Boeing's Troubled 737 Max Plane | β€œBoeing’s Fatal Flaw" Update (full documentary) | FRONTLINE

FRONTLINE PBS | Official
12 Mar 202453:18

Summary

TLDRThe Boeing 737 MAX crisis is explored, detailing the design flaws and oversight failures that led to two catastrophic crashes within five months, killing 346 people. The investigation reveals the pressure to compete with Airbus' fuel-efficient A320neo, the undisclosed MCAS software system, and the FAA's inadequate oversight. Boeing's subsequent attempts to address the issues and the impact on its safety culture are also discussed.

Takeaways

  • 🚨 The Boeing 737 MAX faced critical issues with its design and safety features, leading to two fatal crashes and a subsequent grounding of the aircraft worldwide.
  • πŸ› οΈ The Maneuvering Characteristics Augmentation System (MCAS) was identified as a major factor in the crashes, with faulty angle of attack sensors triggering the system and causing the planes to dive uncontrollably.
  • πŸ” A lack of proper oversight and a rush to market to compete with Airbus's A320neo contributed to the MAX's design flaws and safety issues.
  • πŸ“š Boeing withheld crucial information about the MCAS from pilots and airlines, which was a significant factor in the pilots' inability to regain control of the aircraft during the crashes.
  • πŸ’‘ The FAA's delegation system, where Boeing employees oversaw parts of the MAX's certification process on behalf of the agency, raised concerns about the independence of the oversight.
  • 🚫 Despite warnings and internal concerns about the MCAS system, Boeing continued with its implementation without adequate changes or proper training for pilots.
  • πŸ›« The MAX's return to service after extensive recertification processes highlighted the ongoing challenges in ensuring aviation safety and the need for a robust safety culture within the industry.
  • πŸ“‰ The MAX crisis significantly impacted Boeing's reputation, stock prices, and relationships with airlines and regulators, leading to leadership changes and a focus on rebuilding trust.
  • πŸ”— The MAX incidents exposed broader issues within Boeing's safety culture and the FAA's oversight processes, prompting calls for systemic changes to prevent future disasters.
  • πŸ›οΈ Legal and regulatory consequences, including a criminal settlement and ongoing investigations, have further emphasized the severity of the MAX issues and the need for accountability.

Q & A

  • What was the initial problem with the Boeing 737 MAX that led to the Lion Air Flight JT610 crash?

    -The initial problem was a malfunction of the Maneuvering Characteristics Augmentation System (MCAS), which received incorrect data from an angle of attack sensor, causing the plane to dive uncontrollably and crash.

  • How did Boeing respond to the first crash of the 737 MAX?

    -Boeing initially stood by the MAX, diagnosing the problem internally and working on a fix while continuing to fly the planes worldwide. They issued a formal advisory to pilots about handling potential malfunctions but did not initially disclose the full extent of the MCAS system.

  • What was the role of the FAA in the certification and oversight of the Boeing 737 MAX?

    -The FAA had a delegation system in place, which allowed Boeing employees to oversee certain aspects of the plane's certification process on behalf of the FAA. This system has been criticized for its lack of transparency and potential conflicts of interest.

  • What was the significance of the angle of attack (AOA) sensor in the Boeing 737 MAX crashes?

    -The AOA sensor was crucial because it provided data to the MCAS system. A faulty AOA sensor sent incorrect information, triggering the MCAS to push the plane's nose down repeatedly, which was a key factor in both crashes.

  • How did Boeing's design and production decisions contribute to the MAX crisis?

    -Boeing's design decisions, such as making the MCAS more powerful without sufficient pilot training or documentation, and production failures like missing bolts on a door plug, contributed to the MAX crisis. These decisions were driven by a desire to save costs and avoid additional pilot training needs.

  • What were the consequences for Boeing following the 737 MAX crashes?

    -Boeing faced legal consequences, including a criminal charge of conspiracy to defraud the United States, for which they paid $2.5 billion in settlements. They also had to deal with a significant hit to their reputation and the grounding of their MAX fleet.

  • What actions did Boeing take to address the issues with the 737 MAX after the crashes?

    -Boeing worked on a software fix for the MCAS system and made changes to ensure accidents like these never happen again. They also settled with the Department of Justice and compensated the families of the victims and affected airlines.

  • How did the MAX crisis impact Boeing's relationship with the FAA and the public?

