ISCAP Proceedings: Abstract Presentation
Normal Accidents and High Reliability Breakdown: A Risk Management Teaching Case on the Boeing 737 MAX Using Snook’s Practical Drift
Matthew Boyne
Point Loma Nazarene University
Thea Copeland
Point Loma Nazarene University
Katie Lechner
Point Loma Nazarene University
Abstract
Complex adaptive systems, whether automated manufacturing lines, aviation control systems, or AI-driven operational platforms, are increasingly tightly coupled, allowing subtle failures to cascade rapidly into catastrophic outcomes. This teaching case applies Scott Snook’s practical drift framework, along with High Reliability Organization (HRO) principles and Normal Accident Theory (NAT), to analyze the managerial, cultural, and socio-technical breakdowns that contributed to the 2018 and 2019 Boeing 737 MAX accidents. The case illustrates how organizational drift, erosion of quality and safety culture, and system-level coupling created an environment where risk was normalized and ultimately unmanaged. Students engage with a structured Failure Mode and Effects Analysis (FMEA) to trace risk pathways and develop concrete mitigation strategies. The case provides instructors with a technology-infused, systems-thinking approach for teaching operational, technological, and project risk management within complex information systems environments.