By IJ Arora, Ph.D.
Boeing is in the spotlight again with its 737 MAX planes, which have already had a deeply troubled history. Customer focus (which is clause 5.1.2 of ISO 9001 and AS9100) seems to have been lost somewhere.
I have read several recent articles on these incidents as well as Peter Robison’s book Flying Blind: The 737 MAX Tragedy and the Fall of Boeing, all of which point to a worsening situation for Boeing. The public perception of this great American company, which has always been committed to top-class engineering and trusted products, is changing from one of respect to one of caution. Travelers are wondering, “Should I fly in a 737 MAX?”
Boeing and the aerospace industry in general have high standards for quality and product safety. In this article, I postulate whether a company’s quality management system can guarantee that nothing goes wrong for customers. Can it ensure perfection? If not, what are the alternatives—and why have one at all?
What happened and who is responsible?
For those not familiar with the 737 MAX incident in January, shortly after an Alaska Airlines flight departed from Portland, Oregon, a cabin door panel blew off. As investigations are still ongoing the causes have not yet been fully determined. Boeing also had a software issue on the 737 MAX, resulting in the crash of a Lion Air flight in 2018 and an Ethiopian Airways flight in 2019.
Here in the United States, the Federal Aviation Administration (FAA) plays a critical role in providing regulations to ensure flight safety, and also provides oversight of aircraft manufacturers, airports, and maintenance providers. In the case of the Alaska Airlines flight, it seems that the FAA failed to uphold its trusted role. The FAA’s numerous checks and balances, most of which are intended to focus on customer safety, were like aligning holes in slices of Swiss cheese. It will be interesting to see what changes this incident brings about at the FAA. Then again, can regulatory oversight guarantee safety of flight?
The AS9100 standard, which is specific to the aerospace industry, isn’t the brainchild of a single entity, but rather a collaborative effort driven by two key players:
- The International Aerospace Quality Group (IAQG). This international organization brings together representatives from aviation, space, and defense companies across the Americas, Asia/Pacific, and Europe. They actively participate in developing, maintaining, and updating the AS9100 standard.
- Standardization organizations. These bodies, such as the Society of Automotive Engineers (SAE) in the Americas and the European Association of Aerospace Industries (now the AeroSpace and Defence Industries Association of Europe), officially publish and distribute the standard.
It is important to note that AS9100 builds upon the foundation of the more general ISO 9001 quality management system standard. While ISO 9001 lays the basic framework, the IAQG adds industry-specific requirements crucial for ensuring safety and quality in the aerospace domain.
In addition to the manufacturer and the FAA, the owner/lessor of the aircraft also plays a role in ensuring the plane is properly maintained. This includes selecting a competent maintenance provider, hiring competent engineers, and having robust processes in place. With so many different stakeholders, can blame be attributed to just one when accidents happen? Furthermore, should blame be the name of the game? Perhaps not! It is important to note that the system is implemented to support each user and that all stakeholders in the value chain play their part as well.
Audits, inspections, and management systems: Are these the solution?
Behind every tragedy, casualty, and mishap is a chain of related events. The immediate suspect when these types of critical failures occur are poor inspection protocols, perhaps even the dreaded “human error.” However, this may be the low-hanging fruit and a deeper dive may identify other causal factors, such as asking if the quality audit failed.
What is the difference between an audit and an inspection? Can they replace each other or are inspections alone enough? The simple answer is no! Both are needed due to fundamental differences in approach. Audits look at the processes to ensure the management system produces conforming products and services. An efficient management system must include the following, to name a few:
- It must be well-defined, starting with the “as-is” state of the system.
- Risks must be identified (clause 6.1) based on the context of the organization (clauses 4.1 and 4.2).
- A clear definition of the product must be identified.
- Effective audits and periodic review must be undertaken by management.
- Outsourced processes must be controlled.
Inspections play an important role by identifying defects prior to release, thus protecting not only the client/customer/user/warfighter, etc., but also the reputation of the organization itself. With that said, inspections don’t contribute to continual improvement because they focus on fixes as opposed to long-term solutions. In effect, they do not really add value since the organization has already incurred the cost of producing the defective part or product. The creators of the Toyota Production System (i.e., lean) came up with the Andon process to catch a defect as early in the process as possible so as to fix it before the problem went too far down the line.
