1 00:00:00,980 --> 00:00:03,020 (THEME MUSIC PLAYS) 2 00:00:21,540 --> 00:00:25,580 NIRAJ CHOKSHI: A piece of the plane's body is blown out at row 26. 3 00:00:25,580 --> 00:00:25,820 NIRAJ CHOKSHI: A piece of the plane's body is blown out at row 26. There's just chaos. 4 00:00:25,820 --> 00:00:27,180 There's just chaos. 5 00:00:27,180 --> 00:00:27,420 EVAN SMITH: A boy's shirt was sucked There's just chaos. 6 00:00:27,420 --> 00:00:30,020 EVAN SMITH: A boy's shirt was sucked off him and out of the plane, 7 00:00:30,020 --> 00:00:30,300 and his mother was holding on to him. EVAN SMITH: A boy's shirt was sucked off him and out of the plane, 8 00:00:30,300 --> 00:00:31,660 and his mother was holding on to him. 9 00:00:31,660 --> 00:00:31,940 I saw a half of his body was getting sucked out, and his mother was holding on to him. 10 00:00:31,940 --> 00:00:34,380 I saw a half of his body was getting sucked out, 11 00:00:34,380 --> 00:00:34,620 I saw a half of his body was getting sucked out, and then I was like, "Oh, my God!" 12 00:00:34,620 --> 00:00:37,420 and then I was like, "Oh, my God!" 13 00:00:37,420 --> 00:00:38,660 NEWSREADER: The plane suddenly 14 00:00:38,660 --> 00:00:41,140 lost a section of its fuselage mid-flight. 15 00:00:41,140 --> 00:00:44,260 NEWSREADER: An FAA panel is blasting the aircraft company. 16 00:00:44,260 --> 00:00:47,420 NARRATOR: Amid new problems with Boeing's 737 Max... 17 00:00:47,420 --> 00:00:52,140 Where was the oversight to make sure the most critical pieces were there? 18 00:00:52,140 --> 00:00:55,220 ..a special update to the award-winning investigation 19 00:00:55,220 --> 00:00:57,860 with The New York Times into the problem-plagued aeroplane. 20 00:00:57,860 --> 00:01:00,820 NEWSREADER: Lion Air Flight JT610 went missing from radar. 21 00:01:00,820 --> 00:01:02,460 DAVID GELLES: And then the second plane crashed. 22 00:01:02,460 --> 00:01:05,060 NEWSREADER: Ethiopia crashed minutes after taking off. 23 00:01:05,060 --> 00:01:07,660 This was gonna be an existential crisis for the company. 24 00:01:07,660 --> 00:01:07,940 They had no idea how powerful MCAS was. This was gonna be an existential crisis for the company. 25 00:01:07,940 --> 00:01:11,100 They had no idea how powerful MCAS was. 26 00:01:11,100 --> 00:01:11,380 They had no idea how powerful MCAS was. DOUG PASTERNAK: FAA'S oversight was sorely lacking. 27 00:01:11,380 --> 00:01:13,980 DOUG PASTERNAK: FAA'S oversight was sorely lacking. 28 00:01:13,980 --> 00:01:16,420 NEWSREADER: The mounting pressure on Boeing... 29 00:01:16,420 --> 00:01:18,020 SYDNEY EMBER: This was supposed to be one of the most 30 00:01:18,020 --> 00:01:19,780 highly scrutinised planes in the world, 31 00:01:19,780 --> 00:01:21,580 and here you are with another incident 32 00:01:21,580 --> 00:01:21,820 and here you are that was risking passengers' lives. 33 00:01:21,820 --> 00:01:23,660 that was risking passengers' lives. 34 00:01:23,660 --> 00:01:23,900 VI NGUYEN: In that moment I'm just that was risking passengers' lives. 35 00:01:23,900 --> 00:01:25,860 VI NGUYEN: In that moment I'm just like, "Oh, God, I'm gonna die." 36 00:01:25,860 --> 00:01:28,380 FLIGHT RECORDING: We are emergency. We are depressurised. 37 00:01:40,340 --> 00:01:42,580 GERRY SOEJATMAN: On the morning of October 29, 38 00:01:42,580 --> 00:01:46,100 I was woken up by a colleague 39 00:01:46,100 --> 00:01:46,340 who alerted me that a Lion aircraft crashed. I was woken up by a colleague 40 00:01:46,340 --> 00:01:50,140 who alerted me that a Lion aircraft crashed. 41 00:01:50,140 --> 00:01:50,380 who alerted me that a Lion aircraft crashed. He said, "It's the Max." 42 00:01:50,380 --> 00:01:52,140 He said, "It's the Max." 43 00:01:52,140 --> 00:01:52,380 And I was surprised He said, "It's the Max." 44 00:01:52,380 --> 00:01:55,300 And I was surprised because it was a new aircraft. 45 00:01:55,300 --> 00:01:55,540 And I was surprised My company provided the air data 46 00:01:55,540 --> 00:01:58,580 My company provided the air data 47 00:01:58,580 --> 00:02:01,780 for aircraft flying around the Jakarta area, 48 00:02:01,780 --> 00:02:04,060 so, I went to the computer and looked at the data. 49 00:02:05,940 --> 00:02:09,300 It was immediately apparent that something was wrong. 50 00:02:09,300 --> 00:02:09,540 It was immediately apparent (INDISTINCT RADIO CHATTER) 51 00:02:09,540 --> 00:02:11,220 (INDISTINCT RADIO CHATTER) 52 00:02:11,220 --> 00:02:11,460 The plane went up to about 2,000ft (INDISTINCT RADIO CHATTER) 53 00:02:11,460 --> 00:02:16,060 The plane went up to about 2,000ft just over a minute after take-off, 54 00:02:16,060 --> 00:02:16,300 The plane went up to about 2,000ft and the plane had a bit of a dive, 55 00:02:16,300 --> 00:02:18,220 and the plane had a bit of a dive, 56 00:02:18,220 --> 00:02:22,260 and then the plane climbed to about 5,000ft. 57 00:02:24,300 --> 00:02:28,340 But then at 5,000ft the plane was fluctuating up and down. 58 00:02:28,340 --> 00:02:30,140 And then the plane just started diving. 59 00:02:30,140 --> 00:02:30,380 And then the plane It just didn't make sense. 60 00:02:30,380 --> 00:02:31,820 It just didn't make sense. 61 00:02:31,820 --> 00:02:32,060 You don't see It just didn't make sense. 62 00:02:32,060 --> 00:02:34,700 You don't see planes diving on departure. 63 00:02:34,700 --> 00:02:34,940 You don't see I was baffled. 64 00:02:34,940 --> 00:02:36,180 I was baffled. 65 00:02:36,180 --> 00:02:37,700 Why did it go down? 66 00:02:42,500 --> 00:02:45,700 NEWSREADER: Lion Air Flight JT610 went missing from radar. 67 00:02:45,700 --> 00:02:50,260 189 people were killed in the crash of Lion Air Flight 610. 68 00:02:50,260 --> 00:02:53,380 NEWSREADER: The Boeing 737 Max 8... 69 00:02:53,380 --> 00:02:53,620 NEWSREADER: The plane was a new Boeing 737 Max... 70 00:02:53,620 --> 00:02:56,860 The plane was a new Boeing 737 Max... 71 00:02:56,860 --> 00:02:57,100 NEWSREADER: What do we know The plane was a new Boeing 737 Max... 72 00:02:57,100 --> 00:02:59,700 NEWSREADER: What do we know about this 737 Max 8? 73 00:02:59,700 --> 00:03:02,700 ..the fastest-selling jet in Boeing history, 74 00:03:02,700 --> 00:03:02,940 ..the fastest-selling jet just introduced the year before. 75 00:03:02,940 --> 00:03:04,540 just introduced the year before. 76 00:03:04,540 --> 00:03:04,780 REPORTER: We don't yet know just introduced the year before. 77 00:03:04,780 --> 00:03:07,020 REPORTER: We don't yet know what caused this crash. 78 00:03:07,020 --> 00:03:09,980 A breakthrough this evening - the flight data recorder. 79 00:03:09,980 --> 00:03:10,220 A breakthrough this evening - It holds many of the keys... 80 00:03:10,220 --> 00:03:11,860 It holds many of the keys... 81 00:03:11,860 --> 00:03:15,340 The data from the black box quickly got to FAA engineers 82 00:03:15,340 --> 00:03:16,820 in the United States. 83 00:03:19,020 --> 00:03:20,500 There is a purity of this data. 84 00:03:20,500 --> 00:03:20,740 There is a purity of this data. from the black boxes. 85 00:03:20,740 --> 00:03:23,180 It comes directly from the black boxes. 86 00:03:23,180 --> 00:03:23,460 It comes directly from the black boxes. So, it's recording air speed, altitude. 87 00:03:23,460 --> 00:03:27,220 So, it's recording air speed, altitude. 88 00:03:27,220 --> 00:03:29,820 The data showed what appeared to be a glitch, 89 00:03:29,820 --> 00:03:33,020 something repeatedly moving part of the plane's tail, 90 00:03:33,020 --> 00:03:34,540 controlling its pitch. 91 00:03:34,540 --> 00:03:36,740 It didn't take long, just a couple of minutes, 92 00:03:36,740 --> 00:03:36,980 It didn't take long, to see that 93 00:03:36,980 --> 00:03:38,180 to see that 94 00:03:38,180 --> 00:03:38,380 there was a rapid movement to see that 95 00:03:38,380 --> 00:03:39,660 there was a rapid movement 96 00:03:39,660 --> 00:03:41,460 of the horizontal stabiliser. 97 00:03:41,460 --> 00:03:41,700 of the horizontal stabiliser. It's probably the fastest way to kill yourself in an aeroplane 98 00:03:41,700 --> 00:03:44,540 It's probably the fastest way to kill yourself in an aeroplane 99 00:03:44,540 --> 00:03:46,820 is to have the stabiliser malfunction. 100 00:03:48,860 --> 00:03:50,780 JAMES GLANZ: My spine literally tingled 101 00:03:50,780 --> 00:03:53,300 when I saw the traces from the black box. 102 00:03:53,300 --> 00:03:57,380 The plane continually tried to push the nose down, 103 00:03:57,380 --> 00:03:57,660 and the pilots were trying over and over again to stop the plane, The plane continually tried to push the nose down, 104 00:03:57,660 --> 00:04:02,380 and the pilots were trying over and over again to stop the plane, 105 00:04:02,380 --> 00:04:02,660 and the pilots were trying over and over again to stop the plane, and in the end they lose that battle. 106 00:04:02,660 --> 00:04:05,980 and in the end they lose that battle. 107 00:04:06,940 --> 00:04:10,340 What Boeing had not told airlines or their pilots 108 00:04:10,340 --> 00:04:13,700 was that it had put a powerful software system on the new aeroplane. 109 00:04:13,700 --> 00:04:13,940 was that it had put a powerful In the Lion Air crash 110 00:04:13,940 --> 00:04:15,820 In the Lion Air crash 111 00:04:15,820 --> 00:04:18,900 this system was receiving incorrect information 112 00:04:18,900 --> 00:04:21,780 and that made the plane dive straight downward 113 00:04:21,780 --> 00:04:22,020 and that made the plane and destroy itself. 114 00:04:22,020 --> 00:04:23,540 and destroy itself. 115 00:04:25,060 --> 00:04:28,380 Inside Boeing, they quickly diagnosed the problem 116 00:04:28,380 --> 00:04:30,260 and began working on a fix, 117 00:04:30,260 --> 00:04:31,780 but they stood by the Max 118 00:04:31,780 --> 00:04:35,100 as hundreds of them took to the air around the world, 119 00:04:35,100 --> 00:04:35,340 as hundreds of them took to the air carrying thousands of passengers. 120 00:04:35,340 --> 00:04:37,700 carrying thousands of passengers. 121 00:04:37,700 --> 00:04:37,940 The company alerted pilots about carrying thousands of passengers. 122 00:04:37,940 --> 00:04:41,740 The company alerted pilots about handling a potential malfunction. 123 00:04:41,740 --> 00:04:44,260 NEWSREADER: Boeing and the FAA today warned airlines 124 00:04:44,260 --> 00:04:48,660 that sensors on 737 Max 8 jets can malfunction. 125 00:04:48,660 --> 00:04:51,060 REPORTER: Boeing are calling this a formal advisory 126 00:04:51,060 --> 00:04:52,860 and it's been issued to the pilots. 127 00:04:52,860 --> 00:04:54,460 NATALIE KITROEFF: The reporting showed 128 00:04:54,460 --> 00:04:54,700 NATALIE KITROEFF: Boeing knew that it was risky, 129 00:04:54,700 --> 00:04:57,140 Boeing knew that it was risky, 130 00:04:57,140 --> 00:04:59,380 but their response 131 00:04:59,380 --> 00:04:59,580 was to blame the pilots. but their response 132 00:04:59,580 --> 00:05:02,220 was to blame the pilots. 