Top-line result
F16/100
Decision Quality Index · Critical
A safety-of-flight decision made under time pressure with unanimous consensus, zero documented dissent among 20 participants, and explicit framing of a flight-control override system as a "minor change" to manufacture a regulatory outcome. Every dimension of the DQI framework is simultaneously failing.
Framing EffectPlanning FallacyGroupthink
Uploaded Document
The excerpt the platform analyzed
“Boeing's 2011 board presentation on the 737 MAX program (reconstructed from House Committee report): Boeing evaluated two options — a clean-sheet narrow-body design (est. $15-20B, 7-10 year timeline) vs. re-engining the existing 737 airframe with new LEAP engines (est. $3B, 3-5 year timeline). The board approved the re-engine approach in August 2011, citing: "Airbus is already taking orders for the A320neo. We cannot afford to cede the narrow-body market for a decade." Internal engineering memo (2012): "The larger LEAP engines change the aircraft's handling characteristics, particularly at high angles of attack. We recommend augmentation through a new flight control law." The MCAS system was designed as a "minor flight control modification" — framing that enabled Boeing to classify it as not requiring new type certification.”
Source:House Committee on Transportation and Infrastructure report (2020), Chapter 4; Boeing internal emails and memos cited in DOJ deferred prosecution agreement; FAA ODA audit findings·2011-08-01
Platform-detected signals
5 red flags in the document
Each flag below was detectable from the document text alone. No outcome data. No hindsight.
01
Choosing 3-5 year timeline over 7-10 year timeline primarily due to competitive pressure — time pressure overriding engineering completeness
Critical · Detectable at decision time
02
Framing a flight control system change as "minor modification" to avoid regulatory scrutiny — classic framing effect
Critical · Detectable at decision time
03
Engineering team's recommendation for augmentation acknowledged the handling change but was not paired with redundancy requirements
Critical · Detectable at decision time
04
Unanimous board consensus with no documented dissent — 20 participants yet no one flagged the safety tradeoff explicitly
Critical · Detectable at decision time
05
"No new type rating" as a selling point — anchoring customer value proposition to pilot training avoidance rather than safety
Critical · Detectable at decision time
Cognitive biases detected
6 biases across the document
★ Planning FallacyConfirmation BiasOverconfidence BiasGroupthinkAnchoring BiasFraming Effect
CEO / Board Question Simulator
Questions the steering committee would ask
Predicted from the document's own signals. In the live product, these are generated from your memo — no two runs produce the same list.
“Is there a chance we're underestimating planning fallacy risk on this decision — and what would change our mind if so?”
“Walk me through choosing 3-5 year timeline over 7-10 year timeline primarily due to competitive pressure — time pressure overriding engineering completeness — what's our defensible answer if the board raises it?”
“What would it cost us to do require dual-sensor AoA redundancy for MCAS from inception; disclose MCAS in the Flight Crew Operations Manual and require differences training for 737 NG pi… before we commit?”
“If this memo were re-run in six months with the outcome revealed, what do we think would embarrass us most?”
Counterfactual
What a bias-adjusted process would have done
Recommendation
Require dual-sensor AoA redundancy for MCAS from inception; disclose MCAS in the Flight Crew Operations Manual and require differences training for 737 NG pilots; escalate Curtis Ewbank's concerns to independent safety review outside the 737 MAX program office; separate the Boeing Designated Engineering Representative (DER) function from program schedule pressure; ground the fleet after Lion Air 610 pending root-cause analysis rather than after Ethiopian 302.
Why it would have worked
This is the clearest "framing effect kills people" case in the modern dataset. Classifying a flight-critical automated system as a "minor modification" to avoid simulator training is the bias in its most concrete form. The single-sensor design was knowable, documentable, and dissent was actively present — it was overridden by schedule/cost framing.
Estimated alternative outcome
737 MAX program ships 12–18 months later with dual-sensor MCAS and disclosed training. Both crashes avoided. Boeing avoids $20B+ in direct costs and its certification credibility stays intact — avoiding the subsequent 737 MAX 9 door plug, 787 quality, and leadership turnover cascade.
Evidence Timeline
What was visible, and when
Every event below was documentable before the outcome was known. The platform looks for signals like these in live memos.
- 2011-08American Airlines signals it will order Airbus A320neo unless Boeing responds — forcing Boeing to commit to re-engined 737 (MAX) rather than clean-sheet design.House Committee report, Ch. 2
- 2012Engineers discover larger CFM LEAP engines require mounting forward/higher — creates nose-up pitch tendency under certain conditions. MCAS is designed as a software fix.House Committee report, Ch. 3
- 2013Boeing internal decision to rely on a single Angle-of-Attack sensor for MCAS inputs (rather than both) to avoid triggering a new simulator training requirement.DOJ Deferred Prosecution Agreement, January 2021
- 2016-11Chief Technical Pilot Mark Forkner asks FAA to remove MCAS from the 737 MAX Flight Crew Operations Manual — approved.FAA correspondence, cited in House Committee report
- 2017-03-08FAA grants amended type certificate for 737 MAX — without requiring new simulator training.FAA Type Certificate, 737-8
- 2018-10-29Lion Air Flight 610 crashes into Java Sea, killing 189.KNKT (Indonesia) final report
- 2019-03-10Ethiopian Airlines Flight 302 crashes after takeoff, killing 157. Fleet grounded globally within 72 hours.EAIB Interim Report; FAA emergency order
- 2020-11-18FAA approves return to service after 20-month grounding and MCAS redesign to use both AoA sensors.FAA Airworthiness Directive 2020-24-02
- 2021-01-07DOJ Deferred Prosecution Agreement — Boeing agrees to $2.5B penalty for conspiracy to defraud the FAA.DOJ press release, January 7 2021
Who Was in the Room
Stakeholders and positions
Who advocated, who dissented, who was overruled, and who stayed silent — the most reliable single signal of decision-process quality.
Dennis Muilenburg
AdvocateCEO (2015–2019)
Oversaw MAX program through both crashes. Fired December 2019; received ~$62M in severance and stock.
Kevin McAllister
AdvocateCEO, Boeing Commercial Airplanes
Fired October 2019 amid MAX crisis.
Mark Forkner
OverruledChief Technical Pilot
Asked FAA to drop MCAS from pilot training docs. Acquitted at trial 2022 — jury accepted he was scapegoated for systemic decisions made above him.
Curtis Ewbank
DissenterBoeing engineer
Raised concerns about MCAS single-sensor design during development; concerns were dismissed.
Ali Bahrami
SilentFAA Associate Administrator for Aviation Safety
Previously Boeing lobbyist; symbolizes the FAA-industry revolving door flagged by NTSB.
Edward Pierson
DissenterBoeing 737 production manager (dissenter & whistleblower)
Warned senior leadership in 2018 about production-line quality breakdown at Renton facility.
Cross-Case Pattern
Other decisions with the same pattern
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