A government report released Wednesday concludes that Federal Aviation Administration (FAA) oversight of airplane safety needs further strengthening beyond what the agency has already implemented in response to the two crashes of Boeing’s 737 MAX.

The final report by the Inspector General of the U.S. Department of Transportation highlights failures that led the FAA to miss the flaws in the MAX’s new flight control system during certification of the jet in 2015 and 2016.

“Much work remains to address weaknesses in FAA’s certification guidance and processes,” the report concludes, adding that the agency has not yet taken sufficient steps to ensure proper oversight of the highest-risk and most critical airplane systems.

The report makes 14 specific recommendations , changes it says are “vital to restore confidence” and ensure the highest level of safety in future certification of passenger aircraft.

The FAA received a copy of the report in December and has already agreed to implement all the recommendations.

However, it said that working to harmonize its regulatory processes with foreign authorities will take time, so that the target for acting on many of the recommendations is almost five years out.


The recommendations include various elements of the FAA reform legislation, passed by Congress in December, that mandates beefing up the agency’s oversight capabilities.

Democratic Sen. Maria Cantwell of Washington, a sponsor of that legislation and now chair of the Senate Committee on Commerce, Science, and Transportation, said the report backs up the action taken by Congress and “shows these reforms need to be implemented now.”

In the U.S. House, Rep. Peter DeFazio (D-Ore.), chair of the Committee on Transportation, said he remains “seriously concerned that Boeing was able to put a fatally flawed aircraft into service under FAA’s certification process.”


DeFazio said he’ll push for the FAA to implement the new legislation — the Aircraft Certification, Safety, and Accountability Act — without delay.

While the report focused on shortcomings in FAA oversight, it also criticized Boeing’s role in the certification process. Boeing’s engineers did most of the work to prove the MAX complied with federal safety regulations and did not reveal critical details to the FAA.


In a statement, Boeing said it cooperated extensively with the Inspector General’s review and that it has already “made meaningful improvements across our company” to improve safety and quality.

Sen. Richard Blumenthal (D-Conn.) said the report “adds evidence — and an exclamation point — to findings of Boeing’s shameful concealment and the FAA’s negligence.”

FAA failures in MAX certification

The report reiterates findings in the Inspector General’s preliminary report last June related to how the safety agency missed critical flaws in the design of the MAX’s Maneuvering Characteristics Augmentation System (MCAS), the new flight control software that repeatedly activated and pushed down the nose of the aircraft in both MAX crashes.

A key finding is that the FAA’s certification process is inadequate for assessing new systems introduced to update older model aircraft like the 737.

“The Agency relies on the manufacturer to identify which changes from previous aircraft models are significant,” the final report states. “Because Boeing did not identify MCAS as significant, FAA did not focus on the system during certification reviews.”

The report notes that key assumptions related to pilot reaction to the system were not included in the safety assessment Boeing submitted to the FAA.


And when Boeing expanded the scope of MCAS so that it would operate not only in the extreme flight mode it was originally intended for, but also in a lower speed situation within normal flight conditions, knowledge of this change within the FAA was limited.

The FAA pilots who were test flying the MAX in the summer of 2016 were aware of the change. And Boeing provided briefings to various FAA personnel that mentioned it — but minimized its significance.

“As a result, key FAA personnel lacked an adequate understanding of how and when MCAS activated … and the potential risks associated with multiple erroneous MCAS activations on a flight,” the report states. “These issues limited FAA’s ability to make an informed decision regarding the safety of the aircraft.”

After the first crash

The report found that “FAA engineers did not have a full understanding of MCAS until after the Lion Air accident,” which killed 187 people in October 2018.

After that accident, the FAA began to ask detailed questions related to MCAS at a series of meetings with Boeing in early January 2019 — nearly 20 months after the MAX had entered commercial service.

The FAA prepared a report, which determined that based on the unclear and incomplete information provided by Boeing, “an independent reviewer of the safety assessment would not have been able to fully understand how MCAS worked or how interactions with other systems could impact the safety of the airplane.”


FAA management told the Inspector General that this post-accident report was going through management review at the time of the second crash, of an Ethiopian Airlines MAX, which killed 157 people in March 2019.

At that point, FAA management stated that they did not finalize the report as they “considered it overtaken by events.”

The IG report notes that the FAA’s Boeing Aviation Safety Oversight Office had limited resources, with just 47 staff members, including 25 engineers and technical project managers. This FAA office was a liaison with a Boeing internal organization of 1,500 employees who technically acted on behalf of the FAA to perform most of the certification work.

The report found that engineers in the FAA oversight office face challenges “due to an organizational culture driven by the demand to meet certification schedules.”

Rep. DeFazio said the conclusions in the report are “yet another disturbing reminder of how much work the FAA has ahead to correct the multitude of problems within the current aviation regulatory structure.”

The failures were not just within the FAA. The report also found that the internal Boeing organization that plays the paramount role in certifying new aircraft is not “adequately independent.”


The report cites documented cases of pressure from Boeing management to fast track a finding of compliance with regulations “without sufficient time to perform a review.”

“This pressure could potentially impact aircraft safety and ultimately the flying public,” the report states.

And the Inspector General concluded that although the FAA has already taken some steps to better enforce compliance with regulations, “it is not clear that FAA’s current oversight structure and processes can identify future high-risk
safety concerns.”

The report’s recommendations focus on changing how new system designs on aircraft are certified; updating the guidance related to assumptions about pilot reaction times; and establishing new processes for manufacturers like Boeing to notify the FAA of any changes to system safety assessments.

The report also recommends an examination of possible conflicts of interest when Boeing engineers working on behalf of the FAA to assess certification requirements also finalize design details.

In its response to the report, the FAA said it is forming a team including representatives of foreign civil aviation authorities to evaluate how new versions of existing jets are certified and to ensure “a consistent worldwide approach to safety and the similar evaluation and treatment of design changes.”

It also is establishing an office tasked with ensuring that supervisors at Boeing and other manufacturers apply no “undue pressure” to engineers who work as FAA representatives.