[Senate Hearing 118-726]
[From the U.S. Government Publishing Office]
S. Hrg. 118-726
FAA ORGANIZATION DESIGNATION
AUTHORIZATION (ODA) EXPERT PANEL REPORT
=======================================================================
HEARING
before the
COMMITTEE ON COMMERCE,
SCIENCE, AND TRANSPORTATION
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
APRIL 17, 2024
__________
Printed for the use of the Committee on Commerce, Science, and
Transportation
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available online: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
61-849 PDF WASHINGTON : 2025
SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
MARIA CANTWELL, Washington, Chair
AMY KLOBUCHAR, Minnesota TED CRUZ, Texas, Ranking
BRIAN SCHATZ, Hawaii JOHN THUNE, South Dakota
EDWARD MARKEY, Massachusetts ROGER WICKER, Mississippi
GARY PETERS, Michigan DEB FISCHER, Nebraska
TAMMY BALDWIN, Wisconsin JERRY MORAN, Kansas
TAMMY DUCKWORTH, Illinois DAN SULLIVAN, Alaska
JON TESTER, Montana MARSHA BLACKBURN, Tennessee
KYRSTEN SINEMA, Arizona TODD YOUNG, Indiana
JACKY ROSEN, Nevada TED BUDD, North Carolina
BEN RAY LUJAN, New Mexico ERIC SCHMITT, Missouri
JOHN HICKENLOOPER, Colorado J. D. VANCE, Ohio
RAPHAEL WARNOCK, Georgia SHELLEY MOORE CAPITO, West
PETER WELCH, Vermont Virginia
CYNTHIA LUMMIS, Wyoming
Lila Harper Helms, Staff Director
Melissa Porter, Deputy Staff Director
Jonathan Hale, General Counsel
Brad Grantz, Republican Staff Director
Nicole Christus, Republican Deputy Staff Director
Liam McKenna, General Counsel
C O N T E N T S
----------
Page
Hearing held on April 17, 2024................................... 1
Statement of Senator Cantwell.................................... 1
Statement of Senator Cruz........................................ 3
Statement of Senator Duckworth................................... 5
Statement of Senator Vance....................................... 18
Statement of Senator Rosen....................................... 21
Statement of Senator Budd........................................ 23
Statement of Senator Klobuchar................................... 25
Statement of Senator Schmitt..................................... 26
Statement of Senator Welch....................................... 28
Statement of Senator Blackburn................................... 31
Statement of Senator Warnock..................................... 33
Witnesses
Dr. Javier de Luis, Lecturer, Department of Aeronautics and
Astronautics, Massachusetts Institute of Technology (MIT)...... 6
Prepared statement........................................... 8
Dr. Tracy Dillinger, Manager of Safety Culture, Human Factors in
Mishap Investigations, and Human Reliability Assessment,
National Aeronautics and Space Administration.................. 9
Dr. Najmedin (Najm) Meshkati, Professor, Sonny Astani Department
of Civil/Environmental Engineering, Daniel J. Epstein
Department of Industrial and Systems Engineering, USC Aviation
Safety and Security Program, Viterbi School of Engineering;
Professor, International Relations, Dornsife College of
Letters, Arts and Sciences, University of Southern California.. 11
Prepared statement........................................... 12
Appendix
Response to written questions submitted by Hon. Raphael Warnock
to:
Dr. Javier de Luis........................................... 39
Dr. Tracy Dillinger.......................................... 40
Dr. Najmedin (Najm) Meshkati................................. 41
FAA ORGANIZATION DESIGNATION
AUTHORIZATION (ODA) EXPERT PANEL REPORT
----------
WEDNESDAY, APRIL 17, 2024
U.S. Senate,
Committee on Commerce, Science, and Transportation,
Washington, DC.
The Committee met, pursuant to notice, at 10 a.m., in room
SR-253, Russell Senate Office Building. Hon. Maria Cantwell,
Chair of the Committee, presiding.
Present: Senators Cantwell [presiding], Klobuchar, Markey,
Baldwin, Duckworth, Tester, Rosen, Hickenlooper, Warnock,
Welch, Cruz, Thune, Fischer, Blackburn, Young, Budd, Schmitt,
and Vance.
OPENING STATEMENT OF HON. MARIA CANTWELL,
U.S. SENATOR FROM WASHINGTON
Chair Cantwell. Good morning. The Committee on Commerce,
Science, and Transportation will come to order.
I want to thank our witnesses who are here today on the FAA
ODA Organization Expert Panel Report.
I also want to recognize our former colleague; Peter
DeFazio is in the audience and thank him for his work on the
ACSAA legislation with this committee.
Today, we will hear from three experts on the Organization
Design Authorization, the expert panel's final report.
I want to mention, I appreciate the witnesses being here
today, but I want to acknowledge, this is directly from the
report that, quote, ``The successful completion of this report
was made possible with the cooperation and assistance of the
following organizations: the Federal Aviation Administration;
the Boeing Company; American Airlines; Bell Textron, Inc.;
University of Southern California, Viterbi School of
Engineering; and special thanks to Brittney Goodwin, Mina
Mitchell and Heather Thorson, and analysis supported by Data
and Assessment Teams, within the Office of FAA's ODA.''
I want to mention that because you're the representatives
of all of those people today, and we could have had many people
here, but wanted to appreciate the work of the two Chairs of
the Committee, and for you being here as representatives of
these individuals today.
We are joined by Dr. Javier de Luis, Lecturer of MIT's
School of Technology, Department of Aeronautics and
Astronautics, thank you so much for being here; Dr. Tracy
Dillinger, Manager for Safety Culture of Human Factors at NASA;
and Dr. Najmedin Meshkati, Professor of University of Southern
California School of Engineering and Aviation Safety Programs.
The expert panel's 53 recommendations regarding Boeing's
ODA safety management system safety culture serves as an
important catalyst for us in future aviation legislation. While
we've made some safety improvements through the Air
Certification Reform law, and some of that is still playing out
with a new Administrator who I think is more aggressively
taking the responsibilities of the Act seriously, we look to
build on those advancements with a 5-year authorization bill
and some enhanced safety features.
But we're not going to stop there. There is more to be done
to implement the recommendations from your report. We owe a
debt of gratitude to those who are here today.
I want to especially thank you, Dr. de Luis. Thank you so
much for being here. I can't imagine the tragedy of losing your
sister in one of the MAX crashes and then continuing to be
involved in trying to correct and improve our safety culture.
But I can just say I so appreciate you being here and the
active role that you have played in all of these discussions.
The expert panel's final report focused on the importance
of safety management systems. And while Boeing was required to
adopt an SMS in 2015 as part of an FAA settlement agreement,
and while the FAA later adopted voluntary SMS programs, the
experts panel's report make it clear now that we need a real
SMS with teeth. Both Boeing and the FAA need strong and
effective safety management systems. Not in name, but in
reality.
Safety management system might, for the public, sound like
management strategies that maybe they shouldn't pay attention
to. But when it comes to this management strategy, and it
revolves around aviation, it is about saving lives. That is why
section 102 of ACSAA required that the FAA develop a real SMS
standard for aviation manufacturers. And the agency expects,
the FAA expects, to finalize that SMS rule this June.
This expert panel made several recommendations, findings
about the safety culture and about ODA. And I want to highlight
some that Boeing safety management procedures are not
thoroughly understood throughout the company. I'm sure you'll
expand on this, that it is focused on only one of the four
pillars of what ICAO, the international standard, has said that
you have to meet if you're going to have an SMS program
understood by the workforce writ large. I'm sure you'll expound
on this.
The expert panel raised concerns about the FAA's ability to
effectively oversee Boeing's SMS, and I believe the FAA needs
not only a strong workforce strategy to exercise the oversight
of the manufacturers to ensure proper implementation of SMS,
I'd like to query the panel today on exactly what SMS the FAA
should implement in their own house to make sure that they are
improving the safety culture and standing up on these important
safety measures.
Right now, we are relying on employee safety reporting
system, Speak Up, which you talked about. And I think a
comprehensive system that the employees know and understand has
to be a key component of SMS. And documentation provided by the
interviews of Boeing employees showed that they may not have
understood how safety fit into the culture of the overall
obligations of the company.
Human factors have not been prioritized as a technical
discipline, and human factors are at the core of focus of what
we need to do, both at the FAA and at Boeing. While I think you
did talk about the loss of experience and capability of a
workforce, we definitely want to build that expertise
throughout government, clearly at the FAA, so that they can
keep pace with technological change. And while the
restructuring of Boeing's ODA unit did decrease the
opportunity, as your report is saying, for retaliation, we
still are seeing that interference is occurring. This is
unacceptable.
ACSAA strengthened the FAA's oversight and put them in
charge of these employees. And we certainly expect the FAA to
back up those individual engineers and machinists who are
calling out safety and making sure that they address those.
Although the final report gave Boeing six months to make
this action plan a reality, the expert panel's recommendations,
the FAA Administrator, has cut this time to 90 days, and I
expect the company to comply with this deadline and submit a
serious plan that demonstrates this commitment to these kind of
safety measures.
The FAA must also demonstrate that it is going to be a
strong regulator on these issues. I hope to query the panel
about how to ensure that, how we, as the oversight committee of
the FAA, in strength--basically strengthen this oversight by
the FAA.
So, I look forward to hearing from our witnesses today.
Again, thank you so much for being here.
And now I turn to Senator Cruz for his opening remark, and
then we'll hear from our two subcommittee colleagues on their
statement as well.
Senator Cruz.
STATEMENT OF HON. TED CRUZ,
U.S. SENATOR FROM TEXAS
Senator Cruz. Thank you, Madam Chair.
The United States sets the benchmark for flight safety.
And, by arguably the most important measure, 2023 was a
remarkably safe year for aviation, with no fatal accidents or
hull losses for commercial jet aircraft.
Flying commercial remains the safest way to travel. But
understandably, recent incidents have left the flying public
worried. The perception is things are getting worse. The public
wants the Federal Aviation Administration and Congress to
confront perceived risks in order to restore confidence for
fliers.
That brings me to the topic of today's hearings: the FAA's
Organization Designation Authorization program. ODA is
important to the future of aviation safety, as well as to
American competitiveness. I appreciate the work of our
congressionally-appointed expert panel, which reviewed Boeing's
ODA for transport airplanes.
Congress established this panel in the aftermath of the
tragic crashes of Lion Air Flight 610 in 2018 and Ethiopian
Airlines Flight 302 in 2019, in which 346 people tragically
lost their lives.
The panel's final report was released in February. And
three of its members are here with us today. Welcome.
As a brief aside, I want to in particular acknowledge that
one of our witnesses, Dr. Javier de Luis, lost his sister on
Flight 302. Dr. de Luis, please accept my sincere condolences,
and thank you for continuing to speak out on an issue that I
know has grieved you and your family personally.
I also want to recognize the other families that are here
today remembering their loved ones whose lives were lost on
those two tragic accidents.
Discussing ODA and what changes may be needed is critical,
and I welcome this conversation.
It is worth noting, however, that the FAA is still
implementing the Aircraft Certification, Safety, and
Accountability Act, this committee's response to the MAX 8
crashes. It has not been fully--it has not even fully
implemented the 2018 FAA Authorization Act, even as we are
currently negotiating the current reauthorization.
While it is clear that Boeing's culture and safety
management needs drastic improvement, we should not rush to
legislate just for the sake of legislating.
To that point, I look forward to engaging with today's
witnesses, all of whom deserve our appreciation and thanks for
their hard work on this effort. Their report was a consensus
product issued without any dissenting views, which all of us in
Congress can appreciate is no small accomplishment. And I hope
to better understand their recommendations and how Congress can
work to improve aviation safety in a targeted and effective
manner.
While discussing ODA and Boeing's safety culture is
important, the flying public is also acutely worried about why
pieces of Boeing airplanes are falling from the sky. The
experts' panel report specifically noted that the panel was not
directed to investigate or provide recommendations toward
specific airplane incidents or accidents which occurred prior
to or during the expert panel's work.
In addition to today's hearing, I believe we also need to
hear from the FAA and from Boeing itself about episodes like
Alaska Airlines Flight 1282. Our committee needs to understand
not only Boeing's ODAs, but the specific production missteps
that caused the January incident.
And we need to hear from Boeing directly about the
company's safety culture and safety management writ large. The
public will want to know what changes Boeing is making to
restore confidence in its brand. Boeing is a great American
company with a great history and great legacy, and we all want
Boeing to be successful.
But when accountability is needed, and it clearly is here,
we should not hesitate to demand answers. And for Boeing to
succeed going forward, those answers need to be given and
changes need to be made to ensure that safety is central.
When each of us, when our families, when our children get
on an airplane, we want to trust that we're going to land
safely. That's the topic of this hearing, and I hope subsequent
hearings as well. Thank you.
Chair Cantwell. Thank you, Senator Cruz.
Senator Duckworth.
STATEMENT OF HON. TAMMY DUCKWORTH,
U.S. SENATOR FROM ILLINOIS
Senator Duckworth. Thank you, Chairwoman Cantwell, for
holding this hearing and for your commitment to continued
oversight.
I also want to thank our witnesses and all those who worked
on the expert panel review. This review confirms my view that
we need to judge Boeing not by what it--that we need to judge
Boeing by what it does, not by what it says it's doing.
Boeing says it prioritizes safety above all else. But when
the expert panel asked Boeing to produce evidence of this
commitment, the evidence that Boeing provided, and I quote,
``did not provide objective evidence of a foundational
commitment to safety that matched Boeing's descriptions of that
objective,'' end quote.
That should be shocking. But based on some of Boeing's
recent actions, frankly, it's not. Weeks after a door plug blew
out of a 737 MAX 9, Boeing was still petitioning the FAA for a
safety exemption to rush its next 737 MAX variant into service,
despite the fact that it had known--a known, potentially
catastrophic safety defect. To its credit, under pressure,
Boeing eventually withdrew that petition.
But the fact that Boeing filed it in the first place speaks
volumes about the lack of a proper safety culture at Boeing
and, until recently, the lack of a proper regulatory culture at
the FAA.
Boeing filed this petition because they thought FAA would
grant it. Boeing thought they could minimize the significance
of this safety defect and that the FAA would just let it slide.
Boeing had a good reason to think this. FAA let Boeing's
bad actions on the 737 MAX slide for years; and, go figure,
we're seeing more bad results.
I'll give two examples which I think are particularly
relevant to our discussion today about Boeing's Organization
Designation Authorization, or the ODA.
