Human Factors Challenge

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Team-Based Human Factors Challenges

 


    As we read from the FAA’s website about Human Factors in Aviation Maintenance, the FAA states, “Our research combines scientific understanding of human performance with applied studies conducted with industry partners. The results are solid science, psychology, and engineering delivered in plans, procedures, and software that can be immediately implemented to improve safety.” (Human Factors in Aviation Maintenance, n.d.) The last line about the software that can be implemented to improve safety brings up the Maneuvering Characteristics Augmentation System (MCAS) tragedies that caused two catastrophic crashes, killing 346 people, and grounding Boeing’s 737 MAX 8 in the process.

 

    In short, the MCAS was designed and released by Boeing for the new MAX 8. Due to the larger engines on the MAX 8, the engines were installed forward and higher than the previous positions. The engine housings create more lift, especially at high pitch angles, increasing the aircraft’s chance to enter a stall. The MCAS was designed to use the Angle of Attack (AOA) sensors and determine the aircraft’s pitch. If too high, the MCAS would take over and correct the trim system of the rear stabilizer and lower the nose.  The MCAS is suspected in being responsible for both the Lion Air and Ethiopian Airlines crashes by forcing both airplanes to go nose down regardless of pilot input. (Johnston & Harris, 2019)

 

    Boeing sold and certified the 737 Max as a minor upgrade to the 737 body. Meaning pilots would not have to retrain or spend time in simulators to fly the new 737 MAX, and in turn keeping the MCAS quiet amongst its release. Many factors including poor documentation, rushed release, delayed software updates, and humans out of the loop are all included in the complex situation. (Johnston & Harris, 2019) After the Lion Air crash, pilots complained that they had not been told about the MCAS or received training on it. There are three reports from the Aviation Safety Reporting System (ASRS) about the lack of documentation.

 

    The main problem I want to highlight in this scenario is the rushed release of the software, and the human factors that led to the accidents. Due to being nine months behind the Airbus A320neo, Boeing prodded the engineers in the production of the MCAS release. In conjunction with that, if there wasn’t time for the FAA to complete their reviews, FAA managers either signed off on the documents themselves, or delegated them to Boeing. The FAA noted this due to lack of funding and resources to carry out due diligence. Since the process was rushed, Boeing engineers later found a discrepancy and changed it without notifying the FAA. The FAA would go on to find out about the change when Boeing released a bulletin concerning the MCAS after the Lion Air crash. (Johnston & Harris, 2019)

 

    Ultimately, the FAA allowed Boeing to remove references of the MCAS system, withholding documentation and training from pilots, resulting in the accidents that very well could have been avoided. Between new Airworthiness Directives, potential new lawsuits, and criminal prosecution for Boeing, time will tell how they go forward with improving the culture within the company. (Bodell, 2023)

 


References:

Bodell, L. (2022, November 12). US watchdog will scrutinize FAA oversight of MCAS on Boeing 737 MAX. Simple Flying. Retrieved February 6, 2023, from https://simpleflying.com/boeing-737-max-faa-scrutiny-mcas/

 Human Factors in Aviation Maintenance. (n.d.). Federal Aviation Administration. https://www.faa.gov/about/initiatives/maintenance_hf

Johnston, P., & Harris, R. (2019). The boeing 737 MAX saga: Lessons for software organizations. Software Quality Professional, 21(3), 4-12. http://ezproxy.libproxy.db.erau.edu/login?url=https://www.proquest.com/scholarly-journals/boeing-737-max-saga-lessons-software/docview/2246851715/se-2

The real reason Boeing's new plane crashed twice. YouTube. (2019, April 15). https://youtu.be/H2tuKiiznsY 

Wall, R., & Sherman, M. (2019, August 19). The Multiple Problems, and Potential Fixes, With the Boeing 737 MAX. WSJ. https://www.wsj.com/articles/fixing-the-problems-with-boeings-737-max-11566224866

 

 

 

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