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Boeing concealed faulty design flaws in the 737 Max

The catastrophic consequences of profit considerations over safety.
Faulty governance. Among other things, Boeing hid the fact that one of its own test pilots found the interference of the flawed software to be ‘catastrophic’. Image: David Ryder, Bloomberg

The United States Congressional House Committee on Transportation and Infrastructure has released its final report on the two accidents involving Boeing 737 Max aircraft (Lion Air flight 610 in October 2018, and Ethiopian Airlines flight 302 in March 2019) that killed 346 people and led to the grounding of the aircraft worldwide.

The committee launched the investigation to ensure accountability, transparency and public safety. It is to be noted that further manufacturing defects have been identified, and the 737 Max remains grounded. The investigation took 18 months, concluding that Boeing failed in its design, and that the Federal Aviation Administration (FAA) failed in its oversight.

The committee found that: “The Max crashes were not the result of a singular failure, technical mistake, or mismanaged event. They were the horrific culmination of a series of faulty technical assumptions by Boeing’s engineers, a lack of transparency on the part of Boeing’s management, and grossly insufficient oversight by the FAA – the pernicious result of regulatory capture on the part of the FAA with respect to its responsibilities to perform robust oversight of Boeing and to ensure the safety of the flying public.”

Attempts to shift blame

Negative aspersions were made about the abilities of the pilots of the ill-fated flights, but the committee found that they were seasoned professionals.

Retired airline captain Chesley B ‘Sully’ Sullenberger III, who landed the US Airways flight on the Hudson River in 2009, saving all 155 people on board, summed it up in his testimony by pointing out that pilots should not have to “compensate for and overcome” inherent flaws in the design of aircraft.

Both flights used the new Manoeuvring Characteristics Augmentation System (MCAS) flight control feature that was developed to deal with stability issues, and which became central to the investigation.

Investigative themes

The investigation into the design, development and certification of the 737 Max, and the FAA’s oversight of Boeing, identified and focused on five particular themes:

  • Tremendous financial pressure placed on production;
  • Faulty design and performance assumptions were made (most notably with regards to the MCAS software);
  • Boeing withheld crucial information from the FAA, customers, and the 737 Max pilots (termed ‘culture of concealment’);
  • Inherent conflicts of interest in the FAA’s current oversight structure with respect to Boeing; and
  • Boeing exercised undue influence over the FAA’s oversight structure, which resulted in sub-standard certification practices.

Findings

The FAA failed to ensure the safety of the traveling public

The litany of failures includes the fear of retribution if employees reported safety issues; oversight capabilities eroded by excessive FAA delegation to Boeing; Boeing’s authorised representatives (ARs) may be impaired from acting independently; Boeing ARs were not communicating fundamentally important information about safety, certification or conformity-related issues to the FAA; and FAA technical experts were overruled or undercut by FAA management when noting safety concerns.

Boeing production pressure

The costs, schedule, and production pressures at Boeing undermined the safety of the 737 Max. Employees were put under tremendous pressure to meet the production schedule, with Boeing reducing the work hours on avionics regression testing by 2 000 hours, the flight test simulator by 3 000 hours, and the engineering flight deck simulator by 8 000 hours.

MCAS

Boeing failed to classify MCAS as a safety-critical system, concealed critical information on the system from pilots, and didn’t point out to the FAA that MCAS was a “new function”.

Boeing concealed the fact that the angle-of-attack (AOA) disagree alert was inoperable

Boeing has publicly blamed its software supplier for this fault, even though it failed to detect the problem when it tested this software in 2015.

Boeing then postponed the software update to 2020 so it could be done in conjunction with the rollout of its planned 737 Max 10 aircraft.

Boeing’s economic incentives led to a significant lack of transparency

Boeing had entered into various contracts in which it had agreed to discount the price of the Max aeroplane if the FAA did not require simulator training for all pilots transitioning to the 737 Max. Boeing gave assurance to airlines that pilots qualified to fly a different 737 variant (the 737 Next Generation) need not undergo simulator training to fly the 737 Max. This placed a financial incentive on ensuring that no regulatory training was required (and meant that pilots needing simulator training on the new aircraft did not receive it).

Boeing and the FAA gambled with the public’s safety

Both Boeing and the FAA gambled with the public’s safety after the Lion Air crash which resulted in the deaths of 157 individuals on Ethiopian Airlines flight 302. Boeing did not mention the MCAS in advisories to pilots, and deleted the mention of MCAS in its Emergency Airworthiness Directive.

Unforgivable inconceivable and inexcusable transgressions

Among the worst transgressions:

  • Boeing failed to classify MCAS as a ‘safety-critical system’ which would have attracted greater FAA scrutiny. The MCAS also flouted Boeing’s guidelines which stipulated that the system should not interfere with the piloting of the aeroplane.
  • Boeing continued to deliver Max aircraft to its customers knowing that the ‘AOA disagree alert’ was inoperable on most of these aircraft. “By the time of the Lion Air crash, Boeing had knowingly delivered approximately 200 Max aircraft to customers around the world with non-functioning AOA disagree alerts.”
  • Boeing concealed the result of an internal test in a flight simulator, in which the test pilot found the interference by the MCAS software to be catastrophic.
  • The FAA, as at the date of the publishing of the report, has not held Boeing accountable for delivering aeroplanes with the non-functioning AOA disagree alerts that Boeing knew were inoperable.

