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The FAA released its final report on findings and recommendations from an expert panel on Boeing's safety culture on Monday, claiming there was a disconnect between senior management and other members of the organization on safety culture. Interviewees and Organization Designation Authorization Unit Members questioned whether the Boeing safety culture reporting systems would function in such a way that it enabled open communication and non-retaliation.
The ODA Expert Review Panel convened on March 1, 2023 to review Boeing's safety management processes and their effectiveness for each holder of an ODA for the design and production of transport planes. The safety review panel was formed under the Aircraft Certification, Safety and Accountability Act, which was passed in 2020 to propose changes to FAA airplane certification in the wake of two deadly Boeing 737 MAX crashes. The Act required the panel to make recommendations after its review, suggesting actions to address the deficiencies found after a thorough review. The expert panel found the recommendations for Boeing and the FAA were consistent with the requirements of the act and with the public interest of aviation safety.Read the full report and its findings and recommendations here
Following the review the panel identified 27 findings and 53 associated recommendations. These findings and recommendations are based on the panel members' expertise and a review of over 4,000 pages of Boeing documents, seven surveys, over 250 interviews and meetings with Boeing employees across six company locations. The panelists observed a disconnect between Boeing's senior management and the other members of the organization. The panel often observed "inadequate and confusing implementation of the five components of a positive safety culture." The five components include reporting culture, just culture, flexible culture, learning culture and informed culture.RELATED STORIES:FAA adopts strict new policy on aircraft design changes in wake of deadly Boeing 737 MAX crashesBoeing CEO admits 'mistake' as FAA launches safety probeFAA to keep close watch on Boeing, limit its self-regulation capabilitiesBoeing's head of 737 MAX program is leaving, other leadership changes
The panel also found that Boeing's Safety Management System procedures reflect the ICAO and FAA SMS frameworks, but the Boeing SMS procedures have not been structured in a way that will ensure all employees understand their role in the company's SMS. The panel found that these procedures and the training are complex and in a constant state of change, which can confuse employees, especially across different work sites and employee groups. A lack of awareness of safety-related metrics was observed at all levels of the organization and employees struggled to distinguish the differences among the different measuring methods, their purposes and outcomes.
Boeing's restructuring of the ODA unit management decreased the opportunities for interference and retaliation against UMs, providing an effective organizational message for the independence of UMs. The panel said that the restructuring was an improvement but still allowed for possible retaliation to occur, particularly relating to salary and furlough ranking. This could influence the UM's ability to execute their respective functions effectively. The expert panel also noted other issues at Boeing that could impact aviation safety, including inadequate human factors and a lack of pilot input in aircraft design and operation.A figure representing SMS from the final report
The panel was not directed to investigate specific crashes or incidents, like the 737 MAX crashes in 2018 and 2019 that killed 346 individuals or the January depressurization incident where a door plug was blown off midflight. The final report notes that during the panel's work there were several occasions where serious quality issues with Boeing products became public, amplifying concerns at safety-related messages or behaviors were not being implemented across the entire Boeing population. After being thrown into the public eye again after the January depressurization incident, Boeing has maintained transparency in its changes to the manufacturing process and stricter oversight, including hosting a company-wide stand-down and shifting leadership. Within six months Boeing is expected to review the recommendations included in the report and develop an action plan to include a milestone-based approach that comprehensively addresses each recommendation. Boeing is expected to then share the plan, including implementation dates, with the FAA. The FAA published the final report, noting that it will continue holding Boeing to the highest standard of safety, working to ensure the company comprehensively addresses the recommendations.