The Lever - The Hole In Boeing’s Inspection Program

A new government investigation has found that four key bolts weren’t installed in a Boeing 737 Max plane, leading to a terrifying midair cabin breach last month. How could such a mistake happen? As Freddy Brewster reveals in today’s featured story, 14 different government and whistleblower reports have ascribed such production problems to the fact that the government allows Boeing to conduct its own manufacturing and safety inspections — a situation that one passenger advocate says has left airline regulators “completely hands off.”

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For the past 15 years, the government has allowed Boeing to conduct its own inspections related to many manufacturing and safety issues — and during that time, government reports, experts, and whistleblowers have issued more than a dozen warnings that the self-inspection program has led to serious production issues and contributed to two fatal crashes. 

During much of that period, federal regulators shifted an ever-larger amount of the plane-certification process to Boeing, even as the plane manufacturer cut production corners and pledged to focus on “removing layers that help us be faster.”

Now a new government investigation, a whistleblower report, and aviation experts suggest the self-inspection program could have played a role in multiple recent high-altitude debacles, including a door plug blowing out of an Alaska Airlines flight over Oregon last month because four key bolts weren’t installed.

As Transportation Secretary Pete Buttigieg promises “a bigger-picture examination of any and all quality issues” related to the troubled airplane manufacturer, officials indicate they will be taking a hard look at Boeing’s self-inspection program.

In the wake of a multimillion-dollar lobbying blitz, in 2009 the Federal Aviation Administration (FAA) began allowing Boeing to conduct its own plane inspections and determine for itself whether its designs and production work were airworthy. The move, part of a newly established Organization Designation Authorization (ODA) program, was framed in part as a cost-savings measure.

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Since then, more than a dozen government reports, surveys and whistleblower notices have warned of problems with the ODA program, including a lack of necessary government oversight, staffing shortages, poor training, and a history of allowing safety problems to go undetected.

Most worryingly, after two Boeing crashes in 2018 and 2019 killed 346 people, a Congressional investigation concluded the accidents were due in part to the self-inspection program giving Boeing too much discretion when approving critical safety work.

“The problems with Boeing’s ODA program are clearly significant,” the report states. 

While lawmakers then implemented what was supposed to be sweeping reforms to the ODA program, problems with the self-inspection program have continued, suggests a new whistleblower account.

Following the door plug malfunction on the Jan. 5 Alaska Airlines flight, an anonymous whistleblower claiming to be a Boeing employee wrote in the comments section of an aviation news site on Jan. 16 that poor quality control, a lack of oversight, and a convoluted reporting system allegedly led to Boeing workers missing four bolts that were supposed to secure the door plug.

“The reason the door blew off is stated in black and white in Boeing’s own records,” noted the whistleblower account, which was first reported by the Seattle Times. “It is also very, very stupid and speaks volumes about the quality culture at certain portions of the business.”

The whistleblower’s account is “very, very credible,” said Rep. Peter DeFazio (D-Ore.), a former congressman and chair of the House Committee on Transportation and Infrastructure when it investigated Boeing in 2020 after the two fatal crashes. He added that the report is more evidence of failures within the ODA program. 

Boeing employees in the self-inspection program “should have been observing the production process and the quality of the plane,” DeFazio said. “They should be observing the whole process of the final production of the plane at Boeing.” 

A new preliminary investigation by the National Transportation Safety Board, the agency tasked with investigating civil transportation accidents, found that the Jan. 5 door plug blow-out was in fact due to four missing bolts that were supposed to secure the door plug to the fuselage. 

On Feb. 1, Boeing CEO David Calhoun said the company will begin rewarding employees who highlight safety issues, and that the company will slow its production work to focus on quality.

“Whatever conclusions are reached, Boeing is accountable for what happened,” Calhoun said during an investors call. “Whatever the specific cause of the accident might turn out to be, an event like this simply must not happen on an airplane that leaves one of our factories. We simply must be better.”

Boeing did not respond to a request for comment regarding whether production issues surrounding the door plug are related to its self-inspection program.

During congressional testimony on Feb. 6, FAA Administrator Mike Whitaker promised to implement stricter oversight of Boeing’s production process.

"We will have more boots on the ground closely scrutinizing and monitoring production and manufacturing activities," said Whitaker — but he noted a final decision on Boeing’s role in the ODA program had not yet been reached. 

