And then the second plane crashed. Crashed minutes after taking off. This was going to be an existential crisis for the company. They had no idea how powerful mcas was. Faas oversight was sorely lacking. The mounting pressure on boeing. This was supposed to be one of the most highly scrutinized planes in the world. Here you are with another incident that was risking passengers lives. We are going to approach this, number one, acknowledging our mistake. Narrator now on frontline, it had direct echoes of everything we had been reporting on years ago. Narrator boeings fatal flaw. Frontline is made possible by contributions to your pbs station from viewers like you. Thank you. And by theorporation for public broadcasting. Additional support is provided by the abrams foundation, committed to excellence in journalism. Park foundation, dedicated to heightening Public Awareness of critical issues. The john d. And catherine t. Macarthur foundation committed to building a more just, verdant and peaceful world. More at macfound. Org. The heisingsimons foundation, unlocking knowledge, opportunity and possibilities. At hsfoundation. Org. And by the frontline journalis fund, with major support from jon and jo ann hagler. And Additional Support from koo and patricia yuen, committed to bridging cultural differences in our communities. And from the fredric j. Ridel living trust. On the morning of october 29, i was woken up by a colleague who alerted me that a lion aircraft crashed. He said, its the max, and i was surprised, because it was a new aircraft. My Company Provided the air data for aircraft flying around the jakarta area. So i went to the computer and looked at the data. It was immediately apparent that, okay, something was wrong. indistinct radio chatter the plane went up to about 2,000 feet, just over a minute after takeoff, and the plane had a bit of a dive. And then the plane climbed to about 5,000 feet. indistinct radio chatter but then, at 5,000 feet, the plane was fluctuating up and down. And then the plane just started diving. It, it just didnt make sense. You dont see planes diving on departure. I was baffled. Why did it go down . Lion air flight jt610 went missing from radar. Narrator 189 people were killed in the crash of lion air flight 610. The boeing 737 max 8. Narrator the plane was a new boeing 737 max. What do we know about this 737 max 8 . Narrator the fastestselling jet in boeing history, just introduced the year before. We dont yet know what caused this crash. A breakthrough this evening, the flight data recorder. It holds many of the keys. Narrator the data from the black box quickly got to f. A. A. Engineers in the united states. There is a purity of this data. It comes directly from the black boxes. So its recording airspeed, altitude. Narrator the data showed what appeared to be a glitch, something repeatedly moving part of the planes tail, controlling its pitch. It didnt take long, just a couple of minutes, to see that there was Rapid Movement of the horizontal stabilizer. Its probably the fastest way to kill yourself in an airplane, is to have the stabilizer malfunction. My spine literally tingled when i saw the traces from the black box. The plane continually tried to push the nose down, anthe pilots were trying over and over again to stop the plane. And in the end, they lose that battle. Narrator what boeing had not told airlines or their pilots was that it had put a powerful Software System on the new airplane. In the lion air crash, this system was reiving incorrect information, and that made the plane dive straight downward and destroy itself. Narrator inside boeing, they quickly diagnosed the problem and began working on a fix. Buthey stood by the max as hundreds of them took to the air around the world, carrying thousands of passengers. The company alerted pilots about handling a potential malfunction. Boeing and the f. A. A. Today warned airlines that sensors on 737 max 8 jets can malfunction. Boeing are calling this a formal advisory, and its been issued to the pilots. The reporting showed boeing knew that it was risky, but thr response was to blame the pilots. Pilots did not hit two cutoff switches. Boeing says that action was part of wellestablished protocols for all 737s. And that led to a series of decisions that kept the plane in the air and then we got another crash. Breaking news out of ethiopia, where a plane went down. Narrator it was Ethiopian Airlines flight 302, on its way to nairobi from addis ababa. Where a new 737 max 8 jetliner crashed minutes after taking off. Narrator two crashes, the same plane; 346 People Killed; an iconic american companys reputation in tatters. The storof the boeing 737 max would end up exposing corporate deception and a broken regulatory process. But at the center was a Software System supposed to keep people safe that instead led to their deaths. The black boxes from the ethiopian crash have been recovered. Its the second disaster within five months involving the boeing 737 max. Thats the same kind of aircraft that crashed back in october in indonesia. 157 people, including passengers and crew members on board, all are dead. The first thing you get to see at the site is a very big hole. And then to only imagine this is the place that they were last alive. We learned that there were no survivors on the plane. And then our objective was to go and bring my daughters body home. Now youre in close proximity. Youre able to see the fine details youre able to maybe think these are personal effects belonged to carol, my sister, or my mom. Or. This bone, whose bone is this . And they told us that there was no part of a human that was bigger than a femur that was left. That whole experience is just a jumble of images and painful thoughts and blankness, really, to me. I dont really. I cant really make sense of it. Narrator the crash of ethiopian flight 302 was the second time in five months that a boeing 737 max had gone down. As families gathered at the crash site, across the world, reporters at the New York Times were investigating what had been goinwrong with boeings new