FINAL COMMITTEE REPORT

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 MAXContents

i

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
-FINAL COMMITTEE REPORT: BOEING 737 MAXContents

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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
-FINAL COMMITTEE REPORT: BOEING 737 MAXContents

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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

Angle of Attack (AOA) Disagree Alert – Timeline

100

129

Related Documents Transcripts of the transcribed interviews and other 

documents referenced in this report can be accessed here: 

https://transportation.house.gov/committeeactivity/boeing-737-max-investigation
-FINAL COMMITTEE REPORT: BOEING 737 MAXContents

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References to Senior 

Boeing Officials

During design, development, and certification of the 737 

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

AAR

ACO

AD

AEG

AFSCME

AIA

AIR

AR

APA

ATC

ATP

AVS

BASOO

Boeing 737 Next Generation Airplane

Airplane Assessment Report

Aircraft Certification Office

Airworthiness Directive

Aircraft Evaluation Group

American Federation of State, County and Municipal 

Employees

Aerospace Industries Association

Aircraft Certification Service

Authorized Representative

Allied Pilots Association

Amended Type Certificate

Airline Transport Pilot

Aviation Safety Organization

Boeing Aviation Safety Oversight Office
-FINAL COMMITTEE REPORT: BOEING 737 MAXContents

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BCA

CARB

CAS

CBT

CEO

DER

DOT

DR

EASA

EBAW

ECS

EDFCS

EICAS

EU

FAA

FBW

FCC

FCOM

FSB

FTD

GAO

GM

IEEE

IPT

ISS

JATR

LAM

LGW

MCAS

MOM

NASA

NATCA

NNC

NTSB

ODA

OIG

OMB

PASS

PSSA

QFR

RCAS

R-TARA

SCD

SME

SSA

STC

STS

Boeing Commercial Airplanes

Corrective Action Review Board

Commercial Aviation Services

Computer Based Training

Chief Executive Officer

Designated Engineering Representative

Department of Transportation

Deficiency Report

European Union Aviation Safety Agency

Enhanced Bank Angle Warning

Environmental Control System

Enhanced Digital Flight Control System

Engine Indicating and Crew Alerting System

European Union

Federal Aviation Administration

Fly-by-wire

Flight Control Computer

Flight Crew Operations Manual

Flight Standardization Board

Fleet Team Digest

Government Accountability Office

General Manager

Institute of Electrical and Electronics Engineers

Integrated Product Team

International Space Station

Joint Authorities Technical Review

Landing Attitude Modifier

London Gatwick Airport

Maneuvering Characteristics Augmentation System

Multi Operator Message

National Aeronautics and Space Administration

National Air Traffic Controllers Association

Non-normal Checklist

National Transportation Safety Board

Organization Designation Authorization

Office of Inspector General

Operations Manual Bulletin

Professional Aviation Safety Specialists

Preliminary System Safety Assessment

Questions for the Record

Roll Command Alerting System

Random Transport Airplane Risk Analysis

Specification Control Drawing

Subject Matter Expert

System Description and Safety Analysis

Supplemental Type Certificate

Speed Trim System
-FINAL COMMITTEE REPORT: BOEING 737 MAXContents

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SWA

TARAM

TCBI

TIA

VP

Southwest Airlines

Transport Airplane Risk Assessment Methodology

Tutorial Computer-Based Instruction

Type Inspection Authorization

Vice President
1. Introduction
-FINAL COMMITTEE REPORT: BOEING 737 MAX1. Introduction

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-IntroductionOn 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 fuelefficient 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. 
-FINAL COMMITTEE REPORT: BOEING 737 MAX1. Introduction

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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. 
2. Executive Summary
-FINAL COMMITTEE REPORT: BOEING 737 MAX2. Executive Summary

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-Executive SummaryTechnical 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 airplane4 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-jetcrash

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

5 “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

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: 

https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/$FI

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-crashintl/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 
-FINAL COMMITTEE REPORT: BOEING 737 MAX2. Executive Summary

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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.betterthan.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-airjet-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/ET302%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-maxcertification-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. 
-FINAL COMMITTEE REPORT: BOEING 737 MAX2. Executive Summary

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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 CrashesEthiopian 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-huntfor-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-maxcrashes.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://aviationsafety.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://aviationsafety.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-upto-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 
-FINAL COMMITTEE REPORT: BOEING 737 MAX2. Executive Summary

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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) sensors28 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 stabilizer33 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 deck35 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-attackvane

29 Ibid.

30 “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” pp. 36, 174, accessed here: https://aviationis.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-repairfirm-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-moderncommercialairplanes#:~: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://aviationis.better-than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 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: 
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9

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 nosehttps://aviation.stackexchange.com/questions/66094/cockpit-vs-flightdeck#:~: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.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 39 Ibid., pp. 19-28, accessed here: https://aviation-is.better-than.tv/737%20MAX%202018%20-%20035%20-%20PKLQP%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/wpcontent/uploads/2020/documents/accident/ET302%20%20Interim%20Investigation%20%20Report%20March%209%202020.pdf 43 Ibid. 
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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-yearold 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 

simulator50—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.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 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-allegescorruption-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-maxcrashes.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.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 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/wpcontent/uploads/2020/documents/accident/ET302%20%20Interim%20Investigation%20%20Report%20March%209%202020.pdf

52 Ibid. 
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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-
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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 service59 —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 ThemesThe 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-lastmajor-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-maxupdate-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/boeing737-max-crash.html
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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 pilots63 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/boeingsceo-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-lightmay-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-BBBA8-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
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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-committeesongoing-investigation-into-the-certification-of-the-737-max-chairs-defazio-and-larsen-raise-new-and-serious-concernsto-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).
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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 FindingsListed 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: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

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).
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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/pressreleases/amid-committees-ongoing-investigation-into-the-certification-of-the-737-max-chairs-defazio-and-larsen-raisenew-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.
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 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-maxcertification-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/boeingaerospace/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).
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 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 MAX89 and rehired retired Boeing employees 

84 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, 

October 2, 2019 (Updated October 3, 2019), accessed here: https://www.seattletimes.com/business/boeingaerospace/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: 

https://transportation.house.gov/committee-activity/boeing-737-max-investigation 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/CHRG116hhrg40697/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
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19

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-withproduction-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 TBCT&I 010920, TBC-T&I 010926, accessed at p. 119 here: https://www.govinfo.gov/content/pkg/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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/CHRG116hhrg38282.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-maxexamining-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: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf
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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 

here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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-divergentcondition-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-asoftware-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
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 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.betterthan.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/wpcontent/uploads/2020/documents/accident/ET302%20%20Interim%20Investigation%20%20Report%20March%209%202020.pdf 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.betterthan.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/wpcontent/uploads/2020/documents/accident/ET302%20%20Interim%20Investigation%20%20Report%20March%209%202020.pdf 111 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. 
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 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-tofix-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).
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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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 122 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-lightmay-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).
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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-clausefor-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-22E3-41F5-84EFB3EDAB030B07}

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
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 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. AeroB-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/CHRG116hhrg38282/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 

T&I 129776 - TBC T&I 129782 at TBC T&I 129782 (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 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: 

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

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 132 Ibid. 133 Ibid. 134 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.
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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: 

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

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

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf
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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): 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf

144 Boeing internal instant message, December 12, 2017, at p. 87, accessed here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

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/CHRG116hhrg38282.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/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf
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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/CHRG116hhrg38282.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://aviationis.better-than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 154 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-lightmay-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/CHRG116hhrg38282.pdf
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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-DEFAZIO000028836, 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/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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-nocurrent-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/CHRG116hhrg37277.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/boeing737-max-investigation
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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, 

162 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, at p. 22, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG116hhrg38282.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 
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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 FAAT&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-oversightof-aircraft-certification 171 “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. 32, accessed here: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf 172 “FAA MCAS Oversight Report (draft).” This document was reviewed remotely by Committee staff on May 1, 2020. 173 Ibid. 174 “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. 32, accessed here: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf

175 FAA MCAS Oversight Report (draft), February 8, 2019. 176 “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 
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32

 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 ConclusionBoeing’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 MCAS179 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.

No. AV2020037, June 29, 2020, p. 32, accessed here: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf 177 Boeing employee email, “MCAS Stab Rapid Reversal on PSIM Model,” December 17, 2015, BATES Number TBCT&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, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 178 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

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
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33

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. 
3. Brief Boeing History 

and 737 MAX 

Background
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35

-Brief Boeing History and 737 MAX BackgroundThe 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 Hippocrates190 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 187 “Biography of William E. Boeing,” The Boeing Company, accessed here: 

https://www.boeing.com/history/pioneers/william-e-boeing.page 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) 189 “Biography of William E. Boeing,” The Boeing Company, accessed here: 

https://www.boeing.com/history/pioneers/william-e-boeing.page 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

191 “Biography of William E. Boeing,” The Boeing Company, accessed here: 

https://www.boeing.com/history/pioneers/william-e-boeing.page 192 Ibid. 193 Ibid. 194 Ibid. 195 “Boeing in Brief,” The Boeing Company, accessed here: https://www.boeing.com/company/general-info/
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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 Douglas198 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 

Operating Officer of Boeing.201 In 2004 he 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 a great engineering firm, but people 

invest in a company because they want to make 

money.”202 Those sentiments, according to many 

observers and current and former Boeing 

employees, infected the company. They point to 

that philosophy, which focused on financial 

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-yearsbusiness-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 

Harry Stonecipher, former President 

and Chief Operating Officer of 

Boeing (as quoted in the Chicago 

Tribune) February 29, 2004

“WHEN PEOPLE SAY I CHANGED 

THE CULTURE AT BOEING, THAT 

WAS THE INTENT, SO IT’S RUN 

LIKE A BUSINESS RATHER THAN 

A GREAT ENGINEERING FIRM...”
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37

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-justmade-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
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38

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 

Boeing’s 737 NG aircraft. “At the same 

time, while we haven’t made a firm 

decision,” said Albaugh, “I don’t think we 

will re-engine the 737. It’s really hard to 

come up with a compelling business case to 

do that,” he said. “We think the right answer 

[is] to probably do a new small airplane that 

might come out toward the end of this 

decade.” Albaugh added: “Every customer I 

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-fora320-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-standingby

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/boeing737-max-crash.html 213 Ibid. 

James Albaugh 

former Boeing Commercial Airplanes 

Chief Executive Officer 

January 14, 2011

“EVERY CUSTOMER I TALK TO HAS A 

REAL HARD TIME UNDERSTANDING 

WHY A RE-ENGINED AIRPLANE 

MAKES SENSE.”
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39

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 

said it was “pleased to be the first airline to 

commit to Boeing’s new 737 family offering, 

which [was] expected to provide a new level 

of economic efficiency and operational 

performance, pending final confirmation of 

the program by Boeing.”218

The following month, Boeing 

announced its intent to develop a new 

commercial aircraft. In stark contrast to what 

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 singleaisle 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-standingby

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-familyaircraft.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-Launches737-New-Engine-Family-with-Commitments-for-496-Airplanes-from-Five-Airlines 220 Ibid. 221 Ibid.

