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Rudder issue that plagued the Boeing 737 throughout the 1990s (imgur.com)
936 points by IFR 42 days ago | hide | past | web | favorite | 352 comments

Wow. The quote from Capt Ray Miller is particularly telling:

“I have been told by my company . . . that the FAA and Boeing (were) aware of the problems with the spurious rudder inputs but considered them to be more of a nuisance problem than a flight safety issue. I was informed, that so far as everyone was concerned, the rudder hardovers were a problem but that the `industry' felt the losses would be in the acceptable range. I was being mollified into thinking the incident did not happen, and for the `greater good' it would be best not to pursue the matter. In other words I am expendable as are the passengers I am responsible for, because for liability reasons the FAA, Boeing et al cannot retroactively redesign the rudder mechanisms to improve their reliability."

And this was after the fault had not just caused in-flight emergencies, but had already killed people...

I wonder what solutions there are to these liability/blame problems. I have seen a similar case in Australia, where a parking barrier was an extreme danger as it cross over a biking path, and was hard to see until the last minute. It caused a crash that took a mans leg, and the legal proceedings took years. During that time the barrier remained in place, still a danger, because removing it would have admitted fault.

I think it's different in the US. Post-incident efforts to repair usually aren't considered an admission of responsibility in US tort law. Social policy reason is to encourage repair of hazards, rather than reinforce the circumstance you note.

What was the result of the litigation? From a money perspective, it seemed like "admitting fault" would be far more reasonable, and I think in this sense executives tend to exaggerate effects of "admitting fault", because, in the end, they are betting that legal proceedings would nullify its effects, but as we are learning now, it's not the case at all. Public memory might be short, but it regenerates at alarming speeds if you continue down this path.

They might have not been contractually allowed to admit fault. Many insurance policies do not allow the insured to admit fault, or they forfeit the policy.

This type of term should be made illegal. No civil contract should be able to incite a party to knowingly withhold evidence that could save lives.

A side note: there is a well-defined value of "acceptable range", i.e. regulators regularly make decisions based on whether the cost of a change would be more than the "statistical value of a human life". (https://www.theglobalist.com/the-cost-of-a-human-life-statis...)

The question is whether, through regulatory capture or negligence, monetary costs are being valued too highly.

Yes I have also seen Fight Club

It's not a cynical measure of what makes more money. The risk tolerance is set a lot smaller than that level. Which is a reasonable acknowledgement that you can't prevent all risk. At some point the overhead of your anti-risk measures starts causing more harm than good.

To add a human element to this story, I'm from north of Pittsburgh and the crash of flight 427 is one of the events from my childhood that I can determinedly recall. One of my classmates--eight or nine years old--lost her father in that crash. Our class planted a tree outside our middle school with a plaque to memorialize him. I bother saying this only because, while air travel is impressively safe overall (hats off to the FAA and NTSB), it's natural to mentally dismiss a mere ("mere") 132 deaths in the grand scheme of things without pausing to consider the broader ripples such an event has on history.

If you'd like to experience a moment of somber horror, Wikipedia has a computer reconstruction of the final moments of the plane based on the recordings recovered from the black box: https://en.wikipedia.org/wiki/File:USAir_Flight_427_Chase.og...

I ended up finding my way to that after reading TFA and Googling 427.

Not just that, but the fact that they had audio all the way down, and the pilots utter disbelief that they plane was responding to his inputs in the way that it was.

The idea that they were not actually supposed to pull up in the scenario but leave the stick level and just turn hard right is unbelievable. The amount of training to be able to react like that instinctively would be tremendous.

The plane hit 3 or 4 G and apparently the copilot could be heard straining on the tape. They were analyzing the pilot’s gasping to deduce how he way applying rudder because the black box didn’t record rudder inputs at the time.

All of this is inconceivable. The sheer speed of the event and how quickly that 30 second video is over is probably the most shocking.

This one showing the pilot inputs is even more terrifying:


Also from Pittsburgh, and my wife lost her dad in this crash.

The top comment on this thread (re: "acceptable loss"), is infuriating.

> The top comment on this thread (re: "acceptable loss"), is infuriating.

Do you ever drive a car? Do you think the risk is "acceptable"?

And don't get hung up on semantics, "acceptable" doesn't mean it's not terrible, it means that it's not feasible to prevent every risk with that danger:cost ratio. Especially because anything that causes a drastic reduction in flight will increase car trips and probably cause more deaths.

This is of course different from someone lying about the level of risk. But some risks really are "acceptable".

Get out from behind your computer and talk to people for once.

It's easy to explain to people in the real world how treating life as having infinite value is actually impossible, and nobody actually does it.

Also, the "acceptable" part is the statistical average. It's still a tragedy that any particular person dies. I do have sympathy for you and your wife, but we have millions of deaths per year that deserve equal respect, and we only have so much we can do to prevent each one. We should try very hard, but we can't try infinitely hard.

There's always a tradeoff. We could make driving much safer by enforcing drastically lower legal speed limits, much longer mandatory training for the drivers and even higher safety standars in cars. But we have chosen not to, because that would be perceived as limiting freedom, being inconvenient and cost money. But more than thirty thousand people die in car accidents every year in the US alone.

Reading both of your comments, one has to wonder if your wife and their classmate were one in the same.

Very Probable! @Kibwen what part of town was your friend from (not asking for a name on purpose I’m uninterested in sharing my wife’s name here, however easy it may be to google).

My next door neighbor died in this crash (flight 427). I'm from Virginia. I remember this crash vividly and I was only 10 at the time.

I wrote this, not happy it got picked up and posted here without credit. Here's the original Reddit thread: https://www.reddit.com/r/CatastrophicFailure/comments/adl0jk...

I've put that link at the top and mentioned your username. If there's something else we can do to credit you, let us know.

I briefly changed the submission to point to that URL, but Jolter has a good point too: https://news.ycombinator.com/item?id=19394058.

I'm not justifying how this was linked here, but I'd recommend putting your own attribution on the original source of the content (in this case, Imgur) rather than relying on everyone to access it through the specific forum you originally posted it on.

Also, Hacker News doesn't have submitter filled "descriptions" for linked pages, so there literally is no way to add attribution meta-data when posting a link.

More recent ones do have my username in them. I just never expected anyone outside of Reddit to read it so I didn't structure it in a way that would make that convenient.

Out of curiosity, does Imgur not allow you to modify the text passages in the album after you create it? If it does and I was the author, I would certainly be putting my name/username and a link to the Reddit post in there!

Since I'm not logged in to Imgur when I post the albums, it allows me to modify the text only within 12 hours after posting. This annoys me a lot but I've yet to find a better platform that has all the attributes I want. (I don't want to make an account and actually upload it there because then I'm submitting it to an audience that I have no intention of engaging with and know nothing about.)

You don't need to make the gallery "public" just because you are logged in.

The gallery will not be shared publicly unless you click the "Share to community" button - it will just be available through the URL, exactly like now. With the benefit that you can edit it afterwards.

Even if you are logged in, uploaded content isn't shown to the Imgur "community" unless you choose to "share" it.

You'd be better served hosting this content on a traditional blogging / content platform rather than imgur, IMHO.

"Picked up without credit" on a platform that provides no attribution whatsoever isn't really a hill to die on.

The problem is the copyrights: try for yourself to host under your own name all the pictures seen there. The anonymity allows one to present more content than a non-anonymous "normal" user would be able to use.

To showcase the parent's impressive efforts, it looks like this is but one of a ~70 part series on airplane crashes: https://old.reddit.com/r/AdmiralCloudberg/comments/a4ckhv/pl...

For what it's worth, I recognized this as your content immediately. Thanks for your work.

HN likes to link as closely to the original source as possible, which in this case looks like the imgur album rather than the reddit thread linking to it. It's probably not personal, just a de-noising instinct gone awry.

To a HN reader, posting the Reddit thread would have been less useful than the imgur album, because the reader would have to click through to the album. Maybe you should edit the album and link it back to the reddit thread?

Can't edit the albums more than 12 hours after posting unfortunately, take it up with Imgur's website design department lol. I didn't expect these to be read off of Reddit so I didn't make that convenient (until recently).

For all the effort you put in these posts, I think it would be very much appreciated if you could (re)post it on a blogging platform like WordPress.com. Reddit/imgur content are not made to last but stuff like this definitely is.

Boeing rudder issues in the 1990s? How about the 2010s? A KC-135R(Boeing 707 variant) in 2013 crashed of the same issues as the article.[1] The KC-135R is essentially a modified 707 retooled with 737 engines and a beefed up vertical stabilizer to account for the increased power of the engines. This modification of the KC-135R occurred in the 90s and has been plagued with rudder problems ever since. The accident in 2013 was attributed to pilot error, because there are procedures to turn off the PCU if the rudder goes haywire... but why not just fix the problem outright?


