A Decade Later, Dutch Officials Publish a Study Critical of Boeing
After a Boeing 737 crashed near Amsterdam more than a decade ago, an expert study that sharply criticized the manufacturer was never published by the Dutch safety authorities, and its key findings were either excluded or played down in their accident report.
On Tuesday, the Dutch Safety Board, which had commissioned the study, reversed course —
publishing it a day after The New York Times detailed the findings.
The Times’s review of evidence from the accident, which killed nine people on a Turkish Airlines flight in 2009, showed the study’s conclusions were relevant to investigations into two more recent crashes of Boeing aircraft that killed 346.
[Read The Times’s investigation here.]
The study, by Sidney Dekker, acknowledged that the pilots made serious errors but also found that Boeing bore significant responsibility. It accused the company of trying to deflect attention from its own “design shortcomings” with “hardly credible” statements drawing attention to the pilots’ mistakes.
A spokeswoman for the board had told The Times last week that Dr. Dekker’s study was confidential. But in a statement on Tuesday, Jeroen Dijsselbloem, chairman of the Dutch board, said the study had been posted online because the board’s “current practices” had changed. “We now publish as much as possible,” he said.
The board also defended its investigation of the 2009 crash, which involved a 737 Next Generation, or NG, a predecessor to the 737 Max. The more recent accidents involved the Max, which has been grounded since last year as investigations continue.
Mr. Dijsselbloem noted “the key question” for those investigations was whether lessons from 2009 “were sufficiently learned by Boeing and the American authorities.”
Multiple aviation experts who had read Dr. Dekker’s study told The Times its findings had not been sufficiently incorporated into the final Dutch accident report. In addition, the Times learned, the Dutch removed or minimized criticisms of Boeing after pushback from a team of Americans that included the manufacturer and federal safety officials.
Jan Paternotte, a member of the Dutch House of Representatives, praised the study’s release but called for a hearing of those involved, saying he believed he would secure the necessary support during a committee meeting on Wednesday. “Boeing has been capable of strong-arming outside parties if it serves the short-term interest of the company,” he said. “When safety is at stake, that is a problem.”
The Dutch board on Tuesday acknowledged that it had changed portions of its draft report after the Americans raised objections, but called that “standard procedure” and noted that the Americans’ comments were included in an appendix.“The Dutch Safety Board does its work in strict independence,” Mr. Dijsselbloem said. “The Board decides independently on the outcome of its investigations, the content of its reports and its conclusions and recommendations.”
A Boeing spokesman referred questions to the National Transportation Safety Board, which led the American team that commented on the Dutch draft report. An N.T.S.B. spokesman declined to comment.
The Federal Aviation Administration, which was also a member of the American team participating in the 2009 inquiry, said in a statement that it was “following a thorough process for returning the Boeing 737 Max to passenger service.” The agency added that it was working with international safety regulators to review “proposed changes to the aircraft” as well as “recommendations from safety experts who have examined our certification processes.”
The Dutch board’s final report, released in 2010, focused blame on numerous mistakes by the pilots, including their failure to notice a dangerous drop in speed and their incorrect response to an alert warning of an impending stall. The report contained statements — some nearly verbatim and without attribution — that were originally written by the American team and further emphasized crew errors.
The Times found striking parallels between the accident and the 737 Max crashes. In both cases, design decisions by Boeing allowed a single faulty sensor to activate a powerful computer command. In both cases, Boeing had known of the potential sensor failures but determined that pilots would react correctly and recover the plane. And in both cases, Boeing didn’t include information in the pilots’ manual that could have helped them respond to the malfunctioning automation.
Boeing, the F.A.A and the N.T.S.B. noted that the system involved in the earlier accident differed significantly from the one blamed in the Max crashes. But aviation safety experts, including a senior F.A.A. official who was not authorized to speak publicly, told The Times that the similarities were noteworthy.
Dr. Dekker’s report “should have woken everybody up,” one said. Instead, “the issue got buried.”