Original subtitles

Narrator: Two plane crashes just months apart.

There are no survivors.

Both involve the same plane, the 737 max.

Why do we have not one but two crashes that were caused

Essentially by the same thing?

There is a problem here that we need to look into.

Narrator: How could a brand new plane just fall out of the sky?

The nose of the plane was pushed

Down, resulting in this nosedive into the sea

At 450 miles an hour.

Narrator: Now experts who investigated the crashes--

Why did boeing design the plane the way they designed it?

I'm at a loss.

Narrator: --And those connected to them

Reveal a series of catastrophic failures.

If only that data had been looked at,

Then that crash would have been averted,

And my friend's granddaughter would be alive today.

Narrator: From potentially lethal design problems--

There were efforts to bring to light serious concerns

With the max, and those efforts were either unsuccessful

Or not taken seriously.

Narrator: --To inadequate regulation--

The faa delegated its authority to boeing employees.

There's an immediate conflict of interest.

Narrator: --And investigations uncovering a failure

To disclose key information.

Just trying to blame the pilot or blame the user

Does nothing to solve the systemic problems that

Will lead to future accidents.

Narrator: 10 fatal mistakes that lead to the tragedy

Of the 737 max crashes.

I see an example of what can happen to any company

When they lose track of paying attention to safety.

[music playing]

January 17, 1967.

The world's press gathers to witness the launch of boeing's

Latest commercial jet, the 737.

It is a global hit, and over the next 50 years becomes

Boeing's biggest earner.

Throughout its history, it has flown an estimated 180 million

Flights, amounting to around 100 billion miles and nearly 17

Billion passengers.

It's very, very easy to fly.

I think it's a wonderful airplane.

And it's had an amazing safety record.

It's the most successful production aircraft in history.

Narrator: But five decades on, shortly after boeing

Releases its latest evolution, the 737 max,

The fairy tale becomes a nightmare.

October 29, 2018.

Lion air flight 610 crashes into the java sea near indonesia.

Less than five months later, March

10, 2019, ethiopian airlines flight 302

Nosedives into the ground.

The 346 passengers and crew on board the two flights are dead.

The entire 737 max fleet is grounded around the world.

Global investigations begin.

There's a problem here that we need to look into much further.

Narrator: Over the next two years,

Congressional investigations trace the first mistake

On the road to tragedy, back to the very beginning

Of the 737 max story.

Boeing's decision to update the 737

Is fast tracked in response to commercial competition.

The boeing 737 max was a knee jerk reaction.

Ultimately, in this case, I strongly

Feel that competition is clearly to blame

For these two incidents.

Narrator: Spring 2011.

Boeing's ceo receives an alarming

Phone call from one of its most loyal

Customers, american airlines.

For more than a decade, american has only bought boeing.

But now it's jumping ship and about

To purchase its new planes from boeing's

Main competitor airbus.

When you lose an airline customer,

They don't usually come back because an airline that goes

With airbus versus goes with boeing

Has now made real commitments to training their pilots

Over the long term.

Narrator: Boeing knows it needs to move

Fast to stay competitive.

Just months later in August 2011,

It announces the launch of a brand new plane, an evolution

Of its trusty 737, the 737 max.

Suddenly boeing had a good response to airbus.

Narrator: Since the launch of the original 737,

Boeing has created two more generations of its best seller.

By remodeling it once again, boeing is back in the game.

Not having to design a whole new plane also

Makes commercial sense, saving the company around $7 billion.

Creating a brand new airplane from scratch

Is at least a five year, six year endeavor.

Very expensive, a lot of engineering time,

A lot of original work.

Narrator: Modifying the highly successful 737

Seems the perfect solution.

But it is this decision that sets it on the path to tragedy.

In the us, all aircraft must be certified

Under regulations laid down by the federal

Aviation administration.

But a plane modified from a design already in operation

Can be certified far more quickly.

What is reviewed by the regulator

Is mostly the modifications, and how the modifications affect

The airplane as opposed to starting

From a totally new airplane.

