OVERSPEED.” MAX pilots and airlines that purchased the 737
MAX aircraft were unaware of Boeing’s findings
regarding the catastrophic consequences of a greater than 10-second reaction time to uncommanded
T&I 253262 - TBC T&I 253268 at TBC T&I 253267 (On file with the Committee); and Boeing Coordination Sheet,
MAX (-7/8/9), Revision D, March 30, 2016, accessed at p. 164 here: https://www.govinfo.gov/content/pkg/CHRG-
MAX (-7/8/9), Revision F, December 20, 2017, TBC T&I 037449 - TBC T&I 037457 at TBC T&I 037457 (On file with
the Committee); Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,”
No. Aero-B-BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June, 11 2018, accessed at p. 174 here:
679 Ibid.
680 Email from Boeing attorney to Committee staff, February 10, 2020, 10:42 PM. (On file with the Committee).
681 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” October 19,
2015, TBC-T&I 253262 - TBC-T&I 253268 at TBC-T&I 253262 at TBC-T&I 253267. (On file with the Committee).
115
MCAS activation—and the fact that Boeing’s own test pilot failed to respond quickly enough in a
flight simulator—as far as the Committee is aware.
Even the most senior leadership of Boeing’s 737 MAX program were unaware of the 10-
second reaction time issue. In transcribed interviews with Committee staff in April 2020, Michael
Teal, the former Chief Project Engineer on the 737 MAX program, said he only learned of the 10-
second reaction time issue as part of his preparation for the Committee’s interview. 683 Keith
Leverkuhn, the former 737 MAX Vice President and General Manager, told Committee staff that he
also was unaware of the 10-second reaction time evidence that Boeing had at the time, but deflected
his response regarding whether Boeing had an obligation to share this information with the FAA.
He said he did have a general understanding that “if the crew does not react within that period of
time to certain nonnormals, that they can be catastrophic.” 684
According to Indonesia’s final report on the Lion Air crash, accident investigators testing
MCAS in a 737 MAX simulator found that, “after just two activations of MCAS, absent any counter
from the pilot, the control column force became ‘too heavy’ to move.” 685 MCAS activated more
than 20 times during the roughly six minutes leading up to the Lion Air accident, 686 and MCAS
activated four times in the minutes leading up to the Ethiopian Airlines accident. 687
Boeing had assumed that repetitive MCAS activations would not adversely impact the ability
of the MAX pilots to maintain control of the aircraft despite the fact that a Boeing AR raised this
question. Boeing “Engineering and Test pilots discussed scenario of repeated unintended MCAS
activation during MAX development,” according to a December 2018 Boeing presentation to the
FAA, “and deemed [it] no worse than single unintended MCAS activation.” 688 Those assumptions
were proven tragically wrong.
737 MAX Chief Project Engineer Approved MCAS Without Fully Understanding It
Michael Teal, Vice President, Chief Project Engineer and Deputy Program Manager of the
737 MAX program, approved the design of MCAS, despite being unaware of basic facts about the
system. He was not aware that MCAS relied on a single sensor. He was not aware that MCAS could
684 Committee staff transcribed interview of Keith Leverkuhn, Vice President and General Manager, 737 MAX, Boeing
Commercial Airplanes (BCA), May 19, 2020.

685 Dominic Gates, Lewis Kamb, “Indonesia’s devastating final report blames Boeing 737 MAX design, certification in
Lion Air crash,” Seattle Times, Oct. 24, 2019, accessed here: https://www.seattletimes.com/business/boeing-
aerospace/indonesias-investigation-of-lion-air-737-max-crash-faults-boeing-design-and-faa-certification-as-well-as-
airlines-maintenance-and-pilot-errors
686 Sinead Baker, “This timeline shows exactly what happened on board the Lion Air Boeing 737 Max that crashed in
less than 13 minutes, killing 189 people,” Business Insider, Oct. 29, 2019, accessed here:
https://www.businessinsider.com/lion-air-crash-timeline-boeing-737-max-disaster-killed-189-2019-10
687 Oren Libermann, Robyn Kriel and Kaleyesus Bekele, “Boeing CEO ‘sorry’ for lives lost in 737 MAX accidents,”
CNN, April 5, 2019, accessed here: https://www.cnn.com/2019/04/04/world/ethiopian-airlines-crash-preliminary-

report-intl/index.html
688 “MCAS Development and Certification Overview,” Boeing presentation to FAA, December 17, 2018, TBC-T&I
130075– TBC-T&I 130117, at TBC-T&I 130109, accessed at p. 197 here:

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf. The same presentation
also noted, at TBC-T&I 130109, that the rationale for that assessment was documented in a pilot meeting summary
email on June 22, 2016 but that it was “not documented in formal certification” records.
116
activate repeatedly, and he was not aware that it had taken Boeing’s own test pilot more than 10
seconds to respond to an uncommanded MCAS activation in a flight simulator and the pilot
described his experience as “catastrophic.” Mr. Teal acknowledged this in a Committee staff
interview:
T&I Committee Staff: And just to refresh my recollection, at the

time that you approved MCAS, you were not
aware that it operated from a single AOA
sensor, you were not aware that it could
activate repeatedly, and you were not aware
that Boeing was aware that if a pilot didn't
react in 10 seconds to an MCAS activation the
result could be catastrophic.
At the time you signed -- this was all

information that you were not aware of when
you signed off on MCAS.
Mr. Teal: That is correct. 689
In the interview, Mr. Teal explained that as the Vice President and Chief Project Engineer of
the 737 MAX program, he was “responsible for the requirements, the configuration, the design, the
testing, the certification and overseeing of any issues in the build process, mainly the engineering
work.” 690 Yet, while serving in that position, “no employees actually report[ed] to me. …. no
engineers directly report[ed] to me,” he said. “They all are functionally aligned to the engineering
leaders of the company.” 691 According to Mr. Teal, the structural engineers reported to the lead of
the structural engineering Integrated Product Team (IPT) and the propulsion experts reported up
through the propulsion IPT leader, for example. “But from a daily direction and overseeing of the
program, you know,” Mr. Teal said, “you could say that none of them worked for me but all of them
worked for me, is what I like to say.” 692
That organizational structure seems to have both dampened internal oversight at Boeing and
diminished accountability regarding Boeing’s 737 MAX program, particularly among its most senior
leaders. To thank Mr. Teal for his leadership of the 737 MAX program and for helping to keep the
program on schedule, Mr. Teal received a bonus in the form of restricted Boeing stock shares after
the first flight of the 737 MAX in January 2016. 693 He now serves as the Vice President and Chief
Project Engineer of Boeing’s 777X program.
Pilots Uninformed About MCAS, References Removed
Boeing not only discounted concerns from its own engineers that in hindsight proved
remarkably pertinent to improving the safety of the 737 MAX, but it also did not share certain
690 Ibid.
691 Ibid.
692 Ibid.
693 Ibid.
117
information about what it knew about MCAS with— regulators, and it chose not to inform the vast
majority of MAX pilots about the very existence of MCAS. The unions representing pilots at
American Airlines and Southwest Airlines, both of which operate the 737 MAX, allege their
members were not made aware of MCAS and the system’s ability to command the 737 MAX into a
dive until after the Lion Air crash. Captain Dan Carey, then-President of the Allied Pilots
Association, which represents American Airlines pilots, testified before the Subcommittee on
Aviation in June 2019 that, “[t]he huge error of omission was the fact that Boeing failed to disclose
the existence of the MCAS system to the pilot community around the world.” 694 The Southwest
Airlines Pilots Association has sued Boeing over the omission. 695
However, the Committee’s investigation discovered that Southwest Airlines was made aware
of the existence, and purpose of, MCAS on the 737 MAX. 696 Nevertheless, this information was not
shared with MAX pilots, and references to MCAS were eventually removed from 737 MAX related
documents provided to air carriers, including Southwest Airlines, at Boeing’s request.
In July 2014, before efforts to remove that material took place, Mark Forkner, the 737 Chief
Technical Pilot at Boeing, and a colleague, gave a 75-page presentation to Southwest Airlines that
was labeled: “737-8 MAX Flight Crew Training (For Southwest Airlines internal use only).” 697 Two
slides gave a description of MCAS describing its purpose and operating envelope. Among other
things, the slides explained that MCAS “[a]ugments pitch stability at high angles-of-attack,” that it is
“[r]equired to maintain compliance to FAA Certification requirements,” that it “[o]perates outside of
normal operating envelope,” and that it is “[d]isabled with autopilot engaged.” 698
The presentation also indicated, “MCAS autonomously inputs nose down stabilizer when
angle-of-attack trigger is exceeded;” “MCAS is not active during normal operation; Operates near
stall;” “MCAS produces maneuvering characteristics similar to 737-800;” and “Small amount of trim
wheel movement during MCAS activity.” 699 It is important to note, however, that this was two years
prior to the redesign of MCAS which expanded its range and granted it greater authority.
694 Testimony of Dan Carey, then-President of Allied Pilots Association, Hearing titled, “Status of the Boeing 737 MAX:
Stakeholder Perspectives,” House Committee on Transportation and Infrastructure Subcommittee on Aviation, U.S.
House of Representatives, 116th Congress, First Session, June 19, 2019, p. 18, accessed here:
https://transportation.house.gov/imo/media/doc/CA%20Carey%20Hearing%20testimony%20.pdf); see also Southwest
Airlines Pilots Ass’n v. The Boeing Co., Case No. DC-19-16290 (Dist. Ct. for Dallas County, Texas), Plaintiff’s Original
Petition, at 2 (Oct. 7, 2019) (alleging, in part, that “Boeing made a calculated decision to rush a re-engined aircraft to
market to secure its single-aisle market share and prioritize its bottom line. In doing so, Boeing abandoned sound design
and engineering practices, withheld safety critical information from regulators and deliberately mislead [sic] its
customers, pilots and the public about the true scope of design changes to the 737 MAX.”), accessed here:
https://swaparesources.s3-us-west-2.amazonaws.com/assets/pdf/Communication/Complaint_Against_Boeing_(2).pdf
695 David Koenig, “Southwest pilots’ union sues Boeing over grounding of plane,” Associated Press (AP), October 7, 2019,
accessed here:
https://apnews.com/b07e9d1121b34a0f884d6626c07fa876; see also Southwest Airlines Pilots Ass’n v. The Boeing Co., Case
No. DC-19-16290 (Dist. Ct. for Dallas County, Texas), Plaintiff’s Original Petition, Oct. 7, 2019, accessed here:
https://swaparesources.s3-us-west-2.amazonaws.com/assets/pdf/Communication/Complaint_Against_Boeing_(2).pdf
696 Manager, 737MAX/777X FT Development and 737 MAX Chief Technical Pilot, “737-8 MAX Flight Crew Training,
(For Southwest Airlines internal use only), July 24, 2014, TBC T&I 447158, TBC T&I 447203-447204. (On file with the
Committee).
697 Ibid.
698 Ibid.
699 Ibid.
118
The redesign of MCAS, which was approved in March 2016, also coincided with Boeing’s
efforts to remove MCAS from pilot training materials for its MAX customers. In a March 30, 2016,
email, Mr. Forkner assured an FAA official that references to MCAS could be deleted from the
official FCOM and other 737 MAX training documents because MCAS is “completely transparent
to the flight crew and only operates WAY outside of the normal operating envelope.” 700 The FAA
ultimately permitted Boeing to remove references to MCAS.
According to internal Boeing emails, Mr. Leverkuhn approved of the redesign of MCAS in
March 2016, expanding the range of flight conditions in which MCAS could operate to enable it to
activate at lower speeds. 701 However, Mr. Teal acknowledged in his interview with Committee staff
that he authorized the redesign of MCAS as well. 702
In any event, on March 30, 2016, just a few hours after approval was given to redesign
MCAS, Boeing requested permission from FAA to remove references to MCAS from the FCOM. 703
Mr. Leverkuhn said that he “was not aware” at the time that Mr. Forkner was making a request to
the FAA to remove references to MCAS from the FCOM. 704 Asked (1) if he was aware that Mark
Forkner was planning to make this request to the FAA, (2) when he first learned of this request
being made, (3) whether he was told in advance this request might be made, or (4) if he was aware of
the request to remove MCAS from the FCOM prior to the meeting that approved the redesign of
MCAS—Mr. Teal responded “I don’t recall” to all four questions. 705
The Committee staff did not find evidence as to whether Mr. Forkner was specifically
informed about the redesign of MCAS at the time. Both Mr. Leverkuhn and Mr. Teal said that they
believed Mr. Forkner, and the team of technical pilots he led, should have been informed about their
approval to redesign MCAS, but they are not certain if this information was shared with him or
not. 706 The Committee was unable to interview Mr. Forkner as part of our investigation. The
Committee also sought to interview several other individuals who had previously served in senior
positions at the FAA but was unsuccessful. 707
MCAS Did Not Meet Its Own Design Requirements
On top of all of the other issues surrounding MCAS and the questions from Boeing’s own
engineers that appear to have not been thoroughly addressed, MCAS also failed to meet several of
700 Email from Mark Forkner to FAA, “MCAS Lives in Both FCCs,” March 30, 2016.
Program Manager for the 737 MAX program, May 11, 2020.
with Committee); Email from Mark Forkner to FAA, “Subject: MCAS lives in both FCCs,” March 3, 2016 (On file with
the Committee).
704 Committee staff transcribed interview of Keith Leverkuhn, former Vice President and General Manager, 737 MAX,
Boeing Commercial Airplanes (BCA), May 19, 2020.

Program Manager for the 737 MAX program, May 11, 2020. Committee staff transcribed interview of Keith Leverkuhn,
former Vice President and General Manager, 737 MAX, Boeing Commercial Airplanes (BCA), May 19, 2020.
707 This included, John S. Duncan, former Deputy Associate Administrator for Aviation Safety and former Executive
Director of the FAA's Flight Standards Service; Dorenda Baker, former Director of the Aircraft Certification Service
(AIR), and Margaret “Peggy” Gilligan, former FAA Associate Administrator for Aviation Safety.
119
Boeing’s own design requirements on certain issues. According to the Boeing Coordination Sheets
regarding MCAS, the Aerodynamics Stability & Control Requirements included:
“MCAS shall not have any objectionable interaction with the piloting
of the airplane.” 708
“MCAS shall not interfere with dive recovery.” 709
In both the Lion Air and Ethiopian Airlines accidents MCAS failed to meet these design
requirements. At the Committee’s October 30, 2019, 737 MAX hearing, John Hamilton, then-Chief
Engineer for the Boeing Commercial Airplanes division, acknowledged that at least one of these
requirements was not met in response to a question from Representative Greg Stanton.
Mr. HAMILTON. When the MCAS wasn’t trimmed out, as we

assumed it would be, it caused the airplane to go into a dive that the
crews were not able to recover from.
Mr. STANTON. Mr. Hamilton, was MCAS a contributing factor into

the dive, as noted in the final accident report released by Indonesian
investigators?
Mr. HAMILTON. Yes. 710
In short, MCAS was poorly designed, not adequately tested, and received flawed oversight
by the FAA. Greg Travis, the software engineer and private pilot who wrote about MCAS in the
IEEE’s Spectrum magazine last year put the Boeing design and development process in stark terms:
Boeing produced a dynamically unstable airframe, the 737 Max. That

is big strike No. 1. Boeing then tried to mask the 737’s dynamic
instability with a software system. Big strike No. 2. Finally, the
software relied on systems known for their propensity to fail (angle-
708 Boeing Coordination Sheet March 30, 2016 in House Committee on Transportation and Infrastructure hearing
record, “The Boeing 737 MAX: Examining the Design, Development and Marketing of the Aircraft,” October 30, 2019,
p. 161, accessed at: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf and
Boeing Coordination Sheet June 11, 2018 in House Committee on Transportation and Infrastructure Hearing record,
“The Boeing 737 MAX: Examining the Design, Development and Marketing of the Aircraft,” October 30, 2019, p. 170
accessed at: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf
709 Boeing Coordination Sheet March 30, 2016 in House Committee on Transportation and Infrastructure hearing
record, “The Boeing 737 MAX: Examining the Design, Development and Marketing of the Aircraft,” October 30, 2019,
p. 162 accessed at: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf and
Boeing Coordination Sheet June 11, 2018 in House Committee on Transportation and Infrastructure Hearing record,
“The Boeing 737 MAX: Examining the Design, Development and Marketing of the Aircraft,” October 30, 2019, p. 170
accessed at: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf
30, 2019, p. 80 accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/
CHRG-116hhrg38282.pdf
120
of-attack indicators) and did not appear to include even rudimentary
provisions to cross-check the outputs of the angle-of-attack sensor
against other sensors, or even the other angle-of-attack sensor. Big
strike No. 3. None of the above should have passed muster. 711
Despite that assessment, the two most senior Boeing officials on the 737 MAX program
were both extraordinarily reluctant to acknowledge any missteps or mistakes in the development of
the 737 MAX aircraft. In an interview with Committee staff, Michael Teal, the former 737 MAX
Vice President, Chief Project Engineer and Deputy Program Manager, said: “We believed that we
have a safe aircraft as designed, as intended, and put out with the designs and training associated
with it.” 712 Mr. Teal defended Boeing’s work by saying the company followed its process. For
example:
T&I Committee Staff: [B]ecause you followed the process, your

testimony is that the 737 MAX was safe
when it was certified.
Mr. Teal: My testimony, that by defining and

delivering and certifying the aircraft, it has
been determined as safe. That is the
process we worked through. 713
The responses the Committee has received from senior Boeing officials about MCAS and
the now well-documented technical flaws, management failures, and multiple missed opportunities
to correct the tragic path that MCAS took, and its contribution to two fatal MAX crashes has been
disturbing because of the clear resistance to acknowledge any technical gaffes or managerial
miscalculations on the part of Boeing that now seem blatantly obvious and abundantly clear to
anyone that looks. Unfortunately, MCAS was not the only component on the 737 MAX that had
problems.
711 Gregory Travis, “How the Boeing 737 Max Disaster Looks to a Software Developer,” IEEE Spectrum, April 18, 2019,
accessed here: https://spectrum.ieee.org/aerospace/aviation/how-the-boeing-737-max-disaster-looks-to-a-software-
developer
713 Ibid.
121
6. AOA Disagree
Alert
6. AOA Disagree Alert
-AOA Disagree Alert-
 Boeing has publicly blamed its software supplier, a company now known as Collins
Aerospace Systems, for tying the AOA Disagree alert, which was supposed to be a standard
feature on all 737 MAX aircraft, to an optional AOA Indicator display 714—the result of
which rendered the AOA Disagree alert inoperable on more than 80 percent of the MAX
aircraft. However, the Committee’s investigation found that in July 2015, Boeing tested this
software and failed to detect the problem. 715 Ultimately, Boeing did not publicly
acknowledge that the AOA Disagree alerts on more than 80 percent of the 737 MAX fleet
were inoperative until after the Lion Air crash in October 2018. 716
 In August 2017, three months after the 737 MAX entered revenue service, Boeing issued a
new problem report 717 solely to its software supplier establishing that the 737 MAX’s AOA
Disagree alert was tied to the optional AOA Indicator display and therefore was not
functioning on the vast majority of the 737 MAX fleet worldwide. 718
 Rather than immediately informing the FAA about the inoperable AOA Disagree alert and
advising Boeing to fix the problem as soon as possible, a Boeing Authorized Representative
714 The Boeing Company, Press Statement, “Boeing Statement on AOA Disagree Alert,” May 5, 2019, accessed here:
https://boeing.mediaroom.com/news-releases-statements?item=130431 (Hereafter referred to as “Boeing Statement on
AOA Disagree Alert).
715 “AOA DISAGREE Displayed with AOA Fail Flag,” Problem Report (PR) 195, PR opened: May 14, 2015, PR
closed: July 29, 2015, BATES Number TBC T&I TBC 267345-267346 and BATES Number COLLINS_00075 -
COLLINS_00076. (On file with the Committee). (Hereafter referred to as “AOA Disagree Alert Problem Report
#195”).

may-draw-faa-penalty See also Boeing Statement on AOA Disagree Alert, and Boeing AOA Disagree Alert Narrative at
TBC-T&I 267830 - TBC-T&I 267831 (On file with the Committee).
717 Problem reports are routinely used in the software development and quality assurance process to define, analyze and
resolve software related problems. See: “Software Problem Report,” QA Platforms, March 9, 2019, accessed here:
https://qa-platforms.com/software-problem-report-spr. Various FAA records document how to maintain a proper
problem reporting system, such as “Software Approval Guidelines,” Federal Aviation Administration (FAA), Order
8110.49, CHG 2, accessed here:
https://www.faa.gov/documentLibrary/media/Order/FAA_Order_8110.49_with_chg_2.pdf and “Safety Issues and
Shortcomings With Requirements Definition, Validation, and Verification Processes Final Report,” DOT/FAA/TC-
16/39, December 2016, accessed here:
https://www.faa.gov/aircraft/air_cert/design_approvals/air_software/media/TC-16-39.pdf
718 Boeing AOA Disagree Alert Narrative. BATES Number TBC-T&I 267826 – TBC-T&I 267833 at TBC-T&I 267830
(hereafter referred to as “Boeing AOA Disagree Alert Narrative”) (On file with the Committee); and Alan Levin,
“Boeing Failure to Fix 737 MAX Warning Light May Draw FAA Penalty,” Bloomberg, February 21, 2020, accessed
here: https://www.bloomberg.com/news/articles/2020-02-21/boeing-failure-to-fix-737-max-cockpit-light-may-draw-
faa-penalty. Requirements Definition, Validation, and Verification Processes Final Report,” DOT/FAA/TC-16/39,
December 2016, accessed here: https://www.faa.gov/aircraft/air_cert/design_approvals/air_software/media/TC-16-
39.pdf
718 Boeing AOA Disagree Alert Narrative. BATES Number TBC-T&I 267826 – TBC-T&I 267833 at TBC-T&I 267830,
(Hereafter referred to as “Boeing AOA Disagree Alert Narrative”).
123
INVESTIGATIVE FINDINGS – Continued
 (AR) consented to Boeing’s plan to postpone a software update to fix the problem until
2020, nearly three years later, so it could be done in conjunction with the planned rollout of
the MAX-10 aircraft. 719 This decision to defer the fix to 2020 was made in September
2017. 720
 Boeing’s August 2017 problem report said: “explain how communicated to operators FTD,”
implying that Boeing intended to inform its customer airlines of the AOA Disagree alert
issue via a Fleet Team Digest (FTD). In fact, Boeing ultimately prepared a FTD.
Inexplicably, they never sent it keeping their customers in the dark about this issue. 721
 On August 16, 2018, Boeing produced a Flight Crew Operations Manual (FCOM) for Lion
Air’s MAX aircraft that contained a description and graphic of a functioning AOA Disagree
alert, despite the fact that Boeing had known for one year that it was not functioning on the
majority of the 737 MAX fleet, including Lion Air’s purchased MAX aircraft. 722
 The non-functioning AOA Disagree alert was one of three missed opportunities to discover
that an AOA sensor on the aircraft that would become Lion Air flight 610 was faulty before
flight 610 departed. Testing at Xtra Aerospace could have discovered the AOA sensor’s
mis-calibration before the refurbished part was cleared for return to service. 723 The mis-
calibration could also have been caught when the part was installed on Lion Air’s aircraft in
Denpasar. 724 Third, a properly functioning AOA Disagree alert could have alerted Lion Air’s
Jakarta-bound flight crew, and ultimately aircraft maintenance, that there was a potential
problem with an AOA sensor before the aircraft was used for Lion Air flight 610. 725
 The AOA Disagree alert was not considered a safety-critical component by either Boeing or
the FAA. However, in July 2019, then-Acting FAA Administrator Dan Elwell informed the
Committee that “[a]lthough an AOA disagree message was not necessary to meet FAA
safety regulations, once it was made part of the approved type design, it was required to be
installed and functional on all 737 MAX airplanes Boeing produced.” 726
719 Boeing AOA Disagree Alert Narrative at TBC-T&I 267830 - TBC-T&I 267831.
720 “737-7/-8/-9 MAX Display System MDS Certification Summary,” Document Number D242A408, Release/Revision
F, September 8, 2017, BATES Number TBC T&I 267387-267678, at TBC T&1 267617, pp. 1, 231, (AOA Disagree
Annunciation) (On file with the Committee).
721 “AOA DISAGREE Annunciation,” Problem Report (PR) 693, PR opened: August 10, 2017, PR closed: February 1,
2019, BATES Number TBC-T&I 267363-267365 at TBC-T&I 267365 and BATES Number COLLINS_00014 -
COLLINS_00016. (On file with the Committee). (Hereafter referred to as “AOA Disagree Alert Problem Report
#693”). See also AOA Disagree Alert Narrative at TBC-T&I 267831
722 737-8 Flight Crew Operations Manual, P. T. Lion Mentari, August 16, 2018, accessed at pp. 175-177 here:
https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf. See also Boeing

Statement on AOA Disagree Alert and Boeing AOA Disagree Alert Narrative at TBC-T&I 267830 - TBC-T&I 267831
723 Lion Air Flight 610 Final Aircraft Accident Investigation Report, p. xviii, accessed here: https://aviation-is.better-
724 Ibid.
725 Ibid., p. 178, accessed here: https://aviation-is.better-than.tv/737%20MAX%202018%20-%20035%20-%20PK-
LQP%20Final%20Report.pdf
of functional AOA Disagree alerts on all Boeing 737 MAX aircraft, July 11, 2019 (On file with the Committee).
124
 Boeing has maintained it appropriately deferred the fix to the AOA Disagree alert because
an inoperable alert did not lessen safety. The company also asserted that Boeing’s senior
leadership only became aware of the non-functioning AOA Disagree alert issue after the
Lion Air crash. 727 At the same time, Boeing has said that multiple company officials,
including systems engineers, pilots, and crew operations specialists—as well as an AR—
reviewed the issue in 2017. 728 Yet Boeing continued to produce and deliver its MAX aircraft
to customers before the Lion Air crash knowing the AOA Disagree alert was inoperable on
most 737 MAX aircraft without informing them of this non-functioning component.
 As far as the Committee is aware, the FAA has so far failed to hold Boeing accountable for
its lack of transparency regarding the AOA Disagree alert and the fact that Boeing knowingly
continued to manufacture and deliver MAX aircraft with inoperative AOA Disagree alerts,
which did not conform to the MAX’s FAA approved type certificate.
 The AOA Disagree alert issue may not rise to what Boeing and the FAA believe are critical
safety issues. However, the Committee’s investigation has found that it sheds light on a
broader cultural issue within Boeing regarding business decisions the company makes when
it is forced to confront ethical issues impacting its customers.
Angle of Attack (AOA) Disagree Alert and AOA Indicator
An airplane’s angle of attack (AOA) refers to the angle between an airplane’s wings and the
oncoming air during flight. 729 AOA sensors or vanes, located on the outside of both sides of the
flight deck 730 on the 737 MAX, gather this data, which feeds into various indications, cautions, and
warnings to the flight crew, as well as automated functions. Most importantly, when the AOA vanes
detect a critically high AOA, the airplane’s computers activate a “stick shaker” and associated stall
warnings to inform the flight crew that the airplane is approaching an aerodynamic stall, or a loss of
lift because the air can no longer flow across the wings undisturbed. 731
In the case of the 737 MAX, the AOA Disagree alert is a feature on the flight display that
illuminates if the left or right angle of attack sensors disagreed by more than 10 degrees, for more
than 10 continuous seconds. 732 This safeguard and redundancy was utilized due to the fact that angle
727 Boeing Statement on AOA Disagree Alert.

728 Boeing AOA Disagree Alert Narrative at TBC-T&I 267830 (On file with the Committee).
729 See: “What is Angle of Attack?” AERO, October 2000, The Boeing Company, accessed here:
http://www.boeing.com/commercial/aeromagazine/aero_12/whatisaoa.pdf and “Angle of Attack (AOA) Systems,”

April 2018, UTC Aerospace Systems, accessed here: https://utcaerospacesystems.com/wp-
content/uploads/2018/04/Angle-of-Attack-AOA-Systems.pdf
730 “Flight deck” is the more modern term for a “cockpit.” According to Aviation Stack Exchange, “A cockpit is a hole
with a seat that you strap into for the entire flight. A flight deck is a larger version of a cockpit, where you can at least
leave your seat and walk behind it.” See: https://aviation.stackexchange.com/questions/66094/cockpit-vs-flight-
deck#:~:text=A%20cockpit%20is%20a%20hole,the%20top%20of%20the%20ship
731 “Stall Warning Systems,” Skybrary, accessed here: https://www.skybrary.aero/index.php/Stall_Warning_Systems
125
of attack sensors have been known to fail and to provide faulty data. 733 Starting in 2006, the AOA
Disagree alert became a standard feature on the 737 NG and subsequently on the 737 MAX. 734
Boeing implemented it as a standard feature on the 737 NG in response to a customer request. 735
Some aircraft are also equipped with an AOA Indicator. This indicator is a dial in the upper
right-hand corner of the flight display that shows the airplane’s raw angle of attack data. 736 It offers a
visual indication of the amount of lift the wings are generating, thereby helping the flight crew avoid
a critically high AOA and, ultimately, a stall. 737
On the 737 MAX, while an AOA Indicator was an extra option that could be purchased on
the aircraft, less than 20 percent of MAX airplanes delivered before the Lion Air crash had an AOA
Indicator installed. 738 Since 1999, in response to requests from two separate Boeing customers, the
AOA Indicator has been available as an optional display feature on the MAX’s predecessor aircraft,
the 737 NG, and this option carried over to the 737 MAX. 739
How the AOA Disagree Alert Became Non-Functioning on the 737 MAX
In the case of the 737 MAX, Boeing used a supplier to code the software for the AOA
Disagree alert by following Boeing’s Specification Control Drawing (SCD) for the alert. At the time,
the supplier traded as Rockwell Collins (Collins), though today the company does business as
Collins Aerospace Systems (Collins Aerospace). 740 In essence, the software was responsible for
taking the inputs provided by the two AOA sensors on the left and right sides of the aircraft, and
then computing an angle of attack indication. But how that indication would be used was a subject
of confusion between Boeing and Collins.
733 See: Alan Levin and Ryan Beene, “Sensors Linked to Boeing 737 Crashes Vulnerable to Failure,” Bloomberg, April 10,
2019, accessed here: https://www.bloomberg.com/news/articles/2019-04-11/sensors-linked-to-737-crashes-vulnerable-

to-failure-data-show and Curt Devine and Drew Griffin, “Boeing relied on single sensor for 737 Max that had been
flagged 216 times to FAA,” CNN Investigates, April 30, 2019, accessed here:
https://www.cnn.com/2019/04/30/politics/boeing-sensor-737-max-faa/index.html
734 Boeing AOA Disagree Alert Narrative at TBC-T&I 267826 and TBC-T&I 267829. (On file with the Committee).
735 Boeing AOA Disagree Alert Narrative at TBC-T&I 267828. (On file with the Committee).
737 See: Rob Mark, “How It Works: Angle of Attack Indicator,” Flying, June 5, 2017, accessed here:
https://www.flyingmag.com/how-it-works-angle-attack-indicator/ and Lisa R. Le Vie, “Review of Research on Angle-

of-Attack Indicator Effectiveness, Langley Research Center, Hampton, Virginia, National Aeronautics and Space
Administration (NASA), NASA/TM–2014-218514, August 2014, accessed here:
https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20140011419.pdf
738 Boeing AOA Disagree Alert Narrative at TBC-T&I 267828 - TBC-T&I 267829. (On file with the Committee).
739 Ibid.
740 In November 2018, United Technologies Corporation (UTC) acquired Rockwell Collins and took the name Collins
Aerospace. See: Woodrow Bellamy III , “UTC Completes Acquisition of Rockwell Collins,” Aviation Today, November
27, 2018, accessed here: https://www.aviationtoday.com/2018/11/27/utc-completes-acquisition-rockwell-collins. In
April 2020, United Technologies Corporation, the parent company of Collins Aerospace merged with Raytheon
Corporation forming Raytheon Technologies Corporation. However, its subsidiary Collins Aerospace still maintains that
same name. See, “About Us,” Collins Aerospace, accessed here: https://www.collinsaerospace.com/en/who-we-
are/about-us and Carten Cordell, “Raytheon Completes Merger with United Technologies,” Washington Business Journal,
April 3, 2020, accessed here: https://www.bizjournals.com/washington/news/2020/04/03/raytheon-completes-
merger-with-united-technologies.html
126
In January 2014, Boeing and Collins engaged in a peer review of the software development,
and the result was a Boeing requirement that the AOA Disagree alert should be tied to the optional
AOA indicator. 741
In June 2014, Collins conducted an internal review of high-level requirements, and noticed
that the requirement to display the AOA Disagree alert was silent on whether or not it should be
linked to the AOA Indicator. 742 Collins submitted a change request to Boeing to help clarify this
issue. 743
In November 2014, in response to that change request, Boeing and Collins engaged in
another peer review, which concluded with Boeing stating that the AOA Disagree alert should not
be tied to the optional AOA Indicator. 744
In January and April of 2015, Collins delivered versions of the software build to Boeing that
did not tie the AOA Disagree alert to the optional AOA Indicator. 745
However, in May 2015 Boeing issued a problem report to Collins, concerning the AOA Fail
Flag. 746 The problem was that the AOA Disagree alert could be displayed at the same time the AOA
Fail Flag appeared on the primary flight display, a condition which should not occur. According to
Collins, the Fail Flag, “indicates that there is no valid angle of attack sensor input available on either
the pilot’s or co-pilot’s side.” 747 Such invalid data should not be used. Still, because it operated
independent of the AOA Indicator, the AOA Disagree alert could receive the faulty input data and
incorrectly use it for comparison to input from the opposite AOA sensor. The resulting display of
the AOA Disagree alert would be meaningless if that happened.
To fix the issue, on July 14, 2015, Collins updated the AOA Disagree alert logic to validate
that the AOA Indicator was displayed before displaying an AOA Disagree alert. This fix, however,
effectively tied the display of the AOA Disagree alert back to the display of the optional AOA
741 Letter from Collins Aerospace’s attorney to Chairs DeFazio and Larsen re AOA Disagree Alert, June 20, 2019, p. 8
(On file with the Committee). See also January 2014 Peer Review Report MAXPR-0000148, Finding #54, BATES
number COLLINS_00122 – COLLINS_00185 at COLLINS_00173 - COLLINS_00174. (On file with the Committee).
(On file with the Committee). See also Software High-Level requirements review MDSPR-0000369, finding #3, BATES
number COLLINS_00107 - COLLINS_00121 at COLLINS_00109. (On file with the Committee).
(On file with the Committee). See also PFD SCD Issues found during HL reviews, BATES number COLLINS_00105
(On file with the Committee). See also Boeing/Rockwell Collins Peer Review Record MAXPR-00343, finding #7,
BATES number COLLINS_00187 - COLLINS_00203 at COLLINS_00195 - COLLINS_00196. (On file with the
Committee).

(On file with the Committee). See also 37MAXMDS-S_PR195 (ITRACS PR 195), BATES number COLLINS_00075 -
COLLINS_00076 (On file with the Committee).
127
Indicator. 748 This meant that the AOA Disagree alert, although installed in every Boeing 737 MAX
airplane, would function only on the airplanes that were equipped with the optional AOA Indicator.
Boeing employees “re-tested” the software fix Collins had made and found that the Fail Flag
issue had been appropriately “resolved.” 749 On July 29, 2015, Boeing closed the problem report and
accepted Collins’ solution. 750
No one at Boeing appeared to realize that the fix to the Fail Flag issue had tied the AOA
Disagree alert to the AOA Indicator until years later. Boeing did eventually put new processes in
place to improve its verification and validation methods as a result of this incident, however.
Discovering the Non-Functioning AOA Disagree Alert
In March 2017, the FAA certified the 737 MAX. In August 2017, three months after airlines
had begun flying the MAX in revenue service, Boeing learned through tests it was conducting that
the AOA Disagree alert was not functioning on the vast majority of MAX aircraft. 751 The AOA
Disagree alert was only operating on aircraft whose owners had also purchased the optional AOA
Indicator. 752 Instead of promptly reporting its knowledge of this inoperable alert to the FAA, and
telling affected customers and pilots, Boeing chose to postpone the fix for the defect until 2020,
nearly three years later. 753 In essence, by its actions, Boeing chose to conceal this fact from the FAA,
affected customers, and MAX pilots. Most astoundingly, Boeing continued to manufacture and
deliver scores of MAX aircraft with non-functioning AOA Disagree alerts, without informing the
FAA, airlines, or pilots about the fact that the alert, though described in technical materials provided
to airlines, was not functioning on those airplanes.
Boeing has said none of its senior leadership was aware of the AOA Disagree alert issue at
the time. 754 However, multiple Boeing officials were aware of the AOA Disagree alert issue and the
decision to postpone fixing it for three years. 755 In addition, no one at Boeing, to the Committee’s
knowledge, has been held accountable for the company’s actions.
Furthermore, according to the FAA, the AOA Disagree alert is required to be installed and
functional on all MAX airplanes since it is part of the MAX’s approved type design. 756 Despite that,
to date the Committee is unaware of the FAA taking any punitive action against Boeing for its
handling of the AOA Disagree alert on MAX aircraft.

749 Boeing AOA Disagree Problem Report #195, 37MAXMDS-S_PR195, BATES Number COLLINS_0075 –
COLLINS_0076 at COLLINS_0076
(On file with the Committee). See also 37MAXMDS-S_PR195, BATES number COLLINS_0075 – COLLINS_0076 at
COLLINS_0076
751 Boeing AOA Disagree Alert Narrative at TBC-T&I 267828 - TBC-T&I 267830. (On file with the Committee).
752 Ibid.
753 Ibid. at TBC-T&I 267830 - TBC-T&I 267831
755 Boeing Statement on AOA Disagree Alert; Boeing AOA Disagree Alert Narrative at TBC-T&I 267830 (On file with
the Committee).
756 Letter from then-Acting FAA Administrator Dan Elwell to Chair DeFazio, July 11, 2019. (On file with the
Committee).
128
Angle of Attack (AOA) Disagree Alert - Timeline
January 2014 June 2014 November 2014

A Boeing-Collins peer review of Collins conducts an internal A Boeing-Collins peer review
the AOA Disagree alert software review of high-level concludes with Boeing stating
results in a Boeing requirement requirements for the AOA that the AOA Disagree alert
that the AOA Disagree alert, a Disagree alert but notices it was should not be tied to the
standard feature on all 737 MAX silent on whether or not the alert optional AOA Indicator.
aircraft, should be tied to the should be tied to the AOA
optional AOA Indicator. Indicator. Collins suggests that a
change might be necessary.
January - April 2015 May 2015 July 2015
Collins delivered various Boeing issues a “problem To fix the AOA Fail Flag issue,
versions of the software to report” to Collins concerning Collins updated the AOA
Boeing that did not tie the AOA the AOA Fail Flag, a separate Disagree alert logic, which
Disagree alert to the optional feature that is tied to the AOA resulted in effectively tying the
AOA Indicator per Boeing’s Indicator. AOA Disagree alert back to the
directions. optional AOA Indicator. Boeing
tested and accepted this fix
without realizing it had re-tied
the AOA Disagree alert back to
the AOA Indicator.
August 2017 November 7, 2017 October 29, 2018
During routine tests Boeing At a Collins-Boeing weekly status Lion Air flight 610 crashes killing
realized that the AOA Disagree meeting, Boeing confirmed that it 189 people. By the time of the
alert was now tied to the optional had decided to defer fixing the Lion Air crash Boeing had
AOA Indicator, meaning it only AOA Disagree alert for three knowingly delivered an estimated
functioned on less than 20 years, until 2020 when the 737 200 737 MAX airplanes to its
percent of MAX aircraft with the MAX-10 was then expected to customers with nonfunctioning
optional AOA Indicator. Boeing enter service. Boeing knowingly AOA Disagree alerts and failed
issued a new “problem report” to continued to both manufacture to inform them or the FAA of
Collins indicating that the AOA and deliver aircraft that did not that fact.
Disagree alert should not be tied conform to the 737 MAX’s FAA
to the optional AOA Indicator. approved aircraft type certificate.
November 6-7, 2018 May 2019 July 11, 2019
Boeing issues a Flight Crew After news reports about Boeing Then-Acting FAA Administrator
Operations Manual Bulletin for delivering aircraft with non- writes to Chairs DeFazio and
the 737 MAX, listing the AOA functioning AOA Disagree alerts Larsen. “Although an AOA
Disagree alert as one of several emerged at the end of April 2019, disagree message was not
possible indications of erroneous Boeing issued a statement on its necessary to meet FAA safety
AOA data, “if AOA indicator website, which blamed its regulations, once it was made
option is installed.” The FAA software supplier for the part of the approved type design,
issues a similar alert the following problem. “The software delivered it was required to be installed and
day. to Boeing linked the AOA functional on all 737 MAX
Disagree alert to the AOA airplanes Boeing produced,” it
Indicator, which is an optional says. The Committee is unaware
feature on the [737] MAX and the of any action the FAA has taken
[737] NG.” to hold Boeing responsible for its
actions regarding this matter.
129
Both Boeing 757 and the FAA 758 have argued that an AOA Disagree alert is not a safety-
critical feature. Boeing has also said that the AOA Disagree alert only “provides the flight crew with
supplemental information, not necessary for safety of flight. The alert may direct the crew to
primary flight indicators, such as the airspeed and altitude alerts, which direct specific pilot action.
The alert itself, however, has never been designed to prompt any specific action by the crew…” 759
Nevertheless, as Boeing has also acknowledged to the Committee, the AOA Disagree alert
“would help in understanding flight deck effects resulting from the undetected failure of an AOA
sensor.” 760 Both MAX crashes involved faulty AOA input data from the aircraft’s AOA sensors. 761
Pilots flying aircraft with an AOA Disagree alert could rely on this alert, among other
indications, to inform them of a failed AOA sensor or flawed AOA data. But pilots flying the 737
MAX would have believed the AOA Disagree alert in their aircraft was functional because, although
Boeing knowingly produced 737 MAX airplanes without properly functioning AOA Disagree alerts,
Boeing nonetheless described the alert in the flight crew
Boeing Employee Email operating manuals provided to airlines for dissemination to their
October 5, 2017 pilots. Boeing knew the alert was not functioning properly and
failed to inform their MAX customers that this component was
“I STILL THINK WE inoperative.
NEED A BULLETIN TO
LET THEM [THE In discussing whether or not to inform 737 MAX pilots
PILOT’S] KNOW WHAT about the inoperable AOA Disagree alert through an Operations
Manual Bulletin (OMB), one Boeing employee wrote to a
THEY MAY BE colleague on October 5, 2017, “I still think we need a bulletin to
MISSING….” let them [the pilots] know what they may be missing….” 762 The
employee’s colleague responded by recommending Boeing send a Fleet Team Digest, rather than an
OMB, because the inoperable AOA Disagree alert was not considered a safety issue and because
there are no specific crew procedures to deal with a non-functioning alert. 763 In the end, Boeing
never sent either notice to MAX pilots.
758 Testimony of Earl Lawrence, FAA Executive Director of Aircraft Certification, Hearing titled, “Status of the Boeing
737 MAX: Stakeholder Perspectives,” Subcommittee on Aviation of the House Committee on Transportation &
Infrastructure, U.S. House of Representatives, 116th Congress, First Session, May 15, 2019, p. 46, accessed here:
759 Boeing AOA Disagree Alert Narrative at TBC-T&I 267829 at (On file with the Committee); See also “Transmittal of
Final Decision Safety Review Board SRB Presentation Materials for the Week of December 3, 2018,” Letter from
Boeing to FAA, December 14, 2018, BATES Number TBC T&I 267686-267814, at TBC T&I 267751-267762 (“Issue
Title: Pilot Recognition and Response to AoA Disagree without Flight Deck Indication,” Safety Review Board,
December 6, 2018) (On file with the Committee).
760 Boeing AOA Disagree Alert Narrative at TBC-T&I 267828.
761 See: Dominic Gates, “Pilots struggled against Boeing’s 737 MAX control system on doomed Lion Air flight,” Seattle
Times, November 27, 2018, accessed here: https://www.seattletimes.com/business/boeing-aerospace/black-box-data-

reveals-lion-air-pilots-struggle-against-boeings-737-max-flight-control-system and Chris Loh, “Ethiopia Reveals Initial
Boeing 737 MAX Crash Findings,” Simple Flying, March 9, 2020, accessed here: https://simpleflying.com/ethiopia-
boeing-737-max-crash-findings
762 Internal Boeing Email, “Subject: RE New ops bulletins,” October 5, 2017, 1:50 PM, BATES Number TBC T&I
267376-267382, at TBC T&I 267377. (On file with the Committee).

