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

by Peter Robison

The test of faith and leadership Muilenburg had confidently talked about onstage had arrived. He led a late-night discussion soon after the crash with senior leaders including Anne Toulouse, the head of communications. Much like Burke, he zeroed in on two key questions, starting with safety. “Is the MAX safe? And was MCAS involved?” But unlike the Johnson & Johnson chairman, he’d already convinced himself of the answers—and protecting the product came before people.

The statement Boeing released the Monday after the crash opened like a legal brief. “The 737 MAX is a safe airplane that was designed, built and supported by our skilled employees who approach their work with the utmost integrity,” it said.

Boeing went on to say—falsely—that the software only operates in “a non-normal part of the operating envelope.” That was how it was supposed to work, but it had just fired at least three times on routine takeoffs, due to entirely foreseeable failures; and as Boeing lead director Dave Calhoun later said himself, the “deadly assumption” about how pilots might respond had already started to come to light within the company.

Chinese officials were the first to ground the MAX that Monday.

Trump opted to let the planes stay in the air.

The same day, regulators in the European Union, India, Australia, Singapore, and Canada followed China’s lead in grounding the MAX.

“What we’re looking at here is almost a rebellion against the FAA,” said Sandy Morris, an aerospace analyst

Boeing officials showed Bahrami and his team a graphic that superimposed these traces from the flight in Ethiopia over the Lion Air plane’s last moments. It was a match.

Bahrami walked out of his office and told his boss they needed to ground the fleet. The FAA issued the order that Wednesday, three days after the crash.

cost Boeing $1 billion—a considerable loss but hardly a devastating one.

The Friday after the crash, Paul Njoroge, held up by his father-in-law, John, made his way to the yellow police tape blocking entrance to the field where his family had perished. He’d consumed nothing but water for days. The biting scent of freshly plowed dirt stung his nostrils. When they reached the tape, Paul crumpled and put his head into his hands. “I want to hear my kids talk to me,” he said.

“Everyone’s telling me to be strong,” he said quietly in the chaotic jumble of people piecing through wreckage. “I can’t be. How can I be strong? How can I even live on? My family is my life.”

Within days of the crash, at least one Boeing pilot got served with a federal subpoena while working at the training center in Miami. It sent a chill through the pilot fraternity, suggesting a deep level of familiarity with Boeing’s operations and a shocking sign that the investigation had already escalated beyond anything in its history.

British tabloids bestowed a name on the MAX—“the death jet,” strange to see for a Boeing product.

Muilenburg and Boeing stuck to the script. He insisted, in prepared statements, that “safety is our highest priority,” that every accident was a chain of events, and that people needed to let the i...

On March 17, a Seattle Times story undercut the narrative by revealing what the FAA specialists had been saying privately for months—Boeing had screwed up. The story quoted anonymous engineers who said Boeing had provided the agency with a crucially flawed assessment of the MCAS software...

Too late to avert catastrophe, the software update that Sinnett had been promising since November was finally getting close to completion. Boeing had expected to hand over the final specifications to the FAA in April, six months (and not six weeks–ish, as Sinnett had said) after the first crash. A date had even been scheduled for Stacey Klein, the Aircraft Evaluation chief who’d worked with Forkner, to evaluate the revised software in a simulator in Miami. That date, March 13, turned out to be three days after the crash in Ethiopia. Boeing had been so confident MCAS was fixed that it was actually seeking training even less stringent than the couple of hours on an iPad already approved. This time it had asked for Level A training, the least intensive possible. Pilots simply would be provided with highlighted pages of the operating manual—no test or further practice required.

The attempt at empathy fell flat. All at once, two decades of contained resentment—all the engineers it had tossed away, the regulators it had ignored, the customers it had demeaned—unloaded on Boeing like a crosswind gust on takeoff.

Rick Ludtke and other fired engineers came forward with accounts of how managers had pressured them to compromise the MAX’s design at the expense of safety.

Boeing’s total equity—just like a house, a measure of its debt compared to its assets on hand—stood at $410 million by the end of 2018. It had been $13 billion in 1997, before Stonecipher and his successors started hollowing out the company in the drive to boost the all-important return on net assets.

At a hearing in May, Republican lawmakers led by Sam Graves, a representative from Missouri, suggested that it was foreign pilots rather than Boeing who were most to blame for the crashes. “You have to know how to fly the plane!”

“Absolutely,” Elwell replied to Graves’s criticisms of the pilots, saying he planned to “take a hard look at the training standards globally.” The Republican congressman defended Boeing much as other lawmakers had after the Dreamliner fires, suggesting it would be a mistake to change anything about the way the FAA regulated Boeing. His rationale added a barely concealed nationalism.

Muilenburg told analysts and airlines the plane would reenter service within months. Publicly, the FAA gave no such timeline.

A PowerPoint presentation circulated by one FAA staffer in April, a month after the crash, focused on the plane’s “Return to Service.”

Nader wrote a thundering open letter to Muilenburg after the crash: “You and your team should forfeit your compensation and should resign.”