The manufacturer of the airplane

Is not on the hook to jump through the same number

Of hoops as you would if the airplane

Was designed from scratch.

Narrator: This type of certification process

Is known as the changed product rule.

It's a long established industry standard.

But in the case of the 737 max, assessing modifications rather

Than the whole aircraft allowed potentially dangerous faults

To enter the design.

In any process designed and operated by humans,

Things can slip through the net, and they obviously did here.

The change product rule in this case enabled that.

Narrator: Investigations later suggest the decision to modify

The old 737 is what set the 737 max on the road

To tragedy because the modifications signed off

Under the changed product rule were considered in isolation,

And the effect on the overall handling of the plane

Was not adequately scrutinized.

September 2011, development begins on the modifications

Of the old 737.

Almost immediately, boeing is looking

At a mountain of sales for their new 737 max

From airlines across the globe.

Right from the start, boeing management

Makes it very clear to employees that time means money.

In the investigation report, they

Mention this countdown timer.

And they actually call it an excitement generator.

Understandable, maybe.

But what does it really do?

What it really does is put pressure to meet the deadline

Front and center, therefore putting quality and safety

Slightly in the background.

Narrator: After the crashes, investigations

Suggest that time and money pressures drove decisions that

Ultimately led to disaster.

It certainly has the overarching appearance

That at every step of the way, decisions

Are being made to prioritize profits over safety.

But in the long run, it costs far more, which is

What we see in this accident.

Narrator: By 2012, the development stage of the 737

Max is well underway.

But in that same year, boeing begins

To slash money and testing time on the project.

A congressional investigation after the crashes

Highlights this series of cuts as an area of concern,

Suggesting it compromised the future safety

Of the flying public.

Boeing has historically had a very strong safety record.

The tragedy is that those principles weren't put in place

In the design of this aircraft.

Narrator: In 2012, boeing conducts a financial review

Of the 737 max.

Another project has already cost the company billions in delays.

To save money, the decision is made

To reduce a key testing process during the aircraft's

Development.

So each time we add something new,

We test not only that the new feature works

But the old ones still do.

It seems obvious, but it's all too easy to actually cause

The thing to go backwards.

Narrator: This testing is critical throughout production

To make sure failings do not creep into the design.

But to speed up production and reduce costs,

Boeing cuts the testing time by 2,000 hours.

A house transportation committee hearing suggests some boeing

Employees were feeling exhausted,

And some stated they feared consequences if they

Spoke up about the pressure.

There was at least one engineer

Who spoke up forcefully with his concerns about the situation.

And he had a background in the military where he was quite

Used to the invitation to be very clear

When something's going wrong.

You are obligated to speak up.

And he was told, when he spoke up at boeing,

That this is not the military.

This is a profit making enterprise.

Narrator: Despite concerns raised by boeing employees,

The performance record of the previous generations of the 737

Gives us aviation authority, the faa, enough confidence

To approve the remodeling project.

But the faa's approval is a grave error.

It certainly has the overarching appearance

That at every step of the way, decisions

Are being made to prioritize profits over safety.

Narrator: If time and money had not been such a priority,

Then identified problems with the modifications

To the original 737 might have been solved

Before going any further.

Instead, one of the biggest modifications

Goes on to be the root cause of the fatal crashes,

Putting new larger engines on the 737 body that

Change its behavior in the air.

The issue was, essentially what happens is

The aircraft pitches upwards.

It is at such a steep angle that the wing

Can't produce lift anymore, and so the airplane stalls.

Narrator: To launch their 737 max into the 21st century

And make it more fuel efficient than its airbus rival,

Boeing needs to change the existing engines on the 737.

So the physics dictates better fuel efficiency

Requires bigger engines.

Narrator: But fitting larger engines to the 737 air frame

Isn't an easy job.

This is an airplane that sits very low to the ground.

Its engines sit somewhere in the order of about 17 inches

Off the ground.

Compared to, for example, a boeing 757, which is about 26,

27 inches off the ground.

