Chris Moore and Paul Njoroge, who lost family in the Ethiopian Airlines crash, hold a sign outside a Federal Aviation Administration briefing in Montreal, Sept. 23, 2019.ALLISON MARTELL/Reuters
More than 20 months after their family members were killed in a Boeing 737 crash in Ethiopia, Chris Moore and Paul Njoroge were permitted to speak at federal hearings examining Transport Canada’s approval and oversight of the plane.
However, before their testimony to the House of Commons transport committee was to begin on Nov. 24, the families gave a written statement of their intended testimony to the committee but were told to cut their statements in half, reducing them to five minutes from 10 minutes, forcing them to omit key details.
The Globe and Mail recently obtained the full versions of their intended testimony and is publishing their original statements in their entirety, below:
Testimony of Paul Njoroge, whose three children, wife and mother-in-law died in the 737 Max disaster of March, 2019:
Thank you, chairman and members of the Standing Committee on Transport, Infrastructure and Communities. My name is Paul Njoroge. I am the husband of Carolyne Karanja, father of Ryan Njuguna, Kellie Pauls and Rubi Pauls, and son-in-law of Anne Karanja, who all died in the crash of Ethiopian Airlines Flight 302 on March 10, 2019.
On that day, a Boeing 737 MAX plane dove to the ground at a speed close to the speed of sound. The impact created a crater about 27 metres wide, 37 metres long, and wreckage was driven up to nine metres deep into the soil. Nothing was left of my family, my mum-in-law and the other 152 passengers and crew.
The tragic death of my family left me in a chasm of solitude, desolation, and pain. It changed the lives of my and my wife’s extended families, acquaintances, and communities. Young children at St. Joseph Elementary School in Hamilton, Ont., and friends of Ryan and Kellie developed fear of flying.
I am here today because I believe that the crash that killed my family was preventable. Aviation regulators across the world were not diligent enough in their dispensing of regulatory authority over the certification and validation of the 737 Max plane. Certainly, Canada would not have lost its 18 citizens and an unknown number of Canadian permanent residents had Transport Canada made prudent decisions after the crash of Lion Air Flight 610.
When I bought the flight tickets for my family, I was completely uninformed of the clutter behind the processes of designing, certification, manufacturing, and validation of airplanes. And my wife would not have thought that strapping herself and our children into the plane seats was a death sentence without warning. I have thought about their last six minutes every day of my life. I still have nightmares about how my wife must have felt helpless seeing the fear in our children’s eyes, knowing that they were about to die.
Since the crash of ET 302, the world has learnt that Boeing is more concerned on profit-maximization and stock pumping than on production of safe planes. The FAA has become a cheerleader of the industry instead of focusing on regulatory oversight over Boeing. And regulatory authorities in other parts of world have been sucked into rubber stamping this Boeing-FAA’s clutter. And this is how Transport Canada ended up validating an unsafe plane.
Boeing installed MCAS in the 737 Max planes; a system meant to push the airplane’s nose down in certain circumstances. MCAS activated on input from a single angle-of-attack (AOA) sensor. The expectation was that pilots would be able to mitigate potential malfunctions of MCAS. But these same pilots did not know of the existence of MCAS before the first crash. Boeing concealed this information from agencies and pilots.
Over the last 20 months, a lot has been documented about what affected the design, manufacturing, and certification of the 737 Max. A lot more on the FAA’s and Boeing’s acts, omissions and errors that culminated to these tragedies. My testimony today will not delve into these technicalities. I have provided links to relevant reports in the footnotes of this written testimony.
What is disturbing is that agencies across the world became aware of Boeing and the FAA’s shenanigans after the first crash, but still allowed the plane to continue flying. TCCA (the Transport Canada Civil Aviation directorate) allowed the plane to continue transporting Canadians across the globe. The directorate issued a five-steps memory aid for pilots a few days after the first 737 Max crash. However, in December, 2018, the FAA’s transport airplane risk assessment methodology (TARAM) report predicted that 15 more 737 Max crashes would occur within the lifetime of the airplane. Wasn’t that a concern enough for the Minister of Transport to consider grounding the plane and do an extensive review of the functionality of the 737 Max system? Eighteen Canadians and an unknown number of Canadian permanent residents lost their lives in the second crash because of this oversight.
