Boeing safety system not at fault, says chief executive

https://www.bbc.co.uk/news/business-47980959

by sjcsjc • 7 years ago

50 63 7 years ago

bbc.co.uk

This headline is highly misleading. The article says "Dennis Muilenburg maintained the system was only one factor in a chain of events that led to the disasters."

I watched the actual event and this is generally accurate. He maintained that all accidents are a result of a series of events, all of which would have to occur for there to be a crash.

He did not say that MCAS was not at fault - the opposite, in fact, since he said they were testing a new version of MCAS to prevent future crashes.

noja• 7 years ago

Would the chain of events have been stopped by a functioning MCAS?

linuxftw3• 7 years ago

If it wasn't for MCAS being present, the chain of events would have never started! It's only there because they cut corners in the first place.

jfk132• 7 years ago

He said the MCAS system met its "design and certification criteria". Yet a couple of paragraphs later, we read that "a report suggested that the system malfunctioned, and forced the plane's nose down more than 20 times before it plummeted into the sea."

Is that what it was designed and certified to do? Ouch.

peeters• 7 years ago

Basically the equivalent of a programmer saying "garbage in, garbage out". He's saying MCAS chews on the AoA sensor, and the AoA sensor was malfunctioning (therefore shifting the blame to the user, who is responsible for maintenance). But failing to mention that Boeing had a role to play in those links of the chain too, first in using only one of the AoA sensors and not having the disagree alert work, and two in that there's a rumor that it's a Boeing problem causing the AoA sensors to become damaged in the first place.

hughes• 7 years ago

You really think they're saying it was designed and certified to plummet airplanes into the sea?

If your design and certification criteria are insufficient, you can meet your design and certification criteria and still experience a failure.

jschwartzi• 7 years ago

If you read between the lines, he's basically saying that they did not have complete design and certification criteria for this feature of their aircraft and that that's ultimately at fault. In other words the MCAS met the design criteria established by the systems engineers, and the AoA sensor met the design criteria established by the systems engineers. And it passed all of the system-level testing established for the plane. It's just that the design criteria didn't include statements describing the AoA sensor data as being critical for the MCAS to function effectively.

And as a result nobody analyzed the software design to determine whether a fault in the AoA sensor could cause the MCAS to perform in a state inconsistent with aerodynamics. And nobody who was working on the AoA readout was aware that the AoA sensor fault indicator would also indicate a problem with MCAS. What he's strongly implying is that this was a mistake on Boeing's part.

However what he can't do is come out and say "I'm sorry guys. We fucked up. Our systems people failed to fully and properly account for this new system in the design criteria and as a result we failed to dedicate enough engineering resources to ensuring that faulty sensor inputs to this system couldn't result in a crash."

btown• 7 years ago

"The software wouldn't have crashed if the user didn't click these buttons in a weird order. The bug was only one factor in a chain of events that led to the segfault."

linuxftw3• 7 years ago

Unfortunately, the Ethiopian crash did pretty much everything they were told to do (disable electric stabilizer trim) for the alleged 'memory checklist' procedure and it still wasn't enough.

"Crappy sensor failure, crappy software failure, crappy aerodynamic failure" would be the chain of events, because the pilots did everything right.

panarky2• 7 years ago

Highly disingenuous to infer that if multiple factors that coincide to create a failure, that this component is not "the cause".

Of course there are always multiple factors, but all the evidence points to the MCAS system as a major contributor to these catastrophes.

I don't know who's advising Boeing on their crisis management and media strategy, but they're doing it wrong.

Every time Boeing attempts to sidestep or minimize this it makes me trust them less.

Take a lesson from the Tylenol poisonings [0] and the Rogers Commission investigation of the Challenger disaster [1].

Step 1 in enlightened crisis management: accept responsibility.

