In concert with the paper, we’ll focus on two major separate but related Boeing 737 accidents: 

1. Lyon Air #610 in October 2018 - The plane took off from Jakarta and crashed 13 mins later, with one of the highest death tolls ever for a 737 crash - 189 souls.
2. Ethiopian Airlines #30 in March 2019 - This plane took off from Addis Ababba and crashed minutes into takeoff, killing 157.

The paper’s abstract reads:

Following other contributions about the MAX accidents to this journal, this paper explores the role of betrayal and moral injury in safety engineering related to the U.S. federal regulator’s role in approving the Boeing 737MAX—a plane involved in two crashes that together killed 346 people. It discusses the tension between humility and hubris when engineers are faced with complex systems that create ambiguity, uncertain judgements, and equivocal test results from unstructured situations. It considers the relationship between moral injury, principled outrage and rebuke when the technology ends up involved in disasters. It examines the corporate backdrop against which calls for enhanced employee voice are typically made, and argues that when engineers need to rely on various protections and moral inducements to ‘speak up,’ then the ethical essence of engineering—skepticism, testing, checking, and questioning—has already failed.

Discussion Points:

• Two separate but related air disasters
• The Angle of Attack Sensor 
• MCAS (Maneuvering Characteristics Augmentation System) on the Boeing 737
• Criticality rankings
• The article - Joe Jacobsen, an engineer/whistleblower who came forward
• The claim is that engineers need more moral courage/convictions and training in ethics
• Defining moral injury 
• Engineers - the Challenger accident, the Hyatt collapse
• Disaster literacy – check out the old Disastercast podcast
• Humility and hubris
• Regulatory bodies and their issues
• Solutions and remedies
• Risk assessments
• Other examples outside of Boeing
• Takeaways:
• Profit vs. risk, technical debt
• Don’t romanticize ethics
• Internal emails can be your downfall
• Rewards, accountability, incentives
• Look into the engineering resources
• Answering our episode question: In this paper, it's a sign that things are bad.

Quotes:

“When you develop a new system for an aircraft, one of the first safety things you do is you classify them according to their criticality.” - Drew

“Just like we tend to blame accidents on human error, there’s a tendency to push ethics down to that front line.” - Drew

“There’s this lasting psychological/biological behavioral, social or even spiritual impact of either perpetrating, or failing to prevent, or bearing witness to, these acts that transgress our deeply held moral beliefs and expectations.” - David

“Engineers are sort of taught to think in these binaries, instead of complex tradeoffs, particularly when it comes to ethics.” - Drew

“Whenever you have this whistleblower protection, you’re admitting that whistleblowers are vulnerable.” - Drew

“Engineers see themselves as belonging to a company, not to a profession, when they’re working.” - Drew

Resources:

Link to the paper

The Safety of Work Podcast

The Safety of Work on LinkedIn

Feedback@safetyofwork