A Recipe for Disaster: A Boeing Case Study in Human Factors (Part 2)
A series of serious and sometimes fatal incidents involving Boeing aircraft in recent years – particularly the 737 Max disasters in Ethiopia and Indonesia – has seen the reputation of this once great American business almost completely destroyed.
In Part One, we looked at how the writing was on the wall for Boeing way back in 2003, when a memo released by anonymous Boeing engineers outlined failings by senior management and predicted these would lead to serious safety issues.
In this second and concluding part of our case study, we examine evidence of safety culture leading indicators using the “Dirty Dozen” human error preconditions, and consider how different Boeing’s future could have looked had their employees’ concerns been listened to and acted upon over 20 years ago.
Before The Fall
Before we look at the Dirty Dozen, it’s worth noting how highly regarded the Boeing brand was in the 20th Century. The business had a history of innovation and courageous decision-making, becoming “synonymous with technical excellence and integrity” [Serling, 1992].
Up until the late 1990s, the organization enjoyed a golden reputation as the trustworthy home of the world’s best engineers, with a workforce that was proud to be part of the business.
In 1997, Boeing merged with McDonnell Douglas, with leaders from MD taking high profile C-suite roles.
For many, this signalled the beginning of Boeing’s demise.
The Dirty Dozen
To fully assess the nature of the fall of Boeing, it is necessary to look at what is known within the aviation industry as the Dirty Dozen, which is the foundation of aviation human factors and safety training.
In this context, the Dirty Dozen refers to the 12 most common human error factors that act as precursors to incidents and accidents. These are the factors that influence people to make mistakes which, in aviation, can have catastrophic consequences. The list includes: Lack of Knowledge, Lack of Communication, Complacency, Lack of Resources, Stress, Lack of Teamwork, Lack of Awareness, Norms, Pressure, Lack of Assertiveness, Distraction, and Fatigue.
In this article, we dig deeper into the information contained in the 2003 memo from Boeing engineers which we summarized in Part One, to see if any of these Dirty Dozen were present at Boeing at the time. We quote directly from the memo in this Case Study.
1: Lack of Knowledge
This is the first of the Dirty Dozen human factors that contributed to lack of safety, and ultimately incidents and accidents. It’s clear from the Brain Drain reported in the Los Angeles Times in July 2003 and the memo of 2003 that its writers were concerned about the layoffs of talented American engineers and how they were being replaced by less experienced foreign engineers:
“Most engineers only have a cursory knowledge of [Boeing airplane configuration systems] and rely on local “experts”. The problem is that these local “experts” are becoming fewer and farther between, and their numbers are diminishing rapidly as lay-offs continue.”
Lack of Knowledge human factor present at Boeing? Yes
2: Lack of Communication
The memo is crystal clear about the problems caused by an influx of engineers from overseas, especially those based at the Boeing Design Center in Moscow.
Some of the problems outlined in the memo include the language barrier, time zone challenges, inability to discuss highly technical matters with engineers who had only a basic grasp of English, and the delays caused by the physical distances between engineers, meaning documents were taking days to reach Moscow when; “If the work was done within Boeing, it would only take 10 minutes to walk to Harry’s desk and drop off the document.”
Lack of Communication human factor present at Boeing? Yes
3: Complacency
The Boeing engineers behind the memo were clear in their concern that managers were treating the designing of airplanes like it was just another manufacturing operation, leading to reduced awareness of potential dangers:
“It is important to remember that Boeing’s commercial aircraft business is a bit different from the standard manufacturing company. Boeing designs airplanes – not washing machines, toasters or clock radios.”
Complacency human factor present at Boeing? Yes
4: Lack of Resources
The memo features many references to a lack of resources, which the writers say are the result of 40% cuts to the aircraft design budget instigated by Boeing management.
“Engineers are already forced to make unpleasant compromises with their design because of the shocking scarcity of resources – compromises that threaten the quality, safety and performance of the airplane.”
These cuts included engineering staff and led the writers of the memo to ask:
“How do these cuts affect a company in which airplanes are designed? Airplanes on which millions of people fly each year?”
Lack of Resources human factor present at Boeing? Yes
5 & 6: Stress and Lack of Teamwork
In Boeing’s case, the lack of teamwork was leading to stress among the engineers who were seeing colleagues lose their jobs and being left wondering if their jobs were at risk and their roles at Boeing being devalued:
“Engineers believe that management would like nothing more than to eliminate the entire Boeing engineering department.”
Stress and Lack of Teamwork human factor present at Boeing? Yes
7: Lack of Awareness
According to the memo, Boeing management were unaware of the vital role experienced engineers and their commitment to quality played in ensuring the safe operation of the company and its airplanes. To them, the management was simply forgetting the key pillars of technical quality and safety upon which the success of Boeing had been built:
“We are willing to state that Boeing’s management is “betting the company” on a misguided and ridiculous outsourcing plan that is gutting the company of its hard-won knowledge base and human assets.”
Lack of Awareness human factor present at Boeing? Yes
8: Norms
The elimination of engineering positions at Boeing continued well after the memo was released in 2003, with foreign contractors used for much of the work to save money.
A EuroNews report into the demise of Boeing published in 2024 revealed how Boeing’s engineers ended up being run by McDonnell Douglas’ hard-bitten veterans who were accountants, financial controllers, and other managers obsessed with cost savings.
The report also revealed that Boeing had no board member in charge of safety, unlike other manufacturers.
Norms human factor present at Boeing? Yes
9: Pressure
Given the amount of investment at stake in the airline industry, it remains one of the world’s most competitive sectors.
This was as true in 2003 when the memo was drafted as it is deeper into the 21st Century which has seen increasing demands for the aircraft industry to reduce emissions.
In 2016, GE announced a new LEAP engine, a more energy efficient but much larger airplane engine.
At the time, the design of Boeing’s B737 could not accommodate the LEAP engine which resulted in loss of customers to Airbus whose planes were able to use LEAP.
This left Boeing under pressure to redesign its 737 as quickly as possible to accommodate this new engine which was eventually introduced to the Boeing 737 Max in 2017.
However, the MAX was grounded worldwide between 2019 and 2021 following the crashes in Indonesia and Ethiopia (due to a new automated flight control feature, not the engines).
Subsequent investigations into both crashes determined that Boeing favored cost-saving solutions which led to a flawed design of this new feature.
Pressure human factor present at Boeing? Yes
10, 11 & 12:
Only three of the Dirty Dozen human factors appear not to be present at Boeing since the 2003 memo: Distraction, Lack of Assertiveness and Fatigue. But given that the presence of just one of the dozen is enough to raise serious safety concerns, the fact that Boeing has evidence of 9 of the 12 surely points toward substantial organizational disorientation.
A Final Twist
More internal messages between Boeing engineers have come to light since the memo of 2003. Many discuss the deep unease with the 737 Max and the problems experienced in flight simulators used to train pilots to fly the new jetliner.
One pilot said of the 737 Max, “This airplane is designed by clowns who are in turn supervised by monkeys.”