The Boeing 737 Max: "An airplane

designed by clowns, led by monkeys"

Two disasters, one after the other, with a total of 346 deaths. What went wrong with the
production of the Boeing 737 Max?

https://www.volkskrant.nl/nieuws-achtergrond/de-boeing-737-max-een-vliegtuig-ontworpen-
door-clowns-onder-leiding-van-apen~bdb9f623/

Michael Persson, 10 January 2020

They stand in clumps together behind a barbed wire fence, like prisoners. Dozens of planes,
directionless, soaking wet in the spotlight. They are already colorfully painted, ready to be
picked up by their new owner, but when they are released, no one knows as long as it is
unclear whether they have improved their lives.

This is the 737 Max, the worst-known aircraft in the world. Brand new, but already crashed
twice. Since the last crash in March of last year, all aircraft of this type have been banned
from flying around the world - but Boeing continued to produce them here just south of
Seattle, USA, awaiting a return to society.

"It takes a few weeks," Boeing's senior boss Dennis Muilenburg told airlines in April. "Will
be October," he expected in July. "End of this year," he said in October. He was fired last
month.

The asphalt lines reveal that part of the site was actually a parking space for cars. Boeing has
used all available space here on the banks of the Duwamish River to park the planes that kept
coming from the factory (more than four and a half thousand had already been ordered). But
now it's full. So this week the company completely stopped making the planes.

This brings the biggest crisis in Boeing's history back to where it started: at the factory. From
there, ripples now go through the entire economy - locally, regionally and nationally. Boeing
itself has already set aside an estimated 12 billion to deal with the blows, suppliers are bracing
themselves, the US economy could fall by half a percent.

What happened?
Years earlier

The germ for the accidents that killed 346 in Indonesia in October 2018 and in Ethiopia in
March 2019 was laid years earlier. Boeing, builder of the best-selling aircraft of all time, the
737, was thinking about a successor when the big competitor Airbus simply came up with a
new variant of an existing aircraft, the A320 Neo. The European aircraft manufacturer hung a
few new engines under the wings and behold: 15 percent more efficient.

Boeing needed something, and it needed it quickly.

The company had always been a proud engineering company, but more and more a
shareholder company where "the safety culture had been replaced by a culture of financial
bullshit," former Stan Sorscher employee told The New Republic magazine in September.
With the acquisition of McDonnell Douglas in 1997, the "Hollywood model" was imported:
many temporary employees, outsourced as much as possible. An airplane was seen as a sum
of very many parts, more a logistical puzzle than a smart design.

And what makes more sense, if you need a new plane, then just replace some of those parts?
Boeing decided to put the same economic turbines that would come under the new Airbus
beneath the wings of its own 737. The aim was to change so little that existing 737 pilots did
not have to practice again on a flight simulator, an attractive prospect for many airlines.

There was a problem. The 737 is a little lower on its landing gear than the A320 - a result of
choices fifty years ago, when the aircraft still had a wobbly folding ladder to disembark and
the luggage was often thrown in by hand, two reasons for the fuselage as close to the ground
as possible. That means that the wings of the 737 are lower than those of the A320. Therefore,
the new fuel-efficient engines, which were considerably larger than the old ones, did not
automatically fit under the Boeing. So the designers decided to hang the motors a little further
forward on the wings, so that the thickest part of the devices had more space and became a
kind of transverse extension of the wing.

So a piece of wing was added - but a piece that only provided extra carrying capacity if the
plane was tilted a little while taking off. Hold a toilet roll horizontally out of the window of a
moving car and you will not feel any upward force if you just keep it straight, but you will
feel it if you hold it diagonally in the wind, at an angle called the angle of incidence.
That extra force would make the plane tilt slightly, with its nose up. To compensate for that
tilting movement, the pilots should push the control stick a little forward. And that was not the
intention: the new 737 had to feel exactly like the old one, otherwise the pilots would still
need simulator training.

So the Maneuvering Characteristics Augmentation System was invented, in short MCAS, a

computer intervention that pushed the nose of the aircraft down a little to compensate for the
upward force of the engine.

The pilot did not have to do anything.

Orders

"Hardly anyone comes here," says owner Ying Lei of Sub Shop # 8, a small sandwich shop
diagonally across the huge factory site in Renton, a suburb of Seattle where three thousand
employees let 40 737s roll out every month. It is lunch time and completely empty. Lei shows
the order forms that he normally receives every day from the teams on the assembly line,
teams that had to report to other Boeing locations today. The only customer is a black boy
working on the P-8, a variant of the 737 intended for the navy that is still being produced.
"That hassle with Iran is only good for us."

The wait, Lei says, is until they solve the problems. He picks up two paper baguettes and
holds them together as if it were an airplane - so he can show what went wrong. Everyone
here understands it.