133 00:05:02,220 --> 00:05:02,460 was to blame the pilots. REPORTER: Pilots did not hit two cut-off switches. 134 00:05:02,460 --> 00:05:04,740 REPORTER: Pilots did not hit two cut-off switches. 135 00:05:04,740 --> 00:05:06,100 Boeing says that action 136 00:05:06,100 --> 00:05:06,340 was part of well-established Boeing says that action 137 00:05:06,340 --> 00:05:09,420 was part of well-established protocols for all 737s. 138 00:05:09,420 --> 00:05:12,580 And that led to a series of decisions 139 00:05:12,580 --> 00:05:12,820 And that led that kept the plane in the air. 140 00:05:12,820 --> 00:05:14,700 that kept the plane in the air. 141 00:05:14,700 --> 00:05:17,500 And then we got another crash. 142 00:05:18,460 --> 00:05:21,460 NEWSREADER: Breaking news out of Ethiopia, where a plane went down... 143 00:05:21,460 --> 00:05:24,540 It was Ethiopian Airlines Flight 302 144 00:05:24,540 --> 00:05:27,340 on its way to Nairobi from Addis Ababa. 145 00:05:27,340 --> 00:05:31,620 NEWSREADER: A new 737 Max 8 jetliner crashed minutes after taking off. 146 00:05:31,620 --> 00:05:34,180 Two crashes, the same plane, 147 00:05:34,180 --> 00:05:36,580 346 people killed, 148 00:05:36,580 --> 00:05:40,860 an iconic American company's reputation in tatters. 149 00:05:40,860 --> 00:05:43,620 The story of the Boeing 737 Max 150 00:05:43,620 --> 00:05:46,100 would end up exposing corporate deception 151 00:05:46,100 --> 00:05:48,500 and a broken regulatory process. 152 00:05:48,500 --> 00:05:48,740 But at the centre was a software and a broken regulatory process. 153 00:05:48,740 --> 00:05:53,340 But at the centre was a software system supposed to keep people safe 154 00:05:53,340 --> 00:05:53,580 But at the centre was a software that instead led to their deaths. 155 00:05:53,580 --> 00:05:56,820 that instead led to their deaths. 156 00:05:57,940 --> 00:06:01,900 NEWSREADER: The black boxes from the Ethiopian crash have been recovered. 157 00:06:01,900 --> 00:06:04,220 NEWSREADER: It's the second disaster within five months 158 00:06:04,220 --> 00:06:04,460 NEWSREADER: It's the second disaster involving the Boeing 737 Max. 159 00:06:04,460 --> 00:06:07,580 involving the Boeing 737 Max. 160 00:06:09,300 --> 00:06:11,340 NEWSREADER: That's the same kind of aircraft 161 00:06:11,340 --> 00:06:14,900 that crashed back in October in Indonesia. 162 00:06:18,420 --> 00:06:19,980 NEWSREADER: 157 people, 163 00:06:19,980 --> 00:06:22,580 including passengers and crew members on board, 164 00:06:22,580 --> 00:06:22,820 including passengers all dead. 165 00:06:22,820 --> 00:06:24,300 all dead. 166 00:06:27,180 --> 00:06:29,220 QUINDOS KARANJA: The first thing you get to see at the site 167 00:06:29,220 --> 00:06:29,460 is a very big hole. you get to see at the site 168 00:06:29,460 --> 00:06:31,740 is a very big hole. 169 00:06:32,980 --> 00:06:34,740 And then to only imagine 170 00:06:34,740 --> 00:06:34,980 this is the place And then to only imagine 171 00:06:34,980 --> 00:06:38,020 this is the place that they were last alive. 172 00:06:40,660 --> 00:06:42,180 We learned that 173 00:06:42,180 --> 00:06:42,420 there were no survivors on the plane. We learned that 174 00:06:42,420 --> 00:06:44,980 there were no survivors on the plane. 175 00:06:44,980 --> 00:06:48,300 And then our objective was to go and bring 176 00:06:48,300 --> 00:06:48,540 And then our objective was to go and bring my daughter's body home. 177 00:06:48,540 --> 00:06:50,300 my daughter's body home. 178 00:06:52,460 --> 00:06:54,660 Now you're in close proximity. 179 00:06:54,660 --> 00:06:56,980 You're able to see the fine details. 180 00:06:56,980 --> 00:07:00,460 You're able to maybe think these are personal effects, 181 00:07:00,460 --> 00:07:03,700 "Belongs to Carol my sister or my mum," 182 00:07:03,700 --> 00:07:07,420 or, uh..."This bone, whose bone is this?" 183 00:07:12,540 --> 00:07:17,260 And they told us that there was no part of a human 184 00:07:17,260 --> 00:07:21,140 that was bigger than a femur that was left. 185 00:07:22,220 --> 00:07:26,100 That whole experience is just a jumble of images 186 00:07:26,100 --> 00:07:26,380 and painful thoughts and blankness, really, to me. That whole experience is just a jumble of images 187 00:07:26,380 --> 00:07:30,180 and painful thoughts and blankness, really, to me. 188 00:07:30,180 --> 00:07:30,420 and painful thoughts I don't really... 189 00:07:30,420 --> 00:07:31,700 I don't really... 190 00:07:33,100 --> 00:07:35,420 I can't really make sense of it. 191 00:07:37,580 --> 00:07:41,220 The crash of Ethiopian Flight 302 in 2019 192 00:07:41,220 --> 00:07:46,420 was the second time in five months that a Boeing 737 Max had gone down. 193 00:07:52,860 --> 00:07:55,100 As families gathered at the crash site, 194 00:07:55,100 --> 00:07:56,420 across the world 195 00:07:56,420 --> 00:07:59,060 reporters at The New York Times were investigating 196 00:07:59,060 --> 00:08:03,420 what had been going wrong with Boeing's new commercial jet. 197 00:08:03,420 --> 00:08:05,660 NATALIE KITROEFF: Statistically speaking, 198 00:08:05,660 --> 00:08:08,980 the likelihood that these two accidents 199 00:08:08,980 --> 00:08:09,220 the likelihood were not in some way connected 200 00:08:09,220 --> 00:08:11,460 were not in some way connected 201 00:08:11,460 --> 00:08:13,940 was extremely low. 202 00:08:15,020 --> 00:08:18,420 It suggested that there was something going on with the plane, 203 00:08:18,420 --> 00:08:20,980 and, obviously, we were determined to find out. 204 00:08:20,980 --> 00:08:21,220 (INDISTINCT CHATTER) we were determined to find out. 205 00:08:21,220 --> 00:08:24,300 (INDISTINCT CHATTER) 206 00:08:24,300 --> 00:08:24,540 (INDISTINCT CHATTER) that Boeing was in full crisis mode. 207 00:08:24,540 --> 00:08:28,540 It was clear from the get-go that Boeing was in full crisis mode. 208 00:08:28,540 --> 00:08:28,820 It was clear from the get-go that Boeing was in full crisis mode. As the facts from the accident become available 209 00:08:28,820 --> 00:08:30,860 As the facts from the accident become available 210 00:08:30,860 --> 00:08:33,540 and we understand the necessary next steps, 211 00:08:33,540 --> 00:08:33,820 and we understand the necessary next steps, we're taking action to fully reassure airlines 212 00:08:33,820 --> 00:08:36,700 we're taking action to fully reassure airlines 213 00:08:36,700 --> 00:08:37,940 and their passengers 214 00:08:37,940 --> 00:08:40,460 of the safety of the 737 Max. 215 00:08:40,460 --> 00:08:43,500 This was gonna be an existential crisis for the company 216 00:08:43,500 --> 00:08:45,100 if these two events were related. 217 00:08:46,060 --> 00:08:48,300 China grounds the plane first. 218 00:08:48,300 --> 00:08:50,700 Other international regulators ground the plane. 219 00:08:50,700 --> 00:08:52,580 Then the European Union grounds the plane. 220 00:08:52,580 --> 00:08:52,860 NEWSREADER: But in the US, the FAA says it's not grounding the plane. Then the European Union grounds the plane. 221 00:08:52,860 --> 00:08:56,140 NEWSREADER: But in the US, the FAA says it's not grounding the plane. 222 00:08:56,140 --> 00:08:56,420 NEWSREADER: But in the US, the FAA says it's not grounding the plane. Boeing and the FAA all were saying that they were 223 00:08:56,420 --> 00:08:59,340 Boeing and the FAA all were saying that they were 224 00:08:59,340 --> 00:09:02,340 sort of waiting for the facts before they rushed to judgement 225 00:09:02,340 --> 00:09:04,940 and grounded such an important new plane. 226 00:09:04,940 --> 00:09:05,180 and grounded But for months 227 00:09:05,180 --> 00:09:06,420 But for months 228 00:09:06,420 --> 00:09:07,900 The Times was reporting 229 00:09:07,900 --> 00:09:08,140 there was something wrong The Times was reporting 230 00:09:08,140 --> 00:09:11,500 there was something wrong with the 737 Max itself - 231 00:09:11,500 --> 00:09:16,260 the software system that pilots had not known existed. 232 00:09:16,260 --> 00:09:19,860 JAMES GLANZ: The Manoeuvring Characteristics Augmentation System, 233 00:09:19,860 --> 00:09:20,100 JAMES GLANZ: The Manoeuvring or MCAS. 234 00:09:20,100 --> 00:09:21,780 or MCAS. 235 00:09:22,980 --> 00:09:26,700 The function of this previously undisclosed system 236 00:09:26,700 --> 00:09:26,940 The function of was to save the plane 237 00:09:26,940 --> 00:09:29,860 was to save the plane 238 00:09:29,860 --> 00:09:34,020 when it believed that the plane might go into a stall 239 00:09:34,020 --> 00:09:35,300 and fall out of the sky. 240 00:09:35,300 --> 00:09:38,220 And, so, this system was designed then 241 00:09:38,220 --> 00:09:38,460 And, so, this system to sort of take over the stabiliser 242 00:09:38,460 --> 00:09:40,700 to sort of take over the stabiliser 243 00:09:40,700 --> 00:09:40,940 and push that nose back down to sort of take over the stabiliser 244 00:09:40,940 --> 00:09:44,740 and push that nose back down in case the pilot gets in trouble. 245 00:09:46,100 --> 00:09:49,500 Then a major setback for the company. 246 00:09:53,460 --> 00:09:57,940 Radar showed the two plane's flight patterns were eerily similar. 247 00:09:57,940 --> 00:10:00,820 Days after the rest of the world had reached the same conclusion, 248 00:10:00,820 --> 00:10:01,060 Days after the rest of the world they finally grounded the plane. 249 00:10:01,060 --> 00:10:03,060 they finally grounded the plane. 250 00:10:03,060 --> 00:10:06,100 For The New York Times reporters, 251 00:10:06,100 --> 00:10:08,460 all the signs pointed to MCAS. 252 00:10:08,460 --> 00:10:10,860 We knew that MCAS was the beginning. 253 00:10:10,860 --> 00:10:13,700 We knew that we needed to start with this system. 254 00:10:13,700 --> 00:10:13,980 This was a really problematic software system We knew that we needed to start with this system. 255 00:10:13,980 --> 00:10:17,260 This was a really problematic software system 256 00:10:17,260 --> 00:10:17,500 This was a really problematic software system in the way it was designed. 257 00:10:17,500 --> 00:10:19,540 in the way it was designed. 258 00:10:20,660 --> 00:10:24,940 OK, well, then how the hell did it end up in the plane this way? 259 00:10:27,820 --> 00:10:30,660 Boeing declined to be interviewed for this film. 260 00:10:30,660 --> 00:10:34,820 In a statement, the company said safety is its "top priority" 261 00:10:34,820 --> 00:10:35,060 In a statement, the company said and it has "worked closely" 262 00:10:35,060 --> 00:10:36,620 and it has "worked closely" 263 00:10:36,620 --> 00:10:36,860 with regulators, investigators and it has "worked closely" 264 00:10:36,860 --> 00:10:39,820 with regulators, investigators and stakeholders 265 00:10:39,820 --> 00:10:40,060 with regulators, investigators to "implement changes that ensure 266 00:10:40,060 --> 00:10:41,380 to "implement changes that ensure 267 00:10:41,380 --> 00:10:44,860 "accidents like these never happen again." 