Research summary
Research summary
Topic summary
The crisis was created by statutory reforms that forced the FAA to delegate critical flight-safety approvals directly to Boeing staff.
Key research questions
- Investigate "How Did Boeing Go From Engineering Icon to Crisis?" from this distinct point of divergence: FAA Delegated Oversight and Regulatory Capture.
Important claims and supporting citations
Boeing simulations showed that a pilot response time longer than ten seconds to uncommanded MCAS was catastrophic, but this finding was not provided to the FAA.
The FAA delegated approval of the final corrected Enhanced Digital Flight Control System System Safety Analysis to Boeing in January 2017, only two months prior to 737 MAX certification.
The FAA renewed Boeing's ODA in 2015 during early 737 MAX development, despite the FAA's own oversight office having documented findings of undue management pressure.
Whistleblower disclosures to the Senate Commerce Committee documented that a 2016 FAA evaluation found pilots took up to roughly 16 seconds to respond to MCAS activation, well exceeding the 4-second baseline assumption.
In 2015, a Boeing authorized representative specifically questioned whether MCAS was vulnerable to the failure of a single angle-of-attack sensor prior to aircraft certification.
A December 2020 Senate Commerce Committee report found FAA senior leadership may have obstructed a DOT OIG review of pilot reaction times and engaged in a coordinated effort with Boeing to manipulate MAX recertification.
The FAA Reauthorization Act of 2018 (P.L. 115-254), enacted three weeks before the Lion Air crash, contained provisions pushing the FAA to increase delegations and restricted oversight of ODA holders.
Boeing's original 2013 functional hazard assessment classified MCAS failure as 'major' and specified a 0.6-degree stabilizer authority limit, which was later expanded to 2.5 degrees and repetitive activation without briefing FAA engineers.
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Boeing received its Organization Designation Authorization in 2009, creating an ODA unit of roughly 1,000–1,5…
Boeing received its Organization Designation Authorization in 2009, creating an ODA unit of roughly 1,000–1,500 Boeing employees approving design data on the FAA's behalf while reporting through Boeing management.
Labels: Source-linked, Medium, known
Internal Boeing messages revealed the company discussed framing MCAS to regulators as an extension of the exi…
Internal Boeing messages revealed the company discussed framing MCAS to regulators as an extension of the existing speed-trim system rather than as a distinct new function.
Labels: Source-linked, High, known
Boeing's ODA structure allowed an engineer who participated in designing a feature to approve that same desig…
Boeing's ODA structure allowed an engineer who participated in designing a feature to approve that same design while acting as an FAA ODA unit member.
Labels: Source-linked, Medium, known
Concealment of Simulator Data and Pilot Reaction Times
Concealment of Simulator Data and Pilot Reaction Times
Labels: Inferred, Low
Internal Concerns Over MCAS Design and Single-Sensor Vulnerability
Internal Concerns Over MCAS Design and Single-Sensor Vulnerability
Labels: Inferred, Low
Reports of Undue Management Pressure on ODA Members
Reports of Undue Management Pressure on ODA Members
Labels: Inferred, Low
Establishment and Expansion of the ODA Program
Establishment and Expansion of the ODA Program
Labels: Inferred, Low
Delegation of 737 MAX Certification Plans
Delegation of 737 MAX Certification Plans
Labels: Inferred, Low
Regulatory and Legislative Reforms to ODA Authority
Regulatory and Legislative Reforms to ODA Authority
Labels: Inferred, Low
Investigations into FAA Awareness and MCAS Oversight Failures
Investigations into FAA Awareness and MCAS Oversight Failures
Labels: Inferred, Low
FAA Staffing and Oversight Limitations
FAA Staffing and Oversight Limitations
Labels: Inferred, Low
DOJ Criminal Proceedings and Prosecution of Mark Forkner
DOJ Criminal Proceedings and Prosecution of Mark Forkner
Labels: Inferred, Low
In 2015, a Boeing authorized representative specifically questioned whether MCAS was vulnerable to the failur…
In 2015, a Boeing authorized representative specifically questioned whether MCAS was vulnerable to the failure of a single angle-of-attack sensor prior to aircraft certification.
