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The Rough Notes Company Inc.



June 25
09:33 2019

Risk Management



Airplane giant feels negative effect of redundancy lapse

The definition of trust is the belief that someone is good and honest and will not harm you, or that something is safe and reliable.

Trust takes years to build, seconds to break, and forever to rebuild. That’s what happened at Boeing when two of its 737 MAX jets crashed within five months, taking 346 souls.

The company, founded by William Boeing in 1916, states on its website: At Boeing, our stance on ethical business conduct is simple: do the right thing, every time, and no exceptions. Ensuring that Boeing’s enduring values remain foundational to our work requires a daily commitment from every employee. Our robust ethics and compliance program is focused on integrity, respect, accountability, and inclusion—the same values that lead to strong business outcomes.

We all know the saying: “Actions speak louder than words.” Most of us would agree that this makes sense.

If agents want to be viewed as trusted advisors and not just policy peddlers, they must start their conversations with clients and prospects by explaining what they can prevent.

According to an article published in The Wall Street Journal, Boeing knew about the safety alert problem for a year before telling the Federal Aviation Administration (FAA) and the airlines that use its planes. If this is true, Boeing has a lot of explaining to do.

Reputation is built on trust. Boeing took a big hit that will cost it millions of dollars over time, and it may never fully recover. It also must live with the fact that its actions or inactions may have contributed to the tragic deaths of almost 350 people.

The first disaster occurred on October 29, 2018.Lion Air Flight 610, from Jakarta to Pangkal Pinang, Indonesia, crashed 13 minutes after takeoff, and all 189 people on board the aircraft were killed. This was the deadliest air accident involving all variants of the Boeing 737 and also the first accident involving the Boeing 737 MAX. This same plane had similar control problems on its previous flight but was able to land safely.

The second disaster took place on March 10, 2019. Ethiopian Airlines Flight 302, on a flight from Addis Ababa, Ethiopia, to Nairobi, Kenya, crashed six minutes after takeoff, killing all 157 people aboard. This plane was only four months old at the time of the accident. In response, aviation authorities around the world ordered the grounding of the 737 MAX, with several airlines voluntarily following suit. On March 13, 2019, the FAA became the last authority to ground the aircraft, even though it had said previously that the MAX was safe to fly.

While the investigation continues, former Boeing engineers and aviation officials have criticized Boeing’s original software design for relying on data from a single Angle of Attack (AOA) sensor, claiming that those devices are vulnerable to defects. They say this failed sensor relayed false data to the planes’ MCAS (Maneuvering Characteristics Augmentation System) and pushed the nose of the aircraft down until it crashed.

A report from the FAA states that since 2004 it had received at least 216 reports of AOA sensors failing or having to be repaired, replaced or adjusted, yet it relied on a single sensor for the 737 MAX. That’s a significant safety feature with no redundancy if it fails. This will make me pause every time I board a Boeing aircraft in the future.

This reminds me of a recent conversation I had with the operator of a welding robot at a parts manufacturer while doing a risk assessment for them. I had observed him going into the cage that surrounds the robot between welding cycles to make an adjustment. I asked about the lockout/tagout procedure and found that he was relying on one switch that paused the machine when the door was opened. The scary thing is that he didn’t come up with this on his own; he had been trained to do it this way.

It’s important to remember that every OSHA standard originated in response to a hazard in the workplace. According to OSHA, the standard for the Control of Hazardous Energy (Lockout/Tagout), Title 29 Code of Federal Regulations (CFR) Part 1910.147, addresses the practices and procedures necessary to disable machinery or equipment, thereby preventing the release of hazardous energy while employees perform servicing and maintenance activities. The standard outlines the measures for controlling hazardous energies—electrical, mechanical, hydraulic, pneumatic, chemical, thermal, and other energy sources. Violations of the standard are among the top 10 categories of OSHA citations issued each year.

Relying on a single safety switch or device is not lockout/tagout.

An appropriate lockout/tagout procedure consists of six steps:

  1. Preparation
  2. Shutdown
  3. Isolation
  4. Lockout/tagout
  5. Stored energy check
  6. Isolation/verification

These steps take time and are all too often ignored to increase production. The result? Production over safety instead of safety first.

If agents want to be viewed as trusted advisors and not just policy peddlers, they must start their conversations with clients and prospects by explaining what they can prevent. Then they can describe what they can control, and finally what insurance is needed. Ask yourself what you want to be remembered for: being a salesperson or a prevention, cost containment, and insurance specialist?

We have a choice. Let’s be certain we make the right one. Lives may depend on it.

The author

Randy Boss is a Certified Risk Architect at Ottawa Kent in Jenison, Michigan. As a Risk Architect, he designs, builds and implements risk management and insurance plans for middle market companies in the areas of safety, work comp, human resources, property/casualty and benefits. He has over 40 years’ experience and has been at Ottawa Kent for 37 years. He is the co-founder of, which are web apps for agents to share with employers. Randy can be reached at

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