In the Nov. 18, 2016, Transport Canada flight test debrief note made public in March of this year, TCCA received complaints from Canada’s 737 Max test pilots. The test pilots posed questions about the 737 Max’s automated anti-stall system. It is not known whether these questions were answered at that time. But going by the already documented Boeing’s culture of concealment and secrecy of information, I believe that these questions were not answered. Therefore, TCCA violated their own internal procedures and negligently validated the 737 Max. I call upon TCCA to rebut my reasoning by providing this committee with all communication between them, the FAA and Boeing during that time.
In a March sitting of this committee, Mr. Doherty, the MP for Cariboo-Prince George, sought to understand why TCCA approved the 737 Max plane before test pilots’ concerns were addressed. As a response, Transport Minister Mr. Garneau accused him of not understanding the “complexity of the situation.” He went on to say that it was “very, very clear” that Mr. Doherty did not have any understanding of the process of certifying an airplane.
Mr. Doherty referred to the Transport Canada Concern Paper of Nov. 22, 2018. Just a few days after the first crash. Here is an excerpt from the paper.
The excerpt shows TCCA was concerned that a 737 Max malfunction could cause an inadvertent nose-down pitch command from the stall identification system – MCAS, which was considered catastrophic. That is exactly what happened in both crashes. Throughout the process of certifying and validating the Boeing 737 Max plane, concerns were raised time and time again, yet TCCA continued to allow the plane to transport unsuspecting Canadians across the globe.
On March 11, 2019, a day after the crash of Ethiopian Airlines Flight 302, the Transport Minister appeared on TV and stressed his confidence in the 737 Max, saying that he would board the plane “without hesitation.” Mr. Garneau only spoke in public after a statement from the Air Canada Pilots Association that called on the minister “to take proactive action to ensure the safety of the Canadian travelling public.” Mr. Garneau’s remarks portray excessive hubris analogous to the behaviour exhibited by many within the FAA and Boeing pre and post the 737 Max crashes.
It took Canada four days before grounding the 737 Max planes, leaving Canadians exposed to imminent death in those flying coffins. Why? Given all the documented concerns dating back to 2016? I may not fully understand the bilateral agreement between Canada and the U.S. with respect to aircraft validation, but I am inclined to think that TCCA depended too much on what was decided and documented by the FAA and Boeing. TCCA acted like a mere “rubber-stamping authority” in the validation of the 737 Max planes.
Some Canadian families of ET 302 have wondered if Canadian authorities were so eager to maintain their cozy relationship with the U.S. that they left Canadians at risk of death. Did they seek not to inconvenience the industry at the expense of Canadian lives?
The Prime Minister’s only response to the crash of Flight ET 302 was a tweet of his “thoughts” being with the victims and their families. But when Ukraine Airlines Flight 752 crashed in January of this year, the PM humanely appeared extensively in the media and condemned the Iranian government for shooting down the plane. Why the indifference towards the crash of ET 302? Why didn’t the PM demand accountability and a thorough investigation of the 737 Max planes? Could it be that he was already aware of the 737 Max issues but left uninformed Canadians, like me, to put their families in those flying coffins?
The FAA announced the ungrounding of the 737 Max last week. I believe that the plane is still unsafe to fly. The inherent aerodynamic structural flaws were completely ignored by Boeing and the FAA. The plane is still unstable. If a stall is erroneously detected for whatever reason, for example, because of failure of AOA sensors, MCAS would activate and then shut off to avoid repeated activations that occurred in both crashes. Pilots would be left to regain control of the aircraft using manual trim stabilizer system. Pilots are therefore the redundancy expected to turn the manual trim wheel. In the case of Flight ET 302, this proved to be difficult in scenarios where the aircraft is nose diving at high speed. In addition, the 737 Max is still installed with an older flight-crew-alert system which produces a cacophony of different alerts which can confuse pilots.
This happened in the case of Flight ET 302. The FAA and Boeing sought to avoid the cost of installing a modern flight-crew-system that prioritizes problems without a cacophony.
Boeing and the FAA have been steadfast in their concealment of vital 737 Max information. There has been no disclosure of the assumptions used to avoid grounding the plane in the period between the two crashes. And still no disclosure of the data and information relied upon in their ungrounding decision.
