Aviation Safety Specialists Testify on Boeing Safety Culture : CSPAN3 : May 14, 2024 5:59pm-8:03pm EDT : Free Borrow & Streaming : Internet Archive

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>> the house will be in order. >> this year, c-span celebrates 35 years of covering congress. since 1979, we have been your primary source for capitol hill, providing balanced, unfiltered coverage of government. all with the support of america's cable companies. c-span. 45 years and counting, powered by cable. >> aviation spate -- specialists from boeing highlighted the alaska airlines for plug failure while in flight, reports of employees being penalized for raising

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safety concerns, and the faa role in ensuring safety enforcement. this is two hours. role in ensuy enforcement. this is two hours. >> good morning. the committee on commerce science and transportation will come to order. i want to thank our witnesses that are here today on the faa oda expert panel report. i want to recognize our former colleague, peter defazio, who

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is in the audience but we will hear from three experts . i appreciate the witnesses being here today, but i want to acknowledge that this is directly from the report, that, quote, the successful completion of this report was made possible with the cooperation and assistance of the following organizations. the federal administration -- at deviation -- aviation administration. special thanks to britney goodwin, mina mitchell, and analysis teams within the office of faa's oda. i want to mention that because you are the representatives of all those people today.

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we could've had many people here, but we appreciate the work of the chairs of the committee and for you being here as representatives of these individuals today. we are joined by dr. javier de luis. we have dr. tracy dillinger. the expert panel has 53 recommendations regarding boeing's oda system. safety culture serves as a catalyst for us in future aviation . some of that is still playing out with a new

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administrator who is more aggressively taking the responsibilities of the act seriously. we look to build on those advancements with a five-year authorization bill and some enhanced safety features. we are not going to stop there. there is more to be done to implement the recommendations from the report. we owe a debt of gratitude to those who are here today. i want to especially thank you, dr. javier de luis. thank you for being here. i can't imagine the tragedy of losing your sister and one of the max crashes and then continuing to be involved in trying to correct and improve our safety culture. i so appreciate you being here and the active role you have played in these discussions. the expert panel's report focuses on the importance of safety management systems. they wanted to adopt an sms as part of the faa settlement agreement. while the faa offered voluntary sms systems, we need

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a real sms with teeth. they need strong safety management systems. not in name, but in reality. safety management system might sound to the public like management strategies that they shouldn't pay attention to, but when it comes to this management strategy, and it revolves around aviation, it is about saving lives. that is why section 102 required that the faa develop a sms standard for aviation manufacturers, and the agency expects to finalize that sms rule this june. this expert panel made several recommendations findings about the safety culture and about oda. i want to highlight some.

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that boeing safety procedures are not thoroughly understood throughout the company. i'm sure you'll expand on this, that it is focused on only one of the four pillars of the --. i'm sure you will expound this. they raised concerns about the faa's ability to oversee boeing's sms and i think the faa needs not only a strong workforce strategy to exercise the oversight of the manufacturers to ensure proper implementation of sms. i would like to query the panel today on exactly what sms the faa should implement in their own house to make sure they are improving the safety culture and standing up on these important safety measures. right now, we are relying on employee safety reporting systems, speak up, what you talked about.

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a comprehensive system that employees know and understand has to be a key component of sms and the condition provided by the interviews of boeing employees show that they may not have understood how safety fit into the culture of the overall obligations of the company. human factors have not been prioritized as a technical discipline and human factors are at the core of focus of what we need to do both at the faa and that boeing. while i think you did talk about the loss of experience and capability of a workforce, we definitely want to build that expertise throughout government. clearly, at the faa, so they can keep pace with technological change. and while the restructuring of the boeing oda unit did decrease the opportunity for retaliation, we are still seeing that interference is occurring. this is unacceptable.

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they strengthened the faa oversight and put them in charge of these employees and we certainly expect the faa to back up those individual engineers and machinists who are calling out safety and making sure that they address those. although the final report gave boeing six months to make this action plan a reality, the recommendation -- at the faa administered are cut this time to 90 days and i expect the company to comply with this deadline and submit a serious plant that demonstrates this commitment to these kinds of safety measures. the faa must also demonstrate that it is going to be a strong regulator on these issues. i hope to query the panel about how to ensure that, how we, as the oversight committee of the faa, basically strengthen this oversight by the faa. i look forward to hearing from our witnesses today. again, thank you so much for being here. now, turn to senator cruz for

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his opening remark. then we will hear from our two subcommittee colleagues on their statement, as well. senator cruz. >> thank you, madam chair. the united states sets the benchmark for flight safety and arguably the most important measure, and 2003 was a remarkably safe year for aviation with no fatal accidents or home losses for commercial jet aircraft. flying commercial remains the safest way to travel, but understandably, recent incidents have left the flying public worried. the perception is things are getting worse. the public wants of the federal aviation administration and congress to confront perceived risks in order to restore confidence for flyers. that brings me to the topic of today's hearing. the faa's organization designation authorization program. oda is important to the future of aviation safety, as well as

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to american competitiveness. i appreciate the work of art congressionally appointed panel that reviewed boeing's oda for transport airplanes. congress established this panel after the crash of lien in 2018. 346 people tragically lost their lives. the final report was released in february. three of its members are here with us today. welcome. as a brief aside, i want to in particular acknowledge that one of our witnesses, dr. javier de luis, lost a sister on flight 302. dr. de luis, please accept my sincere condolences and thank you for continuing to speak out on an issue that i know has grieved you and your family personally.

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i also want to recognize the other families that are here today remembering their loved ones whose lives were lost on those accidents. discussing oda and what changes may be needed is critical. i will come this conversation. it is worth noting that the faa is implementing the accountability act, this committee's response to the max eight crashes. it is -- has not implemented the act, even as we are negotiating the reauthorization. the culture needs drastic improvement. we should not rush to legislate just for the sake of legislating. to that point, i look forward to engaging with today's

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witnesses, all of them deserve our appreciation and thanks for their hard work on this effort. their report was a consensus prodded, issued without consent -- dissenting views, which all of a sudden congress can appreciate that it it is no small accomplishment. i hope to better understand their recommendations and how congress can work to improve aviation safety in a targeted manner. while discussing oda, boeing's safety culture is important. the flying public is worried about wipe pieces of boeing airplanes are falling from the sky. the expert panel report noted that the panel was not directed to investigator providing regulations towards specific incidents or s which occurred prior to or during expert work. in addition to today's hearing, i think we have to hear from the faa and from boeing itself about episodes like alaska airlines flight 1282. our committee needs to understand not only boeings

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odas, but the missteps that caused the incident. we need to hear about the safety culture and safety management, writ large. the public will want to know what changes boeing is making to restore confidence in its brand. boeing is a great american company with a great history and great legacy. we all want boeing to be successful. but when accountability is needed, and it clearly is here, we should not hesitate to demand answers. and for boeing to succeed going forward, those answers need to be given, and changes need to be made to ensure that safety is central. when each of us, when her family, when our children get on an airplane, we want to trust that we are going to land safely.

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that is the topic of this hearing. and i hope subsequent hearings, as well. >> thank you. >> thank you, chairwoman cantwell for holding this hearing. i also want to thank our witnesses and those who worked on the expert panel review. this confirms my view that we need to judge boeing by what it does, not what it says it's doing. boeing says it prioritizes safety above all else, but when the expert panel asked them to produce evidence of this kind, the evidence that boeing provided did not provide evidence of a commitment to safety that matched boeing's descriptions of that objective. that should be shocking. based on some of their recent actions, frankly, it is not. weeks after a door plug blew out of a 787 max 9, boeing was

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petitioning faa to rush plants into service. it had a known y catastrophic safety defect. to its credit, under pressure, boeing eventually withdrew that petition, but the fact that they filed it in the first place speaks volumes about a proper safety culture at boeing and the lack of a proper regulatory culture at the faa. they felt this petition because they thought faa would grant it. boeing thought they could minimize the safety of the defect. boeing had a good reason to think this. the faa led boeing slide for years. and go figure, we are seeing more bad results but i will give two examples which i think are particularly relevant to our discussion today about boeing's designation authorization, or the oda.

