The oft-quoted statement of George Santayana comes to mind: "Those who cannot remember the past are condemned to repeat it."
From today's New York Times—offer safety as an "option," for a price, then if the option is not purchased, blame the pilots for the outcome...
How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’
After a Boeing 737 crashed near Amsterdam more than a decade ago, the Dutch investigators focused blame on the pilots for failing to react properly when an automated system malfunctioned and caused the plane to plummet into a field, killing nine people.
The fault was hardly the crew’s alone, however. Decisions by Boeing, including risky design choices and faulty safety assessments, also contributed to the accident on the Turkish Airlines flight. But the Dutch Safety Board either excluded or played down criticisms of the manufacturer in its final report after pushback from a team of Americans that included Boeing and federal safety officials, documents and interviews show.
A review by The New York Times of evidence from the 2009 accident, some of it previously confidential, reveals striking parallels with the recent crashes — and resistance by the team of Americans to a full airing of findings that later proved relevant to the Max.
In the 2009 and Max accidents, for example, the failure of a single sensor caused systems to misfire, with catastrophic results, and Boeing had not provided pilots with information that could have helped them react to the malfunction. The earlier accident “represents such a sentinel event that was never taken seriously,” said Sidney Dekker, an aviation safety expert who was commissioned by the Dutch Safety Board to analyze the crash.
Dr. Dekker’s study accused Boeing of trying to deflect attention from its own “design shortcomings” and other mistakes with “hardly credible” statements that admonished pilots to be more vigilant, according to a copy reviewed by The Times.
The muted criticism of Boeing after the 2009 accident fits within a broader pattern, brought to light since the Max tragedies, of the company benefiting from a light-touch approach by safety officials
Some of the parallels between that accident and the more recent ones are particularly noteworthy. Boeing’s design decisions on both the Max and the plane involved in the 2009 crash — the 737 NG, or Next Generation — allowed a powerful computer command to be triggered by a single faulty sensor, even though each plane was equipped with two sensors, as Bloomberg reported last year. In the two Max accidents, a sensor measuring the plane’s angle to the wind prompted a flight control computer to push its nose down after takeoff; on the Turkish Airlines flight, an altitude sensor caused a different computer to cut the plane’s speed just before landing.
Boeing had determined before 2009 that if the sensor malfunctioned, the crew would quickly recognize the problem and prevent the plane from stalling — much the same assumption about pilot behavior made with the Max.
And as with the more recent crashes, Boeing had not included information in the NG operations manual that could have helped the pilots respond when the sensor failed.
Critically, in the case of the NG, Boeing had already developed the software fix well before the Turkish Airlines crash, including it on new planes starting in 2006 and offering it as an optional update on hundreds of other aircraft. But for some older jets, including the one that crashed near Amsterdam, the update wouldn’t work, and Boeing did not develop a compatible version until after the accident.
The problem with the single sensor, he said, should have dissuaded Boeing from using a similar design in the Max. Instead, “the issue got buried.”
https://www.nytimes.com/2020/01/20/busi ... ents.html
