Cafeteria and i hope you can all come back. Please, thank you. I was always all the way back here and the republicans called a doomed to fail procedural worlds. I have to go back to the floor again. Here is our time around here. Lets proceed to questions. Since i just got back i want to gather myself for a minute. Okay. I presume will be five minutes. I had to ask. Thanks. I want to thank the folks for being here. Doctor im seeing it discussion regarding Human Factors where the issues were looking at Going Forward and how we change if we should change i think we should how we change acidification process and what changes ought to be made. How should we think about incorporating Human Factors analysis into the certification of airplanes . The daca report talks quite a bit about and we concur with the recommendations to emphasize Human Factors more in a certification process. The real value certification is getting a second set of eyes and what is going on. Its way too easy for even very knowledgeable wellintentioned engineers to make incorrect assumptions or errors in their analysis and the ability to have that independent set of eyes looking at whats going on in the process is being used in the outcomes of the results, i think is a showdown early valuable. We need to make sure those teams are equipped with well qualified Human Factors engineers who understand a lot of the complexities of Human Behavior that are involved in these sorts of events particularly with things like automation and alarm situations such as we saw here. In your opinion you may not have an opinion or knowledge maybe someone else does, that have an answer to lock him die. Does the faa currently have people in line to redact Human Factors analysis of airplane designs in system designs . Yes. The faa has at some very well qualified Human Factors professionals. Doctor insider certification of human factor side and very knowledgeable about this. I think the issue is one of having enough people and having those people involved in that process slash other getting the information they need our involved all along the way. That is the most valuable way to incorporate the. You cant just lose empathy and you really have to be involved early on and continuously. Anyone else want to answer that question from an factors skills. Keep really do the faa . Mr. Kyrsten and hearing testimony elicited last year some of the Vice President agreed to conduct a thorough analysis to determine if you production environment has caused safety risks. Two knowledge was that analysis conducted . Thank you the microphone please. Not to my knowledge. Not to run all. It did you do any followup on that whose role would have been to follow up on high . The general managers responsibility with appropriate because of the other organizations like engineering in that circumstance, was mr. Campbell within the over the a or was youre concerned made into the olc a at boeing or was this outside of that . This was a discussion i had with him oneonone. It was involving anybody else. If you argument in a testimony that this is the problem with pressure because of economic factors only problem with the way boeings organized to build and certified airplanes . Drew phrase that again congressman . Is your argument or the point youre making with you testimonies a very good point, because of economic part is only or because of a problem with how boeing cases doj . I dont have a comment about the olivier as far as economic factors go, im not an economist. Why issues were what i saw in the factory in the environment and the things that were happening at the time when those plans were being built and i was in there when the second plane was built. I retired prior to that. That was my concern. I will say just on the topic theres been a lot of discussion about certification process and a lot of discussions on the left side if you will of the process which is the design and the flight training. The right is on the far right which is called the production and boeing has issued a certificate that expects every plane built with the same incredible quality, so thats a really important part of the airplane process airplane certification that we should forget. Thank you. I thank the gentleman. I recognize myself now. Current harks. Weve heard from some through these hearings who have said well if this had happened with u. S. A european pilots, who would not have been a problem because theyre superior training can, yet i believe you were aware of u. S. And european pilots who knew this problem was coming and simulator and around successful and managing it. Is that correct . I am aware of some anecdotal tests that were done with european and north american pilots i went to the airplane. Over speed conditions. I dont believe this evidence that could support the premise that exclusively new to the countries that these accidents were caused by this. Also i think was a you who used the word pen the moon . What are you referring to there. . The fact that when this situation occurs, when the airplane breaks ground you get somewhere between seven simultaneous very distracting really the color in your hands shaking you as a pilot the train comes into how do you sort through the and when you come back to the commonality and sort through that where priority without much noise with the simultaneous failures the word pandemonium is. I think hes had coughing easter where there used. Ive had go off an airplane with passengers and verify itself is enough of a challenge much less now compounded with six to seven other simultaneous warnings and failures, it would be a real hand for. That would fit into the Human Factors approach of solving a pilot could solve that . That was a big factor pilots could respond in three seconds it is a lot of things has to be a recognized to a well trained procedure. We had all kinds of competing alerts mr. Pearson. He mentioned id like to revisit it after your persistence when you finally getting to see how this have been 37 program what you just give us a little color on that meeting . A little more than a testimony. Congressman, here referring to our july 18th or 2018 meeting, as far as just commentaries