BOEING’s repeatedly pushing the ROCK the wrong way.
The Congress of the United States legislated [AIRCRAFT CERTIFICATION, SAFETY AND, ACCOUNTABILITY Act Pub. L, 116-260 Div. V, section 103] that an independent expert panel to
“conduct focused oversight of Boeing’s processes for performing FAA-delegated functions.” (” Section 103 ODA expert Panel”). The 24 members[1] on February 24,2024, issued a 50 page report. Below is Sean Broderick meticulous analysis of the Panel’s Finding and recommendations as published in AvWeek. All should benefit from his usual superb review of this major aviation safety document”.
Here is their Executive Summary:
What are the predicates to the Panel’s findings about Boeing’s “Deep Cracks” in its SMS:
>Secretary Elaine Chao established a Special Committee to Review the FAA’s Aircraft Certification Process on January 16, 2020, a report was issued, among its findings:
- Broader requirement for Safety Management Systems (SMS) for design and manufacturing organizations
- Expansion of System Safety Assessments (SSA), which are an essential component of safety risk management
>House Committee on Transportation and Infrastructure Investigation:
- The House Committee on Transportation and Infrastructure conducted an investigation following the two overseas accidents involving Boeing 737 MAX aircraft that resulted in the loss of 346 lives. Their focus was on ensuring accountability, transparency in the certification process, and passenger safety.
- The final committee report covered the design, development, and certification of the Boeing 737 MAX. It included records from Boeing and the FAA, as well as transcribed interviews with relevant individuals.
>DOT OIG Report on FAA’s Certification and Delegation Processes:
- The Department of Transportation (DOT) Office of Inspector General (OIG) investigated weaknesses in the FAA’s certification and delegation processes related to the Boeing 737 MAX 8. The report highlighted concerns about oversight and certification of civilian aircraft manufactured and operated in the United States.
> Timeline of Activities Leading to Certification of the Boeing 737 MAX 8:
- Another DOT OIG report compiled a timeline of events following the Lion Air Flight 610 crash in October 2018 up until the Ethiopian Air Flight 302 crash in March 2019. This timeline sheds light on critical moments during the certification process
>FAA Actions to Improve Quality Control:
- After grounding the Boeing 737-9 MAX aircraft, the FAA halted Boeing’s production expansion to address quality assurance issues. The agency aims to enhance oversight and ensure safety.
>US DOT OIG FAA Has Completed 737 MAX Return to Service Efforts, but Opportunities Exist To Improve the Agency’s Risk Assessments and Certification Processes AV2023025 | April 26, 2023
>FAA Updates on Boeing 737 MAX two years and more than 30 releases about the FAA’s responses to this problem.
With that history it is difficult to comprehend how this most recent independent review assessment STILL found:
- “SAFETY PROBLEMS RUN DEEPER INTO THE ORGANIZATION”
>Human Factors issues caused by Boeing administrative decisions like “reorganization, decentralization, downsizing, and relocating the company’s headquarters” out of the Seattle area.[2]”
- The panel “could not find [policies or procedures] that ensured the pilot’s safety of flight concerns are adequately addressed independent of the individual occupying executive leadership positions
- The panel “was NOT made AWARE OF documents that EXPLICITLY TRANSLATES CONTENT found in the top-level SMS documents INTO LANGUAGE (I.E., TERMS, DESCRIPTIONS, ETC.) USED MOST OFTEN AT THE WORKING LEVELS OF THE VARIOUS FUNCTIONS ACROSS BOEING.”
- “Boeing’s overarching SMS manual was revised between 2022 and 2023 with the only revision description noted as ‘MAJOR REWRITE,’” the panel said. “No other revision indicators were present throughout the document.”
- FEAR OF RETALIATION!!!
Clearly, NOT ALL/MANY of the Boeing 170,000 employees UNDERSTAND OR ARE COMMITTED TO SMS. How is that possible after:
- the global outcry about the company’s failings,
- repeated high level reports by government organizations and outside experts,
- and
- almost constant critical coverage of every incident/accident in which the word “BOEING” name is mentioned.
This pattern reminds one of the story of the Greek leader of Corinth, SISYPHUS. He angered the gods and was punished by forcing him to roll an immense boulder up a hill only for it to roll back down every time it neared the top, repeating this action for eternity. Boeing seems to be pushing the same boulder up the certification hill. They appear to ignore the repeated message that SMS/SAFETY CULTURE is a LEVER that will return Boeing to its previous position. Do it right from the Boars to the Senior Officer suite then all through management and most importantly- the men and women on the line.
Expert Panel Finds Deep Cracks In Boeing’s Organizational Safety Structure
Sean Broderick February 26, 2024
Credit: Stephen Brashear / Getty Images
Cracks in Boeing’s organizational safety structure remain large and extend well into its fundamental role of designing commercial aircraft, a report from a panel of safety experts found.
