“Responsibility = Accountability = Ownership. And a sense of Ownership is the most powerful train a organization can have to avoid problems.”
Leadership Topics: Situation, Common, Fix? Impact. 5 Lessons: Don’t Compromise your Product, Identify & Mitigate Failure, Training, always possible Defects, Systems sometimes Fail.
The Situation. Just three years after its first flight, the Boeing 737 Max Jet has already been implicated in two fatal accidents: the Oct. 29, 18 Lion Air crash that claimed 189 lives near Jakarta, Indonesia & the March 10, 19 Ethiopian Airlines crash that killed 157 just outside Addis Ababa. No other commercial aircraft has been implicated in as many fatalities (346) so rapidly in the last 50 years. this makes this aircraft the leader in disasters for this period.
Since the second crash, countries around the world have grounded the plane. Investigators have sought clues as to what went wrong. And intense media scrutiny has altered our perceptions of flight safety while uncovering the cozy relationship between Boeing and US regulators.
The definitive causes of the crashes have yet to be fully determined. Here is a look at what we’ve learned so far about the planes and what may have brought them down:
A. What the crashes had in common.
Black-box data shows “clear similarities” between Ethiopian & Lion Air crashes
- Both planes hit trouble just after takeoff.
- Pilots reported flight control challenges.
- Controllers observed erratic, up & down flight patterns.
B. What seems to have gone wrong.
A string of mis-steps may have made the 737 Max “crash-prone”.
- Evidence suggests a safety feature called the Maneuvering Characteristics Augmentation System (MCAS) sent both planes into their fatal dives as pilots struggled to keep aloft.
- The MCAS automatically nudges the nose of the plane down, if sensors detect an imminent stall. A faulty sensor can send the plane into a dive again & again.
- Boeing installed the software on planes without fully informing regulators or pilots about how it works.
A cockpit Warning Light for a mechanical fault was an optional add-on and not mandatory.
- The Lion Air plane did not have this optional safety feature installed in the aircraft.
- Boeing will now provide the warning light as a standard feature, Reuters reports. Airlines have had to pay extra to have it installed.
- The feature would have alerted crew that flight-angle readings were erroneous and likely to trigger the MCAS unnecessarily.
Pilots trained to fly the 737 Max with “an iPad lesson for only an hour”
- The FAA deemed the 737 Max (a variant of the 737-800), so pilots who were already certified to fly the 800 only had to complete one additional hour of training.
- Neither the lesson nor the flight manuals mentioned the MCAS, which was a new feature on the Max.
- Pilots say they only learned about the system after the Lion Air crash.
C. How the AC groundings came about.
A global Satellite network convinced the FAA to ground Boeing’s 737 Max
- Dozens of countries banned the Boeing 737 Max from their airspace shortly after the Ethiopian Airlines crash.
- The US Federal Aviation Administration [FAA] waited three days, saying there were “no systemic performance issues” that its experts could identify.
- US regulators were finally convinced by satellite data from Aireon, which monitors airplanes in remote locations where there are no ground sensors. The company recorded similarities in the flight paths for both downed planes.
President Donald Trump put himself at the center of the Boeing Max crisis
- After making a flurry of phone calls to FAA regulators & Boeing executives, the US president beat his own FAA to the news that the USA was grounding the 737 Max.
- On March 13, President Trump told reporters: “We didn’t have to make this decision today. We could have delayed it. We maybe didn’t have to make it at all. But I felt it was important both psychologically and in a lot of other ways.”
- That same day, acting FAA administrator Dan Elwell later clarified that the decision was “fact-based” and due to “new satellite data available this morning.”
D. How cozy Boeing is with the Administration
The flow of money & influence between the US government & Boeing
- The US government’s handling of the Boeing Max situation “raises the question whether the decision was made – based on what’s in the public interest, or based on relationships & influence,” said Brendan Fischer of watchdog group Campaign Legal Center.
- Boeing “has a strong interest in government policy & contracting, + seeks to exert influence over government officials in any way possible,” he told Quartz.
- The FAA’s initial inaction came as President Trump was told on March 12 by Boeing CEO Dennis Muilenburg that plane was safe, one of multiple conversations they had, people familiar with the calls told Quartz.
