Transcripts For CSPAN3 Aviation 20240703

Enforcement. This is two hours. I went to mentioned that because you were the representatives of all of those people today, i want to appreciate the work of the two jurors of the committee and for you being here as representatives of these individuals today. We are joined by dr. Javier de luis, a director of aeronautics, thank you for being here. Dr. Tracy dillinger at nasa, and a professor of Southern California University Safety programs. The expert panels 50 recommendations regarding boeing s Safety Culture serves as an important catalyst for future aviation legislation. While we have made safety improvements through the air certification reform long, and some of that is still playing up with a new administrator who is more aggressively taking the responsibilities seriously, we look to build on those advancements with a five year authorization bill and at events and features, but we will not stop there. There was more to be done to implement the recommendations from your report. We owe a debt of gratitude to those who are here today. I went to especially thank you for being here. I cannot imagine the tragedy of losing her sister and one of the crashes in continuing to be involved in trying to correct and improve our Safety Culture, but i can just say we so appreciate you being here in the active role that you were played in all these discussions. The expert panels final report focused on the importance of saent systems, and while billing was were hard to adopt an estimate in 2015 as part of an faa Settlement Agreement and while the faa later adopted voluntary programs , the expert panels report makes it clear now that we need a real sms. Both boeing and faa need strong Management System started name, but in reality. Safety Management System might for the public sound like Management Strategies they should not Pay Attention to, but when it comes to this Management Strategy and it evolves around aviation it is about saving lives. That is why section 102 required manufacturers this expert panel made several recommendation findings about the Safety Culture and about oba, and i want to highlight some. That boeing Safety Management procedures are not thoroughly understood throughout the company. It is focused on only one of the four pillars of the International Standard you have to meet if you were going to have an sms program understood by the workforce writ large. The expert panel raise concerns about the faa of to effectively oversee boeing, and i believe the faa needs not only a strong work or 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 Safety Culture and standing up on these important Safety Measures. Right now, we are relying on employee Safety Reporting systems speak up, would you talked about, and i think a comprehensive system that employees has to be a key component of sms, and documentation provided by the get abusive 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 been prioritized as a technical discipline, and Human Factors are at the core of the focus both at the faa and boeing. All you talked about the loss of experience and capability of the workforce, we definitely want to build that expertise throughout government clearly at the faa so they can keep pace with technological change, and while the restructuring of boeings unit did decrease the opportunity as to report a thing for retaliation, we still are seeing that interference is occurring. This is unacceptable. It strengthened faa oversight and put them in charge of these employees, and we certainly expect the faa to back up those individual engineers and machinists, not safety and making sure that they can address those. Although the final report gave boeing six months to make this actual plan action plan, the faa administrator cut this time to 90 days, and i expect the company to comply with the deadline and submit a serious plan that demonstrates this commitment to these kinds of Safety Measures. The faa must also demonstrate that it is going to be a strong regulator on these issues. I hope to query the panel about how to ensure that, how we as the Oversight Committee basically strengthen this oversight by the faa, so i look forward to hearing from our witnesses today. Again, thank you so much for being here, and i turned to senator cruz for his opening remark. The United States sets the benchmark for flightsafety, and arguably the most important measure, 2023 was a remarkably safe year for aviation with no fatal accidents or losses for commercial jet aircraft. Flying commercial remains the safest way to travel, but 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 prevent perceived risks and order to restore confidence for flyers. The faas Organization Designation authorization program. Oda is important to the future of aviation safety, as well as to american competitiveness. I appreciate the work of our congressionally appointed expert panel, which reviewed boeings oda for transport airplanes. Congress establishes panel in the aftermath of tragic crashes in 2018 and 2019. In which 346 people tragically lost their lives. The panels final report was released in february, and three of its members are here with us today. Welcome. As a brief aside, i went to a particular acknowledge that one of our witnesses, dr. Javier de luis, lost her sister on flight 302. 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 on those two tragic accidents. Discussing oda and what changes may be needed is critical, and i welcome this conversation. It is worth noting however that the faa is still implementing the aircraft certification safety and accountability act, this committees response to the crashes. It has not even been fully implemented the 2018 authorization act even as we are currently negotiating the current reauthorization. While it is clear that boeings culture and Safety Management needs drastic improvements, we should not rush to l just for the sake of legislating. To that point i look forward to engaging with todays witnesses, all of whom deserve our appreciation and thanks for their hard work on this effort. The report was consensus product issued without any dissenting views, which all of us in congress can appreciate is no small accomplishment, and i hope to better understand their recommendations and how congress can work to improve aviation safety in a targeted and effective manner. While discussing oda head culture is important, the flying public is also acutely worried about why pieces of boeing airplanes are falling from the sky. The Expert Panel Report specifically noted that the panel was not directed to investigate or provide recommendations toward specific airplane incidents or accidents, which occurred prior to or during the expert panels work. In addition to todays hearing i believe we also need to hear from the and from boeingelf about episodes Like Alaska Airlines flight 482. Our committees to understand not only boeings oda, but the specific missteps that cause the january incident, and we need to hear from boeing directly about the companys Safety Culture and Safety Management writ large. The public will want to know what changes boeing is making to restore confidence and its brands. 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, and 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, when our children get on an airplane, we want to trust that they are going to land safely. That is the topic of this hearing and i hope subsequent hearings as well. Senator duckworth. Thank you for holding this hearing and your commitment to continued oversight. I also want to think our witnesses and all of those who worked on the expert panel review. This review confirms my view that we need to judge boeing by what it does, not by what it says it is suing. Boeing says it prioritizes safety above all else, but when the expert panel as to boeing to produce evidence, the evidence boeing provided did not provide objective evidence of the foundational commitment to safety that is boeings description of that objective. Weeks after a door plug blue out of the 737 max boeing was still petitioning the fda for a safety exemption to rush its next variant into Service Despite the fact that it had a known potentially catastrophic safety defect. Boeing eventually withdrew the petition, but the fact that boeing filed that in the first way speaks volumes about the lack of a proper Safety Culture at boeing, and until recently the lack of a proper regulatory culture at the faa. Boeing sought this petition because they thought the faa would granted. Knowing