Preventing Aviation Disasters; The Importance of Human Thinking

By Luke Wagner ‘27

The recent incident involving a fuselage blowout on an Alaska airlines 737 MAX 9 has brought a great deal of attention to the issue of aircraft safety. How safe is flying, and can it be made safer?

Two recent articles in the Wall Street Journal highlight a contrast between operational safety, which is excellent, and the safety of manufacturing practices, which have room to improve. 

On Jan 7, 2024, an Alaska Airlines 737 MAX 9 was climbing through 16,000ft shortly after taking off from Portland when a plugged emergency door blew off the plane, endangering the lives of passengers and crew. The skilled pilots were able to make an emergency landing back at Portland with no loss of life. 

What went right? 

The plane had been flying on a long-haul route to Hawaii just days earlier, but multiple pressurization alarms caused Alaska to move the plane off of lengthy flights over the ocean so they could quickly land if the warning came back. As reported in the BBC, ” ‘An additional maintenance look’ was requested but ‘not completed’ before the incident”. 

The outcome could have been much worse. As the plane was still climbing, all passengers had their seatbelts on and no one was moving around the cabin. If the plane had been at its cruising altitude (41,000ft) there was a very good chance of someone being sucked out of the plane during the depressurization following the door blowout. Also, the plane could have been flying over the ocean, where it would be impossible to make a quick emergency landing. NBC said, “no one was sitting in the window seat of the row directly next to where the part of the plane fell off, but a mom and son were in the middle and aisle seats of that row.”

Operational safety has improved over the decades

When people are afraid to speak up on safety issues, it can result in grave consequences. In Malcolm Gladwell’s famous novel “Outliers”, he observed that when it came to co-pilots from airlines in some parts of the world, the copilots felt unable to tell their superiors when they were doing something wrong – in contrast to Americans, where the copilots felt free to challenge their superiors. Gladwell’s book used two fatal plane crashes as examples. The first one happened when an airplane flying to Guam was coming in for a landing. The weather was not great, but this in itself did not cause the crash. As the runway could not be seen, distance measuring equipment was used. But, the captain had forgotten that the distance measuring equipment was on a hill next to the airport, not on the airport itself like most are. Also, the crew could have used their glideslope, which acts like a beacon to find the runway, but this device was out of order. The crew saw the runway through the clouds for a second, and turned the plane to go that way. The plane soon gave a 500ft warning, but at this point the crew could not see the runway. The first officer told the captain that because they could not see the runway, they should go around. The captain was slow to respond, and as the pilot was pulling up, they crashed into the side of a hill next to the airport. This crash could have been avoided, but in the culture where the crew was from, subordinates have to defer to superiors no matter what, so the first officers did not question the captain’s decision forcefully enough or soon enough. The results were deadly. 

Gladwell’s second example was when a plane flying from Bogotá, Columbia, was circling a busy New York airport, waiting to land. The plane was beginning to run dangerously low on fuel. The first officer was quite concerned and tried to make the captain understand that he needed to tell the air traffic controller more forcefully that it was an emergency and they needed to land immediately. The captain mentioned the low fuel to air traffic control after being told to go around again, but did not stress the danger of the situation. It sounded like an afterthought, so the controller did not act on it. The first officer tried again to tell the captain that it was an emergency, but the captain was intimidated by the NY air traffic controller as they are known to be pushy and in the culture where the captain was from, you cannot question superiors. Also, there was another cultural difference: In North America, it is up to the speaker to make sure the message they are trying to convey is clear. The pilot of the doomed plane was from a culture where the speaker gives polite hints and it is up to the receiver to figure out the true message. The result was a crash. 

These two crashes show that safety is a shared responsibility, and it should not be up to one person to account for all safety, as people make mistakes and their perceptions and decisions can be flawed. The important lesson from these crashes is that it is essential to question a superior if you think they are doing something wrong that could have a great impact, even if it does not feel very comfortable to do.

More good news:

To put the recent incident in perspective, look at the recent history of America’s airline safety record. It is statistically very safe. There has not been a single fatal plane crash from a major American airline in the past 15 years and counting. According to CNN, “…on average a person would have to travel by air every day for 103,239 years to experience a fatal accident,”. It wasn’t always that way. In the late 1900s, more and more fatal airplane crashes were happening, to the point where it was predicted that by 2015 a major crash would happen every week. Something had to be done. A new system was put in place. Before the new system, the crew would not report their mistakes for fear that they would get in trouble. As a result, even mistakes that led to crashes were not reported for fear of being reprimanded. The new system allowed air crew to report their mistakes without being punished for them. The result was the ability to learn from mistakes by sharing knowledge without fear of punishment. Over time the rate of fatal crashes slowed, then stopped. This is a system that should be used in other contexts, as it has many benefits. 

What went wrong?  The dangers of not prioritizing safety in manufacturing:

Back in 2018 and 2019, two fatal crashes resulting in over 340 deaths caused all 737 MAX 8 planes to be grounded for 2 years. The crashes happened because of a software glitch on the model. Now, after this recent Alaska airlines incident with the MAX-9, Boeing is being questioned on the safety of their manufacturing process. Now that the MAX-9s have been cleared to fly again, Boeing is hoping to ramp up production to keep up with Airbus, but the FAA is not allowing this, as per an article by the New York Times.

One reason for the recent Alaska Airlines blowout could be that in the early 2000s, Boeing started to outsource more of their parts to lower its costs. One of Boeing’s partners, Spirit Aerosystems, manufactures the door plugs and fuselage for the 737 MAX 9s. The plant where the fuselages are produced was owned by Boeing until 2005, when it was taken over by Spirit. In 2020, Spirit laid off many of its employees due to lack of demand because of the pandemic, but now more employees are needed and there are not enough. As a result, there are media reports of workers having to rush to meet unrealistic goals, and allegations that voicing concerns about safety is highly discouraged and sometimes even punished. This could mean that the likelihood of Boeing airplanes having defects is increasing. If so, this is something that needs to be fixed quickly, not unlike the crisis with American airplane crashes 30 years ago. 

Steps should be taken to bring manufacturing safety up to the same level as operational safety. One approach could be to apply the non-punitive system that led to improvements in operational safety, to the manufacturing process used in Boeing’s factories. 

In conclusion, air travel is quite safe but there is still room for improvement.