The US government’s House Transportation and Infrastructure Committee Democratic has blasted both Boeing and the FAA in a 250-page final report which lists a catalogue of errors within the development of the Boeing 737 MAX.

The publication of the report follows an 18-month long investigation by the committee. The 737 MAX has been grounded since March 2019 after two fatal crashes which killed 346 people.

The report lists failures in both the plane’s design and the government approval of the aircraft. The Committee found that: “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.”

Culmination of errors and assumptions

The review said the crashes and resulting loss of life were caused by the culmination of these errors and assumptions coupled with insufficient oversight from regulators. It added that the 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.”

A statement by Boeing said it had “learned many hard lessons as a company from the accidents… and from the mistakes we have made. As this report recognizes, we have made fundamental changes to our company as a result, and continue to look for ways to improve.”

FAA pledges to improve organisational processes and culture

The FAA also pledged to implement improvements identified in the report. It said it was: “focused on advancing overall aviation safety by improving our organisation, processes, and culture.”

The report outlined “faulty design and performance assumptions” which were made by Boeing, particularly in relation to an air safety software system called MCAS, which was identified as a contributing factor in both the Lion Air and Ethiopian Airlines crashes. The system, which was designed to help counter a tendency of the MAX to pitch up, was found to activate after data from only a single sensor.

The report added that Boeing had withheld “crucial information from the FAA, its customers, and 737 MAX pilots” which had also included “concealing the very existence of MCAS from 737 MAX pilots.”

The FAA has required new safeguards to be implemented to the MCAS system, including the requirement of it to receive data from two sensors, before allowing the MAX to return to service.

Boeing failed to disclose existence of MCAS in crew manuals

The report said the safety of the aircraft had been compromised through Boeing employees being granted permission to represent interests of the FAA. It added that the manufacturer had “failed to disclose important information to the FAA that could have enhanced the safety of the 737 MAX.”

Boeing did not disclose the existence of the MCAS system within its crew manuals and sought to convince regulators not to require more expensive simulator training for MAX pilots. Boeing has since agreed to back simulator training before pilots resume flights in the MAX.

The report added that the FAA had “failed to ensure the safety of the travelling public.”

“Tragedy that never should have happened”

Publication of the report has led to a number of proposed reforms which will restructure how the FAA oversees aircraft certification. A Senate committee will take up a reform bill today. The committee has suggested Boeing was wanted to cut costs to get the 737 MAX to market quickly.

House Transportation Committee chairman Peter DeFazio said: “This is a tragedy that never should have happened. We’re going to take steps in our legislation to see that it never happens again as we reform the system.”

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