Boeing Press Release 

August 30, 2011

“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 SINGLEAISLE MARKET.”
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40

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-BoeingLaunches-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-aircraftlike-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-dreamlinerbatteries-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.
-FINAL COMMITTEE REPORT: BOEING 737 MAX3. Brief Boeing History and 737 MAX Background

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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-IranAseman-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-releasesstatements?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-at19bn-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-budgetairlines-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
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42

per day, per airplane237 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-budgetairlines-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: 

https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/$FI

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: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf 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 

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

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
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making it more likely to pitch upward246 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 

246 Ralph Vartabedian, “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

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-divergentcondition-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-maxfixes-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

250 G-1 Issue Paper. 251 G-1 Issue Paper. 252 G-1 Issue Paper. 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/CFR2011-title14-vol1-sec21-101 (The rule was originally issued in 2000 and has been amended several times since then.)
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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 

the change or any areas affected by the change comply with 

all applicable FAA airworthiness requirements.256 There were 

significant changes to the 737 MAX compared to the 737 

NG aircraft. 

In 2012, the FAA raised numerous certificationrelated matters surrounding the 737 MAX. On July 21, 2012, 

for instance, the FAA declared: “[T]he FAA has found that 

the proposed Model 737-8 is a significant product level 

change. Thus, the changed product must comply with the

regulations in effect on the date of application for the 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.

FAA’s G-1 Issue Paper 

on the 737 MAX, 

FAA Position on 

July 21, 2012

“’[T]HE FAA HAS FOUND 

THAT THE PROPOSED 

MODEL 737-8 [MAX 

AIRCRAFT] IS A 

SIGNIFICANT PRODUCT 

LEVEL CHANGE.”
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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 

differences between the 737 MAX and the 

737 NG aircraft. The FAA’s web-page on 

“Airworthiness Certification,” that was last 

modified in December 2019, claimed, for 

instance, “The Boeing 737-8/9 Max design 

had minor changes to the 737 Next 

Generation (NG) design.263 For this reason, 

the FAA issued an Amended Type Certificate 

to the Max airplane, which was based on the 

Type Certificate of the 737NG.”264 Yet, the 

JATR pointed out that changes made under 

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. 262 JATR Report, p. IV. 263 “Airworthiness Certification,” Federal Aviation Administration (FAA), accessed here: 

https://www.faa.gov/aircraft/air_cert/airworthiness_certification 264 Ibid. 265 JATR Report, p. IV. 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-certificationrequirements-for-crew-alerts 267 See G-1 Issue Paper, p. 26 [FAA Position: (February 6, 2014)].

FAA’s G-1 Issue Paper on the 737 MAX, 

FAA Position on July 21, 2012

“BOEING STATED THAT A MAJOR 

REASON FOR NOT STEPPING UP TO 

THE LATEST AMENDMENT IS TO 

MINIMIZE THE IMPACT OF 

CHANGES IN THE FLIGHT DECK 

AND MAINTAIN A COMMON FLIGHT 

DECK PHILOSOPHY WITH THE 737 

FLEET OF AIRPLANES.”
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46

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 

newly certificated transport aircraft. It displays 

aircraft system faults and failures in the cockpit 

and helps pilots prioritize responding to multiple 

or simultaneous indications and alerts, which are 

often accompanied by aural alerts specific to the 

level of severity of a particular fault.

270 But the 

exception from FAA relieved Boeing of the 

requirement that the 737 MAX must be equipped 

with a caution, alert, and advisory system that 

“[p]rovide[s] timely attention-getting cues through 

at least two different senses by a combination of 

aural, visual, or tactile indications” and that 

“[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-pushedfaa-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.

“737 MAX Certification Basis 

Risk Review - EICAS” 

The Boeing Company 

June 14, 2012

“IF WE HAD TO COMPLY 

OUTRIGHT WITH REGULATION: 

CONSIDERABLE PROGRAM COST 

AND SCHEDULE RISK [AND] 

SIGNIFICANT [PILOT TRAINING] 

IMPACT TO OPERATORS WITH A 

FAMILY OF 737S.”
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47

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-toarelax-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-certificationrequirements-for-crew-alerts
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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.
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49

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-finalreport.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-systemicproblems-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. 
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50

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-finalreport.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.”
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51

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 learned302 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 306 Committee staff transcribed interview of Keith Leverkuhn, former Vice President and General Manager of the 737 

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
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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-concerns1450794214
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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-maxdisasters-boeing-had-a-history-of-failing-to-fix-safety-problems/2019/06/26/b4f5f720-86ee-11e9-a870-

b9c411dc4312_story.html

323 Committee staff briefing by the Federal Aviation Administration (FAA), July 12, 2019. 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

325 Committee staff briefing by the Federal Aviation Administration (FAA), July 12, 2019. 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: 

https://www.faa.gov/news/press_releases/news_story.cfm?newsId=19875

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: 

https://www.faa.gov/news/press_releases/news_story.cfm?newsId=19875

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: 

https://www.faa.gov/news/press_releases/news_story.cfm?newsId=19875
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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 

invoke enforcement provisions against Boeing that could 

subject the company to the additional $24 million in penalties.331 

In addition, since Boeing signed the settlement 

agreement with FAA, it has repeated some of the same 

problems that the FAA agreement sought to force the company 

to correct. Last year, for instance, the U.S. Air Force temporarily 

halted deliveries of Boeing’s KC-46 Pegasus tanker twice 

because of foreign object debris found in the aircraft as a result 

of deficiencies in the manufacturing process.332 The KC-46 

tanker is based on the Boeing 767 aircraft. In February 2020, it 

was reported that foreign object debris was also found in the fuel 

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 

331 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-maxdisasters-boeing-had-a-history-of-failing-to-fix-safety-problems/2019/06/26/b4f5f720-86ee-11e9-a870-

b9c411dc4312_story.html

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-deliveriesafter-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-infuel-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).

The Washington Post

June 17, 2019

“[T]OP BOEING 

EMPLOYEES WHO 

WERE SUPPOSED TO 

BE REPRESENTING 

THE FAA AT TIMES 

AGGRESSIVELY 

CHAMPIONED THE 

COMPANY’S 

INTERESTS INSTEAD.”
-FINAL COMMITTEE REPORT: BOEING 737 MAX3. Brief Boeing History and 737 MAX Background

55

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.

335 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-maxdisasters-boeing-had-a-history-of-failing-to-fix-safety-problems/2019/06/26/b4f5f720-86ee-11e9-a870-

b9c411dc4312_story.html 336 “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). 337 Ibid. 338 Ibid.
4. FAA Oversight and 

Delegation of 

Authority
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57

-FAA Oversight and Delegation of AuthorityINVESTIGATIVE 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 safetyrelated 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-

151, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 341 “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).

342 Ibid. 
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58

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/USCODE2011-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-subtitleVIIpartA-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.
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59

Development of Organizational Delegation

 Source: Department of Transportation, Office of Inspector General, Audit Report AV-2016-001349

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 wellunderstood, 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/CHRG116hhrg37277/pdf/CHRG-116hhrg37277.pdf 
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60

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

355 “Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8 Aircraft and Actions Taken After the 

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: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

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
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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/safetyrecord-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-maxdisasters-boeing-had-a-history-of-failing-to-fix-safety-problems/2019/06/26/b4f5f720-86ee-11e9-a870-

b9c411dc4312_story.html

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
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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 riskbased 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.
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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/

375 “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

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 
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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. 

(On file with the Committee). 

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). 
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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:

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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: 

https://www.faa.gov/news/media/attachments/Final_JATR_Submittal_to_FAA_Oct_2019.pdf

390 DOT OIG Report No. AV2020037, p. 3. 391 JATR Report, p. 27. 392 Ibid.
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• “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.
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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 technicalonly 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 Boeingdesignated 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. 402 “Establishment of ODA Program,” 70 FR 59931. 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
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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 

pressure when they are making decisions on 

behalf of the FAA. This review should include 

ensuring the [engineering unit members] have 

open lines of communication to FAA certification 

engineers without fear of punitive action or 

process violation.”409

To its credit, even before that 

recommendation was made, the FAA’s Aviation 

Safety Organization (AVS) had initiated a large 

scale “safety culture survey” that was conducted 

from October 2019 to February 2020. The survey 

was conducted by The MITRE Corporation410 and included all 7,147 AVS members, but only 25 

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

406 “Establishment of ODA Program,” 70 FR 59931. 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 411 FAA Safety Culture Survey. 412 Ibid. 413 Ibid.

Anonymous FAA Employee 

FAA Safety Culture Assessment

(Draft) February 28, 2020

“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.”
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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. 422 JATR Report, p. 28.
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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/boeingaerospace/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: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

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 
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• 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). 429 See: Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. AeroB-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).

430 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).
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72

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: 
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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,” 
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• 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. 

(On file with the Committee).

439 JATR Report, p. 24. 440 DOT OIG Report No. AV2020037, p. 32. 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.
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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 

AR observed that some Boeing groups provided 

great detail on their plans for progressing through 

testing to eventual certification while other groups 

provided no detail at all.445 As a result of these 

differences, the FAA lacked sufficient basis for 

understanding what ARs were approving and had an 

overall incomplete picture of key certification plans. 

“Thus there is no confidence that the FAA is 

understanding what they are accepting (or 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: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf

446 Ibid. 447 FAA Safety Culture Survey. 448 Ibid.

Boeing Authorized Representative 

(AR) Internal Email 

February 25, 2016

“[T]HERE IS NO CONFIDENCE 

THAT THE FAA IS 

UNDERSTANDING WHAT 

THEY ARE ACCEPTING (OR 

REJECTING).” 
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787 Dreamliner Lithium Batteries

In 2011, Boeing’s 787 Dreamliner was certified by the FAA449 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-approvalunder-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-scharger-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-approvalunder-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. 
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“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-boeing737-max-examining-the-federal-aviation-administrations-oversight-of-the-aircrafts-certification 466 Ibid.
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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 

by these new features during the development and 

certification of those airplanes. Neither the lithium 

batteries nor MCAS were considered ‘safety critical’ 

systems and yet they led to safety incidents on the 

787 Dreamliner and two fatal accidents of the 737 

MAX aircraft. As reported by CNN in its analysis 

of NTSB’s November 2014 report on the 787 

Dreamliner battery incidents, “any new piece of 

equipment can pose dangerous problems, even a 

noncritical piece of equipment like batteries.”467 The 

combination of problems, identified by the NTSB 

in the 787 Dreamliner battery incidents and the 

issues identified by the Committee’s investigation of 

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

Anonymous FAA Employee 

FAA Safety Culture Assessment 

Report (Draft) February 28, 2020

“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.”
-FINAL COMMITTEE REPORT: BOEING 737 MAX4. FAA Oversight and Delegation of Authority 

79

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:

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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 
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80

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/CHRG116hhrg38282.pdf

476 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-boeing737-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/CHRG116hhrg38282.pdf

477 Ibid. 478 Ibid. 479 Ibid. 480 Ibid. 481 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-boeing737-max-examining-the-federal-aviation-administrations-oversight-of-the-aircrafts-certification 482 Ibid.
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81

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 

fuel tank lightning protection.

