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No Food for Thought

"Pilot Error"

admin Sunday December 20, 2020

The crash of Lion Air Flight 610 and the resulting 189 deaths raised quite a few questions. Understandably, a lot of suspicion went towards the plane's manufacturer. But Boeing had much luck in those circumstances; what better target for deflecting blame than dead pilots? And indeed, this crash was initially blamed on pilot error.

Unfortunately for Boeing, the flight had a few survivors: its flight recorders ("black boxes"). And with hundreds more equally flawed planes, 5 months later, when an equivalent failure caused a second "737 Max" crash, Boeing's cover-up blew up. In March 2019, an article by the New York Times already made the existence of MCAS (the Margins and Casualties Augmentation System?) public, and the technical causes of these catastrophes were already mostly known.

Ultimately, it's clear these catastrophes are attributable to governmental failure, after the FAA outsourced safety verifications... and not to independent parties, but to parties paid by manufacturers. Thankfully, Canada's government hasn't given up on all its responsibilities yet, as a remarkable The Fifth Estate episode shows. Congratulations to Terence McKenna and the CBC for managing to deliver such a remarkably both technical and emotional picture in just 24 minutes.

The episode from The Fifth Estate is a little too short to fully cover the technical issues, but I recommend others who are curious about these causes and who are passionate about software and security to read the IEEE Spectrum's How the Boeing 737 Max Disaster Looks to a Software Developer, a detailed explanation of the surreal design failures which culminated in these catastrophes. It would be sin not to thank Gregory Travis for writing an accessible explanation which is nevertheless comprehensive in all aspects, either technical (mechanics, redundancy, autopilot, user interface and engineering), historical, social, economic or political. Even though The Fifth Estate's episode had brought me to tears, Travis's careful writing and - having seen quite a few times in my own experience the same patterns he describes - his description of the accumulation of mistakes managed to give me a good laugh.

No bugs, but no design

Despite what the Times article and others may suggest, there is no real "error" which contributed to these crashes. Clearly no pilot error. But also, no defective line of code, nor any kind of software bug. The software behaved as it was intended to behave. All there is are a couple predictable sensor failures, and more importantly, systemic negligence. The wrong engineers influenced by the wrong managers, blind to the few who did manage to foresee what would happen. The wrong people managing critical systems, all under the watch of clueless (or partial) supervisors.

To make a parallel with wheeled vehicles, the "737 Max" is a motor vehicle with a single brake. There is nothing broken in cars which have a single brake. In 1900, owning one would surely have been a great privilege. In 2016 though, there were few ambulances relying on a single brake. And if a hospital was forced to rely on one, you'd expect paramedics driving it to be warned and trained to use it as a last resort only.

Lessons

As outrageous and irresponsible as all this may be, I am not an advocate of market intervention. Governments don't necessarily have to inspect and certify planes themselves. It is unavoidable for airlines to cause negative externalities at times. But if they do, those flying need to accept to internalize these risks. Airlines and governments should warn each passenger and crew member about the risk flying represents. And possibly prevent minors from flying on ridiculously unsafe planes.

Something needs to be done quickly to stop such patterns. Lives fly when you're crashBoeing.

2021-01 Update: Boeing Charged with 737 Max Fraud Conspiracy and Agrees to Pay over $2.5 Billion USD

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