“Boeing has no higher priority than the safety of the flying public,"
Clearly this is not the least bit true.
41
I have to admit the NY Times knows how to pile it on. As usual the NYT tells only one side of the story, as does the rest of the media. I can only conclude they don't want to get sued. Without question the Boeing Max needed the software update. After reading the technical portion of the accident reports of both the Lion Air crash last October and the Ethiopian Airlines crash in March all I could think was WOW.......are you kidding me? Only one sensor input? The rate of stabilizer movement. The travel limits etc...etc..etc. Then..........I got into the transcripts of the cockpit voice recorders, the flight data recorders and newly exposed testimony of the pilots the day before the fateful crash in October. Why......why is there no reporting on what the pilots ""could"" and ""should"" have done to recover and land the plane safely. We know for a fact that last Oct 27 the exact same aircraft experienced the same un-commanded pitch down trim after takeoff and right after ""flaps retracted"". Struggling to regain control by the pilot flying, a Lion Air pilot riding in the cockpit jump seat to Jakarta ""recognized"" the problem and suggested trying the runaway trim procedure. The pilot flying did exactly that and the aircraft landed safely in Jakarta. Any pilot that has flown jets long enough and experienced......would have quickly and calmly identified the problem and taken immediate action to recover. The unfortunate pilots of the two airlines did not.
14
Just turned on youtube for break from a stressful project; the recommendation I'm fed is a Nat Geo "What Really Made the Titanic Sink" documentary. The approx 4:15-4:55:
"2 Years before the scheduled launch date, [White Star head] Isbane met with his chief designer, Alexander Carlisle. They make what they think to be insignificant changes, given the many safety features Titanic will boast."
Isbane: "These staircases will need to be much grander."
Carlyle, an uneasy look on his face: "The bulkheads will have to be lowered."
After a pause, Isbane: "Will that be a problem -- Isn't she safe?"
Carlyle, with a very slight hesitation: "Of course."
This is the kind of dialogue David Mamet (I guess like any great writer, but Mamet makes this a kind of specialty) finds so fascinating: eliptical, with most of the content/communication "between the lines."
Each person in the chain relies on tacit understanding and instructions for "everybody's" mutual protection, that is everybody except the customer I suppose. As it happens, Isbane was one of the few adult men to survive, according to the documentary. (Good to be in charge!)
11
With apologies, some unintentional embellishment on my part; I'd written down the words a half hr, before typing them in my comment, & confused important details of the visuals, conflating with another scene showing guilty and uneasy looks. A serious error on my part. But the Narration and words exchanged btw Isbane and Carlyle are exact as in the program, and subtext is there if a bit more subtly than I thought/indicated.
6
So; when is it time to put a 50+ year old aircraft in the graveyard? Apparently never. The first 737 I worked was a dumpy fat version of the sleeker 727-100 and 727-200. But-of-course, as technology allowed for more fuel efficiency, what airline would want to purchase a tri-engine aircraft when it could get by on a twin-engine?
But...how does one continue to add heft to an engine and maintain a stretched-out narrow fuselage with double the passenger load as its predecessors- and believe nothing could possibly go wrong?
No one has even broached the subject of evacuation standards because the F.A.A. does not keep records(according to the F.A.A.). The aisles of this generation of 737 are almost impossible for flight attendants to traverse-except sideways:
This aircraft is a death-trap.
22
This is criminal. Boeing executives need to be prosecuted, with real prison time a possibility in event of a conviction.
26
Who would have been responsible for bearing the costs of simulator and training the cockpit crew; Boeing or the airlines? Do we really know if American Airlines wasn't involved in deciding it didn't need its pilots trained or require the additional few pages of a manual?
Do we really know if Boeing actually had correct information to include in a manual update?
Hopefully someone's diligent lawyer will subpoena internal memos and emails between Boeing and its largest clients.
9
"Boeing declined to say whether the changes had prompted a new internal safety analysis." -- In other words, Boeing admitted that the changes had NOT prompted a new internal safety analysis. -- AS THEY (and every change) SHOULD HAVE!
Lawyerly minds should never be allowed to be applied to technical issues.
11
The Supreme Court has declared that Corporations are Persons. So perhaps, Boeing should be convicted, fined, and spend some time in prison. Oh wait. We can't do that. But a few of the top people from each of several departments can fill in for the Corporation. And perhaps even a few people on the Board. EVERY Corporation needs to conduct itself as if it's a "man on the street."
25
How Boeing procedures could allow reliance on MCAS to be expanded upon late in the design phase and not have red flags pop up everywhere is staggering. Makes you wonder what other disastrous systems might be hiding away.
13
I would say that modern companies fail in a fundamental way, and that is to put shareholder value (profit) above all else.
Shareholder value. Rush things to market. Move your plant to a cheaper location with less skilled labor. This has not worked out well for Boeing, and will not work out well for a myriad of other companies. Relentless pursuit of shareholder value in the short run, erodes company prospects in the long run.
19
@Will Hogan: I am a shareholder, and I don't feel valued at all.
10
“Boeing has no higher priority than the safety of the flying public,”
That statement is obviously a canard as this article and 346 lives lost show. Sadly as with all multinational corporations, they follow the dictum of Karl Marx's Genesis of the Industrial Capitalist, footnote 15: "... Capital eschews no profit, or very small profit, just as Nature was formerly said to abhor a vacuum. With adequate profit, capital is very bold. A certain 10 per cent. will ensure its employment anywhere; 20 per cent. certain will produce eagerness; 50 per cent., positive audacity; 100 per cent. will make it ready to trample on all human laws; 300 per cent., and there is not a crime at which it will scruple, nor a risk it will not run, even to the chance of its owner being hanged. If turbulence and strife will bring a profit, it will freely encourage both. Smuggling and the slave-trade have amply proved all that is here stated." (T. J. Dunning, l. c., pp. 35, 36.)
Until such a time as the corporate decision makers are punished accordingly to the risk they foist on society or crimes they perpetrate, sadly we will continue to sacrifice lives to their idol of profit above all else...
13
@Catwhisperer: Shareholder democracy is another unrealized dream.
5
I don't think the problem with this airplane is the way the design change was approved. After reading a number of news stories, this is my summary of what happened:
Boeing had an old reliable airplane in the 737. (I've flown on one many times.)
Boeing had new more fuel-efficient engines that it wanted to install on the 737.
But the engines were too big to fit under the wing, because that would mean a complete redesign of the landing gear, the wing, and more.
So, Boeing mounted the big engines way forward of the wing.
The plane could fly that way, but the new engine location made the plane naturally want to climb and stall instead of fly straight.
Boeing had few choices. One choice would be to abandon the design. Perhaps readers who are engineers could explain whether other design changes, such as lengthening the fuselage, might have fixed this propensity to climb and stall.
Boeing decided that the solution to the design problem was to write a computer program (MCAS) that would take control of the plane's angle-of-attack away from the pilots. Which is what they did.
Big mistake.
Seriously, who among you will fly on this plane?
19
Just to challenge all those who profess a simple interpretation that blames everything on Boeing greed, what about your greed? How many times have you selected or even changed travel plans to save $50? How much more would you actually pay to fund improved safety?
7
@Bob Krantz
Yes, we may all have that trait to some degree. But this fact does not diminish Boeing's guilt. If an individual's greed cost over 350 lives (and potentially a lot more) then he/she would be as guilty as Boeing.
11
@Bob Krantz, trying to save money on airfares is not anywhere near equivalent to corporate cutting corners:
- consumers do not interact with airplane manufacturers such as Boeing and Airbus - the airlines do;
- ticket prices ranging from cheap, inflexible fares to expensive flexible fares are designed to maximize the number of seats sold and using various prices is built into airline profit models; and
- the cost of planes are amortized over many years and many thousands of flight hours.
But ultimately, even if it is "greed," your or my trying to save a few bucks on airfare doesn't kill hundreds of people. Corporate cutting corners on key safety features does, and did.
15
In my long career in technology I have observed a seismic shift in culture driven in the USA by the separation of technical, financial, and management disciplines. The culture that built the Apollo success was driven, in the main, by technical managers who had the respect of those they managed, but also the ability to control and shape decisions. They were respected because they had “done” the job, and their experience was hard won - they had lived the job...
Nowadays it is quite regular to deal with a senior leader who has never done the “job”, who has come up through Sales or financial management. Due to this ignorance, the risk framework so essential for safety (from physical systems such as at Boeing, to cyber-physical systems on the Internet), is often missing. Budgets, needed to reduce risk, are withheld to reduce costs and improve margins, and the result is what we see in catastrophic failures of systems such as at Boeing, or the breach of IT systems due to lack of simple controls.
24
If a VP of Boeing (e.g., Michael Sinnett) can defend the idea of using a only single sensor (i.e.,without redundancy) for critical system decisions, Boeing management team as a whole must be incompetent. Any management team of a competent engineering company would have weeded out such idiots out of the company long before they could be a manager let alone a Vice President. This engineering 101 stuff. Certainly makes me more worried about flying any Boeing aircraft.
24
I'm glad we had other reasons to cancel a trip on which we were scheduled on a 737 Max.
This sequence of events, triggered almost entirely by profit concerns, is almost past belief--almost. In other ways, it is just what we might expect of the current antiregulatory business climate.
Climate...that's another issue likely to intrude on our notice sooner than later.
9
Hospitals and medical practitioners are constantly barraged with messages and educational pieces about patient safety, mindful of the statistics and bad publicity from medical mishaps. The stellar safety record of the aerospace industry has always been an example of something we need to emulate, removing human error is always the focus. Now with these catastrophes I am not so sure that the aerospace industry has it figured out at all. A software error and only one sensor? Put engineers in charge of airplanes and doctors in charge of hospitals.
7
@rosy Medical and hospital mistakes are the 3rd leading cause of death in the U.S....reportedly 250,000+ per year.
3
It seems to me that some of the people involved in that entire ordeal acted criminally. That's especially true for the time after the Lion Air crash, and even more true for those 4 days after the Ethiopian Air crash. Boeing acted under a "money first, safety second" moto and, even more disgustingly, so did the FAA.
I won't get on any 737 MAX, because it is built in an aerodynamically-flawed manner. Boeing, had it put safety first, should have fixed the plane aerodynamically, instead of the software band-aid it tried to use (which itself killed 346 innocent people).
In any case, I can only hope - although it might be a little naive - that the US authorities will investigate this entire manner and will prosecute all those whose actions in this ordeal were criminal. They owe at least that to the hundreds of families who suffered an unimaginable loss because of Boeing's greed and the FAA's complacency.
19
Pretty soon, you will see trucks running down the highway without the human backup.
10
The 737 Max should remain on the ground and perhaps the aircraft can be used as a museums around the country, pointing out what happens to companies that take their eye off the ball.
14
After all this, it will be interesting to see if passengers will fly on the Max. Or will it be always ride on the elevator that fell last because it is the the one most recently inspected. IDK.
6
There's a critical warning in this tragedy for designers and proponents of self-driving highway vehicles: Don't let your rush to 'succeed' cloud your judgement, accelerate your timetable or otherwise cause you to overlook potential hazards in your quest to achieve. Every unattended bug, every sign of a problem that's ignored or minimized may be setting the stage for disaster downstream, especially when your system involves automated remote updates, driver/operating system interfaces, or vehicle-to-vehicle communications. And don't forget that human drivers, unlike commercial pilots, don't have training, detailed tech manuals. or the savvy and the job mandate to consult and understand such guidance. Multiply the 737 Max failures by thousands and you get a sense of that's involved.
10
Excellent article and research by the authors. The article is easy to follow and the need to meet deadlines and bypass safety checks by Boeing is ultimately the basis for the flawed design. Safe must always be the priority and full control should never be taken completely from the pilots. Though I am just a layperson, I have worked in high tech and the computer industry to know you can never completely trust any software.
Two crashed planes and hundreds of lost lives are enough to make anyone working in the aero plane manufacturing industry to wake up and pay attention.
12
@Eric
There are actually two sensor on every plane, each pilot has his own sensor and system.
So, it is pretty obvious that there is an issue when one says you are at risk of stalling, and the other doesn't report anything wrong.
Plus, as a pilot, you quickly see by looking outside that the AOA system is not working properly.
Then, pilots must know the two switches they have to pull up to Manually Fly the plane. Those are memory items they have to know by heart.
But yes, automatically deactivating any automation when a discord is detected would have broken the chain of events leading to the crashes and maybe permitted to avoid the crashes.
Still, I am not an expert, so it might be creating other potentially dangerous events or more stress on pilots to have the system deactivating on its own.
As an example, you can take the Airbus 447 Airfrance flight that crashed after the automated system deactivated because a sensors was frozen and couldn't function.
There, the two pilots inadvertently gave opposite commands to the plane, each one with his own joystick. As a result the plane didn't respond.
Unfortunately nothing helped them to figure this out until, moments before the plane crashed, the second pilot in command shouted it.
Is this a criminal act from Airbus engineers: no system alert on conflicting commands (or at least no priority given to one input of commands)?
4
I seldom fly. But I can't imagine voluntarily boarding the 737-Max. Does Boeing think it can sweep the problems and crashes under the rug and folks will just forget?
12
I am amazed that bird strikes on the angle of attack sensor were relatively common, and yet they apparently did nothing to fortify the sensor, provide a second sensor as backup from the beginning , or mark the MCAS control routine offline (and warn the crew) when the sensor failed. It was criminal to have an “invisible” software routine based on a single sensor’s input. What other software flaws are waiting for the right circumstances to surface?
10
Our culture praises the greenback at all costs! As long as annual returns are produced, ALL effort is holy, regardless if safety, lives, or expertise are compromised. For corporate executives and shareholders deadly accidents are just insurance write offs, despite all official statements. Unless the American Public realizes the importance and necessity of functioning regulations and oversight, nothing will change. In fact, the path we all are heading down should alert all of us, as many more accidents are waiting to happen, since all regulators (FAA, EPA, FDA .. ) are already politically and commercially compromised. The B737-8/9max is an engineering blunder, and every aerospace engineer knows that! Taking a 65 year old airframe and still stretching its use into the 21st century is like turning an old VW beetle into a Ferrari. Corporate greed at its finest!
10
A fish rots from the head down. America is a disgrace, with systemic shoddiness and corruption. just look at the untrustworthy US president.
10
Short and direct:
I -- and everybody I've asked, numbering in the hundreds -- will never fly on the 737 Max, no matter what fix is installed. Even for free.
The re-situating the larger engines made the design inherently unstable. No software change can negate that.
Boeing: Kill this craft. Move on. If that is financially disastrous: Better you die than we do.
21
Boeing made a series of mistakes that led to the fatal colossal failure of its plane, not once , but twice. It is reprehensible that Boeing did not reveal the root cause of the plane's failure after the first incident. I cannot imagine they didn't immediately suspect the pitch sensor was the ultimate cause of failure. Boeing probably thought they could manage this and resolve the problem before it reoccurred and thereby save face. The company is not comprised of dumb people, but they are apparently comprised of a group of people in management more concerned about their image than the lives of others. For this they should go to jail and be banned from ever working in aerospace again.
I was incredulous after reading that Boeing relied on only one sensor to control the airplane. That is wrong on so many levels That is stupidity and complete lack of disregard for the consequences of such a decision. When I also read that their initial fix was to install a second sensor that must agree with a second sensor within 5%, i was in shock. What this means is that these sensors that control the pitch of the aircraft are not reliable to any better than 2.5%. If they think that controlling an aircraft's pitch to within 2.5% is acceptable, then I do not want to fly in another new Boeing jet until that entire management is removed from their responsibilities.
9
@Eric
The 2 Angle of Attack (AOA) sensors are on opposite sides of the forward fuselage and can have slightly different readings based on factors as simple as a crosswind gust. In normal flight pitch is rarely greater than about 15 deg nose up or 5 deg nose down. 2.5% is a perfectly reasonable standard.
2
@VCuttolo , thank you.
As per the possibility of a consciously hidden criminal happening at the FAA, or Boeing, or both, I see nothing that is criminal, where you could point your finger and say: "There, they knew this would happen, and they didn't care about the unavoidable crashes it will cause".
I am not saying it is impossible, please do your investigations I say, I welcome those.
But, considering the consequences of even just 1 crash, It is just a nightmare on all levels for everybody. Not to mention economically, its a total disaster.
You would find surely a lot of misshapen, but for safety critical items this is just suicide to pass on them. And there is not just 1 man or 2 than can hide that, there is a chain to validate and test them.
For MCAS, and the system it is part of, I am surprised also to see it relies on 1 single sensors.
But again, as a pilot, looking at the windows and understanding there is something wrong with your AOA system is a matter of seconds. There you have two switches to pull up and take control of the plane.
So, as far as you can argue that MCAS was flawed, that the way they engineered or re-engineered it was "criminal", this is not a Single Point of Failure, MCAS had never reported any issues, and this would not be The Reason for the crashes. But, yes, bring it up.
What both crashes experienced is called a runaway stabilizer, this is one of the first incident a pilot is trained to face.
https://www.youtube.com/watch?v=E-1e3P1cO_8
1
I and many of my fellow 737 pilots believe that although it’s clear Boeing mishandled MCAS engineering and certification, the primary cause of both accidents is pilot error. Both accident flights crews did not perform (or completely and fully perform) an existing “Runaway Stabilizer” emergency checklist, which should have been called for by either pilot after MCAS activation. I believe Boeing’s inadequate design and training should be determined to be a contributing factor.
In the end I hope Boeing will do what it takes to restore their reputation, and that the 737 Max will be as safe as the previous 737 versions.
4
"While prosecutors and lawmakers try to piece together what went wrong, "
LOL, what went wrong was greed and letting the fox guard the chiocken coop.
Don't need to be a genius to figure that out LOL.
6
Heads should roll at Boeing, starting at the top. And the people working directly on the project must go.
6
* Boeing has a better safety record than Airbus (until now, anyway). As the NYT reported a few weeks ago, an old pilots' saying is, "If it's not Boeing, I'm not going."
* There is no question that pilot error was a major factor in these crashes. The system was easily overridable. The two pilots did indeed override the system initially....and then let it go again. Bad decision.
* Boeing's upper management likes market share, but they are not idiots. Crashes are very bad for business. They did not expect this to happen.
BUT, AT THE SAME TIME....
* A small number of people at Boeing upper management were clearly engaging in wishful thinking. A Congressional investigation would be warranted here to help discover who understood the full picture but pushed this through anyway.
* Someone at the FAA clearly dropped the ball. More questions were needed during the approval process.
A fuller understanding of the sitiation here would be highly warranted.
4
Well they don't anymore. Read the first paragraph of the article again.
5
If you read any of the previous articles you would have read it was not easily overrideable.
6
@VCuttolo: It was already difficult to manually crank the horizontal stabilizer on a 737 with earlier engines. These have to be even more difficult. This is probably why the pilots of the second plane turned the system back on, and the MCAS dis its own thing. The pilot in command had lots of time in 737s.
5
From what I have been able to gather, we are all highly trained pilots and security consultants.
It is always so easy to assume criminal intent on every decision made by others.
We all know that people make mistakes all the time. Specifically, nothing that the government does ever works. :-)
I worked in private industry for over 40 years, rare was the day when somebody didn't make a dumb decision.
Some of those decisions go into the field and hurt innocent customers. This is easy to verify by reading recall reports. The daily press shows many instances where private companies fight tooth and nail to paper over critical incidents, causing death in several instances.
Fortunately, few of us are in charge of designing complicated passenger planes, although I am intimately familiar with all the bugs that go into large real time complex software systems.
Boeing made several critical errors in this instance. I hope that they will have learned enough so that they will improve their processes going forward.
Boeing is a highly successful company. This might have led some of their people to believe that they had already covered all their bases. Hopefully, the current catastrophic circumstances will teach them otherwise.
1
They should have hired a statistician - who would've told them that the minimum number of sensors is 30 for basing decisions, and not 1 or 2.
5
@Ram
Source for this? As someone who is fairly statistics literate, a "minimum number of sensors" depends on the reliability of each sensor, the independence of each sensor (is failure correlated across sensors or modalities of sensing?), and the acceptable failure rate of the entire system. Determining each of these factors is complex and I'm not really sure how you came up with the number 30.
13
@Ben
Maybe his point is that it’s not clear why two sensors are enough? In fact if one sensor is faulty there maybe no way to tell which one is the problematic one. They should have had at least 3.
23
@A. Raymond exactly correct, at least two can outvote whichever is the faulty one.
17
This is just so appalling. Why is Boeing allowed to continue? They should be shut down. This is not something that can be allowed to continue with a software patch!
Consumers, refuse to fly any airline that has these planes.
16
@scientella Unrealistic as that would rule out flying on pretty much ALL airlines except maybe Southwest. There are only two serious plane manufacturers on the planet that make long-range passenger aircraft, Airbus and Boeing. Most airlines fly various configurations of planes from both companies.
2
The description of this problem in the article, where no one understood the ramifications of things put in place, is reminiscent of the descriptions of credit default swaps in the financial industry, when the financial system was on the brink in 2008.
Basically, putting a strong stimulus into a complex system with little idea or testing how this will affect the system seems to be the recurrent theme here. And all driven by greed and desire to make more money as quickly as possible.
I wonder if, like in the case of the one single lower level French guy from Goldman-Sachs who was putting together that one single credit default swap, some lower level engineer, perhaps another non-American, will be found "guilty" of making the mistake of making the MCAS more aggressive and making it reliant on one single sensor and be blamed for the crashes of these two MAXes. This would most certainly absolve the company of wrongdoing and save her from paying billions in damages to families and airlines with grounded planes.
If this is how America now operates in the 21st century I am concerned that this kind of America may not survive that 21st century.
38
@reader
Really, what can you expect from a country which inoculated its society with the morbid obesity epidemic starting in the 1970s when high fructose corn syrup was accepted on an industrial scale in all processed foodstuffs? All a ploy to prop up US farmers' declining revenues and do something 'useful' with that corn surplus. The moral : the buyer be ware, for there is no one out there in the world to defend the ordinary person's basic rights to safety and health in the US.
39
@AE
Fortunately, we still have some parts of the press working on protecting us.
That is why they are the "enemy of the people" with power and money.
12
This is where we are in the time of Trump: the FAA was once the global gold standard for making aviation ever-safer. Now knowledgable people are hoping any authority and nation other than the FAA and the US will act to ensure these fundamentally flawed planes are safe enough to return to the skies.
58
@Ryan VB
Wasn’t this designed and first certified during the “time of Obama”?
13
@George S
Yep, under Obama. Some Trump haters (and I am one) want to blame him for every catastrophe. He isn't quite that powerful.
I'm waiting for those folks to demand hurricanes be named after Trump's family members. "Hurricane Jared" has a nice ring to it. Jared Jewelers might get upset. but what's more important, their reputation or your hatred?
6
The journalists note that there is an on-going investigation of both accidents, however they are evidently not willing to wait for the results. They are joining many journalists in their non-expert speculations. The only known, professionally verified fact of the accidents at this point, is that they occurred under pilot duress. But if they are like the vast majority of airline accidents over the last 50 years and more, they involve a complex chain of causal factors that must be carefully unwound.
It is otherwise unusual for the FAA to maintain a passive regulatory posture during the engineering phase, and in its final certification. That posture may be partly explained however, by the prevailing FAA administrative culture at the time of the aircraft’s certification: the former head of the FAA was an Obama political appointee with no aviation engineering, management or regulatory experience of any kind. The FAA Administrator role is a technical one that requires deep industry operations and management experience. Fortunately, the current Administrator has such qualifications. As President Trump continues to discover, his presidential predecessor, also with no business, scientific, military, engineering or financial experience, had a profound effect on the basic qualification criteria for many government positions, which in hindsight appear more motivated by political ideology and identitarianism.
Thank you (Jet Airline Transport Pilot, Instructor)
3
@Matt Andersson
Your political slip is showing. Yes, Trump has the perfect solution to the appointment problem. He just doesn't appoint anyone, and relies on "acting" administrators. Trump even says he prefers this, since they are less independent. And haven't we had great EPA and HHS administrators! And our current AG will clearly go down as one of the most unique in history.
Trump can't discover anything! Even when his National Security Advisors are in total agreement about something, Trump knows better. After all he is a self proclaimed "genius".
15
@Matt Andersson This has absolutely nothing to do with either Obama or Trump. This is a result of a gradual process of budget cutting for government agencies, here F.A.A., increasing self-regulation at Boeing, relaxing safety testing requirements at multiple points and a corporate culture, where money and projected image take priority over decency and responsibility. After the two crashes and all the reporting of the regulatory shortcomings, Trump should set up a commission to investigate and overhaul the F.A.A. Sadly, I think he is too immature and distracted to be able to take such a constructive step.
16
@Matt Andersson the past appointees are eminently more qualified than the current crop. Rick Perry? "Dr" Ben Carson? Just wow.
7
Incidents like these 737 Max crashes make me even more reluctant to fly third world carriers. I know the plane has serious problems, but I also notice that both crashes were with third world airlines.
2
@RandyJ
American pilots were tested with the Lion Air and Ethiopian Air incidents on simulators that included the old MCAS with a failed Angle of Attack sensor.
Each of the pilots already knew about the MCAS and the crashes. Still, almost half of them crashed their simulation runs--and were appalled to find they had 30 to 40 seconds to identify the problem and correct it before the actions of the MCAS pushed the aircraft into an unrecoverable dive.
The pilots of the first plane to crash did not know about MCAS or how to deal with it. The pilots of the Ethiopian Air crash did correctly diagnose the problem (partially disclosed to them by the FAA) and disabled the power to the horizontal stabilizer, preventing MCAS from pushing the nose down farther. Unfortunately, they could not move the manual stabilizer adjustment because of the prressure on the stabilizer (a well known 737 problem) and had to turn the jackscrew power back on to pull the nose up. Unfortunately, this also activated the MCAS which pushed the nose back down further.
In short, your confidence the pilots of US aircraft could have saved these aircraft with the misdesigned MCAS is misplaced, and crash information and the simulation runs by US pilots prove it. Your opinion is yours, but the fact do not support it in this case.
71
@RandyJ - did we read the same article, because it seems abundantly clear to me, that the problem lies with a very greedy and negligent American airplane manufacturer, which is why I’m petitioning to make sure my country - Canada - gets rid of all it’s Boeing aircraft, and stick Airbus, a far superior European company, that cares whether or not people make it to their destination in one piece.
8
@Mark Johnson -->
Exactly! It is disheartening how many "self-described guru's" are unaware of these basic facts as reported in numerous sources like Dominic Gates @ ST and Peter Lemme @ satcom.guru.
Thank you for silencing the misinformed.
5
CEO and key executives at Boeing need to be indicted for manslaughter or worse.
3
This is crazy, with the none sense comments I see I might be able to buy back 737 Max brand new and put it in my garden.
And if I could I'd exclusively fly in it, with all the public harassment, it is going to be the most secure plane in the world.
- USA safest place to fly in the world.
- Max 8 took 8 years to be certified, compared to an average of 3 years for other planes.
- Both crashes show many other issues than the sole trim stabilizers acting wrongly because of a faulty sensor. For example the erroneous reactions of the pilots.
- We can also mention the fact both crashes happened in countries that are very young regarding commercial aviation development and also
- have much lower safety standards.
Then you have CBS making an interview with Boeing CEO and editing the video so that it seems he is actually apologizing for the crashes, when he is apologizing for a maintenance light used for end of flight reporting.
What is this mass whale hunting?
Aviation security is not politics nor economics, it is all about data and factual realities which will realize the outstanding record FAA and Boeing have achieved in the USA airspace.
You can search, research and understand, make speculations, be wise, foresee solutions, but slam Boeing as if it was criminal, so far there is nothing to leverage on, its just down and naive speculation( I am sorry :/).
You have Volkswagen that consciously altered algorithms to avoid regulation, this is criminal, this is for profit.
2
@Vasco
Thank you for pointing out some items omitted by this article. Namely, that Boeing's safety record is superior to that of Airbus, and that inexperienced pilots were undoubtedly a significant factor in those two crashes.
At the same time, it does clearly appear that someone at the FAA blew it, and at least one person at Boeing was involved in an effort to mislead the FAA. That is not acceptable.
1
@VCuttolo: The airplane can be seen porpoising in straight and level flight because those engines have so much leverage over the horizontal stabilizer, being that far forward, that they create positive feedback to both pitching up and pitching down.
3
Good journalism, but they might have mentioned from the get go that the root problem was not the MCAS. It was the redo of an extinct design.
As reported later, when the old fussy test pilot noticed that under certain conditions the plane "wasn't flying smoothly", the fact is that it was tending to snap roll like a nimble fighter plane in a dog fight. Not good for a passenger jet on takeoff.
Naturally, it would be back to the drawing board.
But wait, Boeing's new agile streamlined management decided they could make chicken salad from chicken manure by blessing it with a few lines of hidden computer code.
Boeing-FAA proclaimed it was the best ever salad and the market ate it up, for a while. Then the manure hit the fan.
Boeing's new normal seems to be to pile on more manure and computer code to prove that even a cow chip can fly.
And this is how stuff happens.
7
MBAs at work.
6
@sjm: The problem is with the pitch axis, not the roll axis.
2
The drawn out 787 boondoggle showed that Boeing management in Chicago had lost the ability to design, develop and deliver a plane. So the 737 MAX program was the new model for plane development. Update a current model, so there's less to screw up. Clearly, that didn't go well either.
Boeing needs to hire some competence and start running their business from the factory floor again. Everyone in Chicago should get a severence package.
(Not a Boeing employee, just a passenger that likes to arrive safely)
6
@David Witcraft The 787 is what some airlines are now flying from LAX and SFO non-stop to Australia instead of 747s. It actually has more range than the 747 which barely has enough gas to glide in to Sydney at that distance, but I'd still prefer it to the sketchy 787.
1
I published an article on these issues and how Boeing might have avoided it with a different product development approach. an approach that worked for the development of the Boeing 777. Kudos to NYT for running with some of those ideas as only NYT can. What is missing from the reporting is how they could have done it differently. https://www.innovel.net/how-to-avoid-fatal-product-flaws-with-agile-and-scrum/
2
I am ashamed of Boeing leadership. They should be gone. They should have had the decency to resign. I am ashamed of the shareholders who have allowed Boeing leadership to remain. As a 34-year veteran of Boeing, CEO Muilenburg's first instinct is to protect Boeing, not the passengers or crew. His first instinct, after the second crash, was to call President Trump and ask that the planes keep flying. It was not to apologize abjectly to the families for the loss of their loved ones.
9
I am not a pilot or a aircraft mechanic however after reading the article you can follow how Boeing rushed to complete this plane before the design had been fully vetted. In addition Boeing use of Flight Simulators by it's Chief Test Pilots over actually flying the aircraft is fraud.
1
I do not understand your story. Your statement...
"But many people involved in building, testing and approving the system, known as MCAS, said they hadn’t fully understood the changes."
makes no sense.
How do you build, test and approve something and not know it relies on only one sensor.
We really don't know the real background to how this decision was made.
4
It's obvious using just one sensor is risky, but there must have been a good reason for only using one of the two angle of attack sensors in the software logic. Now they decide to use both sensors. Since only an idiot would use data from just one sensor (and Boeing engineers are not idiots,) I wonder what the original good reason was for deciding to use only one of the sensors?
5
@Johan_Larsen. Two is no better than one, because you don't know which of the two is wrong when they don't agree. That is why Airbus uses three and relies on the two that agree if one is off. Air France had lost an A-340 over the Atlantic when the pilots became disoriented at night after the angle of attack sensor malfunctioned.
6
I think that by « old-school » you mean « common-sense ».
