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Boeing 737 Max Aircraft: Preliminary Investigative Findings [pdf]

238 points by ddulaney 7y ago

kuon 7y ago
Knowing this, how fixable is the 737 MAX technically and politically?
- wizardforhire 7y ago
  Like anything flawed from the gitgo, it’ll take a complete overhaul to fix these planes and this company.
- ReptileMan 7y ago
  Technically - easier. They have to remove MCAS and retrain the pilots as a new type. But rebuilding the trust will be harder.
  - cesarb 7y ago
    It might not be that easy. Making the 737 MAX a new type could mean losing grandfathered exemptions from new rules, which might require several other changes to the aircraft.
    - anticensor 7y ago
      It is not; in fact, it does violate whole books of rules which has been grandfathered to by exemptions.
      - chx 7y ago
        OMG do you have links where I can read more? So that's why they did this whole mess! It never made sense to me that saving a little money on certification was the reason for this but if the plane couldn't be certified today as a new plane ... that'd make a lot more sense.
        mopsi 7y ago
        https://www.seattletimes.com/business/boeing-aerospace/boeing-pushed-faa-to-arelax-737-max-certification-requirements-for-crew-alerts/ https://www.seattletimes.com/business/boeing-aerospace/boein...
        thombat 7y ago
        As an example of the sort of old design which used to be grandfathered in there's the Helios crash [1], where on a plane built in 1997 the exact same alarm horn was used for two situations (configuration error during take-off, and loss of cabin pressure at altitude). The old-school reasoning was that this wouldn't be a problem since the two situations are necessarily disjoint. However as the accident investigation board wrote: "Most pilots are not very likely to experience a cabin pressurization problem and the associated warning horn at any time during their line flying. The Board also considered the role of stress that probably further contributed to the possible confusion of the two meanings of the warning horn. In general, stress, such as that caused by the onset of a loud, distracting alarm in the cockpit, combined with the element of surprise, is known to lead to automatic reactions. Automatic reactions, in turn, are typically those that result from experience and frequency of encounter and are therefore not always appropriate. The Board considered that the flight crew may have automatically reverted to a reaction based on memory before consciously processing the source and significance of the stress factor. This would also explain why the flight crew failed to realize the improbability of their interpretation of the horn as a takeoff configuration horn and why they failed to move on to gathering information for a new, correct diagnosis of the problem at hand." That particular stable door got closed, but at the time it was cited by pilots as an example of legacy design that wouldn't have been permitted on a clean-sheet airliner. [1] https://en.wikipedia.org/wiki/Helios_Airways_Flight_522#Flight_and_crash https://en.wikipedia.org/wiki/Helios_Airways_Flight_522#Flig...
  - deleted 7y ago
    [deleted]
  - masklinn 7y ago
    The source, the entire cause of this mess, was to have the 737 MAX not be a new type. If the "fix" is to not do that, then the 737 MAX is not fixable because it loses the entire reason for its existence.
    - dodobirdlord 7y ago
      > The source, the entire cause of this mess, was to have the 737 MAX not be a new type. If the "fix" is to not do that, then the 737 MAX is not fixable because it loses the entire reason for its existence. There are a ton of existing 737 MAX, and Boeing's production lines are all geared up to produce more. The MCAS etc are there so that it could be called a 737, but the "entire reason for its existence" was to mount larger more fuel-efficient engines.
      - masklinn 7y ago
        > the "entire reason for its existence" was to mount larger more fuel-efficient engines. On a 737 type. Not on a completely different type which would require retraining all 737 crew and lose months worth of flight time. Even less so for companies like Southwest which fly 737s exclusively.
        mrep 7y ago
        Still would be a lot cheaper than scrapping 80 billion dollars worth of planes already built.
        masklinn 7y ago
        Seems like a prime demo of sunk costs fallacy.
        mrep 7y ago
        Half of that is from unsold planes that they built after it got grounded. So for those, their options are retrain pilots and make 40 billion in sales vs not retraining pilots and scrapping the planes/reusing what you can. Pretty sure the 40 billion in sales will easily be greater than retraining the pilots and whatever scrap they could use. Also, "Typically, once an airline takes the aircraft, Boeing makes some guarantees in terms of the performance of that aircraft, and one of them is that the aircraft should be airworthy," says Chris Higgins, an analyst at Morningstar [0]. So even the other half that is already sold isn't necessarily sunk for them as they have contractual obligations that will cost them if the planes have to get scrapped. [0]: https://www.npr.org/2019/03/13/703189895/for-boeing-costs-of-grounding-jets-have-only-just-begun https://www.npr.org/2019/03/13/703189895/for-boeing-costs-of...
  - carlmr 7y ago
    Without MCAS and with retaining you'd need to redesign the whole mechanics properly.
  - kozak 7y ago
    Or add a third angle of attack sensor.
    - JshWright 7y ago
      Even adding a second (as a standard, not an upgrade) would be a start...
      - anticensor 7y ago
        There are already two of them installed in each plane.
        Zak 7y ago
        Two are installed, but MCAS only used one, and the disagree warning light was not operational despite the documentation saying that it was.
  - phire 7y ago
    You can't certify the plane without MCAS or some replacement. MCAS wasn't added because the plane didn't fly the same as the 737. MCAS was added because the plane didn't fly the same as all other certifiable aircraft. It doesn't meet FAA regulations on how the controls need to feel when approaching stall. The type rating mess only caused Boeing to hide MCAS from pilots. This triggered various dangerous design decisions, including designing it to be impossible to disable and making it only take data from one sensor.
  - Zak 7y ago
    The aircraft could probably be safe and pass certification with MCAS in place, but the following issues made it dangerous: * It was undocumented. * It had too much control authority. It was able to adjust the trim such that the elevator could not overcome the trim's pitch-down force, and such that the average pilot did not have enough strength to use the manual trim wheel to neutralize the trim in a dive. * They removed the switch to turn it off. On older 737s, there's one switch to turn off automated control of stabilizer trim, and another to disconnect power to the motor, completely disabling electric trim. On the Max, both switches perform the latter function. * They made it rely on only one sensor. I can't imagine the logic for that since two sensors are physically present, and damage to AOA sensors is not rare. * The AOA disagree warning light, which would have clued pilots in to the presence of a faulty sensor was not present in most aircraft, despite documentation to the contrary.
    - cesarb 7y ago
      > They made it rely on only one sensor. I can't imagine the logic for that since two sensors are physically present, and damage to AOA sensors is not rare. The logic for that is really simple: each sensor is wired to one of the two computers. Each computer uses its own sensor. This was an already existing design, MCAS is just a new function added to these computers. (AFAIK, other aircraft like Airbus have multiple sensors wired to each computer, so for them it would be natural to use more than one sensor.)
      - Zak 7y ago
        That makes a lot of sense actually; it wasn't a deliberate decision, just the path of least resistance.
      - phire 7y ago
        Both computers have access to both sensor's data. The computers are networked together. This is how they implement the AoA disagree function (the one which was broken in 90% of MAXes for unrelated reasons). It's also how they managed to implement a software update which makes MCAS take data from both sensors. The logic for not implementing both sensors is much more insidious. If you implement both sensors, then you have to deal with the case that infomation from sensors might disagree. The computer has no idea sensor is providing correct data, so the only thing it can really do is disable itself when the sensors disagree. If MCAS has the ability to disable itself, then it must provide feedback to pilots it has done so, and have pilots follow some procedures. If there were procedures, then Boeing would have to add pilot training about what MCAS was and how things would be different when it disabled itself. Boeing made it rely on only a single sensor to bypass training requirements.
