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Boeing 737 MAX Disasters’ Root Cause Was Government Regulation (Extended Version)

James Anthony
April 9, 2023

On October 29, 2018, on Lion Air Flight 610 out of Jakarta, Indonesia, a Boeing 737 MAX’s safety control pushed the plane’s nose down hard, paused for 5 seconds, then repeated this cycle, over and over. The pilots fought to pull the nose back up, only to get overpowered again and again. The passengers fell back against their seats, then fell forward, over and over. The seconds stretched on across all these souls’ last moments alive.

On March 10, 2019, on Ethiopian Airlines Flight 302 out of Addis Ababa, Ethiopia, another Boeing 737 MAX’s safety control operated this same way and crashed this second flight.

Deadly consequences follow when simplicity, controllability, innovation, and safety take a back seat. This happens when regulation is done not through the relentless choices of customers but instead by governments [1].

How Producers Learned to Stop Worrying and Love the Regulation

The National Advisory Committee for Aeronautics was created by Democratic Progressives in 1915, before Boeing started in business. The Air Commerce Act was enacted by Republican Progressives in 1926. From then on, civil-aircraft producers have been regulated by governments.

Regulators can’t be industrial-design peers who actively participate in design. Even if they could be, they would be few in number and wouldn’t even see plenty of contributions that are crucial to safety [2].

Regulators risk their reputations if they approve new products that cause harm [3]. On the other hand, regulators face little criticism if they slow-walk [4] or even deny approvals. As a result, regulators are strongly incentivized to severely limit innovation.

Producers minimize their business risks by not resisting regulators and by proactively limiting innovation. The incentives on regulators lead producers’ managers and designers to each barely innovate.

Working together as a fused government/business system, the Federal Aviation Administration (FAA) and Boeing blocked efficient new design of Boeing 737 MAX planes [5]. Boeing managers and designers prioritized marketability: more-efficient engines and wings, negligible training costs, and fast-enough development time, especially the certification time [6]. They took an existing design already certified by regulators and just made modifications.

The existing 737 design had minimal ground clearance. More-efficient engines had larger diameters, so aerodynamics designers moved the engines forward, with their centers higher [7].

This affected pilots’ control of the angle at which the plane flies through the air, which is called the angle of attack. If the angle of attack gets high enough, a plane’s wing suddenly stalls and loses lift, and the plane can crash.

Because of the 737 MAX designs’ engine placement, when a pilot throttles up, the angle of attack increases.

Even worse, as the angle of attack increases for any reason, it increases progressively faster [8]. Imagine if when you would press your car’s brake pedal, the pedal would start out stiff but then get looser as you brake harder. It would be natural for you to lock up the brakes and crash [9]. Piloting these planes in hard pitch-up maneuvers, it would be natural to pitch up too far, stall, and crash.

Compensating controls would need to be added to make these planes not pitch up when a pilot throttles up, and pitch up proportionately when a pilot pulls back on his control column. But the control designers didn’t add such intuitive, continuous basic control [10], they only added overpowering, abrupt safety control [11].

The original angle-of-attack safety control used a single sensor [12], and these sensors can fail if they hit a bird or ice up [13]. When this sensor would fail, this control would pitch the plane’s nose down, pause 5 seconds, and repeat until the plane crashed.

The current fix by Boeing managers and designers, approved by FAA regulators, is that now this control doesn’t override the pilots’ control-column commands. Also, the control uses two sensors, and if the sensors don’t agree, the control doesn’t take action at all. And the control only takes action one time [14]. So now if a single sensor fails or if the control takes action one time, the control doesn’t take action for the remainder of a flight, even though better, intuitive control is still required [15].

The plane’s angle of attack still intrinsically is poorly controllable. This controllability still isn’t improved by intuitive basic control. And this controllability now ends up barely addressed by the safety control that’s approved by government regulators.

If Regulation Was by Customers

Regulation by governments could simply be eliminated [16]. Civil-aircraft producers already have every incentive to keep everyone alive [17] and satisfied. Even so, producers need to not be incentivized by government regulators to compromise, and instead be incentivized by customers to improve.

Governments should make criminal punishment rare, but available to address sabotage. Governments should fully allow civil remedies [18], but limited to actual damages.

Governments should require patent-protected producers to publicly share protected products’ entire electronic records. Producers of trade-secret, safety-critical products should voluntarily have fiduciaries back up these products’ entire electronic records. All electronically-recorded safety-affecting actions would then be guaranteed discoverable [19].

Restoring producers’ full freedom to optimize products would significantly advance safety and value. Restoring producers’ clear responsibility [20] would further incentivize producers to protect safely. When responsibility is more concentrated [21], producers manage safety risks and consequences better and prevent more losses [22].

