The deficiencies found in the report were in Just Culture and Reporting Culture.
The five Key Elements of Safety Culture are:
1) Informed Culture- the organization collects and analyses relevant data, and actively disseminates safety information.
2) Reporting Culture- cultivating an atmosphere where people have confidence to report safety concerns without fear of blame. Employees must know that confidentiality will be maintained and that the information they submit will be acted upon, otherwise they will decide that there is no benefit in their reporting.
3) Learning Culture- an organization is able to learn from its mistakes and make changes. It will also ensure that people understand the SMS processes at a personal level.
4) Just Culture- errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action.
5) Flexible Culture- the organization and the people in it are capable of adapting effectively to changing demands.
I'd note that financial markets driven reorganizations are antithetical to elements 1-4 and this explains how Boeing managed to have a culture of safety but lose it (it's often put as MD management took but an article a bit back showed that this was part of the Boeing CEO seeing the financial writing on the wall). Uh, and that happened "under the watchful eyes" of the FAA.
The opposite of 1-4 could be described as the "culture of lies, ignorance and fear". Fear is a good strategy for getting people working hard (if not always well) and lies make fear universal. Compartmentalizing information is needed to allow more and more functions to be subcontracted. If the company is extracting maximum value from it's assets this year, it has no incentive to report problems that will only appear in the future - by the time the future rolls around, the share holders have their and the shell of the remaining company can be tossed away. etc.
Also, another HN commentator mentioned how eliminating a culture of lies and retaliation is once it's in place. There's never a guarantee that those revealing a problem won't be punished once regulators turn their backs.
And 5 is only useful once 1-4 are in place. Otherwise, it's a culture of flexibly hiding your shit in different places.
Edit: This article was on HN a while back.
https://qz.com/1776080/how-the-mcdonnell-douglas-boeing-merg...
Key quote: These decisions, made by Boeing CEO Phil Condit, were made with a close eye on the company’s bottom line ahead of a hotly anticipated commercial-jet boom. An ambitious program of cost-cutting, outsourcing, and digitalization had already begun.
>> 1) Informed Culture
>> 2) Reporting Culture
>> 3) Learning Culture
>> 4) Just Culture
>
> I'd note that financial markets driven reorganizations are antithetical to elements 1-4
If this idea could be explored in depth, and more-or-less codified as received wisdom about market players, it would be a great contribution to management "science" and economics. My 0,02€.
I'm really at a loss on this news. All the employees at airlines in the US I know of have this drilled into them on a regular basis and it's just taken for granted that you report incidents when they happen (even when someone falls: report it!) and the incident will get investigated.
It just confounds me (but explains a lot) that the manufacturer of the aircraft the airlines operate does not share a similar safety culture given that they are in a similar ecosystem (airlines report issues to the manufacturer and the FAA/NTSB all the time)
Alignment of incentives. Airlines have fewer, smaller conflicts of alignment. Boeing is in a hurry to cash in on huge demand for single-aisle passenger planes before A320/1 or a stretch A220 fill that demand. It gets worse: The longer expansion of 737MAX production is delayed, the less demand. It doesn't just expire, it declines over time. Every sale delayed is also maintenance income delayed.
On top of that, Spirit Aerosystems was spun off so Boeing could demand higher production and lower prices, and fragment their assembly line workforce.
In this environment, when management has been hostile to their workers' unions, how are workers going to feel safe raising a red flag over "minor" production issues? You can't train for correct behavior when the incentives are so far out of alignment.
>> It also noted that employees do not understand how to use the different reporting systems and which reporting system to use and when.
As was noted by the purported insider, re: multiple overlapping systems of record/not-record, Boeing's actual processes themselves are badly in need of overhaul.
This feel like a clear example of where top-down + bottom-up independent read-back verification would have been useful.
I.e. management decides they're going to create Safety Process X using Systems A, B, and C. They do so, then circulate training (top-down). THEN you conduct independent interviews with employees at the bottom, to measure whether the new processes are understood at that level (bottom-up). If results aren't satisfactory, then add additional training or reengineer the processes.
Too often, it seems like this shit gets done at the VP PowerPoint level, and ground reality diverges without anyone noticing.
