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737 Max

DOT Inspector General Report Highlights 737 MAX Problems

DOT Inspector General Report Highlights 737 MAX Problems
Joe Cortez

A 54-page report from the U.S. Department of Transportation Office of the Inspector General offers new insight into how the 737 MAX was approved, and how the Federal Aviation Industry reacted after the two fatal crashes caused by problems with the aircraft.

A new report published by the U.S. Department of Transportation Office of the Inspector General (OIG) is shedding new light on how the Boeing 737 MAX was approved for commercial use, and what the Federal Aviation Administration did after two fatal crashes killed over 300 people. The 54-page report was released on July 1, 2020, detailing all the events before and after the worldwide grounding of the troubled aircraft.

Report Alleges Boeing Made Changes Without FAA Oversight

While the Boeing 737 project dates back to 1967, the 737 MAX 8 was certified with an amended type certificate (ATC), based on the on the 737-800 and part of the “Next Generation” series. But unlike the 737-800, the MAX-8 included the Maneuvering Characteristics Augmentation Systems (MCAS), a new feature of the narrow-body aircraft. This new system was developed to accommodate aerodynamic changes due to the larger engines placed on the wing.

A comparison of engines on the 737-800 (left), and the 737 MAX-8 (right). Source: Boeing; Published by the U.S. DOT OIG.

“MCAS can cause the airplane’s horizontal stabilizer to move without pilot input in certain, limited aircraft configurations related to airspeed and the angle of the aircraft in the air,” the OIG report reads. “This has the effect of moving the plane’s nose down during flight to compensate for the aircraft’s tendency to pitch up.”

An analysis of how the MCAS works on the 737 MAX. Source: OIG analysis of FAA and Boeing data.

Between 2012 and 2014, Boeing and the Federal Aviation Administration worked together on the 737 MAX certification process. This included determining where the FAA would have direct supervision, and what would be delegated to Boeing’s internal team. Once the division of labor was determined, the report claims Boeing made changes to the MCAS software platform, which were not communicated to the FAA.

The report goes on to allege the FAA may have been complicit in the changes, because the MCAS was not under scrutiny. According to the findings: “FAA flight test personnel were aware of this [MCAS] change, but key FAA certification engineers and personnel responsible for approving the level of airline pilot training told us they were unaware of the revision to MCAS.”

It would take Boeing four years to report the changes in the MCAS system to the FAA. While this isn’t unusual in its own right, the lack of research and development may have allowed the flawed MCAS system to go into the final product.

“Boeing’s safety analysis did not assess system-level safety risks as catastrophic,” the report reads. “Thus, Boeing designed MCAS to rely on data from a single aircraft sensor rather than including redundancy, which would have reduced risk.”

Emergency Airworthiness Directive Failed to Note MCAS

After the crash of Lion Air Flight 610 on Oct. 29, 2018, the preliminary investigation discovered the MCAS system activated over 20 times because of inaccurate angle-of-attack data. This led to the pilots losing control of the aircraft, and the ultimate crash.

During the certification process, Boeing’s engineers noted that multiple MCAS activations could happen, but assured it could be counteracted by the pilots after the first indicator. Regardless, Boeing issued a bulletin to operators eight days after the accident, followed by an emergency airworthiness direction from the FAA.

“Although the bulletin and the Emergency AD emphasized pilot procedures for handling repeated nosedown movements, neither specifically mentioned MCAS,” reads the report.

It wasn’t until the Lion Air accident that the FAA began inspections on the MCAS system. Before that, the report alleges that Boeing never presented a full picture of how the MCAS worked. By February 2019, Boeing and the FAA agreed to a MCAS software fix to be completed by Apr. 12, but it wasn’t in time to save Ethiopian Air Flight 302. Like in the crash of Lion Air Flight 610, the MCAS system was a contributing factor in the incident.

Although Boeing has paid $12 million in civil penalties over the certification process and dedicated $100 million to the families of those lost, there may still be issues inside Boeing.

“FAA’s subsequent oversight found that Boeing has not yet resolved all the identified issues, including improving its identification and resolution of the root causes of non-compliances with FAA requirements,” the report reads. “During this time period, Boeing and FAA also identified concerns about undue pressure on ODA personnel at multiple Boeing facilities, which culminated in FAA issuing a formal compliance action against Boeing in November 2018. Boeing’s response to this compliance action remains ongoing.”

