3/28/2019 How Boeing’s 737 MAX Failed - WSJ

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How Boeing’s 737 MAX FailedThe plane’s safety systems, and how they were developed, are at the center of the aerospace giant’sunfolding crisis

Boeing Co. needed the redesign of its crucial 737 jetliner to go swiftly and smoothly,so it pursued a path that reduced regulatory scrutiny and accommodated its biggest customerby requiring as little new training for pilots as possible.

Many pilots now say Boeing’s choices for the 737 MAX left them in the dark about a new featurewhose malfunctioning has been implicated in one deadly crash and is under scrutiny for apossible role in a second—disasters that claimed 346 lives.

Pilots flying the 737 MAX, which entered service in 2017, received no training on a new stall-prevention system and saw almost no mention of it in manuals, according to the pilots andindustry officials. Most would get no visible cockpit warnings when a sensor used to trigger thesystem malfunctioned, and they had no access to simulators that could replicate the kinds ofproblems believed to have downed Lion Air Flight 610 in October.

Following the second crash, in Ethiopia this month, a picture is emerging that suggests Boeing,as it hurried to get the plane on the market, put too much faith in its design and engineering,particularly of the automated stall-prevention system that was supposed to make the planesafer, according to interviews with safety experts, industry officials, former Boeing employeesand former regulators.

Many questions remain about Boeing’s handling of the redesign and what went wrong. TheJustice Department and other federal agencies are investigating whether Boeing providedincomplete or misleading information to get the airliner certified as safe to fly.

Ethiopian investigators have yet to detail their preliminary findings, although authorities havecited similarities between both crashes. Ethiopian Airlines’ chief executive has said the stall-prevention system, called MCAS, appears to have played a role.

March 27, 2019 11�07 a.m. ET

By Andy Pasztor, Andrew Tangel, Robert Wall and Alison Sider

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3/28/2019 How Boeing’s 737 MAX Failed - WSJ

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The first of what is expected to be a series ofcongressional hearings looking at the decisions ofboth Boeing and the Federal AviationAdministration began on Wednesday.

Boeing has said it would overhaul the flight-control system and make safety alerts that hadbeen optional a standard feature. The fix has beenundergoing flight trials since Feb. 7, Boeing said,before the Ethiopian airliner crashed.

A Boeing official said Wednesday the softwarechange didn’t mean the original MCAS designwas inadequate, but that the company “found away to make it more robust.” He also said Boeingwas conducting reviews of other MAX flight-control systems but hadn’t uncovered anypotential problems.

There are indications that Boeing was aware thatsome 737 MAX models in the air lacked all thepossible safety features available.

On Nov. 27, about a month after the first crash,Boeing executive Mike Sinnett told American Airlines ’ pilot union that their pilots wouldn’texperience the sort of problems that doomed the Lion Air flight, according to Dan Carey, unionpresident. That's because American paid for an additional cockpit warning light that wouldhave alerted them to the problem, while Lion Air and most other airlines didn’t.

Cockpit indicators“This wouldn’t have happened to you guys,” Mr. Carey recalled Mr. Sinnett saying during themeeting. The cockpit indicators would have directed pilots to have the potential problemchecked out on the ground. A Boeing spokesman said Mr. Sinnett didn’t recall making thatstatement, and was unavailable for an interview.

The Boeing spokesman said the company followed “established and accepted assumptions andprocesses” in designing and certifying the new stall-prevention system. He said Boeing“determined that a pilot would be able to counteract erroneous system input” by followingestablished procedures for which pilots have received training previously.

Boeing said the FAA considered the system’s final design during its certification of the aircraftand concluded that it met all regulatory requirements.

Sources: Museum of Flight Seattle (old cockpit

The 737 entered service in

3/28/2019 How Boeing’s 737 MAX Failed - WSJ

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One senior Boeing official said the company had decided against disclosing details about thesystem that it felt would inundate the average pilot with too much information—andsignificantly more technical data—than he or she needed or could realistically digest.

