Episode 9 – The Response to Failure: What Was Said and Done
What typically happens after major accidents and disasters?
First, the public experiences profound shock and disorientation. This can lead to unity regarding causal explanations and actions to address harm. Then, competing perspectives emerge, often followed by a bitter blame game, with parties taking opposing positions and jostling for advantage.
In parallel, there are one or more cycles of official investigations, actions, and resolutions, with the goal of “healing” and addressing losses. Responses can also oversimplify and fail to capture the full complexity of a chain of events. Actions that follow can be just as fragmented and divisive.
Response is a clustershambles of its own making – a mess of competing interpretations and acrimonious conflict. The MAX 8 saga is an excellent example of this.
In this episode, I’ve focused on systematically capturing events. I have broken Response into nine groupings and provided prime examples of the activities that stand out. Then, in Episode 10, I will illustrate the dynamics of Response through a select set of fascinating Response stories.
Please share your views, insights, and opinions through the MAX 8 Podcast Comments form. Episode 12 will be dedicated to feedback from listeners such as you.
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EPISODE HIGHLIGHTS:
(0:46) – Introducing the Response to Failure.
(3:54) – How this episode is organized – the “groupings” of Response events.
(5:18) – Defining the notion of “Response.”
(10:29) – Grouping #1: Recap of the interim period Response after the first crash.
(12:37) – Grouping #2: Journalistic coverage.
(17:18) – Grouping #3: Formal investigations.
(32:39) – Grouping #4: Government actions – Congress.
(37:38) – Grouping #5: Government actions – The Courts.
(42:26) – Grouping #6: Independent expert analysis.
(53:54) – Grouping #7: Other financially related judgments.
(56:48) – Grouping #8: Actions within Boeing.
(1:00:07) – Grouping #9: The return to service for the MAX 8.
KEY POINTS:
What is this space of “Response?”
There’s a similar word out there – “reaction,” but its meaning is narrower, representing an instinctive, emotional reply to a situation, often impulsive and based on unfiltered past experiences. Response is more “considered.” It is group-based –or “social,” representing a persistent outcome representing the cumulative results of processing, often in a series of cycles of collaborative thought, action, and reaction.
Groupings of Response – What’s addressed:
The interim period after the first crash of Lion Air 610.
Initially, there was a reaction to blame the pilots and, to some degree, the airlines. Then, attention turned to Boeing, which realized the gravity of the design error. However, Boeing and the FAA issued bulletins, sidestepping MCAS and focusing on the pilot’s execution of the runaway trim procedure. This involved a concerted effort to obscure MCAS while mollifying aviation authorities and the public and proceeding with a fix behind the scenes. So, the politics of perception, blame, and liability began immediately. All the while, there were undertones of concern, primarily by pilot unions and pockets inside the FAA.
Journalistic coverage.
Because official agencies limit the flow of information early on, newspapers tend to be the first source of information and independent perspectives available to most people. Perhaps the most thorough, focused, and rigorous coverage of the MAX 8 story came from the Seattle Times. The New York Times coverage tended to be more diverse, with writers and columnists offering differing perspectives and often expressing strong conclusions. Also, periodic journals provide articles that are often a hybrid of investigative journalism and opinion. So, journalism is an essential force in the Response phase, becoming an active player in establishing narratives.
Formal investigations.
The most important investigations proved to be particularly rigorous, and their significant technical findings, taken as a whole, are essential to our understanding. The Joint Authorities Technical Review (JATR) was perhaps the most comprehensive review. It highlighted the complexity of system interactions at the aircraft level and the multiple factors involved in the failure. The National Transportation Safety Board (NTSB) issued a Safety Recommendation Report that focused particularly on human factors. The Department of Transportation report serves as a key source for technical explanations of MCAS and the MAX 8 certification process. All three reports were consistent in their conclusions. Recently (2024) the FAA issued a highly critical report that pointed to “a disconnect between Boeing’s senior management and other organization members on safety culture."
In contrast, the report of the Ethiopian Aircraft Accident Investigation Bureau presented a totally different explanation of causality that stands in stark opposition to conclusions from other global aviation agencies and remains a matter of serious contention today.
