This blog posting represents the views of the author, David Fosberry. Those opinions may change over time. They do not constitute an expert legal or financial opinion.

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Boeing Again Denies That The 737 Max Is Unsafe.

Posted on 11th May 2021

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I don't think this headline on the BBC is quite right. It should read "Boeing tries, and fails, to refute new safety concerns".

In one example of safety issues a 737 Max was on a flight from Boeing Field airport in Seattle, to deliver the aircraft to Brussels. After problems emerged, it returned to its point of departure. The article says "The aircraft landed safely shortly afterwards". Again, I think that is incorrect; just because it landed successfully does not mean it landed safely.

From a safety perspective the 737 Max is so broken as to not be worth repairing. The design was, from the outset, deeply flawed. No amount of "band-aid" will make it safe.

Boeing should bite the bullet and scrap the plane, and compensate the unfortunate airlines who bought them.

Boeing Again In Trouble For Unsafe Aircraft!

Posted on 11th May 2021

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As reported here by the BBC, Boeing is again under the spotlight for safety issues with their Boeing 737 Max planes.

This time it is an electrical problem, with potential effects on many systems. What is even more of concern is that there is a suggestion that this issue may have been involved in the failed sensors used by the AOA (Angle of Attack) system which caused the crashes of 737 Max planes.

As a result of the discovery of this latest problem, more than 100 Boeing 737 Max aircraft were grounded in April, and deliveries of new aircraft were stopped.

Boeing deemed that the change to manufacturing methods that led to the electrical faults was a "very minor change, so it was not notified to regulators". Again, this is not only a failure by Boeing, but also by the FAA.

Neither Boeing nor the FAA can be trusted to ensure the safety of air travellers.

Boeing pays $2.5 Billion fine, and now another 737 crashes!

Posted on 12th January 2021

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Just in case you were in any doubt that Boeing deliberately put profit ahead of air safety with the development and certification of their 737 Max, the company has just "agreed" to pay a $2.5bn fine for their conspiracy to do just that; in effect they have now admitted guilt.

To cap it all, this week came news of the crash of another Boeing 737 (this time not a 737 Max, but an older design), as reported here and here by the BBC.

Given the already massive impact of Covid-19 on the airline industry, and the fallout of the 737 Max crashes, Boeing will struggle to survive (although the US government is not likely to let them go bust).

When I next take a flight, I will certainly try very hard to ensure that I will not have to travel on a Boeing aircraft.

Boeing's "culture of concealment" to blame for 737 crashes

Posted on 27th September 2020

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As reported in this BBC article, the report on the crashes of the Boeing 737 Max is finally out, and it firmly blames both Boeing and the FAA (the US Federal Aviation Administration).

As was clear from Boeing's press releases on the subject, the aircraft manufacturer has a "culture of concealment". Given this is now established fact, why would any of us believe anything the company says in future? They have been more concerned with how things appear to the flying public than about the safety of their end customers.

The FAA also rightly comes in for heavy criticism, having failed in its duty off oversight and certification. The FAA only really has one responsibility, to ensure that aircraft are safe, and they failed to do so. In effect they colluded with Boeing's concealment of facts.

Now Boeing's reputation with airlines and the public is justly "in the toilet", as is the FAA's. There was a time when certification by the FAA was effectively simply rubber stamped by other certification authorities; those days are over, which will increase aircraft costs and delay the in-service dates of new planes.

Europe Sets Its Own Rules For The 737 Max To Fly Again

Posted on 6th September 2019

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As reported here, by the BBC, the European Aviation Safety Agency (Easa) has decided not to accept re-certification by the US FAA of the Boeing 737 Max.

Instead, Easa will run their own tests on the aircraft before approving its return to commercial flights. In addition they will insist:

  • On an "additional and broader independent design review" by Easa,
  • That the two fatal crashes were "deemed sufficiently understood"
  • And that flight crews have been adequately trained in any changes to the plane.

That is good news. Clearly, with all the revelations about the 737 Max, Boeing cannot be trusted to ensure safety, and neither can the FAA.

Boeing 737 Max Roundup

Posted on 17th July 2019

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The drama and scandal about the safety of the Boeing 737 Max continues. Here is a summary of some of the recent news stories on the subject. None of it makes me want to fly on a 737 Max.

In this BBC report Boeing's Dennis Muilenburg admitted "We clearly fell short and the implementation of this [cockpit warning light for the] angle-of-attack disagree alert was a mistake, right, we did not implement it properly". Based on other reports, that seems to be avoiding the truth. They made it an optional extra, for which airlines had to pay, and many airlines did not buy this option because they did not realise that it was essential to safely fly the aircraft.

This story on The Guardian, covers another safety issue, this time on the 787 Dreamliner. The switch used to extinguish engine fires has failed in a “small number” of instances. The switch also cuts the supply of fuel and hydraulic fluid to the engine, to prevent flames from spreading. Boeing has warned airlines that long-term heating can cause the fire extinguisher switch to stick in the locked position so it can’t be used to release the two fire extinguishers in each engine. Again, this is totally against the rules. Fire extinguishers are unarguable safety critical systems, and there is no system redundancy (such as a second switch or another way to operate the fire extinguishers) as required. Again, not only are Boeing to blame, but also the FAA.