The map is not the world: interviews with a representative random sampling aren't hard.
Boeing has made numerous missteps in the last 15 years after being the world leader in airliners for around half a century. This only happens when knowledge about how to make a safe product is purposefully discarded and attempts to bring that knowledge back are intentionally ignored. In Boeing's case, it's due to desires for increased profits. They are unwilling to learn these lessons because it costs money that _may_ be there at quarter's end.
> errors and unsafe acts will not be punished if the error was unintentional.
No sane organization would ever implement this. If someone repeatedly makes mistakes, they're going to get fired even if the mistakes are unintentional. Anything else is going to cause more safety issues in the long-term as inadequate employees are allowed to proliferate.
This is just blameless post mortems and many, many many places implement this.
There are always going to be some level of "inadequate" employees, and also perfectly adequate employees that sometimes make mistakes in any organization and if your organization requires that no employees ever make mistakes in order to operate safely, then you have serious problems.
The purpose of a statement like that is that you don't just have a post-mortem that is like: "Our company went off the internet because an employee had a typo in a host name. We fired the employee and the problem is solved." When in reality the problem is that you had a system that allowed a typo to go all the way into production.
Just culture doesn't prevent you from firing someone who makes repeated mistakes.
In fact, Just Culture in itself provides the justification for this. As the next line says "However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action". A person who repeated makes mistakes is an unjustifiable risk.
You can really dumb it down to why didn’t you follow the checklist? If someone makes the same mistake after being corrected three times and the proper procedures exist for the worker to follow then the safety culture provides the structure and justification for their dismissal
Ideally, as a result of the post-mortem, the same mistake shouldn't even be repeatable, because mechanisms should be introduced to prevent it.
And if someone keeps making new original mistakes, revealing vulnerabilities in your processes, I would say that it is a very valuable employee, a lucky pen-tester of sorts.
I once destroyed $10k worth of aerospace equipment. I admitted it immediately and my only reprimand was that my boss asked me if I learned my lesson. (I did)
Who do you think came up with this rule, bleeding heart liberals’? Stop and think for a second, why does that rule exist?
You described a fantasy world, in the real world everyone makes mistakes, and if the mistakes are punished, then there are no mistakes because no one reports them. That is until the mistake is so catastrophic, it cannot be covered up- that’s how you get Chernobyl or Boeing max
If it's possible for an employee to unintentionally make the same mistake twice, that's purely management's failure. It's impossible to make systems completely fool proof, but once you know of a specific deficiency in your process you fix it. If you've corrected the issue, it should take deliberate effort for someone to do it again. An organization that knows its processes are deficient but makes no changes and expects a different result is insane.
I think the wording is clumsy, but this is analogous no-blame processes. The wording is just accounting for the possibility of wontonly malicious or recklessly negligent work quality. Think someone either sabotaging the product, or showing up to work very high or drunk.
Isn't this just confirming a seemingly widely held opinion that the safety culture started to break down after 1997 after the merger with McDonnell Douglas?
>Isn't this just confirming a seemingly widely held opinion
Yes-- this represents formal acknowledgement by a regulatory agency. The hope is that agency can now use this formalization to enforce change within Boeing.
Does anyone else share my wish that the result of this investigation was “poof no more Boeing”? I don’t understand why corporations can be fundamentally flawed and keep going, where a person in that situation would be prosecuted as a criminal. If Boeing has a bad safety culture because they keep investing unbelievable sums of money into stock buybacks and dividends, so much so that they don’t even have reporting culture… I don’t think they deserve a second chance, and frankly I think the shareholders deserve jail time so I really don’t care if they lose some money.
Yes, I know some pension fund somewhere is invested in Boeing. No, I don’t care. Will we ever solve corruption and climate change if we refuse to actually change our ways?
And, what, undo capitalism? The motivating forces here are profit, plain and simple. I've come to think that it's not only probable, but _inevitable_ that any growth-oriented, profit-motivated company (read: any company) will reach a point that their only remaining growth path is to undermine quality.
Really started when Congress decided they were supporting too many aerospace companies and some asshat got the idea that forcing some of them to merge would be a good idea.
