The mythical Cassandra was cursed with the gift of accurate prophecy that would never be believed. She correctly warned her people that their enemy was hidden in the Trojan Horse, but they ignored her warnings and Troy fell.
Aviation safety relies on detailed research, the testing of assumptions, and a healthy dose of skepticism that prompts closer scrutiny of claims. As we look through accidents over the years, the root cause is not often intentional malfeasance. Rather, something seemingly small, easily overlooked, a situation considered unlikely, or difficult to foresee human factors led to disaster. Ensuring safety requires some pessimism. Engineers, regulators and management always have to consider the worst case scenario. That’s why aerospace companies need to nurture their naysayers – their in-house Cassandras.
In aviation, we can root out the obvious points of failure, and we’ve become good at considering other contingencies through standards for testing, but it takes many minds to consider all of the repercussions of complex design. If those who suspect a failure don’t speak up, then risk is multiplied. Aviation industry manufacturers have a challenge before them to think of the unthinkable and disprove it. It’s not an easy task and it can be expensive. One way to address these costs is to assign in-house or outside experts – Cassandras – to actively search for trouble earlier in the development process.
We see this approach in digital research and development, particularly in cyber security, where companies will recruit individuals to find fault with their systems, exploiting any opportunities that occur to them, no matter how unlikely.
The structure of aviation engineering, quality control, regulatory oversight and management should foster a similar dynamic. There should be – as there has previously been, in my experience – a healthy level of skepticism when reviewing assumptions and assertions made in the development and certification process.
There needs to be individuals in these organizations, particularly in quality control, engineering, and production who are empowered to look for trouble and be rewarded for finding it. It is the job of management in aviation to find the organization’s Cassandras and listen to them.
Without developing this pool of skeptics, the aviation industry is more vulnerable now than it has been in many years. As we move towards performance-based regulation, with manufacturers influencing the decision-making of the regulations that govern them, and helping to draft the standards of the products they produce, it is vital that there are skeptics in all organizations who can avoid confirmation bias.
Findings of the Joint Authorities Technical Review (JATR) team suggest that Boeing did not consider the impact of multiple changes to the 737 MAX aircraft – both structural and digital – because they were not thought to have an impact. The testing process thus only served to confirm performance expectations of the aircraft based on a stack of assumptions that ‘grandfathered’ design from prior-generation aircraft would hold up in the new and significantly different aircraft.
This is not the first time that Boeing has had a blind spot for tests that could have revealed problems for equipment. The NTSB found that the airframer also failed to consider a risk of thermal runaway propagating through cells caused by an internal short circuit of the 787 Dreamliner’s lithium-ion batteries, and did not design tests with the battery manufacturer accordingly.
But this is not to single out Boeing. The vulnerability of limited perception of risk affects all of aviation. The challenge is that Boeing, because of its position in the industry, sits on many critical rulemaking committees and working groups, including the FAA’s Aviation Rulemaking Advisory Committee (ARAC). This puts Boeing in a position to influence new regulation. That, on its own, is not problematic. After all, regulators need manufacturers to participate in the process and share insights on products. But companies with this level of influence should be the first to foster Cassandras and they should at all times maintain a direct line of communication with the FAA and other regulators.
It is for this reason that the recent revelations of the process of review and approval for the Boeing 737 MAX are so disconcerting. Boeing should hold itself to the highest standards in scrutinizing its work product, fostering a corporate culture that encourages employees to speak out when something is wrong, and being transparent with regulators on developments affecting its operations.
There are changes underway at Boeing, including at top management, but the most significant change is perhaps the company’s announcement of organizational changes that will address concerns over pressure placed on Boeing employees responsible for safety.
Can any corporation be trusted to do the right thing on its own? It would be naive to say yes. However, constant vigilance in the aviation industry is part of self-preservation. It only takes a quick look around to note that, with consolidation, the industry is critically interdependent. Just like a complex aircraft system, an unexpected failure can have deep repercussions for the industry as a whole. To put it simply, the aerospace community cannot afford not to address the worst-case scenario.
Certificate-holding manufacturers have made a contract with regulators and with the flying public that they will build products which can be relied on to operate safely. While there is always a possibility that something unexpected will go wrong, it is the manufacturer’s obligation to thoroughly consider the implications of design, test assumptions, and go beyond minimum compliance, taking whatever actions are required to address and resolve known risk factors while keeping regulators in the loop.
The justification used for moving towards performance-based regulations is that much of the expertise required to draft standards for testing and manufacturing aviation products is at the manufacturer, which has greater resources available for research, development and testing than regulators. If manufacturers do not apply those resources, if they hold to minimum standards which they helped set up, while dismissing their Cassandras’ predictions as too unlikely, they are laying the foundations for tragedy.
Safety isn’t a wish. It’s a practice. It is a science. It requires skepticism. It requires proof.
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