Summary Of The FAA’s Review Of The Boeing 737 MAX
Summary of the FAA’s Review of the Boeing 737 MAXSummary of the FAA’s Review of theBoeing 737 MAXReturn to Service of the Boeing 737 MAX AircraftDate: November 18, 2020
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Summary of the FAA’s Review of the Boeing 737 MAXTable of ContentsExecutive Summary . 5Introduction . 5Post-Accident Actions . 6Summary of Changes to Aircraft Design and Operation . 9Additional Changes Related to the Flight Control Software Update. . 10Training Enhancements . 11Compliance Activity . 12System Safety Analysis . 13Return to Service . 13Conclusion . 141.Purpose of Final Summary . 152.Introduction . 153.FAA Continued Operational Safety Process . 164.737 MAX Accidents and the FAA’s Continued Operational Safety Actions . 175.6.4.1Lion Air Flight 610 (JT610) Emergency Airworthiness Directive . 174.2Ethiopian Airlines Flight 302 (ET302) Emergency Order of Prohibition . 18Identification of Design Aspects for Boeing to Address. 195.1Considerations During Corrective Action Development. 195.2Issues . 20Maneuvering Characteristics Augmentation System (MCAS) System Descriptionand Flight Deck Effects . 226.1System Description . 236.2Cross-FCC Trim Monitor . 286.3Additional Flight Control System Enhancements . 306.4737 MAX Display System (MDS) Updates for AOA DISAGREE . 316.5Non Normal Checklists (NNC) . 326.6 Electrical Wiring Interconnection System (EWIS) Requirements(14 CFR 25.1707) . 347.Training Enhancements . 348.Certification Project: Key Compliance Activities . 352
Summary of the FAA’s Review of the Boeing 737 MAX9.8.1System Change Development and Certification Process . 358.2Certification Requirements . 378.3Means of Compliance . 388.4Software . 418.5Flight Test . 418.6Flightcrew Operations (14 CFR 25.1302 and 25.1523) Compliance Reports . 428.7Flightcrew Alerting (14 CFR 25.1322) Evaluation . 438.8Evaluation of the Airspeed Unreliable Non Normal Checklist . 44Operational Suitability Evaluation, Including Procedures and Training. 479.1Flight Standardization Board . 479.2Flight Standardization Board and Joint Operations Evaluation Board . 4910. Evaluation of new maintenance requirements . 5010.1 Software Upload Considerations . 5010.2 Maintenance Review Board Activity . 5010.3 Instructions for Continued Airworthiness (ICA) and Maintenance Procedures . 5010.4 Master Minimum Equipment List (MMEL) . 5211. Return to Service Steps . 5311.1 Technical Advisory Board (TAB) . 5311.2 Service Information . 5511.3 FAA design change approval . 5611.4 Continued Airworthiness Notification to the International Community(CANIC) . 5611.5 Notices. 5611.6 Airworthiness Directive (AD) . 5612. Recommendations from Independent Panels and Other Investigative Bodies . 5712.1 National Transportation Safety Board (NTSB) Safety Recommendations . 5712.2 Joint Authorities Technical Review (JATR) Submittal. 5912.3 JT610 Final Accident Report . 6412.4 U.S. Department of Transportation Special Committee . 7113. FAA Conclusion . 7613.1 Safety Issue #1: Use of Single Angle of Attack (AOA) Sensor . 7613.2 Safety Issue #2: MCAS Reset Generates Repetitive MCAS Commands . 773
Summary of the FAA’s Review of the Boeing 737 MAX13.3 Safety Issue #3 MCAS Trim Authority . 7713.4 Safety Issue #4 Flightcrew Recognition and Response . 7713.5 Safety Issue #5 AOA DISAGREE Message . 7713.6 Safety Issue #6 Other Possible Stabilizer Runaway Failures . 7813.7 Safety Issue #7 Maintenance Procedures Related to MCAS . 7813.8 Additional FAA Considerations . 78Appendix A: Emergency Order of Prohibition . 80Appendix B: Continued Operational Safety Process Details . 85Appendix C: Emergency Airworthiness Directive . 87Appendix D: Continued Airworthiness Notifications to the International Community . 92Appendix E: Acronyms . 96List of FiguresFIGURE 1 COS PROCESS GENERALIZATION . 17FIGURE 2 SPEED TRIM FAIL ANNUNCIATION . 26FIGURE 3 SIMPLIFIED SCHEMATIC OF THE UPDATED FCC SOFTWARE. 29FIGURE 4 737 MAX MDS PFD WITH AOA DISAGREE AND AOA GAUGE . 31FIGURE 5 737 MAX STABILIZER TRIM MOTOR WIRE SEPARATION . 344
