Making Sense of the Nonsense

Titanic disaster

Years ago, when teaching a Repair Station course, my co-instructor and I spoke about root cause. He used the Titanic disaster as an example of what really happened. Poor rivet quality control and watertight doors that weren’t watertight were some of the Titanic’s root causes – not the iceberg. We were trying to drive Federal Aviation Administration (FAA) inspectors to look below the surface.

What’s below the surface?

I always felt it was the Titanic’s speed that was the accident’s root cause, that it was going too fast through an ice field, that moving slowly at night would’ve been wise. Why? Because an iceberg is more than what was visible on the surface. Just below the surface the well-known iceberg, Titanic’s bane, could’ve widened hundreds of yards in any direction from what Titanic’s lookouts could see. Indeed, Titanic didn’t hit what was seen. Instead, it hit what was unseen.

It's like in aviation. An iceberg could be used as a metaphor for accidents and incident investigations. When accidents and incidents enter the public domain, all eyes look at and look for the visible part of the iceberg, what’s above the surface, things like the death toll, the aircraft model, the airline.

But, with icebergs, there’s so much more below the surface. In accident investigations, what hides below the surface are the safety risks, like union problems, inadequate training, merger upsets, work stoppages, oversight lapses, financials, poor management … the list goes on. But the public doesn’t care about icebergs below the surface because the iceberg they see is scary enough to worry about.

Everyone in the US is in an uproar about Alaska Airline’s door departure on aircraft N704AL, like loose bolts, advisory lights, the door in someone’s yard, the chief executive officer (CEO) apologizing, FAA oversight questions in the news. What’s going on? Lots of information, all of it disconnected. The public’s whipping itself into a frenzy, but nothing makes sense. Nor will it if we continue to walk this futile path. If everyone gets past the opinion traps, maybe we can get to the facts; we’ll see clearly what’s going on below the surface at Boeing and the FAA. Spoiler alert: it ain’t about loose bolts.

Using the iceberg metaphor, the bolts and the advisory light are the shiny peaks of the iceberg, out there under the sun, almost hypnotizing in their dangerous brilliance. We see it, we discuss it, we get past it. All the time we ignore the real threats under the surface; we’re ignoring all that got us here. It’s simple, look below the surface; ignore the media. The loose bolts aren’t important because they’re only a symptom. Then what is important? There’s so much investigators, inspectors and so-called detectives are missing, so it’s time to spotlight the issues.

The FAA

What’s going on at the FAA? What should be looked at?

1.      Some would argue the disconnected events, Ethiopian Airlines 302, Lion Air 610, the Alaska Airlines door are FAA failings, but are they? FAA’s part in Lion Air 610 and Ethiopian Airlines 302 was minimal. The two MAX accidents shouldn’t be tied to what led to the Alaska Airlines event. N704AL should stand on its own. If one reads the Lion Air 610 and Ethiopian Airlines 302 accident reports, they’d see two obvious facts:

a.      One, the people who investigated the accidents had no experience in B737-MAX technology. Furthermore, the investigators were government folks investigating a government airline. That’s called a conflict of interest.

b.      Two, training at Lion Air and Ethiopian was inadequate.

2.      FAA inspectors and engineers all work at home. This means zero on-site personal oversight. No one (at the FAA) is minding the store. And FAA management condones and supports this hands-off mentality. FAA engineers rely solely on photos and videos. This form of interaction with manufacturers is inadequate. How does one oversee Boeing engineers from the comfort of one’s easy chair? Or Airbus? Or Embraer? Or Cessna? Or Aerospatiale? See the problem? See the enormous disconnect? Who ran the FAA before Michael Whitaker? Did they ever take the job seriously? Not likely.

3.      Diversity, Equity, and Inclusion (DEI) policies have led FAA to hire unqualified FAA engineers and inspectors in the wake of the largest FAA exodus … ever. Recent FAA acting administrators pushed DEI hiring practices. Industry is now seeing DEI’s led to unequalled heights of incompetence. FAA (and some airlines) are now DEI Petrie dishes showing the decay of quality, experience, and knowledge in the industry.