While we're bashing Boeing, let us not forget how they tried to swindle taxpayers into buying their tankers... a scandal which led to their CFO going to prison.


Honestly, I can't understand how this was a bad thing given just how dated and stretched-thin the KC-135 fleet was at the time and those problems have only growm worse. The Air Force has been trying to replace thr KC-135 for decades since the newest airframe was produced in 1965 and their entire in-flight refueling logistics rely on these aircraft. Yes, it is unseemly to slip something into a continuing resolution to fund a war effort but when the bureaucratic roadblocks to purchasing something so critically important yet so unsexy as a flying gas station, one has to wonder if the people involved were acting out of good-willed desperation to help avert a massive problem with critical defense infrastructure. While $16 Billion for 100 aircraft may seem exorbitant, it has taken until this past year for the KC-135's replacement to enter servjce at a cost of $179 million per unit. That still beats the inflation adjusted cost of $160m per 767 tanker but think about how !uch money has been wasted on upfit and restoratiom programs for the 60+ year old KC-135 airframes over the 15 years since that "scandal".

Source on KC-46 info and general issues with the agjng KC-135 fleet: https://www.defensenews.com/opinion/commentary/2019/01/16/pe...


In case anyone hasn't heard of Mr. Hands and is wondering why syn0byte didn't provide a citation...

It's extremely NSFW. Suffice to say, a man and a horse are involved, and the man did not survive. Google/Duck it at your own risk.

Seriously wtf is wrong with some people. Googling for this is indeed... risky.

Aside from this specific issue, all of aviation works like this.

E.g. the reason the 747 was decommissioned from passenger flight in the US when it was is because they flew it right up to the day that the FAA mandated that they couldn't fly it anymore.

The reason was that they didn't have then-mandatory fuel tank inerting. For something like a decade there were a bunch of planes in the air carrying people that were known to be more likely to explode than some other planes.

Regulatory safety is always a messy combination of new requirement and timed phase-out of old systems.

Same with cars, you can buy a used car today and even use it as a taxi to ferry passengers without it having safety features that would make it illegal to sell as a newly manufactured vehicle.

"E.g. the reason the 747 was decommissioned from passenger flight in the US when it was is because they flew it right up to the day that the FAA mandated that they couldn't fly it anymore."

I'm sorry, what? Do you have a source?

In 1996 TWA 800, a 747 flight, exploded[1]. The cause was lack of fuel tank inerting. The FAA subsequently published a rule in 2007[2] saying that by December 26th, 2017 all passenger airliners needed to have an inerting system by manufacture or retrofitting.

UA and Delta[3][4] flew such variants of the 747 to within a month of the FAA deadline. The final flight was on November 7, 2017. You can still fly the 747 into or within the US (as e.g. BA does), you just need to have a newer or retrofitted 747. The rule also doesn't apply to cargo planes.

Sorry about the "[747] flight[s] in the US" ambiguity. I was referring to the domestic fleet at the time. Also it wasn't literally "right up to the day" of the rule going into effect, but in the grand scheme of things that's accurate enough. The phase-out was planned to coincide with that rule going into effect, among other reasons.

The point being that airlines can and will fly airframes that in one way or another would be illegal to manufacture today for safety reasons, or which will be grounded by the regulator tomorrow unless an expensive retrofitting is carried out.

I think that's fine, but apparently the fact that airlines are allowed to fly planes with fixable flaws that have "already killed people" just to save some money is surprising to some. It's all a cost/benefit trade-off, and is considered normal by regulators.

There's some more details in this HN comment chain at the time in 2017 that I contributed to[5].

Edit: Some weird HN glitch or mod action seems to have happened. My comment upthread is now a top-level comment, but initially I'd replied to the "already killed people" top-level comment by jfk13[6], and that's definitely how it was rendered for a while.

1. https://en.wikipedia.org/wiki/TWA_Flight_800

2. https://www.faa.gov/documentLibrary/media/Advisory_Circular/...

3. https://eu.usatoday.com/story/travel/flights/todayinthesky/2...

4. https://eu.usatoday.com/story/travel/flights/todayinthesky/2...

5. https://news.ycombinator.com/item?id=16015304

6. https://news.ycombinator.com/item?id=19390633

> The point being that airlines can and will fly airframes that in one way or another would be illegal to manufacture today for safety reasons

Of course, this is also true for cars. The vast majority of cars on the road would be illegal to manufacture today.

> The vast majority of cars on the road would be illegal to manufacture today.


Illegal to manufacture due to lacking significant safety features, or due to other changes over time such as evolving emissions standards?

Both, there's lots of both safety and pollution mandates like that. As just one recent example[1]:

> "the U.S. National Highway Traffic Safety Administration announced that it would require all automobiles sold in the United States built beginning in May 2018 to include backup cameras"

That's less than a year ago. It's a fair bet that most vehicles on the road don't have such systems, but they're now illegal to manufacture.

1. https://en.wikipedia.org/wiki/Backup_camera

> 'The area directly behind vehicles has been described as a "killing zone" due to the associated carnage'

Got to love Wikipedia and their strict adherence to NPOV. That kind of camera does look to be a US (and Canada?)-only requirement at the moment.

Are there (m)any internationally-recognised compulsory safety feature standards that mean a vehicle manufactured, say, five years ago would no longer to be legal to manufacture today?

The "killing zone" isn't something Wikipedia invented, they're quoting Consumer Reports, which isn't exactly just some guy's blog when it comes to this topic.

You seem to just be moving the goal post. No, you are not going to find some safety feature of cars that was introduced in lockstep across the entire globe overnight whose impact is as dramatic as say seat belts or airbags were.

Car safety is all about marginal improvements at this point, and there are many regulatory agencies. In practice the US and EU set the tone for safety across the globe, but they don't act in lockstep.

Most of these mandates are also going to be relatively mundane, e.g. mandating that the A-pillar in newly sold cars this year must be 5% stronger than the previous mandate, or given statistics about pedestrian impact mandating some small adjustment to the design of the front bumper or hood.

Do you mean a specific variant 747? Because 747s are still definitely flying passengers in the U.S. They are still making new ones.

747s are not flying any passengers in the US. They are flying passengers to the US. No US carrier still operates the queen of the skies, though that's mostly due to fuel efficiency. Some US carriers had the 747-400 until a couple years ago when United ditched their last one. I loved flying that bird! A few foreign carriers (Korean, Lufthansa) have the much newer 747-8i, which is a lovely plane but hasn't done well commercially due to those same fuel efficiency concerns.

But parent alleges that the 747 is outside of certification requirements, which is demonstrably false.

Neither United nor Delta retrofitted a fuel tank interting system, that's why they retired their 747s earlier than expected.


Paragraph 2-8 indicates the dates compliance became mandatory (Dec 26, 2017 with a potential one year extension). There are 747-400s flying in the United States, however they've all had interting systems retrofitted, are foreign registered, or both.

This reminded me of the Yak-42 jackscrew failure due to a design defect, which caused a crash killing 132 onboard in 1982 [1]. The entire fleet was grounded for more than two years until the full investigation was completed and the defect was fixed. Three design engineers were convicted.

[1] https://en.wikipedia.org/wiki/Aeroflot_Flight_8641

Convicted of what? Smells like scapegoating.

"The investigation concluded that among the causes of the crash were poor maintenance, as well as the control system of the stabilizer not meeting basic aviation standards”

Probably this:

>the control system of the stabilizer not meeting basic aviation standards

It made me think of the horizontal stabilizer jackscrew jam on Alaska Airlines 261[0], but I misremembered that as a 737 rather than a MD-83. SF radio personality Cynthia Oti was among the passengers.

[0] https://en.wikipedia.org/wiki/Alaska_Airlines_Flight_261

Maybe the FAA should study how Soviet authorities responded to a crash of a new type of aircraft?

> Operation of the entire fleet of Yak-42 aircraft until the elucidation of the causes of the disaster and the elimination of the identified deficiencies was suspended until 1984.

So long as they don't follow the lead of Soviet authorities in charge of the nuclear power industry.

Aviation has an well known acceptable risk level at around 10^-9 for each issue. That's the number that leads government intervention, pilot procedure designing, aircraft designing and everything else. It's expected to lead to a less than 10^-6 chance of accidents per flight. (Somebody calculated the B783 Max odds on 4*10^-6 yesterday, what is a crazy high level.)

That number has been higher in the past, and is moving into 10^-10 per issue with 10^-7 overall risk right now, with large airplanes in scheduled flight very near that level.

> Somebody calculated the B783 Max odds on 4*10^-6 yesterday, what is a crazy high level.