763 Ibid. at TBC T&I 267376.
130
The Indonesian authority’s final report on the Lion Air crash also concluded that this lack of
information and lack of a functioning AOA Disagree alert reduced the flight crew’s situational
awareness. 764
Moreover, in a July 11, 2019, written response to Chair DeFazio and Subcommittee on
Aviation Chair Larsen, then-Acting FAA Administrator Elwell explained that the AOA Disagree
alert was required to be installed and functional on MAX aircraft regardless of whether or not it was
deemed safety-critical:
Once certified by the FAA, all features included on the airplane

become part of the certified type design or approved type design.
These features are mandatory in each airplane produced to that type
design thereafter, whether or not they are required for safety. …
Although an AOA disagree message was not necessary to meet FAA
safety regulations, once it was made part of the approved type design,
it was required to be installed and functional on all 737 MAX airplanes
Boeing produced. 765
Boeing’s Lack of Transparency Regarding the AOA Disagree Alert
In August 2017, upon discovering the AOA Disagree alert on 737 MAX aircraft was only
functioning on aircraft for which owners had purchased an optional AOA Indicator, 766 Boeing
issued a problem report to Collins Aerospace. 767 Boeing also conducted an internal review to
determine if the defect rendered the airplane unsafe, and if it could defer fixing the defect until a
later date. 768 Boeing’s internal review determined that the absence of a functioning AOA Disagree
alert did not adversely impact safety, and because of that, a fix could be deferred until the next
software update which was scheduled to occur in 2020 when the 737 MAX 10 variant was expected
to enter into service. 769 A Boeing AR concurred with the idea that a fix could be deferred. 770 The
decision to defer fixing the inoperable AOA Disagree alert was noted in a Boeing certification
summary document in September 2017. 771 A Collins Aerospace-Boeing weekly status meeting, on
764 Final KNKT.18.10.35.04 Aircraft Accident Investigation Report, PT. Lion Mentari Airlines, Boeing 737-8 (MAX);
Transportasi (KNKT), Republic of Indonesia, issued October 25, 2019, (hereafter referred to as: Lion Air Flight 610
Final Aircraft Accident Investigation Report,”), p. 181, accessed here: https://aviation-is.better-
765 Letter from then-Acting FAA Administrator Dan Elwell to Chair DeFazio, July 11, 2019. (On file with the
Committee).
767 Boeing AOA Disagree Alert Narrative, at TBC T&I 267830 (On file with the Committee). See also Letter from
Collins Aerospace’s attorney to Chairs DeFazio and Larsen re AOA Disagree Alert, June 20, 2019, p. 8 (On file with the
Committee), and 37MAXMDS-S_PR195 (ITRACS PR 195), BATES Number COLLINS_00075 - COLLINS_00076
768 Boeing AOA Disagree Alert Narrative at TBC T&I 267830 (On file with the Committee).
769 Boeing AOA Disagree Alert Narrative at TBC T&I 267830 – 267831 (On file with the Committee).
770 Boeing AOA Disagree Alert Narrative at TBC T&I 267830 (On file with the Committee).
771 “737-7/-8/-9 MAX Display System MDS Certification Summary,” Document Number D242A408, Release/Revision
F, September 8, 2017, BATES Number TBC T&I 267387-267678, at TBC T&1 267617, p. 231, (AOA Disagree
Annunciation). (On file with the Committee).
131
November 7, 2017, also confirmed Boeing’s decision to defer fixing the AOA Disagree alert until
the 737 MAX 10 entered service. 772
Boeing considered notifying

airlines who were flying the 737 MAX
about the defective AOA Disagree
alert, and even prepared a Fleet Team
Digest on the issue. 773 These digests
provide “in-service issues,” including
economic and safety-related
information to Boeing’s customers. 774
Ultimately, however, Boeing never
sent the digest, 775 and Boeing’s
customers and MAX pilots remained
unaware of the inoperable AOA
Disagree alerts until after the Lion Air
crash.
The Committee’s investigation

confirmed that Boeing continued to
mislead MAX pilots and Boeing
customers for more than a year after
Boeing learned about the lack of the
AOA Disagree alert’s functionality in
the majority of the 737 MAX fleet. For
instance, Boeing provided a Flight
Crew Operations Manual (FCOM) on
the 737 MAX to P.T. Lion Mentari,
the parent company of Lion Air, 776
dated August 16, 2018, a full year after
Boeing first learned that the AOA
Disagree alert was not working on most 737 MAX aircraft. 777 Yet the FCOM still contained a
description of a functioning AOA Disagree alert. 778
772 Slide from November 7, 2017 “737 MDS Weekly Telecon” meeting, Collins_00028. (On file with the Committee).
773 Boeing AOA Disagree Alert Narrative at TBC T&I 267831. (On file with the Committee).
774 Peter Weertman, “Working Together to Ensure Safe and Efficient Airplane Operations,” AERO Magazine, Issue 26,
Quarter 02, 2007, The Boeing Company, accessed here:

https://www.boeing.com/commercial/aeromagazine/articles/qtr_2_07/AERO_Q207_article1.pdf
776 “Explanation of Lion Air Company Status and Latest Information on Lion Air JT-610,” Press Release, Lion Air,
April 9, 2019, accessed here: http://www.lionair.co.id/about-us/newsroom/2019/04/09/explanation-of-lion-air-

company-status-and-latest-information-on-lion-air-jt-610
777 “737-8 Flight Crew Operations Manual – P.T. Lion Mentari,” Document Number D6-27370-MAX-MLI-, Revision
Number: 4, Revision Date: August 16, 2018,” accessed here at p. 175, https://www.govinfo.gov/content/pkg/CHRG-
778 “737-8 Flight Crew Operations Manual – P.T. Lion Mentari,” Document Number D6-27370-MAX-MLI-, Revision
Number: 4, Revision Date: August 16, 2018,” accessed here at p. 177 (“Angle of Attack (AOA) Disagree Alert”),
132
Specifically, the FCOM Boeing delivered to Lion Air continued to show pilots an image of a
functioning AOA Disagree alert, and assured them that the alert, “Indicates the Captain’s (left) and
First Officer’s (right) angle of attack values
disagree by more than 10 degrees for more
than 10 continuous seconds.” 779
By the time of the Lion Air crash at

the end of October 2018, a majority of the
MAX planes that Boeing had delivered to its
customers worldwide had flown in revenue
service with non-functioning AOA Disagree
alerts, unbeknownst to the crews who had
flown them. Approximately 250 MAX
airplanes had been delivered by November
2018. 780 Given the fact that more than 80
percent of the MAX aircraft at the time did
not have an optional AOA Indicator, 781
approximately 200 MAX aircraft were flying
at the time with non-functioning AOA
Disagree alerts. Neither Lion Air 782 nor
Ethiopian Airlines purchased the optional
AOA Indicator, so the AOA Disagree alerts
on board at the time of both of those
crashes were not functioning. 783
Following the October 29, 2018, Lion

Air crash, in which erroneous AOA data
appeared to be a contributing factor, Boeing
finally briefed the FAA on the defective
AOA Disagree alerts on MAX planes
lacking optional AOA Indicators. 784 Then,
on November 6, 2018, Boeing issued an
Operations Manual Bulletin (OMB), which
cautioned pilots about the risk of
uncommanded downward stabilizer trim
due to erroneous AOA data, and noted that
one of the indications that a MAX was experiencing erroneous AOA data was the “AOA
779 Boeing 737-8 Flight Crew Operations Manual, August 16, 2018, TBC-T&I 051408, accessed here at pp. 109-110:
780 “737 MAX: Deliveries Report,” The Boeing Company, accessed here:
782 Lion Air Flight 610 Final Aircraft Accident Investigation Report at p. 181.
783 Nick Zazulia, “Boeing Knew the AOA Disagree Alert on the 737 MAX Didn’t Work — and Said Nothing,” Aviation
Today, May 6, 2019, accessed here:

https://www.aviationtoday.com/2019/05/06/boeing-angle-of-attack-disagree-alert
784 Boeing Statement on AOA Disagree Alert
133
DISAGREE alert (if the AOA indicator option is installed).” 785 The following day, the FAA issued
an Emergency Airworthiness Directive (AD) which offered a similar warning to MAX pilots. 786
Also following the Lion Air crash, Boeing decided to accelerate its fix for the defective AOA
Disagree alert, instead of waiting until 2020. 787 On November 14, 2018, Boeing provided revised
software design requirements to Collins Aerospace and began working with the FAA to certify the
revised software. 788 On December 6, 2018, a Boeing Safety Review Board evaluated the AOA
Disagree alert issue and concluded that it “was not a safety issue.” 789 On February 13, 2019, the FAA
informed Boeing that an FAA Corrective Action Review Board (CARB) also found that the lack of
an AOA Disagree alert “did not represent an unsafe condition.” 790 The FAA certified the AOA
Disagree alert software update on February 25, 2019, and Boeing delivered one MAX aircraft with
the revised software installed prior to FAA’s grounding of the MAX on March 13, 2019. 791
When questioned at a Committee hearing in October 2019 by Rep. Sharice Davids about
Boeing’s handling of the its defective AOA Disagree alert,
Boeing’s then-President and Chief Executive Officer John Hamilton
Dennis Muilenburg conceded, “it was part of the airplane Boeing Chief Engineer
baseline. It should have been implemented on the Committee on Transportation
airplanes. It was not correctly implemented. We made a and Infrastructure Hearing
mistake.” 792 October 30, 2019
Rep. Davids pressed further, asking, “How do “I AM NOT SURE WHY WE
you decide which things are baseline that you are not
DIDN’T NOTIFY THE
going to adhere to, and which ones you are?” 793
CUSTOMERS OF THAT.”
Muilenburg responded, “Yes, Congresswoman, we missed on this one. We made a
mistake. We made a mistake. And we have owned up to that. We need to fix it.” 794
116hhrg38282.pdf
786 FAA Emergency Airworthiness Directive # 2018-23-51, November 7, 2018, accessed here:
23-51_Emergency.pdf
788 Ibid.
790 Ibid.
792 Testimony of Dennis Muilenburg, Boeing President and Chief Executive Officer, Hearing titled, “The Boeing 737
MAX: Examining the Design, Development, and Marketing of the Aircraft,” House Committee on Transportation &
Infrastructure, U.S. House of Representatives, 116th Congress, First Session, October 30, 2019, p. 110, accessed here:
793 Rep. Sharice Davids, Hearing titled, “The Boeing 737 MAX: Examining the Design, Development, and Marketing of
the Aircraft,” House Committee on Transportation & Infrastructure, U.S. House of Representatives, 116th Congress,
First Session, October 30, 2019, p. 110, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
794 Testimony of Dennis Muilenburg, Boeing President and Chief Executive Officer, Hearing titled, “The Boeing 737
134
Rep. Davids asked then-Chief Engineer of Boeing Commercial Airplanes, John Hamilton,
about Boeing delivering MAX aircraft to customers with a known, but undisclosed, defect. He
responded, “Congresswoman, yes, the airplane did not conform to the spec that—the disagree was
not working. I am not sure why we didn’t notify the customers of that.” 795
A Missed Opportunity with Lion Air
On October 28, 2018, the day before Lion Air flight 610 crashed into the Java Sea, the
aircraft’s left AOA sensor was replaced in Denpasar, Indonesia. 796 The replacement AOA sensor
was off by 21 degrees, but the mis-calibration went undetected during the installation test. 797
The mis-calibrated AOA sensor resulted in multiple indications on the flight deck during the
aircraft’s very next flight from Denpasar to Jakarta, Indonesia. These indications included IAS
(indicated airspeed) DISAGREE, ALT (altitude) DISAGREE, and FEEL DIFF PRESS (feel
differential pressure) alert lights. Moreover, it activated MCAS and the left control column stick
shaker was active throughout the flight. 798
The Jakarta-bound flight crew struggled to maintain control of the aircraft but were able to
do so with help. An off-duty pilot who happened to be dead-heading was seated in the jump seat in
the cockpit, and was able to tell the crew to cut power to the motor that was causing the stabilizer to
push the plane’s nose down. 799 The flight crew was ultimately able to stop the repetitive MCAS
activation by using the stabilizer trim cutout switch. 800
Upon arrival in Jakarta, the Captain of that flight mentioned to an engineer that the aircraft
had experienced a problem and filed an entry into the Aircraft Flight Maintenance Log, but did not
mention the activation of the stick shaker and did not report “that the STAB TRIM CUTOUT
guarded switches were positioned to CUTOUT during flight and after landing returned to the
NORMAL position” 801—that is, that the crew followed the procedure for a runaway stabilizer and
turned off, or “cut out,” power to the electric motor that moves the horizontal stabilizer (thus
neutralizing MCAS), and then the crew reengaged the power after landing. 802
Infrastructure, U.S. House of Representatives, 116th Congress, First Session, October 30, 2019, p. 110, accessed here:
795 Testimony of John Hamilton, Chief Engineer of Boeing Commercial Airplanes, Hearing titled, “The Boeing 737
Infrastructure, 116th Congress, First Session, October 30, 2019, pp. 109, accessed here:
797 Ibid.
798 Ibid.
799 John Bacon, “Jump-seat pilot reportedly saved Boeing Max jet one day before Lion Air crash,” USA Today, March 20,
2019, accessed here: https://www.usatoday.com/story/news/world/2019/03/20/boeing-max-pilot-reportedly-saved-

jet-one-day-before-lion-air-crash/3220891002
801 Ibid., p. 168.
802 Ibid.
135
Exacerbating the situation, the flight crew was unaware that the AOA Disagree alert was not
functional on the aircraft, 803 since Lion Air had not purchased an optional AOA Indicator. 804 Had
the AOA Disagree alert been functional, it would have indicated the significant difference between
the two AOA sensors. 805 It did not. As a result, the crew’s ability to detect the faulty AOA sensor
was diminished. 806 According to the Indonesian authority’s final investigative report:
…because the AOA DISAGREE message was not available on B737-

8 (MAX) aircraft not fitted with the optional AOA indicator, flight
crews would not be aware that this message would not appear if the
AOA DISAGREE conditions were met. This would contribute to
flight crew being denied valid information about abnormal conditions
being faced and lead to a significant reduction in situational awareness
by the flight crew. 807
A Missed Opportunity at Xtra Aerospace
The mis-calibrated AOA sensor that was installed in Denpasar was a refurbished part
supplied by Xtra Aerospace of Miramar, Florida. The part had been sent to Xtra a year earlier. 808
After it was disassembled, calibrated, and tested, the sensor was approved to return to service in
November 2017. 809 However, as noted above, the refurbished AOA sensor, “had a 21° bias,” which
ultimately went, “undetected during the installation test in Denpasar.” 810
On October 25, 2019, the FAA revoked Xtra Aerospace’s Repair Station Certificate for
failing “to comply with requirements to repair only aircraft parts on its list of parts acceptable to the
FAA that it was capable of repairing,” and failing, “to comply with procedures in its repair station
manual for implementing a capability list in accordance with the Federal Aviation Regulations.” 811
According to the FAA, “The company also did not substantiate that it had adequate facilities, tools,
test equipment, technical publications, and trained and qualified employees to repair parts on its
capability list.” 812
At Least Three Missed Opportunities to Catch Faulty AOA Sensor
In short, there were at least three opportunities to catch the faulty AOA sensor before Lion
Air flight 610 departed. First, testing at Xtra Aerospace could have discovered the AOA sensor’s
mis-calibration before the refurbished part was cleared for return to service. Second, the mis-
803 Ibid., p. 181.

804 Ibid., p. 46.
805 Ibid., p. 178.
806 Ibid.
807 Ibid., p. 181.
808 Dominic Gates, “FAA shuts down Florida repair firm that supplied faulty Lion Air sensor on Boeing 737 MAX,”
Seattle Times, October 25, 2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/faa-shuts-

down-revokes-certificate-of-florida-repair-firm-that-supplied-faulty-lion-air-sensor
809 Ibid.
811 FAA Press Release – FAA Revokes Repair Station Certificate of Xtra Aerospace of South Florida, October 25, 2019,
accessed here: https://www.faa.gov/news/press_releases/news_story.cfm?newsId=24314

812 Ibid.
136
calibration could have been caught when the part was installed on the aircraft in Denpasar. Third,
and most importantly, a properly functioning AOA Disagree alert could have alerted the Jakarta-
bound flight crew, and ultimately aircraft maintenance, that there was a potential problem with an
AOA sensor.
Culture of Omission
Boeing, the FAA, and other aviation experts do not believe the AOA Disagree alert is a
safety critical component. However, the tale of how Boeing dealt with the AOA Disagree alert issue
is extremely important and deeply disturbing. While Boeing has said its senior leadership was
unaware of the AOA Disagree alert issue at the time, it is clear multiple Boeing employees at
multiple levels in the company were fully aware the AOA Disagree alerts were not functioning on
the majority of the 737 MAX fleet. Some even initiated the process of informing Boeing’s customers
of this fact. For whatever reason that information never made its way out the door at Boeing and to
Boeing’s customers. Worse, Boeing continued to knowingly manufacture and deliver dozens of
MAX aircraft with a defective component to its customers, violating their approved type design.
Boeing made a decision to simply omit the fact that the AOA Disagree alert on the majority
of its 737 MAX fleet were inoperative not only from airlines, but from MAX pilots and the FAA as
well. This paints a troubling picture of the corporate and cultural challenges Boeing must squarely
face to regain the trust of Federal regulators, its customers, and the flying public. Boeing’s actions
may not have directly jeopardized the safety of any aircraft, but the way Boeing handled this issue
endangered the reputation of the company.
For its part, the FAA has failed to hold Boeing accountable for its actions on this issue. This
is despite the fact the then-Acting FAA Administrator made it clear to the Committee that once
Boeing decided to include the AOA Disagree alert as a standard feature on its MAX aircraft, it “was
required to be installed and functional on all 737 MAX airplanes Boeing produced,” per its approved
type design. 813 The AOA Disagree alert issue also highlights the fact that the FAA simply does not
have enough insight into Boeing’s activities in order to provide the robust oversight that is necessary
and expected of this Federal regulatory agency.
Letter from then-Acting FAA Administrator Dan Elwell to Chair DeFazio, July 11, 2019 (On file with the
813
Committee).
137
7. Boeing 737 MAX
Pilot Training
7. Boeing 737 MAX Pilot Training
-Boeing 737 MAX Pilot Training-
 Guaranteeing that the 737 MAX did not require simulator training for pilots transitioning
from the 737 NG to the 737 MAX was a key Boeing objective of the 737 MAX program. 814
 This goal demanded that pilot differences training be kept to 16 hours or less of Level B
(non-simulator) training requirements. 815 In the end, the FAA estimated that its approved
computer-based training for the MAX could be completed in approximately two hours. 816
 Ensuring no pilot simulator training was required was also a key feature of Boeing’s business
strategy for marketing the MAX to airlines. 817
 Boeing’s Chief Project Engineer on the 737 MAX program acknowledged in an interview
with Committee staff that ensuring no simulator training was required was a “design
objective” of the MAX program. 818
 Boeing had tremendous financial incentives to ensure the MAX program met this goal. 819
 In December 2011, Boeing agreed to pay Southwest Airlines $1 million per MAX airplane
that Boeing delivered to Southwest if its pilots were unable to operate the 737 NG and 737
MAX interchangeably due to any reason. 820 In addition, if the FAA required more than 10
hours of pilot training and/or required flight simulator training, Boeing would reimburse
SWA for any direct training expense that exceeded 10 hours. 821
 In July 2014, more than two years before the FAA determined its approved pilot training for
the MAX, Boeing publicly claimed no simulator training would be required on the MAX. 822
Program Manager of the 737 MAX program, Boeing Commercial Airplanes, May 11, 2020.
815 Boeing internal email from former 737MAX Chief Project Engineer to Boeing Commercial Airplanes (BCA) Senior
Chiefs and Functional Leaders, “Subject: 737MAX Firm Configuration Status/Help Needed,” Sent: May 4, 2013,
11:35:58 AM, BATES Number TBC-T&I049683-049684. (On file with the Committee).
816 “FAA Responses to Follow-Up Questions from House T&I Staff,” Sent: September 6, 2019, BATES Number FAA-
T&I-000031938 – 000031939. (On file with the Committee).

817 Boeing slide presentation to Ethiopian Airlines, “Subject: 737MAX, 777X & 787-9 Executive Review,” March 4,
2014, BATES Number TBC-T&I00199-002000, 002018, at TBC-T&I002018, accessed at p. 126 here:

819 David Shepardson and Tracy Rucinski, “U.S. lawmakers question Boeing’s $1 mln rebate clause for Southwest 737
MAX orders,” Reuters, October 30, 2019, accessed here: https://www.reuters.com/article/us-boeing-airplane-

southwest/u-s-lawmakers-question-boeings-1-mln-rebate-clause-for-southwest-737-max-orders-idUSKBN1X92D4
820 Letter from Southwest Airlines to Chair, Committee on Transportation and Infrastructure, and Chair, Subcommittee
on Aviation, U.S. House of Representatives, July 26, 2019. (On file with the Committee).
821 Ibid.
822 “Boeing Selects Supplier for 737 MAX Full-Flight Simulator,” Press Release, The Boeing Company, July 11, 2014,
accessed here: https://boeing.mediaroom.com/2014-07-11-Boeing-Selects-Supplier-for-737-MAX-Full-Flight-Simulator
139
 In February 2015, Boeing’s 737 Chief Technical Pilot wrote that MAX simulator training
would be “unrecoverable” for some Boeing customers due to the lack of simulators. 823
 The management directive to have no simulator training constricted technical design

decisions on the 737 MAX—limiting some safety features, such as the inclusion of a
synthetic airspeed indicator, that may have jeopardized the no simulator training goal. 824
 In 2015, the FAA believed several technical systems on the MAX, excluding MCAS, would
require simulator training for MAX pilots. 825 In the end, the FAA did not require any
simulator training for pilots transitioning from the 737 NG to the 737 MAX.
 In September 2016, the Committee has learned, Boeing granted its team of technical pilots
the company’s Commercial Aviation Services (CAS) Service Excellence Award for their role
in “developing the MAX Level B [non-simulator] differences training....” 826
 The influence of Boeing management’s directive to have no simulator training for the MAX
percolated through the entire 737 MAX program. As a result of this directive, the 737 Chief
Technical Pilot successfully talked one Boeing customer airline out of establishing simulator
training requirements for its MAX pilots shortly after the MAX was certified by the FAA. 827
 The 737 Chief Technical Pilot used incredibly disparaging language to describe inquiries
from Boeing customer airlines that asked about pilot simulator training on the 737 MAX and
said Boeing “will not allow” foreign regulators to require simulator training. 828
823 Boeing internal email from former 737 Chief Technical Pilot to former 737MAX VP/GM, former 737MAX Chief
Project Engineer, and others, “Subject: HELP NEEDED Request: 737 CL Program decision, RCAS/MAX training,”
Sent: Friday, February 27, 2015, 3:29 PM, BATES Number TBC-T&I552663-552666 at TBC-T&I 552664 – 552665.
824 Boeing internal emails, “Subject: Synthetic Airspeed,” February 26, 2013, accessed at p. 1 here:
pdf
825 FAA Memorandum, From: Seattle Aircraft Evaluation Group (SEA-AEG), To: Flight Standards, “Subject: Boeing
737 MAX Type Rating Determination and Pilot Training Requirements,” May 10, 2015, BATES Number, FAA-
DEFAZIO-000032887-32890, accessed at p.231 here: https://www.govinfo.gov/content/pkg/CHRG-
826 Boeing internal email, “Subject: RE: Weekly inputs,” September 21, 2016, 4:26:33 PM, BATES Number TBC-T&I

827 See: Boeing internal email, “Subject: RE: 737 MAX ATB/RTL FOTB” Sent: Monday, June 5, 2017, 8:01 PM (p. 14);
Boeing email to airline customer, “Subject: RE: MAX LEVEL B DIFFERENCES SOLUTION,” Sent: Tuesday, June 6,
2017 11:01:40 AM (p. 34); Airline customer email to Boeing, “Subject: RE: MAX LEVEL B DIFFERENCES
SOLUTION,” Sent: Wednesday, June 7, 2017, 12:12 AM (p. 32); and Boeing internal email, “Subject: FW: MAX
LEVEL B DIFFERENCES SOLUTION,” Sent: Wednesday, June 7, 2017, 10:01:41 AM (p. 32); accessed here (at page
numbers indicated in parenthesis):
pdf
828 Boeing internal email, “Subject: RE: Flight Transition costs,” Sent: March 28, 2017, 9:00:58 AM, accessed at p. 28
here:
pdf
140
 The 737 Chief Technical Pilot also boasted that his efforts to talk airlines out of simulator
training saved Boeing “a sick amount of $$$$.” 829
 In January 2020, Boeing made a stunning reversal of its previous goal to prevent pilot
simulator training and recommended that simulator training be required for all MAX pilots
once the plane is ungrounded and returns to service. 830
Faulty Assumptions
Development of the MAX was marred by multiple faulty assumptions and financial
pressures from the very start. The assumption that pilots transitioning from the 737 NG to the 737
MAX would only need a limited amount of differences training and no simulator training
diminished safety, minimized the value of pilot training, and inhibited technical design
improvements. The increased costs to Boeing’s customer airlines in providing simulator training for
MAX pilots and the increased costs to Boeing of adding new design features that could lead to
heightened pilot training requirements drove critical decisions on the 737 MAX program.
Boeing has tacitly conceded the failure of its previous pilot training assumptions by
announcing in January 2020 that it will now recommend simulator training for MAX pilots. 831 On
the technical side, Boeing’s faulty assumptions undermined safety and led, for example, to a lack of
redundant features on MCAS. 832 Financial considerations also contributed to Boeing’s decisions not
to include certain safety features on the aircraft, such as a synthetic airspeed indicator, that would
have increased costs and may have created potential simulator training requirements. 833
Financial pressures to limit pilot training requirements permeated critical design and
development decisions within the MAX program. Boeing assumed that despite new technologies
being added to the MAX aircraft, particularly the inclusion of MCAS, pilots would not need to be
specifically trained to respond to potential MCAS failures, for instance, or even to be aware MCAS
existed. 834 More than any other program objective, ensuring that the FAA’s pilot training
requirements for the MAX did not include simulator training had an incredibly significant cascading
effect on the 737 MAX program that undermined the safety of the flying public.
829 Boeing internal instant message, December 12, 2017, BATES Number TBC-T&I549015 – TBC-T&I549016. (On file
830 “Boeing Statement on 737 MAX Simulator Training,” Press Release, The Boeing Company, January 7, 2020, accessed
here: https://boeing.mediaroom.com/news-releases-statements?item=130596
831 Ibid.
832 Boeing employee email, “RE: MCAS Stab Rapid Reversal on PSIM Model,” Sent: December 17, 2015,10:44:54 AM,
BATES Number TBC-T&I 010584 - TBC-T&I 010586 at TBC-T&I 010584, accessed at p. 121 here:
833 Boeing internal emails, “Subject: Synthetic Airspeed,” February 26, 2013, at p. 1 accessed here:
pdf
834 Email from 737 Chief Technical Pilot to FAA, “Subject: MCAS lives in both FCCs,” Sent: Wednesday, March 30,
2016, 11:16:45.
141
Most alarmingly, Boeing made these assumptions despite the fact that it had internal test
data that contradicted them. 835 In 2012, for instance, it took one of Boeing’s own test pilots more
than 10 seconds during a simulator test to respond to MCAS activation. 836 The pilot, “found this
catastrophic[.]” 837 Boeing did not inform the FAA about this test data and appears to have
discounted the test results, falsely assuming that pilots would quickly recognize and respond to
uncommanded 838 MCAS activation. 839 In the end, MCAS played a key role in both MAX crashes.
In the wake of the Lion Air and Ethiopian Airlines crashes, despite Boeing’s own simulator
test results, both Boeing and the FAA tended to place the blame for the accidents on foreign-trained
pilots and discounted technical design flaws on the MAX. 840 In a briefing to Chair DeFazio and
Subcommittee on Aviation Chair Larsen in February 2019 concerning the Lion Air crash, Ali
Bahrami, the FAA’s Associate Administrator for Aviation Safety, described the crash as a “one off”
event and attributed it to poor pilot performance. 841
However, Boeing’s own test data, cited above, showed that a Boeing test pilot struggled to
effectively respond to uncommanded MCAS activation in a MAX simulator and found the condition
“catastrophic[.]” 842 Real life was no different. Pilots on the doomed Lion Air and Ethiopian Airlines
B-BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision D, March 30, 2016, and
Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-B-
BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June, 11 2018, accessed at pp. 164 and 174 here:
836 Internal Boeing email, “Subject: MCAS Hazard Assessment,” Sent: November 1, 2012, 1:41 PM, BATES Number

837 Ibid.
838 MCAS was designed to activate automatically without any pilot command. Use of the term “uncommanded” in
connection with MCAS activation here is for consistency with Boeing’s own Functional Hazard Assessments which
measured, “Uncommanded MCAS function operation to pilot reaction[,]” and determined that a pilot reaction time of
greater than 10 seconds could be “catastrophic[.]” See: Hearing titled, “The Boeing 737 MAX: Examining the Design,
Development, and Marketing of the Aircraft,” Committee on Transportation & Infrastructure, U.S. House of
Representatives, 116th Congress, First Session, October 30, 2019, pp. 163, 173, accessed here:

840 See: Peter Economy, “Boeing CEO Puts Partial Blame on Pilots of Crashed 737 MAX Aircraft for Not ‘Completely’
Following Procedures,” Inc., April 30, 2019, accessed here: https://www.inc.com/peter-economy/boeing-ceo-puts-

partial-blame-on-pilots-of-crashed-737-max-aircraft-for-not-completely-following-procedures.html; Curt Devine, Aaron
Cooper, and Drew Griffin, “Pilots union to Boeing: ‘Inexcusable’ to blame pilots for 737 Max crashes,” CNN Business,
May 23, 2019, accessed here: https://www.cnn.com/2019/05/23/business/american-airlines-boeing-pilots-
union/index.html; and Testimony of Daniel K. Elwell, Acting Administrator, Federal Aviation Administration, Hearing
titled, “Status of the Boeing 737 MAX,” Subcommittee on Aviation of the Committee on Transportation and
Infrastructure, U.S. House of Representatives, 116th Congress, First Session, May 15, 2019, pp. 32-33, accessed here:
841 Briefing to House Committee on Transportation and Infrastructure Chair Peter DeFazio and Subcommittee on
Aviation Chair Rick Larsen by Ali Bahrami, Associate Administrator for Aviation Safety, Federal Aviation
Administration (FAA), February 14, 2019.
142
flights struggled to regain control of the MAX aircraft following the erroneous activation of MCAS
that led to those two crashes. 843
In a hearing before the Subcommittee on Aviation in May 2019, Robert Sumwalt, Chair of
the National Transportation Safety Board (NTSB), discussed the importance of pilot training
requirements and the assumptions made by aircraft manufacturers. 844 “I think it is important to
point out that if an aircraft manufacturer is going to sell airplanes all across the globe, then it is
important that pilots who are operating those airplanes in those parts of the globe know how to
operate them,” he said. “And I think that is important.” 845 Mr. Sumwalt also concluded that while
U.S. piloting standards are very good, “I don’t think that is part of the answer. … [T]he airplane has
to be trained to the lowest common denominator.” 846
In fact, the FAA has issued Advisory Circulars pointing out that “when assessing the ability
of the flightcrew to cope with a failure condition,” manufacturers should consider whether the
flightcrew can respond to these failures “without requiring exceptional pilot skill or
strength….” 847 (Emphasis added.) While both Boeing and the FAA have pointed to pilot
performance as a factor in the MAX crashes 848 and while pilot performance is often a contributing
factor in any aircraft accident, neither Boeing nor the FAA can shirk their responsibility for
developing and certifying an aircraft that was not safe to fly for all pilots.
What makes Boeing’s decision to stick to its goal of no simulator training most troubling is
the fact that Boeing had information from its own test data suggesting that some pilots, even U.S.-
trained Boeing test pilots, would need more training on the MAX, particularly to respond to an
erroneous activation of MCAS effectively. However, Boeing appears to have discounted this test
data and ignored this evidence, assuming that all pilots would respond quickly and effectively to
uncommanded MCAS activation. Those assumptions were drastically wrong.
843 “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” pp. xviii and 19-28, accessed here:
https://aviation-is.better-than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf and
“Ethiopian Airlines Flight 302 Interim Investigation Report,” pp. 130-132, accessed here: http://www.aib.gov.et/wp-
844 Testimony of Robert L. Sumwalt III, Chairman, National Transportation Safety Board, Hearing titled, “Status of the
Boeing 737 MAX,” Subcommittee on Aviation of the Committee on Transportation and Infrastructure, U.S. House of
Representatives, 116th Congress, First Session, May 15, 2019, pp. 67-68, accessed here:
845 Ibid.
846 Ibid.
847 “Subject: System Design and Analysis,” Advisory Circular, AC No: 25.1309-1A, Federal Aviation Administration,
Department of Transportation, June 21, 1988, p. 15, accessed here:

https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_25_1309-1A.pdf
848 See: Testimony of Daniel K. Elwell, Acting Administrator, Federal Aviation Administration, Hearing titled, “Status of
the Boeing 737 MAX,” Subcommittee on Aviation of the Committee on Transportation and Infrastructure, U.S. House
of Representatives, 116th Congress, First Session, May 15, 2019, pp. 32-33, accessed here:
https://www.govinfo.gov/content/pkg/CHRG-116hhrg37277/pdf/CHRG-116hhrg37277.pdf; Michael Laris, Lori
Aratani, and Ashley Halsey III, “FAA Chief says pilot decisions contributed to Boeing 737 Max crashes,” Washington
Post, May 15, 2019, accessed here: https://www.washingtonpost.com/transportation/2019/05/15/faa-chief-be-pressed-
boeing-max-while-would-be-replacement-faces-questions-his-approach-air-safety and Dominic Gates, “Ethiopian
Airlines calls criticism of its pilots an effort to ‘divert public attention’ from Boeing 737 MAX flaws,” Seattle Times, May
17, 2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/ethiopian-airlines-calls-criticism-of-
its-pilots-an-effort-to-divert-public-attention-from-boeing-737-max-flaws
143
As Captain (“Sully”) Sullenberger said in testimony to the Subcommittee on Aviation in June
2019:
It is clear that the original version of MCAS was fatally flawed and
should never have been approved. It has been suggested that even if
the MCAS software had flaws, the pilots on these flights should have
performed better and been able to solve the sudden unanticipated
crises they faced. Boeing has even said that in designing MCAS they
did not categorize a failure of MCAS as critical because they assumed
that pilot action would be the ultimate safeguard. 849
Captain Sullenberger added, “We should all want pilots to experience these challenging
situations for the first time in a simulator, not in flight with passengers and crew on board.” 850
Boeing’s Level B training goals for the MAX program, however, prevented that from happening.
Design Objective: 737 MAX Level B Training
In a lengthy interview with Committee staff, Michael Teal, the former Chief Project
Engineer for the 737 MAX program and a Boeing Vice President, said efforts to obtain Level B
(non-simulator) pilot training requirements or less from the FAA “was a design objective.” 851
However, he said, “In the end, of course, the FAA was the one that would determine whether it’s
Level B.” Mr. Teal said that Boeing “expected Level B” if it followed its “design process” and
“criteria.” 852
He also said that the FAA “couldn't indicate to me whether or not [the MAX] was at Level
B, C, or what the determination was until they completed their evaluation. And their evaluation
would include flying the airplane through a series of what we call T1, T2, T3 tests. And we had to
complete that process before they could make their ruling.” 853 The FAA did not make its provisional
determination to require Level B training until August 2016. 854
However, the supposition that Boeing was simply going through the process and waiting for
the FAA to make its determination on pilot training requirements is not supported by the facts of
the Committee’s investigation. Level B training was not just a “design objective,” rather it was
imperative to the financial success of the MAX program. Pilot training requirements affected
multiple parts of the MAX program, and Boeing was aggressive about making certain the FAA did
not require simulator training (e.g., greater than Level B training) for pilots transitioning from the
737 NG to the 737 MAX.
849 Prepared Statement of Captain Chesley B. “Sully” Sullenberger III, Hearing titled, “Status of the Boeing 737 MAX:
Stakeholder Perspectives,” Subcommittee on Aviation of the Committee on Transportation and Infrastructure, U.S.
850 Ibid.
Program Manager of the 737 MAX program, Boeing Commercial Airplanes, May 11, 2020, accessed here:
852 Ibid.
853 Ibid.
2016, BATES Number TBC-T&I 010895. (On file with the Committee).
144
In September 2013, Mark Forkner, Boeing’s 737 Chief Technical Pilot, prepared a
presentation that listed “Flight Crew Difference training level no greater than level B from 737NG
family” as one of the “Ground Rules” for the
Mark Forkner 737 MAX. 855 In March 2014, a senior Boeing
former 737 Chief Technical Pilot employee expressed concern that adding new
(On briefing FAA on the MAX) “Asymmetry and Authority alerts” to the 737
MAX could potentially endanger Level B
May 7, 2014
computer-based training requirements. “We told
“WE DEFINITELY WANT TO all our customers MAX will only require up to
Level B training,” wrote the Boeing employee. 856
EMPHASIZE HOW SIMILAR THE The employee was clearly concerned about the
MAX WILL BE TO THE NG WITH impact increased training requirements could
REGARDS TO HANDLING have. “This would have very severe
CHARACTERISTICS/QUALITIES, consequences for the MAX program,” the
AS OPPOSED TO employee wrote to Boeing colleagues more than
DIFFERENT/CHANGED.” two years before the FAA made a decision
regarding pilot training requirements. 857
Furthermore, in a May 2014 email to a Boeing
colleague discussing an upcoming briefing to the FAA regarding pilot training issues, Mr. Forkner,
wrote: “We definitely want to emphasize how similar the MAX will be to the NG with regards to
handling characteristics/qualities, as opposed to different/changed.” 858
Boeing was not simply pushing hard to obtain Level B pilot training, it was blurring the lines
between what it “hoped” the FAA would determine and the FAA’s actual decision concerning pilot
training requirements. In 2014 marketing materials to a potential customer airline, for instance,
Boeing had slides that said pilot training would be “limited to Level B Training only” and only
included a small note indicating that this was “pending 737 MAX certification.” 859
In addition, despite Mr. Teal’s assertion in the transcribed interview that Boeing was waiting
for the FAA to make a determination on the MAX pilot training requirements, in July 2014, more
than two years before the FAA would complete its pilot training evaluations and flight testing to
make a determination, Boeing boldly claimed in a press release that no simulator training would be
required. 860 As an indication of how unusual Boeing’s statement was, a Rockwell Collins official
emailed FAA in April 2015 to inquire if Boeing had some level of agreement from the FAA that
855 Presentation by 737 Chief Technical Pilot, “737 MAX: Flight Crew Operations,” September 2013, Boeing, BATES
Number TBC-T&I 552228, 552230, and 552233. (On file with the Committee).
856 Boeing internal email, “Subject: RE: Update: ROLL/YAW ASYMMETRY NNCs,” March 14, 2014 11:41 AM,
BATES Number TBC-T&I 552823-552824. (On file with the Committee).

