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Westlake Legal Group > federal aviation administration

The Roots of Boeing’s 737 Max Crisis: A Regulator Relaxes Its Oversight

SEATTLE — In the days after the first crash of Boeing’s 737 Max, engineers at the Federal Aviation Administration came to a troubling realization: They didn’t fully understand the automated system that helped send the plane into a nose-dive, killing everyone on board.

Engineers at the agency scoured their files for information about the system designed to help avoid stalls. They didn’t find much. Regulators had never independently assessed the risks of the dangerous software known as MCAS when they approved the plane in 2017.

More than a dozen current and former employees at the F.A.A. and Boeing who spoke with The New York Times described a broken regulatory process that effectively neutered the oversight authority of the agency.

The regulator had been passing off routine tasks to manufacturers for years, with the goal of freeing up specialists to focus on the most important safety concerns. But on the Max, the regulator handed nearly complete control to Boeing, leaving some key agency officials in the dark about important systems like MCAS, according to the current and former employees.

While the agency’s flawed oversight of the Boeing 737 Max has attracted much scrutiny since the first crash in October and a second one in March, a Times investigation revealed previously unreported details about weaknesses in the regulatory process that compromised the safety of the plane.

The company performed its own assessments of the system, which were not stress-tested by the regulator. Turnover at the agency left two relatively inexperienced engineers overseeing Boeing’s early work on the system.

The F.A.A. eventually handed over responsibility for approval of MCAS to the manufacturer. After that, Boeing didn’t have to share the details of the system with the two agency engineers. They weren’t aware of its intricacies, according to two people with knowledge of the matter.

Late in the development of the Max, Boeing decided to expand the use of MCAS, to ensure the plane flew smoothly. The new, riskier version relied on a single sensor and could push down the nose of the plane by a much larger amount.

Boeing did not submit a formal review of MCAS after the overhaul. It wasn’t required by F.A.A. rules. An engineering test pilot at the regulator knew about the changes, according to an agency official. But his job was to evaluate the way the plane flew, not to determine the safety of the system.

The agency ultimately certified the jet as safe, required little training for pilots and allowed the plane to keep flying until a second deadly Max crash, less than five months after the first.

The plane remains grounded as regulators await a fix from Boeing. If the ban persists much longer, Boeing said this past week that it could be forced to halt production.

The F.A.A. and Boeing have defended the plane’s certification, saying they followed proper procedures and adhered to the highest standards.

“The agency’s certification processes are well-established and have consistently produced safe aircraft designs,” the regulator said in a statement Friday. “The 737 Max certification program involved 110,000 hours of work on the part of F.A.A. personnel, including flying or supporting 297 test flights.”

Boeing said “the F.A.A.’s rigor and regulatory leadership has driven ever-increasing levels of safety over the decades,” adding that “the 737 Max met the F.A.A.’s stringent standards and requirements as it was certified through the F.A.A.’s processes.”

[If you have worked at Boeing or the F.A.A. and want to discuss your experience, contact The Times confidentially here.]

ImageWestlake Legal Group merlin_152643222_fdb4e1c8-150f-4d36-863b-94c35dfff0bd-articleLarge The Roots of Boeing’s 737 Max Crisis: A Regulator Relaxes Its Oversight Regulation and Deregulation of Industry Pilots Lion Air Federal Aviation Administration Ethiopian Airlines Engineering and Engineers Conflicts of Interest Boeing Company Boeing 737 Max Groundings and Safety Concerns (2019) Aviation Accidents, Safety and Disasters Airlines and Airplanes

While Ali Bahrami was the Federal Aviation Administration’s top official in Seattle, some engineers believed that he had installed managers who would be deferential to Boeing.CreditJonathan Ernst/Bloomberg

Federal prosecutors and lawmakers are now investigating whether the regulatory process is fundamentally flawed. As planes become more technologically advanced, the rules, even when they are followed, may not be enough to ensure safety. The new software played a role in both disasters, involving Lion Air and Ethiopian Airlines, which together killed 346 people.

“Did MCAS get the attention it needed? That’s one of the things we’re looking at,” said Chris Hart, the former chairman of the National Transportation Safety Board, who is now leading a multiagency task force investigating how the Max was approved. “As it evolved from a less robust system to a more powerful system, were the certifiers aware of the changes?”

Boeing needed the approval process on the Max to go swiftly. Months behind its rival Airbus, the company was racing to finish the plane, a more fuel-efficient version of its best-selling 737.

The regulator’s hands-off approach was pivotal. At crucial moments in the Max’s development, the agency operated in the background, mainly monitoring Boeing’s progress and checking paperwork. The nation’s largest aerospace manufacturer, Boeing was treated as a client, with F.A.A. officials making decisions based on the company’s deadlines and budget.

It has long been a cozy relationship. Top agency officials have shuffled between the government and the industry.

During the Max certification, senior leaders at the F.A.A. sometimes overruled their own staff members’ recommendations after Boeing pushed back. For safety reasons, many agency engineers wanted Boeing to redesign a pair of cables, part of a major system unrelated to MCAS. The company resisted, and F.A.A. managers took Boeing’s side, according to internal agency documents.

After the crash of the Lion Air plane last October, F.A.A. engineers were shocked to discover they didn’t have a complete analysis of MCAS. The safety review in their files didn’t mention that the system could aggressively push down the nose of the plane and trigger repeatedly, making it difficult to regain control of the aircraft, as it did on the doomed Lion Air flight.

Despite their hazy understanding of the system, F.A.A. officials decided against grounding the 737 Max. Instead, they published a notice reminding pilots of existing emergency procedures.

The notice didn’t describe how MCAS worked. At the last minute, an F.A.A. manager told agency engineers to remove the only mention of the system, according to internal agency documents and two people with knowledge of the matter. Instead, airlines learned about it from Boeing.

The F.A.A. department that oversaw the Max development had such a singular focus that it was named after the company: The Boeing Aviation Safety Oversight Office.

Many F.A.A. veterans came to see the department, created in 2009, as a symbol of the agency’s close relationship with the manufacturer. The top official in Seattle at the time, Ali Bahrami, had a tough time persuading employees to join, according to three current and former employees.

Some engineers believed that Mr. Bahrami had installed managers in the office who would defer to Boeing. “He didn’t put enough checks and balances in the system,” Mike McRae, a former F.A.A. engineer, said of Mr. Bahrami. “He really wanted abdication. He didn’t want delegation.”

Before the certification of the Max began, Mr. Bahrami called a group of F.A.A. engineers into his office, the current and former employees said, and asked some of them to join the group. Many didn’t want to change jobs, according to a complaint filed by the National Air Traffic Controllers Association, the union representing F.A.A. engineers.

“I got dragged kicking and screaming,” said Richard Reed, a former systems engineer at the F.A.A. Mr. Reed said he had just left surgery when agency officials called to ask whether he would work in the office. “I always claimed that I was on drugs when I said ‘yes.’”

The F.A.A. said in a statement that Mr. Bahrami “dedicated his career to the advancement of aviation safety in both the private and public sectors.”

F.A.A. offices in Des Moines, Wash. The way the agency dealt with Boeing left engineers at the agency demoralized, two employees said.CreditRuth Fremson/The New York Times

For decades, the F.A.A. relied on engineers inside Boeing to help certify aircraft. But after intense lobbying by industry, the agency adopted rules in 2005 that would give manufacturers like Boeing even more control. Previously, the agency selected the company engineers to work on its behalf; under the new regulations, Boeing could choose them.

Many of the agency’s top leaders embraced the approach. It would allow the F.A.A. to certify planes more efficiently and stretch its limited resources. The regulator had also been finding it harder to compete for talented engineers, their government salaries unable to keep up with the going rates in the industry.

For Boeing, the changes meant shedding a layer of bureaucracy. “The process was working well,” said Tom Heineman, a retired Boeing engineer who worked on the Max. “The F.A.A. was delegating more of the work and the review and the oversight to the manufacturers than it used to.”

But some F.A.A. engineers were concerned that they were no longer able to effectively monitor what was happening inside Boeing. In a PowerPoint presentation to agency managers in 2016, union representatives raised concerns about a “brain drain” and the “inability to hire and retain qualified personnel.”

By 2018, the F.A.A. was letting the company certify 96 percent of its own work, according to an agency official.

Nicole Potter, an F.A.A. propulsion and fuel systems engineer who worked on the Max, said supervisors repeatedly asked her to give up the right to approve safety documents. She often had to fight to keep the work.

“Leadership was targeting a high level of delegation,” Ms. Potter said. When F.A.A. employees didn’t have time to approve a critical document, she said, “managers could delegate it back to Boeing.”

It was a process Mr. Bahrami championed to lawmakers. After spending more than two decades at the F.A.A., he left the agency in 2013 and took a job at the Aerospace Industries Association, a trade group that represents Boeing and other manufacturers.

“We urge the F.A.A. to allow maximum use of delegation,” Mr. Bahrami told Congress in his new lobbying role, arguing it would help American manufacturers compete.

In 2017, Mr. Bahrami returned to the F.A.A. as the head of safety.

With Boeing taking more control, F.A.A. engineers found they had little power, even when they did raise concerns.

Early on, engineers at the F.A.A. discovered a problem with one of the most important new features of the Max: its engines. The Max, the latest version of the 50-year-old 737, featured more fuel-efficient engines, with a larger fan and a high-pressure turbine. But the bigger, more complex engines could do more damage if they broke apart midair.

The F.A.A. engineers were particularly concerned about pieces hitting the cables that control the rudder, according to five people with knowledge of the matter and internal agency documents. A cable severed during takeoff would make it difficult for pilots to regain control, potentially bringing down the jet.

The F.A.A. engineers suggested a couple solutions, three of the people said. The company could add a second set of cables or install a computerized system for controlling the rudder.

Boeing did not want to make a change, according to internal F.A.A. documents reviewed by The Times. A redesign could have caused delays. Company engineers argued that it was unlikely that an engine would break apart and shrapnel would hit the rudder cable.

Most of the F.A.A. engineers working on the issue insisted the change was necessary for safety reasons, according to internal agency emails and documents. But their supervisors balked. In a July 2015 meeting, Jeff Duven, who replaced Mr. Bahrami as the head of the F.A.A.’s Seattle operation, sided with Boeing, said two current employees at the agency.

Boeing Max planes in Renton, Wash. The company downplayed the risks of the software, MCAS, to federal officials.CreditRuth Fremson/The New York Times

F.A.A. managers conceded that the Max “does not meet” agency guidelines “for protecting flight controls,” according to an agency document. But in another document, they added that they had to consider whether any requested changes would interfere with Boeing’s timeline. The managers wrote that it would be “impractical at this late point in the program,” for the company to resolve the issue. Mr. Duven at the F.A.A. also said the decision was based on the safety record of the plane.

Engineers at the agency were demoralized, the two agency employees said. One engineer submitted an anonymous complaint to an internal F.A.A. safety board, which was reviewed by The Times.