    -The crisis led to increased scrutiny of Boeing's practices and the FAA's oversight, revealing a need for significant improvements in both the company's safety culture and the regulatory process. Public trust in Boeing was severely damaged, and the FAA's credibility was also called into question.

  • What were some of the internal concerns raised by Boeing employees about the 737 MAX?

    -Boeing employees raised concerns about the aggressive timeline and cost-cutting measures, the lack of transparency about the MCAS system, and the potential risks associated with relying on single AOA sensor input for MCAS.

  • What were the key findings of the New York Times investigation into the Boeing 737 MAX?

    -The investigation found that Boeing rushed the MAX to market to compete with Airbus, downplayed the significance of MCAS, and withheld crucial information from pilots and regulators. It also highlighted the complex relationship between Boeing and the FAA, and the delegation of oversight responsibilities.

  • What lessons can be learned from the Boeing 737 MAX crisis?

    -The crisis underscores the importance of rigorous safety testing, transparent communication with pilots and regulators, and the need for effective oversight in the aviation industry. It also serves as a reminder of the potential consequences of prioritizing cost-saving measures over safety considerations.

Outlines

00:00

πŸ›« The 737 MAX Crisis: An Overview

This paragraph introduces the 737 MAX crisis, highlighting the loss of the plane mid-flight and the subsequent scrutiny on Boeing and the FAA. It discusses the initial problems with the aircraft, the lack of oversight, and the existential crisis faced by Boeing. The narrative sets the stage for a deeper investigation into the issues surrounding the 737 MAX, including the role of the MCAS system and the company's response to the tragedies.

05:03

πŸ’₯ Two Crashes, Broken Trust

The second paragraph delves into the aftermath of two 737 MAX crashes, emphasizing the loss of 346 lives and the damage to Boeing's reputation. It exposes corporate deception and a flawed regulatory process. The focus is on the software system, MCAS, which was intended to enhance safety but led to fatalities. The narrative follows the investigation by the New York Times, the discovery of the black box data, and the realization of the systemic issues with the 737 MAX.

10:03

πŸš€ The Race for Air Dominance

This paragraph explores the competitive pressure that led to the development of the 737 MAX. It starts in 2011, with Airbus gaining on Boeing in aircraft sales. The introduction of the A320neo by Airbus forced Boeing into a reactive position, leading to a rushed development of the MAX to regain market share. The narrative highlights the internal pressure at Boeing to limit changes and costs, which contributed to the design and certification issues of the MAX.

15:05

πŸ› οΈ Design Flaws and Hidden Risks

The fourth paragraph discusses the design flaws and the underestimation of risks associated with the 737 MAX. It reveals the obsession with limiting changes to reduce training costs, leading to the decision to downplay the significance of the MCAS system. The narrative includes insights from engineers and whistleblowers, who point to a degradation of Boeing's safety-first mindset and the company's failure to properly inform pilots and regulators about MCAS.

20:07

🀝 The Delegation Dilemma

This paragraph examines the relationship between Boeing and the FAA, particularly the delegation arrangement that allowed Boeing employees to oversee certain aspects of the MAX's certification process. It highlights the blurred lines between the regulator and the company, leading to a lack of proper oversight. The narrative also discusses the implications of this arrangement on the MAX's design and certification process.

Mindmap

Keywords

πŸ’‘Boeing 737 MAX

The Boeing 737 MAX is a series of narrow-body aircraft produced by Boeing Commercial Airplanes. It is the fastest-selling jet in Boeing's history but has been marred by two major crashes and subsequent investigations, which revealed design flaws and safety issues, particularly with the Maneuvering Characteristics Augmentation System (MCAS). The plane was grounded worldwide after these incidents, leading to a significant crisis for Boeing.

πŸ’‘MCAS (Maneuvering Characteristics Augmentation System)

MCAS is a software system designed to prevent the aircraft from stalling by automatically adjusting the plane's pitch. However, due to issues with the system receiving incorrect data from the angle of attack sensors, it was implicated in the crashes of Lion Air Flight JT610 and Ethiopian Airlines Flight 302. The system's malfunction and the pilots' lack of knowledge about it were central to the disasters.

πŸ’‘FAA (Federal Aviation Administration)

The FAA is the U.S. government agency responsible for the regulation and oversight of civil aviation. Within the context of the Boeing 737 MAX crisis, the FAA faced criticism for its certification process and the delegation of certain regulatory tasks to Boeing employees, which led to a lack of proper oversight of the MAX's design and safety features.

