Don Hudson

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  1. FAA hits Boeing with $3.9 million fine for slat track issue 07 December, 2019 SOURCE: BY: Jon Hemmerdinger Boston The Federal Aviation Administration has proposed fining Boeing $3.9 million for installing slat components that failed quality inspections on 133 737 jets. The issue, which came to light in June with an FAA airworthiness directive, involves "slat tracks", which are located on the leading edge of 737 wings and guide the movement of slats, says an FAA media release. The issue affected 737NGs and 737 Max. The FAA says Boeing failed to properly oversee suppliers and installed slat tracks that "were weakened by a condition known as hydrogen embrittlement that occurred during the cadmium-titanium plating", the FAA says. "The FAA further alleges that Boeing knowingly submitted aircraft for final FAA airworthiness certification after determining that the parts could not be used due to a failed strength test," it says. FAA documents say supplier Kencoa Aerospace, based in Georgia, provided the slat tracks, and that another company called Southwest United Industries performed the cadmium-titanium plating. Kencoa sent the tracks to Spirit AeroSystems, which eventually shipped the components to Boeing. Southwest United, a division of Washington-based PCC Aerostructures, notified Kencoa in July 2018 that a batch of tracks had failed a quality test, and Kencoa passed that information to Spirit in early August of that year. Spirit then informed Boeing of the problem in September 2018, says the FAA. Before being notified of the issue, Boeing certificated 48 aircraft that may have had affected slats. The company then certificated another 85 potentially affected aircraft after being informed, says the FAA. Boeing has 30 days to respond to the FAA's proposed penalty. The company says it has already inspected and performed required work on all affected 737NGs and that it will address affected 737 Max before those aircraft return to service. "Safety and quality are Boeing’s top priorities, and Boeing has made a number of significant changes to our organisation and processes in recent months that will reinforce and enhance this commitment," Boeing says. Those changes include the creation of a new product safety division and new lines of reporting for engineers. "We are committed to continuing to strengthen our processes to ensure that quality issues in our production system are promptly identified, elevated and resolved," Boeing says. Spirit says it "worked closely with its Boeing customer, regulators and the supplier who procured this part to address the issue. While not a Spirit-made part, we take the safety and quality of everything we provide very seriously". Neither Southwest United nor Kencoa could be reached immediately by FlightGlobal for comment.
  2. Hi seeker; Agree - contrary to "pie-in-the-sky", all indications point to electric, autonomous flight at some point. In my view, December 11th is as much a "Kitty Hawk" moment as the first one, a mere 115 years, 11 months, 24 days ago...
  3.,1,ysiX9taooSB2jCDjMbfpDp71pDfgLs5CBTwEcgG8q4KGAlqPCa_i6df-khmd-hzlfoBn7KH2czbzYtlvq9XNI9U5yOGBdZ19Sq5Q79KliwrblxBYPFYyOA,,&typo=1 The investigation concluded that: The IAC also included a number of contributing factors such as the presence of windshear, crew preparation for the second go-around, and the PIC's loss of situational awareness (spatial disorientation) which led to the final pushover. The report contains a total of 26 recommendations including 6 to the FATA (Russian regulator), 8 to the operator, 3 to the FAA and the HUD manufacturer, 2 to certification authorities, 6 to Boeing, and 1 to ICAO. Boeing is reviewing the details of the final report and will work with the FAA and global regulators to consider the safety recommendations; we have no recommended operator action at this time. Robert J McIntosh Director, Product Safety & Air Safety Investigation Boeing Commercial Airplanes
  4. Hi Rich; Hehe...Same question as, "What's a pixel weigh?" But if course it's the heavy support system that makes, "it weighs nothing", possible. As Einstein understood, there's no free lunch in nature! The reducing-weight-through-burning-fuel problem is partly mitigated by the superior efficiency of electric engines over internal-combustion engines. Perspective: take a look at the clever but highly-inefficient Newcomen engine of ~300 years ago! The challenges are always power-to-weight. Kerosene out-performs current lithium-ion solutions by approximately a 50:1 ratio. Development of Li-ion power/volume/weight ratios is proceeding at about a 3x/year level. Long-range, high-capacity airliners, like autonomous flight, are a long way away yet.
  5. On fuel requirements, good question, J.O. Interestingly, the whole "fuel to carry fuel" and reduced power needs as fuel is burnt would no longer apply because the landing weight of electric aircraft would be the same as the takeoff weight.
  6. FMEA process and Boeing - some history, (January 25, 2013), specifically regarding batteries. The article does not mention an early, serious battery issue with the ELT - AAIB Report. What Went Wrong with Boeing's 787 Dreamliner The production of the jet that was eventually dubbed the Dreamliner was plagued with manufacturing delays, cost overruns and sinking worker morale. By SCOTT MAYEROWITZ Published Jan 25, 2013 at 6:07 AM | Updated at 6:49 AM CST on Jan 25, 2013 AP An All Nippon Airways flight sits at Takamatsu airport in Takamatsu, western Japan after it made an emergency landing Wednesday, Jan. 16, 2013. The flight to Tokyo from Ube in western Japan landed at the airport after a cockpit message showed battery problems, in the latest trouble for the Boeing 787 Dreamliner. The 787 Dreamliner was born in a moment of desperation. It was 2003 and Boeing — the company that defined modern air travel — had just lost its title as the world's largest plane manufacturer to European rival Airbus. Its CEO had resigned in a defense-contract scandal. And its stock had plunged to the lowest price in a decade. Two years after the 9/11 terrorist attacks, financially troubled airlines were reluctant to buy new planes. Boeing needed something revolutionary to win back customers. Salvation had a code name: Yellowstone. It was a plane that promised to be lighter and more technologically advanced than any other. Half of it would be built with new plastics instead of aluminum. The cabin would be more comfortable for passengers, and airlines could cut their fuel bills by 20 percent. But once production started, the gap between vision and reality quickly widened. The jet that was eventually dubbed the Dreamliner became plagued with manufacturing delays, cost overruns and sinking worker morale. In interviews with The Associated Press, a dozen former Boeing engineers, designers and managers recounted the pressure to meet tight deadlines. Adding to the chaos was the company's never-before-tried plan to build a plane from parts made around the globe. The former Boeing workers still stand behind the jetliner — and are proud to have worked on it. But many question whether the rush contributed to a series of problems that led the Federal Aviation Administration last week to take the extraordinary step of grounding the 787. Other countries did the same. Even before a single bolt was tightened, the Dreamliner was different. Because executives didn't want to risk all of the billions of dollars necessary to build a new commercial aircraft, they came up with a novel, but precarious, solution. A global network of suppliers would develop, and then build, most of the parts in locations as far away as Germany, Japan and Sweden. Boeing's own employees would manufacture just 35 percent of the plane before assembling the final aircraft at its plant outside Seattle. The decision haunts Boeing to this day. The FAA's order to stop flying the Dreamliner came after a battery fire aboard a 787 in Boston and another battery incident during a flight in Japan. It was the first time the FAA had grounded a whole fleet of planes since 1979, when it ordered the DC-10 out of the sky following a series of fatal crashes. Inspectors have focused on the plane's lithium-ion batteries and its complicated electrical system, which were developed by subcontractors in Japan, France, Arizona and North Carolina. Boeing declined to comment about the past but said its engineers are working around the clock to fix the recent problems. "Until those investigations conclude, we can't speculate on what the results may be," the company said in a statement. "We are confident the 787 is safe, and we stand behind its overall integrity." For decades, Boeing has been responsible for the biggest advances in aviation. The jet age started in 1958 with a Pan American flight between New York and Paris that took just eight and a half hours aboard the new Boeing 707. In 1970, Boeing ushered in the era of the jumbo jet with the 747. The giant plane, with its distinctive bulbous upper deck, made global air travel affordable. Suddenly a summer vacation in London wasn't just for the rich. By the start of the 21st century, change was much more incremental. Consolidation had left the world with two main commercial jet manufacturers: Boeing and Airbus. Boeing executives initially had not considered government-backed Airbus a serious competitor. But in 2003, the unthinkable happened. Boeing delivered just 281 new jets. Airbus produced 305, becoming for the first time the world's biggest plane manufacturer. American jobs — and pride — were at stake. And that wasn't all. Airbus was starting to develop its own new jet: the A380, the world's largest commercial plane, capable of carrying up to 853 passengers, or the equivalent of at least five Boeing 737s. "They were scaring everybody," said Bryan Dressler, who spent 12 years as a Boeing designer. "People here in Seattle have been through the booms and busts of Boeing so many times, even the slightest smack of a downturn makes people very edgy." Airbus believed that larger airplanes were needed to connect congested airports in the world's largest cities. Boeing executives weren't so sure. They believed airline passengers would pay a premium to avoid those same congested hubs with long nonstop flights between smaller cities. Now they just needed to develop a plane that would somehow make such trips economical. It had been 13 years since Boeing started development of a new plane, the 777. The company had recently scrapped two other major projects: a larger version of the 747 and the Sonic Cruiser, a plane that would fly close to the speed of sound. A development team with a knack for assigning new planes code names based on national parks had just the thing: Project Yellowstone. The plane — eventually rechristened the Dreamliner after a naming contest — was unlike anything else previously proposed. Half of its structure would be made of plastics reinforced with carbon fiber, a composite material that is both lighter and stronger than aluminum. In another first, the plane would rely on rechargeable lithium-ion batteries to start its auxiliary power unit, which provides power on the ground or if the main engines quit. While other planes divert hot air from the engines through internal ducts to power some functions, the 787 uses electricity. Getting rid of those ducts is one thing that makes the plane lighter. There were also benefits for passengers. The plane's extra strength allowed for larger windows and a more comfortable cabin pressure. Because