Comparing Boeing and Indian Railways
Early in my career as an engineer, and even earlier in my education, I was trained to look for patterns, or trends, while investigating failures. There could be failures of the lubricating system causing large scale damage to sub-systems, or of the gear trains, or piston-rings, or seals and rubber. There could even be workmen-level lapses indicating poor training, lack of shop-floor discipline, inadequate supervision. Most of these problem were easy to solve as they fell squarely in the domain of an engineer.
I also learnt that if failures are randomly distributed across various sub-systems and show no pattern or trend, they are difficult to pin down to root technical causes and frustrate the management no end. Therein lies the rub. These failures are not technical – they are manifestations of serious management deficiencies. Two such glaring examples that have come to light in recent times are that of the Boeing Company and the Indian Railways.
The Boeing Company
Two crashes of the Boeing 737 Max in quick succession that killed hundreds of passengers – On October 29, 2018 Lion Air Flight 610, a 737 MAX 8 plane crashed in the sea, 13 minutes after take off, killing all 181 aboard. On March 10, 2019 Ethiopian Airlines Flight 302, a 737 MAX 8 crashed, 8 minutes after take off killing all 157 aboard. These were attributed to software overcorrection of plane’s attitude. Then there were cases of a door-plug detaching causing decompression on January 5, 2024 on an Alaska Airlines Flight 1282, a 737 MAX 9. This was attributed to loose bolts! As Recently as on May 25, 2024 a Southwest Airlines Flight 746 experienced "an uncontrolled side to side yawing motion" called a Dutch roll at an elevation of 32,000 and the plane had to be landed urgently. On June 14 this year it was reported that some sub-contractors (contractors of contractors) had used spurious titanium in aircraft parts. Earlier In April, Boeing told the F.A.A. about a separate episode involving potentially falsified inspection records related to the wings of 787 Dreamliner planes. Boeing reported to the F.A.A. that it might have skipped required inspections.
Causes:
So, we have cases of inadequate testing of software, poor hardware (as in nuts and bolts), suspicious flight controls, inspections that were ignored and records falsified. Whereas these failures may be attributed to lapses on the part of individuals, contractors, teams and validation engineers, they, in the overall reckoning, point to a serious failure of management. The pressure of production and deadlines was so high on the management that sound technical advice was ignored and whistle-blowers penalised. The case of Sam Salehpour, a quality engineer at Boeing may be recalled, who was pushed back against and even threatened with physical violence, when he reported possible weakness in the fuselage of 787, the Dreamliner.
Let’s now come to the recent spate of accidents in Indian Railways.
To mention just a few:
On 2 June, 2023, Nearly 300 people were killed and over 800 injured in a horrific train derailment in Balasore, Orissa. The train derailed and an oncoming train collided with its derailed coaches. There was third train too involved in the crash, a freight train. derailment of 10 to 12 coaches of the Shalimar-Chennai Coromandel Express caused them to fall onto the opposite track. This was attributed to wrong wiring by low level signal staff at a Level Crossing Gate.
On 26 August 2023 the Lucknow-Rameshwaram Bharat Gaurav train which was stationed near Madurai Junction caught fire killing 9 and injuring 20. This reported cause was that the passengers smuggled a gas cylinder aboard the train and were cooking in the coach when the fire broke out.
On 11 October 2023 6 coaches of 12506 Anand Vihar Terminal-Kamakhya Junction North East Express derailed near Raghunathpur Railway Station in Buxar district of Bihar killing 4 and injuring more than 70.
On 29 October 2023 the Visakhapatnam-Rayagada passenger train derailed after colliding with the Visakhapatnam-Palasa passenger train near Kottavalasa Junction railway station in Vizianagaram district, Andhra Pradesh killing at least 14 and injuring 50.
Earlier, on 19 August 2017 the 18478 Puri–Haridwar Kalinga Utkal Express derailed in Khatauli near Muzaffarnagar, Uttar Pradesh. Killing at least 23 and leaving nearly a hundred injured. This was attributed to track defect.
As recently as on 17 June (today) a freight train hit the Kanchanjunga Express near Phansidewa in West Bengal. 5 people reported dead.
Causes of accidents on Indian Railways:
Enquiries are held in all railway accidents and causes that are established range from track defects, signal-failure, drivers-ignoring-signal, failure-of-interlocking, passengers-smoking-in train, to short-circuits. Most of the time some junior level staff is penalised, even sacked. Sometimes senior level functionaries are also transferred as in the case of the Balasore accident. But never is a management failure acknowledged, some of which could be poor training, departments working in silos, incompetent procurement system, ineffective inspections and supervision, insensitive human resources policies, total lack of communication with the field-staff apart from reprimands, obstructionist trade unions, senior officers occupying the same positions for long and so on. Even the much acclaimed administrative reforms, the introduction of a single service cadre, the Indian Railways Management Service (IRMS), which apparently picks the best of the best brains to head administrative units, has failed to make any impact. Loose statements like the “Kavach” safety system will eliminate accidents are made at the highest level. How Kavach will eliminate cases of faulty wiring, fires in coaches, poor track-maintenance, rolling stock defects is left unsaid. How multi-billion-rupee investments will improve the training, motivation, pride and morale of staff and officers is never discussed before committing such expenses.
Action at the Top:
Boeing has taken some measures to penalise the top management - Boeing CEO Dave Calhoun is stepping down along with several top-level executives. Boeing Chair, Larry Kellner, has announced that he will not run for re-election, and Boeing Commercial Airplanes CEO Stan Deal is also stepping down.
#Safety #Boeing # Boeing 737MAx #Railways #Balasore
