Congressional inquiry faults Boeing and FAA failures for deadly 737 Max crashes
npr.org
npr.org
That is being very kind to Boeing management. Its blaming the engineers and the FAA but the management was just not transparent? Boeing fought hard for their autonomy and ability to self certify, so I guess the FAA failed by allowing that. But that doesnt exempt the management at Boeing who was supposed to create an organisation with processes in place to design and build safe airplanes. They had such an organisation but failed to maintain it as such. That's more than a lack of transparency.
Responsibility is for the stupid, certainly not for management.
By system so your mean the MCAS, the airplane, it Boeing. I don't think you're correct if your mean the MCAS or how it integrated with the airplane. You don't think they had any sort of integration tests established? Also, one one the failings was that the system only relied on input from a single sensor, so that failing should have been extremely obvious.
Unless by system you mean Boeing as a whole. I'm sure that as a part of the requirements process they were told that the system can be deactivated (which it could be), and I'm sure they were probably unaware that pilots were not being trained in disabling the MCAS. That makes those technical failures still obvious, but nonetheless understandable and maybe even acceptable in that context.
I meant to say that few things are that obvious if they aren't specified. There should be a point in the risk analysis that handles sensory errors, possible consequences and risk mitigation and if it wasn't specified there, it would have been an error. Go up the chain from there.
I doubt that software engineers necessarily know much about the reliability of sensors. You mostly learn that from experience. That is why you should include as much experience in the analysis process as possible. A pilot or the air techs would probably have mentioned the tendency of sensors freezing or having some form of malfunction.
Only then can the softies develop a fault tolerant system. After a failure it is always obvious to everyone, but as you said, perhaps they just thought the pilots would notice the error and override the system. Also an obvious assumption that should be documented as mitigation to reduce risk.
No risk analysis is perfect, but after the accidents we can expect some diligence and discipline in my opinion and hopefully this accident leads to a review on these processes instead of finding some fall guys.
A thorough integration test would probably also have detected the issue at some point and maybe here are faults as well.
Regardless of whether Boeing were willing to certify the system as not being training, those responsible for pilot competence at the purchasing commands should still have ensured pilots were trained before using the system.
If a garage sells you a roadworthiness/MOT certificate when a vehicle isn't roadworthy, and you know it isn't, then we're both at fault.
That's a management failure right there. But fine, if managers want to take a "shut up and do as I say" attitude, then they need to be responsible for the results of what they said to do.
Also, the thing they were least transparent about was probably hiding the differences between the Max and the regular 737. They hid those differences so that they could be certified as the same type and not require additional pilot training. That's not a lack of transparency, it's deception.
"You clearly misunderstood what I said. I never said to design MCAS. I wanted you to build MCAAS. The extra A implies the redundancy the system requires. Sheeesh." Phew, now I'm no longer responsible for this mess.
There absolutely would have been systems engineers in charge of the various budgets and margins baked into the design. Safety is always a top one in aviation. In fact, Id be surprised to find there wasn't a team of systems safety engineering on the max. We need to see their analysis to understand whether this was a fault of engineering or management. If the engineers had done a thorough systems safety analysis and quantified the risk, then the responsibility definitely does not fall on engineering.
But generally there is a R&D lead that makes the decision to implement it. There may be responsibility there, but the decision to design the plane this way was an economic one.
Some reported internal pressure to develop quickly. By now, that is probably standard in the industry where any software is involved. So apart from an engineering position that could nearly crash or delay such a project...
If the system reactivated wrongly, it is certainly a bug and I think they have already fixed that problem. But an error that is hard to identify and the system was basically just designed to conform to regulations defining flight characteristics to evade renewed certification and training.
Of course there are still valid design criticisms possible if you take security real serious.
For starters, display good leadership traits like accountability, including to themselves. I'm worried the signal we're sending right now is that weak leadership traits are rewarded which incentivizes weak leaders.
These people's success is measured in dollars and little else so of course everything gets thrown under the bus if doing so will make more money.
Who are 'them'? The executives of these companies? Yes, of course some of them will act this way at least some of the time, and the question is what do we do, if we don't like it? We have some options, such as preferring candidates who favor stronger accountability and effective protection of whistle-blowers, and who are opposed to installing, as the political appointees heading the regulatory bodies such as the FAA, people to whom these executives can go to to get pressure applied to the professional regulators to back off their objections to what is going on. We can also support responsible investigative journalism by subscribing to it.
So, yeah, I'm not expecting things to improve anytime soon.
Also, I’m astonished that Boeing continues to talk about when it’ll deliver the 737 Max when no-one will ever willingly fly in one of those planes.
Even their own staff have said in writing that they wouldn’t let their families fly in one of those planes.
Boeing’s utter lack of awareness of the gravity of the situation continues to amaze as much as the absurdity of this statement.
Part of the reason Boeing is going to survive is the pure fact that Airbus can't make enough airplanes to cover the market.
China already has a 737 MAX competitor - the COMAC C919.
People have been a bit wary of Chinese safety but Boeing kind of gifted them the benefit of the doubt on that front.
>gifted them the benefit of the doubt on that front
I haven't seen anyone discuss this, but China was responsible for (justifiably) grounding the MAX around the world and crippling Boeing short term. CAAC was the first to ground Chinese MAX fleet after Ethiopian crash, which inspired everyone else to despite FAA insisting MAX airworthiness. I'm sure US is going to remember that when COMAC is open for deliveries, not that the US will ever buy, but the smearing is going to be rough.
I expect Ethiopia will be happy to buy COMAC. As will most other countries in the world that witnessed this shitshow.
The plane is pretty much ready. It'll start flying in 2021.
When Boeing starts shipping 737-8200 instead of 737 Max 8, then most people are going to be releaved that they're not on a Max, when they are.
Personally, I'd like to see what experts think about the fixes, and let other people try out the planes first, but this doesn't seem like an unfixable problem. The proposed fixes seem to me like they'll be effective even if I think other changes would be better. Although there was a lot of new scrutiny, there weren't many other issues uncovered.
I am really impressed with the flight crews ability to work as a team to get the thing on the ground upright most of the time while remaining calm on the radio. Don't get me wrong, I love flying and plan to get my pilots license some day. I am just not a fan of the aging fleet and very dated technology.
My experience in this industry is that many of the most important engineering decisions are made by management. Not to excuse their engineers, but on the topic of management getting of lightly, I wonder how many of those "faulty technical assumptions" should fall at the feet of Boeing's management.
