Report Raps Boeing Internal Safety Oversight


While Boeing brass brag about the safety culture in the company, frontline employees who implement the safety processes aren’t getting the same message according to a report commissioned by the FAA. The report, done by a panel of experts in response to the fallout of the crash of two Boeing 737 MAX aircraft in 2018 and 2019, found “a disconnect between Boeing’s senior management and other members of the organization on safety culture.” It also said the implementation of the safety culture at the company was “inadequate and confusing” and that the rules and the training to meet those rules are in “constant state of change, creating employee confusion, especially among different work sites and employee groups.”

The report focused on the function of the 1,000 staff members with Organization Designation Authorization who have the legal responsibility to oversee safety standards on the shop floor. In addition to not clearly understanding their mandate, they also feared retaliation for speaking up, the report says. “This influences the ability of UMs [unit members] to execute their delegated functions effectively.” The panel did note that Boeing had restructured management of the ODA but that members could still face retaliation through salary and ranking for booking holidays.

Russ Niles
Russ Niles is Editor-in-Chief of AVweb. He has been a pilot for 30 years and joined AVweb 22 years ago. He and his wife Marni live in southern British Columbia where they also operate a small winery.


  1. Had a cousin who was a nurse and moved into factory nursing in a chocolate factory. She was dubbed “the most powerful person in the factory” as she could shut down the line for safety concerns — no-one else could. Still only got a nurse’s pay though.
    Maybe Boeing should hire more nurses.

  2. I hope that will reclaim its reputation on a world-leading aircraft manufacturer of finest planes ever built. Upper management need to return to Washington state to work directly with its employees.

    How Boeing rises to occasion and prove to themselves, if no else, that Boeing is the envy of the world.

    • The 50-page report goes into detail about SMS and other safety practices, and how Boeing was deficient in implementing them.

    • I’m onboard with you guys. The FAA and NTSB shoved the SMS program (“Safety Culture” or “Culture of Safety”) down our throats with little to no guidance as the fix to all our woes. The SMS should be the headline of every incident and accident.

  3. Planes built in Washington, company moves headquarters and senior execs to Chicago. What could possibly go wrong?

    • Yeah – I remember reading an article years ago about the most successful computer processor maker at that time and its CEO. In it was a photo of the CEO at his desk. He was located on the large office floor alongside all of the other office employees – no walls or barriers of any kind in sight.

  4. For some reason, I am not able to open the FAA report at the link. Does anyone know the timeframe of when the FAA’s panel was looking at Boeing’s safety practices?

  5. What about the employees on the assembly line? Don’t they care about how the planes are built? Don’t they have pride in their workmanship? Where are the supervisors looking over their workmanship? To me it sounds like the assembly line rumors in the Detroit auto factories of old: beware of cars built on Fridays and Mondays…………!

  6. As President and founder of our small company I can understand how upper management becomes separated from “shop floor” reality. I can only imagine what a broken culture exists at Boeing.

    • Mine, too. Engineers take grief for poor design on many products, when usually they provide good design, but it’s cut to pieces by the bean-counters for a few pennies.

      • That’s a pendulum that can swing too far in the other direction, but it does seem to have gotten stuck on the finance side for a long while.

  7. as long as the CEO is being rewarded for short term profits there will continue to be a problem.

    he/she will do what ever gets them the most money. to change this we need to make their bonuses contingent on what the stock and profits are 5 years ahead. then they will act to do things that will make the company do well long term like good quality control, keep the smarter people, good design. we (the investors) are the problem because there is no reason for me as an investor to ask my stock broker about how will I get the most return 5 years from now. my proposal is to make the reduction in capital gains tax only for a long term (like 5 years) Anything shorter is taxed at standard income rates. that will force me as an investor ask the CEO what they are doing to make my stock worth something 5 years from now and thus doing actions that promote long term value like good quality.