- gpm 7y ago
  I don't think the hardest challenge they face is either technical or political. I think it's company culture. They need to somehow change that so they don't run into the same issues down the road, and I don't think anyone fully understands how to do that.
  - samstave 7y ago
    I find that the sense of safety in the public eye is really whats at stake here. FFS flying is stressful enough in general - but when you have specific events (the crashes) and specific evidence of corporate [corruption/concealment/negligence/malfeasance or whatever the truth is within Boeing] which detracts from the faith in the safety of their life critical product(s) -- it has just destroyed a fair amount of trust in the company and the industry as a whole.
    - hn3333 7y ago
      Not sure why flying is stressful.. It's a super fast mode of transport, it's usually comfortable, the view out the window is amazing and I even like the airport shops. Ok I guess if you are afraid of flying maybe it is, but that is fixable..
      - meddlepal 7y ago
        I don't find flying stressful either (I wouldn't say it's comfortable...), but it is important to remember everyone is wired different. My mother turns into a mess if she needs to get on a plane.
      - lapnitnelav 7y ago
        You're locked in a big tin can flying hundreds of miles per hour, high in the sky and if things go wrong, you better be emotionally ready to meet your maker. And that's just the flying bit. Not to detract from your points, but if you have any inclination to anxiety, yeah flying is stress-inducing.
      - ferzul 7y ago
        getting to an airport is hell and ex´ensive, if you miss your flight tough shit so you have to leave hours early and just wait. airport shops are so expensive it costs more to buy tax free there than at the nearest shop at home. what's to like?
- phire 7y ago
  Large parts of the certification process were skipped or glossed over. All they really need to do is recertify the entire aircraft, which is no small task.
- Dahoon 7y ago
  >politically Boeing is too big to fail and too powerful to punish so nothing will really happen. If it was a Chinese company it would be banned from the US. As a US company it will go on like nothing happened. Well maybe the engineers who refused to sign will be fired. Give it some time and a "fix" will be made and the MAX will fly again.
  - tgsovlerkhgsel 7y ago
    It's not just about Boeing though. It is kind of expected that companies will try to cut corners. That's why there are regulators like the FAA. And in this case, there are non-US regulators in play too. They used to just blindly trust the FAA and approve anything the FAA approved, but that has likely changed now - the FAA (rightfully) lost a lot of trust due to this. Pressuring the FAA into approving another unsafe design isn't enough anymore. I suspect that if the FAA approves but EASA doesn't, many other authorities will be heavily inclined to trust EASA on this one. Which could make the plane a "US only" plane. Maybe some close allies could be pressured into allowing it but I doubt any airline outside of North America could meaningfully integrate them into their fleet with a different type rating and a small set of countries that allow them.
leeoniya 7y ago
> These five recurring themes paint a disturbing picture of Boeing’s development and production of the 737 MAX and the FAA’s ability to provide appropriate oversight of Boeing’s 737 MAX program. No, these five recurring themes paint a disturbing picture of Boeing’s development and production of ALL its aircraft.
- gpm 7y ago
  I don't think the statement even needs to be limited to aircraft. We can see the same themes in the development of the CST-100 starliner capsule (spacecraft).
  - HarryHirsch 7y ago
    Boeing engineering has been systematically trained to paper over problems, even over the showstopping kind. A major aerospace contractor and one of the world's two manufacturers of widebody planes has been completely hollowed out. It's a national security issue, nothing less.
  - ImaCake 7y ago
    I think this explains a bit of the fanboy love for SpaceX. It's the energetic little guy versus the corrupt lethargic vampires.
    - HarryHirsch 7y ago
      They want to deliver man-rated rockets but can't even construct a fuel tank that won't blow up. SpaceX has got its own set of problems.
      - zlsa 7y ago
        You're leaving out their 83 completely successful launches of Falcon 9 and Falcon Heavy[0] in favor of their R&D efforts. [0]: https://en.wikipedia.org/wiki/List_of_Falcon_9_and_Falcon_Heavy_launches https://en.wikipedia.org/wiki/List_of_Falcon_9_and_Falcon_He...
nrki 7y ago
This is huge. It confirms basically everything I've read over the past year on the topic (mainly on hn). Culture of concealment, production pressure, self-oversight, conflicts of interest, faulty assumptions. Like many other lessons borrowed from commercial aviation, these are supremely relevant to tech companies. Edit: BA stock down 1.27% in after-hours trade. I guess the market has decided that this behaviour is fine.
- nrb 7y ago
  > Edit: BA stock down 1.27% in after-hours trade. I guess the market has decided that this behaviour is fine. Like you said, this basically confirms everything we already knew. So it stands to reason that the stock is already priced accordingly and a large drop wouldn’t be expected. It’s already down about 35-40% since the crashes.
  - Scipio_Afri 7y ago
    Right but until regulators or congress acts on a plan moving forward with BA, the stock will continue to slide based on the time out of the market not selling this aircraft. There is still uncertainty over how long until they’re able to sell this aircraft again, if at all, and if so to what extent they need to retrofit. So costs to retrofit, time before they get revenue in and the profit or lack there of from this product. Also, seems doubtful but possibly additional issues may still be found with this aircraft design as it is. Possibly though retrofits aren’t found to fully solve these problems or themselves create other issues.
  - nrki 7y ago
    I posit that we should account for their stock price before the employees of Boeing embarked on the road of corruption, fraud and manslaughter. i.e.: before their profits, especially due to sales of the MAX, are taken into account. I guess the markets have a short memory as long as you only kill people instead of simply losing people's money.
- pjc50 7y ago
  Boeing is too nationalist to fail; there is no way the US government will allow itself to be without a civilian airliner builder and have to buy planes from Airbus or Embraer. Plus they'd take with them the absorbed remains of McDonnell Douglas.
unlinked_dll 7y ago
Most troubling to me is this: > AA technical and safety experts determined that certain Boeing design approaches on its transport category aircraft were potentially unsafe and failed to comply with FAA regulation, only to have FAA management overrule them and side with Boeing instead from the linked citation [0]: > In 2015, the FAA drafted an issue paper, finalized in 2016, that offered Boeing a chance to establish compliance without implementing a design change.4 At least six FAA specialists refused to concur >It is our understanding that non-concurrence by FAA technical specialists is fairly infrequent and not to be taken lightly. In addition, my staff has been told that it was virtually unprecedented for six or more FAA specialists to jointly non-concur on a single issue, highlighting the gravity of their concerns regarding the rudder cable issue. Despite all of this, in June 2017, the F AA's Transport Airplane Directorate upheld the controversial issue paper Someone needs to name names, and those people should be investigated for corruption. [0] https://transportation.house.gov/news/press-releases/amid-committees-ongoing-investigation-into-the-certification-of-the-737-max-chairs-defazio-and-larsen-raise-new-and-serious-concerns-to-faa-about-other-safety-related-issues- https://transportation.house.gov/news/press-releases/amid-co...
- cptskippy 7y ago
  Sounds like the FAA needs to do some house cleaning in there upper management because they're in bed with Boeing.
  - unlinked_dll 7y ago
    It's the White House that is responsible for doing that "house cleaning" of the FAA's upper management, since those folks are political appointees that serve at the pleasure of the President. I don't know about you, but I don't see the current admin prioritizing the flushing out of regulators in bed with industry. That's why I say name some names.