Engineers are almost never to blame in these situations, even if they are the direct cause of an issue. There's usually so many of them that someone catches problems. But they are powerless to do much more than send a strongly worded email to their management.
Until C-suites and board members are held personally liable for tragedies like this, I doubt much will ever change. There's no real incentive to fix problems, when it costs too much money because the worst thing that will happen is, a few years down the road, there might be a Congressional inquiry and a modest fine.
Of course, any engineer whose malfeasance costs the company even 0.001% of that fine will find themselves in jail at the behest of company leadership, even if no lives were lost or any measurable damage was done to the company..
I strongly disagree with this. Engineering is a profession of public trust, even if operating under an industrial exemption to circumnavigate licensure. We need to hold ourselves accountable to those standards or else it risks becoming a vocation devoid of responsibility and lacking accountability similar to the C-suite positions that people rail against in this thread. I don't think society would cut a doctor or lawyer slack for 'just doing as they're told' and I think engineers are in the same area of public trust.
Good organizations should have dissenting opinion processes. The advantage is that it gives a way to hold management accountable (e.g., they must formally acknowledge that risk). Sure, using that process may come with professional risk, but that should come with the territory of a position of public trust.
If I make a mistake, which is discovered, as long as I attempt to correct the problem, I'm absolved of fault. A miscalculation is an accident. Knowingly deploying a faulty device due miscalculation is malfeasance. I may have made the calculation, but I never made the decision to let it kill people.
I don't know about how NASA handled dissenting opinions in the Challenger days but my understanding is they have grown into more of a risk-informed decision making culture. I do think they have engineers who can stop work and force management to formally accept that risk nowadays. I don't know if Boeing has similar processes.
This isn't a miscalculation scenario. This is knowingly not following their own processes. At least according the the hazard analysis reported by the Seattle times, their own processes said there should have been a default redundant sensor. Not as optional equipment, but as the default configuration. The engineer may not have the final say but they do have a responsibility to drive that risk decision. If they know they are doing something dangerous or unethical, in my (perhaps unpopular) opinion they have a responsibility to voice that or leave. I say that as somebody who has been pressured in these types of decisions in an aerospace domain.
Challenger was somewhat different. Challenger was from a lack of temperature data, meaning they didn't have a good probabilistic rationale for either GO/NOGO decision. In hindsight, the safe bet was to wait for conditions that fell within the known data. As I understand the Boeing case, they identified the hazard but didn't follow their own procedures to mitigate it. That isn't really the same case of an "known unknown" but rather an "known known" that they didn't mitigate. I do think the engineers are culpable to a certain extent there.
Edit: >I may have made the calculation, but I never made the decision to let it kill people.
I think this may go along with our differing opinions on the standards of the profession. In my view, there is a certain level of expected competence one should be held accountable for. That’s why doctors can be sued for negligence even if it was an “honest mistake”
How do you know they didn't?
They will keep leaving and management will keep firing people until such a time they get people that will go with their decision.
Management has final say.
> Challenger was from a lack of temperature data
No, they had data alright. They had data from previous flights showing O-ring degradation. There were two, and at least one flight the seal got broken on the first O-ring completely and started on the second. NASA's own procedures would not allow launch if they were routinely exceeding their safety margins, so those got changed.
On the day of the fateful launch, engineers responsible for the boosters raised concerns due to the low temperatures. Those were escalated to a very high level in NASA. They were ultimately overruled.
Maybe they did, but the point I was countering was that they don't have responsibility, not that they have to stay. I.e., I disagree that you can ethically both shed responsibility and stay doing the job knowingly in an unsafe manner. If the end state is they only hire people who agree, it stands to reason both the engineers and managers share culpability. For those engineers who hold licenses, that becomes a backbone-stiffening measure. Not only do you approve said design, management needs you to in order for the design to be legal.
>They had data from previous flights showing O-ring degradation.
This isn't the same as saying they had data regarding the O-ring reliability at the low launch conditions of the day of the catastrophic failure. IIRC, the unique condition was the launch was occurring during previously un-encountered launch temps. "Raising concerns" isn't the same as saying you have incontrovertible evidence; that was the main crux of the decision. There will always be people raising technical concerns on these programs. Without good relevant data, schedule risk outweighed the un-quantifiable technical risk. It's been a while since I read the report so maybe I'm wrong on this.
IMO, Columbia is a better analogy. It was a known out-of-spec condition they decided not to mitigate because they were lulled into complacency
See: Challenger: A Rush To Launch https://www.youtube.com/watch?v=2FehGJQlOf0
If you believe engineering is a public trust profession, you owe it to the public to at least do due diligence. My issue is the people in this thread saying "It's all managements fault" and displacing any responsibility from the engineers. The engineers are the technical authority for management. We should strive to make sure management understands that technical risk; if they do and proceed anyway I think the engineers have done their job. That's what I think happened with Challenger. That's different from placating management because you're afraid for your job or plowing forward knowing a design will put people at risk.
If the bar was to get every program engineer to give a GO, there would never be another launch. There are engineers who don't trust aircraft that have flown for decades in part because we are bad at judging overall systemic risk. NASA has since instituted formal dissenting opinion processes and distinct technical authorities to allow risks to be raised and formally acknowledged without grinding the process to a halt.
The next day, Challenger lifted off from its pad at Kennedy Space Center. At first, the launch appeared normal, but 73 seconds into flight the shuttle exploded, sending fragments arcing across the bright Florida sky. In view of a horrified public, including thousands of schoolchildren watching a live broadcast, seven astronauts plummeted to their deaths in the Atlantic ocean."
You might want to read the full article:
https://whistleblowing.us/2012/02/remembering-roger-m-boisjo...
As for Congress blaming "the engineers."
Virtually all American whistle blowers lose their jobs and are placed on a banned list. They are branded traitors and conveniently become sexual predators, rapists and pedophiles. From the ensuing manhunt, you'd think the whistle blower's the head of a terrorist organization. It's straight to prison if they are caught. And a constant looking over their shoulders if they escape the country.
But "management", the guys who actually did something illegal? Life goes on uninterrupted,... retire and become an amazon director.
Knowing the risk involved, how can anyone expect any rational engineer to leak stuff?
If not a single Boeing executive goes to prison for this, then this exercise is a sham, looking for helpless scapegoats to salvage the company's reputation and reduce its loss of plane orders.