This article on the BBC, about how the company is giving $100M to the families of the 737 Max crash victims, seems, at first, to show Boeing in a better light, until you read this piece, also on the BBC, describing how Being has been bullying the families of crash victims into signing an agreement that forfeits their rights to sue for compensation, thus preventing them from getting more money later, as more embarrassing facts about Boeing come to light.

Finally, for now, at least, is this BBC report about how Boeing seems to be trying to rebrand the 737 Max as the 737-8200. The worrying thing is that this may well work, with many air travelers. It looks to be that spending money and effort on safety is much less important than PR, for Boeing.

My general conclusion from all this is that Boeing planes are not safe, and not just the 737 Max (or 737-8200); that Boeing do not care about people affected by their lack of safety; that the FAA has the same disregard for safety as the manufacturers they are meant to regulate; and that most airlines are no better than Boeing and the FAA - they continue to order 737 Max aircraft, and are playing along with Boeing's attempts to side-step the consequences of their poor design and testing.

The 737 Max is a flawed design: am attempt to bolt new technology onto a very outdated aircraft, which has badly compromised the safety and flyability of the plane. It should probably never be allowed to fly again; I certainly don't want to be a passenger on one.

Boeing 737 Max - Boeing Finally Comes Clean

Posted on 5th June 2019

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In my previous post about the Boeing 737 Max I wrote about the rules that apply to safety critical systems.

As made clear in this article on CNN, Boeing neatly sidestepped these rules, by simply deciding that the Angle Of Attack (AOA) system was not safety critical.

The AOA system being treated as not safety critical meant that there was no requirement for redundant systems or sensors. The AOA system relies on only one sensor, even though two are fitted to the 737 Max. Even two sensors would not have been enough, because, in the case where one fails, it is not possible to decide which is correct and which has failed; three sensors are needed to build a proper redundant system.

Without a third sensor, the only option is to do what Boeing is now planning to do: disable the AOA system when readings from the two sensors disagree. I have to ask, why only now, after two crashes and many deaths? The FAA has received at least 216 reports of AOA sensors failing or having to be repaired, replaced or adjusted since 2004, so the failure mode behind the two crashes should have been noticed by Boeing and the FAA.

That is, however, not really the key issue here. More important is how on earth did Boeing get away with declaring a system which can crash a plan when it fails as not safety critical? Not only are Boeing to blame for this, but so are the FAA, for failed oversight.

Due to all the press attention on Boeing and the FAA in the wake of the crashes and subsequent investigations, more safety issues have come to light with then 737 Max, including faulty parts related to the leading edge slats. If these do not deploy when they should, the plane is at risk of stalling during take-off and landing.

Some people, including some airlines which own 737 Max aircraft, are hoping and even planning on the basis that the planes will be cleared to fly again in June or July this year. That seems to be extremely premature, given that the investigations are not yet concluded, and probably won't be until the end of 2019 or later.

I think that this debacle will mean that, in future, other aircraft regulators will be less eager to accept certification by the FAA as a basis for certification in other jurisdictions. I see that as a healthy development, although it will increase costs and delays in certifying aircraft, pushing up the costs of air travel.

Boeing 737 Max - How Is Aircraft Safety Ensured?

Posted on 14th April 2019

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There has been a steady drip-feed of news about the safety of Boeing's 737 Max aircraft since the Ethiopian Airlines crash. This report, on the BBC, looks at the possible effect of the two crashes, on Boeing.

Some readers may not know so much about how aircraft designers ensure that their planes are safe. Having worked in the avionics industry, I thought that I would explain some of the basic techniques.

Part of the news piece states that "The new anti-stall mechanism on the Max relied on data from one single sensor at the front of the aircraft". This would be against policy and design guidelines. For safety critical systems, including flight control systems, redundant systems, including redundant sensors, are required: normally 3 systems or components (like sensors), so that in the event of an error or failure in one, the output of two correct systems will be selected by a voting system. Reports from other news sources suggest that the Max has multiple angle of attack sensors; the issue seems to be deciding what to do when the sensors disagree, which just seems to be bad design.

Given that design, coding and construction errors will always exist in complex systems, how do aircraft companies avoid crashes? The answer is by doing failure modes analysis. Failure modes analysis is a laborious process in which engineers imagine all the possible things that could go wrong (including multiple different failures) and then analyse how the systems will react and cope with those failures. This technique requires people (cannot be automated, even by AI) with good imagination, even paranoia, as well as an understanding of all the systems involved. It is expensive and complex, and sometimes things get overlooked, which often eventually leads to people dying or being injured.

If a proper failure modes analysis had been done for the Max's anti-stall system, the impact of one or more failed sensors would have been identified, and the necessary redesign would have been performed, this eliminating the issue. While no failure modes analysis is simple, what would be needed for the anti-stall system is far simpler than many on an aircraft like the 737 Max. The obvious conclusion is that either the analysis was not done, or more likely it was done badly.

