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The Boeing 737 MAX: Lessons for Engineering Ethics

• Original Research/Scholarship
• Published: 10 July 2020
• Volume 26 , pages 2957–2974, ( 2020 )

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• Joseph Herkert 1 ,
• Jason Borenstein 2 &
• Keith Miller 3  

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The crash of two 737 MAX passenger aircraft in late 2018 and early 2019, and subsequent grounding of the entire fleet of 737 MAX jets, turned a global spotlight on Boeing’s practices and culture. Explanations for the crashes include: design flaws within the MAX’s new flight control software system designed to prevent stalls; internal pressure to keep pace with Boeing’s chief competitor, Airbus; Boeing’s lack of transparency about the new software; and the lack of adequate monitoring of Boeing by the FAA, especially during the certification of the MAX and following the first crash. While these and other factors have been the subject of numerous government reports and investigative journalism articles, little to date has been written on the ethical significance of the accidents, in particular the ethical responsibilities of the engineers at Boeing and the FAA involved in designing and certifying the MAX. Lessons learned from this case include the need to strengthen the voice of engineers within large organizations. There is also the need for greater involvement of professional engineering societies in ethics-related activities and for broader focus on moral courage in engineering ethics education.

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Introduction

In October 2018 and March 2019, Boeing 737 MAX passenger jets crashed minutes after takeoff; these two accidents claimed nearly 350 lives. After the second incident, all 737 MAX planes were grounded worldwide. The 737 MAX was an updated version of the 737 workhorse that first began flying in the 1960s. The crashes were precipitated by a failure of an Angle of Attack (AOA) sensor and the subsequent activation of new flight control software, the Maneuvering Characteristics Augmentation System (MCAS). The MCAS software was intended to compensate for changes in the size and placement of the engines on the MAX as compared to prior versions of the 737. The existence of the software, designed to prevent a stall due to the reconfiguration of the engines, was not disclosed to pilots until after the first crash. Even after that tragic incident, pilots were not required to undergo simulation training on the 737 MAX.

In this paper, we examine several aspects of the case, including technical and other factors that led up to the crashes, especially Boeing’s design choices and organizational tensions internal to the company, and between Boeing and the U.S. Federal Aviation Administration (FAA). While the case is ongoing and at this writing, the 737 MAX has yet to be recertified for flight, our analysis is based on numerous government reports and detailed news accounts currently available. We conclude with a discussion of specific lessons for engineers and engineering educators regarding engineering ethics.

Overview of 737 MAX History and Crashes

In December 2010, Boeing’s primary competitor Airbus announced the A320neo family of jetliners, an update of their successful A320 narrow-body aircraft. The A320neo featured larger, more fuel-efficient engines. Boeing had been planning to introduce a totally new aircraft to replace its successful, but dated, 737 line of jets; yet to remain competitive with Airbus, Boeing instead announced in August 2011 the 737 MAX family, an update of the 737NG with similar engine upgrades to the A320neo and other improvements (Gelles et al. 2019 ). The 737 MAX, which entered service in May 2017, became Boeing’s fastest-selling airliner of all time with 5000 orders from over 100 airlines worldwide (Boeing n.d. a) (See Fig.  1 for timeline of 737 MAX key events).

737 MAX timeline showing key events from 2010 to 2019

The 737 MAX had been in operation for over a year when on October 29, 2018, Lion Air flight JT610 crashed into the Java Sea 13 minutes after takeoff from Jakarta, Indonesia; all 189 passengers and crew on board died. Monitoring from the flight data recorder recovered from the wreckage indicated that MCAS, the software specifically designed for the MAX, forced the nose of the aircraft down 26 times in 10 minutes (Gates 2018 ). In October 2019, the Final Report of Indonesia’s Lion Air Accident Investigation was issued. The Report placed some of the blame on the pilots and maintenance crews but concluded that Boeing and the FAA were primarily responsible for the crash (Republic of Indonesia 2019 ).

MCAS was not identified in the original documentation/training for 737 MAX pilots (Glanz et al. 2019 ). But after the Lion Air crash, Boeing ( 2018 ) issued a Flight Crew Operations Manual Bulletin on November 6, 2018 containing procedures for responding to flight control problems due to possible erroneous AOA inputs. The next day the FAA ( 2018a ) issued an Emergency Airworthiness Directive on the same subject; however, the FAA did not ground the 737 MAX at that time. According to published reports, these notices were the first time that airline pilots learned of the existence of MCAS (e.g., Bushey 2019 ).

On March 20, 2019, about four months after the Lion Air crash, Ethiopian Airlines Flight ET302 crashed 6 minutes after takeoff in a field 39 miles from Addis Ababa Airport. The accident caused the deaths of all 157 passengers and crew. The Preliminary Report of the Ethiopian Airlines Accident Investigation (Federal Democratic Republic of Ethiopia 2019 ), issued in April 2019, indicated that the pilots followed the checklist from the Boeing Flight Crew Operations Manual Bulletin posted after the Lion Air crash but could not control the plane (Ahmed et al. 2019 ). This was followed by an Interim Report (Federal Democratic Republic of Ethiopia 2020 ) issued in March 2020 that exonerated the pilots and airline, and placed blame for the accident on design flaws in the MAX (Marks and Dahir 2020 ). Following the second crash, the 737 MAX was grounded worldwide with the U.S., through the FAA, being the last country to act on March 13, 2019 (Kaplan et al. 2019 ).

Design Choices that Led to the Crashes

As noted above, with its belief that it must keep up with its main competitor, Airbus, Boeing elected to modify the latest generation of the 737 family, the 737NG, rather than design an entirely new aircraft. Yet this raised a significant engineering challenge for Boeing. Mounting larger, more fuel-efficient engines, similar to those employed on the A320neo, on the existing 737 airframe posed a serious design problem, because the 737 family was built closer to the ground than the Airbus A320. In order to provide appropriate ground clearance, the larger engines had to be mounted higher and farther forward on the wings than previous models of the 737 (see Fig.  2 ). This significantly changed the aerodynamics of the aircraft and created the possibility of a nose-up stall under certain flight conditions (Travis 2019 ; Glanz et al. 2019 ).

(Image source: https://www.norebbo.com )

Boeing 737 MAX (left) compared to Boeing 737NG (right) showing larger 737 MAX engines mounted higher and more forward on the wing.

Boeing’s attempt to solve this problem involved incorporating MCAS as a software fix for the potential stall condition. The 737 was designed with two AOA sensors, one on each side of the aircraft. Yet Boeing decided that the 737 MAX would only use input from one of the plane’s two AOA sensors. If the single AOA sensor was triggered, MCAS would detect a dangerous nose-up condition and send a signal to the horizontal stabilizer located in the tail. Movement of the stabilizer would then force the plane’s tail up and the nose down (Travis 2019 ). In both the Lion Air and Ethiopian Air crashes, the AOA sensor malfunctioned, repeatedly activating MCAS (Gates 2018 ; Ahmed et al. 2019 ). Since the two crashes, Boeing has made adjustments to the MCAS, including that the system will rely on input from the two AOA sensors instead of just one. But still more problems with MCAS have been uncovered. For example, an indicator light that would alert pilots if the jet’s two AOA sensors disagreed, thought by Boeing to be standard on all MAX aircraft, would only operate as part of an optional equipment package that neither airline involved in the crashes purchased (Gelles and Kitroeff 2019a ).

Similar to its responses to previous accidents, Boeing has been reluctant to admit to a design flaw in its aircraft, instead blaming pilot error (Hall and Goelz 2019 ). In the 737 MAX case, the company pointed to the pilots’ alleged inability to control the planes under stall conditions (Economy 2019 ). Following the Ethiopian Airlines crash, Boeing acknowledged for the first time that MCAS played a primary role in the crashes, while continuing to highlight that other factors, such as pilot error, were also involved (Hall and Goelz 2019 ). For example, on April 29, 2019, more than a month after the second crash, then Boeing CEO Dennis Muilenburg defended MCAS by stating:

We've confirmed that [the MCAS system] was designed per our standards, certified per our standards, and we're confident in that process. So, it operated according to those design and certification standards. So, we haven't seen a technical slip or gap in terms of the fundamental design and certification of the approach. (Economy 2019 )

The view that MCAS was not primarily at fault was supported within an article written by noted journalist and pilot William Langewiesche ( 2019 ). While not denying Boeing made serious mistakes, he placed ultimate blame on the use of inexperienced pilots by the two airlines involved in the crashes. Langewiesche suggested that the accidents resulted from the cost-cutting practices of the airlines and the lax regulatory environments in which they operated. He argued that more experienced pilots, despite their lack of information on MCAS, should have been able to take corrective action to control the planes using customary stall prevention procedures. Langewiesche ( 2019 ) concludes in his article that:

What we had in the two downed airplanes was a textbook failure of airmanship. In broad daylight, these pilots couldn’t decipher a variant of a simple runaway trim, and they ended up flying too fast at low altitude, neglecting to throttle back and leading their passengers over an aerodynamic edge into oblivion. They were the deciding factor here — not the MCAS, not the Max.

Others have taken a more critical view of MCAS, Boeing, and the FAA. These critics prominently include Captain Chesley “Sully” Sullenberger, who famously crash-landed an A320 in the Hudson River after bird strikes had knocked out both of the plane’s engines. Sullenberger responded directly to Langewiesche in a letter to the Editor:

… Langewiesche draws the conclusion that the pilots are primarily to blame for the fatal crashes of Lion Air 610 and Ethiopian 302. In resurrecting this age-old aviation canard, Langewiesche minimizes the fatal design flaws and certification failures that precipitated those tragedies, and still pose a threat to the flying public. I have long stated, as he does note, that pilots must be capable of absolute mastery of the aircraft and the situation at all times, a concept pilots call airmanship. Inadequate pilot training and insufficient pilot experience are problems worldwide, but they do not excuse the fatally flawed design of the Maneuvering Characteristics Augmentation System (MCAS) that was a death trap.... (Sullenberger 2019 )

Noting that he is one of the few pilots to have encountered both accident sequences in a 737 MAX simulator, Sullenberger continued:

These emergencies did not present as a classic runaway stabilizer problem, but initially as ambiguous unreliable airspeed and altitude situations, masking MCAS. The MCAS design should never have been approved, not by Boeing, and not by the Federal Aviation Administration (FAA)…. (Sullenberger 2019 )

In June 2019, Sullenberger noted in Congressional Testimony that “These crashes are demonstrable evidence that our current system of aircraft design and certification has failed us. These accidents should never have happened” (Benning and DiFurio 2019 ).

Others have agreed with Sullenberger’s assessment. Software developer and pilot Gregory Travis ( 2019 ) argues that Boeing’s design for the 737 MAX violated industry norms and that the company unwisely used software to compensate for inadequacies in the hardware design. Travis also contends that the existence of MCAS was not disclosed to pilots in order to preserve the fiction that the 737 MAX was just an update of earlier 737 models, which served as a way to circumvent the more stringent FAA certification requirements for a new airplane. Reports from government agencies seem to support this assessment, emphasizing the chaotic cockpit conditions created by MCAS and poor certification practices. The U.S. National Transportation Safety Board (NTSB) ( 2019 ) Safety Recommendations to the FAA in September 2019 indicated that Boeing underestimated the effect MCAS malfunction would have on the cockpit environment (Kitroeff 2019 , a , b ). The FAA Joint Authorities Technical Review ( 2019 ), which included international participation, issued its Final Report in October 2019. The Report faulted Boeing and FAA in MCAS certification (Koenig 2019 ).

Despite Boeing’s attempts to downplay the role of MCAS, it began to work on a fix for the system shortly after the Lion Air crash (Gates 2019 ). MCAS operation will now be based on inputs from both AOA sensors, instead of just one sensor, with a cockpit indicator light when the sensors disagree. In addition, MCAS will only be activated once for an AOA warning rather than multiple times. What follows is that the system would only seek to prevent a stall once per AOA warning. Also, MCAS’s power will be limited in terms of how much it can move the stabilizer and manual override by the pilot will always be possible (Bellamy 2019 ; Boeing n.d. b; Gates 2019 ). For over a year after the Lion Air crash, Boeing held that pilot simulator training would not be required for the redesigned MCAS system. In January 2020, Boeing relented and recommended that pilot simulator training be required when the 737 MAX returns to service (Pasztor et al. 2020 ).

