Flying Blind: The 737 MAX Tragedy and the Fall of Boeing

by Peter Robison

In rejecting the safety enhancement, managers twice cited concerns about the “cost and potential (pilot) training impact.”

“People have to die before Boeing will change things,” Ewbank was...

One person who left was a PhD—“the kind of talent you can’t afford to lose,” Ludtke said. “They were targeting the highly paid, highly experienced engineers.” It was the same kind of lucrative purge McNerney had overseen at 3M, which ended in his successor determining that the belt-tightening had come at the expense of innovation.

Overall, Boeing’s workforce fell 7 percent in 2015, while making many more planes.

The climate didn’t reward people willing to...

“It was pretty intense low morale because of all the layoffs—constant, grinding layoffs, year after year,” he said. “So you really watched your step and were careful about what you said.”

Some engineers warily eyed a floor where young programmers from the India-based outsourcing firm HCL were based. The contract workers in the United States with H-1B visas earned half of what the Boeing engineers made. In India it was even less, as little as nine dollars an hour.

The shift of Dreamliner production to South Carolina had come with its own drawbacks. The state might have been cheap, but the people Boeing hired—at half the hourly wage of those in Seattle—had little experience building airplanes.

William Hobek, a quality manager there, filed suit in federal court claiming he’d been fired after reporting defects up the chain of command. When he complained, a supervisor replied, “Bill, you know we can’t find all defects,” according to the suit. Hobek called over an inspector, who quickly found forty problems.

“In the past, we may have said our best engineers are working on the new thing,” he said. “Now, we want our best engineers working on innovative reuse.”

While they pressured the engineers for savings, Boeing enriched shareholders, spending $41.5 billion on stock buybacks from 2013 to 2018—enough capital to develop several all-new aircraft, had they chosen to. Almost 80 percent of the free cash during that period went to buybacks. McNerney himself made $231 million from 2001 to 2016, with a retirement package that wasn’t Welch-sized but in the neighborhood: at least $58.5 million. For his part, Muilenburg made $106 million from 2011 to 2018.

the sales team would sell planes for delivery four years out at prices the company couldn’t yet hit from an engineering standpoint—creating immense pressure to drive down costs. “How long do you want to keep polishing that apple?” was a phrase the Boeing managers sometimes used with engineers who wanted to keep testing. The message: the product is fine, let’s keep things moving.

“It was engineering that would have to bend,”

“Idea’s [sic] are measured in dollars,” as a manager put it in another engineer’s annual evaluation.

managers at both the FAA and Boeing agreed to table disagreements about technical issues in order to avoid delays.

Many of Boeing’s instructors wanted to offer more intensive training, but were told the company had other priorities.

The outsourcing to freelancers meant that training wasn’t always consistent.

Again—all but unavoidably at this late stage—the answer would be the software. They would expand MCAS to cover low speeds as well as high. It had the benefit, once more, of being cheap.

Teal’s team reprogrammed the MCAS software to make it capable of adjusting the stabilizer 2.5 degrees in low-speed conditions, instead of the previous limit of 0.6 degrees.

“It was all about the bottom line and the feeling that you were just a cog in that, and that people didn’t matter,”

Finally, in November 2016, Boeing’s engineers handed over the system safety assessment of the MCAS software to the FAA. The document didn’t include anything about the new angle of the stabilizer, or the software changes made to MCAS in the final “black label” version. That version was known as Revision E. The FAA’s specialists, the Forrest Gumps, were shown analysis based on an earlier iteration of the software, Revision C. They got their bewildering “drawer full of paper,” as one of the engineers had put it.

Rick Ludtke, the controls designer, didn’t have much time to join in the festivities when the MAX won official certification the following March; he was laid off. “I was getting too expensive,”

Employees were still finding bugs in the manual in April of that year, when the MAX started rolling out of assembly lines. “Oh I’m sure it’ll get better when Boeing engineers design a whole new one. Wait? Who is left to do such a thing?” one worker wrote in...

Eventually one more mistake would be discovered: An alert showing a discrepancy between the two angle-of-attack vanes wasn’t lighting up on a majority of the MAX planes Boeing had started delivering. The alert was mistakenly tied to an optional indicator showing the raw angle-of-attack data, which most airlines (including Southwest and Lion Air) hadn’...

“Jedi-mind tricking regulators into accepting the training that I got accepted by FAA etc.”

For all his alarm, Forkner, a Pickett’s charge guy to the end, stuck to his mission. In a conversation with Klein later that month, he didn’t mention any of his private concerns to her. Later he reminded her that they’d agreed to delete MCAS from the manual.

And when Lion Air, receiving its first MAX planes the next year, asked for simulator instruction, he didn’t respond charitably. “Idiots!” he wrote, before orchestrating a few days of conference calls to convince the airline it was unnecessary. Recounting his intervention later to a colleague, he wrote, “I save this company a sick amount of $$$$.”

“Airbus helps us to be better,” Kirana said.

The support from Boeing was more haphazard. In the 1970s and 1980s, it had stationed people at maintenance hangars, too, so they could watch over what airlines were doing with their planes and offer advice, according to John Goglia, a mechanic at United and USAir for thirty years who was an NTSB board member from 1995 to 2004. More recently, he said, Boeing had relied on field service representatives covering multiple airlines, often stretched thin across thousands of miles. “It just faded away over time—there’s a Boeing rep around there someplace, but you have to call,” he said.

a pilot had been asked to sign one certification document “clearly based on a lie.” There had been audio problems with the devices, software glitches, old data, leaking air lines. In instant messages, the employees commiserated over Boeing’s cost-motivated decision to award the simulator contract to the low bidder, a unit of Textron called Tru Simulation + Training based in Goose Creek, South Carolina. “I’ll be shocked if the FAA passes this turd,” one wrote in a message later turned over to congressional investigators.

