Boeing's seven thirty-seven MAX eight disasters John Sterman and James Quinn
Boeing's seven thirty-seven MAX eight disasters John Sterman and James Quinn
On October twenty-ninth, twenty eighteen, a nearly new Boeing seven thirty-seven MAX eight jet plunged into the Java Sea at four hundred miles per hour, killing all one hundred eighty-nine people onboard. The sudden and rapid descent of Indonesia's Lion Air Flight six ten commenced at five thousand feet, just eleven minutes after taking off from Jakarta's Soekarno-Hatta International Airport. Captain Bhavye Suneja and First Officer Harvino, who went by a single name as was common in Indonesia, contacted air traffic control requesting immediate return to Jakarta before losing control of the aircraft. The plane crashed into the sea, "hitting the water with such force that some metal fixtures on the aircraft disintegrated."
The accident initially seemed to be a senseless and anomalous tragedy. Air safety, enforced in large part by the certification process of the Federal Aviation Administration, was enjoying an exemplary record: Globally, the five-year worldwide average stood at one fatal airliner crash for every two point five million to three million flights. In the United States, airline safety had reached record levels, with only one passenger fatality in more than ten years.
Boeing's initial response to the crash focused on Lion Air's airline maintenance procedures and suggested the pilots were at fault. Nonetheless, about eight days later, on November sixth, twenty eighteen, Boeing issued a bulletin to all seven thirty-seven MAX eight and seven thirty-seven MAX nine operators indicating that "erroneous angle-of-attack data" could result in "uncommanded nose-down movement of the aircraft and that this action can repeat until the related system is deactivated." The Boeing bulletin provided additional instructions to pilots who might encounter such a dangerous situation. On November seventh, twenty eighteen, the Federal Aviation Administration followed by issuing an Emergency Airworthiness Directive requiring Boeing to revise the operating procedures in its flight manual for the seven thirty-seven MAX aircraft. Of specific concern was the new Maneuvering Characteristics Augmentation System, software designed to prevent the aircraft from stalling by automatically pushing the nose of the plane down when a high angle of attack, or nose-up condition, was detected.
Officially, Boeing, including CEO Dennis Muilenburg, repeatedly declared "... the seven thirty-seven MAX is safe." But, as investigative reporter Peter Robison documented, "Behind the scenes, some of the largest and most respected airlines in the world were screaming that Boeing had hidden the existence of potentially deadly software inside their planes." Internal communications that Boeing handed over to the U.S. Department of Justice and Congressional investigators would later show that the company's own engineers and test pilots had known about the Maneuvering Characteristics Augmentation System problem well before the crashes.
After the Lion Air crash, Boeing rushed to redesign Maneuvering Characteristics Augmentation System. Boeing Vice President Mike Sinnett initially promised it would take "not a year, but ... maybe six weeks-ish" to "tame the system." By March twenty nineteen, the revisions were still not completed.
Then, on March tenth, twenty nineteen, shortly after Ethiopian Airlines Flight three zero two took off from Addis Ababa Bole International Airport bound for Nairobi, Kenya, Captain Yared Getachew and First Officer Ahmed Nur Mohammod Nur struggled to ascend at a stable speed. Getachew sent out a distress call, but contact with air traffic control was lost six minutes into the flight. The same model Boeing MAX eight that had plummeted into the Java Sea crashed near Bishoftu, a town southeast of Addis Ababa. All one hundred fifty-seven onboard, hailing from thirty-five different countries, were killed.
A maelstrom of questions immediately followed, from maintenance crews in Indonesia and Ethiopia, airlines and pilots flying the MAX eight around the world, Boeing leadership at its Chicago-based headquarters, the Federal Aviation Administration and U.S. Congress, and the families of the victims. High-stakes public disputes arose over the root causes of the crashes. U.S. Congressman Sam Graves declared, "Pilots trained in the United States would have been able to handle the emergencies on both jets." Others, however, blamed Maneuving Characteristics Augmentation System and a flawed design process at Boeing. Still others faulted the Federal Aviation Administration. A subsequent report by the U.S. Department of Transportation's Inspector General, entitled "Weaknesses in Federal Aviation Administration's Certification and Delegation Processes Hindered Its Oversight of the seven thirty-seven MAX eight," identified "limitations in Federal Aviation Administration's guidance and processes that impacted certification .... " These included "communication gaps," "management and oversight weaknesses," and "process and structure that do not ensure Federal Aviation Administration personnel are adequately independent."
On March thirteenth, twenty nineteen, under pressure from the Indonesian and Ethiopian governments, airlines, pilots, the public, and the families of the three hundred forty-six dead, the President of the United States Donald Trump ordered the grounding of all seven thirty-seven MAX aircraft. Several independent review boards were created to identify the root causes of the two crashes and the changes regulators would require Boeing to implement before the aircraft could return to service.
Boeing's best-selling plane remained grounded for twenty-one months, while customers continued to cancel orders. Through the end of October twenty twenty, Boeing removed five hundred ninety-five MAX orders from the backlog and canceled a further four hundred forty-eight, a total loss of one thousand forty-three orders, leaving a backlog of three thousand three hundred twenty. Boeing's rival Airbus had a backlog of five thousand nine hundred fifty-six jets for its A three twenty neo family, a direct competitor to the seven thirty-seven MAX.
