♪ ♪ >> On the morning of October 29th, I was woken up by a colleague who alerted me that a Lion aircraft crashed.

He said, "It's 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.

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.

But then, at 5,000 feet, the plane was fluctuating up and down.

And then the plane just started diving.

It just didn't make sense.

You don't 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 fastest-selling jet in Boeing history-- just introduced the year before.

>> We don't 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 it's recording airspeed, altitude.

>> NARRATOR: The data showed what appeared to be a glitch-- something repeatedly moving part of the plane's tail, controlling its pitch.

>> It didn't take long, just a couple of minutes, to see that there was rapid movement of the horizontal stabilizer.

It's 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 and the 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 receiving 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.

But they 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 the 737 MAX 8 jets can malfunction.

>> Boeing are calling this a formal advisory and it's been issued to the pilots.

>> The reporting showed Boeing knew that it was risky, but their response was to blame the pilots.

>> Pilots did not hit two cut- off switches.

Boeing says that action was part of well-established 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.

>> A new 737 MAX 8 jetliner crashed minutes after taking off.

>> NARRATOR: Two crashes, the same plane: 346 people killed, an iconic American company's reputation in tatters.

The story of 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.

>> It's the second disaster within five months involving the Boeing 737 MAX.

>> That's 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 daughter's body home.

>> Now, you're in close proximity, you're able to see the fine details, you're able to maybe think, these are personal effects belonged to Carol, my sister, or my mom.

Um... uh...

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 don't really...

I can't 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 going wrong with Boeing's 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 get-go that Boeing was in full crisis mode.

>> As the facts from the accident become available, and we understand the necessary next steps, we're 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 it's 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.

>> The 2011 Paris Air Show officially opened Monday.

>> Boeing and Airbus had been going head-to-head for at least a decade.

But Airbus had been quickly catching up and really nipping at Boeing's heels.

>> It's the best air show ever for Airbus in terms of aircraft numbers sold.

>> In 2010, Airbus introduced the A320neo, a more fuel efficient version of its stalwart A320.

>> The A320 is the direct competitor to the Boeing 737.

Airlines wanted an airplane that was more fuel efficient than the airplanes then in service.

Airbus chose to re-engine the A320 into what they call the Neo, the new engine option.

>> It's a record 200 orders for its A320neo.

>> It was one of the fastest-selling programs of aviation history.

>> And it placed enormous pressure on Boeing to respond.

>> About 40% of the profits for the entire Boeing Company came from the 737.

>> The 737 was the best-selling commercial airplane of all time.

>> The 10,000th 737 aircraft is going to roll off the assembly line today.

>> More than 10,000 of these airplanes have been used by hundreds of airlines all over the globe.

>> The official 737 christening ceremony took place in the new final assembly building... >> What always amazed me is that the 737 was first introduced when the Beatles were still together.

>> Right.

>> January 17, 1967.

Flight attendants christened the first Boeing 737 by smashing champagne bottles over the wings.

♪ ♪ >> It was designed to be very low to the ground.

Now by the 1980s, Boeing had to upgrade the 737, and they created what was called 737 Classic, which had a new engine on it.

>> First brand new 737-500... >> In the 1990s you had the 737 Next Generation, which had a new wing on it and some fuselage stretches.

>> And so here we are in 2011 with the Paris Airshow with the A320neo and Boeing frankly was caught flat-footed.

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.

It's a courtesy call at this point.

Just letting their longtime supplier of airplanes know they're 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 re-engine 737 which later became branded as the MAX.

>> From the very beginning, from its birth, it was marked by competitive pressure.

♪ ♪ >> You need to understand what was going on with Boeing at the time that the MAX program was launched.

Boeing was billions of dollars over-budget on its 787 program, on its 747-8 program.

Airlines were thoroughly ticked off at Boeing over the delays.

And Boeing was looking at the MAX to restore its own credibility.

♪ ♪ >> NARRATOR: Within days of the second 737 MAX crash, another investigation was underway in Washington, 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 the first time he is speaking publicly 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 Boeing.

♪ ♪ >> NARRATOR: Boeing publicly said the MAX went through a deliberate six-year development process.

But in their first stories, the "New York Times" reporters found insiders 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 in limiting changes.

>> This program was a much more intense pressure cooker than I'd ever been in.

The company was trying to avoid costs.

Minimum change to simplify the training differences, and get it done quickly.

