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John J. Bastiat / May 9, 2019

Boeing in MAX Trouble

The company knew about flaws with the safety system long before two recent crashes.

In the wake of two crashes of its 737 MAX-8 commercial airliner — involving the deaths of almost 350 people and causally linked to design-related failures in one of its flight control safety systems — Boeing’s “sins” continue to mount. The latest bombshell: Boeing knew about flaws with the safety system long before the two crashes. A warning, up-front: Hindsight is always 20-20.

In its most recent statement, Boeing indicated its engineers had discovered the root cause of the problem in its Maneuvering Characteristics Augmentation System (MCAS) at least as early as 2017, well before the fatal crashes of both Lion and Ethiopian airlines last October and this past March, respectively. The system’s use of erroneous flight-parameter sensing information — coupled with MCAS design flaws that effectively overrode the pilots’ inputs — were identified as causal factors in both crashes.

Boeing’s engineers determined at some point in 2017 that to ensure fidelity of the MCAS a discrepancy-sensing sensor was needed to warn if disagreement occurred between two critical flight-parameter sensors on the MAX. Unfortunately, that checking sensor was installed only as an optional feature, and most carriers opted not to buy it, viewing it as an unneeded, additional expense. Boeing conducted an internal risk-management review of the issue, concluding the lack of the checking system did not impact overall airplane safety. In the aftermath of the Lion Air crash Boeing reevaluated the MCAS issue, again concluding the absence of the checking sensor was not critical. On the basis of Boeing’s findings and report, the FAA concluded the overall issue to be “low-risk” and mandated the inclusion of the checking sensor as a part of Boeing’s remedy to the Lion Air crash.

For its part the FAA wasted no time throwing Boeing once again under the bus, explaining that while the FAA indeed had determined the issue to be “low-risk,” “Boeing’s timely or earlier communication with the operators would have helped to reduce or eliminate possible confusion.” Sure. What also might have helped would have been for the FAA to maintain oversight of its own air transport certification program, rather than delegating critical elements — like, say, certification of MCAS on the MAX — to the interested-party manufacturer being evaluated, but we digress.

Beyond blame-levying, however, unfortunately the problem of so-called “tombstone engineering” — engineering a fix only after the high-visibility highlighting associated with people dying as a result of the defect — cannot be avoided. Commercial transport aircraft are extremely complex, and although every effort is made to eliminate error and minimize risk, some error and risk will always exist in any complex system. While whole sciences — safety, risk management, and reliability engineering, to name only a few — have derived from societies’ need to control unknowns and keep people safe, the only certain way to prevent aircraft mishaps is not to operate transport aircraft. Clearly, this won’t work.

The rational alternative is to minimize risk as much as economically practical, and then to accept and manage the remaining risk. This concept is “block-&-tackle” fare for Boeing, a world leader in the practical application of such ideas and sciences. We thus remain confident Boeing will emerge from this catastrophe with valuable lessons-learned and that it will remain the world’s leader in aircraft manufacturing, notwithstanding its current self-inflicted woes. In the meantime, it must do everything it can to restore the public’s faith in its product lines — especially in its 737 MAX fleet.

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