Transcripts For CSPAN3 Aviation 20240703

Gives you a front row seat to how issues are debated and designed with no commentary, no interruptions, and completely unfiltered. Cspan, your unfiltered view of government. Aviation Safety Specialist testified on boeings Safety Culture admit several reported problems with the aircraft. They highlight the Alaska Airlines store plug failure well in flight. Reports of employees being penalized for raising safety concerns and the faa role in ensuring safety and enforcement. This is two hours. Good morning. The committee on commerce, science and transportation will come to order. I want to thank our witnesses that are here today on the faa oda Organization Expert panel board. I also want to recognize our former colleague Peter Defazio is in the audience and thanked him for his work on legislation with this committee. Today we will hear from three experts on the Organization Design authorization. I want to mention, i appreciate the witnesses being here today but i want to acknowledge this is directly from the report that the successful completion of the report was made possible with cooperation and assistance of the following organizations, the faa, the boeing company, american lines, university of Southern California school of engineering and a special thanks to britney goodwin, mina mitchell, Heather Doris and and the data assessment teams within the office of the faa oda. I want to mention because you are the representatives of those people today. We will add many people here but i wanted to appreciate the work of the two cares as cochairs of the committee and for you being here. We are joined by dr. Javier de luis from the mit school of Technology Department of aeronautics and astronautics. Thank you so much for being here. Dr. Tracy dillinger, the manager for safety and Human Factors at nasa and dr. Najmedin meshkati , professor at the university of Southern California school of engineering and aviation Safety Programs. The 53 recommendations regarding the oda Safety Management system, Safety Culture, services an important catalyst for us and future aviation legislation. While we have made safety improvements through the air certification reform law and some of that is still playing out with the new administrator that i think is more aggressively taking the responsibility seriously we look to build on those advancements with the fiveyear authorization bill, enhanced safety features, but we are not going to stop there. Theres more to be done to implement the recommendations from the report. We owe a debt of gratitude to those that are here today. I want to especially thank you, javier de luis, thank you for being here. I cannot imagine the tragedy of losing your sister and one of the max crashes and continuing to be involved in trying to correct and improve our Safety Culture. I can just say i so appreciate you being here and the active role you have played in these discussions. The final report focused on the apartment of Safety Management systems. While boeing was required to adopt an sms in 2015 as part of an faa Settlement Agreement and the faa later adopted voluntary programs, the report makes it clear that we need a real sms with chief teeth. Both boeing and the faa needs strong Safety Management systems not in name but in reality. The Safety Management system might for the public sound like Management Strategies that maybe they should Pay Attention to, but when it comes to this Management Strategy revolving around aviation it is about saving lives. That is why section 102 required that the faa develop a real sms standard for aviation manufacturers and the agency expects to finalize that rule this june. This expert panel made several recommendations, findings about the Safety Culture and about oda. I want to highlight some. The boeing Safety Management procedures are not thoroughly understood throughout the company. Im sure you will expand on this. It is focused on only one of the four pillars of what the International Standard has said you have to meet if you are going to have an sms program understood by the workforce at large. Im sure you will expand on this. The expert panel raised concerns about the ability to effectively oversee boeings sms. I believe it needs not only a strong workforce strategy to exercise the oversight of the manufacturers to ensure proper implementation. I would like to query the panel today on exactly what sms the faa should implement in their own house to make sure they are improving the Safety Culture and standing up on these important Safety Measures. Right now we are relying on employee Safety Reporting systems speak up which you talked about. I think a comprehensive system that employees know and understand has to be a key component. Documentation provided by the interviews of boeing employees show that they may not have understood how safety fit into the culture of the overall obligations of the company. Human factors have not been prioritized as a technical discipline. Human factors are at the core focus of what we need to do both at the faa and that boeing. While i think you spoke about the loss of experience and the ability of the workforce, we definitely want to build that expertise throughout government clearly at the faa so they can keep pace with the change and while the restructuring of the unit did decrease the opportunity as your report was seen for retaliation we still were seeing that interference is a crime. This is unacceptable. This strengthenedthe faa oversight and put them in charge of these employees and we certainly expect the faa to back up those individual engineers and machinists who are calling out safety and making sure they address those. Although the final report gave boeing six months to make this action plan a reality, the Expert Panel Recommendations have cut this time to 90 days. I expect the company to comply with this deadline and submit a serious plan that demonstrates this commitment to these kind of Safety Measures. They must also demonstrate that they will be a strong regulator on these issues. I hope to query the panel about how to assure that, how we as the Oversight Committee can strengthen this oversight by the faa. I look forward to hearing from our witnesses today. Again, thank you so much for being here. I turned to senator cruise for his opening remark and we will hear from subcommittee colleagues on their statement as well. Senator. Thank you. The United States sets the benchmark for Flight Safety and by arguably the most important measure 2023 was a remarkably safe year for aviation with no fatal accidents for commercial jet aircraft. Flying commercial remains the safest way to travel. Understandably, recent incidents have left the flying public worried. The perception is things are getting worse. The public wants the federal Aviation Administration and congress to confront perceived risks in order to restore confidence for flyers. That brings me to the topic of todays hearing. The faas Organization Designation authorization program. Oda is important to the future of aviation safety as well as to american competitors. I appreciate the work of the congressionally reported expert panel which reviewed the oda for transporter points. Congress examines this in the crashes of lion air flight 610 and 2018 and ethiopian airplanes flight 302 in 2019 in which 346 people tragically lost their lives. The panels final report was released in february. Three of its members are here with us today. Welcome. As a brief aside, i want to in particular acknowledge that one of our witnesses, dr. Javier de luis, lost his sister on flight 302. Doctor, please accept my sincere condolences and thank you for continuing to speak out on an issue that i know has grieved you and your family personally. I also want to recognize the other families that are here today remembering their loved ones whose lives were lost in those tragic accidents. Discussing oda and what changes may be needed is critical. I welcome this conversation. It is worth noting, however, that the faa is still implementing the aircraft certification safety and accountability act, the response to these crashes. It has not even fully implemented the 2018 faa authorization act. Even as we are currently negotiating the reauthorization. While it is clear that boeings culture and Safety Management needs drastic improvement, we should not rush to legislate just for the sake of legislating. To that point i look forward to engaging in todays witnesses all of whom deserve our appreciation and thank you for their hard work on this effort. The report was a consensus product issued without any dissenting views which all of us in congress can appreciate is no small accomplishment. I hope to better understand the recommendations and how congress can work to improve aviation safety in a targeted and effective manner. While discussing oda and Safety Culture is important, the flying public is also acutely worried about why pieces of boeing airplanes are falling from the sky. The Expert Panel Reports specifically noted that the panel was not directed to investigate or provide recommendations towards specific airplane incidents or accidents which occurred prior to or during their work. In addition to todays hearing i believe we also need to hear from the faa and from boeing itself about episodes like Alaska Airlines flight 1282. The committee needs to understand not only boeing oda but the specific production missteps that caused the january incident. We need to hear from boeing directly about their Safety Culture and Safety Management at large. The public will want to know what changes boeing is making to restore confidence in the brand. Boeing is a Great American company with a great history and great legacy. We all want boeing to be successful, but when accountability is needed and it clearly is here, we should not hesitate to demand answers. For boeing to succeed going forward, those answers need to be given and changes need to be made to ensure that safety is central. When each of us when our families and children get on an airplane, we want to trust that we will land safely. That is the topic of this hearing and i hope subsequent hearings as well. Thank you. Senator duckworth. Thank you, chairwoman account will, for holding this hearing and your commitment to oversight. I want to