>> That 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 decision-making that was somewhat arbitrary and didn't involve as much of the, what engineering considers healthy, um, 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 there's that incentive.

That's 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 fuel-efficient 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 50-year-old 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 didn't even have a plane built yet, so this wasn't, 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 MCAS' development and final configuration.

But Boeing has a complex and close relationship with the agency that oversees it.

>> The airplanes are part of the story, 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: It's a decades-old arrangement known as "delegation" that allows federal agencies to give oversight powers to the companies 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.

There was one key person inside the F.A.A.

: Ali Bahrami.

>> I'm Ali Bahrami, my job at the F.A.A.

is to lead and manage aviation safety organization.

>> NARRATOR: In the midst of a long career at the F.A.A., Ali Bahrami had left to spend four years as a lobbyist for the Aerospace Industries Association.

>> While he's in that lobbying role, he says, "We urge the F.A.A..." >> We urge the F.A.A.

to allow greater use of delegation not only to take full advantage of industry expertise but to increase the collaboration that improves aviation safety.

>> So here's the guy who would ultimately lead the F.A.A.

's safety operation, encouraging the F.A.A.

to let industry do as much of its certification work as possible.

♪ ♪ >> NARRATOR: Neither Ali Bahrami nor the F.A.A.

would agree to an interview, but former F.A.A.

administrator Michael Huerta spoke to us about delegation and the relationship between the agency and Boeing.

>> There are those that believe it is the fox guarding the henhouse.

Here is why it's not.

The company has an organization whose responsibility is to ensure that it is in compliance with the standards that are set by the F.A.A.

and it has a level of independence from the entities that they're overseeing.

What that gets back at is the issue of trust, and transparency, because the whole regulatory framework, and the whole delegation process is premised upon a notion that everyone is going to share their knowledge and their expertise with one another.

>> 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 that's what happened in this case.

It handed it over.

♪ ♪ >> NARRATOR: In a statement, the F.A.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.

Congress has ordered the agency to revise the delegation process.

♪ ♪ After years of going through design and development, the 737 MAX prototype was rolled out of Boeing's Renton factory for its maiden flight.

>> Look at all the excited faces, they wouldn't miss it.

>> Ed Wilson is in the cockpit, he's the new chief pilot, and he takes off.

>> And let's just take a listen as this airplane gets ready for its very first takeoff.

(cheers and applause) >> A short time after this first maiden flight, Ed Wilson, he and his co-pilots start to realize that the 737 MAX is not handling as smoothly as it should in certain low-speed situations.

It's shortly after takeoff.

You know, it's still kind of climbing to ascent.

It's 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 high-speed maneuvers, and so theoretically, MCAS could also be used in these other situations to also smooth out the handling.

Crucially, it's already been created.

It's already been approved.

And it's something that we could just apply, you know, to a different phase of flight.

It's 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 system is designed for low-speed 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.

It's happening in an automated fashion and a repeated fashion.

This fundamentally changes MCAS.

It makes it much more aggressive, much more risky.

It's a far more dangerous system.

♪ ♪ >> NARRATOR: Boeing was doubling down on the system, expanding it, despite the earlier catastrophic result in a simulator test.

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.

He came up through the Air Force Academy.

He flew for Alaska Airlines.

And he became the chief technical pilot for the 737.

He had played a definitive role in making sure that there was minimal pilot training on the MAX.

>> Boeing released to our committee instant messages and emails from Mark Forkner and some of his colleagues.

In one of these emails that Mark Forkner sent out, he says, "I want to stress the importance of holding firm that there will not be any type of simulator training required to transition to MAX."

And he said, "Boeing will not allow that to happen."

>> He was this key liaison between the company and the F.A.A.

>> He was the person who personally emailed the F.A.A.

asking for MCAS to be removed from the pilot manual.

That was an important piece of this because we understood that the F.A.A.

really didn't know that MCAS became more powerful.

>> He was speaking, absolutely, on behalf of the company-- this was not some low level employee.

And he was asking for something that was really quite substantial: that a new piece of software that made the plane behave in ways that it previously hadn't, be concealed from the pilots.

This is where the commercial pressures from the executive level come right down to the development of the airplane.

♪ ♪ >> Mark Forkner certainly was not a lone actor in what he did.

He was following through on a policy by Boeing to ensure that the program did not have to put pilots in a flight simulator.

>> It got to the point where Mark Forkner got an award for keeping training on the 737 MAX to a minimum.