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they played down the mcas so successfully that they to get out of the flight manual . investigators uncovered and internal boeing memo showing that boeing had been planning to downplay mcas to avoid regulatory scrutiny. the plan called for boeing to not even use the term mcas when describing the plane to a regulator. even worse, the memo showed an oda member approved the plan. when this memo surfaced, the faa did nothing. it did not even investigate. by sitting on its hands, the faa told boeing that this type of conduct was perfectly fine. the second example concerns the aoa disagree alert. boeing found that the aoa

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disagree alert was not functioning on most of the 787 max jets. boeing intentionally concealed this and continued to manufacture more 787 max jets with the same defects. in other words, boeing made a decision to knowingly and repeatedly violate its approved type design for years. boeing's oda know about this but did not alert the faa. one faa found out that boeing had been repeatedly violating its type design, the faa did nothing. this effectively told boeing that type design doesn't matter because the faa isn't going to always enforce it. when the faa fails to take action in response to bad behavior, it sends a message to both boeing and its employees that that behavior is

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acceptable. no wonder the expert panel found that boeing employees are so confused. faa needs to more closely scrutinize boeing's behavior and make use of its civil enforcement authority when appropriate. i am pleased by the more aggressive regulatory tone administrator whitaker has brought to the agency. as this expert panel review makes clear, there is still a long way to go to bring an effective safety culture back to boeing. we have our work cut out for us on this committee as we continue oversight and consider whether additional legislation is needed. i think the panelists for being here. i appreciate your hard work on this to make flights safer for the american people. thank you and i yield back to the chair. >> thank you so much, senator duckworth and for your leadership and your help on the faa reauthorization safety improvements to that bill. i guess senator moran will not be here for the opening statement. i'm sure he will be attending. we will go to the witnesses. dr. de luis, thank you for

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being here. you are free to open -- making opening statement. >> thank you very much, senator. chair campbell, senator cruz, on behalf of myself and the panelists, i want to thank you for the opportunity to come here and talk about our recommendations from the final report. my name is dr. javier de luis. i meant aerospace engineer. i spent my 40 year career in private industry, mostly running small businesses that helped start where we built hardware for nasa, dod and other agencies. i'm currently a lecturer at mit. my sister was killed in the airplane she was on, the 737 max. a crash after takeoff, killing all the people on board. this has been an opportunity for me to prevent anyone else from going through what i have expensed these past five years. our panel met for almost a year.

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we interviewed 200 boeing employees from the exit of sweet down to the people that tighten the bolts across six different geographic plants from across the country and we reviewed thousands of survey responses that came to us through several surveys that we have conducted. s has been noticed in the consensus report -- i would be remiss if i did not give full credit to this to michael barjon and keith morgan for hurting this unruly group to a hopefully productive end. our panel was charged to focus its review on three specific topics. safety culture, safety management systems, and the oda program at boeing. we were also allowed to evaluate other topics of concern that would impact the

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safety of the flying public. as aoa disagree alert noted, we were not charged with investigating specific airplane incidents that occurred prior to our panel, but it is understandable -- on several occasions, when safety issues arose, with boeing products, we considered them. my fellow witnesses and i felt it would be useful to expand on several of the key recommendations in our report, as this may set the stage for today's hearing. first and foremost, it's one that has been talked about since the report came out. our finding that there exists a disconnect, for lack of a better word between the words that are being said by boeing management and what is being seen and experienced by employees across the company. they hear safety is our number one priority. what they see is that that is only true as long as your production milestones are met.

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at that point, it's push it out the door as fast as you can but they here speak up if you see anything that is unsafe. what they see is that if they do speak up, they get very little feedback, and if they insist, they may find themselves at the short end of the stick the next time raises or job transfers,, or were spread we u almost at all levels and worksites we visited. we heard it from technicians. we heard it from engineers. we heard it from members of the oda that are delegated by the faa to conduct inspections and tests on behalf of the government. to me, it is clear that the commitment to change, the level of change, and the pace of change that boeing is not commensurate with the events that created the need for all this change in the first place, namely, the two fatal crashes

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of two brand-new airplanes five years ago. it was distressing to read a recent statement by bryan west, the cfo of boeing, speaking about the alaska air incident from this past january where he said, for years -- this is a quote -- for years, we prioritized the movement of the airplane through the factory over getting it done right. that's got to change. the leadership team got it in the immediate aftermath of january 5th. now, i would've thought that they would've gotten it five years ago. in closing, i will note that for the last 20 years, every faa reauthorization act pushed more and more responsibility to the many pressures side. at the time, this was done with the objective of increasing efficiency and productivity. the two max rashes showed that the pendulum swung too far. but that cannot be the high watermark.

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you have to increase the faa oversight of boeing. you have to ensure that all of our panels are fully implemented. this is the only way we can return this company to what it once was. a company known for engineering excellence predictably where the headlines were written about it because of its accomplishments and not because of its failures. i believe the flying public deserves no less. i will now turn it over to my colleague, dr. dillinger. >> dr. dillinger, welcome. whatever opening statement you can make, that would be great. >> thank you. >> jerry cantwell and members of the committee, thank you for the opportunity to discuss the oda . i am dr. tracy dillinger. y the senior executive psychologist for safety culture and human

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factors program within the nasa office of safety assurance. i have checked the agency's safety culture working group and the human factors task force. i'm responsible for nasa's safety culture survey, safety culture sources, audits and assessments, human factors, human factor training, and our annual human factors report. i'm also a proud veteran of the united states air force. for over 20 years, i was eight human factors investigator, human factors instructor, 10 years as the chief aviation psychologist, and in numerous roles including the chief of safety assessments for the air force safety center and served investigation board. i have spent the majority of my career working in the field of aerospace and aviation safety. i am truly passionate about

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safety culture, human factors, and their combined effect on organizational performance. clearly, a robust safety culture is essential to safety is a nasa core value, along with excellence, teamwork, integrity, and diversity. and it is integral to everything we do. we strive to create an environment where everyone works safely, feels comfortable communicating safety issues, learns from both mistakes and successes, and feels confident balancing challenges and risks. the international civil aviation organization describes safety culture as arguably the single most influence on the management of safety. it recognizes the interdependence of safety culture and safety management, noting that effective safety management empowers a positive safety culture and a safety culture empowers effective

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safety management. i was wished to participate in the oda panel, or i let my passion for safety culture to the work of my fellow panelists, with whom i had the privilege to serve. boeing, like nasa uses the five factor model of safety culture comprised of reporting, just, flexible, learning, and informed elements bridwell the company has begun addressing reporting and just culture training, it needs to enlarge its safety culture program to include all areas with all five factors, using multiple means, and the program should be endorsed, promoted, and modeled by its leaders. employees, including team leads, managers, and senior leaders, need to know what to do when a deficit has been reported.

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that includes ensuring that tools and processes are available so employees can report without fear of reprisal . managers can listen, reported issues are fixed, and then communicated, with recognition given to those who have come forward with concerns. it is equally important that senior leaders continually message and demonstrate to their workforce that safety is a critical, fundamental aspect of doing business, even over profit. aviation safety isn't just good for the flying public. ultimately, it is good for successful operations. and mission accomplishment, and that is good for business.

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i believe that successful adoption of the reports recommendations will improve the level of safety provided by boeing to its workforce operators and the public. i would note that while the panel focused on boeing as the oda holder, the panel's findings and recommendations contained numerous best practices that could assist other companies with similar authorizations to implement successful safety culture, safety management systems, or oda programs. thank you once again for inviting me to appear before you today. i look forward to discussing these important issues with members of the committee. i yield to dr. meshkaty. >> thank you for inviting us to

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testify before you today. i am najmedin meshkati. i'm the professor of engineering at the university of southern california. i'm also a senior faculty member with the the u.s. aviation safety program. i have an affiliation with harvard. for the past four decades, i have been conducting interdisciplinary research on system safety, human factors, safety culture and risk reduction of complex technological systems. these systems include aviation, oil and gas drilling, pipeline, and refining, and healthcare.

