Maria Cantwell Leads Senate Commerce Committee Hearing On FAA ODA Expert Panel Report

4/19/2024

On Wednesday, the Senate Commerce Committee held a hearing about the FAA Organization Designation Authorization (ODA) Expert Panel Report.

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Transcript

00:00:00 The Committee on Commerce Science and Transportation will come to order. I want to thank our witnesses who are here today on

00:00:07 the FAA

00:00:09 ODA

00:00:12 Organization

00:00:13 Expert Panel Report. I also want to recognize our former colleague

00:00:18 Peter Defazio is in the audience and thank him for his work on the angst of legislation

00:00:23 With this committee. Today we will hear from three experts on the organization design

00:00:29 authorization and the expert panels final report. I want to mention I

00:00:34 Appreciate the witnesses being here today, but I want to acknowledge this is directly from the

00:00:39 report

00:00:41 That quote the successful completion of this report was made possible with the cooperation and assistance of the following organizations the Federal

00:00:49 Aviation Administration the Boeing Company American Airlines Bell Textron Inc University of Southern, California

00:00:57 Viterbi School of Engineering and

00:01:00 Special thanks to Brittany Goodwin, Mina Mitchell and Heather Thorson analysis supported by data and assessment teams

00:01:07 Within the office of FAA's ODA. I want to mention that because you're the representatives of all of those people today and we could have had

00:01:15 many people here

00:01:17 But wanted to appreciate the work of the two chairs of the committee and for you being here as representatives of these individuals today

00:01:25 We are joined by Dr. Javier DeLuise

00:01:28 lecturer of MIT's School of Technology Department of Aeronautics and

00:01:34 Astronautics. Thank you so much for being here. Dr. Tracy Dillinger manager for safety culture of human factors at NASA and

00:01:41 Dr. Namedin

00:01:46 Mishkati

00:01:48 Professor of University of Southern California School of Engineering and Aviation Safety Programs

00:01:52 The expert panels 53 recommendations regarding Boeing's ODA safety management system safety culture

00:01:59 serves as an important catalyst for us in future aviation legislation

00:02:03 while we've made some safety improvements through the air certification reform law and

00:02:08 Some of that is still playing out with a new administrator who I think is more aggressively taking the responsibilities of the act

00:02:15 Seriously, we look to build on those advancements with a five-year authorization bill and some enhanced safety features

00:02:22 But we're not going to stop there. There's more to be done to implement the recommendations from your report

00:02:28 We owe a debt of gratitude to those who are here today. I want to

00:02:34 Especially thank you

00:02:38 Dr. DeLuise, thank you so much for being here. I can't imagine

00:02:42 The tragedy of losing your sister in one of the max crashes and then continuing to be involved in trying to

00:02:52 Correct and improve our safety culture

00:02:54 But I can just say I so appreciate you being here in the active role that you have played in all of these discussions

00:03:01 The expert panels final report focused on the importance of safety management systems

00:03:06 and while Boeing was required to adopt an SMS in

00:03:09 2015 as part of an FAA settlement agreement and while the FAA later adopted

00:03:17 Voluntary SMS programs the experts panels report make it clear now that we need a real SMS with teeth

00:03:24 Both Boeing and the FAA need strong and effective safety management systems not in name

00:03:31 but in reality

00:03:33 safety management system might for the public sound like

00:03:36 Management strategies that maybe they shouldn't pay attention to but when it comes to this management strategy and it revolves around

00:03:46 Aviation it is about saving lives

00:03:48 That is why section 102 of

00:03:51 ANCSA

00:03:53 required that the FAA develop a real SMS standard for aviation manufacturers and the

00:03:59 A and the agency expects the FAA's expects to finalize that SMS rule this June

00:04:05 This expert panel made several recommendations

00:04:08 findings about the safety culture and about ODA and I want to highlight some that Boeing safety management procedures

00:04:16 Are not thoroughly understood throughout the company. I'm sure you'll expand on this that it is focused

00:04:22 on

00:04:23 Only one of the four pillars of what ICAO the international standard has said that you have to meet if you're going to have an SMS

00:04:32 program

00:04:33 Understood by the workforce writ large

00:04:35 I'm sure you'll expound on this the expert panel raised concerns about the FAA's ability to effectively oversee Boeing's

00:04:42 SMS and I believe the FAA needs not only a strong workforce

00:04:46 Strategy to exercise the oversight of the manufacturers to ensure proper implementation of SMS

00:04:53 I'd like to query the panel today on exactly what SMS the

00:04:58 FAA should implement in their own house to make sure that they are

00:05:02 Improving the safety culture and standing up on these important safety measures

00:05:07 right now

00:05:11 We are relying on employee safety reporting systems speak up which you talked about and I think the

00:05:18 comprehensive system that the employees know and understand has to be a key component of SMS and

00:05:24 documentation provided by the interviews of Boeing employees showed that they

00:05:29 May not have understood how safety fit into the culture of the overall

00:05:37 obligations of the company. Human factors have not been prioritized as a technical discipline and

00:05:44 Human factors are at the core of focus of what we need to do both at the FAA and at Boeing

00:05:50 While I think you did talk about the loss of experience and capability of a workforce

00:05:55 We definitely want to build that expertise throughout

00:05:59 Government clearly at the FAA so that they can keep pace with technological change

00:06:04 And while the restructuring of Boeing's ODA unit

00:06:08 Did decrease the opportunity as your report is saying for retaliation

00:06:14 We still are seeing that interference is occurring. This is unacceptable

00:06:20 ANCSA strengthened

00:06:22 The FAA's oversight and put them in charge of these employees and we certainly expect the FAA to back up those

00:06:30 Individual engineers and machinists who are calling out safety and making sure that they address those

00:06:35 Although the final report gave Boeing six months to make this action plan a reality the expert panels recommendations

00:06:42 The FAA administrator has cut this time to 90 days

00:06:45 And I expect the company to comply with this deadline and submit a serious plan that

00:06:51 Demonstrates this commitment to these kind of safety measures

00:06:54 The FAA must also demonstrate that it is going to be a strong regulator on these issues

00:07:00 I hope to query the panel about how to ensure that how we as the oversight committee of the FAA and

00:07:06 Strength basically strengthen this oversight by the FAA. So I look forward to hearing from our witnesses today again

00:07:14 Thank you so much for being here. And now I turn to Senator Cruz for his opening remark and then we'll hear from our two

00:07:19 Subcommittee colleagues on their statement as well. Senator Cruz

00:07:24 Thank You Madam Chair

00:07:26 The United States sets the benchmark for flight safety and by arguably the most important measure

00:07:32 2023 was a remarkably safe year for aviation with no fatal accidents or hull losses for commercial jet aircraft

00:07:42 Flying commercial remains the safest way to travel

00:07:46 But understandably recent incidents have left the flying public worried

00:07:53 The perception is things are getting worse

00:07:55 The public wants the Federal Aviation Administration and Congress to confront perceived risks in order to restore

00:08:03 confidence for flyers

00:08:05 That brings me to the topic of today's hearings the FAA's

00:08:09 organization designation authorization program

00:08:12 ODA is

00:08:15 Important to the future of aviation safety as well as to American competitiveness. I

00:08:22 Appreciate the work of our congressionally appointed expert panel which reviewed Boeing's ODA for transport airplanes

00:08:29 Congress established this panel in the aftermath of the tragic crashes of Lion Air Flight 610 in 2018 and

00:08:37 Ethiopian Airlines Flight 302 in 2019 in which

00:08:42 346 people tragically lost their lives

00:08:47 The panel's final report was released in February and three of its members are here with us today

00:08:52 Welcome

00:08:54 As a brief aside, I want to in particular acknowledge that one of our witnesses

00:08:59 Dr. Javier de Luis lost his sister on flight 302

00:09:04 Dr. De Luis, please accept my sincere condolences and

00:09:09 Thank you for continuing to speak out on an issue that I know has grieved you and your family personally

00:09:17 I also want to recognize the other families that are here today

00:09:21 Remembering their loved ones whose lives were lost on those two tragic accidents

00:09:26 Discussing ODA and what changes may be needed is critical and I welcome this conversation

00:09:34 It is worth noting

00:09:36 However that the FAA is still implementing the aircraft certification safety and accountability act

00:09:41 This committee's response to the max-8 crashes crashes

00:09:46 It has not even been fully it is not even fully implemented the 2018 FAA authorization act

00:09:52 Even as we are currently

00:09:55 negotiating the current reauthorization

00:09:57 While it is clear that Boeing's culture and safety management

00:10:02 needs drastic improvement

00:10:04 We should not rush to legislate just for the sake of legislating

00:10:09 to that point I look forward to engaging with today's witnesses all of whom deserve our appreciation and

00:10:16 Thanks for their hard work on this effort

00:10:18 Their report was a consensus product

00:10:20 issued without any dissenting views

00:10:23 Which all of us in Congress can appreciate is no small accomplishment

00:10:28 And I hope to better understand their recommendations and how Congress can work to improve

00:10:33 aviation safety in a targeted and effective manner

00:10:37 While discussing ODA and Boeing safety culture is important

00:10:42 The flying public is also acutely worried about why pieces of Boeing airplanes are falling from the sky

00:10:49 The experts panel report specifically noted that the panel was not directed to investigate or provide

00:10:56 recommendations towards specific airplane incidents or accidents

00:11:01 Which occurred prior to or during the expert panels work?

00:11:05 In addition to today's hearing I believe we also need to hear from the FAA and

00:11:11 from Boeing itself

00:11:13 about episodes like Alaska Airlines flight 1282

00:11:17 Our committee needs to understand not only Boeing's ODAs

00:11:22 but the specific production missteps that caused the January incident and

00:11:27 we need to hear from Boeing directly about the company's safety culture and

00:11:32 safety management writ large

00:11:35 The public will want to know what changes Boeing is making to restore confidence in its brand

00:11:42 Boeing is a great American company with a great history and great legacy. We all want Boeing to be successful

00:11:49 But when accountability is needed and it clearly is here

00:11:53 We should not hesitate to demand answers and

00:11:58 for Boeing to succeed going forward

00:12:01 Those answers need to be given and changes need to be made

00:12:07 To ensure that safety is central

00:12:11 When each of us when our families when our children's get on an airplane

00:12:16 We want to trust that we're gonna land safely

00:12:21 That's the topic of this hearing and I hope subsequent hearings as well. Thank you. Thank you. Senator Cruz senator Duckworth

00:12:29 Thank You chairwoman Cantwell for holding this hearing and for your commitment to continued oversight

00:12:35 I also want to thank our witnesses and all those who worked on the expert panel review

00:12:40 This review confirms my view that we need to judge Boeing not by what it

00:12:45 That we need to judge Boeing by what it does not by what it says it's doing

00:12:49 Boeing says it prioritizes safety above all else

00:12:52 But when the expert panel asked Boeing to produce evidence of this commitment the evidence that Boeing provided and I quote

00:13:00 Did not provide objective evidence of a foundational commitment to safety that matched Boeing's descriptions of that objective end quote

00:13:06 That should be shocking but based on some of Boeing's recent actions, frankly, it's not

00:13:12 Weeks after a door plug blew out of a 737 max 9

00:13:16 Boeing was still petitioning the FAA for a safety exemption to rush its next 737 max variant into service

00:13:23 Despite the fact that it had no it had a known potentially catastrophic safety defect

00:13:29 To its credit under pressure Boeing eventually withdrew that petition

00:13:34 but the fact that Boeing filed it in the first place speaks volumes about the lack of a proper safety culture at Boeing and