composites can't corrode like aluminum, the humidity in the cabin could be as much as 16 percent, double that of a typical aircraft. That meant fewer dry throats and stuffy noses. Before a single aircraft was built, the plane was an instant hit, becoming the fastest-selling new jet in history. Advance orders were placed for more than 800 planes. Boeing seemed to be on its way back. "Employees knew this was going to be a game changer, and they were stoked that the company was taking the risk to do something big," said Michael Cook, who spent 17 years as a computer developer at Boeing. But this was no longer the trailblazing, risk-taking Boeing of a generation earlier. The company had acquired rival McDonnell Douglas in 1997. Many McDonnell Douglas executives held leadership positions in the new company. The joke was that McDonnell Douglas used Boeing's money to buy Boeing. The 707 and 747 were blockbuster bets that nearly ruined the company before paying off. McDonnell Douglas executives didn't have the same appetite for gambling. So the only way the board of directors would sign off on the Dreamliner was to spread the risk among a global chain of suppliers. In December 2003, they agreed to take on half of the estimated $10 billion development cost. The plan backfired as production problems quickly surfaced. "I saw total chaos. Boeing bit off more than it could chew," said Larry Caracciolo, an engineer who spent three years managing 787 supplier quality. First, there were problems with the molding of the new plastics. Then parts made by different suppliers didn't fit properly. For instance, the nose-and-cockpit section was out of alignment with the rest of the plane, leaving a 0.3-inch gap. By giving up control of its supply chain, Boeing had lost the ability to oversee each step of production. Problems sometimes weren't discovered until the parts came together at its Everett, Wash., plant. Fixes weren't easy, and cultures among the suppliers often clashed. "It seemed like the Italians only worked three days a week. They were always on vacation. And the Japanese, they worked six days a week," said Jack Al-Kahwati, a former Boeing structural weight engineer. Even simple conversations between Boeing employees and those from the suppliers working in-house in Everett weren't so simple. Because of government regulations controlling the export of defense-related technology, any talks with international suppliers had to take place in designated conference rooms. Each country had its own, separate space for conversations. There were also deep fears, especially among veteran Boeing workers, that "we were giving up all of our trade secrets to the Japanese and that they would be our competition in 10 years," Al-Kahwati said. As the project fell further behind schedule, pressure mounted. It became increasingly clear that delivery deadlines wouldn't be met. Each success, no matter how small, was celebrated. The first delivery of a new part or the government certification of an engine would lead to a gathering in one of the engineering building atriums. Banners were hung and commemorative cards — like baseball cards — or coins were handed out. Those working on the plane brought home a constant stream of trinkets: hats, Frisbees, 787 M&Ms, travel mugs, plane-shaped chocolates, laser pointers and lapel pins. Many of the items can now be found for sale on eBay. "It kept you going because there was this underlying suspicion that we weren't going to hit these targets that they were setting," said Matt Henson, who spent five and a half years as an engineer on the project. The world got its first glimpse of the Dreamliner on July 8, 2007. The date was chosen not because of some production milestone but for public relations value. It was, after all, 7/8/7. Tom Brokaw served as the master of ceremonies at an event that drew 15,000 people. The crowd was in awe. It was "beyond experiencing a rock star on stage," said Dressler, a former Boeing designer. "This thing is so sexy, between the paint job and the lines and the fact that it's here now and you can touch it." But like so much of show business, the plane was just a prop. It lacked most flight controls. Parts of the fuselage were temporarily fastened together just for the event. Some savvy observers noted that bolt heads were sticking out from the aircraft's composite skin. Boeing CEO Jim McNerney told the crowd that the plane would fly within two months. Instead, the company soon announced the first of what would be many delays. It would be more than two years before the plane's first test flight. To overcome production problems, Boeing replaced executives and bought several of the suppliers to gain greater control. Work continued at breakneck pace. "We were competing against time. We were competing against the deadline of delivering the first airplane," said Roman Sherbak, who spent four years on the project. Then on a cold, overcast morning in December 2009, it all came together. A crowd gathered at Paine Field, the airport adjacent to Boeing's factory. The Dreamliner climbed deftly into the sky for a three-hour test flight. But there were still plenty of glitches, including an onboard fire during a November 2010 test flight. Smoke had entered the cabin from an electronics panel in the rear of the plane. The fleet was grounded for six weeks. This month's safety problems appear unrelated. Deliveries were pushed back yet again. Passengers wouldn't first step aboard the plane until Oct. 26, 2011, three and a half years after Boeing first promised. That first, four-hour journey — from Tokyo to Hong Kong — was more of a party than a flight. Passengers posed for photos as they climbed stairs into the jet. Alcohol flowed freely. Boeing executives were on hand, showing off the plane's new features. Everybody, it seemed, needed to use the bathroom if only to check out the bidet and giant window inside. More airlines started to fly the plane. Each new route was met with celebration. Travelers shifted itineraries to catch a ride on the new plane. Boeing had hoped by the end of 2013 to double production of the Dreamliner to 10 planes a month. There are 799 unfilled orders for the plane, which carries a $206.8 million list price, although airlines often negotiate deep discounts. Then, this month, all the progress came to a jarring halt. First, a battery ignited on a Japan Airlines 787 shortly after it landed at Boston's Logan International Airport. Passengers had already left the plane, but it took firefighters 40 minutes to put out the blaze. Problems also popped up on other planes. There were fuel and oil leaks, a cracked cockpit window and a computer glitch that erroneously indicated a brake problem. Then a 787 flown by Japan's All Nippon Airways made an emergency landing after pilots learned of battery problems and detected a burning smell. Both Japanese airlines grounded their Dreamliner fleets. The FAA, which just days earlier insisted that the plane was safe, did the same for U.S. planes. Each new aircraft comes with problems. The A380 had its own glitches, including an in-flight engine explosion that damaged fuel and hydraulic lines and the landing flaps. But the unique nature of the 787 worries regulators. American and Japanese investigators have yet to determine the cause of the problems, and the longer the 787 stays grounded, the more money Boeing must pay airlines in penalties. "It's been a very expensive process, and it's not going to let up anytime soon," said Richard Aboulafia, an aerospace analyst with the Teal Group. "At this point, the aircraft still looks very promising. I don't think anybody is talking about canceling orders but people are nervous about the schedule." As investigators try to figure out the cause of the plane's latest problems the world finds itself in a familiar position with the Dreamliner: waiting. Copyright Associated Press
  7. The basis for and the popular notion of "justice" and more recently, "the public interest" appear to me to be resident in historical tort law. Tort law, (British Common Law) supercedes private confidentiality agreements of all kinds including those agreements intended to protect "the greater good", which is the notion that I apply to flight safety programs and processes. Clearly there will be disagreements regarding such interpretation, and I am a flight safety person and not educated/trained as a lawyer. It seems to me that one cannot argue against the long history of British Common Law, upon which Canadian law, with the exception of Quebec, is based. But there is a broader question of judgement, which of course tort law can and does accomodate in argument; it has to be reasonably demonstrated and logically-argued and it can go either way as we have seen. Even the Nova Scotia ruling is careful to detail its considerations while taking cockpit voice recordings into the semi-public sphere. Keeping society "safe" is a recent notion and priority, brought about chiefly through litigation and the new notion of targeted accountability. None of this is disputable in my view. What is disputable is the claim of efficacy of the use of such data in enhancing "the public interest". The ruling claims "balance" but fails to demonstrate how such balance is materially achieved. The opposing case is easily demonstrated: release data into the public sphere, and such data-gathering, self-reporting and SMS programs will swiftly shut-down, citing the very principle that originally mandates such programs, "due diligence". The question here is, who benefits from this ruling and why?
  8. The definition of what consitutes "the public interest" needs to be examined and where necessary, challenged if this is what it permits. This isn't good enough for a risk-based business such as aviation that, unlike some endeavours which eschew reality, must deal in hard and present realities and, ultimately, in life-and-death processes, decision-making and accountabilities.
  9. The notion of "the public interest" is the sole legal justification for this and previous rulings by Canada's courts. The court's ruling is wrong. Such release of safety data does not serve "the public interest." There is no other good reason to release CVR data, and plenty of good reasons not to. For good and demonstrable reasons, flight safety programs such as confidential reporting systems, flight data monitoring systems, incident review systems and SMS are protected by confidentiality agreements. Such programs are staffed by experts who are trained and experienced in flight safety work. Left to their design and purpose, such safety systems are proven to work effectively, while time and again, the release of, and even the legal threat to release flight safety data is proven to "chill" such safety programs, potentially destroying earned, long-term trust in the integrity of such programs. Trust and integrity are the only currencies that flight safety programs possess. Once trust in such programs is destroyed, it is extremely difficult to regain. Any ruling that threatens such programs by the public release of the products of such flight safety programs for narrow, possibly-picayune justifications therefore acts against "the public interest". There is no evidence that such rulings enhance airline and aviation safety or "the public interest". This is because "the public interest" is already best-served by robust, effective and confidential flight safety programs. The "interesting case" would be a countersuit, arguing the above, brought by the TSB, ATAC and all Canadian pilot associations.
