As news of potential mishandling in the development, certification, and pilot training for Boeing’s 737 Max continues to percolate, the possibility that both the crashes of Ethiopian Airlines flight 302 and Lion Air flight 307 could have been avoided looms increasingly large.
It’s too early to paint a full picture, but the commonalities between the two incidents are uncanny. Operated by the nearly brand-new Boeing 737 Max, the two flights followed an unusual ascent pattern at take-off, crashing to the soil after less than fifteen minutes from departure.
As indicated by the Ethiopian flight’s jackscrew and the data Indonesian investigators have collected since the Lion Air crash back in November, in both cases, the aircraft’s Maneuvering Characteristics Augmentation System (MCAS) played a key role.
The 737 Max’s vaunted efficiency came with larger engines that had to be placed further up on the plane’s wing — a change that affected the airframe’s aerodynamic lift. To correct this imbalance, Boeing added the MCAS as a background adjustment process. The design was implemented in order to give the plane’s nose a downward kick in case a steep climb caused an aerodynamic stall.
Since the MCAS was supposed to correct the angle of the plane’s nose automatically, Boeing probably concluded that the pilots didn’t need to know about the changes this new piece of software was making to their ability to control the aircraft. And in keeping with the plane’s high-efficiency aura, a short iPad training session, rather than a full-fledged flight simulation, was considered enough to prepare the pilots to fly the new model 737.
In the meantime, the MCAS depended on a single sensor, which, as we know now, if faulty, could trigger fatal adjustments. And, much like the MCAS’ one-sided reliance on that single sensor, the FAA delegated the safety verification procedures of the new plane to Boeing’s internal auto-certification process.
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Clearly, neither Boeing nor the FAA accounted for the bias effect of external and internal pressures on key development and certification decisions that needed to be made prior to the release of the new 737. Yet, the weight of such pernicious forces may have been more than a contributing factor in shaping the disastrous outcome we are looking at today.
As the delivery of Airbus’ A320neos, an aircraft model comparable to Boeing’s 737, started hitting the market in early 2016, Boeing felt compelled to accelerate delivery of the first Max to early 2017, roughly six months ahead of schedule.
The compounded effects of both competitive and time pressure on decision-making can be fatal to ethical sense making and reasoning of decision-makers. For example, research has shown that the mere introduction of uncorroborated information from a competitor inhibits the use of pro-ethical reasoning strategies (e.g., anticipating consequences, considering the impact of one’s decisions on others, questioning one’s own judgment, etc.) and ultimately increases the likelihood of unethical decisions.
Similarly, the simple fact of having one’s performance compared to the performance of a peer makes people more likely to explain away the performance of others as somewhat unethical, an attribution that, in turn, may help rationalize one’s own unethical conduct.
What do these insights mean when applied to the 737 Max’s delivery and the competitive relationship between Boeing and Airbus? First, the very fact that Airbus was releasing a plane comparable to the 737 so far ahead of Boeing’s own schedule may have led Boeing to believe that Airbus was taking certain shortcuts. This, along with the initial evidence about the suggested cozy relationship between Boeing and the FAA may have had the effect of increasing the perceived legitimacy of pushing for and taking ‘unconventional’ steps in the plane’s certification process.
Second, the fact that Airbus was positioning the release of the A320neo as “by far the most efficient and most silent aircraft on short- and medium-haul routes…with lower fuel consumption and…lower CO2 emissions” may have led Boeing to focus on what it needed to do to match or exceed Airbus’ promises rather than on anticipating the consequences of its decisions on pilots, customers, and stakeholders.
The risk of jaded decision-making seems especially high in Boeing’s case because of the time pressure under which the company found itself. As various studies show, the more time pressure decision-makers are exposed to: the less time they spend on collecting information, the more likely they are to rely on feelings and gut checks, and the more imbalanced their approach to risk becomes. The effect of time pressure on ethical principles is equally corrosive, and often suppresses people’s ability to stop to consider the needs of others.
Within the context of the 737’s development at Boeing, pressure to accelerate the release of the new aircraft may have led decision-makers to evaluate data from completed test procedures as fully sufficient and adequately reflective of the plane’s safety. Yet, what the two crashes suggest today is that the plane’s weaknesses kick in under less ordinary circumstances — these scenarios would have required more time and testing to be fully understood.
Similarly, even though it was the first time the aircraft’s technology would take full control away from pilots, time pressure may have prevented Boeing from addressing the pilots’ need to know about the critical changes to the old 737. Instead, the idea that the pilots were familiar with the old 737 model and the use of software that enabled automatic adjustments may have been deemed enough. This, in turn, could have conveniently led Boeing to discount the importance of transparent information sharing and high-quality training.
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It’s remarkable that Boeing has responded to the current crisis by reclaiming its purpose and core values. Yet, if Boeing’s purpose “…is to bring family, friends and loved ones together with…commercial airplanes — safely,” and if safety “is at the core” of Boeing’s mission, why then did the company demure last week?
More importantly, knowing the potential weaknesses of its own development and certification process better than anybody else, why, immediately after the Lion Air crash, wasn’t Boeing more candid about the risks associated with the 737?
It looks like Boeing is still underestimating the bias that affected its decision-making process in the first place.
Caterina Bulgarella, Ph.D., pictured above, is the co-founder of Be Thread, a platform of tools for human-centric work environments, an SAI Global influencer, and a member of Ethical Systems’ core team. She’s a culture architect and ethics expert who advises senior leaders on culture change and ethical challenges. She can be contacted here.
It is one thing to suggest, based on research, that Boeing itself, and perhaps regulators, and even courts, should consider the bias impact Dr. Bulgarella describes. It is quite another thing to lay out an assumed scenario that has the number of "may haves" and "could haves" upon which Dr. Bulgarella's analysis hinges.
Thanks, John, for your comment. Indeed, there is a difference between the two.The former would amount to a theoretical formulation. The latter is a simulated analysis meant to highlight the very impact of the biases discussed in this new piece. Mounting evidence that pressure played an important role at Boeing (see this NYT piece: https://www.nytimes.com/2019/03/23/business/boeing-737-max-crash.html) prior to the release of the new 737 makes it vital for all of us to consider the practical impact these biases are likely to have. Especially because we are blind to them and tend to remain such until we ignore them or simply consider them from a merely theoretical standpoint.
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