857 Ibid.
858 Email from former 737 Chief Technical Pilot to Boeing employee, “Subject: RE: Systems Summary briefing,” Sent:
Wednesday, May 7, 2014, 8:22 AM, BATES Number TBC-T&I180771. (On file with the Committee).
859 Boeing slide presentation to Ethiopian Airlines, “Subject: 737MAX, 777X & 787-9 Executive Review,” March 4,
2014, BATES Number TBC-T&I001999-002000, 002018, at TBC-T&I002018, accessed at p. 126 here:

860 “Boeing Selects Supplier for 737 MAX Full-Flight Simulator,” Boeing News Release, July 11, 2014, accessed here:
145
would allow it to make this claim. 861 The FAA had not, in fact, made any agreements with Boeing
and, as noted above, would not establish its final position on MAX pilot training requirements for
two more years.
Despite that reality, the Boeing press release said there would only be a “short differences
training course for” pilots transitioning from the 737 NG to the 737 MAX. 862 “Pilots already
certified on the Next-Generation 737 will not require a
simulator course to transition to the 737 MAX,” the Boeing Press Release
press release claimed. There was no caveat in the
863
July 11, 2014
press release informing the public that the FAA had not
yet made that decision. “PILOTS ALREADY
CERTIFIED ON THE NEXT-
Marketing the MAX GENERATION 737 WILL NOT
REQUIRE A SIMULATOR
The “design objective” to obtain Level B COURSE TO TRANSITION TO
training requirements or less from the FAA played a THE 737 MAX.”
critical role in marketing the MAX to Boeing’s
customers. A central component of Boeing’s marketing strategy for the 737 MAX was that pilots
who were certified to operate the 737 NG would require minimal, non-simulator-based training to
obtain certification on the 737 MAX. 864 Because airlines stood to incur increased training costs if
737 NG-certified pilots were required to complete simulator-based instruction to earn certification
on the 737 MAX, Boeing marketed the MAX with the premise and the promise that pilots—
following minimal “differences training”—could operate the 737 NG and MAX interchangeably. 865
In addition to the costs that airlines would incur if they were required to provide simulator-
based training to their pilots, the task of running thousands of pilots through the few simulators that
exist could take many months and slow airlines’ ability to get their airplanes into service. 866
According to the aviation industry trade publication, Flight Global, as of January 2020, only 34 full-
motion 737 MAX simulators existed worldwide, and U.S. airlines only had a “handful.” 867 Southwest
Airlines, based in Dallas, had three MAX simulators in January 2020 and reportedly was expected to
receive three additional MAX simulators during the year. 868 As of January 2020, Southwest had
nearly 10,000 pilots, 869 and when the MAX was grounded, the airline had 34 MAX aircraft in its fleet
861 Rockwell Collins email to FAA, “Subject: 737 MAX training question,” Sent: Wednesday, April 29, 2015, 7:12 AM,
BATES Number FAA-DEFAZIO-000032886, accessed at p. 230 here:
862 “Boeing Selects Supplier for 737 MAX Full-Flight Simulator,” The Boeing Company, July 11, 2014, accessed here:
863 Ibid.
864 Ibid.
865 Ibid.
866 Jon Hemmerdinger, “Boeing changes mind, recommends simulator training for all 737 Max pilots,” Flight Global,
January 7, 2020, accessed here: https://www.flightglobal.com/air-transport/boeing-changes-mind-recommends-

simulator-training-for-all-737-max-pilots/136028.article
867 Ibid.
868 Kyle Arnold, “Boeing says 737 Max pilots should get simulator training, including thousands at American and
Southwest,” Dallas Morning News, January 7, 2020, accessed here:

https://www.dallasnews.com/business/airlines/2020/01/07/boeing-says-737-max-pilots-should-get-simulator-training-
including-thousands-at-american-and-southwest
869 “SWAPA Fast Facts,” Southwest Airlines Pilots Association, January 1, 2020, accessed here:
https://swaparesources.s3-us-west-2.amazonaws.com/assets/public_article/FastFacts2020.pdf
146
with plans to increase its MAX fleet up to nearly 400 aircraft by 2026. 870 American Airlines, based in
Fort Worth, had 24 MAX airplanes as of the end of 2019—with 76 future MAX airplane deliveries
planned—and just one MAX simulator for its 4,200 737 pilots. 871 It could take years to move all of
these pilots through these MAX simulators. For airlines such as Southwest and American that
operate variants of the 737, this training bottleneck would limit the availability of pilots who are
certified to fly the 737 MAX and affect the efficiency of their “mixed fleet” operations. 872
In February 2015, well before the FAA evaluated what training requirements would be
necessary on the MAX, Mr. Forkner addressed this very issue. In an email to Keith Leverkuhn,
former General Manager of the 737 MAX program, and Mr. Teal, Mr. Forkner wrote, “HELP
NEEDED: Request Program Leadership intervention with the FAA Aircraft Evaluation Group
(AEG).” 873 Mr. Forkner’s email explained that AEG personnel were maintaining that they would
not be able to make any preliminary training level determinations until after completion of T-3 Test
evaluations which were not expected to happen until late 2016. 874 “This carries tremendous risk to
the Program,” wrote Mr. Forkner, “as differences greater than Level B will be unrecoverable for our
early NG/MAX customers like [redacted], due to simulator availability.” 875
870 “Southwest Airlines Reports 47th Consecutive Year of Profitability,” Southwest Airlines Company, January 23, 2020,
p. 3 (showing fleet and capacity) and p. 10 (showing 737 Delivery Schedule as of December 31, 2019) accessed here:
http://www.southwestairlinesinvestorrelations.com/tools/viewpdf.aspx?page={DBC2A948-97F6-47E0-B3A2-
5E844D962A08} and Kyle Arnold, “Boeing says 737 Max pilots should get simulator training, including thousands at
American and Southwest,” Dallas Morning News, January 7, 2020, accessed here:
871 “Fleet Fact Sheet,” American Airlines, updated February 2020, accessed here:
https://s21.q4cdn.com/616071541/files/doc_downloads/FactSheets/2020/Fleet-Facts_022020.pdf and Kyle Arnold,

“Boeing says 737 Max pilots should get simulator training, including thousands at American and Southwest,” Dallas
Morning News, January 7, 2020, accessed here:
872 In mixed fleet operations, a pilot could be scheduled, for example, to fly a 737 NG on an earlier flight and a 737
MAX on a later flight during the pilot’s duty day.

874 Ibid. Note that the System Differences Test and Validation of Training and Checking—Test 3 (T3) “is used to
evaluate the proposed differences and/or related aircraft differences training, checking, and training devices at level B, C,
or D;” see: “Subject: Guidance for Conducting and Use of Flight Standardization Board Evaluations,” Advisory
Circular, AC No: 120-53B, Change 1, Federal Aviation Administration, Department of Transportation, October 24,
2016, Appendix 3, p. 5, accessed here: https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_120-
53B_Chg_1.pdf
147
Gambling on Level B
Although Boeing assumed that the FAA would approve Level B (non-simulator) training for
the MAX, that was a tremendous and risky gamble given the multiple new features on the MAX and
the company’s business strategy to sell the MAX to customers as not requiring simulator training
years before the FAA had made a determination on this issue. In December 2011, Boeing entered
into a contract with Southwest Airlines, its U.S. launch customer, that laid out financial terms and
conditions if Boeing failed to obtain a Level B pilot training requirement from the FAA. 876
Southwest’s first 737 MAX began scheduled service on October 1, 2017. 877
As part of the contract, Boeing agreed to pay Southwest $1 million per MAX airplane that
Boeing delivered to Southwest if its pilots were unable to operate the 737 NG and 737 MAX
“interchangeably” “due to any reason.” 878 On top of that, Boeing agreed to reimburse Southwest for
any training expenses that exceeded 10 hours if the FAA required more than 10 hours of pilot
training and/or required flight simulator training. 879 That agreement left Boeing with significant
financial exposure if it failed to obtain Level B (non-simulator) training requirements from the FAA.
When Ethiopian Airlines flight 302 crashed in March 2019, Southwest had 34 MAX aircraft
in its fleet. 880 In October 2019, one year after the Lion Air flight 610 crash, Southwest had 246 firm
MAX orders, 34 of its MAX aircraft were grounded, and it had the option to purchase 115
additional MAX aircraft. 881 Thus, if the FAA had required pilot simulator training for MAX pilots,
Boeing would have been required to pay Southwest nearly $400 million to offset the simulator-based
pilot training requirements.
Although obtaining Level B or less training requirements was a central pillar of the 737
MAX program, the program’s two most senior officials, Mr. Leverkuhn, the former General
Manager of the 737 MAX program and Mr. Teal, the program’s former Chief Project Engineer, said
in separate interviews with Committee staff that they were not involved in the Southwest Airlines
contract negotiations and were largely unaware of the contract. 882 They also said they did not believe
that Mr. Forkner was involved in those negotiations either. 883 Mr. Forkner left Boeing in July 2018
877 “Southwest Corporate Fact Sheet,” Fleet as of December 31, 2019, Southwest Airlines, accessed here:
https://www.swamedia.com/pages/corporate-fact-sheet#fleet
879 Ibid.
880 “Southwest Airlines Statement Regarding 737 MAX 8,” Southwest Airlines Company, March 13, 2019, accessed here:
http://www.southwestairlinesinvestorrelations.com/tools/viewpdf.aspx?page={DEA8FE8F-94F9-4DBE-BC91-
F63964B49593}
881 See: “Southwest Corporate Fact Sheet,” Southwest Airlines Company, 2020, accessed here:
https://www.swamedia.com/pages/corporate-fact-sheet#fleet; and “Southwest Reports Record Third Quarter Net

Income And Earnings Per Share,” Southwest Airlines Company, October 24, 2019, accessed here:
http://www.southwestairlinesinvestorrelations.com/news-and-events/news-releases/2019/10-24-2019-112936719
882 Committee staff transcribed interview of Keith Leverkuhn, former Boeing Vice President and General Manager of
the 737 MAX program, Boeing Commercial Airplanes, May 19, 2020, and Committee staff transcribed interview of
Michael Teal, former Vice President, Chief Project Engineer and Deputy Program Manager of the 737 MAX program,
Boeing Commercial Airplanes, May 11, 2020.
883 Ibid.
148
after nearly seven years and took a position as First Officer at Southwest Airlines. 884 According to
recent news reports, Mr. Forkner took an early buyout at Southwest and planned to leave his
position there at the end of August 2020. 885
Both Mr. Leverkuhn and Mr. Teal said that the Level B training issue was not something
that was specifically briefed to higher management at Boeing, including the CEO of The Boeing
Company or the CEO of the Boeing Commercial Airplanes (BCA) division. 886 Mr. Leverkuhn
acknowledged that had Boeing not obtained Level B training, one impact would have been in
obtaining enough MAX simulators for customer airlines’ flightcrews, which would have delayed
getting the MAX into service. 887 He also said the “larger impact” would have been compensating the
airlines “in some manner.” 888
Mr. Teal, however, was always confident Boeing would meet its Level B training goal.
“[G]reater than Level B training was never really a concern,” he said. 889 He was apparently so
confident in meeting this program goal that he says he does not recall talking about it with senior
Boeing management. “I don't recall ever talking about it, because we were very confident that we
would meet Level B.” 890
Level B Implications to MCAS and other MAX Systems
In his interview with Committee staff, Mr. Teal also claimed that he did not believe MCAS
was a concern in regard to the impact it could have on obtaining Level B training. “I don't recall the
MCAS ever being a concern associated with level B training,” he said. 891 That statement, however,
does not square with the facts. In May 2013, Mr. Teal sent an email to senior leaders on the MAX
team regarding significant risk issues. That email very specifically tied the inclusion of MCAS in the
aircraft to potentially jeopardizing Boeing’s goal of obtaining Level B training. Specifically, the email
said: “Differences Pilot Training: Ensuring that the level of change on the MAX keeps the
Differences training to 16 hours or less of Level B training. Concerns include the impact of the
884 Mark Forkner’s LinkedIn page, accessed here: https://www.linkedin.com/in/mark-forkner-652355103

885 Kyle Arnold, “Test pilot at center of 737 Max investigation takes buyout from Southwest Airlines,” The Dallas Morning
News, August 7, 2020, accessed here: https://www.dallasnews.com/business/airlines/2020/08/07/test-pilot-at-center-
of-737-max-investigation-takes-buyout-from-southwest-airlines
the 737 MAX program, Boeing Commercial Airplanes, May 19, 2020, and Committee staff transcribed interview of
Michael Teal, former Vice President, Chief Project Engineer and Deputy Program Manager of the 737 MAX program,
the 737 MAX program, Boeing Commercial Airplanes, May 19, 2020.
888 Ibid.
890 Ibid.
891 Ibid.
149
resolution of 25.1322 trade 892 and the Autopilot roll saturation change driven by the addition of
MCAS to the flight controls system.” 893
Mr. Teal said he did not recall the concern about MCAS but did recall a concern that the
Roll Control Alerting System (RCAS) on the airplane “potentially had the act of requiring higher
than level B training.” 894 However, a little more than two weeks after Mr. Teal sent his May 2013
email about MCAS and “pilot differences training,” several Boeing employees had a meeting to
specifically discuss MCAS and the impact it could have on pilot training and certification
requirements for the 737 MAX aircraft. 895 An email summarizing that meeting said, “If we
emphasize MCAS is a new function there may be greater certification and training impact.” 896 In
his interview, Mr. Teal said he was unaware of this meeting. 897
Regardless, it is clear that MCAS did pose a risk to Level B non-simulator training and that
it was a concern inside Boeing. However, it was not the only system on the MAX that posed a risk
to Level B training requirements and endangered Boeing’s “no simulator” goal for MAX pilots.
Pushing Back on Level B
For its part, the FAA’s Seattle Aircraft Evaluation Group (AEG) recognized that the 737
MAX was a complex modification to Boeing’s predecessor model airplane, the 737 NG, that
incorporated many “substantial systems changes due to new certification requirements.” 898 In a May
10, 2015, internal email concerning this issue, an official in the Seattle AEG that would determine
pilot training requirements wrote that “[t]he B737MAX presents some very contentious issues
between Boeing and the FAA that will likely heat-up as we approach rollout and evaluation of the
aircraft.” 899 Further, this official said, “[w]e have reason to believe that Boeing’s assessment of B
892 This is a reference to the FAA’s Advisory Circular number 25.1322-1 on “Flightcrew Alerting” that provides
guidance for showing compliance with certain requirements of Title 14 of the Code of Federal Regulations (14 CFR),
part 25, for the design approval of flightcrew-alerting functions. See “Subject: Flightcrew Alerting,” Advisory Circular,
AC No: 25.1322-1, Federal Aviation Administration, Department of Transportation, December 13, 2010, accessed here:
https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_25.1322-1.pdf
893 Boeing internal email from former 737MAX Chief Project Engineer to Boeing Commercial Airplanes (BCA) Senior
Chiefs and Functional Leaders, “Subject: 737MAX Firm Configuration Status/Help Needed,” Sent: May 4, 2013,
11:35:58 AM, BATES Number TBC-T&I049683-049684. (On file with the Committee).
895 Boeing “ITRACS” report, “Title: MCAS/Speed Trim,” 37MAXFCI-PDR_AI22, Item entered: May 21, 2013, Item
closed: June 27, 2013, BATES Number TBC-T&I 549172 – 549173. (On file with the Committee).
896 Boeing internal email, “Subject: PRG – 37MAXFCI-PDR_AI22 – MCAS/Speed Trim,” June 7, 2013, 9:13:10 PM,
pdf
897 Committee staff transcribed interview of Michael Teal, Boeing Vice President, Chief Project Engineer and Deputy
899 FAA internal email, “Subject: RE: 737 MAX training question,” Sent: May 10, 2015, 1:44 PM, BATES Number FAA-
DEFAZIO-000032884, accessed at p. 228 here: https://www.govinfo.gov/content/pkg/CHRG-

150
Level training differences (Computer Based Training) between the MAX and NG will be
insufficient.” 900
Attached to that email, the AEG official included a memorandum that outlined the AEG’s
concerns regarding the possible need for simulator training on the 737 MAX as a result of several
planned systems that were to be included on the aircraft. 901 The memo listed six separate systems
that could require increased pilot training requirements. 902 These included Fly-by-wire (FBW)
Spoilers, Direct Lift Control, Landing Attitude Modifier (LAM), Roll Command Alerting System
(RCAS), Max Display System, and Environmental Control System (ECS). 903 Interestingly, MCAS
was not listed at the time.
The AEG had serious concerns about Boeing’s aggressive and contentious efforts to avoid
simulator training on the MAX, but in 2015 that focus was on other systems on the aircraft and not
MCAS. In fact, Boeing’s description of MCAS as just an addition to the Speed Trim System and the
operational parameters of MCAS before it was redesigned did not give AEG officials much pause.
They remained unaware of Boeing’s dramatic
Memo from Seattle AEG Manager to redesign of MCAS in March 2016 that gave
FAA, Director, Flight Standards the system much greater authority to control
the aircraft until after the Lion Air crash. 904
May 10, 2015
Had they known of those changes to MCAS
“FOR THE PAST 3 YEARS, BOEING prior to certification, it may have altered their
HAS CONTINUALLY ARGUED WITH assessment of the aircraft.
THE BASOO THAT THEY CANNOT
Also included in the Seattle AEG’s
MEET THE LATEST AMENDMENTS May 2015 memorandum concerning the
TO AIRCRAFT CERTIFICATION effect of the MAX’s new systems on training
REGULATIONS DUE TO THE IMPACT requirements, the author stressed that
ON FLIGHT CREW TRAINING.” although Boeing had been consistently
pushing for minimal Level B differences
training for pilots currently qualified on the 737 NG, the FAA might have to require higher-level
simulator training. 905 The memo expressly pointed out the negative impact Boeing’s goal of no
simulator training was having on Boeing’s ability to meet Federal aviation regulations. 906 “For the
900 Ibid.
902 Ibid.
903 Ibid.
October 2018 Lion Air Accident,” Department of Transportation, Office of Inspector General, Report No. AV2020037,
June 29, 2020, pp. 21-22, accessed here:
906 Ibid.
151
past 3 years, Boeing has continually argued with the BASOO that they cannot meet the latest
amendments to aircraft certification regulations due to the impact on flight crew training,” the
memo said. 907
The memo also laid out the AEG’s concerns with Boeing’s approach to training. “It is
Boeing’s intention not to have a task trainer or simulator to train pilots between the NG and the
MAX; The SEA AEG disagrees with this assessment,” the memo said. 908 The memo listed the six
systems cited above as potentially requiring additional pilot training. In particular, the memo
highlighted three systems that were likely to
require simulator training. Regarding the Memo from Seattle AEG Manager to
Direct Lift Control system, the memo said: “It FAA, Director, Flight Standards
is the opinion of the AEG that this system May 10, 2015
will need to have a full flight simulator to train
the pilots.” 909 On the Landing Attitude “IT IS BOEING’S INTENTION NOT
Modifier (LAM), the memo indicated: “Only a TO HAVE A TASK TRAINER OR
full flight simulator can be used for takeoff SIMULATOR TO TRAIN PILOTS
and landing credit.” Additionally, regarding BETWEEN THE NG AND THE
the Enhanced Bank Angle Warning (EBAW) MAX; THE SEA AEG DISAGREES
system, that is part of the Roll Command WITH THIS ASSESSMENT.
Alerting System (RCAS), the memo said: ….
“This is highly integrated system that may IT IS COMMON PRACTICE FOR
require simulator training.” 910
THE MANUFACTURER TO
The AEG memo also pointed out: “It REQUEST MINIMAL PILOT
is common practice for the manufacturer to TRAINING DUE TO THE COST
request minimal pilot training due to the cost IMPACT FOR THEIR CUSTOMERS.”
impact for their customers.” 911 Despite its concerns, in the end, the FAA did not require simulator-
based training for any of these systems. The FAA believed that Boeing had satisfactorily resolved all
of their concerns.
Safety and Commonality
In his interview with Committee staff, Mr. Leverkuhn claimed that the objective to avoid
simulator training requirements was not about cost, but about safety. Boeing realized they could not
obtain “a common type rating between the [737] classic, the NG, and the MAX,” he said. 912
“Ultimately, it was determined that that just was not going to be possible because the changes
between those three, particularly, the classic, were too significant to expect the pilot to be able to,
for instance, operate all three on any given day. And that was a determination made not only by the
FAA but certainly internally at Boeing as well,” said Mr. Leverkuhn. 913 “So the commonality
907 Ibid. Note that the BASOO is the Boeing Aviation System Oversight Office based in Seattle, Washington, and is
FAA’s office charged with overseeing Boeing’s certification compliance on all Boeing commercial aircraft.
908 Ibid.
909 Ibid.
910 Ibid.
911 Ibid.

913 Ibid.
152
approach is to assure that when a pilot flies an airplane for which he is type rated and knowing that
there is a possibility of flying on, you know, flying from Houston to Kansas City on an NG, and
then from Kansas City to Detroit on a MAX, does the airplane have the same look, feel, flying
characteristics, handling characteristics so that the pilot is not having to constantly remember, you
know, which airplane he might be flying on?” 914
For his part, Mr. Teal argued that the “commonality” between the 737 NG and the 737
MAX made the planes safer to fly and that greater than Level B training simply was not needed. “To
me, this is a safety conversation. It’s not about the dollars and cents associated with what I consider
a minor cost of the … training differences. It’s about the safety aspect,” said Mr. Teal. 915 However,
he also suggested that if a regulator had required an “additional level of training” it would have
indicated “that we have failed in meeting our requirements of having a safe airplane….” 916
Human factors experts, particularly in the wake of the MAX crashes and the revelations
about the flaws in MCAS’s technical design issues, have emphasized the need for simulator training
on new features on new or derivative model aircraft. In testimony to the Committee in December
2019, Dr. Mica Endsley, a Committee Chair at the Human Factors and Ergonomics Society and a
former Chief Scientist of the United States Air Force, described the importance of pilot simulator
training, particularly to familiarize pilots with new automation-related technologies, such as MCAS.
New automation should be introduced with training to allow pilots to

develop accurate mental models of how it works, an understanding
of its limitations and reliability in different situations, and information
on how to detect and recover from abnormal events and failure
conditions. As a significantly new piece of automation that had a
direct effect on aircraft control, experiential training (e.g. via
simulations) should have been provided that would allow pilots to
experience MCAS operations, its failure conditions, and to perform
the tasks needed to recover from and effectively overcome abnormal
conditions. 917
Unfortunately, Boeing’s Level B (non-simulator) training goals and the FAA’s ultimate
decision granting Level B training on the MAX undermined the best practices training procedures
outlined by Dr. Endsley. In 2016, the Seattle AEG proceeded with flight testing of the MAX via its
Flight Standardization Board, and on August 17, 2016, informed Boeing of its determination
concerning pilot training requirements. 918 In a decision highly favorable to Boeing, the AEG said
that after running its flight tests it determined that Level B differences training would be required for
914 Ibid.
916 Ibid.
917 Prepared statement of Dr. Mica R. Endsley, Human Factors and Ergonomics Society, Hearing titled, “The Boeing
737 MAX: Examining the Federal Aviation Administration’s Oversight of the Aircraft’s Certification,” Committee on
Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019,
accessed here: https://transportation.house.gov/committee-activity/hearings/the-boeing-737-max-examining-the-
federal-aviation-administrations-oversight-of-the-aircrafts-certification
2016, BATES Number TBC-T&I 010895 (On file with the Committee).
153
pilots seeking to transition from the 737 NG to the MAX. 919 Thus, no simulator training would be
required to transition from flying the 737 NG to flying the 737 MAX aircraft.
Obtaining Level B training on the MAX was a huge victory for Boeing. On Tuesday, August
16, 2016, one day prior to the official FAA letter granting this provisional approval, Mr. Forkner, the
737 Chief Technical Pilot, sent an email to 40 Boeing employees and supervisors, including Mr.
Leverkuhn and Mr. Teal, announcing this achievement. 920 The subject line on the email said:
“Subject: MAX Differences Training approved at Level B!!!!!” The email expressed a sense of
jubilation in obtaining Level B training on the MAX. Mr. Forkner wrote:
This culminates more than 3 years of tireless and collaborative efforts

across many business units. Flight Technical, Flight Technical Data,
Training Development, Flight Deck Crew Ops, All MAX engineering
teams, Flight Test Engineering and of course [redacted] Engineering
Test Pilot team all should be commended for their efforts in getting
us to the finish line. 921
One excited Boeing colleague emailed Mr. Forkner: “And, just to confirm, there are
absolutely no formal checks? And, no functional currency issues between the NG and MAX … you
can be away from the NG for 30-years and still be able to jump into a MAX? LOVE IT!” 922 Mr.
Forkner responded: “… No special currency issues or formal checks of any sort were identified by
the regulators. That’s the whole point of Level B.” 923
Boeing Will Not Allow That to Happen
Obtaining Level B training must have come as a tremendous relief to Mr. Forkner. It is clear
from emails and instant messages provided to the Committee by Boeing that Mr. Forkner was under
tremendous pressure to ensure Boeing achieved Level B training on the MAX. In a December 2014
email to a Boeing colleague, 20 months prior to the FAA’s decision on the MAX’s training
requirements, Mr. Forkner expressed concern based on his responsibility to coordinate training
requirements with the FAA’s Flight Standardization Board. “[I]f we lose Level B,” he wrote, the
blame “will be thrown squarely on my shoulders,” conveying his feeling that he would be held
919 Ibid.
920 Boeing internal email, “Subject: MAX Differences Training approved at Level B!!!!!,” Sent: Tuesday, August 16, 2016,
2:48 PM, BATES Number TBC-T&I 010893 – 010894, at pp. 139-140, accessed here:
921 Ibid.
922 Boeing internal email, “Subject: RE: Differences Training approved at Level B!!!!!,” Sent: Tuesday, August 16, 2016,
3:43 PM, accessed at p. 12 here:

pdf
923 Boeing internal email, “Subject: RE: Differences Training approved at Level B!!!!!,” Sent: Wednesday, August 17,
2016, 1:43 PM, accessed at pp. 11-12 here:

pdf
154
personally responsible by Boeing’s leadership for the financial consequences of not obtaining Level
B training. 924
Mr. Forkner’s emails and instant messages show how closely intertwined the Level B (non-
simulator) training goal was with technical decisions that affected training. In July 2014, for example,
the Level B training goal overshadowed discussions Mr. Forkner had with a colleague concerning
the development of pilot checklists for the Flight Crew Training Manual. As related to the specific
checklists they were developing, Mr. Forkner advised that they follow “the path with the least risk to
Level B” and “sell” an action pertaining to trim technique as a “very intuitive basic pilot skill.” 925
Mr. Forkner’s colleague cautioned: “I fear that skill is not very intuitive any more with the
younger pilots and those who have become too reliant on automation.” 926
Mr. Forkner responded: “Probably true, but it’s the box we’re painted into with the Level B
training requirements.” 927
The pressure to achieve Level B training also was evident in Mr. Forkner’s disdain for FAA’s
AEG, which would ultimately determine training requirements. In May 2015, Mr. Forkner derided
the AEG in instant messages with a Boeing colleague in which he described a briefing to the AEG
on the 737 MAX. “[I]t was like dogs watching TV for the AEG (and me too) curves, slopes, graphs,
blah blah blah, stuff non-engineers and test pilots can’t really understand other than the lines all line
up between max and NG, which is supposed to prove they fly the same.” 928
In November 2015, Mr. Forkner also wrote about the need to “push back very hard” against
the AEG regarding potential simulator training requirements and said he “will likely need support at
the highest levels” at Boeing in negotiating with the FAA regarding such requirements for the 737
MAX’s Roll Command Alerting System (RCAS). “Failure to obtain Level B training for RCAS is a
planet-killer for the MAX,” wrote Mr. Forkner. 929
924 Boeing internal email, “Subject: RE: Tomorrow,” December 18, 2014, 12:28:37 PM, accessed at p. 6 here:
pdf
925 Boeing internal email, “Subject: RE: RCAS testing of training,” Sent: Tuesday, July 22, 2014, 8:27 PM, p. 3-4,
accessed here:
pdf
926 Boeing internal email, “Subject: RE: RCAS testing of training,” Sent: Wednesday, July 23, 2014, 7:11 AM, p. 3,
accessed here:
pdf
927 Boeing internal email, “Subject: RE: RCAS testing of training,” Sent: July 23, 2014, 7:43:41 PM, p. 3, accessed here:
pdf
928 Instant Message from 737 Chief Technical Pilot to Boeing staff, Sent: May 29, 2015, 8:08 AM, BATES Number:
TBC-T&I 549002 (On file with the Committee).

929 Boeing internal email, “Subject: RE: !!! Important Help Needed!!!EASA RSAT/RCAS ECD dates,” Sent: Tuesday,
November 17, 2015, 2:21 PM, p. 90, accessed here:

pdf
155
Once the FAA obviated the need for simulator-based differences training on the MAX in
August 2016, a decision that largely affected U.S. airlines, and after the MAX was certified in March
2017, Boeing aggressively discouraged foreign-flagged airlines from setting their own simulator
training requirements. In particular, emails from Mr. Forkner concerning the company’s foreign
airline customers show strong opposition to simulator training and grossly inappropriate language in
reacting to airlines that even inquired about simulator training needs for their MAX pilots. Mr.
Forkner also boasted that his efforts to talk airlines out of simulator training was of significant
financial benefit to Boeing.
For example:
• In response to a March 2017 request from Boeing’s Africa & Caribbean Sales Director
related to an inquiry from a customer airline about costs to provide training to its flight
crews, Mr. Forkner wrote: “I want to stress the importance of holding firm that there
will not be any type of simulator training required to transition from the NG to the
MAX. Boeing will not allow that to happen. We’ll go face to face with any regulator who
tries to make that a requirement.” 930
• In June 2017, in response to an airline that was considering simulator-based training for
its pilots transitioning to the MAX, Mr. Forkner wrote in an email, “There is absolutely
no reason to require your pilots to require a MAX simulator to begin flying the MAX.
Once the engines are started, there is only one difference between NG and MAX
procedurally, and that is that there is no OFF position of the gear handle. Boeing does
not understand what is to be gained by a 3 hour simulator session, when the procedures
are essentially the same.” 931 … “A simulator training requirement would be quite
burdensome to your operation,” wrote Mr. Forkner in a separate email. 932
• In a separate instant message exchange with a Boeing colleague, also in June 2017, Mr.
Forkner wrote: “Now friggin Lion Air might need a sim to fly the MAX, and maybe
because of their own stupidity. I’m scrambling to figure out how to unscrew this now!
idiots” 933 That same month Mr. Forkner emailed a colleague, “I’m putting out fires with
the [redacted] who suddenly think they need simulator training to fly the MAX!
ARGGGGGGGGGGGGGGGGGGGGGGGGGGGGHHHHH!!!!!!!!!!!” 934
930 Boeing internal email, “Subject: RE: Flight Transition costs,” March 28, 2017, 9:00:58 AM, accessed at p. 28 here:
pdf
931 Boeing email to airline customer, “Subject: RE: MAX LEVEL B DIFFERENCES SOLUTION,” Sent: Tuesday,
June 6, 2017, 11:01:40 AM, accessed at p. 34 and p. 60 here:

pdf
932 Boeing email to airline customer, “Subject: RE: MAX LEVEL B DIFFERENCES SOLUTION,” Sent: Monday,
June 5, 2017, 10:59 PM, accessed at p. 33 and p. 59 here:

pdf
933 Boeing internal instant message, Sent: June 5, 2017, 6:57 PM, BATES Number TBC-T&I 549015. (On file with the
Committee).
934 Boeing internal email, “Subject: RE: 737 MAX ATB/RTL FOTB,” Sent: Monday, June 5, 2017, 8:01 PM, accessed at
p. 14 here:
156
• In December 2017, Mr. Forkner informed a colleague in an instant message exchange

that he made a foreign airline “feel stupid about trying to require any additional training
requirements.” “… I just jedi mind tricked this [sic] fools,” Mr. Forkner wrote. “I should
be given $1000 every time I take one of these calls,” he said, and then added “I save this
company a sick amount of $$$$” 935
Pressuring Airlines
Mr. Leverkuhn and Mr. Teal both claimed in interviews with Committee staff that they were
unaware of these communications at the
Boeing’s 737 Chief Technical Pilot, time. 936 They also both claimed that they
Internal Email were unaware of Mr. Forkner’s efforts to
March 28, 2017 pressure Boeing’s customer airlines out of
simulator training.
“I WANT TO STRESS THE
IMPORTANCE OF HOLDING FIRM Neither Mr. Teal nor Mr. Leverkuhn
THAT THERE WILL NOT BE ANY had a supervisory role over Mr. Forkner,
TYPE OF SIMULATOR TRAINING who reported through a different chain
within Boeing. However, Mr. Forkner
REQUIRED TO TRANSITION FROM
worked closely with the MAX program. In
THE NG TO THE MAX. BOEING WILL his interview with Committee staff, Mr. Teal
NOT ALLOW THAT TO HAPPEN. said he was unaware of Mr. Forkner acting
WE’LL GO FACE TO FACE WITH ANY unprofessionally or inappropriately and said
REGULATOR WHO TRIES TO MAKE he did not recall anyone complaining about
THAT A REQUIREMENT.” Mr. Forkner or him being reprimanded or
disciplined in any way. 937 For his part, Mr.
Leverkuhn said: “I didn't have any issues raised with Mark.” 938
The offensive and inappropriate language Mr. Forkner used in his emails and instant
messages was highly disturbing. Since they were released, Boeing has condemned these
communications. In January 2020 Boeing released a statement that said, in part:
We regret the content of these communications, and apologize to the

FAA, Congress, our airline customers, and to the flying public for
them. We have made significant changes as a company to enhance
pdf
935 Boeing internal instant message, December 12, 2017, BATES Number TBC-T&I 549024-549025. (On file with the
Committee).
Program Manager of the 737 MAX program, Boeing Commercial Airplanes, May 11, 2020, and Committee staff
transcribed interview of Keith Leverkuhn, former Vice President and General Manager of the 737 MAX program,
157
our safety processes, organizations, and culture. The language used in
these communications, and some of the sentiments they express, are
inconsistent with Boeing values, and the company is taking
appropriate action in response. This will ultimately include
disciplinary or other personnel action, once the necessary reviews are
completed. 939
There is absolutely no excuse for the language used in these communications, and it is deeply
troubling that Boeing employees pushed back on the pilot training concerns of their customers that
may have affected the safety of their airlines. In February 2020, Bloomberg reported that Boeing put
three employees who worked with the company’s former 737 Chief Technical Pilot (Mark Forkner)
on administrative leave regarding their involvement in those communications. 940
However, Mr. Forkner’s hard sell tactics to dissuade airlines from simulator training was the
result of an implied message from Boeing management to discourage such training because of the
threat it posed to the marketing strategy and ultimately the profitability of the 737 MAX program.
In fact, the Committee has learned that in September 2016, one month after the FAA
provided Boeing with provisional approval for Level B (non-simulator) training for 737 MAX pilots,
Mr. Forkner and his team of technical pilots that had been promoting Level B training were granted
an award for their efforts from Boeing. An internal Boeing email said that the technical pilot team
received the company’s Commercial Aviation Services (CAS) Service Excellence Award on
September 14, 2016, “along with the Training Development Team for their role is [sic] developing
the MAX Level B differences training which was approved by the FAA.” 941 The Committee has
confirmed that at least one of those who received this award was one of the three individuals Boeing
put on administrative leave earlier this year.
737 MAX Simulator Discrepancy Reports and Schedule Pressure
While Boeing successfully convinced the FAA not to require MAX simulator training for
those pilots transitioning between the 737 NG and 737 MAX aircraft, flight simulators are part and
parcel of the aircraft development process and the continued operational requirements of
commercial aircraft in general. They help to replicate potential flight conditions for the manufacturer
during the certification process and for customer airlines during routine training of their pilots. The
use of simulators can reduce costs on fuel and maintenance because pilots are not actually flying the
aircraft. They can also simulate a wide range of conditions to both test the pilots’ flying abilities and
to observe or tweak technical features on the aircraft. 942
939 “Boeing Statement on Employee Messages Provided to U.S. Congress and FAA,” Boeing, January 9, 2020, accessed
here: https://boeing.mediaroom.com/news-releases-statements?item=130600%20
940 Peter Robison, Julie Johnsson and Alan Levin, “Boeing Suspends Co-Workers of Pilot at Center of Max Scrutiny,”
Bloomberg, February 21, 2020, accessed here: https://www.bloomberg.com/news/articles/2020-02-22/boeing-suspends-

co-workers-of-pilot-at-center-of-max-scrutiny
941 Boeing internal email, “Subject: RE: Weekly inputs,” September 21, 2016, 4:26 PM, BATES Number TBC T&I TBC-

942 See: “The perfect illusion: Technology of full flight simulators,” ProFlight, accessed here:
https://www.proflight.com/en/full-flight-simulatoren/technologie.php
158
In the case of Boeing and the 737 MAX aircraft, as with virtually all other commercial
aircraft, flight simulators were necessary as a normal tool to help familiarize potential customer
airlines with the MAX and to help maintain routine training credentials of pilots. With support from
its supplier, 943 Boeing operates an entire division that provides pilot training and simulator
management and support services for customer airlines. 944 The FAA also has a role in setting flight
simulator requirements and assessing their performance. 945 In May 2016, for instance, new FAA
regulations went into effect amending previous standards for flight simulators. 946
But like the aircraft itself, Boeing’s MAX simulators had problems. In the spring of 2018, for
instance, more than one year after the MAX received its type certification from the FAA, Boeing
emails and instant messages show that Boeing employees had serious concerns about the quality of
the MAX simulators. They were also deeply troubled by Boeing’s poor management of the simulator
program, lack of adequate engineering support, and schedule pressure that they felt was driving a
rushed process resulting in mistakes and apprehension about the quality of the simulators. For
example:
• In February 2018, a Boeing employee said there were 180 discrepancy reports (DRs)
with the MAX simulator in England at its London Gatwick (LGW) site. 947 “Honesty is
the only way in this job – integrity when lives are on the line on the aircraft and training
programs shouldn’t be taken with a pinch of salt,” wrote one frustrated Boeing
employee. 948 “Would you put your family on a MAX simulator trained aircraft? I
wouldn’t,” he said to his colleague, who answered: “No.” 949
943 “TRU Delivers First Ever Boeing 737 MAX Full Flight Simulator,” Press Release, TRU Simulation + Training,
November 2, 2017, accessed here: https://www.trusimulation.com/media-hub/tru-delivers-first-ever-boeing-737-max-

full-flight-simulator. TRU Simulation + Training, based in Goose Creek, South Carolina, is a subsidiary of Textron Inc.
The company has a 10-year exclusive agreement with Boeing to provide multiple 737 MAX full flight training suites to
Boeing’s training campuses worldwide.
944 See: Boeing Simulator Management, accessed here: https://www.boeing.com/commercial/services/training-and-
resourcing/simulator-management.page and Boeing Simulator Services, accessed here:

https://www.boeing.com/commercial/services/flight-operations-solutions/simulator-services
945 See “Flight Simulation Training Device Qualification Standards for Extended Envelope and Adverse Weather Event
Training Tasks, Final Rule” Department of Transportation, Federal Aviation Administration, 14 CFR Part 60, published
in Federal Register, Vol. 81, No. 61, March 30, 2016, accessed here:
https://www.federalregister.gov/documents/2016/03/30/2016-05860/flight-simulation-training-device-qualification-
standards-for-extended-envelope-and-adverse-weather
946 Ibid.
947 Boeing internal instant messages, “Subject: Conversation with [redacted],” February 8, 2018, 8:25:29 PM, accessed at
p. 102 here:
pdf
948 Ibid, p. 103.
949 Ibid, p. 103.
159
• In March 2018, the issue of high numbers of discrepancy reports on the MAX
simulators was still a major issue. “It’s a bloody joke,” quipped one Boeing employee. 950
“They do not understand the liability we as a company are taking on,” he wrote. 951
• In April 2018, a Boeing employee lamented: “This is a direct result of a pour [sic] plan
which I objected to repeatedly since day 1. The schedule simply did not permit for any
corrective actions to be taken…” 952 A colleague responded: “I agree with you entirely
and agree with the whole failure to plan this program properly from the Boeing side.” 953
In a separate exchange that same month a Boeing employee observed that the flight
simulator was pitching his colleague into a stall and then added, “We have been trying to
fix that for over 6 months.” 954
• In May 2018, a frustrated Boeing employee mentioned it took six hours to resolve the
large number of deficiency reports and complained about Boeing management pushing
forward despite the problems. “[T]hey are ploughing forward regardless of the danger,
failing to appreciate the implication of Boeing failing to qualify a Boeing device…” he
wrote. “They are failing to appreciate that a delay would be less costly than the incurred
costs….” 955
In response to these and other communications that it provided to Congress, and the
Committee made public in January 2020, Boeing said in a statement:
These communications contain provocative language, and, in certain

instances, raise questions about Boeing’s interactions with the FAA in
connection with the simulator qualification process.
Having carefully reviewed the issue, we are confident that all of

