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How Boeing’s Flawed 737 Max Made It Into the Air

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FILM CLIP / NEWSREEL:

Breaking news: The search for wreckage is under way after a passenger jet —

FILM CLIP / NEWSREEL:

Lion Air Flight JT610 went missing from radar —

FILM CLIP / NEWSREEL:

What do we know about this 737 Max 8?

RANEY ARONSON-RATH:

Boeing is one of the world's most iconic companies. However, their legacy was challenged when tragedy hit in 2018 and 19.

FILM CLIP / NEWSREEL:

New 737 Max jetliner crashed today —

FILM CLIP / NEWSREEL:

Investigators say that flight had similar problems to the Lion Air crash —

Two planes crashed. One in Indonesia, and only five months later, another in Ethiopia, killing a total of 346 people.

FILM CLIP / NEWSREEL:

It’s the second disaster within five months involving the Boeing 737 Max —

FILM CLIP / NEWSREEL:

That’s the same kind of aircraft that crashed back in October in Indonesia —

Both involved the same kind of plane. The new 737 Max, the fastest selling jet in Boeing's history.

FILM CLIP / NATALIE KITROEFF:

The likelihood that these two accidents were not in some way connected was extremely low. It suggested that there was something going on with the plane, and obviously we were determined to find out.

ARONSON-RATH:

That's New York Times reporter Natalie Kitroeff. Drawing on extensive reporting and interviews with key sources, our investigation and partnership with The New York Times examines what Boeing knew about the potential for disaster and when the company knew it. From our film, Boeing's Fatal Flaw, we’re here with director Tom Jennings and Times reporter David Gelles, who will help us to understand the market pressures, corporate culture and failed oversight that led to the deadly crashes, And who, if anyone, has been held accountable. I'm Raney Aronson-Rath, executive producer of FRONTLINE, and this is The FRONTLINE Dispatch.

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ARONSON-RATH:

Tom and David, thanks so much for joining me on The Dispatch.

TOM JENNINGS:

Thank you.

DAVID GELLES:

Happy to be here.

ARONSON-RATH:

I want to start, Tom, with you, because of course the origination of a film usually happens between a filmmaker and me, or one of our senior team, talking about: Why this story? And I was really moved by the idea that we could tell an accountability story with characters at the center of the narrative. I really want to know what compelled you —

JENNINGS:

What compelled me about the Boeing story. First and foremost was the tragedy at the center of it, and it's one of those stories that is not something that's private. It's a very public story that everybody kind of knew about, including me, but didn't really know everything about. And when there's something like that at play, especially when there's, you know, human life that's involved at the center of it — the 346 people who lost their lives — that's something I want to know about. So, I think you and I both knew that there was a really powerful story here. We just didn't completely understand it. And that's what drives us. We needed to understand what was going on.

ARONSON-RATH:

David, how did you get involved with this? And what was the first thing that really sparked you to say, like, “All right, this is going to be my next big story.”

GELLES:

Well, like many people, when the first plane crashed in Indonesia, it sort of passed across my news radar, but It was written off as sort of another tragic, but perhaps not all too uncommon, aviation accident in a developing world country at an airline that had its own complicated safety record. And so it just didn't register for many people. And then when that second plane crashed, I remember sitting on my couch that evening, and it was late on a Sunday night in New York when the first news came out. And I remember sort of joining up the dots in my head and being like: “Wait. That's the second one of these that's gone down in a few months. That seems off.”

ARONSON-RATH:

Right. So, OK, let's dive into some of this together. What were some of the technical issues with this new plane, the 737 Max?

GELLES:

Part of the initial project was just doing our best to understand what had actually happened on the planes. Essentially the 737 Max was the latest iteration of a plane that had been introduced in the 1960s.

FILM CLIP / NEWSREEL:

The official 737 christening ceremony took place in the new final assembly building —

GELLES:

When the plane was first introduced, it was smaller. It sat lower to the ground. And so, when Boeing re-upped it one more time several years ago, they had to put bigger engines on the plane to make it more fuel efficient. In doing so, they changed the aerodynamic profile of the 737 just enough so that when they were testing this plane in wind tunnels, before the first flight had even happened, they started to notice that it behaved a little peculiarly in very specific extreme maneuvers. That led them to install a piece of software, which is colloquially known as MCAS — the Maneuvering Characteristics Augmentation System.

And what that software did was — using just really one input, one censor on the fuselage of the plane — it would decide whether or not the plane was approaching a stall. And if it felt like the plane was approaching a stall — based on this one input — it would correct the plane and would push the nose of the plane down. And what happened on both of these flights, tragically, was that one censor malfunctioned and essentially told the brains of the plane that the Max was in danger of stalling, and as a result, it pushed — in both of these instances — the planes into a nose dive from which it just couldn't recover.