Because that is the ethical mandate of the profession. “Profession” as in the root of the word to profess a vow. That consideration doesn’t come with the caveat of “as long as it’s convenient to your career.”
I get that it’s not easy. I just don’t like how people will give themselves ethical loopholes in a professional realm but not a personal one. As I stated in a different comment, I don’t think Challenger is the same as this Boeing case. In any event, NASA has instituted procedures to try an empower engineers to hold managers accountable
And yet, Columbia happened. Again, concerns from engineers were dismissed.
I'm not making a claim they are perfect, but they may strive to be. Columbia instituted more changes, including a completely separate safety technical authority. This is a separate signatory who must approve operational decisions and (in theory) doesn't face the same schedule pressure. I'm still somewhat personally skeptical if this will avoid such further incidents because much of these are rooted in humans inability to understand risk in a statistical manner.
When losing your career potentially means losing your home, your health insurance, and putting your family out on the streets; it's a lot more than just "an inconvenience" to your career.
What needs to change is that there need to be more stringent protections in place for engineers who blow the whistle on this kind of stuff and prevents companies from effectively destroying the lives of those who blow the whistle.
Luckily, we're talking about rare cases. Would you extend the same to a doctor who puts a patient at risk because he needs to make a mortgage payment?
Maybe I'm unreasonable, but I think if someone isn't willing to hold an ethical line they shouldn't be in a career of public trust. There's no shame in pursuing other professions, there should be shame in undermining the public trust because you aren't willing hold that line.
Informally, you have the onus to create a culture of accountability and each individual has the responsibility to uphold it. One way you do the opposite is for people to claim "engineers are almost never to blame". Maybe this is a third rail to bring up at this moment, but you can see how much culture matters when bad policing surfaces. Would you say "Beat cops can't be blamed, it's only the chief's fault"?
Formally, you can lean on licensure requirements. Requiring an official "approval" from a licensed engineer (and the accountability that goes with it) helps ensure the public trust oath isn't just a rubber stamp.
Most. If engineering has to be subordinate to management and not equal, then management must take responsibility for their decisions.
Yes, but that failure is enormous. That a certifier should hand off certification duties to the entity being certified boggles the mind, and they should bear very substantial blame for that decision.
To what extent should shareholders take some of the brunt for their fickle behavior and threatening to short Boeing stock if they don't sell sell sell earn earn earn, instead of holding long term for Boeing to resolve safety issues at the right pace, which in turn sets the behavior of internal managers at Boeing?
Blame in an engineering context is rarely if ever productive. But, if you have to blame, you really need to check if the issue was raised to management before you blame. In this case I'm pretty sure the issue was raised, so it's not really on the engineers.
> Republicans on the committee did not endorse the investigative report. [..] criticized Democrats for an investigation that "began by concluding that our system was broken and worked backwards from there."
So, do many republicans hold the view that killing 346 people in the first year of service is acceptable business practice?
Sounds a lot like whataboutism to me
Working backwards from a desired claim to generate only supporting facts would reinforce only that claim. It’d be like the police only investigating the one usual suspect and refusing to look for evidence that did not pertain to that suspect.
Working forwards from gathering facts to a conclusion may lead to the same place or somewhere entirely different.
It’s called parallel construction. When police use it, it’s grounds to get your whole case thrown out (for very valid reasons... if you can prove it).
See:
In my opinion, the crashes are not facts with which anyone could reasonably argue. I don't think there's room to argue that maybe the crashes were unrelated, for instance. Given that we can all agree that the crashes occurred and were caused by a similar fault (in this case MCAS), I think it's entirely reasonable to "work back from there" and figure out _why_ this airliner was certified as safe and through that exercise discover what changes can be made to that certification process to prevent other dangerous airliners from being certified.
I don't know if that is really a desired claim, but both sides in politics have their desired claim to support whatever solution better fits their desired end.
First you very carefully selected what to quote. You cut out this part:
> A statement from ranking member Sam Graves of Missouri says, "if aviation and safety experts determine that areas in the FAA's processes for certifying aircraft and equipment can be improved, then Congress will act."
Which makes it clear they mostly disagree about what the investigation results say about FAA, not Boeing business.
Then you suggest the republicans not being ok with the investigation findings means they are ok with killing people. They do not agree with WHY and HOW these people got killed, obviously not disagree that this should have not happened.
How you can misrepresent the other side so badly and still be so self righteous is beyond me.
It takes some pretty significant mental gymnastics to convince yourself that the FAA's approval process wasn't critically flawed in the case of the MAX.
The reality is one party long believes in giving business a lot of slack, and then only speaks in grumpy platitudes about the limits of business free-for-all when people die. They don't want a bullshit idea to be seen as bullshit. They just want to profit as much as possible with a number of deaths that the public finds acceptable enough to not call b.s. on the system itself.
If any event involving hundreds of deaths at the same time could be pinned on a person, they'd go to prison. This system is expressly designed to spread the blame and obfuscate just enough that fines will be paid, and life goes on. Except for those who died.
I agree this doesn't exactly equate to the conclusion drawn about republicans, but it does further expose that there is no limit to generating partisan/political quotes where they don't belong.
Regardless of who you side with, note that many on the congressional investigative team took contributions from Boeing and tried to steer blame to individual pilots/airlines (including Sam Graves and some democrats).
Source: https://www.corporatecrimereporter.com/news/200/blaming-dead...
That's quite the assumption. I don't even know what 'broken' would mean for a certification process as byzantine as the one used by the FAA. I think you should either be more specific, or take the time to learn a bit about the systems, processes, and failure modes of complex multi-stakeholder processes.
Yes, but for me, regulatory capture seems to be a central issue in what went wrong, so I am highly skeptical that this is not an ideologically-flavored conclusion.
FWIW, I first approached this incident (prior to the second crash) from the point of view that it was probably either pilot error and/or an unfortunate malfunction, so I think I can fairly say that I have come to my conclusions in a forwards direction.
The fact that this is an accepted business practice is insane to me.
Note that without the revolving door both sides would be worse off. (Unless you take some other action to mitigate this - I can't think of anything but there might be a complex answer)
The process of doing so and ensuring it would be very laborious in that you would have to document every last detail, go through and make sure they were covered, make sure they were retained, and make sure that their understanding of every last detail is identical. Making matters worse is the mix of implicit and explicit. If you use a sprocket on something the design implicitly states "Do not allow it to rotate that way!" An added strut on a panel already more than capable of supporting itself and the rest of the structure may be redundant or needed to shift resonant frequencies into a range where they would be irrelevant.