Boeing’s MAX simulators are functioning effectively. The
950 Boeing internal instant messages, “Subject: Conversation with [redacted],” March 22, 2018, 9:25 AM, accessed at p.
74 here:
pdf
951 Ibid, p. 75.
952 Boeing email, “Subject: RE: Updated QTG,” April 24, 2018, 23:33, accessed at p. 105 here:
pdf
953 Boeing email, “Subject: RE: Updated QTG,” April 24, 2018, 4:02:27 PM, p. 105, accessed here:
pdf
954 Boeing internal instant message, “Subject: Testing of TP 2.3.57 / Binary 3.19.4.0a,” April 8, 2018, 8:10:13 AM,
pdf
955 Boeing internal instant message, “Subject: Conversation with [redacted],” May 15, 2018, 12:09:52 PM, accessed at p.
97 here:
pdf
160
qualification activities referenced in these communications occurred
early in the service life of these simulators. 956
It is worth noting that the simulator incidents described above all occurred roughly one year
or more after the 737 MAX was certified by the FAA.
Reverse Course
By Boeing’s own actions, it has acknowledged multiple failures on the 737 MAX, although it
has been reluctant to articulate those facts publicly. The changes it has said it will make or has
already made to the 737 MAX, however, are a tacit confession of the program’s original failings.
Boeing has redesigned MCAS to rely on two AOA sensors and to not activate repeatedly. In
addition, Boeing has fixed the AOA Disagree alert issue. Finally, in January 2020, with two lethal
MAX accidents behind them, Boeing reversed course and said it would recommend simulator
training for all MAX pilots. 957
In a short statement on January 7, 2020, Boeing announced:
Boeing is recommending 737 MAX simulator training in addition to

computer based training for all MAX pilots prior to return to service
of the 737 MAX. This recommendation takes into account our
unstinting commitment to the safe return of service as well as
changes to the airplane and test results. Final determination will be
established by the regulators. 958
The New York Times reported that, “[t]he decision stems from Boeing’s analysis of recent
flight simulator tests that were part of the work necessary to return the Max to service, which
showed that pilots were not using the right procedures to handle emergencies.” 959 It is important to
remember, as described in this report’s previous discussion of MCAS, that Boeing was aware of slow
pilot reaction times that could jeopardize the safety of the MAX well before the airplane was
certified. 960
In 2012, Boeing had evidence from its own test pilot that some pilots may not respond
rapidly enough to successfully counter uncommanded MCAS activation, a condition Boeing’s test
956 “Boeing Statement on Employee Messages Provided to U.S. Congress and FAA,” Boeing News Release, January 9,
2020, accessed here: https://boeing.mediaroom.com/news-releases-statements?item=130600%20
957 “Boeing Statement on 737 MAX Simulator Training,” Boeing News Release, January 7, 2020, accessed here:
958 Ibid.
959 Natalie Kitroeff and David Gelles, “In Reversal, Boeing Recommends 737 Max Simulator Training for Pilots,” New
York Times, January 7, 2020, accessed here: https://www.nytimes.com/2020/01/07/business/boeing-737-max-

simulator-training.html
B-BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision D, March 30, 2016, and Boeing Coordination Sheet,
MAX (-7/8/9), Revision G, June, 11 2018, accessed at pp. 164 and 174 here:
161
pilot found to be “catastrophic[.]” 961 Rather than fully investigating that issue and determining if
greater training requirements might be required to improve those sorts of pilot responses, Boeing
essentially explained away the test results, ignored the evidence they had, and chose not to inform
the FAA, its customers, or MAX pilots about this internal data—because it was not required to be
shared, according to Boeing’s interpretation of Federal regulations.
Fear of being forced to accommodate simulator training requirements was prevalent

throughout the MAX program. This had an overriding impact on design decisions—avoiding
changes that could potentially lead the FAA to require simulator training even if these design
enhancements improved safety. A May 2019 article in Bloomberg titled: “Former Boeing Engineers
Say Relentless Cost-Cutting Sacrificed Safety,” pointed out that, “The failures of the 737 Max
appear to be the result of an emphasis on speed, cost, and above all shareholder value.” 962
Some of the former Boeing engineers interviewed for the article noted how Boeing’s desire
not to have simulator training had a detrimental impact on the MAX’s engineering decisions.
One former employee said that internal Boeing performance reviews focused on cost savings
and not safety. The article emphasized that corporate pressure regarding simulator training
on the MAX is “essential to understanding how an emphasis on costs twisted a process that’s
supposed to produce the best, safest planes.” 963 The Committee’s investigation has revealed
similar findings.
Boeing’s recent decision to recommend simulator training for all MAX pilots is appropriate
and long overdue. However, it was a clear and stunning admission that its previous assumptions
about pilot training requirements were inaccurate and inadequate. In addition, the efforts to obtain
Level B training requirements did not just limit pilot training, they hindered the inclusion of
technologies on the MAX that may have improved safety.
In the push to produce an economically and operationally viable aircraft to compete with
Airbus’s A320neo, Boeing undermined safety, tarnished its reputation, and as a result of the MAX’s
grounding, created severe financial consequences for its customer airlines and for itself. 964 Most
importantly, these combined actions and faulty assumptions led to two tragic accidents and the
death of 346 people.
The problems that enveloped the 737 MAX program were not isolated to the design and
development of the aircraft. Once the aircraft was certified by the FAA in March 2017 and the MAX
began rolling off of Boeing’s production line in Seattle, Washington, other issues began to emerge.
962 Peter Robison, “Former Boeing Engineers Say Relentless Cost-Cutting Sacrificed Safety,” Bloomberg, May 9, 2019,
accessed here: https://www.bloomberg.com/news/features/2019-05-09/former-boeing-engineers-say-relentless-cost-

cutting-sacrificed-safety
963 Ibid.
964 Dominic Rushe, “Boeing puts cost of 737 Max crashes at $19bn as it slumps to annual loss,” The Guardian, January
29, 2020, accessed here: https://www.theguardian.com/business/2020/jan/29/boeing-puts-cost-of-737-max-crashes-at-

19bn-as-it-slumps-to-annual-loss and Darryl Campbell, “The 737 Built Southwest, and the 737 MAX Could Be its
Undoing,” The Verge, October 23, 2019, accessed here: https://www.theverge.com/2019/10/23/20927213/boeing-737-
max-southwest-planes-crash-budget-airlines-grounded-cost-maintenance
162
8. Production Pressure
-Production Pressure -
 The 737 MAX program was launched under intense financial pressure to aggressively compete
with Airbus’ new A320neo aircraft. 965
 The MAX became the fastest selling aircraft in Boeing’s history with more than 5,000 orders
at its peak in 2018. 966
 Boeing’s historic marketing success of the 737 MAX created enormous production pressure
that negatively impacted its workforce and the quality and safety of the MAX program. 967
 To emphasize that sticking to the production schedule was of the utmost priority, senior
Boeing management installed “Countdown Clocks” in their conference room in order to make
employees on the MAX program aware of key markers in the MAX’s development schedule. 968
 The Committee has learned that when the MAX completed its first flight in January 2016, 969
Michael Teal, Boeing’s Chief Project Engineer on the 737 MAX program, received restricted
stock options from Boeing to show appreciation for his efforts on the MAX program. 970
 Boeing’s focus on reducing costs and meeting the production schedule resulted in excluding
some technologies that may have improved the safety of the 737 MAX, such as synthetic
airspeed. 971
965 David Gelles, Natalie Kitroeff, Jack Nicas and Rebecca R. Ruiz, “Boeing Was ‘Go, Go, Go’ to Beat Airbus With the
737 MAX,” New York Times, March 29, 2019, accessed here: https://www.nytimes.com/2019/03/23/business/boeing-
737-max-crash.html
966 See: Brianna Gurciullo and Patterson Clark, “What You Need to Know About the Boeing 737 MAX Grounding,”
PoliticoPro, July 2020, accessed here: https://subscriber.politicopro.com/datapoint/2020/07/pro-analysis-what-you-

need-to-know-about-the-boeing-737-max-grounding-101374 and Avie Schneider, “Boeing 737 Max, Involved In 2
Crashes, Is Fastest-Selling Plane in Company’s History,” National Public Radio (NPR), March 11, 2019, accessed here:
https://www.npr.org/2019/03/11/702211493/boeing-737-max-involved-in-two-crashes-is-fastest-selling-plane-in-
companys-hist
967 Prepared Statement of Edward F. Pierson, former Boeing Employee, Hearing titled, “The Boeing 737 MAX:
Examining the Federal Aviation Administration’s Oversight of the Aircraft’s Certification,” House Committee on
116hhrg40697.pdf
the 737 MAX program, Boeing Commercial Airplanes (BCA), May 19, 2020.
969 “737 MAX Completes Successful First Flight,” The Boeing Company, January 30, 2016, accessed here:
https://www.boeing.com/commercial/737max/first-flight/#/overview
Manager of the 737 MAX Program, Boeing Commercial Airplanes (BCA), May 11, 2020 and Boeing clarification.
971 See: Boeing internal emails, “Subject: Synthetic Airspeed,” February 26, 2013, at p. 1, accessed here:
https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production
pdf, Natalie Kitroeff, David Gelles and Jack Nicas, “Boeing 737 Max Safety System Was Vetoed, Engineer Says,” New
York Times, October 2, 2019, (Updated 29, 2019), accessed here:
https://www.nytimes.com/2019/10/02/business/boeing-737-max-crashes.html and Dominic Gates, Steve Miletich
and Lewis Kamb, “Boeing rejected 737 MAX safety upgrades before fatal crashes, whistleblower says,” Seattle Times,
164
 In November 2016, at the height of the development of the 737 MAX, an internal Boeing
survey regarding pressure on its Authorized Representatives (ARs), who are supposed to
represent the interests of the FAA and not Boeing, found that 39 percent of those surveyed
believed they had experienced “undue influence.” 972
 Some of Boeing’s web of global suppliers and subcontractors had a difficult time keeping up
with the pace of the 737 MAX’s production. This resulted in a haphazard production process
as workers had to pause the traditionally surgically-precise assembly of some MAX aircraft in
order to await delivery of key parts and supplies to complete the aircraft’s assembly. 973
 In June 2018, Ed Pierson, a Boeing plant supervisor at the Renton, Washington, 737 MAX
final assembly plant raised dire warnings with Scott Campbell, Boeing’s 737 General Manager,
regarding safety and quality control issues that he believed were undermining the integrity of
the 737 MAX aircraft due to worker fatigue and extreme production pressures. 974 “As a retired
Naval Officer and former Squadron Commanding Officer,” wrote Mr. Pierson, “I know how
dangerous even the smallest of defects can be to the safety of an airplane. Frankly right now
all my internal warning bells are going off. And for the first time in my life, I’m sorry to say
that I’m hesitant about putting my family on a Boeing airplane.” 975
 In July 2018, five weeks after Mr. Pierson’s email, he finally met with Mr. Campbell in Mr.
Campbell’s office. According to Mr. Pierson’s testimony to the Committee, he told Mr.
Campbell that in the military they would temporarily halt production if they had the kinds of
safety problems that Mr. Pierson was seeing on the MAX factory floor. According to Mr.
Pierson, Mr. Campbell responded: ‘‘The military isn’t a profit-making organization.’’ 976
October 2, 2019 (Updated October 3, 2019), accessed here: https://www.seattletimes.com/business/boeing-

aerospace/boeing-whistleblowers-complaint-says-737-max-safety-upgrades-were-rejected-over-cost
972 Boeing presentation “Undue Pressure: Key Learnings and Next Steps,” The Boeing Company, November 2016,
accessed here at p. 145: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf

116hhrg40697.pdf
974 Email from Ed Pierson to Scott A. Campbell, “Subject: Recovery Operations & Safety Concerns,” Saturday, June 9,
2018 1:32 PM. (Available here: Hearing titled, “The Boeing 737 MAX: Examining the Federal Aviation Administration’s
Oversight of the Aircraft’s Certification,” House Committee on Transportation and Infrastructure, 116th Congress, First
Session, U.S. House of Representatives, December 11, 2019, pp. 83-84, accessed here:
975 Ibid.
165
 Rather than heeding Mr. Pierson’s dire warnings and thoroughly evaluating his safety
concerns, Boeing continued to ramp up production. 977 Lion Air flight 610 crashed in October
2018, three months after Mr. Pierson retired early out of frustration that Boeing was not
adequately addressing his safety concerns.
737 MAX Production Line
Competitive pressure had a significant and deleterious influence on cost, schedule, and
production issues on the 737 MAX program. The MAX followed a 50-year production history of
Boeing’s 737 model airplane. The combined 737 fleet has flown more than 16.8 billion passengers
since the first 737 entered commercial service in 1968. 978 In March 2018, one year after the 737
MAX was certified by the FAA, Boeing employees produced the 10,000th 737 to come off the
production line. 979 The 10,000th 737 produced was a 737 MAX that rolled out of Boeing’s 737
Renton, Washington, production factory in 2018, setting a Guinness World Record title for the
“Most produced commercial jet aircraft model” in history. 980
In fact, the MAX became the fastest selling airplane model ever built with nearly 4,700 MAX
orders from more than 100 global customers by the time of the Lion Air crash in October 2018. 982
981
Combined orders and deliveries of the MAX peaked at more than 5,000 983 in 2018, with 387 MAX
aircraft delivered to Boeing’s customers by the time the plane was grounded in March 2019 days
after the crash of Ethiopian Airlines flight 302. 984
An estimated 30-percent of the worldwide commercial airplane fleet flying today were
produced at Boeing’s Renton plant, which has produced the Boeing 707, 727, 737 and 757
977 The Boeing Company, Q2 2018 Earnings Call, July 25, 2018, p. 6, p.12 and p.26, accessed here:
978 “Renton Production Facility,” The Boeing Company, accessed here: https://www.boeing.com/company/about-
bca/renton-production-facility.page
979 Kristen Stephenson, “Boeing celebrates its 10,000th 737 aircraft with a new record,” Guinness World Records,
March 20, 2018, accessed here: https://www.guinnessworldrecords.com/news/commercial/2018/3/boeing-celebrates-

its-10-000th-737-aircraft-with-a-new-record-518888
980 See: “Renton Production Facility,” The Boeing Company, accessed here: https://www.boeing.com/company/about-
bca/renton-production-facility.page and Kristen Stephenson, “Boeing celebrates its 10,000th 737 aircraft with a new
record,” Guinness World Records, March 20, 2018, accessed here:
https://www.guinnessworldrecords.com/news/commercial/2018/3/boeing-celebrates-its-10-000th-737-aircraft-with-a-
new-record-518888
981 “737 MAX Global Customers That Have Taken Delivery,” The Boeing Company, October 30, 2018,
accessed here:
https://web.archive.org/web/20181030034621/https:/www.boeing.com/commercial/737max/#/customers
982 Since the Lion Air crash orders for the 737 MAX have declined. As of June 2020, Boeing had 4,559 MAX
orders and had delivered 387 aircraft to its customers. See: “Orders & Deliveries: 737 MAX Summary Through
June 2020,” The Boeing Company, accessed here: http://www.boeing.com/commercial/#/orders-deliveries
983 Brianna Gurciullo and Patterson Clark, “What You Need to Know About the Boeing 737 MAX Grounding,”
PoliticoPro, July 2020, accessed here: https://subscriber.politicopro.com/datapoint/2020/07/pro-analysis-what-you-

need-to-know-about-the-boeing-737-max-grounding-101374.
984 “Orders & Deliveries: 737 MAX Summary Through June 2020,” The Boeing Company, accessed here:
http://www.boeing.com/commercial/#/orders-deliveries. (On this webpage you need to generate a “report” on the

737 MAX, which will produce the “737 MAX Summary Through June 2020,” indicating 387 MAX aircraft have been
delivered as of June 2020).
166
aircraft. 985 Today, the Renton plant’s 737 production facility covers 1.1 million square feet of factory
space, 986 equivalent to 25 acres or 19 football fields.
Boeing’s production of a 737 MAX airplane encompasses components from an estimated

600 separate suppliers and hundreds of additional subcontractors. 987 It takes 10 days to assemble a
MAX aircraft from the time the airplane’s fuselage enters the factory floor. 988 Boeing has an entire
online video depicting this complicated and intricate process dubbed “Incredible: The Story of the
Boeing Renton Site.” 989
In March 2014, Boeing reached a historic first by producing 42 airplanes of its 737 NG
model aircraft in a single month at its Renton factory, a 33 percent increase from its 2010
production levels. 990 Boeing’s internal magazine Frontiers touted this achievement: “To meet demand,
Boeing is producing its best-selling 737 jetliner at rates that once might have seemed unthinkable. …
While the focus now is on sustaining that rate, Boeing Commercial Airplanes has scheduled another
increase to 47 a month in 2017 and is studying rates beyond that, should the market demand it.” 991
Indeed, Boeing’s marketing and the market demand for the 737 MAX pushed the industrial
conveyor belt of 737 MAX airplanes well beyond that rate. At its peak the Renton final assembly
building was producing 52 MAX airplanes per month. 992
But this herculean pace came with consequences. At times Boeing’s multitude of suppliers
and subcontractors simply could not keep up. In June 2018, for example, Boeing had more than
three dozen partially completed 737 MAX airplanes staged outside of the Renton factory while it
awaited the delivery of parts from suppliers to complete the production process. 993 This resulted in
“out of sequence” work, which can lead to potential quality and safety issues. 994
986 Ibid.
987 David Slotnick, “Boeing's move to halt 737 Max production could hurt the 600 suppliers that make parts for the
plane despite its promise not to cut its own workforce,” Business Insider, December 17, 2019, accessed here,
https://www.businessinsider.com/boeing-737-max-production-halt-suppliers-components-2019-
12#:~:text=A%20network%20of%20about%20600,such%20as%20wings%20or%20fuselages
989 “Incredible: The Story of the Boeing Renton Site,” The Boeing Company, accessed here:
https://www.boeing.com/company/about-bca/renton-tour/index.page
990 “Record Performance,” Frontiers, Volume XII, Issue XI, The Boeing Company, April 2014, p. 19, accessed here:
http://www.boeing.com/news/frontiers/archive/2014/april/pubData/source/Frontiers%20APRIL14_Complete.pdf
991 Ibid, p. 16.
992 See: Dennis Muilenburg testimony, Hearing titled, “The Boeing 737 MAX: Examining the Design, Development, and
Marketing of the Aircraft,” Committee on Transportation and Infrastructure, U.S. House of Representatives, 116th
Congress, First Session, October 30, 2019, p. 52, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
116hhrg38282/pdf/CHRG-116hhrg38282.pdf and Daniel McCoy, “Analyst sees 737 MAX production restarting at
fewer than 20 aircraft per month,” Wichita Business Journal, January 15, 2020, accessed here:
https://www.bizjournals.com/wichita/news/2020/01/15/analyst-sees-737-max-production-restarting-at.html
993 Email from Ed Pierson to Scott Campbell, “Subject: Recovery Operations & Safety Concerns,” Sunday, June 10,
2018, 6:48 AM, p. 83, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-

116hhrg40697.pdf
994 Cynthia McFadden, Anna Schecter, Kevin Monahan and Rich Schapiro, “Former Boeing manager says he warned
company of problems prior to 737 crashes,” NBC News, December 9, 2019, accessed here:
https://www.nbcnews.com/news/us-news/former-boeing-manager-says-he-warned-company-problems-prior-737-
n1098536
167
Each 737 MAX-8 airplane costs more than $121 million, 995 and Boeing has made an
estimated $12 to $15 million per MAX airplane it has sold, according to Moody’s credit-rating
agency. 996 Given these figures, this has amounted to profits between $624-$780 million per month
during the MAX’s peak production period.
While the MAX was tremendously profitable for Boeing, this rapid rate of production was
troubling to some Boeing employees who were concerned about its impact on the quality and safety
of the airplane and the workers assembling the aircraft. But sticking to a tight schedule was not just a
concern once the MAX was certified by the FAA and Boeing began to produce it on the assembly
line. Schedule pressure was a constant concern of senior Boeing officials during the design and
development phases of the MAX as well, and Boeing’s leadership made sure that concern was
relayed to Boeing’s engineers and others designing and developing the 737 MAX aircraft.
Countdown Clock
To remind Boeing employees of how critical sticking to the program’s schedule was,
Boeing’s management introduced “countdown clocks” into the MAX program, and they made
certain that they were easy to spot. 997 In a transcribed interview with Committee staff, the former
Boeing Vice President and General Manager of the 737 MAX program, Keith Leverkuhn, explained
that there were countdown clocks associated with two major 737 MAX milestones—one was
“power on” (when the airplane is powered up for the first time in the factory). The second was “first
flight,” 998 which occurred on January 30, 2016, as scores of Boeing employees watched and
applauded as the 737 MAX took off for the first time. 999
The “countdown clocks” were located in the conference room where the 737 MAX
program’s senior-most management held “business performance reviews,” “technical review
boards,” and other meetings. 1000 Mr. Leverkuhn acknowledged that it was his “desire” to install these
“countdown clocks.” 1001 He suggested that the countdown clocks were “an excitement generator to
remind people that we were doing something remarkable on the development of the [737 MAX]
program.” 1002
However, Mr. Leverkuhn further acknowledged that the countdown clocks were also about
keeping to the MAX’s planned production schedule. “[O]ne of the mantras that we had was the
value of a day, and making sure that we were being prudent with our time,” said Mr. Leverkuhn,
“that we were being thorough, but yet, that there was a schedule that needed to be met, and, in fact,
995 “About Boeing Commercial Airplanes,” The Boeing Company, accessed here:
http://www.boeing.com/company/about-bca/#/prices
996 Benjamin Zhang, “Here’s how much Boeing is estimated to make on each 737 MAX 8 plane,” Business Insider India,
March 13, 2019, accessed here: https://www.businessinsider.com/boeing-737-max-profit-moodys-2019-3

998 Ibid.
999 “737 MAX Completes Successful First Flight,” The Boeing Company, January 30, 2016, accessed here:
https://www.boeing.com/commercial/737max/first-flight/#/overview
1001 Ibid.
1002 Ibid, p. 38.
168
again, the importance of what we were doing, because ultimately, this was a product that was going
to be flying millions and millions of passengers throughout the sky.” 1003
Michael Teal, the 737 MAX’s former Chief Project Engineer and Deputy Program Manager
of the 737 MAX program, said the countdown clock was put into place in 2012. 1004 “[I]t was very
prevalent to keep everyone on schedule to get the airplane flying,” said Mr. Teal. 1005 “I recall
that.” 1006 The 737 MAX countdown clock was a vivid visual reminder to Boeing’s employees—from
Boeing’s management—that emphasized the need to stay on schedule.
Nevertheless, sticking to the 737 MAX’s production schedule was not the only factor that
was important to Boeing’s management. As with any for-profit business, cost was also a significant
element of concern to Boeing’s leadership. In the case of the 737 MAX program, these concerns led
Boeing’s management to decide not to pursue certain technical features that may have improved the
safety of the aircraft because they came with increased costs and presented risks to the program’s
goal that pilots who were transitioning from the 737 NG would not require simulator training.
Synthetic Airspeed
Early in the 737 MAX design and development process, Boeing rejected at least one design
proposal by Boeing engineers—equipage of a synthetic airspeed indicator on the 737 MAX--due to
alleged cost concerns. 1007 In 2013, a Boeing employee suggested that it would be a challenge to install
a synthetic airspeed indicator on the 737 MAX. 1008 However, synthetic airspeed indication was
already a basic feature on Boeing’s 787 Dreamliner. 1009
An airplane’s instruments normally measure airspeed by measuring the pressure at which air
molecules enter small tubes called pitot tubes, which protrude from the left and right sides of the
airplane’s nose, and comparing those measurements against measurements of “static pressure”—the
air pressure in the atmosphere outside the airplane. 1010 If any part of the combined pitot-static
1003 Ibid, p. 37-38.

1004 Committee staff transcribed interview of Michael Teal, former Vice President, Chief Project Engineer & Deputy
Program Manager of the 737 MAX program, Boeing Commercial Airplanes (BCA), May 11, 2020.
1005 Ibid.
1006 Ibid.
1007 Natalie Kitroeff, David Gelles and Jack Nicas, “Boeing 737 Max Safety System Was Vetoed, Engineer Says, “ New
York Times, October 2, 2019, accessed here: https://www.nytimes.com/2019/10/02/business/boeing-737-max-

crashes.html
1008 Boeing internal email, “Subject: Synthetic Airspeed,” February 26, 2013, p.1, accessed here:
pdf
1009 See: Boeing Coordination Sheet, “BCA Strategy for Reducing the Risk of Loss of Control Events,” B-E911-FD-13-
038, March 3, 2014, BATES Number: TBC-T&I020864 – TBC-T&I020879, at TBC-T&I020876 (On file with the
Committee); Tom Dodt, “Introducing the 787,” The Boeing Company, September 2011, at pp. 40-41, accessed here:
http://www.caf-swisswing.ch/alt/images_fotogalerie/video/20110900BCA_Introducing_the_787__ISASI.pdf; and
Natalie Kitroeff, David Gelles and Jack Nicas, “Boeing 737 Max Safety System Was Vetoed, Engineer Says, “ New York
Times, October 2, 2019, accessed here: https://www.nytimes.com/2019/10/02/business/boeing-737-max-crashes.html
1010 Pilot’s Handbook of Aeronautical Knowledge, No. FAA-H-8083-25B, at 8-2, Federal Aviation Administration, (2016).
169
system fails, the airplane’s computers can no longer compute airspeed, presenting the risk of a stall
or loss of control. 1011
A synthetic airspeed system addresses that risk by creating a redundancy to the mechanical
pitot-static system. This system computes airspeed by “synthesizing” various other independent data
points—chiefly a GPS-based measurement of the airplane’s speed over the ground, the airplane’s
angle of attack, the last computed measurement of the angle and speed of winds aloft, and the
airplane’s pitch attitude and heading. 1012 A synthetic airspeed system solves the problem of a loss of
conventional airspeed data and provides pilots with a “stopgap” estimate of airspeed on which they
can rely to maintain control of the airplane through landing.
However, because the system relies on AOA data as one datapoint, the system can also be
used to assess the reliability of AOA sensors. 1013 In other words, if AOA data is lost but not
announced to the pilots because of the absence of an AOA Disagree alert, the pilots could infer
from the simultaneous loss of a synthetic airspeed computation that one or both of the AOA
sensors had failed. Therefore, it is possible that inclusion of a synthetic airspeed system on the 737
MAX could have provided the Lion Air flight 610 flight crew with another clue to help them deduce
that at least one AOA sensor had failed (the pilots of Ethiopian Airlines flight 302 correctly
diagnosed the problem). Unfortunately, the request to install synthetic airspeed on the 737 MAX
was rejected by Boeing management because its introduction would have been too costly and may
have resulted in the FAA requiring simulator training on the MAX – something that would have
jeopardized the 737 MAX program’s clear and consistent goal to avoid simulator training
requirements. 1014
In February 2013, a Boeing employee emailed a 737 Technical Pilot and wrote: “It will be a
challenge to implement synthetic airspeed on the 737” MAX, noting that the implementation would
“need to be different from the 787” Dreamliner. 1015 The Technical Pilot responded,
As I pointed out in the telecom today, an introduction of synthetic

airspeed to the MAX would drastically alter [the Airspeed Unreliable]
Critical Action, Memory Item Non-Normal Checklist. If synthetic
1011 Ibid.; See also: “Final Report on the Accident on 1st June 2009 to the A330-203 Registered F-GZCP Operated by Air
France Flight AF 447 Rio de Janeiro-Paris,” Bureau d’Enquetes et d’Analyses pour la securite de l’aviation civile, at 31-
33, accessed here: https://www.bea.aero/docspa/2009/f-cp090601.en/pdf/f-cp090601.en.pdf
1012 See:Matt Miltner, Pengfei (Phil) Duan, and Dr. Maarten Uijt de Haag, “Modeling and Utilization of Synthetic Data
for Improved Automation and Human-Machine Interface Continuity” (presentation at Digital Avionics Systems
Conference), Colorado Springs, Colo., Oct. 5-9, 2014), accessed here:
https://ieeexplore.ieee.org/stamp/stamp.jsp?arnumber=6979576
1013 See: Letter from Boeing Employee to the U.S. Senate Commerce, Science, and Transportation Committee, June 5,
2020 and Dominic Gates, “Boeing whistleblower alleges systemic problems with 737 max,” Seattle Times, June 18, 2020,
accessed here: https://www.seattletimes.com/business/boeing-aerospace/boeing-whistleblower-alleges-systemic-
problems-with-737-max
1014 See: Boeing internal emails, “Subject: Synthetic Airspeed,” February 26, 2013, p.1, accessed here:
pdf and Dominic Gates, “Boeing whistleblower’s complaint says 737 MAX safety upgrades were rejected over cost,”
Seattle Times, October 2, 2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/boeing-
whistleblowers-complaint-says-737-max-safety-upgrades-were-rejected-over-cost
1015 Boeing internal emails, “Subject: Synthetic Airspeed,” February 26, 2013, p.1, accessed here:
pdf
170
airspeed is standard as opposed to an option, it would likely
jeopardize the Program directive to maintain Level B training for our
customers. 1016
Loss of Control
However, some Boeing engineers believed synthetic airspeed was a key feature that should
have been included on the 737 MAX. A year after that email exchange, on March 3, 2014, Boeing
produced an internal Coordination Sheet that provided the rationale for and description of synthetic
airspeed. 1017 Synthetic airspeed was among eight
Boeing Coordination Sheet proposed design changes in that document to
“BCA Strategy for Reducing the address Boeing aircraft loss of control accidents
Risk of Loss of Control Events” and events on various Boeing aircraft, which
March 3, 2014 included, but was not limited to, the Boeing 737
model aircraft. 1018 These Boeing aircraft events
accounted for 1,493 onboard fatalities and 80
“UNLIKE ALL OTHER BOEING
external fatalities worldwide from 2002 to
MODELS, THE 737 HAS NO WAY TO 2011. 1019
REMOVE ERRONEOUS AIR DATA
FROM A DISPLAY AND REPLACE IT The Coordination Sheet recommended
WITH CORRECT DATA.” implementing synthetic airspeed on the 737 NG
and the 737 MAX at the next appropriate
software update. 1020 The Boeing internal document also listed three key reasons for including
synthetic airspeed on the 737-model aircraft:
1) it would help to eliminate “erroneous air data” readings that can trigger an “aural” alert
that “continuously sound without a way to correct or cancel” the alert; 1021
2) erroneous airspeed can result in a stall warning speed alert that “will cause a continuous
stick shaker without a way to correct the situation or cancel the alert;” 1022 and
3) “unlike all other Boeing models, the 737 has no way to remove erroneous air data from a
display and replace it with correct data.” 1023
Adding synthetic airspeed would have helped to eliminate these potential conditions that
could lead to pilot confusion and distraction. However, Boeing chose not to do that. A Boeing
engineer involved in this issue recently wrote to the Senate Committee on Commerce, Science, and
Transportation about his frustrations related to synthetic airspeed and other issues regarding the
1016 Ibid.
1017 Boeing Coordination Sheet, “BCA Strategy for Reducing the Risk of Loss of Control Events,” B-E911-FD-13-038,
March 3, 2014, BATES Number: TBC-T&I020864 – TBC-T&I020879 (On file with the Committee).
1018 Ibid.
1019 Ibid, at TBC-T&I020866
1020 Ibid, at TBC-T&I020876
1020 Ibid.
1021 Ibid.
1022 Ibid.
1023 Ibid.
171
development of the 737 MAX. “I specifically advocated for a system that would have enabled”
synthetic airspeed to be placed on the 737, “but upper management shut down the project over cost
and training concerns,” he wrote. 1024
The notion of adding synthetic airspeed to the MAX was raised three separate times with
Boeing managers and rejected on the basis of cost and potential pilot training impacts, according to
an internal Boeing complaint filed by a Boeing engineer and reported on by both the Seattle Times
and the New York Times. 1025 According to the Seattle Times story, Michael Teal cited those reasons
when he ultimately made a decision not to include synthetic airspeed on the MAX. 1026
According to the Seattle Times, the Boeing employee who filed the complaint said
management was more concerned with cost and schedule than safety or quality. The complaint also
alleged that Boeing hid inflight safety incident data from the European Union Aviation Safety
Agency (EASA), according to the newspaper. Further, it reported that the employee who filed the
complaint expressed concerns about retaliation for even raising these issues internally at Boeing.
The Boeing employee apparently wrote, that given “the nature of this complaint, the fear of
retaliation is high, despite all official assurances that this should not be the case. There is a
suppressive cultural attitude towards criticism of corporate policy – especially if that criticism comes
as a result of fatal accidents,” wrote the employee. 1027
Keith Leverkuhn, the former General Manager of the MAX program, said he was unaware
of any efforts to install synthetic airspeed on the MAX until these stories appeared in the media.
However, during a transcribed interview with Committee staff, he said: “[W]hat I can say is that
changes to the airplane, we had a very, very detailed process associated with any change that was
being forwarded to make its way on the airplane, and sometimes, those changes were not accepted
and it was either due to schedule or cost, or frankly, functionality that wasn’t required.” 1028
Some Boeing engineers, however, strenuously argued that synthetic airspeed was one
technical feature that may have dramatically improved safety on the 737 MAX if it had been
installed. Even more chilling was that the Boeing engineer who wrote to the Senate Committee on
Commerce, Science, and Transportation said that in 2015 his Boeing manager argued against
1024 Letter from Boeing Employee to the U.S. Senate Commerce, Science, and Transportation Committee, June 5, 2020,
at. p. 4. (On file with the Committee).

1025 See: Dominic Gates, “Boeing whistleblower’s complaint says 737 MAX safety upgrades were rejected over cost,”
Seattle Times, October 2, 2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/boeing-

whistleblowers-complaint-says-737-max-safety-upgrades-were-rejected-over-cost and Natalie Kitroeff, David Gelles and
Jack Nicas, “Boeing 737 Max Safety System Was Vetoed, Engineer Says,” New York Times, (originally published) October
2, 2019, (updated October 29, 2019), accessed here: https://www.nytimes.com/2019/10/02/business/boeing-737-max-
crashes.html
1026 Dominic Gates, “Boeing whistleblower’s complaint says 737 MAX safety upgrades were rejected over cost,” Seattle
Times, October 2, 2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/boeing-

1027 Dominic Gates, “Boeing whistleblower’s complaint says 737 MAX safety upgrades were rejected over cost,” Seattle
Times, October 2, 2019, accessed here: https://www.seattletimes.com/business/boeing-aerospace/boeing-

172
including synthetic airspeed on the MAX, reportedly stating, “People have to die before Boeing will
change things.” 1029
The Renton Plant Production Line
Beyond the design and development phases of the 737 MAX, schedule and production
pressure were common themes on the 737 MAX on the factory floor of Renton’s final assembly
plant. On a January 31, 2018, fourth quarter 2017 earnings call with the media and aviation industry
analysts, Dennis Muilenburg, then-Chairman, President and Chief Executive Officer (CEO) of The
Boeing Company at the time discussed the Renton facility’s 737 production line. 1030
I had a chance to be out on the line again just recently. And they're
implementing productivity improvements, production line flow
improvements, tack time improvements, all while rolling the MAX
into the line.
So while it's a challenging situation, it's a high-volume line, fast

moving line. We're continuing to ramp up while we introduce the
MAX into the line. It requires daily focus and daily attention. The
ramp up continues on track, and we're not seeing issues or any
problems that are out of the ordinary. And I remain confident that
we'll achieve our MAX ramp-up goals for 2018. 1031
Those were ambitious goals. Production of the MAX had ramped up from 42 aircraft per
month to 47 aircraft per month in 2017, 1032 and Boeing set a goal of increasing the MAX production
rate from 47 aircraft per month to 52 aircraft per month in 2018, 1033 with the ultimate goal of
reaching a production rate of 57 aircraft per month in 2019. 1034
For those working on the factory floor and supervising the monumental task of assembling
the 737 MAX aircraft at this rapid production rate, however, the problems they encountered were
intensified by the pressure to produce. In the spring and summer of 2018, with literally thousands of
MAX orders on the books and production ramping up, employees at the Renton plant were working
1029 Letter from Boeing Employee to the U.S. Senate Commerce, Science, and Transportation Committee, June 5, 2020

1030 The Boeing Company, Q4 2017 Earnings Call, January 31, 2018, p. 19, accessed here:
https://s2.q4cdn.com/661678649/files/doc_transcripts/2018/Q417-Earnings-Transcript.pdf
1032 See: The Boeing Company, Q4 2017 Earnings Call, January 31, 2018, p. 4, accessed here:
https://s2.q4cdn.com/661678649/files/doc_transcripts/2018/Q417-Earnings-Transcript.pdf and Dominic Gates,

