Understanding the Boeing Mess

"Opportunism is obviously at work in the many explanations of Boeing's safety lapses circulated in the media and social media: Boeing was too preoccupied with diversity goals (says Elon Musk), it was too focused on reducing the clout of organized labor (say supporters of organized labor), it was too focused on shareholder profit (goes the press's reflexive narrative).

That Boeing cared too much about A and not enough about B has a tautological appeal especially if you think shareholder returns and safety are inversely related (ask a shareholder if they are inversely related). Along the way, an interesting story is missed.

The two crashes of Boeing's then-new 737 MAX signally departed from a global trend toward increased air safety. As the media never grokked, they were also two different crashes, the second coming four months after the first, and after Boeing and the FAA issued emergency directives instructing pilots how to compensate for Boeing's poorly designed flight control software.

The story should have ended after the first crash except the second set of pilots behaved in unexpected, unpredictable ways, flying a flyable Ethiopian Airlines jet into the ground.

Boeing is guilty of designing a fallible system and placing an undue burden on pilots. The evidence strongly suggests, however, that the Ethiopian crew was never required to master the simple remedy despite the global furor occasioned by the first crash. To boot, they committed an additional error by overspeeding the aircraft in defiance of aural, visual and stick-shaker warnings against doing so.

It got almost no coverage, but on the same day the Ethiopian government issued its final findings on the accident in late 2022, the U.S. National Transportation Safety Board, in what it called an "unusual step," issued its own "comment" rebuking the Ethiopian report for "inaccurate" statements, for ignoring the crew's role, for ignoring how readily the accident should have been avoided.

In the U.S. media, alas, "profits over people" was the story line before the first reporter opened his notebook.

Chronology became causation, with every clip from the Boeing clip file laid end-to-end as if they all pointed directly to the MAX crashes.

In reality, the global industry was reorganized largely along competitive profit-and-loss lines after the 1970s, and yet this coincided with enormous increases in safety, notwithstanding the sausage factory elements occasionally on display (witness the little-reported parking of hundreds of Airbus planes over a faulty new engine).

The point here isn't blame but to note that 100,000 repetitions likely wouldn't reproduce the flukish second MAX crash and everything that followed from it.

Rather than surfacing Boeing's deeply hidden problems, it seems the second crash gave birth to them. The subsequent 20-month grounding and production shutdown, combined with Covid, cost Boeing thousands of skilled workers. The pressure of its duopoly competition with Airbus plus customers clamoring for their backordered planes made management unwisely desperate to restart production.

January's nonfatal door-plug blowout of an Alaska Airlines 737 appears to have been a one-off when Boeing workers failed to reinstall the plug properly after removing it to fix faulty fuselage rivets. Not a one-off, apparently, are faulty rivets as Boeing has strained to hire new staff and resume production of half-finished planes.

Boeing will sort out its troubles eventually by applying the oldest of manufacturing insights: Training, repetition, standardization and careful documentation are the way to error-free complex manufacturing.

The problem of automation vs. pilots, covered here since 2005, will be with us a lot longer.

Accident investigators already know what they're doing. News reporters are the ones who might try searching for explanations rather than crowd-sourced narrative hooks. Brian Klaas of University College London, in a new book, examines the role of nonsystematic or wild-card factors in incidents with far-reaching consequences. The second MAX crash caught Boeing up in a disorienting global media and political storm that it didn't know how to handle and, indeed, has handled fairly badly.

Worth a revisit too is Charles Perrow's 1984 "Normal Accidents," about system complexity and unforeseen interactions. In my view, still inadequately explained is how Boeing came to amp up the effects of its MCAS software in the final days before certification without recognizing the dangerous potential introduced by the failure of a single input during the busy moments after takeoff.

All this might have the added benefit of being interesting to the reader. The market opportunity would seem to be great for brand-name news outlets to provide carefully vetted facts and reasoning amid our information chaos. But first they have to stop being part of the chaos." [1]

Firing skilled workers during a crisis and hiring untrained ones after a crisis saves American business a little money, but does not add security, reliability, and reputation. In this case, the European order, where people are not so easily dismissed, proved to be better.

1. Understanding the Boeing Mess. Jenkins, Holman W; Jr.  Wall Street Journal, Eastern edition; New York, N.Y.. 20 Mar 2024: A.15.