Spreading manufacturing all over the US is also more to do with getting kore congressional districts “pregnant” than with national defense. In war you want multiple, as in redundant, supply lines so if one is cut, you can source matériel from somewhere else. What we have is multiple, as in single point of failure, supply lines. Lose one and everything collapses.
It's been covered for at least the last 5 years by many reputable news orgs. That HN link (you looked at the link right?) includes several refs, and a Google search dozens more.
This is the real problem with Boeing. The MCAS design fiasco and the door plug falling off were not isolated incidents, but symptoms of broader issues. I can only wonder what remaining hidden flaws aircraft currently in the air may have, and what they might cause in the future. Recently I had the option to fly on either 737MAX or 20 year old A319, and chose the latter option simply because I have more faith in safety culture at Airbus.
As long as maintenance is done properly there's nothing wrong with old aircraft, there are very well defined maintenance programs that specify which parts should be checked / changed and when. The airline in question is among the oldest in EU, and has an excellent safety record.
> The panel expressed concern that the confusion might discourage employees from reporting what they see as safety problems.
so who is opening bets that this was at least partially intentional?
Quite often when there are overly complicated reporting pipelines and people not knowing how to use them is because the company doesn't want you to report because that leaves a paper trail which could screw them over if they ignore it and something goes wrong.
Dieselgate is an example of what happens when managers are rewarded for achieving goals they haven’t been given the resources to achieve. When you promote people for achieving the impossible without investigating how they achieved it, that’s how you end up with superfund sites, pollution, or giant safety recalls.
They didn’t do what you asked. They found a way to cheat. And worse, their coworkers and reports know what they did, and see them getting rewarded. The “morally flexible” copy, and the boy scouts leave, or burn out.
Dieselgate started as far up the top of VWs fod chain as you can get: the CEO handpicked and protected by the god father himself, Ferdinand Piech. Well possible that Piech was involved in all of that as well. It started as a deliberate decision to limit AdBlue tank volume to safe money, and extend AdBlue usage to the point drivers didn't have to replenish themselves between inspections, which allowed VW to make more money on service.
That cheating was not engineers cutting corners to please management, it was engineers at the very top of management deliberately ordering the organization to cheat.
20 years ago nobody thought there'd be a another US automaker beyond the big three (Ford, GM, Chrysler)... yet today here we are with Tesla and a list of others.
Are there any other US companies today that could ostensibly be viable alternatives to Boeing's spot 20 years from now?
Electric-first-and-only was the differentiator for Tesla vs big three... what differentiator will it be in the aero industry?
In the US we have Cessna and Gulfstream, and in Canada we have Bombardier which designed and sort of made the CSeries/A220 in Alabama in conjunction with Airbus.
The whole Bombardier CSeries fiasco was basically Boeing using the US government to try to kill Bombardier because they had managed to put together a plane that was very competitive with with the 737-MAX in a number of categories. The takeaway though is that it is possible, with significant government support, for a small jet manufacturer to put up a feasible competitor to Airbus/Boeing.
Probably the biggest barrier to a new creating a new commercial airline manufacturer is that there just aren't that many new planes sold each year. There aren't that many customers for commercial airplanes, and existing airplanes can last for decades when properly maintained.
Combine all that with the inherently high costs of running a commercial airline manufacturer, and there just isn't enough demand to support more companies in the space. Changing that would require huge technical breakthroughs, or fundamental changes to how passenger air travel works. Neither of those seem to be likely in the near future.
Imagine you've spent 20 billion USD to develop, certify and create a production line. How you're going to convince airlines to buy hundreds of new planes they have no pilots for, no maintenance facilities and no predictions of reliability?
It'd be a business decision; it'd be hard to imagine a brand-new manufacturer of a competitor to the 737 doing well for that reason. But maybe a supersonic jet, or electric-powered with lower operating costs, or more automation to reduce pilot needs.. there are many ways to innovate.
The barrier of entry is much higher with commercial aviation. You can get started with a lousy car but a lousy plane will never be acceptable. The MAX fiasco could have killed Boeing. Maybe Boom will succeed by getting its feet wet in the supersonic flight niche. Time will tell.
