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
Challenges for investigators
of the Ethiopian Airlines
Boeing 737 Max-8 accident
Published: March 12, 2019
Not since the fatal accidents involving three De Havilland Comets within the first year of commercial service back in the early 1950’s has the world’s attention been drawn to the safety of one type of commercial aircraft.
Having occurred within 6 months of the same model used by Lion Air of Indonesia, the Ethiopian Airlines Boeing 737 Max-8 accident on 10 March 2019 has had the same effect.
At first blush, the similarities between the two Boeing accidents immediately raise suspicions about the Maneuvering Characteristics Augmentation System (MCAS). The preliminary findings of the Lion Air flight 610 accident investigation suggest the MCAS system activated but the crew were unable to override it or overcome its effects.
Whether the crew of Ethiopian flight 302 experienced the same issue is yet to be confirmed. Analysis of the flight data and cockpit voice recorders will be critical in this regard. Between now and then, however, the Ethiopian investigation authority, indeed airlines and governments world-wide, face some particularly daunting challenges.
First, the pressure to draw conclusions or make pronouncements on the causal or contributing factors in the absence of substantiated evidence. The pressure will be significant - everyone wants answers and quickly.
Of utmost importance is to allow the investigation to run its course to know what happened and why, and how it can be prevented going forward. A properly managed investigation takes time, especially one as complex as this will certainly turn out to be.
Linked to this is the importance of resisting the urge to lay blame or attribute liability. Statements made and actions taken recently are already establishing safe and unsafe camps. Whether or not these positions are safety, politically or economically motivated is irrelevant - the lines are being drawn.
Second, the investigation process led by Ethiopia’s investigation authority must preserve its objectivity and independence. There are significant and powerful parties with a vested interest in the outcomes of this investigation who may sway, implicitly or otherwise, the direction of inquiry in a manner that supports their positions. Article 3.2 of Annexe 13 to the Convention on International Aviation, which deals with accident investigation, bears repeating:
“A State shall establish an accident authority that is independent from State aviation authorities and other entities that could interfere with the conduct or objectivity of an investigation.”
Ethiopian authorities will want to keep their own counsel during the investigation, manage accumulated information carefully, and consider making use of experts and expertise independent from the parties in question.
Given the short time span and initial similarities between this and the Lion Air accident underscores the importance of the investigation. There is much at stake.
This is not an Ethiopian issue, it is an international civil aviation safety issue. As with the De Havilland Comet, the lessons learned from the investigation will have an impact aviation for years to come. Therefore, protecting the integrity of the investigation process is of paramount importance for the advancement of aviation safety and for the loved ones of the victims of both Lion Air 610 and Ethiopian 302.
Bryce Fisher
Fisher