“During meetings regarding this issue the cost to Boeing to upgrade the design was discussed,” the engineer wrote. “The comment was made that there may be better places for Boeing to spend their safety dollars.”

An F.A.A. panel investigated the complaint. It found managers siding with Boeing had created “an environment of mistrust that hampers the ability of the agency to work effectively,” the panel said in a 2017 report, which was reviewed by The Times. The panel cautioned against allowing Boeing to handle this kind of approval, saying “the company has a vested interest in minimizing costs and schedule impact.”

By then, the panel’s findings were moot. Managers at the agency had already given Boeing the right to approve the cables, and they were installed on the Max.

In the middle of the Max’s development, two of the most seasoned engineers in the F.A.A.’s Boeing office left.

The engineers, who had a combined 50 years of experience, had joined the office at its creation, taking on responsibility for flight control systems, including MCAS. But they both grew frustrated with the work, which they saw as mostly paper pushing, according to two people with knowledge of the staff changes.

In their place, the F.A.A. appointed an engineer who had little experience in flight controls, and a new hire who had gotten his master’s degree three years earlier. People who worked with the two engineers said they seemed ill-equipped to identify any problems in a complex system like MCAS.

And Boeing played down the importance of MCAS from the outset.

An early review by the company didn’t consider the system risky, and it didn’t prompt additional scrutiny from the F.A.A. engineers, according to two agency officials. The review described a system that would activate only in rare situations, when a plane was making a sharp turn at high speeds.

The F.A.A. engineers who had been overseeing MCAS never received another safety assessment. As Boeing raced to finish the Max in 2016, agency managers gave the company the power to approve a batch of safety assessments — some of the most important documents in any certification. They believed the issues were low risk.

One of the managers, Julie Alger, delegated the review of MCAS. Previously, the F.A.A. had the final say over the system.

The F.A.A. said that decision reflected the consensus of the team.

Boeing was in the middle of overhauling MCAS. To help pilots control the plane and avoid a stall, the company allowed MCAS to trigger at low speeds, rather than just at high speeds. The overhauled version would move the stabilizer by as much as 2.5 degrees each time it triggered, significantly pushing down the nose of the plane. The earlier version moved the stabilizer by 0.6 degrees.

When company engineers analyzed the change, they figured that the system had not become any riskier, according to two people familiar with Boeing’s discussions on the matter. They assumed that pilots would respond to a malfunction in three seconds, quickly bringing the nose of the plane back up. In their view, any problems would be less dangerous at low speeds.

So the company never submitted an updated safety assessment of those changes to the agency. In several briefings in 2016, an F.A.A. test pilot learned the details of the system from Boeing. But the two F.A.A. engineers didn’t understand that MCAS could move the tail as much as 2.5 degrees, according to two people familiar with their thinking.

Under the impression the system was insignificant, officials didn’t require Boeing to tell pilots about MCAS. When the company asked to remove mention of MCAS from the pilot’s manual, the agency agreed. The F.A.A. also did not mention the software in 30 pages of detailed descriptions noting differences between the Max and the previous iteration of the 737.

Days after the Lion Air crash, the agency invited Boeing executives to the F.A.A.’s Seattle headquarters, according to two people with knowledge of the matter. The officials sat incredulous as Boeing executives explained details about the system that they didn’t know.

In the middle of the conversation, an F.A.A. employee, one of the people said, interrupted to ask a question on the minds of several agency engineers: Why hadn’t Boeing updated the safety analysis of a system that had become so dangerous?

Real Estate, and Personal Injury Lawyers. Contact us at: https://westlakelegal.com 

Boeing’s 737 Max Suffers Setback in Flight Simulator Test

Westlake Legal Group 26boeing-facebookJumbo Boeing’s 737 Max Suffers Setback in Flight Simulator Test Federal Aviation Administration Boeing Company Boeing 737 Max Groundings and Safety Concerns (2019) Airlines and Airplanes

The Federal Aviation Administration said Wednesday that it had recently discovered a new problem with the 737 Max jet that Boeing must correct before the plane is returned to service.

In a flight simulator last week, F.A.A. pilots tested erroneous activations of anti-stall software that pushes down the nose of the Max, two people with knowledge of the matter said. The software, known as MCAS, was involved in two crashes that killed 346 people.

In at least one instance, an F.A.A. pilot was unable to quickly and easily follow Boeing’s emergency procedures to regain control of the plane. The pilot rated that failure as catastrophic, meaning it could lead to the loss of an aircraft midflight, the people said. The situation that was tested is highly unlikely to occur during a typical passenger flight, but the regulator is still requiring Boeing to make a fix, one of the people said.

The discovery may erode confidence in Boeing’s assertions, in conversations with regulators, airlines and aviation unions, that well-trained pilots can easily handle a software malfunction based on their understanding of standard emergency procedures.

It also adds to the roadblocks that have kept pushing back the Max’s return to flight. Nearly 500 Max jets have remained grounded across the globe since March, as the company faces a barrage of questions from the F.A.A. and international regulators.

In recent weeks, the F.A.A. has been testing a broad array of potential failures involving the anti-stall software, partly to ensure that the fix Boeing has developed does not introduce new problems.

In a statement on Wednesday, Gordon Johndroe, a Boeing spokesman, said the company had been working for eight months to provide a comprehensive update to the software. “The safety of our airplanes is Boeing’s highest priority,” Mr. Johndroe said.

He added, “Boeing will not offer the 737 Max for certification by the F.A.A. until we have satisfied all requirements for certification of the Max and its safe return to service.”

Boeing hopes to have the Max back in the air early in the fall. Several airlines have canceled flights on the plane into early September.

During a congressional hearing last week, aviation leaders criticized Boeing’s conduct after the two deadly accidents — a Lion Air flight in Indonesia in October and an Ethiopian Airlines flight in March. They also questioned the design, certification and production of the Max and discussed whether foreign pilots had sufficient training.

Real Estate, and Personal Injury Lawyers. Contact us at: https://westlakelegal.com 

Boeing’s 737 Max Suffers Setback in Flight Simulator Test

Westlake Legal Group 26boeing-facebookJumbo Boeing’s 737 Max Suffers Setback in Flight Simulator Test Federal Aviation Administration Boeing Company Boeing 737 Max Groundings and Safety Concerns (2019) Airlines and Airplanes

The Federal Aviation Administration said Wednesday that it had recently discovered a new problem with the 737 Max jet that Boeing must correct before the plane is returned to service.

In a flight simulator last week, F.A.A. pilots tested erroneous activations of anti-stall software that pushes down the nose of the Max, two people with knowledge of the matter said. The software, known as MCAS, was involved in two crashes that killed 346 people.

In at least one instance, an F.A.A. pilot was unable to quickly and easily follow Boeing’s emergency procedures to regain control of the plane. The pilot rated that failure as catastrophic, meaning it could lead to the loss of an aircraft midflight, the people said. The situation that was tested is highly unlikely to occur during a typical passenger flight, but the regulator is still requiring Boeing to make a fix, one of the people said.

The discovery may erode confidence in Boeing’s assertions, in conversations with regulators, airlines and aviation unions, that well-trained pilots can easily handle a software malfunction based on their understanding of standard emergency procedures.

It also adds to the roadblocks that have kept pushing back the Max’s return to flight. Nearly 500 Max jets have remained grounded across the globe since March, as the company faces a barrage of questions from the F.A.A. and international regulators.

In recent weeks, the F.A.A. has been testing a broad array of potential failures involving the anti-stall software, partly to ensure that the fix Boeing has developed does not introduce new problems.

In a statement on Wednesday, Gordon Johndroe, a Boeing spokesman, said the company had been working for eight months to provide a comprehensive update to the software. “The safety of our airplanes is Boeing’s highest priority,” Mr. Johndroe said.

He added, “Boeing will not offer the 737 Max for certification by the F.A.A. until we have satisfied all requirements for certification of the Max and its safe return to service.”

Boeing hopes to have the Max back in the air early in the fall. Several airlines have canceled flights on the plane into early September.

During a congressional hearing last week, aviation leaders criticized Boeing’s conduct after the two deadly accidents — a Lion Air flight in Indonesia in October and an Ethiopian Airlines flight in March. They also questioned the design, certification and production of the Max and discussed whether foreign pilots had sufficient training.

Real Estate, and Personal Injury Lawyers. Contact us at: https://westlakelegal.com 

Boeing Built Deadly Assumptions Into 737 Max, Blind to a Late Design Change

SEATTLE — The fatal flaws with Boeing’s 737 Max can be traced to a breakdown late in the plane’s development, when test pilots, engineers and regulators were left in the dark about a fundamental overhaul to an automated system that would ultimately play a role in two crashes.

A year before the plane was finished, Boeing made the system more aggressive and riskier. While the original version relied on data from at least two types of sensors, the ultimate used just one, leaving the system without a critical safeguard. In both doomed flights, pilots struggled as a single damaged sensor sent the planes into irrecoverable nose-dives within minutes, killing 346 people and prompting regulators around the world to ground the Max.

But many people involved in building, testing and approving the system, known as MCAS, said they hadn’t fully understood the changes. Current and former employees at Boeing and the Federal Aviation Administration who spoke with The New York Times said they had assumed the system relied on more sensors and would rarely, if ever, activate. Based on those misguided assumptions, many made critical decisions, affecting design, certification and training.

“It doesn’t make any sense,” said a former test pilot who worked on the Max. “I wish I had the full story.”

While prosecutors and lawmakers try to piece together what went wrong, the current and former employees point to the single, fateful decision to change the system, which led to a series of design mistakes and regulatory oversights. As Boeing rushed to get the plane done, many of the employees say, they didn’t recognize the importance of the decision. They described a compartmentalized approach, each of them focusing on a small part of the plane. The process left them without a complete view of a critical and ultimately dangerous system.

The company also played down the scope of the system to regulators. Boeing never disclosed the revamp of MCAS to Federal Aviation Administration officials involved in determining pilot training needs, according to three agency officials. When Boeing asked to remove the description of the system from the pilot’s manual, the F.A.A. agreed. As a result, most Max pilots did not know about the software until after the first crash, in October.

“Boeing has no higher priority than the safety of the flying public,” a company spokesman, Gordon Johndroe, said in a statement.

He added that Boeing and regulators had followed standard procedures. “The F.A.A. considered the final configuration and operating parameters of MCAS during Max certification, and concluded that it met all certification and regulatory requirements,” Mr. Johndroe said.

At first, MCAS — Maneuvering Characteristics Augmentation System — wasn’t a very risky piece of software. The system would trigger only in rare conditions, nudging down the nose of the plane to make the Max handle more smoothly during high-speed moves. And it relied on data from multiple sensors measuring the plane’s acceleration and its angle to the wind, helping to ensure that the software didn’t activate erroneously.

