(THEME MUSIC PLAYS)
NIRAJ CHOKSHI: A piece of the plane's body is blown out at row 26.
There's just chaos.
EVAN SMITH: A boy's shirt was sucked There's just chaos.
EVAN SMITH: A boy's shirt was sucked off him and out of the plane,
and his mother was holding on to him. EVAN SMITH: A boy's shirt was sucked off him and out of the plane,
and his mother was holding on to him.
I saw a half of his body was getting sucked out, and his mother was holding on to him.
I saw a half of his body was getting sucked out,
and then I was like, "Oh, my God!"
NEWSREADER: The plane suddenly
lost a section of its fuselage mid-flight.
NEWSREADER: An FAA panel is blasting the aircraft company.
NARRATOR: Amid new problems with Boeing's 737 Max...
Where was the oversight to make sure the most critical pieces were there?
..a special update to the award-winning investigation
with The New York Times into the problem-plagued aeroplane.
NEWSREADER: Lion Air Flight JT610 went missing from radar.
DAVID GELLES: And then the second plane crashed.
NEWSREADER: Ethiopia crashed minutes after taking off.
This was gonna be an existential crisis for the company.
They had no idea how powerful MCAS was. This was gonna be an existential crisis for the company.
They had no idea how powerful MCAS was.
DOUG PASTERNAK: FAA'S oversight was sorely lacking.
NEWSREADER: The mounting pressure on Boeing...
SYDNEY EMBER: This was supposed to be one of the most
highly scrutinised planes in the world,
and here you are with another incident
and here you are that was risking passengers' lives.
VI NGUYEN: In that moment I'm just that was risking passengers' lives.
VI NGUYEN: In that moment I'm just like, "Oh, God, I'm gonna die."
FLIGHT RECORDING: We are emergency. We are depressurised.
GERRY SOEJATMAN: On the morning of October 29,
I was woken up by a colleague
who alerted me that a Lion aircraft crashed. I was woken up by a colleague
who alerted me that a Lion aircraft crashed.
He said, "It's the Max."
And I was surprised He said, "It's the Max."
And I was surprised because it was a new aircraft.
And I was surprised My company provided the air data
for aircraft flying around the Jakarta area,
so, I went to the computer and looked at the data.
It was immediately apparent that something was wrong.
It was immediately apparent (INDISTINCT RADIO CHATTER)
The plane went up to about 2,000ft (INDISTINCT RADIO CHATTER)
The plane went up to about 2,000ft just over a minute after take-off,
The plane went up to about 2,000ft and the plane had a bit of a dive,
and then the plane climbed to about 5,000ft.
But then at 5,000ft the plane was fluctuating up and down.
And then the plane just started diving.
And then the plane It just didn't make sense.
You don't see It just didn't make sense.
You don't see planes diving on departure.
You don't see I was baffled.
Why did it go down?
NEWSREADER: Lion Air Flight JT610 went missing from radar.
189 people were killed in the crash of Lion Air Flight 610.
NEWSREADER: The Boeing 737 Max 8...
NEWSREADER: The plane was a new Boeing 737 Max...
NEWSREADER: What do we know The plane was a new Boeing 737 Max...
NEWSREADER: What do we know about this 737 Max 8?
..the fastest-selling jet in Boeing history,
..the fastest-selling jet just introduced the year before.
REPORTER: We don't yet know just introduced the year before.
REPORTER: We don't yet know what caused this crash.
A breakthrough this evening - the flight data recorder.
A breakthrough this evening - It holds many of the keys...
The data from the black box quickly got to FAA engineers
in the United States.
There is a purity of this data.
from the black boxes.
It comes directly from the black boxes.
So, it's recording air speed, altitude.
The data showed what appeared to be a glitch,
something repeatedly moving part of the plane's tail,
controlling its pitch.
It didn't take long, just a couple of minutes,
It didn't take long, to see that
there was a rapid movement to see that
there was a rapid movement
of the horizontal stabiliser.
It's probably the fastest way to kill yourself in an aeroplane
is to have the stabiliser malfunction.
JAMES GLANZ: My spine literally tingled
when I saw the traces from the black box.
The plane continually tried to push the nose down,
and the pilots were trying over and over again to stop the plane, The plane continually tried to push the nose down,
and the pilots were trying over and over again to stop the plane,
and in the end they lose that battle.
What Boeing had not told airlines or their pilots
was that it had put a powerful software system on the new aeroplane.
was that it had put a powerful In the Lion Air crash
this system was receiving incorrect information
and that made the plane dive straight downward
and that made the plane and destroy itself.
Inside Boeing, they quickly diagnosed the problem
and began working on a fix,
but they stood by the Max
as hundreds of them took to the air around the world,
as hundreds of them took to the air carrying thousands of passengers.
The company alerted pilots about carrying thousands of passengers.
