The Boeing 737 MAX Crashes (2018-2019)
* The Boeing 737 Max crashes (notably Lion Air Flight 620 crash and Ethiopian Airlines Flight 302 crash) revealed a series of failures that, at their core, violated basic common sense principles of safety and engineering.
* At the center was the MCAS, a sofware system designed to automatically push the aircraft’s nose down under certain conditions. A fundamental mistake was allowing MCAS to rely on input from a single sensor. In any safety-critical system, common sense dictates redundancy, cdross-checking muliple data sources to prevent one faulty reading from triggering dangerous actions. That safeguard was missing.
* Another issue was transparency. Pilots were not clearly informed about MCAS or how aggressiverly it could act. From a practical standpoint, its risky to introduce a system with significant control authority without ensuring the people responsible for the aircraft fully understand it. When the system malfunctioned, pilots were left confused and overwhelmed.
* There was a failure in prioritizing human factors. MCAS could repeatedly activate and counteract pilot inputs, creating a situaation where the aircraft behaved unpredictably. Common sense suggests that automated systems should assist, not fight, human operators, especially in high-stress scenarios.
* Finally, organizational decisions reflected poor judgment. Efforts to minimize costs and avoid extensive pilot retraining led to downplaying the system’s importance. Basic safety culture would prioritize thorough training and disclousure over convenience or competitive pressure.
* In short, the crashes weren’t caused by a single obscure technical flaw, they stemmed from igoring straighforward safety principles; build in redundancy, communicate clearly, respect human operators, and prioritize safety over cost or speed.
NO COMMON SENSE
ANALYZE THE EXAMPLE
* Which supports and barriers were in play?
* What were the dynamics?
* Who, or what, won the Tug-of-War?
* Discuss the outcome with your friends and family.
* Use Post #4 as a reference for the relationships and dynamics between supports and barriers.
