Incident: Boeing's 737 Max Software Failure: Safety Lapses and Compliance Issues

Published Date: 2019-06-27

Postmortem Analysis
Timeline 1. The software failure incident involving Boeing's 737 Max planes happened in October 2018 [85784].
System unknown
Responsible Organization 1. Boeing subcontractor falsifying certifications on cargo doors for hundreds of 777s [85784] 2. Boeing mechanics leaving tools inside plane wings [85784] 3. Improper installation of wires in 787s [85784] 4. Boeing's failure to meet obligations under the settlement agreement, including late or incomplete safety submissions [85784] 5. Boeing's delay in notifying the FAA about a software problem in the 737 Max [85784]
Impacted Organization 1. Boeing [85784] 2. Federal Aviation Administration (FAA) [85784]
Software Causes 1. The software cause of the failure incident was related to a software problem that disabled a crucial warning light connected to the automated system in the Boeing 737 Max planes, which took Boeing more than a year to notify the FAA about [85784].
Non-software Causes 1. Falsifying certifications on cargo doors by a Boeing subcontractor [85784] 2. Leaving tools inside plane wings by Boeing mechanics [85784] 3. Improperly installing wires in 787s by Boeing workers [85784] 4. Boeing's failure to rid its newly built planes of "Foreign Object Debris" [85784] 5. Boeing's delays in providing airlines with technical information to comply with safety regulations [85784]
Impacts 1. Boeing faced intense scrutiny and backlash over back-to-back crashes of its 737 Max jets, leading to questions about the soundness of the aircraft and the company's approach to safety [85784]. 2. The software problem that disabled a crucial warning light connected to the automated system at the center of the tragedies in the 737 Max took Boeing more than a year to notify the FAA about, impacting safety measures [85784]. 3. Boeing's inability to rid its newly built planes of "Foreign Object Debris" (FOD) like tools left behind was a problem that prompted a settlement agreement, but the company continued to struggle with this issue, affecting quality control and safety [85784]. 4. Boeing failed to meet some of its obligations under the settlement agreement with the FAA, indicating a lack of compliance with safety regulations and potentially compromising safety standards [85784]. 5. The settlement agreement aimed to address broader corporate culture and governance issues at Boeing, highlighting the need for systemic changes in safety practices and compliance with regulations [85784].
Preventions 1. Implementing a more rigorous oversight and enforcement mechanism to ensure that Boeing complies with safety regulations and addresses safety lapses promptly [85784]. 2. Enhancing transparency and communication between Boeing and regulatory authorities to ensure timely reporting of software problems and defects [85784]. 3. Strengthening the internal safety systems and practices within Boeing to prevent recurring safety issues and ensure compliance with regulations [85784]. 4. Improving the quality and timeliness of information provided by Boeing to regulatory authorities, such as the FAA, regarding software problems and corrective actions [85784]. 5. Enforcing penalties and holding Boeing accountable for failing to meet its obligations under settlement agreements related to safety improvements and compliance [85784].
Fixes 1. Implementing significant changes in internal safety systems and practices to ensure compliance with regulations [85784] 2. Addressing broader corporate culture and governance issues, including transparency [85784] 3. Expanding the use of an internal tool to determine root causes of safety problems and ensure they are fixed and stay fixed [85784] 4. Being more responsive to required safety submissions and taking remedial steps [85784] 5. Using the "Boeing Problem Solving Model" to examine causes of problems and come up with systemic solutions [85784] 6. Providing on-demand reports covering documentation related to implementing the agreement [85784]
References 1. Federal Aviation Administration (FAA) officials 2. Boeing CEO Dennis Muilenburg 3. Boeing 4. National Transportation Safety Board (NTSB) 5. Iwado Industry Co. 6. Kawasaki Heavy Industries 7. Seattle Times

