After deadly 737 Max crashes, damning whistleblower report reveals sidelined engineers, scarcity of expertise, more
- Reference: 1639532877
- News link: https://www.theregister.co.uk/2021/12/15/boeing_737_max_senate_report/
- Source link:
The report
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was produced at the behest of the Senate Committee on Commerce, Science, and Transportation in response to two Boeing 737 MAX crashes in 2018 and 2019 that killed 346 people. It is based on testimony from seven industry whistleblowers from Boeing, GE, and the Federal Aviation Administration (FAA).Boeing designed the 737 Max to compete against the Airbus A320neo. In order to achieve comparable fuel efficiency, Boeing basically put new engines on the existing 737 air frame, which allowed the passenger jet to avoid going through a new regulatory approval process.
Boeing 737 Max chief technical pilot charged with deceiving US aviation regulators over MCAS [2]READ MORE
The resulting 737 Max, however, had different handling characteristics from the 737, and Boeing attempted to compensate by adding a software layer called MCAS, the Maneuvering Characteristics Augmentation System.
MCAS adjusts the aircraft's trim, setting plane control surfaces to maintain a set attitude. It was designed to do so based on input from a single angle-of-attack sensor, compared to three sensors in the comparable Airbus model. And it proved to be disastrous.
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In 2018, Lion Air Flight 610, a 737 Max, crashed near Jakarta, Indonesia, due to false sensor readings that MCAS used to put the plane in full nose-down trim, from which the crew did not have time to recover.
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In 2019, the pilots of Ethiopian Airlines Flight 302, also a 737 Max, attempted to counteract the effects of MCAS but [6]could not physically move the mechanical trim wheel due to the aerodynamic force from plunging toward the ground.
Boeing in January [7]agreed to pay $2.5bn to settle criminal charges arising from the two fatal 737 Max crashes. The manufacturer did not admit guilt, however, which would have prevented it from receiving future government contracts. Instead, it entered into a deferred prosecution agreement.
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No company executive faces imprisonment for the misconduct that the biz has acknowledged. Boeing fired CEO Dennis Muilenburg in late 2019 over the 737 Max accidents and he departed with [9]$62m in compensation.
The Justice Department in October [10]indicted Mark A. Forkner , a former Boeing 737 MAX chief technical pilot, for fraud. The government contends Forkner provided the FAA with false, inaccurate, and incomplete information about MCAS and that led to the misunderstandings that contributed to the two crashes.
The Senate's Aviation Whistleblower report follows on the heels of the Aircraft Certification, Safety, and Accountability Act, an aviation safety reform law enacted in December, 2020, to address the problems that led to the two crashes.
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It details testimony from Ed Pierson, a former Boeing senior manager, who described 13 other reported safety incidents with the 737 Max that did not result in any loss of life. He observed:
Most shocking of all, 11 of these 13 safety incidents occurred in the five months between the Lion Air crash and the Ethiopian Airlines crash. Thus 2 safety incidents per month. So at a time when Boeing and the FAA should have been operating at an extremely heightened sense of awareness after the Lion Air crash, the MAX continued to average two safety incidents per month for the five months leading up to the Ethiopian Airlines crash. At this rate, if the MAX had not been grounded in March 2019, there could have been another 42 safety incidents involving airplane systems (other than MCAS) by December 2020—which means a correspondingly higher probability of another fatal accident.
The report has found that the FAA certification process places aviation personnel under undue pressure.
For example, Richard Kucera, a former GE Aviation engineer, recounted "being placed in an untenable position where he was responsible for conducting engine conformity tests on behalf of [the] FAA, while also being charged with preparing GE engines to pass these same tests." And Boeing personnel, it's said, faced "relentless" schedule pressure with regard to the 737 Max.
The FAA, whistleblowers said, had too few safety engineers in its Seattle office overseeing Boeing, and had certification processes that did not reflect current airworthiness standards.
Not only that, senior FAA engineers who raised safety concerns "were sidelined during the 737 Max certification," the report states.
The FAA and the aviation industry, according to the report, also faces a challenge certifying and operating complex technical systems that involve the interaction of both people and automated systems, compounded by the scarcity of experts who truly understand these systems.
