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

by Peter Robison

In August 2018, Muilenburg and Jennifer Lowe, a vice president in Boeing Government Operations who had helped plan the ceremony for Reagan’s funeral in a previous job as a Republican congressional staffer, were at Trump National Golf Club in Bedminster, New Jersey. They had the prime seats next to Trump and his wife, Melania, at a dinner for business leaders. “We’re going to build a record number of airplanes this year thanks to the policies of this administration,” Muilenburg said. Trump cut in, “Boeing is doing very well. I think Boeing has to like me a lot. Right? You’re doing very well. Yeah, I think everybody, frankly, in this room likes me. We’ll keep it that way.”

On September 24, he gave his most public endorsement yet of Biblical Business Training, the St. Louis nonprofit whose curriculum had formed the basis for those early-morning study sessions in the cafeteria. (The leader of the local branch was a Boeing training executive who’d helped recruit Muilenburg as chairman of the national organization.) The group’s stated purpose was to “equip and empower God’s people in the workplace.”

For a few minutes they had a stilted conversation about the importance of investing in aerospace and education—Muilenburg once again thanking Trump for “your policies around tax reform and regulatory reform”—before the president, now addressing the reporters in the room, broke in.

“I don’t know if you know what’s happening,” he said. “People are coming over from Honduras. They have like 5,000 people. Honduras and Guatemala, El Salvador. Some of these people are hard criminals. Hardened criminals.” It was a month before the 2018 midterm election, and misinformation fueled by Trump on Twitter and then picked up by Fox News had turned footage of a protest march by Central American migrants into a supposed “caravan” of asylum seekers heading for the United States. “They broke through in Guatemala,” he said. “These are some bad people coming through. These aren’t babies, these aren’t little angels coming into our country, going to work for Boeing.” When a reporter asked for evidence they were criminals, Trump’s tone got derisive: “Oh please—don’t be a baby. Take a look.” (The reporter was a woman.) Muilenburg and Shanahan, both data-driven engineers with masters’ degrees, listened mutely.

The first drop was like falling into a deep hole. Then came the screams, everyone praying to God. This was not the deadly flight but another, luckier Lion Air flight. Minutes after the 737 MAX departed Bali for Jakarta, just after nine p.m. on Sunday, October 28, 2018, the software that Boeing had pressed regulators to delete from the manual had kicked in. As the plane seesawed up and down over the next ten minutes, Surprianto Sudarto, seated in the second row, saw flight attendants and pilots going in and out of the cockpit carrying what looked like dictionaries. “Is that the instruction book or what?” he thought to himself.

At least one person vomited. 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.

By chance, this crew had an advantage that pilots Suneja and Harvino would not when they stepped into the very same plane, only hours later. A third, off-duty pilot was sitting in the jump seat between the two at the controls, hitching a ride. In the commotion he noticed the trim wheel between them moving. That suggested to him the proper checklist, among the dozens in the handbook—the one for a runaway stabilizer. The captain flipped a switch to turn off the stabilizer motor, just as Boeing engineers had reasoned a pilot would. For the rest of the flight, he had to turn the wheel himself, a remarkably rustic thing to ask of a pilot of a large commercial aircraft in the twenty-first century. The control column also kept vibrating in his hand; there was no mechanism in the MAX to shut off the stick shaker if the data were faulty. But the crew managed to land safely in Jakarta ninety minutes later.

So the Lion Air maintenance team never knew to replace the bad vane. They turned off the power, followed the procedures for the other alerts, and, without any other reason to hold it back, the plane was allowed to depart the next morning.

Suneja and Harvino would be unwitting guinea pigs, this time without a third pilot to guide them.

In the wrangling over the Boeing rudder design blamed for two crashes back in the 1990s, litigation had eventually turned up a memo titled “We Have a Problem,” in which engineers acknowledged—even before a second crash—that a rudder valve had the potential to jam.

There was another reason for the reluctance to push back against Boeing’s stated assumptions—one that involved race, not cost. The empathy that Boeing’s aviators might have had for a pilot who looked like them wasn’t being extended to Suneja and Harvino. Conversations at Boeing kept focusing on how Harvino, once he took over the controls, hadn’t been able to trim the plane with the thumb switch. Boeing’s pilots, predominantly older white men, had long had private jokes about the incompetent crews they ran into overseas. “Too dumb to spell 737,” went a frequent refrain of one pilot. Another trainer would ask rhetorically if “Chung Fo Ho” could handle a certain procedure.

