Boeings 747 Risk

Assessment
REBECCA CARUS – OGL 421 RISK ASSESSMENT
Case Study Overview

“ W i th h u n d re d s d e a d , t h e p o p u l a r 7 3 7 M a x j e t r e m a i n s g r o u n d e d a s i nv e s t i g a t o r s e x a m i n e
h o w a n a u t o m a t e d s y s te m o n t h e p la n e s c o n tr i b u t e d t o th e c ra s h e s ( G e l l e s , 2 0 1 9 ) .”

• W h a t i s t h e M A X 7 3 7 B o e i n g ? - I t i s a s i n g l e a i s l e j e t th a t c a rr i e s u p t o 2 0 0 h u n d r e d
p a s s e n g e rs . I t w a s r e m od e l e d a f t e r t h e m a ny v e rs i o n s o f t h e B oe i n g 7 3 7 fi r s t c a m e o u t
i n 1 9 6 0 ’s .

• Tw o l a r g e e n g i n e s a r e m o u n t e d o n e a c h s i d e o f th e a i r c ra f t. To o ff s e t s t a l l ri s k s M CA S
w a s d e v e l o p e d . M a n e u v e r i n g C h a ra c te r i s ti c s A u g m e n t a ti o n Sy s te m ( M A C S ) i n l a m e n t s
t e r m s a r e t w o s e n s o rs p l a c e d o n e a c h s i d e o f t h e p l a n e t o lo c a t e t h e w h e r e a b o u t s of t h e
a i rc ra f t w h i l e i n fl i g h t.

• T h e a i r c ra f t w a s s o s u c c e s s f u l fo r B o e i n g t h a t t h e y q u i c k l y o r d e re d 5 , 0 0 0 t o b e
m a n u f a c t u r e d . S i n c e t h e tw o m a l f u n c t i o n e d p l a n e s t h a t r e s u l t e d in h u n d r e d s d e a d t h e y
h av e h a d t o h a l t p r o d u c t i o n .
Case Study Overview
Continued

• Th e fi rst c ra sh took pl ac e Oc tober 1 8,

20 1 8 wh il e t he s ec on d cra sh to ok pla ce
Ma rc h 1 0, 2 0 19 .

• Re spon se to th ese i nc ide nt s we re th at

al l MA X fl ig h ts were t o be c an c ele d.

• A ll ev ide nc e tha t was re cove red

foll owing ea c h c ra sh poin ts t owa rds t he
MACS t ha t wa s put i nt o pla c e i n orde r
to avoi d st all s.
Risk Identification

The updates to the Boeing 737 have been well underway because the
company does not want to scrap costly work. What the engineers,
designers, sponsors, and all involved need to be doing is speaking to
those who will be operating the aircraft – the pilots. According to one
ar t i c l e , “ T h e Ve r g e   s p o ke t o a d o z e n p i l o t s , i n s t ru c t o r s , e n g i n e e r s , a n d
experts about the 737 Max and its development, rollout, and the two
crashes that have claimed the lives of 346 people. What emerged was a
story of cascading failure — the many small human errors at every
p h a s e o f t h e a i r p l a n e ’ s d e s i g n , c e r t i fi c a t i o n , a n d o p e r a t i o n p r o c e s s .
Those errors came to a terrible and deadly climax in the skies above the
J a v a S e a i n O c t o b e r 2 0 1 8 a n d a b o v e t h e E t h i o p i a n c o u n t r y s i d e fi v e
m o n t h s l a t e r ( C a m p b e l l , 2 0 1 9 ) .”
Risk Identification Continued. . .

What were the main sources of risk?

• Boeing rushed to compete with its competitor aircraf t, the Airbus, and placed the MAX 737 on the market
as quickly as possible.

• Due to Boeing cutting corners, pilots would only need an additional 2.5hour training program that could be
conducted via a computer or iPad. T h i s d o e s n o t i n s t i l l c o n fi d e n c e w i t h i n p i l o t s , p a s s e n g e r s , a n d i n v e s t o r s
with the capabilities of the pilots to handle the aircraf t.

• T h e M C A S m a y h a v e b e e n t h e c a u s e o f t h e c r a s h e s , b u t t h e F e d e ra l A v i a t i o n A d m i n i s t r a t i o n ( FA A ) i s j u s t a s
much to blame they reluctantly reported. The administration failed to abreast the pilots of the new system
installed or regulated its safety before allowing it to be utilized.