268 00:10:46,540 --> 00:10:50,220 Within days of the second 737 Max crash 269 00:10:50,220 --> 00:10:54,540 another investigation was underway in Washington, DC. 270 00:10:54,540 --> 00:10:57,180 DOUG PASTERNAK: We started getting information in 271 00:10:57,180 --> 00:10:57,420 DOUG PASTERNAK: from whistleblowers, from people, 272 00:10:57,420 --> 00:10:59,100 from whistleblowers, from people, 273 00:10:59,100 --> 00:10:59,340 both current and former FAA and Boeing employees. from whistleblowers, from people, 274 00:10:59,340 --> 00:11:02,860 both current and former FAA and Boeing employees. 275 00:11:03,820 --> 00:11:07,420 Doug Pasternak was leading a congressional investigation. 276 00:11:07,420 --> 00:11:11,020 This is his first interview about what he found. 277 00:11:12,500 --> 00:11:15,860 As soon as the second accident occurred, 278 00:11:15,860 --> 00:11:16,100 As soon as the second accident we started our investigation 279 00:11:16,100 --> 00:11:17,780 we started our investigation 280 00:11:17,780 --> 00:11:18,020 and our focus was on the design, we started our investigation 281 00:11:18,020 --> 00:11:21,780 and our focus was on the design, development and certification 282 00:11:21,780 --> 00:11:22,020 and our focus was on the design, of the Max. 283 00:11:22,020 --> 00:11:23,020 of the Max. 284 00:11:23,020 --> 00:11:28,620 We got hundreds of thousands of pages of documents from Boeing. 285 00:11:29,860 --> 00:11:32,180 One of the things that really struck me 286 00:11:32,180 --> 00:11:35,340 from speaking to a lot of Boeing employees 287 00:11:35,340 --> 00:11:39,380 was that they were so excited to go to work at Boeing. 288 00:11:39,380 --> 00:11:40,540 (CHEERING, APPLAUSE) 289 00:11:40,540 --> 00:11:45,500 Boeing is a tremendous engineering company and a technical marvel, 290 00:11:45,500 --> 00:11:45,740 Boeing is a tremendous engineering but almost without failure 291 00:11:45,740 --> 00:11:48,220 but almost without failure 292 00:11:48,220 --> 00:11:48,460 they point to a degradation but almost without failure 293 00:11:48,460 --> 00:11:52,180 they point to a degradation of that mindset 294 00:11:52,180 --> 00:11:56,460 and that safety suffered as a result. 295 00:11:56,460 --> 00:11:56,700 and that safety suffered Looking backwards, 296 00:11:56,700 --> 00:11:58,540 Looking backwards, 297 00:11:58,540 --> 00:12:00,940 I think you can clearly see 298 00:12:00,940 --> 00:12:06,660 the trajectory, the tragedy, along the way at Boeing. 299 00:12:06,660 --> 00:12:06,900 (ENGINES WHINE) the trajectory, the tragedy, along the way at Boeing. 300 00:12:06,900 --> 00:12:10,660 (ENGINES WHINE) 301 00:12:10,660 --> 00:12:12,140 Boeing publicly said 302 00:12:12,140 --> 00:12:16,380 the Max went through a deliberate six-year development process. 303 00:12:16,380 --> 00:12:16,620 the Max went through a deliberate six-year development process. But in their first stories 304 00:12:16,620 --> 00:12:18,500 But in their first stories 305 00:12:18,500 --> 00:12:21,220 The New York Times reporters found insiders 306 00:12:21,220 --> 00:12:24,700 who said that Boeing executives had been putting the pressure on 307 00:12:24,700 --> 00:12:29,820 to design the new 737 quickly and cheaply. 308 00:12:29,820 --> 00:12:32,060 JACK NICAS: One specific engineer we spoke to was Rick Ludtke. 309 00:12:32,060 --> 00:12:34,340 He helped design the cockpit in the Max, 310 00:12:34,340 --> 00:12:34,580 He helped design the cockpit and he talked a lot about 311 00:12:34,580 --> 00:12:35,660 and he talked a lot about 312 00:12:35,660 --> 00:12:35,900 how there was an obsession and he talked a lot about 313 00:12:35,900 --> 00:12:38,900 how there was an obsession in limiting changes. 314 00:12:38,900 --> 00:12:42,700 RICK LUDTKE: This program was a much more intense pressure cooker 315 00:12:42,700 --> 00:12:42,940 RICK LUDTKE: This program was than I've ever been in. 316 00:12:42,940 --> 00:12:44,540 than I've ever been in. 317 00:12:44,540 --> 00:12:49,060 The company was trying to avoid costs. 318 00:12:49,060 --> 00:12:52,420 Minimum change to simplify the training differences 319 00:12:52,420 --> 00:12:52,660 Minimum change to simplify and to get it done quickly. 320 00:12:52,660 --> 00:12:55,020 and to get it done quickly. 321 00:12:55,980 --> 00:12:58,700 Speed was what they seemed to desire. 322 00:12:58,700 --> 00:12:58,940 Speed was what There was a lot of decision-making 323 00:12:58,940 --> 00:13:01,180 There was a lot of decision-making 324 00:13:01,180 --> 00:13:03,380 that was somewhat arbitrary 325 00:13:03,380 --> 00:13:05,660 and didn't involve as much the... 326 00:13:05,660 --> 00:13:05,900 ..of what engineering and didn't involve as much the... 327 00:13:05,900 --> 00:13:10,660 ..of what engineering considers healthy, um...debate. 328 00:13:10,660 --> 00:13:12,580 The challenge to the Boeing designers 329 00:13:12,580 --> 00:13:12,820 The challenge was that any designs we created 330 00:13:12,820 --> 00:13:15,940 was that any designs we created 331 00:13:15,940 --> 00:13:16,180 would not drive any new training was that any designs we created 332 00:13:16,180 --> 00:13:21,300 would not drive any new training that required a simulator. 333 00:13:21,300 --> 00:13:23,940 In his recorded interview with The Times, 334 00:13:23,940 --> 00:13:24,180 In his recorded interview Ludtke said Boeing management 335 00:13:24,180 --> 00:13:25,580 Ludtke said Boeing management 336 00:13:25,580 --> 00:13:29,340 was so determined to avoid the expense of new training 337 00:13:29,340 --> 00:13:30,980 they made a bold promise. 338 00:13:30,980 --> 00:13:33,980 Sales had made a commitment with Southwest 339 00:13:33,980 --> 00:13:36,500 that, for any aeroplane they delivered 340 00:13:36,500 --> 00:13:39,820 that had a new Level D differences training, 341 00:13:39,820 --> 00:13:42,060 Boeing would pay the company $1 million 342 00:13:42,060 --> 00:13:44,380 per every aeroplane delivered. 343 00:13:44,380 --> 00:13:48,180 DAVID GELLES: If the Max required simulator training, 344 00:13:48,180 --> 00:13:48,420 it would rebate Southwest DAVID GELLES: If the Max required simulator training, 345 00:13:48,420 --> 00:13:50,700 it would rebate Southwest 346 00:13:50,700 --> 00:13:53,620 $1 million per plane. 347 00:13:53,620 --> 00:13:55,100 And there's that incentive. 348 00:13:55,100 --> 00:13:55,340 And there's that incentive. That's why it was so important to Boeing 349 00:13:55,340 --> 00:13:57,620 That's why it was so important to Boeing 350 00:13:57,620 --> 00:14:00,020 that pilot training be kept to a minimum. 351 00:14:00,020 --> 00:14:00,260 All of this comes out of that pilot training be kept to a minimum. 352 00:14:00,260 --> 00:14:01,740 All of this comes out of 353 00:14:01,740 --> 00:14:04,700 trying to give airlines 354 00:14:04,700 --> 00:14:07,340 the most fuel-efficient 355 00:14:07,340 --> 00:14:07,540 the most fuel-efficient version of a plane 356 00:14:07,540 --> 00:14:08,820 version of a plane 357 00:14:08,820 --> 00:14:12,900 that they can spend as little money training their pilots on. 358 00:14:14,660 --> 00:14:18,380 JACK NICAS: That meant Boeing had to do a number of things 359 00:14:18,380 --> 00:14:20,460 to make this plane fly like the old one, 360 00:14:20,460 --> 00:14:20,700 to make this plane and that was because 361 00:14:20,700 --> 00:14:22,620 and that was because 362 00:14:22,620 --> 00:14:22,860 the Max had much bigger engines on it to make them more fuel-efficient. and that was because 363 00:14:22,860 --> 00:14:27,540 the Max had much bigger engines on it to make them more fuel-efficient. 364 00:14:27,540 --> 00:14:27,780 the Max had much bigger engines on it to make them more fuel-efficient. But because the 737 365 00:14:27,780 --> 00:14:29,460 But because the 737 366 00:14:29,460 --> 00:14:33,420 was a 50-year-old aeroplane at this time, practically, 367 00:14:33,420 --> 00:14:38,820 when it came time for Boeing to put those engines on the wings, 368 00:14:38,820 --> 00:14:40,220 the engines were so darn big 369 00:14:40,220 --> 00:14:44,220 they had to mount them further forward on the wings. 370 00:14:44,220 --> 00:14:46,540 They were testing in this wind tunnel 371 00:14:46,540 --> 00:14:46,780 They were testing and they were discovering 372 00:14:46,780 --> 00:14:48,020 and they were discovering 373 00:14:48,020 --> 00:14:48,260 the plane was handling and they were discovering 374 00:14:48,260 --> 00:14:49,980 the plane was handling just a little bit differently, 375 00:14:49,980 --> 00:14:51,700 but they didn't even have a plane built yet, 376 00:14:51,700 --> 00:14:53,700 so, this wasn't, you know, happening in real flight. 377 00:14:53,700 --> 00:14:53,940 so, this wasn't, you know, This is something you have to fix. 378 00:14:53,940 --> 00:14:55,940 This is something you have to fix. 379 00:14:55,940 --> 00:14:58,460 And they leaned on 380 00:14:58,460 --> 00:15:02,980 a system that they had used once before in a military tanker. 381 00:15:02,980 --> 00:15:06,300 It was designed as a system on the plane 382 00:15:06,300 --> 00:15:11,300 to really just smooth out the way the plane handled. 383 00:15:11,300 --> 00:15:13,180 It was MCAS. 384 00:15:14,620 --> 00:15:18,980 It was designed for these extremely unusual manoeuvres, 385 00:15:18,980 --> 00:15:22,620 situations that hopefully the plane would never get in. 386 00:15:22,620 --> 00:15:26,820 And to prevent the nose from getting too high, 387 00:15:26,820 --> 00:15:30,500 the system would move the stabiliser on the back of the plane 388 00:15:30,500 --> 00:15:30,740 the system would move the stabiliser to push the nose back down. 389 00:15:30,740 --> 00:15:33,060 to push the nose back down. 390 00:15:36,060 --> 00:15:39,380 But inside Boeing there were early signs of trouble. 391 00:15:39,380 --> 00:15:43,300 DOUG PASTERNAK: One of the first documents we found 392 00:15:43,300 --> 00:15:43,540 DOUG PASTERNAK: was from November of 2012. 393 00:15:43,540 --> 00:15:46,460 was from November of 2012. 394 00:15:46,460 --> 00:15:46,700 A Boeing test pilot was from November of 2012. 