On April 2nd, Boeing CEO Kelly Ortberg testified before the Senate Commerce, Science, and Transportation Committee. He addressed concerns about Boeing aircraft safety, the company’s safety culture, and the changes needed to restore its reputation.
Unfortunately, as anticipated, the Senators’ questions were largely superficial, lacking the depth required for real accountability. For instance, when asked about defects in Boeing airplanes, Ortberg highlighted the company's efforts to improve safety and quality but failed to address the ongoing engineering and manufacturing defects that still exist within 737 MAX airplanes. Additionally, when questioned about quality control improvements, CEO Ortberg neglected to mention the company’s removal of thousands of quality control inspections on individual aircraft—an action taken without the FAA’s knowledge. When asked about manufacturing related electrical defects contributing to the two MAX airplanes that crashed, Mr. Ortberg indicated he was unaware of such reporting. He also failed to mention that before he took over as Boeing’s CEO, he was President of the company that made the angle of attack sensors and MCAS software that failed in both crashes.
To truly enhance aviation safety, we need our legislators to ask more pointed, in-depth questions. Softball questions will not even begin to solve any of the significant problems at Boeing.
Sadly, March 10th marked the sixth anniversary of the Ethiopian Airlines Flight 302 crash which killed 157 people. Just four months earlier, Lion Air Flight 610, another Boeing 737 MAX airplane, crashed into the Java Sea claiming 189 lives. Following these crashes MAX aircraft were grounded while the investigations were underway, and the aircraft recertification process was undertaken. Despite being hailed as the “most comprehensive in history,” by then FAA Administrator Steve Dickson, the recertification process narrowly focused on MCAS software and pilot training, while ignoring critical issues including manufacturing related electrical system failures. The MAX fleet continues to experience significant problems as outlined by our cover story in this edition of the Aviation Watchdog Report.
Last month, victim families and representatives from The Foundation for Aviation Safety met with Congressional staffers to urge Congress to act. Legislative staff were shocked to learn that Boeing’s 737 MAX airplane still has numerous unresolved engineering and manufacturing defects, all of which were uncovered after the FAA's 20-month recertification process.
Family members highlighted the repetitive cycle that is all too common. An accident occurs with the loss of life that is so traumatic. This is followed by media attention and promises of investigations and corrective actions. With the passage of time comes complacency as the accident becomes old news. Then another tragedy occurs, and it starts all over again. Family members are calling on Congress to support an interagency task force under the DOT to urgently address systemic aviation safety issues. Additionally, they urged Congress to demand NTSB Chair Jennifer Homendy release newly uncovered evidence related to the Ethiopian crash, evidence she is withholding in violation of ICAO standards. Without transparency and a new approach, these recurring problems will never be fixed. In this edition, we cover flying with children, a couple near-misses, and a fatal engine defect that remains unresolved. Thank you for your interest in aviation safety.
After what has been called the “most comprehensive certification in the history of aviation” the 737 MAX design and manufacturing defects continue to pile up. You can reference the updated 737 MAX Design and Manufacturing Problems Table here.
In March and December of 2023, two separate engine bird strike events activated the Load Reduction Device (LRD), which released toxic smoke (heated oil) into the airplane. On March 5, a right engine LRD activation filled the passenger cabin with smoke on Southwest 3923. On December 20, a left engine LRD activation on Southwest 554 filled the flight deck with smoke. Nearly a year after the second event the NTSB finally opened an investigation. The preliminary report states that Boeing is developing a software fix to this design flaw that will immediately close the bleed air system after an LRD activation. Recent information indicates that the software fix won’t be available until 2026, three years after the first event. In the meantime, the flying public is asked to accept the risk, with no mitigation. Sound familiar?
Another critical design flaw involves the Stall Management Yaw Damper (SMYD). In September of 2023, the FAA granted an exemption from lightning and high intensity radiated field (HIRF) requirements. Then, on January 21, 2025, Boeing petitioned for another exemption for the SMYD software. This is particularly concerning since on May 25, 2024, Southwest 746 experienced rudder control damage by what appears to be a yaw damper malfunction (rudder oscillation). This is another open NTSB investigation. The Air Line Pilots Association (ALPA) has joined our Foundation in opposition to this latest exemption request.