that they could minimize the significance of the safety defect and the faa would let it slide. Boeing had a good reason to think this. The faa let boeings actions slide four years, and go figure, we are seeing more better results. I will give two examples which i think are particularly relevant to our discussion today about boeings organization authorization. The first example involves mcas. Actually persuaded the faa to let it remove it from the flight panel, and after mcas crashed two planes, investigators uncovered an internal boeing memo showing boeing admin planning to downplay mcas in order to avoid regulatory scrutiny. The plan called for boeing to not even use the term mcas when describing the plane to a regulator. The memo showed a member approved of this plan to deceive a regulator, and yet when this Member Service surfaced, the faa did nothing. The faa told boeing this conduct was perfectly fine. The second example includes an alert. Shortly after the 737 max went into service boeing discovered it was not functioning on most of the 737 max jets, which was a violation of the approved design. Instead of reporting this to the faa and pilots, going intentionally concealed this and continue to manufacture more 737 max jets with the same defects. In other words boeing made the decision to knowingly and repeatedly violate its approved design for years. Boeings oda knew about this but did not like the faa, and when the faa found out, the faa did nothing. This effectively told boeing that design does not matter, because the faa is not going to always enforce it. When the faa fails to take action in response to a behavior it sends an unmistakable message to both boeing and its employees that better behavior is acceptable. No wonder the panel found that boeing employees are so confused. The faa needs to more closely scrutinize boeings behavior and make use of its authority when appropriate, and i am pleased by the more aggressive tone administrative administrator whitaker has brought to the table. We have our work cut out for us on this committee as we continue our oversight and consider whether additional legislation may be needed, and i think the paddlers were being here. Ppreciate your hard work on this. Thank you, senator duckworth, for your leadership and your help on the reauthorization and safety improvements. Senator moran will not be here for an Opening Statement, so we will now go to the witnesses. You are free to make an Opening Statement. Thank you senator. On behalf of myself and my fellow panelists i want to thank you for the opportunity to come here and talk about our findings and recommendations from the final report. My name is javier de luis. I am an aerospace engineer. I earned a doctorate from m. I. T. And spent my 40 year career in private industry mostly running Small Businesses but i hope to start and then built hardware for nasa, goody and other agencies. I am also the brother of my sister who was killed when the airplane she was on crashed a few minutes after takeoff killing all people on board, so for me serving on this panel has been an opportunity to prevent anyone else from going through what are you in my family have sadly experienced these past five years. Our panel meant for muster year, review documents provided to us by boeing, interviewed 250 boeing employees at all levels of the organization from the executive suite down to the people who tighten the bolts across six geographic lands across the country, and we reviewed thousands of survey responses that came to us through several surveys that were conducted. As has been noted this is a consensus report, and i would be remiss if i did not give full credit to this of our cultures for herding this group to a productive and. Our panel was charged to focus our review on three safety topics, Safety Culture, Management Systems, and the oda program at boeing. We were also allowed to evaluate other topics of concerns that would impact the safety of the flying public. As senator cruz noted, we were not charged with investigating specific airplane incidents that occurred prior to our panel, but as it is understandable on several occasions to activities when safety issues arose with boeing products we consider them. My fellow witnesses and i thought it would be useful to expand on several key recommendations in a report, as this may set the stage for todays hearing. At first and foremost is one that has been talked about recently. There exist 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 is our number one priority, but with a c is that is only true as long as your production milestones are met, and at that point it is pushed out the door as fast as you can. They hear or speak up if you see anything that is unsafe, but what they see is that if they do speak up they get very little feedback, and if they insist they may find themselves on the short end of the stick next time raises were bonuses or job transfers, or even worse. We found this disconnect to be present at almost all levels of the worksites that we visited. We heard from tech missions, engineers, and we heard it more concerning for members of oda delegated by the faa to conduct tests. To me it is clear the commitment to change, the level of change, and the pace of change at boeing s not commensurate 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 the cfo of boeing speaking about the alaska incidents from this past january, where he said for years , and this is a quote, for years we prioritize the movement of the airplane to the factory over getting it done right. That has got to change. The Leadership Team got it in the immediate aftermath of january 5. Now, i wouldve thought they wouldve gotten it five years ago. In closing, for the last 25 years every fa reauthorization act push more responsibility over the fence to the manufacturer side. At the time this was done with the understandable objective of increasing efficiency and productivity. The two crashes showed the pendulum swung too far. It cannot be the High Water Mark in your efforts. I urge you to debate additional steps that could be taken to ensure that you increase faa oversight of billing and that you keep pushing for structural change of the company as well as ensuring that all of our panels 53 recommendations are fully implemented. We 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 and accompany the headlines were written about it because of its accomplishments, and not because of its failures. I believe the flying public deserves no less. I will now turn it over to my colleague, dr. Dillinger. Dr. Dillinger, welcome. Whatever Opening Statement you can make. Chair cantwell and distinguish members of the committee, thank you for the opportunity to discuss the report from the expert panel review. I am dr. Tracy dillinger, and i am currently the Senior Executive psychologist received a culture and Human Factors programs within the nasa office of safety and mission assurance. In this position ive created and shared the Safety Culture working group and Human Factors task force, and im responsible for nasas Safety Culture survey, Safety Culture courses, Safety Culture audits and support, Human Factors training, and our annual Human Factors report. I am also a proud veteran of the United States air force where for over 20 years i served as a Human Factors investigator, instructor, 10 years as the chief Aviation Psychologist and did numerous roles including chief of safety assessments for the unforeseen center and served on the columbia accident investigation aboard. I have spent the majority of my career working in the field of aerospace and aviation safety. I am truly passionate about the Safety Culture, Human Factors, and their combined effect on organizational performance. It clearly a robust Safety Culture is essential to preventing mishaps. Cp is a nasa or value along with excellence, teamwork, integrity, and diversity, and it is incredible integral to everything that we do. We strive to create an environment where everyone knows safety, it learns from mistakes and successes, and feels confident balancing challenges and risks. The International Civil Aviation Organization describes Safety Culture is 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 a positive Safety Culture empowers effective Safety Management. I was privileged to participate in the oda panel where i was able to lend my knowledge and passion to the work of my fellow panelists with whom i had the privilege to serve. Boeing like a nasa uses the five factor safety model comprised of