Well, you could make a small plane if it's not lousy. Lilium and Electra are betting on something like an air taxi niche opening up if the fuel savings are worth it: https://www.electra.aero/https://lilium.com/jet
Boom is taking a Tesla approach to aerospace focusing on high end first with a Concord replacement. I am sure there are others working their way up the value chain
I'm not sure how big a differentiation it was. There are no haggle dealerships, a lot of people still need financing, and people still need to get their cars serviced.
Somebody, somewhere will make an electric jet that is good enough. It will be very destructive for the old manufacturers, for old airports, and for many airliners. It won't need the long airways we are used to so we will likely get more point-to-point like travel to/from city centers (multiple sites for bigger cities).
Longer-distance travel will still remain the remit of traditional jets -- but they will have a much smaller market so there won't be much R&D, except through state subsidies and military contracts.
The leaders of Boeing are clearly fumbling the ball, paying themselves more than ever, shitting on their labor and supply chain sub-contractors, all while costing ME as a taxpayer and occasional user more money and stress than ever.
Such a small group of leaders extracting maximum value for themselves at both the cost of the company, greater economy, AND the US Taxpayer sounds, I don't know... criminal?
Something that helps a lot: have a safety incident team with absolutely no connection to HR. They have no ability to fire anyone or report on your performance review, they don't talk to managers about people and just record and compile safety related issues. Yeah, you may have an employee or two who screams wolf a lot, but their job is just to investigate, fix the specific issue, anonymize, and aggregate the reports. This lack of connection should be very public so everyone feels comfortable talking to them.
This is part of how the FAA vastly reduced the fatality rate in GA. They stopped playing cop and started playing engineer.
I like the idea, but I am pessimistic. The more experienced I get (aka getting older), the more I see administrative bloating as the cancer of institutions---a somewhat equally inescapable fate. Installing a safety reporting administration may do what it set out to do, initially. But at some point, promotions may be handed out to those with most reports, perhaps perverting the initial intent.
In another thread I read that the EASA and FAA used to send Airbus/EASA engineers to Boeing (and maybe vice versa) who could raise all sorts of hell if mistakes were found. Such a setup seems perhaps harder to "game". I do not know this for a fact, I recall it from reading another debate, so take it as hearsay.
It's not that Boeing doesn't have any safety policies or procedures, it's just that no-one is aware of them, so nothing gets reported or fixed? Those findings are worse than you'd expect.. Wonder what it's like over at Airbus and Embraer.
As far as I know they have a very strict safety culture at Airbus. Living in Hamburg, close to their location there, made a factory tour once and met multiple employees during the years and had chats with them about general ways how things are done at the place.
But a few chats with employees and a factory tour isn't the most reliable source to judge this.
I read at least two different sets of problems in this report. But first, some background. In the following paragraphs you can substitute "safety" with "quality" in every instance to get equivalent statements that might be more analogous to your experiences.
There is big letter "Safety Culture". This is what happens when you study emergent behavior that you want to replicate, and try to systematize it as much as possible. For excample - as noted in the report, "Safety Culture" consists of 5 pillars - this categorization is purely the result of research and analysis and post-hoc reasoning. The point of "Safety Culture" is that we noticed some organizations that have (little letters) "safety cultures" or "cultures of safety" which were able to achieve long-term excellence in terms of safety, and decided to study their common elements. A company "implements" a big letter "Safety Culture" in hopes of inoculating and maintaining an actual "safety culture".
A Safety Management System is a tool used to achieve and maintain the Safety Culture. For those not sure of what "X management system" means - it's basically a stack of documentation that defines a meta-process and processes that all of your other processes need to conform to, and by doing so, your employees will be forced into "doing the right thing", and aligning their actions and outputs with the goals of Safety Culture, and therefore eventually getting you an actual culture of safety.
In the worst case when you fail at actually sustaining a real safety culture, an SMS then becomes a tool to enforce a minimal standard of safety, from even the most apathetic employee. This comes at enourmous cost of course. Anyone who has had to wait for 3 different authorizations to get a replacement computer at work has witnessed an analogous situation.
