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00:00On the morning of October 29th,
00:30I was woken up by a colleague who alerted me that a line aircraft crashed.
00:37He said, it's the MAX, and I was surprised because it was a new aircraft.
00:43My company provided the air data for aircraft flying around the Jakarta area.
00:49So I went to the computer and looked at the data.
00:53It was immediately apparent that, okay, something was wrong.
00:57The plane went up to about 2,000 feet, just over a minute after takeoff.
01:04And the plane had a bit of a dive.
01:06And then the plane had climbed to about 5,000 feet.
01:11But then at 5,000 feet, the plane was fluctuating up and down.
01:16And the plane just started diving.
01:18It just didn't make sense.
01:19You don't see planes diving on departure.
01:22I was baffled.
01:24Why did it go down?
01:30Lion Air flight JT 610 went missing from radar.
01:33189 people were killed in the crash of Lion Air flight 610.
01:38The Boeing 737 MAX 8.
01:41The plane was a new Boeing 737 MAX.
01:44What do we know about this 737 MAX 8?
01:47The fastest selling jet in Boeing history.
01:50Just introduced the year before.
01:52We don't yet know what caused this crash.
01:53A breakthrough this evening in a flight data recorder.
01:57It holds many of the keys.
01:59The data from the black box quickly got to FAA engineers in the United States.
02:06There is a purity of this data.
02:08It comes directly from the black boxes.
02:11So it's recording airspeed, altitude.
02:14The data showed what appeared to be a glitch.
02:17Something repeatedly moving part of the plane's tail, controlling its pitch.
02:21It didn't take long, just a couple of minutes,
02:24to see that there was rapid movement of the horizontal stabilizer.
02:29It's probably the fastest way to kill yourself in an airplane,
02:32is to have the stabilizer malfunction.
02:36My spine literally tingled when I saw the traces from the black box.
02:41The plane continually tried to push the nose down.
02:45And the pilots were trying over and over again to stop the plane.
02:49And in the end, they lose that battle.
02:54What Boeing had not told airlines or their pilots
02:57was that it had put a powerful software system on the new airplane.
03:01In the Lion Air crash, this system was receiving incorrect information.
03:06And that made a plane dive straight downward and destroy itself.
03:11Inside Boeing, they quickly diagnosed the problem and began working on a fix.
03:17But they stood by the MAX as hundreds of them took to the air around the world,
03:22carrying thousands of passengers.
03:25The company alerted pilots about handling a potential malfunction.
03:28Boeing and the FAA today warned airlines that sensors on 737 MAX 8 jets can malfunction.
03:35Boeing are calling this a formal advisory, and it's been issued to the pilots.
03:40The reporting showed Boeing knew that it was risky.
03:45But their response was to blame the pilots.
03:50Pilots did not hit two cutoff switches.
03:52Boeing says that action was part of well-established protocols for all 737s.
03:56And that led to a series of decisions that kept the plane in the air.
04:02And then we got another crash.
04:06Breaking news out of Ethiopia, where a plane went down.
04:09It was Ethiopian Airlines Flight 302 on its way to Nairobi from Addis Ababa.
04:14For a new 737 MAX 8 jetliner crashed minutes after taking off.
04:19Two crashes, the same plane.
04:22346 people killed.
04:23An iconic American company's reputation in tatters.
04:28The story of the Boeing 737 MAX would end up exposing corporate deception and a broken regulatory process.
04:36But at the center was a software system supposed to keep people safe that instead led to their deaths.
04:43Black boxes from the Ethiopian crash.
05:13Have been recovered.
05:16It's the second disaster within five months involving the Boeing 737 MAX.
05:23That's the same kind of aircraft that crashed back in October in Indonesia.
05:28157 people, including passengers and crew members on board, all dead.
05:38The first thing you get to see at the site is a very big hole.
05:47And then to only imagine this is the place that they were last alive.
05:52We learned that there were no survivors on the plane.
05:59And then our objective was to go and bring my daughter's body home.
06:04Now you're in close proximity, you're able to see the fine details, you're able to maybe think these are personal effects,
06:15it belongs to my sister or my mom, or this bone, whose bone is this.
06:21And they told us that there was no part of a human that was bigger than a femur that was left.
06:36That whole experience is just a jumble of images and painful thoughts and blankness really to me.
06:44The crash of Ethiopian Flight 302 was the second time in five months that a Boeing 737 MAX had gone down.