reporting, flexible learning, and informed elements. While the company has begun addressing reporting and training, it needs to enlarge it Safety Culture program to include all areas using multiple means, and 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 deficit is been reported. That includes ensuring that tools and processes are available so that employees get a report without fear of reprisal, managers can listen, reported issues are fixed, and then communicated with recommendation given to those who come forward with concerns. It is equally important that Senior Leaders continue with and demonstrate to their work force 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, and that is good for business. I believe that successful adoption of the reports recommendations the level of safety provided by boeing to its workforce, operators, and the public. I would note that while the Panel Focused on boeing as a holder, 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. Inc. You once again for inviting me to appear before you today, and i look forward to discussing these important issues with members of the committee. Thank you again for being here and thank you for your Management Strategy books. Thank you so much for the leadership at the university of these issues. Good morning, chairman cantwell and distinguish senators and distinguished members of the committee. Thank you for inviting us, faa Expert Panel Members to testify before you today. I am a professor of engineering at the university of Southern California. I am also a senior faculty member with the 72yearold safety and aviation program, and i have an affiliation with the project. For the past four decades i have been conducting Interdisciplinary Research on symptom system safety, Human Factors, reduction of conflicts, technological systems. These systems include aviation, oil and gas drilling, pipeline, refining Nuclear Power, and health care. System failures in this industry and safety Critical Systems have a deadly impact on humans and the environment. I have developed many courses that usc. I have been involved in several accident investigations. I have visited several Nuclear Plants including fukushima, but my participation in this distinguish expert panel and working with my great colleagues on the spindle further corroborated what my Research Experience has taught me the last four 40 years. It culture is the foundation, as dr. Dillinger mentioned. Safety culture is the foundation of any processes in an organization. It could make or break the system. As my mentor said, Safety Culture can affect all elements in the system for good or evil. I believe Safety Culture is analogous to bodies in the immune system which protects it against pathogens and defense of diseases. And it is incumbent upon the leadership of any organization to strive for immunizing and constantly boosting the health and Safety Culture of the company. A healthy Safety Culture is based on competence, trust, transparency, and accountability. Another equally important lesson that i have learned through my participation on this panel, which i also incorporated but learned throughout my career, is that human operators in this safety critical system such as pilots and airplanes or human operators in a Nuclear Plant always constitutes the systems first and last layer of defense. First and last layer of defense. As we saw in the case of the hudson and the fukushima Nuclear Plant. As such, our panel recommended Human Factors should receive attention commensurate to their importance in aviation safety. Human factors as a crosscutting science should become a standalone and highly prioritized discipline, and a Design Practice at a boeing and the other companies that deal with vertical safety systems, and finally my Research Experience has taught me that the fourth class Engineering Companies that it makes or operates the safety Critical Systems of aircraft must be run by engineers who are thoroughly trained to understand, respect, and impact Human Factors and Safety Culture. Thank you once again for attention to our panels report and for appearing before you. Thank you to all of the witnesses. Appreciate you being here. I think i just have a question generally. I want to draw this out from your report, because you have emphasized that some of these terms may just be lost on people and their significance. You are saying there is not a singular Culture Program on safety that is understood by the employees or that is implemented or responded to by the employees , and again, i want to make sure, because i am going to get to my sheet about machinists. At the frontline people are saying these are the safety problems. They are just not being backed up. Your report says there are three different programs and people do not know which one to Pay Attention to at any given time. Is that a correct understanding . If i may, they are a couple of things there. It is true that there is an overwhelming amount of documentation on sms and Safety Culture at boeing, but as it is been described to me it is like if you were trying to teach a kid to drive and you give them a statute book on all the road rules, but what they really want is the drivers manual. While all the documentation that exists right now on sms and Safety Culture checks all the boxes for the person on the ground turning the bolts and hammering the nails, they do not know. We ask that all of our interviews what is the safety metric you were working toward . How do you know if you were doing a safe thing . We got deer in the headlights stairs. We had production metrics, but there was not anything about that. That thing you were referring to about it being multiple ways, there are multiple reporting ways at boeing right now, and it is not necessarily a bad thing. Having multiple ways of reporting is good and the problem that we found is that they just did not seem they lack confidence. If you tried to reported anonymously, there was lack of confidence anonymity would be maintained. There was a very real fear of retribution and payback if you held your ground, and advocacy those are things that are not compatible with any sort of Safety Culture. Any of the other witnesses went to add to that 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 fitted altogether so that it works together as a system. At nasa we use the dna logo for. At nasa when somebody report something, somebody listens to it. The way that they treat them needs to be fair and there needs to be an environment of psychological safety. They need to learn from it, communicate that and pass it on, and to create that everybody in theneeds to know what they are supposed to do and how to do it and what is expected of them, and if that does not work they need to know the next option, and 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 would be to know who is the chief of safety. That would be where the buck stops, and in one of the surveys we sought 95 of the people who responded did not know who the chief of safety was. That is a deficit that could be corrected, but people need to learn who the key people are and that system, so they know who they can go to when the processes do not work. I wonder to what degree this committee or i did as Ranking Member of the committee a whistleblower report that detailed an engineer who described an instance where the management overruled an engineer regarding a lithium ion battery and the 787, and the faa had to ground the 787 in response to fires caused by the battery, so there was an instance where people were not listening to what people were saying on the line, when needed to be done. There is another incident where a doctor stated a more secure Safety Reporting system may have prevented him from facing retaliation for filing complaints about different components not eating faa standards. So how do we ensure that those who are speaking up about Safety Measures get listen to . I am sure in these cases the new could go to, but they were not listened to. What do we need to do with this part of the problem . What do we need to do with the faa . In a properly functioning sms, and a properly functioning Safety Culture those questions with up he asked, because people would be empowered, they would have confidence that they would not be snacked on if they spoke up. I do not think this is what we are dealing with here, which is one of the reasons why in one of our recommendations we recommended that boeing established aviation safety action programs. They are very common in airlines, and it is a