1
At a tense meeting with the pilots’ union at American Airlines in November, Boeing executives dismissed concerns. “It’s been reported that it’s a single point failure, but it is not considered by design or certification a single point,” said Mike Sinnett, a Boeing vice president, according to a recording of the meeting.
His reasoning? The pilots were the backup.
In my understanding of this massive xxup pilots had NO ability to counter the system
4
@opinions for free
They did. They could have overridden the system. Pilot inexperience was a major factor here.
The worst in Boeing's wicked behaviour was in my perspective its unthoughtful haste towards imposing a dubious model in the middle of a successful competition by Airbus.
1
As and engineer and scientist, I would like to point out to the public that these systems we build are extremely complex - look how long it took to uncover these details on these two disparate failures. I work in the biopharmaceutical industry and can assure you that what we engineer to fight cancer is extremely intricate, detailed and this is a heavily regulated industry, just like the airline industry. For example, the pharma industry is now retraining your own immune system to fight cancer; look up CAR-T cells. As with all new therapies, this is not 100% understood but it is a miracle cure for some people and will be perfected over time.
I caution commenters who want to assign criminal negligence for the very rare catastrophic airplane failures. We engineers and scientists do everything we can to cure disease, make heavier than air flying machines, and build skyscapers and bridges that do can hold up thousands of people. When there is a failure, we work to fix it, as the Boeing engineers are doing now.
As I always tell young people: if you want to be part of the solution, get involved. We're all in this together.
3
,,, can be traced to a breakdown late in the plane’s development..
It started earlier than that. With the decision to mount an engine on an airframe for which it was not designed. Result: An inherently unstable aircraft during take off
It should have stopped right there. Instead Boeing decided to "fix" a fundamentally unstable design with a software patch.
A correctly designed aircraft does not need software patches.
5
"They described a compartmentalized approach, each of them focusing on a small part of the plane." This line in this excellent article seems to me to be the heart of the problem.
As a young engineer in the military I worked with counterparts in the aircraft industry and saw that the above statement to be largely true, particularly at the design level. One did not get to see the more of the broader design issues until one advanced to higher positions, and then one was occupied with other problems rather than design.
When I was finishing my active service I was offered positions in this industry. I decided to seek employment outside the aerospace field, one reason being the above statement. I have never regretted this decision.
5
I am neither an engineer nor a pilot but there's one factor that nobody mentioned in the comments I've read, a small selection of the total. I agree with the majority that it appears profit trumped safety. What I do not understand is the lack of communications between various entities. Weren't there project meetings, emails to all stakeholders about any changes, involving each discipline from, safety, engineering, FAA, design, etc. Shouldn't pilots know about anything that impacts operation of the aircraft? How in the world does one change a factor that is involved in the operation of the aircraft and not inform pilots? Wouldn't an update to the operating manual, sent to the pilots, be warranted? An email to all pilots informing them that updates are on the way? Maybe even asking for input?
Heads should roll on Executive Row and bonuses should flatline for every VP and up whose area of responsibility contributed to this fiasco. The loss of 500 souls should invalidate any golden parachute.
Inadequate communication contributed to this problem just as much as that single sensor. I'll hazard a guess that if pilots knew that in the decision stage, 500 or so people would be alive today.
6
I don't know anything about airplanes.
It seems to me there should be a simple switch [just one button push or one lever to pull] to allow the pilot to immediately disable the automated features and allow the pilot to fly the plane manually.
@david
Who says there isn't? I'm not a pilot either, but the pilots in these crashes had overridden those systems....until they chose not to. Pilot error is a major factor here.
A friend who works in IT (from which I retired several years ago) told me recently of the trend to “agile programming.” You modify a few functions, test them, and implement them. If a problem arises you patch it. Rinse, repeat. Her company in retail, so if something goes awry some bills or orders might be wrong. It sounds like Boeing was following a similar, uhh, methodology, with more serious consequences.
3
Why depend on one flight sensor? In 1980, my first computer science professor mentioned that the Space Shuttle would have three computers monitoring and testing each other. "They vote", he said, "and if one disagrees with the other two, the Shuttle knows that computer system is broken and ignores it". That is how we designed systems, and how fault-tolerant computer systems are built. How could Boeing engineers assume that a single sensor is always correct?
7
It would be huge but I wonder how many Max customers are weighing the cost of cancelling their orders and begging Airbus to open another new 320 line? I got back on the DC-10 on occasions when there was no other option, but I think I might have flown my last Max.
4
@Edna Purviance: Airbus has the facility where they build A-380s coming available because most airlines won't buy that behemoth.
@Edna Purviance
Boeing has always had a better safety record than Airbus. At least until now. I wouldn't go rushing to Airbus too quickly.
"Boeing has no higher priority than the safety of the flying public" Gordon Johndroe of Boeing says. Just one higher one Gordon like the rest of the S&P500. Same exact one. The rush to skip steps when new product launch delays endanger prior earnings guidance. It's obvious. To everyone. Boeing credibility can only start getting rebuilt when you own that and show how the next design process will address it.
9
This informative and detailed article does much to let the public know so many important facets of two tragic and avoidable plane crashes that ended the lives of over 300 passengers on the Boeing 737 Max.
One of the takeaways that this article makes clear is the lack of Boeing personnel being given a COMPLETE view of the entire working system of the plane. Instead, design engineers were focused only on a limited, separate part of the whole plane.
Had Boeing made it mandatory to guide engineering decision-making on several required full-grid views of the plane's operational systems before passing as "OK", perhaps the missing information would have been spotted and soon corrected.
When the complex data and functions of these computerized flight systems are separated by a limited compartmentalized understanding, the result is disintegration, and so failure is inevitable.
It seems totally irresponsible that FAA requirements didn't cover a total systems analysis on the part of every engineer before a passing grade was given to any plane. I understand that Boeing itself has even been influential in some FAA regulations and decisions--a direct conflict of interest that should be thoroughly investigated and remedied if need be.
3
No matter how big we need to stop putting business ahead of safety. Its clear these tragedies happened to save money, on sensors, on pilot training and mostly putting larger more efficient engines on an old design. If we don't have more accountability how can we expect correction? The millions they will pay out will just be paid by the flying public in larger fees, people responsible should have manslaughter charges also, maybe they wouldn't cut corners.
6
So much talk from anonymous sources, both at Boeing and in the FAA. Vague ambiguities, rationale, suggestive finger pointing and it-ain't-our-fault kinds of statements will not correct the fundamental problem.
When Boeing decided to change its policy removing pilot's flight control priority over the airplane, it made a fatal and culpable mistake. When the FAA was notified of this change and did not require extensive testing as a result of the change, the FAA made a fatal and culpable mistake. Even built-in process safety redundancy reviews didn't work this time. Especially, when the reviews pertaining to engineering policy (a basic assumption) are not necessarily reportable.
5
@Charles Gains: People familiar with control system theory might see this problem coming without being aviators.
4
The fact that data was taken only from one sensor, and a sensor failure scenario was not tested means that the crash scenarios were not tested. All of the satellites I worked with had multiple sensors, with software to indicate when a sensor had failed.
Taken together, it feels like they rushed the design, then rushed the testing, and emphasized minimizing development and training expenses. Shame. Boeing's excellent reputation for thoroughness seems to have given way to one of financial expediency. Both for them, and for the airlines.
11
I own Boeing stock but despite possible loss to me there needs to be a detailed thorough investigation into the 737 development process
as was done with the Challenger disaster. This article is a good beginning. Individual culpability needs to be assessed. We do too little of that in this country. In failing to do so we miss the opportunity to learn lessons going forward.
6
The MAX has become a cancer for Boeing. Acknowledged too late, and therefore not treated aggressively after the first crash, It has now eaten away at a once respected manufacturer. To follow the simile, the cure is to remove what is slowly killing the host. Boeing needs to abandon the MAX. The cost will be great, probably in the billions, but it might save the company.
7
@DH: The backlog of orders is about 5000 planes at $100,000,000 each.
https://en.wikipedia.org/wiki/List_of_Boeing_737_MAX_orders_and_deliveries
1
Look how close to the ground those huge new engines are. How is that safe?
1
@Tony Flagg: You don't want to land one of these in a strong crosswind. The Max 9s, which are 2.5 meters longer, have to be landed faster to keep the tail from dragging too. This adds to wear of brakes, tires, and engines, and makes rollout longer.
6
Of all the bad reporting on this issue, this article is generally informative and seems to be accurate. This sentence in the second paragraph, however, fails in both areas: “In both doomed flights, pilots struggled as a single damaged sensor sent the planes into irrecoverable nose-dives within minutes...”
Neither aircraft was irrecoverable; in both cases the pilots failed to take manual control of their aircraft and fly them. This is not to diminish the failures of Boeing in all of the other ways described in the article. But at the end of the day, the Pilot In Command (PIC) has the authority and responsibility for the safe operation of their aircraft and the safety of their passengers and crew.
Every model of 737, including the MAX, has the exact same procedure for managing a “runaway trim” condition: flip two switches on the center console, easily reached by either pilot, and turn it off. Then fly the airplane. Manage airspeed and attitude. Other pilots of the aircraft involved in the LionAir crash did so and saved their passengers but they and their airline failed to replace the faulty AOA sensor or give the problem the necessary procedural attention.
The First Officer (FO) of the Ethiopian aircraft had just a few hundred hours of total flying time and should never have been in the cockpit of a commercial jet. The crew initially switched off the trim system but failed to manage airspeed such that they couldn’t manually re-trim it. The FO then switched it back on.
5
How come the pilots did not follow that procedure? Remember MCAS was not in the manual. If the pilots had been trained on this new system they would have understood what was happening. The pilots did not understand what was happening. in other writeups they talk about the physical effort the pilots put in as they fought against the motors and hydraulics run by MCAS. Boeing management wanted to call the max, a very different aircraft, a 737. The reality it had bigger engines, a different point of balance, and lift generated by thrust. all of which makes it a different aircraft to fly. Boeing could have called it the 838 and marketed it as a bigger better 737 and been transparent about all the new features and changes.
3
@Robin Dymond
When activated, MCAS dials in nose-down horizontal stabilizer trim. It only activates when the aircraft is being hand-flown (autopilot off) so the pilots would have noticed an uncommanded nose-down control input. This uncommanded input requires the pilot to take back control of the aircraft just as they are trained to do for any runaway trim incident. The fact that such uncommanded input was a function of a new piece of software called MCAS is irrelevant to the fact that the pilot finds him or herself dealing with an aircraft that is not doing what they expect it to do. Their training already specifies for them to flip the switches to turn off the automatic stabilizer trim, manage airspeed and manually retrim the aircraft.
I'm shocked and disgusted by Boeing's shameful recklessness and disregard for safety. I don't know enough about airplanes to evaluate what should or shouldn't have been done, but from what I've read, the horrible tragedies that resulted might have been avoided if precautions had been taken.
3
If nothing else, this story competely confirms William Deresiewicz's "Excellent Sheep" thesis, that schools have been systematically eviscerating the ethical & moral development of students by training success/money-driven conformists impervious to the critical self-reflection literature & the humanities have always fostered before reductionist idealogues took over.
Frankly, we see this in nazi-style "just doing my narrow job/following orders" buck-passing in which nobody seems to be responsible for anything, because the division of labor shielded everyone from respsonsibility for any considerations except technical efficiency in a narrow function, & by extension, profitability.
In Deresiewicz's thesis, this amoralization of students relies on destroying normal literary experience, turning it into a TRANSACTIONAL, symbolic-interactionist (grade production) hoop navigated for career & money, vitiating moral development. In school, the MEDIUM (credentialing), aka "hidden curriculum", becomes the MESSAGE.
One need only read Arthur Miller's "All My Sons" to know this faulty airplane design/corrupt executive story, with exhaustive exposition of the moral themes, was presented in a classic literary form which, had corrupt education (maybe their own defective, singular SENSOR, GRADES, at fault!!!) not VITIATED THE CONVEYANCE, would have prepared graduated adults to face the challenges involved with a modicum of integrity. But alas, a TRAINED INCAPACITY TO THINK and TO CARE.
9
By the way, I was indeed surprised to learn that Mr. Deresiewicz's name is a variant of, and is pronounced the same as, "Dershowitz;" the two could well be related.
I would like to see Deresiewicz--Dershowitz debate on ethical responsibility, the humanities, the law, and the uses and abuses of cop-outs in connection with this story. The former, an arch-moralist devoting his career to using literature to heighten moral reflection and responsibility, the latter a foremost proponent of legal-moral pragmatism in an openly "Machiavellian" vein. It would never happen, but it would be a classic.
3
Fly Boeing! Navy Salvage Divers need the work!
2
Boeing and Boeing alone is responsible for killing some 500 people. It should be held responsible in court, especially the executives. Instead they continue to collect outrageous salaries. May Airbus bring them down!
6
Think of the thousands of companies in China that similarly cut corners and evade Good Manufacturing Practices, slowly killing thousands of people around the world with no accountability. The deaths are often unspectacular and gradual as contaminated and adulterated products (including pharmaceuticals, antibiotics, vitamins and vaccines) cause organs to shut down. The profit motive puts customers, especially foreign customers, at risk of death or unrecoverable illness. There are many companies in Asia and North America that put profits above customers. Boeing is today’s news. Tomorrow it can be a company in China or India. The problem with products from irresponsible companies is that reports of adverse events come in gradually, after they are consumed by the public, then the FDA belatedly takes action, banning further import, issuing recalls. Hundreds fall ill and may die before any action is taken. The company changes its name and opens shop in a distant province, bribing local inspectors, and producing more dangerous products under a different brand, faking QA certificates. The Boeing problem is a transnational problem driven by avarice and greed. Maybe a few hundred Boeing executives have done much to destroy Boeing’s reputation worldwide. It will take many years of zero mishaps for Boeing to recover, not just with the Max, but with all Boeing planes.
2
oh my - how is this possible? big business putting profits above all else, and all so some CEO could have their ninth vacation home and fourth yacht? and to learn that the CEO and entire echelon of top management who knew of this will not have to suffer for their unbridled greed and lack of ethics?
how could i be so gullible and easily duped as to think we should continue turning a de-regulated blind eye to big business, passing laws that allows them do whatever they wish in the name of 'free enterprise'.
how was this not completely predictable? i'm so shocked!
Jefferson said that the nation that wishes to be both ignorant and free wishes for what never was, and never will be.
2
This classic book on career transitions might be relevant to some of the participants in this story: "What Color is Your Parachute?"
3
...Unfortunately, btw, if knowledge of our corporate and legal culture serves correctly, in this case it will be "golden."
1
"Penny wise and pound foolish, pay me now or pay me later." They'll get you every time. These were not crimes, just poor decisions that chained together created disaster. It's a lesson for us all.
1
Love all the feint surprises. When it is cutting corners to save cost everyone is on board and some probably pushed for more cuts but when something went wrong, it is always "I didn't know this would happen "
5
The public will boycott the 737 Max in droves unless they are absolutely certain that the 'Max' refers to safety and not profits. The company is reported to be changing the name of the aircraft - presumably to confuse the public into thinking it's a different plane. May I suggest the name 'Airbus' followed by a random number?
Seriously though, I won't be flying a Boeing aircraft anytime soon.
8
The more I learn about this, the more sickened and angry I am. I don’t trust that it can be fixed. No matter how many patches they come up with, I will not get on this plane.
10
When this blows over and a remedy is implemented, the plane will no longer be the 737 Max but renamed 787 or some other numerical designation.
@LLM Thank you for letting me know. I will keep track of it and not get on the renamed plane. If you call a dog a duck....
2
The software and automated controls would not have been necessary if the plane was properly engineered. This is the real issue. Boeing, to save time and money, bolted bigger modern engines onto a circa 1960s airframe, discovering, likely to no one's surprise, the result is dangerous in flight. Determined to make a big profit, Boeing came up with sensors, software and automatic controls (opaque to pilots). Regulators, knowing how important Boeing is to the US economy, looked the other way. Innocent people went down to their deaths in the new planes, not once, but twice, in what Boeing and the FAA insist on calling a "software glitch". No, the truth is a badly engineered, inherently dangerous aircraft pushed into production to goose profits. No Max should be allowed to fly anywhere, ever, regardless of almost certain FAA approvals & claims from Boeing that they have overcome the "glitch". Apart from the civil lawsuits, a criminal investigation ought to be launched as well as an inquiry into the FAA's sorry role in all of this.
11
Thanks to shortcuts, both in design, instruction (and instruction manuals) to pilots, and regulatory oversight, the 737 Max aircraft involved in these two crashes were unairworthy prior to leaving the gates on their fatal flights.
Unairworthiness voids airlines' limitations of liability provisions in their contracts of carriage (tickets) with passengers, whether it be domestic (local) limits of liability or the Warsaw Convention of 1929 and its progeny, which set forth the duties and liabilities of carriers flying international routes.
Our FAA in effect rubber-stamping Boeing's policies is a great example of GOP "conservatism" in full inaction. Call it what it is: malign neglect for corporate profits (and a skim to politicians).
3
Boeing -- the gang that can no longer shoot straight. As much as anything, the story of the descent of Boeing seems to be the story of the failure of corporate governance in the United States. What oversight is the board providing? It would seem, almost none. Instead, the boards have been happy to hire a series of Slick-Willy's for the C-suites, bypassing talented aviation people (e.g. Alan Mulally, who lead the development of the 777 - the last really successful new Boeing aircraft introduction). Instead of directing the company to leap its technology forward, the boards have been cheer leaders for half-baked add-ons to fifty year old aircraft with lipstick applied by the marketing department. If Boeing wants to be around for the long-haul, then it had better change course and do so quickly. Or, one day soon, we will looking at an Air Force One built in Toulouse.
6
@fafield. The Boeing Board is still controlled by the same group of pre-merger stockholders that drove McDonnell Douglas out of the commercial airplane business.
2
I am utterly amazed at the blindingly obvious gross complacency in the design and testing process for the 737 Max. Everybody in this mess seems to be saying that it was sombody else's job to figure out the degree of risk MCAS posed. And most seemed to have not bothered to inform themselves of how MCAS worked. Most disappointing seems to be the test pilots. They're supposed to know everything about the airplane and be the last defense for safety. I hope that the USAF & USN Test Pilot Schools (where most of them come from) offer this as a case study for how not to design and test an aircraft.
2
@Jim Stark: The test pilots must have detected the pitch instability in testing to motivate the development of MCAS. We don't know who thought this could be handled with MCAS and a too-slow actuator designed only for trim adjustments.
3
@Steve Bolger
Steve, I believe you are correct. They apparently discovered handling qualities (stick force/g) during flight test that were different from earlier 737 variants. MCAS was an elegant solution but very badly designed. My point is that test pilots should work hand-in-glove with designers to provide "care-free" handling qualities. In this case, it would seem that the test pilots & flight test engineers did not have the intricate knowledge of the flight control system that they (and the FAA test pilots) were supposed to test and "bless" as safe for civil aviation. This would seem to indicate a systemic problem in Boeing's design and flight test organization. In other words, THEY ALL AIN'T TALKING TO EACH OTHER!
2
I had respect for Boeing, ever since my father worked in the aviation and aerospace industries in the 1960s. Boeing was something Americans could be proud of. I was in awe of Boeing's jets, its engineers' and desingers' brilliance, and the expertise and professionalism of its workforce who assembled its planes. Losing respect for Boeing and not being able to trust this American success story have left me with a jaundiced view of Boeing. In my years left on this amazing planet, Boeing will never get back my trust and respect. Boeing's unethical actions are worthy of a Shakespearen tragedy. The final act would have ended with the company's parties responsible for this colossal blunder going to prison, or suffering some other ignominious fate.
8
Citizens United v. FEC allows corporations to be regarded as citizens when it comes to electoral elections, therefore they must be considered as individual citizens when it comes to criminal prosecution also. If they can play an active role in electing politicians, they should also be incarcerated when proven guilty.
8
@Chris: Corporations are only persons sometimes.
3
Time to Market adds pressure to keeping design reviews on schedule. As designs become more complex we need to spend more time teaching our engineers the art of risk management. I worked in a different industry, where we had a major catastrophic event. After this event my company setup a assurance review process to monitor design through various phrases from concept to issue for release. It added cost, however we found problems that could have been consequencial had they not been corrected (i.e., consequences that could be deadly and damage your company's reputation).
2
generally in fault tolerant systems, two items (sensors) are worse than one. It doubles the chance of one failing but then the system is left trying to decide which one is failed and which is good. You really need 3 sensors so you can do majority vote logic or you can put dual sensor mechanisms in each sensor so it can compare the two results and mark itself as down when they don't match leaving the other sensor (pair) up to provide the data.
4
@Larry: The Airbus competitor airplane does use three angle of attack detectors.
4
The Boeing Company totally changed after the merger with McDonnell Douglas, where large amounts of stock were owned by just a few individuals. Pre-merger Boeing was a technically strong company with every engineer encouraged to voice ideas and concerns. The new, combined company’s senior leaders became followers of the Jack Welch philosophy of short term, shareholder value, where groups were focused only on their assigned task. Management compensation was (and is) based on meeting the assigned “numbers,” especially cost reduction and schedule. This resulted in engineers learning to keep their concerns quiet, or (having potentially cost their manager tens of thousands of dollars) find themselves moved to another job.
An expanded examination of what happened must include the measurable goals provided to the responsible managers. That will explain completely why these engineering decisions were made, and why internal oversight must be moved toward those without a financial stake in a delayed delivery.
11
I am an engineer by training. I often see this dynamic play out in large organizations. Good design is not simply an act. In the case of complex systems like planes it is an iterative process, that requires complete transparency, open collaboration, and most importantly active support of dissenting opinions. Design and engineering can often be contentious, and that is normal and should be allowed. The problem arises when non-engineering people, who do not understand that design process, seek to subvert it for short term goals driven by sales or competition, or finance. I believe that in this cases criminal charges should be brought against those who knowingly subverted long standing practices common to aerospace. Without criminal charges, this practice will not change and we will have more tragedies.. Finally, hats off to the New York Times for continuous coverage of this. Without good journalism this problem will be swept under the rug by wall street and the investors..
17
“For a successful technology, reality must take precedence over public relations, for Nature cannot be fooled.”
— Richard Feynman
It appears that Boeing executives did not absorb the hard lessons of the Space Shuttle program, which are elegantly summarized in this quote from Feynman’s contribution to the report on the Challenger accident.
13
Let me point out that there are Angle of Attack sensors that cannot be broken by birds.
Some fighter aircraft have a matrix of tiny holes in the skin of airplanes and compute the AOA + other safety critical information from the pressure differences between the holes.
The high probability of failures of vane type AOA sensors could be overcome by these types of AOA sensors.
They also reduce the drag of the aircraft ==> saving fuel
7
"While the original version relied on data from at least two types of sensors, the final version used just one, leaving the system without a critical safeguard."
Boeing deserves bankruptcy due to it's moral depravity!
7
Boeing's infuriating habit of casting aspersions on the training and abilities of the pilots only added insult to injury.
14
Having worked directly alongside aerospace executives on safety matters for years, I can tell you that zero is going to happen to the person or persons who made that dumb decision which killed hundreds. Nothing. No culpability. There's even a strong chance a promotion will occur, because a promotion covers up a lot of trash.
And, if you think for a second that exactly who made that decision is not identifiable, think again. That corporation knows completely and fully who is responsible. They mentored, coached, and encouraged the individual into that dumb decision that was not reviewed by anyone. And, if it was reviewed, any persons who objected were either considered hands off and placed near a window and out of the way or were paid off and retired early.
Speaking from experience, I can tell you for fact the responsible people will not be disciplined, they may even be promoted, or they'll be shuffled to the side, and either offered every opportunity at a lateral to a semi important but out of the decision making stream if they are connected to an executive or board member, or they'll be offered every opportunity to find a new job in aerospace or industry with the full blessing and backing of the corporation, or barring that, they'll retire early with a payout package, 'for personal reasons.'
Good luck expecting any responsible behavior that smells ethical out of this mess.
Is the FAA hiring?
14
Tell me again about all those burdensome regulations.....
10
"The disasters might have been avoided, if employees and regulators had a better understanding of MCAS".
The disasters might've been avoided, if Boeing execs and regulators had more honesty and guts.
6
I’ll be dames if I want Faulkner as my pilot on southwest
2
Huge thanks to the NYT for staying with this story.
7
No matter how much lipstick (software, sensors, training) Boeing puts on the Max, it's still a pig (flawed design). And pigs can't fly.
10
May their stock price tumble and make all their senior management 401K and deferred comp plans worthless
5
Your tax dollars at work.... Thanks FAA
1
“Boeing has no higher priority than the safety of the flying public,” a company spokesman, Gordon Johndroe, said in a statement.
How much do you have to pay someone to get him to make a statement like that? Did he just take his bosses' word that that was their priority?
5
"A year before the plane was finished, Boeing made the system more aggressive and riskier."
More aggressive? More idiotic, to be kind. Criminal, to be not so kind. And what other flaws are lurking behind the rushed and "compartmentalized" development? I bet Boeing is working on a similarly desperate quest as the original development right now, trying to fix other problems before they become public.
5
A plane malfunction, rare, is horrific: you have no control and blindly rely on pilots.
I have the utmost respect for pilots.
A thought to the victims, may they rest in peace.
Aviation is the safest transport thank to a data driven approach institutions like the FAA and IATA adopt. In 10y. just 1 crash was reported in the USA.
I read main stream media with consternation, aiming at Boeing as the main responsible for the crashes.
This article, this Tale as it describes itself, is sided with the obvious fact Boeing is responsible, this is a bias.
Unfair to readers who will believe those assumptions.
Why?
Two crashes with the same plane model call for a deep investigation on what, exclusively from the plane model, is a common link in both accidents.
When something is found, it has to be changed, this is duly being executed.
Desperately trying to excavate something criminal from Boeing is narrow-minded and dangerous.
You can, but what about Operators, Foreign Regulators and so on?
As an example, in the two crashes pilots didn't react appropriately. LionAir pilots couldn't resolve memory items and fought the system.
Ethiopians pilots kept the plane's full speed, unable to manually stabilize, eventually reengaging the system.
Shouldn't manually fling a plane, including to cut automation, be The Skill pilots must master?
In respect of the lost lives you must address everything with facts to truly and effectively improve aviation safety.
facts b737.org.uk/mcas.htm
1
@Vasco: The altitude fluctuations of both planes in their crashes suggests that the lagging actuator both overshot and undershot necessary corrections.
3
@Vasco Sorry, but I think that all the spots on the Boeing board are filled.
Boeing redesigned a high legacy airplane on the cheap. They moved the engines to save fuel. The plane does not fly true and is dangerous.
6
The whole notion that large companies will self-monitor is a monstrous lie. They layoff essential people off to save money. They make deals with regulatory agencies so that they can put their product to market faster than the competition. They didn't tell pilots about a major software change which resulted in the death of 387 people!!! This is total callous disregard of anyone but themselves. Want to cut a buck off the cost? Sure. So let's install a starter which is shorter than the previous one and not tell owners. When people started having mysterious accidents let's say it was driver error. They lied about the real cause. Oh and let's put exploding airbags into cars and cover it up for 3 years. And let's not collect all the dangerous air bags purchased but not yet installed. Guess what? Those air bags have been installed. Why aren't any of the people who made these decisions in jail??? Companies heavily fined??? Because the US gov right now doesn't care about health and safety, consumer issues, etc.
10
A plane malfunction, rare, is horrific: you have no control and blindly rely on pilots.
I have the utmost respect for pilots.
A thought to the victims, may they rest in peace.
Aviation is the safest transport thank to a data driven approach institutions like the FAA and IATA adopt. In 10y. just 1 crash was reported in the USA.
I read main stream media with consternation, aiming at Boeing as the main responsible for the crashes.
This article, this Tale as it describes itself, is sided with the obvious fact Boeing is responsible, this is a bias.
Unfair to readers who will believe those assumptions.
Why?
Two crashes with the same plane model call for a deep investigation on what, exclusively from the plane model, is a common link in both accidents.
When something is found, it has to be changed, this is duly being executed.
Desperately trying to excavate something criminal from Boeing is narrow-minded and dangerous.
You can, but what about Operators, Foreign Regulators and so on?
As an example, in the two crashes pilots didn't react appropriately. LionAir pilots couldn't resolve memory items and fought the system.
Ethiopians pilots kept the plane's full speed, unable to manually stabilize, eventually reengaging the system.
Shouldn't manually fling a plane, including to cut automation, be The Skill pilots must master?
In respect of the lost lives you must address everything with facts to truly and effectively improve aviation safety.
facts b737.org.uk/mcas.htm
Questions for the writers:
Could it be that the engines are just too big/heavy ? And because of the competative pressure from AirBus- Boeing didn't spend the time to fix that major design flaw rendering the 737 Max permanently undependable?
1
The very article describes consistent obfuscation of the facts from management concerning every angle and complete reluctance by every pilot to dismiss the safety liability. Expense wise ,how much will this cost them now?
2
There are several comments suggesting that criminal charges be filed against officials at Boeing. Having been given insight into the role of top management in this disaster of a product, it is my guess that upper management has already identified a half dozen lower level individuals who will be blamed and bear the full responsibility for decisions made at the top levels of the company. This will be the second tragedy that will come out of Boeing.
5
The corporate animal is basically amoral - like a tiger for instance.
And, like a tiger, it is useful in the general scheme of things. But it can be dangerous when hungry, or threatened. They must be regulated, something anathema to them and the GOP who represent them in this country (and in others through the World Bank and the ITO). The regulation must be careful but constant.
6
Engineering half-think. All software suffers from this, programming engineers need to take more time and accept more input from the public. When public safety is concerned the failures become deadly. It is a good thing smart toasters and fridges don’t kill.
2
So the Max had these oversized engines that caused the airplane to become unstable. That was the first design failure. Then, engineers had to design a system to 'fix' the potential problem, if or when it might occur. It sounds like Boeing decided to use duct tape and rubber bands to fix what originally was a mistake. This entire story is absurd. It will be hard to convince me that the geniuses at Boeing have finally got it right.
17
This is another in-depth article telling the American public the truth. This is the reason I keep my subscription to the NY Times. Thank you, great job!
12
“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.”.. same issue we have in development of all major software. Moving to agile/micro services/shareware as against the traditional way of development.
2
I will not fly in a 737 MAX. My dollars will go to other airlines who are not caught in the economic conundrum of flying these planes when a supposed fix has been made, or doing the right thing and cancel orders for future deliveries.
7
Fly Amtrak or Greyhound.
1
“Boeing has no higher priority than the safety of the flying public.”
After reading this article one is left with the impression that this corporate principle is unattainable based on the core methodology of its business model. Like most large businesses Boeing has fallen under the control of finance and their partners in obfuscation, attorneys.
Finance creates easily measured silos within companies. Better to apply metrics and facilitate the lowest cost solutions. Attorneys enable this behavior by misdirecting accountability. After all, what do lawyers and finance people know about building complex machines? What they do understand well are the tools of control and power. Fracturing a knowledge based business and creating social distance between knowledge workers is a recipe for failure.
The most striking point of this article was the dependency of a critical system on a single censor. Growing up, the mantra of NASA and the entire aerospace industry was redundancy. Mission critical elements should never be trusted to a single element. This is a core principle when human life is valued. Redundancy is also anathema to finance thinking. It increases cost and prolongs time lines.
I trust there are many engineers within Boeing who would instinctively recognize the danger of a single censor dependency. This is particularly the case when there are data supporting its vulnerabilities.
13
Rick you saved me a lot of typing. I too worked in the industry. Incompetent and greed are the only things that make sense here.
2
My thanks to NYT for its continuing investigative reporting on the 737 Max fiasco. I look forward to future articles on this matter.
