FAA Report Criticizes Boeing’s Safety Culture After 737 Max Problems

The report follows two fatal Boeing aircraft crashes, killing nearly 350 people, and the recent incident where a doorplug blew out midflight, resulting in the grounding of Boeing's 737 Max fleet.

Federal aviation experts have identified a number of concerning safety behavior issues among Boeing staff, as the aircraft maker continues to face harsh criticism for ongoing problems with its 737 Max planes.

The Federal Aviation Administration (FAA) Organization Designations Authorization (ODA) Expert Review Panel has issued a report indicating it found gaps in Boeing’s safety management processes, with many employees not understanding procedures or the process of reporting safety issues.

The Boeing panel review report was released by the FAA on February 26, and was conducted under the requirement of the 2020 Aircraft Certification, Safety, and Accountability Act (ACSAA), which requires a panel of industry experts to review transport airplane safety procedures and make recommendations to address any deficiencies found to the FAA.

The agency has already imposed new safety management rules for airplanes, in response to two fatal crashes involving the Boeing 737-8 MAX model, which occurred shortly after the introduction of the redesigned aircraft.

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Boeing Safety Concerns

Boeing has been under scrutiny over the last several years due to ongoing safety concerns with its redesigned 737 Max airplane introduced in 2016. The aircraft maker agreed to pay $2.5 billion to the U.S. Department of Justice in 2021, to resolve criminal charges that alleged it conspired to defraud the U.S. government. The lawsuit followed two fatal 737 Max accidents, which killed 346 individuals combined.

The first occurred in October 2018, when Lion Air Flight 610 crashed 13 minutes after take-off, killing all passengers and crew onboard. Investigators found pilots fought to keep the Boeing 737-8 Max airplane in the air for 11 minutes, while the plane’s Angle of Attack sensor continued to push the plane nose down, with pilots unable to shut it off.

A second fatal crash involving a Boeing 737-8 Max occurred just months later in March 2019. Similar to the first accident, Ethiopian Airline Flight 302 crashed just minutes after take-off, killing all passengers and crew. The entire 737 Max fleet was grounded worldwide shortly after, and investigators also attributed the crash to the plane’s Angle of Attack system.

Boeing faced another issue with its 737 Max fleet just recently, after the door plug blew out of a 737-9 Max aircraft mid-flight in January. The Alaska Airlines Flight 1282 incident occurred at about 16,000 feet in the air, while carrying nearly 200 passengers. An investigation revealed the door was missing four critical bolts that secured it in place, which were not reinstalled correctly after repairs were made during production.

A group of passengers on the Alaska Airlines flight filed a Boeing 737 Max 9 class action lawsuit. They claim Boeing delivered a defective and unsafe aircraft to Alaska Airlines, and the violent change in air pressure left them physically and emotionally terrified.

The FAA grounded more than 170 Boeing 737-9 Max planes in response to the recent incident. Officials required the planes be inspected before returning to service.

Boeing Safety Culture Problems

Aviation industry experts reviewed Boeing safety policy and procedure documents published between 2020 and 2023. They found documents were constantly changed, some during the review, and many revisions lacked clarity, leading to employee confusion. Many safety procedure descriptions were vague, and troubling gaps in communicating employee safety roles and reporting processes were identified through employee surveys and interviews.

The experts found the company made efforts to establish safety programs and hired an expert to train staff on safety culture, but many employees lacked knowledge of safety processes and the importance of following them.

Boeing’s safety program established a safety manual that described the role and responsibility of safety management personnel, but did not name specific employees that others or the panel could identify or report to, the investigators noted. Certain manufacturing sites utilize a tri-party Aviation Safety Action Program (ASAP), but not all facilities have implemented the reporting system, the panel indicates.

In reviewing employee safety training, Boeing documented which employees completed training but did not measure training competency. The majority of employees were not aware of daily safety activities, and experts found that supervisors who make staff performance evaluations, salary decisions, and disciplinary actions also lead safety management investigations. They indicate this could conflict with safety goals if the supervisor is investigating an employee within their own department, or cause hesitation among staff to report safety concerns for fear of retaliation.

Experts also identified concerning faults in Boeing’s safety reporting system and could not identify a clear or consistent process to report safety issues, or to inform employees of the report outcome. They found staff did not understand the different reporting systems, when or how to use them, and many feared remaining anonymous, preferring to report directly to their manager instead of using the reporting system.

The panel could not verify whether safety concerns reported to managers were documented or resolved.

Another concerning factor experts found was loss of experienced staff due to retirement, and the COVID-19 pandemic. The panel indicated that Boeing did not consistently monitor the number of engineers, their experience, or expertise, which left some feeling isolated during work and in making decisions. Engineers reported they felt less supported, were given little mentoring or knowledge, and lacked ability to communicate with other organizations during the design phase, which hindered the engineering process.

The panel indicated Boeing’s Chief Aerospace Safety Office implemented a successful program to teach employees of safety initiatives, and encouraged other executives to follow suit.

In a press release issued on the same day, the FAA indicates it will begin a thorough review of the report and determine the appropriate next steps. It will continue to hold Boeing to the highest safety standards and work to ensure the company addresses the issues.


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