I think that may have been me (1/250000), but that was based on a couple of generous assumptions - two crashes across 4 flights/day on 350 planes for an average of 365 days. Unfortunately I think a more reasonable flights/day number is 3 or lower - a lot of Max 8s are on longer routes - and the flight day average is almost certainly lower than 365 (which assumes linear deliveries for the past two years, with no days for maintenance).

A few years ago I calculated with a friend the accident rate of several cohorts of Brazilian aviation (well, the part of aviation that operates on aerodromes, so no agriculture or sports). Our worst cohort was for private planes, private pilots, on small airports, on fast growing cities. It was just a little bit under 4*10^-6 accidents (all, not only fatal) per airport operation (that is, twice your number).

I was really scared by your number. I wouldn't ever jump into a random private plane, and seems that people refusing to jump into a B733 Max (looks like I wrote it wrong earlier) are doing a reasonable thing.

Do those people jump into cars?

For long distance trips where they have an option? I'd guess that many don't.

Still that 4e-6 per trip number is worse than the city driving statistics I've found. And that 8e-6 per trip (4 per airport operation) is around the motorcycle values.

That's also assuming there's no correlated issue causing all the crashes.

When something happens 2 times, even a simplistic error analysis is going to show at least a 3x range in probably (2+/-1 incidents is 1 to 3)

Also, I believe the statistic of interest here is incidents per operating hour, not per flight?

Given that the Max crashes both happened shortly after takeoff, I'd be more interested in a per-flight statistic. But I'm not sure how the industry does it.

The industry/NTSB/FAA generally cares more about flight hours, but I agree with you. Both of these accidents happened shortly after takeoff. I am surprised that no accident has happened during landing.

Is the same sensor used the same way in landing?

I would imagine so. As long as the pilot wants to control the rudder, that same sensor would be used. What I would like to know is if the MAX has a different setup. I think it'd be idiotic of Boeing to use the same rudder control configuration as the old 737 considering the problems that they had as demonstrated by this post.

All of accidents per hour, accidents per operation, and fatality per passenger are relevant.

Is that 10^-6 figure is for any sort of accident, or just catastrophic ones?

It is called "accident" is when there is severe damage to the airplane or fatality. In aviation, the other are called "incident" when there is some damage, or merely "occurrence". But that last one is overloaded with way too many meanings.

I had heard of the history of the "rudder hardover" problems with the 737 but have never heard that Boeing was actively subverting the investigation. Assuming it's true, I'd agree that it's appalling behavior, but this post alone doesn't convince me. A lot of complex systems can fail in unlikely ways and it doesn't imply malfeasance that the company was wrong about the cause.

How many times have you investigated a weird, intermittent software or system problem and gone down the wrong path (or paths) because what turned out to be the actual cause seemed so unlikely, even if there were clues that in retrospect you should have given more weight.

I have never hindered any investigative agency, internal or otherwise, attempting to discover flaws in systems I have built. Doing so would be morally abhorrent, and hopefully someday illegal

I also never filed the serial numbers off replacement parts that I then put into a rudder servo of a large airliner while forgetting to fill out the necessary paperwork.

They are removing evidence and that implies malfeasance.

> Instead, Boeing tried to claim that flight 427 crashed because a pilot had a seizure and depressed the rudder. NTSB investigators dismissed this as ridiculous.

> Boeing had no choice but to carry out the changes, but the company never stopped trying to deflect blame. While the investigation was ongoing, it adopted a philosophy of trying to avoid paying out damages to families of crews because this could be legally interpreted as an admission of responsibility. It had tampered with the PCU from the Colorado Springs crash and repeatedly tried to misdirect the investigation with “alternative” theories.

Should not there be some criminal charges?

I do not wish to diminish how serious any tampering with the evidence would have been, or of Boeing's more general attitude of dismissing signs that there was a problem with the equipment, but it is not entirely clear from the article that someone from Boeing removed the Colorado Springs PCU spring and end cap. The article says the item had apparently been in the possession of United Airlines and valve designer/manufacturer Parker Bertea before their absence was noticed. The unit is also described as having been heavily damaged in the crash, to the point where several other parts had to be replaced before it was tested.

Boeing's more general attitude of dismissing signs that there was a problem with the equipment

Having worked in software for decades, I've noted a particular sort of bias in myself and other developers. We tend to feel that our creations are like our children, and we are far too ready to blame the user. I've caught myself doing this. I've been caught out by QA doing this. I've caught fellow developers doing this, where I am in the position of the user. On that last count, I'm still surprised at the unrealistic levels of incompetence and/or malice ascribed to me in support of those face saving theories.

Emotions are a tricky thing. Do not formulate theories in the heat of them. If you care about being truthful, be especially mindful of your incentives in those moments.

That's why dogfooding is so powerful. The best way to first hand experience the shortcomings of your product is to use it. This makes me wonder if anyone at Google is using G-Suite themselves.

The effect of dogfooding is limited though: when you know all the quirks you won't when notice that you constantly work around them.

when you know all the quirks you won't when notice that you constantly work around them.

Unfortunately, we programmers are particularly good at doing this. We are extremely good at being "nice" to software. ("Mechanical sympathy")

My child has bypassed the lock screen on my laptop and caused a gray-screen-of-death, just by banging on the keyboard. I saw it, I am unable to replicate it. Everything should be tested by a child before it can enter production service.

My kid subscribed me to Apple Music by playing with the apple tv remote...

I know exactly what you mean - from toggling a mode on a mechanical keyboard I didn't know existed and spent 20min looking for how to turn it off, to managing to delete several Powerpoint slides that were not on the screen at all, solely via keyboard (so that I didn't notice it until saving/closing the file and losing them forever). It's amazing :)

I recall a kids game where the game exited when the spacebar was touched. It was pretty exasperating, because the kiddies couldn't figure out how to get the game running again.

Human-powered fuzzing! As a parent of three kids under 6, I wholeheartedly endorse this.

Doesn't matter if the devs know it's broken, if the managers decide it's not worth paying to fix.

Nearly everyone at Google uses GSuite.

Arguably, not enough people at Google use the competitors stuff. The employees are sitting there thinking they're making a great minidisc player while the rest of the world has moved on to streaming audio...

I’ve used software that’s so bad and thought there’s no way anyone at the company that made this has ever used this.

For most Googlers it's all they use...

In my experience end users are very often wrong, QA departments are rarely wrong. If pilots are saying I pressed the rudder and it didn't move healthy skepticism may be needed, I'd hazard less skepticism than for an average end user as the pilots are presumably highly skilled users of the product. But if after very thorough investigations a large group of pilot reports and the NTSB are telling you something is wrong then you should assume that something is wrong and do your best to prove it otherwise.

As you note emotions, and frankly legal liability, play huge roles in this realm. Worrying about legal liability might be harder to tame but in my experience it is easier to disabuse yourself of the notion that you can do no wrong.

In my experience end users are very often wrong, QA departments are rarely wrong.

This is true. However, even in the cases where I have spent considerable time analyzing the situation and have included specific information, I get the distinct impression that devs simply don't listen to what users say. I get the distinct impression that most of them simply disdain me and don't even listen to what I have to say.

The cases of "surging" where people claimed they were pressing hard on the brake when the car lept forward come to mind. (The most credible explanation is they put their foot on the gas instead, or are simply trying deflect blame away from themselves for the crash.)

That's not the most credible explanation.


I don't buy it. Heck, I've even stepped on the gas instead of the brake. Besides, the brakes are much more effective than that little Toyota engine is. Try it yourself. Go full throttle and step hard on the brake. You'll stop.

Look at slide 8.

With wide open throttle, why would the power brakes lose vacuum? Vacuum is lost when the engine quits.

Besides, just to stand on one foot requires 100 lbs of force exerted on your foot. If you can walk, you can do that. Pressing with 175 lbs is not a problem.

The point is, the brakes can override the engine torque. Unless, of course, you're standing on the gas instead of the brake.

You can also just turn the key off on a runaway engine.

That would require more evidence than it sounds like there is. And that's assuming that you subscribe to the motivations put forward in this article. I generally follow Hanlon's razor - "Never ascribe to malice that which can adequately be explained by incompetence". I have a hard time believing that a cover-up in Boeing was orchestrated over several years by a group of people all who didn't care about loss of life. I can easily believe that they didn't take the problem seriously, and that they were biased towards conclusions that weren't their fault.

> I have a hard time believing that a cover-up in Boeing was orchestrated over several years by a group of people all who didn't care about loss of life.

No orchestration is needed. Managers only need to look with disdain to anyone that brings the issue.

If your company does not put a lot of resources to make it transparent it is going to be opaque by default. Transparency is hard to achieve when humans are so good reading a superior expression of disapproval. Most people does not need to be told to not bring that problem again, all that we need is a subtle clue.