thank our witnesses. This review confirms my view that we need to judge boeing by what it does, not by what it says. Boeing says it prioritizes safety above all else but when the expert panel is going to produce evidence of this, the evidence boeing provided did not provide evidence of a foundational commitment to safety that matched the objective. That should be shocking. Based on some recent actions, it is not. We accept that a door plug blew out of the 737 max 9 boeing was still petitioning for a Safety Inspection despite the fact that they had a known potentially catastrophic safety defense. To its credit under pressure boeing eventually withdrew the petition. The fact that boeing filed it in the first place volumes about the lack of a proper Safety Culture and until recently the lack of a proper regulatory culture. Boeing filed the petition because they thought they could minimize the significance of the safety defect and the faa with let it slide. Boeing have good reason to think this. The faa let the bad actions on the 737 max slide for years. And go figure. We are seeing more bad results. I will give two examples which i think are relevant about the Organization Designation authorization. The first example involves they actually persuaded the faa to let them remove it. After it crashed two planes with 346 people investigators uncovered an internal memo showing that boeing had been explicitly planning to downplay. They wanted to not even use the term when describing the plane to regulators. Even worse, they showed a member improved approved the plan to deceive a regulator. The faa did nothing. They did not even investigate. By sitting on its hands, the faa affectively told boeing that this type of conduct was perfectly fine. The second example concerns the angle of the alert. Shortly after the 737 max 8 went into service they discovered that it was not functioning on most of the 737 max jets which was a violation of the approved type design. Instead of reporting this to the faa and two 737 max pilots, boeing intentionally concealed it and continue to manufacture more jets with the same defect. In other words, boeing made the decision to knowingly and repeatedly violate the approved type design for years. Boeing knew about this but did not warn the faa. When the faa finally found out boeing had been knowingly and repeatedly violating this approved type design the faa did nothing. This told boeing that type design does not matter because the faa is not going to always enforce it. When the faa fails to take action in response to bad behavior it sends an unmistakable message to boeing and employees that bad behavior is acceptable. No wonder the panel found that boeing employees are so confused. The faa needs to more closely scrutinize this behavior and make use of the Civil Enforcement authority when appropriate. Im pleased by the more aggressive regular cherry tone that administrator whitaker has brought to the agency. As this panel review makes clear, there is still a long way to go to bring an effective Safety Culture back. We have our work cut out for us on the committee as we continue oversight and consider whether additional legislation may be needed and i think the panelists were being here. I appreciate your hard work on this to make flying safer for the american people. Thank you and i yelled back. Thank you, senator for your leadership and help on the faa reauthorization and safety improvements bill. We will now go to the witnesses. Dr. De luis, thank you for being here. You are free to make an Opening Statement. Thank you, senator. Chair cant will chair cantwell, Ranking Member and members of the committee i thank you for the opportunity to come here to talk about our recommendations from the final report. My name as you know is javier de luis. Im an aerospace engineer. I have a doctorate from mit. I spent my 40 year career in private industry with Small Businesses that i helped start. I am currently a lecturer at mit. I am also the brother of a woman that was killed when the airplane that she was on crashed a few minutes after takeoff killing all 157 people on board. For me serving on this panel has been an opportunity to help prevent anyone else from going through what i and my family have sadly experienced this past five years. Our panel met for almost a year and reviewed 4000 pages of documents provided by boeing. Interviewed 250 boeing employees at all levels of the organization from executive down to the people that tighten the bolts across six different geographic plants across the country and we reviewed thousands of survey responses that came to us through several surveys that were conducted. As had been noted, this is a consensus report. I would be remiss if i did not get full credit us to our cochairs for hurting this diverse and unruly group. Our panel was charged to focus the review on three specific topics. The Safety Culture, Safety Management systems and oda program. We were however also allowed to evaluate other topics of concern we might identify that would impact the safety of the flying public. As senator cruz noted previously we were not charged with investigating certain incidents but as understandable on several occasions during activities when safety issues arose we, of course, consider them. My fellow witnesses and i felt it would be useful to expand on recommendations in the report as this may help set the stage for the hearing today. First and foremost is one that has been talked about since the report came out is the finding that there exists a disconnect for lack of a better word between the words that are being said by boeing management and what is being seen and experienced by employees across the company. They hear safety as the number one priority. What they see as that is only true as long as production milestones are met. At that point it is pushing out the door as fast as you can. They here speak up if you see anything unsafe. What they see is if they do speak up they get very little feedback. If they insist they might find themselves on the short end of the stick next time raises or bonuses or job transfers come up or even worse. We found this disconnect be present in almost all levels and all worksites we visited. We heard this from technicians, engineers, and we heard it from members of the oda that are delegated by the faa to conduct inspections and tests on behalf of the government. To me it is clear that the commitment to change, the level of change and the pace of change at boeing is not come as a it with the events that created the need for all of this change in the first place, namely the two fatal crashes of two brandnew airplanes five years ago. It was distressing to read a recent statement by bryan west, the cfo of boeing speaking about the alaska air incident from this past january where he said for years we have prioritized the movement of the airplane through the factory over getting it done right. That has got to change. The Leadership Team got it in the immediate aftermath of january 5. I would have thought they would have gotten it five years ago. In closing, i will note that for the last 20 years every faa reauthorization act push more responsibility to the manufacturers site. At the time this was done with the objective of increasing efficiency and productivity. The two max crashes shown that it swung too far and it was the response to try to correct this. It cannot be the high watermark in your efforts. I urge you as you debate additional steps that can be taken to ensure that you increase faa oversight and keep at the company as well as nge ensuring all of the panels are fully implemented. I believe this is the only way we can return this company to what we all remember it once being, a company known for engineering excellence. A company where headlines were written because of accomplishments and not because of failures. I believe the flying public deserves no less. I will turn it over to my colleague, dr. Dillinger. Dr. Dillinger, welcome. Whatever Opening Statement you can make that would be great. Thank you. Chair cantwell , and distinguished members of the committee thank you for having us here to discuss the expert panel review. I am dr. Tracy dillinger, the Senior Executive psychologist for Safety Culture and Human Factors programs within the nasa office of safety and mission assurance. In this position i have created and shared the agency Safety Culture working group and Human Factors task force. Im responsible for the Safety Culture survey, Safety Culture courses, Safety Culture audits and assessments. Human factors, investigation support, Human Factors training and the annual Human Factors report. Im also a proud veteran of the u. S. Air force for over 20 years where i served as a Human Factors investigator, instructor, 10 years as the chief Aviation Psychologist and in numerous roles including the chief of Safety Assessment for the air force Safety Center and served on the columbia accident investigation board. I have spent the majority of my career working in the field of aerospace and aviation safety. I am truly passionate about Safety Culture, Human Factors and their combined effect on organizational performance. Clearly a robust Safety Culture is essential to mishaps. Safety is a nasa core value along with llence, teamwork, integrity, and diversity. Its integral to everything we do. We strive to create an environment where everybody works safely, feels comfortable communicating safety issues, learns from both mistakes and successes, and feels confident balancing challenges and risks. The International Civil Aviation Organization describes Safety Culture as arguably the single most important influence on the management of safety and recognizes the interdependence of Safety Culture and Safety Management. Noting that effective Safety Management empowers a positive Safety Culture and effective Safety Management. I was privileged to participate in the oda panel where i was able to lend my knowledge and passion for Safety Culture to the work of my fellow panelists with whom i had the privilege to serve. Boeing, like nasa, use the five factor model of Safety Culture comprised of reporting, flexible learning and informed elements. While the company has begun addressing reporting and just culture training, it needs to enlarge its Safety Culture program