♪ ♪
On the morning of October 29th, I was woken up by a
colleague who alerted me that a Lion aircraft crashed.
He said, "It's the MAX." And I was surprised because it
was a new aircraft. My company provided the air data
for aircraft flying around the Jakarta area.
So I went to the computer and looked at the data.
It was immediately apparent that, okay, something was wrong.
The plane went up to about 2,000 feet, just over a minute after
takeoff, and the plane had a bit of a dive.
And then the plane climbed to about 5,000 feet.
But then, at 5,000 feet, the plane was fluctuating up and
down. And then the plane just started
diving. It just didn't make sense.
You don't see planes diving on departure.
I was baffled. Why did it go down?
♪ ♪ Lion Air flight JT610 went
missing from radar... NARRATOR: 189 people were
killed in the crash of Lion Air Flight 610.
The Boeing 737 MAX 8. NARRATOR: The plane was a new
Boeing 737 MAX... What do we know about this
737 MAX 8? NARRATOR: the
fastest-selling jet in Boeing history... just introduced the
year before. We don't yet know what caused
this crash. A breakthrough this evening.
The flight data recorder. It holds many of the keys...
NARRATOR: The data from the black box quickly got to F.A.A.
engineers in the United States. ♪ ♪
There is a purity of this data.
It comes directly from the black boxes.
So it's recording airspeed, altitude.
NARRATOR: The data showed what appeared to be a glitch...
Something repeatedly moving part of the plane's tail, controlling
its pitch. It didn't take long, just a
couple of minutes, to see that there was rapid movement of the
horizontal stabilizer. It's probably the fastest way to
kill yourself in an airplane is to have the stabilizer
malfunction. ♪ ♪
My spine literally tingled when I saw the traces from the
black box. The plane continually tried to
push the nose down and the pilots were trying over and over
again to stop the plane. And in the end, they lose that
battle. NARRATOR: What Boeing had not
told airlines or their pilots was that it had put a powerful
software system on the new airplane.
In the Lion Air crash, this system was receiving incorrect
information, and that made the plane dive straight downward and
destroy itself. NARRATOR: Inside Boeing, they
quickly diagnosed the problem and began working on a fix.
But they stood by the MAX as hundreds of them took to the air
around the world, carrying thousands of passengers.
The company alerted pilots about handling a potential
malfunction. Boeing and the F.A.A. today
warned airlines that sensors on the 737 MAX 8 jets can
malfunction. Boeing are calling this a
formal advisory and it's been issued to the pilots.
The reporting showed Boeing knew that it was risky, but
their response was to blame the pilots.
Pilots did not hit two cut- off switches.
Boeing says that action was part of well-established protocols
for all 737s. And that led to a series of
decisions that kept the plane in the air.
And then we got another crash. Breaking news out of
Ethiopia, where a plane went down.
NARRATOR: It was Ethiopian Airlines Flight 302, on its way
to Nairobi from Addis Ababa. A new 737 MAX 8 jetliner
crashed minutes after taking off.
NARRATOR: Two crashes, the same plane: 346 people killed,
an iconic American company's reputation in tatters.
The story of the Boeing 737 MAX would end up exposing corporate
deception and a broken regulatory process.
But at the center was a software system supposed to keep people
safe that instead led to their deaths.
The black boxes from the
Ethiopian crash have been recovered.
It's the second disaster within five months involving the
Boeing 737 MAX. That's the same kind of
aircraft that crashed back in October in Indonesia.
♪ ♪ 157 people, including
passengers and crew members on board, all are dead.
♪ ♪ The first thing you get to
see at the site is a very big hole.
And then to only imagine, this is the place that they were
last alive. ♪ ♪
We learned that there were no survivors on the plane.
And then our objective was to go and bring my daughter's body
home. Now, you're in close
proximity, you're able to see the fine details, you're able to
maybe think, these are personal effects belonged to Carol, my
sister, or my mom. Um... uh...
This bone, whose bone is this? ♪ ♪
And they told us that there was no part of a human that was
bigger than a femur that was left.
That whole experience is just a jumble of images and painful
thoughts and blankness, really, to me; I don't really...
I can't really make sense of it. NARRATOR: The crash of
Ethiopian Flight 302 was the second time in five months that
a Boeing 737 MAX had gone down. ♪ ♪
As families gathered at the crash site, across the world,
reporters at the "New York Times" were investigating what
had been going wrong with Boeing's new commercial jet.
Statistically speaking, the likelihood that these two
accidents were not in some way connected was extremely low.