One of the reasons DARPA program managers sit a fixed term is to precisely prevent careerism and castle building. The reason members of congress have a staff is to support them in researching topics.
But ultimately it comes down to the public, being informed by media, holding politicians responsible. I may disagree with portions of Bernie and AOC's political platforms, but one thing I don't have to worry about with them is that they're in the pocket of a company like Boeing.
We get the government we ask for. Want better? Raise your expectations and vote accordingly.
It’s ironically not unlike the regulatory landscape that led to the Boeing situation in the first place - the entity charged with oversight was much too deferential to those it was supposed to be overseeing.
This statement alone is hilarious considering that the FAA approval is a poster-child example of regulatory capture.
Here's the secret: the FAA let's the companies SELF-REGULATE and SELF-APPROVE planes.
The FAA did NOT approve the Max, because Boeing did.
>>A total of 79 companies are allowed under federal policies to let engineers or other workers considered qualified report on safety to the FAA on systems deemed not to be the most critical rather than leaving all inspections to the government agency.
>>To critics, it's a regulatory blind spot.
Once you know how this works, that statement by bad-faith-actor Sam Graves is laid bare. Of course we know how to improve the processes: Step 1: Don't put the Fox in charge of the Hens!
>>> How you can misrepresent the other side so badly and still be so self righteous is beyond me."
Something you yourself could have learned from before posting!
"Here are the total contributions from Boeing to members of the House Aviation Subcommittee during the 2018 election cycle. Republicans: Troy Balderson (R-Ohio) $0. Brian Fitzpatrick (R-Pennsylvania) $9,700. Mike Gallagher (R-Wisconsin) $5,999. Garret Graves (R-Louisiana) $6,000. Sam Graves (R-Missouri) $10,000. John Katko (R-New York) $15,400. Thomas Massie (R-Kentucky) $0. Brian Mast (R-Florida) $7,681. Paul Mitchell (R-Michigan) $5,000. Scott Perry (R-Pennsylvania) $3,000. David Rouzer (R-North Carolina) $2,000. Lloyd Smucker (R-Pennsylvania) $8,000. Ross Spano (R-Florida) $0. Pete Stauber (R-Minnesota) $0. Daniel Webster (R-Florida) $0. Rob Woodall (R-Georgia) $2,000. Don Young (R-Alaska) $1,000. Total Boeing Contributions to Republicans on the Aviation Subcommittee $75,780. Average for each of the 17 members: $4,457.
Democrats: Colin Allred (D-Texas) $94. Anthony Brown (D-Maryland) $8,500. Julia Brownley (D-California) $0. Salud Carbajal (D-California) $5,000. Andre Carson (D-Indiana) $10,000. Steve Cohen (D-Tennessee) $2,000. Angie Craig (D-Minnesota) $703. Sharice Davids (D-Kansas) $122. Peter DeFazio (D-Oregon) $5,000. Jesus Garcia (D-Illinois) $0. Eddie Bernice Johnson (D-Texas) $6,000. Henry Johnson (D-Georgia) $1,000. Rick Larsen (D-Washington) $7,048. Daniel Lipinski (D-Illinois) $6,000. Stephen Lynch (D-Massachusetts) $0. Sean Patrick Maloney (D-New York) $3,500. Grace Napolitano (D-Washington) $0. Eleanor Holmes Norton (D-DC) $0. Donald Payne (D-New Jersey) $1,000. Stacey Plaskett (D-USVI) $0. Greg Stanton (D-Arizona) $2. Dina Titus (D-Nevada) $3,000. Total Amount Boeing contributions to Democrats on the Aviation Subcommittee in 2018 cycle: $58,969. Average for each of the 22 members. $2,680.
Total contributed by Boeing to the 39 members of the Subcommittee: $134,749. Average per member: $3,455."
Source: https://www.corporatecrimereporter.com/news/200/blaming-dead...
You know, there has to be a story behind this. I'm not sure what it is, but I hope it is good.
The implication of course being that Boeing and its engineers want to kill people and the only thing standing between them and their goals of mass murder is the government.
It's not that management wants to kill people on a personal/visceral level, it's that they're willing to take on unacceptable risks in order to lock in short term monetary gains. We have seen this over and over again with modern large corporations, across industries.
And is it surprising management behaves this way? Their compensation is directly tied to short term stock value shifts. Meanwhile, when the game of musical chairs stops, they know that they'll still be able to make a lateral career shift to another similar company and just play the same game all over again.
I'm less clear on what Sam Graves means when he says "if aviation and safety experts determine that areas in the FAA's processes for certifying aircraft and equipment can be improved, then Congress will act," but I can see why people would be upset. It seems to me that we don't need input from anyone after two crashed airliners, be they safety experts or not: there clearly are areas in which the FAA's processes can be improved and they should be improved ASAP.
Yes, my comment was a gut reaction. That reaction was purely based on the gall of calling into question whether the system is broken at all. To formalize my thought process:
1. $system exists to certify machines in $domain (premise)
2. 346 people die in two related $domain failures (premise)
3. $politician rejects the notion that $system is broken (premise)
4. a well-functioning system is apparently allowed to result in 346 deaths (conclusion)
Hundreds to thousands of people die everyday in vehicles and the NTSB doesn’t even open investigations. It’s regarded as a well-functioning system. Are Democrats fine with thousands of deaths every year?
But not due to systemic issues like the Toyota unintended accelerations.
Deaths arising from systemic issues in automotive manufacture or poor road design are relatively rare in comparison to driver-induced deaths due to e.g. impairment by alcohol.
>> and the NTSB doesn’t even open investigations
It does for (systemic issues - the issues in question this whole conversation)
"driving while 80 years old"
"driving while on 4 hours of sleep in the past 72"
"driving with the brake warning light on"
I'd count all of the above as "systemic", and bet that they cause a multitude of deaths. We just don't want to accept the societal and monetary cost to eliminate them. Others, like "driving while intoxicated", we penalize but still do not take more than superficial steps to combat. (Superficial from the perspective of aviation, at least)
Adding just a few lessons from Aviation - things like "only allow the use of spare parts that are approved by the manufacturer", "forbid use when diagnostic errors are present", "mandate pilot rest periods and duty cycles" and "revoke the license of anyone with a sufficiently serious medical condition" would have huge consequences. I'm personally confident that each of those would reduce driving fatalities in the US by more than 346/yr. Of course, they'd also destroy the livelihoods of millions, make car travel far more expensive, and have (prior to 2020) unfathomable social consequences. But hey, any system that allowed that many deaths must be broken!