The report concluded: “Boeing’s design and development of the 737 Max was marred by technical design failures, lack of transparency with both regulators and customers, and efforts to downplay or disregard concerns about the operation of the aircraft”, and that the “FAA’s certification review of Boeing’s 737 Max was grossly insufficient and that the FAA failed in its duty to identify key safety problems and to ensure that they were adequately addressed during the certification process.

“The combination of these problems doomed the Lion Air and Ethiopian Airlines flights.”

Despite what the investigation found, Boeing and the FAA have suggested that the certification of the 737 Max was compliant with FAA regulations.

Whatever the results of the legislative actions that follow, this will be scant comfort for the families of the 346 people killed in the two accidents.

If Boeing and the FAA were effective in one thing, it was in swatting down the multiple red flags that kept on popping up.

But it is the fact that these transgressions occurred within a huge and until-then highly well-regarded multinational operating in a sector where safety is mission-critical – and, as so tragically evident, could not be hidden – that is alarming.

May this whole sorry story be a lesson for all companies, whether big or small, local or global.

Profit matters, but never to such an extent.

* Comair, which is under business rescue, took delivery of its first 737 Max 8 on February 27, 2019. This aircraft has however been grounded under the worldwide grounding order. Comair expects to resume operations by November 1, 2020.

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I used to be a bit worried at the age of some of SAAs planes….

..and your point is………SAA is safer than BOEING!!

Boeing knew exactly what they were doing and cannot and may not shift the blame. They are responsible for many deaths in the name of PROFIT!

As for the FAA, it’s a known fact that most of the responsibility lies with Boeing who have to report in..It’s a shared responsibility.. interestingly enough it was reported that an FAA Official joined Boeing..”Brothers in Arms”

I hope the families are remunerated for this criminal act, because that’s what it is

The 737 Max is a perfect metaphor for the South African economy under the control of the disastrous ANC government. The automated system of checks and balances is ineffective and counterproductive. The socialist government is a serious design flaw.

Civil society and journalists are the pilots who are fighting to identify and correct the counterproductive and disastrous inputs from the MCAS system housed in Luthuli House. The ANC conceals the fact that the AOA system(criminal justice system) is dangerously ineffective. The more civil society and journalists struggle to improve the angle of attack to save the country, the more the MCAS pushes the nose down. They asked the IMF to provide extra power to the engines, but the angle of attack prevents the aircraft from flying. The ANC keeps on overruling the input from the pilots, and MCAS is deliberately crashing the 737 Max of the Rainbow Nation National Airlines.

Who is to blame for installing a self-destructive socialist organisation as the government of a modern economy? These parties are complicit and liable for the loss of lives and opportunities.

Regrettably I cannot see your ‘connection’. This is not a political matter. This article is about gross negligence that caused death. The shame is that nobody will be held to account despite the loss of life.

Having said that, engineers within the industry will tell you, Boeing is not the only people who cut corners to save maintenance money.

I am a cost conscientious (township) traveller and always opt for the cheapest flight – Boeings are out of my budget. Go SAA! No dramas with your VW beetle aircraft.

Perfect analogy Sensei!

Not only do we need a anti virus cure for Covid but also for the ANC.

The South African Plane (economy and all its belonging) are on a one way Trajectory into the ground, that is the only curved which is going to be flatterned.

I’ve spotted a suitable landing spot for my family and most South Africans who have a about R2mil available would probably make a decent life there.

Time to put on the parachutes and jump.

At least the Americans call it as it is. Compare this to the ANC commissions of investigation. Made to conceal the truth.

Intriguingly at the time, read up a few articles re technical viewpoints. To add to Barbara’s comment:

Boeing was also under severe competitive pressure during the conceiving of the “787-Max” development programme, against the latest competition from Airbus A320 “neo”.

Boeing’s senior execs took a financial “bet” at the time:

“…either we design & develop a brand new Boeing from scratch for this medium haul market segment, which would take years to fully develop/test…by that time Airbus 320 would capture more of the market, and it will cost airline customers more as result of new pilot training requirements on a new design”….”OR we can take an already successful plane, our B737NG, and developed it to the max (no pun intended), at comparative reduced cost giving us a timely match for Airbus’ A320 neo.”

A hallmark of the B737max was the larger, more powerful, yet more efficient engines (which would be one of Boeing’s best selling features against the Airbus). The larger, heavier engines were placed more forward on the wing leading edge (as there was too little safe clearance between engine-cowling and runway)…which caused the Centre of Gravity to shift…leading to all kinds of undesirable flight characteristics (for example, a stronger inclination to point nose up during full power)……so at THIS design point…this attempt should’ve been called off right there and then. But no, a (critical) software fix was added to flight control system to counter a (critical) ‘hardware’ flaw.

I heard Boeing staff & critics say “all started to go wrong when Boeing replaced many of its senior execs, which had a technical background, by financial people like bankers”

Needless to say, the financial ‘bet’ was lost.

Now a new Boeing, designed from the ground up, would be the only long-term solution. The B737’s development has gone too far beyond its original design, some experts claim. It’s basic design has been (successfully) flying since the late sixties, albeit with various improved versions along the way.

How about Boeing reaching an agreement with Airbus on a “badge engineered” A320 Neo in Boeing livery?? *lol* (well, its common in the vehicle industry…you can badge-engineer a Nissan Navara into a Merc X-Class for the less-informed Merc buyer, or a Fiat 500X into a Jeep Renegade…for your less-informed Jeep fan 😉

That is the problem when office jhonnies tells the technical people what to do.

End of comments.

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