ARONSON-RATH:

OK, so the obvious next question is: There’s early signs of challenges at the very least, right? So how did the software even end up on the plane?

GELLES:

This was what we spent a year trying to understand. And there's sort of the short answer and the long answer, and the short answer is some of what I just described. It was a series of engineering decisions that happened over the course of many years within multiple groups inside Boeing, in meetings and design processes that involved hundreds of people. No one, of course, put this on knowing that it could be, you know, so tragically malfunctioned. And yet it fell through the cracks, and Boeing engineers didn't catch it; the FAA didn't catch it; and there it was on the planes.

ARONSON-RATH:

OK, Tom. I want to ask you about the congressional investigation that was conducted after the second crash, which occurred in Ethiopia. You guys were able to get exclusive access to Doug Pasternak, who talked to you all. And he is the person who directed the investigations and oversight on the Transportation and Infrastructure committee.

FILM CLIP / DOUG PASTERNAK:

As soon as the second accident occurred, we started our investigation. And 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. 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.

ARONSON-RATH:

What did the committee's investigation reveal to you that you found revelatory?

JENNINGS:

So, one of the things was internal documentation going very far back, as early as 2012, revealing that internally within Boeing, there were concerns expressed about this system, MCAS. And one of the things that they discovered was a person who was an engineer at Boeing, who was very concerned about this reliance on that one censor that David is talking about. And that person's concerns were dismissed close to the launch of the airplane. Here was hard evidence that it was actually somebody internally saying there was something wrong with the design. This idea, this very simple idea that there is no fail safe to this input, which is a very odd engineering idea in a system that's so complicated as an airplane.

GELLES:

And despite all that, MCAS was still put on the plane. There were opportunities to stop this, if some of the lower-level people inside the company had been listened to, frankly. But the momentum behind this plane, the commercial prerogative to get the 737 Max to market as quickly as possible, with as little as hassle as possible, and as little additional scrutiny from the FAA as possible, essentially drown out any of those concerns that were being expressed by some of the lower-level engineers.

ARONSON-RATH:

Right, I mean, I’ll tell you, you know, the one interview, the recorded interview ​​that you all had from Rick Ludtke was so unbelievable. You know, how he speaks to the intense pressure-cooker situation that they were in.

FILM CLIP / RICK LUDTKE:

The company was trying to avoid costs — minimum change to simplify the training differences and to get it done quickly. Speed was what they seemed to desire. There was a lot of decision-making that was somewhat arbitrary and didn’t involve as much of the — of what engineering considers healthy debate.

GELLES:

Rick was one of the engineers who worked directly on the 737 Max program, and what he described was an environment where Boeing was essentially telling its airplane development team to update this 737 Max in absolute record time and, critically, to minimize any changes that might increase the likelihood that pilots would need simulator training. Because simulator training is costly and it's expensive. And so what Boeing understood from the get-go is that it needed to minimize the changes so airlines wouldn't have to pay a fortune to have their pilots take simulator training in order to fly the Max. And Boeing even went so far as to promise Southwest Airlines a million dollars per plane if it ever needed simulator training.

JENNINGS:

That was such a critical period of time. Because that really unleashes this torrent of decision-making that, in the end, kind of leads us all the way to the Java Sea and that field outside of Addis Ababa where the two planes crashed. That decision inculcated a real demand and drive to keep costs low. And it was really a top-down corporate decision. There was a lot of pressure that was put into play at Boeing, and into the design teams and the engineering teams, and in the people who tested the designs themselves, and one of these people who was testing the designs was a Boeing pilot named Mark Forkner. And he knows that there's a lot of desire on the airlines' part to keep their cost low, as well, and that is really manifest most, you know, distinctly in what it costs to train a pilot.

And he has a mandate — there's a corporate mandate — to make sure that there — in this transition between the old generation of the 737 and this new airplane, the 737 Max — that there is no new training requirements. And he becomes kind of a zealot about it, seems to me. His team is awarded a prize for keeping those costs out of the design process. But I think it's really important to say that he also has taken on kind of an outsized position as the person who is the bad guy. But as David said early on in this, in this discussion, it's much more about group-think; it's about a corporate process. And he was a bit of a cog, but he's taken on a kind of an outsized position as a person who represents everything that went wrong at Boeing.