The first example involves MCAS. Boeing downplayed MCAS so
successfully, it actually persuaded the FAA to let Boeing
remove it from the flight manual. And after MCAS crashed two
737 MAX planes, killing 346 people, investigators uncovered an
internal Boeing memo, showing that Boeing had been explicitly
planning to downplay MCAS in order to avoid regulatory
scrutiny. The plan called for Boeing to not even use the term
``MCAS'' when describing the plane to a regulator.
Even worse, the memo showed an ODA unit member approved
this plan to deceive a regulator. And yet, when this memo
surfaced, the FAA did nothing. It did not even investigate. By
sitting on its hands, FAA effectively told Boeing that this
type of conduct was perfectly fine.
The second example concerns the angle-of-attack disagree
alert, the AOA disagree alert. Shortly after the 737 MAX 8 went
into service, Boeing discovered that the AOA disagree alert was
not functioning on most of the 737 MAX jets, which was a
violation of the plane's approved type design.
Instead of reporting this to the FAA and to 737 MAX pilots,
Boeing intentionally concealed this and continued to
manufacture more than--more 737 MAX jets with the same defects.
In other words, Boeing made a decision to knowingly and
repeatedly violate its approved type design for years. Boeing's
ODA knew about this, but did not alert the FAA.
And when FAA finally found out that Boeing had been
knowingly and repeatedly violating its approved type design,
the FAA did nothing. This effectively told Boeing that type
design doesn't matter, because the FAA isn't going to always
enforce it.
When the FAA fails to take action in response to bad
behavior, it sends an unmistakable message to both Boeing and
its employees that bad behavior is acceptable. No wonder the
expert panel found that Boeing employees are so confused.
FAA needs to more closely scrutinize Boeing's behavior and
make use of its civil enforcement authority when appropriate.
And I am pleased by the more aggressive regulatory tone
Administrator Whitaker has brought to the agency. But as this
expert panel review makes clear, there is still a long way to
go to bring an effective safety culture back to Boeing.
We have our work cut out for us on this committee, as we
continue our oversight and consider whether additional
legislation may be needed. And I thank the panelists for being
here. I really appreciate your hard work on this to make flying
safer for the American people.
Thank you, and I yield back, Madam Chair.
Chair Cantwell. Thank you so much, Senator Duckworth, and
for your leadership and your help on the FAA reauthorization,
and safety improvements in that bill.
I guess Senator Moran will not be here for an opening
statement. I'm sure he will be attending, but we'll now just go
to the witnesses.
So Dr. de Luis, again, thank you so much for being here.
You're free to make an opening statement.
STATEMENT OF DR. JAVIER de LUIS, LECTURER,
DEPARTMENT OF AERONAUTICS AND ASTRONAUTICS,
MASSACHUSETTS INSTITUTE OF TECHNOLOGY (MIT)
Dr. de Luis. Thank you very much, Senator. Chair Cantwell,
Ranking Member Cruz, and members of the Committee, on behalf of
myself and my fellow panelists, I want to thank you for the
opportunity to come here and talk about our findings and
recommendations from the final report.
My name, as you know, is Javier de Luis. I'm an aerospace
engineer, as I would describe myself. I earned a doctorate
from--in aeronautics and astronautics from MIT. I spent my 40-
year career in private industry, mostly running small
businesses that I helped start. Then we built hardware for
NASA, DOD, and other agencies. I'm currently a lecturer at MIT.
But I'm also the brother of Graziella de Luis, as you have
noted. And my sister was killed when the airplane she was on,
the 737 MAX, crashed a few minutes after takeoff, killing all
157 people on board. So for me, serving on this panel has been
an opportunity to help prevent anyone else from going through
what I and my family have sadly experienced these past 5 years.
Our panel met for almost a year; reviewed over 4,000 pages
of documents provided to us by Boeing; interviewed 250 Boeing
employees at all levels of the organization, from the executive
suite down to the people that tightened the bolts, across six
different geographic plants across the country; and we reviewed
thousands of survey responses that came to us through several
surveys that were conducted.
As has been noticed, this is a consensus report, and I'd be
remiss if I did not give full credit to this, to our co-chair--
co-chairs Michael Bartron and Keith Morgan, for herding what
was at time this diverse and rather unruly group to hopefully a
productive end.
Our channel--our panel was charged by ACSAA to focus its
review on three specific topics: the safety culture, the safety
management systems, and the ODA program at Boeing. We were,
however, also allowed to evaluate other topics of concern that
we might identify that would impact the safety of the flying
public.
As Senator Cruz noted, we were not charged--or I'm sorry,
as one of--as was noticed previously, we were not charged with
investigating specific airplane incidents that occurred prior
to our panels. But it was--as understandable, on several
occasions during our activities when safety issues arose with
Boeing products, we, of course, considered them.
My fellow witnesses and I felt that it would be useful to
expand on several of the key recommendations in our report, as
this may help the stage for today's--set the stage for today's
hearing.
First and foremost is one that has been talked about since
the report came out, is our finding that there exists a
disconnect, for lack of a better word, between the words that
are being said by Boeing management, and what is being seen and
experienced by employees across the company.
They hear, ``Safety is our number one priority.'' But what
they see is that that's only true as long as your production
milestones are met. And at that point, it's push it out the
door as fast as you can.
They hear, ``Speak up if you see anything that's unsafe.''
But what they see is that if they do speak up, they get very
little feedback. And if they insist, they may find themselves
on the short end of the stick next time raises or bonuses or
job transfers come up, or even worse.
We found this disconnect to be present at almost all levels
and at all worksites that we visited. We heard it from
technicians, we heard it from engineers, and we heard it, more
concerning, from members of the ODA that are delegated by the
FAA to conduct inspections and tests on behalf of the
government.
To me, it is clear that the commitment to change, the level
of change, and the pace of change at Boeing is not commensurate
with the events that created the need for all this change in
the first place: namely, the two fatal crashes of two brand new
airplanes 5 years ago. It was distressing to read a recent
statement by Brian West, the CFO of Boeing, speaking about the
Alaska Air incidents from this past January, where he said,
``For years,'' and this is a quote, ``For years, we prioritized
the movement of the airplane through the factory over getting
it done right. That's got to change.''
The leadership team got it in the immediate aftermath of
January 5. Now I would have thought that they would have gotten
it 5 years ago.
In closing, I'll note that for the last 20 years, every FAA
Reauthorization Act pushed more and more responsibility over
the fence to the manufacturer's side. At the time, this was
done with the understandable objective of increasing efficiency
and productivity.
The two MAX crashes showed that the pendulum had swung too
far, and ACSAA was the response to try to correct this.
But ACSAA cannot be the high-water mark in your efforts. I
urge you, as you debate additional steps that can be taken, to
ensure that you increase the FAA oversight of Boeing, and that
you keep pushing for structural change at the company, and as
well as ensuring that all of our panel's 53 recommendations are
fully implemented.
I believe that this is the only way that we can return this
company to what we all remember it once being: a company known
for engineering excellence, and a company where the headlines
were written about it because of its accomplishments and not
because of its failures. I believe the flying public deserves
no less.
I will now turn it over to my colleague, Dr. Dillinger.
[The prepared statement of Dr. de Luis follows:]
Prepared Statement of Dr. Javier de Luis, Lecturer,
Department of Aeronautics and Astronautics,
Massachusetts Institute of Technology (MIT)
Chair Cantwell, Ranking Member Cruz, members of the Committee. On
behalf of myself and my fellow FAA Expert Review Panel members, I want
to thank you for the opportunity to come here today and discuss the
findings and recommendations from our final report.
My name is Javier de Luis. I am an aerospace engineer. I earned a
doctorate in aeronautics and astronautics from MIT. I spent my entire
career in private industry, mostly in small businesses that I helped
start, where we built hardware for NASA, DoD, and other organizations.
Though I'm trying to retire, I currently hold a lecturer appointment at
MIT, where I help teach system engineering to seniors and graduate
students and have lectured at several universities across the US.
That is, however, not why I am here. I am here because I am also
the brother of Graziella de Luis, who was killed when the airplane she
was on, a 737Max flown by Ethiopian Airlines, crashed a few minutes
after takeoff killing all 157 people on board. For me, serving on this
panel is an opportunity to do something that might keep anyone else
from going through what I and my family have experienced these past
five years.
Our panel met for almost a year, reviewed 4000 pages of documents
provided to us by Boeing, interviewed 250 Boeing employees at all
levels of the organization, across six Boeing's locations, and reviewed
thousands of survey responses. It should be noted that we were required
to sign Non-Disclosure Agreements (NDA), however no NDA-protected data
is in our report, which contains 27 findings and 53 recommendations.
It is a consensus report, with no dissenting opinions. I would be
remiss if I did not give full credit for this to our co-chairs, Mr.
Michael Bartron from the FAA and Mr. Keith Morgan from Pratt & Whitney,
for herding this diverse and at-times unruly group to a productive end.
Our panel was charged by the Aircraft Certification, Safety, and
Accountability Act (ACSAA) to focus its review on the three topics:
safety culture, safety management systems (SMS), and the Organization
Designation Authorization (ODA) program, while also evaluating other
topics of concern for the safety of the flying public. The Act also
defined the required composition of the Panel.
However, we were not charged with investigating specific airplane
incidents which occurred prior to or during the Expert Panel's work.
Nevertheless, on several occasions during the Panel's activities,
serious safety issues with Boeing products which became public were
considered.
My fellow witnesses and I felt that it would be useful to expand on
a few of the recommendations in our report, as they may serve to set
the stage for today's hearing. First among these is our finding that
there exists a ``disconnect'' between the words that are being said by
Boeing management, and what is being seen and experienced by the
technicians and engineers. They hear ``safety is our number one
priority'', but they see that that is only true as long as you meet
your production milestones. They hear ``speak up if you see anything
unsafe'', but they see that when they do, there's little feedback, and
if they insist, they may find themselves on the short end of the stick
next time raises are distributed, or worse.
We identified this disconnect based on our interviews and survey
responses. It was present at almost all levels and almost all worksites
that we visited. We heard it from technicians and engineers, as well as
from members of the ODA that are delegated by the FAA to conduct
mandated inspection and tests on behalf of the government.
To me and I think to our Panel, it is clear that the commitment to
change, the level of change, and the pace of change at Boeing is not
commensurate with the events that created the need for all this in the
first place: the two fatal crashes brand new airplanes, killing all
aboard. I believe it is safe to say, given our findings, that the
events of Jan 5 and the subsequent NTSB investigation identifying the
missing bolts in the Alaska Air door did not really come as a surprise.
What was distressing, though, was the recent statement by Mr. Brian
West, Boeing's finance chief at a investor conference where he said:
``For years, we prioritized the movement of the airplane
through the factory over getting it done right. That's got to
change. The leadership team got it in the immediate aftermath
of January 5.''
I would have thought that they would have ``gotten it'' five years
ago.
In closing, I would like to say that for the last 20 years, every
FAA authorization act has pushed more and more responsibility over the
fence to the manufacturer side, usually with the understandable
objective of increasing efficiency and productivity. The two 737 Max
crashes showed that the pendulum had swung too far. ACSAA was your
response to trying to correct this imbalance. But recent events show us
that we're not there yet, and ACSAA cannot be seen as a high-water mark
in this effort. It is just a first step, and I urge you as you debate
additional steps that can be taken either as separate legislation or
though the reauthorization, to increase FAA oversight at all levels and
keep pushing for structural change at Boeing, as well and to ensure
that all of our Panel's 53 recommendations are fully implemented. This
is the only way that we can return this company to what we all remember
it being: a company known for engineering excellence, where headlines
were written about it because of their accomplishments, not because of
their failures. The flying public expects and deserves no less.
Chair Cantwell. Dr. Dillinger, welcome. Whatever opening
statement you can make, that would be great.
STATEMENT OF DR. TRACY DILLINGER, MANAGER OF
SAFETY CULTURE, HUMAN FACTORS IN MISHAP
INVESTIGATIONS, AND HUMAN RELIABILITY ASSESSMENT,
NATIONAL AERONAUTICS AND SPACE ADMINISTRATION
Dr. Dillinger. Thank you.
Chair Cantwell and distinguished members of the Committee,
thank you for the opportunity to appear today to discuss the
report of the ODA for transport airplanes from the expert panel
review. I'm Dr. Tracy Dillinger, and I'm currently the Senior
Executive Psychologist for Safety, Culture, and Human Factors
programs within the NASA Office of Safety and Mission
Assurance.
In this position, I have created and chaired the agency's
Safety Culture Working Group and the Human Factors Task Force.
And I am responsible for NASA's safety culture survey, safety
culture courses, safety culture audits and assessments, human
factors mishap investigation support, human factors training,
and our annual human factors report.
I am also a proud veteran of the United States Air Force,
where for over 20 years, I served as a human factors
investigator; human factors instructor; 10 years as the chief
aviation psychologist; and in numerous roles, including the
chief of safety assessments for the Air Force Safety Center;
and served on the Columbia Accident Investigation Board.
I've spent the majority of my career working in the field
of aerospace and aviation safety. I'm truly passionate about
safety culture, human factors, and their combined effect on
organizational performance.
Clearly, a robust safety culture is essential to preventing
mishaps. Safety is a NASA core value, along with excellence,
teamwork, integrity, and diversity, and it's integral to
everything we do. We strive to create an environment where
everyone works safely, feels comfortable communicating safety
issues, learns from both mistakes and successes, and feels
confident balancing challenges and risks.
The International Civil Aviation Organization describes
safety culture as arguably the single most important influence
on the management of safety and recognizes the interdependence
of safety culture and safety management, noting that effective
safety management empowers a positive safety culture; and a
positive safety culture empowers effective safety management.
I was privileged to participate in the ODA panel, where I
was able to lend my knowledge and passion for safety culture to
the work of my fellow panelists with whom I had the privilege
to serve. Boeing, like NASA, uses Jim Reason's five-factor
model of safety culture, comprised of reporting, just,
flexible, learning, and informed elements.
While the company has begun addressing reporting and just
culture training, it needs to enlarge its safety culture
program to include all areas, all five factors, using multiple
means; and the program should be endorsed, promoted, and
modeled by its leaders.
Employees, including team leads, managers, and senior
leaders need to know what to do when a deficit has been
reported.
That includes ensuring that tools and processes are
available so employees can report without fear of reprisal.
Managers can listen, reported issues are fixed, and then
communicated with recognition given to those who come forward
with concerns.
It's equally important that senior leaders continually
message and demonstrate to their workforce that safety is a
critical, fundamental aspect of doing business, even over
profit. Aviation safety isn't just good for the flying public.
Ultimately, it's good for successful operations and mission
accomplishment, and that's good for business.
