Incident: Boeing 737 Max Flight Computer Software Glitch Detected during Review

Published Date: 2020-01-17

Postmortem Analysis
Timeline 1. The software failure incident with Boeing's 737 Max occurred recently as per the article [94234]. 2. Published on 2020-01-17 08:00:00+00:00. 3. The software failure incident with the Boeing 737 Max likely occurred in January 2020.
System 1. Boeing 737 Max flight computers [94234]
Responsible Organization 1. Boeing [94234]
Impacted Organization 1. Boeing [94234]
Software Causes 1. The software cause of the failure incident was an issue with the plane's flight computers related to the software power up monitoring function observed during a technical review of the Boeing 737 Max [Article 94234].
Non-software Causes 1. The issue with the plane's flight computers on the Boeing 737 Max was related to the software power up monitoring function, which checks for anomalies when turning on the computers [94234].
Impacts 1. The software failure incident with Boeing's 737 Max led to the grounding of the aircraft since March following two fatal crashes that killed 346 people [94234]. 2. The incident resulted in Boeing reporting more cancellations than new business in 2019, and its order book for the troubled 737 Max shrank by 183 jets [94234].
Preventions 1. Implementing more rigorous software testing procedures during the development phase to catch issues like the computer glitch before deployment [94234]. 2. Conducting thorough software quality assurance checks to ensure the proper functioning of critical systems like the flight computers on the Boeing 737 Max [94234].
Fixes 1. Boeing is working on a software fix for the safety system believed to be the cause of the two fatal crashes [94234]. 2. Boeing observed an issue with the plane's flight computers during a recent technical review and is planning to fix the problem [94234].
References 1. Source familiar with the matter mentioned in the article [94234]