Then Boeing engineers reconceived the system, expanding its role to avoid stalls in all types of situations. They allowed the software to operate throughout much more of the flight. They enabled it to aggressively push down the nose of the plane. And they used only data about the plane’s angle, removing some of the safeguards.

ImageWestlake Legal Group 00boeing2-articleLarge Boeing Built Deadly Assumptions Into 737 Max, Blind to a Late Design Change Sensors Pilots Lion Air Federal Aviation Administration Ethiopian Airlines Boeing Company Boeing 737 Max Groundings and Safety Concerns (2019) Aviation Accidents, Safety and Disasters Airlines and Airplanes

Ray Craig, shown in a 2003 Boeing magazine, was the chief test pilot when he put the Max through maneuvers in a flight simulator in 2012.Creditvia Boeing’s Aero Magazine

The disasters might have been avoided, if employees and regulators had a better understanding of MCAS.

A test pilot who originally advocated for the expansion of the system didn’t understand how the changes affected its safety. Safety analysts said they would have acted differently if they had known it used just one sensor. Regulators didn’t conduct a formal safety assessment of the new version of MCAS.

The current and former employees, many of whom spoke on the condition of anonymity because of the continuing investigations, said that after the first crash, they were stunned to discover MCAS relied on a single sensor.

“That’s nuts,” said an engineer who helped design MCAS.

“I’m shocked,” said a safety analyst who scrutinized it.

“To me, it seems like somebody didn’t understand what they were doing,” said an engineer who assessed the system’s sensors.

In 2012, the chief test pilot for the Max had a problem.

During the early development of the 737 Max, the pilot, Ray Craig, a silver-haired retired Navy airman, was trying out high-speed situations on a flight simulator, like maneuvers to avoid an obstacle or to escape a powerful vortex from another plane. While such moves might never be necessary for the pilot of a passenger plane, the F.A.A. requires that a jet handle well in those situations.

But the plane wasn’t flying smoothly, partly because of the Max’s bigger engines. To fix the issue, Boeing decided to use a piece of software. The system was meant to work in the background, so pilots effectively wouldn’t know it was there.

Mr. Craig, who had been with Boeing since 1988, didn’t like it, according to one person involved in the testing. An old-school pilot, he eschewed systems that take control from pilots and would have preferred an aerodynamic fix such as vortex generators, thin fins on the wings. But engineers who tested the Max design in a wind tunnel weren’t convinced they would work, the person said.

Mr. Craig relented. Such high-speed situations were so rare that he figured the software would never actually kick in.

To ensure it didn’t misfire, engineers initially designed MCAS to trigger when the plane exceeded at least two separate thresholds, according to three people who worked on the 737 Max. One involved the plane’s angle to the wind, and the other involved so-called G-force, or the force on the plane that typically comes from accelerating.

A Boeing 737-800 flight simulator. When Mr. Craig simulated high-speed maneuvers for the Max, it didn’t fly smoothly, so Boeing settled on MCAS for a fix.CreditAviation-Images.com, via Getty Images

The Max would need to hit an exceedingly high G-force that passenger planes would probably never experience. For the jet’s angle, the system took data from the angle-of-attack sensor. The sensor, several inches long, is essentially a small wind vane affixed to the jet’s fuselage.

On a rainy day in late January 2016, thousands of Boeing employees gathered at a runway next to the 737 factory in Renton, Wash. They cheered as the first Max, nicknamed the Spirit of Renton, lifted off for its maiden test flight.

“The flight was a success,” Ed Wilson, the new chief test pilot for the Max, said in a news release at the time. Mr. Wilson, who had tested Boeing fighter jets, had replaced Mr. Craig the previous year.

“The 737 Max just felt right in flight, giving us complete confidence that this airplane will meet our customers’ expectations,” he said.

But a few weeks later, Mr. Wilson and his co-pilot began noticing that something was off, according to a person with direct knowledge of the flights. The Max wasn’t handling well when nearing stalls at low speeds.

In a meeting at Boeing Field in Seattle, Mr. Wilson told engineers that the issue would need to be fixed. He and his co-pilot proposed MCAS, the person said.

The change didn’t elicit much debate in the group, which included just a handful of people. It was considered “a run-of-the-mill adjustment,” according to the person. Instead, the group mostly discussed the logistics of how MCAS would be used in the new scenarios.

“I don’t recall ever having any real debates over whether it was a good idea or not,” the person said.

The change proved pivotal. Expanding the use of MCAS to lower-speed situations required removing the G-force threshold. MCAS now needed to work at low speeds so G-force didn’t apply.

The change meant that a single angle-of-attack sensor was the lone guard against a misfire. Although modern 737 jets have two angle-of-attack sensors, the final version of MCAS took data from just one.

Ed Wilson, right, with his co-pilot, Craig Bomben, after the first Max test flight in 2016.CreditElaine Thompson/Associated Press

Using MCAS at lower speeds also required increasing the power of the system. When a plane is flying slowly, flight controls are less sensitive, and far more movement is needed to steer. Think of turning a car’s steering wheel at 20 miles an hour versus 70.

The original version of MCAS could move the stabilizer — the part of the tail that controls the vertical direction of the jet — a maximum of about 0.6 degrees in about 10 seconds. The new version could move the stabilizer up to 2.5 degrees in 10 seconds.

Test pilots aren’t responsible for dealing with the ramifications of such changes. Their job is to ensure the plane handles smoothly. Other colleagues are responsible for making the changes, and still others for assessing their impact on safety.

Boeing declined to say whether the changes had prompted a new internal safety analysis.

While the F.A.A. officials in charge of training didn’t know about the changes, another arm of the agency involved in certification did. But it did not conduct a safety analysis on the changes.

The F.A.A. had already approved the previous version of MCAS. And the agency’s rules didn’t require it to take a second look because the changes didn’t affect how the plane operated in extreme situations.

“The F.A.A. was aware of Boeing’s MCAS design during the certification of the 737 Max,” the agency said in a statement. “Consistent with regulatory requirements, the agency evaluated data and conducted flight tests within the normal flight envelope that included MCAS activation in low-speed stall and other flight conditions.”

After engineers installed the second version of MCAS, Mr. Wilson and his co-pilot took the 737 Max for a spin.

The flights were uneventful. They tested two potential failures of MCAS: a high-speed maneuver in which the system doesn’t trigger, and a low-speed stall when it activates but then freezes. In both cases, the pilots were able to easily fly the jet, according to a person with knowledge of the flights.

In those flights, they did not test what would happen if MCAS activated as a result of a faulty angle-of-attack sensor — a problem in the two crashes.

Boeing engineers did consider such a possibility in their safety analysis of the original MCAS. They classified the event as “hazardous,” one rung below the most serious designation of catastrophic, according to two people. In regulatory-speak, it meant that MCAS could trigger erroneously less often than once in 10 million flight hours.

Boeing Max fuselages on their way to an assembly plant. The company declined to say whether it had conducted a new safety analysis of the revised MCAS.CreditWilliam Campbell/Corbis, via Getty Images

That probability may have underestimated the risk of so-called external events that have damaged sensors in the past, such as collisions with birds, bumps from ramp stairs or mechanics’ stepping on them. While part of the assessment considers such incidents, they are not included in the probability. Investigators suspect the angle-of-attack sensor was hit on the doomed Ethiopian Airlines flight in March.

Bird strikes on angle-of-attack sensors are relatively common.

A Times review of two F.A.A. databases found hundreds of reports of bent, cracked, sheared-off, poorly installed or otherwise malfunctioning angle-of-attack sensors on commercial aircraft over three decades.

Since 1990, one database has recorded 1,172 instances when birds — meadowlarks, geese, sandpipers, pelicans and turkey vultures, among others — damaged sensors of various kinds, with 122 strikes on angle-of-attack vanes. The other database showed 85 problems with angle-of-attack sensors on Boeing aircraft, including 38 on 737s since 1995.

And the public databases don’t necessarily capture the extent of incidents involving angle-of-attack sensors, since the F.A.A. has additional information. “I feel confidence in saying that there’s a lot more that were struck,” said Richard Dolbeer, a wildlife specialist who has spent over 20 years studying the issue at the United States Department of Agriculture, which tracks the issue for the F.A.A.

On March 30, 2016, Mark Forkner, the Max’s chief technical pilot, sent an email to senior F.A.A. officials with a seemingly innocuous request: Would it be O.K. to remove MCAS from the pilot’s manual?

The officials, who helped determine pilot training needs, had been briefed on the original version of MCAS months earlier. Mr. Forkner and Boeing never mentioned to them that MCAS was in the midst of an overhaul, according to the three F.A.A. officials.

Under the impression that the system was relatively benign and rarely used, the F.A.A. eventually approved Mr. Forkner’s request, the three officials said.

Boeing wanted to limit changes to the Max, from previous versions of the 737. Anything major could have required airlines to spend millions of dollars on additional training. Boeing, facing competitive pressure from Airbus, tried to avoid that.

Mr. Forkner, a former F.A.A. employee, was at the front lines of this effort. As the chief technical pilot, he was the primary liaison with the F.A.A. on training and worked on the pilot’s manual.

“The pressure on us,” said Rick Ludtke, a cockpit designer on the Max, “was huge.”

“And that all got funneled through Mark,” Mr. Ludtke added. “And the pushback and resistance from the F.A.A. got funneled through Mark.”

Federal Aviation Administration officials said Boeing’s request to remove MCAS from the pilot’s manual didn’t mention that the system was being overhauled.CreditJason Redmond/Agence France-Presse — Getty Images

Like others, Mr. Forkner may have had an imperfect understanding of MCAS.

Technical pilots at Boeing like him previously flew planes regularly, two former employees said. “Then the company made a strategic change where they decided tech pilots would no longer be active pilots,” Mr. Ludtke said.

Mr. Forkner largely worked on flight simulators, which didn’t fully mimic MCAS.

It is unclear whether Mr. Forkner, now a pilot for Southwest Airlines, was aware of the changes to the system.

Mr. Forkner’s attorney, David Gerger, said his client did not mislead the F.A.A. “Mark is an Air Force veteran who put safety first and was transparent in his work,” Mr. Gerger said.

“In thousands of tests, nothing like this had ever happened,” he said. “Based on what he was told and what he knew, he never dreamed that it could.”

The F.A.A. group that worked with Mr. Forkner made some decisions based on an incomplete view of the system. It never tested a malfunctioning sensor, according to the three officials. It didn’t require additional training.

William Schubbe, a senior F.A.A. official who worked with the training group, told pilots and airlines in an April meeting in Washington, D.C., that Boeing had underplayed MCAS, according to a recording reviewed by The Times.

“The way the system was presented to the F.A.A.,” Mr. Schubbe said, “the Boeing Corporation said this thing is so transparent to the pilot that there’s no need to demonstrate any kind of failing.”

The F.A.A. officials involved in training weren’t the only ones operating with outdated information.

An April 2017 maintenance manual that Boeing provided to airlines refers to the original version of MCAS. By that point, Boeing had started delivering the planes. The current manual is updated.

