《知識》關於波音737 MAX事件「操控特性增益系統 (MCAS)」與波音企業文化的轉變 The Boeing 737 MAX Accident and the Transformation of Boeing's Corporate Culture

波音737 MAX事件是什麼？

2018年10月29日印尼獅子航空JT610航班與2019年3月10日衣索比亞航空ET302航班發生空難，合計346人喪命。兩起空難共同點是飛機皆為波音737 MAX 8，一款服役不到2年的新型飛機。在相關報導中MCAS成為了這兩起空難調查的重點。

操控特性增益系統 (Maneuvering Characteristics Augmentation System, MCAS) 是波音737 MAX客機獨有的一個自動化系統，主要功能是防止飛機失速。MCAS一旦感應到攻角過大，就會取代飛行員操作，自動讓飛機「低頭」，減少攻角，避免飛機失速；然而，假如攻角感應器失靈，讀取錯誤的數據，在飛機正常飛行時，電腦誤以為攻角過大，MCAS就有可能會下令飛機無故大幅「低頭」，向地面俯衝墜毀。

2019年4月4日，波音CEO Dennis Muilenburg發表公開聲明承認，顯然MCAS在這兩起空難事件中，因為讀取到錯誤的攻角資訊而被啟動。對此，波音發布了737 MAX軟體更新和培訓計劃，包括讓MCAS對比兩個測量飛機攻角的傳感器的讀數、MCAS只會在非正常條件下被觸發、人類飛行員對飛機的控制權始終高於MCAS。

為什麼波音要在737 MAX機型新增MCAS設計？
MCAS的設計背後，其實有段曲折的歷程，而這段歷程與波音的決策及波音的企業文化有關。

2011年春天，波音高層碰上一個重大難題。波音的主要客戶之一美國航空，通知了波音，他們準備要放棄原本的波音737機隊，改採歐洲空中巴士生產的A320 NEO (New Engine Option)的新一代客機。原因是空中巴士的新機型不僅改良了空氣動力特性，而且可以選用新款引擎，讓飛行更安靜、更環保，而且最重要的是更省油。

A320與737這兩款商用客機，是全球中短途飛航市場上的兩大競爭對手。對波音和空中巴士這兩家飛機製造業龍頭來說，中短程機型不但是產品線主力，更是公司主要獲利來源。以當時的航空業市況來看，A320和737幾乎可說平分秋色，各占有一半市場，但A320 NEO機型於2016年的問世，卻敲響了波音內部的警鐘。

和1980年代才問世的A320系列相較，737明顯是舊時代的產物。1967年首飛的737系列，為了方便乘客和貨物上下飛機，在設計上刻意地降低機身；但這項過去優勢，如今卻成了劣勢，因為新推出的環保省油發動機，體積上普遍較大，低底盤設計讓737在升級上變得礙手礙腳。

另一方面，波音最新機型787夢幻客機，當時又遭遇了難產，研發經費不斷推高，上市時間卻遙遙無期。此時若是737系列也必須打掉重練，從頭設計，勢必讓波音落入蠟燭兩頭燒的境地。在這時間點上，又傳出美國航空可能轉單到空中巴士的消息，波音若不能即刻回應，勢必流失大量訂單。

最終，波音高層做出了重大的決策，捨棄大改款這條路，僅就737原設計做小幅修正，只要讓舊機身能夠裝上新型引擎即可。相較開發全新737機型約需200億美元，改良版僅需25億美元。

保留大部分原設計，替波音省下大筆開發經費和冗長的飛安審核程序，但新引擎要如何裝載在低底盤737機身上，又成了頭痛問題。飛機機翼下掛了更大引擎，引擎底部就離地面越近，但引擎若離地面太近，會吸入地面雜物造成引擎受損危險，於是波音只好將飛機抬高，拉長起落架鼻輪20公分，但這還不夠，因此又把引擎的位置往前挪並提高，這樣才讓引擎達到安全的離地高度。

但這麼做，卻又造成了空氣動力特性以及操控感受上的改變。為了糾正這個問題，設計團隊決定在737 MAX加入MCAS設計，讓機身過度上仰時自動介入，壓低機鼻，好讓駕駛員獲得與過去一致的操控感，減少重新訓練的費用和時間，藉此加速737 MAX上市時程。