Software Taxonomy of Faults

Category Option Rationale
Recurring one_organization (a) The software failure incident related to the Boeing 737 Max involved a new glitch with the plane's flight computers, which was not related to the software revisions made after two fatal crashes. This incident occurred within the same organization, Boeing, which has been facing challenges with the 737 Max software and safety system [Article 94234]. (b) There is no information in the provided article about a similar software failure incident happening at other organizations or with their products and services.
Phase (Design/Operation) design (a) The software failure incident related to the design phase is evident in the article. Boeing observed an issue with the plane's flight computers during a technical review of the 737 Max. The issue was related to the software power-up monitoring function, which checks for anomalies when turning on the computers. This indicates a failure due to contributing factors introduced during system development or updates [94234]. (b) The software failure incident related to the operation phase is not explicitly mentioned in the article. Therefore, there is no information available regarding a failure due to contributing factors introduced by the operation or misuse of the system.
Boundary (Internal/External) within_system (a) The software failure incident related to the Boeing 737 Max involved an issue with the plane's flight computers that was observed during a technical review. The issue was specifically related to the software power up monitoring function, which checks for anomalies when turning on the computers. This indicates that the failure was within the system, as it was a glitch within the software of the aircraft itself [94234].
Nature (Human/Non-human) non-human_actions, human_actions (a) The software failure incident in the Boeing 737 Max was related to a glitch in the plane's flight computers that was observed during a technical review. This issue with the software power up monitoring function was not related to the software revisions made by Boeing after the two fatal crashes. The glitch was discovered during the process of booting up the computers on the ground, indicating a non-human action as the contributing factor to the failure [94234]. (b) The software fix for the safety system believed to be the cause of the two fatal crashes was being worked on by Boeing, indicating human actions in introducing changes to address the software-related issues in the 737 Max [94234].
Dimension (Hardware/Software) software (a) The software failure incident mentioned in the article is not related to hardware issues but rather to a glitch observed in the plane's flight computers during a technical review. The issue specifically pertains to the software power up monitoring function when booting up the computers on the Boeing 737 Max [94234]. (b) The software failure incident is directly related to software issues, as Boeing has been working on a software fix for the safety system believed to be the cause of the two fatal crashes. The article mentions that the computer issue observed during the technical review is not related to the software revisions made to address the crashes but is a separate software glitch that Boeing intends to fix [94234].
Objective (Malicious/Non-malicious) non-malicious (a) The software failure incident related to the Boeing 737 Max was non-malicious. The issue with the plane's flight computers, specifically the software power up monitoring function, was observed during a technical review and was not related to the software revisions made to address the cause of the two fatal crashes. Boeing identified the issue when booting up the computers on the Max while on the ground, and the test was intended to find and fix any anomalies like this one. Boeing stated that they are making necessary updates and working with the FAA on submission of the software changes to ensure the 737 Max is safe and meets all regulatory requirements before it returns to service [94234].
Intent (Poor/Accidental Decisions) unknown The software failure incident related to the Boeing 737 Max involved an issue with the plane's flight computers that was observed during a technical review. The issue was related to the software power up monitoring function, which checks for anomalies when turning on the computers. This incident does not seem to be directly related to the software revisions made by Boeing to address the cause of the two fatal crashes. The test that revealed the computer issue was intended to find any issues like this one, indicating a proactive approach to identifying and addressing potential problems [94234].
Capability (Incompetence/Accidental) accidental (a) The software failure incident related to the Boeing 737 Max was not due to development incompetence. The article mentions that the issue with the plane's flight computers was observed during a technical review and was not related to the software revisions made by Boeing to address the cause of the fatal crashes. It was described as a glitch in the software power up monitoring function, which checks for anomalies when turning on the computers. Boeing was actively working on a software fix for the safety system believed to be the cause of the crashes, indicating a proactive approach to addressing the issue [94234]. (b) The software failure incident related to the Boeing 737 Max appears to be accidental. The article describes the computer issue as a new glitch observed during a technical review, indicating that it was not an intended outcome. The issue was discovered when booting up the computers on the Max and was not expected to occur during flight. Boeing stated that they are making necessary updates and working with the FAA on submission of the software changes to ensure the safety of the 737 Max, suggesting that the incident was accidental rather than intentional [94234].
Duration temporary The software failure incident related to the Boeing 737 Max involved a temporary issue with the plane's flight computers. The glitch was observed during a technical review and was related to the software power up monitoring function. It was noted that the issue would not occur during flight and was specific to the process of turning on the computers when the plane is on the ground. Boeing stated that they would fix the problem, indicating that it was a temporary issue that could be addressed [94234].
Behaviour other (a) crash: The software failure incident related to the Boeing 737 Max involved an issue with the plane's flight computers that was observed during a technical review. The issue was with the software power up monitoring function, which checks for anomalies when turning on the computers. This issue was not related to the software revisions made to address the cause of two fatal crashes, and it was noted that the problem would not occur during flight [94234]. (b) omission: There is no specific mention of the software failure incident being related to the system omitting to perform its intended functions at an instance(s) in the provided article. (c) timing: The article does not indicate that the software failure incident was related to the system performing its intended functions correctly, but too late or too early. (d) value: The software failure incident was not described as a failure due to the system performing its intended functions incorrectly in the article. (e) byzantine: The article does not mention the software failure incident being related to the system behaving erroneously with inconsistent responses and interactions. (f) other: The behavior of the software failure incident in this case was related to a glitch in the flight computers of the Boeing 737 Max, specifically with the software power up monitoring function. This glitch was observed during a technical review and was not related to the previous software revisions made by Boeing to address the cause of two fatal crashes. The issue was noted to occur when booting up the computers on the Max while on the ground, rather than during flight [94234].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence death, harm (a) death: The software failure incident related to the Boeing 737 Max did result in two fatal crashes that killed 346 people [94234].
Domain transportation (a) The failed system was intended to support the transportation industry. The software glitch was related to Boeing's 737 Max aircraft, which is a crucial component in the transportation sector [94234].

Sources

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