“Boeing tops Airbus in 2017 with jet-production record,” Seattle Times, January 9, 2018, accessed here:
https://www.seattletimes.com/business/boeing-aerospace/boeing-tops-airbus-in-2017-with-new-jet-production-record
1034 Ibid. The 737 MAX never met the ultimate production rate of 57 aircraft per month. The top rate of production was
52 MAX aircraft per month. See: Email from Boeing to T&I Committee staff, July 24, 2020 (On file with the
Committee).
173
significant overtime, including back-to-back weekends. 1035 Like any large-scale industrial
manufacturing facility, safety and quality control were key concerns. But the Committee’s
investigation has found that in at least some cases those concerns appeared to take a back seat to
Boeing management’s concerns about staying on schedule on the 737 MAX production line.
In particular, in June 2018, a Boeing plant supervisor at the Renton final assembly facility
began to raise serious concerns with senior Boeing management regarding safety and quality control
problems he was witnessing in the production of the 737 MAX. 1036 The supervisor, Edward Pierson,
voluntarily retired early in August 2018 primarily due to his belief that Boeing management was not
taking these issues seriously enough or confronting them thoroughly enough to adequately address
his safety concerns. 1037 He had not planned to retire for several more years. However, he was
uncomfortable standing by and watching these safety issues continue to percolate throughout the
plant while senior Boeing management was not fully implementing his suggestions for correcting
them. 1038
Mr. Pierson was not a “disgruntled” employee or someone that habitually complained about
safety problems at the Renton plant or grumbled about working conditions at Boeing. He took his
job seriously and voiced his concerns about safety and quality issues at the Renton plant loudly and
clearly to the senior-most official in charge of the 737 MAX production facility. 1039
Mr. Pierson is a graduate of the U.S. Naval Academy and retired in 2015 as a Captain
following 30 years of service in the U.S. Navy and U.S. Navy Reserves. 1040 Following graduation, he
attended U.S. Navy Flight School in Pensacola, Florida and was designated a Naval Flight Officer.
Over his career, he held various posts, including as an Action Officer for the Joint Chiefs of Staff at
the Pentagon, as a Crisis Management Officer at the U.S. Department of State, as a Squadron
Commanding Officer in Whidbey Island, Washington, and as Director of the Joint Operations
Center at the Naval Submarine Base in Bangor, Washington. 1041 Among his assignments in the
Pacific Northwest, he was selected to teach leadership and ethics to fellow Naval Officers and Non-
Commissioned Officers. 1042
In 2008, while still in the U.S. Navy Reserves, Mr. Pierson joined Boeing as part of the
company’s Commercial Aviation Services division and in 2010 moved to a role as Senior Manager of
Business Operations in Boeing’s Test & Evaluation division. 1043 From April 2015 to August 2018,
Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, pp.
74-75, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf
1036 Ibid, p. 75.
1037 Ibid, pp. 74-76.
1038 Ibid.
Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, p.
1040 Resume of Ed Pierson, accessed here: https://docs.house.gov/meetings/PW/PW00/20191211/110296/HHRG-
116-PW00-Bio-PiersonE-20191211.pdf
1041 Ibid.
1042 Ibid.
1043 Ibid.
174
Mr. Pierson served as a Senior Manager for Production System Support for both the Boeing 737
final assembly program and Boeing’s P-8 Poseidon anti-submarine warfare aircraft program. 1044 In
this role, Mr. Pierson was a senior leader of the 737 MAX final assembly facility and “coordinated
production for manufacturing operations with engineering, quality, tooling, supply chain, facilities
and IT organizations.” 1045 He also supported “team members and industrial engineers in developing
production reports and metrics while leveraging data analytics to drive strategic operational
improvements.” 1046
Production Pressure
In June 2018, as MAX production rates were ramping up from 47 aircraft per month to 52
aircraft per month, 1047 the problems Mr. Pierson was witnessing in the Renton plant hit a crescendo.
He was concerned not just for the safety of
the Boeing workforce that he managed but Ed Pierson, Boeing Senior Manager,
for the safety of the passengers who would 737 MAX Final Assembly Plant
be flying on the aircraft the Boeing factory Email to Scott Campbell,
was producing. On Saturday, June 9, 2018, at
737 General Manager
1:32 p.m., Mr. Pierson wrote an email to
Scott Campbell, the General Manager of the June 9, 2018
737 program and the senior most official at “MY FIRST CONCERN IS THAT OUR
the Renton production facility. 1048 WORKFORCE IS EXHAUSTED. … MY
“Scott, I have some safety concerns SECOND CONCERN IS SCHEDULE
that I need to share with you as the leader of PRESSURE (COMBINED WITH
the 737 Program,” wrote Mr. Pierson. 1049
FATIGUE) IS CREATING A CULTURE
“Today we have 38 unfinished airplanes WHERE EMPLOYEES ARE EITHER
located outside the factory. The following DELIBERATELY OR
concerns are based on my own observations UNCONSCIOUSLY CIRCUMVENTING
and 30 years of aviation safety experience.” 1050
Mr. Pierson cited two key concerns. “My first ESTABLISHED PROCESSES.”
concern is that our workforce is exhausted.
…. Fatigued employees make mistakes,” he warned. 1051 “My second concern is schedule pressure
1044 Ibid.
1045 Ibid.
1046 Ibid.
Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, p.
1048 Email from Ed Pierson to Scott A. Campbell, The Boeing Company, “Subject: Recovery Operations & Safety
Concerns,” Saturday, June 9, 2018 1:32 PM, accessed here at pp. 83-84:
1049 Ibid.
1050 Ibid.
1051 Ibid.
175
(combined with fatigue) is creating a culture where employees are either deliberately or
unconsciously circumventing established
Ed Pierson, Boeing Senior Manager, processes.” 1052
737 MAX Final Assembly Plant
Email to Scott Campbell, Mr. Pierson detailed some of these
737 General Manager specific concerns and said these issues could lead
June 9, 2018 to “inadvertently imbedding safety hazard(s) into
our airplanes. As a retired Naval Officer and
“FRANKLY RIGHT NOW ALL MY former Squadron Commanding Officer, I know
INTERNAL WARNING BELLS ARE how dangerous even the smallest of defects can
be to the safety of an airplane. Frankly right now,”
GOING OFF. AND FOR THE FIRST he wrote, “all my internal warning bells are going
TIME IN MY LIFE, I’M SORRY TO off. And for the first time in my life, I’m sorry to
SAY THAT I’M HESITANT ABOUT say that I’m hesitant about putting my family on a
PUTTING MY FAMILY ON A Boeing airplane. …. I fear serious process
BOEING AIRPLANE. breakdowns will continue to occur if we continue
pushing our employees to the limit,” he wrote. 1053
….
Mr. Pierson recommended temporarily
I FEAR SERIOUS PROCESS shutting down the production line “to allow our
BREAKDOWNS WILL CONTINUE team time to regroup so we can safely finish the
TO OCCUR IF WE CONTINUE planes outside and then shift our attention to the
PUSHING OUR EMPLOYEES TO planes inside. I don’t make this recommendation
lightly,” he wrote. 1054 “I know this would take a lot
THE LIMIT.”
of planning, but the alternative of rushing the
build is far riskier. Nothing we do is as important that it is worth hurting someone,” Mr. Pierson
declared. 1055
Mr. Campbell responded to Mr. Pierson at 6:48 a.m. the following morning, Sunday, June 10,
2018. 1056 His reply suggested he clearly understood Mr. Pierson’s concerns. Mr. Campbell wrote:
We need and will remind everyone constantly that quality is number

one and schedule come [sic] after that. We are trying to make sure
people take time off so the [sic] can recharge…because your [sic] right
we don’t want people coming to work tired. 1057
1052 Ibid
1053 Ibid.
1054 Ibid.
1055 Ibid.
1056 Email from Scott A. Campbell, The Boeing Company, to Ed Pierson, “Subject: RE: Recovery Operations & Safety
Concerns,” Sunday, June 10, 2018 6:48 AM, accessed here at pp. 83-84:
1057 Ibid.
176
However, it took more than five weeks and another email from Mr. Pierson to Mr.
Campbell’s assistant to arrange a meeting on the topic. 1058 Mr. Pierson finally met with Mr. Campbell
on Wednesday, July 18, 2018, in Mr. Campbell’s office. Mr. Pierson described the meeting as
tense. 1059 According to Mr. Pierson’s testimony to the Committee in December 2019, when he
walked into Mr. Campbell’s office, Mr. Campbell asked him: “Why are you here?” 1060 Mr. Pierson
reminded him about their email exchange and the safety issues he had raised. Mr. Pierson recalled
telling Mr. Campbell: ‘‘In … military operations, if we have these kinds of indications of unstable
safety type of things, we would stop.’’ 1061 Mr. Pierson was attempting to highlight his previous
recommendation that the Renton plant’s production line should temporarily cease operation because
of his significant safety concerns. Mr. Campbell responded: ‘‘The military is not a profit-making
organization,’’ according to Mr. Pierson. 1062
The following day, Mr. Pierson sent an email to Mr. Campbell thanking him for his time and
reiterating the concerns that he had about schedule pressure and safety issues. 1063 Mr. Campbell
responded saying he was already taking actions to address these issues but did not list any specific
measures he was planning to institute as a reaction to Mr. Pierson’s concerns. 1064 In fact, rather than
heeding Mr. Pierson’s dire warnings and thoroughly evaluating his safety concerns, Boeing
continued to ramp up production on the 737 MAX. 1065 Lion Air flight 610 crashed three months
later. 1066
One week after Mr. Pierson and Mr. Campbell met, Boeing held its second quarter 2018
quarterly earnings call with reporters and industry analysts. 1067 Boeing’s then-CEO Dennis
Muilenburg noted that production on the 737 MAX was continuing to ramp up and that the
company had delivered 162 MAX aircraft to its customers to date. 1068 The Lion Air accident aircraft
1058 Email from Ed Pierson to Marla A. Andrus, The Boeing Company, “Subject: FW: Recovery Operations & Safety
Concerns,” Monday, July 9, 2018 12:47 PM, accessed here at p. 82: https://www.govinfo.gov/content/pkg/CHRG-
1059 Prepared Statement of Edward F. Pierson, former Boeing Employee, Hearing titled “The Boeing 737 MAX:
116hhrg40697.pdf
1060 Testimony of Ed Pierson, former Boeing Employee, at Hearing titled, “The Boeing 737 MAX: Examining the
Federal Aviation Administration’s Oversight of the Aircraft’s Certification,” House Committee on Transportation and
Infrastructure, 116th Congress, First Session, U.S. House of Representatives, December 11, 2019, see page 139, accessed
1061 Ibid.
1062 Ibid.
1063 Email from Ed Pierson to Scott A. Campbell, The Boeing Company, “Subject: FW: Recovery Operations & Safety
Concerns,” Tuesday, July 19, 2018 2:47 PM, accessed here at pp. 81-82:
1064 Email from Scott A. Campbell, The Boeing Company, to Ed Pierson, “Subject: RE: Recovery Operations & Safety
Concerns,” Thursday, July 20, 2018 6:49 AM, accessed here at p. 81: https://www.govinfo.gov/content/pkg/CHRG-
1065 The Boeing Company, Q2 2018 Earnings Call, July 25, 2018, p. 6, p.12 and p. 26, accessed here:
1066 “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” accessed here: https://aviation-is.better-
1067 The Boeing Company, Q2 2018 Earnings Call, July 25, 2018, accessed here:
1068 Ibid, p. 4.
177
was produced shortly after that phone call. The aircraft that crashed while operating Lion Air flight
610 on October 29, 2018, was the 172nd MAX airplane to roll off the Renton factory’s production
line. 1069 The airplane that operated Ethiopian Airlines flight 302 was the 239th MAX aircraft to be
produced. 1070
Given the production rate at the time, it appears both planes were manufactured shortly
after the time period when Mr. Pierson was raising concerns about production and safety issues at
the Renton plant. In August 2018, Mr. Pierson voluntarily retired early from Boeing after one decade
at the company. He believed that Boeing was more focused on the quantity of airplanes being
produced rather than thoroughly correcting the quality control and safety concerns he had identified.
In September 2018, just a month after Mr. Pierson retired, several news stories reported on
the disarray at the Renton plant. Things seemed to have become even worse just a few weeks after
Mr. Pierson retired. The Australian magazine Traveller indicated that Boeing had rehired about 600
retired Boeing employees, particularly mechanics and inspectors on a temporary basis to come back
to help on the production line at the Renton plant. 1071 The story indicated that the production issues
that had existed at the plant in July 2018, where the factory was moving too quickly and the 737
MAX suppliers could not keep up with the plant’s rapid production rate had grown even worse. 1072
According to the story, which was published on September 12, 2018, “About 50 semi-finished 737s
were scattered around the Renton plant last week, analysts said, several times the number of semi-
finished aircraft reported in July.” 1073
The Seattle Times reported that on August 30, 2018, the Renton plant was roughly 26,600 jobs
behind schedule and that this number had “swelled” to about 31,000 jobs by the first week of
September 2018, just one month after Mr. Pierson left his position at the plant. 1074 As the Seattle
Times explained, “Each job is one discrete task, each varying in complexity and the time and
resources for completion.” 1075 These included items such as specific tests or installing electronics, for
instance.
The story seemed to validate all of the issues that Mr. Pierson had laid out for Boeing’s 737
General Manager Scott Campbell and had warned him about two months earlier. One worker who
spoke to the Seattle Times described the Renton plant as being in “total chaos.” 1076 Another worker
said: “We’re ripping apart some of the electronics racks already assembled to replace wire bundles
that aren’t right.” 1077 The Seattle Times story noted that there were lots of “out-of-sequence work,”
which Mr. Pierson had also noted, and that some workers had worked as many as nine weekends in
1069 Boeing email to T&I Committee Staff, April 9, 2019. (On file with the Committee).
1070 Ibid.
1071 “Boeing 737 MAX: Retired former employees come back to help with production,” Traveller, September 12, 2018,
accessed here: https://www.traveller.com.au/boeing-737-max-retired-former-employees-come-back-to-help-with-

production-h157in#
1072 Ibid.
1073 Ibid.
1074 Dominic Gates, “737 problems have grown in Renton despite Boeing’s reassurances,” The Seattle Times, September 6,
2018, accessed here: https://www.seattletimes.com/business/boeing-aerospace/737-problems-have-grown-in-renton-

despite-boeings-reassurances
1075 Ibid.
1076 Ibid.
1077 Ibid.
178
a row without a break. 1078 Others were calling in sick just to be able to take a day off and get some
rest.
The Seattle Times also reported that some work groups at the plant had “asked their managers
about perhaps stopping the production lines in order to catch up” on all of the half-finished
airplanes that were accumulating at the Boeing factory. “Managers have responded categorically that
a pause cannot happen because of the severe impact it would have on suppliers, on airline customers
and on the company’s stock price,” wrote the Seattle Times. 1079
No Slowing Down – Production Goes On
The Boeing 737 MAX suffered its first fatal crash in late October 2018, a little less than
three months after Ed Pierson retired from Boeing on August 1, 2018 in frustration that the
company was pushing production over safety. The crash of Lion Air flight 610 hit him hard. This
was the concern that had caused him to worry and to warn senior Boeing officials about months
earlier. While Mr. Pierson was not involved at all in the design or development of the 737 MAX and
was unaware of the key design issues that have played central roles in the crash of the MAX
airplanes, including the Maneuvering Characteristics Augmentation System (MCAS), which relied on
a single angle of attack (AOA) sensor, he still wonders if the frantic assembly pace he witnessed and
the failure of Boeing’s management to quickly and fully address the safety and quality control issues
he identified had inadvertently and unknowingly created a condition that may have contributed to
the MAX crashes. 1080
Following the Lion Air crash, although he was now retired, Mr. Pierson renewed his efforts
to inform Boeing of the problems he had witnessed on the production line as a Boeing supervisor.
On multiple occasions, he attempted to contact the lead Boeing investigator on the Lion Air
accident investigation to share his experiences at the Renton factory, which he believed may have
contributed to the crash. 1081 He was not successful. Finally, on December 19, 2018, he sent a letter
directly to then-CEO Dennis Muilenburg. 1082
Mr. Pierson explained who he was, his role at Boeing, and that he believed he had
information about the 737 MAX production process that could be helpful for the investigation of
the Lion Air crash. “I have made repeated efforts to identify and speak with the individual who is
the Boeing primary lead” on the Lion Air investigation, Mr. Pierson explained to Mr. Muilenburg in
1078 Ibid.
1079 Ibid.
116hhrg40697.pdf
1081 Ibid.
accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf and
Letter from Ed Pierson to Dennis Muilenburg, CEO, The Boeing Company, December 19, 2018, accessed here at p. 85:
179
his letter. 1083 He also explained that he had left his name and number with various Boeing officials
several times but never received a return phone call. His letter said, in part:
Admittedly the information I need to share isn’t favorable to Boeing,

but I believe it is very important nonetheless. …. Like everyone else I
feel horrible for the families of the 189 people that lost their lives. My
sole objective is helping to ensure this never happens again. I am
specifically asking your assistance to help me get in touch with the
Boeing lead. 1084
An Assistant General Counsel for Boeing Commercial Airplanes (BCA), Padraic Fennelly,
reached out to Mr. Pierson on January 7, 2019, as follow-up to Mr. Pierson’s letter to Mr.
Muilenburg. 1085 The two discussed Mr. Pierson’s concerns. 1086
On February 7, 2019, Mr. Ed Pierson, former Boeing Senior Manager,

Pierson sent another email extensively
detailing all of the production issues he 737 MAX Final Assembly Plant
had been raising to both Mr. Fennelly Email to Boeing General Counsel
as well as Boeing’s General Counsel, February 7, 2019
Michael Luttig. 1087 The email described
the following issues that Mr. Pierson had “EMPLOYEES WITH 20+ YEARS 737
previously raised with Boeing’s EXPERIENCE STATED THEY HAD NEVER
management: SEEN THE PRODUCTION SYSTEM IN SUCH
BAD SHAPE. AS YOU STATED, [BOEING]
• Employee Fatigue &
Schedule Pressure LEADERS BASED IN CHICAGO WERE
• Leadership Actions & AWARE OF THESE RECOVERY ISSUES.
Inactions ….
• Quality Issues
• Supply Chain Disruptions THE QUESTION IS WHETHER OR NOT
• Staffing Constraints THERE IS THE ETHICAL LEADERSHIP
• Process Deviations AND WILL TO SET ASIDE PRIDE AND
• Communication Breakdowns POTENTIAL LIABILITIES TO GET TO THE
• Safety Incidents TRUTH.”
1083 Letter from Ed Pierson to Dennis Muilenburg, CEO, The Boeing Company, December 19, 2018, accessed here at p.
85: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf
1084 Ibid.
1086 Ibid.
1087 Email from Ed Pierson to Michael Luttig, General Counsel, The Boeing Company, and Padraic Fennelly, Assistant
General Counsel, Boeing Commercial Airplanes (BCA), “Subject: RE: 737 Program Safety Concerns,” February 7, 2019
9:06 AM, accessed here at pp. 87-90: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-
116hhrg40697.pdf
180
• Functional Test Delays & Failures

• Facility Limitations
• Equipment Shortcomings
• Recovery Planning Efforts
• Deteriorating Factory Health Metrics 1088
Mr. Pierson concluded his letter to Boeing’s attorneys with a warning about the risks these
issues posed to Boeing, its aircraft, and the flying public:
Taken as a whole, the sheer volume of these issues highlights the

considerable & unnecessary risk the company was (is still?) taking to
meet ever increasing airplane production rates and delivery schedules.
Employees with 20+ years 737 experience stated they had never seen
the production system in such bad shape. As you stated, leaders
based in Chicago were aware of these recovery issues. Nonetheless
being aware of these problems and fixing them are two completely
different matters. Just because an airplane flies safely one day doesn’t
mean it will fly safely the next. This is the insidious nature of
imbedded defects….
Again to be very clear, I’m not saying anyone did anything deliberate
to jeopardize the Lion Air airplane. What I am saying is production
mistakes may have been made with this airplane and potentially
others, due to the reasons outlined above. I believe Boeing has a duty
to proactively support the accident investigation. I can’t help but
wonder what Boeing’s response would be if this had been a U.S.
airline accident. I know there are billions of dollars at stake in the
contract between Boeing & Lion Air. I’m confident Boeing has the
resources to fix these problems. The question is whether or not there
is the ethical leadership and will to set aside pride and potential
liabilities to get to the truth. 1089
On February 19, 2019, Mr. Pierson escalated his concerns yet again, this time to Boeing’s
Board of Directors—all of them. 1090 He sent a detailed four-page letter that included several
attachments to the dozen members of Boeing’s Board of Directors. He summarized his concerns
and requested that the Board look into them. He also wanted them to share his concerns with the
accident investigators at the National Transportation Safety Board (NTSB), with the Federal
Aviation Administration (FAA), and with Indonesian civil aviation authorities. Mr. Pierson’s letter to
the Boeing Board of Directors concluded:
I have no interest in scaring the public or wasting anyone’s time. I

also don’t want to wake up one morning and hear about another
tragedy and have personal regrets. Of course, this is something no
1088 Ibid.
1089 Ibid., p. 89.
1090 See: Letter from Ed Pierson to Boeing Board of Directors, February 19, 2019, accessed here at pp. 91-95:
181
one wants to happen. For what it is worth, if requested I would make
myself available to the Board to answer any questions or provide
additional information.
I’m trying to give Boeing every opportunity to do the right thing

because only Boeing can fix these internal problems. We owe it to the
families devastated by the Lion Air accident, our employees,
stockholders and the people that continue to trust their lives with
Boeing airplanes around the world. 1091
Mr. Pierson never received a response from the Boeing Board of Directors. 1092 Less than
three weeks later the 737 MAX suffered its second fatal crash in less than five months. On March
12, 2019, two days after the Ethiopian Airlines crash, Mr. Pierson wrote to the Boeing Board of
Directors again. 1093
He reminded the Board about the previous safety issues he highlighted in his letter. “In my
opinion these safety concerns came about as a result of senior leadership actions/inactions, schedule
pressure, overworked employees, understaffing, process deviations, supplier and quality issues,” he
wrote, clearly frustrated with the Board’s lack of a response to his previous letter. He continued,
“I’m very proud to have worked at Boeing and truly believe these issues are all fixable. However, I’m
not proud of the way Boeing has handled this matter. I have offered to help the company identify
and address these issues both as an employee and as a retiree. This offer still stands,” he wrote. Mr.
Pierson also emphasized that his concerns about Boeing’s harried production process was not
limited to the 737 MAX, but also potentially impacted the 737 NG and the U.S. Navy’s P-8 aircraft
as well. 1094
When Mr. Pierson wrote to the Boeing Board of Directors on February 19 and March 12,
2019, he copied all of the Board members, including David Calhoun. In December 2019, Boeing
announced that Mr. Calhoun would become the company’s new Chief Executive Officer (CEO)
replacing Dennis Muilenburg. 1095 Mr. Pierson has said that none of the Board members, including
David Calhoun, ever responded to him.
1091 Ibid., p. 94.

1093 Letter from Ed Pierson to Boeing Board of Directors, March 12, 2019, accessed here at p. 96:
1094 Ibid.
1095 Leslie Josephs, “‘He’s not new blood.’ What to know about Boeing’s new CEO as 737 Max crisis drags on,” CNBC,
December 23, 2019, accessed here: https://www.cnbc.com/2019/12/23/what-to-know-about-new-boeing-ceo-david-

calhoun.html
182
Renton Review
Following the Ethiopian Airlines crash on March 10, 2019, Mr. Pierson also made multiple
attempts to speak with Federal agencies supporting the 737 MAX crash investigations. 1096 As part of
this process, he and his attorneys sent three letters to the FAA Administrator, three letters to the
NTSB, and one letter to the Secretary of Transportation Elaine Chao. 1097 He wanted them to review
the production operations at Boeing’s Renton production plant and to share his experience and
observations with them. After this Committee initiated its investigation into the design,
development, and certification of the 737 MAX and related issues, and established a whistleblower
hotline, 1098 Mr. Pierson reached out to the Committee to furnish information about his experience
and concerns working at the Renton final assembly facility. Mr. Pierson eventually agreed to testify
publicly at the Committee’s December 11, 2019, hearing on the 737 MAX. 1099
At that hearing, both Democratic and Republican Members of Congress questioned the
FAA Administrator, Stephen Dickson, about the FAA’s lack of response to the concerns raised by
Mr. Pierson in his multiple letters to the agency after the Ethiopian Airlines crash. 1100 Representative
Sean Patrick Maloney (D-NY) was particularly alarmed and frustrated that the FAA had not
responded much more thoroughly and with far greater urgency to the issues Mr. Pierson had
raised. 1101 Specifically, Rep. Maloney and then-Representative Mark Meadows (R-NC) requested that
the FAA take several specific actions. They requested that the FAA conduct an interview with Ed
Pierson, conduct interviews of Boeing employees at the Renton 737 final assembly plant, and
conduct inspections of the Renton facility, among other actions. 1102
In a March 11, 2020, letter to Chair DeFazio, FAA Administrator Dickson provided an
update on FAA’s efforts to address the requests by Representatives Maloney and Meadows. 1103
According to the FAA, as of that date, the FAA had interviewed more than one dozen employees at
Boeing’s Renton production facility including engineers, technicians, managers, and individuals in
Boeing’s Organization Designation Authorization (ODA) unit; conducted a 3-hour, in-person
interview of Ed Pierson; arranged for regular reporting up to Administrator Dickson of pilot
accessed here at p. 77-78: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-
116hhrg40697.pdf
1097 Ibid.
1098 “Whistleblower Rights,” U.S. House Committee on Transportation and Infrastructure, accessed here:
https://transportation.house.gov/whistleblower-rights
Certification,” House Committee on Transportation and Infrastructure, 116th Congress, First Session, U.S. House of
Representatives, December 11, 2019, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
1100 Questions from Representative Sean Patrick Maloney and Representative Mark Meadows, Hearing titled, “The
Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight of the Aircraft’s Certification,” House
December 11, 2019, accessed here at pp. 50-53: https://www.govinfo.gov/content/pkg/CHRG-
1101 Ibid, pp. 50-53.
1102 Ibid, pp. 50-55.
1103 Letter from FAA Administrator Stephen Dickson to Chairman Peter DeFazio, March 11, 2020. (On file with the
Committee).
183
complaints and disclosures through the Aviation Safety Reporting System and FAA hotline; and
reviewed areas for certification improvement identified by internal reviews, including the Joint
Authorities Technical Review (JATR), the NTSB, the Lion Air accident investigation report, and the
Secretary of Transportation’s Special Committee to Review FAA’s Aircraft Certification Process. 1104
Mr. Pierson was impressed by the FAA officials that interviewed him. However, he
described the FAA’s response to his concerns as “dangerously slow.” 1105 It took the FAA five
months to arrange an interview with him, for instance, and only after direct public pressure from
Congress. He also remains highly skeptical that the agency has done enough to follow up on his
concerns. 1106 Mr. Pierson provided the FAA with a list of current and former Boeing employees he
believed they should interview, for instance. One of these individuals—who was at the top of Mr.
Pierson’s list of individuals he believed the FAA should speak with—specifically reached out to Mr.
Pierson after his public testimony saying he wanted to cooperate with the FAA about his safety
concerns. 1107 However, as of the end of August 2020, six months after Mr. Pierson had met with the
FAA, this individual told Mr. Pierson that the FAA had still not contacted him, according to Mr.
Pierson. 1108
It should not have taken a congressional hearing, requests by multiple Members of Congress,
and three letters from a former senior Boeing manager with eye-witness experience on the 737 MAX
production line, for the FAA to initiate a review of the issues Mr. Pierson identified that may have
affected the safety of the flying public and aviation community.
In testimony to the Committee in October 2019, Boeing’s then-CEO Dennis Muilenburg,

suggested that Boeing also responded to the concerns raised by Mr. Pierson.
We took a number of actions on taking a look at each of the work

locations within the factory, each of the production stops. We
implemented some additional quality checkpoints in the process. We
also just took a look at his concerns, because he was not actually in
the factory at that point, but he raised some good concerns, so we
went back and took a look at his concerns. And in some cases we
identified areas where we thought his issues had already been
addressed, and we provided that information back to him. But this is
part of our continuous process in our factories. It is very, very
important that we set up a culture where, again, safety is first in the
factories. 1109
1104 Ibid.
1105 Ed Pierson email to T&I Democratic Staff regarding question about his interactions with the FAA after the
Committee’s December 2019 hearing, July 23, 2020. (On file with the Committee).
1106 Telephone call between Ed Pierson and his attorneys and T&I Democratic Staff, August 28, 2020.
1107 Ed Pierson email to T&I Democratic Staff regarding question about his interactions with the FAA after the
1108 Telephone call between Ed Pierson and his attorneys and T&I Democratic Staff, August 28, 2020.
30, 2019, accessed here at p. 52: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-
116hhrg38282.pdf
184
It is apparent from Mr. Muilenburg’s testimony, however, that the actions Boeing reportedly
took were only taken months after Mr. Pierson raised these issues since he had already voluntarily
retired from Boeing. In addition, despite Mr. Muilenburg’s testimony to the contrary, Mr. Pierson
says that Boeing never provided any information “back to him” regarding the issues he raised, as
suggested by Mr. Muilenburg in his testimony. 1110 Furthermore, at that same hearing Chair DeFazio
asked Mr. Muilenburg about the concerns Mr. Pierson raised in June and July 2018 regarding the
high rate of production at the Renton plant. 1111
Mr. DeFazio: Did you reduce the rate of production at that point in
time? ….
Mr. Muilenburg: Sir, we did not change the production rate. 1112
That response is both telling and troubling. There is no evidence that the specific production
issues identified by Mr. Pierson contributed to either of the MAX crashes. However, it is very clear
that Boeing did not put safety first. Boeing did not heed Mr. Pierson’s advice to temporarily halt the
737 MAX’s production line because it seems schedule, not safety, was Boeing’s first priority.
Aside from production pressure on the factory floor, undue influence was a separate type of
pressure that was experienced by many Boeing employees involved in the design, development, and
certification of the 737 MAX aircraft.
Undue Influence Pressure 2016 Survey
A Boeing internal survey conducted in November 2016 at the height of the 737 MAX’s
certification activities, and provided to the Committee from a whistleblower, highlighted a number
of findings related to undue influence at Boeing. 1113 The survey focused on Boeing’s Authorized
Representatives (ARs), part of the ODA program, who although they are Boeing employees, are
supposed to represent the interests of the FAA.
Over 520 Boeing ODA members participated in the survey. 1114 Alarmingly, the survey found
that 39 percent of the Boeing ARs that responded believed they had experienced undue pressure,
painting a disturbing picture of cultural issues at Boeing that can undermine safety and oversight. 1115
In addition, of those 39 percent, 80 percent had encountered more than one situation where they
perceived potential undue pressure. 1116 Boeing employees participating in the survey also provided
comments identifying eight specific undue pressure related issues. Among those issues were the
1110 Ed Pierson email to T&I Democratic Staff regarding question about Mr. Muilenburg’s testimony after the
116hhrg38282.pdf
1112Ibid, pp. 52-53.
1113 Boeing presentation, “Undue Pressure: Key Learnings and Next Steps,” The Boeing Company, November 2016,
accessed here at p. 144-151: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-

116hhrg38282.pdf
1114 Ibid., p. 145.
1115 Ibid.
1116 Ibid.
185
following: “High Workload causes pressure,” “Schedule Pressure,” and the “Dual role” of ARs vs.
(Boeing’s) Subject Matter Experts (SMEs) that “can cause confusion leading to potential undue
pressure.” 1117
At the Committee’s October 30, 2019, hearing, Mr. Muilenburg emphasized that 97 percent
of Boeing employees in the survey understand the “process” of reporting undue pressure, but he
completely ignored the key issue he was asked
about, that 39 percent of Boeing’s ARs said they Boeing Undue Influence Survey
believed they had experienced undue pressure November 2016
from Boeing employees and managers. 1118
That is a remarkable figure and should have
been a warning sign to both Boeing and the
FAA regarding undue pressure on Boeing
employees tasked with providing critical
oversight roles in the certification process.
Testifying at the Committee’s October

2019 hearing, Boeing’s then-Chief Engineer,
John Hamilton, said, “We do do recurrent
training with managers in engineering,
manufacturing and quality about how they
deal with ARs, and how they need to be
treated and what is undue pressure. And we
do take followup actions. We do audits, and
the FAA has come in and actually audited
what we did, and they have agreed with what
actions were taken.” 1119
Mr. Muilenburg, did, however,

acknowledge that “pressure” exists but
suggested that it never interferes with safety. “Now, I will say it is true that we have competitive
pressures every day,” admitted Mr. Muilenburg. 1120 “We operate in a tough, globally competitive
world. But that never, never takes priority over safety,” he said. 1121 Unfortunately, that is not what
the Committee’s investigation of the 737 MAX has revealed.
Despite the safety concerns raised by Mr. Pierson, the Boeing 737 MAX production line did
not slow down even after the Lion Air crash. In fact, the Renton plant continued to ramp up
production at the same time Mr. Pierson was raising the alarm to senior Boeing management about
safety related issues. Only in April 2019, weeks after the Ethiopian Airlines crash, did production of
1117 Ibid., p. 145.

116hhrg38282.pdf
1119 Ibid.
1120 Ibid., p. 52.
1121 Ibid.
186
the MAX finally slow down from 52 airplanes per month to 42 airplanes per month. 1122 Production
was not suspended on the MAX production line, however, until January 2020, more than 18-months
after Mr. Pierson recommended this action. 1123
In December 2019, Boeing made the announcement about the pause in production starting
in early 2020. The statement said, “Safely returning the 737 MAX to service is our top priority.” 1124
However, it then went on to focus on the production issues regarding the 737 MAX:
Throughout the grounding of the 737 MAX, Boeing has continued to

build new airplanes and there are now approximately 400 airplanes in
storage. We have previously stated that we would continually evaluate
our production plans should the MAX grounding continue longer
than we expected. As a result of this ongoing evaluation, we have
decided to prioritize the delivery of stored aircraft and temporarily
suspend production on the 737 program beginning next month.
We believe this decision is least disruptive to maintaining long-term

production system and supply chain health. This decision is driven by
a number of factors, including the extension of certification into
2020, the uncertainty about the timing and conditions of return to
service and global training approvals, and the importance of ensuring
that we can prioritize the delivery of stored aircraft. We will continue
to assess our progress towards return to service milestones and make
determinations about resuming production and deliveries
accordingly. 1125
Boeing did not halt production based on the safety concerns originally raised by Mr. Pierson.
They did not cease production after the Lion Air crash or even after the Ethiopian Airlines crash,
although production did slow down. The temporary halt in production Boeing described above had
to do with schedule and delivery issues related to the MAX and not safety concerns. The 737 MAX
production line restarted in May 2020. 1126
Overall, Mr. Pierson’s testimony to the Committee and the public is incredibly important.
Although he clearly acknowledges that he is unaware of any specific production related safety issue
that may have contributed to the Lion Air or Ethiopian Airlines crashes, his first-hand account
paints a deeply troubling picture of Boeing’s production first, safety second, culture among Boeing’s
senior leadership. He raised multiple red flags multiple times by warning Boeing’s senior leaders
prior to both the Lion Air and the Ethiopian Airlines crashes that Boeing’s production pace and the
pressure it put on its employees was endangering the safety of the public. He raised these issues with
1122 The Boeing Company, Q1 2019 Earnings Call, April 24, 2019, p. 4, accessed here:
https://s2.q4cdn.com/661678649/files/doc_financials/quarterly/2019/q1/1Q19-Earnings-Call-Transcript-(1).pdf
1123 Clare Duffy, “Boeing is halting production of the embattled 737 Max starting in January,” CNN, December 17,
2019, accessed here: https://www.cnn.com/2019/12/16/business/boeing-suspends-737-max-production/index.html

1124 “Boeing Statement Regarding 737 MAX Production,” Press Release, The Boeing Company, December 16, 2019,
accessed here: https://boeing.mediaroom.com/2019-12-16-Boeing-Statement-Regarding-737-MAX-Production

1125 Ibid.
1126 Leslie Josephs, “Boeing resumes production of beleaguered 737 Max planes,” CNBC, May 27, 2020, accessed here:
https://www.cnbc.com/2020/05/27/boeing-resumes-production-of-beleaguered-737-max.html
187
the General Manager of the 737 program, the Boeing General Counsel, Boeing’s Chief Executive
Officer (CEO) and Boeing’s Board of Directors. All of them failed to respond sufficiently or swiftly
enough to his warnings.
The Committee’s investigation has shown that schedule pressure and cost concerns
transcended the production process and greatly influenced the design and development of the 737
MAX as well. There were multiple Boeing employees who voiced concerns about the design of
specific 737 MAX technologies, most notably MCAS. In other instances, safety related technologies,
such as synthetic airspeed, were specifically excluded from being included on the MAX because they
would have impacted cost and potentially jeopardized limited pilot training requirements. On the
production side, schedule—rather than safety—seems to have been the foremost priority in the final
assembly process. Taken together these issues resulted in a serious degradation to the safety of the
flying public. In a rush to push forward to meet production goals and market demand for the 737
MAX, senior Boeing leaders chose to put production priorities above safety.
188
9. Post-Accident
Response
9. Post-Accident Response
-Post-Accident Response-
 Both Boeing and the FAA were quick to blame the pilots of Lion Air flight 610 for the crash
of that MAX aircraft and were slow to truly and fully understand and acknowledge how
dangerous the design decisions and operational authority granted to the Maneuvering
Characteristics Augmentation System (MCAS) was to the flight crew and safety of the
airplane. 1127
 Immediately following the Lion Air crash, both Boeing and the FAA failed to alert MAX pilots
of the very existence of MCAS. 1128 The FAA even removed reference to MCAS from its draft
Emergency Airworthiness Directive (AD). 1129
 In June 2016, more than two years prior to the October 2018 crash of the Lion Air flight,
Boeing engineers had predicted some of the key issues that led to the Lion Air crash, including
the potential adverse consequences of erroneous AOA sensor data on MCAS, and they
questioned whether or not pilots would have trouble combatting repetitive MCAS activation.
These concerns, however, were either not adequately addressed or largely dismissed by their
Boeing colleagues. 1130
 Even after the Lion Air accident, Boeing balked at admitting that there were technical design
issues with MCAS and that pilots of the 737 MAX needed any significant training on
MCAS. 1131
1127 Douglas McMilan, “’Our daughter dies in van’: What Boeing learns from plane crashes,” Washington Post, October
28, 2019, accessed here: https://www.washingtonpost.com/business/2019/10/28/our-daughter-died-vain-what-boeing-
learns-plane-crashes
1128 See: Flight Crew Operations Manual Bulletin for the Boeing Company, Number TBC-19, 737-8/-9, Uncommanded
Nose Down Stabilizer Trim Due To Erroneous Angle of Attack (AOA) During Manual Flight Only, November 6, 2018,
116hhrg38282.pdf and Questions from Hon. Peter A. DeFazio for Hon. Stephen M. Dickson, Administrator, Federal
Aviation Administration, Hearing titled: “The Boeing 737 MAX: Examining the Federal Aviation Administration’s
Oversight of the Aircraft’s Certification,” Committee on Transportation and Infrastructure, U.S. House of
Representatives, 116th Congress, First Session, December 11, 2019, accessed here at pp. 243-244:
Administration, Hearing titled, “The Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight of
1130 See: Boeing internal email, “Subject: RE: S&C Brief Summary: 1A001, Test 009-25 6/13/16 [BLOC 2],” Wednesday,
June 15, 2016, 1:01 PM, BATES Number TBC T&I 246488 – T&I 246493 at T&I 246489 (On file with Committee),
and Boeing internal email, “Subject RE: Squawk for MCAS trim Event,” June 20, 2016, 6:38 a.m., BATES Number TBC
T&I 220826.
1131 Draft Transcript of Audio Recording of Meeting between Boeing officials and Allied Pilots Association (APA)
officials, November 27, 2018. (On file with the Committee).
190
 In January 2019, in the wake of the Lion Air accident, Boeing proposed MAX pilots should
only receive Level A training regarding MCAS, the lowest training level available, that
encompasses simply reviewing written material. 1132
 In December 2018, Boeing acknowledged in a presentation on MCAS to the FAA that several
tests on the 737 MAX were only conducted before MCAS was redesigned in 2016 and not
after it was redesigned and given increased operational authority. Still, Boeing determined that
none of its missteps led to violations of FAA regulations or non-compliance. 1133
 Similarly, in January 2019, three months after the Lion Air crash, the FAA initiated its own
internal review of MCAS. 1134 This was the first detailed analysis of MCAS that the FAA
conducted and the first time they were presented with a full, clear picture of how MCAS
worked, according to the Department of Transportation (DOT) Office of Inspector General
(OIG). 1135
 The FAA’s review resulted in a draft report that was never completed. The FAA told the IG’s
office that the “report was going through management review and comment at the time of the
Ethiopian accident, at which time the Agency considered it overtaken by events.” 1136
 Committee staff reviewed a copy of the draft report, which found that Boeing’s actions with
regards to MCAS and the information they shared with the FAA during the development of
MCAS was compliant with FAA regulations. 1137
 The fact that there were so many technical misjudgments, bureaucratic missteps, and flawed
design decisions surrounding MCAS, including Boeing’s opaque description of MCAS to some
FAA officials and its limited description to others—none of which were deemed
noncompliant by the FAA—paints a deeply disturbing picture of a Federal regulatory structure
in immediate need of robust reforms.
1132 Letter from Boeing ODA Deputy Lead Administrator to FAA Aircraft Evaluation Group, January 30, 2019, BATES
Number TBC-T&I 297017 - TBC-T&I 297018, accessed at pp. 134-135 here:

1133 “MCAS Development and Certification Overview,” The Boeing Company, Presentation given by Boeing to the FAA
on December 17, 2018, Bates Number TBC T&I 130073-130117, see pp. 178-201, accessed here:
October 2018 Lion Air Accident,” DOT OIG, June 29, 2020, pp. 32-33, accessed here:
1135 Ibid.
1136 Ibid.
(Draft). (Reviewed remotely “in camera” via access to FAA website by Committee Staff on May 1, 2020)
191
Post-Accident Response
The Committee’s investigation has identified many problems in the design, development,
and certification of the 737 MAX aircraft. These include inadequate testing protocols on new MAX
related technologies and systems, 1138 faulty assumptions on both technical design criteria 1139 and pilot
reaction times, 1140 a lack of transparency on the part of Boeing with the FAA and its MAX
customers, 1141 and a failure on the part of the FAA to properly fulfill its critical regulatory oversight
role of Boeing. 1142
The Committee also examined the response of both Boeing and the FAA after the crash of
Lion Air flight 610 on October 29, 2018, and before the crash of Ethiopian Airlines flight 302 on
March 10, 2019. The collective responses in this critical time period were woefully inadequate and
appeared predisposed to blame the pilots. In the case of the FAA, even as evidence mounted that
Boeing had not been fully transparent with them regarding key data and actions related to issues
surrounding Boeing’s analysis of the redesigned MCAS system, for instance, 1143 the agency failed to
take those actions into account in regards to its decision to continue to let the 737 MAX fly.
Instead, as the months moved on and even in the aftermath of the second MAX crash of
Ethiopian Airlines flight 302, the FAA appeared to follow Boeing’s lead on blaming the pilots 1144 for
both MAX crashes and downplaying the fundamental technical design flaws that Boeing designed
30, 2019, See: Boeing internal email, AOA Sensor email string—TBC-T&I 10584–10586, December 17, 2016, accessed
on p.121, here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf
BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision D, March 30, 2016, accessed at p. 164 here:
1141 “Boeing Statement on AOA Disagree Alert,” Press Statement, The Boeing Company, May 5, 2019, accessed here:
Certification,” House Committee on Transportation & Infrastructure, U.S. House of Representatives, 116th Congress,
First Session, December 11, 2019, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
1142 Ibid., p. 21.
1144 See: Peter Economy, “Boeing CEO Puts Partial Blame on Pilots of Crashed 737 MAX Aircraft for Not 'Completely'
Following Procedures,” Inc., April 30, 2019, accessed here: https://www.inc.com/peter-economy/boeing-ceo-puts-

partial-blame-on-pilots-of-crashed-737-max-aircraft-for-not-completely-following-procedures.html; Curt Devine, Aaron
Cooper and Drew Griffin, “Pilots union to Boeing: 'Inexcusable' to blame pilots for 737 Max crashes,” CNN, May 23,
2019, https://www.cnn.com/2019/05/23/business/american-airlines-boeing-pilots-union/index.html; Clement
Charpentreau, “Boeing 737 MAX: FAA defends its processes, blames pilots,” AeroTime, May 16, 2019, accessed here:
https://www.aerotime.aero/clement.charpentreau/22646-boeing-737-max-faa-defends-its-processes-blames-pilots; Curt
Devine, “FAA chief says nothing shows agency failed in review or certification of Boeing 737 MAX,” CNN, May 24,
2019, accessed here: https://www.cnn.com/2019/05/23/politics/faa-boeing-max-crashes-elwell/index.html
192
into the 737 MAX aircraft and that the FAA either did not identify or failed to adequately
understand prior to its certification of the MAX. 1145
The Pilot Response Blame Game
In the immediate aftermath of the Lion Air crash, Boeing issued a statement:
The Boeing Company is deeply saddened by the loss of Lion

Air Flight JT 610. We extend our heartfelt sympathies to the
families and loved ones of those on board. 1146
However, Boeing still shied away from taking responsibility for the design issues that clearly
contributed to the fatal crash of Lion Air flight 610. Most aviation accidents are the result of
multiple factors that may include pilot actions or inactions as one key component. 1147 But Boeing
and the FAA overemphasized the role of the MAX pilots in the Lion Air crash and demonstrably
underemphasized the technical design flaws Boeing built into the 737 MAX, particularly MCAS, that
the FAA approved and that ultimately proved unsafe. Both Boeing and the FAA were slow to
confront these realities even as Boeing’s poor technical design choices regarding the 737 MAX and
the Federal regulatory loopholes surrounding the certification of the aircraft, and particularly MCAS,
came into focus and became transparent.
On November 6, 2018, eight days after the Lion Air crash, Boeing issued an Operations
Manual Bulletin (OMB) that directed airline operators and flight crews to various flight crew
procedures to address erroneous angle-of-attack (AOA) sensor data, 1148 which was—one week after
the crash of the Lion Air flight—believed to be a core contributing cause of the accident.
The OMB issued by Boeing had the subject line, “Uncommanded Nose Down Stabilizer
Trim Due to Erroneous Angle of Attack (AOA) During Manual Flight Only.” 1149 The “reason”
given for the bulletin was, “To emphasize the Procedures Provided in the Runaway Stabilizer Non-
Normal Checklist (NNC).” 1150 The “Background Information” section of the OMB said:
The Indonesian National Transportation Safety Committee has

indicated that Lion Air flight 610 experienced erroneous AOA data.
Boeing would like to call attention to an AOA failure condition that
can occur during manual flight only. This bulletin directs flight
1145 Curt Devine, “FAA chief says nothing shows agency failed in review or certification of Boeing 737 MAX,” CNN,
May 24, 2019, accessed here: https://www.cnn.com/2019/05/23/politics/faa-boeing-max-crashes-elwell/index.html

1146 “Boeing Statement on Operations Manual Bulletin,” The Boeing Company, accessed here:
1147 Mary S. Reveley and Jeffrey L. Briggs, et. al., “Causal Factors and Adverse Conditions of Aviation Accidents and
Incidents Related to Integrated Resilient Aircraft Control,” National Aeronautics and

Space Administration (NASA), NASA/TM—2010-216261, November 2010, accessed here:
https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20100040414.pdf
116hhrg38282.pdf
1149 Ibid.
1150 Ibid.
193
crews to existing procedures to address this condition. 1151 (Emphasis in
original).
Noticeably absent from the Boeing bulletin was any reference to the “Maneuvering
Characteristics Augmentation System” or “MCAS.” 1152 It did include a description of the operational
conditions associated with MCAS, though. “In the event of erroneous AOA data, the pitch trim
system can trim the stabilizer nose down in increments lasting up to 10 seconds,” it said. 1153 “The
nose down stabilizer trim movement can be stopped and reversed with the use of the electric
stabilizer trim switches but may restart 5 seconds after the electric stabilizer trim switches are
released. Repetitive cycles of uncommanded nose down stabilizer continue to occur unless the
stabilizer trim system is deactivated through use of both STAB TRIM CUTOUT switches in
accordance with the existing procedures in the Runaway Stabilizer NNC [Non-Normal
Conditions].” 1154
The Boeing OMB also “reminded” pilots that “an erroneous AOA can cause some or all of
the following indications and effects:” 1155
• Continuous or intermittent stick shaker on the affected side only.