06:59As families gathered at the crash site, across the world, reporters at the New York Times were investigating
07:13what had been going wrong with Boeing's new commercial jet.
07:18Statistically speaking, the likelihood that these two accidents were not in some way connected was extremely low.
07:29It suggested that there was something going on with the plane, and obviously we were determined to find out.
07:38It was clear from the get-go that Boeing was in full crisis mode.
07:43As the facts from the accident become available and we understand the necessary next steps,
07:48we're taking action to fully reassure airlines and their passengers of the safety of the 737 MAX.
07:55This was going to be an existential crisis for the company if these two events were related.
07:59China grounds the plane first, other international regulators ground the plane, then the European Union grounds the plane.
08:07But in the U.S., the FAA says it's not grounding the plane.
08:10Boeing and the FAA all were saying that they were sort of waiting for the facts
08:15before they rushed to judgment and grounded such an important new plane.
08:19But for months, the Times was reporting there was something wrong with the 737 MAX itself.
08:25The software system that pilots had not known existed.
08:29The Maneuvering Characteristics Augmentation System, or MCAS.
08:34The function of this previously undisclosed system was to save the plane when it believed that the plane might go into a stall and fall out of the sky.
08:48And so this system was designed then to sort of take over the stabilizer and push that nose back down in case the pilot gets in trouble.
08:59Then, a major setback for the company.
09:04Radar showed the two planes' flight patterns were eerily similar.
09:10Days after the rest of the world had reached the same conclusion, they finally grounded the plane.
09:18For the New York Times reporters, all the signs pointed to MCAS.
09:23We knew that MCAS was the beginning. We knew that we needed to start with this system.
09:28This was a really problematic software system in the way it was designed.
09:35Okay, well, then how the hell did it end up in the plane this way?
09:43Boeing declined to be interviewed for this film.
09:46In a statement, the company said safety is its top priority, and it has worked closely with regulators, investigators, and stakeholders
09:54to implement changes that ensure accidents like these never happen again.
10:02This story really begins in 2011.
10:08The 2011 Paris Air Show officially opened Monday.
10:12Boeing and Airbus had been going head-to-head for at least a decade.
10:16But Airbus had been quickly catching up and really nipping at Boeing's heels.
10:20It's the best air show ever for Airbus in terms of aircraft numbers sold.
10:27In 2010, Airbus introduced the A320neo, a more fuel-efficient version of its stalwart A320.
10:35The A320 is the direct competitor to the Boeing 737.
10:41Airlines wanted an airplane that was more fuel-efficient than the airplanes then in service.
10:49Airbus chose to re-engine the A320 into what they called the NEO, the New Engine Option.
10:54It's a record 200 orders for its A320neo.
10:58It was one of the fastest-selling programs of aviation history.
11:03And it placed enormous pressure on Boeing to respond.
11:07About 40% of the profits for the entire Boeing company came from the 737.
11:13The 737 was the best-selling commercial airplane of all time.
11:1710,000 737 aircraft is going to roll the assembly line.
11:21More than 10,000 of these airplanes have been used by hundreds of airlines all over the globe.
11:26The official 737 christening ceremony took place in the new final assembly building.
11:31What always amazed me is that the 737 was first introduced when the Beatles were still together.
11:37Right.
11:37January 17, 1967, flight attendants christened the first Boeing 737 by smashing champagne bottles over the wings.
11:44It was designed to be very low to the ground.
11:49Now, by the 1980s, Boeing had to upgrade the 737, and they created what was called 737 Classic,
11:58which had a new engine on it.
12:00Brand new Boeing 737-500.
12:02In the 1990s, you had the 737 Next Generation, which had a new wing on it and some fuselage stretches.
12:10And so here we are in 2011 at the Paris Air Show with the A320neo, and Boeing, frankly, was caught flat-footed.
12:20Within a couple of weeks, Airbus and American Airlines have the preliminary workings of what would become the first deal for American to buy Airbus planes in more than a decade.
12:31Gerard Arpey, the CEO of American Airlines, calls Jim McNerney, the CEO of Boeing, so it's a courtesy call at this point, just letting their long-time supplier of airplanes know they're going to go with the competition.
12:46And that is essentially a dagger in the heart of Boeing.
12:51And within 48 hours, Boeing had decided to pull the trigger on launching the re-engine 737, which later became branded as the MAX.