Because the 787 Dreamliner consists of more 

than 50 percent carbon fiber composites that are not 

inherently conductive, it is at greater risk to damage 

from lightning strikes compared to other aircraft.483 To 

mitigate this risk, Boeing designed and initially 

produced aircraft with copper foil on a portion of the 

wing. The foil served to rapidly dissipate excessive 

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-objectedto-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/CHRG116hhrg38282.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

FAA Employee 

Internal FAA Email 

June 14, 2019

“THIS IS CLEARLY A 

CONTENTIOUS ISSUE AND 

BOEING IS RUSHING THE 

CERTIFICATION SO THEY 

CAN DELIVER AIPLANES.” 
-FINAL COMMITTEE REPORT: BOEING 737 MAX4. FAA Oversight and Delegation of Authority 

82

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 safetyrelated 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. 
-FINAL COMMITTEE REPORT: BOEING 737 MAX4. FAA Oversight and Delegation of Authority 

83

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 

497 “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, accessed here: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf

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,” GAO20-642, Government Accountability Office (GAO), August 18, 2020, accessed here: 

https://www.gao.gov/assets/710/708877.pdf

501 Ibid., p. 19. 
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84

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).
5. Maneuvering 

Characteristics 

Augmentation 

System (MCAS)
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-Maneuvering Characteristics Augmentation System (MCAS)-

INVESTIGATIVE FINDINGS

 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 

data511 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: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf and Boeing ITRACS Item, “MCAS/Speed Trim,” 37MAXFCI-PDR AI22, BATES Number TBC T&I 549172-

549173. (On file with the Committee). 510 Boeing employee email, “MCAS Stab Rapid Reversal on PSIM Model,” December 17, 2015, BATES Number TBCT&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, 

accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 511 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 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). 515 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 (BCA), May 11, 2020.

516 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-BBBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June 11, 2018, accessed at p. 170 here: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf
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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,” 

Committee on Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, 

October 30, 2019, pp. 163-164 and 173-174, accessed here: https://www.govinfo.gov/content/pkg/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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. 522 Ralph Vartabedian, “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

523 Ibid. 524 Ibid. 525 Ibid. 526 Ibid. 
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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 

fall out of the sky absent 

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-tomake-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/timeswatchdog/the-inside-story-of-mcas-how-boeings-737-max-system-gained-power-and-lost-safeguards 532 Ibid. 

Source: “What is Angle of Attack?” AERO Magazine,

The Boeing Company, October 2000.
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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

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/CFR2011-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/timeswatchdog/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/timeswatchdog/the-inside-story-of-mcas-how-boeings-737-max-system-gained-power-and-lost-safeguards

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).
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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, thenBoeing 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); 

PKLQP, Tanjung Karawang, West Java, Republic of Indonesia, 29 October 2018,” Komite Nasional Keselamatan 

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.betterthan.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/ET302%20%20Interim%20Investigation%20%20Report%20March%209%202020.pdf

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-maxfaa/index.html

539 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, pp. 119-120, accessed here: https://www.govinfo.gov/content/pkg/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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.
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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-softwaredeveloper

548 T&I Democratic staff email exchange with Gregory Travis, April 20, 2020. 
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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: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

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/CHRG116hhrg38282/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/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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: 

https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/83ec7f95f3e5bfbd8625833e0070a070/$FILE/2018-

23-51_Emergency.pdf. Boeing finally issued a Multi Operator Message (MOM) to 737 fleet operators regarding MCAS 
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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, 

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

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf

556 Ibid. at pp. 32-33. 557 Internal Boeing email, “PRG – 37MAXFCI-PDR_AI22 – MCAS/Speed Trim,” June 7, 2013, 9:10 PM, accessed at p. 

93 here:

558 Internal Boeing email, “PRG – 37MAXFCI-PDR_AI22 – MCAS/Speed Trim,” June 7, 2013, 9:10 PM, accessed at p. 

93 here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf

559 Ibid. 560 Ibid. 561 Boeing ITRACS Item, “MCAS/Speed Trim,” 37MAXFCI-PDR AI22, BATES Number TBC T&I 549172-549173. 

(On file with the Committee).

562 Internal Boeing email, “PRG – 37MAXFCI-PDR_AI22 – MCAS/Speed Trim,” June 7, 2013, 9:10 PM, accessed at p. 

93 here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf
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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 preexisting 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.

563 Boeing ITRACS Item, “MCAS/Speed Trim,” 37MAXFCI-PDR AI22, BATES Number TBC T&I 549172-549173. 

(On file with the Committee).

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/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf
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May/June 2013 

MCAS/Speed Trim - Strategy Meeting Data
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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.
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trade573 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. 579 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-BBBA8-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 580 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. 98, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG116hhrg38282.pdf

581 Ibid at p. 97.
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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/boeingsceo-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.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 584 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. 34, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG116hhrg38282.pdf

585 Email from Mark Forkner to FAA, “MCAS Lives in Both FCCs,” Mar. 30, 2016.
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Maneuvering Characteristics Augmentation System (MCAS) – Timeline

November 1, 2012 November 8, 2102 May 4, 2103

A Boeing test pilot takes more than 

10 seconds to respond to 

uncommanded MCAS activation in 

a flight simulator and finds the 

condition “catastrophic.” Boeing 

repeatedly referred to that test data 

in internal documents but never 

relayed that information to the FAA 

or to MAX pilots because there was 

no specific requirement to share it.

A Boeing Preliminary Design 

Decision Memo shows plans for an 

MCAS annunciator on the flight 

deck of the 737 MAX to indicate if 

MCAS fails to activate. However, 

the annunciator was not ultimately 

included on the aircraft.

Michael Teal, former Chief Project 

Engineer on the 737 MAX program, 

sends an email to senior Boeing 

managers indicating “concerns” 

about the addition of MCAS to the 

flight controls system and its impact 

on Boeing’s ability to obtain Level B 

(non-simulator) pilot differences 

training for 737 MAX pilots.

May-June 2013 July 8, 2015 December 17, 2015

Boeing employees devised a strategy 

on June 7, 2013, to treat MCAS as an 

“addition to Speed Trim” to help 

prevent increased “cost” due to 

changed manuals. The strategy, 

approved by a Boeing Authorized 

Representative (AR), is outlined in an 

email, saying: “If we emphasize 

MCAS is a new function there may 

be greater certification and training 

impact.”

Boeing notes its test pilot’s slow, 

“catastrophic” reaction time to 

uncommanded MCAS activation in 

its Coordination Sheet for the first 

time, saying, “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.” Boeing updated this 

record, citing this same information, 

six times from 2015 to 2018 but 

never shared this data with the FAA. 

A Boeing AR asked in an email, “Are 

we vulnerable to single AOA sensor 

failures with the MCAS 

implementation or is there some 

checking that occurs?” In the end, 

MCAS was certified with a single 

AOA sensor and erroneous AOA 

data contributed to both 737 MAX 

accidents. Boeing is now 

implementing changes in the wake of 

both MAX crashes so that MCAS 

relies on two AOA sensors. 

March 30, 2016 (8:00 am) March 30, 2016 (11:16 am) June 15, 2016

Keith Leverkuhn, Boeing’s former 

737 MAX program General 

Manager, and Michael Teal, former 

Chief Project Engineer on the MAX 

program, approve the redesign of 

MCAS that enables it to activate at 

lower speeds. 

Mark Forkner, former 737 Chief 

Technical Pilot, emails an FAA 

official in the Seattle AEG at 11:16 

a.m. requesting permission to remove 

references to MCAS from the MAX’s 

Flight Crew Operations Manual and 

training material. Unaware of the 

MCAS redesign, the FAA official 

grants this request. The Committee 

has been unable to determine if Mr. 

Forkner was aware that Boeing had 

approved a design change to MCAS 

at the time he emailed FAA.

A Boeing AR Advisor emailed a 

colleague and asked, “What happens 

when we have faulty AOA or Mach 

number?” The colleague responds, 

“As for faulty AOA and/or Mach 

number...if they are faulty then 

MCAS shuts down immediately.” 

Faulty AOA data was a major 

contributing factor in both MAX 

crashes and MCAS did not shut 

down in either of those accidents.

June 16, 2016 October 29, 2018 March 10, 2019

Referring to a Boeing test pilot’s 

problem trimming the MAX due to 

repetitive MCAS activations, a 

Boeing engineer asks, “Is this 

considered a safety or cert[ification] 

issue?” On June 20, 2016, a colleague 

responds, “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.” This 

is exactly what happened on both 

MAX aircraft that crashed.

Lion Air flight 610 crashes 13 

minutes after takeoff killing 189 

people. MCAS is quickly determined 

to be a major factor in the crash. 

Faulty AOA data erroneously caused 

MCAS to repetitively activate more 

than 20 times as the pilots battled 

MCAS for control of the aircraft. 

These safety issues were identified by 

Boeing’s engineers years before the 

Lion Air crash, but they were not 

appropriately addressed or dismissed.

Ethiopian Airlines flight 302 crashes 

six minutes after takeoff killing all 

157 passengers and crew. The FAA 

is the last civil aviation authority to 

ground the 737 MAX on March 13, 

2020, three days after the Ethiopian 

crash. The 737 MAX aircraft has 

been grounded worldwide ever since. 
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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: 

https://www.faa.gov/news/media/attachments/Final_JATR_Submittal_to_FAA_Oct_2019.pdf

587 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: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf 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.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 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.
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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-trainingafter-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: 
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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; 

https://www.nytimes.com/2019/06/01/business/boeing-737-max-crash.html?searchResultPosition=1 604 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-BBBA8-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; 

https://www.nytimes.com/2019/06/01/business/boeing-737-max-crash.html?searchResultPosition=1 605 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; 

https://www.nytimes.com/2019/06/01/business/boeing-737-max-crash.html?searchResultPosition=1 606 See: Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. AeroB-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.betterthan.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/wpcontent/uploads/2020/documents/accident/ET302%20%20Interim%20Investigation%20%20Report%20March%209%202020.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 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-
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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 simulator614 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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. 610 Internal Boeing email, “Subject: 5-15 update,” April 1, 2016, 3:28 p.m., BATES Number TBC T&I 255562. (On file 

with Committee).