Summary of the FAA’s Review of the Boeing 737 MAXExecutive SummaryIntroductionThis report provides a detailed technical account of the lessons learned since the two fatalaccidents involving the Boeing 737 MAX aircraft, as well as actions the U.S. FederalAviation Administration (FAA) took to ensure the airplane’s safe return to service. As theState of Design agent, the FAA is providing this report to all States of Registry and to thegeneral public to explain how the agency identified and addressed the safety issuesaffecting the 737 MAX.The FAA’s intent is to assure the global community that the 737 MAX is safe to operateand meets FAA certification standards. This report contains details of the FAA’scomprehensive review of the manufacturer’s proposed changes to the airplane’sManeuvering Characteristics Augmentation System (MCAS). This includes associatedsystem parts, software and mechanical characteristics, safety assumptions, and systemsassessments. Additionally, this report discusses the design, operation, revised pilottraining, and maintenance changes that effectively address the causes of the Lion AirFlight 610 (JT610) and Ethiopian Airlines Flight 302 (ET302) accidents.During its evaluation of Boeing’s proposed modifications, the FAA retained all compliancefindings and approvals associated with the design changes related to MCAS. This thoroughreview has taken more than 22 months and included the full-time work of more than 40engineers, inspectors, pilots, and technical support staff. The effort represents more than60,000 FAA hours of review, certification testing, and evaluation of pertinent documents.This includes approximately 50 hours of FAA flight or simulator tests and FAA analysis ofmore than 4,000 hours of company flight and simulator testing.The FAA has a longstanding commitment to transparency, continuous improvement, andinformation sharing to encourage increased aviation safety worldwide. To these ends, theagency supported numerous reviews, investigations, and robust international engagementwith fellow Civil Aviation Authorities (CAAs). The FAA took into account the finalrecommendations of the U.S. National Transportation Safety Board (NTSB) andIndonesia’s Komite Nasional Keselamatan Transportasi (KNKT), as well as all availablepreliminary information from the accident investigations.The FAA and other U.S. bodies commissioned a number of studies to evaluate the initialcertification of the 737 MAX, as well as the certification process itself. The FAA invited nineother CAAs to be a part of the Joint Authorities Technical Review (JATR), which assessedthe certification of the 737 MAX flight control system. The FAA took into consideration allrelevant findings of the JATR, as well as those of the U.S. Department of TransportationSpecial Committee, the U.S. Department of Transportation Office of the Inspector General(OIG), and other expert reviews.The FAA also commissioned a Technical Advisory Board (TAB) to independently reviewBoeing’s proposed corrective actions. The TAB consisted of a number of technical experts5
Summary of the FAA’s Review of the Boeing 737 MAXwith no involvement in the initial certification of the 737 MAX. Several of these expertswere from other U.S. government agencies. The actions by the FAA and Boeing,summarized in this report, adopted the TAB’s recommendations.This summary is part of FAA’s extensive outreach to technical experts from CAAs aroundthe globe to address their concerns about the aircraft. The FAA also actively supportedconcurrent validation activities of the aircraft by the CAAs of other States of Design oflarge transport airplanes. Each authority will make its own assessment of the FAA’sprocess and findings, as well as Boeing’s actions to address the findings.Due to the nature of the certification process, the FAA continually engaged with the CAAson all aspects of the review. Likewise, all of the CAAs reviewed identical data from Boeingto make their respective findings.Details of the aircraft’s flight control system, as well as the FAA’s evaluation and validationof the changes to the design of