While automated flight control systems can enhance safety, increased reliance on automation creates new safety challenges
"While automated flight control systems can enhance safety, increased reliance on automation creates new safety challenges," the report says.
"These range from failure of pilots to correctly operate automated flight systems, to software malfunctions that generate faulty data, to the degradation of manual piloting skills."
The report makes numerous recommendations to augment the FAA's oversight capabilities, particularly with regard to its Organization Designation Authorization (ODA) program – by which the US aviation watchdog delegates its watching duties to workers at companies it's supposed to watch.
This practice of letting employees of aviation firms act on behalf of FAA personnel, as the report notes, has led to the approval of systems that should not have been approved.
For example, Michael Collins, a former FAA engineer, testified that FAA managers delegated 95 per cent of the certification of the Boeing 787 Dreamliner to Boeing personnel.
"This delegation decision included the certification of new high-risk battery installation technology, a decision made against the recommendation of a technical specialist who identified the system’s safety critical design flaw," the report stated.
"In the absence of FAA technical and safety engineer oversight, Boeing’s ODA found the lithium battery system design to be compliant. Later on, this exact design flaw led to dangerous 787 fire incidents and the eventual FAA grounding of the 787 Dreamliner." ®
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[1] https://www.commerce.senate.gov/services/files/48E3E2DE-6DFC-4602-BADF-8926F551B670
[2] https://www.theregister.com/2021/10/15/boeing_737_max_tech_pilot_charged_mcas/
[3] https://pubads.g.doubleclick.net/gampad/jump?co=1&iu=/6978/reg_software/front&sz=300x50%7C300x100%7C300x250%7C300x251%7C300x252%7C300x600%7C300x601&tile=2&c=2Ybl2fTbdZ5X1cPlVKHZM-gAAAFU&t=ct%3Dns%26unitnum%3D2%26raptor%3Dcondor%26pos%3Dtop%26test%3D0
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[6] https://www.theregister.com/2019/05/20/737_max_flight_simulators_not_accurate_report/
[7] https://www.justice.gov/opa/pr/boeing-charged-737-max-fraud-conspiracy-and-agrees-pay-over-25-billion
[8] https://pubads.g.doubleclick.net/gampad/jump?co=1&iu=/6978/reg_software/front&sz=300x50%7C300x100%7C300x250%7C300x251%7C300x252%7C300x600%7C300x601&tile=4&c=44Ybl2fTbdZ5X1cPlVKHZM-gAAAFU&t=ct%3Dns%26unitnum%3D4%26raptor%3Dfalcon%26pos%3Dmid%26test%3D0
[9] https://www.reuters.com/article/us-boeing-737-max-ceo-severance/boeings-ousted-ceo-departs-with-62-million-even-without-severance-pay-idUSKBN1Z92DQ
[10] https://www.theregister.com/2021/10/15/boeing_737_max_tech_pilot_charged_mcas/
[11] https://pubads.g.doubleclick.net/gampad/jump?co=1&iu=/6978/reg_software/front&sz=300x50%7C300x100%7C300x250%7C300x251%7C300x252%7C300x600%7C300x601&tile=3&c=33Ybl2fTbdZ5X1cPlVKHZM-gAAAFU&t=ct%3Dns%26unitnum%3D3%26raptor%3Deagle%26pos%3Dmid%26test%3D0
[12] https://whitepapers.theregister.com/
Add the Federal Highway Administration to that list. These transformations go back to the mid-1990s where most of the Federal oversight capability was converted to a corporate facilitation function. In the case of FHWA, that went as far as forcing the States to adopt the same model. All compliance testing of highway/bridge/airport materials was transferred to the suppliers and contractors.
This is chickens coming home to roost.
What? But surely one aeronautical engineer is as good as any other for these certifications!
(/sarcasm, before downvotes arrive...)
"scientific testing" of safety is done by the manufacturing companies
There is nothing wrong with companies performing scientific testing of their products and then forwarding the results to the regulating agencies. Proper scientific tests will give reproducible and reliable results (that's the 'scientific' part in the phrase).
