Incident: Boeing 737 Max Electrical Problem Grounds Fleet, Impacting Airlines

Published Date: 2021-05-13

Postmortem Analysis
Timeline 1. The software failure incident involving a potential electrical problem with the Boeing 737 Max fleet happened in late April [114062]. 2. Published on 2021-05-13. 3. The incident occurred in late April 2021.
System 1. Electrical power systems on the new 737 Max 8 airplane [114062] 2. Certain models of the 737 Max 8 and the 737 Max 9 [114062]
Responsible Organization 1. Boeing - The software failure incident was caused by an electrical problem in Boeing's 737 Max fleet, leading to the grounding of a portion of the planes [114062].
Impacted Organization 1. Airlines operating the Boeing 737 Max fleet were impacted by the software failure incident [114062].
Software Causes 1. The software cause of the failure incident was a potential electrical problem with the Boeing 737 Max fleet, leading to a grounding of a portion of the planes [114062]. 2. The issue was related to design changes in the Max's flight deck, resulting in insufficient electrical grounding of installed equipment, which could have led to the loss of critical functions and other problems on the flight deck [114062].
Non-software Causes 1. Insufficient electrical grounding of installed equipment due to design changes in the Max's flight deck [114062] 2. Engine failure in Pratt & Whitney engine-equipped Boeing 777 planes [114062]
Impacts 1. The software failure incident led to the grounding of a portion of Boeing's troubled 737 Max fleet for more than a month, affecting airlines in the United States [114062]. 2. The incident resulted in Boeing notifying 16 airlines and other customers of a potential electrical problem with the Max, recommending them to temporarily stop flying some planes [114062]. 3. The software failure incident affected 71 U.S.-registered planes and globally impacted 109 planes, amounting to more than a fifth of the 737 Max fleet [114062]. 4. The 2019 crashes aboard the 737 Max, which were partly attributed to software issues, killed 346 people and significantly damaged Boeing's reputation, leading to the firing of its chief executive and substantial financial losses [114062].
Preventions 1. More thorough testing of the electrical power systems on the new 737 Max 8 airplane before delivery to airlines could have potentially prevented the software failure incident [114062]. 2. Ensuring proper electrical grounding of installed equipment in the Max's flight deck through rigorous design and testing processes could have helped prevent the loss of critical functions and other problems on the flight deck [114062].
Fixes 1. Boeing received approval for proposed fixes to an electrical problem that grounded a portion of its 737 Max fleet, including updating the Max’s flight control software and rerouting some electrical wiring [114062]. 2. Boeing issued service bulletins for the affected fleet after receiving final approval from the regulator for proposed modifications to address the electrical issue [114062].
References 1. The Federal Aviation Administration (F.A.A.) [Article 114062] 2. Boeing [Article 114062] 3. The Wall Street Journal [Article 114062]