Boeing continued to defend MCAS and its reliance on a single sensor after the first crash, involving Indonesia’s Lion Air.

At a tense meeting with the pilots’ union at American Airlines in November, Boeing executives dismissed concerns. “It’s been reported that it’s a single point failure, but it is not considered by design or certification a single point,” said Mike Sinnett, a Boeing vice president, according to a recording of the meeting.

His reasoning? The pilots were the backup.

“Because the function and the trained pilot work side by side and are part of the system,” he said.

Four months later, a second 737 Max crashed in Ethiopia. Within days, the Max was grounded around the world.

As part of the fix, Boeing has reworked MCAS to more closely resemble the first version. It will be less aggressive, and it will rely on two sensors.

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F.A.A. Chief Defends Boeing Certification Process at House Hearing

The acting head of the Federal Aviation Administration defended the agency’s certification procedures involving the now-grounded Boeing 737 Max airplane, telling the House Transportation Committee on Wednesday that the process by which company-paid employees inspected their own aircraft was “a good system.”

The F.A.A. executive, Daniel Elwell, said his agency was reviewing a decades-old practice that allowed F.A.A.-certified employees at 79 aircraft manufacturers to assist in the certification of airplanes. But he said he supported the idea of delegating “certain tasks and certain decisions” in the certification process to private employees, despite criticism that the practice has led to lax oversight.

Mr. Elwell, a former pilot and industry lobbyist, faced two hours of questions from skeptical members of the committee, the first of several hearings the committee plans to hold about the regulator’s role in the wake of two fatal crashes involving the troubled airliner.

“How can we have a single point of failure on a modern aircraft?” asked Representative Peter A. DeFazio, Democrat of Oregon and the committee’s chairman, who questioned whether the inspection system may have led to the problems with airliner. “How was that certified? We shouldn’t have to be here today.”

Representative Rick Larsen, a Democrat from Washington who heads the Transportation Committee’s Subcommittee on Aviation, pressed Mr. Elwell on the agency’s designee authorization process, and the F.A.A.’s role in the development of pilot training procedures for the 737 Max. Pilots were not told about an anti-stall system known as MCAS that was new to the plane and which played a role in both crashes.

[Read our article about how Boeing executives resisted pilots’ urgent calls to fix the 737 Max.]

“The committee’s investigation is just getting started, and it will take some time to get answers, but one thing is clear right now: The F.A.A. has a credibility problem,” Mr. Larsen said.

The 737 Max was grounded in March after an Ethiopian Airlines flight crashed shortly after takeoff from Addis Ababa, killing all 157 people on board. Less than five months earlier, a Lion Air 737 Max flight went down in Indonesia, killing 189 people.

“I thought the MCAS should have been more adequately explained” to pilots around the world, Mr. Elwell said. He faced a number of questions about whether pilots were given proper training on changes to the plane’s navigation and stabilization systems.

ImageWestlake Legal Group merlin_154526991_0806b611-d08d-4766-9d40-0416397ee62d-articleLarge F.A.A. Chief Defends Boeing Certification Process at House Hearing National Transportation Safety Board House Committee on Transportation Federal Aviation Administration Elwell, Daniel K Dickson, Stephen DeFazio, Peter A Boeing Company Boeing 737 Max Groundings and Safety Concerns (2019)

Boeing 737 Max airplanes at the Boeing Factory in Renton, Wash. “The committee’s investigation is just getting started,” said Representative Rick Larsen, a Democrat on the House Transportation Committee.CreditLindsey Wasson/Reuters

The agency, Mr. Elwell said, delegates to the employees of manufacturers only those aspects of aircraft inspection that do not pertain directly to an aircraft’s core safety functions. But Mr. Elwell did acknowledge that the problems with MCAS were, indeed, considered a critical safety issue — raising new questions about whether Boeing employees should have been allowed to inspect it.

Mr. Elwell also said he was “not happy” with the 13-month lag between reports of a “software anomaly” involving a warning light that notifies pilots of a disagreement in sensors that measure which direction the plane is pointed, and Boeing’s actions to address the problem. Boeing discovered in 2017 that the warning light worked only on planes with an optional indicator that displayed the sensor readings. That indicator was sold as an add-on, and only 20 percent of 737 Max customers purchased it. Neither the Lion Air not the Ethiopian Airlines plane had it.

Still, Mr. Elwell said he did not believe that problem contributed to either crash.

Boeing is expected to soon submit a software fix that would keep the automated system from activating based on erroneous data, a factor in both crashes, according to agency investigators. An early version of the new software is being tested in simulators, F.A.A. officials said.

Mr. Elwell gave no timetable for when the plane might be cleared to fly again. He said the agency would only clear the planes on the recommendation of a multiagency technical advisory board made up of experts from the F.A.A., the Air Force, NASA and the Volpe National Transportation Systems Center who were not involved in the initial certification of the 737 Max.

F.A.A. officials convened a meeting with aviation officials from other countries this month to address their concerns about the plane, he said, an effort to bolster confidence in the “un-grounding” of the plane when it is finally approved.

Mr. Elwell was also pressed about why the F.A.A. did not ground the plane until China, much of Europe and Canada already had.

“Why did it take so long?” asked Eleanor Holmes Norton, a Democrat and the District of Columbia’s nonvoting delegate to the House.

“The public perception,” added Representative Dina Titus, a Democrat from Nevada, is that the F.A.A. “is in bed” with Boeing.

Mr. Elwell said the decision to ground the jets was based on consultations with Canadian authorities who provided radar tracking information that linked the two crashes to the MCAS system. He defended the F.A.A. as a “data-driven” organization and said that of the 24 reports of handling issues with the plane, “none” were related to MCAS.

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Westlake Legal Group 13boeing-promo-videoSixteenByNine3000-v2 F.A.A. Chief Defends Boeing Certification Process at House Hearing National Transportation Safety Board House Committee on Transportation Federal Aviation Administration Elwell, Daniel K Dickson, Stephen DeFazio, Peter A Boeing Company Boeing 737 Max Groundings and Safety Concerns (2019)

Boeing introduced the 737 Max as a reliable fuel- and cost-efficient solution to air travel in the 21st century. After two fatal Max crashes, all of the Max aircraft in the world are believed to have been grounded.CreditCreditChang W. Lee/The New York Times

He also suggested throughout the hearing that the inexperience and actions by the flight crews in both accidents might have contributed to the crashes.

“They never controlled the airspeeds,” he said.

Earl Lawrence, the agency’s executive director of aircraft certification, said the F.A.A. was in the process of establishing a new office to oversee the public-private inspection process. He added that the 737 Max was approved only after five years and 10,000 “man hours” of work.

“We take advantage of the expertise of the people who are designing and building the aircraft to assist us,” Mr. Lawrence said.

“I’m proud of my team,” he added of the federal employees who oversaw Boeing’s work.

Also on Wednesday, the Senate Commerce, Science and Transportation Committee questioned Stephen Dickson, the former Delta Air Lines executive whom President Trump has tapped to permanently lead the F.A.A., about the plane. He kept his responses relatively vague, saying regulators “must never rest” in their quest for a perfect safety record.

Over the past two months, Mr. DeFazio has requested a trove of documents from the F.A.A. and Boeing regarding the inspection process and the review undertaken to determine the safety of MCAS. He is especially focused on why Boeing did not require pilots to undergo further training with the anti-stall system.

Mr. DeFazio has received none of the requested documents yet, although the F.A.A. is expected to begin releasing documents to the committee soon. It is not clear when Boeing intends to reply — and Mr. DeFazio warned the manufacturer that it needed to supply the documents “voluntarily” or he would seek other means to the obtain them.

Senator Edward J. Markey, a Democrat of Massachusetts and a member of the Commerce, Science and Transportation Committee, also sent a request to Boeing for answers on its procedures. He has received a two-page later that referred to Mr. Elwell’s previous public statements but provided little new information.

At times, members of the committee seemed impatient with Mr. Elwell’s reluctance to provide detailed answers about what internal improvements the agency was planning to undertake.

For his part, Mr. Elwell expressed concern that the criticism of F.A.A.’s actions was having a negative impact on the agency.

“I’m a little bit worried about morale right now across the F.A.A.,” Mr. Elwell said.

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Boeing Believed a 737 Max Warning Light Was Standard. It Wasn’t.

When Boeing began delivering its 737 Max to customers in 2017, the company believed that a key cockpit warning light was a standard feature in all of the new jets.

But months after the planes were flying, company engineers realized that the warning light worked only on planes whose customers had bought a different, optional indicator.

In essence, that meant a safety feature that Boeing thought was standard was actually a premium add-on.

Boeing detailed its initial confusion about the warning light in a statement released on Sunday, adding new details to what was already known about the flawed design and introduction of the 737 Max, its best-selling jetliner.

The initial lack of knowledge about the feature’s functionality, along with the delayed disclosure, add to the concern about Boeing’s management of the Max’s design. The revelations add to Boeing’s mounting problems, which include frayed relations with airlines and customers, multiple federal investigations, growing financial costs and the remaining work to get the Max flying again.

The warning light notifies pilots of a disagreement in the sensors that measure which direction the plane is pointed, a potential sign of a malfunction. This light could have provided critical information to the pilots on two flights that crashed shortly after takeoff in recent months.

In both doomed flights — Lion Air Flight 610 and Ethiopian Airlines Flight 302 — preliminary investigations suggest that there were problems with these so-called angle of attack sensors early in the flights, activating new anti-stall software that sent the planes into unrecoverable nose-dives.

But the disagree alert worked only on planes with an optional indicator that displays the readings from the angle of attack sensors, Boeing said on Sunday.

Because only 20 percent of customers had purchased the optional indicator, the warning light was not working on most of Boeing’s new jets. Neither Lion Air nor Ethiopian had the indicator.

After discovering the lapse in 2017, Boeing performed an internal review and determined that the lack of a working warning light “did not adversely impact airplane safety or operation,” it said in its statement.

As a result, Boeing said it did not inform airlines or the Federal Aviation Administration about the mistake for a year.

Only after the crash of Lion Air Flight 610 last October did Boeing discuss the matter with the F.A.A. The company then conducted another review and again found the missing alert did not pose a safety threat, and told the F.A.A. as much.

Boeing and the F.A.A. put out public updates late last year that described the warning light as available only if the optional indicator had been purchased as well.

But neither statement made it clear that Boeing had intended for the disagree alert to be standard in all planes.

ImageWestlake Legal Group merlin_154111020_862cf3d6-2480-4f6d-8377-e276f8d148fd-articleLarge Boeing Believed a 737 Max Warning Light Was Standard. It Wasn’t. Sensors Lion Air Federal Aviation Administration Ethiopian Airlines Boeing Company Boeing 737 Max Groundings and Safety Concerns (2019) Aviation Accidents, Safety and Disasters Airlines and Airplanes

The cockpit of a Boeing 737 Max plane. The 737 Max has been grounded for more than a month, after an Ethiopian Airlines crash, as Boeing works on software fixes.CreditAbhirup Roy/Reuters

The F.A.A. said on Sunday that Boeing briefed it on the confusion in November, and that it deemed the issue to be “low risk.”

