In 737 Max Crashes, Boeing Pointed to Pilot Error — Despite a Fatal Design Flaw

September 14, 2021

When a Boeing 737 Max passenger jet crashed shortly after takeoff in March 2019, the second such 737 Max 8 crash in five months, among the 157 people killed were Quindos Karanja’s mother, his sister and her three children. One of them, baby Rubi, was less than 1 year old.

“It’s not like there is a manual of how you need to react,” says Karanja, who remembers feeling “infuriated” as he digested the news that five of his beloved family members had died in the crash of Ethiopian Airlines Flight 302.

He also recalls something else.

“I remember the Boeing company blaming what they call the foreign pilots and deflecting blame to them,” Karanja says in the above excerpt from Boeing’s Fatal Flaw, a new FRONTLINE documentary in collaboration with The New York Times.

Then-Boeing CEO Dennis Muilenburg latched onto findings that pilot inexperience and lack of training were part of a chain of events that led to the tragedies. Yet both the March 2019 Ethiopian Airlines crash and the October 2018 crash of Lion Air Flight 610 involved a software system, MCAS, that was supposed to keep people safe — but instead contributed to tragic deaths when triggered by a single faulty sensor.

From award-winning FRONTLINE director Tom Jennings, Boeing’s Fatal Flaw premiered Tuesday, Sept. 14, on PBS and online and is now available to stream in full. Drawing on extensive reporting from a team of New York Times investigative journalists, as well as original interviews with key sources, the film tells the inside story of the fastest-selling jet in Boeing history, the two deadly crashes that killed a combined 346 people, and how intense market pressure and failed oversight contributed to a catastrophic crisis for one of the world’s most iconic industrial names.

“One of the things that really struck me, from speaking to a lot of Boeing employees, was that they were so excited to go to work at Boeing,” says Doug Pasternak, who led the 2019-2020 congressional investigation into the 737 Max and speaks publicly in the film for the first time about what he found. “Boeing is a tremendous engineering company and a technical marvel, but almost without failure, they point to a degradation of that mindset — and that safety suffered as a result. Looking backwards, I think you can clearly see the trajectory to tragedy along the way at Boeing.”

In vivid detail, the documentary pieces together what Boeing knew about the potential for disaster with the 737 Max and when the company knew it. Pasternak says in the film that in 2012, a “Boeing test pilot was flying the MAX in a flight simulator and trying to respond to an activation of MCAS, and that resulted in what he described as a catastrophic event. It showed that if that had been in real life, he [could] have lost the airplane. They realize from that moment on, even a Boeing test pilot may have trouble responding to MCAS.”

Yet internal communications explored in the film show that Boeing was determined to maintain the status quo: avoiding potential scrutiny by the Federal Aviation Administration that would add costs; keeping new simulator training for pilots to a minimum; and even requesting that MCAS be removed from pilot training manuals.

As Boeing’s Fatal Flaw reports, in the wake of the first deadly 737 Max crash, the company identified a design flaw, began working on a fix and issued an advisory to pilots about potential malfunctions. But it stood by its new commercial jet and suggested pilot error played a role, and the FAA did not ground the planes. Some five months later came the crash of Ethiopian Airlines Flight 302.

So when American Airlines pilot and spokesperson for the Allied Pilots Association Dennis Tajer reviewed the black box data from Flight 302, he was stunned by what he found. Two minutes into the flight, based on faulty data from a sensor, MCAS kicked in and began pushing the plane’s nose down — and the first officer, despite being what Tajer described as “lesser experienced” than the crew’s captain, initially followed Boeing’s emergency procedures.

“I have a very clear memory of noting a time mark where the first officer is quoted as saying, ‘Stab trim cutout switches,’” which takes the weapon away from MCAS, which is what Boeing told us to do,” Tajer says in the above excerpt.

Tajer then becomes emotional: “I probably swore. I said: ‘The kid got it right. That kid got it right,’” he recalls.

After switching off the electricity, the first officer tried to bring the plane out of its dive by manually turning its trim wheel.

“The problem was, at that point, the plane was going so fast that, even after they took manual control, they could not physically get the plane to right itself,” says Natalie Kitroeff, one of the The New York Times reporters who investigated the crashes. Correctly flipping the switches to turn off MCAS amid a cacophony of alarms, the pilots did not throttle-back after takeoff. “They shouldn’t have been going that fast.”

With no apparent recourse, the pilots reached for the stabilizer switches — and MCAS was reactivated.

“Now the airplane is in near full nose-down trim,” Tajer says. “And you can pull back forever, and there’s not enough metal in the back of the airplane to make that airplane come up to a nose-up.”

The lives of Quindos Karanja’s family members and the other 152 people aboard the 737 Max would end soon after.

“If MCAS hadn’t been on those planes, those planes wouldn’t have crashed,” David Gelles of The New York Times says in the film. “It’s that simple.”

Of visiting the crash site, Karanja recalls in the film: “Now, you’re in close proximity. You’re able to see the fine details. You’re able to maybe think, These are personal effects belong[ing] to … my sister or my mom. This bone, whose bone is this?”

Boeing declined to be interviewed for the film. In a statement, the company said safety is its top priority and it has worked closely with regulators, investigators and stakeholders “to implement changes that ensure accidents like these never happen again.”

Earlier this year, the company resolved a criminal charge of conspiracy to defraud the United States brought by the Department of Justice and admitted to “misleading statements, half-truths and omissions” about MCAS. It agreed to pay a $2.5 billion settlement: $500 million to the families of the victims and most of the rest to compensate the airlines.

The FAA cleared the 737 Max to resume flights, and it is once again flying passengers around the world.

For the full story, watch Boeing’s Fatal Flaw:

In addition to being embedded in this story, the documentary is now available in FRONTLINE’s online collection of streaming films, in the PBS Video App and on FRONTLINE’s YouTube channel. Boeing’s Fatal Flaw is a FRONTLINE production with The New York Times and Left/Right Docs. The writer and director is Tom Jennings. The producers are Vanessa Fica and Kate McCormick. The reporters are David Gelles, James Glanz, Natalie Kitroeff and Jack Nicas. The senior producer is Frank Koughan. The executive producers for Left/Right Docs are Ken Druckerman and Banks Tarver. The executive producer of FRONTLINE is Raney Aronson-Rath.

Patrice Taddonio

Patrice Taddonio, Digital Writer & Audience Development Strategist, FRONTLINE



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