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]