GELLES:

And if you think about why that is, it’s sort of easy to understand. Because he was a chief technical pilot, you have to step back and wonder: Why was someone like that also tasked with a commercial imperative? And therein lies the big cultural problem that I think we sort of identified time and again inside Boeing. Which was that this was a company that grew up on engineering, that was, you know, made great by a century of a culture that really prioritized engineering above all else. And then something shifted over the last 20 or so years, where even the engineers were worrying about the bottom line.

ARONSON-RATH:

That part of the story is really something that then puts them on a totally different path forward. David, I’ll continue with you. After the crashes, Boeing’s then-CEO launched into the findings that the pilots’ inexperience and lack of training were part of a chain of events, as well, that led to the disasters. What do you make of that?

GELLES:

The pilots on the Indonesian flight literally did not know that MCAS existed. And when MCAS activated, a whole bunch of things started happening inside the cockpit at the same time. Alerts start going off; the plane starts behaving differently. So, they were left to try to respond, not knowing at all what was happening to their flights. And, of course, they weren't tragically able to recover the plane.

By the time the second plane came around, the Ethiopian pilots had received a bulletin that Boeing issued after the first crash, reminding them of a pre-existing set of steps that they would take if they ever encountered a situation similar to MCAS malfunction. And at first, the Ethiopian pilots actually did the right things. But by this time, they were going so fast that even those steps weren't enough to save the plane.

And so, Boeing keeps coming back to this notion: that if only the pilots had done the right thing, maybe these planes wouldn't have crashed. But that ignores the fact that, were it not for the original design of the 737 Max, were it not for the fact that MCAS was there in the first place and was reliant on only one censor, they would have never been in that situation in the first place.

ARONSON-RATH:

Tom, add to that. How did you actually show us about this in the film?

JENNINGS:

Very early on in that discussion that I was having with the team, they all circled around a moment early on in their reporting. It was right after the Ethiopian crash, where they got a preliminary report. This report was the initial, preliminary analysis done by the Ethiopian Civil Aviation Authority about what had happened. And so they called a 737 pilot, this guy named Dennis Tajer, who flies for American Airlines. And they'd sent him this report and they asked him to go through it, moment by moment, without knowing what was happening next, as if he was a pilot in that airplane. And each one of those reporters, to a person, described this as being a very revelatory moment. And this is one of those moments that just made it very clear that it was a profound, profound experience for them.

And so when we did the interviews with the team individually, I had them reconstruct that moment, and I remember talking to some folks, and they were saying, “Oh great, you're going to turn an office meeting into a film.” And I thought, Well, yeah. I mean, it was, you know, when somebody has such a profound experience, that's just going to be, that's kind of manna from the gods for folks like us.

ARONSON-RATH:

I will say, for the record, Tom, I was not one of those people. I really didn't have another solution, and I was so intrigued. I at least wanted to see it, you know, after I heard the power of the exchange. So, yeah — I mean, it's a challenge.

JENNINGS:

It wasn’t obvious, was it? No, it’s a challenge.

ARONSON-RATH:

It’s a challenge, right? But it really worked well, and we’ll play it now.

FILM CLIP / DENNIS TAJER:

My mission was to provide them: "I’m in the cockpit, I see what’s happening now." So, we walk through each line, and I had no idea what was in it. I knew that the crew had an experienced captain and a lesser experienced first officer.

FILM CLIP / NARRATOR:

Two minutes into the flight, based on faulty data from the AOA sensor, MCAS kicked in and began pushing the nose down.

FILM CLIP / COCKPIT ALERT VOICE:

Don't sink. Pull up.

FILM CLIP / TAJER:

And 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. And I have to confess, I probably swore. I said: "The kid got it right. The kid got it right."

GELLES:

To hear him get to the verge of tears, as he's reading this black-box data, left a deep, deep impact in me. And also, critically again, reinforced the sense that something had really gone wrong. And it was clearly a profound experience for him, too. Because his faith in this machine was shattered.

ARONSON-RATH:

Hmm. That shattering, it's really quite something, it’s something that, you know, I just will never forget seeing as well. One of the features that you did for The New York Times that really, you know, certainly got under my skin, and so many’s, was the big feature you did about the victims.

GELLES:

You know, that, at the end of the day, is what the story is all about: 346 people lost their lives, and the families of those 346 people are to this day living in a nightmare, as one of them put it to me. And within a few months of the second crash and my involvement on the story, you know, certainly those first couple months were just consumed with understanding the technical and corporate aspects.

But in time, especially as the families became more engaged in the process of trying to hold Boeing accountable, I began to get to know several of the families: Americans, Ethiopians, Kenyans. I got to see their pain up close, and it was enormously difficult. And the ability to be present with them, to try to make room for their, you know, deep human grief, but also their real righteous indignation at this corporation. And the failure of regulators to prevent this from happening made for this powerful combination, especially for the families of the Ethiopian flight, who felt even more wronged, because again Boeing understood the problem and kept letting the planes fly.