I believe that successful adoption of the report's
recommendations will improve the level of safety provided by
Boeing to its workforce, operators, and the public.
I would note that while the panel focused on Boeing as an
ODA holder, the panel's findings and recommendations contain
numerous best practices that could assist other companies with
similar authorizations to implement successful safety culture,
safety management systems, or ODA programs.
Thank you once again for inviting me to appear before you
today, and I look forward to discussing these important issues
with members of the Committee.
I yield to Dr. Meshkati.
Chair Cantwell. Thank you again so much for being here, and
thank you for your management strategy books, ``Managing the
Risks of Organizational Accidents'' from James Reason. Thank
you so much for the leadership at the University on these
issues.
STATEMENT OF DR. NAJMEDIN (NAJM) MESHKATI,
PROFESSOR, SONNY ASTANI DEPARTMENT OF CIVIL/
ENVIRONMENTAL ENGINEERING, DANIEL J. EPSTEIN
DEPARTMENT OF INDUSTRIAL AND SYSTEMS ENGINEERING,
USC AVIATION SAFETY AND SECURITY PROGRAM, VITERBI
SCHOOL OF ENGINEERING; PROFESSOR, INTERNATIONAL
RELATIONS, DORNSIFE COLLEGE OF LETTERS, ARTS AND
SCIENCES, UNIVERSITY OF SOUTHERN CALIFORNIA
Dr. Meshkati. Good morning, Chairman Cantwell and
distinguished senators and distinguished members of the
Committee. Thank you for inviting us, the FAA expert panel
members, to testify before you today.
I am Najm Meshkati. I am a professor of engineering at the
University of Southern California. I'm also a senior faculty
member with the 72-years-old USC Aviation Safety and Security
Program. And I have an affiliation with Harvard Kennedy School
Project on Managing the Atom.
For the past four decades, I have been conducting
interdisciplinary research on system safety, human factors,
safety culture, and risk reduction of complex technological
systems. These systems include aviation, oil and gas drilling,
pipeline and refining, nuclear power, and healthcare. System
failures in these industries, these safety-critical systems,
have a deadly impact on humans and the environment.
I have developed many courses at USC around this area. I've
been involved in several accident investigations like BP
Deepwater Horizon. I have visited several nuclear plants like
Chernobyl, Fukushima, and Three Mile Island. But my
participation in this distinguished expert panel, and working
with my great colleagues on this panel, further corroborated
what my research experience has taught me in the last 40 years.
And this is it. The safety culture is the foundation, as
Dr. Dillinger mentioned. Safety culture is the foundation of
any processes and operation in organization. It could make or
break the system. As my mentor, Professor James Reason said,
``Safety culture can affect all elements in the system, for
good or ill.''
I believe safety culture is analogous to human body's
immune system, which protects it against pathogens and fend off
diseases. And it is incumbent upon the leadership of any
organization to strive for immunizing and constantly boosting
the healthy safety culture of the company. A healthy safety
culture is based on competence, trust, transparency, and
accountability.
Another equally important lesson that I've learned by my
participation in this panel, which also corroborated what I
have learned in my career, is that human operators in the
safety-critical system, such as pilots in the airplanes or
human operators in a control room of a nuclear plant, always
constitutes the system's both first and last layer of defense.
First and last layer of defense. Human operators. As we saw
it in the case of The Miracle on the Hudson, and also at
Fukushima Daini nuclear plant.
As such, our panel found and recommended human factors and
human systems integration consideration should receive
attention commensurate to their importance in aviation safety
and aircraft design and operation.
Human factors as a cross-cutting science should become a
formal, stand-alone, and highly prioritized discipline, and a
design practice at Boeing and within any company that they deal
with safety-critical system.
And finally, my research experience has taught me that a
world class engineering company that makes or operates a
safety-critical system such as an aircraft, must be run by
world class engineers who are thoroughly trained to understand,
respect, and impact human factors and safety culture.
Thank you once again for your attention to our panel's
report and appearing before you. Thank you.
[The prepared statement of Dr. Meshkati follows:]
Prepared Statement of Dr. Najmedin (Najm) Meshkati, Professor, Sonny
Astani Department of Civil/Environmental Engineering, Daniel J. Epstein
Department of Industrial and Systems Engineering, USC Aviation Safety
and Security Program, Viterbi School of Engineering; Professor,
International Relations, Dornsife College of Letters, Arts and
Sciences, University of Southern California
Good morning, Chairman Cantwell, Ranking Member Cruz, and
distinguished Members of the Committee. Thank you for inviting us--the
FAA Expert Panel members-to testify before you today.
I am Najm Meshkati, a professor of engineering and international
relations at the University of Southern California (USC). I am also a
senior faculty member of the 72-year-old USC Aviation Safety and
Security Program, and an Associate (ex-Research Fellow) with the
Project on Managing the Atom at the Belfer Center for Science and
International Affairs at the Harvard Kennedy School.
For the past four decades, I have been conducting interdisciplinary
research on system safety, human factors, safety culture, and risk
reduction of complex, safety-critical technological systems. These
systems include aviation, oil and gas drilling, pipeline and refining,
nuclear power, and healthcare. System failures in these industries can
have a deadly impact on humans and the environment.
At USC, I have had the privilege of developing and teaching several
undergraduate, doctoral, and executive training courses on human
factors in aviation and process safety management, mental workload
measurement, root-cause analysis, High Reliability Organization (HRO),
nuclear safety culture, and engineering diplomacy.
I have been an eyewitness to the unfolding of several disasters'
consequences. I worked with the U.S. Chemical Safety and Hazard
Investigation Board as an expert on human factors and safety culture in
the investigation of the BP Refinery explosion in Texas City in 2005,
which killed 15 and injured 180 people. I was a member of two
committees, which were convened by the National Academies (NASEM) and
the National Research Council, and investigated two major accidents,
the BP Deepwater Horizon, and the Fukushima nuclear plant disasters. I
have visited and studied many complex systems, including more than a
dozen nuclear plants around the world, including Three Mile Island,
Chernobyl, Fukushima Daiichi and Daini.
My participation in the FAA Expert Panel and working with my great
colleagues on this Panel have further corroborated what my research
experience has taught me: That safety culture is the foundation of any
process and operation in an organization; it could make or break the
system. And as my mentor, Prof James Reason, succinctly put it,
``safety culture. . .can affect all elements in a system for good or
ill.''
I believe safety culture is analogous to the human body's immune
system, which protects it against pathogens and fends off diseases. And
it is incumbent upon the leadership to strive for immunizing, and
constantly boosting! the healthy safety culture of the company. A
healthy safety culture is based on competence, trust, transparency, and
accountability. A primary evidence of a healthy safety culture is that
equal or at least proportional attention paid to safety versus
production/profitability goals.
Another equally important lesson that I have learned and
participation in the Panel reinforced that is human operators of
safety-critical systems, such as pilots in an airplane, always
constitute the system's both first and last layer of defense against a
catastrophic failure. As such, as our Panel found and recommended,
human factors and human-systems integration considerations should
receive attention commensurate to their importance in aviation safety
in aircraft design and operation. Human factors, as a cross-cutting
science, should become a formal, stand-alone, and highly prioritized
technical discipline and ``design practice'' at Boeing and within
companies such as Boeing.
Our 24-member strong panel and support staff, under the exemplary
leadership of Mr. Michael Bartron and Keith Morgan, worked diligently
for almost a year on this unprecedented report, which includes 27
findings and 53 associated recommendations to Boeing and the FAA. These
recommendations are vital, and we hope that all of them are implemented
in their entirety.
And finally, my research experience has taught me that a world-
class engineering company that makes or operates a safety-critical
system such as an aircraft must be run by world-class engineers who are
also thoroughly trained to understand, respect and implement human
factors and a healthy safety culture.
Our written testimony further elaborates on our points, which we
have submitted for the record, and I'll be delighted to answer
questions about those issues, as well as the issue at hand.
Thank you once again for your attention to our Panel's report and
inviting us to appear before you today.
Chair Cantwell. Well, thank you to all the witnesses.
Appreciate you being here.
I think I have a question just generally. I want to draw
this out a little bit from your report, because you've again
emphasized it.
But some of these terms may just be lost on people and
their significance. And so I'm just trying to--you're saying
there isn't a singular culture program on safety that is
understood by the employees, or that is implemented or
responded to by the employees. And again, I want to make sure,
because I'm going to get to a question about SPEEA and
Machinists, because the frontline people are saying these are
the safety problems. They're just not being backed up.
And so, but I want to understand why the phenomenon exists.
And I think your report says because there are three different
programs, and people don't know which one to pay attention to
at any given time. Is that--is that a correct understanding?
Dr. de Luis. Well, if I may, I think there are a couple of
things there, and I'll just try to tease them out.
It is true that there is an overwhelming amount of
documentation on SMS and safety culture at Boeing. But as has
been described to me by someone recently, it's sort of like if
you're trying to teach your kid to drive, and you give them the
statute book on all the road rules, you know? But what they
really want is the driver's manual.
And what you're referring to is, one observation that we
made is that while all the documentation that exists right now
on SMS and safety culture checks all the boxes that ICAO says
you're supposed to, for the person on the ground turning the
bolts and hammering the nails, they don't know.
We asked at all of our interviews. We said, ``What's the
safety metric are you working toward? How do you know that
you're doing a safe thing?''
And we got like the deer in the headlights. ``What are you
talking about?'' ``Oh, safety. We have production metrics, we
got this metric,'' but there wasn't anything about that. So
that was one thing.
I think the thing that you're referring to about it being
multiple ways, there are multiple reporting ways right now at
Boeing, and that's not necessarily a bad thing. Having multiple
ways of reporting is good and is encouraged.
The problem we found was that they just didn't seem to--
there was lack of confidence in, say, for example, if you tried
to report it anonymously.
There was a lack of confidence that there would be an
anonymous that would be maintained.
There was lack of confidence that things would actually get
done about what you were doing.
And there was a very real fear of retribution and payback
if you held your ground.
And obviously those are things that are just not compatible
with any sort of safety culture or SMS system.
Chair Cantwell. Any of the other witnesses want to add to
that?
Dr. Dillinger. Boeing has been working to develop and field
a safety culture model throughout the organization. They've
been successful in providing training on some of the elements
of it; they have not yet put it all together so that it works
together as a system.
At NASA, we use the DNA logo for it. You know, all of those
parts work together. When someone reports something, somebody
has to listen to it. The way they treat them has to be fair.
There needs to be an environment of psychological safety. They
need to learn from that, and communicate it, and pass it on.
And to create that, everybody in the system needs to know
what they're supposed to do, and how to do it, and what's
expected of them.
And if that doesn't work, they need to know the next
option. And if that doesn't work, they need to know the next
option.
That's why having multiple reporting systems can be a good
thing, because if one doesn't work, the employee needs to know
what else they can go to.
One of the things, for example, would be to know who is the
chief of safety. That would be where the buck stops. And in one
of the surveys that we saw, 95 percent of the people who
responded to the survey did not know who the chief of safety
was. That's a deficit that could be corrected. But people need
to learn who the key people are in that system, so they know
who they can go to when the processes don't work.
Chair Cantwell. Well, I wondered to what degree this
committee, or I did as Ranking Member of the Committee. Then a
whistleblower report that detailed in 2021, an FAA engineer,
Michael Collins, describes an instance where the FAA management
overruled an engineer regarding a lithium ion battery in the
787. And notably later, the FAA had to ground the 787 in
response to fires caused by the very lithium ion batteries.
So there was an instance where people were not listening to
what people were saying on the line, what needed to be done.
There's another incidence where Dr. Martin Bickeboeller
stated that a more secure safety reporting system may have
prevented him from facing retaliation for filing complaints
about different components not meeting FAA standards.
So how do we ensure that those who are speaking up about
safety measures get listened to? I'm sure in this case, these
two knew who to go to, but just because they've been very
experienced people; but this--they weren't listened to. So what
do we need--what do we do with this part of the problem? What
do we need to do with the FAA?
Dr. de Luis. Well, you know, in a properly functioning SMS
and a properly functioning safety culture, those questions
wouldn't be asked. Right? Because they--people would be
empowered. People would have confidence that they wouldn't be,
that they wouldn't be smacked down if they spoke up.
I don't think that's what we're dealing with here. And
which is one of the reasons that, by the way, that we, in one
of our recommendations, we encouraged, we recommended that
Boeing establish what are called ASAP programs, aviation safety
action programs. They're very common in airlines.
And an ASAP program has--is a tripartite program. It has
the FAA, the labor, and management. And if you initiate an ASAP
event, you're protected. But more importantly than being
protected, the event gets visibility at the FAA level and at,
as well as the management level.
And for me, I've been in--and when I started on this
committee, I quickly became a big convert to visibility,
because I am convinced that if enough eyes had seen the MCAS
design 10 years ago, somebody would have raised their hand and
said, ``Hey, wait a second, maybe having a system that if one
sensor failed, it crashes the airplane to the ground is not the
best idea.''
But they didn't, because as was noted, it was purposely
hidden. Right? So I'm honor-bound----
Chair Cantwell. Well, just to be clear, there were
whistleblowers who did bring this up and said that it was
unsafe, but they weren't listened to.
Dr. de Luis. They weren't listened to.
Chair Cantwell. So it's hard; they weren't listened to. And
so we're--this is why we're saying good engineering, as I think
you agree, wins the day. But people have to listen to the
engineers----
Dr. de Luis. You're about to lose----
Chair Cantwell.--and so we're trying to discover here, what
kind of--look, our committee can only do the oversight of the
FAA that enforces the FAA to do its oversight job correctly.
And we want to know what we need to do to strengthen this.
But my time has expired. I have a suspicion I'll be able to
come back to this and we'll, yes, go back to, but I'll turn to
Senator Duckworth.
Senator Duckworth. Thank you, Chairwoman.
Again, you know, I want to dig deeper into this
conversation. I mean, since the door plug fell out of the 737
MAX 9 for Alaska Airlines, there has been a lot of attention on
Boeing's stunning lack of quality control throughout its supply
chain. And this is understandable.
And yet, as we've already heard, the expert panel appears
to have identified a much broader problem at Boeing, the utter
absence of an effective safety culture. And I fear that merely
increasing scrutiny on how a door plug is removed and replaced
will fail to solve the more fundamental cultural failures that
are at the root of the Boeing's flawed development and
production of the 737 MAX.
And Dr. de Luis, I would love for you just to go deeper in
the conversation we're already having, because I think you
would agree with me, would you not, that fixing a specific
assembly line problem would not be sufficient to get Boeing
back on track.