“However, Boeing’s timely or earlier communication with the operators would have helped to reduce or eliminate possible confusion,” the F.A.A. said.

The anti-stall system, created to compensate for the Max’s large new engines, will push down the nose of the plane if the angle of attack sensors indicate the plane is dangerously close to stalling.

But the system relied on only one of the two angle of attack sensors, introducing a potential single point of failure into a critical flight system. And the anti-stall system was also changed late in the design process to make it much more powerful.

Airlines and pilots were not informed about the system until the Lion Air crash.

When Boeing explained to pilots in one meeting how systems on the Max worked, the company said that the disagree alert would function on the ground. In the late November meeting, Boeing told pilots for American Airlines (which had bought the add-on) that their disagree alert would have notified them of problems before takeoff.

“We were told that if the A.O.A. vane, like on Lion Air, was in a massive difference, we would receive an alert on the ground and therefore not even take off,” said Dennis Tajer, a spokesman for the union representing American Airlines pilots. “That gave us additional confidence in continuing to fly that aircraft.”

But in the last several weeks, Boeing has been saying something different. Mr. Tajer said the company recently told American pilots that the system would not alert pilots about any sensor disagreement until the aircraft is 400 feet above the ground.

A Boeing spokesman confirmed this, stressing that the disagree alert does not work on the ground, and thus could not have alerted the Lion Air pilots to a faulty sensor before takeoff.

Mr. Tajer said Boeing seemed to have “provided information that was not accurate” and said the pilots have asked for clarification from the company.

Mr. Tajer, who is also a 737 pilot, said he was concerned that Boeing did not seem to fully grasp how every aspect of the Max worked.

“You better start knowing things about the airplane you’re building and selling because my life and the passengers that I carry safely across the globe depends on it,” Mr. Tajer said.

The Lion Air crash also spurred Boeing to notify Southwest pilots about the disagree light. “We thought it worked,” said Jon Weaks, the president of the Southwest Pilots’ Association. “If they knew it in 2017, why did we get to nearly the end of 2018 until the manual was changed?”

In the months after the Lion Air crash, Boeing quietly worked to appease some customers, according to a person briefed on the matter. In several instances, it activated the angle of attack indicator for free, which then turned on the disagree alert.

The 737 Max has been grounded for more than a month, after the Ethiopian Airlines crash. Boeing is working on a software fix that it plans to submit to the F.A.A. soon, in hopes that the Max can return to flight later this summer. The update will make the anti-stall system less powerful and reliant on both sensors.

Boeing is also developing a separate software update that will unlink the disagree alert from the angle of attack indicators, which will also be installed before the Max can fly again.

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Boeing’s South Carolina Plant Subject to Increased Scrutiny

The Federal Aviation Administration has been increasing its scrutiny of Boeing’s plant near Charleston, S.C., where manufacturing errors have at times threatened to undermine safety.

Since September, the agency has investigated and confirmed three safety complaints made by employees who detailed problems with planes in the final stages of production, according to an F.A.A. official and an internal agency email. The regulator is also looking into a claim that an employee faced pressure to sign off on work related to the airworthiness of a jet during the last week of March.

In recent years, the F.A.A. has subjected the North Charleston factory to a high level of oversight, a sign that the agency has had concerns. As part of that added oversight, the agency has forced employees to take extra steps to demonstrate that they are complying with federal regulations, according to an internal F.A.A. memo reviewed by The New York Times.

From June 2013 to October 2014, the agency did not allow employees from the plant to certify aircraft, instead requiring that F.A.A. personnel directly sign off on all jets made there, the memo said. Typically, the agency relies on the manufacturer’s employees to help certify the aircraft. Even today, the agency is visiting the plant “every other week” to ensure that tools are not being lost, an extra level of vigilance by the regulator.

The memo, sent by a top safety official to the agency’s head of aircraft certification, directly addressed a recent Times investigation that revealed manufacturing problems and weak oversight at the plant, which makes half of all 787 Dreamliners.

The factory was built to meet the strong demand for 787 Dreamliners. But from the beginning Boeing pushed employees there to quickly turn out jets as it raced to meet deadlines. Current and former employees told The Times that the pressure meant that managers sometimes overlooked safety risks.

Boeing’s broader culture is under a microscope after two deadly crashes involving another jet, the 737 Max. Lawmakers, regulators and prosecutors are trying to determine whether lapses in Boeing’s safety and quality procedures contributed to flaws in an anti-stall system that played a role in a March crash in Ethiopia and an October accident in Indonesia.

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What You Need to Know After Deadly Boeing 737 Max Crashes

Boeing has come under intense scrutiny after its best-selling 737 Max jet was involved in two deadly crashes in five months.

“Boeing and the F.A.A. implement a rigorous inspection process to ensure that all our airplanes are safe and built with the highest levels of quality,” said Gordon Johndroe, a Boeing spokesman. “All our planes go through multiple safety and test flights, as well as extensive Boeing, F.A.A. and airline inspections before they leave our factory and before the traveling public boards those planes for the first time.”

But at the North Charleston plant, current and former employees who spoke with The Times described systemic problems, particularly with debris being left on aircraft. Workers said that a stray bolt had been discovered in an engine and that a ladder had been left in the tail of planes that went up for test flights. Metal shavings were routinely left under floor panels, hanging over wiring that controls the plane.

The F.A.A. said in the memo that it “was unaware of the ladder” left in a tail, but did know about a string of lights left in a tail of another aircraft.

In 2017, the F.A.A. instructed Boeing to remove metal slivers from all of its aircraft. The memo said the agency was now requiring that an F.A.A. representative sign off on every floor panel installation at the factory, a rare instance of hand-holding by the regulator.

There are “several open compliance and enforcement cases” regarding debris being left inside aircraft and keeping track of tools in the factory, issues the F.A.A. describes as “a problem across all sites” at Boeing, according to the memo.

“Safety is the F.A.A.’s top priority,” Lynn Lunsford, an F.A.A. spokesman, said in a statement. “We thoroughly investigate whistle-blower complaints and take action if the allegations are substantiated.”

The agency, in the memo, also confirmed other details reported by The Times, including that Qatar Airways stopped receiving aircraft delivered from North Charleston in 2014.

That year, workers at the plant were told to watch a video of the airline’s chief executive chiding them for production delays, employees told The Times. Boeing now delivers all of Qatar’s airplanes out of its plant in Everett, Wash., the F.A.A. said.

“Boeing considers Qatar Airways to have higher than normal airline standards,” the agency noted in the memo.

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Claims of Shoddy Production Draw Scrutiny to a Second Boeing Jet

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NORTH CHARLESTON, S.C. — When Boeing broke ground on its new factory near Charleston in 2009, the plant was trumpeted as a state-of-the-art manufacturing hub, building one of the most advanced aircraft in the world. But in the decade since, the factory, which makes the 787 Dreamliner, has been plagued by shoddy production and weak oversight that have threatened to compromise safety.

A New York Times review of hundreds of pages of internal emails, corporate documents and federal records, as well as interviews with more than a dozen current and former employees, reveals a culture that often valued production speed over quality. Facing long manufacturing delays, Boeing pushed its work force to quickly turn out Dreamliners, at times ignoring issues raised by employees.

Complaints about the frenzied pace echo broader concerns about the company in the wake of two deadly crashes involving another jet, the 737 Max. Boeing is now facing questions about whether the race to get the Max done, and catch up to its rival Airbus, led it to miss safety risks in the design, like an anti-stall system that played a role in both crashes.

Safety lapses at the North Charleston plant have drawn the scrutiny of airlines and regulators. Qatar Airways stopped accepting planes from the factory after manufacturing mishaps damaged jets and delayed deliveries. Workers have filed nearly a dozen whistle-blower claims and safety complaints with federal regulators, describing issues like defective manufacturing, debris left on planes and pressure to not report violations. Others have sued Boeing, saying they were retaliated against for flagging manufacturing mistakes.

Joseph Clayton, a technician at the North Charleston plant, one of two facilities where the Dreamliner is built, said he routinely found debris dangerously close to wiring beneath cockpits.

“I’ve told my wife that I never plan to fly on it,” he said. “It’s just a safety issue.”

In an industry where safety is paramount, the collective concerns involving two crucial Boeing planes — the company’s workhorse, the 737 Max, and another crown jewel, the 787 Dreamliner — point to potentially systemic problems. Regulators and lawmakers are taking a deeper look at Boeing’s priorities, and whether profits sometimes trumped safety. The leadership of Boeing, one of the country’s largest exporters, now finds itself in the unfamiliar position of having to defend its practices and motivations.

“Boeing South Carolina teammates are producing the highest levels of quality in our history,” Kevin McAllister, Boeing’s head of commercial airplanes, said in a statement. “I am proud of our teams’ exceptional commitment to quality and stand behind the work they do each and every day.”

All factories deal with manufacturing errors, and there is no evidence that the problems in South Carolina have led to any major safety incidents. The Dreamliner has never crashed, although the fleet was briefly grounded after a battery fire. Airlines, too, have confidence in the Dreamliner.

But workers sometimes made dangerous mistakes, according to the current and former Boeing employees, some of whom spoke on the condition of anonymity because they feared retaliation.

Faulty parts have been installed in planes. Tools and metal shavings have routinely been left inside jets, often near electrical systems. Aircraft have taken test flights with debris in an engine and a tail, risking failure.

On several planes, John Barnett, a former quality manager who worked at Boeing for nearly three decades and retired in 2017, discovered clusters of metal slivers hanging over the wiring that commands the flight controls. If the sharp metal pieces — produced when fasteners were fitted into nuts — penetrate the wires, he said, it could be “catastrophic.”

ImageWestlake Legal Group 00boeing2-articleLarge Claims of Shoddy Production Draw Scrutiny to a Second Boeing Jet Workplace Hazards and Violations Whistle-Blowers Transportation Department (US) North Charleston (SC) National Labor Relations Board Japan Airlines Fines (Penalties) Federal Aviation Administration Factories and Manufacturing Everett (Wash) Defective Products Boeing Company Boeing 737 Max Groundings and Safety Concerns (2019) Aviation Accidents, Safety and Disasters American Airlines Airlines and Airplanes Airbus Industrie

John Barnett, a former Boeing quality manager, said bosses had refused his repeated efforts to deal with production issues. He has filed a whistle-blower complaint.CreditSwikar Patel for The New York Times

Mr. Barnett, who filed a whistle-blower complaint with regulators, said he had repeatedly urged his bosses to remove the shavings. But they refused and moved him to another part of the plant.

A spokesman for the Federal Aviation Administration, Lynn Lunsford, said the agency had inspected several planes certified by Boeing as free of such debris and found those same metal slivers. In certain circumstances, he said, the problem can lead to electrical shorts and cause fires.

