Flying Blind: The 737 MAX Tragedy and the Fall of Boeing
What happened to Boeing and what can we learn from it?
For most of its history, people have looked favorably upon plane manufacturer Boeing: in 2019, it was #18 on Fortune’s “[100] most admired companies” list, up from #40 in 2009, likely given its soaring stock price and release of the new “Dreamliner” 787 plane. This was the last time it was on the list.
Over the course of 6 months in 2018/2019, 2 Boeing planes crashed, resulting in the tragic deaths of 346 people. The crashes, we all learned, were the result of corners Boeing had cut and issues with the plane they were aware of and didn’t disclose. The journalist Peter Robison dives into why this happened in Flying Blind.
Flying Blind: The 737 MAX Tragedy and the Fall of Boeing by Peter Robison (306 pages)
Summary
In October 2018, a Lion Air flight in Indonesia crashed, killing all 189 passengers and crew onboard people. The plane was the newly introduced Boeing 737 MAX. After the crash, Boeing executives reassured the public that their planes were safe. But less than 6 months later, another 737 MAX, operated by Air Ethiopia, crashed as well, killing another 157 people. This lead to an in-depth investigation that revealed that the crashes were caused by the same issue that Boeing knew about and hadn’t raised. How did this tragedy happen?
First, the original Boeing 737 was hastily designed as the company tried to compete with Airbus’s A320 line. And subsequent 737 generations didn’t address past problems, but simply patched on more and more workarounds. As the author explains:
Picture the basement of a hundred-year-old house, knob-and-tube wiring snaking through the joists, water pipes (some lead, some copper) running up the walls, all a reflection of compromises made over the decades
The 737 MAX was also a reaction to competitive threats. Airbus had unveiled a more fuel efficient A320, which Boeing needed to compete with. Given how expensive designing new airplanes is, they simply updated the current 737 design to make it more fuel efficient
The updated design caused the plane to “pitch up,” which is dangerous. To counter this, Boeing added autopilot software that would detect if the plane was flying at too steep an angle and correct it.
But if the sensor feeding the computer was faulty or wrong, the plane would start pointing down unnecessarily
Boeing developed technology to address this and tell the pilot when the sensor data was potentially faulty. But this was sold as an additional add-on that neither Lion Air nor Air Ethiopia bought.
Even without this, there were ways for pilots to regain control over the plane. However, Boeing excluded all references to the above system in the training materials / manuals for the new plane, in part so pilots wouldn’t have to spend time training on the new planes (= more costs for airlines as they are paying for nonproductive pilots)
The FAA didn’t do much after the first crash to prevent the second from happening
In short, it was a worst-case scenario where multiple things went wrong, leading to horrific consequences. Robison blames two specific issues:
A culture focused on short-term profits: Historically, Boeing represented engineering and product excellence. But in recent times - especially after its merger with McDonnell Douglas - Boeing was focused on increasing its stock price, which required, among other things, the on-time delivery of planes. Anything that would delay planes being delivered - which fixing the above would do - would cost the company money and profits in the short-run. As a result, teams cut corners. Some workers described finding “defective manufacturing, debris left on planes - wrenches, metal slivers, even a ladder” and facing pressure to not report these issues.
A captured regulator: Boeing was regulated by the FAA (US Federal Aviation Administration), which oversaw the safety of its planes and training of pilots. Over time, the FAA allowed itself to be pushed around by Boeing, and even started referring to it as a “customer.” This resulted in less oversight of the 737 MAX than there should’ve been.
Since the two crashes, the FAA has apparently cracked down on Boeing and held them to stricter standards. As a recent article puts it:
For years, Boeing and the Federal Aviation Administration handled 787 Dreamliner deliveries as though the perfect was the enemy of the good.
The FAA allowed the plane maker to deliver the wide-body jets with some minor flaws, so long as there was no immediate threat to safety. The expectation was that Boeing would fix such defects after the planes began carrying passengers, according to government officials and current and former Boeing executives.
That approach doesn’t fly anymore. Two deadly crashes of a different Boeing airplane, the 737 MAX, ushered in a new era of intense scrutiny of everything rolling out of Boeing’s factories.
Key takeaways
Don’t hide bad news - as one old Boeing manager would say, “The only thing that will make me rip off your head and s*** down your neck is withholding information”
What is convenient in the short term is often harder in the long term, and the more you patch over a mistake, the harder it becomes to unwind or fix
Many mistakes take multiple bad things or a “perfect storm” to happen, but over a long enough time horizon, they become more and more likely to happen. The best designed products and systems anticipate the “worst case scenarios” and address them
Thoughts and reactions
If you’re a manager or leader, how do you ensure that people aren’t hiding bad news from you? How do you even measure this? (you might catch some mistakes yourself, but what if you don’t?). I definitely don’t have the answer, but a few observations:
If you are a worker deciding whether to tell your boss bad news, you’ll take a few things into account: the consequences if you tell your boss now (you might look bad), the chance that the bad news will be found out, and the consequences if you don’t say anything now and you are found out.
If you want somebody to not hide bad news, you should try to make the consequences of them telling you proactively fairly low, and raise the cost of them hiding it (by increasing the probability that they’ll be found out = checking their work and making the consequences for hiding their work much higher.)
In other words, you should make an environment where people feel safe to bring up issues and potential mistakes, but where they also know that any issue they hide is likely to be found out and be a worse outcome for them. At the same time, a great leader will do this while maintaining high standards and expectations. The restauranteur Danny Meyer has this idea of “constant, gentle pressure” which he discusses in his excellent Setting the Table
This might be an argument against leading purely with fear - if your team is scared to even bring small pieces of bad news to you, it might cause more issues down the road
The lesson about identifying errors and fixing them quickly is an important one. Big projects take on a life of their own and continue picking up momentum, so waiting too long to fix or acknowledge an issue makes it really hard to deal with. And if you wait too long to bring something up and then finally do (rightfully so), you have opened up a “can of worms” where the other parties wonder (understandably) what else you’ve been hiding from them
This is tricky to fix. The authors of Overload, which I previously discussed, would say this is symptomatic of our current work culture, where people need to do too much in too little time, leading them to focus on getting things done as opposed to producing thoughtful and high-quality output.