395 00:15:46,700 --> 00:15:51,980 A Boeing test pilot was flying the Max 396 00:15:51,980 --> 00:15:52,220 in a flight simulator A Boeing test pilot was flying the Max 397 00:15:52,220 --> 00:15:54,100 in a flight simulator 398 00:15:54,100 --> 00:15:55,980 and trying to respond 399 00:15:55,980 --> 00:15:58,420 to an activation of MCAS, 400 00:15:58,420 --> 00:15:58,660 to an activation of MCAS, and that resulted in what he described as a 'catastrophic' event. 401 00:15:58,660 --> 00:16:03,700 and that resulted in what he described as a 'catastrophic' event. 402 00:16:05,620 --> 00:16:09,300 It showed that, if that had been in real life, 403 00:16:09,300 --> 00:16:11,020 he could have lost the aeroplane. 404 00:16:11,020 --> 00:16:13,780 They realised from that moment on 405 00:16:13,780 --> 00:16:18,780 even a Boeing test pilot may have trouble responding to MCAS. 406 00:16:19,820 --> 00:16:23,540 The company kept quiet about the simulator experience 407 00:16:23,540 --> 00:16:27,180 and appeared to have discounted the test results. 408 00:16:27,180 --> 00:16:27,420 and appeared to have discounted Still, in the following months, 409 00:16:27,420 --> 00:16:29,220 Still, in the following months, 410 00:16:29,220 --> 00:16:30,700 some Boeing employees 411 00:16:30,700 --> 00:16:30,940 suggested simply removing some Boeing employees 412 00:16:30,940 --> 00:16:33,940 suggested simply removing all references to MCAS 413 00:16:33,940 --> 00:16:34,180 suggested simply removing from training manuals. 414 00:16:34,180 --> 00:16:35,860 from training manuals. 415 00:16:36,860 --> 00:16:39,980 Boeing, from almost the very beginning, 416 00:16:39,980 --> 00:16:43,060 realised the significance of MCAS 417 00:16:43,060 --> 00:16:49,940 and the significance MCAS would have on pilot simulator training. 418 00:16:49,940 --> 00:16:54,180 (READS) "If we emphasise MCAS is a new function, 419 00:16:54,180 --> 00:16:58,180 "there may be a greater certification and training impact. 420 00:16:58,180 --> 00:17:04,420 "Recommended action - investigate deletion of MCAS nomenclature." 421 00:17:04,420 --> 00:17:04,660 "Recommended action - investigate What that meant 422 00:17:04,660 --> 00:17:05,900 What that meant 423 00:17:05,900 --> 00:17:10,420 was that, if they said MCAS was a new function, 424 00:17:10,420 --> 00:17:13,500 the FAA was gonna scrutinise it a lot more. 425 00:17:16,180 --> 00:17:19,500 Boeing told Congress it kept the FAA informed 426 00:17:19,500 --> 00:17:22,860 about MCAS's development and final configuration. 427 00:17:23,860 --> 00:17:27,300 But Boeing has a complex and close relationship 428 00:17:27,300 --> 00:17:27,540 But Boeing has a complex with the agency that oversees it. 429 00:17:27,540 --> 00:17:30,020 with the agency that oversees it. 430 00:17:30,020 --> 00:17:30,260 NATALIE KITROEFF: The aeroplanes with the agency that oversees it. 431 00:17:30,260 --> 00:17:32,900 NATALIE KITROEFF: The aeroplanes are part of the story, 432 00:17:32,900 --> 00:17:33,140 NATALIE KITROEFF: The aeroplanes but so are the regulators. 433 00:17:33,140 --> 00:17:34,980 but so are the regulators. 434 00:17:34,980 --> 00:17:37,380 The FAA regulated Boeing 435 00:17:37,380 --> 00:17:37,620 in part The FAA regulated Boeing 436 00:17:37,620 --> 00:17:43,260 in part with a handful of Boeing employees 437 00:17:43,260 --> 00:17:43,500 in part whose paycheques came from Boeing 438 00:17:43,500 --> 00:17:46,220 whose paycheques came from Boeing 439 00:17:46,220 --> 00:17:49,060 but whose jobs 440 00:17:49,060 --> 00:17:51,580 were to represent 441 00:17:51,580 --> 00:17:51,820 the interests were to represent 442 00:17:51,820 --> 00:17:54,340 the interests of the FAA. 443 00:17:55,300 --> 00:17:59,140 It's a decades-old arrangement known as 'delegation' 444 00:17:59,140 --> 00:17:59,380 It's a decades-old arrangement that allows federal agencies 445 00:17:59,380 --> 00:18:01,100 that allows federal agencies 446 00:18:01,100 --> 00:18:01,340 to give oversight powers that allows federal agencies 447 00:18:01,340 --> 00:18:04,940 to give oversight powers to the companies they regulate. 448 00:18:04,940 --> 00:18:08,740 In the beginning there was a really good reason for this. 449 00:18:08,740 --> 00:18:08,980 In the beginning there was The FAA was certifying things 450 00:18:08,980 --> 00:18:12,020 The FAA was certifying things 451 00:18:12,020 --> 00:18:14,020 that made no sense 452 00:18:14,020 --> 00:18:14,260 to have them certify every single that made no sense 453 00:18:14,260 --> 00:18:19,300 to have them certify every single exit sign or bathroom sign or paint. 454 00:18:19,300 --> 00:18:24,060 The issue that many of the FAA employees that we talked to had 455 00:18:24,060 --> 00:18:28,420 was that it went way beyond bathroom signs. 456 00:18:29,380 --> 00:18:32,580 Over time, Congress passed laws 457 00:18:32,580 --> 00:18:36,860 that pushed the FAA to hand over the responsibility 458 00:18:36,860 --> 00:18:37,100 that pushed the FAA for more and more tasks 459 00:18:37,100 --> 00:18:39,180 for more and more tasks 460 00:18:39,180 --> 00:18:40,940 to the company, to Boeing. 461 00:18:40,940 --> 00:18:44,220 In the design of the 737 Max, 462 00:18:44,220 --> 00:18:46,900 many things would be delegated to Boeing. 463 00:18:46,900 --> 00:18:47,140 many things That included MCAS. 464 00:18:47,140 --> 00:18:49,420 That included MCAS. 465 00:18:51,820 --> 00:18:56,620 Under the impression that this was a relatively benign system, 466 00:18:56,620 --> 00:18:56,860 Under the impression that this the FAA agreed to delegate it, 467 00:18:56,860 --> 00:18:58,740 the FAA agreed to delegate it, 468 00:18:58,740 --> 00:19:02,300 as is the custom with the FAA and Boeing. 469 00:19:02,300 --> 00:19:03,860 And that's what happened in this case. 470 00:19:03,860 --> 00:19:04,100 And that's what happened It handed it over. 471 00:19:04,100 --> 00:19:05,940 It handed it over. 472 00:19:09,940 --> 00:19:11,420 In a statement 473 00:19:11,420 --> 00:19:14,180 the FAA blamed ineffective coordination 474 00:19:14,180 --> 00:19:17,780 and said it had not focused on MCAS when it certified the Max 475 00:19:17,780 --> 00:19:22,340 because Boeing had not identified MCAS as significant. 476 00:19:22,340 --> 00:19:23,780 Under orders from Congress, 477 00:19:23,780 --> 00:19:27,500 the FAA has since made changes to the delegation process. 478 00:19:32,180 --> 00:19:35,860 After years of going through design and development, 479 00:19:35,860 --> 00:19:39,860 a 737 Max prototype was rolled out of Boeing's Renton Factory 480 00:19:39,860 --> 00:19:40,100 a 737 Max prototype was rolled out for its maiden flight. 481 00:19:40,100 --> 00:19:41,540 for its maiden flight. 482 00:19:41,540 --> 00:19:43,140 (CHEERING) 483 00:19:43,140 --> 00:19:45,540 Ed Wilson is in the cockpit, 484 00:19:45,540 --> 00:19:47,780 he's the new chief pilot, and he takes off. 485 00:19:47,780 --> 00:19:49,100 REPORTER: And let's just take a listen 486 00:19:49,100 --> 00:19:51,620 as this aeroplane gets ready for its very first take-off. 487 00:19:51,620 --> 00:19:54,700 (ENGINES WHINE) 488 00:19:57,580 --> 00:19:59,940 A short time after this first maiden flight, 489 00:19:59,940 --> 00:20:04,100 Ed Wilson, he and his co-pilot start to realise that 490 00:20:04,100 --> 00:20:04,380 the 737 Max is not handling as smoothly as it should Ed Wilson, he and his co-pilot start to realise that 491 00:20:04,380 --> 00:20:07,900 the 737 Max is not handling as smoothly as it should 492 00:20:07,900 --> 00:20:08,140 the 737 Max is not handling in certain low-speed situations. 493 00:20:08,140 --> 00:20:10,060 in certain low-speed situations. 494 00:20:10,060 --> 00:20:10,260 in certain low-speed situations. It's shortly after take-off, 495 00:20:10,260 --> 00:20:11,380 It's shortly after take-off, 496 00:20:11,380 --> 00:20:11,620 you know, it's still It's shortly after take-off, 497 00:20:11,620 --> 00:20:13,020 you know, it's still kind of climbing to ascend, 498 00:20:13,020 --> 00:20:13,260 you know, it's still it's not going full speed. 499 00:20:13,260 --> 00:20:14,660 it's not going full speed. 500 00:20:15,620 --> 00:20:19,180 Boeing engineers had an idea for how to deal with this. 501 00:20:19,180 --> 00:20:21,140 They know about MCAS 502 00:20:21,140 --> 00:20:25,900 and they know that MCAS was actually used for a similar situation 503 00:20:25,900 --> 00:20:26,140 and they know that MCAS was actually in these high-speed manoeuvres. 504 00:20:26,140 --> 00:20:28,220 in these high-speed manoeuvres. 505 00:20:28,220 --> 00:20:30,020 And, so, theoretically, 506 00:20:30,020 --> 00:20:34,140 MCAS could also be used in these other situations 507 00:20:34,140 --> 00:20:34,380 MCAS could also be used to also smooth out the handling. 508 00:20:34,380 --> 00:20:35,660 to also smooth out the handling. 509 00:20:35,660 --> 00:20:38,420 Crucially, it's already been created, 510 00:20:38,420 --> 00:20:40,180 it's already been approved, 511 00:20:40,180 --> 00:20:43,700 and it's something that we could just apply, you know, 512 00:20:43,700 --> 00:20:43,940 and it's something to a different phase of flight. 513 00:20:43,940 --> 00:20:45,460 to a different phase of flight. 514 00:20:45,460 --> 00:20:49,260 It's actually a pretty easy fix. 515 00:20:50,380 --> 00:20:54,820 This ends up being an extremely fateful decision. 516 00:20:54,820 --> 00:20:58,340 They enable the stabiliser to move much more, 517 00:20:58,340 --> 00:20:58,580 They enable the stabiliser actually four times as much. 518 00:20:58,580 --> 00:21:00,220 actually four times as much. 519 00:21:00,220 --> 00:21:00,460 Now the system's designed actually four times as much. 520 00:21:00,460 --> 00:21:02,980 Now the system's designed for low-speed situations, 521 00:21:02,980 --> 00:21:03,220 Now the system's designed like just after take-off, 522 00:21:03,220 --> 00:21:04,940 like just after take-off, 523 00:21:04,940 --> 00:21:06,700 and after take-off 524 00:21:06,700 --> 00:21:06,940 is when the plane is still only and after take-off 525 00:21:06,940 --> 00:21:10,700 is when the plane is still only a few thousand feet over the ground. 526 00:21:10,700 --> 00:21:13,820 That means you have much less room for error. 527 00:21:13,820 --> 00:21:18,380 It's happening in automated fashion and a repeated fashion. 528 00:21:18,380 --> 00:21:21,500 This fundamentally changes MCAS. 529 00:21:22,460 --> 00:21:25,100 It makes it much more aggressive, 530 00:21:25,100 --> 00:21:26,820 much more risky. 531 00:21:26,820 --> 00:21:28,900 It's a far more dangerous system. 532 00:21:31,660 --> 00:21:34,380 Boeing was doubling down on the system, 533 00:21:34,380 --> 00:21:34,620 Boeing was doubling down expanding it 534 00:21:34,620 --> 00:21:35,860 expanding it 535 00:21:35,860 --> 00:21:40,100 despite the earlier catastrophic result in a simulator test. 536 00:21:41,060 --> 00:21:45,980 The Times' reporting on MCAS focused on a former Boeing pilot. 