Over the course of 7 months in 2011, Boeing did an about-face. While in January it eschewed the idea of putting new engines on its 44-year old workhorse, the 737, by July, executives embraced the idea. The change in attitude was in response to the re-engined Airbus A 320 neo, which was racking up orders for the Toulouse-based planemaker, including some from formerly loyal Boeing airline customers.
The calculation that it would be cheaper and faster to tweak an old model than to design a new one, led to the Boeing 737 Max.
Like a Greek tragedy, with all of the sorrow, the intrigue, the hubris and the deceit, the decision brought the company to the biggest crisis in its history.
The nearly non-stop coverage of LionAir 610 in October 2018 and Ethiopian Airlines 302 in March 2019, might have you thinking that the story of Boeing’s corporate misbehavior has been fully told. That was my thinking as I turned the first of the 246-page report from the House Committee investigating the design development and marketing of the 737 Max.
Many of the juicy bits have appeared in various news accounts, including the creation of a secret software system MCAS, that would usurp pilots’ control and send the airplane into a dive, the decision to allow just one sensor to trigger the activation of the MCAS, and Boeing’s apparent disregard of regulators and customers as revealed in disparaging internal company emails.
Still, house investigators harvested new details in even more emails as well as company documents and interviews with executives, engineers, FAA officials and company whistleblowers. By putting all this together in one, extremely readable document, the Transportation Committee investigators have created a frightening whole larger than the sum of its parts.
The report details a virtual mountain of head-scratching design decisions, faulty hazard analyses and ignored warnings, which it attributes to the pressure Boeing felt to get an airplane to market to meet the competition from Airbus’s A320neo. It is an indictment of Boeing to be sure, but also of the Federal Aviation Administration and the system through which the two are supposed to be assuring the safety of the traveling public.
These are among the takeaways:
Point 1. Boeing repeatedly made faulty assumptions about its designs and how they would work in airline service.
By its own analysis which it presented to the FAA before the airplane was certified, should the now-infamous MCAS software trigger an uncommanded dive on the Max, a pilot would have sufficient time to recognize the problem and fix it. But the investigators found that as far back as 2012, a Boeing test pilot was unable to respond that quickly in the simulator. This pilot characterized the possible consequence of that failure to be “catastrophic”.
While this foretold exactly what was to come in Indonesia and Ethiopia the information was never shared with the FAA or Max operators.
Similarly, communications shot back and forth at Boeing in 2015 regarding reliability when referencing just one angle of attack indicator. But questioners were reassured. This despite the fact that AOA vanes are often damaged due to their position, protruding from either side of the front of the aircraft where they are subject to damage from airport and service equipment on the ground and birds and ice and hail in the air.
Point 2. A culture of deceit permeates the company and is too often used as a tool for dealing with its regulators and its customers
The MCAS system had another problem. Should it be presented as something novel on the Max, it would require pilot training and Boeing had already promised airlines the Max would not have an accompanying training cost. The issue was so important to Southwest Airlines that it extracted a promise from Boeing that should pilot training be required, the company would rebate $1 million per airplane. Engineers at the company were hashing through this dilemma as far back as 2013 when one explained, “If we emphasize MCAS is a new function there may be a greater certification and training.”
For this and other reasons, Boeing adopted a strategy to conceal differences between previous versions of the 737 and the Max and other issues. (See Point 1.)
Point 3. FAA’s supervisory role is undermined by conflicts of interest and an attitude of deference to Boeing
That Boeing was so successful at dissembling on these critical safety matters, was due in large part to an FAA that deputizes Boeing employees to act in its sted. In one telling interview, Michael Teal, the FAA’s former chief project engineer on the 737 Max said when he approved the new and more powerful MCAS in 2016, he was unaware of three factors that turned out to be critical; it operated from a single AOA sensor, that it could repeatedly thrust the airplane into a dive and that Boeing’s own test pilots needed more than 10 seconds to react to the uncommanded pitch when flying the Max in the sim.
Teal may have been unaware of these factors when he signed the paperwork sealing the fate of those aboard LionAir and Ethiopian Airlines but the report reveals that four Boeing employees who were authorized to serve as the FAA’s representatives were aware of that critical simulator flight and never passed the information along to the regulator.
Deference is the only way one can describe the attitude of FAA’s lead safety officer, Ali Bahrami. The report barely stops short of calling him a liar, as it recounts how claimed not to know about half a dozen headline-making stories about Boeing’s apparent duplicity.
He told investigators he couldn’t recall having a single conversation with Boeing in the critical four months between the LionAir accident in October and the Ethiopian Airlines disaster the following March. But the report documents that Bahrami was scheduled to talk to Boeing’s Beth Pasztor in January 2019. It’s a small detail, not a smoking gun, but it contributes credibility to the committee’s claim that that FAA often acted more like an advocate for Boeing than its safety overseer.
Point 4. Competitive pressure and an unrelenting production schedule created an unsafe environment for airplane building
While the race not to lose ground to Airbus sets the stage for most of the bad behavior detailed in the report, the one that is hardest to see but easy to imagine comes from a Boeing whistleblower who told investigators that unrelenting pressure degraded the performance of even the most conscientious workers.
Ed Pierson, senior leader of the 737 MAX final assembly facility said “all my internal warning bells were going off” in an email to a superior at Boeing. Assembly line workers were “exhausted” he wrote and “employees are either deliberately or unconsciously circumventing established processes.”
Pierson suggested shutting down the assembly line to regroup but when production was increased instead, he resigned. Two months later LionAir flight 610 crashed.
In ancient Greece, the role of tragic theater was to take the audience on an emotional journey through pity for the victims, fear of the danger and anger towards the perpetrator. This culminates in resolution and catharsis.
The events leading to the 737 Max accidents in 2018 and 2019 are Act 1. The Transportation Committee’s well-documented report is Act 2. Whether the audience of this real-life drama will see resolution in the future, awaits the writing of Act 3.
Author of The New York Times bestseller, The Crash Detectives, I am also a journalist, public speaker and broadcaster specializing in aviation and travel.