the flight control system, are contained in the body of thisreport. This report also includes the FAA’s decision-making logic and supportinginformation.Post-Accident ActionsOn October 29, 2018, Lion Air Flight 610 (JT610), a Boeing 737 MAX, crashed shortly aftertakeoff in Jakarta, Indonesia. On November 5, 2018, after evidence emerged of apotential contributor to the accident, the FAA conducted a preliminary risk assessmentusing the continued operation safety process established in FAA Order 8110.107A, MonitorSafety/Analyze Data (MSAD). Based on this risk assessment, the FAA determined urgentmandatory action was needed.On November 6, 2018, the FAA issued a Continued Airworthiness Notification to theInternational Community (CANIC) (see Appendix D) to notify CAAs around the world thatthe FAA intended to issue an Emergency Airworthiness Directive (AD) to correct an unsafecondition on all 737 MAX aircraft. On November 7, 2018, the FAA issued Emergency AD2018-23-51 (see Appendix C) requiring flight crews to use a revised runaway stabilizeroperational procedure if they encountered certain conditions. The Emergency AD was aninterim action, and further action was planned based on what the FAA and Boeing learnedfrom investigating the JT610 accident.On March 10, 2019, Ethiopian Airlines Flight 302, also a Boeing 737 MAX airplane, crashedshortly after takeoff in Addis Ababa, Ethiopia. Partial data (e.g., altitude, airspeed andvertical speed) was available from a land-based Automatic Dependent Surveillance—Broadcast (ADS-B) system. On March 11, 2019, the FAA issued another CANIC (seeAppendix D) indicating the FAA was actively involved in supporting the investigations.On March 11, the FAA received additional ADS-B data. The data was analyzed andreviewed on March 12 and through the early hours of March 13. Also on March 13,physical evidence from the crash site indicated that the aircraft was in a configuration that6
Summary of the FAA’s Review of the Boeing 737 MAXwould have armed MCAS. The satellite ADS-B data from ET302, when compared with theLion Air Flight Data Recorder (FDR) and physical data, indicated a potential causal linkbetween the accidents. On March 13, with the potential relationship established betweenthe two accidents, the FAA issued an Emergency Order of Prohibition (see Appendix A)grounding 737 MAX aircraft.As of this report, KNKT has issued its final JT610 accident report. The ET302 accidentinvestigation by the Aircraft Accident Investigation Bureau of Ethiopia is still underway.This report reflects the FAA’s review of the JT610 final report and of the preliminary andinterim reports from the ET302 investigation.The FAA reviewed the contributing factors and available data from both accidents andreviewed the existing MCAS design to identify issues and determine the actions needed tosafely operate the 737 MAX. The FAA determined that the aircraft, flightcrew, andmaintenance issues summarized in the chart below must be addressed. The chart alsoincludes a summary of the required corrective actions, all of which are further explained inthe body of this report.Identified IssueFAA Determination of IssuesThat Must Be AddressedCorrective Action*Safety Item #1: USE OF SINGLEANGLE OF ATTACK (AOA) SENSOR:Erroneous data from a single AOAsensor activated MCAS andsubsequently caused airplane nosedown trim of the horizontalstabilizer.Ensure that an erroneous signalfrom a failed single AOA sensormeets all FAA requirements, doesnot prevent continued safe flightand landing, and specifically that itdoes not generate erroneous MCASactivation.Boeing updated the Flight ControlComputer (FCC) software toeliminate MCAS reliance on asingle AOA sensor signal by usingboth AOA sensor inputs andchanging flight control laws tosafeguard against MCAS activationdue to a failed or erroneous AOAsensor.Safety Item #2: MCAS RESETGENERATES REPETITIVE MCASCOMMANDS: When a continuouserroneous high AOA sensor valueexists, the MCAS control law usespilot release of the electric trimswitch to reset MCAS activation.Once reset, the MCAS system willmake another airplane nose-downstabilizer trim command after fiveseconds. This scenario repeats eachtime MCAS makes a command andthe pilot makes an electric trimcommand of any duration andreleases the trim switch.Ensure that if MCAS is activated, itwill generate a single nose-downcommand activation.Boeing changed flight control lawsto ensure that MCAS will notcommand repeated movements ofthe horizontal stabilizer. Therevised flight control laws permitonly one activation of MCAS persensed high-AOA event. Anysubsequent activation of MCASwould only be possible after theairplane returns to a low-AOAstate.7
