On October 29, 2018, approximately thirteen minutes after taking off from Jakarta, Indonesia, Lion Air Flight 610 crashed into the Java Sea, killing all 189 passengers and crew aboard. The weather was fair, with good visibility and low winds. After the crash, an Indonesian rescue diver died in the recovery attempts, bringing the total death toll of the accident up to 190 lives. Less than five months later on March 10, 2019, Ethiopian Airlines Flight 302, carrying 157 passengers and crew, crashed just minutes after takeoff. Both airplanes were Boeing 737 MAXs, the aviation giant’s newest and most modern line of planes, and both were less than 4 months old when they crashed. After retrieving the planes’ crash data, aviation experts concluded that out of a myriad of possible issues that could have contributed to the crashes, both were primarily caused by a malfunction to the Maneuvering Characteristics Augmentation System (MCAS) of both planes. On March 18, 2019, the U.S. Federal Aviation Administration (FAA) grounded all 387 of the 737 MAXs that were flying at that time.
The grounding lasted for a record-breaking 20 months, the longest in U.S. history of a single airliner. On November 18, 2020, after publishing numerous new requirements for pilot training and changes that needed to be made to the planes, the FAA ended the grounding, allowing 737 MAXs back into the air. But not everyone is convinced that the problems with the planes have been fixed.
Reporting From Inside Boeing
Ed Pierson, a former 737 Senior Manager for Production System Support, says that the investigations didn’t go far enough — and that the 737 MAXs may still be unsafe to fly. Since the two fatal crashes, Pierson has launched his own investigation into the events that led up to the malfunctions, and he has contradicted Boeing’s repeated claims that the MAXs are safe to fly. He considers himself a whistleblower, putting aside a comfortable career in the aviation industry to bring attention to what he believes to be an unfixed issue. In a recent interview with WNN, Pierson explains the production issues he saw while working at Boeing, and discusses the toxic leadership culture that pervaded the upper echelons of the company.
Pierson’s flagship report on the issue, “Boeing 737 MAX – Still Not Fixed,” dated Jan 20, 2021, explains that although the MCAS system may very well have caused both planes to crash, system-wide electrical defects that were never fixed during the manufacturing process may have caused MCAS to behave erratically. Four months after publishing his report, more than 100 737 MAXs were grounded again on April 30, 2021. The FAA announced that this time, the grounding was because of “an electrical issue” that could “affect the operation of certain systems, including engine ice protection, and result in loss of critical functions and/or multiple simultaneous flight deck effects, which may prevent continued safe flight and landing.” While the planes soon returned to the air in May after the FAA announced a fix to the problem, Pierson says that there are almost certainly more electrical issues hidden within the hundreds of 737 MAXs made at the Boeing factory in Renton, Washington.
Pierson knows his way around aviation equipment and personnel. Before joining Boeing as a Commercial Aviation Services Specialist in 2008, he attended Naval Flight School and served in the Navy for 30 years. Although he worked in multiple different roles there, many of them involved the Navy’s flight program and aviation technology. At Boeing, he quickly rose through the ranks to become responsible for “production system support” and “support for manufacturing operations with engineering, quality, tooling, supply chain, facilities and IT organizations.” In 2015, Pierson began working at the Boeing factory in Renton.
The Boeing Renton Factory “leads the industry as the most efficient airplane factory in the world,” according to Boeing’s website. Pierson says that this efficiency came at a cost. In the interview, Pierson says that starting in 2017, working conditions at the Renton factory began to deteriorate. While this was originally due to disruptions in supply chains for certain plane parts, issues became more widespread in 2018. Building a plane requires extensive testing at almost every step of the way. Because of this rigorous and sequential process, lacking requisite equipment, parts, or skilled staff can produce huge backups in the production chain. As equipment shortages got worse, employees started to become chronically overworked, Pierson tells WNN. Because of the individual specialization required to test and build a commercial airplane, some engineers and technicians were unable to take days off for weeks at a time.
Pierson says that workers were so tired that he saw a direct uptick in human error safety incidents. He says that he recalls driving to work one morning and missing his exit to the factory because he went into microsleep, one of the body’s ways of coping with being chronically overtired. While he tried to warn his superiors at the company about the level of overwork that was taking place on the factory floor, the factory supervisors didn’t make substantial changes. Instead, they replaced the “family-style” morning team meetings with much larger group meetings of 100 employees or more. Pierson says that these meetings “deteriorated to the point where first and second line managers were publicly shamed and embarrassed in a misguided effort to get employees to work faster and harder.”
In June of 2018, Pierson contacted the manager of the 737 program asking for a meeting and requesting that the factory be shut down for a period of time so that workers could get back on their feet. He presented his concerns in emails to the manager and in an in-person meeting, saying that he was extremely concerned that the pressure leadership was putting on employees could have the effect of “embedding safety hazard(s) into our airplanes.” He worried that “schedule pressure (combined with fatigue) is creating a culture where employees are either deliberately or unconsciously circumventing established processes.” The factory manager did not take his recommendations.
Pieson also noted that 737 MAXs were not the only planes being build under these sub-optimal working conditions. Both the 737 Next Generation (NG) and the P-8 military airplanes were being built in the same building and next door.
Meanwhile, on the production floor, factory manufacturing employees were working to finish a 737-8 MAX, Production Line Number 7058, which would be finished and delivered to Lion Air on August 15, 2018. This was the same plane that would crash into the Java Sea in October, barely two months old.
In August of 2018, Pierson left Boeing, citing inadequately answered safety concerns as a primary reason for leaving. In October, Pierson watched, horrified, as one of the planes he had warned people about crashed, realizing his worst fears.