00:13:41 Until recently the lack of a proper regulatory culture at the FAA

00:13:45 Boeing filed this petition because they thought FAA would grant it

00:13:49 Boeing thought they could minimize the significance of this safety defect and that the FAA would just let it slide

00:13:55 Boeing had a good reason to think this

00:13:58 FAA let Boeing's bad actions on the 737 max slide for years and go figure we're seeing more bad results

00:14:06 I'll give two examples which I think are particularly relevant to our discussion today about Boeing's organization designation

00:14:14 Authorization or the ODA the first example involves MCAS

00:14:18 Boeing downplayed MCAS so successfully it actually persuaded the FAA to let Boeing remove it from the flight manual and

00:14:27 after MCAS

00:14:28 crashed two 737 max planes killing

00:14:31 346 people

00:14:34 investigators uncovered an internal Boeing memo

00:14:36 Showing that Boeing had been explicitly planning to downplay MCAS in order to avoid regulatory scrutiny

00:14:43 The plan called for Boeing to not even use the term MCAS when describing the plane to a regulator

00:14:50 Even worse the memo showed an ODA unit member approved this plan to deceive a regulator

00:14:57 And yet when this memo surface the FAA did

00:15:00 Nothing it did not even investigate by sitting on its hands FAA effectively told Boeing that this type of conduct was

00:15:08 Perfectly fine the second example concerns the angle of attack disagree alert the AOA disagree alert

00:15:14 Shortly after the 737 max 8 went into service Boeing discovered that the AOA

00:15:20 disagree alert was not functioning on most of the 737 max jets which was a violation of the planes approved type design

00:15:28 Instead of reporting this to the FAA and to 737 max pilots

00:15:33 Boeing intentionally concealed this and continued to manufacture more than more 737 max jets with the same defects

00:15:40 In other words Boeing made a decision to knowingly and repeatedly

00:15:44 Violate its approved type design for years

00:15:48 Boeing's ODA knew about this but did not alert the FAA and when FAA finally found out that

00:15:54 Boeing had been knowingly and repeatedly violating its approved type design the FAA did

00:16:00 Nothing this effectively told Boeing that type design doesn't matter because the FAA isn't going to always enforce it

00:16:08 When the FAA fails to take action in response to bad behavior

00:16:13 It sends an unmistakable message to both Boeing and its employees that bad behavior is acceptable

00:16:18 No wonder the expert panel found that Boeing employees are so confused

00:16:22 FAA needs to more closely scrutinize Boeing's behavior and make use of its civil enforcement authority when appropriate

00:16:29 And I am pleased by the more aggressive regulatory tone administrator Whitaker has brought to the agency

00:16:35 But as this expert panel review makes clear there is still a long way to go to bring an effective safety culture back to Boeing

00:16:43 We have our work cut out for us on this committee as we continue our oversight and consider whether additional

00:16:48 Legislation may be needed and I thank the panelists for being here

00:16:51 I really appreciate your hard work on this to make flying safer for the American people. Thank you and I yield back Madam Chair

00:16:57 Thank you so much. Senator Duckworth and for your leadership and your help on the

00:17:02 FAA reauthorization and safety improvements in that bill. I guess Senator Moran will not be here for an opening statement

00:17:09 I'm sure he will be attending but we'll now just go to the witnesses. So dr. DeLuis again

00:17:14 Thank you so much for being here. You're free to make an opening statement

00:17:18 Thank you very much senator

00:17:22 Chair Cantwell ranking member Cruz and members of the committee on behalf of myself and my fellow panelists

00:17:28 I want to thank you for the opportunity to come here and talk about our findings and recommendations from the final report

00:17:33 My name as you know is Javier DeLuis. I'm an aerospace engineer. So I would describe myself

00:17:38 I'm Aaron the doctorate from in aeronautics and astronautics from MIT

00:17:42 I spent my 40 year career in private industry mostly running small businesses

00:17:46 That I helped start then we built hardware for NASA DOD and other agencies

00:17:51 I'm currently a lecturer at MIT

00:17:53 But I'm also the brother of Graciela that we says you have noted and my sister was killed when the airplane

00:17:59 She was on the 737 max crashed a few minutes after takeoff killing all 157 people on board

00:18:07 So for me serving on this panel has been an opportunity to help prevent anyone else from going through what I and my family

00:18:14 Have sadly experienced these past five years

00:18:16 Our panel met for almost a year reviewed over 4,000 pages documents provided to us by Boeing

00:18:23 interviewed 250 Boeing employees at all levels of the organization from the executive suite down to the

00:18:30 People that tighten the bolts across six different geographic plants

00:18:35 Across the country and we reviewed thousands of survey responses

00:18:39 That came to us through several surveys that we could that were conducted as has been noticed

00:18:45 This is a consensus report and I'd be remiss if I did not give full credit to this to our coach

00:18:51 Oh co-chairs Michael Bartrand and Keith Morgan

00:18:54 For hurting what was at time this diverse and rather unruly group to hopefully a productive end

00:19:00 Our channel with our panel was charged by AXA

00:19:04 To focus its review on three specific topics the safety culture

00:19:08 The safety management systems and the ODA program at Boeing

00:19:13 We were however also allowed to evaluate other topics of concern that we might identify that would impact the safety of the flying public

00:19:20 As senator Cruz noted we were not charged or I'm sorry when it was noticed previously

00:19:26 We were not charged with investigating specific airplane incidents that occurred prior to our panels

00:19:32 But it was as you as understandable on several occasions during our activities when it safety issues

00:19:38 Arose with Boeing products. We of course considered them

00:19:41 My fellow witnesses and I felt that it would be useful to expand on several of the key

00:19:46 Recommendations in our report as this may help the stage for today's set the stage for today's hearing

00:19:51 first and foremost is one that has been talked about since the report came out is our finding that there exists a

00:19:59 disconnect for lack of a better word between the words that are being

00:20:03 Said by Boeing management and what is being seen and experienced by employees across the company

00:20:11 They hear safety is our number one priority

00:20:14 But what they see is that that's only true as long as your production milestones are met and at that point

00:20:20 It's pushing out the door as fast you can

00:20:22 They hear speak up if you see anything, that's unsafe

00:20:27 But what they see is that if they do speak up

00:20:29 They get very little feedback

00:20:32 and if they insist they may find themselves in the short end of the stick next time raises or bonuses or

00:20:39 Our job transfers come up or even worse

00:20:42 We found this disconnect to be present at almost all levels and at all work sites that we visited

00:20:48 We heard it from technicians. We heard it from engineers and we heard it more concerning from members of the ODA

00:20:55 That are delegated by the FAA to conduct inspections and tests on behalf of the government

00:21:00 To me it is clear that the commitment to change

00:21:04 the level of change and the pace of change at Boeing is

00:21:09 Not commensurate with the events that created the need for all this change in the first place

00:21:14 Namely the two fatal crashes of two brand new airplanes five years ago

00:21:19 it was

00:21:21 distressing to read a recent statement by

00:21:25 Brian West the CFO of Boeing

00:21:27 Speaking about the Alaska air incidents from this past January where he said for years and this is a quote for years

00:21:33 We prioritized the movement of the airplane through the factory over getting it done, right?

00:21:39 That's got to change the leadership team got it in the immediate aftermath of January 5th

00:21:47 Now I would have thought that they would have gotten it five years ago

00:21:54 In closing I'll note that for the last 20 years every FAA

00:21:57 Reauthorization Act pushed more and more responsibility over the fence to the manufacturer's side at the time

00:22:03 This was done with the understandable objective of increasing efficiency and productivity

00:22:08 The two max crashes showed that the pendulum had swung too far and AXA was the response to try to correct this

00:22:15 But AXA cannot be the high-water mark in your efforts

00:22:19 I urge you as you debate additional steps that can be taken to ensure

00:22:23 that you increase the FAA oversight of Boeing and that you keep pushing for structural change at the company and

00:22:29 As well as ensuring that all of our panels 53 recommendations are fully implemented

00:22:33 Believe that this is the only way that we can return this company to what we all remember it once being a company known for

00:22:40 Engineering excellence and a company where the headlines were written about it because of its accomplishments and not because of its failures

00:22:47 I believe the flying public deserves no less. I

00:22:50 Will not turn it over to my colleague. Dr. Dillinger. Dr. Dillinger. Welcome

00:22:55 Whatever opening statement you can make that would be great

00:22:59 Thank you, Chair Cantwell and distinguished members of the committee

00:23:05 Thank you for the opportunity to appear today to discuss the report of the ODA for transport airplanes

00:23:11 From the expert panel review. I'm Dr. Tracy Dillinger

00:23:15 And I'm currently the senior executive psychologist for safety culture and human factors programs

00:23:21 Within the NASA Office of Safety and Mission Assurance in this position

00:23:26 I have created and chaired the agency's safety culture working group and the human factors task force

00:23:32 And I'm responsible for NASA's safety culture survey

00:23:35 safety culture courses safety culture audits and assessments

00:23:40 Human factors mishap investigation support human factors training and our annual human factors report

00:23:47 I'm also a proud veteran of the United States Air Force where for over 20 years

00:23:52 I served as a human factors investigator human factors instructor

00:23:56 10 years as the chief aviation psychologist and in numerous roles including the chief of safety

00:24:03 Assessments for the Air Force Safety Center and served on the Columbia accident investigation board

00:24:10 I've spent the majority of my career working in the field of aerospace and aviation safety

00:24:16 I'm truly passionate about safety culture human factors and their combined effect on

00:24:23 organizational performance

00:24:25 Clearly a robust safety culture is essential to preventing mishaps

00:24:29 Safety is a NASA core value along with excellence

00:24:35 Teamwork integrity and diversity and it's integral to everything we do

00:24:40 We strive to create an environment where everyone works safely feels comfortable

00:24:46 communicating safety issues learns from both mistakes and

00:24:50 successes and feels confident balancing challenges and risks

00:24:56 the International Civil Aviation

00:25:00 Organization describes safety culture as arguably the single most important influence on the management of safety and

00:25:08 recognizes the interdependence of safety culture and safety management

00:25:13 Noting that effective safety management empowers a positive safety culture and a positive safety culture

00:25:20 empowers effective safety management I

00:25:24 Was privileged to participate in the ODA panel where I was able to lend my knowledge and passion

00:25:30 For safety culture to the work of my fellow panelists with whom I had the privilege to serve

00:25:35 Boeing like NASA uses Jim Reason's five-factor model of safety culture comprised of reporting

00:25:44 just

00:25:46 flexible learning and informed elements

00:25:51 While the company has begun addressing

00:25:53 Reporting and just culture training it needs to enlarge its safety culture program to include all areas

00:26:01 All five factors using multiple means and the program should be endorsed

00:26:06 promoted and modeled by its leaders

00:26:10 employees

00:26:12 including team leads

00:26:14 Managers and senior leaders need to know what to do when a deficit has been reported

00:26:21 That includes ensuring that tools and processes are available

00:26:26 So so employees can report without fear of reprisal

00:26:30 managers can listen

00:26:33 reported issues are fixed and then

00:26:35 communicated with

00:26:38 recognition given to those who come forward with concerns

00:26:43 it's equally important that senior leaders continually message and

00:26:48 Demonstrate to their workforce that safety is a critical

00:26:52 fundamental aspect of doing business

00:26:55 even

00:26:57 over-profit

00:26:59 Aviation safety isn't just good for the flying public

00:27:02 Ultimately, it's good for successful operations and mission accomplishment and that's good for business

00:27:10 I believe that successful adoption of the reports recommendations

00:27:15 Will improve the level of safety provided by Boeing to its workforce operators and the public.

