A cascade of false assumptions, mismanagement, rushed deadlines, miscommunication and outright deception led to the failure to catch the design flaws that led to two deadly crashes of Boeing’s now-grounded 737 Max jetliner, finds a congressional report released Wednesday. “Boeing failed in its design and development of the Max, and the Federal Aviation Agency failed in its oversight of Boeing and its certification of the aircraft,” concludes the House Transportation and Infrastructure Committee’s 238-page report on the jetliner.

The report pinpoints multiple times engineers questioned the safety of features that went into the jet, only to have their concerns dismissed as lacking importance or jeopardizing the development timeline or budget, the report finds. Employees charged with keeping the FAA informed about those debates didn’t pass on that information to the agency.

Despite ample opportunities to have realized the plane’s deadly shortcomings, the 737 Max passed muster with both Boeing and the FAA, which labeled it “compliant” in certifying it as safe to go into service with many airlines in the U.S. and abroad. “The problem is it was ‘compliant’ and not safe – and people died,” Rep. Peter DeFazio, D-Ore., the committee’s chairman, said in a brief statement to reporters.

A 737 Max operated by Lion Air plunged into the Java Sea 13 minutes after takeoff in Indonesia in October 2018, taking 189 lives. Five months later, an Ethiopian Airlines jet with 157 passengers and crew augered into the earth six minutes into its flight from Addis Ababa. As similar circumstances in both crashes came to light, the 737 Max has remained grounded worldwide. The FAA and other global aviation safety agencies are reviewing Boeing’s improvements to decide whether to allow it to fly again.

Those improvements focus primarily on software changes in a new system added to the jet and blamed for the crashes. In both the fatal Lion Air and Ethiopian Airlines flights, pilots wrestled with the new computer system, the Maneuvering Characteristics Augmentation System, or MCAS, that wasn’t on previous versions of the 737.

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