The Federal Aviation Administration has published a 50-page final report by an Organization Designation Authorization Expert Review Panel tasked by Congress to evaluate the effectiveness of Boeing’s
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The Expert Panel reviewed 4,000 pages of Boeing documents on safety management, conducted seven surveys, interviewed over 250 employees, and met with others at six Boeing locations. It found that Boeing has made its SMS confusing to employees and failed to implement a safety management culture fully to ensure its effectiveness.
The panel also found that Boeing sometimes fails to make safety reporting non-punitive and does not appropriately take pilot input on programs. In all, the Expert Panel had 27 findings of concern in Boeing’s safety management practices and made 53 recommendations.
Boeing’s Dysfunctional Safety Management System
While Boeing has implemented SMS procedures on paper, in keeping with the FAA and the International Civil Aviation Organization standards, the Expert Panel found the company failed to ensure all employees understood their role in maintaining safety.
“The procedures and training are complex and in a constant state of change, creating employee confusion, especially among different work sites and employee groups,” the panel wrote in its findings. It also found “a lack of awareness of safety-related metrics at all levels of the organization.”
Boeing restructured the management of the Organization Designation Authorization unit, which effectively authorized Boeing to inspect itself with employees acting as representatives of the FAA in a way intended to decrease the risk of interference and retaliation against ODA unit members reporting issues. However, Boeing failed to do so effectively. The current system, the Expert Panel wrote, “still allows opportunities for retaliation to occur, particularly with regards to salary and furlough ranking. This influences the ability of UMs to execute their delegated functions effectively.”
Other findings include “inadequate human factors consideration commensurate to its importance to aviation safety and lack of pilot input in aircraft design and operation.”
Interviewees Went Through Boeing Legal Brief Before Meeting With FAA Panel
One of the insights from the report, which reflects a dysfunction in Boeing’s stated safety management and the practical realities, is that some employees interviewed by the FAA’s expert panel did not feel comfortable speaking up as encouraged to do by Boeing’s own Seek, Speak & Listen policy.
“Each interview with Boeing employees started with an opening statement that the Expert Panel was ‘…very interested in hearing your perspective on each topic.’ However, it appears to some Expert Panel members that Boeing employees viewed the Expert Panel’s work as an audit; not an opportunity to collaborate. Interviewees asked minimal questions of the experts. Some interviewees mentioned a briefing was provided by Boeing legal prior to the interviews,” the Expert Panel reported.
Lost Knowledge In A ‘Dispersed,’ ‘Diminishing’ Engineering Base
Boeing’s ODA unit consists of over 1,000 personnel performing FAA-delegated manufacturing and engineering oversight functions. The Expert Panel found that their “ability to ensure adequate experience with aviation safety requirements, processes and procedures is declining.” Also, the panel found that “current experience in the manufacturing and engineering arenas decreased as the more seasoned staff left or took retirement during the pandemic.”
Boeing’s “reliance on dispersed engineering experience, expertise and guidance does not appear to be coordinated or consistently monitored for sufficiency in numbers, experience, expertise or communications channels.” The Expert panel found that Boeing engineers outside Washington state felt “isolated in work and decision-making” with less support and knowledge sharing.
“With the diminishing senior engineering resources..less time may be available for the mentoring and training of less experienced engineers, which may lead to lower first pass quality on certification plans and reports, test parameters, and other documentation used to support showings of compliance. The ability to comply with the ODA’s approved procedures is present; however, the integration of the SMS processes, procedures and data collection requirements has not been accomplished.”
Administrative Decisions Erode Human Factors Integration, Pilot Input Unheard
The Expert Panel also found a deterioration in Boeing’s human factors integration to ensure aircraft designs in which crew can perform their functions optimally and safely. “BCA’s human factors in flight deck design and operations were the gold standard with pilots, engineers, product support, and human factors specialists,” the panel wrote. “The role of human factors and its influence eroded due to a series of administrative decisions at Boeing, which includes reorganization, decentralization, downsizing, and relocating the company’s headquarters.”
During interviews, Senior Boeing management told the Expert Panel that the company is rebuilding this capability.
Additionally, the Expert Panel determined that “pilot inputs within Boeing are neither directly nor consistently delivered to the highest-level decision venues where pilots did not occupy a seat at the table.” Some interviewees expressed concerns that pilots’ likelihood of having their views heard depended “on the individuals occupying executive positions within Boeing.”
The panel recommended that the top pilot have sufficient authority to ensure “the pilot’s voice is heard and considered in safety of flight, training and human factors related decisions.”
Boeing’s Employees Expressed Concerns Over Safety Management System
The Expert Panel reported, “Boeing employees across all disciplines and roles expressed concerns over the lasting power of the SMS program and safety initiatives. This raises concerns about the sustainability of SMS. The lack of feedback and/or delay in providing feedback jeopardizes the longevity of SMS. Sustainability is additionally challenged by Boeing’s strategy to not disrupt legacy safety processes.”
Additionally, the Expert Panel cast doubts over the FAA’s ability to oversee expanding SMS regulations effectively at Boeing. “Interviews with FAA employees and managers also conveyed concerns about the sustainability of Boeing SMS,” the panel wrote.
Boeing President and CEO Dave Calhoun told employees in a statement accompanying the company’s fourth-quarter results that Boeing has “a commitment to listening to each other and speaking up.” The findings of the Expert Panel suggest Boeing is unsuccessful in delivering on this commitment.
Calhoun also said in that statement, “This increased scrutiny – whether from ourselves, from our regulator, or from others – will make us better.” Boeing’s subsequent actions implementing the recommendations from the Expert Panel will determine whether that is the case.
The findings of this report will influence the FAA’s decision-making on how much authority for safety oversight it should continue to delegate to Boeing. It will also affect the FAA’s view of Boeing’s readiness to ramp up production on its 737 MAX program.
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