00:27:22 I would note that while the panel focused on Boeing as an ODA holder the panel's findings and recommendations

00:27:29 contain numerous best practices that could assist other companies with similar authorizations to implement

00:27:37 successful safety culture safety management systems or ODA programs

00:27:41 Thank you once again for inviting me to appear before you today

00:27:45 And I look forward to discussing these important issues with members of the committee.

00:27:51 I yield to Dr. Nishikari

00:27:54 Thank you again so much for being here and thank you for your

00:28:01 Safety management strategy books managing the risk of organizational accidents from James Reason. Thank you so much

00:28:07 For the leadership at the university on these issues

00:28:10 Good morning Chairman Canfield and

00:28:14 distinguished senators

00:28:17 And distinguished members of the committee. Thank you for inviting us

00:28:21 FAA expert panel members to testify before you today. I am Naj Mishkati

00:28:28 I'm a professor of engineering at the University of Southern, California

00:28:32 I'm also a senior faculty member with the

00:28:36 72 years old USC aviation safety and security program

00:28:43 And I have an affiliation with Harvard Kennedy School project on managing the atom. For the past

00:28:51 four decades I have been conducting

00:28:56 interdisciplinary research on

00:28:58 system safety

00:29:00 human factors

00:29:02 safety culture and risk reduction of

00:29:04 complex technological systems

00:29:07 These systems include aviation

00:29:11 oil and gas drilling

00:29:15 pipeline and refining nuclear power and healthcare

00:29:19 system failures in these industries is safety critical systems

00:29:25 Have a deadly impact on humans and the environment. I

00:29:29 Have developed many courses at USC around this area. I've been involved in several

00:29:35 Accident investigation like BP Deepwater Horizon. I visited several nuclear plants like Chernobyl, Fukushima and

00:29:43 Tremal Island, but my participation in

00:29:47 this

00:29:49 Distinguished expert panel and working with my great colleagues on this panel

00:29:54 further corroborated what my research experience has taught me in the last 40 years and

00:30:00 This is it. This safety culture is the foundation as Dr.

00:30:06 Dillinger mentioned. Safety culture is the foundation of any processes and operation in

00:30:12 Organization it could make or break the system. As my mentor professor James Reason said

00:30:22 "Safety culture can affect all elements in the system for good or ill"

00:30:28 I

00:30:31 Believe safety culture is analogous to human body's immune system

00:30:36 Which protects it against pathogens and fend off diseases

00:30:43 and

00:30:46 It is incumbent upon the leadership of any organization to strive for

00:30:52 immunizing and

00:30:54 Constantly boosting the healthy safety culture of the company

00:30:58 Healthy safety culture is based on competence

00:31:03 Trust transparency and accountability

00:31:10 Another equally important lesson that I've learned by my

00:31:15 participation in this panel which also corroborated what I have learned in my career is that

00:31:23 human operators in this safety critical system

00:31:27 Such as pilots in the airplanes or human operators in a control room of a nuclear plant

00:31:35 always

00:31:38 constitutes the system's both first and last layer of defense

00:31:42 first and last layer of defense human operators as we saw in

00:31:48 the case of the miracle on the Hudson and also at Fukushima Daiichi nuclear plant

00:31:55 as such our

00:31:57 panel found and recommended human factors and human systems integration consideration

00:32:02 Should receive attention commensurate to their importance in aviation safety and aircraft design and operation

00:32:10 human factors as a

00:32:13 cross-cutting science

00:32:15 Should become a formal

00:32:17 standalone and highly prioritized

00:32:20 discipline and

00:32:23 a design practice at Boeing and within any company that they deal with safety critical system and

00:32:31 finally

00:32:32 My research experience has taught me that a world-class engineering company

00:32:37 That makes or operates a

00:32:41 safety critical system such as aircraft must be run by world-class engineers

00:32:48 Who are thoroughly trained to understand respect and impact human factors and safety culture

00:32:57 Thank you once again for attention to our panel support and

00:33:00 Appealing before you. Thank you

00:33:03 Well, thank you to all the witnesses

00:33:05 Appreciate you being here. I think I have a question just generally

00:33:11 I want to draw this out a little bit from your report because you've

00:33:14 Again emphasized it, but some of these terms may just be

00:33:19 In lost on people in their significance, and so I'm just trying to say you're saying there isn't a

00:33:27 singular

00:33:28 culture

00:33:30 Program on safety that is understood by the employees or that is

00:33:35 Implemented or responded to by the employees and and again, I want to make sure because I'm gonna get to a question about

00:33:41 Spea and machinists because the frontline people are saying these are the safety problems

00:33:46 They're just not being backed up

00:33:47 And so but I want to understand why the phenomenon exists and I think your report says because there's three different

00:33:53 Programs and people don't know which one to pay attention to at any given time

00:33:57 Is that is that a correct understanding?

00:33:59 If I if I may I think there there are a couple of things there. I'll just try to tease them out

00:34:05 It is true that there is an overwhelming amount of documentation on

00:34:11 SMS and safety culture at Boeing, but as has been described to me by someone recently

00:34:17 it's sort of like if you're trying to teach your kid to drive and you give them the

00:34:21 statute book on all the road rules, you know, but but they really want is the driver's manual and

00:34:26 What what you're referring to is one observation that we made is that while all the documentation that exists right now on SMS and safety culture

00:34:34 Checks all the boxes that IKO says you're supposed to

00:34:37 For the person on the ground

00:34:40 Turning the bolts and hammering the nails

00:34:43 It's they don't know we asked that all of our interviews. We said how what's the safety metric? Are you working towards?

00:34:50 How do you how do you know that you're doing a safe thing and we got like

00:34:54 Yeah, you're in the headlights. There's what are you talking about? Oh safety matter where you know, we have production metrics

00:35:01 We got this matter, but there wasn't anything about that. So so that that was one thing

00:35:06 I think the thing you're referring to about it being multiple

00:35:09 Multiple ways it's there are multiple reporting ways right now at Boeing and that's not necessarily a bad thing

00:35:17 Having multiple ways of reporting is is good and it's encouraged the problem. We found was that

00:35:22 You know, they they're they just didn't seem to

00:35:27 There was lack of confidence and say for example, if you were tried to report it anonymously

00:35:32 There was lack of confidence that there would be an anonymous that we've maintained

00:35:35 There was a lack of confidence that things would actually get done about what you were doing

00:35:39 and there was a very real fear of retribution and and and payback if if you held your ground and

00:35:45 obviously those are things that are just not compatible with any sort of safety culture or

00:35:51 SMS any of the other witnesses want to add to that?

00:35:55 Boeing has been working to develop and field a safety culture model throughout the

00:36:09 organization

00:36:11 they've been

00:36:13 successful in providing training on

00:36:16 Some of the elements of it. They have not yet put it all together so that it

00:36:22 It works together as a system at NASA. We use the DNA logo for it

00:36:28 You know all of those parts work together when someone reports something

00:36:32 Somebody has to listen to it the way they treat them has to be fair

00:36:37 There needs to be an environment of psychological safety

00:36:41 They need to learn from that and communicate it and pass it on and to create that

00:36:47 Everybody in the system needs to know what they're supposed to do and how to do it and what's expected of them

00:36:54 And if that doesn't work, they need to know the the next option and if that doesn't work

00:37:00 They need to know the next option

00:37:02 That's why having multiple reporting systems can be a good thing because if one doesn't work

00:37:08 The employee needs to know what else they can go to

00:37:12 One of the things for example would be to know who is the chief of safety that would be where the buck stops

00:37:20 And in one of the surveys that we saw

00:37:24 95% of the people who responded to the survey did not know who the chief of safety was

00:37:31 That that's a deficit that could be created corrected

00:37:37 But people need to learn

00:37:39 Who the key people are in that system so they know who they can go to when the processes don't work

00:37:47 well, I wondered to what degree this committee or I did as

00:37:53 ranking member of the committee then a whistleblower report that

00:37:57 Detailed in 2021 an FAA engineer Michael Collins describes an instance where the FAA management

00:38:04 Management overruled an engineer regarding a lithium-ion battery in the 787

00:38:09 Notably later the FAA had to ground the 787 in response to fires caused by the very lithium-ion battery

00:38:16 So there was an instance where people were not listening to what people were saying on the line what needed to be done

00:38:22 There's another

00:38:26 Incidence where dr. Martin Bickboler

00:38:30 Stated that a more secure safety reporting system may have prevented him from facing retaliation for filing

00:38:37 Complaints about different components not meeting FAA standards

00:38:41 So, how do we how do we ensure that those who are speaking up about safety measures get listened to?

00:38:47 I'm sure in this case these two knew who to go to but just because they've been very experienced people

00:38:53 But this that they weren't listened to so what do we need?

00:38:56 What do we do with this part of the problem? What do we need to do with the FAA?

00:39:00 Well

00:39:02 Well

00:39:04 You know in a properly functioning SMS and a properly function safety culture those

00:39:09 questions wouldn't be asked right because they people would be empowered people would have confidence that they wouldn't be

00:39:15 That they wouldn't be smacked down if they spoke up

00:39:18 I don't think that's what we're dealing with here

00:39:21 And which is one of the reasons that by the way that we in one of our recommendations we we encouraged

00:39:27 We recommended that Boeing established

00:39:29 What are called ASAP?

00:39:31 programs

00:39:33 Aviation safety action programs, they're very common in airlines and an ASAP program has is a tripartite program

00:39:41 It has the FAA the labor and management and if you initiate an ASAP event

00:39:47 You're protected but more importantly than being protected you the event gets visibility at the FAA level and at and at and at as

00:39:56 well as the management level and for me I've been and when I am as the when I started on this committee I I

00:40:03 Quickly became became a big convert to visibility because I'm convinced that if enough eyes had seen the MCAS design

00:40:11 Ten years ago

00:40:13 Somebody would have raised their hand and said hey wait a second

00:40:16 Maybe having a system that if one sensor fail it crashes the airplane to the ground is not the best idea

00:40:22 But they didn't because as was noted it was purposely hidden, right?

00:40:25 So I'm well just to be clear there were whistleblowers who did bring this up and said that it was

00:40:30 Unsafe, but they weren't listened to it wasn't hard

00:40:33 They weren't listened to and so we're this is why we're saying good engineering as I think you agree wins the day

00:40:39 But people have to listen to the engineers and so we're trying to discover here

00:40:44 What kind of look our committee can only do the oversight of the FAA that enforces the FAA to do its oversight job correctly

00:40:51 And we want to know what we need to do to strengthen this, but my time is expired

00:40:56 I have a suspicion. I'll be able to come back to this and we'll go back to but I'll turn to Senator Duckworth

00:41:02 Thank You chairwoman again, you know I I want to dig

00:41:06 Deeper into this conversation

00:41:09 I mean since the door plug fell out of the of the 737 max 9 for Alaska Airlines

00:41:14 It's been a lot of attention on Boeing's stunning lack of quality control throughout its supply chain

00:41:21 And this is understandable and yet

00:41:23 As we've already heard the expert panel appears to have identified a much broader problem at Boeing

00:41:27 the utter absence of an effective safety culture and I fear that merely

00:41:32 Increasing scrutiny on how a door plug is removed and replaced will fail to solve the more fundamental

00:41:36 Cultural failures that are at the root of the Boeing's flawed development and production of the 737 max

00:41:42 And dr. DeLuis I would love for you to serve go deeper

00:41:47 You know the conversation we're already having because I think you would agree with me

00:41:50 Would you not that fixing a specific assembly line problem?