Another point that's relevant is that the "Safety Culture" model that Boeing (and ICAO) is referencing is acutally quite young compared to Boeing's overall age. The Safety Culture references in the report are from 1997. The first edition of the ICAO Safety Management manual is from 2006. Boeing has been building safe plans for decades before these "new fangled" capital letter things have even existed. It's absolutely possible for an organization to build safe product without formalized adherence to the formalized "Safety Culture".
Back to problems identified in the report:
The first is that Boeing rolled out a new Safety Management System (SMS) in the last 5-8 years, along with adopting "Safety Culture" policies. But they seem to have blotched the roll out. The report notes that Boeing has its legacy policies and processes for dealing with safety, and those continue in parallel to the new policies and procedures defined in their SMS. They also noted that employees were skeptical of the sustainability of the SMS - ie, they were not sure if this was just some management fad. Many of the findings about "lack of knowledge" read exactly as I'd expect from someone who apathetically clicked through an online training module because they assumed it was useless fluff, because all the real work they've ever seen was handled through legacy processes. Note that a blotched roll out is not the predestined result, even in an environment which was previously lacking a real safety culture, or even middling management.
This is a problem, but could maybe be tolerable (from the perspective of short-term safety), except for the fact that it seemed that that legacy backbone has been rotting away in terms of its effectiveness. The dual system surely isn't helping with its effectiveness.
In other words, while this report focuses on Boeing's failure to achieve "big letter" Safety Culture, reading between the lines also implies a general lack of actual safety culture, and a lack of competent change management.
Readit News
The five Key Elements of Safety Culture are:
1) Informed Culture- the organization collects and analyses relevant data, and actively disseminates safety information.
2) Reporting Culture- cultivating an atmosphere where people have confidence to report safety concerns without fear of blame. Employees must know that confidentiality will be maintained and that the information they submit will be acted upon, otherwise they will decide that there is no benefit in their reporting.
3) Learning Culture- an organization is able to learn from its mistakes and make changes. It will also ensure that people understand the SMS processes at a personal level.
4) Just Culture- errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action.
5) Flexible Culture- the organization and the people in it are capable of adapting effectively to changing demands.
Sources:
https://www.faa.gov/newsroom/Sec103_ExpertPanelReview_Report...
https://www.airsafety.aero/safety-information-and-reporting/...
The opposite of 1-4 could be described as the "culture of lies, ignorance and fear". Fear is a good strategy for getting people working hard (if not always well) and lies make fear universal. Compartmentalizing information is needed to allow more and more functions to be subcontracted. If the company is extracting maximum value from it's assets this year, it has no incentive to report problems that will only appear in the future - by the time the future rolls around, the share holders have their and the shell of the remaining company can be tossed away. etc.
Also, another HN commentator mentioned how eliminating a culture of lies and retaliation is once it's in place. There's never a guarantee that those revealing a problem won't be punished once regulators turn their backs.
And 5 is only useful once 1-4 are in place. Otherwise, it's a culture of flexibly hiding your shit in different places.
Edit: This article was on HN a while back. https://qz.com/1776080/how-the-mcdonnell-douglas-boeing-merg... Key quote: These decisions, made by Boeing CEO Phil Condit, were made with a close eye on the company’s bottom line ahead of a hotly anticipated commercial-jet boom. An ambitious program of cost-cutting, outsourcing, and digitalization had already begun.
If this idea could be explored in depth, and more-or-less codified as received wisdom about market players, it would be a great contribution to management "science" and economics. My 0,02€.
It just confounds me (but explains a lot) that the manufacturer of the aircraft the airlines operate does not share a similar safety culture given that they are in a similar ecosystem (airlines report issues to the manufacturer and the FAA/NTSB all the time)
On top of that, Spirit Aerosystems was spun off so Boeing could demand higher production and lower prices, and fragment their assembly line workforce.
In this environment, when management has been hostile to their workers' unions, how are workers going to feel safe raising a red flag over "minor" production issues? You can't train for correct behavior when the incentives are so far out of alignment.
>> It also noted that employees do not understand how to use the different reporting systems and which reporting system to use and when.
As was noted by the purported insider, re: multiple overlapping systems of record/not-record, Boeing's actual processes themselves are badly in need of overhaul.
