Control System Logic Trim commands were mechanically linked, overriding pilot control inputs. The pressure to deliver on cost and schedule, combined with a regulatory culture that increasingly deferred to manufacturer safety analyses, created an environment where these latent risks were not sufficiently challenged or mitigated.
Root Cause Analysis: How MCAS Reliance on a Single AOA Sensor and System Design Flaws Led to Disaster
Furthermore, the system was certified under an assumption that a single-point failure would be addressed by pilot training and procedures, a calculation that failed to account for the simultaneous failure of a primary instrument and the physical limitations a pilot faces during an unexpected high-speed dive. In both incidents, pilots were confronted with an unresponsive stabilizer trim system and an overwhelming barrage of alerts, including the activation of the stick shaker—a stall warning that should never have been active in level flight.
Factor Contribution to Crashes Single AOA Sensor Provided false data to MCAS, triggering uncommanded nose-down input. The checklists provided were ambiguous and did not directly address the runaway trim scenario caused by MCAS.
Root Cause Analysis: How Boeing 737 Max's MCAS and Single AOA Sensor Led to the Crashes
The critical flaw lay in its dependence on a single angle-of-attack (AOA) sensor, creating a dangerous vulnerability where a faulty or misaligned sensor could feed incorrect data, triggering an uncommanded nose-down input that was difficult for pilots to override. To counteract this, Boeing implemented MCAS, which could automatically command the nose-down pitch using a single actuator on the horizontal stabilizer.
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