Also, when losses do happen, producers do better at preventing subsequent losses. After the customer-regulated chemical producers’ Bhopal disaster, these producers quickly collaborated with peers and outsiders to understand all that went wrong and prevent all kinds of avoidable disasters from happening in the future [23]. Government regulation arrived only much later [24].

Under regulation by customers, producers aren’t forced to dilute their efforts just to make their liberty and property at least somewhat secure from regulators in governments. Plus, when producers have minimal distractions [25], small, lean teams of people can then perform their core tasks best [26-27]. It becomes efficient for producers to develop new, better designs faster.

And this becomes a competitive necessity. The customer-regulated computer producers haven’t harmed people, and they’ve increased computing efficiency approximately exponentially [28] from 1900 through 2020 [29].

If civil-aircraft producers were customer-regulated, producers developing new models would always develop new aerodynamics, propulsion, and structural designs [30]. In new aerodynamics designs, controllability is designed in. Control designers would further make control increasingly intuitive.

Boeing control designers would fit all 737 MAX planes with angle-of-attack controls that are robust and intuitive. Three sensors would provide fault-tolerance and fast response [31]. Basic control would make throttle and control-column responses intuitive. Safety control would sense when a pilot was trying to use his controls to nullify the basic control and would disengage the basic control intuitively [32] (like touching your car’s brake pedal disengages the cruise control).

Technology will keep advancing. People will still have limitations. No one wants to cause disasters. And yet, all the government/business system dynamics that caused the Boeing 737 MAX disasters remain in place and operating the same [5].

To prevent more such disasters, it’s necessary to improve on the current management of regulation and production [33]. First lay off all the government regulators.