  10. MAX Training Requirements Still To Be Determined, FAA’s Dickson Says Nov 20, 2019 Sean Broderick and Steve Trimble | Aviation Daily Stephen Brashear/Getty Images DUBAI—The FAA is leaving the door open for mandatory simulator sessions as a condition for pilots to return to flying The Boeing 737 MAX, the agency’s top official acknowledged. “It’s impossible to say at this time” if the revised minimum requirements will include simulator sessions as part of transition training, FAA Administrator Steve Dickson said at the Dubai Air Show Nov. 20. “We’ll evaluate the [Boeing training] proposal and we’ll see how simulations come out.” Boeing is in the final stages of completing revisions to the MAX flight control computer software and related training prompted by two accidents in five months. The global fleet has been grounded since the second accident, the Mar. 10 crash of Ethiopian Airlines Flight 302. Validation of Boeing’s changes by pilots in both engineering and full-flight simulators are among the key next steps in Boeing’s effort to demonstrate the MAX is safe to fly again. Dickson said trials involving high-workload scenarios, where pilots must prioritize and manage multiple failures, could happen “within the next few days.” Other steps include completing reviews of all documentation detailing the changes and flying a certification flight. Revised training modules also must be validated. This will require public input on a revised draft of the 737 Flight Standardization Board (FSB) report that factors in line pilot input gathered during simulator sessions. The FSB is where the simulator requirements would appear, as part of mandated training for pilots transitioning from earlier generations of the 737 to the MAX. Earlier drafts of the revised FSB did not include mandatory simulator sessions, but subsequent work on the MAX flight control software has been done. The new training will include modules covering the MAX’s maneuvering characteristics augmentation system (MCAS) flight control law. MCAS played a role in both MAX accident sequences, leading regulators to order changes to its logic. The changes are designed to ensure the system, which commands automatic nose-down stabilizer input, only operates when needed. In both accident sequences, faulty sensor data triggered the MCAS when it wasn’t needed, confusing both flight crews and eventually triggering uncontrollable dives. MCAS was not included in the original MAX flight manuals or training. Dickson emphasized that the FAA is not following any time line on the MAX return-to-service effort. “We’re going to make sure that we’re very methodical and very diligent,” he said.
  11. New York Times, October 31 2019 Before Deadly Crashes, Boeing Pushed for Law That Undercut Oversight The government has been handing over more responsibility to manufacturers for years. The new law makes it even harder for regulators to review Boeing’s work. Months after a second crash of the Boeing Max 737, the plane remains grounded and the company mired in crisis.Credit...Gary He/Reuters By Natalie Kitroeff and David Gelles · Published Oct. 27, 2019 Updated Oct. 31, 2019 With a few short paragraphs tucked into 463 pages of legislation last year, Boeing scored one of its biggest lobbying wins: a law that undercuts the government’s role in approving the design of new airplanes. For years, the government had been handing over more responsibility to manufacturers as a way to reduce bureaucracy. But those paragraphs cemented the industry’s power, allowing manufacturers to challenge regulators over safety disputes and making it difficult for the government to usurp companies’ authority. Although the law applies broadly to the industry, Boeing, the nation’s dominant aerospace manufacturer, is the biggest beneficiary. An examination by The New York Times, based on interviews with more than 50 regulators, industry executives, congressional staff members and lobbyists, as well as drafts of the bill and federal documents, found that Boeing and its allies helped craft the legislation to their liking, shaping the language of the law and overcoming criticism from regulators. In a stark warning as the bill was being written, the Federal Aviation Administration said that it would “not be in the best interest of safety.” A labor group representing agency inspectors raised concerns that the rules would turn the F.A.A. into a “rubber stamp” that would only be able to intervene after a plane crashed “and people are killed,” according to internal union documents reviewed by The Times. Weeks after the law was passed, a Boeing 737 Max jet crashed off the coast of Indonesia, killing everyone on board. A second Max crashed in Ethiopia less than five months later, and the plane was grounded. On both doomed flights, a new automated system on the Max, designed to help avoid stalls, triggered erroneously, sending them into fatal nose-dives. Mired in crisis, Boeing is still trying to fix the plane and get it flying again. In the aftermath, lawmakers have seized on flaws in a regulatory system that cedes control to industry — an issue that is likely to put Boeing on the defensive this week when the company’s chief executive, Dennis A. Muilenburg, testifies before Congress for the first time since the two crashes. The F.A.A. never fully analyzed the automated system known as MCAS, while Boeing played down its risks. Late in the plane’s development, Boeing made the system more aggressive, changes that were not submitted in a safety assessment to the agency. The Max was certified under the old rules. The new law, the F.A.A. Reauthorization Act of 2018, makes it even more difficult for the government to review manufacturers’ work. President Trump signed the F.A.A. Reauthorization Act of 2018 into law last October. Most of the attention on the legislation had been on a failed Republican effort to privatize the air traffic control system.Credit...Official White House Photo by Joyce N. Boghosia In the past, agency officials could decide whether to delegate oversight to the company or to maintain control, depending on the importance of a system or concerns about safety. Now, the agency, at the outset of the development process, has to hand over responsibility for certifying almost every aspect of new planes. If F.A.A. officials decide a system may compromise safety, the new rules dictate that they will need to conduct an investigation or an inspection to make their case before taking back control. If the officials raise concerns, ask for changes or otherwise miss certification deadlines, any disputes are automatically elevated by law to managers at the agency and the company. The law also creates a committee of mostly aerospace executives to ensure that the regulator is meeting metrics set by the industry, and the law allows companies to make recommendations about the compensation of F.A.A. employees. “The reauthorization act mandated regulatory capture,” said Doug Anderson, a former attorney in the agency’s office of chief counsel who reviewed the legislation. “It set the F.A.A. up for being totally deferential to the industry.” A spokesman for Boeing, Gordon Johndroe, said that the certification process is “part of an effective F.A.A. oversight of safety that permits them to focus on the most important issues that are critical to the safety of flight.” He added that “this authority has been a proven way for decades for government regulators across many industries to prioritize resources and rely on technical experts to maintain quality, safety and integrity.” When the legislation was hashed out, the lobbying effort barely registered in the country’s vast political machine. Boeing’s push, and the use of industry language in the crucial paragraphs, was standard amid the deregulatory drive by many businesses. Most of the attention on the bill was focused on a failed Republican effort to privatize the air traffic control system. Since the two fatal accidents, the law has set off worries in Washington about whether the rules championed by Boeing make company deadlines a priority over passenger safety. The manufacturer helped author a report that congressional aides used as a reference while writing the law, borrowing language and ideas that had long been used by Boeing. Its executives pressed Michael Huerta, then the head of the F.A.A., for support, telling him that the regulator’s inefficiency was threatening Boeing’s ability to compete against its chief rival, Airbus of France. They also helped persuade Senator Maria Cantwell, Democrat of Washington State, where Boeing has its manufacturing hub, to introduce language that requires the F.A.A. to relinquish control of many parts of the certification process. “The method by which the F.A.A. certifies aircraft is in need of repair — I don’t think anyone could argue otherwise at this point,” Representative Rick Larsen, a Democrat from Washington, who voted in favor of the legislation, said in an interview. “No matter what we did last year, we need to be pulling some of that back into the public sphere, and take some of it out of the hands of industry.” Language of the Law Dennis Muilenburg, Boeing’s chief executive, is testifying before Congress this week.Credit...Johannes Eisele/Agence France-Presse — Getty Images In closed-door meetings with congressional staff members, in testimony on Capitol Hill, in memos to lawmakers, the talking points were all the same. Starting in 2014, Boeing and its trade associations explained that streamlining certification would make American aerospace companies more competitive with overseas rivals, by allowing them to develop planes more efficiently. They argued that F.A.A. employees were interpreting the rules in seemingly arbitrary ways and slowing down the development process, according to seven people involved in the discussions and documents reviewed by The Times. In a 2015 memo sent to congressional staff members that was reviewed by The Times, the General Aviation Manufacturers Association, which represents the business jet unit of Boeing, urged lawmakers to “fully implement” the so-called system of delegation. If disputes caused delays, the trade group called for “automatic escalation to appropriate F.A.A. and company management” so that issues didn’t languish. The Aerospace Industries Association, which was headed during part of the lobbying campaign by Mr. Muilenburg of Boeing, echoed those priorities. Richard Efford, a lobbyist for the group, said in an interview that he emphasized the need to “fully utilize” delegation. Boeing executives made the same pitch to Mr. Huerta at industry events and in meetings at the F.A.A., according to three people with knowledge of the matter. It became a routine discussion, they said. And they made their case publicly as well, at times citing the company’s safety record. In a 2015 hearing, Ray Conner, then the head of Boeing’s commercial airplane division, pushed like others for making “full use” of the system. He said it took too long to get approvals for interiors, like seats and bathrooms, that company engineers could assess. He argued that European regulators outsource far more. The language of their lobbying push was rooted in a 2012 report from an industry-dominated committee run by Christine Thompson, a Boeing executive, and Ali Bahrami, an F.A.A. official at the time who later became a lobbyist. Ali Bahrami, a Federal Aviation Administration official and former lobbyist, was co-chairman of a committee that in 2012 recommended streamlining certification.Credit...Andrew Harrer/Bloomberg In aerospace speak, it called for “full utilization of available delegation,” outsourcing as much oversight as possible. It outlined six recommendations that “will result in the reduction of certification delays” and “enhance the global competitiveness of the U.S. aviation industry.” “There was a consensus that they had good recommendations, and that we ought to put them into writing,” said Matt Bormet, who formerly worked for Mr. Larsen. “I heard no complaints about the report.” Boeing and its allies found a receptive audience in the head of the House transportation committee, Bill Shuster, a Pennsylvania Republican staunchly in favor of deregulation, and his aide working on the legislation, Holly Woodruff Lyons. The F.A.A. Reauthorization Act of 2018 was broadly meant to provide agency funding for the coming years. Lawmakers also used it to introduce new rules for drones, airport noise and the certification