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tv   FAA Administrator Whistleblowers Testify on Boeing 737 MAX Part 2  CSPAN  December 16, 2019 11:25pm-11:48pm EST

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swim boats are pending so we're going t okay so votes are pending. we
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will move along now, even though that was not quite five minutes. panel to i like to icons welcome the next panel appearing with many years of experience in the industry, mr. g. michael collins faa retiree appearing in his individual capacity and with many years experience and his regulatory role, and doctor michael inslee, former chief scientist, u.s. air, force and kept in a john cox, president ceo of safety operating systems, thank you all for being here today look for your testimony, without objection your full statement will be included in the record and so we will now proceed with your testimony, five minutes, as best you want to summarize. mr. pierson. >> i don't think it's on.
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>> i forgot to put the budget, sorry. members of the committee good afternoon thank you for inviting me to testify today, my name is ed pierson, i would first like to provide my heartfelt condolences for the family and friends who lost loved winds on flying air -- lion air, we are -- he's let me provide a bit of information about myself, i retired from the boeing company as a senior manager of the 7:37 factory in washington, i graduated from the naval academy served in the military as a naval flight officer and how old several leadership oppositions -- positions. i have 30 years of aviation experience, i believe production problems may have contributed to these tragic crashes but i don't believe our regulators are paying enough attention to that factory and
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i'm calling for further investigation. i formally warned boeing and leadership rating on multiple occasions, specifically ones before the lion air crash and again before the ethiopian aircraft about potential airplane risk and the unstable operating environment within the factory those warnings went ignored, in june 9th 2018 while the lion air aircraft was being produced for months before the crash a rhoden email to the general manager advising him to shut down the production lime to allow our team time to regroup, following that email i requested a one-on-one meeting, i requested a one-on-one meeting with the general on july 19th and repeated my recommendation to shut down the factory for a brief period of time. when i mentioned that i've seen operations in the military shut down for lesser safety concerns, i will never forget his response, which was,
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military isn't a profit making organization. during this timeframe 7:37 a chaos, every single factory health metric was getting record low marks, each one was trending in the long -- wrong direction. those metrics are detailed in my written testimony, include overtime, quality, reports and work, keep in mind in on october 9th when the lion air crashed killing 189 people whose only two months old. after the crash, i wrote a letter directed to boeing chairman ceo dennis small burke, mr. mom burke asked his general counsel to communicate with me and we spoke on three occasions, where i renewed my warnings, i stressed that investigating the factory, talking with frontline employees was urgent as i was very concerned that this might not be an isolated incident. in
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february, on february 14 2019 the general counsel assured me that boeing had seen nothing that would suggest the existence of quality or safety issues, i wrote a follow-up letter with supporting documentation to the board of directors requesting that they take urgent action but received no response. last in the months later on march ten 2019, there and fight through to crash killing 157 people. the airplane was only four months old. the regulars investigation precious has been as disappointing as boeing's consistency has little cyst -- issues for the last six months out deliberately formation about the factory to those regulators investigators. i specifically requested this information be shared international investigators on the indonesian ethiopia. i also show production quality concerns about other 77 airplanes it during that time
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freeman is in fact surrey where the national transportation safety board and you department of transportation. the disturbing responses of these leaders are the two of them are in testimony. this part more information regulars of the continued to direct our primary perhaps exclusive focus on the sort of official process training any design failure the financial system specifically the software. when the component first failure of the crashes as the angle attack sensors part which is a historically reliable part. both boeing of the faa new in december 2018 that the original attack sensor on the lion air airplane had failed, which is clearly a production issue since the airplane was brand-new. although the fact in self censor was replaced with the virus top heart before the crash, that does not explain rowdy boring part fell in the first place. it appears the same sense roughly upon
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ethiopians airline flights. let me be clear, i'm not saying that i know fact you conditions calls these two crashes, i'm seeing a combination of three -- of those factory conditions. first to, there had been to fatal crashes, and for the record i'd like to know that there was actually a total of 347 people died were killed as utilities crashes. but during recovery operations are also passed. my second retailers i saw firsthand the factory were stressed beyond anything in my experience, i had third there had been 13 other safety incidents involving faulty hardware or other systems many of which were serious. any one of the circumstances a launch a justified investigation of production and together they are allowed to an open and shut case for such an investigation. bottom line is the 737 max factor needs to be thoroughly
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investigated and monitored by authorities specifically faa on a continuous basis. into the future. i've include recommendations in my reinstatement. thank you for providing it is a part opportunity i'm ready to answer questions. >> i want to thank chairman defazio and members of the committee for this opportunity to testify. i want to offer my condolences to family members and visit those who died in the two tragic 7:37 accidents. i'm a retired from the faa with over 29 years of experience, before that i worked a boring for five years. hours a weed faa engineer on the ntsb's twa800 investigation and that was caused by an explosion or a fuel tank on an airplane, therefore i have seen firsthand the devastation caused by a catastrophic airplane accident. i became the faa seal -- the
