US aircraft manufacturer Boeing has received unwelcome publicity over its safety record in recent years. Ron Alalouff sees what lessons can be learnt.
Boeing has been in the spotlight over the safety record of its Boeing 737 Max aircraft since 189 passengers and crew died in a Lion Air flight, which crashed shortly after take-off from Jakarta in October 2018. Just six months later, an Ethiopian Airlines 737 Max flying from Addis Ababa to Nairobi crashed killing 157 people. Both incidents involved anti-stall software that could override pilots and force the aircraft downwards. All Boeing Max aircraft were grounded for 20 months while safety enhancements were made.
Since then, Boeing’s safety culture has been receiving a great deal of scrutiny, principally from the Federal Aviation Administration in the United States. In March 2023 an expert panel convened to assess Boeing’s safety standards under the Aircraft Certification, Safety and Accountability Act.
In February 2024, the FAA released the expert panel’s report, which focussed on Boeing’s safety culture, safety management system (SMS), and FAA-delegated Organisation Designation Authorisation (ODA) activities. It found a “disconnect” between Boeing’s senior management and other members of the organisation on safety culture. Interviewees also questioned whether the company’s safety reporting systems functioned “in a way that ensures open communication and non-retaliation”. The panel also found inadequate and confusing implementation of the five components of a positive safety culture (reporting culture, just culture, flexible culture, learning culture and informed culture).
“The expert panel also found a lack of awareness of safety-related metrics at all levels in the organisation”
Although Boeing’s safety management system procedures reflected the International Civil Aviation Organisation’s and the FAA’s frameworks, they were not structured in a way that all employees understood their roles in those procedures. The procedures and training were “complex and in a constant state of change,” creating confusion. The expert panel also found a lack of awareness of safety-related metrics at all levels in the organisation, with employees having difficulty distinguishing between various measuring methods, their purpose and their outcomes.
The expert panel acknowledged that Boeing’s restructuring of the ODA unit’s management reduced opportunities for interference and retaliation against members of the unit. But there were still opportunities for retaliation to occur, which affected the ability of unit members to execute their delegated functions effectively. The expert panel also found additional issues that affected aviation safety, which include inadequate consideration of human factors commensurate with aviation safety, and a lack of pilot input in aircraft design and operation.
The expert panel was not directed to investigate or make recommendations following specific incidents or accidents. On several occasions during the panel’s activities, however, serious quality issues with Boeing products became public, amplifying the panel’s concerns that safety-related messages or behaviours were not being implemented across the company.
The panel stated that within six months of the publication of their report, Boeing should review its recommendations and develop an action plan that includes a milestone-based approach to comprehensively address each recommendation.
“Successful adoption of the recommendations is expected to improve the level of safety provided by Boeing to its workforce, operators and the public,” the report concludes. “While the expert panel focussed on Boeing as an ODA holder, the enclosed findings and recommendations may assist other companies with similar authorisations to implement successful safety cultures, safety management systems or ODA programmes.”
The findings and recommendations are based on the review of more than 4,000 pages of Boeing documents, seven surveys, over 250 interviews, and meetings with Boeing employees across six of the company’s locations.
Since the two fatal accidents in 2018/2019, among various initiatives Boeing has:
Regarding ‘Seek, speak and listen’, the panel observed through its discovery and assessment process that attention was given to ‘speak’, but with little or no attention given to ‘seek’ or ‘listen’. It said it had provided numerous opportunities through its engagements with Boeing for it to seek information from the expert panel, but received minimal questions from the company.
On 5 January 2024, an exit door panel blew out of an Alaska Airlines 737 Max at 16,000 feet, leading to the loss of passengers’ possessions. Thankfully, none of the passengers fell out of the gaping hole, and the aircraft landed safely back in Portland, Oregon. All Boeing 737 Max 9s with the same “door plug” configuration were grounded, with subsequent inspections of these models revealing loose hardware and bolts that needed additional tightening.
“It found multiple instances where the companies allegedly failed to comply with manufacturing quality control requirements.”
Following the exit door panel incident, the FAA conducted a six-week audit of Boeing and its fuselage supplier, Spirit AeroSystems. It found multiple instances where the companies allegedly failed to comply with manufacturing quality control requirements. The FAA identified non-compliance issues in Boeing’s manufacturing process control, parts handling and storage, and product control. The FAA told Boeing that it must “address the audit’s findings as part of its comprehensive corrective plan to fix systemic quality control issues”.
“In the immediate aftermath of January 5, the FAA took unprecedented steps to increase oversight on Boeing,” said FAA Administrator, Mike Whitaker in May 2024. “Over the last 90 days, that has meant everything from more safety inspectors in the facilities to halting production expansion. Today, we reviewed Boeing’s roadmap to set a new standard of safety and underscored that they must follow through on corrective actions and effectively transform their safety culture.
“On the FAA’s part, we will make sure they do and that their fixes are effective. This does not mark the end of our increased oversight of Boeing and its suppliers, but it sets a new standard of how Boeing does business.”
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“Regarding ‘Seek, speak and listen’, the panel observed through its discovery and assessment process that attention was given to ‘speak’, but with little or no attention given to ‘seek’ or ‘listen’.” This is surely familiar to many of us. Employees are told they should speak up, but there’s little effort by management to actively seek feedback, and the ‘listen’ element is woefully lacking – which then makes employees feel there’s no point in saying anything. Communication isn’t happening unless the speaker gets a message back to say that their message was heard and understood. When communication is electronic, this feedback… Read more »