這個解套方案，順利通過了主管機關審核，讓新機型得以於2017年服役。然而，在2年內傳起2起737 MAX重大空難後，MCAS也馬上被外界認為是罪魁禍首。


波音企業文化的轉變

自1916年創立、被封為航空業先驅的波音，一直是美國聲譽最好的企業之一。疫情前，全球機場每1.5秒就有一架波音737起降。波音737 MAX事件背後主因，是波音從幾十年前逐漸墮落的企業文化導致。

在過去，波音很長一段時間都由工程師治理，這些工程專家對華爾街投資人不屑一顧，一心只想著產品的安全與性能。可惜一切在1997年與麥道公司(McDonnell Douglas)合併後變了調。

當時波音為迎戰日漸壯大的對手歐洲空中巴士，決定與擅長製造軍用飛機的麥道公司合併。合併後，麥道前執行長Harry Stonecipher出任波音總裁。曾在奇異工作十多年的Harry也將前主管，也就是奇異前執行長Jack Welch提倡的「股東至上」原則帶進波音。

1998年波音股價持續下跌，被逼急的Harry設計了一份價值計分表，鼓勵主管讓公司資產、支付成本輕量化。甚至曾有規定是，不讓工程師拿到完整的成本資料，免得知自己的設計被偷工減料。

2003年空中巴士首次超越波音，成為全球最大商用飛機製造商，於是波音以開發新機型波音787因應。開發前Harry規定：成本不能高於前款飛機波音777的百分之四十。為達到此目標，團隊只好將多項工作外包給便宜的小廠商。

《華爾街日報》曾做出一期深度調查報導，直指「供應商分包」政策導致波音飛安隱憂。據報導，與許多美國製造商一樣，波音越來越多將用於製造飛機複雜機器的零件生產外包了出去。

原本波音飛機的製造過程中，是先由數十家工廠製造客機的關鍵零件，之後波音再對這些飛機進行組裝。這其中就包括位於美國堪薩斯州威奇托市的一家規模龐大的機身工廠，波音一直到2005年都是這家工廠的所有者。

波音高層決定將工廠出售給私募股權投資公司，讓波音專注於總裝業務。在總裝過程中，波音可以為它們的飛機增加最大價值。這家工廠現在由上市公司Spirit AeroSystems經營，自從波音將其工作的這部分責任移交給Spirit後，後者一直受到生產問題和品質缺陷的困擾。這也導致2024年1月5日，美國阿拉斯加航空一架波音 737Max 9 機型在飛行途中機身部分脫落，導致機艙減壓。飛機緊急下降，最後成功折返波特蘭降落，萬幸未造成傷亡。

波音賣掉數間大型零件製造廠，只為讓公司的淨資產報酬率好看一點。然而這卻使團隊工作更困難，以往增加一個小零件，只要一通電話；外包後則需經過律師、採購主管層層關卡。且額外衍生的法律糾紛及監督成本，使公司營運成本提升，不得不把更多業務繼續外包，形成惡性循環。

早在2001年，波音一位名叫 John Hart-Smith 的航空工程師，在內部技術研討會上提交了一份白皮書，提醒同事注意分包策略的風險，尤其是如果波音外包了太多的工作，又沒有為供應商提供足夠的現場品質和技術支援，那麼「水平最低的供應商的能力，將決定了這個一流飛機製造商表現的上限。」 Hart-Smith 寫道「這些代價不會因為這些工作看不到而消失了。」這份報告在波音內部引起了轟動。它在工程師中流傳開來，張貼在工廠的牆上。

企業文化與方針有這麼大轉變，內部其實也有反彈聲音。當時一名曾效命波音的物理學家提出討論，認為開發飛機並非普通的製造業，不應以成本為決策導向。但員工卻深陷領導者設計的績效體制，無暇思考；2007年波音將高層的獎金計算基礎，改成資產淨額優化，亦即成本愈低能帶來愈多獎金。

