Insights from the Expert Review Panel into Aviation Safety at Boeing

In January this year, the door blew out of a Boeing aircraft mid-flight. The impact ripped headrests off seats and a shirt off a passenger. It was only luck that prevented a more disastrous outcome – it just happened that on that flight nobody was assigned to seats 26A and 26B, located immediately next to the door.

How could this happen?

Boeing was on notice that it had issues with its aircraft after two of their planes malfunctioned mid-flight in 2018 and 2019.  These crashes resulted in nearly 350 deaths – all the passengers and crew on board.

Boeing was also on notice that they had issues with their workplace culture.

At a US congressional hearing after the 2018 and 2019 crashes, Ed Pierson, a former senior engineer at Boeing, testified that he’d tried to bring up safety concerns, but they were ignored.  Before the crashes he wrote an email to the general manager of the Boeing factory stating that, for the first time in his life, he was hesitant about putting his family on a Boeing airplane.

Ed was ignored, and said he felt he had no choice but to leave the company.

In the Federal Aviation Administration’s expert report released last month, it was noted that while Boeing had taken steps to improve its safety culture, employees were still hesitant to speak up and voice concerns, because they didn’t trust the process and feared retaliation or futility.

When employees don’t feel safe to speak up because they fear that it will come at a personal cost, or they don’t see action being taken when they raise concerns, silence follows. 

The report noted that after the 2018 and 2019 crashes, Boeing introduced an internal “Speak Up” portal, to enable employees to raise concerns confidentially.  The report found that employees weren’t clear what types of issues should be raised using the portal, and did not trust that confidentiality would be maintained if they did so.  The lack of use of a central system to raise safety concerns also meant that information was silo-ed and it was more difficult to detect patterns of risk.

The report highlighted that managers with power to make decisions on performance, promotion and remuneration, could also be tasked with conducting investigations into issues raised.  This dual responsibility and authority created hesitation in reporting safety concerns for fear of retaliation.  Employees knew that a report about a safety issue could result in their own manager investigating the issue in their own reporting chain, which increased the perceived threat of retaliation. When there is a risk that raising an issue will come at a personal cost, this discourages employees from raising safety concerns.

The report also highlighted that when issues were raised, employees were not kept informed of whether their concern was being acted upon, or the outcome.  This leads to employees being unsure whether there was any point in taking the risk of speaking up.  If their concern is not going to be listed to, why take the risk? One of the report recommendations is that Boeing ensures that every issue raised receives an answer.  This sends a strong signal to employees that their voice is needed, and welcomed.

Four key takeaways

The report made a number of findings about Boeing’s safety culture and recommendations to improve it.   Here are four key takeaways from the report that are relevant to every organisation.

  1. Communicate: When introducing a new system or change process, it is crucial that employees understand what that system is, and how to use it. A strong communications campaign, reinforced by ongoing messaging from senior leadership sets the foundation.
  2. Ensure independent investigation processes: If an investigation is required, it is crucial that the investigation process is sufficiently autonomous to ensure confidence in non-retaliatory measures. When the person who has the power to promote or fire you is also responsible for investigating an issue you have raised in their own reporting chain, this makes it more likely that employees will self-protect by staying silent, rather than speaking up.
  3. Centralise data capture: Consider streamlining reporting processes into a centralised, organisation wide system to enable better tracking of issues across the organisation to identify themes and trends.
  4. Build trust through transparency: When an employee reports an issue, where possible keep them informed of how the issue is being handled and resolved. Share outcomes with all employees to reinforce that if employees speak up, the organisation will listen and take action, leading to positive improvement.

Rely and Your Call provide independent reporting hotlines and issue management solutions to enable safer workplaces.  Book a demo to find out more.

 

Kirsty Harvison

Head of Advisory, Your Call