to include all areas, all five factors in using multiple means. The program should be endorsed, promoted, and modeled by its leaders. Employees including team leads, managers, and Senior Leaders need to know what to do when a been reported. That includes ensuring that tools and processes are available so employees can report without fear of reprisal. Managers can listen, reported issues are fixed and communicated with recognition given to those who come forward with concerns. It is equally important that Senior Leaders continually message and demonstrate to their workforce that safety is a critical, fundamental aspect of doing business even over profit. Aviation safety is not just good for the flying public. Ultimately it is good for successful operations and mission accomplishment. That is good for business. I believe that successful adoption of the report recommendations will improve the level of safety to the workforce operators and the public. I would note that while the Panel Focused on boeing, the findings and recommendations contained numerous best practices that could assist other companies with similar authorizations to implement successful Safety Culture, Safety Management systems, or oda programs. Thank you once again for inviting me to appear before you today and i look forward to discussing these important issues with members of the community. I yield to dr. Najmedin meshkati. Thank you for being here and thank you for your Management Strategy books, managing the risk of organizational accident. Thank you so much for the leadership of the university on these issues. Good morning, chairman cantwell, distinguished senators, and distinguished members of the committee. Thank you for inviting us faa panel expert members to testify before you today. I am Najmedin Meshkati, a professor of engineering at the university of Southern California. I am also a senior faculty member with the usc aviation safety and security program. I have an affiliation with harvard project on managing. For the past four decades i have been conducting Interdisciplinary Research on system safety, Human Factors, Safety Culture and Risk Reduction of complex technological systems. These systems include aviation, oil and gas drilling, pipeline, refining Nuclear Power and healthcare. System failures in these industries have a deadly impact on humans and the environment. I have developed many courses at usc and been involved in several accident investigations. I have visited several Nuclear Plants like chernobyl, fukushima. But my participation in this distinguished expert panel working with my great colleagues on this panel further collaborated my experience over the last 40 years. The Safety Culture is the foundation as dr. Dillinger mentioned. Safety culture is the foundation of any processes and operation an organization. As my mentor said, Safety Culture can affect our elements in the system for good or evil. I believe Safety Culture is analogous to the human bodys immune system. That protects it against pathogens and fends off diseases. It is incumbent upon the leadership of any organization to strive for constantly loosing the healthy safety constructs. A healthy Safety Culture is based on competent, trust, transparency,. Another equally important lesson that i have learned prior to my participation in this panel which i have also learned in my career is that human operators in a safety critical system such as pilots and the airplanes or human operators in the control room of a nuclear plant, all of these are the first and last layer of defense for the system. Human operators. As we saw in the case of america on the hudson and also the Fukushima Nuclear plant. As such, our fit panel said the human system should receive attention commensurate to their importance in the safety. Human factors as a crosscutting science should be part of the formal, standalone discipline and a Design Practice at boeing and safety critical systems. Finally, my Research Experience has taught me that a world class Engineering Company that makes or operates a safety critical system such as an aircraft must be run by world class engineers who are thoroughly trained to understand, respect, and impact Human Factors and Safety Culture. Thank you once again for attention to our report. Thank you to all of the witnesses. We appreciate you being here. I think i have a general question. I want to draw this out a little bit from the report. You have emphasized that some of these terms may just be lost on people in their significance. So you are saying there is not a singular Culture Program on safety that is understood by the employees or implemented or responded to by the employees. The frontline people are saying these are the safety problems. They are just not being back up. I want to understand why this phenomenon exists. The report says there are three different programs and people dont know which one to Pay Attention to. Is that a correct understanding . If i may i think there are a couple of things there. It is true that there is an overwhelming amount of documentation. As has been described to me by someone recently, its like if you are trying to teach your kid to drive and you give them the book with all the road rules what they really want is the drivers manual. What you are referring to is one observation that i made that all of the documentation that exists right now on the Safety Culture, it checks all of the boxes that you are supposed to. For the person on the ground, turning the bolts and hammering the nails, they do not know. We ask. They say, what is the safety metric you are working towards. How do you know that you are doing the same thing. We got like deer in the headlights. We have production metrics, there wasnt anything about that. That was one thing. The thing you are referring to about it being multiple ways, there are multiple reporting ways right now at boeing. Thats not necessarily a bad thing. It is good and encouraged. The problem we found was that there was a lack of confidence and if you try to report anonymously. There was lack of confidence that it would be maintained anonymous. There was a lack of confidence that things would get done and a very real fear of retribution and payback if you hold your ground. Obviously those are things that are not compatible with any sort of Safety Culture. Any other witnesses want to add to that . Boeing has been working to develop and field a Safety Culture model throughout the organization. They have been successful in providing training on some of the elements of it. They have not yet put it all together. It works together as a system. At nasa we use the local for it. All of those parts Work Together. When somebody reports something somebody has to listen to it. The way that they treat them has to be fair. There needs to be an environment of psychological safety. They need to learn from that and communicate and pass that on. To create that everybody in the system needs to know what they are supposed to do and how to do it and what is expected of them. If that does not work they need to know the next option. If that does not work they need to know the next option. That is why having multiple reporting systems can be a good thing because if one does not work the employee needs to know what else they can go to. One of the things, example, would be to know who was the chief of safety. That would be where the buck stops. In one of the surveys that we saw, 95 of the people who responded to the survey did not know who the chief of safety was. Thats a deficit that could be corrected but people need to learn who the key people are in stem so they know who they can go to when the processes dont work. I wonder to what degree this committee or i did as Ranking Member of the committee, a whistleblower report that detailed in 2021 an instance where the faa management overruled an engineer regarding a lithium ion battery in a 787. Notably later the faa had to ground the 787 in response to fires caused by those batteries. There was an instance where people were not listening to what people were saying on the line, what needed to be done. There was another incident where it was stated that a more secure Safety Reporting system may have prevented retaliation for filing complaints about different components not meeting faa standards. How do we ensure that those who are speaking up about Safety Measures are listened to. Im sure in this case they knew who to go to but they were not listened to. What do we do with this part of the problem . What do we need to do with the faa . In a properly functioning Safety Culture those questions would not be asked. People would be empowered and have confidence that they would not be smacked down if they spoke up. I do not think that is what we are dealing with here which is one of the reasons in one of our recommendations we encouraged and recommended that boeing establish what are called asap programs. Aviation safety action programs. They are very common with airlines. It is a try part program. It has the faa, the labor and management. If you initiate an event you are protected. More and more, the event gets visibility at the faa level as well as the management level. For me, when i started on this committee i quickly gain visibility because im convinced that if enough eyes had seen the mcas design 10 years ago somebody wouldve raised their hand and said, wait a second, maybe having a system with the sensor feel that crashes the airplane to the ground is not the best idea but they didnt because as was noted it was hidden. To be clear there were whistleblowers that brought this up and said it was unsafe but they were not listened to. This is why we are saying good engineering as i think you agree wins the day but people have to listen to the engineers. We are trying to discover. Our committee can only do the oversight of the faa that forces the faa to do its oversight job correctly. We want to know what we need to do to strengthen this. My time is expired. I have a suspicion i will be able to come back to this. We will turn to senator. Worth. Thank you. Since the door plug fell out of the 737 max 9 there has been a lot of attention on the stunning lack of Quality Control through the supply chain. This is understandable. The expert panel appears to have identified a much broader problem to the