2017年波音737 MAX首飛，波音獲利激增67%，走勢甚至延續到首場印尼空難後，2019年初年營收破千億美元，股價上漲至近 400 美元，創下新高。漂亮的數字使時任執行長的Dennis Muilenburg持續提升生產部門每月產能，好交付更多台737 MAX。Dennis 甚至因此拿到1000多萬美元的績效獎金。一直到第二場空難，波音737 MAX被踢爆各種瑕疵而被勒令禁飛後，Dennis 才領走約 6000萬美元的退休金下台。

針對波音737 MAX事件，以及波音企業文化的衰敗，也被Netflix拍成紀錄片「墜」，有興趣的讀者可以找來看看。

空中巴士怎麼看待波音737 MAX事件？

波音發生兩起重大737 MAX失事，在這段期間，波音的最大競爭對手空中巴士卻未乘勝追擊，甚至發表「相信波音會很快站穩腳步」的言論。業內人士表示，兩家公司獨特的雙頭壟斷局面、相似的營運策略，都是空中巴士不敢利用波音的困境來擴大市佔、超前對手的原因。

空中巴士採取謹慎態度的原因是，航空市場幾乎由空中巴士、波音壟斷，市場力量促使兩家公司保持一致，任何變動都有可能造成兩家公司大地震。維持大眾對飛機的信任感是雙方共同利益，針對飛行安全性作文章恐怕只會有反效果。空中巴士執行長談到737 MAX事件時表示：「這對航空業來說並不是好消息。」

曾啟發波音革新商用飛機市場的哈佛商學院教授Clayton Christensen，在2014年名為《資本家兩難》的文章中反思：「資本家的兩難多半源自像我們這樣的學者，推廣了一套判定企業成敗的財務公式，最終毒害了企業。」

企業管理大師Jim Collins在1994年著作《基業長青》中指出波音的成功關鍵是：「花費龐大資金、人力，完成大膽、刺激的目標。」意味著曾賭上身家、瀕臨破產也要研發新機型的波音，一旦轉從股東身上獲取收益，而非產品、技術，公司注定變得平庸。

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The Boeing 737 MAX Accident and the Transformation of Boeing's Corporate Culture

What is the Boeing 737 MAX accident?

On October 29, 2018, Lion Air Flight JT610 crashed, and on March 10, 2019, Ethiopian Airlines Flight ET302 also crashed. These two accidents resulted in the loss of 346 lives. The common factor in both accidents was that the airplanes involved were Boeing 737 MAX 8, which was a newly introduced aircraft type that had been in service for less than two years. The investigations into these accidents have focused on MCAS, a system that has been linked to the crashes.

The Maneuvering Characteristics Augmentation System (MCAS) is an automated system that is unique to the Boeing 737 MAX aircraft. Its main function is to prevent the aircraft from stalling by detecting excessive angle of attack. When MCAS senses this condition, it overrides pilot controls and automatically lowers the nose of the aircraft to reduce the angle of attack and prevent stalling. However, if the angle of attack sensor fails and provides inaccurate data while the aircraft is flying normally, the computer may mistakenly interpret the data as indicating a high angle of attack. As a result, MCAS may order the aircraft to suddenly lower its nose for no apparent reason, causing the plane to dive and potentially crash.

On April 4, 2019, the CEO of Boeing, Dennis Muilenburg, publicly acknowledged that the MCAS was activated in two accidents due to incorrect angle of attack information. In response, Boeing released a software update and training plan, which involved comparing the readings of two sensors that measure the aircraft's angle of attack. Additionally, MCAS will now only be activated in abnormal conditions, and human pilots will always have control over the aircraft.

Why did Boeing add the MCAS design to the 737 MAX?
The design of MCAS has a complex history, influenced by Boeing's decision-making and corporate culture.

In the spring of 2011, executives at Boeing faced a significant challenge when American Airlines, one of its major customers, informed them that they intended to replace their existing fleet of Boeing 737 planes with the new generation of Airbus A320 NEO (New Engine Option) aircraft. The reason for this shift was that the new Airbus models not only boasted improved aerodynamics but also offered the option to choose new engines, resulting in quieter, more eco-friendly flights, and most crucially, enhanced fuel efficiency.

