Flying Blind: The 737 MAX Tragedy and the Fall of Boeing

Book Preface

The scene before dawn at Soekarno-Hatta International Airport in Jakarta on October  29, 2018, was like that at any other big airport in the age of routinized international travel. In the concourses, bleary-eyed families and solo travelers clumped outside gates or gulped a hurried breakfast from Dunkin’ Donuts or Burger King, the latter of which, in this majority Muslim country, offered a Halal-certified rice and crispy chicken combo (the King Deal). Others window-shopped for Kiehl’s face cream or electronic gadgets. As the sun rose it was finally light enough to see the tropical gardens of narra trees, palms, and orchids outside—one of the few clues the traveler wasn’t in Kansas City or Stuttgart.

Not many gave a thought to the machines parked beside the jetways, many of them Boeing 737s, the stub-nosed workhorses of airline fleets since the 1970s. Commercial aircraft are considered the world’s premier expression of manufacturing excellence, designed by tens of thousands of people around the world who put their hands on them—at first figuratively, on the computer screens of engineers, and then literally when machinists climb underneath them to hand-crank stubborn rivets to the desired torque. Before the planes leave Boeing’s factory near Seattle, airlines send their own representatives to inspect every inch and reject the machines if they find, say, a loose bin or a fray in the forty miles of wiring (or, as sometimes happens, a forgotten wrench or gum wrapper).

The people gathered around Gate B5 that morning for Lion Air Flight 610 were about to board the newest and most advanced of more than ten thousand 737s Boeing had manufactured. It was called the 737 MAX 8. A far cry from the original 737, which had two tiny cigar-shaped engines tucked under its wings, this one had two massive turbofans. Almost six feet in diameter, they were so big they had to be mounted in front of the wings instead of beneath them, and the average person could stand inside the cowlings. The engines generated twenty-eight thousand pounds of thrust—double that of the first 737 models—while drastically lowering fuel consumption. The new jetliner was economical enough that Lion Air could charge sixty dollars for the one-hour flight from Jakarta to Pangkal Pinang, a city of three hundred thousand on Indonesia’s Bangka Island.

A Lion Air subsidiary, in fact, had been the first to fly the 737 MAX, which was particularly popular with Asian airlines springing up to transport the continent’s millions of newly mobile middle-class travelers. One of them, Paul Ayorbaba, forty-three, sent his family a choppy WhatsApp video of his mundane walk through the jetway and out to the plane, painted a cheery orange and white. In the minutes before the doors closed, twenty-two-year-old Deryl Fida Febrianto, a newlywed of two weeks, texted a selfie to his bride as he departed for a job on a cruise ship. Wahyu Aldilla sat with his son, Xherdan Fahrezi, after visiting Jakarta for a soccer match. A grieving family—Michelle Vergina Bongkal, twenty-one, her father, Adonia, and brother Mathew, thirteen—was heading to Bangka Island for the funeral of Michelle’s grandmother. Twenty employees of the country’s finance ministry, returning from a weekend in Jakarta, had caught the early-morning flight to reach the office in time.

Taking the MAX through a preflight checklist, the pilot, Bhavye Suneja, typified a new generation of pilots across Asia. At thirty-one, he had already flown six thousand hours, almost all of them on previous versions of the 737. His copilot, who went by the single name Harvino, was a decade older and had about five thousand hours. Neither knew that a tiny sensor on the left side of the plane, just below Suneja’s window, had a twenty-one-degree misalignment in its delicate innards—an oversight by mechanics who had inspected it. The device, known as an angle-of-attack sensor, was basically a weather vane. It measured the angle of the wing against the oncoming air—too high, and the plane might stall. In the triple-redundant engineering of a product now more than a century old, dating to a pair of bicycle makers who hitched a 12-horsepower engine and a chain sprocket to a spruce wood frame, it wasn’t even considered a particularly relevant indicator on most airplanes. Other dials measured the all-important airspeed, altitude, and pitch.

It was 6:20 a.m. when Lion Air 610 departed the runway. The nose gear had barely left the ground when Suneja’s control column began shaking, the cue for a potential stall. Two alerts signaling bad altitude and airspeed readings blinked on. Flight data recorders don’t pick up the expressions on pilots’ faces, or the stab in their spines, when they sense their docile machine might kill them. Harvino, the copilot, immediately asked the captain if he planned to turn around. Suneja suggested they get clearance to a holding point to buy some time. “Flight control problem,” Harvino radioed. As Suneja steered toward the new heading, the nose mysteriously dipped. He squeezed a switch on the control column under his thumb to push it back up. The nose lifted, but then it dipped again. For eight minutes, the tug-of-war continued. The blue expanse of Jakarta Bay filled the windows.