Narrator: When the original 737 was designed 50 years ago,

The low slung body was a design feature, not a flaw.

It was designed to be an aircraft that could go around

The world, including into developing countries that would

Lack the infrastructure that would be

Available in some other airports so that you

Have easy passenger loading.

Narrator: But the 737's low slung body

Means there's not enough room to fit the newer, larger engines

In their previous position.

Instead, the new engines are placed further forward

And higher up on the wings, and this leads to a major problem.

Wind tunnel testing reveals the relocation of the bigger more

Fuel efficient engines has changed the way

The plane behaves in flight.

In some rare instances, at cruising altitude,

It could push the plane's nose upwards.

So the problem with the nose pitching up

Is if the aircraft starts to be at too steep an angle,

It can lose the ability to remain aloft.

At that point, boeing could have

And should have stopped to think whether it was worth continuing

With the design.

Narrator: Had boeing scrapped the project at this point,

The fatal crashes would never have happened.

Instead, engineers are tasked with finding a solution

To keep both the 737 body and the new fuel efficient engines.

What they come up with is arguably the biggest

Single mistake on the road to the fatal crashes,

The addition of software to overcome the problem

And make the plane fly like the previous 737.

But this has unintended consequences.

There have been reports that suggest that the shear force

With which it pushed the airplane into a downward spiral

Made it virtually impossible for pilots to effectively

Recover from what was a dive.

Narrator: In 2012 software called

Mcas is added to the 737 max.

It's designed to ensure the larger engines won't affect

The handling of the plane during a specific and very rare

High speed maneuver.

The software gathers information from different sensors,

Which monitor the plane's g-force and pitch.

If the sensors show the plane's nose rising rapidly,

The software will react and push the nose back down.

On paper, the mcas makes perfect technical sense.

If the nose pitches up past a certain angle,

You rely on a piece of technology to lower the nose.

Narrator: The new software is a clever solution

That solves this extremely rare handling problem.

And this is what is included in the plans

That boeing originally submits to the faa.

But then flight testing reveals another issue.

The nose of the max can also pitch up

At lower speeds after takeoff.

And unlike the high speed maneuver,

This isn't a rare event.

It could happen any time the plane flies.

So boeing uses the same mcas software

To solve this problem as well.

That's a totally different environment

To take a high speed device and put

It in a low speed environment.

And that's when you have to be very,

Very vigilant about your underlying assumptions.

Do those assumptions for the high speed regime

Still fit in the low speed regime?

Those details were not adequately addressed.

Narrator: Due to the relatively low speeds after takeoff,

There would not be enough g-force to trigger

The g-sensor.

This would prevent mcas functioning in

This new low speed environment.

So boeing reprograms this software to trigger

Without the g-sensor.

Two sensors were also originally needed to trigger mcas.

But the 737 max software now relies

On just a single pitch sensor.

Boeing says it did tell the faa about this change,

But the house committee on transportation

And infrastructure concluded it had not been properly

Highlighted, allowing it to go through

Without sufficient scrutiny.

Powerful software should never rely on one sensor.

I am convinced that if the right people on either side

Had known about that problem, the faa would

Never have let it go out of the factory

Door with only one sensor.

Narrator: Tragically, both crashes

Reveal the danger of relying on a single pitch sensor.

If it develops a fault, the software

Has no way to tell that it is now responding

To false information.

Imagine you looked at a thermometer

And it's minus 30 one moment and it's plus 20 the next moment.

If in 3/4 of a second, you saw a thermometer change like that, I

Don't think you would immediately

Throw your clothes on and say, gee,

I guess it got very cold outside.

I think you would say, well, something's

Wrong with the thermometer.

Narrator: In both crashes, mcas responded to faulty sensor data

Suggesting the planes were about to stall.

Less than two minutes into the first doomed lion air flight,

The 737 max's software reacts to the erroneous data

And pushes the plane's nose down.

13 minutes after takeoff, the plane plummets into the java

Sea at 450 miles per hour.