    - nolok 7y ago
      Just a remainder: at the start of his presidency, Trump wanted to appoint his own personal pilot at the head of the FAA. So yes, don't expect too much from them in cleaning the upper levels.
mazsa 7y ago
The key technical reason is this one: "While multiple factors led to these accidents, both crashes shared a key contributing factor: a new software system called the Maneuvering Characteristics Augmentation System (MCAS), which Boeing developed to address stability issues in certain flight conditions induced by the plane’s new, larger engines, and their relative placement on the 737 MAX aircraft compared to the engines’ placement on the 737 NG."
- mazsa 7y ago
  Cf. "How the Boeing 737 Max Disaster Looks to a Software Developer / Design shortcuts meant to make a new plane seem like an old, familiar one are to blame" https://spectrum.ieee.org/aerospace/aviation/how-the-boeing-737-max-disaster-looks-to-a-software-developer https://spectrum.ieee.org/aerospace/aviation/how-the-boeing-...
- deleted 7y ago
  [deleted]
haltingproblem 7y ago
(edits: formatting). Cue the obligatory comment of Boeing is a company with an insanely great engineering culture and their engineers lived in an idyllic culture of building great and safe products. This great culture was all lost as a result of the merger with McDonnell Douglas [1], [2], [3]. Somehow the Boeing apologists want you to think that the unholy trinity of the ghost of McDonnell Douglas through the CEO at the time of the merger Harry C. Stonecipher (the father) and Dennis Muilenburg (the Son) who greenlighted the 737 MAX are responsible for this abomination. So much so that of the thousands of engineers who worked on the 737 Max not a single one raised issues with the engineering of the aircraft or wrote a blistering memo calling out its failing or quit in protest. They were all held in thrall by the power of this unholy trinity! In the theory of causation, we distinguish between proximate vs. ultimate causality. Every proximate event can plausibly be claimed to be the cause for a subsequent event. As they say for want of a nail the war was lost. What is plausibly the cause for the engineering fiasco of the 737 Max? Why go back to the merger and why not blame the 9/11 or the election of G.W Bush or even Barack Obama's for this disaster? Why go back to the 1997 merger with McDonnell Douglas? Because it allows Boeing engineers to deflect blame for the terrible product they built and foisted on the flying public by coasting on their past reputations. Eventually, all stellar organizations, public or private, become complacent (e.g. Israeli Intelligence Failure, 1973). Boeing made an unstable plane with a dangerous MCAS to get it to market fast. They then topped it off by making it rely on a single sensor and made the dual-sensor an upgrade. A sophomore engineering student with a 101 course on probability can see that this is tailor-made for diaster. They made an essential safety feature an upgrade!! They then proceeded to hide this monstrosity from every regulator and airline on the planet and insist that the plane was no different in every aspect of its flight behavior than its predecessor which was over 30 years old. Boeing had become so criminally blatant that the head of airline training at Lion Air inquired about extra training for the 737 Max and they rebuffed him. After the Lion Air crash, Boeing proceeded to cast aspersion on the safety practices of Lion Air. Lion Air does have a spotty safety record but in this case, Boeing rebuffed their requests for additional training because it would set a precedent for other airlines in SE Asia. When that lack of training was a factor in the crash, Boeing proceeded to blame Lion Air. The mind boggles at the sheer chutzpah! The recently released messages show how Boeing employees worked in unison to ensure no extra simulator training was required. Great engineering culture obsessed with safety, this aint! Go ahead and blame the McDonnel Douglas merger for this. Or accept that whatever stellar engineering culture existed at Boeing is dead. We as a society need to stop scapegoating imaginary forces in the past and giving Boeing's engineers a pass. We need to start agreeing that strong regulation is necessary to ensure the safety of the products Boeing puts out. [1] https://qz.com/1776080/how-the-mcdonnell-douglas-boeing-merger-led-to-the-737-max-crisis/ https://qz.com/1776080/how-the-mcdonnell-douglas-boeing-merg... [2] https://fortune.com/longform/boeing-737-max-crisis-shareholder-first-culture/ https://fortune.com/longform/boeing-737-max-crisis-sharehold... [3] https://www.perell.com/blog/boeing-737-max https://www.perell.com/blog/boeing-737-max
WalterBright 7y ago
> Boeing also withheld knowledge that a pilot would need to diagnose and respond to a “stabilizer runaway” condition caused by an erroneous MCAS activation in 10 seconds or less, or risk catastrophic consequences.1 Both the LA and EA crews did respond withing 10 seconds and restore normal trim using the electric trim switches. LA worked on the issue for 5 minutes, EA for a couple minutes. The findings did not mention that Boeing issued an Emergency Airworthiness Directive to all MAX crews after the LA crash that contained correct instructions on how to recover from it - restore normal trim with the electric trim switches, then cut off the stab trim with the console switch. Both crews were able to restore normal trim repeatedly with the electric trim switches. But LA never cut off the trim, and EA cut off the trim when it was in a dive, not after restoring the normal trim.
- acqq 7y ago
  I was not the pilot error, neither the first nor the second time. The planes behaved exactly how no plane should be allowed to behave, effectively turning on the “I’m afraid I can’t let you do that Dave” reaction many times. And there are no reasonable excuses to that.
  - WalterBright 7y ago
    I'm not arguing that Boeing didn't make mistakes with the design, they did. I'm pointing out that the "10 seconds" thing is not the cause of the crashes, and that both crews (especially the EA one) did have the information they needed to recover. Runaway stab trim should never happen, but the reason the cutoff switches are there are so it can be recovered from. It's the same with fire extinguishers on airplanes. Fire should never happen on an airplane, but we expect the pilots to know how to use the fire extinguishing systems when it does.
    - acqq 7y ago
      Some important points from the PDF that show that it was not the problem with the pilots: - In 2015, a Boeing AR raised the question of whether MCAS was “vulnerable to single AOA sensor failures….” Despite this, the aircraft was delivered with MCAS dependent on a single AOA sensor. - After Boeing redesigned MCAS in 2016 to increase its power to move the aircraft’s stabilizer at low speed, Boeing never reevaluated a single- and multiple-failure analysis of MCAS. - In March 2016, Boeing sought, and the FAA approved, removal of references to MCAS from Boeing’s Flight Crew Operations Manual (FCOM), ensuring 737 MAX pilots were unaware of this new software and its potential effect on the aircraft’s handling without pilot command. - Boeing’s design of MCAS violated its own internal requirements which demanded that the system “not have any objectionable interaction with the piloting of the airplane” and “not interfere with dive recovery,” which occurred in both 737 MAX crashes. - In August 2017, five months after the 737 MAX was certified by the FAA and three months after it entered revenue service, Boeing issued a problem report to its supplier complaining that the 737 MAX’s AOA Disagree alert was tied to an optional AOA Indicator display and therefore was not functioning on the vast majority of the 737 MAX fleet worldwide. - Rather than immediately informing the FAA and Boeing customers about this issue, and advising Boeing to fix the problem via a software update as soon as possible, a Boeing AR consented to Boeing’s plan to postpone the software update until 2020 (...) - Although Boeing prepared a “Fleet Team Digest” to inform its customers about the inoperable AOA Disagree alert, the company never sent it, keeping its customers in the dark about the inoperable alert. - Boeing provided Lion Air a Flight Crew Operations Manual (FCOM) on August 16, 2018, one year after learning that the AOA Disagree alert was not functioning on most 737 MAX aircraft, highlighting the operation of the AOA Disagree alert. Boeing failed to indicate that it knew the AOA Disagree alert on the Lion Air 737 MAX aircraft was not operational. - Boeing did not acknowledge that the AOA Disagree alerts on an estimated 80 percent of the 737 MAX fleet were inoperative until after the Lion Air crash in October 2018. - Boeing’s own analysis showed that if pilots took more than 10 seconds to identify and respond to a “stabilizer runaway” condition caused by uncommanded MCAS activation the result could be catastrophic. The Committee has found no evidence that Boeing shared this information with the FAA, customers, or 737 MAX pilots. - Boeing had tremendous financial incentive to ensure that no regulatory determination requiring pilot simulator training for the 737 MAX was made. This incentive included a Boeing contract with Southwest Airlines, its U.S. launch customer, that would have cost Boeing more than $1 million per aircraft it delivered to Southwest if pilot simulator training was required for Southwest pilots transitioning to the 737 MAX from the 737 NG. At the time of the Lion Air crash, Southwest had ordered or pre-ordered an estimated 280 737 MAX aircraft from Boeing. - In March 2017, the month the 737 MAX was certified by the FAA, Boeing’s 737 Chief Technical Pilot responded to colleagues about the prospects of 737 MAX simulator training, saying: “Boeing will not allow that to happen. We’ll go face to face with any regulator who tries to make that a requirement.”
