Case of Boeing 737-MAX: Safety Issues and Management


According to customers’ surveys, safety is the main concern for those travelling by air. Interestingly enough, statistically, the chances of perishing due to an airplane crash are meager. Today, they are estimated at one in 11 million for a single person taking a commercial flight. For the sake of scalability, one may want to compare the odds to those for a car crash – one in 5,000 (IATA, 2018). Yet, despite their rarity, airplane crashes are probably some of the most socially resonant incidents, generating media attention and raising concerns among airline customers. Probably, one of the most “unfortunate” airline models that has quite a history of disastrous crashes is Boeing 737.

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The older model has seen tens of accidents since the 1940s. Its successor, Boeing 737-MAX crashed two times – in 2018 and 2019, killing more than 300 people, including the crew. The tragedy ended up in an array of sanctions against Boeing with aviation authorities grounding the model across the board. It is readily imaginable how big of a blow the reputation of the airline took after two consequent crashes and what it will require to restore it. This paper discusses the safety management trajectory of Boeing 737-MAX. Aside from this, the paper ponders the implications of the incident for Boeing and the entire industry.

The Case of Boeing 737-MAX 3 pages
Indonesian Plane Crash

Lion Air Lion Air Flight 610 was supposed to be regular domestic flight by the Indonesian airline Lion Air. On October 29, 2019, the Boeing 737-MAX left Soekarno-Hatta International Airport in Jakarta for Depati Amir Airport in Pangkal Pinang. The plane did not make it to its destination: 13 minutes after takeoff, it crashed into the Java Sea (Calder, 2019). The incident became the deadliest in Indonesian history – it took the lives of 189 passengers and crew. For the new Boeing 737 MAX, it was the very first incident; for the model in general, it was the most tragic out of all the crashes it had.

Right after the incident, the Indonesian government started a search and rescue operation. In three days, the troop was able to locate the flight data recorder and recover information for analysis. Preliminary investigation suggested that the crew struggled with flight control. The flight control issues were nothing new for the model: on the previous flights, they led to traumas in passengers and the crew.

Apparently, it was not taken seriously enough as well as the obvious problems with Angle of attack (AoA) sensors were dismissed and forgotten. It was the inherent design flaw in the Maneuvering Characteristics Augmentation System (MCAS) of the 737 MAX series that led to the crash. Despite the deaths of hundreds of people and previous reports indicating unsolvable issues, the model was not grounded. Instead, the United States Federal Aviation Administration and Boeing took preventive measures. They issued warnings and training advisories to all operators of the 737 MAX series.

Ethiopian Plane Crash

On March 10, 2019, flight ET302 left the Ethiopian capital Addis Ababa at 08:38 local time for a two-hour flight to the Kenyan capital, Nairobi. At 08:44, six minutes after it took off, the plane crashed in 30 miles from the airport, next to the town of Bishoftu (Calder, 2019). The magnitude of the impact misplaced both engines, burying them at a depth of 10m, in a hole 28m wide and 40m long. The crash was fatal for 157 passengers, coming from 35 countries. On board were 32 Kenyans, 18 Canadians, nine Ethiopians, and eight Americans. The UN Secretary-General, Antonio Guerras, called the catastrophe a “global tragedy (Calder, 2019).” Many of the passengers on the flight were UN-affiliated and on their way to an international UN conference on environmental issues in Nairobi, Kenya.

Soon after the crash, a new investigation started – now using the Lion Air flight crash as the point of comparison for exposing the faults. As per the preliminary report conducted by Ethiopia’s Aircraft Accident, the airplane took off without issues. However, soon two sensors that were supposed to gauge the angle of the plane’s flight began to mingle the readings. That issue triggered an automated safety system, which ended up in the plane repeatedly diving with its nose down. As the report stated, the same issues were observed during the fatal Lion Air flight. The Ethiopian authorities reported the pilots’ attempts to disengage the automatic system. Namely, there was an attempt to steady the plan manually, but to no avail. The system continued to push the nose down until the airplane crashed.

