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

by Peter Robison

Not many gave a thought to the machines parked beside the jetways, many of them Boeing 737s, the stub-nosed workhorses of airline fleets since the 1970s. Commercial aircraft are considered the world’s premier expression of manufacturing excellence, designed by tens of thousands of people around the world who put their hands on them—at first figuratively, on the computer screens of engineers, and then literally when machinists climb underneath them to hand-crank stubborn fasteners to the desired torque. Before the planes leave Boeing’s factory near Seattle, airlines send their own representatives to inspect every inch and reject the machines if they find, say, a loose bin or a fray in the forty miles of wiring (or, as sometimes happens, a forgotten wrench or gum wrapper). The people gathered around Gate B5 that morning for Lion Air Flight 610 were about to board the newest and most advanced of more than ten thousand 737s Boeing had manufactured. It was called the 737 MAX 8. A far cry from the original 737, which had two tiny cigar-shaped engines tucked under its wings, this one had two massive turbofans. Almost six feet in diameter, they were so big they had to be mounted in front of the wings instead of beneath them, and the average person could stand inside the cowlings. The engines generated twenty-eight thousand pounds of thrust—double that of the first 737 models—while drastically lowering fuel consumption. The new jetliner was economical enough that Lion Air could cha...

They called in Boeing engineers, who explained about automated software known as the Maneuvering Characteristics Augmentation System, or MCAS (“em-kass,” as it was pronounced). Only a few people at the FAA had even heard of it. “What’s MCAS?” asked one agency official. It was immediately clear that the software was far more powerful than Boeing had suggested in documents submitted to win the plane’s approval. The engineers had drastically underestimated the software’s ability to move the horizontal stabilizer, the small wing on the plane’s tail. What’s more, it had fired because of bad data from the single misaligned sensor—a flaw Boeing’s vaunted processes were supposed to find and root out long before the plane was in flight with commercial passengers.

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.

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. (Even the space shuttle, originally developed in the 1970s, had five separate computers.) That leaves passengers on the 737, in comparison to planes like the Airbus A320 or Boeing’s own 787, more vulnerable to decisions made in the heat of the moment by confused pilots.

Boeing employed more than a hundred thousand people, and hundreds of thousands more at suppliers around the world owed their livelihoods to a company that literally connects the world. Its influence reached high in government, with Boeing veterans rising to powerful posts in the FAA, the Justice Department, the Defense Department, and multiple branches of the military. To the extent that ordinary people thought about Boeing, it was often with the same reverence accorded to elevators or light switches: the planes always seemed to work.

War was actually the reason the American company would go on to dominate the jet age that brought international travel to the masses in the decades that followed. Days after Germany’s surrender in May 1945, a Boeing engineer named George Schairer sent a letter from a forest near the town of Braunschweig. Schairer had joined a team of civilian advisers working with U.S. Army intelligence there to examine the research files of the Reichsmarschall Hermann Göring Aeronautical Research Institute. What he saw stunned him. The Germans, he realized, understood far more than anyone else about the potential of mating jet engines to swept-back wings. Most planes at the time still used propellers and perpendicular wings, jutting out from the fuselage at ninety-degree angles. Wind tunnel data that Schairer examined in the files showed a massive increase in speed and performance when wings were made to point slightly back, particularly when the engines hung beneath the wings in pods rather than being nested inside them, as had been the custom. The arrangement compensated for drag by making the wing itself more flexible in meeting wind resistance. Schairer sent seven cramped pages of mathematical formulas and sketches to a colleague in Seattle.

The task of testing the new Dash 80 went to a onetime barnstormer from Kansas named Alvin “Tex” Johnston. He got his nickname in the 1940s when he showed up in cowboy boots for a job with Bell Aircraft in Niagara Falls, New York. It soon took him to the famous Muroc Army Air Base in California (now Edwards Air Force Base), where another pilot, Chuck Yeager, would fly the Bell X-1 past the sound barrier. In the fraternity of pilots, there is no shortage of ego. Tex wrote in his autobiography that he had a one-word answer when an attractive young female psychologist evaluating him for a job at Boeing asked what he liked better than anything in the world: “Copulation.” Johnston earned a place in company lore when, in 1955, at a time when skepticism of jets was still high, he executed a barrel roll of the Dash 80 over a crowd of three hundred thousand spectators—and a second one so that people who had missed the first one could see it. He hadn’t told anyone of his plans before flying over the Gold Cup, a hydroplane race on Lake Washington that happened to coincide with a pair of industry conventions. Afterward, Allen asked what he thought he was doing. “Selling airplanes,” Johnston replied. (As the pilot describes it in his autobiography, Allen gave him a mild dressing-down, then invited him for dinner with Eddie Rickenbacker, the World War I fighter ace who then ran Eastern Air Lines. Rickenbacker pulled Tex’s Stetson over his ears and exclaimed, “You slow rollin’ S.O.B.!”)