So, to get a cover up you only need to do nothing.

“It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”

Exactly right - same thing that happened at NASA. There aren’t grand conspiracies - just people acting in their own interests, based on the incentives that have been set up (or evolved) in the organization.

No orchestration is needed. Managers only need to look with disdain to anyone that brings the issue.

Networks and social media extend the reach of these kinds of disdain, and take these mechanisms beyond the walls of the office and organization. In the present day climate, where accusations causing outrage tend more easily to become viral, one need not be someone's manager or even have a close relationship to exercise such power of disdain. The incentive structures in social media can act as a very efficient transmission substrate for these mechanisms.

One doesn't have to look far, to see how social media amplified groupthink has short circuited professional judgement -- even in highly visible and public circumstances. In particular, forums, email lists, and social media groups of journalists can be seen to be having such effects.

So, to get a cover up you only need to do nothing.

With just a modicum of digging, this can be seen quite clearly in 2019, in the mainstream media, which is declining but still trusted by the public.

“It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”

This effect is very real and very powerful. This is why we as a society should be wary of the political exclusiveness of entire professions, entire industries, and of academia. If you're surrounded only by people of like minds, you're far less likely to have your idea checked by people highly motivated to find your faults. It's only diversity of opinions which guards against groupthink.

It’s not really social pressure when managers have so much direct power not just in major events like a lay off or promotion, but also day to day tasking. This generally results in people becoming hypersensitive to their boss’s disapproval.

Social networks on the other hand have far less direct impact which results in less socially accepted statements becoming common.

This generally results in people becoming hypersensitive to their boss’s disapproval.

In 2019, there are lots of examples of people being quite sensitive to approval over social media. This differs by individual circumstance. However, in 2019 there are entire fields where people must ascribe to some form of group consensus, or basically become un-personed from it. Media work seems to be particularly sensitive to this.

not just in major events like a lay off or promotion, but also day to day tasking

There are examples of journalists consulting and influencing each other in the context of news cycle events.

Social networks on the other hand have far less direct impact

This was once true but now is simply out of date and very wrong. In 2019, there are social networks which have very direct impact, and very large impacts on people's livelihood. There are entire fields where such social networks and online communication can get someone un-personed. These are basically the 2019 version of the "old boy network."

Over 32,000 journalists are working full time in the US, social media focus on a minute fraction of them.

Social media can be a near full time job. One many successful people simply don’t have time for.

So sure many NYT reporters might post their wedding photos online, but deeper interactions are often limited to people focusing on such things.

Over 32,000 journalists are working full time in the US, social media focus on a minute fraction of them.

You're conflating two entirely different things here. Much of the dysfunction/groupthink occurs through things like legacy media journalists using social media.

The point is that networks and social media enables offline channels for groupthink, which then affects other media.


So sure many NYT reporters might post their wedding photos online

This of course, isn't an issue. (But mistakenly considered as such, it might as well be a strawman.) What is an issue are blue checkmark journalists engaging in toxic groupthink on Twitter. This also happens on email lists and industry insider forums.

(This isn't actually a new phenomenon. There are Vietnam era journalists who complained about how some correspondents never left bars in Saigon. The difference is that the groupthink can follow people around in their smartphone and come at them every waking hour.)

> “some correspondents” never left bars in Saigon

My point is group think requires significant interaction over social media. This requires more than visiting a bar one a month / posting wedding photos. It requires significant amounts of time and crossing that threashold is not very common.

So, sure a small fraction are significantly influenced but the majority is not. Making the overall influence far less significant than it might appear.

On top of that mainstream news organizations like FOX, CNN, NPR differentiate based on appealing to different groups. Which creates different spheres of social media for each segment. This has been intensified with online sources the Drudge Report going mainstream and gathering vast followings. Which means social media is pulling different reporters in different directions.

My point is group think requires significant interaction over social media.

Then the behavior of many journalists over social media should greatly concern you.

This requires more than visiting a bar one a month / posting wedding photos. It requires significant amounts of time and crossing that threshold is not very common.

This is common among journalists. Particularly those working in niche media.

Making the overall influence far less significant than it might appear.

Those who know the facts behind certain niche stories are amazed at the degree of reality warping done by the mainstream media. Just look at what happened around the Covington kids.

The Covington Kids story shows how social media amplified both sides of an issue. It’s the opposite of group think with multiple narratives showing up.

What you’re describing “group consensus” is a systemic bias. A historical example of say US WWII propaganda qualifies as essentially all US news is shifted in the same direction.

Waves of news with story X being updated to story Y over time is a different thing. That’s a question of which organizations get involved over time. You can find examples that support any narrative based on timing. But, bias would mean the story did not evolve.

The Covington Kids story shows how social media amplified both sides of an issue.

The behavior of mainstream journalists calling for the doxxing of and violence against these kids just strikes me as amazing. The groupthink involved with accepting the initial narrative is quite apparent.

What you’re describing “group consensus” is a systemic bias.

When systematic bias reaches the point where journalists completely abandon fact-checking and basic adult judgement, it's more than just "group consensus." Offering sexual favors to do things against kids? I'm sorry, but if I made something like that up, it would be purple prose. Journalists were swept up in that kind of groupthink!

A historical example of say US WWII propaganda qualifies as essentially all US news is shifted in the same direction.

Read Manufacturing Consent -- it's the same in 2019 as it was in the 1980's, we in the west just do it faster and harder with the bias, emotional words only for one side, and selective coverage. The thesis was that the west is just as bad as Pravda. In 2019, I find that Pravda was more subtle about it.

bias would mean the story did not evolve.

Bias can also mean that the retractions were either absent or all but meant to be invisible. In 2019, the typical media modus operandi is to technically be about the truth and retract, but engineer this to have basically zero effect. The number of mainstream sites who will edit a story, but give no indication of that, is just amazing to me.

Individual action does not imply collective action. Talking points can make it seem that way.

You need to factor in how stories are simply copied around the ecco chamber of mainstream news. But also how stories evolve not just what gets retracted.

You are focusing on an individual story, but also a specific point in time. A different narrative showed up and was passed around mainstream media changing your view of what happened. That’s more than a simple retraction.

What I find fascinating is it was even considered a story in the first place. But, it really resonated with you, so I guess they know what they are doing.

> "Never ascribe to malice that which can adequately be explained by incompetence"

I don't see that that should be applied as a rule of thumb to investigations involving civil liability and possible criminal liability.

We have a situation where there are literally piles of dead bodies, massive civil and possible criminal liability, and key evidence goes missing when in the possession of the party that was in the end found to be at fault, who more than anyone else would have realized that the evidence that disappeared was a smoking gun. It's reasonable to assume that malice might have been a factor in such a scenario and it's a reasonable hypothesis to investigate.

> Never underestimate the power of a cliched thought terminating pithy statement.

Don't slit your wrists with Hanlon's razor.

As a rule, it has high performance, but as a policy, it's trivial to exploit. Children figure out how to play dumb before they figure out how to articulate complete sentences. If you let conmen do it, they'll bleed us all dry.

Hanlon's razor doesn't apply here. No one is implying that anyone at Boeing allowed this to happen due to malice, that would be truly insane.

Negligence perpetuated by greed is far more likely and equally as criminal.

In this case I mean it as 'active' vs 'passive'.

There is the implication in the article that Boeing purposefully went and stole springs that could be used to diagnose an issue that they were fully aware of. That I would describe as 'active' and I have trouble believing.

Didn't put credence, time and effort into reports because they were inconvenient I would describe as 'passive'.

Passive is still bad - likely results in the same number of people dying, but a different interpretation of the situation.

> "Never ascribe to malice that which can adequately be explained by incompetence"

That's why we have a term "criminal negligence", because sometimes it's impossible to tell malice from incompetence.

So the law basically decided, "Well, fuck this, if you do something as stupid as (putting a faulty brake on a train, for example), then you deserve to go to jail, and we don't care if you were actually thrilled to kill passengers or were simply too stupid to understand what you were doing."

> "Never ascribe to malice that which can adequately be explained by incompetence"

Clever people deliberately structure their malice to be plausibly explained away as incompetence.

I don't think Hanlon's razor should be applied to multi-billion dollar corporate persons. Private individuals, even small to medium sized institutions with limited resources and unproven levels of competence, are fair applicants to Hanlon.

But a) Boeing is typically a hyper competent corporate person, having executed massive, multi-decade engineering projects that have been largely successful, and b) regardless of (a), the disappearance of a very specific piece of technical evidence while in the possession of the potentially liable party, while the rest of the evidence is successfully delivered, is not adequately explained by incompetence.

Agreed. The implications of the story make a good movie script, but it's hard for me to imagine how this could play out practically across so many people and so many years. I mean whole careers started and ended in this saga.