Labels: Source-linked, High, known
The Aircraft Certification, Safety, and Accountability Act (ACSAA), enacted December 27, 2020, required the F…
The Aircraft Certification, Safety, and Accountability Act (ACSAA), enacted December 27, 2020, required the FAA to approve ODA unit members directly and mandated protections against management interference.
Labels: Source-linked, Low, known
The FAA Modernization and Reform Act of 2012 prompted an implementation plan that prioritized the 'Enhanced U…
The FAA Modernization and Reform Act of 2012 prompted an implementation plan that prioritized the 'Enhanced Use of Delegation' to improve certification efficiency.
Labels: Source-linked, Low, known
The FAA initially delegated 28 of 87 detailed certification plans for the 737 MAX, but ultimately delegated a…
The FAA initially delegated 28 of 87 detailed certification plans for the 737 MAX, but ultimately delegated all 91 plans to Boeing by March 2017.
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The October 2019 Joint Authorities Technical Review (JATR) found that the FAA lacked adequate awareness of MC…
The October 2019 Joint Authorities Technical Review (JATR) found that the FAA lacked adequate awareness of MCAS functionality and that the ODA structure gave FAA engineers insufficient visibility into Boeing's delegated analyses.
Labels: Source-linked, Medium, known
On January 7, 2021, the DOJ announced a Deferred Prosecution Agreement charging Boeing with conspiracy to def…
On January 7, 2021, the DOJ announced a Deferred Prosecution Agreement charging Boeing with conspiracy to defraud the FAA's Aircraft Evaluation Group regarding MCAS, with Boeing agreeing to pay over $2.5 billion.
Labels: Source-linked, Medium, known
A Boeing survey begun in December 2019 revealed that 40% of responding ODA unit members perceived undue press…
A Boeing survey begun in December 2019 revealed that 40% of responding ODA unit members perceived undue pressure within the preceding 24 months, largely driven by schedule and cost concerns.
Labels: Source-linked, High, known
Boeing simulations showed that a pilot response time longer than ten seconds to uncommanded MCAS was catastro…
Boeing simulations showed that a pilot response time longer than ten seconds to uncommanded MCAS was catastrophic, but this finding was not provided to the FAA.
Labels: Source-linked, High, known
The statutory basis for the FAA's self-certification ODA program was created by the Vision 100—Century of Avi…
The statutory basis for the FAA's self-certification ODA program was created by the Vision 100—Century of Aviation Reauthorization Act of 2003 (Public Law 108-176), allowing delegation to entire company-run units rather than only individuals.
Labels: Source-linked, Low, known
A 2012 internal FAA survey revealed that a substantial portion of Boeing authorized representatives perceived…
A 2012 internal FAA survey revealed that a substantial portion of Boeing authorized representatives perceived undue pressure from company management when executing delegated safety tasks.
Labels: Source-linked, Medium, known
The FAA Reauthorization Act of 2018 (P.L.
The FAA Reauthorization Act of 2018 (P.L. 115-254), enacted three weeks before the Lion Air crash, contained provisions pushing the FAA to increase delegations and restricted oversight of ODA holders.
Labels: Source-linked, Medium, known
GAO reports published between 2005 and 2015 repeatedly warned that the FAA lacked the staff, data, and risk-b…
GAO reports published between 2005 and 2015 repeatedly warned that the FAA lacked the staff, data, and risk-based oversight needed to monitor its expanding delegation and designee workload.
Labels: Source-linked, Low, known
Staffing shortages in the FAA's Boeing Aviation Safety Oversight Office hindered retained certification tasks…
Staffing shortages in the FAA's Boeing Aviation Safety Oversight Office hindered retained certification tasks and ODA oversight, with some engineers lacking experience in key MAX technologies.
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In November 2019, FAA Administrator Steve Dickson stripped Boeing's longstanding delegated authority by annou…
In November 2019, FAA Administrator Steve Dickson stripped Boeing's longstanding delegated authority by announcing the agency would individually issue airworthiness certificates for every newly built 737 MAX.
