After 2 737 MAX Crashes, Boeing Gears up to Renew its Safety Culture

May 24, 2022
Boeing's Chief Aerospace Safety Officer Mike Delaney on Monday outlined how — beyond specific changes to its design practices and its manufacturing operations — the company's leadership aims to rebuild and improve its entire safety culture.

May 24—In response to the two deadly 737 MAX crashes, Boeing's Chief Aerospace Safety Officer Mike Delaney on Monday outlined how — beyond specific changes to its design practices and its manufacturing operations — the company's leadership aims to rebuild and improve its entire safety culture.

Delaney said the new safety program he leads will focus not on looking back but on the future.

It will include enhanced oversight of safety; the use of analytical data from airlines, suppliers and Boeing's factories to pinpoint risk; encouragement of employees to speak up when they notice safety issues; and partnering with airlines to ensure that the in-service fleet of Boeing jets remains safe.

To succeed, the top-down organizational restructuring Delaney outlined will require buy-in and belief from the entire Boeing workforce.

"We have to move forward," Delaney said. "And we've got to take 140,000 people with us."

Speaking at Boeing's Safety Promotion Center in Everett, designed to remind employees of the weighty responsibilities of their work by highlighting past air accidents, Delaney said engineering teams have done root-cause analysis to figure out what went wrong in the two crashes that killed 346 people and delivered a traumatic shock to the company.

Boeing has changed its design practices accordingly to take more account of pilot reactions, and to make sure automatic flight controls have limited authority and have sufficient sensors to ensure redundancy in case of a failure.

Speaking of frontline engineers and mechanics, Delaney said, "You want people to look steely-eyed back and say, 'This will never happen again on my watch.'"

To achieve that, besides the fixes to the MAX that allowed its return to service, Delaney said Boeing aims to make strategic and cultural changes.

Yet Delaney said employees, those involved in the MAX's development and those not, are in various phases of how they think about the crashes.

Some stress that they'll "never forget" and want to move forward from there, while others "are maybe defensive. Some people are in denial," he said.

Reflecting this internal ambivalence about culpability, Boeing's top executives remain unwilling to publicly state that engineering design failures allowed the MAX's new flight control software — the Maneuvering Characteristics Augmentation System (MCAS) — to overwhelm the pilots in the two crashes.

"I did not want this office to look like a commission on what went wrong or what didn't go wrong," Delaney said. "We are where we are. And we have to build forward ... We have to own it. We have to improve it."

'Never forget the accidents'

In the lobby of the Safety Promotion Center building, adjacent to the office towers where thousands of engineers work, a series of small alcoves lines the wall, each displaying a stopped watch with a date and a time marking the moment of a terrible airplane crash.

They include the 1985 Japan Air Lines Flight 123 crash of a 747 that killed 520 people, and the 1989 crash of a DC-10 in Sioux City, Iowa, that killed 112 people on United Airlines Flight 232.

As a visitor walks past these memorials, on the facing wall a new one catches the eye. A continuously running fall of water inside a glass display is dedicated to the memories of those who died in 2018 and 2019 in the two MAX crashes.

The company is working on making the space accessible virtually to all its employees.

The purpose, Delaney said is "so that people can understand the design decisions, the history, never forget the accidents, the roles we've played in them."

He added that a newly hired engineer should come here so that "they are able to build on the history of 100 years of Boeing engineering."

Boeing chose this reflective venue to offer a small group of journalists its plan for preventing future crashes.

Learning lessons

Once a week Delaney attends a safety review with Boeing CEO Dave Calhoun, Chief Engineer Greg Hyslop and other executives.

One tool they look at is a digital dashboard of analytics that is designed to flag any issues in the worldwide fleet and in the factories.

Vishwa Uddanwadiker, vice president for aerospace safety analytics, said the system, created by "the best people from our applied math team," uses artificial intelligence and machine learning to identify risks by trolling multiple data sources, including safety concerns raised by employees and inflight incident reports from airlines.

The data, he said, will highlight bad news and bring it to the attention of managers and executives.

To illustrate how analytics could help prevent accidents, Delaney recalled the 2005 crash of a Helios Airways 737 when the cabin depressurized and all aboard lost consciousness. The crew mistook a depressurization warning for one indicating that the landing gear was down and hadn't reacted by donning their oxygen masks.

Delaney said the initial reaction by Boeing investigators was that this was likely a one-off freak accident. But then it learned from airlines that their pilots had experienced similar confusion in a series of non-fatal incidents. The information hadn't been passed on to Boeing.

Boeing changed the cockpit alerts to make them different. Delaney said if only the data from the airlines had been shared, that would have flagged the problem before the Helios crash.

"In hindsight, all of that data was there," he said. "But if you think about the early 2000s, everything was handwritten. There were no digital databases."

Now he said, Boeing's new system will tap into a huge trove of such operational data.

Another safety project, still in early development and led by Lacey Pittman, vice president for Boeing's global aerospace safety initiative, will send Boeing pilots around the globe to work with airlines, sitting in on safety reviews and flight operations meetings.

And her team has devised a new app that on an iPad provides a 3D simulation of a 737 cockpit for initial pilot training.

The centerpiece of Boeing's enhanced oversight regime is the establishment company-wide of what's called a Safety Management System.

This entails baking safety assessments into every aspect of the design and building of an airplane in close collaboration with regulators, especially the Federal Aviation Administration.

"It's really taking what we've always tried to do in terms of having best practices across our programs and putting in place a much more formal system to make sure that that's successful," said Tom Galantowicz, vice president of product and services safety.

The system will depend on frontline employees fully participating, ready to raise their hands and point to potential hazards without fear of retaliation for doing so.

In the early 2000s, engineers who questioned Boeing's massive outsourcing of design work on the 787 Dreamliner soon found themselves off the program. On the 737 MAX program, Curtis Ewbank, an engineer who filed an ethics complaint, was silenced and left the company.

Boeing must now convince its employees of a truly new transparency that offers protection for whistleblowers.

One way is the appointment of an independent ombudsman to listen to employee complaints, a measure that was required in the settlement of a shareholder lawsuit.

Delaney said someone has been chosen to fill that role and will be announced soon.

He said Boeing's leadership will move forward with the new approach and hopes to bring employees along.

"We have to extend our hand," Delaney said. "I will always assume positive intent, of our team and of our leaders. And we will reach out and do everything we can."

"We're going to move forward, I'm not looking back," he added. "We want our people on this journey with us."

Gallantowicz offered one data point to indicate that the new safety reporting culture is already taking hold within the company: Comparing the first quarter of last year to this year, Boeing has seen a 32% increase in internal quality and safety reports.

As further evidence of change, Delaney cited how Boeing has stopped all deliveries of the 787 Dreamliner as it sorts out a fix for manufacturing errors that resulted in small gaps between structural parts.

He said the workforce that builds the 787 has uncovered one new problem after another, prolonging the delivery stoppage that is starving Boeing of cash. But he said they have realized that's what the company wants them to do.

When he visited the 787 assembly plant in South Carolina, he said, "You could just see viscerally in their body language. It's like, OK, the leadership has our back. They want us to deliver a safe airplane ... And it's our job to do that."

Once those safety issues are fixed — and only then, he said — Boeing will use its resources to figure out how to recover the business losses.


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