537 00:21:45,980 --> 00:21:50,980 NATALIE KITROEFF: I started to hear about a pilot at Boeing 538 00:21:50,980 --> 00:21:52,620 whose name was Mark Forkner... 539 00:21:53,580 --> 00:21:57,340 ..the chief technical pilot for the 737. 540 00:21:57,340 --> 00:21:57,580 ..the chief technical pilot He was the person 541 00:21:57,580 --> 00:21:59,100 He was the person 542 00:21:59,100 --> 00:22:03,460 who personally emailed the FAA 543 00:22:03,460 --> 00:22:03,700 asking for MCAS to be removed from the pilot manual. who personally emailed the FAA 544 00:22:03,700 --> 00:22:07,660 asking for MCAS to be removed from the pilot manual. 545 00:22:10,060 --> 00:22:11,740 That was an important piece of this 546 00:22:11,740 --> 00:22:11,980 because we understood That was an important piece of this 547 00:22:11,980 --> 00:22:16,460 because we understood that the FAA really didn't know 548 00:22:16,460 --> 00:22:16,700 because we understood that MCAS became more powerful. 549 00:22:16,700 --> 00:22:18,460 that MCAS became more powerful. 550 00:22:20,300 --> 00:22:21,780 He was speaking 551 00:22:21,780 --> 00:22:22,020 absolutely on behalf of the company. He was speaking 552 00:22:22,020 --> 00:22:23,860 absolutely on behalf of the company. 553 00:22:23,860 --> 00:22:26,180 This was not some low-level employee. 554 00:22:26,180 --> 00:22:27,660 And he was asking for something 555 00:22:27,660 --> 00:22:27,900 And he was asking for something that was really quite substantial - 556 00:22:27,900 --> 00:22:29,780 that was really quite substantial - 557 00:22:29,780 --> 00:22:31,700 that a new piece of software 558 00:22:31,700 --> 00:22:35,580 that made the plane behave in ways that it previously hadn't 559 00:22:35,580 --> 00:22:35,820 that made the plane behave in ways be concealed from the pilots. 560 00:22:35,820 --> 00:22:37,140 be concealed from the pilots. 561 00:22:37,140 --> 00:22:37,380 This is where the commercial be concealed from the pilots. 562 00:22:37,380 --> 00:22:43,020 This is where the commercial pressures from the executive level 563 00:22:43,020 --> 00:22:47,060 come right down to the development of the aeroplane. 564 00:22:48,340 --> 00:22:51,980 DOUG PASTERNAK: Mark Forkner certainly was not a lone actor 565 00:22:51,980 --> 00:22:52,220 DOUG PASTERNAK: Mark Forkner in what he did. 566 00:22:52,220 --> 00:22:53,540 in what he did. 567 00:22:53,540 --> 00:22:53,780 He was following through on a policy by Boeing in what he did. 568 00:22:53,780 --> 00:22:56,860 He was following through on a policy by Boeing 569 00:22:56,860 --> 00:22:57,100 He was following through to ensure that the program 570 00:22:57,100 --> 00:23:00,100 to ensure that the program 571 00:23:00,100 --> 00:23:00,340 to ensure that the program did not have to put pilots in a flight simulator. 572 00:23:00,340 --> 00:23:03,900 did not have to put pilots in a flight simulator. 573 00:23:03,900 --> 00:23:09,100 It got to the point where Mark Forkner got an award 574 00:23:09,100 --> 00:23:14,100 for keeping training on the 737 Max to a minimum. 575 00:23:15,060 --> 00:23:17,060 Nearly eight months after requesting 576 00:23:17,060 --> 00:23:20,340 that MCAS be removed from pilot training manuals, 577 00:23:20,340 --> 00:23:24,980 Forkner texted a colleague with a shocking realisation. 578 00:23:24,980 --> 00:23:26,860 NATALIE KITROEFF: This appears to be the moment 579 00:23:26,860 --> 00:23:30,940 where Mark Forkner learns that MCAS has been expanded. 580 00:23:30,940 --> 00:23:31,180 where Mark Forkner learns He writes in that message, 581 00:23:31,180 --> 00:23:32,500 He writes in that message, 582 00:23:32,500 --> 00:23:36,100 "I basically lied to the regulators unknowingly." 583 00:23:36,100 --> 00:23:39,300 But he never went back and corrected the record. 584 00:23:39,300 --> 00:23:41,820 He never went back and fixed the error. 585 00:23:44,820 --> 00:23:47,180 Mark Forkner wouldn't speak to us. 586 00:23:47,180 --> 00:23:47,420 He was indicted for lying Mark Forkner wouldn't speak to us. 587 00:23:47,420 --> 00:23:51,740 He was indicted for lying to FAA investigators about MCAS, 588 00:23:51,740 --> 00:23:55,620 but later found not guilty of all charges in federal court. 589 00:23:55,620 --> 00:23:55,860 but later found not guilty His lawyer told The Times reporters 590 00:23:55,860 --> 00:23:57,860 His lawyer told The Times reporters 591 00:23:57,860 --> 00:23:58,100 that his communications with the FAA His lawyer told The Times reporters 592 00:23:58,100 --> 00:24:01,020 that his communications with the FAA were honest 593 00:24:01,020 --> 00:24:01,260 that his communications with the FAA and that he would never jeopardise 594 00:24:01,260 --> 00:24:02,580 and that he would never jeopardise 595 00:24:02,580 --> 00:24:05,900 the safety of other pilots or their passengers. 596 00:24:08,660 --> 00:24:12,020 When Boeing engineers expanded the MCAS system 597 00:24:12,020 --> 00:24:15,860 they included a feature that would make it particularly dangerous. 598 00:24:15,860 --> 00:24:19,140 DAVID GELLES: Planes have millions of parts in them, 599 00:24:19,140 --> 00:24:22,180 and there's one little one on the 737 600 00:24:22,180 --> 00:24:22,420 and there's one little one that sticks out of the fuselage. 601 00:24:22,420 --> 00:24:24,700 that sticks out of the fuselage. 602 00:24:24,700 --> 00:24:28,060 REPORTER: See that little black circle there? That is called... 603 00:24:28,060 --> 00:24:28,300 REPORTER: See that little black The angle-of-attack sensor. 604 00:24:28,300 --> 00:24:29,900 The angle-of-attack sensor. 605 00:24:30,860 --> 00:24:32,620 On the 737 Max 606 00:24:32,620 --> 00:24:36,460 it had the power to trigger MCAS. 607 00:24:36,460 --> 00:24:37,740 It's the AOA sensor 608 00:24:37,740 --> 00:24:41,580 that is one of the crucial parameters 609 00:24:41,580 --> 00:24:41,820 that is one of to the computer 610 00:24:41,820 --> 00:24:43,180 to the computer 611 00:24:43,180 --> 00:24:47,700 to tell the plane that it's in a perilous condition. 612 00:24:48,580 --> 00:24:51,060 The angle-of-attack sensor would activate MCAS 613 00:24:51,060 --> 00:24:54,460 by telling the system that the plane's nose was too high, 614 00:24:54,460 --> 00:24:56,980 and then MCAS would try to push the nose down. 615 00:24:56,980 --> 00:25:00,700 But if this sensor is broken, for whatever reason, 616 00:25:00,700 --> 00:25:00,940 But if this sensor is broken, the MCAS never realises, 617 00:25:00,940 --> 00:25:05,420 the MCAS never realises, 618 00:25:05,420 --> 00:25:08,620 and, so, it keeps pushing the nose of the plane down 619 00:25:08,620 --> 00:25:08,860 and, so, it keeps over and over again. 620 00:25:08,860 --> 00:25:11,620 over and over again. 621 00:25:13,220 --> 00:25:16,020 Congressional investigators would later find documents 622 00:25:16,020 --> 00:25:20,180 showing that Boeing engineers had raised this very concern. 623 00:25:20,180 --> 00:25:21,780 DOUG PASTERNAK: An engineer asked, 624 00:25:21,780 --> 00:25:24,500 "What if we have a faulty AOA sensor?" 625 00:25:24,500 --> 00:25:27,900 Because AOA sensors are known to be faulty. 626 00:25:27,900 --> 00:25:30,420 You know, what happens to the aeroplane? 627 00:25:31,380 --> 00:25:33,940 So, you have those concerns raised, 628 00:25:33,940 --> 00:25:37,580 and the response again from Boeing engineers 629 00:25:37,580 --> 00:25:41,100 was to essentially dismiss those. 630 00:25:41,100 --> 00:25:45,860 Three! Two! One! 631 00:25:45,860 --> 00:25:50,820 Boeing began delivering the new 737 Max in mid-2017. 632 00:25:50,820 --> 00:25:57,020 At the outset, 737 Max was arguably one of Boeing's biggest successes. 633 00:25:57,020 --> 00:25:59,260 It had become its best-selling jet ever. 634 00:25:59,260 --> 00:26:04,100 Advanced sales were estimated at $370 billion. 635 00:26:04,100 --> 00:26:04,340 Advanced sales American had orders for 100, 636 00:26:04,340 --> 00:26:07,220 American had orders for 100, 637 00:26:07,220 --> 00:26:09,460 Southwest Airlines for 200. 638 00:26:09,460 --> 00:26:11,340 Boeing had focused especially hard 639 00:26:11,340 --> 00:26:14,460 on selling to developing markets in Asia, 640 00:26:14,460 --> 00:26:14,700 on selling to developing markets where Lion Air's parent company 641 00:26:14,700 --> 00:26:16,380 where Lion Air's parent company 642 00:26:16,380 --> 00:26:16,620 became the first customer where Lion Air's parent company 643 00:26:16,620 --> 00:26:20,340 became the first customer to fly the 737 Max, 644 00:26:20,340 --> 00:26:24,900 signing an agreement worth more than $20 billion. 645 00:26:24,900 --> 00:26:28,740 NEWSREADER: The new 737 Max 8 jetliner crashed today. 646 00:26:28,740 --> 00:26:31,260 NEWSREADER: Investigators say that flight had similar problems 647 00:26:31,260 --> 00:26:32,620 to the Lion Air crash. 648 00:26:32,620 --> 00:26:35,660 Once again, the angle-of-attack sensor is malfunctioning. 649 00:26:35,660 --> 00:26:38,940 But there is this question now about systems within the aircraft. 650 00:26:38,940 --> 00:26:43,020 If MCAS hadn't been on those planes, those planes wouldn't have crashed. 651 00:26:43,020 --> 00:26:43,780 It's that simple. 652 00:26:43,780 --> 00:26:47,380 Boeing CEO Dennis Muilenburg latched on to findings 653 00:26:47,380 --> 00:26:50,180 that inexperience and lack of training 654 00:26:50,180 --> 00:26:53,580 were part of a chain of events that led to the crashes. 655 00:26:53,580 --> 00:26:53,820 were part of a chain of events It was a controversial position. 656 00:26:53,820 --> 00:26:55,780 It was a controversial position. 657 00:26:55,780 --> 00:26:58,940 Understand that these aeroplanes are flown in the hands of pilots 658 00:26:58,940 --> 00:27:01,460 and, in some cases, our system safety analysis 659 00:27:01,460 --> 00:27:03,700 includes not only the engineering design 660 00:27:03,700 --> 00:27:06,540 but also the actions that pilots would take 661 00:27:06,540 --> 00:27:06,780 but also the actions as part of a failure scenario... 662 00:27:06,780 --> 00:27:09,300 as part of a failure scenario... 663 00:27:09,300 --> 00:27:12,420 JAMES GLANZ: Boeing's contention from the beginning 664 00:27:12,420 --> 00:27:18,100 was that, even though the pilots did not know that MCAS existed, 665 00:27:18,100 --> 00:27:18,340 was that, even though the pilots that they did not NEED to know that. 666 00:27:18,340 --> 00:27:21,140 that they did not NEED to know that. 667 00:27:21,140 --> 00:27:25,300 And in some cases those procedures were not completely followed... 668 00:27:25,300 --> 00:27:29,740 Boeing believed that the pilots should have been able to realise 669 00:27:29,740 --> 00:27:34,180 that it was very similar to a runaway stabiliser situation. 