• Minimum speed bar (red and black) on the affected side only.
• Increasing nose down control forces.
• Inability to engage autopilot.
• Automatic disengagement of autopilot.
• IAS DISAGREE Alert.
• ALT DISAGREE Alert.
• AOA DISAGREE alert (if the AOA indicator option is
installed). 1156
• FEEL DIFF PRESS light. 1157
The Startle Effect
The Boeing OMB did not indicate to flight crews that they may experience multiple alerts at
once leading to cognitive confusion and mental overload, often referred to as the “startle effect”.
The FAA defines “startle” as, “An uncontrollable, automatic muscle reflex, raised heart rate, blood
1151 Ibid.
1152 Ibid.
1153 Ibid
1153 Ibid.
1154 Ibid.
1155 Ibid.
1156 The AOA Disagree alert was supposed to be a standard feature on all 737 MAX aircraft. However, because of a
software glitch the alert only worked on MAX aircraft that had also purchased an optional AOA Indicator. Boeing was
aware of this issue starting in August 2017 but did not plan to implement a fix for three years until 2020 with the roll out
of the MAX-10 aircraft. As a result, the AOA Disagree alert was inoperable on more than 80 percent of the 737 MAX
fleet. Boeing knowingly continued to produce and deliver MAX aircraft with this known flaw and never informed the
FAA and Boeing’s MAX customers until after the Lion Air crash.
1157 Ibid.
194
pressure, etc., elicited by exposure to a sudden, intense event that violates a pilot’s expectations.” 1158
This is believed to have impacted the
pilots of Lion Air flight 610, impairing Retired Airline Captain
their ability to respond effectively to the Chesley B. “Sully” Sullenberger III
design flaws in the 737 MAX that led to House Aviation Subcommittee Hearing
the crash. 1159
June 19, 2019
Few pilots have survived to share “WITHIN SECONDS, THESE CREWS

their experiences about the startle effect, WOULD HAVE BEEN FIGHTING FOR
but retired airline captain Chesley B. THEIR LIVES IN THE FIGHT OF THEIR
“Sully” Sullenberger III is one of them. LIVES. … IN BOTH 737 MAX ACCIDENTS,
He landed U.S. Airways flight 1549 on the THE FAILURE OF AN AOA SENSOR
Hudson River in 2009 saving all 155 QUICKLY CAUSED MULTIPLE
people on board in what came to be
known as the “Miracle on the INSTRUMENT INDICATION ANOMALIES
Hudson.” 1160 In June 2019, Captain AND COCKPIT WARNINGS.”
Sullenberger testified before a
Subcommittee on Aviation hearing on the 737 MAX accidents. 1161 In his prepared statement Captain
Sullenberger wrote:
I’m one of the relatively small group of people who have experienced
such a sudden crisis – and lived to share what we learned about it. I
can tell you firsthand that the startle factor is real and it is huge – it
interferes with one’s ability to quickly analyze the crisis and take
effective action. Within seconds, these crews would have been
fighting for their lives in the fight of their lives. 1162
Captain Sullenberger continued, “In both 737 MAX accidents, the failure of an AOA sensor
quickly caused multiple instrument indication anomalies and cockpit warnings.” He also made clear
that the pilots should not be blamed for the tragic MAX crashes. “Accidents are the end result of a
causal chain of events, and in the case of the Boeing 737 MAX, the chain began with decisions that
had been made years before, to update a half-century-old design,” he wrote. 1163 However, as we now
know, and the Committee’s investigation has clearly documented, one of Boeing’s key goals for the
1158 FAA Advisory Circular, “Subject: Upset Prevention and Recovery Training,” AC No: 120-111, Federal Aviation
Administration (FAA), January 4, 2017, p. 3, accessed here:

https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_120-111_CHG_1.pdf
1159 Prepared statement of retired Captain Chesley B. “Sully” Sullenberger III, Hearing titled, “Status of the Boeing 737
MAX: Stakeholder Perspectives,” Subcommittee on Aviation, Committee on Transportation and Infrastructure, U.S.
1160 Biography of Chesley N. Sullenberger, III, U.S. House of Representatives Committee Repository, accessed here:
https://docs.house.gov/meetings/PW/PW05/20190619/109642/HHRG-116-PW05-Bio-SullenbergerC-20190619.pdf
1161 Prepared statement of retired Captain Chesley B. “Sully” Sullenberger III, Hearing titled, “Status of the Boeing 737
MAX: Stakeholder Perspectives,” Subcommittee on Aviation, Committee on Transportation and Infrastructure, U.S.
1162 Ibid.
1163 Ibid.
195
737 MAX program was ensuring that pilot simulator training on the MAX was not required. 1164 The
Boeing OMB failed to directly alert crews to the fact that the Lion Air pilots were overcome by
multiple warnings and alerts leading to confusion in the cockpit. It also did not reference MCAS. 1165
In a set of safety recommendations issued following the Lion Air and Ethiopian Airlines
accidents, the U.S. National Transportation Safety Board observed that Boeing failed to account for
the multitude of seemingly unrelated cautions and warnings, including an attention-getting stick
shaker, when assessing that only four seconds would be needed for pilots to successfully respond to
an erroneous MCAS activation. 1166 Moreover, a University of North Dakota researcher concluded in
his dissertation in 2016 that pilots don’t regain their full cognitive abilities for 30 to 60 seconds after
a “startle” event. 1167 The conspicuous omission from the Boeing OMB of information relevant to
the role of the startle factor in the Lion Air accident is consistent with Boeing’s failure to establish
realistic assumptions regarding the time necessary for pilots to successfully respond to an erroneous
MCAS activation.
The OMB did indicate to flight crews, however, that the AOA Disagree alert, which was a
standard feature on all 737 MAX aircraft and which the FAA required to be functional on every
MAX aircraft Boeing delivered was only working on less than 20 percent of those aircraft where the
Boeing customers had also purchased the optional AOA Indicator. 1168 But it did this in a subtle,
nuanced way. As cited above, Boeing simply wrote: “AOA DISAGREE alert (if the AOA indicator
option is installed).” 1169 Even in the wake of the Lion Air crash Boeing continued to obscure
information related to the 737 MAX rather than being straightforward, transparent, and complete in
the data they provided.
1164 Boeing internal email, “Subject: 737MAX Firm Configuration Status/Help Needed,” Saturday, May 4, 2013, BATES
Number TBC T&I 049683-049684, (On file with Committee), Released at Hearing before the House Committee on
Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, October 30, 2019, p.
116hhrg38282.pdf
Alerts and Indications on Pilot Performance,” National Transportation Safety Board (NTSB), September 19, 2019, at p.
8, accessed here: https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf
1167 Michael Gillen, “A study evaluating if targeted training for startle effect can improve pilot reactions in handling
unexpected situations in a flight simulator,” Dissertation, University of North Dakota (in partial fulfillment of the
requirements for the degree of Doctor of Philosophy), December 1, 2016, accessed here:
https://commons.und.edu/theses/345
1168 Boeing AOA Disagree Alert Narrative. BATES Number TBC-T&I 267826 – TBC-T&I 267833 (On file with
Committee); and Alan Levin, “Boeing Failure to Fix 737 MAX Warning Light May Draw FAA Penalty,” Bloomberg,
February 21, 2020, accessed here: https://www.bloomberg.com/news/articles/2020-02-21/boeing-failure-to-fix-737-
max-cockpit-light-may-draw-faa-penalty
116hhrg38282.pdf
196
FAA’s Emergency Airworthiness Directive
On November 7, 2018, the day after Boeing issued its OMB, the FAA issued an Emergency
AD) to owners and operators of the 737 MAX. 1170 Like the Boeing OMB, the FAA’s AD did not
reference the “Maneuvering Characteristics Augmentation System” or “MCAS.” 1171 It also did not
even include any specific reference to the Lion Air crash. 1172 The FAA’s Emergency AD said:
This emergency AD was prompted by analysis performed by the

manufacturer showing that if an erroneously high single angle of
attack (AOA) sensor input is received by the flight control system,
there is a potential for repeated nose-down trim commands of the
horizontal stabilizer. This condition, if not addressed, could cause the
flight crew to have difficulty controlling the airplane, and lead to
excessive nose-down attitude, significant altitude loss, and possible
impact with terrain. 1173
Predicting Problems
More than two years earlier, on June 15, 2016, a Boeing Authorized Representative (AR)
asked his colleagues: “What happens when we have faulty AOA or Mach number?” 1174 His
colleague, a Boeing engineer, quickly assured him that this was not something to worry about. “As
for faulty AOA and/or Mach number,” his colleague responded, “… if they are faulty then MCAS
shuts down immediately.” 1175 That may have been the intent, but that did not happen on Lion Air
flight 610.
The following day, on June 16, 2016, another issue that would ultimately prove critical to the
Lion Air crash was also raised by a Boeing employee. A different Boeing engineer who was aware of
a Boeing test pilot having trouble countering repetitive MCAS activations during a test flight asked
his colleague if the difficulties the Boeing test pilot had countering repetitive MCAS activation was a
safety or a certification issue. His Boeing colleague responded:
1170 Emergency Airworthiness Directive to Owners and Operators of the Boeing Company Model 737-9 and -9
Airplanes, Federal Aviation Administration (FAA) Aviation Safety, AD #: 2018–23–51, November 7, 2018, p. 1,
accessed here:
23-51_Emergency.pdf
Airplanes, Federal Aviation Administration (FAA) Aviation Safety, AD #: 2018–23–51, November 7, 2018, accessed
here:
23-51_Emergency.pdf
1172 Ibid.
1173 Ibid.
1174 Boeing internal email, “Subject: RE: S&C Brief Summary: 1A001, Test 009-25 6/13/16 [BLOC 2],” Wednesday,
June 15, 2016, 1:01 PM, BATES Number TBC T&I 246488 – T&I 246493 at T&I 246489. (On file with Committee).
1175 Boeing internal email, “Subject: RE: S&C Brief Summary: 1A001, Test 009-25 6/13/16 [BLOC 2],” Wednesday,
June 15, 2016, 1:43 PM, BATES Number TBC T&I 246488 – T&I 246493 at T&I 246489. (On file with Committee).
197
I don’t think this is safety other then (sic) the pilot could fight the
MCAS input and over time find themselves in a large mistrim. 1176
Unfortunately, that is exactly what happened in the Lion Air crash. The pilots fought MCAS
as it repeatedly activated more than 20 times before crashing as a result of faulty AOA sensor
data. 1177 This was the sort of catastrophic scenario that at least some individuals within Boeing raised
the alarm about years earlier. However, their concerns were essentially discarded with the
presumption that they were invalid. Clearly, in hindsight they were not.
The lack of effort to thoroughly resolve those concerns were one of several preventable
issues that resulted in tragedy. It is also a reminder that there were many points in the 737 MAX’s
development and path towards certification where more thorough evaluations and fuller reviews of
questions raised by some Boeing technical experts could have resulted in life altering outcomes.
The FAA Emergency AD that was issued included a list of “potential effects and
indications” of erroneous AOA input that is almost identical to the list in the Boeing OMB. 1178
Specifically, it directed flight crews to comply with Runaway Stabilizer procedures if they
experienced uncommanded horizontal stabilizer trim movement combined with one of the
following conditions:
• Continuous or intermittent stick shaker on the affected side only.

• Minimum speed bar (red and black) on the affected side only.
• Increasing nose down control forces.
• IAS DISAGREE alert.
• ALT DISAGREE alert.
• AOA DISAGREE alert (if the option is installed).
• FEEL DIFF PRESS light.
• Autopilot may disengage.
• Inability to engage autopilot. 1179
Neither the FAA’s AD nor Boeing’s OMB mentioned MCAS, depriving MAX pilots of
important information.
1176 Boeing internal email, “Subject RE: Squawk for MCAS trim Event,” June 20, 2016, 6:38 a.m., BATES Number TBC
1177 See: “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” pp. 19-28, accessed here: https://aviation-
is.better-than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf and Sinead Baker,

“This timeline shows exactly what happened on board the Lion Air Boeing 737 Max that crashed in less than 13
minutes, killing 189 people,” Business Insider, October 29, 2019, accessed here: https://www.businessinsider.com/lion-air-
crash-timeline-boeing-737-max-disaster-killed-189-2019-10
Airplanes, Federal Aviation Administration (FAA) Aviation Safety, AD #: 2018–23–51, November 7, 2018, accessed
here:
23-51_Emergency.pdf
1179 Ibid.
198
Omitting MCAS
Stephen Dickson, the Administrator of the FAA, described the agency’s rationale for not
including reference to MCAS in its Emergency AD in response to questions for the record (QFRs)
from Chair DeFazio at the Committee’s December 11, 2019, hearing on the 737 MAX.
Administrator Dickson claimed that at the time the FAA issued its Emergency AD the role of
MCAS in the Lion Air accident was
unclear. 1180 “Furthermore, the FAA’s FAA Administrator Stephen Dickson
opinion at the time was that introducing a Response to Questions for the Record from
new system name that did not exist in the Committee Chair DeFazio
aircraft documentation available to pilots December 19, 2019 Hearing
had the potential to cause confusion in an
emergency situation,” the FAA wrote in “[T]HE FAA’S OPINION AT THE TIME
response to Chair DeFazio. 1181 This may WAS THAT INTRODUCING A NEW
have been the FAA’s justification for not
referencing MCAS in the AD, but SYSTEM NAME THAT DID NOT EXIST
nevertheless their actions resulted in IN THE AIRCRAFT DOCUMENTATION
omitting critical information about MCAS AVAILABLE TO PILOTS HAD THE
from 737 MAX pilots and airlines. POTENTIAL TO CAUSE CONFUSION IN
AN EMERGENCY SITUATION.
Both Boeing and the FAA seemed
….
more intent on justifying their previous
mistakes and missteps than in fully THE FAA THEREFORE DECIDED TO
confronting the safety issues that began to REMOVE THE MCAS REFERENCE
encircle and ensnarl the 737 MAX aircraft
in the aftermath of the Lion Air crash. In
FROM THE DRAFT AD SO THAT
July 2019, the New York Times ran an FLIGHT CREWS WOULD FOCUS ON
investigative story titled: “The Roots of RUNAWAY STABILIZER RECOGNITION
Boeing’s 737 MAX Crisis: A Regulator INSTEAD OF ATTEMPTING TO
Relaxes Its Oversight.” 1182 The story noted TROUBLESHOOT MCAS.”
that the FAA’s Emergency AD made no
mention of MCAS. “At the last minute, an F.A.A. manager told agency engineers to remove the only
mention of the system, according to internal agency documents and two people with knowledge of
the matter,” the New York Times reported. 1183
Mr. Dickson acknowledged this in response to QFRs from Chair DeFazio from the
Committee’s December 11, 2019, 737 MAX hearing. Suggesting that reference to MCAS would
confuse pilots, the FAA Administrator wrote: “The FAA therefore decided to remove the MCAS
reference from the draft AD so that flight crews would focus on runaway stabilizer recognition
1181 Ibid.
1182 Natalie Kitroeff, Daid Gelles and Jack Nicas, “The Roots of Boeing’s 737 MAX Crisis: A Regulator Relaxes Its
Oversight,” New York Times, July 27, 2019, accessed here: https://nyti.ms/2K0xdd7
1183 Ibid.
199
instead of attempting to troubleshoot MCAS. In an emergency situation, it was more important for a
crew to recognize and respond to a runaway stabilizer event than it was to troubleshoot MCAS.” 1184
Other aviation experts, however, strongly disagree with that assessment. Dr. Mica Endsley, a
senior officer at the Human Factors and Ergonomics Society and a former Chief Scientist of the
U.S. Air Force also testified at that same hearing. 1185 In her response to QFRs about the FAA’s
Emergency AD, she wrote:
The Emergency Airworthiness Directive (AD) was clearly

insufficient for preventing the second accident [of] the 737
MAX. While the AD addressed the issue of blocked AOA
sensors affecting aircraft performance, it did not address the
MCAS by name, nor did it explain how the MCAS used the
sensor inputs to control the aircraft’s pitch, leaving pilots
with an insufficient mental model of MCAS in normal and
abnormal situations. More importantly, it failed to mandate
training on the MCAS, on correctly identifying problems with
improper MCAS operations, and on proper procedure
execution.
The revision to the flight manual in the AD provide only a

long list of potential problems that were not sufficiently
diagnostic of the MCAS failure condition. The cues received
by the pilots due to degraded sensors affecting MCAS were
significantly different than the cues received with a runaway
stabilizer trim, the procedure that Boeing and the [FAA] AD
instructed pilots to use, slowing diagnosis of the problem.” 1186
The decision by both the FAA and Boeing to omit information about MCAS from
communications with the public, 737 MAX customers, and MAX pilots did not last long.
Boeing Multi Operator Message (MOM)
Three days after the FAA issued its Emergency AD, Boeing issued a Multi Operator
Message (MOM) on November 10, 2018, “to all 737 NG/MAX Customers, Regional Directors,
1185 Biography of Dr. Mica R. Endsley, U.S. House of Representatives Committee Repository, accessed here:
https://docs.house.gov/meetings/PW/PW00/20191211/110296/HHRG-116-PW00-Bio-EndsleyM-20191211.pdf
1186 Questions from Hon. Peter A. DeFazio for Mica R. Endsley, Ph.D., appearing on behalf of the Human Factors and
Ergonomics Society, Hearing titled, “The Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight
of the Aircraft’s Certification,” Committee on Transportation and Infrastructure, U.S. House of Representatives, 116th
Congress, First Session, December 11, 2019, accessed here at pp. 263: https://www.govinfo.gov/content/pkg/CHRG-
200
Regional Managers and Boeing Field Service Bases.” 1187 The message had the subject line,
“Information – Multi-Modal Stall Warning and Pitch Augmentation Operation.” 1188 The MOM
provided a description of MCAS that had been excluded from Boeing’s original OMB and the
FAA’s Emergency AD. However, it was also clear that Boeing only did this under intense pressure
from its 737 MAX customers who wanted more information about the Lion Air crash. According to
the MOM, “Boeing has received many requests for the same information from 737 fleet operators”
and the MOM provided a technical description of MCAS while never specifically mentioning the
Lion Air crash. 1189
The MOM said that the “message provides technical information and operational details”
related to MCAS. 1190 For example, the MOM described how MCAS is activated, the rate and
magnitude of stabilizer movement, and its repetitive nature. 1191 “The [MCAS] function is
commanded by the Flight Control computer using input data from sensors and other airplane
systems,” the MOM said. “The MCAS function becomes active when the airplane Angle of Attack
exceeds a threshold based on airspeed and altitude.” 1192
For the vast majority of 737 MAX flight crews and operators, this was the first time they
learned of the existence of MCAS on the 737 MAX and any details of its operation. Boeing had
requested, and the FAA had approved, removal of references to MCAS from Boeing’s Flight Crew
Operations Manual (FCOM) in March 2016 1193 and from the FAA’s Flight Standardization Board
Report in January 2017. 1194 Boeing also chose not to include reference to MCAS in its OMB released
just after the Lion Air crash and the FAA acknowledged to the Committee that it had drafted—and
then deleted—reference to MCAS that had originally appeared in a draft of its Emergency AD. 1195
1187 The Boeing Company Multi Operator Message, Subject: Information – Multi-Modal Stall Warning and Pitch
Augmentation Operation, MOM-MOM-18-0655-01B, November 10, 2018, accessed here at p. 290: https://aviation-
1188 Ibid.
1189 Ibid.
1190 Ibid.
1191 Ibid.
1192 Ibid.
1193 Forkner Email FCOM citation.Email from Mark Forkner, Chief Technical Pilot, The Boeing Company to FAA
employee, Subject: “MCAS lives in both FCCs,” Wednesday, March 30, 2016 (On file with Committee).
1194 Email from Mark Forkner, Chief Technical Pilot, The Boeing Company, to FAA employee, Subject: “a few DT
updates please,” Tuesday, January 17, 2017 19:00:58 (On file with the Committee).
Administration, Hearing titled: “The Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight of
201
Within 48 hours of releasing the MOM to Boeing’s 737 MAX customers, U.S. 1196 and
foreign media outlets quickly began reporting on the existence of the MCAS, its operational
1197
function and its role in the Lion Air crash. They also focused in on the fact that Boeing had left both
pilots and its 737 MAX customers in the dark about MCAS. On November 12, 2018, the Seattle
Times ran a story with the headline: “U.S. pilots flying 737 MAX weren’t told about new automatic
systems change linked to Lion Air crash.” 1198 The next day the Wall Street Journal ran a story with the
headline: “Boeing Withheld Information on 737 Model, According to Safety Experts and
Others.” 1199 The same day Air Transport Review, a Russian language publication’s headline exclaimed:
“Pilots not warned of 737MAX stall prevention system.” 1200 On November 14, 2018, a headline in
the German language publication Süddeutsche Zeitung read: “What if the on-board computer does
dangerous nonsense?” 1201
MCAS Pilot Blowback
Both the FAA and Boeing made a tremendous miscalculation and blundered their immediate
response to the Lion Air tragedy by failing to fully and directly share what they knew about MCAS
and its suspected role in the crash of Lion Air flight 610 immediately after the accident. Instead, they
1196 See: Andy Pasztor and Andrew Tangel, “Boeing Withheld Information on 737 Model, According to Safety Experts
and Others,” Wall Street Journal, November 13, 2018, accessed here: https://www.wsj.com/articles/boeing-withheld-
information-on-737-model-according-to-safety-experts-and-others-1542082575 and Dominic Gates, “U.S. pilots flying
737 MAX weren’t told about new automatic systems change linked to Lion Air crash,” Seattle Times, November 12, 2018,
accessed here: https://www.seattletimes.com/business/boeing-aerospace/u-s-pilots-flying-737-max-werent-told-about-
new-automatic-systems-change-linked-to-lion-air-crash/; and “Gregory Polek, “Boeing Guidance on 737 Max Stall
Protection System Under Fire,” Aviation International News, November 13, 2018, accessed here:
https://www.ainonline.com/aviation-news/air-transport/2018-11-13/boeing-guidance-737-max-stall-protection-
system-under-fire
1197 See: Patrick Illinger, “What if the on-board computer does dangerous nonsense?” Süddeutsche Zeitung, November 14,
2018, (German language publication), accessed here:

https://www.sueddeutsche.de/panorama/flugzeugabsturz-in-indonesien-was-wenn-der-bordcomputer-gefaehrlichen-
unsinn-treibt-1.4210624 and
“Pilots not warned of 737MAX stall prevention system,” Air Transport Review, November 13, 2018, (Russian language
publication), accessed here: http://www.ato.ru/content/pilotov-ne-predupredili-o-sisteme-predotvrashcheniya-
svalivaniya-na-737max; Juho Tuomisto, “The pilots were enraged by the secret system of Boeing's new aircraft, which
could destroy the aircraft in Indonesia: “This was not told in the training” - What is MCAS?” Yle News, November 14,
2018, (Finnish language publication), accessed here: https://yle.fi/uutiset/3-10507125
1198 Dominic Gates, “U.S. pilots flying 737 MAX weren’t told about new automatic systems change linked to Lion Air
crash,” Seattle Times, November 12, 2018, accessed here: https://www.seattletimes.com/business/boeing-aerospace/u-s-

pilots-flying-737-max-werent-told-about-new-automatic-systems-change-linked-to-lion-air-crash
1199 Andy Pasztor and Andrew Tangel, “Boeing Withheld Information on 737 Model, According to Safety Experts and
Others,” Wall Street Journal, November 13, 2018, accessed here: https://www.wsj.com/articles/boeing-withheld-
information-on-737-model-according-to-safety-experts-and-others-1542082575
1200 “Pilots not warned of 737MAX stall prevention system,” Air Transport Review, November 13, 2018, (Russian language
publication), accessed here: http://www.ato.ru/content/pilotov-ne-predupredili-o-sisteme-predotvrashcheniya-

svalivaniya-na-737max
1201 Patrick Illinger, “What if the on-board computer does dangerous nonsense?” Süddeutsche Zeitung, November 14, 2018,
(German language publication), accessed here:

https://www.sueddeutsche.de/panorama/flugzeugabsturz-in-indonesien-was-wenn-der-bordcomputer-gefaehrlichen-
unsinn-treibt-1.4210624
202
continued a strategy of shielding the very existence of MCAS from MAX pilots that Boeing initiated
and the FAA authorized years earlier. This flawed
Boeing Official in Meeting strategy, which was justified under the presumption they
with Allied Pilots Association did not want to confuse pilots with unnecessary
November 27, 2018 information, backfired once the aviation community
learned about MCAS and Boeing’s efforts to omit
“MCAS IS A CONTROL LAW references to MCAS from 737 MAX pilots.
… IT’S JUST A LITTLE BIT
OF SOFTWARE IN THE On November 27, 2018, two weeks after Boeing
FLIGHT CONTROL SYSTEM issued its MOM alert to its 737 MAX customers, Boeing
officials sat down with representatives from the Allied
THAT IS DESIGNED TO Pilots Association (APA), the union that represents the
CHANGE THE HANDLING 15,000 pilots that fly for American Airlines at APA’s
CHARACTERISTICS OF THE headquarters in Fort Worth, Texas. 1202 American Airlines
AIRPLANE AT HIGH had 24 MAX airplanes in service at the time of the Lion
ANGLES OF ATTACK.” Air crash. 1203 The tense meeting was recorded and the
transcript was provided to the media and the
Committee. 1204
According to the draft transcript of that meeting, one of the Boeing officials attempted to
explain away MCAS to the American Airlines pilots:
MCAS is a control law, which it’s–it’s in the flight control system. So

it’s just a little bit of software in the flight control system that is
designed to change the handling characteristics of the airplane at high
angles of attack. 1205
The efforts by Boeing to underplay the significance of MCAS by describing it simply as a

“little bit of software” that was a “control law” within the flight computer is technically accurate, but
demonstrably misleading. “Control laws” are not afterthoughts or unnecessary appendages of
technical systems. They play pivotal roles in the function, utility, and safety of a multitude of various
technologies. “Control laws” have permitted man to land on the moon, 1206 the advancement of
1202 “About Us,” Allied Pilots Association (APA), accessed here: https://www.alliedpilots.org/AboutUs
1203 “Fleet Fact Sheet,” American Airlines, accessed here:
https://s21.q4cdn.com/616071541/files/doc_downloads/FactSheets/2020/Fleet-Facts_022020.pdf
1204 See: Kris Van Cleave, “Audio reveals pilots confronting Boeing about new features suspected in deadly crashes,”
CBS Evening News, May 14, 2019, accessed here: https://www.cbsnews.com/news/boeing-737-max-audio-reveals-pilots-

confronting-official-about-features-suspected-in-deadly-crashes-2019-05-14; Luke Kenton, “'These guys didn't even
know the damn system was on the airplane — nor did anybody else': Newly surfaced audio reveals how American
Airlines pilots confronted Boeing after Lion Air crash,” Daily Mail, May 15, 2019, accessed here:
https://www.dailymail.co.uk/news/article-7032007/Newly-surfaced-audio-reveals-AA-pilots-union-pilots-confronted-
Boeing-Lion-Air-crash.html; and Jan Tegler, “Learning from the MAX,” Aerospace America, July/August 2019, accessed
here: https://www.aiaa.org/docs/default-source/uploadedfiles/publications/aerospace-america-july-august-
2019.pdf?sfvrsn=1f307f7d_0

1206 David G. Hoag, “Apollo Navigation, Guidance, and Control Systems: A Progress Report,” Massachusetts Institute
of Technology (MIT), April 1969, accessed here:

https://web.mit.edu/digitalapollo/Documents/Chapter6/hoagprogreport.pdf
203
unmanned aircraft applications, 1207 physicians to perform MRIs 1208 and ultrasounds 1209 on patients,
and the operational control of autonomous underwater vehicles 1210 and satellites, 1211 to name a few
applications.
The argument from MAX pilots was not that they needed to know about every bit of
software code or all the control laws in the airplane. In the aftermath of the Lion Air tragedy, MAX
pilots argued that they needed to know—and should have been told—about critical software,
namely the MCAS control law, that was designed to take control of their aircraft away from them.
At the meeting with American Airline pilots, one of the Boeing officials said that despite the
reports that MCAS was a “single-point failure” system,
that was not true because they believed the pilots were Allied Pilots Association
part of the “system” and essentially served as a backup Official in Meeting with Boeing
to any technical failure of MCAS. 1212 “So the [MCAS] November 27, 2018
function and trained pilot are part of the system,” said
one of the Boeing officials. “So rightly or wrongly, that “THESE GUYS DIDN’T EVEN
was the design criteria, and that’s how they’re being KNOW THE DAMN [MCAS]
certified with the – the – the system and the pilot
working together,” he said. 1213
SYSTEM WAS ON THE
AIRPLANE – THESE GUYS
The FAA appeared to agree with Boeing DIDN’T EVEN KNOW THE
regarding the notion that the MAX pilots were the DAMN SYSTEM WAS ON THE
redundant features for MCAS and was clearly on the AIRPLANE. … [N]OR DID
same page as Boeing regarding other key design ANYBODY ELSE… THAT’S
decisions about MCAS and the MAX in general. In a
December 2019 transcribed interview with Committee THE PROBLEM I HAVE.”
staff, for instance, Ali Bahrami, FAA’s top safety official, defended the FAA’s actions in the
aftermath of the Lion Air crash when the agency permitted the continued operation of the 737
1207 Najib Menti and Tarek Hamel, “Visual servoing control law with orientation limits,” Automation in Construction, Vol.
17, Issue 1, November 2007, accessed here:

https://www.sciencedirect.com/science/article/abs/pii/S0926580507000052
1208 Aaron Becker, Ouajdi Felfoul, and Pierre E. Dupont, “Simultaneously powering and controlling many actuators with
a clinical MRI scanner,” 2014 IEEE/RSJ International Conference on Intelligent Robots and Systems, September 2014,
accessed here: https://ieeexplore.ieee.org/abstract/document/6942831
1209 N. Koizumi, S. Warisawa, M. Mitsuishi, and H. Hashizume, “Impedance controller for a remote ultrasound
diagnostic system,” Proceedings 2002 IEEE International Conference on Robotics and Automation, May 2002,
accessed here: https://ieeexplore.ieee.org/abstract/document/1013432
1210 G. Antonelli, F. Caccavale, S. Chiaverini, G. Fusco, “A novel adaptive control law for underwater vehicles,” IEEE
Transactions on Control Systems Technology, Vol. 11, Issue 2, March 2003, accessed here:
https://ieeexplore.ieee.org/abstract/document/1186752
1211 G.C. Walsh, R. Montgomery, and S.S. Sastry, “Orientation control of the dynamic satellite,” Proceedings of 1994
American Control Conference, June 1994, accessed here: https://ieeexplore.ieee.org/abstract/document/751710 and S.

Monaco and S. Stornelli, “A nonlinear attitude control law for a satellite with flexible appendages,” 1985 24th IEEE
Conference on Decision and Control, December 1985, accessed here:
https://ieeexplore.ieee.org/abstract/document/4048597

1213 Ibid.
204
MAX while Boeing was contemplating a redesign for MCAS. 1214 In the interview with Mr. Bahrami,
he also seemed unphased by many of the revelations that have deeply disturbed many aviation
experts and engineers about the MAX since they were revealed in the wake of the MAX crashes.
Committee staff asked Mr. Bahrami about some of these issues in the interview:
Committee Staff: On a personal level, did what FAA learned after

Lion Air—MCAS reliance on a single sensor, MCAS re-design,
absence of a risk assessment on the MCAS re-design, non-
functioning AOA disagree alert on a majority of 737 MAX planes—
raise serious red flags for you?
Ali Bahrami: No, it did not. Because the basic—the flight deck
philosophy design was based on pilot intervention and action. 1215
The message from the FAA and Boeing was that the pilots should have compensated for the
MAX’s flawed technical designs. During the APA meeting with Boeing, the Boeing officials
acknowledged, however, that they were looking at several changes that included preventing MCAS’s
repetitive activation to ensure that it only fires once, for instance. Boeing anticipated a quick fix to
these problems and said fixes to MCAS would be finalized “in a fairly short period of time; weeks,
not – not – not a year, but a couple – maybe six weeks-ish,” 1216 a Boeing official said. He made that
prediction 22 months ago.
The Boeing official also suggested that regardless of the cause of stabilizer trim runaway,
whether it was due to MCAS or something else, that the procedures to correct that condition were
all the same. But a frustrated APA official, referring to the Lion Air pilots said, “These guys didn’t
even know the damn [MCAS] system was on the airplane – These guys didn’t even know the damn
system was on the airplane. … [N]or did anybody else… that’s the problem I have.” 1217
Despite the heated exchanges, one of the Boeing officials attempted to emphasize that safety
was Boeing’s number one priority.
You’ve got to understand that our commitment to safety is as great as

yours. It really is. And the worst thing that can ever happen is a
tragedy like this, and the—and the even worse thing would be
another one. So we have to do all the things we can to make sure that
this never happens again, and we will, and we always do. We have
that commitment to safety. 1218
Fifteen weeks later, the 737 MAX suffered its second fatal crash.
1214 Committee staff transcribed interview with Ali Bahrami, FAA Associate Administrator for Aviation Safety,
December 5, 2019. (On file with the Committee).
1215 Ibid.

