1 00:00:03,714 --> 00:00:07,392 Narrator: Two plane crashes just months apart. 2 00:00:07,467 --> 00:00:09,399 There are no survivors. 3 00:00:11,947 --> 00:00:17,072 Both involve the same plane, the 737 max. 4 00:00:17,107 --> 00:00:20,632 Why do we have not one but two crashes that were caused 5 00:00:20,707 --> 00:00:22,272 Essentially by the same thing? 6 00:00:22,307 --> 00:00:24,912 There is a problem here that we need to look into. 7 00:00:24,947 --> 00:00:28,432 Narrator: How could a brand new plane just fall out of the sky? 8 00:00:28,467 --> 00:00:30,032 The nose of the plane was pushed 9 00:00:30,067 --> 00:00:33,232 Down, resulting in this nosedive into the sea 10 00:00:33,267 --> 00:00:35,232 At 450 miles an hour. 11 00:00:35,267 --> 00:00:38,112 Narrator: Now experts who investigated the crashes-- 12 00:00:38,147 --> 00:00:40,999 Why did boeing design the plane the way they designed it? 13 00:00:41,074 --> 00:00:42,352 I'm at a loss. 14 00:00:42,387 --> 00:00:43,799 Narrator: --And those connected to them 15 00:00:43,874 --> 00:00:47,752 Reveal a series of catastrophic failures. 16 00:00:47,827 --> 00:00:49,632 If only that data had been looked at, 17 00:00:49,667 --> 00:00:51,312 Then that crash would have been averted, 18 00:00:51,347 --> 00:00:53,072 And my friend's granddaughter would be alive today. 19 00:00:53,107 --> 00:00:56,152 Narrator: From potentially lethal design problems-- 20 00:00:56,227 --> 00:00:59,959 There were efforts to bring to light serious concerns 21 00:01:00,034 --> 00:01:03,592 With the max, and those efforts were either unsuccessful 22 00:01:03,667 --> 00:01:05,632 Or not taken seriously. 23 00:01:05,667 --> 00:01:07,872 Narrator: --To inadequate regulation-- 24 00:01:07,907 --> 00:01:13,712 The faa delegated its authority to boeing employees. 25 00:01:13,747 --> 00:01:16,112 There's an immediate conflict of interest. 26 00:01:16,147 --> 00:01:18,912 Narrator: --And investigations uncovering a failure 27 00:01:18,947 --> 00:01:20,839 To disclose key information. 28 00:01:20,914 --> 00:01:24,072 Just trying to blame the pilot or blame the user 29 00:01:24,147 --> 00:01:26,472 Does nothing to solve the systemic problems that 30 00:01:26,547 --> 00:01:29,232 Will lead to future accidents. 31 00:01:29,267 --> 00:01:32,352 Narrator: 10 fatal mistakes that lead to the tragedy 32 00:01:32,387 --> 00:01:35,872 Of the 737 max crashes. 33 00:01:35,907 --> 00:01:39,472 I see an example of what can happen to any company 34 00:01:39,507 --> 00:01:44,032 When they lose track of paying attention to safety. 35 00:01:44,107 --> 00:01:47,439 [music playing] 36 00:01:56,307 --> 00:02:01,072 January 17, 1967. 37 00:02:01,107 --> 00:02:04,192 The world's press gathers to witness the launch of boeing's 38 00:02:04,201 --> 00:02:08,199 Latest commercial jet, the 737. 39 00:02:08,274 --> 00:02:11,799 It is a global hit, and over the next 50 years becomes 40 00:02:11,874 --> 00:02:14,072 Boeing's biggest earner. 41 00:02:14,147 --> 00:02:18,112 Throughout its history, it has flown an estimated 180 million 42 00:02:18,147 --> 00:02:23,272 Flights, amounting to around 100 billion miles and nearly 17 43 00:02:23,347 --> 00:02:26,312 Billion passengers. 44 00:02:26,387 --> 00:02:28,352 It's very, very easy to fly. 45 00:02:28,387 --> 00:02:30,832 I think it's a wonderful airplane. 46 00:02:30,841 --> 00:02:33,912 And it's had an amazing safety record. 47 00:02:33,987 --> 00:02:38,792 It's the most successful production aircraft in history. 48 00:02:38,867 --> 00:02:41,752 Narrator: But five decades on, shortly after boeing 49 00:02:41,827 --> 00:02:45,392 Releases its latest evolution, the 737 max, 50 00:02:45,467 --> 00:02:47,759 The fairy tale becomes a nightmare. 51 00:02:50,547 --> 00:02:54,032 October 29, 2018. 52 00:02:54,107 --> 00:02:58,479 Lion air flight 610 crashes into the java sea near indonesia. 53 00:03:01,107 --> 00:03:03,232 Less than five months later, March 54 00:03:03,267 --> 00:03:07,392 10, 2019, ethiopian airlines flight 302 55 00:03:07,427 --> 00:03:11,072 Nosedives into the ground. 56 00:03:11,107 --> 00:03:17,959 The 346 passengers and crew on board the two flights are dead. 57 00:03:18,034 --> 00:03:23,312 The entire 737 max fleet is grounded around the world. 58 00:03:23,347 --> 00:03:26,752 Global investigations begin. 59 00:03:26,827 --> 00:03:31,552 There's a problem here that we need to look into much further. 60 00:03:31,627 --> 00:03:33,232 Narrator: Over the next two years, 61 00:03:33,307 --> 00:03:36,679 Congressional investigations trace the first mistake 62 00:03:36,754 --> 00:03:39,872 On the road to tragedy, back to the very beginning 63 00:03:39,907 --> 00:03:42,672 Of the 737 max story. 64 00:03:42,707 --> 00:03:45,639 Boeing's decision to update the 737 65 00:03:45,714 --> 00:03:49,799 Is fast tracked in response to commercial competition. 66 00:03:49,874 --> 00:03:53,872 The boeing 737 max was a knee jerk reaction. 67 00:03:53,907 --> 00:03:56,839 Ultimately, in this case, I strongly 68 00:03:56,914 --> 00:03:59,472 Feel that competition is clearly to blame 69 00:03:59,507 --> 00:04:01,079 For these two incidents. 70 00:04:07,987 --> 00:04:10,152 Narrator: Spring 2011. 71 00:04:10,227 --> 00:04:12,592 Boeing's ceo receives an alarming 72 00:04:12,627 --> 00:04:14,472 Phone call from one of its most loyal 73 00:04:14,547 --> 00:04:18,032 Customers, american airlines. 74 00:04:18,107 --> 00:04:22,592 For more than a decade, american has only bought boeing. 75 00:04:22,627 --> 00:04:24,832 But now it's jumping ship and about 76 00:04:24,841 --> 00:04:27,392 To purchase its new planes from boeing's 77 00:04:27,427 --> 00:04:30,192 Main competitor airbus. 78 00:04:30,227 --> 00:04:33,232 When you lose an airline customer, 79 00:04:33,307 --> 00:04:37,392 They don't usually come back because an airline that goes 80 00:04:37,467 --> 00:04:39,959 With airbus versus goes with boeing 81 00:04:40,034 --> 00:04:44,032 Has now made real commitments to training their pilots 82 00:04:44,067 --> 00:04:45,119 Over the long term. 83 00:04:50,787 --> 00:04:52,592 Narrator: Boeing knows it needs to move 84 00:04:52,627 --> 00:04:55,632 Fast to stay competitive. 85 00:04:55,667 --> 00:04:58,832 Just months later in August 2011, 86 00:04:58,867 --> 00:05:03,272 It announces the launch of a brand new plane, an evolution 87 00:05:03,347 --> 00:05:07,279 Of its trusty 737, the 737 max. 88 00:05:11,827 --> 00:05:14,952 Suddenly boeing had a good response to airbus. 89 00:05:15,027 --> 00:05:17,952 Narrator: Since the launch of the original 737, 90 00:05:17,987 --> 00:05:21,952 Boeing has created two more generations of its best seller. 91 00:05:21,961 --> 00:05:27,272 By remodeling it once again, boeing is back in the game. 92 00:05:27,347 --> 00:05:30,192 Not having to design a whole new plane also 93 00:05:30,227 --> 00:05:35,792 Makes commercial sense, saving the company around $7 billion. 94 00:05:35,827 --> 00:05:37,792 Creating a brand new airplane from scratch 95 00:05:37,827 --> 00:05:41,479 Is at least a five year, six year endeavor. 96 00:05:41,554 --> 00:05:44,312 Very expensive, a lot of engineering time, 97 00:05:44,387 --> 00:05:47,632 A lot of original work. 98 00:05:47,667 --> 00:05:50,432 Narrator: Modifying the highly successful 737 99 00:05:50,467 --> 00:05:53,712 Seems the perfect solution. 