I submit that what we have here is more proof that when business interests conflict with safety concerns one is going to have to give way to the other.
The job of the FAA regulators should have been to ensure that safety concerns prevailed. Obviously, quite the opposite occurred.
7
"The software upgrade is in the mail," is Boeing's response to a badly designed series of troubled MAX planes.
5
I’ve been a safety engineer in aviation/aerospace for almost 30 years: what is described in this article is no different than I am currently seeing in my own personal experience. Every day in my job as a senior safety engineer in the space program, I speak out on issues I see, but I am dismissed, denigrated, and retaliated against for fighting for the safety of our employees and our missions.
Being a safety engineer is exhausting and demoralizing, and I’m finding it no longer worth the effort: I am seeking employment in another field because I can fight no longer. Talented colleagues are doing the same, leaving those in that “go with the flow” to review designs. The people that bow to management pressure to ignore safety processes, however, are not the ones you want to keep the flying public safe.
What is described in this article about Boeing is an erosion of the disciplined processes that are ESSENTIAL to ensure safe designs are fielded. This goes well beyond the MCAS system, and should call into question the entire design/test/certification process.
The more complicated systems become, the more we have to ensure that they cannot operate in a way that is unexpectedly unsafe. The industry learns this repeatedly, but the complacency erodes it until we lose lives.
Integrity costs too much these days, and few want to pay for it.
38
First, kudos to the NYT to be, without question, the most prominent publication continuing to report on this matter.
Regarding this passage:
“The current and former employees, many of whom spoke on the condition of anonymity because of the continuing investigations, said that after the first crash, they were stunned to discover MCAS relied on a single sensor.”
Did any of these people speak up? Four months went by between the first and the second crashes. And even after the *second* crash, Boeing did not want to take action. I struggle to understand how the CEO can continue holding onto his job and that none of these people have faced civil or criminal penalties for what they did.
16
@blondiegoodlooks, with the government's persecution of whistleblowers, why should they? As Manning and Assange rot in prison and Snowden lives out his life in hiding, I would assume that era of the whistleblower is over. This will become an increasingly common occurrence I'm afraid.
6
You are right on. Nobody in aerospace relies on ONLY one sensor. Triple redundancy or quadruple redundancy.
I skydive with two independent altimeter sensors AND a standby third sensor to open my parachute if I am unconscious in free fall. It measures altitude and falling speed simultaneously. I am no rocket scientist. Just a humble non-engineer that strives for common sense.
9
When the "peanut counters" are held criminally responsible for their employers direction of cost cutting, so more revenue enters their (corporate big wigs) personal coffers, perhaps a small window of opportunity can become a portal of ennui.
Then again, as a realist I understand it takes (but shouldn't) sacrificing life from the little people to demand reasonable change from unreasonable wealth "above the law."
3
As others have commented, it is time to hold Boeing officials and FAA and other government officials accountable for their actions to hide aspects of MCAS and avoid commonsense actions (more pilot training) to protect the bottom line financially. These are not mere "lapses" in the design and certification program. They are massive failures of control and responsible action. Every statement that Boeing takes the safety of passengers seriously rings hollow when you see their actual actions.
4
I am not an engineer. That said:
It seems to me that it could be that what the larger engines really required was a total redesign of the fuselage and it’s aerodynamics, and a redistribution of weight across the entire aircraft.
Boing wanted to save themselves that expense and relied on software to allow for handling adjustments and corrections.
Would an experienced aerodynamic engineer please comment on this thought?
If I am correct, I will NEVER fly on the MAX.
5
@unreceivedogma: The dihedral of the wings might have been increased so the engines could be positioned as usual. You can see in the photo how they sag down close to the ground. But such a change requires recertification of the whole design.
6
The root of the problem is bad basic design that requires computer gimmicks to overcome. As a former private pilot I am surprised that there is no Big Red Button the pilot can push to instantly take absolute manual control overriding all automated systems. I had a switch on the yoke that turned OFF the autopilot, I did not have to keep it pressed down to override the autopilot much less keep pressing it as the autopilot tried to regain control.
4
@Burton: A normal airplane will hold its attitude when trimmed up, with the autopilot off.
I remember Elaine Chao foolishly bragging about how safe this aircraft was - just a few days before it was grounded. It’s just another example of a Trump appointee blindly catering to big corporations and carelessly putting the public at risk.
17
@Lisa Kelly’s: Mitch McConnell's wife. She doesn't have to worry about accountability for this.
9
"If it ain't broke don't fix it". That glib phrase has a greater and more tragic meaning in this and other cases. The original 737 workhorse is a fine airplane. Why change it and create unexpected problems? Saving a little fuel or going a little faster wasn't worth 300+ lives.
This applies to technology and automation in general. Increasing automation decreases skills. Pilots I've talked to have mentioned this frequently. Just sitting in the cockpit watching instruments isn't flying.
There is an optimum level of automation where exceeding it makes things worse not better.
Now we're getting automated cars. I shudder to think what unexpected tragedies will happen here.
6
As a retired electrical engineer, I read the accounts of the 737 failure with disbelief. All of the newspaper accounts relate to faults in the software and depending on input from only a single sensor. But I have not read anything that questioned the type of sensor being used -- a vane switch! I used mechanical vane switches to measure air flow 50 years ago. It's an antiquated and fault-prone technology, The Times mentions that there have been "122 strikes on angle-of-attack vanes." If a smart phone can have a position sensor that is not open to the atmosphere, why can't a Boeing jet liner?
18
Perhaps Boeing has allowed weapons manufacturing thinking and market analysis to pervade the commercial aircraft side of their business?
4
When I worked with Boeing many years ago, they had great engineers. I am sure they. and their successors would know about the use of triple modular redundancy (TMR) the technique used to achieve reliability in the presence of failures. TMR requires 3 inputs and a voting mechanism, that disables a divergent input. It was used for the NASA mission, not only to prevent loss of life, but also the image of the United Sates. I don't know if it ever was employed in actual flights,outside of tests. With thousands of take-offs a day a rare occurrence is certain to happen Here it would require installing a third angle-of-attack sensor, wiring, and simpler software than contemplated for the proposed patch. The good name of US industry requires quality solutions.
7
@Gio Wiederhold
yeah; that’s how Airbus handles AoA input…
Yet another case where marketing trumps engineering. And piddling over the added cost of training trumps safety. Pinto gas tanks and Challenger o-rings, anybody?
8
@Sandra Boeing will invest precious dollars in a slick ad campaign to win back the public's confidence in their hacked airplanes. "It was only a software problem" after all.
4
I've done single points of failure analysis for single buildings in a telecomms network that were probably longer than the MCAS single points of failure analysis.
Boeing truly failed on this one. Add another plane on which I shall never fly.
5
Why do we regulate the airline industry? Let the free market take care of it. If an airline or a particular aircraft crashes often enough, people will stop flying on it. Isn't that how the anti-regulation people claim The Market is supposed to work?
13
Lock them up. Complicit execs are criminals.
5
This industry regulates and oversees itself. What could go wrong? It is so willfully stupid and called "good for business". Democrats may over regulate here and there, but regulator's and oversight by dis interested party's is the remedy. Many have died because "it's good for business". Great priority profit, isn't it? I hear war is good for business, too. Hard to swallow.
2
The people responsible for testing and certification "assumed there was more than one sensor"? This is obviously wrong. Either they are lying covering up a bad design, or we have imbeciles doing these jobs.
2
If we forget for a moment all the technical intrinsics around the whole issue, a few facts remain. When Boeing put out the plane, it knew is had a serious design flaw that needed to be patched by a (secret) software patch. (!!!!). Knowing this, after the first crash it continued to maintain that the plane was safe (!!!!). These two things, in a "walks like a duck, looks like a duck, etc>" way: criminal!!!!!!!
5
“You can have it good; you can have it fast; you can have it cheap. Pick any two.” — Red Adair
8
So what's all that about cutting government regulation to make American industry more competitive?
22:25 EDT, 6/01
5
Great article but no mention of why they made the change at the beginning which is best explained here https://youtu.be/H2tuKiiznsY
1
If the "Lock them Up!" rally cry were ever applicable, it is now.
2
The NYT is late to this party. It was all laid out in several WSJ articles more than a month ago. You could look them up.
I am dumbstruck by how smug the US has gotten over my lifetime. As if God is its copilot.
6
The pilot who says he wished he had the full story says much more than the NYT headline. Can't the NYT get the full story before blasting Boeing?. It seems totaly incongruous that "somebody didn't know what they were doing." Quality control surely exists at Boeing; if not, we may all be doomed.
Planes don't kill people; corporate greed does.
7
NYT, leave it to Aviation Week a s Space Technology to do technical reporting, they employ aerospace experts. Buy the story and reprint it. Please close the comments sections on technical stories, I’m sick of internet experts and their ignorant comments.
Comments by airline pilots are useless also, they need to be shown where the cockpit is, the airlines merely teach them what button to push when, they are ill equipped to deal with abnormal situations. Pilots literally only fly the first and last 200 feet, the rest is autopilot.
I know I spent 30 years as a airline line mechanic explaining to pilots that what they think is a fault is normal operation. It’s usually not the plane that will kill you but the guy in front. Both of these crashes were preventable with a competent pilot. The Lion Air guy 200 hours total time! He had no business in the cockpit.
2
@Paulie The problem with your theory is that if Boeing and airlines are aware that they "merely teach them which buttons to push" then they need to decide to put in the training manual which MCAS button to push and they did apparently not. You can't have it both ways.
3
"If it's Boeing, I ain't going."
4
Hey, let's slap a couple of huge engines on an old airframe . . . . . . and like what's the worst that could happen.
8
This is a future case study for MBAs on how greed, poor communication, lack of accountability, a rush to judgment and just plain stupidity can ruin a company. Unfortunately all who died paid the price instead of the Boeing executives who should all be fired as they are not fit to run this company. IMO what happened here is criminal negligence. Let the punishment fit the crime.
5
Boeing CEO Muilenburg needs to be charged with criminal negligence causing death as would any one else in a country with a rule of law, which unfortunately does not apply in the USA which even allows a mad president to be above the law. The Devine Right of Kings was eliminated in the real democracies of the world in the 18th century.
2
NYT misses the mark. The issue is bigger and deeper than MCAS or the sensor, or training.
THE ENTIRE AIRFRAME IS FATALLY FLAWED.
The plane is too low to the ground for the huge new engines which will always pull the nose up..
THIS is the definitive article on this problem:
https://spectrum.ieee.org/aerospace/aviation/how-the-boeing-737-max-disaster-looks-to-a-software-developer.amp.html
8
I will never fly on a 737 Max.
2
For the sake of the planet, quit flying. Stay learn to appreciate and take care of your home community. Drive if you must travel. Above all, avoid commercial aircraft.
2
this plane was designed to kill. Heaven forbid spending a few million more on safety.
Boeing is guilty of manslaughter.
2
What has happened to the USA? This is a country for which I fought and bled. Based on many factors, Boeing is criminally negligent but the President of the United States is a traitor to the USA as is his Cabinet. Nothing will happen. It is the new American Exceptionalism; greed, profit and Ego. I really wonder why this country has any government at all if it is not going to serve its' people.
8
There is a chance these aircraft never fly again.
Airlines scramble to buy the Airbus 321 NEO and cancel all orders of the MAX.
1
When will the CEO, COO and CFO of Boeing be fired, resign and/or be criminally investigated, prosecuted and indicted?
Lock them up!
6
“Boeing never disclosed the revamp of MCAS to Federal Aviation Administration officials involved in determining pilot training needs...”
Ug. The more you learn about this fiasco the more Boeing seems negligent. It’s almost beyond belief that such a monumental error was made.
2
This is an astonishing story. Bravo to Jack Nicas, Natalie Kitroeff, David Gelles and James Glanz, including their editors and everyone who helped them from top to bottom at The New York Times.
The failures at Boeing and the FAA should not go unpunished. The 346 innocent victims of their criminal negligence must be redressed.
4
possibly, most people don't think about this sad story and its ramifications at all, but based on the comments here, I'd say that one error and bad decision after another, combined with lax oversight from a crippled FAA, have already overwhelmed any advantage that motivated Boeing's negligence. by focusing on the wrong objectives, management has shot itself in the foot and possibly damaged Boeing's reputation beyond repair. and that reputation was the company's most valuable asset. was it Benjamin Franklin who said penny wise but pound foolish?
1
What is so disgusting about these tragic events is Boeing’s attempt to smear the pilots and imputation of ‘what do you expect - these are 3rd world countries’ - not our fault.
5
Why is upper management still in place at Boeing.
5
@ron As always, money. Modern management is just one big cost-benefit analysis with human life, or the loss thereof, as just another externality dwarfed by ever increasing profit maximization. And if that fails, rely on the "I'll be gone, you'll be gone" exit strategy. The banks have already done the trailblazing on this path.
2
This is a great article and makes clear, as many have pointed out, that the 737 isn't safe to fly even after the MCAS updates Boeing promised are in place. The quick and dirty solutions need to stop. The plane needs a complete aerodynamic redesign. NYT reporters: 1) can you please figure out WHO made the decision to replace two angle of attack sensor inputs with one and charge extra for the second one? 2) can you please follow up on what the FFA's position is on the inherent aerodynamic instability of the plane, which caused MCAS to be deployed in this deadly way in the first place?
2
Hey! You gotta keep those shareholders happy!
1
trump has blood on his hands! His reckless government shutdown caused protracted delays in identifying and correcting problems with the Boeing 737 Max aircraft and his reckless incompetence in the lax handling of senior management appointments including directorships at the FAA seriously compromised aircraft safety diligence.
3
A close colleague of mine died on Ethiopian 302. I can assure that he knew nothing of MCAS or AoA sensors. He probably didn’t even know the type of aircraft he was on. I can’t help but think about what the last 6 minutes of his life were like. Immediately after take off, a little bumpy. Not uncommon. Veteran flyers such as he ignore it. Then, some unusual fluctuations in altitude. He starts to take notice. “I’m sure it’s nothing.” As those fluctuations became more severe, and the passengers around him became more agitated, what must he have been thinking? “The pilots are experienced; they’ll correct it or we’ll have to return to the airport. Should I worry? No, no, we’ll be ok.” And then, as the plane began to undulate like a rollercoaster, gaining more speed and losing altitude, did he realize what was happening? As passengers are screaming, praying, crying, vomiting around him, was he making a mental note of where the emergency exits were? Thinking this can’t be happening? Realizing he might not make it? Thinking about his family, his girlfriend, his work? Praying for God to get him out of it alive, or take him swiftly as the plane hurtled to earth at over 500 mph? I can only hope he had some peace in those final, few seconds of his life. Ten days later we had a memorial service for him. No body, no remains, no personal property was recovered. He is part of a wheat field in Ethiopia. If this was painful to read, I apologize. Boeing & the FAA must be held accountable.
14
The problem is structual. As per the article one of the test pilots for the 737 Max 8 said he "would have preferred an aerodynamic fix such as vortex generators, thin fins on the wings." The fix is not computer code, but in the airframe itself. Boeing needs to fix it right, not add more code.
5
But republicans would have you believe that private enterprise does not require, and is only hampered by Federal regulation and oversight. Banks and corporations are fully able to police themselves – HA! Tell that to the swindled, sickened and dead.
6
Boeing built a non-air worthy plane and tried to fix it with a software patch.
This is wrong on so many levels.
Will you ever fly on a MAX? I won't.
4
Essentially the 737 has the flight characteristics of a smooth rock.
1
The real issue is unbridled capitalism that encourages quarterly profits over safety. Unchecked, capitalism kills not just people but entire companies. Boeing destroyed itself because we allowed them to self police their own safety. There is a term for this. It’s called regulatory capture. I call it regulatory suicide.
3
The catastrophe and failure of Libertarian ideology is evident again - in this terrible tragedy. Add The Boeing Max 8's development and deployment to the list of unfettered capitalism's horror stories, paid for with cruel, meaningless deaths of consumers.
"...The company also played down the scope of the system to regulators. ...Regulators didn’t conduct a formal safety assessment of the new version of MCAS."
Not to be believed for a nano-second within American capitalism:
“Boeing has no higher priority than the safety of the flying public"
Profits and maximizing share holder value trumps safety.
1
So bird strikes alone damage significant numbers of angle-of-attack sensors. There's something called redundancy when there's a good chance of failure (especially if a system is critical). Always good practice. This system though unlikely to engage, had only one sensor that could be easily damaged. Without the sensor the system basically goes rogue. Earlier MCAS systems had two sensors in case of failure of one. This is the line of thought that doesn't make sense to me personally. That's why you have a pilot and co-pilot. If something goes wrong with the pilot, he has the redundant system in the seat next to him. That extra sensor couldn't have cost that much in the grand scheme of things.......
3
Telling lies is the in thing to do now, from the President of the United States right on down the line.
The sooner Boeing goes out of business, the better.
1
I fly the friendly skies no more/after all the recent gore/When the love of profit rules/companies turn into ghouls/Boeing is the latest case/of this corporate disgrace.
2
Kudos to the NYT on an excellent article.
Question- the newly-updated MCAS system no longer verifies high speed or g-force conditions before it kicks in to deal with an emergency high speed maneuvering situation?
Question- I think airlines are now installing vortex generators on the wings to reduce the risk of low speed stalling. Can your writer confirm this?
1
Put this system on Air Force One, and the problem would be solved overnight.
3
As an engineer and a flight instructor, this is poorly written from a technical perspective, fanning a sensationalist implication that Boeing is an evil enterprise, putting profit above safety.
Companies are made of dedicated people (engineers and pilots) that come to work to make the world a better place, not to enrich the shareholders. (I have never worked for Boeing, but I have designed safety and emission critical automotive and truck control - I work to make vehicle clean and safe).
1) In the second fatal flight, the crew HAD been briefed on MCAS, and were still unable to control the aircraft. That undermines the point that Boeing excluding the feature from the pilot training was a factor.
2) When designing pilot training, you need to balance clear understanding of necessary functions, with information overload. In driving a car, if you had to understand how your EGR valve stuck open could reduce acceleration merging on the freeway, you would be distracted from the traffic merging pattern. All you need to know is your vehicle could lose power at any time, and you need to drive defensively such that you have room to maneuver away from harm.
3) The article doesn't address the issues associated with automation and humans, and decaying pilot skills. A car that drives itself most of the time, but only gives control to the driver when things get difficult is a real problem: drivers will become less skilled, and have poor situational awareness when the automation fails.
3
@Tom Stoltz
1) Briefed does not equal Training
2) this happened at Low altitude there was no time to be defensive
3) they knew what was going on but physically were unable to correct it
You may work to make people safe but you are whitewashing a company and possibly an industry and slandering the pilots. Would it take a US plane going down for you to reassess your position?
1
@David
My point is the author assumes the premises that corporations are evil, we need more regulation, and the existing agencies are lap-dogs, then provides evidence to support that narrative. The situation is much more complex.
I, for one, will wait until the final reports are issues to decide how much is a Boeing management and culture problem, an FAA funding or industry relations problem, if this defect was extremely narrow or indicative of wide-spread safety errors in Boeing's design process, if two accidents in a row were a random outlier, social-risk implications for transitioning from human control to automation quickly or incrementally, as well as the role of airlines in maintenance and training.
I am still waiting to see why the Lion Air AOA sensor failed, and why the aircraft was cleared for flight after landing with the same defect. The first accident is a MAJOR maintenance and airline concern. Why a brand-new MAX has a bad air probe AND a bad AOA? Manufacturing QC defect? Lion air stealing new parts to keep their marginally airworthy fleet in going?
Also, understanding how a first officer with 400 hours of total time ends up in the flight deck of a full passenger flight when the US requires 1500 hours for an ATP also raises a couple questions.
Nah, that is too much work and takes too long. Let's just blame the evil capitalist.
2
@Tom Stoltz
Airbus has three sensors Boeing has one actually functioning. Boeing has updated a 50 year old design because it was behind in the race against a designed from scratch aircraft. Boeing hid the new functions so that airlines would not have to go through expensive retraining. All these facts are available for public consumption. If it looks like a duck ....
1
“Boeing has no higher priority than the safety of the flying public,” said company spokesman Gordon Johndroe. What he should have said was: “Boeing has no higher priority than making money." I wouldn't be surprised if no one ever buys a Boeing again.
2
The executives who placed profit over people and the political lackeys who did their bidding should be charged with crimes and jailed for years.
1
To all of you “I’ll never fly in another Max” you will have no ideas what the airplane model is, the will just stop calling it a Max. I doubt the average passenger can tell one aircraft from another. Can you tell the difference between a 400, 500, 700 and 800 without the emergency card, I doubt it.
2
@Pauli
Then Airbus it is.
Boing was not motivated by concern for the safety of the flying public. It, meaning the people in charge, was motivated to make profit... money for the company and themselves. Pure greed. The CEO on down ought to be indicted.
1
What is this plane worth without an aggressive MCAS? If pilots disengage it, what is the risk of stalling?
This is a complete failure of engineering management. Heads should roll.
1
Do I have this correct?. Muilenburg insists the pane is safe, the FAA dithers, Trump himself orders the plane grounded. The non technical Trump got it right.
1
I heard an interview with Ralph Nader, famous consumer watchdog, who had a niece on the second Boeing Max that crashed. He voiced what I, and probably many others, had suspected. The design of this aircraft was fatally flawed, having too much front ended weight. Aircraft, he explained, that are designed correctly, do not need software to correct their flight path. Certainly, the public, along with the assistance of Ralph Nader, should pursue making Boeing criminally responsible for the deaths resulting from these two horrible crashes.
3
The real problem is not with the sensors, relying on one instead of two etc.
It's the fact that a piece of software was flying the plane unable to compensate for human error or allow for one to correct it.
As a software engineer with 40 years of experience, I oppose turning over tasks to machines which should be left to humans. You can bet that the current mindless march to automated cars will provide many such stories as this one about the 737 Max. Life-critical decisions should not be made by software as it is impossible to ever prove the absence of bugs. For example, suppose a terrible flaw is found in one car's software. Oh... but millions of cars have the bug. Do we "ground" them all? Of course not; that would never happen as it would mean the owners' "freedom" is being taken away. Meanwhile, engineers would be pushed by management to come up with a solution NOW, which means minimal testing.
Worse, once terrorists hack into these systems, they could cause thousands or even millions of car crashes simultaneously. Don't believe those who say these problems are "trivial" or that Google's 20-something programmers can do anything. However bad buggy software is in planes, its dangers in cars will be far greater.
There is nothing wrong with assistive technology, but we don't know enough to replace human judgment and morals with pre-programmed algorithms. The human must remain in charge.
2
As an engineer, I see this type of error being made frequently. Management likes relying on simulations and using simulators to reduce test costs but the problem with that approach is that the testing using simulators is only as good as the imagination of the person(s) writing the simulator's software and their ability to foresee every real-world situation.
This is becoming a critical area in Artificial Intelligence (AI) based systems and how they are trained. The truth is that there are just too many edge case scenarios to predict every one of them or how to deal with those scenarios.
Every piece of software that controls the movement of a plane, car, train, etc. should have as part of its testing, what happens if this piece of software fails in a catastrophic way? Does the pilot/driver lose control of the vehicle? Can the pilot/driver override a failure? If it relies on sensors or input from another module, same questions. It costs time and money to do it right.
If you want to see an example of the two approaches happening today, watch Waymo's and Tesla's approach to automated driving. Waymo relies on limited real world testing in a somewhat controlled environment with heavy reliance on simulation and a suite of sensors most of which are not reliable in all conditions while Tesla relies on the collection of billions of miles of real world data and an uncontrolled environment with much more limited simulation.
Time will tell which approach is better.
I worked for the FAA as an air traffic controller for 25 years.
It's a great agency, filled with people who care deeply about safety and doing the absolute best job possible to protect the public.
But a rot infected the agency. It started a bit in the Clinton Administration era, but got thousands of times worse in the George W Bush era.
Bush appointed an FAA Administrator who had no real experience in aviation; her background was PR.
The Administration actively promoted the idea that the FAA was not a regulatory agency, but instead was a "service provider", and that our customers were not the American people, but the users of the system- the airlines and private business jet owners.
Even ATC, one of the most inherently governmental functions many people can imagine, was deemed to be a commercial service.
Funding was cut and many people were promoted on the basis of agreement with the political ideology. This went deeply into the middle and upper management of the agency.
The notion that "the market" would correct errors underlies much of this change. As an example, Boeing wouldn't cut corners on safety-critical things like the MCAS system, because if they suffered crashes, the market wound punish them.
Of course, anyone with any familiarity of corporate America in these days sees the folly in this.
In my own field, ATC, we ran absolutely unreasonable risks while beta testing incredibly buggy software on live traffic. The FAA got lucky nothing bad happened.
7
Good article
The description looks like one of a "low probability and high consequence" event.
These type of events are often hard to envisage - it therefore requires a comprehensive understanding and even then the person/group who gets to that understanding can be over-ruled by "the group" that declares "that will never happen".
I think that this scenario needs to really thought through.
2
Boeing, airlines, and the FAA are tiptoeing around the elephant in the room. The 737 Max with its 1960s airframe and repositioned bigger new engines is inherently unstable aerodynamically and should never fly again. I’d like to say “will” never fly again, but I’m not sure that concern for safety of flight will prevail over fear of the severe financial consequences for Boeing and the airlines of this tragic failure.
5
Starting in 2016, Boeing delivered 387 737 Max's. 72 went to US airlines - 34 to Southwest, 24 to American, and 14 to United. To date, these airlines have flown over 240,000 flights with these planes.
There have been no crashes or "incidents."
You have overlooked the elephant in the living room.
The two crashes were foreign airlines, and not national or flag lines but new, cut-rate ones. Ethiopian and Indonesian oversight and regulators are highly questionable. They allow pilots on commercial flights with training and experience far below those that are required by US lines. The co-pilot on the Lion Air flight had barely 200 hours of flight experience. No US line could have even considered him as a pilot. Every US line requires a minimum of 1,500 hours of experience.
The lack of proper maintenance, proper inspection, and pilot experience on these lines was crucial. US lines, and probably foreign flag lines, as well, maintain fully and on time, inspect properly, and use only pilots with enough flight experience to deal with any issues like this one. These "Johnny-come-lately" lines did not.
How else can you explain 240,000 US flights in this model airliner with no problems, and these 2 crashes after just a relative handful?
3
@Diogenes: The cut-rate airlines chose not to buy the optional second sensor and software safety upgrade. (There, that should satisfy anyone's desire for a blame-the-victim narrative.) Of course it is an engineering and ethical obscenity for Boeing to have created and marketed a system with a single point of failure and safety an optional add-on. Do note that Boeing has now made the full system standard.
7
That’s a red herring. Both airlines that flew the Max had excellent flying records. Don’t blame pilot error. If I’m driving in England on the left side of the road and crash because of it that’s why fault. If I crash on the left side because my car is unsafe that’s. Or my fault. The pilots had excellent ratings too.
3
@Richard Schumacher
Did you buy a car without a 5-point safety belt, or built-in roll cage? Whose fault would it be, then, if you were killed in that car a high-speed crash?
Do you always travel accompanied by two fully armed, trained, licensed body-guards? Whose fault would it be, then, if you were mugged and rolled?
Nice try, passing off the failure of these two lines to equip their planes as they should have been equipped, to Boeing.
1
I would like to know more about Boeing's decision to mount the new heavier engines on the 737 instead of designing and building a new plane to hold the engines. My understanding is that Boeing decided to put new engines on an old plane design in order to more profitably compete against Airbus. I am led to believe that MCAS was designed to counterbalance or offset this poor design.
10
The only reason for Boeing’s scrimping on safety was so C level executives could get their big checks from the sale of the 737 Max quicker. This was at least highly unethical. Sneaking this scrimping past and so thus effectively hiding it from the FAA and the engineering team was criminal. These Boeing executives belong in jail.
4
It seems to me that When the company moved their headquarters from the factory in Washington to the financial center in Chicago, their focus shifted from making great airplanes to making great profits. Union busting, wholesale outsourcing and shortcuts to safety followed.
“Safety is our SECOND priority” just doesn’t have the same ring, but it seems more accurate.
8
The tragedy of Boeing’s 737 Max is that the FAA forgot its responsibilities to the general public. Boeing’s primary purpose is to make money for itself and stockholders by promising the best and most efficient product on the market. The FAA’s job is regulatory; that is, to ensure that such products are safe for consumers. No one in the chain is fully responsible for safety except the FAA. The airlines that purchase the products depend on this responsibility, as does the general public. By allowing Boeing to regulate itself, the FAA ignored a fundamental responsibility.
Laws are fully effective only when regulation is fully effective. To ignore – and eliminate, as Trump and Republicans like to do – the regulatory side of business is make us all less safe in the air and on the ground.
6
This is not the first time a great company has been undone by short-term financial pressures. I suspect this story will not be fully told until the role of Wall Street is also scrutinized.
4
Back in 2015, I was working on a project down in Charleston, SC and was at a dinner downtown with the client.
Talk turned to the economic advantages of locating plants in SC, and he brought up Boeing.
The gist of the conversation was that the new Boeing CEO....no fan of Obama, liberals, regulations, and all the ‘crazy FAA tests and rules’, were ‘unnecessarily delaying their ability to ‘deliver profits’, and that their proposed expansion plant... despite a hefty economic package from Washington state and DC contracts, was going to be in SC.... and that the CEO was sick of being ‘fleeced and burdened’ by regulations, unions and the general attitude of DC, the PNW.
He point blank stated he would never build another plant ‘up there’ and that he would shut the rest down if he could, especially if the ‘libs remain in control’.
This told me all I needed to know about the culture of a once brilliant company.
I try to fly on Airbus planes now whenever possible.
Nice to know the CEO is more concerned about costs, while negating the culture of safety his specific product demands.
15
They updated a 50 year old design rather than replace it with a new one. Because they could make more profit that way. And look what happened. Greed is the Achilles Heel of American capitalism.
9
Same issue in China and India. But much worse.
This is the sociopathic nature of the corporation. It’s the model, not any individual’s fault. If one individual puts ethics above profits, the board will simply replace the person. Reminds me, as a physician, of business managers telling us when to discharge patients, and then punishing doctors who refuse in subtle, nearly untraceable ways. One reason that hospitals whose CEOs are physicians have statistically better outcomes.
5
The worst part about this whole matter isn't the deaths alone. It is that Boeing's executive management and the Board of Directors still fail to recognize that they were not constantly promoting safety as the primary company value. They still are not. Neither of them comprehends this basic fact. They killed those people and victimized their families, friends and associates and unduly endangered the rest of us.
Boeing will not kill the 737 MAX. Customers should pressure the airline carriers to kill it. Domestically that means avoid flying Southwest, United and American Airlines as they fly the 737 MAX. If you're flying internationally ask the carrier what type of plane they will be flying.
5
To all those suggesting this investigation be criminalized and "those people should do real jail time if they're ever going to learn from this tragedy": NO. The moment you criminalize investigations like this is the moment you become countries like Russia.
In investigations, even ones like this, where people died and someone was directly responsible—think of the DC-10 debacle in which the cargo doors of two loaded jumbo jets exploded out at 10,000 feet, one barely making it to the ground with superb flying skills but another plunging out of control to the ground holding 346 people—if you're threatening people with jail terms, all of a sudden any investigation goes quiet. People clam up all the way up the line.
In this case, people are calling for the heads of certain people at Boeing. Perhaps it would give a number of people a sense of satisfaction if the top man at Boeing or the FAA went to jail for twenty years, but is twenty years really enough? Why not the death penalty? Isn't that more appropriate?
