波音737MAX空难调查报告（最终版）

1、ContentsReport HYPERLINK l _TOC_250001 Introduction 1 HYPERLINK l _TOC_250000 Executive Summary 4The Max Crashes Investigative Themes Investigative FindingsBoeing History and 737 MAX Background 34Merging Companies Changing Cultures Competitive PressureFrom Marketing Marvel to Financial Burden Certif

2、ying the 737 MAXChanged Product Rule Exceptions to the RuleEngine Indicating and Crew Alerting System (EICAS) Human FactorsA Holistic Review Process? Trouble from the StartBoeing-FAA Settlement AgreementFAAs Organization Designation Authorization ProgramFAA Oversight and Delegation of Authority 56De

3、legation Authority BackgroundODA Program Effectiveness and ConcernsBoeing Aviation Safety Oversight Office Concerns and IssuesConflicts of InterestCertification Process Affected by Mismanaged CommunicationsHistory of FAA Bias Favoring BoeingEffectiveness of Compliance and Enforcement ActionsManeuver

4、ing Characteristics Augmentation System 85New Larger Engines Resulted in Aerodynamic Instability in Critical SituationsWhat is Angle-of-Attack (AOA)?Boeing Rejected the Idea of an MCAS Indicator Light A Plan to Downplay MCASEffect of MCAS on Pilot Differences Training How MCAS was Presented to Regul

5、atorsFragmented Oversight of MCASMilitary MCAS vs. Commercial 737 MAX MCAS Redesigning MCASCommunication IssuesMCAS was Vulnerable to Single AOA Sensor Failure Squawk and Repetitive MCAS ActivationFaulty Assumptions, Fatal Timing Catastrophic Consequences737 MAX Chief Project Engineer Approved MCAS

6、Without Fully Understanding ItPilots Uninformed About MCAS, References RemovedMCAS Did Not Meet Its Own Design RequirementsAOA Disagree Alert 122Angle of Attack (AOA) Disagree Alert and AOA IndicatorHow the AOA Disagree Alert Became Non-Functioning on the 737 MAXDiscovering the Non-Functioning AOA D

7、isagree Alert Boeings Lack of Transparency Regarding the AOADisagree AlertA Missed Opportunity with Lion AirA Missed Opportunity at Xtra AerospaceAt Least Three Missed Opportunities to Catch Faulty AOA SensorCulture of OmissionBoeing 737 MAX Pilot Training 138Faulty AssumptionsDesign Objective: 737

8、MAX Level B Training Marketing the MAXGambling on Level BLevel B Implications to MCAS and other MAX Systems Pushing Back on Level BSafety and CommonalityBoeing Will Not Allow That to Happen Pressuring Airlines737 MAX Simulator Discrepancy Reports and Schedule PressureReverse CourseProduction Pressur

9、e 163737 MAX Production Line Countdown Clock Synthetic AirspeedLoss of ControlThe Renton Plant Production LineProduction PressureNo Slowing Down Production Goes On Renton ReviewUndue Influence Pressure 2016 SurveyPost-Accident Response 189Post-Accident ResponseThe Pilot Response Blame Game The Start

10、le EffectFAAs Emergency Airworthiness Directive Predicting ProblemsOmitting MCASBoeing Multi Operator Message (MOM) MCAS Pilot BlowbackA 10-Second “Catastrophic” MCAS Test Scenario by Boeings Own Test PilotRed FlagsRisk Analysis: Gambling with the Publics Safety Analyzing the TARAM AnalysisTARAM Ris

11、k Analysis: Who Knew?The BASOOs Post-Lion Air MCAS System Oversight ReportGrounding the 737 MAXNew Issues Emerge 222New IssuesFinal Observations 228Observations on BoeingObservations on the Federal Aviation Administration (FAA)Improving Safety CulturesFAAs Cooperation with the Committee Time for a C

12、ulture ChangeDo Things Right and Do the Right Thing The Once Great Engineering FirmFiguresManeuvering Characteristics Augmentation System (MCAS) Timeline100Angle of Attack (AOA) Disagree Alert Timeline129Related DocumentsTranscripts of the transcribed interviews and otherdocuments referenced in this

13、 report can be accessed here: HYPERLINK /committee-activity/boeing-737-max-investigation /committee- HYPERLINK /committee-activity/boeing-737-max-investigation activity/boeing-737-max-investigationReferences to Senior Boeing OfficialsDuring design, development, and certification of the 737 MAX, the

14、following individuals held senior positions at Boeing and are referred to in Boeing documents that are linked to this report by their titles.Keith Leverkuhn served as Vice President (VP) and General Manager (GM) of the 737 MAX Program from April 2013 to April 2018. In Boeing documents, references to