100 00:05:53,787 --> 00:05:57,279 But it is this decision that sets it on the path to tragedy. 101 00:05:59,987 --> 00:06:03,232 In the us, all aircraft must be certified 102 00:06:03,267 --> 00:06:05,432 Under regulations laid down by the federal 103 00:06:05,507 --> 00:06:08,952 Aviation administration. 104 00:06:09,027 --> 00:06:12,432 But a plane modified from a design already in operation 105 00:06:12,467 --> 00:06:14,679 Can be certified far more quickly. 106 00:06:14,754 --> 00:06:17,072 What is reviewed by the regulator 107 00:06:17,107 --> 00:06:20,432 Is mostly the modifications, and how the modifications affect 108 00:06:20,467 --> 00:06:22,272 The airplane as opposed to starting 109 00:06:22,307 --> 00:06:23,632 From a totally new airplane. 110 00:06:23,667 --> 00:06:25,872 The manufacturer of the airplane 111 00:06:25,907 --> 00:06:30,472 Is not on the hook to jump through the same number 112 00:06:30,547 --> 00:06:33,392 Of hoops as you would if the airplane 113 00:06:33,427 --> 00:06:35,712 Was designed from scratch. 114 00:06:35,747 --> 00:06:38,199 Narrator: This type of certification process 115 00:06:38,274 --> 00:06:40,672 Is known as the changed product rule. 116 00:06:40,707 --> 00:06:43,959 It's a long established industry standard. 117 00:06:44,034 --> 00:06:48,272 But in the case of the 737 max, assessing modifications rather 118 00:06:48,307 --> 00:06:52,192 Than the whole aircraft allowed potentially dangerous faults 119 00:06:52,227 --> 00:06:54,472 To enter the design. 120 00:06:54,547 --> 00:06:57,792 In any process designed and operated by humans, 121 00:06:57,827 --> 00:07:00,792 Things can slip through the net, and they obviously did here. 122 00:07:00,867 --> 00:07:04,272 The change product rule in this case enabled that. 123 00:07:04,307 --> 00:07:08,032 Narrator: Investigations later suggest the decision to modify 124 00:07:08,067 --> 00:07:12,832 The old 737 is what set the 737 max on the road 125 00:07:12,867 --> 00:07:16,272 To tragedy because the modifications signed off 126 00:07:16,307 --> 00:07:19,952 Under the changed product rule were considered in isolation, 127 00:07:19,987 --> 00:07:22,592 And the effect on the overall handling of the plane 128 00:07:22,627 --> 00:07:24,639 Was not adequately scrutinized. 129 00:07:28,067 --> 00:07:32,272 September 2011, development begins on the modifications 130 00:07:32,347 --> 00:07:35,392 Of the old 737. 131 00:07:35,427 --> 00:07:37,952 Almost immediately, boeing is looking 132 00:07:37,961 --> 00:07:41,312 At a mountain of sales for their new 737 max 133 00:07:41,347 --> 00:07:44,272 From airlines across the globe. 134 00:07:44,307 --> 00:07:46,592 Right from the start, boeing management 135 00:07:46,667 --> 00:07:51,552 Makes it very clear to employees that time means money. 136 00:07:51,627 --> 00:07:54,032 In the investigation report, they 137 00:07:54,107 --> 00:07:56,432 Mention this countdown timer. 138 00:07:56,507 --> 00:08:00,192 And they actually call it an excitement generator. 139 00:08:00,227 --> 00:08:02,192 Understandable, maybe. 140 00:08:02,227 --> 00:08:04,152 But what does it really do? 141 00:08:04,227 --> 00:08:08,432 What it really does is put pressure to meet the deadline 142 00:08:08,467 --> 00:08:14,839 Front and center, therefore putting quality and safety 143 00:08:14,914 --> 00:08:16,839 Slightly in the background. 144 00:08:16,914 --> 00:08:19,152 Narrator: After the crashes, investigations 145 00:08:19,161 --> 00:08:22,839 Suggest that time and money pressures drove decisions that 146 00:08:22,914 --> 00:08:25,312 Ultimately led to disaster. 147 00:08:25,321 --> 00:08:29,912 It certainly has the overarching appearance 148 00:08:29,987 --> 00:08:32,152 That at every step of the way, decisions 149 00:08:32,227 --> 00:08:36,832 Are being made to prioritize profits over safety. 150 00:08:36,867 --> 00:08:39,592 But in the long run, it costs far more, which is 151 00:08:39,667 --> 00:08:41,239 What we see in this accident. 152 00:08:53,027 --> 00:08:56,832 Narrator: By 2012, the development stage of the 737 153 00:08:56,867 --> 00:08:59,072 Max is well underway. 154 00:08:59,107 --> 00:09:01,232 But in that same year, boeing begins 155 00:09:01,307 --> 00:09:04,592 To slash money and testing time on the project. 156 00:09:04,627 --> 00:09:07,592 A congressional investigation after the crashes 157 00:09:07,667 --> 00:09:11,152 Highlights this series of cuts as an area of concern, 158 00:09:11,187 --> 00:09:13,799 Suggesting it compromised the future safety 159 00:09:13,874 --> 00:09:15,872 Of the flying public. 160 00:09:15,907 --> 00:09:19,639 Boeing has historically had a very strong safety record. 161 00:09:19,714 --> 00:09:22,432 The tragedy is that those principles weren't put in place 162 00:09:22,467 --> 00:09:24,359 In the design of this aircraft. 163 00:09:35,347 --> 00:09:38,832 Narrator: In 2012, boeing conducts a financial review 164 00:09:38,841 --> 00:09:41,712 Of the 737 max. 165 00:09:41,747 --> 00:09:46,432 Another project has already cost the company billions in delays. 166 00:09:46,507 --> 00:09:49,072 To save money, the decision is made 167 00:09:49,107 --> 00:09:52,359 To reduce a key testing process during the aircraft's 168 00:09:52,434 --> 00:09:54,112 Development. 169 00:09:54,147 --> 00:09:56,912 So each time we add something new, 170 00:09:56,947 --> 00:10:00,672 We test not only that the new feature works 171 00:10:00,707 --> 00:10:02,672 But the old ones still do. 172 00:10:02,707 --> 00:10:06,992 It seems obvious, but it's all too easy to actually cause 173 00:10:07,027 --> 00:10:09,432 The thing to go backwards. 174 00:10:09,507 --> 00:10:12,592 Narrator: This testing is critical throughout production 175 00:10:12,627 --> 00:10:16,792 To make sure failings do not creep into the design. 176 00:10:16,867 --> 00:10:19,872 But to speed up production and reduce costs, 177 00:10:19,907 --> 00:10:24,112 Boeing cuts the testing time by 2,000 hours. 178 00:10:24,187 --> 00:10:27,392 A house transportation committee hearing suggests some boeing 179 00:10:27,467 --> 00:10:29,952 Employees were feeling exhausted, 180 00:10:29,987 --> 00:10:33,232 And some stated they feared consequences if they 181 00:10:33,267 --> 00:10:34,999 Spoke up about the pressure. 182 00:10:35,074 --> 00:10:36,832 There was at least one engineer 183 00:10:36,867 --> 00:10:41,072 Who spoke up forcefully with his concerns about the situation. 184 00:10:41,147 --> 00:10:44,199 And he had a background in the military where he was quite 185 00:10:44,274 --> 00:10:47,432 Used to the invitation to be very clear 186 00:10:47,507 --> 00:10:48,912 When something's going wrong. 187 00:10:48,947 --> 00:10:51,312 You are obligated to speak up. 188 00:10:51,347 --> 00:10:54,672 And he was told, when he spoke up at boeing, 189 00:10:54,707 --> 00:10:57,152 That this is not the military. 190 00:10:57,187 --> 00:11:00,992 This is a profit making enterprise. 191 00:11:01,027 --> 00:11:05,072 Narrator: Despite concerns raised by boeing employees, 192 00:11:05,107 --> 00:11:09,159 The performance record of the previous generations of the 737 193 00:11:09,234 --> 00:11:13,872 Gives us aviation authority, the faa, enough confidence 194 00:11:13,907 --> 00:11:16,672 To approve the remodeling project. 