Boeing had no competing aircraft. In the mind of its president, Allen, this was not necessarily a bad thing. The Douglas model was designed to take about eighty people around five hundred miles. The carriers who flew those routes were generally small and struggling—not exactly profitable customers. One internal study in 1965 estimated that Boeing could lose $150 million (equivalent to $1.25 billion in 2020) if its own competing entry into the market didn’t sell. But some on Allen’s board hated the idea of ceding any ground to Douglas. They argued it would be fine to build a loss leader—an entry-level model that small airlines could start with before moving up to bigger Boeing jets. It was the General Motors strategy: Sell young buyers a Chevrolet before they could afford a Cadillac. Reluctantly, Allen decided to design a new plane. — And so the 737 was born—quick and dirty. Most of Boeing’s engineering resources were going into the massive 747, not to mention the hugely ambitious project for a supersonic transport. The company’s first successful sales meeting, with Germany’s Lufthansa in 1965, didn’t have an auspicious start. Boeing had shipped to Cologne a hardwood box with massive hinges and a Yale lock, containing charts and diagrams about the plane’s performance, for the airline’s board to examine. It had neglected to include a key. The airline’s chief executive had to pry the box open with a hammer and a screwdriver. Two years behind the DC-9 in the race to put out a ...

Pondering a line drawing at his desk one day, Sutter pulled out a pair of scissors, sliced the engines off the back, and tucked them under the wings instead. It would allow him to squeeze in six extra seats, potentially a huge swing in revenue and profitability for a small airline.

Boeing debuted the 737 in January 1967, with stewardesses in miniskirts from no-frills PSA, Pacific Southwest Airlines, lined up along the wing. The San Diego–based carrier’s business model helped inspire a Texas lawyer named Herb Kelleher to start Southwest Airlines at Love Field in Dallas that same year. Competing on short-hop flights within California and Texas, the airlines were beyond the reach of the all-powerful federal Civil Aeronautics Board that determined interstate fares and routes.

Early sales of the 737 weren’t helping matters. The outlook was so bad, in fact, that Boeing offered to sell the entire production line to Mitsubishi; the Japanese company refused. “We were broke,” a Boeing manager later summed it up. To eke out sales, engineers put a gravel-deflecting skid on the underbelly so that it could land on unpaved airstrips in places like western Alaska and Peru—not exactly the coveted markets Boeing might once have dreamed of for its new model. In 1972, just fourteen of the planes were sold. The next year, Boeing considered canceling the program altogether. But the baby Boeing would have its day. While Boeing was preoccupied with other planes it considered more important, the 737 would lead one of the most remarkable product comebacks in aviation history.

Eventually Mitsubishi would get the CRJ line

Remarkably, the praise came only a month after the crash of a 747 in Japan that killed 520 people and became the deadliest single-aircraft accident ever, surpassing the grim record set by the DC-10 a decade earlier. A half hour into a short domestic flight, the plane’s vertical fin had ruptured, and it plowed into a mountain ridge. Speculation began swirling that the skins of the giant planes were vulnerable to fatigue, the dreaded issue that had ruined the reputation of De Havilland’s Comet thirty years earlier. Wilson at the time was handing authority over the company to a genial lawyer from Boise, Idaho, Frank Shrontz, who became president in 1985 and succeeded him as CEO the following year. The Seattle plane maker surprised crash investigators when it issued a mea culpa just weeks after the crash. A statement said one of its repair teams had incorrectly installed a splice plate on the jet’s rear bulkhead after a hard landing that damaged the tail section years earlier. Japanese officials, just settling in for a long examination and tough negotiations, were stunned at the company’s transparency. In a single stroke, Boeing had swiftly curtailed a drawn-out legal fight—and ended any doubts about the company’s integrity.