Software Taxonomy of Faults

Category Option Rationale
Recurring one_organization, multiple_organization (a) The software failure incident related to the Boeing 737 Max fleet involved a potential electrical problem that grounded a portion of the fleet. This incident is separate from the 2019 grounding directive after the crashes in Indonesia and Ethiopia. Boeing had to propose fixes to the electrical issue, and the Federal Aviation Administration approved these fixes, allowing the affected airlines to return the jets to service [114062]. (b) The software failure incident with the Boeing 737 Max fleet affected multiple organizations globally, as the electrical issue impacted 109 planes, which is more than a fifth of the 737 Max fleet. The issue was not limited to a single airline or country, indicating a widespread impact on various airlines operating the 737 Max aircraft [114062].
Phase (Design/Operation) design, operation (a) The software failure incident related to the design phase is evident in the article as it mentions an "electrical problem with the Max" that led to the grounding of some Boeing 737 Max planes. The issue was specifically related to design changes in the Max's flight deck, resulting in "insufficient electrical grounding of installed equipment" which could have led to the loss of critical functions and other problems on the flight deck [114062]. (b) The software failure incident related to the operation phase is also highlighted in the article when it mentions that the electrical power systems on a new 737 Max 8 airplane "did not perform as expected" during routine tests before delivery to an airline. This indicates a failure during the operation or testing phase of the system [114062].
Boundary (Internal/External) within_system (a) within_system: The software failure incident related to the electrical problem with Boeing's 737 Max fleet was within the system. The issue was specifically related to design changes in the Max's flight deck that resulted in insufficient electrical grounding of installed equipment, leading to potential loss of critical functions and other problems on the flight deck [114062].
Nature (Human/Non-human) non-human_actions, human_actions (a) The software failure incident related to the electrical problem in Boeing's 737 Max fleet was primarily due to non-human actions. The issue was related to design changes in the Max's flight deck that resulted in insufficient electrical grounding of installed equipment, leading to a potential loss of critical functions and other problems on the flight deck [114062]. (b) However, human actions were also involved in the aftermath of the software failure incident. Boeing and the F.A.A. had to work together to propose fixes, issue directives, and approve modifications to address the electrical problem in the 737 Max fleet. Additionally, the legal settlement with the Justice Department highlighted human actions that withheld information from the F.A.A. about changes made to software implicated in the crashes [114062].
Dimension (Hardware/Software) hardware (a) The software failure incident related to hardware: - The article mentions an electrical problem with the Boeing 737 Max fleet, specifically related to insufficient electrical grounding of installed equipment due to design changes in the Max's flight deck [114062]. - The electrical issue affected certain models of the 737 Max 8 and the 737 Max 9, leading to potential loss of critical functions and other problems on the flight deck [114062]. (b) The software failure incident related to software: - The article discusses how Boeing and airlines updated the Max's flight control software as part of the changes required for the fleet to fly again after the grounding following the crashes in Indonesia and Ethiopia [114062]. - The software failure incident is not directly attributed to software issues but rather to an electrical problem that required modifications to the electrical wiring and flight control software of the 737 Max fleet [114062].
Objective (Malicious/Non-malicious) non-malicious (a) The software failure incident related to the Boeing 737 Max fleet was non-malicious. The incident involved an electrical problem that was identified during routine tests before delivery to an airline. The issue was related to design changes in the flight deck that resulted in insufficient electrical grounding of installed equipment, potentially leading to the loss of critical functions and other problems on the flight deck [114062].
Intent (Poor/Accidental Decisions) poor_decisions, accidental_decisions (a) The software failure incident related to the Boeing 737 Max fleet was primarily due to poor decisions made by Boeing. The article mentions that the 737 Max plane was initially grounded in March 2019 after a pair of crashes in Indonesia and Ethiopia, which led to the grounding directive by the Federal Aviation Administration (FAA). The crashes were attributed to issues with the Max's flight control software and other changes made by Boeing. Additionally, the article highlights that Boeing later notified airlines of a potential electrical problem with the Max, which was unrelated to the 2019 grounding directive. This indicates that the software failure incident was a result of poor decisions made during the design and implementation of the aircraft's systems [114062]. (b) The software failure incident can also be attributed to accidental decisions or mistakes made during the design and manufacturing process. The article mentions that the electrical issue on the new 737 Max 8 airplane was related to design changes that resulted in insufficient electrical grounding of installed equipment. This design flaw led to a potential loss of critical functions and other problems on the flight deck, indicating that the incident was a result of unintended decisions or mistakes made during the development of the aircraft's systems [114062].
Capability (Incompetence/Accidental) development_incompetence (a) The software failure incident related to development incompetence is evident in the article as it mentions the 2019 crashes aboard the 737 Max that killed 346 people and deeply damaged Boeing’s reputation. This incident was attributed to the actions of two employees who withheld information from the F.A.A. about changes made to software that was later implicated in both crashes [114062]. (b) The accidental software failure incident is highlighted in the article when it discusses the electrical problem that grounded a portion of Boeing's 737 Max fleet. The article mentions that the latest electrical issue was unrelated to the 2019 grounding directive and was due to design changes that resulted in insufficient electrical grounding of installed equipment, potentially leading to the loss of critical functions and other problems on the flight deck [114062].
Duration temporary (a) The software failure incident in this case was temporary. Boeing had to ground a portion of its 737 Max fleet due to a potential electrical problem, which was not a permanent issue but rather a specific circumstance affecting certain models of the 737 Max 8 and 737 Max 9 planes. The problem was related to design changes in the flight deck that resulted in insufficient electrical grounding of installed equipment, potentially leading to the loss of critical functions and other problems on the flight deck [114062].
Behaviour crash, other (a) crash: The software failure incident related to the Boeing 737 Max fleet involved an electrical problem that could have resulted in loss of critical functions and other problems on the flight deck, potentially leading to a crash [114062]. (b) omission: The software failure incident did not specifically mention any instances of the system omitting to perform its intended functions at a particular instance. (c) timing: The software failure incident did not involve the system performing its intended functions too late or too early. (d) value: The software failure incident did not mention the system performing its intended functions incorrectly. (e) byzantine: The software failure incident did not involve the system behaving erroneously with inconsistent responses and interactions. (f) other: The software failure incident involved a potential electrical problem with the Boeing 737 Max fleet, leading to a grounding of a portion of the fleet and the need for proposed fixes to address the issue [114062].

IoT System Layer

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

Other Details

Category Option Rationale
Consequence death, harm, property (a) death: The software failure incident related to the Boeing 737 Max crashes in 2019 resulted in the deaths of 346 people [114062]. (d) property: The software failure incident led to Boeing paying billions of dollars in fines, settlements, and lost orders, as well as firing its chief executive [114062].
Domain transportation (a) The failed system was intended to support the transportation industry. The software failure incident was related to Boeing's troubled 737 Max fleet, which had been grounded due to various issues, including an electrical problem that required fixes to the flight control software and electrical wiring [114062]. The grounding of the 737 Max fleet impacted airlines and their operations, highlighting the significance of the transportation industry in this context.

Sources

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