195 00:11:16,681 --> 00:11:19,712 But the faa's approval is a grave error. 196 00:11:19,747 --> 00:11:24,432 It certainly has the overarching appearance 197 00:11:24,467 --> 00:11:26,672 That at every step of the way, decisions 198 00:11:26,707 --> 00:11:30,272 Are being made to prioritize profits over safety. 199 00:11:30,307 --> 00:11:33,952 Narrator: If time and money had not been such a priority, 200 00:11:33,961 --> 00:11:36,632 Then identified problems with the modifications 201 00:11:36,707 --> 00:11:39,792 To the original 737 might have been solved 202 00:11:39,801 --> 00:11:41,872 Before going any further. 203 00:11:41,907 --> 00:11:44,352 Instead, one of the biggest modifications 204 00:11:44,387 --> 00:11:48,272 Goes on to be the root cause of the fatal crashes, 205 00:11:48,347 --> 00:11:52,112 Putting new larger engines on the 737 body that 206 00:11:52,147 --> 00:11:54,112 Change its behavior in the air. 207 00:11:54,147 --> 00:11:56,512 The issue was, essentially what happens is 208 00:11:56,547 --> 00:11:58,472 The aircraft pitches upwards. 209 00:11:58,547 --> 00:12:00,632 It is at such a steep angle that the wing 210 00:12:00,707 --> 00:12:03,479 Can't produce lift anymore, and so the airplane stalls. 211 00:12:14,067 --> 00:12:17,792 Narrator: To launch their 737 max into the 21st century 212 00:12:17,801 --> 00:12:21,272 And make it more fuel efficient than its airbus rival, 213 00:12:21,347 --> 00:12:26,032 Boeing needs to change the existing engines on the 737. 214 00:12:26,067 --> 00:12:30,952 So the physics dictates better fuel efficiency 215 00:12:31,027 --> 00:12:35,272 Requires bigger engines. 216 00:12:35,347 --> 00:12:38,672 Narrator: But fitting larger engines to the 737 air frame 217 00:12:38,707 --> 00:12:40,519 Isn't an easy job. 218 00:12:40,594 --> 00:12:44,199 This is an airplane that sits very low to the ground. 219 00:12:44,274 --> 00:12:48,992 Its engines sit somewhere in the order of about 17 inches 220 00:12:49,001 --> 00:12:50,679 Off the ground. 221 00:12:50,754 --> 00:12:54,432 Compared to, for example, a boeing 757, which is about 26, 222 00:12:54,507 --> 00:12:57,312 27 inches off the ground. 223 00:12:57,347 --> 00:13:01,232 Narrator: When the original 737 was designed 50 years ago, 224 00:13:01,307 --> 00:13:06,072 The low slung body was a design feature, not a flaw. 225 00:13:06,147 --> 00:13:10,832 It was designed to be an aircraft that could go around 226 00:13:10,867 --> 00:13:15,392 The world, including into developing countries that would 227 00:13:15,427 --> 00:13:17,632 Lack the infrastructure that would be 228 00:13:17,667 --> 00:13:20,272 Available in some other airports so that you 229 00:13:20,307 --> 00:13:23,639 Have easy passenger loading. 230 00:13:23,714 --> 00:13:26,472 Narrator: But the 737's low slung body 231 00:13:26,547 --> 00:13:29,959 Means there's not enough room to fit the newer, larger engines 232 00:13:30,034 --> 00:13:31,399 In their previous position. 233 00:13:33,987 --> 00:13:37,232 Instead, the new engines are placed further forward 234 00:13:37,307 --> 00:13:41,719 And higher up on the wings, and this leads to a major problem. 235 00:13:45,027 --> 00:13:48,512 Wind tunnel testing reveals the relocation of the bigger more 236 00:13:48,547 --> 00:13:51,152 Fuel efficient engines has changed the way 237 00:13:51,187 --> 00:13:54,032 The plane behaves in flight. 238 00:13:54,067 --> 00:13:56,912 In some rare instances, at cruising altitude, 239 00:13:56,987 --> 00:14:00,192 It could push the plane's nose upwards. 240 00:14:00,227 --> 00:14:03,112 So the problem with the nose pitching up 241 00:14:03,187 --> 00:14:07,552 Is if the aircraft starts to be at too steep an angle, 242 00:14:07,587 --> 00:14:10,672 It can lose the ability to remain aloft. 243 00:14:10,707 --> 00:14:12,992 At that point, boeing could have 244 00:14:13,027 --> 00:14:16,752 And should have stopped to think whether it was worth continuing 245 00:14:16,827 --> 00:14:18,199 With the design. 246 00:14:20,274 --> 00:14:22,912 Narrator: Had boeing scrapped the project at this point, 247 00:14:22,947 --> 00:14:26,272 The fatal crashes would never have happened. 248 00:14:26,307 --> 00:14:29,392 Instead, engineers are tasked with finding a solution 249 00:14:29,427 --> 00:14:35,112 To keep both the 737 body and the new fuel efficient engines. 250 00:14:35,187 --> 00:14:37,639 What they come up with is arguably the biggest 251 00:14:37,714 --> 00:14:42,832 Single mistake on the road to the fatal crashes, 252 00:14:42,867 --> 00:14:45,952 The addition of software to overcome the problem 253 00:14:45,987 --> 00:14:50,272 And make the plane fly like the previous 737. 254 00:14:50,307 --> 00:14:53,232 But this has unintended consequences. 255 00:14:53,267 --> 00:14:59,799 There have been reports that suggest that the shear force 256 00:14:59,874 --> 00:15:03,632 With which it pushed the airplane into a downward spiral 257 00:15:03,667 --> 00:15:08,472 Made it virtually impossible for pilots to effectively 258 00:15:08,547 --> 00:15:10,439 Recover from what was a dive. 259 00:15:16,521 --> 00:15:19,392 Narrator: In 2012 software called 260 00:15:19,427 --> 00:15:23,872 Mcas is added to the 737 max. 261 00:15:23,907 --> 00:15:26,992 It's designed to ensure the larger engines won't affect 262 00:15:27,027 --> 00:15:30,672 The handling of the plane during a specific and very rare 263 00:15:30,707 --> 00:15:32,832 High speed maneuver. 264 00:15:32,867 --> 00:15:36,032 The software gathers information from different sensors, 265 00:15:36,107 --> 00:15:39,152 Which monitor the plane's g-force and pitch. 266 00:15:39,161 --> 00:15:42,192 If the sensors show the plane's nose rising rapidly, 267 00:15:42,227 --> 00:15:46,272 The software will react and push the nose back down. 268 00:15:46,347 --> 00:15:50,592 On paper, the mcas makes perfect technical sense. 269 00:15:50,627 --> 00:15:54,112 If the nose pitches up past a certain angle, 270 00:15:54,147 --> 00:15:58,152 You rely on a piece of technology to lower the nose. 271 00:15:58,227 --> 00:16:00,472 Narrator: The new software is a clever solution 272 00:16:00,547 --> 00:16:04,359 That solves this extremely rare handling problem. 273 00:16:04,434 --> 00:16:06,952 And this is what is included in the plans 274 00:16:07,027 --> 00:16:11,792 That boeing originally submits to the faa. 275 00:16:11,827 --> 00:16:16,032 But then flight testing reveals another issue. 276 00:16:16,067 --> 00:16:18,432 The nose of the max can also pitch up 277 00:16:18,467 --> 00:16:21,232 At lower speeds after takeoff. 278 00:16:21,307 --> 00:16:23,392 And unlike the high speed maneuver, 279 00:16:23,427 --> 00:16:25,112 This isn't a rare event. 280 00:16:25,187 --> 00:16:28,832 It could happen any time the plane flies. 281 00:16:28,867 --> 00:16:31,392 So boeing uses the same mcas software 282 00:16:31,427 --> 00:16:33,792 To solve this problem as well. 283 00:16:33,827 --> 00:16:35,632 That's a totally different environment 284 00:16:35,667 --> 00:16:37,392 To take a high speed device and put 285 00:16:37,467 --> 00:16:38,832 It in a low speed environment. 286 00:16:38,867 --> 00:16:40,359 And that's when you have to be very, 287 00:16:40,434 --> 00:16:43,072 Very vigilant about your underlying assumptions. 288 00:16:43,107 --> 00:16:45,112 Do those assumptions for the high speed regime 289 00:16:45,187 --> 00:16:47,639 Still fit in the low speed regime? 