• N o a d d i t i o n a l t r a i n i n g w a s t h o u g h t t o b e m a n d a t o r y, a s i d e f o r a 3 0 m i n s e l f- s t u d y v i d e o o v e r o p e r a t i n g t h e
MCAS before piloting a plane.

• O v e r a l l , n o t e n o u g h t e s t fl i g h t s w e r e c o n d u c t e d a n d a f t e r t h e fi r s t i n c i d e n t t h e r e w e r e z e r o m a n u a l s i n
p l a c e t o a s s i s t t h e p i l o t s i f t h e m a l f u n c t i o n o c c u r r e d a f t e r t h e fi r s t i n c i d e n t .
Were these risks managed?

RISKS HOW THEY WERE MANAGED

1. W i t h n e w s o f t w a r e i m p l e m e n t e d B o e i n g n e e d e d t o c o n d u c t
1. N e w s o f t w a r e w a s i m p l e m e n t e d t h a t i s many test simulations. Following virtual sims live runs

s li g h t l y d iff e r e n t f r o m t h e o l d s y s t e m s . with only essential personnel should have been conducted

to ensure all was safe and the pilots understand the new
e q u i p m e n t f u l l y. These steps were not taken and this risk
2. N e w m a n u a l s n e e d t o b e c r e a t e d t o was not managed at all.

m a n a ge n e w s y s t e m s . 2. N o m a n u a l s w e r e c r e a t e d a n d s t o w e d o n t h e p l a n e f o r t h e
p i l o t s t o u t i l i z e i n t h e e v e n t o f a n e m e r g e n c y.

3. B o e i n g r e p u t a t i o n i s o n t h e l i n e w i t h a 3. B o e i n g w a s m o r e c o n c e r n e d w i t h c o m p e t i n g w i t h i t s
competitors rather than the safety of the product they
n e w a i r c ra f t o n t h e m a r k e t a g a in s t placed on the market. After two consecutive airplane

competitors. crashes their reputation spiraled downhill.

4. B e f o r e o r d e r i n g 5 , 0 0 0 M A X 7 3 7 t o b e e n g i n e e r e d a n d

4. C o s t e ff e c t i v e n e s s v e r s u s m a l f u n c t i o n s m a n u f a c t u r e d , B o e i n g s h o u l d h a v e v e r i fi e d t h e s a f e t y a n d
e ff e c t i v e n e s s o f t h e a i r c r a f t . The lawsuits alone from the
two incidents have left Boeing needing to push for the MAX
5. A i r c ra f t s t a n d a r d s u p t o c o d e a g a i n s t 737 to not be scrapped.

t h e FA A r e g u l a t i o n s . 5. W i t h t h e F A A l e a v i n g i t t o B o e i n g t o p o l i c e t h e i r o w n o n
maintaining aircraft standards and abiding by regulations,
B o e i n g s o i l e d a n y c h a n c e t h e y h a d a t b e i n g t r u s t w o r t h y.
In my opinion, were these risks handled correctly?

No, a t n o poi nt was a ny th in g h an dle d in th e m a nn er i t s hou ld have been . A s a we ll - k nown

ai rcraf t l ine i t took yea rs t o bu ild th e rep ut at ion th ey inc u rre d j ust t o s oi l it in th e na m e of
compe ti tion . Th e r ea son f or c om put er si m ul at ions t o te st out n ew s of t wa re i s to t est t he
dura bi li ty, li m its , a nd pote nt ia l r is k s b ef or e li ve t es ts be g in . A qua nt it at ive a nd qua l ita ti ve
ri sk a na ly s is a ss ess m en t sh ou ld have bee n c ond ucted . Or m ore s pec ifi c a lly th e st an in e
ap proa ch would h ave don e b ea uti fu ll y f or n ew s of t wa re a nd en g in ee re d d esi g n ed of t he M A X
73 7 . A ri sk m a tr ix i s wha t woul d have f ollowed ne xt in orde r t o ra te th e pr ob abi li ty an d
impa ct of ea c h va r y in g r is k as soc ia te d.

WH AT N EX T ?
Continued. . .

