Executive Summary (copied exactly - footnotes indicated in [brackets])
This report conveys the findings and recommendations of the Organization Designation Authorization (ODA) Expert Review Panel (herein referred to as the “Expert Panel” or “Panel”) formed under Section 103 of the 2020 Aircraft Certification, Safety, and Accountability Act (ACSAA), Pub. L. 116-260, Div. V, § 1031[1] (herein referred to as the “the Act”). The Act identifies the Administrator of the Federal Aviation Administration (FAA) and Congressional committees of jurisdiction as recipients of this report.
The Act requires the Expert Panel to review the safety management processes and their effectiveness for each holder of an ODA for the design and production of transport airplanes.[2] The Act also requires the Expert Panel to make recommendations to the Administrator regarding suggested actions to address any deficiencies found after review of the matters listed in Section 103(a)(2) of the Act. The Expert Panel concluded that recommendations for The Boeing Company [3] (herein referred to as “Boeing”) and the FAA are consistent with the requirements of the Act and with the public interest in aviation safety. The Expert Panel expects that the FAA Administrator will review the recommendations and reinforce them as appropriate.
Section 103(a)(3) of the Act defines the required composition of the Expert Panel. Appendix A of this report identifies the Expert Panel membership.
The Expert Panel focused its review on safety culture, safety management systems (SMS), and ODA, while also evaluating other topics of concern for the safety of the flying public.
Following its review, the Expert Panel identified 27 findings and 53 associated recommendations. The findings and recommendations are based upon the Panel’s expertise and review of more than 4,000 pages of Boeing documents, seven surveys, over 250 interviews, and meetings with Boeing employees across six company locations.
A summary of the Expert Panel’s work is as follows:
• The Expert Panel observed a disconnect between Boeing’s senior management and other members of the organization on safety culture. Interviewees, including ODA Unit Members (UM), also questioned whether Boeing’s safety reporting systems would function in a way that ensures open communication and non-retaliation. The Expert Panel also observed inadequate and confusing implementation of the five components of a positive safety culture (Reporting Culture, Just Culture, Flexible Culture, Learning Culture, and Informed Culture).
• The Expert Panel found Boeing’s SMS procedures reflect the International Civil Aviation Organization (ICAO) and the FAA SMS frameworks. However, the Boeing SMS procedures are not structured in a way that ensures all employees understand their role in the company’s SMS. The procedures and training are complex and in a constant state of change, creating employee confusion especially among different work sites and employee groups. The Expert Panel also found a lack of awareness of safety-related metrics at all levels of the organization; employees had difficulty distinguishing the differences among various measuring methods, their purpose, and outcomes.
• Boeing’s restructuring of the management of the ODA unit decreased opportunities for interference and retaliation against UMs, and provides effective organizational messaging regarding independence of UMs. However, the restructuring, while better, still allows opportunities for retaliation to occur,
particularly with regards to salary and furlough ranking. This influences the ability of UMs to execute their delegated functions effectively.
• The Expert Panel also found additional issues at Boeing that affect aviation safety, which include inadequate human factors consideration commensurate to its importance to aviation safety and lack of pilot input in aircraft design and operation.
The Act did not direct the Expert Panel to investigate specific airplane incidents or accidents, or to make recommendations toward a specific airplane incident or accident, which either occurred prior to or during the Expert Panel’s work. However, on several occasions during the Expert Panel’s activities, serious quality issues with Boeing products became public. These quality issues amplified the Expert Panel’s concerns that the safety-related messages or behaviors are not being implemented across the entire Boeing population.
Within six months of the issuance of this report, Boeing should review the recommendations contained in this report and develop an action plan that includes a milestone-based approach that comprehensively addresses each recommendation. Boeing should then share that action plan, including implementation dates with the FAA.
Successful adoption of the recommendations is expected to improve the level of safety provided by Boeing to its workforce, operators, and the public. While the Expert Panel focused on Boeing as an ODA holder, the enclosed findings and recommendations may assist other companies with similar authorizations to implement successful safety culture, SMS, or ODA programs.
The professional opinions expressed in this report solely belong to the Expert Panel and is not representative of any employer, organization, or other group or individual.
[Footnotes in Exec. Summary]
1 Section 103, Expert Review of Organization Designation Authorizations for Transport Airplanes, Aircraft Certification, Safety, and Accountability Act (ACSAA), 2020.
2 Section 137(6), Definitions, of ACSAA 2020, defines transport airplanes as a transport category airplane designed for operation by an air carrier or foreign air carrier type-certificated with a passenger seating capacity of 30 or more or an all-cargo or combi derivative of such an airplane. This definition limited the scope of the panel review to Boeing Commercial Airplanes (BCA), a business unit of The Boeing Company.
3 As stated in The Boeing Company’s 2023 4Q Form 10-K, The Boeing Company, together with its subsidiaries is one of the world’s major aerospace firms. Boeing is organized based on the products and services offered through three reportable segments: Commercial Airplanes (BCA); Defense, Space & Security (BDS); and Global Services (BGS).
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