Semantron 23 Summer 2023

346 lives: to what extent was the Boeing 737 MAX crisis due to a human error?

Matthew Wu

346 lives lost in 2 separate crashes, on the same type of aircraft, on 2 different airlines, due to the same cause, within 5 months. 1 These two accidents shattered the families and relatives of the deceased, but what shocked the world was: how did the product of the world’s safest company manage to crash twice? On 29 th October 2018, the very first Boeing 737 MAX incident was recorded. The aircraft involved was a Lion Air B737 MAX, delivered 3 months before the crash, in which, as a result of hull loss 189 people aboard lost their lives. 2 Boeing, suspecting their newly-developed system Manoeuvring Characteristics Augmentation System (MCAS) had gone wrong, issued an alert service bulletin, advising pilots what to do to tackle the ‘uncommanded nose down’

Figure 1: Service Bulletin issued by the Boeing Company a week after the crash of the Lion Air B737 MAX aircraft.

manoeuvre conducted by the aircraft itself. 3 The Federal Aviation Administration (FAA) issued an emergency Airworthiness Directives (AD 2018-23-51), 4 briefing all B737 MAX pilots about the potential nose-dive issue on the aircraft. Boeing reassured the public: ‘ We are confident in the safety of the 737 MAX. Safety remains our top priority and is a core value for everyone at Boeing. ’ 5 On 10 th March 2019, 6 the second Boeing 737 MAX aircraft crashed in Ethiopia, shortly after take-off. This news shocked the aviation industry. The fact that two brand new aircraft had crashed within 5 months was almost unbelievable. Countries started to ban B737 MAX aircraft from flying, and this sparked the 22-month long grounding of the aircraft, as well as investigations by the Boeing Company, which later on turned out to be one of the biggest scandals in aviation history.

1 Komite Nasional Keselamatan Transportasi 2019, Aircraft Accident Investigation Report – PK-LQP : 28; Aircraft Accident Investigation Bureau 2019, Aircraft Accident Investigation Preliminary Report – ET-AVJ : 12. 2 Aviation Safety Network [n.d.], PK-LQP .

3 Ostrower 2018, Boeing issues 737 Max fleet bulletin on AoA warning after Lion Air crash . 4 Federal Aviation Administration 2018, Airworthiness Directives AD 2018-23-51 . 5 The Boeing Company [n.d.], Boeing Statement on Lion Air Flight JT 610 Investigation . 6 Aviation Safety Network [n.d.], ET-AVJ .


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