Harvino flipped through Boeing’s Quick Reference Handbook, searching through pages of emergency checklists for an answer. Air Speed Unreliable. Duct Bleed. Pack Trip Off. Wing-Body Overheat. Nothing seemed to explain the ghost fighting them for control of the plane. Twenty-one times Suneja pressed the switch to keep the nose pointing up. The plane was cleared for twenty-seven thousand feet but had reached less than six thousand, the fishing boats in the sea below like toys in a tub. The passengers felt every sickening undulation in their stomachs. Suneja finally got on the phone to ask a flight attendant to come into the cockpit. “Yes, sir,” she answered, replacing the phone with a ca-chunk (audible on the cockpit voice recorder) and opening the door. He asked her to send in a Lion Air engineer who happened to be aboard to help them figure out the problem. The chimes of the intercom sounded as she called him forward.

Suneja, preparing to brief his colleague and probably wanting a look at the handbook himself, told his copilot to take over the controls. The nose dipped again. “Wah, it’s very…” Harvino muttered. He flicked the thumb switch, but not as firmly as the captain had. After a few seconds the nose fell again, and again he hit the switch. The jet tilted toward the water. Harvino exclaimed that the plane was pointing down. Suneja, distracted, answered, “It’s okay.” Ten seconds later they were plummeting at ten thousand feet a minute. Harvino pulled desperately on the control column, alarms blaring (“Sink rate, sink rate!”). The water was now immense and terrifying as the glare of early-morning light streamed into the cockpit. The copilot began repeating “Allahu Akbar, Allahu Akbar”—the Muslim expression of faith meaning “God is greater”—and a harsh robotic voice intoned, “Terrain, terrain.” Suneja was silent.
At 6:32  a.m., the ghost won. Horrified fishermen on a nearby boat watched as the jet, carrying 189 people, hit the sea at a nearly vertical angle at five hundred miles per hour. Television stations soon began broadcasting images of floating debris and interviewing the victims’ stunned relatives. “I’m sure Dad could swim his way out,” said Nanda Ayorbaba, the thirteen-year-old daughter of the man who only hours before had sent the choppy video.

The crash triggered the well-worn machinery of accident investigations, dominated for decades by Boeing and American regulators. The National Transportation Safety Board and the venerable plane maker both dispatched teams to Jakarta, and at the FAA office near Seattle, a modernist edifice surrounded by embankments on all sides to deter car bombers, staffers began dissecting what went wrong. They called in Boeing engineers, who explained about automated software known as the Maneuvering Characteristics Augmentation System, or MCAS (“em-kass,” as it was pronounced). Only a few people at the FAA had even heard of it. “What’s MCAS?” asked one agency official.

It was immediately clear that the software was far more powerful than Boeing had suggested in documents submitted to win the plane’s approval. The engineers had drastically underestimated the software’s ability to move the horizontal stabilizer, the small wing on the plane’s tail. What’s more, it had fired because of bad data from the single misaligned sensor—a  flaw Boeing’s vaunted processes were supposed to find and root out long before the plane was in flight with commercial passengers.
At this point, in November 2018, the story went in two directions. There was a public narrative, the one advanced by Boeing chief executive officer Dennis Muilenburg, his top engineers, and FAA officials to convince airline pilots and passengers—and maybe even themselves—that the plane was safe. The problem (as they all but said) was one badly run airline from Indonesia. They insisted that an updated checklist was all it would take for any competent pilot to manage the unlikely scenario that brought down the Lion Air plane.

And then there was the private narrative. Behind the scenes, some of the largest and most respected airlines in the world were screaming that Boeing had hidden the existence of potentially deadly software inside their planes. Pilots for American Airlines in Texas were so distrustful that they recorded a tense meeting with Boeing executives. Whistleblowers got the attention of federal investigators, who opened a criminal probe into the plane’s design. A Boeing manager asked pilots to come up with a list of airlines who might still struggle with the new checklist. Technical experts at the FAA privately questioned the assurances that Boeing and their own bosses were providing to the public.

Finally, the stories collided. On March 10, 2019, less than five months after the Lion Air crash, another MAX  8, this one operated by Ethiopian Airlines, took off from Addis Ababa. The 157 people aboard represented thirty-five nationalities. Twenty-one passengers were United Nations staffers, many of them heading to an environmental conference. Seven worked for the Rome-based World Food Program. Four were from Catholic Relief Services. There was a Nigerian-born author of satirical essays, a Georgetown University law student, brothers from California having an adventure together, and two interpreters for the African Union. Six minutes after takeoff, they were all dead. The software—despite the confident statements from Boeing and the FAA—had again taken control of a plane even as the pilots struggled in vain to follow the new checklist.

The deaths of 346 people on a brand-new aircraft within five months badly shook the widely shared assumption of safety in air travel. There was the chilling fact that software had overridden humans. Then, too, it became clear that the FAA had abdicated much of its oversight to Boeing itself. Most disturbing was what the crashes revealed about the rotted culture of an iconic American company, as the plane’s grounding stretched to almost two years, cost more than $20  billion, and finally forced the departure of Muilenburg. Once ruled by engineers who thumbed their noses at Wall Street, Boeing had reinvented itself into one of the most shareholder-friendly creatures of the market. It celebrated managers for cost cutting, co-opted regulators with heaps of money, and pressured suppliers with Walmart-style tactics.