13:01From the very beginning, from its birth, it was marked by competitive pressure.
13:08You need to understand what was going on with Boeing at the time that the MAX program was launched.
13:16Boeing was billions of dollars over budget on its 787 program, on its 747-8 program.
13:22Airlines were thoroughly ticked off at Boeing over the delays, and Boeing was looking at the MAX to restore its own credibility.
13:36Within days of the second 737 MAX crash, another investigation was underway in Washington, D.C.
13:43We started getting information in from whistleblowers from people, both current and former FAA and Boeing employees.
13:52Doug Pasternak was leading a congressional investigation.
13:56This is the first time he is speaking publicly about what he found.
14:00As soon as the second accident occurred, we started our investigation, and our focus was on the design, development, and certification of the MAX.
14:12We got hundreds of thousands of pages of documents from Boeing.
14:19One 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.
14:29Boeing is a tremendous engineering company and a technical marvel, but almost without failure, they point to a degradation of that mindset.
14:41And that safety suffered as a result.
14:46Looking backwards, I think you can clearly see the trajectory to tragedy along the way at Boeing.
15:00Boeing publicly said the MAX went through a deliberate six-year development process.
15:04But 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.
15:17One specific engineer we spoke to was Rick Ludkey.
15:21He helped design the cockpit in the MAX.
15:23And he talked a lot about how there was an obsession in limiting changes.
15:27This program was a much more intense pressure cooker than I'd ever been in.
15:32The company was trying to avoid costs, minimum change to simplify the training differences and to get it done quickly.
15:44That put what had happened in the context of this broader corporate narrative.
15:49Yeah.
15:50Speed was what they seemed to desire.
15:53There was a lot of decision-making that was somewhat arbitrary and didn't involve as much of what engineering considers healthy debate.
16:04The challenge to the Boeing designers was that any designs we create would not drive any new training that required a simulator.
16:17In his recorded interview with the Times, Ludkey said Boeing management was so determined to avoid the expense of new training, they made a bold promise.
16:26Sales had made a commitment with Southwest that for any airplane they delivered that had a new level B differences training, Boeing would pay the company $1 million per every airplane delivered.
16:39If the MAX required simulator training, it would rebate Southwest $1 million per plane.
16:49And there's that incentive.
16:50That's why it was so important to Boeing that pilot training be kept to a minimum.
16:55All 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.
17:10That meant Boeing had to do a number of things to make this plane fly like the old one.
17:16And that was because the MAX had much bigger engines on it to make them more fuel efficient.
17:22But because the 737 was a 50-year-old airplane at this time practically, when it came time for Boeing to put those engines on the wings, the engines were so darn big, they had to mount them further forward on the wings.
17:39They were testing in this wind tunnel and they were discovering the plane was handling just a little bit differently, but they didn't even have a plane built yet.
17:46So this wasn't, you know, happening in real flight.
17:48This is something you have to fix.
17:50This is something you have to fix.
17:51And they leaned on a system that they had used once before in a military tank.
17:59It was designed as a system on the plane to really just smooth out the way the plane handled.
18:06It was MCAS.
18:07It was designed for these extremely unusual maneuvers, situations that hopefully the plane would never get in.
18:17And to prevent the nose from getting too high, the system would move the stabilizer on the back of the plane to push the nose back down.
18:27But inside Boeing, there were early signs of trouble.
18:34One of the first documents we found was from November of 2012.
18:41A Boeing test pilot was flying the MAX in a flight simulator and trying to respond to an activation of MCAS.
18:53And that resulted in what he described as a catastrophic event.
19:01It showed that if that had been in real life, he could have lost the airplane.
19:06They realized from that moment on, even a Boeing test pilot may have trouble responding to MCAS.
19:15The company kept quiet about the simulator experience and appeared to have discounted the test results.
19:22Still, in the following months, some Boeing employees suggested simply removing all references to MCAS from training manuals.
19:31Boeing, from almost the very beginning, realized the significance of MCAS and the significance MCAS would have on pilot simulator training.
19:44If we emphasize MCAS is a new function, there may be a greater certification and training impact.
19:53Recommended action.
19:55Investigate deletion of MCAS nomenclature.
19:59What that meant was that if they said MCAS was a new function, the FAA was going to scrutinize it a lot more.
20:08Boeing told Congress it kept the FAA informed about MCAS's development and final configuration.
20:19But Boeing has a complex and close relationship with the agency that oversees it.