Management systems are not just a collection of documents. To function properly, they require commitment at all levels of the organization, including top management providing the needed resources. It takes time to build a culture of quality in which shortcuts are avoided and there is no fear of speaking up. Customer focus must not be compromised. For example, release of conforming product should go through the process specifically called out by clause 8.6; any interference by top management to truncate this process would imply the loss of customer focus. Is this a possibility? Perhaps, but the investigation must reveal the truth. In this case of the Alaska Air incident both the Boeing customers and Boeing as a company have suffered. It is my hope that investigators will identify all failed parts of the system from each responsible party. These may include not only failed inspections, but also suboptimal processes. This could end up taking us back to an inadequate quality management system.
Quality management systems: Can they deliver?
Given the above, can a properly designed and well-audited management system (supported by good inspection techniques to help ensure conforming product) guarantee that nothing goes wrong with an organization’s output? My opinion is that no one can guarantee this completely. However, risk can certainly be greatly reduced when everything is implemented well. This includes the training of personnel, which correlates strongly to competence; unfortunately, this is often the first budget to get cut when resources are scarce.
When high-visibility incidents like these occur, it may be forgotten that airplanes remain the statistically safest mode of travel on earth. This is primarily due to robust quality management systems, well-adopted regulatory frameworks, and regular oversight. Humans play an important role in the success of the management system, from the commitment at the top to the buy-in by the workforce (clause 5 to clauses 7.1.3, 7.1.4, and 10.3). Taken together, this helps create an environment where quality can flourish within the organization.
Boeing may be doing a lot correctly, and yet the results could be unacceptable depending on the performance of outsourced processes (clauses 8.41/8.4.2/8.4.3). After all, the fuselages for the 737 MAX are made by Spirit AeroSystems Holdings Inc. Spirit AeroSystems is located in Wichita, Kansas; once these fuselages are manufactured, they are shipped by rail to Boeing’s facility in Renton, Washington. Therefore, not only is a major component of the 737 MAX outsourced, but the shipping and preservation of product (clause 8.5.4) also could contribute to the product’s nonconformity. Overall, Boeing remains responsible for the entire supply chain (clause 4.3), with their obligation to “ensure conformity of its products and services and the enhancement of customer satisfaction.”
Even with a solid quality management system in place, this or similar failures can occur. There is no way to assure the public of 100-percent performing (i.e., perfect) output. The fear in the minds of air travelers is valid and will remain so until an exhaustive root cause analysis of this issue is performed and those root causes are resolved. The current events beg the question: Did Boeing improve their management system after the Ethiopian Airlines 737 MAX crash? If they had bent to the oars and gone deep into their review to uncover and permanently fix the holes in their management system, this event may never have occurred. Surface corrections, or what some organizations call “fix -it” solutions, only remove the symptoms. The root causes must be addressed and resolved (clause 10.2.1). There are no shortcuts to quality.
It has taken years for air travelers to feel safe and unconcerned about air safety. I travel a lot internationally, and often pick an airline based on their service and comfort, but now I (as well as the broader public, I would imagine) need to consider which aircraft will transport us. It is a new fear about product safety that has its genesis in Boeing not operating its management system efficiently and losing customer focus. The worst is the erosion of public confidence in federal oversight and its intent to keep the customer safe.
I have spent my life studying similar complex problems and leading teams in helping organizations find long-term sustainable solutions. This requires bold and dynamic leadership (clauses 5.3 and 5.1) for leaders to plan and implement change. Appreciating and accepting risks (i.e., keeping the customer in focus) and moving forward is integral to true leadership. Ethics is still not a clause of ISO 9001 and AS9100, but ethical leadership is about doing the correct thing for all stakeholders.
In seminars at which I present, I often ask senior managers: “If you have a choice between following the procedure and/or doing the correct thing, what would you do as a leader?” The answer—I hope—is to do the correct thing at all times. But then, hope is not a plan. Air safety cannot be based on hope and faith. Boeing needs the leadership to redesign their system if they are to bring the public trust back for this great American company.
About the author
Inderjit (IJ) Arora, Ph.D., is the President and CEO of QMII. He serves as a team leader for consulting, advising, auditing, and training regarding management systems. He has conducted many courses for the United States Coast Guard and is a popular speaker at several universities and forums on management systems. Arora is a Master Mariner who holds a Ph.D., a master’s degree, an MBA, and has a 34-year record of achievement in the military, mercantile marine, and civilian industry.