611 Ibid. 612 Ibid. 613 “737 MAX / Stall Characteristics – Mitigation,” Aero S&C, March 30, 2016, BATES Number TBC-T&I 214928-

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 615 “737 MAX / Stall Characteristics – Mitigation,” Aero S&C, March 30, 2016, BATES Number TBC-T&I 214928-

214941 at p. 6, TBC-T&I 214933 (On file with Committee). 616 “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). 617 Ibid.
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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.

618 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: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf 619 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.

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. 
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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: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg37277/pdf/CHRG-116hhrg37277.pdf
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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-onmaintenance-of-sensors-that-were-key-to-737-max-crashes 627 Ibid. 628 Ibid. 629 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-maxfaa/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 633 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-BBBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June, 11 2018, accessed at p. 163 here: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf
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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.635 They are mounted on the plane’s fuselage near the nose and have a long history of known 

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 

equipment on the ground, or striking birds in flight. In 

at least 25 cases in the U.S., Canada and Europe, the 

damage triggered cockpit alerts or emergencies.”636 In a 

slightly different analysis, CNN identified “at least 216 

reports of AOA sensors failing or having to be repaired, 

replaced or adjusted since 2004,” according to data from 

the FAA’s Service Difficulty Reporting website.

637

Fifteen months prior to the FAA’s certification of 

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-tofailure-data-show 637 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 638 Boeing employee email, “MCAS Stab Rapid Reversal on PSIM Model,” December 17, 2015, BATES Number TBCT&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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 639 Lion Air Flight 610 Final Aircraft Accident Investigation Report, p. 195, accessed here: https://aviation-is.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf

Boeing Internal Email 

December 17, 2015

“ARE WE VULNERABLE TO 

SINGLE AOA SENSOR 

FAILURES WITH THE MCAS 

IMPLEMENTATION OR IS 

THERE SOME CHECKING 

THAT OCCURS?”
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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 lowspeed 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.betterthan.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/wpcontent/uploads/2020/documents/accident/ET302%20%20Interim%20Investigation%20%20Report%20March%209%202020.pdf

646 Boeing internal email, Subject “RE: Discussion of MCAS Characteristics,” Wednesday, June 22, 2016 1:59 PM; TBCT&I292457 – TBC-T&I292458 at TBC-T&I292457. 647 “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 372829 (On file with the Committee).
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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 

down immediately.”649 That may have been the 

planned intent, but that did not happen on either 

the Lion Air or Ethiopian Airlines flights. In both 

cases faulty AOA data played critical roles in the 

crashes, and MCAS did not shut down due to 

erroneous AOA data received by MCAS. 

Further, another engineer who raised 

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 

“ratchiness” (or repetitive activation) was not a significant 

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 

posed “no real requirement violation.”653

Further, in reference to the concern about “fail high AOA 

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

648 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). 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.

Boeing Internal Email 

June 15, 2016

“WHAT HAPPENS 

WHEN WE HAVE 

FAULTY AOA OR 

MACH NUMBER?”

Boeing Internal Email 

June 16, 2016

“I DON’T THINK IT IS SAFETY, 

OTHER THAN THE PILOT COULD 

FIGHT MCAS INPUT AND OVER 

TIME FIND THEMSELVES IN A 

LARGE MISTRIM.”
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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. 
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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

The JATR also noted that “[a]nalysis 

of aviation accidents demonstrates that pilots 

may take a significantly longer time to 

recognize a malfunction and respond to it 

than the test flight guidance suggests” and 

that “[t]he FAA’s guidance concerning pilot 

reaction time of 3 seconds may not be 

appropriate[.]”664

In addition, according to the NTSB, 

“Multiple alerts and indications can increase 

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 

662 “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 https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf.

663 JATR Report, p. 15. 664 JATR Report, pp. 15-16. 665 “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, p. 7, 

accessed here: https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf

National Transportation Safety Board 

September 18, 2019

“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.”
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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. 669 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-BBBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June, 11 2018, accessed at p. 174 here: 

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

676 “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, 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).

678 See: Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. AeroB-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
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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 produced two of these coordination sheets 

in 2015, two in 2016, and one in 2017. It is notable 

that Boeing also produced an updated coordination 

sheet on June 11, 2018, more than one year after the 

737 MAX had been certified by the FAA and was 

already flying in commercial service, and the 

assessment of a pilot taking more than 10-seconds 

to react to uncommanded MCAS activation 

remained unchanged.682 Yet the FAA, as well as 

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, 

“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/CHRG116hhrg38282/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 

T&I 129776 - TBC T&I 129782 at TBC T&I 129782 (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 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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). 682 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-BBBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June, 11 2018, accessed at p. 174 here: 

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

Boeing MCAS Coordination Sheets 

2015-2018

“A SLOW REACTION TIME 

SCENARIO (>10 SECONDS) 

FOUND THE FAILURE TO BE 

CATASTROPHIC DUE TO THE 

INABILITY TO ARREST THE 

AIRPLANE OVERSPEED.”
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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 

683 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.

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/boeingaerospace/indonesias-investigation-of-lion-air-737-max-crash-faults-boeing-design-and-faa-certification-as-well-asairlines-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-preliminaryreport-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.
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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 

689 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.

690 Ibid. 691 Ibid. 692 Ibid. 693 Ibid.
-FINAL COMMITTEE REPORT: BOEING 737 MAX5. Maneuvering Characteristics Augmentation System (MCAS)

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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.
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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. 701 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). 

702 Committee staff transcribed interview of Michael Teal, former Vice President, Chief Project Engineer and Deputy 

Program Manager for the 737 MAX program, May 11, 2020.

703 Internal Boeing email, “Subject: 5-15 update,” April 1, 2016, 3:28 p.m., BATES Number TBC T&I 255562. (On file 

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.

705 Committee staff transcribed interview of Michael Teal, former Vice President, Chief Project Engineer and Deputy 

Program Manager for the 737 MAX program, May 11, 2020.

706 Committee staff transcribed interview of Michael Teal, former Vice President, Chief Project Engineer and Deputy 

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. 
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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 (angle708 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

710 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. 80 accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/

CHRG-116hhrg38282.pdf
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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-softwaredeveloper

712 Committee staff transcribed interview of Michael Teal, former Vice President, Chief Project Engineer and Deputy 

Program Manager for the 737 MAX program, May 11, 2020. 713 Ibid.
6. AOA Disagree

Alert
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-AOA Disagree AlertINVESTIGATIVE FINDINGS

 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 display714—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 report717 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”).

716 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-lightmay-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/TC16/39, 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-drawfaa-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”).
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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 miscalibration 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 

(On file with the Committee).

723 Lion Air Flight 610 Final Aircraft Accident Investigation Report, p. xviii, accessed here: https://aviation-is.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 724 Ibid. 725 Ibid., p. 178, accessed here: https://aviation-is.better-than.tv/737%20MAX%202018%20-%20035%20-%20PKLQP%20Final%20Report.pdf 726 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).
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INVESTIGATIVE FINDINGS - Continued

 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 deck730 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/wpcontent/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-flightdeck#:~: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 732 Boeing AOA Disagree Alert Narrative at TBC-T&I 267826 (On file with the Committee).
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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-vulnerableto-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). 736 Boeing AOA Disagree Alert Narrative at TBC-T&I 267826. (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 Angleof-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-weare/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-completesmerger-with-united-technologies.html
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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.742Collins 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). 742 Letter from Collins Aerospace’s attorney to Chairs DeFazio and Larsen re AOA Disagree Alert, June 20, 2019, p. 5 

(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). 743 Letter from Collins Aerospace’s attorney to Chairs DeFazio and Larsen re AOA Disagree Alert, June 20, 2019, p. 5 

(On file with the Committee). See also PFD SCD Issues found during HL reviews, BATES number COLLINS_00105 

(On file with the Committee).

744 Letter from Collins Aerospace’s attorney to Chairs DeFazio and Larsen re AOA Disagree Alert, June 20, 2019, p. 6 

(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).

745 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). 746 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 37MAXMDS-S_PR195 (ITRACS PR 195), BATES number COLLINS_00075 -

COLLINS_00076 (On file with the Committee). 747 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).
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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.

748 Letter from Collins Aerospace’s attorney to Chairs DeFazio and Larsen re AOA Disagree Alert, June 20, 2019, p. 9 

(On file with the Committee).

749 Boeing AOA Disagree Problem Report #195, 37MAXMDS-S_PR195, BATES Number COLLINS_0075 –

COLLINS_0076 at COLLINS_0076

750 Letter from Collins Aerospace’s attorney to Chairs DeFazio and Larsen re AOA Disagree Alert, June 20, 2019, p. 9 

(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 754 Boeing Statement on AOA Disagree Alert. 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).
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Angle of Attack (AOA) Disagree Alert - Timeline

January 2014 June 2014 November 2014

A Boeing-Collins peer review of 

the AOA Disagree alert software 

results in a Boeing requirement 

that the AOA Disagree alert, a 

standard feature on all 737 MAX 

aircraft, should be tied to the 

optional AOA Indicator. 

Collins conducts an internal 

review of high-level 

requirements for the AOA 

Disagree alert but notices it was 

silent on whether or not the alert 

should be tied to the AOA 

Indicator. Collins suggests that a 

change might be necessary.

A Boeing-Collins peer review 

concludes with Boeing stating 

that the AOA Disagree alert 

should not be tied to the 

optional AOA Indicator. 

January - April 2015 May 2015 July 2015

Collins delivered various 

versions of the software to 

Boeing that did not tie the AOA 

Disagree alert to the optional 

AOA Indicator per Boeing’s 

directions.

Boeing issues a “problem 

report” to Collins concerning 

the AOA Fail Flag, a separate 

feature that is tied to the AOA 

Indicator. 

To fix the AOA Fail Flag issue, 

Collins updated the AOA 

Disagree alert logic, which 

resulted in effectively tying the 

AOA Disagree alert back to the 

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 

realized that the AOA Disagree 

alert was now tied to the optional 

AOA Indicator, meaning it only 

functioned on less than 20 

percent of MAX aircraft with the 

optional AOA Indicator. Boeing 

issued a new “problem report” to 

Collins indicating that the AOA 

Disagree alert should not be tied 

to the optional AOA Indicator. 

At a Collins-Boeing weekly status 

meeting, Boeing confirmed that it 

had decided to defer fixing the 

AOA Disagree alert for three 

years, until 2020 when the 737 

MAX-10 was then expected to 

enter service. Boeing knowingly 

continued to both manufacture 

and deliver aircraft that did not 

conform to the 737 MAX’s FAA 

approved aircraft type certificate.

Lion Air flight 610 crashes killing 

189 people. By the time of the 

Lion Air crash Boeing had 

knowingly delivered an estimated 

200 737 MAX airplanes to its 

customers with nonfunctioning 

AOA Disagree alerts and failed 

to inform them or the FAA of 

that fact. 