The Airbus A320 and Boeing 737 are the two main competitors in the global short- and medium-haul aviation market. These two models are also the main source of profit for the company. At the time, the market conditions of the aviation industry showed that the A320 and 737 were almost evenly divided, with each occupying half of the market. However, the launch of the A320neo model in 2016 sounded the alarm bells for Boeing.

Compared to the series of airplanes known as A320, which was first introduced in the 1980s, the 737 is clearly an older model. The 737 made its first flight in 1967, intentionally lowering the fuselage to make it easier to load and unload passengers and cargo. While this was a benefit in the past, it has now become a drawback, as the latest fuel-efficient and eco-friendly engines are generally larger in size. Due to its low-fuselage design, it's difficult to upgrade the 737 to accommodate these new engines.

Meanwhile, Boeing was facing challenges with their latest aircraft, the 787 Dreamliner. Research and development expenses were increasing, and the launch date was uncertain. If the 737 series also needed to be scrapped and redesigned, it would put Boeing in a difficult position. Furthermore, there were rumors that American Airlines might switch their orders to Airbus. To avoid losing a significant number of orders, Boeing needed to act quickly.

Boeing executives ultimately decided to make minor alterations to the original 737 design and incorporate new engines in the old fuselage instead of undertaking a major overhaul. This improved version would cost only $2.5 billion compared to the $20 billion required to develop a new 737 model.

Keeping most of the original design can save development costs and avoid lengthy flight safety certification procedures. However, the challenge was installing the new engine on the low-fuselage 737. The larger engines placed under the wings led to the bottom of the engine being closer to the ground, which increased the risk of debris getting sucked in and damaging the engine. To address this issue, Boeing had to raise the aircraft and extend the nose wheel of the landing gear by 20 centimeters. But even this wasn't enough, so the engine was moved forward and raised to ensure there was enough safe space around it.

To do so, the design of the 737 MAX caused changes in aerodynamic and flight experience for pilots. To solve this issue, the design team added the MCAS to the aircraft. This system automatically intervenes when the fuselage pitches up too much, pressing down the nose of the aircraft. This allows the pilot to have the same flight experience as before, reducing the cost and time of retraining. As a result, this accelerated the launch schedule of the 737 MAX.

The regulatory authorities approved the solution, which allowed the new model to be put into service in 2017. However, after two major accidents happened within two years, the MCAS system was immediately considered by the public to be the cause of the accidents.

The Transformation of Boeing's Corporate Culture

Boeing, established in 1916, has been a pioneering company in the aviation industry and has enjoyed a stellar reputation in the United States. Prior to the pandemic, a Boeing 737 took off or landed every 1.5 seconds at airports worldwide. The cause of the Boeing 737 MAX accident can be traced back to the weakening of the company's culture over the last few decades.

In the past, Boeing was governed by engineers who disdained Wall Street investors and focused on product safety and performance. However, everything changed after the merger with McDonnell Douglas in 1997.

In order to compete with its rival Airbus, Boeing decided to merge with McDonnell Douglas, a company that specializes in manufacturing military aircraft. After the merger, Harry Stonecipher, the former CEO of McDonnell Douglas, became the president of Boeing. Harry had worked at General Electric for more than ten years, and he brought the "shareholder primacy" principle advocated by his former boss, Jack Welch (the former CEO of General Electric), to Boeing.

In 1998, Boeing experienced a decline in its stock price. In response, Harry created a value scorecard to prompt managers to optimize the company's assets and reduce costs. To prevent engineers from realizing that their designs were being compromised, they were not given complete access to cost data.

In 2003, Airbus overtook Boeing to become the world's largest commercial aircraft manufacturer. In response, Boeing began developing the new Boeing 787. Harry, who was leading the project, stipulated that the cost of the new aircraft could not exceed 40% of the previous Boeing 777. To achieve this goal, the team had no choice but to outsource many jobs to small, inexpensive manufacturers.

A Wall Street Journal investigation revealed that Boeing's flight safety concerns were caused by its "supplier subcontracting" policy. To manufacture complex aircraft components, Boeing outsourced the production of parts like many American manufacturers.

In the past, Boeing used to manufacture key parts of their aircraft in several factories before assembling them together. One of these factories was a large fuselage factory situated in Wichita, Kansas, USA, which was owned by Boeing until 2005.