The NTSB investigation of the Alaska 1282 door plug blowout is also continuing. Of particular interest is Boeing’s extensive removal of quality control inspections leading up to the blowout. This includes one specific inspection, the “okay to install insulation blanket” that is directly relevant. Had that inspection been conducted it is likely the missing door plug hardware would have been detected.
Continuing on the manufacturing side, we’re tracking an Airworthiness Directive (AD 2024-23-11) for misrouted wire bundles to the fly-by-wire spoilers, which threaten a spoiler hardover and loss of control. In addition, the NTSB has asked for more urgency to correct a “stuck” rudder defect resulting from an incorrectly installed seal in certain rollout guidance actuators. Currently the guidance to aircrew is to “push harder” should the rudder become jammed in flight. Seriously…
We’re also waiting for a Boeing schedule to fix the potential severe engine inlet cowl structural damage due to heating of the engine anti-ice system (AD 2023-15-05).
While the NTSB investigates the current accidents, they also have the responsibility to pass on newly uncovered documents relating to the Ethiopian Airlines 302 crash. During recent meetings in Washington DC, (March 10-14) the Foundation asked for Congressional pressure on the NTSB to meet their responsibilities to share these documents under ICAO Annex 13. The Foundation provided the documents to the NTSB in July 2024, and they have refused to share them with international investigators.
On April 17, 2018, Southwest 1380 experienced a fan-blade-out (FBO) event that tragically led to the death of a passenger, Jennifer Riordan. The fan blade fractured and destroyed the engine cowling resulting in debris puncturing the fuselage. The aircraft was aerodynamically compromised, and we came closer to a crash than most people understand. The full NTSB investigation is available here.
Perhaps even more distressing is that this event had a precursor. Nearly 18 months earlier a similar incident occurred; however, the fuselage was not penetrated, and the aircraft made an emergency landing. After this incident the FAA stated it, “promotes a strong safety culture across the industry” and had acted in “an expedient manner.” Obviously, they did not respond quickly enough to save Jennifer’s life. So, it begs the question, “where are we today with this problem?”
In December the FAA issued a Notice of Proposed Rulemaking (NPRM) that, if adopted, will strengthen the engine inlet and produce a compliant design. However, the final rule has not been issued. Just last month, in March of 2025, the FAA published Airworthiness Directives requiring inspections or maintenance records checks, but not actual modifications to prevent future FBO incidents. Manufacturers are being given until July 2028 to comply in certain cases, nearly 12 years after the first incident and over 10 years after the second. Does this feel "expedient" to you?
Nearly everyone has watched the striking video of Southwest Flight 2504 conduct a go-around to avoid a potential collision with a Flexjet aircraft at Midway Airport on February 25. Some might view this as an isolated incident, but the truth is far more serious. In fact, in fiscal year 2024 there were 1,758 runway incursions. But what exactly is a runway incursion?
The FAA website provides the following information:
What is a Runway Incursion? Any occurrence at an aerodrome involving the incorrect presence of an aircraft, vehicle or person on the protected area of a surface designated for the landing and take off of aircraft.
What is a Surface Incident? A surface incident is an unauthorized or unapproved movement within the designated movement area (excluding runway incursions) or an occurrence in that same area associated with the operation of an aircraft that affects or could affect the safety of flight.
There are four categories of runway incursions:
Category A is a serious incident in which a collision was narrowly avoided.
Category B is an incident in which separation decreases and there is a significant potential for collision, which may result in a time critical corrective/evasive response to avoid a collision.
Category C is an incident characterized by ample time and/or distance to avoid a collision.
Category D is an incident that meets the definition of runway incursion such as incorrect presence of a single vehicle/person/aircraft on the protected area of a surface designated for the landing and take-off of aircraft but with no immediate safety consequences.