πŸ’‘Crash Investigations

Crash investigations are in-depth analyses conducted after aviation accidents to determine the causes and contributing factors. These investigations are critical for improving safety measures and preventing future incidents. In the case of the Boeing 737 MAX, crash investigations into the Lion Air and Ethiopian Airlines disasters revealed critical design flaws and systemic issues within Boeing and the FAA.

πŸ’‘Pilot Training and Awareness

Pilot training and awareness refer to the education and knowledge pilots have about their aircraft's systems and potential emergency situations. In the context of the Boeing 737 MAX, the lack of adequate training and awareness about the MCAS system was a significant factor in the crashes, as pilots were unable to properly respond to the system's malfunction.

πŸ’‘Corporate Deception

Corporate deception refers to the deliberate act of misleading or providing false information by a company, often to protect its interests or reputation. In the case of Boeing, corporate deception is evident in the downplaying of the MCAS system's risks and the omission of critical information from pilots and regulators, which contributed to the MAX crashes.

πŸ’‘Regulatory Process

The regulatory process involves the rules, guidelines, and oversight provided by government agencies to ensure safety and compliance in various industries, including aviation. In the context of the Boeing 737 MAX, the regulatory process was criticized for its inadequacy and the close relationship between Boeing and the FAA, which led to insufficient scrutiny of the MAX's design and safety features.

πŸ’‘Design Flaw

A design flaw is an error or oversight in the planning or creation of a product that can lead to malfunction, inefficiency, or safety risks. In the case of the Boeing 737 MAX, the design flaw specifically refers to the MCAS system, which was not properly understood by pilots and had the potential to force the plane into a dangerous nose-down pitch.

πŸ’‘Safety Culture

Safety culture refers to the attitudes, values, behaviors, and practices that an organization develops towards health and safety. It encompasses the commitment to making safety a priority at all levels within the company. The script suggests that Boeing's safety culture was inadequate and contributed to the MAX crisis, indicating a lack of emphasis on safety in the company's decision-making processes.

πŸ’‘Grounding of Aircraft

The grounding of aircraft is a safety measure taken by aviation authorities or airlines to withdraw an aircraft from service due to concerns about its safety. In the case of the Boeing 737 MAX, the grounding was a global response to the MAX's involvement in two fatal crashes, which prompted investigations and the identification of critical safety issues.

πŸ’‘Whistleblowers

Whistleblowers are individuals who expose wrongdoing, illegal activities, or unethical practices within an organization. In the context of the Boeing 737 MAX, whistleblowers played a crucial role by providing information that led to investigations into the MAX's design and the FAA's oversight process.

Highlights

The Boeing 737 MAX experienced critical issues leading to two fatal crashes.

The FAA panel criticized the aircraft company for oversight failures.

Boeing's 737 MAX was the fastest-selling jet in its history before the crashes.

A software system called MCAS was identified as a contributing factor in the crashes.

Boeing did not disclose the full extent of MCAS to pilots, which was a significant oversight.

After the Lion Air Flight JT610 crash, Boeing and the FAA issued a warning about malfunctioning sensors.

The Ethiopian Airlines Flight 302 crash resulted in a global grounding of the 737 MAX.

Boeing's response to the crashes was criticized as they initially blamed the pilots for not following protocols.

The MAX was designed quickly and cheaply in response to competition from Airbus.

Boeing engineers raised concerns about the MCAS system before the crashes, but were dismissed.

The FAA's delegation process allowed Boeing to self-regulate, leading to issues with oversight.

Boeing's CEO Dennis Muilenburg faced Congress and admitted to mistakes.

Boeing settled a criminal charge by admitting to misleading statements about MCAS and agreed to pay $2.5 billion.

The 737 MAX was recertified by the FAA after 20 months of being grounded.

A new incident with a MAX 9 raised further concerns about Boeing's safety culture and the FAA's oversight.

Boeing's safety culture and quality control issues are under investigation by the Justice Department.

The MAX crisis exposed corporate deception and a broken regulatory process.

Boeing's response to the MAX issues has been to acknowledge mistakes and implement a plan to strengthen safety and quality.

Transcripts

00:05

>> The plane suddenly lost a section

00:06

of its fuselage mid-flight...