"It's the software," says Lei, and he moves a bag of bread with the tip up. "If the plane went
too steep, the software had to intervene." He moves the bread bag with the tip down. 'You
see? But the software also intervened when things didn't go too steep. "The bread bag goes
lower and lower and crashes into the counter. "The pilots did not know what was happening.
Bad software. "

Boeing always made aircrafts in which the pilots had the final say - a crucial cultural
difference with Airbus. But now the software suddenly took control. MCAS became a
program with power: it would not only compensate the upward force of the engines, but also
intervene at other times when the angle of the aircraft became too large according to the
computer (then an aircraft could fall out of the sky). Then the automatic reflex was: nose
down.
In the eleven minutes prior to the crash in Indonesia, the pilots would try to get their nose up
again 22 times, while desperately browsing the manual. But there was nothing about MCAS
in it. The less the pilots were told, the more logical it was that they didn't have to practice for
it.

The wife of Ying Lei has also joined. "They will now adjust the software," she says. "But I
don't know if I would still fly in it. I don't know what else they told the pilots. "

Oversight

The surveillance in the aviation sector is famous and notorious. Everything that is new is
extensively tested and certified - there is no bolt that is tightened if it is not approved. The
regional office of the American regulator FAA is located in Des Moines, just a few miles
from Seattle, so that dozens of experts can look up and tap Boeing up close. A special
department was even created for the 737 Max: the Boeing Aviation Safety Oversight Office.

The fact that Boeing engineers were walking in and out of that office for a long time was
considered logical: aviation supervision is so detailed and so intensive that it has been
"delegated" to the company to be monitored for years. Thanks to intensive lobbying,
manufacturers such as Boeing gained even more control over that supervision in 2005: they
have since been allowed to choose the people who supervise them. The then FAA boss in Des
Moines, Ali Bahrami, thought it was fine. "It was no longer delegation, it was taking
distance," Mike McRae, a former engineer at the FAA, told The New York Times last year. In
recent years, the FAA left some 96 percent of the approval of new aircraft components to
Boeing itself.

It could happen that the FAA also "delegated" the approval of the MCAS anti-slip software to
Boeing in 2016. The system did not even feature in a manual in which the FAA listed all the
important differences between the old and the new 737. And when Boeing asked to remove
the reference to the anti-cover system from the pilot's manual, the FAA was fine with that.

Boeing chuckled. The tactic to hide as many of the novelties as possible and thus prevent the
pilots from having to train for a 737 Max on a flight simulator worked out well. Boeing
employees laughed at the FAA, as shown by dozens of pages with internal communication
from that time on Thursday. "God has not forgiven me for everything I swept under the carpet
last year," one e-mailed to a colleague. And another one, about the 737 Max: "This aircraft
was designed by clowns, led by monkeys."
"We regret the content of this communication and apologize to the FAA, Congress, the
airlines that are our customers and the flying public," Boeing said in a statement Thursday
night.

The poor supervision has proved deadly. The MCAS is operating by a sensor that at two times
incorrectly measured the angle of attack and reacts by steering the aircraft down. The pilots
have no idea what is happening, they cannot find the system in the manual, and they crash.
That a single faulty sensor, a so-called single point of failure, can lead to a disaster is unheard
of in aviation - there is always a spare system that can take over a defect. It is also unheard of
that after the first disaster, Mike Sinnett, a Boeing board member, dared to say that it was "not
a single point of failure" at all, because "the trained pilot is part of the system".

In other words: the pilots, who were deliberately not trained, and therefore did not even know
that there was a failing system of which they were part, they should have made up for the
error. According to a statement from Boeing, they should have done that in three seconds.

Issues

That sensor was really not the only problem, says Ed Pierson, a former manager in the
assembly hall of the 737 Max, who rang the bell in the summer of 2018 because he saw
problems everywhere. "The workload became much too high. Many parts were delayed, the
work order began to change, people were put to work in places other than where they usually
worked. I knew for sure: that's how we're going to make mistakes. "

Pierson, who testified before Congress in December about his experiences in the factory, tells
this Tuesday afternoon in his hometown of Bremerton, a place on a cove one hour's boat ride
from Seattle, about how management's demands could have disastrous effects on quality of
the aircraft that were built at the time.

"Due to delays in the supply of parts, we were already lagging behind our delivery schedule.
The management then decided to catch up - we had to make 47 rather than 52 aircraft per
month. That only made the chaos bigger. We rolled out planes that had no engines
underneath, which sometimes lacked the fuselage. They all had to be finished at a time and in
a place that was not meant for that. Teams were pulled apart, people did odd jobs at places in
the assembly line that were not meant for that at all. Supervision was difficult, safety was at
stake, both for employees and future passengers. "
For example, a hastily manufactured angle sensor was installed in that hectic pace. "We don't
know on which aircraft that sensor is all," says Pierson. "What I would like in any case is for
the FAA to sound the alarm and check them all."