Officials believe the shavings may have damaged an in-service airplane on one occasion in 2012, according to two people with knowledge of the matter.

The F.A.A. issued a directive in 2017 requiring that Dreamliners be cleared of shavings before they are delivered. Boeing said it was complying and was working with the supplier to improve the design of the nut. But it has determined that the issue does not present a flight safety issue.

“As a quality manager at Boeing, you’re the last line of defense before a defect makes it out to the flying public,” Mr. Barnett said. “And I haven’t seen a plane out of Charleston yet that I’d put my name on saying it’s safe and airworthy.”

The head of the 787 program reminded workers in North Charleston this month that stray objects left inside planes “can potentially have serious safety consequences when left unchecked.”CreditTravis Dove/Bloomberg

Less than a month after the crash of the second 737 Max jet, Boeing called North Charleston employees to an urgent meeting. The company had a problem: Customers were finding random objects in new planes.

A senior manager implored workers to check more carefully, invoking the crashes. “The company is going through a very difficult time right now,” he said, according to two employees who were present and spoke on the condition of anonymity.

So-called foreign object debris is a common issue in aviation. Employees are supposed to clean the bowels of the aircraft as they work, often with a vacuum, so they don’t accidentally contaminate the planes with shavings, tools, parts or other items.

But debris has remained a persistent problem in South Carolina. In an email this month, Brad Zaback, the head of the 787 program, reminded the North Charleston staff that stray objects left inside planes “can potentially have serious safety consequences when left unchecked.”

The issue has cost Boeing at other plants. In March, the Air Force halted deliveries of the KC-46 tanker, built in Everett, Wash., after finding a wrench, bolts and trash inside new planes.

“To say it bluntly, this is unacceptable,” Will Roper, an assistant secretary of the Air Force, told a congressional subcommittee in March. “Our flight lines are spotless. Our depots are spotless, because debris translates into a safety issue.”

Boeing said it was working to address the issue with the Air Force, which resumed deliveries this month.

At the North Charleston plant, the current and former workers describe a losing battle with debris.

“I’ve found tubes of sealant, nuts, stuff from the build process,” said Rich Mester, a former technician who reviewed planes before delivery. Mr. Mester was fired, and a claim was filed on his behalf with the National Labor Relations Board over his termination. “They’re supposed to have been inspected for this stuff, and it still makes it out to us.”

Rich Mester, a former technician who reviewed planes before delivery, described a losing battle with debris: “I’ve found tubes of sealant, nuts, stuff from the build process.”CreditSwikar Patel for The New York Times

Employees have found a ladder and a string of lights left inside the tails of planes, near the gears of the horizontal stabilizer. “It could have locked up the gears,” Mr. Mester said.

Dan Ormson, who worked for American Airlines until retiring this year, regularly found debris while inspecting Dreamliners in North Charleston, according to three people with knowledge of the situation.

Mr. Ormson discovered loose objects touching electrical wiring and rags near the landing gear. He often collected bits and pieces in zip-lock bags to show one of the plant’s top executives, Dave Carbon.

The debris can create hazardous situations. One of the people said Mr. Ormson had once found a piece of Bubble Wrap near the pedal the co-pilot uses to control the plane’s direction, which could have jammed midflight.

On a Dreamliner that Boeing had already given a test flight, Mr. Ormson saw that a bolt was loose inside one of the engines. The small piece of metal could have caused the engine to malfunction.

American Airlines said it conducted rigorous inspections of new planes before putting them into service. “We have confidence in the 787s we have in our fleet,” said Ross Feinstein, a spokesman for the airline.

Boeing had trouble finding qualified workers for its North Charleston plant. There was no work force comparable to the generations of aerospace professionals the company has nurtured in the Seattle area.CreditRandall Hill/Reuters

When it was unveiled in 2007, the 787 Dreamliner was Boeing’s most important new plane in a generation. The wide-body jet, with a lightweight carbon fiber fuselage and advanced technology, was a hit with carriers craving fuel savings.

Airlines ordered hundreds of the planes, which cost upward of $200 million each. Spurred by high demand, Boeing set up a new factory.

North Charleston was ideal in many ways. South Carolina has the lowest percentage of union representation in the nation, giving Boeing a potentially less expensive work force.

South Carolina doled out nearly $1 billion in tax incentives, including $33 million to train local workers. Boeing pledged to create 3,800 jobs.

While Boeing has nurtured generations of aerospace professionals in the Seattle area, there was no comparable work force in South Carolina. Instead, managers had to recruit from technical colleges in Tulsa, Okla., and Atlanta.

Managers were also urged to not hire unionized employees from the Boeing factory in Everett, where the Dreamliner is also made, according to two former employees.

“They didn’t want us bringing union employees out to a nonunion area,” said David Kitson, a former quality manager, who oversaw a team responsible for ensuring that planes are safe to fly.

“We struggled with that,” said Mr. Kitson, who retired in 2015. “There wasn’t the qualified labor pool locally.” Another former manager, Michael Storey, confirmed his account.

The 787 was already running years behind schedule because of manufacturing hiccups and supplier delays. The labor shortages in North Charleston only made it worse.

The initial excitement when the first Dreamliners entered service in late 2011 was short lived. A little more than a year later, the entire fleet was grounded after a battery fire on a Japan Airlines plane.

Boeing was forced to compensate carriers, hurting profit. All the while, the production delays mounted, and Airbus was close behind with a rival plane, the A350.

In North Charleston, the time crunch had consequences. Hundreds of tools began disappearing, according to complaints filed in 2014 with the F.A.A. by two former managers, Jennifer Jacobsen and David McClaughlin. Some were “found lying around the aircraft,” Ms. Jacobsen said in her complaint.

The two managers also said they had been pushed to cover up delays. Managers told employees to install equipment out of order to make it “appear to Boeing executives in Chicago, the aircraft purchasers and Boeing’s shareholders that the work is being performed on schedule, where in fact the aircraft is far behind schedule,” according to their complaints.

The F.A.A. investigated the complaints and didn’t find violations on its visit to the plant in early 2014. But the agency said it had previously found “improper tool control” and the “presence of foreign object debris.”

Both managers left after they were accused of inaccurately approving the time sheets of employees who did not report to them. They both claim they were retaliated against for flagging violations. Through their lawyer, Rob Turkewitz, they declined to comment.

Gordon Johndroe, a spokesman for Boeing, said, “We prioritize safety and quality over speed, but all three can be accomplished while still producing one of the safest airplanes flying today.”

Planes were also damaged during manufacturing. A Dreamliner built for American Airlines suffered a flood in the cabin so severe that seats, ceiling panels, carpeting and electronics had to be replaced in a weekslong process.

While inspecting a plane being prepared for delivery, Mr. Clayton, the technician currently at the plant, recently found chewing gum holding together part of a door’s trim. “It was not a safety issue, but it’s not what you want to present to a customer,” he said.

An employee filed a complaint about the gum with the F.A.A. The agency is investigating, an F.A.A. official said.

[If you’ve worked at Boeing and want to discuss your experience, reach us confidentially here.]

The disarray frustrated one major carrier. In 2014, factory employees were told to watch a video from the chief executive of Qatar Airways.

He chastised the North Charleston workers, saying he was upset that Boeing wasn’t being transparent about the length or cause of delays. In several instances, workers had damaged the exterior of planes made for the airline, requiring Boeing to push back delivery to fix the jets.

Ever since, Qatar has bought only Dreamliners built in Everett.

In a statement, Qatar Airways said it “continues to be a long-term supporter of Boeing and has full confidence in all its aircraft and manufacturing facilities.”

A spokesman for Boeing, Gordon Johndroe, said, “We prioritize safety and quality over speed, but all three can be accomplished while still producing one of the safest airplanes flying today.”CreditTravis Dove/Bloomberg

In the interest of meeting deadlines, managers sometimes played down or ignored problems, according to current and former workers.

Mr. Barnett, the former quality manager, who goes by Swampy in a nod to his Louisiana roots, learned in 2016 that a senior manager had pulled a dented hydraulic tube from a scrap bin, he said. He said the tube, part of the central system controlling the plane’s movement, was installed on a Dreamliner.

Mr. Barnett said the senior manager had told him, “Don’t worry about it.” He filed a complaint with human resources, company documents show.

He also reported to management that defective parts had gone missing, raising the prospect that they had been installed in planes. His bosses, he said, told him to finish the paperwork on the missing parts without figuring out where they had gone.

The F.A.A. investigated and found that Boeing had lost some damaged parts. Boeing said that as a precautionary matter, it had sent notices to airlines about the issue. The company said it had also investigated the flawed hydraulic tube and hadn’t substantiated Mr. Barnett’s claims.

Cynthia Kitchens, a former quality manager at the plant, said her superiors penalized her in performance reviews after she flagged wire bundles rife with metal shavings and defective metal parts that had been installed on planes.CreditSwikar Patel for The New York Times

“Safety issues are immediately investigated, and changes are made wherever necessary,” said the Boeing spokesman, Mr. Johndroe.

But several former employees said high-level managers pushed internal quality inspectors to stop recording defects.

Cynthia Kitchens, a former quality manager, said her superiors penalized her in performance reviews and berated her on the factory floor after she flagged wire bundles rife with metal shavings and defective metal parts that had been installed on planes.

“It was intimidation,” she said. “Every time I started finding stuff, I was harassed.”

Ms. Kitchens left in 2016 and sued Boeing for age and sex discrimination. The case was dismissed.

Some employees said they had been punished or fired when they voiced concerns.

Mr. Barnett was reprimanded in 2014 for documenting errors. In a performance review seen by The Times, a senior manager downgraded him for “using email to express process violations,” instead of engaging “F2F,” or face to face.

He took that to mean he shouldn’t put problems in writing. The manager said Mr. Barnett needed to get better at “working in the gray areas and help find a way while maintaining compliance.”

Liam Wallis, a former quality manager, said in a wrongful-termination lawsuit that Boeing had fired him after he discovered that planes were being manufactured using obsolete engineering specifications. Mr. Wallis also said in the suit, filed in March, that an employee who didn’t exist had signed off on the repairs of an aircraft.

His boss had criticized him in the past for writing up violations, according to the lawsuit and emails reviewed by The Times. Boeing said it had fired Mr. Wallis for falsifying documents.

Through his lawyers, Mr. Wallis declined to comment for this article. Boeing has denied his claims and moved to dismiss the case.

In North Charleston, the pace of production has quickened. Starting this year, Boeing is producing 14 Dreamliners a month, split between North Charleston and Everett, up from the previous 12. At the same time, Boeing said it was eliminating about a hundred quality control positions in North Charleston.

“They’re trying to shorten the time of manufacturing,” said Mr. Mester, the former mechanic. “But are you willing to sacrifice the safety of our product to maximize profit?”