The real problem is fraud, cheating, and systematic cutting of corners - - with the government agencies firmly looking the other way because they are underfunded, understaffed and under pressure to facilitate the business of the industry they regulate.
The People ARE The System.
Any system becomes a bad system once it has been compromised. And, unfortunately, no system humans will ever create will be immune from compromise. The key is for all participants to perform to clear and well understood ethical standards, and to talk about them frequently.
I've helped create aircraft instruments, after which I had to flip my hat around and help get them certified. I love writing software and doing systems engineering. I hate testing: It's boring as hell. I only want to do the testing until it passes, and to know that the pass is a good pass, not an accident or a statistical fluke. So I'm a testing asshole.
I worked with FAA DERs (Designated Engineering Representatives) to completely overhaul our testing environment, from the ground up. The equipment we used, the procedures we followed, the test artifacts we generated, the environments within which testing was performed. We used formal proofs when needed, but we much preferred to test our instruments to extremes in the lab, and with lots of flight hours on company test aircraft.
This was always part of the company culture: One of the first things said to me during my first interview was: "We are a test and certification company that happens to make aircraft instruments." Every new engineering hire, after getting up to speed on the product and its development, was then expected to make substantial and meaningful contributions to the test and certification system. I had experience in other safety-critical sectors, including nuclear power, and I was expected to bring all of that experience to bear on all of our processes, including test and certification.
We intentionally chose to not have in-house DERs. We always hired independent contractors, typically a couple junior ones and one senior-as-hell greybeard to get the best out of them. The advantage being that we could rotate DERs on each project, and learn from each other. Well, we never rotated that senior bastard: He was just too good at what he did.
Re: The People ARE The System.
QA is a much underrated function. I worked with the same colleagues for many years through several companies and these two despite being good friends (eventually) were the bane of my life because they used to take pride in destroying our creations. All for a good cause, of course, but note how these people, while critical, were also regarded as somewhat less than us 'real' engineers by the bosses. (Management thought that all they did was press buttons.)
Back in the 2000s our daughter was studying aeronautical engineering and did a summer interning at the 737 plant in Seattle. She told me a familiar tale, of the engineering staff being mostly entry level or older people who were either close to retirement or had retired and were working on contract. She had entertained thoughts of working for the company but the HR department, located in another state, wasn't interested (she graduated with what would be called in UK-speak a "double first" but at the time the business was going through one of its periodic cycles so she got sucked into the energy sector instead.) The hiring tale was all too familiar to me in my own branch of engineering, back then everyone was complaining about a chronic skills shortage but the voices were ignored while the profits seemed to be robust.
(The best thing Boeing could do is spin its aircraft making division off into a separate company and leave the financial engineers in Chicago to continue to do their magic with virtual profits. Engineering is hard and the result of failure can be spectacular. Its best left to the professionals.)
Fired
I wish I could be fired and still walk away with $62 million.
Re: Fired
The likely deal breaker: how many people are you prepared to kill for that bonus?
Procedural changes
It sounds almost to me like there could be two procedural changes that'd help.
1) It really sounds like it'd be better if there was no liaison at all between the FAA and the engineers; engineering concerns are filed like bug reports, and the FAA could then be immediately aware if the engineers had concerns and how they were addressed.
2) It should be made clear to Boeing et. al's non-engineers that any given design is going to see millions of cumulative operating hours. I mean, the saying for saying something is unlikely is "Wow, that's a million to one chance", well in this case a million to once chance per hour means it's reasonably likely to actually occur sooner or later. You're still dealing with statistics (even a triple-redundant sensor or computer, with 3 seperate designs, has that very low chance of triple fault, but it gets to be statistically low.) It would probably be good to make sure the non-managers responsible for anything safety-related have a good handle of statistics.
For example, Michael Collins, a former FAA engineer, testified that FAA managers delegated 95 per cent of the certification of the Boeing 787 Dreamliner to Boeing personnel.
Also in pharma and pesticides "scientific testing" of safety is done by the manufacturing companies, by law. That is very unscientific.