    • I’m not going to pretend to know the fix, but you are correct the incentives in the US have gotten all messed up. We could likely do with a lot of simplification. This is an above average IQ bunch on Avweb (including the “idiots” who disagree with me on everything 🤣😂🤣). Still, how much of how things actually work do we all really understand? Yet we are smarter than the average voter and voters are supposed to be deciding so much of these things.

  8. Until Boeing puts engineers are put back in charge instead of MBAs and bean counters this won’t be fixed. The 737 MAX MCAS disaster would never have happened without extraordinary pressure from management to push out a SINGLE POINT OF FAILURE system that could overpower the pilots.

    The results of that single point failure along with crew mismanagement of that failure resulted in the two terrible accidents of the MAX. Both were avoidable if an additional AOA sensor had been added and there is no way the engineers did not push hard for that second sensor.

    To bad Boeing won’t do a full military type aviation debrief when there are no punches pulled no matter of rank or seniority. Just the truth and facts to make things better and safer. We won’t hold our breath.

    • Precisely, Tom. For a while, I worked in reliability engineering on a large black airplane. There were stringent requirements for everything to be tested and reported upon at the vendor’s facilities. Then we’d collect that data, have meetings with engineering and make sure we had a fix for everything. Every two weeks, either the structures crowd or the avionics crowd would have to brief the VP of logistics and engineering. Woe be the person who didn’t have an answer for everything. In the end, that airplane was one of the most reliable ever. Even then, some things got past everyone; witness the crash of one of ’em due to water ingestion in one of the air data external ports and a checklist that had things in the wrong order. If someone had pitched a single point failure mode item; they’d have been whacked BIG time. That’s why you immerse engineering into everything.

  9. Complexity, safety, rigidity. For any highly complex activity, managing the interaction between these factors is a continual battle. And of course, no one can even mention the obvious question “How safe is safe enough?” even though in our personal activities we face and answer it in hundreds of small actions every day.

  10. I flew the 800 “new gen” for almost 4 years and, after 10k+ hours on MD 80’s, I was extremely disappointed in fit, function and overall handling of the 737. I dubbed it the sky turd. It only got worse with the “max” as it was changed way too much from the original certificate to be on the same certificate. Today Boeing is run by bean counter instead of aeronautical engineers, hence we have an airplane that has been bandaided instead of redesigned and has resulted in one catastrophe after another. The people that work on the line know the truth of the “safety culture”. They should be listened to instead of intimidated into silence.

    • At some point the new certificate was allowed to get so expensive it killed innovation in everything except avoiding doing a new one.

  11. Did anyone read the report? It’s seems like it’s written in “bureaucratese”, i.e. long winded, pedantic and pompous generalities, on and on page after page. I don’t see anything concrete. From my experience as an engineer, this would drive most engineers crazy. Engineers are highly focused on solving problems, in very concrete ways. From my understanding of the 737 max problems, many issues originated with the re-engining with more powerful engines. This created a greater pitch up moment with the under-slung engines. Rather than redesign the airframe/engine configuration, the problem was addressed with a bandaid, i.e, a computerized trim system designed to compensate for the pitch up tendency. The trim system was flawed and allowed a runaway pitch change. If management would listen and heed the warnings and recommendations from engineering, things like that could be avoided. Yes, of course there must be high level protocols to make aircraft safe. But IMO, it could be done in a more focused way, having a more direct connection to actual problems. But this report puts me to sleep, with its endless platitudes. Think of the Lockheed “Skunk Works”. Do you think they endured such nonsense as this report? No, they simply knew how to build world class airplanes, being led by inspired leadership, and their personnel dedicated and passionate about their craft, not cogs in a giant bureaucratic machine.


    Based on the comments and the FAA report, several potential problem-solving solutions emerge:

    1. Addressing the leadership disconnect:
    • Relocation of leadership: Consider having key decision-makers spend more time at production facilities to understand the realities faced by frontline employees. (e.g., “Rolfe Tessem: Planes built in Washington, company moves headquarters and senior execs to Chicago. What could possibly go wrong?”)
    • Prioritizing engineers and long-term safety: Re-evaluate decision-making processes to give engineers more influence and prioritize long-term safety over short-term cost-cutting measures. (e.g., “Tom Newman: Until Boeing puts engineers back in charge… this won’t be fixed.”)