Boeing and the FAA

There is mounting evidence that Boeing, and the FAA as well, had warnings about the inadequacy of MCAS’s design, and about the lack of communication to pilots about its existence and functioning. In 2015, for example, an unnamed Boeing engineer raised in an email the issue of relying on a single AOA sensor (Bellamy 2019 ). In 2016, Mark Forkner, Boeing’s Chief Technical Pilot, in an email to a colleague flagged the erratic behavior of MCAS in a flight simulator noting: “It’s running rampant” (Gelles and Kitroeff 2019c ). Forkner subsequently came under federal investigation regarding whether he misled the FAA regarding MCAS (Kitroeff and Schmidt 2020 ).

In December 2018, following the Lion Air Crash, the FAA ( 2018b ) conducted a Risk Assessment that estimated that fifteen more 737 MAX crashes would occur in the expected fleet life of 45 years if the flight control issues were not addressed; this Risk Assessment was not publicly disclosed until Congressional hearings a year later in December 2019 (Arnold 2019 ). After the two crashes, a senior Boeing engineer, Curtis Ewbank, filed an internal ethics complaint in 2019 about management squelching of a system that might have uncovered errors in the AOA sensors. Ewbank has since publicly stated that “I was willing to stand up for safety and quality… Boeing management was more concerned with cost and schedule than safety or quality” (Kitroeff et al. 2019b ).

One factor in Boeing’s apparent reluctance to heed such warnings may be attributed to the seeming transformation of the company’s engineering and safety culture over time to a finance orientation beginning with Boeing’s merger with McDonnell–Douglas in 1997 (Tkacik 2019 ; Useem 2019 ). Critical changes after the merger included replacing many in Boeing’s top management, historically engineers, with business executives from McDonnell–Douglas and moving the corporate headquarters to Chicago, while leaving the engineering staff in Seattle (Useem 2019 ). According to Tkacik ( 2019 ), the new management even went so far as “maligning and marginalizing engineers as a class”.

Financial drivers thus began to place an inordinate amount of strain on Boeing employees, including engineers. During the development of the 737 MAX, significant production pressure to keep pace with the Airbus 320neo was ever-present. For example, Boeing management allegedly rejected any design changes that would prolong certification or require additional pilot training for the MAX (Gelles et al. 2019 ). As Adam Dickson, a former Boeing engineer, explained in a television documentary (BBC Panorama 2019 ): “There was a lot of interest and pressure on the certification and analysis engineers in particular, to look at any changes to the Max as minor changes”.

Production pressures were exacerbated by the “cozy relationship” between Boeing and the FAA (Kitroeff et al. 2019a ; see also Gelles and Kaplan 2019 ; Hall and Goelz 2019 ). Beginning in 2005, the FAA increased its reliance on manufacturers to certify their own planes. Self-certification became standard practice throughout the U.S. airline industry. By 2018, Boeing was certifying 96% of its own work (Kitroeff et al. 2019a ).

The serious drawbacks to self-certification became acutely apparent in this case. Of particular concern, the safety analysis for MCAS delegated to Boeing by the FAA was flawed in at least three respects: (1) the analysis underestimated the power of MCAS to move the plane’s horizontal tail and thus how difficult it would be for pilots to maintain control of the aircraft; (2) it did not account for the system deploying multiple times; and (3) it underestimated the risk level if MCAS failed, thus permitting a design feature—the single AOA sensor input to MCAS—that did not have built-in redundancy (Gates 2019 ). Related to these concerns, the ability of MCAS to move the horizontal tail was increased without properly updating the safety analysis or notifying the FAA about the change (Gates 2019 ). In addition, the FAA did not require pilot training for MCAS or simulator training for the 737 MAX (Gelles and Kaplan 2019 ). Since the MAX grounding, the FAA has been become more independent during its assessments and certifications—for example, they will not use Boeing personnel when certifying approvals of new 737 MAX planes (Josephs 2019 ).

The role of the FAA has also been subject to political scrutiny. The report of a study of the FAA certification process commissioned by Secretary of Transportation Elaine Chao (DOT 2020 ), released January 16, 2020, concluded that the FAA certification process was “appropriate and effective,” and that certification of the MAX as a new airplane would not have made a difference in the plane’s safety. At the same time, the report recommended a number of measures to strengthen the process and augment FAA’s staff (Pasztor and Cameron 2020 ). In contrast, a report of preliminary investigative findings by the Democratic staff of the House Committee on Transportation and Infrastructure (House TI 2020 ), issued in March 2020, characterized FAA’s certification of the MAX as “grossly insufficient” and criticized Boeing’s design flaws and lack of transparency with the FAA, airlines, and pilots (Duncan and Laris 2020 ).

Boeing has incurred significant economic losses from the crashes and subsequent grounding of the MAX. In December 2019, Boeing CEO Dennis Muilenburg was fired and the corporation announced that 737 MAX production would be suspended in January 2020 (Rich 2019 ) (see Fig.  1 ). Boeing is facing numerous lawsuits and possible criminal investigations. Boeing estimates that its economic losses for the 737 MAX will exceed $18 billion (Gelles 2020 ). In addition to the need to fix MCAS, other issues have arisen in recertification of the aircraft, including wiring for controls of the tail stabilizer, possible weaknesses in the engine rotors, and vulnerabilities in lightning protection for the engines (Kitroeff and Gelles 2020 ). The FAA had planned to flight test the 737 MAX early in 2020, and it was supposed to return to service in summer 2020 (Gelles and Kitroeff 2020 ). Given the global impact of the COVID-19 pandemic and other factors, it is difficult to predict when MAX flights might resume. In addition, uncertainty of passenger demand has resulted in some airlines delaying or cancelling orders for the MAX (Bogaisky 2020 ). Even after obtaining flight approval, public resistance to flying in the 737 MAX will probably be considerable (Gelles 2019 ).

Lessons for Engineering Ethics

The 737 MAX case is still unfolding and will continue to do so for some time. Yet important lessons can already be learned (or relearned) from the case. Some of those lessons are straightforward, and others are more subtle. A key and clear lesson is that engineers may need reminders about prioritizing the public good, and more specifically, the public’s safety. A more subtle lesson pertains to the ways in which the problem of many hands may or may not apply here. Other lessons involve the need for corporations, engineering societies, and engineering educators to rise to the challenge of nurturing and supporting ethical behavior on the part of engineers, especially in light of the difficulties revealed in this case.

All contemporary codes of ethics promulgated by major engineering societies state that an engineer’s paramount responsibility is to protect the “safety, health, and welfare” of the public. The American Institute of Aeronautics and Astronautics Code of Ethics indicates that engineers must “[H]old paramount the safety, health, and welfare of the public in the performance of their duties” (AIAA 2013 ). The Institute of Electrical and Electronics Engineers (IEEE) Code of Ethics goes further, pledging its members: “…to hold paramount the safety, health, and welfare of the public, to strive to comply with ethical design and sustainable development practices, and to disclose promptly factors that might endanger the public or the environment” (IEEE 2017 ). The IEEE Computer Society (CS) cooperated with the Association for Computing Machinery (ACM) in developing a Software Engineering Code of Ethics ( 1997 ) which holds that software engineers shall: “Approve software only if they have a well-founded belief that it is safe, meets specifications, passes appropriate tests, and does not diminish quality of life, diminish privacy or harm the environment….” According to Gotterbarn and Miller ( 2009 ), the latter code is a useful guide when examining cases involving software design and underscores the fact that during design, as in all engineering practice, the well-being of the public should be the overriding concern. While engineering codes of ethics are plentiful in number, they differ in their source of moral authority (i.e., organizational codes vs. professional codes), are often unenforceable through the law, and formally apply to different groups of engineers (e.g., based on discipline or organizational membership). However, the codes are generally recognized as a statement of the values inherent to engineering and its ethical commitments (Davis 2015 ).

An engineer’s ethical responsibility does not preclude consideration of factors such as cost and schedule (Pinkus et al. 1997 ). Engineers always have to grapple with constraints, including time and resource limitations. The engineers working at Boeing did have legitimate concerns about their company losing contracts to its competitor Airbus. But being an engineer means that public safety and welfare must be the highest priority (Davis 1991 ). The aforementioned software and other design errors in the development of the 737 MAX, which resulted in hundreds of deaths, would thus seem to be clear violations of engineering codes of ethics. In addition to pointing to engineering codes, Peterson ( 2019 ) argues that Boeing engineers and managers violated widely accepted ethical norms such as informed consent and the precautionary principle.

From an engineering perspective, the central ethical issue in the MAX case arguably circulates around the decision to use software (i.e., MCAS) to “mask” a questionable hardware design—the repositioning of the engines that disrupted the aerodynamics of the airframe (Travis 2019 ). As Johnston and Harris ( 2019 ) argue: “To meet the design goals and avoid an expensive hardware change, Boeing created the MCAS as a software Band-Aid.” Though a reliance on software fixes often happens in this manner, it places a high burden of safety on such fixes that they may not be able to handle, as is illustrated by the case of the Therac-25 radiation therapy machine. In the Therac-25 case, hardware safety interlocks employed in earlier models of the machine were replaced by software safety controls. In addition, information about how the software might malfunction was lacking from the user manual for the Therac machine. Thus, when certain types of errors appeared on its interface, the machine’s operators did not know how to respond. Software flaws, among other factors, contributed to six patients being given massive radiation overdoses, resulting in deaths and serious injuries (Leveson and Turner 1993 ). A more recent case involves problems with the embedded software guiding the electronic throttle in Toyota vehicles. In 2013, “…a jury found Toyota responsible for two unintended acceleration deaths, with expert witnesses citing bugs in the software and throttle fail safe defects” (Cummings and Britton 2020 ).

Boeing’s use of MCAS to mask the significant change in hardware configuration of the MAX was compounded by not providing redundancy for components prone to failure (i.e., the AOA sensors) (Campbell 2019 ), and by failing to notify pilots about the new software. In such cases, it is especially crucial that pilots receive clear documentation and relevant training so that they know how to manage the hand-off with an automated system properly (Johnston and Harris 2019 ). Part of the necessity for such training is related to trust calibration (Borenstein et al. 2020 ; Borenstein et al. 2018 ), a factor that has contributed to previous airplane accidents (e.g., Carr 2014 ). For example, if pilots do not place enough trust in an automated system, they may add risk by intervening in system operation. Conversely, if pilots trust an automated system too much, they may lack sufficient time to act once they identify a problem. This is further complicated in the MAX case because pilots were not fully aware, if at all, of MCAS’s existence and how the system functioned.

In addition to engineering decision-making that failed to prioritize public safety, questionable management decisions were also made at both Boeing and the FAA. As noted earlier, Boeing managerial leadership ignored numerous warning signs that the 737 MAX was not safe. Also, FAA’s shift to greater reliance on self-regulation by Boeing was ill-advised; that lesson appears to have been learned at the expense of hundreds of lives (Duncan and Aratani 2019 ).

The Problem of Many Hands Revisited

Actions, or inaction, by large, complex organizations, in this case corporate and government entities, suggest that the “problem of many hands” may be relevant to the 737 MAX case. At a high level of abstraction, the problem of many hands involves the idea that accountability is difficult to assign in the face of collective action, especially in a computerized society (Thompson 1980 ; Nissenbaum 1994 ). According to Nissenbaum ( 1996 , 29), “Where a mishap is the work of ‘many hands,’ it may not be obvious who is to blame because frequently its most salient and immediate causal antecedents do not converge with its locus of decision-making. The conditions for blame, therefore, are not satisfied in a way normally satisfied when a single individual is held blameworthy for a harm”.

However, there is an alternative understanding of the problem of many hands. In this version of the problem, the lack of accountability is not merely because multiple people and multiple decisions figure into a final outcome. Instead, in order to “qualify” as the problem of many hands, the component decisions should be benign, or at least far less harmful, if examined in isolation; only when the individual decisions are collectively combined do we see the most harmful result. In this understanding, the individual decision-makers should not have the same moral culpability as they would if they made all the decisions by themselves (Noorman 2020 ).

Both of these understandings of the problem of many hands could shed light on the 737 MAX case. Yet we focus on the first version of the problem. We admit the possibility that some of the isolated decisions about the 737 MAX may have been made in part because of ignorance of a broader picture. While we do not stake a claim on whether this is what actually happened in the MAX case, we acknowledge that it may be true in some circumstances. However, we think the more important point is that some of the 737 MAX decisions were so clearly misguided that a competent engineer should have seen the implications, even if the engineer was not aware of all of the broader context. The problem then is to identify responsibility for the questionable decisions in a way that discourages bad judgments in the future, a task made more challenging by the complexities of the decision-making. Legal proceedings about this case are likely to explore those complexities in detail and are outside the scope of this article. But such complexities must be examined carefully so as not to act as an insulator to accountability.