00:08

>> The FAA panel is blasting the aircraft company...

00:10

>> NARRATOR: Amid new problems with Boeing's 737 MAX,

00:14

>> Where was the oversight to make sure

00:16

the most critical pieces were there?

00:18

>> A special update to the award-winning investigation with

00:21

the "New York Times," into the problem-plagued airplane.

00:24

>> Lion Air flight JT610 went missing from radar...

00:27

>> And then the second plane crashed.

00:29

>> Crashed minutes after taking off...

00:31

>> This was going to be an existential crisis

00:33

for the company.

00:35

>> They had no idea how powerful MCAS was.

00:38

>> FAA's oversight was sorely lacking.

00:40

>> The mounting pressure on Boeing.

00:42

>> This was supposed to be one of the most highly

00:44

scrutinized planes in the world.

00:46

Here you are with another incident that

00:48

was risking passengers' lives.

00:50

>> We are going to approach this, number one,

00:52

acknowledging our mistake.

00:54

>> NARRATOR: Now on FRONTLINE,

00:55

>> It had direct echoes of everything

00:58

we had been reporting on years ago.

01:00

>> NARRATOR: Boeing's Fatal Flaw.

01:07

β™ͺ β™ͺ

01:13

>> On the morning of October 29,

01:14

I was woken up by a colleague

01:18

who alerted me that a Lion aircraft crashed.

01:22

He said, "It's the MAX,"

01:25

and I was surprised, because it was a new aircraft.

01:27

My company provided the air data

01:31

for aircraft flying around the Jakarta area.

01:33

So I went to the computer and looked at the data.

01:39

It was immediately apparent that, okay, something was wrong.

01:41

(indistinct radio chatter)

01:44

The plane went up to about 2,000 feet,

01:47

just over a minute after takeoff,

01:48

and the plane had a bit of a dive.

01:50

And then the plane climbed to about 5,000 feet.

01:55

(indistinct radio chatter)

01:57

But then, at 5,000 feet,

01:59

the plane was fluctuating up and down.

02:00

And then the plane just started diving.

02:02

It, it just didn't make sense.

02:04

You don't see planes diving on departure.

02:07

I was baffled. Why did it go down?

02:09

β™ͺ β™ͺ

02:14

>> Lion Air Flight JT610 went missing from radar...

02:18

>> NARRATOR: 189 people were killed in the crash

02:20

of Lion Air Flight 610.

02:22

>> The Boeing 737 MAX 8...

02:25

>> NARRATOR: The plane was a new Boeing 737 MAX.

02:29

>> What do we know about this 737 MAX 8?

02:33

>> NARRATOR: The fastest-selling jet in Boeing history,

02:35

just introduced the year before.

02:36

>> We don't yet know what caused this crash.

02:39

>> A breakthrough this evening,

02:41

the flight data recorder.

02:42

It holds many of the keys...

02:44

>> NARRATOR: The data from the black box

02:46

quickly got to F.A.A. engineers in the United States.

02:49

β™ͺ β™ͺ

02:51

>> There is a purity of this data.

02:53

It comes directly from the black boxes.

02:55

So it's recording airspeed, altitude.

02:59

>> NARRATOR: The data showed what appeared to be a glitch,

03:02

something repeatedly moving part of the plane's tail,

03:05

controlling its pitch.

03:07

>> It didn't take long, just a couple of minutes, to see

03:10

that there was rapid movement

03:12

of the horizontal stabilizer.

03:14

It's probably the fastest way to kill yourself

03:16

in an airplane, is to have the stabilizer malfunction.

03:19

β™ͺ β™ͺ

03:21

>> My spine literally tingled

03:24

when I saw the traces from the black box.

03:26

The plane continually tried to push the nose down,

03:29

and the pilots were trying over and over again

03:33

to stop the plane.

03:34

And in the end, they lose that battle.

03:38

β™ͺ β™ͺ

03:40

>> NARRATOR: What Boeing had not told airlines

03:41

or their pilots was that it had put

03:44

a powerful software system on the new airplane.

03:46

>> In the Lion Air crash,

03:48

this system was receiving incorrect information,

03:50

and that made the plane dive straight downward

03:54

and destroy itself.

03:55

β™ͺ β™ͺ

03:57

>> NARRATOR: Inside Boeing,

03:59

they quickly diagnosed the problem

04:00

and began working on a fix.

