In a scathing 246 page report by the House Transportation Committee, Democrats found multiple Boeing engineers and test pilots expressed concerns about the system that would ultimately be linked to two deadly 737 Max crashes – and yet those problems were never fixed.
The plane was deemed compliant by the FAA according to existing standards, but was "demonstratively unsafe," casting doubt on the certification process, according to committee investigators.
"The FAA failed to ensure the safety of the traveling public," the report found.
"It's mind boggling," said committee chairman Peter DeFazio, a Democrat from Oregon. "Both the FAA and Boeing came to the conclusion that the certification of the max that killed 346 people was 'compliant' but the problem was it was compliant and people died."
The two crashes killed 346 people and the 737 Max has been grounded since March 2019. The report, the most thorough to date, was compiled without Republican staff. The report is being released as a key step toward ungrounding the plane is playing out at a London-area airport, where a panel of 737 pilots have gathered to evaluate proposed new training requirements.
Boeing has acknowledged its assumptions about pilot response time were incorrect, but the report reveals new details of the plane's development.
To respond to issues with the MCAS anti-stall system, a key factor in the two crashes, Boeing had assumed a pilot could respond in about four seconds. But, as far back as 2012, internal Boeing test data revealed "it took a Boeing test pilot more than 10 seconds to diagnose and respond to the uncommanded MCAS activation" in a flight simulator, the report says. Citing Boeing documents, the test pilot found the condition to be "catastrophic."
While that outcome was noted on six different internal reports over a multiyear period, the FAA and 737 Max customers were never told — such disclosure was not required by the FAA.
During the plane's development in 2016, an engineer, observing a pilot struggle to maintain control in a simulator, asked about repeated MCAS activations. Another Boeing employee questioned the use of a single Angel of Attack sensor with MCAS. In both crashes a failed sensor kicked off the deadly MCAS response.
But the report said questions about MCAS were "not thoroughly investigated or dismissed."
Instead, according to the report, Boeing tried to not to disclose MCAS as a new function, because that would risk additional scrutiny and the possibility of simulator training. If simulator training were required, that would have driven up costs for Boeing – up to $400 million in its contract with Southwest Airlines alone.
"Boeing presented a massive amount of data to the FAA but they never highlighted MCAS as a novel or new system, in fact they had an internal meeting in 2013 where they agreed they'd never talk about MCAS outside of Boeing," DeFazio said during a call with reporters.
The report also expressed concerns over undue pressure from Boeing on company employees who act as FAA representatives during the certification process. It faulted FAA management for undercutting the authority and judgment of its own technical experts, as well as "poor, disjointed FAA communication."
The FAA "failed in its duty to hold Boeing accountable" and "did not ask enough questions or sufficiently scrutinize Boeing responses," the report said.
"FAA showed a lack of insight into what was going on at Boeing and lack of oversight of Boeing," one investigator who worked on the report said. "How do you have an aircraft that is demonstratively unsafe yet it complied with FAA regulations? That is really striking."
The report also faulted the FAA for not acting faster after the initial 737 Max crash.
In a statement from Boeing, the company said, "We have learned many hard lessons as a company from the accidents of Lion Air Flight 610 and Ethiopian Flight 302, and from the mistakes we have made. Change is always hard and requires daily commitment, but we as a company are dedicated to doing the work."
The FAA told CBS News, "The FAA is committed to continually advancing aviation safety and looks forward to working with the Committee to implement improvements identified in its report. We are already undertaking important initiatives based on what we have learned from our own internal reviews as well as independent reviews of the Lion Air and Ethiopian Airlines accidents."
The report was critical of the pace the Department of Transportation, which houses the FAA, has turned over documents as part of this investigation.
On Wednesday, the Senate Commerce Committee is holding a markup on its FAA reform bill. The House is yet to propose regulatory reform but this report will be the backbone of that proposed legislation.