And frankly, I personally think that Boeing's recent
manufacturing problems are merely a symptom of a much deeper
problem, the destruction of a proper safety culture by share-
price executives who time after time prioritize Wall Street
profits over long-term production excellence. It's sort of the
replacement, the driving out of the engineers that were at the
heart of what Boeing was.
So can you talk a little bit about manufacturing problems--
--
Dr. de Luis. Sure.
Senator Duckworth. --Are more of a symptom. Would you agree
they're more of a symptom of the bigger problem than--you can't
just fix a quality control issue and think that that's going to
solve it.
Dr. de Luis. Right. I completely agree.
And let's talk about the door plug and just use that as an
example. Everyone's seen the picture, right? Of the door plug
sitting there without three of the bolts; you can't see the
fourth one, right? But everyone's seen that picture, and you
go, ``Oh, my goodness, their bolts are missing. Where was the
inspector?''
Oh, OK. Should have been inspected.
But more importantly, I think, why did a mechanic install
the door and walk away, leaving it in that condition? Why
wasn't he or she trained to know that you just can't do that,
right? And that's where you go to, you know, yes, more
inspection is good.
I firmly believe you can't inspect your way to quality, and
you can't inspect your way to safety, because all it's going to
take is one slip, and we're back here again.
It's got to be in the DNA of the people that understand
that you don't walk away from a door, leaving it in an unsafe
condition. Now you can even take that a little further and say
you shouldn't design a door which allows the bolts to be
separated from the door so that, you know, so, I mean, it
should be captured or something. I mean, you can take it all
the way back up to the design level.
But I completely agree that just putting out Whack-a-Mole,
trying to--playing Whack-a-Mole with Q.A. problems is not the
way that you're going to get there, because that's impossible.
The car industry learned this a long time ago, right? You
don't let cars move forward when they have defects. You fix the
defect, and you figure out why the defect's there, and then it
doesn't show up again.
That's not happening here. When problems arise on the line,
the line keeps moving forward. And I think that until they take
a page from what the U.S. auto industry learned 30 or 40 years
ago, we're not going to be able to get to where we need to be
for Boeing.
Senator Duckworth. I would agree with you. And by the way,
that picture was from a cell phone text message, because when
the NTSB went and asked Boeing to provide all the logs--and,
you know, back in my--in the, you know, when I flew for the
Army, it was all paper logs, and we switched to computerized.
They couldn't find any logs for anybody who inspected it, who
took it off, or put it back on. They still haven't been able to
identify who did the work.
But that picture wasn't even official. That was just a text
message between workers.
I want to get into the ODA reforms. After all the ODA
reforms, I am frustrated that Boeing's ODA still allows
opportunities for retaliation against those who raise safety
concerns. And the expert panel found continuing problems
tracking safety concerns once they're made.
This sounds eerily like how ODA operated before Congress
passed the ACSAA Act. And in 2016, an internal Boeing survey
found that 39 percent of Boeing authorized representatives had
experienced undue pressure from Boeing. We've already talked
about this a little bit.
A 2020 FAA survey found that 56 percent of respondents from
its aircraft certification service believe external pressure
from industry is perceived to get in the way of safety
decisions. And 49 percent of respondents from FAA's aviation
safety office believe that safety concerns will not be
addressed, so they don't bother to report them.
I would love for both Dr. de Luis and Dr. Meshkati to
address this issue. Congress tried to fix this in the Aircraft
Certification and Reform Accountability Act, but clearly a
problem remains. Does Congress have more legislative work to
do? And what do you--would you recommend we do? I know that the
panel found, made 54 suggestions, but I would love to hear.
Dr. Meshkati, would you like to kick us off?
Dr. Meshkati. Thank you, Senator. That has been a major
issue about the fearful retaliation and the independence of
ODA. And we talk about that, and we heard about that during our
interviews and surveys and the documents that we reviewed.
One important conclusion that we came up with, this
reorganization of ODA within Boeing, that the old--because
Boeing, as you know better than I do, is a matrix organization.
You have the functional group, and you have the program group.
ODA in the past was in the basically program group. Now they
are reporting to the functional group.
And there have been some--something which was a little bit
of a surprise to me, that there were some non-Boeing ODA
members also, which were contractors, which their security
could be subject to job stability and security could be subject
to the review that they get.
But with this reorganization that they have done, that the
ODA unit members, they report to the functional group, they--it
could fix that. And I want to open a prontices (phonetic
0:57:30) here, Senator, that in our panel, we have had
manufacturer's representative that they have ODA. We had person
from Gulfstream, we have person from Bell Textron, and GE, and
Pratt & Whitney. They do ODA correctly. It's not that there is
something fundamentally wrong or inherently wrong with ODA. ODA
can be managed correctly, and these issues would not appear as
much as we saw here.
Dr. de Luis. The--if I may, the--you asked what could the
FAA do whatever. I think that the FAA needs to take a very
close look.
The FAA right now approves ODA members. Right? I think it
needs to take a very close look as to what the organizational
structure of the ODA within the company is, and require it to
be, you know, to be independent when it comes to decisions that
affect the person's livelihood.
It's a very hard ask for someone, you know? I mean, do--
you're putting your livelihood at stake in order to stand your
ground. Most engineers are ethical and are going to do it. But
we shouldn't have to ask them, you know, to risk their family
livelihood.
And Najm, Professor Meshkati, brought up the issue of the
contractors as ODA members. That's--to me, I'm--I was very
troubled by that, because, you know, a contractor's
relationship with a company is very tenuous financially. Right?
I mean, you're basically there at will, completely at whim.
It's a big ask to have a contractor, and that's going to stand
their ground, knowing that they could be shown the door the
next day.
There are times where they're needed, you know, recently
retired people that you want to bring back because of their
expertise. I completely get that. But that should be the
exception, I believe, and not the rule. I mean, I think you
really want these to be full-time employees that have a little
bit more security, whether they're SPEEA members or not or
whatever.
Senator Duckworth. You've been very indulgent, Madam Chair.
Thank you.
Chair Cantwell. Senator Vance. And then Senator Rosen.
STATEMENT OF HON. J. D. VANCE,
U.S. SENATOR FROM OHIO
Senator Vance. Great. Thank you, Madam Chair. And thanks to
you and the ranking member for hosting. And thanks to all of
you for being here.
So first, I want to thank each of the witnesses for the
important work you put into this report. And I'd like to focus
my questions on the ODA, the Organization Designation Authority
culture at Boeing, and more broadly, some of the concerns that
have been raised about retaliation against employees for
identifying defects and other problems in the course of
Boeing's operations.
So in the report's executive summary, the expert panel
found that even though ``Boeing's restructuring the management
of the ODA unit decreased opportunities for interference and
retaliation against'' ODA unit managers and provided better
organizational messaging regarding the independence of unit
managers, something was missing.
Now Dr. de Luis--I hope I'm getting that pronunciation
right. In your executive summary, you say, and this is quoting
from the report, The ODA ``restructuring, while better, still
allows opportunities for retaliation to occur, particularly
with regards to salary and furlough ranking. This influences
the ability of unit managers to execute their delegated
functions effectively,'' end quote.
So Dr. de Luis, I want to understand how this fear of
retaliation manifests itself on the assembly line. So in your
investigation, did you find Boeing employees on the factory
floor were empowered and encouraged by management to stop the
processes if an employee detected a nonconformity or a possible
defect?
Dr. de Luis. No, Senator, as I understand it, the only
thing that stops the line on the factory floor is an OSHA
violation. If an employee thinks that his or her life or health
can be threatened, they can stop the line.
Everything else basically gets written up and gets put into
one of various processes. Depending on how--where it sits, it
gets written up, and then supposedly gets addressed down the
line. And this leads to the traveled-work problem that we've
heard about before, where you have a problem, you'll fix it
later; but in order to fix it later, you have to take apart
something that, you know, wasn't there before.
And that's in part what caused the door problem, by the
way. Right? They had to replace some rivets. They had to remove
the door. They put the door back, they forgot the bolts, et
cetera.
But no. To answer your question directly, we did not find
any encouragement or any empowering to stop the line. They're
focused on reporting it. And supposedly that loop should be
closed and those problems fixed. But it's very difficult to say
that that's actually happening.
I can give you an example in one of our interviews that I
believe you and I did, Tracy. We were at the receiving area,
the receiving room--receiving section, where they check out the
airplanes before the FAA inspects them. And I asked them,
``What is the major thing that you find?''
They say, ``Oh, it's FOD.'' Foreign object debris.
And I'm like, ``So what happens?''
``Well, you know, we report it, we clean it up, and we move
on.''
I say, ``Well, don't you track back where the FOD came
from, so you can be sure it doesn't happen again?''
And they're like, ``Well, we put the report in, and
somebody's supposed to do it, but it keeps on showing up.''
Senator Vance. Yup.
Dr. de Luis. And that's not how you're supposed to do
things if you want to fix the problem once and for all.
Senator Vance. Got it. So it sounds--it sounds like there
was not exactly a promotion of people sort of stopping the line
or raising these issues. I mean, is there any evidence that
there was actually the opposite, there was retribution or that
people were actually penalized for raising some safety
concerns?
Dr. de Luis. Yes, that's correct. We heard reports--we
heard several reports of people that felt that they were
transferred or didn't get the raise that they were expecting.
Now please understand, we were not empowered to conduct a
statistically significant, all-encompassing review. And I am
very well aware that data is not the plural of anecdote. Right?
I mean, we----
Senator Vance. Sure.
Dr. de Luis.--we were--I'm recounting anecdotes. But,
that's what we heard. And that's--I think that's our impression
from----
Senator Vance. OK.
Dr. de Luis.--from a year of studying this.
Senator Vance. So being mindful of time--I appreciate your
testimony. One quick question, I guess, just to follow up, and
maybe we can sort of further follow up with my staff in a
detailed way. I mean, is there anything that you think Congress
could do to sort of solve or at least improve this sort of
basic incentive problem? Right?
If you're going to be penalized for raising safety
concerns, then you're not going to raise safety concerns. So we
want to actually promote people for raising valid safety
concerns. What do you think Congress could do to meaningfully
change this?
Dr. de Luis. As I mentioned in response to an earlier
question, one thing you could do is you could--I'm not in your
shoes, so I don't know if it's legislation or encourage or
direct, but the setting up additional channels for where people
can come and report without fear of retaliation, such as the
ASAP program, I think would be a very good step.
Senator Vance. OK. Well, thank you, Dr. de Luis, and I
appreciate it. And I know you personally have suffered some
tragedy because of some of these problems. And so I'm grateful
for your work on this, but also my condolences.
Thank you, Madam Chair.
Chair Cantwell. And just on that point about the ASAP,
because I don't want it to get too confusing about existing
systems.
Dr. Luis, you're saying that if somebody knew about either
the batteries or the MCAS or whatever, that what you want is a
larger universe of people, not just one engineer talking to one
line manager. You want a broader awareness. And you want a
broader awareness even at the FAA, so that it isn't just the
FAA, one person overriding the line manager.
Dr. de Luis. Right, Senator. I mean, you know, I'm a belt-
and-suspenders kind of guy. I think that you need to have--you
need to have more visibility in order to prevent the things
that we saw on MCAS in Congressman DeFazio's report, you know,
that where one person could basically hide the existence, or
suppress the existence of certain systems, or make sure that
they don't go very far.
It's not--when we were discussing this in our panel,
several people brought up, ``You know, in a properly
functioning SMS, you don't need ASAP programs.'' That is
absolutely true.
But that's not the world that we're in right now. So, and
there may be other things besides ASAP. ASAP was just the one
that when we were at American Airlines, they talked to us about
it, and they were very, very positive about the impact that
that's had on their SMS at American.
And so it really resonated with many of us on the panel,
and that's why it's in the report.
Chair Cantwell. As a broadening of the communication.
Dr. de Luis. Right.
Chair Cantwell. The key thing----
Dr. de Luis. Yes, right. Exactly.
Chair Cantwell. The key thing is to broaden--again, I would
just want to, I know you keep referring to this one instance,
but I'm assuming you're referring to some of the actions by
people who may have tried to hide that information from the
FAA. But this committee also received whistleblower reports
from people who made it very clear they had concerns.
Dr. de Luis. Right.
Chair Cantwell. It's just that you--we have to figure out
this larger communication.
Dr. de Luis. And it shouldn't take a whistleblower report.
Right? I mean, a whistleblower report is a big deal for
somebody to do, right? I mean----
Chair Cantwell. Yes.
Dr. de Luis.--it's often a career-ending move. Whereas as
the ASAP has been described to us, you know, a mechanic can
say--this was actually a case that was brought up. ``You know,
I'm not sure if I put in the locking pins on that panel.'' And
he goes and reports it. And that immediately--he's not going to
be fired for making that mistake.
The focus is going to be, ``Well, why didn't you? Is there
a problem in the process?'' The focus is first--it's let's get
the airplane down if it's in the air and make sure it's safe,
and then it's why didn't it happen? Is there a problem with the
process? Is there a problem with the training? And then make
sure that that never happens again.
I think that's the attitude that we need to encourage
across the airplane--the aviation world, but in particular at
Boeing.
Chair Cantwell. Thank you.
Senator Rosen.
STATEMENT OF HON. JACKY ROSEN,
U.S. SENATOR FROM NEVADA
Senator Rosen. [Technical issue] it's really important, and
this hearing is so important. And I really want to thank the
panel for your hard work on this and your care. Well, it
matters, and we're grateful.
Because as Americans look to Congress to address recent
Boeing incidents that have placed passenger safety at risk,
we're reminded that American air travel can only remain safe
and reliable as a form of transportation through vigilant
oversight and accountability, just like the hearing we're
having right now.
I want to thank you again for taking the time to be here
answering questions about the findings, and the recommendations
that were provided in the expert review panel's final report.
And so the report found that for aviation safety matters,
input from Boeing's pilots--pilots were neither consistently
nor directly, directly delivered to the highest level of
decisionmakers in the organization.
It also noted that the chief pilot position did not have
the same authority as other executive positions. This is
concerning, given that Boeing's pilots are uniquely qualified
to identify those safety issues and hazards inherent to a
company's aircraft. It's clear that the expertise pilots
provide need to be elevated within Boeing's ODA process, and
your recommendations are consistent with that.
So Dr. Meshkati, and then Dr. Dillinger, can you both
elaborate on why the expertise that pilots provide is essential
to evaluating Boeing's aircraft? And what can Congress do to
ensure that pilots have a greater seat, not just in the
cockpit, but at the table moving forward, so that their
expertise can enhance aviation safety. We'll go to Dr. Meshkati
first, please.