“Would you put your family on a MAX simulator trained aircraft? I wouldn’t.” “No,” came the reply.

Others were just as disillusioned. “Everybody has it in their head meeting schedule is most important because that’s what Leadership pressures and manages,” one person wrote. He was a manager himself. He’d participated in a “Go/No Go meeting” that, he said, became known internally as the “Go/Go meeting” because saying “no” wasn’t an option. Yet as he pointed out, “We haven’t even fully checked the requirements Tru is supposed to be meeting.” The manager lamented how “the lowest ranking and most unproven supplier” had won the simulator contract, “solely based on bottom dollar.”

Then he put his finger on the forces that had been building for years, decades even, and would soon destroy lives and reputations: “It’s systemic. It’s culture. It’s the fact that we have a senior leadership team that understand very little about the business and yet are driving us to certain objectives. Its [sic] lots of individual groups that aren’t working closely and being accountable….

Instead of slowing things down, managers only heaped on more pressure. At town hall meetings, some 737 managers asked underlings pointed questions about the delays, in front of a hundred or more of their peers. Boeing tracks quality defects in a computerized database, and Pierson saw that reports of issues—malfunctioning equipment, missing inspections, incorrect parts—had risen 30 percent.

“Frankly right now all my internal warning bells are going off. For the first time in my life, I’m sorry to say that I’m hesitant about putting my family on a Boeing airplane.” Campbell assured him in his response that safety and quality came first. A month later, with conditions only worsening, Pierson asked for an in-person meeting. He laid out all of the evidence that quality was suffering and asked Campbell to shut down the line. “We can’t do that. I can’t do that,” Campbell said. Pierson replied that he had seen operations in the military shut down over less substantial safety issues. Campbell answered tersely, “The military isn’t a profit-making organization.”

At profit making, Boeing now excelled. Two decades after Harry Stonecipher had berated its proud engineers as hobbyists who didn’t know how to run a business, Boeing had become a Wall Street darling. It had reported a 67 percent jump in 2017 earnings, to $8.2 billion from $4.9 billion the previous year, and its operating margin—the amount of sales left after expenses—had climbed to a once-unthinkable 11 percent. The stock price had responded, tripling in the three years of Muilenburg’s tenure.

Boeing was finally the industrial titan against which all others were measured.

CFO Greg Smith told staff the stock could hit $800 or $900 if Boeing continued pushing for efficiency and redirecting cash into dividends and buybacks.

Muilenburg declared that Boeing’s ambition was to be nothing less than a model of profitability—in

Over the previous two years, Bahrami proudly said, enforcement actions had dropped 70 percent. “We used to measure success by how high our stack of hate mail was,” he said. “That’s no longer the case.” On a call that year with analysts, Muilenburg complimented the government for its “focus on deregulation” and the “streamlined” certification process that had helped bring the MAX to market.

The FAA was stripped of some of its most fundamental authority—to decide, for instance, whether a manufacturer like Boeing was qualified to certify its own work.

“It’s basically putting the regulatory decisions into the hands of those who are being regulated,” he said.

On October 22, Boeing collected the Robert W. Campbell Award for leadership in safety from the National Safety Council,

On October 24, just days before a single fateful vane on an Indonesian plane would malfunction and go undetected, Boeing reported that third-quarter free cash flow jumped 37 percent to $4.1 billion, more than double analyst estimates, sparking a 3 percent jump in its share price. “The cash is the cash, you can’t deny it,” said Ken Herbert, an analyst with Canaccord Genuity.

Unknown to pilots, at the base in Bali mechanics had replaced a faulty angle-of-attack vane on the almost brand-new jet with a used one from a repair shop in Florida. The vanes, sitting like nostrils on either side of the plane’s nose, are designed to detect how steeply the craft is flying into oncoming winds. A protruding part of the vane rotates in response to the airflow. It’s attached to what looks like a system of gears inside—actually small electrical transformers called resolvers that read the angle in comparison to a static reference and then feed that information into the plane’s computer. A test is supposed to be performed before installation to make sure the resolvers are properly calibrated. No one at the shop or the maintenance base noticed that the resolvers on this particular vane were misaligned by 21 degrees.

It was sloppy—one of the links in the “chain of errors” often said to accumulate in aviation accidents, the heartbreaking clarity coming only in hindsight. But the sloppiness had started at Boeing, in the early compromises of the plane’s design, and then in the loose ends left dangling in the final days of development.

He and the mechanics never saw the alert that would have pinpointed the problem—aoa disagree, suggesting a discrepancy between the left and right angle-of-attack vanes. The reason: Lion Air hadn’t paid for it. They had purchased a bare-bones MAX plane, with no such indicator. Moreover, Boeing had never disclosed the potential issue to customers.

With its spotty safety record, Lion Air took most of the heat for the crash. A week after the accident, grieving family members crowded into a sweaty auditorium for a meeting led by Indonesia’s transport minister. They spotted Lion Air founder Kirana in the crowd and demanded he identify himself. He stood and bowed his head, a gesture they took as either contrition or shame.

At the FAA’s Boeing Aviation Safety Oversight Office in Seattle, engineers began scouring their files for information about the software in question and discovered what looked like incomplete and inaccurate work by the deputies entrusted to oversee safety at Boeing.

The system safety assessment for MCAS had been turned over to the agency just five months before the plane was officially certified, which, given the voluminous paperwork in...