Case studies of tacit knowledge for business benefit (part 3): Safer air travel

Case study 6, tacit knowledge failure – Boeing

• Lion Air Flight 610 disaster. On 29 October 2018, Lion Air Flight 610¹, a Boeing 737 MAX 8 aircraft, crashed killing all 189 people on board.
• Ethiopian Airlines Flight 302 disaster. On 10 March 2019, Ethiopian Airlines Flight 302², also a Boeing 737 MAX 8 aircraft, crashed killing all 157 people on board.
• Worldwide grounding of the 737 MAX. In the immediate wake of the crashes, the United States (U.S.) Federal Aviation Administration (FAA) issued an emergency order prohibiting the operation of Boeing 737 MAX aircraft by U.S.-certificated operators or in U.S. territory. An associated international airworthiness notification³ resulted in the grounding of the 737 MAX worldwide.
• Erroneous readings from angle of attack sensor. The preliminary report⁴ into the crash of Ethiopian Airlines Flight 302 revealed that shortly after takeoff, the aircraft’s left angle of attack sensor started to send erroneous readings, and the pilots experienced flight control problems. In attempting to deal with the flight control problems, the pilots were found to have followed the procedures in Boeing’s 737 flight manual. Most significant among the problems was “an automatic aircraft nose down (AND) trim command four times without pilot’s input.” The pilots struggled to try to overcome these commands, but were unable to do so resulting in the aircraft crashing.
• Maneuvering Characteristics Augmentation System (MCAS) implicated. In response, CEO of Boeing at the time, Dennis Muilenburg, stated⁵ that “with the release of the preliminary report of the Ethiopian Airlines Flight 302 accident investigation, it’s apparent that in both flights the Maneuvering Characteristics Augmentation System, known as MCAS, activated in response to erroneous angle of attack information.”
• Pilots weren’t told about MCAS. Critically, Boeing hadn’t told 737 MAX pilots about MCAS, which had been deployed to address the risk of the aircraft stalling due to the engines being located in a different position to previous 737 models. Amid the chaotic scenes in the cockpit, the pilots of Lion Air Flight 610 and Ethiopian Airlines Flight 302 didn’t realise that taking actions to disable the MCAS would have solved the automatic aircraft nose down problem, because they didn’t know that the MCAS existed.
• Boeing’s knowledge transfer failure. After the crash of Lion Air Flight 610 and before the crash of Ethiopian Airlines Flight 302, angry American Airlines pilots had confronted Boeing about its lack of knowledge transfer in regard to the MCAS, as revealed in the following recording⁶:

• The situational awareness knowledge challenge. Boeing’s failure to transfer knowledge about MCAS to pilots is not simply because it sought to hide vital information. Rather, as the recording above reveals, Boeing erred in the wrong direction in addressing the challenge⁷ of providing the right amount of knowledge in the face of the need for situational awareness. The chapter⁸ “Situation Awareness In Aviation Systems” in the Handbook of Aviation Human Factors states that in regard to system design, “The capabilities of the aircraft for acquiring needed information and the way in which it presents that information will have a large impact on aircrew SA [situational awareness]. While a lack of information can certainly be seen as a problem for SA, too much information poses an equal problem.”
• Billions in losses. By the beginning of 2025, Boeing had faced over US$35 billion in losses⁹ since the fatal crashes in 2019.
• Tacit knowledge exchange could have helped. Boeing should not have made the decision on its own to not transfer knowledge about MCAS. The tacit knowledge of the pilots and other aircrew who would fly the 737 MAX could and should have been much more effectively engaged in the design of the aircraft. Their tacit knowledge comes from years of experience in real world situations, so they are the ones who should have decided what they needed to know about MCAS.
• The shortcomings of traditional approaches to knowledge management (KM). It needs to be noted that Boeing’s MCAS knowledge transfer failure occurred despite the company having the much-lauded knowledge management (KM) program¹⁰ discussed in the cover story¹¹ of the October 2007 issue of the company’s Frontiers magazine. Boeing’s traditional-style KM program is internally focused, to the neglect of external knowledge flows between Boeing and the users of its products and the complexity that occurs around that interface.
• Complex vs. complicated. The shortcomings of Boeing’s traditional KM program are compounded by a mistaken view in the KM community that aircraft are complicated rather than complex. However, as highlighted by the challenge of providing the right amount of knowledge in the face of the need for situational awareness, as raised above, the reality is that aircraft are intrinsically connected to humans¹² through complex interactions. Seeking to separate the aircraft from the humans is reductionist thinking.
• The way forward? While traditional internally-focused approaches to knowledge management (KM) still have value, they alone are not enough when dealing with complex systems. As well as knowledge managers and organization staff, engaging the tacit knowledge of stakeholders outside the organization is essential. Professor Gabriele Bammer, team leader and originator of Integration and Implementation Sciences (i2S)¹³ at the Australian National University (ANU), advises that¹⁴ “[Complex problems require a] mindset that appreciates that stakeholders have an essential role in making complexity evident and that limiting stakeholder involvement also limits the ability to understand and effectively act on complex problems.” In the case of Boeing’s KM, these stakeholders include pilots and other aircrew, as well as experts in aircraft systems and complexity.
• Has Boeing improved? On 5 January 2024, at about 16,000 ft in the air, an exit door plug violently blew out on Alaska Airlines Flight 1282, a Boeing 737 MAX 9 aircraft, instantly depressurizing the plane and leaving a large hole in the fuselage. Fortunately, no one was injured. Analysis of the incident¹⁵ shows that contributing factors include continued tacit knowledge failures by Boeing.
• Read more: RealKM Magazine Heart of the problems with Boeing, Takata, & Toyota 5-part series.

Case study 7, tacit knowledge success – Airbus

• Situational awareness and aircraft cockpit design. A Digital Avionics Systems Conference paper¹⁶ advises that “In the design of safe, functional, and productive person-machine systems, situational awareness is an issue of central concern. The potential difficulty is vividly present in the conventional cockpit of commercial aircraft.”
• Airbus and situational awareness. Aircraft manufacturer Airbus places a strong emphasis on situational awareness, stating in the Flight Operations Briefing Note Enhancing Situational Awareness¹⁷ that “Situational awareness is not just a theoretical notion and is pertinent to most accident or incident cases. It is real, and its absence causes accidents … Approximately 85 percent of incident reports include a mention of loss of situational awareness.”
• Airline pilot input into cockpit design. In contrast to Boeing, Airbus states that¹⁸:

Right from its conception, expert Airbus pilots took part in the design of the A350 cockpit. Moreover, during the development phase of the A350, not only Airbus experts but also airline pilots fine-tuned the design, resulting in the most technologically advanced cockpit in the market …

The cockpit layout, using six identical large screens, makes the task of sharing operational information between pilots much easier, while privileging information that corresponds to the given situation. Overall, the design aims at reducing overall pilot workload and increasing situational awareness.