How to avoid a safety downfall

By Mark Jones

I wasn’t expecting “Downfall: The Case Against Boeing” to be particularly relatable to my life, but I found some surprising resonance with my experiences as an industrial chemist. The documentary tells the story of the 737 Max defects that led to two tragic crashes. The filmmakers detail the technical issues but spend far more time talking about the cultural issues within Boeing. They present a compelling case that cultural issues led to putting a flawed plane into service. A safety- and quality-centered culture was replaced by a business-centered culture.

I was indoctrinated with safety within the chemical industry and with the concept of layers of protection. A process is never designed where a single point of failure can lead to catastrophe. But Boeing did this. The failure of one angle of attack sensor sent the Maneuvering Characteristics Augmentation System (MCAS) into maniacal efforts to force the nose of the plane earthward. A safety-critical system had a single failure point.

Corporate culture is a term that is often thrown around. It covers things from whether the CEO wears short sleeves, to whether office doors are left open, to how rapidly employees must answer emails. To the credit of my long-term employer, through all the corporate upheavals, management never stopped reinforcing safety as the number one priority. There were safety stand-downs. Safety signs were in all the halls, even in the corporate center. Safety reinforcing tags were worn with your ID. All were clear signals sent by management to every employee not to shirk safety. Unlike Boeing, the chemical industry (or at least the part I lived in) never forgot that safety was non-negotiable.

Downfall drives the point that a singular focus on business changed the Boeing culture. A culture built up, brick by brick, year by year, can come tumbling down pretty quickly. Entropy is powerful. I observed some erosion but never a collapse of the safety culture. I frequently worked at high pressure, with flammable and toxic materials, using automated systems that operated 24/7. When I started, the safety pre-startup inspection was a major event. Inspections would begin in a conference room with a detailed presentation on the chemistry and hazards to a collection of peers. We’d move into discussion of how the risks were handled and the layers of protection we stood behind before giving the equipment and control systems a thorough once-over. Inspections could take hours. By the point in my career where I left the lab, these were considerably reduced. Standardized checklists had replaced more detailed peer-to-peer discussions. The time we were spending, it was conjectured, was not adding value. We could be more efficient and reach the same goal.

The danger of erosion is that you don’t know what it will uncover. You likely won’t know the limit has been pushed too far until something bad happens. To date, I’m unaware of any bad outcomes of the efficiency movement I witnessed. Boeing didn’t see the erosion of their safety culture until it contributed to the tragic crashes.

Boeing sadly now stands as a cautionary tale. The utility of cautionary tales is that we learn from them, hopefully avoiding the mistakes made by others. Boeing employees were confronted with time and cost concerns similar to those faced by many. All must remember that safety truly comes first. Without that mindset, the whole enterprise is at risk.