It suggested that there was something going on with the
plane and obviously we were determined to find out.
♪ ♪ It was clear from the get-go
that Boeing was in full crisis mode.
As the facts from the accident become available, and
we understand the necessary next steps, we're taking action to
fully reassure airlines and their passengers of the safety
of the 737 MAX. This was going to be an
existential crisis for the company if these two events were
related. China grounds the plane
first. Other international regulators
ground the plane. Then the European Union grounds
the plane. But in the U.S., the F.A.A.
says it's not grounding the plane.
Boeing and the F.A.A. all were saying that they were sort
of waiting for the facts before they rushed to judgment and
grounded such an important new plane.
NARRATOR: But for months, the "Times" was reporting there was
something wrong with the 737 MAX itself... the software system
that pilots had not known existed.
The Maneuvering Characteristics Augmentation
System, or MCAS. The function of this previously
undisclosed system was to save the plane, when it believed that
the plane might go into a stall, and fall out of the sky.
And so this system was designed then to sort of take over the
stabilizer and push that nose back down in case the pilot gets
in trouble. NARRATOR: Then a major
setback for the company. Radar showed the two planes'
flight patterns were eerily similar.
Days after the rest of the world had reached the same
conclusion, they finally grounded the plane.
NARRATOR: For the "New York Times" reporters all the signs
pointed to MCAS. We knew that MCAS was the
beginning and we knew that we needed to start with this
system. This was a really problematic
software system in the way it was designed.
Okay, well, then how the hell did it end up in the plane this
way? ♪ ♪
NARRATOR: Boeing declined to be interviewed for this film.
In a statement, the company said safety is its top priority and
it has worked closely with regulators, investigators, and
stakeholders "to implement changes that ensure accidents
like these never happen again." ♪ ♪
This story really begins in 2011.
The 2011 Paris Air Show officially opened Monday.
Boeing and Airbus had been going head-to-head for at least
a decade. But Airbus had been quickly
catching up and really nipping at Boeing's heels.
It's the best air show ever for Airbus in terms of aircraft
numbers sold. In 2010, Airbus introduced
the A320neo, a more fuel efficient version of its
stalwart A320. The A320 is the direct
competitor to the Boeing 737. Airlines wanted an airplane that
was more fuel efficient than the airplanes then in service.
Airbus chose to re-engine the A320 into what they call the
Neo, the new engine option. It's a record 200 orders for
its A320neo. It was one of the
fastest-selling programs of aviation history.
And it placed enormous pressure on Boeing to respond.
About 40% of the profits for the entire Boeing Company came
from the 737. The 737 was the best-selling
commercial airplane of all time. The 10,000th 737 aircraft is
going to roll off the assembly line today.
More than 10,000 of these airplanes have been used by
hundreds of airlines all over the globe.
The official 737 christening ceremony took place in the new
final assembly building... What always amazed me is that
the 737 was first introduced when the Beatles were still
together. Right.
January 17, 1967. Flight attendants christened the
first Boeing 737 by smashing champagne bottles over the
wings. ♪ ♪
It was designed to be very low to the ground.
Now by the 1980s, Boeing had to upgrade the 737, and they
created what was called 737 Classic, which had a new engine
on it. First brand new 737-500...
In the 1990s you had the 737 Next Generation, which had a
new wing on it and some fuselage stretches.
And so here we are in 2011 with the Paris Airshow with the
A320neo and Boeing frankly was caught flat-footed.
Within a couple of weeks, Airbus and American Airlines
have the preliminary workings of what would become the first deal
for American to buy Airbus planes in more than a decade.
Gerard Arpey, the C.E.O. of American Airlines, calls Jim
McNerney, the C.E.O. of Boeing. It's a courtesy call at this
point. Just letting their longtime
supplier of airplanes know they're going to go with the
competition. And that is essentially a
dagger in the heart of Boeing. And within 48 hours, Boeing
had decided to pull the trigger on launching the re-engine 737
which later became branded as the MAX.
From the very beginning, from its birth, it was marked by
competitive pressure. ♪ ♪
You need to understand what was going on with Boeing at the
time that the MAX program was launched.
Boeing was billions of dollars over-budget on its 787 program,
on its 747-8 program. Airlines were thoroughly ticked
off at Boeing over the delays. And Boeing was looking at the
MAX to restore its own credibility.
♪ ♪ NARRATOR: Within days of the
second 737 MAX crash, another investigation was underway in
Washington, D.C. We started getting
information in from whistleblowers, from people both
current and former F.A.A. and Boeing employees.