process. As Ms. Lyons helped write the law, she was in regular touch with Boeing, according to two people with knowledge of the discussions. The critical paragraphs in the final bill borrowed heavily from industry language, instituting the “full utilization of F.A.A. delegation.” “The certification reforms in the F.A.A. bill were strongly desired and had bipartisan support,” Mr. Shuster said in an email, noting that delegation “has worked well and safely for over 50 years.” Then-Representative Bill Shuster, the Pennsylvania Republican who headed the transportation committee, in 2015. He recently said, “The certification reforms in the F.A.A. bill were strongly desired and had bipartisan support.”Credit...Bill Clark/CQ Roll Call The evolution of the bill had the imprint of industry. An early version that Ms. Lyons sent to lobbyists directed the F.A.A. to measure its own performance, according to a draft reviewed by The Times. In one circulated a month later, staff members had added a clause specifying that the agency would be judged in part by a committee dominated by aerospace executives, which would come up with metrics for the regulator. As the Senate prepared its own version in early 2016, Boeing was in close contact with the office of Ms. Cantwell. “Senator Cantwell is responsive to the needs of Washington State businesses,” said Nick Sutter, one of her former staff members. “Boeing people were in and out of the office all the time.” In conversations with a top aide for the senator, Matt McCarthy, Boeing lobbyists pushed for language that would compel the F.A.A. to rely more on manufacturers, according to two people directly involved in the discussions. Mr. McCarthy took a job as a lobbyist for Boeing in September. Regulators and companies agreed that the F.A.A.’s resources were best focused on new and high-risk systems, according to Peggy Gilligan, the agency’s head of safety back then, and several other officials. As the Senate prepared its own version of the bill in early 2016, Boeing was in close contact with the office of Senator Maria Cantwell, Democrat of Washington State.Credit...Sarah Silbiger/The New York Times Ms. Cantwell submitted an amendment that directed the F.A.A. to automatically give companies the right to approve anything deemed “low and medium risk” on an airplane. It was language that particularly helped Boeing, with its wide range of planes. “Listening to your constituents is always the first step in legislating, but it’s certainly not the last,” said Ansley Lacitis, deputy chief of staff for Ms. Cantwell. “This concept of risk-based oversight was bipartisan, consensus-based and recommended by experts.” The amendment passed without any debate. At the hearing, then-Senator Bill Nelson, a Democrat of Florida, cheered the changes. The law, he said, “will boost U.S. manufacturing and exports and — most importantly — create good jobs for Americans.” Quieting Criticis A 737 Max plane at the Boeing factory in Renton, Wash., earlier this year.Credit...Lindsey Wasson/Reuters F.A.A. officials tried to push back, raising concerns to congressional staff members and aerospace executives. But they were constrained in their efforts. As a federal agency, the F.A.A. is forbidden by law to use government resources to influence and lobby Congress. At most, officials could provide comments and feedback, so-called technical assistance in the legislative process. “It is true that we were supportive of delegation as a general philosophy,” said Mr. Huerta, the former F.A.A. chief. “It is not true that means the agency supported every proposal to expand delegation and impose limits on the agency’s ability to take back delegations.” Early on, Ms. Gilligan, the former F.A.A. official, said industry lobbyists suggested that the law should give companies input on performance evaluations of individual F.A.A. employees overseeing the certification of their planes. Two other agency officials confirmed her account. “It appeared they were looking to influence the individuals’ pay outcome in some way, and for the F.A.A. employees to know that potential pay impact,” Ms. Gilligan said. The final bill did not completely satisfy her concerns. The law created a panel with industry representatives to help assess “performance incentive policies” for F.A.A. employees, as long as they “do not conflict with the public interest.” Peggy Gilligan, then an F.A.A. official, testifying to Congress in 2014. She recently said industry lobbyists suggested that the reauthorization law give companies input on performance evaluations of individual F.A.A. employees.Credit...Win Mcnamee/Getty Images Mostly, top F.A.A. officials worried about the unintended consequences of giving more authority to manufacturers. Boeing employees have described pressures from their managers to meet deadlines while approving systems. Under the old rules, the F.A.A. could decide to take back oversight authority on a system if they were concerned about safety. The new law would require the agency to conduct an investigation or inspection to prove that there was a problem before stepping in, a potentially lengthy process. Industry groups told congressional staff members that manufacturers were sometimes subject to the whims of individual F.A.A. employees, who could block approvals and delay production schedules, according to three people with knowledge of the discussions. “It causes delays and a lot of frustration within the companies,” said Mr. Efford, the lobbyist. But regulators were concerned that the new law would keep them from effectively doing their job. In early 2015, Brian Morris, a safety official at the agency, prepared feedback for lawmakers, arguing that the legislation would prevent the regulator from acting until a dangerous system had already been introduced onto an aircraft. “With this language, Congress is asking us to wait till we find a hazard before removing delegation,” he wrote, according to an F.A.A. document reviewed by The Times. A current and a former F.A.A. official said that Mr. Morris was collecting feedback from multiple departments, so the comments reflected the opinions of other agency staff members. The document notes that the comments were “provided in response to a congressional request.” The Professional Aviation Safety Specialists union, a small labor group that represents F.A.A. employees, had a similar warning. If the regulator could only intercede after documenting problems, it may not be able to stop manufacturers from installing risky systems. “That will, as a practical matter, mean after the accident has happened and people are killed,” the union said in comments prepared for Congress in early 2016, which were reviewed by The Times. Through a spokesman, Ms. Lyons, the congressional aide writing the law, said she did not receive comments from Mr. Morris or the union, but was aware of the F.A.A.’s worries. “The concerns were discussed and considered in a bipartisan manner,” said the House transportation committee spokesman, Justin Harclerode. “Members did not agree with this interpretation of the language, and were not convinced the language would negatively impact the FAA’s ability to safely oversee the aviation industry.” He added that the F.A.A., under the law, could set the parameters of the investigation or inspection. Lawmaker’s Remorse Demonstrators hold pictures of victims of the crash of the Boeing 737 Max in Ethiopia at a vigil last month outside the Department of Transportation in Washington.Credit...Jose Luis Magana/Associated Press At a ceremony in the Oval Office last October, President Trump signed the F.A.A. Reauthorization Act into law, while Representative Shuster, who shepherded the legislation, looked over his shoulder. The agency has already begun to make the required changes. In August, it announced the formation of the advisory committee charged with setting goals for the regulator. The committee includes two union representatives and 17 industry officials, among them Beth Pasztor, one of Boeing’s top executives. The F.A.A. recently selected managers for an internal office that will help enforce provisions of the law. As the rules take hold, some lawmakers who originally supported the legislation are backing away. Mr. Nelson, the former senator who co-sponsored the law, said he did not fully understand the ramifications. “This was never brought to my attention,” he said in an interview. “Had I known about it, I would have tried to put the kibosh on it.” Representative Peter DeFazio, the Oregon Democrat who is the chairman of the House transportation committee, celebrated the bill’s changes last year, saying it would maintain safety and “will help our manufacturers become much more competitive in the world market and introduce their products more quickly.” Mr. DeFazio, who is currently leading a congressional investigation into the crashes, said in an interview that he was reconsidering the law and might introduce legislation to restore some of the agency’s oversight authority. “If the F.A.A. basically deferred on a safety critical system and did not provide proper oversight, then either the individuals involved are going to be at risk, or the whole system itself isn’t working properly,” he said. A version of this article appears in print on Oct. 28, 2019, Section A, Page 1 of the New York edition with the headline: Before Crashes, Boeing Pushed To Undercut F.A.A. Oversight. Order Reprints | Today’s Paper | Subscribe
  12. It's possible that MCAS was indeed a certification-as-same-type solution before the test flights, but after flight testing, Boeing quietly, (as in, didn't communicate the change to others), increased the MCAS response rate from 0.6deg ND per application to 2.5deg ND per application and didn't tell anyone who would need to have known, (like pilots). Though Boeing continues to state that MCAS was not designed as a "stall prevention" system, if that adjustment in HS trim speed turned MCAS into a stall-prevention system from merely a "feels-the-same-for-common-type purposes" system then Boeing has a significant problem and so does the FAA. I think this is why we are beginning to see these comments. From AC25-7D: To ensure that inadvertent operation of the stall identification system does not jeopardize safe flight, and to maintain crew confidence in the system, it should be shown that:  No single failure will result in inadvertent operation of the stall identification system; and  The probability of inadvertent operation from all causes is improbable (not greater than 10-5 per flight hour). Also, the shift in thinking concerning MCAS may be coming from the JATR, Finding 3.7A: Joint Authorities Technical Review Boeing 737 MAX Flight Control System Executive Summary ____________________________________________________________________________ VI Recommendation R3 Based on the JATR team’s observations and findings related to the certification of the B737 MAX flight control system and related interfaces, JATR team members recommend that the FAA review the B737 MAX compliance to 14 CFR §§ 25.1329 (Flight Guidance System), 25.1581 (Airplane Flight Manual – General), and 25.201 (Stall Demonstration) and ensure the consistent application and interpretation of regulatory guidance material for the system safety assessment, handling qualities rating method, and conformity requirements for engineering simulators and devices. Should there be a non-compliance, the root cause should be identified and measures implemented to prevent recurrence. and, Recommendation R3.7: The FAA should review how compliance was shown for the stall identification system on the B737 MAX with respect to inadvertent operation due to single failures. o Finding F3.7-A: The JATR team considers that system features on the B737 MAX might constitute a stall identification system. This system is vulnerable to inadvertent actuation due to a single failure, which would not meet the accepted guidance contained within AC 25-7C, Chapter 8, Section 228. Edited to add: I disagree with the use of the word, "identification" in the paragraph above. MCAS is not "identifying" an impending stall, it is responding to AoA data that indicates an impending stall. "Identifying" a potential stall is the work of the stick shaker, and any addition to that system would necessarily have to be part of the FCOM as it is a major change in the flight control system, (much the same as a stick pusher). This is a longitudinal stability issue, one that has history.