Dr. Meshkati. Thank you very much, Senator Rosen. That's a
very, very important and profound question that, in fact,
relates to our findings of number 24, 25 and toward several
recommendations about that.
It is my position, and I think our expert panel has very
specifically said that the chief pilot, and the pilot, and
basically the way that the pilots, they could bring up their
voice to be heard and be paid attention to, is through a very
robust human factors group.
If we can have that robust human factors group and make it
a line function with the authority that commensurates (sic)
with its role, I think that issue that you said, can be
resolved.
I heard that in Boeing, they say, ``Structures is the
king,'' because of the impact and importance that they have.
And I've said that to my student. If structures is the king,
human factors and voice of pilot has to be at least a queen in
Boeing. Because this is equally important, as equally important
as the structures.
I think this issue that you raised is very close to my
heart and very close to the heart of my colleagues and the
panel, and that's what we made with this recommendation. We
used the term, Senator ``design practice'' in our
recommendation--recommendation for these findings associated
with the findings about that.
Design practice has a very special and important meaning in
Boeing. And if this issue that you said be raised at that level
and it gets to the design practice, I think some of these
issues can be resolved.
Senator Rosen. Thank you.
Dr. Dillinger, would you like to add something?
Dr. Dillinger. Thank you. Thank you, Senator.
The pilots are the customers in a great sense. And so the
reason why it's important to hear from the pilots is they are
critical in the design from a human factors perspective of the
flight deck.
The human factors inputs and the pilot's inputs go
together. The pilots need to have a strong voice, and their
opinion needs to have a strong weight. They should be the ones
who are providing feedback to those designs, and making
adjustments in those designs.
Equally so, we learned as the panel that when you say
``Boeing pilots,'' that has changed a little bit. And the
pilots are no longer Boeing employees, they're contractor
employees. And so again, the ability for them to have a voice
at the proper level with the design modifications that take
their opinions into account, the panel felt that that was
important.
Senator Rosen. Well, thank you very much. I see my time has
expired. But I do want to say, the human factor matters. There
are humans on that plane. It matters to all of us. It's not
just the structure. And so thank you for your hard work.
Madam Chair, I yield back.
Chair Cantwell. Thank you so much, Senator Rosen. Senator
Budd.
STATEMENT OF HON. TED BUDD,
U.S. SENATOR FROM NORTH CAROLINA
Senator Budd. Thank you, Chair. And again, thank you all
for being here.
You know, the expert panel report notes that Boeing human
factors specialists have played a diminished role in the design
and functionality of recent aircraft. But it was once
considered the gold standard in this area.
Dr. Dillinger, can you share any of the specific steps
Boeing staff shared with the expert panel to rebuild its human
factors capability, or any additional recommendations you have
to Boeing to restore Boeing as the gold standard in human
factors engineering? And Dr. Dillinger, please.
Dr. Dillinger. Thank you, Senator. The human factors cadre
has diminished recently, and the company has made a great
effort to bring in more human factors expertise. They know that
that is critical.
It needs to also be in a stand-alone organization, where
they can have a voice formally. And we were introduced to the
new senior tech discipline lead for human factors, who is
developing a new cadre. But that is a critical element to the
design, and it's essential for future designs.
Senator Budd. Thank you.
Dr. de Luis, again, thank you for being here.
In 2019, Boeing launched the Speak Up portal, an internal
online platform meant to provide a place where employees could
confidentially report concerns on a number of factors,
including production quality. Speak Up is one of the many
channels employees have used to report concerns to the company.
Yet in several places, the report finds that employees, and
I quote, ``did not understand how to utilize the different
reporting systems, which reporting system to use and when,''
end quote. And that many of the employees preferred to report
issues directly to their manager.
So is there any record of how many production quality
concerns were reported through the Speak Up program or other
reporting system, as opposed to reporting directly to the
managers?
Dr. de Luis. I know they keep track of how many Speak Up
reports they have. I don't have those numbers in front of me.
I did, however, recently read that since the door incident,
they've had a 500 percent increase.
And I remember that one of the last briefings we got from
Boeing, I asked, was that good or is that bad? Right? Because
there are two ways to look at this. What's--how many Speak Ups
would you expect normally? Right? Never really got clear.
But to go to your point, to your question, excuse me,
there's nothing wrong with having multiple reporting systems.
What our concern was, what our concerns were, there were
multiple.
One is that people are--have trouble believing that
anything they put in Speak Up is going to actually result in
any action. That was one.
The other concern was that most people prefer to deal with
their problems by talking to their manager. That's not
necessarily a bad thing. However, we were not convinced that
there was actually a path from when that report goes up to the
manager for it to be captured into the safety system.
So what I mean is, if you have a problem in your particular
station on the line, for example, and you report it to your
manager, you may fix it right then and there, and then that's
the end of it. And maybe that's appropriate for minor things.
But for all you know, somebody at another production, in
another line, is having exactly that same problem. And there
wasn't--we did not see any sort of mandatory reporting sort of
requirements in order to make sure that that gets captured, and
subsequently learn from them. I mean, that's one of the key
tenets of SMS, right? You're supposed to be--you're supposed to
learn from your--from what happens. And so that was
problematic.
In addition, of course, that sometimes you want--that if
you're just doing it that way, there is no assurance that it
was done in the best and most proper way, as opposed to the way
to just get it done and keep the line moving.
So you want to have those--you want to make sure that you
have those checks and balances as well.
So those were sort of our broad concerns about Speak Up.
It's a good program, I think. I mean, it's not a bad--the
intentions are very good. It can be a good program. People need
to be trained.
And people--well, more importantly, people need to begin to
see results when they report stuff into it, that things
actually change, that nobody gets fired for reporting, that
nobody gets--you know, anything bad happens, and that--and that
their reporting is making a difference. I think that there was
a lot of skepticism about that, which is why people keep going
to their managers or their union rep or whatever. The most
local.
Senator Budd. Do you think the 500 percent increase in
reporting in the system was due to more training, or
clarifying, or just a new safety emphasis? Do you think it's
a--what's your notion? Is that a good thing or a bad thing?
Dr. de Luis. Well, there was clearly at the--you know,
they've been told yet again that to, that if they see
something, they need to speak up. So I think that there's some
of that. I think that the real question is, is it going to be a
lasting, lasting blip?
You know, there's probably a right number of Speak Up
reports to have per month. I don't know what that number is. If
you have zero, well, maybe you're doing a perfect job, but most
likely nobody is really using the system.
And if you have thousands, well, you got deeper problems,
right? I'm not sure where the balance is, unfortunately. We
need to look at what the longer-term data is going to show us.
Senator Budd. Thank you all for being here.
Chair Cantwell. Thank you so much. I just wanted to note,
too, in this large discussion about human factors in ACSAA, we
required that the human factors assessment has to be done
before the certification, and that no longer can the FAA
delegate the human factors assessment. They have to do it
themselves. So.
Senator Klobuchar, and then Senator Schmitt and, I think,
Senator Welch. So, Senator Klobuchar.
STATEMENT OF HON. AMY KLOBUCHAR,
U.S. SENATOR FROM MINNESOTA
Senator Klobuchar. Yes. Thank you, Chair, for this
important hearing.
And thank you--and I'm so sorry, Dr. de Luis, about your
sister. We also lost a Minnesotan on that plane, and thank you
for your advocacy.
I'm going to start with you, Professor Meshkati, and can
you talk about why it's critical we invest in a strong pipeline
to the aviation field? And I'm obsessed with this just because,
you know, whether it's air traffic controllers or mechanics or
the like, what's going to happen if we don't invest?
Dr. Meshkati. Sorry, your question, Senator Klobuchar, was
investing on the pipeline for training in----
Senator Klobuchar. Yes.
Dr. Meshkati.--aviation safety?
Senator Klobuchar. Yes.
Dr. Meshkati. That's extremely important, particularly--and
thanks for that question. Right now, one of the issues that we
are facing is the workforce attrition. There have been a lot of
retirement and exodus from Boeing and other places.
And the issue of training is becoming very important in
workforce development. In fact, this thing for the safety-
critical system; in the case of aviation, being air traffic
controller and pilots and engineers and machinists, and also in
other industries.
I've been just two weeks ago at the board of Gulf Offshore
Energy Safety of National Academy. The workforce development
for the energy system in the Gulf of Mexico is also another
issue, particularly with coming with the new technologies like
wind turbine.
In this particular case, one solution is basically joining
forces with technical colleges and universities, and develop
internship program. And for the students that they get the
training and they go work, and then they come back and continue
their education.
This is something that I know that for this new technology
of the offshore wind, some organizations in the Gulf of Mexico,
and some companies, and maybe BSA is getting involved in that.
Senator Klobuchar. OK, thank you.
Dr. Dillinger, you mentioned how pilots and crew need to
play an important role in the design and evaluation of
aircrafts. Can you also speak to the importance of training new
pilots?
Dr. Dillinger. It's essential that we grow new pilots, and
that novice pilots have experienced pilots to help them learn
and become superior experienced pilots.
And the pipeline of pilots is a constant effort. I think
from a human factors perspective, again, the more experience we
get from the pilot cadre and the more they learn how to speak
up and make their needs known, especially from a design
perspective. The panel was very concerned about the human
factors element coming into design from the very beginning, and
that requires experienced pilots having input into that
process.
Senator Klobuchar. OK, very good. Thank you.
Dr. de Luis, what additional FAA oversight do you believe
is necessary to ensure a stronger safety culture?
Dr. de Luis. I think that we covered it a little bit before
with regards to making sure that the FAA is able to vet and
approve not just the people, but also the organizations, as
well as higher scrutiny for non-employee ODA members.
I think that one of the things that has been touched on
here is the need for the FAA to also establish its own SMS.
Right? I mean, the FAA has an SMS on the ATC side, but not on
the other side.
I--as I understand it, and I'm by no means, even though I'm
on an expert panel, I'm an expert in SMS. But as I understand
it, SMS's work best when they sort of intermesh with each
other. Boeing, with its suppliers and the regulators.
I--you know, it's a little difficult to see how the FAA is
going to be able to do sort of the bidding of the Boeing SMS
system--sorry. Without having its own SMS. Sorry.
Senator Klobuchar. Exactly. OK. Just one last question.
Professor Meshkati, on the--I passed a bill with Senators
Moran and Capito, Senator Stauber in the House--Representative
Stauber in the house, which alerts personnel to potential
safety hazards, the NOTAM system, and how we need to upgrade
it. As we do the long overdue work of upgrading that
technology, how can updated technology strengthen safety
culture?
Dr. Meshkati. The technology needs to be updated with equal
and adequate attention to organizational factors. One thing
that we have said over here, just by bringing the new
technology, or even if you have a updated technology, but if
you don't do workforce training and also change the
organizational mechanism that could adopt that technology, it
wouldn't work.
The issue of the adoption of the technology in the
organization is very important. We have seen that Senator
Klobuchar, in the case of positive train control, for example,
for railroad system, this is very important issue that you
raise and needs to be addressed in a very systematic manner.
Senator Klobuchar. OK. Thank you.
Chair Cantwell. Thank you.
Senator Schmitt.
STATEMENT OF HON. ERIC SCHMITT,
U.S. SENATOR FROM MISSOURI
Senator Schmitt. Thank you, Madam Chair. When I first
learned about this hearing, I was under the impression that we
would be speaking to people on the ground, whether current or
previous, with current or previous experience within Boeing, to
examine the current safety issues the company is facing.
However, I'm surprised to see that not a single Boeing
employee or executive present today to discuss their safety and
cultural practices and ongoing efforts to right the wrongs that
have unfortunately occurred.
So let me reiterate. We have a hearing about Boeing safety
practices without Boeing present. This is frustrating.
It's even more frustrating that another committee, just sat
down the hallway here, is instead having a Boeing
representative appear before their members to answer their
questions and concerns.
Member of the Senate--as members of the Senate Commerce
Committee, we possess the authority to hear from
representatives from Boeing on--or any other company that falls
within our jurisdiction on short notice. Today's hearing is
about examining the findings of a report about Boeing's
procedures. They should, at the very least, be here today to
respond to any recommendations or findings from the report.
On a similar note, I've been on this committee now for
almost a year and a half, and during that time, our
transportation sector has experienced a number of challenges
under this administration, including a concerning train
derailment in East Palestine, a nationwide shutdown of our
national air system, near misses along runways at our Nation's
airports, and most recently, a devastating collapse of the
Francis Scott Key Bridge. Yet, I along with my colleagues, have
yet to have the opportunity to question Secretary Buttigieg,
the one person charged with leading our transportation system.
Joining this committee, I expected us, in a bipartisan way,
to rigorously examine and resolve critical issues facing our
Nation that fall within the jurisdiction of this committee. Yet
today, it appears we are again missing the mark.
Therefore, today's hearing is yet another chapter in an
unfortunate series of events where we as a committee could be
making a larger impact, finding answers to questions, and fully
executing the duties as members of this great committee.
To be clear, this is not an indictment of our witnesses,
whose knowledge and insight are invaluable. The report to which
they contributed provides many recommendations, to which I hope
Boeing not only reads, but strongly considers in its efforts to
get its house in order.
However, for a comprehensive oversight, I think we should
be hearing directly from Boeing and its representatives today
on how they're addressing the findings and executing changes
within the company. Rumored hearings in months down the line
don't do anything to help Missourians flying today.
As I want to transition the questions for our panel today,
I do want to focus on how as a committee, with the Chair, who I
do enjoy working with, how we can actually deliver the world's
leading transportation system and keep Americans safe.
So with that, I don't have a lot of time. But Dr.
Dillinger, based on the report and based on the findings--
again, this would be something I would be asking somebody from
Boeing, but to your knowledge, what changes are being
implemented? Clearly, there's a sort of a cultural challenge
with feedback, and being collaborative based on the report. So
are you aware of any changes that are taking place? And this
would be for any of you.
Dr. Dillinger. Thank you, Senator. When the panel completed
the report, our mission was done. And so the panel has, in
effect, disbanded since the report was submitted. However, the
follow-up responsibilities to the findings and recommendations
have been provided to the FAA, and the Administrator has made
appropriate replies to that, from what we could tell.
Dr. de Luis. We believe that all of our recommendations
should be implemented. I don't believe that any have been yet.
I mean, it's only been a few weeks. But our feeling is that
while not a comprehensive set of remedies for all that ails
Boeing, it's at least a really good set of first steps if they
were to implement what we have recommended.
Dr. Meshkati. And if I may add, in our last findings and as
recommendation 51, 52, 53 to both Boeing and FAA to work
together and meet periodically to make sure that
recommendations are being implemented. And as far as I
remember, FAA Administrator, Mr. Whitaker, has given Boeing
three months since February or early March to come up with a
plan as how they are going to implement that.