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system failures have a deadly impact on humans and the environment. at usc around this area. rses i have been involved with several investigations. i have visited several nuclear plants. but my participation in this panel, working with my great colleagues on this panel, it further corroborated what my colleagues have said. safety culture is the foundation , as a dr. dillinger mentioned. safety culture is the foundation of any processes in the organization. the could make or break the system. as my mentor, professor james

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said, quote, safety culture can affect all the elements in the system for good or ill. end of quote. i believe safety culture is analogous to the human body's immune system. it protects it against pathogens and fends off diseases. it is incumbent upon the leadership of any organization to strive for immunizing and constantly boosting the healthy safety culture of the company. the healthy safety culture is based on competence, trust, transparency, and responsibility. another equally important lesson that i have learned by my participation on this panel, which corroborated what i have

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learned in my career is that human operators in this safety critical system, such as pilots and the airplanes or human operators in the control room of a nuclear power plant, always , they are the first and later -- last layer of defense. human operators. as we saw with the miracle on the hudson and at fukushima nuclear plant. as such, we recommend human systems integration. it should receive attention commensurate with their importance in aviation safety and aircraft operation. human factors is a crosscutting science. it should become the formal, standalone, and highly

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prioritized discipline -- and a design practice at boeing. by research experts estimate that a world-class engineering company that makes or operates a safety critical system such as aircraft must be run by world-class engineers, who are thoroughly trained to understand, respect human factors and safety culture. thank you once again for your attention to our panel's report, and having us before you. >> thank you to all the witnesses. i appreciate you being here. i think i have a question. generally, i want to draw this out a little bit from the report because you emphasized it. some of these terms may just be

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lost on people in their significance. you are saying there isn't a singular culture program on safety that is understood by the employees or that is implemented and responded to by the employees. i'm going to get to a question about the machinists. the front-line people are saying these are the safety problems. i want to understand why the phenomenon exists. i think your report says because there are three different programs and people don't know what to pay attention to at any given time. is that a correct understanding? >> i think there are a couple of things there. i will try to tease them out. it is true that there is an overwhelming amount of documentation on sms and safety culture at boeing. as has been described to me by

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someone recently, it is like if you are trying to teach her get to drive and you give them the statute book on all the road rules -- what they really want is the driver's manual. what you are referring to is one observationally made that all that augmentation that exists right now on sms and safety culture checks all the boxes that you are supposed to for the person on the ground, they don't know. we said, what is the safety metric? how do you know you are doing the safe thing? we got there in the headlights. we got production metrics. there wasn't anything about that. that was one thing. i think the thing you are referring to about multiple ways -- there were multiple reporting ways right now at

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boeing. that is not necessarily a bad thing. having multiple ways of reporting is good and encouraged. the problem we found was that, you know, they just didn't -- there was a lack of confidence -- if you try to reported and not ominously -- anonymously -- there was a lack of confidence that it would be anonymous. there was a very real fear of retribution and payback. those are things that are not compatible with any sort of safety culture or sms system. >> any other witnesses want to add to that? >> boeing has been working to develop and field a safety culture model throughout the organization. they have been successful in providing training on some of the elements of it. they have not yet put it all together so that it works

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together as a system. at nasa, we use the dna logo for it. all of those parts work together . when someone reports something, someone has to listen to it. the way they treat them has to be fair. there needs to be an environment of psychological safety. they need to learn from that and communicate it and pass it on, and to create that, everybody in the system needs to know what they are supposed to do and how to do it and what is expected of them. and if that doesn't work, they need to know the next option. if that doesn't work, they need to know the next option. that is why having multiple systems needs to work. they need to know where else they can go to. one of the things for example would be to know, who is the chief of safety. that is where the buck stops.

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one of the surveys we saw -- 95% of the people that responded to the survey did not know who the chief of safety was. that is a deficit that could be corrected, but people need to learn who the key people are in that system so they know who they can go to when the processes don't work. >> well, i wonder, to what degree this committee -- or i did, a whistleblower report that detailed in 2021, a report where management overruled an engineer regarding a lithium ion battery in the 787. later, the faa had to ground the plane. there was an instance where people were not listening to

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what people were saying on the line. what needed to be done. there is another incident where dr. martin stated a more secure safety reporting system may have prevented him from facing regulation for complaining about different components not meeting faa standards. how do we ensure that those that are speaking up about safety measures get listened to? i'm sure in this case, these two new who to go to, but just because they have been very experienced people. but they were not listened to. what do we do with this part of the problem? what do we need to do with the faa? >> well, in a properly functioning sms, and a properly functioning safety culture, discussions would not be asked. people would be empowered. people would have confidence that they wouldn't be smacked

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down if they spoke. i don't think that is what we are dealing with here. it is one of the reasons that -- and one of our recommendations, we encouraged -- we recommended that boeing establish what i call asap programs. aviation safety action programs. they are common with airlines. it is a tripartite program. it has the faa, the labor, and the management. if you initiate an asap event, you are protected. more importantly, the event gets visibility at the faa level , as well as the management level. for me, when i started on this committee, i quickly became a comfort to visibility because i'm convinced that if enough eyes had seen the design 10 years ago, somebody would have raised their hand and said,

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hey, wait a second, maybe having a system where if one sensor fails, it crashes the plane to the ground, it's not the best idea. they didn't because as was noted, it was purposely hidden. >> to be clear, there were whistleblowers who did bring this up and said that it was unsafe, but they were not listened to. they were not listened to. this is why we are saying good engineering, i think you agree, wins the day. people have to listen to the engineers. we are trying to discover here -- our committee can only do the oversight of the faa that enforces the faa to do its job correctly. and we want to know what we need to do to strengthen this. but my time is expired. i have a suspicion i'll be able to come back to this. i turn it to senator duckworth. >> i want to go deeper into this conversation. it has been a lot of attention on the lack of quality control

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throughout the supply chain. this is understandable, and yet, as we have heard, the expert panel has identified a broader problem at boeing, the utter absence of an effective safety culture. i fear that increasing scrutiny on how a door plug is replaced will fail to solve the fundamental cultural failures that are at the root of the boeing's flawed development of the 737 max. i would love to go deeper into the conversation we are having. fixing a specific assembly-line problem would not be sufficient to get boeing back on track. frankly, i personally think that boeing's recent manufacturing problems or symptoms of a deeper problem, the destruction of a proper safety culture by share obsessed executives. it is the replacement, the driving out of engineers out of the heart of what boeing was.

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can you talk about manufacturing problems as a symptom of the bigger problem. you can just fix the quality control issue and think that will solve it. >> i agree. everyone has seen the picture -- sitting there. without that, you can see the fourth one. everyone goes, the bolts are missing. where was the inspector? okay. it should've been inspected. more importantly, i think, why did the mechanic install the door and walk away, leaving it in that condition? why wasn't he or she trained to know that you just can't do that? right. that is where you go to, you know, yes. more inspections is good. i think you can't inspect your way to quality and safety. all it takes is one slip, and we are back here again. it's got to be in the dna of

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the people that understand that you don't walk away from a door, leaving it in an unsafe condition. you can take that further and say, you shouldn't design a door which allows the bolts to be separated from the door so that nothing can be captured. you can take it all the way to the design level, but i agree that just putting it out, likable, trying to play like a mole -- whac-a-mole is not possible. you don't let cars move forward. when they have defects pretty fix --. you fix the defect and figure out why it is happening. the line keeps moving forward when problems arise on the line. until they take a page from what the u.s. auto industry learned, we are not going to figure out

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how to get where we need to be with boeing. >> i agree with you. that picture was from a cell phone message. when i flew for the army, it was all paper logs. they couldn't find any logs for anyone who inspected it. they haven't been able to identify who did the work, but that picture wasn't even official. that was a text message between workers. i want to get into the oda reforms. i am frustrated that boeing's oda allows opportunities for retaliation against those who raise safety concerns. they found problems tracking safety concerns once they were made. this sounds like how it operated before they passed the acsca act. we talked about this a little bit.

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they found that 26% of respondents from the certification service believe that pressure got in the way of those positions and 49% of respondents said they did not address it. they do not bother to report them. i would love for both dr. de luis and dr. meshkaty to address this. >> this congress have more legislative work to do? what would you recommend we do? we made suggestions, but i would love to hear. >> thank you. that has been a major issue -- fear of retaliation and the independence of oda. we talked about that and we heard about that. we heard about that in interviews and surveys.

