Federal Reports

What We Looked AtThe Federal Aviation Administration (FAA) has historically maintained an excellent safety record. However, two fatal accidents in 2018 and 2019 involving the Boeing 737 MAX 8 raised concerns about FAA's oversight and certification of civilian aircraft manufactured and operated in the United States. At the request of Secretary of Transportation Elaine L. Chao and several members of Congress, our office has undertaken a series of reviews related to FAA's certification of the MAX and its safety oversight, including the Agency's oversight of Boeing's Organization Designation Authorization (ODA). Our overall audit objective was to determine and evaluate FAA's process for certifying the Boeing 737 MAX series of aircraft. In this report, we focused on assessing (1) the effectiveness of FAA's guidance and processes for managing the certification of the 737 MAX 8 and (2) FAA's oversight of the Boeing ODA.What We FoundWhile FAA and Boeing followed the established certification process for the 737 MAX 8, we identified limitations in FAA's guidance and processes that impacted certification and led to a significant misunderstanding of the Maneuvering Characteristics Augmentation System (MCAS), the flight control software identified as contributing to the two accidents. First, FAA's certification guidance does not adequately address integrating new technologies into existing aircraft models. Second, FAA did not have a complete understanding of Boeing's safety assessments performed on MCAS until after the first accident. Communication gaps further hindered the effectiveness of the certification process. In addition, management and oversight weaknesses limit FAA's ability to assess and mitigate risks with the Boeing ODA. For example, FAA has not yet implemented a risk-based approach to ODA oversight, and engineers in FAA's Boeing oversight office continue to face challenges in balancing certification and oversight responsibilities. Moreover, the Boeing ODA process and structure do not ensure ODA personnel are adequately independent. While the Agency has taken steps to develop a risk-based oversight model and address concerns of undue pressure at the Boeing ODA, it is not clear that FAA's current oversight structure and processes can effectively identify future high-risk safety concerns at the ODA.Our RecommendationsWe made 14 recommendations to improve the Agency's aircraft certification process and oversight of the Boeing ODA. FAA concurred with all 14 of our recommendations and provided appropriate actions and planned completion dates.

The Medicare hospice benefit allows providers to claim Medicare reimbursement for hospice services provided to individuals with a life expectancy of 6 months or less and who have elected hospice care. Previous OIG reviews found that Medicare inappropriately paid for hospice services that did not meet certain Medicare requirements.Our objective was to determine whether hospice services provided by Tidewell Hospice, Inc., (Tidewell) complied with Medicare requirements.

In accordance with our annual plan, the Office of Inspector General conducted a follow-up on the Department's implementation of the recommendations in Report Number OIG-2017-01. Our objective was to confirm the Department took appropriate corrective actions in implementing the recommendations. Our scope included existing controls related to implementation of the recommendations outlined in our previous report.