On March 11, 2019, Boeing posted a news release in its online media room (which can be read here). Included were the following two sequential paragraphs:
“Safety is a core value for everyone at Boeing and the safety of our airplanes, our customers’ passengers and their crews is always our top priority. The 737 MAX is a safe airplane that was designed, built and supported by our skilled employees who approach their work with the utmost integrity.
“For the past several months and in the aftermath of Lion Air Flight 610, Boeing has been developing a flight control software enhancement for the 737 MAX, designed to make an already safe aircraft even safer. This includes updates to the Maneuvering Characteristics Augmentation System (MCAS) flight control law, pilot displays, operation manuals and crew training. The enhanced flight control law incorporates angle of attack (AOA) inputs, limits stabilizer trim commands in response to an erroneous angle of attack reading, and provides a limit to the stabilizer command in order to retain elevator authority.”
The FAA continues towing the company line with its own March 11 information release at https://www.faa.gov/news/ updates/media/CAN_2019_03.pdf which largely mirrored the Boeing news release but with slightly more detail in certain areas:
“Ongoing oversight activities by the FAA include:
– Boeing’s completion of the flight control system enhancements, which provide reduced reliance on procedures associated with required pilot memory items. The FAA anticipates mandating these design changes by AD no later than April 2019.
– Design changes include:
- MCAS Activation Enhancements
- MCAS AOA Signal Enhancements
- MCAS Maximum Command Limit
– Boeing’s plans to update training requirements and flight crew manuals to go with the MCAS design change include:
Airplane Flight Manual (AFM) and Flight Crew Operations Manual (FCOM) Continued Airworthiness Notification to the International Community Page 2
Quick Reference Handbook (QRH) – notes in Speed Trim Fail checklist
Airplane Maintenance Manual (AMM)
Interactive Fault Isolation Manual (iFIM)
Boeing has proposed Level A training impacts”
More than 115 years ago, the Wright Brothers began flying over the dunes of Kitty Hawk, North Carolina. Boeing began building commercial airplanes about 100 years ago and delivered its first jet airliner about 60 years ago, the 707. One of the cardinal safety principles developed in Aeronautical Engineering over these many years is redundancy of critical sensors and systems, as stated in Boeing’s own design philosophy online at https://www.boeing.com/ company/about-bca/aviation- safety.page:
“Safety is the primary consideration when Boeing engineers design an airplane. In addition to meeting regulatory requirements before certification, each airplane model must meet Boeing’s time-proven design standards. Often these standards are more stringent than regulatory requirements.
“Regulatory requirements include ensuring redundancy in all critical systems. Every system vital to the safe operation of an airplane has a backup, and in some cases more than one backup.
“Boeing airplanes are rigorously tested to ensure they meet or exceed design standards and certification requirements.
“Testing also helps Boeing find and fix problems before an airplane enters service.”
At least twice in the past 10 years, Boeing has failed to adhere to these time-proven principles of system redundancy and safety priority on its 737 airliners with fatal consequences. In 2009, Turkish Airlines Flight 1951 crashed on approach to Amsterdam Schiphol airport killing nine aboard and injuring another 120. In October, 2018, Lion Air Flight 610 crashed into the Java Sea during initial climb out after takeoff at Jakarta, Indonesia, killing all 189 aboard.
The Turkish Airlines Flight 1951 crash report was written by the Dutch Safety Board and is available at https://catsr.vse.gmu.edu/ SYST460/TA1951_AccidentReport. pdf. In summary, Boeing failed to design its autothrottle engine power control system to use multiple, redundant radio altimeter sensor inputs and instead only used one input, and when that input failed, the autothrottle control system malfunctioned, causing a loss of airspeed and overall airplane control that the pilots failed to correct before impact with the ground. Boeing had known about this failure mode and design issue for many years prior to this accident and instead of making the appropriate design changes, it relied upon guidance to airlines on how mechanics and pilots could deal with the problem when it occurs.
In response to the Turkish Airlines Flight 1951 crash findings and public pressure, Boeing subsequently made a software change such that the autothrottle used multiple, redundant radio altimeter inputs with quality monitoring of all inputs to detect bad inputs, otherwise known as “voting” of inputs as all other Boeing airliners in production besides the lowly 737 already had in place. Boeing intentionally went cheap and less-safe on the 737 autothrottle design to save money and it cost lives and terrible injuries including quadriplegic status for a rising young Turkish attorney and political hopeful. It also cost Boeing and its insurers a lot of money and industry reputation among safety professionals.
The 2018 Lion Air crash is still under investigation by the Indonesian safety authorities. However, as evidenced by the information available for that crash prior to and after the March 10 Ethiopian Airlines Flight 302 crash and worldwide groundings of the 737 MAX airplanes, Boeing once again intentionally went cheap and less-safe on the 737 MAX design with a single, non-redundant angle of attack (AOA) input to a critical flight control system, the Maneuvering Characteristics Augmentation System (MCAS). Even worse this time, Boeing and its airline partners appear to have intentionally gone cheap on pilot education and training for this MCAS system, all for the sake of avoiding the extra cost of Differences Training and likely some other related costs like revised manuals.
To top it off, Boeing and the FAA appear to have waited almost five months after the Lion Air Flight 610 crash while they developed a software fix to once again add sensor input redundancy to fix their “cheap” single input problem as they did after the Turkish Airlines Flight 1951 crash. But this time another fatal accident happened before they got around to implementing their fix – Ethiopian Airlines Flight 302 with 157 souls lost.
“It has yet to be determined if the cause of the Ethiopian 737 MAX crash is the same AOA sensor failure and MCAS nightmare scenario that appears to have caused the Lion Air accident,” said Robert A. Clifford, founder and senior partner of Clifford Law Offices, an international aviation firm in Chicago that has represented victims and their families in numerous air crash cases throughout the world. “If it was, then Boeing will have 346 bloody stains on its reputation with nobody to blame other than themselves. Blaming it on the Lion Air and Ethiopian pilots for their failure to react in time and turn off the failed, poorly-designed, non-redundant Boeing flight control system that was trying to drive them into the ground just after takeoff would not be surprising given Boeing’s position of liability and denial, but would be another example of Boeing failing to live up to the expectations of the Aeronautical Engineering and public transportation worlds.”
Clifford continued, “And where does the FAA sit in all this? As usual, well-funded and protected from liability in the passenger seat of the Boeing mothership, the company echoes the line that the 737 has a long history of safe operation and that there have only been two fatal MAX accidents in two years of operation around the world, and that the new software update and flight crew education and training Airworthiness Directive will be out sometime next month. Meanwhile, the world around them grounds the MAX out of respect for the underlying safety principles of the Aeronautical Engineering and public transportation worlds.”
For further information or to speak to Robert A. Clifford or one of the aviation partners at the firm, contact Clifford Law Offices Communications Partner, Pamela Sakowicz Menaker at 847-721-0909 (cell).