04:02

But they stood by the MAX as hundreds of them

04:05

took to the air around the world,

04:07

carrying thousands of passengers.

04:10

The company alerted pilots

04:12

about handling a potential malfunction.

04:14

>> Boeing and the F.A.A. today warned airlines

04:16

that sensors on 737 MAX 8 jets can malfunction.

04:21

>> Boeing are calling this a formal advisory,

04:23

and it's been issued to the pilots.

04:25

>> The reporting showed Boeing knew

04:28

that it was risky,

04:30

but their response

04:31

was to blame the pilots.

04:34

>> Pilots did not hit two cut-off switches.

04:37

Boeing says that action was part of

04:39

well-established protocols for all 737s.

04:41

>> And that led to a series of decisions

04:45

that kept the plane in the air.

04:47

And then we got another crash.

04:49

>> Breaking news out of Ethiopia,

04:52

where a plane went down...

04:54

>> NARRATOR: It was Ethiopian Airlines Flight 302,

04:56

on its way to Nairobi from Addis Ababa.

04:59

>> ...where a new 737 MAX 8 jetliner

05:02

crashed minutes after taking off.

05:04

>> NARRATOR: Two crashes, the same plane;

05:06

346 people killed;

05:08

an iconic American company's reputation in tatters.

05:14

The story of the Boeing 737 MAX would end up

05:16

exposing corporate deception

05:19

and a broken regulatory process.

05:21

But at the center was a software system

05:23

supposed to keep people safe

05:26

that instead led to their deaths.

05:37

>> The black boxes from the Ethiopian crash

05:39

have been recovered.

05:42

>> It's the second disaster

05:44

within five months involving the Boeing 737 MAX.

05:50

>> That's the same kind of aircraft that crashed

05:52

back in October in Indonesia.

05:55

β™ͺ β™ͺ

05:59

>> 157 people, including passengers

06:02

and crew members on board, all are dead.

06:08

>> The first thing you get to see at the site

06:10

is a very big hole.

06:13

And then to only imagine

06:15

this is the place

06:16

that they were last alive.

06:18

β™ͺ β™ͺ

06:22

>> We learned that there were no survivors on the plane.

06:25

And then our objective was to go and

06:28

bring my daughter's body home.

06:32

>> Now you're in close proximity.

06:35

You're able to see the fine details.

06:37

You're able to maybe think

06:39

these are personal effects

06:41

belonged to Carol, my sister, or my mom.

06:44

Or...

06:46

This bone, whose bone is this?

06:49

β™ͺ β™ͺ

06:52

>> And they told us that there was

06:55

no part of a human

06:58

that was bigger than a femur that was left.

07:02

>> That whole experience is just a jumble of

07:06

images and painful thoughts

07:09

and blankness, really, to me. I don't really...

07:13

I can't really make sense of it.

07:18

>> NARRATOR: The crash of Ethiopian Flight 302

07:20

was the second time in five months

07:22

that a Boeing 737 MAX had gone down.

07:25

β™ͺ β™ͺ

07:33

As families gathered at the crash site,

07:35

across the world, reporters at "The New York Times"

07:38

were investigating what had been going wrong

07:41

with Boeing's new commercial jet.

07:44

>> Statistically speaking, the likelihood that

07:48

these two accidents were not in some way connected

07:51

was extremely low.

07:56

It suggested that there was something going on

07:58

with the plane, and obviously

07:59

we were determined to find out.

08:01

β™ͺ β™ͺ

08:05

>> It was clear from the get-go

08:06

that Boeing was in full crisis mode.

08:08

>> As the facts from

08:10

the accident become available

08:11

and we understand

08:12

the necessary next steps,

08:13

we're taking action to fully

08:15

reassure airlines and their passengers

08:18

of the safety of the 737 MAX.

08:21

>> This was going to be an existential crisis

08:23

for the company if these two events were related.

08:26

>> China grounds the plane first.

08:28

Other international regulators ground the plane.

08:30

Then the European Union grounds the plane.

08:33

>> But in the U.S., the F.A.A. says

08:35

it's not grounding the plane.

08:37

>> Boeing and the F.A.A. all were saying

08:39

that they were sort of waiting

08:40

for the facts before they rushed to judgment

08:43

and grounded such an important new plane.

08:45

>> NARRATOR: But for months,

08:47

the "Times" was reporting there was something wrong

08:50

with the 737 MAX itself:

08:51

the software system that pilots had not known existed.