Climate experts determined things too. Congress has acted... by ignoring those experts. Why should we expect them to listen this time when they have demonstrated an unwillingness to listen in the past? Judging by history, they aren't planning on acting.
Even if the conclusion is that it is "acceptable business practice", it doesn't make the system less broken. Just as making a bug "won't fix" doesn't make the bug disappear.
But this is all political bickering, I don't think republicans are proud when American planes crash and kill their passengers, some of them US citizens. But because the report is written by democrats, and I suspect it is a little about safety and a lot about attacking the republican government, somehow, republicans feel the need to fight back instead of trying to find solutions.
I hope there are real engineers trying to actually solve the problem behind the scenes.
As a parallel I submit to you the FAA Medical process - a system by which it is better for a pilot to conceal or not report until terrible a condition that could invalidate their medical and remove them from flight duties.
While both of these are bad for the consumer, I ask - who is at fault? The big company, the pilot, or the people making the rules that encourage such behaviors.
Please present one system that you designed and implemented and it worked without faults. Imperfect (as all things are) does not equal broken!
From a system design point of view I've lived to see multiple "broken" systems being replaced by a worse system with the best of intentions.
Also: https://en.wikipedia.org/wiki/Post_hoc_analysis
To be clear: I am not saying FAA is faultless, I am no expert on aviation security, I simply have no opinion. I'm just saying some people are quick to take out the pitchforks.
Killing 300+ people is broken. And our obligation is to admit that it is broken, and fix that thing. When we find another thing, we admit that the system is broken there as well, and go fix that.
Trying to diminish the seriousness of 300 deaths with mealy-mouth terms like "imperfect" is pure spin. If a plane, staffed by pilots allegedly trained on how to fly it, crashes from pilot error... TWICE, the system is broken. terribly broken.
See also: Security, physical or digital.
Terrorists flew planes into the World Trade Center. The system was broken. We fixed some of it. We put on some secuity theatre too. But we didn't say, "It's impossible to fix everything, so the system is fine." We didn't shrug it off as "imperfect."
We always begin by being truthful with ourselves about the fact that we have discovered that the system is broken. And if the consequences of its broken-ness are unacceptable, we fix it.
"Imperfect" is a word that should only be used for acceptable faults. Like, "The seating in economy is imperfect." It's too close together, but we don't have planes falling from the sky because they're cramming passengers together.
---
And now a footnote: Please avoid ad hominem arguments like "please name one system you've..." If the speaker's argument has a logical fallacy, point it out. If the speaker's argument is sound, it doesn't matter whether they write faultless software, or even whether they write software at all.
It's the argument we are discussing, not the person making it.
This is a massive trivilisation of the problem.
This is not 'code' - it's a massively complex system of large companies, various bits of tech, supply chains, varying international standards, considerably amount of legislation and that's before we get into the humane issue of 'acceptable loses' because '0 deaths' may not actually be feasible. Maybe, but maybe not.
"Terrorists flew planes into the World Trade Center. The system was broken. We fixed some of it."
Again, this is a misrepresentation. The system was not 'broken' because culturally, people 'didn't do things like that'. The 'fix' for this wouldn't be 'more security' but rather to encourage a civil culture where people don't take over planes and fly them into buildings. And some of the solutions are systematic, i.e. not 'safety checks on planes' but externalities like 'invading countries and destroying places where terrorist plan things' - which isn't so nice.
These are very complicated problems that don't have obvious solutions.
All systemic problems have complex sets of interactions and unexpected consequences. Racism, automobile deaths[1], and yes, air transportation.
We still don't shrug our shoulders and deny that the causes of deaths reflect a broken system, nor do we refuse to attempt to find solutions just because it's damn hard to make progress.
[1]: Sometimes, making the vehicle safer makes drivers more reckless. Making cars safer in practice is not as obvious as it appears in theory.
And it's possible in attempting to launch several thousand pounds of metal into the air that sometimes your testing is off and people die. That may mean the system is broken, it may mean it's just imperfect - it is not sufficient for either of those claims by itself. That people died does not mean the system is inherently broken - life is not without risk nor should our goal be to make that risk non-existent.
Security, to use your example, is fundamentally a trade off - accessibility vs security. Are we willing to trade a more intrusive screening process to prevent some set of attacks? Even if we make that tradeoff and an attack still happens, should we keep it? Would you be willing to be stripped search each and every time you fly if it lowered that risk of an attack another 10%?
Your call out of an ad hominem is incorrect. Parent is generalizing human behavior in an uncertain world, not attacking you as an individual. Nobody can write a perfect system, even NASA has failures. A super abstract argument about flawless systems loses to real life statistics every time - theory is great but only reality matters.
The difference between an accident and what happened here is that the issue was caused _deliberately_ by a series of bad choices, reflected in the fact it happened twice in exactly the same way. Yes, it took a lot of bad choices to get to the point of creating the issue, but that doesn’t really matter, and in fact, might only serve to further the point.
When a system allows for deliberate choices to cause an issue, the system needs to be addressed.
Anecdotally, I have never worked at a company where the management didn’t have an outsized say in how we broke apart our time between product development and stability.
I suspect this is endemic of a system that lacks accountability for people in managerial positions, and is probably even beyond the scope of the FAA, MCAS or Boeing.
Have you considered you may not be correct here? I know that may be difficult to comprehend, but you are not a teacher shedding light on the unenlightened - you're just another layperson attempting to understand a complex system.
> what happened here is that the issue was caused _deliberately_ by a series of bad choices
Are you suggesting Boeing intentionally downed it's own planes? That would seem to be an extraordinary claim - and not one reflected by any news source.
> When a system allows for deliberate choices to cause an issue, the system needs to be addressed.
What was the deliberate choice here? Only enabling one MCAS sensor or having calibration issues? Was it not making the need to disable the MCAS sensor in some situations clear? Was it changing the altitude model without changing the plane model number and forcing a pilot relicense?
Or, was the issue with Boeing being able to do their own testing? Was it due to a lack of guidelines on MCAS sensor calibration and placement?