November 6-7, 2018 May 2019 July 11, 2019

Boeing issues a Flight Crew 

Operations Manual Bulletin for 

the 737 MAX, listing the AOA 

Disagree alert as one of several 

possible indications of erroneous 

AOA data, “if AOA indicator 

option is installed.” The FAA 

issues a similar alert the following 

day. 

After news reports about Boeing 

delivering aircraft with nonfunctioning AOA Disagree alerts 

emerged at the end of April 2019, 

Boeing issued a statement on its 

website, which blamed its 

software supplier for the 

problem. “The software delivered 

to Boeing linked the AOA 

Disagree alert to the AOA 

Indicator, which is an optional 

feature on the [737] MAX and the 

[737] NG.”

Then-Acting FAA Administrator 

writes to Chairs DeFazio and 

Larsen. “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,” it 

says. The Committee is unaware 

of any action the FAA has taken 

to hold Boeing responsible for its 

actions regarding this matter. 
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Both Boeing757 and the FAA758 have argued that an AOA Disagree alert is not a safetycritical 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 

operating manuals provided to airlines for dissemination to their

pilots. Boeing knew the alert was not functioning properly and 

failed to inform their MAX customers that this component was 

inoperative.

In discussing whether or not to inform 737 MAX pilots 

about the inoperable AOA Disagree alert through an Operations 

Manual Bulletin (OMB), one Boeing employee wrote to a 

colleague on October 5, 2017, “I still think we need a bulletin to 

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. 

757 Boeing AOA Disagree Alert Narrative at TBC-T&I 267830. (On file with the Committee). 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg37277/pdf/CHRG-116hhrg37277.pdf 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-datareveals-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/ethiopiaboeing-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. 

Boeing Employee Email

October 5, 2017

“I STILL THINK WE 

NEED A BULLETIN TO 

LET THEM [THE 

PILOT’S] KNOW WHAT 

THEY MAY BE 

MISSING....”
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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); 

PKLQP, Tanjung Karawang, West Java, Republic of Indonesia, 29 October 2018,” Komite Nasional Keselamatan 

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.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 765 Letter from then-Acting FAA Administrator Dan Elwell to Chair DeFazio, July 11, 2019. (On file with the 

Committee).

766 Boeing Statement on AOA Disagree Alert. 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 

(On file with the Committee).

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).
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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

775 Boeing AOA Disagree Alert Narrative at TBC-T&I 267831. (On file with the Committee). 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-aircompany-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/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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”), 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf
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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 Air782 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 780 “737 MAX: Deliveries Report,” The Boeing Company, accessed here: 

http://www.boeing.com/commercial/#/orders-deliveries 781 Boeing AOA Disagree Alert Narrative at TBC-T&I 267828 (On file with the Committee). 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
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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 

Dennis Muilenburg conceded, “it was part of the airplane 

baseline. It should have been implemented on the 

airplanes. It was not correctly implemented. We made a 

mistake.”792

Rep. Davids pressed further, asking, “How do 

you decide which things are baseline that you are not 

going to adhere to, and which ones you are?”793 

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

785 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/CHRG116hhrg38282.pdf

786 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 787 Boeing AOA Disagree Alert Narrative at TBC-T&I 267833 (On file with the Committee). 788 Ibid. 789 Boeing AOA Disagree Alert Narrative at TBC-T&I 267832 (On file with the Committee). 790 Ibid. 791 Boeing AOA Disagree Alert Narrative at TBC-T&I 267833 (On file with the Committee). 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 794 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 & 

John Hamilton 

Boeing Chief Engineer 

Committee on Transportation 

and Infrastructure Hearing 

October 30, 2019

“I AM NOT SURE WHY WE 

DIDN’T NOTIFY THE 

CUSTOMERS OF THAT.”
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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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 795 Testimony of John Hamilton, Chief Engineer of Boeing Commercial Airplanes, Hearing titled, “The Boeing 737 

MAX: Examining the Design, Development, and Marketing of the Aircraft,” House Committee on Transportation & 

Infrastructure, 116th Congress, First Session, October 30, 2019, pp. 109, accessed here: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 796 Lion Air Flight 610 Final Aircraft Accident Investigation Report, p. xviii, accessed here: https://aviation-is.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 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-savedjet-one-day-before-lion-air-crash/3220891002 800 Lion Air Flight 610 Final Aircraft Accident Investigation Report, p. xviii, accessed here: https://aviation-is.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 801 Ibid., p. 168. 802 Ibid. 
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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 mis803 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-shutsdown-revokes-certificate-of-florida-repair-firm-that-supplied-faulty-lion-air-sensor 809 Ibid. 810 Lion Air Flight 610 Final Aircraft Accident Investigation Report, p. xviii, accessed here: https://aviation-is.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 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.
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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 Jakartabound 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. 

813 Letter from then-Acting FAA Administrator Dan Elwell to Chair DeFazio, July 11, 2019 (On file with the 

Committee).
7. Boeing 737 MAX 

Pilot Training
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-Boeing 737 MAX Pilot TrainingINVESTIGATIVE FINDINGS

 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

814 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.

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 FAAT&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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 818 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. 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-airplanesouthwest/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
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INVESTIGATIVE FINDINGS - Continued

 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. 

(On file with the Committee).

824 Boeing internal emails, “Subject: Synthetic Airspeed,” February 26, 2013, accessed at p. 1 here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

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, FAADEFAZIO-000032887-32890, accessed at p.231 here: https://www.govinfo.gov/content/pkg/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 826 Boeing internal email, “Subject: RE: Weekly inputs,” September 21, 2016, 4:26:33 PM, BATES Number TBC-T&I 

552192. (On file with the Committee).

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): 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf

828 Boeing internal email, “Subject: RE: Flight Transition costs,” Sent: March 28, 2017, 9:00:58 AM, accessed at p. 28 

here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf
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INVESTIGATIVE FINDINGS - Continued

 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 

with the Committee).

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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 833 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

834 Email from 737 Chief Technical Pilot to FAA, “Subject: MCAS lives in both FCCs,” Sent: Wednesday, March 30, 

2016, 11:16:45.
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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 

uncommanded838 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 

835 See: Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. AeroB-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-BBBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June, 11 2018, accessed at pp. 164 and 174 here: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 836 Internal Boeing email, “Subject: MCAS Hazard Assessment,” Sent: November 1, 2012, 1:41 PM, BATES Number 

TBC-T&I 131226 – 131227. (On file with the Committee). 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 838 Internal Boeing email, “Subject: MCAS Hazard Assessment,” Sent: November 1, 2012, 1:41 PM, BATES Number 

TBC-T&I 131226 – 131227. (On file with the Committee). 839 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-BBBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June, 11 2018, accessed at p. 173 here: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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-putspartial-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-pilotsunion/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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg37277/pdf/CHRG-116hhrg37277.pdf 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.

842 Internal Boeing email, “Subject: MCAS Hazard Assessment,” Sent: November 1, 2012, 1:41 PM, BATES Number 

TBC-T&I 131226 – 131227. (On file with the Committee). 
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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 crashes848 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/wpcontent/uploads/2020/documents/accident/ET302%20%20Interim%20Investigation%20%20Report%20March%209%202020.pdf 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg37277/pdf/CHRG-116hhrg37277.pdf 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-pressedboeing-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-ofits-pilots-an-effort-to-divert-public-attention-from-boeing-737-max-flaws 
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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. 

House of Representatives, 116th Congress, First Session, June 19, 2019, accessed here: 

https://transportation.house.gov/imo/media/doc/Sully%20Sullenberger%20Testimony.pdf

850 Ibid. 851 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, accessed here: 

https://transportation.house.gov/committee-activity/boeing-737-max-investigation 852 Ibid. 853 Ibid. 854 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).
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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 

737 MAX.855 In March 2014, a senior Boeing 

employee expressed concern that adding new 

“Asymmetry and Authority alerts” to the 737 

MAX could potentially endanger Level B 

computer-based training requirements. “We told 

all our customers MAX will only require up to 

Level B training,” wrote the Boeing employee.856

The employee was clearly concerned about the 

impact increased training requirements could 

have. “This would have very severe 

consequences for the MAX program,” the 

employee wrote to Boeing colleagues more than 

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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 860 “Boeing Selects Supplier for 737 MAX Full-Flight Simulator,” Boeing News Release, July 11, 2014, accessed here: 

https://boeing.mediaroom.com/2014-07-11-Boeing-Selects-Supplier-for-737-MAX-Full-Flight-Simulator

Mark Forkner 

former 737 Chief Technical Pilot 

(On briefing FAA on the MAX) 

May 7, 2014

“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.”
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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 

press release claimed.863 There was no caveat in the 

press release informing the public that the FAA had not 

yet made that decision.

Marketing the MAX

The “design objective” to obtain Level B 

training requirements or less from the FAA played a 

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 simulatorbased 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 fullmotion 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 862 “Boeing Selects Supplier for 737 MAX Full-Flight Simulator,” The Boeing Company, July 11, 2014, accessed here: 

https://boeing.mediaroom.com/2014-07-11-Boeing-Selects-Supplier-for-737-MAX-Full-Flight-Simulator 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-recommendssimulator-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-trainingincluding-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 

Boeing Press Release 

July 11, 2014

“PILOTS ALREADY 

CERTIFIED ON THE NEXTGENERATION 737 WILL NOT 

REQUIRE A SIMULATOR 

COURSE TO TRANSITION TO 

THE 737 MAX.”
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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: 

https://www.dallasnews.com/business/airlines/2020/01/07/boeing-says-737-max-pilots-should-get-simulator-trainingincluding-thousands-at-american-and-southwest 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: 

https://www.dallasnews.com/business/airlines/2020/01/07/boeing-says-737-max-pilots-should-get-simulator-trainingincluding-thousands-at-american-and-southwest 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. 

873 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. 

(On file with the Committee).

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

875 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. 

(On file with the Committee).
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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

876 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). 

877 “Southwest Corporate Fact Sheet,” Fleet as of December 31, 2019, Southwest Airlines, accessed here: 

https://www.swamedia.com/pages/corporate-fact-sheet#fleet 878 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). 

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. 
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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-centerof-737-max-investigation-takes-buyout-from-southwest-airlines 886 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.

887 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.

888 Ibid. 889 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.

890 Ibid. 891 Ibid.
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resolution of 25.1322 trade892 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). 894 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.

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, 

accessed at p. 93 here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf

897 Committee staff transcribed interview of Michael Teal, Boeing Vice President, Chief Project Engineer and Deputy 

Program Manager of the 737 MAX program, Boeing Commercial Airplanes, May 11, 2020.