While an analysis of the thousands of incursions might reveal many of them are of the Category D variety, they still represent significant warning signs. Nearly all aviation accidents (as defined by the FAA) have been preceded by “close calls” or “near misses.” Simply ignoring them because no injuries or deaths occurred is irresponsible. In fact, that complacency will inevitably lead to an accident that was not only foreseeable but preventable had appropriate action been taken. There’s an old saying in the safety world that continually rings true: “There are no accidents, just predictable outcomes.”
Although the DCA midair collision in January was not strictly the result of a runway incursion it was certainly the result of ignoring the warning signs related to inadequate aircraft separation. Unbelievably, the last major airport in the U.S. opened in 1995. We are constantly trying to fit more aircraft into the same airspace each day. The question is now being asked more frequently, “is it safe to fly?” Statistically it is safe, but it can always be safer. There are at least 1,758 reasons to make it safer right now! Saying it is safe doesn’t help make it better nor offer any comfort to those hesitant to fly or to those who have lost loved ones to a tragic accident.
A safe airspace system is reliant upon all organizations to do their jobs with attention to detail and unwavering dedication to proper procedures, policies, clear communication, and appropriate accountability. The Foundation calls on the FAA, all part 91, 135, and 121 carriers and operators, and all aviators to take more aggressive action to prevent this unacceptable number of incursions. The system is stressed and rides upon a razor’s edge each day. We must be better than this.
After departing Colorado Springs (COS) on March 13, 2025, an American Airlines Boeing 737-800 experienced high vibration in the right engine. The aircrew reduced thrust on that engine and diverted to Denver International Airport (DIA) where they made an uneventful landing.
Shortly after the airplane parked at the gate a flammable fluid pool fire occurred under the right engine near the fuselage. Passengers appear to have evacuated the airplane through the jetway and the right aft exit door that is equipped with a slide. Images from the accident showed passengers also exited through the left overwing exit. However, the flaps had been retracted and many passengers were unable to safely reach the ground since the 737 overwing exits do not have evacuation slides. Procedure dictates that extended flaps be used as a slide surface. Passengers were left standing on the wing, a fuel tank itself, until ground personnel were able to bring portable access ladders to the aircraft.
Fortunately, the DIA Fire Department was quick to respond to the fire and there were only 12 minor injuries. Large flammable fluid fed pool fires under the wing and fuselage are a serious safety hazard. In 2007 there was a similar incident involving a 737-800 that resulted in a fuel tank explosion. In that case the ground fire also occurred near the engine and fuselage post-taxi. Evacuation of the airplane was conducted through the doors with slides. All passengers and flight crew departed the airplane; however, immediately following evacuation the center fuel tank exploded. Details of this accident and a video showing the evacuation and fuel tank explosion are available on the FAA Lessons Learned site.
The NTSB is investigating the Denver fire, but as we wait for the preliminary report there are certainly a lot more questions than answers.
What caused the flammable liquid leak? Was it related to the vibration?
Did the crew shutdown the engine either inflight or while taxiing?
When did the fire become evident? Did the crew get a fire warning or were all engine systems shutdown?
Who initiated the evacuation? Flight attendants? Flight Crew? Or did the passengers themselves start opening over wing hatches?
Why was the only slide deployed on the same side as the fire?
The media is quick to move on after this incident, but the answers to the questions offered here are vital to the success of aviation safety. Leaving passengers stranded on a wing while a 737-800 burns at the gate is unacceptable. Only through the actions of the DIA Fire Department can we deem this incident any form of success. The Foundation looks forward to seeing the preliminary investigation and following up on any recommendations made.
According to media reporting, the passengers injured during the Delta 4819 Toronto crash included at least one infant. This reminds us how vulnerable our children are during traumatic events such as this. Even a moment of turbulence in flight can result in severe injuries for children, or even adults who are not secured. This is especially true if those children are infants or toddlers. A study by Pediatric Emergency Care found there were 400 children injured in a five-year period (2009-2013) while flying on commercial airlines with infants representing nearly 36% of those injuries.
Children under two years of age are allowed to sit on an adult’s lap while traveling; they are commonly called “lap children.” Although allowed by FAA regulation, it may not be the safest option nor the easiest to execute. Think tired, hungry, and frustrated baby on your lap.