The company alerted pilots about handling a potential malfunction.
NEWSREADER: Boeing and the FAA today warned airlines
that sensors on 737 Max 8 jets can malfunction.
REPORTER: Boeing are calling this a formal advisory
and it's been issued to the pilots.
NATALIE KITROEFF: The reporting showed
NATALIE KITROEFF: Boeing knew that it was risky,
but their response
was to blame the pilots. but their response
was to blame the pilots.
REPORTER: Pilots did not hit two cut-off switches.
Boeing says that action
was part of well-established Boeing says that action
was part of well-established protocols for all 737s.
And that led to a series of decisions
And that led that kept the plane in the air.
And then we got another crash.
NEWSREADER: Breaking news out of Ethiopia, where a plane went down...
It was Ethiopian Airlines Flight 302
on its way to Nairobi from Addis Ababa.
NEWSREADER: A new 737 Max 8 jetliner crashed minutes after taking off.
Two crashes, the same plane,
346 people killed,
an iconic American company's reputation in tatters.
The story of the Boeing 737 Max
would end up exposing corporate deception
and a broken regulatory process.
But at the centre was a software and a broken regulatory process.
But at the centre was a software system supposed to keep people safe
But at the centre was a software that instead led to their deaths.
NEWSREADER: The black boxes from the Ethiopian crash have been recovered.
NEWSREADER: It's the second disaster within five months
NEWSREADER: It's the second disaster involving the Boeing 737 Max.
NEWSREADER: That's the same kind of aircraft
that crashed back in October in Indonesia.
NEWSREADER: 157 people,
including passengers and crew members on board,
including passengers all dead.
QUINDOS KARANJA: The first thing you get to see at the site
is a very big hole. you get to see at the site
is a very big hole.
And then to only imagine
this is the place And then to only imagine
this is the place that they were last alive.
We learned that
there were no survivors on the plane. We learned that
there were no survivors on the plane.
And then our objective was to go and bring
my daughter's body home.
Now you're in close proximity.
You're able to see the fine details.
You're able to maybe think these are personal effects,
"Belongs to Carol my sister or my mum,"
or, uh..."This bone, whose bone is this?"
And they told us that there was no part of a human
that was bigger than a femur that was left.
That whole experience is just a jumble of images
and painful thoughts and blankness, really, to me. That whole experience is just a jumble of images
and painful thoughts and blankness, really, to me.
and painful thoughts I don't really...
I can't really make sense of it.
The crash of Ethiopian Flight 302 in 2019
was the second time in five months that a Boeing 737 Max had gone down.
As families gathered at the crash site,
across the world
reporters at The New York Times were investigating
what had been going wrong with Boeing's new commercial jet.
NATALIE KITROEFF: Statistically speaking,
the likelihood that these two accidents
the likelihood were not in some way connected
was extremely low.
It suggested that there was something going on with the plane,
and, obviously, we were determined to find out.
(INDISTINCT CHATTER) we were determined to find out.
(INDISTINCT CHATTER)
that Boeing was in full crisis mode.
It was clear from the get-go that Boeing was in full crisis mode.
As the facts from the accident become available
and we understand the necessary next steps,
we're taking action to fully reassure airlines
and their passengers
of the safety of the 737 Max.
This was gonna be an existential crisis for the company
if these two events were related.
China grounds the plane first.
Other international regulators ground the plane.
Then the European Union grounds the plane.
NEWSREADER: But in the US, the FAA says it's not grounding the plane. Then the European Union grounds the plane.
NEWSREADER: But in the US, the FAA says it's not grounding the plane.
Boeing and the FAA all were saying that they were
sort of waiting for the facts before they rushed to judgement
and grounded such an important new plane.
and grounded But for months
The Times was reporting
there was something wrong The Times was reporting
there was something wrong with the 737 Max itself -
the software system that pilots had not known existed.
JAMES GLANZ: The Manoeuvring Characteristics Augmentation System,
JAMES GLANZ: The Manoeuvring or MCAS.
The function of this previously undisclosed system
The function of was to save the plane
when it believed that the plane might go into a stall
and fall out of the sky.
And, so, this system was designed then
And, so, this system to sort of take over the stabiliser
and push that nose back down to sort of take over the stabiliser
and push that nose back down in case the pilot gets in trouble.
Then a major setback for the company.
Radar showed the two plane's flight patterns were eerily similar.
Days after the rest of the world had reached the same conclusion,
Days after the rest of the world they finally grounded the plane.
For The New York Times reporters,
all the signs pointed to MCAS.
We knew that MCAS was the beginning.
We knew that we needed to start with this system.
This was a really problematic software system We knew that we needed to start with this system.
This was a really problematic software system
in the way it was designed.
OK, well, then how the hell did it end up in the plane this way?
Boeing declined to be interviewed for this film.
