1. **First Line of Defense (Operational Management)* *: "Faulty MCAS Design"*: Boeing's operational management failed to adequately identify and address the risks associated with the Maneuvering Characteristics Augmentation System (MCAS) in the 737 MAX. The design of the MCAS system was flawed and relied on a single sensor, making it susceptible to erroneous data, and yet this critical design flaw was not sufficiently addressed. Lack of Pilot Training* *: Operational management did not ensure that adequate training was provided to pilots about the new MCAS system. Pilots were not adequately informed about its existence or how to respond to malfunctions, contributing to confusion during critical moments in flight. 2. *Second Line of Defense (Risk and Compliance Functions) * *: - *Inadequate Internal Oversight* *: Boeing's risk management and compliance functions failed to detect and rectify the issues related to MCAS in a timely manner. There was insufficient oversight and auditing of the MCAS system's design and the potential risks associated with it. *Pressure to Meet Deadlines"*: There were allegations of management exerting undue pressure on engineers and safety experts to expedite the certification process of the 737 MAX to meet tight production schedules. This may have compromised the effectiveness of the second line of defense. 3. **Third Line of Defense (Internal Audit and External Oversight)* *: *Lack of Independence in Certification* *: The third line of defense, whichincluded internal and external oversight, was criticized for lacking independence. Regulatory agencies, such as the FAA, faced scrutiny for relying on Boeing's own safety assessments, which created conflicts of interest and undermined the effectiveness of external oversight. ""Delayed Response to Red Flags**: Both internal auditors and external oversight bodies did not respond promptly to red flags raised by whistleblowers and engineers regarding safety concerns with the 737 MAX. This delay allowed the flawed MCAS system to remain in operation longer than it should have. These problems in the three lines of defense collectively contributed to the 737 MAX crashes in 2018 and 2019. The failures in risk management, inadequate oversight, and regulatory shortcomings underscored the need for significant reforms in the aviation industry to prevent such tragic accidents from happening again