And our panel, and I think it's in our report, we
volunteered to help Boeing during our interviews, to resolve
some of these issues.
There is a statement somewhere in our report that they
didn't really take this opportunity to our kind offer to help.
At least in my case, they didn't ask.
Senator Schmitt. OK, thank you.
I yield back. Thank you, Madam Chair.
Chair Cantwell. Thank you, Senator Schmitt. I will note
that we are going to hear from the company, and we've long said
we were going to go to the FAA and then the company, because
our oversight job is with the FAA and making sure they're
implementing.
But I did mention at the beginning of this that they did
cooperate with the interviews that you did conduct. And so we
will hear from them. And my sense is, they've digested your
report, and by the time they get here, they'll have a lot of
commentary about this. And so we'll look forward to hearing it.
Senator Welch.
STATEMENT OF HON. PETER WELCH,
U.S. SENATOR FROM VERMONT
Senator Welch. Thank you very much.
Thank the witnesses.
You know, people are pretty terrified. I mean, it's unreal
when you think about it. In October 2018, the Indonesian
flight, 189 people, Dr. de Luis, died. March 2019, Ethiopia
Airlines. And then of course on January 5, the door blows off.
I mean, bottom line, people are wondering all the time
whether they should fly on a Boeing plane. Is the public safe
right now?
I'll start with you, Dr. Dillinger, and we'll go down the
line. That's the bottom line question a lot of folks have. Are
we safe on a Boeing plane?
Dr. Dillinger. As best I understand it at this point, I--I
have continued to fly on Boeing aircraft, and I hope that they
have taken our findings and recommendations to heart and
implement them.
Senator Welch. The hesitation makes me feel like you're
taking your chances.
Dr. de Lu----
Dr. de Luis. Yes----
Senator Welch. De Luis. I'm sorry.
Dr. de Luis. Sir, that's fine.
I get asked this question all the time. I get asked this
question, is it safe----
Senator Welch. And I do too.
Dr. de Luis. Is it safe? And so here--here's what I answer.
And I don't know if it's a--I say, ``You know, the safest place
for a rocket is sitting on the pad. The safest place for an
airplane is sitting in a hangar. The safest place for you and
me is on our couch, doom-scrolling through Instagram.''
And yet every day, rockets launch, airplanes fly. And we
get up and we go and do something productive.
Safety is always a trade.
Having said that, the--within the airplane world, you have
to look at what's happening and go, ``How comfortable am I
flying in this airplane versus that airplane?'' For me
personally, I keep track of what's happening on the MAX for
obvious reasons----
Senator Welch. Right.
Dr. de Luis.--and I'm worried about what's happening on the
MAX.
Senator Welch. Thank you.
Dr. de Luis. Now if I had to fly somewhere because there
were--and there was no other option, I would absolutely fly it
versus driving, for example, because I can make that trade.
Senator Welch. But, you know, I think the public's entitled
to more confidence in the security and safety of flying.
Dr. Meshkati, there's--you know, there seems to be like two
issues about safety. One are the practices and the culture of
the manufacturer. And the other is how much they put profit
ahead of safety. Because it is a trade-off. The more they're
going to focus on safety, that's going to come at some expense.
And I understand there are problems in both of those
elements for Boeing. Would you say that's true?
Dr. Meshkati. It was very much discussed, Senator, I think,
in this seminal book by Peter Robison, ``Flying Blind,'' and
the issue of the putting--and basically, this is a delicate
balance, Senator, between safety and profitability. And we know
that these companies are not in philanthropic business. They
need to make money.
But it's really the job. This is one of the tenets of
safety culture, to give proportional attention to safety goals
versus production goals.
And in the case of Boeing, unfortunately, based on the way
that is chronicled very nicely in this book, that has happened
after the merger with McDonnell Douglas.
Senator Welch. So can you attribute--you attribute some of
that change to after the merger?
Dr. Meshkati. Yes----
Senator Welch. And tell me what the dynamic was.
Dr. Meshkati. The dynamic was because if you look at the
history of McDonnell Douglas, in fact, I was reading another
book by John Nance about--it's called ``Blind Trust,'' about
the series of problems that McDonnell Douglas had, crashes and
that.
And the mentality over there was just to push, push, and
make more aircraft. Not really pay attention to detail, and
then somehow resolve that later. And that, unfortunately,
according to my reading of the book by Peter Robison and some
of the series of great articles by Mr. Dominic Gates in Seattle
Times. It also chronicles this issue. And we have seen that,
unfortunately.
Senator Welch. Let me ask you one last question. What would
you have to see from Boeing for you to have confidence that
they had successfully developed human factors as a technical
discipline in design practice?
Dr. Meshkati. I personally, and I may distance myself from
my distinguished colleague a little bit, I use my USC
professorial academic freedom. I like to see the human factors
person, the top person, have equal power and authority as the
chief engineer. This is what I would like to see.
Senator Welch. OK, thank you.
I yield back. Thank you all.
Dr. Meshkati. Thank you.
Chair Cantwell. Thank you. Following up on that, we may
have a couple more members coming, but if not, we'll conclude
the hearing soon.
But Dr. Meshkati, the report states that during the
development of the 757 and 767, human factors and flight deck
operations ``were the gold standard'' in part because human
factor specialists worked ``closely and collectively'' in
Seattle. Then the report goes on to say, quote, ``the role of
human factors and its influence eroded due to a series of''
administration issues, including ``reorganization,
decentralization, downsizing, and relocation of the company's
headquarters.''
What does that have to do with human factors?
Dr. Meshkati. Human factors works very good when they are
very close to engineers and system designers. They exchange
information, they work together, they work on the design of the
system. And then they work on the training and that, and they
solve that problem together.
Again, I'm--I'm not in the business of promoting book, but
chapter nine of this book, which is about human factors, which
I strongly recommend that that shows the way that the demise of
the human factors or erosion of the human factors.
One of them, for example, is chronicled in the book, is
when and--when the simulator trainings, and that was totally
moved away from the design and that from Seattle to Florida or
somewhere else. That--that is when you see a problem, you're
in----
Chair Cantwell. I think that was just the training, though,
right, that----
Dr. Meshkati. The training, but before that, also, that
they during the design, because you get some of that input from
the training coming back----
Chair Cantwell. Oh, I see.
Dr. Meshkati.--to the design.
Chair Cantwell. You--you think that doesn't exist in a
holistic way, you're saying?
Dr. Meshkati. Absolutely.
Chair Cantwell. OK. And then--and that's all feedback----
Dr. Meshkati. Holistic and centralized way. Holistic and
centralized way.
Chair Cantwell. Holistic and central. OK.
Dr. Meshkati. Thank you, Senator.
Chair Cantwell. I wanted to ask about this in regards to
the FAA. So most of the report is focused on what you can do to
make sure that you have a strong safety culture within the
organization, and how much that has to be backed up by the FAA.
What does the FAA need to do to have its own safety system
improvements to make sure that it is thinking about human
factors--or across the board, a variety of issues that can
enhance security, particularly at a time of changing
technology?
How do we get an FAA who is up to speed? ACSAA said, let's
have this group that is at the beginning of the certification
process kind of detail out more of the risk factors, so that
that discussion could happen.
Dr. de Luis. So that's actually very--you know, we focused
a lot about, especially since January 5, on the need to put
more FAA boots on the grounds in the factory. And I am by no
means saying that's a bad idea. That's an excellent idea.
But what you point out about the technology is why I think
that ODA or DER or delegation of some sort is here with us
forever. Because the FAA does not have the resources to be able
to be the world's experts on these technologies. That's not
what they're there for. The world's experts reside at Boeing or
whatever.
The key thing, I think, is that the FAA has to have the
ability to interface with the world's experts. And that's a
different set of skills that's needed. You're not going to be
conducting the cutting-edge research, but you should be able to
talk to the people that are developing that technology and be
able to understand it, and in particular understand how it
impacts the safety and the operation of the aircraft.
I keep going back to a--something that was said earlier
about the need for the FAA to really step up its own SMS. I
think that that's critical. If you have that, then you have a
chance of being able to appropriately interface with the people
you're supposed to regulate.
If you don't have that, you're sort of, you know,
spectators at the party here. And I think that that--they
should be encouraged or directed or whatever it is, however it
is that you do it, to move in that direction.
Chair Cantwell. Thank you.
Senator Blackburn, are you ready?
STATEMENT OF HON. MARSHA BLACKBURN,
U.S. SENATOR FROM TENNESSEE
Senator Blackburn. Thank you, Madam Chair, and I want to
thank all of you for being with us today. I think this aviation
safety issue is something that we are all concerned about and
are--we are going to stay in behind this. I appreciate the
Chairman's attention to this issue.
Dr. Meshkati, I want to come to you, and I think I'm saying
your name right. Correct me if I'm not. I was reading a report
about the aerospace maintenance competition where the 450
airplane mechanics met to show off their skills. And they were
working in 15-minute time slots, troubleshooting issues.
And I think in 15 minutes, it's pretty remarkable what
people are able to do. And it's important to know that there
are skilled people. You look at what has happened with these
different reports, Alaska Airlines, United Airlines, the Boeing
planes, that have come up.
So when you look at this, and you see the skills training
that some of them have, where is the disconnect in this? Where
is--is it a lack of skill? Is it a lack of training or
preparation? Or, you know, is it inattention? Why are we
beginning to have such a negative impact, see such a negative
impact on safety?
Dr. Meshkati. Thank you, Senator. This issue, we didn't
study that here, but your question reminds me of Aloha Airline
and the accident that it had around--I think it was 1988 or so.
And it was--started with the aviation maintenance-related
problem.
And at that time, FAA really looked a very hard look at
aviation maintenance. And I think they created a program called
National Plan for Aviation Maintenance. And then at that time,
one board member of NTSB who was later elected to NTSB, the
Hon. John Goglia, pushed on this a lot. The issue of aviation
maintenance, ma'am, is extremely sensitive to the human factors
and safety culture issues that my colleague, Dr. Dillinger, is
talking about here.
Senator Blackburn. OK. Let me do this. Dr. Dillinger, let
me come to you, because I know you conducted hours of
interviews for the safety report that you produced. Did you
speak with any of the whistleblowers when you conducted those
interviews?
Dr. Dillinger. As far as I recollect, we did not speak to
a----
Senator Blackburn. Did not.
Dr. Dillinger.--whistleblower.
Senator Blackburn. Why did you not talk to any of the
whistleblowers?
Dr. Dillinger. That--that was not the purview of the--of
the panel. And at the time, I don't think--we weren't aware of
the whistleblowers or----
Senator Blackburn. OK. Well, let me----
Dr. Dillinger.--or that----
Senator Blackburn.--ask you this, then. Does Boeing do
enough to ensure that their employees know that there will be
no retaliation if they come forward and report safety issues?
Dr. Dillinger. The panel believes they need to do a lot
more than what they are currently doing.
Senator Blackburn. And, you know, one of the things that we
have heard from--from NTSB is that there is a problem getting
information from Boeing. Do you think that Boeing executives do
not understand, when there is an investigation, they need to
come forward with complete information?
Dr. de Luis. I mean, I can't speak for the executives. I--I
will say that Boeing is a very large and very bureaucratic
company that produces a lot of paper. And I'm not surprised
that there are lags in their responses, because that's--they're
just--that's just the way it is. But I can't speak for them.
Senator Blackburn. I--I will tell you, reading the report
and Boeing's safety culture being described as ``inadequate and
confusing,'' this is something that harms the flying public.
And I appreciate the attention to the issue.
Thank you, Madam Chairman.
Chair Cantwell. Thank you, Senator Blackburn.
Senator Warnock.
STATEMENT OF HON. RAPHAEL WARNOCK,
U.S. SENATOR FROM GEORGIA
Senator Warnock. Thank you, Madam Chair. Listen, the stakes
are simply too high for a commercial aircraft to have the kinds
of systemic problems that we're seeing with Boeing. So I'd like
to examine how we got here with this panel.
Dr. de Luis, yes or no, through organization designation
authorizations or ODAs, can the FAA--can the FAA delegate
certain safety certification and other responsibilities to an
aircraft manufacturer like Boeing? Yes or no?
Yes or no?
Dr. de Luis. Yes----
Senator Warnock. Yes.
Dr. de Luis.--but, currently, yes, because it's done with
other manufacturers. But there are issues, as described in our
report, that makes us be leery of saying, yes, go ahead and
just do it. I think Boeing needs to prove that it is capable of
doing it.
Senator Warnock. But the question is, are they able to
delegate certain safety and certification responsibilities to
an aircraft, like, so--so they are--the answer is yes, correct?
Dr. de Luis. Yes.
Senator Warnock. OK. So, Dr. Dillinger, yes or no, can an
aircraft manufacturer like Boeing subcontract manufacturing
responsibilities for, say, the fuselage of its signature MAX
aircraft line to another company?
Dr. Dillinger. The work of the panel, I think, would say
yes, like with ODAs, that we heard successful examples of ODA
delegation. However, the concerns remain about the risk that
Boeing's safety culture presents to that process.
Senator Warnock. Yes, I share that concern, which is why
I'm asking the question.
Dr. Meshkati, yes or no, can a manufacturer subcontracted
by Boeing, such as Spirit Aerosystems, assign manufacturing
responsibilities to an international affiliate, in Malaysia,
for example?
Dr. Meshkati. 787 is now made all over the world. Wings in
one country, the other wing in another country, fuselage in
another country. They are doing that.
Senator Warnock. So the authorization can then be passed
from FAA to a manufacturer.
The manufacturer can subcontract that manufacturing
responsibility to another entity.
And then the manufacturer subcontracted by Boeing can
assign manufacturing responsibilities to an international
affiliate.
Which I'm sure you've realized that what we walked through
step-by-step is a supply chain of the Boeing MAX 9 aircraft at
the heart of the near-catastrophic door plug blowout that
happened on January--in January 2024 to an Alaska Airlines
flight.
You know, there are many words for this. You can call it
``delegating,'' ``subcontracting,'' ``reassigning''; at the end
of the day, it's ``outsourcing.'' Outsourcing key
responsibilities, none more important than safety oversight to
someone else. To someone else. To someone else.
I submit that while we're focused on Boeing, this is
obviously not just a Boeing problem. This is far too common
across aviation systems and its suppliers.
Whether the result of poor leadership, a focus on
production targets, profit margins at all costs, even the cost
of safety, or some combination of both, Congress must take a
serious look at this culture of outsourcing and its safety
implications. This is an instance in which we can't afford a
mistake. It costs too much.