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in documents that we review. one important conclusion that we came up with his reorganization of oda within boeing. because boeing, as you know better than i do, is a matrix organization. you have the functional group and the program group. oda was in the program group. no, they are reporting to the functional group. there was a surprise. there were some non-jik02 members that were contractors. their security could be subject to the review. but with this reorganization that they have done, at the oda, they reported the functional group.

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in our panel, we have had manufacturers that presented the oda. we have the from off the street. they do oda correctly. there is something fundamentally wrong or inherently wrong with oda. oda can be managed correctly, and these issues would not appear as much as we saw here. >> if i may, he asked, what could the faa do. i think that the faa needs to take a close look at it. the faa approves the oda members but i think it needs to take a close look at what the

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organizational structure of the oda within the company is, and require it to be, you know, to be independent. when it comes to decisions that affect the person's livelihood. it is a very hard ask for someone. you could put your livelihood at stake to stand your ground. most engineers are ethical and will do it, but we shouldn't have to ask them to risk their family livelihood. they brought up the issue of the contractor. i was very troubled by that. the contractor's relationship with the company is very tenuous financially. you are basically there at will, at a whim. it is a big ask to have a contractor that is going to stand their ground, knowing that they could be shown the door the next day. there are times when they are needed. there are retired people that you want to bring back because of their expertise.

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i get that, but that should be the exception, i believe, and not the rule. you want full-time employees to have more security. >> senator vance, and then senator rosen. >> thank you, madam chair. thank you to the ranking member for hosting. thank you to all of you for being here. first of all, i want to thank each of the witnesses for the work you put into this report. and i would like to focus my questions on the oda, the organization designation authority culture at boeing and some of the concerns that were brought up about retaliation against in place for identifying defects and other problems in the course of boeing's operations. so in that report summary, the expert panel found that even though they disc -- decreased opportunities for france and retaliation against oda unit managers and provided better organizational messaging regarding the independence of

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unit managers, something was missing. dr. de luis -- i hope i'm getting that pronunciation right -- in your executive summary, you say, this is quoting from the report, while better, it allows opportunities for retaliation to occur, especially with regards to salary and for low ranking. this influences the ability of managers to execute their designated functions accordingly. so dr. de luis, i want to understand how this fear of retaliation manifests itself on the assembly line. in the investigation, did you find boeing employees on the factory floor were empowered and encouraged by management to stop the processes if the employee detected nonconformity or a possible defect? >> no. senator, as i understand it, the only thing that stops the line on the factory floor is an osha violation. if an employee believes that his or her life or health can be threatened, they can stop the line.

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everything else basically gets written up and gets put into one of the various processes depending on how -- where it sits. it gets written up and supposedly gets addressed down the line. this leads to the travel work problem that we have heard about before, where you have a problem. you will fix it later, but in order to fix it later, you have to take apart something that, you know, wasn't there before. that is what caused the door problem, by the way. they had to remove the door. they had to move the bullets, et cetera. to answer your question directly, we did not find any encouragement or any empowering to stop the line. their focus -- they are focused on reporting it.

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that loop should be closed and those problems fixed, but it is very difficult to say that is actually happening. i can give you an example. in one of our interviews that you and i did, tracy, we were at the receiving area, the receiving room -- the receiving section, where they check out the airplanes before the faa inspects them. i asked them, what is the major thing you find? they said it is foreign object debris. what happens? we reported and clean it up. well, that you trackback where the fod came from? >> welcome someone is supposed to do it, but he keeps on showing up. that is not how you are supposed to do things if you want to fix the problem once and for all. >> got it. it sounds like there was not exactly a promotion of people stopping the line or raising these issues.

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is there evidence that there was actually the opposite? that there was retribution, that people were penalized for raising safety concerns? >> yes. that's correct. we heard several reports of people that felt that they were transferred or didn't get the race they were expecting. please understand. we were not empowered to conduct a statistically significant all-encompassing review. i'm aware that data is not the plural of anecdote. i'm recounting anecdotes. that is what we heard. that's our impression from my year with this. >> to be mindful of time, i appreciate your testimony. one quick question -- this is follow-up and maybe we can further follow-up with my staff in a detailed way. is there anything you think that congress could do to sort of solve or at least improve this basic incentive problem. if you are going to be penalized for raising safety

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concerns, you're going to raise safety concerns. would you think congress could do to meaningfully change this? >> as i mentioned earlier, one thing you could do is you could -- i'm not in your shoes so i don't know if it is legislation or encouraged or direct, but setting up additional channels for people to comment report without fear of retaliation, such as the asap program, i think would be a very good step. >> thank you, dr. de luis. i appreciate it. i know you personally have suffered tragedy because of these problems. i'm grateful for your work on this but also, my condolences. thank you, madam chair. >> and just on that point about the asap, because i don't want it to get too confusing about the existing systems, dr. de luis, you are saying that if someone knew about either the batteries or the mcas, that

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what you want is a larger universe of people. not just one engineer talking to a line manager. you want broader awareness and broader awareness even at the faa so that it isn't just the faa, one person overwriting belt line manager. >> right, senator. i'm a belt and suspenders kind of guy. i think that you need to have more visibility to prevent the things that we saw on mcas. and one person could basically hide the existence -- or suppress the existence of certain systems, or make sure that they don't go very far. when we were discussing this in the panel, several people brought it up. in a properly functioning sms, you don't need asap programs. that is true, but that is not the world we are in right now. there may be other things.

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when we were at american airlines, they talked to us about it and they were very, very positive about the impact that that has had on their sms at american. it really resonated with many of us on the panel. >> as a broadening of the communication. >> right. >> the key thing is to broaden -- i need you keep referring to this one instance, but i'm assuming you are referring to some of the actions by people that may have hidden that information from the faa. this committee receives reports from people who made it clear they had concerns. we have to figure out this larger communication. >> and it shouldn't take a whistleblower report. that is a big deal for someone to do. it is often a career ending move, whereas, the asap, as it

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has been described to us, and mechanic can say, this was a case that was brought up, i'm not sure if i put in the locking pins on the panel, and he reports it, and immediately -- he's not going to be fired for making that mistake. the focus is going to be, why didn't you? is there a process problem? the focus is, let's get the airplane down if it is in the air. then it is why did it happen? is there a problem with the process? is there a problem with the training? that is the attitude that we need to encourage across the aviation world, but in particular at boeing. >> thank you. senator rosen. >> it is so important. i want to thank the panel for your hard work on this and your care. it matters, and we are grateful. it can place passenger safety at risk. american air travel can only

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remain safe and reliable with vigilant oversight and accountability. i want to thank you again for taking the time to be here, answering questions about the findings and recommendations that were provided for the expert review panel's final report. they were neither consistently nor directly threatening to deliver to the highest level of decision-makers in the organization. they noted that the chief pilot positihave the same authority as other executive decisions. this is concerning. boeings pilots are qualified to identify those safety issues inherent to a company's aircraft. it is clear that the expertise needs to be elevated within the boeing oda process. so dr. meshkaty and dr. dr.,

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can you elaborate? what can congress do to ensure that pilots have a greater seat , not just in the cockpit, but at the table, moving forward so that their expertise can enhance aviation safety? findi0 five and several recommendations about that. our expert panel has specifically said the chief pilot and basically, the way the pilots could bring up their voice to be heard and paid attent pilot and the pilot and basically the way that the pilots they could bring up their voice to be heard and to be paid attention to is to a very robust human factors group. if we can have that robust human factors group and make it a line

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function, i think that issue that you said can be resolved. i heard that in boeing they say structures is the king. because of the impact and importance that they have. and i've said that to my student, if structures is the king, human factors and voice of pilot has to be at least the queen in boeing. because this is equally important, as equally important as the structures. i think this ush you that you raise is very close to my heart and very close to the heart of my colleagues and the panel and that's what we made recommendation. we use the term, senator, design

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practice in our recommendation for these findings, the findings about that. design practice has a very special and important meaning in boeing. and if this issue that you said be raised at that level and it gets to a design practice, i think some of these issues can be resolved. >> thank you. dr. dillinger, would you like to add something? >> thank you. thank you, senator. the pilots are the customers in a great sense, and so the reason why it's important to hear from the pilots is they're critical in the design from a human factors perspective of the flight deck. factors inputs and the pilots inputs go together. the pilots need to have a strong voice and their opinion needs to have a strong weight.

