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Audit Reports


Weaknesses in FAA’s Certification and Delegation Processes Hindered Its Oversight of the 737 MAX 8

Requested By
Requested by Secretary Elaine L. Chao; the Chairmen of the House Committee on Transportation & Infrastructure and Aviation Subcommittee; the Chairman and Ranking Member of the Senate Appropriations Transportation-HUD Subcommittee; and Senator Blumenthal
Project ID
File Attachment
What We Looked At
The Federal Aviation Administration (FAA) has historically maintained an excellent safety record. However, two fatal accidents in 2018 and 2019 involving the Boeing 737 MAX 8 raised concerns about FAA’s oversight and certification of civilian aircraft manufactured and operated in the United States. At the request of Secretary of Transportation Elaine L. Chao and several members of Congress, our office has undertaken a series of reviews related to FAA’s certification of the MAX and its safety oversight, including the Agency’s oversight of Boeing’s Organization Designation Authorization (ODA). Our overall audit objective was to determine and evaluate FAA’s process for certifying the Boeing 737 MAX series of aircraft. In this report, we focused on assessing (1) the effectiveness of FAA’s guidance and processes for managing the certification of the 737 MAX 8 and (2) FAA’s oversight of the Boeing ODA.
What We Found
While FAA and Boeing followed the established certification process for the 737 MAX 8, we identified limitations in FAA’s guidance and processes that impacted certification and led to a significant misunderstanding of the Maneuvering Characteristics Augmentation System (MCAS), the flight control software identified as contributing to the two accidents. First, FAA’s certification guidance does not adequately address integrating new technologies into existing aircraft models. Second, FAA did not have a complete understanding of Boeing’s safety assessments performed on MCAS until after the first accident. Communication gaps further hindered the effectiveness of the certification process. In addition, management and oversight weaknesses limit FAA’s ability to assess and mitigate risks with the Boeing ODA. For example, FAA has not yet implemented a risk-based approach to ODA oversight, and engineers in FAA’s Boeing oversight office continue to face challenges in balancing certification and oversight responsibilities. Moreover, the Boeing ODA process and structure do not ensure ODA personnel are adequately independent. While the Agency has taken steps to develop a risk-based oversight model and address concerns of undue pressure at the Boeing ODA, it is not clear that FAA’s current oversight structure and processes can effectively identify future high-risk safety concerns at the ODA.
Our Recommendations
We made 14 recommendations to improve the Agency’s aircraft certification process and oversight of the Boeing ODA. FAA concurred with all 14 of our recommendations and provided appropriate actions and planned completion dates.


No. 1 to FAA
Update the Changed Product Rule to address the integration of technological advances and exceptions.
No. 2 to FAA
Evaluate criteria for determining whether a system meets the definition of a "novel or unusual design feature," add specificity, and implement identified improvements.
No. 3 to FAA
Require applicants to submit failure probability analysis and key assumptions in certification deliverables.
No. 4 to FAA
Assess and update Advisory Circular 25.1309 guidance related to engineering assumptions regarding pilot actions, pilot reaction times, and failure mode testing.
No. 5 to FAA
Establish and implement processes for manufacturers to officially notify FAA certification engineers of any changes made to System Safety Assessments, including after FAA flight testing has begun.
No. 6 to FAA
Establish and implement communication and coordination procedures between Boeing and FAA, and within FAA among flight test, certification, and Flight Standards.
No. 7 to FAA
Establish and implement policies and procedures for the AircraftEvaluation Group related to its role in the certification process that require,at a minimum: formal documentation of approvals; documentation of operationalflight test parameters, procedures, and outcomes; expanded written guidance onthe FSB process; and improved consistency of procedures between AEG offices.
No. 8 to FAA
Incorporate lessons learned from the Boeing 737 MAX accidents into the ODA oversight process guidance implementing a risk-based approach.
No. 9 to FAA
Clarify priorities, roles, and responsibilities for FAA engineers regarding oversight and certification work, including the timing of when oversight should be performed.
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No. 10 to FAA
Perform a workforce assessment at FAA’s Boeing Aviation Safety Oversight office to determine engineer resource and expertise needs, particularly in the areas of systems engineering, human factors, and software development, to both perform certification and oversight work, and take action as necessary. 
No. 11 to FAA
Conduct an assessment to determine how frequently unit members serve as both the company engineer involved in a design as the applicant and also find compliance on FAA's behalf on that same design. Based on the results of this assessment, revise ODA guidance to strengthen controls in this area.
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No. 12 to FAA
Revise ODA program requirements to ensure ODAs have internal controls in place and are organized in a way that prevents interference with ODA unit members.В  В 
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No. 13 to FAA
Determine if Boeing has met the requirements of the 2015 Settlement Agreement, including reporting metrics, given the deadline of December 31, 2020 and take further actions as necessary.
No. 14 to FAA
Complete the ongoing rulemaking project that proposes requiring manufacturers to implement Safety Management Systems, including setting and publishing expected timeframes.