ML21165A186
| ML21165A186 | |
| Person / Time | |
|---|---|
| Issue date: | 06/14/2021 |
| From: | Ismael Garcia, David Rahn, Michael Waters NRC/NRR/DEX/EICB, NRC/NRR/DEX/ELTB, Office of Nuclear Security and Incident Response |
| To: | |
| Michael Waters 301-415-4039 | |
| References | |
| Download: ML21165A186 (12) | |
Text
Breaking Through to Deployment PRELIMINARY INSIGHTS ON DIGITAL INSTRUMENTATION AND CONTROL REGULATORY LESSONS FROM THE BOEING 737 MAX 8 CRASH EVENTS Michael Waters, David Rahn, and Ismael Garcia U.S. Nuclear Regulatory Commission Washington, D.C. 20555 michael.waters@nrc.gov; david.rahn@nrc.gov; ismael.garcia@nrc.gov
Outline
- Introduction
- Boeing 737 MCAS Development & Certification
- Lion Air Crash
- Evaluation of Key Regulatory and Technical Themes
- Preliminary Regulatory Insights for NRC
- Closing Remarks/Take-Aways This presentation is not intended to represent formal NRC policy. The information and views presented are those of the authors and do not necessary represent formal positions of the NRC.
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Introduction 3
Boeing 737 MAX Design Source: U.S. Department of Transportation Office of Inspector General Report - Weaknesses in FAAs Certification and Delegation Processes Hindered Its Oversight of the 737 MAX 8, https://www.oig.dot.gov/sites/default/files/FAA%20Certification%20of%20737%20MAX%20Boeing%20II%20Final%20Report%5E2-23-2021.pdf 4
MCAS Design and Implementation Source: U.S. Department of Transportation Office of Inspector General Report - Weaknesses in FAAs Certification and Delegation Processes Hindered Its Oversight of the 737 MAX 8, https://www.oig.dot.gov/sites/default/files/FAA%20Certification%20of%20737%20MAX%20Boeing%20II%20Final%20Report%5E2-23-2021.pdf 5
Lion Air 610 Crash Event Source: Final KNKT.18.10.35.04 Aircraft Accident Investigation Report, http://docs.house.gov/meetings/PW/PW00/20191030/110066/HHRG-116-PW00-20191030-SD002.pdf 6
Evaluation of Key Technical and Regulatory Issues Design and Implementation Themes Design Specifications and Safety Assessment including Equipment Design and Defense-In-Depth Hazard Analysis and Risk Implementation Operational Specifications Performance Monitoring Production and Certification Regulatory Oversight Themes Certification and Licensing Amended Certification Regulating Technical Standards Processes Innovation Coordination Among Delegation of Certification Personnel Capabilities of the Regulatory Standards and and Post-Certification Design Regulator Certification Bodies Change Processes Safety Culture 7
Sample Preliminary Technical Insights
- A robust defense-in-depth approach is an effective engineering means to account for uncertainties in digital equipment and human performance.
- Systematic engineering lifecycle approaches from design to operation, maintenance, and human factors is important for ensuring that an I&C design achieves it intended safety function.
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Sample Preliminary Regulatory Insights
- A strong safety culture at NRC remains paramount.
- NRC should maintain integration and communication among digital design and human factors experts during the licensing review and subsequent inspection oversight processes.
- NRC organizational staffing activities should address knowledge management and long-term attrition of expert Agency staff in the digital arena.
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Closing Remarks
- The 737MAX has been returned to service with changes to MCAS and pilot training.
- NRCs preliminary review has validated many of our regulatory approaches and processes; and identified potential opportunities for enhancement.
- Contributors: Sergiu Basturescu, Eric Benner, Norbert Carte, Dave Desaulniers, Ismael Garcia, Brian Green, Jeanne Johnston, David Rahn, Dinesh Taneja, Michael Waters 10
11 737MAX Crash Reports
- Official Report of the Special Committee to Review the Federal Aviation Administration's Aircraft Certification Process
- Joint Authorities Technical Review - Observations, Findings, and Recommendations
- National Transportation Safety Board Report - Assumptions Used in the Safety Assessment Process and the Effects of Multiple Alerts and Indications on Pilot Performance
- Final KNKT.18.10.35.04 Aircraft Accident Investigation Report
- U.S. Department of Transportation Office of Inspector General Report - Weaknesses in FAAs Certification and Delegation Processes Hindered Its Oversight of the 737 MAX 8
- Department of Transportation Office of Inspector General - Timeline of Activities Leading to the Certification of the Boeing 737 MAX 8 Aircraft and Actions Taken After the October 2018 Lion Air Accident
- The House Committee on Transportation & Infrastructure Final Report on the Design, Development &
Certification of the Boeing 737 Max
- U.S. Senate Committee on Commerce, Science, & Transportation Investigation Report on Aviation Safety Oversight 12