  13. Where is this going now?... The notion that MCAS was intended as "stall prevention" in rare corners of operation is showing up and now being discussed. The implications are significant. Stall prevention systems are not permitted single-points-of-failure, For ease of reference, here is the link to the JATR,
  14. His comments on the deHavilland Comet are equally interesting, and not flattering to the effort. But "rip-stop" design that Boeing incorporated emerged from the Comet's problems. The entire KNKT Report is well worth reading, for pilots and management personnel as well as designers, engineers, human-factors / flight safety personnel and even though the matter is far from over for the U. S. Regulator and Boeing, the general public if they wish to know what really happened and why. For example, take a look at the following sections of the report which detail the Xtra company's work as it relates to the AoA sensor. These sections examine precisely how the left AoA sensor output on the accident aircraft came to be tested as "normal" by Lion Air Mtce but was in fact 20deg out of calibration: 1.6.4 Angle of Attack (AOA) Sensors Historical Record 1.17.3 Xtra Aerospace LLC 2.6 Xtra Aerospace LLC
  15. From the archives of the Royal Aeronautical Society, D. P. Davies, (Handling the Big Jets) speaks about design, especially 40:00 to 47:00.
  16. Very sad....survivable but for the prop/blade. Rare, but loss of a blade does occur. Some details: METAR/SPECI from PADU, Unalaska, Unalaska Airport (United States). SA 18/10/2019 00:56-> METAR PADU 180056Z 31011KT 10SM FEW034 BKN047 BKN060 07/01 A2950 RMK AO2 SLP995 T00720011= SA 17/10/2019 23:56-> METAR PADU 172356Z 31006KT 10SM BKN036 BKN044 07/01 A2951 RMK AO2 RAB12E25 SLP999 P0000 60000 T00670011 10083 20056 53005= No short TAF reports from PADU during solicited interval in the database. large TAF from PADU, Unalaska, Unalaska Airport (United States). FT 17/10/2019 23:39-> TAF PADU 172339Z 1800/1824 28008G20KT P6SM -SHRA SCT035 BKN050 FM181900 20006G15KT P6SM -SHRA SCT025= g
  17. The loss of trust, prestige, status, reputation and 'face' are already incalculable by comparison to the dollar figure which could exceed US$100b. Trust and integrity are necessary qualities for aviation to sustain itself - that is its only "stock-and-trade"; the rest is mere technology which is worth nothing against "character".
  18. International regulator report slams Boeing, FAA over 737 MAX design and approval Oct. 11, 2019 at 9:31 am Updated Oct. 11, 2019 at 8:51 pm By Dominic Gates Seattle Times aerospace reporter An international panel of air-safety regulators convened by the Federal Aviation Administration (FAA) released a damning report Friday that criticizes both Boeing and the FAA for how they assessed and approved the design of the 737 MAX automated flight-control system implicated in two fatal airliner crashes. More broadly, the panel also questioned how systems on the the MAX were certified as derivative of a now-50-year-old aircraft design. And it further recommended that airplane-safety systems address the new reality of increased cockpit automation by reducing the reliance on pilots to respond to emergencies, and instead designing protections as part of the systems. The report from officials representing 10 different regulatory bodies carries the weight of the world’s aviation experts. Its findings point to glaring shortcomings in how Boeing’s 737 MAX was certified as safe, with the company effectively auditing its own design and and the FAA unable to fulfill its oversight role. That’s a blow to Boeing’s reputation but also to the long-established primacy of the FAA among global aviation bodies. And the report raises serious questions as to how the regulatory system can be fixed to prevent similar accidents in the future. The Joint Authorities Technical Review (JATR) panel found that the MAX’s new flight-control system, which played a central role in the accidents in Indonesia and Ethiopia that killed 346 people, was not properly evaluated in the certification documents that Boeing submitted to the FAA. 737 MAX CRISIS COMPLETE COVERAGE » Dennis Muilenburg out as Boeing chairman but keeps CEO position Boeing rejected 737 MAX safety upgrades before fatal crashes, whistleblower says Boeing pushed FAA to relax 737 MAX certification requirements for crew alerts Echoing a Seattle Times report on March 17, less than a week after the second crash, the panel found that Boeing submitted to the FAA an inadequate technical description of the airplane’s new Maneuvering Characteristics Augmentation System (MCAS), lacking full details of when the system activated and the extent of its power to push an airplane nose down. Boeing’s documentation of MCAS was fragmented and incomplete, the report said. When Boeing changed the design to make it more powerful and to reduce the trigger mechanism to a single sensor, that wasn’t fully communicated to the FAA. Undue pressure The report also found that the FAA had “limited involvement” in the evaluation of MCAS and left most of the work of assessing the system to Boeing itself. “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,” the report declares. In practice, FAA personnel had “inadequate awareness” of how MCAS worked, which “resulted in an inability of the FAA to provide an independent assessment.” The report, confirming a Seattle Times report on May 5, also cites indications that Boeing employees working on the certification of the airplane on behalf of the FAA faced “undue pressure” from managers who prioritized cost and schedule. The report recommends revision of the system whereby the FAA delegates much of the oversight of airplane certification to Boeing, a system known as Organization Designation Authorization. Under ODA, Boeing engineers who do the certification analysis and testing report to managers within the Boeing organization who relay the results to the FAA. The JATR recommends adjusting this structure so that authorized engineers at Boeing have direct, “open lines of communication to FAA certification engineers without fear of punitive action or process violation” to ensure they “are working without any undue pressure when they are making decisions on behalf of the FAA.” This recommendation mirrors the advice of experts cited in the May 5 Seattle Times story who advised the FAA to revert to elements of an earlier oversight structure — called Designated Engineering Representatives or DERs — in which the Boeing engineers who act on behalf of the FAA report to their technical counterparts at the FAA. Pilots unable to cope The panel also questions the assumption in FAA regulations that pilots will recognize something wrong within 1 second when flying the plane manually and will take corrective action within 3 seconds. The report indicates that the 737’s crew-alerting systems that tell pilots when something goes wrong may not be adequate for such an assumption. The JATR noted that a system fault can result in cascading failures, and asked the FAA to assess the adequacy of both the certification process and of pilot training to address “the impact of multiple alarms, along with possible startle effect, on the ability of pilots to respond appropriately.” Regulators need to ensure there’s adequate training so pilots can “respond effectively to failures that they may never have encountered before,” the report states. Last week, the Seattle Times reported that Boeing pushed the FAA to relax certification requirements for crew alerts on the 737 MAX. As a result, the JATR team determined, the certification process did not adequately address this issue of multiple clamoring alarms and the expected pilot response. JATR therefore recommends a top-down reassessment of how airplanes like the MAX that are derivatives of earlier models are certified, to determine when an aging aircraft design is “incapable of supporting the safety advancements introduced by the latest regulations.” The report states that the FAA raised concerns to Boeing about the cumulative effect of cockpit system changes from the previous 737 model to the MAX and suggested that might create a need for simulator level pilot training. Boeing’s response to this concern, which the FAA accepted, was that there was “no precedent” for a demand for enhanced training in previous certifications of derivative models. In a teleconference call Friday, JATR chairman Christopher Hart, former chair of the National Transportation Safety Board (NTSB), said that the increasing prevalence of automation on aircraft means that the problems with the MAX are “not just an airplane problem, but an airplane/pilot problem,” which he said complicates decisions about grounding and ungrounding an aircraft and is likely to become a major issue in the future. “As automation becomes more and more complex, pilots are less likely to fully understand it and more likely to have problems and more likely to encounter scenarios in real operations that they haven’t seen even in a simulator,” he said. Hart called on the FAA and regulators worldwide to recognize and address “this new reality of super-complex automation and pilots not necessarily understanding how to operate it.” The JATR report says that as systems become more complex, the certification process should ensure that aircraft incorporate “fail-safe” designs, meaning that any system failure triggers an automatic default into a safe mode. The goal is to eliminate or mitigate hazards “through design, minimizing reliance on pilot action as primary means of risk mitigation,” the report goes on. The panel separately recommends that “the FAA should review the natural (bare airframe) stalling characteristics of the B737 MAX to determine if unsafe characteristics exist.” This implies JATR wants the FAA to assess the safety of the plane without MCAS in operation. Boeing has said that the purpose of MCAS is not to prevent a stall but simply to make sure it handles exactly like the earlier model 737 when going through certain stall testing. Some criticism of the company on social media has been skeptical of this, proclaiming the MAX “inherently unstable” because it needs software to fly safely. To demonstrate otherwise, Boeing test pilots this summer repeatedly flew that required stall test on the MAX — an extreme maneuver called a “wind-up turn” — both with and without the revamped MCAS operating. Boeing says it is satisfied with the results. The FAA and overseas regulators will conduct their own flight tests, likely next month. MCAS upgraded JATR was convened in April by the FAA to independently evaluate all aspects of the design and certification of MCAS. The panel is made up of technical safety experts from the FAA and NASA along with the civil aviation authorities of Australia, Brazil, Canada, China, the European Union, Japan, Indonesia, Singapore and the United Arab Emirates. Boeing did not directly address the report’s findings Friday but said in a statement that it “is committed to working with the FAA.” FAA Administrator Steve Dickson issued a statement thanking JATR for its “unvarnished and independent” report. “I will review every recommendation and take appropriate action,” Dickson said. “We welcome this scrutiny.” MCAS consists of new flight-control software added to the MAX. If a sensor that measures the jet’s angle of attack, the angle between the wing and the oncoming air flow, indicates that the nose of the aircraft is pitching up, MCAS is designed to swivel the jet’s horizontal tail — called the horizontal stabilizer — so as to push the nose of the aircraft back down. The JATR report notes the failure in communication between Boeing and the FAA during the certification process as MCAS evolved “from a relatively benign system to a much more aggressive system.” The result was a failure to address the potential unintended consequences that resulted from “designing software for one scenario — in this case, high-speed windup turns — and then modifying the software for a different scenario — in this case reducing the pitch-up tendency at higher angles of attack at low speeds.” Boeing has prepared a redesign of MCAS that addresses the inadequacies of the original design, which was activated by a single angle-of-attack sensor. On both crash flights, the accidents were initiated by a false signal from that one sensor. The updated MCAS software will be activated only if both such sensors on the aircraft show the same high angle of attack. In addition, the system is now redesigned so that it can activate only once. And Boeing has changed the overall software system architecture to compare readings from both flight control computers, instead of using only one, and to shut down MCAS in less than a second if the computers disagree. But as regulators evaluate those improvements and the pilot training that will be required, the 737 MAX remains grounded worldwide seven months after the second crash. On Friday’s teleconference, FAA spokesman Lynn Lunsford said that because the FAA is doing an entirely new safety analysis of all the changes to the MAX before giving the plane clearance to return to service, “the majority of the return to flight issues that have been raised by JATR are being addressed.” “We are going through the recommendations one more time to make sure that any of them that aren’t being addressed will be as part of the current review,” Lunsford added. Page 1 of Final JATR Submittal to FAA Oct 2019 DocumentCloud Contributed to DocumentCloud by Judy Averill of The Seattle Times • View document Dominic Gates: 206-464-2963 or; on Twitter: @dominicgates.
