Flying Blind

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.

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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.

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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.

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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.

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In shocking emails handed over to congressional investigators, a Boeing pilot boasted of using “Jedi mind tricks” to convince airlines and regulators there was no need for pilots who’d flown the previous version of the 737 (like Suneja and Harvino) to undergo expensive simulator training on the MAX. An employee despairing of foul-ups wrote, “This airplane is designed by clowns, who in turn are supervised by monkeys.” Other evidence showed that Boeing pressured pilots to skimp on testing and ignored engineers’ entreaties for sophisticated flight controls that might have prevented the tragedies. The company even turned down a request from Lion Air itself for additional training. (“Idiots,” a Boeing pilot grumbled to a colleague.)

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Barack Obama, who stood beside Lion Air’s CEO in Bali when it signed a $22 billion order for MAX planes, once said he deserved a gold watch from Boeing.

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The acquisition of McDonnell Douglas a year earlier had brought hordes of cutthroat managers, trained in the win-at-all-costs ways of defense contracting, into Boeing’s more professorial ranks in the misty Puget Sound. A federal mediator who refereed a strike by Boeing engineers two years later described the merger privately as “hunter killer assassins” meeting Boy Scouts.

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American cities for weeks on end because of escalating carbon emissions. All stem at least in part from the failed belief that corporations will police themselves and shower us in riches if they’re just left alone to do so (and are lightly taxed all the while).

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In just one example, the Agriculture Department in 2019 quietly cut the number of inspectors in pork plants by more than half. Finding defects—feces, sex organs, toenails, bladders—was mostly left to the companies themselves, much in the way that the FAA relied on Boeing’s own employees to ensure aircraft safety. “If this continues across the nation, when you open your package of meat, what you’re going to get for a pathogen is going to be a mystery,” a longtime inspector said in December 2019.

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It’s impossible to divorce these regulatory failings from the financial imperatives underlying them.

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In this business, though, change comes slowly, and so do consequences.

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In the absence of improvements, more people will find themselves waking up to the question Javier de Luis asked himself in March 2019, after learning that his sister, UN translator Graziella de Luis y Ponce, died in the crash in Ethiopia: “How unlucky do you have to be to die in an airplane accident?”

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De Luis is an aeronautical engineer and the former chief scientist of a drone company in Cambridge, Massachusetts, that was eventually sold to Boeing itself. He’s taught courses in aerospace systems design at the Massachusetts Institute of Technology. As he discovered when he dug into the data on the MAX, the answer to that question was: a lot less unlucky than he’d imagined. And a better one was: Why weren’t government overseers doing more to slow the rush to put an obviously flawed plane back in the sky? The 737 remains the only large commercial aircraft without an electronic checklist to assist its pilots, who depend on heavy binders laden with step-by-step instructions to guide them in the event of an emergency. At the same time, Boeing has fitfully squeezed in software to guide some aspects of the plane, using two redundant computers with processing power that approximates a 1990s Nintendo gaming console. (Even the space shuttle, originally developed in the 1970s, had five separate

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How did a company that prided itself on its engineering prowess, that had perfectionism in its DNA, go so wildly off course? What were the forces, and who were the actors, that contributed to the fall of a seemingly insurmountable titan? Over a century in business, Boeing had become the biggest American exporter, with annual revenues surpassing $100 billion and a manufacturing line capable of shifting the country’s balance

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The plane was the first to use a kind of electronic checklist that sharply reduced pilots’ workloads. It had computer displays known as EICAS, for “engine indicating and crew alerting system.” Older planes—like the 737—showed the status of the plane’s various mechanical systems with translucent buttons that had a comparatively primitive “yes/no” logic. When a button marked, say, low oil pressure, blinked on, it was the pilot’s cue to turn to the handbook or a memorized procedure. The EICAS, by contrast, showed the fuel level, oil temperature, and other important indicators in real time. If a fault was detected, a message popped up giving pilots more detail about how to handle it. The system prioritized the alerts by color—red for emergencies, amber for cautions.