00:41:53 Would not be sufficient to get Boeing back on track and frankly

00:41:58 I personally think that Boeing's recent manufacturing problems are merely a symptom of a much deeper problem

00:42:03 the destruction of a proper safety culture by you know share price of

00:42:08 Executives who time after time prioritize Wall Street profits over long-term production excellence

00:42:13 It's it's sort of the replacement the driving out of the engineers at war

00:42:17 the heart of what Boeing was

00:42:19 So can you talk a little bit about manufacturing problems?

00:42:22 Or more of a symptom would you agree?

00:42:24 They're more of a symptom of the bigger problem

00:42:26 Then then you can't just fix a quality control issue and think that that's going to solve it, right?

00:42:31 Completely agree and let's talk about door pulling just using an example

00:42:35 Everyone's seen the picture right of the door plug sitting there without three of the bolts

00:42:39 You can't see the fourth one right but everyone's seen that picture and you go. Oh my goodness

00:42:42 Their bolts are missing. Where was the inspector? Okay should have been inspected

00:42:47 but more importantly, I think why did a

00:42:51 Mechanic install the door and walk away leaving it in that condition

00:42:56 Why wasn't he or she trained to know that you just can't do that, right?

00:43:02 And that's where you go to you know, yes more inspections good

00:43:07 I firmly believe you can't inspect your way to quality and you can't inspect your way to safety because all it's going to take is

00:43:12 One slip and you know, we're back here again. It's got to be in the in the DNA of the people that

00:43:20 Understand that you don't walk away from a door leaving it in an unsafe condition

00:43:24 Now you can even take that a little further and say you shouldn't design a door

00:43:28 Which allows the bolts to be separated from the door so that you know

00:43:32 So I mean it should be captured or something

00:43:33 I mean you can take it all the way back up to the design level

00:43:36 but I completely agree that just putting out, you know whack-a-mole trying to

00:43:41 Playing whack-a-mole with with QA is problems is not the way that you're going to get there because that's impossible

00:43:47 They you know, the car industry learned this a long time ago, right?

00:43:51 You you don't let you don't let cars move forward when they have defects you fix the defect and you figure out

00:43:59 Why did the effects there and then it doesn't show up again? That's not happening here when problems arise on the line

00:44:06 they the line keeps moving forward and I think that until they take a page from

00:44:11 From what the the the US auto industry learned 30 or 40 years ago

00:44:15 We're not gonna we're not going to be able to get to where we need to be for

00:44:20 Boeing I would agree with you. And by the way that picture was from a cell phone

00:44:25 text message because when the NTSB went and asked Boeing to provide all the logs and you know

00:44:32 Back in my in the you know when I flew for the army, it was all paper logs and we switch computerized

00:44:36 They can't find any logs for anybody who inspected it who took it off and put it back on

00:44:41 They still haven't been able to identify who did the work, but that picture wasn't even official

00:44:46 That was just a text message between workers

00:44:49 I want to get into the ODA

00:44:51 Reforms after all the ODA reforms

00:44:53 I am frustrated that Boeing's ODA still allows opportunities for retaliation against those who raise safety concerns and the expert panel found

00:45:01 Continuing problems tracking safety concerns once they're made this sounds early like how ODA operated before Congress passed the

00:45:08 ACSAA Act and in 2016 an internal Boeing survey found a 39% of Boeing authorized

00:45:14 Representatives had experienced undue pressure from Boeing

00:45:18 We've already talked about this a little bit a 2020 FAA survey found a 56% of respondents from its aircraft certification service

00:45:24 believe external pressure from industry is perceived to get in the way of safety decisions and

00:45:30 39% of respondents from FAA's Aviation Safety Office believe that safety concerns will not be addressed so they don't bother to report them

00:45:37 I would love for both

00:45:40 Dr. DeLuis and

00:45:44 Dr. Mishkati to address this issue

00:45:46 Congress tried to fix this in the Aircraft Certification Reform Accountability Act, but clearly a problem remains

00:45:51 Does Congress have more legislative work to do and what do you would you recommend we do?

00:45:56 I know that the panel found made 54 suggestions, but I would love to hear

00:46:00 Dr. Mishkati would you like to kick us off?

00:46:03 Thank You senator that has been a major issue about the fear for retaliation and the

00:46:10 independence of ODA and

00:46:12 we

00:46:15 Talk about that and we heard about that during our interviews and surveys and the documents that we reviewed

00:46:23 One important conclusion that we came up with this

00:46:28 reorganization of ODA within Boeing that they are because Boeing as you know better than I do is

00:46:35 a matrix organization

00:46:38 You have the functional group and you have the program group ODA in the past

00:46:42 Was in the basically program group now

00:46:45 They are reporting to the functional group and there have been some

00:46:50 Something which was a little bit

00:46:53 Surprised to me that there were some non Boeing ODA members also

00:47:00 Which were contractors which their security could be subject to

00:47:05 Job stability and security could be subject to the review that they can but with this

00:47:11 reorganization that they have done that the ODA unit members they

00:47:16 reported a

00:47:18 Functional group they it could fix that and I want to open a process here senator that

00:47:25 in our panel we have had

00:47:28 Manufacturers

00:47:31 representative that they have ODA we had person from

00:47:35 Gulfstream we have person from

00:47:39 Bell Tetra and

00:47:42 GE and Pratt & Whitney they do ODA correctly

00:47:47 It's not that there is something fundamentally wrong or inherently wrong with ODA

00:47:53 ODA can be managed

00:47:56 Correctly and these issues would not appear as much as we saw here

00:48:02 the

00:48:05 if I may the you asked what what could the FAA do whatever my I

00:48:10 Think that the FAA needs to take a very close look we have a right now approves ODA members, right?

00:48:16 I think it needs to take a very close look as to

00:48:18 what the organizational structure of the ODA within the company is and

00:48:23 require it to be

00:48:25 You know

00:48:27 To be independent when it comes to decisions that affect the person's livelihood

00:48:31 It's a very hard asked for someone, you know

00:48:34 I mean do you're putting your livelihood at stake in order to stand your ground?

00:48:36 most engineers are ethical and are going to do it, but we shouldn't have to ask them, you know to

00:48:41 risk their family livelihood and

00:48:44 knowledge

00:48:46 Brought up the issue of the contractors as ODA members

00:48:49 That's to me. I'm I was very troubled by that because you know a contractor's relationship with a company is very tenuous financially, right?

00:48:57 I mean, you're basically there at at will completely at whim

00:49:01 It's a big ask to have a contractor and that's going to stand their ground knowing that they could be you know

00:49:07 Showing the door the next day. I

00:49:09 There are up there at times where they're needed, you know

00:49:11 We see the retired people that you want to bring back because their expertise I completely get that but that should be the exception

00:49:18 I believe and not the rule

00:49:19 I mean, I think you really want these to be full-time employees that have a little bit more security whether they're SPIA members or not

00:49:25 You've been very indulgent right now chair. Thank you

00:49:29 Senator Vance and then Senator Rosen great. Thank you, madam chair and thank to you in the ranking member for

00:49:35 Hosting and thanks to all of you for being here

00:49:38 So first of all, I think to each of the witnesses for the important work you put

00:49:43 Into this report and I'd like to focus my questions on the ODA the organization designation authority culture at Boeing and more broadly

00:49:52 Some of the concerns that have been raised about retaliation against employees

00:49:56 For identifying defects and other problems in the course of Boeing's operations

00:50:00 So so in the reports executive summary

00:50:03 the expert panel found that even though Boeing's restructuring the management of the ODA unit decreased opportunities for interference and

00:50:10 retaliation against ODA unit managers and

00:50:13 Provided better organizational messaging regarding the independence of unit managers. Something was missing

00:50:17 Now dr. DeLuis and I hope I'm getting that that pronunciation right in your executive summary

00:50:24 You say and this is quoting from the report the ODA restructuring while better

00:50:28 Still allows opportunities for retaliation to occur particularly with regards to salary and furlough ranking

00:50:34 This influences the ability of unit managers to execute their delegated functions effectively in quote

00:50:40 So dr. DeLuis, I want to understand this how this fear of retaliation

00:50:46 Manifests itself on the assembly line. So in your investigation

00:50:51 Did you find Boeing employees on the factory floor were empowered and encouraged by management?

00:50:55 To stop the processes if an employee detected a non-conformity or a possible defect

00:51:01 No senator as I understand it

00:51:04 The only thing that stops the line on the factory floor is a no-show violation

00:51:10 if an employee thinks that his or her life or

00:51:15 Health can be threatened they can stop like everything else basically gets written up and gets put into a prop one of various processes

00:51:23 depending on how

00:51:25 Where where it sits it gets written up and then supposedly gets addressed down the line

00:51:31 And this leads to the travel work problem that we've heard about before where you know, you you have a problem

00:51:37 You'll fix it later. But in order to fix it later, you have to take apart something that you know

00:51:42 It wasn't there before and that's in part what caused the door problem, by the way, right?

00:51:47 They had to replace some rivets. They had to remove the door. They put the door back. They forgot the bolts, etc

00:51:53 But no to answer your question directly. We did not find any

00:51:58 Any encouragement or any any empowering to stop the line?

00:52:03 They they're focused at

00:52:06 they're focused on

00:52:08 reporting it and

00:52:10 supposedly that loop should be closed and those problems fixed but

00:52:14 It's very difficult to say that that's actually happening. I can give you an example

00:52:18 In one of our interviews that I believe you and I did Tracy. We were at the receiving area the receiving room

00:52:25 receiving

00:52:28 section where they check out the airplanes before the FAA inspects them and

00:52:32 I asked them what is the major thing that you find? They say oh, it's FOD or an object

00:52:38 Debris and I'm like so what happens? Well, you know, we reported we clean it up and we move on I said well

00:52:43 Don't you track back where the FOD came from so you can be sure it doesn't happen again

00:52:48 Well, we put the report in and somebody's supposed to do it, but it keeps on showing up

00:52:53 Yeah, and that's not how you're supposed to do things if you want to fix the problem once got it. So so

00:53:00 It sounds it's

00:53:04 it sounds like there was not exactly a promotion of

00:53:09 People sort of stopping the line or raising these issues

00:53:14 I mean is there any evidence there was actually the opposite there was retribution that people were actually penalized for raising some safety concerns

00:53:20 Yes, that's correct we heard reports we heard several reports of people

00:53:25 That that felt that they were transferred or didn't get the raise that they were expecting now

00:53:32 Please understand we were not empowered to conduct a statistically significant all-encompassing review

00:53:38 And I am very well aware that you know data is not the plural of anecdote, right? I mean we sure we were I'm replay

00:53:44 I'm recounting anecdotes

00:53:46 But that's what we heard and that's I think that that's that's our impression from okay

00:53:51 I'm a year and so so be mindful of time. I appreciate your I appreciate your testimony

00:53:57 I mean one quick question, I guess just follow up and maybe we can sort of further follow up with my staff

00:54:02 in

00:54:03 In a detailed way. I mean is there anything that you think Congress could do to sort of solve or at least improve?

00:54:11 This this this sort of basic incentive problem, right?

00:54:14 If you're gonna be penalized for raising safety concerns, then you're gonna raise safety concerns

00:54:18 So we would actually promote people for for raising valid safety concerns. What do you think Congress could do to meaningfully change this?