Between December of 2018 and February of 2019, Pierson wrote to Boeing’s CEO, the Chief Counsel, and Boeing’s board of directors, pleading with them to investigate the working conditions at the Renton factory and “involve international accident investigators.” All of these requests resulted in no action from the company.
In March, the second Renton-produced 737 MAX crashed, again killing everyone aboard. A week later, 737 MAXs were grounded by the FAA. With the help of his attorneys Eric Havian and Chris McLamb, Pierson sent requests to the National Transportation Safety Board (NTSB) and the FAA, asking them to involve international accident investigators. These, too, were ignored.
In these letters, Pierson revealed that through his own research, he had found 13 different 737 MAX safety incidents between May 2018 and ten months later in March 2019, when the model was grounded. All of the planes involved in these safety incidents were less than 14 months old. Of the 387 planes flying during that period of time and including the two fatal crashes, that results in an incident rate of 4%, or 1 out of 25 airplanes. In 6 of these incidents the pilots transmitted emergency communication messages, underscoring the fact that some of these incidents could have resulted in fatal accidents.
Congressional Report And 737 MAXs Un-Grounding
In December of 2019, Pierson testified in front of the House Transportation & Infrastructure Committee, presenting his evidence of what conditions were like at the Renton factory during the period of time when the two crashed planes were assembled. As a result of his testimony, the Committee directed the FAA Administrator to interview Pierson and investigate the Renton factory. By June of 2020, the FAA Administrator was interviewed in front of the Senate, where he provided no evidence that international accident investigators were allowed to investigate the Renton factory.
In September of last year, the House Transportation & Infrastructure Committee released their final report on the crashes, and on Boeing’s training and production leading up to the incidents. The report includes information on the working conditions at the Renton factory, noting that “Boeing had more than three dozen partially completed 737 MAX airplanes staged outside of the Renton factory while it awaited the delivery of parts from suppliers to complete the production process. This resulted in ‘out of sequence’ work, which can lead to potential quality and safety issues.”
However, the report essentially settles on blaming faulty Angle of Attack (AOA) sensors for activating the MCAS system and sending the planes into uncontrollable nosedives, with the pilots having little to no required training on how to manage an out of control MCAS system, or how to adjust stabilizers once MCAS had been manually deactivated.
The report notes that the crashes “were the horrific culmination of a series of faulty technical assumptions by Boeing’s engineers, a lack of transparency on the part of Boeing’s management, and grossly insufficient oversight by the FAA — the pernicious result of regulatory capture on the part of the FAA with respect to its responsibilities to perform robust oversight of Boeing and to ensure the safety of the flying public.” It claims that the FAA was not fully capable of performing its responsibilities and regulating Boeing.
Two months later, the FAA un-grounded the planes, claiming that it was “the most scrutinized plane in history” and “100% safe.” But Pierson claims in his January 2021 report that the problems with the planes are more complex than faulty sensors, and stem from a possibly diverse group of issues with the electrical systems of the planes. He says that “We can either investigate these production problems and fix them, or we can wait for another disaster.”
Another Cycle Of Grounding And Calls For Enhanced Oversight
In April of 2021, a number of 737 MAXs were grounded again for electrical issues stemming from a design change during production that did not require authorization by the FAA. Pierson released an addendum to his January report, saying that at the very least, this re-grounding shows that the recertification process the FAA instituted was not rigorous enough to catch possible electrical issues. “Boeing and the FAA were motivated to expedite the recertification process and despite promises not to cut any corners, simply neglected to address the electrical system anomalies identified in the accident reports. Instead, they focused their attention on MCAS software and pilot training while defending the actions and inactions of their employees,” the addendum states.
By May, the planes were in the air again. Boeing continues to deny that electrical issues with the 737 MAXs have anything to do with production problems.
Pierson says that the two main culprits of the continuing disaster are the FAA leadership and Boeing corporate culture. Boeing’s CEO, Dennis Muilenburg, resigned and was replaced quickly after the House Transportation & Infrastructure Committee began its investigation. But Pierson believes that this was not close to enough to change the profit-first culture he says exists at the top levels of the company.
Pierson speaks highly of the FAA employees that he met during his time with Boeing, but said that they barely had a presence in the production process: “I worked in the factory for 3 years and never saw an FAA employee.” When he asked how many FAA regulators were working at the Renton factory, a facility with over 3000 daily employees, he was told that there were five. “Five people couldn’t possibly keep track of what was going on.”
Pierson believes that the two separate recertification processes clearly demonstrate that the FAA needs restructuring and increased oversight, as it seems unable to complete its tasks in its current state. As the FAA falls under the purview of the U.S. Department of Transportation (DOT), he has been calling for a meeting with Secretary of Transportation Pete Buttigieg. Buttigieg’s office has not responded.
Pierson’s Whistleblower Experience
Ever since he first began to report his concerns about Boeing’s planes internally, Pierson has faced the unique obstacles that whistleblowers of all kinds deal with daily. He has put aside a normal and profitable career for one that yields little personal reward or compensation. Through it all, he says that Tom Mueller’s book “Crisis of Conscience: whistleblowing in the age of Fraud” has helped him come to terms with the morality of what he has decided to do with his life.
Pierson hopes to share his experiences as a whistleblower so that others can learn about how important it is to report lack of institutional oversight when you see it. He says he’s “hoping to convert some of this into ongoing safety advocacy,” possibly going out on the speaking circuit. His experience as a moral person who saw the potential for safety issues has galvanized him into an advocate for change.