Software Taxonomy of Faults

Category Option Rationale
Recurring multiple_organization (a) The software failure incident having happened again at one_organization: The articles do not specifically mention a software failure incident happening again within the same organization (Boeing) related to the incidents reported in the news articles. Therefore, there is no direct information available about a similar software failure incident happening again at Boeing. (b) The software failure incident having happened again at multiple_organization: The articles mention that Boeing subcontractors were falsifying certifications on cargo doors for hundreds of 777s, indicating a failure in the certification process [85784]. This incident raises concerns about the oversight of Boeing's global network of suppliers and the need for accurate information in the manufacturing process.
Phase (Design/Operation) design, operation (a) The article mentions that in the case of the Boeing 737 Max, Boeing took more than a year to notify the FAA about a software problem that disabled a crucial warning light connected to the automated system at the center of the tragedies. This delay in notifying the FAA about the software issue could be attributed to a failure in the design phase, where contributing factors introduced during system development or updates led to the software problem not being addressed promptly [85784]. (b) In terms of failures related to the operation of the system, the article discusses how Boeing mechanics were leaving tools inside plane wings, which could potentially lead to issues with the operation of the aircraft. Additionally, there were instances where Boeing workers failed to insert "lock wires" into holes in bolts used to build planes, which could affect the operation of critical parts during flight. These operational failures, such as leaving tools inside the wings or not properly securing bolts, could be attributed to factors introduced during the operation or maintenance of the system [85784].
Boundary (Internal/External) within_system (a) The software failure incident related to the Boeing 737 Max jets crashing in Indonesia and Ethiopia can be categorized as within_system. The articles highlight that Boeing had known safety problems identified by federal regulators for years, including issues with safety lapses, failures of corrective action, and problems with the quality and timeliness of information provided to the FAA [85784]. These issues were internal to Boeing's operations and processes, indicating that the contributing factors originated from within the system.
Nature (Human/Non-human) human_actions (a) The software failure incident occurring due to non-human actions: - The articles do not specifically mention a software failure incident occurring due to non-human actions. The incidents reported in the articles mainly focus on safety problems, compliance issues, and failures related to manufacturing processes, oversight, and certification rather than a direct software failure incident caused by non-human actions [85784]. (b) The software failure incident occurring due to human actions: - The articles highlight instances where Boeing employees were found to be leaving tools inside plane wings, improperly installing wires in planes, and recording false information for certain planes, which could lead to safety risks and failures [85784]. These instances point to software failure incidents occurring due to human actions introducing contributing factors that could compromise safety and compliance.
Dimension (Hardware/Software) software (a) The articles do not specifically mention a software failure incident occurring due to hardware issues. (b) The software failure incident mentioned in the articles is related to Boeing's 737 Max planes. The failure was due to a software problem that disabled a crucial warning light connected to the automated system at the center of the tragedies involving the crashes of the Lion Air and Ethiopian Airlines flights. Boeing took more than a year to notify the FAA about this software problem, which was a contributing factor to the incidents [85784].
Objective (Malicious/Non-malicious) unknown From the provided articles, there is no specific mention of a software failure incident related to a malicious or non-malicious objective. The articles primarily focus on safety problems, compliance issues, and oversight concerns within Boeing, rather than a specific software failure incident. Therefore, the information related to a software failure incident with a malicious or non-malicious objective is unknown.
Intent (Poor/Accidental Decisions) unknown [a] The intent of the software failure incident: - The articles do not specifically mention a software failure incident related to poor decisions or accidental decisions. The focus of the articles is on safety problems, compliance issues, and failures in meeting safety regulations within Boeing's manufacturing processes and corporate culture.
Capability (Incompetence/Accidental) accidental (a) The articles do not specifically mention a software failure incident related to development incompetence. (b) The articles mention instances of accidental failures related to Boeing's operations. For example, Boeing mechanics were leaving tools inside plane wings, workers were improperly installing wires in 787s, and there were issues with inserting "lock wires" into bolts. These instances were not intentional but were accidental errors that could lead to safety risks [85784].
Duration unknown The articles do not specifically mention a software failure incident that can be categorized as either permanent or temporary. The focus of the articles is on safety problems, compliance issues, and oversight related to Boeing's manufacturing processes and regulatory interactions.
Behaviour crash, omission, value, other (a) crash: The software failure incident related to the Boeing 737 Max jets crashing in Indonesia and Ethiopia can be categorized as a crash failure. The incidents led to the loss of state in the system, resulting in the planes not performing their intended functions, ultimately leading to tragic crashes [85784]. (b) omission: The articles mention instances where Boeing failed to comply with safety regulations, agreed to fix safety lapses, but then failed to do so. This can be seen as a failure of omission, where the system omitted to perform its intended functions at specific instances [85784]. (c) timing: There is no specific mention of a timing-related failure in the articles provided. (d) value: The software failure incident related to the Boeing 737 Max planes includes failures where Boeing workers left tools inside plane wings, workers improperly installed wires in planes, and Boeing failed to meet some of its obligations under the settlement agreement. These instances can be categorized as failures due to the system performing its intended functions incorrectly [85784]. (e) byzantine: The articles do not provide information about a byzantine behavior in the software failure incident. (f) other: The software failure incident also includes failures related to Boeing's inability to rid its newly built planes of "Foreign Object Debris," such as tools left behind, and Boeing's struggle with the issue even after the settlement agreement. This can be considered as another behavior of the software failure incident [85784].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence death, harm (a) death: People lost their lives due to the software failure The software failure incident related to the Boeing 737 Max planes crashing in Indonesia and Ethiopia resulted in the deaths of 346 people [Article 85784].
Domain information (a) The failed system was related to the production and distribution of information. The software failure incident discussed in the articles pertains to Boeing's safety problems known to federal regulators for years, including issues with safety certifications, compliance with safety regulations, and internal safety systems and practices [85784].

Sources

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