V_Terranova_Jr 7y ago
Having worked with Boeing on other aerospace programs (not commercial though) and having been on the Gov side, the basic findings ring true. Boeing's culture really is as flawed as the report reads. The idea that Dennis Muilenburg, however, originated or did more than prior company management to foster this culture, is nonsense. They remain, even today, operating with this culture. The real problem that stands in the way of "fundamental structural reform" is that regardless of specific aerospace market, few alternatives to Boeing exist. And don't think the corporate cultures at other traditional US aerospace primes is consistently better. The points about Government acquiescence to Boeing pressure in performing regulation also resonate. Beware the tendency to make this a single-axis "more vs. less" regulation issue. The solution isn't "more regulation". The central concern should about regulatory culture. Ultimately, responsibility lines must be drawn, standards established, adjudication performed, and unique or specific situations accommodated. Inevitably, the "less regulation" crowd corrodes the kind of regulatory culture that serves the best interests of the populace in these processes. Good regulation depends on having highly-competent, wise, empowered, and apolitical persons on the Government side. While providing regulatory organizations lots of funding doesn't ensure that they hire, empower, and maintain such a cadre, starving them of resources and implying the Government can never be competent, so it should reflect the role back to Industry, is pathological and will produce outcomes like the 737 Max. We need to not just empower and provide adequate resources to regulators, but also demand and foster a culture of competence and good judgment^. Making that happen is a lot harder than arguing about "more or less", but necessary for proper outcomes. ^"good judgment" here explicitly excludes decision-making with regard to political implications
- lisper 7y ago
  Can confirm from first-hand experience: I worked for NASA for about 15 years (1988-2003) so I got to see how the aerospace sausage is made. Everything you say rings very true to me. It's actually kind of amazing to me that there aren't more problems like the 737-max. Even in my day there were strong dis-incentives for anyone to raise a red flag when they saw corners being cut or decisions being made for political rather than technical reasons (which happened a lot). That's ultimately why I quit: I was faced with a very stark choice between doing what I thought was the Right Thing and torpedoing my career, or keeping my very cushy and vert well-paid job and becoming part of the problem. Apply that incentive structure to a few hundred thousand employees and the result is MCAS.
mrtksn 7y ago
There was an interview with the new Boing CEO quite recently: https://www.nytimes.com/2020/03/05/business/boeing-david-calhoun.html https://www.nytimes.com/2020/03/05/business/boeing-david-cal... He pretty much blamed it all on the previous CEO. Asked whether he believed American pilots would have been able to handle a malfunction of the software, Mr. Calhoun asked to speak off the record. The New York Times declined to do so. “Forget it,” Mr. Calhoun then said. “You can guess the answer.” Does it mean that Boeing maintains its position that the MCAS was not "that bad" and it's on the pilots for not handling the Boeing's mistake? Is he suggesting that we should avoid Boeing Aircraft unless the pilots are American?
- bumby 7y ago
  This seems like a rationalization in the CEO’s part. Boeing’s system safety analysis categorized MCAS as ‘hazardous’. Even with the wrong categorization (there’s a strong argument it should’ve been labeled ‘catastrophic’) if they followed their own design procedures hazardous systems should have redundant sensors. Besides the fact his reply defies a good understanding of human factors in engineering, when management deflects responsibility to their customers it is extremely troubling. Cognitive dissonance is dangerous in leadership.
  - temac 7y ago
    It's even worse than that. If it is believed that the plane is only suitable for American pilots, it should not even be sold outside of the USA...
- imtringued 7y ago
  The problem with the MCAS is that turning it off makes the plane illegal to fly. The MCAS is just a compliance trick. If the pilots had a choice they would just retrain to fly the new plane without MCAS but they aren't allowed to do that.
ps747 7y ago
Wow, this is incredibly damning and all but blames the Boeing and ineffective FAA oversight for the tragic crashes. I hope this leads to significant fines for Boeing and jailtime for the more egregious actors involved; according to the report, their negligence directly led to the loss of lives. Knowing how important Boeing is to national security/the economy, I'm skeptical that enough will be done...
thrwaway8347346 7y ago
> In March 2016,Boeing sought,and the FAA approved,removal of references to MCAS from Boeing’s Flight Crew Operations Manual (FCOM),ensuring 737 MAX pilots were unaware of this new software and its potential effect on the aircraft’s handling without pilot command. Are the execs in jail?
- salawat 7y ago
  No, but the Chief Technical Pilot who requested it has lawyered up with an independent lawyer from Boeing's general counsel. Odds are his conscience is weighing heavily on him, and he doesn't trust that Boeing's council won't attempt to pin it on him acting alone. Corporate culture is rife with leaving subordinates to act on implied mandates in order to insulate executives from the potential for criminal liability. The idea is if the criminal thing works and no one finds out, the exec gets their bonus; if it blows up, the exec never told them to do it.
everybodyknows 7y ago
Other reporting has called MCAS the product of a systemic failure, and asserts underfunding of the FAA to be among the ultimate causes. Underfunding being "worked-around" by delegating the work to Boeing: >(ARs)—Boeing employees who are granted special permission to represent the interests of the FAA and to act on the agency’s behalf in validating aircraft systems and designs’ compliance with FAA requirements Others have pointed out that the conflict of interest inherent in this must pervade AR's daily work environment, and indeed the report pays brief lip service to the contradiction: >4) Conflicted Representation. The Committee has found that the FAA’s current oversight structure with respect to Boeing creates inherent conflicts of interest ... So why do it that way, and why do my searches of the investigation's PDF for "funding", "budget", and "staffing" come up empty? Consider, then, that responsibility for setting the operating budget of the FAA belongs to the House -- the very same running this investigation. https://www.transportation.gov/sites/dot.gov/files/docs/mission/budget/304496/faa-fy2019cj-budgetfinal508compliant.pdf https://www.transportation.gov/sites/dot.gov/files/docs/miss...
sn41 7y ago
I am concerned that the Dreamliner is also a potentially unsafe aircraft, as has been suggested often. Please see the last bullet point on page 5. Is anyone aware of this exact issue?
aschatten 7y ago
An excellent write up of the crashed by a pilot: https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-crashes.html https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-c... I highly recommend you read it. It‘s not to exonerate Boeing, but it does bring up issues that none else talked about.