“They’re Completely Hands Off”

For decades, the FAA was considered the global gold standard for overseeing the aviation industry. It helped set the bar for global air travel regulations, and integrated innovative aviation designs and equipment throughout its history. The FAA also helped establish air traffic control systems and precision radar for commercial airlines.

Since 1927, the FAA has partnered with aviation industry experts to conduct safety and regulatory inspections — but experts said oversight was essentially handed over to airline manufacturers in 2005, when the FAA, under President George W. Bush, created the ODA program.

The program allowed the FAA to delegate “any statutorily authorized functions” to qualified companies. In practice, this meant that aviation companies would be allowed to conduct major repairs or modifications without FAA approval, conduct their own aircraft inspections, and even determine for themselves whether their aircraft were fit to fly, among other actions.

At the time, government regulators justified the move by saying that the new self-inspection program will “increase the efficiency” of FAA oversight and allow the FAA to “concentrate its resources on the most safety-critical matters,” regulators noted in the 2005 rule summary. 

“As aviation industry needs continue to expand at a rate exceeding that of FAA resources, the need for the ODA program has become more apparent,” regulators wrote. “Expansion of the available authorized functions will reduce the time and cost for these certification activities.”

Regulators also noted that the new ODA program, which would cost the government $2.1 million a year, would save the aviation industry more than $3.4 million annually.

However, in comments submitted to the FAA, critics said the new program would not be the most efficient use of FAA resources. “More than one commenter states that the FAA should be hiring more inspectors, not spending its limited resources creating an organizational designee system,” regulators noted in the rule summary. 

Organizations opposed to the program included the National Air Traffic Controllers Association and what is now known as the Professional Aviation Safety Specialists, which represents more than 11,000 FAA and Defense Department employees.

In the lead-up to the FAA establishing the self-inspection program, Boeing spent nearly $26 million lobbying Congress on reforms and funding for the FAA, commercial aviation issues, and other issues. 

By 2009, when the ODA program was fully phased in under the direction of President Barack Obama, Boeing and other plane manufacturers were conducting their own regulatory inspections of new planes and granting themselves the ability to approve major repairs and modifications for their aircraft. 

At that point, Boeing essentially assumed full responsibility for its own safety oversight, said Paul Hudson, president of FlyersRights, a passenger advocacy group.

“The FAA may have some oversight, but they’re completely hands off,” Hudson told The Lever.

“Failed To Conduct Proper Oversight”

Since 2011, there have been at least 14 government reports, surveys, and whistleblower notices warning the FAA of problems with the self-inspection program. Concerns include a lack of federal oversight for Boeing, understaffing of safety engineers at the FAA office overseeing Boeing’s self-inspection work, “undue pressure” from Boeing management of employees in the self-inspection program, and other issues. 

A 2011 Transportation Department report sounded the alarm when it found that the FAA “significantly reduced its role in approving individuals who perform work on FAA’s behalf.” The report also warned that without proper FAA oversight, companies could appoint inspectors with “inadequate qualifications or a history of poor performance to approve certification projects.”

In 2012, the Transportation Department issued another alert, warning the FAA that it was not tracking or addressing poorly performing industry employees enrolled in the self-inspection program, and that the FAA was failing to properly train its engineers on new ODA enforcement responsibilities.

In response to the Transportation Department’s warning, the FAA implemented personnel reviews of industry employees in the ODA program for their first two years and strengthened its training courses, among other improvements. 

But issues with the self-inspection program continued.

The next year, Boeing’s 787-series planes were grounded for four months worldwide due to a lithium battery that caught fire during a Japan Airlines flight on Jan. 7, 2013. A subsequent government investigation found Boeing failed to incorporate adequate design requirements and that the FAA “failed to uncover this design vulnerability as part of its review and approval of Boeing’s electrical power system certification plan and proposed methods of compliance.”

In December 2013, Rep. Defazio requested the Transportation Department to review the FAA’s staffing and oversight of the ODA program. He was particularly concerned that the FAA may not have adequate resources to “provide effective oversight of an expanded ODA program.” 

The resulting Transportation Department audit concluded that the FAA lacked a process to determine proper staffing levels in the self-inspection program and that the “FAA does not conduct sufficient oversight of ODA personnel conducting certification work at companies that supply components to other manufacturers.” In response, the FAA agreed to develop a process to determine proper staffing levels and provide “guidance” on how it planned to conduct better oversight of the ODA program. 

