It’s another podcast this week, and a conversation I recently had with Bloomberg reporter and author of “Flying Blind: The 737 Max Tragedy and the Fall of Boeing,” Peter Robison. For those who would rather read than listen the full transcript of the interview is below too:
George Bearfield: So how did you come to be interested in the topic of the Boeing 737 Max tragedies and interested enough to write a book about it?
Peter Robison: It really comes from my experience covering Boeing as a reporter for Bloomberg in the late 90s and early 2000s. I moved to Seattle for Bloomberg. I was the Beat reporter and Boeing at the time was flying high. It was, you know, widely considered one of the preeminent American manufacturers, and it had more than 60% of the aircraft market. But I was surprised to find there was a lot of internal disagreement about the course it was taking. It was pursuing a sort of a strategy replicating what General Electric and Jack Welch were doing and focusing on services rather than manufacturing, and top leadership is less interested in commercial airplanes as a business. Engineers at the time were telling me that there seemed to be less of a basic commitment to technical engineering that that research was being cut back. In 2000 there was a strike where the engineers left for 40 days and that was largely due to their disagreements with the company’s strategy.
So I mean, there's a very powerful narrative that you pull out in the book around the strategic change to Boeing over a very significant period of time. I've got some questions that I want to get into on that. But before we do, would it be possible just to explain, for those who don't know, what actually happened in those two really impactful accidents.
Yeah, of course the thing that really drew me in was the two accidents that happened within five months of each other in 2018 and 2019. It was almost a brand new plane: You know, the Max was supposed to be a simple update. It was launched, it was flying with airlines and then there was a crash with Lion Air in Indonesia and then five months later, a crash in Ethiopia. It became quickly apparent that they were due to the same cause, which was that a faulty AOA [Angle of Attack] vein had sent a signal to a piece of software called MCAS that ultimately tipped the nose of the plane down. The pilots had no control over the descent. So it was the single point of failure that commercial aircraft aren't supposed to have. And part of the book was in trying to understand how and why that happened.
It paints a pretty horrific picture of how that must have felt for the pilot and for those on board, doesn't it to have that kind of fault where the, plane is literally doing the opposite of what you want it to do. It's a really terrible fault mode. So going back to the story of Boeing then you paint the picture of Boeing: this sort of pioneer of aviation with a really good safety record. And then you paint the story of the various things that happened and almost inevitably seem to happen when their focus shifts to commerciality. And the bit that interests me is that it's such a long time frame, the story that you tell in the book, and it almost feels like there's a horrible inevitability to everything, and so I guess there are two questions I had. The first one is from your insights and what you've learned, how do you catch that in a reasonable amount of time and and steer things back?
Well, I mean, it's an interesting question because it does raise the idea of the narrative fallacy. You know, is it only obvious because we're looking at it in retrospect? But certainly when at the time, going back 20 years, there were warnings that something like what happened with these crashes was likely to happen. And you know the other really excruciating thing I'm trying to understand the narrative was that there were people on the engineering team who were raising questions about what might happen in this failure mode. What happens if we get a faulty AOA vein, and that person was told, you know, don't worry, the system will shut off immediately. And that was incorrect because there was a faulty communications loop. There had been a lot of business decisions made that separated people who had previously worked side by side from being in close contact with each other and you know the argument I make in the book is that it ultimately came back to this commercial pressure that was put on the engineering teams and that if they've been given the time to run all these problems to ground, you wouldn't have seen these crashes. The engineers that I talked to had worked there for decades, you know, said that what Boeing strengths had always been was that it identified problems, you know there are always problems that come up in something that has millions of parts. But you know Boeing’s strengths had been in putting huge teams of people together and just crushing the problems. And in this case, more recently, Boeing was pulling apart it's teams and trying to make do with less. It's structures were redesigned to focus on services and to outsource more and more.
Yeah, the other thing that interests me, as an engineer, is that I spend a lot of time thinking about how to manage complexity because there's a growing creep towards automation and to making things more complicated. Complexity seems to be almost an end in itself sometimes, but actually the interesting thing here was that the AOA failure mode - despite all the complexity in the plane - was something that was fairly basic. Sort of undergraduate reliability engineering.