It took years for the effects shake out, with early experiments like Laker Airways fizzling, fabled names like Braniff and Pan Am disappearing, and the now-familiar Big Three—American, United, and Delta—finally consolidating their control. They did it with a strategy few anticipated at the time, funneling traffic from smaller cities into big hubs like Chicago and Atlanta, and from there directing fliers on to their final destinations. This would require many more small jets making frequent flights.

Airlines now needed smaller planes that could make frequent, short hops, and cheaply. “The 757 would sell beautifully if it had 150 seats,” a Lufthansa executive said of the 220-seat plane while it was under development.

Alongside the newly cutthroat airlines, it was getting harder for Boeing to escape the fact that Airbus was a real threat. A mid-1990s internal analysis came to the unthinkable conclusion that Airbus, a consortium of European manufacturers it had always derided as a glorified jobs program, actually had a cost advantage over Boeing. Its factories produced planes 12 percent to 15 percent cheaper than Boeing’s, the study reported. Ironically, this was in part because of rigid labor laws in Europe, which made layoffs more expensive and, in places like Germany, forced the involvement of labor unions in management decisions. As a consequence, Airbus was quicker to adopt automated machinery, but also more likely to train and develop its workers rather than to fire them. Condit and his predecessor as CEO, Frank Shrontz, looked to Japan for answers, sending executives to study the lean manufacturing techniques of companies like Toyota and Hitachi. These managers came back to Boeing and implemented ideas they’d learned about there, involving workers in commonsense solutions like creating cutouts for tools at every workbench so it was easy to see if one was missing.

Mulally often repeated maxims like “no secrets” and “the data will set you free.” When his temper flared, he put it less delicately. “The only thing that will make me rip off your head and shit down your neck is withholding information,” one engineer recalls him saying. In a measure of his intensity, he frequently ended meetings by pulling out a marker to write down on one of the plastic transparency sheets under the overhead projector what each person had agreed to do and having them all sign it. “Accountability is huge with him,” said a former lieutenant. “Burying things and letting them fester—Darth Vader comes out.”

Buybacks of the sort Stonecipher had instigated were once considered market manipulation. They represent a technique in which a company uses its revenue to acquire its own shares on the open market, then cancels them. With fewer shares outstanding, the ones left are more valuable. Hold a single share in a company that issued one hundred shares and you own a 1 percent stake. If the company buys back half of the existing shares, you now own 2 percent, artificially increasing the value of your share and increasing your dividends, without any additional expenditure on your part. 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. From the point of view of executives and board members at public companies, who are typically rewarded primarily in stock, it offered a virtuous circle: buybacks mean more money for their investors and more for themselves. But the money isn’t free. When companies buy back shares, they’re forgoing other spending, like investments in their next line of products or pension contributions. McDonnell Douglas ramped up buybacks over the next two years; simultaneously, it cut its R&D spending 60 percent.

When it came to the dark arts of corporate one-upmanship, many at Boeing were novices. Their products may have won in the marketplace, but the people who designed them were scientists and craftsmen, not sharp-elbowed operators. A wine club for employees drew such exacting hobbyists that it spawned more than a dozen commercial wineries, some regularly rated among Washington State’s best. There was undoubtedly some fat to be trimmed; T. Wilson himself, asked once how many people worked at Boeing, had jabbed back: “About half.”

Speea was an open shop, meaning membership wasn’t a condition of employment; only about half of the represented workers actually paid dues. On the morning of February 9, 2000, the day of a planned strike, Sorscher waited alone outside the 737 factory on the south end of Lake Washington, his only company three circling seagulls. Doubts began wheeling through his head, too: was it foolish to think highly paid professionals, many of them PhDs like him, would actually strike? At the appointed hour of nine a.m., all was still quiet. Sorscher went over to a few guys sharing a cigarette in the parking lot and asked if they’d seen anybody around. Just us, they said. Ten long minutes after nine, hundreds of engineers streamed out. They were late because they’d marched around the factory, cheering and clapping, as machinists on the assembly line shouted encouragement. Thousands packed into a nearby football stadium, where the brainiacs finally looked like a real union, roaring chants like “No nerds, no birds!”

Three federal mediators were brought in to try to resolve the standoff. After one resolution attempt failed, one of the mediators shared his own doubts that the merged company could survive, said Cynthia Cole, a striking engineer who would later become Speea’s president. The mediators were supposed to stay neutral but in a moment of frustration at the hotel where talks were taking place, he confided that he saw the partnership as doomed. The executives who’d come from McDonnell Douglas, he said, were “hunter killer assassins”—and those from Boeing, “Boy Scouts.”

