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

by Peter Robison

The software—despite the confident statements from Boeing and the FAA—had again taken control of a plane even as the pilots struggled in vain to follow the new checklist. The deaths of 346 people on a brand-new aircraft within five months badly shook the widely shared assumption of safety in air travel.

it became clear that the FAA had abdicated much of its oversight to Boeing itself.

Once ruled by engineers who thumbed their noses at Wall Street, Boeing had reinvented itself into one of the most shareholder-friendly creatures of the market. It celebrated managers for cost cutting, co-opted regulators with heaps of money, and pressured suppliers with Walmart-style tactics.

In shocking emails handed over to congressional investigators, a Boeing pilot boasted of using “Jedi mind tricks” to convince airlines and regulators there was no need for pilots who’d flown the previous version of the 737 (like Suneja and Harvino) to undergo expensive simulator training on the MAX. An employee despairing of foul-ups wrote, “This airplane is designed by clowns, who in turn are supervised by monkeys.”

Other evidence showed that Boeing pressured pilots to skimp on testing and ignored engineers’ entreaties for sophisticated flight controls t...

The company even turned down a request from Lion Air itself for additional training. (“Idiots,” a Boeing ...

The acquisition of McDonnell Douglas a year earlier had brought hordes of cutthroat managers, trained in the win-at-all-costs ways of defense contracting, into Boeing’s more professorial ranks in the misty Puget Sound. A federal mediator who refereed a strike by Boeing engineers two years later described the merger privately as “hunter killer assassins” meeting Boy Scouts.

It’s become sadly apparent that at Boeing—as at so many other places—the assassins won. Some of the very people who ran McDonnell Douglas into the ground resurrected the same penny-pinching policies that sank their old company. Borrowing a page from another flawed idol, Jack Welch’s General Electric, they executed what today might be called the standard corporate playbook: anti-union, regulation-light, outsourcing-heavy. But pro-handout, at least when it comes to tax breaks and lucrative government contracts.

The 737 remains the only large commercial aircraft without an electronic checklist to assist its pilots, who depend on heavy binders laden with step-by-step instructions to guide them in the event of an emergency. At the same time, Boeing has fitfully squeezed in software to guide some aspects of the plane, using two redundant computers with processing power that approximates a 1990s Nintendo gaming console.

They concluded it wasn’t ambitious enough, carrying just thirty-six passengers. The design Boeing would be implementing called for one hundred seats, which would allow it to generate more revenue—though some at Boeing argued the public would never stomach so many fatalities at once in the event of an accident.

The first crash of one of the new fully loaded wide-body planes was an international scandal, provoking newspaper coverage of shocking design lapses, televised congressional hearings, and even a full-length book exposé. Soon after the plane’s takeoff from Paris Orly Airport in March 1974, an explosion blew out the cargo door, buckling the floor and severing hydraulic lines. All 346 people aboard died when the plane plunged into Ermenonville forest outside Paris, the worst airliner crash in history at the time. Debris was scattered for a half mile through wooded trails popular with Sunday hikers.

a McDonnell Douglas executive blamed an “illiterate” baggage handler at Turkish Airlines (who spoke three languages) for failing to latch the cargo door properly.

It emerged that Douglas engineers had known the design was vulnerable to a catastrophic failure, and indeed, two years earlier, a near disaster had ensued on a flight over Windsor, Ontario, which also lost a cargo door. The pilot had been able to land the plane in that case. Instead of fixing the issue immediately, McDonnell Douglas had convinced the FAA to let it add a support plate over time to the doors—a “gentlemen’s agreement” revealed in the congressional hearings.

Records at Douglas showed that the support plate had been added to the Turkish Airlines plane, when it had not. Three company inspectors ...

May 1979 brought another disaster. A DC-10 operated by American Airlines crashed in Chicago, killing 273, when the left engine and pylon simply fell off the wing on takeoff.

For decades, the Securities and Exchange Commission limited how often companies could buy back shares, but a Reagan administration rule in 1982—a year after Welch became the chief executive at General Electric—did away with those restrictions.

In the year McNerney took over, Boeing spent $9.2 million on lobbying, with 66 lobbyists. Five years later it spent $18.1 million, with 143, ranking sixth among all American companies. “We used to have a few people in Washington, D.C., and now we have an empire,”

Even the air force refueling tanker, lost in scandal, returned; Boeing won a $35 billion contract.

In 1999, executive compensation had been based on earnings from operations, as well as such intangibles as “customer and employee satisfaction, safety, and diversity.” By 2007, the focus was on “optimizing net assets,” as the Boeing proxy statement explained. “This is done through more efficient processes, cost containment and minimized inventory, among many other ways.”

Boeing—the epitome of American engineering excellence—was going downmarket. It even started selling bare-bones versions, offering as options equipment that Airbus sold as standard. A backup fire extinguisher in the cargo hold, for instance, cost extra. This was permissible because a backup wasn’t mandated by the FAA. (In places including Japan, however, regulators did require it, mindful of incidents in which the primary system had failed.)

In another fateful example, Boeing charged $80,000 for an angle-of-attack indicator—the seemingly peripheral cockpit gauge whose absence would figure in the doomed Lion Air and Ethiopian flights, neither of which was equipped with the optional equipment.

That logic was one of the things that caused trouble for Boeing, Leahy said: “ ‘Let’s make everything an optional extra, let’s strip the airplane down; we can’t do extra training, we don’t want to make the airplane too expensive, we’re in a price war.’ ”

In McNerney’s single-minded emphasis on cost savings, there was something else that went unmentioned in his letter to stockholders: Safety. For five years of his tenure—from 2010 through 2014—the word was nowhere to be found in the company’s annual proxy statements.

