The Cost of Safety – an Analysis of Systemic Issues Plaguing the Aviation Industry

“WHOOP WHOOP, SINK RATE. PULL UP.” Those are the last words the pilots of Lion Air Flight 610 and Ethiopian Airlines Flight 302 heard as the terrain below filled their windshields—the stone-cold computerized voice of their 737 MAX’s ground proximity warning system alerting them of their impending demise. These accidents did not have to happen. Boeing’s missteps in the 737 MAX catastrophe are indicative of broad industry-wide problems, and treating them as anything less would be a grave mistake.

First, some background on the 737 MAX. First conceptualized in 2011 to rival the competing Airbus A320 NEO, Boeing sought to improve the efficiency of their best-selling airframe, the 737 NG. By keeping commonality with this older, well-established design, Boeing saved a fortune in development costs while making the MAX an attractive option for airlines looking to replace their aging workhorses while maintaining fleet commonality. With this goal in mind, Boeing made the fateful decision to implement the Maneuvering Characteristics Augmentation System (MCAS), allowing the 737 MAX’s handling characteristics to qualify as “similar enough” to its older NG brother as to not necessitate costly pilot re-training. It was designed to operate out of sight, and out of mind, only coming to life if it sensed a dangerously high pitch attitude, a condition the MAX is more susceptible to because of its larger forward-mounted engines.

Problems began just over a year after launch, first with the crash of Lion Air 610 in late 2018, followed by Ethiopian 302 less than half a year later. Such a string of accidents for a brand-new airplane is virtually unheard of, and the 737 MAX was promptly grounded worldwide. The two crashes shared virtually identical accident sequences—a failed angle of attack (AOA) sensor, followed by MCAS activation, where the computerized system, interpreting junk data from the faulty sensor, pushed the plane into a nosedive, correcting for a perceived (but in reality, non-existent) nose-high pitch angle. (National Transportation Safety Board [NTSB], 2019).

Before analyzing what Boeing did wrong, it would be prudent to dispel common misconceptions by addressing what they did not do wrong. It is important to understand that the 737 MAX is not a fundamentally unstable airplane. The sole purpose of MCAS was to take advantage of loopholes that removed the need for additional pilot training by automatically correcting for the differences in handling characteristics between the two generations of 737. MCAS was in no way necessary for the 737 MAX to fly, and without it, the 737 MAX would be a perfectly airworthy machine. As such, there is nothing inherently wrong with Boeing’s intent to re-engine an older plane design—the previous generation 737 NG continues to be one of the safest and best-selling airframes in the world, so Boeing’s desire to capitalize on this was perfectly reasonable. Rather, this is the story of a miserably failed and grossly negligent implementation of an otherwise sound plan.

The negligence and complacency exhibited by Boeing are evident in hindsight. By skimping on testing and not fixing known problems, Boeing got their flawed plane out to market quicker, increasing their competitiveness in the industry. By not providing sufficient documentation or training materials on the MCAS system (most pilots did not even know it existed), Boeing saved both themselves and potential operators money and time. This was justified under the mistaken assumption that MCAS needed no pilot training because it would only ever live in the background as a last-resort safety feature. As any pilot would tell you, this assumption was tragically naïve. The above issues were compounded by a violation of a golden rule in aviation—redundancy. In having MCAS rely on just one AOA sensor, a single-point failure could doom the whole plane. While the latter issue may be attributed to a complacent oversight, the former two shortcomings were clearly driven by profit. The shareholders spoke, and Boeing listened.

It is also worth mentioning that Boeing charged airlines extra for “optional” add-ons, despite many of these being safety-critical features like an alarm warning of AOA sensor malfunctions (Gelles & Tabuchi, 2019). While it is unclear that these would have prevented either of the 737 MAX accidents, this practice, akin to car companies charging extra for upgraded seatbelts, highlights the disturbing attitude of profit over safety. These decisions are in clear violation of perhaps the most vital part of the American Institute of Aeronautics and Astronautics (AIAA) Code of Ethics, which is to “hold paramount the safety, health, and welfare of the public in the performance of their duties” (2013). Boeing failed to uphold this standard to save a buck, and the real price was paid in human blood.