290 00:16:47,714 --> 00:16:50,512 Those details were not adequately addressed. 291 00:16:50,547 --> 00:16:53,479 Narrator: Due to the relatively low speeds after takeoff, 292 00:16:53,554 --> 00:16:55,792 There would not be enough g-force to trigger 293 00:16:55,827 --> 00:16:57,152 The g-sensor. 294 00:16:57,161 --> 00:16:59,312 This would prevent mcas functioning in 295 00:16:59,347 --> 00:17:01,792 This new low speed environment. 296 00:17:01,827 --> 00:17:04,519 So boeing reprograms this software to trigger 297 00:17:04,594 --> 00:17:07,792 Without the g-sensor. 298 00:17:07,801 --> 00:17:12,352 Two sensors were also originally needed to trigger mcas. 299 00:17:12,387 --> 00:17:15,472 But the 737 max software now relies 300 00:17:15,507 --> 00:17:18,792 On just a single pitch sensor. 301 00:17:18,867 --> 00:17:22,032 Boeing says it did tell the faa about this change, 302 00:17:22,107 --> 00:17:24,112 But the house committee on transportation 303 00:17:24,147 --> 00:17:27,072 And infrastructure concluded it had not been properly 304 00:17:27,107 --> 00:17:29,392 Highlighted, allowing it to go through 305 00:17:29,427 --> 00:17:31,592 Without sufficient scrutiny. 306 00:17:31,667 --> 00:17:34,359 Powerful software should never rely on one sensor. 307 00:17:34,434 --> 00:17:39,232 I am convinced that if the right people on either side 308 00:17:39,267 --> 00:17:41,799 Had known about that problem, the faa would 309 00:17:41,874 --> 00:17:44,032 Never have let it go out of the factory 310 00:17:44,107 --> 00:17:46,999 Door with only one sensor. 311 00:17:47,074 --> 00:17:49,112 Narrator: Tragically, both crashes 312 00:17:49,187 --> 00:17:52,832 Reveal the danger of relying on a single pitch sensor. 313 00:17:52,867 --> 00:17:55,392 If it develops a fault, the software 314 00:17:55,467 --> 00:17:58,032 Has no way to tell that it is now responding 315 00:17:58,067 --> 00:17:59,872 To false information. 316 00:17:59,907 --> 00:18:01,752 Imagine you looked at a thermometer 317 00:18:01,827 --> 00:18:06,999 And it's minus 30 one moment and it's plus 20 the next moment. 318 00:18:07,074 --> 00:18:10,839 If in 3/4 of a second, you saw a thermometer change like that, I 319 00:18:10,914 --> 00:18:12,199 Don't think you would immediately 320 00:18:12,274 --> 00:18:13,632 Throw your clothes on and say, gee, 321 00:18:13,667 --> 00:18:15,312 I guess it got very cold outside. 322 00:18:15,321 --> 00:18:16,752 I think you would say, well, something's 323 00:18:16,787 --> 00:18:18,472 Wrong with the thermometer. 324 00:18:18,547 --> 00:18:22,592 Narrator: In both crashes, mcas responded to faulty sensor data 325 00:18:22,627 --> 00:18:26,199 Suggesting the planes were about to stall. 326 00:18:26,274 --> 00:18:29,959 Less than two minutes into the first doomed lion air flight, 327 00:18:30,034 --> 00:18:34,199 The 737 max's software reacts to the erroneous data 328 00:18:34,274 --> 00:18:37,472 And pushes the plane's nose down. 329 00:18:37,481 --> 00:18:41,472 13 minutes after takeoff, the plane plummets into the java 330 00:18:41,507 --> 00:18:44,792 Sea at 450 miles per hour. 331 00:18:44,867 --> 00:18:49,392 189 passengers and crew are killed. 332 00:18:49,427 --> 00:18:52,192 Less than five months later, the pitch sensor 333 00:18:52,227 --> 00:18:58,192 On an ethiopian airlines 737 max also fails. 334 00:18:58,227 --> 00:19:01,432 After a terrifying six minutes for all on board, 335 00:19:01,507 --> 00:19:05,632 Flight 302 nose dives into the ground. 336 00:19:05,667 --> 00:19:08,192 Again, there are no survivors. 337 00:19:08,227 --> 00:19:11,159 Why couldn't mcas have had that amount of design 338 00:19:11,234 --> 00:19:13,472 To be intelligent enough to disregard 339 00:19:13,507 --> 00:19:16,272 And ignore the bad data? 340 00:19:16,307 --> 00:19:19,592 Then that crash would have been averted 341 00:19:19,667 --> 00:19:22,159 And my friend's granddaughter would be alive today. 342 00:19:24,627 --> 00:19:29,592 Narrator: In January 2021, two years after the fatal crashes, 343 00:19:29,667 --> 00:19:33,072 The us justice department brings criminal charges of fraud 344 00:19:33,107 --> 00:19:36,832 Against boeing for the failure of two of its key employees 345 00:19:36,867 --> 00:19:40,839 To be completely transparent with the regulator about mcas. 346 00:19:43,027 --> 00:19:45,632 But this situation was compounded by 347 00:19:45,667 --> 00:19:49,392 Another huge error of judgment. 348 00:19:49,467 --> 00:19:51,632 This is the equivalent of letting 349 00:19:51,641 --> 00:19:53,719 The fox guard the chicken pen. 350 00:20:02,947 --> 00:20:04,839 Narrator: During development of the 737 max, 351 00:20:04,914 --> 00:20:07,552 Boeing introduces software to overcome handling issues. 352 00:20:07,627 --> 00:20:09,632 Critical changes are made to the system 353 00:20:09,667 --> 00:20:12,512 And are not highlighted to the industry regulator. 354 00:20:12,547 --> 00:20:15,152 These are directly responsible for the deaths 355 00:20:15,187 --> 00:20:18,752 Of 346 passengers and crew. 356 00:20:18,787 --> 00:20:22,519 But the regulator itself is also part of the problem. 357 00:20:22,594 --> 00:20:25,312 It makes a huge mistake, giving boeing 358 00:20:25,347 --> 00:20:30,632 The power to effectively sign off much of the 737 max design. 359 00:20:30,707 --> 00:20:34,839 The real glaring standout fact in all this 360 00:20:34,914 --> 00:20:39,799 Is that the faa, the regulator, delegated its work 361 00:20:39,874 --> 00:20:45,712 And its authority to boeing employees, which in my view 362 00:20:45,747 --> 00:20:50,759 Should never have happened and should never happen again. 363 00:20:58,867 --> 00:21:01,872 Narrator: In the united states, all new plane designs 364 00:21:01,947 --> 00:21:06,032 Must be green-lit by america's aviation regulator, the federal 365 00:21:06,067 --> 00:21:08,239 Aviation administration. 366 00:21:10,307 --> 00:21:12,832 They regulate all aspects of aviation-- 367 00:21:12,867 --> 00:21:15,112 Big planes, small planes, planes in between, 368 00:21:15,187 --> 00:21:16,912 Pilots, manufacturers. 369 00:21:16,947 --> 00:21:20,272 Every aspect of aviation is regulated for safety 370 00:21:20,347 --> 00:21:21,792 By the federal aviation administration 371 00:21:21,827 --> 00:21:23,079 In the united states. 372 00:21:25,747 --> 00:21:28,672 Narrator: Although the faa is responsible for the final sign 373 00:21:28,707 --> 00:21:31,272 Off on any new project, it routinely 374 00:21:31,347 --> 00:21:33,312 Delegates large parts of this process 375 00:21:33,347 --> 00:21:36,999 To the aircraft manufacturers. 376 00:21:37,074 --> 00:21:38,912 The aircraft manufacturers have 377 00:21:38,987 --> 00:21:44,839 Been able to in some sense self certify much of their process. 378 00:21:44,914 --> 00:21:47,712 Not just boeing, but any manufacturer in order 379 00:21:47,747 --> 00:21:50,112 That the faa not become a bottleneck for that process, 380 00:21:50,147 --> 00:21:54,592 Because otherwise that could slow it down to a standstill. 381 00:21:54,667 --> 00:21:57,472 Narrator: At the time of the 737 max development, 382 00:21:57,507 --> 00:22:00,272 The faa didn't have the staffing capacity 383 00:22:00,307 --> 00:22:02,792 To monitor the entire program. 