In a statement, the company said safety is its "top priority"
In a statement, the company said and it has "worked closely"
with regulators, investigators and it has "worked closely"
with regulators, investigators and stakeholders
with regulators, investigators to "implement changes that ensure
"accidents like these never happen again."
Within days of the second 737 Max crash
another investigation was underway in Washington, DC.
DOUG PASTERNAK: We started getting information in
DOUG PASTERNAK: from whistleblowers, from people,
both current and former FAA and Boeing employees. from whistleblowers, from people,
both current and former FAA and Boeing employees.
Doug Pasternak was leading a congressional investigation.
This is his first interview about what he found.
As soon as the second accident occurred,
As soon as the second accident we started our investigation
and our focus was on the design, we started our investigation
and our focus was on the design, development and certification
and our focus was on the design, of the Max.
We got hundreds of thousands of pages of documents from Boeing.
One of the things that really struck me
from speaking to a lot of Boeing employees
was that they were so excited to go to work at Boeing.
(CHEERING, APPLAUSE)
Boeing is a tremendous engineering company and a technical marvel,
Boeing is a tremendous engineering but almost without failure
they point to a degradation but almost without failure
they point to a degradation of that mindset
and that safety suffered as a result.
and that safety suffered Looking backwards,
I think you can clearly see
the trajectory, the tragedy, along the way at Boeing.
(ENGINES WHINE) the trajectory, the tragedy, along the way at Boeing.
(ENGINES WHINE)
Boeing publicly said
the Max went through a deliberate six-year development process.
But in their first stories
The New York Times reporters found insiders
who said that Boeing executives had been putting the pressure on
to design the new 737 quickly and cheaply.
JACK NICAS: One specific engineer we spoke to was Rick Ludtke.
He helped design the cockpit in the Max,
He helped design the cockpit and he talked a lot about
how there was an obsession and he talked a lot about
how there was an obsession in limiting changes.
RICK LUDTKE: This program was a much more intense pressure cooker
RICK LUDTKE: This program was than I've ever been in.
The company was trying to avoid costs.
Minimum change to simplify the training differences
Minimum change to simplify and to get it done quickly.
Speed was what they seemed to desire.
Speed was what There was a lot of decision-making
that was somewhat arbitrary
and didn't involve as much the...
..of what engineering and didn't involve as much the...
..of what engineering considers healthy, um...debate.
The challenge to the Boeing designers
The challenge was that any designs we created
would not drive any new training was that any designs we created
would not drive any new training that required a simulator.
In his recorded interview with The Times,
In his recorded interview Ludtke said Boeing management
was so determined to avoid the expense of new training
they made a bold promise.
Sales had made a commitment with Southwest
that, for any aeroplane they delivered
that had a new Level D differences training,
Boeing would pay the company $1 million
per every aeroplane delivered.
DAVID GELLES: If the Max required simulator training,
it would rebate Southwest DAVID GELLES: If the Max required simulator training,
it would rebate Southwest
$1 million per plane.
And there's that incentive.
That's why it was so important to Boeing
that pilot training be kept to a minimum.
All of this comes out of that pilot training be kept to a minimum.
All of this comes out of
trying to give airlines
the most fuel-efficient
version of a plane
that they can spend as little money training their pilots on.
JACK NICAS: That meant Boeing had to do a number of things
to make this plane fly like the old one,
to make this plane and that was because
the Max had much bigger engines on it to make them more fuel-efficient. and that was because
the Max had much bigger engines on it to make them more fuel-efficient.
But because the 737
was a 50-year-old aeroplane at this time, practically,
when it came time for Boeing to put those engines on the wings,
the engines were so darn big
they had to mount them further forward on the wings.
They were testing in this wind tunnel
They were testing and they were discovering
the plane was handling and they were discovering
the plane was handling just a little bit differently,
but they didn't even have a plane built yet,
so, this wasn't, you know, happening in real flight.
so, this wasn't, you know, This is something you have to fix.
And they leaned on
a system that they had used once before in a military tanker.
It was designed as a system on the plane
to really just smooth out the way the plane handled.
It was MCAS.
It was designed for these extremely unusual manoeuvres,
situations that hopefully the plane would never get in.
And to prevent the nose from getting too high,
the system would move the stabiliser on the back of the plane
the system would move the stabiliser to push the nose back down.
But inside Boeing there were early signs of trouble.
DOUG PASTERNAK: One of the first documents we found
DOUG PASTERNAK: was from November of 2012.
A Boeing test pilot was from November of 2012.
A Boeing test pilot was flying the Max
in a flight simulator A Boeing test pilot was flying the Max
in a flight simulator
and trying to respond
to an activation of MCAS,
and that resulted in what he described as a 'catastrophic' event.
It showed that, if that had been in real life,
he could have lost the aeroplane.