189 passengers and crew are killed.

Less than five months later, the pitch sensor

On an ethiopian airlines 737 max also fails.

After a terrifying six minutes for all on board,

Flight 302 nose dives into the ground.

Again, there are no survivors.

Why couldn't mcas have had that amount of design

To be intelligent enough to disregard

And ignore the bad data?

Then that crash would have been averted

And my friend's granddaughter would be alive today.

Narrator: In January 2021, two years after the fatal crashes,

The us justice department brings criminal charges of fraud

Against boeing for the failure of two of its key employees

To be completely transparent with the regulator about mcas.

But this situation was compounded by

Another huge error of judgment.

This is the equivalent of letting

The fox guard the chicken pen.

Narrator: During development of the 737 max,

Boeing introduces software to overcome handling issues.

Critical changes are made to the system

And are not highlighted to the industry regulator.

These are directly responsible for the deaths

Of 346 passengers and crew.

But the regulator itself is also part of the problem.

It makes a huge mistake, giving boeing

The power to effectively sign off much of the 737 max design.

The real glaring standout fact in all this

Is that the faa, the regulator, delegated its work

And its authority to boeing employees, which in my view

Should never have happened and should never happen again.

Narrator: In the united states, all new plane designs

Must be green-lit by america's aviation regulator, the federal

Aviation administration.

They regulate all aspects of aviation--

Big planes, small planes, planes in between,

Pilots, manufacturers.

Every aspect of aviation is regulated for safety

By the federal aviation administration

In the united states.

Narrator: Although the faa is responsible for the final sign

Off on any new project, it routinely

Delegates large parts of this process

To the aircraft manufacturers.

The aircraft manufacturers have

Been able to in some sense self certify much of their process.

Not just boeing, but any manufacturer in order

That the faa not become a bottleneck for that process,

Because otherwise that could slow it down to a standstill.

Narrator: At the time of the 737 max development,

The faa didn't have the staffing capacity

To monitor the entire program.

So by the time the 737 max was green-lit to fly commercially,

It had delegated so much authority,

Boeing had responsibility for 87% of the checks

Needed to certify the plane.

Boeing of course turns around and says,

"our plane is fit to fly.

Why would we say any differently?"

In any situation where an organization can self certify,

There's an immediate conflict of interest.

Why on earth would an organization not certify their

Own project as fit for purpose?

Narrator: Later investigations report there are signs

That the staff members delegated by the faa

Are put under undue pressure by boeing.

If individuals feel it's not in their interest to report

Problems or that, worse, that they're not heard or even

Intimidated, then the aircraft itself

Becomes an object of concern.

Narrator: The failure to highlight key information

About mcas results in the 737 max leaving the factory

With fatal design flaws.

But a further decision signed off by the faa results

In another devastating mistake.

Pilots don't go through simulator training

Before flying the new 737 max.

They didn't have the training to be

Able to diagnose the problem when it was happening.

They didn't have the information.

And so they were really operating in the dark.

Narrator: By 2016, the first 737 max is about to roll

Off the production line.

Boeing is now looking at a bulging order book.

One of the max's key selling points is its fuel efficiency.

The other is that it flies in exactly the same way

As the old favorite 737.

Boeing was trying to increase the attractiveness

Of their aircraft to airlines by saying, hey, this is a 737,

Therefore you can have pilots be able to hop in the pilot seat

Very easily and fly this plane.

This is a really big deal because it wouldn't necessitate

Additional training, additional flight

Simulator time, all of which is costly to the airlines.

Narrator: Instead of expensive flight simulator training,

Boeing offers up a more cost effective and quicker approach.

If they were already used to flying the 737 version,

Pilots were encouraged to use ipads to train

Up for the new 737 max.

Narrator: In 2011, indonesian carrier lion air

Buys 230 planes at a cost of over $20 billion.

17 months prior to the lion air crash,

Lion air actually requested from boeing if their pilots could

Have flight simulator training on arrival

Of the new max models.