4.      FAA management, in order to conceal the dangers of hiring per DEI policies, mix hirable physically handicapped persons (who have never been denied employment) with persons with a ‘psychiatric disability’. A psychiatric disability (PD) is an ambiguous term. Define the PDs. What type of PDs are hirable? Are PD persons emotionally or psychologically able to function within the FAA’s work parameters? Can PD persons function in a cockpit during flight? Will PD persons endanger flight crew members, namely pilots, in flight? Will PD persons nullify cockpit security measures, such as locked doors, by having access – by regulation – to the cockpit? Are we so immune to 9/11 lessons that we’d subject flight crew and passengers to that danger again? Are we insane?

5.      In 2022, a former FAA acting administrator disclosed there were unqualified engineers at Boeing, that FAA failed to maintain proper oversight over Boeing engineers. Were these problems fixed or is Alaska’s event a sign of this lingering problem?

Boeing

Boeing CEO David Calhoun

Boeing’s CEO Dave Calhoun recently apologized for the N704AL incident, even before any facts were identified. Some see this humble apology as good, but it’s a major distraction. It takes air out of the argument and attention off Boeing. Consider this: if President Clinton had owned his affairs, would the public have cared about all the embarrassing details? No. Apologies put people off balance. The public begins to sympathize with the Apologist; they don’t forgive, but suddenly investigators become the bad guys; they’re harassing Boeing. What else?

1.      Boeing’s lawyers are throwing money at everything but the problem(s). Alaska’s passengers have begun their lawsuits, so like good lawyers, they settle; make them go away. These lawyers will divert crucial attention away from fixing Boeing, Spirit Aero, and the FAA and will concentrate solely on Boeing’s public relations (PR).

2.      Boeing’s CEO Dave Calhoun’s PR stunt diverted attention away from safety – not towards it. And industry people bought into it, thinking Calhoun ‘brave’ and ‘professional’, a ‘true leader’, when he’s not. Otherwise, Alaska’s door departure never would’ve happened.

3.      What exactly does ‘Boeing’s loose bolts’ mean? Oversized bolt holes? Wrong hardware? Improper torquing? No washers? Inferior quality hardware? Unsafetied hardware? Is focus on engineering or the ones who physically installed the bolts?

4.      Like the FAA, Boeing has undergone a mass exodus of qualified persons, namely qualified engineers. DEI policies were identified at Boeing over a year ago; it is unclear how DEI hiring policies at Boeing have affected the manufacturer’s safety-sensitive positions. Are they hiring engineers with psychiatric disabilities like the FAA?

5.      Are Boeing engineers who approve and sign off on all models of aircraft qualified? Are they DEI hired engineers? Is Boeing’s management qualified to oversee the engineering departments? At what level are Boeing’s engineering problems at?

Alaska Airlines

People are convinced Alaska is innocent of everything. However, Alaska has been flying N704AL since October. That means N704AL has flown between 240 to 480 flight cycles and well over 1000 flight hours. That’s more than ‘just since October’ suggests. If N704AL flew ETOPs, the flight hours were much higher. The aircraft has been through maintenance on several occasions, with multiple opportunities to open that door. This dismissal of responsibility happened with Emery 17 in 1999. Is it happening again? Did passengers complain about pressurization noises from the door? Were there pressurization concerns from the pilots?

The National Transportation Safety Board (NTSB)

It’s hard to imagine any agency less qualified to investigate this MAX event than the NTSB … unless, of course, one includes those who investigated Lion Air 610 and Ethiopian Airlines 302. What was done to fix those accident findings? Madam Chairwoman Homendy’s press conference was cringeworthy. She should’ve set a sobering scene; safety integrity is a serious business, not an opportunity to get in front of the cameras. Homendy’s smiling ‘happy snaps’ around the door on ‘Bob’s’ property were inappropriate. They demonstrated the NTSB views this investigation as nothing more than a photo-op. Retrieving the door wasn’t a Kodak moment, it was recovering evidence in a safety investigation. If there were deaths, would ‘happy snaps’ be improper? In the end, the NTSB will come up with a probable cause that finds nothing but the obvious. The ‘probably’ cause will get safety nowhere and will fix nothing.

The aviation industry needs to remain focused; emotions should be the furthest thing from any investigation. Apologies, snapshots, interest in the irrelevant, these divert attention away from safety-focused investigating. Considering the 737-MAX refuses to release its grip on infamy, then investigators need to concentrate on what keeps dragging Boeing, the FAA, and all other participants into the limelight. Focus on what’s under the surface because that’s where the fundamental answers are, it’s where the answers to fix the MAX are. Nowhere else.