absence of an effective Safety Culture. I fear that merely increasing scrutiny on how what door plug is removed and replaced will fail to solve the more fundamental sale failures of the 737 max. I would love for you to go deeper in the conversation we are already having. I think you agree with me that fixing this problem would not be sufficient to get boeing back on track. Frankly, i think that these manufacture problems are mainly a symptom of a much deeper problem. The destruction of the proper Safety Culture by executives that prioritizewall street. It is the replacement driving out of the engineers for the heart of what boeing was. Can you talk a little bit about manufacturing problems. Would you agree they are more of a symptom of the bigger problem . We cant just fix a Quality Control issue and to that was hold it. I completely agree. Lets talk about the door plug issue. Everybody seen the picture of the door sitting there. You save my goodness the bolts are missing. Where was the inspector. More importantly i think, why did a mechanic install the door and walk away leaving it in that condition . Why wasnt he or she trained to know that you just cant do that. That is where you go to, yes, more inspection is good. I believe you cannot inspect your way to quality or safety because all it takes is one slip and we are back here again. It has to be in the dna of the people that understand that you do not walk away from the door leaving it in unsafe condition. You can take that further and say you should not design a door which allows the bolts to be separated from the door. You can take it all the way to design. I completely agree that just playing whack a mole with qa problems is not the way to get there because that is impossible. The car industry learned this a long time ago. You do not let cars move forward when they have defects. You fix the defect and figure out why it is there so it does not show up again. That is not happening here. When problems arise on the line the line keeps moving forward. I think until they take a page from what the u. S. Auto industry learned, we are not going to be able to get to where we need to be for boeing. I would agree with you. That picture was from a cell phone text message because when the ntsb went and asked boeing to provide the logs, when i flew for the army it was all paper logs. They cant find any logs for anybody who inspected it. They still have not been able to identify who did the work. That was just a text message between workers. I want to get into the oda reforms. Im frustrated that boeing still allows opportunities for retaliation against those that raised 50 concerns. The expert panel found continuing problems tracking safety concerns once they are made. This sounds like how they all operated before Congress Passed the act. In 2016 a survey found that 39 of boeing representatives had experienced undue pressure from boeing. In 2020 and faa survey found 26 of respondents believe external pressure from industries perceived to get in the way of safety decisions. 49 believe that safety concerns are not being addressed so they dont bother to report them. I would love for dr. De luis and Najmedin Meshkati to address this issue. Congress try to fix this but clearly a problem remains. Does congress have legislative work to do and what would you recommend we do . Dr. Najmedin meshkati would you like to kick this off . Thank you, senator. Thats been a major issue. The fear for retaliation and independence of oda. We have talked about that and heard about that in the interviews and surveys and documents that we reviewed. One important conclusion that we came to is reorganization of oda within boeing. In the past oda was a program group. Now they are reporting to the function. Now they have something which was a surprise to me that there were some nonboeing oda members and contractors which would be subject to job stability. With this reorganization that they have done, they report to the functional group. It could fix. I want to say that in our panel we have had manufacturers representative. You had a person from and ge. They do the work correctly. Its just not that there is something fundamentally wrong or inherently wrong. Oda can be managed correctly, but these issues would not appear as much. If i may, you asked what more could the faa do. I think the faa needs to take a very close look. And needs to take a very close what the organizational structure of the oda is and require it to be independent and it comes to decisions that affect a persons livelihood. It is a hard ask for somebody. They are putting their livelihood at stake to stand your ground. Most engineers are ethical to do it but we should not have to ask them to risk their family. The issue of contractors as oda members, i was very troubled with that. The relationship is very tenuous financially. It is a big ask to have a contractor that will stand the ground knowing that they could be shown the door the next day. There are times when they are needed, recently retired people that you want to ring back because of expertise i get that but that should be the exception rather than the role. You want the employees to have a little security. Thank you. Senator vance and then senator rosen. Thank you hosting and thank you to all of you for being here. First i want to thank each of the witnesses for the hard work you put into this report. I would like to focus my questions on the oda Designation Authority culture at boeing and the concerns that have been raised about retaliation against employees for the defects and problems. In the executive summary people found that even though the boeing restructuring management of the oda unit decreased opportunities for interference and retaliation, organizational messaging regarding the independent something was missing. Dr. De luis, i hope im getting that pronunciation right. In your executive summaries say that the oda restructuring still allows opportunities for retaliation. This influences the ability of managers to execute their delegated functions effectively. Dr. De luis, i want to understand how this fear of retaliation manifests itself on the assembly line. In your investigation did you find boeing employees on the factory floor were empowered and encouraged by management to stop processes if they detected nonconformity or a possible defect . No, senator. As i understand the only thing that stops the line on the factory floor is an osha violation. If an employee thinks his life or health can be threatened he can stop the line. Everything else gets put into a process depending on where it sits. Gets written up and supposedly gets addressed down the line. This leads to the travel problem weve heard about before where you have a problem, you will fix it later but then you have to take apart something that was not there before. That is in part was what called the door plug issue. To answer your question, we did not find any encouragement or empowerment to stop. They are focused on reporting. Supposedly it was fixed but thats very difficult to say that it is actually happening. I can give you an example. We were at the receiving area where they check out the airplanes before the faa inspects them. I asked them, whats the major thing that you find. They say it is foreign object debris. So i asked what happens. They say we clean it up and move on. I asked what you track right came from so you can be sure it does not happen again. So they say we put in the report and somebody supposed to do it but it keeps showing up. That is not how you fix the problem once and for all. Got it. It sounds like there is not exactly people stopping the line or raising issues. There was retribution and people were penalized for raising safety concerns . That is correct. We heard several reports from people that felt that they were transferred. Please understand we were not empowered to conduct the encompassing review. Im fairly where very well aware that we are recounting anecdotes but thats what we heard. That is our impression. I appreciate your testimony. G safety is there anything you think rn congress could do to solve or improve this problem. If you will be penalized, we want to promote people for raising safety concerns. What can congress do to immediately change this . As i mentioned earlier, one thing you could do im not in your shoes, so i dont know if its legislation or direct, but setting up additional channels for people who come and report without fear of retaliation, such as the program would be a very good step. Thank you. I appreciate it. I know that you personally have suffered tragedy because of some of these problems. I am grateful for your work on this, but also my condolences. Thank you, madam chair. On that point, i dont want to get it to too confusing. If someone knew about either of the batteries, and test or whatever, then what you want is a larger universe of people and not just one engineer talking to one line manager. You want a broader awareness even at the faa, so that it isnt just the faa one person overwriting the line manager. I think that you need to have more visibility in order to prevent things that we saw and the reports that one person could basically hide the existence or suppress the existence of certain systems or make sure they dont go very far. When we were looking at this, several people brought up that you dont need these programs. That is absolutely true. That is not the world we are in right now. There may be other things. I suppose just the one where we were at American Airlines and they talked to us about it and they were very positive about the impact that it has had at american. It resonated with many of us on the panel, so that is why it is on the floor. As a broadening of the communication, the key thing again, and you keep referring to this one instance, but im assuming that you are referring to some actions by people who may have tried to hide the information, but this Committee Also received reports for people who made it clear that they had concerns. Its just that we have to figure out this larger communication. A whistleblower report is a big deal for somebody to do. We are talking about a career ending move. As it has been described to us, a mechanic can say that it was brought up. Im not sure that i put in the locking pins on that panel and he