A question of Safety or Ethics, how Boeing & Alcoa handled differently.

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Two accidents of the Boeing flagship aircraft in the 1990s and lawsuits awarding damages worth USD 25.5 million reveal shocking truths about the Boeing Company. The Seattle Times reported the company’s long-standing awareness of the rudder’s propensity to deflect on its own. What’s more, the papers released by the court show Boeing discovered in the early 1980s, that there was little pilots could do to recover from some rogue deflections, yet failed to point out the significance of that finding to safety regulators and airlines.

Boeing insists it did nothing wrong, and everything was done as was required to by federal safety regulations.

In a report released in 2014, the U.S. National Transportation Safety Board (NTSB) found plenty of blame to go around when reviewing a lithium-ion battery fire inside a 787 Dreamliner passenger aircraft in January 2013.

The board’s report in particular singles out the plane’s manufacturer (Boeing), its contracted battery supplier (GS Yuasa), and the Federal Aviation Administration (FAA) as falling short in ensuring public safety. Last year during NTSB hearings, Boeing Vice President Mike Sinnett called their self-policing policy with FAA “in retrospect… [not] conservative enough.”

The NTSB apparently agrees. Its report says FAA provided “insufficient guidance” for its own certification engineers to develop testing for rechargeable batteries used in a commercial jumbo jet.

On the other extreme end of Safety is Paul O’Neill the CEO of Alcoa, the biggest aluminum manufacturer in USA. A must watch video for all. There are 3 basic elements which promote safety.

  • Are you treated with dignity with respect every day by everyone you encounter?
  • Are you given the things you need. Tools, training, equipment, encouragement so that you can make contribution and make meaning to your life?
  • Do you get recognised for what you do?

The Lion Air followed by the Ethiopian Airlines B-737 Max accident has drawn the attention towards a similar technical issue. The Maneuvering Characteristics Augmentation System (MCAS) was a design feature incorporated in the ill- fated Lion Air B-737 Max but the pilots did not know about it. The larger engines of the B-737 Max required the airframe to be modified as had been carried out by the Airbus on the A320-NEO. Due to the bigger size of the engines, the Airbus redesigned the wing and raised the nose thereby, altering the centre of gravity slightly, which affects the balance of the aircraft. Boeing, on the other hand, did not re-design the wing but raised the nose and introduced a design feature called MCAS, which would compensate for the change in the aircraft balance and the tendency for the nose to pitch up. The MCAS, whose function was to prevent an excessive nose up pitch, may have malfunctioned-possibly leading to the aircraft pitching down, leaving the crew in a confused state.

The Boeing-737 has been the best selling aircraft in history having taken 14,985 orders till October 2018. Boeing delivered the 10,000th B737 to Southwest Airlines in April 2018. Work on B-737 was started in 1964 and the 1st aircraft flew in 1967. After the huge commercial success of B-737, the Boeing company has another best seller, the B-777 which is about 2,000 aircraft orders behind.

Boeing introduced variants of the B-737 from 1971 onwards to cater for safety, aerodynamic and fuel efficiency issues. The latest variant, the Boeing 737 Max was launched in May 2017.

Technology changes with time, and industry has to keep pace with developments. This is because they have to keep up with the competitors and maintain the superior edge in-terms of hardware and software advances. All these developments and changes have to be made within the purview of the safety bubble. The manufacturer cannot afford to compromise the safety of the passengers, crew and the aircraft in any way. There are detailed systems and processes, which test each system for robustness and reliability. The regulator, who has the final authority and is responsible for safety gives the go ahead when they are convinced beyond doubt that the probability of a failure is kept to the minimum acceptable level.

The B-737 has had a series of technical issues with the aircraft rudder. The Seattle Times has given the chronology of the events, reproduced below:

“The B-737 started having technical issues beginning 1969 after Boeing issued service bulletin regarding rudders moving inadvertently. Between 1980-90 pilots filed hundreds of reports. The pilots reported rudder problems but Boeing blamed the yaw damper. There were two accidents:

  1. March 3, 1991: On final approach into Colorado Springs, United Flight 585 rolls right and takes a steep drop. All 25 on board die.
  2. Sept. 8, 1994: Descending in calm skies, USAir Flight 427 peels left and dives into a wooded ravine near Pittsburgh. All 132 on board die.

Seattle Times news report on the Boeing 737 safety issues.

November 1994: Boeing issued instructions for 737 pilots to shut off yaw damper if a jet veers slightly left or right. A series of tests and modifications were carried out thereafter.

Nov. 1, 1996: Boeing issued a service bulletin recommending that airlines operating 737s test the rudder power-control units of their aircraft to detect a potential jam condition.

After the Lion Air B-737 Max accident 24 years later, Boeing issued a service bulletin followed by a FAA emergency directive.

Nov 2018, Boeing issued a service bulletin informing the crew of uncommanded nose down Stabilizer trim due to Erroneous Angle of Attack during manual flight.”

