Examining Risk Management Failures: The Case of the Boeing 737 MAX Program

Abstract

The loss of two Boeing 737 MAX aircraft, their 346 passengers and crew in 2018 and 2019 stunned the aerospace community and the flying public.  There is a natural inclination after an aviation mishap to ask, “What if…?”  What if latent design flaws in the system had been found earlier?  What if the aircrew had taken different steps in handling the non-normal events?  What if the B-737 MAX certification by the Federal Aviation Administration (FAA) had been handled more rigorously?  This paper will re-examine the antecedent events leading up to the mishaps through a counterfactual lens to envision how the two tragedies could have been avoided.  Throughout the paper observations based on our combined 120+ years of aerospace, engineering and risk management experience will be offered to readers.