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they should be the ones who are providing feedback to those designs and making adjustments in those designs. equally so we learned as the panel that when you say boeing pilots, that has changed a little bit and the pilots are no longer boeing employees, they're contractor employees. so again, the ability for them to have a voice at the proper level with the design modifications that take their opinions into account, the panel felt that that was important. >> well, thank you very much. i see my time is expired, but i do want to say the human factor matters. there are humans on that plane. it matters to all of us. it's not just the structure. and so thank you for your hard work. >> thank you so much, senator rosen. senator bud? >> thank you, chair. and thank you all for being here. the experter panel notes that

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boeing human factors specialists have played a di americaned role in the the sign and function nalty of recent aircraft. it was once considered the gold standard in this area. dr. dillinger, can you share any of the specific steps boeing staff shared with tex pert panei to rebuild its human factors capability or any additional recommendations you have to boeing to restore boeing as the gold standard in human factors engineering. dr. dillinger, please. >> thank you, senator. the human factors cadre has diminished recently, and the company has made a great effort to bring in more human factors expertise. they know that that is critical. it needs to also be in a standalone organization where they can have a voice formally and we were introduced to the new senior tech discipline leave

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for human factors who is developing a new cadre, but that is a critical element to the design and it's essential for future designs. >> thank you.r. de luis, again,u for being here. in 2019 boeing launched the speak up portal, an internal online platform meant to provido a place where employees could confidentially report concernsny on a numb were of factor, including production quality. speak up is one of the many channels employees have used to report concerns to the company, yet in several places the report finds that employee, and i quote, did not understand how to utilize the different reporting systems, which reporting systems to use, and when, end quote. and that many of the employees preferred to report issues directly to their manager. so is there any record of how many production quality concerns were reported through the speak up program or other reporting

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system as opposed to reporting directly to the managers? >> i know they keep track of how many speak up reports they have. i toebt have those numbers in front of me. i did, however, recently read that since the incident they'vee had a 500% increase. and i remember that one of the last briefings we got from boeing i asked was that good or is that bad, right? because there's two ways to look at this. how many speak ups would you expect normally, right? never really got it clear. but to go to your point, to your question, excuse me, the -- there's nothing wrong with having multiple reporting systems. what our concern was -- what our concerns were, they were multiple. one is that people are -- have trouble believing that anything actually result in any action.to that was one. the other concern was that most people prefer to deal with their problems by talking to their

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manager. that's not necessarily a bad thing. however, we were not convinced that there was actually a path from when that report goes up to the manager for it to be captured into the safety system. so what i mean is if you have a problem in your particular station on the line, for example, and you report it to your manager, you may fix it right then and there and then that's the end of it. and maybe that's appropriate for minor things, but for all you know, somebody in another line is having exactly that same problem, and we did not see any sort of mandatory reporting sort of requirements in order to make sure that that gets captured and subsequently learned from. i mean, that's one of the key ten nets of sms. you're supposed to learn from what happens. and so that was problematic. in addition, of course, that sometimes you -- that if you're just doing it that way, there is no assurance that it was done in

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the best and most proper way as opposed to the way to just get it done and keep the line moving. so you want to have those -- you want to make sure that you have those checks and balances as well. so those were sort of our broad concerns about speak up. it's a good program, we think. intentions are very good. it can be a good program. people need to be trained p more importantly, people need to begin to see results when they report stuff into it, that things actually change, nobody gets fired for reporting, nobody gets anything bad happens, and that the reporting is making a difference. i think that there was a lot of skepticism about that, which is why people go to their managers or union rep or whatever. >> do you think the 500% increase in reporting in the system was due to more training or clarifying or just a new safety emphasis? what's your notion, is that a

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good thing or a bad thing? >> they've been told yet again to -- that if they see something, they need to speak up. so i think there's some of that. i think the real question is is it going to be a lasting blip. there's probably a right number of speak up reports to have each month. i don't know what that number is. if you have zero, well, maybe you're doing a perfect job. but most likely nobody is using the system. and if you have thousands, you've got deeper problems. >> thank you all for being here. >> thank you so much. i just wanted to note too that in this large discussion about human factors, we required that the human factors assessment has to be done before the certification and that no longer can the faa delegate the human factors assessment. they have to do it themselves.

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so senator klobuchar, and then senator schmidt and i think senator welch. so senator klobuchar. >> yes, thank you, chair, for this important hearing. and thank you and i'm so sorry, dr. de luis, about your sister. we also lost a minnesotan on that plane, and thank you for your advocacy. i'm going to start with you, professor najmedin meshkati, can you tell us why it's critical we invest into a strong pipeline into the aviation field? i'm obsessed with this because whether it's air traffic controllers or mechanics or the like, what's going to happen if we don't invest? >> i'm sorry, the question was investing on the pipeline for training in aviation safety?

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>> yes, yes. >> that's, streamly important particularly -- and thanks for that question. right now one of the issues that we are facing is the workforce attrition. there have been a lot of retirement and exodus from boeing and other places. and the issue of training is becoming very important and workforce development. in fact, this thing for the safety critical system in the case of aviation being air traffic controller and pilots and engineers and machinists and also in other industries i've been just two weeks ago at the border, the workforce development for the energy system in the gulf of mexico is also another issue particularly with coming with the new technologies like wind turbine. in this particular case, one solution is basically joining

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forces with technical colleges and universities and develop interstate program for the students to get the trainings and go work and then they come back and continue their education. this is something that i know that for this new technology of the offshore wind, some organizations in the gulf of mexico and some companies and maybe bseu is getting involved in that. >> okay, thank you. dr. dillinger, you mentioned how pilots and crew need to play an important role in the design and evaluation of aircrafts. can you also speak to the importance of training new pilots? >>ts it's essential that we grow new pilots and that novice pilots have experienced pilots to help them learn and become

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superior experienced pilots. and the pipeline of pilots is a constant effort. i think from a human factors perspective, again, the more experience we get from the pilot cadre and the more they learn how to speak up and make their needs known, especially from a design perspective, the panel was very concerned about the human factors element coming into design from the very beginning and that requires experienced pilots having input into that process. >> okay, very good, thank you. dr. de luis, what additional faa oversight do you believe is necessary to ensure a stronger safety culture? >> i think we covered it a little bit before with regards to making sure that the faa is able to vet and approve the -- not just the people but also the

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organizations, as well as higher scrutiny for nonem members. i think that one of the things that has been touched on here is the need for the faa to also establish its on sms. i mean, the faa has an sms on the atc side but not on the other side. as i understand it, and by no mean, even though i'm an expert panel, i'm an expert in sms, but as i understand it, smss work best when they mesh with each other. with its suppliers and the regulators. you know, it's a little difficult to see how the faa is going to be able to do sort of the boeing sms system, i'm sorry. without having its own sms. sorry. >> exactly. just one last question for

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professor meshkati on the -- representative staaber in the house which alerts personnel to potential safety hazards, the notem system, and how we need to update it. how can that strengthen safety culture? >> the technology needs to be updated with equal and adequate attention to organizational factors. one of the things we have said over, just by bringing the new technology or even if you have updated technology, but if you don't do workforce training and also change the organization of mechanics and can adopt that technology, it wouldn't work. the issue of the adoption of the technology in the organization is very important. we have seen that, as senator

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klobuchar indicates, a railroad system. this is an important issue you raise and needs to be addressed in a systematic manner. >> thank t you. >> thank you, senator schmidt. >> thank you, madame chair. when i first learned about this heas under the impression that we would be speaking to people on the ground whether current or -- with current or previous experience within boeing to examine the current safety issues the company is facing. however, i'm surprised to see that not a single boeing employee or executive present today discussed their safety and cultural practices and ongoing efforts to right the wrongs that have unfortunately occurred. so let me reiterate, we have a hearing about bog's safety practices without boeing present. this is frustrating. it's even more frustrating that another committee just down the hallway here is instead having a

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boeing representative appear before their members to answer their questions and concerns. as members of the senate commerce committee, we possess the authority to hear from representatives from boeing on -- or any other company that falls with within our jurisdiction on short notice. today's hearing is about examining the findings of a report about boeing's procedures. they should at the very least be here today to respond to any recommendations or findings from the report. on a similar note, i've been on this committee now for almost a year and a half, and during that time our transportation sector has experienced a number of challenges under this administration, including a concerning train derailment in east palestine, a nationwide shutdown of our national air system, near misses along runways at our nation's airport, and most recently a devastating collapse of the francis scott key bridge, yet i along with my