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Above: Extract of the US court ruling

If what the Seattle Times reported, after the US Air 427, as per documents in their possession, after being released by court and the Lion Air 610 accident, is true, there seems to be an issue with respect to ethics rather than with safety. Boeing is a commercial organization, which manufactures the B-737, however, there is a dire need to look beyond the balance sheet and commitment to safety. The commitment to safety pays off in the long run if it becomes a habit and no corners are cut when safety issues are identified. The debate about safety and ethics is for the readers to decide by carrying out more research prior to forming an opinion.

Interestingly Boeing chose to respond to one of my blogs on another media. At that stage only Lion Air had gone down and Boeing was very confident about their tough stance of not budging. Please read the response which is filled with sentiment of safety in text only and not apparently in actions.

Boeing response
Boeing response

Safety is an important ingredient for survival but is safety an indicator of corporate progress? Most corporates focus on their balance sheets and the top management has only a basic understanding of the concept of safety.

In October 1987, the new CEO of Aloca, the worlds eight largest aluminum producer gave his maiden speech to the shareholders.

I want to talk to you about worker safety.

Every year, numerous Alcoa workers are injured so badly that they miss a day of work.  Our safety record is better than the general workforce, especially considering that our employees work with metals that are 1500 degrees and we have machines that can rip a man’s arm off.  But it’s not good enough.  I intend to make Alcoa the safest company in America.  I intend to go for zero injuries”.

A shareholder asks about inventories in the aerospace division. Another asks about the company’s capital ratios.

I’m not certain you heard me.  If you want to understand how Alcoa is doing, you need to look at our workplace safety figures.  If we bring our injury rates down, it won’t be because of cheerleading or the nonsense you sometimes hear from other CEOs.  It will be because the individuals at this company have agreed to become part of something important: They’ve devoted themselves to creating a habit of excellence.  Safety will be an indicator that we’re making progress in changing our habits across the entire institution. That’s how we should be judged”.

The audience was confused. Why wasn’t O’Neill making them feel warm and fuzzy?  How were they going to make money by focusing on safety? Most CEO’s would use this opportunity to get shareholders excited that they were going to focus the company on increasing sales and reducing costs, for improved shareholder return.  But O’Neill was different.

O’Neill’s safety speech is considered as one of the best in the 20th century. He started with explaining “why”, which got the shareholder’s attention, then moved to “how” they were going to do it and finally “what”.

As quoted in his book by Charles Duhigg, The Power of Habit, O’Neill said, “you can’t order people to change. That’s not how the brain works. So I decided I was going to start by focusing on one thing. If I could start disrupting the habits around one thing, it would spread throughout the entire company”.

He chose improving safety as the key habit to bring the entire company together.  He chose a habit that would have everyone in alignment – unions and managers.  And it meant total operational transformation.

Humans can only learn and remember so much information at once.  The more information you give people – the more it can paralyze them.

But what he also did rather skillfully was to encourage group behaviour.   He encouraged Alcoa workers to consider the safety of the group rather than themselves.  He rallied the workforce to work together for a common goal.

Humans see themselves in terms of other people and groups.  Evolution has taught us that it is beneficial to live in tribes, where we can share out the work of daily survival.

O’Neill harnessed the strong human need for group identity to build a thriving organisation. The trick in using group identity when wanting staff to change behaviour or embrace a new goal is to word it so they make a decision based on what’s best for the group.  Activating peer pressure is an effective way to get a group to persuade others to act in a certain way

And you’ll notice that O’Neill never used the word “I” in his speech.  Saving lives wasn’t about him. It was about the group – it was about the Alcoa workforce.

He also cleverly used a shareholder meeting, to let his staff know, that he wasn’t there to increase shareholder returns.  He was there to improve their quality of life, to ensure that they would arrive home safely at the end of the day.  By launching his first speech to outsiders, he powerfully communicated to staff, just how committed he was to improving their workplace.  That he could be trusted.  That he was on their side.

O’Neill believed that they way to keep employees staff was to discover why injuries were occurring in the first place.

Studying what was going wrong in the manufacturing process did this.  Employees received training about quality control and how to work more efficiently.  By ensuring that employees developed the habit to do tasks right in the first place, their work became safer.

O’Neill transformed the company, within a year of O’Neill’s speech, Alcoa’s profits hit a record high. By the time O’Neill retired in 2000 to become Treasury Secretary, the company’s annual net income was five times larger than before he arrived, and its market capitalization had risen by $27 billion.

This is the power of Safety and making Safety a habit.

About Capt. Amit Singh

I think therefore I am https://www.linkedin.com/in/traintofly/ Airlines Operations and Safety balance expert. A former head of operations/training and safety of successful LCC's in India. An experienced member of the startup teams of these airlines has hands-on experience in establishing airlines systems and processes.

3 Responses

  1. Shyam Kumar

    Sir, the article mentions that airbus ‘raised the nose’ on the neos to account for the larger engines. I know they tilted the engines upward facing angle of about 2.5 degrees and also the nacelle to ground clearance is reduced, but was the aircraft nose height also raised? Wouldn’t that also result in an incrseased cockpit to ground height? But as per the fcom ‘dimesnsions’ data, they are the same as for the comventional A320s?

    1. The NEO CG has shifted slightly. As per my initial discussions with Airbus, they had disclosed that they would redesign the wing and raise the nose to accommodate the larger engines. Maybe not sigificantly.

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