Dr. Dillinger, what more can Boeing do to improve its
safety culture and our own--and our own responsibility for the
safety of its products?
Dr. Dillinger. Thank you, Senator. The panel focused a
great deal on safety culture, and there is so much that they
could be doing.
Part of it has to do with the timing. And if they were to
accelerate the efforts, I think, and the panel thinks, that
that would be beneficial. There has been a very soft start to
that, to implementing the training, to getting feedback back
from employees via their own surveys, to providing workshops,
to focusing specifically on training at different levels.
So, for example, executive training, yes. But down through
the other layers of the organization, to managers and
supervisors, targeted training, those are--there are multiple
ways that they could be going after that, and as they look at a
more comprehensive way where they really dive in, and in a more
timely way, address that, the panel felt that that would be
important and that it was in our recommendations.
Senator Warnock. Great. Thank you so very much for that.
Dr. de Luis and Dr. Meshkati, last question. What more can
Congress do to encourage both the FAA and manufacturers like
Boeing to take direct responsibility for the safety of aircraft
and our aviation system?
Dr. de Luis. I believe that the Congress and this committee
needs to keep the--essentially the pressure on, to make sure
that the waivers are not granted on safety-related issues, for
example. That would be a--a good thing, because they--right now
there are a handful of waivers on the MAX that directly affect
safety.
But you need to keep the spotlight on this, because it--in
doing our interviews, we heard often the sentiment expressed,
``Yes, this is happening now, but as soon as everybody moves on
to something else, we're going to go back to the way things
were.''
And that can't happen. It's too--as you say, it's too
expensive and the cost in human lives is just way too high.
Dr. Meshkati. Thank you, Senator. That is also related to
an earlier question by Senator Cantwell. I think what Congress
can do vis-a-vis FAA--and that's also related to the SMS.
There is a document which is signed by FAA Administrator
and then Chair of NTSB, the Hon. Robert Sumwalt. It's called
``State Safety Program.'' This is something that United States
files with the International Civil Aviation Organization. In
this one, this is very interesting, Senator. It talks about the
safety management responsibility for the state, for the
application of SMS at FAA.
What I would suggest, and what can Congress do, is to
create another panel like the one that we are in, Section 103,
to look at the implementation of this report. And how does
United States stand vis-a-vis this report?
If this state safety program being fully implemented, what
needs to be done, because that has a kind of a impact, or--or
it can tremendously impact FAA's power on using, basically--in
the case of SMS, for example, in United States, it's only FAA--
correct me, my colleagues here--has the SMS on for air traffic
controller.
Senator Warnock. Right.
Dr. Meshkati. And SMS needs--there is a Notice of
Rulemaking for SMS, but SMS needs to be fully incorporated. And
if this document be fully implemented at FAA and other places,
I think that would be a good solution.
Senator Warnock. Thank you so much.
I know I'm way out of time. I appreciate your indulgence,
Madam Chair, and I look forward to working with my colleagues
on this committee to improve aviation safety.
Chair Cantwell. Thank you so much.
And just to clarify again one more time on this issue,
because it's related to what he said and Senator Schmitt, and I
want to emphasize, you know, people, we all represent big
aviation states. We want this to be right. And we definitely
believe in the workforce that we have in our states. We want
them to continue to grow in expertise and excellence.
So recommendation 30 and 31 of your report says, ``Foster
an effective safety culture and publish a roadmap for workforce
development'' with ``engineers and inspectors'' and ``oversee
SMS for design and manufacturing organizations.'' And ``Partner
with industry to'' measure the ``success of SMS'' and design,
and organization ``jointly review these measures of success on
a regular basis.''
OK, those are your two key recommendations about SMS.
So the FAA is now in this rulemaking that is going to come
out in the next 90 days. And so what specifically do you want
to see in that rulemaking that will help guarantee this
success?
And then second, what do we do about this problem that Dr.
de Luis suggests? Which, listen, it's a whole of government
issue, if you ask me, because we could ask Dr. Dillinger about
space in general, but it's--we're trying to keep the government
at pace with technological change.
So you're saying the FAA may not have some of these people,
and so how do we, what do we need to do? Because obviously we
do want to listen to what these sectors say and they have
input. They really have some of the smartest people about this
technology, but we also have to get our oversight correctly.
So how do we make sure the FAA rulemaking has what we want
to see in it? And how do we deal with this lack of engineering,
if you will, skillset at the FAA, not at the company? At the
company, I think it exists; I think we're just not listening
closely enough.
Dr. de Luis. I think, if I may, I think with regards to
your first question, fortunately, SMS isn't new. Right? It has
been around in the aviation world now for 30 years----
Chair Cantwell. But it was voluntarily implemented----
Dr. de Luis. Right.
Chair Cantwell.--as part of a 2015 Consent Decree instead
of being a real mandatory SMS. So I'm hoping the FAA gets this
right this time, but----
Dr. de Luis. Yes. No, what I meant is that it's been in the
aviation industry for 30 years, not at Boeing. You're
absolutely correct.
So fortunately, I mean, in a sense, all the FAA has to do
is look at what it's done successfully with organizations like
the airlines and others and apply those same standards and the
same rules to Boeing. So they're--they don't--it's not a blank
sheet of paper, is what I'm saying. They got something to draw
on.
With regards to your other question, I've always been a
strong advocate of government agencies like the FAA drawing on
the resources of the national academies. I mean, I see when new
technology enters a field, such, let's say for example, AI, for
example. Because that's the one, that's the new technology du
jour right now.
You know, I've always been an advocate that you have these
national academies right down the street here with members that
you can draw upon to basically go in, and advise, and give
stuff--people that know a lot more about these subjects than
any of us. And I don't--some organizations do it more than
others. But I think that the--that that's a resource that FAA
and NASA and other agencies don't use enough, in my opinion.
Dr. Meshkati. The National Academy, I have just one good
news, Dr. de Luis. FAA has gone to National Academy, and
National Academy has created a panel of, they call it community
of experts for risk analysis of transport aircraft. And that
one I have the privilege of being a member. We meet over Zoom
weekly, and I think it has been great, because FAA has reached
out to nuclear power industry for that community of experts,
how do they do PRA, probabilistic risk assessment? They do that
here.
Back to you, Senator Cantwell, I think that two
recommendations that you brought up, 31 and 30, is fantastic.
That's exactly that I think in light of this state safety
program, if these two be combined together, I think that's
going to be a paradigm shift for SMS.
Chair Cantwell. Well, I think it's pretty simple to get a
real SMS. And I think it's a great idea, as we envisioned in
ACSAA, to get a panel of experts. I'm glad to see that that is
actually happening with the national academies as it relates to
this input. I--I don't--we'll have to query the FAA more on
exactly how broad that can go.
Dr. Dillinger, I'm going to leave the last question to you,
because you know, as--as painful as all this is to me, we can
get through it.
And--and I think you were referencing your work on the
Columbia. That was also a very painful moment for NASA, very
painful moment for this committee. I sat on the oversight
investigation of that, that the Committee did in joint session
with other Senate committees. So but we did get through that.
What do you think are the lessons learned here? How can
you--how can we successfully move past this and onto the
success that we want to see in aviation? Because I think the
foundation is very strong. We have a great hundred years of
aviation success. We want to build on it. As Dr. de Luis said,
we want to be known for the successes that the United States
has had in aviation, and I--I think the elements are there. But
what--what is it that we need to do to learn from what Columbia
learned on how to move forward?
Dr. Dillinger. Thank you, Senator. That has been my life
for decades. I think what we learned from Columbia that's
applicable here and was applicable to the report, is how
important people are and the relationships between people.
That's what the safety culture issues all address.
It's about trust. It's about communication. It's about
being there. And having a workforce that comes in that is
prepared, that's trained, that's energetic, that's curious,
that's dedicated, that will work their heart out, an
organization can recover from a catastrophic loss when that's
happened, by pulling all of those resources together, and
focusing on, then, the mission and how everybody works toward
the mission to make that happen.
But to do that, all of those parts, including the
processes, have to come together with safety as a priority,
where people understand that it's just part of doing business.
It's--Bryan O'Connor, the former chief of safety for NASA, used
to talk about, ``Safety isn't the mission, it's how we do the
mission.'' And that's a critical lesson learned for us.
Chair Cantwell. Thank you.
Well, I want to thank the witnesses again today. You'll--
the record will remain open until May 15. Any Senators wishing
to submit questions for the record should do so by May 1. And
we ask responses be returned by May 15.
That concludes our hearing today.
And again, thank you for your report and your willingness
to be here today.
We're adjourned.
[Whereupon, at 11:55 a.m., the hearing was adjourned.]
A P P E N D I X
Response to Written Questions Submitted by Hon. Raphael Warnock to
Dr. Javier de Luis
Aviation Workforce Needs
In its report, the Expert Panel noted that many Boeing employees
did not demonstrate knowledge of the company-wide safety culture
efforts.\1\ The report also raises concerns that experienced ODA Unit
Members are leaving Boeing and the Federal Aviation Administration
(FAA) and not being replaced in a timely fashion.\2\ In a March 2024
report on commercial aviation manufacturing, the Government
Accountability Office found that many aviation manufacturers are facing
difficulty maintaining enough sufficiently skilled workers to meet
current production demands.\3\ Many manufacturers have lost employees
due to layoffs, retirements, and decisions to leave the industry and
are facing difficulties in hiring skilled labor to competition for
workers, a lack of skilled and experienced labor supply, and labor cost
increases.\4\
---------------------------------------------------------------------------
\1\ Section 103 Organization Designation Authorizations (ODA) for
Transport Airplanes Expert Panel Review Report, Federal Aviation
Administration (Feb. 26, 2024), https://www.faa.gov/newsroom/review-
panels-final-report-organization-designation-authorizations-oda-design-
and.
\2\ Id at p. 37.
\3\ Heather Krause, Commercial Aviation Manufacturing: Supply Chain
Challenges and Actions to Address Them, Government Accountability
Office (Mar. 6, 2024), https://www.gao.gov/products/gao-24-106493.
\4\ Id at p. 19, 21-23.
Question 1. Would a more robust aviation workforce pipeline,
including expanded partnerships with academic institutions, improve
Boeing's safety culture?
Answer. As noted in the question above, the overall reduction in
the experience level of the average worker at Boeing is a factor in
establishing and maintaining a safety culture. Partnering with outside
organizations, including academic institutions (both traditional and
community college-level) in the areas where Boeing has facilities could
help increase the number of people applying for jobs, but as we noted
in the report, Boeing needs to increase its efforts to retain this
workforce once they are in-house and trained. We noted, for example, a
recent large exodus of experienced engineers last year due to issues
related to pension and retirement funds, which made it economically
unfeasible for many to stay without losing a significant portion of
their retirement savings. As a result, a large amount of corporate
knowledge walked out the door. This could have been avoided with better
planning and compensation on the part of Boeing.
Question 2. How would the aviation system benefit from a diverse
and representative pipeline of aviation technical experts?
Answer. As noted above, a pipeline is just one of the necessary
components. Retention is the other one. Boeing needs to engage with its
workers at all levels, both those represented by unions and those that
are not, and implement policies that will encourage them to stay at the
company for the long term.
Safety Reporting
During its investigation, the ODA Expert Panel observed a
disconnect between Boeing's senior management and employees on safety
culture, with some employees questioning the effectiveness of the
company's safety reporting systems.\5\ The report found that managers
who oversee employee performance, salaries, and disciplinary actions
might also be tasked with investigating safety reports, which may cause
some employees to hesitate reporting safety concerns in fear of
retaliation.\6\ The Panel also found that Boeing does not have a clear
and consistent safety reporting process and employees may lack
understanding of which process to use and when.\7\ Boeing promotes the
Speak Up reporting system as a preferred method of safety reporting for
employees, but many employees distrust the anonymity of the system and
prefer to report safety issues to their managers.\8\ The Expert Panel
could not verify, however, whether safety concerns reported to managers
are captured and resolved in a systematic way.\9\ In addition, the
Panel found that safety of flight concerns raised by test pilots during
the certification process are not adequately addressed when evaluating
aircraft design.\10\
---------------------------------------------------------------------------
\5\ Section 103 Organization Designation Authorizations (ODA) for
Transport Airplanes Expert Panel Review Report, Federal Aviation
Administration (Feb. 26, 2024), https://www.faa.gov/newsroom/review-
panels-final-report-organization-designation-authorizations-oda-design-
and.
\6\ Id at p. 32.
\7\ Id at p. 32.
\8\ Id at p. 32.
\9\ Id at p. 33.
\10\ Id at p. 39.
Question 1. Has Boeing failed to establish an effective safety
culture?
Answer. The panel found that there are significant shortfalls in
Boeing's efforts to establish a safety culture throughout the company.
We observed inadequate and confusing implementation of the safety
culture principals (Reporting Culture, Just Culture, Flexible Culture,
Learning Culture, and Informed Culture). We also found confusing
documentation that made it difficult for the typical employee to
understand how their job impacts product safety, and how that impact
can be measured.
Question 2. What has been the result of Boeing's systemic safety
culture failures?
Answer. The result has been two fatal accidents, one near-fatal one
(Alaska Air), and multiple safety-related violations with a new one
coming to light every few weeks. I think our report showed that it
would be a mistake to treat all of these separately, and simply limit
our response to fixing whatever the particular issue is for that one
particular case (e.g., MCAS, missing bolts, etc). The common cause for
all these problems is the lack of focus on product safety over and
above the focus on meeting production targets.
Question 3. Would Boeing, and the national airspace system, benefit
from more robust oversight from the FAA or independent watchdogs?
Answer. Until Boeing demonstrates that it has fundamentally
changed, additional oversight in the form of more inspectors on the
factory floor, and more review of submitted designs, is inevitable. The
ODA system is one that is built on trust. It will take many years
before that trust is restored.
______
Response to Written Questions Submitted by Hon. Raphael Warnock to
Dr. Tracy Dillinger
Aviation Workforce Needs
In its report, the Expert Panel noted that many Boeing employees
did not demonstrate knowledge of the company-wide safety culture
efforts.\1\ The report also raises concerns that experienced ODA Unit
Members are leaving Boeing and the Federal Aviation Administration
(FAA) and not being replaced in a timely fashion.\2\ In a March 2024
report on commercial aviation manufacturing, the Government
Accountability Office found that many aviation manufacturers are facing
difficulty maintaining enough sufficiently skilled workers to meet
current production demands.\3\ Many manufacturers have lost employees
due to layoffs, retirements, and decisions to leave the industry and
are facing difficulties in hiring skilled labor to competition for
workers, a lack of skilled and experienced labor supply, and labor cost
increases.\4\
---------------------------------------------------------------------------
\1\ Section 103 Organization Designation Authorizations (ODA) for
Transport Airplanes Expert Panel Review Report, Federal Aviation
Administration (Feb. 26, 2024), https://www.faa.gov/newsroom/review-
panels-final-report-organization-designation-authorizations-oda-design-
and.