The congressionally mandated report called for an independent review of Boeing’s SAFETY MANAGEMENT PROCESSES, INCLUDING ITS ORGANIZATIONAL DESIGNATION AUTHORIZATION (ODA), and recommendations on how to address any issues. It found problems in the ODA, despite Boeing’s and the FAA’s efforts to make changes in the aftermath of two 737 MAX accidents linked at least in part to certification-related ODA shortcomings.
However, the 24-member panel found Boeing’s SAFETY PROBLEMS RUN DEEPER INTO THE ORGANIZATION. The role and influence of human factors during aircraft design has “eroded due to a series of administrative decisions at Boeing, which includes reorganization, decentralization, downsizing, and relocating the company’s headquarters” out of the Seattle area, the report said.
Pilot input, even from internal sources, is not handled consistently during aircraft design, particularly when “pilots did not occupy a seat at the table,” the report said. The panel “could not find [policies or procedures] that ensured the pilot’s safety of flight concerns are adequately addressed independent of the individual occupying executive leadership positions,” it added.
Boeing told the panel it is “rebuilding” its commercial airplanes human factors capability.
Absence of sufficient human factors considerations is one of many factors that set the stage for the two fatal 737 MAX accidents in 2018 and 2019. Regulators and manufacturers are responding with new rules and procedural changes.
Development of Boeing’s Safety Management System (SMS), launched in 2015, and recent changes in the ODA program have led to SOME IMPROVEMENTS, the panel found. BUT MANY ISSUES REMAIN. AMONG THEM: EMPLOYEES LACK A CLEAR UNDERSTANDING OF BOEING’S SMS AND THEIR ROLES IN IT.
“The Expert Panel struggled to identify effective guidance that translated Boeing’s SMS expectations in each employees’ role,” panelists wrote. The panel “was NOT made AWARE OF documents that EXPLICITLY TRANSLATES CONTENT found in the top-level SMS documents INTO LANGUAGE (I.E., TERMS, DESCRIPTIONS, ETC.) USED MOST OFTEN AT THE WORKING LEVELS OF THE VARIOUS FUNCTIONS ACROSS BOEING.”
Adding to the confusion: Updates to Boeing’s core SMS documentation are not clearly communicated.
“For example, Boeing’s overarching SMS manual was revised between 2022 and 2023 with the only revision description noted as ‘MAJOR REWRITE,’” the panel said. “No other revision indicators were present throughout the document.”
The panel hinted at signs of Boeing’s issues exhibited in the process of their work.
Panelists embraced a “seek, speak, and listen” approach to the project, mimicking a Boeing principle introduced in 2021 as part of broader safety-culture reforms, the report said.
“Throughout the discovery and assessment process … ATTENTION WAS GIVEN TO SPEAK, WITH LITTLE OR NO ATTENTION GIVEN TO SEEK OR LISTEN,” the report said. “THE EXPERT PANEL PROVIDED NUMEROUS OPPORTUNITIES THROUGHOUT ITS ENGAGEMENTS WITH BOEING FOR IT TO SEEK INFORMATION FROM THE EXPERT PANEL’S EXPERIENCES ON APPROACHES TO SAFETY CULTURE, SMS, OR ODA. THE EXPERT PANEL RECEIVED MINIMAL QUESTIONS FROM BOEING DURING THESE ENGAGEMENTS.”
The panel also noted that some Boeing employees view its work as an audit rather than a collaboration opportunity.
“Interviewees asked minimal questions of the experts,” the report said. “Some interviewees mentioned a briefing was provided by Boeing legal prior to the interviews.”
The panel’s report lists 27 findings and 53 related recommendations for both Boeing and the FAA.
“Within six months of the issuance of this report, Boeing should review the recommendations contained in this report and develop an action plan that includes a milestone-based approach that comprehensively addresses each recommendation,” the panel said. “Boeing should then share that action plan, including implementation dates, with the FAA.”
The FAA, which is auditing some of Boeing’s production processes as part of a different probe, said it “will immediately begin a thorough review of the report and determine next steps regarding the recommendations as appropriate.”
The report is based on 4,000 pages of Boeing documents dating back to 2009—the beginning of its ODA—seven surveys, and more than 250 interviews. Panel members included representatives from the FAA, other manufacturers, operators, labor groups, academia, and regulatory policy.
Senior Air Transport & Safety Editor Sean Broderick covers aviation safety, MRO, and the airline business…
[1] The categories of Members were set by Congress. The FAA appointed 5 USG members, 5 labor members, 2 academics, 4 Part 121 members and 4 OEM ODAs.
[2] #FAA looking for #BOEING inspections from 3rd party inspections? Bring back #UL that was the #FIRST to #CERTIFICATE #AIRCRAFT!!!History has an ANSWER for FAA’s 3rd party inspections – JDA Journal (jdasolutions.aero)It was suggested that Boeing’s return of its Executives to Renton would show that they are part of the SMS team. However, the Boeing rejected a shareholder-sponsored proposal to do that.