goes and reports it. He immediately is not going to be fired for making that mistake, but why didnt you . Is there a problem in the process . First, lets get the airplane down if its in the air and make sure its safe. Is there a problem with the process . Is the problem with training . Make sure that it never happens again. That is attitude we need to encourage across the aviation world, but in particular at boeing. Thank you. Senator . This hearing is so important and i want to thank the panel for your hard work on this and your care. It matters and we are grateful, because to address recent boeing incidents and puts passengers safety at risk. Can only remain safe and reliable as a form of transportation through vigilant oversight and accountability. I want to thank you for taking the time to be here and answering questions about the findings and recommendations provided in the Expert Panel Report. The report found through the aviation safety matters pilots were neither consistently nor directly delivered to the highest level of decisionmakers in the organization, but also noted that the chief pilot position did not have authority as other executive positions. This is concerning giving that the pilots are uniquely qualified to identify safety issues and hazards inherent with Company Aircraft grade it is clear that the expertise needs to be elevated within boeings process and recommendations are consistent with that. Can you both elaborate on why the expertise that the pilots provide is essential to evaluating boeings aircrafts . How can we make sure that pilotseater seat at the table and cockpit moving forward, so that their expertise can enhance aviation safety . Thank you very much, senator. That is a very important and profound question. Relates to several recommendations about that. It is my position and expert panel has very specifically said says that the chief pilot, pilot and they could bring up their voice to be heard and paid attention to is through robust Human Factors group. If we can have that robust group and make it a line function with authority that commits rates with this role, then i think the issue that you said can be resolved. I heard that in boeing , they say that the structures are the king due to the impact of the importance that we have. I have said that to my students. If the structures, then Human Factors has to be queen. This is equally important as the structures. This issue is close to my heart and very close to the heart of my colleagues and panel, which is why you have made the recommendation. We use the term Design Practice for these findings. Design practice is a very special and important meaning in boeing. If this issue is raised at that level and gets to Design Practice, then some issues can be resolved. Thank you, dr. , would you like to add something . Thank you, senator. The pilots are the customers in a great sense. The reason why its important to hear from the pilots is that they are critical in the design from the Human Factors perspective of the flight deck. The human inputs and pilots inputs go together. The pilots need to have a strong voice and their opinion needs to have a strong weight. They should be the ones providing feedback to those designs in making adjustments. Equally so, he learned that when you say boeing pilots, that has changed a little bit and the pilots are no longer boeing employees, but contractor employees. Again, the ability for them to have a voice at the proper level with the design modifications that take their opinions into account, the panel felt that it was important. Thank you very much. I see that my time has expired, but i want to see that the human factor matters and there are humans on that plane. They matter to all of us and its not just the structure. Thank you for your hard work. Thank you very much, rosen. Again, thank you for being here. The Expert Panel Report notes that boeings factors played a diminished role in the design and functionality of recent aircraft, but it was once considered the Gold Standard. Dr. Dillinger, can you share any specific steps that they shared with the panel to rebuild its Human Factors capability or any additional recommendations you have to boeing to restore boeing as the Gold Standard in engineering . Dr. Dillinger . Thank you, senator. The Human Factors have diminished recently. The company has made a great effort to bring in more Human Factors expertise and they know that it is critical. It needs to be in a standalone organization where they can have a voice formerly formally. We were introduced to the new senior tech discipline laid for Human Factors is developing, but that is a critical element to the design and its essential for future designs. Thank you. Thank you for being here. In 2019, boeing launched the speaker portal, which was an internal Online Platform for employees to confidentially report concerns on a number of factors, including production quality. Speak up is one of the many channels employees have used it to report concerns to the company, but in several places, they find that employees and i quote, did not understand how to utilize the different reporting systems, which were sporting systems to use and when. Many of the employees preferred to report issues directly to the manager. Is there any record of how many production quality concerns were reported to the Speaker Program or other reporting systems as opposed to reporting directly to the managers . I dont have those numbers in front of me. I did recently read that since the door incident, they had a 500 increase. I remember one of the last that we got, asked, is that good or bad . How many speakers would you expect normally . I never got the clear, but to go to yoyour question, there is nothing long with multiple reporting systems. Our concerns were multiple. One is that people have trouble believing that anything will actually result in action. The other concern was that most people prefer to deal with problems by talking to their manager. That is not a bad thing, however we were not convinced that there was a path om when the report goes up to the manager for it to be captured into the Safety System. What i mean is that if you have a problem in your station on the line and you are reporting to your manager, then you may fix it then and there, then thats the end of it. Maybe thats appropriate for minor things, but for all you know somebody is having the exact same problem and we did not see any mandatory reportings for these requirements in order to make sure that that gets captured and subsequently learn from them. That is one of the key tenets. You are supposed to learn. That was problematic. In addition, sometimes if you are just doing it that way, there is no assurance that it was done in the best and proper way as opposed to getting it done and keeping the line moving. You want to make sure that you have those checks and balances, as well. Those were some of our concerns. It is a good program and the intentions are very good and it can be a good program. People need to be trained, but more importantly, people need to see results when they report stuff to it. Nobody gets fired for reporting and nobody gets anything bad happens. Their reporting is making a difference. I think there was skepticism about that, which is why people keep going to the managers, union rep or whatever. Do you think the 500 increase in reporting in the system was due to training or clarifying or a new safety emphasis . What is your notion . Is that a good thing or bad thing . They have been told yet again that if they see something, they need to speak up. I think the real question is, will it be lasting . There is probably a right number of speaker purports to have per month and i dont know what that is, but if you have zero, then maybe you are doing a perfect job, but most likely nobody is really using the system. If you have thousands, you have more problems. Im not sure where that balance is unfortunately, but we need to look at the longerterm data. Thank you all for being here. Thank you. In this large discussion about Human Factors, we require that Human Factors have to be done before the certification and no longer can the faa delegate the Human Factors assessment. They have to do it themselves. Senator, then senator schmidt and senator welch. Thank you, chair for this important hearing. Thank you and im so sorry about your sister. We also less a minnesotan on that plane. Thank you for your advocacy. I will start with you, professor. Can you talk about why its critical that we invest in a strong pipeline into the aviation field . Im obsessed with this, because whether it is air traffic controllers, mechanics or the like, what is going to happen if we dont invest . Im sorry, but your question was investing on the pipeline for training in aviation safety . Are yes. That is extremely important. Thank you for that question. One of the issues that we are facing is that there have been a lot of retirement and exodus from boeing and other places. The issue of training is becoming very important in Workforce Development. For the safety critical system in the case of aviation being air traffic control, pilots, engineers and machinists and other industries. Just two, Energy Safety of National Academy. The Workforce Development for the Energy System in the gulf of mexico is also another issue particularly with the coming new technologies. In this case, one solution is joining forces with technical colleges and universities and developing internship programs for students where they can get the training, go work and come back , then continue their education. This is something that i know for this new technology, some organizations in the gulf of mexico and some countries are getting involved with that. Thank you. Dr. Dillinger, you mentioned how pilots and crew need to play an Important Role in the design and evaluation of aircrafts. Can you also speak to the importance of training new pilots . Its essential that we grow new pilots and that novice pilots have experienced pilots help them learn and become superior experienced pilots. The pipeline of pilots is a constant effort. I think from a human perspective, the more experience we get and the more they learn how to speak up and to make their needs known, especially from a design perspective, the panel was very concerned