Design ideas

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“We were looking for somebody to say, ‘Hey, this looks wrong,’ ” Morton said. “Nobody did.”

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But Wilson had little use for the trappings of corporate leadership, driving himself to work in a Chevrolet Camaro and living in the same house in a nondescript Seattle suburb that he and his wife had bought thirty years earlier. He kept bees and did crossword puzzles. Boeing had just a single small corporate jet and encouraged all but a handful of top executives to fly commercial to support its customers. A New York Times profile in September 1985 said Wilson was “putting Boeing in a class by itself.”

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down to the fact that discarded salt packets from passengers’ meal trays in the galley tended to corrode the aluminum in the belly underneath. Some people had the feeling that Condit kept his impressive colleague, only four years younger, at arm’s length from his own superiors and board members to avoid being outshone. One former executive remembers Condit once telling Mulally there was no room on the corporate jet he’d be traveling on with then CEO Shrontz, when a seat was actually available. Mulally always projected enthusiasm; when Condit was promoted to president, he leapt across the table to grab Condit’s hand and blurted, “Great choice!”

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smoke detectors, among other issues to have emerged in the 1970s and 1980s. The NTSB, somewhat degradingly, releases a “Most Wanted List” of safety improvements, to gain at least some leverage. (Among those the FAA still hasn’t addressed: a recommendation for cockpit recorders capable of recording images as well as voice, to speed accident investigations.)

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“I’m here because my only child died at Sioux City, Iowa, in 1989, when a DC-10 crashed,” he said. “One hundred eleven died, one hundred eighty-nine lived. Heather was twenty-four years old. She was a graduate of Tulane Law School, a member of the New Jersey Bar, and a captain in the U.S. Army JAG Corps, serving at Fort Collins, Colorado, at the time of her death. She was found on the tarmac.” O’Mara, balding and round-chinned, paused in his prepared speech for a moment. He said he’d been “a corporate guy” like most of them before the crash, a sales manager for the Wall Street Journal. But soon after the crash he saw the newspaper’s headline referring to “the Achilles heel” of the DC-10. He said it was the first time he’d considered that regulators might let a safety problem linger because of a cold cost-benefit analysis. “Pretty naive, wasn’t

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As he’d learned, ever since that first crash of a Turkish Air DC-10 at Orly, when the cargo door popped open and hydraulic lines under the floor snapped, regulators had known how vulnerable those lines were. In the accident that killed his daughter, a blown engine spewed fragments that severed all three lines and left United Airlines captain Al Haynes without controls to steer the jet. He lined up for an emergency landing by alternating thrust on the two working engines. But the right wingtip hit the runway first, igniting fuel, and then the plane careened over and broke into pieces. If a safety valve for the hydraulic lines had been mandated fifteen years earlier—“a $10,000 item back then,” O’Mara said—the flight controls would not have been lost. For the families of crash victims, he told the group, that knowledge was just as painful as losing them. “The first mugging is the crash,” he said. “The second mugging is discovering that their loved ones didn’t have to die.” People applauded,

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The consultant went directly into his own prepared remarks about how data should guide all of the advisory committee’s decisions—in his case the data in question was an industry-funded study showing no correlation between cabin air quality and flight attendants’ health. After the grieving father’s emotional speech, it was a jarring juxtaposition. “By focusing on performance-based outcomes rather than design end points, participants are given a greater latitude in utilizing qualitative and quantitative…

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Prest called last on the Association of Flight Attendants’ representative, Christopher Witkowski, who wasted little time addressing the elephant in the room. “It’s our belief that Congress and the American people have lost oversight of the deep workings of this major rule making committee,” he said. “It’s dominated by…

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President Bush’s choice to run the FAA would be someone deeply familiar with the backstage workings at the agency. Marion Blakey had run a public affairs consulting firm in Washington. Her biggest clients were transportation companies. She helped plan their PR campaigns, write white papers, and set up “Astroturf” organizations to give corporate messaging the…

