Safety is an important concept in the aviation industry because it underscores the need to protect passengers and crew against accidents. The quality of safety and risk management processes influence how flight operations are managed and how airlines respond to disasters (Vasigh & Fleming, 2016). Consequently, civil aviation authorities have embraced safety risk assessments as an important component of their flight management systems (FAA Aviation Safety, 2019).
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Their decisions are covered by risk management techniques that promote high levels of efficiency and industry performance (Vasigh & Fleming, 2016). Indeed, as explained by JATR (2019), the current safety risk management systems adopted in the aviation industry are formalised ways of managing flight hazards. The system is based on logical reasoning where the risks of flight operations are assessed against their potential benefits (FAA Aviation Safety, 2019). This analytical process involves different groups of stakeholders in the aviation sector, including pilots and regulators, who have to not only identify potential hazards in flight operations but also respond appropriately to emergencies and disasters (Silva & Hansman, 2015).
Broadly, safety risk management procedures in the aviation industry involve a three-pronged process that allows pilots to identify hazards, investigate the likelihood of impact on flight operations and minimising them to protect human life and financial loss (FAA Aviation Safety, 2019). Most safety procedures adopted in the aviation sector are associated with an analysis of flight failures and impact minimisation through reforms in education, training and regulatory compliance (FAA Aviation Safety, 2019).
However, they have not yielded desired outcomes because new risk profiles that have emerged through innovation change traditional risk management techniques (Silva & Hansman, 2015). Particularly, there has been a need to review the safety procedures used in pilot certification because recent air crashes involving Boeing have been attributed to human error (JATR, 2019). Particularly, concerns about the safety of Boeing’s 737-MAX aircraft provide a case study for understanding risk management processes in the aviation industry. This document reviews Boeing’s safety record, vis-à-vis the guidelines provided by the Federal Aviation Authority (FAA) on flight safety, to identify possible areas of reform that would improve airline safety.
Boeing’s Safety Record
America’s leading airline manufacturer, Boeing, provides a useful case analysis of risk management processes in the aviation sector because two of the most recently publicised air crashes in the aviation industry involved its aircraft – Boeing 737-MAX. In 2006, the Boeing 737-MAX was presented as one of the most technologically advanced aircraft in the aviation industry (JATR, 2019). It is a fourth-generation model that traces its roots to the Boeing 737 fleet of planes.
The first Boeing 737-MAX flight was completed in 2016 and soon after (in 2017), it received FAA certification (JATR, 2019). However, two recent crashes drew the world’s attention to the safety of the aircraft. The first one occurred in Indonesia, in October 2018, and the second crash happened in March 2019, in Ethiopia, killing everyone on board (JATR, 2019). Consequently, the aircraft has been grounded pending a comprehensive review of its safety record. The Federal Aviation Administration was forced to undertake investigations on the cause of the two accidents and their findings suggest that a malfunction of the aircraft’s anti-stalling system was the main cause of both crashes (JATR, 2019).
For a long time, Boeing has taken pride in achieving some of the highest safety records in the airline industry (Boeing Aerospace, 2019). However, the above-mentioned air crashes have cast doubt on the airline’s safety commitment (JATR, 2019). Notably, the Indonesian and Ethiopian air crashes have been attributed to the airline’s overestimation of a pilot’s ability to correct a malfunction of the system (Josephs, 2019). This view has been supported by the National Transport and Safety Board (NTSB), which has emphasised the need to review how pilots respond to alerts when there is a system malfunction (Josephs, 2019).
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Ironically, many existing regulations cover this area of compliance – pilot response to system malfunctions. For example, the NTSB has a set of guidelines for reviewing a pilot’s competence in flying, including an evaluation of human responses during an emergency (Josephs, 2019). Subject to the Indonesian and Ethiopian air crashes, the above-mentioned guidelines were “inadequate” in addressing the hazards posed by the innovative design of the Boeing 737-MAX’s operating system to the extent that they did not account for pilot responses.
