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My Letter to the Editor of New York Times Magazine

666 points| kaboro | 6 years ago |sullysullenberger.com

201 comments

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[+] rswail|6 years ago|reply
Blaming the user is a pernicious problem in UX engineering, especially when a feature is introduced not for the actual users, but the executives making the purchasing decisions.

MCAS was an economics driven decision by Boeing to be able to sell it as a "no cost" upgrade to existing 737 fleets. "You get all this and you don't need to retrain your people"

The entire concept of the 737 MAX was flawed, marketing an inherently unstable aircraft with a patched undocumented system to control that instability. Then, incredibly, making the safety indicators an optional extra was criminal.

The FAA is also liable for regulatory capture and handing over its responsibilities the actual organization it is supposed to be supervising.

Ultimately, it's an example of what happens when MBA execs, convinced that they can run "any business" take over from a rigourous engineering culture. The Harvard (and other) Business Schools have a lot to be blamed for.

[+] PuffinBlue|6 years ago|reply
> marketing an inherently unstable aircraft

The 737 Max is not an inherently unstable aircraft and to say so grossly misunderstands the term and what MCAS was doing.

MCAS existed to make an inherently stable aircraft handle in the same was as previous 737 generations. Design changes had forced the addition of this system in order to retain the same type rating because those design changes caused the aircraft to handle differently to previous generations.

MCAS was about keeping the same type rating and the same handling characteristics. It had absolutely nothing whatsoever to do with 'inherent instability' - the 737 Max is an inherently stable aircraft without MCAS.

Continuing to spread misinformation about what MCAS is and the 737 Max stability is detrimental to the discussion.

EDIT - There is clearly a lot of misunderstand about the terms 'stable' and 'unstable'. These has a defined meaning in aircraft handling. I encourage you to educate yourselves on the term, on what stability actually is in relation to this discussion.

https://www.boldmethod.com/learn-to-fly/aerodynamics/3-types...

The 737 Max is a stable aircraft. The 737 Max without MCAS activated is a stable aircraft. It is an inherently stable design.

The 737 Max can and was flown without MCAS activated (even by the same aircraft as crashed, the pilots of the previous flight pulled the stabiliser cut out switches and went to manual trim control).

It is a stable aircraft.

[+] crispyambulance|6 years ago|reply

    > ...  it's an example of what happens when MBA execs, convinced that they can run "any business" take over from a rigourous engineering culture. The Harvard (and other) Business Schools have a lot to be blamed for.
Sadly, the culture problems brought by bean-counters are the very last thing that will see the light of day. They're really the "long story" root cause problem here. It's the same kind of mentality that lead to the Challenger disaster, new building collapses in China and countless other less dramatic failures of big projects and systems.

Don't hold your breath for anyone to held accountable, don't expect that business will learn a lesson from this.

[+] anonu|6 years ago|reply
> The Harvard (and other) Business Schools have a lot to be blamed for

Is this documented? Did MBAs from HBS flood the FAA? And how would that lead to a plane falling out of the sky?

I'm with you on the general gist of your comment with regards to HBS - but I'd be careful about starting a witch hunt.

[+] ericmay|6 years ago|reply
This went unnoticed but, do we know whether the executives or those who made the decisions here were all MBA graduates? I am an MBA student and we do case studies on exactly these kinds of issues and how the correct course of action, but ethically and financially is to do the right thing. Maybe others disagree but this comment definitely stood out to me.
[+] situational87|6 years ago|reply
I'm not sure why we're even having this discussion, even a non-technical layperson reading a description of how MCAS was supposed to work can immediately realize it's a horribly flawed and unsafe design. You don't need any experience with aviation or engineering, that's how awful the design is.
[+] panarky|6 years ago|reply
> such a pernicious and deadly design

Yes, MCAS is a pernicious and deadly design.

Equally, Boeing's corporate governance and FAA's regulation and oversight are also "pernicious and deadly".

All must be fixed before this aircraft flies again.

[+] eru|6 years ago|reply
I'm not sure why you get so worked up?

From what I can tell flying is far too safe for its own good. Seriously:

Flying is regulated to ridiculous level of safety. At current levels, each marginal dollar spent on flight safety would do much better being spent on driving safety or more radically, preventing deaths from malaria.

If we apply unequal dollar amounts to how much we are willing to pay for each life saved in different areas of life, we are saving fewer lives than we could.