20:24The airplanes are part of the story, but so are the regulators.
20:29The FAA regulated Boeing in part with a handful of Boeing employees whose paychecks came from Boeing, but whose jobs were to represent the interests of the FAA.
20:49It's a decades old arrangement known as delegation that allows federal agencies to give oversight powers to the companies they regulate.
21:00In the beginning, there was a really good reason for this.
21:04The FAA was certifying things that made no sense to have them certify every single exit sign or bathroom sign or paint.
21:13The issue that many of the FAA employees that we talked to had was that it went way beyond bathroom signs.
21:24Over time, Congress passed laws that pushed the FAA to hand over the responsibility for more and more tasks to the company, to Boeing.
21:35With this level of delegation between the company and the FAA, it became hard to understand who was working for who.
21:46There was one key person inside the FAA, Ali Barami.
21:50I'm Ali Barami. My job at the FAA is to lead and manage aviation safety organization.
22:00In the midst of a long career at the FAA, Ali Barami had left to spend four years as a lobbyist for the Aerospace Industries Association.
22:09While he's in that lobbying role, he says, we urge the FAA to allow greater use of delegation, not only to take full advantage of industry expertise, but to increase the collaboration that improves aviation safety.
22:26So here's the guy who would ultimately lead the FAA's safety operation, encouraging the FAA to let industry do as much of its certification work as possible.
22:36Neither Ali Barami nor the FAA would agree to an interview, but former FAA Administrator Michael Huerta spoke to us about delegation and the relationship between the agency and Boeing.
22:52There are those that believe it is the fox guarding the hen house. Here is why it's not.
22:58The company has an organization whose responsibility is to ensure that it is in compliance with the standards that are set by the FAA.
23:10And it has a level of independence from the entities that they're overseeing.
23:15What that gets back at is the issue of trust and transparency, because the whole regulatory framework and the whole delegation process is premised upon a notion that everyone is going to share their knowledge and their expertise with one another.
23:38In the design of the 737 MAX, many things would be delegated to Boeing. That included MCAS.
23:50Under the impression that this was a relatively benign system, the FAA agreed to delegate it, as is the custom with the FAA and Boeing.
24:00And that's what happened in this case. It handed it over.
24:08In 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.
24:21Congress has ordered the agency to revise the delegation process.
24:25After years of going through design and development, the 737 MAX prototype was rolled out of Boeing's Renton factory for its maiden flight.
24:40Ed Wilson is in the cockpit. He's the new chief pilot, and he takes off.
24:46And let's just take a listen as this airplane gets ready for its very first take.
24:49A short time after this first maiden flight, Ed Wilson, he and his co-pilot start to realize that the 737 MAX is not handling as smoothly as it should in certain low speed situations.
25:08It's shortly after takeoff. You know, it's still kind of climbing to ascend. It's not going full speed.
25:13Boeing engineers had an idea for how to deal with this.
25:16They know about MCAS, and they know that MCAS was actually used for a similar situation in these high speed maneuvers.
25:26And so, theoretically, MCAS could also be used in these other situations to also smooth out the handling.
25:34Crucially, it's already been created. It's already been approved.
25:37And it's something that we could just apply, you know, to a different phase of flight.
25:44It's actually a pretty easy fix.
25:48This ends up being an extremely fateful decision.
25:53They enable the stabilizer to move much more, actually four times as much.
25:57Now the system's designed for low speed situations like just after takeoff.
26:04And after takeoff is when the plane is still only a few thousand feet over the ground.
26:09That means you have much less room for error.
26:12It's happening in automated fashion and a repeated fashion.
26:15This fundamentally changes MCAS.
26:20It makes it much more aggressive, much more risky.
26:25It's a far more dangerous system.
26:30Boeing was doubling down on the system, expanding it, despite the earlier catastrophic result in a simulator test.
26:37The Times reporting on MCAS focused on a former Boeing pilot.
26:44I started to hear about a pilot at Boeing whose name was Mark Forkner.
26:51He came up through the Air Force Academy, he flew for Alaska Airlines, and he became the chief technical pilot for the 737.
26:58He had played a definitive role in making sure that there was minimal pilot training on the MAX.
27:11Boeing released to our committee instant messages and emails from Mark Forkner and some of his colleagues.
27:20In one of these emails that Mark Forkner sent out, he says,
27:25I want to stress the importance of holding firm that there will not be any type of simulator training required to transition to MAX.