[The reporters on this article can be reached at Natalie.Kitroeff@nytimes.com and David.Gelles@nytimes.com.]

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Claims of Shoddy Production Draw Scrutiny to a Second Boeing Jet

NORTH CHARLESTON, S.C. — When Boeing broke ground on its new factory near Charleston in 2009, the plant was trumpeted as a state-of-the-art manufacturing hub, building one of the most advanced aircraft in the world. But in the decade since, the factory, which makes the 787 Dreamliner, has been plagued by shoddy production and weak oversight that have threatened to compromise safety.

A New York Times review of hundreds of pages of internal emails, corporate documents and federal records, as well as interviews with more than a dozen current and former employees, reveals a culture that often valued production speed over quality. Facing long manufacturing delays, Boeing pushed its work force to quickly turn out Dreamliners, at times ignoring issues raised by employees.

Complaints about the frenzied pace echo broader concerns about the company in the wake of two deadly crashes involving another jet, the 737 Max. Boeing is now facing questions about whether the race to get the Max done, and catch up to its rival Airbus, led it to miss safety risks in the design, like an anti-stall system that played a role in both crashes.

Safety lapses at the North Charleston plant have drawn the scrutiny of airlines and regulators. Qatar Airways stopped accepting planes from the factory after manufacturing mishaps damaged jets and delayed deliveries. Workers have filed nearly a dozen whistle-blower claims and safety complaints with federal regulators, describing issues like defective manufacturing, debris left on planes and pressure to not report violations. Others have sued Boeing, saying they were retaliated against for flagging manufacturing mistakes.

Joseph Clayton, a technician at the North Charleston plant, one of two facilities where the Dreamliner is built, said he routinely found debris dangerously close to wiring beneath cockpits.

“I’ve told my wife that I never plan to fly on it,” he said. “It’s just a safety issue.”

In an industry where safety is paramount, the collective concerns involving two crucial Boeing planes — the company’s workhorse, the 737 Max, and another crown jewel, the 787 Dreamliner — point to potentially systemic problems. Regulators and lawmakers are taking a deeper look at Boeing’s priorities, and whether profits sometimes trumped safety. The leadership of Boeing, one of the country’s largest exporters, now finds itself in the unfamiliar position of having to defend its practices and motivations.

“Boeing South Carolina teammates are producing the highest levels of quality in our history,” Kevin McAllister, Boeing’s head of commercial airplanes, said in a statement. “I am proud of our teams’ exceptional commitment to quality and stand behind the work they do each and every day.”

All factories deal with manufacturing errors, and there is no evidence that the problems in South Carolina have led to any major safety incidents. The Dreamliner has never crashed, although the fleet was briefly grounded after a battery fire. Airlines, too, have confidence in the Dreamliner.

But workers sometimes made dangerous mistakes, according to the current and former Boeing employees, some of whom spoke on the condition of anonymity because they feared retaliation.

Faulty parts have been installed in planes. Tools and metal shavings have routinely been left inside jets, often near electrical systems. Aircraft have taken test flights with debris in an engine and a tail, risking failure.

On several planes, John Barnett, a former quality manager who worked at Boeing for nearly three decades and retired in 2017, discovered clusters of metal slivers hanging over the wiring that commands the flight controls. If the sharp metal pieces — produced when fasteners were fitted into nuts — penetrate the wires, he said, it could be “catastrophic.”

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John Barnett, a former Boeing quality manager, said bosses had refused his repeated efforts to deal with production issues. He has filed a whistle-blower complaint.CreditSwikar Patel for The New York Times

Mr. Barnett, who filed a whistle-blower complaint with regulators, said he had repeatedly urged his bosses to remove the shavings. But they refused and moved him to another part of the plant.

A spokesman for the Federal Aviation Administration, Lynn Lunsford, said the agency had inspected several planes certified by Boeing as free of such debris and found those same metal slivers. In certain circumstances, he said, the problem can lead to electrical shorts and cause fires.

Officials believe the shavings may have damaged an in-service airplane on one occasion in 2012, according to two people with knowledge of the matter.

The F.A.A. issued a directive in 2017 requiring that Dreamliners be cleared of shavings before they are delivered. Boeing said it was complying and was working with the supplier to improve the design of the nut. But it has determined that the issue does not present a flight safety issue.

“As a quality manager at Boeing, you’re the last line of defense before a defect makes it out to the flying public,” Mr. Barnett said. “And I haven’t seen a plane out of Charleston yet that I’d put my name on saying it’s safe and airworthy.”

The head of the 787 program reminded workers in North Charleston this month that stray objects left inside planes “can potentially have serious safety consequences when left unchecked.”CreditTravis Dove/Bloomberg

Less than a month after the crash of the second 737 Max jet, Boeing called North Charleston employees to an urgent meeting. The company had a problem: Customers were finding random objects in new planes.

A senior manager implored workers to check more carefully, invoking the crashes. “The company is going through a very difficult time right now,” he said, according to two employees who were present and spoke on the condition of anonymity.

So-called foreign object debris is a common issue in aviation. Employees are supposed to clean the bowels of the aircraft as they work, often with a vacuum, so they don’t accidentally contaminate the planes with shavings, tools, parts or other items.

But debris has remained a persistent problem in South Carolina. In an email this month, Brad Zaback, the head of the 787 program, reminded the North Charleston staff that stray objects left inside planes “can potentially have serious safety consequences when left unchecked.”

The issue has cost Boeing at other plants. In March, the Air Force halted deliveries of the KC-46 tanker, built in Everett, Wash., after finding a wrench, bolts and trash inside new planes.

“To say it bluntly, this is unacceptable,” Will Roper, an assistant secretary of the Air Force, told a congressional subcommittee in March. “Our flight lines are spotless. Our depots are spotless, because debris translates into a safety issue.”

Boeing said it was working to address the issue with the Air Force, which resumed deliveries this month.

At the North Charleston plant, the current and former workers describe a losing battle with debris.

“I’ve found tubes of sealant, nuts, stuff from the build process,” said Rich Mester, a former technician who reviewed planes before delivery. Mr. Mester was fired, and a claim was filed on his behalf with the National Labor Relations Board over his termination. “They’re supposed to have been inspected for this stuff, and it still makes it out to us.”

Rich Mester, a former technician who reviewed planes before delivery, described a losing battle with debris: “I’ve found tubes of sealant, nuts, stuff from the build process.”CreditSwikar Patel for The New York Times

Employees have found a ladder and a string of lights left inside the tails of planes, near the gears of the horizontal stabilizer. “It could have locked up the gears,” Mr. Mester said.

Dan Ormson, who worked for American Airlines until retiring this year, regularly found debris while inspecting Dreamliners in North Charleston, according to three people with knowledge of the situation.

Mr. Ormson discovered loose objects touching electrical wiring and rags near the landing gear. He often collected bits and pieces in zip-lock bags to show one of the plant’s top executives, Dave Carbon.

The debris can create hazardous situations. One of the people said Mr. Ormson had once found a piece of Bubble Wrap near the pedal the co-pilot uses to control the plane’s direction, which could have jammed midflight.

On a Dreamliner that Boeing had already given a test flight, Mr. Ormson saw that a bolt was loose inside one of the engines. The small piece of metal could have caused the engine to malfunction.

American Airlines said it conducted rigorous inspections of new planes before putting them into service. “We have confidence in the 787s we have in our fleet,” said Ross Feinstein, a spokesman for the airline.

Boeing had trouble finding qualified workers for its North Charleston plant. There was no work force comparable to the generations of aerospace professionals the company has nurtured in the Seattle area.CreditRandall Hill/Reuters

When it was unveiled in 2007, the 787 Dreamliner was Boeing’s most important new plane in a generation. The wide-body jet, with a lightweight carbon fiber fuselage and advanced technology, was a hit with carriers craving fuel savings.

Airlines ordered hundreds of the planes, which cost upward of $200 million each. Spurred by high demand, Boeing set up a new factory.

North Charleston was ideal in many ways. South Carolina has the lowest percentage of union representation in the nation, giving Boeing a potentially less expensive work force.

South Carolina doled out nearly $1 billion in tax incentives, including $33 million to train local workers. Boeing pledged to create 3,800 jobs.

While Boeing has nurtured generations of aerospace professionals in the Seattle area, there was no comparable work force in South Carolina. Instead, managers had to recruit from technical colleges in Tulsa, Okla., and Atlanta.

Managers were also urged to not hire unionized employees from the Boeing factory in Everett, where the Dreamliner is also made, according to two former employees.

“They didn’t want us bringing union employees out to a nonunion area,” said David Kitson, a former quality manager, who oversaw a team responsible for ensuring that planes are safe to fly.

“We struggled with that,” said Mr. Kitson, who retired in 2015. “There wasn’t the qualified labor pool locally.” Another former manager, Michael Storey, confirmed his account.

The 787 was already running years behind schedule because of manufacturing hiccups and supplier delays. The labor shortages in North Charleston only made it worse.

The initial excitement when the first Dreamliners entered service in late 2011 was short lived. A little more than a year later, the entire fleet was grounded after a battery fire on a Japan Airlines plane.

Boeing was forced to compensate carriers, hurting profit. All the while, the production delays mounted, and Airbus was close behind with a rival plane, the A350.

In North Charleston, the time crunch had consequences. Hundreds of tools began disappearing, according to complaints filed in 2014 with the F.A.A. by two former managers, Jennifer Jacobsen and David McClaughlin. Some were “found lying around the aircraft,” Ms. Jacobsen said in her complaint.

The two managers also said they had been pushed to cover up delays. Managers told employees to install equipment out of order to make it “appear to Boeing executives in Chicago, the aircraft purchasers and Boeing’s shareholders that the work is being performed on schedule, where in fact the aircraft is far behind schedule,” according to their complaints.

The F.A.A. investigated the complaints and didn’t find violations on its visit to the plant in early 2014. But the agency said it had previously found “improper tool control” and the “presence of foreign object debris.”

Both managers left after they were accused of inaccurately approving the time sheets of employees who did not report to them. They both claim they were retaliated against for flagging violations. Through their lawyer, Rob Turkewitz, they declined to comment.

Gordon Johndroe, a spokesman for Boeing, said, “We prioritize safety and quality over speed, but all three can be accomplished while still producing one of the safest airplanes flying today.”

Planes were also damaged during manufacturing. A Dreamliner built for American Airlines suffered a flood in the cabin so severe that seats, ceiling panels, carpeting and electronics had to be replaced in a weekslong process.

While inspecting a plane being prepared for delivery, Mr. Clayton, the technician currently at the plant, recently found chewing gum holding together part of a door’s trim. “It was not a safety issue, but it’s not what you want to present to a customer,” he said.

An employee filed a complaint about the gum with the F.A.A. The agency is investigating, an F.A.A. official said.

[If you’ve worked at Boeing and want to discuss your experience, reach us confidentially here.]

The disarray frustrated one major carrier. In 2014, factory employees were told to watch a video from the chief executive of Qatar Airways.