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The House Transportation Committee's September 2020 final report concluded the MAX crashes resulted from faul…
The House Transportation Committee's September 2020 final report concluded the MAX crashes resulted from faulty technical assumptions, lack of transparency, and grossly insufficient oversight by the FAA, leaving FAA engineers without basic knowledge of MCAS.
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A December 2020 Senate Commerce Committee report found FAA senior leadership may have obstructed a DOT OIG re…
A December 2020 Senate Commerce Committee report found FAA senior leadership may have obstructed a DOT OIG review of pilot reaction times and engaged in a coordinated effort with Boeing to manipulate MAX recertification.
Labels: Source-linked, High, known
DOT OIG found that the FAA and Boeing technically adhered to established certification processes, concluding…
DOT OIG found that the FAA and Boeing technically adhered to established certification processes, concluding that the blind spots regarding MCAS stemmed from systemic process weaknesses.
Labels: Source-linked, Medium, known
In June 2016, a Boeing authorized representative raised concerns about repetitive MCAS operation after a test…
In June 2016, a Boeing authorized representative raised concerns about repetitive MCAS operation after a test pilot had difficulty trimming against the system.
Labels: Inferred, High, known
The FAA delegated approval of the final corrected Enhanced Digital Flight Control System System Safety Analys…
The FAA delegated approval of the final corrected Enhanced Digital Flight Control System System Safety Analysis to Boeing in January 2017, only two months prior to 737 MAX certification.
Labels: Source-linked, High, known
The FAA renewed Boeing's ODA in 2015 during early 737 MAX development, despite the FAA's own oversight office…
The FAA renewed Boeing's ODA in 2015 during early 737 MAX development, despite the FAA's own oversight office having documented findings of undue management pressure.
Labels: Source-linked, High, known
Whistleblower disclosures to the Senate Commerce Committee documented that a 2016 FAA evaluation found pilots…
Whistleblower disclosures to the Senate Commerce Committee documented that a 2016 FAA evaluation found pilots took up to roughly 16 seconds to respond to MCAS activation, well exceeding the 4-second baseline assumption.
Labels: Source-linked, High, known
Mark Forkner was indicted in October 2021 as the only individual criminally charged over the MAX certificatio…
Mark Forkner was indicted in October 2021 as the only individual criminally charged over the MAX certification and was acquitted by a federal jury in March 2022.
Labels: Source-linked, Medium, known
Boeing technical pilot Mark Forkner messaged a colleague in November 2016 that MCAS was 'running rampant in t…
Boeing technical pilot Mark Forkner messaged a colleague in November 2016 that MCAS was 'running rampant in the sim,' an exchange withheld from the FAA's Aircraft Evaluation Group.
Labels: Source-linked, High, known
The FAA's Boeing Aviation Safety Oversight Office (BASOO) had only roughly 40–45 engineers assigned to overse…
The FAA's Boeing Aviation Safety Oversight Office (BASOO) had only roughly 40–45 engineers assigned to oversee Boeing's internal ODA unit of over 1,000 employees.
Labels: Source-linked, Medium, known
The FAA delegated the system safety assessment of the flight control system including MCAS to Boeing's ODA un…
The FAA delegated the system safety assessment of the flight control system including MCAS to Boeing's ODA unit, allowing Boeing employees to approve the safety classification permitting MCAS to rely on a single AOA sensor.
Labels: Source-linked, Medium, known
Certain FAA certification engineers and pilot-training approval personnel lacked adequate knowledge of MCAS a…
Certain FAA certification engineers and pilot-training approval personnel lacked adequate knowledge of MCAS activation triggers, system interactions, and repeated operation risks.
Labels: Source-linked, Medium, known
Boeing's original 2013 functional hazard assessment classified MCAS failure as 'major' and specified a 0.6-de…
Boeing's original 2013 functional hazard assessment classified MCAS failure as 'major' and specified a 0.6-degree stabilizer authority limit, which was later expanded to 2.5 degrees and repetitive activation without briefing FAA engineers.
Labels: Source-linked, Medium, known