I was thinking a more likely explanation is that once the original issue that ultimately was found to be the cause was dismissed, and after more and more fatalities built up, the consequence of admitting the problem may have been perceived as game over for Boeing. As in the financial and legal consequences would be unrecoverable. So basically like the web of lies problem - once they passed a certain point they couldn't go back.


These are companies driven by greed. If they're in any way culpable, they should suffer consequences. There's nothing else to it.

The root motivation may very well be greed - I'm not attempting to go that deep. And whether or not they should or shouldn't suffer consequences is also a different issue.

It's not a different issue. If they're responsible, there should be consequences.

The Volskwagen saga can also be attributed to incomptenence but alas! it was not caused by it but by malice.

We are humans after all and money talks.

The razor is for non-economical causes.

"The razor" is for credulous morons. "Never attribute"? Yeah that sounds logical we should just stop thinking bad thoughts and being suspicious of people who got rich by destroying our society.

> didn't take the problem seriously, and that they were biased towards conclusions that weren't their fault.

I think that is malice personally.

I was about to say, then that is a definition you have made for yourself. My understanding of the word malice is to mean "desire to cause pain, injury, or distress to another" as Webster defines the word.

But I discovered there is a second, legal context for the word which means "intent to commit an unlawful act or cause harm without legal justification or excuse" so I guess in the law, "malice" is just another word for "deliberate."

I still think the first definition is what most people are familiar with, and that unless you think the engineers deliberately designed the rudder control system to behave in this way, knowing it would cause crashes and fatalities, the company having a bias after the fact to not blame themselves does not rise to that standard.

I would call it human nature. Like Upton Sinclair said, "It is difficult to get a man to understand something, when his salary depends on his not understanding it."

I generally follow: never ascribe a reason until you have sufficient evidence to support it, Be it malice or incompetence...

I think you might be missing the point stated in the article: the damage to the reputation of Boeing and possibly US economy is more important than the loss of a few (hundred) lives. You can say they cared about the loss of lives, just not as much as the damage to their company.

> Should not there be some criminal charges?

With the size of the defense contract they have with the USG?

> Should not there be some criminal charges?

That depends on whether you can convince the court.

Don’t those facing charges get brought to the court, guilt being decided by the court? Does the court press charges anywhere?

Having theories and arguments that are convenient and self serving is not a crime. It's called public relations.

For crime to happen there has to be criminal activity.

> It had tampered with the PCU from the Colorado Springs crash

This looks like "activity" to me.

Good point. This claim seems to be very original.

Having theories and arguments that are convenient and self serving is not a crime. It's called public relations

It's not just PR. It's default behavior for Homo sapiens.

would it be a stretch to say criminally negligent? or conspiring to obstruct an active investigation? obviously it would require further investigating the back channel of communication within the company and the individuals involved, but in this day and age courts can request company emails and phone records.

I worked under a CEO who had worked at Boeing before, and he said before that at times there was a number that a life was worth when making decisions while he worked there, in a conversation about diminishing returns in quality.

Now I’m not sure if he meant that literally and there’s a number in the Boeing employee handbook, but he had a point. He said they could make planes cost twice as much and save a few lives that will be lost one day, but no one would be able to afford flying.

This case definitely seems like that mentality gone wrong, but it’s interesting to realize yes, cost was spared in making your plane/car/boat/train as safe as possible

The NHTSA has a similar number, I believe its in the realm of $2 million per life. Its based off of medical costs and a few other "organic" numbers to estimate what the population as a whole values a life at.

Its morbid but it has to be this way or transportation would be unaffordable.

Unsurprisingly, the aviation insurance industry has also cost per life calculations. An aviation insurance broker who bought industry data from us wanted to know if there was any way we could provide them with hard data or reliable estimates the percentage of passengers flown by an airline flights who were American citizens, because the potential liabilities associated with the loss of American lives were so much greater...

It's $9.6 million per life. They have a really nice set of guides here [0] on how to use it. There's a high and low value and also injury costs. Also, there's a cost to lost travel time.

[0] https://www.transportation.gov/regulations/economic-values-u...

Sure. But the Ray Miller quote suggests that the issue was not that a modification to make the rudder mechanism more reliable was itself prohibitively expensive from an engineering point of view. Rather, the concern was that making such a modification could open up liability issues, as it would be an acknowledgement that the plane was faulty, and the FAA and Boeing were anxious to avoid being held liable.

That is what I think people find offensive.

This looks like a system set up for catastrophic failures. I mean, if everybody involved that has means and knowledge to do anything about safety faults has a huge incentive to not do anything about them, how we expect not to have very bad outcomes? I think it'd be smart to move on from "boo selfish people, how could they!A" to "we must redesign the system so people are not hugely disincentivized from doing the thing we want to be done"? Otherwise we have hopeless war against human nature on our hands here.

Sure. It seems to me that if a company has followed established "good practices" for design and engineering in its field, and the appropriate checks and approvals have been granted, this should go a long way to mitigate its liability for unforeseen problems that may later appear, despite the good intentions and best efforts of all concerned.

This may well be applicable to the earliest B737 rudder incidents, for example.

Acting to rectify the (previously unsuspected) fault should not increase the company's liability for a problem it was unable to anticipate.

But once a problem has been discovered/reported, if the company does not act to rectify it in a timely way, its liability for any further problems that occur should rise rapidly. And once several serious in-flight emergencies related to the B737 rudder had occurred, it seems (judging by the story as presented here) like Boeing was probably guilty of this and should be severely penalized.

I think that’s also extended from the same mentality of treatingives as numbers, but I read it as Boeing didn’t want to fix it because of cost and the fact they’d be admitting there was a problem, and the lack of payouts was due to not wanting to accept legal liability separately of admitting there was a problem. Which honestly is Ben worse, adding insult to the families of the people their actions killed.

> but it’s interesting to realize yes, cost was spared in making your plane/car/boat/train as safe as possible

Isn't it always the case? Driving cars and flying planes is a risky activity (the former much riskier, but still). There are ways to reduce the risks, but millions of people choose to buy cars without most recent safety features. A lot of people choose to drive tired, intoxicated, distracted, under bad weather conditions, while using mobile devices, etc. - knowing it is risky. There could be more safety features in cars - stronger materials, more accident-preventing electronics, enforced speed limits, etc. - but nobody would buy a car that costs $200K and can go only 30 mph, even it'd be super-safe for the driver. So yes, we know we trade some safety for reduced cost (either directly monetary or convenience). There's no surprise there, and there's no surprise manufacturers participate in the balance too. Of course, the consumer can make voluntary decision about accepting risk only if they are informed about the risks - if the risks are purposely concealed from consumers, then it's a problem.

this is a huge discussion and if seen with a cynic eye would lead to troubling results. For example telling someone to pay more for this flight so that is 1/100000 chance of dying becomes 1/1000001 .. this is a field of psychology even. Put this mixed with capitalism, profit etc. Not taking sides. I just find this extremely complex

Sounds like something a CEO would say to cover up for shitty management and cost cutting R&D.

He was a a great CEO, and invested in R&D greatly for a startup that self funded, and more importantly for me, a good person and someone I still consider a friend.

Kind of rude if you to jump at the throat like that.

I'm sorry I came in hot. I even misread the original comment. These recent events with Boeing have got me bothered I apologize for my rudeness.

That was harrowing... I feel like there should be quite a few Boeing executives in prison for life because of this.

Yeah, if things had gone just slightly differently. That, and also the company may well have ended and another gained US airline dominance.

I'd like to see a James Burke "Connections" style series on near-misses. What could have been. Another case I like to think about is Sears missing the boat on the Internet. They were catalog based 80 years before Amazon and well could have decimated the industry if a few key decisions were different.

This would be an awesome series. Blockbuster/Netflix. Fall and rise of certain social media networks. "Missed Connections"

Somewhat related:


This one is interesting:

In March 2010, a 29-year-old shift nurse left her job in Atlanta, Georgia and headed to her boyfriend’s house. She was driving her 2005 Chevy Cobalt on a two-lane road as she approached a half-mile downhill straightaway. As the road leveled after the straightaway, she approached an area where some rainwater had accumulated. Shortly after encountering this section of roadway, she apparently lost control of her Cobalt as it hydroplaned across the center line. The rear passenger side of her car was struck by an oncoming Ford Focus, causing the Cobalt to spin off the road and fall 15 feet before landing in a large creek around 7:30 p.m. The impact of the crash broke the nurse’s neck, an injury that led to her death shortly after she arrived at the hospital.

While this tragedy might sound like a typical crash scenario, it was particularly puzzling to the victim’s parents. Why? According to Atlanta magazine, she always wore her seat belt and never had a speeding ticket. So how did she suddenly lose control of her car on that fateful evening? Sadly, this unsettling question remained unanswered until several years later—after many more drivers suffered similar fates.