384 00:22:02,867 --> 00:22:07,159 So by the time the 737 max was green-lit to fly commercially, 385 00:22:07,234 --> 00:22:09,639 It had delegated so much authority, 386 00:22:09,714 --> 00:22:13,799 Boeing had responsibility for 87% of the checks 387 00:22:13,874 --> 00:22:16,472 Needed to certify the plane. 388 00:22:16,547 --> 00:22:19,872 Boeing of course turns around and says, 389 00:22:19,947 --> 00:22:21,472 "our plane is fit to fly. 390 00:22:21,507 --> 00:22:24,592 Why would we say any differently?" 391 00:22:24,627 --> 00:22:29,952 In any situation where an organization can self certify, 392 00:22:29,987 --> 00:22:32,832 There's an immediate conflict of interest. 393 00:22:32,867 --> 00:22:36,912 Why on earth would an organization not certify their 394 00:22:36,947 --> 00:22:40,832 Own project as fit for purpose? 395 00:22:40,867 --> 00:22:43,432 Narrator: Later investigations report there are signs 396 00:22:43,507 --> 00:22:46,592 That the staff members delegated by the faa 397 00:22:46,667 --> 00:22:50,832 Are put under undue pressure by boeing. 398 00:22:50,841 --> 00:22:54,199 If individuals feel it's not in their interest to report 399 00:22:54,274 --> 00:22:59,312 Problems or that, worse, that they're not heard or even 400 00:22:59,347 --> 00:23:02,592 Intimidated, then the aircraft itself 401 00:23:02,667 --> 00:23:06,992 Becomes an object of concern. 402 00:23:07,001 --> 00:23:09,792 Narrator: The failure to highlight key information 403 00:23:09,827 --> 00:23:14,072 About mcas results in the 737 max leaving the factory 404 00:23:14,147 --> 00:23:16,632 With fatal design flaws. 405 00:23:16,707 --> 00:23:20,032 But a further decision signed off by the faa results 406 00:23:20,067 --> 00:23:23,472 In another devastating mistake. 407 00:23:23,507 --> 00:23:25,872 Pilots don't go through simulator training 408 00:23:25,947 --> 00:23:29,232 Before flying the new 737 max. 409 00:23:29,307 --> 00:23:30,912 They didn't have the training to be 410 00:23:30,947 --> 00:23:34,632 Able to diagnose the problem when it was happening. 411 00:23:34,707 --> 00:23:36,672 They didn't have the information. 412 00:23:36,707 --> 00:23:39,479 And so they were really operating in the dark. 413 00:23:47,987 --> 00:23:52,839 Narrator: By 2016, the first 737 max is about to roll 414 00:23:52,914 --> 00:23:55,472 Off the production line. 415 00:23:55,507 --> 00:23:58,319 Boeing is now looking at a bulging order book. 416 00:24:01,074 --> 00:24:05,432 One of the max's key selling points is its fuel efficiency. 417 00:24:05,507 --> 00:24:08,152 The other is that it flies in exactly the same way 418 00:24:08,227 --> 00:24:11,072 As the old favorite 737. 419 00:24:11,107 --> 00:24:14,679 Boeing was trying to increase the attractiveness 420 00:24:14,754 --> 00:24:20,992 Of their aircraft to airlines by saying, hey, this is a 737, 421 00:24:21,027 --> 00:24:24,032 Therefore you can have pilots be able to hop in the pilot seat 422 00:24:24,067 --> 00:24:26,679 Very easily and fly this plane. 423 00:24:26,754 --> 00:24:30,512 This is a really big deal because it wouldn't necessitate 424 00:24:30,547 --> 00:24:32,832 Additional training, additional flight 425 00:24:32,867 --> 00:24:37,112 Simulator time, all of which is costly to the airlines. 426 00:24:37,187 --> 00:24:40,592 Narrator: Instead of expensive flight simulator training, 427 00:24:40,667 --> 00:24:44,832 Boeing offers up a more cost effective and quicker approach. 428 00:24:44,867 --> 00:24:48,912 If they were already used to flying the 737 version, 429 00:24:48,947 --> 00:24:51,952 Pilots were encouraged to use ipads to train 430 00:24:51,987 --> 00:24:54,959 Up for the new 737 max. 431 00:24:58,067 --> 00:25:01,872 Narrator: In 2011, indonesian carrier lion air 432 00:25:01,907 --> 00:25:08,032 Buys 230 planes at a cost of over $20 billion. 433 00:25:08,067 --> 00:25:10,912 17 months prior to the lion air crash, 434 00:25:10,947 --> 00:25:14,512 Lion air actually requested from boeing if their pilots could 435 00:25:14,547 --> 00:25:17,232 Have flight simulator training on arrival 436 00:25:17,267 --> 00:25:19,152 Of the new max models. 437 00:25:19,187 --> 00:25:22,359 Narrator: This is way beyond the two hours of ipad training 438 00:25:22,434 --> 00:25:24,072 Boeing has been pushing. 439 00:25:24,147 --> 00:25:27,632 The minute boeing sets a precedent suggesting that one 440 00:25:27,667 --> 00:25:30,632 Group of pilots requires training, 441 00:25:30,707 --> 00:25:34,352 The concern would be that other airlines, other customers would 442 00:25:34,361 --> 00:25:36,672 Say we also need training. 443 00:25:36,681 --> 00:25:40,352 And hang on a second, we were promised an airplane 444 00:25:40,361 --> 00:25:42,199 That required minimal training. 445 00:25:42,274 --> 00:25:46,832 So why are we now on the hook to pay for this? 446 00:25:46,867 --> 00:25:49,319 Narrator: Boeing persuades lion air that simulator 447 00:25:49,394 --> 00:25:50,919 Training is unnecessary. 448 00:25:56,387 --> 00:26:00,792 Pilot training is very, very important, with the idea being 449 00:26:00,867 --> 00:26:04,199 That when an emergency comes, the instincts are correct, 450 00:26:04,274 --> 00:26:06,112 The muscle memory is there. 451 00:26:06,187 --> 00:26:10,592 So to go through a modern approved training syllabus 452 00:26:10,667 --> 00:26:12,672 Makes you completely comfortable. 453 00:26:12,707 --> 00:26:14,832 If you've got through all the hurdles 454 00:26:14,867 --> 00:26:17,872 And you climb into the airplane after all that training, 455 00:26:17,907 --> 00:26:20,192 You just feel completely confident. 456 00:26:20,227 --> 00:26:23,472 Narrator: If the pilots in both crashes had simulator training, 457 00:26:23,481 --> 00:26:25,152 They might have been better prepared 458 00:26:25,187 --> 00:26:27,232 When things went wrong. 459 00:26:27,307 --> 00:26:31,872 But even then, another key decision proves critical. 460 00:26:31,907 --> 00:26:35,792 Boeing makes no mention at all of the mcas software 461 00:26:35,801 --> 00:26:39,112 In the 737 max flight manual. 462 00:26:39,187 --> 00:26:42,272 I met with the head of the accident investigation 463 00:26:42,307 --> 00:26:44,192 Committee in jakarta. 464 00:26:44,227 --> 00:26:49,639 And I was astonished when he told me that the pilots were 465 00:26:49,714 --> 00:26:52,912 Not even aware of the mcas system, 466 00:26:52,947 --> 00:26:57,632 This incredibly powerful system that is figuring 467 00:26:57,641 --> 00:26:59,552 Prominently in the crash. 468 00:26:59,587 --> 00:27:01,472 It wasn't even in their flight manual. 469 00:27:01,507 --> 00:27:05,872 So when the lion air pilots were experiencing these problems, 470 00:27:05,907 --> 00:27:07,479 They didn't even know mcas existed. 471 00:27:18,067 --> 00:27:24,912 Narrator: January 2016, the 737 max makes its maiden flight. 472 00:27:24,947 --> 00:27:28,832 Two months later, boeing convinces the faa the plane's 473 00:27:28,867 --> 00:27:31,319 Mcas software doesn't need to be included 474 00:27:31,394 --> 00:27:34,112 In the plane's flight manual. 475 00:27:34,147 --> 00:27:38,359 The later congressional report suggests this was to avoid mcas 476 00:27:38,434 --> 00:27:40,792 Being seen as a new feature. 