A case study of real lives lost.

Technical 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. (p. 5)

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 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.  (p. 6)

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. (p. 230)

Source: Final Committee Report on the Design, Development, and Certification of the Boeing 737 MAX, September 2020,  accessed 200918.

For committee activities, see https://transportation.house.gov/committee-activity/boeing-737-max-investigation, accessed 200918.