Our Objective(s)
To assess the Federal Aviation Administration's (FAA) actions in response to recent incidents of toxic smoke and fumes entering aircrafts' cockpit or cabin when load reduction devices (LRD) are activated. Our findings are organized as follows: (1) FAA's Corrective Action Review Board's (CARB) recommendation, (2) additional safety concerns identified by accident investigators, (3) potential issues unaddressed by the CARB, and (4) FAA's Flight Standards' assessment of simulator technology.
Why This Audit
In March and December 2023, bird strikes damaged the engines of Boeing 737 MAX 8 airplanes, causing oil mist and irritating fumes to enter the aircraft and putting aircrews and passengers at risk. In light of these incidents, and the disagreement between FAA offices about adoption of interim changes which could affect safety, we initiated this audit.
What We Found
FAA's CARB recommended an Airworthiness Directive via a Notice of Proposed Rulemaking (NPRM).
- The CARB, held on November 26, 2024, resulted in a consensus decision to address the risks posed by LRD activation incidents in LEAP-1B engines. The CARB recommended FAA publish an NPRM requiring the Agency to issue an Airworthiness Directive when LRD software updates become available.
FAA's Office of Accident Investigation and Prevention accident investigators identified several safety concerns that the CARB's recommended actions did not resolve to investigators' satisfaction.
- FAA's senior air accident investigators identified several risks and provided associated recommendations to FAA leadership. The CARB did not agree that all the investigators' concerns required action.
The CARB did not address potential process and safety issues.
- We identified several issues that could require further analysis and additional action, including how FAA monitors how long it will take to develop and install the updated engine software across the entire fleet of 737 MAX aircraft, notifies newly hired pilots of LRD activation hazards, and trains pilots on how to properly use oxygen equipment.
FAA's Flight Standards determined that simulator technology updates were needed to address LRD activation.
- In response to FAA's request for a safety review of current flight simulator capabilities, two airlines indicated 737 MAX full flight simulators can increase vibration but do not incorporate LRD activation directly nor simulate smoke or fumes in the flight deck.
Recommendations
We made 4 recommendations to improve aviation safety related to LRD activation.
Update: As required by the James M. Inhofe National Defense Authorization Act for Fiscal Year 2023, this report has been updated to include comments submitted by non-governmental organizations or business entities specifically identified in the report (see Appendix B).
