Abstract

This paper highlights several critically important facts involving the Lion Air Flight 610 and Ethiopian Airlines Flight 302 accident investigations while raising numerous unanswered questions.  Much of the blame for these tragedies has been focused on the design of the 737 MAX, specifically the MCAS software, the regulatory oversight failures of the FAA, and the lack of training provided to pilots.  Although each of these problems played major roles in both accidents, they were not the triggering events. 

The paper's author, Ed Pierson, retired from Boeing in August 2018.  Prior to his retirement, Mr. Pierson served as a Senior Manager within the 737 Factory in Renton, Washington.  Mr. Pierson is also a retired Navy Captain.  He held a variety of senior leadership roles in the military including Squadron Commanding Officer and Operations Center Director. Mr. Pierson testified as a whistleblower before Congress in December 2019 regarding the 737 MAX.  The paper underscores the likely role a chaotic and dangerously unstable production environment played in the accidents.  Mr. Pierson also puts forth three other plausible accident scenarios not addressed in the accident investigations. The 14-page report includes a timeline and an analysis that ties the two 737 MAX airplane crashes together in ways not previously reported.  Most importantly, Mr. Pierson’s analysis raises serious doubts as to the safety of the 737 MAX.  Alarmingly, the FAA’s recertification fixes do not address the problems identified in the report.

Captain Sullenberger has read this paper and said that “it raises many important questions that must be answered.”  Dr. Daniel Ossmann, a recognized expert in aerospace fault detection, has also reviewed the paper and “concluded that it illustrates an excellent compact summary of the events and raises concerns that should be thoughtfully addressed.”