Congress statutorily mandated that the FAA commission an Expert Panel (EP) to examine what could be learned from the Boeing Max 8 disasters. The enabling statute specified that the independent study include 6 constituencies from which to draw: FAA and NASA (6),INDEPENDENT EXPERTS (2), individuals holding Organization Designation Approvals (4), airlines (4) and Unions (5).
The long study concluded recently and produces a 50 page report. Here are the EP’s recommendations:
These four observations are more akin to a Doctor’s listing of symptoms, NOT WHAT WAS THE SOURCE OF BOEING’S PROBLEMS- ANALOGY: DISEASE. Yes, there was a failure to communicate, but WHY ? The pretty SMS pamphlets contained all of the SAFETY CULTURE buzz wors, but the Unit Members feared RETALIATION, WHY? The “inadequate human factors” and “pilot input” are getting closer to a real diagnosis, but what was the source for Boeing’s fatal ommission?
SMS’ principles follow the wisdom of CORPORATE LAW- power starts at the Board room and the one who holds the Business Scepter is the Chair/CEO. The Members of that critical leadership group should have done more than approve some motion on SMS. Experts should have been brought in to a Board meeting and taken their valuable time to really know how this risk management approach works—
- understand the meta data that are the foundation of this discipline;
- become aware of the analytical tools that identify potential problems;
- hear a review of the SMS team’s process, especially the dialogue among the 360o perspectives, in setting PRIORTIES AND ACTION PLANS;
- meet with the safety critical organization in certification—the ODA which is designated to exercise the certification authority of the Administrator while assuring that the Agency staff is provided with the information involving new and/or significant risk;
AND
- Most importantly participate in the selection of the ACCOUNTABLE EXECUTIVE—the individual most responsible for EVERYONE of the EP’s list, MUST BE
- A visible point person who assures that SAFETY > PRODUCTION, that the QA/QC PARAMETERS are well designed and always faithfully executed (this should never be a target for LEAN manufacturing).
- A FAMILIAR FACE on the production line, who stops to ask questions and even probes when she/he perceives something which could be improved.
- A VOICE that speaks in small group meetings and reinforces the VALUE of submitting POSSIBLE RISKS to the SMS process and especially ideas that may enhance safety.
- A PERSON who intuitively understands WHEN and HOW BEST TO REWARD POSITIVE SMS behavior. Recognizes the individuals who. Even when action is not immediately adopted, the AE should make all know that the initiative is consnant with SMS.
- An EXPERIENCED professional (ideally an ENGINEER) who is familiar with the Boeing manufacturing processes, who has established trust with the Boeing ODA Unit and with the FAA office surveilling the process.
- One who knows at what are the PRESSURE POINTS on the hangar floor, in the QA/QC design office and among the design/test engineers. Time spent listening to these is a key to assuring that SAFETY CULTURE exists not just at inception points but 24/7/365.
- An INDIVIDUAL with the stature and expertise to come to the Board to report on the Good and BAD.
Proof that true Safety Culture exits will be marked when a Board member asks that the Chief Engineer and the AE to regularly attend and brief this corporate power point. This area is what is needed to return Boeing to its past allegiance to safety. Wall Street has shown the consequences of not holding SAFETY as the preeminent pronciple.
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