Nadia and her husband, Michael Stumo, had spent several of the days since the loss of a second child unable even to get out of

“Two adult male pilots pulled back on the stick and could not move it because it was designed that the software would override the pilots,” she said. “That that could go through the FAA and not be caught? That’s crazy. That means that the FAA does not have the systems, the expertise, the oversight, to actually keep us safe.”

Then Claybrook brought the focus back to Boeing. Nader had called on the day of the crash to tell her Samya was dead. Claybrook remembered that her broker had invested $35,000 in Boeing stock for her retirement account three years previously. When she hung up, she called the broker to ask what the stock was now worth; it had appreciated by $100,000. “It just shows,” Claybrook told the crowd, “that this company was not putting money into the airplane and into flying, it was putting the money into profit—of course, from which the members of that executive board and others profited as well.” She said she could no longer see it as anything but “blood money.” Claybrook sold the stock and donated the proceeds, in Samya’s name, to the Nader museum.

felt that the reason why my family died was because when the first crash happened in October of 2018 it happened in Indonesia and not in the U.S. or Canada or the U.K., where lives matter more than in other places,” he said. “The Indonesian people were seen as mere Indonesians. And that’s why Boeing never felt compelled to ground the planes.”

They made it to fifty offices, Nadia eventually bowing out because the conversations brought such pain.

“They’re not used to dealing with the very people they’re supposed to protect,” Stumo said.

Tarek sat in on one of the family meetings with the FAA, but couldn’t shake the impression that they were only pretending to listen while planning to do exactly what they’d been working toward ever since the Lion Air crash: endorse Boeing’s revised software and move on.

FAA officials explained how in the forthcoming, revised MCAS, the software would rely on two AoA sensors instead of one. In any cases of disagreement, it would shut down. De Luis listened in disbelief. Even the space shuttle, developed in the 1970s, had five redundant computers. Airbus planes typically used three sensors. The solution also seemed shockingly clunky: If the software was necessary to keep the plane’s nose from pitching up in certain situations, what would happen in a flight that encountered one of those rare situations and didn’t have MCAS available?

“If a student came in with this design, I wouldn’t pass him,” de Luis told them.

Boeing’s own guidance said that the plane could enter an unstoppable nosedive if pilots didn’t complete the proper checklist within ten seconds.

Despite the coaching from Boeing, however, the airline veteran needed sixteen seconds. He was dead.

An FAA inspector who worked with Southwest crews in Dallas heard about the failure and conducted informal tests of his own in a simulator there. The three pilots he tested took forty-nine seconds, fifty-three seconds, and sixty-two seconds to complete a similar procedure. Those findings spooked even Elwell, the FAA’s acting administrator.

Congress, he said, should return the FAA to the system of oversight that had existed before the manufacturers co-opted it. He asked for criminal prosecution of Boeing and its executives, who, he pointed out, “have been the primary beneficiaries of this strategy to extract wealth from this storied company.”

He had just described with infuriating nonchalance how the FAA’s “processes” had killed her daughter.

He’d actually admitted to gambling with her daughter’s life.

Nadia and Tor talked to the reporters as planned, holding a sign that said keep boeing 737 max 8 grounded ali bahrami and boeing execs go to jail.

Bahrami said he had a daughter of his own and couldn’t imagine losing her. Tor asked him if there was anything he’d learned from the accidents or wished he could have done differently. He said he couldn’t think of anything. They left the office more enraged than ever.

250 factory-fresh MAX planes, inventory worth about as much as a mission to the moon.

They soon found another issue—rags and other debris left in the fuel tanks, a sign of the hasty production ramp-up.

By making a relatively low-ranking pilot the focus of attention, Boeing was drawing it away from the managers whose directives he was carrying out.

lawyers were out there going after these last remaining families to clean up liability for Boeing,”

Boeing came to my office shortly after these crashes and said they were the result of pilot error. Those pilots never had a chance. These loved ones never had a chance. They were in flying coffins as a result of Boeing deciding that it was going to conceal MCAS from the pilots.”

Blumenthal proceeded to answer his own question. He explained that in a sixteen-hundred-page manual, MCAS was mentioned only once—in the glossary, a pattern of deliberate concealment. “So when Boeing came to us and said it’s the pilots, you were lying to us as well,” the senator said. “Would you agree that this system of oversight is absolutely broken—that’s the lesson here, isn’t it? That Boeing lobbied the Congress for more delegation and now we have to reverse that delegation authority?”

“A pilot’s best friend is time and altitude. And on takeoff he’s got no altitude, and he’s got no time. You set those pilots up for failure.”

Muilenburg said he was made aware of it as part of the discovery process in the investigation early in the year and had counted on counsel to handle it. “ ‘I was made aware,’ passive voice, disclaiming responsibility,” Cruz cut in, with a mocking tone. “You’re the CEO, the buck stops with you,” he thundered. “How did your team not put it in front of you, run in with their hair on fire saying, ‘We’ve got a real problem here’? How did that not happen and what does that say about the culture at Boeing if they didn’t give it to you and you didn’t read it and say, ‘I want to see what happened!’ How did you not in February send out a 911 fire alarm to say we need to figure out exactly what happened, not after all the hearings, not after the pressure, but because 346 people have died and we don’t want another person to die?”