A deeper analysis of Boeing’s safety record shows that key security features are often developed during the initial stages of network design (Boeing Aerospace, 2019). Indeed, the airline’s engineers boast of building aircraft that could operate under conditions that would not be deemed “normal” (Boeing Aerospace, 2019). Through airline design, they are also able to anticipate flight problems and minimise the probability of an accident occurring because of system upgrades (Boeing Aerospace, 2019). Boeing also uses the human factor engineering method that strives to minimise the impact of human error in flight operations (Griffin, Young, & Stanton, 2015). Most of their systems are designed to benefit from double or triple backups (Griffin et al., 2015).
Since studies have shown that 70% of all air crashes are caused by human error (Mabonga, 2015), Boeing has consistently focused on reducing human input in-flight procedures (Boeing Aerospace, 2019). However, this strategy has created a different problem of adjusting past processes with future outcomes. Human factor engineering processes adopted by Boeing focus on adjusting different metrics of aircraft safety performance, such as improving computer interface designs and flight deck operations, to improve safety (Griffin et al., 2015).
There are also human factor specialists that work to improve a pilot’s experience when flying by accounting for cognitive performance, physiological effects, visual perceptions and ergonomics in flight operations. Their main goal is to improve the quality of interaction between human input and machine output.
Although the above safety procedures have been adopted by Boeing to improve its safety compliance record, the company has still been unable to prevent air crash disasters. For example, its safety assessment of the Boeing 737-MAX was based on an erroneous assessment of a pilot’s flight response time (JATR, 2019). Therefore, there is a need to re-evaluate the airline’s risk assessment procedures based on a reassessment of the effects of all flight deck alerts on flight operations.
This technique highlights the need to review pilot training specifications and design changes to improve the minimum safety assessment procedures adopted by the company. Overall, safety is an important consideration for Boeing because it owes a duty to its shareholders to maintain the highest standards of compliance in the industry. This consideration is not only applicable to its aircraft but also its crew and pilots.
Most aviation rules and safety standards that should be observed by Boeing should be enforced by regulatory agencies because it is the latter’s job to enforce existing safety standards (Houle, 2015). For example, it is the government’s responsibility (through regulatory authorities) to undertake “check rides” to observe pilots during flights. They are also supposed to review airline training programs to make sure they are updated to current safety standards. There should also be an audit of maintenance records and airport security to account for all risk areas of flight operations. Boeing has an engineering and safety officer that undertakes this function (Boeing Aerospace, 2019).
FAA’s Safety Record
The rules and procedures developed by the FAA on aircraft safety have helped the regulatory body to enable the development of safe aircraft that have characterised the aviation industry’s exemplary safety record. Current statistics show that the FAA’s safety record has reduced air crash accidents to only one fatality per every 3,000,000 flights (JATR, 2019). Its US safety record is better because the average number of air crash fatalities is one in every ten years (JATR, 2019). Nonetheless, similar to other safety techniques designed by human beings, the FAA guidelines are imperfect. This attribute was confirmed in the two recent crashes involving the Boeing 737-MAX aircraft. Consequently, there has been a need to investigate whether improvements are warranted.
One of the most pertinent areas of concern for the FAA’s certification process is the inadequacy of rules guiding assessments. Similarly, it is believed that the Boeing 737-MAX was certified under a framework of out-dated rules and procedures (JATR, 2019). This gap in assessment revealed that the two recent air crash disasters involving the Boeing 737-MAX were products of several unrealistic attempts at solving complex safety problems (JATR, 2019).
This view is linked with the inability of pilots to respond appropriately to emergencies. Although the FAA has acknowledged weaknesses in its safety approvals systems, it recognises the need to embrace continuous improvement (JATR, 2019). Indeed, the lessons learnt from the two crashes (Indonesian and Ethiopian) provide the impetus for developing a new level of safety in the aviation industry.
One of the key issues in aviation security and risk management that emerged after the Indonesian air crash investigation was the need to review pilot training procedures to make sure that officers could manage the automated procedures linked with modern aircraft (JATR, 2019).