He chastised the North Charleston workers, saying he was upset that Boeing wasn’t being transparent about the length or cause of delays. In several instances, workers had damaged the exterior of planes made for the airline, requiring Boeing to push back delivery to fix the jets.

Ever since, Qatar has bought only Dreamliners built in Everett.

In a statement, Qatar Airways said it “continues to be a long-term supporter of Boeing and has full confidence in all its aircraft and manufacturing facilities.”

A spokesman for Boeing, Gordon Johndroe, said, “We prioritize safety and quality over speed, but all three can be accomplished while still producing one of the safest airplanes flying today.”CreditTravis Dove/Bloomberg

In the interest of meeting deadlines, managers sometimes played down or ignored problems, according to current and former workers.

Mr. Barnett, the former quality manager, who goes by Swampy in a nod to his Louisiana roots, learned in 2016 that a senior manager had pulled a dented hydraulic tube from a scrap bin, he said. He said the tube, part of the central system controlling the plane’s movement, was installed on a Dreamliner.

Mr. Barnett said the senior manager had told him, “Don’t worry about it.” He filed a complaint with human resources, company documents show.

He also reported to management that defective parts had gone missing, raising the prospect that they had been installed in planes. His bosses, he said, told him to finish the paperwork on the missing parts without figuring out where they had gone.

The F.A.A. investigated and found that Boeing had lost some damaged parts. Boeing said that as a precautionary matter, it had sent notices to airlines about the issue. The company said it had also investigated the flawed hydraulic tube and hadn’t substantiated Mr. Barnett’s claims.

Cynthia Kitchens, a former quality manager at the plant, said her superiors penalized her in performance reviews after she flagged wire bundles rife with metal shavings and defective metal parts that had been installed on planes.CreditSwikar Patel for The New York Times

“Safety issues are immediately investigated, and changes are made wherever necessary,” said the Boeing spokesman, Mr. Johndroe.

But several former employees said high-level managers pushed internal quality inspectors to stop recording defects.

Cynthia Kitchens, a former quality manager, said her superiors penalized her in performance reviews and berated her on the factory floor after she flagged wire bundles rife with metal shavings and defective metal parts that had been installed on planes.

“It was intimidation,” she said. “Every time I started finding stuff, I was harassed.”

Ms. Kitchens left in 2016 and sued Boeing for age and sex discrimination. The case was dismissed.

Some employees said they had been punished or fired when they voiced concerns.

Mr. Barnett was reprimanded in 2014 for documenting errors. In a performance review seen by The Times, a senior manager downgraded him for “using email to express process violations,” instead of engaging “F2F,” or face to face.

He took that to mean he shouldn’t put problems in writing. The manager said Mr. Barnett needed to get better at “working in the gray areas and help find a way while maintaining compliance.”

Liam Wallis, a former quality manager, said in a wrongful-termination lawsuit that Boeing had fired him after he discovered that planes were being manufactured using obsolete engineering specifications. Mr. Wallis also said in the suit, filed in March, that an employee who didn’t exist had signed off on the repairs of an aircraft.

His boss had criticized him in the past for writing up violations, according to the lawsuit and emails reviewed by The Times. Boeing said it had fired Mr. Wallis for falsifying documents.

Through his lawyers, Mr. Wallis declined to comment for this article. Boeing has denied his claims and moved to dismiss the case.

In North Charleston, the pace of production has quickened. Starting this year, Boeing is producing 14 Dreamliners a month, split between North Charleston and Everett, up from the previous 12. At the same time, Boeing said it was eliminating about a hundred quality control positions in North Charleston.

“They’re trying to shorten the time of manufacturing,” said Mr. Mester, the former mechanic. “But are you willing to sacrifice the safety of our product to maximize profit?”

[The reporters on this article can be reached at Natalie.Kitroeff@nytimes.com and David.Gelles@nytimes.com.]

Real Estate, and Personal Injury Lawyers. Contact us at: https://westlakelegal.com 

Changes to Flight Software on 737 Max Escaped F.A.A. Scrutiny

While it was designing its newest jet, Boeing decided to quadruple the power of an automated system that could push down the plane’s nose — a movement that made it difficult for the pilots on two doomed flights to regain control.

The company also expanded the use of the software to activate in more situations, as it did erroneously in the two deadly crashes involving the plane, the 737 Max, in recent months.

None of those changes to the anti-stall system, known as MCAS, were fully examined by the Federal Aviation Administration.

Although officials were aware of the changes, the modifications didn’t require a new safety review, according to three people with knowledge of the process. It wasn’t necessary under F.A.A. rules since the changes didn’t affect what the agency considers an especially critical or risky phase of flight.

A new review would have required F.A.A. officials to take a closer look at the system’s effect on the overall safety of the plane, as well as to consider the potential consequences of a malfunction. Instead, the agency relied on an earlier assessment of the system, which was less powerful and activated in more limited circumstances.

Ever since the crashes — in Indonesia last October and Ethiopia last month — investigators, prosecutors and lawmakers have scrutinized what went wrong, from the design and certification to the training and response.

In both crashes, the authorities suspect that faulty sensor data triggered the anti-stall system, revealing a single point of failure on the plane. Pilots weren’t informed about the system until after the Lion Air crash in Indonesia, and even then, Boeing didn’t fully explain or understand the risks. The F.A.A. outsourced much of the certification to Boeing employees, creating a cozy relationship between the company and its regulator.

But the omission by the F.A.A. exposes an embedded weakness in the approval process, providing new information about the failings that most likely contributed to the crashes in Indonesia and Ethiopia.

[“Boeing’s 737 Max: 1960s design, 1990s computing power and paper manuals”]

The F.A.A. is supposed to be the gold standard in global aviation regulation, with the toughest and most stringent rules for certifying planes. But the miscalculation over MCAS undermines the government’s oversight, raising further concerns about its ability to push back against the industry or root out design flaws.

While it is unclear which officials were involved in the review of the anti-stall system, they followed a set of bureaucratic procedures, rather than taking a proactive approach. The result is that officials didn’t fully understand the risks of the more robust anti-stall system, which could cause a crash in less than a minute.

“The more we know, the more we realize what we don’t know,” said John Cox, an aviation safety consultant and former 737 pilot.

The F.A.A. defended its certification process, saying it has consistently produced safe aircraft. An F.A.A. spokesman said agency employees collectively spent more than 110,000 hours reviewing the Max, including 297 test flights.

The spokesman said F.A.A. employees were following agency rules when they didn’t review the change. “The change to MCAS didn’t trigger an additional safety assessment because it did not affect the most critical phase of flight, considered to be higher cruise speeds,” an agency spokesman said. “At lower speeds, greater control movements are often necessary.”

A spokesman for Boeing said, “The F.A.A. considered the final configuration and operating parameters of MCAS during Max certification, and concluded that it met all certification and regulatory requirements.”

Some of the details of the evolving design of MCAS were earlier reported by The Seattle Times.

MCAS was created to help make the 737 Max handle like its predecessors, part of Boeing’s strategy to get the plane done more quickly and cheaply.

The system was initially designed to engage only in rare circumstances, namely high-speed maneuvers, in order to make the plane handle more smoothly and predictably for pilots used to flying older 737s, according to two former Boeing employees who spoke on the condition of anonymity because of the open investigations.

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The Dangerous Flaws in Boeing’s Automated System

Here’s why a system designed to stabilize the 737 Max may have caused two deadly crashes in five months.

For those situations, MCAS was limited to moving the stabilizer — the part of the plane that changes the vertical direction of the jet — about 0.6 degrees in about 10 seconds.

It was around that design stage that the F.A.A. reviewed the initial MCAS design. The planes hadn’t yet gone through their first test flights.

After the test flights began in early 2016, Boeing pilots found that just before a stall at various speeds, the Max handled less predictably than they wanted. So they suggested using MCAS for those scenarios, too, according to one former employee with direct knowledge of the conversations.

But the system needed more power to work in a broader range of situations.

At higher speeds, flight controls are more sensitive and less movement is needed to steer the plane. Consider the effect of turning a car’s steering wheel at 70 miles an hour versus 30 miles an hour.

To prevent stalls at lower speeds, Boeing engineers decided that MCAS needed to move the stabilizer faster and by a larger amount. So Boeing engineers quadrupled the amount it could move the stabilizer in one cycle, to 2.5 degrees in less than 10 seconds.

“That’s a huge difference,” said Dennis Tajer, a spokesman for the American Airlines pilots’ union who has flown 737s for a decade. “That’s the difference between controlled flight or not.”

Speed was a defining characteristic for the F.A.A. The agency’s rules require an additional review only if the changes affect how the plane operates in riskier phases of flight: at high speeds and altitudes. Because the changes to the anti-stall system affected how it operated at lower speeds and altitudes, F.A.A. employees didn’t need to take a closer look at them.

The overall system represented a major departure from Boeing’s design philosophy. Boeing has traditionally favored giving pilots control over their planes, rather than automated flight systems.

“In creating MCAS, they violated a longstanding principle at Boeing to always have pilots ultimately in control of the aircraft,” said Chesley B. Sullenberger III, the retired pilot who landed a jet in the Hudson River. “In mitigating one risk, they created another, greater risk.”

The missed risks, by the F.A.A. and Boeing, flowed to other decisions. A deep explanation of the system wasn’t included in the plane manual. The F.A.A. didn’t require training on it. Even Boeing test pilots weren’t fully briefed on MCAS.

“Therein lies the issue with the design change: Those pitch rates were never articulated to us,” said one test pilot, Matthew Menza.

Mr. Menza said he looked at documentation he still had and did not see mention of the rate of movement on MCAS. “So they certainly didn’t mention anything about pitch rates to us,” he said, “and I certainly would’ve loved to have known.”

The system’s increased power was also compounded by its design: The software engaged repeatedly if the sensor suggested it was necessary to avoid a stall. In the Lion Air crash, data showed that the pilots, who weren’t aware of MCAS, fought for control of the plane, as it pushed the nose back down each time they pulled it up.

Few truly understood just how powerful the system would prove. It wasn’t fully disclosed until after the Lion Air disaster, killing all 189 people on board. On the Ethiopian Airlines flight, the pilots struggled to regain control after MCAS engaged at least three times.

Last month, during flight simulations recreating the problems with the Lion Air flight, American pilots were surprised at how strong MCAS was. They essentially had less than 40 seconds to manually override a system malfunction before a crash.

Updates to the software by Boeing, which the F.A.A. will have to approve, will address some of the concerns with the anti-stall system. The changes will limit the system to engaging just once in most cases. And they will prevent MCAS from pushing the plane’s nose down more than a pilot could counteract by pulling up on the controls.

Boeing had hoped to deliver the software fix to the F.A.A. by now but it was delayed by several weeks. As a result, the grounding of the jet is expected to drag on. Southwest Airlines and American Airlines have already canceled some flights through May.

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