They realised from that moment on
even a Boeing test pilot may have trouble responding to MCAS.
The company kept quiet about the simulator experience
and appeared to have discounted the test results.
and appeared to have discounted Still, in the following months,
some Boeing employees
suggested simply removing some Boeing employees
suggested simply removing all references to MCAS
suggested simply removing from training manuals.
Boeing, from almost the very beginning,
realised the significance of MCAS
and the significance MCAS would have on pilot simulator training.
(READS) "If we emphasise MCAS is a new function,
"there may be a greater certification and training impact.
"Recommended action - investigate deletion of MCAS nomenclature."
"Recommended action - investigate What that meant
was that, if they said MCAS was a new function,
the FAA was gonna scrutinise it a lot more.
Boeing told Congress it kept the FAA informed
about MCAS's development and final configuration.
But Boeing has a complex and close relationship
But Boeing has a complex with the agency that oversees it.
NATALIE KITROEFF: The aeroplanes with the agency that oversees it.
NATALIE KITROEFF: The aeroplanes are part of the story,
NATALIE KITROEFF: The aeroplanes but so are the regulators.
The FAA regulated Boeing
in part The FAA regulated Boeing
in part with a handful of Boeing employees
in part whose paycheques came from Boeing
but whose jobs
were to represent
the interests were to represent
the interests of the FAA.
It's a decades-old arrangement known as 'delegation'
It's a decades-old arrangement that allows federal agencies
to give oversight powers that allows federal agencies
to give oversight powers to the companies they regulate.
In the beginning there was a really good reason for this.
In the beginning there was The FAA was certifying things
that made no sense
to have them certify every single that made no sense
to have them certify every single exit sign or bathroom sign or paint.
The issue that many of the FAA employees that we talked to had
was that it went way beyond bathroom signs.
Over time, Congress passed laws
that pushed the FAA to hand over the responsibility
that pushed the FAA for more and more tasks
to the company, to Boeing.
In the design of the 737 Max,
many things would be delegated to Boeing.
many things That included MCAS.
Under the impression that this was a relatively benign system,
Under the impression that this the FAA agreed to delegate it,
as is the custom with the FAA and Boeing.
And that's what happened in this case.
And that's what happened It handed it over.
In a statement
the FAA blamed ineffective coordination
and said it had not focused on MCAS when it certified the Max
because Boeing had not identified MCAS as significant.
Under orders from Congress,
the FAA has since made changes to the delegation process.
After years of going through design and development,
a 737 Max prototype was rolled out of Boeing's Renton Factory
a 737 Max prototype was rolled out for its maiden flight.
(CHEERING)
Ed Wilson is in the cockpit,
he's the new chief pilot, and he takes off.
REPORTER: And let's just take a listen
as this aeroplane gets ready for its very first take-off.
(ENGINES WHINE)
A short time after this first maiden flight,
Ed Wilson, he and his co-pilot start to realise that
the 737 Max is not handling as smoothly as it should Ed Wilson, he and his co-pilot start to realise that
the 737 Max is not handling as smoothly as it should
the 737 Max is not handling in certain low-speed situations.
It's shortly after take-off,
you know, it's still It's shortly after take-off,
you know, it's still kind of climbing to ascend,
you know, it's still it's not going full speed.
Boeing engineers had an idea for how to deal with this.
They know about MCAS
and they know that MCAS was actually used for a similar situation
and they know that MCAS was actually in these high-speed manoeuvres.
And, so, theoretically,
MCAS could also be used in these other situations
MCAS could also be used to also smooth out the handling.
Crucially, it's already been created,
it's already been approved,
and it's something that we could just apply, you know,
and it's something to a different phase of flight.
It's actually a pretty easy fix.
This ends up being an extremely fateful decision.
They enable the stabiliser to move much more,
They enable the stabiliser actually four times as much.
Now the system's designed actually four times as much.
Now the system's designed for low-speed situations,
Now the system's designed like just after take-off,
and after take-off
is when the plane is still only and after take-off
is when the plane is still only a few thousand feet over the ground.
That means you have much less room for error.
It's happening in automated fashion and a repeated fashion.
This fundamentally changes MCAS.
It makes it much more aggressive,
much more risky.
It's a far more dangerous system.
Boeing was doubling down on the system,
Boeing was doubling down expanding it
despite the earlier catastrophic result in a simulator test.
The Times' reporting on MCAS focused on a former Boeing pilot.
NATALIE KITROEFF: I started to hear about a pilot at Boeing
whose name was Mark Forkner...
..the chief technical pilot for the 737.
..the chief technical pilot He was the person
who personally emailed the FAA
asking for MCAS to be removed from the pilot manual. who personally emailed the FAA
asking for MCAS to be removed from the pilot manual.
That was an important piece of this
because we understood That was an important piece of this
because we understood that the FAA really didn't know
because we understood that MCAS became more powerful.