[0] https://en.wikipedia.org/wiki/Chicago_Tylenol_murders

[1] https://en.wikipedia.org/wiki/Rogers_Commission_Report

SkyMarshal• 7 years ago

Yeah, based on all the info we have so far it appears MCAS was the root cause. Mounting bigger engines higher up and forward changed the plane's center of gravity and made it more likely to go too high AoA under acceleration and stall. MCAS was installed to fix that, but was sloppily implemented, misinterpreted AoA sensor data under some conditions, and was not pilot-overide-able.

Major fuckup by Boeing that cost many lives. They've already lost the narrative on this. The CEO's equivocation isn't helping.

tempguy9999• 7 years ago

Step 1 in enlightened crisis management: accept responsibility.

Agreed completely, but let me be devil's advocate here.

If he accepts responsibility then boeing is presumably fully and immediately legally liable. I guess that, particularly under US culture of suing anything that moves, everyone will try to cash in to the maximal extent possible. Including airlines possibly cancelling their existing orders - might they cancel 4,700 plane orders? What would that do to the company? By how much would boeing's liability increase on a straightforward "mea culpa"?

I can't agree with his butt-covering but I can see why it's happening. There seems to be little upside to accepting the blame. Could it destroy boeing? How many jobs lost?

"Boeing employs more than 153,000 people across the United States and in more than 65 countries" <https://www.boeing.com/company/general-info/> and a whole long-tail of US jobs indirectly.

How would it affect the US economy and standing in the world (I mean, more than it's already doing now)? I'm sure he's being leant on from above.

etc.

(please note I'm presenting a possible explanation, not endorsing it. There seems no moral way out of this. The real cause is the historical stupidity that allowed this to occur, for which he should definitely swing, and a few more suits. I am NOT endorsing these things I wrote but they seem things he will have considered. NB am a brit so I'm looking at this from the outside).

shadofx• 7 years ago

Step 0 in enlightened crisis management: don't be perceived as corrupt and greedy

Which they've mostly already failed, so that strategy is a wash

Gibbon1• 7 years ago

I don't know who's advising Boeing on their crisis management and media strategy, but they're doing it wrong.

You have to consider the four possibilities. Whether the media strategy is in the interest of

1. The flying public.

2. The Boeing as a company.

3. Boeing's stockholders.

4. The perceived interest of Dennis Muilenburg.

I'm assuming #4

bgirard2• 7 years ago

He maintained that all accidents are a result of a series of events, all of which would have to occur for there to be a crash.

That statement is a truism to deflect blame. He also blamed the pilots for not following the checklist.

Someone12343• 7 years ago

They followed Boeing's checklist in one of the two, and still crashed. Boeing's checklist doesn't account for high aerodynamic loads on the horizontal stabilizer making manual trim adjustment difficult to impractical.

Ethiopian is an interesting crash because they followed Boeing's procedure, were still in imminent danger, and then had to diverge from procedure (i.e. re-enable electronic trim to electronic adjust) but that only worsened the problem since MCAS's five second delay had elapsed.

I'd hope we're well passed blaming pilots for this one. Even Lion Air's maintenance team might deserve a little slack, as the MCAS system kept on switching between faulty AoA sensor and working one every time the aircraft was restarted, meaning the maintenance team might not have been able to reproduce the issue.

bookofjoe• 7 years ago

According to the classic book "Normal Accidents" by Charles Perrow, "tight coupling" of events in a chain is invariably the critical factor.

CaptainZapp2• 7 years ago

Well,

From [1] : Boeing CEO says 737 Max was designed properly and pilots did not 'completely' follow procedure

So he still can't resist smearing the pilots, despite the facts coming to light until now.

In my book Boeing changed into the epitome of an evil company, putting profits vastly before safety of their (end) customers. I would be very, very reluctant to set foot into this murder machine. Despite the additional software kludges they try to apply.

Kludges onto a 50 year old designe rendered aerodynamically unstable by bigger and diffferent positioned engines.