>> NARRATOR: Nearly eight months after requesting that MCAS be removed from pilot training manuals, Forkner texted a colleague with a shocking realization.

>> This appears to be the moment where Mark Forkner learns that MCAS has been expanded.

He writes in that message, "I basically lied to the regulators, unknowingly."

>> But he never went back and corrected the record.

He never went back and fixed the error.

>> NARRATOR: Mark Forkner wouldn't speak to us but his lawyer told the "Times" reporters that his communications with the F.A.A.

were honest and that "he would never jeopardize the safety of other pilots or their passengers."

♪ ♪ When Boeing engineers expanded the MCAS system, they included a feature that would make it particularly dangerous.

>> Planes have millions of parts in them.

And there's one little one on the 737 that sticks out of the fuselage.

>> See that little black circle there, that is called... >> The angle of attack sensor.

>> NARRATOR: On the 737 MAX, it had the power to trigger MCAS.

>> It's the A.O.A.

sensor that is one of the crucial parameters to the computer to tell the plane that it's in a perilous condition.

>> The angle of attack sensor would activate MCAS by telling the system that the plane's nose was too high and then MCAS would try to push the nose down.

>> But if this sensor is broken, for whatever reason, MCAS never realizes and so it keeps pushing the nose of the plane down over and over again.

>> NARRATOR: Congressional investigators would later find documents showing that Boeing engineers had raised this very concern.

>> An engineer asked, "What if we have a faulty A.O.A.

sensor," because A.O.A.

sensors are known to be faulty.

You know, what happens to the airplane?

So you have those concerns raised and the response is again from Boeing engineers was to essentially dismiss those.

♪ ♪ >> Three, two, one!

>> NARRATOR: Boeing began delivering the new 737 MAX in mid-2017.

>> At the outset, 737 MAX was arguably one of Boeing's biggest successes.

It had become its best-selling jet ever.

>> NARRATOR: Advanced sales were estimated at $370 billion.

American had orders for 100.

Southwest Airlines for 200.

Boeing had focused especially hard on selling to developing markets in Asia, where Lion Air's parent company became the first customer to fly the 737 MAX, signing an agreement worth more than $20 billion.

>> Airlines loved it.

There was a years-long waiting list to get one.

>> But Boeing's signature new jet had a fatal flaw.

♪ ♪ >> Breaking news.

The search for wreckage is underway after a passenger jet with 189 people on board crashed.

>> A Lion Air Boeing 737... >> A nearly brand-new 737 MAX... >> NARRATOR: Investigators from the U.S. National Transportation Safety Board contributed to an analysis of what led to the Lion Air crash.

>> Leading up to the Lion Air accident, the angle of attack probe itself was miscalibrated.

The maintenance crew was not able to properly identify this miscalibration.

>> The angle of attack sensor sent bad data to MCAS.

>> The plane thought it was in a stall because of bad information.

>> And as a consequence of this angle of attack data error, the MCAS activated when it really shouldn't have.

♪ ♪ >> Five months later, almost the exact same thing happens halfway across the world.

>> New 737 MAX-8 jetliner crashed today.

>> Investigators say that flight had similar problems to the Lion Air crash.

>> Once again the angle of attack sensor is malfunctioning.

>> There is this question now about systems within the aircraft.

>> If MCAS hadn't been on those planes, those planes wouldn't have crashed.

It's that simple.

>> The world mourns 157 people killed in the Sunday crash.

♪ ♪ >> On the flight of 737 MAX crash, we... we lost five of our family members.

We had our mom, Ann Karanja, our dear sister, Caroline Karanja.

Her three kids, Ryan Njoroge, Kelli Wanjiku, and Rubi Wangui.

♪ ♪ It's not like there is a manual of how you need to react, you're just there, it's like motionless.

You just feel infuriated by anyone and everyone at that point.

I remember the Boeing Company blaming what they call the foreign pilots and deflecting blame to... to them, saying they are the cause.

♪ ♪ >> All of us at Boeing are deeply sorry for the loss of life in the Ethiopian Airlines Flight 302 and Lion Air Flight 610 accidents.

>> NARRATOR: Boeing C.E.O.

Dennis Muilenburg latched onto findings that inexperience and lack of training were part of a chain of events that led to the crashes.

It was a controversial position.

