I recently wrote a very popular article on the troubled Boeing 737 Max in which I made the argument that the 737 Max should be permanently grounded. As expected, individuals from Boeing reached out to me to try to persuade me to change my mind. I didn’t. Instead, I have come to realize that my argument for permanently grounding the 737 Max has actually grown stronger. Here’s why.
First and foremost, Boeing CEO Dennis Muilenburg is woefully out of his depth to serve as the company’s CEO. This is just one of many videos I have watched of Muilenberg as he struggles to keep his emotions under control. Muilenberg is apparently incapable of conveying any believable sense of true sadness or remorse for the victims of the two 737 Max crashes. Instead, Muilenberg appears frustrated by the fact so many people don’t understand how hard it is to build a jet in the first place. I imagine that behind Muilenberg’s stoicism, the following thoughts were running through his mind on a continuous loop as he was speaking and answering questions: Doggone it, why don’t you %$#@!!@ people understand that Boeing is a special company????????!!!! I’ve been with Boeing for 34 years. Don’t even %$#@& think about questioning my integrity or the integrity of this company!!!!! We’re Boeing. We’ve got this. Move along as there is nothing to see here!!!!
The impression I have of Muilenberg is that he is the consummate insider and bureaucrat. (In my role as a consultant, a telltale sign I look for to identify people who aren’t doing their jobs or who should be terminated are individuals who justify their existence or their value because of the number of years they’ve worked for a company. Muilenberg has a habit of repeating that he has worked for Boeing for 34 years.) Watch this video of Muilenberg answering questions and judge for yourself.
My disagreement with Muilenberg is that a leader would have made the decision to hire an independent firm to thoroughly investigate Boeing’s culture, decision making, manufacturing process, internal communications, effectiveness of the Board of Directors, relationships with suppliers and, of course, testing and safety procedures. A leader would keep a commitment to make the results of an independent investigation public along with the list of recommendations for correcting issues and permanently preventing any possibility of any future issues like the MCAS fiasco. A leader would make sure to shake up the Board of Directors with a goal to replace as many board members with individuals from outside of the aviation industry as possible. I guess my view of leadership is much different than Muilenberg’s.
Over the weeks since the crashes occurred (I use the word ‘crash’ a lot when I write about the 737 Max as Boeing does everything possible to avoid using the word), a number of reporters have written in-depth articles on Boeing’s culture and issues surrounding every aspect of the 737 Max. Of all the articles I’ve read, however, this article by The New York Times does the best job of outlining what went on behind the scenes. According to the article, the fatal flaws with Boeing’s 737 Max can be traced to a breakdown late in the plane’s development, when test pilots, engineers and regulators were left in the dark about a fundamental overhaul to an automated system that would ultimately play a role in two crashes.
A year before the plane was finished, Boeing made the system more aggressive and riskier. While the original version relied on data from at least two types of sensors, the final version ultimately used just one, leaving the system without a critical safeguard. In both doomed flights, pilots struggled as a single damaged sensor sent the planes into irrecoverable nose-dives within minutes, killing 346 people and prompting regulators around the world to ground the 737 Max, stated the Times.
But many people involved in building, testing and approving the system, known as MCAS, said they hadn’t fully understood the changes. Current and former employees at Boeing and the Federal Aviation Administration (FAA) who spoke with The New York Times said they had assumed the system relied on more sensors and would rarely, if ever, activate. Based on those misguided assumptions, many made critical decisions, affecting design, certification and training.
While prosecutors and lawmakers try to piece together what went wrong, the current and former employees point to the single, fateful decision to change the system, which led to a series of design mistakes and regulatory oversights. As Boeing rushed to get the plane done, many of the employees say, they didn’t recognize the importance of the decision. They described a compartmentalized approach, each of them focusing on a small part of the plane. The process left them without a complete view of a critical and ultimately dangerous system.