It is Boeing’s biggest crisis in years. The 737 has been the centerpiece of Boeing’s businessfor decades, and the MAX was intended to carry that on. Now the entire 737 MAX fleet is

grounded. Industry executives and former regulators say it could take years for the company torebuild trust among airlines, pilots and foreign regulators. The fallout could affect the way theFAA monitors the development and approval of new aircraft essential for airlines to meetsoaring global demand for air travel.

Boeing needed the MAX to offer a fuel-efficient option for customers to avoid losing marketshare to chief rival Airbus SE . Boeing didn’t even wait for its board of directors to approve thedesign before offering it to American Airlines, which was on the cusp of buying planes fromAirbus. Boeing’s board didn’t formally sign off on the MAX until a month later.

“Design, development and certification was consistent with our approach to previous new andderivative airplane designs,” Boeing said.

Boeing engineers realized the MAX needed engineering changes from the existing 737s toaccommodate its larger, fuel-efficient engines. The engines made the new plane tougher to

fly in certain conditions than the 737s already in service, according to people familiar with theplane’s development. To help pilots manage that, Boeing decided to add the MCAS stall-prevention system.

In the Lion Air crash, the stall-prevention system, based on erroneous sensor information,repeatedly pushed the plane’s nose down. According to a preliminary accident probe, the pilotbattled the flight controls while facing a cacophony of alarms before losing control andplunging into the Java Sea.

Some former Boeing engineers, safety experts and pilots said that while the system wasconceived to enhance safety, the design fell short.

Minimizing changesThroughout the MAX’s development, Boeing was intent on minimizing design changes thatcould require extra pilot training, said Rick Ludtke, a former Boeing engineer who worked on737 MAX cockpit features but not the MCAS system. Extra training could have added costs forairlines introducing the MAX into service.

The company had promised Southwest Airlines Co. , the plane’s biggest customer, to keep pilottraining to a minimum so the new jet could seamlessly slot into the carrier’s fleet of older 737s,according to regulators and industry officials.

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Mr. Ludtke recalled midlevel managers telling subordinates that Boeing had committed to paythe airline $1 million per plane if its design ended up requiring pilots to spend additionalsimulator time. “We had never, ever seen commitments like that before,” he said.

Southwest, which has ordered 280 MAX aircraft, declined to comment on the issue, as didBoeing. A Southwest spokeswoman has said the airline developed its 737 MAX training basedon Boeing’s information and was a recipient of, not a driver of, the training mandates.

It was difficult for Boeing to figure out what changes it could make without triggering the needfor more training, Mr. Ludtke said, in part because of the FAA’s approval process.

According to Mr. Ludtke and a U.S. government official, the agency would evaluate the entireplane only after it was complete, and wouldn’t give step-by-step guidance on what would orwouldn’t lead to additional training demands. That added pressure on Boeing’s engineers tokeep changes to a minimum, he said.

The FAA has said that the 737 MAX was approved as part of the agency’s standard certificationprocess.

The MAX planesentered servicebefore the firstflightsimulators wereeven ready foruse by airlines,according toairline

Boeing employees at the Renton, Wash., factory last year celebrated the 10,000th 737 to come o� the production line. PHOTO:BOEING

RELATED

Southwest 737 MAX Makes Emergency Landing in Orlando, Fla. (March 26)

Boeing Plans Fixes to Make 737 MAX Stall-Prevention Feature Easier for Pilots to Control (March 23)

Prosecutors, Transportation Department Scrutinize Development of Boeing’s 737 MAX (March 18)

Ethiopian Airlines Black Boxes Showed ‘Clear Similarities’ With Lion Air Crash (March 17)

U.S. Grounds Boeing 737 MAX Jets (March 13)

3/28/2019 How Boeing’s 737 MAX Failed - WSJ

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executives, and the few that have now been introduced can’t replicate the malfunction the LionAir crew faced. The simulators are set to be enhanced to allow pilots to practice dealing withsuch failures, though the upgrade could be months away.

Following the Lion Air crash, Boeing said that pilots are routinely trained to respond toerroneous automated nose-down pushes regardless of the cause and turn off related systems.The company has told pilot groups and others that the system behaves similarly to the ones inan earlier generation of 737s. It said it discussed the MCAS system’s functions at several airlineconferences in recent years and wrote manuals to include information it believed pilots neededto operate the aircraft safely.