Muilenburg immediately launched into the first point of his mental script, sounding, as usual, a little too rehearsed. “Well, Maria, I think it’s important that we all express our sympathies for the loss of Lion Air 610 and certainly our thoughts go to the families affected,”

“The bottom line here is the 737 MAX is safe. Safety is a core value for us at Boeing.” She asked what happened, and he essentially blamed the pilots. The airplane “has the ability to handle” a bad sensor like the one suspected in the Indonesian crash, he said. Boeing, he stressed, had already issued a bulletin pointing pilots to “existing flight procedures.”

Bartiromo pressed: But was that information available to the pilots? “Yeah, that’s part of the training manual, it’s an existing procedure,” he said. “Oh, I see,” she said, apparently mollified.

MCAS, of course, wasn’t in the manual—not unless you counted the glossary, which defined the term but didn’t explain what it did. (The definition was likely a vestige of an earlier draft, before Mark Forkner convinced the FAA to delete a fuller description.)

Muilenburg told him the FAA had put out a “helpful” statement clarifying it wasn’t doing a probe of its own,

On November 5, Rini Soegiyono took her newly orphaned nieces, then eleven and seven, to one of the rooms in the Ibis to meet with a psychologist. Her sister, Niar Soegiyono, and brother-in-law, Andri Wiranofa, had both been on the MAX.

That same day, Rini got a call from a notary who invited her to an office on the third floor of the hotel to sign some documents. The notary was there along with two officials from Lion Air, and they showed her a release form that she’d need to sign to claim 1.3 billion rupiah, or $91,600. “I was not in a state to sign anything,” Rini said.

“Oh my God, this is insane,” one relative wrote in a WhatsApp chat thread, describing how he’d been brought into the room and told he couldn’t consult anyone about the form. It felt like a CIA interrogation. A camera was mounted on a tripod in a corner of the room, a table with folding metal legs in the center.

Indrajana heard about other families ushered into the room who couldn’t even read—they were verbally told what the agreement said and urged to sign it.

Even by Indonesian standards, the amount was a pittance when considered as compensation for the wrongful death of a loved one—not even four times a typical Jakarta professional’s salary of $25,000.

“I’m sorry, did you say trained pilot?” interrupted American captain Michael Michaelis, who had gone by the call sign “Taz” as an F-16 pilot in the U.S. Air Force and had the physical appearance of a compact bulldog.

“Yes, yes,” Sinnett answered. He started to continue his presentation, but the pilots didn’t let him talk much longer before jumping in again. There was the obvious fact that Boeing hadn’t trained the pilots on MCAS—as Michaelis pointed out, “These guys didn’t even know the damn system was on the airplane.” And if it malfunctioned, the pilots said, it would be hard for a pilot in the heat of the moment to diagnose the problem amid all the conflicting alerts.

The next day, Indonesian authorities released the results of their preliminary investigation. Their report suggested the pilots had been confused by the automated software, while also pointing out the mistakes made by the maintenance crew.

Boeing put out its own statement, which highlighted the maintenance mistakes as the beginning of the chain of errors. Which of the two narratives prevailed was easy enough to glean from stock quotes. Within days, Boeing shares had risen to $360, higher even than before the crash.

Safety chief Bahrami met in February with Peter DeFazio, who chaired the U.S. House Transportation and Infrastructure Committee, and Rick Larsen, head of the aviation subcommittee. He called the crash a “one off” caused by poor pilot performance.

Samya Stumo

Sintayehu Shafi, a thirty-one-year-old Toyota mechanic on his way to Nairobi for a certification course, called his older sister, Konjit; the siblings were so close that he picked her up from work every day. Now his voice was unusually tight. The family’s house happened to be under the flight path, and Sintayehu asked her to go outside and look for the plane. Baffled, she went to the front gate, but some kids were playing soccer there and she felt awkward about breaking through their game to scan the sky. She could hear the engines, though, so she told him, “You guessed right.” Then she asked, how is your phone working while airborne? “I don’t know,” he answered, then suddenly called out, “Chaw!” Konjit heard a rising sound that immediately produced a pit in her stomach before the call abruptly ended.

An operator at Boeing’s twenty-four-hour crisis center was the first to tell its chief executive, Dennis Muilenburg. Two crashes in five months.

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. “We need to make a strong statement on the first, and be clear that there are no supporting facts on the second,” Muilenburg wrote later that day to Toulouse, who was in the midst of drafting the company’s response.

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.

Trump opted to let the planes stay in the air. His transportation secretary, Elaine Chao, said she had asked the FAA’s deputy administrator to “continue to monitor this situation” and to update her “personally” on developments.

