Boeing 737 Max could have seen 15 more crashes, but why did DGCA ignore threat?

Boeing knew that if a pilot didn’t react to the unanticipated MCAS activation on the B737 Max within 10 seconds, the result could be catastrophic

Boeing 737 Max could have seen 15 more crashes, but why did DGCA ignore threat?
A SpiceJet Boeing B737 Max. Image courtesy: Twitter/@flyspicejet

The final committee report prepared by the US Committee on Transportation and Infrastructure is a comprehensive study on the design, development and certification of the Boeing 737 Max based on the facts and data when the aircraft was certified to fly for the first time. There were two tragic accidents which followed in quick succession, which everyone will remember, involving Lion Air and Ethiopian Airlines. The B737 Max was grounded worldwide following these crashes.

There are a number of startling, yet expected conclusions that the report draws, but there is one which no one must ignore.

In December 2018, the Federal Aviation Administration (FAA) conducted a risk assessment based on its Transport Aircraft Risk Assessment Methodology (TARAM) and estimated that without a fix to the Manoeuvring Characteristics Augmentation System (MCAS) during the lifetime of the B737 Max, there could potentially be 15 additional fatal crashes resulting in over 2,900 deaths. Read the full report here.

The obvious question: Why wasn't the aircraft grounded?

The Boeing officials said that they were unaware of it, knew there was such a process, but didn’t know they had evaluated this plane and this system. But according to this analysis, the FAA, post the Lion Air crash, predicted that there could potentially be 15 more fatal crashes in the lifetime of these aircraft in operation. 

Boeing knew that if a pilot didn’t react to the unanticipated MCAS activation within 10 seconds, the result could be catastrophic.

Data-driven process

We have seen it with the Airbus A320 Neo engine trouble. The regulator, Directorate General of Civil Aviation (DGCA), refused to disclose if any kind of risk assessment was carried out by the operators or the regulator. Supposedly, informed decisions were taken by the regulator to facilitate the operation of the Neo aircraft and minimise disruption of schedules for the operators. Data-driven Monte Carlo assessment was not carried out. Safety, therefore, remains perceptional in nature. Ignorance remains a bliss for the regulator.

Also read: Boeing's killer B737 Max ungrounded, but Spicejet need not celebrate yet

The fact that there was a TARAM report on the Boeing 737 Max cannot be ignored. The question which arises is that the regulator looked the other way when pointed questions needed to be asked and a risk assessment carried out. A change management process under the Safety Management System will ask such questions in due course if the systems are implemented with an intent to enhance safety.

Ungrounding of B737 Max

The Boeing 737 Max's airworthiness directive has been approved by the FAA and it now rests on the individual regulators to independently assess the airworthiness and training aspects to deem the aircraft safe for flight. Will the regulators accept the FAA assessment of the B737 Max as they have been doing or make some cosmetic changes to the FAA AD in order to expedite the ungrounding and oblige the airlines in waiting?

Also read: IndiGo gets rid of A320 Neo ghost, GoAir planes continue to be scary

Where does the public stand in the whole process?

The travelling public is the main stakeholder and they need to be a part of the process. Unfortunately, the assessment is worded in a rather technical manner, thereby making the public disinterested. Safety, therefore, remains a rather intangible subject. Safety is seen around, but when looked up to help, fails to hold the weight of the structure.

Captain Amit Singh is a training and safety expert with over 30 years of experience in the commercial air transport industry. He has been associated with two startup low-cost carriers and has hands-on experience with their needs and challenges. He has been a part of the senior management at IndiGo and Air Asia India. Captain Singh has been speaking at international fora on training and safety. He is also the author of mindFly the Human Factors blog.

(This article first appeared in