The first in a series on the historical parallels and lessons that unite the groundings of the DC-10 and 737 Max.I hope he's right about the series, because this first part is a must-read account of the truly disturbing parallels between the dysfunction at McDonnell-Douglas and the FAA that led to the May 25th 1979 Chicago crash of a DC-10, and the dysfunction at Boeing (whose management is mostly the result of the merger with McDonnell-Douglas) and the FAA that led to the two 737 MAX crashes. Ostrow writes:
The grounding of the DC-10 ignited a debate over system redundancy, crew alerting, requirements for certification, and insufficient oversight and expertise of an under-resourced regulator — all familiar topics that are today at the center of the 737 Max grounding. To revisit the events of 40 years ago is to revisit a safety crisis that, swapping a few specific details, presents striking similarities four decades later, all the way down to the verbiage.Below the fold, some commentary with links to other reporting.
The RegulatorsThe DC-10 crashed because one of the pylons holding the under-wing engines broke, with massive damage to the wing. Despite this obvious mechanical failure, it took 12 days for the FAA to ground DC-10s:
On June 6, all 138 DC-10s at eight U.S. airlines were ordered grounded by the FAA when it revoked the jet’s airworthiness certificate and would stay that way for 37 days in 1979. The FAA initially opposed the grounding and the crash forced a legal battle with the American Airline Passengers Association, which sought an injunction to halt DC-10 flying in the U.S. “pending fuller analysis,” according to coverage in Flight. Inspections in the days that followed the Chicago crash revealed cracks on the engine pylons on other aircraft. FAA Administrator Langhorne Bond had no choice but to withdraw the roughly 275-seat jet’s airworthiness certificate. Carriers and regulators around the world — totaling some 274 aircraft, including 74 in Europe — followed suit.The cause of the Lion Air crash wasn't clear, but after the Ethiopian Airlines crash it took China and Indonesia less than a day to ground the 737 MAX:
McDonnell Douglas called the order “an extreme and unwarranted act.”
Responding to the second crash of a Boeing 737 Max 8 soon after takeoff in less than five months, China and Indonesia ordered their airlines on Monday to ground all of these aircraft that they operate.It took the FAA three days to realize that they couldn't allow the 737 MAX to continue flying:
The Civil Aviation Administration of China noted in its announcement on Monday morning of the grounding that both the Ethiopian Airlines crash on Sunday and a Lion Air crash in Indonesia in late October had involved very recently delivered Boeing 737 Max 8 aircraft that crashed soon after takeoff.
Indonesia joined China about nine hours later in also ordering its airlines to stop operating their Boeing 737 Max 8 aircraft.
On Wednesday, when announcing the grounding of the 737 MAX, the FAA cited similarities in the flight trajectory of the Lion Air flight and the crash of Ethiopian Airlines Flight 302 last Sunday.It is doubtful whether the FAA would have acted so fast had they not been preempted. In both cases, the FAA set up a blue-ribbon review board. The 1980 board concluded:
“The committee finds that, as the design of airplanes grows more complex, the FAA is placing greater reliance on the manufacturer,” the blue-ribbon panel wrote in 1980. “The FAA’s human resources are not remotely adequate to the enormous job of certifying an airliner,” wrote Newhouse, and said the lure of more attractive salaries in the private sector meant 94% of approval work was delegated to the manufacturers. “The committee finds that the technical competence and up-to-date knowledge required of people in the FAA have fallen behind those in industry.”Dominic Gates reports this is still the case today:
The FAA, citing lack of funding and resources, has over the years delegated increasing authority to Boeing to take on more of the work of certifying the safety of its own airplanes.The 2019 review agreed:
Early on in certification of the 737 MAX, the FAA safety engineering team divided up the technical assessments that would be delegated to Boeing versus those they considered more critical and would be retained within the FAA.
But several FAA technical experts said in interviews that as certification proceeded, managers prodded them to speed the process. Development of the MAX was lagging nine months behind the rival Airbus A320neo. Time was of the essence for Boeing.
A former FAA safety engineer who was directly involved in certifying the MAX said that halfway through the certification process, "we were asked by management to re-evaluate what would be delegated. Management thought we had retained too much at the FAA."
"There was constant pressure to re-evaluate our initial decisions," the former engineer said. "And even after we had reassessed it ... there was continued discussion by management about delegating even more items down to the Boeing Company."
