A legal and moral question: The crash of Turkish Airlines flight 981 (2021)

> But McDonnell Douglas never wavered from its belief that human error was the only cause of cargo door failures, [...] even attempted initially to pin the Turkish airlines disaster on the “illiterate” baggage handler Mohammed Mahmoudi, who hadn’t even deviated from proper procedure (Mahmoudi also pointed out that he was in fact literate in three languages, thank you very much!).

The only comic relief in this somber yet riveting exposition. More importantly, it shows MD's desperate desire to externalize the blame. I just see the same too often in engineering firms and, even more unfortunately, in life.

“That system, although it has undergone radical changes, is still similar in several key ways. So similar, in fact, that in 2017 the Boeing 737 MAX 8 could be produced with an egregious design flaw, kept hidden from the FAA, which resulted in two preventable crashes at unready airlines in developing countries, killing (coincidentally) 346 people. And so, while it is true that flying today is much safer than it was in 1974 — passengers today need not worry about their planes crashing because of badly designed doors — the same basic factors that led to the DC-10 cargo door saga still exist and still cause accidents.“

Kyra might have to sadly walk even the caveat on this one back after yesterday’s incident on Alaska Airlines flight 1282 (another 737 MAX), which had an in-flight decompression emergency in which a body panel blew out due to some defect related to an unused doorframe obscured behind the paneling in that section. Thankfully it didn’t crash, but if the panel had hit some control surface on its way off of the plane, it might have been a much less happy story.

Still amazing that MD spent years blaming multiple failures of people working in the ground rather than being dragged on the coals for making an aircraft that could fail catastrophically due to an invisible error made by a single hypothetically unskilled luggage handler (though note that at least one of the people they attacked as illiterate spoke 3 languages).

But even more so, once they were "aware of the design error" they made a "gentleman's agreement" with the FAA to fix it as long as the FAA didn't do anything that would force them to actually fix it, and then none of the MD executives went to jail for homicide after killing the occupants of flight 981.

Then after all of this BS, McDonnell Douglas knew the cargo door was faulty before even Windsor happened. They had had the cargo door fail in their own testing prior to any accidents and went with it anyway. Again, the ability of executives to remove themselves from criminal accountability is astounding.

The same happened with the 737MAX: it was executives who signed off on deceiving the FAA, it was executives that approved the single point of failure, it was executives and the board of directors who claim their compensation is due to them having responsibility, and yet they have not been charged with murder. If I sell you a car with faulty breaks, and tell you they are not faulty, and provide falsified reports claiming that they're safe, and then you die when the breaks fail, I would be charged with at minimum manslaughter, but likely some variation of homicide: the deaths followed from the criminal act which means the deaths themselves are criminal acts. It's the same reason that if you hold up a bank and the teller dies as a result of a heart attack you would be charged criminally for that death.

Until the executives and board directors of companies are themselves subjected to liability in addition to the company's civil liability nothing will change.

> In fact, 75% of the DC-10’s certification items were handled by FAA-designated engineers who worked for McDonnell Douglas, a practice known as delegation. Delegation is necessary to some extent because the FAA lacks enough staff to certify every part of every new airplane. But in this case, the engineer who the FAA had assigned to certify the vent door was the same man who had conducted the tests of the door on behalf of McDonnell Douglas.

Note that it crashed in 1974, and not 2021 as the title may seem to imply.

Note the same McD management ended up in charge of Boeing after their merger.

It boggles my mind how a pattern that every (capable) engineer can spot a mile away and know for a fact that a disaster is waiting to happen, can persist. It seems to be a human condition that we sleepwalk into disaster regularly.

> And so, while it is true that flying today is much safer than it was in 1974 — passengers today need not worry about their planes crashing because of badly designed doors — the same basic factors that led to the DC-10 cargo door saga still exist and still cause accidents.

I guess we still do have to worry about the doors and door plugs today. Maybe the 737 Max is the new DC 10?

> All systems intended to ensure that the door was properly closed had now been overcome […] Countless side characters stepped in and out of the picture, from the engineer who certified his own work and missed a clear design flaw, to the Turkish Air Force officials who wanted to use the DC-10 to carry troops to Cyprus, each of them unwittingly playing a small but possibly crucial role in the buildup to disaster. It wasn’t just a door — it was the system itself which failed.

This article totally reminded me of one I read in the Atlantic many years ago analyzing a different airline crash. I’ll try to find the link, but the author or one of the main interviewers had argued that in airline safety, Murphy’s Law is the exact opposite of what happens. In reality, if anything can go right, it will go right, and we only get catastrophes when every part of a system fails, and a whole chain of events conspires to go wrong. They made a compelling case in the article, and this one backs the argument up completely. Fascinating.

Edit:

The Lessons of ValueJet 592

https://web.archive.org/web/20230103195248/https://www.theat...

“The ValuJet accident is different. I would argue that it represents the third and most elusive kind of disaster, a "system accident," which may lie beyond the reach of conventional solution, and which a small group of thinkers, inspired by the Yale sociologist Charles Perrow, has been exploring elsewhere—for example, in power generation, chemical manufacturing, nuclear-weapons control, and space flight.

“The people involved do not consciously trade safety for money or convenience, but they inevitably make a lot of bad little choices. They get away with those choices because, as Perrow says, Murphy's Law is wrong—what can go wrong usually goes right. But then one day a few of the bad little choices come together, and circumstances take an airplane down. Who, then, is really to blame?”

BTW: this blog is often cited for excellent analysis in the various aviation forums I frequent.

I think it was this flight, my father’s friend missed it at the gate by a minute. He then sued the airline... for taking off a minute earlier than scheduled.