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The official report only provided some details regarding the technical side of the crash. It did not state explicitly who or what was to blame for the fatal crash taking lives of hundreds of people. However, from the reading, it appeared clear that the main issue was the automated safety system, otherwise known as Manoeuvring Characteristics Augmentation System (MCAS). Initially, the system was designed to avert incidents where the plane would stall during steep turns when controlled manually. A stall is a term referring to a dangerous situation occurring when a plane takes off at an angle that is too steep. If something goes wrong, the lift created by the wings can decrease dramatically, which may end up in a crash.

Basically, the MCAS mimics what a pilot would do manually in case of stalling – pushes the nose of the plane down to change the angle of attack. The MCAS automatizes this reaction by making the change more precise and preventing the plane from dropping. In the case of the Ethiopian incident, the safety system was fed false readings from the sensor regarding the angle of attack. Therefore, it was impossible for the MCAS to interpret what was happening in any other than to classify it as stalling. According to the Ethiopian authorities, the incident had the following timeline:

a sensor on the pilot’s side provides false readings that hint at stalling, by which it triggers the MCAS that in turn, starts making the plane take a nosedive;
the pilots tried to rectify the situation: they adjusted the angle of tail stabilisers so that the nose could return to a more neutral position. For that, they used electrical switches on their control wheels, i.e. stabilized the angle manually;
the next step was to disable the electrical system that was providing power for the software;
two minutes before the crash, the crew made one more attempt to control the stabilisers manually, but it was difficult to accomplish due to high speed;
the attempt at manual control did not work out, so the crew had to turn the electricity back on. This led to the engagement of the automated system that plunged the plane into the ground.
Practical Implications for Boeing and the Industry

After the incidents that killed 346 people, Boeing went into a deep crisis. It is easy to see how to subsequent tragedies over the span of less than a year can damage an airline’s reputation for good. First, in the world that witnesses one catastrophe after another, people grow cautious of any situations that may endanger their lives. Regarding travelling by plane, psychologists even describe a particular type of phobia – aerophobia.

Busscher, Spinhoven, and de Geus (2015) state that aerophobia is a complex psychological condition that draws on many factors. Some people dislike the confined spaces of airplanes or get nauseous, but the overarching theme is fear for one’s life. Evidently, learning about incidents like Lion Air and ET302 can and do trigger phobias in people, which may turn them away from using the airline. Besides, due to the ubiquitous use of social media, every incident receives a large coverage (IATA, 2019). People learn all the details in an instant and make their conclusions – a process that is difficult to manage and control.

It appears that Boeing was not able to handle the situation properly right after each of the incidents. By not providing a meaningful reaction in the first days after the crashes, the airline only undermined its already shaky standing. The first moments after the catastrophe were the time when the company could share information and provide guidance – to governments, airlines, pilots, and others involved in the industry (Park & Johnson, 2019). While countries around the world and eventually the United States were grounding flights involving the unfortunate model, Boeing kept silence.

Silence is not a valid management strategy in today’s environment. As Larry (2019) puts it, the modern world has adopted a different system of values regarding safety in transportation. Larry (2019) argues that first and foremost, Boeing was supposed to focus on transparency, credibility, accountability, and responsibility. What is especially surprising is that an American company chose to disengage from the situation, given that the American corporate culture promotes straightforwardness, clarity, and action-orientedness.

Crisis management is very different from common knowledge. If in everyday life, silence is golden, when an accident occurs, a company has no right to stay aloof. In the case of Boeing, silence can be interpreted as agreement – the destructive kind (Larry, 2019). Back then, what was required was not generic apologies and condolences but factual information clarifying the situation. Larry (2019) states that when Boeing actually spoke up, it preferred to present the issue as B2B (business-to-business) and not B2C (business-to-customer).

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Namely, the company’s spokesmen used engineering and computer science vocabulary to explain what happened. Larry (2019) thinks that Boeing did not show enough consideration for whether people who are not involved in aircraft engineering could understand the situation. All in all, the initial response onBoeing’s side was not well-calculated, and more troubles had yet to come.