>> Understand that these airplanes are flown in the hands of pilots and in some cases our system safety analysis includes not only the engineering design but also the actions that pilots would take as part of a failure scenario.

>> Boeing's contention from the beginning was that even though the pilots did not know that MCAS existed, that they did not need to know that.

>> And in some cases, those procedures were not completely followed.

>> Boeing believed that the pilot should have been able to realize that it was very similar to a runaway stabilizer situation.

>> NARRATOR: Runaway stabilizer is an aviation term for a malfunctioning stabilizer.

After the Lion Air crash, Boeing had issued a directive to pilots to be aware of this possibility, and told them what to do if it happened.

>> When that part of the tail was not acting the way that it should be, you take manual control of it.

>> The pilots could have stopped their rollercoaster ride by turning these two switches off.

>> To shut off power to the stabilizer, you stop it from moving on its own.

And then you start cranking a wheel in the cockpit that literally will manually move the stabilizer back to where you want it to move.

>> The issue was, were there things happening inside the cockpit that might have made that harder to do.

That's what we were asking.

♪ ♪ >> When we finally got the preliminary black box data from the Ethiopian crash, we called up Dennis Tajer, an American Airlines 737 pilot, and sent him the data, and we read through it together.

>> My mission was to provide them, I'm in the cockpit, I see what's happening now.

So we walk through each line and I had no idea what was in it.

I knew that the crew had an experienced captain and a lesser experienced first officer.

>> We go, second by second, through these few minutes of this flight.

>> Going through the steps that the pilots had taken and saying, "Yup, I would have done that.

Yup, I would have done that."

>> And as soon as they lift off the ground, all these different alerts started popping up.

The airspeed was unreliable, the altitude was showing unreliable, there were alerts related to that, but they bring the gear up and they continue to climb out.

>> NARRATOR: Two minutes into the flight, based on faulty data from the A.O.A.

sensor, MCAS kicked in, and began pushing the nose down.

>> Don't sync.

>> And I have... A very clear memory of noting a time mark where the first officer is quoted as saying, "Stab trim cutout switches," which takes the weapon away from MCAS, which is what Boeing told us to do.

But I have to confess...

I probably swore, I said, "The kid got it right.

The kid got it right."

>> What had happened was the pilots did do what they were supposed to do, they had cut the electricity off.

>> Don't sync.

>> They hit these switches, and they tried to take manual control.

>> The first officer is reaching to this large wheel on his left and that's the manual trim wheel and trying to turn it.

It's like lifting up a ten-ton bucket of cement out of a deep well.

>> The problem was, at that point, the plane was going so fast that even after they took manual control, they could not physically get the plane to right itself.

They shouldn't have been going that fast.

>> Too low.

Terrain.

>> And they're continuing to accelerate towards the ground.

The ground is approaching them.

>> NARRATOR: Then, with no apparent recourse, the pilots reached for the stabilizer switches.

>> I'm yelling into the cockpit, "Don't do that!"

But I don't know what they're facing.

>> NARRATOR: MCAS was reactivated.

>> Pull up.

>> MCAS says, "Hey, I'm back on, here we go."

(imitates whirring) And now the airplane is in near full nose down trim and you can pull back forever and there's not enough metal in the back of the airplane to make that airplane come up to a nose-up.

>> Terrain.

Terrain.

Pull up.

Pull up.

(echoing): Pull up.

(birds twittering) >> She died when she was 24.

It's unbearable that she's not with us.

And the only thing I can do is try to prevent this for other people.

>> NARRATOR: About four months after the Ethiopian Airlines crash, the family of Samya Stumo was about to receive news they would find bewildering.

>> We were eating dinner and I hadn't looked at my phone for a long time.

And it was blowing up.

>> We are joined today by Ali Bahrami, the associate administrator for Aviation Safety.

>> Chairman Collins, Ranking Member... >> There were families from Kenya, from Ethiopia, from all over saying, "Who is this Ali Bahrami?"

>> We continue to evaluate Boeing's software modification to the MCAS.

>> NARRATOR: The F.A.A.

's Ali Bahrami had been called before Congress, where he was questioned about revelations the F.A.A.

had known there was a risk of another MAX crashing-- after Lion Air.

>> If the agency's own analysis found MCAS to be an unacceptable risk, why did the F.A.A.

not take immediate action to address those risks?

>> The families hadn't known that before.

They didn't know that the safety agency gambled with passenger lives.

>> We knew that eventual solution would be to have the modification.