> I suspect this is endemic of a system that lacks accountability...
Yet we are talking about this after their fleet was grounded, a congressional inquiry has happened and the investigation and analysis are ongoing. That doesn't seem like a lack of accountability to me.
Again, you're making the claim that the system is broken intrinsically because this occurred. You keep even saying it's deliberate - do you have evidence here? Because making poor choices is not the same as intent, and a bad actor does not a fundamentally broken system make. You seem to be in the position that because bad things happened we must dismantle the entire system without actually proposing a replacement - it is not enough to throw stones, we must actually put forth a solution set.
Wait until you find out how many people die in car crashes every single day. It does not mean “the system is broken”. In the real world systems can be improved without throwing disruptive tantrums to make fundamental changes.
>Terrorists flew planes into the World Trade Center. The system was broken. We fixed some of it. We put on some secuity theatre too. But we didn't say, "It's impossible to fix everything, so the system is fine." We didn't shrug it off as "imperfect."
Excellent example of an extreme overreaction that caused immense destruction to the aviation industry because emotional politicians wanted to fix a “fundamentally broken system”. The correct approach would have been, “we’ve found a big flaw in security, we will now install flight deck door locks”. Instead, some dim politicians went with the “system is broken” approach and now we have nudity machines (or grope-downs if you don’t submit) at every major airport in the US.
You don’t drastically change a system on the discovery of a single flaw, no matter how big. You fix the flaw because it’s one known bad vs the giant pile of unknown flaws with fundamental redesigns.
Nevertheless, in my lifetime cars have gotten safer by several metrics, most notably by distance traveled.[1] And they did not get better by thinking that driving around in deathtraps without seat belts and swigging whisky behind the wheel was acceptable.
They got better when people like Nader and MADD stood up and defied arguments like yours and loudly complained that yes, the system was BROKEN and needed to be fixed.
And then other people went about trying to fix automobile safety. Imperfectly. In fits and starts. And sometimes entirely wrongly. But nevertheless, progress happened when people attempted to fix things they acknowledged were broken.
[1]: https://en.wikipedia.org/wiki/Motor_vehicle_fatality_rate_in...
I don’t think you understand. Cars are still killing thousands of people and the system is not considered broken right now. You’re emotionally lashing out and assuming I’m promoting drinking and driving when I said no such thing.
The entire point is that deaths alone do not indicate a broken system. Society is riddled with acceptable death rates in countless industries and people don’t childishly accuse politicians of being “okay with people dying”.
There is a world where nobody can accept any deaths and then there is reality where the adults exist and make trade-offs to have a functioning society.
Very, very funny considering it took TWO crashes for people to start bringing out pitchforks.
Isn't this just outcome bias though? You're arguing that because there are 346 deaths, the system is necessarily broken. That may not be the case. From what I've seen, it probably is, but it's not a foregone conclusion, and we shouldn't look for evidence supporting that conclusion. 346 deaths might actually be a very small number compared to what could have happened had the system actually been broken. The point is, it's a logical fallacy to say that because there were 346 deaths, the system is broken, and we need to work back from there. This could have been a rare combinatorial explosion of bad luck.
And no system is so broken and corrupt that you won't find plenty of people willing to insist that it is all just fine as it is.
This is mostly a management and political issue, not an engineering one. And being cynical, I'm pretty hopeless about politicians or managers taking responsibility for their actions here.
Well yeah the US had 36k automobile deaths and globally its 1.3 million (that's 3500 per day). You need to accept some level of fatalities as normal.
Probably not the best example...!
https://en.wikipedia.org/wiki/List_of_countries_by_traffic-r...
America has such huge clout for setting design standards for vehicles, has very large, very well funded law enforcement departments, a reasonably young average age for registered cars.
If it wanted, it could smash those fatality figures in not much time at all.
I knew roads in the US were dangerous, I didn't realize they were nearly as dangerous as Bangladesh or Egypt! No slight against those countries in particular but they are comparatively less prosperous (meaning older, less-safe vehicles, more pedestrians), have worse roads, and presumably not as advanced healthcare systems. I'm amazed the US, with all its advantages, does so poorly.
https://en.wikipedia.org/wiki/List_of_countries_by_vehicles_...
No, you don't. You never "accept" it. You always strive to preserve life.
When did life stop being precious?
346 people in the first year is a horrible. It is also an outlier. In general, flying is extremely safe, and new planes are safe.
If we freak out about everything that ever goes wrong and try to create a system with zero deaths ever no matter what, we risk not being able to do anything new because it is paralyzed by regulation.
Of course, it's a balance, and the balance that commercial aviation has found is heavily focused on safety.
I generally ask if anyone anymore believes in cause and effect. By and large aviation is safe because of the work of governments and corporations together to create safe aviation. It doesn't just "exist." As we see here with the 737.
> we risk not being able to do anything new because it is paralyzed by regulation.
This isn't frontier science or sending someone to the moon. Aviation can be extremely safe and innovative if based on sound principles and not just trying to make an extra buck.
The problem isn't that flying is unsafe, but that the MAX specifically was/is, and something very clearly failed both at Boeing and in regulation.
Yet would one consider mandatory seatbelts and stricter laws on driving under influence and so forth "paralyzing regulation"? You are talking about the other extreme with its polar opposite of not having any rules. But there evidently is a huge middle-ground where we can have regulation and not having people killed in large numbers.
Consequently, if we look at history most of these "freak outs" have in fact resulted in regulation that has saved lives. Eg the gun laws in UK. We as humans are very short-sighted in general and I think it's more of a rule rather than the exception, that we need these kinds of accidents to improve the regulation and the laws in place. Sometimes maybe to the extreme, but I think it's better to be too strict than too lax.
Even if 100% of global elextricity generation was replaced with nuclear, that wouldn't be true. You'd have to also replace (for instance) 100% of transportation with nuclear. (And that's assuming that the infrastructure construction and maintenance costs of doing all that are carbon neutral, too, and that the reduced demand and price for fossil fuels resulting from that shift doesn't open up new uses that get you back into problems, which—absent aggressive regulation—youd naturally expect it would.) [55% reduction is CO2 is needed, electricity is 27%, transportation 28%.)
Or maybe you are thinking that the absence of nuclear safety regulation would result in enough accidents to reduce the growth of population and industry enough to solve climate change, which I guess is a valid thought, if an extreme example of glass-half-full thinking.