about Human Factors element coming into design from the very beginning, which requires experienced pilots having input into that process. Very good. Thank you. What additional oversight do you believe is necessary to ensure a stronger Safety Culture . We heard a little bit before with regards to making sure that the faa is able to bet and approve not just the people, but the organizations, as well as higher scrutiny for nonemployee oda members. I think one of the things that has been touched on is the need for the faa to also establish its own sms. The faa has fms on the atc side, but not the other side. As i understand and by no means am i an expert, but in sms, but as i understand, it works best as the inner mesh with each other. Boeing with its suppliers and regulators. It is a little difficult to see if the faa will be able to do im sorry . Exactly. One last question, professor meshkati, on the bill, which alerts personnel to potential safety hazards and how we need to upgrade it. As we do the longoverdue work of upgrading technology, how can updated Technology Strength and Safety Culture . Technology needs to be updated equally and with adequate attention to organizational factors. One thing that we have said over here just by bringing the new technology or even if you have updated technology, but if you dont do workforce training and also change the organization of mechanism that could add up that technology, it would then fall. The issue of the adoption of the elegy in the organization is very important. We have seen that, senator, in the case of positive training control, for example. This is a very important issue that needs to be addressed in a systematic manner. Okay. Thank you. Thank you, senator. Thank you, madam chair. I was under the impression that we would be speaking to people on the ground where their current or previous experience within boeing to examine the current safety issues that the company is facing. I am surprised to see that not a single boeing employee or executive discussed their safety and cultural practices and ongoing efforts to right the wrongs that have unfortunately occurred. We have a hearing about boeing Safety Practices without boeing presence. This is frustrating. It is even more frustrating that another committee down the hallway here is instead having a boeing representative appear before their members to answer questions and concerns. As members of the Senate Commerce committee, we possess the authority to hear from representatives of boeing or any other company that falls within our jurisdiction on short notice. Todays hearing is about examining the findings of a report about boeings procedures and should at the very least be here today to respond to any recommendations or findings from the reports. On a similar note, i have been on this committee for almost a year and a half. During that time, our transportation sector has experienced a number of challenges under this administration, including a concerning trail derailment in east palestine, National Shutdown of our air system, runways on our nations airports and the devastating collapse of the princes got key bridge, yet i along with my colleagues have yet to have the opportunity to question secretary buttigieg, the one person charged with leading our Transportation System. Joining this committee, i expected us in a bipartisan way to resolve issues facing our nation that fall within the jurisdiction of the committee, yet it appears that we are missing the mark, therefore todays hearing is another chapter in an unfortunate series of events where we as a committee could be making larger impact finding answers to questions and fully executing duties as members of this great committee. To be clear, this is not an indictment of our witnesses whose knowledges and insight are not valuable, but the report to which they contributed provides many recommendations to which i hope boeing not only reads, but strongly considers in its efforts to get its house in order. For a comprehensive oversight, i think we should be hearing directly from boeing in its representatives today on how they are addressing findings and executing changes within the company. Rumored hearings in months down the line dont do anything to help missourians flying today. I want to transition the questions. With the chair, who i do enjoy working with, how we can actually deliver the worlds leading Transportation System to keep americans safe. With that, i dont have a lot of time, but dr. Dillinger, based on rapport and findings , this would be something i would be asking somebody from boeing, but to your knowledge, what changes are being implemented . There is clearly a cultural challenge with feedback and being collaborative based on the report. Are you aware of changes taking place . This would be for any of you. Thank you, senator. When the panel completed the report, our mission was done. The panel has disbanded since the report was submitted, however the followup responsibilities to the findings and recommendations have been provided to the faa and the administrator has made appropriate replies to that from what we could tell. We believe that all of our recommendations should be implemented. I dont believe that any have been yet and its only been a few weeks, but are feeling is that while not a comprehensive set of remedies, it is at least a good set of first steps if they have implemented what we recommended. If i may add, our last findings and recommendation to both boeing and faa to Work Together and meet periodically to make sure that recommendations are being implemented. As i remember, if administrator has given boeing three months since february or march to come up with a plan. I think its in our report. We volunteered help boeing during our interview to resolve some of these issues. It is a statement that somebody reported. They didnt really take this opportunity or kind offer to help. At least in my case, they didnt ask. I yelled back. Thank you, madam chair. Thank you, senator schmitt. We will hear from the company. Our oversight job is with the faa and making sure that they are implementing. I did mention at the beginning that they did cooperate with interviews that you did conduct. We will hear from them and my senses have digested your report. By the time they get here, they will have commentary about this. I look over to hearing it. Senator . Thank you very much. People are pretty terrified. Its unreal when you think about it. October 2018 of the indonesian flight with 189 people who died. March 2019, ethiopian airlines. Of course, on january 5th, a door blows off. Bottom line, people are wondering all the time whether they should fly on a boeing plane. Is the public safe . I will start with you, dillinger , then go down the line. That is a lot of questions that folks have. Are we safe on a boeing plane . As best i understand at this point, i have continued to fly on boeing aircraft and i hope that they have taken our findings and recommendations to heart and implement them. Hesitation makes me feel like you have taken your chances. I get asked this question all the time. I do, too. Here is my answer. I say, you know, the safest place for the rocket is sitting on the pad. The safest place for the airplane is on the hanger. For you and me, on our couch. Every day, rocket launchers fly and we do our productions. It is always a trade. Having said that, within the airplane world, you have to look at whats happening and go, how comfortable am i applying this airplane versus that airplane . For me personally, i keep track on whats happening and im worried about whats happening. Thank you. If i had to fly somewhere and there was no other option, i would absolutely fly it versus driving, because i can make that trade. I think the public is entitled to more confidence in the security and safety of flying. Dr. Meshkati, there seems to be two issues about safety. One is the practices and culture of the manufacturer. The other is how much they put profit ahead of safety, because it is a tradeoff. The more they focus on safety, that will come at some expense. I understand that there are problems in both elements for boeing. Would you say thats true . It was very much discussed. I think the seminar book by Peter Robinson and the issue of basically that this is a delicate balance between safety and profitability. We know that these companies are not philanthropic business. They need to make money. This is one of the tenants of Safety Culture to give proportional attended and to goals versus production goals. In the case of boeing, based on the data, that has happened. You attribute some of that change to after the merger . Tell me what the dynamic was. If you look at the history and i was reading another book by john about blind trust and the series of problems. The mentality over there was to push and make more aircraft and not really Pay Attention to detail. Somehow, resolve that later. Unfortunately and according to my reading of the book by Peter Robinson and some of the cities of great articles by several times, it is also chronic as this issue and we have seen that, unfortunately. Let me ask you one last question. What do you have to see from boeing for you to have confidence that they successfully developed Human Factors as discipline and practice . I made sense myself from my distinguished colleague, i like to see the Human Factors person and top percent have equal power and authority as the chief engineer. This is what i like to see. Thank you. I yelled back. Thank you all. Following up on that, we have some members coming and if not, we will conclude the hearing soon. Dr. Meshkati, during the development of the Human Factors on flight deck operations were the golden standard in part because they worked closely and collectively in seattle, then the report goes on to say, the role of Human Factors in its influence eroded to a series of administration issues, including organization, decentralization, downsizing and relocation of the companys headquarters. What does that have to do with Human Factors . Human factors work very good when they are close to engineers and system designers. They exchange information, Work Together and work on the design of the system, then they work on training. They solve that problem together. Again, im not in the business of