The ignition switch did not meet the mechanical specifications for torque and required less force to turn the key than its designers originally ordered. If the driver’s knee hit the key fob, the car would often turn off, causing stalling at highway speeds and disabling the airbags.


Edit: apparently NASA is checking referrer and you can’t follow this link directly. It’s the third case study down the page from the first link.

While this tragedy might sound like a typical crash scenario, it was particularly puzzling to the victim’s parents. Why? According to Atlanta magazine, she always wore her seat belt and never had a speeding ticket. So how did she suddenly lose control of her car on that fateful evening? Sadly, this unsettling question remained unanswered until several years later—after many more drivers suffered similar fates.

I don't understand why this paragraph was written this way. Driving highway speeds and hitting a puddle of water seems like a reasonable cause to lose control of a car and result in the crash. I don't understand why this would be puzzling. On the other hand, the lack of airbag deployment would be puzzling.

The case study is worth reading even if that one paragraph isn’t the best introduction to the issue. It goes off on occasional tangents in order to relate the issue back to NASA and repeats itself here and there, so maybe it just needed an editor.

Maybe it's a question of why rainwater was accumulating there? Is the road design faulty?

The "hidden-hazards" link says "This is a NASA-Only site"

That is weird. They must be checking referrer. If you click the first link then scroll down it’s the third case study and you can follow the link from there. Sorry I hadn’t noticed.

In my opinion the GM ignition switch thing was over blown.

Getting worn out and sloppy and failing in one of several ways (e.g. turning the car off unexpectedly) is not an atypical failure mode of old ignition switches. The only reason it was a big deal was because wealth-ish people (i.e. not someone driving a 1993 Corolla) driving fairly new (at the time) vehicles died.

Their cover up was somewhat scummy but I don't think it wasn't the kind of thing they should not have had to cover up.

Edit: should not have

> over blown

The faulty ignitions have been linked (by GM itself) to 124 deaths.

> old ignition switches

Five years is not an old ignition switch.

> should have had to cover up

On June 5, 2014, Valukas' report on the recall was made public. In it, he asserted that the company's failure to fix the defective switches sooner was not due to a cover-up on the company's part, but rather due to "their failure to understand, quite simply, how the car was built."

As well, the case study doesn't mention cover up once, but instead points out a variety of secondary issues: inadequate communication, a lack of understanding of the problem, a lack of urgency, a lack of oversight, and company culture.

>As well, the case study doesn't mention cover up once, but instead points out a variety of secondary issues: inadequate communication, a lack of understanding of the problem, a lack of urgency, a lack of oversight, and company culture.

That was a typo on my part. Regardless the media portrayed it as a coverup.

> Investigators discovered upon their arrival that someone had made off with the spring and end cap, but at the time they did not know the significance of this act. The NTSB and Parker Bertea replaced the spring, the end cap, and several other parts that were ruined in the crash and began running tests on the valve. Nothing abnormal was found. Boeing, which had packed the valve for shipping, did not explain why it kept the spring and the end cap. It instead tried to steer the NTSB toward a conclusion that the crash was caused by a wind rotor, a phenomenon similar to a sideways tornado that could sometimes be found along the Rocky Mountains.

Is this true?

FWIW the rudder hardover described in this very interesting link doesn't appear to be related to the Max 8 issues near MCAS.

Correct. Not to play psychic, but I'm assuming the original poster chose to share this as a friendly reminder that as a general rule, Boeing does not have a track record of placing human lives above their continued corporate profitability.

"If Boeing knew about a problem with the MCAS, they'd have told the FAA and corrected it" is not a hypothesis in-line with their past behavior, should anyone be holding that hypothesis in their minds.

I don't understand this. Each of these scandals is a mortal danger to Boeing. One of them might someday finally put it out of business. Whereas if they reacted to each case by being committed to finding the problem whatever it is, they could greatly reduce their liability by reducing the ultimate number of fatalities due to any one problem.

People don't buy planes though, other corporations that are doing the same thing buy them. Southwest has probably pushed as much on making these things not as clear or as helpful as they could be to avoid having to retrain for a new type. And when this is said and done, they are going to buy more airplanes and people are going to continue to buy flights from them because they are cheap.

The entire airline industry relies on a sterling reputation for safety. The experience is scary for a lot of people, and the ability to say “the ride to the airport is the most dangerous part” or “it’s safer than putting on pants standing up” does a great deal to get the public to accept air travel. If they lose that reputation, air travel would drop significantly and everyone involved would lose tons of money.

Why single out southwest specifically in this hypothetical scenario? If any airline seems 'people focused' I'd think it would be them..

Southwest is probably called out specifically here because they're somewhat unique in the airline world in that their entire fleet is 737s.

This allows them to save on maintenance costs since there's so much commonality among their fleet, but puts them in more peril when something affects the entire class of craft.

Also, because boeing said,

'we should label these switches like this and put them here', and southwest said,

'no, that will change the type and we will have to retrain pilots, we'd rather have things be the same type with an asterisks and just let our pilots know than retrain'

And because southwest is the largest consumer of the 8max, Boeing did it. From what I understand, that was a precondition of sale for the contract.

And the result it seems is that the plane can act in a way that is confusing to people who are expecting one behavior and seeing another, this comes right down to labeling switches as one thing, when they are kinda another.

My assumption, and this will probably be borne out in the investigation, is that, because southwest was part of the decision process here, they are at very little risk because of a little additional lite pilot training where they point out these switches are labeled wrong and this behavior will seem funny but this is what it's going to do. But not all airlines are going to train like that, it's the same type right?

i've seen nothing of this southwest feature request in the coverage thus far - is there a source?

either way, a customer requesting a design change doesn't make the customer part of the 'decision process' - customers request changes to the vendor, who then decides whether or not the change makes sense, and if necessary tries to influence customer expectations or at worst lose the business if necessary if it does not.

If Boeing had a reasonable expectation that the avionics changes for the new jets would impact flight characteristics to the point that the pilots needed to be retrained, then they should have dealt accordingly, even if this meant sticking to the original design you claim and insisting southwest 'suck it up' as far as pilot retraining, and the decision not to do this, if true, was solely theirs to make.

also, this wouldn't explain the 'buggy avionics software relying on a single sensor' which could also be part of the equation as I understand it.

Southwest was one of the first airlines to come out with a strong response, declaring full confidence in the MAX 8s.

I assume because they exclusively fly 737s and have a good number of MAX 8s


> Southwest operates a fleet of more than 750 Boeing 737s, and the 34 737 MAX 8 aircraft account for less than five (5) percent of our daily flights.

> Each of these scandals is a mortal danger to Boeing. One of them might someday finally put it out of business.

I don't think this is true, and I think that their cost/benefit analysis clearly agrees with me. Military and other large contractors go out of business when they run out of friends. For them to run out of friends, they would either have to have people fear for their jobs if they choose Boeing, or a competitor who offers more for friendship.

There will never be enough pressure from the public to not pick Boeing that people would be risking their jobs by choosing them. In addition, the US government is willing to sweeten any friendships they need sweetened. Boeing is a company of the size that taxpayers actively shill for them overseas, and that business for them is included in treaties and foreign aid.

I can't even imagine a situation bad enough that Boeing would even need to change its name.

Boeing had this scandal and is still here. In that sense, they're demonstrably not mortal dangers.

It's normalization of risk writ large over corporate lifecycle timescales. "Should we report this? Well, the last time we got 200 people killed, nobody went to jail, so..."

Boeing is a US military supplier and a strategic US asset in the airspace industry, the US government will ensure that they do not go under no matter how much damage they do (see car industry). Furthermore even if that wasn't the case the people who cause these issues have almost zero chance of facing personal liability. As a result, it's in the personal interest of the people running Boeing to cut corners and extract maximum short term reward (ie: personal promotions, stock grants valuations, etc.).

This is an excess of capitalism: those with capital are given too much power, and their self interest ends up being entirely selfish at the expense of society at large. Capitalism needs regulation, and if the system ends up entrenching itself so that regulation becomes impossible (because of corruption, self-interest, short-term gains, etc), then it means the entire system of capitalism is faulty.

Regulation is exactly why the problem that you're complaining about exists. Only in the presence of regulation does a company become "too big to fail." That's not an attribute of market economics.

Note that I'm not making a value judgment about regulation in the general case, just pointing out that you've misidentified the problem in this particular case.

