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All case studies

Catastrophic failureAerospace2018

Boeing

Boeing 737 MAX MCAS Crashes

Estimated impact: $20B+ in costs; 346 deaths; 20-month grounding

F12

Decision Quality Index

Critical — 7 biases detected, 5 toxic combinations

Two Boeing 737 MAX crashes (Lion Air 610 and Ethiopian Airlines 302) killed 346 people. The MCAS flight control system, designed to compensate for engine placement changes, relied on a single angle-of-attack sensor and could override pilot inputs. Boeing did not adequately disclose MCAS to airlines or pilots.

Decision context

Whether to certify the 737 MAX with a single-sensor MCAS system, classify it as a minor change to avoid pilot retraining requirements, and whether to ground the fleet after the first crash.

Deep hindsight-stripped analysis coming soon. This case is part of our ongoing backfill to reconstruct what the platform would have flagged at decision time. The summary and bias profile below are drawn from primary sources.

Biases present in the decision

Loss Aversion★ Framing EffectOverconfidence BiasAuthority BiasPlanning FallacyHalo EffectZeigarnik Effect

3D Decision Knowledge Graph

Boeing — 7 biases, 5 toxic combinations

Drag to rotate · Scroll to zoom · Click to explore

Decision

Critical

High

Medium

Toxic

Bias Intensity Profile

Severity × confidence across 7 detected biases

Toxic combinations

Blind Sprint
Yes Committee
Optimism Trap
Golden Child
Deadline Panic

Reference class base rates

Across all 146 curated case studies in our library:

90%

base failure rate

10%

base success rate

Lessons learned

Framing MCAS as a minor change avoided simulator training requirements but hid a system that could override pilots
Loss aversion: Boeing's competitive pressure from Airbus A320neo drove schedule-first decisions that compromised safety margins
After Lion Air, availability heuristic failure: Boeing and FAA did not ground the fleet because a single crash was not seen as systemic

Source: U.S. House Committee on Transportation and Infrastructure Report (2020); JATR Report (2019); Indonesian KNKT and Ethiopian AIB reports (Post Mortem)

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Boeing 737 MAX MCAS Design Failures

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NASA

NASA Space Shuttle Challenger Disaster

Catastrophic failure2003

NASA

NASA Space Shuttle Columbia Disaster

Lessons learned

Framing MCAS as a minor change avoided simulator training requirements but hid a system that could override pilots

Loss aversion: Boeing's competitive pressure from Airbus A320neo drove schedule-first decisions that compromised safety margins

After Lion Air, availability heuristic failure: Boeing and FAA did not ground the fleet because a single crash was not seen as systemic