00:54:29 As I as I mentioned in response to an earlier question one one thing you could do is you could

00:54:35 I'm not I'm not a I'm not a in your shoes

00:54:38 I don't know if it's legislation or encourage or direct but the

00:54:42 Setting up additional channels for where people can come and report without fear retaliation

00:54:47 Such as the ASAP program I think would be a very good step

00:54:51 Well, thank you. Dr. Lewis and I appreciate it

00:54:55 And I know you you personally have suffered some some tragedy because of some of these problems

00:54:59 And so I'm grateful for your work on this, but also my condolences. Thank you, Madam Chair

00:55:04 And just on that

00:55:07 Point about the the ASAP because I don't want it to get too confusing about existing systems. Dr.

00:55:13 Lewis you're saying that if somebody knew about either the batteries or

00:55:17 The MCAS or whatever that what you want is a larger universe of people not just one

00:55:24 Engineer talking to one line manager you want a broader awareness

00:55:28 And you want a broader awareness even at the FAA so that it isn't just the FAA one person

00:55:34 overriding the line manager

00:55:37 Right senator. I mean, you know, I'm a belt and suspenders kind of guy. I think that you need to have

00:55:43 You need to have more visibility in order to prevent the things that we saw

00:55:48 on MCAS and in

00:55:51 Congressman DeFazio's report, you know that where one person could basically hide the existence or

00:55:57 Suppress the existence of certain systems or or make sure that they don't go very far

00:56:03 It's not

00:56:05 When we were discussing this in our panel several people brought up, you know in a properly functioning SMS

00:56:10 You don't need ASAP programs. That is absolutely true

00:56:13 But that's not the world that we're in right now

00:56:17 So and there may be other things besides they said I suppose just the one that when we were at American Airlines

00:56:23 They talked to us about it and they were very very positive

00:56:26 about the the impact that that's had on their SMS at American and so it really

00:56:31 resonated with many of us on the panel and that's why it's in the war as

00:56:36 An a broadening of the communication right? Yeah, right exactly. The key thing is to brought again

00:56:43 I would just want to I know you keep referring to this one instance

00:56:46 but I'm assuming you're referring to some of the

00:56:49 Actions by people who may have tried to hide that information from the FA

00:56:53 But this committee also received whistleblower reports from people who made it very clear. They had concerns, right?

00:56:59 It's just that you we have to figure out this larger communication and it shouldn't take a whistleblower report, right?

00:57:05 I mean a whistleblower report is a big deal for somebody to do right? I mean, it's often a career-ending move

00:57:10 Whereas is that as the ASAP?

00:57:13 Has been described to us, you know, I'm a mechanic can say this was actually a case that was brought up, you know

00:57:18 I'm not sure if I put in the locking pins on that panel and he goes and reports it and that

00:57:23 Immediately, he's not going to be fired for making that mistake. The focus is going to be well, why didn't you?

00:57:29 Is there a problem in the process?

00:57:31 The first the focus is first is let's get the airplane down if it's in the air and make sure it's safe and then it's why

00:57:36 Didn't it happen? What is there a problem with the process?

00:57:38 Is there a problem with the training and then make sure that that never happens again?

00:57:42 I think that's the attitude that we need to encourage across the airplane the aviation world, but in particular at Boeing

00:57:49 Thank you, Senator Rosen

00:57:51 Occasions it's really important in this hearing is so important and I really want to thank the panel for

00:58:02 Your hard work on this and your care

00:58:06 It matters and we're grateful because as Americans look to Congress to address recent Boeing

00:58:11 Incidents that have placed passenger safety at risk

00:58:15 We're reminded that American air travel can only remain safe and reliable as a form of transportation through vigilant

00:58:22 Oversight and accountability just like the hearing we're having right now

00:58:25 I want to thank you again for taking the time to be here answering questions about the findings and the

00:58:32 recommendations that were provided in the expert review panels final report and

00:58:36 So the report found that for aviation safety matters input from Boeing's pilots were neither consistently nor

00:58:44 directly

00:58:46 Directly delivered to the highest level of decision makers in the organization

00:58:49 But also noted that the chief pilot position did not have the same authority as other executive positions

00:58:56 This is concerning getting the Boeing's pilots are uniquely qualified to identify those safety issues and hazards

00:59:03 Inherent to a company's aircraft. It's clear that the expertise

00:59:07 Pilots provide need to be elevated within Boeing's ODA process and your recommendations are consistent with that

00:59:14 So dr. Mishka D and then dr. Dillinger

00:59:17 Can you both elaborate and why the expertise that pilots provide is essential to evaluating Boeing's aircrafts?

00:59:24 And what can Congress do to ensure that pilots have a greater seat not just in the cockpit but at the table

00:59:31 That will be forward so that their expertise can enhance aviation safety

00:59:36 We'll go dr. Mishka D

00:59:40 Thank you very much. Senator Olsen. That's a very very important and profound question that in fact relates to

00:59:47 Our findings number 2425 and towards several recommendations about that

00:59:53 It is my position and I think our expert panel has very specifically said that that the

01:00:01 chief pilot and the pilot and

01:00:03 basically

01:00:05 The way that the pilots they could

01:00:07 Bring up their voice to be heard and be paid attention to is through a very robust human factors group

01:00:15 If we can have that robust human factors group and make it a line function

01:00:21 With the authority that commensurates with its role. I think that issue that you said can be resolved

01:00:28 I heard that in

01:00:31 in Boeing they say

01:00:34 Structures is the king

01:00:37 Because of the impact and importance that they have and I've said that to my student if structures is the king

01:00:45 Human factors and voice of pilot has to be at least a queen in Boeing

01:00:51 Because this is equally important as as equal

01:00:55 Really important as the structures. I think

01:00:59 This

01:01:02 Issue that you raised is very close to my heart and very close to the heart of my colleagues on the panel

01:01:10 And that's what we made was recommendation. We use the term

01:01:13 senator design practice in our recommendation

01:01:20 Recommendation

01:01:22 For the these findings associated with the findings about that design practice has a very special and important

01:01:30 meaning in in Boeing and if this

01:01:34 Issue that you said be raised at that level and it gets to a design practice

01:01:39 I think some of these issues can be resolved

01:01:42 Thank You. Dr. Dellinger. Would you like to add something?

01:01:48 Thank you, thank you senator

01:01:50 the pilots are the customers in a

01:01:55 Great sense and so the reason why it's important to hear from the pilots is they're critical in the design

01:02:02 from a human factors perspective of the flight deck

01:02:06 The human factors inputs and the pilots inputs go together

01:02:11 The pilots need to have a strong voice and their opinion

01:02:17 needs to have a

01:02:19 strong weight

01:02:21 They should be the ones who are providing feedback to those designs and making adjustments in those designs

01:02:29 Equally so we we learned as the panel that when you say Boeing pilots that has changed a little bit

01:02:36 And then the pilots are no longer Boeing employees. They're contractor

01:02:40 employees and so again the

01:02:44 Ability for them to have a voice at the proper level with the design

01:02:49 Modifications that take their opinions into account the panel felt that that was important

01:02:55 Well, thank you very much. I see my time is expired

01:02:58 But I do want to say the human factor matters there are humans on that plane. It matters to all of us

01:03:05 It's not just the structure. And so thank you for your hard work. I'm not I'm sure you'll come

01:03:10 Thank you so much. Senator Rosen

01:03:13 Senator Budd

01:03:14 Thank You chair and again, thank you all for being here

01:03:17 The expert panel report notes that Boeing human factors specialists have played a diminished role in the design and functionality of recent aircraft

01:03:26 But it was once considered the gold standard in this area

01:03:30 Dr. Dillinger, can you share any of the specific steps Boeing staff shared with the expert panel to rebuild its human factors capability?

01:03:38 Or any additional recommendations you have to Boeing?

01:03:42 To restore Boeing as the gold standard and human factors engineering. Dr. Dillinger, please

01:03:47 Thank You senator

01:03:51 the human factors

01:03:53 cadre has diminished and

01:03:55 Recently and the company has made a great effort to bring in more human factors expertise

01:04:03 They know that that is critical

01:04:05 It needs to also be in a standalone

01:04:10 organization where they can have a voice formally and

01:04:14 We were introduced to the new senior

01:04:18 tech

01:04:20 Discipline lead for human factors who is developing a new cadre

01:04:25 but that is a critical element to the design and

01:04:29 And it's essential for future designs. Thank you

01:04:34 Dr. DeLuise again, thank you for being here. In 2019 Boeing launched the speak up portal an

01:04:40 Internal online platform meant to provide a place for employees who could confidentially report concerns on a number of factors

01:04:47 including production quality

01:04:50 Speak up is one of the many channels employees have used to report concerns

01:04:55 To the company yet in several places the report finds that employees and I quote did not understand how to utilize

01:05:04 the different reporting systems which are which reporting systems to use and when in quote and

01:05:09 That many of the employees preferred to report issues directly to their manager

01:05:14 So is there any record of how many production quality concerns were reported through

01:05:19 The speak up program or other reporting system as opposed to reporting directly to the managers

01:05:25 I know they keep track of how many speak up reports. I don't have those numbers in front of me

01:05:31 I did however recently read that since the

01:05:35 door incident they've had a 500%

01:05:38 increase and

01:05:40 I remember that one of the last briefings we got from Boeing I asked was that good or is that bad right because there are

01:05:46 Two ways to look at this. What's up? What num how many speak ups would you expect normally, right?

01:05:51 Never really got a clear but to go to your point

01:05:54 to your question, excuse me the

01:05:58 There's nothing wrong with having multiple reporting systems what our concern was

01:06:02 What our concerns were there were multiple one is that people?

01:06:07 are

01:06:09 Have trouble believing that anything they put in speak up is going to actually result in any action

01:06:14 That was one the other concern was that most people

01:06:19 Prefer to deal with their problems by talking to their manager. That's not necessarily a bad thing

01:06:24 However, we were not convinced that there was actually a path

01:06:29 From when that report goes up to the manager for it to be captured

01:06:34 Into the safety system

01:06:36 So what I mean is if you have a problem in your particular station on the line, for example

01:06:41 And you report it to your manager

01:06:43 You may fix it right then and there and then that's the end of it

01:06:47 It may be that's appropriate for minor things

01:06:49 but for all you know somebody at another production and another line is having exactly that same problem and

01:06:54 There wasn't we did not see any sort of mandatory reporting sort of requirements in order to make sure that that gets captured

01:07:02 and

01:07:04 Subsequently learned from I mean that's one of the key tenets of SMS, right?

01:07:08 It's supposed to be you're supposed to learn from your from from what happens. And so that was problematic and

01:07:13 in addition, of course that

01:07:17 Sometimes you want that if you're just doing it that way there is no

01:07:21 Assurance that it was done in the best and most proper way as opposed to the way to just get it done and keep the line

01:07:28 Moving so you might you want to have those you want to make sure that though you have those checks and balances as well

01:07:33 So those were sort of our broad concerns about speak up. It's a good program. I think I mean, it's not about its

01:07:39 Intentions are very good. It can be a good program people need to be trained and people more importantly people need to begin to see results

01:07:46 When they report stuff into it that things actually change and nobody gets fired for reporting that nobody gets, you know

01:07:53 Anything bad happens and that and that and that they're reporting is making a difference

01:07:59 I think that there was a lot of skepticism about that

01:08:01 Which is why people keep going to their managers or the union rep or whatever

01:08:05 Do you think the 500%?

01:08:09 increase in reporting

01:08:11 In the system was due to more training or clarifying or just a new safety emphasis

01:08:16 Do you think it's a you think it's what's your notion? Is that a good thing or a bad thing?

01:08:21 Well, I there was clearly at the you know, they've been told

01:08:24 Yet again that to that they see something they need to speak up. So I think that there's some of that

01:08:30 I think that the real question is is it going to be a lasting a lasting blip?