477 00:27:40,867 --> 00:27:44,432 They were worried about the specter of raising 478 00:27:44,467 --> 00:27:47,312 The possibility that there was something profoundly 479 00:27:47,347 --> 00:27:49,872 Fundamentally new here that pilots might 480 00:27:49,907 --> 00:27:52,592 Need to know something about. 481 00:27:52,627 --> 00:27:56,679 Narrator: Boeing's sales pitch is that flying the new 737 max 482 00:27:56,754 --> 00:28:01,632 Is exactly the same as flying the previous 737. 483 00:28:01,667 --> 00:28:03,752 But the two subsequent plane crashes 484 00:28:03,827 --> 00:28:07,119 Prove the reality of this claim was very different. 485 00:28:13,667 --> 00:28:18,672 October 29, 2018, lion air flight 610 486 00:28:18,707 --> 00:28:21,319 Is less than two minutes into its journey 487 00:28:21,394 --> 00:28:26,152 When the plane's nose starts to be pushed down. 488 00:28:26,227 --> 00:28:29,712 Because the pilots have no clue the mcas software has been 489 00:28:29,747 --> 00:28:32,112 Fitted to the plane, they have no idea 490 00:28:32,147 --> 00:28:34,792 How to stop this happening. 491 00:28:34,867 --> 00:28:37,312 Within minutes, the control of that aircraft 492 00:28:37,347 --> 00:28:39,272 Was out of their hands. 493 00:28:39,347 --> 00:28:40,399 They were not prepared for it. 494 00:28:43,147 --> 00:28:46,839 The lion air pilots were experiencing these problems. 495 00:28:46,914 --> 00:28:48,832 They didn't even know mcas existed. 496 00:28:48,867 --> 00:28:51,392 They had no way to know why the plane 497 00:28:51,427 --> 00:28:54,432 Was acting erratically for them and why 498 00:28:54,467 --> 00:28:57,392 It wasn't easy to control. 499 00:28:57,427 --> 00:28:59,152 This was a major problem. 500 00:28:59,161 --> 00:29:01,472 Narrator: Ultimately, the pilots can't pull the plane out 501 00:29:01,481 --> 00:29:06,472 Of its final deadly dive, and it crashes 502 00:29:06,547 --> 00:29:09,952 Off the coast of indonesia. 503 00:29:09,961 --> 00:29:13,792 Given that mcas wasn't mentioned in the aircraft manual, 504 00:29:13,827 --> 00:29:17,712 A post crash hearing suggested it was a flawed assumption 505 00:29:17,787 --> 00:29:20,752 The pilots would be able to overcome the problems caused 506 00:29:20,827 --> 00:29:22,992 By this software. 507 00:29:23,001 --> 00:29:26,632 Had the pilots known about the existence of the software, 508 00:29:26,707 --> 00:29:30,592 They may have been able to work out how to override it. 509 00:29:30,627 --> 00:29:34,352 Tragically, had it not been for yet another mistake, 510 00:29:34,387 --> 00:29:36,199 The lion air flight might have been prevented 511 00:29:36,274 --> 00:29:40,632 From taking off altogether. 512 00:29:40,707 --> 00:29:43,232 The day before, the same aircraft 513 00:29:43,267 --> 00:29:47,072 Experiences a similar problem, but details of how 514 00:29:47,107 --> 00:29:49,479 It was solved aren't passed on. 515 00:29:49,554 --> 00:29:52,112 The information just fell between the cracks, 516 00:29:52,147 --> 00:29:55,279 And the next crew didn't know how they solved it. 517 00:30:04,867 --> 00:30:11,432 Narrator: October 28, 2018, lion air flight jt043 takes off 518 00:30:11,507 --> 00:30:14,912 On a two hour internal journey to the indonesian capital, 519 00:30:14,947 --> 00:30:16,432 Jakarta. 520 00:30:16,467 --> 00:30:18,912 The aircraft was less than six months old, 521 00:30:18,947 --> 00:30:21,432 Less than 800 hours of flying time, which is 522 00:30:21,507 --> 00:30:24,832 Relatively new for an aircraft. 523 00:30:24,867 --> 00:30:28,592 Narrator: Minutes after takeoff, at an altitude of just 400 524 00:30:28,667 --> 00:30:30,999 Feet, the control stick in the cockpit 525 00:30:31,074 --> 00:30:34,832 Begins to shake violently. 526 00:30:34,841 --> 00:30:37,112 Some airliners have stick shake 527 00:30:37,187 --> 00:30:41,632 To artificially tell you when you're approaching a stall. 528 00:30:41,641 --> 00:30:43,712 Narrator: But unknown to the pilots, 529 00:30:43,747 --> 00:30:46,512 The plane is not in danger of stalling. 530 00:30:46,547 --> 00:30:48,952 The stick shaker is vibrating in response 531 00:30:49,027 --> 00:30:51,152 To a malfunctioning external sensor, 532 00:30:51,187 --> 00:30:56,272 The same single sensor that feeds into the mcas software. 533 00:30:56,307 --> 00:30:58,992 The mcas responds to the false data 534 00:30:59,027 --> 00:31:01,639 By forcing the plane into a dive. 535 00:31:01,714 --> 00:31:04,032 You do not want this system functioning 536 00:31:04,067 --> 00:31:08,592 When the airplane is trying to maintain stable flight. 537 00:31:08,627 --> 00:31:12,352 If the system kicks in during these points in time, 538 00:31:12,361 --> 00:31:16,032 The worst case scenario is a crash. 539 00:31:16,067 --> 00:31:19,159 Narrator: Unaware of the existence of the mcas software, 540 00:31:19,234 --> 00:31:22,119 The pilots send out frantic mayday signals. 541 00:31:25,027 --> 00:31:27,159 But three minutes later, they manage 542 00:31:27,234 --> 00:31:28,919 To regain control of the plane. 543 00:31:31,947 --> 00:31:35,432 It's really interesting to me that the crew that 544 00:31:35,507 --> 00:31:38,672 Flew the airplane just before the accident was 545 00:31:38,707 --> 00:31:42,832 Able to stumble upon the right cut out procedure. 546 00:31:42,841 --> 00:31:45,792 And what was interesting there was it wasn't the crew that was 547 00:31:45,801 --> 00:31:47,872 Involved in flying the airplane at the time, 548 00:31:47,907 --> 00:31:50,672 But it was the pilot in the jump seat behind them 549 00:31:50,707 --> 00:31:52,832 That actually figured out the right response. 550 00:31:52,867 --> 00:31:55,632 He was able to perform a procedure known 551 00:31:55,667 --> 00:31:59,152 As the runaway stabilizer, which is 552 00:31:59,187 --> 00:32:03,799 A mechanical process to restore the balance of the plane. 553 00:32:03,874 --> 00:32:07,072 Narrator: The same problem recurs throughout the journey. 554 00:32:07,107 --> 00:32:10,032 But each time, the crew manages to override 555 00:32:10,067 --> 00:32:12,192 The deadly software. 556 00:32:12,227 --> 00:32:15,392 Passengers later described the flight as a terrifying roller 557 00:32:15,467 --> 00:32:17,112 Coaster ride. 558 00:32:17,187 --> 00:32:20,672 As soon as the plane lands, the pilot reports the incident 559 00:32:20,707 --> 00:32:23,479 To the ground maintenance engineers, 560 00:32:23,554 --> 00:32:26,599 But key information isn't passed on. 561 00:32:28,547 --> 00:32:30,312 There was no record in the lion 562 00:32:30,387 --> 00:32:34,032 Air logs of how they'd actually gone about fixing this problem. 563 00:32:34,107 --> 00:32:36,272 Narrator: Less than 24 hours later, 564 00:32:36,307 --> 00:32:40,592 Flight 610's pilots board the same 737 max 565 00:32:40,627 --> 00:32:43,639 With no knowledge of what they're about to face. 566 00:32:43,714 --> 00:32:47,712 Had the runaway stabilizer checklist procedure 567 00:32:47,747 --> 00:32:52,672 Been reported as a solution in that maintenance log, the pilot 568 00:32:52,707 --> 00:32:55,872 The next day on that tragic lion air crash 569 00:32:55,947 --> 00:32:59,152 May have been in more of a position to understand how 570 00:32:59,187 --> 00:33:01,952 To tackle the mcas system, despite not knowing it 571 00:33:01,987 --> 00:33:04,512 Was installed on the aircraft. 572 00:33:04,547 --> 00:33:06,832 Narrator: If that information had been passed on, 573 00:33:06,867 --> 00:33:12,032 Disaster might have been averted less than 24 hours later. 