You see where that road leads?
But the real purpose of any investigation of tragedies such as these is for them not to be repeated—not for the guilty to be punished, even though that might seem the appropriate measures at the time.
If it's any consolation, accidents like these have become vanishingly rare. Just Google "Aviation in 1985" to see how far we've come.
1
@Nicholas Robinson
Indeed, that is why NTSB investigations may NOT be used for prosecution purposes
1
There is a missed story here and that is deregulation .
Due to the lack of crashes in recent years Boeing was allowed to " self regulate " on plane safety . We have seen this allowed also for food and drugs at the FDA and worker safety regulated by OSHA . Much of this is due to budget and personnel cuts at these agencies as our Defense budget , with Homeland Security , now is about a trillion dollars a year , coupled with tax cuts for banks , corporations and the rich .
To their credit , The International Association of Machinists (IAM) , the union at Boeing , screamed about this for at least the last couple of years with little media coverage . They told us the Execs only cared about profits , their compensation , and the stockholders , and safety was secondary .
If you want to find out about a company , interview their workers and their union if they have one , and NOT the Bosses .
8
It’s called regulatory capture.
1
I used to work in aerospace and am an avid skydiver, loving flight without the trappings of an airframe. But I have TWO altimeters, one audible in my helmet, one on my wrist.
Boeing would give me an egg timer and say ‘good to go’.
5
We don't just expect a company and its stock to survive. We expect it to do well. We expect it to do even better than well. We want our investment to keep growing and growing. Its CEO likes to keeps his job and his bonus. Pressure is growing. Schedule has to be shortened. Profit has to keep increasing. Something has to go. Company capability is equal to its people capability. Short cut may lead to possible issues. For some cases, consequence is dear. This is one of those. We then get upset. We have to blame someone. This example is to teach us about our limitation, our shortcoming and some humility.
Why on earth would you remove a cheap sensor on an expensive plane? Why not use 20 sensors?
There seems to be a chain of bad decisions- the kind made when money trumps engineering:
1. Cut corners in the engineering process to rush out a product. In fact, charge people for this safety feature
2. Deny and hide the problem (aka Lion air)
3. The denials become so ingrained in their believe that even after a second crash in a few months - that they continue to deny any issues
4. Add another bandaid, maybe a couple of extra sensors. That will reduce the probability of another failure, make it even more difficult to trace down the root cause of the next failure.
5. Hope that the next failure doesn’t happen for a long time (till the current executives are gone)
1
Major catastrophes are almost always a chain of tiny events, each of which could have changed the course. It’s called attention to detail.
2
Let's be clear here - this is a massive failure on Boeing's part. While the details of the decision making - sleepwalking to disaster - is fascinating and reflects excellent reporting, Boeing had as its highest priority ensuring that no further training on the plane was required. They focused on that while failing to think through how their decision decisions impacted safety. It has reorganized itself to the point where crucial design decisions are compartmentalized and not adequately coordinated and considered. It has placed commercial goals ahead of engineering imperatives. Management presided over and indeed drove a catastrophic failure. They all need to go right now.
5
@Jim
I love your line, "Boeing had as its highest priority ensuring that no further training on the plane was required." How they could trot out their standard "Safety is our highest priority" line and expect anyone to believe it is beyond belief.
2
@jacreilly
“Safety is our second priority” just doesn’t have the same ring, even though it has the ring of truth.
2
This article describes a shocking breakdown of systems engineering on the 737 MAX program. The failure of corporate management and of the FAA to recognize that deficiency borders on criminal neglect. If we had a competent administration, the aeronautics side of NASA would be tasked to review Boeing's program management and systems engineering practices and to recommend changed to ensure that they are adequate to execute aircraft development programs. Clearly, today they are not.
4
Classic case of sales people making technical decisions behind engineers’ backs to save money.
2
The sequence of errors in judgement point to increasingly flawed attempts to cover up an inherently un-airworthy plane: too big engines stuck on an old plane design unable to compensate for the bigger engines.
The solution: software development with no broad oversight and sensors that break.
Boeing is guilty of criminal negligence. The FAA? Incompetent.
8
@Patricia G: The FAA is subject to the whims and ample incompetence of Congress. No doubt Congress will find a scapegoat somewhere in its table of organization.
2
I will be flying twice this summer to both Mexico and Portugal. I'm more than a little concerned that I will be flying in the Boeing 737 max with a new and improved version of the MCAS. I sure hope they don't use the beta version. At least one positive result is that it motivated me to prepare a will which is something I've been neglecting for years. Oh well I guess there's a silver lining in everything....
1
What a.display of extremely poor management of change in the design of this plane. And what a display of extremely poor investigation of the first crash. All these facts could have come out then and saved lives.
This is the culture of corporate America right now. Government regulation and enforcement is a joke. As a former chemical engineer It really makes me afraid of what's going to happen in aging nuclear and chemical plants.
5
While Boeing should take all the blames to design a flawed airplane, but FAA should also take responsibility because they are the last defense for our civilian safety. They are more than just a bunch of officials just stamp the documents, but rather poke, probe, research, and verify all the changes Boeing made or requested. It is a disgrace that it was the Chinese government ordered the stop of flying Boeing 737 MAX first.
7
The FAA is full of former corporate players from the aviation industry too.
1
Every design problem has it;s hidden potential traps. professional design teams must have "belts and suspenders" design reviews to avoid this (typical) kind of flaw - reviewers checking reviewers, outside designers brought in to try to find the blind spots that can afflict any team with a complex project. T think of this as risk management, each level of review reduces the statistical probability of failure by a finite amount, but the failure rate never can go to zero. The airline industry as a whole has a spectacularly low failure rate, so the occasional glitches are the more noticeable.
Boeing has a spectacular safety record. But still the glitches slip in, the problems always look obvious in hindsight, and so another level if review will add another decimal place to their failure rate. But let's not try to solve the problem for Boeing - we (or the FAA) can advise them, but they know better than anyone how to approach it.
2
@geochandler
Boeing got it wrong to start. Then they got it wrong after the first crash. It appears that their culture of safety and problem solving is broken. That's why two planes crashed. If they can't clean up the mess themselves, someone needs to provide oversight. They don't get the chance to crash a third plane full of people.
1
I very much appreciate the Times’ reporting in this article. It enabled me, a lay person with no knowledge of airplane handling or safety, to understand the safety issue, and how it arose.
I do, however, have a question. The last sentence of the article says “[the reworked MCAS]… will rely on two sensors.” Does that mean that the reworked system will rely on data from two angle-of-attack sensors or that it will rely on data from the two types of sensors originally envisioned, i.e., angle-of-attack sensors and acceleration sensors, or both? If it means only the first of these, because adding back the acceleration sensors would result in the system not activating to smooth out handling at low speeds, will that be sufficient to ensure safety? If only one of the angle-of-attack sensors is functioning, will the system be activated only when it should be, will it work properly in those situations, and will pilots be able to, and be trained to, override the system if it malfunctions? At least the original chief test pilot, Ray Craig, seemed skeptical of systems, like this one, that took control away from the pilot.
3
@Alvin Knott
The two sensor "fix" to me is still a problem...to have signal validation from sensors, three or more are needed. If there are only two, if one fails, it would be difficult for the system software to determine which one of two has failed. A discrepancy between two sensors could be alarmed with the system then disables, but that would depend if the sensor failures could be identified. With three or more sensors, a single failure can be eliminated by the two remaining good signals.
On a system that can override the pilot, I would expect a three sensor system. But I don't have direct knowledge of this particular control system.
1
@glennmr
As I understand the new version, if the two sensors don’t agree MCAS won’t activate.
FAR LESS robust than the much more integrated and capable protection systems on Airbus aircraft.
1
@glennmr
The Airbus A320 has three sensors.
1
Boeing has engaged in a criminal act. In order to save money, they knowingly failed to correct issues with the 737 Max that resulted in the death of 100’s of people. If I took my car on the road that I knew had a safety problem (bald tires, bad brakes, faulty steering) that resulted in the death of just one innocent person, I would be held criminally responsible. At best, manslaughter. Why should the people at Boeing who deceived the public and the FAA, be any less accountable? Let us also not forget that the FAA have abdicated their responsibility for flying safety to the companies they are supposed to regulate. It is a sickening reality.
8
@Stuart D. Patterson
Do you think any Ford execs faced a jury after Explorers were flipping over killing people?
The only thing they had to worry about was the quarterly bottom line.
As an old engineer I cringe every time I read and hear about the 737 Max. No matter how many ways Boeing spins the failure, this strikes me as a classic case of nervous senior management being overtaken by Airbus. Senior Boeing executives decided to let expediency to catch up to Airbus (while minimizing new investment) trump safety. This failure goes right to the very top of senior management. Time for an overhaul of the Boeing Board and senior executives.
25
For me, the major outcome from this fiasco (and other recent fiascos), based on their weak verbal responses, sluggish reactions, and inability to take responsibility, is that I do not trust Boeing, nor the FAA, nor the heads of the Department of Transportation or Department of Defense.
The action I take, as with other recent losses of trust in corporations such as Boeing, is to learn to live without spending money on the products of those corporations or any of their affiliates. I have found other purposes for my money and am getting along just fine.
3
While I am not an engineer, I was a NAVY pilot and the Navy was very much invested in AOA because of the need for precise speed control during carrier landings, much more so than the Air Force, at least in my perception in the Vietnam time frame. The sensor is dependant upon undisturbed air flow and it is hard to imagine any kind of cage around it that would not or could not do just that–disturb the flow of air over the sensor. In my experience the systems were very reliable even though they utilized only one sensor. The MAX apparently has multiple, independent sensors which, if utilized, should have prevented what happened and/or notified the flight crew that there was a discrepancy and a portion of the flight control system has been shut off. Commercial aircraft have had design flaws before and, after being corrected, whet on to have many years of successful use. The DC-10 is one example.
2
@Peter
But the low-speed regime of MCAS didn’t require the accelerometer input and only used one AOA input -not just for an AOA indication (like in your Navy aircraft) but to physically apply control pressure so great that the pilots could not override it. Instead, they needed to to shut it off before it got critical—and everyone dies. And, oh yeah, they didn’t mention that.
what this article glosses over and so does boeing and the FAA is that the reason for the MCAS is not to have "smooth handling" but to avoid a stall because the plane is more difficult to fly due to large wing mounted engines that are forward mounted. i have yet to see an article or analysis that outlines exactly the differences in the stall characteristics of the MAX which is the real issue. how far off from the original 737 these stall characteristics are is the definition of the real safety problem with the MAX. i am waiting for that analysis.
10
As a 50 year Quality/Reliability Engineering professional, this design oversight is part of the new world ofthinking...."cheaper, better, faster"... mantra first seen with NASA's second generation of management!
We have reached the point where checking on the checkers is not a viable alternative, an independent, second look, sign-off is now necessary from design to build!
4
If Boeing had designed hydraulically boosted elevator controls in the 737, either originally or as a modification, the crews of the accident airplanes would have been able to keep the nose level with only moderate back pressure on the control column while they sorted out the problems with the stabilizer run-away condition. Other Boeing aircraft have hydraulically boosted controls for the ailerons, elevators, and rudder. The 737 only has a boost for the rudder. The pilot manual warnings of the manual trim wheel being difficult to move in a high speed nose down attitude leaves no doubt Boeing was aware of this design deficiency on ALL 737s ever made.
2
This article seems to be saying that these failings occurred due to bureaucratic compartmentalization and division of labor. A classic rationalization used by corporations to deflect and defuse responsibility and culpability. Also used by the FAA it seems. This does not change the fact that hundreds died because of this plane and the people involved in its development and release. Boeing and the FAA must be held accountable.
7
As a state and federal litigator and ex-prosecutor, this is a fairly straightforward example of gross negligence in the civil setting, but possibly also criminally negligent homicide. Under New York Penal Law Section 125.10, for example, charging a person with criminally negligent homicide requires that they acted in a reckless manner or failed to act in a responsible manner resulting in the death of another person. Either way, Johndroe's statement that Boeing has no priority higher than the safety of the flying public is demonstrably false; they were driven by a desire to make profits and best the competition. If the Trump administration doesn't order a DOJ investigation into possible criminal charges, the reason will be as plain as his comb-over.
12
Nice to know that going forward the 737-Max will have 2 sensors. But what about the hundreds of planes which were delivered with only one? Will they be retrofitted - at Boeing's expense - with a second sensor or will we be flying fingers crossed?
4
@Barbara
The angle of attack sensors were already there and used for other functions. MCAS just wasn’t looking at both of them—and therein lies the issue.
Why isn't the angle of attack sensor mounted inside the fuselage? Measuring angles does not require a sensor externally exposed to the atmosphere and all it's hazards.
@Haef:
You may be thinking of pitch attitude, the value of which is gleaned from gyroscopes (usually of the ring laser type, or mechanical in most aircraft).
To get angle of attack readings requires measuring the airflow angle, necessitating the sensor to outside the aircraft.
In certain flight situations, issues can occur when there is a large difference between the pitch attitude and the angle of attack. Ostensibly, this is what the MCAS system was to address—but would be dangerous when relying upon faulty sensor data.
4
FAA has a lot of responsibility to bear .The conduct of Boeing in this whole episode has been shameful
If VW corporates leaders can be taken into account for frauds committed with the pollution control equipment which directly did not kill people then what's stopping from the criminal prosecution of people responsible for these accidents .
The reason would be Boeing being an American company and the the two aircrashes do not involve American lives
5
The FAA is controlled by the Trump Administration. They don't care and the FAA apparently doesn't care either. Say no more.
They'll just lie about it and move on.
Brings one great comfort when Going essentially admits they did the minimum safety controls required...wonder if they also release bids for critical components to the lowest budduer.
4
As a Boeing employee many years ago I recall reading an internal memo that bothered me. It stated that using short lengths of wire insufficient to safely carry high currents under certain circumstances was OK as long as smoke removal capability for the compartment was available. I was a very young engineer of limited experience, but it seemed to me to be a risky proposition.
13
Boeing can redesign the bejeesus out of its MCAS system, but if the 737 Max is ever put back into service and I have to fly somewhere I’ll make sure it’s *not* in one of these planes.
13
Now I understand why my father, a former Boeing engineer, had a cartoon up in his garage for the last 40 years. It shows an engineer with a pocket protector and a pencil behind his ear standing by the pencil sharpener with his finger in the sharpener. The caption reads The secrecy of my job prevents me from knowing what I am doing.
8
@Pete: Boeing learned how to build high altitude pressurized airplanes while making B-29s to bomb Japan. There were lots of crashes in the process.
https://en.wikipedia.org/wiki/Boeing_B-29_Superfortress
Those of us living in Washington remember the big hubbub about moving Boeing headquarters to Chicago several years ago. Some people even said at the time that this would result in prioritizing corporate profits over safety. Guess they were right, weren't they?
6
These atrocities will continue until the specific individuals who gave and carried out the dangerous orders are prosecuted and punished - up to and including the death penalty for capital murder (which should be expanded to include gross negligence likely to lead to mass fatalities). The principle of the Nuremberg trials should be applied: following orders is no excuse. Encourage whistle-blowers BEFORE the tragedy takes place.
12
@Observer
Criminal negligence, perhaps. Maybe even likely. Not atrocities or murder. Jeez.
Recall he plane. The size and forward placement of the engines is not aerodynamically sound. Software should not have to be relied upon to compensate for a design flaw.
14
@an observer
A more complete fly-by-wire system should have been designed to accommodate this configuration, not this bolted on “fix”.
The newest 737 still lags behind the A320 from 3 decades ago
I suppose that in an environment of divided responsibility, no one will be held to be actually responsible. And that's just too bad. Boeing deserves serious punishment for this criminally negligent piece of work. And the MAX should be classified as a new aircraft, requiring full-bore recertification and corresponding crew training.
8
the root cause is always about money, no matter what excuses Boeing come up with. with the FAA in the palms of the airline industry there is no way that they can be an impartial referee in all these matters. adding in Trump's protection of corporate profits over the general public, the only conclusion that can come out of this is a top level cover up and a rush to put the 737 Max back in service so that the whole airline industry can continue to make money on the backs of passengers' safety.
sad but true..
2
The tragedy that happened with the 737-Max and the follow-up of it reminds me of the Discovery space shuttle disaster. Insiders knew that launching the rocket after freezing temperatures could severely damage the hull of the boosters. Some asked to delay the departure of the rocket. Nasa gave the green light for it...and no one has been punished for this dramatic failure of decision making...
7
@robert
That was actually the Challenger, and the problem was that the rubber O-rings that sealed the booster sections at their joints lost their flexibility in the cold. But your point is correct.
5
I believe you’re thinking of the Challenger disaster. I still remember the name of the contractor that built the boosters: Morton Thiokol. And how the eminent physicist Richard Feynman, on the panel that was formed to investigate the disaster, demonstrated how the booster’s O-ring sealers became less expansive when cold: he deformed one with a small C-clamp and stuck it in a coffee cup full of ice water. The Morton Thiokol executives were furious.
8
@robert
The engineer that recommended not launching the shuttle in cold weather was actually shunned by his colleagues...and subsequently resigned.
2
There are two fundamental issues that transcend the Boeing problem. One is the tendency of us to overlook assumptions. And there are assumptions and implicit assumptions. The other is related in that we fail to realize that our language refers to and expresses certain realities but are not the actual reality. We see this daily as people, business and politicians "frame" their message to fit their desire to create a reality favorable to their interests. The verbal reality we "create" is a useful tool but only a tool and its assumptions need to be examined all the time.
4
@WhiskeyJack: People overlook the basics in the US.
Last evening my wife and I saw the latest revival of Arthur Miller's All My Sons. It is hard to miss how Miller's 1947 play resonates still as our American-born obsession with business and productivity creates a veil that too often hides from us our humanity.
"The company also played down the scope of the system to regulators. Boeing never disclosed the revamp of MCAS to Federal Aviation Administration 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 F.A.A. agreed. As a result, most Max pilots did not know about the software until after the first crash, in October."
13
Going forward, I think the pilot unions from the various airlines and countries should be involved in the design and certification of new systems. They are the only ones with both the knowledge and incentive to make sure systems are designed correctly. Airlines themselves can’t do this because their incentive is to get a new product for the lowest price with the quickest turnaround. Governments agencies can’t do it alone because they are staffed, top heavy with individuals whose next jobs are back in industry. Furthermore, government agencies are constantly under attack for over regulating so there is incentive for them to streamline and hence weakening the oversight process.
9
I have only a basic understanding of aerodynamic principles. But I do have an understanding of corporate culture, and I think that was the primary cause of Boeing's 747 Max debacle. Large corporations don't exist to make airplanes, cars, shampoo or air conditioners. They exist to make money.
The MBA mentality takes that worldview to the extreme, sometimes to the detriment of the boring stuff a corporation has to do to generate a money stream. When Boeing moved its executive offices from Seattle to Chicago, it physically isolated top management from the humdrum problems of making aircraft in Seattle or South Charleston. Sure, they still talked to each other, but the emphasis shifted from great airplanes to great profits.
21
@Charles Tiege - I completely agree. I have been exposed to some of that corporate thought and I knew the Renton to Chicago move was for the benefit of executives, not the company or the consumer or the products.
5
Take a look frontally at the 737 Max's competitor the Airbus Neo. It stands higher off the ground allowing for placing a larger engine on the wing. It also has more sensors. The giant engine on the Max actually is above wing level when looked at frontally because the Max sits lower to the ground than the Neo. This is a design issue which now is being compensated for with algorithms for the sake of profit? Boeing spent tens of billions of dollars on stock buybacks in the last decade to elevate its share value and enrich in executives...what about using its riches for a real redesign of the 737? Boeing has to go back to the drawing board ...new landing gear system to raise the level of the airplane and move the engines back and down?
I used to be a flight attendant and there is no way I would work or travel on the aircraft. Shame on the FAA and Boeing for creating what Ralph Nader called a "killer jet." His grand niece died on the Ethiopian jetliner.
24
@Chaussettes
You are essentially correct but it’s my understanding that just redesigning the landing gear to raise the plane is not possible. They do need to go all the way back to the drawing board and design a completely new, modern replacement for this 1960s plane. The cost will be high—that’s why Boeing avoided it. Enormous mistake, it turns out.
2
My question is, was MCAS the first time an AoA sensor was given CONTROL of an aircraft? I do know that AoA sensors inform flight crew of stall situations and do activate the stick shaker, but was MCAS the first time they controlled the aircraft?
If so, then Boeing has made a big design error.
6
@wnhoke
It’s my understanding that Airbus has a similar automatic system, but it polls multiple sensors and does not allow the massive automatic trim adjustments the Boeing system did.
1
@wnhoke: It has to be spooky to fly an airplane with inherent pitch instability by stick and rudder. MCAS was expected to hide it.
Boeing’s continues to spout mindless platitudes in response to growing evidence of its recklessness. The Company’s (and the individual executives’) defense appears to be resist and deny, this will all blow over.
It’s been obvious since the second crash and subsequent grounding of the fleet that the Max will never fly again, yet they continue to produce them. Still, I’d be fearful about shorting the stock, this is the government’s favorite pet-company, with more than half of revenues from government contracts. They’ll eventually engineer a way to pass the losses on to the taxpayers (oh, and bond holders) through those contracts.
4
“As Boeing rushed to get the plane done...” the culture of greed finally catches up to an icon of American industry. This would not have happened in an earlier era when Boeing’s corporate culture was still heavily influenced by its close association with a military that was itself still influenced by WWII and serving as “The Arsenal of Democracy” When greed is your only motivating factor safety takes a back seat. Will Boeing learn from its hugely costly mistake?
11
Are all the brilliant minds at Boeing unable to design a simple cage for sensors to keep bird attacks at bay? Is this really too difficult or is it too simple-minded thinking? Anyhow, we now know that just because a company has great engineers does not mean it has leaders who get the critical aspect of the aircraft business: the need to earn and retain the public's trust.
5
Boeing was busy attacking Bombardier C-Series and getting a 200% tariff on it. That forced Bombardier to give the project to Aribus, becoming the A-220, before the tariff was thrown out in court. The irony is that the C-Series was not a competitor to any Boeing aircraft and it was a totally new design, no need for MCAS. Next, instead of designing a safe new competitor, Boeing bought in on whatever Embraer was building. Boeing needs to re-think how and why they are in business.
6
The headline uses the word “assumptions.” Just as effective “cockpit resource management” has help aircrews improve flight safety by rooting out assumptions, Boeing needs better “production resource management” to avoid assumptions in design and manufacturing. These catastrophes grew out of human assumptions - plain and simple.
6
Aircraft are dynamically coupled systems of systems and have been developed since the first aircraft by Otto Lilienthal in a top-down way by first developing the mathematical model of the overall system of aircraft, environment, pilot/autopilot. Bill Boeing introduced this method when he started Boeing.
Digital systems of systems in modern aircraft are also dynamically coupled systems of systems and have to be developed top-down. This principle was introduced at Boeing starting with the 777 and continued under strict Navy requirements on the P-8a (derived from 737NG)---an airplane with the highest availability.
When Boeing changed the 737 from mechanical to digital they did not introduce top down design for networked digital systems and hence had no process to develop MCAS correctly on 737MAX.
Recent Boeing publications show that it has moved integration from the design office to suppliers---moving to bottom-up development. It therefore no longer uses a process to avoid similar problems as with the 737MAX.
3
If you were purchasing on behalf of another country in the future would you buy from Boeing? Me either
4
I have made my choice: I will never fly on anything made by Boeing.
2
@James Murphy
I would say that’s a bit over-the-top. Boeing has made plenty of fantastic airplanes, including the original 737. I do understand people’s reluctance to get on a 737-MAX, however.
1
@James Murphy Let me know how that works out for you. There’s no way you can fly frequently without being on a Boeing plane.
Ironically, the fast certification process of the F.A.A. and Boeing, with regard to the 737 Max, “Took It To the Max” (as the Eagles sang), but the flaws of the computerized MCAS system in avoiding ‘take-off’ stalls may well be prescient of a far broader existential danger in AI software “fast take-off”.
2
A well researched article, one of the type of investigative pieces which makes the NYT one of the great English language newspapers.
Boeing had several issues with its 787 launch and battery power device that would start burning leading to grounding of already delivered models for a while. Seems like nothing was learned at Boeing from that incident.
Large commercial airplane designs today seem to involve too much outsourcing of different component parts to too many companies (for cost savings reasons) combined with compartimentalized approach to putting an complicated aircraft together. Too many cooks in charge of preparing a very complicated soup...
Must be very happy reading for Airbus executives in Europe this weekend. This combined with Trump threats towards China (largest growing individual civil aviation market in the world), where gov't can just say adios to Boeing if they so wish (Chinese are also quietly and slowly developing their own new commercial aviation jets with Russia). In India where Trump is also threatening trade sanctions against a newly elected PM (one of the other major growing civil aviation markets).
6
@Marc Faltheim: the 787 issue was confined to the lithium batteries backing up the flight controls. The battery design was corrected and the containment improved. The airplane is sound, but there have been issues with debris left in planes after manufacture.
2
You read about a lunchroom worker being fired for giving a free lunch to a student on welfare, and, yet, the CEO of Boeing keeps his job after two major crashes of a plane he and his team produced.
15
@Amanda Jones: So it goes in Trumped America.
Why did the accident report show that, as the two aircraft were descending rapidly, pilots had throttles at max power?
1
@Raymond Goodman Jr.
Increasing speed is a basic, correct response to an impending stall.
1
Most citizens, and certainly most of commentators here, understand what happened. But there are no major consequences at Boing. No arrests. No firings. No indictments. Why?
7
Lets just watch what happens when they un-ground the Max, and the flying public won't touch it...
5
@AmorFati
Airlines will stop disclosing what type of aircraft is being flown for each flight.
All the pressure was on all sides to save money. To completely redesign a plane and decide to cut corners by not training pilots is ludicrous. The FAA sounds imbecilic in fawning over Boeing while our President touts the many benefits of deregulation. To remove a computer system that takes over control of the plane from the manual rises to criminality. Boeing was pretending it didn't matter but it defies logic to believe them. All about dollars and damage control. If I ran the world it would cost them 100 million dollars every time they said safety is their highest priority. Bald-faced lie. Alternative facts? No, money. Beat the Airbus. Rush it out as cheap as can be and hope for the best. Disgusting.
6
“Boeing has no higher priority than the safety of the flying public,” a company spokesman, Gordon Johndroe, said in a statement" . . . thereby lying to the public and stating the exact opposite of what the facts clearly show in this post-truth world.
5
The failed MCAS software system was an attempt to fix a flight problem that still remains. The aerodynamic design changes moving the wing higher and forward on the fuselage still exist. A redesign is necessary. The remaining 737-800 Supermax aircraft should be scrapped.
6
@Wordless: A passive inherent aerodynamic solution could be credible to the public.
1
This plane, due to its redisign to accomate larger engines, is inherintendly prone to stall. Airliners cannot recover from stalls. No passenger plane should have that risk. The Max-80 should be banned for good. They are made from aluminum, so Boeing can sell them to companies that make pots and pans.
Yours,
Tom Zynda
5
Is anyone going to jail over all these deaths? Boeing was clever, spreading the blame to make sure no any one person is held accountable.
4
@Héloïse - the company officers, board of directors and the executive team are always there to be held accountable. And outsized executive compensation should come with commensurate accountability.
While visiting his airplane building shop at the Duwamish shipyard in 1916, Boeing (William E., Founder/Owner/President/Board Chairman) saw a set of improperly sawed spruce ribs. He brushed them to the floor and walked all over them until they were broken. A frayed aileron cable caused him to remark, "I, for one, will close up shop rather than send out work of this kind.”
6
There is absolutely no way I am ever flying on this plane. I don't care what they do to it. I would rather walk.
3
Sounds like Mark Forkner should be charged with manslaughter at the least.
Article does not properly state why he advocated to the FAA for MCAS to be taken out of the manual.
Full picture or not, it's clear there's something not entirely ethical with his actions.
1
“Boeing has no higher priority than the safety of the flying public,” a company spokesman, Gordon Johndroe, said in a statement.
That is obviously not true.
1
Why didn't Boeing solve the problem of fitting the larger engines by lengthening the wheel struts to create more clearance under the wings?
@Albert Donnay
I had the same question, and I don’t remember the exact reason, but there are apparently critical engineering problems with that approach. They obviously would have gone that route had it been possible. The plane is just too old. It was designed in the 1960s. Time for Boeing to buck up and build a new, modern single-aisle airliner.
2
I want some prosecutions of those who decided to do the wrong thing, no matter what it was and who it impacted. I want them in prison - every single one of them. They are liars and they continued lying after the planes went down. CONTINUED. LYING. AFTER. THE. PLANES. WENT. DOWN.
3
An excellent article that of itself fully justifies my subscription to the NYT. It will cause me to ask many more questions and be very sceptical of any answers from Boeing, before I next step aboard a 737 Max. What other systems in the 737 have a single point of failure designed in and hidden.
2
Can you for one second imagine the terror those people on board felt as they hurtled nose down at top speed towards earth? That horror is being relived every day, and particularly night, by the surviving family members. Boeing has to be made to compensate as much as possible for their unbelievable arrogance and irresponsibility in their corporate processes. Since they can't be roasted slowly at the stake, they have to PAY! That's all we have in our legal process.
4
And this is just one of the many built-in system failures throughout the country where the wolf is guarding the hen house. Get ready America for your next disaster and you’re next at your next and your next. Straight from the wolf White House
3
The CEO must resign on Monday.
2
My conclusion: there is a very simple fix.
Boeing just needs to redesign the hull and wings of the 737 Max so it can fit the larger engines on the aerodynamically appropriate place under the wings. No MCAS needed.
Oh, but this takes time and money to accomplish and Boeing wasn't willing to spend this effort on its cash cow product
So here we go, Boeing claiming "security first" but acting on "profitability is paramount".
Pathetic.
5
“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 used just one, leaving the system without a critical safeguard.”
In our classes, we teach our students how to design fault-tolerant systems when system components are likely to fail asynchronously. With only one sensor, how could any system be fail-safe? Even two sensors would not be enough since they can feed conflicting signals.
What Boeing did is unthinkable. Please do employ our students from State University of New York who would at least provide better safer architectures.
2
On a flight from San Antonio, strictly by chance, I was seated next to the parents of one of the victims of the Ethiopian flight. They'd been to a memorial service for their son at Ft. Sam Houston. The mom told me about her son, a decorated soldier, a husband, a father of two young sons. She showed me the pamphlet that detailed his military life and accomplishments. She showed me a picture of him with his wife and children, a beautiful, smiling family. She told me she couldn't cry any more. The dad was silent; his forward gaze didn't waver as she spoke to me. These two broken-hearted parents represent but one victim. One lost man.
The men responsible for this young man's death -- and the hundreds of others -- should be charged and convicted as the criminals they are. Their greed, negligence, and disrespect of human life is appalling. They and they alone are responsible for the loss of these souls; yes, there's a reason flight crews refer to their passengers as "souls on board."
543
@Deborah Schmidt if yours was the attitude over the centuries as transportation technology evolved, we'd still be just walking everywhere.
11
@Deborah Schmidt
"The men and women responsible..."
11
@Deborah Schmidt
Let's just start with firing the Boeing Board and getting rid of the top tiers of management. Replace the leadership, restore trust, identify the problem, fix. Then innovate beyond the wild imagination of flight. Use this tragedy to spur progress.
As for prosecuting and prison, be reasonable. No one malicious act can be identified. Just greed, and lets face it, we are all guilty of that. We want cheap flights, fast, efficient, etc... We are all guilty of capitalism.