01:08:35 You know, there there's probably a right number of speak-up reports to have per month

01:08:40 I don't know what that number is if you have zero

01:08:42 Well, maybe you're doing a perfect job, but most likely nobody is really

01:08:47 Using the system and if you have thousands, well, you've got deeper problems, right?

01:08:52 I'm not sure where the balance is. Unfortunately, we need to look at what the longer-term data is. Thank you all for being here

01:08:59 Thank you so much. I just wanted to note to the in this large discussion about human factors in angsa

01:09:06 We required that the human factors assessment has to be done before

01:09:11 The certification and that no longer can the FAA delegate the human factors assessment. They have to do it themselves. So

01:09:20 Senator Klobuchar and then Senator Schmidt in I think Senator Welch

01:09:26 So Senator Klobuchar, yes, thank you chair for this important hearing

01:09:33 and

01:09:35 Thank you, and I'm so sorry

01:09:37 Dr. DeLuis about your sister. We also lost some Minnesotan on that plane and

01:09:43 Thank you for your advocacy

01:09:45 I'm gonna start with you

01:09:48 Professor Mishkati and can you talk about why it's critical we invest in a strong pipeline into the aviation field and

01:09:58 I'm obsessed with this just because you know

01:10:02 Whether it's air traffic controllers or mechanics or the like

01:10:06 What's gonna happen if we don't invest

01:10:10 Sorry your questions senator Klobuchar was

01:10:14 Investing on the pipeline for training in in yes aviation safety. That's extremely important particularly

01:10:22 and thanks for that question right now one of the issues that we are facing is the

01:10:29 workforce attrition it have been a lot of

01:10:32 retirement and exodus from Boeing and other places and

01:10:36 The issue of training is becoming very important and workforce development. In fact

01:10:42 this thing for

01:10:45 the safety critical system

01:10:48 in in the case of aviation being air traffic controller and pilots and engineers and

01:10:55 Machinists and also in other industries. I've been just two weeks ago at the Board of

01:11:01 Gulf offshore energy safety of National Academy the workforce development for the

01:11:06 Energy system in the Gulf of Mexico is also another issue particularly with coming with the new technologies like a

01:11:14 VIN turbine in this particular case one solution is basically

01:11:20 joining forces with technical colleges and universities and develop internship program and

01:11:26 For the students that they get the training and they go work and then they come back and continue their education

01:11:34 This is something that I know that for

01:11:37 this new technology of the offshore VIN some

01:11:41 Organizations in the Gulf of Mexico and some companies and maybe BSE is getting involved in that

01:11:49 Okay. Thank you. Dr. Dillinger. You mentioned how

01:11:53 Pilots and crew need to play an important role in the design and evaluation of aircrafts

01:11:59 Can you also speak to the importance of training new pilots?

01:12:04 It's essential that we grow

01:12:11 new pilots and that

01:12:14 novice pilots have experienced pilots to help them learn and

01:12:19 become superior

01:12:21 Experienced pilots and the pipeline of pilots is a constant effort

01:12:26 I think from a human factors perspective again the more

01:12:30 Experience we get from the pilot cadre and the more they learn how to

01:12:35 Speak up and make their needs known especially from a design perspective

01:12:40 The panel was very concerned about the human factors

01:12:45 Element coming into design from the very beginning and that requires experienced pilots having input into that process

01:12:53 Okay, very good, thank you

01:12:57 Dr. De Luis

01:13:00 What additional FAA oversight you believe is necessary to ensure a stronger safety culture?

01:13:06 I think that we covered a little bit before with regards to making sure that the FAA

01:13:13 Is able to vet and and approve the not just the people but also the organizations

01:13:19 As well as as higher scrutiny for non-employee ODA members, I think that

01:13:27 One of the things that that has been touched on here is the need for the FAA to also establish

01:13:34 Its own SMS, right? I mean the FAA has an SMS on the ATC side, but not on the other side

01:13:42 I as I understand it and I'm by no means even though I'm an expert panel. I'm an expert in SMS

01:13:48 but as I understand it SMS has worked best when they sort of intermesh with each other the

01:13:54 Boeing with its with its suppliers and the regulators

01:14:00 I you know, it's a little difficult to see how the FAA is going to be able to do

01:14:04 Sort of the betting the Boeing SMS system. I'm sorry

01:14:10 Without it having its own SMS. Sorry, exactly. Okay, just one last question

01:14:15 Professor professor Mishkati on the I passed a bill with Senators Moran and Capito Senator Stauber in the House

01:14:23 Representative Stauber in the House

01:14:26 which alerts personnel to

01:14:28 Potential safety hazards the no-tam system and how we need to upgrade it

01:14:35 As we do the long overdue work of upgrading that technology, how can updated technology strengthen safety culture?

01:14:43 The technology needs to be updated with equal and

01:14:50 adequate attention to organizational factors one thing that we have said over here just by

01:14:56 bringing the new technology or even if you have a

01:15:00 Updated technology, but if you don't do workforce training and also change the organizational

01:15:05 Mechanism that could adopt that technology

01:15:08 It would import the issue of the adoption of the technology in the organization is very important

01:15:16 We have seen that

01:15:17 Senator Corbett are in the case of positive train control for example for railroad system

01:15:23 This is very important issue that you raised and needs to be addressed in a very systematic manner

01:15:30 Okay, thank you, thank you senator Schmidt

01:15:33 Thank you madam chair when I first learned about this hearing I was under the impression that we would be speaking to people on the ground

01:15:41 Where their current or previous with current or previous experience within Boeing to examine the current safety issues the company's facing

01:15:49 however

01:15:50 I'm surprised to see that not a single Boeing employee or executive present today discuss their safety and cultural

01:15:57 Practices and ongoing efforts to right the wrongs that have unfortunately occurred

01:16:02 So let me reiterate we have a hearing about Boeing safety practices

01:16:07 Without Boeing present. This is frustrating

01:16:11 It's even more frustrating that

01:16:14 Another committee just set

01:16:18 Down the hallway here is instead having a Boeing representative appear before their members to answer their questions and concerns

01:16:26 The member of the Senate as a member as members of the Senate Commerce Committee

01:16:31 We possess the authority to hear from representatives from Boeing on

01:16:34 Or any other company that falls within our jurisdiction on short notice

01:16:39 Today's hearing is about examining the findings of a report about Boeing's procedures

01:16:44 They should at the very least be here today to respond to any recommendations or findings from the report on a similar note

01:16:53 I've been on this committee now for almost a year and a half and during that time our

01:16:58 Transportation sector has experienced a number of challenges under this administration

01:17:03 Including a concerning trail train derailment in East Palestine a nationwide shutdown of our national air system

01:17:10 Near misses along runways in our nation's airports and most recently a devastating collapse of the Francis Scott Key Bridge yet

01:17:18 I along with my colleagues

01:17:20 Have yet to have the opportunity to question

01:17:22 Secretary Buttigieg the one person charged with leading our transportation system

01:17:28 Joining this committee

01:17:31 I expected us in a bipartisan way to rigorously examine and resolve critical issues facing our nation

01:17:37 That fall within the jurisdiction of this committee yet today it appears. We are again missing the mark

01:17:42 Therefore today's hearing is yet another chapter in an unfortunate series of events

01:17:48 Where we as a committee

01:17:50 Could be making a larger impact finding answers to questions and fully executing the duties as members of this great committee

01:17:57 To be clear. This is not an indictment of our witnesses whose knowledge and insight are invaluable

01:18:04 the report

01:18:06 To which they contributed provides many recommendations to which I hope Boeing not only reads

01:18:12 But strongly considers in its efforts to get its house in order

01:18:17 however

01:18:18 for a

01:18:20 comprehensive oversight I

01:18:22 Think we should be hearing directly from Boeing

01:18:24 in its representatives today on how they're addressing the findings and

01:18:30 executing changes within the company

01:18:33 rumored hearings in months down the line

01:18:36 Don't do anything to help Missourians flying today as

01:18:40 I want to transition the questions or a panel today. I do want to focus on how as a committee

01:18:46 with the chair

01:18:48 Who I do enjoy working with

01:18:52 How we can actually

01:18:56 Deliver the world's leading transportation system and keep Americans safe. So with that I don't have a lot of time but dr. Dr. Dillinger

01:19:04 Based on the report and based on the findings

01:19:08 Again this would be something I would be asking somebody from Boeing but to your knowledge

01:19:16 What changes are being implemented?

01:19:18 clearly there's a sort of a cultural challenge with feedback and

01:19:22 Being collaborative based on the report. So are you aware of any changes that are taking place and this would be for for any of you

01:19:30 Thank You senator

01:19:35 when the panel

01:19:37 Completed the report our mission was done. And so the panel has in effect

01:19:44 Expanded since the report was submitted

01:19:46 however, the follow-up responsibilities to the findings and recommendations have been provided to the FAA and the

01:19:55 administrator

01:19:56 has made

01:19:58 Appropriate replies to that from what we could tell

01:20:01 We we believe that all of our

01:20:06 Recommendations should be implemented. I don't believe that any have been yet. I mean, it's only been a few weeks

01:20:13 but

01:20:14 our wreck our

01:20:16 feeling is that

01:20:18 while not a

01:20:20 comprehensive set of remedies for all that ails Boeing

01:20:24 It's at least a really good set of first steps if they were to implement what we have recommended

01:20:30 And if I may add in our last findings and as

01:20:37 Recommendation 51 52 53 to both Boeing and FAA's to work together

01:20:42 and meet

01:20:45 Periodically to make sure that recommendations are being implemented and as far as I remember

01:20:50 FAA administrator

01:20:52 Mr. Whittaker has given Boeing three months since

01:20:56 February or early March to come up with a plan as hard you are gonna

01:21:01 Implement that and our panel and I think it's in our report

01:21:05 We volunteered to help Boeing during our interview

01:21:09 To to resolve some of these issues, but there is a statement somewhere in our report that they didn't really take this

01:21:17 opportunity to

01:21:20 Kind offer to have at least in my case. They didn't ask. Okay. Thank you. I yield back. Thank you, Madam Chair

01:21:28 Thank You senator Schmidt

01:21:29 I will know that we are going to hear from the company and we've long said we were going to go to the FAA and

01:21:35 Then the company because our oversight job is with the FAA and making sure they're implementing

01:21:39 But I did mention at the beginning of this that they did cooperate

01:21:42 With the interviews that you did conduct and so we will hear from them in my census

01:21:47 They've digested your report and by the time they get here

01:21:50 They'll have a lot of commentary about this and so we'll look forward to hearing it senator Welch

01:21:56 Thank you very much. Thank the witnesses, you know, people are pretty terrified

01:22:00 It's unreal when you think about it in October 2018

01:22:04 The Indonesian flight 189 people. Mr. Dela Dr. Dela died

01:22:11 March 2019 Ethiopia Airlines and then of course on January 5th, the door blows off

01:22:19 I mean bottom line

01:22:21 people are

01:22:23 Wondering and all the time whether they should fly on a Boeing plane

01:22:27 Is the public safe right now?

01:22:30 I'll start with you. Dr. Dillon or dr. Dillinger and we'll go down the line

01:22:35 That's the bottom line question. A lot of folks have

01:22:38 Are we safe on a Boeing plane?

01:22:41 As best I understand it at this point I

01:22:48 I

01:22:50 have continued to fly on Boeing aircraft and

01:22:53 And I hope that they have taken our findings and recommendations to heart and implement them

01:23:00 Hesitation makes me feel like you've taken your chances

01:23:05 Dr. D. Dr.