program that is faa, labor, and management, and if you initiate an event, you are protected. The event its visibility at the the faa level as well as the management level, and for me and when i started on this committee , i quickly became a convert to visibility, because i am convinced if enough eyes had seen the mcas design somebody would have raised their hand and said wait a minute, having a sensor that may crash the airline into the ground is not a good idea. It was purposefully hidden. There were whistleblowers who did bring this up and said it was unsafe, but there were not listened to. This is why we are saying good engineering wins the day. People have to listen to the engineers. Our committee can only do the oversight of the faa that enforces the faa to do its oversight job correctly, and we want to know what we need to do to strengthen i have a suspicion i will be able to come back to this. I will turn to senator duckworth. Thank you, chairwoman. Since the door plug a lot of the 737 max Airline Terrace spend a lot of attention on boeings stunning lack of Quality Control throughout its supply chain, and this is understandable, and yet as we have already heard the expert panel appears to have identified a much broader problem, the absence of a Safety Culture, and i fear that merely increasing scrutiny we fail to solve the fundamental failures. I would love for you to go deeper. The conversation we are already having, because i think you would agree with me that this is a specific Assembly Line problem that fixing would not allow boeing to get back on track. I think the problems are a symptom of a much bigger problem, the destruction of the proper Safety Culture by shareprice of the executives. It is the replacement driving out the engineers that were the heart of what boeing was. Can you talk about manufacturing problems. Would you agree they are more a symptom of the bigger problem. You cannot just fix a Quality Control issue and think that will solve it. I completely agree. Everyone has seen the picture of the door plugged sitting there without revolts. The bolts were missing. Where was the inspector . Ok, should have been inspected, but more importantly why did a mechanic installed the door and walk away leaving it in that condition . Why wasnt he or she trained to know that you just cannot do that, right . And that is where you go to, yes, more inspections are good. I firmly believe you cannot inspect your way quality, because all it will take is one slip, and we are back here again. It has got to be in the dna of the people that understand you do not walk away from a door leaving it in an unsafe condition. You can take that further and say you should not design the door which allows the balls to be separated from the door allows the bolts to be separated from the door. Putting out walkable whcack a mole is not the way that you will get there. The car industry learn this a long time ago. You do not let cars move forward when they have defects. You fix the defect in figural by the defect is there, and then it does not show up again. That is not happening here. When the problems arise on the line, the line keeps moving forward, and until they take a page from what the u. S. Auto industry learn 30 or 40 years ago we are not going to be able to get to where we need to be for boeing. By the way, that picture was from his cell phone text message because ntsb went to ask boeing provide the logs. When i flew for the army it was all paper logs. They cannot find any logs for anyone who inspected it. They still have not been able to identify who did the work, but that picture was not official. That was a text message between workers. I want to get into oda reforms. I am frustrated boeings oda still allows retaliation from those who raise concerns, and the panel found problems tracking safety concerns. This sounds like out oda operated before Congress Passed the act. Representatives had experienced undue pressure from boeing. A 2020 faa survey found 56 of respondents from its aircraft certifications are visibly to external pressure from industries were perceived to get away and though she decisions, and 40 in believed safety concerns were not being addressed so they did not bother to report them. I would love for both to address this issue. A problem remains. Does congress have more legislative work to do, and what would you recommend we do . I know that the panel found 54 suggestions. Would you like to cook a solve . Check us off . That has been a major consideration of oda. And we talk about that and heard about that during interviews and surveys, and the documents that we reviewed. One important conclusion that we came up with is the organization of oda within boeing, because boeing as you know better than i do is a matrix organization. Oda was in the program group. Now they are reporting to the functional group, and there has been something which was a little bit of a surprise to me. There are some nonboeing oda members which are contractors. Their Security Group is subject to the review that they give, but with this reorganization they have done that the oda members report to the functional group, it could fix that. In our panel we have fed manufacturers that presented that they have oda. We have persons from tesla and ge, they do oda correctly. There is something it is not that there is something fundamentally wrong with oda. Oda can be managed correctly and these issues would not appear as much as we saw here. If i may, u. S. With the faa could do or whatever . I think the faa needs to take a very close look. The faa approves oda members. They need to take a closer look at what the structure within the company is set to require it to be, you know, to be independent when it comes to decisions that affect a persons livelihood. It is a very hard task for someone. Most engineers are ethical and that will do it, but we should not have to ask them to risk their family livelihood. They brought up the issue of the contractors. To me i was very troubled by that, because a contractor relationship with the company is very tenuous financially. You are basically there complete yet when. It is a big ask that will have a contractor being asked to stand their ground knowing they could be shown the door the next day. Some of the retired people you want to bring back because of their expertise, but that should be the exception, and not the rule. You want these to be fulltime employees that have a little more senator vance, and then senator rosen. Thank you to the Ranking Member for hosting and thanks to all of you for being here. I thank each of the witnesses for the work you put into this report. I would like to put my question on the oda Designation Authority culture at boeing and more broadly concerns that have been raised about retaliation against employees for identifying defects in the course of boeing operations. In the summary, the expert panel found that even though boeings restructuring of the oda unit increased opportunities for retaliation against oda unit managers and provide better organizational messaging, something was missing. Dr. De luis, and i hope i am getting that pronunciation right, in the summary you say the oda restructuring while better still allows opportunities for retaliation to occur with regards to salary and for low ranking. This influences the ability of unit managers to delegate their functions effectively. Dr. De luis, i want to understand how this fear over retaliation manifests on the Assembly Line. In your investigation, did you find boeing employees on the factory floor were empowered by management to stop processes if an employee detected a nonconformity or possible defect . No, senator, as i understand it, the only thing that stops the line on the factory floor is if an employee thinks his or her life or health, can be threatened, they can stop the line. Everything else basically gets written up and put into one of various processes depending on where it sets. Then supposedly gets addressed down the line. This leads to the problem we heard about before where you have a problem, you will fix it later but to fix it later, you have to take apart something that wasnt there before. Thats in part what cause the door problem, by the way. They had to replace some rivets, remove the door, put the door back, they forgot the bolts, etc. But to answer your question directly, we did not find any encouragement or empowering to stop the line. They are focused on reporting it and supposedly, that loop should be closed, as those problems fixed. But its