Do Lessons from the Boeing 737 Max disaster apply t​​o E&P?

Yes, they do!

An OEM decided that the fastest and cheapest way to add horsepower to their top drive’s motors was to change the software configuration tables’ horsepower limits. Why change out hardware and potentially redesign the entire top drive when you can meet the customer’s needs with a software tweak? What could possibly go wrong? 

Now let’s take a look at what occurred with the 737 Max.

Apparently the 737 Max pitched up a bit too much for comfort on power application as well as at already-high angles of attack. So, instead of going back to the drawing board and getting the airframe hardware right Boeing relied on something called the “Maneuvering Characteristics Augmentation System,” or MCAS. In other words, Boeing’s solution to its hardware problem was software. The result?

Lion Air Flight 610 took off from Jakarta, Indonesia on Monday, October 29th, 2018, at 6:20AM local time. Twelve minutes after takeoff, the plane crashed into the Java Sea, killing all 189 passengers and crew. Nearly five months later, Ethiopian Airlines Flight 302 took off from Addis Ababa, Ethiopia on Sunday, March 10th, 2019, at 8:38AM local time. Six minutes after takeoff, the plane crashed, killing all 157 people aboard.

Now, back to our top drive example. Though (thankfully) no one was harmed due to the top drive’s software tweak, months of drilling time were lost on a hazardous environment rig that had a limited drilling window. The causes were the same. A hardware manufacturer cut hardware development costs by a technologically questionable software change.

Why do you care?

When you get a quick change to software that your engineers know might be an untested and technologically risky tweak, do NOT accept it. There are other examples where faulty software has caused massive system failures and death. Don’t be one of those statistics.

What can you do about it?

You have the tools. We discussed them in some of our previous blog entries. Look at risk reduction though management of change, FMECAs and hazard identification and mitigation. Software can and will kill you and your employees – if you let it!!!

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