Boeing's 737 MAX 8 Disasters

John D. Sterman

James Quinn

Jul 26, 2023

Abstract

On October 29, 2018, Indonesia’s Lion Air flight 610, a nearly new Boeing 737 MAX 8 jet, plunged into the Java Sea at 400 miles per hour, killing all 189 people on board. Eight days later Boeing issued a bulletin to all 737 MAX 8 and 737 MAX 9 operators stating that “erroneous angle-of-attack data” could result in “uncommanded nose-down movement of the aircraft and that this action can repeat until the related system is deactivated.” The US Federal Aviation Administration (FAA) followed by issuing an Emergency Airworthiness Directive requiring Boeing to revise the operating procedures in its flight manual for 737 MAX aircraft, including the new Maneuvering Characteristics Augmentation System (MCAS), software designed to prevent the aircraft from stalling by automatically pushing the nose of the plane down it detected a high angle of attack. Boeing promised the software would be fixed in a few weeks, but by March 2019 the revisions were still not completed. Then, on March 10, Ethiopian Airlines flight 302 from Addis Ababa to Nairobi, Kenya, the same model 737 MAX 8, crashed shortly after takeoff, killing all 157 on board.

Under pressure from Indonesia and Ethiopia, airlines, pilots, the public—and the families of the 346 dead—the President of the United States ordered the grounding of all 737 MAX aircraft on March 13, 2019. Other nations followed suit, grounding Boeing’s best selling plane worldwide for 21 months. Hundreds of MAX 8 orders were canceled, Boeing suffered billions in losses, the CEO was replaced, and multiple civil and criminal investigations were launched. Evidence soon showed that the company’s own engineers and test pilots had known about the MCAS problem well before the crashes, but that knowledge was not shared with the FAA, airlines, or pilots.

Learning Objectives

This case explores the causes of and responses to the accidents, from multiple perspectives, from the design of the MAX 8 and MCAS software to Boeing’s corporate culture to government oversight. Questions to consider include:

What role did company engineers play in causing the two catastrophes? What about their managers? Their test pilots?
What role did Boeing’s CEO, board, and other senior leaders play in shaping the processes, procedures, and corporate culture that may have set the stage for the disasters?
Why were the problems with MCAS covered up?
Why didn’t the F.A.A. detect the flaws in the design before allowing the 737 MAX 8 to enter service?
How could future disasters be prevented?
And what of the families of the 346 victims?

Appropriate for the Following Course(s)

operations management, industrial engineering, computer science, product design, organizational behavior, corporate strategy, public policy, government regulation, and ethics