difficult to say that is actually happening. It sounds like there was not exactly a promotion of people stopping the liner raising these issues. If anything, the opposite. There was rep you shouldnt perturbation, people are penalized for raising safety concerns. We had several reports from people that thought they were transferred or didnt get the raise they were expecting. Please understand, we were not empowered to conduct a significantly statistic all review. I am recounting anecdotes but thats what we heard. Thats our impression. I appreciate your testimony. One quick question to followup and maybe we can follow up with my staff and a detailed way. Is there Anything Congress could do to solve or improve this basic problem . If you are penalized for raising safety concerns, you wont raise concerns. What can congress do to meaningfully change this . As i mentioned in response to an earlier question, one thing you could do im not in your shoes, so i dont know if it is legislation, encourage, or direct, but setting up additional channels where people can report without fear of retaliation. That would be a very good step. Thank you, and i appreciate it. You personally suffered tragedy because of some of these problems. So, im grateful for your work on this but also, my condolences. Thank you, madam chair. Just on the point about that stuff, i dont want to get too confused about existing systems. If somebody you about either the batteries or whatever, that what you want is a larger universe of people, not just one engineer talking to one line manager. You want broader awareness, even at the faa, so it isnt just one person overriding a line manager. Right, senator. I am a belt and suspenders kind of guy. I think you need to have more visibility to prevent the things we saw on mcas in the report where one person could hide the existence, or suppress the existence, of certain systems, or make sure they dont go very far. When we discussed in our panel, in a properly functioning sms, you dont need those programs. That is absolutely true but thats not the world we are in right now. There may be other things besides this. When we were at american airlines, they talked about it and they were very positive about the impact that has had on sms in america. It resonated with many of us on the panel and thats why its in the report. On a broadening of the communication, the key thing, again, you keep referring to this one instance but im assuming you are referring to actions by people who may have tried to hide information from the faa. This Committee Also receives whistleblower reports from people who made it clear they had concerns. Is just that we have to figure out this larger communication. It shouldnt take a whistleblower report. It is a big deal for somebody to do. Talk about a careerending move, whereas as the asap has been described, a flight mechanic and bring this up. Im not sure if i put in the locking pins on that panel and he goes unreported. Immediately, he will not be fired for making that mistake, the focus will be, why didnt you . The focus is first lets get the airplane down from the air and make it safe. Then why did it happen . Is there a problem with the process, training, and make sure that never happens again. Thats the attitude we need to encourage across the airplane the aviation world, but in particular, at boeing. Thank you. Senator rosen. Die want to thank the panel for your hard work and care. It matters and were grateful. Recent boeing ve placed passenger safety at risk. American air travel can only remain safe and reliable through vigilant oversight and accountability like the hearing we are having now. I want to thank you again for taking the time to be here answering questions about the findings and recommendations provided in the Expert Review Panel final report. Pilots [indiscernible] it noted that the chief pilots position does not have the same authority as other executive positions. Pilots are uniquely qualified to identify safety issues inherent in aircraft . Expertise needs to be elevated within boeings oda process. Dr. Meshkati and dr. Dillinger, can you elaborate on why the expertise pilot provides is essential . And what can congress do to ensure that pilots have a greater seat at the table, so their expertise can enhance aviation safety . Dr. Meshkati . Thank you, senator rosen. That is an important and profound question as it relates to our findings number 24, 20 five and several recommendations about that. Our expert panel has specifically said the chief pilot and basically, the way the pilots could bring up their voice to be heard and paid attention to, is through a robust Human Factors group. If we can make it aligned with maturity that commensurate with the role, that issue you said can be resolved. I heard that in boeing, they say structure is the king because of the impact and importance that they have. I have said that to my students. Structure is the king, Human Factors has to be at least the queen at boeing. Because this is equally important, as important as the structures. This issue you raise is very close to my heart and the heart of my colleagues. We use the term Design Practice in our recommendation for these findings associated with that. Design practice has a special and important meaning in boeing. If this issue is right at that level of design factors, some of these issues can be resolved. Dr. Dillinger, would you like to add comment . Thank you, senator. The pilots are the customers in a great sense. And so, the reason it is important to hear from the pilots is they are critical and in the design from a Human Factors perspective, of the flight deck. Human factors inputs and the pilots inputs go together. The pilots need to have a strong voice in their opinion needs to have a strong weight. They should be the ones providing feedback to those designs and making adjustments. Equally so, we learned as a panel that when you say boeing pilots, that has changed, and the pilots are no longer boeing employees. They are contractor employees. So 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 was important. Thank you. My time has expired. Human factors matters to all of us. It is not just the structure. So thank you for your hard work. Senator budd. Thank you all fe. The Expert Panel Report notes that going Human Factors specialists 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 boeing staff shared with the expert panel to rebuild its Human Factors capability . For additional recommendations to boeing to restore boeing as the Gold Standard in Human Factors engineering . Thank you, senator. The Human Factors cadre has diminished recently. And the company has made a great effort to bring in more Human Factors expertise. They know that is critical. It needs to also be in a standalone organization, where. We were introduced to the new senior tech discipline lead for Human Factors, who is developing a new cadre, but that is a critical element to the design and it is essential for future designs. Dr. De luis, in 2019, boeing launched the speak up portal, an internal Online Platform to provide a place where employees could confidentially report concerns on a number of factors, including production quality. Speak up is one of the many channels employees have used to report concerns to the company. In several places, the report finds that employees did not understand how to utilize the different reporting systems, which systems to use and when. And many employees preferred to report issued directly to their manager. Is there a record of how many quality concerns were reported through the speak up program or other reporting system as opposed to directly to the managers . They keep track of how many speak up reports they have. I dont have those numbers in front of me. I did rec read that since the door incident, they have had a 500 increase. I asked was that good or bad. There are two ways to look at this. How many speak up to would you expect normally, right . Never really got clear but to go to your point to your question, excuse me there is nothing wrong with having multiple reporting systems. Our concerns, there were multiple, when is that people have trouble believing anything they put him speak up will result in any action. That was one. The other concern is most people prefer to deal with problems by talking to their manager. Not necessarily a bad thing. However, we were not convinced that there was actually a path for what that report goes to the manager to be captured into the safety system. If you have a slight problem in