The Boeing 737 Max 8 Crashes

System-based Approach to Safety — A Different Perspective

Abstract

This review article presents in a brief manner the lessons learnt from the Boeing 737 MAX 8 crashes using the System approach to safety perspective.  Learning the right lessons from past accidents is a huge challenge from the organisational learning perspective; as Professor James Reason cautioned us, “Being blessed with both uninvolvement and hindsight, it is a great temptation for retrospective observers to slip into a censorious frame of mind and to wonder at how these people [i.e. those involved in design and development, safety assurance of these planes] could have been so blind, stupid, arrogant, ignorant or reckless” (Reason 1990, p.214).  To distinguish it from the classical approach to safety, the “System approach” perspective used in the paper additionally includes human and organisational aspects.  Drawing upon a brief review of case studies published by Chizek (2020) and Daniels (2020), this paper highlights the need to conduct accident case study analysis based upon the concept of System approach to safety.  Such an approach will focus attention on two basic kinds of failures, namely, active and latent failures conditions.  Latent failure conditions relating to human and organisational factors in particular refer to fallible decisions made at the higher levels of a socio-technical system; these were defined by Reason (1990, 1993).  That identification of latent failure conditions, and addressing them, is a continuing challenge for both System safety research and System safety practice domains is also noted.