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managers they began addressing lessons learned from the twa accident. during this time the issue major fielding safety rules one focus on preventing feel things in the second for his on from ability. i've heard faa say he did state the safety they're the highest priority. i agree that safety was their highest priority when i started working with the faa in 1989. however, over the last 15 years or so, the faa management culture has shifted toward the onset applicants now are often take precedence over the safety of the traveling public. i clear example of this is the issue of the rather control of the 737 max, or the objections of the special this. the airplane was approved area was iron change from the original 1960s designed. he has a single string control system consisting of quebec cables -- this news or in the event of an army continued asian failure during takeoff a catastrophic
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loss overall the airplane could obscure if an engine fragment cars one of the cables. in 1989 80 seat and crash during the landing after an end in hanoi continued failure. and gingerbread damaged airplanes three independent hydraulic systems. this to say both of the flight controls. the flight crew attempted to land but crashed row landing. the result was 111 fatalities. because of the dc-10 accident and based on industry committee recommendations, in 1997 the faa updated compliance policy in a revised ac for 20 dash 28 a. the ac requires protecting the controls from a one third disk fragment projectile indian veteran uncontained engine failure. during the max project the faa manager agree that the existing desire did not comply with the affairs and consider the nation on the airplane. i
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certification date neared and pointed lawmakers design change, the faa management decided not to require a modified of 50 overcontrol design. and they employee submitted the issue the faa's internal safety reporting process as a safety concern report. i was one of four members of the faa safety oversight board from the safety concerns were submitted, includes two aerial speech engineers and managers. it included the issue the document agreement with the applicant on their compliance. is she proven signed by for managers but all seven aerospace engineers and a project pilot disagreed with his of compliance. the board identified to review the report and recommendation to the board. the panel included for aerial sweeps engineers and two managers. often various faa offices. the consensus based regulations included a statement that the method of compiling from the issue keep
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it is not my with associated faa regulation. the faa are is. the border we with the panel and forwarded to the management as a board recommendation. manager did not expect recommendations therefore overwhelming aboard on a panel. their manager was the same area over the technical specialists on the issue paper process. when considering the non concurrence is on the issue paper, the panel and the oversight board recommendations of a total of at least 13 faa aerial space engineers, one powered analysis for faa managers disagreed with the method of compliance. the other managers allowed to be used. for comparison all the the plane was approved with his similar design, we also work with airbus to reach agreements that alberta revised to design heating the guidance and in 1997 asi, and incorporated new designs on our a320 series
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airplanes. thank you for this opportunity. i hope i testimony will help improve the faa management safety culture and the aircraft certification circus. >> thank you. >> fishermen the faster over the native manner to the committee. thank you video eternity to testify today on the behalf of the human factors ergonomic society. i express my heartfelt sympathies to the families of the victims of lion air and ethiopian airlines crash is. it's heartbreaking.thc they in wasted technology design affects the performance of the operator, optimizing with susan human it's not global system is the essence of human factors engineering. when the system is easy to use a cards against a typical human limitations enters and helps people rapidly understand key information about what is happening, high-level's of human performance can be achieved. when a system
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designed to this can prevent them. a key foundation to save our travel is the design and development of a controls, displays and automated systems that pilots rely upon to operate the aircraft. our second year history shows our aviation safety significantly enhancement human factors engineers prioritized into the design and development of aircrafts. he's also honesty catastrophic consequences on human factors designers secretary to other considerations are right ignored indicative the boeing 737 max eight, they failure to incorporate non human factors design principles and human factors engineer processes its analysis, design, testing and certification paved the way for both the lion air and the ethiopian airline crashes. each accident with the former accurate of right on the aircrafts sensor and cascading and effect on comcast. he additionally creating
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significant new challenges for pele performers i were not addressed. where are the mission can be a beneficial, it also leads to new types of human error. slower incorrect pilot actions in operating in intervening and automation control are common problems found in over 26 out of which are related accidents among air carriers. human factors research shed light on several automation deficiencies that impacted pilots of the 737 max eight. first, our nation leads to workload spikes an abnormal situations. in both accidents the pals were significantly overloaded with mentally and physically are forced to manage multiple others saw that the more from the cast problem and we needed to exert considerable force on the control column so county impasse actions only if i control. secondly, i donation also results in law situation
