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This case study is designed for undergraduate or MBA students who are specializing in the areas of operations management, supply chain, new product development, leadership and organization behavior. The goal of case study is to discern the antecedents of two airplane accidents involving the Boeing MAX 737. The theory of normal accidents serves as lens to comprehend the hazard stemming from MAX design with dissonance between two critical systems: engine propulsion and flight control. Cooper's framework further delineates lack of cultural safety during prototype development from project's inception along six dimensions: management/supervision, safety systems, risk, work pressure, competence, and procedures/rules. The analysis indicates dearth of leadership commitment for a safety culture under time pressure and budget constraint. Our results corroborate the paramount of importance for pilot’s extensive simulator training in order to test the interaction between innovative Maneuvering Characteristics Augmentation System and human behavior response time.