Management thought to have a solution for the delays. It abolished the usual work transfer
between teams and instead started organizing two or three times a day shame meetings in
which employees had to stand up in front of about a hundred colleagues and explain why they
had not achieved a certain milestone. "That only increased the pressure," says Pierson. "It
only got worse. It was an unstable environment. "

In June 2018, he sent a first letter to Scott Campbell, the manager of the 737 Max program.
"Sorry to say so," he wrote, "but for the first time in my life I hesitate to let my family fly
with Boeing." Pierson, a man who has flown with the navy for years, looks pained. "He let me
come and I told him to stop the production line to put things in order. I said: I have seen
operations in the navy that were stopped for less. Then he said: yes, but the navy does not
have to make a profit. "

Pierson was struck dumb, he says. "It was the worst thing he could say. He actually said: no
matter how bad the situation is, money is more important. "

Pierson resigned a few weeks later. "I didn't want to be part of that anymore."

Two months later, the first 737 Max crashed, less than five weeks old. "I was sick when I
heard it," says Pierson. When he got over the worst shock, he tried to get in touch with the
Boeing experts who would assist with the investigation into the circumstances of the accident,
to point out the problems in the assembly line. He sent an email to the highest boss,
Muilenburg. He had a lawyer call back, but Pierson did not get in touch with the investigators.
He sent his findings to all members of the supervisory board, all of them a printed package,
but he received no reply. Then the second plane crashed.

All over the world the aviation authorities immediately said: that 737 Max is no longer
allowed to fly. In the US, the FAA only came to that conclusion after three days. Then the
device was finally grounded.

Pierson searched databases and discovered that the 737 Max had thirteen incidents in those
first months of his flying existence in addition to the two fatal accidents. Problems with the
hydraulics, a failed engine, the anti-ice system, the steering. "It's incredible that new planes
have so many problems," he says.

He tried to raise his concerns with the NTSB accident council and the FAA regulator, but got
zero there. Only after his testimony to Congress in December, did the FAA promise to call
him. "That hasn't happened yet," says Pierson.

In a statement, Boeing states that "the suggestion of a link between Mr. Pierson's concerns
and recent accidents is completely unfounded" and that "none of the authorities investigating
the accidents found anything to indicate that production conditions in the 737 plant
contributed in any way to the accidents. "

Well, they never looked at that, says Pierson. Incidentally, Boeing is going to take "measured
decisions" about the production speed of new aircraft, the manufacturer says. What exactly he
means by that remains unclear.

This week, The New York Times reported that Boeing has discovered new potential
problems, now with the wiring where short circuits could occur because the cables are too
close together.

The European aviation authority EASA, counterpart to the FAA, places the responsibility for
checking the Boeings assembly with the Americans. "Production falls under the supervision
of the country where the aircraft was designed - in the case of Boeing, that supervision comes
from the FAA. We are in good contact with the FAA on all aspects of the return of the 737
Max, including in this area."

Pride of the city

Boeing, founded in 1916 by a wealthy timber trader who could not have his newly purchased
aircraft repaired anywhere in Seattle, was the city's pride for years. Between the hangars and
offices at the Boeing Field is the beautiful Museum of Flight, containing the very first head
office of the company, the Red Barn. In the nearby Randy's Restaurant, a stopping place for
Boeing employees, you sit between model airplanes and doors of World War II shot bombers
and tell waitress Kirsten Meyers that she is very sure that the 737 Max will fly again: "I get
mechanics every day over the floor who say it will be okay. "

But pride has gotten a blow. Boeing himself made a big mess this week. After the accidents,
the MCAS system was watered down and based on two sensors. An alarm sounds if the two
disagree. Boeing thought that was sufficient and insisted that the pilots for the 737 Max did
not have to practice in a flight simulator. But in recent months it has become apparent that
even pilots who know how the system works can still get confused.

So, Boeing said on Monday, all pilots have to start training in a flight simulator. Exactly what
the company wanted to prevent for years. "Boeing won't let that happen," the main test pilot
wrote in one of the emails released on Thursday. "We are going very hard against any
regulator who makes the simulator a requirement." And another: "I have misled those losers
(the Indian aviation authority, ed.). I save the company a sick amount of $$$$. "

The pride thus makes way for shame. In the Boeing store near the factory in Renton, the
model airplanes of all modern Boeings are neatly arranged, but the 737 Max shines with its
absence. In the clearing where you would expect him to be chronologically, a solid military
tank aircraft adorns. The Max is tucked away on a high shelf, almost out of sight.

Is it safe to fly in a 737 Max again? Pierson doesn't know yet, he says. "I remain very
skeptical." At the parking lot in front of one of the offices is a large matrix sign. "We're going
for zero accidents," it says. "Do not use the telephone while walking." Yes, safety is
paramount on the ground at Boeing.