Of course, while it is easy to pin the blame entirely on Boeing, that does not get to the root of the issue. To be sure, Boeing deserves every bit of their $2.5 billion fine, full stop. But Boeing is far from alone, and the fact that they were able to get away with their negligence is indicative of industry-wide structural issues. For starters, there is a severe lack of oversight, which, in the United States, is primarily the job of the Federal Aviation Administration (FAA). Being severely understaffed and underfunded, the FAA has resorted to allowing companies like Boeing to “self-certify” large chunks of their processes, a major loophole that allowed the problems with the 737 MAX to slip through the cracks (Davis & Lopes, 2019). Regardless of industry reputation and experience, self-certification inevitably breeds complacency, and Boeing is no exception. Self-oversight simply does not work—it never has and never will. This is not the first time such an arrangement has killed—when a cargo door blew off a McDonnell Douglas DC-10 in 1972, the FAA reached a “gentlemen’s agreement” with McDonnell Douglas that the problem would be fixed, in lieu of seeing to it that fixes actually took place (Barro et al., 2011). Unsurprisingly, nothing would be done until, eventually, 346 people paid with their lives, a classic case of tombstone regulation. Nevertheless, the potential for profit seems to induce amnesia in the industry when it comes to lessons learned. Self-certification is as blatant as it gets in terms of conflict of interest, violating another key part of the AIAA Code of Ethics, not to mention Boeing’s own code of conduct. A regulatory agency should never have to resort to such a hands-off approach, and the problems at the FAA represent a systemic emergency and a danger to the flying public.

Beyond the FAA, other issues also plague the aviation industry. Scapegoats are often used to direct attention away from the deeper issues that underlie accidents, and the 737 MAX case has proved to be no exception, with Boeing test pilot Mark Forkner charged with fraud (Leggett, 2021). While Forkner may not be blameless, the allegations against him only deflect attention away from the real questions: what kind of safety culture at Boeing drove him to lie to regulators, and why is it that regulatory agencies rely on the word of a Boeing employee instead of doing their own checks, and, well, regulating? Hostility against whistleblowers is also a notable concern—while whistleblower protection is not explicitly part of the AIAA Code of Ethics, it is part of other engineering ethical guidelines, including those of the Institute of Electrical and Electronics Engineers (IEEE). Whistleblowers have not fared well in the past—in 1998, John Liotine sounded the alarm on Alaska Airlines’ flawed maintenance, whereupon he was promptly put on leave and slandered on the official company website (Miletich, 2001). Less than two years later, 88 people would be dead after their Alaska Airlines MD-83 spiraled into the ocean due to—you guessed it—inadequate maintenance. Despite theoretical government protections, the existing precedent almost certainly discourages people from speaking up. As former Inspector General Mary Schiavo put it, “you need to be prepared to find another line of work because you will not work in the industry, and you will not work in the government. In most cases, it’s almost impossible to be a whistleblower and survive in your career” (Weir & Lanning, 2003). Boeing has committed to changing this culture on paper, and in 2014, when Curtis Ewbank lobbied for additional safety systems in the 737 MAX, to Boeing’s credit, Ewbank was not fired. However, his ideas were rejected due to cost and scheduling constraints, so the outcome was practically the same—safety took a backseat to cost (Gates, 2020).

Ultimately, no amount of colorful web pages or glowing statistics will change the grim reality of the industry’s rampant ethical failings. In a sector where money does the talking and regulators look the other way, companies know they can get away with nearly anything, as the unfortunate reality is that people will forget. And companies know that people will forget. The flying public is not talking about the DC-10 accidents from 50 years ago, or the 737 accidents from 20 years ago, and 20 years from now, no one will be talking about the 737 MAX. Hoping that the 737 MAX fiasco will spontaneously shock the industry into change would be an easy assumption to make. But such an assumption would be one final, tragic mistake, in a chain of already tragic events.

References

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[7] Gates, D. (2020, June 18). Boeing whistleblower alleges systemic problems with 737 MAX. The Seatle Times. Retrieved from https://www.seattletimes.com/business/boeing-aerospace/boeing-whistleblower-alleges-systemic-problems-with-737-max/

[8] Gelles, D., & Tabuchi, H. (2019, March 21). Doomed Boeing Jets Lacked 2 Safety Features That Company Sold Only as Extras. The New York Times. https://www.nytimes.com/2019/03/21/business/boeing-safety-features-charge.html

[9] Institute of Electrical and Electronics Engineers. (2020, June). IEEE Code of Ethics. Institute of Electrical and Electronics Engineers. Retrieved from https://www.ieee.org/about/corporate/governance/p7-8.html

[10] Leggett, T. (2021, October 15). Former Boeing 737 Max pilot charged with fraud. BBC. Retrieved from https://www.bbc.com/news/business-58926196

[11] Miletich, S. (2001, December 20). No criminal charges against Alaska; airline settles with whistle-blower. The Seatle Times. Retrieved from https://archive.seattletimes.com/archive/?date=20011220&slug=alaska20

[12] National Transportation Safety Board. (2019, September 19). Safety Recommendation Report: Assumptions Used in the Safety Assessment Process and the Effects of Multiple Alerts and Indications on Pilot Performance. National Transportation Safety Board. Retrieved from https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf

[13] Weir, A. (Writer), & Lanning, G. (Director). (2003, October 15). Cutting Corners (Season 1, Episode 5) [TV series episode]. In Air Crash Investigation. Galaxie Productions & NF Inc.