#mistakes

waynerad@diasp.org

I was going to skip commenting on the Boeing 737-Max fuselage door blowout, but I decided to make some comments after all. I think I can legitimately collect an "I told you so" on this one. The reason is in 2019 when the MCAS (Maneuvering Characteristics Augmentation System) crashes happened, I did a lot of investigation, including watching Congressional testimony, studying a book on preventing mistakes (Sidney Dekker's "Field Guide to Understanding 'Human Error'"), with many examples from the aviation industry, and investigating the culture of Boeing itself to see how it compared with the "blame the process culture" vs "blame the person" culture discussed in the book. I have an interest in mistakes because I've gotten in trouble for making mistakes. People say, "It's ok to make mistakes," but it's definitely not.

In the interest of brevity, I won't rehash all that here. Just to quickly summarize: What I discovered is that when Boeing and McDonnell Douglas merged, the management of McDonnell Douglas came out on top -- they succeeded in making themselves the management of the combined company. Unfortunately, the leadership of McDonnell Douglas was finance-focused, not engineering-focused, like the leadership of Boeing had been since its founding. Once the McDonnell Douglas people came to be in charge of Boeing, they cranked up the pressure to cut corners to increase profits.

In spite of this, a CEO with an engineering background, from Boeing's military side, had managed to get into the CEO position (Dennis Muilenburg). He was CEO at the time of the MCAS crashes. Boeing ousted him and put in the current CEO, a guy with a background in (you guessed it) private equity finance (Dave Calhoun).

I had no way of predicting this specific mishap would occur, which apparently relates to bolts on a "plug" door (it serves as a placeholder for a door to be installed later if there is a need for an additional exit). The specific details are not my point here today. What I could predict is that Boeing would continue to have quality control issues and that more mishaps would occur. I said Boeing would have been better off leaving their current CEO in place, despite the MCAS accidents happening on his watch. He made public commitments to improve safety, as did his replacement CEO with the private equity finance background, but the difference is that his public commitments to safety were more credible due to his engineering background. Boeing did the wrong thing by ousting him and replacing him with a finance guy and I predicted more mishaps would occur.

It saddens me to say this but my prediction going forward is more of the same. There will be more quality control problems, and more mishaps, and hopefully not too many crashes where people die.

Full interview: Former Boeing manager turned whistleblower Ed Pierson - KIRO 7 News

#mistakes #aviation #boeing #737max