1) How qualified are the congressional investigators to evaluate technical decisions in the MCAS design?
2)Second point: Notably, the article is quite vague about the actual mistakes that where made. Is there any specific bad decisions it notes that would be errors without the benefit of hindsight?
Despite the punch pulling, there were also admissions that the plane (without the MCAS flight law) would not have passed certification requirements for carrying passengers, cementing a solid motive for regulatory obstruction and perception management.
Mary a mention or touching on any of that in the report. It went to great lengths to show that the "process worked as followed" yet never addressed the issue that said process led to 346 deaths.
It's frustrating, because I left the report with the feeling the conclusion was "Process is fine, people just need to follow it better" when the entire point of having a process is to take into account human capacity to err and designing it out.
I think Representatives are basically applying their plank to the report. Which is bloody stupid, because they need to be reading between the lines and focusing on the problem, not whether their party leaders approve of their approach or output.
Apparently the ML behind autocorrect or my fat fingers betray me once again after not checking back for 2 hours.
This same story is repeating throughout all the American regulatory bodies and it is only going to get worse.
Then people will again start saying "we've had no accidents for years, therefore flying is really safe, so why all this burdensome regulation?". Regulation will get scaled back, something like the 737 MAX will happen again, the FAA will get beefed up, and so on, ad infinitum.
It's this sort of regulatory boom and bust that makes me feel humans shouldn't be allowed to do anything that's dangerous on a really large scale (such as nuclear power).
I was like you before, it's the "default" sentiment to feel like nuclear power is dangerous and dirty.
Please do your homework and collect information from reliable sources on the matter. It might change your mind, or at least give you a more balanced viewpoint.
Nuclear industry is a textbook example of regulatory capture. If the renewable guys were anywhere near as good we’d see 0 deaths from solar and wind. “The solar panel didn’t kill him, it was gravity and a slippery ladder”
Well, I did. And did not find any convincing claims. Try to take a step back and not see everyone as either anti or pro. Show me your evidence for your claims.
"Assassinated whistleblowers" is a pretty strong statement, it requires pretty strong evidence.
This is not true.
The space destroyed to make way for coal strip-mining in Germany alone, is larger than Tchernobyl exclusion zone.
You had a good comment except for the last line. Nuclear power is the safest form of energy production out there (and by far).
The industry was very heavily regulated globally before Chernobyl and Fukushima, but look what happened.
I’m not saying I’m against nuclear power (as I’m not). I’m not saying that any industry regulation is generally ineffective most of the time, especially when financials and greed gets involved (even though it appears to be true). I’m just saying humans are bad at moderating risk over long periods of time.
Gross incompetence and huge design issues 40 years ago on one hand, and complacency+incompetence that required a huge natural disaster to pose a problem, and even then it resulted in less death and destruction than the evacuation, the natural disaster itself or your regular fossil fuel power plant? Not sure that's a good example.
https://en.wikipedia.org/wiki/Fukushima_Daiichi_nuclear_disa...
https://en.wikipedia.org/wiki/Fukushima_Daiichi_nuclear_disa...
https://en.wikipedia.org/wiki/Fukushima_Daiichi_nuclear_disa...
Apart from Chernobyl which was poorly designed and managed to begin with, other plants have proven safe. Even Fukushima hardly caused any death while several thousands people were killed by a once-in-a-lifetime tsunami. Let's put things in perspective, please.
We are not really "fit" for any technology, but lack of technology wouldn't keep us safe from existential risks either. The solution is to transcend our biological substrate altogether.
Only on average. The potential worst case fuckup is the most spectacular compared to any other energy source.
Dams failures are WAY worse in terms of deaths.
The 'worst case' with a modern reactor is basically zero to very few people die and there is some leaked out radiation. This is what happened in Fukushima. Its hard to find a worse case with a modern reactor.
Just like plane crashes make for horrific headlines. Meantime, a lot more people die every year driving their car to work, and nobody talks about it. Your point is, we don't know how to grasp data?
I have some bad news for you...
The root cause is pretty easy to describe: benefits are apparent and risks are hidden.
It's much harder for people to weigh things that might happen against things that will happen. Especially when the former is negative and latter is positive (positive outcome bias).
Consequently, in meeting after meeting, risk safeguards are erroded. Because each meeting has a relatively minor "Do we want this benefit, or to hedge this risk?" decision, and in aggregate, people pick the former.
For more thinking along these lines, see the book “Normal Accidents: Living with High-Risk Technologies” (1984) by sociologist Charles Perrow (concerning nuclear power), the book “The Limits of Safety — Organizations, Accidents and Nuclear Weapons” (1993) by Scott Sagan concerning nuclear weapons, and the work of philosopher Hans Jonas on the “imperative of responsibility” (1980s).
It would also require every other nation on earth to agree with the restriction, which isn't really compatible with the premise in the first place; if the regulations are self-imposed, people will stop following them.
Some HN readers apparently don't like to hear this but I don't see any other way.
As for how we can reduce regulatory capture, I don't believe there is any good solution other than constant vigilance.
- Better whistleblower protections
- Personal liability for making false or misleading statements to a regulatory agent
- Corporate death penalty. No more "too big to fail" nonsense. If there were actual competition among aviation manufacturers, the government could just dissolve the company and auction off the product lines to competitors.
Safeguarding against capture from the regulatory side is more difficult. But I guess term limits for decision-making positions could help, or having a good process for identifying and declaring conflicts of interest?
There are a number of industries and companies that will exist as long as the current USG does, at least for our lifetimes, due to decisions that were made long ago.
Examples include Lockheed, Boeing, and Microsoft.
Any solution to the problem needs to accept and address the levels of deep integration between these companies and the state.
It'd require a lot more ass-covering to pretend that the company isn't just an arm of the government, entitled to a neverending stream of practically unlimited tax dollars.
Look at the whole kerfuffle that Amazon is making over JEDI being given to Microsoft. Under the current system, that's probably better avoided.
