The Boeing 737 Max crisis
is where the manufacturer must work closely with the regulator…’ , 138 as stated by the experimental test pilot.
It is important for manufacturers to acknowledge that ‘ pilots are not gods and as every human we make mistakes […] designing planes not for super pilots but for lower -than- average level pilots…’ 139 Captain Davydov used the Swiss Cheese analogy – there are holes in different layers during the certification process and after-certification. It starts from Boeing, then FAA, Pilot Training, and finally, the pilots themselves. When the hazard enters the m odel, without any ‘barricades’, the hazards can easily pass through Boeing’s layer, reaching FAA’s layer. However, the chances of these many hazards passing
through each layer should ideally be decreasing, and finally mitigating the risks completely, but filtering out the hazards when it reaches different layers. 140 What we could do to improve air safety is to close off as many holes as possible. This can be done by more regulations on the operations or certification process, more vigorous testing, more proactive communication between the authority and the manufacturer. In the long term, we should
Figure 20: A snapshot of Captain Davydov’s analogy on the Swiss Cheese Model
focus on how regulations should be tightened and conducted, and who should be regulating the regional aviation authorities in the broader global community. ‘ There needs to be a much stronger recognition by the 193 ICAO Contracting States […] ICAO is our world’s aviat ion regulatory body which has the responsibility to assure safe civil aviation. ’ 141 The whole crisis was tragic, and it destroyed many families. It can be infuriating to see how greed could endanger human beings, and how severe some of the misconducts involved were, and how much we could have done to prevent this crisis and the loss of the 346 lives. But what is more important, is how we use this painful story – one which involved 346 precious lives – to improve the current system, to mitigate the ‘holes’ on the Swiss Cheese, and to prevent the same tragedy from happening ever again. As Rep. Peter DeFazio said: ‘ We have seen that pressures from Wall Street have a way of influencing the decisions of the best companies in the worst way, endangering the public, jeopardizing the good work of countless, countless hardworking employees on the factory lines. And I hope that’s not the story that is ultimately going to be written about this long-admired company. ’ 142
Bibliography
737ng.co.uk, 737 Quick Reference Handbook . https://www.737ng.co.uk/737-
800%20Quick%20Reference%20Handbook%20(QRH).pdf. Consulted March 6, 2022. Airbus, A320neo . https://aircraft.airbus.com/en/aircraft/a320/a320neo. Consulted February 27, 2022.
138 Anonymous 2022, Interview by Matthew Wu . 139 Davydov 2022, Email Questionnaire with Captain Denys Davydov by Matthew Wu . 140 Pilot Blog 2020, Is it SAFE to Fly on New Boeing 737 MAX? Boeing Pilot opinion. : 21:18. 141 Everard 2022, Email Questionnaire with Colin Everard by Matthew Wu . 142 Netflix 20 22, Downfall: The Case Against Boeing .
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