27:36And he said, quote, Boeing will not allow that to happen.
27:41He was this key liaison between the company and the FAA.
27:45He was the person who personally emailed the FAA asking for MCAS to be removed from the pilot manual.
27:58That was an important piece of this because we understood that the FAA really didn't know that MCAS became more powerful.
28:06He was speaking absolutely on behalf of the company.
28:12This was not some low level employee.
28:15And he was asking for something that was really quite substantial.
28:18That a new piece of software that made the plane behave in ways that it previously hadn't be concealed from the pilots.
28:25This is where the commercial pressures from the executive level come right down to the development of the airplane.
28:36Mark Forkner certainly was not a lone actor in what he did.
28:42He was following through in a policy by Boeing to ensure that the program did not have to put pilots in a flight simulator.
28:51It got to the point where Mark Forkner got an award for keeping training on the 737 MAX to a minimum.
29:03Nearly eight months after requesting that MCAS be removed from pilot training manuals,
29:09Forkner texted a colleague with a shocking realization.
29:13This appears to be the moment where Mark Forkner learns that MCAS has been expanded.
29:19He writes in that message, I basically lied to the regulators unknowingly.
29:24But he never went back and corrected the record.
29:28He never went back and fixed the error.
29:34Mark Forkner wouldn't speak to us, but his lawyer told the Times reporters that his communications with the FAA were honest.
29:41And that he would never jeopardize the safety of other pilots or their passengers.
29:45When Boeing engineers expanded the MCAS system, they included a feature that would make it particularly dangerous.
29:56Planes have millions of parts in them.
29:59And there's one little one on the 737 that sticks out of the fuselage.
30:04See that little black circle there that is called the angle of attack sensor.
30:11On the 737 MAX, it had the power to trigger MCAS.
30:16It's the AOA sensor that is one of the crucial parameters to the computer to tell the plane that it's in a perilous condition.
30:28The angle of attack sensor would activate MCAS by telling the system that the plane's nose was too high.
30:35And then MCAS would try to push the nose down.
30:38But if this sensor is broken for whatever reason, MCAS never realizes.
30:44And so it keeps pushing the nose of the plane down over and over again.
30:54Congressional investigators would later find documents showing that Boeing engineers had raised this very concern.
30:59An engineer asked, what if we have a faulty AOA sensor?
31:05Because AOA sensors are known to be faulty.
31:08You know, what happens to the airplane?
31:11So you have those concerns raised.
31:15And the responses, again, from Boeing engineers was to essentially dismiss those.
31:22Three, two, one.
31:25Boeing began delivering the new 737 MAX in mid-2017.
31:31At the outset, 737 MAX was arguably one of Boeing's biggest successes.
31:38It had become its best-selling jet ever.
31:40Advanced sales were estimated at $370 billion.
31:44American had orders for $100.
31:47Southwest Airlines for $200.
31:49Boeing had focused especially hard on selling to developing markets in Asia,
31:55where Lion Air's parent company became the first customer to fly the 737 MAX,
32:01signing an agreement worth more than $20 billion.
32:05Airlines loved it.
32:06There was a years-long waiting list to get one.
32:10But Boeing's signature new jet had a fatal flaw.
32:17Breaking news, the search for wreckage is underway after a passenger jet with 189 people on board crashed.
32:25A Lion Air Boeing 737.
32:27An nearly brand-new Boeing 737.
32:29Investigators from the U.S. National Transportation Safety Board contributed to an analysis of what led to the Lion Air crash.
32:36Leading up to the Lion Air accident, the angle of attack probe itself was miscalibrated.
32:42The maintenance crew was not able to properly identify this miscalibration.
32:49The angle of attack sensor sent bad data to MCAS.
32:53The plane thought it was in a stall because of bad information.
32:56And as a consequence of this angle of attack data error, the MCAS activated when it really shouldn't have.
33:04Five months later, almost the exact same thing happens halfway across the world.
33:14New 737 MAX 8 jetliner crashed today.
33:18Investigators say that flight had similar problems to the Lion Air crash.
33:22Once again, the angle of attack sensor is malfunctioning.
33:25But there is this question now about systems within the aircraft.
33:28If MCAS hadn't been on those planes, those planes wouldn't have crashed.
33:31It's that simple.
33:32The world mourns 157 people killed in the Sunday crash.