Even the work that was retained, such as reviewing technical documents provided by Boeing, was sometimes curtailed.
The New York Times would call the panel’s findings “damning” for Boeing and the FAA. The JATR, which included regulators from nine countries along with the U.S., found “signs of undue pressure” on the delegated Boeing staff responsible for regulatory approvals of the MCAS system, which it said (without elaborating) “may be attributed to conflicting priorities and an environment that does not support FAA requirements.”The 1980 review pointed to the problem that the regulations were treated as the maximum the manufacturer needed to do:
Maynard Pennell, retired Boeing executive and aerodynamicist drafted to the blue-ribbon commission for the review of the FAA and DC-10 told Newhouse: “Douglas met the letter of the FAA regulations, but it did not build as safe an airplane as it could have. This was not a deliberate policy on its part…Douglas was determined not to over-run or do more than required by regulation to do.”The 2019 review agreed:
The JATR concluded Boeing broadly met every regulation, but raised “the foundational issue” of whether or not regulations can go far enough to foster a safety culture without creating complacency. “To the extent they do not address every scenario, compliance with every applicable regulation and standard does not necessarily ensure safety.Ostrower ends by explicitly linking the two reviews:
On the closing page of its 1980 report, the blue-ribbon committee made a recommendation stemming directly from the lessons it saw as crucial from the 1979 DC-10 crash. The report recommended that each commercial aircraft manufacturer “consider having an internal aircraft safety organization to provide additional assurance of airworthiness to company management.” [Emphasis theirs] McDonnell Douglas had created roving non-advocate review boards to assess program safety, according to a former Douglas executive, but it stopped short of a central organization. But the virtue of the recommendation didn’t end in 1980. Whether it realized it or not, Boeing’s Board of Directors on September 30, 2019 adopted the committee’s suggestion, forty years later.
The ManufacturerIt is important to note that the current Boeing management evolved from the McDonnell-Douglas management of 1997. As I wrote in Boeing 737 MAX: Two Competing Views :
[Maureen Tkacik] recounts how Boeing bought the failing McDonnell-Douglas in 1997 and basically handed management of the combined company to the team that had driven McDonnell-Douglas into the ditch:In fact, the Stonecipher-engineered buyout closed on 1st August 1997, a mere 68 days after the DC-10 crash.
The line on Stonecipher was that he had “bought Boeing with Boeing’s money.” Indeed, Boeing didn’t ultimately get much for the $13 billion it spent on McDonnell Douglas, which had almost gone under a few years earlier. But the McDonnell board loved Stonecipher for engineering the McDonnell buyout, and Boeing’s came to love him as well.
Work on the DC-10 started in 1968 and it entered service in 1971. Ostrower writes:
Douglas was determined to beat the L-1011 Tristar to the sky in 1970 and did so 10 weeks before Lockheed. The externally similar looking tri-jet occupied an identical spot in the market. And arriving first would be part of the competitive advantage, Douglas surmised. That expediency by Douglas (recently merged in 1967 with McDonnell) would invite some of withering criticism from those tasked with officially evaluating the jet after Flight 191, including that its design might’ve met the letter of the law, but fell far short of its spirit of safety.They were right about the "competitive advantage":
Although the L-1011 was more technologically advanced, the DC-10 would go on to outsell the L-1011 by a significant margin due to the DC-10's lower price and earlier entry into the market.In Flawed analysis, failed oversight: How Boeing and FAA certified the suspect 737 MAX flight control system Dominic Gates of the Seattle Times explains that Boeing was desperate to get the 737 MAX in the air because the Airbus A320 Neo had a 9-month lead in the market. And that Boeing also had a serious competitive disadvantage against Airbus. Airbus's planes are fly-by-wire, and the flight control software minimizes the differences between different models, reducing the need for pilot training. Boeing was also desperate to ensure that pilots certified for earlier 737 vesions would not need significant training to fly the MAX. Gates writes that Boeing:
had promised Southwest Airlines Co., the plane’s biggest customer, to keep pilot training to a minimum so the new jet could seamlessly slot into the carrier’s fleet of older 737s, according to regulators and industry officials.
[Former Boeing engineer] Mr. [Rick] Ludtke [who worked on 737 MAX cockpit features] recalled midlevel managers telling subordinates that Boeing had committed to pay the airline $1 million per plane if its design ended up requiring pilots to spend additional simulator time. “We had never, ever seen commitments like that before,” he said.