This feel like a clear example of where top-down + bottom-up independent read-back verification would have been useful.
I.e. management decides they're going to create Safety Process X using Systems A, B, and C. They do so, then circulate training (top-down). THEN you conduct independent interviews with employees at the bottom, to measure whether the new processes are understood at that level (bottom-up). If results aren't satisfactory, then add additional training or reengineer the processes.
Too often, it seems like this shit gets done at the VP PowerPoint level, and ground reality diverges without anyone noticing.
The map is not the world: interviews with a representative random sampling aren't hard.
Boeing has made numerous missteps in the last 15 years after being the world leader in airliners for around half a century. This only happens when knowledge about how to make a safe product is purposefully discarded and attempts to bring that knowledge back are intentionally ignored. In Boeing's case, it's due to desires for increased profits. They are unwilling to learn these lessons because it costs money that _may_ be there at quarter's end.
No sane organization would ever implement this. If someone repeatedly makes mistakes, they're going to get fired even if the mistakes are unintentional. Anything else is going to cause more safety issues in the long-term as inadequate employees are allowed to proliferate.
There are always going to be some level of "inadequate" employees, and also perfectly adequate employees that sometimes make mistakes in any organization and if your organization requires that no employees ever make mistakes in order to operate safely, then you have serious problems.
The purpose of a statement like that is that you don't just have a post-mortem that is like: "Our company went off the internet because an employee had a typo in a host name. We fired the employee and the problem is solved." When in reality the problem is that you had a system that allowed a typo to go all the way into production.
In fact, Just Culture in itself provides the justification for this. As the next line says "However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action". A person who repeated makes mistakes is an unjustifiable risk.
And if someone keeps making new original mistakes, revealing vulnerabilities in your processes, I would say that it is a very valuable employee, a lucky pen-tester of sorts.
You described a fantasy world, in the real world everyone makes mistakes, and if the mistakes are punished, then there are no mistakes because no one reports them. That is until the mistake is so catastrophic, it cannot be covered up- that’s how you get Chernobyl or Boeing max
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See also: https://news.ycombinator.com/item?id=26417095
Yes-- this represents formal acknowledgement by a regulatory agency. The hope is that agency can now use this formalization to enforce change within Boeing.
Yes, I know some pension fund somewhere is invested in Boeing. No, I don’t care. Will we ever solve corruption and climate change if we refuse to actually change our ways?
Not sure if confirms the cause of those issues or where/when the infection took hold.
Spreading manufacturing all over the US is also more to do with getting kore congressional districts “pregnant” than with national defense. In war you want multiple, as in redundant, supply lines so if one is cut, you can source matériel from somewhere else. What we have is multiple, as in single point of failure, supply lines. Lose one and everything collapses.
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Everything Wendover Productions makes is so helpful!
so who is opening bets that this was at least partially intentional?
Quite often when there are overly complicated reporting pipelines and people not knowing how to use them is because the company doesn't want you to report because that leaves a paper trail which could screw them over if they ignore it and something goes wrong.
They didn’t do what you asked. They found a way to cheat. And worse, their coworkers and reports know what they did, and see them getting rewarded. The “morally flexible” copy, and the boy scouts leave, or burn out.
That cheating was not engineers cutting corners to please management, it was engineers at the very top of management deliberately ordering the organization to cheat.
Are there any other US companies today that could ostensibly be viable alternatives to Boeing's spot 20 years from now?
Electric-first-and-only was the differentiator for Tesla vs big three... what differentiator will it be in the aero industry?
In the US we have Cessna and Gulfstream, and in Canada we have Bombardier which designed and sort of made the CSeries/A220 in Alabama in conjunction with Airbus.
The whole Bombardier CSeries fiasco was basically Boeing using the US government to try to kill Bombardier because they had managed to put together a plane that was very competitive with with the 737-MAX in a number of categories. The takeaway though is that it is possible, with significant government support, for a small jet manufacturer to put up a feasible competitor to Airbus/Boeing.
Combine all that with the inherently high costs of running a commercial airline manufacturer, and there just isn't enough demand to support more companies in the space. Changing that would require huge technical breakthroughs, or fundamental changes to how passenger air travel works. Neither of those seem to be likely in the near future.