The same day, regulators in the European Union, India, Australia, Singapore, and Canada followed China’s lead in grounding the MAX. Boeing and the slow-to-act FAA looked isolated in a new era of airline safety, one in which other countries no longer deferred to America for guidance. “What we’re looking at here is almost a rebellion against the FAA,” said Sandy Morris, an aerospace analyst at Jefferies International in London. “It’s the first time I’ve ever seen this happen.”

Satellite transponders on aircraft record the position, altitude, direction, and speed every eight seconds. The 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. In addition, a piece of the plane had been recovered that showed the flaps were in an “up” position—a precondition for MCAS to fire. There was nothing more to say; 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. It was the second such admission of failure in just six years for a new Boeing model, following the Dreamliner—a grim milestone that even much-maligned McDonnell Douglas never reached. Its only grounding was the DC-10.

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.

Ewbank filed an internal ethics complaint saying managers were “more concerned with cost and schedule than safety and quality.” Mechanics at the Dreamliner plant in South Carolina described shoddy manufacturing, debris left on planes, and pressure not to report defects.

One stunning instance came in April, when Boeing acknowledged that some of its managers had known for a year before the first crash that the aoa disagree warning, alerting crews to a bad angle-of-attack vane, wouldn’t work for most airlines, who had acquired models that didn’t include the corresponding indicator. Boeing’s concession pointedly excluded “senior company leadership” (like Muilenburg and Luttig) from the group in the know.

Dominic Gates, the Seattle Times beat reporter who would win a Pulitzer Prize for his reporting that year on Boeing, asked in his cutting Irish accent why Boeing couldn’t just admit it had made a mistake. “Never mind the processes,” he said. “What you came up with was flawed, was it not?”

Muilenburg again couldn’t muster an answer that sounded human or reflective. “We followed exactly the steps in our design and certification processes that consistently produce safe airplanes,” he said. A Boeing representative cut the press conference short after fifteen minutes. Another reporter called out: “Three hundred and forty-six people died, can you answer a few questions here about that?” Muilenburg walked offstage,

Muilenburg told analysts and airlines the plane would reenter service within months.

In the 1990s, Nader even took on the airline industry with a book called Collision Course, which argued that the FAA was too close to the industry it regulated. After Samya died, Nader blamed himself for not warning her about the MAX. He’d closely followed the Lion Air story and had his own doubts about the plane. 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 bed. But they resolved to make Samya’s death have meaning. In late June, they held a remembrance—part eulogy and part campaign strategy session—at the American Museum of Tort Law, housed in a gray stone neoclassical building in Winsted, Connecticut. Nader had opened the museum in his hometown as a monument to plaintiffs’ lawyers and his own brand of anticorporate populism. A cherry-red Corvair sat in the building’s main hall. Only the previous December, Nader had convinced—really, commanded—his great-nephew Adnaan to play a solo fiddle concert there after learning the young man had been busking

case was his own dead grand-niece.

“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.”

Claybrook told the audience that Samya once came to a dinner party at her house in Washington; it snowed and one of her guests’ cars got stuck. Samya went outside and started shoveling snow away from the tires with her hands, even though she was wearing a beautiful pair of red suede shoes. “I’ve never seen a more joyful person in my life,” she said.

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.

Once he’d finished his investigation, the issues seemed so clear: The dangerous flaw revealed by the Lion Air crash. The pattern of rewarding shareholders and top executives while skimping on investments. The neutering of the FAA. It sent him into an even deeper depression, certain that he could have saved his family if only he had paid better attention.

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.”

To Tarek, the FAA managers were a crowd of dim bulbs, mindlessly repeating what Boeing had told them and promoting half-baked methods of statistical analysis, like the spreadsheet meant to calculate the risk of keeping the MAX flying. He couldn’t believe the FAA had treated a very rough estimate—the guess that one out of one hundred pilots would struggle with the new checklist—as if it were a definitive, observed rate.

Separately, they took turns gripping the wheel as their smooth flight was interrupted by the jarring stick shaker and blaring alerts announcing the malfunction. Boeing’s own guidance said that the plane could enter an unstoppable nosedive if pilots didn’t complete the proper checklist within ten seconds. It took the test pilot just four seconds to spot the trim wheel moving, get right on that pickle switch (as the Boeing official had so helpfully reminded), and then hit the cutout. It was a maneuver he’d done probably hundreds of times over the years in the FAA’s repetitive tests of various scenarios. Despite the coaching from Boeing, however, the airline veteran needed sixteen seconds. He was dead.