This Sunday, I was paging through my Twitter feed and saw an article from The New York Times titled: Boeing Built Deadly Assumptions Into 737 Max, Blind to a Late Design Change. Despite the sensationalistic headline, I went to check it out (amazingly, I still do, occasionally, have time to read things besides other travel blogs).
As it turns out, the article is a fascinating look into the history of the 737 MAX and its maligned MCAS computer system. I’ve read many posts on the subject but each one tended to focus on a singular aspect of the plane or the two crashes. This article puts everything into perspective, putting the pieces together.
I took several things away from the NYT’s article which I’ll start talking about here. I’m not going to repost the content of the article, so if you’re going to keep reading this, go to the Times website first. You get five free articles a month. I’ll wait.
I’m no expert on airplanes. My entire reason for not flying a 737 MAX was totally arbitrary. What I know now is that the 737 MAX wasn’t just an improved version of a plane I’ve flown on for years. The design changes were major, necessitating a total rethink of the plane’s systems. Could this have influenced the decisions of everyone involved? You’re dealing with pilots, designers, engineers and regulators who you’d think wouldn’t let the 737’s history influence them, but people are people and there’s always a chance of bias, even if it’s only subconscious.
I also read the article looking at all of the places where a single decision on its own played only a minor part in the story but when the series of seemingly innocuous events reached the conclusion, the results were disastrous.
The interviews have a flavor that those involved are revising history, and I get it. Would I want to think for the rest of my life that a decision I made, even a seemingly innocent and truthful one, resulted in the deaths of 346 people?
Everyone involved claims their input had nothing to do with the end product failure and in hindsight, they blame decisions made after theirs as the ones which caused the problem. The regulators are blaming others for not providing them with full information. Pilots are blaming the engineers for making changes they were unaware of. A corporate decision led to changes being tested in a simulator, not a real plane.
Sure, some people made calls for changes which were more significant and open for critique. There will always be questions if these changes were pushed for by Boeing superiors. I doubt there’s a smoking gun anywhere. My gut tells me, and this is pure conjecture, the story will end showing Boeing putting pressure to reach a goal. Under that stress, some people made decisions they normally wouldn’t have, just to finish the project on time. Those people convinced themselves the changes weren’t major and there were backup systems in place so everything would be fine. At the end of the day, there are pilots flying the plane, not computers and sensors.
In all, if one had to sum up who’s to blame right now, it’s complicated. There was no one person in charge of every decision. Well, I’m sure there was a project manager and there’s always the CEO but they don’t make every decision. Each department had a role in designing the plane. Every test pilot had a chance to make their comments and register concerns. Regulators could have asked for more information instead of taking Boeing’s word on the insignificance of some slight change to a system. Boeing could have tested changes on a real plane instead of a simulation.
What can be done?
When you’re working with anything where an error can prove fatal, it’s not enough just to solve problems. You need to prevent them from happening in the first place.
That’s where you need to do a Root cause analysis.
Root cause analysis (RCA) is a systematic process for identifying “root causes” of problems or events and an approach for responding to them. RCA is based on the basic idea that effective management requires more than merely “putting out fires” for problems that develop, but finding a way to prevent them.
Why was each of these decisions, that led to the eventual crash of two airlines and the death of 346 people, allowed to happen? More importantly, what systems can be put into place to prevent it from happening in the future? I hope these questions are going to take place at Boeing (and other airline manufacturers as well). Regulators need to figure out why they missed the significance of these changes.
As for the airlines, they can’t seem to say enough about how they’re confident in the safety of the 737 MAX. United’s CEO Oscar Munoz has gone as far to say that he’ll be on the first United 737 MAX flight once they’re cleared for flight.
Ethiopian Airlines CEO, understandingly, has a different feeling about the plane.
Speaking at the IATA annual general meeting in Seoul today, Ethiopian chief executive Tewolde Gebremariam told reporters that the African carrier will only restart flights with the type “after the regulators decide and when we see airlines start flying it”, adding: “We will be the last one”.
After reading the article, I’m more concerned than I was before. It wasn’t just a single decision that causes the problem. Instead, it was a series of little changes, each of them minor and seemingly insignificant that led to the flaw in the final product. While it would seem that this would mean the likelihood of anything like this happening again to be almost impossible, what would be the odds for making every bad decision again? Just ask the people who have been struck by lightning, twice, about how odds work. It’s just as likely to happen the second time as it was the first. And it’s already happened.
Here’s hoping that the lives lost on the two aircraft were not in vain and we learn from this event how to make sure something like this never happens again.
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This post first appeared on Your Mileage May Vary