Flying Blind: The 737 MAX Tragedy and the Fall of Boeing

by Peter Robison

After taking in the proposal, Arpey informed Boeing that American had made its decision: it would split the order between the two plane makers.

Many Wall Street analysts reacted with relief; the program would cost $2.5 billion, compared with $20 billion for a full-blown replacement.

“Stingy with a purpose.”

“We’ve advanced success metrics that are at best superficial and at worst harmful.”

The implication was clear enough: the regulators were there in service of Boeing, not to police them.

The implicit message was clear: the FAA’s primary responsibility was to hasten the production and sale of American airplanes, not to burden plane makers with red tape.

This shift in the balance of power between Boeing and the FAA was the culmination of a decades-long war for influence, one embedded in the very nature of a place sometimes derided as “the tombstone agency” because it only seemed to act swiftly when people were dead.

Plane makers wanted license, in other words, to deputize and police themselves.

“It’s our belief that Congress and the American people have lost oversight of the deep workings of this major rule making committee,” he said. “It’s dominated by industry representatives whose goals may sometimes be at odds with the public interest.”

set up “Astroturf” organizations to give corporate messaging the appearance of grassroots support.

In her first major speech as FAA administrator, at the Aero Club in Washington in February 2003, Blakey announced what she called the “customer service initiative.” It was a breathtaking shift in emphasis. She said the FAA needed to be more responsive to its customers—by which she meant manufacturers and airlines, not the flying public. She expressed sympathy for the inconsistent answers and long waits they sometimes experienced—as if the country’s top aviation authority was some kind of corporate call center—without mentioning the funding shortfalls that had starved it of resources.

in the long term the public will see that what we have is a less safe system.”

“There is nothing in place to support the inspectors that are intimidated by the FAA management and by the airline because they do their job,” Bobby Boutris, the inspector at Southwest, testified in 2008. “In the performance of my duties, I have been asked by Southwest Airlines management to make a violation go away. In addition, I have been threatened by Southwest Airlines management that they could have me removed from the certificate”—denied the authority to certify planes—“by picking up the phone.”

Southwest had flown dozens of jets on tens of thousands of flights without inspecting them as required. When it finally did, it found cracks in a half dozen of the planes, including one crack that was four inches long. (Corrosion and cracking had also caused an Aloha Airlines 737 to rupture midflight in 1988, killing a flight attendant.)

In fiscal 2007, one goal assigned to Dorenda Baker, then deputy director of aircraft certification, read: “Certify the GEnx 1B [a General Electric engine] on the Boeing 787 by September 30, 2007.”

Steve Foss, a former FAA test pilot, watched as Boeing executives buttonholed his supervisors in parking lots after meetings. “It was push, push, push, shove, shove, shove, to get the airplane into the customer’s hands,”

When the specialists raised technical issues, they’d be told to stand down—often by Bahrami, the official in Seattle most responsible for ensuring the safety of Boeing airplanes.

The review of the battery was delegated to one of Boeing’s deputies, who decided the fire risk was remote enough that an enclosure wasn’t needed.

On January 7, 2013, firefighters at Boston’s Logan International Airport extinguished a blaze sparked by overheating lithium-ion batteries in a 787 Dreamliner parked there. No one was hurt.

when his phone started vibrating with messages about another battery fire. Passengers had to descend on the emergency slides of an All Nippon Airways Dreamliner after the captain smelled smoke in the cockpit

The next morning, despite the dramatic events, both Boeing and the FAA agreed the plane should keep flying.

Data still suggested battery fires were a rare event; it was possibly just a fluke that two happened in such close proximity.

It took three months to design the fix—an enclosure like the one the FAA engineer had asked about years earlier.

Most troubling to the agency’s specialists was that it wasn’t even a particularly complicated engineering problem; it was resolved almost as soon as it was raised.

“They should be handling these certifications much, much faster,”

I think if they started giving out some bonuses to move some things faster, they probably would see a lot of this backlog wiped out pretty quickly.”

McNerney only increased the intensity. The drive for efficiency was ratcheted up to the degree that workers were running scared throughout the development of the 737’s latest overhaul, the MAX.

a threat from corporate to move work outside of the Pacific Northwest had real teeth. Boeing started doing exactly that, and also sought pension reductions, even as plane orders rolled in and earnings soared.

During the MAX’s development, Boeing shipped more than thirty-nine hundred jobs out of the Puget Sound area.

Boeing closed an advanced research unit in Seattle and sent the work to Missouri and Alabama, two less union-friendly states.

“We’ve made choices there to go to more affordable areas within the business to again drive productivity and profitability,”

“The heart will still be beating, the employees will still be cowering.”

Boeing had introduced a new employee-ranking system that, according to Speea, made it more likely that experienced workers would be laid off. For engineers in their forties, the chances of a layoff doubled; in their fifties, it tripled.

“We no longer think that we’re hiring people forever,”

McNerney’s phrase—“more for less”—became the company’s driving theme as it embarked on the MAX, a sharp contrast to “Working Together,” the motto Phil Condit had advanced in the early 1990s during the successful creation of the 777. The implications were clear: More performance, lower cost. More range, less fuel burn. But also: more work, fewer people. And ultimately: more risk, catastrophic return.

On the 737-600, one of the Next Generation models introduced in the 1990s, Paul Russell, the product safety executive, stood up to argue with colleagues who were thinking about making a change to the fuel tank that might have created a single-point failure. “How much blood do you want on the seat covers?” he demanded of people in the room. (The design was changed.)

the MAX involved thousands of people spread across offices at Boeing and suppliers around the world, making tens of thousands of individual decisions.

also sent an update to the finance staff when critical project milestones were breached.

In dealing with the agency’s specialists, Boeing’s engineers came up with what was called “the drawer full of paper” technique. “If you can just inundate them with information it makes them go away,” he said.

Early in the program, Boeing managers told the flight controls team that under no circumstances were they to make any changes that would require pilots switching from the previous 737 to the MAX to step into a simulator. The reason: Boeing had promised Southwest $1 million per airplane if simulator training was required—and the carrier by 2019 had ordered 246. That was all the incentive Boeing needed.

But that would have been expensive, involving changes that would ripple out to other parts of the plane, and potentially jeopardize the all-important schedule.

Chief pilot Craig, for one, didn’t like the solution; he preferred a hardware fix.

But the benefit of software was simple enough: it was cheaper. The MAX program was already under cost pressure. Managers talked frequently about how any change would have to “buy its way onto the airplane”—suggesting that even safety-related improvements took a back seat to cost.

At a budget meeting in 2012, managers took a pencil to the planned test flights even before they had begun, asking for a reduction of three thousand work hours for flight test support and eight thousand hours for use of an engineering flight simulator.

“If we emphasize MCAS is a new function there may be a greater certification and training impact,”

As the memo noted, if everyone agreed it was just part of the same old system, no one would have to design any training or update the manual.

Boeing had chosen an unproven supplier to build the simulator for the MAX, the lowest bidder, and those simulators likely weren’t going to be ready in time for the MAX’s entry into service.

It could prove an obstacle to getting the entire program finished on time if the FAA ruled that pilots had to get into simulators before flying the new plane.

It was one compromise too many, and someone needed to say so—to stand up and make a “blood on the seat covers” declaration. No such objection came. The FAA’s deputies at Boeing signed off on the software solution to thwart potential stalls.

Ewbank and the others urged implementation of a backup system called “synthetic airspeed” already in use on the Dreamliner—essentially a computer program to compare values of all the sensors. If an illogical reading came from any of them—such as the AoA vanes linked to the new MCAS software—it would be deactivated.