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awareness and in these accidents the pilot struggles as they were not provided with the needed displaced for understanding the functioning of them cast, nor with the airways of the disagreement displaced our needs overseer. the various hurlers tender weariness stored nor diagnostic and confusing. ohio reporting that our president appears the ethiopian airlines crew lost situation arena so there are speed. they are, automation confusion is a frequent challenge in aviation accidents and it was a central problem on the max 8. our donations confusion stands from both for transparency of behavior the automation and inadequate displays as well as inadequate understanding of how impassable mission works with inadequate training on the system. conditions are failing to include in-flight during their provide actual experience and diagnosing and responding to you conditions was not provided. finally, the pilot will be able
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to take over in five manually without clear unambiguous fairly educations and training, air crew could not carry out the provisional timeframe accepted and manual forces required footage but look at not be maintained. the most affordable accidents the ethiopian airlines in my aircraft is provided for given factors lessons that should be leveraged to improve the safety of our aviation system and to get similar problems in other safety critical systems. >> it's automation problems could have been easily presented by falling established even factors assigned principles and that is for human automation interaction, and along presentation. emphasis on human factors engineering an aircraft systems analysis designed is critical for building in aviation safety. we are partly since timer so the faa administrator to reinforce our commitments to safety as the highest priority and we hope they continue to soar porter
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message to their actions. i supported testimony provides greater only design and the utilities and longer term prevention recommendations. thank you for the opportunity to show these insights today and i look forward to answering your questions. kevin cox. >> good afternoon mister chairman i thank you in the committee for asking me to share my views on the issues raised by these two tragic 737 max accidents. in my 50 years in aviation and 33 as an aircraft accident investigator, i have not seen a more complex accident than liner six. sadly it was a full warning of our unanticipated conditions that existed which could lead to another accident. ethiopian fly through to where that accident. for an investigator, the most difficult accident to their reoccurrence. i started in the mid 90s when the accident near
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pittsburgh in september 1994. it was a reoccurrence over father had brought down the united airlines flight 85 three years earlier. you know learn all because a bit of 132 perished in pittsburgh. we did not learn all we could from liner 16 before the ethiopian throw to acceding it. the investigation was not complete. >> there was compelling evidence of a single failure that could cause multiple warnings and affect the handling characteristics of the airplane. it's crucial that we learn all we can from these accidents, so that there is no recurrence of the numerous factors out that the catastrophic loss of these two fights. there are humans complexities in these accidents. they are characterized oval office in control in-flight accident, however the contributing factors or numerous. since the loss of these five to have the numerous attempts to blame one or two
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organizations or individuals. this is inaccurate and misguided. only with the consideration of all the contributing factors can we learn all the lessons. in the line accident they're contributing factors on aircraft design, certification oversight, maintenance execution, pilot performance, pilot dependence on automation, human factors, culture and regulatory oversight of the operator. within each of these contributor numerous issues. this is why i make the statement. this is the most complex accident i have seen in 33 years. as the committee is where the national transportation safety board and these technical reviews have for their commended the future certification of aircraft include multiple warnings caused by a single failure. this was a critical factor in both of the accidents. the flight crew had multiple warnings, -- during the ensuing
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pulling the recognition of the inappropriate stabilizer trim rover would've been difficult. this is one reason at the runaway trim stabilizer trim procedure was not immediately accomplished. aviation is the safest from public transportation. we will flat four and a half million passengers this year, and 45 million flights safely. we've gotten progressively better since the first flight in 1903, and while the record is exceptional is not good enough for tomorrow the day after. deviation has to continue to be safer. i frequently ask the question, is the last going to be safe when he returns to service? my answer is yes. before i have great confidence in the faa and in boeing, additionally i have confidence that the recommendations from the indonesian transportation safety committee in the
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national transportation safety board and the drone authority technical review, these recommendations for safety are only for the max prefer aviation overall. we have a chance to take the lessons from these communities to make our skies safer. well asked not squander this opportunity. and as carefully review each of the contributing factors of these accidents, and improve the design, certification processes to better address human factors. better failure now through multiple systems failures, better pilot training with improved emphasis on money or handling skills, and improved organizational culture for the focus is on safety first. this committee's recommendation of actions can improve aviation security. we can enhanced the faa's ability to improve failure novices, system safety analysis which may prevent a future accident. let me
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conclude an observation. i first started in 1970. had we maintained the same accident rate from then today, it would've been hundreds more accidents and thousands more felonies. we were not satisfied with our safety record, nor should we be with today's much-improved safety record. let us learn all we can in the max accidents to improve aviation safety. i look forward to your questions, thank you mister chairman. thank you very testimony. we have three votes coming up on the floor of the house. right now or in process so the committee will adjourn and our return immediately after the votes. let's say they drag out votes around here. yeah okay, recess. sorry. we'll take a break. i would say minutes, you can run on the


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