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colleagues have yet to question secretary buttigieg, the one person charged with leading our transportation system. joining this committee, i expected us in a bipartisan way to rigorously examine and reesolve critical issues facing our nation that fall within the jurs duction of this committee, yet today it appears we are again missing the mark. therefore today's hearing is yet another chapter in an unfortunate series of events where we as a committee could be making a larger impact, finding answers to questions, and fully executing the duties as members of this great committee. to be clear, this is not an indictment of our witnesses whose knowledge and insight are invaluable. the report to which they contributed provides many recommendations to which i hope boeing not only reads but strongly considers in its efforts to get its house in order. however, for a comprehensive oversight, i think we should be

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hearing directly from boeing and its representatives today on how they're addressing the findings and executing changes within the company. rumored hearings in months down the line don't do anything to help missourians flying today. i do want to focus on how as a committee with the chair who i do enjoy working with how we can actually deliver the world's leading transportation system and keep americans safe. so with that, i don't have a lot of time, but dr. dillinger, based on the report and based on the findings, again, this would be something i would be asking somebody from boeing, but to your knowledge, what changes are being implemented? clearly there's sortaw of a

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cultural challenge with feedback and being collaborative based on the report, so are you aware of any changes that are taking place? and this would be for any of you. >> thank you, senator. when the panel completed the report, oursion was done. and so the panel has, in effect, disbanded since the report was submitted. however, the follow-up responsibilities to the findings on recommendations have been provided to the faa and the administrator has made appropriate replies to that from what we could tell. >> we believe that all of our recommendations should be implemented. i don't believe that any have been yet. i mean, it's only been a few but our feeling is that while not a comprehensive set of

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remedies for all t ails boeing, it's at least a really good set of first steps if they were to implement what we have recommended. >> and if i may add, as recommendation 51, 52, 53 to both boeing and faa to work together and meet periodically to make sure that recommendations are being implemented. and as far as i remember, if an administrator has given boeing three months since february or early march to come up with a plan as to how they are going to implement that. and our panel -- and i think it's in our report -- we volunteered to help boeing during our interview, in fact, to resolve some of these issues. but there is a statement somewhere in our report that they didn't really take this opportunity, our kind offer to

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help. at least in my case, they didn't ask for it. >> okay, you. i yield back, thank you, madame chair. >> i will note that we are going to who are from the company, and we've long said we were going to go to the faa and then the company because our oversight job is with the faa and making sure they're implementing, but i did mention at the beginning of this that they did cooperate with the interviews that you did conduct. and so we will hear from them in my census. they've digested your report. by the time they get here, they'll have a lot of commentary about this, so we'll look forward to hearing it. senator welch? >> thank you very much. i thank the witnesses. you know, people are pretty terrified. it's unreal when you think about it. october 2018, the indonesian flight 189 people died. march 2019 ethiopia airlines. and then, of course, on january 5th, the door blows off.

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i mean, bottom line, people are wondering all the time whether they should fly on a boeing plane. is the public safe right now? i'll start with you, dr. dillinger, and go down the line. that's the bottom line question a lot of folks have. are we safe on a boeing plane? >> as best i understand it, at this point, i have continued to fly on boeing aircraft, and i hope that they have taken our findings and recommendations to heart and implement them. >> hesitation makes me feel like you've taken your chances. dr. de luis, i'm sorry. >> that's fine. i get asked this question all the time. i get asked this question -- >> and i do too. >> is it safe. so here's what i answer.

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and i don't know if it's -- i say, you know, the safest place for a rocket is sitting on the pad, the safest place for an airplane is in a hangar. the safest place with you and me is on our couch scrolling through instagram. yet every day rockets launch, airplanes fly, and we do something productive. safety is always a trade. having said that, the -- within the airplane world, you have to look at what's happening and go how comfortable am i flying in this airplane versus that airplane. for me personally, i keep track of what's happening on the max, for obvious reason, and i'm worried about what's happening on the max. >> thank you. >> now, if i had to fly somewhere because -- and there was no other option, i would absolutely fly it versus driving, for example, because i can make that trade. >> but you know, i think public's entitled to more confidence than the security and

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safety of flying. dr. meshkati, there seems to be two issues about safety. one are the practices and the culture of the manufacturer. and the other is how much they put profit ahead of safety. because it is a tradeoff. the more they're going to focus on safety, that's going to come at some expense. and i understand there's problems in both those elements for boeing. would you say that's true? >> it was very much discussed, senator, i think in this seminal book by peter robinson, flying blind. and the issue of putting and basically the -- this is a delicate balance, senator, between safety and profitability. we know that these companies are not in flan teardropen flan troc

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business, they need to make money. to give proportional attention to safety course versus production course. and in the case of boeing, unfortunately, based on the way that are it's chronicled very nicely in this book, that has happened after the merger with maclaren douglas. >> so you attribute some of that change to after the merger. >> yes. >> tell me what the dynamic was. >> the dynamic was -- if you look at the history of mcdonough douglas, about the series of problems mcdonough douglas had. the mentality over there was just to push, push, and make more aircraft, not really pay attention to detail. and then somehow resolve that later. and that, unfortunately, according to my reading of the

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book by peter robinson and some of a series of great articles in the seattle time, it also chronicles this issue. and we have seen that unfortunately. >> let me ask you one last question. what would you have to see from boeing for you to have confidence that they had successfully developed humanst factors as a technical discipline and design practice? >> i personally, and it's just myself from my distinguished colleague, i like to see the human factors person, the top person, have equal power and authority as the chief engineer. this is what i like to see. >> okay, thank you. i yield back. thank you all. >> thank you. >> following up on that, we may have a couple more members coming, but if not, we'll conclude the hearing soon. but dr. meshkati, the report states that during the development of the 5 and 67

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human factors and flight deck operations were the gold standard in part because human factor specials worked closely in seattle. quote, the role of human factors is in its influence eroaded to a series of administration issue, including reorganization, decentralization, downsizing, and reelocation of the company's headquarters. what does that have to do with human factors? >> human factors works very good when they're very close to engineers and system designers. they exchange information, they work together, they work on the design of the system, and then they work on the training and that, they solve this problem together. again, i'm not in the business of promoting book, but chapter nine of this book, which isct about human factors, which i strongly recommend, that shows the way that the demise of the human factors or erosion of the

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human factors. one of them, for example, is chronicled in the book, when the simulator trainings and that was totally moved away from the design and that from seattle to florida or somewhere else. that is when you see a problem -- >> i think that was just the training, though, right? >> the training, but before that also during the design because you get some of that input from the training coming back to the designers. >> oh, i see, you think that doesn't exist in a holistic way. >> absolutely. >> you're saying -- okay, and that's all feedback. >> holistic and centralized. >> holistic and central. okay. >> thank you, senator. >> i wanted to ask about this, in regards to the faa. 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 and how much that has to be backed up by the faa. what doeso the faa need to do to have its own safety system improvements to make sure that

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it is thinking about human factors or across the board a variety of ush yous that could enhance security, particularly at a time of changing technology, how do we get an faa who is up to speed? let's have this group is at the beginning of the recertification process kind of detail out more of the risk factors so that that discussion could happen. >> so that's actually very -- you know, we focused a lot about, especially since january 5th, on the need to put more faa boots on the ground and the factory. and i'm by no means saying that's a bad idea, that's an excellent idea. but what you point out about the technology is why i think that oda or der or delegation of some sort is here with us forever, because the faa does not have the resources to be able to be

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the world's experts on these technologies. that's not what they're there for, the world's experts reside at boeing or whatever. the key thing i think is that the faa has to have the ability to interface with the world's experts. and that's a different is the of skills that's needed. you're note going to be conducting the cutting edge research, but you should be able to talk to the people that are developing that technology and be able to understand it and in particular understand how it impacts the safety and the operation of the aircraft. i keep going back to a -- something i said earlier aboutha the need for the faa to really step up its own sms. i think that that's critical. if you have that, then you have a chance of being able to appropriately interface with the people you're supposed to regulate. if you don't have that, you're sort of, you no, spectators at the party here. and i think that that -- they should be encouraged or directed or whatever it is, however it i>

