The Democratic majority on the House Transportation Committee released the results of their 18-month investigation into the Boeing 737 MAX 8 crashes.

It has been described as the most comprehensive report yet that looks the roles Boeing and the Federal Aviation Administration (FAA) played.

Among other information, the inquiry found that Boeing prioritized profit over public safety and that the FAA provided “grossly insufficient oversight.”

The report comes as the FAA is expected to recertify the MAX 8 to fly within just a few months.

House Committee Report

A sweeping Congressional investigation released Wednesday directly blamed Boeing and the Federal Aviation Administration (FAA) for two 737 MAX 8 planes that crashed within five months of each other, killing 346.

The inquiry, which was released by the Democratic majority on the House Transportation Committee, has been described as the most comprehensive report yet regarding the role both Boeing and the FAA played in certifying the plane that caused two fatal crashes.

In October 2018, a MAX 8 operated by Lion Air crashed off the coast of Indonesia resulting in the death of 189 people. Then, in March 2019, another MAX 8 operated by Ethiopian Airlines crashed outside of Addis Ababa, killing all 157 people on board.

Drawing from interviews with two dozen Boeing and FAA employees and around 600,000 pages of records, the findings of the committee’s 18-month investigation paint a grim picture of the numerous issues with the development and certification of the MAX 8, and specifically, the software system faulted with bringing both planes down.

The Maneuvering Characteristics Augmentation System (MCAS) was designed to automatically correct the level the plane was flying at to prevent it from stalling and falling out of the sky. However, investigations found that on both the Lion Air and Ethiopian Airlines flights, MCAS had pushed the planes’ noses down at a dangerous angle.

When the pilots tried to stabilize, the system kept pushing them down again and again until they eventually went into uncontrollable nose-dives and crashed. Further complicating matters was the fact that after the first crash, numerous pilots came forward and said they were never told about MCAS, were not trained on it, and that it had been left out of their flight manuals.

Five Key Themes

In their report, the Democrats explicitly state that the crashes were “the horrific culmination of a series of faulty technical assumptions by Boeing’s engineers, a lack of transparency on the part of Boeing’s management, and grossly insufficient oversight by the FAA.”

To illustrate their findings, the committee outlined five overarching themes that they say ultimately lead to such fundamental problems with the MAX 8’s design, construction, and certification.

The first theme is “Production Pressure.” Here the inquiry notes that there was significant financial pressure on Boeing to quickly build and certify the MAX 8 because the model was designed to compete with a new line of planes being developed by their biggest rival, Airbus.

This, the committee says, led Boeing to prioritize cost-cutting, production goals, and maintaining their schedule to meet certification deadlines over public safety.

The second theme the report outlines is “Faulty Design and Performance Assumptions.” Specifically, it says that Boeing made “fundamentally faulty assumptions about critical technologies on the 737 MAX, most notably with MCAS.”

The committee then goes on to list a handful of examples, like the fact that MCAS relied on only one sensor, so if that censor failed — as it did during both the crashes — it could cause MCAS to engage when it should not. It also says Boeing expected that pilots would be able to deal with that malfunction even though they did not know the system even existed.

Notably, the report claims that Boeing “failed to classify MCAS as a safety-critical system, which would have attracted greater FAA scrutiny during the certification process,” and that “the operation of MCAS also violated Boeing’s own internal design guidelines” regarding interactions with piloting and interfering in dive recovery.

The overarching problem the inquiry flagged was “Culture of Concealment.”

“In several critical instances, Boeing withheld crucial information from the FAA, its customers, and 737 MAX pilots,” it stated before going to provide examples.

In addition to the fact that Boeing did not tell pilots about MCAS, the company also failed to disclose that a crucial safety feature was “inoperable on the vast majority of the 737 MAX fleet, despite having been certified as a standard aircraft feature.”

The safety feature in question informed pilots if the sensors that activated MCAS were feeding the system incorrect data, which is what happened in both the Lion Air and Ethiopian Airlines flights.