Yeah, it's interesting. And that's sort of the contrast of this plane. By the standards of modern aircraft, the 737 is rudimentary, according to the pilots and engineers I talked to. It was [originally] designed in an analogue era before there were significant amounts of software on the plane. And over time, it's been updated so that it's neither one nor the other. And that was where the potential for problems arose because there is a handoff between the automation and the person and unless the person is aware of what the automation is doing, they're not going to be able to intervene and understand what's going on.
Yeah, that was very apparent from reading through the book. If you're familiar with the ‘Swiss cheese model’ of accident causation: It's a bit like, if you've got a leak eventually the water will find the way through the holes. There's maybe aspects of narrative fallacy, if you like, but the other side of it is if you put enough pressure on a system, eventually you'll find the holes through it. There seems to be, again, that classic example of the alignment of the different circumstances where you had the commercial pressures; you had this underlying fault; you had the training requirements being watered down; You had the failure to put in place an electronic checklist and in effect not making the fault fully visible. Then another aspect to it was the regulatory side, which I thought was quite fascinating and the sort of approach to ‘self-assurance’. Is it possible just to say a few words about what you gathered around what happened there and the dynamic around that?
Yeah, for decades the regulation had been outsourced to some extent from the FAA to the manufacturers and the FAA relied on engineers at Boeing to check off on these dozens and dozens of individual requirements that needed to be followed, which would have ensured that there was redundancy in commercial aircraft systems over time. The FAA [had historically ensured that there were] checks and balances to that and the system that have been in place at Boeing. This relied on this ‘dotted line’ reporting relationship between the delegates at Boeing and managers at the FAA. But increasingly Congress, partly to save money and partly for philosophical reasons handed more control to private industry, Congress started allowing the FAA to allow the managers at Boeing to sign off on more of their own work. There was less of a relationship with the FAA manager. The engineers at Boeing would report to their managers at Boeing. The managers at Boeing would then interface with people at the FAA and the engineers at the ground level felt that what emerged was managers at both the manufacturer and the regulator working together to speed the aircraft to meet compliance rather than holding manufacturer's feet to the fire and making sure from the start that the compliance was met.
And it is interesting because I like looking at trends and partly this is complexity driven, isn't it? Because the more you localize design, the more design complexity you make and the more of a sort of broader supply chain you have, the more it is likely that the regulator is not going to have the skills they need to truly understand the system. It sounds horrific when you look at it in the post-accident scenario. But also it's a function of the growing complexity of some of these technological systems.
Yeah. And also almost the deliberate dumbing down of the regulator. It was increasingly lacking funding to hire the best people to train its own workforce and just to have the number of people that needed to do that job.
The other aspect of this is of course that Boeing is a huge corporation - there can't be many people who haven't flown on a Boeing plane, you know, many times - and the financial impact, because you talk about the cost savings and the cost drivers for this. But the financial impact of these accidents is astronomical. So, I mean, I remember reading somewhere that it caused 1/4 of a point drop in US GDP for a year or something - I'll come up with a figure - But it was something frightening. [Note: sources speculated that a pause in 737 Max production in 2020 would lead to 0.2 percentage points from US GDP growth for the year GDP effect of a longer pause in 737 MAX production.]
Yeah, Boeing has long been the biggest manufacturing exporter in the country. And for a long time it's been also one of the few manufacturers that still has many jobs that are in in the United States rather than shifting overseas.
And a massive supply chain as well, I guess.
Yeah, a massive supply chain that so that that plays a role in, you know, decisions made by government where it's difficult to force change when you know so much of the economy depends on this company.
Yes. So as well as obviously the massive human cost you've got, you know, it is an irony, isn't it - in the analogies it’s the costs under the iceberg isn't it? If you could properly visualize the risk on the bottom line then clearly those cost savings didn't even make sense from a financial perspective.