33:36On the flight of 737 MAX crash, we lost five of our family members.
33:49We had our mom, Ann Karanja, our dear sister, Caroline Karanja, her three kids, Ryan Djoroge, Kelly Wanjiku, and Ruby Wangoi.
34:00It's not like there is a manual of how you need to react.
34:08You're just there. It's like motionless.
34:11You just feel infuriated by anyone and everyone at that point.
34:16I remember the Boeing company blaming what they call the foreign pilots and deflating blame to them, saying they are the cause.
34:28All of us at Boeing are deeply sorry for the loss of life in the Ethiopian Airlines Flight 302 and Lion Air Flight 610 accidents.
34:43Boeing CEO Dennis Mullenberg latched onto findings that inexperience and lack of training were part of a chain of events that led to the crashes.
34:51It was a controversial position.
34:54Understand that these airplanes are flown in the hands of pilots.
34:57And in some cases, our system safety analysis includes not only the engineering design, but also the actions that pilots would take as part of a failure scenario.
35:08Boeing's contention from the beginning was that even though the pilots did not know that MCAS existed, that they did not need to know that.
35:19And in some cases, those procedures were not completely followed.
35:24Boeing believed that the pilots should have been able to realize that it was very similar to a runaway stabilizer situation.
35:33Runaway stabilizer is an aviation term for a malfunctioning stabilizer.
35:39After the Lion Air crash, Boeing had issued a directive to pilots to be aware of this possibility and told them what to do if it happened.
35:47When that part of the tail was not acting the way that it should be, you take manual control of it.
35:54The pilots could have stopped their roller coaster ride by turning these two switches off.
35:59To shut off power to the stabilizer, you stop it from moving on its own.
36:02And then you start cranking a wheel in the cockpit that literally will manually move the stabilizer back to where you want it to move.
36:12The issue was, were there things happening inside the cockpit that might have made that harder to do?
36:22That's what we were asking.
36:23When we finally got the preliminary black box data from the Ethiopian crash, we called up Dennis Tazier, an American Airlines 737 pilot, and sent him the data, and we read through it together.
36:41My mission was to provide them, I'm in the cockpit, I see what's happening now.
36:47So we walked through each line, and I had no idea what was in it.
36:53I knew that the crew had an experienced captain and a lesser experienced first officer.
37:00We go, second by second, through the few minutes of this flight.
37:07Going through the steps that the pilots had taken, and saying, yep, I would have done that, yep, I would have done that.
37:13And as soon as they lifted off the ground, all these different alerts started popping up.
37:19The airspeed was unreliable, the altitude was showing unreliable, there were alerts related to that.
37:24But they bring the gear up, and they continue to climb out.
37:29Two minutes into the flight, based on faulty data from the AOA sensor, MCAS kicked in and began pushing the nose down.
37:38Don't think.
37:39And I have very clear memory of noting a time mark
37:51where 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.
38:02And I have to confess.
38:07I probably swore, I said, the kid got it right.
38:11That kid got it right.
38:14What had happened was, the pilots did do what they were supposed to do.
38:19They had cut the electricity off.
38:21Don't think.
38:22They hit these switches, and they tried to take manual control.
38:26The first officer is reaching to this large wheel on his left, and that's the manual trim wheel, and trying to turn it.
38:34It's like lifting up a 10-ton bucket of cement out of a deep well.
38:39The problem was, at that point, the plane was going so fast that even after they took manual control, they could not physically get the plane to right itself.
38:52They shouldn't have been going that fast.
38:54Too low.
38:55Terrain.
38:56And they're continuing to accelerate towards the ground.
38:59The ground is approaching them.
39:02Then, with no apparent recourse, the pilots reached for the stabilizer switches.
39:08I'm yelling into the cockpit.
39:11Don't do that.
39:13But I don't know what they're facing.
39:15Terrain.
39:16MCAS was reactivated.
39:18MCAS says, hey, I'm back on.
39:20Here we go.
39:21Zzzz.
39:22And now the airplane is in near full nose down trim, and you can pull back forever.
39:29And there's not enough metal in the back of the airplane to make that airplane come up to a nose up.
39:34Terrain.
39:35Terrain.
39:36Pull up.
39:37Pull up.
39:38Pull up.
39:39Pull up.
39:45She died when she was 24.
39:47It's unbearable that she's not with us.
39:57And the only thing I can do is try to prevent this for other people.