Two incidents in a row with the death count this high led to immediate sanctions against Boeing. By now, the model has been grounded for more than eight months with no resolution. Boeing settles one lawsuit after another, and as the company states now, it is not up to the airline to decide whether the model will be employed again. The company took a $5 billion after-tax charge in the second quarter of 2019 to make amends to airlines impacted by the grounding.

Moreover, it seems that the two Boeing incidents had a larger scope of damage to the industry than expected. Josephs (2019) states that even those airlines that did not have Maxes in their fleet (e.g. Delta Airlines) suffered from the grounding. They experienced more air traffic than usual and ran into non-fuel related costs such as higher employee wages. While Boeing 737-Max is grounded, other models have to work overtime to compensate for its absence.

What Boeing Has Done to Rectify the Situation

Despite the initial poor response to the situation, as of now, Boeing is taking active measures to fix the faulty software and ensure safety for passengers and the crew. Earlier this year, Boeing published a return-to-service update on the airplane model under the motto of “Safety. Quality. Integrity.” The company expressed commitment to bringing about a change not only in how Boeing 737-MAX operates but also how the entire company regards issues of safety and accountability. The report covered the six key aspects with regards to the two fatal incidents:

Boeing stated that the new, updated software has three layers of protection. The company has changed the flight control to allow for more safety and redundancy. The new model had been through 800+ test and production flights, totalling to 1500 hours of testing. Thus, according to Boeing 737-MAX, the main problem that led to the incidents has been fixed; however, the official review of the updates has yet to come;
Boeing introduced comprehensive safety training with global regulators. The company made sure to maintain communication between pilots around the globe. Besides, it implemented one of the most innovative methods of training in the aircraft industry – simulator sessions. 90% of MAX operators participated in simulation training to become familiar with software update. Aside from the crew, regular employees also participated in quality stand-down and training;
In order to improve fleet support, Boeing organized a 24/7 operations center that delivers high-quality on-the-ground support. The company applied the entry-into-service approach to easen the return of MAX to service with advanced analytics;
Boeing made an effort to involve all the stakeholders in the value co-creation process. For businesses and organizations (operators and financiers), the company organized 20 global conferences that united 1100 experts from 250 organizations. As for customers, they had a chance to partake in simulator sessions to make sure that the new software is safe. All in all, Boeing made continued listening, gaining, and providing feedback an indispensable part of its newest safety management;
Boeing augmented airplane production by ensuring quality and stability across production system. The company is now closely collaborating with 900 suppliers for Boeing 737-MAX. It is taking proactive measures to make measured decisions and plan for the future;
Boeing acknowledged the impact that the incidents had not only for the company but also for the entire industry. Therefore, Boeing made it a point to become a trailblazer in improving safety across the board. One of the current goals is to strengthen the culture of safety at Boeing and on the market. Earlier this year, the company separated Chairman and CEO positions, making its current CEO lose its Chairman duties and privileges. According to Boeing, it was made to provide CEO with more time and space to focus on safety. Lastly, Boeing made safety, quality, and integrity the focus points of its annual recommitment (Boeing, 2019a; Boeing, 2019c).

As seen from the list of proposed and implemented changes, Boeing approached the issue from three different standpoints – technical, organizational, and people-centered. Even though the faulty software (MCAS) was the main issue behind the crashes, the company seems to have realized that updating it is nowhere enough. Boeing needs a structural change and rearrangement, affecting the company at all levels, starting with regular employees and ending with top management. Aside from that, Boeing acknowledged that the two crashes are a full-fledged humanitarian tragedy. Even technical and organizational fixes cannot help the families of the deceased and compensate for their losses.

Regarding the last point, it should be noted that Boeing established a compensation fund for victims and their families. As VOA News (2019) report, the families of the 346 people killed in two Boeing 737-MAX crashes will be eligible for $145,000 compensations from the company. So far, Boeing has set a $50 million worth fund to reach out to victims’ families. The initiative was launched in September, and the fund will continue accepting applications up until December 31, 2019. The company’s spokesman announced that those families who had already filed a lawsuit against the company will not have to waive their right to sue to receive their compensations.