However, different countries around the world have varied pilot training procedures (Silva & Hansman, 2015). The US has among the strictest requirements of pilot training, such as the 1,500-hour rule that requires pilots to fly for the same number of hours before they are certified to fly a commercial airline (Josephs, 2019). The guidelines for flying are also partly informed by the levels of risk assessment underpinning flight operations. More importantly, pilots need to understand different levels of risk involved in flight operations because some emergency procedures are “low risk,” while others have a “high risk.”
The response accorded to each level of risk needs to be commensurate with the risk profile. FAA Aviation Safety (2019) also mentions this need through the deployment of flight risk assessment tools. It helps pilots to proactively identify hazards and visually depict each level of risk involved to develop the appropriate response. The risk assessment process should cover four key areas of flight safety operations: pilots, aircraft, environment and pressures (FAA Aviation Safety, 2019).
The theory of cockpit culture could be used a basis for understanding most pilot training review certification programs because it underscores the importance of an attitude shift in the manner pilots handle air safety disasters (Western Washington University, 2018). It has also been used to explain other aircraft disasters, such as the series of accidents that affected Air Korea in the 1980s and 1990s (Western Washington University, 2018). Investigators that examined these accidents found that most pilots were undertrained and often followed improper safety controls (Western Washington University, 2018).
These weaknesses in flight operations were linked to a culture of incompetence and a lack of accountability that affected the quality of decisions made by most pilots in the airline. This is why there has been a strong attempt to link pilot training programs with air safety culture. This relationship has been broadly covered using the ethnic theory of air crashes which presupposes that the demographic profile of pilots could be the single-most defining characteristic of plane crashes (Western Washington University, 2018). Therefore, the culture of origin affects how pilots respond to emergencies and how they implement risk management procedures.
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The recommendations highlighted in this report stem from three processes characterising risk management in the aviation industry: hazard identification, risk assessment and risk mitigation. Hazard identification involves the mentioning of factors that could affect flight operations. In the context of this case study, pilot training and certification emerged as the most significant risk factor for Boeing 737-MAX flight operations. The second step of risk assessment focuses on evaluating the potential for this risk factor impacting flight operations and causing a fatal accident. Based on the two crashes mentioned in this report, the risk profile for pilot training emerges as a top cause of concern.
This statement explains why there was a global grounding of the Boeing 737-MAX flights because there was evidence that the likelihood of a human interface problem impacting flight operations was significantly high. This statement leads to the third step of risk management, which is risk mitigation. It forms the basis for the recommendations highlighted in this report.
There is a need to modernise FAA’s certification processes to address safety and security processes of air travel. This proposal was made by JATR (2019) as part of a wider list of recommendations, which sought to understand the impact of complex aircraft systems on airline safety. Associated discussions have been contextualised to understanding the impact of such complexities on the FAA’s certification processes.
Part of the problem has been linked to the automation of flight operations and understanding how different information systems interact with one another (JATR, 2019). Indeed, as aircraft operations become more sophisticated and automated, it becomes increasingly difficult to make sure that all areas of compliance are addressed. This area of concern highlights one fundamental issue in air safety, which is the merit of tweaking a system that has been used for decades to maintain air safety standards. Particularly, the need to adjust safety risk management systems to address compliance and safety issues has been an important area of analysis and research.
Broadly, as systems become complex and user interfaces interact in previously inconceivable ways, there is a low possibility of FAA’s safety record to address all conceivable hazards. To the extent that it may be possible to address most safety issues, it is similarly difficult to ensure compliance and safety at the same time. In light of this concern, the JATR (2019) says that the safety of aircraft systems warrant the incorporation of fail-safe designs. These recommendations identify the need to increase airline safety through design changes and a declined reliance on pilot input, as a primary risk mitigation measure.
The two crashes involving the Boeing 737-MAX emphasise the need to achieve seamless connectivity of data across different information centres. Consequently, there is a need to account for the unintended consequences of transitioning from a benign system of communication to a more aggressive one (Federal Aviation Administration, 2019). Particularly, the effects of inadequate communication in understanding the impact of a software redesign on flight operations are still poorly understood.