promoting the book, but on chapter 9 of this book, it is about Human Factors, which i strongly recommend that. It shows the way that the Human Factors erosion of the Human Factors. One of them in the book is when the simulator trainings were totally moved away from the design at that from seattle to florida or somewhere else. That is when you see a problem. I think that was just the training. The training, but before that also during the design. You get some of that input from the training coming back. You think that doesnt exist in a holistic way . Absolutely. How was to holistic and centralized way. I wanted to ask about this in regards to the faa. Most of the report is focused on what you can do to make sure you have a strong Safety Culture within the organization and how much that has to be backed up. What does the faa needs to do to have its own Safety System improvements to make sure that they are thinking about Human Factors or acrosstheboard, a variety of issues that can enhance security, particularly at a time of change of technology. How do we get faa that is up to speed and have a group at the beginning of the certification process detail out more of the risk factors, so that the discussion can happen . We focused a lot ins january 5th on the need to put more faa boots on the ground and i am in no means saying that it is a bad idea. It is an excellent idea. What you point out about the technology is why i think the oda, or delegation of some sort is here with us forever. The faa does not have the resources to be the worlds experts on these technologies. That is not what theyre there for. The key thing is that the faa has to have the ability to interface with the worlds experts, which is a different set of skills needed. You want to be conducting cuttingedge research, but you should be able to talk to people developing that technology and to be able to understand it and how it impacts the safety and operation of the aircraft. I keep going back to something that i said earlier about the need for the faa to really step up its own sms. I think thats critical. If you have that, you have a chance of being able to properly interface with the pee supposed to regulate. If you dont have that, you are sort of spectators at the party here and i think they should be encouraged, directed or however it is that you do it to move in that direction. Thank you. Senator blackburn, are you ready . Thank you. I want to thank all of you for being with us today. I think this aviation safety issue is something that we are so concerned about and we are going to stay behind this. I appreciate the attention to this issue. Dr. Meshkati, i want to come to you. I was reading a report about the Aerospace Maintenance competition where the 450 airplane mechanics met to show off their skills and were working in 15 minute time slots troubleshooting issues. In 15 minutes, its pretty remarkable what people are able to do. It is important to know that they are skilled and you look at what has happened with these different reports for Alaska Airlines, united airlines, the boeing planes. When you look at this and see the skills training that some of them have, where is the disconnect . Is it a lack of skill . Is it a lack of training or preparation . Is it attention . Why are we beginning to have a negative impact see such a negative impact on safety . Thank you, senator. Your question reminds me of a low hot airline and the accident in 1998 or and it started with the aviation maintenance related problem. At that time, faa really looked very hard at the aviation maintenancei think they created a problem called National Plan for aviation maintenance. At that time, one board member of ntsb who was elected pushed on this a lot. The issue of aviation maintenance is extremely sensitive to the Human Factors and Safety Culture issues that my colleague dr. Dillinger is talking about. Let me do this. Dr. Dillinger, let me come to you. I know you conducted hours of interviews for the Safety Report that you produce. Did you speak with any of the whistleblowers when you conducted those interviews . As far as i recollect, we did not. Why did you not talk to any of the whistleblowers . That was not the purview of the panel. At the time, we were not aware of the whistleblowers. Does boeing do enough to ensure that their employees know that there will be no retaliation if they come forward and report safety issues . The panel believes that they need to do a lot more than what they are currently doing. One of the things that we have heard from ntsb is that there is a problem getting information from boeing. Do you think boeing executives do not understand when there is an investigation that they need to come forward with complete information . I cant speak for the executives, but i will say that boeing is a very large and Bureaucratic Company that produces a lot of paper. I am not surprised that there are lax in their responses, because that is the way it is. I cant speak for them. Reading the report, boeings Safety Culture being described as inadequate and confusing is something that harms the flying public and i appreciate the attention to the issue. Thank you, madam chairman. Thank you, senator blackburn. The stakes are simply too high for commercial aircraft to have systemic problems that we are seeing with boeing , so i would like to examine how we got here. Dr. Tran 18, through Organization Designation authorizations or oda, can the faa delegate certain safety certification and other responsibilities to an aircraft manufacturer like boeing . Yes or no . Yes, but currently yes, because it is done with other manufacturers. There are issues described in our report that makes us leery of saying, go ahead and do it. I think boeing needs to prove that they are capable of doing it. Are they able to delegate certain safety certification responsibilities to an aircraft . The answer is yes . Dr. Dillinger, yes or no . Can an aircraft manufacturer like boeing subcontract manufacturing responsibilities for the few of the signature mass aircraft lineto another company . The work of the panel would say yes, like with oda. Successful examples of oda delegation, however the concerns remain about the risk that the culture presents to that process. I share that concern, which is why im asking the question. Dr. Meshkati, can the manufacture subcontract by boeing, such as air systems manufacturing responsibilities to an International Affiliate in malaysia, for example . 787 is now made all over the world. The wing is in one country and the other in another. They are doing that. The authorization can be passed from faa to a manufacturer . A manufacturer can subcontract that responsibility to another entity. Another manufacturer subcontracted by boeing can assign responsibilities to an International Affiliate, which im sure that you realized what we have walked through stepby step is a supply chain of the boeing max 9 aircraft at the near catastrophic door plug blowout, which happened january 2024 to an Alaskan Airlines flight. There are many words for this and you can call it delegating, subcontracting, reassigning and outsourcing. Outsourcing key responsibilities are now more important than safety. Oversight to someone else. I submit that while we are focused on boeing, this is not just a boeing problem. This is far too common across Aviation Systems and suppliers, whether the result of poor leadership and production targets, Profit Margins at all costs and even the cost of safety or some combination of both. Congress must take a look at this culture of outsourcing. Safety implications. This is an instance in which we cant afford. It costs too much. Dr. Dillinger, what more can boeing do to improve its Safety Culture in our own responsibility for the safety of its products . Thank you, senator. The Panel Focused a great deal on Safety Culture. There is so much they could be doing. Part of it has to do with the timing and if they were to accelerate the efforts, then that would be beneficial. There has been a soft start to that to implementing training to getting feedback from employees via their own surveys to providing workshops and focusing specifically on training at levels. For example, executive training , but down through the other layers of the organization to managers and supervisors. There are multiple ways that they could be going after. As you look at a more comprehensive way where they really dive in and in a more timely way, address that the panel felt that it would be important. Thank you for that. Dr. De luis and dr. Meshkati, what more can congress do to encourage both the faa and manufacturers like boeing to take direct responsibility for the safety of aircraft and Aviation Systems . I believe the congress in this Committee Meets to keep the pressure on to make sure that the waivers are not great granted on safety related issues, which would be a good thing. Right now, there are a handful of waivers that directly affect safety. You need to keep the spotlight on this, because in during our interviews, we heard that this is happening, but as soon as everyone moves on to something else, we will go back to the way things were. That cant happen. As you say, it is too expensive and the cost of human lives is way too high. Thank you, senator. That is also related to an earlier question. I think what congress can do is also related to sms. There is a document, which is signed by administrator and tear of ntsb. It is called state Safety Program. This is something that stays with the International Civil Aviation Organization. In this one, it is very interesting. It talks about the Safety Management responsibility for the state and application of sms at faa. What i would suggest and what congress can do is create another panel, like the one we are in section 1 and three to look at the implementation of this report and how does United States stand with this report . If this state Safety Program is being fully implemented, what needs to be done . That has an impact or it can tremendously affect faas power on using in the case of sms in the u. S. , only faa correct me, my colleagues, sms for air traffic. Sms sms needs to be fully cooperating. If this document is being fully implemented, then i think that would be a good solution. I know im out of time, but i appreciate it. I look forward to