The investigation also found that Boeing concealed a flight simulation where it took a test pilot more than 10 seconds to respond to an unwanted MCAS activation — “a condition the pilot found to be ‘catastrophic’” — given the fact that federal guidelines assumed pilots would respond to massive system problems of that nature within four seconds.

While the report does note that Boeing was not legally required to disclose these things to the FAA or its customers, it still argued that it was “inconceivable and inexcusable that Boeing withheld this information from them.”

Under the fourth theme, “Conflicted Representation,” the committee reported that “the FAA’s current oversight structure with respect to Boeing creates inherent conflicts of interest that have jeopardized the safety of the flying public.”

It goes on to note several documented instances where Authorized Representatives, which are Boeing employees who were given the ability to act on behalf of the FAA and certify that some of the plane’s designs meet the agency’s requirements, “failed to disclose important information to the FAA that could have enhanced the safety of the 737 MAX aircraft.”

The inquiry also states that some of the concerns raised internally by those representatives that were not relayed to the FAA, not investigated, or dismissed by Boeing employees involved the same issues with MCAS that caused both the Lion Air and Ethiopian Airlines crashes.

The final theme the committee put forward in their report was “Boeing’s Influence Over the FAA’s Oversight Structure.”

There, the investigation found multiple instances documented by FAA officials where “FAA technical and safety experts determined that certain Boeing design approaches on its transport category aircraft were potentially unsafe and failed to comply with FAA regulations, only to have FAA management overrule them and side with Boeing instead.”

Broader Issues

The last theme is extremely important in understanding both how Boeing got into this debacle and how the industry can move forward.

For years, the FAA — at the direction of Congress — has been giving more and more regulatory oversight powers to plane manufacturers like Boeing. That has been a win-win for both the FAA and Boeing.

The FAA is a government agency with very limited resources, so giving Boeing more authority over day-to-day safety assessments lets them focus their energy on the bigger picture safety aspects of the certification process.

For Boeing, which has lobbied Congress in favor of these practices, it cuts back a ton of red tape so they can speed up the certification of their planes and compete with foreign rivals like Airbus.

Both the FAA and plane manufacturers have said they are using this cooperation to make planes safer, but watchdog groups and unions have repeatedly expressed concerns that letting manufacturers self-regulate too much could compromise safety and allow plane manufacturers to act in their own self-interest.

Those concerns grew during the aftermath of the MAX 8 crashes and the mounting evidence from investigations and hearings. While the House committee’s report does not provide many new pieces of bombshell information, many believe it is the necessary first step in crafting legislation to better regulate the aerospace industry.

In a statement with the release of the inquiry’s findings, Rep. Peter DeFazio (D-Or.), who chairs the House Transportation Committee, said it was “mind-boggling” that “both FAA and Boeing came to the conclusion that the certification of the Max was compliant.”

“The problem is it was compliant and not safe. And people died,” he said, adding that it is “clear evidence that the current regulatory system is fundamentally flawed and needs to be repaired.”

“This is a tragedy that never should have happened. It could have been prevented and we’re going to take steps in our legislation to see that it never happens again as we reform the system.”

While the Senate Commerce Committee is set to consider a bill this week to strengthen the airplane certification process, House Republicans on the Transportation Committee did not endorse the investigative report.

In a statement regarding the Democrat’s report, the committee’s ranking member Rep. Sam Graves (R-Mo.) criticized Democrats for an investigation that “began by concluding that our system was broken and worked backwards from there.”

“If aviation and safety experts determine that areas in the FAA’s processes for certifying aircraft and equipment can be improved, then Congress will act,” he added.

But Congress may be running out of time.

“The report was issued as the F.A.A. appeared close to lifting its grounding order for the Max after test flights this summer. F.A.A. clearance could lead aviation authorities elsewhere to follow suit and allow the plane to fly again as soon as this winter,” The New York Times noted in its coverage of the committee’s report on Wednesday

Boeing has been doing a lot of work to update the problems with the plane and make it flyable. However, there are still many concerns as to whether or not lawmakers, airlines, and customers should still trust the company to fix the flawed aircraft without an overhaul to the regulatory system — especially given all the flaws in the certification system that so many investigations have revealed.