in the meeting started though the fallout of the evil that i had rain requesting such shut down. I worked in the office and they asked me why youre here, and im here to follow up to my earlier communication with you. He asked me how i was going and i explained it was getting worse in my opinion, and that i echoed my recommendations. How did the person looking at that point and we talked gettable putting overtime records and how much work they were asking about human employees and thats obviously really important, but also the managers are overseeing them and then the engineering quality analysis that are requested to be done to see if there was any possible issues require us to alert our customers. And nothing changed . Not to my knowledge. I retired in august. We asked to see you in the last hearing off to pick of the recommendation from you, did you close down the line and on the abuse you asked for over time of years they were disregarded were you positive from your experience with the navy, this would say no. Weve got to stop, and revisit this. And you know, and fix it, but he did say to you something about the navy isnt a profit making, was that . He said when i explained to him that in the military operations we have these kinds of indications with unstable safeties things we would stop. And he said that military is not a profitmaking organization. Now mr. Collins, your involvement in the issue regarding the placement of and lack of protection of the runner control cable, i understand it. In the end there were how many people involved in the non, wht did you call it a non concurrence . There was the srp non channel recommendation was rejected, and the board recommendation. So i think it was a total of 13 engineers, one project pilot and four managers documented they did not agree with the decision. And this was to the best of your knowledge of overruled by a single manager who is in the off bowing in washington state. Yes he was in a consolidated office he was the manager at the time that signed it and took responsibility. Others supported other managers supported him. And there were questions raised by the minority that we should bring in former faa administrator or someone else. To the best of your knowledge did the decision on, and only this is one decision and there have been others and we are gonna track these down. But do you think anyone higher up like in the National Office was involved in the better cable issue or even aware of it . While the safety, srp report that the boards recommendation, the manager had to come back and explain why he disagreed with that. That went up to air two, the Deputy Director of aircraft certification. The earlier decision, it has been my experience in issues like this they are discussed with the aircraft certification s deputy or director. And that is someone based washington. Yes in washington. Good that is a string to follow for us we will see what goes from there. Thank you, that is helpful. With that i dont have any questions at the moment and i recognize were presented nor. Thank you, mr. Chairman, i appreciate you inviting these witnesses as well. Because they have broadened our understanding i think i would like to begin with mr. Pearson because your testimony as i understood it focused primarily on the written washington factory. But in past hearings, ive raised things about the South Carolina factory which makes the boeing 787 dreamliner. There we have reports of concerns by employees of defective manufacturing. Even pressure not to report violations. Each time my office raised concern with boeing representatives, they have assured me and my staff that the problems found in South Carolina were not systemic. Your testimony indicates some of the same issues were present and written and washington. To your knowledge how widespread were are these issues do you believe . Mr. Pearson. Yes congresswoman, i have no experience with the South Carolina facility. But what you speak of, i did witness at the written factory. And there are certainly and an ornament amount of schedule pressure placed on the employees and we had a lot of challenges with the parts when the factories running well, then we kind of had a cascading problem and it just kind of got out of hand. I dont know why we would want to do that. Without making sure that the faa should go farther in would you one that . Of the faa doing investigation of the boeing factories . I would encourage that i would be encouraged or the faa would go in and do a thorough investigation. I really feel that is necessary. And i guess it before not even going in and identifying but maintaining the president the presence going into the future. Mr. Collins you say that the culture, at the faa shifted from supporting faa technical specialist to favoring industry positions. This is something that concerned me and my questions this morning. I would like to know what immediate steps you think faa leadership can take to return the agency to a culture of safety. You apparently experience when you first began . Yes i think the culture has evolved so would take something to turn it around. Maybe i had experience working with Flight Standards for a bit and they rewarded employees with who raise safety issues. They rewarded employees and managers to address safety issues, that would be a good help. I mean ive heard but i dont have evidence, that managers bonuses and things were based on impart applicants schedules. What. For projects finishing on time. Isnt that what leadership tell about . They cant change and a comprehensive way if you dont have somebody at the top of a complicated organization forcing change down. Do you think the present leadership, for example, at faa has the capacity to bring that kind of change, or make that kind of change happens at boeing . Well, and i can speak to the faa. At the faa i think they have the ability to do that but i think is going to take work to change the culture at the Different Levels it is evolved over time. Yes, and apparently this has by now built into the culture of places like boeing, thats what my question to mr. Pearson was about what you see it one boeing factory wont be the case at