From Boeing comes this announcement regarding the Ethiopian air tragedy:

Boeing continues to support the investigation… Safety is our highest priority as we design, maintain and support our airplanes. As part of our standard practice following any accident, we examine our aircraft design and operation, and when appropriate, institute product updates to further improve safety. While investigators continue to work to establish definitive conclusions, Boeing is finalizing its design of a previously-announced software update and pilot training revision that will address the MCAS flight control law’s behavior in response to erroneous sensor inputs.

This is world-class example of corporate-speak approved by Boeing’s legal staff.

Here’s the “rough draft” input for the final press release:

We screwed up big time. We knew of this problem but thought we could fix it before anyone died. We were wrong. Twice. Oops. So, sue us already!

 

We have a known problem that can cause pilots to lose control of their 737 MAX aircraft as there’s a feature we put in place called MCAS but didn’t tell our customers and pilots about that most likely caused 2 of our aircraft to crash, one in Indonesia and one in Ethiopia.

 

Sadly, if a pilot didn’t know how to neutralize the MCAS feature when the problem occurs (because we intentionally didn’t tell the pilots about the existence of the MCAS feature!), the plane can crash killing everyone on board. Our bad.

 

Our marketing portrayed our new 737 MAX aircraft to be identical to our existing 737 aircraft in terms of pilot training needs. This wasn’t entirely true. We tried to make them “identical” by adding the MCAS system to the plane without properly communicating the implications of the feature which can override input from the pilots flying the plane. Due to really bad luck, it just so happens there are technical problems with this interface. So, our attempt for MCAS to “make the complex simple” didn’t work out so well. We tried. We’re spinning up MCAS 2.0 as we speak. We hope we won’t need MCAS 3.0.

 

The “training” we put on the iPads didn’t include MCAS information. And, the flight simulators don’t include it either because all our customers and pilots needed to know was that they are “the same”–except for the critical differences we didn’t tell 737 MAX pilots about that can cause them to lose control of the aircraft causing it to crash. Our earlier press release referred to this as a “revision” but it’s really an “addition” as we intentionally left out all mention of MCAS in existing training materials. Yeah, yeah–talk to the hand.

 

Thank you for putting your trust in Boeing.

So if we contrast the Boeing statement from mine, I think you’ll agree there is huge corporate product liability for Boeing. The horror the pilots, crew and passengers experienced in the final minutes of their lives adds to Boeing’s liability. This horror passes to the families of the victims as well.

Boeing played their hand poorly all the way to the planes being grounded world-wide. Boeing should have initiated the grounding for all 737 MAX aircraft and not waited for this to happen on a country-by-country basis.

The FAA should also have thrown a flag on continued flight operations of the 737 MAX but did not. Did the FAA not want to impact the perceived market viability of the 737 MAX? The FAA is not a marketing arm for Boeing.

Boeing almost got away with it. There are people who are part of the 737 MAX project who signed off on MCAS and didn’t see it posing business or technical risk to Boeing’s customers and their passengers. They were wrong. What questions did they fail to ask?

They failed to ask (1) what could possibly go wrong with the MCAS solution as designed and implemented, and, (2) what might the implications be of something going wrong? I’d argue it was foreseeable that there could be a loss of flight control and the issues that might flow from that scenario.

Had the pilots known of MCAS, they would have thought through what action to take in a calm, non-emergency environment. Not knowing of MCAS would have left the pilots bewildered and confused about what was happening to their aircraft, not the state you want a pilot to be in so low to the ground . There was no time to look for a section of the emergency checklist that had intentionally been omitted.

There are so many lessons to be learned from this story.

Note: Photo courtesy of Nathan Walkowiak on Flickr

Thought for the week:

In honor of those killed and wounded in New Zealand, I offer this thought:

“Peace can only come as a natural consequence of universal enlightenment and merging of races, and we are still far from this blissful realization.” – Nikola Tesla

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What do you think? I welcome your comments! Dave Gardner
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Dave Gardner

Dave Gardner is a management consultant, speaker, author, and blogger based in Silicon Valley. He's been in the front row for the birth and evolution of Silicon Valley, the innovation capital of the world. Since 1992, Dave Gardner focuses on making the complex simple around people, process and technology. Dave is the author of Mass Customization: An Enterprise-Wide Business Strategy - How Build to Order, Assemble to Order, Configure to Order, Make to Order, and Engineer to Order Manufacturers Increase Profits and Better Satisfy Customers.

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