That doesn't make much sense though. The size of rewards might incentivize how hard someone works for them and to what extremes, but the objective they're working towards depends on what the reward is, well, rewarding, which is a separate thing. It's perfectly possible to imagine a system where executive compensation was based purely around safety for example, say "$5 million for no flaw-derived fatalities during tenure of 10 years and another $5 million for no flaw-derived fatalities for anything manufactured during tenure for 10 years after retirement", or whatever exact numbers/details you wish. Of course, even that could be "outsized" in that too high+unbalanced a level might encourage the extreme of too little innovation. But merely saying "executives shouldn't get paid more than [number pulled out a random because who knows]" doesn't seem like a directed policy that'd help. And in fact is quite contrary to other comments calling for more personal responsibility and the like.
like holding family members hostage? Or perhaps violent mutilation on failure? The financial route has been ramped up as far as can be imagined - $100m's are paid to CEOs to fail, and to wreak the economy, society and the planet at the same time.
There are some CEOs in the Fortune 500 with 750k base, but bonus and stock exceed that by multiples.
"The median total compensation for Fortune 500 CEOs who had been in their role for at least two years was $11.5 million"
https://www.marketwatch.com/story/fortune-500-ceos-are-paid-...
I think a fifty times multiplier is already too high though so I don't know if I can agree to pushing that up any further. The goal is specifically to change things for the better, to NOT maintain the status quo.
I am not sure what capping executive salaries would achieve. You'd still get the same kind of people at the top anyway - even if the top salaries were identical to that of a janitor, the fact that you have power over others is its own motivator for many people out there. Proof in point: politicians don't make outrageous amounts of money (compared to CEOs), but they are addicted to power and control just as well.
You might have seen this recent news article. I won't summarise, as I don't think I can do better than the URL:
https://arstechnica.com/gaming/2020/08/ea-shareholders-say-n...
So Boing will pay not only the massive costs of withdrawing the MAX since orders for it are plummeting. But this event will affect all its business. This is why there is lobbying/political pressure to divert at least some of the blame, the implications are in the tens of billions in the next few years.
So the good news is that the company will be forced to clean-up its act voluntarily, a similar safety disaster could mean extinction.
The refund would be made at gate level, since the plane allocations are made in the last minute.
It's certainly a factor behind the hundreds of MAX orders that were canceled thus far. Fitch lowered it's delivery estimate from 700 to 75 MAX planes for 2020.
It seems like the current two-party system is in fact part of the "corporatocracy and regulatory capture", but with current electoral law they are unlikely to ever be dislodged.
Fortunately, the individual states are not prevented from implementing reforms like Ranked Choice Voting, which would allow new parties to form and gain a reputation in politics at least at the state level.
If a party repeated that success across multiple states, that could be used to pressure the largest two parties to support similar reforms, like making Congressional districts return multiple representatives (proportional to the vote within that district).
There are elections coming up in November. You'll have at least 2 federal races on the ballot. Figure out where the candidates stand with regards to corporatocracy and regulatory capture and vote accordingly.
If you don't like where any of the candidates stand, there will be another election in 2 years. In the mean time, let the candidates know how you feel. Donate to, or volunteer for the candidates who you want to win.
But probably will not happen.
What I don't understand, and does bother me, is why the plane continued to fly after the first crash and even, inexcusably, for days after the second crash! That seems to me a bigger indictment of Boeing's and the FAA's reluctance to put safety over money.
It turns out (in my view) that this is just the inevitable result of a slow abandonment of the role that the military, federal government, and the US people elected to play in the development of civil aviation in the last century.
Maybe many have forgotten, but our civil aviation legacy largely came from R&D and production of aircraft during WW2 and later. Boeing, McDonnell, Grumman, Northrop, these were all companies that formed from that legacy. But what they produced besides planes was a government infrastructure that was expert in procuring, regulating, and evaluating the performance of not just aircraft but also companies.
And it also produced aircraft companies that worked closely with government -- but most importantly, with their concerns in mind. They were partly the customer!
Over 50 years, the pressures of public debt, cost of employees, efficiency, etc. meant that that expertise in the regulatory bodies gradually began to be hollowed out. Experts in government found themselves too bothered by the heavier and heavier constraints of government, and lured by the higher salaries of the private sector. The leaders of a new field were replaced by mere maintainers of it. We all know what happens as that changes, I think.
Government gradually also became less of a "customer" in the design and production of planes. And the airplane companies themselves became more profit-need-driven. They are basically like the auto manufacturers with huge workforces that need their insurance and IAM wages paid.
So what do you get in a situation like this? The inevitable:
Aircraft manufacturers that start to optimize their designs and production for low cost and "simple" variations on old designs (don't want to invest in from-scratch new planes). Regulators who don't know how to evaluate properly new designs, and anyway whose responsibilities are basically staffed for and by the airline because few people want to be regulators. And a public that incentivizes this all because we have other debts to pay and don't want to cough up the $ in ticket prices or taxes.
Until a plane crashes.
Anyway, that's my take. So if they were honest, Congress would point the mirror at themselves too, in this exercise.
The important thing to remember is that true engineering is building Electron and React apps not whatever nonsense all these guys who go around constantly accidentally killing people do. Aeronautics, such a poor field with poor standards. Any guy using React+Redux is a superior engineer. After all, he won't be killing anyone by accident.
I'm going on the competent/incompetent angle which is orthogonal. The problem is that those guys just aren't good engineers. If they want to kill people and they're doing it, or they want to sell to ICE and they're doing it, or they want to monetize murders and they're doing it, then they're good at it. That's competence.
Aeronautics engineers, though. They want to make things fly and they fall instead. I don't think they've wanted to kill Boeing passengers, but you know, considering their skill, perhaps they did, perhaps they did. In which case, you're right, that's a field of highly competent passenger killers who we thought were incompetent passenger fliers!
Web developers writing React on the other hand? Zero people intended to be killed. Zero people killed. Billions of dollars of value. Creativity. Ability. Competence. The virtues of a real engineer. Perhaps one day other fields can emulate their techniques to understand how they do it.
If you don't see it as an incredible achievement and don't feel proud of it, you don't have any perspective on what's the other parts of the world are like, and were like for the most part of history. Don't take things like this for granted.
It's a sign. Encouraging to some, but empty, dust filled, and tasteless to many who expected much more of the system. I'm hoping these deaths will not be in vain and that this may kindle a political will to encourage greater corporate accountability and responsibility down the road; but beyond doing my small part I can't say as I entertain an excess of confidence of that happening. No offense meant, but it is also cold comfort indeed to be taking solace from, "we could be even more corrupt".
Then again, maybe, just maybe we'll manage to pull a rabbit out of this.
After all, it was an act of Congress, and if a bunch of people have done it, well...
Stands to reason yet another group of folks can do it.