He was speaking
absolutely on behalf of the company. He was speaking
absolutely on behalf of the company.
This was not some low-level employee.
And he was asking for something
that was really quite substantial -
that a new piece of software
that made the plane behave in ways that it previously hadn't
that made the plane behave in ways be concealed from the pilots.
This is where the commercial be concealed from the pilots.
This is where the commercial pressures from the executive level
come right down to the development of the aeroplane.
DOUG PASTERNAK: Mark Forkner certainly was not a lone actor
DOUG PASTERNAK: Mark Forkner in what he did.
He was following through on a policy by Boeing in what he did.
He was following through on a policy by Boeing
He was following through to ensure that the program
did not have to put pilots in a flight simulator.
It got to the point where Mark Forkner got an award
for keeping training on the 737 Max to a minimum.
Nearly eight months after requesting
that MCAS be removed from pilot training manuals,
Forkner texted a colleague with a shocking realisation.
NATALIE KITROEFF: This appears to be the moment
where Mark Forkner learns that MCAS has been expanded.
where Mark Forkner learns He writes in that message,
"I basically lied to the regulators unknowingly."
But he never went back and corrected the record.
He never went back and fixed the error.
Mark Forkner wouldn't speak to us.
He was indicted for lying Mark Forkner wouldn't speak to us.
He was indicted for lying to FAA investigators about MCAS,
but later found not guilty of all charges in federal court.
but later found not guilty His lawyer told The Times reporters
that his communications with the FAA His lawyer told The Times reporters
that his communications with the FAA were honest
that his communications with the FAA and that he would never jeopardise
the safety of other pilots or their passengers.
When Boeing engineers expanded the MCAS system
they included a feature that would make it particularly dangerous.
DAVID GELLES: Planes have millions of parts in them,
and there's one little one on the 737
and there's one little one that sticks out of the fuselage.
REPORTER: See that little black circle there? That is called...
REPORTER: See that little black The angle-of-attack sensor.
On the 737 Max
it had the power to trigger MCAS.
It's the AOA sensor
that is one of the crucial parameters
that is one of to the computer
to tell the plane that it's in a perilous condition.
The angle-of-attack sensor would activate MCAS
by telling the system that the plane's nose was too high,
and then MCAS would try to push the nose down.
But if this sensor is broken, for whatever reason,
But if this sensor is broken, the MCAS never realises,
and, so, it keeps pushing the nose of the plane down
and, so, it keeps over and over again.
Congressional investigators would later find documents
showing that Boeing engineers had raised this very concern.
DOUG PASTERNAK: An engineer asked,
"What if we have a faulty AOA sensor?"
Because AOA sensors are known to be faulty.
You know, what happens to the aeroplane?
So, you have those concerns raised,
and the response again from Boeing engineers
was to essentially dismiss those.
Three! Two! One!
Boeing began delivering the new 737 Max in mid-2017.
At the outset, 737 Max was arguably one of Boeing's biggest successes.
It had become its best-selling jet ever.
Advanced sales were estimated at $370 billion.
Advanced sales American had orders for 100,
Southwest Airlines for 200.
Boeing had focused especially hard
on selling to developing markets in Asia,
on selling to developing markets where Lion Air's parent company
became the first customer where Lion Air's parent company
became the first customer to fly the 737 Max,
signing an agreement worth more than $20 billion.
NEWSREADER: The new 737 Max 8 jetliner crashed today.
NEWSREADER: Investigators say that flight had similar problems
to the Lion Air crash.
Once again, the angle-of-attack sensor is malfunctioning.
But there is this question now about systems within the aircraft.
If MCAS hadn't been on those planes, those planes wouldn't have crashed.
It's that simple.
Boeing CEO Dennis Muilenburg latched on to findings
that inexperience and lack of training
were part of a chain of events that led to the crashes.
were part of a chain of events It was a controversial position.
Understand that these aeroplanes are flown in the hands of pilots
and, in some cases, our system safety analysis
includes not only the engineering design
but also the actions that pilots would take
but also the actions as part of a failure scenario...
JAMES GLANZ: Boeing's contention from the beginning
was that, even though the pilots did not know that MCAS existed,
was that, even though the pilots that they did not NEED to know that.
And in some cases those procedures were not completely followed...
Boeing believed that the pilots should have been able to realise
that it was very similar to a runaway stabiliser situation.
that it was very similar 'Runaway stabiliser'
is an aviation term for a malfunctioning stabiliser.
After the Lion Air crash,
Boeing had issued a directive to pilots
Boeing had issued to be aware of this possibility
and told them what to do if it happened.
NATALIE KITROEFF: When that part of the tail
was not acting the way that it should be,
was not acting you take manual control of it.
REPORTER: The pilots could have stopped their roller-coaster ride
by turning these two switches off.