On November eighteenth, twenty twenty, just over two years after the Lion Air crash, Federal Aviation Administration Administrator Steve Dickson signed an order permitting the seven thirty-seven MAX to return to commercial service. At the time of Dickson's order, the COVID-nineteen pandemic had slashed global air travel. Airlines announced plans to return their seven thirty-seven MAX aircraft to service slowly.
Yet major questions remained as passengers once again began flying on the MAX eight, which Boeing rebranded the seven thirty-seven eight. What role, if any, did company engineers play in causing the two catastrophes? What about their managers? Their test pilots? What role did Boeing's CEO, board, and other senior leaders play in shaping the processes, procedures, and corporate culture that may have set the stage for the disasters? Why didn't the Federal Aviation Administration detect the flaws in the design before allowing the seven thirty-seven MAX eight to enter service? How could future disasters be prevented?
Air Safety
Air Safety
Over many decades, commercial aviation had become much safer. Technical innovation in engines, airframes, cockpit instrumentation, communications, software, and control systems-together with better procedures and stronger regulations governing aircraft testing, certification, pilot training, operations, and air traffic control-all contributed to improving safety.
Measured by accidents per passenger miles flown, the improvements were impressive. In twenty eighteen, the National Safety Council reported only one death per one hundred million passenger miles on scheduled airlines in the United States. Exhibit one shows United States commercial aviation accidents, nineteen seventy-five to twenty eighteen.
However, the number of flights, flight hours, and passenger miles traveled per year all exploded as people around the world became more affluent and average fares fell. From twenty ten to twenty nineteen (the year before COVID-nineteen drastically cut airline travel), passengers carried by scheduled commercial air traffic grew from two point seven billion to four point five billion worldwide, and total flight miles grew from less than three point one trillion to nearly five point four trillion passenger miles. The industry formed a complex web with more than one thousand four hundred scheduled airlines, twenty-six thousand aircraft, three thousand nine hundred airports, one hundred seventy-three air navigation centers, three hundred sixty thousand pilots, and eighty-six thousand air traffic controllers.
The growth in air travel meant that the accident rate did not fall as much as data on accident per flight or per passenger mile suggested. Between nineteen fifty-nine and two thousand eight, thirty-three point eight commercial jet accidents per year occurred worldwide, thirty-five percent of which involved fatalities. Between two thousand nine and two thousand eighteen, forty-one point four accidents per year occurred, thirteen percent of which were fatal.
The root causes of accidents remained a hotly contested topic. Human error was often the go-to explanation. In a two thousand six study, the FAA noted, "Although percentages vary, most would agree that somewhere between sixty to eighty percent of aviation accidents are due, at least in part, to human error."
Safety experts, however, argued that most human errors were the result of poorly designed equipment and systems. In addition to focusing on "personal safety"-roughly speaking, admonishing people to be careful-designers focused on increasing "process safety"-designing an intrinsically safe system that minimized opportunities for and consequences of human error. As safety expert and psychologist James Reason noted, "Though we cannot change the human condition, we can change the conditions under which humans work."
Incorporated in nineteen sixteen by timber baron William E. Boeing, the company's first contracts were with the U.S. Navy, for which Boeing produced seaplanes, patrol flying boats, and torpedo bombers. During World War Two, Boeing produced nearly one hundred thousand aircraft, including the famous B-seventeen Flying Fortress. Between nineteen forty-two and nineteen forty-four, the company ramped up production from sixty to three hundred sixty-two B-seventeens per month. After the war, Boeing went on to develop the B-fifty-two Stratofortress strategic bomber and other critical military aircraft. Boeing also developed the nation's first commercial jet airliner, the Boeing seven zero seven, delivering the first one to Pan Am to serve a transatlantic route.
Boeing became the preeminent player in the commercial airline industry. Author John Newhouse wrote:
Back in the nineteen seventies and early nineteen eighties, four companies divided the turbulent business of making and selling passenger airplanes. One of them, the Boeing Company, was dominant. The other two big American players-the Lockheed Aircraft Corporation and the McDonnell Douglas Corporation- labored in the wake of their own mistakes. Lockheed's were terminal, and McDonnell Douglas, known in the trade as McDac, hadn't come to terms with reality. The reality was that a small European company called Airbus Industrie, generally known only as Airbus, had abruptly become not just a player but a mortal threat. Simply put, Airbus was eating McDac's lunch.
In the nineteen eighties, ... Boeing was universally judged one of America's best and most admired companies, partly because its sales abroad of large commercial airplanes were the country's biggest export, and partly because it had learned to build these airplanes better, faster, and cheaper than anyone else had done. 'World-class' was Boeing's lofty but accurate characterization of itself.
By the end of nineteen ninety, Boeing held sixty-two percent of the commercial airline market, with sales of twenty point three billion dollars and earnings of nine hundred seventy-three million dollars. McDonnell Douglas (twenty-three percent) and Airbus (fifteen percent) trailed far behind.