Enforcement. This is two hours. I went to mentioned that because you were the representatives of all of those people today, i want to appreciate the work of the two jurors of the committee and for you being here as representatives of these individuals today. We are joined by dr. Javier de luis, a director of aeronautics, thank you for being here. Dr. Tracy dillinger at nasa, and a professor of Southern CaliforniaUniversity Safety programs. The expert panels 50 recommendations regarding boeing s Safety Culture serves as an important catalyst for future aviation legislation. While we have made safety improvements through the air certification reform long, and some of that is still playing up with a new administrator who is more aggressively taking the responsibilities seriously, we look to build on those advancements with a five year authorization bill and at events and features, but we will not stop there. There was more to be done to implement the recommendations from your report. We owe a debt of gratitude to those who are here today. I went to especially thank you for being here. I cannot imagine the tragedy of losing her sister and one of the crashes in continuing to be involved in trying to correct and improve our Safety Culture, but i can just say we so appreciate you being here in the active role that you were played in all these discussions. The expert panels final report focused on the importance of saent systems, and while billing was were hard to adopt an estimate in 2015 as part of an faa Settlement Agreement and while the faa later adopted voluntary programs , the expert panels report makes it clear now that we need a real sms. Both boeing and faa need strong Management System started name, but in reality. Safety Management System might for the public sound like Management Strategies they should not Pay Attention to, but when it comes to this Management Strategy and it evolves around aviation it is about saving lives. That is why section 102 required manufacturers this expert panel made several recommendation findings about the Safety Culture and about oba, and i want to highlight some. That boeing Safety Management procedures are not thoroughly understood throughout the company. It is focused on only one of the four pillars of the International Standard you have to meet if you were going to have an sms program understood by the workforce writ large. The expert panel raise concerns about the faa of to effectively oversee boeing, and i believe the faa needs not only a strong work or strategy to exercise the oversight of the manufacturers to ensure proper implementation. I would like to query the panel today on exactly what sms the faa should implement in their own house to make sure they are improving Safety Culture and standing up on these important Safety Measures. Right now, we are relying on employee Safety Reporting systems speak up, would you talked about, and i think a comprehensive system that employees has to be a key component of sms, and documentation provided by the get abusive boeing employees show that they may not have understood how safety fit into the culture of the overall obligations of the company. Human factors have been prioritized as a technical discipline, and Human Factors are at the core of the focus both at the faa and boeing. All you talked about the loss of experience and capability of the workforce, we definitely want to build that expertise throughout government clearly at the faa so they can keep pace with technological change, and while the restructuring of boeings unit did decrease the opportunity as to report a thing for retaliation, we still are seeing that interference is occurring. This is unacceptable. It strengthened faa oversight and put them in charge of these employees, and we certainly expect the faa to back up those individual engineers and machinists, not safety and making sure that they can address those. Although the final report gave boeing six months to make this actual plan action plan, the faa administrator cut this time to 90 days, and i expect the company to comply with the deadline and submit a serious plan that demonstrates this commitment to these kinds of Safety Measures. The faa must also demonstrate that it is going to be a strong regulator on these issues. I hope to query the panel about how to ensure that, how we as the Oversight Committee basically strengthen this oversight by the faa, so i look forward to hearing from our witnesses today. Again, thank you so much for being here, and i turned to senator cruz for his opening remark. The United States sets the benchmark for flightsafety, and arguably the most important measure, 2023 was a remarkably safe year for aviation with no fatal accidents or losses for commercial jet aircraft. Flying commercial remains the safest way to travel, but understandably recent incidents have left the flying public worried. The perception is things are getting worse. The public wants the federal Aviation Administration and congress to prevent perceived risks and order to restore confidence for flyers. The faas Organization Designation authorization program. Oda is important to the future of aviation safety, as well as to american competitiveness. I appreciate the work of our congressionally appointed expert panel, which reviewed boeings oda for transport airplanes. Congress establishes panel in the aftermath of tragic crashes in 2018 and 2019. In which 346 people tragically lost their lives. The panels final report was released in february, and three of its members are here with us today. Welcome. As a brief aside, i went to a particular acknowledge that one of our witnesses, dr. Javier de luis, lost her sister