In June 2014, the FAA received a whistleblower complaint from an employee at Alenia, a Boeing supplier based in Italy, who alleged that Boeing “failed to conduct proper oversight” and that “Boeing provided misleading information to the FAA” regarding the certification process for some of its planes. Boeing and the FAA confirmed some of the whistleblower’s allegations.

That same year, union representatives also voiced their concerns about the lack of FAA staffing overseeing the self-inspection program. 

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“The representatives told us that due to staffing shortages and increased workload, FAA did not have enough inspectors and engineers to provide the proper surveillance of the designees who had already been granted this authority,” a 2015 Government Accountability Office report found.

By 2015, Boeing was engaged in 13 pending or civil enforcement cases for a slew of issues, including delays in reporting safety information and quality control issues with its production process. That year, in a “first-of-its-kind settlement,” Boeing agreed to pay $12 million in penalties, with an additional $24 million fine if the manufacturer failed to fully enact the improvements required by federal regulators by 2021.

As part of the settlement, the Transportation Department issued stronger reporting, auditing, and production compliance standards for Boeing. It also made Boeing implement a “safety management system” to meet internationally accepted safety standards. Some of the problems arising on Boeing planes at the time reportedly involved fuel tanks at risk of catching fire, tools left in completed planes, and “millions of incorrectly shaped fasteners.” 

In its enforcement announcement, the Transportation Department made sure to note that the FAA “did not allege that these issues created unsafe conditions” on Boeing planes.

Internal problems at Boeing continued to arise and a November 2016 Boeing whistleblower survey found 39 percent of Boeing employees in the self-inspection program had experienced “undue pressure” from management. Of the respondents, 29 percent said they “were concerned about consequences” if they reported pressure from management.

A later Transportation Department analysis found that by November 2016, the FAA had delegated 79 out of 91 tasks associated with its certification program, or more than 85 percent of the process, to Boeing employees in the ODA program.

A 2017 report conducted by the National Air Traffic Controllers Association and other aviation industry groups warned the FAA about a lack of engineers involved in overseeing aircraft certifications. According to the report, audits conducted by the FAA after aircrafts have been certified is a “fundamentally flawed concept and is not based upon data or risk analysis.”

That same year, senior Boeing officials seemingly became concerned about Boeing’s culture and sought to speed up the company’s work processes. 

“One of the things we are working on in conjunction with our CEO and senior leadership team is really thinking about how we drive things like agility and speed into our organization that is sometimes heavily processed and a little bit more conservative in terms of taking risks,” said Heidi Capozzi, then-vice president of human resources, in an interview with the University of South Carolina. 

Meanwhile, problems with FAA oversight continued. In 2018, a former industry employee enrolled in the ODA program who was supposed to physically inspect and certify aircraft parts was charged with fraud for filing false reports.

An FAA official would later tell the New York Times that around that time, the agency was letting Boeing certify 96 percent of its own work.

Congress passed legislation to reform the ODA program in October 2018, directing the FAA to establish an office dedicated to ODA oversight and to submit a report on how the FAA plans to address staffing concerns, among other issues. 

Just weeks later, the first of two Boeing 737 Max planes crashed in Indonesia, killing 189 people. Boeing initially blamed pilot error on the crash, but five months later another 737 Max plane crashed in Ethiopia, killing another 157. 

“Grossly Insufficient Oversight By The FAA”

In 2020, a House Committee on Transportation and Infrastructure investigation into the two fatal 737 Max crashes concluded that the FAA’s failure to properly oversee the ODA program contributed to the crashes.

“The MAX crashes were not the result of a singular failure, technical mistake, or mismanaged event,” the report states. “They were the horrific culmination of a series of faulty technical assumptions by Boeing’s engineers, a lack of transparency on the part of Boeing’s management, and grossly insufficient oversight by the FAA — the pernicious result of regulatory capture on the part of the FAA with respect to its responsibilities to perform robust oversight of Boeing and to ensure the safety of the flying public.” 

Boeing executives later admitted that its own design played a role in the crashes — a design flaw that the FAA should have caught, the House investigation stated.

“​​The FAA’s oversight was hampered by poor, disjointed FAA communication among the agency’s own internal offices responsible for certifying new critical 737 MAX systems,” the House investigation stated. “From FAA leadership down, ineffective communication and lack of coordination on key certification and safety issues jeopardized the safety of the flying public.”