Ne xt, I wou ld have b ee n worr ie d a bou t t he ri sk res pons e pla n af t er th e d es ig n a nd sof twa re
pa sse d t he s im ul at ion ph as e. Whe n i t ca m e to th e overa ll pr ojec t I woul d say m it ig a ti on i s
th e b ig g e st a nd m ost re li ab le re spons e. If a n or g a niz a tion hol ds th e li ve s of i ts c on su m er s
wi th in th ei r g ras ps th an m i ti g at in g a ny hi cc up s i s th e b est p os si ble out com e . A f t er th e
fa il ure of th e en g in eer ed des ig n, u pon th e t wo horr ibl e pl an e c ra she s, t ra ns fer en ce i s
pre fe rr ed wh en fi na nc es a re i nvolve d. Th e or g a niz a tion t ook a h ug e pay ri sk wh en laws ui ts
we re t aken out on top of t he 5 , 00 0 M A X 7 37 ’s ord ere d t o be bu il t. I woul d s ay c ou ple
tra ns fe ren ce wi th es ca la ti on a s well t o c ap ita li ze on a ll ri sk r es ponse e ff or t s. Es ca la ti on
occur s wh en a ri sk is out side t he a uth ori ty of t he pr ojec t m an ag er an d I would say the
dea th of hu ndr eds of pa ss eng er s a f te r the FA A ap proved of the c h an g es fa ll s with in th at
ca te gor y.
Risk Solutions – What could have been done to avert project
risks?

• A SW OT i s a l way s i m por tant to have as i t l ets o rganiz ations w eigh the pros and cons of any
projec t l a rge or s mal l . Each pr oj ect s ho ul d benefi t an or ga niza tion in a large way w hether
or not i t i s a s teppi ng- s tone to a chi eve the go al s of a la rger pr oject overall . A SWOT al so
ass is t the o rg an i zat i on i n v i ew i ng the ri s k atti t ude whic h is how they would res pond to a
cer tai n ri s k s hou l d i t occ ur.

• A detai l e d and co nti nua l l y update ri s k r eg i s ter s hould have been draf ted, imple mented, and
util ized th ro ug h the en ti re proj e ct l i fecyc l e. Each i dentifi ed risk shoul d be assi gne d a level
of oc currenc e l i kel i ho od and t he fol l ow i ng i nf orma tion for e ach risk should be addre ssed.

• Identi fi cat i on, des c ri pti o n of ri s k , i mpac t on the proj ect with l evel ass igned, f requ enc y
of occ urrence addre s s ed, w ho i s res pons i bl e for s aid ris k, budget for risk that should be
al l o tted, and m i ti g ati on pl a n.
Risk Solutions Continued. . .

• A f t e r e a c h r i s k h a s b e e n i d e n t i fi e d a n d b r o k e n d o w n i t m u s t b e a n a l y z e d e v e n f u r t h e r. This means
evaluating the impact and likelihood of each individual risk that transpired.

• Next, identifying the risk triggers is crucial. If everything occurs in the order that was predicted the
p r o j e c t m a n a g e r s h o u l d b e a b l e t o a s s i g n r e s p o n s i b i l i t i e s t o s p e c i fi c t e a m m e m b e r s f o r e a c h t r i g g e r
t h a t h a s b e e n i d e n t i fi e d .

• Next, the team assigned for each risk and trigger should brainstorm solutions. All of this is
annotated on the risk register and updated continuously throughout the project. Contingency
methods should be placed in order to produce the best possible outcomes. This coupled with
creating a plan for each solution. M e a n i n g , o n e o f t h e t w o t y p e s o f m i t i g a t i o n p r o c e s s e s w i l l o c c u r,
p r e v e n t a t i v e o r c o n t i n g e n c y.

• L a s t l y, I c a n n o t e m p h a s i s e n o u g h t h a t c o n t i n u o u s l y m o n i t o r i n g a n d e v a l u a t i n g t h e r i s k s t h r o u g h o u t
the entire process is crucial. I f d o n e c o r r e c t l y, a p r o j e c t s h o u l d a l w a y s p r o g r e s s t o t h e e n d f a i r l y
s m o o t h i f n o t fl a w l e s s l y f o r t h e b e s t p o s s i b l e o u t c o m e s .
Reference(s)

• Gel le s, D. ( 20 1 9, M a rc h 22 ) . B oei ng 73 7 M a x: Wha t' s H a ppe ned A f t er the 2 D e adl y

Cra s he s. Retr ie ved Oc tober 0 9, 2 02 0, f rom
ht tps :/ /www. ny tim e s. c om /i nte ra ct ive / 20 1 9/b usi ne ss /b oe in g - 7 37 - crash es . ht m l

• Campb ell , D. ( 20 1 9, M ay 0 2 ) . Re dli ne . Retr ie ved Oct ober 1 0, 20 2 0, f rom

ht tps :/ /www. t hev erg e . com /20 1 9/ 5/2 / 18 51 8 17 6/ boei ng - 7 3 7- m a x- c ras h- pr oble m s- h um a n-
er ror- m c as - fa a