34
I'm an engineer. I've been in meetings like this. I've pondered the calculus and power structure involved that yield decisions from these meetings and find that we have a flawed authority structure in American business that prioritizes schedule over functionality. Add to this the reliance upon software changes to "patch up" fundamental problems with the hardware (which are much more costly and time consuming to change), and it's easy to see how this can happen.
Scientists and engineers need more authority in determining when something is appropriate or "right". They do this in Germany. But in America this authority resides with program directors who are often more motivated by schedule and cost considerations than they are by technical performance and safety.
8
Another blatant example of why industries and businesses need to be regulated.
7
Ever have your car's sensors activate to correct for how you're negotiating a curve?
Feels exactly like the car getting loose because of slippery pavement.
What happens when it decides to activate while you might be on slippery pavement and you try to correct by steering toward the slide?
2
The problem with the 737 MAX is that the engines were located forward and higher on the wings to fit larger engines. This caused sudden and difficult handling in certain flight situations - adding power while flying low and slow (e.g. takeoff and climb out) caused the nose to pitch up into a stall. MCAS was designed to help pilots deal with that situation, albeit unknowingly. It doesn't fix the problem. IMHO this plane has to be redesigned to be accepted by the airlines and the public. Tweaks to MCAS, while certainly important, will not do it.
6
even the most perfect fix now will be like locking the barn door after the cows have gone. possibly the underlying technical problem can be fixed (how would I know?), but the underlying error is irreparable. you can fix stupid.
Unheard-of lack of redundancy in sensors. In the offshore/marine world, a typical Dynamic Positioning system uses a Voting System to:
Detect local interface errors in each controller
Detect sensor errors
Ensure that all three computers use the same data as a basis for calculations of command signals ... (thanks to Kongsberg)
It is astounding that they would think you can trust just one senor of any kind. Did it really save that much money? Compared to killing two plane loads of passengers and crew?
Again, a Macondo-like failure to appreciate risk in the risk-vs-reward assessment.
5
Single points of failure are to be avoided if at all possible. The fact that a system that could override pilot commands and crash a plane relied on a single sensor was unforgivable, especially since so many other sensors were available to provide further data.
3
the fundamental problem here seems to be mismatching engine and plane, then thinking a software correction can overcome a basic design flaw. Doesn't make sense but you get the feeling that Boeing is so far down the road financially with this plane that it doesn't want to turn back. I'm probably not the only one that will always avoid this plane. it'll add another feature to travel booking- looking at which kind of plane we will be on
3
@ break
Sounds as if Boeing fell for the Fallacy of Sunken Costs. Always remember that the amount of prior investment in anything (a stock, an airplane, a marriage) does not justify continuing investment as-is once a fatal flaw has been identified. Instead, actually fix the fatal flaw or exit — b/c glossing over the flaw merely postpones final disaster.
2
There needs to be criminal prosecutions of Boeing executives and the largest fine in corporate history (with all of the money going to crash victim’s families.). And there needs to be government oversight of Boeing for a minimum of 10 years. They cannot be trusted anymore.
8
Re: Criminal Investigation of Boeing
GM's faulty ignition lock, known to GM for years, killed 124 people - and no one went to jail
The US justice system is very leery of damaging the compatitive standing of US companies. Foreign owned ones are an other matter (see VW)
4
"Technical pilots at Boeing like him previously flew planes regularly, two former employees said. “Then the company made a strategic change where they decided tech pilots would no longer be active pilots,” Mr. Ludtke said."
This must be close to the top of the list of Boeing's most poorly deliberated decisions.
6
The "more aggressive" MCAS response also included putting backpressure on the yoke. This backpressure resisted pilots attempting to pull the nose up. The amount of backpressure applied (fully artificially) by MCAS quickly rose to a force so high no pilot had the strength to pull back against it.
This is very likely why if the problem was not corrected within something like 30 to 40 seconds, the aircraft was dooomed--and why experienced pilots tested in a simulator that modeled a failed AoA sensor crashed almost half of their test flights despite knowing they were going to test MCAS.
It is beyond belief that nobody at Boeing appears to have done the analysis of what would happen in the event that the single sensor feeding the MCAS control failed or was stuck in the "on the ground" condition. Of course, while sitting on the ground the Angle of Attack sensor is -- correctly -- showing full stall. When it is stuck there, the moment flaps are fully retracted MCAS is auto-enabled. The level aircraft has its nose driven into a steep dive, and the yoke becomes very stiff. While the pilots could overcome the inital MCAS applied backpressure resisting nose-up, it increased with each activation of MCAS, quickly exceeding the power any pilot could apply to the yoke.
This article does not mention the large role the MCAS generated backpressure had in ensuring aircraft loss when the AoA sensor used by the MCAS was stuck in the "ground" or "full stall" state.
7
the only important engineering work is the 29th of the month... the delivery date.. ( don't worry, they can adjust it in the field)
2
Even the best pilots on the planet could have been overwhelmed by a malfunctioning MCAS. You are only a few thousand feet above the ground, traveling at over 200 knots and suddenly the plane noses over and starts heading for the ground. Pilots would have five to ten seconds to get it right and fix the problem.
No “safety” system should ever expose pilots and passengers to such failures. Shame on Boeing for not building in redundancy to the system. Shame on Boeing for trying to pin blame on pilots. And shame on the F.A.A. for turning itself into a lap-dog agency for Boeing.
My guess is that now both Boeing and the F.A.A. are going over the entire Max design and approval process. It now seems that they have enough time to get it right. Big surprise.
4
Silly article. MCAS's reliance on a single angle of attack sensor was known months ago. And relying on emotional statements from shocked test pilots, etc. has no place in what should have been a more scientific-focused article.
Yes, Boeing is culpable given that they were foolish to not rely on redundant sensors on an aircraft, particularly when a computerized flight control system was using the data. But the pilots of the lost airplanes were also culpable, since they didn't learn the flight manual which had the instructions for how to defeat MCAS. Just because they're victims doesn't mean they weren't (partially) responsible.
Overall, an unbalanced, emotion-laden article that is meant to raise readers' ire towards Boeing, rather than coldly examine what went wrong, allowing readers to draw their own conclusions.
@H
You wrote:
"....the pilots of the lost airplanes were also culpable, since they didn't learn the flight manual which had the instructions for how to defeat MCAS. Just because they're victims doesn't mean they weren't (partially) responsible."
According to the article , MCAS was removed from the manual:
"On March 30, 2016, Mark Forkner, the Max’s chief technical pilot, sent an email to senior F.A.A. officials with a seemingly innocuous request: Would it be O.K. to remove MCAS from the pilot’s manual? The officials, who helped determine pilot training needs, had been briefed on the original version of MCAS months earlier. Mr. Forkner and Boeing never mentioned to them that MCAS was in the midst of an overhaul, according to the three F.A.A. officials.
Under the impression that the system was relatively benign and rarely used, the F.A.A. eventually approved Mr. Forkner’s request, the three officials said."
8
@H
This is a silly comment. It's also been reported that Boeing made the choices that made it rather difficult for pilots to figure out what to do in this particular situation, by having to look in a paper manual in a time-sensitive situation, and that that there were two possible choices to make, and only of them -- a manual, permanent disabling of the system would work.
@H Complete corporate lies and spin. A comment made by an individual who refuses to grasp the facts. I will never fly on this monstrosity and I hope the Flying public simply refuses to board. The corporate goons at Boeing haven't been plunged nose forward into a mountain or the ocean. Starve the Max 737 and put it out of the sky for good.
Planes are supposed to be flyable by pilots. Software is only supposed to kick in to prevent pilots making errors. The Ethiopian pilots knew about the software, but when they turned it off they were unable to control the plane.
5
The CEO knew the planes were dangerous! To be frank it doesn’t matter why. HE KNEW! He and his lobbyists pressured the FAA not to ground them and even after they killed two plane loads of people he kept it up and even called the President. In my opinion, The CEO should be prosecuted for depraved indifference murder. And he should be joined by his enablers . Until we take a strong stand against CEOs who make these decisions that places profits over the lives of people nothing will change!
7
One of the things that stands out in this story is how effectively capitalism creates layers of responsibility between corporate decisionmakers and dead people
10
If MCAS was not in the pilot's manual, would the doomed pilots have fought the system to the end and have lacked the training to recognize the malfunction and disengage?
Unbelievable!! Who was in charge of Systems Engineering, System Safety, Human Factors, Flightdeck Integration? They appear to have been left out of the loop. This is a management and process problem.
4
@Joann no it’s a crime. Management in the person of the CEO ignored the risks and people died!
Story plays out as if the bean-counters took control.
5
Boing should train their future pilots at Southwest Airlines. In the mean time, a thorough investigation should be conducted to find the source of the problem that cause the loss of two planes.
If Boeing was a Chinese company, executives and others would have been sentenced to death. I want Boeing officials, FAA regulators, and safety engineers to think about that.
5
@Zev they know they won’t even spend a day in jail and they will likely get more money in the pay packet!
Criminal charges should be brought against Boeing executives at least for negligent behaviors, if not for stronger charges. Their decisions were based on making profits, but they led to hundreds of deaths and places thousands more lives at risk of death.
Beyond the need for criminal charges, stockholders have lost much value because of the stupidity of those criminal decisions, and those executives, and the members of the board that allowed them to behave this way, need to be given the sack and blacklisted from further participation in any corporations whatsoever.
The usual passing over of any consequences by corporate executives and boards must end. It is past time to hold accountable the criminal activities of corporate officials. Their collision with government officials in allowing such behaviors must end.
To borrow a phrase from the Trump supporters and to apply it where deserved: lock 'em up.
5
This is a very good investigative story BUT:
Why no pictures of an angle of attack sensor, the most major item in this story, and maybe even a damaged one!
Instead there are several photos that are not relevent to the story when their could be some illustrations showing the location of the sensors, and other relevent details mentioned int he article.
6
In the current issue of Southwest Magazine, CEO Gary Kelly says about the 737MAX,. "Safety is our top priority and always will be." Yet he refused to ground all of his 737Max after the first crash. He said he trusted Boing and the FAA.
It was not only Boing that put lives at risk, it was Southwest, as well. And I say this as one that flies the airline about 100 times a year. That is used to. Kelly failed his passengers and employees and put us at risk, all for the bottom line.
3
Boeing has no higher priority than....PROFIT. This plane should never fly again, and the corporation's executives need to be charged with manslaughter. Moving the administration of the company to Chicago, and employing undertrained and incompetent help in South Carolina to get away from the unions in Washington State were just some of the reasons for the string of catastrophes that have ensued. Grafting new systems again and again on an outdated design reached its apotheosis with this piece of junk. People need to vote with their feet to force airlines to abandon this plane, and Boeing should not be able to sell any more. That will punish those who inflicted this monstrosity on the world.
7
How much can a sensor used on all planes for 100 years possibly cost? They company acts like they were solid gold and diamond embedded. They couldnt spare an extra few pennies to put 2 more on each plane?
And no one in the big company full of stanford and mit or wherever engineers thought a bird might hit one or a piece of dirt or ice might get in one or a wire could be bumped?
Obviously the ceo didnt even care to find out as he called trump to keep the things flying instead of his own engineering department.
5
The public has to stop flying American and Southwest Air as long as these cos continue to even consider putting these planes back in service.
3
Trump has selected one of Boeing's inept 737 decision-makers to lead the Defense Department. Trump is obviously threatened by competency.
3
I wish we knew more about the people who are gone forever from this earth along with their hopes, accomplishments, endeavors. They seem tragically lost again in this horrendous story of Boeing Greed.
5
The NYT has produced a well researched series on the failure of Boeing to design a more efficient version of the 737 aircraft.
Boeing was under pressure to match the Airbus 320neo series. Instead of developing a new plane after 50 years of service they chose to push the 737 beyond its capabilities. They also cut corners to save money and after the final product did not perform smoothly they started to patch up the problem. The fix changed the MCAS from a minor background software to a death trap. On top of this the regulatory process broke down with too much reliance of the FAA on Boeing’s voluntary cooperation.
The flying public has lost trust in the 737 MAX. Boeing’s reputation is damaged. And other nations will not follow the FAA blindly anymore.
I have a suggestion for Boeing: stop the MAX production, sell the older version at a discount and start developing a state-of-the-art airplane for the 21st century. Anything else will again be a short term fix, we already know how this ends.
1
Dennis Muilenburg, Boeing CEO, has no business still being employed.
What does that say for trust in Boeing?
3
Does Boeing think that if it says ‘safety is it’s top priority’ enough that they can convince a skeptical public that it’s a true statement? This is nothing but a classic example of a company ‘too big to regulate.’ The 737 debacle and the recently discovered problems at the Boeing 777 South Carolina plant, leave me far from confident that Boeing has a clue how bad their reputation has become virtually overnight. No matter how many times the airline CEO’s or Boeing try to say that ‘safety’ is their top priority, it’s clear from their actions that ‘money’ is the top priority, not safety. This is why independent regulatory bodies are needed.
4
“Boeing has no higher priority than the safety of the flying public,” a company spokesman, Gordon Johndroe.
Then why did they allow the aircraft to fly after the the Lion Air Indonesia flight? Prior to that flight's take off, the problems had already been logged on the craft's previous leg. Approximately two months passed between the two crashes and there was already plenty enough speculation about the MCAS.
Boeing still cannot come to terms with its failure to ensure passenger and craft safety. Junk unbelievable statements coming from company spokesmen will only provoke cynicism. How can Boeing recover an ounce of public confidence if they keep spouting nonsense like this.
334
@Svirchev
Why? Because they blamed the crash on poorly trained pilots in 3rd world country. Systemic racism/elitism/imperialism call it what you like.
BTW inside Boeing they still think it was pilot error. Something about a chain of events, blah, blah.
14
@Svirchev Not only did they not ground their aircraft after Lion Air, they called Trump after Ethiopian Air to convince him to keep the plane flying. That alone shows gross negligence bordering on a criminal act
31
@Christine A. Roux
I really do have to wonder why none of Southwest's thousands of flights in this plane in the USA has ever had this problem. Have they never flown this Max?
6
Bottom line - For Boeing, and for the FAA, safety was NOT the bottom line. Why not?
See "All My Sons", stage or screen version. Head of a company that manufactures parts for fighter planes during WWII, rather than halt production and lose money, crosses his fingers hoping it won't cause a problem. Pilot's die and, at the end, he says "They were all, all my sons."
4
Boeing will file for 11 soon. at this point Airbus should make a bid to buy some Boeing properties just for the factory space.
In the age of computers everything is getting more complicated. The article excellently describes the many factors that came together to cause a catastrophic failure. This is the nature of things. Complex software is a huge issue. Look at how many updates Microsoft does and still there are big problems. The first iron bridges were cast iron and many failed catastrophically before the problems were solved and understood. You can always drive or take the train...
1
Boeing still continues to manufacture this type, right? 47 per month? Where do they park them? Do they really believe that the can sell them for profit?
3
The Boeing Engineering Change System failed, surprisingly and in a deadly manner. Some software managers and upper 737 max program management either failed to fully understand the flight safety implications or simply agreed to not validate the system change to one sensor. These people who should have known better but signed off these serious, late, design changes made serious mistakes under pressure to minimize cost and time. They need to be removed from doing so any such work ever again.
5
The Airbus that competes with this Boeing is a fully fly-by-wire system that has no comparable actuator time lag issues.
9
People should be going to prison for this.
But not the people mentioned in the article. For the most part, the problem seems to have been due to an imperfect system, an imperfect review process, or whatever. It is terrible to say it, but these things happen.
However, what happened next was criminal. After the first crash, nothing was changed. Somebody high-up in Boeing needed to quickly realise the problem and ground the planes until it was fixed - at least, correct the software, inform other pilots. But for strategic / image reasons apparently, this did not happen.
And then there was another crash.
And after that second crash, Dennis Muilenburg personally phoned Donald Trump and reassured him that the 737 Max was safe.
What could possibly be more criminally negligent than that. Mr Muilenburg clearly made a strategic decision that he was more worried about Boeing's image and cash-flow than about safety. It is impossible that he did not realise the truth, especially given that it had been reported in most of the world's newspapers before his call with Trump.
Why is Mr. Muilenburg not in jail?
54
@Denis Agree. Further, the MAX design was a rush to catch up to its competition. I would add that the FAA is complicit also.
They rolled the dice and lost.
3
@Denis
Because the majority of the deaths are brown people from places most Americans can't find on a map. Had this happened to a US airline, with American deaths, I imagine a very different scenario unfolding for Boeing.
8
No, they rolled the dice, and other people lost.
1
Perhaps we have reached the point where the complexity of technology is beyond the grasp of human oversight. This doesn’t seem like a cost issue as much as it is a failure of government oversight from a workforce that doesn’t have the number of people and the right skills to understand when an aircraft manufacturer is unsafe. Even inside Boeing, I am sure no one thought the decisions they were making would lead to two crashes. All of this is compounded by an FAA political head who attacks foreign pilots as less skilled than American pilots. Why would any foreign airline company buy a Boeing aircraft after that. It’s also clear that Airbus builds in a larger margin of safety into the control systems to take away pilot control. If I were a CEO of a foreign airline, I’d never buy a Boeing airplane again. I’d always opt for Airbus.
11
@John Smith
it was a cost issue cause Boeing did not want to spend more money for training etc.
it's almost always about the money.
8
@John Smith It is a failure of oversight, but not of government oversight. Responsibility for oversight was turned over to Boeing; the FAA just went along with whatever Boeing thought best. This is what happens in a corporatocracy in which there is constant social expectation to believe that government is incompetent. Boeing has simply followed in the self-centered footsteps of Wall Street banksters, who insisted they could be trusted as long as Glass-Steagall and other regulations were revoked.
5
@John Smith Completely fly by wire planes is too much confidence in a system allowing no human hands. I tell you something else, I like driving my own car!
The result of monopolies, very predictable. Probably Inevitable. Money over everything else, because people do not have a choice. Classic "Free Market" principles depend on competition, which the USA has legislated out of existence. Unfettered, or low regulation capitalism is bad for consumers, but one would not know that reading the current economic press.
15
@gratis
Legislated out of existence, perhaps, for within the US. But not globally. This is where it's going.
1
trump has blood on his hands! His reckless government shutdown caused protracted delays in identifying and correcting problems with the Boeing 737 Max aircraft, and more expeditious suspension of public aircraft operations. Boeing senior management’s direct communications |with trump resulted in FAA delaying such suspensions while foreign regulators worldwide were imposing suspensions. Also it is important to note that trump’s laxness in handling senior management appointments including the directorship at the FAA seriously compromised aircraft safety diligence in general.
17
@John Townsend
Sure - it is up to President Trump to count the number of AoA sensors on each jet while being investigated for...what?
@John Townsend
to me, the article indicates that boeing implemented a poorly designed software override system that was not well analyzed then increased its power many folds without informing the faa nor the pilots of these features. it's hard for me to blame the faa for these crashes.
1
I have been a pilot for 35+ years. Before the accident if you had asked me "How many angle of attack sensors do you think there are providing data to the flight control computers?" I would have said "at least 2 and probably more in the way of performance data comparison from the computers."
Nearly every system on a modern jet has a redundant backup system; there are at least two of most everything. Not having dual, if not triple, angle of attack sensors is an error and omission of huge importance. Actually the original design called for two.
The biggest failure is the software. There are numerous ways the flight computers should have been verifying the data from the angle of attack sensor. While any airplane can stall at any configuration and speed, we are talking about the "takeoff phase" of flight; plus we are talking about an airliner not a acrobatics plane. The software didn't consider airspeed, attitude, vertical speed, rate of turn and radar altimeter? Then the software commanded a full trim down condition, near the ground? Then as the altitude decreased and airspeed increased it didn't level level off? I will assume the computer already added power.
Computers are essential to the operation of a modern airliner. But computers are only as good as their software and the data they are given. I would never have thought Boeing could made like this.
39
Boeing:Once the pride of American engineering and manufacturing appears to have fallen prey to Wall Street and the never ending race to increase profit. In the end the rank and file workers will pay the price not the folks at the top.
29
This made be pause and read again:
"When Boeing asked to remove the description of the system from the pilot’s manual, the F.A.A. agreed. As a result, most Max pilots did not know about the software until after the first crash, in October."
Certainly conspiring to "remove" critical safety information from the pilot's manual is criminal negligence. If it's not, the law needs to be changed.
34
@DL. Exactly, it’s the willful act that makes it criminal. The engineering stupidity that created the MCAS fix, as gross as it was, could be forgiven as an error, the lack of FAA oversight as another mistake. Both indicate organizational failures that must be rectified. But stripping the mention from the manual in order to avoid training costs is willful, and criminal.
3
As a former Navy pilot and airline pilot (30 years) who is now retired, I wonder what the rote procedures were for the 737 Max in case of the stabilizer unexpectedly pushing the nose down.By "rote procedures," I mean memorized pilot action taken by pilots in the event of a sudden emergency such as an engine fire (pull the fire handle and shut off the fuel, etc.) In these 2 accidents, the emergency to be taken care of was the stabilizer "running away."
The 727 and other aircraft had a procedure that relied on the pilots memory which was very simple and straightforward, "turn off the stabilizer trim switch."
12
@tom boyd: All previous versions of this airplane are inherently pitch-stable. Only this version with the large engines mounted far forward tends to rear back as the angle of attack increases.
11
@Steve Bolger: I would add that the same effect must take place when the angle of attack goes negative, which is why the altitude of the planes oscillated during the crash process.
4
@Tom Boyd. The ‘rote procedure’ was exactly the same as the prior 737, which is the root of the criminal problem. Boeing decided to avoid any new model training costs by pretending that there was no difference at all. Thus, the more or less standalone MCAS fix wasn’t mentioned to pilots, wasn’t in the manual, and was not integrated with the rest of the flight software. All those people died because the stabilizer runaway response wasn’t going to work. A few pilots writing comments thought that shutting the two breakers would do it, or that using the yoke switch would do it. Then crank the (mechanical) trim wheels against extreme air pressure at extreme angle somehow before impact. Plus the basic engineering violation of using one of the two AoA sensors with no comparison, or even a panel indication. The single simulator they built did not even replicate the problem. Worst of the worst, chapter and verse.
5
The only criterion companies like Boeing seem to understand and value is money. If the flying public absolutely refuses to board a 737 MAX, perhaps it will send Boeing and other company executives of this narrow mind set the message they need to hear. Words are cheap. After every act of gun violence we hear from legislators gibberish about "thoughts and prayers." Responsible, caring action, not canned cliches, is what is required, and economic force rather than rhetorical rubbish will likely have more efficacious results in keeping the public safe from both airline and gun-manufacturing executives.
20
Who to sue? Boeing for not informing pilots of possible problems, or FAA for not being tougher on changes made by Boeing to an aging aircraft. Both I guess.
8
This is sloppy work on the part of Boeing--period.
MCAS needs to be completely removed from every aircraft. Every passenger around the world will ask if this system is on the aircraft they will be flying on (I will) and it will be a slow death knell for a company that creates a positive trade balance with the rest of the world. I guess the employees can work for Airbus.
5
@wudger
Clearly Boeing lost its way. The whole MCAS process was a disaster -- or two disasters more accurately.
However, be advised that augmented flight control systems are embedded in most commercial aircraft these days. These systems are analogous to MCAS. If anything, Boeing has been far behind AIrbus in introducing these types of systems.
3
@Insider...Your closing sentence says it all. From Boeing’s perspective, competition from Airbus raises a much higher priority than the safety of the flying public.
1
@wudger
"sloppy work"...
Well, being meticulous and exacting and careful cost money. And that means profits lost. What in the world could possibly be worse than losing profits? For corporate America, including companies like Facebook, nothing is worse.
1
I know nothing about aviation at any level but reducing sensor input while increasing the dependency of a central piece of software seems to be a huge design fault good for only one thing, and one thing only, namely, cost.
People may joke about how the space program of yore was still using the old technologies developed for the first moon landing (certainly space tech has to be changed by now!) but there are reasons for slow adoptions in critical systems. And reducing redundancy which is a safeguard against critical path system failures seems to be against best practice in every book
17
The same design flaws are being built into our digital infrastructure every day by companies, other than Boeing, which will have far greater consequences. These flaws are inherent in the system because of the speed with which innovation it is brought to the market....that need for speedy innovation is part of the culture of competition: get it to market and deal with the flaw as you go.
Focusing on Boeing is easy because of 2 catastrophic events. Quit being distracted by Boeing and look at digital companies like Facebook and Twitter
10
@Allen82
Look at everything
Everything gets to be paid attention to
Your idea of diverting attention from one problem because of another is worse is silly. There is time for each problem to be brought to light.
2
@Allen82: People need to develop their own personal filters for internet twaddle like Facebook and Twitter. It is not an engineering issue.
I fly very seldom, maybe once every two or three years. So no one will notice that I will never fly in a Boeing aircraft. Am I alone?
5
From an engineering standpoint, on critical systems you always use two inputs to compare data - accept if they match reject if they do not. Based on what I have read - engineers and pilots where not made aware of this "cost saving measure", This may be Boeing's swan song. Whomever approved the use of one sensor is responsible for those crashes.
16
@JAF: Even with two sensors, the time lag of the actuator is too great for the software to cancel the positive-feedback effect.
2
@JAF
If the system is truly critical (meaning that no backup, human or otherwise, can take over from them in time) you better use three inputs and then majority voting to make sure the system still works when one input is badly wrong. That's apparently what Airbus has been doing for its own equivalent of MCAS, from what I read in some previous article. That sure costs some money, but it's not as if those sensors would be a million dollars a piece.
4
@Steve Bolger - The comparison of sensors would be written into the software prior to the actuation routine thereby stopping the MCAS from taking control. Since it would not take control of the aircraft there is no Positive feedback - and for those that do not understand your argument, positive-feedback enhances or amplifies an effect by it having an influence on the process which gave rise to it. For example, when part of an electronic output signal returns to the input, and is in phase with it, the system gain is increased.
2
Great informative article. Relying on Boeing to the do the right thing, even with all the info we have now, is magical thinking. What will shut this plane down and the malfunctioning system is if we, the passengers refuse to fly it, and Boeing suffers massive economic losses. Human life does not seem to be enough motivation. Count me in. Never a MCAS!
16
I’m a technical guy but not an aeronautics expert. That the Boeing was based on such an old design with so many updates instead of a clean new design with proper basic functionality. The automotive equivalent would be a brand new 1959 Edsel Station Wagon with all the latest modern conveniences. A flying model T.
15
@John
Software systems may be so complex that nobody has an overview. Programmers (to use an old term) may not remember what and why they have written, may have left, may be inarticulate, may never have understood issues in the first place. Programmers may be stonewalling among themselves, may resent each other: programming is a highly social activity.
In general, systems are checked by testing. But testing itself is also not completely reliable: how to account for all possibilities that can occur in the real world? Much testing occurs in practice. This may have happened here.
"A clean new design" is indeed often the preferred solution, although then some basic fundamental flaws may be overlooked. The best solution is to strive continually for simplification and to take continually the long term into account. Simplification keeps people on edge. It is expensive, though. Much software is frozen, and no one dares to touch it.
What happens in practice is that large errors on the higher systems level are swept under the carpet. With the dieselgate scandal that did not work. Air crashes are even less easily swept away.
Modern society has become highly dependent on software systems. They are transparent until they go awry. Although some people are in theory responsible, in practice the responsibility is hard to point out when things go wrong. Someone should pay attention to this all. But who? The media, politicians, regulators, the public?
2
I think CEOs are paid way too much. They are so busy playing with their money that they don't pay attention to their jobs.
19
I feel like Boeing is still evading culpability for their catastrophic cost-cutting moves. My solution would be to ban the airplane indefinitely, have some of the executives do real time in a real prison for negligent homicide and make sure that the law suit payouts are to the maximum. I'd lean towards taking some large proportion of the companies profit and divvying that number up. As for the FAA, I would increase the work force and make it fully independent of the industry. It is too cozy now and too vulnerable to industry interference. Let's fire some of those negligent decision makers at FAA.
Hey, if it seems radical to propose these moves, I consider them to be less onerous than my first impulse, which was to force Boeing into federal receivership and totally re-regulate the airline industry.
26
Whatever happened with Boing carbon-fiber composite fuselage technology? Was the 787 a one-off? And what about the most advanced CAD system in the industry? Why does it still take 10 years to implement a new design?
2
Self regulation is doomed to fail if profit is on the line.
28
@gene
Exactly especially when they own our politicians.
1
Completely agree! I worked in the chemical industry for many years. It became a holymmantra for all management employees to repeat ad nauseam “ we do not need the EPA t regulate us. We know much better than they do, what is good and what isn’t”. Well, after years of this thought process prevailing, and with this administration actively creating an impotent EPA , the results are obvious and worse is yet to come. Same goes for the incestuous relationship between the FDA and industry. Glyphosate Exhibit A
3
It sounds as if they created this death risk. Most likely it was not eliminated for they developed a sales threat plan . By not buying an extra safety measure purchased total death could occur. Boeing top executives should be charged with criminal prosecution. It is impossible to fathom that they did not deliberately incorporate this into their sales and marketing plan. Why then was it not corrected? Boeing has had to much uncontrolled power without real checks and balances. They were so desperate to shift production to lower cost locations outside of the US to gain even better cash flow. They are operating a monopoly and should be broken up.
16
It boggles my mind that Boeing would base this airplane built for a 30 year service life on a 50 year old design.
13
I'm still perplexed that such a deficiently simplistic software design was allowed for the critical task of overriding pilot flight control inputs. Even more shocking is that it was not fixed immediately with an emergency software patch after the first crash. A few "if then else" software instructions in the code could have avoided this whole nightmare.
7
This article quotes a lot of people saying they "never dreamed" some thing would happen. One thing I've learned doing regulatory compliance for over two decades is to imagine (dream of) the absolute worst case scenario and then try and make sure the risk is taken as low as possible for that. In airplane design, that would have to mean taking risk to ZERO in terms of design and pilot training (the manual). For these highly experienced workers to say they never dreamed something could happen tells me they weren't paying attention, or had become jaded to the process or, most likely, succumbed to pressure to gloss over details. Money talks and that is why we have regulators. But they clearly have been compromised or were lied to. But again, if you're a regulator you're supposed to have systems for discovering problems like this, including the company's hiding something you need to make good decisions. Does the FAA regularly audit plane manufacturers, airlines, or pilot training programs? This is an excellent article but I have a lot of questions.
23
@Carla: These are issues plain to see by pilots. Somewhere in the hierarchy there was a Trump-type who squashed the people who warned about it.
21
@Steve Bolger as with the Columbia disaster the engineers knew the sealing rings failed at low temperatures but they 'knew' the senior managers did not want to be faced with difficult decision taking under political pressure. See "Surely you are joking Mr. Feynman"
6
@Steve Bolger Same kind of failing responsible for the Challenger explosion in 1986.
The plane is badly designed. Patches and fixes and adjustments make it more complex not better. Not safer. Sloppy work Boeing. Not to mention deadly. How can you be trusted to do it right this time?
21
In addition to all of the excellent comments and reporting I’m struck by 2 thoughts;
1) We’ve elevated engineers in our society to near godlike status and they can become immune to challenges to their expertise which in more complex scenarios like this tend to be highly specialized with a narrow focus-they don’t see the whole picture and don’t know what they don’t know
2) I don’t see a mention of a chief risk officer. We require financial institutions to take take stress tests and keep enormous capital (protection) against financial catastrophes to ensure sound financial markets. The chief risk officer role (along with others) views disparate bits of information into a more comprehensive picture to assess likelihood of various risk scenarios.
15
@Julie Stolzer
Re: "... they can become immune to challenges to their expertise ..."