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that you do it to move in that direction. >> thank you. senator blackburn, are you ready? >> thank you, madame i want to thank all of you for being with us today. i think this aviation safety issue is something that we are all concerned about and are -- we're going to stay in behind this. i appreciate the chairman's attention to this -- to this issue. dr. meshkati, i want to come to you. and i think i'm saying your name right, correct me if i'm not. i was reading a report about the aerospace maintenance competition where the 450 airplane mechanics met to show off their skills and they were

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working in 15-minute time slots troubleshooting issues, and i think in 15 minutes it's pretty remarkable what people are able to do. and it's important to know that there are skilled people. you look at what has happened with these different reports. alaska airlines, united airlines, the boeing planes that have come up. so when you look at this and you see the skills training that some of them have, where is the disconnect in this? where is -- is it a lack of skill? is it a lack of training or preparation o you know, is it inattention? why are we beginning to have such a negative impact, see such a negative impact on safety? >> thank you, senator. this issue with didn't study

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that here, but your question reminds me of aloha airline and the accident that it had around, i think it was 1998 or so. and it was started with the aviation maintenance-related problem. and at that time, faa really looked very hard look at aviation maintenance and they, i think they created a program called national plan for aviation maintenance. and then at that time one board member of ntsb who was later elected to ntsb, the honorable john pushed on this a lot. the issue offoffuation maintenance is extremely sensitive to the human factors and safety culture issues that my colleague dr. dillinger is talking about here. >> okay, let me do this. dr. dillinger, let me come to

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you, because i know you conducted hours of interviews for the safety report that you produced. did you speak with any of the whistleblowers when you conducted those interviews? >> as far as i recollect, we did not speak to a whistleblower. >> did not. why did you not talk to any of the whistleblowers? >> that was not the purview of the panel. and at the time, i don't think -- we weren't aware of the whistleblowers or -- >> okay, let me ask you this then, does boeing do enough to ensure that their employees know that there will be no are taluation if they come forward and report safety issues? >> the panel believes they need to do a lot more than what they are currently doing.

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>> and you know, one of the things that we have heard from ntsb is that there is a problem getting from boeing. do you think that boeing executives do not understand when there is an investigation they need to come forward with complete information? >> i mean, i can't speak for the executives. i will say that boeing is a very large and very bureaucratic company that produces a lot of paper. and i'm not surprised that there are lags in their responses because that's -- they're just -- that's just the way it is. but i can't speak for them. >> i will tell you, reading the report and boeing's safety culture being described as inadequate and confusing, this is something that harms the flying public. and i appreciate the attention

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to the issue. thank you, madame chairman. senator warnock? >> thank you, madame chair. listen, the stakes are simply too high for commercial aircraft the kind of systemic problems that we're seeing with boeing. so i'd like to examine how we got here with this panel. dr. de luis, yes or no, through organization designation authorizations or odas, can the faa delegate certain safety certification and other responsibilities to an aircraft manufacturer like boeing? yes or no? >> yes, but currently -- yes because it's done with other manufacturers. but there are issues as described in our report that

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makes us be leery of saying, yeah, go ahead and just do it. i think boeing needs to prove that it is capable of doing it. >> the question is, are they able to delegate certain safety and certification responsibilities to an aircraft -- so they are -- the answer's yes, correct? >> mm-hmm. >> okay, so dr. dilling yes or no, can an aircraft manufacturer like boeing subcontract manufacturing responsibilities for, say, the fuselage of its signature max aircraft line to another company? >> the s work of the panel, i think, would say yes, like with odas that we heard successfull examples of oda delegation. however, the concerns remain about the risk that boeing's

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safety culture presents to that process. >> yeah, i share that concern, which is why i'm asking the question. dr. meshkati, yes or no, can a subcontractor of boeing assign manufacturer responsibilities to an international affiliate, in malaysia, for example? >> 787 is not made all over the world. wings in one country. another wing in another country. fuselage in another country. they are doing that. >> so the authorization can then be passed from faa to a manufacturer. the manufacturer can subcontract that manufacturer responsibility to another entity, and then the

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manufacturer subcontracted by boeing can assign manufacturing responsibilities to an international affiliate. i'm sure you've realized what we've walked through step by step is a supply chain of the boeing max 9 aircraft at the heart of the near catastrophic door plug blowout that happened in january 2024 to an alaska airlines flight. you know, there are many words for this. you can call it delegating, subcontracting, reassigning, at the end of the day, it's outsourcing. outsourcing key responsibility, none more important than safetyl oversight, to someone else to someone else to someone else. i submit that while we're focused on boeing, this is obviously not just a boeing problem. this is far too common across aviation systems and its suppliers whether the result of

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poor leadership, a focus on profit margins at all cost, even the cost of safety, or some combination of both, congress must take a serious look at this culture of outsourcing and its safety implications. this is an instance in which we can't afford a mistake. it costs too much. dr. dillinger, what more can boeing do to improve its safety culture and our ownus responsibility for the safety of its products? >> thank you, senator. the panel focused a great deal on safety culture, and there is so much that they could be doing. part of it has to do with the timing and if they were to accelerate the efforts, i think -- and the panel thinks that that would be beneficial. there has been a very soft start

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to that to implementing the training to getting feedback back from employees via their own surveys to providing workshops to focussing specifically on training at different levels. so for example, executive training, yes, but down through the other layers of the organization to managers and supervisors, targeted training. there's multiple ways that they could be going after that, and as they look at a more comprehensive way where they really dive in and in a more timely way address that the panel felt that that would be important and that it was in our recommendations. >> great. thank you so very much for that. dr. de luis and dr. meshkati, last question. what more can congress do to encourage both the faa and manufacturers like boeing to take direct responsibility for the safety of aircraft and our

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aviation system? >> i believe that the congress and this committee needs to keep the, essentially, the pressure on to make sure that the waivers are not granted on safety-related issues, for example. that would be a good thing, because they -- right now there are a handful of waivers on the max that directly affect safety. but you need to keep the spotlight on this, because -- and during our interviews we heard often the sentiment expressed, yeah, this is happening now, but as soon as everybody moves on to something else, we're going to go back to the way things were. and that can't happen. as you say, it's too expensive, and the cost in human lives is just way too high. >> thank you, senator. that is also related to an earlier question by senator cantwell.

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i think what congress can do, that's related to sms. there's a document signed by then chair of ntsb called state safety program. this is something that united states files with the international civil aviation organization. in this one, this is very interesting, senator. it talks about the safety management responsibility for the state for the application of sms at faa. what i would suggest and what can congress do is to create another panel like the one that we are in, section 103, to look at the implementation of this report and how does united states stand with the report. if this state safety program being fully #i78 pleasanted, what needs to be done, b that has a kind of an impact or

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it can tremendously impact faa's power on using basically in the case of sms, for example, in united states, it's only faa -- correct me, my colleagues here -- has sms for air traffic controllers. sms needs -- there's a notice of rule making for sms, but sms needs to be fully incorporated. and if this document be fully implemented at faa and other places, i think that would be a good solution.>> thank you so m. i know i'm way out of time. i appreciate your indulgence, madame chair, and i look forward to working with my colleagues on this committee to up prove aviation safety. >> thank you so much. and just to clarify again, one more time on this issue, because it's related to what he said and senator schmidt, i want to emphasize we all represent big

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aviation states. we want this to be right. and we definitely believe in the workforce that we have in our states. we want them to continue to grow in expertise and excellence. so recommendation 30 and 31 of your report says foster an effective safety culture and public a road map for workforce development with engineers and inspectors and oversee sms and partner with industry to measure the success of sm, and is design and organization jointly review these measures of success on a regular basis. okay, those are your two key recommendations about sms. so the faa is now in this rule making that's going to come out in the next 90 days. so what specifically do you want to see in that rule making that will help guarantee this success. and then secondly, what do we do about this problem that dr. de luis suggests, which is a whole