  19. When is a "whistleblower" not a whistleblower? What is the need for such a role in an organization and what processes, if any, make such a role redundant or at least unnecessary?
  20. Boeing whistleblower’s complaint says 737 MAX safety upgrades were rejected over cost Oct. 2, 2019 at 6:00 am 1 of 2 | (Gabriel Campanario / The Seattle Times) By Dominic Gates , Steve Miletich and Lewis Kamb Seattle Times staff reporters Seven weeks after the second fatal crash of a 737 MAX in March, a Boeing engineer submitted a scathing internal ethics complaint alleging that management — determined to keep down costs for airline customers — had blocked significant safety improvements during the jet’s development. The ethics charge, filed by 33-year-old engineer Curtis Ewbank, whose job involved studying past crashes and using that information to make new planes safer, describes how around 2014 his group presented to managers and senior executives a proposal to add various safety upgrades to the MAX. The complaint, a copy of which was reviewed by The Seattle Times, suggests that one of the proposed systems could have potentially prevented the crashes in Indonesia and Ethiopia that killed 346 people. Three of Ewbank’s former colleagues interviewed for this story concurred. The details revealed in the ethics complaint raise new questions about the culture at Boeing and whether the long-held imperative that safety must be the overarching priority was compromised on the MAX by business considerations and management’s focus on schedule and cost. Managers twice rejected adding the new system on the basis of “cost and potential (pilot) training impact,” the complaint states. It was then raised a third time in a meeting with 737 MAX chief project engineer, Michael Teal, who cited the same objections as he killed the proposal. 737 MAX crisis | Complete coverage » · Boeing made erroneous assumptions on pilots’ response to alerts in 737 MAX, NTSB says · Boeing’s board calls for better internal safety oversight in wake of 737 MAX crashes · Boeing CEO sees ‘endgame’ in effort to lift grounding of 737 MAX A version of the proposed system, called synthetic airspeed, was already installed on the 787 Dreamliner. It was not directly related to the flight-control system — the Maneuvering Characteristics Augmentation System (MCAS) — that contributed to both crashes. But it would have detected the false angle of attack signal that initiated events in both accidents, and so potentially could have stopped MCAS from activating and repeatedly pushing down the nose of each jet. But installing it in the MAX would likely have meant 737 pilots needed extra training in flight simulators. Running thousands of pilots through simulator sessions would have delayed the jet’s entry into service and added substantial costs for Boeing’s airline customers, damaging the MAX’s competitive edge against the rival Airbus A320neo. Ewbank’s complaint goes further than the decision not to install this one new system. He describes management as “more concerned with cost and schedule than safety and quality.” And he alleges that in one instance Boeing hid inflight safety incident data from the European Union Aviation Safety Agency (EASA). As first reported in The Seattle Times, Boeing did an inadequate system safety assessment that missed flaws in the design of MCAS that were central to the two MAX disasters. And Boeing engineers were under pressure to limit safety testing to certify the MAX. These fresh allegations from inside Boeing indicate that the problems with jetmaker’s safety culture may go deeper than MCAS. Submitted via Boeing’s internal whistleblower system, Ewbank’s complaint alleges that MAX program managers, concerned with avoiding higher costs and more pilot training, were intent on “shutting down trade studies that attempted to modernize the airplane and avoiding awareness of known issues encountered in historical 737 operation.” Federal investigators The FBI has interviewed at least two Boeing employees about the complaint. It’s unclear how the Boeing document reached the agency, but federal investigators are known to have issued subpoenas to the company. Department of Justice prosecutors, Department of Transportation inspectors and Securities and Exchange Commission (SEC) officials are all involved in a wide-ranging federal investigation into possible wrongdoing at Boeing during certification of the MAX that was already under way before the engineer filed his internal complaint in April. Boeing declined to comment on the details of the ethics complaint. Teal, 737 MAX chief project engineer, could not be reached for comment. The Department of Justice also declined to comment. The Seattle Times is not naming the employees who have been questioned by the FBI to protect the identity of the source of that information. Ewbanks declined to be interviewed. The Seattle Times is naming him because he identified himself in his complaint to Boeing. The MAX has been grounded worldwide for almost seven months as Boeing works on a comprehensive fix to its flight-control systems that will satisfy air safety regulators around the globe. The final updates to the systems are expected to be submitted to the Federal Aviation Administration (FAA) this month, and Boeing anticipates clearance to return the jet to the sky in November. Meanwhile, multiple investigations and reviews, internal and external, are examining what caused the deadly crashes. Last week, Boeing’s board announced a revamp of the company’s reporting structures aimed at producing better internal safety oversight. On Monday, Boeing chairman and chief executive Dennis Muilenburg said he’s “taking immediate steps” to implement those recommendations. The engineer Ewbank’s ethics complaint expressed concern about the possible personal consequences of stepping forward inside the company. “Given the nature of this complaint, the fear of retaliation is high, despite all official assurances that this should not be the case,” he wrote. “There is a suppressive cultural attitude towards criticism of corporate policy — especially if that criticism comes as a result of fatal accidents.” Ewbank wrote that co-workers told him in private they are afraid to speak up about similar safety concerns out of “fear for their jobs.” In a statement responding to requests for comment this week, Boeing said it “has rigorous processes in place, both to ensure that such complaints receive thorough consideration and to protect the confidentiality of employees who make them.” Most Read Business Stories · Buying a home in Seattle area may get thousands of dollars cheaper, after rule change by agents this week · Boeing whistleblower’s complaint says 737 MAX safety upgrades were rejected over cost | Times Watchdog · Seattle company is using artificial intelligence to make pizza; check out the assembly line VIEW · New partnership involving T-Mobile, UW, Bellevue and others could turn region into a 5G hub · Two thirds of Forever 21 stores in Washington could close by end of year “Accordingly, Boeing does not comment on the substance or existence of such internal complaints,” the statement added. Ewbank’s LinkedIn profile shows he graduated from Embry-Riddle Aeronautical University in 2008 with a degree in aeronautical engineering, then got a master’s at Purdue. After college, he took a job as rocket scientist, doing launch site design engineering at the Kennedy Space Center in Florida with United Space Alliance, the joint venture between Boeing and Lockheed Martin. He was hired by Boeing in 2010 to work on designing commercial airplane flight deck systems, including the MAX. He now works on airplane systems integration for the 777X program. However, dissatisfied with his experience on the MAX program, he took a break from Boeing. LinkedIn shows he left the company in April 2015 and returned to work on the 777X only last November. The reason for the career break is cited in the ethics complaint: his feeling that Boeing management was “squeezing the engineering budget for new programs … more concerned with cost and schedule than safety and quality.” In his first stint at Boeing, he worked on the safety of flight deck systems across multiple jet programs. It put him at the center of what has become one focus of the investigations into the crashes: The systems that tell pilots how their plane is performing in flight and alert them to anything going wrong. Ewbank’s complaint says his job included “designing appropriate crew alerting and crew procedures based on expected (system) failures.” Last week, a National Transportation Safety Board (NTSB) report called for improvements to such systems and criticized Boeing’s testing of the MAX for failing to simulate the possible barrage of system failures and warnings the pilots on the crashed flights faced. The memo The proposal for system upgrades that Ewbank discusses in his complaint emerged from work he did alongside several veteran employees in Boeing’s Aviation Safety department “to analyze Loss of Control inflight accidents and design flight deck features that would work to break the accident chain of events.” One was Associate Technical Fellow Randy Mumaw, a cognitive psychologist and “human factors” expert in how pilots react to an airplane’s instruments. Mumaw, who left Boeing in 2015, said that as a non-engineer he can’t assess the technicalities of the synthetic airspeed system. But he said he knew Ewbank as “highly respected and bright.” The Seattle Times interviewed four former Boeing employees who were involved in the work of assessing the proposed safety upgrades. Rick Ludtke, a former flight deck integration engineer, worked alongside Ewbank and was a key participant in the proposal, which was presented in an engineering memo titled “Boeing Commercial Airplanes Strategy for Reducing the Risk of Loss of Control Events.” Ludtke said the purpose of the memo, which Ewbank cites in his complaint, was to “capture the approval” of executives and to try to get a list of six system improvements accepted across Boeing’s airplane programs, including the MAX, which was then in early development. The memo, which was signed off by Todd Zarfos, the Boeing vice president who heads the company’s engineering design centers, recommended that synthetic airspeed be installed on the MAX “with the next appropriate software update.” Another