When many individuals are involved in the design of a computing device, for example, and a serious failure occurs, each person might try to absolve themselves of responsibility by indicating that “too many people” and “too many decisions” were involved for any individual person to know that the problem was going to happen. This is a common, and often dubious, excuse in the attempt to abdicate responsibility for a harm. While it can have different levels of magnitude and severity, the problem of many hands often arises in large scale ethical failures in engineering such as in the Deepwater Horizon oil spill (Thompson 2014 ).

Possible examples in the 737 MAX case of the difficulty of assigning moral responsibility due to the problem of many hands include:

The decision to reposition the engines;

The decision to mask the jet’s subsequent dynamic instability with MCAS;

The decision to rely on only one AOA sensor in designing MCAS; and

The decision to not inform nor properly train pilots about the MCAS system.

While overall responsibility for each of these decisions may be difficult to allocate precisely, at least points 1–3 above arguably reflect fundamental errors in engineering judgement (Travis 2019 ). Boeing engineers and FAA engineers either participated in or were aware of these decisions (Kitroeff and Gelles 2019 ) and may have had opportunities to reconsider or redirect such decisions. As Davis has noted ( 2012 ), responsible engineering professionals make it their business to address problems even when they did not cause the problem, or, we would argue, solely cause it. As noted earlier, reports indicate that at least one Boeing engineer expressed reservations about the design of MCAS (Bellamy 2019 ). Since the two crashes, one Boeing engineer, Curtis Ewbank, filed an internal ethics complaint (Kitroeff et al. 2019b ) and several current and former Boeing engineers and other employees have gone public with various concerns about the 737 MAX (Pasztor 2019 ). And yet, as is often the case, the flawed design went forward with tragic results.

Enabling Ethical Engineers

The MAX case is eerily reminiscent of other well-known engineering ethics case studies such as the Ford Pinto (Birsch and Fielder 1994 ), Space Shuttle Challenger (Werhane 1991 ), and GM ignition switch (Jennings and Trautman 2016 ). In the Pinto case, Ford engineers were aware of the unsafe placement of the fuel tank well before the car was released to the public and signed off on the design even though crash tests showed the tank was vulnerable to rupture during low-speed rear-end collisions (Baura 2006 ). In the case of the GM ignition switch, engineers knew for at least four years about the faulty design, a flaw that resulted in at least a dozen fatal accidents (Stephan 2016 ). In the case of the well-documented Challenger accident, engineer Roger Boisjoly warned his supervisors at Morton Thiokol of potentially catastrophic flaws in the shuttle’s solid rocket boosters a full six months before the accident. He, along with other engineers, unsuccessfully argued on the eve of launch for a delay due to the effect that freezing temperatures could have on the boosters’ O-ring seals. Boisjoly was also one of a handful of engineers to describe these warnings to the Presidential commission investigating the accident (Boisjoly et al. 1989 ).

Returning to the 737 MAX case, could Ewbank or others with concerns about the safety of the airplane have done more than filing ethics complaints or offering public testimony only after the Lion Air and Ethiopian Airlines crashes? One might argue that requiring professional registration by all engineers in the U.S. would result in more ethical conduct (for example, by giving state licensing boards greater oversight authority). Yet the well-entrenched “industry exemption” from registration for most engineers working in large corporations has undermined such calls (Kline 2001 ).

It could empower engineers with safety concerns if Boeing and other corporations would strengthen internal ethics processes, including sincere and meaningful responsiveness to anonymous complaint channels. Schwartz ( 2013 ) outlines three core components of an ethical corporate culture, including strong core ethical values, a formal ethics program (including an ethics hotline), and capable ethical leadership. Schwartz points to Siemens’ creation of an ethics and compliance department following a bribery scandal as an example of a good solution. Boeing has had a compliance department for quite some time (Schnebel and Bienert 2004 ) and has taken efforts in the past to evaluate its effectiveness (Boeing 2003 ). Yet it is clear that more robust measures are needed in response to ethics concerns and complaints. Since the MAX crashes, Boeing’s Board has implemented a number of changes including establishing a corporate safety group and revising internal reporting procedures so that lead engineers primarily report to the chief engineer rather than business managers (Gelles and Kitroeff 2019b , Boeing n.d. c). Whether these measures will be enough to restore Boeing’s former engineering-centered focus remains to be seen.

Professional engineering societies could play a stronger role in communicating and enforcing codes of ethics, in supporting ethical behavior of engineers, and by providing more educational opportunities for learning about ethics and about the ethical responsibilities of engineers. Some societies, including ACM and IEEE, have become increasingly engaged in ethics-related activities. Initially ethics engagement by the societies consisted primarily of a focus on macroethical issues such as sustainable development (Herkert 2004 ). Recently, however, the societies have also turned to a greater focus on microethical issues (the behavior of individuals). The 2017 revision to the IEEE Code of Ethics, for example, highlights the importance of “ethical design” (Adamson and Herkert 2020 ). This parallels IEEE activities in the area of design of autonomous and intelligent systems (e.g., IEEE 2018 ). A promising outcome of this emphasis is a move toward implementing “ethical design” frameworks (Peters et al. 2020 ).

In terms of engineering education, educators need to place a greater emphasis on fostering moral courage, that is the courage to act on one’s moral convictions including adherence to codes of ethics. This is of particular significance in large organizations such as Boeing and the FAA where the agency of engineers may be limited by factors such as organizational culture (Watts and Buckley 2017 ). In a study of twenty-six ethics interventions in engineering programs, Hess and Fore ( 2018 ) found that only twenty-seven percent had a learning goal of development of “ethical courage, confidence or commitment”. This goal could be operationalized in a number of ways, for example through a focus on virtue ethics (Harris 2008 ) or professional identity (Hashemian and Loui 2010 ). This need should not only be addressed within the engineering curriculum but during lifelong learning initiatives and other professional development opportunities as well (Miller 2019 ).

The circumstances surrounding the 737 MAX airplane could certainly serve as an informative case study for ethics or technical courses. The case can shed light on important lessons for engineers including the complex interactions, and sometimes tensions, between engineering and managerial considerations. The case also tangibly displays that what seems to be relatively small-scale, and likely well-intended, decisions by individual engineers can combine collectively to result in large-scale tragedy. No individual person wanted to do harm, but it happened nonetheless. Thus, the case can serve a reminder to current and future generations of engineers that public safety must be the first and foremost priority. A particularly useful pedagogical method for considering this case is to assign students to the roles of engineers, managers, and regulators, as well as the flying public, airline personnel, and representatives of engineering societies (Herkert 1997 ). In addition to illuminating the perspectives and responsibilities of each stakeholder group, role-playing can also shed light on the “macroethical” issues raised by the case (Martin et al. 2019 ) such as airline safety standards and the proper role for engineers and engineering societies in the regulation of the industry.

Conclusions and Recommendations

The case of the Boeing 737 MAX provides valuable lessons for engineers and engineering educators concerning the ethical responsibilities of the profession. Safety is not cheap, but careless engineering design in the name of minimizing costs and adhering to a delivery schedule is a symptom of ethical blight. Using almost any standard ethical analysis or framework, Boeing’s actions regarding the safety of the 737 MAX, particularly decisions regarding MCAS, fall short.

Boeing failed in its obligations to protect the public. At a minimum, the company had an obligation to inform airlines and pilots of significant design changes, especially the role of MCAS in compensating for repositioning of engines in the MAX from prior versions of the 737. Clearly, it was a “significant” change because it had a direct, and unfortunately tragic, impact on the public’s safety. The Boeing and FAA interaction underscores the fact that conflicts of interest are a serious concern in regulatory actions within the airline industry.

Internal and external organizational factors may have interfered with Boeing and FAA engineers’ fulfillment of their professional ethical responsibilities; this is an all too common problem that merits serious attention from industry leaders, regulators, professional societies, and educators. The lessons to be learned in this case are not new. After large scale tragedies involving engineering decision-making, calls for change often emerge. But such lessons apparently must be retaught and relearned by each generation of engineers.

ACM/IEEE-CS Joint Task Force. (1997). Software Engineering Code of Ethics and Professional Practice, https://ethics.acm.org/code-of-ethics/software-engineering-code/ .

Adamson, G., & Herkert, J. (2020). Addressing intelligent systems and ethical design in the IEEE Code of Ethics. In Codes of ethics and ethical guidelines: Emerging technologies, changing fields . New York: Springer ( in press ).

Ahmed, H., Glanz, J., & Beech, H. (2019). Ethiopian airlines pilots followed Boeing’s safety procedures before crash, Report Shows. The New York Times, April 4, https://www.nytimes.com/2019/04/04/world/asia/ethiopia-crash-boeing.html .

AIAA. (2013). Code of Ethics, https://www.aiaa.org/about/Governance/Code-of-Ethics .

Arnold, K. (2019). FAA report predicted there could be 15 more 737 MAX crashes. The Dallas Morning News, December 11, https://www.dallasnews.com/business/airlines/2019/12/11/faa-chief-says-boeings-737-max-wont-be-approved-in-2019/

Baura, G. (2006). Engineering ethics: an industrial perspective . Amsterdam: Elsevier.

Google Scholar  

BBC News. (2019). Work on production line of Boeing 737 MAX ‘Not Adequately Funded’. July 29, https://www.bbc.com/news/business-49142761 .

Bellamy, W. (2019). Boeing CEO outlines 737 MAX MCAS software fix in congressional hearings. Aviation Today, November 2, https://www.aviationtoday.com/2019/11/02/boeing-ceo-outlines-mcas-updates-congressional-hearings/ .

Benning, T., & DiFurio, D. (2019). American Airlines Pilots Union boss prods lawmakers to solve 'Crisis of Trust' over Boeing 737 MAX. The Dallas Morning News, June 19, https://www.dallasnews.com/business/airlines/2019/06/19/american-airlines-pilots-union-boss-prods-lawmakers-to-solve-crisis-of-trust-over-boeing-737-max/ .

Birsch, D., & Fielder, J. (Eds.). (1994). The ford pinto case: A study in applied ethics, business, and technology . New York: The State University of New York Press.

Boeing. (2003). Boeing Releases Independent Reviews of Company Ethics Program. December 18, https://boeing.mediaroom.com/2003-12-18-Boeing-Releases-Independent-Reviews-of-Company-Ethics-Program .

Boeing. (2018). Flight crew operations manual bulletin for the Boeing company. November 6, https://www.avioesemusicas.com/wp-content/uploads/2018/10/TBC-19-Uncommanded-Nose-Down-Stab-Trim-Due-to-AOA.pdf .

Boeing. (n.d. a). About the Boeing 737 MAX. https://www.boeing.com/commercial/737max/ .

Boeing. (n.d. b). 737 MAX Updates. https://www.boeing.com/737-max-updates/ .

Boeing. (n.d. c). Initial actions: sharpening our focus on safety. https://www.boeing.com/737-max-updates/resources/ .

Bogaisky, J. (2020). Boeing stock plunges as coronavirus imperils quick ramp up in 737 MAX deliveries. Forbes, March 11, https://www.forbes.com/sites/jeremybogaisky/2020/03/11/boeing-coronavirus-737-max/#1b9eb8955b5a .

Boisjoly, R. P., Curtis, E. F., & Mellican, E. (1989). Roger Boisjoly and the challenger disaster: The ethical dimensions. J Bus Ethics, 8 (4), 217–230.

Article   Google Scholar  

Borenstein, J., Mahajan, H. P., Wagner, A. R., & Howard, A. (2020). Trust and pediatric exoskeletons: A comparative study of clinician and parental perspectives. IEEE Transactions on Technology and Society , 1 (2), 83–88.

Borenstein, J., Wagner, A. R., & Howard, A. (2018). Overtrust of pediatric health-care robots: A preliminary survey of parent perspectives. IEEE Robot Autom Mag, 25 (1), 46–54.

Bushey, C. (2019). The Tough Crowd Boeing Needs to Convince. Crain’s Chicago Business, October 25, https://www.chicagobusiness.com/manufacturing/tough-crowd-boeing-needs-convince .

Campbell, D. (2019). The many human errors that brought down the Boeing 737 MAX. The Verge, May 2, https://www.theverge.com/2019/5/2/18518176/boeing-737-max-crash-problems-human-error-mcas-faa .

