April 29, 2019, © Leeham News: Boeing got roundly thumped for blaming the pilots in the Lion Air flight 610 crash involving the 737 MAX last October.
It took months before Boeing CEO Dennis Muilenburg issued a video in which, among other things, he said, “We own it.” He was referring to safety of the MAX.
This was widely interpreted as Boeing stepping up and taking responsibility for at least some of the causes of the Lion Air and Ethiopian Airlines crashes.
Last Wednesday, he took it all back.
On the first quarter earnings call, Muilenburg denied there was any “technical slip or gap” in designing the now famous MCAS system. He said “actions not taken” contributed to the crash, a thinly veiled reference once again to pilot error. (More on this below.)
Aerospace analyst Ron Epstein asked Muilenburg on the earnings call the obvious question: How could this happen. Muilenburg’s reply:
There is no technical slip or gap here. Again, as I mentioned, we know that both accidents were a series of events, and that is very common to all accidents that we’ve seen in history. And what we know is that in this case, there was erroneous angle-of-attack information that came into the airplane from multiple causes. We know that at some point during the flight, that activated the MCAS control laws, and we know that ultimately there were actions or actions not taken that contributed to the final outcome.
I can tell you with confidence that we understand our airplane, we understand how the design was accomplished, how the certification was accomplished, and we main fully confident in the product that we put in the field. But we also know there are areas that we can improve, and that is the source of the software update here. But there was no surprise or gap or unknown here or something that somehow slipped through a certification process. Quite the opposite. We know exactly how the airplane was designed. We know exactly how it was certified. We have taken the time to understand that. That has led to the software update that we’ve been implementing and testing, and we’re very confident that when the fleet comes back up, the MAX will be one of the safest airplanes ever to fly.
Industry consultant Richard Aboulafia told The Seattle Times that Muilenburg’s statements were a clear indication Boeing’s lawyers are in charge of the messaging.
But, in fairness, Muilenburg’s statement is not wrong. Every accident is a series of events. It’s axiomatic that if one link in a chain of events doesn’t happen, the accident doesn’t happen.
There have been press reports that US pilots, citing superior training here vs overseas, believe pilot error is the principal cause of the two accidents. I wrote a column April 15 on this very topic. I’ve talked with the flight safety director of a US airline who is adamant the pilots should have successfully flown through the incidents had training been better.
On LinkedIn, there is a Boeing 787 captain for a major US airline whose career includes flying the 737. He published three long articles about the crashes. He believes pilot error is the prime cause of both accidents, with Boeing’s own culpability contributing factors.
The articles are here:
Cordell’s case for pilot error is a little light on assessing the automation part of the accidents (auto throttles, for example), but he goes step-by-step about what the pilots should have been doing. Among the issues: with the auto throttles keeping the thrust at take off power, this created flow over the horizontal stabilizer, rendering them impossible to move.
This “blow back” is something LNA’s Bjorn Fehrm wrote about on March 22.
Returning to Muilenburg’s statement that there was no technical gap in the MCAS system.
Linking MCAS to one angle of attack sensor is, arguably, the key technical gap in the system. It is a rule in aviation you don’t have a single point of failure. Boeing argued the pilots were the back-up, but in upgrading the MCAS (or “fixing” it might be another term), MCAS is now being linked to the second AOA indicator on the 737.
The tug of war between MCAS and the pilot might, arguably, be another technical gap. This, too, is being upgraded (fixed).
Failing to tell airlines and the pilots about MCAS may not be a technical gap, technically speaking. It nevertheless is a serious gap that has drawn embittered fire from the unions at Southwest and American airlines. The flight safety director I spoke with is also angry Boeing didn’t reveal MCAS to his carrier.
It was Boeing that didn’t tell Southwest Airlines (and presumably others) that the AOA disagree feature on the 737 NG was turned off on the 737 MAX.
Boeing said it didn’t want to “inundate” pilots with information. Yet it also said MCAS training would take half an hour on an iPad or similar device.
My view: Boeing’s decision to link MCAS to a single AOA and point of failure, the repetitive engagement of MCAS and not telling airlines and pilots about MCAS started the chain of events that gave pilots a situation about which they didn’t know what was happening or how to react. Training was inadequate and pilot errors occurred, even if they were “trapped” into making them. The chain links start with Boeing.
I’m reminded of Robert Crandall’s reaction after an American Airlines Boeing 757 flew into a mountain in Colombia, killing all aboard. Crandall was CEO of American. In a move that was unprecedented, Crandall acknowledged shortly after the accident it was American’s fault. No excuses. No buts. The pilots simply mis-programmed the flight computer for approach to the airport.
Muilenburg’s video statement, We own it, seemed like Crandall’s example of manning up. Instead, I’m reminded of the “I’m sorry, but,” syndrome.
A city councilman of the Seattle suburb of Sammamish (where I used to live) recently was found to have sent a highly inflammatory text message to another councilman. In it, Jason Ritchie used a vulgar sexist term, followed by a comment with racial overtones and ended with a political threat.
The ensuing firestorm prompted Ritchie to apologize on Facebook, followed by nearly 800 words of 16 months of grievances against his fellow council members for setting his mood and frustrations, leading to his text message outbursts.
It was the classic case of, “I’m sorry, but.”
Muilenburg’s is, “We own it, but.”