1217 Ibid.
1218 Ibid.
205
The APA President at the time, Captain Dan Carey, thanked the Boeing officials for their
time. “You were candid and forthright, and we really appreciate that,” he said. However, there were
critical details about MCAS that the Boeing officials did not share at that time, and it is unclear if the
Boeing officials that briefed the APA pilots were even aware of them.
In June 2019, Captain Carey testified at an Aviation Subcommittee Hearing on the MAX. He
discussed the issues with MCAS that concerned the pilot community in the wake of the Lion Air
and Ethiopian Airlines crashes. 1219 Captain Carey included the following in his written testimony:
There are certain facts we know:
1. The 737 MAX was designed to provide the same aircraft feel to the
pilots as the 737. This was intended to minimize the operating cost to
Boeing’s customers by allowing the MAX to be certified by the FAA
as a 737. The point was to provide Boeing’s customers with a new
advanced aircraft while minimizing the training cost associated with a
different aircraft certification. This led Boeing’s engineers to add the
MCAS system. Many mistakes were subsequently made by Boeing
engineers as MCAS was designed as a “federated” not “integrated”
system. As a single-point-of-failure design, this meant that any
redundancy to the system, if it failed, was completely dependent on the
Captain and First Officer of the aircraft.
2. The huge error of omission is that Boeing failed to disclose the

existence of MCAS to the pilot community.
3. The final fatal mistake was, therefore, the absence of robust pilot
training in the event that the MCAS failed. 1220
A 10-Second “Catastrophic” MCAS Test Scenario by Boeing’s Own Test Pilot
Boeing’s failure to disclose the very existence of MCAS to MAX pilots was its most well-
known omission, but there were others too. In the aftermath of the Lion Air crash, Boeing
attempted to focus attention on the pilots as a central cause of the accident. However, they did not
share the fact that one of Boeing’s own test pilots in late 2012 had failed to recover from
uncommanded MCAS activation that led to runaway stabilizer trim in a flight simulator. 1221 While
FAA guidance indicates that pilots should recognize and react to a runaway stabilizer condition in
four seconds, 1222 it took the Boeing test pilot more than 10 seconds—an amount of time that could
1219 Prepared Statement of Captain Daniel Carey, President, Allied Pilots Association, Hearing titled, “Status of the
Boeing 737 MAX: Stakeholder Perspectives,” Subcommittee on Aviation of the House Committee on Transportation
and Infrastructure, 116th Congress, First Session, June 19, 2019, p. 20, accessed here:
1220 Ibid.
1222 “Approval of Flight Guidance Systems,” Advisory Circular (AC) 25.1329-1C, Federal Aviation Administration
(FAA), U.S. Department of Transportation (DOT), October 27, 2014, at p. 78, accessed here:
https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_25_1329-1C_CHG_1_.pdf
206
have resulted in a catastrophic outcome were it to have occurred on an actual flight. 1223 This was a
fundamentally important event that Boeing chose not to share with the FAA or its MAX customers.
Boeing noted the event in at least six separate internal Coordination Sheets about MCAS’s
requirements between 2015 and 2018, including one that was produced after the MAX was certified
by the FAA. However, Boeing has informed the Committee that it has been unable to locate any
record showing that this information was shared with the FAA. 1224 Although the Boeing test
incident was noted in Boeing’s internal documents, the implications of this internal test data, that
should have led to increased pilot training requirements regarding how to manage MCAS, appears to
have been brushed aside by Boeing and its engineers. They did not take the time to determine
methods to effectively eradicate the potential for the sort of experience one of Boeing’s own test
pilots had in a flight simulator that the pilot found to be “catastrophic[.]” Instead, they assumed
away the danger, which was a tragic miscalculation.
Surprisingly, Michael Teal, the Chief Project Engineer for the 737 MAX program, told the
Committee he was not aware of this internal Boeing test data until preparing for a transcribed
interview with Committee staff in May 2020. He also attempted to explain away the importance of
these test results and Boeing’s lack of follow-up actions saying, “I’ve always known that a stab trim
runaway would have catastrophic effects if the pilots did not intervene.” 1225
Chair DeFazio also asked FAA Administrator Dickson in QFRs after the Committee’s
December 11, 2019, 737 MAX hearing whether the FAA was aware of the Boeing test pilot’s 10-
second response time to uncommanded MCAS activation at the time it issued its Emergency AD.
Administrator Dickson’s response mimicked that of Mr. Teal without directly answering the
question. “At the time of [the] original 737MAX certification, the FAA knew an MCAS failure could
present itself as a runaway trim stab event, which is a well-known procedure in which pilots are
trained.” 1226
However, both of those responses completely miss the point. Obviously, there are
potentially fatal consequences if pilots do not intervene in time to various aviation incidents or
technical mishaps. In this case, however, Boeing had internal test data revealing that its own test
pilot tried – but failed – to respond in time to an uncommanded MCAS activation event in a flight
simulator which would have resulted in the loss of the aircraft in a real world situation. This was not
simply a hypothetical scenario. It was the result of a flight simulator test by a trained Boeing test
pilot. From everything the Committee has learned in its investigation, there is no evidence we have
found that shows Boeing shared the results of that test with the FAA or its 737 MAX customers.
Boeing simply assumed away this potentially deadly scenario with the false expectation that pilots
would be the backup to any technical design flaw. Boeing gambled on the fact that the pilots would
1224 Email from Boeing attorney to T&I Committee staff, February 10, 2020, 10:42 PM (On file with the Committee).
1225 Committee staff Transcribed Interview of Michael Teal, former Vice President, Chief Project Engineer and Deputy
First Session, December 11, 2019, p. 244, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
207
be the fail-safe mechanism to prevent an aviation tragedy which contributed to fatal consequences in
both MAX crashes.
Red Flags
For the FAA, in the aftermath of the Lion Air crash, there were other warning signs that
emerged regarding Boeing’s testing of MCAS and the FAA’s own certification review of MCAS that
should have raised additional red flags about potential safety issues on the 737 MAX. On December
17, 2018, Boeing met with FAA officials to provide them with an “MCAS Development and
Certification Overview.” 1227 A core theme that has emerged from the Committee’s investigation is
that both Boeing and the FAA did identify testing lapses and other problems regarding the lack of
completeness of the certification review of the 737 MAX, particularly MCAS, in the wake of the
Lion Air crash, yet they both reached the conclusion that these actions were still compliant with
FAA regulations.
Boeing’s MCAS overview made this point absolutely clear. The presentation identified
multiple missteps, yet Boeing concluded none of these resulted in any process violations or non-
compliances with the FAA’s regulations. For instance, Boeing concluded:
• Erroneous AOA data was “identified and not analyzed as part of” the single &
multiple failure assessment “per Engineering judgment.” 1228
• The single & multiple failure assessment “analysis [was] complete prior to the design
change to MCAS control law during flight test.” However, “[r]eevaluation of [the]
design change [was] not required…” 1229
• The Boeing review also determined that there was “[n]o process violation or non-
compliance” for the removal of the MCAS Control Law from the Flight Crew
Operations Manual (FCOM) and the pilot Differences Training Table. 1230
• There was “[n]o process violation or non-compliance” regarding “repeated

unintended MCAS control law activation” because during the MAX development
this was “deemed no worse than single unintended MCAS activation.” 1231
• The description of the functional failure of MCAS in the Fault Hazard Assessment
table referenced the “preliminary MCAS control law authority limits and was not
updated to reflect [the] certified design.” 1232
1227 “MCAS Development and Certification Overview,” Boeing presentation to FAA, December 17, 2018, TBC-T&I
130075– TBC-T&I 130117, at pp. 178-201, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
1228 Ibid., p. 191.
1229 Ibid.
1230 Ibid., p. 197.
1231 Ibid.
1232 Ibid., p. 198.
208
• Erroneous AOA data from a single AOA sensor “was identified and not analyzed as
part of” the single & multiple failure assessment. This did not entail a “process
violation or non-compliance.” 1233
• Loss of one AOA sensor followed by erroneous AOA data from the second AOA
sensor “was not evaluated in the simulator but deemed acceptable as failure was
found to be extremely improbable.” This did not entail a “process violation or non-
compliance.” 1234
• The single and multiple failure analysis was “completed prior to the design change to
MCAS control law during flight test and not reevaluated.” This did not entail a
“process violation or non-compliance.” 1235
Although the Boeing presentation highlighted many areas where a more robust review
should have been conducted, it still asserted that none of these failures, either singularly or in
combination with each other, amounted to a violation of FAA regulations.
In its own examination of MCAS after the Lion Air crash, in early 2019, the FAA reached
the same conclusion. 1236 The FAA did not identify any “noncompliances” by Boeing despite the
litany of incomplete test results on MCAS, the lack of transparency by Boeing with the FAA on
critically important data regarding potential pilot reactions to uncommanded MCAS activation, or
the disjointed communications by Boeing with the FAA regarding the redesign of MCAS. This
points to a current aviation regulatory framework that demands critical and urgent reforms.
Risk Analysis: Gambling with the Public’s Safety
Even after the Lion Air crash both Boeing and the FAA continued to gamble with the
public’s safety. The FAA often uses a quantitative method in an attempt to predict the potential for
future accidents or the risk of technical incidents. 1237 This Transport Airplane Risk Assessment
Methodology (TARAM) was used to evaluate the conditions that led to the Lion Air crash in order
to predict the risk to the 737 MAX fleet of another potential accident. 1238
On December 3, 2018, less than one week after Boeing’s meeting with the APA pilots, the
FAA prepared a quantitative risk assessment, known as a Random Transport Airplane Risk Analysis
1233 Ibid.
1234 Ibid.
1235 Ibid.
1236 “FAA MCAS Oversight Report,” February 8, 2019, Prepared by: FAA AIR-860 BASOO, (Draft), Boeing Aviation
Safety Oversight Office (BASOO), Federal Aviation Administration (FAA). This document was reviewed remotely by
Committee staff on May 1, 2020.
1237 “Transport Airplane Risk Assessment Methodology (TARAM) Handbook,” FAA Transport Airplane Directorate,
ANM-100, accessed here:

https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgPolicy.nsf/0/4e5ae8707164674a862579510061f96b/$FILE/P
S-ANM-25-05%20TARAM%20Handbook.pdf
1238 Federal Aviation Administration, TAD Corrective Action Review Board Presentation Form, “Title: Maneuver
Characteristics Augmentation System (MCAS) response to Angle of Attack (AOA) failed high,” 18-PAD-0048,
December 11, 2018, BATES Number FAA-DEFAZIO-000028834 – 000028842, p. 165 -173, accessed here:
209
(R-TARA), that was based on the TARAM method of analysis regarding the risk to the 737 MAX
fleet from continued operations. 1239 The analysis was reviewed by the FAA’s Seattle Aircraft
Certification Office’s Corrective Action Review Board (CARB) during a presentation on December
11, 2018, titled, “Maneuver Characteristics Augmentation System (MCAS) response to Angle of
Attack (AOA) failed high.” 1240
The analysis was based on the assumption that only one out of 100 pilots would fail to react
properly to uncommanded MCAS activation resulting in Stabilizer Trim Runaway. 1241 This seems to
be a gross over estimation that predicted 99 out of every 100 pilots would correctly respond to this
scenario, given the fact that one of Boeing’s own test pilots failed to respond quickly enough in a
simulator test. It seems
the number of
potential future
accidents without a fix
to MCAS may have
been much higher than
these predictions
assumed.
Nevertheless,
the results of the
TARAM analysis
indicated that even
with the FAA’s
Emergency AD, but
without a fix to MCAS,
there could be more than 15 fatal 737 MAX crashes over the estimated 30-year lifetime of the fleet,
then estimated to be 4,800 aircraft, resulting in over 2,900 deaths. 1242 Statistically this meant that the
FAA was predicting there would be one fatal 737 MAX accident every two years for the next 30
years—or one fatal accident roughly every 24 months for the next 360 months. The FAA assumed
that these potential future crashes would result in the loss of life for everyone on board the planes
and some bystanders on the ground as well. 1243 However, they also estimated that Boeing would
1239 Ibid., p. 167.

December 11, 2018, BATES Number FAA-DEFAZIO-000028834 – 000028842, p. 165 -173, accessed here:
1241 FAA briefing to Committee staff, December 4, 2019.
1242 FAA briefing to Committee staff, December 4, 2019, and Federal Aviation Administration, TAD Corrective Action
Review Board Presentation Form, “Title: Maneuver Characteristics Augmentation System (MCAS) response to Angle of
Attack (AOA) failed high,” 18-PAD-0048, December 11, 2018, BATES Number FAA-DEFAZIO-000028834 –
000028842, p. 167, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-
116hhrg40697.pdf
December 11, 2018, BATES Number FAA-DEFAZIO-000028834 – 000028842, p. 167, accessed here:
https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf (Note: The Injury Ratio
factor of 1.05 means the loss of 5 bystanders for every 100 airplane occupant losses.)
210
have a fix for MCAS by July 2019. 1244 Until MCAS was fixed, however, the aircraft and its passengers
were still at risk.
Despite the TARAM analysis, the FAA permitted the 737 MAX aircraft to continue flying.
In addition, Boeing continued to expand the MAX fleet in between the time of the Lion Air crash in
October 2018 and the Ethiopian Airlines crash in March 2019. 1245 In those five months, Boeing
delivered nearly 150 more aircraft to its customers, increasing the global 737 MAX fleet to 387
aircraft. 1246 Each new aircraft deployed without a fix to MCAS increased the risk to the public. The
FAA and Boeing were gambling on the fact that issuance of the Boeing OMB and the FAA’s
Emergency AD would be enough to save MAX pilots and the flying public from the potentially
devastating and deadly effect of MCAS.
Analyzing the TARAM Analysis
At the Committee’s December 2019 hearing, Chair DeFazio asked FAA Administrator
Dickson if he believed the MAX fleet should have been grounded given the TARAM analysis after
the Lion Air crash. Administrator Dickson emphasized that the FAA is a “data-driven organization”
and said there is no acceptable number of aviation accidents. 1247 “So remember,” he continued, “the
information that was available at the time was we really didn’t know what the root cause of the
accident—” was, said Administrator Dickson. 1248
Administrator Dickson appeared to back track on his original comments in his response to
QFRs from Chair DeFazio regarding the FAA’s knowledge of the role of MCAS in the Lion Air
crash. “After the Lion Air accident, the FAA knew there was a faulty AOA sensor which sent
incorrect information to the aircraft flight control computer which then erroneously attempted to
correct a nonexistent high angle of attack situation by trimming the aircraft nose down via the
MCAS system,” Administrator Dickson wrote in his response. 1249
Administrator Dickson’s original response at the hearing that the FAA was unaware of the
“root cause” of the Lion Air accident also contradicts other information he provided in responses to
QFRs regarding the FAA’s preparation of the TARAM. A final analysis of the “root cause” of the
Lion Air crash would take a full year to complete, 1250 but MCAS became the primary culprit of that
tragedy almost immediately after the fatal Lion Air crash.
1244 U.S. Department of Transportation, Office of Inspector General, “Timeline of Activities Leading to the Certification
of the Boeing 737 MAX 8 Aircraft and Actions Taken After the October 2018 Lion Air Accident,” Report No.
AV2020037, June 29, 2020, at p. 32, accessed here:
1245 Boeing 737 MAX Deliveries Report, The Boeing Company, accessed here:
1246 Ibid.
First Session, December 11, 2019, p.20, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
1248 Ibid., p. 21.
1249 Ibid., p. 244
1250 “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” accessed here: https://aviation-is.better-
211
Administrator Dickson’s written follow-up response to Chair DeFazio’s QFRs painted a

different picture of what FAA knew at the time it issued its Emergency AD than what he had said in
his testimony at the hearing. Administrator Dickson wrote: “The FAA issued an emergency AD
reminding pilots how to deal with runaway speed trim eight days after the Lion Air accident and
before the TARAM analysis was complete. When the AD was issued, the FAA determined the
permanent action was to require a design change to address MCAS.” 1251
So, despite his testimony that FAA was unaware of the root cause of the Lion Air accident,
it is clear that the FAA was fully aware that MCAS was a primary cause of the Lion Air accident at
the time it conducted the TARAM analysis in late 2018. Despite that, the FAA chose to let the 737
MAX keep flying with the uncorrected and dangerously defective MCAS software operating on the
airplanes.
TARAM Risk Analysis: Who Knew?
The FAA provided the Committee with a copy of their TARAM analysis and related
presentations. However, the FAA has refused to respond to questions from Chair DeFazio about
who exactly at FAA was aware of the TARAM analysis at the time it was conducted. The FAA has
also refused to provide the Committee with internal FAA communications about the TARAM
analysis that was requested by Chair DeFazio in follow up QFRs to Administrator Dickson. The
FAA’s response to these requests has been disappointing. “The FAA senior staff who prepared the
TARAM were interviewed by Committee Staff,” the FAA wrote in response to this request. 1252
“They answered staff questions related to the TARAM,” the FAA said. That is true. It is also
completely unresponsive to Chair DeFazio’s specific request for information on who was aware of
the TARAM analysis and not just who prepared the document.
Based on its investigation, the Committee understands that the TARAM analysis was
presented to the Seattle Aircraft Certification Office’s Corrective Action Review Board (CARB).
However, we remain unaware of who within FAA’s senior leadership was aware of the fact that the
FAA had conducted an internal statistical analysis predicting that another 15 fatal MAX accidents
would occur over the lifetime of the MAX fleet if there was no fix to MCAS—and then permitted
the MAX to keep flying.
Despite not knowing who was aware of the TARAM, the Committee does know that the
FAA’s Associate Administrator for Aviation Safety, Ali Bahrami, for instance, said he was familiar
with the TARAM process, but not the specific details regarding the TARAM analysis conducted
after the Lion Air crash, according to his interview with Committee staff. 1253 “I'm not familiar with
the details of it,” he said. 1254
This raises several disturbing questions regarding top level FAA management of critical
safety issues that can have dire implications for the flying public. Although Mr. Bahrami said he was
1251 Ibid., p. 245.

1252 Ibid.
1253 Committee staff transcribed interview of FAA Associate Administrator for Aviation Safety Ali Bahrami, December
5, 2019.
1254 Ibid.
212
unfamiliar with the details of the TARAM analysis that predicted 15 more fatal MAX crashes over
the lifetime of the MAX fleet, he said he believed FAA officials “used the [TARAM] process the
right way.” 1255 He also acknowledged that the Emergency AD and the focus on pilot responses was
only an interim fix. “[T]he fundamental issue was the redesign of the MCAS system, which [was]
going to happen via software change, which immediately started right after the first accident,” said
Mr. Bahrami. 1256
In his interview with Committee staff, Mr. Bahrami was asked about the decisions to
permit the 737 MAX to keep flying passengers while awaiting a fix for MCAS.
Committee staff: But you made a decision that those changes could
wait --
Ali Bahrami: Yes, we did.
Committee staff: -- and still the plane could fly, and you were
relying on the pilots to prevent a catastrophic failure.
Ali Bahrami: There are a lot of other scenarios out there that we --
again, it gets back to the cockpit design philosophy. Pilots are part of
the system, and we rely on the pilots to do certain things. 1257
Mr. Bahrami briefed Chair DeFazio and Subcommittee on Aviation Chair Larsen on the
Lion Air accident on February 14, 2019. 1258 Even though there was plenty of evidence mounting
within the FAA regarding the fatal MCAS flaws in the 737 MAX at that time, Mr. Bahrami and the
others from the FAA at that time continued to focus their time on blaming the Lion Air pilots. It
seemed they were thoroughly convinced that MCAS was an easy fix and that the pilots deserved the
vast bulk of the blame for the accidents. At that time the FAA and Mr. Bahrami described the Lion
Air accident as a “one-off” to Chairs DeFazio and Larsen. 1259 Less than one month later Ethiopian
Airlines flight 302 became the second MAX aircraft to crash in less than five months killing all on
board.
Mr. Bahrami first began work for the FAA in 1989 and later served as the Manager of the
FAA’s Transport Airplane Directorate in Renton, Washington from 2004 to 2013. 1260 He left FAA
in the wake of Boeing’s last grounding of the 787 Dreamliner that suffered two lithium battery fires
1255 Ibid.
1256 Ibid.
1257 Ibid.
1258 Ali Bahrami, Associate Administrator for Aviation Safety, Federal Aviation Administration (FAA), briefing to Chair
DeFazio and Subcommittee Chair Larsen, February 14, 2019.

1259 See comments by Chair DeFazio, Hearing titled: “The Boeing 737 MAX: Examining the Federal Aviation
Administration’s Oversight of the Aircraft’s Certification,” Committee on Transportation and Infrastructure, U.S.
House of Representatives, 116th Congress, First Session, December 11, 2019, p. 19, accessed here:
1260 Ali Bahrami, Associate Administrator for Aviation Safety, Federal Aviation Administration (FAA), Biography,
accessed here: https://www.faa.gov/about/key_officials/bahrami_avs/
213
on the aircraft. 1261 A subsequent investigation by the National Transportation Safety Board (NTSB),
that was completed in November 2014, identified several issues regarding Boeing and the FAA that
draw striking parallels to problems identified in the certification of the 737 MAX today, including
inadequate testing, lax oversight of Boeing by the FAA, and flawed technical assumptions. 1262
Mr. Bahrami had served for 10 years as a senior engineer at McDonnell Douglas from 1979
to 1989, prior to joining the FAA. 1263 McDonnell Douglas merged with The Boeing Company in
1997, while Mr. Bahrami was at the FAA. 1264 In 2013, Mr. Bahrami left the FAA to take a position as
the Vice President for Civil Aviation at the Aerospace Industries Association (AIA), the aviation
trade group that represents Boeing and many other aviation companies. 1265 Boeing officials serve in
leadership positions on AIA’s Executive Committee. 1266
Importantly, Mr. Bahrami was not at the FAA during the bulk of the 737 MAX’s
certification process and played no role in the ultimate certification of the airplane. He returned to
the FAA from AIA in July 2017, 1267 four months after the 737 MAX received its FAA certification.
However, Mr. Bahrami returned to FAA as the lead safety officer in the agency. Given that
role and the somber and significant consequences of the Lion Air crash, it was surprising to the
Committee that Mr. Bahrami appeared to be largely disengaged from the aftermath and
repercussions of the Lion Air accident. He was unaware of the FAA’s TARAM analysis. He also said
he was unaware that Boeing had internal test data showing that it took of Boeing’s own test pilots
more than 10-seconds to respond to uncommanded MCAS activation, which the pilot described as
“catastrophic.” 1268 This was despite the fact the Committee held a hearing in October 2019 where
this information was released and it was widely covered by the media. 1269 In addition, and perhaps
most surprisingly, Mr. Bahrami claimed to not recall any conversations with any Boeing officials
about the MAX in between the Lion Air and Ethiopian Airlines accidents.
1261 Alwyn Scott and Andrea Shalal-Esa, “US safety board seeks lesson in Boeing 787 battery fire,” Reuters, April 23,
2013, accessed here: https://www.reuters.com/article/us-ntsb-boeing-hearing/us-safety-board-seeks-lesson-in-boeing-
787-battery-fire-idUSBRE93M0QJ20130423
1262 “Aviation Incident Report: Auxiliary Power Unit Battery Fire Japan Airlines Boeing 787-8, JA829J, Boston
Massachusetts,” January 7, 2013, NTSB/AIR-14/01, National Transportation Safety Board (NTSB), November 21,
2014, accessed here: https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR1401.pdf
1263 Ibid.
1264 Natasha Frost, “The 1997 merger that paved the way for the Boeing 737 Max crisis,” Yahoo! Finance, January 3, 2020,
accessed here: https://finance.yahoo.com/news/1997-merger-paved-way-boeing-090042193.html

1265 “Bahrami Named Vice President of Civil Aviation,” July 9, 2013, accessed here: https://www.aia-
aerospace.org/news/bahrami-named-vice-president-of-civil-aviation
1266 “Executive Committee Leadership,” Aerospace Industries Association (AIA), accessed here: https://www.aia-
aerospace.org/about-aia/leadership-and-governance/executive-committee
5, 2019.
1268 Ibid.
1269 See: Hearing titled: “The Boeing 737 MAX: Examining the Design, Development, and Marketing of the Aircraft,”
116hhrg38282.pdf and Ian Duncan, Michael Laris and Lori Aratani, “House committee confronts Boeing CEO with
new documents on 737 Max safety,” The Washington Post, October 30, 2019, accessed here:
https://www.washingtonpost.com/local/trafficandcommuting/house-committee-confronts-boeing-ceo-with-new-
documents-on-737-max-safety/2019/10/30/ef3a8334-fa92-11e9-ac8c-8eced29ca6ef_story.html
214
Committee Staff: Between Lion Air and the Ethiopian accident, did
you have discussions with Boeing, direct discussions?
Mr. Bahrami: I really don't recall, honestly, because I relied on the

team to do -- to do their work. Most of the information, even if I
have a conversation, it would be through the director, through the
other people. Those are the guys that know the details.
Committee Staff: So they would report up?
Mr. Bahrami: Yes, they would report up to me. I don't necessarily

have the specific discussion about the accident with them.
Committee Staff: So –
Mr. Bahrami: From Boeing.
Committee Staff: So from what you recall, you know, you never had
discussions between Lion Air and Ethiopian Air with Boeing about
the MAX?
Mr. Bahrami: I don't recall a conversation about that between the

two accidents. 1270
Chair DeFazio asked FAA Administrator Dickson about Mr. Bahrami’s discussions with
Boeing related to the MAX accidents in between the Lion Air and Ethiopian Airlines crashes in
QFRs after the Committee’s December 2019 hearing. The FAA responded:
The Associate Administrator for Aviation Safety communicates

regularly with Boeing representatives on a variety of aviation safety
topics via different modes of communication, including during the
time period referenced. The Associate Administrator for Aviation
Safety provided more detailed information about his communications
with Boeing during his transcribed interview with Committee staff on
December 5, 2019. 1271
That response is surprising since it appears to contradict what Mr. Bahrami relayed to
Committee staff regarding his interactions with Boeing. While the FAA claimed that as Associate
Administrator for Aviation Safety at the FAA that Mr. Bahrami frequently communicated with
Boeing about safety issues, Mr. Bahrami suggested he rarely, if ever, had those direct conversations.
Furthermore, Mr. Bahrami claimed not to recall having any discussions at all with Boeing about the
MAX in between the two MAX crashes.
5, 2019.
Session, December 11, 2019, p. 245, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
215
Despite Mr. Bahrami’s lack of recollection, some of the email records the Committee
received from Boeing included an email from Elizabeth (“Beth”) Pasztor to Mr. Bahrami on January
24, 2019. 1272 Ms. Pasztor was the Boeing Commercial Airplane’s (BCA’s) Vice President of Safety,
Security and Compliance. 1273 In her email to Mr. Bahrami, she wrote:
I would appreciate a few minutes of your time, the topic is on Lion

Air. Would it be possible to connect today or tomorrow? Please let
me know, thanks for your time. 1274
Mr. Bahrami responded: “Let’s plan for tomorrow. Let me know what works fo[r] you.” The
two scheduled a call for 11:30 a.m. on January 25, 2019. 1275
It is unclear if they actually ended up speaking to each other or who else may have been on
that call. However, five days after they were scheduled to speak, Ms. Pasztor’s deputy at Boeing
wrote to the FAA regarding proposed pilot training requirements related to MCAS in the aftermath
of the Lion Air crash. 1276 That letter was responding to a December 13, 2018, letter from the Chair
of the FAA’s 737 MAX Flight Standardization Board (FSB) in the agency’s Seattle Aircraft
Evaluation Group (AEG). 1277 The letter said that Boeing and the FAA had met the same day (on
December 13, 2018) “to discuss a plan to review, evaluate, and validate B-737 MAX system
enhancements to the Maneuver Characteristics Augmentation System (MCAS),” 1278 and informed
Boeing that the FAA required Boeing to propose pilot training for the new MCAS enhancements. 1279
Boeing sent a response letter on January 30, 2019, outlining Boeing’s proposed training
requirements for MCAS, which seemed out of touch with what was being learned about the737
MAX in the wake of the Lion Air crash.
As you will recall, the Maneuver Characteristics Augmentation

System (MCAS) flight control law was not originally included in the
737 NG to 737 MAX differences tables nor was a specific reference
included in the FCOM/QRH. 1280 Boeing believes that the rationale
supporting that decision remains valid. 1281
1272 Email from Vice President, Safety, Security and Compliance, Boeing Commercial Airplanes (BCA) to Associate
Administrator for Aviation Safety, Federal Aviation Administration (FAA), January 24, 2019, 3:48 PM, BATES Number
TBC T&I 552822 (On file with the Committee).
1273 Ibid.
1274 Ibid.
1275 Ibid.

1277 Letter from FAA B-737 FSB Chair to Boeing, December 13, 2018, BATES Number TBC-T&I 297016, accessed
here, at p. 133: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf

1278 Ibid.
1279 Ibid.
1280 FCOM/QRH stands for Flight Crew Operations Manual/Quick Reference Handbook.

216
Boeing only seemed to concede that some training may be necessary simply to placate
inquiries from MAX “operators” and “customers.” Boeing proposed Level A training requirements
on MCAS for pilots transitioning from the 737 NG to the 737 MAX. 1282 This is the least aggressive
form of training available and only requires a review of written material. It was clear that by January
2019, even as Boeing was in the midst of redesigning MCAS to enhance its safety functions, the
company’s officials strained to admit that MCAS posed any risk at all to MAX pilots or that they
needed any significant training on MCAS whatsoever. The letter continued:
As background to support this recommendation, Boeing believes that

difference between the 737 NG and 737 MAX relating to the MCAS
flight control law do not affect pilot knowledge, skills, abilities, or
flight safety. 1283
Two days later, on March 1, 2019, Boeing received its response from the FAA’s FSB Chair.
The FAA accepted Boeing’s proposal for Level A MCAS training that included conducting tests in
the 737 NG and 737 MAX Full Flight Simulators on March 13, 2019, at Boeing’s Miami, Florida
training facility. 1284
However, the FSB Chair reminded Boeing that when MCAS was originally described to the
Seattle AEG, that it “was presented as autonomous to the pilot, operation was ‘way’ outside the
normal operating envelope, and no flight crew procedures or checklists were affected by the
addition of the flight control law. The original level of training differences that was proposed in
2016 was Level B differences,” the FSB Chair wrote. 1285 The FSB Chair added,
The FAA is concerned that software change, FCC 12.1 may not meet
the definition of Level A differences. Specifically, Level A states that
the change does not adversely affect safety of flight if the information
regarding MCAS operation is not reviewed or forgotten. The FAA is
willing to evaluate Boeing’s proposal for Level A training; however,
we are advising the Boeing Company that the evaluation is
proceeding at risk. 1286
Nine days later, Ethiopian Airlines flight 302 crashed six minutes after takeoff.
1282 Ibid.
1283 Ibid.
1284 Letter from FAA B-737 MAX FSB Chair to Boeing 737 Chief Technical Pilot, March 1, 2019, BATES Number
TBC-T&I 297019 - TBC-T&I 297020, accessed at pp. 136-137 here: https://www.govinfo.gov/content/pkg/CHRG-

1285 Ibid.
1286 Ibid.
217
The BASOO’s Post-Lion Air MCAS System Oversight Report
The FAA had begun a review of MCAS prior to the Ethiopian Airlines crash. In January
2019, the FAA’s Boeing Aviation Safety Oversight Office (BASOO), based in Seattle, began
compiling an after action review, “737-8 MAX Maneuvering Characteristics Augmentation System
Oversight Report,” to look back at Boeing’s submissions to FAA on MCAS as well as the office’s
certification work on that system. 1287 The Committee found the results of this review troubling. The
FAA’s draft review of MCAS following the Lion Air crash found it to be fully compliant with FAA
regulations. If MCAS was compliant, yet it made the 737 MAX unsafe, this points to fundamental
problems in the FAA’s certification process.
The draft document concluded: “The [FAA’s] oversight activity did not reveal any
noncompliance [by Boeing], but did observe some assumptions used by the Applicant and accepted
by the FAA. The following opportunities do not
“737-8 MAX Maneuvering require corrective action; however, they are
Characteristics Augmentation System included to be addressed for improvement.” 1288
Oversight Report”
After the Committee was informed
FAA’s Boeing Aviation Safety about this document in January 2020, the
Oversight Office (BASOO) Committee made numerous requests for a copy
February 8, 2019 of it with both DOT and directly to FAA
Administrator Dickson. The FAA refused to
“THE [FAA’S] OVERSIGHT provide a copy of this report to the Committee
ACTIVITY DID NOT REVEAL ANY because it was a draft. However, FAA did make
NONCOMPLIANCE [BY BOEING], a copy available for Committee staff to review
BUT DID OBSERVE SOME “in camera” remotely. Committee staff reviewed
ASSUMPTIONS USED BY THE the document on May 2, 2020.
APPLICANT AND ACCEPTED BY According to the FAA, the document
THE FAA. THE FOLLOWING was never ultimately completed. They have
OPPORTUNITIES DO NOT claimed that their review of MCAS was going
REQUIRE CORRECTIVE ACTION; through management review and was overtaken
HOWEVER, THEY ARE INCLUDED by the crash of Ethiopian Airlines flight 302. 1289
Based on the Committee’s review of the metadata
TO BE ADDRESSED FOR
associated with the draft “737-8 MAX
IMPROVEMENT.” Maneuvering Characteristics Augmentation
System Oversight Report” that Committee staff reviewed, the draft document was prepared on
February 8, 2019. On March 11, 2019—the day after the Ethiopian Airlines crash—the draft
document was opened and printed by an FAA employee. However, the report was never finalized or
officially issued.
(Draft). (Reviewed remotely “in camera” via access to FAA website by Committee Staff on May 1, 2020).
1288 Ibid.
218
According to the draft report, in multiple instances there were “traceability” issues with the
documentation Boeing provided to the FAA regarding MCAS. “Not all compliance
showing/findings were contained within artifacts proposed by the relevant certification plans,” the
draft report said. 1290 “Although Boeing was able to provide artifacts (e.g. emails and internal
coordination sheets) substantiating detailed aspects of their compliance showing, not all of these
artifacts were traceable via a review of the certification plans [and] our compliance deliverables.” 1291
The draft concluded that while there were some assumptions made by Boeing and accepted by the
FAA that there was room for improvement in the certification process. 1292
Based on the FAA’s limited original review of MCAS demonstrated by this document, as
well as what has been documented elsewhere with regard to Boeing’s efforts to downplay MCAS to
regulators, this underscores questions about the effectiveness of the FAA’s certification process. If
Boeing was technically compliant, but the FAA did not have a full understanding of MCAS, 1293 and
the result was two deadly plane crashes, the aviation certification process is in desperate need of
repair.
Grounding the 737 MAX
The crash of Ethiopian Airlines flight 302 occurred on Sunday, March 10, 2019. The FAA,
which has always prided itself on being a “data driven” organization, did not believe they had
enough data—factual evidence—immediately after the Ethiopian Airlines crash suggesting that the
737 MAX was unsafe to fly. They held fast as other foreign civil aviation authorities used their
authority to ground the aircraft. The FAA did not.
On March 11, 2019, the day after the Ethiopian Airlines crash, the FAA issued a Continued
Airworthiness Certification to the International Community permitting the 737 MAX to keep flying.
In part, the document said: “External reports are drawing similarities between this accident and the
Lion Air Flight 610 accident on October 29, 2018. However, this investigation has just begun and to
date we have not been provided data to draw any conclusions or take any actions.” 1294
BASOO, Boeing Aviation Safety Oversight Office (BASOO), Federal Aviation Administration (FAA), February 8, 2019,
p. 8, 12 (Draft). (Reviewed remotely “in camera” via access to FAA website by Committee Staff on May 1, 2020).
1290 Ibid.
p. 8, 12 (Draft). (Reviewed remotely “in camera” via access to FAA website by Committee Staff on May 1, 2020);
“Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8 Aircraft and Actions Taken After the
p. 8, 12 (Draft). (Reviewed remotely “in camera” via access to FAA website by Committee Staff on May 1, 2020).
1293 See JATR p. 13: “The FAA was not completely unaware of MCAS; however, because the information and
discussions about MCAS were so fragmented and were delivered to disconnected groups within the process, it was
difficult to recognize the impacts and implications of this system.” accessed here:
1294 FAA Continued Airworthiness Notification to the International Community, March 11, 2019, accessed here:
https://www.faa.gov/news/updates/media/CAN_2019_03.pdf
219
By March 12, 2019, two days after Ethiopian Airlines flight 302 crashed, civil aviation
authorities in China, Australia, Britain, France, Germany, Ireland, Malaysia, Mongolia, Oman and
Singapore had already grounded the 737 MAX in addition to airlines in Brazil, South Africa, South
Korea, Norway, India, Turkey and other countries. 1295 At the time of the Ethiopian Airlines accident
the 737 MAX fleet consisted of 387 airplanes operating with 59 total air carriers worldwide,
including 74 operating with U.S. based airlines. 1296
By the evening of March 12, 2019, at 6:10 p.m. then-Acting FAA Administrator Dan K.
Elwell issued a statement on Boeing’s 737 MAX:
The FAA continues to review extensively all available data and

aggregate safety performance from operators and pilots of the Boeing
737 MAX. Thus far, our review shows no systemic performance
issues and provides no basis to order grounding the aircraft. Nor
have other civil aviation authorities provided data to us that would
warrant action. In the course of our urgent review of data on the
Ethiopian Airlines Flight 302 crash, if any issues affecting the
continued airworthiness of the aircraft are identified, the FAA will
take immediate and appropriate action. 1297
In his transcribed interview with Committee staff, Ali Bahrami, FAA’s head of safety, also
said that the FAA felt they simply did not have enough data at that point to ground the MAX.
However, on the morning of Wednesday, March 13, 2019, he said there was an “urgent call with
Boeing” that he was asked to be on with Beth Pasztor, who had emailed him at the end of January
2019 to talk about Lion Air, in addition to the Boeing accident investigator who was on site in
Ethiopia and several other people. 1298
According to Mr. Bahrami, “Beth basically said, Ali, we have some information that we need
to share with you….” 1299 Mr. Bahrami did not recall who was in the room with him, but Boeing sent
them data that they put on a screen. They superimposed the traces from both the Lion Air flight and
the Ethiopian Airlines flight on the screen and Boeing explained their similarities. They did not yet
have the flight data recorder from the Ethiopian Airlines flight. Boeing also told Mr. Bahrami that
they found physical evidence at the crash site. “The physical evidence they found was the flap
actuator,” said Mr. Bahrami. 1300 “[The f]lap actuator was in a retract position. And MCAS gets
activated when flaps are up,” said Mr. Bahrami. 1301 “So now we have data that says … the two
1295 “Boeing’s 737 MAX 8: who’s grounding, who’s still flying troubled jet after Ethiopia crash,” South China Morning Post,
March 12, 2019, accessed here: https://www.scmp.com/news/world/united-states-canada/article/3001206/boeings-
737-max-8-whos-grounding-whos-still-flying
1296 FAA Continued Airworthiness Notification to the International Community, March 11, 2019, accessed here:
https://www.faa.gov/news/updates/media/CAN_2019_03.pdf
1297 March 12, 2019 6:10pm Update, Statement from FAA Acting Administrator Daniel K. Elwell
https://www.faa.gov/news/updates/?newsId=93206
1298 Committee staff Transcribed Interview of FAA Associate Administrator for Aviation Safety Ali Bahrami, December
5, 2019.
1299 Ibid.
1300 Ibid.
1301 Ibid.
220
scenarios, maneuvers, were the same and we also have a flap actuator that is in a retract position,” he
said. 1302
I saw that and I said, thank you, anything else? And they said, well,
what are you going to do? I said, we’ll get back to you. And I walk
out of my office, went to Dan’s [Dan Elwell, then-Acting FAA
Administrator’s] office, and I said, we need to ground the fleet. 1303
At 3:00 p.m. on March 13, 2019, the FAA grounded the 737 MAX fleet. 1304 The FAA issued
a brief statement that said:
The FAA is ordering the temporary grounding of Boeing 737 MAX

aircraft operated by U.S. airlines or in U.S. territory. The agency made
this decision as a result of the data gathering process and new
evidence collected at the site and analyzed today. This evidence,
together with newly refined satellite data available to FAA this
morning, led to this decision. 1305
That “temporary grounding” remains in effect as of the writing of this report. Eighteen
months since the grounding went into effect the public has learned a lot more about the design
decisions and certification weaknesses that led to the MAX tragedies. Multiple new problems,
seemingly unrelated to the two fatal MAX crashes, have also surfaced.
1302 Ibid.
1303 Ibid.
1304 “Statement from the FAA on Ethiopian Airlines,” March 13, 2019 3:00 pm Update, Federal Aviation Administration
(FAA), accessed here: https://www.faa.gov/news/updates/?newsId=93206; FAA Emergency Order of Prohibition to

Operators of Boeing Company Model 737-8 and Boeing Company Model 737-9 Airplanes, March 13, 2019, accessed
here: https://www.faa.gov/news/updates/media/Emergency_Order.pdf
1305 “Statement from the FAA on Ethiopian Airlines,” March 13, 2019 3:00 pm Update, Federal Aviation Administration
(FAA), accessed here: https://www.faa.gov/news/updates/?newsId=93206
221
10. New Issues Emerge
-New Issues Emerge-
The 737 MAX has been grounded for 18 months following the crash of Ethiopian Airlines
flight 302. During this time, Boeing has faced challenges in correcting both known problems with
the airplane that contributed to both MAX crashes as well as newly identified manufacturing defects.
The myriad issues that have become manifest during the airplane’s grounding underscore the FAA’s
systemic oversight shortcomings and problems with Boeing’s design, development, and production
as described in this report. The combination of these weaknesses contributed to the 737 MAX’s
significant safety deficiencies and ultimately the crash of both MAX airplanes. The new issues that
have emerged since the MAX’s grounding pose additional barriers to the airplane’s safe return to
service.
New Issues
From software glitches to manufacturing defects and production quality deficiencies, several
areas of concern related to both previously identified and newly found problems have emerged
following the 737 MAX’s grounding in March 2019. These include:
Nonconforming Slat Tracks
In December 2019 and January 2020, the FAA proposed $9.3 million in civil penalties
against Boeing for the company’s alleged installation of slat tracks—components used to guide the
movement of panels (slats) on the wing’s leading edge that extend to provide additional lift during
takeoff and landing—that were weakened during the manufacturing process. 1306 These proposed
penalties cover 133 Boeing 737 NG airplanes and 178 Boeing 737 MAX airplanes. The FAA says
that Boeing’s failure to oversee its suppliers resulted in the installation of slat tracks that were
weakened by a condition known as hydrogen embrittlement that occurred during cadmium-titanium
plating. 1307 The FAA had previously issued an Airworthiness Directive (AD) in June 2019 to require
inspections of affected aircraft and various actions based on the ability to identify the faulty slat
tracks. 1308
Flight Control Computer
In January 2020, the two flight control computers installed on a 737 MAX test airplane failed
to properly power-up after the installation of updated software that Boeing developed following the
Lion Air and Ethiopian Airlines crashes. 1309 The software intended to monitor the power-up
1306 FAA Press Release, “FAA Proposes $3.9 Million Civil Penalty Against The Boeing Co.,” December 6, 2019,
accessed here: https://www.faa.gov/news/press_releases/news_story.cfm?newsId=24456 and FAA Press Release,
“FAA Proposes $5.4 Million Civil Penalty Against The Boeing Co.,” January 10, 2020, accessed here:
1307 Ibid.
1308 Identification of the defective slat tracks was hindered because the manufacturer—a Boeing supplier—did not apply
a protective coating over the identification mark that is required to be displayed during the manufacturing process. See
FAA Press Release, “FAA Proposes $3.9 Million Civil Penalty Against The Boeing Co.,” December 6, 2019, accessed
here: https://www.faa.gov/news/press_releases/news_story.cfm?newsId=24456
1309 Andy Pasztor, “Boeing Finds New Software Problem That Could Complicate 737 MAX’s Return,” Wall Street
Journal, January 17, 2020, accessed here: https://www.wsj.com/articles/boeing-finds-new-software-problem-that-could-

complicate-737-max-return-11579290347
223
function did not operate properly and prevented the computers from starting. 1310 Previously, the
software had been tested on simulators where no power-up problems occurred. 1311
In April 2020, Boeing said that it needed to again update the flight control computer
software to address two separate issues—one which could lead to a runaway stabilizer condition
(that is not related to MCAS) and a second which could lead to disengagement of the autopilot
feature during final approach. 1312 This situation raises questions as to whether the airplane’s flight
control computers—which date back to a 1996 design 1313—can be programmed to reliably integrate
new features, such as MCAS, that make the 737 MAX more complex than earlier versions of the
airplane. The FAA issued a proposed AD for the MAX in August 2020 that includes a requirement
to install updated flight control software for the flight control computer with new control laws
designed to prevent erroneous MCAS activation. 1314
Wire Bundles
Electrical wiring originally installed on 737 MAX airplanes did not meet FAA regulations for
safe wire separation. 1315 Wire bundles in these airplanes were spaced too close in about 12 locations,
which created the potential that arcing 1316 could occur between the bundles and damage the wires. 1317
While the possibility is remote, such damage could result in a pilot’s inability to operate the electric
motor that moves the airplane’s stabilizer and cause the pilot to lose control of the airplane. 1318 In
March 2020, according to media reports, Boeing said that it would separate the wiring bundles in its
previously-manufactured airplanes before the 737 MAX returns to service. The FAA had rejected
1310 Ibid.
1311 Ibid.
1312 David Shepardson, “Boeing making new 737 MAX software updates to address computer issue,” Reuters, April 7,
2020, accessed here: https://www.reuters.com/article/us-boeing-737max-software/boeing-making-new-737-max-

software-updates-to-address-computer-issue-idUSKBN21P3K3
1313 Darryl Campbell, “The Ancient Computers in the 737 MAX are Holding Up a Fix,” The Verge, April 9, 2020,
accessed here: https://www.theverge.com/2020/4/9/21197162/boeing-737-max-software-hardware-computer-fcc-

crash
1314 See 85 FR 47698; Docket No. FAA-2020-0686; Docket Name: 2019-NM-035-AD; Airworthiness Directives; The
Boeing Company Airplanes; Notice of Proposed Rulemaking (NPRM), Federal Aviation Administration, August 6, 2020,
accessed here: https://www.federalregister.gov/documents/2020/08/06/2020-17221/airworthiness-directives-the-
boeing-company-airplanes
1315 Dominic Gates, “FAA faces dilemma over 737 MAX wiring flaws that Boeing missed,” Seattle Times, February 14,
2020, accessed here: https://www.seattletimes.com/business/boeing-aerospace/faa-faces-dilemma-over-737-max-

wiring-flaw-that-boeing-missed/?utm_source=referral&utm_medium=mobile-app&utm_campaign=ios
1316 Modern commercial transport aircraft contain miles of wire that can be the source of electrical fires. One possible
source of such fires is the touching of exposed metal, such as could occur when the insulation that surrounds wires
becomes worn, that causes an electrical arc or spark. When electricity jumps between two conducting electrodes, such as
two exposed pieces of wire, it makes an electrical arc, which is referred to as “arcing.” See “Electrical Fires,” SKYbrary,
accessed here: https://www.skybrary.aero/index.php/Electrical_Fires and “What is an electrical arc?” How it Works,
December 30, 2010, accessed here: https://www.howitworksdaily.com/question-of-the-day-what-is-an-electrical-arc/#
1317 Alan Levin, “Boeing Argues It Doesn’t Need to Move 737 MAX Wiring Bundles,” Bloomberg, April 15, 2020,
accessed here: https://www.bloombergquint.com/business/boeing-argues-it-doesn-t-need-to-relocate-737-max-wiring-

bundles
1318 Dominic Gates, “FAA faces dilemma over 737 MAX wiring flaws that Boeing missed,” Seattle Times, February 14,
2020, accessed here: https://www.seattletimes.com/business/boeing-aerospace/faa-faces-dilemma-over-737-max-

wiring-flaw-that-boeing-missed/?utm_source=referral&utm_medium=mobile-app&utm_campaign=ios
224
Boeing’s request to leave the bundles in place. 1319 In June 2020, Boeing reported that it had received
FAA approval on the required wiring modifications and was coordinating modification efforts with
the airlines. 1320 Boeing will also incorporate this wiring update in the manufacturing of future
airplanes. 1321 The FAA’s August 2020 proposed AD codifies the wire routing requirements to restore
compliance with FAA’s latest wire separation safety standards. 1322
Fuel Tank Debris
In February 2020, Boeing discovered that some of its stored 737 MAX airplanes had foreign
object debris (FOD) such as rags and tools in their fuel tanks—a condition that creates a potential
safety hazard. 1323 The presence of FOD that Boeing found in the fuel tanks and other interior spaces
in approximately half of the estimated 400 undelivered 737 MAX airplanes that it inspected is a
production quality control issue that Boeing has also experienced on other types of aircraft that it
has manufactured. 1324 For example, the U.S. Air Force has temporarily halted deliveries of Boeing’s
KC-46A tanker because of FOD issues twice before. 1325 As previously described, Edward Pierson,
Boeing’s Senior Manager for Production Support at its 737 factory in Renton, Washington, had
raised concerns in 2018 about workmanship mistakes on the 737 MAX airplanes being produced at
the factory that stemmed, in part, from Boeing’s push to increase production. 1326 He feared that
production quality issues were potentially undermining safety. The presence of FOD was the type of
mistake that he worried could be brought on by an overworked, fatigued workforce. The recent
reports of FOD in the 737 MAX airplanes also caused regulatory authorities to take notice. A
weekly report by FAA’s Seattle Aircraft Certification Office on May 11, 2020, contained an entry on
“FOD in Fuel Tanks” on 737 MAX airplanes which noted that the FAA had received several
messages from foreign civil aviation authorities, including the European Union Aviation Safety
1319 Eric M. Johnson and David Shepardson, “Exclusive: Boeing to separate 737 MAX wire bundles before jet’s return to
service – sources,” Reuters, March 11, 2020, accessed here: https://www.reuters.com/article/us-boeing-737max-wiring-

exclusive/exclusive-boeing-to-separate-737-max-wire-bundles-before-jets-return-to-service-sources-idUSKBN20Y3E3
1320 David Shepardson, “Boeing aims for key 737 MAX certification flight in late June: sources,” Reuters, June 10, 2020,
accessed here: https://www.reuters.com/article/us-boeing-737max/boeing-aims-for-key-737-max-certification-flight-in-

late-june-sources-idUSKBN23H2O7
1321 Ibid.
Boeing Company Airplanes; Notice of Proposed Rulemaking (NPRM), Federal Aviation Administration, August 6, 2020,
accessed here: https://www.federalregister.gov/documents/2020/08/06/2020-17221/airworthiness-directives-the-
boeing-company-airplanes
1323 Scott Hamilton, “Boeing finds debris left in new 737 MAXes, now in storage,” Leeham News, February 18, 2020,
accessed here: https://leehamnews.com/2020/02/18/boeing-finds-debris-left-in-new-737-maxes-now-in-storage/ and

