The 737 Max Tragedy and the Fall of Boeing

On the third anniversary of the tragic crash of the Ethiopia Airlines flight 302 the story of Boeing's rise and fall has already become a cautionary tale for all times.

Today is the third anniversary of the tragic crash of the Ethiopia Airlines flight 302 - the second of two devastating crashes of the Boeing 737 Max airplane. Two narratives of the events leading to those crashes have recently appeared. The Netflix documentary “Downfall - The Case Against Boeing’ was released last month and focuses on those killed and their relatives fight for justice. Peter Robison’s book “Flying Blind: The 737 Max Tragedy and the Fall of Boeing” instead tells an epic story of Boeing’s rise and fall as one of the America’s corporate titans. It is a real world fable, a cautionary tale of hubris, greed and tragedy that we should learn by heart and share with the generations to come.

Engineering safety pioneers

Boeing had been a pioneer from the early days of flight. By the latter half of the 20th century the Seattle founded company had grown from its military beginnings to be a powerhouse of aviation engineering, employing a peak of 142,000 people in the 1960s. And it had come to dominate commercial aviation, with passengers convinced of its inherent safety advantage over its rivals. As the saying went, “If it aint Boeing, I aint going.”

In its golden era, the company was an engineering company at heart and expert led. It pioneered the use of fault trees, the fundamental tool of reliability engineering to this day. ‘Flying blind’ recounts how, when a test pilot suggested a $22 million redesign of a planes’ thrust reverser to address its lack of power ($200 million at today’s value), his manager simply said:

Well, if thats what you think, we’ll do it.

It was around this time, in the mid 1960s, that the original 737 was born as a quick and dirty competitor for Douglas’ DC-9 which was thriving with the growth of short haul flights. The 737 was simply designed but it was solidly and efficiently built, with sensible compromises for the time. Robison reports that one Boeing executive said:

It may not be the most exotic thing but boy, it’s what you want to be in if the weather gets rough.

One particular design decision was to mount the engines under the wings, to squeeze in an extra six seats. Boeing had stumbled upon what gradually became a cash cow - a plane that was dominant in commerical aviation for the next fifty years. The 747 ‘jumbo jet’ followed as Boeing cemented its position as the poster boy of the jet age.

Losing its way

Boeing’s engineering led approach atrophied in the decades that followed the introduction of the 737. It made a number of commercial missteps in its development of new planes in that time but nevertheless the company became more and more profitable. Robison’s book tells how, over the years of Reaganomics, leading up to the end of the 20th century, the companies management:

executed what might be called the standard corporate playbook: anti-union, regulation light, outsourcing heavy. But pro-handout, at least when it comes to tax breaks and lucrative government contracts.

Overall Boeings workforce fell 7 percent in 2015 while making many more planes. Many that left were experienced engineers and human factors specialists. And in these days of de-regulation and corporate power Boeing gradually subverted its safety regulator too. The Federal Aviation Administration (FAA) initially delegated authority for certification to Boeing, and eventually FAA certifiers ended up reporting to Boeing managers. The relationship is still fraught and for many unsatisfactory.

In these latter years Airbus evolved from being a pan-European vanity project to Boeing’s main competitor. The launch of the Airbus A320 provided a particular challenge to the 737. A technologically sophisticated ‘fly by wire’ vehicle, it was raising the bar for capacity, reliability and efficiency on short haul flights. The competition really intensified when Airbus introduced a fuel efficient variant: the A320neo. Boeing needed to staunch its loss of customers to Airbus by building its own modern plane. But it decided to do this by producing the ‘737 Max’ as an iteration of its old, trusted war horse. This would have the advantage of minimising delivery, training and certification costs. The book quotes a Boeing executive’s letter to stockholders on the matter:

With development costs and risks far below [those of] an all-new airplane, the 737 MAX will provide customers the capabilities they want, at a price they are willing to pay, on a shorter more certain timeline.

Boeing’s leaders instead poured more than $30 billion of its excess cash into stock buy-backs, enriching shareholders.

The accidents

The 737 Max inherited some undesirable legacy issues from its ancestors. It lacked a computerised ‘electronic checklist’ to help the pilot navigate through tasks, particularly when something went wrong. Combining the larger more fuel efficient engines that were now needed with the 737’s low-slung design fundamentally changed its aerodynamics too, making the plane unstable if it climbed at too steep an angle. Boeing’s answer? Put in an automated system that would take over from the pilot in these circumstances and push the planes nose down. However this design feature was hidden from view, in order to miminse training and maintain the illusion that the 737 Max was just an iterative update, (the thirteenth to be based upon the original 1967 certification). In emails handed over to congressional investigators following the two accidents, it was found that a Boeing pilot had boasted of using “Jedi mind tricks” to convince airlines and regulators there was no need for pilots who’d flown the previous version of the 737 to undergo expensive simulator training.

The result of all of this was that the pilots of LionAir flight 610 and Ethiopia Airlines flight 302 were each unaware of how to respond when a key sensor failed, and their planes continually pitched downwards. Unable to wrest back control they both crashed with the loss of 346 lives in total. These were tragedies that were many years in the making. But they are indicative of the situation any industry or company under commerical pressure can find itself in if it loses long-term ownership of its core safety principles and capabilities, and assumes that major accidents are a thing of the past.

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Thanks for reading

All views are my own and I reserve the right to change my opinion (particularly when readers inform me of things of which I was unaware).

If you’re interested in any advice, guidance or collaboration on any of the topics raised please feel free to drop me an e-mail on george.bearfield@ntlworld.com: My particular area of professional and research interest is practical risk and assurance of new technology. I’m always keen to engage on interesting projects in this area.