898 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, FAADEFAZIO-000032887-32890, accessed at p.231 here: https://www.govinfo.gov/content/pkg/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 899 FAA internal email, “Subject: RE: 737 MAX training question,” Sent: May 10, 2015, 1:44 PM, BATES Number FAADEFAZIO-000032884, accessed at p. 228 here: https://www.govinfo.gov/content/pkg/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf
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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 

redesign of MCAS in March 2016 that gave

the system much greater authority to control 

the aircraft until after the Lion Air crash.904

Had they known of those changes to MCAS 

prior to certification, it may have altered their 

assessment of the aircraft. 

Also included in the Seattle AEG’s 

May 2015 memorandum concerning the 

effect of the MAX’s new systems on training 

requirements, the author stressed that 

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. 901 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, FAADEFAZIO-000032887-32890, accessed at p.231 here: https://www.govinfo.gov/content/pkg/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 902 Ibid. 903 Ibid. 904 “Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8 Aircraft and Actions Taken After the 

October 2018 Lion Air Accident,” Department of Transportation, Office of Inspector General, Report No. AV2020037, 

June 29, 2020, pp. 21-22, accessed here: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf 905 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, FAADEFAZIO-000032887-32890, accessed at p.231 here: https://www.govinfo.gov/content/pkg/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 906 Ibid.

Memo from Seattle AEG Manager to 

FAA, Director, Flight Standards

May 10, 2015

“FOR THE 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.”
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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 

Direct Lift Control system, the memo said: “It 

is the opinion of the AEG that this system 

will need to have a full flight simulator to train 

the pilots.”909 On the Landing Attitude 

Modifier (LAM), the memo indicated: “Only a 

full flight simulator can be used for takeoff 

and landing credit.” Additionally, regarding 

the Enhanced Bank Angle Warning (EBAW) 

system, that is part of the Roll Command 

Alerting System (RCAS), the memo said: 

“This is highly integrated system that may 

require simulator training.”910

The AEG memo also pointed out: “It 

is common practice for the manufacturer to 

request minimal pilot training due to the cost 

impact for their customers.”911 Despite its concerns, in the end, the FAA did not require simulatorbased 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. 912 Committee staff transcribed interview of Keith Leverkuhn, former Vice President and General Manager of the 737 

MAX program, Boeing Commercial Airplanes, May 19, 2020. 

913 Ibid.

Memo from Seattle AEG Manager to 

FAA, Director, Flight Standards

May 10, 2015

“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. 

....

IT IS COMMON PRACTICE FOR 

THE MANUFACTURER TO 

REQUEST MINIMAL PILOT 

TRAINING DUE TO THE COST 

IMPACT FOR THEIR CUSTOMERS.”
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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. 915 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. 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-thefederal-aviation-administrations-oversight-of-the-aircrafts-certification 918 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). 
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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: 

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

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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: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

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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 (nonsimulator) 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: 

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925 Boeing internal email, “Subject: RE: RCAS testing of training,” Sent: Tuesday, July 22, 2014, 8:27 PM, p. 3-4, 

accessed here: 

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926 Boeing internal email, “Subject: RE: RCAS testing of training,” Sent: Wednesday, July 23, 2014, 7:11 AM, p. 3, 

accessed here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf 927 Boeing internal email, “Subject: RE: RCAS testing of training,” Sent: July 23, 2014, 7:43:41 PM, p. 3, accessed here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

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: 

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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: 

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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: 

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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: 

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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: 
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• 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 

time.936 They also both claimed that they 

were unaware of Mr. Forkner’s efforts to 

pressure Boeing’s customer airlines out of 

simulator training.

Neither Mr. Teal nor Mr. Leverkuhn 

had a supervisory role over Mr. Forkner, 

who reported through a different chain 

within Boeing. However, Mr. Forkner 

worked closely with the MAX program. In

his interview with Committee staff, Mr. Teal 

said he was unaware of Mr. Forkner acting 

unprofessionally or inappropriately and said 

he did not recall anyone complaining about 

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 

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pdf 935 Boeing internal instant message, December 12, 2017, BATES Number TBC-T&I 549024-549025. (On file with the 

Committee).

936 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 Vice President and General Manager of the 737 MAX program, 

Boeing Commercial Airplanes, May 19, 2020.

937 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. 938 Committee staff transcribed interview of Keith Leverkuhn, former Vice President and General Manager of the 737 

MAX program, Boeing Commercial Airplanes, May 19, 2020. 

Boeing’s 737 Chief Technical Pilot, 

Internal Email

March 28, 2017

“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.”
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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-suspendsco-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 TBCT&I 552192. (On file with the Committee). 942 See: “The perfect illusion: Technology of full flight simulators,” ProFlight, accessed here: 

https://www.proflight.com/en/full-flight-simulatoren/technologie.php
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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-maxfull-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-andresourcing/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-qualificationstandards-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: 

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948 Ibid, p. 103. 949 Ibid, p. 103.
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• 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: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf

951 Ibid, p. 75. 952 Boeing email, “Subject: RE: Updated QTG,” April 24, 2018, 23:33, accessed at p. 105 here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf

953 Boeing email, “Subject: RE: Updated QTG,” April 24, 2018, 4:02:27 PM, p. 105, accessed here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

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, 

accessed at p. 98 here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf

955 Boeing internal instant message, “Subject: Conversation with [redacted],” May 15, 2018, 12:09:52 PM, accessed at p. 

97 here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf
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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: 

https://boeing.mediaroom.com/news-releases-statements?item=130596 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-maxsimulator-training.html 960 See: Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. AeroB-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: 

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

961 Internal Boeing email, “Subject: MCAS Hazard Assessment,” Sent: November 1, 2012, 1:41 PM, BATES Number 

TBC-T&I 131226 – 131227. (On file with the Committee). 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-costcutting-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-at19bn-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
8. Production Pressure 
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-Production Pressure -

INVESTIGATIVE FINDINGS

 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/boeing737-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-youneed-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-incompanys-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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, 

accessed here at pp. 74-77: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG116hhrg40697.pdf

968 Committee staff transcribed interview of Keith Leverkuhn, former Boeing Vice President and General Manager of 

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 970 Committee staff interview of Michael Teal, former Vice President, Chief Project Engineer and Deputy Program 

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, 
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INVESTIGATIVE FINDINGS - Continued

 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/boeingaerospace/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 973 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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, 

accessed here at pp. 74-77: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG116hhrg40697.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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 975 Ibid. 976 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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, 

accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf
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INVESTIGATIVE FINDINGS - Continued

 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 

orders981 from more than 100 global customers by the time of the Lion Air crash in October 2018.982

Combined orders and deliveries of the MAX peaked at more than 5,000983 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: 

https://s2.q4cdn.com/661678649/files/doc_financials/quarterly/2018/q2/2Q18-Earnings-Call-Transcript-Final.pdf 978 “Renton Production Facility,” The Boeing Company, accessed here: https://www.boeing.com/company/aboutbca/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-celebratesits-10-000th-737-aircraft-with-a-new-record-518888 980 See: “Renton Production Facility,” The Boeing Company, accessed here: https://www.boeing.com/company/aboutbca/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-anew-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-youneed-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).
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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

985 “Renton Production Facility,” The Boeing Company, accessed here: https://www.boeing.com/company/aboutbca/renton-production-facility.page 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

988 “Renton Production Facility,” The Boeing Company, accessed here: https://www.boeing.com/company/aboutbca/renton-production-facility.page 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/CHRG116hhrg38282/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/CHRG116hhrg40697.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 
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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-2019-3 997 Committee staff transcribed interview of Keith Leverkuhn, former Boeing Vice President and General Manager of 

the 737 MAX program, Boeing Commercial Airplanes (BCA), May 19, 2020. 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 1000 Committee staff transcribed interview of Keith Leverkuhn, former Boeing Vice President and General Manager of 

the 737 MAX program, Boeing Commercial Airplanes (BCA), May 19, 2020.

1001 Ibid. 1002 Ibid, p. 38.
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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-maxcrashes.html

1008 Boeing internal email, “Subject: Synthetic Airspeed,” February 26, 2013, p.1, accessed here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

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).
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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-systemicproblems-with-737-max 1014 See: Boeing internal emails, “Subject: Synthetic Airspeed,” February 26, 2013, p.1, accessed here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

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/boeingwhistleblowers-complaint-says-737-max-safety-upgrades-were-rejected-over-cost 1015 Boeing internal emails, “Subject: Synthetic Airspeed,” February 26, 2013, p.1, accessed here: 

https://transportation.house.gov/imo/media/doc/Compressed%20Updated%202020.01.09%20Boeing%20Production.

pdf
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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 

proposed design changes in that document to 

address Boeing aircraft loss of control accidents 

and events on various Boeing aircraft, which 

included, but was not limited to, the Boeing 737 

model aircraft.1018 These Boeing aircraft events 

accounted for 1,493 onboard fatalities and 80 

external fatalities worldwide from 2002 to 

2011.1019

The Coordination Sheet recommended 

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.

Boeing Coordination Sheet 

“BCA Strategy for Reducing the 

Risk of Loss of Control Events” 

March 3, 2014

“UNLIKE ALL OTHER BOEING 

MODELS, THE 737 HAS NO WAY TO 

REMOVE ERRONEOUS AIR DATA 

FROM A DISPLAY AND REPLACE IT 

WITH CORRECT DATA.”
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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/boeingwhistleblowers-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-maxcrashes.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/boeingwhistleblowers-complaint-says-737-max-safety-upgrades-were-rejected-over-cost 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/boeingwhistleblowers-complaint-says-737-max-safety-upgrades-were-rejected-over-cost 1028 Committee staff transcribed interview of Keith Leverkuhn, former Boeing Vice President and General Manager of 

the 737 MAX program, Boeing Commercial Airplanes (BCA), May 19, 2020.
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173

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 

(On file with the Committee).

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 1031 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 1033 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 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).
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174

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 NonCommissioned 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, 

1035 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 

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. 1039 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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, p. 

75, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1040 Resume of Ed Pierson, accessed here: https://docs.house.gov/meetings/PW/PW00/20191211/110296/HHRG116-PW00-Bio-PiersonE-20191211.pdf 1041 Ibid. 1042 Ibid. 1043 Ibid. 
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175

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 

for the safety of the passengers who would 

be flying on the aircraft the Boeing factory 

was producing. On Saturday, June 9, 2018, at 

1:32 p.m., Mr. Pierson wrote an email to 

Scott Campbell, the General Manager of the 

737 program and the senior most official at 

the Renton production facility.1048

“Scott, I have some safety concerns 

that I need to share with you as the leader of 

the 737 Program,” wrote Mr. Pierson.1049

“Today we have 38 unfinished airplanes 

located outside the factory. The following 

concerns are based on my own observations 

and 30 years of aviation safety experience.”1050

Mr. Pierson cited two key concerns. “My first 

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. 1047 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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, p. 

74, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1049 Ibid. 1050 Ibid. 1051 Ibid.