I'm not saying market economics is the problem. I think that concept gets conflated with capitalism too often. I think markets are a good tool for economic organization. The problem is the system of capitalism, i.e. the centralization of power and capital in the hands of the few, and the rules of a system that incentivize and enable that. This bad system of rules, capitalism, is certainly a form of regulation (is that what you mean?). But when I use the word regulation, I mean a rule that checks the otherwise unlimited exploitative power of capital, rather than any rule at all. Maybe you think that any rule at all would cause this, and I think that's not true.

A big problem we found 11 years ago was that some companies were "too big to fail"

The solution isn't to stop those companies from failing, it's to prevent companies from being "too big to fail"

Couldn't they just bring it back to life under a new name?

I'd be very surprised if Boeing have their assets structured in such a way that a massive liability in one area could take out the entire business.

At a very minimum they will have Boeing spares and maintenance ltd. Probably one in each country they operate in.

So they are 'too big to fail' ?

There's a good chance that if you aren't proactive about these issues, they won't get noticed until after you've left the company. Let the next CEO/board/director deal with the repercussions and costs if they ever come up.

Are there any corporations that do have a demonstrable track record of placing human lives above profitability?

Depending on how you turn your head and squint, Amazon is doing the right thing today [https://news.ycombinator.com/item?id=19391696].

... though I wouldn't say that this one-off rises to the claim of "demonstrable track record." They have some explaining to do about the working conditions of their warehouses.

The articles says that since the valve was redisigned, there has been no more accidents.

I think the point here was to show how Boeing has responded to issues in the past.

Of course they haven't, no different than car manufacturers doing the same types of deflections and cover-ups. See also tesla autopilot problems, or any of dozens of other such scenarios.

A problem is found with a design after a fatality (or near fatality), manufacturer deflects, blames the operator, etc until someone proves that they are 100% at fault. Eventual recall.

Takata airbags, Ford Explorer tires, GM Cobalt ignitions...

Of course the flip narrative is that even though things appear to be bad, they're actually getting better.

For this PCU issue, it looks like Boeing was able to derail the issue for years, even throughout several crashes. This time, Boeing was basically able to subvert the FAA for two days - the pressure of disagreeing with other country's regulatory bodies simply became too great.

"Boeing blamed the yaw damper…"

What if this MAX thing isn't pitot tube or MCAS software…

I know these comments are kind of frowned upon on threads talking about an issue like this, but very interesting use of imgur. Effectively a blog post focused on images, which is a very good way of thinking about posts I feel. People love images rather than only words. Has imgur been looking at this? Trying to push it as another big use for its platform?

This format is a known use case and results in some of Imgur’s most interesting content. Imgurian missfilipina feeds her village’s kids for free every Sunday using donations from the Imgur community and shares her stories like so - https://imgur.com/gallery/nFoh5Bn

Human interest stories are the most common posts to use the format but educational stuff like this is definitely seen too.

This is a common pattern for posts on r/DIY on Reddit, where people have 5-100 photos covering each step of a project, and each photo has a bit of text below it explaining the process.

I thing it works great, and I much prefer it over videos because I can take my time, and videos tend to gloss over the details. My only issue with Imgur is that on mobile the images are very low-res, so zooming in to see details doesn't work.

My biggest complaint with the pattern is that there's no way to easily save the text with the images. If you "download the post", you get the images, but not the text. Even an XML or JSON of the text as a large "blob" would be better than nothing. Heck, for that matter, a flat ASCII file delimited with line breaks would be fine.

IMO "Print to PDF" works perfectly for this kind of thing (and blog posts, etc)

FYI, the post is by reddit user /u/Admiral_Cloudberg/, who has done a number of flight crash investigation posts on imgur like that: https://www.reddit.com/user/Admiral_Cloudberg/submitted/

Edit: Ooops, someone already mentioned this below. Oh well.

no oops. Your comment was what helped me find it. In a thread with hundreds of comments, it's okay to have information repeated if it's done so in a relevant way. The alternative would be a whole bunch of intra-thread linking that just isn't feasible. So, thank you.

Vepr157 [1] on Reddit has several similar Imgur albums on the design of submarines, such as "American Second Generation SSNs" [2] and "Soviet and Russian Submarine Propulsors" [3].

[1] https://www.reddit.com/user/Vepr157/

[2] https://imgur.com/a/9h3gD

[3] https://imgur.com/a/t6UjU

I felt the same reading it. Thinking wow this is the best use of imgur.

That was a surprisingly interesting read. I have to admit I was skeptical just because it was hosted on imgur, but both the images/text paint an interesting picture worthy of discussion.

If you want to read more, this is from a series on the subreddit /r/catastrophicfailure, written by Admiral_Cloudberg: https://www.reddit.com/user/Admiral_Cloudberg

I was going to ask if this was his, I always look forward to the new one each week.

The author has posted many of these, all on imgur.

Boeing certainly hasn't been inspiring a lot of confidence lately, given that decisions like this:


have apparently been leading to decisions like this:


"Best" part of the first article:

> Aero Mechanic, the District 751 monthly newspaper, accused Boeing of “essentially masking defects,” by pressuring inspectors to not record defects when found but instead to simply have them fixed, then afterward produce data to the FAA showing a big decrease in defects as a justification for cutting out inspections.

Manufacturers take the blame for this. And they take the blame for things like no global transponder in the loss of the 777 over the Atlantic. Unfortunately the FAA processes, while enlightened in some ways, and firmly grounded in the science of safety, are effectively a strong deterrent for a manufacturer to avoid changing anything in a design.

The result is that many aircraft operate for a very long time with very outdated systems. Replacing designs is prohibitively expensive to prove to the FAA that there will be no corresponding degradation of the system's performance or new safety risk. Unfortunately such a process does not calculate the cost of not replacing the system. No cost is attributed with keeping something that is old and lacking in capability.

The result is that aircraft systems are woefully behind what technology can offer. And this is not just the hardware or the software, it includes the procedures and the overall set of capabilities. The result is that aircraft are being operated to the standards of the 50s, when in fact a much higher standard of crew and aircraft performance is possible. When I say performance I am also talking about safety performance, the ability to operate without harm causing failure.

That's not what happened in this case. They used a single piston where commonly two or more pistons would be used to control the rudder.

I do not agree in general, but I admit to not knowing the details of that system. Those of us in the industry have been waiting for 737 rudders to fail for a long time. The data was there. This is the same as waiting for a pilot to rip the tail off an airplane as happened over New York. The certification basis of those aircraft was not in harmony with the information the operators used to fly them and gravely distorted the engineering that had gone into designing the aircraft.

In both cases, there was a certain inevitability given the processes at work, the conditions, the changes and the difference between engineering reality and what is presented in the FAA Type Certification process as the basis for the modification of the Type Certificate. As an engineer working on aircraft, one thing is for certain, engineering data is laundered to the bare minimum in the interests of certification. This is in contrast to the engineering NASA does. The cert process does not achieve transparency, as it is a legal not an engineering process.

One can blame manufacturers, but there really is no way for them to be transparent and ever ship anything (ref. Lear Fan). I am not, however, advocating retracting any responsibility from Boeing. They must bear the responsibility for their product. I am only saying that we have created an environment as a country that makes it unlikely we will see the behavior we desire from manufacturers. As a person who likes to land the same number of times I take off, my interest is in helping the government improve as well as the manufacturers.

So Boeing decided to conclude that the existing system was sufficient. And they proved it to the FAA. There is no precedent or standard applied to the parts of the airplane that are not changed, once they are deemed not to need changing. This is similar to the housing code. Replace a socket in a house with knob-and-spool wiring, and you do not need to fix a thing. Rewire a bedroom in a house with knob and spool wiring, and the code will not let you put new knob and spool wiring in, one must then bring the house's electrical system up to code.

The reason there still is a 737 is the tremendous economic benefit afforded to manufacturers who use safety analysis to show that the previous iteration of the aircraft's systems are sufficient given proposed changes on the aircraft. That's why it has ridiculous engine nacelles, ridiculous landing gear, in many 737's ridiculous avionics. A new airframe is required, but the cost of a new airframe's certification is much greater than the hacky re-certification of an old type certificate obtained when standards and processes were very different and much out of date.

There are many examples too. The concorde is one that has my current prize for being the most extreme example. One crash, retire them all. There was no reasonable way to operate that aircraft by modern safety standards. But it was certified in what, the 60's. One likely could have certified a barn door strapped to a Concorde engine in those days ;-)

The Concorde was not retired directly after the crash. It flew for three more years and was retired for financial reasons. The crash probably reduced the demand though and thus contributed.

I think that is inaccurate. One fleet was grounded quickly. The 30 million Kevlar tank linings were underestimated in cost I think dramatically. As for profit, I am not sure the aircraft was ever a profit center. Any reasonable observer saw Non-recoverable Engineering Expenses that the company any could never recover from as a result of having to mitigate a new safety requirement onto an old aircraft that was never designed with modern standards in mind.