Carr, N. (2014). The glass cage: Automation and us . Norton.

Cummings, M. L., & Britton, D. (2020). Regulating safety-critical autonomous systems: past, present, and future perspectives. In Living with robots (pp. 119–140). Academic Press, New York.

Davis, M. (1991). Thinking like an engineer: The place of a code of ethics in the practice of a profession. Philos Publ Affairs, 20 (2), 150–167.

Davis, M. (2012). “Ain’t no one here but us social forces”: Constructing the professional responsibility of engineers. Sci Eng Ethics, 18 (1), 13–34.

Davis, M. (2015). Engineering as profession: Some methodological problems in its study. In Engineering identities, epistemologies and values (pp. 65–79). Springer, New York.

Department of Transportation (DOT). (2020). Official report of the special committee to review the Federal Aviation Administration’s Aircraft Certification Process, January 16. https://www.transportation.gov/sites/dot.gov/files/2020-01/scc-final-report.pdf .

Duncan, I., & Aratani, L. (2019). FAA flexes its authority in final stages of Boeing 737 MAX safety review. The Washington Post, November 27, https://www.washingtonpost.com/transportation/2019/11/27/faa-flexes-its-authority-final-stages-boeing-max-safety-review/ .

Duncan, I., & Laris, M. (2020). House report on 737 Max crashes faults Boeing’s ‘culture of concealment’ and labels FAA ‘grossly insufficient’. The Washington Post, March 6, https://www.washingtonpost.com/local/trafficandcommuting/house-report-on-737-max-crashes-faults-boeings-culture-of-concealment-and-labels-faa-grossly-insufficient/2020/03/06/9e336b9e-5fce-11ea-b014-4fafa866bb81_story.html .

Economy, P. (2019). Boeing CEO Puts Partial Blame on Pilots of Crashed 737 MAX Aircraft for Not 'Completely' Following Procedures. Inc., April 30, https://www.inc.com/peter-economy/boeing-ceo-puts-partial-blame-on-pilots-of-crashed-737-max-aircraft-for-not-completely-following-procedures.html .

Federal Aviation Administration (FAA). (2018a). Airworthiness directives; the Boeing company airplanes. FR Doc No: R1-2018-26365. https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/fe8237743be9b8968625835b004fc051/$FILE/2018-23-51_Correction.pdf .

Federal Aviation Administration (FAA). (2018b). Quantitative Risk Assessment. https://www.documentcloud.org/documents/6573544-Risk-Assessment-for-Release-1.html#document/p1 .

Federal Aviation Administration (FAA). (2019). Joint authorities technical review: observations, findings, and recommendations. October 11, https://www.faa.gov/news/media/attachments/Final_JATR_Submittal_to_FAA_Oct_2019.pdf .

Federal Democratic Republic of Ethiopia. (2019). Aircraft accident investigation preliminary report. Report No. AI-01/19, April 4, https://leehamnews.com/wp-content/uploads/2019/04/Preliminary-Report-B737-800MAX-ET-AVJ.pdf .

Federal Democratic Republic of Ethiopia. (2020). Aircraft Accident Investigation Interim Report. Report No. AI-01/19, March 20, https://www.aib.gov.et/wp-content/uploads/2020/documents/accident/ET-302%2520%2520Interim%2520Investigation%2520%2520Report%2520March%25209%25202020.pdf .

Gates, D. (2018). Pilots struggled against Boeing's 737 MAX control system on doomed Lion Air flight. The Seattle Times, November 27, https://www.seattletimes.com/business/boeing-aerospace/black-box-data-reveals-lion-air-pilots-struggle-against-boeings-737-max-flight-control-system/ .

Gates, D. (2019). Flawed analysis, failed oversight: how Boeing, FAA Certified the Suspect 737 MAX Flight Control System. The Seattle Times, March 17, https://www.seattletimes.com/business/boeing-aerospace/failed-certification-faa-missed-safety-issues-in-the-737-max-system-implicated-in-the-lion-air-crash/ .

Gelles, D. (2019). Boeing can’t fly its 737 MAX, but it’s ready to sell its safety. The New York Times, December 24 (updated February 10, 2020), https://www.nytimes.com/2019/12/24/business/boeing-737-max-survey.html .

Gelles, D. (2020). Boeing expects 737 MAX costs will surpass $18 Billion. The New York Times, January 29, https://www.nytimes.com/2020/01/29/business/boeing-737-max-costs.html .

Gelles, D., & Kaplan, T. (2019). F.A.A. Approval of Boeing jet involved in two crashes comes under scrutiny. The New York Times, March 19, https://www.nytimes.com/2019/03/19/business/boeing-elaine-chao.html .

Gelles, D., & Kitroeff, N. (2019a). Boeing Believed a 737 MAX warning light was standard. It wasn’t. New York: The New York Times. https://www.nytimes.com/2019/05/05/business/boeing-737-max-warning-light.html .

Gelles, D., & Kitroeff, N. (2019b). Boeing board to call for safety changes after 737 MAX Crashes. The New York Times, September 15, (updated October 2), https://www.nytimes.com/2019/09/15/business/boeing-safety-737-max.html .

Gelles, D., & Kitroeff, N. (2019c). Boeing pilot complained of ‘Egregious’ issue with 737 MAX in 2016. The New York Times, October 18, https://www.nytimes.com/2019/10/18/business/boeing-flight-simulator-text-message.html .

Gelles, D., & Kitroeff, N. (2020). What needs to happen to get Boeing’s 737 MAX flying again?. The New York Times, February 10, https://www.nytimes.com/2020/02/10/business/boeing-737-max-fly-again.html .

Gelles, D., Kitroeff, N., Nicas, J., & Ruiz, R. R. (2019). Boeing was ‘Go, Go, Go’ to beat airbus with the 737 MAX. The New York Times, March 23, https://www.nytimes.com/2019/03/23/business/boeing-737-max-crash.html .

Glanz, J., Creswell, J., Kaplan, T., & Wichter, Z. (2019). After a Lion Air 737 MAX Crashed in October, Questions About the Plane Arose. The New York Times, February 3, https://www.nytimes.com/2019/02/03/world/asia/lion-air-plane-crash-pilots.html .

Gotterbarn, D., & Miller, K. W. (2009). The public is the priority: Making decisions using the software engineering code of ethics. Computer, 42 (6), 66–73.

Hall, J., & Goelz, P. (2019). The Boeing 737 MAX Crisis Is a Leadership Failure, The New York Times, July 17, https://www.nytimes.com/2019/07/17/opinion/boeing-737-max.html .

Harris, C. E. (2008). The good engineer: Giving virtue its due in engineering ethics. Science and Engineering Ethics, 14 (2), 153–164.

Hashemian, G., & Loui, M. C. (2010). Can instruction in engineering ethics change students’ feelings about professional responsibility? Science and Engineering Ethics, 16 (1), 201–215.

Herkert, J. R. (1997). Collaborative learning in engineering ethics. Science and Engineering Ethics, 3 (4), 447–462.

Herkert, J. R. (2004). Microethics, macroethics, and professional engineering societies. In Emerging technologies and ethical issues in engineering: papers from a workshop (pp. 107–114). National Academies Press, New York.

Hess, J. L., & Fore, G. (2018). A systematic literature review of US engineering ethics interventions. Science and Engineering Ethics, 24 (2), 551–583.

House Committee on Transportation and Infrastructure (House TI). (2020). The Boeing 737 MAX Aircraft: Costs, Consequences, and Lessons from its Design, Development, and Certification-Preliminary Investigative Findings, March. https://transportation.house.gov/imo/media/doc/TI%2520Preliminary%2520Investigative%2520Findings%2520Boeing%2520737%2520MAX%2520March%25202020.pdf .

IEEE. (2017). IEEE Code of Ethics. https://www.ieee.org/about/corporate/governance/p7-8.html .

IEEE. (2018). Ethically Aligned Design: A Vision for Prioritizing Human Well-being with Autonomous and Intelligent Systems (version 2). https://standards.ieee.org/content/dam/ieee-standards/standards/web/documents/other/ead_v2.pdf .

Jennings, M., & Trautman, L. J. (2016). Ethical culture and legal liability: The GM switch crisis and lessons in governance. Boston University Journal of Science and Technology Law, 22 , 187.

Johnston, P., & Harris, R. (2019). The Boeing 737 MAX Saga: Lessons for software organizations. Software Quality Professional, 21 (3), 4–12.

Josephs, L. (2019). FAA tightens grip on Boeing with plan to individually review each new 737 MAX Jetliner. CNBC, November 27, https://www.cnbc.com/2019/11/27/faa-tightens-grip-on-boeing-with-plan-to-individually-inspect-max-jets.html .

Kaplan, T., Austen, I., & Gebrekidan, S. (2019). The New York Times, March 13. https://www.nytimes.com/2019/03/13/business/canada-737-max.html .

Kitroeff, N. (2019). Boeing underestimated cockpit chaos on 737 MAX, N.T.S.B. Says. The New York Times, September 26, https://www.nytimes.com/2019/09/26/business/boeing-737-max-ntsb-mcas.html .

Kitroeff, N., & Gelles, D. (2019). Legislators call on F.A.A. to say why it overruled its experts on 737 MAX. The New York Times, November 7 (updated December 11), https://www.nytimes.com/2019/11/07/business/boeing-737-max-faa.html .

Kitroeff, N., & Gelles, D. (2020). It’s not just software: New safety risks under scrutiny on Boeing’s 737 MAX. The New York Times, January 5, https://www.nytimes.com/2020/01/05/business/boeing-737-max.html .

Kitroeff, N., & Schmidt, M. S. (2020). Federal prosecutors investigating whether Boeing pilot lied to F.A.A. The New York Times, February 21, https://www.nytimes.com/2020/02/21/business/boeing-737-max-investigation.html .

Kitroeff, N., Gelles, D., & Nicas, J. (2019a). The roots of Boeing’s 737 MAX Crisis: A regulator relaxes its oversight. The New York Times, July 27, https://www.nytimes.com/2019/07/27/business/boeing-737-max-faa.html .

Kitroeff, N., Gelles, D., & Nicas, J. (2019b). Boeing 737 MAX safety system was vetoed, Engineer Says. The New York Times, October 2, https://www.nytimes.com/2019/10/02/business/boeing-737-max-crashes.html .

Kline, R. R. (2001). Using history and sociology to teach engineering ethics. IEEE Technology and Society Magazine, 20 (4), 13–20.

Koenig, D. (2019). Boeing, FAA both faulted in certification of the 737 MAX. AP, October 11, https://apnews.com/470abf326cdb4229bdc18c8ad8caa78a .

Langewiesche, W. (2019). What really brought down the Boeing 737 MAX? The New York Times, September 18, https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-crashes.html .

Leveson, N. G., & Turner, C. S. (1993). An investigation of the Therac-25 accidents. Computer, 26 (7), 18–41.

Marks, S., & Dahir, A. L. (2020). Ethiopian report on 737 Max Crash Blames Boeing, March 9, https://www.nytimes.com/2020/03/09/world/africa/ethiopia-crash-boeing.html .

Martin, D. A., Conlon, E., & Bowe, B. (2019). The role of role-play in student awareness of the social dimension of the engineering profession. European Journal of Engineering Education, 44 (6), 882–905.

Miller, G. (2019). Toward lifelong excellence: navigating the engineering-business space. In The Engineering-Business Nexus (pp. 81–101). Springer, Cham.

National Transportation Safety Board (NTSB). (2019). Safety Recommendations Report, September 19, https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf .

Nissenbaum, H. (1994). Computing and accountability. Communications of the ACM , January, https://dl.acm.org/doi/10.1145/175222.175228 .

Nissenbaum, H. (1996). Accountability in a computerized society. Science and Engineering Ethics, 2 (1), 25–42.

Noorman, M. (2020). Computing and moral responsibility. In Zalta, E. N. (Ed.). The Stanford Encyclopedia of Philosophy (Spring), https://plato.stanford.edu/archives/spr2020/entries/computing-responsibility .

Pasztor, A. (2019). More Whistleblower complaints emerge in Boeing 737 MAX Safety Inquiries. The Wall Street Journal, April 27, https://www.wsj.com/articles/more-whistleblower-complaints-emerge-in-boeing-737-max-safety-inquiries-11556418721 .

Pasztor, A., & Cameron, D. (2020). U.S. News: Panel Backs How FAA gave safety approval for 737 MAX. The Wall Street Journal, January 17, https://www.wsj.com/articles/panel-clears-737-maxs-safety-approval-process-at-faa-11579188086 .