Hubris is a dangerous sin.
@Julie Stolzer
Interesting to read about engineers having godlike status: must be something new. Do they make so much money today? Are people willing to listen to them nowadays? In the past I sometimes had the impression that in the eyes of managers engineers were the lowest of the lowest.
3
Question. Perhaps someone has an answer. Is the computer in the Max, where the MCAS software resides, in any way connected to the Internet? If so, isn't hacking a concern? ( I have little faith in anything Internet-connected nowadays.)
2
My father flew a bomber - he said the design was not flawed - the pilots were not knowledgeable and/or experienced with the change. He said the plane has been flown tens of thousands flights by US trained pilots without incident. It’s not Boeing’s fault; at the end of the day, he said it’s pilot error.
@JMS MCAS appears to be an aggressive automated system that overrides pilot input under certain flight conditions. By its very nature it takes control away from the pilots. It also seems to have been extremely poorly documented and did not feature in type certification training. It’s easy to say it was pilot error as that is the cause of many aviation accidents, but in this case the information that is publicly available suggests there was nothing the pilots could do to bring the nose up when the malfunctioning MCAS was pushing it down.
32
Flight Directors as sophisticated as this one were not installed until 50 years after you Father’s service as a bomber pilot ( assuming circa WWII). And if it was pilot error, and not a design flaw, why have all the American carriers grounded their 737 Max fleet? If you watch the recreations of the accident that are already on the internet, you will clearly understand that it wasn’t the pilots who were in error- the planes were out of control.
28
Well he is just wrong if you actually read the article. The sensor malfunctioned causing the MCAS system to activate. The pilots were not trained and it was removed from their manual.
1
If safety is their first concern, they would have grounded the planes after the first crash. The company and its directors must be made to pay dearly for this failure since we know that it is money that is really their first concern.
25
Another example of America's focus on greed over excellence. While the oligarchs may have built their fortunes on American innovation and excellence, their greed has eroded the business culture from one focused on the customer to one focused on maximizing personal wealth.
35
@Mister Ed: Engines are the core of airplanes. The whole rest of the plane is designed around them. These engines are just too large for this airframe designed for the earliest low bypass ratio engines.
15
The design flaw in the 737 Max is the location of the new, much larger, more fuel efficient engines: they were moved forward on the wind so they wouldn't drag on the ground during takeoffs and landings. That's what created the problem: the location and weight of the engines caused the nose of the aircraft to pitch up, risking stall. MACS was installed to offset a defectively designed aircraft. By focusing on computer software, the authors of this story have entirely missed what's wrong with the aircraft: a defectively designed aircraft that cannot be fixed with better software, but an entirely new aircraft designed to have the much larger engines.
40
@reaylward: This is a positive feedback effect that is extremely tricky to balance out with any trim system. It was foolish not to redesign the plane to have good old fashioned inherent pitch stability.
1
Let's summarize,
1. Boeing created an inherently unstable plane
2. Boeing created a software fix that not only overrides pilots but relies on ONE sensor
3. Boeing misled everyone about all of this at every step
4. No one at Boeing or the government put a stop to this until TWO planes full of people crashed
Clearly the design process is flawed, the company is rotten, and the regulators are out to lunch.
I have little faith the new patch will be sufficiently safe ("Hey, Homer let's hook up the other sensor!") Meanwhile, I'm wondering if there are other major flaws with this plane that we ought to know about.
82
@S cool Item 1) on your list is incorrect, at least from the data in the article. Item 2) is kinda right about the override (it's not so much "overriding" but fighting against the pilot because it thinks the plane is heading into a stall that the pilot isn't aware of) but you are spot on about relying on a single sensor to make this critical decision. Item 3 is misleading itself; what happened is that Boeing's design review process is flawed.
While a flawed design or process is bad in an aircraft manufacturing situation, they do not indicate ethical shortcomings. We are all human.
Item 4 is the real problem. When a relatively new plane crashes, waiting to ground it to figure out the issue is inexcusably driven by business concerns
2
@Bruce H Re item 1) While the article doesn't say much about this topic, there is enough information elsewhere on the inherent instability of the plane at high angles of attack which is where the risk of stalling becomes relevant (i.e. the plane tends to pitch further up on its own at high AoA, worsening the stalling risk, rather than pitching down, as an inherently stable airpane would). The instability was apparently introduced by having to position the engines further forward, moving the center of aerodynamic lift forward beyond the center of gravity at high AoA. That was apparently (one of ?) the reason(s) that MCAS had to be introduced which, as a first for a passenger airplane, should definitely have been scrutinized a lot more than it was.
4
@S cool
On item 1), the issue is not so much that the plane is unstable (all planes are unstable if you push them far out of range, some just sooner/worse than others) but more that Boeing wanted hard it to sell it as flying just like the non-max 737 and therefore needing no pilot retraining. They probably could have had it certified with that instability, but then the airlines would have needed much quite expensive pilot retraining and would not have been as interested.
Excellent article and comments to which I can only add:simply shameful on every level; not least of which is the fact that the Max was not grounded in the US until Donald Trump issued an executive order to that effect. Where do we go from here?
13
OK, time to stop the remarks, the hand wringing, and 'our hearts and minds go out to the families of the victims', though I can't recall Boeing showing any remorse - it is time to take Boeing and the FAA to court - the first for gross negligence of the safety of crews and passengers in its manufacturing: the second for gross negligence of its duty to assure the airlines of the world that they are purchasing and flying safe planes.
25
According to this article, enough evidence was available to Boeing after the first crash for the responsible parties to be able to identify the cause. Why did they not ground the planes immediately? Apparently Boeing’s primary commitment to passenger safety had not penetrated to the lower echelons in the corporate hierarchy. From Trump to corporate greed, everything seems to fit together.
14
@Ostinato
"Boeing’s primary commitment to passenger safety had not penetrated to the lower echelons in the corporate hierarchy. "
Executives directly and indirectly determine a company's culture. If the executives primary commitment was to passenger safety, the lower echelons would also be primarily committed to safety.
4
@ Ostinato
Boeing will be taken to court. One of the victims of the Ethiopian crash was Ralph Nader’s twenty-something-year old niece. She was coming home from a visit she took to look at NGO projects. She, like every other victim, was beloved, talented, and full of promise. Unlike the others, she has an uncle who blazed the trail in US litigation over products made w/deadly design flaws.
When the guiding principle of a company is: "maximize share-price, cut costs, and ship as many as possible" thereby ignoring the health and safety of the ultimate user, this is what happens.
I, for one, no longer fly anywhere. given the state of air-travel today that decision was an easy one.
11
Somebody please explains something to me. Why are even two angle-of-attack sensors adequate? If you get two disparate readings, don't you need a third sensor that acts as the tie-breaker? Surely this would be preferable to using other, indirect means of sensing angle of attack.
22
You are correct. You do need at least three to reduce the probability of not knowing which readings to trust to 1/n^2, n is probability of a sensor failure. Given the number of bird hits, it sounds like n is rather high. So to reduce the probability to 1/n^3, you need 5 sensors. They could also try to find a way to reduce n, if possible, say by making bird hits less likely.
Given all this, it baffles me how people are so eager to get into a car driven by software and sensors.
26
@RickF, If you have experienced the lack of care (and outright recklessness) people take in driving that I have, you might prefer software-driven cars.
@Ronald Aaronson
Especially so in this plane!
The Boeing business is a perfect metaphor for what has happened to the reputation of the U.S. That is, going DOWN.
17
The reputation of the U.S. has been going down for quite some time now. Ever since you elected George W Bush as president. When Trump came into play, it just cemented the belief around the world that the U.S is no longer a force of good and no longer the land of the free.
1
Good article that lays bare the appalling systemic and cultural failures within the Boeing organization, (not to forget the FAA). The safety barriers, inasmuch as they were at all applied, seem to have collapsed one after the other. With all the goodwill and understanding in the world, one cannot but think that on top of the organizational and management deficiencies an appalling lack of professionalism on the part of some key specialists, mostly engineers & test pilots, was at play. As is well known, the buck stops ultimately with the top brass responsible for this kind of horrible mess. The way Boeing’s top management handled communications after both the Lion Air and the Ethiopian tragedies was simply scandalous and highly unprofessional. If only for that reason, regardless of legal and strategic considerations, the Boeing board would be well advised to fire Muilenburg & friends ipso facto. Better an end in horror than a never ending horror (as we are already witnessing today). This management, if maintained, will continue to dig the hole it has gotten itself into, even further.
26
I understand that the Boeing spokesperson is doing their job, but that does not give them an excuse to lie. If Boeing’s
Concern was safety none of this would happened.
28
The Boeing spokesperson did a lousy job and should also be fired. No communications professional of a so called reputable company like Boeing would react as the Boeing person did. After the Lion Air accident, the bodies were not yet all recovered that the Boeing person was hinting that the probable cause was bad maintenance by the airline and/or lack of professionalism on the part of the pilots. Even after the Ethiopian accident Boeing didn‘t deviate much from that „narrative“. On top of that Muilenburg‘s silence was long deafening. It hardly can get any worse. The public and especially Boeing‘s customers the airlines are not going to forget this one very easily...
1
@Paul Eckert
Sounds like the playbook of the current Trump press secretary.
It is not just "two sensors". It needs to be two redundant sensors.
In the original version, with a faulty sensor the "crash" would be postponed to the point in time when the pilots commanded a high-G-maneuver. Still close to "one faulty sensor, one crash", but possibly at a different point in the flight.
The essential thing is that MCAS influences basic flight parameters based on a single sensor that is prone to failure. In such cases you need to be sure that the sensor data is valid.
2
@REW
A very interesting point. In this huge mess the cure was worse than the disease. (Although this plane also has the low speed stall issue.)
3
Boeing's engineering used to be the gold standard. It looks like they forgot their craft, or lost their integrity, or, incompetent greedy management forced them to do shoddy irresponsible work. No safety engineer worth 10c would approve a system with an obvious single point of failure, and Boeing's excuse that this particular single point of failure could be not fatal was beyond ridiculous. An external independent criminal investigation should take place and top engineering managers who were responsible for approving the MCAS redesign decision, and the decision to not fully inform the FAA and the pilots flying this plane, should be charged and jailed for manslaughter. The fact that the board has not fired yet the CEO for cause is inexplicable, as he bears ultimate responsibility for the corporate processes that should have prevented this egregious error and following disasters from happening.
40
A clear picture of the amazing difficulties to build a safe modern passenger plane or make money from it. Unfortunately Boeing made the wrong choice. Maybe now aeronautical businesses will not make a choice and build good planes and make money from them. I hope Boeing goes bankrupt. Over three hundred lives are worth more than that company.
8
@Jo Ann; Boeing will no go bankrupt for many reasons. For one, it is way too important for the US, for another, it has a huge military and space business, aside of civil aviation. And, IMO it should not go bankrupt, but rather, it should be forced to fundamentally reorganize with its top management fired for cause, and if criminal negligence is found by external independent investigators, charged and jailed. While we are all jumping on Boeing here, and justifiably so, Airbus is not any better (remember the lost A330 over the Pacific due to frozen pitot tube sensors, which was a result of failed specification or cost saving).
3
@Eva
The A330 had 4 pitot tube sensors and they all froze due to very bad weather. This is not the same as a company rushing too fast to get a new plane out. And you’re right. So much of Boeing and other companies depend on wars fabricated by the American government.
10
@Eva Please read the wikipedia article on flight 447. The A330 had triple redundant pitot tubes. The model used was known to have icing problems, and AF delayed following a recommendation by Airbus to have them replaced. But the result of the failure was that the autopilot disengaged and the flight mode changed from (stall protected) normal to alternate mode. The airplane was still perfectly flyable by traditional pitch and power. What crashed the plane in this case was hubris (why did the skipper go to sleep and let his second officers fly through thunderstorm area where the two LH jets in front decided to divert) and sheer incompentence on the part of the junior second officer, who did not recognize a stall even when the plane was reminding him. There are few cases of nearly pure pilot error, but this was probably one of them.
6
An aircraft manufacturer -- especially one as respected as Boeing was -- should never have attempted to fix an aerodynamics issue with a software patch. At the moment when the words "aerodynamics issue" came up, they should have come up with a physical solution, not a software one.
Considering that each and every one of us has dealt with computer glitches at some point, how many of us are willing to entrust our lives to software?
Releasing an airplane to transport the flying public with a known aerodynamic problem is inexcusable. And no, I'm not going to trust the software patch when the physical problem still exists.
If Boeing ever wants to recover from this mess, it will pull the 737 Max from service permanently and design something new. Now that the aerodynamics issues and manufacturing shortcuts have been publicized, travelers really aren't going to want to step onto these planes. I know I don't.
64
@Jeff: I fully agree, but to correctly fix that aerodynamical instability would have required a major airframe redesign (with its cost and time) which Boeing wanted to avoid. In general, the 737 airframe is great but too old, they should have designed a new single isle airframe, but failed to do it. And when Airbus has beaten them to the market with their NEO they scrambled to catch up quickly and cheaply. This led to a flawed unstable airframe and an even more flawed software kludge to cover it up.
14
@Eva
Yes, that point was covered in excellent detail in a previous Times piece (well worth reading).
But once they got to that one key word -- "flawed" -- common sense needed to prevail. This is a company with a wonderful history and reputation. It is nearly unthinkable that a company of Boeing's stature and trustworthiness would risk everything to cut corners and rush an inferior product to market, as we now know they did.
The company will never be able to use "Boeing engineering & reliability" as a selling point again, when it's stained with the blood of 300+ innocent passengers.
5
@Jeff
“... how many of us are willing to entrust our lives to software?”
Evidently, just about all of us. The “fly by wire“ systems that control all modern airliners depend on just that, software.
1
The analogy of more input being needed when an aircraft is flying at lower speeds, comparing it to a car, is backwards. Because of tire slip, a car’s turning radius is extended at higher speeds. My take-away from the relevant paragraph in the article is that at slower speeds, an aircraft needs more inout rather than less. A better analogy would have been with a water craft, as is often the case when comparing air craft and water craft.
3
All the problem-solving hoo-ha about fixing the MCAS is just a sideshow drawing attention away from several other potentially lethal last-generation systems on the Max that modern passenger aircraft have long since abandoned for safer alternatives.
1. The system of cables and pulleys to control the Max are no longer used in modern designs. Modern passenger planes “fly-by-wire,” with the pilot's movement of the flight controls fed to a computer that directs the plane. This allows for systems that prevent the jet from entering dangerous situations, such as flying too fast or too low.
2. Max pilots still complete preflight checklists manually in a book. In modern planes, electronic systems take pilots through their checklists, ensuring they don’t skip a step and miss a possibly malfunctioning part.
3. The flight-control computers on the Max have the processing power of 1990s home computers.
4. On the Max, a light indicates a problem and pilots have to waste precious seconds flipping through their paper manuals to find what to do. On modern passenger jets, a computer alerts pilots to hazardous situations and instantly lays out recommended steps to resolve them during flight.
35
@Kaikopere: There is nothing wrong with cables and pulleys. The old versions of the 737 have been the most used and safest planes flying, with all those cables and pulleys. Fly by wire and trusting everything to flight control computers is not inherently safer than traditional airplanes with hydraulic controls. The problems with the MAX have nothing to do with cables and pulleys, to the contrary.
4
@Kaikopere
How did you find this interesting information?
@reader I condensed the article in the NY Times on the 8th of April 'Boeing’s 737 Max: 1960s Design, 1990s Computing Power and Paper Manuals."
https://www.nytimes.com/2019/04/08/business/boeing-737-max-.html
To even fathom that the company can release this statement: “Boeing has no higher priority than the safety of the flying public,” in the wake of two horrific events, both of which could have been avoided, had Boeing acted in accordance with their own standard operating procedures, tells a story of unimaginable incompetence, insensitivity and greed.
51
@Kristian Thyregod Yes, talk about an automated corporate PC press release with no thinking behind it. People need to start losing their jobs because of this corporate fiasco, even criminal proceedings in certain cases.
27
Indeed... One has to love it when, every time, some company says, “we were in full compliance with all relevant regulations”... especially when these same people helped to write those regulations... please..
3
The article was very enlightening to me. However, it didn't answer a basic question I've been wondering about. If the plane has two angle of attack sensors, why would anyone design MCAS to work from data from just one? Why have a second sensor if you don't use it? Do other systems that require data from these sensors have the same problem? The article indicates that there were many factors that contributed to the disasters, but the single sensor problem seems to be a particularly critical one that wasn't discussed.
7
@Jun H
The article explained that the original system used two different sensors. When it was reconfigured one of those sensors was removed because it wouldn't work with the new configuration. The system was also, at that time, was adapted to different uses. No one appears to have noticed that in the reconfiguration it left the system operating on one sensor. So it wasn't designed with one sensor, it was remodeled and one was removed. However, I also read elsewhere that the Max could be ordered with a dual sensor MCAS but it cost more. I think we don't have all the information yet but clearly there were failings in joining up the information and a complete global safety review before certification. The fault looks to be both at Boeing and also with the Federal regulatory system in my view. A mouse watching the cheese situation.
6
@Jun H, AFAIK, the signal from one AOA sensor is sent to the computer running the pilot's display and the other signal is sent to the computer running the 1st officer's display.
The FAA requires manufacturers to show different maximum probabilities of failure for different systems depending on how severe the consequences of failure are. The FAA also provides guidance on how to meet those required max probabilities.
For the severity of failure the MCAS was certified, a single sensor input would be OK. But, removing the high-g requirement and allowing MCAS to give much more stabilizer deflection meant MCAS failure should have been re-categorized as catastrophic. For that level of severity, redundant inputs would have been required.
My speculation is that Boeing completely underestimated the aerodynamic issues due to the placement of the new engines. It sounds like they first noticed the aerodynamics issues at high-speed high-g scenarios. MCAS may have been appropriate if this was the only issue. But when the low-speed tests showed aero issues, they tried to use MCAS to fix it. The problem may have been that MCAS was already designed and possibly accepted by the FAA.
Boeing was trying to avoid 2 big actions from the FAA - 1) requirement for new type certification, and 2) no significant pilot training required.
Mentioning the changes in MCAS's purpose and power would require more pilot training. So they lied about it,
9
Being a pilot and a mechanical engineer I’m going to speculate - I have no 1st hand knowledge, but deal with failures all the time in a variety of industries. The issue typically centers on having two sensors that don’t provide the same output all the time - which one do you use and which one is right? Not a huge deal and a some sort of logic can be developed where an average is used or one is rejected when it’s deemed to be wrong. Alternatively additional information in the form of data is used to verify, but this is starting to get complicated and would require time, money and training to develop a robust system. This is exactly what Boeing was trying to avoid with utilizing MCAS and the Max 8 development. It’s not too much of a stretch to imagine that a decision was made to just go with one sensor for the sake of simplicity. In the engineering world these types of decisions happen and it’s supposed to get caught with comprehensive reviews and analysis, but it looks like this either didn’t happen or it was glossed over. It’s often a chain of events, each by themselves not that critical, but taken together, with nothing to break them, can be disastrous or at least an expensive mistake. The other red flag is that the FAA allowed Boeing to self-certify and this should never be allowed for the obvious reasons.
7
Boeing made dramatic modifications to MCAS after the certification process and then lobbied, successfully, to eliminate the information from the manual and training process.
After the first crash the manufacturer claimed that the MCAS did NOT suffer from a single point of failure for two reasons: The certification process and the "well-trained" pilot.
The single point of failure is clear: Executive Greed.
The is a known fix for this point of failure, prison.
54
The problem with the 737 is to many design changes over decades.The bottom line is the cost of a type rating on the aircraft.Boeing should have done a total redesign of there narrow body aircraft years ago.This however would have caused airlines to pay for all there pilots who would fly these aircraft to get a new type rating.To cozy of a relationship with the FAA and putting to much emphasis on the bottom line is now costing them.Hopefully this is the last new type of 737.
11
@Sean Mulligan
Sean, you make an extremely important point which keeps getting overlooked in all the coverage of these plane crashes. The only reason the faulty system was needed in the first place is because the engines are too heavy for the 737 body. Boeing hasn’t designed a new type of plane both because of the cost of certifying pilots on a new type as you said and also because it is very expensive to design a new plane. Instead they added a faulty system to offset the possible stalling caused by the heavier engines - and hundreds of men, women and children died.
12
This article is why I read The New York Times. In depth journalism based on direct sources.
However, according to the article, it seems that the source of the problem is lack of communication.
I disagree.
From my experience, when everybody use the "I didn't know" excuse, it's that everybody knew but nobody wanted to face the issue.
Such reaction means that the issue was impossible to fix. They had no solution: they couldn't fix the problem and they couldn't stop the project, it was too big to fail.
So my hypothesis is:
1) The 737 Max has an impossible to fix flaw (the new fuel efficient engines can't fit on this 50 years old design).
2) They hoped that through software they will mitigate it enough to get away with it.
3) Because they didn't want to throw light on the flaw, they didn't initiate the proper safety evaluation of their fix (thus the unbelievable reliance on only one sensor). They even took active steps to hide their fix (by removing the MCAS from the manual).
72
@Ferdy
Brilliant analysis. If you are correct, the MAX will never fly again and there is a good chance Boeing will go bankrupt because of this.
6
I’m sure you’re right. But what were these people thinking? Why did they go along with the disgusting demands of their managers? Are there no other jobs for a qualified engineer?
3
@reader
The secret powers in this country, including the secret networks that land a BOEING person in the Department of Defense and private calls from BOEING CEO to President Trump to stop the grounding of the MAX, will prevent this.
Sadly.
Or are the any DAs that will start to indict?
1
Since the 1970's deregulation was considered the Holy Grail to productivity and global competition the antidote to labor unionization costs and inefficiency. But here we have a case study of how those policies actually lead to less safety and more risk being taken because globalization and competition create new and overarching existential threats that take priority over safety and being risk averse.
The financial crisis is another example , but in the banking and securities industry. In both instances, executives were more motivated by the specter of losing out to the competition than concern about their products' safety and risk.
9
I will never set foot on one of these planes. Nor will I fly on any newer Boeing planes, because the current executives cannot be trusted to be honest or competent. I don't know how any of them can sleep at night.
Assume for a moment that the compartmentalization did cause them to lose sight of the vulnerability of the altered MCAS system. Why did they not discover this immediately, and make corrections after the Lion Air crash?
29
Because 5000 future orders buoyed the stock price, which is still high. I wish airlines would cancel orders more.
16
@Ellen A. I don't fly much, but have enjoyed flying Boeing 757 and Airbus A319, 320. Even an original A300 in 1979. These are all stable aircraft, and have proper autopilot designs.
This article describes a company in chaos! Profits first. Customers and safety second,
Boeing needs to be punished by the flying public. And their management fired across the board -- if not jailed.
The right response of the public is to not fly their planes. Let the 737 Max fly packages as a transport for a decade.
31
@taxpayer
And what have those poor freight dogs done to you, since you suggest such a cruel punishment?
Boeing is just another egregious example of American cutthroat capitalism. Newer kids on the block such as Amazon or Uber are lambasted for their basic lack of respect for human rights in their treatment of employees. It is unfortunate that a venerable symbol of American technology has chosen to follow the race to the bottom trends characterizing the business world today. This demonstrates that Communist China now sets the tone for business practices : to cut costs and maximize profits, disregard the human element and count your gold.
21
Boeing is responsible for deaths of the passengers on the Lion Air and Ethiopian Air 737 Max flights.
Lion Air released an unserviceable aircraft into service making that operator equally responsible for the deaths of their passengers.
Ethiopian Air inexplicably scheduled an inexperienced First Officer and an unqualified Second Officer together on an Air Transport flight making that operator equally responsible for the deaths of their passengers.
Both Boeing and the operators are responsible.
The investigations of both these catastrophic flights will show other stakeholders have some culpability if they are carried out properly.
3
Good grief!! What else didn’t Boeing tell its pilots, the FAA, or anybody else.
I wonder whether I’d feel more apprehensive now about flying in this new aircraft, because if Boeing rushed to get it flying back then, what other changes are they making now that they are not telling pilots, staff, or regulators to get the planes fixed, out of inventory, and in the sky again?
And with a Boeing executive at the head of the relevant agency!!!
18
Good article, showing clearly how the design process behind the Max and MCAS system, and subsequent FAA approval, was compartmentalized, leading to a situation in which nobody, besides unnamed and top-level officials in Boeing, had any idea of the ramifications of the system.
Airbus did the job right with the A320neo, designing the aircraft around the new high-efficiency and larger engines. This aircraft was snapped up by airlines, since it promised significant savings.
Boeing, in an effort to regain top position in aircraft sales, did a quick fix on the 737, shoving new larger engines on an airframe designed for smaller engines. In order to prevent the larger engines dragging on the ground, the fix involved placing them forward and higher on the wing, which had the effect of unbalancing the aircraft. So, MCAS was conceived as a magic wand to "fix the fix". And then MCAS was further "developed", and ... people ended up dying.
Heads should roll at Boeing, starting at the top!
65
@Rob
The laws of nature said: "it cannot be done".
The engineers said: "software will overpower the laws of nature".
The laws of nature won.
7
@reader Physics doesn't care about stock price or market share. Greed and arrogance blind them to that reality.
1
It usually takes 3 mistakes for an adverse event to occur. In this instance there were at least 3: Boeing being allowed to approve of changes instead of the FAA, Test pilots using only simulators, Manuals not containing complete information. All because of unchecked greed and capitalism. The MBA's are being allowed to rule unchecked and the cost is in lives.
People often try to use Aviation practices in the practice of Medicine. Or the use of Japanese manufacturing techniques to speed up throughput in Hospitals. Unfortunately, when the Business only folks get their hands on the practice of Science, to the exclusion of Scientists, you will see disasters due to their hubris.
30
@Sasha what you call "mistakes" were all calculated gambles based on the existential need to retain market share that Airbus was taking. Defective products were sold, but the sales kept Boeing as the top provider of commercial aircraft. Global competition and deregulation were the real "mistakes" that compelled executives to prioritize getting to market quicker over safety.
4
Boeing made design changes that made the plane inherently risky, and made the now exposed as false claim that no new pilot training was needed. It gave them a sales advantage that made them huge profits.
Their automated control system made 2 planes crash with hundreds of lives lost, and necessitated the grounding of a large part of the fleet for many airlines.
Now we're asked to believe they've fixed the problems, when clearly the planes inherent design flaws remain, and airlines are in essence being asked to beta test the revised software.
I wonder how sales of Boeing in general and the 737 Max series in particular will go in future.
19
@Steve Bright The deregulated airplane and airline industries, reinforced by by FAA's role as promoter has a simple mantra: Airplanes are always completely free of design weaknesses and manufacturing defects. If any design weakness or manufacturing defect is found, it is fixed and so airplanes again have no weaknesses or defects.
3
@Steve Bright --> "inherent design flaws remain"
The essence of the problem articulated in 4 words. > A+
Safety is always first when it comes to making public comments. But the reality is revenue and profit is ALWAYS, ALWAYS first. Why else would they have not provided additional training for pilots? Simple, because it would have delayed the sale of those planes, affecting revenue and profit numbers, which clearly took precedence over safety. The modern corporate and incentives system is hugely flawed.
35
@Jimmy H Technology isn't as easy as making something work once. Just imagine what the software industry would be if their products were never released until they were error free. We'd still be using adding machines.
2
@Jimmy H -->
It's really much worse than that !
Boeing needed to stay on an expedited time frame for development & production of new variant Max under FAA "expedited approval status" under "essentially the same operationally" as earlier 737ng variant.
Recognizing material changes were sufficient in scope to require additional pilot training & re-documentation of extant flight manuals would likely lead to roadblocks.
Smoke and mirrors, wink & nod, led us to here and now.
To date, Boeing & FAA to some extent have maintained some control of story line. Once the true depths of malfeasance and callous indifference are plumbed in the go-along-to-get-along mentality at Boeing & FAA
criminality should be transparent.
@LivesLightly a computer crashing doesn’t have quite the negative impact as a fully loaded 737 crashing.
1
Sounds like overconfidence in their own technology and their own organization led to a serious problem slipping through the cracks in the floor.
5
@David Martin
Hubris seems to be a major problem afflicting many institutions. The unsolvable Catholic Church sex scandals and the Ivy League's complicity with mendacious college applicant's parents are two glaring examples which illustrate the dictum 'power corrupts'.
What should worry every flyer is what if there are safety issues other than the MCAS in these planes which have not yet surfaced? If the plane design and safety evaluation process is so disorganised, there is every chance of another safety system being faulty. It may just take another crash to bring to everyone's notice.
14
@Shekhar Any one who believes airplanes are free of design flaws and sample defects is simply ignorant. There's risk in using any technology. And for air travel it's the risk of death.
If and when people all over the world refuse to fly on the Max - that’s the only time Boeing will truly pay the price for their mistakes.
23
@Nick Very few passengers bother to know what brand and model of plane they're flying in. The price of the ticket is uppermost on their minds. Their assumption is since it was approved by the FAA and the airline it's safe.
3
If Boeing and its key corporate executives and employees are not charged with criminal corporate negligence, then there is no God.
10
@Ex New Yorker
The existence of intelligent design in our world does not equate the intervention of a concerned deity. The Deists had it right, as the daily outrages demonstrate quite well.
5
American Aerospace Engineering superiority is officially over.
Basic inferior design were allowed and serious safety issues made through the system that are supposedly designed to stop them.
That means the system failed that was what led to the plane crashes.
Management deflects the blame to the pilots and admits one error at a time only if they unfold in public.
That is another sign of system incompetence.
It’s not about one or two sensors or how they control the plane. The whole design and reliability of the plane should be questioned. Boeing engineers may fix the plane by redesign them, but for that to happen, current management team must go. They don’t deserve to continue after that many passengers died on their clock. They can never restore public confidence, they should be fired.
28
When designing something as complex as a commercial airplane, office work environments that facilitate collaboration are of course very important. However, being able to concentrate on the technical details is critical too. Many Boeing offices where its engineers and software developers work are crowded, noisy, and distracting. In such workplaces, the risk of making careless mistakes or overlooking important details increases. What, if anything, is Boeing going to do about that? It is easy to measure the cost of office space. It is more difficult to measure the loss of productivity and the increased likelihood of errors when workplaces are crowded, noisy, and distracting.
12
@Richard Fuhr this wasn't due to carelessness or overlooking anything. It was a conscious decision to roll the plane out quickly to meet the competitive threat from Airbus. As the article described, all Boeing 737 engineers and designers were under great pressure(the specter of losing their jobs) not to raise issues that would hinder delivery.
7
@Richard Fuhr
A very interesting observation. I presume you have been at Boeing or know someone who works there.
This is just one more piece of the puzzle that seems to be telling me never to board another of their planes.
why has no one lost their job at either Boeing or FAA?
28
@J H
No one in the leadership at Boeing thinks any mistakes were made, per their own statements, and Eleine Chao still perhaps does not even understand that this may be her area of responsibility to make FAA heads roll.
I would not be surprised if the administration decides to abolish the FAA entirely, claiming this as proof that their existence is meaningless.
5
@J H
Welcome to the Era of Mediocrity where Bart Simpson the proud-to-be-an-underachiever is everyone's patron saint. Then there is also the law of 'too big to fail'.
The article uses various forms of the word "aggressive," as in "The Boeing engineers ... enabled [the MCAS software] to aggressively push down the nose of the plane." To bulldoze opposition and get their way, management types often use the word "aggressive." (E.g., "We are going to complete this project on an aggressive schedule.")
Unfortunately and destructively, in American culture, when the boss uses the word "aggressive," all opposition suddenly vanishes, doubtless because the opponents know that opposing anything labeled "aggressive" would make them look weak--and of course the appearance of weakness must be avoided at all costs. Tragically, that cost goes all the way up to causing innocent people to lose their lives.
