The Best Analysis Of What Really Happened To The Boeing 737 Max From A Pilot & Software Engineer

The following tweets from Trevor Sumner, CEO of Perch Experience, of what really happened to the Boeing 737 Max, may be one of the best summaries of the events that led to the two recent airplane crashes, and also why Boeing's "software upgrade" response is a farce.


And for those who are not particular fans of tweetstorms, here it is recapped:

BEST analysis of what really is happening on the #Boeing737Max issue from my brother in law @davekammeyer, who’s a pilot, software engineer & deep thinker. Bottom line don’t blame software that’s the band aid for many other engineering and economic forces in effect.

Some people are calling the 737MAX tragedies a #software failure. Here's my response: It's not a software problem. It was an

  • Economic problem that the 737 engines used too much fuel, so they decided to install more efficient engines with bigger fans and make the 737MAX.
  • Airframe problem. They wanted to use the 737 airframe for economic reasons, but needed more ground clearance with bigger engines.The 737 design can't be practically modified to have taller main landing gear. The solution was to mount them higher & more forward.
  • Aerodynamic problem. The airframe with the engines mounted differently did not have adequately stable handling at high AoA to be certifiable. Boeing decided to create the MCAS system to electronically correct for the aircraft's handling deficiencies.

During the course of developing the MCAS, there was a:

  • Systems engineering problem. Boeing wanted the simplest possible fix that fit their existing systems architecture, so that it required minimal engineering rework, and minimal new training for pilots and maintenance crews.

The easiest way to do this was to add some features to the existing Elevator Feel Shift system. Like the #EFS system, the #MCAS relies on non-redundant sensors to decide how much trim to add. Unlike the EFS system, MCAS can make huge nose down trim changes.

On both ill-fated flights, there was a:

  • Sensor problem. The AoA vane on the 737MAX appears to not be very reliable and gave wildly wrong readings. On #LionAir, this was compounded by a
  • Maintenance practices problem. The previous crew had experienced the same problem and didn't record the problem in the maintenance logbook. This was compounded by a...
  • Pilot training problem. On LionAir, pilots were never even told about the MCAS, and by the time of the Ethiopian flight, there was an emergency AD issued, but no one had done sim training on this failure. This was compounded by an..
  • Economic problem. Boeing sells an option package that includes an extra AoA vane, and an AoA disagree light, which lets pilots know that this problem was happening. Both 737MAXes that crashed were delivered without this option. No 737MAX with this option has ever crashed.

All of this was compounded by a:

  • Pilot expertise problem. If the pilots had correctly and quickly identified the problem and run the stab trim runaway checklist, they would not have crashed.

Nowhere in here is there a software problem. The computers & software performed their jobs according to spec without error. The specification was just shitty. Now the quickest way for Boeing to solve this mess is to call up the software guys to come up with another band-aid.

I'm a software engineer, and we're sometimes called on to fix the deficiencies of mechanical or aero or electrical engineering, because the metal has already been cut or the molds have already been made or the chip has already been fabed, and so that problem can't be solved.

But the software can always be pushed to the update server or reflashed. When the software band-aid comes off in a 500mph wind, it's tempting to just blame the band-aid.