Government actions - Congress.
An 18-month investigation by the U.S. House of Representatives Committee on Transportation and Infrastructure, Subcommittee on Aviation tells us a lot about how disasters are vetted publicly. Committee debate often took on partisan color. The focus was heavily on Boeing's leadership actions. The House committee argued that Boeing management intentionally put profits over safety, leading to the development of a deadly aircraft. The report identified five areas of acts, omissions, and errors: 1) production pressures, 2) faulty design and performance assumptions, 3) a culture of concealment, 4) conflicted representation of the in-house Boeing regulatory personnel, and 5) Boeing’s influence over FAA oversight structure.
Government actions – The Courts.
In January 7, 2021, a “deferred prosecution agreement” was reached between Boeing and the DOJ. It involved only one count of conspiracy to defraud the FAA. In it, Boeing agreed to pay over $ 2.5 billion. No Boeing executives were charged. Then, two “messes” subsequently unfolded. First, the DOJ created a problem for itself by not informing the victims' families before the agreement was announced. This led to a rebuke from those families and a growing conflict between the two parties. Second, Boeing created a problem for itself in 2024 by triggering a federal audit of its current manufacturing practices due to the Alaska Airlines incident. As a result, the DOJ reopened the deferred prosecution agreement just months before the probation period was to end.
Independent expert analysis.
Established industry analysts and observers can be wonderful sources of insight and information on a topic, providing deeper technical explanations and fresh, particular angles on a story not available elsewhere. One of the most notable is Chris Brady, a deeply experienced commercial 737 pilot and author of “The Boeing 737 Technical Site." Brady disagrees strongly with Boeing’s core assumption about pilots reacting to MCAS as if it is a case of runaway trim. He concludes that “an average” crew would not recognize MCAS failure as such. Martin Chizek, a product safety officer and senior engineering fellow at Lockheed Martin, offers the perspective of an engineer looking carefully at what happened during the design phase at Boeing. Other compelling professional perspectives come from individuals who are seasoned commercial pilots themselves - Sully" Sullenberger for example - although even here, we see strong differences in views expressed.
Other financially related judgments.
Boeing agreed to a $237.5 million settlement to company shareholders in November 2021 in a lawsuit filed by large pension funds that had been holding Boeing stock. Furthermore, Boeing was charged in September 2022 by the Securities and Exchange Commission for misleading investors by suggesting that human error was to blame for two deadly crashes and omitting the company’s concerns about the plane in investor relations communications.
Actions within Boeing.
Immediately following the crashes, we see an inability for Boeing leadership to wrap their heads around what happened. Then there are the promises made by Boeing’s new CEO, Dave Calhoun, subsequent to Dennis Muilenberg’s ouster in December 2019, to address the admitted gaps in safety processes and practices. However, the events of 2024 demonstrated a failure of these actions to realize actual change in the trenches. So much so that Boeing was again prosecuted by the DOJ and Calhoun was asked to step down as CEO, replaced on August 8th by Kelly Ortberg.
Return to service of the MAX 8.
As it turned out, the rigorous review of MCAS and the MAX 8 after it was grounded also exposed additional issues unrelated to MCAS. For example, a totally separate issue tied to the FCCs emerged that was also related to a runaway stabilizer. Unrelated wiring issues were also identified. Regarding MCAS, the fix was addressed in a software update and a number of related system fixes, plus updates to aircraft manuals. The revised design reportedly took more than 375,000 engineering and test hours and 1,300 test flights. It is a shame even a fraction of such an investment was not made upfront.
USEFUL EPISODE RESOURCES:
Joint Authorities Technical Review. Boeing 737 MAX Flight Control System.
Robert Kegan and Lisa Laskow Lahey, Immunity to Change: How to Overcome It.
Alec MacGillis, “The Case Against Boeing,” The New Yorker, November 2019.
Ethiopian Aviation Accident Investigation Bureau (EAAIB) - Final Report on Ethiopian Flight 302.
National Transportation Safety Board (NTSB), Investigation Site.
THING 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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