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of government issue, if you ask me, because we could ask dr. dillinger about space in general, but it's -- we're trying to keep the government at pace with technological change. so you're saying the faa may not have some of these people, anday so how do we -- what do we need to do? because obviously we do want to listen to what these sectors say, and they have input. they really have some of the smartest people about this technology. but we also have to get our oversight correctly. so how do we make sure the faa rule making has what we want to see in it. and how do we deal with this lack of engineering, if you will, skill set at the faa. not at the company. at the company i think it exists. i think we're just not listening closely enough. >> in response to your first question, unfortunately, sms isn't new, right? it's been around in the aviation world now for 30 years. >> but it was voluntarily

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implemented as part of a 2015 consent decree instead of being a real mandatory sms. so i'm hoping the faa gets this right this time. >> yes. what i meant is it's been in the aviation industry for 30 your, not at you're absolutely correct. in a sense, all the faa has to do is look at what it's done successfully with organizations like the airlines and others and apply those same standards ineg and the same rules to boeing. so they adopt -- it's not a blank sheet of paper is what i'm saying. they've got something they're drawing. question, i've been a strong advocate of national agencies drawing on the resources of the national academies. new technology enters a field, ai for example, because that's the one that's the technology du jour right now. i've always been an advocate that you have these national galleries right down the street right here with members that you

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can draw upon to basically go in and advise and give -- people that know a lot more about these subjects than any of us. and i don't -- some organizations do it more than others, but i think that's a resource that faa and nasa and other agencies don't use enough in my opinion. >> the national academy, i have just one good news, dr. de luis. faa has gone to national academy, and national academy has created community of experts for risk and analysis of transport aircraft. and that one i have the privilege of being a member. we meet over zoom weekly. and i think it has been great, because faa has reached out to nuclear power industry for that community of experts. how the they do pra proper assessing, they do that here. back to you, senator cantwell, i

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think the two reck men dayses you brought up, 31 and 30, is fantastic. that's exactly that i think in light of this state safety program if these two two combine together, i think that's going to be a paradigm shift for sms. >> well, i think it's pretty simple to get a real sms. and i think it's a great idea as we envisioned to get a panel of, perts. i'm glad to see that is actually happening with the national academies as it relates to this input. i don't -- we'll have to query the faa more on exactly how broad that can go. dr. dillinger, i'm going to leave the last question to you, because you know, as painful as all this is, to me we can get through it. and i think you're referencing your work on the columbia that was also a very painful moment for nasa, very painful moment

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for this committee. i sat on the oversight investigation of that that the committee did in joint session with other senate committees. so but we did get through that. what do you think are the lessons learned here? how can you -- how can we successfully move past this and on to the success that we want to see in aviation. because i think the foundation is very strong. we have a great hundred years of aviation success. we tant to build on it. as dr. de luis said, we want to be known for the successes the united states has had in aviation. i think elementses are there. but what is it that we need to do to learn what columbia learned on how to move forward. >> thank you, senator. that has been my life for decades. i think what we learned from was applicable to the report is how important people are in the relationships between people.

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that's what the safety culture issues all address. it's about trust. it's about communication. it's about being there. and having a that comes in that is from paired, that's trained that's energetic, that's curious, that's dedicated, that will work their heart out, an organization can recover from a catastrophic loss. when that's happened by pulling all of those resources together and focussing on the mission and how everybody works towards the mission to make that happen. but to do that, all of those part, including the processes, have to come together with safety as a priority where people understand that it's just part of doing business. it's -- brian o'connor, the former chief of safety for nasa, used to talk about, safety isn't the mission, it's how we do the

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mission. and that's a critical lesson learned for us. >> thank you. well, i want to thank the witnesses again today. you'll -- the record will remain open until may 15th. any senators wishing to submit questions for record should do so by may 1st. and we ask responses be returned by may 15th. that concludes our hearing today. and again, thank you for your report and your willingness to be here today. we're adjourned.

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one of the reasons why i wanted them to come -- originally we were thinking we were just going to go to the faa and then the company. you know, we wanted to hear from ntsb about the investigation. we wanted some of the information from the investigation because we thought that would be illuminating, but that's still challenged in some ways. so we thought that the work of

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this panel because it was so specific to the culture needed to be illuminated because i do think when we get to some of the discussions with the faa that, you know, they were given a lot of response bts. and one of them now they're executing on. we'll see, we'll see what they come out in their order. it can't be sms light. it has to be real safety culture structure. so what i heard today was just how -- i mean, i had already read the report, obviously, and thought highly of it, but what you heard from their discussion with members is, like, this can be accomplished. this can be accomplished. it's not -- it's not like overly bureaucratic or cumbersome. it's about the culture. like she said at the end, it's not -- it's not the function, it's how the mission is -- becomes -- it's not the mission, it's the success of the mission. and i think that that's what we're just trying to say. this isn't like overly

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bureaucratic, it's just getting it done and listening to the people who have the most advice. >> do you think that you'll have enough time to get a separate aviation bill done this year and still hearing from other panels? >> you know, again, it depends on what else happens in the investigations, but i think so. yeah. just because last time when we got it done, we got it done and then we worked with the -- i think we got it done and then we got it out within like two months of getting it done in committee eand working with the house. so it depends, obviously, the fall being an election year could make some changes, but -- and i can't remember we got that done in the lame duck or not. where's melissa? go grab, melissa. actually, you might now, gigi. yeah, it was after the election. so that gives us time too. but i think what we decided was that there was so much right now on safety in faa with the number

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of air traffic controllers, near misses, aviation inspectors that we wanted to get done right now that we didn't want to miss that opportunity. so i think it helps us actually focus more on like -- just like he said, it was a good start, but it's not the ending, period. and so the challenges that they have to get implemented and the last acting administrator probably wasn't as aggressive as we wanted him to be on audits and oversight, but this one is being very agress uf. that's helping us get more progress on the requirements. >> a big one also when you're considering legislation, a big topic here today was the whistleblowers and retaliation. and you know, that was addressed in the last -- >> but we're all talking about stuff that happened after that. so that's the problem. >> right, right, so it's still happening, i guess my question is what is f a,a -- or i guess, like what are you considering in

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the bill, you know, you're looking at what faa can doo look into that. i guess what can faa do and what are you considering as you're looking at this legislation? >> well, they -- so in it we put fines in there, and i guess we'd have to ask the faa what other tools they think they need. but part of it is making the faa stand up. i mean, in these instances that i mentioned on the 787 battery technology and other things, the engineers were saying -- they got overridden not by the company -- well, the company probably said we don't have to do this, but the faa immediate manager said, oh ya, you don't have to do that. and so what we're trying to get is, no, the faa has to stand up and back up the line engineers when they say there's a problem. what is it going to take for them to do that? first of all, we're saying, where's your really strong safety management system rule? and what are you going to do to ensure that? and then we want to see too this

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last point they have to have enough technology, people. imagine this discussion today now when it relates to ai, okay? there's a lot of knowledge on aviation. there's very little on ai, so how are we going to, you know, do both of those? i mean, you need to have the technology at the faa to know what the issues are. i'm glad leaning on national academy people, but we'll see -- do you have a strong sms rule. are you backing up the engineers. are you working with other technology expert who is know what the issues are so you don't fall behind. that's what we want to see from administrator being aggressive. >> okay. >> i'm sorry, senator. >> sorry, go ahead. there's more safety engineers in the faa bill. that's the other thing we want them to do is have those safety engineers, you know, on the ground. because they're like a reflection of who you can go talk to.

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you know. sorry. >> just on whistleblowers -- [ inaudible question ] strengthen some penalties against any organizations that try to retaliate against -- provision. >> cool. >> just wanted to flag that. >> thank you. >> -- future hearings going to depend on how faa bill goes, do you have updates around whether you're on track to meet a deadline for that? >> very close. >> -- boeing executive donations, i think over the weekend, are you hopeful that other members of the senate xhrs committee will follow suit? >> we just said we have an investigation, and we're not going to focus -- we're going

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tv Aviation Safety Specialists Testify on Boeing Safety Culture CSPAN May 14, 2024 5:59pm-8:03pm EDT

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tv Aviation Safety Specialists Testify on Boeing Safety Culture CSPAN May 14, 2024 5:59pm-8:03pm EDT

Aviation Safety Specialists Testify on Boeing Safety CultureCSPAN May 14, 2024 5:59pm-8:03pm EDT

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Aviation Safety Specialists Testify on Boeing Safety Culture
CSPAN May 14, 2024 5:59pm-8:03pm EDT