01:23:08 Dillard yes, I'm sorry. So that's fine. I

01:23:12 Get asked this question all the time. I get asked this question is I do too. Is it safe? And so here here

01:23:20 Is what I answer and I don't know if it's a I say, you know

01:23:23 The safest place for a rocket is sitting on the pad the safest place for an airplane is sitting in a hangar

01:23:28 The safest place for you and me is on our couch doing scrolling through Instagram and yet every day

01:23:34 Rockets launch airplanes fly and we get up and we go and do something productive

01:23:37 Safety is always a trade

01:23:40 having said that the

01:23:43 Within the airplane worlds you have to look at what's happening

01:23:50 And go how comfortable am I flying in this airplane versus that airplane for me personally?

01:23:56 Yeah, I keep track of what's happening on the max for obvious reasons and and I'm worried about what's happening on the max

01:24:03 Thank you. Now if I had to fly somewhere

01:24:07 Because there was and there was no other option

01:24:10 I would absolutely fly it versus driving for example because I can make that trade

01:24:16 But you know, I think the I think the public's entitled to more confidence and the security and safety of it flying

01:24:21 Dr. Mishkati, there's you know, there seems to be like to be two issues about safety

01:24:26 One are the practices in the culture of the manufacturer?

01:24:31 In the other is how much they put profit ahead of safety because it is a trade-off

01:24:37 The more they're gonna focus on safety that's going to come in some expense

01:24:41 And I understand there's problems in both

01:24:45 Of those elements for Boeing it would you say that's true

01:24:49 It was a very much discussed senator. I think in this

01:24:55 seminal book by Peter Robinson

01:24:58 flying blind and the issue of the putting and

01:25:03 basically that this this is a delicate balance senator between

01:25:09 safety and

01:25:12 Accountability and we know that these companies are not in philanthropic business. They need to make money

01:25:18 But it's really the job. This is one of the tenets of safety culture to give

01:25:24 proportional attention to safety goals versus

01:25:28 Production goals and in the case of Boeing

01:25:31 Unfortunately based on the way that is chronicled very nicely in this book that has happened after the merger with McDonnell Douglas

01:25:39 So can you attribute you attribute some of that change to after the merger?

01:25:44 Yes

01:25:45 And they tell me what the dynamic was the dynamic was because if you look at the history of McDonald Douglas

01:25:51 In fact, I was reading another book by John Nance

01:25:54 about it's called blind trust about the series of problems that McDonald Douglas had crashes at that and

01:26:02 The mentality over there was just to push push and make more aircraft

01:26:08 Not really pay attention to detail and then somehow resolve that later and that

01:26:15 unfortunately according to my reading of the book by Peter Robinson and some of the series of great articles by

01:26:22 by

01:26:23 Mr. Dominic Gates in Seattle Times. It also chronicles this issue and we have seen that

01:26:30 Unfortunately, let me ask you one last question

01:26:33 What would you have to see from Boeing to for you to have confidence that they had successfully developed human factors as a technical?

01:26:40 discipline in design practice

01:26:43 in I

01:26:44 Personally and I may distance myself from my distinguished colleague a little bit. I use my

01:26:49 USC professorial academic freedom

01:26:51 I like to see the human factors person the top person have

01:26:57 Equal power and authority as the chief engineer. This is what I like to see

01:27:02 Okay. Thank you. I yield back. Thank you all. Thank you. Thank you

01:27:06 Following up on that. We may have a couple more members coming, but if not, we'll

01:27:12 Conclude the hearing soon, but dr

01:27:15 Mishka D the report states that during the development of the five seven and six seven human factors in flight deck operations were the gold standard

01:27:23 In part because human factor specials worked closely and collectively in Seattle

01:27:28 then the report goes on to say quote the role of human factors is

01:27:32 Its influence eroded to a series of administration issues including reorganization

01:27:37 decentralization downsizing and

01:27:39 relocation of the company's headquarters

01:27:42 What does that have to do with?

01:27:44 human factors

01:27:45 Human factors works very good when they are very close to engineers and system designers

01:27:51 They exchange information they work together

01:27:54 they work on the design of the system and then they work on the training and that and they

01:28:00 They solve that problem together again

01:28:03 I'm not in the business of promoting book, but chapter 9 of this book, which is about human factors, which I

01:28:12 Strongly recommend that that shows the way that the demise of the human factors or erosion of the human factors

01:28:20 one of them for example is chronicled in the book is when and

01:28:25 When the simulator trainings and that was totally moved away from the design and that from Seattle to Florida or somewhere else

01:28:33 That the that is when you see a problem

01:28:36 I think that was just the training though, right the training but before that also the during the design because you get some of that

01:28:44 Input from the training coming back to the design. You think that doesn't exist in a in a holistic way. You're absolutely

01:28:51 Okay, holistic and centralized way. Holistic and centralized. Holistic and central. Okay. Thank you senator

01:28:58 I

01:29:01 Wanted to ask about this and in regards to the FAA

01:29:05 So most of the report is focused on what you can do to make sure that you have a strong safety culture within the organization

01:29:11 And how much that has to be backed up by the FAA. What does the FAA need to do to have its own safety system?

01:29:20 Improvements to make sure that it is thinking about human factors

01:29:24 Or across the board a variety of issues that can enhance security particularly at a time of changing technology

01:29:33 How do we get an FAA who is is up to speed?

01:29:36 Anxious and let's have this group that is at the beginning of the certification process

01:29:41 Kind of detail out more of the risk factors so that that discussion could happen

01:29:49 So

01:29:51 That's actually

01:29:53 You know we focused a lot about

01:29:56 Especially since January 5th on the need to put more FAA boots on the grounds in the factory

01:30:00 And I might by no means saying that's a bad idea. That's an excellent idea

01:30:04 but

01:30:05 What you point out about the technology is why I think that

01:30:09 ODA or DER or delegation of some sort is here with us forever because the FAA

01:30:16 Does not have the resources to be able to

01:30:20 To be the world's experts on these technologies

01:30:25 That's not what they're there for the world's experts reside at Boeing or whatever the key thing

01:30:29 I think is that the FAA has to have the ability to interface with the world's experts

01:30:35 And that's a different set of skills that that that's needed

01:30:39 You're not going to be conducting the cutting-edge research

01:30:41 But you should be able to talk to the people that are developing that technology and be able to understand it and in particular

01:30:48 Understand how it impacts the safety and the operation of the aircraft

01:30:52 I keep going back to a

01:30:55 Something that was said earlier about the need for the FAA to really step up its own SMS

01:31:01 I think that that's that's critical if you have that then you have a chance of being able to

01:31:08 Appropriately interface with the people you're supposed to regulate if you don't have that you're sort of you know

01:31:14 spectators at the at the party here and

01:31:17 I think that that they should be they should be encouraged or directed or whatever it is

01:31:22 However, it is that you do it to to move in that direction

01:31:26 Thank You senator Blackburn. Are you ready?

01:31:34 Madam chairman, and I want to thank all of you for being with us today

01:31:40 I think this aviation safety issue is

01:31:43 something that we are all concerned about and our

01:31:49 We're going to stay in behind this I appreciate the chairman's attention to this

01:31:56 To this issue. Dr. Muscati. I want to come to you and I think I'm saying your name, right?

01:32:03 Correct me if I'm not

01:32:05 I was

01:32:07 reading a report about the aerospace maintenance competition

01:32:12 where the

01:32:15 450 airplane mechanics met to show off their skills and they were working in 15-minute time slots

01:32:23 troubleshooting

01:32:25 Issues and I think in 15 minutes. It's pretty remarkable

01:32:28 what people are able to do and

01:32:32 It's important to know that there are skilled people you look at what has happened with these different

01:32:39 reports, Alaska Airlines United Airlines the Boeing planes that have

01:32:44 Come up

01:32:46 So when you look at this and you see the skills training that some of them have where is the disconnect in this?

01:32:54 Where is is it a lack of skill is it?

01:32:58 a

01:33:00 lack of training or preparation or

01:33:03 You know, is it in attention?

01:33:06 Why are we beginning to have such a negative impact see such a negative impact on on safety?

01:33:16 Thank You senator this issue we didn't

01:33:21 study that here, but your question reminds me of

01:33:25 Aloha Airline and

01:33:28 The accident that it had around I think it was 1998 or so and it was

01:33:34 started with the aviation maintenance related problem and at that time

01:33:39 FAA

01:33:42 Really looked a very hard look at the aviation maintenance and they I think they created a program called

01:33:49 National plan for aviation maintenance and then at that time one board member of

01:33:56 NTSB who was later elected to NTSB

01:33:59 The honor where John Golia pushed on this a lot the issue of aviation maintenance

01:34:04 ma'am is extremely sensitive to the human factors and safety culture issues that

01:34:10 My colleague dr. Dillinger is talking about here

01:34:14 Dr. Dillinger, let me come to you because I know you conducted hours of interviews for

01:34:25 The safety report that you produce did you?

01:34:29 Speak with any of the whistleblowers when you conducted those interviews

01:34:35 As

01:34:41 Far as I recollect we did not speak to why did you not talk to any of the whistleblowers?

01:34:49 That was not what the purview of the

01:34:55 Of the panel and at the time

01:34:57 I don't think we weren't aware of the whistleblowers

01:35:01 Let me ask you this then does Boeing do enough to ensure that their employees know that there will be no

01:35:08 Retaliation if they come forward and report safety issues

01:35:13 The panel believes they need to do a lot more than what they are currently doing and

01:35:22 You know one of the things that we have heard from

01:35:25 From NTSB is that there is a problem getting information from Boeing

01:35:33 Do you think that Boeing executives do not understand when there is an investigation they need to come forward with complete information?

01:35:42 I mean I can't speak for the executives. I will say that Boeing is a very large and very bureaucratic company

01:35:52 That produces a lot of paper

01:35:54 and

01:35:55 I'm not surprised that there are lags and their responses because that's there

01:36:00 They're just that's just the way it is, but I can't speak for them. I

01:36:03 Will tell you reading the report and Boeing's

01:36:09 safety culture being described as inadequate and confusing

01:36:16 This is something that harms the flying public and I appreciate the attention to the issue. Thank you madam chairman

01:36:22 Thank You senator Blackburn

01:36:24 Senator Warnock Thank You madam chair

01:36:26 Listen the stakes are simply too high

01:36:29 For commercial aircraft to have the kinds of systemic problems that we're seeing with Boeing

01:36:36 So I'd like to examine how we got here with this panel

01:36:41 Dr. DeLuise

01:36:43 Yes, or no

01:36:45 through

01:36:46 organization

01:36:47 designation authorizations or

01:36:49 ODAs can the FAA can the FAA

01:36:53 delegate certain safety

01:36:55 certification and other responsibilities

01:36:58 To an aircraft manufacturer like Boeing

01:37:02 Yes, or no

01:37:05 Yes, yes

01:37:09 Currently

01:37:13 Yes, because it's done with other manufacturers

01:37:17 But there are issues as described in our report that makes us

01:37:22 Be weary of saying yeah, go ahead and just do it. I think Boeing needs to prove that it is capable of doing

01:37:30 The question is

01:37:33 Are they able to delegate certain safety and certification?