670 00:27:34,180 --> 00:27:34,420 that it was very similar 'Runaway stabiliser' 671 00:27:34,420 --> 00:27:36,060 'Runaway stabiliser' 672 00:27:36,060 --> 00:27:40,820 is an aviation term for a malfunctioning stabiliser. 673 00:27:40,820 --> 00:27:42,340 After the Lion Air crash, 674 00:27:42,340 --> 00:27:44,420 Boeing had issued a directive to pilots 675 00:27:44,420 --> 00:27:44,660 Boeing had issued to be aware of this possibility 676 00:27:44,660 --> 00:27:46,900 to be aware of this possibility 677 00:27:46,900 --> 00:27:49,500 and told them what to do if it happened. 678 00:27:49,500 --> 00:27:51,740 NATALIE KITROEFF: When that part of the tail 679 00:27:51,740 --> 00:27:53,900 was not acting the way that it should be, 680 00:27:53,900 --> 00:27:54,140 was not acting you take manual control of it. 681 00:27:54,140 --> 00:27:55,820 you take manual control of it. 682 00:27:55,820 --> 00:27:58,300 REPORTER: The pilots could have stopped their roller-coaster ride 683 00:27:58,300 --> 00:28:00,580 by turning these two switches off. 684 00:28:00,580 --> 00:28:02,980 To shut off power to the stabiliser, 685 00:28:02,980 --> 00:28:04,300 you stop it from moving on its own, 686 00:28:04,300 --> 00:28:08,620 and then you start cranking a wheel in the cockpit 687 00:28:08,620 --> 00:28:11,580 that literally will manually move the stabiliser 688 00:28:11,580 --> 00:28:11,820 that literally will manually back to where you want it to move. 689 00:28:11,820 --> 00:28:14,580 back to where you want it to move. 690 00:28:14,580 --> 00:28:19,700 The issue was were there things happening inside the cockpit 691 00:28:19,700 --> 00:28:22,100 that might have made that harder to do? 692 00:28:23,420 --> 00:28:25,700 That's what we were asking. 693 00:28:28,420 --> 00:28:31,740 DAVID GELLES: When we finally got the preliminary black-box data 694 00:28:31,740 --> 00:28:31,980 DAVID GELLES: When we finally from the Ethiopian crash, 695 00:28:31,980 --> 00:28:33,500 from the Ethiopian crash, 696 00:28:33,500 --> 00:28:35,620 we called up Dennis Tajer, 697 00:28:35,620 --> 00:28:38,620 an American Airlines 737 pilot, 698 00:28:38,620 --> 00:28:40,380 and sent him the data 699 00:28:40,380 --> 00:28:42,860 and we read through it together. 700 00:28:42,860 --> 00:28:46,260 My mission was to provide them, 701 00:28:46,260 --> 00:28:46,500 "I'm in the cockpit. My mission was to provide them, 702 00:28:46,500 --> 00:28:48,780 "I'm in the cockpit. I see what's happening now." 703 00:28:48,780 --> 00:28:49,020 "I'm in the cockpit. I see what's happening now." So, we walk through each line... 704 00:28:49,020 --> 00:28:51,300 So, we walk through each line... 705 00:28:52,860 --> 00:28:55,060 ..and I had no idea what was in it. 706 00:28:55,060 --> 00:28:56,980 I knew that the crew had 707 00:28:56,980 --> 00:29:01,780 an experienced captain and a lesser-experienced first officer. 708 00:29:03,220 --> 00:29:08,660 We go second by second through the few minutes of this flight. 709 00:29:08,660 --> 00:29:12,500 Going through the steps that the pilots had taken and saying, 710 00:29:12,500 --> 00:29:15,380 "Yep, I would have done that. Yep, I would have done that." 711 00:29:16,660 --> 00:29:18,700 And as soon as they lift off the ground, 712 00:29:18,700 --> 00:29:20,620 all these different alerts started popping up. 713 00:29:20,620 --> 00:29:23,740 The airspeed was unreliable, the altitude was showing unreliable. 714 00:29:23,740 --> 00:29:23,980 The airspeed was unreliable, There were alerts related to that. 715 00:29:23,980 --> 00:29:26,220 There were alerts related to that. 716 00:29:26,220 --> 00:29:29,780 But they bring the gear up and they continue to climb out. 717 00:29:30,820 --> 00:29:32,700 Two minutes into the flight, 718 00:29:32,700 --> 00:29:32,940 based on faulty data Two minutes into the flight, 719 00:29:32,940 --> 00:29:35,900 based on faulty data from the AOA sensor, 720 00:29:35,900 --> 00:29:39,220 MCAS kicked in and began pushing the nose down. 721 00:29:39,220 --> 00:29:39,460 MCAS kicked in ALERT: Don't sink. 722 00:29:39,460 --> 00:29:40,300 ALERT: Don't sink. 723 00:29:40,300 --> 00:29:41,980 And I have... 724 00:29:41,980 --> 00:29:43,100 ALERT: Pull up. 725 00:29:44,900 --> 00:29:46,780 ..very clear memory... 726 00:29:49,140 --> 00:29:52,020 ..of noting a time mark 727 00:29:52,020 --> 00:29:54,420 where the first officer 728 00:29:54,420 --> 00:29:57,820 is quoted as saying, "Stab trim cutout switches," 729 00:29:57,820 --> 00:30:00,260 which takes the weapon away from MCAS, 730 00:30:00,260 --> 00:30:02,500 which is what Boeing told us to do. 731 00:30:03,540 --> 00:30:05,380 And I have to confess... 732 00:30:08,300 --> 00:30:09,660 I probably swore. 733 00:30:09,660 --> 00:30:11,700 I said, "The kid got it right. 734 00:30:11,700 --> 00:30:13,820 "That kid got it right." 735 00:30:15,020 --> 00:30:20,220 What had happened was the pilots DID do what they were supposed to do. 736 00:30:20,220 --> 00:30:20,460 What had happened was the pilots DID They had cut the electricity off. 737 00:30:20,460 --> 00:30:22,740 They had cut the electricity off. 738 00:30:22,740 --> 00:30:25,900 ALERT: Don't sink. Pull up. They hit these switches 739 00:30:25,900 --> 00:30:28,140 and they tried to take manual control. 740 00:30:28,140 --> 00:30:31,820 The first officer is reaching to this large wheel on his left... 741 00:30:31,820 --> 00:30:33,540 ALERT: Pull up. ..and that's the manual trim wheel, 742 00:30:33,540 --> 00:30:35,900 and trying to turn it. ALERT: Pull up. 743 00:30:35,900 --> 00:30:40,380 It's like lifting up a 10-tonne bucket of cement out of a deep well. 744 00:30:40,380 --> 00:30:42,580 ALERT: Don't sink. The problem was at that point 745 00:30:42,580 --> 00:30:45,020 the plane was going so fast... ALERT: Pull up. 746 00:30:45,020 --> 00:30:47,700 ..that, even after they took manual control, 747 00:30:47,700 --> 00:30:47,940 they could not physically ..that, even after they took manual control, 748 00:30:47,940 --> 00:30:51,060 they could not physically 749 00:30:51,060 --> 00:30:53,700 get the plane to right itself. 750 00:30:53,700 --> 00:30:53,940 get the plane to right itself. They shouldn't have been going that fast. 751 00:30:53,940 --> 00:30:56,060 They shouldn't have been going that fast. 752 00:30:56,060 --> 00:30:57,380 ALERT: Too low. Terrain. 753 00:30:57,380 --> 00:31:00,220 And they're continuing to accelerate towards the ground. 754 00:31:00,220 --> 00:31:00,460 And they're continuing to accelerate ALERT: Pull up. 755 00:31:00,460 --> 00:31:01,740 ALERT: Pull up. 756 00:31:01,740 --> 00:31:04,060 The ground is approaching them. 757 00:31:04,060 --> 00:31:07,020 Then, with no apparent recourse, 758 00:31:07,020 --> 00:31:09,580 the pilots reached for the stabiliser switches. 759 00:31:09,580 --> 00:31:09,820 the pilots reached I'm yelling into the cockpit, 760 00:31:09,820 --> 00:31:12,420 I'm yelling into the cockpit, 761 00:31:12,420 --> 00:31:13,860 "Don't do that!" 762 00:31:13,860 --> 00:31:15,460 But I don't know what they're facing. 763 00:31:15,460 --> 00:31:15,700 But I don't know ALERT: Caution - terrain. 764 00:31:15,700 --> 00:31:16,980 ALERT: Caution - terrain. 765 00:31:16,980 --> 00:31:18,540 The MCAS was reactivated. 766 00:31:18,540 --> 00:31:21,380 ALERT: Pull up. MCAS says, "Hey, I'm back on. 767 00:31:21,380 --> 00:31:21,620 ALERT: Pull up. "Here we go. Zzz-zzz." 768 00:31:21,620 --> 00:31:23,620 "Here we go. Zzz-zzz." 769 00:31:23,620 --> 00:31:27,940 And now the aeroplane is in near-full nose-down trim, 770 00:31:27,940 --> 00:31:30,300 and you can pull back forever 771 00:31:30,300 --> 00:31:33,100 and there's not enough metal in the back of the aeroplane 772 00:31:33,100 --> 00:31:35,860 to make that aeroplane come up to a nose up. 773 00:31:35,860 --> 00:31:36,100 to make that aeroplane ALERT: Terrain. Terrain. 774 00:31:36,100 --> 00:31:37,180 ALERT: Terrain. Terrain. 775 00:31:37,180 --> 00:31:41,140 Pull up. Pull up. Pull up. 776 00:31:42,220 --> 00:31:45,100 (BIRDS TWITTER) 777 00:31:46,460 --> 00:31:49,460 NADIA MILLERON: She died when she was 24. 778 00:31:49,460 --> 00:31:54,780 It's unbearable that she's not with us. 779 00:31:54,780 --> 00:31:55,020 It's unbearable And the only thing I can do is... 780 00:31:55,020 --> 00:31:57,340 And the only thing I can do is... 781 00:31:59,500 --> 00:32:01,740 ..try to prevent this for other people. 782 00:32:04,140 --> 00:32:07,980 About four months after the Ethiopian Airlines crash, 783 00:32:07,980 --> 00:32:09,580 the family of Samya Stumo 784 00:32:09,580 --> 00:32:14,100 was about to receive news they would find bewildering. 785 00:32:14,100 --> 00:32:17,860 We were eating dinner and I hadn't looked at my phone for a long time 786 00:32:17,860 --> 00:32:18,100 We were eating dinner and I hadn't and it was blowing up. 787 00:32:18,100 --> 00:32:20,100 and it was blowing up. 788 00:32:20,100 --> 00:32:20,340 The Federal Aviation Administration, now in the hot seat in Washington and it was blowing up. 789 00:32:20,340 --> 00:32:23,980 The Federal Aviation Administration, now in the hot seat in Washington 790 00:32:23,980 --> 00:32:27,740 over its certification of Boeing 737 Max planes. 791 00:32:27,740 --> 00:32:28,020 over its certification of Boeing 737 Max planes. SUSAN COLLINS: We are joined today by Ali Bahrami, 792 00:32:28,020 --> 00:32:31,540 SUSAN COLLINS: We are joined today by Ali Bahrami, 793 00:32:31,540 --> 00:32:35,820 the Associate Administrator for Aviation Safety. 794 00:32:35,820 --> 00:32:36,100 We continue to evaluate Boeing's software modification to the MCAS. the Associate Administrator for Aviation Safety. 795 00:32:36,100 --> 00:32:40,460 We continue to evaluate Boeing's software modification to the MCAS. 796 00:32:40,460 --> 00:32:41,500 In addition... 797 00:32:41,500 --> 00:32:41,700 In addition... FAA official Ali Bahrami 798 00:32:41,700 --> 00:32:43,660 FAA official Ali Bahrami 799 00:32:43,660 --> 00:32:45,340 had been called before Congress, 800 00:32:45,340 --> 00:32:48,020 where he was questioned about revelations 801 00:32:48,020 --> 00:32:52,980 the FAA had known there was a risk of another Max crashing after Lion Air. 802 00:32:52,980 --> 00:32:53,220 the FAA had known there was a risk of If the agency's own analysis 803 00:32:53,220 --> 00:32:56,500 If the agency's own analysis 804 00:32:56,500 --> 00:32:56,740 found MCAS If the agency's own analysis 805 00:32:56,740 --> 00:33:01,180 found MCAS to be an unacceptable risk, 806 00:33:01,180 --> 00:33:08,980 why did the FAA not take immediate action to address those risks? 