working with my colleagues on this committee to improve aviation safety. Just to clarify one more time on this issue, because its related to what he said and senator schmitt. We all represent big aviation states and we want this to be right. We definitely believe in the workforce that we have in our states. We want them to continue to grow in expertise and excellence. Recommendation 30 and 31 of the report says, foster an effective Safety Culture and publish a road map for workforce developing with engineers and inspectors and oversee sms for design and manufacturing organizations and partner with industry to measure the success of sms and design an organization to jointly review measures of success on a regular basis. Those are your two key recommendations. The faa is in a rulemaking that will come out in the next 90 days, so what specifically do you want to see in the rulemaking that will help guarantee the success . Secondly, what do we do about the problem that dr. Dewees suggests . It is a poll of government issue, if you ask me. We can ask about space in general, but we are trying to keep the government at pace with technological change. You are saying that the faa did not have some of these people, so what do we need to do . Obviously, we do want to listen to what these sectors say and they have input. They have some of the smartest people about this technology, but we have to get our oversight correctly. How do we make sure that the rulemaking has what we want to see and how do we deal with this lack of engineering skill set and not at the company, but i think it exists and i dont think we are listening closely enough. For your first question, fortunately, its not new and it has been around in the aviation world for 30 years. It was voluntarily implemented as part of a consent degree. Im hoping that they get this right this time. What i meant is that it has been in the on industry and not at boeing. You are correct. In a sense, all they have to do is look at what it has done successfully with organizations like the airlines and others and apply those same standards and rules to boeing. It is not a blank sheet of paper. They have something to draw. With regards to your other question, i have always been a strong advocate of government agencies, like drawing on the resources of National Academies. When new Technology Enters a field, like ai, which is the one. I have always been an advocate. You have these right down the street here with members that you can draw upon to basically go in, advise and give people who know a lot more about the subjects than any of us. Some organizations do it more than others, but i think that is a resource that faa, nasa and other agencies dont use enough in my opinion. The National Academy have good news. Faa has got to National Academy and National Academy has created a Panel Committee expert for risk analysis of transport aircraft. That one, i have the privilege of being a member where we meet over zoom weekly. Faa has reached out to Nuclear Industry for that community of experts. How do they do the assessment . They do that here. Back to you, senator. I think the recommendations that you brought out is fantastic. That is exactly in light of the state Safety Program. If these two are combined together, i think that will be a paradigm shift. I think its simple to get real sms and i think it is a great idea as we envisioned to get a panel of experts and im glad to see that its actually happening with the National Academies as it relates to this input. We will have to query the faa more on exactly how broad that can go. Dr. Dillinger, the last question to you. As painful as all of this is, we can get through it. I think you are referencing your work on columbia, which was also a painful moment for nasa and this committee. I sat on the oversight investigation of that that the committee did in joint session with other senate committees. We did get through that. What are the Lessons Learned . How can we successfully move past this and onto the six that we want to see in aviation . I think the foundation is strong. We have a great 100 years in success and we want to build on it. We want to be known for the successes that the u. S. Has had in aviation and i think the elements are there,but what do we need to do to learn about what columbia learned about how to move forward . Thank you. That has been my life for decades. What we learned that is applicable here and to the report is how important people are and the relationships between people. That is what the Safety Culture issues address. It is about trust and communication. It is about being there. Having a workforce that comes in prepared, trained and energetic. Curious, dedicated and will work their heart out. An organization can recover from a catastrophic loss when that has happened by pulling all of those resources together and focusing on the mission and how everyone works towards the mission to make that happen. To do that, all of those parts, processes have to come together with safety as a priority where people understand that it is just part of doing business. Brian oconnor, former chief of staff safety used to talk about how safety is not the mission, but how we do the mission. That is a critical Lesson Learned for us. Thank you. I want to thank the witnesses again today. The record will remain open until may 15th and any senators willing to submit questions for the record should do so by may 1st and we ask that responses be returned by may 15th. That concludes our hearing. Thank you for your report and willingness to be here today. We are adjourned. This process today that will form a separate aviation bill you said you want in addition . One of the reasons i wanted them, originally we were thinking we would go to the faa, we want to hear from ntsb about the investigation. We wanted some of the investigation. M we thought that would be illuminating. But that is still challenged in some ways. So, we thought that the work of this panel, because it was so specific to the culture needed to be illuminated. I think when we get to some of the discussions with the faa that, they have a lot of responsibilities, one of them w will see. It has to be real Safety Culture structure. What i heard today was just i had read the report obviously and thought highly of it, but what you heard from the discussion with members is, this can be accomplished, this can be accomplished. It is not overly bureaucratic or cumbersome. Its really about the culture, just like she said at the end, it is not the function, it is how the mission its not the mission, its the success of the mission. And i think that is what we are trying to say. Listening to the people who have the most advice. Do you think youll have enough time to get a separate aviation bill done this year and still hearing from other panels . Again, it depends on what else happens in the investigation. But i think so. Just because last time when we got it done, we got it done, i think we got it done and then got out within two months of getting it done in committee and working with the house. It depends, obviously. The fall being an Election Year could make changes. I cant remember whether we got that done in a lameduck or not. Where is melissa . You might know, sorry. It was after election. I think that gives us time. I think what we decided was that there was so much right now on safety and faa with a number of airtraffic controllers, near misses, aviation inspectors, that we wanted to get it done right now. We didnt want to miss that opportunity. I think it helps us, actually, focus more, just like he said, it was a good start but its not the ending period. The challenge is it had to get implemented in the last acting administrator probably wasnt as aggressive as we wanted it to be, but this one is being very aggressive. So that is helping us get more progress on the requirements. When youre considering legislation the topic here today was retaliation, that was addressed we are talking about stuff happen. After that. That the problem. My question is what are you considering in the bill when youre looking at what faa can do to look into that what can faa do and what you considering as you look at this legislation . We put fines in their, i guess you would have to ask the faa what other tools they think they need. Part of it is making the faa stand up. In these instances i mentioned on the 787 three technology and other things, the engineers were saying they got overridden, not by the company, well, the company probably said we dont have to do this, but the faa immediate manager said, you dont have to do that. Were trying to get is, no, the faa has to stand up and back of the line engineers when they say theres a problem. They need to back them up. What is going to take for them to do that . Crystal we are saying, where is your really strong Safety Management system rule . And what are you going to do to ensure that . And then we want to see, too, this last point, they have to have enough technology people. Imagine this discussion when it relates to ai today, there is a lot of knowledge on aviation, very little on a i. I mean, you need to have the technology at the faa to know what the issues are. Im glad theyre leaning on National Academy people. Are you backing up the engineers . Are you working with other Technology Experts who know what the issues are so you dont fall behind . Thats what we want to see from the administrator being aggressive. And, there is more safety engineers in the faa bill. Thats the other thing we wanted to do is have the safety engineers on the ground. Because they are like a reflection of who you can talk to. Any organizations that try to retaliate ash i just wanted to flag that. The future hearings depend on how the faa bill goes, do you have any updates around whether or not you are still on track to meet the may 10 deadline for that . You swore off boeing executive donations over the weekend are you hoping other members of the committee will follow suit . We said we have an investigation we are going to focus on investigation. Thank you. This afternoon officials from the Veterans Affairs Department Office of information and technology testify on president bidens 2025 budget request. Before a house veterans subcommittee. 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