The 737 Max design, certification and validation story is a convoluted web of lies, greed, deceit, and concealment of information. TCCA has assured Canadians that the 737 Max will not fly in Canada until their independent validation process is completed. This validation process needs to be redefined as it failed to consider the 2016 and 2018 concerns of the Canadian test pilots. Improvement of this process should start with an independent inquiry into the decision-making process by the Transport Minister and TCCA, pre and post the 737 Max crashes. Canadians deserve a competent and transparent process.
Thank you for allowing me to speak today.
Testimony of Chris Moore, whose 24-year-old daughter, Danielle, died in the 737 Max disaster of March, 2019:
Mr. Chair and other members of this committee, we are here today to call for an independent inquiry into Transport Canada’s validation of the Boeing 737 Max. We know an inquiry will improve Canada’s validation process of aviation products certified by other countries. Because our government didn’t fully understand what they were validating, Transport Canada was essentially rubber-stamping a doomed Max plane. Eighteen Canadians perished and our government shrugged. The minister should have grounded the Max after the first crash; it would have triggered other countries and agencies to take notice and follow suit, saving hundreds of lives.
I want to begin this testimony by stating that I am speaking on behalf of the family of Danielle Moore, my daughter, whose life was snuffed out after flight ET 302 crashed into a farmer’s field in Ethiopia. She was on her way to the United Nations Environmental Assembly representing Canada through a federal government youth program. Her loss will always remain a devastating shock to her family and friends. Her death has left a gaping hole in Canada’s sustainability communities.
Danielle lived her life full of hope and believed in creating great change for a more just and environmentally sustainable planet. In her 24 years, she touched the lives of countless people across Canada and around the world. She was a courageous leader, champion for justice, and environmental activist always keen to carry the hard work of sustainability forward. Although she accomplished so much in her life, there was so much more left to give – a future full of hopes and dreams that could fill several lifespans. Because there is so much more to say about Danielle, I’ve provided a short biography for you to read. As you take the time to read about Danielle’s life, please reflect on the scale and magnitude of this tragedy. My daughter was one of 346 incredible people who lost their lives because of political expediency, broken government regulations, and criminal negligence.
We strongly believe that an independent inquiry should investigate the events in Canada leading to the grounding of this deadly plane, especially actions taken or neglected by Transport Canada. Only then can this committee make well-informed changes to restore Canada’s leadership in aviation safety. I have provided an updated document that outlines the fundamental questions that the inquiry must uncover. It is based on a list of questions presented to the minister and Transport Canada which has gone unanswered for almost a year.
Improve Canada’s Validation Process:
During the certification of the Max, Transport Canada’s role was to validate the product against Canadian Aviation Regulations to ensure its airworthiness. According to the Oxford dictionary, “Validation” is defined as “the act of stating officially that something is useful and of an acceptable standard.” “Airworthy,” as defined by the Canadian Aviation Regulations, means “in a fit and safe state for flight and in conformity with its type design.” Validation is akin to peer review of the product. It is obvious that this plane was neither fit, nor safe to be flown; the protracted period of its grounding underlines this fact.
On Oct. 29, 2018, Flight JT 610 crashed into the Java Sea. An errant activation of the stabilizers through MCAS and pilot overload exacerbated by the omission of adequate pilot training and awareness of this system were the primary causes. The system safety analysis neglected to categorize the changes to the flight control automation software as catastrophic. Because of this significant blunder, only a streamlined review during validation was performed by the overseeing agencies. Shame on the FAA. These facts were apparent even to the general public within one month after the first crash. Why didn’t Transport Canada rescind their validation and ground the plane? Consider this scenario: If there was a qualification to the flight controls plan for the Max stating, “the hazard category may be catastrophic – Boeing is working on a fix,” would Transport Canada validate the plane? I think the answer is “No”- because it would not be airworthy. Shame on Transport Canada! We need to know why Canada issued only a memory aid when they didn’t even understand what they validated.
Consider too, as we learned at the previous committee meeting, that Transport Canada sent a concern letter to the FAA prior to validation about the specifics of the anti-stall system or MCAS. The FAA never responded until one month after the first crash. Again, this crash should have been fresh in the minds of any engineer working on the review of the Max. The Transport Canada engineers who reviewed the MCAS need to provide testimony regarding the communications surrounding this letter. Transport Canada was concerned about MCAS before 189 people died and your response was just to do a more thorough review in subsequent validations?
