Episode 10 – The Response to Failure: Making Sense of Response
This episode explores four fascinating stories about people central to the Response to the 737 MAX 8 crashes, vividly illustrating the ongoing and contentious debate surrounding cause and blame.
I then present four distinct examples of how the facts got confused in the process - to be “obfuscated” - that is to cloud a precise understanding of causality. With these stories in hand, we can see several different ways “obfuscation” occurs.
Through all of this, we see how differing perspectives and accurate information mixed with incorrect or dubious information influence perceptions, conclusions, actions, and outcomes. This helps us appreciate how Response unfolds imperfectly.
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:
(0:42) – My approach in this episode: a few fascinating stories.
(2:57) – Side story #1: The Ethiopian crash investigation.
(13:04) – Side story #2: The Whistleblower.
(19:20) – Side story #3: The victims’ families.
(23:51) – Side story #4: The Mark Forkner trial.
(33:50) – Example of obfuscation #1: Misclassification of MCAS.
(38:30) – Example of obfuscation #2: Disregard for safety.
(41:01) – Example of obfuscation #3: Prioritization of revenues.
(43:26) – Example of obfuscation #4: Amplification of obfuscation.
(47:59) – Different types of misunderstanding: Causality confusion, causality simplification, causality misattribution, causality manipulation.
(50:52) – Conclusions on Response to Failure.
(55:25) – The terminus of the Framework of Failure.
KEY POINTS:
The approach for this episode is to explore a series of fascinating stories about how Response unfolds, focusing on how “obfuscation” occurs.
Obfuscation is often at the heart of Response. It is defined as: “to make something less clear and harder to understand, especially intentionally.”
The four side stories:
The Ethiopian crash investigation – The Ethiopian Aviation Accident Investigation Agency (EAAIB) argues that only production quality defects with the electrical wiring could have caused the Ethiopian crash and that this is the sole factor. In contrast, the European investigative bureau, the BEA, believes the crew's performance was also important – this is tied to problems utilizing the autothrottle that preceded MCAS activation on that flight. The Ethiopian authorities don’t like this argument because it is rooted in the memory training that pilots should have executed. So, the EAAIB may be shielding its pilots and, therefore, the airline from blame and liability.
The Whistleblower - Ed Pierson is an aviation safety advocate and a 737 MAX whistleblower. He argues that poor manufacturing involving wiring installation has been a huge, ongoing problem for the MAX aircraft series, affecting many systems, and that it is the core cause of the MAX 8 crashes. Therefore, the updates to MCAS software do not resolve this much more profound problem. Pierson suggests a cover-up by Boeing because this larger issue is unresolved. This explanation is embraced by the EAAIB and the families of victims of the Ethiopian crash and has taken on a life of its own. However, Pierson does not provide an explanation of the Structure and Occurrence of Failure – how did this happen socio-technically with the pilots and MCAS?
The victims’ families - The Ethiopian 302 families became very influential in the Response Phase, demanding accountability and transparency. Their wrath focused on the actions of Boeing's leadership, which they felt were intentional and criminal – actions to cover up engineering problems as opposed to fixing them, driven by the priority of financial goals. Part of what motivates them is a commitment to fixing all problems and learning valuable lessons. However, they do so by embracing the weak logical arguments posed by the EAAIB and Ed Pierson about the precise cause of the two crashes. Simplicity is helpful in a crusade but not in honest analysis.
The Mark Forkner trial - Mark Forkner, a manager overseeing pilot training standards for the MAX, was the only person prosecuted in the MAX 8 story. He was accused of knowingly and actively deceiving the FAA and two airlines for Boeing’s financial benefit by hiding the MCAS design change, which could have influenced aircraft purchase contracts. The jury felt, however, that there was insufficient evidence that he knowingly misled the FAA and airlines. However, information inside and outside the trial demonstrated that he knew about the MCAS change. He was caught in a very difficult position, likely with no guidance. It is possible to accept both propositions that Forkner was being scapegoated by Boeing and that he knowingly misled the FAA to some degree.
Example of obfuscation:
Misclassification of MCAS - Some journalists, politicians, and aviation experts have described MCAS as an “anti-stall” or “safety” system, thus making Boeing’s sloppy design decisions appear particularly egregious and criminal. However, the top technical experts demonstrate how MCAS enhances stability (the control column “feel”) but does not operate in stall prevention. Yet, the “anti-stall” element of the story was widely used and is likely accepted by many people. This misclassification has become a significant point of contention in the press and public debate, heightening tensions and distorting perceptions regarding Boeing’s actions.
Disregard for safety - Many news programs and articles presented a narrative that Boeing executives consciously and brazenly disregarded passenger safety in pursuing program goals. They pointed to early test data and the series of weak signals. “Boeing was doubling down on the system, expanding it, despite the earlier catastrophic result in a simulator test.” Yes, we know the wrong conclusions and decisions were made. However, engineers carried out the design process for MCAS according to specific procedures, and they were documented. No evidence exists that executives personally reviewed those tests or made a conscious, amoral business decision to cover up the results.
Prioritization of revenues – Many argued that revenue considerations dominated day-to-day business decisions regarding the MAX. Much of this is based on the $1mn airline contract penalty clause to Boeing if pilots required simulator training. However, this conflates the penalty with the airline’s desire to seamlessly transition pilots from the NG to the MAX. It appears that the penalty was less important to Boeing's leadership than the airline’s desire for a seamless transition.
Amplification of obfuscation - This is the tendency for incorrect information to be repeated and amplified to the point that it is seared into the public memory. Well-respected sources as diverse as the New York Times, PBS, and John Oliver repeated simplistic and, at times, incorrect explanations of causality. Also, the focus tended to be on individuals, as it is easier and more entertaining to do such, as opposed to explaining the complex socio-technical factors and dynamics, which feel esoteric and difficult to understand.
Different types of actions that promote misunderstanding and obfuscation:
Causality confusion - Stating or holding a misinformed view of causality.
Causality simplification - Making a causality case that is incomplete, often by ignoring or discounting key factors and events.
Causality misattribution - Promoting a wrong causal explanation by unintentionally promoting incorrect elements of the cause or misassigning responsibility.
Causality manipulation – Intentionally promoting a cause that is wrong with the intent of shifting responsibility for the benefit of one group over another.
Key conclusions:
Response to Failure is not primarily about the pursuit of a “fair,” “balanced,” or “complete” explanation. Response is a social phenomenon involving groups with like-minded interests or perspectives developing points of view on causality that are inherently incomplete and often biased to the perspective of that group.
Groups build connections or antagonisms with other groups and drive a form of competition in the realms of public opinion, the law, and technical and organizational change, including processes and practices.
These narratives then take on a life of their own. They are shaped and can often occur in a boxing ring, where investigations and advocacy become political.
Along the way, explanations are simplified and crowd out other more complete and balanced explanations that are essential to improving safety.
USEFUL EPISODE RESOURCES:
Ethiopian Aviation Accident Investigation Bureau (EAAIB) - Final Report on Ethiopian Flight 302.
Peter Robison. Flying Blind: The 737 MAX Tragedy and the Fall of Boeing. Doubleday, 2021.
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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