NARRATOR: Doug Pasternak was leading a congressional
investigation. This is the first time he is
speaking publicly about what he found.
As soon as the second accident occurred, we started
our investigation, and our focus was on the design, development,
and certification of the MAX. We got hundreds of thousands of
pages of documents from Boeing. One of the things that really
struck me from speaking to a lot of Boeing employees was that
they were so excited to go to work at Boeing.
Boeing is a tremendous engineering company and a
technical marvel but almost without failure, they point to a
degradation of that mindset. And that safety suffered as a
result. Looking backwards, I think you
can clearly see the trajectory to tragedy, along the way, at
Boeing. ♪ ♪
NARRATOR: Boeing publicly said the MAX went through a
deliberate six-year development process.
But in their first stories, the "New York Times" reporters found
insiders who said that Boeing executives had been putting the
pressure on to design the new 737 quickly and cheaply.
One specific engineer we spoke to was Rick Ludtke, he
helped design the cockpit in the MAX and he talked a lot about
how there was an obsession in limiting changes.
This program was a much more intense pressure cooker than
I'd ever been in. The company was trying to avoid
costs. Minimum change to simplify the
training differences, and get it done quickly.
That put what had happened in the context of this broader
corporate narrative. Yeah.
Speed was what they seemed to desire.
There was a lot of decision-making that was
somewhat arbitrary and didn't involve as much of the, what
engineering considers healthy, um, debate.
The challenge to the Boeing designers was that any designs
we create would not drive any new training that required a
simulator. NARRATOR: In his recorded
interview with the "Times," Ludtke said Boeing management
was so determined to avoid the expense of new training, they
made a bold promise. Sales had made a commitment
with Southwest that for any airplane they delivered that had
a new Level D differences training, Boeing would pay the
company $1 million per every airplane delivered.
If the MAX required simulator training, it would rebate
Southwest a million dollars per plane.
And there's that incentive. That's why it was so important
to Boeing that pilot training be kept to a minimum.
All of this comes out of trying to give airlines the most
fuel-efficient version of a plane that they can spend as
little money training their pilots on.
♪ ♪ That meant Boeing had to do a
number of things to make this plane fly like the old one and
that was because the MAX had much bigger engines on it to
make them more fuel efficient. But because the 737 was a
50-year-old airplane at this time practically, when it came
time for Boeing to put those engines on the wings, the
engines were so darn big, they had to mount them further
forward on the wings. They were testing in this
wind tunnel, and they were discovering the plane was
handling just a little bit differently.
But they didn't even have a plane built yet, so this wasn't,
you know, happening in real flight.
This is something you have to fix.
And they leaned on a system that they had used once before in a
military tanker. It was designed as a system on
the plane to really just smooth out the way the plane handled.
NARRATOR: It was MCAS. It was designed for these
extremely unusual maneuvers. Situations that hopefully the
plane would never get in. And to prevent the nose from
getting too high, the system would move the stabilizer on the
back of the plane to push the nose back down.
NARRATOR: But inside Boeing, there were early signs of
trouble. One of the first documents we
found was from November of 2012. A Boeing test pilot was flying
the MAX in a flight simulator and trying to respond to an
activation of MCAS. And that resulted in what he
described as a catastrophic event.
It showed that if that had been in real life, he could have lost
the airplane. They realize from that moment on
even a Boeing test pilot may have trouble responding to MCAS.
NARRATOR: The company kept quiet about the simulator
experience and appeared to have discounted the test results.
Still, in the following months, some Boeing employees suggested
simply removing all references to MCAS from training manuals.
Boeing, from almost the very beginning, realized the
significance of MCAS, and the significance MCAS would have on
pilot simulator training. "If we emphasize MCAS is a new
function, there may be a greater certification and training
impact. Recommended action: investigate
deletion of MCAS nomenclature." What that meant was that if they
said MCAS was a new function, the F.A.A. was going to
scrutinize it a lot more. ♪ ♪
NARRATOR: Boeing told Congress it kept the F.A.A.
informed about MCAS' development and final configuration.
But Boeing has a complex and close relationship with the
agency that oversees it. The airplanes are part of the
story, but so are the regulators.
The F.A.A. regulated Boeing, in part, with a handful of Boeing
employees, whose paychecks came from Boeing, but whose jobs were
to represent the interests of the F.A.A.
NARRATOR: It's a decades-old arrangement known as
"delegation" that allows federal agencies to give
oversight powers to the companies they regulate.