Ian Duncan, “Boeing finds debris in fuel tanks of undelivered 737 Max jets,” Washington Post, February 18, 2020,
accessed here: https://www.washingtonpost.com/dc-md-va/2020/02/18/boeing-finds-debris-fuel-tanks-undelivered-
737-max-jets
1324 Andy Pasztor and Andrew Tangel, “Prosecutors, Regulators Probe Boeing 737 MAX Production Issues,” Wall Street
Journal, April 28, 2020, accessed here: https://www.wsj.com/articles/prosecutors-regulators-probe-boeing-737-max-

production-issues-11588085503
1325 Scott Hamilton, “Boeing finds debris left in new 737 MAXes, now in storage,” Leeham News, February 18, 2020,
accessed here: https://leehamnews.com/2020/02/18/boeing-finds-debris-left-in-new-737-maxes-now-in-storage

1326 Prepared Statement of Edward F. Pierson, Hearing titled, “The Boeing 737 MAX: Examining the Federal Aviation
Administration’s Oversight of the Aircraft’s Certification,” Committee on Transportation and Infrastructure, U.S. House
of Representatives, 116th Congress, First Session, December 11, 2019, accessed here:
https://transportation.house.gov/imo/media/doc/Pierson%20Testimony.pdf
225
Agency, expressing concern for “Boeing Quality Issues.” 1327
Engine Panel Electrical Bonding
In June 2020, the FAA adopted an AD to require the inspection of all 737 MAX airplanes to
determine the adequacy of the electrical bonding of panels on top of the LEAP-1B engines. 1328
These panels are designed to protect the encased engine wiring from the energy of High-Intensity
Radiated Fields (HIRF). 1329 Defects in the manufacturing of these panels arose when workers who
were polishing the engine pods at the end of the production process ground away some of the metal
foil that underlies the panels. 1330 The resulting damage to the foil could prevent it from shielding the
engine wiring from the electromagnetic effects of HIRF, which could potentially lead to engine
power loss or the display of misleading information about propulsion parameters. 1331 The FAA AD
requires that all 737 MAX airplanes undergo inspection and that any needed repairs are made before
further flight. 1332
Head-Up Guidance System Sensors
In March 2020, the FAA initiated action to impose a $19.68 million civil penalty against
Boeing for the company’s alleged use of sensors in Head-up Guidance Systems 1333 that had not been
tested or approved as being compatible with those guidance systems. 1334 In its press release, the FAA
alleged that Boeing violated Federal Aviation Regulations between June 2015 and April 2019 when
it certified 791 airplanes equipped with these sensors—comprised of 618 Boeing 737 NG airplanes
and 173 Boeing 737 MAX airplanes—as airworthy when they were not in compliance with their type
1327 “Weekly Report,” Seattle ACO Branch, AIR-780, May 11, 2020, Seattle Aircraft Certification Office, Federal
Aviation Administration. (On file with the Committee).
1328 See 85 FR 38055; Docket No. FAA-2020-0091; Docket Name: 2020-NM-012-AD The Boeing Company Model
737-8 and 737-9 airplanes; Airworthiness Directives; The Boeing Company Airplanes; Final Rule, Federal Aviation
Administration, June 25, 2020, accessed here: https://www.federalregister.gov/documents/2020/06/25/2020-
13481/airworthiness-directives-the-boeing-company-airplanes
1329 Aircraft are exposed to the HIRF environments that emanate, for example, from high-powered radio and television
frequency transmitters, radar and satellite uplink transmitters, and large microwave communications systems. Aircraft
electrical and electronic systems may be adversely affected by the electromagnetic energy generated by HIRF-producing
equipment, and the failure of such systems could lead to the inability to operate the aircraft’s engines and other flight
controls. See: “High-Intensity Radiated Fields (HIRF) Risk Analysis,” DOT/FAA/AR-99/50, Final Report, July 1999,
accessed here: http://www.tc.faa.gov/its/worldpac/techrpt/ar99-50.pdf
1330 Dominic Gates, “FAA orders inspections of all Boeing 737 MAXs to fix defect,” Seattle Times, February 25, 2020,
accessed here: https://www.seattletimes.com/business/boeing-aerospace/faa-directive-requires-boeing-to-inspect-and-

fix-a-manufacturing-defect-on-all-737-maxs/
1331 See 85 FR 38055; Docket No. FAA-2020-0091; Docket Name: 2020-NM-012-AD The Boeing Company Model
737-8 and 737-9 airplanes; Airworthiness Directives; The Boeing Company Airplanes; Final Rule, Federal Aviation
Administration, June 25, 2020, accessed here: https://www.federalregister.gov/documents/2020/06/25/2020-
1332 Ibid.
1333 A head-up guidance system uses a transparent screen located at the flight deck window level to display flight
information. The system is intended to enable “eyes-forward” flying and increase situational awareness such as by
helping pilots to see through weather and low visibility conditions. For additional information on the head-up guidance
system produced by Collins Aerospace for the Boeing 737, see https://www.collinsaerospace.com/-
/media/project/collinsaerospace/collinsaerospace-website/product-assets/marketing/h/head-up-display/collins_evs-
3600-hgs-6000_4pg_bro_final-web.pdf?rev=9088c989e09646be869197d152eb705c
1334 FAA Press Release, “FAA Proposes $19.68 Million Civil Penalty Against The Boeing Co.,” March 6, 2020, accessed
here: https://www.faa.gov/news/press_releases/news_story.cfm?newsId=24716
226
certificate. 1335 Further, the FAA alleged that Boeing failed to follow its own business process
instructions, which are in place to help prevent such situations from occurring. 1336 According to the
FAA, the manufacturer of the Head-up Guidance System, Rockwell Collins, subsequently conducted
the necessary testing. 1337
On August 6, 2020, the Office of the Federal Register published FAA’s proposed AD that
would mandate a number of changes to the 737 MAX, including the changes described above to the
flight control software that operates MCAS and to the airplane’s wire bundles. 1338 This step—nearly
18 months following the FAA’s order to ground the airplane—formally began the public process for
establishing the requirements for the airplane’s return to service. 1339
1335 Ibid.
1336 Ibid.
1337 Ibid.
Boeing Company Airplanes, accessed here: https://www.federalregister.gov/documents/2020/08/06/2020-

1339 A 45-day public comment period began when FAA’s proposed Airworthiness Directive published in the Federal
Register.
227
11. Final Observations
-Final Observations-
Observations on Boeing
Restoring Boeing’s Safety Focus
The beginning of this report mentioned that in 1916, soon after William Boeing established
his company, he went to his airplane factory housed at the Duwamish shipyard in Seattle and began
to step all over improperly sawed “spruce ribs” until they broke. 1340 He used these wooden boards to
build his new airplanes. The point, as relayed from his official Boeing biography, was that he was a
perfectionist and demanded that his products be of the highest quality and safe. 1341
The Boeing Company needs to restore its reputation as a company focused squarely on
safety and quality as Mr. Boeing envisioned and demanded. By heeding the horrific lessons from the
MAX accidents, Boeing can and must take significant steps to create and maintain an effective,
fulsome, and forthright safety culture. This would help to reinvigorate its workers’ morale and public
confidence that Boeing is on the road to recovery stemming from the flaws that have been exposed
as a result of the MAX crashes. However, the Committee’s investigation raises questions regarding
Boeing’s commitment to doing that or even to simply acknowledging that it made mistakes in the
design, development, and certification of the 737 MAX aircraft.
What Lessons Has Boeing Learned?
Boeing says it has learned lessons and made changes since the grounding of the 737 MAX.
After the Committee’s October 2019 hearing on the MAX, Chair DeFazio asked follow-up
questions for the record of Boeing’s then-CEO Dennis Muilenburg. Among his questions, Chair
DeFazio asked about efforts Boeing had taken “to ensure future airplane designs do not have similar
fates.” 1342
In Boeing’s response on behalf of Mr. Muilenburg, the company said that it had “initiated a
review by a special board committee. That committee recommended several changes to our
organization and processes designed to enhance safety culture of the company. These changes
include:
(1) Creating a permanent Aerospace Safety Committee within our Board

of Directors to oversee and ensure safe design, development,
manufacture, maintenance, and delivery of our products and services;
(2) Creating a Product and Services Safety organization to review all

aspects of product safety;
1340 Spruce ribs are a type of wood used to build boats that Mr. Boeing used to build his first airplanes. “Biography of
William E. Boeing,” The Boeing Company, accessed here: https://www.boeing.com/history/pioneers/william-e-

boeing.page
1341 Ibid.
116hhrg38282.pdf
229
(3) Realigning the Engineering function within the company, so that

engineers across Boeing will report directly to the Chief Engineer;
(4) Establishing a design requirements program to further facilitate the

incorporation of historical design materials, data and information,
best practices, lessons learned, and detailed after action reports to
reinforce Boeing’s commitment to continuous improvement;
(5) Enhancing our Continued Operational Safety Program to aid

transparency and visibility of safety related issues; the Continued
Operational Safety Program now will require the Chief Engineer’s
review of all safety and potential safety reports;
(6) To anticipate the needs of future pilot populations, re-examining

assumptions about flight deck design and operation in partnership
with our airline customers and industry members;
(7) Expanding our Safety Promotion Center for employees to learn and
reflect on our safety culture and renew personal commitments to
safety;
(8) Expanding our anonymous safety reporting system to strengthen

safety management systems within Boeing and our supply chain;
(9) Investing in new capabilities, including enhanced flight simulation

and computing, and advanced R&D for future flight decks, as well as
pilot and maintenance technician training and STEM education.” 1343
The effectiveness of these organizational and procedural changes that have been
recommended following its internal review will be dependent on Boeing’s willingness to change.
However, Boeing does not appear to have fully accepted the lessons from the MAX accidents or
taken responsibility for design errors. Without that recognition it is hard to believe that Boeing will
make the changes necessary to improve its safety culture.
In another question for the record following the October 2019 hearing, Chair DeFazio asked
Mr. Muilenburg to identify what new information Boeing learned in the wake of the Lion Air and
Ethiopian Airlines crashes that it did not already know. 1344 Chair DeFazio noted in his question that,
prior to the Lion Air crash, Boeing was already aware that one of its own engineers had raised
concern about MCAS relying on a single sensor, and Boeing also knew that if a pilot took more than
10 seconds to respond to an uncommanded MCAS activation, the result could be “catastrophic.” 1345
1343 Ibid.
1344 Ibid., p. 279
1345 Ibid.
230
Instead of acknowledging in its reply that Boeing learned post crashes that its design was
flawed, or that it had made mistakes, Boeing blamed industry-wide assumptions regarding pilot
response times:
In designing MCAS, Boeing relied on well-accepted, industry-wide

assumptions in evaluating how pilots would react to the
uncommanded activation of MCAS for any reason, including
erroneous AOA. Those assumptions proved not to be accurate in
these accidents. Accordingly, we now know that there is a greater risk
from unintended activation of MCAS due to erroneous AOA data
than we originally thought. Our system redesign addresses this
issue. 1346
Except as the Committee’s investigation has shown, Boeing did, in fact, have information
that those industry-wide assumptions were wrong. Boeing knew this because it had internal test data
it had acquired as early as November 2012 that its own test pilot took more than 10 seconds to
respond to uncommanded MCAS activation during a test scenario in a flight simulator, a condition
the pilot found to be “catastrophic[.]” 1347 Boeing clearly realized the significance of a delayed
response to MCAS activation because it described this “catastrophic” test result in six separate
Coordination Sheets about MCAS that were completed from 2015 to 2018. 1348 What is less clear is
why Boeing never shared this important data with the FAA, its customers, or 737 MAX pilots.
Boeing’s reluctance to admit mistakes is also evident in its response to another question for
the record from Rep. Sharice Davids in which she asked if Boeing had taken any disciplinary action
against employees who were aware that the AOA Disagree alert was not functioning on the majority
of MAX airplanes prior to the Lion Air crash and failed to take appropriate steps to inform the FAA
or Boeing’s customers. 1349 In its reply, Boeing said the priority was returning the 737 MAX to
service:
1346 Ibid.
1347 Ibid.
BBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision B, July 8, 2015, TBC T&I 191227 - TBC T&I 191232 at TBC
T&I 191231 (On file with Committee); Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim
T&I 253262 - TBC T&I 253268 at TBC T&I 253267 (On file with Committee); Boeing Coordination Sheet, “737MAX
Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-B-BBA8-C12-0159, Model: 737-MAX (-7/8/9),
Revision D, March 30, 2016, accessed at p. 164 here: https://www.govinfo.gov/content/pkg/CHRG-
T&I 129776 - TBC T&I 129782 at TBC T&I 129782 (On file with Committee); Boeing Coordination Sheet, “737MAX
Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-B-BBA8-C12-0159, Model: 737-MAX (-7/8/9),
Revision F, December 20, 2017, TBC T&I 037449 - TBC T&I 037457 at TBC T&I 037457 (On file with Committee);
Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-B-
116hhrg38282.pdf
231
As Mr. Muilenburg testified, our current focus as a Company is on
doing everything possible to ensure the safe return of the MAX to
service. We owe this to our customers and the flying public. That
said, once the MAX is safely back in service, the time will come to
consider further questions of accountability. And Boeing will not
hesitate to hold people accountable, where appropriate. 1350
This response indicates that Boeing remains focused first and foremost on returning the
MAX to service instead of focusing on accountability and fixing past mistakes and processes that led
to the design, certification, and production of an unsafe airplane.
Observations on the Federal Aviation Administration (FAA)
Restoring FAA’s Safety Focus
For its part, the MAX crashes show that the FAA must develop a more aggressive
certification and oversight structure to ensure safe aircraft designs. Traditionally, the FAA has been
the primary leader of the world’s civilian aviation authorities, but questions raised about the FAA’s
role in the 737 MAX crisis have punctured its reputation as the gold standard in aviation safety and
international civil aviation authorities have clashed with the FAA over the 737 MAX. 1351 For
example, the European Union Aviation Safety Agency (EASA) has raised concerns about the lack of
a third AOA sensor on the 737 MAX. EASA has reportedly insisted that changes be made to the
MAX to address its concerns, and its insistence on such changes has reportedly caused tension
between EASA and the FAA. 1352 In addition, Transport Canada may lag behind the FAA in
approving the 737 MAX to return to service based on its demands to give pilots the option to
disable the “stick shaker”—a warning mechanism that noisily vibrates the airplane’s yoke when the
airplane is at risk of entering a stall—to reduce the risk of pilot distraction in the event of erroneous
activation of the safety feature. 1353 As regulators have historically presented a united front in public,
the reported disagreements between foreign authorities and the FAA provides insight into the
reputational damage suffered by the agency in the wake of the 737 MAX crashes.
What Lessons Has FAA Learned?
Following the 737 MAX crashes, numerous studies, including the JATR, NTSB, and the
DOT’s Special Committee, have generated a multitude of findings and recommendations to
improve aviation safety. These recommendations largely focused on how the FAA could improve its
certification processes and enhance its oversight of Boeing and other aircraft manufacturers. It
remains to be seen, however, how the FAA will address these issues and whether it will fully
embrace these recommendations.
1350 Ibid.
1351 Siddharth Philip, Julie Johnsson, Charlotte Ryan, and Kait Bolongaro, “Boeing 737 MAX Return Outside U.S. Seen
Slowed by Regulators,” Bloomberg News, August 11, 2020, accessed here: https://www.bnnbloomberg.ca/boeing-737-
max-return-outside-u-s-seen-slowed-by-regulators-1.1478539 and Dominic Gates, “Foreign regulators demand
substantial new changes to Boeing 737 MAX flight controls,” Seattle Times, June 24, 2020, accessed here:
https://www.seattletimes.com/business/boeing-aerospace/foreign-regulators-demand-substantial-new-changes-to-
boeing-737-max-flight-controls
1352 Ibid.
1353 Ibid.
232
More broadly, in his prepared testimony for the Committee’s December 2019, hearing, FAA
Administrator Dickson acknowledged several issues the FAA needs to address to improve its
certification process, including:
• moving toward a more holistic versus transactional, item-by-item

approach to aircraft certification—taking into account the
interactions between all aircraft systems and the crew;
• integrating human factors considerations more effectively

throughout the design process, as aircraft become more
automated and systems more complex; and
• ensuring coordinated and flexible information flow during the

oversight process. 1354
Improving Safety Cultures
To benefit from the recommendations that have been directed to them, both Boeing and the
FAA will need to address fundamental issues within their respective ranks concerning the roles and
responsibilities of Authorized Representatives (ARs), and remove barriers that prevent them from
acting as the eyes and ears of the FAA with the singular goal of ensuring the safety of the flying
public. The current structure of the Organization Designation Authorization (ODA) program makes
that difficult. It creates inherent conflicts-of-interest and too often, as this report has revealed,
hinders ARs from consistently representing the interests of the FAA. Boeing’s corporate interests
often influence the actions of ARs and present barriers to enhancing aviation safety for the benefit
of the flying public. These ARs need to have, and know they have, wide latitude and clear channels
of communication with the FAA so that they can raise safety concerns and work in concert with the
FAA to help address these concerns together. This report has shown that this is not currently the
case.
In November 2016, at the height of the 737 MAX development process, Boeing conducted
an internal survey of its ARs regarding “undue pressure.” The results showed that 97 percent of
those surveyed said they understood the process for reporting “undue pressure,” and 90 percent felt
comfortable raising issues of “undue pressure” with their management. However, the results also
clearly pointed to significant problems with the current ODA structure. In the survey, for example,
39 percent of those responding said they had experienced “undue pressure” and 29 percent were
“concerned about consequences” if they reported acts of “undue pressure.” In addition, 80 percent
of those who said they had experienced undue pressure reported having experienced it on more than
one occasion. 1355
Session, December 11, 2019, p. 14, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
1355 Boeing presentation, “Undue Pressure: Key Learnings and Next Steps,” The Boeing Company, November 2016,
233
The FAA’s own internal survey of its “safety culture” was also troubling. A recent internal
survey of FAA employees in the Aviation Safety Organization (AVS) 1356 conducted in November
and December 2019, found that 54 percent of FAA employees in the Aircraft Certification Service
(AIR)—a part of AVS—said the FAA does not appropriately delegate certification activities to
external FAA designees. 1357 The survey found 43 percent of AVS-wide respondents felt the same
way. 1358 In addition, 56 percent of AIR employees believed there was too much external influence on
the agency and that it was having an impact on safety. 1359 Another 49 percent of all AVS-wide
respondents said they believed “safety concerns/incidents” will not be addressed by the agency. 1360
Additionally, nearly half of the survey respondents “disagreed that FAA makes data-driven
decisions about safety regardless of external pressure,” 1361 (emphasis in original).
The agency’s waning safety culture stands as a significant barrier to its capacity to learn
lessons from the MAX tragedies and make fundamental organizational improvements. This safety
culture survey demands close scrutiny and inspection by FAA’s top leaders. It mirrors many of the
Committee’s findings and raises serious questions about the agency’s ability to fulfill its safety
mission. According to the FAA’s survey, a key takeaway is that “AVS senior leadership’s response to
and management of industry pressure is at the heart of the organization’s core safety culture
challenges: lack of trust, inconsistent accountability, FAA role confusion, and the perception that
AVS is moving further away from its safety mission.” 1362
FAA’s Cooperation with the Committee
Chair DeFazio and Subcommittee on Aviation Chair Larsen originally wrote to the FAA on
April 1, 2019, with a records request relating to the design, development, and certification of the 737
MAX, and related issues. 1363 The request sought 13 separate categories of information. Since then,
the FAA has provided the Committee with more than 42,000 pages of records. While this is
significant, the Committee has received nearly 550,000 pages of records from Boeing, for
comparison.
The FAA records provided by DOT have been extremely important to the Committee’s
investigation. However, as was noted in the Executive Summary to this report, DOT’s production
of records has been inexplicably slow and is seemingly incomplete. The DOT has yet to
communicate to the Committee its progress toward a full and complete response to the
Committee’s records request. Rather, the DOT has repeatedly and consistently refused to provide
1356 See “Safety Culture Assessment Report,” Federal Aviation Administration, Aviation Safety Organization (AVS),
prepared by The MITRE Corporation, (DRAFT) February 28, 2020, (hereafter referred to as “FAA Safety Culture
Assessment Report”) (On file with the Committee), and “Safety Culture Survey Findings,” Federal Aviation
Administration, Aviation Safety Organization (AVS), prepared by The MITRE Corporation, February 28, 2020,
(hereafter referred to as “FAA Safety Culture Survey Findings”) (On file with the Committee).
1357 “FAA Safety Culture Survey Findings,” pp. 8 and 85.
1358 Ibid., p. 85.
1359 Ibid., p. 44.
1360 Ibid., p. 23.
1361 FAA Safety Culture Assessment Report, p. 32.
1362 Ibid., p. 7.
1363 “As Part of Investigation into Boeing 737 MAX Certification Process, Committee Sends Records Requests to FAA,
Boeing,” Press Release, Committee on Transportation and Infrastructure, April 1, 2019, accessed here:
https://transportation.house.gov/news/press-releases/as-part-of-investigation-into-boeing-737-max-certification-
process-committee-sends-records-requests-to-faa-boeing
234
updates on the status of this and related requests. 1364 As previously noted in this report, the DOT’s
actions in its response to oversight requests have frustrated Committees and Chairs in both houses
of Congress who have experienced remarkably similar situations. 1365
The DOT’s lack of full and thorough cooperation with the Committee regarding its
investigation of the 737 MAX inevitably raises questions about whether DOT will take the steps
necessary to renew FAA’s focus on safety, be transparent about these steps with the public, and
recommit to improving its oversight of Boeing. This report concludes the bulk of the Committee’s
work on the 737 MAX investigation. However, if the Committee becomes aware of additional issues
that warrant follow-up based on new records it receives from the FAA, DOT, or others, the
Committee will take those issues seriously and pursue them as warranted.
Time for a Culture Change
Both Boeing and the FAA share responsibility for the development and ultimate certification
of an aircraft that was unsafe. Both must learn critical lessons from these tragic accidents to improve
the certification process, and the FAA must dramatically amplify and improve its oversight of
Boeing. While the changes that the FAA and Boeing have proposed will be the start of a long
process, changing the fundamental cultural issues that led to an environment that permitted Boeing
to build, and FAA to certify, a technologically faulty aircraft will take much longer.
At the Committee’s December 2019 hearing on the MAX, Dr. Mica Endsley, a human
factors expert and former Chief Scientist of the U.S. Air Force noted the importance of cultural
changes at both the FAA and Boeing:
There has been considerable discussion here today and also

previously in the press about concerns about safety culture at both
Boeing and the FAA that sort of underlie a lot of the failures we saw
in good process and ended up being in good design.
1364 In June 2019, DOT/FAA informed the House Committee on Transportation and Infrastructure that, regarding the
Committee’s investigation of the 737 MAX, it had between 92,265 and 592,915 potentially responsive emails to just a
few of the Committee’s April 1, 2019, records requests. The FAA acknowledged it had 592,915 emails with the term
“MCAS” or “AOA Sensors,” for instance, between March 2014 and April 25, 2019. This included 338,074 emails with
the terms “MCAS” or “AOA Sensors” and the terms “development” or “testing” or “fielding” or “certification.” For
the period between March 2014 and October 29, 2018, the number of emails that the FAA identified with the term
“MCAS” or “AOA Sensors” was 234,425. In relation to the terms “MCAS” or “AOA Sensors” and the terms
“development” or “testing” or “fielding” or “certification,” for that same time period, the FAA had identified 92,265
emails. See: “FAA Responses to Follow-Up Questions from House T&I Staff,” June 7, 2019, BATES Number FAA-
T&I-000192. In addition, in November 2019, in order to help DOT manage the scope of the Committee’s requests and
at the specific suggestion of DOT, the Committee provided DOT with a list of 13 specific searches of 27 current and
former FAA officials. The Committee has received several productions of records related to this request. However,
DOT has been unable or unwilling to inform the Committee which of these 13 searches have been performed or
completed or which of the 27 individuals’ records have been searched. The Committee remains unaware of the status of
its records requests to FAA regarding the 737 MAX despite repeated requests to DOT about this issue.
1365 Prepared Statement, Chairman Roger Wicker, Hearing titled: “Examining the Federal Aviation Administration’s
Oversight of Aircraft Certification,” Senate Committee on Commerce, Science & Transportation, June 17, 2020,
accessed here: https://www.commerce.senate.gov/2020/6/examining-the-federal-aviation-administration-s-oversight-
of-aircraft-certification
235
The FAA Administrator and Boeing have made a number of
announcements of things they are going to do to try to fix that, and
we? are glad to see that, but changing culture is really hard. You can’t
just give a one-shot and it is done. It is something you have to do
every day.
It has a lot more to do with actions than with words, and so, the
importance of really following up on those actions of taking safety
issues very seriously, of reprioritizing safety with regard to
production and cost in schedule, those changes are going to require a
lot of continued interaction by management…. 1366
Do Things Right and Do the Right Thing
One of the fundamental canons for engineers is that they hold paramount the safety, health,
and welfare of the public. 1367 Or as Texas State University Engineering Professor Karl Stephan says,
“A good engineer both does things right, and does the right thing.” 1368 In the case of the 737 MAX,
unfortunately, Boeing failed to meet both criteria. It did not do things “right” when it designed
MCAS, for instance. It failed to build in essential redundancies by permitting MCAS to rely on a
single AOA sensor. It allowed MCAS to activate repetitively, although at least one Boeing engineer
had raised concerns about that capability. And it did not appropriately address the question of faulty
AOA data and the negative implications for MCAS because a Boeing engineer falsely assumed that
MCAS would not allow that to happen and “shut down.” That did not happen in either of the MAX
crashes.
Furthermore, Boeing did not do the “right thing” when it removed references to MCAS
from the pilot’s Flight Crew Operations Manual (FCOM). Without question, it was not right for
Boeing to fail to share with the FAA Boeing’s own test data showing that it had taken a test pilot
more than 10 seconds to respond to uncommanded MCAS activation, and the test pilot believed the
condition was “catastrophic[.]” Nor did Boeing do the “right thing” when it became aware that the
AOA Disagree alert was not functioning on more than 80 percent of the 737 MAX fleet and then
failed to alert the FAA, its customers, and MAX pilots while it continued to both manufacture and
deliver an estimated 200 airplanes with this known nonfunctional component.
In the weeks after the Lion Air crash, Boeing defended its development and certification of
MCAS to the FAA, writing that there was “no process violation or non-compliance” regarding the
inconsistencies in the system’s development and Boeing’s actions, including (1) removing reference
to MCAS from the FCOM, (2) determining “repeated unintended MCAS” activation to be no worse
than a single unintended activation, (3) determining the loss of one AOA sensor followed by
erroneous readings from the other AOA sensor to be extremely remote and not analyzing this
Session, December 11, 2019, pp. 149-150, accessed here: https://www.govinfo.gov/content/pkg/CHRG-
1367 “Code of Ethics for Engineers,” National Society of Professional Engineers, accessed here:
https://www.nspe.org/sites/default/files/resources/pdfs/Ethics/CodeofEthics/NSPECodeofEthicsforEngineers.pdf
1368 Karl Stephan, “About the Engineering Ethics Blog” Engineering Ethics Blog, accessed here:
http://engineeringethicsblog.blogspot.com/p/about-engineering-ethics-blog.html
236
scenario in its failure assessments, and (4) not reassessing failure analyses following the MCAS
design change. 1369
The FAA’s own draft review of MCAS in the wake of the Lion Air crash also found no
“non-compliances” with FAA regulations on the part of Boeing. 1370 The fact that multiple technical
design missteps or certification blunders were deemed compliant by the FAA points to a critical
need for legislative and regulatory reforms. 1371 That Boeing was able to show that its new transport
category commercial aircraft met the FAA’s certification criteria, yet was involved in two fatal
crashes within the span of just two years and two days after the FAA granted certification, is
disconcerting. The FAA’s aviation oversight system failed in dramatic fashion. This sentiment is
underscored by Tommaso Sgobba, Executive Director of the International Association for the
Advancement of Space Safety (IAASS), who recently observed: “The Boeing B-737 MAX accidents
represent a major failure of the aviation regulatory system….” 1372
Indeed, producing a compliant aircraft that proved unsafe should have been an immediate
wake-up call to both Boeing and the FAA that the current regulatory system that certified the MAX
is broken. Unfortunately, serious questions remain as to whether Boeing and the FAA have fully and
correctly learned the lessons from the MAX failures.
The Once Great Engineering Firm
The beginning of this report quoted Harry Stonecipher, the Chief Executive Officer of
McDonnell Douglas who became the President and Chief Operating Officer of Boeing, who in 2004
told the Chicago Tribune: “When people say I changed the culture of Boeing, that was the intent, so
it’s run like a business rather than a great engineering firm.” It is unfortunate that many current and
former Boeing employees the Committee has spoken to during this investigation believe Boeing has
succeeded in meeting that goal. They understand they once worked for a great engineering firm, and
many hope that they will again in the future. But they realize this will happen only if Boeing begins
to refocus its engineering expertise on building great, safe aircraft, and that this endeavor will be a
long-term challenge.
1369 Boeing letter to FAA, “Subject: Submittal of MCAS Development and Certification Overview,” RA-19-00256,
March 1, 2019, TBC-T&I 130073–130074, 130075–130117, at pp. 178-179, 180-201 accessed here:
1370 See “737-8 MAX Maneuvering Characteristics Augmentation System Oversight Report,” Prepared by: FAA AIR-860
p. 8, 12 (Draft). (Reviewed remotely “in camera” via access to FAA website by Committee Staff on May 1, 2020.) and
DOT Office of Inspector General, “Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8
Aircraft and Actions Taken After the October 2018 Lion Air Accident,” Report No. AV2020037, June 29, 2020, pp. 32-
233, accessed here:
p. 8, 12 (Draft). (Reviewed remotely “in camera” via access to FAA website by Committee Staff on May 1, 2020.)
1372 Tommaso Sgobba, “B-737 MAX and the crash of the regulatory system,” Journal of Space Safety Engineering, Volume 6,
Issue 4, December 2019, Pages 299-303, accessed here:

https://www.sciencedirect.com/science/article/abs/pii/S246889671930093X
237
This report’s main investigative findings point to a company culture that is in serious need of
a safety reset. Boeing has gone from being a great engineering company to being a big business
focused on financial success. Continuing on the same path it followed with the 737 MAX, where
safety was sacrificed to production pressures, exposes the company to potentially repeating those
mistakes and to additional reputational damage and financial losses. One of the first steps on a new
path is understanding and acknowledging the problems that did occur, the technical mistakes that
were made, and the management missteps that led to the 737 MAX tragedies and the preventable
death of 346 people.
However, the Committee’s investigation leaves open the question of Boeing’s willingness to
admit to and learn from the company’s mistakes. In a transcribed interview with Committee staff,
Keith Leverkuhn, the former senior-most official on Boeing’s 737 MAX program, who is now Vice
President of Supply Chain Propulsion for Boeing Commercial Airplanes, appeared unable or
unwilling to either take responsibility for any of the problems that occurred on the MAX program or
to even acknowledge that any problems existed at all.
T&I Committee staff: In light of the two crashes and the fact that
the MAX has been grounded for more than a year, would you
consider the development of the MAX a success?
Mr. Leverkuhn: Yes, I would. ….
…. I do challenge the suggestion that the development [of the 737

MAX] was a failure. 1373
Several weeks before this report was finalized, multiple news stories suggested that Boeing
was endeavoring to change the name of the 737 MAX to the 737-8 in an effort to combat the
indelible image problems now surrounding the aircraft. 1374 If the Committee’s investigation offers
any lessons for Boeing, it is that a name change and a public relations effort will not address the
cultural issues at Boeing that hampered the safety of the 737 MAX in the first place and ultimately
led to two fatal accidents and the death of 346 people. A name change may help confront a public
relations problem, but only a genuine, holistic, and assertive commitment to changing the cultural
issues unearthed in the Committee’s investigation at both Boeing and the FAA can enhance aviation
safety and truly help both Boeing and the FAA learn from the dire lessons of the 737 MAX
tragedies.

1374 See: Chris Woodyard, “Boeing may be tackling 737 Max's PR problem with a new name,” USA Today, August 19,
2020, accessed here: https://www.usatoday.com/story/news/2020/08/19/boeing-737-max-jetliners-appears-getting-

new-name/5612691002; David Slotnick, “Boeing may be dropping the 'Max' from the name of its troubled jet, calling
the latest version the 737-8,” Business Insider, August 19, 2020, accessed here: https://www.businessinsider.com/boeing-
737-max-name-change-rebrand-2020-8 and Dan Reed, “MAX No More? For Some Reason Boeing Won’t Admit It, But
It’s Changing The Name Of Its New Generation Of 737s,” Forbes, August 24, 2020, accessed here:
https://www.forbes.com/sites/danielreed/2020/08/24/max-no-more-for-some-reason-boeing-wont-admit-it-but-its-
changing-the-name-of-its-new-generation-of-737s/#20dc4753619b
238

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What is the purpose of the report?

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What were some of the investigative findings of the report regarding the Boeing 737 MAX crashes?

What were some of the investigative findings of the report regarding the Boeing 737 MAX crashes?

F I N AL C O M M I T T E E R E P O R T

THE DESIGN, DEVELOPMENT & CERTIFICATION OF THE

BOEING 737 MAX

CHAIR OF THE COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE

CHAIR OF THE SUBCOMMITTEE ON AVIATION

3. Boeing History and 737 MAX Background 34

4. FAA Oversight and Delegation of Authority 56

5. Maneuvering Characteristics Augmentation System 85

6. AOA Disagree Alert 122

7. Boeing 737 MAX Pilot Training 138

8. Production Pressure 163

9. Post-Accident Response 189

10. New Issues Emerge 222

11. Final Observations 228

Figures Maneuvering Characteristics Augmentation System (MCAS)

Angle of Attack (AOA) Disagree Alert – Timeline 129

Related Documents Transcripts of the transcribed interviews and other

• Keith Leverkuhn served as Vice President (VP) and

• Michael Teal served as Vice President and 737 Chief

• Mark Forkner served as 737 Technical Pilot from 2011

• Elizabeth “Beth” Pasztor served as Vice President (VP)

Abbreviations 737 NG Boeing 737 Next Generation Airplane

2017, accessed here:

2017, accessed here:

Max 8 planes,” CNN, November 1, 2018, accessed here: https://www.cnn.com/2018/10/30/asia/lion-air-plane-crash-

November 3, 2018, accessed here: https://www.abc.net.au/news/2018-11-03/indonesian-rescue-diver-dies-in-lion-air-

Representatives, accessed here: https://transportation.house.gov/committee-activity/boeing-737-max-investigation

Commercial Airplanes. He retired from Boeing this year.

-The MAX Crashes-

23, 2018, accessed here: https://www.reuters.com/article/us-ethiopia-airlines-africa/ethiopian-airlines-steps-up-hunt-

18, 2019, accessed here: https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-

accessed here: https://aviation-

accessed here: https://boeing.mediaroom.com/2011-11-17-Boeing-Lion-Air-Announce-Historic-Commitment-for-up-

accessed here: https://www.usatoday.com/story/news/2019/10/07/ethiopian-airlines-whistleblower-alleges-

18, 2019, accessed here: https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-

On It,” New York Times, March 20, 2019, accessed here:

These crashes are demonstrable evidence that our current system of

https://www.nytimes.com/2009/01/16/nyregion/16crash.html and Hearing titled, “Status of the Boeing 737 MAX:

Administration, August 2, 2018, accessed here: https://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=22975;

Times, March 15, 2019, accessed here: https://www.latimes.com/local/california/la-fi-boeing-max-design-20190315-

Today, April 7, 2019, accessed here: https://www.usatoday.com/story/travel/flights/2019/04/06/boeing-737-max-8-

New York Times, January 29, 2020, accessed here: https://www.nytimes.com/2020/01/05/business/boeing-737-

2) Faulty Design and Performance Assumptions. Boeing made fundamentally faulty

accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf

accessed here: https://www.bloomberg.com/news/articles/2020-02-21/boeing-failure-to-fix-737-max-cockpit-light-

68 JATR Report p.14, accessed here:

 Excessive FAA delegation to Boeing has eroded FAA’s oversight capabilities.

 Boeing’s Authorized Representatives (ARs) may be impaired from acting independently.

76 T&I Committee Press Release, November 7, 2019, accessed here: https://transportation.house.gov/news/press-

Boeing Production Pressure – Costs, schedule, and production pressures at Boeing

011072 - 011073 (On file with the Committee).

2018 1:32 PM.

Maneuvering Characteristics Augmentation System (MCAS) – Boeing failed to

T&I 010920, TBC-T&I 010926, accessed at p. 119 here: https://www.govinfo.gov/content/pkg/CHRG-