E. a “promised” Fix was once delayed
Boeing will release a software update to make the 737 Max safer
- Boeing planed to release a software patch in April that will limit the number of times the MCAS can nudge down the nose of a plane
- The fix will be designed to make it simpler for pilots to trouble-shoot problems with the flight-control system.
- Software upgrades, originally expected in January, were delayed, the Wall Street Journal reported Feb. 10, because of “engineering challenges,” “differences of opinion” between federal & Boeing officials + the 35-day government shutdown.
F. How we see Air Safety now
Where the Boeing 737 Max stands among the world’s “most fatal” commercial aircraft
- No other commercial aircraft has been implicated in as many fatalities so rapidly in the past 50 years (from a list of 46 other models flown in commercial fleets), according to a Quartz analysis of Aviation Safety Network data.
- Russian Tupolev Tu-154 are more fatalities, than any of the 47 aircraft models Quartz analyzed. (3,065). Boeing 737 Max (367).
These Crashes are changing our perception of Commercial Airline Safety
- World-wide, 1.2 million people die in Auto Accidents every year. Over the past 50 years, about 200 die per year in Commercial Aircraft accidents. We’re hoping that the 737 Max is not a start of an upward trend.
- Still, the glimpse into the workings of Commercial Aviation that the 737 Max findings offers, highlights how prone to human error the systems, authorities, & protocols meant to keep us safe – really are.
- The cascade of international groundings, as Washington Post columnist put it, “Under-mined faith in the FAA as a strong leader in Air Safety, exposing it instead as “a weak follower.”
G. What is the Business impact?
What will happen to Boeing now?
- Since the Ethiopian Airlines crash, Boeing has lost tens of billions of dollars in market value. Boeing may also face regulatory fines & class-action lawsuits.
- Boeing had been riding high on a wave of 737 Max orders. Now, an over-saturated market, airlines’ losses from grounded flights, and scrutiny of the jets’ safety will significantly slow business.
Boeing’s stock Share price has a strangely large impact on the Dow
- Boeing has the capacity to make the Dow Jones Industrial Average swing wildly.
- Boeing’s share price is many multiples of almost every other company in the stock index, with volume outstripped by only Apple and Microsoft.
- This is why it has an outsized influence on the Dow, with a percentage weighting of over 11%.
It would be tough for fast-growing Ethiopian Airlines to break up with Boeing
- The business relationship between Boeing & Ethiopia Airlines goes back 60 years, helping transform the carrier into Africa’s largest & most successful airline, with one of the newest major fleets in the world.
- The crash has brought renewed attention to its regional & global aspirations and its plans to open itself up for private investment.
- Although Ethiopian Airlines also buys planes from rival manufacturer Airbus, it is unlikely to switch its long-standing allegiance from Boeing.
H. The impact on the 1%
What’s a private 737 Max owner to do?
- There were 21 private orders for the “now-grounded” Boeing 737 Max in the sales pipeline, with price tags starting at $74 million each.
- Two were already delivered to completion facilities for finishing. The first is expected to be ready for its unnamed USA owner by the end of the year.
- Until world governments lift the bans on flying the 737 Max, no one can use them.
I. There’s a Slang word for this situation
“Kludge” comes up when pilots and engineers discuss the 737 Max
- Merriam-Webster defines kludge—sometimes spelled kluge—as “a haphazard or makeshift solution to a problem and especially to a computer or programming problem.”
- Oxford’s definition: “A machine, system, or program that has been badly put together, especially a clumsy – but temporarily effective – solution to a particular fault or problem.”
- Used in a sentence: “The Maneuvering MCAS system – a software patched together to make up for the fact that the 737 Max is particularly prone to stall at high speeds – turned out to be a disastrous “kludge” !!!
5 Lessons from Boeing 737 Max Crisis
The two crashes of Boeing’s new 737 MAX aircraft under similar circumstances was within six months of each other. The fallout from these disasters may only be starting, as aircraft around the world have been grounded, production of the 737 MAX has been decreased + March sales of the aircraft dropped to zero. The damage to Boeings reputation as a safety leader has now also come into question as investigations have been opened into how the system at the center of the investigations, MCAS, was developed and certified.