574 00:33:12,107 --> 00:33:16,959 Instead, the very same 737 max crashes on its next flight. 575 00:33:20,067 --> 00:33:25,272 Then tragically, less than five months later, another 737 max 576 00:33:25,347 --> 00:33:28,672 Falls from the skies. 577 00:33:28,707 --> 00:33:31,479 When the second accident happened, 578 00:33:31,554 --> 00:33:33,239 It was a different ballgame. 579 00:33:43,481 --> 00:33:48,632 Narrator: October 29, 2018, less than 24 hours 580 00:33:48,707 --> 00:33:51,112 After a terrifying roller coaster flight, 581 00:33:51,187 --> 00:33:57,432 The same 737 max departs from jakarta at 6:20 am. 582 00:33:57,507 --> 00:33:59,952 Almost immediately, the software mistakenly 583 00:33:59,987 --> 00:34:04,359 Pushes the plane's nose down, just as it did the day before. 584 00:34:07,714 --> 00:34:12,679 This time, there is no off duty pilot on board to save the day. 585 00:34:12,754 --> 00:34:15,472 The plane crashes into the java sea 13 586 00:34:15,481 --> 00:34:20,359 Minutes after takeoff, killing all 189 people on board. 587 00:34:20,434 --> 00:34:23,592 The nose of the plane was pushed down by the system 588 00:34:23,667 --> 00:34:26,592 At an angle of almost 40 degrees, 589 00:34:26,627 --> 00:34:29,872 Resulting into this nose dive into the sea at a speed 590 00:34:29,907 --> 00:34:32,672 Of 450 miles an hour. 591 00:34:32,707 --> 00:34:34,592 Narrator: Although flight recordings highlight 592 00:34:34,667 --> 00:34:36,912 Technical faults, it is suggested 593 00:34:36,947 --> 00:34:39,432 The real problem was not with the plane, 594 00:34:39,507 --> 00:34:41,959 The problem was pilot error. 595 00:34:42,034 --> 00:34:44,359 This delays the real problem from being 596 00:34:44,434 --> 00:34:49,632 Fully investigated until after the second 737 max crash. 597 00:34:49,667 --> 00:34:52,832 Just trying to blame the pilot or blame the user 598 00:34:52,867 --> 00:34:55,272 Does nothing to solve the systemic problems that 599 00:34:55,347 --> 00:34:56,719 Will lead to future accidents. 600 00:35:08,594 --> 00:35:11,232 Narrator: In the aftermath of the lion air crash, 601 00:35:11,307 --> 00:35:14,672 Boeing releases a press statement saying that the 737 602 00:35:14,707 --> 00:35:17,639 Max is as safe as any airplane that 603 00:35:17,714 --> 00:35:20,519 Has ever flown in the skies. 604 00:35:20,594 --> 00:35:23,159 The finger of blame is pointed at the pilots 605 00:35:23,234 --> 00:35:25,272 Rather than the plane itself. 606 00:35:25,347 --> 00:35:27,152 It goes with the job. 607 00:35:27,161 --> 00:35:29,792 You accept it, that the first person 608 00:35:29,801 --> 00:35:34,999 That's going to be looked at is you as the captain. 609 00:35:35,074 --> 00:35:36,672 It's just how it is. 610 00:35:36,707 --> 00:35:39,072 And would I call it a burden? 611 00:35:39,107 --> 00:35:41,959 I just, I think I have acceptance 612 00:35:42,034 --> 00:35:44,432 That that's how it is. 613 00:35:44,507 --> 00:35:46,112 Narrator: Blaming the pilots means 614 00:35:46,147 --> 00:35:51,592 Attention focuses on the airline, not the 737 max. 615 00:35:51,667 --> 00:35:55,552 If you start to even imply that it might be partly 616 00:35:55,587 --> 00:35:59,632 Your fault, your stock price is going to take a hit, 617 00:35:59,667 --> 00:36:03,592 There are going to be huge financial consequences, maybe 618 00:36:03,667 --> 00:36:07,152 Legal consequences as well. 619 00:36:07,187 --> 00:36:11,752 Narrator: In this situation, lion air makes an easy target. 620 00:36:11,827 --> 00:36:15,232 Lion air had a dubious safety record, 621 00:36:15,267 --> 00:36:18,512 Large number of incidents in the previous 20 years. 622 00:36:18,547 --> 00:36:20,752 There were issues with pilot training recorded. 623 00:36:20,787 --> 00:36:23,072 There were issues with maintenance 624 00:36:23,107 --> 00:36:27,712 And general engineering within the organization. 625 00:36:27,747 --> 00:36:29,472 Narrator: Boeing implies the solution 626 00:36:29,507 --> 00:36:33,632 To the software problem is simply a standard procedure. 627 00:36:33,667 --> 00:36:36,912 It's called the runaway stabilizer checklist 628 00:36:36,947 --> 00:36:38,512 And is found in the manual. 629 00:36:38,547 --> 00:36:41,872 In reality, the runaway stabilizer checklist 630 00:36:41,907 --> 00:36:43,872 Is a non-normal procedure. 631 00:36:43,947 --> 00:36:47,392 And in that situation, pilots will be looking 632 00:36:47,467 --> 00:36:50,359 Through a physical hard copy checklist, 633 00:36:50,434 --> 00:36:53,712 Trying to identify what they need to do in that situation. 634 00:36:53,747 --> 00:36:55,712 And with minutes to spare or even seconds 635 00:36:55,747 --> 00:36:59,112 To spare in the cockpit, that's not reality. 636 00:36:59,187 --> 00:37:01,319 Narrator: Focusing on the pilot's actions 637 00:37:01,394 --> 00:37:03,959 Deflects attention away from the real problem, 638 00:37:04,034 --> 00:37:07,392 The plane's technical issues. 639 00:37:07,467 --> 00:37:09,799 In the weeks that follow, the company goes on 640 00:37:09,874 --> 00:37:13,152 To highlight the information that shows how to override 641 00:37:13,187 --> 00:37:19,559 The deadly software problem, and 737 max sales continue to soar. 642 00:37:21,107 --> 00:37:25,072 Then less than five months after the lion air crash, 643 00:37:25,107 --> 00:37:29,872 An ethiopian airline 737 max nose dives into the ground 644 00:37:29,907 --> 00:37:31,239 Six minutes after takeoff. 645 00:37:34,274 --> 00:37:38,912 All 157 passengers and crew are killed. 646 00:37:38,947 --> 00:37:42,112 The plane's black box reveals striking similarities 647 00:37:42,147 --> 00:37:43,792 With the lion air crash. 648 00:37:43,827 --> 00:37:46,832 When the second accident happened, 649 00:37:46,867 --> 00:37:50,072 It was a different ballgame because ethiopian 650 00:37:50,147 --> 00:37:53,632 Have a fantastic reputation, and are very well thought 651 00:37:53,667 --> 00:37:55,792 Of in the rest of the world. 652 00:37:55,827 --> 00:37:59,872 And suddenly, you couldn't blame, 653 00:37:59,947 --> 00:38:02,352 You couldn't get away with it anymore. 654 00:38:02,387 --> 00:38:04,672 Narrator: If the focus had been on the plane 655 00:38:04,707 --> 00:38:07,712 Rather than blaming the pilots, the technical issues might have 656 00:38:07,787 --> 00:38:10,672 Been solved and the second crash averted 657 00:38:10,707 --> 00:38:12,999 Because there was only one real difference 658 00:38:13,074 --> 00:38:15,392 Between the two crashes. 659 00:38:15,427 --> 00:38:18,832 The pilots of the ethiopian airlines 737 max 660 00:38:18,867 --> 00:38:22,272 Did have knowledge of how to deal with the software problem 661 00:38:22,307 --> 00:38:26,832 If it occurred, but the plane still crashed. 662 00:38:26,867 --> 00:38:31,552 A key mistake made long before the first 737 max rolled off 663 00:38:31,627 --> 00:38:34,512 The production line meant that whatever the pilots did, 664 00:38:34,547 --> 00:38:37,639 The odds were stacked against them. 665 00:38:37,714 --> 00:38:43,792 When they designed the 737 max and assumed it would be safe 666 00:38:43,801 --> 00:38:45,639 And safely operated by pilots who 667 00:38:45,714 --> 00:38:49,639 Are comfortable with the 737, they didn't take 668 00:38:49,714 --> 00:38:51,232 Into account the human factor. 