807 00:33:08,980 --> 00:33:11,140 The families hadn't known that before. 808 00:33:11,140 --> 00:33:16,980 They didn't know that the safety agency gambled with passenger lives. 809 00:33:16,980 --> 00:33:22,140 We knew that eventual solution would be to have the modification, 810 00:33:22,140 --> 00:33:22,380 We knew that eventual solution and, based on our risk assessment, 811 00:33:22,380 --> 00:33:24,180 and, based on our risk assessment, 812 00:33:24,180 --> 00:33:29,820 we felt that we had sufficient time to be able to do the modification, 813 00:33:29,820 --> 00:33:30,060 we felt that we had sufficient time you know, and get the final fix. 814 00:33:30,060 --> 00:33:32,540 you know, and get the final fix. 815 00:33:33,540 --> 00:33:35,540 After the Lion Air crash, 816 00:33:35,540 --> 00:33:38,020 the FAA had conducted an analysis 817 00:33:38,020 --> 00:33:38,260 of the likelihood the FAA had conducted an analysis 818 00:33:38,260 --> 00:33:41,980 of the likelihood of another 737 Max crashing. 819 00:33:42,940 --> 00:33:45,980 The worst-case scenario was grim. 820 00:33:45,980 --> 00:33:47,740 DOUG PASTERNAK: They looked at 821 00:33:47,740 --> 00:33:47,940 the probability that there could be DOUG PASTERNAK: They looked at 822 00:33:47,940 --> 00:33:50,340 the probability that there could be 823 00:33:50,340 --> 00:33:54,780 another crash of a 737 Max 824 00:33:54,780 --> 00:33:58,260 if the FAA didn't do anything to MCAS 825 00:33:58,260 --> 00:34:00,500 and just let the plane keep flying. 826 00:34:00,500 --> 00:34:02,740 And what that assessment showed 827 00:34:02,740 --> 00:34:05,140 was that FAA predicted 828 00:34:05,140 --> 00:34:12,980 there could potentially be 15 more fatal accidents of 737 Max aircraft 829 00:34:12,980 --> 00:34:16,660 over the lifespan of the fleet. 830 00:34:16,660 --> 00:34:19,700 About one crash every other year. 831 00:34:20,740 --> 00:34:24,460 But, in explaining its decision not to ground the plane, 832 00:34:24,460 --> 00:34:28,340 the FAA said in its statement that the actual risk at the time, 833 00:34:28,340 --> 00:34:30,940 considering the number of planes in the air, 834 00:34:30,940 --> 00:34:34,740 was as close to zero as their calculations allowed. 835 00:34:37,260 --> 00:34:40,980 Boeing CEO Dennis Muilenburg appeared before Congress. 836 00:34:40,980 --> 00:34:43,540 NEWSREADER: Boeing's CEO is expected to acknowledge 837 00:34:43,540 --> 00:34:45,580 that his company made mistakes in the... 838 00:34:45,580 --> 00:34:48,500 And here's the first time this guy's in the hot seat. 839 00:34:48,500 --> 00:34:48,740 And here's the first time We appreciate the opportunity... 840 00:34:48,740 --> 00:34:50,220 We appreciate the opportunity... 841 00:34:50,220 --> 00:34:54,540 By then he'd become the face of the 737 Max crisis. 842 00:34:54,540 --> 00:34:56,660 PETER DEFAZIO: I've been on this committee a long time. 843 00:34:56,660 --> 00:34:59,620 We have never undertaken an investigation of this magnitude. 844 00:34:59,620 --> 00:35:03,780 We intentionally put the families close to the witness. 845 00:35:03,780 --> 00:35:04,020 We intentionally put the families They're the victims here, 846 00:35:04,020 --> 00:35:06,060 They're the victims here, 847 00:35:06,060 --> 00:35:06,300 and it should be like, you know, a trial in court They're the victims here, 848 00:35:06,300 --> 00:35:08,580 and it should be like, you know, a trial in court 849 00:35:08,580 --> 00:35:12,860 where you get to face the person who, you know... 850 00:35:12,860 --> 00:35:15,260 ..who committed a violent act against you. 851 00:35:18,020 --> 00:35:19,660 The committee confronted Muilenburg 852 00:35:19,660 --> 00:35:22,340 with an array of internal Boeing documents. 853 00:35:22,340 --> 00:35:24,180 SHARICE DAVIDS: Boeing's marketing representatives 854 00:35:24,180 --> 00:35:24,420 SHARICE DAVIDS: emphasised to potential customers 855 00:35:24,420 --> 00:35:25,660 emphasised to potential customers 856 00:35:25,660 --> 00:35:25,900 that FAA had reduced the length emphasised to potential customers 857 00:35:25,900 --> 00:35:28,260 that FAA had reduced the length of pilot training... 858 00:35:28,260 --> 00:35:28,540 PETER DEFAZIO: A slow reaction-time scenario - 10 seconds - that FAA had reduced the length of pilot training... 859 00:35:28,540 --> 00:35:31,100 PETER DEFAZIO: A slow reaction-time scenario - 10 seconds - 860 00:35:31,100 --> 00:35:33,980 found the failure to be catastrophic. 861 00:35:33,980 --> 00:35:35,900 NATALIE KITROEFF: For those families, 862 00:35:35,900 --> 00:35:38,420 the pain of this was accentuated 863 00:35:38,420 --> 00:35:42,380 because this evidence that was going up on the screen 864 00:35:42,380 --> 00:35:42,620 was information that they felt that was going up on the screen 865 00:35:42,620 --> 00:35:44,820 was information that they felt 866 00:35:44,820 --> 00:35:47,260 that Mr Muilenburg COULD have used 867 00:35:47,260 --> 00:35:47,500 that Mr Muilenburg COULD have used to inform his decision about keeping the plane in the air or not. 868 00:35:47,500 --> 00:35:52,100 to inform his decision about keeping the plane in the air or not. 869 00:35:52,100 --> 00:35:52,340 to inform his decision about Nadia Milleron - she was... 870 00:35:52,340 --> 00:35:54,940 Nadia Milleron - she was... 871 00:35:54,940 --> 00:35:59,140 ..radiating with anger over this. 872 00:35:59,140 --> 00:35:59,380 NADIA MILLERON: ..radiating with anger over this. 873 00:35:59,380 --> 00:36:01,100 NADIA MILLERON: It's come to the point 874 00:36:01,100 --> 00:36:03,980 where you're not the person anymore to solve the situation. 875 00:36:03,980 --> 00:36:06,900 I want to say it to YOU directly 876 00:36:06,900 --> 00:36:09,420 because I don't think you understand what we're saying. 877 00:36:09,420 --> 00:36:10,860 She was right in front of him. 878 00:36:10,860 --> 00:36:12,380 And here you have the CEO 879 00:36:12,380 --> 00:36:15,380 of what is one of the most important American companies, 880 00:36:15,380 --> 00:36:17,460 one of the most important companies in the world... 881 00:36:17,460 --> 00:36:19,100 In the end, it's about safety, and I... 882 00:36:19,100 --> 00:36:21,620 Even if you're not CAPABLE of doing that? 883 00:36:21,620 --> 00:36:21,860 Even if you're not CAPABLE ..looking in the eyes 884 00:36:21,860 --> 00:36:24,100 ..looking in the eyes 885 00:36:24,100 --> 00:36:29,220 of the mother of a young woman who died on his aeroplane. 886 00:36:30,980 --> 00:36:33,740 I know that she wasn't afraid of flying at all 887 00:36:33,740 --> 00:36:37,420 until the last six minutes of her life. 888 00:36:39,180 --> 00:36:42,780 That's just a horrible betrayal 889 00:36:42,780 --> 00:36:46,260 that Boeing and the FAA caused 890 00:36:46,260 --> 00:36:46,500 that Boeing and the FAA caused for this person in the last moments of their life. 891 00:36:46,500 --> 00:36:48,780 for this person in the last moments of their life. 892 00:36:48,780 --> 00:36:53,420 And it kills me that that trust was betrayed. 893 00:36:53,420 --> 00:36:56,340 REPORTER: Boeing's really kind of stuck in a hard spot here... 894 00:36:56,340 --> 00:36:59,500 REPORTER: Dennis Muilenburg was blasted on Capitol Hill... 895 00:36:59,500 --> 00:37:01,980 Two months later, with the company's stock plummeting... 896 00:37:01,980 --> 00:37:04,140 REPORTER: Boeing's stock has been dropping all day... 897 00:37:04,140 --> 00:37:08,140 REPORTER: But it's down 22% since the 737 Max jet was first grounded. 898 00:37:08,140 --> 00:37:10,460 ..and the Max still grounded, 899 00:37:10,460 --> 00:37:12,020 Dennis Muilenburg was out. 900 00:37:12,020 --> 00:37:16,460 (ENGINES WHINE) 901 00:37:18,460 --> 00:37:20,660 In March of 2021 902 00:37:20,660 --> 00:37:22,540 families gathered in Washington, DC, 903 00:37:22,540 --> 00:37:24,020 for the second anniversary 904 00:37:24,020 --> 00:37:28,940 of the crash of Ethiopian Airlines Flight 302. 905 00:37:28,940 --> 00:37:30,860 Boeing had recently settled a criminal charge 906 00:37:30,860 --> 00:37:33,380 of conspiracy to defraud the United States 907 00:37:33,380 --> 00:37:35,620 brought by the Department of Justice. 908 00:37:35,620 --> 00:37:37,820 We have some breaking news on Boeing... 909 00:37:37,820 --> 00:37:39,220 In the settlement, 910 00:37:39,220 --> 00:37:42,420 Boeing admitted to misleading statements, half-truths 911 00:37:42,420 --> 00:37:42,660 Boeing admitted and omissions about MCAS. 912 00:37:42,660 --> 00:37:45,900 and omissions about MCAS. 913 00:37:45,900 --> 00:37:48,420 It agreed to pay $2.5 billion - 914 00:37:48,420 --> 00:37:51,580 $500 million to the families of the victims 915 00:37:51,580 --> 00:37:55,420 and most of the rest to compensate the airlines. 916 00:37:57,460 --> 00:37:59,780 After 20 months of being grounded, 917 00:37:59,780 --> 00:38:03,780 the 737 Max was approved by the FAA to fly again. 918 00:38:11,540 --> 00:38:13,980 (INDISTINCT FLIGHT RECORDING) 919 00:38:15,580 --> 00:38:18,820 (INDISTINCT YELLING) 920 00:38:27,820 --> 00:38:33,340 A 737 Max flown by Alaska Airlines had taken off from Portland, Oregon, 921 00:38:33,340 --> 00:38:34,860 about seven minutes earlier. 922 00:38:34,860 --> 00:38:36,860 At an altitude of 16,000ft 923 00:38:36,860 --> 00:38:38,740 there's a very loud bang. 924 00:38:38,740 --> 00:38:42,740 A piece of the plane's body is blown out at row 26. 925 00:38:42,740 --> 00:38:48,100 HUY TRAN: I opened my eyes to a giant hole in the plane 926 00:38:48,100 --> 00:38:48,340 and I could see the city lights. HUY TRAN: I opened my eyes to a giant hole in the plane 927 00:38:48,340 --> 00:38:50,140 and I could see the city lights. 928 00:38:52,300 --> 00:38:53,220 OK. 929 00:38:53,220 --> 00:38:56,100 There's a deafening wind howling through the plane. 930 00:38:56,100 --> 00:38:56,340 There's a deafening wind The cockpit door flies open. 931 00:38:56,340 --> 00:38:58,140 The cockpit door flies open. 932 00:38:58,140 --> 00:39:00,340 One of the pilots loses her headset. 933 00:39:00,340 --> 00:39:00,580 Another pilot almost loses his One of the pilots loses her headset. 934 00:39:00,580 --> 00:39:04,260 Another pilot almost loses his after his head slams into a display. 935 00:39:04,260 --> 00:39:04,500 Another pilot almost loses his There's just chaos. 936 00:39:04,500 --> 00:39:05,580 There's just chaos. 