The Boeing 737 MAX: a Predictable New Failure

The Boeing 737 MAX is in the news again for all the wrong reasons: we foresaw the possibility of this nearly four years ago, and we still have to ask if any lessons will be learned… Why? Because Complexity still abounds without being properly understood.

There are times in life that finding you’ve managed to correctly anticipate the future brings great satisfaction.

And then there are those times that it only seems as if your fears were realised.

Whilst these latter times may bring a sense of vindication, they rarely bring satisfaction, and the recent incident involving Alaska Airlines Flight 1282 definitely falls into this category.

After all, back in 2020, we used the Boeing 737 MAX – the aircraft again involved in the latest incident – as a tragic example of failing to account for Complexity.

Despite the aircraft having taken back to the skies, we specifically wondered if any lessons had really been learned.

And only four years later, here we are again with a fresh issue affecting the aircraft…

What Happened

On the evening of 5th January 2024, about six minutes after taking off from Portland in Oregon to Ontario in California, Flight 1282 had reached an altitude of 16,300 feet.

Suddenly, a door plug – an unused cabin door used to fill an emergency exit not needed in Alaska Airlines’ configuration of the plane – blew out, rapidly depressurising the cabin and causing chaos.

One boy had his shirt sucked off him, with his mother holding onto him to stop him from following it, and other items also flew out of the newly-created hole – including an iPhone which was later found intact.

(Good publicity for Apple, then, even if not for Boeing…)

Thankfully, being so early in the flight, all passengers still had their seatbelts on, and the seat nearest the fuselage breach was unoccupied – any occupant there would have been most at risk at being sucked out of the plane.

Twenty-nine minutes later, after an emergency landing, all passengers and crew disembarked the plane safely (notwithstanding three passengers with minor injuries).

And then the speculation and analysis began, with the National Transportation Safety Board (NTSB) launching an investigation and all of the same model of the Boeing 737 MAX being grounded.

Why This Matters

This all matters not just because of the ordeal experienced by all 177 people on board Flight 1282, but because – as we detailed in 2020 – the Boeing 737 MAX had only relatively recently gone back into service following two tragic crashes that saw all 346 people aboard killed.

And, at least on the surface, the parallels between all three incidents are striking – the same aircraft involved, things going wrong just after takeoff, and all Boeing 737 MAX aircraft subsequently grounded.

Now, it should be stressed that the investigation into the latest incident is only beginning, and it should be acknowledged that the BBC quoted aviation expert John Strickland emphasising that the latest incident was very different to the crashes in 2018 and 2019.

Indeed, he stated that “While we know little evidence of why this section of the fuselage has come out – this has nothing to do with the aircraft being grounded for 18 months“.

But even the surface parallels surely make it natural to wonder if this is just an unfortunate coincidence or indicative of something more fundamental going on…

…and this sense only seems confirmed when digging a bit deeper, at which point the parallels and apparent continuity seem even clearer.

Digging Deeper

When we look back at what we wrote last time, we see several key themes:

  1. How Boeing had accelerated the 737 MAX to market, leading to design tradeoffs that “…solved one problem, but created another“.
  2. A breakdown in communication where known issues were not passed on.
  3. Key information from pilots and testers either unavailable or ignored.
  4. Pressure to get the plane back in the skies on the assumption that the issues were resolved.
  5. New issues continuing to be found, with debris discovered in new planes’ fuel tanks.

And when we look at the latest incident in light of these things, the parallels become even more uncomfortable:

On design: this Yahoo piece suggests that use of a door plug is a design choice not found in all planes – not only is an expert quoted as saying “The plug is in my opinion a bad design, because it can blow out and did blow out in this case” but this Reuters piece specifically contrasts the design on the Boeing 737 MAX with that used by Airbus.

On known issues, there are already two sources of concern:

On key information: one no doubt panic-inducing moment for all involved was when the cockpit door flew open – panic no doubt enhanced by the crew not being aware that this was a specific design feature.

With pressure to get the plane back in the skies: as we saw above, the specific plane involved had been kept up in the air despite warnings, but more generally it is notable that – especially with the backdrop of previous tragedies:

Again, was the assumption that the issue was known and dealt with?

In the days since, though, United Airlines has reported more loose bolts, and it has been reported that – since the 2018 and 2019 crashes – “conditions inside Boeing’s factories have not improved, and that the US regulator has been ineffective in holding the company to account.”

The pattern of new issues would seem to be continuing…

It is therefore fitting that Boeing’s president and chief executive has said the firm is “acknowledging out mistake“ and there is absolutely no reason to doubt his sincerity in saying on 7th January that:

“When it comes to the safety of our products and services, every decision and every action matters. And when serious accidents like this occur, it is critical for us to work transparently with our customers and regulators to understand and address the causes of the event, and to ensure they don’t happen again. This is and must be the focus of our team right now.“

But – as we asked back in 2020 – “can we really be confident that anything has really been learned about the nature of Complex situations and how to respond to them?“

The Remaining Concerns

This matters because an understanding of Complex situations is what enabled us to not just analyse what happened back in 2018 and 2019, but to voice concerns for the future – concerns that still remain.

Complexity specifically means that:

  • Fully explaining any situation is impossible, with hidden dependencies and unforeseen consequences.
  • Information needs to be fully and immediately available to those that need it.
  • Checklists and procedures are not sufficient to mitigate against issues occurring or to deal with them when they arise.

And far more besides.

As we then see in the commercial world’s general failure to adequately understand and respond to Complexity, Boeing are absolutely not unique here.

Indeed, bad luck arguably plays a significant part in their particular exposure – including that issues in their industry are liable to have especially dramatic and drastic consequences.

But unless Complexity is properly understood and accounted-for, the chances of serious problems are far higher…

…and that’s why it was no real surprise to find the Boeing 737 Max again in the spotlight.

As I said at the start of this piece, that brings a sense of vindication at being “right”, but it comes with no satisfaction.

All it really comes with is a question: when will the commercial world truly wake up to today’s Complex world?

Closer to home, and – if you haven’t already – when will you?

Even though it is unlikely that they’d be as high-profile or catastrophic as those affecting Boeing, what ticking timebombs might otherwise be just around the corner?

Article contributed by Stephen Bruce

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