Report Comes as 737 MAX Flies Again

The timeline report is released at a critical time for both Boeing and the FAA. On Monday, June 29, 2020, the first re-certification test flight of the 737 MAX took off from Boeing Field, and lasted several hours. The test was supervised by both Boeing and FAA officials. Boeing has not yet commented on the results of the test flight.

Meanwhile, the FAA remains under fire over how they handled the launch of the 737 MAX. During a Senate hearing, lawmakers on both sides of the aisle expressed frustration on how the FAA is “stonewalling” open investigations, and that nobody from the FAA has been excused from their jobs due to the accidents.

Neither Boeing nor the FAA have commented publicly on the OIG report.

View Comments (8)


  1. DMIND00

    July 2, 2020 at 5:24 am

    f the 737 Max is ever allowed to be used by airlines in the future, I doubt I will every fly on it. It sounds like a too complicated type of plane and I do not trust some fo the mechanical features and the reasons for their design. Also will not fly on them because of the blatant miss steps both Boeing and the FAA did that resulted in all the deaths of the 2 airplane crashes. It is very sad that this country has only one airplane manufacture.

  2. edgewood49

    July 2, 2020 at 8:10 am

    DMIND00 if you were to fly the 777 it too has many of the same systems as does Air Bus in their newer generation planes. The old days of hydraulic’s, flight management controls have been “turned” over to programs. Been that way for a very long time. If one were to say I won’t fly on these then trains and boats seem to be your best choice .

    Now back to reality Joe any word on the status on the current flight eval testing ?

  3. CEB

    July 2, 2020 at 8:28 am

    Another trashy recycle by Cortez to bad mouth Boeing. Completely uncalled for as the reality is that NOW the FAA has taken control of the re-certification process and Boeing is making significant progress toward getting the 737 MAX back in the air under the watchful eye of the FAA. I’m sure that Cortez will continue with his trash talk as that seems to be the only thing he knows.

  4. Joe Cortez

    July 2, 2020 at 8:41 am

    The three days of testing are complete, and the FAA provided video of the tests as they happened. I’ll publish an update on the story today.

  5. BC Shelby

    July 2, 2020 at 1:31 pm

    ….what they need to do is totally dump MCAS require retraining./type certification of aircrews on the Max as a new aircraft type due to the difference in handling because of the engine placement, and then I might consider flying on one. I have no issue with full FBW butr MCAS was a kluge to make the Max handle like the 737 “Classic” so airlines (which gouge us with more and more fees) could pad their profit margin further by skirting the costs of retraining of aircrews.

    Instead of introducing a totally new aircraft type (an outgrowth of the 757) Boeing’s “solution” was to push the 737 far beyond it’s original concept of a small airport short to medium haul jetliner out of fear of losing customers to rival Airbus. If they wanted to keep the 737 line going, they should have worked with engine developers for a more efficient powerplant that didn’t affect the physical flight characteristics (like the P&W geared turbofans used on the A 220) instead of trying to fit an engine that is just too large for the 737’s low stance

    The LEAP engine would pose no issue on a 757 it is designated as one of the powerplant options for the A321 NEO and XLR which is in the same class.

  6. horseymike

    July 3, 2020 at 4:32 am

    BC Shelby your comments are spot on. well said.

  7. DMIND00

    July 3, 2020 at 3:11 pm

    edgewood49 & CEB 300 peoples lives dying from the 737 MAX is a major issue that I do not take lightly and find that you show lack of concern of these deaths on Boeing aircraft. This never should have happened and would not have happened if they would have provided the plane for Commerical use only after all through testing had been done and all problems corrected and provided the required training for the pilots. Never should pilot training or safety features be optional on purchasing planes. I have read all and Boeing really dropped the ball. These deaths never should have happened. I do not consider Cortez story trash. It appears to me that you two do not value peoples lives or take seriously the major miss steps that Boeing and the FAA took all in trying to beat Airbus.

  8. Cedar Jet

    July 4, 2020 at 5:56 pm

    Criminal company, death trap, ill thought aircraft. Pass…..wont ever get me on that ‘thing’.

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