40:06About four months after the Ethiopian Airlines crash, the family of Samya Stumo was about to receive news they would find bewildering.
40:16We were eating dinner, and I hadn't looked at my phone for a long time.
40:20And it was blowing up.
40:23We are joined today by Ali Bahrami, the Associate Administrator for Aviation Safety.
40:30German College, ranking member.
40:32There were families from Kenya, from Ethiopia, from all over saying, who is this Ali Bahrami?
40:39We continue to evaluate Boeing's software modification to the MCAS.
40:44The FAA's 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.
40:54After Lion Air.
40:56If the agency's own analysis found MCAS to be an unacceptable risk, why did the FAA not take immediate action to address those risks?
41:12The families hadn't known that before.
41:14They didn't know that the safety agency gambled with passenger lives.
41:19We knew that eventual solution would be to have the modification, and based on our risk assessment, we felt that we had sufficient time to be able to do the modification, you know, and get the final fix.
41:35After the Lion Air crash, the FAA had conducted an analysis of the likelihood of another 737 MAX crashing.
41:45The worst case scenario was grim.
41:49They 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.
42:03And 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.
42:18About one crash every other year.
42:22But 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.
42:39The agency had given Boeing 150 days to fix MCAS and issued official directives to pilots.
42:46They were gambling.
42:48They were betting against time that they would have a fix to MCAS before the next crash happened.
42:54And unfortunately, they lost that bet.
42:59Not everyone within the FAA agreed with the agency's gamble.
43:04People too quickly jumped to that conclusion that the pilot should have been able to figure out what's going wrong and be able to intervene properly.
43:13FAA engineer Joe Jacobson examined the data from the Lion Air crash and quickly raised concerns about the safety of the MAX.
43:23This is his first on-camera interview.
43:26I was pointing out a design flaw.
43:28It was purposely designed and certified to use only one AOA input to drive MCAS to move the horizontal stabilizer at a high rate.
43:37I talked to three managers and said this is a design flaw.
43:40They were skeptical, not really buying in, saying, you know, the pilots should have been able to intervene.
43:46It's a failure.
43:49Our job is aviation safety, and when airplanes go down, we feel a real personal sense of loss and remorse and failure.
44:00And it affects a lot of people.
44:03In the fall of 2019, with the MAX having been grounded for seven months, congressional investigators released internal communications they found during their investigation.
44:17Test pilots working for Boeing write about problems with the MCAS system two years before the first fatal crash.
44:24They offered further evidence of the company's attempt to avoid pilot training for the MAX.
44:30Then we got the messages, and I remember where I was in my kitchen because it was Mark Forkner.
44:36In one document, the former Boeing pilot who had written notes assuring MCAS would not be put in training manuals, joked about swaying regulators with Jedi mind-tricking.
44:49Other documents released later even showed Forkner dismissing the idea of pilot training for Lion Air.
44:56When Lion Air, the airline that ultimately flew the first plane that crashed, was asking for simulator training, he was disparaging them to his colleagues, calling them stupid.
45:10I mean, seriously?
45:11Did that ever cross their minds that they were going to let something go into the air that could potentially kill people?
45:25Boeing's CEO Dennis Mullenberg appeared before Congress.
45:29Boeing's CEO is expected to acknowledge that his company made mistakes.
45:33And here's the first time that this guy's in the hot seat.
45:38By then, he'd become the face of the 737 MAX crisis.
45:43We should have been on this committee a long time.
45:45We have never undertaken an investigation of this magnitude.
45:48We intentionally put the families close to the witness.
45:52They're the victims here.
45:54And 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.
46:03The committee confronted Mullenberg with an array of internal Boeing documents.
46:10Next slide.
46:12This shows that Boeing became aware that the disagree alert wasn't working.
46:15Does appear from this that Boeing understood how important crew training...
46:19The pilots didn't know about this is unacceptable.
46:22Boeing's marketing representatives emphasized to potential customers that FAA had reduced the length of pilot training that...
46:27Slow reaction time scenario, 10 seconds, found the failure to be catastrophic.
46:33For those families, the pain of this was accentuated because this evidence that was going up on the screen was information that they felt that Mr. Mullenberg could have used to inform his decision about keeping the plane in the air or not.
46:51We do know that Boeing engineers actually proposed placing a MCAS enunciator in the cockpit.
46:58Are we vulnerable to a single AOA sensor failure?