\2\ Id at p. 37.
\3\ Heather Krause, Commercial Aviation Manufacturing: Supply Chain
Challenges and Actions to Address Them, Government Accountability
Office (Mar. 6, 2024), https://www.gao.gov/products/gao-24-106493.
\4\ Id at p. 19, 21-23.
Question 1. Would a more robust aviation workforce pipeline,
including expanded partnerships with academic institutions, improve
Boeing's safety culture?
Answer. There are people eager to help with strong knowledge and
experience in the area of safety culture, and various academic
institutions have programs in place devoted to educating people about
multiple aspects of aviation industry, including management,
leadership, operations, flying, and maintenance. Engagement with these
entities could be beneficial to any organization's safety culture.
Question 2. How would the aviation system benefit from a diverse
and representative pipeline of aviation technical experts?
Answer. The aviation workforce has aged and experienced the
attrition predicted years ago, as well as the impacts of the COVID-19
pandemic, leading to people leaving the workforce and creating
challenges across the industry. Thus, it is all the more important that
the aviation industry have a robust pipeline dedicated to developing
technical experts across all of its constituent areas (e.g., air
traffic control, human factors, and others).
Safety Reporting
During its investigation, the ODA Expert Panel observed a
disconnect between Boeing's senior management and employees on safety
culture, with some employees questioning the effectiveness of the
company's safety reporting systems.\5\ The report found that managers
who oversee employee performance, salaries, and disciplinary actions
might also be tasked with investigating safety reports, which may cause
some employees to hesitate reporting safety concerns in fear of
retaliation.\6\ The Panel also found that Boeing does not have a clear
and consistent safety reporting process and employees may lack
understanding of which process to use and when.\7\ Boeing promotes the
Speak Up reporting system as a preferred method of safety reporting for
employees, but many employees distrust the anonymity of the system and
prefer to report safety issues to their managers.\8\ The Expert Panel
could not verify, however, whether safety concerns reported to managers
are captured and resolved in a systematic way.\9\ In addition, the
Panel found that safety of flight concerns raised by test pilots during
the certification process are not adequately addressed when evaluating
aircraft design.\10\
---------------------------------------------------------------------------
\5\ Section 103 Organization Designation Authorizations (ODA) for
Transport Airplanes Expert Panel Review Report, Federal Aviation
Administration (Feb. 26, 2024), https://www.faa.gov/newsroom/review-
panels-final-report-organization-designation-authorizations-oda-design-
and.
\6\ Id at p. 32.
\7\ Id at p. 32.
\8\ Id at p. 32.
\9\ Id at p. 33.
\10\ Id at p. 39.
Question 1. Has Boeing failed to establish an effective safety
culture?
Answer. The ODA Expert Panel, of which I was a part, found that in
some places, Boeing's safety culture is strong and effective, and in
others, it is growing and improving. Other areas require a great deal
more attention, education, encouragement, and management engagement.
Question 2. What has been the result of Boeing's systemic safety
culture failures?
Answer. The ODA Expert Panel, of which I was a part, discussed
potential outcomes of any aviation mishaps attributable to
organizational safety culture. The most obvious potential outcome of
any safety culture failures, of course, is the loss of life or serious
injury, coupled with the resulting impacts to family and friends.
Beyond this, such failures could damage the reputation of--and public
confidence in--any company involved in aviation mishaps and possibly
American aviation generally. This may lead to decreased competitiveness
globally, and losses in revenue and stock value from reduced orders of
aircraft.
Question 3. Would Boeing, and the national airspace system, benefit
from more robust oversight from the FAA or independent watchdogs?
Answer. I would defer to the Federal Aviation Administration (FAA)
regarding their level of oversight on the national airspace system.
______
Response to Written Questions Submitted by Hon. Raphael Warnock to
Dr. Najmedin (Najm) Meshkati
Aviation Workforce Needs
In its report, the Expert Panel noted that many Boeing employees
did not demonstrate knowledge of the company-wide safety culture
efforts.\1\ The report also raises concerns that experienced ODA Unit
Members are leaving Boeing and the Federal Aviation Administration
(FAA) and not being replaced in a timely fashion.\2\ In a March 2024
report on commercial aviation manufacturing, the Government
Accountability Office found that many aviation manufacturers are facing
difficulty maintaining enough sufficiently skilled workers to meet
current production demands.\3\ Many manufacturers have lost employees
due to layoffs, retirements, and decisions to leave the industry and
are facing difficulties in hiring skilled labor to competition for
workers, a lack of skilled and experienced labor supply, and labor cost
increases.\4\
---------------------------------------------------------------------------
\1\ Section 103 Organization Designation Authorizations (ODA) for
Transport Airplanes Expert Panel Review Report, Federal Aviation
Administration (Feb. 26, 2024), https://www.faa.gov/newsroom/review-
panels-final-report-organization-designation-authorizations-oda-design-
and.
\2\ Id at p. 37.
\3\ Heather Krause, Commercial Aviation Manufacturing: Supply Chain
Challenges and Actions to Address Them, Government Accountability
Office (Mar. 6, 2024), https://www.gao.gov/products/gao-24-106493.
\4\ Id at p. 19, 21-23.
Question 1. Would a more robust aviation workforce pipeline,
including expanded partnerships with academic institutions, improve
Boeing's safety culture?
[My response to this and the following questions posed by Senator
Raphael Warnock are based on my last four decades of aviation safety-
related research and teaching experience. It should not necessarily be
construed as representative position(s) of the FAA Organization
Designation Authorization (ODA) Expert Panel, of which I was a member.]
Answer. A highly-trained, robust aviation workforce that is treated
with dignity and respect, whose ``perceived equity of rewards'' is
considered and addressed, and compensated competitively, is essential
for achieving and maintaining a healthy safety culture. Engaging in
collaborative efforts and forging partnerships with Boeing's labor
unions, e.g., the International Association of Machinists (IAM) and the
Society of Professional Engineering Employees in Aerospace (SPEEA),
will help ensure growth opportunities and sustain the robustness and
retention of the workforce.
Boeing has already established a partnership with the Embry-Riddle
Aeronautical University by creating the Boeing Center for Aviation and
Aerospace Safety. Although this is a step in the right direction, it is
not sufficient enough. There are other academic institutions in the
country, such as the University of Southern California, Ohio State
University, University of Illinois, Purdue University, George Mason
University, and the University of North Dakota, with solid research and
teaching experience in aviation safety that could (and should) be
potential partners with Boeing for workforce development and enhanced
professional training.
Moreover, in addition to technical and engineering education
provided by the above universities and many other institutions, there
have to be context-specific educational efforts to address all
``systemic'' facets of aviation safety necessary to find and report
hazards, the accountable communication to hear and understand reports,
and the effective leadership to use hazard reports to inform and
motivate organizational change. Each step taught by this type of
education builds a safety management system necessary for an
organization as large and complex as Boeing to avoid ``errors'' and
reach the technical standards that customers and the flying public
deserve.
Question 2. How would the aviation system benefit from a diverse
and representative pipeline of aviation technical experts?
Answer. I firmly believe the more diverse the workforce, the
better/stronger the workforce. As mentioned before, various aviation
training institutions in the country have diverse foci that could (and
should) become ``feeders'' of the aviation system. A prudent approach
is to establish an overarching coordinating entity to identify the
strategic needs of the aviation industry and align them with the
feeding institutions.
Safety Reporting
During its investigation, the ODA Expert Panel observed a
disconnect between Boeing's senior management and employees on safety
culture, with some employees questioning the effectiveness of the
company's safety reporting systems.\5\ The report found that managers
who oversee employee performance, salaries, and disciplinary actions
might also be tasked with investigating safety reports, which may cause
some employees to hesitate reporting safety concerns in fear of
retaliation.\6\ The Panel also found that Boeing does not have a clear
and consistent safety reporting process and employees may lack
understanding of which process to use and when.\7\ Boeing promotes the
Speak Up reporting system as a preferred method of safety reporting for
employees, but many employees distrust the anonymity of the system and
prefer to report safety issues to their managers.\8\ The Expert Panel
could not verify, however, whether safety concerns reported to managers
are captured and resolved in a systematic way.\9\ In addition, the
Panel found that safety of flight concerns raised by test pilots during
the certification process are not adequately addressed when evaluating
aircraft design.\10\
---------------------------------------------------------------------------
\5\ Section 103 Organization Designation Authorizations (ODA) for
Transport Airplanes Expert Panel Review Report, Federal Aviation
Administration (Feb. 26, 2024), https://www.faa.gov/newsroom/review-
panels-final-report-organization-designation-authorizations-oda-design-
and.
\6\ Id at p. 32.
\7\ Id at p. 32.
\8\ Id at p. 32.
\9\ Id at p. 33.
\10\ Id at p. 39.
Question 1. Has Boeing failed to establish an effective safety
culture?
Answer. As the FAA ODA Expert Panel reported, Boeing's safety
culture suffered from ``inadequate and confusing implementation of the
five components of a positive safety culture (Reporting Culture, Just
Culture, Flexible Culture, Learning Culture, and Informed Culture).''
[Section 103 Organization Designation Authorizations (ODA) for
Transport Airplanes Expert Panel Review Report, Federal Aviation
Administration (Feb. 26, 2024), p. 4.]
Question 2. What has been the result of Boeing's systemic safety
culture failures?
Answer. As mentioned in my opening statement, I believe that safety
culture is the foundation of every process and operation in an
organization; it could make or break the system. And as my mentor, Prof
James Reason, succinctly put it, ``safety culture . . . can affect all
elements in a system for good or ill.''
Many of Boeing's recent problems, especially how MCAS was designed,
developed, deployed, and certified, could primarily be attributed to
the failure of Boeing's errored safety culture, which precipitated
inadequate (or lack of) attention to human factors considerations. [For
justification and further elaboration, refer to the Expert Panel's
report, observation #3.6 on human factors and human systems integration
(p. 24), Finding #26, and its associated two recommendations, # 49 and
#50 (p. 40).]
Question 3. Would Boeing, and the national airspace system, benefit
from more robust oversight from the FAA or independent watchdogs?
Answer. More robust FAA oversight is always welcomed. However, the
FAA suffers from the same market trends (competitive environment and
workforce demographics) as Boeing. Their direct oversight abilities are
thus constrained. However, if they were to partner with outside
expertise (similar to what was done with the FAA ODA Expert Panel),
their ability to see through the corporate veil would be significantly
enhanced.
Furthermore, the advancement of new safety-critical technologies,
e.g., flight deck automation, and increasing system complexity, which
outpace oversight regulatory agencies' capabilities, has posed a
serious challenge. This widening gap could have adverse consequences
and serious safety-implications for the users, the public, and society.
Controlling and regulating the risks of these technologies requires a
new mindset and regulatory paradigms, a proactive strategy, and systems
thinking. This paradigm should be based on mutual trust between
business--technology vendors and their operating companies-and
government oversight agencies, in full transparency with clearly
delineated lines of authority, responsibility, and accountability.
The burden and onus for the safety of these advanced systems and
devices will be increasingly on the shoulders of the industry. The
regulatory agencies will have less and less capability and/or influence
because of that monotonically increasing widening gap between the
exponential advancement of technology and the plateauing or diminishing
capabilities of regulatory agencies, such as the FAA. As such, the
ultimate ``watchdog'' of safety for Boeing should emerge internally and
empowered by revamping the structure and overhauling the membership of
its Board of Directors, who can initiate, nurture, and sustain a
healthy safety culture, which is the foundation of everything else.
Boeing's safety culture has eroded over the last twenty years after
its merger with McDonnell Douglas, under the direct watch of its
leaders and Board of Directors (BoD), who have been complicit in and
ultimately responsible for its present problems. Boeing has also
suffered from a series of ill-conceived administrative decisions,
including reorganization, decentralization, downsizing, and moving its
headquarters away from Seattle.
Boeing's corporate governance and perpetually cloned BoD must be
overhauled and diversified; its headquarters should be moved back to
Seattle, and all the FAA Expert Panel's 53 recommendations should be
systematically implemented. The reimagined BoD should include a member
from at least one of Boeing's two major unions, the International
Association of Machinists (IAM) and the Society of Professional
Engineering Employees in Aerospace (SPEEA), who, along with its pilots,
make up the backbone of Boeing's workforce.
Other nationally renowned aviation safety-conscious candidates
should also seriously be considered for the election to Boeing's BoD
and chairing and populating the Board's Aerospace Safety Committee.
Examples of two such candidates of national stature with unimpeachable
credentials include Dr. Javier de Luis and ex-Congressman the Honorable
Peter DeFazio.
Dr. de Luis, who lost his sister in a 737 Max Ethiopian crash, has
three degrees in engineering and an MS in management, all from MIT,
where he also teaches. He has decades of professional experience in the
fields of safety, aerospace research and operations, engineering design
and analysis, and technology management. He was a FAA Expert Panel
member and testified before the Senate Committee on Commerce, Science,
and Transportation on Wednesday, April 17, 2024.
Congressman DeFazio, who chaired the U.S. House of Representatives
Committee on Transportation and Infrastructure, is intimately familiar
with Boeing's missteps in the past. He conducted extensive hearings on
Boeing crashes and produced a seminal report, The Design, Development &
Certification of the Boeing 737 Max (September 2020), known and
referred to in the aviation safety community as the ``DeFazio Report.''
[I have neither been asked nor solicited by the named entities and
individuals (FAA Expert Panel, IAM, SEEPA, Dr. de Luis, and Mr.
DeFazio). This recommendation for revamping Boeing's BoD is entirely
based on my professional experience and observations.]
Finally, another ``independent'' layer of technical support and
oversight that could significantly help both Boeing and the FAA to
ensure and advance aviation safety in the future could be the
establishment of the specialized ``Aviation Research Program'' at the
National Academies of Sciences, Engineering, and Medicine (NASEM), to
be modeled after the exemplary Gulf Research Program (GRP). In the
aftermath of the Deepwater Horizon accident in 2010, a criminal
settlement agreement led to the creation of the GRP at the NASEM in
2013. The agreement set aside $500 million in penalties for an
endowment at the National Academy of Sciences to ``carry out studies,
projects, and other activities'' focused on offshore energy safety,
human health, and environmental protection in the Gulf of Mexico and
along the U.S. Outer Continental Shelf.
[all]