on flight 302. Please accept my sincere condolences, and thank you for continuing to speak out on an issue that i know has grieved you and your family personally. I also want to recognize the other families that are here today remembering their loved ones whose lives were lost on those two tragic accidents. Discussing oda and what changes may be needed is critical, and i welcome this conversation. It is worth noting however that the faa is still implementing the aircraft certification safety and accountability act, this committees response to the crashes. It has not even been fully implemented the 2018 authorization act even as we are currently negotiating the current reauthorization. While it is clear that boeings culture and Safety Management needs drastic improvements, we should not rush to l just for the sake of legislating. To that point i look forward to engaging with todays witnesses, all of whom deserve our appreciation and thanks for their hard work on this effort. The report was consensus product issued without any dissenting views, which all of us in congress can appreciate is no small accomplishment, and i hope to better understand their recommendations and how congress can work to improve aviation safety in a targeted and effective manner. While discussing oda head culture is important, the flying public is also acutely worried about why pieces of boeing airplanes are falling from the sky. The Expert Panel Report specifically noted that the panel was not directed to investigate or provide recommendations toward specific airplane incidents or accidents, which occurred prior to or during the expert panels work. In addition to todays hearing i believe we also need to hear from the and from boeingelf about episodes Like Alaska Airlines flight 482. Our committees to understand not only boeings oda, but the specific missteps that cause the january incident, and we need to hear from boeing directly about the companys Safety Culture and Safety Management writ large. The public will want to know what changes boeing is making to restore confidence and its brands. Boeing is a Great American company with a great history and great legacy. We all want boeing to be successful, but when accountability is needed, and it clearly is here, we should not hesitate to demand answers, and for boeing to succeed going forward, those answers need to be given, and changes need to be made to ensure that safety is central. When each of us, when our families, when our children get on an airplane, we want to trust that they are going to land safely. That is the topic of this hearing and i hope subsequent hearings as well. Senator duckworth. Thank you for holding this hearing and your commitment to continued oversight. I also want to think our witnesses and all of those who worked on the expert panel review. This review confirms my view that we need to judge boeing by what it does, not by what it says it is suing. Boeing says it prioritizes safety above all else, but when the expert panel as to boeing to produce evidence, the evidence boeing provided did not provide objective evidence of the foundational commitment to safety that is boeings description of that objective. Weeks after a door plug blue out of the 737 max boeing was still petitioning the fda for a safety exemption to rush its next variant into Service Despite the fact that it had a known potentially catastrophic safety defect. Boeing eventually withdrew the petition, but the fact that boeing filed that in the first way speaks volumes about the lack of a proper Safety Culture at boeing, and until recently the lack of a proper regulatory culture at the faa. Boeing sought this petition because they thought the faa would granted. Knowing that they could minimize the significance of the safety defect and the faa would let it slide. Boeing had a good reason to think this. The faa let boeings actions slide four years, and go figure, we are seeing more better results. I will give two examples which i think are particularly relevant to our discussion today about boeings organization authorization. The first example involves mcas. Actually persuaded the faa to let it remove it from the flight panel, and after mcas crashed two planes, investigators uncovered an internal boeing memo showing boeing admin planning to downplay mcas in order to avoid regulatory scrutiny. The plan called for boeing to not even use the term mcas when describing the plane to a regulator. The memo showed a member approved of this plan to deceive a regulator, and yet when this Member Service surfaced, the faa did nothing. The faa told boeing this conduct was perfectly fine. The second example includes an alert. Shortly after the 737 max went into service boeing discovered it was not functioning on most of the 737 max jets, which was a violation of the approved design. Instead of reporting this to the faa and pilots, going intentionally concealed this and continue to manufacture more 737 max jets with the same defects. In other words boeing made the decision to knowingly and repeatedly violate its approved design for years. Boeings oda knew about this but did not like the faa, and when the faa found out, the faa did nothing. This effectively told boeing that design does not matter, because the faa is not going to always enforce it. When the faa fails to take action in response to a behavior it sends an unmistakable message to both boeing and its employees that better behavior is acceptable. No wonder the panel found that boeing employees are so confused. The faa needs to more closely scrutinize boeings behavior and make use of its authority when appropriate, and i am pleased by the more aggressive tone