[+] statusquoantefa|6 years ago|reply
> Blaming the user is a pernicious problem in UX engineering

I've been around computers since well before it was called UX, and since UX? trust me, I never blame users, I definitely blame UX.

we need to bring back UI.

[+] IfOnlyYouKnew|6 years ago|reply
Langewiesche is a terrific writer, but it does seem like the overwhelming majority of people in the business consider his take on the 737MAX to be misguided.

Reading his article, I got the impression that he has a certain idealised image of what a pilot should be like. One that I have also noticed quite a few people here on HN seem to be rather fond of.

Namely: that being a pilot should not just be someone's job, but their calling. To use a weird phrase I once saw here, they are supposed to be "fixed-wing enthusiasts".

There also seems to be a certain, somewhat outdated, concept of masculinity at play here. And, of course, combining these expectations with stereotypes of African and Asian companies (and people) initially led many to the conclusion that these pilots were either incompetent ("because of a lack of calories in early childhood" to quote one line of reasoning I saw (luckily not here)) or incapable of independent thinking. Never mind that at least one of the captains was trained in the US.

These ideas couldn't be farther from how the system is actually evolving, and how it should be: Flying needs to be boring. If your pilot has a chance to become a hero, the system has already failed. The goal must be a system of technology, institutions, curricula, etc. that makes it perfectly safe to trust any decent high school student to become a competent(-enough) pilot. Candidates with a sense for adventure should be screened out, because flying an airliner is dreadfully boring, and a volatile personality will soon find a way to make it more exciting (drinking, usually).

And planes should become more and more automated. Software and design errors tend to occur just once. Humans tend to make mistakes, even repeatedly, even with the best training. The 737MAX disaster is a terrible outlier that shouldn't obfuscate the fact that in the last 50 years or so, airline fatalities have dropped by an order of magnitude, even thought miles traveled have increased by a similar magnitude.

Combining the two: air travel today is 50 to 100x safer than it was in the golden age of piloting so many seem to glorify.

[+] endymi0n|6 years ago|reply
Exactly this.

The Langewiesche legacy goes back to his father Wolfgang Langewiesche, who is also a terrific writer, incidentally about probably still the best book about flying fixed wings, Stick and Rudder (1936).

But flying has moved on a lot since then. Although I also appreciate "The story of Mel", computing has moved on so far from moving some bits and bytes on a drum memory, that I absolutely prefer someone writing readable code today to someone who produces unreadable, but performant code (spare a few niches of inner loop optimization).

The same goes for flying back now and then. When there's not just "Stick and Rudder" in a modern airplane, but caring for massively diverse aspects such as ATC, passenger air quality, airspace control or fuel optimization, I don't need specialists. I need competent generalists.

Of course it makes for a nice hero story if a pilot just makes it to the runway because they took an airliner into a forward slip like the Gimli Glider, but the point is that they absolutely should not have to.

Humans are not meant for sensing to fly. The average VFR pilot loses not just orientation, but control over the airplane an average of around 178 seconds (!) after going into a cloud.

We need less heroes and more engineers who can build reliable automated safety systems.

[+] seanmcdirmid|6 years ago|reply
If flying becomes boring, it becomes a tedious job that requires a lot of mental fortitude to slog through. Boring jobs are dangerous, because human beings don’t do boring very well.

And I think we’ve already reached that point in aviation, as much of the work has been offloaded to automated systems, making it easy for attention to doze elsewhere, and making transitions to where manual intervention is unexpectedly required even more difficult. It’s the same with self driving cars: the only safe options seem to be no automation and all automation since humans simply don’t do boring very well.

[+] plemer|6 years ago|reply
>If your pilot has a chance to become a hero, the system has already failed.

Very well said.

[+] reacweb|6 years ago|reply
Flying is boring when everything works well. I remember a story from a friend, a pilot of an airline that was going to sell all its aircraft of a model. 6 month before the sell, the preventive maintenance was reduced to only the legal minimum. In each flight during this 6 month, my friend has encountered technical issues (sometimes as severe as a broken reactor). IMHO, the role of a pilot is to keep a cool head to analyze faults with sometimes slight symptoms and find the right answers occasionally in opposition to the manual. That's also why I want the pilot to be in the same aircraft as me (no remote piloting).
[+] briandear|6 years ago|reply
> Never mind that at least one of the captains was trained in the US.