And based on our risk assessment, we felt that this... we had sufficient time to be able to do the modification, you know, and-and get the final fix.

>> NARRATOR: After the Lion Air crash, the F.A.A.

had conducted an analysis of the likelihood of another 737 MAX crashing.

The worst-case scenario was grim.

>> They looked at the probability that there could be another crash of a 737 MAX, if the F.A.A.

didn't do anything to MCAS and just let the plane keep flying.

And what that assessment showed was that F.A.A.

predicted there could potentially be 15 more fatal accidents of 737 MAX aircraft over the lifespan of the fleet, about one crash, every other year.

>> NARRATOR: But in explaining its decision not to ground the plane, the F.A.A.

said in its statement that the actual risk at the time-- considering the number of planes in the air-- was as close to zero as their calculations allowed.

The agency had given Boeing 150 days to fix MCAS and issued official directives to pilots.

>> They were gambling, they were betting against time that they would have a fix to MCAS before the next crash happened.

And, unfortunately, they lost that bet.

>> NARRATOR: Not everyone within the F.A.A.

agreed with the agency's gamble.

>> People too quickly jumped to that conclusion, that the pilot should have been able to figure out what's going wrong and be able to intervene properly.

>> NARRATOR: F.A.A.

engineer Joe Jacobsen examined the data from the Lion Air crash, and quickly raised concerns about the safety of the MAX.

This is his first on-camera interview.

>> I was pointing out a design flaw.

It was purposely designed and certified to use only one A.O.A.

input to drive MCAS to move the horizontal stabilizer at a high rate.

I talked to three managers, said, "This a design flaw."

They were skeptical, not really buying in, saying, you know, "The pilot should have been able to intervene."

It's a failure.

Our job is aviation safety, and when airplanes go down, we feel a real personal sense of loss and remorse and failure, and it affects a lot of people.

♪ ♪ >> NARRATOR: In the fall of 2019, with the MAX having been grounded for seven months, congressional investigators released internal communications they found during their investigation.

>> Test pilots working for Boeing wrtie about problems with the MCAS system two years before the first fatal crash in Indonesia.

>> NARRATOR: They offered further evidence of the company's attempt to avoid pilot training for the MAX.

>> When we got the messages, and I remember where I was in my kitchen, because it was Mark Forkner.

>> NARRATOR: In one document, the former Boeing pilot who had written notes assuring MCAS would not be put in training manuals, joked about swaying regulators with "Jedi mind tricking."

Other documents released later even showed Forkner dismissing the idea of pilot training for Lion Air.

>> When Lion Air, the airline that ultimately flew the first plane that crashed, was asking for simulator training, he was disparaging them to his colleagues.

Calling them stupid.

>> I mean, seriously?

Did that ever cross their minds that they were going to let something go into the air that could potentially kill people?

♪ ♪ >> NARRATOR: Boeing C.E.O.

Dennis Muilenburg appeared before Congress.

>> Boeing C.E.O.

is expected to acknowledge that his company made mistakes.

>> And here's the first time this guy's in the hot seat.

>> NARRATOR: By then he'd become the face of the 737 MAX crisis.

>> I have been on this a committee a long time.

We have never undertaken an investigation of this magnitude.

We intentionally put the families close to the witness.

They're the victims here.

And it should be like a, you know, a trial in court, where you get to face the person who, you know, who committed a violent act against you.

♪ ♪ >> NARRATOR: The Committee confronted Muilenburg with an array of internal Boeing documents.

>> The next slide.

This shows that Boeing became aware that the disagree alert wasn't working.

>> It does appear from this that Boeing understood how important the crew training... >> That pilots didn't know about this is unacceptable.

>> Boeing's marketing representatives emphasized to potential customers that F.A.A.

had reduced the length of pilot training that... >> Slow reaction time scenario, ten seconds, found the failure to be catastrophic.

>> For those families, the pain of this was accentuated because this evidence that was going up on the screen was information that they felt that Mr. Muilenburg could have used to inform his decision about keeping the plane in the air-- or not.

>> We do know that Boeing engineers actually proposed placing a MCAS annunciator in the cockpit.

Are we vulnerable to a single A.O.A.

sensor failure with the MCAS?

Now, as you emphasized, flight control will now compare inputs from both A.O.A.

sensors.

And I guess the question is why wasn't it that way from day one?