To shut off power to the stabiliser,
you stop it from moving on its own,
and then you start cranking a wheel in the cockpit
that literally will manually move the stabiliser
that literally will manually back to where you want it to move.
The issue was were there things happening inside the cockpit
that might have made that harder to do?
That's what we were asking.
DAVID GELLES: When we finally got the preliminary black-box data
DAVID GELLES: When we finally from the Ethiopian crash,
we called up Dennis Tajer,
an American Airlines 737 pilot,
and sent him the data
and we read through it together.
My mission was to provide them,
"I'm in the cockpit. My mission was to provide them,
"I'm in the cockpit. I see what's happening now."
So, we walk through each line...
..and I had no idea what was in it.
I knew that the crew had
an experienced captain and a lesser-experienced first officer.
We go second by second through the few minutes of this flight.
Going through the steps that the pilots had taken and saying,
"Yep, I would have done that. Yep, I would have done that."
And as soon as they lift off the ground,
all these different alerts started popping up.
The airspeed was unreliable, the altitude was showing unreliable.
The airspeed was unreliable, There were alerts related to that.
But they bring the gear up and they continue to climb out.
Two minutes into the flight,
based on faulty data Two minutes into the flight,
based on faulty data from the AOA sensor,
MCAS kicked in and began pushing the nose down.
MCAS kicked in ALERT: Don't sink.
And I have...
ALERT: Pull up.
..very clear memory...
..of noting a time mark
where the first officer
is quoted as saying, "Stab trim cutout switches,"
which takes the weapon away from MCAS,
which is what Boeing told us to do.
And I have to confess...
I probably swore.
I said, "The kid got it right.
"That kid got it right."
What had happened was the pilots DID do what they were supposed to do.
What had happened was the pilots DID They had cut the electricity off.
ALERT: Don't sink. Pull up. They hit these switches
and they tried to take manual control.
The first officer is reaching to this large wheel on his left...
ALERT: Pull up. ..and that's the manual trim wheel,
and trying to turn it. ALERT: Pull up.
It's like lifting up a 10-tonne bucket of cement out of a deep well.
ALERT: Don't sink. The problem was at that point
the plane was going so fast... ALERT: Pull up.
..that, even after they took manual control,
they could not physically ..that, even after they took manual control,
they could not physically
get the plane to right itself.
They shouldn't have been going that fast.
ALERT: Too low. Terrain.
And they're continuing to accelerate towards the ground.
And they're continuing to accelerate ALERT: Pull up.
The ground is approaching them.
Then, with no apparent recourse,
the pilots reached for the stabiliser switches.
the pilots reached I'm yelling into the cockpit,
"Don't do that!"
But I don't know what they're facing.
But I don't know ALERT: Caution - terrain.
The MCAS was reactivated.
ALERT: Pull up. MCAS says, "Hey, I'm back on.
ALERT: Pull up. "Here we go. Zzz-zzz."
And now the aeroplane is in near-full nose-down trim,
and you can pull back forever
and there's not enough metal in the back of the aeroplane
to make that aeroplane come up to a nose up.
to make that aeroplane ALERT: Terrain. Terrain.
Pull up. Pull up. Pull up.
(BIRDS TWITTER)
NADIA MILLERON: She died when she was 24.
It's unbearable that she's not with us.
It's unbearable And the only thing I can do is...
..try to prevent this for other people.
About four months after the Ethiopian Airlines crash,
the family of Samya Stumo
was about to receive news they would find bewildering.
We were eating dinner and I hadn't looked at my phone for a long time
We were eating dinner and I hadn't and it was blowing up.
The Federal Aviation Administration, now in the hot seat in Washington and it was blowing up.
The Federal Aviation Administration, now in the hot seat in Washington
over its certification of Boeing 737 Max planes.
SUSAN COLLINS: We are joined today by Ali Bahrami,
the Associate Administrator for Aviation Safety.
We continue to evaluate Boeing's software modification to the MCAS. the Associate Administrator for Aviation Safety.
We continue to evaluate Boeing's software modification to the MCAS.
In addition...
FAA official Ali Bahrami
had been called before Congress,
where he was questioned about revelations
the FAA had known there was a risk of another Max crashing after Lion Air.
the FAA had known there was a risk of If the agency's own analysis
found MCAS If the agency's own analysis
found MCAS to be an unacceptable risk,
why did the FAA not take immediate action to address those risks?
The families hadn't known that before.
They didn't know that the safety agency gambled with passenger lives.
We knew that eventual solution would be to have the modification,
We knew that eventual solution and, based on our risk assessment,
we felt that we had sufficient time to be able to do the modification,
we felt that we had sufficient time you know, and get the final fix.
After the Lion Air crash,
the FAA had conducted an analysis
of the likelihood the FAA had conducted an analysis
of the likelihood of another 737 Max crashing.
