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Boeing-737-MAX.png"The airline probably needed to do a better job to make sure its pilots understood exactly what to do in case the aircraft was performing in a unique, unusual way, and how to get out of the problem," former National Transportation Safety Board chair Mark Rosenker tells CBS News in the recent documentary Downfall: The Case Against Boeing (directed by Rory Kennedy, written by Mark Bailey and Keven McAlester, and streaming on Netflix). He then downplays the risk to passengers: "Certainly in the United States they understand how to operate this aircraft."

Rosenker was speaking soon after the 2018 Lion Air crash.

Three oh-my-god wrong things here: the smug assumption that *of course* American personnel are more competent than their Indonesian counterparts (see also contemporaneous articles dissing Indonesia's airline safety record); the presumption that a Boeing aircraft is safe and the crash a non-recurring phenomenon; and the logical sequitur that it must be the pilot's fault. All that went largely unchallenged until the Ethiopian Airlines crash, 19 weeks later. Even then, numerous countries grounded the plane before the US finally followed suit - and even *then* it was ordered by the president, not the Federal Aviation Authority. The FAA's regulatory failure needs its own movie.

As we all now know, a faulty attack sensor sent bad data to the aircraft's Maneuvering Characteristics Augmentation System, software intended to stabilize the plane. The pilot did his best in an impossible situation. Even after that became clear, Boeing still blamed the crew for not turning off MCAS. The reason: Boeing didn't tell them it was there. In Congressional testimony, the hero of the Hudson, Captain Sully Sullenberger, summed it up thusly: "We shouldn't expect pilots to have to compensate for flawed designs."

This blame game was a betrayal. One reason aviation is so safe is that all sides have understood that every crash damages everyone. The industry therefore embraced extensive cross-collaboration in which everyone is open about the causes of failures and shares solutions. Blame destroys that culture.

All of this could be a worked example in Jessie Singer's recent book There Are No Accidents: The Deadly Rise of Injury and Disaster - Who Profits and Who Pays the Price. Of course unintended injuries happen, but calling them "accidents" removes culpability and stops us from thinking too much about larger causes. "Accident" means: "nothing to see here".

With the 737 MAX, as press articles suggested at the time and the documentary shows, that larger cause was the demise of Boeing's pride-of-America safety-first engineering culture, which rewarded employees for notifying problems. The rot began in 1997, when a merger meant new bosses from McDonnell Douglas executives arrived, and, former quality manager John Barnett tells the camera, "Everything you've learned for 30 years is now wrong." Value for shareholders replaced safety-first. Employees were thinned. Planes were made of cheaper materials. Headquarters left Seattle, where engineering was based, for Chicago. The culture of safety gave way to a culture of concealment.

Aviation learned early the importance of ergonomic design to avoid pilot error. This is where the documentary is damning: Boeing's own emails show the company knew pilots needed training for MCAS and never provided it, even when directly asked - by Lion Air itself, in 2017. Boeing executives mocked them for asking, even though its own risk assessments predicted a 737 MAX crash every fifteen years. Boeing bet it could fix, test, and implement MCAS before it caused more trouble. It was wrong.

A fully-loaded plane crash makes headlines and sparks protests and Congressional investigations. Most of the "accidents" Singer writes about, however - traffic crashes, house fires, falls, drownings, and the nearly 840,000 opioid deaths classed as "unintentional injury by drug poisoning" since 1999 (see also Alex Gibney's Crime of the Century) - near-invisibly kill in a statistical trickle. One such was her best friend, killed when a car hit his bike. All these are "accidents" caused by human error. But even with undercounts of everything from shootings to medical errors, the "accidents" were the third leading cause of death in the US in 2019, behind heart disease and "malignant neoplasms" (cancer), ahead of cerebrovascular disease, chronic lower respiratory disease, Alzheimers, and diabetes. We research all those *and( covid-19, which was number three in 2020. Why not "accidents"? (Note: this all skews American; other wealthy countries are safer.)

Singer's argument resonates because during my ten years as the in-house writer for RISCS, then-director Angela Sasse argued repeatedly that users will do the secure thing if it's the easiest path to follow, and "user errors" are often failed security policies. Sometimes, fixes seem tangential, such as lessening worker stress by hiring more staff, updating computer systems, or ensuring better work-life balance, which may improve security because tired, stressed workers make more mistakes.

Singer argues that the human errors that cause "accidents" are predictable and preventable, and surviving them is a "marker of privilege". Across the US, she finds poverty correlated with "accidental" death and wealth with safety. The pandemic made this explicit. But Singer reminds that the same forces frame people crossing the street as "jaywalkers" and blame workers killed on factory lines for not following posted rules. Each time the less powerful is framed as the cause of their own demise. And so it required that second 737 MAX crash and 157 more deaths to ground that plane.

Illustrations: The Boeing 737 MAX (Boeing).

Wendy M. Grossman is the 2013 winner of the Enigma Award. Her Web site has an extensive archive of her books, articles, and music, and an archive of earlier columns in this series. Stories about the border wars between cyberspace and real life are posted occasionally during the week at the net.wars Pinboard - or follow on Twitter.


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