I think it is a very good example of how old systems continue to operate while the public believes they are up to modern standards. We see it in civil engineering now too. A bridge collapses in Pennsylvania and the public is told that over 1/3 of US bridges are outside of their designed life span and more expensive to fix than replace with municipalities that cannot afford to do either. The Concord was old and had what we call Tech Debt. It could not be made modern. Risk is just negative opportunity cost. When it crashed that debt was realized and the company had to write it down. One thing for sure is correct in your statement. It is about money driving the decisions, not engineering.

What is inaccurate? The accident happened in 2000 and the last flights were in 2003 by both airlines. What do you mean by one fleet being grounded quickly?

The exact motives for retiring the plane are hard to know. Safety almost surely played a part if nothing else by reducing demand. I was just correcting that you seemed to be saying the plane has been retired after the accident when it did in fact return to service.

To me its interesting that they wouldn't redesign the part as it would be admission of causing previous crashes? Kinda scary that the lawyers rule USA at the end of the day.

Its easy to blame Boeing for faults like this but its a miracle that these things fly so reliably with so many moving parts and human involvement.

Lawyers don't design planes. CEOs who intentionally lie about their planes' safety do.

Without lawyers, those CEOs could go on killing people and never have any accountability.

>Kinda scary that the lawyers rule USA at the end of the day.

I'm not sure you thought that one through. Are you really surprised? Who else should it be? I'm sure no one would say the politicians.

This is why we have the NTSB, prioror to it’s existence manufacturers were the primary investigators of their planes’ accidents with predictable results like above.

They write such great reports. Technical, but also accessible. I'm not a pilot and I find them interesting to read.

Agreed, the CSB has great reports too.

And their videos are excellent too: https://www.youtube.com/user/USCSB

Think all the investigation shows on Discovery, but with zero filler.

I like the idea of a Discovery like channel ... but full those videos.

Discovery, the History Channel, used to be full of random filler like old military equipment videos that were just videos from demos and trade shows and someone who sounded like they were reading out of a Jane's book or something ;)

Same went for some disaster / failures videos done by (I forget who) some risk / aftermath assessment company.

I miss those days.


The CSB has the most amazing youtube channel where they outline accidents including 3d renderings. I find it so fascinating how these accidents happen.

The Wikipedia article on this is also good https://en.wikipedia.org/wiki/Boeing_737_rudder_issues

My previous company made software for DOTs. Over the years I learned that DOTs assign a dollar amount to human lives/deaths when calculating the cost benefit ratio of implementing roadway safety improvements. It very much reminds me of the acceptable number of deaths mentioned in the article. DOTs don't like talking about this of course.

There should be a law that grants companies safe harbor for reporting and fixing defects in their product without the risk of accepting liability. Sort of like self-whistle blowing.

Is there realistically any other way to do this though? The value of life, as estimated by a human in a generic situation is presumably infinite. However, companies, governments, regulating bodies, etc, have to regulate actual physical measures, which cost money, time etc- all very finite things. These agents need to act in actual physical environment like for example limited budgets or having to choose between two different safety measures. At some point the human life is going to have to enter that equation, if we are going to be talking about safety issues. How do you calculate en equation with finite and infinite variables without assuming a finite value for the human life?

Wow and this content is just posted on imgur with no link to sources? Is anyone already working on posting this through a legit source? If this content is real, it seems wild that it's not even published somewhere that is searchable online.

The source is here: https://www.reddit.com/r/CatastrophicFailure/comments/adl0jk...

I wrote this. I noticed it jumped 12,000 views and I got no username mention on Reddit, so I asked around and found it came from here. Made an account just to post the source. I'm pretty pissed that someone linked it completely without credit.

As for what it is, it's part of a series I write for reddit where I read as many sources as I can about a plane crash, write it up in a way that's understandable to laymen, and then post it for others to read. Taken away from me and my reputation on Reddit it has zero credibility because it's just a random album on Imgur.

I'm not sure you have the right to be upset about lack of attributions when your articles lack attributions for the sources of information and all of the images.

I'm not sure what you mean, the second paragraph of the article is: "Images sourced from The Seattle Times, the NTSB, Boeing, Tails Through Time, the Colorado Springs Gazette, The Times of India, Wikipedia, TribLIVE, The Flight 427 Air Disaster Support League, and Forbes. Video clips courtesy of Cineflix and the Weather Channel. Special thanks to the Seattle Times for its series of articles on the subject in 1996, which brought to light many of the details referenced here."

That was added after my post.

Thanks for doing this Admiral_Cloudberg, you have definitely opened peoples eyes in ways that the FAA and Boeing have not.

This was uploaded in January 7th by the way if you check the date, not recently so this isn't to explain the Lion Air issue but rather Boeing's history

I imagine that Boeing engineers are decent people who want to be able to look at themselves in the mirror and be able to sleep at night. So I find it hard to believe in an active conspiracy, but the propensity for groupthink and self-delusion seems extraordinarily high.

I always quote this, but only because it’s always applicable:

“It is difficult to get a man to understand something, when his salary depends upon his not understanding it!” - Upton Sinclair

People tend to understand this as saying that people will fight you and feign ignorance. I think it should be taken more literally: a person’s financial position affects their reasoning, and it is literally difficult for them to understand something that will harm them. Not impossible by any means, but when there’s a financial incentive not to understand, it’s far more likely that people just won’t get it.

If you've spent your career at a company, who can fire you for not parroting the company line, in a field as small as aviation, chances are you'll not get hired elsewhere, and you'll do as your indirectly expected to.

I am as cowardly and timid about my job as any other clock puncher, but I would not knowingly risk peoples lives.

I suppose the distinction I'm making is one between bona fide self-delusion and knowing cynicism.

I doubt that would have gotten past their unions (for either the engineers or the engineering technicians).

I imagine some of it has to do with not wanting to be wrong. And especially not wanting to be wrong when that means you have caused/contributed to someone's death. That is a powerful motivator to find alternate explanations.

Everyone here is probably intimately familiar with that attitude, since it permeates software engineering (and probably every other technical field).

This makes me wonder how we'll view space travel generations from now. Will the descendants of companies like SpaceX and Blue Origin face outrage and calls for criminal charges like Boeing is receiving now?

Risk is inherent in fast modes of transportation, and I think it's very easy for us to ignore the underlying complexity of these feats. Great example: regular air travelers I'm sure are use to the preflight safety announcement run by the cabin crew, but when was the last time you (of the royal variety) actually stopped what you were doing, focused on the briefing, and made a mental note of the plane's safety features?

"when was the last time you (of the royal variety) actually stopped what you were doing, focused on the briefing, and made a mental note of the plane's safety features?"

Every. Single. Time. I fly.

I'm a pilot, and I know the chance of an accident is small and the chance of a situation where my actions will make a difference to the outcome are even smaller. However, since I'm locked in a seat with nothing important to do, paying attention and noting where the life vest is, how you put it on, and where the exits are in relation to my location has an opportunity cost of zero.

I personally don't pay THAT much attention to the briefing because I'm an aviation nut. However, I will still pull the safety card and check exactly which aircraft I'm in and where the emergency exits are.

EDIT: I do pay a lot of attention during the takeoff and landing phases. That's when most of the issues happen, so headphones and sleep can wait.

New information (to me anyway) and I didn't see it mentioned here yet. Apparently the MCAS was put into place to begin with in order to deal with a potential "imbalance" situation created by attaching new, bigger engines to an old airframe design.

"The new 737, named as the 737 MAX, would require -as usually- bigger engines, to offer an increased fuel efficiency, competitive to the one of the A320neo. And again, there was no room for them. So, the solution was to extend the front landing gear by eight inches and at the same time to move the LEAP-1B engines even more forward and higher up (image 3). This last design modification was later found to create an upward pitching moment during flight, which could bring the aircraft closer to stall under specific operating conditions. To tackle this problem, Boeing introduced the so-called Maneuvering Characteristics Augmentation System (MCAS). The MACS simply trims the stabilizer nose down, to counterbalance the moment created by the new engine positions."


Any whistle blowers in Boeing who could come out & share facts on how employees of Boeing are reacting to these incidents?

Do we think they're all in conspiracy overdrive mode looking for ways to cover their asses and burning all the evidence?

Chances are better that (assuming they don't already know the answer) that a bunch of them are working long hours trying to find the cause and solution to this problem. I imagine every flight simulator at Boeing's disposal is being used to analyze this from every angle.

See what happened to John Liotine. https://en.wikipedia.org/wiki/Alaska_Airlines_Flight_261 Honestly, I'm more scared of airlines skimping on maintenance and fights with their mechanics (southwest) than this.

Some tried back in 2011, didn't go to well: https://youtu.be/vWxxtzBTxGU

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