08:56

>> The Maneuvering Characteristics

08:59

Augmentation System, or MCAS.

09:02

β™ͺ β™ͺ

09:04

The function of this previously undisclosed system

09:07

was to save the plane

09:11

when it believed that the plane might go into a stall

09:14

and fall out of the sky.

09:15

And so this system was designed then to

09:19

sort of take over the stabilizer

09:21

and push that nose back down,

09:23

in case the pilot gets in trouble.

09:26

>> NARRATOR: Then, a major setback for the company:

09:34

Radar showed the two planes' flight patterns

09:36

were eerily similar.

09:38

>> Days after the rest of the world

09:40

had reached the same conclusion,

09:41

they finally grounded the plane.

09:43

>> NARRATOR: For the "New York Times" reporters,

09:46

all the signs pointed to MCAS.

09:48

>> We knew that MCAS was the beginning,

09:51

and we knew that we needed to start with this system.

09:54

>> This was a really

09:56

problematic software system

09:57

in the way it was designed.

10:01

Okay, well, then,

10:03

how the hell did it end up in the plane this way?

10:05

β™ͺ β™ͺ

10:08

>> NARRATOR: Boeing declined to be interviewed for this film.

10:11

In a statement, the company said

10:13

safety is its top priority

10:15

and it has worked closely with regulators,

10:17

investigators, and stakeholders

10:19

"to implement changes that ensure

10:21

accidents like these never happen again."

10:28

>> This story really begins in 2011.

10:31

(jet engine roaring)

10:33

>> The 2011 Paris Air Show

10:35

officially opened Monday.

10:38

>> Boeing and Airbus had been going head-to-head

10:40

for at least a decade.

10:41

But Air... Airbus had been

10:44

quickly catching up and really

10:45

nipping at Boeing's heels.

10:46

>> It's the best air show ever for Airbus

10:50

in terms of aircraft numbers sold.

10:54

>> In 2010, Airbus introduced the A320neo,

10:56

a more fuel-efficient version

10:59

of its stalwart A320.

11:01

>> The A320 is the direct competitor to the Boeing 737.

11:06

Airlines wanted an airplane

11:08

that was more fuel-efficient

11:12

than the airplanes then in service.

11:15

Airbus chose to re-engine the A320

11:17

into what they call the "neo," the "new engine option."

11:21

>> It's a record 200 orders for its A320neo.

11:23

>> It was one of the fastest-selling programs

11:26

of aviation history.

11:28

>> And it placed enormous pressure on Boeing to respond.

11:32

β™ͺ β™ͺ

11:36

Boeing, frankly, was caught flat-footed.

11:38

Within a couple of weeks,

11:39

Airbus and American Airlines

11:42

have the preliminary workings

11:43

of what would become the first deal for American

11:47

to buy Airbus planes in more than a decade.

11:49

Gerard Arpey, the C.E.O. of American Airlines,

11:53

calls Jim McNerney, the C.E.O. of Boeing.

11:55

It's a courtesy call

11:56

at this point,

11:58

just letting their longtime supplier

12:00

of airplanes know they're going to go

12:02

with the competition.

12:04

>> And that is essentially

12:06

a dagger in the heart of Boeing.

12:09

>> And within 48 hours,

12:11

Boeing had decided to pull the trigger

12:13

on launching the re-engined 737,

12:16

which later became branded as the MAX.

12:20

>> From the very beginning,

12:21

from its birth,

12:23

it was marked by

12:25

competitive pressure.

12:28

β™ͺ β™ͺ

12:32

>> NARRATOR: Within days of the second 737 MAX crash,

12:35

another investigation

12:37

was underway in Washington, D.C.

12:39

>> We started getting information

12:41

in from whistleblowers, from people,

12:43

both current and former F.A.A. and Boeing employees.

12:48

>> NARRATOR: Doug Pasternak was leading

12:50

a congressional investigation.

12:51

This is his first interview

12:54

about what he found.

12:57

>> As soon as the second accident occurred,

13:00

we started our investigation,

13:03

and our focus was on the design, development,

13:05

and certification of the MAX.

13:07

We got hundreds of thousands of pages of documents

13:12

from Boeing.

13:14

One of the things that really struck me

13:17

from speaking to a lot of Boeing employees

13:20

was that they were so excited

13:22

to go to work at Boeing.