Point of fact, that captain did initial private pilot training in San Carlos in Cessnas — his airline training was at the airline. “US trained” in this context is similar to a doctor being “US trained” because he did an undergraduate degree in the US but his medical degree somewhere else.

[+] xNal|6 years ago|reply
This is completely wrong. If you watch air crash investigation, the majority of pilots who saved planes under extreme circumstances were fixed wing enthusiasts, often flew small planes or gliders for fun.

Especially in situations like the MAX crashes you need a feeling for the aircraft.

I'm astonished what this has to do with masculinity, which is of course not outdated (watch who women date ...).

[+] mcguire|6 years ago|reply
"Namely: that being a pilot should not just be someone's job, but their calling. To use a weird phrase I once saw here, they are supposed to be "fixed-wing enthusiasts"."

Rotary-wing enthusiasts are just crazy. Everybody knows that.

[+] PopeDotNinja|6 years ago|reply
My takeaway from the letter is that pilots should be at the top of there game at all times, and one shouldn't be cheap when building an airplane. Blaming pilots for a shoddy aircraft is weak sauce, and Sulli wantd us to know that.
[+] harry8|6 years ago|reply
Wow he didn't miss. It's a good example of an interesting change in our information dissemination dynamic. 30 years ago he would have been waving his arms trying to get other news organisations to run a counter-story and then be subject to having quotes taken out of context and having his thoughts filtered through the story the journalist was trying to write or that the editor thought was more compelling. Giving everyone the best possible motives, which was frequently reasonable, it had serious issues.

Now he writes the letter. Publishes it himself very cheaply. Then allows it to be read by a very large number of people directly, un-edited. There are many of examples of this kind of thing nowadays (and it's easy to see it doesn't always work too). When it does work the world is just a little bit better.

[+] skybrian|6 years ago|reply
Aviation accidents are typically about defense-in-depth being undermined (the "swiss cheese model"). The object of an investigation should be to find multiple vulnerabilities that could be fixed, at all levels. Focusing exclusively on one of them to the exclusion of others would be a problem.

Sullenberger says the same: "we need to fix all the flaws in the current system — corporate governance, regulatory oversight, aircraft maintenance, and yes, pilot training and experience."

But this doesn't mean any particular article can't focus on one problem more than others, so long as they don't claim it's the only problem.

Looking at the original article, the clickbait headline (typically not written by the author) pretends we can find a single cause ("What Really Brought Down the Boeing 737 Max?") but the subhead takes it back ("equally guilty"). The article focuses on problems at some airlines, Lion Air in particular, and alleged differences internationally in how airlines approach safety. Apparently that's what the author wanted to focus on?

So I guess it comes down to a difference in emphasis?

[+] phjesusthatguy3|6 years ago|reply
I would suggest changing the title of this HN post. Maybe "The MCAS design should never have been approved" or something to that effect. IMO, the current "My Letter to the Editor of New York Times Magazine" is far too ambiguous.
[+] iosonofuturista|6 years ago|reply
The title is no good, but maybe a compromise would be "Capt. “Sully” Sullenberger on the 737 MAX". Picking a just a sentence without the context seems to be against the spirit of the no clickbait rules.
[+] mpweiher|6 years ago|reply
Central point of Sully's letter:

These emergencies did not present as a classic runaway stabilizer problem, ...

Which flatly contradicts Langewiesche's claim that that is what they presented themself as and therefore should have been handled by any competent pilot.

I have to admit I also found the Langewiesche article extremely tendentious and...not sure "racist" is quite the right term, but it certainly felt close to it.

Ethopian for example had an excellent reputation and safety record up until the MAX accident, something never mentioned in the article. Instead we learn a lot about Adam air, an airline that went belly up before the 737 MAX program was even started. How that is supposed to be relevant except for a "well, those Indonesiens ..." dismissal is beyond me, and of course there is no connection to Ethopian except, well, darker skinned foreigners.

Not a good look, New York Times.

[+] dombili|6 years ago|reply
I'm glad Mr. Sullenberger spoke up about this. As some people have pointed out in this thread, Langewiesche is indeed a terrific writer, but the tone of the piece in question was off-putting.

For those who're interested, Patrick Smith (aka Ask the Pilot) also wrote a critical piece about the article last month: https://www.askthepilot.com/plane-and-pilot/

[+] axaxs|6 years ago|reply
> The MCAS design should never have been approved, not by Boeing, and not by the Federal Aviation Administration (FAA).

