“I have nightmares about how they must have clung to their mother, crying, seeing the fright in her eyes as they sat there helplessly. And there was nothing I could do to save them.”
This heartbreaking evidence from Paul Njoroge begins the report by the US House Committee on Transportation and Infrastructure into the Boeing 737 Max — a plane whose fatally flawed design caused 346 needless deaths.
Mr Njoroge, from Toronto, lost his wife, his three young children and his mother-in-law aboard Ethiopian Airlines flight 302 from Addis Ababa to Kenya. On a bright Sunday morning, their Boeing 737 Max crashed shortly after take-off.
“The story of the Boeing 737 Max was never expected to be associated with catastrophe,” the committee says.
“It was supposed to be a story of American ingenuity and technological success — a modern, more fuel-efficient airplane that had already become the manufacturing giant’s best-selling jet in its storied history.”
In March 2017, the Federal Aviation Administration (FAA) certified the latest version of the Boeing 737 as safe to fly.
“Clearly it was not,” the report notes. Instead, a “culture of concealment” meant that within 20 months, 189 people died aboard a Lion Air flight shortly after take off from Jakarta.
Barely two years after the FAA’s sign-off, the Ethiopian jet came down. Yet in the following days, the planemaker and the US safety regulator doubled down and continued to insist the Boeing 737 Max was sound.
As the chillingly similar circumstances of the two tragedies became apparent, aviation authorities around the world started grounding the plane. Eventually, the FAA followed suit; no 737 Max has flown a paying passenger for the past 18 months.
The Boeing 737 is the most successful aircraft design in aviation history. The Max variant that first flew commercially in 2017 shared the same fuselage and wing profile as the original, which took to the skies half-a-century earlier. But rather than the slim, cigar-shaped engines of 1967, the Max has very large, efficient engines.
Had they been hung from the wings, as on previous versions, they ran the risk of scraping against the ground. So the designers of the Boeing 737 Max moved the engines further forward and blended them into each wing.
The aerodynamic consequence was identified early on in the design process: the engine housing itself generated lift and could tilt the aircraft upwards.
The designers concluded this characteristic increased the risk of a stall — when the wings do not generate sufficient lift to keep the plane flying safely. So they devised what they intended as a safety measure: proprietary software named the Manoeuvering Characteristics Augmentation System (MCAS).
This anti-stall system was designed to kick in when the angle between the wing and the airflow, known as the “angle of attack,” was deemed to be too high.
The variable is measured by a vane on the outside of the aircraft. If the system detects that the angle is getting dangerously steep, it operates an elevator in the tail to nudge the nose downwards — and does so repeatedly, even overriding the pilots’ commands.
MCAS was installed, said Boeing, “to enhance the pitch stability of the airplane — so that it feels and flies like other 737s”.
In both crashes, a single faulty sensor triggered the software system. MCAS was designed to be pilot-proof — to the point where the computer could point the plane into the ground and defeat the strength of the flight crew to overcome it.
Boeing knew about this problem, the report says. The planemaker concealed internal test data from as early as 2012 that showed one of the company’s test pilots took more than 10 seconds to diagnose and respond to uncommanded MCAS activation in a flight simulator.
Federal guidelines assume pilots will respond to this condition within four seconds. The pilot described the experience as “catastrophic”.
“This event should have focused Boeing’s attention on the need for enhanced pilot training for Max pilots,” says the report. "It didn’t.”
Instead, the planemaker assumed that pilots, who were largely unaware that the system even existed, would be able to mitigate any potential malfunction.
Boeing withheld crucial information from the FAA and its airline customers — and concealed the very existence of MCAS from 737 Max pilots.
The report notes: “There was tremendous financial pressure on Boeing and the 737 Max programme to compete with Airbus’s new A320neo aircraft”
Southwest Airlines, the most consistently loyal customer for the Boeing 737, agreed that the planemaker would pay it $1m for each aircraft if the FAA had required simulator training for pilots transitioning from older versions of the 737 to the Max.
The development team at Boeing were warned during an internal meeting: “If we emphasise MCAS is a new function there may be a greater certification and training impact”.
In December 2017, the chief technical pilot boasted of his efforts to talk airlines out of the need for simulator training, writing to a Boeing colleague: “I save this company a sick amount of $$$$.”
These cost-cutting moves were happening despite the oversight of the safety regulator.
“FAA management has undercut the authority and judgment of its own technical experts and sided with Boeing on design issues that failed to adequately address safety issues and appear to have violated FAA regulations,” the report says.
Even after the Lion Air crash, Boeing and the FAA failed to take the actions needed to avert a second crash, the committee concluded.
In December 2018 — three months before the Ethiopian Airlines crash — FAA conducted a risk assessment which concluded that without a fix to MCAS, during the lifetime of the Max fleet there could potentially be 15 additional fatal crashes resulting in over 2,900 deaths.
“Boeing and FAA share responsibility for the development and certification of an aircraft that was unsafe,” the report says.
“For two brand-new airplanes, of a brand-new derivative model, to crash within five months of each other was extraordinary given significant advances in aviation safety over the last two decades
“The Max crashes were not the result of a singular failure, technical mistake, or mismanaged event.
"They were the horrific culmination of a series of faulty technical assumptions by Boeing’s engineers, a lack of transparency on the part of Boeing’s management, and grossly insufficient oversight by the FAA — the pernicious result of regulatory capture on the part of the FAA with respect to its responsibilities to perform robust oversight of Boeing and to ensure the safety of the flying public.
"The fact that a compliant airplane suffered from two deadly crashes in less than five months is clear evidence that the current regulatory system is fundamentally flawed and needs to be repaired.
“The Boeing 737 Max is now the subject of multiple investigations and lawsuits around the world and will be forever associated with the tragic deaths of 346 people killed in two separate crashes within five months of each other, as well as one rescue diver who died attempting to recover bodies from the Lion Air crash in the Java Sea.”
Safety agencies from the UK, the EU and beyond are currently meeting at Gatwick airport to assess whether the heavily modified jet can be cleared to carry passengers again.
A statement on Boeing’s website reads: "These two tragic accidents continue to weigh heavily on everyone at Boeing.
“We have established a $100m relief fund to meet family and community needs of those affected by these accidents.”
The human cost of the failures by Boeing and the FAA is shown by the conclusion of Paul Njoroge’s evidence to the committee about his family: “I miss their laughter, their playfulness, their touch.”