commercial jet. Statistically speaking, the likelihood that these two accidents were not in some way connected was extremely low. It suggested that there was something going on with the plane, and obviously we were determined to find out. It was clear from the getgo that boeing was in full crisis mode. As the facts from the accident become available and we understand the necessary next steps, were taking action to fully reassure airlines and their passengers of the safety of the 737 max. This was going to be an existential crisis for the company if these two events were related. China grounds the plane first. Other International Regulators ground the plane. Then the European Union grounds the plane. But in the u. S. , the f. A. A. Says its not grounding the plane. Boeing and the f. A. A. All were saying that they were sort of waiting for the facts before they rushed to judgment and grounded such an important new plane. Narrator but for months, the times was reporting there was something wrong with the 737 max itself the Software System that pilots had not known existed. The maneuvering characteristics augmentation system, or mcas. The function of this previously undisclosed system was to save the plane when it believed that the plane might go into a stall and fall out of the sky. And so this system was designed then to sort of take over the stabilizer and push that nose back down, in case the pilot gets in trouble. Narrator then, a major setback for the Company Radar showed the two planes flight patterns were eerily similar. Days after the rest of the world had reached the same conclusion, they finally grounded the plane. Narrator for the New York Times reporters, all the signs pointed to mcas. We knew that mcas was the beginning, and we knew that we needed to start with this system. This was a really problematic Software System in the way it was designed. Okay, well, then, how the hell did it end up in the plane this way . Narrator boeing declined to be interviewed for this film. In a statement, the company said safety is its top priority and it has worked closely with regulators, investigators, and stakeholders to implement changes that ensure accidents like these never happen again. This story really begins in 2011. jet engine roaring the 2011 Paris Air Show officially opened monday. Boeing and airbus had been going headtohead for at least a decade. But air. Airbus had been quickly catching up and really nipping at boeings heels. Its the best air show ever for airbus in terms of aircraft numbers sold. In 2010, airbus introduced the a320neo, a more fuelefficient version of its stalwart a320. The a320 is the direct competitor to the boeing 737. Airlines wanted an airplane that was more fuelefficient than the airplanes then in service. Airbus chose to reengine the a320 into what they call the neo, the new engine option. Its a record 200 orders for its a320neo. It was one of the fastestselling programs of aviation history. And it placed enormous pressure on boeing to respond. Boeing, frankly, was caught flatfooted. Within a couple of weeks, airbus and American Airlines have the preliminary workings of what would become the first deal for american to buy airbus planes in more than a decade. Gerard arpey, the c. E. O. Of American Airlines, calls jim mcnerney, the c. E. O. Of boeing. Its a Courtesy Call at this point, just letting their longtime supplier of airplanes know theyre going to go with the competition. And that is essentially a dagger in the heart of boeing. And within 48 hours, boeing had decided to pull the trigger on launching the reengined 737, which later became branded as the max. From the very beginning, from its birth, it was marked by competitive pressure. Narrator within days of the second 737 max crash, another investigation was underway in waington, d. C. We started getting information in from whistleblowers, from people, both current and former f. A. A. And boeing employees. Narrator Doug Pasternak was leading a congressional investigation. This is his first interview about what he found. As soon as the second accident occurred, we started our investigation, and our focus was on the design, development, and certification of the max. We got hundreds of thousands of pages of documents from boeing. One of the things that really struck me from speaking to a lot of boeing employees was that they were so excited to go to work at boeing. Boeing is a tremendous Engineering Company and a technical marvel, but, almost without failure, they point to a degradation of that mindset and that safety suffered as a result. Looking backwards, i think you can clearly see the trajectory to tragedy along the way at, at boeing. Narrator boeing publicly said the max went through a deliberate sixyear development process. But in their first stories, the New York Times reporters found inders who said that boeing executives had been putting the pressure on to design the new 737 quickly and cheaply. One specific engineer we spoke to was rick ludtke. He helped design the cockpit in the max, and he talked a lot about how there was an obsession limiting changes. This program was a much morer than ive ever been in. The company was trying to avoid costs. Minimum change to simplify the training differences, and to get it done quickly. It put what had happened in the context of this broader corporate narrative. Yeah. Speed was what they seemed to desire. There was a lot of decisionmaking that was somewhat arbitrary and didnt involve as much of the, of what engineering considers healthy debate. The challenge to the boeing designers was that any designs we create would not drive any new training that required a simulator. Narrator in his recorded interview with the times, ludtke said boeing management was so determined to avoid the expense of new training, they made a bold promise. Sales had made a commitment with southwest that for any airplane they delivered that had a new level d differences training, boeing would pay the company 1 million per every airplane delivered. If the max required simulator training, it would rebate southwest a Million Dollars per