This is the line that stuck out to me. Basically, it never occurred to me that the FAA has to approve aircraft designs. And if that assumption is correct, who exactly would the approvers be, and are or can they even be qualified? It feels like they'd just be mostly trusting Boeing's judgment as not to upset the Juggernaut, which seems like a rather useless process.

[+] inamberclad|6 years ago|reply
The FAA actually does keep engineers on staff, and the aircraft manufacturer will have to explain and demonstrate how their aircraft complies with thousands of different requirements. This is actually one of the larger sub-controversies of the whole MCAS issue; the FAA has been progressively delegating more and more of airworthiness compliance to Boeing's engineers and trusting their results instead of verifying it themselves.

With regards to the regulations, they're excruciatingly detailed. I encourage you to read 14 CFR 23, Airworthiness Standards: Normal Category Airplanes, and 14 CFR 25, Airworthiness Standards, Transport Category Airplanes.

[+] hlms|6 years ago|reply
Sully's the man. His description of the experience of piloting in a crisis and analysis of the design and regulatory issues reminds me of Sidney Dekker and 'Safety Differently': http://sidneydekker.com/
[+] aussiegeek|6 years ago|reply
Interesting story: Sully actually lost a copy of one of Sidney Dekker's books in the forced water landing that he'd borrowed form the library.
[+] ec109685|6 years ago|reply
The worst thing about these accidents is the pilots never encountered the situation in simulators.

For non-lethal failures, tech companies do extensive game day testing to practice failure conditions and engineers responses. The fact that it wasn't done in this case because the failure was too expensive, unlikely to occur and the new plane wasn’t different enough was a huge failure on Boeing’s and the FAA.

[+] ablation|6 years ago|reply
Worth noting that Langewiesche wrote a book about Sullenberger’s infamous flight on the Hudson. Not a critical one, but they do have a previous relationship at least of some sort.
[+] starpilot|6 years ago|reply
Calling it "infamous" is a bit critical, isn't it? "Famous" would make more sense.
[+] dgudkov|6 years ago|reply
This letter is something the modern internet and media are sorely missing - a real expert opinion instead of a flood of "armchair expert" opinions. I would always prefer one opinion of someone who does, over a hundred opinions of those who think.
[+] ken|6 years ago|reply
OTOH, there's plenty of experts in every field who can and do say "I've been doing this for 30 years, and I know that ..." and then mention something they do which statisticians have since shown isn't effective.

Sully is worth listening to here because the facts are on his side, in terms of blaming the victim versus analyzing the system as a whole. Sully is getting a lot of airtime in the media because he's a famous public figure, but a new pilot 6 months out of flight school would be just as correct with the same facts.

He's a smart guy who is obviously familiar with the safety research done in his field. His own decades of experience do not constitute research on their own, though.

[+] bumby|6 years ago|reply
Even if the pilots are partly to blame it indicates a bad design philosophy. The hierarchy of mitigation in safety critical systems is

1. Engineer the hazard out so it no longer becomes possible

2. Use other systems to detect and safe the system (ideally, if it's a software hazard, use non-software mitigation)

3. Procedural or administrative mitigation

#3 is by far the least desirable, meaning you only use it as a primary mitigation if the other two are infeasible. If Boeing uses this defense I would want to know why they were not willing to implement the other, better methods, because it would seemingly point to managerial or technical deficiencies

[+] metalliqaz|6 years ago|reply
The risk wasn't identified in the first place. Remember that the updated MCAS was itself a mitigation.
[+] yread|6 years ago|reply
Am I the only one surprised by the whole professional personal brand management of Sully? Do they also sell mugs with his face?

It's not like he is the only person to ever glide with an airliner to a safe landing

https://en.wikipedia.org/wiki/List_of_airline_flights_that_r...

[+] colinbartlett|6 years ago|reply
He is an author who does speaking and consulting on the basis of his experience. I don’t believe his branding is anything abnormal or differing much from that of prominent software development authors, speakers, and consultants.
[+] coldcode|6 years ago|reply
He is one of very few to glide into a water landing with zero fatalities, and the only one in the middle of one of the world's largest cities.
[+] ken|6 years ago|reply
Not relevant to the content of this letter, but "this age-old aviation canard" in a note about MCAS has got to be the best word choice I've seen all year.