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Case Study of 737 MAX Airplane sustainability Article Psychological Safety in Aviation New Product Development Teams: Case Study of 737 MAX Airplane Michael Naor 1,*, Nicole Adler 1, Gavriel David Pinto 2 and Alon Dumanis 2 1 School of Busines Administration, Hebrew University, Jerusalem 9190501, Israel; [email protected] 2 Industrial Engineering and Management, Azrieli College of Engineering, Jerusalem 9103501, Israel; [email protected] (G.D.P.); [email protected] (A.D.) * Correspondence: [email protected] Received: 6 October 2020; Accepted: 27 October 2020; Published: 29 October 2020 Abstract: 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a prototype during the new product development stage and the hazard stemming from improvisation to extend the life of outdated engineering design.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. Keywords: psychological safety; organizational culture; aviation safety; cooper’s culture framework; artificial intelligence 1. Introduction In October 2018, 189 passengers perished when Lion Air Flight 610 crashed a few minutes after taking off from Jakarta. Boeing implied that the crash was due to human error and embarked on a process meant to update the online training software administered to pilots. A few months later, in March 2019, Ethiopian Airlines Flight 302, a second airplane of same type, the 737 MAX model, carrying 157 passengers, crashed. Investigations into both accidents are continuing, but data from the black boxes’ flight data recordings immediately indicated several similarities between the two accidents. One major issue seems to be that the system designed to prevent the plane from stalling appears to have malfunctioned, instead pushing down the nose of the airplanes towards the ground. That system, known as MCAS (Maneuvering Characteristics Augmentation System, Figure1), was a recent addition to the MAX. However, most pilots were neither aware of its existence nor trained in how to override it. Sustainability 2020, 12, 8994; doi:10.3390/su12218994 www.mdpi.com/journal/sustainability Sustainability 2020, 12, 8994 2 of 15 Sustainability 2020, 12, x FOR PEER REVIEW 2 of 15 FigureFigure 1. MCAS Operations. BackBack inin 2011,2011, BoeingBoeing plannedplanned to design a brand-ne brand-neww airplane airplane to to substitute substitute the the aging aging fleet fleet of of 737. 737. Instead,Instead, vyingvying forfor controlcontrol ofof thethe 21st21st centurycentury market to replace agin agingg aircraft aircraft fleets fleets with with its its leading leading EuropeanEuropean rivalrival AirbusAirbus [[1],1], itit decideddecided toto upgradeupgrade the 737 instead. In In order order to to expedite expedite the the FAA’s FAA’s authorizationauthorization of of the the new new airplane, airplane, Boeing Boeing maintained maintained that that the the MAX MAX model model was was simply simply a a derivative derivative of theof traditionalthe traditional 737 737 aircraft. aircraft. However, However, that that was was not thenot case. the case. The aeronauticalThe aeronautical engineers engineers made made a major a modificationmajor modification to the airplane’sto the airplane’s airframe airframe which whic shiftedh shifted its center its center of gravity. of gravity. Had Had the FAAthe FAA known known that manufacturerthat manufacturer was making was making suchfundamental such fundamental redesign, redesign, it would it would have required have required the company the company to conduct to extensiveconduct extensive test flights test of flights a prototype of a prototype in order toin examine order to its examine systems its as systems contingency as contingency for approving for mass-productionapproving mass-production of the aircraft of [the2]. aircraft [2]. TheThe MAXMAX waswas designeddesigned toto bebe aa single-aisle,single-aisle, 200-passenger jet jet that that is is more more sustainable sustainable and and fuel fuel eefficientfficient thanthan previousprevious 737737 modelsmodels [[3].3]. To accomplishaccomplish these goals, goals, the the manufacturer manufacturer equipped equipped the the MAXMAX with with larger larger engines engines and shiftedand shifted their locationtheir lo forward,cation forward, which disrupted which thedisrupted plane’s aerodynamicthe plane’s structure,aerodynamic causing structure, it to become causing susceptible it to become to susceptible stalling under to stalling certain under flight certain scenarios. flight To scenarios. obviate thisTo problem,obviate this manufacturer problem, manufacturer developed the developed MCAS system, the MCAS which pushedsystem, thewhich plane’s pushed nose the down plane’s to stabilize nose thedown aircraft to stabilize [4]. When the aircraft needed, [4]. the When system needed, engaged the system automatically. engaged Theautomatically. pilots could The not pilots deactivate could itnot unless deactivate they hadit unless been they properly had been trained properly to do traine so ind to a do simulator, so in a simulator, and even and so, even the so, system the system would havewould reactivated have reactivated by itself afterby itself a few after seconds. a few Following seconds. theFollowing second accident,the second the accident, FAA grounded the FAA the MAXgrounded model the indefinitely, MAX model while indefinitely, engineers while struggled engineers to findstruggled a solution to find to a the solution aircraft’s to the engineering aircraft’s drawbacksengineering [5 drawbacks]. [5]. TheThe goalgoal of this study study is is to to investigate investigate the the antecedents antecedents of these of these airplane airplane accidents accidents involving involving the thenew new MAX MAX 737 737utilizing utilizing an organizational an organizational behavior behavior lens. The lens. chain The of chain events of that events led to that each led accident to each accidentare portrayed are portrayed with an withemphasis an emphasis on the dearth on the of dearth learning of learningcurve [6], curve which [6 ],could which have could saved have at savedleast atthe least passengers the passengers on second onsecond flight if flight the MAX if the fleet MAX ha fleetd been had grounded been grounded immediately immediately after the after first thecrash. first crash.Instead, Instead, the manufacturer the manufacturer responded responded to the to thefirst first crash crash by byplacing placing responsibility responsibility on on flight flight crew crew human-errorhuman-error and and appeased appeased the the FAA FAA by by issuing issuing an Operationsan Operations Manual Manual Bulletin Bulletin (OMB) (OMB) to remind to remind pilots howpilots to how behave to behave if they encounteredif they encountered a similar a emergencysimilar emergency situation situation again. When again. asked When in asked both houses in both of houses of Congress after the second crash whether he had any concerns about the system, the CEO Congress after the second crash whether he had any concerns about the system, the CEO of Boeing, Sustainability 2020, 12, 8994 3 of 15 Dennis Muilenburg, euphemistically replied: “I think about that decision over and over again. If we knew everything back then that we know now, we would have made a different decision.” [7] In its mission statement, Boeing emphasizes that one of its core values is its commitment to safety. “We value human life and well-being above all else and take action accordingly. We are personally accountable for our own safety and collectively responsible for the safety of our teammates and workplaces, our products and services, and the customers who depend on them. When it comes to safety, there are no competing priorities.” Schein [8] postulates that culture and leadership constructs are intrinsically connected. The Malcolm Baldrige National Quality Award supports this notion by positioning leadership as the first building block in its framework, which drives all elements of improvement [9]. Psychological safety is required in order to maintain the cultural traits mentioned above. Team psychological safety is defined as a shared belief that the organization constitutes a safe work environment for interpersonal risk taking in order to foster learning behavior, innovation, and growth [10]. The employees should neither be reprimanded for raising concerns during meetings about potential occurrence of defects in process that can
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