In the beginning, there was a really good reason for this.
The F.A.A. was certifying things that made no sense to have them
certify every single exit sign or bathroom sign or paint.
The issue that many of the F.A.A. employees that we talked
to had was that it went way beyond bathroom signs.
Over time, Congress passed laws that pushed the F.A.A. to hand
over the responsibility for more and more tasks to the company,
to Boeing. With this level of delegation
between the company and the F.A.A., it became hard to
understand who was working for who.
There was one key person inside the F.A.A.: Ali Bahrami.
I'm Ali Bahrami, my job at the F.A.A. is to lead and manage
aviation safety organization. NARRATOR: In the midst of a
long career at the F.A.A., Ali Bahrami had left to spend four
years as a lobbyist for the Aerospace Industries
Association. While he's in that lobbying
role, he says, "We urge the F.A.A..."
We urge the F.A.A. to allow greater use of delegation not
only to take full advantage of industry expertise but to
increase the collaboration that improves aviation safety.
So here's the guy who would ultimately lead the F.A.A.'s
safety operation, encouraging the F.A.A. to let industry do as
much of its certification work as possible.
♪ ♪ NARRATOR: Neither Ali Bahrami
nor the F.A.A. would agree to an interview, but former F.A.A.
administrator Michael Huerta spoke to us about delegation and
the relationship between the agency and Boeing.
There are those that believe it is the fox guarding the
henhouse. Here is why it's not.
The company has an organization whose responsibility is to
ensure that it is in compliance with the standards that are set
by the F.A.A. and it has a level of independence from the
entities that they're overseeing.
What that gets back at is the issue of trust, and
transparency, because the whole regulatory framework, and the
whole delegation process is premised upon a notion that
everyone is going to share their knowledge and their expertise
with one another. NARRATOR: In the design of
the 737 MAX, many things would be delegated to Boeing.
That included MCAS. Under the impression that
this was a relatively benign system, the F.A.A. agreed to
delegate it, as is the custom with the F.A.A. and Boeing, and
that's what happened in this case.
It handed it over. ♪ ♪
NARRATOR: In a statement, the F.A.A. blamed ineffective
coordination, and said it had not focused on MCAS when it
certified the MAX because Boeing had not identified MCAS as
significant. Congress has ordered the agency
to revise the delegation process.
♪ ♪ After years of going through
design and development, the 737 MAX prototype was rolled out of
Boeing's Renton factory for its maiden flight.
Look at all the excited faces, they wouldn't miss it.
Ed Wilson is in the cockpit, he's the new chief pilot, and he
takes off. And let's just take a listen
as this airplane gets ready for its very first takeoff.
(cheers and applause) A short time after this first
maiden flight, Ed Wilson, he and his co-pilots start to realize
that the 737 MAX is not handling as smoothly as it should in
certain low-speed situations. It's shortly after takeoff.
You know, it's still kind of climbing to ascent.
It's not going full speed. NARRATOR: Boeing engineers
had an idea for how to deal with this.
They know about MCAS and they know that MCAS was actually used
for a similar situation in these high-speed maneuvers, and so
theoretically, MCAS could also be used in these other
situations to also smooth out the handling.
Crucially, it's already been created.
It's already been approved. And it's something that we could
just apply, you know, to a different phase of flight.
It's actually a pretty easy fix. This ends up being an extremely
fateful decision. They enable the stabilizer to
move much more, actually four times as much.
Now the system is designed for low-speed situations like just
after takeoff. And after takeoff is when the
plane is still only a few thousand feet over the ground,
that means you have much less room for error.
It's happening in an automated fashion and a repeated fashion.
This fundamentally changes MCAS. It makes it much more
aggressive, much more risky. It's a far more dangerous
system. ♪ ♪
NARRATOR: Boeing was doubling down on the system, expanding
it, despite the earlier catastrophic result in a
simulator test. The "Times'" reporting on MCAS
focused on a former Boeing pilot.
I started to hear about a pilot at Boeing whose name was
Mark Forkner. He came up through the Air Force
Academy. He flew for Alaska Airlines.
And he became the chief technical pilot for the 737.
He had played a definitive role in making sure that there was
minimal pilot training on the MAX.
Boeing released to our committee instant messages and
emails from Mark Forkner and some of his colleagues.
In one of these emails that Mark Forkner sent out, he says, "I
want to stress the importance of holding firm that there will
not be any type of simulator training required to transition
to MAX." And he said, "Boeing will not
allow that to happen." He was this key liaison
between the company and the F.A.A.