The solution? Change American culture so that invocation of the word "aggressive" (and other rapacious and warlike words) to get one's way is no longer seen as unstoppably glamorous and valiant and strong, but instead as a sign of a venomous greed, and of a sociopathic lust for a vicious power over others.
17
@FaceIt But deregulation and global competition have created new existential threats to companies and when they find themselves behind the choice is to either cut corners or go out of business(lose their jobs). It's essentially like armed conflict where one side will be the victor and the other totally annihilated or consigned to extreme humiliation, poverty and hardship.
Boeing and the US government stand to lose the most when sale of the aircraft is halted. Revenues and GDP numbers will be impacted. They will try any means of arm twisting to get this flight up even if that means rushing through another patch, deflecting blame to the pilots, influencing airline regulators. The FAA/USA was the very last regulator/country to grudgingly call for the flight to be grounded with no sense of remorse or compunction. The CEO's crocodile tears and PR stunt to restore public confidence is more ro appease the investor than to appeal to the passengers. I am a software engineer and i am nervous when the safety of the flight is trusted upon a patched up software and control system that has fundamental design flaws to begin with. If you really want to restore passenger confidence have the executive team resign, compensate the family members generously, admit guilt instead of deflecting blame by gradually influencing the investigation and members of Congress and halt production of the aircraft. When it's patched up, the exec team should fly in Airlines piloted by foreign pilots outside the US. The stench of their depravity tugs my heart and yet the corporates and officials at Boeing/FAA walk scott free. When will this stop?
21
The biggest question is not about engineering/techincal issues. Is abou lost lifes by bad management which should be investigated, causing Boeing to respond to the law.
14
In my opinion the MCAS is total nonsense. I flew the B-737 for many years as a commercial pilot. I was a check airman and simulator instructor. What they're doing is allowing the engineers to fly the aircraft,vortex is no problem,
If a pilot has to be notified that is in a stall condition he shouldn't be flying airplane. As soon as trouble starts the aircraft should be brought back to manual flying. The problem starts with Junior birdmen that think they know all the answers. I have 5000 hours in the B737 more than 30,000 all types Commercial airlines Check Airman and the last 16 years as an FAA inspector.
27
@Bill Jolly
FYI, the cockpit recordings of both crashes clearly indicate full stall alarms (I have heard them), while the aircraft was clearly not in an actual stalled state (in fact, it was executing "MCAS controlled flight into ground"). The stall alarms continued up to the moment the plane hit the ground. Even to a non-pilot, those alarms and stick-shakers are loud, tactile, and obvious.
The slight difference in behavior of the 737-MAX family compared to earlier 737's was most apparent at high angles of attack and high engine power, which added an additional nose-up force compared to earlier 737 models. Training existing 737 pilots on this behavior would have likely required simulator time, and the simulators were not then ready (and the training would add to the aquisition cost of the airline). Avoiding these delays and costs was the justification for the MCAS.
Boeing was attempting to mask aircraft performance from the pilot using MCAS. Pilots are responsible for flying their aircraft---by law, and by existing practice.
The fixes to MCAS appear to be correct, and should make it safe, and seems to put pilots back in charge. Teaching MCAS to pilots, and letting them at least have a simulator run with it active also seems prudent.
It may be that no MCAS with pilot training on the 737-MAX differnces is safer and better than the redesigned MCAS. No MCAS would have been much better than the old version.
9
@Bill Jolly The 737Max is simply not as stable as preceding versions, so your experience isn't valid. Some military aircraft are flown by computer because they are so unstable(by design for performance) no human could control them. Military planes also crash more often than commercial airplanes...
6
Boeing management should be charged. There must be consequences for their negligence.
28
Unbelievable! Boeing shortchanged safety in order to get a new airplane in the air fast to keep up with a competitor. This is not about an add-on patch for a small part of an airplane that was a little bit different from the original. This was the only difference and it was huge--the plane didn't fly well at slow speeds compared to the original and would tend to pitch up from bigger engines located aerodynamically different on the aircraft. Hiding references to "fixes" for this in the manual says that they didn't want their buyers to know there was a problem in the first place. Not explaining thoroughly to the FAA that there had been a change to the original fix, and explaining why this was necessary, and that it had been thoroughly tested with all documentation presented (where it should have been immediately evident that this was NOT a redundant system) evidently also didn't happen.
How much of this is that the FAA didn't do their own testing under the ODA (Otherwise-you do it act) put in by our unregulators-at-any-cost Congress. We are seeing this magnified exponentially by the present administration as Republicans in Congress, openly quid pro quo pawns of the fossil fuel industry, cheer. It is criminal to poison people from mercury and fine particulates from coal plants, when you know this is happening. Banning the science is criminal. So is ignoring safety at the FAA, and worst of all putting immigrant families at the border thru a Sophie's Choice situation.
20
Can 737 MAX recover from a stall? Is recovering altitude greater than current 737s?
1
@Tom Thomas If the aircraft is close enough to the ground, it will crash before it recovers. If it's a high speed stall, the air frame may fail due to increasing speed during stall recovery. The original MCAS was only to prevent high speed stalls. The modified MCAS was developed so pilots wouldn't have to be trained about the MAX's increased chance of low speed stall.
2
It seems like this project got so complex and compartmentalized that they guys who always have their eye on the safety aspects, and as the saying goes, "Arrive first at the scene of the accident", did not know that MCAS could be catastrophically activated (the two accidents prove that point) by a single component (the angle-of-attack-sensor) which is known to be subject to compromise by birds, ground accidents, etc.
Based on my aviation experience, if anyone had told knowledgeable airline transport pilots (the people who normally fly these things) of this frailty, they would have demanded that it be fixed before the aircraft ever went into service.
It sounds like, regrettably, that the people who made these fateful decisions were engineers and others who never thought of one of the cardinal rules of aviation - would you let your family fly in that plane.
Although all of these articles understandably use the term "Boeing did this, or that, etc.) we all know that these decisions were made by people, and before this is all over we need to know who they were and why they made the decisions because that goes to the very big question of preventing this type of misjudgement in the future.
5
@Robit17 You font have to reinvent the wheel to fix this going forward. I retired from the aerospace design industry. A formal Systems Engineering process which includes all stakeholders would have caught this. This is not a new process, but one I thought was standard in the industry. Get back to basics.
12
@Robit17
I spent a big part of my career as an engineer on process control and failure management of several kinds of critical systems.
No competent, capable engineer designing aircraft control systems could neglect sensor failure analysis or "what if" analysis. A professional engineer is every bit as responsible for safety as a pilot--for the same reason: an omission or mistake can kill people, or destroy equipment. Engineers also know that any error they leave in a product designed to be used for years and copied thousands of times will find even the smallest of error cases sooner or later--with likely unpleasant results.
Boeing was once famous as a place where product quality and safety came first--with management controls in place to ensure this. The MCAS story suggests none of this is still trum.
Boeing needs to ask what they did wrong as an orgaization. The MCAS design seems to have been thrown together over a cheezeburger by "Tommy the Intern". Worse, the first pass at fixing MCAS after the crashes still had glaring flaws. The current design now looks reasonable-but is no longer possible to trust the implementation will correctly follow the design.
Is Boeing using the Facebook motto: "Move fast and Break things"?
6
@Robit17 But according to the article, the test pilot, not the engineers, decided the MCAS should be modified to activate under less extreme situations.
"In a meeting at Boeing Field in Seattle, Mr. Wilson told engineers that the issue would need to be fixed. He and his co-pilot proposed MCAS, the person said. The change didn’t elicit much debate in the group, which included just a handful of people."
Everybody's hero: Ronald Reagan, hollywood actor, said it, and it got him elected:
"Government is the problem."
I said it:
"Unregulated capitalism is the problem".
I know I am smarter than Ron was, but it does not matter.
Greed trumps intelligence every time, pun intended.
52
The engines are simply too big for the plane, either replace the engines, or build a plane that can take the big heavy engines safely.
50
@Allan
Exactly! Why is no one investigating and reporting on this. It was an easy fix for an already designed workhorse plane with a great reputation, except it did not fit. They have to redesign this plane.
18
@Allan
The timeline for bringing a new airplane into service calls for dedication to an ideal which is about as rare in major manufacturing as Monarch Butterflies are in the natural world these days.
6
@Allan
This is exactly the point, and the elephant in the room. It’s a fundamentally flawed aircraft patched up with a bandaid. Nobody wants to talk about scrapping it because of the catastrophic effects on the manufacturer.
7
I now understand that the problem with the Max isn't MCAS. MCAS was to be the solution to the real problem; poor flying characteristics near stall at low speed. MCAS, the hoped for solution turned out to be an additional problem. Correcting MCAS still leaves the original problem unsolved; low speed instability.
77
This might be a stretch, but reading through this article vividly reminds me of what happened when Morton-Thiokol engineers had misgivings about their management pushing really hard to get the Space Shuttle Challenger launched after wide swings in weather that created frozen portions of the booster rocket. Adding to this pressure was NASA. And the technical staff was either ignored or couldn't get management to slow down and carefully evaluate what was in front of them.
These revelations about eliminating a second sensor are totally unusual. Why do eliminate a back-up designed to provide redundancy in event of a failure of primary system? This is the crux of the investigative thread that should be followed all the way to initial decision making, ongoing pushback (assuming there was such), and how the Boeing Technical Staff was treated. The flying public assumes these decisions are made by management. If Boeing management short-circuited decisions, the rush to produce a competitive plane to Airbus sadly speaks how far Boeing slipped from a preeminent point of engineering excellence.
Competent regulation and oversight is not to be budgeted out when it comes to protecting lives of travelers. FAA staffing and mission has been gutted over the years. (Today Trump wants to build a wall for $5.7B.) Why should Americans feel safer flying today?
Accountability, transparency of investigation's results, and corrective action. That's where all of this starts and ultimately ends.
43
@Peter Vander Arend
I think this is different. I read here that engineers were NOT raising alarms here, unlike in Morton-Thiokol case.
Instead, when presented with a proposal to use MCAS for solving a brand new issue, which involved removing many assumptions critical to the original design (only with high-G readings and in very rare situations and small adjustments), the engineering team focused on "how to get this done" question instead of "should it be done / how will it affect safety" question.
And NO ONE in the company questioned the continuing reliance on the original safety analysis of MCAS, even though many people knew that the system has changed in "some way" since the original design.
This is an engineering culture/leadership failure.
21
@Igor Lubashev the article isn't clear but it mentions several times that there doesn't seem to have been a safety analysis by Boeing or the FAA on the new MCAS design. The original design used only one angle of attack sensor. The software changes were much simpler(quicker) to only eliminate the G sensor input and add new control parameters than to add a second attack angle sensor input and decision logic. The change occurred very late in the process when delivery dates had likely been promised.
1
I don't know how long the F.A.A.( and Department of Transportation) has been on autopilot (absolutely no pun intended), but it certainly did not begin with this administration.
Years of quietly acquiescing to aircraft manufacturing and airline lobbyists and zero oversight from that branch of government charged with legislation and oversight...we now have aircraft pieced together with glue-of-greed and malfeasance. Aircraft whose life-span ranges about 30 years and a flying public with zero options.
But...this is capitalism at its hardiest. Those who have dreamed of markets policing themselves- Boeing is your child.
80
"Test pilots aren’t responsible for dealing with the ramifications of such changes. Their job is to ensure the plane handles smoothly."
What a weird thing to ever say! "'Right stuff' is not my job."
11
Why just one sensor? The aircraft has two AOA sensors. It's never been made public why this was the case. There is no good answer in my mind.
16
@Thomas Serrano
An early rumor suggested that if 2 sensors were used, the FAA would classify MCAS as critical (since it required redundant protection.) A Critical component might have required a higher level (beyond "none") of discolsure, more testing, and possibly a requirement that crews would need some simulation time (on the simulator that was not ready). If this drove the decisions, Boeing needs a new decision process and new decisions -- starting from the top.
It is utterly implausible to me that nobody asked what would happen if the sensor hard-failed in "full stall" stale (which may be the most common AoA failure). If that was the case, Boeing needs to formalize a fault-tolerant analysis process that cannot be bypassed. Otherwise, Boeing needs to determine why the issues raised were not acted on responsibly.
The two AoA sensors are not sufficient. If they differ--and the MCAS is important enough to be needed at all--then it is not OK to just disable MCAS. There are a wide range of other indications and instruments available to calculate the most likely AoA (with a larger error factor than the AoA sensor reading). Then the best AoA sensor can be used.
3
@Mark Johnson The intent was to make the 737MAX fly just like the earlier models. Without modified MCAS, the MAX would still be certifiable but pilots would have to be trained in its particular stalling behavior. The competitive selling point Boeing was making to customers that has 737s and were considering Airbus was that no additional training was required.
1
I have one question, which I would like an aviation expert to answer. Is a plane designed in the 1960’s relevant today? Can a 737 be engineered to be fuel efficient and safe? Can an engineering team take a 1963 Porsche install all the modern day safety features, make fuel efficient, without intrinsically changing the design of the car and make it handle safely.
A 2019 Porsche is a completely different vehicle than a 1963 Porsche. They just carry the same badge.
26
The B-52 bomber is just about 70 now.
Airplanes aren’t cars the basics of aerodynamics and flight characteristics kind of stay the same which is why all the passenger jets look really similar.
The 737 may have been first designed in the 60’s but it has been constantly redesigned and the problems with this latest redesign stem from adding much bigger and more efficient engines which changed the balance of the aircraft.
The mcas system could have been a fine solution for the change in flight characteristics but it was fatally flawed because it had a single point of failure.
This was a more a failure of the deregulated capitalist system and of those who push for “self regulation” in markets where there should be actual impartial regulatory oversight looking for fatal flaws over profits.
45
@Robert Houllahan
Speaking about the much bigger engines for 737 MAX, I understand that the engines are very close to the ground. Could this be another accident waiting to happen in case of hard landing?
7
@Shepard Sherwood I'm no expert but I'll observe that the Air Force is still flying B-52s, designed in the 1950's
1
My deep condolences to Ralph Nader and his family for the loss of his niece in one of the 737 crashes. But it is a rather cosmic coincidence that the one man who can bring corporations to their knees over consumer protection has a personal stake in this case. We will all fly much safer by the time Ralph is done.
45
Thanks to Republicans and their “less regulation” policies, the FAA and other governmental “oversight” agencies are quickly becoming rubber-stamp extensions of corporate America whose sole reason for existence is to maximize profit for its shareholders.
98
@Ron don't overlook the effect that globalization has on putting competitive pressures on companies like Boeing that formerly had a virtual monopoly in certain product lines. In a hyper competitive business regulation is a easy efficiency target because it adds cost that could have been avoided with more effective quality control.
I hope Qantas never buys these flawed aircraft. Airbus seem to have done a better job of modernising it's short-haul aircraft, glad there's at least another option out there.
The terrible thing is that Boeing has the resources to develop a new plane, instead of stretching the life of the 737, but they chose profit over performance and safety. This will be written about for years to come as a total failure of leadership, decision making and short term thinking.
61
@Carl
Profit had no part in the MCAS flaw here.
It was a culture/leadership failure to recognize that a change in many assumption that were critical to the original safety certification of MCAS system required a new safety review of the system.
I blame engineers and their managers.
@Igor Lubashev I suspect the Engineers were pressured to "speed up the process." It's always about Profit.
11
@Igor Lubashev If you follow more closely you'll find that Boeing deliberately chose MCAS as a fudge over the cost to airlines of training for a new variant so they could sell the model as the same type. They then hid the fact of MCAS from he pilots out of the same commercial incentive. It was to avoid the cost of pilot retraining and hence making the 737 MAX less competitive with the A320NEO that motivated Boeing to trade off safety for profit.
7
I will not fly on these planes. I have never considered the type of aircraft before but now I'm paying attention. I'd rather pay a higher price and fly on a safer aircraft. If I owned Boeing stock, I'd dump it. They're toast.
45
The 737 MAX Is Intrinsically Flawed, Misshaped, Software Won’t Fix It
Flawed aircraft have existed before in the history of aviation. There were actually more flawed types than successful ones, arguably starting with the first three plane models. They were made by Ader, a French engineer who, helped by military contracts, built the very first planes, coal powered planes inspired by bats (first flight, 1890 CE, 13 years before the Wright brothers…) However, the main problem of Ader was that the internal combustion engine was not mature enough yet, and his coal engines were too heavy. Plus his planes had to carry coal and water… That could be fixed, and was fixed.
Boeing, airlines and aviation authorities don’t have these excuses with the 737 MAX. With the 737 MAX, as with Brexit, that offending assault against reason, the cause is the same: the financialization of the world, its greedsterization, not to say gangsterization. Never before has a so obviously flawed plane type been ordered in such immense numbers (more than 5,000). This absurdity, an exit from reason, illustrates the world’s corruption. This is a world failure. A flying Titanic, loved by all, until it dives.
So why is the 737 MAX so flawed? Engine location. The engines are too powerful and too forward of the 737 Max’s wing.
The A320 has longer legs, so the new engines could be left under the wing. Also the A 320 has three angle of attack sensors. If one sensor differs from the other two, the A320 AI ignores it.
50
@Patrice Ayme Considering the number of 737MAX flights that have been made to the number of crashes, it's still much safer that driving a car. All aircraft have flaws. Remember the Air France flight 296 A320 crash that was also due to sensor failure and a automated system that confused pilots?
@Patrice Ayme -->
"Misshaped" is the perfect word to get thru to them.
MCAS was necessary bc the rushed to production Max was 'misshaped' from the very beginning - a design flaw that no work around will fix.
Rule number one in engineering development process is to avoid introducing last minute changes to the product as they have the potential to destabilize the product.
54
@ma Rule number two is ignore rule number one when your competitor is ahead of you and you've promised customers a delivery date.
3
“Boeing has no higher priority than the safety of the flying public” this may have been true historically but not today. Boeing's actions are clearly not safety first.
45
I also read that quote and thought "that's simply not true. They are a publicly traded company and so the highest priority is profit to the shareholders".
22
Even capitalism has its own mini-Chernobyl.
9
What has happened to the United States since I entered this world during World War II when the U. S. saved Western Democracy? For what purpose did the the American people do that given what Boeing, djt, the Republican Party, etc, etc, etc have been doing to destroy the honor, honesty, and reputation of the United States nationally and internationally. The word of the U. S. Government and world confidence in American products today is meaningless.
74
@Bill N. You're guilty of "survivor's bias". The US military made many bad decisions in WWII that needlessly cost thousands of US soldier's lives. If yours was one of them, you wouldn't be so nostalgic today.
Boeing needs to do an audit of its change management process to make sure it is followed and working and strive to continuously improve the process.
One would think a well established engineering company like Boeing is making use of a project life management software to manage engineering changes, provide a central location for design information, help identify dependencies between component and automatically notifies affected teams about change(s) that impact their work.
4
Ha! Boeing clearly can't and shouldn't audit itself or none of this would have happened. They need an independent, outside agency or company to audit their systems... and it definitely shouldn't be the FAA.
8
@ma
I guess that was intended as a satire of the sterile inhuman jargon that people use to cover their tracks these days ?
Well done!
According to the FAA website, the Agency oversees 24,833,000 hors of flight per year. So each year we might expect 2.5 failures on average within this zone? Didn't anyone do this simple arithmetic?
4
The article sounds like a lab of gobbledygook to justify Boeing saying they corrected the problem and everybody should now fly the 727 maxes. Once all of the judgments and payouts are done will there be a company. Are there no individuals who can be indicted?
6
“727 maxes” nice!!
Mmmmmmm. Smells like capitalism
8
I used to admire American independent thinking, team work with equality in opinion and research sharing and the ability to bluntly stand up to authority. I guess that holds no more. Scary! Because the rest of the world is still controlled by patriarchy, misogyny, authoritarianism and autocracy...which means blunt insightful communication, even when it can save lives, is not forthcoming. Goddess help this world of useless or dangerous misogynistic corrupt male systems now.
7
@ExhaustedFightingForJusticeEveryDay
Ya, if only Betsy DeVos or Elizabeth Holmes were running things, this sort of thing would never happen.
Yep, it's all down to guys. Some really intellectual deduction there.
@ExhaustedFightingForJusticeEveryDay
A good portion of Americans love "patriarchy, misogyny, authoritarianism and autocracy", they put it right into the White House.
1
I used to admire American independent thinking, team work with equality in opinion and research sharing and the ability to bluntly stand up to authority. I guess that holds no more. Scary! Because the rest of the world is still controlled by patriarchy, misogyny, authoritarianism and autocracy...which means blunt insightful communication, even when it can save lives, is not forthcoming. Goddess help this world of useless or dangerous misogynistic corrupt male systems now.
2
I am an engineer with 30+ years experience in a/c components engineering. In fact Airbus a/c have also had their share of crashes in years past, due to situations where systems operated outside their design parameters.
All modern a/c are designed to learn from the experience base of problems that were not supposed to happen but somehow did. They are a team effort: specification, air-frame, system suppliers, integration, test. Thousands of people are involved, all working with sincere intentions to deliver "the best."
Do you remember decades ago when aircraft had attractive square windows? Oops! It turns out from computer-based mechanical engineering analysis that square corners involve high mechanical stress, which could and did lead to window breakage in-flight and loss of life.
Fatal flaw analysis is an inexact engineering science. It has improved dramatically with improved technology and processes. You can be sure that square windows will never again be found in commercial a/c, and that the next generations of a/c will scrupulously avoid whatever flaws may be revealed in the 737 Max investigation. Both the design / test, and certification processes will be improved, and new or updated a/c will be safer, whether Airbus or Boeing.
11
@Jamyang
It is true that earlier aircraft both boeing and airbus had design issues that led to fatal crashes. Eg, the famous rudder hardover issues that led the fatal 737 crashes in the 1990's. But those did not seem to be to oversight or an "inferior by design". The conclusion was reached after long and painstaking analysis of the crashes and there were lessons learnt that made recent versions of 737 other than the MAX extremely safe and reliable.
The situation with 737-MAX seems to be different compared to recent versions of 737 s. The MAX seems to have regressed with respect to recent earlier 737 versions in terms of 1) aerodynamic instability at low speeds. This needed a software workaround to attempt to compensate for it 2) software workaround itself relying on a single sensor thus a single point of failure.
Boeing and FAA are trying to address only "2" which is not even state of the art - its pretty basic.
11
Please explain a/c. Is it air conditioning or aircraft. Do not understand the comment.
If the MCAS is now limited to operating "to more closely resemble the first version, It will be less aggressive...", then isn't there once again the risk of "The Max wasn’t handling well when nearing stalls at low speeds." the stuff that MCAS was trying to be used as a workaround for in the first place?
Earlier recent 737 versions seem to be better designed as they don't even need an MCAS system to compensate for inherent aircraft instability. It seems that 737 MAX would tend to stall more often at low speeds from which it would be harder to recover compared to earlier 737 versions as the MAX would tend to pitch upwards due the engine placement. Isn't additional pilot training necessary to compensate for inferior 737 MAX design?
8
Having been involved in fly-by-wire system safety in my pre-retirement life, it amazes me that the safety analysis did not get rerun when this feature was modified. The single point of failure that occurred with the faulty detector should have shone bright in the analysis.
20
@John Storvick From the article it seem everyone directly involved wanted to minimize the change, likely to avoid being the one who delayed the delivery date when Airbus was already shipping A320s.
"The fatal flaws with Boeing’s 737 Max can be traced to a breakdown late in the plane’s development" -- yes, that is how it looks on the surface. I would suggest, however, that the problems the article describes are themselves a symptom of a much greater sin.
Boeing's 737 Max is a fundamentally flawed design.
The new 737 airframe is too aerodynamically unstable to be safely controlled by humans. Had 737 being flown by its flight computer, that would not be an issue. Flight computers allow fighter planes to be purposely unstable beyond what a human can handle (for better maneuverability). And A320's flight computer was the miracle behind saving everyone on US Airways Flight 1549, keeping the plane rock stable and leveled at stalling speeds all the way till splashdown in Hudson.
But 737, being 1960s tech, still relies on its pilots for keeping it stable in flight. That makes airframe with poor aerodynamics unsuitable -- and, yet, Boeing went ahead with it to save money. When its own test pilots point out the obvious issue, Boeing decided to patch it at last minute with duct tape, while trying to hide that fact as much as possible.
My bet is that 737 MAX will never fly again. As for Boeing itself.. we'll see.
54
@Yuri, there are a number of aircraft that are specifically designed to be unstable in order to optimize performance. The F16 requires a fly by wire system. Absent computer control F16s can’t be flown by a human.
The issue at the heart of this is incomplete test plans, lack of good QA oversight, and bad change control. The aircraft is likely safer now given the level of scrutiny it’s receiving.
2
@Joseph Finsterwald --> "The issue at the heart of this is ..."
No! As issue is whether an aerodynamically unstable airframe is suitable for transport class carrier service.
While fly-by-wire may be necessary for F-16 hi-performance craft, aviation experts tend to agree it is not compatible w/ carrier class craft.
Great illuminating article. So when Boeing and the FAA say the Max is now safe to fly, will you have any hesitation about flying on one?
9
@Lawyers, Guns And Mone Are there any aircraft that the manufacturer and FAA say is safe to fly but was removed from service because people have hesitation to fly in it? BTW there are still Chevy Corvair clubs that proudly drive their vehicles. Probably some Ford Pinto ones too.
So it sounds like Boeing knew there was a problem but tried to hide it so that potential customers would think there was no pilot re-training involved. After the fiasco what airline is going to buy a 737 MAX unless they're desperate because Airbus can't make planes quickly enough? How's the shareholder value looking now guys?
27
Boeing's flawed design, persistent stonewalling and blaming the pilots for the crashes have all drawn criticism. Many articles have been written here and elsewhere. But I haven't found a single article on the collusion of airlines with Boeing. Despite their own pilots' reservations airlines are wholeheartedly endorsing the Max. They don't want to spend on additional training. They want to get the grounded planes flying asap. If the airlines had an ounce of responsibility towards their own pilots and their customers, they would have pushed Boeing harder on Max after the first crash. But no, all they did was cheerlead for the Max. They are still doing it. It's a vicious cycle. Airlines' penny pinching drives Boeing which cuts corner to keep the airlines in the fantasy world of no training for new aircrafts. The flying public must make it clear to the airlines that they won't step into a Max. This is the only way to break this unholy nexus.
44
yes, this sounds all too logical when you consider how airlines nickel-and-dime their customers.
10
The thing that really bug me is every Boeing executive talk for umpteen minutes about how they regard safety as the top priority whenever they answer a single question about the cause of this accident. That safety statement blankets all the subsequent actual statements so that you don't know what the cause or what they are talking about.
11
Boeing's flawed design, persistent stonewalling and blaming the pilots for the crashes have all drawn criticism. Many articles have been written here and elsewhere. But I haven't found a single article on the collusion of airlines with Boeing. Despite their own pilots' reservations airlines are wholeheartedly endorsing the Max. They don't want to spend on additional training. They want to get the grounded planes flying asap. If the airlines had an ounce of responsibility towards their own pilots and their customers, they would have pushed Boeing harder on Max after the first crash. But no, all they did was cheerlead for the Max. They are still doing it. It's a vicious cycle. Airlines' penny pinching drives Boeing which cuts corner to keep the airlines in the fantasy world of no training for new aircrafts. The flying public must make it clear to the airlines that they won't step into a Max. This is the only way to break this unholy nexus.
4
Something very serious went wrong at Boeing. There's a good chance this was negligence; perhaps criminal negligence. 350 people died. Punishment is very likely warranted.
The first job is to conduct a thorough enough analysis of all involved processes, both business and technical, to insure something like this never happens again, at Boeing or anywhere else.
Next, regulators, lawmakers, and prosecutors must decide how punishment will be determined, and who will oversee the process. It should not be America's badly broken civil tort system.
If the trial lawyers play a role, enormous payouts will likely be made to the attorneys who make it to the courtroom fastest. The lawyers will become fabulously wealthy. The initial clients, likely families of the victims, will get something (which is appropriate). But, there may not be any money left for families that are not first in line. This is not justice.
And Boeing will likely be bankrupted. This would be a serious problem because Boeing is one of only two companies among Western countries that manufacturers long haul passenger jets. The other is Airbus, which has also had planes crash. In simple terms, Boeing is too big to fail. Society needs the company's products, and having only one supplier, Airbus, left building planes would not be a good thing.
Strong punishment will likely be appropriate. But the government, Congress and/or regulators should met it out, not America's lawyers.
9
I don’t trust this government to do it. I trust civil and criminal juries more. They will make Boeing pay.
Boeing will take a financial hit, as they should. But they won’t go bankrupt, they will just have to change leadership and add some people to their board who understand safety instead of the celebrities and yes-men and women they now have.
7
Relying on a single sensor proved fatal. Surely, given that the MCAS was capable of flying the plane into the ground, there should have been a second or even a third sensor, and if the software calculated there was a discrepancy between sensors, the automated system should have disengaged. I always thought redundancy was built into these things.
And finally, if the plane was clearly trying to fly itself into the ground, shouldn't there have been a big red button to push that said "DISENGAGE" that would have shut down the autopilot giving full control to back to the human pilots?
14
I remember reading Arthur Miller's play All My Sons as an undergraduate. It was shocking to me, and I never forgot it. This is on a par, if not worse. than the situation in the play. This is not one flawed person but an entire organization, or should I say entire organizations - characterized by mediocrity, sloppiness, and shiftiness which has yet to show any signs of an ethical or moral reckoning with the blood on their hands.
26
I read this between episodes of the dramatization of the Chernobyl nuclear disaster. There seem to be some common features.
8
“Boeing has no higher priority than the safety of the flying public,” a company spokesman, Gordon Johndroe, said in a statement.
If that were actually true, they would have grounded the planes after the first crash.
32
@Tim Lewis I agree. And Johndroe's statement sounds like something a robot would be programmed to say.
8
@Tim Lewis- Right, And they would have conducted a second safety analysis after major changes to the MCAS system back when no one was watching.
5
The other thing that really amazes me is the continued sycophantic behavior or the FAA. They were the last to recommend grounding of this plane and now they seem over eager to get it back in the air. I will never fly this particular aircraft.
9
"...would have preferred an aerodynamic fix such as vortex generators, thin fins on the wings. But engineers who tested the Max design in a wind tunnel weren’t convinced they would work, the person said...
But they were somehow convinced a digital fix to a digital model would...
Or - perhaps they were convinced that wind tunnel tests might show that nothing could fix what ailed this beast...
You journalists have done your job - you've opened Pandora's Box with this diligent work...
What's within will take it from here...
Just remember which of our Presidents taught the world that - in America - legal contrivance bests technical prowess...
PS
The other piece that's been left twisting int the wind is the list of airports - mentioned in a Seattle paper - that was redacted from a legal brief...
Airports to which this thing should not go...
More recently...
https://www.latimes.com/business/la-fi-boeing-max-8-airports-20190411-story.html
2
@W in the Middle
Hope springs eternal - just one day later...
https://www.nytimes.com/2019/06/02/business/boeing-faa-737-part.html
Understand - regularly pay more attention to the lead-in pic or last paragraph of a NYT piece, than the rest of it...
The 6/1 piece, no different...
If someone said to central engineering: "Is there any single field-replaceable part on this thing that would actually fix - or at least greatly improve - things?"
Just looking at the lead-in pic - the answer would be the leading-edge slat tracks...
Till fifteen minutes ago, didn't even know what they were called...