    2. Empowering frontline employees:
    • Clear and consistent safety guidelines: Establish clear, concise, and readily available safety procedures and protocols for all employees. (e.g., “Matt W: No mention of SMS. I thought SMS was the cure all for safety issues!”) ” Kirk Wennerstrom: The 50-page report goes into detail about SMS and other safety practices, and how Boeing was deficient in implementing them.”
    • Eliminate fear of retaliation: Implement robust and transparent mechanisms for employees to report safety concerns without fear of repercussions. (e.g., “jethro B: The employees do care until upper management drives that caring out of them.”)
    3. Fostering a culture of open communication:

    • Focus on listening and addressing concerns: Encourage open communication and actively listen to employee concerns regarding safety issues. (e.g., “John D: Did anyone read the report? It’s seems like it’s written in ‘bureaucratese’… From my experience as an engineer, this would drive most engineers crazy.”)
    • Transparent communication with stakeholders: Maintain open and transparent communication with relevant stakeholders, including regulators, the public, and investors, regarding safety efforts and any potential issues.

    4. Continuous improvement and accountability:

    • Regular safety assessments: Conduct regular and independent safety assessments to identify and address potential risks before incidents occur. (e.g., “Jim C: Today Boeing is run by bean counters instead of aeronautical engineers… The people that work on the line know the truth of the ‘safety culture’. They should be listened to instead of intimidated into silence.”)
    • Link CEO compensation to long-term performance: Consider tying CEO compensation to long-term safety performance and positive safety culture indicators, not just short-term financial gains. (e.g., “william Lawson: as long as the CEO is being rewarded for short term profits there will continue to be a problem.”)

    5. Then there is: “[email protected]: Need more of the MBWA culture.” Best one! It’s not a one-size-fits-all solution but keeps everyone awake.

    • Many, many years ago, I worked as a manager for a very large food production company. The job included supervising 30 maintenance personnel in a 24/7, three-shift union environment. It was not for the faint of heart.
      On a couple of occasions, usually deep in a shift and staring at pending doom to production, I’d give instruction to a technician who would respond, “Okay boss, but are you sure you want me to do that?”
      I learned to listen, early and often.

  13. I wonder what might happen if the CEO showed up on the shop floor one day and asked the front line employees the following questions:

    In your opinion what do we do well as a company? What do we do terribly?
    How can we help you improve your job here at Boeing?
    What three things would you change here if you had the chance?
    What do you need from the company to do your best work?
    Do you feel you, you work and your opinion matters to the company? If not, how might we change that?

    The answers most often are on the shop floor and it would be wise for the C suite occupants to both understand that and to help close the chasm that always seems to exist between management and labor. One thing that’s obvious, a paradigm shift for management is in order.

  14. Reminds me of when I worked at Boeing Wichita back in the 70’s. We were doing the B-52 re-wing project. They were having all manor of issues. Management was scratching their heads trying to solve the problem. When they looked at the roster they saw all the familiar names from the original build crew. On closer inspection what they found was that the people who came to work were not the original builders but the sons and daughters of those workers. All of that tribal knowledge had retired.

  15. The report only addresses the “design” and certification side. If they are looking into safety culture, then what about the Quality and manufacturing organization? (The complete manufacturing side, which includes the AMEs and Manufacturing and Maintenance delegates)? For a complete picture, both sides should have been reviewed.

    When I worked in the industry (in SMS and engineering), the majority of non-punitive reports submitted came from the manufacturing sites and production lines. Reports were then required to be dispositioned by the SMS system using subject matter experts such as AME, DER, MRB members, etc… It would only seem to make sense that if one was evaluating the SMS system or the safety culture, a complete picture would be required.