47:01Now, as you emphasize, flight control will now compare inputs from both AOA sensors.
47:08I guess the question is, why wasn't it that way from day one?
47:13Mr. Chairman, we've asked ourselves that same question over and over.
47:18And if back then we knew everything that we know now, we would have made a different decision.
47:23Nadia Milleron, she was radiating with anger over this.
47:30It's come to the point where you're not the person anymore to solve the situation.
47:35I want to say it to you directly because I don't think you understand what we're saying.
47:40She was right in front of him. And here you have the CEO of what is one of the most important American companies.
47:46One of the most important companies in the world.
47:48In the end, it's about safety.
47:50Even if you're not capable of doing that.
47:52Looking in the eyes of the mother of a young woman who died on his airplane.
48:00I know that she wasn't afraid of flying at all until the last six minutes of her life.
48:08That's just a horrible betrayal that Boeing and the FAA caused for this person in the last moments of their life.
48:20And it kills me that that trust was betrayed.
48:24Boeing's really kind of stuck in a hard spot here.
48:28Dennis Mullenberg was blasted on Capitol Hill.
48:31Two months later, with the company's stock plummeting.
48:34Boeing's stock has been dropping all day.
48:36But it's down 22% since the 737 MAX jet was first grounded.
48:40And the MAX still grounded.
48:42Dennis Mullenberg was out.
48:44Near the one-year anniversary of the second 737 MAX crash, New York Times reporters Natalie Kitraweff and David Gellis flew to St. Louis.
49:00By then, Boeing was recommending pilot training and retooling the MCAS software with a second AOA input as a failsafe.
49:10They'd been invited to Boeing's offices there by the new CEO.
49:14Welcome.
49:15Thank you for having us. We're happy to be here.
49:17The interview was recorded.
49:19Badger here.
49:20We've got a lot of questions.
49:21He had been on the company board of directors throughout the 737 MAX program and described himself as the company's backup plan to Dennis Mullenberg's handling of the crisis.
49:34Boards are invested in their CEOs until they're not.
49:39We had a backup plan. I think this board was incredibly well prepared.
49:43I am the backup plan.
49:45David Galhoun had been on the board of Boeing for several years.
49:50He laid the blame squarely at the feet of Dennis Mullenberg.
49:55He was in the midst of damage control.
49:58It's more than I imagined it would be, honestly.
50:03And it speaks to the weaknesses of our leadership.
50:07He was shooting straight from the hip.
50:10It was kind of disarming to hear from the CEO of Boeing.
50:15He told the reporters the company had indeed made a fatal mistake, which was assuming all pilots could counteract a misfire of MCAS.
50:25We made a decision in December to recommend simulator training everywhere in the world because of the regulators and the pilots in the developing world.
50:36Not because the U.S. airlines needed it. They probably don't.
50:43There is this narrative that some Fordham pilots are not as good as American pilots.
50:48And Boeing seemed to be suggesting as much.
50:50We pressed Calhoun on this issue.
50:53Do you believe that if U.S. pilots had encountered the MCAS malfunction that Lion Air and ETO 302 experienced, would they have been able to deal with it in your estimation?
51:04And I'm not going to let you write this down.
51:08Do you agree you're not going to write it down?
51:10No.
51:11No.
51:12No.
51:13No.
51:14No.
51:15No.
51:16No.
51:17No.
51:18That interview was essentially the last Boeing story that we did.
51:19No.
51:20No.
51:21No.
51:22No.
51:23No.
51:24No.
51:25No.
51:26No.
51:27No.
51:28No.
51:29No.
51:30No.
51:31No.
51:32No.
51:33No.
51:35No.
51:36No.
51:37No.
51:38No.
51:39in march of 2021 families gathered in washington dc for the second anniversary of the crash of
51:46ethiopian airlines flight 302. boeing had recently settled a criminal charge of conspiracy to defraud
51:53the united states brought by the department of justice we have some breaking news on boeing
51:59in the settlement boeing admitted to misleading statements half-truths and omissions about mcas
52:05it agreed to pay 2.5 billion dollars 500 million to the families of the victims
52:13and most of the rest to compensate the airlines
52:18the faa retested and approved the 737 max it is once again flying passengers around the world
52:35for more on this and other frontline programs
53:04visit our website at pbs.org frontline
53:17frontline's boeing's fatal flaw is available on amazon prime video
53:34so
53:45you
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