>> Mr. Chairman, we've asked ourselves that same question over and over.

And if back then we knew everything that we know now, we would have made a different decision.

>> Nadia Milleron, she was radiating with anger over this.

>> It's come to the point where you're not the person anymore to solve the situation.

I want to say it to you directly, because I don't think you understand what we're saying.

>> She was right in front of him.

And here you have the C.E.O.

of what is one of the most important American companies, one of the most important companies in the world... >> In the end, it's about safety.

>> Even if you're not capable of doing that?

>> ...looking in the eyes of the mother of a young woman who died on his airplane.

>> I know that she wasn't afraid of flying at all, until the last six minutes of her life.

That's just a horrible betrayal that Boeing and the F.A.A.

caused for this person, the last moments of their life, and it kills me that that trust was betrayed.

>> Boeing is really kind of stuck in a hard spot here.

>> Dennis Muilenburg was blasted on Capitol Hill.

>> NARRATOR: Two months later, with the company's stock plummeting... >> Boeing stock has been dropping all day.

>> It's down 22% since the 737 MAX jet was first grounded back in... >> NARRATOR: ...and the MAX still grounded, Dennis Muilenburg was out.

Near the one-year anniversary of the second 737 MAX crash, New York Times reporters Natalie Kitroeff and David Gelles flew to St. Louis.

♪ ♪ By then, Boeing was recommending pilot training and retooling the MCAS software with a second A.O.A.

input as a failsafe.

They'd been invited to Boeing's offices there by the new C.E.O.

>> Welcome.

>> Thank you for having us.

>> NARRATOR: The interview was recorded.

>> Glad you're here.

>> We got a lot of questions.

>> NARRATOR: He had been on the company board of directors throughout the 737 MAX program and described himself as the company's "backup plan" to Dennis Muilenburg's handling of the crisis.

>> Boards are invested in their C.E.O.s until they're not.

We had a backup plan.

I think this board was incredibly well prepared.

I am the backup plan.

>> David Calhoun had been on the board of Boeing for several years.

He laid the blame squarely at the feet of Dennis Muilenburg.

>> NARRATOR: He was in the midst of damage control.

>> It's more than I imagined it would be, honestly.

And it speaks to the weaknesses of our leadership.

>> He was shooting straight from the hip.

It was kind of disarming to hear from the C.E.O.

of Boeing.

>> NARRATOR: He told the reporters the company had indeed made a "fatal mistake," which was assuming all pilots could counteract a misfire of MCAS.

>> We made a decision in December to recommend simulator training everywhere in the world because of the regulators and the pilots in the developing world.

Not because the U.S. airlines needed it.

They probably don't.

>> There is this narrative that some foreign pilots are not as good as American pilots.

And Boeing seemed to be suggesting as much.

We pressed Calhoun on this issue.

Do you believe that if U.S. pilots had encountered the MCAS malfunction, that Lion Air and Ethiopian 302 experienced, would they have been able to deal with it in your estimation?

>> And, um...

I'm not gonna let you write this down.

You agree you're not going to write it down?

>> No.

>> All right, forget it.

You can guess the answer.

>> That interview was essentially the last Boeing story that we did.

To this day, I think, Boeing doesn't accept full responsibility for these crashes.

There's always the implication that if the pilots had acted appropriately, those 346 people would still be alive today.

♪ ♪ >> NARRATOR: In March of 2021, families gathered in Washington, D.C., for the second anniversary of the crash of Ethiopian Airlines Flight 302.

Boeing had recently settled a criminal charge of conspiracy to defraud the United States brought by the Department of Justice.

>> We have some breaking news on Boeing.

>> NARRATOR: In the settlement, Boeing admitted to "misleading statements, half-truths and omissions" about MCAS.

It agreed to pay $2.5 billion-- $500 million to the families of the victims, and most of the rest to compensate the airlines.

The F.A.A.

has retested and approved the 737 MAX.

It is once again flying passengers around the world.

>> Go to pbs.org/frontline for more on what’s happened since the crashes of the 737 Max.

>> We had a backup plan.

I think this board was incredibly well prepared.

I am the backup plan.

>> And more reporting from our partners at The New York Times.

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Captioned by Media Access Group at WGBH access.wgbh.org >> For more on this and other "Frontline" programs, visit our website at pbs.org/frontline.

♪ ♪ Frontline's "Boeing's Fatal Flaw" is avaliable on Amazon Prime Video.