Marie Douglas, an analyst from Lazard Asset Management, that the strike had been emotional. He said the feelings were far different from anything he’d ever experienced at Boeing, which now seemed ruled by anger, fear, and pride. “Really? That’s my experience every day on Wall Street,” replied Douglas, then twenty-eight. Blond, six foot three, and a countess from Sweden, Douglas would go on to marry George David, the CEO of United Technologies, another of the aerospace companies she covered. (Their divorce at the height of the Great Recession in 2009 became a tabloid sensation when, though the couple were childless, she asked for $53,000 in maintenance—per week. That included $4,500 a week for clothing, $1,570 a week for horse care, and $600 a week for flowers.)

The latter project, called Cinema Connexion by Boeing, signed AMC Entertainment as an early customer. AMC hoped to replace the film canisters and projection reels then still in use in its theaters with 50-gigabyte digital files transmitted via a secure network of satellites and ground stations. Stonecipher hosted a weird press conference at Boeing’s headquarters in November 2000 featuring a video linkup with Ben Affleck, star of Bounce, the first Hollywood movie delivered via satellite to a theater through the new Boeing system. The movie was about an advertising executive (Affleck) who gives his airline ticket to a stranger—who is then killed when the flight crashes. Affleck, awash in guilt, manages the ad campaign to help the airline recover, while trying to summon the courage to confess his own role to the man’s grieving wife (Gwyneth Paltrow). It was a mark of the plane maker’s reputation at the time that news stories about the venture, and Boeing itself, breezed past the unlikely choice of subject matter. “It’s more of a love story,” a spokesperson said.

District Lodge 751 of the International Association of Machinists—were practically the last union of manufacturing workers in America with real leverage. The reason was simple: they could, and did, shut Boeing down.

Boeing’s internal deliberations were revealed in the politically charged legal fight that followed. Albaugh had told the board that the move to South Carolina brought both extra costs and additional risk. They’d have to spend $1.5 billion, train inexperienced workers, and accept lower earnings on the first Dreamliners built there. But Project Gemini, as it was called, would undercut the union’s leverage and gain “important political support from a key state.” Boeing got more than $800 million in new tax breaks from South Carolina, where Republican Nikki Haley, elected governor in 2010, frequently declared that she wore high heels to kick unions out. Workers would make fourteen dollars an hour there compared to twenty-eight dollars in the Seattle area.

The Next Generation models introduced in the 1990s had proven remarkably durable, with orders surpassing seven thousand. What’s more, with the initial investments in design and factory tooling long since paid off, the plane was a cash cow: the profit on each one was $12 million. The persistent issue remained: In the biggest, most important part of the aircraft market, the 737 was no longer the premier product. The Airbus A320 was.

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. Customers often came back to Airbus and told them Boeing’s offer was lower priced, and its salespeople would have to pore through the details to see what was missing, said John Leahy, the New York native who ran sales at Airbus for thirty years. It reached the point that Airbus estimated a bare-bones A320 had $2.5 million to $3 million more in standard equipment than a 737. 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.’ ”

The Airbus team courted American’s CEO, Gerard Arpey, and its president, Tom Horton, over frequent lunches at the Mansion on Turtle Creek in Dallas, a boutique hotel where they didn’t think they’d be spotted. Moving to the Ritz-Carlton during a stretch of hundred-degree days lasting nearly two weeks that July, they reached agreement on an order for hundreds of planes. Arpey called Albaugh to let him know the carrier was ready to buy Airbus aircraft; what could Boeing do for them? Albaugh kept his cool and said he’d get back to American with an offer of his own. Privately, though, he was furious that his Dallas residents hadn’t picked up any intelligence about the talks and unenthusiastic about making a public U-turn in strategy. Within a week, Boeing made a counterproposal for a hypothetical 737 outfitted with more powerful engines, a model so new it didn’t yet have a name. The world would come to know it as the 737 MAX 8. — Just like the original 737, the design was quick and dirty. Over the decades, the 737’s engines had gone from cigar-shaped, to ovoids squished on the bottom, to soda cans clipped in front of the wings. Now, to fit even bigger turbofans onto the same basic low-slung fuselage, Boeing would mount them still farther forward of the wings, and raise the nose gear about eight inches. This would change the plane’s center of gravity, not to mention the view from the cockpit for pilots, potentially forcing them to undertake additional training, always costly for...