plane. And theres that incentive. Thats why it was so important to boeing that Pilot Training be kept to a minimum. All of this comes out of trying to give airlines the most fuelefficient version of a plane that they can spend as little money training their pilots on. That meant boeing had to do a number of things to make this plane fly like the old one, and that was because the max had much bigger engines on it to make them more fuel efficient. But because the 737 was a a 50yearold airplane at this time, practically, when it came time for boeing to put those engines on the wings, the engines were so darn big, they had to mount them further forward on the wings. They were testing in this wind tunnel, and they were discovering the plane was handling just a little bit differently but they didnt even have a plane built yet, so this wasnt, you know, happening in real flight this is something you have to fix. And they leaned on a system that they had used once before in a military tanker. It was designed as a system on the plane to really just smooth out the way the plane handled. Narrator it was mcas. It was designed for these extremely unusual maneuvers. Situations that, hopefully, the plane would never get in. And to prevent the nose from getting too high, the system would move the stabilizer on the back of the plane to push the nose back down. Narrator but inside boeing, there were early signs of trouble. One of the first documents we found was from november of 2012. A boeing test pilot was flying the max in a Flight Simulator and trying to respond to an activation of mcas. And that resulted in what he described as a catastrophic event. It showed that if that had been in real life, he could have lost the airplane. They realize from that moment on, even a boeing test pilot may have trouble responding to mcas. Narrator the company kept quiet about the simulator experience and appeared to have discounted the test results. Still, in the following months, some boeing employees suggested simply removing all references to mcas from training manuals. Boeing from almost the very beginning realized the significance of mcas, and the significance mcas would have on pilot simulator training. If we emphasize mcas is a new function, there may be a greater certification and training impact. Recommended action investigate deletion of mcas nomenclature. What that meant was that if they said mcas was a new function, the f. A. A. Was going to scrutinize it a lot more. Narrator boeing told congress it kept the f. A. A. Informed about mcass development and final configuration. But boeing has a complex and close relationship with the agency that oversees it. The airplanes are part of thetory, but so are the regulators. The f. A. A. Regulated boeing, in part, with a handful of boeing employees whose paychecks came from boeing, but whose jobs were to represent the interests of the f. A. A. Narrator its a decadesold arrangement known as delegation that allows federal agencies to give oversight powers to the comnies they regulate. In the beginning, there was a really good reason for this. The f. A. A. Was certifying things that made no sense to have them certify every single exit sign or bathroom sign or paint. The issue that many of the f. A. A. Employees that we talked to had was that it went way beyond bathroom signs. Over time, Congress Passed laws that pushed the f. A. A. To hand over the responsibility for more and more tasks to the company, to boeing. With this level of delegation between the company and the f. A. A. , it became hard to understand who was working for who. Narrator in the design of the 737 max, many things would be delegated to boeing. That included mcas. Under the impression that this was a relatively benign system, the f. A. A. Agreed to delegate it, as is the custom with the f. A. A. And boeing. And thats what happened in this case. It handed it over. Narrator in a statement, the f. A. Blamed ineffective coordination and said it had not focused on mcas when it certified the max, because boeing had not identified mcas as significant. Under the orders from congress, the f. A. A. Has since made changes to the delegation process. After years of going through design and development, the 737 max prototype was rolled out of Boeings Renton factory for its maiden flight. Look at all the excited faces, wouldldnt miss. Ed wilson is in the cockpit. Hes the new chief pilot, and he takes off. And lets just take a listen as this airplane gets ready for its very first takeoff. engine roars a short time after this first maiden flight, ed wilson, he and his copilots start to realize that the 737 max is not handling as smoothly as it should in certain lowspeed situations. Its shortly after takeoff, you know, its still kind of climbing to ascent. Its not going full speed. Narrator boeing engineers had an idea for how to deal with this. They know about mcas and they know that mcas was actually used for a similar situation in these highspeed maneuvers, d so theoretically, mcas could also be used in these other situations to also smooth out the handling. Crucially, its already been created, its already been approved, and its something that we could just apply, you know, to a different phase of flight. Its actually a pretty easy fix. This ends up being an extremely fateful decision. They enable the stabilizer to move much more actually, four times as much. Now the systems designed for lowspeed situations, like just after takeoff. And after takeoff is when the plane is still only a few thousand feet over the ground. That means you have much less room for error. Its happening in an automated fashion and a repeated fashion. This fundamentally changes mcas. It makes it much more aggressive, much more risky. Its a far more dangerous system. Narrator boeing was doubling down on the system, expanding it, despite the earlier catastrophic result in a simulator test. Narrator the times reporting on mcas focused on a former boeing pilot. I started to hear about a pilot at boeing whose name was mark forkner, the chief technical pilot for the 737. He was this key liaison