After the Boeing 737-9 fuselage structure failure of 5th January 2024 Boeing issued a statement:
https://boeing.mediaroom.com/2024-01-06-Boeing-Statement-on-737-9-Inspections
“Safety is our top priority and we deeply regret the impact this event has had on our customers and their passengers…”
How often have we all heard exactly these first five words? Each time I read them I squirm for the discomfort I imagine the senior executive must feel when knowing they have to be used. I’ve seen the words criticised – “no it is not, your first priority is to stay in business!” but don’t sympathise with those who feel this. These five words are an expected formula, as is “you are now looking at the person responsible for your safety”.
To me they are both indicative of a form of desperation: it is not so much that they are wrong, more that they hide a lack of strategy to make them tangible: they are hollow words.
So I don’t intend to criticise those who use these phrases. The recent Boeing case was at the same time horrifying (for what it could have been) and a welcome relief (for what it was – a relatively benign warning).
What the case did for me was to revive consideration of a point I’ve made for many years, namely that there is an important difference between ‘general’ health and safety (OHS, WHS and so on) and ‘operational’ safety. The latter needs specialist knowledge to understand the relevant risk and the former a knowledge that is general in the sense that it can be applied in greatly varying situations, from warehouse to shop to kitchen and so on.
See also my Chapter 5 article Operational and general safety – a gulf between the two
In this Boeing case, the specialist needs a fairly deep understanding of structures, not to the point of designing them perhaps but to the point of understanding that structural fasteners (such as nuts and bolts) must be tightened to the correct specifications for the structure to perform as required. The carefully phrased press releases (“bolts in need of additional tightening”) have subsequently been shown to be a whitewash – according to the Seattle Times (6th Feb 2024) these bolts were actually missing.
In this case one would reasonably expect the operational safety person to have their eye on one thing only – zero tolerance for assemblies whose fasteners were not tightened to specifications. Amongst other initiatives, this means awareness of why they might not be – shift changeover, production pressures, staff workload along with who the staff are – their knowledge, skill and training. The fact that all this has worked without fail perhaps for generations of aeroplanes and workers indicates how well technical specialists know their job, whether there is ‘safety’ in the job title or not.
As you read this you may think this ‘zero tolerance’ job sounds like a quality control one, not a ‘safety’ one. You’d be right in thinking this, but need to ensure someone is looking over the shoulder of the quality controller to ensure the significance of the job is understood? And, who does 100% checks on the final product?
This relationship between quality and technical aspects of safety reminds me of an assignment I had in 1985. My client wanted me to provide them with a safety concept that was new and would take them through to the far-off millennium, the year 2000. I discovered the organisation was in the throws of implementing Process Improvement Teams, the Japanese quality initiative. These team consisted of representatives of anyone and everyone with an interest in how the process ran – production workers, electricians, mechanics, laboratory staff, engineers. The team were educated in their task and in the statistical techniques they needed and required to meet regularly. They were told to expect incremental improvements and occasionally revolutionary ones.
My advice was to include injury prevention in the scope of these teams and to educate them in what it meant, with a focus on what could go wrong and how to prevent it by plant design. I heard nothing from the company after submitting my report, until about 20 years later when I visited the same site with a number of overseas visitors for whom I was a host. By chance the current CEO had been there in 1985 and he remembered my name and the report. He told me that they implemented my recommendation with the result that the number of serious injuries dropped “out of sight” (they had not always been there) and stayed there. They had to import a psychology-based safety programme, more or less to keep the safety department employed.