Joe Sutter and other engineers at Boeing wrote the first set of jetliner regulations, known as SR 422, themselves because no one in government had designed a jet before.

Conversations that used to take place at the specialist level became tense negotiations with higher-ranking executives in the Boeing regulatory unit. Steve Foss, a former FAA test pilot, watched as Boeing executives buttonholed his supervisors in parking lots after meetings. “It was push, push, push, shove, shove, shove, to get the airplane into the customer’s hands,” he said. When the specialists raised technical issues, they’d be told to stand down—often by Bahrami, the official in Seattle most responsible for ensuring the safety of Boeing airplanes. One senior manager who disagreed with the new approach remembers Bahrami frequently assuring staffers they should trust Boeing. “They know the systems, they know the rules,” Bahrami would say. After this person raised his concerns privately, Bahrami gave the impression the manager’s career depended on going along: “I’m trying to help you,” Bahrami said. The fragmentation of responsibilities left Ken Schroer, the FAA program manager who’d had such a warm feeling about collaboration with Boeing on the 777, struggling to get clear answers; it was often difficult to tell who was telling who what. He retired in part because of his frustration.

A week later, 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 that there’s smoke and fire in these planes!” He said the Dreamliners could fly again when he go...

The 737 by then accounted for about a third of the entire company’s profit, but it was still the redheaded stepchild, not something you spent money on. “It’s a pig with lipstick, just a simple old airplane,” said one former Boeing pilot. The resources and people devoted to the program reflected that; it got the “B” team. Many of the others working on it, like Ludtke, squeezed in their work on the MAX alongside other more pressing projects. “The 737 was something of a backwater,” said Peter Lemme, a former flight controls engineer. What’s more, low-cost Southwest Airlines, the biggest customer, had no desire to push the envelope. It wanted its ten thousand pilots to be able to step into the new plane without any additional training, which would save it huge costs as well as logistical headaches. Early in the program, Boeing managers told the flight controls team that under no circumstances were they to make any changes that would require pilots switching from the previous 737 to the MAX to step into a simulator. The reason: Boeing had promised Southwest $1 million per airplane if simulator training was required—and the carrier by 2019 had ordered 246. That was all the incentive Boeing needed.

Simulator vs. incentive

At a meeting in 2012, Reed, the FAA engineer who had so reluctantly joined the Boeing Aviation Safety Oversight Office, questioned Boeing managers about the plan to leave the cockpit of the new MAX largely unchanged. It would make the 737 the last big commercial jet flying without an electronic crew alerting system—like the one Boeing had pioneered on the 757 and 767 fully thirty years earlier. “I was saying, ‘Guys, make the break, put a modern flight deck in this airplane,’ ” Reed recalls. He pointed out that many of the older pilots who grew up with 737s were retiring. Younger pilots had often started in commuter planes made by Embraer in Brazil or Bombardier in Canada, with far more advanced cockpits. Even the newest military planes had checklists that appeared on touch screens. If a hydraulic pump failed, a message would pop up showing specific actions the pilot should take. On the 737, a light showing “low hydraulic pressure” might illuminate with no further explanation. Pilots would have to rely on memory or turn to their paper handbook. “Training issue,” the Boeing executive responded to Reed, in rejecting such changes. If Boeing had been building a brand-new plane, it would have been required to have the electronic checklist. But because the MAX was being examined as an amendment to the original type certificate awarded in 1967, managers could pursue an exception. The MAX was actually the thirteenth version of the plane, counting all the variants along the way—the ...

Why no electronic checklist

At Sioux Center High School, Muilenburg was a standout, and not just for math. He was one of the best artists Ted De Hoogh, one of his teachers, ever taught. This was especially so with pencil sketches; his drawings had a great command of light, shading, and texture. For years Dennis’s depiction of the high school’s facade adorned the booklets handed out at the graduation ceremony.

While Muilenburg participated in research for a high-speed civil transport, most of his career was spent on military projects: the F-22, the 767 AWACS, the 747 Airborne Laser, the EX surveillance platform, the Advanced Tactical Fighter, and “a number of proprietary programs,” as his résumé put it. They were the kind of predictable programs (and predictable revenue) that Mr. Mac and his progeny, part of Boeing’s DNA since the merger, had always preferred. The outcome depended on lobbying, politics, and closed-door maneuvering as much as standout engineering.