administrative administrator whitaker has brought to the table. We have our work cut out for us on this committee as we continue our oversight and consider whether additional legislation may be needed, and i think the paddlers were being here. Ppreciate your hard work on this. Thank you, senator duckworth, for your leadership and your help on the reauthorization and safety improvements. Senator moran will not be here for an Opening Statement, so we will now go to the witnesses. You are free to make an Opening Statement. Thank you senator. On behalf of myself and my fellow panelists i want to thank you for the opportunity to come here and talk about our findings and recommendations from the final report. My name is javier de luis. I am an aerospace engineer. I earned a doctorate from m. I. T. And spent my 40 year career in private industry mostly running Small Businesses but i hope to start and then built hardware for nasa, goody and other agencies. I am also the brother of my sister who was killed when the airplane she was on crashed a few minutes after takeoff killing all people on board, so for me serving on this panel has been an opportunity to prevent anyone else from going through what are you in my family have sadly experienced these past five years. Our panel meant for muster year, review documents provided to us by boeing, interviewed 250 boeing employees at all levels of the organization from the executive suite down to the people who tighten the bolts across six geographic lands across the country, and we reviewed thousands of survey responses that came to us through several surveys that were conducted. As has been noted this is a consensus report, and i would be remiss if i did not give full credit to this of our cultures for herding this group to a productive and. Our panel was charged to focus our review on three safety topics, Safety Culture, Management Systems, and the oda program at boeing. We were also allowed to evaluate other topics of concerns that would impact the safety of the flying public. As senator cruz noted, we were not charged with investigating specific airplane incidents that occurred prior to our panel, but as it is understandable on several occasions to activities when safety issues arose with boeing products we consider them. My fellow witnesses and i thought it would be useful to expand on several key recommendations in a report, as this may set the stage for todays hearing. At first and foremost is one that has been talked about recently. There exist a disconnect for lack of a better word between the words that are being said by boeing management, and what is being seen and experienced by employees across the company. They hear safety is our number one priority, but with a c is that is only true as long as your production milestones are met, and at that point it is pushed out the door as fast as you can. They hear or speak up if you see anything that is unsafe, but what they see is that if they do speak up they get very little feedback, and if they insist they may find themselves on the short end of the stick next time raises were bonuses or job transfers, or even worse. We found this disconnect to be present at almost all levels of the worksites that we visited. We heard from tech missions, engineers, and we heard it more concerning for members of oda delegated by the faa to conduct tests. To me it is clear the commitment to change, the level of change, and the pace of change at boeing s not commensurate with the events that created the need for all of this change in the first place, namely the two fatal crashes of two brandnew airplanes five years ago. It was distressing to read a recent statement by the cfo of boeing speaking about the alaska incidents from this past january, where he said for years , and this is a quote, for years we prioritize the movement of the airplane to the factory over getting it done right. That has got to change. The Leadership Team got it in the immediate aftermath of january 5. Now, i wouldve thought they wouldve gotten it five years ago. In closing, for the last 25 years every fa reauthorization act push more responsibility over the fence to the manufacturer side. At the time this was done with the understandable objective of increasing efficiency and productivity. The two crashes showed the pendulum swung too far. It cannot be the High Water Mark in your efforts. I urge you to debate additional steps that could be taken to ensure that you increase faa oversight of billing and that you keep pushing for structural change of the company as well as ensuring that all of our panels 53 recommendations are fully implemented. We believe this is the only way we can return this company to what we all remember it once being, a company known for engineering excellence and accompany the headlines were written about it because of its accomplishments, and not because of its failures. I believe the flying public deserves no less. I will now turn it over to my colleague, dr. Dillinger. Dr. Dillinger, welcome. Whatever Opening Statement you can make. Chair cantwell and distinguish members of the committee, thank you for the opportunity to discuss the report from the expert panel review. I am dr. Tracy dillinger, and i am currently the Senior Executive psychologist received a culture and Human Factors programs within the nasa office of safety and mission assurance. In this position ive created and shared the Safety Culture working group and Human Factors task force, and im responsible for nasas Safety Culture survey, Safety Culture courses, Safety Culture audits and support, Human Factors training, and our annual Human Factors report. I am also a proud veteran of the Un