There are some restrictions when flying with a lap child. You are limited to one lap child per adult. If one adult is flying with two children, then a seat must be purchased for at least one child. There is also a limit of two lap children per row as there are limited oxygen masks available to each row. Airlines also impose age restrictions including a minimum age (typically 7 or 14 days old) and a maximum of two years old. Check with your airline and be prepared to offer written proof of age. Lastly, if you’re flying a foreign carrier check their policies carefully as they may differ from the FAA’s.
As you prioritize the child’s safety related to airline flying consider your options for child restraint systems (CRS), lap children securement, and additional systems for children in their own airplane seat.
Strapping our young children into a car seat on the way to the airport is a legal requirement, but also the best way to protect them in the event of a collision. This is not required when flying with your children although the same logic applies. Although car seats are specifically designed for use in automobiles, most are also approved for use in aircraft. Flight attendants are generally not allowed to assist passengers with securing car seats so be prepared to do it yourself.
According to the Flying with Children FAA website:
“The FAA strongly urges you to secure your child in an approved CRS or other approved device for the entirety of your flight. Buying a ticket for your child is the only way to guarantee that you will be able to use a CRS.
A CRS must be certified for use in aircraft. Confirm your child’s seat has “This restraint is certified for use in motor vehicles and aircraft” printed on it or it is approved by a foreign government and bears the required label or marking.”
Keep in mind there may be device or seating restrictions when flying with young children. First, the Code of Federal Regulations (CFR) prohibit anyone under the age of 15 to occupy an exit row, so that’s a non-starter for infants and toddlers. They must be placed in the window or middle seat so as not to impede emergency evacuation. Also, always check with your airline regarding seat dimensions. Seat width varies by aircraft model so be sure your CRS will fit before you purchase a ticket. Note that some car seats require a seat belt with a shoulder harness to be secured properly. These cannot be used in an airline seat that is fitted with only a lap belt.
Regulations do not allow children to be secured to an adult while in their lap. However, there is an FAA approved device that secures the child to the adult’s lap belt. The Baby B’Air Flight Vest* is such a device. It keeps a child under two years old on the adult’s lap during flight but still allows freedom of movement. The vest is available in infant and toddler sizes based on the child’s head circumference. A sizing guide and FAQ’s can be found here. Baby B’Air is approved only for in-flight use- not for taxi, takeoff, or landing. It has been tested to 17g’s and is specifically designed for aircraft use.
Another option for children over 12 months old and between 22-44 lbs. is the Child Aviation Restraint System (CARES).* This device secures a child who is old enough to sit in their own airplane seat by using a harness system that attaches to the seat back. This device is FAA approved for all phases of flight. Attaching it to the seat requires some cooperation from anyone sitting in the row behind the child as the seat tray will likely have to be lowered for the CARES attachment and then raised again.
Standard car “booster seats” such as those with no back support are not allowed for use on commercial aircraft. Additionally, any other vests or securement devices that do not have the required FAA approval label are prohibited. There are many counterfeit devices out there, often at lower prices, so buyer beware. Always check with your airline prior to planning your flight. All airlines have information and FAQ’s about flying with children on their websites along with customer service contact information.
Keeping children safe is the priority. Options are available so be ready to protect your young ones before you step aboard the airplane. Aviation poses many hazardous situations on a daily basis- thunderstorms, wind gusts, and clear air turbulence to name a few that could be dangerous for your child if not properly protected. As always, follow all safety rules and instructions from flight attendants. Know where the closest exit is and what you are going to do in case an evacuation is required.
*The Foundation for Aviation Safety does not endorse any specific products.
Everyone at The Foundation for Aviation Safety thanks you for reading this edition of the Aviation Watchdog Report. We monitor this fast-moving industry daily and strive to bring you the latest information pertinent to all those who fly across the globe.
We receive input from a multitude of sources including our readers. Please let us know if your airplane experienced a safety related incident or if you have other aviation safety related information that you would like to share. Submit a Safety Report anytime.