your particular station on the line, for example, and reported to your manager, you may fix it right then and there, and thats the end of it. That may be appropriate for minor things, but somebody on another line may be having that same problem. We did not see any mandatory reporting requi to make sure that its captured. And subsequently learn from them. Thats one of the key tenets of sms, you are supposed to learn from what happens. So that was problematic. In addition, some tides if youre just doing it that way, there is no assurance that it was done in the best and most proper way. As opposed to keep the line moving. You want to make sure you have those checks and balances. Those were our broad concerns about speak up. Its a good program, i think, the intentions are very good. It can be a very good program. People need to be trained and more importantly they need to seek results when they report stuff into it and things actually change and nobody gets fired for reporting. Nobody gets anything bad happens, and that the reporting is picking a difference. There was skepticism which is why people keep going to their managers or union rep or whatever. To you think the 500 increase in reporting under the system was due to more training, or just a new safety emphasis . Whats your notion, is that a good thing, or a bad thing . Clearly, they have been told yet again that if they see something, to speak up. There is some of that. The real question is there is probably a right numbers become reports to have her month. I dont know what that is, if you have zero maybe you are doing a perfect job, but most likely nobody is really using the system. And if you have thousands, well, you have got deeper problems. Im not sure where the balance is, unfortunately. We need to look at the longerterm data. I just wanted to note that in the large discussion in Human Factors, we required that the Human Factors assessment has to be done before the certification. And no longer can the faa the Human Factors assessment. They have to do it themselves. Senator klobuchar, then senator schmitt and i think, senator welch. Thank you, chair, for this important hearing. Thank you, and im so sorry, doc tor about your sister. Thank you for your advocacy. I will start with you, professor meshkati, can you talk about why it is critical we invest in a strong pipeline to the aviation field . I am am obsessed with this because whether it is air Traffic Controllers or mechanics, or the like, whats going to happen if we dont invest . Thank you for a question, senator klobuchar. I was investing in the pipeline for training in the aviation sector. That is important. Right now, one of the issues were facing is workforce attrition. There have been a lot of retirements from boeing and other places. The issue of training is becoming important in Workforce Development. In fact, for the safety critical system, in the case of aviation being air Traffic Controllers up, pilots, engineers and machinists. Two weeks ago, the Workforce Development for the Energy System in the gulf of mexico is another issue, particularly with new technologies like wind turbine. In this case, one solution is joining with technical colleges and universities, and develop internship programs for students to get the training and go work. Then they come back and continue the education. I know that for this new technology of offshore wind, some organizations in the gulf of mexico, maybe it is getting involved in that. Dr. Dillinger, you mentioned how pilots and crew need to play an Important Role in the design and value lu asian and evaluation of aircraft. Can you speak to the importance of training new pilots . It is essential that we grow new pilots. And that novice pilots have experienced pilots to help them learn and become superior experienced pilots. The pipeline a pilots is a constant effort. From a Human Factors perspective, again, the more experience we get from the pilot cadre and the more they learn how to speak up and make their needs known, especially from a design perspective. The panel was very concerned about the Human Factors element coming into design from the very beginning. That requires experienced pilots having input into that process. Very good thank you. Dr. De luis, what additional faa oversight do you believe is necessary to ensure stronger Safety Culture . We heard a little before with regards to making sure the faa is able to vet and approve, not just the people but also the organizations, as well as higher scrutiny for not employee ou members. One thing that has been touched on is the need for the faa to establish its own sms. The faa has an sms on the atc side, but not on the other side. I am by no means, even though i am an expert in sms, but it has worked best when they enter mesh with each other. Boeing with its suppliers and the regulators. Just one last question for professor meshkati on the bill which alert personnel to potential safety hazards, notams system, and how we need to upgrade it. As we do the longoverdue work of upgrading that technology, how can upgraded technology strengthens Safety Culture . Technology needs to be updated with adequate attention to organizational factors. One big we had said thing we had said is if he dont do workforce training and change the organizational mechanism which could adopt the technology, the issue of adoption of the technology in the organization is very important. We have seen that in the case of positive training control for radio systems. This is an important issue that you raised that needs to be addressed in a systematic manner. Thank you, senator schmitt. When i first learned about this hearing, i was under the impression that we would speak to people on the ground with current or previous experience within boeing to examine the current safety issues the company is facing. However, i am surprised to see not a single boeing employee present today to discuss their safety and cultural practices and ongoing efforts to right the wrongs that have unfortunately occurred. Let me reiterate. We have a hearing about boeing Safety Practices without boeing present. This is frustrating. It is even more frustrating that another committee down the hallway has a boeing representative appear before their members to answer their concerns. As members of the Senate Commerce committee, we possess the authority to hear from representatives from boeing or any other company that falls within our jurisdiction on short notice. Todays hearing is examining the findings of a report about procedures. They should at the least be here today to respond to recommendations or findings from the report. On a similar note, i have been on this committee now almost a year and a half. During that time, our transportation sector variance to a spray and stuff like number of challenges under this administration, including a trained her ailment in east palestine. I nationwide shutdown of our air system. Near misses that runways at our airports and most recently the devastating collapse of the Francis Scott key bridge, yet i and my colleagues have yet to have the opportunity to ration question secretary buttigieg, the one person charged with leading our Transportation System. I inspected us in a bipartisan way to rigorously examine and resolve Critical Issues facing our nation that fall within the jurisdiction of this committee. Yet today we are again missing the mark. Todays hearing is yet another chapter in an unfortunate series of events where we as a committee could be making a larger impact finding answers to questions and fully executing the duties, as members of this tee. To be clear, this is not an indictment of our witnesses, whose knowledge and insight are invaluable. The report to which they contributed provides many recommendations to which i hope boeing on only reads, but strongly considers, in its efforts to get its house in order. However for comprehensive of oversight, we should be hearing directly from boeing. And its representatives today, on how they are addressing the findings and executing changes within the company. Rumored hearings in months down the line dont do anything to help. I want to transition the questions. I want to focus on how as a committee, with the chair, who i do enjoy working with, how we can actually deliver the worlds leading Transportation System and keep americans safe . I dont have a lot of time but dr. Dillinger, based on the report and findings, this would be something i would be asking somebody from boeing. But to your knowledge, what changes are being of limited