Pasztor, A., Cameron.D., & Sider, A. (2020). Boeing backs MAX simulator training in reversal of stance. The Wall Street Journal, January 7, https://www.wsj.com/articles/boeing-recommends-fresh-max-simulator-training-11578423221 .

Peters, D., Vold, K., Robinson, D., & Calvo, R. A. (2020). Responsible AI—two frameworks for ethical design practice. IEEE Transactions on Technology and Society, 1 (1), 34–47.

Peterson, M. (2019). The ethical failures behind the Boeing disasters. Blog of the APA, April 8, https://blog.apaonline.org/2019/04/08/the-ethical-failures-behind-the-boeing-disasters/ .

Pinkus, R. L., Pinkus, R. L. B., Shuman, L. J., Hummon, N. P., & Wolfe, H. (1997). Engineering ethics: Balancing cost, schedule, and risk-lessons learned from the space shuttle . Cambridge: Cambridge University Press.

Republic of Indonesia. (2019). Final Aircraft Accident Investigation Report. KNKT.18.10.35.04, https://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2018%2520-%2520035%2520-%2520PK-LQP%2520Final%2520Report.pdf .

Rich, G. (2019). Boeing 737 MAX should return in 2020 but the crisis won't be over. Investor's Business Daily, December 31, https://www.investors.com/news/boeing-737-max-service-return-2020-crisis-not-over/ .

Schnebel, E., & Bienert, M. A. (2004). Implementing ethics in business organizations. Journal of Business Ethics, 53 (1–2), 203–211.

Schwartz, M. S. (2013). Developing and sustaining an ethical corporate culture: The core elements. Business Horizons, 56 (1), 39–50.

Stephan, K. (2016). GM Ignition Switch Recall: Too Little Too Late? [Ethical Dilemmas]. IEEE Technology and Society Magazine, 35 (2), 34–35.

Sullenberger, S. (2019). My letter to the editor of New York Times Magazine, https://www.sullysullenberger.com/my-letter-to-the-editor-of-new-york-times-magazine/ .

Thompson, D. F. (1980). Moral responsibility of public officials: The problem of many hands. American Political Science Review, 74 (4), 905–916.

Thompson, D. F. (2014). Responsibility for failures of government: The problem of many hands. The American Review of Public Administration, 44 (3), 259–273.

Tkacik, M. (2019). Crash course: how Boeing’s managerial revolution created the 737 MAX Disaster. The New Republic, September 18, https://newrepublic.com/article/154944/boeing-737-max-investigation-indonesia-lion-air-ethiopian-airlines-managerial-revolution .

Travis, G. (2019). How the Boeing 737 MAX disaster looks to a software developer. IEEE Spectrum , April 18, https://spectrum.ieee.org/aerospace/aviation/how-the-boeing-737-max-disaster-looks-to-a-software-developer .

Useem, J. (2019). The long-forgotten flight that sent Boeing off course. The Atlantic, November 20, https://www.theatlantic.com/ideas/archive/2019/11/how-boeing-lost-its-bearings/602188/ .

Watts, L. L., & Buckley, M. R. (2017). A dual-processing model of moral whistleblowing in organizations. Journal of Business Ethics, 146 (3), 669–683.

Werhane, P. H. (1991). Engineers and management: The challenge of the Challenger incident. Journal of Business Ethics, 10 (8), 605–616.

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Herkert, J., Borenstein, J. & Miller, K. The Boeing 737 MAX: Lessons for Engineering Ethics. Sci Eng Ethics 26 , 2957–2974 (2020). https://doi.org/10.1007/s11948-020-00252-y

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NSPE’s Board of Ethical Review has published six new case studies that provide engineering ethics guidance using factbased scenarios. The cases cover the topics of plan stamping; gifts; the public health, safety, and welfare; conflicts of interest; responsible charge; and job qualifications. NSPE established the Board of Ethical Review in June 1954 due to many requests by engineers, state societies, and chapters for interpretations of the Code of Ethics in specific circumstances. Since the publishing of the first case in 1958, which involved questionable actions on a World Bank-financed hydroelectric project, the case catalog has grown to nearly 650.

Today, there are many real-world examples in which engineering ethics has a direct impact on the public, especially those related to technology advancement. For example, NSPE encourages policymakers to protect the public health, safety, and welfare when developing artificial intelligence and autonomous vehicles. In comments to the National Institute of Standards and Technology in August, NSPE called for the involvement of ethically accountable licensed professional engineers or duly certified individuals in the AI development process. The Society has also called on NIST to create AI technical standards that include an ethical framework that can be applied universally in the development of AI decision-making.

Each of the BER’s just-released cases dives into subjects that practicing professional engineers and engineer interns can face on the job. In Case 20-4 , a PE for a metropolitan water commission and a consulting engineer retained by the commission are faced with ethical dilemmas surrounding the commission’s consideration of a change in its water supply source—a change with public health, safety, and welfare implications. In another case ( 20-1 ), an engineer intern applies for a position at a consulting firm. The job requires the candidate to hold a PE license or to become licensed within 90 days. The firm offers the job to the engineer intern, but complications arise when the EI fails the PE exam and is found to have withheld information from the firm.

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Welcome to the case studies pages of the EPC’s Engineering Ethics toolkit, produced in partnership with the Royal Academy of Engineering. Click here for the toolkit homepage.

Case studies are one tool that can be used to address the context and impact of engineering ethics, and have been proven to be an effective teaching and learning method.

These case studies cover a variety of engineering disciplines, professional situations, and personal dilemmas and focuses on several areas of moral pedagogy. They were developed for use in higher education, but may also be of use in other settings.

To accommodate many educational levels, the case studies are divided between Beginner, Intermediate, and Advanced cases. They are written in parts so that educators have the flexibility to use them as is best suited to their teaching content and environment, and all cases permit and encourage the integration of technical content. Along with learning and teaching notes, the cases contain suggested questions and activities as well as supplementary materials.

They are aligned to the Engineering Council and Royal Academy of Engineering’s Joint Statement of Ethical Principles and the expectations of the 4th Edition of the Engineering Council’s Accreditation of Higher Education Programmes and are therefore appropriate for UK teaching and learning contexts. They are, however, easily adapted for use in other countries.

Guidance articles are also available to help situate the case studies in an educational context and to signpost to additional research and resources on engineering ethics.

In developing the cases and articles in this resource, the authors and advisory group took into account recent scholarship on best practices in teaching engineering ethics through case studies. They also reviewed existing case study libraries in order to add to the growing body of material available on engineering ethics. 

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Ethics in Engineering

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This course is for engineering students and professionals but designed for anyone interested in the underlying causes of engineering failures.

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Key factors that led to historical cases of engineering failures

The causes and outcomes of these classic engineering failures

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There are 4 modules in this course

Explore unique case studies in engineering ethics. In this four-week course, you’ll examine different historical case studies and understand how they led to classic engineering failures.

Though each case is unique and has a distinct context, they all share common themes; a backstory, a disastrous event, a post-event with ramifications, and outcomes. For each case, you’ll watch and hear video lectures and explore foundational literature. You’ll also have the opportunity to discuss the case in detail and check your knowledge through quizzes and reflections on your understanding of the case. This format will help you develop a working knowledge of ethical foundations. Delve into four case studies, including the VW emissions scandal, the failure of the Denver airport baggage system, the fatal case of the Therac 25 radiation machine, and the software failure of the Ariane 5 rocket launch. With each case, you’ll identify key aspects that led to the engineering failures and discuss the outcomes of the failures. You’ll also explore the significance of each case and how they led to corrective actions. Develop your knowledge of engineering alongside experts in the industry. The course will help you reflect on engineering as a design discipline and its impact on humans. You’ll be guided by Dr. David Chesney, an expert in both industry and academics with 20 years of experience at General Motors Corporation and 20 years working at the University of Michigan. Dr. Chesney’s background is in Mechanical Engineering, Biomedical Engineering, and Computer Science and he is the Toby Teorey Collegiate Lecturer in Electrical Engineering and Computer Science at the University of Michigan College of Engineering. This course will be particularly useful for engineering students and professionals, although no prior experience is required.

Welcome to the Ethics in Engineering Course! Let’s get to know each other, meet Dr. Chesney, and get an overview of what we will learn.

What's included

9 videos 8 readings 2 quizzes 5 discussion prompts

9 videos • Total 54 minutes

• Welcome to Ethics in Engineering! • 1 minute • Preview module
• Overview of Ethical Models (Part 1) • 7 minutes
• Overview of Ethical Models (Part 2) • 11 minutes
• Introduction to the VW Emissions Scandal • 1 minute
• The Backstory of the VW Emissions Scandal • 11 minutes
• What Happened with the VW Emissions Scandal? • 7 minutes
• The Aftermath of the W Emissions Scandal • 6 minutes
• Lessons Learned & Summary of the VW Emissions Scandal • 4 minutes
• One More Thing to Add on the VW Emissions Scandal • 3 minutes

8 readings • Total 80 minutes

• About this course • 10 minutes
• Syllabus & DEI statement • 10 minutes
• Pre-Course Survey • 10 minutes
• Course Case Studies • 10 minutes
• Introduction to the VW Emissions Scandal • 10 minutes
• The Case Study • 10 minutes
• A Deep Dive to the Event of the VW Emissions Scandal • 10 minutes
• End of Week 1 and Coming Up Next • 10 minutes

2 quizzes • Total 60 minutes

• Knowledge Check: What did you learn about the case study so far? • 30 minutes
• Week 1 Final Test • 30 minutes

5 discussion prompts • Total 50 minutes

• Introduce Yourself • 10 minutes
• What does "engineering ethics" bring to your mind? • 10 minutes
• Reflection and Discussion on the VW Emissions Scandal • 10 minutes
• Reflection and Discussion on the VW Emissions Scandal's Event • 10 minutes
• Reflection and Discussion on the Aftermath of the Event • 10 minutes

Welcome to our second case study! We start with an introduction to the DIA baggage handling catastrophe so that we ground our understanding in facts.

6 videos 5 readings 2 quizzes 2 discussion prompts

6 videos • Total 35 minutes

• Introduction to DIA Baggage Handling Catastrophe • 3 minutes • Preview module
• The Backstory of the DIA Baggage Handling Catastrophe • 16 minutes
• What Happened with the DIA Baggage Handling Catastrophe? • 2 minutes
• After the Event of the DIA Baggage Handling Catastrophe • 1 minute
• Lessons Learned & Summary of the DIA Baggage Handling Catastrophe • 7 minutes
• One More Thing to Add on the DIA Baggage Handling Catastrophe • 3 minutes

5 readings • Total 50 minutes

• Introduction to DIA Baggage Handling Catastrophe • 10 minutes
• Reflection and Discussion on the DIA Baggage Handling Catastrophe • 10 minutes
• A Deep Dive to the Event of the DIA Baggage Handling Catastrophe • 10 minutes
• End of Week 2 and Coming Up Next • 10 minutes

2 quizzes • Total 90 minutes

• Week 2 Final Test • 60 minutes

2 discussion prompts • Total 20 minutes

• Reflection and Discussion on the Event of the DIA Baggage Handling Catastrophe • 10 minutes

Welcome to our third case study! We start with an introduction to the Therac 25 radiation machine malfunction so that we ground our understanding in facts.

6 videos 5 readings 2 quizzes 3 discussion prompts

6 videos • Total 40 minutes

• Introduction to the Therac 25 Radiation Machine Malfunction • 2 minutes • Preview module
• The Backstory of the Therac 25 Radiation Machine Malfunction • 11 minutes
• What Happened with the Therac 25 Radiation Machine Malfunction? • 7 minutes
• The Aftermath of the Therac 25 Radiation Machine Malfunction • 7 minutes
• Lessons Learned & Summary of the Therac 25 Radiation Machine Malfunction • 9 minutes
• One More Thing to Add on the Therac 25 Radiation Machine Malfunction • 2 minutes
• Content Warning • 10 minutes
• Introduction to the Therac 25 Radiation Machine Malfunction • 10 minutes
• A Deep Dive to the Event of the Therac 25 Radiation Machine Malfunction • 10 minutes
• End of Week 3 and Coming Up Next • 10 minutes
• Week 3 Final Test • 60 minutes

3 discussion prompts • Total 30 minutes

• Reflection & Discussion on The Therac 25 Radiation Machine Malfunction • 10 minutes
• Reflection and Discussion on the Event of the Therac 25 Radiation Machine Malfunction • 10 minutes

Welcome to our fourth case study! We start with an introduction to the Ariane 5 rocket launch disaster so that we ground our understanding in facts.