Narrator: This is way beyond the two hours of ipad training

Boeing has been pushing.

The minute boeing sets a precedent suggesting that one

Group of pilots requires training,

The concern would be that other airlines, other customers would

Say we also need training.

And hang on a second, we were promised an airplane

That required minimal training.

So why are we now on the hook to pay for this?

Narrator: Boeing persuades lion air that simulator

Training is unnecessary.

Pilot training is very, very important, with the idea being

That when an emergency comes, the instincts are correct,

The muscle memory is there.

So to go through a modern approved training syllabus

Makes you completely comfortable.

If you've got through all the hurdles

And you climb into the airplane after all that training,

You just feel completely confident.

Narrator: If the pilots in both crashes had simulator training,

They might have been better prepared

When things went wrong.

But even then, another key decision proves critical.

Boeing makes no mention at all of the mcas software

In the 737 max flight manual.

I met with the head of the accident investigation

Committee in jakarta.

And I was astonished when he told me that the pilots were

Not even aware of the mcas system,

This incredibly powerful system that is figuring

Prominently in the crash.

It wasn't even in their flight manual.

So when the lion air pilots were experiencing these problems,

They didn't even know mcas existed.

Narrator: January 2016, the 737 max makes its maiden flight.

Two months later, boeing convinces the faa the plane's

Mcas software doesn't need to be included

In the plane's flight manual.

The later congressional report suggests this was to avoid mcas

Being seen as a new feature.

They were worried about the specter of raising

The possibility that there was something profoundly

Fundamentally new here that pilots might

Need to know something about.

Narrator: Boeing's sales pitch is that flying the new 737 max

Is exactly the same as flying the previous 737.

But the two subsequent plane crashes

Prove the reality of this claim was very different.

October 29, 2018, lion air flight 610

Is less than two minutes into its journey

When the plane's nose starts to be pushed down.

Because the pilots have no clue the mcas software has been

Fitted to the plane, they have no idea

How to stop this happening.

Within minutes, the control of that aircraft

Was out of their hands.

They were not prepared for it.

The lion air pilots were experiencing these problems.

They didn't even know mcas existed.

They had no way to know why the plane

Was acting erratically for them and why

It wasn't easy to control.

This was a major problem.

Narrator: Ultimately, the pilots can't pull the plane out

Of its final deadly dive, and it crashes

Off the coast of indonesia.

Given that mcas wasn't mentioned in the aircraft manual,

A post crash hearing suggested it was a flawed assumption

The pilots would be able to overcome the problems caused

By this software.

Had the pilots known about the existence of the software,

They may have been able to work out how to override it.

Tragically, had it not been for yet another mistake,

The lion air flight might have been prevented

From taking off altogether.

The day before, the same aircraft

Experiences a similar problem, but details of how

It was solved aren't passed on.

The information just fell between the cracks,

And the next crew didn't know how they solved it.

Narrator: October 28, 2018, lion air flight jt043 takes off

On a two hour internal journey to the indonesian capital,

Jakarta.

The aircraft was less than six months old,

Less than 800 hours of flying time, which is

Relatively new for an aircraft.

Narrator: Minutes after takeoff, at an altitude of just 400

Feet, the control stick in the cockpit

Begins to shake violently.

Some airliners have stick shake

To artificially tell you when you're approaching a stall.

Narrator: But unknown to the pilots,

The plane is not in danger of stalling.

The stick shaker is vibrating in response

To a malfunctioning external sensor,

The same single sensor that feeds into the mcas software.

The mcas responds to the false data

By forcing the plane into a dive.

You do not want this system functioning

When the airplane is trying to maintain stable flight.

If the system kicks in during these points in time,

The worst case scenario is a crash.

Narrator: Unaware of the existence of the mcas software,

The pilots send out frantic mayday signals.

But three minutes later, they manage

To regain control of the plane.

It's really interesting to me that the crew that

Flew the airplane just before the accident was

Able to stumble upon the right cut out procedure.