238 points by ddulaney 7y ago

kuon 7y ago

Knowing this, how fixable is the 737 MAX technically and politically?

wizardforhire 7y ago
Like anything flawed from the gitgo, it’ll take a complete overhaul to fix these planes and this company.
ReptileMan 7y ago
Technically - easier. They have to remove MCAS and retrain the pilots as a new type. But rebuilding the trust will be harder.
- cesarb 7y ago
  It might not be that easy. Making the 737 MAX a new type could mean losing grandfathered exemptions from new rules, which might require several other changes to the aircraft.
  - anticensor 7y ago
    It is not; in fact, it does violate whole books of rules which has been grandfathered to by exemptions.
    - chx 7y ago
      OMG do you have links where I can read more? So that's why they did this whole mess! It never made sense to me that saving a little money on certification was the reason for this but if the plane couldn't be certified today as a new plane ... that'd make a lot more sense.
      - mopsi 7y ago
        https://www.seattletimes.com/business/boeing-aerospace/boeing-pushed-faa-to-arelax-737-max-certification-requirements-for-crew-alerts/ https://www.seattletimes.com/business/boeing-aerospace/boein...
      - thombat 7y ago
        As an example of the sort of old design which used to be grandfathered in there's the Helios crash [1], where on a plane built in 1997 the exact same alarm horn was used for two situations (configuration error during take-off, and loss of cabin pressure at altitude). The old-school reasoning was that this wouldn't be a problem since the two situations are necessarily disjoint. However as the accident investigation board wrote: "Most pilots are not very likely to experience a cabin pressurization problem and the associated warning horn at any time during their line flying. The Board also considered the role of stress that probably further contributed to the possible confusion of the two meanings of the warning horn. In general, stress, such as that caused by the onset of a loud, distracting alarm in the cockpit, combined with the element of surprise, is known to lead to automatic reactions. Automatic reactions, in turn, are typically those that result from experience and frequency of encounter and are therefore not always appropriate. The Board considered that the flight crew may have automatically reverted to a reaction based on memory before consciously processing the source and significance of the stress factor. This would also explain why the flight crew failed to realize the improbability of their interpretation of the horn as a takeoff configuration horn and why they failed to move on to gathering information for a new, correct diagnosis of the problem at hand." That particular stable door got closed, but at the time it was cited by pilots as an example of legacy design that wouldn't have been permitted on a clean-sheet airliner. [1] https://en.wikipedia.org/wiki/Helios_Airways_Flight_522#Flight_and_crash https://en.wikipedia.org/wiki/Helios_Airways_Flight_522#Flig...
- deleted 7y ago
  [deleted]
- masklinn 7y ago
  The source, the entire cause of this mess, was to have the 737 MAX not be a new type. If the "fix" is to not do that, then the 737 MAX is not fixable because it loses the entire reason for its existence.
  - dodobirdlord 7y ago
    > The source, the entire cause of this mess, was to have the 737 MAX not be a new type. If the "fix" is to not do that, then the 737 MAX is not fixable because it loses the entire reason for its existence. There are a ton of existing 737 MAX, and Boeing's production lines are all geared up to produce more. The MCAS etc are there so that it could be called a 737, but the "entire reason for its existence" was to mount larger more fuel-efficient engines.
    - masklinn 7y ago
      > the "entire reason for its existence" was to mount larger more fuel-efficient engines. On a 737 type. Not on a completely different type which would require retraining all 737 crew and lose months worth of flight time. Even less so for companies like Southwest which fly 737s exclusively.
      - mrep 7y ago
        Still would be a lot cheaper than scrapping 80 billion dollars worth of planes already built.
        masklinn 7y ago
        Seems like a prime demo of sunk costs fallacy.
        mrep 7y ago
        Half of that is from unsold planes that they built after it got grounded. So for those, their options are retrain pilots and make 40 billion in sales vs not retraining pilots and scrapping the planes/reusing what you can. Pretty sure the 40 billion in sales will easily be greater than retraining the pilots and whatever scrap they could use. Also, "Typically, once an airline takes the aircraft, Boeing makes some guarantees in terms of the performance of that aircraft, and one of them is that the aircraft should be airworthy," says Chris Higgins, an analyst at Morningstar [0]. So even the other half that is already sold isn't necessarily sunk for them as they have contractual obligations that will cost them if the planes have to get scrapped. [0]: https://www.npr.org/2019/03/13/703189895/for-boeing-costs-of-grounding-jets-have-only-just-begun https://www.npr.org/2019/03/13/703189895/for-boeing-costs-of...
- carlmr 7y ago
  Without MCAS and with retaining you'd need to redesign the whole mechanics properly.
- kozak 7y ago
  Or add a third angle of attack sensor.
  - JshWright 7y ago
    Even adding a second (as a standard, not an upgrade) would be a start...
    - anticensor 7y ago
      There are already two of them installed in each plane.
      - Zak 7y ago
        Two are installed, but MCAS only used one, and the disagree warning light was not operational despite the documentation saying that it was.
- phire 7y ago
  You can't certify the plane without MCAS or some replacement. MCAS wasn't added because the plane didn't fly the same as the 737. MCAS was added because the plane didn't fly the same as all other certifiable aircraft. It doesn't meet FAA regulations on how the controls need to feel when approaching stall. The type rating mess only caused Boeing to hide MCAS from pilots. This triggered various dangerous design decisions, including designing it to be impossible to disable and making it only take data from one sensor.
- Zak 7y ago
  The aircraft could probably be safe and pass certification with MCAS in place, but the following issues made it dangerous: * It was undocumented. * It had too much control authority. It was able to adjust the trim such that the elevator could not overcome the trim's pitch-down force, and such that the average pilot did not have enough strength to use the manual trim wheel to neutralize the trim in a dive. * They removed the switch to turn it off. On older 737s, there's one switch to turn off automated control of stabilizer trim, and another to disconnect power to the motor, completely disabling electric trim. On the Max, both switches perform the latter function. * They made it rely on only one sensor. I can't imagine the logic for that since two sensors are physically present, and damage to AOA sensors is not rare. * The AOA disagree warning light, which would have clued pilots in to the presence of a faulty sensor was not present in most aircraft, despite documentation to the contrary.
  - cesarb 7y ago
    > They made it rely on only one sensor. I can't imagine the logic for that since two sensors are physically present, and damage to AOA sensors is not rare. The logic for that is really simple: each sensor is wired to one of the two computers. Each computer uses its own sensor. This was an already existing design, MCAS is just a new function added to these computers. (AFAIK, other aircraft like Airbus have multiple sensors wired to each computer, so for them it would be natural to use more than one sensor.)
    - Zak 7y ago
      That makes a lot of sense actually; it wasn't a deliberate decision, just the path of least resistance.
    - phire 7y ago
      Both computers have access to both sensor's data. The computers are networked together. This is how they implement the AoA disagree function (the one which was broken in 90% of MAXes for unrelated reasons). It's also how they managed to implement a software update which makes MCAS take data from both sensors. The logic for not implementing both sensors is much more insidious. If you implement both sensors, then you have to deal with the case that infomation from sensors might disagree. The computer has no idea sensor is providing correct data, so the only thing it can really do is disable itself when the sensors disagree. If MCAS has the ability to disable itself, then it must provide feedback to pilots it has done so, and have pilots follow some procedures. If there were procedures, then Boeing would have to add pilot training about what MCAS was and how things would be different when it disabled itself. Boeing made it rely on only a single sensor to bypass training requirements.
gpm 7y ago
I don't think the hardest challenge they face is either technical or political. I think it's company culture. They need to somehow change that so they don't run into the same issues down the road, and I don't think anyone fully understands how to do that.
- samstave 7y ago
  I find that the sense of safety in the public eye is really whats at stake here. FFS flying is stressful enough in general - but when you have specific events (the crashes) and specific evidence of corporate [corruption/concealment/negligence/malfeasance or whatever the truth is within Boeing] which detracts from the faith in the safety of their life critical product(s) -- it has just destroyed a fair amount of trust in the company and the industry as a whole.
  - hn3333 7y ago
    Not sure why flying is stressful.. It's a super fast mode of transport, it's usually comfortable, the view out the window is amazing and I even like the airport shops. Ok I guess if you are afraid of flying maybe it is, but that is fixable..
    - meddlepal 7y ago
      I don't find flying stressful either (I wouldn't say it's comfortable...), but it is important to remember everyone is wired different. My mother turns into a mess if she needs to get on a plane.
    - lapnitnelav 7y ago
      You're locked in a big tin can flying hundreds of miles per hour, high in the sky and if things go wrong, you better be emotionally ready to meet your maker. And that's just the flying bit. Not to detract from your points, but if you have any inclination to anxiety, yeah flying is stress-inducing.
    - ferzul 7y ago
      getting to an airport is hell and ex´ensive, if you miss your flight tough shit so you have to leave hours early and just wait. airport shops are so expensive it costs more to buy tax free there than at the nearest shop at home. what's to like?
phire 7y ago
Large parts of the certification process were skipped or glossed over. All they really need to do is recertify the entire aircraft, which is no small task.
Dahoon 7y ago
>politically Boeing is too big to fail and too powerful to punish so nothing will really happen. If it was a Chinese company it would be banned from the US. As a US company it will go on like nothing happened. Well maybe the engineers who refused to sign will be fired. Give it some time and a "fix" will be made and the MAX will fly again.
- tgsovlerkhgsel 7y ago
  It's not just about Boeing though. It is kind of expected that companies will try to cut corners. That's why there are regulators like the FAA. And in this case, there are non-US regulators in play too. They used to just blindly trust the FAA and approve anything the FAA approved, but that has likely changed now - the FAA (rightfully) lost a lot of trust due to this. Pressuring the FAA into approving another unsafe design isn't enough anymore. I suspect that if the FAA approves but EASA doesn't, many other authorities will be heavily inclined to trust EASA on this one. Which could make the plane a "US only" plane. Maybe some close allies could be pressured into allowing it but I doubt any airline outside of North America could meaningfully integrate them into their fleet with a different type rating and a small set of countries that allow them.

