Episode 4 – The Context of Failure: Setting the Stage, Part 2
I conclude our examination of key forces that have shaped aircraft design and manufacturing – and subsequently, the MAX 8 – by addressing major trends in manufacturing operations and the regulatory environment.
Then, we turn to the MAX's origin story and the context it set for design. The competitive threat posed by the Airbus A320neo created dilemmas for Boeing that constrained its options. Emerging from this were three critical program business imperatives that profoundly shaped how program leadership thought and acted, setting the stage for risky decision-making.
Please share your views, insights, and opinions through the MAX8 Podcast Comments form. Episode 12 will be dedicated to feedback from listeners such as you.
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EPISODE HIGHLIGHTS:
(0:51) – Structure of this episode?
(1:13) – Forces shaping the industry: Manufacturing operations.
(6:45) – Forces shaping the industry: Regulatory environment.
(15:53) – The 737 MAX 8 program – The competitive challenge and Boeing’s dilemmas.
(20:54) – Three profoundly influential program imperatives.
(23:57) – Early design issues and decisions.
(31:37) – Seeing the mechanics of failure better with a “Context” perspective.
KEY POINTS:
Manufacturing Operations.
A substantial move to outsourcing and more complex supply arrangements have led to challenges in oversight and quality control. These issues first appeared with the Boeing 787 Dreamliner program a few years ago and have recently captured the attention of the media regarding the MAX program. The lesson is that poorly controlled supply chains and poor manufacturing work practices can lead to all sorts of safety issues, leading to what some have described as a “broken production system.”
Regulatory Environment.
The FAA’s certification process is very complicated, and its explanation should be left to other experts (see the U.S. Department of Transportation report on the aircraft certification process under Useful Episode Resources).
In the episode, however, I address two important concepts. The first is the process of how new aircraft are certified, leading to a “Type Certificate” (TC). The FAA approved the original 737 design in 1967 under a TC. For each subsequent 737 generation, however, the design has been certified through an “Amended Type Certificate,” which narrows the areas of design that are closely examined, thus saving time and cost. The MAX was no different.
An important part of simplifying the process involves the “Changed Product Rule.” Here, the FAA can grant exceptions to certify a modified area to an older standard under certain circumstances. This means that a patchwork of changes can occur narrowly in specific areas without a big-picture review of the potential combined impacts on existing systems and related interactions at the aircraft level,
One other point about the impact of regulation on design decisions: because of certification challenges, designers sometimes decide to limit changes even where a more substantial change could lead to a better outcome.
The changing organizational structure of regulation.
For years now, the FAA has had a capacity problem—it was not staffed and skilled sufficiently to oversee the development and manufacture of today’s complex aircraft. This led to “manufacturer self-certification” where day-to-day responsibility for aircraft design certification activities lies with the manufacturer’s employees, who then report results to the FAA.
A particularly consequential change in this arrangement occurred 20 years ago. Under the original regulatory structure, Boeing’s on-site safety engineers, who were dedicated to certification duties, were appointed by the FAA and reported directly to their counterparts at the FAA – Boeing just paid the salaries. Starting in 2004, these engineers began reporting directly to Boeing managers, not the FAA. Also, their certification work might not be full-time, which can affect their priorities.
The competitive challenge and Boeing’s dilemmas.
Boeing had boxed itself in strategically due to previous indecision and delays on the future of the 737-model line and the sudden threat of the A320neo.
Here, Boeing faced two dilemmas.
A total replacement aircraft now faced potential development costs of over $10 billion and take years to achieve while potentially not offering the airlines much more economically over a new 737 variant in the short term.
Boeing had a “lock” on existing 737 customers. It was economically very difficult for airlines to move to Airbus because of the tremendous costs tied to operational and training changes. Offering fully new Boeing aircraft made the airlines’ option to switch to Airbus economically equivalent.
So, Boeing saw the airlines' preferences for a new 737 variant that could be delivered quickly. Central was the guarantee that a pilot certified on the existing 737 NG model would be able to fly a new 737 variant without significant retraining. That requires minimal differences in the cockpit design and in how the aircraft “flies” for pilots – what is called “handling characteristics.”
Three powerful program imperatives.
Boeing's leadership established three business imperatives (goals) for the new MAX program, which were clearly and adamantly communicated to the program team:
Meet the airlines' agreed-to delivery dates for pre-ordered MAX aircraft.
Strictly limit recertification requirements of the airplane’s design. This was key to meeting the delivery dates and meant that the MAX must carry forward all prior NG certifications except where essential changes are made.
Strictly minimize required training for pilots already certified on the NG. This is tied closely to the recertification process—the fewer design elements requiring recertification, the less new training is required.
This created a mindset of strictly controlling recertification activities and pilot training and led to an intense focus on minimizing design changes to the prior 737NG variant, including the cockpit experience for pilots.
Here, we see a powerful example of how business context—in this case, program goals—shapes people's thinking and actions.
Early design issues and decisions.
The critical change in the 737’s design was the installation of larger, more fuel-efficient engines that had to be repositioned forward and then up on the wings to clear the ground compared to their previous location on the 737 NG model. This created a problem with the center of gravity front to back of the aircraft.
Moving the engines forward shifted the aircraft’s overall balance point, or “center of gravity,” in a way that would come to haunt the design process in the Structure phase.
One non-decision was not installing a state-of-the-art “Engine-Indicating and Crew-Alerting System,” available from other aircraft programs, which presents faults on a digital screen and directs pilots to the appropriate emergency checklist. Retrofitting this into the 737 represented a substantial effort and ran counter to the three business imperatives.
A growing inability to see problems.
A practical impact of this environment was an emerging inability to react to “weak signals.” Organizations with strong safety and reliability processes and practices are very good at recognizing things that sort of “don’t feel right”—that is, a weak signal versus a blatant, in-your-face problem—and investigating them thoroughly, then doing what is right.
“Context” as a distinct element in organizational failure.
We must separate events in Context from later decisions and actions. Boeing's culture shifted from engineering-centric to profit-centric. This sets the stage for dangerous decisions but is not the socio-technical mechanism that caused the two crashes.
An example of this is the financial and program goals. The goals were undoubtedly a powerful factor, but in what ways precisely? They are not the work of design, testing, and certifications for the MAX and MCAS. How did the three business imperatives lead to disaster on those two mornings half a world apart? They did so by shaping how people thought.
This sets the stage for mistakes downstream. It sets the “context” in which engineers, managers, and other parties would subsequently act, and those actions are part of the Structure of Failure. Both phases must be understood in their own way and addressed appropriately to intercept failure before it happens.
USEFUL EPISODE RESOURCES:
Ostrower, Jon. “Boeing’s MCAS on the 737 Max may not have been needed at all.” The Air Current. January 10, 2021. (This article also provides excellent insight into the design process, relevant to the next two episodes of this podcast.)
U.S. Department of Transportation. “Official Report of the Special Committee to Review the Federal Aviation Administration’s Aircraft Certification Process.” January 16, 2020.
THING YOU CAN DO:
Let me know your thoughts.
Please share your views, insights, and opinions. Episode 12 will be dedicated to feedback from listeners such as you.
You can contact me through the MAX8 Podcast Comments form. While I may not be able to respond to all comments, I will read each one carefully. I’m very interested in your thoughts.
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