669 00:38:51,267 --> 00:38:54,432 They didn't take into account what happens 670 00:38:54,467 --> 00:38:57,272 In those very few seconds when you're startled 671 00:38:57,347 --> 00:38:59,679 By an unexpected event. 672 00:39:08,867 --> 00:39:14,199 Narrator: March 10, 2019, 8:38 am, 673 00:39:14,274 --> 00:39:19,039 Ethiopian airlines flight 302 is only seconds into its ascent. 674 00:39:22,067 --> 00:39:25,552 Just like lion air flight 610, the plane 675 00:39:25,587 --> 00:39:28,199 Stick shaker begins to vibrate violently 676 00:39:28,274 --> 00:39:32,112 And the plane nosedives. 677 00:39:32,187 --> 00:39:35,472 The black box recordings and the details clearly show that 678 00:39:35,507 --> 00:39:39,712 The pilot and the co-pilot were frantic in their efforts 679 00:39:39,787 --> 00:39:43,312 To try and stabilize the plane. 680 00:39:43,347 --> 00:39:46,112 Narrator: Armed with knowledge of how to override the problem, 681 00:39:46,147 --> 00:39:49,639 The pilots manage to regain control. 682 00:39:49,714 --> 00:39:53,552 But seconds later, the plane pitches down again. 683 00:39:53,627 --> 00:39:56,512 The automated system would kick back in, 684 00:39:56,547 --> 00:40:00,199 Time and time again, and that's ultimately 685 00:40:00,274 --> 00:40:02,632 What led to the crashes. 686 00:40:02,707 --> 00:40:04,632 Narrator: The ethiopian air pilots lose 687 00:40:04,707 --> 00:40:06,992 And regain control three times. 688 00:40:07,027 --> 00:40:11,312 The fourth time they lose control, they are not so lucky. 689 00:40:11,347 --> 00:40:16,032 The plane crashes into the ground with total loss of life. 690 00:40:16,067 --> 00:40:17,432 They were overloaded physically in trying 691 00:40:17,507 --> 00:40:19,312 To handle the aircraft. 692 00:40:19,347 --> 00:40:22,032 And then when they did try to take over manual control, 693 00:40:22,067 --> 00:40:23,952 They found it very, very difficult to do so. 694 00:40:23,987 --> 00:40:25,952 So they had, there was a whole cascading 695 00:40:25,987 --> 00:40:30,352 Series of events that happened that led to this accident. 696 00:40:30,387 --> 00:40:32,632 Narrator: The pilots struggled to rectify the problem 697 00:40:32,707 --> 00:40:36,432 For four terrifying minutes. 698 00:40:36,507 --> 00:40:39,952 Regulators base their certification on the assumption 699 00:40:39,987 --> 00:40:44,519 That this sort of problem can be solved in just four seconds. 700 00:40:44,594 --> 00:40:47,872 If the airplane can't be recovered after that four 701 00:40:47,947 --> 00:40:50,032 Seconds without herculean effort by the pilot, 702 00:40:50,107 --> 00:40:52,352 Or without potentially damaging the airplane, 703 00:40:52,387 --> 00:40:55,072 Or hurting passengers, then it doesn't pass. 704 00:40:55,147 --> 00:40:56,992 Narrator: But later investigations 705 00:40:57,001 --> 00:41:00,072 Uncover internal documents revealing boeing was not only 706 00:41:00,147 --> 00:41:03,799 Aware of the problem, but in one simulator test, 707 00:41:03,874 --> 00:41:07,232 It took their pilot 10 seconds to resolve. 708 00:41:07,267 --> 00:41:11,872 Boeing did not highlight this catastrophic situation. 709 00:41:11,907 --> 00:41:15,072 When a boeing employee raised concerns about the ability 710 00:41:15,107 --> 00:41:19,072 Of pilots to respond to mcas activating repeatedly, 711 00:41:19,107 --> 00:41:22,752 Those concerns were not addressed. 712 00:41:22,787 --> 00:41:26,112 Every human has a stress performance curve 713 00:41:26,147 --> 00:41:32,632 Depending on their experience, their attitude, their training. 714 00:41:32,707 --> 00:41:36,839 And there's a startle effect, which we all have. 715 00:41:36,914 --> 00:41:40,592 That is when intensive events within the cockpit 716 00:41:40,667 --> 00:41:43,712 Cause the pilot's blood pressure to rise, 717 00:41:43,747 --> 00:41:47,632 Their heartbeat rate to increase. 718 00:41:47,667 --> 00:41:49,552 Narrator: The startle effect is found 719 00:41:49,587 --> 00:41:51,952 To be one of the critical human factors 720 00:41:51,987 --> 00:41:57,479 Which was underestimated during the development of the 737 max. 721 00:41:57,554 --> 00:41:59,952 One of the tragedies of these accidents 722 00:41:59,987 --> 00:42:03,712 Were that the basic foundational principles and procedures 723 00:42:03,747 --> 00:42:05,912 Of human factors engineering don't 724 00:42:05,987 --> 00:42:10,359 Appear to have been applied when they designed the 737 max. 725 00:42:10,434 --> 00:42:13,632 If you want to reduce or even eliminate human error, 726 00:42:13,667 --> 00:42:15,799 Then you have to design the technology 727 00:42:15,874 --> 00:42:18,832 To be compatible with how people operate. 728 00:42:18,867 --> 00:42:24,272 Narrator: By March 13, 2019, every 737 max around the globe 729 00:42:24,347 --> 00:42:26,032 Has been grounded. 730 00:42:26,107 --> 00:42:28,672 Following investigations, the faa 731 00:42:28,681 --> 00:42:32,472 Is criticized for its handling of the max project. 732 00:42:32,547 --> 00:42:34,992 The faa was asleep at the wheel when 733 00:42:35,027 --> 00:42:36,592 It comes to certifying the max. 734 00:42:36,627 --> 00:42:39,872 It didn't carry its job out properly. 735 00:42:39,907 --> 00:42:42,752 Narrator: The justice department charges boeing with conspiracy 736 00:42:42,787 --> 00:42:45,632 To commit fraud for two of its key employees 737 00:42:45,667 --> 00:42:48,352 Concealing information from the faa 738 00:42:48,387 --> 00:42:51,439 About the operation of its mcas software. 739 00:42:53,347 --> 00:42:55,712 Under a deferred prosecution agreement, 740 00:42:55,747 --> 00:43:00,752 Boeing pays out $2.5 billion in fines and compensation. 741 00:43:00,787 --> 00:43:04,072 I think all of us who were testifying very much 742 00:43:04,147 --> 00:43:08,272 Felt that those people deserved to have something come out 743 00:43:08,307 --> 00:43:10,839 Of this accident that could be used to improve 744 00:43:10,914 --> 00:43:12,792 Air transportation safety. 745 00:43:12,867 --> 00:43:15,912 Narrator: The company agrees to be monitored by the fbi fraud 746 00:43:15,987 --> 00:43:19,632 Department for three years. 747 00:43:19,667 --> 00:43:24,112 In December 2020, the 737 max is finally 748 00:43:24,147 --> 00:43:26,792 Given permission to fly again. 749 00:43:26,867 --> 00:43:30,839 But it's mcas software now relies on two pitch sensors 750 00:43:30,914 --> 00:43:33,912 And all pilots get full simulator training before 751 00:43:33,987 --> 00:43:37,472 Entering a 737 max cockpit. 752 00:43:37,507 --> 00:43:39,632 Sometimes it's easy to step back 753 00:43:39,641 --> 00:43:41,159 And say, well, this thing is just too complex. 754 00:43:41,234 --> 00:43:43,752 It can't be preventable. 755 00:43:43,827 --> 00:43:46,512 I don't agree with that perspective. 756 00:43:46,547 --> 00:43:48,032 These are not accidents that just happen 757 00:43:48,107 --> 00:43:49,712 Because some fluke thing. 758 00:43:49,747 --> 00:43:52,679 But I think the bigger issue is the tug of war 759 00:43:52,754 --> 00:43:56,679 And the battle between the financial goals 760 00:43:56,754 --> 00:44:01,799 Of a corporation and its ethical duties. 761 00:44:01,874 --> 00:44:04,032 That's what we see here. 762 00:44:04,067 --> 00:44:07,359 [music playing]