leeoniya 7y ago

> These five recurring themes paint a disturbing picture of Boeing’s development and production of the 737 MAX and the FAA’s ability to provide appropriate oversight of Boeing’s 737 MAX program. No, these five recurring themes paint a disturbing picture of Boeing’s development and production of ALL its aircraft.

gpm 7y ago
I don't think the statement even needs to be limited to aircraft. We can see the same themes in the development of the CST-100 starliner capsule (spacecraft).
- HarryHirsch 7y ago
  Boeing engineering has been systematically trained to paper over problems, even over the showstopping kind. A major aerospace contractor and one of the world's two manufacturers of widebody planes has been completely hollowed out. It's a national security issue, nothing less.
- ImaCake 7y ago
  I think this explains a bit of the fanboy love for SpaceX. It's the energetic little guy versus the corrupt lethargic vampires.
  - HarryHirsch 7y ago
    They want to deliver man-rated rockets but can't even construct a fuel tank that won't blow up. SpaceX has got its own set of problems.
    - zlsa 7y ago
      You're leaving out their 83 completely successful launches of Falcon 9 and Falcon Heavy[0] in favor of their R&D efforts. [0]: https://en.wikipedia.org/wiki/List_of_Falcon_9_and_Falcon_Heavy_launches https://en.wikipedia.org/wiki/List_of_Falcon_9_and_Falcon_He...

nrki 7y ago

This is huge. It confirms basically everything I've read over the past year on the topic (mainly on hn). Culture of concealment, production pressure, self-oversight, conflicts of interest, faulty assumptions. Like many other lessons borrowed from commercial aviation, these are supremely relevant to tech companies. Edit: BA stock down 1.27% in after-hours trade. I guess the market has decided that this behaviour is fine.

nrb 7y ago
> Edit: BA stock down 1.27% in after-hours trade. I guess the market has decided that this behaviour is fine. Like you said, this basically confirms everything we already knew. So it stands to reason that the stock is already priced accordingly and a large drop wouldn’t be expected. It’s already down about 35-40% since the crashes.
- Scipio_Afri 7y ago
  Right but until regulators or congress acts on a plan moving forward with BA, the stock will continue to slide based on the time out of the market not selling this aircraft. There is still uncertainty over how long until they’re able to sell this aircraft again, if at all, and if so to what extent they need to retrofit. So costs to retrofit, time before they get revenue in and the profit or lack there of from this product. Also, seems doubtful but possibly additional issues may still be found with this aircraft design as it is. Possibly though retrofits aren’t found to fully solve these problems or themselves create other issues.
- nrki 7y ago
  I posit that we should account for their stock price before the employees of Boeing embarked on the road of corruption, fraud and manslaughter. i.e.: before their profits, especially due to sales of the MAX, are taken into account. I guess the markets have a short memory as long as you only kill people instead of simply losing people's money.
pjc50 7y ago
Boeing is too nationalist to fail; there is no way the US government will allow itself to be without a civilian airliner builder and have to buy planes from Airbus or Embraer. Plus they'd take with them the absorbed remains of McDonnell Douglas.

unlinked_dll 7y ago

Most troubling to me is this: > AA technical and safety experts determined that certain Boeing design approaches on its transport category aircraft were potentially unsafe and failed to comply with FAA regulation, only to have FAA management overrule them and side with Boeing instead from the linked citation [0]: > In 2015, the FAA drafted an issue paper, finalized in 2016, that offered Boeing a chance to establish compliance without implementing a design change.4 At least six FAA specialists refused to concur >It is our understanding that non-concurrence by FAA technical specialists is fairly infrequent and not to be taken lightly. In addition, my staff has been told that it was virtually unprecedented for six or more FAA specialists to jointly non-concur on a single issue, highlighting the gravity of their concerns regarding the rudder cable issue. Despite all of this, in June 2017, the F AA's Transport Airplane Directorate upheld the controversial issue paper Someone needs to name names, and those people should be investigated for corruption. [0] https://transportation.house.gov/news/press-releases/amid-committees-ongoing-investigation-into-the-certification-of-the-737-max-chairs-defazio-and-larsen-raise-new-and-serious-concerns-to-faa-about-other-safety-related-issues- https://transportation.house.gov/news/press-releases/amid-co...

cptskippy 7y ago
Sounds like the FAA needs to do some house cleaning in there upper management because they're in bed with Boeing.
- unlinked_dll 7y ago
  It's the White House that is responsible for doing that "house cleaning" of the FAA's upper management, since those folks are political appointees that serve at the pleasure of the President. I don't know about you, but I don't see the current admin prioritizing the flushing out of regulators in bed with industry. That's why I say name some names.
  - nolok 7y ago
    Just a remainder: at the start of his presidency, Trump wanted to appoint his own personal pilot at the head of the FAA. So yes, don't expect too much from them in cleaning the upper levels.

