In addition to yesterday’s breaking news indicating that Boeing will be establishing a permanent board-level safety committee, and seven months since the two tragic 737 MAX aircraft accidents, the U.S. National Transportation Safety Board (NTSB) today issued a report based on the two prior accident investigations.

The NTSB report suggests that both Boeing and the U.S. Federal Aviation Agency (FAA) utilized unrealistic pilot response assumptions regarding the flight control systems of this aircraft. The report suggested that modern jets require much better designed pilot alerting systems, going beyond current systems design, and much beyond the legacy systems of the 737 aircraft family.   Grounded Boeing 737 MAX's

The agency urged Boeing and the FAA to pay special attention to interactions among average experienced pilots among cockpit computers and what was termed as overly optimistic assumptions about the speed and effectiveness of cockpit crew responses to complex automated, software or hardware driven failures.

According to reporting by The Wall Street Journal:

NTSB officials told reporters that, before the MAX began commercial service, Boeing failed to initially test—and the FAA never asked to see demonstrated—the full range of alerts, warnings and related system failures that could result from an MCAS (flight control system) misfire. Pilots of the ill-fated jets were overwhelmed by multiple alerts caused by a single malfunctioning sensor, leading to what safety experts call task saturation.”

According to other reporting by the Seattle Times:

The NTSB recommendations go beyond the MAX. They are also asking the FAA to re-evaluate whether other airplanes besides the 737 MAX may also have major system vulnerabilities undetected during certification testing.

Among a listing of seven non-binding recommendations for better testing, five called for more objective methods to predict likely pilot responses to failure scenarios. A further recommendation calls for the FAA to assist foreign regulators identify regulatory gaps when certifying aircraft flying within their countries.

The FAA for its part, has indicated that the agency will carefully review all recommendations provided as part of the agency’s ongoing efforts to safely return the 737 Max to operational service.

Boeing responded by indicating that it is cooperating with regulators around the world as it is determined to keep improving on safety in partnership with the global aerospace industry.

The NTSB itself continues to assist respective air safety agencies investigating both the Lion Air accident last October and the Ethiopian Airlines accident in March, both suspected of being caused by flight control system complications.


Potential Implications

The release of this NTSB report adds to the pressures on Boeing and the FAA in the process of returning the 737 MAX to global-wide service.

The emphasis placed on design assumptions related to average pilot interactions with the aircraft’s MCAS flight control systems will likely reinforce beliefs from some global regulators such as Europe, that additional pilot training and simulator testing may be appropriate before re-certification.

In either case, assumptions that the 737 MAX will return to global-wide service by the end of 2019 may be premature.

For Boeing’s 737 internal manufacturing and logistics,  as well as external supply network teams, the NTSB report recommendations will likely provide added dimensions of supply chain disruption. Compounded with Boeing’s Board level determination of the need for a corporate level safety committee and the notions of a Chief Engineer role, reporting directly to the CEO, one gets the sense that process, practice and accountability changes are eminent.


Bob Ferrari

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