implemented . Clearly there is a cultural challenge with feedback and collaborative based on the report. Are you aware of changes taking place . This would be for any of you. Thank you you, senator. When the panel completed the report, our mission was done. So, the panel has in effect disbanded to since the report was submitted. However, the followup responsibilities to the findings have been provided to the faa, and the administrator made appropriate replies from what we could tell. We believe that all of our recommendations should be implement it. I dont believe any have been yet. Its only been a few weeks but our feeling is that while not a comprehensive set of remedies, it is at least a good set of first steps if they were to implement what we recommended. In our last findings, recommendation is for boeing and faa to Work Together and meet periodically to make sure recommendations are being implemented. As i remember, it is three months since february or early march to come up with a plan. We volunteered to help boeing to resolve some of these issues. There is a statement in our report that they didnt really take this opportunity, our kind offer to have, at least in my case. I will note that we are going to hear from the company. We have long said we were going to go to the faa and then the company. Our oversight job is making sure they are implementing. I mentioned at the beginning but that they cooperated with the interviews that you did conduct. They have digested your report, by the time they get here, they will have a lot of commentary, so we look forward to hearing it. Senator welch . Thank you very much. People are terrified. It is unreal when you think about it. March 2019, ethiopian airlines. And on january 5, a door blows off. Plot allied bottom line, people are wondering whether they should fly in a boeing claim. Is the public safe right now . We can go down the line. Thats the bottom line question a lot of 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 they have taken our recommendations to heart and implement them. I get asked this question all the time. And i do, too. Is it safe . Here is what i answer and i dont know if it is, the safest place for a rocket is sitting on a pad, the safest place for you and me is on our couch doom scrolling through instagram. It every day we get up and go do something productive. Safety is always a tradeoff. Having said that, within the airplane world, you have to look at whats happening and go how comfortable am i flying in this airplane verses that airplane. For me personally, i keep track of what is happening on the max for obvious reasons and i am worried. Now, if i had to fly somewhere because there was no other option, i would fly versus driving because i can make that trade. The public is entitled to confidence in the security of the planes. There seems to be two issues about safety. One are the practices and culture of the manufacturer. The other is how much should they put profit ahead of safety . The more they focus on safety, thats going to come at some expense. As i understand, there is problems in both those elements for boeing. Would you say that is true . It was very much discussed in this seminal book by peter robinson, flying blind. Basically, this is a delicate balance between safety and profitability. These companies are not a philanthropic business, they need to make money. This is one of the tenets of Safety Culture, to keep your personal attention to safety goals versus production goals. Unfortunately, based on the way it is chronicled in this book, that has happened. You attribute some of that change to after the merger . Yes. Can you tell me what the dynamic was . I was reading another book called blind trust about a series of problems. The mentality over there which is to push and make more aircraft. Not really Pay Attention to detail. And then somehow resolve that later. Some of the series of great articles by mr. Dominic case in seattle times. It also chronicles this issue. We have seen that unfortunately. One last question. What would you have to see from boeing to have confidence that they successfully developed Human Factors as a technical discipline and desig practice . I heard this from my distinguished colleague. I like to see Human Factors have equal power as the chief engineer. I yield back. Thank you, all. Following up, we may have a couple more members coming but if not, we will conclude the hearing soon. Dr. Meshkati, the report states factors in flight deckt hum operations was a Gold Standard because specialists worked closely and collectively in seattle. The report says the role of Human Factors eroded due to administration issues including decentralization, downsizing and relook asian of the company headquartered relocation of the company headquarters. What does that have to do with Human Factors . Human factors works very close to engineers and system designers. They exchange information. They Work Together on the design of the system and then they work on the training and they solve that problem together. Im not in the business of promoting, but chapter nine of this book about Human Factors, i recommend that. That shows the erosion of the Human Factors. One for example is chronicled in the book, simulator trainings was moved away from seattle to florida or somewhere else. That was just the training, right . Also during the design. You get some input from the training coming back to the design. You think that does exist in a holistic way . Holistic sense what i say. Holistic and central. I wanted to ask in regards to the faa. Most of the report is focused on what you can do to make sure you have strong Safety Culture within the organization. And how much that has to be backed up by the faa. Was the faa need to do to have its own safety improvements to make sure it is thinking about Human Factors, or acrosstheboard, a variety of issues that can enhance security particularly at a time a changing technology. How do we get an faa up to speed . Detail out more of the risk factors so that discussion could happen. We focused a lot especially since january 5 to put more faa boots on the ground in the factory. Thats an excellent idea. What you point out about the technology is why i think that a delegation of some sort is here with us forever because the faa does not have the resources to be the world experts on these technologies. Thats not what they are there for. The key thing, i think, is the faa has to have the ability to interface with the worlds experts. That is a different set of skills that is needed. You will not be conducting cuttingedge research but you should be able to talk to the people developing that technology and be able to understand it. In particular, how it impacts the safety and operation of the aircraft. I keep going back to something i said earlier about the need for the faa to step up. That is critical. If you have that, then you have a chance of able to appropriately interface with the people youre supposed to regulate. If you dont have that, you are sort of spectators at the party here. It should be encouraged or directed, however it is that you do it, to move on that direction. Senator blackburn, are you ready . Thank you, madam chair. I want to thank all of you for being with us today. This aviation safety issue is something we are all concerned about. What people are able to do. It is important to know that there are skilled people. You look what happened with these different reports. Alaska airlines, united airlines, the boeing planes that have come up. When you look and see the skills training some of them have, where is the disconnect in this . Where is it a lack of skill, a lack of training or preparation . Is it inattention . Why are we beginning to have such a negative impact on safety . Thank you, senator. This issue we didnt study that here. Your question reminds me of all Ohio Airlines Aloha Airlines in the accident in 1998 or so. It started with an aviation maintenancerelated problem. At that time, faa looked hard at aviation maintenance. They created a program called National Plan for aviation maintenance. One board member who was later elected to ntsb pushed on this a lot. The issue of aviation maintenance is extremely sensitive to the Human Factors and Safety Culture issues my colleague dr. Dillinger is talking about here. Dr. Dillinger, let me come to you, because i know you conducted hours of interviews for the Safety Report you produced. 