6 videos 5 readings 2 quizzes 4 discussion prompts

6 videos • Total 23 minutes

• Introduction to the Ariane 5 Rocket Launch Disaster • 0 minutes • Preview module
• The Backstory of the Ariane 5 Rocket Launch Disaster • 3 minutes
• What Happened with the Ariane 5 Rocket Launch Disaster? • 4 minutes
• The Aftermath of Ariane 5 Rocket Launch Disaster • 4 minutes
• Lessons Learned & Summary of the Ariane 5 Rocket Launch Disaster • 5 minutes
• One More Thing to Add on the Ariane 5 Rocket Launch Disaster • 3 minutes
• Introduction to the Ariane 5 Rocket Launch Disaster • 10 minutes
• A Deep Dive to the Event of the Ariane 5 Rocket Launch Disaster • 10 minutes
• Post-Course Survey • 10 minutes
• Week 4 Final Test • 30 minutes

4 discussion prompts • Total 40 minutes

• Reflection & Discussion on the Ariane 5 Rocket Launch Disaster • 10 minutes
• Reflection and Discussion on the Event of the Ariane 5 Rocket Launch Disaster • 10 minutes
• Concluding Thoughts • 10 minutes

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Gilbane Gold Summary and Plan

Summary of a discussion and lesson plan from Texas A&M using elements of a fictional case dramatized in the video tape, "Gilbane Gold, a Video Case Study" produced by The National Institute for Engineering Ethics of the NSPE.

The case was originally prepared by the National Institute for Engineering Ethics of the National Society of Professional Engineers.

The case involves a young engineer, David Jackson, who faces a problem posed by discharges from his plant Z CORP, which is located in the town of Gilbane. Jackson has replaced a consultant who believes he was released because of his warnings about the discharge of toxic materials. David is concerned about Z CORP's heavy metals discharge, and his concern is further intensified when he learns that Z CORP has signed a that will result in a five-fold increase in the discharge of heavy metals. David finally decides to blow the whistle on the plant's discharge levels by talking to the local TV newscaster.

The primary ethical issue raised in the case is whistle-blowing, obligations of engineers with respect to environmental issues, management problems having to do with honesty and trust between business and its host community, the issue of the fairness of a community towards local manufacturing plants, the problems raised for individuals and groups by the necessity for action in the face of inconclusive scientific evidence, and the relationship of law and ethics.

Introduction to the Case

This case was originally prepared by the National Institute for Engineering Ethics of the National Society of Professional Engineers. It is a fictional but highly plausible case, suggested by actual situations. Students will find it easy to identify with the junior environmental engineer, David Jackson, who is caught between his desire to be a good employee and his sense of obligation as an engineer to protect the health, safety, and welfare of the public.

Although the primary ethical issue raised in the case is whistle blowing, secondary ethical issues include the obligations of engineers with respect to environmental issues, management problems having to do with honesty and trust between business and its host community, the issue of the fairness of a community towards local manufacturing plants, the problems raised for individuals and groups by the necessity for action in the face of inconclusive scientific evidence, and the relationship of law and morality.

The case takes place in the imaginary town of Gilbane. The sludge from the Gilbane sewage plant has been used for many years as a fertilizer and is sold under the name "Gilbane Gold." The revenue from the sale of Gilbane Gold enables the city to supplement its tax revenues, saving a family of four approximately $300/year in taxes. In order to protect this source of income, the town placed severe restrictions on the discharge of heavy metals into the sewage, so the sewage would be safe for use by farmers as fertilizer. The restrictions are ten times more stringent than federal regulations.

Before implementing these regulations, Gilbane had aggressively marketed itself as a city with a good business climate, offering tax abatements to industries that chose to move there. After several high-tech firms moved to the area, the more stringent regulations were enacted. Z CORP was one of the companies that moved to Gilbane. Its Gilbane plant manufactures computer components, but the plant's manufacturing process creates substantial quantities of toxic materials, primarily heavy metals. Z CORP monitors its waste discharge monthly.

Two facts about the regulations affect the resolution of the case. First, plants in Gilbane are responsible for supplying test data to the city. The data must be signed by an engineer, who attests to its accuracy. The law governing effluents is flawed, however, for it only regulates effluent discharge in terms of the amount of toxic material for a given volume of discharge, not in terms of the total quantity of contaminant. So a plant can always operate within Gilbane standards by simply increasing the volume of discharge.

Second, a newer and more sensitive (but also more expensive) test for heavy metals has been developed since the city enacted its standards. The newer test is not required by the city, and the city of Gilbane does not use it. Z CORP employees have access to the test, and it shows that the plant has apparently been slightly exceeding the allowable emissions on a number of occasions. This produces a problem for Z CORP. If it discloses the results of the new test, the city might take legal action against it. If it does not disclose the results, some of its own employees may believe it is exhibiting bad faith with the city.

The plant's junior environmental engineer, David Jackson, is a new employee. He has replaced a consultant who believes he was released because of his warnings about the discharge of toxic materials. David is concerned about Z Corp.'s heavy metals discharge, and his concern is further intensified when he learns that Z CORP has signed a contract that will result in a five-fold increase in the discharge of heavy metals. David finally decides to blow the whistle on the plant's discharge levels by talking to the local TV newscaster.

The Standpoints of the Judge and the Agent

In preparation for leading a class discussion, you will want to view the tape at least once, and preferably twice. Announce to the class that present-time scenes are in color and flashbacks are in black and white. Because this case is based on the video, there is no critical need for overheads or bibliographies, although having one overhead with the names and roles of the chief characters and another summarizing the key ethical issues in the case has been found helpful.

It is important to ask what one expects the student to learn from viewing and discussing Gilbane Gold. We believe the best answer to this question is that the student should develop some skills which would be useful in her own professional career. The primary skills we have in mind here are the abilities to (1) analyze moral issues and to (2) resolve them in creative and professionally responsible ways. In order to do this, the student should attempt to put herself in the position of David Jackson and to decide how she would handle the issues that David faces. That is, the student should take the standpoint of the principal agent in the case, not the position of a judge. This means the student should place herself in the situation and approach it from the standpoint of one who must make a decision, not take the standpoint of one who evaluates David's actions from the standpoint of a spectator. Taking an "internal" and present-tense standpoint, in other words, is more instructive than taking an "external" and "after-the-fact" perspective. While it may require more effort to analyze the issue and construct one's own solution than to simply evaluate David's actions, the former exercise is ultimately more challenging and more valuable for a young engineer's professional development.

The recommendation, then, is to focus on David Jackson, to encourage the student to put herself in David's place and decide what she would do if she were facing his situation. Of course the comparison of how one would handle the situation with the way David actually dealt with it may lead to an implicit judgment of David's action, but the principal aim of the discussion should be to prompt the student to come up with the plan of action that she herself would take.

We shall approach this case somewhat differently from the others, in that we shall make a more concerted effort to employ the concepts and modes of ethical analysis developed in the essays entitled "MoralConcepts and Theories" and "Basic Concepts and Methods in Ethics" which appear at the end of the cases in this report. While the analysis may be somewhat more formal and structured than the analysis that will emerge in the classroom discussion, it should assist you in leading the discussion. We shall begin with a discussion of some of the important factual issues in the case and then proceed to a discussion of the relevant conceptual and moral issues.

The Factual Issues

The factual issues that are relevant to a case are always of crucial importance. Often, however, the place of a factual issue in a moral problem is not clear. Three theses regarding the place of factual issues in a moral problem can illustrate this claim.

First, many times disagreements that appear to be over moral issues turn out to be disagreements over the relevant facts. Suppose two engineers disagree over whether the government should enforce affirmative action policies in the workplace. They may think their disagreement is over the moral issue of the permissibility of affirmative action policies. Further discussion may reveal, however, that their real difference is over the factual question of how discrimination can be eliminated. On the one hand, Tom may think that, apart from affirmative action policies, women and minorities will continue to experience gross discrimination in the workplace. Jim, on the other hand, may believe that fair treatment in the workplace can be achieved without governmental intervention. Furthermore, Jim may admit that if governmental intervention is the only way to eliminate injustice in the hiring system, he would be in favor of it too. Thus the real difference between Tom and Jim is not over any moral beliefs, but over a factual belief about what it takes to eliminate unjust hiring practices. If they could agree on the factual question as to how injustice to women and minorities could be eliminated, they could agree on their moral evaluation of the permissibility of governmental intervention.

A second thesis about factual issues is that often disagreement over the facts is every bit as difficult to resolve as disagreement over moral principles. Let us continue the example of the argument between Jim and Tom over affirmative action policies. Whether or not governmental intervention in hiring policies is the only way to eliminate injustice toward women and minorities is an issue over which people can and do argue interminably. Tom may cite cases in which discriminatory hiring practices continued for many years and were only eliminated when affirmative action policies were enforced. Jim may argue that now things are different, that younger people would be much more inclined than their elders to hire on the basis of merit. Tom may reply that Jim's assumption about the future is as yet unproved, and the argument may continue without resolution. Sometimes factual disputes cannot be resolved.

A third thesis about factual issues is that, once the factual issues are clearly isolated, moral disagreement may re emerge on another (and more clearly defined) level. Suppose Tom and Jim finally agree that their dispute over whether affirmative action policies are necessary to eliminate injustice in hiring policies cannot be resolved. They may then agree that the issue between them must be reformulated in the following way:

Given that the question whether affirmative action policies are necessary to eliminate injustice in hiring practices cannot be resolved, which policy should we adopt? Should we agree that affirmative action policies are right, because they make it less likely that women and minorities will suffer discrimination? Or should we conclude that affirmative action policies are wrong, because, in the face of uncertainty, greater weight should be given to the freedom of employers to hire whom they will?

Jim and Tom may still disagree, but the nature of their disagreement will be much clearer. Now it is clear that the real issue is what should be done in the face of factual uncertainty. The possibility of their coming to agreement is also much greater.

It is particularly important for engineering students to appreciate the central place of facts in moral controversies and the necessity of isolating the precise nature of disagreements over the facts. Sometimes engineering students leave a classroom discussion of a moral issue with an attitude that might be stated like this:

Well, here was another dispute about ethics in which nobody could agree. I am glad that I am in engineering, where everything depends on the facts that everybody can agree on.

Ethics is just too subjective.

As the example given above illustrates, such beliefs are often based on profound confusions about what was really going on in an ethical debate. Many times it is impossible to know what the facts are, especially when they have to do with future consequences and degrees of risk and safety. Many times so-called ethical disagreements are disagreements about the facts. When the differing factual assumptions are isolated and resolved, people can often agree. And when the factual disagreements are clearly isolated, sometimes the moral issues can be more clearly formulated, and even resolved.

Part of David Jackson's dilemma may be attributable to his problems in resolving some of the factual issues in the case. Let us consider some areas in which David may encounter such problems.

First, there seems to be some doubt as to whether and to what extent Z CORP has violated city regulations. On the one hand, Tom Richards, the environmental engineering consultant fired by Z CORP, believes that Z CORP has violated the regulations repeatedly. Professor Massin, on the other hand, believes that the case against Z CORP is not conclusive. Part of the problem is that two different tests are involved: an older and less sensitive test and a newer and more sensitive one. The newer test seems to show that Z CORP is violating the regulations- -though only slightly. There is a question as to how long the violations have been going on, because the new tests have been used for only a short time.

Second, there is a question about the legal status of the new tests. Would courts use the old tests or the new tests in determining whether Z CORP has violated the law? The law specifies the old tests as the measure, but there might be reason to wonder what the courts would do if it were known that Z CORP was aware that it was violating the standards by the more sensitive tests.

Third, there is a question about the exact nature of the reports on discharge purity that David sends to the city each month. Does the report merely give the amount of heavy metals discharged for a given unit of effluent, or does it explicitly state that the discharge of heavy metals is of a certain amount as measured by the old test? The answer to this question is important in considering the first question whether David is deceiving the city, although it is not sufficient to answer that question.

Fourth, David might have reason to wonder whether the consultant, Tom Richards, has ulterior motives which bias his position with respect to Z CORP. His consulting firm lost a valuable client in Z CORP, and he was insulted by being summarily dismissed by Z CORP. Is he pressing David to blow the whistle on Z CORP in order to punish the company for their treatment of him and vindicate his warnings about the toxic discharges?