The worst-case scenario was grim.
DOUG PASTERNAK: They looked at
the probability that there could be DOUG PASTERNAK: They looked at
the probability that there could be
another crash of a 737 Max
if the FAA didn't do anything to MCAS
and just let the plane keep flying.
And what that assessment showed
was that FAA predicted
there could potentially be 15 more fatal accidents of 737 Max aircraft
over the lifespan of the fleet.
About one crash every other year.
But, in explaining its decision not to ground the plane,
the FAA said in its statement that the actual risk at the time,
considering the number of planes in the air,
was as close to zero as their calculations allowed.
Boeing CEO Dennis Muilenburg appeared before Congress.
NEWSREADER: Boeing's CEO is expected to acknowledge
that his company made mistakes in the...
And here's the first time this guy's in the hot seat.
And here's the first time We appreciate the opportunity...
By then he'd become the face of the 737 Max crisis.
PETER DEFAZIO: I've been on this committee a long time.
We have never undertaken an investigation of this magnitude.
We intentionally put the families close to the witness.
We intentionally put the families They're the victims here,
and it should be like, you know, a trial in court They're the victims here,
and it should be like, you know, a trial in court
where you get to face the person who, you know...
..who committed a violent act against you.
The committee confronted Muilenburg
with an array of internal Boeing documents.
SHARICE DAVIDS: Boeing's marketing representatives
SHARICE DAVIDS: emphasised to potential customers
that FAA had reduced the length emphasised to potential customers
that FAA had reduced the length of pilot training...
PETER DEFAZIO: A slow reaction-time scenario - 10 seconds - that FAA had reduced the length of pilot training...
PETER DEFAZIO: A slow reaction-time scenario - 10 seconds -
found the failure to be catastrophic.
NATALIE KITROEFF: For those families,
the pain of this was accentuated
because this evidence that was going up on the screen
was information that they felt that was going up on the screen
was information that they felt
that Mr Muilenburg COULD have used
to inform his decision about keeping the plane in the air or not.
to inform his decision about Nadia Milleron - she was...
..radiating with anger over this.
NADIA MILLERON: ..radiating with anger over this.
NADIA MILLERON: It's come to the point
where you're not the person anymore to solve the situation.
I want to say it to YOU directly
because I don't think you understand what we're saying.
She was right in front of him.
And here you have the CEO
of what is one of the most important American companies,
one of the most important companies in the world...
In the end, it's about safety, and I...
Even if you're not CAPABLE of doing that?
Even if you're not CAPABLE ..looking in the eyes
of the mother of a young woman who died on his aeroplane.
I know that she wasn't afraid of flying at all
until the last six minutes of her life.
That's just a horrible betrayal
that Boeing and the FAA caused
for this person in the last moments of their life.
And it kills me that that trust was betrayed.
REPORTER: Boeing's really kind of stuck in a hard spot here...
REPORTER: Dennis Muilenburg was blasted on Capitol Hill...
Two months later, with the company's stock plummeting...
REPORTER: Boeing's stock has been dropping all day...
REPORTER: But it's down 22% since the 737 Max jet was first grounded.
..and the Max still grounded,
Dennis Muilenburg was out.
(ENGINES WHINE)
In March of 2021
families gathered in Washington, DC,
for the second anniversary
of the crash of Ethiopian Airlines Flight 302.
Boeing had recently settled a criminal charge
of conspiracy to defraud the United States
brought by the Department of Justice.
We have some breaking news on Boeing...
In the settlement,
Boeing admitted to misleading statements, half-truths
Boeing admitted and omissions about MCAS.
It agreed to pay $2.5 billion -
$500 million to the families of the victims
and most of the rest to compensate the airlines.
After 20 months of being grounded,
the 737 Max was approved by the FAA to fly again.
(INDISTINCT FLIGHT RECORDING)
(INDISTINCT YELLING)
A 737 Max flown by Alaska Airlines had taken off from Portland, Oregon,
about seven minutes earlier.
At an altitude of 16,000ft
there's a very loud bang.
A piece of the plane's body is blown out at row 26.
HUY TRAN: I opened my eyes to a giant hole in the plane
and I could see the city lights. HUY TRAN: I opened my eyes to a giant hole in the plane
and I could see the city lights.
OK.
There's a deafening wind howling through the plane.
There's a deafening wind The cockpit door flies open.
One of the pilots loses her headset.
Another pilot almost loses his One of the pilots loses her headset.
Another pilot almost loses his after his head slams into a display.
Another pilot almost loses his There's just chaos.
EVAN SMITH: A boy's shirt was sucked off him and out of the plane,
and his mother was holding on to him. EVAN SMITH: A boy's shirt was sucked off him and out of the plane,
and his mother was holding on to him.