  16. It’s noteworthy that since 2022 Boeing’s headquarters is in Arlington, Virginia (near DC) which is far away from their original base in Washington state and nowhere’s near any of their manufacturing. Bureaucracy rules, it seems.

  17. While Boeing’s workforce is around 160,000, its economic impact is extensive. A 2018 study by the Aerospace Industries Association estimated Boeing supported 1.7 million jobs and $282 billion in economic activity in the US. This includes dependents, supply chain employees, and individuals benefiting from increased spending.

    Boeing’s contributions are substantial:

    • Jobs: They directly employ many and indirectly support even more through their supply chain and economic activity.
    • Taxes: They generate significant tax revenue for various government levels.
    • Exports: A leading US exporter, contributing positively to the trade balance.
    • Innovation: They invest heavily in research and development, leading to advancements benefiting various sectors.

    Challenges may exist, but remember the proverb: “Do not bite the hand that feeds you.” Make it work!

  18. Just read the report. To me it looks like neither the FAA or Boeing don’t believe in SMS. The FAA because of “not invented here” attitude. I have seen this long before the Boeing situation. Boeing because management is still convinced their own in house safety programs are better, obviously some of the past accidents and other issues say otherwise. Although I didn’t see any mention of this, I wonder if Boeing’s wonderful relationship with the Seattle area unions are inhibiting cooperation on this. As I have said before, just because you have a SMS program in force, if management doesn’t believe in it, it becomes nothing more than a paperwork exercise that adds work but accomplishes nothing.

    • “just because you have a SMS program in force, if management doesn’t believe in it, it becomes nothing more than a paperwork exercise that adds work but accomplishes nothing.”


      That was one of my take-aways from this report. It reads:
      “Boeing launched a ‘Seek, Speak, & Listen’ initiative led by senior management and functional leaders to encourage employees to proactively seek out and raise concerns related to product safety and other subjects.”

      But the report then observed:
      “Referencing Boeing’s Seek, Speak, & Listen behaviors, the Expert Panel observed throughout the discovery and assessment process that attention was given to Speak, with little or no attention given to Seek or Listen.”

    • Matt I agree with you that SMS without management buy-in is ineffective. However your years long opposition to SMS in this comment section makes me wonder if you disagree with the SMS concept period, or if you agree with the SMS concept in principle but simply had the misfortune of choosing to work for the wrong company, one in which management doesn’t buy in to the SMS concept? Which is it?

      • The company I used to work for followed the SMS as long as it did not interfere with what the company owner wanted to do. It did nothing for me since I already followed safe airplane operating procedures, so it just added to my workload with no benefit to me. The company I now work for already is not what is referred to as a pt134 1/2 company. Maintenance is top notch and no one is expected to do anything unsafe or illegal. I see the upcoming SMS requirement as just another item to unnecessarily increase my workload. Since I know the FAA doesn’t believe in it either, this SMS reminds me of all of the workplace “fads” I have had to deal with over the years prior to my aviation career. “Time management”, ISO 9000 are examples. I know of one company who supplies the auto companies who told them when the auto companies wanted that supplier to follow ISO9000, told the auto companies to pound sand. That supplier has been and is still now known as the best product out there and they were not going to change that. Applying SMS to pt91 passenger carrying VFR ops like the NTSB wants will in effect shut most of them down due to cost and delays. For example, can you imagine filling out a FRAT score on each load flying skydivers. Most turbine drop zones need to have to minimize time on the ground between loads to make the plane profitable. To me SMS is just another workplace “fad” that when regulators find it doesn’t help will come up with another “fad” to justify their jobs.

  19. It looks like, Boeing’s struggles are a double-edged sword for the aviation industry. While Airbus might see an initial surge, it won’t be enough to single-handedly satisfy the growing demand for commercial aircraft. This opens the door for smaller players like Embraer and potentially even China’s best, COMAC to carve out a significant niche, especially in the regional jet market. This situation could act as a catalyst for innovation and potentially disrupt the established dominance of Boeing and Airbus.