  1. Anthony, James. “Socialism Kills Freedom.” rConstitution.us, 26 Mar. 2021, rconstitution.us/socialism-kills-freedom/. Accessed 9 Apr. 2023.
  2. Wendel, W. Bradley. “Technological Solutions to Human Error and How They Can Kill You: Understanding the Boeing 737 Max Products Liability Litigation.” Journal of Air Law and Commerce, vol. 84, no. 3, 2018, pp. 379-444; p. 412.
  3. Tabarrok, Alexander. “Assessing the FDA via the Anomaly of Off-Label Drug Prescribing.” The Independent Review, vol. 5, no. 1, Summer 2000, pp. 25-53; p. 39.
  4. Gieringer, Dale H. “The Safety and Efficacy of New Drug Approval.” Cato Journal, vol. 5, no. 1, Spring/Summer 1985, pp. 177-201.
  5. Campbell, Darryl. “Boeing Redline: The Many Human Errors that Brought Down the Boeing 737 Max.” The Verge, 2 May 2019, www.theverge.com/2019/5/2/18518176/boeing-737-max-crash-problems-human-error-mcas-faa. Accessed 9 Apr. 2023.
  6. Langewiesche, William. “What Really Brought Down the Boeing 737 Max?” The New York Times Magazine, 2 July 2021, www.nytimes.com/2019/09/18/magazine/boeing-737-max-crashes.html. Accessed 9 Apr. 2023.
  7. Vartabedian, Ralph. “How a 50-Year-Old Design Came Back to Haunt Boeing with Its Troubled 737 Max Jet.” Los Angeles Times, 15 Mar. 2019, www.latimes.com/local/california/la-fi-boeing-max-design-20190315-story.html. Accessed 9 Apr. 2023.
  8. Travis, Gregory. “How the Boeing 737 Max Disaster Looks to a Software Developer.” IEEE Spectrum, Apr. 2019, spectrum.ieee.org/how-the-boeing-737-max-disaster-looks-to-a-software-developer. Accessed 9 Apr. 2023.
  9. K, John. “Why Does the Stick Force Per-G Test Require It to Be Harder for Pilots to Pull Back on the Yoke Instead of Easier?” Aviation StackExchange, 27 Dec. 2019, aviation.stackexchange.com/questions/72876/why-does-the-stick-force-per-g-test-require-it-to-be-harder-for-pilots-to-pull-b. Accessed 9 Apr. 2023.
  10. Okih, Emmanuel. “Safety Instrumented Systems vs Basic Process Control Systems.” The Automation Blog, 13 Nov. 2019, theautomationblog.com/safety-instrumented-systems-vs-basic-process-control-systems/. Accessed 9 Apr. 2023.
  11. “Safety Instrumented Functions and Systems.” Control Automation, control.com/textbook/process-safety-and-instrumentation/safety-instrumented-functions-and-systems/. Accessed 9 Apr. 2023.
  12. Gates, Dominic, and Mike Baker. “The Inside Story of MCAS: How Boeing’s 737 Max System Gained Power and Lost Safeguards.” The Seattle Times, 26 June 2019, www.adn.com/nation-world/2019/06/27/the-inside-story-of-mcas-how-boeings-737-max-system-gained-power-and-lost-safeguards/. Accessed 9 Apr. 2023.
  13. United States, Congress, House of Representatives, Committee on Transportation & Infrastructure, Majority Staff. The Design, Development & Certification of the Boeing 737 Max. Final Committee Report, Sep. 2020, democrats-transportation.house.gov/imo/media/doc/2020.09.15%20FINAL%20737%20MAX%20Report%20for%20Public%20Release.pdf, p. 108. Accessed 9 Apr. 2023.
  14. “Changes to the 737 MAX / MCAS.” Boeing, www.boeing.com/737-max-updates/mcas/. Accessed 9 Apr. 2023.
  15. United States, Aeronautics and Space. “Static Longitudinal Stability.” 14 CFR 25.173 (c), www.ecfr.gov/current/title-14/chapter-I/subchapter-C/part-25/subpart-B/subject-group-ECFR5bdca815681aa9d#p-25.173(c). Accessed 9 Apr. 2023.
  16. Block, Walter. “Theories of Highway Safety.” Transportation Research Record, vol. 912, 1983, pp. 7-10.
  17. Soupcoff, Marni. “The Extra-Rational Horror of Self-Regulation.” Regulation, vol. 42, no. 2, Summer 2019, p. 76.
  18. Block, Walter. “Environmentalism and Economic Freedom: The Case for Private Property Rights.” Journal of Business Ethics, 17, no. 16, 1998, pp. 1887-99.
  19. Dekker, Sidney W. A. “Just Culture: Who Gets to Draw the Line?” Cognition, Technology & Work, vol. 11, no. 3, Sep. 2009, pp. 177-85.
  20. Coffee, John C. “Nosedive: Boeing and the Corruption of the Deferred Prosecution Agreement.” SSRN, 6 June 2022, papers.ssrn.com/sol3/Papers.cfm?abstract_id=4105514. Accessed 9 Apr. 2023.
  21. Paradies, Mark. “Has Process Safety Missed the Boat?” Process Safety Progress, vol. 30, no. 4, Dec. 2011, pp. 310-314.
  22. Dankwa, David. “RIMS: FM Global Finds Engineering Study Superior to Actuarial Predictions.” BestWire Services, 26 Apr. 2006, web.archive.org/web/20070705065336/http:/www.fmglobal.com/pdfs/bestreview.pdf. Accessed 9 Apr. 2023.
  23. “History.” Center for Chemical Process Safety, www.aiche.org/ccps/history. Accessed 9 Apr. 2023.
  24. Murphy, John F. “Safety Considerations in the Chemical Process Industries.” Handbook of Industrial Chemistry and Biotechnology, 13th ed., edited by James A. Kent et al, Springer, 2017, pp. 1805-88.
  25. Brooks, Frederick P., Jr. “The Mythical Man-Month.” Datamation, Dec. 1974, pp. 44-52.
  26. Curtis, Bill, et al. “A Field Study of the Software Design Process for Large Systems.” Communications of the ACM, vol. 31, no. 11, Nov. 1988, pp. 1268-87.
  27. Blackburn, Joseph D., et al. “Improving Speed and Productivity of Software Development: A Global Survey of Software Developers.” IEEE Transactions on Software Engineering, vol. 22, no. 12, Dec. 1996, pp. 875-85.
  28. Flamm, Kenneth. “Measuring Moore’s Law: Evidence from Price, Cost, and Quality Indexes.” Measuring and Accounting for Innovation in the Twenty-First Century, edited by Carol Corrado et al., University of Chicago Press, 2021, pp. 403-70.
  29. Van de Kerkhof, J. et al. “Lithography for Now and the Future.” Solid State Electronics, vol. 155, May 2019, pp. 20-6.
  30. Gonzalez, Gomez, et al. “The Cormoran Project: A New Concept in Commercial Aircraft Design.” KTH, 30 Jan. 2013, kth.diva-portal.org/smash/get/diva2:618581/FULLTEXT01.pdf. Accessed 9 Apr. 2023.
  31. McMillan, Greg. “Tip #88: Use Middle Signal Selection to Improve pH Measurement Reliability.” 101 Tips for a Successful Automation Career, Greg McMillan and Hunter Vegas, ISA, 2013, pp. 175-6.
  32. “Airbus AoA – Angle of Attach Sensor Issue.” Pen Test Partners, 3 Oct. 2022, www.pentestpartners.com/security-blog/airbus-aoa-angle-of-attack-sensor-issue/. Accessed 9 Apr. 2023.
  33. Anthony, James. “Offsetting Powers.” us, rconstitution.us/boundaries/#off-bound. Accessed 9 Apr. 2023.

James Anthony is an experienced chemical engineer who applies process design, dynamics, and control to government processes. For more information, see his media and about pages. Mr. Anthony was propulsion lead for skunkworks concept demonstration of a tailsitter vertical take-off and landing unmanned aerial vehicle.


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