He was the person who personally emailed the F.A.A.
asking for MCAS to be removed from the pilot manual.
That was an important piece of this because we understood that
the F.A.A. really didn't know that MCAS became more powerful.
He was speaking, absolutely, on behalf of the company... this
was not some low level employee. And he was asking for something
that was really quite substantial: that a new piece of
software that made the plane behave in ways that it
previously hadn't, be concealed from the pilots.
This is where the commercial pressures from the executive
level come right down to the development of the airplane.
♪ ♪ Mark Forkner certainly was
not a lone actor in what he did. He was following through on a
policy by Boeing to ensure that the program did not have to put
pilots in a flight simulator. It got to the point where
Mark Forkner got an award for keeping training on the 737 MAX
to a minimum. NARRATOR: Nearly eight months
after requesting that MCAS be removed from pilot training
manuals, Forkner texted a colleague with a shocking
realization. This appears to be the moment
where Mark Forkner learns that MCAS has been expanded.
He writes in that message, "I basically lied to the
regulators, unknowingly." But he never went back and
corrected the record. He never went back and fixed the
error. NARRATOR: Mark Forkner
wouldn't speak to us but his lawyer told the "Times"
reporters that his communications with the F.A.A.
were honest and that "he would never jeopardize the safety of
other pilots or their passengers."
♪ ♪ When Boeing engineers expanded
the MCAS system, they included a feature that would make it
particularly dangerous. Planes have millions of parts
in them. And there's one little one on
the 737 that sticks out of the fuselage.
See that little black circle there, that is called...
The angle of attack sensor. NARRATOR: On the 737 MAX, it
had the power to trigger MCAS. It's the A.O.A. sensor that
is one of the crucial parameters to the computer to tell the
plane that it's in a perilous condition.
The angle of attack sensor would activate MCAS by telling
the system that the plane's nose was too high and then MCAS would
try to push the nose down. But if this sensor is broken,
for whatever reason, MCAS never realizes and so it keeps pushing
the nose of the plane down over and over again.
NARRATOR: Congressional investigators would later find
documents showing that Boeing engineers had raised this very
concern. An engineer asked, "What if
we have a faulty A.O.A. sensor," because A.O.A. sensors are known
to be faulty. You know, what happens to the
airplane? So you have those concerns
raised and the response is again from Boeing engineers was to
essentially dismiss those. ♪ ♪
Three, two, one! NARRATOR: Boeing began
delivering the new 737 MAX in mid-2017.
At the outset, 737 MAX was arguably one of Boeing's biggest
successes. It had become its best-selling
jet ever. NARRATOR: Advanced sales were
estimated at $370 billion. American had orders for 100.
Southwest Airlines for 200. Boeing had focused especially
hard on selling to developing markets in Asia, where Lion
Air's parent company became the first customer to fly the 737
MAX, signing an agreement worth more than $20 billion.
Airlines loved it. There was a years-long waiting
list to get one. But Boeing's signature new
jet had a fatal flaw. ♪ ♪
Breaking news. The search for wreckage is
underway after a passenger jet with 189 people on board
crashed. A Lion Air Boeing 737...
A nearly brand-new 737 MAX... NARRATOR: Investigators from
the U.S. National Transportation Safety Board contributed to an
analysis of what led to the Lion Air crash.
Leading up to the Lion Air accident, the angle of attack
probe itself was miscalibrated. The maintenance crew was not
able to properly identify this miscalibration.
The angle of attack sensor sent bad data to MCAS.
The plane thought it was in a stall because of bad
information. And as a consequence of this
angle of attack data error, the MCAS activated when it really
shouldn't have. ♪ ♪
Five months later, almost the exact same thing happens halfway
across the world. New 737 MAX-8 jetliner
crashed today. Investigators say that flight
had similar problems to the Lion Air crash.
Once again the angle of attack sensor is malfunctioning.
There is this question now about systems within the
aircraft. If MCAS hadn't been on those
planes, those planes wouldn't have crashed.
It's that simple. The world mourns 157 people
killed in the Sunday crash. ♪ ♪
On the flight of 737 MAX crash, we... we lost five of our
family members. We had our mom, Ann Karanja, our
dear sister, Caroline Karanja. Her three kids, Ryan Njoroge,
Kelli Wanjiku, and Rubi Wangui. ♪ ♪
It's not like there is a manual of how you need to react, you're
just there, it's like motionless.
