It’s happy hour and my inhibitions are down, so I’ll confess that I am a major National Transportation Safety Board (NTSB) report junkie. Sadly, I’ve read almost all of the major incident reports going back for a stretch of time I’m embarrassed to name. So, I know that I shouldn’t speculate about the two 737 MAX incidents, but tequila tells me differently.
First, as a matter of historical interest, this isn’t the first time 737s have fallen out of the sky. In the early 90’s, an issue with the rudder actuator in 737s caused a couple of fatal accidents. If the first of these (in Colorado Springs) had happened today, it would have killed at least 100 people. However, back in the days before computer systems that sell every seat, 25 people were killed. Read that Wikipedia article I linked to see some excellent engineering in practice, as the NTSB was able to weave together a similar incident in a 747 to help solve the mystery of 737s falling out of the sky.
Second, the FAA has always been an industry lackey. If you read through NTSB reports, you’ll find that a remarkable number of their recommendations are rejected by the FAA. A good example is fire suppression. The NTSB had consistently recommended the use of fire-resistant materials in planes, and also the use of materials that don’t turn into poisonous gas if they burn. It took Air Canada 797 in 1983, where a fire in the lavatory ended up killing 23 persons despite some Sullenberger-level flying from pilot Donald Cameron, to push the FAA to finally beef up their recommendations for fire retardant materials and other measures to combat fire in an airplane. Everyone flying today owes a debt of gratitude to those poor people who died the miserable deaths that finally changed aviation. Since commercial aviation accidents are rare, it’s always easy for the FAA (with industry prodding) to say that the accident was an “isolated incident” or “pilot error” or whatever bullshit excuse they want to use.
Third, Boeing ain’t what they used to be. Their decision to farm out the manufacturing of the 787 to every corner of the Earth caused delays and if it weren’t the batteries that caused the grounding of that plane, it would probably be something else. With the 737 MAX, Boeing’s issue was that they wanted to push out another new variant of their popular narrow body plane without re-training pilots. Since the engines on the new variant were so large that they have issues with the 1960s era design of the 737, Boeing used a software hack (MCAS) to address a possible issue when the 737-trained pilots flew the 737 MAX by hand, and they somehow lubed up the FAA to accept that an airplane with a much different instrument layout didn’t need new training. But don’t trust me, listen to what a pilot said:
I think it is unconscionable that a manufacturer, the FAA, and the airlines would have pilots flying an airplane without adequately training, or even providing available resources and sufficient documentation to understand the highly complex systems that differentiate this aircraft from prior models. The fact that this airplane requires such jury rigging to fly is a red flag. Now we know the systems employed are error prone–even if the pilots aren’t sure what those systems are, what redundancies are in place, and failure modes.
MCAS plus an equipment failure is probably what caused the crash in Indonesia, and perhaps what happened in Ethiopia. The good news is that, unlike a rudder actuator or metal fatigue. this problem can be fixed with a combination of software upgrades and pilot training.
Fourth, Trump’s government shut down probably contributed to this problem. Boeing was working on a software fix to MCAS that was held up when the FAA shut down slowed negotiations.
Finally, if you’re interested in more on this, look at James Fallows’ posts.
The post title is a reference to the fact that human beings take for granted that once a engineering challenge is solved, it should be trivially easy to solve it the second time, so it should take a fraction of the time and money to fix. The 737 MAX is a great example of why this isn’t true: Boeing engineers, under massive constraint, built a new plane and called it a 737. If their engineers had started with a blank slate, Boeing management would have been a lot more cautious about rolling it out. Instead, here we are.