But had pictured - months ago, in spitball space - the oscillating vortices that could be churned at the nacelle<>wing confluence, under the wrong conditions...
So localized, the AoA sensor might as well be on another plane...
The simplest thing would be to decrease their range of movement, and see if that helped...
Second - modify their cross-sectional profile...
Finally, their rework their shape and surface near to the nacelles...
The tell that they had actually fixed the plane would be the MCAS...
Not that they had fixed it - that they had removed it...
Why it never talked about the software development was out sourced to India? The quality were so bad that Boeing decided to move it back to US but won’t be able to redo the Indian software for 737max and 787
10
Is this true that the MCAS software was out-sourced to India? For a while I managed a team in Bangalore. It was very difficult to control. Everything had to be specified in excruciating detail and there was no common sense interpretation of requirements. They never pushed back if anything was not clear or did not make sense in the requirements specs as was common with my local team in California. Everything needed to be tested back in the US since little was tested at the point of origin, resulting in cycles of corrections and retesting
I would guess that MCAS is a multi-threaded real-time control system with numerous nested state machines. I would never have considered farming this out to a remote location. This sounds more suited to the creative intelligence of a Seattle based software engineering team
I would like to learn more from the software engineering community about the process model used to specify, design, implement,and test the MCAS software.
I know many large corporations have had great success in developing software in India. But for a critical real time control system it adds another layer of complexity to have the software team remote from the core engineering design team. I think there is more to learn here.
7
“Boeing has no higher priority than the safety of the flying public,” a company spokesman, Gordon Johndroe, said in a statement.
If Sarah HS ever tires of life at Trump's White House, Johndroe could hit the ground running.
15
This is insufferable reading these comments. Look at that jet’s wing. Tell me how any of us writing them has any clue as to how some dragon-like looking thing as that defies gravity let alone gets our Amazon package on our doorstep 10 seconds after we click on a mouse button. Let’s all curse technology and then happily return to our torch-lit caves and chew on bronto-burgers. Stuff happens.
2
Just like the people who avoided listening to the warning set the tiles on the spacecraft were not safe.No stuff doesn’t just happen. In this case somebody was criminally negligent.
9
@John Doe I'm not sure whether we are reading the same comments. Nobody is cursing tech. It's Boeing's flawed design and blatant stonewalling that's causing outrage. Critical tech should be designed right just because "stuff" happens.
11
@John Doe
Stuff happens means beyond reasonable expectation of human control. That does not seem to be the case here.
7
Wasn't there a "disagree alert" system to compensate for malfunctioning sensors that Boeing decided to sell as an "option" for an additional fee (less than $10,000)?
The senior management at Boeing must be grateful that Kim Jong-Un is not in charge of the investigation.
7
@JMK I've read that installing a "disagree alert" would have involved retraining pilots. Not sure if that's true.
Virtual planes don't behave like real planes?
Why I love the NYT.
2
After the first crash it’s criminal that Boeing didn’t own up to faulty plane!
5
Just past the anniversary to the Chernobyl disaster it is illuminating consider that Boeing and the former Soviet Union follow the identical playbook.
6
I was just thinking the same thing after watching Chernobyl mini series on HBO. How the CEO of Boeing is still in office is beyond me.
7
Corporate America running wild in search of bigger and bigger profits.
Shareholders must be fed, incompetence in the White House, now planes are falling out of the sky because no one is in charge and no one brothers to think.
We have lost any credibility in regards to air travel.
6
I’m a longtime Boeing shareholder and this report sickens me. I’m seriously considering liquidating all of my $15,000 in shares to show that I won’t countenance this sort of corporate behavior. Not on my dime.
9
I bought $7000 of Boeing for my grandson’s college fund on Mar 1. Needless to say that didn’t pan out. I wonder if the executives will be held liable for their lies and deceptions. I doubt it.
2
@Dan i hope more shareholders follow your lead.
3
@Dan Yeah, do it fast before they are worthless. Just to show them.
1
Boeing actually monitized deaths of its customers, much like Ford did with the Pinto and it's exploding gas tanks. For want of a piece of metal to protect the gas tanks from exploding on rear end collisions, 500 people died. Their reasoning: cost to correct exceeded law suit deaths costs. Boeing acted in a similar manner with MCAS and pressure to beat Airbus to market. One thing American companies do best is monetize everything, even lives of its customers.
13
This is an indictment of Boeing and its leadership. Liars, liars, liars. It's also an indictment of the F.A.A. for its blind reliance on the self-serving interests of Boeing to make decisions that impact so many people. I hope the airlines that were flying the Max 8 realize that this article does nothing to reassure those of us who fly that Boeing can be trusted. What other corners have been cut and hidden? Despite the hassles of modern travel, I still love to fly, but now I'm going to be carefully checking the type of plane before I book. Essentially Boeing has made me afraid to fly. American, United, Southwest and other airlines will hopefully realize that, even if the Max 8 is put back in service, passengers like me will be actively looking for other planes on which to fly.
7
Kindly allow me to hazard a wild guess here:
Not one C-Suite from Boeing will be sent to jail.
20
Clear black eye for Boeing and American aviation. Heads need to roll.
3
In some ways the 737MAX problems are analogous to the pharmaceutical industry, but the lack of oversight there usually kills you slowly, and less dramatically and obviously.
6
This article glosses over critical issues, with language that obfuscates and neglects key factors — issues that the lay audience it's intended for can and must clearly grasp.
1st, the problems began from the start of the 737Max program. The low-slung 737's wings meant that enlarged engines Boeing wanted to compete with Airbus, would interfere with smooth airflow over the wings. That created the problems that MCAS was needed to overcome: a tendency to stall unpredictably.
2nd, Boeing made crucial safety features like redundancy a high-cost option for customers, including 2 angle-of-attack sensors that should be standard. Even fire extinguishers are added cost.
To state that the plane "wasn't flying smoothly" is highly misleading. The correct language: "would go into an unrecoverable stall." Then again: "wasn’t handling well when nearing stalls." This smells like a nervous editor overriding the intent of writers, much like the problems Boeing and the FAA face. Why would the Times weaken the story in an otherwise important investigative work?
3rd, the cozy relationship between Boeing and the FAA is hinted at, yet it couldn't be more clear that this is a seminal example of the rot between industry and the regulatory structure we all depend upon for our very lives. It is criminal and a conspiracy that needs to be treated as such. It deserves no courtesy.
26
@Craig
Your 1st point is spot on but it needs to be made brutally clear:
Boeing relied on software to compensate for an inherently bad aerodynamic design.
What could possibly go wrong? Even with redundant sensors, this totally irresponsible.
22:40 EDT, 6/01
1
CEO Dennis Muilenberg was interviewed on CBS Morning News last week and he came across with little empathy, caring or sense of responsibility. He sounded like he had been briefed by his lawyers to admit nothing, speak platitudes and never accept true responsibility. It was really disgusting and an embarrassment to what once was a truly great company. When a plane is released to the flying public, the CEO is responsible that there are no communication voids or misunderstands as reported in this article. He must go.
43
China might have some thing. Remember what happened to the head fellow when contaminated milk was released throughout the country?
1
Speaking for myself, I never want to fly on a Max 737. I don't trust Boeing anymore. I suspect most feel like me and will cancel airline flights if they are scheduled to be on a Max 737.
15
Does Boeing's reps really think the public buys their self-serving and false statement, "Boeing has no higher priority than the safety of the flying public. . ." They basically hid significant last minute design changes from both the test pilots and the certifiers, creating an opaque situation where actual pilots were kept in the dark about the MCAS and now are just hiding behind the cop-out that says hey! we were certified. Well, they hid the ball from the FAA and the certification team, didn't really look very hard did they, probably because Boeing put a lot of pressure on them to certify the plane to get out ahead of Airbus. Looks like all they've done is promoted Airbus and killed a bunch of people in the process. Shame.
32
@Barry Fisher
It is now time for the relatives of those killed to teach Boeing a lesson - multiple law suits.
Clearly, Boeing's negligence will cost them dearly. Airbus here come your customers.
4
The more I know, the worse it gets...what putrification has happened at this company? I won’t ever trust Boeing’s current leadership
16
The drive to cheap, or higher profits. resulted in a quick and dirty software patch to fix a defective aerodynamic design as a result of larger engines. One sensor? Cheap! Was the return of 346 lives on investment worth it?
8
@PAN
and it was a sensor exposed to known mishaps.
1
So what system is now in place to identify and rectify all the other single-point-of-failure design errors in Boeing's aircraft?
8
This is masterful report. The Reporters were able to explain a series of obtuse systems- human and mechanical- so that we everyday people can understand what caused these tragedies. It is not one thing, now, is it?
23
Engineering and safety are slow and time consuming. Unglamorous and methodical. Costly and necessary. All things abhorrent to modern business that wants fast, flashy, and cheap.
23
I am surprised how fast things can go wrong in designing an airplane. Thanks for this detailed account of what went wrong.
8
I would like to make a few comments:
1. From the author, there was some MCAS software change that was supposed to help to prevent stalling at low speed. Now that this MCAS software is being changed again, I wonder if its effectiveness is still there.
2. It would be easier for reader to follow if the author list out (itemize) clearly all input factors to this MCAS software before, after changes and now.
3. The rationale of depending only on one attack angle sensor is rather strange. The assumption of failure 1 per 1million hours seem a bit idealistic. It would be good to analyze existing data to see what the failure rate of these attack angle sensors. Aircraft builders and airlines should have actual data.
4. Note that besides actual stalling scenarios, there are cases where sensors input are corrupted such as failed sensors or corrupted input data path,etc. Hopefully there were testings that cover all anomalous cases.
5. If the author is correct, it seems like a complete analysis of attack angle sensors to MCAS software was not done. One wonders if this was done for this latest improvement. To take it one step further, are there other pieces of software that have some kind of preventive control effect similar to MCAS which may take over control of the 737 MAX that we are not aware of?
8
As an old pilot I have followed this from day one. Each day brings more pieces to the puzzle table.The factors are almost beyond human comprehension. So my focus is how could this end.
Unfortunately, it may be a very long time because it is in the hands of the flying public. Will they board the Max8 or not?
Not me.
32
Horrendous to read, all those minds and no clarity or commu nication between departments and changes. And of course Boeing had to continue to be greedy and make millions in profit, so no retraining, just to keep pace with the Airbus. All those poor souls dying in terror and vain. That plane should never fly again.
27
@susan Blanchard, I agree- it should never fly again, if, for no other reason than shame.
7
@susan Blanchard
IF I have any choice at all, I will never fly on a Boeing aircraft again.
I would rather take the risk of driving the highway to my destination.
I cannot imagine the "arrogance" of those at Boeing who made these slipshod decision. Perhaps criminal liability should be considered and prosecuted.
4
The regulators were diligent in their work. But they were working off an old regulations book?
It is not like one can pop open the hood and notice a single sensor instead of two . It is not that simple anymore, is it?
We should be glad that these government regulators were not using a 1970 Boeing 737 design book to regulate.
Or, were they?!
4
The article appears to have distilled the 737 Max issues into three broad hypotheses:
1. All the problems with 737 Max aircrafts are due to inherent design flaws of the Maneuvering Characteristics Augmentation System (MCAS) software.
2. Corporate greed prompted Boeing executives to hide Max’s problems from FAA.
3. There was a concerted effort to hide the original MCAS and its refined version from pilots.
AS a senior engineer, I conclude that these three assertions will be proven wrong when the formal investigation concludes. No criminal intent or culpability will be established.
A complex piece of machinery like a Boeing 737 Max will not easily lend itself to superficial nontechnical media scrutiny. The problems will be fixed and the flying public will forget the notoriety that the recent crashes created.
Since airlines cannot easily switch fleets or cancel orders, notwithstanding the unfortunate recent accidents, the refined 737 Maxes will be flying again soon.
6
@Appu Nair, I am not sure that you correctly characterize what you refer to as ‘hypotheses’. Boeing had access to data that reported the frequency of bird strikes involving a sensor. It knew, and yet modified the system by reducing two sensors to one. Did it even test on its simulator the consequences of a bird strike on a single sensor system?
It may not be willful or criminal- but surely it is negligent.
1
@Appu Nair No, the flying public will not forget and this aircraft will forever be known as the model that crashed because of its design defects. Boing has lost billions of dollars on shareholder value and their once impeccable reputation has been forever tarnished as a result of their ineptness and greed. The internet does not forget.
2
@Appu Nair
"The problems will be fixed and the flying public will forget the notoriety that the recent crashes created".
I doubt that then relatives of the deceased will soon forget what happened.
1
Read the FAA Flight Standard Board’s training requirements (FSB). The document details the necessary requirements for the 737 and the variants. There is zero mention of the MCAS system for the 800 Max. The FAA is culpable.
4
@Dan, but, was the FAA duped by Boeing? The FAA was given one system, but were unaware of the modification to the system. How were they supposed to know?
1
Who will be held accountable for those lives lost? I'm not suggesting that Boeing should be dissolved as a company but there was CRIMINAL NEGLIGENCE involved in these 2 tragic AVOIDABLE crashes. WHO will face criminal charges for those heinous coverups that lead to those crashes?
24
I will be flabbergasted if anyone responsible for this is actually punished.
7
Boeing clearly cannot be trusted to build a safe plane.
But is there any reason to believe Airbus is any better? Maybe Boring had the bad luck to have its plane malfunction first, but who knows what is going on under the hood with Airbus?
4
Aha... self regulation has proven time and time again to be a boon to profit oriented enterprises. Pity the poor consumers who pay for the malfeasance of those more interested in their own profits than the well-beings of those who use their products.
15
I'm honestly surprised we haven't had more events like this. That's catastrophes due to too many assumptions as system's complexity's explode. A sword cuts both ways and too many seem to miss that. And everyone gets so excited about self driving cars.
4
@Mark, good point about self-driving cars. Truly, as a person who drives a car for varying times every day, I cannot see a reason that anyone would want to be in a car that self-drives. It is deeply stupid.
3
The Boeing Company, a corporate entity and a person as determined by the Supreme Court, the CEO and all executives holding responsibility for the development of this iteration are all guilty of, at a minimum, three and possibly four charges:
dereliction of duty to the flying public,
willful neglect,
reckless endangerment
manslaughter
and all should be punished accordingly.
28
@Ken Sulowe, what criminal law would apply? US? Indonesia?
Where did the crime occur? Washington (State), Washington DC, Jakarta?
Your excellent coverage of the MCAS issue reminds me of a crash that took place in Europe in 2008.
Here is a link to the accident report:
https://reports.aviation-safety.net/2008/20081127-0_A320_D-AXLA.pdf
It was an Airbus A320, and two of the plane's three angle-of-attack sensors were giving erroneous readings because of ice infiltration. The plane's flight software was designed to deal with confusing readings from its angle-of-attack sensors by scanning all three sensors and in the event of an inconsistency, to take the data from two sensors out of three (the idea being that it was unlikely that two sensors would malfunction at the same time). In this case, it took the erroneous data from the two malfunctioning sensors (and ignored good data from the one well-functioning one), which played havoc with the aircraft's flight computer and eventually led it to crash (for slightly complicated reasons). All this is to say that to design a system that relies on a single angle-of-attack sensor is madness, as your story emphasizes. It's not like the industry has never had to deal with these issues before.
7
Boeing, like an increasing number of modern companies, is failing the engineering sniff test. The pace of development is faster, the pay and benefits are worse, engineering staffing is thinner all around, questionable decisions that in the past would be caught in later engineering review are more likely to snow ball out of control and become non reversible by the staff that understands what is going on.
Once middle management and up has been informed of the state of development, making a change that impacts the schedules is unlikely. "Look, one sensor failing might cause a crash." "Might? You have hard numbers? No? Well, changing this design now WILL CAUSE A SCHEDULE CRASH. Make this a suggestion for the next iteration of the 737 frame". Usually, one either gets away with it, or a few close calls and changes are quietly made. Been there, done that.
5
@MH Boeing, like another iconic American company (GE) dominated industries because of their expertise in managing large and exceedingly complex projects. We have already seen how GE failed miserably with the financial aspects of their biggest projects in recent years as the executive team struggled with a legacy of higher and higher returns.
If this article is mostly correct about how the 737 Max project was handled, the issue of changes being made in one silo of the project without adequate communication to other project silos will be used as examples in project management classes for years to come.
For any complex project to succeed, clear and transparent communication between and among modules (or silos in the case of Boeing's dysfunctional 737 Max design team) is essential. This is not news. It's been an aspect of project management since the days of sailing ships.
1
Greed drives Boeing. Profits are more important than people are shown in Boeing's actions. Corporations, such as Boeing, are without both souls and morals. Only excellence and concern about the flying public will renew people's confidence in Boeing.
4
"Under the impression that the system was relatively benign and rarely used, the F.A.A. eventually approved Mr. Forkner’s request, the three officials said". So let's get this straight, the people responsible for keeping faulty and unsafe aircraft out of the sky, has no idea what the 737 max safety mechanisms are our how often they are used? And this is happening in America? This is not just embarrassing but its deadly and causing people their lives. What else is the F.A.A missing?
As for the 737 Max, they should just scrap that plane and start fresh, becuase neither me nor anyone I know is going to set foot on one of those ever again regardless of what they do. That model is done Boeing's incompetence made sure of that.
7
Whatever happened to concurrent engineering or Deming’s concerns for communication and coordination? Someone forgot the quality movement less learned as the Japanese overtook and surpassed US manufacturing in the ‘80s. Apparently each generation needs to learn the same lessons on its own.
6
@Jim
The phony exercises of the Quality movement, while theoretically sound, failed to deliver. The country that adopted and embraced Deming, Japan lost its dominance in industry. Period.
Malcolm Balridge Award recipients have gone out of business shortly after receiving that 'quality' award.
There is no magic silver business. Leadership, innovation and a dose of luck make the difference.
3
Two things seem obvious to anyone who has dug through this whole saga: 1) Boeing rushed the process of finishing the designs on this plane purely for monetary benefit, and they were clearly negligent if not criminally reckless in this process; and 2) the FAA was completely asleep at the desk, and is another of Trump's incompetently staffed agencies, and because of this, the FAA has lost its world leadership position as the ultimate arbiter of flight safety.
Boeing engaged in this reckless behavior for money, so money must be the price for its reckless disregard of safety. The penalties should be at least in the tens of billions, maybe $50 billion or more. CEO Dennis Muilenberg should also lose his job.
Trump has still never nominated an FAA administrator, and it's basically on the rest of the world to monitor flight safety until Trump is replaced by a competent president, who can in turn appoint an able and responsible FAA administrator.
22
You're right except on the timing. It was the Obama-era FAA at work here.
1
@Mondo Man
Yes true. But the philosophy behind this fiasco is the mantra of zealous deregulation promoted by Republicans since Saint Reagan, who put people in charge of regulatory agencies to destroy them. The Obama FAA had the business can regulate itself says the Koch Brothers bias built into its structure and personnel since well before Obama; and there was no impetus to change it until now. It’s the same save our plutocrat owners a buck philosophy that led to the financial collapse in 2008, and lead poisoned water in Flint Michigan; in short, the Republican Way: everything for the rich, the rest of you, go take a hike.
5
@Nelson Yu --> "...another of Trump's incompetently staffed agencies ..."
These problems were the result of actions taken in 2011 by Boeing out of fear of losing market share to Airbus A-320 when competitive bidding was announced for a new fleet of energy efficients by AA.
Blame James McNerney. Who was Pres. in 2011 ?
I admit this is simplistic, but part of the problem with this and, for example, the 2008 financial meltdown is that some people profit (some BIG TIME) and, when people die or lose their life's savings, no one is responsible. Someone goes bankrupt, some people multiple times, and yet they are viewed as successes and they go on to greater wealth. Some even become....
10
I have read many articles about the Max 8. This is the first mention I have seen of an FAA database with multiple reports of damage to angle-of-attack sensors by bird strikes. However, I can hardly believe that trained aerospace engineers would not be aware of this information.
In this context, reliance on a single sensor strikes me as completely irresponsible, especially since there were two physical sensors present on the aircraft.
Moreover, I simply cannot believe that a mechanical vane on the front of the aircraft is the only means of determining the angle of attack. A computer program capable of nose-diving an aircraft into the ground should be integrating the output of multiple independent sensors, and be easily overridden by the pilot when the sensors fail. This is elementary common sense.
It’s time for Boeing to drop its emphasis on cabin lighting and in-flight entertainment systems, and focus properly on the technical soundness of its product.
26
An enormously complex and high stakes version of the left hand not knowing what the right hand is doing. What a terrible price to pay.
5
The Chief Executive Officer of Boeing is the one ultimately responsible for the tragic deaths of 346 people. Human beings who trusted in Boeing died. Countries that bought the aircraft relying on Boeing's experience and technical superiority innocently sent passengers to their death.
In the competitive fever that fueled haste, rush and decision making based on getting the 737's sold and on their way, Boeing fueled tragedy.
No one held accountable. I hold the CEO and all senior engineers regardless of what they knew accountable. I hold those at the FAA who assumed safety procedures were in effect, but did no insist on further testing accountable.
All should be dismissed. At once. Otherwise the technical language scams which none of understand is the hide-behind language that preserves jobs and a huge salary and bonus for Boeing's CEO.
THEY ARE ACCOUNTABLE. Boeing's Board of Directors, the oversight committees of the United States Congress need to demand accountability via dismissal. No panels giving sanctimonious speeches aired on national TV. More more pointless questions and investigations ending in nothing at all.
Dismissal. Anything less is a corruption of standards by which we entrust our lives to companies like Boeing. Anything less is unacceptable.
14
@miriam summ
I sincerely hope he loses some vacation days, the same penalty accorded to cops who shoot innocent people of color.
4
Self regulation by corporations drives innovation, what can go wrong?
6
No, the "fatal flaws can be traced to..." GREED. The entire design approach, inherent instability of the redesign, rushed method, lack of quality control, cover-ups and lies, all can be ascribed to profits and turf. The executives should be held criminally liable for the deaths of the passengers and be put on trial.
9
I can't believe Boeing's technical pilots only fly simulators. Wnat if the simulator software developers didn't include a rare, but not improbable "what If" condition?
I'd be curious to find out what the simulator would have done if they had fed it that faulty AoA readings.
358
@raduray Boeing only recently announced that their 737Max8 simulator did not actually include the MCAS that the plane actually came with. There was only 1 such simulator in the world, and it was defective too.
If other safety regulators demand pilots to be trained on a simulator that actually simulated the real plane, that will add big $ costs and delay.
Boeing still says an hour or less on an ipad is all that's needed for training.
58
@raduray A reasonable question, with a logical answer; Having developed safety-critical software myself, I must agree that a simulator is not a full analog for the actual product. However, some scenarios are flown only with a simulator because the risk of injury is too great.
For the unfamiliar, an FMEA (Failure Mode Effect Analysis) is basically engineers and designers determining the cascade of detrimental effects that can occur from a single point of failure, and what can be done to prevent and counteract those effects.
The question in my mind is, how did this ever pass a FMEA ?
63
@raduray "I'd be curious to find out what the simulator would have done if they had fed it that faulty AoA readings."
They actually did recently test this situation (after the fact). The test pilots had 40 seconds to correct the situation or the plane entered an unrecoverable dive.
https://www.nytimes.com/2019/03/25/business/boeing-simulation-error.html
29
“The company also played down the scope of the system to regulators. Boeing never disclosed the revamp of MCAS to Federal Aviation Administration officials involved in determining pilot training needs, according to three agency officials. “
Why isn’t this a criminal case against Boeing. This problem is at the very top of management.
605
@steve
There is a criminal investigation
https://www.seattletimes.com/business/boeing-aerospace/kirkland-consultant-questioned-for-six-hours-in-criminal-probe-of-737-crashes/
27
@steve Because corporate America is not subject to any law. They pay for our politicians and the laws they create. Remember how many people went to jail after 2008?
that says it all.
17
@Carole This is different than the 2008 financial crisis because of representations made to federal regulators. If those representations knowingly were false, they we indeed are in criminal territory.
By contrast, the factors that led to 2008 either were disclosed or were not required to be disclosed. Plenty of individuals and companies were taking extraordinary risk, but there simply was no safeguard to guard against the correlated risk that ultimately tanked the economy.
4
On my way to work with the car on one of the highways here in NYC there is a large advertisement for rubber floor mats for cars and trucks. At the bottom of the advertisement is a statement that goes something like this "proud to be American-made".
Well, I guess that is all this country's industry can be proud of. Rubber floor mats for cars and trucks. Planes, not so much. Too complicated. This cannot be made in America any more and be reliable. The people here cannot even elect an intelligent person to run this country.
11
@reader
Only intelligent?
Please. He's a very stable genius!
Remember how he described himself?
3
The tragic result of this conflict between technical truths and marketing/executive priorities cannot be allowed to be relegated to a lapse in the design or certification process - a problem with the 'system'. The men/women who knew the 737 Max design was headed down a dangerous path must be held accountable - which means serve jail time. Only when this happens will the professionals in similar situations feel obligated to stand up and be heard. When the end result is that the shareholder pays damages, or the CEO retires or loses half a $M bonus - nobody is responsible, and nobody will ever feel responsible. True for 737 Max crashes, VW pollution, PG&E fires,...
550
@crosem But did anyone know the 737 Max design was headed down a dangerous path? If so, who?
8
@Bill --> Who ??
Read Seattle Times: Flawed Design, Failed Oversight published about 3mo ago. Critics were silenced.
8
...the 2008 economic crisis and resulting fallout.
nothing. no accountability for old white guys and gals in corner offices with big mahogany desks.
reminds me a lot of, "I could shoot a guy on 5th Ave..."
13
I'm a pilot and support Boeing. It's a great American company with an amazing track record. However, I'll watch how Boeing acknowledges it's failures here. It will only remain worthy of my respect if it acknowledges it's mistakes and doesn't try to litigate away its accountability. I hope its current management honors the company's history by doing what's right for the families of those who died because of its mistakes.
511
Not enough. They have committed criminal acts and must be prosecuted.
64
@Michael Keep us posted.
8
@Michael I doubt it. This is the age of Trump and accountability is a vanished attribute.
53
I have a question. Were there optional additional sensors that airlines could have purchased to improve safety of the Max? If so, how much did they cost and did any airlines buy them?
1
The very idea of removing a reference to a flight control system from the pilot manual is in itself extremely suspect. This confirms that Boeing knew that such a system would prompt airlines to want their pilots trained on it, a cost consideration Boeing did not want as a factor in airlines decision to purchase the Max. If this single act alone isn’t criminal, it sure should be.
1554
Is there a daring DA somewhere who will prosecute criminal neglect of oversight? The civil cases might bring financial pain to Boeing, but only a criminal case will teach executives the appropriate lessons.
118
@CitizenTM
Ain't going to happen. These are white collar crimes and the purported "criminals" are very white.
Anyway, the president of Boeing stated publicly two days after the latest crash that the 737 Max was safe and shouldn't be grounded. He even called his buddy Trump to resist grounding the plane.
85
@Paul -- not having union employees on Boeing's Board of Directors seems . . . nearly criminal to me.
Safety obviously requires stakeholder oversight, and there are no bigger stakeholders than Boeing's Employees.
Call it Democratic Socialism, if you must. But until employees -- stakeholders -- have a say, getting folks back on that plane's gonna be a pretty Hard sell.
65
Boeing's fatal problem with the MCAS design was the absence of a single safety specialist looking over the development of the MCAS system from a probabilistic risk assessment (PRA) perspective.
E.g., knowing the significant enough frequency of AoA sensors failing on the B737 should have given rise to avoiding tying the MCAS actuation to a single AoA sensor when two AoA sensors acting in concert were available control to control actuation.
2
I don't care what kind of "MacGyvering" they come up with or bug-prone software fix, I personally will never set foot of a Boeing 737 MAX and neither will any of my family members if I have anything to do with it.. This whole plane needs to be junked and a new plane designed to fit the larger newer engines that required the adaptation in the first place. I'm not sorry if the Boeing shareholders will lose some money. They tried to cut corners to maximize their profits, knowing of the potential problem before the first crash. Then knew OF the problems after the first crash. Stonewalled on the problem after the second crash. And then even tried to continue to fly the plane, telling the public it was safe. Just unconscionable. When the civil litigation starts and discovery reveals the criminal obstruction and knowledge of the problem, as the trove of email correspondence will show, people need to go to jail for manslaughter, if not premeditated murder.
22
I really can’t believe the “I didn’t know” line by the engineers and safety monitors about the reliance on a single sensor. Isn’t it their “job” to know that and ask the right questions ?!!!!
Seriously, if they don’t know the questions to ask how did they qualify to get their positions.
It’s a professional embarrassment, but we all know claiming that “I didn’t know” is not a defense.
To me it looks like there is at a minimum professional maleficence.
Leave the defense of “I didn’t know” to the prosecutor. It’s plain embarrassing and absurd to claim that.
Best with the AG
6
I keep reading that the choice of a single angle-of-attack sensor is the root cause of the design error. Isn't the root design error the decision to use the too large LEAP-1B CFM International engines in their bizarre location forward of the wing's leading edge? "...The Max wasn’t handling well when nearing stalls at low speeds...." Not "handling well" seems an understatement.
7
True reporting excellence. Thank you to these reporters.
I’ve tried to imagine myself involved in these decisions. I would feel such extreme shame and horror. I do not think I could continue working.
So it fascinates me that Boeing executives have these meetings and claim safety is their priority. A clear lie. How can they do it? Just lie like that with all these innocent people dead?
And how can the ceo face anyone? His family, his colleagues? The families of the dead? Why isn’t he overwhelmed by shame?
I really do not understand.
10
@Wyoming Observer
Profit at the expense of morality is misguided pride over rightful shame. There's your answer.
“Boeing has no higher priority than the safety of the flying public,” a company spokesman, Gordon Johndroe, said in a statement.
Should read: "Boeing has no higher priority than to make money for its shareholders and safety is an afterthought".
10
The sheer inability in developing of this plane, as shown in this article, makes it hard to believe in any recertification. Not in August, not this year, not ever.
1
What is this Flaw, this Single Point of Failure? MCAS, by definition of a Single Point of Failure, is not a Single Point of Failure.
I read through the tale, a lot surely can break the chain.
Another crash example, Airbus 447 crashed because one pilot was pushing the nose down, the copilot was pulling up. Even if the pilot vocally took command, the copilot’s move was countering the pilot’s command. As crazy as it seems no system alerted of the conflict, and the plane didn’t respond.
With the 737, the two crashes have a different chain of events:
- LionAir pilots couldn’t deactivate automation, and fought it.
- Ethiopian pilots deactivated automation, kept a near maximum power throttle, and, unable to recover, reactivated automation.
In both crashes MCAS was a link, and this is duly addressed. MCAS can be deactivated with two switches. The malfunction is part of a runaway stabilizer event, a Must Know to pilots.
Lionair pilots couldn’t resolve the memory items of a runaway stabilizer, considering the time they took fighting the AOA inputs, this could have saved them. Ethiopian is more critical, would have reducing speed allowed for manual stabilization of the plane? Investigation is still ongoing.
Redundant AOA sensors can brake the chain. As Jack rightfully points out, even if MCAS will virtually never fail, this is not of the input information AOA sensors, It being much more exposed. But this is not a Single Point of Failure, the Pilot is there and can address it.
2
Great reporting. Thanks.
2
Profit is Boeing's first priority. Honesty is further down the list.
7
What's good for Boeing is good for America. Where else do we have a single point of failure in this great big country?
5
Difficult to comprehend why the Boeing CEO doesn't 'step aside', with so much blood on his executive hands. Is it but a matter of time, when his kids/?grandkids lovingly query him at the Sunday dinner table, that he buckles?
3