15、 “Former 737 MAX VP/GM” are references to Mr. Leverkuhn.Michael Teal served as Vice President and 737 Chief Project Engineer from August 2011 to March 2017. In Boeing documents, references to “Former 737 MAX Chief Project Engineer” are references to Mr. Teal.Mark Forkner served as 737 Technical Pilo

16、t from 2011 to 2015 and as 737 Chief Technical Pilot from 2015 until 2018 when he left Boeing to work at Southwest Airlines. In Boeing documents, references to “Former 737 Chief Technical Pilot” are references to Mr. Forkner.Elizabeth “Beth” Pasztor served as Vice President (VP) of Boeing Commercial

17、 Airplanes (BCA) Safety, Security and Compliance and in this role was the ODA Lead Administrator. In Fall 2019, Ms. Pasztor became Vice President and General Manager of Product & Services Safety. In Boeing documents, references to “VP BCA Safety, Security and Compliance” are references to Ms. Paszto

18、r.Abbreviations737 NGAAR ACO AD AEGAFSCMEAIA AIR AR APA ATC ATP AVSBoeing 737 Next Generation Airplane Airplane Assessment ReportAircraft Certification Office Airworthiness Directive Aircraft Evaluation GroupAmerican Federation of State, County and Municipal EmployeesAerospace Industries Association

19、 Aircraft Certification Service Authorized RepresentativeAllied Pilots Association Amended Type Certificate Airline Transport Pilot Aviation Safety Organization BASOOBoeing Aviation Safety Oversight OfficeBCA CARB CAS CBT CEO DER DOT DR EASA EBAW ECS EDFCS EICAS EU FAA FBW FCC FCOM FSB FTD GAO GM IE

20、EE IPTISS JATR LAM LGW MCAS MOM NASA NATCA NNC NTSB ODA OIG OMB PASS PSSA QFR RCASR-TARA SCD SME SSA STC STSBoeing Commercial Airplanes Corrective Action Review Board Commercial Aviation Services Computer Based TrainingChief Executive OfficerDesignated Engineering Representative Department of Transp

21、ortation Deficiency ReportEuropean Union Aviation Safety Agency Enhanced Bank Angle Warning Environmental Control System Enhanced Digital Flight Control SystemEngine Indicating and Crew Alerting System European UnionFederal Aviation Administration Fly-by-wireFlight Control ComputerFlight Crew Operat

22、ions Manual Flight Standardization Board Fleet Team DigestGovernment Accountability Office General ManagerInstitute of Electrical and Electronics Engineers Integrated Product TeamInternational Space StationJoint Authorities Technical Review Landing Attitude Modifier London Gatwick AirportManeuvering

23、 Characteristics Augmentation System Multi Operator MessageNational Aeronautics and Space Administration National Air Traffic Controllers Association Non-normal ChecklistNational Transportation Safety Board Organization Designation Authorization Office of Inspector GeneralOperations Manual Bulletin

24、Professional Aviation Safety Specialists Preliminary System Safety Assessment Questions for the RecordRoll Command Alerting SystemRandom Transport Airplane Risk Analysis Specification Control DrawingSubject Matter ExpertSystem Description and Safety Analysis Supplemental Type CertificateSpeed Trim S

25、ystemSWA TARAM TCBI TIAVPSouthwest AirlinesTransport Airplane Risk Assessment Methodology Tutorial Computer-Based InstructionType Inspection Authorization Vice PresidentIntroduction-Introduction-On the evening of March 9, 2019, Paul Njoroge was up late, tracking a flight from Toronto, Canada to Addi

26、s Ababa, Ethiopia. It was the first leg of his familys journey to visit relatives in Kenya for what was to be the trip of their lifetimes. After his family arrived safely at their layover in Addis Ababa, Mr. Njoroge went to bed, expecting to check in again the next day.As he slept, his wife Carolyne

27、, their three children6-year-old Ryan, 4-year-old Kelli, and 9- month-old Rubiand his mother-in-law, Ann, continued their journey by boarding Ethiopian Airlines flight 302 from Addis Ababa, Ethiopia, to Nairobi, Kenya. It was a crystal-clear day, but within minutes of take-off the unthinkable happen

28、ed: the Boeing 737 MAX, a brand new aircraft with 157 passengers and crew members on board, began to dive back towards the ground as the pilots fought to force the planes nose back up toward the sky. The battle did not last long. Six minutes after take-off, Ethiopian Airlines flight 302 crashed. The