[1] https://edition.cnn.com/2019/04/29/investing/boeing-annual-m... (warning! auto-play video)

jonplackett3• 7 years ago

Since the main battle to getting this plane flying again is going to be public trust, I think they’re going about this all wrong.

First admit full responsibility. Then at least you have a shot at people trusting you to fix it.

ralph84• 7 years ago

Perhaps, but it's understandable why Boeing is parsing their words carefully here. For some critics full responsibility would mean nothing short of Boeing admitting the 737 design had reached end of life and they should have never tried to shoehorn larger engines onto the 737 airframe. That would mean ceding the trillion dollar narrowbody market to Airbus for the foreseeable future.

jonplackett3• 7 years ago

I just think they need to accept responsibility for all those dead people.

Personally I don't see anything wrong with the idea of the redesign. It's the execution that was the problem.

If he came out and said, look we screwed up. There should have been a backup sensor/proper training/proper manuals/software that took a bloody hint and maybe there should be more gov oversight in general because this kind of cock up should not be possible. At least then you'd believe they're actually tackling the problem.

Reading all that back, it is actually quite a lot to ask for isn't it.

kevin_thibedeau2• 7 years ago

At this point the planes either need to be retrofitted with their original engines or scrapped. They will remain flying deathtraps no matter how much software is piled on to patch the issue.

travbrack2• 7 years ago

Why? What I've heard is that if the pilots know how to disable the pitch correction, the plane won't fight them in the event of a sensor failure and they can land safely.

theclaw9• 7 years ago

Video of Muilenburg press conference: https://youtu.be/xOQmQpKHVWA

He says MCAS is a “system that’s designed to provide handling qualities to the pilot that meet pilot preferences.” That’s somewhat economical with the truth. It’s designed more to meet the airline’s preference not to have to retrain their pilots, and Boeing’s preference to recover lost market share from Airbus.

jumelles2• 7 years ago

Boeing just keeps digging in and it's both a bad look and a poor strategy. This is not how you should react when people are scared to fly on planes you manufactured.

goldcd• 7 years ago

The scary thing I take away from this, is that I'm now interested to know what plane I'm going to get on.

For my entire life I'd thought (rightly) that "aircraft are the safest mode of travel" - this issue has for the first time ever made me realize that aircraft safety is not an absolute. People making planes put up with all the same crap I do at work.

jumelles2• 7 years ago

It's still the safest mode of travel.

travbrack2• 7 years ago

I'd be curious to know how many planes could crash every year and still produce a lower death toll than auto crashes.

ajnin• 7 years ago

It said that once the 737 Max 8 returns to the skies, it will "have an activated and operable disagree alert and an optional angle of attack indicator".

Really, after all that they're still going to hide part of that arguably critical system behind a (presumably paid-for) option ?

theclaw9• 7 years ago

The disagree alert/indicator was previously an optional extra[0]. Boeing are saying it will now be fitted as standard on all 737-MAX, including those already out there.

[0] https://www.reuters.com/article/us-indonesia-crash-boeing-ao...

azr79• 7 years ago

Well that's too late, isn't it? Personally I'm not getting into any of those flying death traps ever

pcurve• 7 years ago

He added: "As in most accidents, there are a chain of events that occur. It is not correct to attribute that to any single item."

He is selling this point hard. The problem is the chain is short and every chain has Boeing's fingerprint on it.

linuxftw3• 7 years ago

Mr Muilenburg said that both accidents occurred because of faulty data from a sensor which triggered the plane's Manoeuvring Characteristics Augmentation System (MCAS).

As if Boeing wasn't responsible for the faulty data and the poor programming that caused the plane to nose into the ground?

I suppose we should just go ahead and blame the earth for being in the flight path as the leading factor in the crash.

ncmncm• 7 years ago

The only thing that could get Boeing out of the hole this guy keeps digging deeper and deeper would be for him and his chief engineer to resign.

The longer he takes about it, the worse it will get.

Boeing safety system not at fault, says chief executive

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