In a previous post, we explored how the disasters involving the Boeing 737 MAX aircraft since 2018 reflect the importance of effective procedural documentation and proper training, particularly during the introduction of new products or services that are drastically different from earlier versions. The 737 MAX story, however, provides many lessons that can be applied to any industry. Today, we’ll look at how the failure of quality culture at Boeing led to such extraordinary human tragedy.
To review the facts, Boeing introduced the 737 MAX as an update to the 737 NG to compete with Airbus. This update included a structural redesign that made the 737 MAX vulnerable to stalls resulting from the nose drifting up during certain maneuvers. To remedy this, Boeing designed the maneuvering characteristics augmentation system (MCAS), a software application that would correct the angle of attack by pushing the nose back down without the pilots being aware it was going on. While this was a good idea in theory, bad data from external sensors meant MCAS decided the aircraft was in danger of stalling when it wasn’t. MCAS pushed the nose down, the pilots didn’t know how to turn it off and regain control of the plane, and two 737 MAX aircraft crashed killing more than 300 people.
We’ve learned quite a lot about Boeing’s quality culture since those events. In January, Boeing released to the press a collection of internal emails from the period during which engineers were working on the 737 MAX. These messages are, to say the least, astonishing. They show senior executives treating both employees and regulators with contempt, ignoring the advice of aircraft engineers, and cutting corners on quality and safety as they focused on profit and schedules.
In the following message, the chief technical pilot of the 737 program states Boeing’s position on requiring extra training for 737 MAX pilots,which would create extra financial and scheduling burdens that made the 737 MAX a less attractive product for airlines to purchase.
- I want to stress the importance of holding firm that there will not be any type of simulator training required to transition from NG to MAX. Boeing will not allow that to happen. We’ll go face to face with any regulator who tries to make that a requirement. If a particular customerwants to add additional training due to concerns with their particular experience level of their pilot group, then that is an internal issue to that airline.
Despite the fact that MCAS could have a significant impact on the way pilots operated the aircraft, Boeing continued to convey the message that no additional training was necessary for 737 MAX pilots.
- There is absolutely no reason to require your pilots to require a MAX simulator to begin flying the MAX. Once the engines are started, there is only one difference between NG and MAX procedurally, and that is that there is no OFF position of the gear handle. Boeing does not understand what is to be gained by a 3–hour simulator session, when the procedures are essentially the same. Perhaps we should discuss at your earliest opportunity. The FAA, EASA, Transport Canada, China, Malaysia, and Argentina authorities have all accepted the CBT requirement as the only training needed to begin flying the MAX. I’d be happy to share the operational differences presentation with you, to help you understand that a MAX simulator is both impractical and unnecessary for your pilots.
Even the name MCAS was chosen to ensure that regulators would see it as simply new functionality for an existing system, which would therefore not require any additional simulator training for pilots. In the following excerpt, Boeing outlines how this will allow them to avoid training pilots on how to use it or even informing them that it exists.
- After speaking with the Aeroflight AR, concurrence was provided thatwe can continue to use the MCAS nomenclature internally while still considering MCAS to be an addition to the Speed Trim function. This will allow us to maintain the MCAS nomenclature while not driving additional work due to training impacts and maintenance manual expansions.
Meanwhile, engineers and managers were struggling to meet the demands set out by executives while maintaining their own professional integrity.
- Everyone has it in their head meeting schedule is most important because that’s what Leadership pressures and messages. All the messages are about meeting schedule, not delivering quality. We managers were told names were being taken by senior leadership at the level D Go/NoGo meeting…Sometimes there are understandablereasons why we have schedule pressures—such as major impacts to customers. But not always…But not looking bad by missing schedule was more important and we missed the opportunity to fix things when there was no impact.
- I don’t know how to fix these things…it’s systemic. It’s culture. It’s the fact that we have a senior leadership team that understand very little about the business and yet are driving us to certain objectives. It’s lots of individual groups that aren’t working closely and being accountable…Sometimes you have to let things fail big so that everyone can identify a problem…maybe that’s what has to happen rather than just continuing to scrape by.
– I don’t know how to refer to the very, very few of us on the program who are interested only in the truth. But it’s mostly depressing that it’s so few.
– Honesty is the only way in this job… Would you put your family on a MAX simulator trained aircraft? I wouldn’t.
- This airplane is designed by clowns, who in turn are supervised by monkeys.
These messages are a glimpse into a toxic culture of quality at Boeing, one in which failures would eventually be measured by the number of lives lost.
Though unrelated to these crashes, Boeing was also recently hit with a fine of $5.4M for knowingly installing faulty parts on the 737 MAX. These fines relate to slat tracks located on the wings, which were submitted to the FAA for approval despite Boeing being aware that they had failed a strength test.
The consequences of Boeing’s failures of quality culture will echo for years to come. CEO Dennis Muilenburg was fired in December, the 737 MAX has been grounded since March with no indication of when it will fly again, and Boeing suppliers have begun eliminating jobs relating to the stalled 737 MAX program, with Spirit Aerosystems cutting 2,800 jobs in Kansas so far. Most tragic of all, the family and friends of more than 300 people will live the rest of their lives knowing that the people they loved died because of the perceived importance of meeting a schedule on time and maximizing profit.
Boeing lost sight of not only its internal culture of quality, but also of the industry it serves. The aviation industry is the best example of a high-reliability organization (HRO), in which a complex organizational system runs 24/7 with no tolerance for downtime or failure. In HROs, automated systems, navigation, maintenance, operation, and air traffic control are closely integrated with highly developed human competencies and operate continuously across the globe. When HROs are confronted with disruptive events, they must be resilient enough to continue operating at a high level of performance. HROs have multiple redundancies, a vigilance against error, and a rigorous attention to root causes to prevent failure. They also require a commitment to deferring to expertise, which means that even leadership is obligated to listen to experts whose knowledge is crucial to maintaining the integrity of the system.
In the cockpit of each airliner, flight crews practice a specialized approach to operations and problem solving known as CRM (crew resource management). CRM addresses the reality that humans are the most frequent points of failure in a complex system and works to reduce those errors by a method that focuses on six core skill sets:
- situational awareness
- decision making
- management of limits of crew members’ capacities, and
Boeing’s quality failures not only disrupted their own internal safety and quality culture, they also infected and disrupted the highly calibrated culture of the aviation industry at large. By failing to give pilots all the information they needed about the systems operating behind the scenes on the 737 MAX, Boeing effectively disabled the CRM methods in the cockpit to disastrous effect. HROs require a delicate integration of people, processes, and tools to maintain operation; Boeing’s quality failures managed to disrupt all three of these elements as the pilots struggled in vain to protect the hundreds of lives with which they had been entrusted.
The lesson is that organizational cultures of quality and safety are vital to protecting everyone in the supply chain, and that poor organizational culture at one point can quickly infect and disrupt others. Not every organization is an HRO, but we should all look to the Boeing disasters astragic examples of the consequences of systemic quality failures.