Safety is our number one priority. How many companies make this claim? How many include this philosophy in their mission statement? How many times have you heard this statement during your aviation career?
Almost every single company in the aviation industry includes this statement in their company mission state;ment. But have we lost sight of what that statement really means? Are we just reciting it from rote memory with no real understanding of what the ramifications of that statement are?
I feel compelled to keep writing about the Boeing situation. The January 10, 2020 release of internal emails between Boeing engineers, managers and flight test pilots show they were flippant about serious safety issues that continued to crop up with the 737 Max.
As I read through those released emails, I found a familiar ease with the back and forth between these various professionals. Clearly, they wanted to be effective and efficient. But problems cropped up and continued to rear their ugly heads. In those telltale emails, one thing becomes clear. The only encouragement given was towards speed; finishing and finding ways around problems – not fixing them. A few examples of phrases, which you may have already seen nor heard in the news include “jedi mind-tricking” the authorities; “a game we have to play with the regulators.” “I want to stress the importance of holding firm that there will not be any type of simulator training required to transition from NG to MAX.”
It appears one potential customer pushed back numerous times on the Boeing assertion that no additional pilot training would be necessary to which Boeing emails firmly respond, “There is absolutely no reason to require your pilots to require a MAX simulator to begin flying the MAX…what is to be gained by a 3 hour simulator session…?”
Read through these snippets from hundreds of emails and ask yourself if you would put your family on this now infamous aircraft. “I’ll downplay that this is mandatory.” “Is it too early to start drinking?” “I have a flight test guy questioning us about T1 vs. T2/T3 etc., trying to blow up our whole plan.” “I don’t feel like wasting time and energy on an email if I don’t have to.” “OMG this process is so messed up.” “We Boeing elected to forego the T-1 because we thought it was a little too risky to send guys into the MAX with no training.” “Keep our fingers crossed no one notices it and if they do, worst case we say there will be a fix for it coming.”
After referring to their own flight test pilots as “bubbas” and asking if the pitch issue that needed correcting was noticeable, “They’ve said in our meetings it’s definitely noticeable…maybe only to test pilots it’s noticeable?” “You can’t lie if you don’t have to talk.” “I think with all the inexperience present, we should be able to gang up on them and steer it the direction we want.” “I crashed big time my first few times, that is what scares me about showing any of this to them. You can get decent at it after 3-4 tries, but the first few are ugly.” “It’s easy to start chasing pitch and power and get in a PIO [pilot induced oscillation].” “It was like dogs watching TV for the AEG [aircraft evaluations group at FAA] curves, slopes, graphs non-engineers and test pilots really can’t understand.” “I’ll be shocked if the FAA passes this turd.”
After months, the emails indicate that team members were mired in the deception: “I have used the words ‘misleading’ and ‘mischaracterization’ a lot over the last two years in relation to his program.” “I would really struggle to defend the sim in front of the FAA next week.” “They are desperate for a go.” An entire back and forth about being forgiven by god and going to hell. “What of the irreparable damage to the Boeing name if it fails.” Q; “What is their concern?” A: “Pitch oscillation during flap retraction.”
One employee clearly felt strongly enough to not lie but considered quitting: “Not sure I will be returning in April given this – am not lying to the FAA. Will leave that to people who have no integrity.”
It does seem as though employees were trying hard to make headway in addressing the problems: “We need lots of operationally simulated testing using the FMC the way the pilots do, not engineers and engineering pilots flying between BFI and Moses [Lake].”
But later the extreme pressure to continue down the quickest path was clear: “Failure to obtain Level B training for RCAS is a planet-killer for the MAX.” There is also a long discussion about how bad the pitch problems were and how Boeing’s “other pilots would probably sign off on it.”
Also on how the company was manipulating the situation: “It is masking figures to manipulate perception.” “Would you put your family on a MAX simulator trained aircraft? I wouldn’t.” And again, an occasional voice of clarity: “Our arrogance is our demise.” “The FAA were neither thorough nor demanding and failed to write up many issues.”
This email came a mere four months prior to the Lion Air accident in October 2018: “Everyone has it in their head meeting schedule is the most important because that’s what Leadership pressures and messages. All the messages are about meeting schedule, not delivering quality.” And, of course, the snippet that got the most air play, “This airplane is designed by clowns, who in turn are supervised by monkeys.”
Have you ever repeated a word over and over again only to find after saying 50 times it doesn’t have a meaning anymore? There is a term for that – semantic satiation. You continue to see the letters of the word or hear the sound of the word, but they no longer make the word; it becomes gobbledygook. The meaning has vanished. I can only imagine that these otherwise successful and committed professionals had become victims of semantic satiation with regards to the word “safety.” But that is still no excuse.
Could that happen in your company with regards to the word safety? Why would an aviation company lose sight of that? The almighty dollar. All meaning and clarity in hindsight.