29、 jets impact left a massive crater in a field just a few miles from the airport. Not a single soul survived.Over one year later, Mr. Njoroge testified before the U.S. House Committee on Transportation and Infrastructure that he is still haunted by the image of his young childrens final moments. “I h

30、ave nightmares about how they must have clung to their mother, crying, seeing the fright in her eyes as they sat there helplessly. And there was nothing I could do to save them,” he said. “I miss their laughter, their playfulness, their touch.”Mr. Njoroge would soon learn that his family members wer

31、e the victims of not the first, but the second Boeing 737 MAX aircraft that was involved in a catastrophic, fatal crash killing everyone on boardan extraordinary fact given the significant advances in aviation safety over the last two decades, and the fact that the 737 MAX was a newly certified airc

32、raft.The story of the Boeing 737 MAX was never expected to be associated with catastrophe. It was supposed to be a story of American ingenuity and technological successa modern, more fuel- efficient airplane that had already become the manufacturing giants best-selling jet in its storied history pri

33、or to the first MAX crash of Lion Air flight 610 in Indonesia on October 28, 2018.Ethiopian Airlines flight 302 crashed on March 10, 2019, just two years and two days after the Federal Aviation Administration (FAA) had certified the new 737 derivative aircraft as safe to fly. Clearly it was not.The

34、Boeing 737 MAX is now the subject of multiple investigations and lawsuits around the world and will be forever associated with the tragic deaths of 346 people killed in two separate crashes within five months of each other, as well as one rescue diver who died attempting to recover bodies from the L

35、ion Air crash in the Java Sea.This report concludes the U.S. House Committee on Transportation and Infrastructures 18- month long investigation of the design, development, and certification of the 737 MAX aircraft, and related matters. The Committees investigation has revealed multiple missed opport

36、unities that could have turned the trajectory of the MAXs design and development toward a safer course due to flawed technical design criteria, faulty assumptions about pilot response times, and production pressures. The FAA also missed its own opportunities to change the direction of the 737 MAX ba

37、sed on its aviation safety mission. Boeing failed in its design and development of the MAX, and the FAA failed in its oversight of Boeing and its certification of the aircraft.At the direction of Committee Chair Peter DeFazio and Subcommittee on Aviation Chair Rick Larsen, this report is being relea

38、sed to help inform the publics understanding of what went so horrifically wrong and why. Despite the sweeping and substantive problems that have been identified by this Committees investigation as well as various other investigations, both Boeing and the FAA have suggested that the certification of

39、the 737 MAX was compliant with FAA regulations. The fact that a compliant airplane suffered from two deadly crashes in less than five months is clear evidence that the current regulatory system is fundamentally flawed and needs to be repaired.Executive Summary-Executive Summary-Technical design flaw

40、s, faulty assumptions about pilot responses, and management failures by both The Boeing Company (Boeing) and the Federal Aviation Administration (FAA) played instrumental and causative roles in the chain of errors that led to the crashes of Lion Air flight 610 in October 2018, HYPERLINK l _bookmark0

41、 1 and Ethiopian Airlines flight 302 in March 2019, HYPERLINK l _bookmark1 2 that resulted in the tragic and preventable deaths of 346 people. Both crashes involved Boeing 737 MAX airplanes.On March 8, 2017, the FAA granted an amended type certificate to Boeing for the 737-8 aircraft, the first of t

42、he 737 MAX family. HYPERLINK l _bookmark2 3 The MAX is the 4th generation 737 model airplane HYPERLINK l _bookmark3 4 and is the successor to the companys 737 Next Generation (NG) family of aircraft. HYPERLINK l _bookmark4 5 The 737 MAX was the 12th derivative model of the 737 aircraft, HYPERLINK l

43、_bookmark5 6 which was first certified half a century earlier in 1967. HYPERLINK l _bookmark6 7 In May 2017, the 737 MAX first entered revenue passenger service with Malindo Air, a Malaysian air carrier, two months after its FAA certification. HYPERLINK l _bookmark7 8 Seventeen months later the 737

44、MAX suffered its first fatal crash. HYPERLINK l _bookmark8 9On October 29, 2018, Lion Air flight 610 flying from SoekarnoHatta International Airport in Jakarta, Indonesia, to Depati Amir Airport in Pangkal Pinang, Indonesia, crashed into the Java Sea 13 minutes after takeoff, killing all 189 passeng

45、ers and crew. HYPERLINK l _bookmark9 10 One Indonesian rescue diver also died1 Barbara S. Peterson, “How Could a Brand New Boeing Jet Crash Without Warning?,” Popular Mechanics, October 31, 2018, accessed here: HYPERLINK /flight/airlines/a24405573/indonesia-boeing-737-max-jet-crash/ /flight/airlines

