Semantron 23 Summer 2023

The Boeing 737 Max crisis

software, according to an NTSB report. 133 In Collins’ defence, they described themselves as ‘ merely executing Boeing's design […] denied making any errors in its work on the flight control computers.’ 134

Captain Davydov mentioned in the interview, ‘I don’t know why they didn’t limit the stabilizer travel for the MCAS system. I don’t get why the MCAS was p rogrammed to trim again and again even after pilots interfere in its operation by using the standard electric trim on the yoke in the other direction. ’ 135

It is clear that there were serious development flaws, which left pilots unclear as to why the MCAS had so much power in controlling the aircraft. Boeing employees’ attitudes also played a huge role here – the arrogance, the greed, and the overbearing attitude were the catalysts. Accidents wouldn’t have happened if Boeing employees had treated safety as seriously as it was stated on the company’s website. The root of the problem was the extremely poor company culture.

Evaluation: what could be improved or changed to increase flight safety?

All parties – Boeing, FAA, airlines and pilots – were flawed in the crisis. This should be a collective responsibility, while Boeing and FAA were the main culprits . It is evident that the crisis wouldn’t have happened if Boeing hadn’t had such poor company culture, and if the FAA had been more independent and ‘careful’. I agree that the whole B737 MAX scandal was an accumulation of human errors. Realistically, there shouldn’t be any ‘luck’ involved in the aviation industry, as everything is so systematic and evidence-based. These 2 crashes were catastrophic, but we were lucky to only have two crashes. According to a Transport Aircraft Risk Assessment Methodology (TARAM) conducted by the FAA after the Lion Air crash, it has been predicted that without fixing the MCAS problem, there would have been 15 more crashes throughout the lifetime of the Boeing 737 MAX aircraft. 136 This could have meant, more than 3000 lives could have been lost, due to this technical fault. After 18 months of investigation, Congress passed the Aircraft Certification, Safety, and Accountability Act. 137 This act calls for a change in the Organization Delegation Authorization (ODA) process, and more specifically, the ODA for Boeing. This strengthens FAA oversight. We have explored a lot in the cause of the crisis, but the true question is – how can we use this experience, and the 346 lives contributed, to improve aircraft safety and to avoid similar incidents from happening? In the short term, although a lot of improvement works and fixes have been done, it is still necessary for the aircraft manufacturers and aviation authorities to find ways that could further increase flight safety. ‘ The regulatory system generally works well and has a human factor in design process. The biggest challenge for the regulator is staying up to date with new designs and systems. This

133 Hamby 2019, Far from the Spotlight, a Boeing Partner Feels the Heat . 134 Ibid. 135 Davydov 2022, Email Questionnaire with Captain Denys Davydov by Matthew Wu . 136 Gelles (@dgelles) 2019, Here’s a shot of the TARAM analysis the FAA did after the first crash . 137 Cook 2020, Congress Passes ‘Aircraft Certification, Safety, and Accountability Act .


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