Ed Pierson, Boeing Senior Manager, 

737 MAX Final Assembly Plant 

Email to Scott Campbell, 

737 General Manager 

June 9, 2018

“MY FIRST CONCERN IS THAT OUR 

WORKFORCE IS EXHAUSTED. ... MY 

SECOND CONCERN IS SCHEDULE 

PRESSURE (COMBINED WITH 

FATIGUE) IS CREATING A CULTURE 

WHERE EMPLOYEES ARE EITHER 

DELIBERATELY OR 

UNCONSCIOUSLY CIRCUMVENTING 

ESTABLISHED PROCESSES.”
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(combined with fatigue) is creating a culture where employees are either deliberately or 

unconsciously circumventing established 

processes.”1052

Mr. Pierson detailed some of these 

specific concerns and said these issues could lead 

to “inadvertently imbedding safety hazard(s) into 

our airplanes. As a retired Naval Officer and 

former Squadron Commanding Officer, I know 

how dangerous even the smallest of defects can 

be to the safety of an airplane. Frankly right now,” 

he wrote, “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. .... I fear serious process 

breakdowns will continue to occur if we continue 

pushing our employees to the limit,” he wrote.1053

Mr. Pierson recommended temporarily 

shutting down the production line “to allow our 

team time to regroup so we can safely finish the 

planes outside and then shift our attention to the 

planes inside. I don’t make this recommendation 

lightly,” he wrote.1054 “I know this would take a lot 

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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1057 Ibid.

Ed Pierson, Boeing Senior Manager, 

737 MAX Final Assembly Plant 

Email to Scott Campbell, 

737 General Manager 

June 9, 2018

“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.

....

I FEAR SERIOUS PROCESS 

BREAKDOWNS WILL CONTINUE 

TO OCCUR IF WE CONTINUE 

PUSHING OUR EMPLOYEES TO 

THE LIMIT.”
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177

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/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1059 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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, 

accessed here at pp. 76-77: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG116hhrg40697.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 

here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1065 The Boeing Company, Q2 2018 Earnings Call, July 25, 2018, p. 6, p.12 and p. 26, accessed here: 

https://s2.q4cdn.com/661678649/files/doc_financials/quarterly/2018/q2/2Q18-Earnings-Call-Transcript-Final.pdf 1066 “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” accessed here: https://aviation-is.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 1067 The Boeing Company, Q2 2018 Earnings Call, July 25, 2018, accessed here: 

https://s2.q4cdn.com/661678649/files/doc_financials/quarterly/2018/q2/2Q18-Earnings-Call-Transcript-Final.pdf 1068 Ibid, p. 4.
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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 semifinished 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-withproduction-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-rentondespite-boeings-reassurances 1075 Ibid. 1076 Ibid. 1077 Ibid.
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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. 1080 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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, 

accessed here at pp. 74-79: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG116hhrg40697.pdf

1081 Ibid. 1082 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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, 

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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf
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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. 

Pierson sent another email extensively 

detailing all of the production issues he 

had been raising to both Mr. Fennelly 

as well as Boeing’s General Counsel, 

Michael Luttig.1087 The email described 

the following issues that Mr. Pierson had 

previously raised with Boeing’s 

management: 

• Employee Fatigue &

Schedule Pressure

• Leadership Actions &

Inactions

• Quality Issues

• Supply Chain Disruptions

• Staffing Constraints

• Process Deviations

• Communication Breakdowns

• Safety Incidents

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. 1085 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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, 

accessed here at p. 76: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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/CHRG116hhrg40697.pdf 

Ed Pierson, former Boeing Senior Manager, 

737 MAX Final Assembly Plant 

Email to Boeing General Counsel 

February 7, 2019

“EMPLOYEES WITH 20+ YEARS 737

EXPERIENCE STATED THEY HAD NEVER

SEEN THE PRODUCTION SYSTEM IN SUCH

BAD SHAPE. AS YOU STATED, [BOEING]

LEADERS BASED IN CHICAGO WERE 

AWARE OF THESE RECOVERY ISSUES. 

.... 

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.”
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• Functional Test Delays & Failures

• Facility Limitations

• Equipment Shortcomings

• Recovery Planning Efforts

• Deteriorating Factory Health Metrics1088

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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf
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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. 1092 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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, 

accessed here at p. 77: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1093 Letter from Ed Pierson to Boeing Board of Directors, March 12, 2019, accessed here at p. 96: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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-davidcalhoun.html
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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 

1096 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 

Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, December 11, 2019, 

accessed here at p. 77-78: https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG116hhrg40697.pdf

1097 Ibid. 1098 “Whistleblower Rights,” U.S. House Committee on Transportation and Infrastructure, accessed here: 

https://transportation.house.gov/whistleblower-rights 1099 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/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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 

Committee on Transportation and Infrastructure, U.S. House of Representatives, 116th Congress, First Session, 

December 11, 2019, accessed here at pp. 50-53: https://www.govinfo.gov/content/pkg/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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).
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184

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 

Committee’s December 2019 hearing, July 23, 2020. (On file with the Committee).

1108 Telephone call between Ed Pierson and his attorneys and T&I Democratic Staff, August 28, 2020. 1109 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, accessed here at p. 52: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG116hhrg38282.pdf
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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 

Committee’s December 2019 hearing, July 22, 2020. (On file with the Committee). 1111 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, accessed here at p. 52: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG116hhrg38282.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/CHRG116hhrg38282.pdf

1114 Ibid., p. 145. 1115 Ibid. 1116 Ibid. 
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186

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 

believed they had experienced undue pressure

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. 1118 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, accessed here at p. 102: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG116hhrg38282.pdf

1119 Ibid. 1120 Ibid., p. 52. 1121 Ibid.

Boeing Undue Influence Survey 

November 2016
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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
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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.
9. Post-Accident

Response
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-Post-Accident ResponseINVESTIGATIVE FINDINGS

 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-boeinglearns-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, 

accessed here at pp. 95-96: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG116hhrg38282.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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1129 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. 241-253: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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).
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INVESTIGATIVE FINDINGS - Continued

 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: 

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

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 1134 “Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8 Aircraft and Actions Taken After the 

October 2018 Lion Air Accident,” DOT OIG, June 29, 2020, pp. 32-33, accessed here: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf

1135 Ibid. 1136 Ibid. 1137 “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)
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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 criteria1139 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 pilots1144 for 

both MAX crashes and downplaying the fundamental technical design flaws that Boeing designed 

1138 “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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 1139 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, 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 1140 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-BBBA8-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 1141 “Boeing Statement on AOA Disagree Alert,” Press Statement, The Boeing Company, May 5, 2019, accessed here: 

https://boeing.mediaroom.com/news-releases-statements?item=130431 1142 Hearing titled, “The Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight of the Aircraft’s 

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/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1142 Ibid., p. 21. 1143 “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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 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-putspartial-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
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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 NonNormal 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: 

https://boeing.mediaroom.com/news-releases-statements?item=130327 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 1148 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/CHRG116hhrg38282.pdf

1149 Ibid. 1150 Ibid. 
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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.
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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 

their ability to respond effectively to the 

design flaws in the 737 MAX that led to 

the crash.1159

Few pilots have survived to share 

their experiences about the startle effect, 

but retired airline captain Chesley B. 

“Sully” Sullenberger III is one of them. 

He 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.”1160 In June 2019, Captain 

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. 

House of Representatives, 116th Congress, First Session, June 19, 2019, accessed here: 

https://transportation.house.gov/imo/media/doc/Sully%20Sullenberger%20Testimony.pdf

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. 

House of Representatives, 116th Congress, First Session, June 19, 2019, accessed here: 

https://transportation.house.gov/imo/media/doc/Sully%20Sullenberger%20Testimony.pdf 1162 Ibid. 1163 Ibid.

Retired Airline Captain 

Chesley B. “Sully” Sullenberger III 

House Aviation Subcommittee Hearing 

June 19, 2019

“WITHIN SECONDS, THESE CREWS 

WOULD HAVE BEEN FIGHTING FOR 

THEIR LIVES IN THE FIGHT OF THEIR 

LIVES. ... IN BOTH 737 MAX ACCIDENTS, 

THE FAILURE OF AN AOA SENSOR 

QUICKLY CAUSED MULTIPLE 

INSTRUMENT INDICATION ANOMALIES 

AND COCKPIT WARNINGS.”
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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. 

129, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 1165 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/CHRG116hhrg38282.pdf

1166 “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, 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 1169 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/CHRG116hhrg38282.pdf
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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: 

https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/83ec7f95f3e5bfbd8625833e0070a070/$FILE/2018-

23-51_Emergency.pdf 1171 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, accessed 

here: 

https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/83ec7f95f3e5bfbd8625833e0070a070/$FILE/2018-

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). 
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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 

T&I 220826. (On file with the Committee).

1177 See: “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” pp. 19-28, accessed here: https://aviationis.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-aircrash-timeline-boeing-737-max-disaster-killed-189-2019-10 1178 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, accessed 

here: 

https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/83ec7f95f3e5bfbd8625833e0070a070/$FILE/2018-

23-51_Emergency.pdf 1179 Ibid.
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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 

opinion at the time was that introducing a 

new system name that did not exist in the 

aircraft documentation available to pilots 

had the potential to cause confusion in an 

emergency situation,” the FAA wrote in 

response to Chair DeFazio.

1181 This may 

have been the FAA’s justification for not 

referencing MCAS in the AD, but 

nevertheless their actions resulted in 

omitting critical information about MCAS 

from 737 MAX pilots and airlines.

Both Boeing and the FAA seemed 

more intent on justifying their previous 

mistakes and missteps than in fully 

confronting the safety issues that began to 

encircle and ensnarl the 737 MAX aircraft 

in the aftermath of the Lion Air crash. In 

July 2019, the New York Times ran an 

investigative story titled: “The Roots of 

Boeing’s 737 MAX Crisis: A Regulator 

Relaxes Its Oversight.”1182 The story noted 

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 

1180 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. 241-253: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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.

FAA Administrator Stephen Dickson 

Response to Questions for the Record from 

Committee Chair DeFazio 

December 19, 2019 Hearing 

“[T]HE FAA’S OPINION AT THE TIME 

WAS THAT INTRODUCING A NEW 

SYSTEM NAME THAT DID NOT EXIST 

IN THE AIRCRAFT DOCUMENTATION 

AVAILABLE TO PILOTS HAD THE 

POTENTIAL TO CAUSE CONFUSION IN 

AN EMERGENCY SITUATION. 

....

THE FAA THEREFORE DECIDED TO 

REMOVE THE MCAS REFERENCE 

FROM THE DRAFT AD SO THAT 

FLIGHT CREWS WOULD FOCUS ON 

RUNAWAY STABILIZER RECOGNITION 

INSTEAD OF ATTEMPTING TO 

TROUBLESHOOT MCAS.”
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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, 

1184 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf
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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 20161193 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://aviationis.better-than.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf 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).