You just feel infuriated by anyone and everyone at that
point. I remember the Boeing Company
blaming what they call the foreign pilots and deflecting
blame to... to them, saying they are the cause.
♪ ♪ All of us at Boeing are
deeply sorry for the loss of life in the Ethiopian Airlines
Flight 302 and Lion Air Flight 610 accidents.
NARRATOR: Boeing C.E.O. Dennis Muilenburg latched onto
findings that inexperience and lack of training were part of a
chain of events that led to the crashes.
It was a controversial position. Understand that these
airplanes are flown in the hands of pilots and in some cases our
system safety analysis includes not only the engineering design
but also the actions that pilots would take as part of a failure
scenario. Boeing's contention from the
beginning was that even though the pilots did not know that
MCAS existed, that they did not need to know that.
And in some cases, those procedures were not completely
followed. Boeing believed that the
pilot should have been able to realize that it was very similar
to a runaway stabilizer situation.
NARRATOR: Runaway stabilizer is an aviation term for a
malfunctioning stabilizer. After the Lion Air crash, Boeing
had issued a directive to pilots to be aware of this possibility,
and told them what to do if it happened.
When that part of the tail was not acting the way that it
should be, you take manual control of it.
The pilots could have stopped their rollercoaster ride by
turning these two switches off. To shut off power to the
stabilizer, you stop it from moving on its own.
And then you start cranking a wheel in the cockpit that
literally will manually move the stabilizer back to where you
want it to move. The issue was, were there
things happening inside the cockpit that might have made
that harder to do. That's what we were asking.
♪ ♪ When we finally got the
preliminary black box data from the Ethiopian crash, we called
up Dennis Tajer, an American Airlines 737 pilot, and sent him
the data, and we read through it together.
My mission was to provide them, I'm in the cockpit, I see
what's happening now. So we walk through each line and
I had no idea what was in it. I knew that the crew had an
experienced captain and a lesser experienced first officer.
We go, second by second, through these few minutes of
this flight. Going through the steps that
the pilots had taken and saying, "Yup, I would have done that.
Yup, I would have done that." And as soon as they lift off
the ground, all these different alerts started popping up.
The airspeed was unreliable, the altitude was showing unreliable,
there were alerts related to that, but they bring the gear up
and they continue to climb out. NARRATOR: Two minutes into
the flight, based on faulty data from the A.O.A. sensor, MCAS
kicked in, and began pushing the nose down.
Don't sync. And I have...
A very clear memory of noting a time mark where the first
officer is quoted as saying, "Stab trim cutout switches,"
which takes the weapon away from MCAS, which is what Boeing told
us to do. But I have to confess...
I probably swore, I said, "The kid got it right.
The kid got it right." What had happened was the
pilots did do what they were supposed to do, they had cut the
electricity off. Don't sync.
They hit these switches, and they tried to take manual
control. The first officer is reaching
to this large wheel on his left and that's the manual trim wheel
and trying to turn it. It's like lifting up a ten-ton
bucket of cement out of a deep well.
The problem was, at that point, the plane was going so
fast that even after they took manual control, they could not
physically get the plane to right itself.
They shouldn't have been going that fast.
Too low. Terrain.
And they're continuing to accelerate towards the ground.
The ground is approaching them. NARRATOR: Then, with no
apparent recourse, the pilots reached for the stabilizer
switches. I'm yelling into the cockpit,
"Don't do that!" But I don't know what they're
facing. NARRATOR: MCAS was
reactivated. Pull up.
MCAS says, "Hey, I'm back on, here we go."
(imitates whirring) And now the airplane is in near
full nose down trim and you can pull back forever and there's
not enough metal in the back of the airplane to make that
airplane come up to a nose-up. Terrain.
Pull up.
(echoing): Pull up.
(birds twittering) She died when she was 24.
It's unbearable that she's not with us.
And the only thing I can do is try to prevent this for other
people. NARRATOR: About four months
after the Ethiopian Airlines crash, the family of Samya Stumo
was about to receive news they would find bewildering.
We were eating dinner and I hadn't looked at my phone for a
long time. And it was blowing up.
We are joined today by Ali Bahrami, the associate
administrator for Aviation Safety.
Chairman Collins, Ranking Member...
There were families from Kenya, from Ethiopia, from all
over saying, "Who is this Ali Bahrami?"
We continue to evaluate Boeing's software modification
to the MCAS. NARRATOR: The F.A.A.'s Ali
Bahrami had been called before Congress, where he was
questioned about revelations the F.A.A. had known there was a
risk of another MAX crashing... After Lion Air.