I saw a half of his body was getting sucked out, and his mother was holding on to him.
I saw a half of his body was getting sucked out,
and then I was like, "Oh, my God!" was getting sucked out,
and then I was like, "Oh, my God!"
VI NGUYEN: I look over and there's a hole on the side of the plane,
and in that moment I'm just like, "Oh, God, I'm gonna die."
The plane was able to make an emergency landing back in Portland.
But the incident resurrected concerns about Boeing and the Max.
We were very fortunate we didn't have a third crash on January 5. But the incident resurrected concerns about Boeing and the Max.
We were very fortunate we didn't have a third crash on January 5.
We're gonna (BLEEP!) die!
Joe Jacobsen has continued to monitor the Max
since retiring from the FAA in 2021.
Alaska 1282 could have very easily been a fatal crash.
Higher altitudes, some passengers may have lost consciousness,
pilots could have lost consciousness.
This time the FAA immediately grounded similar Max 9s
so that each plane could be inspected.
NEWSREADER: Hundreds of flights are cancelled across the US.
NEWSREADER: Boeing 737 Max... NEWSREADER: Pulled out of service...
..now grounded around the world... ..forcing hundreds...
At The New York Times
a new team was picking up At The New York Times
a new team was picking up the reporting on the Max
a new team was picking up and what it meant for Boeing.
SYDNEY EMBER: The real bombshell moment
comes in early February SYDNEY EMBER: The real bombshell moment
comes in early February
when the National Transportation comes in early February
when the National Transportation Safety Board
when the National Transportation releases its preliminary report
on the incident.
What the NTSB's report makes clear
is this was a problem on Boeing's factory floor.
is this was a problem This was Boeing's problem.
The NTSB focused on a piece of the plane
that replaced an unused emergency exit called a door plug.
that replaced an unused Boeing workers had failed to install
four bolts
that secured it to the plane.
The company later said it had no documentation of the work.
MARK WALKER: Where was the oversight?
Where was the redundant checks
for someone to come back
to make sure that the most critical pieces to it were there? for someone to come back
to make sure that the most critical pieces to it were there?
NIRAJ CHOKSHI: Nothing in plane design or plane production
is done without several layers of redundancy,
without frequent inspections, without frequent checks,
without frequent inspections, and the idea that
something as important as a part of the plane's body
could leave the factory without the bolts needed to hold it in place
could leave the factory without is...shocking.
SYDNEY EMBER: This was supposed to be
one of the most highly scrutinised planes in the world,
and here you are with another incident
and here you are that was risking passengers' lives.
Boeing CEO Dave Calhoun was quick to own the failure
in a series of appearances.
We're gonna approach this, number one, acknowledging our mistake.
I want everybody, everybody on every aeroplane We're gonna approach this, number one, acknowledging our mistake.
I want everybody, everybody on every aeroplane
to know that Boeing owns it.
The door plug was a production failure,
The door plug MCAS was a design flaw,
but both raised questions
about Boeing's safety culture and the FAA's oversight.
The shocking thing about the Max is the sheer number of problems,
design problems, manufacturing problems.
Joe Jacobsen is now working with families of the victims
Joe Jacobsen is now working of the 737 Max 8 crashes
to bring other safety concerns to the FAA.
And this is after, you know,
the supposedly most comprehensive recertification
the supposedly most comprehensive in the history of aviation.
DAVID GELLES: in the history of aviation.
DAVID GELLES: I think what's most scary
is that you have both kinds of accidents
is that you have both kinds happening at the same company.
That, to me, reveals a culture inside the company.
I mean, I know we keep coming back to this word 'culture',
but it's right at the root of what happened in both sets of accidents.
In a statement but it's right at the root of what happened in both sets of accidents.
In a statement
Boeing said it is dedicated to transparency
and it is implementing a comprehensive plan
to strengthen safety and quality. a comprehensive plan
to strengthen safety and quality.
Less than seven weeks after the Alaska Air incident,
the executive running the Max program was out.
In early March
the FAA said it had found multiple quality control issues with the Max.
The agency also released a report that found Boeing's safety culture
The agency also released a report has been inadequate and confusing.
And now the Justice Department is investigating the company.
Cultural change doesn't happen overnight,
especially at big corporations like this.
And it doesn't happen just because he got slapped with a fine.
It's the product of millions of decisions,
It's the product whatever it might mean
in terms of lost profits that impact the share price in the short term.
But if Boeing wants to get back to that place of grandeur
where it was for so long,
one of the most important American companies,
one of the most important it's gonna take...not four years,
but it might take 14.
More than 170 Max 9s were grounded by the FAA
More than 170 Max 9s after the Alaska Airlines incident.
Nearly all are now back in service.
(THEME MUSIC PLAYS)
Captions by Red Bee Media
Copyright Australian Broadcasting Corporation