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Déja vu - Boeing 737 Max Accident


Published: March 27, 2019

For those of us of a certain age, the picture above is a grim reminder of what can go wrong with risky technologies. In 1986, the space shuttle Challenger disintegrated 73 seconds after liftoff killing all seven on board.


Why I am bringing up the Challenger disaster up in relation to the Boeing 737 Max accidents? 


A first blush, the recent Boeing 737 Max accidents seem to have the potential for similar historical significance. Like the space shuttle Challenger accident, emerging information about the design, manufacture, certification and operation of the Boeing 737 Max suggests a deep probe is necessary. 


While some may dismiss the Challenger disaster as an aerospace rather than aviation accident, it may be instructive to refresh our collective memories of the lessons learned from it. 


The immediate suspect in both the Challenger and Max disasters is technological. In the case of the former it is the O-rings and, in the later, the Maneuvering Augmentation System (MCAS).


Also, organizations are involved: NASA and Boeing respectively. While proven at NASA, we will likely learn that economic and production pressures at Boeing contributed to managerial short-circuiting of safety processes, or that management either did not fully understand the scientific or technical safety issues, or, if it did, it discounted or dismissed them. 


In the case of the Max, there is the role of the regulator. As the authority responsible for the safety certification of the B737 Max series, the Federal Aviation Administration (FAA) of the United States is involved in the causal story. As of this writing, the Inspector General of the United States Department of Transport will examine what role the FAA played. Surely, the apparent conflict of the FAA’s dual mandate to promote the civil aviation industry and regulate it on behalf of the public will be raised once again. As an aside, the FBI is now involved, therefore, criminal acts and/or malfeasance is in now scope. 


Like NASA, the Boeing and FAA “brands” have suffered severely. The public’s faith in them to manage safety on their behalf has been shaken to its core. Only after all the investigations have been completed and credible and observable changes made will Boeing and the FAA be able to restore their reputations and the public’s trust. 


Finally, unlike the Challenger where a Presidential Commission (Rogers Commission) was convened, no decision has been made to hold one for the B737 Max, though calls for one have already been voiced. 


As the title of this article suggests, we have seen the B737 Max story unfold before in the space shuttle Challenger accident. It should follow to ask whether the lessons learned have been wasted or not. 


The Rogers Commission made nine sets of recommendations. These ranged in scope from broad to narrow, from addressing larger managerial to more specific technical issues. NASA developed a corrective action plan to address each set of recommendations. These, it seems, did not have the desired effect. 


Seventeen years later, the space shuttle Columbia disintegrated upon re-entry killing all seven crew members on board. The Columbia Accident Investigation Board (CAIB) examined NASA’s safety management practices and said: “…the causes of the institutional failure responsible for Challenger have not been fixed.” 


In piecing together the information emerging from the Lion Air and Ethiopian Airlines accident investigations and news reports, I am reminded of Diane Vaughan’s ethnographic study of the launch decision of the space shuttle Challenger. In The Challenger Launch Decision – Risky Technology, Culture, and Deviance at NASA, Professor Vaughan suggests her study shows “how mistake, mishap, and disaster are socially organized and systematically produced by social structures…The cause of the disaster was a mistake embedded in the banality of organizational life and facilitated by an environment of scarcity and competition, elite bargaining, uncertain technology, incrementalism, patterns of information, routinization, organizational and interorganizational structures in a complex culture.”  


In September of this year, the International Society of Air Safety Investigators (ISASI) will be holding its annual conference in The Hague. The theme of this year’s offering asks: “Future safety: Has the past become irrelevant?” 


On this, I will defer to Professor Ms. Vaughan: “No one has forgotten the astronauts, the incident, or the shape of those billowing clouds that recorded the final seconds of the Challenger’s flight. Nonetheless, the loss of the Challenger, has receded into history, as the unfolding present, urgently demanding attention, replaces the past.” 


I think ISASI has its answer. 


Bryce Fisher

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