mazsa 7y ago

The key technical reason is this one: "While multiple factors led to these accidents, both crashes shared a key contributing factor: a new software system called the Maneuvering Characteristics Augmentation System (MCAS), which Boeing developed to address stability issues in certain flight conditions induced by the plane’s new, larger engines, and their relative placement on the 737 MAX aircraft compared to the engines’ placement on the 737 NG."

mazsa 7y ago
Cf. "How the Boeing 737 Max Disaster Looks to a Software Developer / Design shortcuts meant to make a new plane seem like an old, familiar one are to blame" https://spectrum.ieee.org/aerospace/aviation/how-the-boeing-737-max-disaster-looks-to-a-software-developer https://spectrum.ieee.org/aerospace/aviation/how-the-boeing-...
deleted 7y ago
[deleted]

haltingproblem 7y ago

(edits: formatting). Cue the obligatory comment of Boeing is a company with an insanely great engineering culture and their engineers lived in an idyllic culture of building great and safe products. This great culture was all lost as a result of the merger with McDonnell Douglas [1], [2], [3]. Somehow the Boeing apologists want you to think that the unholy trinity of the ghost of McDonnell Douglas through the CEO at the time of the merger Harry C. Stonecipher (the father) and Dennis Muilenburg (the Son) who greenlighted the 737 MAX are responsible for this abomination. So much so that of the thousands of engineers who worked on the 737 Max not a single one raised issues with the engineering of the aircraft or wrote a blistering memo calling out its failing or quit in protest. They were all held in thrall by the power of this unholy trinity! In the theory of causation, we distinguish between proximate vs. ultimate causality. Every proximate event can plausibly be claimed to be the cause for a subsequent event. As they say for want of a nail the war was lost. What is plausibly the cause for the engineering fiasco of the 737 Max? Why go back to the merger and why not blame the 9/11 or the election of G.W Bush or even Barack Obama's for this disaster? Why go back to the 1997 merger with McDonnell Douglas? Because it allows Boeing engineers to deflect blame for the terrible product they built and foisted on the flying public by coasting on their past reputations. Eventually, all stellar organizations, public or private, become complacent (e.g. Israeli Intelligence Failure, 1973). Boeing made an unstable plane with a dangerous MCAS to get it to market fast. They then topped it off by making it rely on a single sensor and made the dual-sensor an upgrade. A sophomore engineering student with a 101 course on probability can see that this is tailor-made for diaster. They made an essential safety feature an upgrade!! They then proceeded to hide this monstrosity from every regulator and airline on the planet and insist that the plane was no different in every aspect of its flight behavior than its predecessor which was over 30 years old. Boeing had become so criminally blatant that the head of airline training at Lion Air inquired about extra training for the 737 Max and they rebuffed him. After the Lion Air crash, Boeing proceeded to cast aspersion on the safety practices of Lion Air. Lion Air does have a spotty safety record but in this case, Boeing rebuffed their requests for additional training because it would set a precedent for other airlines in SE Asia. When that lack of training was a factor in the crash, Boeing proceeded to blame Lion Air. The mind boggles at the sheer chutzpah! The recently released messages show how Boeing employees worked in unison to ensure no extra simulator training was required. Great engineering culture obsessed with safety, this aint! Go ahead and blame the McDonnel Douglas merger for this. Or accept that whatever stellar engineering culture existed at Boeing is dead. We as a society need to stop scapegoating imaginary forces in the past and giving Boeing's engineers a pass. We need to start agreeing that strong regulation is necessary to ensure the safety of the products Boeing puts out. [1] https://qz.com/1776080/how-the-mcdonnell-douglas-boeing-merger-led-to-the-737-max-crisis/ https://qz.com/1776080/how-the-mcdonnell-douglas-boeing-merg... [2] https://fortune.com/longform/boeing-737-max-crisis-shareholder-first-culture/ https://fortune.com/longform/boeing-737-max-crisis-sharehold... [3] https://www.perell.com/blog/boeing-737-max https://www.perell.com/blog/boeing-737-max

WalterBright 7y ago

> Boeing also withheld knowledge that a pilot would need to diagnose and respond to a “stabilizer runaway” condition caused by an erroneous MCAS activation in 10 seconds or less, or risk catastrophic consequences.1 Both the LA and EA crews did respond withing 10 seconds and restore normal trim using the electric trim switches. LA worked on the issue for 5 minutes, EA for a couple minutes. The findings did not mention that Boeing issued an Emergency Airworthiness Directive to all MAX crews after the LA crash that contained correct instructions on how to recover from it - restore normal trim with the electric trim switches, then cut off the stab trim with the console switch. Both crews were able to restore normal trim repeatedly with the electric trim switches. But LA never cut off the trim, and EA cut off the trim when it was in a dive, not after restoring the normal trim.

acqq 7y ago
I was not the pilot error, neither the first nor the second time. The planes behaved exactly how no plane should be allowed to behave, effectively turning on the “I’m afraid I can’t let you do that Dave” reaction many times. And there are no reasonable excuses to that.
- WalterBright 7y ago
  I'm not arguing that Boeing didn't make mistakes with the design, they did. I'm pointing out that the "10 seconds" thing is not the cause of the crashes, and that both crews (especially the EA one) did have the information they needed to recover. Runaway stab trim should never happen, but the reason the cutoff switches are there are so it can be recovered from. It's the same with fire extinguishers on airplanes. Fire should never happen on an airplane, but we expect the pilots to know how to use the fire extinguishing systems when it does.
  - acqq 7y ago
    Some important points from the PDF that show that it was not the problem with the pilots: - In 2015, a Boeing AR raised the question of whether MCAS was “vulnerable to single AOA sensor failures….” Despite this, the aircraft was delivered with MCAS dependent on a single AOA sensor. - After Boeing redesigned MCAS in 2016 to increase its power to move the aircraft’s stabilizer at low speed, Boeing never reevaluated a single- and multiple-failure analysis of MCAS. - In March 2016, Boeing sought, and the FAA approved, removal of references to MCAS from Boeing’s Flight Crew Operations Manual (FCOM), ensuring 737 MAX pilots were unaware of this new software and its potential effect on the aircraft’s handling without pilot command. - Boeing’s design of MCAS violated its own internal requirements which demanded that the system “not have any objectionable interaction with the piloting of the airplane” and “not interfere with dive recovery,” which occurred in both 737 MAX crashes. - In August 2017, five months after the 737 MAX was certified by the FAA and three months after it entered revenue service, Boeing issued a problem report to its supplier complaining that the 737 MAX’s AOA Disagree alert was tied to an optional AOA Indicator display and therefore was not functioning on the vast majority of the 737 MAX fleet worldwide. - Rather than immediately informing the FAA and Boeing customers about this issue, and advising Boeing to fix the problem via a software update as soon as possible, a Boeing AR consented to Boeing’s plan to postpone the software update until 2020 (...) - Although Boeing prepared a “Fleet Team Digest” to inform its customers about the inoperable AOA Disagree alert, the company never sent it, keeping its customers in the dark about the inoperable alert. - Boeing provided Lion Air a Flight Crew Operations Manual (FCOM) on August 16, 2018, one year after learning that the AOA Disagree alert was not functioning on most 737 MAX aircraft, highlighting the operation of the AOA Disagree alert. Boeing failed to indicate that it knew the AOA Disagree alert on the Lion Air 737 MAX aircraft was not operational. - Boeing did not acknowledge that the AOA Disagree alerts on an estimated 80 percent of the 737 MAX fleet were inoperative until after the Lion Air crash in October 2018. - Boeing’s own analysis showed that if pilots took more than 10 seconds to identify and respond to a “stabilizer runaway” condition caused by uncommanded MCAS activation the result could be catastrophic. The Committee has found no evidence that Boeing shared this information with the FAA, customers, or 737 MAX pilots. - Boeing had tremendous financial incentive to ensure that no regulatory determination requiring pilot simulator training for the 737 MAX was made. This incentive included a Boeing contract with Southwest Airlines, its U.S. launch customer, that would have cost Boeing more than $1 million per aircraft it delivered to Southwest if pilot simulator training was required for Southwest pilots transitioning to the 737 MAX from the 737 NG. At the time of the Lion Air crash, Southwest had ordered or pre-ordered an estimated 280 737 MAX aircraft from Boeing. - In March 2017, the month the 737 MAX was certified by the FAA, Boeing’s 737 Chief Technical Pilot responded to colleagues about the prospects of 737 MAX simulator training, saying: “Boeing will not allow that to happen. We’ll go face to face with any regulator who tries to make that a requirement.”

