The 737 MAX: Human Factors in Complex System
summary
A design workaround adds larger forward-mounted engines that increase nose-up tendency, so Boeing implements a software fix called MCAS that reads angle-of-attack inputs and drives the horizontal stabilizer. After removing a redundancy and boosting MCAS authority it can move trim over four times farther than originally analyzed, MCAS activates from a single faulty AoA sensor, pilots receive no documentation or type‑rating training to avoid retraining costs, and two failures kill 189 and 157 people, grounding 387 jets and costing at least $7.3 billion.
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chapters (22)
- 0:00Introduction and speaker background
- 1:50What is human factors engineering
- 3:36Life critical systems overview
- 5:02737 MAX crashes and impacts
- 7:09Timeline of the 737 MAX development
- 9:37Engine design changes and MCAS introduction
- 13:03Type ratings and training simplification
- 15:52Boeing's decision to hide MCAS
- 17:39Manual override systems in the cockpit
- 19:25Lion Air Flight 610 crash analysis
- 23:14Ethiopian Airlines Flight 302 crash analysis
- 25:44Summary of the two crashes
- 26:27When to teach users about complex systems
- 29:17Performance versus knowledge curve
- 31:49Boeing's flawed safety assumptions
- 32:30Ensuring users recognize system issues
- 36:44Levels of automation in systems
- 38:52Redundancy and single points of failure
- 42:04Change management and MCAS modifications
- 44:11Retiring legacy systems and compromises
- 44:53Developers' responsibilities in safety
- 47:00Q&A session introduction
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