veteran Boeing engineer and associate technical fellow, Carlo Ruelos, was the early champion of synthetic airspeed at Boeing. A pilot flying any airplane needs to know the current airspeed — the plane’s speed relative to the air. Depending on the direction of the wind, that can be faster or slower than the groundspeed, the plane’s speed relative to the earth. Too high an airspeed could stress the airframe. Too low an airspeed could stall the plane. This key piece of data is measured by pitot-static air pressure sensors, little tubes that stick out of the fuselage on both sides under the cockpit. It’s entered into multiple calculations performed by the flight control computer, so an accurate value is important. Synthetic airspeed is a new system that provides an additional, indirect calculation of airspeed using different sensors, including the plane’s angle-of-attack sensors. The system enters the airplane’s angle of attack, its weight, the position of its control surfaces and other parameters into a proprietary Boeing algorithm to come up with an independently measured airspeed reading. The independence of the synthetic reading means that if it matches the direct airspeed readings, it verifies the data as highly reliable. If there’s a discrepancy, the air data is rejected and the plane’s automated systems won’t use it. Ewbank’s complaint cites a study that found air data reliability, and airspeed awareness in particular, as a “dominant theme” in airplane accidents where the pilots lost control. The only Boeing airplane using synthetic airspeed today is its latest all-new jet, the 787 Dreamliner. On the MAX, Ruelos saw an opportunity because the jet had a new integrated air data system box installed that had more computational power than that on the previous 737 NG model. That extra capability, Ruelos decided, would make it possible to add a variant of the 787 synthetic airspeed system to the MAX. And if it could be added, he felt it should be — because it would broadly enhance the reliability of the 737’s air data systems. Ruelos, now 75 and retired, said in an interview that the pitot and static probes used for standard airspeed measurement“stick out of the airplane and can be damaged by a bird strike. Or something can plug the very small hole.” So, he said, “I firmly believe that as another means of verifying the air data, (synthetic airspeed) is a key element in maintaining the safety of the airplane.” “We pushed very hard for it, because safety is always the No.1 priority,” he added. With the new air data avionics box on the MAX, he believed the system was “ready to go” on the new jet. The crashes At the time of this proposal, no one had identified MCAS as a concern. Back then, the original design of MCAS was more benign than the final version that went haywire on the two crash flights. It required two sensors to activate — a high angle of attack and and a high G-force —and was less extensive in its ability to push the nose down. It wasn’t until March 2016 that the MCAS design was changed to depend solely on a single angle-of-attack sensor. Synthetic airspeed gains significance in the aftermath of the accidents because the system’s cross-check of the independent airspeed readings would raise a red flag if there’s any angle-of-attack sensor fault. If the readings disagree, Ewbank wrote in his complaint, the system as implemented on the 787 is designed to “monitor and detect erroneous angle-of-attack data, and then work to prevent the use of erroneous data by downstream systems.” While Ewbank prefaces this statement with a careful qualifier — “It is not possible to say for certain that any actual implementation of synthetic airspeed on the 737 MAX would have prevented the accidents” — his implication is clear: Synthetic airspeed might have stopped MCAS from activating in the circumstances of the two crashed flights. Ludtke and Ruelos agreed. There’s “a very good chance” that if Boeing had implemented synthetic airspeed on the MAX, it would have prevented the crashes, Ludtke said. “In our department, we never designed anything without comparators,” meaning monitors that compare independent sensor readings and de-activate the system if they disagree, he said. “Curtis, I know, had several types of comparators in that synthetic airspeed system.” Asked separately if synthetic airspeed might have prevented the crashes, Ruelos responded: “I think so. The left and right systems do cross checks, and if there is a discrepancy, it won’t let the automatic system take control of the airplane. … It would disengage and the downstream systems wouldn’t use the data.” The cost concerns Of course, Boeing could have achieved the same result in simpler ways, for example if MCAS had been designed from the start to compare readings from the two angle-of-attack sensors instead of only one. Still, in hindsight the rejection of synthetic airspeed seems fateful. In his complaint, Ewbank puts it down to “a corporate culture … of expediency of design-to-market and cost-cutting.” “The 737 MAX was designed via piecemeal updates to prevent triggering expensive certification and (pilot) training,” his complaint states. Ludtke agreed. Synthetic airspeed was rejected “probably because of cost,” he said. He said Boeing had promised the airlines that the MAX would be so minimally different from the prior 737 model that no additional pilot certification or flight simulator training would be necessary. He said his manager told him Boeing promised MAX launch customer Southwest “$1 million per tail” if the FAA were to require expensive simulator training. “The MAX program leaders had always mandated that, if it’s not required for function or certification, it’s not going on the airplane,” Ludtke said. They looked upon synthetic airspeed as “a good improvement, but just an improvement,” not a necessity. “We still tried. Because we believed these aircraft need improving for the quality of pilots we are experiencing,” Ludtke added. “In the old days, before the MAX, that’s how we did business. At the launch of a new program, its leaders would be very interested in including all the latest ideas and safety improvements. “The MAX was different from the very beginning,” he said. “We’re just going to put these new engines on and the minimum change to make that happen. That’s it. We’re not spending money.” “That concept broke the company,” Ludtke concluded. Another former Boeing employee, a veteran test pilot also involved in the assessment of the proposed system changes, wasn’t close enough to the technical details of synthetic airspeed to be sure it would have prevented the accidents, yet agreed that any similar system based on angle of attack likely would have cut out MCAS. “That’s how you would hope the system would work,” said the pilot, who asked for anonymity to preserve relationships at Boeing. And the pilot agreed with Ludtke that preserving the MAX’s common type rating — certifying it as just a variant of the prior 737 NG model, rather than a new airplane — and ensuring that airline pilots wouldn’t be required to train for the MAX on flight simulators was “such a huge deal” that it blocked potential updates to the avionics systems. “I couldn’t believe they kept stretching the 737, both literally (with a longer fuselage) and also in terms of cockpit design,” the pilot said. The culture Ray Craig, former chief pilot on the 737 MAX until he retired in 2015, had a very different take. He said he worked with Ewbank and knew him as a “very sharp, very dedicated” engineer. Yet he defended the safety culture atBoeing and around the MAX program. “Safety was paramount. If there was something we thought was a safety issue, there was no question, it was taken care of,” Craig said. “But it’s not always a black-and-white decision.” Lacking full technical details, he wouldn’t venture an opinion about whether synthetic airspeed could have prevented the crashes. “I don’t remember it as ready to go. It wasn’t just a simple plug-and-play,” Craig said. “It wasn’t as program-ready as perhaps some of the folks were thinking. But I don’t remember the exact reason it was shot down.” Talk to us We continue to seek information on the design, training and certification of the Boeing 737 MAX. If you have insights, please get in touch with aerospace reporter Dominic Gates at 206-464-2963 or To communicate on a confidential and encrypted channel, follow the options available at Ewbank’s ethics complaint is much broader than the failure to install synthetic airspeed. He attacks the company’s culture around aviation safety and questions Craig’s and Boeing’s assertion that safety is always paramount. He recounts an episode in his department when he says Boeing hid in-flight safety incidents from Europe’s aviation regulator. This occurred when EASA found five events where 737s experienced a problem with the autothrottle disconnecting on approach and a confusing alert led to an inappropriate pilot response. EASA asked if Boeing was aware of any other such events and Ewbank was assigned to search the in-service databases. But when he identified five further similar incidents on 737s, his ethics complaint says his manager decided “to not tell EASA about these events” and that instead “we would fix the issue ourselves.” Ewbank, a relatively young engineer at the start of his career and with less than six years at Boeing over his two employment stints, even goes so far in the complaint as to directly attack CEO Muilenburg. He cites Muilenburg’s statement on a quarterly earnings teleconference, just four days before Ewbank filed the ethics complaint, denying that the two recent MAX crashes were due to any “technical slip” by Boeing during the jet’s design or certification. Ewbank calls this “a false statement.” “When CEO Muilenburg and others state that the Max was a safe airplane as designed, they seriously misrepresent what Boeing Engineering has learned about how data and control functions should be treated,” Ewbank wrote. Seattle Times researcher Miyoko Wolf contributed to this report. Dominic Gates: 206-464-2963 or; on Twitter: @dominicgates. Steve Miletich: 206-464-3302 or; on Twitter: @stevemiletich. Lewis Kamb: 206-464-2932 or; on Twitter: @lewiskamb. View 67 Comments The opinions expressed in reader comments are those of the author only, and do not reflect the opinions of The Seattle Times.