Numerous pilots and safety experts interviewed by The Wall Street Journal said that inpractice, amid the chaos of an aircraft lurching into a steep dive with emergency warningsblaring, it is unrealistic to expect pilots to recognize what is happening and respond almostinstantaneously.

BryanLesko, anairline pilotwho wrotean articlelast year forhis union’smagazineabout the737 MAXbefore itenteredservice,repeatedly

asked Boeing officials if there were any major new systems. The answer was no, according to aperson who recently discussed the matter with him. The union declined to make Mr. Leskoavailable for comment.

Since the stall-prevention system emerged as a potential factor in the Lion Air crash, industryand government officials around the world have learned that the system can in certainsituations push the plane’s nose down repeatedly, undercutting the pilot’s ability to regaincontrol manually.

A software overhaul Boeing is set to distribute to airlines in the coming weeks will address thatproblem.

Debris from the crash this month of the Ethiopian Airlines Boeing 737 MAX. PHOTO: BAZ RATNER�REUTERS

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An earlier design decision by Boeing engineers was intended to make the stall-preventionsystem simple. It relied on data from a single sensor, rather than two, to measure the angle ofthe plane’s nose, Boeing said.

Safety experts, pilots and some former Boeing engineers say it is rare for aircraft to rely on justone sensor for almost any system whose failure could cause a crash. A sensor malfunction wasimplicated in the 2009 crash of Air France Flight 447, when an iced-up airspeed sensortriggered a series of events that caused the plane to plunge into the Atlantic.

“If your airplane needs such a Band-Aid, then it is incumbent on you to make sure it’s a goodBand-Aid,” said Frank McCormick, a former Boeing flight-controls engineer who became aconsultant to regulators and manufacturers before retiring.

The Boeing spokesman said the plane maker’s analysis determined that a pilot would be able toaddress the flight-control system misfiring with switches to counteract it or turn it off. “Singlesources of data are considered acceptable in such cases by our industry, and additional changesto the system were not deemed warranted,” he said.

An FAA-sponsored panel of international safety experts years ago concluded that crew trainingtended to stress that computers typically handle unusual situations more smoothly andeffectively than the pilots. “There is a natural reluctance to turn [systems] off, because it’s notclear what else is being turned off,” said Ray Valeika, a retired senior maintenance andengineering official at Delta Air Lines Inc.

Boeing is changing its approach to provide pilots with information about the sensors thatmeasure the angle of a plane’s nose.

Boeing 737 MAX airplanes were designed to be a fuel-ef�icient competitor to those of the company’s chief rival, Airbus. PHOTO:LINDSEY WASSON�REUTERS

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Boeing has long argued that such angle-of-attack information wasn’t necessary for crews tosafely operate aircraft, and that other data such as altitude and airspeed were more relevant.Over the years, a few carriers, such as American Airlines and Delta, have pushed Boeing toprovide its pilots additional angle-of-attack information, according to an airline official.

In the wake of the Lion Air and Ethiopian Air crashes, Boeing now is making the alerts standardon the MAX, rather than as a paid option.

Thepromisedsoftwarefixesforthe737MAXamount toreversal of

key Boeing design decisions in developing the plane. With the new software in place, the stall-prevention system will rely on data from two sensors, not one, and won’t activate if the datafrom those angle-of-attack sensors doesn’t match.

—Ben Otto, Jim Oberman and Elisa Cho contributed to this article.

Write to Andy Pasztor at andy.pasztor@wsj.com, Andrew Tangel at Andrew.Tangel@wsj.com,Robert Wall at robert.wall@wsj.com and Alison Sider at alison.sider@wsj.com

Appeared in the March 28, 2019, print edition as 'Boeing’s Zeal to Revamp 737 Left Pilots in theDark.'

A 737 MAX airplane on Boeing’s production line in Renton, Wash., in 2015. PHOTO: DAVID RYDER�BLOOMBERG NEWS