“I’m here because my only child died at Sioux City, Iowa, in 1989, when a DC-10 crashed,” he said. “One hundred eleven died, one hundred eighty-nine lived. Heather was twenty-four years old.

O’Mara, balding and round-chinned, paused in his prepared speech for a moment. He said he’d been “a corporate guy” like most of them before the crash, a sales manager for the Wall Street Journal.

As he’d learned, ever since that first crash of a Turkish Air DC-10 at Orly, when the cargo door popped open and hydraulic lines under the floor snapped, regulators had known how vulnerable those lines were.

In the accident that killed his daughter, a blown engine spewed fragments that severed all three lines and left United Airlines captain Al Haynes without controls to steer the jet.

If a safety valve for the hydraulic lines had been mandated fifteen years earlier—“a $10,000 item back then,” O’Mara said—the flight controls would not have been lost.

For the families of crash victims, he told the group, that knowledge was just as painful as losing them. “The first mugging is the crash,” he said. “The second mugging is discovering that their loved ones didn’t have to die.”

President Bush’s choice to run the FAA would be someone deeply familiar with the backstage workings at the agency. Marion Blakey had run a public affairs consulting firm in Washington. Her biggest clients were transportation companies.

In her first major speech as FAA administrator, at the Aero Club in Washington in February 2003, Blakey announced what she called the “customer service initiative.”

Blakey still stressed the importance of safety, but the message was awkwardly mingled with business buzzwords.

“One of these goals, our stock price—if you will—is the lowest possible accident rate, first and foremost,” she said.

“We are committed to a dynamic, results-oriented plan that we’re going to pulse regularly, measure quarterly, and adapt as necessary real-time,” she said. “In shor...

General Electric, one of the largest makers of jet engines and thus a key beneficiary of the loosened oversight, said in its comments that “it was particularly satisfying to see that the FAA had left intact the spirit of the recommendations” developed in the working groups.

“The ultimate responsible party for safety is the government, and this new FAA policy essentially is trying to transfer that responsibility. It may work in the short term, but in the long term the public will see that what we have is a less safe system.” The customer service initiative had predictable results.

Bobby Boutris, the inspector at Southwest, testified in 2008. “In the performance of my duties, I have been asked by Southwest Airlines management to make a violation go away. In addition, I have been threatened by Southwest Airlines management that they could have me removed from the certificate”—denied the authority to certify planes—“by picking up the phone.”

Southwest had flown dozens of jets on tens of thousands of flights without inspecting them as required. When it finally did, it found cracks in a half dozen of the planes, including one crack that was four inches long. (Corrosion and cracking had also caused an Aloha Airlines 737 to rupture midflight in 1988, killing a flight attendant.)

In part because of the congressional scrutiny, the FAA proposed a $10.2 million fine on Southwest that year. It was the largest fine it had ever levied on an airline—but it amounted to the loss of about one-third of a single day of operati...

“Essentially if you want to move up you are pretty much pressured to delegate even more”—to hand over more of the responsibility of oversight to manufacturers.

The goals set for managers in the agency’s formal business plans reflected the shift.

These included measures related to encouraging the use of manufacturer “delegates,” or for approving work by certain dates.

In fiscal 2007, one goal assigned to Dorenda Baker, then deputy director of aircraft certification, read: “Certify the GEnx 1B [a General Electric engine] on the Boeing 787 by September 30, 2007.”

At one point, Boeing managers asked for input from the FAA engineering staff on a particular staff appointment. Giving the lie to their efforts at consultation, they ended up choosing the person who had received the most objections from the FAA,

Boeing also promoted another person whose FAA evaluations had shown “a consistent lack of integrity, unsound judgment, and an uncooperative attitude towards FAA,” the 2017 report said.

Early on, one of the FAA’s engineers, Steve Oshiro, asked his counterparts at Boeing why the plane’s design didn’t include an enclosure around the new lithium-ion batteries, according to three people familiar with the conversation. Fires are considered one of the very worst hazards on airplanes, and lithium-ion batteries are notorious for erupting in flames, as the Arizona building collapse in 2006 well attested.

Oshiro thought Boeing should design a steel box that vented outside the airplane to help avert such a disaster. He was told not to worry about it. The review of the battery was delegated to one of Boeing’s deputies, who decided the fire risk was remote enough that an enclosure wasn’t needed.

on the evening of January 15, Boeing CEO Jim McNerney was just setting out some fish to bake at his house, a many-gabled French country-style château in the Chicago suburb of Lake Forest, when his phone started vibrating with messages about another battery fire. Passengers had to descend on the emergency slides of an All Nippon Airways Dreamliner after the captain smelled smoke in the cockpit and diverted midflight to the nearest runway in Japan. A flurry of phone calls followed, but to little effect. The next morning, despite the dramatic events, both Boeing and the FAA agreed the plane should keep flying.

The agency’s administrator, Michael Huerta, spoke to LaHood and told him the staff was reluctant to ground the plane. Data still suggested battery fires were a rare event; it was possibly just a fluke that two happened in such close proximity.

LaHood decided to trust his gut instead. “Michael, it’s my call, I’m doing it,” he told him. He ordered the FAA to ground the Dreamliner, the first time the agency had done so for a Boeing jetliner and its only grounding of any model since the McDonnell Douglas DC-10, when a federal judge ordered it after the Chicago crash in 1979. LaHood called McNerney, and the CEO started raising objections. “I know you’re not happy,” LaHood replied in his prairie-flat midwestern accent. “And you know what, I’m not happy about the fact th...