The investigations into the sequence of events that led to the loss of these aircraft and the causes will take quite some time to be fully complete by the accident investigators. However, with the information that has currently been released, embedded systems companies and developers can look at this fiasco that Boeing is currently going thru and learn + be reminded of several general lessons that they can apply to their own industries & products. Let’s examine those lessons.
Lesson #1 – Don’t Compromise your Product to save or make $$$ short-term
There is the normative pressure on businesses today to increase revenue, reduce costs & ship products as fast as possible. The mantra isn’t Quality. It isn’t Security. It isn’t User-friendly. The mantra is maximum short-term growth – and in my opinion – at any cost, as long as the short-term growth is maximized. Now, I don’t believe this was Boeing’s mantra or even their intent, but given the pressure that they appeared to be under from customers & shareholders to deliver an aircraft that could compete with the Airbus A319 Neo, I do believe that we can see that they may have started to give-in to this normative pressure.
Don’t risk compromising your product to save or make more $$$. It’s important to be successful in the short term, but there is more to every business beyond – just how much sales & revenue was generated this quarter. Even when the competition releases a competitive product and clients put the pressure on, it’s important to keep the long-term goals in mind and not sacrifice quality, reputation or put the client’s businesses in jeopardy.
Lesson #2 – Identify & Mitigate “single points of failure”
In any embedded system that is being developed, it’s important to understand the potential failure modes and what effect those failures will have on the system + how they can be mitigated. There are many ways that teams go about doing this, including performing a Design Failure & Effects Analysis (DFMEA) which analyzes design functions & failure modes + their effect on the customer or user. Once such an analysis is done, we can then determine how we can mitigate the effect of a failure.
Lesson #3 – Don’t “assume” your User can handle it. Do sufficient Training.
An interesting lesson that I think many engineers can take from the fiasco, is that we can’t assume or rely on our users to properly operate our devices – especially if those devices are meant to operate autonomously. I’m not saying that to be derogatory, but just to point out that complex systems require more time to analyze & trouble-shoot. It seems that Boeing assumed that if an issue arose, the user had enough training & experience, + knew the existing procedures well enough -to compensate. Right or wrong, as designers, we may need to use “lowered expectations” and do everything we can to protect the user from himself.
Lesson #4 – Highly Tested & even Certified systems may have Defects
Program testing can be used to show the presence of bugs, but never to show their absence.” We can’t show that a system doesn’t have bugs – which means we have to assume that even our highly-tested & certified systems can have defects. This should change the way every developer thinks about how they write SW. Instead of trying to expose defects on a case-by-case basis, we should be developing “defect strategies” that can detect the system is not behaving properly or that something does not seem normal with its inputs. By doing this, we can test as many defects out of our system as possible. But when a new one arises in the field, a generic Defect Resolving process will hopefully be able to detect that something is wrong and take a Corrective Action.
Lesson #5 – Sensors & Automatic systems sometimes Fail
The fact that “Sensors & systems sometimes fail” should seem like an obvious statement, but I see quite a few developers who write SW as if their micro-controller will never lock-up, encounter a single event upset or have corrupted memory. Sensors freeze, processors lock-up, garbage-in will produce garbage-out. As developers, we need to assume that things will go wrong, then write the code to handle those cases – rather than assume – we will always have a system that works as well in the field as it does in Test. If you design your system considering the fact that it could fail, you’ll end up with a more “robust” system that has to do a lot of hard work to do – before it finally finds a way to fail (if it ever does).
Conclusions: While it will be months before we have the full reports on what happened – that caused the 737 MAX crashes + results from the Congressional Hearings as to how the aircraft was Certified, we don’t have to wait for those results to draw lessons from them. We’ve examined several important reminders that all businesses need to carefully consider to make sure that they are not going down a similar path with their own systems. The question you should now be asking is” “What compromises am I making now and what actions am I going to initiate immediately, to make sure they don’t result in my own fiasco tomorrow.
Comments: Are there any other Leadership Lessons from the Boeing 737MAX Crisis that you can think of?
from DNYUZ & Design News 5/19 enhanced by Peter/CXO Wiz4.biz
For more Info, click on Leadership.