01:37:38 Responsibilities to an aircraft like so so they are the answer is yes, correct. Okay. So dr. Dillinger yes or no can a

01:37:46 An aircraft manufacturer like Boeing

01:37:50 subcontract

01:37:53 Manufacturing responsibilities for say the fuselage of its signature mass

01:37:58 max aircraft line to the another company

01:38:05 The work of the panel I think would say yes like with ODAs that we heard

01:38:11 successful examples of ODA delegation, however, the concerns remain about the

01:38:19 Risk that Boeing safety culture presents to that process. Yeah, I

01:38:24 Share that concern which is why I'm asking the question. Dr. Mishkadi. Yes or no. Can a manufacturer

01:38:30 subcontracted by Boeing

01:38:33 such as Spirit Aerosystems assign

01:38:35 Manufacturing responsibilities to an international affiliate in Malaysia, for example

01:38:43 787 is now made all over the world being seen one country at the other being in another country fuselage in another country

01:38:54 They are doing that

01:38:56 So so the authorization

01:38:58 Can then be passed?

01:39:02 From FAA to a manufacturer

01:39:06 The manufacturer can subcontract that manufacturer

01:39:10 responsibility

01:39:13 To another entity and

01:39:17 Then the manufacturer subcontracted by Boeing can assign manufacturing responsibilities to an international affiliate

01:39:24 Which which I'm sure you've realized that what we walk through step by step is a supply chain

01:39:32 Of the Boeing max 9 aircraft at the heart of the near catastrophic

01:39:38 Door plug blowout that happened on January in January

01:39:43 2024 to an Alaska Airlines flight

01:39:46 You know, there are many words for this you can call it delegating

01:39:52 Subcontracting

01:39:54 Reassigning at the end of the day is outsourcing

01:39:58 Outsourcing key responsibilities none more important than safety oversight to someone else to someone else

01:40:04 to someone else I

01:40:07 Submit that while we're focused on Boeing. This is obviously not just a Boeing problem

01:40:12 This far too this is far too common across aviation systems and its suppliers

01:40:18 Whether the result of poor leadership a focus on production targets

01:40:24 Profit margins at all costs even the cost of safety or some combination of both

01:40:30 Congress must take a serious. Look at this culture of outsourcing

01:40:35 and its safety implications

01:40:38 This is an instance in which we can't afford a mistake it cost too much

01:40:48 Dr. Dillinger what more can Boeing do to improve its safety culture and our own risk and our own

01:40:54 responsibility for the safety of its products

01:40:57 Thank You senator the panel

01:41:02 Focused a great deal on safety culture and there is so much that they could be doing

01:41:08 Part of it has to do with the timing and if they were to accelerate the efforts

01:41:14 I think we and the panel thinks that that would be beneficial

01:41:18 there has been a very soft start to that to implementing the training to

01:41:25 getting feedback back from employees via their own surveys to

01:41:31 providing workshops to

01:41:34 focusing specifically on

01:41:37 training at different levels

01:41:39 So for example executive training, yes, but down through the other layers of the organization to managers and supervisors

01:41:47 targeted training

01:41:49 Those are there's a multiple ways that they could be going after that and as they look at a more comprehensive

01:41:55 Way where they really dive in and in a more timely way address that the panel

01:42:02 Felt that that would be important and that it was in our recommendations. Thank you. Thank you so very much for that

01:42:07 Dr. D Louise and dr. Meshkati last question. What more can Congress do?

01:42:12 to encourage both the FAA and

01:42:16 Manufacturers like Boeing to take direct responsibility for the safety of aircraft and our aviation system. I

01:42:23 Believe that

01:42:26 the Congress in this committee needs to keep the essentially the pressure on to make sure that

01:42:35 The F the waivers are not granted on safety related issues

01:42:39 for example

01:42:39 That would be a good thing because they they right now there are a handful of waivers on the max

01:42:45 that directly affects safety

01:42:48 but you need to keep the spotlight on this because

01:42:52 In during our interviews we heard often the sentiment expressed. Yeah, this is happening now

01:42:59 but as soon as everybody moves on to something else, we're gonna go back to the way things were and

01:43:05 That can't happen it's - as you say, it's too expensive and the cost in human lives is way too high

01:43:12 Thank You senator that is also related to earlier question by senator Cantwell

01:43:18 I think what Congress can do is a VFA and that's also related to the SMS

01:43:25 There is a document which is signed by FAA

01:43:28 Administrator and then chair of NTSB the honor of a Robert some world is called state safety program

01:43:35 this is something that United States files with the

01:43:39 international civil aviation

01:43:42 organization

01:43:44 In this one, this is very interesting senator

01:43:47 It talks about the safety management responsibility for this state for the application of SMS at FAA

01:43:56 What I would suggest and what can Congress do is to create another panel like the one that we are in

01:44:03 section 103 to look at the implementation of this report and how does United States stand

01:44:11 vis-a-vis this report if this

01:44:14 state safety program being fully implemented what needs to be done because that has a

01:44:20 kind of

01:44:22 impact or it can

01:44:25 tremendously impact

01:44:27 FAA's power on

01:44:29 using basically in the case of SMS for example in

01:44:34 United States is only FAA

01:44:37 Correct me my colleagues here has the SMS on for air traffic controller

01:44:43 And SMS needs there is a notice of rulemaking for SMS

01:44:49 But SMS needs to be fully incorporated and if this document be

01:44:55 Fully implemented at FAA and other places. I think that would be a good solution. Thank you so much

01:45:03 I know I'm way out of time

01:45:05 Appreciate your indulgence madam chair, and I look forward to working with my colleagues on this committee to improve aviation safety

01:45:12 Thank you so much

01:45:13 and just to clarify again one more time on this issue because it's related to what he said and

01:45:18 Senator Schmidt and I want to emphasize you know people we all represent big aviation states

01:45:22 We want this to be right and we definitely

01:45:25 Believe in the workforce that we have in our states

01:45:28 We want them you know to continue to grow in expertise and excellence

01:45:33 So recommendation 30 and 31 of your report

01:45:37 says foster an effective safety culture and publish a

01:45:40 Roadmap for workforce development with engineers and inspectors and oversee SMS for design and manufacturing

01:45:46 organizations and partner with industry to measure the success of SMS and

01:45:52 Design an organization jointly reviewed these measures of success on a regular basis

01:45:58 Okay, those are two key recommendations about SMS

01:46:01 So the FAA is now in this rulemaking that is going to come out in the next 90 days

01:46:06 And so what specifically do you want to see in that rulemaking that will help guarantee?

01:46:11 This success and then secondly what do we do about this problem that dr. DeLuis?

01:46:17 suggests which it listen it's a whole of

01:46:21 government issue if you ask me because

01:46:24 We could act as dr. Dillinger about space in general

01:46:28 But it's we're trying to keep the government at pace with technological change

01:46:33 So you're saying the FAA may not have some of these people and so how do we?

01:46:38 What do we need to do because obviously we do want to listen to what these sectors say and and they have input

01:46:45 They they really have some of the smartest people about this technology, but we also have to get our oversight correctly

01:46:51 So how do we make sure the FAA rulemaking has what we want to see in it, and how do we deal with this?

01:46:56 lack of

01:47:00 Engineering if you will skill set at the FAA not at the company at the company. I think it exists

01:47:05 I think we're just not listening closely enough. I

01:47:07 Think if I if I may I think that with the rest of your first question fortunately

01:47:13 SMS isn't new right it's been around in the aviation world now for

01:47:18 30 years, but it was voluntarily implemented as part of a 2015 consent decree instead of being a real mandatory SMS

01:47:26 So I'm hoping the FAA gets this right this time

01:47:29 But no what I meant is is that it's been in the aviation industry for 30 years not at Boeing you're absolutely correct

01:47:34 So fortunately I mean in a sense all the FAA has to do is is look at what it's done successfully with

01:47:42 organizations like the airlines and and others and

01:47:46 Apply those same

01:47:48 Standards and the same rules to to Boeing so they're there

01:47:51 They don't it's not a blank sheet of paper is what I'm saying they got something to draw

01:47:54 With regards to your other question. I've always been a strong advocate of

01:47:59 Government agencies like the FAA drawing on the resources of the National Academies

01:48:05 I mean I see when when new technology enters a field such let's say for example AI for example

01:48:11 Because that's the one that's that's the new technology du jour right now

01:48:15 You know I've always been an advocate that you know you have these

01:48:18 National Academies right down the street here with members that you can draw upon to basically go in and advise and gives that people that

01:48:26 know know a lot more about these subjects than any of us and

01:48:29 I don't some some some organizations do it more than others

01:48:34 But I think that the that that's a resource that FAA and NASA and other agencies

01:48:40 Don't don't use enough in my in my opinion

01:48:44 The National Academy I have just one good news

01:48:48 Dr. DeLuz

01:48:50 FAA has gone to National Academy and National Academy has created a

01:48:54 panel of they call it community of expert for risk analysis of

01:48:59 Transport aircraft and that one I have the privilege of being a member we meet over zoom

01:49:05 Weekly, and I think it has been great because FAA has reached out to nuclear power industry for that community of experts

01:49:14 How do they do PRA probabilistic assessment they do that here back to you senator Cantor?

01:49:20 I think that two recommendations that you brought up 31 and 30 is fantastic

01:49:26 That's exactly that I think in light of this state safety program if these two be combined together I

01:49:34 Think that's gonna be a paradigm shift for SMS well

01:49:39 I I think it's pretty simple to get a real SMS

01:49:43 And I think it's a great idea as we envisioned in Anxa to get a panel of experts

01:49:50 I'm glad to see that that is actually happening with the National Academies as it relates to this

01:49:54 Input I don't we'll have to query the FAA more on exactly how broad that can go dr. Dillinger

01:50:03 I'm gonna leave the last question to you because

01:50:05 you know is

01:50:07 Is is painful as all this is to me we can get through it and and I?

01:50:12 Think you're referencing your work on the Columbia

01:50:17 That was also a very painful moment for NASA a very painful moment for this committee. I sat on the oversight

01:50:23 investigation of that that the committee did in joint

01:50:27 session with

01:50:29 other

01:50:31 Senate committees so but but we did get through that. What do you think are the lessons learned here?

01:50:37 How can you how can we successfully move past to this and on to?

01:50:41 The success that we want to see in aviation

01:50:44 Because I think the foundation is very strong. We have a great hundred years of aviation success. We want to build on it as dr

01:50:51 Louise said we want to be known for the successes that the United States has had in aviation

01:50:56 And I I think the elements are there, but what is it that we need to do to learn from what Columbia learned on?

01:51:02 How to move forward

01:51:05 Thank You senator that has been my life for decades

01:51:08 I think

01:51:10 What we learned from Columbia that's applicable here and was applicable to the report is how important people are and the?

01:51:19 Relationships between people that's what the safety culture issues all address. It's about trust

01:51:26 it's about communication, it's about being there and

01:51:31 Having a workforce that comes in that is prepared that's trained. That's energetic. That's curious

01:51:38 that's dedicated that will work their heart out an

01:51:41 organization can recover from a catastrophic loss

01:51:45 when that's happened by pulling all of those resources together and

01:51:51 Focusing on then the mission and how everybody works towards the mission to make that happen

01:51:58 but to do that all of those parts including the processes have to come together with safety as a

01:52:05 priority where people

01:52:07 Understand that it's just part of doing business

01:52:11 It's Brian O'Connor the former chief of safety for NASA used to talk about

01:52:16 It's safety isn't the mission. It's how we do the mission and

01:52:21 That's a critical lesson learned for for us. Thank you

01:52:27 Well, I want to thank the witnesses again today. You'll

01:52:30 The record will remain open until May 15th any senators wishing to submit questions for the record should do so by May 1st

01:52:38 And we ask responses be returned by May 15th that concludes our hearing today and again

01:52:43 Thank you for your report and your willingness to be here today. We're adjourned

01:52:47 [GUNSHOT]

Maria Cantwell Leads Senate Commerce Committee Hearing On FAA ODA Expert Panel Report

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