1195 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf
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Within 48 hours of releasing the MOM to Boeing’s 737 MAX customers, U.S.1196 and 

foreign1197 media outlets quickly began reporting on the existence of the MCAS, its operational 

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-withheldinformation-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-aboutnew-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-protectionsystem-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-gefaehrlichenunsinn-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-predotvrashcheniyasvalivaniya-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-spilots-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-withheldinformation-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-predotvrashcheniyasvalivaniya-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-gefaehrlichenunsinn-treibt-1.4210624 
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continued a strategy of shielding the very existence of MCAS from MAX pilots that Boeing initiated 

and the FAA authorized years earlier. This flawed 

strategy, which was justified under the presumption they 

did not want to confuse pilots with unnecessary 

information, backfired once the aviation community 

learned about MCAS and Boeing’s efforts to omit 

references to MCAS from 737 MAX pilots.

On November 27, 2018, two weeks after Boeing 

issued its MOM alert to its 737 MAX customers, Boeing 

officials sat down with representatives from the Allied 

Pilots Association (APA), the union that represents the 

15,000 pilots that fly for American Airlines at APA’s 

headquarters in Fort Worth, Texas.1202 American Airlines 

had 24 MAX airplanes in service at the time of the Lion 

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-pilotsconfronting-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-confrontedBoeing-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-august2019.pdf?sfvrsn=1f307f7d_0 1205 Draft Transcript of Audio Recording of Meeting between Boeing officials and Allied Pilots Association (APA) 

officials, November 27, 2018. (On file with the Committee).

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

Boeing Official in Meeting 

with Allied Pilots Association 

November 27, 2018 

“MCAS IS A CONTROL LAW 

... 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.”
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unmanned aircraft applications,1207 physicians to perform MRIs1208 and ultrasounds1209 on patients, 

and the operational control of autonomous underwater vehicles1210 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 

part of the “system” and essentially served as a backup 

to any technical failure of MCAS.1212 “So the [MCAS] 

function and trained pilot are part of the system,” said 

one of the Boeing officials. “So rightly or wrongly, that 

was the design criteria, and that’s how they’re being 

certified with the – the – the system and the pilot 

working together,” he said.1213

The FAA appeared to agree with Boeing 

regarding the notion that the MAX pilots were the 

redundant features for MCAS and was clearly on the 

same page as Boeing regarding other key design 

decisions about MCAS and the MAX in general. In a 

December 2019 transcribed interview with Committee 

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

1212 Draft Transcript of Audio Recording of Meeting between Boeing officials and Allied Pilots Association (APA) 

officials, November 27, 2018. (On file with the Committee).

1213 Ibid.

Allied Pilots Association 

Official in Meeting with Boeing 

November 27, 2018 

“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.”
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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, nonfunctioning 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. 1216 Draft Transcript of Audio Recording of Meeting between Boeing officials and Allied Pilots Association (APA) 

officials, November 27, 2018. (On file with the Committee).

1217 Ibid. 1218 Ibid. 
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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 wellknown 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg37476/pdf/CHRG-116hhrg37476.pdf 1220 Ibid. 1221 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). 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
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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 

1223 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). 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 

Program Manager for the 737 MAX program, Boeing Commercial Airplanes (BCA), May 11, 2020. 1226 Hearing titled, “The Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight of the Aircraft’s 

Certification,” House Committee on Transportation & Infrastructure, U.S. House of Representatives, 116th Congress, 

First Session, December 11, 2019, p. 244, accessed here: https://www.govinfo.gov/content/pkg/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf
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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 noncompliances 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 noncompliance” 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/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 1228 Ibid., p. 191. 1229 Ibid. 1230 Ibid., p. 197. 1231 Ibid. 1232 Ibid., p. 198.
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• 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 noncompliance.”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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf
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(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. 1240 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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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/CHRG116hhrg40697.pdf

1243 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 (Note: The Injury Ratio 

factor of 1.05 means the loss of 5 bystanders for every 100 airplane occupant losses.)
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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: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf

1245 Boeing 737 MAX Deliveries Report, The Boeing Company, accessed here: 

http://www.boeing.com/commercial/#/orders-deliveries 1246 Ibid. 1247 Hearing titled, “The Boeing 737 MAX: Examining the Federal Aviation Administration’s Oversight of the Aircraft’s 

Certification,” House Committee on Transportation & Infrastructure, U.S. House of Representatives, 116th Congress, 

First Session, December 11, 2019, p.20, accessed here: https://www.govinfo.gov/content/pkg/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1248 Ibid., p. 21. 1249 Ibid., p. 244 1250 “Lion Air Flight 610 Final Aircraft Accident Investigation Report,” accessed here: https://aviation-is.betterthan.tv/737%20MAX%202018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf
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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.
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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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1260 Ali Bahrami, Associate Administrator for Aviation Safety, Federal Aviation Administration (FAA), Biography, 

accessed here: https://www.faa.gov/about/key_officials/bahrami_avs/
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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-boeing787-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.aiaaerospace.org/news/bahrami-named-vice-president-of-civil-aviation 1266 “Executive Committee Leadership,” Aerospace Industries Association (AIA), accessed here: https://www.aiaaerospace.org/about-aia/leadership-and-governance/executive-committee 1267 Committee staff transcribed interview of FAA Associate Administrator for Aviation Safety Ali Bahrami, December 

5, 2019.

1268 Ibid. 1269 See: 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. 22, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG116hhrg38282.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-newdocuments-on-737-max-safety/2019/10/30/ef3a8334-fa92-11e9-ac8c-8eced29ca6ef_story.html
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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. 

1270 Committee staff transcribed interview of FAA Associate Administrator for Aviation Safety Ali Bahrami, December 

5, 2019.

1271 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. 245, accessed here: https://www.govinfo.gov/content/pkg/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf
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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. 1276 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 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. 1281 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
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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/CHRG116hhrg38282/pdf/CHRG-116hhrg38282.pdf 1285 Ibid. 1286 Ibid. 
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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.1287The 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 

require corrective action; however, they are 

included to be addressed for improvement.”1288

After the Committee was informed 

about this document in January 2020, the 

Committee made numerous requests for a copy 

of it with both DOT and directly to FAA 

Administrator Dickson. The FAA refused to 

provide a copy of this report to the Committee 

because it was a draft. However, FAA did make 

a copy available for Committee staff to review 

“in camera” remotely. Committee staff reviewed 

the document on May 2, 2020. 

According to the FAA, the document 

was never ultimately completed. They have 

claimed that their review of MCAS was going 

through management review and was overtaken 

by the crash of Ethiopian Airlines flight 302.1289

Based on the Committee’s review of the metadata 

associated with the draft “737-8 MAX 

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.

1287 “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).

1288 Ibid. 1289 “Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8 Aircraft and Actions Taken After the 

October 2018 Lion Air Accident,” DOT OIG, June 29, 2020, pp. 32-33, accessed here: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf

“737-8 MAX Maneuvering 

Characteristics Augmentation System 

Oversight Report” 

FAA’s Boeing Aviation Safety 

Oversight Office (BASOO) 

February 8, 2019

“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 

REQUIRE CORRECTIVE ACTION; 

HOWEVER, THEY ARE INCLUDED 

TO BE ADDRESSED FOR 

IMPROVEMENT.”
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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

1290 “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, 

p. 8, 12 (Draft). (Reviewed remotely “in camera” via access to FAA website by Committee Staff on May 1, 2020). 1290 Ibid. 1291 “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, 

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 

October 2018 Lion Air Accident,” DOT OIG, June 29, 2020, pp. 32-33, accessed here: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf

1292 “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, 

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: 

https://www.faa.gov/news/media/attachments/Final_JATR_Submittal_to_FAA_Oct_2019.pdf

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
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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/boeings737-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. 
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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
10. New Issues Emerge
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-New Issues EmergeThe 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: 

https://www.faa.gov/news/press_releases/news_story.cfm?newsId=24574 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-couldcomplicate-737-max-return-11579290347
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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 design1313—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 arcing1316 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-maxsoftware-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-fcccrash

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-theboeing-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-maxwiring-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-wiringbundles

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-maxwiring-flaw-that-boeing-missed/?utm_source=referral&utm_medium=mobile-app&utm_campaign=ios
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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-wiringexclusive/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-inlate-june-sources-idUSKBN23H2O7 1321 Ibid. 1322 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-theboeing-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-undelivered737-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-maxproduction-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
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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 Systems1333 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-andfix-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-

13481/airworthiness-directives-the-boeing-company-airplanes 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_evs3600-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
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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. 1338 See 85 FR 47698; Docket No. FAA-2020-0686; Docket Name: 2019-NM-035-AD; Airworthiness Directives; The 

Boeing Company Airplanes, accessed here: https://www.federalregister.gov/documents/2020/08/06/2020-

17221/airworthiness-directives-the-boeing-company-airplanes 1339 A 45-day public comment period began when FAA’s proposed Airworthiness Directive published in the Federal 

Register.
11. Final Observations
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-Final ObservationsObservations 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-eboeing.page

1341 Ibid. 1342 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, p. 275, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG116hhrg38282.pdf
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(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.
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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. 1348 Boeing Coordination Sheet, “737MAX Flaps Up High Alpha Stabilizer Trim (MCAS) Requirements,” No. Aero-BBBA8-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 

(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 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/CHRG116hhrg38282/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 

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-BBBA8-C12-0159, Model: 737-MAX (-7/8/9), Revision G, June, 11 2018, accessed at p. 174 here: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 1349 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, p. 281, accessed here: https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG116hhrg38282.pdf
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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-toboeing-737-max-flight-controls 1352 Ibid. 1353 Ibid. 
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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

1354 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. 14, accessed here: https://www.govinfo.gov/content/pkg/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf 1355 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
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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-certificationprocess-committee-sends-records-requests-to-faa-boeing
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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 FAAT&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-oversightof-aircraft-certification
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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 

1366 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, pp. 149-150, accessed here: https://www.govinfo.gov/content/pkg/CHRG116hhrg40697/pdf/CHRG-116hhrg40697.pdf 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
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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: 

https://www.govinfo.gov/content/pkg/CHRG-116hhrg38282/pdf/CHRG-116hhrg38282.pdf 1370 See “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, 

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: 

https://www.oig.dot.gov/sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%

20Timeline%20Final%20Report.pdf

1371 “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, 

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
-FINAL COMMITTEE REPORT: BOEING 737 MAX11. Final Observations

238

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. 

1373 Committee staff transcribed interview of Keith Leverkuhn, former Vice President and General Manager of the 737 

MAX program, Boeing Commercial Airplanes, May 19, 2020. 

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-gettingnew-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/boeing737-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-itschanging-the-name-of-its-new-generation-of-737s/#20dc4753619b