If this statement was applied to the Boeing 737-MAX crashes, it is akin to using the software designed for regulating high-speed wind-up turns to minimising the pitch-up tendencies that caused the accidents. Therefore, the need for good communication emerges as an important adjustment to be made in FAA certification (Federal Aviation Administration, 2019).
Improved communications would ensure there is a proper understanding of certification requirements and in line with this observation, there is a need to review the FAA’s guidelines regarding the pilot response time during emergencies. Particularly, authorities should investigate whether existing standards are sophisticated enough to understand the complexity of today’s automated systems, or not. Furthermore, there is a need to review the implications of a faulty operating system on flight operations. Broadly, these changes could alter how the certification process addresses the impact of multiple failures or cascading alarms on pilot responses during emergencies. Coupled with the impact of the “startle effect,” it is equally vital to review how pilots respond to such emergencies.
The failure to respond appropriately to cockpit hazards draws attention to the theory of flight, as explained by the Flight Safety Foundation (2019), which discussed the inevitable consequences of flight. This theory suggests that several systemic processes have to be followed to safeguard flight safety (Flight Safety Foundation, 2019). The failure to adhere to these steps could ultimately lead to the loss of control of an aircraft (Flight Safety Foundation, 2019). Generic evidence shows that most pilots have been taught this principle but some of them fail to apply it until late in their careers (Flight Safety Foundation, 2019).
Overall, the findings highlighted in this study reveal that assumptions about a pilot’s capability to manage emergencies involving the Boeing 737-Max were factored in the aircraft’s design. The gap between Boeing’s assumptions about human involvement in managing emergencies and the real-world experiences of the pilots caused the two crashes described in this document. The presence of multiple alarms going off during an emergency was also highlighted by NTSB as a possible cause of workload surge which similarly affects the quality of decisions made by the pilots during emergencies (Josephs, 2019).
It can be deduced that the initial flight tests undertaken by the FAA significantly underestimated the risks involved in Boeing 737-MAX’s flight operations. This is why the pilots who flew the ill-fated aircraft did not respond to emergencies in the manner Boeing and FAA believed they should. Furthermore, the original tests were oversimplified because they failed to account for the impact of system alarms and alerts.
Boeing and FAA’s ultimate goal should be improving the level of interaction between human beings and machines. Globally, variations in pilot training standards, coupled with the degradation of manual flight operations, could yield varied responses in emergencies. The difference in pilot techniques to manage emergencies requires a commensurate change in regulatory attitude to account for its effects. So far, there has been little attention paid to this area of regulatory compliance because flight safety procedures are slow in adapting to technological changes that happen in the industry.
Broadly, the findings highlighted in this document show that air safety cannot be taken for granted because of its implications on human life and the performance of the aviation industry. Nonetheless, Boeing is expected to submit its software fixes for further approval from relevant authorities, such as the FAA. There are reports showing that the company is working with some pilots from selected aviation companies, such as United and American airlines, to test new software changes on the Boeing 737 Max to determine whether they improve the quality of air safety, subject to the findings of the Ethiopian and Indonesian air crash incidents (JATR, 2019).
Overall, there is a need to constantly monitor hazards impacting flight safety operations involving operations of the Boeing 737-MAX and other aircraft. The safety risk management report of the airline shows promise that the aircraft may be certified to fly again by the end of 2019 (in the US) and in early 2020 for Europe and other parts of the world.
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Griffin, T.G., Young, M.S., & Stanton, N. A. (2015). Human factors models for aviation accident analysis and prevention. New York, NY: Ashgate Publishing, Ltd.
Houle, P. D. (2015). The crash of Piedmont Airlines Flight 22: Completing the record of the 1967 midair collision near Hendersonville, North Carolina. New York, NY: McFarland.
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Josephs, L. (2019). Boeing overestimated pilots’ ability to handle misfires on 737 Max, NTSB says.
Mabonga, F. (2015). Introduction to aviation. London, UK: Author House.
Silva, S. S., & Hansman, R. J. (2015). Divergence between flight crew mental model and aircraft system state in auto-throttle mode confusion accident and incident cases. Journal of Cognitive Engineering and Decision Making, 9(4), 312-328.
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