V_Terranova_Jr 7y ago

Having worked with Boeing on other aerospace programs (not commercial though) and having been on the Gov side, the basic findings ring true. Boeing's culture really is as flawed as the report reads. The idea that Dennis Muilenburg, however, originated or did more than prior company management to foster this culture, is nonsense. They remain, even today, operating with this culture. The real problem that stands in the way of "fundamental structural reform" is that regardless of specific aerospace market, few alternatives to Boeing exist. And don't think the corporate cultures at other traditional US aerospace primes is consistently better. The points about Government acquiescence to Boeing pressure in performing regulation also resonate. Beware the tendency to make this a single-axis "more vs. less" regulation issue. The solution isn't "more regulation". The central concern should about regulatory culture. Ultimately, responsibility lines must be drawn, standards established, adjudication performed, and unique or specific situations accommodated. Inevitably, the "less regulation" crowd corrodes the kind of regulatory culture that serves the best interests of the populace in these processes. Good regulation depends on having highly-competent, wise, empowered, and apolitical persons on the Government side. While providing regulatory organizations lots of funding doesn't ensure that they hire, empower, and maintain such a cadre, starving them of resources and implying the Government can never be competent, so it should reflect the role back to Industry, is pathological and will produce outcomes like the 737 Max. We need to not just empower and provide adequate resources to regulators, but also demand and foster a culture of competence and good judgment^. Making that happen is a lot harder than arguing about "more or less", but necessary for proper outcomes. ^"good judgment" here explicitly excludes decision-making with regard to political implications

lisper 7y ago
Can confirm from first-hand experience: I worked for NASA for about 15 years (1988-2003) so I got to see how the aerospace sausage is made. Everything you say rings very true to me. It's actually kind of amazing to me that there aren't more problems like the 737-max. Even in my day there were strong dis-incentives for anyone to raise a red flag when they saw corners being cut or decisions being made for political rather than technical reasons (which happened a lot). That's ultimately why I quit: I was faced with a very stark choice between doing what I thought was the Right Thing and torpedoing my career, or keeping my very cushy and vert well-paid job and becoming part of the problem. Apply that incentive structure to a few hundred thousand employees and the result is MCAS.

mrtksn 7y ago

There was an interview with the new Boing CEO quite recently: https://www.nytimes.com/2020/03/05/business/boeing-david-calhoun.html https://www.nytimes.com/2020/03/05/business/boeing-david-cal... He pretty much blamed it all on the previous CEO. Asked whether he believed American pilots would have been able to handle a malfunction of the software, Mr. Calhoun asked to speak off the record. The New York Times declined to do so. “Forget it,” Mr. Calhoun then said. “You can guess the answer.” Does it mean that Boeing maintains its position that the MCAS was not "that bad" and it's on the pilots for not handling the Boeing's mistake? Is he suggesting that we should avoid Boeing Aircraft unless the pilots are American?

bumby 7y ago
This seems like a rationalization in the CEO’s part. Boeing’s system safety analysis categorized MCAS as ‘hazardous’. Even with the wrong categorization (there’s a strong argument it should’ve been labeled ‘catastrophic’) if they followed their own design procedures hazardous systems should have redundant sensors. Besides the fact his reply defies a good understanding of human factors in engineering, when management deflects responsibility to their customers it is extremely troubling. Cognitive dissonance is dangerous in leadership.
- temac 7y ago
  It's even worse than that. If it is believed that the plane is only suitable for American pilots, it should not even be sold outside of the USA...
imtringued 7y ago
The problem with the MCAS is that turning it off makes the plane illegal to fly. The MCAS is just a compliance trick. If the pilots had a choice they would just retrain to fly the new plane without MCAS but they aren't allowed to do that.

ps747 7y ago

Wow, this is incredibly damning and all but blames the Boeing and ineffective FAA oversight for the tragic crashes. I hope this leads to significant fines for Boeing and jailtime for the more egregious actors involved; according to the report, their negligence directly led to the loss of lives. Knowing how important Boeing is to national security/the economy, I'm skeptical that enough will be done...

thrwaway8347346 7y ago

> In March 2016,Boeing sought,and the FAA approved,removal of references to MCAS from Boeing’s Flight Crew Operations Manual (FCOM),ensuring 737 MAX pilots were unaware of this new software and its potential effect on the aircraft’s handling without pilot command. Are the execs in jail?

salawat 7y ago
No, but the Chief Technical Pilot who requested it has lawyered up with an independent lawyer from Boeing's general counsel. Odds are his conscience is weighing heavily on him, and he doesn't trust that Boeing's council won't attempt to pin it on him acting alone. Corporate culture is rife with leaving subordinates to act on implied mandates in order to insulate executives from the potential for criminal liability. The idea is if the criminal thing works and no one finds out, the exec gets their bonus; if it blows up, the exec never told them to do it.

everybodyknows 7y ago

Other reporting has called MCAS the product of a systemic failure, and asserts underfunding of the FAA to be among the ultimate causes. Underfunding being "worked-around" by delegating the work to Boeing: >(ARs)—Boeing employees who are granted special permission to represent the interests of the FAA and to act on the agency’s behalf in validating aircraft systems and designs’ compliance with FAA requirements Others have pointed out that the conflict of interest inherent in this must pervade AR's daily work environment, and indeed the report pays brief lip service to the contradiction: >4) Conflicted Representation. The Committee has found that the FAA’s current oversight structure with respect to Boeing creates inherent conflicts of interest ... So why do it that way, and why do my searches of the investigation's PDF for "funding", "budget", and "staffing" come up empty? Consider, then, that responsibility for setting the operating budget of the FAA belongs to the House -- the very same running this investigation. https://www.transportation.gov/sites/dot.gov/files/docs/mission/budget/304496/faa-fy2019cj-budgetfinal508compliant.pdf https://www.transportation.gov/sites/dot.gov/files/docs/miss...

sn41 7y ago

I am concerned that the Dreamliner is also a potentially unsafe aircraft, as has been suggested often. Please see the last bullet point on page 5. Is anyone aware of this exact issue?

aschatten 7y ago

An excellent write up of the crashed by a pilot: https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-crashes.html https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-c... I highly recommend you read it. It‘s not to exonerate Boeing, but it does bring up issues that none else talked about.