The Boeing 737 MAX case, When indifference to weak signals kills 346 people and costs 20 billion dollars
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Ladies and gentlemen,
After three decades of analyzing, charting and attempting to master operational risks in high-critical sectors, I have to admit that: few dossiers have frozen my blood as much as that of Boeing 737 MAX.
346 dead. More than 20 billion dollars of direct losses. Two new planes hit the ground in a few minutes. Yet, everything had been whispered, written, reported, years before the crashes of the Lion Air 610 flight and the Ethiopian Airlines 302 flight.
The MCAS: anatomy of a poorly designed system
In 2010, Airbus launched the A320neo with more efficient engines. Commercial pressure on Boeing was immediate and brutal. On August 30, 2011, Boeing approved the 737 MAX project — with the only CFM LEAP-1B engine — to recover the delay. The new LEAP-1B CFM engines, larger and more powerful, had to be placed forward and higher on the wing to ensure the distance from the ground.
This modification altered the aerodynamic characteristics of the plane, increasing the tendency to cabaret (to rotate a aircraft around its transversal axis to lift the snout (the bow) compared to the horizon line, usually to start a climb) at high angle of attack — with the concrete risk of entering the stall.
Boeing chose a software solution instead of structurally redesigning the aircraft. A choice that would require years of development and a complete new certification. The MCAS (Maneuvering Characteristics Augmentation System) was programmed to automatically lower the tail plane when the system detected an anomalous attack angle, bringing the muzzle down and thus compensating for the cabata trend.
A year before the 737 MAX was completed, Boeing made the system even more aggressive. While the original version was based on the data of at least two different sensors, the final version used only one — leaving the system without any protection against the malfunctions of a single component.
FAA, in its final report of November 2020, identified three key safety issues related to MCAS.
Safety Issue #1 — The unique sensor : the MCAS depended on a single sensor of the attack angle (AOA), without redundancy or cross-checking system. In aviation, the principle of redundancy is sacred. No critical system should depend on a single fault point. Here, this fundamental rule has been deliberately violated — for reasons of cost and calendar.
Safety Issue #2 — Reactivation every 5 seconds: when the sensor provided incorrect data, the MCAS was activated repeatedly, lowering the aircraft’s nose with increasing force. The pilots could counter it manually, but the system automatically reactivated every 5 seconds. The control of the aircraft became progressively impossible — exactly what happened on flights Lion Air 610 and Ethiopian Airlines 302.
Safety Issue #3 — Pilots did not know that the MCAS existed: Boeing had deliberately omitted to mention the system in the original flight manuals, to avoid the obligation of additional training on simulator. A training that would increase costs for airlines and reduce the commercial attractiveness of 737 MAX compared to A320neo. The pilots found themselves fighting a system of which they ignored the existence, operation and deactivation procedures. This was not a technical review. It was a deliberate, documented choice, valid at all levels of the command chain.
The weak signals, all ignored
- Internal reports suffocated
Commercial pressure was not limited to high management plans. It permeated every level of the Boeing organization — until engineers working directly on the 737 MAX program.
The investigation of the Transport Commission of the United States Chamber, which lasted 18 months and based on over 600,000 internal documents, revealed a chilling picture. Boeing employees were under constant pressure to comply with production and delivery calendars. The rush was symbolized by “goers with countdown” hanging on the walls of the conference rooms — an implicit but very powerful message: time counts more than safety.
In this climate, several engineers had expressed concrete concerns about the design of MCAS.
Their reports included three specific points:
- the subassessment of the criticality of the system
- dependence on a single AOA sensor
- the absence of training dedicated to the pilots.
These reports have not been lost by chance. They were systematically marginalized. The decision not to accept the proposed changes was not dictated by incompetence, but by the awareness that their implementation would entail a slowdown in the program, the need for a new certification and the obligation to impose a training on simulator to airlines. This choice would result in a loss of billions of dollars and would allow the Airbus A320neo to gain ground on the market.
The most revealing statement emerged during the investigation of the American Congress in 2020. A Boeing engineer had described the MCAS as “designed by clowns, supervised by monkeys”. A brutal phrase — but that hid something deeper than a simple frustration. It was the voice of a professional who saw fundamental safety standards compromises, and who knew no one was listening.
FAA CEO Michael Whitaker’s statement before the American Senate in September 2024 confirmed that this cultural issue was not limited to the 2018-2019 crashes. Boeing “must maintain robust security reporting programs and promote a safe and proactive signaling culture within its organizations”. Six years later, the regulator still imposed on Boeing what should have been the starting point.
