The Boeing 737 MAX featured a new system called the Maneuvering Characteristics Augmentation System (MCAS). It was designed to automatically push the nose down if it detected the plane might stall. However, the pilots didn’t know that it existed.

In the entire 1,600-page flight manual, MCAS was mentioned only in the glossary. No explanation of what it did. No instructions on how to disable it. Nothing.

Why would Boeing omit such critical information? The answer reveals something troubling about how we communicate in high-stakes industries. Boeing wanted to market the 737 MAX as requiring minimal additional training for pilots who had flown previous 737 models. More documentation meant more training. More training meant higher costs. Higher costs meant fewer sales.

Lives were literally traded for market shares.

Links in a Fatal Chain

The Indonesian investigation identified five critical factors that led to this disaster, and nearly every single one involved a failure of technical communication.

One: A critical sensor, which miscalibrated during earlier repair, was installed without proper testing or documentation.

Two: 31 pages were missing from the maintenance log—information that should have grounded the plane before its fatal flight.

Three:  The checklist included a long‑standing ‘runaway stabilizer’ procedure that could have addressed the malfunction, but pilots were unaware that the new MCAS system was responsible for causing it.

Four: The cockpit warning systems provided conflicting information that the pilots couldn’t reconcile.

Five: The previous day’s crew experienced the exact same issue but didn’t effectively communicate the severity to the maintenance crew.

The day before the crash, a pilot traveling as a passenger in the jump seat of the same aircraft recognized the issue and explained to the flight crew how to disable the system.

Those pilots landed safely. However, that knowledge—that critical, life-saving information—wasn’t documented. It wasn’t passed on. It wasn’t communicated to the next crew.

A total of 189 people died because of it.

A Second Chance Missed  

After the Lion Air crash, Boeing finally issued a bulletin explaining the MCAS and how to disable it. However, they insisted the 737 MAX was still safe to fly without further changes.

Five months later, on March 10, 2019, Ethiopian Airlines Flight 302 crashed under nearly identical circumstances. 157 more lives were lost.

They were the result of a choice—a choice to prioritize simplicity over safety, profits over people, and, most critically, a choice to withhold information rather than communicate.

The Communication Gap  

A dangerous myth exists in engineering and the technical fields: that good technical work speaks for itself. That the data tells its own story. That if something is important, people will figure it out.

This is dangerously wrong.

The hard truth is this: Your brilliant design, your revolutionary code, your groundbreaking research is worthless if you can’t communicate it effectively. Technical communication isn’t just about transferring information. It’s about transferring understanding.

And understanding can save lives.

The Responsibility We All Share

So, what do we do about this? How do we prevent the next Lion Air disaster in our own fields?

First, we need to recognize that technical communication is not an afterthought. It’s not something to be delegated to technical writers after the real work is done. It is the real work.

Second, we need to document for crisis, not for convenience. The true test of technical documentation isn’t whether it works when everything goes right. It’s whether it works when everything goes wrong.

Third, we must understand our audiences very well. The Boeing case shows the fatal consequences of one-size-fits-all documentation practices. The engineers wrote for other engineers, not for pilots in crisis situations. They assumed technical knowledge that didn’t exist. They failed to consider how pilots would use this information under extreme stress. Knowing your audience, their knowledge level, and their needs isn’t optional. It’s essential. Different audiences require different approaches, and assuming that one type of writing works for everyone is a dangerous mistake.

Fourth, we need to create cultures where communication is valued as highly as innovation—where an engineer who writes clear documentation is celebrated as much as one who writes clever code.

History is filled with communication failures as dramatic and as preventable as Boeing’s. In the 2003 Columbia Space Shuttle disaster, poorly designed PowerPoint slides obscured critical safety information that might have saved the lives of seven astronauts [1]. Similarly, the 1981 Hyatt Regency walkway collapse in Kansas City, which killed 114 people, was partly the result of unclear communication between engineers and fabricators about a seemingly minor design change [2]. These are just two additional examples, but there are countless other tragedies where poor communication played a decisive role.

Your Turn  

As an engineer, you must continually ask yourself: What critical information am I holding right now? What knowledge seems obvious to me but might be invisible to someone else? What am I assuming “they’ll figure out” when the stakes are high?

Most importantly: What am I not communicating that could cost someone everything?

The 346 people who died in the two 737 MAX crashes can’t speak to us. But their story can. It tells us that in a world of increasingly complex systems, our greatest vulnerability isn’t technical failure. It’s a communication breakdown.

The pilots of those Boeing planes were fighting not just a malfunctioning system, but a vacuum of information. They were trying to solve a problem they didn’t know existed, with tools they didn’t know they had.

Don’t let that happen on your watch.

Because the most dangerous words in any industry aren’t “I don’t know.” They’re “I didn’t tell you.”