It would have to be a horizontal play by an existing company with large amounts of capital and relationships, like a Lockheed Martin or something.
Somebody, somewhere will make an electric jet that is good enough. It will be very destructive for the old manufacturers, for old airports, and for many airliners. It won't need the long airways we are used to so we will likely get more point-to-point like travel to/from city centers (multiple sites for bigger cities).
Longer-distance travel will still remain the remit of traditional jets -- but they will have a much smaller market so there won't be much R&D, except through state subsidies and military contracts.
Such a small group of leaders extracting maximum value for themselves at both the cost of the company, greater economy, AND the US Taxpayer sounds, I don't know... criminal?
Welcome to Techno-Neo-Feudalism. Your superiors are handling their own compensation quite nicely, thank you. Now get back to work !!
This is part of how the FAA vastly reduced the fatality rate in GA. They stopped playing cop and started playing engineer.
In another thread I read that the EASA and FAA used to send Airbus/EASA engineers to Boeing (and maybe vice versa) who could raise all sorts of hell if mistakes were found. Such a setup seems perhaps harder to "game". I do not know this for a fact, I recall it from reading another debate, so take it as hearsay.
But a few chats with employees and a factory tour isn't the most reliable source to judge this.
I read at least two different sets of problems in this report. But first, some background. In the following paragraphs you can substitute "safety" with "quality" in every instance to get equivalent statements that might be more analogous to your experiences.
There is big letter "Safety Culture". This is what happens when you study emergent behavior that you want to replicate, and try to systematize it as much as possible. For excample - as noted in the report, "Safety Culture" consists of 5 pillars - this categorization is purely the result of research and analysis and post-hoc reasoning. The point of "Safety Culture" is that we noticed some organizations that have (little letters) "safety cultures" or "cultures of safety" which were able to achieve long-term excellence in terms of safety, and decided to study their common elements. A company "implements" a big letter "Safety Culture" in hopes of inoculating and maintaining an actual "safety culture".
A Safety Management System is a tool used to achieve and maintain the Safety Culture. For those not sure of what "X management system" means - it's basically a stack of documentation that defines a meta-process and processes that all of your other processes need to conform to, and by doing so, your employees will be forced into "doing the right thing", and aligning their actions and outputs with the goals of Safety Culture, and therefore eventually getting you an actual culture of safety.
In the worst case when you fail at actually sustaining a real safety culture, an SMS then becomes a tool to enforce a minimal standard of safety, from even the most apathetic employee. This comes at enourmous cost of course. Anyone who has had to wait for 3 different authorizations to get a replacement computer at work has witnessed an analogous situation.
Another point that's relevant is that the "Safety Culture" model that Boeing (and ICAO) is referencing is acutally quite young compared to Boeing's overall age. The Safety Culture references in the report are from 1997. The first edition of the ICAO Safety Management manual is from 2006. Boeing has been building safe plans for decades before these "new fangled" capital letter things have even existed. It's absolutely possible for an organization to build safe product without formalized adherence to the formalized "Safety Culture".
Back to problems identified in the report:
The first is that Boeing rolled out a new Safety Management System (SMS) in the last 5-8 years, along with adopting "Safety Culture" policies. But they seem to have blotched the roll out. The report notes that Boeing has its legacy policies and processes for dealing with safety, and those continue in parallel to the new policies and procedures defined in their SMS. They also noted that employees were skeptical of the sustainability of the SMS - ie, they were not sure if this was just some management fad. Many of the findings about "lack of knowledge" read exactly as I'd expect from someone who apathetically clicked through an online training module because they assumed it was useless fluff, because all the real work they've ever seen was handled through legacy processes. Note that a blotched roll out is not the predestined result, even in an environment which was previously lacking a real safety culture, or even middling management.
This is a problem, but could maybe be tolerable (from the perspective of short-term safety), except for the fact that it seemed that that legacy backbone has been rotting away in terms of its effectiveness. The dual system surely isn't helping with its effectiveness.
In other words, while this report focuses on Boeing's failure to achieve "big letter" Safety Culture, reading between the lines also implies a general lack of actual safety culture, and a lack of competent change management.