The goal of current study is to discern the antecedents of two airplane accidents involving the Boeing MAX 737. The theory of normal accidents serves as a lens to comprehend the hazard stemming from MAX design with dissonance between two critical systems: engine propulsion and flight control. Cooper’s framework further delineates lack of psychological safety during prototype development from the project’s inception along six dimensions: management/supervision, safety systems, risk, work pressure, competence, and procedures/rules. The analysis indicates dearth of leadership commitment for a safety culture under time pressure and budget constraint. Our results corroborate the paramount importance of the pilot’s extensive simulator training in order to test the interaction between the innovative Maneuvering Characteristics Augmentation System and human behavior response time. Lessons gleaned from the study include three insights. First, the importance of meticulously testing a prototype during the new product development stage and the hazard stemming from improvisation to extend the life of outdated engineering design. Second, the necessity of regulatory authorities, such as the Federal Aviation Administration, undergoing a modernization process by invigorating their ranks with data scientists attuned to 21st century skills in big data analytics. Third, FAA should diminish the delegation of self-certified permits to manufacturers.
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