The company also played down the scope of the system to regulators. Boeing never disclosed the revamp of MCAS to FAA officials involved in determining pilot training needs, according to three agency officials. When Boeing asked to remove the description of the system from the pilot’s manual, the FAA agreed. As a result, most 737 Max pilots did not know about the software until after the first crash, in October. Let that last sentence sink in. Imagine you’re a pilot of a plane carrying passengers and the only reason you learned about specific software on the plane is because of a crash. How would you feel?
The Curse of MCAS
At first, MCAS— the Maneuvering Characteristics Augmentation System—wasn’t a very risky piece of software according to the Times. The system would trigger only in rare conditions, nudging down the nose of the plane to make the 737 Max handle more smoothly during high-speed moves. And it relied on data from multiple sensors measuring the plane’s acceleration and its angle to the wind, helping to ensure that the software didn’t activate erroneously.
Then, Boeing engineers reconceived the system, expanding its role to avoid stalls in all types of situations. They allowed the software to operate throughout much more of the flight. They enabled it to aggressively push down the nose of the plane. And they used only data about the plane’s angle, removing some of the safeguards. A test pilot who originally advocated for the expansion of the system didn’t understand how the changes affected its safety. Safety analysts said they would have acted differently if they had known it used just one sensor. Regulators didn’t conduct a formal safety assessment of the new version of MCAS, according to interviews conducted by the Times.
In my article, “Flawed: Why The Boeing 737 Max Should Permanently Be Grounded,” I described the fact that Boeing added engines on the 737 Max that were larger and heavier than engines on the original design. To compensate for the additional size and weight, Boeing engineers mounted the engines in a more forward position on the wings. The result? The plane didn’t fly smoothly, and it wasn’t handling well when nearing stalls at low speeds. To fix the issue, Boeing decided to use a piece of software. The system was meant to work in the background, so pilots effectively wouldn’t know it was there.
The change proved pivotal. Expanding the use of MCAS to lower-speed situations required removing the G-force threshold. MCAS now needed to work at low speeds so G-force didn’t apply. The change meant that a single angle-of-attack sensor was the lone guard against a misfire. Although modern 737 jets have two angle-of-attack sensors, the final version of MCAS took data from just one. Using MCAS at lower speeds also required increasing the power of the system. When a plane is flying slowly, flight controls are less sensitive, and far more movement is needed to steer. Think of turning a car’s steering wheel at 20 miles an hour versus 70.
The investigation by the Times sheds light on another issue—after engineers installed the second version of MCAS, Boeing did not test what would happen if MCAS activated as a result of a faulty angle-of-attack sensor, a problem in the two 737 Max crashes. Boeing engineers, however, did consider such a possibility in their safety analysis of the original MCAS. They classified the event as “hazardous,” one rung below the most serious designation of catastrophic, according to two people. In regulatory-speak, it meant that MCAS could trigger erroneously less often than once in 10 million flight hours.
That probability may have underestimated the risk of so-called external events that have damaged sensors in the past, such as collisions with birds, bumps from ramp stairs or mechanics’ stepping on them. While part of the assessment considers such incidents, they are not included in the probability. Investigators suspect the angle-of-attack sensor was hit on the doomed Ethiopian Airlines flight in March, stated the Times.
A Times review of two FAA databases found hundreds of reports of bent, cracked, sheared-off, poorly installed or otherwise malfunctioning angle-of-attack sensors on commercial aircraft over three decades.
Since 1990, one database has recorded 1,172 instances when birds—meadowlarks, geese, sandpipers, pelicans and turkey vultures, among others—damaged sensors of various kinds, with 122 strikes on angle-of-attack vanes. The other database showed 85 problems with angle-of-attack sensors on Boeing aircraft, including 38 on 737s since 1995.
In a case of too little, too late, Boeing has reworked MCAS to more closely resemble the first version. It will be less aggressive, and it will rely on two sensors. I’m sure the families of the passengers killed on both Boeing 737 Max crashes appreciate Boeing’s diligence. Ahem.