Fifth, there are questions about the long-term health effects of introducing various amounts of heavy metals into Gilbane Gold. In his interview with the reporter, Professor Massin said that if Z CORP substantially increased its production, "then, we may have a problem." How substantial would this problem be? At what levels will there be a problem? Professor Massin may not be sure, although he seems to believe that the problem would be significant. Other experts may be equally unsure.

Sixth, what would happen if Z CORP officials were to take David's suggestion and present their problem to the city? Would city officials recognize Z Corp.'s financial problems and attempt to work out some sort of equitable agreement with Z CORP? If Z CORP officials knew the city would make this response--perhaps by giving Z CORP further tax relief--they would probably not hesitate to follow David's suggestion. No one knows how the city of Gilbane would respond to an overture of this nature, but assumptions (and these are factual assumptions) as to how the city would react can have a powerful influence on one's judgment as to what should be done.

You can probably think of other factual issues which are important in the case. The exercise of isolating these issues and deciding how they influence one's thinking is an important part of the analysis of Gilbane Gold.

Conceptual Issues

A conceptual issue is a matter of definition, of what we mean by a term. Getting clear about the meanings of crucial terms is an important part of responsible ethical thinking. There are several conceptual issues in the case that call for clarification.

First, in commenting on the flaw in the law that allows Z CORP to legally discharge more toxic materials by increasing the volume of the discharge, Lloyd Bremen, former state commissioner of environmental protection, says that this loophole allows Z CORP to legally "poison" the sludge. He might just as easily have used other terms that would have conveyed a similar meaning. For example, he might have said that Z CORP is "endangering" the public by its actions. To say that Z CORP is "poisoning" or "endangering" the public would ordinarily be the same as saying that Z CORP is doing something wrong, for we do not ordinarily think that "poisoning" or "endangering" people is a good thing. Words, such as this, however, will repay closer examination.

Many terms used in ethical discussion have both a factual and a value component. The best way to see the double aspect of such words is to continue with the process of definition. Suppose we define "poisoning" or "endangering" as "imposing an unacceptable risk." Now the factual and value components are clear, for the term "unacceptable" implies a value dimension.

It is true that in determining what constitutes an unacceptable level of risk with regard to heavy metals in the sludge, we must determine the effects on human health of various levels of the contaminants. This is a factual issue. There is another dimension, however, which involves value judgments. In order to determine what constitutes "poisoning" the sludge, or "endangering" the public, we must determine the acceptable level of risk. What is the highest level of heavy metals that should be tolerated? At what level do the concentrations of heavy metals become unacceptable? We may decide that any measurable increase in heavy metals in the bodies of those who consume the vegetables fertilized by Gilbane Gold is unacceptable. Or we may decide that any level which produces any noticeable effects is unacceptable or we may decide that any level which produces a given effect in a given percentage of the population is unacceptable. Or one may use some other criterion.

In any case, a value judgment must be made in determining the levels at which the discharge is "poisoning" or "endangering" the public. Dr. Massin seems to believe that present levels of heavy metal discharge by Z CORP are acceptable, but that substantial increases may be unacceptable. David must decide whether to accept Dr. Massin's definitions.

A second conceptual issue has to do with the question whether David is engaging in "deception" when he signs the monthly reports to the city without disclosing that newer and more sensitive tests show that Z CORP is violating city standards. To say that someone is engaged in "deception" is ordinarily to say that he is doing something wrong, although there may be justifiable instances of deception. If David is deceiving the city, this means he is doing something wrong, unless this is a justifiable instance of deception. Therefore it is important for David to know what he means by "deception."

It is not easy to come up with a satisfactory definition of deception. Most people would probably agree that actively denying something a person knows to be true or affirming something a person knows to be false are examples of deception. If David is called to testify before city officials and denies that the newer test shows Z CORP to be violating the standards, he would be engaged in deception. But this is not David's most immediate concern. Deliberately attempting to conceal information would probably also be considered a type of deception by most people, but David does not appear to be engaged in such a cover-up. The best description of David's action is probably that he has failed to come forward with information that is relevant, but which has not as of yet been required by the city. Is this deception?

Let us consider an example from medicine. Suppose a physician discovers that her patient has cancer and fails to reveal this information to him, even though she does not lie or actively conceal it. Most people would probably say she is deceiving her patient, even if they think the deception is justified. This is because (a) the information that a physician fails to reveal is important for the patient, and (b) patients ordinarily expect their physicians to tell them about their illness, given their relationship to the physician.

Both of these considerations seem important in the concept of deception. Failing to reveal information that is irrelevant to a situation would not ordinarily be considered deception. If a physician is making inquiries about my health and I fail to mention that I have an interest in antique cars, this would not usually be considered deception. My interest in old cars is just not relevant to the state of my health. If I fail to mention that I am a heavy smoker, this would be deception.

Likewise, what one would ordinarily expect a person to reveal is also relevant to the issue of deception. A person whom I have just met does not expect me to reveal the details of my sexual history or the traumas of my early childhood. Failing to reveal this information is not deception. Similarly, I am not expected to reveal the proprietary secrets of my company, and the fact that I do not is not a case of deception. Everyone knows that I am not going to do this, even though it involves a failure to divulge information that might be relevant in a certain context.

Perhaps we can use these insights to construct a more formal definition of deception:

X deceives Y if X denies what is the case or asserts what is not the case or conceals information from Y or even fails to reveal information to Y (a) which is important for Y or (b) which Y would customarily expect X to reveal to Y, given X's relationship to Y.

This definition still leaves two questions unanswered. (1) David must decide whether his relationship to the city is one in which the city would customarily expect David to be forthcoming with information about the new test. (2) Even if David decides that his failure to come forward with the information is deception, he must decide whether it is a justifiable case of deception.

A third conceptual issue has to do with the definition of "fairness," a concept which is relevant to at least two issue in the Gilbane Gold case. There is a question whether the city of Gilbane is unfair in requiring Z CORP and other businesses to bear the full financial burden of complying with the stringent standards imposed on industrial discharges into the sewer system. There is also a question whether Z CORP is fair to David in forcing him to take the possible legal liability associated with failing to disclose the results of the new tests to the city.

The concept of fairness is enormously complex and probably not subject to any simple definition. Perhaps it will be enough to say that fairness involves at least two elements. First, it requires free and informed consent. In order to be treated fairly, a person must be given the opportunity to make decisions in a non-coercive atmosphere and on the basis of as much information as possible. In particular, information relevant to his decision should not be deliberately concealed from him. Second, fairness requires that harm and benefit be shared in a roughly equal manner, unless there are other relevant circumstances. For example, it is not fair for one group to enjoy all of the benefits of a social policy and another group to bear all of its negative features.

In the next section we shall see how David might use these concepts in attempting to think clearly and responsibly about the moral and professional dilemma in which he finds himself. You may be able to think of other concepts which must be clearly defined before moral reasoning can proceed, but these are three of the most important. Now we shall consider the use of these concepts in making moral judgments.

Moral Issues: Relevance Problems

There are several moral issues in the case. Using terminology developed in the essay "Basic Concepts and Methods in Ethics," (appended to this report at the end of the cases) we can point out three relevance problems and one conflict problem that David must resolve. Recall that a relevance problem is one in which there is a difficulty in determining whether a concept applies in a given situation. A conflict problem is one in which two or more moral principles seem to be relevant to a given situation, and they seem to point to different judgments as to what should be done.

First, David must decide whether Z CORP is "poisoning" the sludge or "endangering" the health of those who consume the vegetables fertilized by Gilbane Gold. The facts are not completely clear, but it appears that Z CORP is violating the strict city regulations by the standards of the newer and more expensive test. The violations must be very small, however, for otherwise they would be detected by the older test. Since the strict regulations are intended to keep plants from poisoning the sludge and since the violations are minimal, it is difficult to argue that Z CORP is "poisoning" the sludge at the present time. If Z CORP increases its production 500%, then, as Professor Massin said, "we may have a problem." At the time of the story, however, it seems implausible to say that Z CORP is poisoning the sludge.

Second, David must decide whether he is engaged in deception in refusing to reveal the results of the new test to the city. We have given a definition of the concept of "deception" in the previous section. Now David must decide whether he is in compliance with this definition. Let us look at the definition again:

It is certainly true that David is failing to reveal information to city officials which is important to them; the only question is whether the city would "customarily expect" David to reveal the information. One might argue that the relation of David to city officials is not at all like the relationship of a physician to her patient. David is an employee of Z CORP, and so one might argue that his relationship with the city is adversarial. Perhaps city officials expect that he will reveal as little information as possible to them.

While it may be true that whether or not David is engaged in deception depends in part on the expectations that others have of him in his role as the environmental representative to the city for Z CORP, it is also true that David is a professional engineer. There are certain expectations that come with this role as well. As an engineer, David is expected to adhere to standards of honesty and integrity. According to professional engineering codes, he is also expected to be concerned with the health, safety, and welfare of the public. It is difficult to believe that city officials would not consider David's concealing the information from the new tests to be a breach of faith and perhaps even a violation of the law. The letter from the city to David is an indication that city officials expect David to be forthright with them. So it seems reasonable to conclude that if David fails to reveal the information about the new tests, he is engaged in deception.

In the deliberation that he is engaged in, David might attempt to persuade himself that, while failure to disclose the results of the new tests to the city is a type of deception, it is justifiable deception. He might point out that Z CORP is not required to use the new tests, and therefore that Z CORP is not required by law to reveal the results of these tests to the city. He might also recall that Z Corp.'s plant is only marginally profitable and that the plant's closing would represent a substantial loss to the city. Finally, David could argue that the new test was performed at Z Corp.'s own expense, and he might even claim that the information about the tests should be considered "proprietary."

While not without a point, these arguments are ultimately unconvincing. The fact that something is not required by law does not mean it is not morally obligatory, so the fact that reporting the results of the new test is not a legal requirement does not mean is not a moral requirement. The fact that the plant is only marginally profitable does not mean that its economic viability should be preserved by deceptive practices. There may be other ways (which will be discussed later) to preserve the plant. Finally, even though Z CORP may have paid for the tests, their results are not proprietary information, and their results may be relevant to the health of the public.

There are other reasons for believing that deception is not justified in this situation. David has a legitimate concern for his own legal liability, professional reputation, and the possible loss of his license. Considerations of self interest are legitimate, within certain limits, and this is one situation in which these concerns seem legitimate. Deception is also not justifiable when the health and safety of the public are at risk.

Probably David's most pressing concern is the prospect of a five-fold increase in Z Corp.'s production, and what this will mean for the health of those who consume vegetables fertilized by Gilbane Gold. He probably believes that a dialogue should be started with the city as soon as possible, and that this dialogue cannot be conducted effectively if Z CORP has already shown bad faith with the city. Concealing information will only exacerbate the problem, and the information probably cannot be concealed for very long in any case. Here, as in most cases, honesty is the best policy.

David faces a third relevance problem in deciding whether principles of fairness have been violated. One of the issues involving fairness is whether the city of Gilbane has itself acted unfairly toward Z CORP. There are good arguments that Z CORP has been treated unfairly in terms of both of the elements of fairness discussed earlier.

Fair treatment involves free and informed consent. David could argue that Z CORP was treated unfairly because the company was enticed with tax abatements to build a plant in Gilbane, and then the city imposed unusually stringent regulations on the discharge of heavy metals. Even if it is true that (1) the standards have been impartially imposed on all firms, that (2) the standards may be necessary to make Gilbane Gold safe, and that (3) the city of Gilbane may not have been fully aware of the dangers posed by the increased discharge of the heavy metals until after the new plants were built, it is also true that firms such as Z CORP were not able to make a free and informed decision about building the Gilbane plant.

A second aspect of fairness is that harms and benefits should be roughly equally distributed. Yet the city of Gilbane appears to be forcing the business sector to bear the full economic burden of protecting Gilbane Gold from contamination, while keeping all of the profits from the sale of Gilbane Gold for itself. City officials would no doubt argue that the plants that cause the pollution should have to clean it up, but Z CORP officials might argue that fairness requires only that Z CORP clean up its discharge to the level stipulated by national standards. Gilbane's regulations, by contrast, are ten times more stringent than those imposed by the United States government. Furthermore, the unusual restrictions are needed only because the city uses the sludge to make Gilbane Gold. Perhaps fairness requires the city to bear that part of the cost of pollution control that is created by the city's stricter standards. It could do this by a tax rebate to the plants or by a direct payment to them.