another. It seems to me that given what we have learned, there are issues with boeing. It is going to be on us if we do not take the steps to systematically look at boeing factories across the united states. Thank you, mr. Chairman. Since thank you gentle lady. Thank you, doctor ensley of the faa is looking at in incorporating Human Factors in consideration of design and certification process. Can you tell me about that . Yes that was one of the recommendations to the j atr and we certainly concur with that. What needs to be done is to increase the staff, thats available. We also need to increase research thats needed to look at the weather were having challenges with such as multiple learning with lots of interactions. This needs to be done to enable the certification to really consider Human Factors. I think its really important that they are part of that team and that they get the kind of data thats needed in the process. From the analysis to looking at the design, to reviewing test procedures and test results. And thats really important thing to be incorporated all the way through. That was sort of my second question as well. So you are talking about multiple factors, multiple Human Factors in the beginning of your statement. Yes. So Human Factors is really looking at every aspect of how humans perceive think, how they move, all of the human characteristics and human capabilities and limitations. And in designing the systems to be compatible with how we work and how to guard against were some of our known failure points are. So its a systematic way of divide signing system based on the research on how they work. And thats really the way to improve human performance. It works to not only improve the efficiency of your system but to guard against errors that lead to accidents. Some people freeze. Other people the adrenaline starts to flow. So that will be difficult unless they are trained consistently how to react to specific problems, dont you think . Training is extremely important its of what we look at with Human Factors. The first thing we want to do is design the system appropriately. Very hard to train for bad design. You want to design it appropriately first. And then he went to train people. In training people on what to do an emergency situation is important. Its very important for doing things like automation, automation failures, and getting into these sorts of edges of the envelope for the automation does not behave properly. And you have to really expose people to that know what cues look like, how to prioritize information, how to respond, how to communicate. Those wellearned behaviors can be executed much more smoothly when the real thing happens. How do we tackle that automation surprise . We try to avoid it. So the way we have to address it is one, training some people actually get good training on the automation which didnt happen in these accidents. But we know its very important for automation its very complex. Even if you are an experienced pilot they dont know how the operation is going to happen. Training is important. The other thing is really the displays we provide. Even well trained pilots are going to the right thing if they dont get the right information. For example here, they didnt have information on what theyre doing. They didnt have the information to even understand the angle of the tax sensors were disagreed, or had a problem with it. They did not have the information they needed. To overwrite it so to speak . So having all the procedures and all the training wont work if you dont have the situation information. Thank you youll back my time. Thank you gentle lady. Thank you chairman, mr. Pearson thank you very much for being here today. It gives me a great deal of comfort to know that there are people like yourself out there, that when you see something wrong you are willing to speak out. And let people know what is going on and how you feel. I think as someone who travels on planes is very comforting to know that you would try to do the right thing. You went to the management, they ignored you. And this morning, i just cant believe that after all we have gone through, this morning we finally got a commitment for mro investigate. Theyre going to investigate all of your emails and the reasons that happens. So that is amazing to me after all of this time, it took this hearing for them to just to even look and investigates what your comments were. So, i thank you. You are reckoned youre welcome mr. Congressman, its the right thing to do. Was this person with unique employees with boeing or just because of the 737 max and how to get them out . Or was this something that was all the time at boeing . Is it a cultural pressure to push push push . In my experience at boeing the other positions i was in at boeing, i didnt see that. It was my vantage. It was the factory, it was in the Production Facility, thats where the pressure and the scheduling after 30 years the military i never thought that level of schedule pressure put on people. When you put people in that kind of pressure, and theyre tired, mistakes are made. And i think the doctor would agree with that. Can you give me other examples of what was going on . I am not reversed on the factory and some of the issues. What you saw. Well very quickly with you the factory everything is planned. Everything is planned in is supposed to be done in accordance with their faa approved production certificate. And when things are working fine, parts are getting delivered on time, the people are working in position, the plane moves down the line and is benchley is properly flight tested et cetera. So the end of 2,172,018, what i started observing and thats why been adamant about talking to others at the site. We started having flights with our parts being delivered and it wasnt just big parts like the engines, but which was a chronic problem, we had other things they were very important. Every part of the plane is very important but wiring and wire bundles are really important things. This starts to lead to a lot of out of sequence work. So resources are stretched. People are used to working in one position or two are now being asked to work all the way