46、/a24405573/indonesia-boeing-737-max-jet- HYPERLINK /flight/airlines/a24405573/indonesia-boeing-737-max-jet-crash/ crash2 Hadra Ahmed, Norimitsu Onishi, Dionne Searcey and Hannah Beech, “Ethiopian Airlines Plane Is the 2nd Boeing Max 8 to Crash in Months,” New York Times, March 10, 2019, accessed her

47、e: HYPERLINK /2019/03/10/world/africa/ethiopian-airlines-plane-crash.html /2019/03/10/world/africa/ethiopian-airlines-plane-crash.html3 “Type Certificate Data Sheet A16WE,” Federal Aviation Administration, Department of Transportation, March 8, 2017, accessed here: HYPERLINK /Regulatory_and_Guidance

48、_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/%24FILE/A16WE_Rev_58.pdf /Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/$FI HYPERLINK /Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/%24FILE/A16WE_Rev_58.pdf LE/A16WE

49、_Rev_58.pdf4 “Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8 Aircraft and Actions Taken After the October 2018 Lion Air Accident,” Office of Inspector General (OIG), Department of Transportation (DOT), Report No. AV2020037, June 29, 2020, p. 5, accessed here: HYPERLINK /

50、sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%20Timeline%20Final%20Report.pdf /sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification% HYPERLINK /sites/default/files/FAA%20Oversight%20of%20Boeing%20737%20MAX%20Certification%20Timeline%20Final%20

51、Report.pdf 20Timeline%20Final%20Report.pdf5 “Type Certificate Data Sheet A16WE,” Federal Aviation Administration, Department of Transportation, March 8, 2017, accessed here: HYPERLINK /Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/%24FILE/A16WE_Rev_58.pdf /Regula

52、tory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/$FI HYPERLINK /Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/%24FILE/A16WE_Rev_58.pdf LE/A16WE_Rev_58.pdf6 The 737 MAX was the 12th “derivative” of the original 737-100 aircraft certifie

53、d in 1967, making it the 13th 737 model produced by Boeing. See: “Type Certificate Data Sheet A16WE,” Federal Aviation Administration, Department of Transportation, March 8, 2017, accessed here: HYPERLINK /Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/%24FILE/A16

54、WE_Rev_58.pdf /Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/$FI HYPERLINK /Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/0970d54d00efbb9a862580de006a83cc/%24FILE/A16WE_Rev_58.pdf LE/A16WE_Rev_58.pdf7 Ibid.8 Firdaus Hashim, “Malindo operates worlds first 737

55、Max flight,” FlightGlobal, May 22, 2017, accessed here: HYPERLINK /orders-and-deliveries/malindo-operates-worlds-first-737-max-flight/124109.article /orders-and-deliveries/malindo-operates-worlds-first-737-max-flight/124109.article9 James Griffiths, Steve George, Kathy Quiano and Helen Regan, “Lion

56、Air crash: Indonesia to inspect all Boeing 737 Max 8 planes,” CNN, November 1, 2018, accessed here: HYPERLINK /2018/10/30/asia/lion-air-plane-crash-intl/index.html /2018/10/30/asia/lion-air-plane-crash- HYPERLINK /2018/10/30/asia/lion-air-plane-crash-intl/index.html intl/index.html10 “Final KNKT.4 A

57、ircraft Accident Investigation Report, PT. Lion Mentari Airlines, Boeing 737-8 (MAX); PKLQP, Tanjung Karawang, West Java, Republic of Indonesia, 29 October 2018,” Komite Nasional Keselamatan Transportasi (KNKT), Republic of Indonesia, issued October 25, 2019, pp. 19-27 (hereafter referred to as: “Li

58、on Airduring recovery efforts. HYPERLINK l _bookmark10 11 Less than five months later, on March 10, 2019, in strikingly similar circumstances, Ethiopian Airlines flight 302 crashed six minutes after takeoff on a flight from Addis Ababa, Ethiopia, to Nairobi, Kenya, killing all 157 passengers and cre

59、w, including eight U.S. citizens. HYPERLINK l _bookmark11 12In March 2019, within days of the crash of Ethiopian Airlines flight 302, the House Committee on Transportation and Infrastructure (Committee), under the leadership of Chair PeterA. DeFazio and Subcommittee on Aviation Chair Rick Larsen, la

60、unched an investigation into the design, development, and certification of the 737 MAX aircraft and related matters that led to these crashes. HYPERLINK l _bookmark12 13 Since then, the Committee has held five hearings on issues related to the 737 MAX program; HYPERLINK l _bookmark13 14 written 23 o