When software became a point of failure: The Boeing 737 MAX crisis and the governance of safety-critical IT systems

Abstract

This case study examined the Boeing 737 MAX crisis from the perspectives of safety-critical software development, information technology management, and managerial decision-making. The case was set against the backdrop of two fatal aviation accidents in 2018 and 2019 that led to the worldwide grounding of the 737 MAX fleet. Investigations identified the Maneuvering Characteristics Augmentation System (MCAS), a capability in flight-control software, as a crucial contributing factor. MCAS depended on a single sensor input, functioned with minimal redundancy, and was inadequately communicated to pilots, thereby raising significant concerns regarding software design, risk assessment, and certification procedures. Beyond technical shortcomings, the case emphasized systemic challenges pertaining to information technology governance, risk management, and decision-making authority within a complex socio-technical system. Competitive pressures, urgent time-to-market demands, and regulatory delegation influenced critical design and certification decisions, exposing tensions between engineering rigour and managerial priorities. By synthesizing principles from safety-critical systems engineering, enterprise IT governance, and organizational risk theory. The case was developed for graduate and postgraduate programs in management, information systems, IT governance, digital risk management, and technological integrity. It prompts students to assess how large organizations can reconcile rapid innovation with the requirements for resilient, transparent, and ethically governed IT infrastructures.

The authors' abstract, as published at the source. Journal of Information Technology Teaching Cases, 2026 · DOI ↗