There are, of course, many other ways that safety is assured in aircraft and other safety critical systems:

Peer review of requirements specifications. The creating of executable requirements specifications. Prototyping of the systems, involving creating a program, independently of the final design that will be put into the aircraft, that fulfills some of the requirements of the actual system, albeit not as fast nor as completely as the final system. Peer review of designs. Peer review of code, electrical design and of mechanical design. Various different kinds of testing of system components, and whole systems.

Many companies have also dabbled in formal methods: the use of mathematically based languages and methods to achieve "right first time" design. I have worked with such methods and languages; they are not yet good enough.

There are two different perspectives used in the above: validation (did I build the right thing?) and verification (did I build it right?). The inherent flaw with most of the methods listed above is that they depend on people, so things may be missed or misinterpreted; sometimes things are, therefore, missed or misinterpreted. This is the reason for the interest in formal methods, to take people out of the equation, to some extent.

For safety critical systems like aircraft, nearly all the quality assurance methods listed above are mandatory (mandated by certification authorities like the FAA), although not formal methods, executable specifications nor prototyping.

The bottom line is that, despite the huge effort, and therefore cost, applied to making systems safe, there is always a chance that a dangerous error finds its way into a product. The cost of trying to assure safety in systems is normally the majority of the cost of creating those systems, and even this is not always enough.

The other basic problem is that projects are always delayed, and over budget. When this happens, testing and other verification and validation activities get trimmed: less time, and fewer resources. The results of this are inevitable: failures and accidents.

Cheap And Nasty Obstacle Avoidance System!

Posted on 16th April 2017

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I am very concerned about the news now percolating out about the crash of Rescue 116, which collided with Blackrock Island on 14 March. The latest report from the BBC (here) contains the very worrying information that Blackrock (an island which is well known because it has a lighthouse on it, and is therefore marked on all marine and air maps of the area) was not in the database of the obstacle-avoidance system installed on the helicopter.

Many people are probably now thinking "How terrible!" and yes, it is really dreadful that such a well known and well mapped obstacle was not in the system's database, and I am sure that someone is rushing to roll out updates to the databases of all such systems, but that is not what worries me. What concerns me is that an obstacle-avoidance system apparently relies only on a database of known obstacles; there doesn't seem to be any integration of radar data into the system.

Just look at the photo in the BBC report: the island is about the size of an aircraft carrier, and should be easily visible on radar from a long way off. Any useful obstacle-avoidance system should help to avoid not only fixed obstacles, but also mobile obstacles like ships and other aircraft. So, something is wrong: either the Irish coast-guard bought a cheap and nasty system which doesn't use radar data, or the radar was not working (either switched off, or not fit for purpose).

I began my professional career in avionics, so I do have some idea what I am talking about.

Either way, someone needs to be held accountable. In the meantime, I will not be volunteering to fly on any Irish coast-guard helicopters.

Rebels assumed civilian aircraft were avoiding the area

Posted on 20th July 2014

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Since I posted the comment about the Malaysian Arlines' jet shot down in Eastern Ukraine, I have found a new story from the Associated Press.

There is one very pertinent statement in their story: "the rebels ... had assumed civilian aircraft were avoiding the area and that anything in the air was hostile." Apparently information about this assumption was posted online before the shooting down of MH17, on social media, and therefore accessible to both airlines and air-traffic-control.

All this really begs the question: why did the people responsible for aircraft routing continue to assume that flights over the conflict zone were safe, in contradiction to the evidence available (and common sense)?

The main thrust of the AP story is that the rebels used only half of a missile system: only the SA-11 launcher, and not the central radar command to which is is meant to be connected. They apparently don't have the central radar command units, which help to identify the aircraft detected by the launcher's targeting radar (using, for example, IFF). This is a bit like driving a car that has no brakes.

Airlines divert flights away from eastern Ukraine

Posted on 18th July 2014

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This BBC story reports the crash of a Malaysia Airlines jet (flight MH17) carrying 295 people in Eastern Ukraine., probably shot down by the pro-Russian separatist rebels. In it, and also in this story, also on the BBC, is reported that the air route over the conflict zone in East Ukraine is now closed.

I do feel a little sorry for Malaysia Airlines, still suffering from the aftermath of the loss of flight MH370, which disappeared en route from Malaysia to China in March and still has not been found.

What really worries me is that airlines continued to fly over a conflict zone (there has been fighting there for quite a while) even after the shooting down of a Ukrainian military transport on 14th July 2014, as reported in this BBC piece.

People seem to have assumed that a commercial flight at 10,000m (about 30,000ft) would be out of range of any missiles that the rebels had, but the military transport was flying at 6,500m (21,325ft): if they have missiles that can reach 6,500m, they can also probably reach 10,000m. So why did the airlines and air-traffic control continue flying through this danger-zone when it was clear that the flights were at risk? Apparently saving a little money on fuel costs is more important than passenger safety.

I am sure that Malaysia Airlines will try to claim the cost of their lost aircraft on flight MH17, and the passenger compensation costs, from their insurance company. I do hope that the insurance company gives them a really hard time over that claim, because, in my opinion, it is at least in part Malaysia Airlines' fault.