Episode 1 – The Boeing MAX8 Disasters: Much More Than Meets the Eye
In this first episode, I lay the foundation of this podcast series with a concise summary of the remarkable Boeing 737 MAX 8 story. I'll address the two crashes in 2018 (Lion Air Flight 610) and 2019 (Ethiopian Airlines Flight 302), the discovery of MCAS as the technical trigger of the flight emergencies, the investigations and public reactions, and the key outcomes. I'll then lay out the most striking questions that emerge -- many still unanswered.
Please share your views, insights, and opinions through the MAX8 Podcast Comments form. Episode 12 will be dedicated to feedback from listeners such as you.
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EPISODE HIGHLIGHTS:
(0:40) – Why this Podcast?
(3:44) – The first crash: Lion Air Flight 610.
(6:49) – The preliminary findings: Perplexing, disturbing, and “far away”.
(11:58) – The second crash: Ethiopian Airlines Flight 302.
(14:20) – The ensuing media frenzy.
(15:04) – Investigations and Boeing’s response.
(21:25) – Only two legal actions taken.
(24:10) – Stepping back – An uneasy feeling lingers?
(27:13) – Top-of-mind questions.
(29:42) – Conclusions.
KEY POINTS:The Boeing 737 MAX 8 saga is an enormous and perplexing story.
The story includes not only the devastating 2018 and 2019 crashes but also the six-year design and development program to build the new MAX, as well as a myriad of investigations and public reactions afterward.
The multitude of elements in the story can be overwhelming: official investigations, investigative journalism, expert technical analyses, congressional hearings, subpoenaed Boeing documents, and lawsuits.
These two crashes had the same technical root cause – flight control software called MCAS. Amazingly, Boeing and FAA engineers identified the cause after the first crash and calculated that another could occur within a year. However, the MAX wasn’t grounded, and few knew the seriousness of the situation.
Also, during the aircraft's development, test pilots and engineers repeatedly raised issues with the design of MCAS. Their concerns were properly reviewed through established processes but ultimately dismissed.
The stark reality is that the MAX8 was an airplane everyone wanted and wanted now. Therefore, it dodged the depth of scrutiny one would expect.
Investigations confirm and, in some ways, contradict each other.
One major report, entitled the Joint Authorities Technical Review (JATR), was a rigorous and thorough assessment, highlighting multiple factors involved in the failure. This report represents the deeply held aviation wisdom that nearly all aircraft accidents result from multiple contributing factors.
In contrast, the U.S. House of Representatives Committee on Transportation and Infrastructure investigation focused on the actions of Boeing executives, suggesting that Boeing may have knowingly hid MCAS from the FAA and the Airlines to speed the airplane to market. This helped shape the public perception of the crashes as resulting from blinding corporate greed.
However, from the beginning, Boeing insisted that it never intentionally hid unsafe new technology from the FAA, other foreign aviation agencies, or the airlines.
Boeing repeatedly emphasized several key points.
First, internal analysis determined that the design for MCAS was acceptable under airplane certification regulations because the probability of failure was calculated to be extremely low.
Second, other technologies already operate in the background on modern airplanes to simplify pilot operations. MCAS was one of those. Informing pilots about elements they don’t need to know to fly the airplane could increase risk by burdening them with superfluous information.
Third, MCAS's design, engineering, and testing were conducted correctly according to established and accepted analytic methods and met certification and safety standards.
However, Boeing’s most prominent point was that engineers had made two key assumptions in the design process and safety assessment: first, pilots would perceive any MCAS failure as another related malfunction that they are trained for, and second, they would respond within three seconds.
Regardless, the design was very intentional in many ways, based on decisions explicitly made by engineers and managers during the MAX’s development over six years.
Events in 2024 have opened a can of worms.
In January 2024, a door panel blew off an Alaska Airlines Boeing 737 MAX 9 early in the flight. Then, other unfortunate events began to unfold for the MAX and for Boeing more generally, including additional in-flight incidents on United and Southwest Airlines and a series of new whistle-blower revelations.
Boeing suddenly faced the prospect of felony criminal prosecution for breach of a 2021 Department of Justice agreement. Such a trial could reveal much about what occurred inside Boeing.
Difficult questions linger.
Engineering, design, and certification: How could engineers, test pilots, safety professionals, and regulators have missed such a bad design over six years from the initial design to the first commercial flight?
Organizational behavior: Was Boeing’s executive leadership directly responsible and criminally negligent, or did the design failure occur in work groups, away from leadership, as part of daily work? If the latter, were workers intentionally negligent, or were they doing their jobs as they thought best and as they were directed?
Technology: Are airplanes becoming too automated? Is there a disconnect between pilots and the advanced technologies and automation they deal with? Are piloting abilities declining as a result?
Airline operations: What are the airlines’ pilot training and maintenance responsibilities?
Quite quickly, we can see a much larger story with many moving parts, multiple mistakes, and unclear cause-and-effect relationships.
USEFUL EPISODE RESOURCES:
THINGS YOU CAN DO:
Let me know your thoughts.
Please share your views, insights, and opinions. Episode 12 will be dedicated to feedback from listeners such as you.
You can contact me through the MAX8 Podcast Comments form. While I may not be able to respond to all comments, I will read each one carefully. I’m very interested in your thoughts.
Download my Framework of Failure description.
The Framework of Failure is summarized in a six-page PDF that can be downloaded. Access is at the bottom of the Home Page at BradIvie.com.
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This podcast is created for many audiences: business professionals, management consultations, aeronautics industry professionals, aviation enthusiasts, policymakers, and the general public. Please share this episode with those who you feel would be interested in this story and benefit from the information provided and the analytic approach taken. Or perhaps the video trailer for the series.