If the agency's own analysis found MCAS to be an unacceptable
risk, why did the F.A.A. not take immediate action to address
those risks? The families hadn't known
that before. They didn't know that the safety
agency gambled with passenger lives.
We knew that eventual solution would be to have the
modification. And based on our risk
assessment, we felt that this... we had sufficient time to be
able to do the modification, you know, and-and get the final
fix. NARRATOR: After the Lion Air
crash, the F.A.A. had conducted an analysis of the likelihood of
another 737 MAX crashing. The worst-case scenario was
grim. They looked at the
probability that there could be another crash of a 737 MAX, if
the F.A.A. didn't do anything to MCAS and just let the plane keep
flying. And what that assessment showed
was that F.A.A. predicted there could potentially be 15 more
fatal accidents of 737 MAX aircraft over the lifespan of
the fleet, about one crash, every other year.
NARRATOR: But in explaining its decision not to ground the
plane, the F.A.A. said in its statement that the actual risk
at the time... considering the number of planes in the air...
Was as close to zero as their calculations allowed.
The agency had given Boeing 150 days to fix MCAS and issued
official directives to pilots. They were gambling, they were
betting against time that they would have a fix to MCAS before
the next crash happened. And, unfortunately, they lost
that bet. NARRATOR: Not everyone within
the F.A.A. agreed with the agency's gamble.
People too quickly jumped to that conclusion, that the pilot
should have been able to figure out what's going wrong and be
able to intervene properly. NARRATOR: F.A.A. engineer
Joe Jacobsen examined the data from the Lion Air crash, and
quickly raised concerns about the safety of the MAX.
This is his first on-camera interview.
I was pointing out a design flaw.
It was purposely designed and certified to use only one A.O.A.
input to drive MCAS to move the horizontal stabilizer at a high
rate. I talked to three managers,
said, "This a design flaw." They were skeptical, not really
buying in, saying, you know, "The pilot should have been
able to intervene." It's a failure.
Our job is aviation safety, and when airplanes go down, we feel
a real personal sense of loss and remorse and failure, and it
affects a lot of people. ♪ ♪
NARRATOR: In the fall of 2019, with the MAX having been
grounded for seven months, congressional investigators
released internal communications they found during their
investigation. Test pilots working for
Boeing wrtie about problems with the MCAS system two years
before the first fatal crash in Indonesia.
NARRATOR: They offered further evidence of the
company's attempt to avoid pilot training for the MAX.
When we got the messages, and I remember where I was in my
kitchen, because it was Mark Forkner.
NARRATOR: In one document, the former Boeing pilot who had
written notes assuring MCAS would not be put in training
manuals, joked about swaying regulators with "Jedi
mind tricking." Other documents released later
even showed Forkner dismissing the idea of pilot training for
Lion Air. When Lion Air, the airline
that ultimately flew the first plane that crashed, was asking
for simulator training, he was disparaging them to his
colleagues. Calling them stupid.
I mean, seriously? Did that ever cross their minds
that they were going to let something go into the air that
could potentially kill people? ♪ ♪
NARRATOR: Boeing C.E.O. Dennis Muilenburg appeared
before Congress. Boeing C.E.O. is expected to
acknowledge that his company made mistakes.
And here's the first time this guy's in the hot seat.
NARRATOR: By then he'd become the face of the 737 MAX crisis.
I have been on this a committee a long time.
We have never undertaken an investigation of this magnitude.
We intentionally put the families close to the witness.
They're the victims here. And it should be like a, you
know, a trial in court, where you get to face the person who,
you know, who committed a violent act against you.
♪ ♪ NARRATOR: The Committee
confronted Muilenburg with an array of internal Boeing
documents. The next slide.
This shows that Boeing became aware that the disagree alert
wasn't working. It does appear from this that
Boeing understood how important the crew training...
That pilots didn't know about this is unacceptable.
Boeing's marketing representatives emphasized to
potential customers that F.A.A. had reduced the length of pilot
training that... Slow reaction time scenario,
ten seconds, found the failure to be catastrophic.
For those families, the pain of this was accentuated because
this evidence that was going up on the screen was information
that they felt that Mr. Muilenburg could have used to
inform his decision about keeping the plane in the air...
Or not. We do know that Boeing
engineers actually proposed placing a MCAS annunciator in
the cockpit. Are we vulnerable to a single
A.O.A. sensor failure with the MCAS?