Another government report found that the FAA’s production and safety certification had “eroded” and that the FAA had “increasingly delegated away its authority.”

DeFazio, the former congressman and chair of the Transportation and Infrastructure committee, helped pass legislation overhauling the FAA and the self-inspection program after the crashes. Among other things, the legislation brought greater FAA oversight of the self-inspection program and helped shield industry employees in the ODA program from management pressure.

In 2020, Congress directed the FAA to create an expert panel to review and make recommendations on the design and production process for each company in the self-inspection program. 

More reforms followed in 2021, with the FAA assigning safety advisors to Boeing and two other major aircraft manufacturers. The agency also created a new review and approval process for industry employees in the self-inspection program, and founded an office dedicated to standardizing the ODA program agencywide, an FAA spokesperson told The Lever in an email. 

“[The office] enables the FAA to more quickly identify and address areas of concern within delegation programs, making sure safety does not take a back seat to business objectives,” the spokesperson said. 

The following year, the FAA implemented stronger protections for industry employees in the ODA program by protecting them from interference and pushback from management. The new policy required companies like Boeing to report and investigate all allegations of management pushback and report them to the FAA. 

In January 2023, a panel of industry experts from NASA, the FAA, labor unions, and other organizations began reviewing Boeing’s safety culture and its safety management process. A report is due to Congress and the FAA in early 2024. 

But the recent high-altitude debacles and the whistleblower report has, once again, called Boeing’s production and safety management into question. 

“We believe that Boeing and other industry parties have too much undue influence in safety [oversight] in particular, and that often translates into the [FAA] adopting whatever the position is of the regulated party,” said Hudson, president of FlyersRights.

The new National Transportation Safety Board investigation into the Jan. 5 door plug blowout concluded that four key bolts were missing from the door plug when it was re-installed after maintenance work was done on damaged rivets near the door plug.

“Photo documentation obtained from Boeing shows evidence of the left-hand [door] plug closed with no retention hardware (bolts) in the three visible locations,” the NTSB wrote in its Feb. 6 report.

DeFazio said the missing bolts should have been caught by Boeing employees in the ODA program and that the reforms to the self-inspection program weren’t enough to fix Boeing’s production errors. 

“We totally changed the whole process, but it obviously wasn’t adequate and something more needs to be done,” DeFazio said. 

“Reinstate Criminal Prosecution”

The Lever previously reported that four airlines have filed more than 1,800 reports warning the FAA about chronic safety issues and system malfunctions on Boeing’s 737 Max planes since they were allowed to begin flying again in December 2020, following the two fatal crashes.

Just hours after the story was published, Transportation Secretary Pete Buttigieg announced that the FAA will conduct a thorough review of Boeing’s oversight and quality control processes.

​​“I think that’s going to include a structural discussion about how best to conduct this kind of oversight going forward,” Buttigieg told reporters on Jan. 24.

The FAA also announced on Jan. 24 that it will not approve any production expansion of Boeing’s 737 Max series until the manufacturer addresses quality control issues. 

“This won’t be back to business as usual for Boeing,” FAA Administrator Whitaker said in a press release. “The quality assurance issues we have seen are unacceptable.”

Whitaker also said the agency is reconsidering Boeing’s role in the ODA program.

“The grounding of the 737 [Max 9] and the multiple production-related issues identified in recent years require us to look at every option to reduce risk,” Whitaker said in a press release. “The FAA is exploring the use of an independent third party to oversee Boeing’s inspections and its quality system.”

Sen. Maria Cantwell, a Democrat who represents Washington State where a major Boeing production facility is located, said she will investigate the “root causes” of Boeing’s recent safety and production issues.

“The American flying public and Boeing line workers deserve a culture of leadership at Boeing that puts safety ahead of profits,” Cantwell said in a press release.

DeFazio applauded the FAA’s recent actions against Boeing. But he said there needs to be changes in Boeing’s management — and that the Justice Department needs to rescind a deferred prosecution agreement that shielded Boeing executives from criminal charges in the wake of the 2018 and 2019 crashes. 

“It’s these jerks who are more concerned about their stock options than they are about the safety of the flying public,” DeFazio said. “Clearly, [Boeing] did not meet the new safety culture provisions and requirements of the deferred prosecution agreement and the Biden Administration should reinstate criminal prosecution.”

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