The appropriate recommendation would be to ground the Max based on the omission of documentation from FAA coupled with a catastrophic event; certification should have been deemed null and void. There was no redundancy or fail-safe mechanism for a critical system that resulted in the deaths of our loved ones. Why was it allowed to stay in the air? Did any engineer recommend grounding the plane? Did Canadian and American authorities feel superior in their knowledge and downplay these crashes because they occurred in a developing country? Would Canada have grounded the Max if the crash happened in Canada?
There was enough data, information and evidence to ground the plane after the first Max crash. In fact, after the airworthiness directive was issued following the first crash, the FAA performed an analysis which concluded that, if left uncorrected, the MCAS design flaw in the 737 Max could result in as many as 15 future fatal crashes or 3,000 deaths over the life of the fleet.
Transport Canada cannot, in good conscience, defend their inaction by saying that they might have grounded the plane “in hindsight.” Boeing and the aviation agencies had six years to get it right. However, flight crews only had four seconds to diagnose the problem and to take action.
Furthermore, the minister’s issuance of a memory aid to Canadian operators did not make the Max any airworthier. He followed the FAA in lockstep but modified it to a memory aid for simplicity; he knew the crew needed more time to react. This memory-aid sounds clever but was insufficient since there was still an inherent catastrophic design flaw with the Max. Since the minister prides himself on making decisions based on facts and data, we demand to see the risk analysis he used to support his issuance of a memory aid in lieu of grounding the plane in Canada.
Blind Faith:
Canada and the U.S. are dependent upon each other when it comes to validation due to their bilateral harmonization agreements. In this case, the IPA agreement authorizes Transport Canada to accept the information provided to them by the FAA as true. In conformance with this agreement, plans with minimal risk such as the one that concealed the true risk of MCAS, do not need much scrutiny. Is this Transport Canada’s defence for overlooking the MCAS? The validation of the plane was neither complete nor independent. Note: This doesn’t excuse the minister from allowing the plane to fly after the first crash.
Like the appointment of the FAA administrator, the appointment of the Minister of Transport in Canada is political. Safety directives should be recommended and implemented by those who know the technical information best, not for political optics. Safety should be apolitical. Was there any discussion whatsoever within Transport Canada regarding the grounding of the Max? We need to understand this to ensure that Transport Canada’s process of safeguarding travelers conforms with their mission statement. It is still unclear if safety is the top priority for Transport Canada.
The minister has stated that he doesn’t take action until all the facts are available. But he did not even follow his own logic after the first crash because he did not fully understand what his own department validated; the validation was premature. His evasion of facts and complicity with the U.S. is further evident after the second crash. Two days after 18 Canadians were killed on this plane, the minister doubled down on his position by stating that he would board a Boeing 737 “without hesitation.” This was one day after he said that he “doesn’t want to make any premature decisions.” His actions do not match his words … they match the United States aviation industry’s objectives. Let the record show that Canada was the last non-state-of-design country to ground the Max. Canada cannot call itself a leader in aviation safety.
No Third Crash:
In addition to safety hazards carried over from the previous derivative, built into this plane is an inherent aerodynamic eccentricity that can lead to an emergency. The Max will never be safe until the engines are repositioned. Sadly, Canadian flyers will have no choice but to fly upon the Max if they make their travel arrangement with an operator that has a Max in their fleet. Let’s remind ourselves that the [Joint Authorities Technical Review] JATR Report stated that certification of this plane was rushed. How can the agency be sure that the other changes were not errantly certified as well? Three variants, three operational requirements equate to more confusion. Pilots will essentially need an airworthiness directive in order to fly this plane.
Ultimately, we demand the same transparency and accountability that the minister and the Prime Minister demanded of the Iranian government after Flight 752 was shot down. Canadians demand that safety is not compromised by industry making a quick buck or errant safety assurances from another country. Canada can make the certification process safer by making our validation process safer.
On behalf of my daughter Danielle and the concerned flying public, we demand that the actions taken by Canada’s Transport Minister and civil aviation agency be examined as it pertains to validation and continuous operational safety of the Boeing 737 Max. Only a thorough independent inquiry can achieve this. Thank you, and I look forward to your questions.
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