Right, right. Yeah. I mean, Boeing has for a long time been reluctant to fully update the 737 because of the sunk cost of this huge manufacturing and supply base. You know, the initial tooling is paid off. So its profitability for each of these airplanes is good. And so if it were to invest the amount that analysts had said, they would need to invest for an all new plane to match Airbus, which developed its plane 20 years later. That amount would have been $10-15 billion. Boeing made the argument to its board that [they could do it cheaper]. The tagline for its pitch to the board was that this new derivative would be “stingy a with a purpose” and the purpose was to match Airbus but not spend anymore than they needed to. It was that the cost was going to be a billion or two instead. Then Boeing had these terrible accidents and human toll and costs to its reputation. And the financial penalty ended up being more than $20 billion when all was said and done.
Are you still following progress? I'm aware obviously that plane finally got its certification to go back into operations some time ago internationally and I guess that was quite a ‘bun fight’ between European regulators and American regulators and others with the ongoing competition between Airbus and Boeing. But are you up to speed with where things are currently and is it possible to summarize from your perspective?
Yeah, well, you know, so the Max is back in service in most of the world. The big exception there is China, which had been up to 1/3 of Boeing's order book for single aisles planes. But China - partly because it's developing its own single aisle plane - seems to be withholding support. So that's a real question for Boeing's commercial prospects going forward if that relationship isn't fixed. The other way that these accidents set back Boeing was that it had been on the verge of potentially introducing a new single aisle plane to match Airbus, the 797. However, Boeing has now said that that is not going to happen for at least a decade. In the meantime, Airbus is scoring thousands of orders: well ahead of Boeing in that market. So there's a real risk that Boeing tails off, as McDonnell/Douglas did before it, and becomes a secondary player going forward. These things take a long time so this is going forward over 10/20 years.
You're right. I mean, nothing is permanent, is it? And they are certainly an impactful couple of accidents that are obviously going to have a major impact on the business. As a safety engineer, there are certain accidents that have happened in the past that become fundamental in terms of learning. That's one of the things you can always take out of a major accident in consolation and often the bereaved do that, by saying “Well, at least we can make sure that nothing like this ever happens again.” On the safety side, accidents like Challenger, Piper Alpha and the Bhopal chemical disaster in India spring to mind. For me now, the 737 Max has become one of those cautionary tales. They each have their own high-level lessons to learn. How would you summarize the kind of fundamental learning from what's happened with the 737 Max?
I mean the fundamental lesson as it's been described to me is, is that you need to take into account the the human factors. That was the core problem in this crash that the reaction of the pilots was not what was expected. And that's because their reaction was not tested before Boeing introduced this plane and allowed the public to fly on it. That there was a rudimentary test done, but it didn't simulate what would actually be happening in the cockpit, which was a big change from how Boeing had preceded in the past, when it tested and tested and tested in in the real world, you know, each of these problems. So that's something that in the legislation the Congress introduced is supposed to be addressed: that the human factors need to be considered in any new aircraft. So hopefully that is a lesson that comes out of this and that these problems relating to the interface between the machine and the person don't crop up with the same severity in the future.
Thanks for writing the book, Peter, because as I say with these sorts of incidents, it's really good to get the learning out. To be able to have a really strong narrative, and an engrossing book such as yours is a way of keeping some of those messages and information alive and sharing the learning. You know, you can read the technical reports, but I always try and search out the books like yours because it's a way of engaging with the topics without it being too dry or feeling like work. So for what it's worth, my thanks for taking the time and effort to do it. Has it piqued your interest for any other similar sorts of issues in the safety and technological space and is there anything you're researching now that you could talk about?
I mean, I'm still an investigative reporter for Bloomberg. So I'm, you know, always looking into new things but the main thing I'm writing about lately is online sports betting.
OK. Well actually I'm quite interested in that myself as a student of probability and risk assessment. But there you go, that's another conversation.
That's a different book.
Yes. Well, thanks ever so much. It's a pleasure talking to you and I would highly recommend the book to anybody who's listening and wants to get a really engrossing trip through this really important story, to learn the experience from these accidents.
Thanks so much.
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All views here are my own. Please feel free to feed back any thoughts or comments and please do feel free to drop me an e-mail on george.bearfield@ntlworld.com: My particular area of professional and research interest is practical risk management and assurance of new technology. I’m always keen to engage on interesting projects in this area.
The Story of the 737 Max