The following entry is a record in the “Catalogue of Catastrophe” – a list of failed or troubled projects from around the world.

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Organization : Boeing Commercial Airplanes
Project name : 737-MAX
Project type : Commercial aircraft design
Date : Apr 2019
Cost : 346 lives lost

Synopsis :

Designing and building today’s commercial aircraft must be among the most complex projects in the modern age. The two leading players in the industry are America’s Boeing Commercial Airplanes and Europe’s Airbus SE. Fierce competition between the two often leads to tit for tat designs as each vies for business in the various segments of the commercial aircraft market.

One recent exchange has been in the narrow body (single aisle) market, in which Boeing’s venerable 737 competes with the Airbus A320. In 2010 Airbus had announced plans to upgrade the A320 design to make the aircraft more efficient. The new ‘A320NEO’ has new engines and improved aerodynamics that make the plane both more fuel efficient and quieter.

In response Boeing announced their tit for tat plan to do similar upgrades to the 737. The new ‘737-MAX’ was intended to ensure the 737 remained competitive in its market segment and ensure Boeing as a whole retained its strong position in the commercial aviation field as a whole.

Upgrading an aircraft may be simpler and faster than designing from scratch, but the complexity is still enormous. The degree of difficulty is in part dependent on your starting point (i.e. how well the old design lends itself to the new changes). In this particular case reports indicate that Airbus had the advantage. The A320’s existing configuration better suited the new larger diameter engines (necessary to get the required fuel efficiency) than did the old 737 design.

Despite the issues Boeing’s 737-MAX took to the air for the first time in 2016. Sales were strong and deliveries to airlines started in 2017. Unfortunately as many readers will be aware, the aircraft suffered a crash in Oct of 2018 (Lion Air 610). Reports indicated that the pilots had lost control of the aircraft because of the failure of a sensor and the subsequent interventions of the aircraft’s systems (in particular the Maneuvering Characteristics Augmentation System). While pilot training issues were initially floated as a primary cause, a second crash (Ethiopian Airlines 302) in March 2019 highlighted that there were deeper issues with the aircraft’s design and the project as a whole.

To prevent any further incidents, in Mar 2019 the worldwide fleet of nearly 400 aircraft was grounded. At the time of writing the grounding has now been in effect for ten months and the emerging story paints a picture of serious issues in the management of the project and the related certification process. A Jan 2020 public release of Boeing’s internal emails succinctly captures the concern. In what may become the project’s enduring soundbite, the writer notes that “this airplane is designed by clowns who in turn are supervised by monkeys”.

Although the story is still emerging, evidence is beginning to point to a conclusion that cost related issues (and an underlying culture that at times focused on financial considerations over engineering excellence) were factors in the way key decisions were made. Reports in the Washington Post and BBC illustrate Boeing’s attempts to minimize costs. Quotes indicate that suggestions that 737 pilots would need simulator based training before flying the new design were suppressed because of the additional training costs involved. Internal emails from a senior member of the project team contain the following revelation “We’ll go face to face with any regulator who tries to make that a requirement”. As of Jan 2020, Boeing has now reversed that position and is advising that as part of the return to service plan, simulator training will be required for all pilots.

I’ve written extensively on this site about how corporate culture shapes behaviours, decisions and ultimately outcomes. The MAX project is shaping up to be further evidence that for the safety of the public and the future prosperity of the organization, Senior Management need to carefully manage their corporate values. In an organization like Boeing, pledges of excellence and safety must never be cultural lip service, they need to be the nucleus of decision-making.

Contributing factors as reported in the press:
Issues relating to self-regulation, corporate culture and allowing financial considerations to disproportionately influence technical decisions. Failure to train end-users (pilots) effectively.

Related stories:

1. The bean counters blind spot – How spreadsheets distort decision-making.
2. The 737 MAX project also helps demonstrate that the concept of lesson ‘learned’ is in some organizations, just a concept  As demonstrated by a post I wrote in 2013, the issues experienced in the MAX project are not a first for Boeing. Listed as the cause of troubled in the Boeing 787 Dreamliner project was the following “financial considerations trumped sound advise from the technical experts”. Back in 2013 I noted on this blog that I was hopefully Boeing would take a different path in the future. The MAX project implies that was not the case. That failure to learn is perhaps another pointer to deeper cultural based issues.

Reference links:

1. Boeing 737 Max: Worker said plane ‘designed by clowns’
2. Internal Boeing messages detail how pressure to cut costs eroded company’s renowned safety culture
3. Boeing, reversing itself, says all 737 MAX pilots will need costly flight simulator training
4. Boeing apologizes as internal memos reveal how workers spoke of deceiving regulators, airlines