Cause Analysis of two Boeing 737 MAX Crashes:#br# Based on FLAP Model of Human-Automation Interaction
WANG Xin-ye,Wang Shuo, Lin Jing-kang, Du Lei
1.School of Public Security, Northwestern University of Politics and Law, Xi’an 710122, China; 2.School of Psychology, Shaanxi Normal University, Xi’an 710062, China; 3.Tibet Airlines Co., Ltd, Chengdu, China
Abstract：In less than five months from October 2018 to March 2019, two newly delivered Boeing 737 MAX aircraft crashed one after another. Accident investigations have identified fatal design flaws in the MACS as the proximate cause of both crashes. Boeing designed MCAS to automatically control the horizontal stabilizer in the tail of the aircraft to improve the pitch characteristics of the aircraft. However, the logic of the MACS operation and its behavior were divorced from the crews’ understanding of the Boeing 737 family of aircraft control systems, so the two crashes were classic examples of human-automation interaction failures. Different from other human-automation interaction models, FLAP model not only examines the interaction problems when the automation system and human are functioning properly, but also includes the crew defects, automation system failures and avionics system abnormalities. The FLAP model would help researchers to simulate the problems associated with automation systems in today’s commercial transport aircraft in a top-down, generalizable way. The FLAP model could be used to trace back the causes of the two air accidents. The study found that, in addition to poor MACS design, Boeing and the FAA’s failure to adhere to aviation safety culture was the most profound cause of the two accidents. Therefore, the system design should adhere to the human-centered principle; regulators, aircraft manufacturers and operating companies all need to strengthen aviation safety culture. Finally, the study also verified that the FLAP model was an excellent cognitive tool for analyzing the interaction between pilot and automation.
王新野,王朔,林靖康, 杜磊. 两起波音737 MAX空难的致因分析： 基于人—自动化交互的FLAP模型[J]. 应用心理学, 2024, 30(6): 483-494.
WANG Xin-ye,Wang Shuo, Lin Jing-kang, Du Lei. Cause Analysis of two Boeing 737 MAX Crashes:#br# Based on FLAP Model of Human-Automation Interaction. 应用心理学, 2024, 30(6): 483-494.
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