Boeing is really having a bad stretch. Or more specifically, the passengers flying in its 737 MAX aircraft are.
Most recently a ‘plug’ flew off the side of Boeing 737 MAX 9 plane in flight, leaving a refrigerator sized hole next to startled (but mercifully still living) passengers. A ‘plug’ is a panel that seals up a hole in the fuselage that is included during manufacture to allow an optional emergency exit to be installed.
This failure is not a good look … especially for a three-month-old plane. Lots of manufacturers of different machines throughout history have been able to successfully bolt panels to cover holes of a similar size to that of an aircraft emergency exit. It is not hard to do. Nor is it hard to have systems in place to make sure it is done right.
And then there are the two earlier crashes of Boeing 737 MAX 8 planes in 2018 and 2019, killing a total of 346 people. A thing called the ‘Maneuvering Characteristics Augmentation System’ or MCAS forced both planes into nosedives that the pilots didn’t know how to stop.
Some observers and commentators have already spoken or written about these issues, and how the loss of the ‘plug’ on the 737 MAX 9 is not technologically related to the MCAS failures on the 737 MAX 8. And perhaps by extension … we shouldn’t be too worried that Boeing is still in the same perilous state that resulted in the deadly crashes several years ago.
I’m not buying it. At least not yet.
Many casual observers who watch news bulletins and read newspapers can probably recall that the ‘MCAS acronym’ was used to describe the bits of the Boeing planes that caused the deadly crashes. Not as many people know why it is even a thing.
The 737 MAX aircraft are the 4th generation of Boeing’s famous 737 line of aircraft. Before any plane is allowed to fly, it must be certified by regulatory organizations like the United States Federal Aviation Administration or FAA. This is time consuming and expensive. If a manufacturer can convince the FAA that a new aircraft is actually a new model of an existing (certified) aircraft, then things are a lot faster and cheaper.
So Boeing fought really hard to convince the FAA that the 737 MAX aircraft were just that. The trouble was that so many changes had been made (like the engines sitting further forward) that it simply didn’t fly the same. Enter MCAS.
MCAS is a software system that was intended to have the 737 MAX aircraft handle in precisely the same way as previous 737 variants. This means that you don’t have to retrain pilots, and importantly, don’t have to go through the whole recertification process.
But Boeing went several steps further. They incited a highly toxic relationship with the FAA. Boeing was able to do a lot of its certification ‘in-house,’ eliminating FAA oversight in some cases. And of course, when defects and problems arose, both Boeing and FAA actively participated in covering up those issues (no doubt because the FAA would be embarrassed at how more widespread knowledge of these defects would highlight their ‘hands off approach’ to certification.) The FAA actually retaliated against internal whistleblowers … which is an odd thing for a regulator to do. And Boeing was also waging war with suppliers by demanding outlandish cuts to the cost of parts. So we had a recipe for disaster.
But this recipe was initially rewarded by shareholders who were impressed by the massive profits of these cheaper aircraft that were somehow being manufactured with little regulatory delay.
Until things went bad.
Boeing has since paid massive fines, incurred lots of lost earnings as airlines cancel orders, and is otherwise still reeling from the disaster that is the 737 MAX story.
But of course, Boeing is adamant that the errors of the past are … in the past.
The huge problem with this is that organizational change is often slow, or impossible. In 1986, the managers within NASA overruled the engineers who were concerned about the seals in the external fuel tank during a very cold space shuttle launch in late January. And these seals failed 79 seconds after the Challenger left the ground, killing the entire crew. Lots of investigation and programs and ‘cultural change’ happened. And then in 2003, managers within NASA overruled the engineers who were concerned about insulating foam striking the space shuttle during launch. And then a foam strike damaged the left wing of the Columbia orbiter vehicle during launch, which then caused death of the entire crew during re-entry.
These failures are technologically unrelated. But the phrase ‘echoes of Challenger’ was carpet bombed throughout the report of the Columbia Accident Investigation Board, where blame for both incidents fell squarely on the culture that NASA could not or would not change within its space shuttle program.
So what about Boeing? There was a phrase that many experienced pilots used to bandy about:
… if it isn’t Boeing, I’m not going …
It’s not being said much anymore. It harkens back to a time where Boeing had built a reputation for quality, reliability, and generally just doing the right thing when it came to producing cutting edge aircraft. NASA never had such a visage, so perhaps Boeing can turn things around.
But it is beyond alarming that the same organization that cut corners and oppressed whistleblowers can’t even secure a ‘plug’ to a plane (several airlines have since discovered that the bolts holding the ‘plugs’ on their planes were indeed loose). This is not rocket science.
A real concern is that the ‘corporate culture’ that is dominated by a board of old white guys in suits whose main claims to fame are that they are professional ‘board members’ would actually take cultural change seriously. It is not only plausible, but demonstrated throughout history that the way ‘corporate people’ respond to ‘strategic shocks’ tends to revolve around the question ‘how little can we do before we are back on track?’ Which means they focus on placating external critics so they can get back to cutting costs and side-stepping regulators and all the other behaviors that got them in that mess in the first place.
Reliability and quality is an ongoing endeavour. Or it isn’t an endeavour at all.
The important message that resonates with me is “where blame for both incidents fell squarely on the culture” of the organization and, ultimately, upper management, be it Boeing or NASA.
What are the priorities – schedule, shareholder value, (short-term) cost management, or quality, reliability and safety? Priorities are not set by the engineers.
Richard Feynman, in his inquiry into the 1986 Challenger explosion, found that upper NASA management thought that the probability of a catastrophic failure of a shuttle was 1 in 100,000. Feynman thought that that was too low – one could launch a shuttle every day for nearly 300 years with only one failure. When he questioned the engineers, the sentiment was the chance of such failure was 1 in 100. You can bullsh*t all you want but you can’t fool nature.
Feynman was particularly scathing during his part of the review into the Challenger disaster … in a good way. He wanted to include his own addendum or appendix to the final report, and threatened to have his name removed from the Commission if this did not happen.
I actually believe that the answers he got from the engineers he classified as being between 1 in 50 to 1 in 100. Either way … physics can not be fooled!
So I fully concur with your sentiment … and thanks for reminding us about the echoes in history!