In operating risk management, there is a fundamental principle:
- an organization in which those who report a risk are perceived as an obstacle to business — and not as a security guarantor — has already chosen, unknowingly, its next disaster.
Boeing proved it twice. In five months.
The cost of acceptance
When risk signals are systematically ignored, the final account is not only paid in cash. You pay in:
- human lives
- in reputation destroyed
- in deciduous organizations
- sanctions.
The Boeing 737 MAX case produced one of the most devastating balance sheets in the history of commercial aviation.
Human cost
346 people have lost their lives in five months. Not in two separate accidents — but in the same accident, repeated twice. The Lion Air 610 flight of 29 October 2018 and the Ethiopian Airlines 302 flight of 10 March 2019 followed the same sequence of events, produced by the same faulty system, ignored by the same people.
Behind all statistics is an individual, a family, an irrecoverable life.
The financial cost
The 737 MAX remained on the ground for 20 months — from March 2019 to November 2020 — the longest block in the history of commercial aviation. The total cost for Boeing has been estimated in over 20 billion dollars, including compensation to the families of the victims, reimbursement to the airlines, loss of orders, redesign costs and recertification.
In January 2021, Boeing reached an agreement with the US Justice Department for $2.5 billion — acknowledging that he deceived the FAA during the MCAS certification process. In September 2022, Boeing was ordered to pay an additional fine of $200 million to the SEC for misleading statements to accident investors.
The cost of not hearing engineers raising concerns? A fraction of these numbers.
The reputational cost
Boeing was an American engineering icon. A symbol of precision, reliability, technical excellence. The case 737 MAX has severed this reputation permanently.
The public’s confidence in commercial aviation was shaken. Airlines had to manage passengers who refused to board a 737 MAX. Some pilots formally asked not to be assigned to that type of aircraft. A brand built in decades has been damaged in a few months.
Operating and systemic cost
The supply chains have been destabilised. Suppliers who depended on Boeing programs suffered huge losses. The Board was decimated — CEO Dennis Muilenburg was fired in December 2019.
Mathe deepest cost, what does not appear in the budgets iscultural cost. As FAA CEO Michael Whitaker said in September 2024, six years after Boeing disasters, he must still be obliged to “encourage his employees to speak without fear of retaliation”. An organization where silence is still the norm has not yet paid the most important account.
The culture.
Conclusion
The Boeing 737 MAX did not collapse for a sudden technical failure. It collapsed for a chain of deliberate choices, documented, validated at all levels of an organization that had stopped listening.
Signals existed. Engineers had spoken. The quasi-incidents had been recorded. The unique sensor was a known heresy. The pilots didn’t know that the MCAS existed.
Yet, nothing has changed — until two planes have crashed to the ground in five months.
What this case teaches us, with a rare brutality, is that operating risk is not a support function. It’s a matter of survival. A risk management system worthy of this name does not merely map the risks on a table. Ensures unfiltered transmission of weak signals. Protects those who raise their voice. It imposes a real independence of control. And, above all, it refuses to subordinate security to financial performance.
As FAA CEO Michael Whitaker stated in front of the US Senate in September 2024 — six years after crashes — Boeing must still be obliged to build a culture in which employees can report risks without fear of retaliation. Six years. Two disasters. 346 dead. And the lesson has not yet been fully learned.
When you listen to “it’s under control” or “don’t worry” or similar phrases, ask yourself three questions: who says it, with what proof, and under which blind corner?
The biggest operating disasters do not come from the unknown. They come from identified, documented risks — and deliberately put aside.
Keep listening. Listen to the base. Treat each signal as a precursor of potential crisis. This is the risk manager’s DNA.
The day when you stop doing it, the price counts in human lives and billions.
Rodolfo Liuzzi, CEO Wrm
Sources: FAA Summary of the Review of the Boeing 737 MAX (November 2020) — ITAFSC, Boeing B737 MAX: The SMS Would Have Avoided Two Fatal Accidents (May 2021) — Il Sole 24 Ore, Le vicissitudini del Boeing 737 MAX (January 2024) — Report by the US Chamber Transport Commission (September 2020) — U.S. Department of Transportation, FAA Oversight of Boeing’s Broken Safety Culture, Michael Whitaker’s Declaration, FAA Director, US Senate (September 2024).