FILM CLIP / QUINDOS KARANJA:

The first thing you get to see at the site is a very big hole. And then to only imagine this is the place that they were last alive. Now you're in close proximity. You're able to see the fine details. You're able to maybe think, these are personal effects belonged to Carol, my sister, or my mom. This bone, whose bone is this?

ARONSON-RATH:

That's so powerful. And Tom, can you fill in the blanks here about the FAA? That's one thing that we haven't spoken about, in terms of accountability here.

JENNINGS:

Well, in some ways, that's kind of the most frightening part of the story for me, because it's the public government agency that's out there, really tasked with protecting us, as consumers and as flyers. And the revelation to me of how closely intertwined the agency that regulates safety for an airplane manufacturer like Boeing, was with Boeing, how integrated they were in this process, called delegated authority or delegation. It was just kind of astounding to me. But more so was how that process had become weighted over time towards the benefit of Boeing. And that, at the end of the day, is the nub of the problem, is that there's so much of the authority, of regulatory oversight, was given over to Boeing by the FAA.

ARONSON-RATH:

So, I guess we'll jump ahead. What's the current status of this plane, David?

GELLES:

The 737 Max is active and flying in most countries around the world at this point. Orders have started coming in again, and there is every indication that the Max is going to be almost entirely as important a plane as executives at the company expected it would be, before the two crashes.

ARONSON-RATH:

Hmm. So, what changed? What's, what's the change in the planes that are now flying?

GELLES:

They made a series of changes to the design of MCAS — in exactly how the software operates — that, by all accounts, should prevent what happened in Indonesia and Ethiopia from ever happening again.

ARONSON-RATH:

OK, and on the regulatory side, Tom, what happened in the wake of these fatal crashes?

JENNINGS:

Well there, there was a lot of, a lot of heat put on Boeing, as we document in the film, a lot of congressional hearings, that were, so, you know, kind of humiliating corporately to Boeing, that it was a contributing factor in the firing of the CEO at the time, Dennis Muilenburg. Subsequent to it though, this idea of delegation and delegated authority came under a strong microscopic lens. There was a congressional mandate that was attached to some budget authority that required the FAA to revamp the delegation process, so that there is more independence of FAA regulators in the process of developing airplanes and safety regulations surrounding the development of airplanes.

ARONSON-RATH:

OK, so, David, how do you feel when you're walking onto a Boeing plane now?

GELLES:

I haven’t flown on a Max now, but I wouldn’t hesitate, and again, in large part because I got to know some of the pilots, who gave me an enormous amount of faith.

ARONSON-RATH:

Tom, I'll ask you the same question. How do you feel walking on a plane — Boeing, any plane? How are you feeling these days?

JENNINGS:

Well, yeah, I have hesitation. For sure. I mean, what I learned in this process of reporting and making this film was that all these systems — that we were told over years and upon years that this process was there to protect us and it's as safe as anything in the world — is to be questioned. So, I will fly. I'll fly on a Max. But I have to tell you, when I get on a Max, it will be at least with a sense of irony that I'm flying, but it will certainly also be with a bit of you know, white knuckles, a few white knuckles, too. Just because of what we learned, and what I learned in this process. And I think that's a healthy concern, actually. I think it's a healthy fear, and it's not about the pilots for me. I trust the pilots implicitly.

ARONSON-RATH:

I appreciate that. OK, both, thank you so much for being on The Dispatch, and we’ll keep following the story. And David, thanks to you and your colleagues at The New York Times for opening your notebooks with us, and working really hard on this with us, and making really an extraordinary documentary with us. Thanks again.

GELLES:

Thank you, and thanks to you and Tom for making the film so terrific.

JENNINGS:

Thanks, David. Thank you.

ARONSON-RATH:

Since this conversation, Boeing test pilot Mark Forkner was indicted on federal criminal charges. And there’s a lot more of this story in our documentary, Boeing's Fatal Flaw, including statements from the company and excerpts of The New York Times interview with Boeing’s CEO. You can find it at www.frontline.org. We hope you'll watch.

Our podcast producers are Erika Howard, Miles Alvord, and production support comes from Megan McGough Christian. Katherine Griwert is our editorial coordinating producer. Frank Koughan is our senior producer. Lauren Ezell is our senior editor, and Andrew Metz is our managing editor. I’m Raney Aronson-Rath, executive producer of FRONTLINE. Music in this episode comes from Stellwagen Symphonette. The FRONTLINE Dispatch is produced at GBH and powered by PRX.

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