Now, as you emphasized, flight control will now compare inputs
from both A.O.A. sensors. And I guess the question is why
wasn't it that way from day one? Mr. Chairman, we've asked
ourselves that same question over and over.
And if back then we knew everything that we know now, we
would have made a different decision.
Nadia Milleron, she was radiating with anger over this.
It's come to the point where you're not the person anymore
to solve the situation. I want to say it to you
directly, because I don't think you understand what we're
saying. She was right in front of
him. And here you have the C.E.O. of
what is one of the most important American companies,
one of the most important companies in the world...
In the end, it's about safety.
Even if you're not capable of doing that?
Looking in the eyes of the mother of a young woman who died
on his airplane. I know that she wasn't afraid
of flying at all, until the last six minutes of her life.
That's just a horrible betrayal that Boeing and the F.A.A.
caused for this person, the last moments of their life, and it
kills me that that trust was betrayed.
Boeing is really kind of stuck in a hard spot here.
Dennis Muilenburg was blasted on Capitol Hill.
NARRATOR: Two months later, with the company's stock
plummeting... Boeing stock has been
dropping all day. It's down 22% since the 737
MAX jet was first grounded back in...
NARRATOR: and the MAX still grounded, Dennis
Muilenburg was out. Near the one-year anniversary of
the second 737 MAX crash, New York Times reporters
Natalie Kitroeff and David Gelles flew to St. Louis.
♪ ♪ By then, Boeing was recommending
pilot training and retooling the MCAS software with a second
A.O.A. input as a failsafe. They'd been invited to Boeing's
offices there by the new C.E.O. Welcome.
Thank you for having us. NARRATOR: The interview was
recorded. Glad you're here.
We got a lot of questions. NARRATOR: He had been on the
company board of directors throughout the 737 MAX program
and described himself as the company's "backup plan" to
Dennis Muilenburg's handling of the crisis.
Boards are invested in their C.E.O.s until they're not.
We had a backup plan. I think this board was
incredibly well prepared. I am the backup plan.
David Calhoun had been on the board of Boeing for several
years. He laid the blame squarely at
the feet of Dennis Muilenburg. NARRATOR: He was in the midst
of damage control. It's more than I imagined it
would be, honestly. And it speaks to the weaknesses
of our leadership. He was shooting straight from
the hip. It was kind of disarming to hear
from the C.E.O. of Boeing. NARRATOR: He told the
reporters the company had indeed made a "fatal mistake," which
was assuming all pilots could counteract a misfire of MCAS.
We made a decision in December to recommend simulator
training everywhere in the world because of the regulators and
the pilots in the developing world.
Not because the U.S. airlines needed it.
They probably don't. There is this narrative that
some foreign pilots are not as good as American pilots.
And Boeing seemed to be suggesting as much.
We pressed Calhoun on this issue.
Do you believe that if U.S. pilots had encountered the MCAS
malfunction, that Lion Air and Ethiopian 302 experienced, would
they have been able to deal with it in your estimation?
And, um... I'm not gonna let you write this down.
You agree you're not going to write it down?
No. All right, forget it.
You can guess the answer. That interview was
essentially the last Boeing story that we did.
To this day, I think, Boeing doesn't accept full
responsibility for these crashes.
There's always the implication that if the pilots had acted
appropriately, those 346 people would still be alive today.
♪ ♪ NARRATOR: In March of 2021,
families gathered in Washington, D.C., for the second anniversary
of the crash of Ethiopian Airlines Flight 302.
Boeing had recently settled a criminal charge of conspiracy to
defraud the United States brought by the Department of
Justice. We have some breaking news on
Boeing. NARRATOR: In the settlement,
Boeing admitted to "misleading statements, half-truths and
omissions" about MCAS. It agreed to pay $2.5 billion...
$500 million to the families of the victims, and most of the
rest to compensate the airlines. The F.A.A. has retested
and approved the 737 MAX. It is once again flying
passengers around the world.
Go to pbs.org/frontline for more on what’s happened since
the crashes of the 737 Max. We had a backup plan.
I think this board was incredibly well prepared.
I am the backup plan. And more reporting from
our partners at The New York Times.
Then visit the FRONTLINE archive to stream our films about 9/11
and hundreds more. Connect with FRONTLINE on
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And stream anytime on the PBS Video App or pbs.org/frontline.
Captioned by Media Access Group at WGBH
access.wgbh.org For more on this and other
"Frontline" programs, visit our website at pbs.org/frontline.
♪ ♪ Frontline's "Boeing's Fatal
Flaw" is avaliable on
Amazon Prime Video.