  21. Hi Greg; Re the New Republic article being "of interest", yes it is. There are themes that are familiar, certainly! But I have stopped writing about such matters. It's very difficult to marshall it all and still sustain attention/focus and to invite "care-full" thought without turning the discussion into a political tribal rally these days. I'm not a fan of OpEd explanations by non-experts, of aircraft accident. But you are right - there are some ideas in Tkacik's article, (The New Republic) that I found relevant to views I have held for a very long time and expressed here and elsewhere. In thinking about the points made in the article, it is obvious that we cannot point directly to this or that "cause" - one certainly cannot say, "capitalism caused these B737 accidents" without serious, and deserved, challenges to one's thought processes! However, the notions of a "propensity-for", or perhaps, if one imagines, "the garden in which certain ideas and ways flourished while others withered" we can say that there are certain possibilities for examination of how a post-war social/political/moral/cultural/business milieu provided fertile ground for the kinds of organizational behaviours and results which are now familiar. I posted links to two books which were largely cohort studies, (2010 & 2015 respectively), describing in detail the results of corporate and organizational behaviours for employees at Boeing, particularly after 1997. Interestingly, these theories (about Boeing's problems but also the American workers'), are now achieving mainstream and perhaps even investigatory status as Boeing and the FAA are examined under numerous microscopes, as they ought to be. But the American political economy, particularly after 2008, though under constant challenge, retains those characteristics which institutionally carve massive sectors of "ordinary people" out of the benefits of multi-trillion-dollar economies. Anyway, I will leave it there as this is a tech forum, but thank you for mentioning it.
  22. From the September 26 2019 release: NTSB - Safety Recommendations Report and links to ongoing work: Assumptions Used in the Safety Assessment Process and the Effects of Multiple Alerts and Indications on Pilot Performance:
  23. Good morning, boestar; A logical and reasonable question. From my limited awareness regarding the history of the MCAS design and implementation, and a very tiny smattering of U. S. certification standards, (CFR-25), and reading the many speculative statements on the matter, MCAS is not a "stall prevention" system, whereas stick pushers and stick shakers are. Boeing's approach to stall prevention for the B737 type certificate is set and not subject to change, (a separate, complex topic now under proper examination) without changes to the type certificate. MCAS is a response to slight changes in stick force in lower speed regimes as the AoA increases to a threshold. A lighter stick force than was required by certification appeared to be demonstrated in test flights, (wind-up turns, etc. and other flight test stuff I don't know about). Part of the initial stall prevention system is the increase in stick forces as AoA increases with a reduction in CAS, "forcing" the pilots to respond to the increase. In a way, it is an extension of how trim works in the first place...the B737-type STS trims "against" the pilot to force a response when such response is necessary. It works, (as does/did MCAS) and has since the type was certified in the mid-60's. The MCAS was not, itself, "certified", nor was it formally tested using Failure and Error Mode Analysis, (FMEA) processes, nor was the system examined for potential single-point-of-failure outcomes. Boeing rested upon past certifications of the stabilizer system and, perhaps because the "runaway stabilizer" drill was in place, (this is speculation only; I have seen opinions that Boeing didn't consider this far into the change), any untoward behaviour of the stabilizer would be handled by the crew. But five-second ND blips of the trim-wheel, a UAS indication, a stick-shaker and several other warnings immediately after takeoff were results of the loss of AoA signal from one sensor. I think most here who fly these types can attest to the confusion regarding which drill/checklist one would call for first, particular if the stick was getting heavier and heavier by the second. This scenario was not imagined and considered by Boeing nor was the change in the flight control system conveyed to users and was not in the FCOM or FCTM. I am certain there are bits left out and perhaps others can fill in blanks...;-) Don
  24. Indonesia to Fault 737 MAX Design, U.S. Oversight in Lion Air Crash Report First formal government finding on crash also likely to detail pilot and maintenance missteps; NTSB preparing separate safety recommendations Indonesian officials have found design and oversight lapses played a central role in October’s Lion Air crash. Above, wreckage from Lion Air flight JT610, Karawang, Nov. 3, 2018. Photo: antara foto/Jaya Kusuma/Reuters By Andy Pasztor and Andrew Tangel Sept. 22, 2019 4:54 pm ET Indonesian investigators have determined that design and oversight lapses played a central role in the fatal crash of a Boeing 737 MAX jet in October, according to people familiar with the matter, in what is expected to be the first formal government finding of fault. The draft conclusions, these people said, also identify a string of pilot errors and maintenance mistakes as causal factors in the fatal plunge of the Boeing Co. plane into the Java Sea, echoing a preliminary report from Indonesia last year. Related Coverage International Panel Set to Criticize FAA’s Approval Process for Boeing 737 MAX Jets (Sept. 16) New Delays Could Keep Boeing 737 MAX Grounded Into Holiday Travel Season (Sept. 1) The Four-Second Catastrophe: How Boeing Doomed the 737 MAX (Aug. 16) Misfires of an automated flight-control feature called MCAS on the MAX fleet led to the nosedive of the Lion Air jet and a similar crash of an Ethiopian Airlines MAX shortly after takeoff from Addis Ababa in March. The two crashes took 346 lives, prompted the grounding of all 737 MAX planes and disrupted the global aviation industry. Details of the Indonesian report, which haven’t been reported previously, are subject to change and further analysis. Indonesian investigators declined to comment, except to say the final document is likely to come out in early November. A Boeing spokesman said the plane maker continues to work with Indonesian authorities as they complete the report. U.S. air-crash investigators are preparing to make public a handful of separate safety recommendations, ranging from bolstering the manual flying skills of pilots to enhancing FAA vetting of new aircraft designs. The U.S. National Transportation Safety Board is expected around the end of the month to call for improvements to cockpit training and crew decision making, according to industry and government officials. The goal is to ensure pilot proficiency when automated systems are malfunctioning or turned off, to help ensure appropriate responses to contradictory cockpit warnings such as those that occurred prior to the MAX crashes, the officials said. The board also is expected to emphasize the importance of setting priorities when executing emergency checklists. Is the Federal Aviation Administration too close to the industry it regulates? In the wake of the Boeing 737 MAX 8 crashes in Indonesia and Ethiopia, The Wall Street Journal examines why the FAA is facing renewed scrutiny into its aircraft certification process. In addition, the NTSB is expected to focus on potential changes to the certification of new airliners. The board is poised to recommend re-evaluation of FAA procedures that give the industry authority to sign off on certain safety matters, the officials said. The aim is to make such approvals more transparent, with the goal of greater predictability and more-consistent federal oversight across various types of onboard systems. Neither the U.S. nor Indonesian recommendations will be binding on the FAA, though the agency already faces escalating congressional and public pressure to change certification procedures. More than half a dozen outside inquiries, including a Justice Department criminal probe and various blue-ribbon advisory panels, are delving into the FAA’s 2017 approval of MCAS. Earlier this month, a Senate appropriations subcommittee backed legislation that would require FAA officials to address recommendations from ongoing investigations and audits. The FAA has said it welcomes the independent reviews, will carefully consider their results and doesn’t have a firm timetable for allowing MAX jets back in the air. Boeing has said it is collaborating with U.S. and foreign officials to safely return the MAX to service. Steve Dickson, the FAA’s new head, and top lieutenants are scheduled to meet Monday in Montreal with some four dozen foreign regulators to provide a closed-door update on anticipated fixes to the MAX’s flight-control software and computers. The crashes prompted the grounding of all 737 MAX planes and disrupted the global aviation industry. The FAA is urging a core group of regulators—from Canada, Australia, Brazil and New Zealand—to approve the fixes around November, which would be roughly in tandem with informal U.S. timelines. FAA leaders also are trying to persuade aviation authorities in Europe and other regions to follow by lifting their grounding orders shortly afterward, according to U.S. government and industry officials familiar with the deliberations.But such coordination efforts are running into significant hurdles. Canadian aviation regulators have signaled to the FAA that they expect to require pilots to undergo simulator training before they can start flying the MAX, something the FAA is unlikely to mandate. It could take until March for Air Canada to phase the bulk of its MAX aircraft into regular schedules, according to a person briefed on the details, months later than projected for U.S. operators.In Europe, regulators previously said they won’t accept the FAA’s technical verifications of fixes and intend to perform their own certification analyses, possibly adding weeks or months to the timetable. Meanwhile, FAA officials said in recent weeks that Boeing hasn’t provided all of the requested details laying out the description and safety assessments of the MAX’s redesigned flight-control system. The latest version of Indonesia’s accident report has been shared with the FAA and NTSB for comment. U.S. officials are expected to visit Indonesia around the end of this month to finalize the document. People familiar with the process said NTSB experts don’t appear to have major disagreements with the draft. Boeing and the FAA, on the other hand, are concerned the final report will unduly emphasize design and FAA certification missteps, some of these people said. Unlike NTSB reports that identify the primary cause of accidents and then list contributing issues determined to be less significant, Indonesia is following a convention used by many foreign regulators of listing causal factors without ranking them. Instead, the report is expected to list more than 100 elements of the crash chronology, according to a person briefed on the details. Many of those points are likely to refer to missteps by pilots and mechanics initially revealed last year in Indonesia’s preliminary report. Indonesian authorities now are asking for comments on the draft conclusions dealing with those missteps, as well as findings that investigators have determined constitute engineering shortcomings, including reliance on a sole sensor in the original design of MCAS, according to people familiar with the matter. —Kim Mackrael and Ben Otto contributed to this article. Write to Andy Pasztor at and Andrew Tangel at