And what was interesting there was it wasn't the crew that was

Involved in flying the airplane at the time,

But it was the pilot in the jump seat behind them

That actually figured out the right response.

He was able to perform a procedure known

As the runaway stabilizer, which is

A mechanical process to restore the balance of the plane.

Narrator: The same problem recurs throughout the journey.

But each time, the crew manages to override

The deadly software.

Passengers later described the flight as a terrifying roller

Coaster ride.

As soon as the plane lands, the pilot reports the incident

To the ground maintenance engineers,

But key information isn't passed on.

There was no record in the lion

Air logs of how they'd actually gone about fixing this problem.

Narrator: Less than 24 hours later,

Flight 610's pilots board the same 737 max

With no knowledge of what they're about to face.

Had the runaway stabilizer checklist procedure

Been reported as a solution in that maintenance log, the pilot

The next day on that tragic lion air crash

May have been in more of a position to understand how

To tackle the mcas system, despite not knowing it

Was installed on the aircraft.

Narrator: If that information had been passed on,

Disaster might have been averted less than 24 hours later.

Instead, the very same 737 max crashes on its next flight.

Then tragically, less than five months later, another 737 max

Falls from the skies.

When the second accident happened,

It was a different ballgame.

Narrator: October 29, 2018, less than 24 hours

After a terrifying roller coaster flight,

The same 737 max departs from jakarta at 6:20 am.

Almost immediately, the software mistakenly

Pushes the plane's nose down, just as it did the day before.

This time, there is no off duty pilot on board to save the day.

The plane crashes into the java sea 13

Minutes after takeoff, killing all 189 people on board.

The nose of the plane was pushed down by the system

At an angle of almost 40 degrees,

Resulting into this nose dive into the sea at a speed

Of 450 miles an hour.

Narrator: Although flight recordings highlight

Technical faults, it is suggested

The real problem was not with the plane,

The problem was pilot error.

This delays the real problem from being

Fully investigated until after the second 737 max crash.

Just trying to blame the pilot or blame the user

Does nothing to solve the systemic problems that

Will lead to future accidents.

Narrator: In the aftermath of the lion air crash,

Boeing releases a press statement saying that the 737

Max is as safe as any airplane that

Has ever flown in the skies.

The finger of blame is pointed at the pilots

Rather than the plane itself.

It goes with the job.

You accept it, that the first person

That's going to be looked at is you as the captain.

It's just how it is.

And would I call it a burden?

I just, I think I have acceptance

That that's how it is.

Narrator: Blaming the pilots means

Attention focuses on the airline, not the 737 max.

If you start to even imply that it might be partly

Your fault, your stock price is going to take a hit,

There are going to be huge financial consequences, maybe

Legal consequences as well.

Narrator: In this situation, lion air makes an easy target.

Lion air had a dubious safety record,

Large number of incidents in the previous 20 years.

There were issues with pilot training recorded.

There were issues with maintenance

And general engineering within the organization.

Narrator: Boeing implies the solution

To the software problem is simply a standard procedure.

It's called the runaway stabilizer checklist

And is found in the manual.

In reality, the runaway stabilizer checklist

Is a non-normal procedure.

And in that situation, pilots will be looking

Through a physical hard copy checklist,

Trying to identify what they need to do in that situation.

And with minutes to spare or even seconds

To spare in the cockpit, that's not reality.

Narrator: Focusing on the pilot's actions

Deflects attention away from the real problem,

The plane's technical issues.

In the weeks that follow, the company goes on

To highlight the information that shows how to override

The deadly software problem, and 737 max sales continue to soar.

Then less than five months after the lion air crash,

An ethiopian airline 737 max nose dives into the ground

Six minutes after takeoff.

All 157 passengers and crew are killed.

The plane's black box reveals striking similarities

With the lion air crash.

When the second accident happened,

It was a different ballgame because ethiopian

Have a fantastic reputation, and are very well thought

Of in the rest of the world.

And suddenly, you couldn't blame,

You couldn't get away with it anymore.

