Organizational Silence as Systemic Risk: A Case Analysis of Decision Failures in the Boeing 737 MAX Development Program

Abstract

Background: The Boeing 737 MAX crashes of October 2018 and March 2019, which claimed 346 lives across two accidents, constitute one of the most extensively documented organizational failures in aviation history. Congressional investigations, regulatory reviews, and journalistic investigations collectively documented that engineering concerns about the MCAS (Maneuvering Characteristics Augmentation System) were present within the organization but systematically failed to reach, or were suppressed from reaching, the decision-making levels at which they could have altered the program's course. Objective: This case analysis applies organizational silence theory — specifically, Morrison and Milliken's (2000) foundational framework and Vaughan's (1996) normalization of deviance concept — to the Boeing 737 MAX development program, examining the organizational mechanisms through which silence functioned as a systemic risk factor. Method: Qualitative case study design (Yin, 2014) drawing on publicly available primary sources including the U.S.