In the light of these considerations, David might well conclude that there is an issue of fairness between Z CORP and the city of Gilbane. This implies that if Z CORP officials inform the city of the results of the new test, they would have a good moral case for asking the city to agree to some type of accommodation. Whether the city would do this is, of course, another matter.

There is another issue of fairness in the case. In forcing David to sign the documents affirming Z Corp.'s compliance with city discharge standards when he knows that by the more sensitive tests Z CORP is violating those standards, Z CORP is being unfair to David. It is forcing him to make decisions that are neither free nor informed. When David took employment with Z CORP, he probably did not agree to engage in such questionable activities. Furthermore, David is being forced to place his professional career in jeopardy. If he signs the documents he knows to be misleading, he may be in danger of losing his license and facing prosecution. If he refuses to sign the documents or blows the whistle, he may be dismissed and blackballed by other employers.

Moral Issues: Conflict Problems

David's situation confronts him with a number of conflicting moral demands. He must evaluate these demands and try to find a way to reconcile as many of them as possible. It will be helpful to enumerate these demands and evaluate their strengths.

The results of the previous analysis strongly suggest that David cannot continue to sign reports asserting that Z CORP is in compliance with city regulations on thee discharge of heavy metals. In the light of David's knowledge of the results of the new test, he would be guilty of deception with regard to the city. It is also unfair to him for Z CORP to ask him to jeopardize his license and perhaps even his professional career by forcing him to sign documents that he knows to be misleading.

David may well believe not only that continuing to sign the documents would violate the ethical prohibitions against deception and fairness, but also that it would violate his positive obligation as an engineer to protect the health and safety of the public. While present discharge levels (even if slightly above regulations by the new test) may not constitute any severe health risk, the time will soon come when Z CORP will be discharging heavy metals in quantities that will be a threat to public health. Z CORP should begin negotiating with the city as soon as possible, and this negotiation must take place in an atmosphere of trust. This will be much more difficult if Z CORP is known to have engaged in deceptive reporting to the city.

David also has an obligation to Z CORP. He is an employee and therefore has an obligation to defend the company insofar as ethical considerations will allow. His obligation is not only to defend the integrity of the company, but also to do what he can to insure that a marginally profitable plant survives economically. Furthermore, the city may well have been unfair to Z CORP in imposing the strict discharge standards after Z CORP had moved to Gilbane and without giving financial assistance to the company in meeting the standards.

David has an obligation to the people of Gilbane as well. In addition to the obligation to protect their health and safety, he also has an obligation to do what he can to save a marginally profitable plant that employs thousands of local residents. Z CORP may not be the only plant that is in financial trouble. If the new test is required by city regulations and if the law is rewritten to prevent plants from being able to comply with the law merely by increasing their volume of discharge, other plants may face closure. David must try to meet the need of Gilbane citizens for jobs as well as their need for good health.

Resolving the Conflict Problem: What Should David Do?

David must find some way to honor these conflicting moral demands in an ethically and professionally responsible manner. It is important for students to understand that the preceding ethical analysis does not provide a ready made guideline as to how he should do this. The preceding analysis establishes ethical constraints, but it does not tell David precisely how he should solve the problem within the context of these constraints. As with a problem in engineering design, it is one thing to supply the constraints in terms of which the problem must be solved and another thing entirely to provide a solution to the problem.

Let us briefly review the ethical constraints in terms of which any solution should be found. We have concluded that David should not continue to sign the documents reporting the discharges into the sewer line. We shall also assume that, as an employee of Z CORP, David should represent his company in a responsible way to the public (including the city) and that he should do what he can to promote the plant's economic viability. We have not argued for this claim, except to point out that there is an element of unfairness in the city's imposition of the unusually strict discharge requirements. It goes without saying that an employee owes his employer responsible service, insofar as this is compatible with ethical considerations. We shall also assume that David should attempt to protect his own professional reputation and his career. This is merely legitimate self-interest, and it is especially important in the light of the fact that Z CORP seems to be imposing an unfair burden on David in requiring him to sign the discharge reports under questionable circumstances.

Now the question is: How should David act so as to honor these constraints in the way that provides the optimal solution? There are many possible solutions, just as there are many possible solutions to a problem in engineering design. Some solutions are good, and others are bad, and there may be no single correct solution. David must engage in some brainstorming in order to act in the most creative and ethically responsible way.

David's inadequacies were probably most evident in his resolution of the conflict problem. He seems to be aware of most of the important ethical constraints, but his solution of the problem may not have been a very good one. It was made very quickly in the conversation with Prof. Massin and Tom Richards. Let us attempt to take David's standpoint (the standpoint of the agent) and determine whether any more thoughtful resolutions of his problem are possible.

(1) Probably the most appealing option for David is to attempt an inexpensive technical solution to the problem. If the discharge of heavy metals can be reduced to acceptable amounts, even as measured by the new test, Z Corp.'s problems would be eliminated. If the amounts of heavy metals discharged with increased production can be reduced to a total amount no greater than present allowable discharges, even Z Corp.'s long-term problem will be resolved. It is David's responsibility as an employee and a professional engineer, as well as his responsibility to himself and his own career, to explore this avenue as thoroughly as possible.

There are two broadly different ways in which the discharge of heavy metals could be reduced. One way is to reduce the amounts of heavy metal wastes from the production process itself. The other is to prevent the heavy metals from being discharged into the sewer. If neither of these procedures can be accomplished in an economically feasible way, David should document this and bring it to the attention of management.

(2) Let us suppose that David finds that there is no inexpensive technical solution to the problem. One option open to him is to explain to his superiors why he believes that Z CORP should attempt to work out some accommodation with the city. He should come up with a specific recommendation for solving Z Corp.'s problem. While emphasizing that he does not want to usurp her management role, he might suggest to Diane that she could provide city officials with documentation that would verify her claims that Z CORP operates on a narrow profit margin and that there is no inexpensive solution to the problem of the discharge of heavy metals. He might also suggest that Diane talk to managers of other industries in the area. If they are experiencing similar problems, perhaps the managers could meet as a group with city officials and ask for additional tax relief.

Diane claims that corporate headquarters is not interested in the plant's problems, but she may not have made a serious effort to convince them of the seriousness of the problem. David could try to persuade Diane that it is part of her responsibility to make a more forceful case with corporate management. She could point out that, with increased production, the problem is only going to get worse and that the city is finally going to learn about the problem. At that time, the atmosphere between Z CORP and the city will be much less conducive to profitable negotiations, because the relationship of trust will have been broken. Now is the time to approach the city with concrete proposals for a solution.

(3) Another option is for David to talk to officials of his professional society. This course of action was mentioned in the tape, but it was not pursued. It is not clear whether professional societies would be helpful: their record of supporting ethical professionals is not encouraging. At the very least, professional society officers might be able to offer a young engineer some helpful advice.

(4) Another option for David is to make clear to Phil and Diane that he believes his professional integrity is on the line in this issue. He could say that, if he continues to sign the discharge reports, he is going to have to make it clear to city officials that Z CORP is conforming to city regulations only by the old standards (if indeed it is), but not by the new standards. Unlike the other options, this is a type of insubordination, and it might cost him his job, but firing David in the present circumstances might be difficult for Z CORP.

(5) Another possibility is for David to take his case directly to corporate officers outside the Gilbane plant. This is a dangerous tactic in terms of his own career. Since his obligation to his own professional development is a real and completely legitimate one, he should not take this option if at all possible.

(6) A more desirable option is to tell Phil and Diane that he has already been summoned to appear before city officials and that he is going to mention the results of the new tests. He should make it clear to Phil and Diane that his professional integrity and his concern for his own legal liability will not allow him to do anything else. At the same time, he should emphasize that he will try to represent Z CORP in a responsible manner and that he will tell city officials that Z CORP is in a difficult financial situation and that there is no inexpensive technical solution to the problem.

(7) Still another possibility is to tell Phil and Diane that his professional integrity will no longer allow him to sign the discharge reports to the city. He should make such a statement without a self-righteous tone and in as non-confrontational a manner as possible. He should probably make it clear that, at least at the present time, he will not make any attempt to go public and that he will make every effort to continue to be a loyal employee. He should also say that he may not be able to keep the matter within the company, because city officials already want to talk to him. He should also emphasize that the problem is only going to get worse for Z CORP. The new production will only increase the discharge of toxic materials. Even if Z CORP is able to fulfill the technical requirements of the law by increasing the volume of discharge, the public is already aware of the problem, and the law will probably be changed. He should use all of his powers of persuasion to argue that firing him or refusing to face the problem will make matters worse for Z CORP.

(8) The final--and probably most undesirable--option is the one David chose, namely granting an interview to the TV reporter. This option is the least desirable for several reasons. First, it breaks the relationship with Z CORP and severely jeopardizes his own career. Second, it poisons the relationship between Z CORP and the local community. Third, it does not solve any problems. It does not, provide any plan for reducing the toxic discharges or for solving Z Corp.'s economic problem. All of these problems must be worked out later--and in a much more adversarial atmosphere. This option should be used only as a last resort.

Additional Notes

Essay #7, "Engineering and the Environment" appended to the end of the cases listed in this report will be particularly relevant to the instructor preparing to lead discussion on "Gilbane Gold." Similarly, Essay #6 "Loyalty and ProfessionalRights" will also be pertinent. Also, Essays #1 through #4 will have relevant background information for the instructor preparing to lead classroom discussions. Their titles are, respectively: "Ethics and Professionalism in Engineering: Why the Interest in Engineering Ethics?;" "Basic Concepts and Methods in Ethics;" "Basic Concepts and Methods in Ethics;" and "Engineering Design: Literature on Social Responsibility Versus Legal Liability."

The video-tape "Gilbane Gold" is available through the National Society of Professional Engineers, 1420 King Street, Alexandria, VA 22314.

Gilbane Gold Overheads

1. Cast of Characters 2. Ethical Issues Of The Case

GILBANE GOLD

Cast of characters.

Z CORP is a computer components manufacturer which discharges wastewater containing small amounts of lead and arsenic into the city sewer system.

Diane Collins : Z CORP vice president in charge of the Gilbane plant. She is the only link between the plant and corporate headquarters.

Frank Seeders : An engineer, is in charge of the plant operations. Phil Port is the chief environmental officer for Z CORP.

David Jackson : As a registered professional engineer, is responsible for signing plant discharge reports and keeping the plant in compliance with regulations.

Dan Martin : A lawyer for Z CORP.

Tom Richards is an environmental engineering consultant who was dismissed by Z CORP for advocating the use of newer and more sensitive tests which show that Z CORP is often not in compliance with the standards for heavy-metals emissions.

Lloyd Bremen, former state commissioner of environmental protection, is a retired farmer who uses Gilbane Gold on his ranch. Though he oversaw the enforcement of the regulations designed to protect Gilbane Gold from contamination, he now believes they may be too weak.

Dr. Winslow Massin is professor emeritus at Hanover University School of Engineering.

Maria Renato is a TV reporter who narrates the coverage of the controversy over Gilbane Gold.

Questions for Discussion

In this case you have been asked to assume the role of David Jackson and ask yourself what you would do in his situation. The following questions are directed to you in your role as David Jackson.

1. Does the presentation of the case by Maria Renato affect the decision made by David Jackson?

2. In what ways does the fact that David's boss is not an engineer affect David's actions?

3. Does Prof. Massin add any insight into what actions David should perform? That is, would you look to a former professor to help you deal with an ethical issue?

4. If you were David would you look to your professional society for advice on how to handle the situation?

5. The plant manager is presented with conflicting reports from her employees. How could David have presented his concerns more effectively to the plant manager?

6. Do you think Z CORP is "poisoning" the soil at present levels of discharge? What about a 500% increase?

7. Do you think David is deceiving the city if he does not reveal the results of the new test? Regardless of whether he is deceiving the city, is failing to reveal the results of the new test justified?

8. Do you think Diane's actions are unfair to David?

9. Do you think the city is treating Z CORP unfairly? Should it bear some of the expense of complying with its strict effluent standards?

10. Do the actions of the ex-consultant Tom Richards seem in any way to have ulterior motives?

11. Does David have any other options that he did not consider?

Additional case materials provided and prepared in: The Departments of Philosophy and Mechanical Engineering, Texas A&M University. NSF Grant Number: DIR-9012252.

More information about the "Gilbane Gold" recording can be found at the Murdough Center for Engineering Professionalism at Texas Tech University.

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This material is based upon work supported by the National Science Foundation under Award No. 2055332. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.

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