> But McDonnell Douglas never wavered from its belief that human error was the only cause of cargo door failures, [...] even attempted initially to pin the Turkish airlines disaster on the “illiterate” baggage handler Mohammed Mahmoudi, who hadn’t even deviated from proper procedure (Mahmoudi also pointed out that he was in fact literate in three languages, thank you very much!).
The only comic relief in this somber yet riveting exposition. More importantly, it shows MD's desperate desire to externalize the blame. I just see the same too often in engineering firms and, even more unfortunately, in life.
And the author slightly joins on on that with his off-the-cuff characterization of the two 737 Max 8 crashes (at Lion Air and Ethiopian) as
>two preventable crashes at unready airlines in developing countries
Ethiopian is a large and by all accounts modern and well-run airline which has been operating jets since the early 1960s, and performs maintenance for other airlines. While it was originally set up as essentially a branch of TWA with American staff, it hasn't relied on foreign staff since the 70s. It's been an early adopter of new Boeing aircraft since the early 80s (with the 767) and was the first airline outside Japan to fly the 787 commercially.
“That system, although it has undergone radical changes, is still similar in several key ways. So similar, in fact, that in 2017 the Boeing 737 MAX 8 could be produced with an egregious design flaw, kept hidden from the FAA, which resulted in two preventable crashes at unready airlines in developing countries, killing (coincidentally) 346 people. And so, while it is true that flying today is much safer than it was in 1974 — passengers today need not worry about their planes crashing because of badly designed doors — the same basic factors that led to the DC-10 cargo door saga still exist and still cause accidents.“
Kyra might have to sadly walk even the caveat on this one back after yesterday’s incident on Alaska Airlines flight 1282 (another 737 MAX), which had an in-flight decompression emergency in which a body panel blew out due to some defect related to an unused doorframe obscured behind the paneling in that section. Thankfully it didn’t crash, but if the panel had hit some control surface on its way off of the plane, it might have been a much less happy story.
Not sure the caveat ever made sense… the next full hull loss due to a badly designed door is, really, always just a matter of time + financial incentives + regulatory gaps.
And, since we now know (after Asiana 8124) that an untrained and motivated individual can open the damned things in the most critical phases of flight, ejecting a exit slide into the path of an engine in the act, I’m not sure a caveat for even what we’d currently call well-designed doors is reasonable.
There's probably an unavoidable element of trade-off in the design of a door which normally must not open, yet must do so in a wide variety of abnormal situations.
Sure… and you shouldn’t feel particularly safe sitting beside any such door, especially if there’s an astronaut that really wants to exit the craft between you and it, if it’s got a failure state that lets it open in any situation in which it normally must not open.
Putting aside the low probability sitting next to an astronaut who if in any frame of mind, if it turns out that the problem with this door plug is also manifest in emergency exit doors, then yes, there are grounds for concern.
That door that fell off in the Alaskan Airlines flight the other day are plug-type doors. They're not actually doors with handles and passengers aren't able to open them.
I wasn’t implying that this blank plug was passenger operable… my implication is that now humanity knows that that the non-blank plug doors that do have handles can be opened in the critical descent and ascent phases (due to insufficient pressure differential) the caveat doesn’t mean much.
And it doesn’t… you can be killed by a poorly designed blanking plug (it’s just sheer luck no one died in the Alaska incident) or by a properly designed door operated at the right time of flight by someone with either delusional or malicious intent.
Still amazing that MD spent years blaming multiple failures of people working in the ground rather than being dragged on the coals for making an aircraft that could fail catastrophically due to an invisible error made by a single hypothetically unskilled luggage handler (though note that at least one of the people they attacked as illiterate spoke 3 languages).
But even more so, once they were "aware of the design error" they made a "gentleman's agreement" with the FAA to fix it as long as the FAA didn't do anything that would force them to actually fix it, and then none of the MD executives went to jail for homicide after killing the occupants of flight 981.
Then after all of this BS, McDonnell Douglas knew the cargo door was faulty before even Windsor happened. They had had the cargo door fail in their own testing prior to any accidents and went with it anyway. Again, the ability of executives to remove themselves from criminal accountability is astounding.
The same happened with the 737MAX: it was executives who signed off on deceiving the FAA, it was executives that approved the single point of failure, it was executives and the board of directors who claim their compensation is due to them having responsibility, and yet they have not been charged with murder. If I sell you a car with faulty breaks, and tell you they are not faulty, and provide falsified reports claiming that they're safe, and then you die when the breaks fail, I would be charged with at minimum manslaughter, but likely some variation of homicide: the deaths followed from the criminal act which means the deaths themselves are criminal acts. It's the same reason that if you hold up a bank and the teller dies as a result of a heart attack you would be charged criminally for that death.
Until the executives and board directors of companies are themselves subjected to liability in addition to the company's civil liability nothing will change.