Boeing executives made the decision to sell their factory to a private equity investment firm. The sale allowed Boeing to focus on their final assembly business, where they could add the most value to their aircraft. The factory is now managed by Spirit AeroSystems, a listed company. Since Boeing transferred some of its work responsibilities to Spirit, the company has experienced production problems and quality defects. This led to an accident on January 5, 2024, when an Alaska Airlines Boeing 737 Max 9 aircraft lost part of its fuselage in flight, resulting in cabin depressurization. The plane made an emergency descent and safely returned to Portland without causing any casualties.

Boeing had sold off several of their large parts manufacturing plants in order to improve the company's net asset return rate. Unfortunately, this decision made the team's work more difficult than before. In the past, adding a small part to their production line only required a simple phone call. However, after outsourcing, they had to go through layers of lawyers and procurement managers, which resulted in delays and increased costs. Moreover, the additional legal disputes and supervision expenses further raised the company's operating costs, forcing them to outsource even more. As a result, this practice of outsourcing became a vicious circle that they couldn't easily escape from.

In 2001, John Hart-Smith, an aeronautical engineer at Boeing, presented a white paper at an internal technical seminar. His paper warned his colleagues about the risks of subcontracting strategy, especially if Boeing outsourced too much work and failed to provide suppliers with adequate on-site quality and technical assistance. Hart-Smith emphasized that the capability of the lowest-level supplier would determine the upper limit on the performance of this 'world-class' aircraft manufacturer. He also underscored that these costs would not go away just because they were not visible. This report caused a stir within Boeing. It circulated among engineers and was posted on the walls of factories.

In response to a new corporate culture and policy, there was some backlash from within the company. A physicist who worked for Boeing at the time argued that the development of aircraft is not the same as ordinary manufacturing and should not be driven solely by cost. However, employees were heavily involved in the performance system created by the company leaders and did not have time to consider this issue. In 2007, Boeing changed the basis for calculating executive bonuses to net asset optimization. This meant that the lower the cost, the more bonuses could be earned.

In 2017, when the Boeing 737 MAX made its first flight, Boeing's profits surged by 67%. This trend continued even after the first crash in Indonesia. In early 2019, Boeing's annual revenue exceeded 100 billion US dollars, and its stock price reached a new high of nearly 400 US dollars. The impressive numbers motivated then-CEO Dennis Muilenburg to increase the monthly production capacity of the production department to deliver more 737 MAXs. Dennis even received a performance bonus of over 10 million US dollars for this achievement. However, it wasn't until the second crash, when the Boeing 737 MAX was found to have various flaws and ordered to be grounded, that Dennis resigned with a retirement package of roughly 60 million US dollars.

The accident involving Boeing 737 MAX and the decline of its corporate culture have been documented in "Downfall: The Case Against Boeing" by Netflix. Interested viewers can watch it.

How does Airbus view the Boeing 737 MAX Accident?

While Boeing suffered two major crashes of their 737 MAX, Airbus did not take advantage of the situation. Instead, they even made statements like "I believe Boeing will soon get back on its feet." Industry insiders think that Airbus did not take advantage of Boeing's challenge to expand its market share and overtake its rival due to their unique duopoly and similar operating strategies.

Airbus is taking a cautious approach because the aviation market is almost monopolized by Airbus and Boeing. Market forces are pushing the two companies to stay the same. Any change could cause a major earthquake for both companies. Maintaining public trust in airplanes is in the common interest of both parties. Trying to make an issue out of flight safety is likely to backfire. Airbus CEO said of the 737 MAX accident: "This is not good news for the aviation industry."

Clayton Christensen, a Harvard Business School professor who once inspired Boeing to revolutionize the commercial aircraft market, reflected in his 2014 article "The Capitalist's Dilemma": "The capitalist's dilemma mostly stems from scholars like us, who have promoted a set of financial formulas for judging corporate success, which ultimately poisoned the company."

In this 1994 book "Built to Last," management guru Jim Collins pointed out that the key to Boeing's success is: "Spending huge amounts of money and manpower to achieve bold and exciting goals." This means that when Boeing, which once risked its existence and almost went bankrupt to develop new models, turns to prioritizing shareholders' profits over investing in new products and technology, the company is bound to become average.