From the description of the new policities, it seems that Boeing is serious about its intentions to improve safety. The question arises as to whether what has been done so far enough for the reviewing institution – the FAA (Federal Aviation Administration). The FAA has not yet provided any definite ruling, making the date of the removal of the grounding unclear. So far, the only thing that is apparent is that Boeing does not meet its own deadlines for fixes and updates. It is said that initially, the company planned to return Boeing 737-MAX before the fourth quarter of the year 2019. Now, the most optimistic prognosis is to see Maxes in February 2020.

According to Wallace and Marsch (2019), the delays in the review are happening for two reasons – one on Boeing’s and one on the FAA’s side. It is said that in the ongoing fourth quarter, Boeing has yet to submit to regulators its proposed fixes. The FAA, on the other hand, contributed to the delays by rejecting a typical timeline for a review. As Wallace and Marsch state, the FAA regards the case serious enough to approach it in a special way. The administration is conducting a thorough investigation that will take exactly as much time as it requires. At the same time, it seems that Boeing is not yet done inspecting its Maxes across the major airlines. It is not clear whether some airlines are showing resistance, but as Wallace and Marsch write, some airline operators claim that they never had problems with their Boeing airplanes.

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It seems that while waiting for the ruling, Boeing is expanding its scope of change to involve more aspects of its business operations. Namely, in one of the publicly accessible reports, the company describes ten more new changes that will be brought about across the board:

A permanent airspace safety committee will oversee safety, design, and development as well as ensure the best possible maintenance and delivery;
A newly established product and services safety organization will report directly to the company’s chief engineer and the Board of Directors;
Engineering function realignment will entail a new duty: engineers across the company will have to report directly to the chief engineer;
A new design requirements program will help the company to store data, learn from the past, analyze relevant information, and store reports in a convenient and accessible way;
The continue operation safety program will require the chief engineer to review all the safety reports;
Flight deck design and operation reexamination will be conducted in collaboration with stakeholders;
Safety promotion center expansion will focus on reaching out to global communities and exchanging experience;
Strengthening safety systems;
New capabilities: Boeing invested in advanced research and development tools;
Investing in new talent will address the global need to aerospace talent (Boeing, 2019b).

Lion Air and ET302 airplane crashes have been some of the deadliest aerospace catastrophes of this decade. In both cases, the model Boeing 737-MAX was employed, and the crew ran into the same issues with the faulty sensor and safety systems. The official reports have shown that the sensors miscalculated the angle of attack, feeding the automated safety system wrong information about the plane’s position in the air.

The system tried to save the plane from alleged stalling and pushed it nose down till it collided with the ground. In the first few days after each tragedy, Boeing did not handle the news well. It violated one of the main rules of crisis management by remaining silent. After some time, however, the company made a significant effort in addressing the issue from various standpoints. It fixed the technical mishaps, restructured the organization, and reached out to victims’ families. For all the efforts, the Federal Aviation Administration is reluctant to repeal the grounding.


Boeing. (2019a). 737-MAX return to service update. Web.

Boeing. (2019b). Ten fundamental changes. Web.

Boeing. (2019c). Your 737 MAX questions. Answered. Web.

Busscher, B., Spinhoven, P., & de Geus, E. J. (2015). Psychological distress and physiological reactivity during in vivo exposure in people with aviophobia. Psychosomatic Medicine, 77(7), 762-774.

Calder, S. (2019). Boeing condemned in Lion Air 737 MAX accident report. The Independent. Web.

IATA. (2019). Annual review-2019. Web.

Josephs, J. (2019). Costs pile up for airlines as Boeing 737 Max grounding enters eighth month. Web.

Light, L. (2019). Can the Boeing 737 Max brand reputation be repaired? 

Park, K., & Johnson, J. (2019). When Will Boeing 737 Max Fly Again and More Questions. The Washington Post. Web.

VOA News. (2019). Boeing Opens Compensation Fund for Crash Victims’ Families. Web.

Wallace, G., & Marsch, R. (2019). American Airlines hopes 737 Max flights to resume in mid-January as Boeing misses target for return. Web.

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