Among the Boeing pilots, it would have been hard to guess that the most famous of them to emerge from the MAX’s development would be Mark Forkner. In the pecking order of Boeing’s pilots—who knew their pecking order implicitly—Forkner’s group came in about dead last. First came the test pilots, the Chuck Yeagers and Tex Johnstons who executed the daring maneuvers and talked to the press about it in leather bomber jackets afterward. They might nose the plane into a stall, or drag its tail along the runway like a hot-rodder on a motorcycle—the “velocity minimum unstick” test to determine takeoff speeds. The test pilots were sometimes known as the “McChord mafia” because many of them had flown for the air force at the nearby Lewis McChord Joint Base.

Finally there was Forkner’s group, called Flight Technical and Safety. They wrote the manuals. They weren’t even in the same division of the company as the test pilots, in part because Boeing had decided two decades previously that customer training was a business that should make money. Forkner’s group reported to Boeing Global Services in Plano, Texas, which had been tasked in 2016 with an ambitious target from Muilenburg: increasing revenue to $50 billion within five or ten years, from just under $15 billion. Despite his lowly status, Forkner was technically McChord mafia. He was a former air force pilot who had flown C-17 cargo planes and then worked at Alaska Airlines before doing a stint at the FAA in the air-traffic management unit. His wife worked there, too, as a manager in an office that oversees airports.

In an airport once, he spotted Ethan Pocic, a college lineman the Seahawks had recently drafted, and Forkner went military officer on him, barking, “You have one job, and that is to protect Russell Wilson, understood?”

The industry’s rapid growth badly stretched its ability to recruit and train people to fly all the planes it was selling, and in at least some corners of Boeing, pilots well knew how much these customers struggled with basic proficiency. After a visit to an airline in Africa, a Boeing trainer reported to his boss that he’d be writing up a short report: “Should not fly airplanes.” A carrier in Russia, S7, was considered dangerous enough that some Boeing instructors refused to fly on it unless they were at the controls. Most admitted privately that for young pilots, so accustomed to having computers tell them what to do, their 737 was a difficult beast. One high-ranking Boeing executive told people that if he were flying in Asia, he would prefer to be on an Airbus.

The same propensity to pitch up at high speeds, the quirk of design that had led to the adoption of MCAS, was also present during some tests of low-speed stalls. Regulation required the control stick to give steadily increasing forces in such an event, signaling to pilots the onset of a stall; instead it got mushy, less reactive. The pilots told Teal the plane wasn’t “certifiable” in that condition, meaning it wouldn’t pass muster with the FAA. By the end of that March, the engineers and test pilots had arrived at a solution. 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. “All changes are minimal / low collateral damage, therefore no additional flight testing,” one memo said. The same day Leverkuhn and Teal approved the plan, Forkner emailed the FAA’s Klein for permission to delete MCAS from the flight manual because it “only operates WAY outside of the normal operating envelope.” Still focused on his mission of minimizing training, he possibly didn’t even know about the software changes. Klein certainly didn’t; she agreed. By this time, many of the engineers who had worked on the MAX early in its design had moved on to other projects. Ewbank and others with expertise in human factors were gone. Many of those who remained (the pilots thought of them as interchangeable units from the University of Washington, making $90,000 a year) lacke...

Forkner, chief of the MAX manual writers, felt relaxed enough to send a note to an old friend he’d worked with at the FAA. “Things are calming down a bit for my airplane cert, at least for now,” he wrote. The only things left were validating the simulator for the MAX and a bit of traveling, or, as he put it: “Jedi-mind tricking regulators into accepting the training that I got accepted by FAA etc.” By November, though, he was seeing the plane in a different light. Sitting in a hotel room in Miami with a Grey Goose, he vented to his deputy, a former Ryanair pilot named Patrik Gustavsson, about the plane’s “egregious” performance in the simulator. No one had told him that MCAS, originally intended to prevent stalls at high speed, could now possibly fire at speeds as low as 150 miles per hour. “I’m levelling off at like 4000 ft, 230 knots and the plane is trimming itself like craxy [sic],” he wrote. “I’m like, WHAT?” Gustavsson’s first reaction was the sheer frustration of the fed-up office worker. “Oh great,” he replied—now they had to update the description in the manual. But Forkner appeared to have deeper concerns. He wrote that it meant he had “lied (unknowingly) to the regulator” about the system’s authority over the stabilizer, its ability to flummox a pilot. “Why are we just now hearing about this?” Forkner asked. “I don’t know, the test pilots have kept us out of the loop,” Gustavsson replied. “They’re all so damn busy, and getting pressure from the program,” Forkner...