Summary of the FAA’s Review of the Boeing 737 MAXIdentified IssueFAA Determination of IssuesThat Must Be AddressedCorrective Action*Safety Item #3: MCAS TRIMAUTHORITY: All MCAS commandswere incremental commands, whichmoved the horizontal stabilizer afixed amount, regardless of thecurrent position of the stabilizer.Therefore, multiple MCAScommands resulted in a significanthorizontal stabilizer mistrimcondition, which the flightcrew couldnot counter using only elevatorcontrol.Ensure that if MCAS is erroneouslyactivated, the MCAS systempreserves the flightcrew’s ability,using basic piloting techniques, tocontrol the airplane after theactivation.Boeing changed flight control lawsto include a limit for MCAScommands. The MCAS will stopcommanding stabilizer movementat a point that preserves enoughelevator movement for sufficientpilot control of aircraft pitchattitude for current operatingconditions.Safety Item #4: FLIGHTCREWRECOGNITION AND RESPONSE: FDRdata from both accidents show thatthe flightcrews were unable toeffectively manage the stabilizermovement and multiple flight deckeffects that resulted from the singleAOA sensor failure.Ensure that after any foreseeablefailure of the stabilizer system, safeflight is not dependent on thetimeliness of the flightcrewperforming a non-normal procedure.In addition to the softwarechanges noted in Safety Items#1, #2 and #3, Boeing revised oradded eight non-normal flightcrewprocedures to the Airplane FlightManual and proposed additionaltraining. The flightcrewprocedures and the revised pilottraining provide the pilotadditional information to recognizeand respond to erroneousstabilizer movement and theeffects of potential AOA sensorfailures.Safety item #5: AOA DISAGREE:The AOA DISAGREE alert messageon the Primary Flight Display is notfunctional unless the AOA indicatoroption was chosen by the airline.This alert message is intended to bestandard on all 737 MAX airplanes.Ensure 737 MAX Display System(MDS) software will alert theflightcrew with the AOA DISAGREEmessage if there is disagreementbetween the Left and Right AOASensors.Boeing has revised the AOADISAGREE alert messageimplementation to achieve theoriginal design intent to bestandard on all 737 MAX aircraft.Safety Item #6: OTHER POSSIBLEFCC STABILIZER RUNAWAYFAILURES: A comprehensive reviewof the integrated System SafetyAnalysis (SSA) of MCAS by Boeingand the FAA identified an extremelyremote FCC failure condition thatrequired timely pilot intervention toensure continued safe flight andlanding.Ensure that after any foreseeablefailure of the stabilizer system,continued safe flight and landing isnot dependent on the timeliness ofthe flightcrew performing a nonnormal procedure.Boeing implemented a cross FCCTrim Monitor, which caneffectively detect and shut downerroneous stabilizer commandsfrom the FCCs. This makescontinued safe flight and landingfor this type of failure notdependent on pilot reaction time.8
Summary of the FAA’s Review of the Boeing 737 MAXIdentified IssueFAA Determination of IssuesThat Must Be AddressedSafety Item #7: MAINTENANCEPROCEDURES RELATED TO THEMCAS: The KNKT final repor
affecting the 737 MAX. The FAA’s intent is to assure the global community that the 737 MAX is safe to operate and meets FAA certification standards. This report contains details of the FAA’s comprehensive review of the manufacturer’s proposed changes to the airplane’s Maneuvering Characteristics Augmentation System (MCAS).
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