The News Keeps Getting Worse Regarding the Boeing 737
As if two crashes of the 737 Max weren’t enough to prove there are serious issues at Boeing, a report by the FAA on June 3, 2019, has identified that more than 300 737 Max and 737 Next Generation (NG) planes have faulty parts in the wings. The Federal Aviation Administration’s statement indicated the manufacturing problem doesn’t pose an imminent accident hazard. But the move comes during heightened global scrutiny of the 737 Max’s safety and amid separate efforts by the FAA and plane maker to agree on a software fix to prevent misfires of a potentially dangerous flight-control system.
Regardless of the severity of the defective parts, it provides additional evidence that Boeing is struggling to build jets that are safe (free from defects), as well as provide the required oversight of its suppliers to ensure flawless parts are manufactured and installed. A part may not provide an imminent threat of an accident, but that doesn’t mean a defective part cannot cause a chain of events to occur that causes a Boeing 737 to crash. We’ve already seen this happen on two Boeing 737 Max jets.
Boeing’s CEO and spokespersons continue to state how serious Boeing takes safety and how diligent Boeing is at building its aircraft. If that’s true, why are so many articles coming out identifying one issue after another with the 737? The question that needs to be answered is this: Is the 737 the only aircraft with flaws or are there so many systemic issues inside Boeing that other Boeing aircraft are also unsafe? As I stated earlier, a strong CEO would hire an independent firm to audit every aspect of the company to separate fact from fiction.
Where Are the Heads?
I have no sympathy for Boeing. Two of their 737 Max jets crashed, they didn’t have an accident. The jets crashed because of poor decision-making, a compartmentalized manufacturing process and a culture that isn’t as focused on safety as much as Muilenburg claims. Boeing isn’t the victim in this affair. Boeing is the reason why the crashes occurred.
The more I read about Boeing and the 737 Max the less I like. Among the questions I have are: Where are the heads? Who is being fired at Boeing? Will there be a shakeup of the Board of Directors? Will the FAA punish Boeing? Why is a person who worked at Boeing for 34 years still the CEO?
As I stated in my article “Flawed,” no one should ever allow someone they love to fly on a 737 Max. Muilenberg’s focus is simple: Contain the damage and get the 737 Max flying again as soon as possible. Muilenberg has even gone so far as to state that he would be comfortable putting his own family on the 737 Max as passengers. How reassuring. It’s also complete BS.
Regardless of how many touchy-feely videos and statements Muilenberg and other Boeing executives share with the press, there is only one thing that matters—keeping the 737 Max grounded until Congress and the FAA release their final reports. If this means the 737 Max remains grounded for the next one to two years, or longer, so be it.
However, make no mistake, just as I was certain that it was only a matter of time before Muilenberg would grovel to the press and state that he would be comfortable with his family flying on the 737 Max, it will only be a matter of time before Muilenberg begins to make statements that keeping the 737 Max grounded will impact the “hard working men and women of Boeing” and also damage our country’s economy. Inside the mind of Muilenberg he will think over and over: What’s wrong with you %$#@! people? Don’t you know we control the chain? Don’t you understand the 737 Max is now the safest plane in the sky, even though we pushed the original design of the 737 far beyond what it was meant to do? Trust us, we’re Boeing, and we don’t make the same mistake three times in a row.
Note to Boeing: It’s time to bring in an outsider to be the CEO. Who should it be? That’s easy, Tim Cook the CEO of Apple or Wes Bush the chairman of the Northrop Grumman Corporation. (Tim Cook may not want to leave Apple, but if asked, I believe Cook would view it as his moral duty to leave in order to become Boeing’s CEO.)
Meanwhile, around the world, families who lost loved ones as a result of Boeing’s negligence are looking at pictures of people they will never see again. And they think to themselves, how will I ever get over this? When will the pain ever end? Why did this have to happen? And the tears begin to flow.