Narrator: If the focus had been on the plane

Rather than blaming the pilots, the technical issues might have

Been solved and the second crash averted

Because there was only one real difference

Between the two crashes.

The pilots of the ethiopian airlines 737 max

Did have knowledge of how to deal with the software problem

If it occurred, but the plane still crashed.

A key mistake made long before the first 737 max rolled off

The production line meant that whatever the pilots did,

The odds were stacked against them.

When they designed the 737 max and assumed it would be safe

And safely operated by pilots who

Are comfortable with the 737, they didn't take

Into account the human factor.

They didn't take into account what happens

In those very few seconds when you're startled

By an unexpected event.

Narrator: March 10, 2019, 8:38 am,

Ethiopian airlines flight 302 is only seconds into its ascent.

Just like lion air flight 610, the plane

Stick shaker begins to vibrate violently

And the plane nosedives.

The black box recordings and the details clearly show that

The pilot and the co-pilot were frantic in their efforts

To try and stabilize the plane.

Narrator: Armed with knowledge of how to override the problem,

The pilots manage to regain control.

But seconds later, the plane pitches down again.

The automated system would kick back in,

Time and time again, and that's ultimately

What led to the crashes.

Narrator: The ethiopian air pilots lose

And regain control three times.

The fourth time they lose control, they are not so lucky.

The plane crashes into the ground with total loss of life.

They were overloaded physically in trying

To handle the aircraft.

And then when they did try to take over manual control,

They found it very, very difficult to do so.

So they had, there was a whole cascading

Series of events that happened that led to this accident.

Narrator: The pilots struggled to rectify the problem

For four terrifying minutes.

Regulators base their certification on the assumption

That this sort of problem can be solved in just four seconds.

If the airplane can't be recovered after that four

Seconds without herculean effort by the pilot,

Or without potentially damaging the airplane,

Or hurting passengers, then it doesn't pass.

Narrator: But later investigations

Uncover internal documents revealing boeing was not only

Aware of the problem, but in one simulator test,

It took their pilot 10 seconds to resolve.

Boeing did not highlight this catastrophic situation.

When a boeing employee raised concerns about the ability

Of pilots to respond to mcas activating repeatedly,

Those concerns were not addressed.

Every human has a stress performance curve

Depending on their experience, their attitude, their training.

And there's a startle effect, which we all have.

That is when intensive events within the cockpit

Cause the pilot's blood pressure to rise,

Their heartbeat rate to increase.

Narrator: The startle effect is found

To be one of the critical human factors

Which was underestimated during the development of the 737 max.

One of the tragedies of these accidents

Were that the basic foundational principles and procedures

Of human factors engineering don't

Appear to have been applied when they designed the 737 max.

If you want to reduce or even eliminate human error,

Then you have to design the technology

To be compatible with how people operate.

Narrator: By March 13, 2019, every 737 max around the globe

Has been grounded.

Following investigations, the faa

Is criticized for its handling of the max project.

The faa was asleep at the wheel when

It comes to certifying the max.

It didn't carry its job out properly.

Narrator: The justice department charges boeing with conspiracy

To commit fraud for two of its key employees

Concealing information from the faa

About the operation of its mcas software.

Under a deferred prosecution agreement,

Boeing pays out $2.5 billion in fines and compensation.

I think all of us who were testifying very much

Felt that those people deserved to have something come out

Of this accident that could be used to improve

Air transportation safety.

Narrator: The company agrees to be monitored by the fbi fraud

Department for three years.

In December 2020, the 737 max is finally

Given permission to fly again.

But it's mcas software now relies on two pitch sensors

And all pilots get full simulator training before

Entering a 737 max cockpit.

Sometimes it's easy to step back

And say, well, this thing is just too complex.

It can't be preventable.

I don't agree with that perspective.

These are not accidents that just happen

Because some fluke thing.

But I think the bigger issue is the tug of war

And the battle between the financial goals

Of a corporation and its ethical duties.

That's what we see here.

[music playing]