A Recipe for Disaster: Boeing - A Case Study in Human Factors (part 1)
This year marks the 21st anniversary of an anonymous internal memo from Boeing engineers who wanted to state their human factors concerns and make their company’s damaging practices public knowledge.
Entitled ‘The Downfall of a Great American Airplane Company – An Insider’s Perspective’ we have access to the contents of this memo, which was allegedly written by highly experienced aerospace design engineers with “intimate knowledge of the inner workings of engineering at Boeing”.
The creators of the memo did not want to reveal their identities at the time for obvious reasons.
We are “in the trenches” every day, they wrote,
“involved in the nuts-and-bolts business of designing airplanes. We have a unique and in-depth insider’s view of the damage being sown at the Boeing Company by [CEO] Phil Condit and his cohorts.”
The memo contained many chilling statements, including:
“The safety and quality of Boeing airplanes is in jeopardy because of the foolhardy actions of Boeing’s senior management. Even the hint of safety and quality issues with Boeing’s airplanes can have disastrous results for its Commercial Airplane business.”
Why did these engineers feel compelled to write this memo? How come we have seen little if no further discussion about this matter in the intervening years, especially as much of what they predicted has come to pass?
Most of all, if they had been listened to in 2003, could lives have been saved?
The Context
It’s important to establish the context of this memo which was sent in 2003. Earlier that year in February, the Space Shuttle Columbia disintegrated during re-entry into the Earth’s atmosphere with the loss of all lives on board. Boeing engineers had been part of the Debris Assessment Team assigned to determine the extent of the damage caused by a debris strike on Columbia’s left wing sustained during take-off.
The team concluded that the Columbia crew would be able to return safely, a decision that was to have catastrophic consequences. At the time, a report in the Los Angeles Times, blamed the Boeing Brain Drain – a loss of key engineering talent from the business – on the flawed analysis of the Columbia situation.
The internal memo we are about to reveal stated that this Brain Drain was also affecting the commercial arm of Boeing’s business.
The Content
Airliners.net forum post: “Bombastic! Boeing Going Through an Internal Crisis’
Many aviation buffs are familiar with Airliners.net. What began as a site which posted pictures of airplanes, by the early 2000s Airliners.net was the go-to forum for discussing all things aviation. It was to this site in 2003 that a user named Ciro shared an internal memo allegedly written by disgruntled Boeing engineers. The memo is a warts-and-all assessment of the state of engineering at Boeing and the damage being inflicted by the severe cuts to its design engineering staff. The authors argued that by laying off highly experienced staff and hiring less experienced, cheaper engineers, Boeing was creating an environment in which the errors that can cause airline catastrophes are much more likely to occur.
The creators of the memo make several references to Boeing’s massive layoffs of American engineers and technical designers, and the management’s strategy of “offloading design work to foreign design centers,” including the Boeing Design Center in Moscow, causing the company to lose control of its engineering processes.
The memo states: “Based on Russian commercial aviation history, do we really want to fly a commercial airplane designed by Russian engineers?” Key problems associated with using Russian engineers to design Boeing airplanes are then outlined in the report, focusing on their:
“Lack of experience designing airplanes.”
“Inability to speak English well enough to have an in-depth technical conversation.”
“Inability to take initiative and to come up with creative solutions.”
The writers strike a more conciliatory tone by adding,” It wouldn’t be fair to omit the fact that Airbus has also opened a Design Center in Moscow. However, the main difference between Airbus and Boeing is that Airbus is smart and doesn’t intend to have the Russians do primary systems and structures design, instead limiting them to interiors work. Airbus isn’t willing to give away the “crown jewels”.
The memo goes on to state that people only had “to look back less than a decade to see where the current senior managers at Boeing are leading the business – to the once glorious McDonnell-Douglas Commercial Aircraft division which has since faded into oblivion. “
Throughout the memo, grim predictions about the future of the company are made, such as:
“Soon Boeing may reach (if it hasn’t already) a “point of no return” where irreversible damage has been done to the company’s ability to design and build safe airplanes.”
“[Boeing management is] pursuing a strategy of accumulating a network of “risk-sharing partners” so Boeing can concentrate on its core competency of “large scale systems integration.”
“At what point do Boeing’s suppliers decide that they no longer need Boeing?”
“The engineers with 20 or more years at Boeing are stoically waiting for that golden day when they will retire and wash their hands of the mess that Phil Condit and Harry Stonecipher have created.”
The memo concluded:
“The Boeing Company is headed down a dark and dangerous path. The safety and quality of Boeing airplanes is at jeopardy because of the foolhardy actions of Boeing’s senior management.”
The Reaction
It has to be stated that the reaction to the memo from some of the engineers who received it (both within and outside of Boeing) was mixed:
“No offense, but that’s written by some very disgruntled employees. To believe it, would show a very high degree of ignorance. I’ll leave someone with more time to go through and refute most of the hogwash….”
“A passionate argument made by persons with a passionate interest in protecting their jobs. I truly take offense (and find unprofessional) the suggestions that safety is being compromised. Any employee making that suggestion could and should be terminated on the spot.”
“Some sadly familiar complaints there, related to outsourcing generally – one day soon I hope somebody will write a chapter in a Management Handbook entitled “You Pay Peanuts – You Get Monkeys”.
“The document was well written, and clearly documents individual elements which are excellent points. Unless you personally work for BCA, or anyone else here, my guess is there’s not a single one of us qualified to refute or validate any of the contents.”
“What´s written in there may to some extent be frustration, but looking at the world as it is today there´s some truth in it: product quality is deteriorating if you let unexperienced youngsters do what professionals did before.”
“This insider “statement” has LABOR UNION written all over it. I’ve got news for them…if they accepted competitive salaries instead of organizing and demanding almost twice what engineers at other US companies make (according to a friend who’s an engineer at Boeing), then I guarantee all those jobs would have stayed right here in the USA! Unions are a killer of American jobs. Steel industry, auto industry, and now the airplane industry. Such a shame.”
The Benefit of Hindsight
What’s chilling looking at the content of the memo over two decades later – especially in the light of the 737 Max disasters – is how those engineers knew what was coming for Boeing, stating that the actions of the commercial airplane division were ‘seriously jeopardizing the quality and safety of its airplanes.’
The creators of the memo also pointed out how little discussion there had been in media about the matter at the time, something that has prevailed in the years since.
“Perhaps this story is not newsworthy,” the memo writers’ state. “However, everyone with whom we have spoken has been… let’s say “shocked” (although that does not do it justice) … when told of what is going on. We are not prone to exaggeration. We are engineers. We live and breathe logic and facts. We are witnessing first-hand the destructive effects of Phil Condit’s “Vision 2016”. There may not be a Boeing Commercial Aircraft Company in 2016 because of Phil Condit.”
Coming Up…
In Part 2 of our Case Study, we look at how the cracks of organizational disorientation were already apparent at Boeing 21 years ago when the memo was published. And we ask, if Boeing employees had been listened to back in 2003 and those insights had been acted upon, could Boeing’s downfall have been prevented?
A Final Twist
Phil Condit’s tenure as Boeing CEO was to end the very same year the memo was released, although his resignation was not connected with safety but as the result of an internal investigation into a procurement matter.