13:23

β™ͺ β™ͺ

13:25

Boeing is a tremendous engineering company

13:28

and a technical marvel, but,

13:31

almost without failure,

13:33

they point to

13:34

a degradation of that mindset

13:37

and that safety suffered as a result.

13:41

Looking backwards,

13:43

I think you can clearly see

13:46

the trajectory to tragedy

13:48

along the way at, at Boeing.

13:51

β™ͺ β™ͺ

13:55

>> NARRATOR: Boeing publicly said the MAX

13:58

went through a deliberate six-year development process.

14:01

But in their first stories,

14:03

the "New York Times" reporters found insiders who said

14:06

that Boeing executives had been putting the pressure on

14:09

to design the new 737 quickly and cheaply.

14:14

>> One specific engineer we spoke to was Rick Ludtke.

14:16

He helped design the cockpit in the MAX,

14:19

and he talked a lot about how there was an obsession

14:21

in limiting changes.

14:23

>> This program was a much more intense pressure cooker

14:27

than I've ever been in.

14:29

The company was trying to avoid costs...

14:33

minimum change to simplify the training differences,

14:37

and to get it done quickly.

14:40

It put what had happened

14:42

in the context of this

14:44

broader corporate narrative.

14:45

>> Yeah.

14:47

>> Speed was what they seemed to desire.

14:49

There was a lot of decision-making

14:52

that was somewhat arbitrary and didn't involve as much of the,

14:57

of what engineering considers healthy debate.

15:02

The challenge to the Boeing designers was that

15:04

any designs we create would not drive any new training

15:09

that required a simulator.

15:12

>> NARRATOR: In his recorded interview with the "Times,"

15:15

Ludtke said Boeing management was so determined

15:17

to avoid the expense of new training,

15:20

they made a bold promise.

15:22

>> Sales had made a commitment

15:23

with Southwest that for any airplane they delivered

15:27

that had a new Level D differences training,

15:30

Boeing would pay the company $1 million

15:33

per every airplane delivered.

15:35

>> If the MAX required simulator training,

15:39

it would rebate Southwest a million dollars per plane.

15:44

And there's that incentive.

15:46

That's why it was so important to Boeing

15:48

that pilot training be kept to a minimum.

15:50

All of this comes out of

15:53

trying to give airlines

15:55

the most fuel-efficient

15:58

version of a plane

16:00

that they can spend as little money training their pilots on.

16:03

β™ͺ β™ͺ

16:05

>> That meant Boeing had to do a number of things

16:10

to make this plane fly like the old one,

16:12

and that was because the MAX had much bigger engines on it

16:16

to make them more fuel efficient.

16:18

>> But because the 737 was

16:21

a 50-year-old airplane at this time, practically,

16:24

when it came time for Boeing

16:25

to put those engines on the wings,

16:29

the engines were so darn big,

16:31

they had to mount them further forward on the wings.

16:35

>> They were testing in this wind tunnel,

16:38

and they were discovering the plane was handling

16:40

just a little bit differently-- but they didn't even have

16:42

a plane built yet, so this wasn't, you know,

16:44

happening in real flight-- this is something you have to fix.

16:46

And they leaned on

16:49

a system that they had used once before in a military tanker.

16:53

It was designed as a system on the plane

16:57

to really just smooth out the way the plane handled.

17:01

>> NARRATOR: It was MCAS.

17:05

>> It was designed for these extremely unusual maneuvers.

17:09

Situations that, hopefully, the plane would never get in.

17:13

And to prevent the nose from getting too high,

17:18

the system would move the stabilizer

17:20

on the back of the plane to push the nose back down.

17:27

>> NARRATOR: But inside Boeing,

17:28

there were early signs of trouble.

17:30

>> One of the first documents we found

17:34

was from November of 2012.

17:37

A Boeing test pilot was flying the MAX

17:42

in a flight simulator

17:45

and trying to respond

17:47

to an activation of MCAS.

17:49

And that resulted

17:51

in what he described as a catastrophic event.

17:54

β™ͺ β™ͺ

17:56

It showed that if that had been in real life,

18:00

he could have lost the airplane.

18:01

They realize from that moment on,

18:04

even a Boeing test pilot may have trouble responding to MCAS.

18:10

>> NARRATOR: The company kept quiet

18:12

about the simulator experience