Back on the ground, the captain documented what had happened in the logbook, and Lion Air’s mechanics got to work clearing the plane for the next flight. The captain’s note included the alerts he’d seen—alt disagree, ias disagree, and feel diff press (indicating bad altitude, airspeed, and hydraulic pressure). 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. 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. A quirk of the software, however, meant that after a power-down, the bad sensor would again feed into the captain’s controls on the left side. Suneja and Harvino would be unwitting guinea pigs, this time without a third pilot to guide them. The IOU that Boeing’s engineers had left dangling in the hastily completed software finally came due.

The MAX had a single cutout switch. If pilots flipped it, as directed in an emergency, they’d no longer be able to adjust the electric trim with the button under their thumbs. They’d have no choice but to use the manual trim wheel, the one that the deadheading third pilot had noticed was moving on its own the night before the Lion Air crash. That wasn’t easy. Pilots trained on moving the wheel in refresher courses once a year, but some went their whole careers without ever using it in flight. It was especially rare to have to deal with conditions so jarring in the midst of a takeoff or a landing, the most critical moments of any flight. Boeing had reports of the stick shaker activating at or shortly after takeoff only thirty times between 2001 and 2018, during which hundreds of millions of flights had taken place. Of those instances, twenty-seven were on 737s.

It was hard to imagine that a low-fare airline had mobilized such a well-coordinated legal response just a few days after the crash; solving the puzzle of who did became a consuming passion for Rini and the lawyers she eventually hired.

“The underbelly of aviation is the disenfranchisement of people of color globally—they’re being treated like absolute pawns,”

Some pilots weren’t so willing to let the matter drop. In Shanghai that fall, a couple of Boeing trainers ran into a pilot from American Airlines, who laid into them for “the lives that we cost” in Indonesia, as one of the pilots later described the uncomfortable encounter. “Hey, hold on,” the Boeing pilot responded, cautioning him to wait for more evidence. Back in Seattle, he joined a half dozen fellow Boeing trainers for a briefing about how the MCAS software worked from Patrik Gustavsson, the former Ryanair pilot who had traded frustrated messages with Forkner two years earlier. Gustavsson was now the chief 737 technical pilot. When Gustavsson told them the software fired based on a single angle-of-attack vane and that it would continue firing even after a bad reading, “we were universally shocked,” this person said. The group consisted of trainers who’d been left “out of the loop,” as Gustavsson himself had put it. They instantly recognized the flaw in its design. “The pilot’s fighting the jet the entire time,” as one person there put it. One of Boeing’s engineers had said virtually the same thing during the testing of MCAS, but his email had an unhurried, innocuous tone—you could sense the coffee and air-conditioning. To these pilots, the stakes were immediately clear. The situation was life-threatening.

Without mentioning that Boeing had botched the software implementation on other planes, he explained that American had purchased the optional angle-of-attack indicator, which Lion Air had not. Had it been Michaelis’s plane, a little flag notice would have popped up alerting him to disagreement between the AoA vanes, and mechanics would have fixed the sensor on the ground. “So you would not have taken the airplane,” he said.

He said Boeing was working hard on an MCAS update to tame the system. “Not a year, but a couple—maybe six weeks–ish,” he said. 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.

Ali Bahrami, the FAA’s safety chief, kept taking calls from his foreign counterparts. They’d say, “ ‘Ali, ‘I’m really sorry, minister asked us to ground the fleet,’ ” as he described it later. He insisted there was still no data. That Monday, the FAA had gotten the readout from the plane’s satellite transponder, but the agency didn’t have the expertise to analyze it. (“Other authorities may have,” Bahrami later said. “We don’t have any of that.”) The FAA handed the readout to the NTSB, which delivered it to Boeing, whose engineers then examined it. They asked Bahrami for an urgent conference call on Wednesday morning. 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.

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.

Muilenburg was pictured leading from the front, sitting in the cockpit with pilots testing the latest software upgrades on the MAX. Wearing a pressed blue Oxford shirt on the factory floor, he said, “We own it” in a recorded video. He repeated the message a week later, in Dallas, at the George W. Bush Presidential Center forum on leadership. “That’s what we do at Boeing: We own it. As our veterans know so well, how you respond to a tough situation will make all the difference to your organization and your country.”