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 what the purview of the panel. At the time, we werent aware of the whistleblower. Let me ask you then, does boeing do enough to ensure their employees know there will be no retaliation if they come forward and report safety issues. The panel believes they need to do a lot more than they are currently doing. One of the things we have heard from ntsb i there is a problem getting information from boeing. Do you think boeing executives do not understand when there is an investigation, they need to come forward with complete information . I cant speak for the executives. Boeing is a very large and Bureaucratic Company that produces a lot of paper. I am not surprised that there are lies in their responses because that is just the way it is. But i cant speak for them. I will tell you, reading the report and boeings Safety Culture being described as inadequate and confusing. This is something that harms the flying public. I appreciate the attention to the issue. Senator warnock . The stakes are simply too high for commercial aircraft to have the kind of systemic problems were seeing with boeing. I would like to examine how we got here. Dr. De luis, yes or no, through organization designated authorizations, 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, but there are issues described in our report that make us leery of saying go ahead and do it. Boeing needs to prove it is capable of doing it. Are they able to delegate certain safety and certification responsibilities, so the answer is yes, correct . Dr. Dillinger, yes or no, can an aircraft manufacturer like boeing subcontract manufacturing responsibilities for lets say the fuselage of the max aircraft. The bulk of the panel, i think, would say yes. We heard successful examples of oda delegation, however, concerns remain about the risks boeings Safety Culture presents that process. I share that concern which is why am asking the question. Dr. Meshkati, can catholic subcontractor such as Spirit Aerosystems assign manufacturing responsibilities to an International Affiliate in malaysia for example . 787 is now made all over the world. Weighing in one country, wing in one country, fusillades in another country, they are doing that. Authorization can be passed from faa to a manufacturer . The manufacturer can subcontract that responsibility to another entity . And then the manufacturer subcontracted by boeing can assign manufacturing responsibilities to an International Affiliate . What we walked through stepbystep is the supply chain of the boeing max 9 aircraft at the heart of the near catastrophic door plug blowout that happened in january 2024 to an Alaska Airlines flight. Do you call it delegating, subcontracting, reassigning, at the end of the day, it is outsourcing key responsibilities none more important than safety oversight to someone else. Someone else. I submit that while were focused on boeing, this is obviously not just a boeing problem. This is far too common across the Aviation Systems and its suppliers, whether the result of poor leadership, focus on production targets, Profit Margins at all costs, even the cost of safety, or some combination of both. Congress most take a serious look at this culture of outsourcing and its safety implications. This is an instance in which we cant afford a mistake, it costs too much. Dr. Mellinger, what more can boeing do to improve its Safety Culture and our responsibility for the safety of its products . Thank you, senator. The Panel Focused a great deal on Safety Culture. There iat they could be doing. Part of it has to do with the timing. And if they were to accelerate efforts, the panel things that will be beneficial, there has been a soft start to implementing the training to getting feedback from employees via their own surveys. To providing workshops, to focusing specifically on Different Levels prayed for example executive training yes but down through the other layers of the organization to managers and supervisors. Targeted training. There is multiple ways they could go after that. As they look at a more comprehensive way where they really dive in, and a timely way address that, the panel felt that was important and it was in our recommendation. Last question. What more can congress do to encourage both faa and manufacturers like boeing to take direct responsibility for the safety of aircraft and our Aviation System . I believe congress and this committee needs to keep the pressure on to make sure waivers are not granted on safetyrelated issues. That would be a good thing because right now there are a handful of waivers on the max that directly affect safety. You need to keep the spotlight on this because during our interviews we often heard the sentiment, this is happening now but as soon as everyone moves 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 in human lives is way too high. That is also related to an earlier question by senator katz. That is also related to the sms recent document signed by the administrator. It is called the state safety program. This is something the United States files with the International Civil Aviation Organization. This is interesting, sandra. It talks about the Safety Management responsibility for the application of the sms act. What i suggest congress do is create we already have section one and 3 to look at the implementation of this report, and how does United States stand visavis this report. With this state Program Fully implemented come what needs to be done. That impact, or it can tremendously impact faa in the case of sms, formple in United States, it is only faa. Has sms for air Traffic Controllers. There is a notice of rulemaking for sms, but sms needs to be fully cooperated. If this is fully implemented that will be a a solution. I look forward to working with my colleagues on this committee to improve aviation safety. Just to clarify one more time on this issue. It is related to what he said and senator schmitt, we all represent big aviation states. We want this to be right. We definitely believe in the workforce we have in our states. We want them to continue to grow in expertise and excellence. Recommendations 30 and 31 says foster public Safety Culture and encourage a roadmap for Workforce Development with engineers and inspectors. And partner with industry to measure the success of sms. Design and organization jointly review these measures on a regular basis. Those are your two key recommendations. The faa is in this rulemaking that will come out in the next 90 days. What specifically do you want in that rulemaking that will guarantee success. What we do about this problem dr. De luis suggests, which it isnt a ola government issue if you ask me, you could ask dr. Dillinger about space in general. We are trying to keep the government at pace with technological change. You say the faa may not have some people, so what do we need to do . Obviously, we want to listen to what the sectors say, and they have input. They have the smartest people about this technology but we have to get oversight correctly. How do we make sure the faa rulemaking has what we want to see in it . How do we deal with this lack of engineering skill set at the faa, not the company. At the company, were just not listening closely enough. To address your first question, sms is not new. It has been in the aviation world now for 30 years. But it was voluntarily implemented as part of a 2015 consent decree. Im hoping the faa gets this right this time. I meant it has been in the Aviation Industry for 20 years, not at boeing. In defense, all the faa has 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. With regards to your other question, i have always been a strong advocate of Government Agencies like the faa drawing on the resources of the National Academies. When new Technology Enters the field, lets say ai for example, because that is the one that is the new technology du jour right now. I have been an advocate of National Academies down the street with members you can draw upon to advise. 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 and nasa dont use enough in my opinion. National academy i have just one good news, dr. Duluth. Faa has gone to National Academy and it has created a committee of experts for risk analysis of transport aircraft. That month i had the privilege of being a member. I think it has been great because faa has reached out to Nuclear Power industry for the communication of experts. Back to you, senator cantwell, with the recommendations you brought up. That is fantastic. It needs to be combined together. I think that will be a paradigm shift for sms