> In fact, 75% of the DC-10’s certification items were handled by FAA-designated engineers who worked for McDonnell Douglas, a practice known as delegation. Delegation is necessary to some extent because the FAA lacks enough staff to certify every part of every new airplane. But in this case, the engineer who the FAA had assigned to certify the vent door was the same man who had conducted the tests of the door on behalf of McDonnell Douglas.
Seems Douglas was a cursed company. It was on a brink of bankruptcy, was acquired by McDonnel, which went to almost bankruptcy itself, and now it is happening to Boeing.
Starliner (I assume that's what you mean by CST) is pure Boeing, not ULA. It's also worth mentioning that ULA's probably about to be sold [1]; the three potential buyers are Blue Origin, the private equity fund Cerberus [2], and the aerospace contractor Textron.
This seems like the eventual subject of a business case study in how dysfunctional corporate cultures can lay somewhat dormant in a company, and then infect the other parties in a merger.
The article even calls management's decisions "necessary or right" because they might lose their jobs. But you know what hit me hardest in that article? That the top highlight (a few minutes ago at least) was this sentence
> In the end, it would have been less expensive for McDonnell Douglas if they had just fixed the planes.
Again a fixation on money. As if that isn't the root cause.
Fixation with money would lead to the conclusion that it is imperative to fix the planes to avoid costly lawsuits, upset clients, and loss of reputation and ultimately, bankruptcy.
There is absolutely no money fixation.
And upon further examination, you can see there is no money fixation because the emoloyees lack clear long-term thinking. Its all robots obsessed with CYA, promotions, and turft wars instead of focusing on making money, and what makes money long term for the company
I don't see the contradiction. CYA is driven by shareholders pressing the board, the board distributing the pressure to divisions, division heads distributing that to middle management, middle management distributing that onto assembly and sales teams, and everyone keeping their heads down. We don't call it bean counting for nothing.
> promotions
I.e. money.
Perhaps I can be clearer. This is in contrast to managing a company based on e.g. ethics and longevity. The question whether or not it is cheaper to sacrifice lives because of litigation and reputation loss should never come up.
It boggles my mind how a pattern that every (capable) engineer can spot a mile away and know for a fact that a disaster is waiting to happen, can persist. It seems to be a human condition that we sleepwalk into disaster regularly.
It is mind-boggling, but remember, still to this day, engineers are controlled/bossed by non-scientific people. Some will argue that upper management doesn't have to be educated in the fields they control/manage. Tell that to the families of the victims.
not me. I've worked at multiple places where I've warned my manager (and people higher in the company) about a potential disaster scenario...which was ignored.
The disaster, in some shape or form, eventually came to pass. I then had to clean up the mess. Luckily, nobody died.
> And so, while it is true that flying today is much safer than it was in 1974 — passengers today need not worry about their planes crashing because of badly designed doors — the same basic factors that led to the DC-10 cargo door saga still exist and still cause accidents.
I guess we still do have to worry about the doors and door plugs today. Maybe the 737 Max is the new DC 10?
> All systems intended to ensure that the door was properly closed had now been overcome […] Countless side characters stepped in and out of the picture, from the engineer who certified his own work and missed a clear design flaw, to the Turkish Air Force officials who wanted to use the DC-10 to carry troops to Cyprus, each of them unwittingly playing a small but possibly crucial role in the buildup to disaster. It wasn’t just a door — it was the system itself which failed.
This article totally reminded me of one I read in the Atlantic many years ago analyzing a different airline crash. I’ll try to find the link, but the author or one of the main interviewers had argued that in airline safety, Murphy’s Law is the exact opposite of what happens. In reality, if anything can go right, it will go right, and we only get catastrophes when every part of a system fails, and a whole chain of events conspires to go wrong. They made a compelling case in the article, and this one backs the argument up completely. Fascinating.
“The ValuJet accident is different. I would argue that it represents the third and most elusive kind of disaster, a "system accident," which may lie beyond the reach of conventional solution, and which a small group of thinkers, inspired by the Yale sociologist Charles Perrow, has been exploring elsewhere—for example, in power generation, chemical manufacturing, nuclear-weapons control, and space flight.
“The people involved do not consciously trade safety for money or convenience, but they inevitably make a lot of bad little choices. They get away with those choices because, as Perrow says, Murphy's Law is wrong—what can go wrong usually goes right. But then one day a few of the bad little choices come together, and circumstances take an airplane down. Who, then, is really to blame?”
I think it was this flight, my father’s friend missed it at the gate by a minute. He then sued the airline... for taking off a minute earlier than scheduled.
The only comic relief in this somber yet riveting exposition. More importantly, it shows MD's desperate desire to externalize the blame. I just see the same too often in engineering firms and, even more unfortunately, in life.