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Numerous design, management and regulatory failures during the development of the 737 Max preceded the “preventable death” of 346 people in two crashes of the popular Boeing jetliner, according to a damning congressional report released Wednesday.

The House Committee on Transportation and Infrastructure’s 238-page report, put together by its Democratic leaders and their staff, painted a Boeing that prioritized profits over safety and detailed “disturbing cultural issues” relating to employee surveys showing some experienced “undue pressure” as the manufacturer raced to finish the plane to compete with rival Airbus. The report said concerns about the aircraft weren’t sufficiently addressed to spur design changes.

Some lawmakers this year introduced legislation that aims to increase the Federal Aviation Administration’s oversight of the industry. The lawmakers found the FAA failed to protect the traveling public, in part because of “excessive” delegation of certification work to Boeing.

Responding to the report, the agency said: “The FAA is committed to continually advancing aviation safety and looks forward to working with the Committee to implement improvements identified in its report.” It said it has implemented several initiatives “focused on advancing overall aviation safety by improving our organization, processes, and culture.”

The report, in the works for about 18 months, comes as regulators are in the final stretch of work to recertify the planes. The 737 Max has been grounded worldwide since March 2019, following the second of the planes’ two fatal crashes.

“They were the horrific culmination of a series of faulty technical assumptions by Boeing’s engineers, a lack of transparency on the part of Boeing’s management, and grossly insufficient oversight by the FAA — the pernicious result of regulatory capture on the part of the FAA with respect to its responsibilities to perform robust oversight of Boeing and to ensure the safety of the flying public,” the report said. The lawmakers and staff said they received 600,000 pages of records from Boeing, the FAA, airlines and others, for its investigation, conducted interviews with two dozen employees and regulators, and considered comments from whistleblowers who reached out to the committee.

On Oct. 29, 2018, Lion Air Flight 610 from Jakarta, Indonesia, and on March 10, 2019, Ethiopian Airlines Flight 302 from Addis Ababa, Ethiopia, crashed shortly after takeoff, killing everyone on board. At the center of the crashes was an automated system known as MCAS, against which pilots for both flights battled to override. It was activated after receiving inaccurate sensor data. 

Pilots were not informed of MCAS until after the first crash and mentions of it were removed from their manuals. Last year, the National Transportation Safety Board found Boeing overestimated pilots’ ability to handle a flurry of alerts during malfunctions. 

Boeing has made changes to the MCAS system that render it less powerful, give pilots greater control and provide it with more data before it is activated. That is among other changes regulators have reviewed as part of the process in recertifying the planes as safe for the traveling public.

“We have learned many hard lessons as a company from the accidents of Lion Air Flight 610 and Ethiopian Flight 302, and from the mistakes we have made,” Boeing said in a statement. “As this report recognizes, we have made fundamental changes to our company as a result, and continue to look for ways to improve. Change is always hard and requires daily commitment, but we as a company are dedicated to doing the work.”

The House report, led by Rep. Peter DeFazio, D-Ore., the committee chair, and Rep. Rick Larsen, D-Wash., head of the aviation subcommittee, said its investigation “leaves open the question of Boeing’s willingness to admit to and learn from the company’s mistakes.”

Some of crash victims’ family members say Boeing has not done enough.

“I think the project as a whole should be scrapped,” said Yalena Lopez-Lewis, whose husband, Antoine, was killed on the Ethiopian Airlines flight. “I think this was a rushed project and … now they’re rushing to recertify. You can’t place a dollar value on the lives of any passenger.”

Michael Stumo, whose daughter Samya Stumo also was killed in the Ethiopian crash, said Boeing and regulators didn’t do enough after the first crash five months earlier.

“Before Lion Air, it was a mistake. After Lion Air it was unforgivable,” he said.

The crashes pushed Boeing into its biggest-ever crisis, as its bestselling aircraft couldn’t be delivered to customers and costs mounted. The missteps cost Dennis Muilenburg his job as Boeing CEO and prompted the company to undergo an internal restructuring to improve its approach to safety. Now, the coronavirus pandemic that has roiled air travel demand worldwide coupled with the extensive grounding presents Boeing with a new problem: cancellations of the planes are piling up. 

The manufacturer’s problems don’t end with the 737 Max. It recently discovered flaws on some 787 Dreamliners, prompting inspections that have slowed deliveries of the wide-body aircraft.