While I appreciate the amount of effort the author put into writing this, Matt Stoller’s analysis of the Boeing situation remains the best I’ve found so far: https://mattstoller.substack.com/p/the-coming-boeing-bailout
> The key decision was, rather than fix the fundamental aerodynamic control problems caused by the new engine, to bandaid the existing 737 software, while pretending that flying the 737 Max was just like flying old ones. That way, airlines would be able to buy the plane and not have to retrain their pilots, as pilots must be re-certified any changed flight procedures but don’t have to be recertified for new models with unchanged flying qualities. Unfortunately, the aerodynamics of the 737 body didn’t fit with the Max’s bulkier engine, which was obvious during the first wind tunnel tests.
I wish Mr. Stoller took more time on this:
> The Federal Aviation Administration, having outsourced much of its own regulatory capacity to Boeing, didn’t know what was going on, and Boeing didn’t tell airlines and pilots about the new and crucial safety procedures.
This seems like big deal to me.
The gist of it is extremely simple: most fatal accidents happen because of a sum of mistakes, a chain of more or less important errors which, taken individually, would seldom lead to an accident, but together form "the perfect storm". This is btw the true meaning of Murphy's famous quote (especially the 'worst possible time' part, e.g. software failing in-flight as opposed to during tests), and how we avoid such outcomes.
The beauty of accidentology, beyond engineering / repairing honesty, beyond tons of carefully written procedures and double checklists, is also quite simple: to systematically track the origin of mistakes, to reward people who were involved in finding the issue, and fix the problem once and for all through better practice, better documentation, changing procedures.
It contributed to make air travel statistically the safest means of transportation for human beings (the rationale was that plane crashes were so traumatising to the general public that it wasn't enough to be "better" than cars or trains or ferrys; air travel had to be 99.99...% safe to succeed).
In this case, we indeed have multiple failures which form a chain of events: the manufacturer (Boeing) cutting corners on safety, the regulator (FAA) also cutting corners in what looks like plain and simple corruption here, and somehow everyone else (companies, pilots) taking for granted what Boeing/FAA said. All in the name of more profit, for a ridiculously tiny part of the population. The results are the tragedies we witnessed. And while the first crash should have been a wake-up call, the fact that Boeing themselves didn't come forward and did let a second crash occur is borderline criminal (for courts to decide, anyway, but the question seems salient in this case).
It's all extremely worrying and sets a dire precedent for the USA as a lax or incompetent regulator, and a champion of big corporations now apparently digging way too far down the 'profit hole' — it has literally become a grave by that point.