937 00:39:08,140 --> 00:39:10,940 EVAN SMITH: A boy's shirt was sucked off him and out of the plane, 938 00:39:10,940 --> 00:39:11,220 and his mother was holding on to him. EVAN SMITH: A boy's shirt was sucked off him and out of the plane, 939 00:39:11,220 --> 00:39:12,580 and his mother was holding on to him. 940 00:39:12,580 --> 00:39:12,860 I saw a half of his body was getting sucked out, and his mother was holding on to him. 941 00:39:12,860 --> 00:39:15,980 I saw a half of his body was getting sucked out, 942 00:39:15,980 --> 00:39:16,220 and then I was like, "Oh, my God!" was getting sucked out, 943 00:39:16,220 --> 00:39:18,220 and then I was like, "Oh, my God!" 944 00:39:19,500 --> 00:39:21,820 VI NGUYEN: I look over and there's a hole on the side of the plane, 945 00:39:21,820 --> 00:39:24,580 and in that moment I'm just like, "Oh, God, I'm gonna die." 946 00:39:29,660 --> 00:39:33,380 The plane was able to make an emergency landing back in Portland. 947 00:39:34,740 --> 00:39:39,820 But the incident resurrected concerns about Boeing and the Max. 948 00:39:39,820 --> 00:39:40,100 We were very fortunate we didn't have a third crash on January 5. But the incident resurrected concerns about Boeing and the Max. 949 00:39:40,100 --> 00:39:44,020 We were very fortunate we didn't have a third crash on January 5. 950 00:39:45,620 --> 00:39:47,100 We're gonna (BLEEP!) die! 951 00:39:47,100 --> 00:39:47,340 We're gonna (BLEEP!) die! Joe Jacobsen has continued to monitor the Max 952 00:39:47,340 --> 00:39:50,260 Joe Jacobsen has continued to monitor the Max 953 00:39:50,260 --> 00:39:53,380 since retiring from the FAA in 2021. 954 00:39:53,380 --> 00:39:59,060 Alaska 1282 could have very easily been a fatal crash. 955 00:39:59,060 --> 00:40:04,820 Higher altitudes, some passengers may have lost consciousness, 956 00:40:04,820 --> 00:40:06,700 pilots could have lost consciousness. 957 00:40:06,700 --> 00:40:11,260 This time the FAA immediately grounded similar Max 9s 958 00:40:11,260 --> 00:40:13,060 so that each plane could be inspected. 959 00:40:13,060 --> 00:40:15,500 NEWSREADER: Hundreds of flights are cancelled across the US. 960 00:40:15,500 --> 00:40:17,540 NEWSREADER: Boeing 737 Max... NEWSREADER: Pulled out of service... 961 00:40:17,540 --> 00:40:19,580 ..now grounded around the world... ..forcing hundreds... 962 00:40:20,940 --> 00:40:22,420 At The New York Times 963 00:40:22,420 --> 00:40:22,660 a new team was picking up At The New York Times 964 00:40:22,660 --> 00:40:25,460 a new team was picking up the reporting on the Max 965 00:40:25,460 --> 00:40:25,700 a new team was picking up and what it meant for Boeing. 966 00:40:25,700 --> 00:40:27,460 and what it meant for Boeing. 967 00:40:27,460 --> 00:40:29,260 SYDNEY EMBER: The real bombshell moment 968 00:40:29,260 --> 00:40:29,500 comes in early February SYDNEY EMBER: The real bombshell moment 969 00:40:29,500 --> 00:40:31,300 comes in early February 970 00:40:31,300 --> 00:40:31,540 when the National Transportation comes in early February 971 00:40:31,540 --> 00:40:33,540 when the National Transportation Safety Board 972 00:40:33,540 --> 00:40:33,780 when the National Transportation releases its preliminary report 973 00:40:33,780 --> 00:40:36,020 releases its preliminary report 974 00:40:36,020 --> 00:40:37,580 on the incident. 975 00:40:37,580 --> 00:40:39,980 What the NTSB's report makes clear 976 00:40:39,980 --> 00:40:43,860 is this was a problem on Boeing's factory floor. 977 00:40:43,860 --> 00:40:44,100 is this was a problem This was Boeing's problem. 978 00:40:44,100 --> 00:40:45,380 This was Boeing's problem. 979 00:40:46,340 --> 00:40:48,580 The NTSB focused on a piece of the plane 980 00:40:48,580 --> 00:40:53,220 that replaced an unused emergency exit called a door plug. 981 00:40:53,220 --> 00:40:53,460 that replaced an unused Boeing workers had failed to install 982 00:40:53,460 --> 00:40:55,180 Boeing workers had failed to install 983 00:40:55,180 --> 00:40:56,740 four bolts 984 00:40:56,740 --> 00:40:58,580 that secured it to the plane. 985 00:40:58,580 --> 00:41:02,700 The company later said it had no documentation of the work. 986 00:41:02,700 --> 00:41:05,220 MARK WALKER: Where was the oversight? 987 00:41:05,220 --> 00:41:07,340 Where was the redundant checks 988 00:41:07,340 --> 00:41:08,940 for someone to come back 989 00:41:08,940 --> 00:41:09,180 to make sure that the most critical pieces to it were there? for someone to come back 990 00:41:09,180 --> 00:41:14,100 to make sure that the most critical pieces to it were there? 991 00:41:14,100 --> 00:41:14,380 to make sure that the most critical pieces to it were there? NIRAJ CHOKSHI: Nothing in plane design or plane production 992 00:41:14,380 --> 00:41:17,620 NIRAJ CHOKSHI: Nothing in plane design or plane production 993 00:41:17,620 --> 00:41:20,300 is done without several layers of redundancy, 994 00:41:20,300 --> 00:41:23,180 without frequent inspections, without frequent checks, 995 00:41:23,180 --> 00:41:23,420 without frequent inspections, and the idea that 996 00:41:23,420 --> 00:41:24,900 and the idea that 997 00:41:24,900 --> 00:41:27,980 something as important as a part of the plane's body 998 00:41:27,980 --> 00:41:31,220 could leave the factory without the bolts needed to hold it in place 999 00:41:31,220 --> 00:41:31,460 could leave the factory without is...shocking. 1000 00:41:31,460 --> 00:41:33,100 is...shocking. 1001 00:41:33,100 --> 00:41:34,580 SYDNEY EMBER: This was supposed to be 1002 00:41:34,580 --> 00:41:38,740 one of the most highly scrutinised planes in the world, 1003 00:41:38,740 --> 00:41:41,020 and here you are with another incident 1004 00:41:41,020 --> 00:41:41,260 and here you are that was risking passengers' lives. 1005 00:41:41,260 --> 00:41:43,540 that was risking passengers' lives. 1006 00:41:44,500 --> 00:41:47,860 Boeing CEO Dave Calhoun was quick to own the failure 1007 00:41:47,860 --> 00:41:49,340 in a series of appearances. 1008 00:41:49,340 --> 00:41:54,060 We're gonna approach this, number one, acknowledging our mistake. 1009 00:41:54,060 --> 00:41:54,340 I want everybody, everybody on every aeroplane We're gonna approach this, number one, acknowledging our mistake. 1010 00:41:54,340 --> 00:41:57,460 I want everybody, everybody on every aeroplane 1011 00:41:57,460 --> 00:41:58,740 to know that Boeing owns it. 1012 00:42:00,500 --> 00:42:03,300 The door plug was a production failure, 1013 00:42:03,300 --> 00:42:03,540 The door plug MCAS was a design flaw, 1014 00:42:03,540 --> 00:42:05,580 MCAS was a design flaw, 1015 00:42:05,580 --> 00:42:07,180 but both raised questions 1016 00:42:07,180 --> 00:42:11,180 about Boeing's safety culture and the FAA's oversight. 1017 00:42:11,180 --> 00:42:18,580 The shocking thing about the Max is the sheer number of problems, 1018 00:42:18,580 --> 00:42:21,460 design problems, manufacturing problems. 1019 00:42:21,460 --> 00:42:24,700 Joe Jacobsen is now working with families of the victims 1020 00:42:24,700 --> 00:42:24,940 Joe Jacobsen is now working of the 737 Max 8 crashes 1021 00:42:24,940 --> 00:42:27,420 of the 737 Max 8 crashes 1022 00:42:27,420 --> 00:42:30,860 to bring other safety concerns to the FAA. 1023 00:42:30,860 --> 00:42:32,460 And this is after, you know, 1024 00:42:32,460 --> 00:42:36,500 the supposedly most comprehensive recertification 1025 00:42:36,500 --> 00:42:36,740 the supposedly most comprehensive in the history of aviation. 1026 00:42:36,740 --> 00:42:37,980 in the history of aviation. 1027 00:42:37,980 --> 00:42:38,220 DAVID GELLES: in the history of aviation. 1028 00:42:38,220 --> 00:42:40,180 DAVID GELLES: I think what's most scary 1029 00:42:40,180 --> 00:42:42,740 is that you have both kinds of accidents 1030 00:42:42,740 --> 00:42:42,980 is that you have both kinds happening at the same company. 1031 00:42:42,980 --> 00:42:45,020 happening at the same company. 1032 00:42:45,020 --> 00:42:49,540 That, to me, reveals a culture inside the company. 1033 00:42:49,540 --> 00:42:51,780 I mean, I know we keep coming back to this word 'culture', 1034 00:42:51,780 --> 00:42:56,500 but it's right at the root of what happened in both sets of accidents. 1035 00:42:56,500 --> 00:42:56,740 In a statement but it's right at the root of what happened in both sets of accidents. 1036 00:42:56,740 --> 00:42:58,380 In a statement 1037 00:42:58,380 --> 00:43:01,780 Boeing said it is dedicated to transparency 1038 00:43:01,780 --> 00:43:04,580 and it is implementing a comprehensive plan 1039 00:43:04,580 --> 00:43:04,820 to strengthen safety and quality. a comprehensive plan 1040 00:43:04,820 --> 00:43:07,500 to strengthen safety and quality. 1041 00:43:07,500 --> 00:43:07,740 to strengthen safety and quality. Less than seven weeks after the Alaska Air incident, 1042 00:43:07,740 --> 00:43:10,500 Less than seven weeks after the Alaska Air incident, 1043 00:43:10,500 --> 00:43:13,420 the executive running the Max program was out. 1044 00:43:14,940 --> 00:43:16,420 In early March 1045 00:43:16,420 --> 00:43:21,260 the FAA said it had found multiple quality control issues with the Max. 1046 00:43:21,260 --> 00:43:24,700 The agency also released a report that found Boeing's safety culture 1047 00:43:24,700 --> 00:43:24,940 The agency also released a report has been inadequate and confusing. 1048 00:43:24,940 --> 00:43:27,340 has been inadequate and confusing. 1049 00:43:28,300 --> 00:43:31,900 And now the Justice Department is investigating the company. 1050 00:43:32,860 --> 00:43:35,100 Cultural change doesn't happen overnight, 1051 00:43:35,100 --> 00:43:37,780 especially at big corporations like this. 1052 00:43:37,780 --> 00:43:41,780 And it doesn't happen just because he got slapped with a fine. 1053 00:43:41,780 --> 00:43:44,660 It's the product of millions of decisions, 1054 00:43:44,660 --> 00:43:44,900 It's the product whatever it might mean 1055 00:43:44,900 --> 00:43:46,580 whatever it might mean 1056 00:43:46,580 --> 00:43:51,820 in terms of lost profits that impact the share price in the short term. 1057 00:43:51,820 --> 00:43:56,300 But if Boeing wants to get back to that place of grandeur 1058 00:43:56,300 --> 00:43:57,660 where it was for so long, 1059 00:43:57,660 --> 00:44:00,620 one of the most important American companies, 1060 00:44:00,620 --> 00:44:00,860 one of the most important it's gonna take...not four years, 1061 00:44:00,860 --> 00:44:03,340 it's gonna take...not four years, 1062 00:44:03,340 --> 00:44:05,540 but it might take 14. 1063 00:44:07,060 --> 00:44:10,700 More than 170 Max 9s were grounded by the FAA 1064 00:44:10,700 --> 00:44:10,940 More than 170 Max 9s after the Alaska Airlines incident. 1065 00:44:10,940 --> 00:44:13,820 after the Alaska Airlines incident. 1066 00:44:14,780 --> 00:44:17,700 Nearly all are now back in service. 1067 00:44:20,820 --> 00:44:22,580 (THEME MUSIC PLAYS) 1068 00:44:38,620 --> 00:44:40,620 Captions by Red Bee Media 1069 00:44:40,620 --> 00:44:42,820 Copyright Australian Broadcasting Corporation