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In her first major speech as FAA administrator, at the Aero Club in Washington in February 2003, Blakey announced what she called the “customer service initiative.” It was a breathtaking shift in emphasis. She said the FAA needed to be more responsive to its customers—by which she meant manufacturers and airlines, not the flying public. She expressed sympathy for the inconsistent answers and long waits they sometimes experienced—as if the country’s top aviation…

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out, this wasn’t the date of their historic twelve-second flight, but three days earlier, when Wilbur stalled the Flyer and crashed it into the dunes. “I want to bring to the FAA such a spirit of readjustment, for the willingness to correct, to recalibrate, is the real secret of aviation,” Blakey said. The message seemed to be that the industry should get points for trying. Then she all but encouraged corporate managers to second-guess the agency’s decisions and tattle on inspectors who tried to hold them up. “We’re going to let them know that they have the right to ask for review on any inspector’s decision on any call that’s made in the certification process—that they can ‘buck it up’ to first-line supervisors, field office managers, regional division managers, or even to Washington…

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Just like its much-hailed predecessors, the MAX involved thousands of people spread across offices at Boeing and suppliers around the world, making tens of thousands of individual decisions. Boeing had computer software called DOORS that was supposed to keep everyone around the world updated instantly on the status of each change. It was like an Excel spreadsheet on steroids, with cells that turned red and also sent an update to the finance staff when critical project milestones were breached.

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(director of program management best practices and program management functional excellence), declared the plans “the best I’ve seen.”

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practice, people tended to communicate the way they do in offices everywhere—with emails, instant messages, and phone calls. Whoever yelled loudest got what they wanted, said one person who worked directly with the engineers who coded the MAX software. When it came to fulfilling the FAA’s requirements, he said, the regulator was just one more constituency to satisfy. And not a particularly forceful one. In dealing with the agency’s specialists, Boeing’s engineers came up with what was called “the drawer full of paper” technique. “If you can just inundate them with information it makes them go away,” he said.

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FAA records showed more than two hundred instances of malfunctioning AoA vanes alone since 2004, some of which had set off cockpit alerts. Ewbank and the others urged implementation of a backup system called “synthetic airspeed” already in use on the Dreamliner—essentially a computer program to compare values of all the sensors. If an illogical reading came from any of them—such as the AoA vanes linked to the new MCAS software—it would be deactivated. In rejecting the safety enhancement, managers twice cited concerns about the

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“People have to die before Boeing will change things,” Ewbank was told by his manager. When Ewbank and the others raised the idea a third time in a meeting with the MAX’s chief engineer, Michael Teal, he cited the same objections as he killed the proposal. Keith Leverkuhn, Teal’s boss and the MAX program manager, later said he never even heard about the idea.

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Many of those who departed were experts in human factors, trained to spot flaws in how people interact with the machine that engineers might miss. (As a joke in the field goes, “Dogs have fleas, and engineers have human factors.”) One person who left was a PhD—“the kind of talent you can’t afford to lose,” Ludtke said. “They were targeting the highly paid, highly experienced engineers.” It was the

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“the Lazy B” for its technocratic culture of second-guessing. Now the jokes were about keeping up with Muilenburg’s energy. In St. Louis, he’d end meetings in a ground-floor conference room by inviting people to walk or run eight flights back upstairs with him. An avid cyclist, he led pelotons of employees during site visits and boasted of getting in more than one hundred miles a week. People called him “a machine,” one that seemed fueled by the half dozen cans of Diet Mountain Dew he chugged in the course of a day.

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creating immense pressure to drive down costs. “How long do you want to keep polishing that apple?” was a phrase the Boeing managers sometimes used with engineers who wanted to keep testing. The message: the product is fine, let’s keep things moving. In 2016, Boeing started asking for specific time and cost reductions as part of managers’ performance evaluations, and by 2018, Dickson said, his superiors warned “very directly and [in] threatening ways” that pay was at risk if the targets weren’t met. “It was engineering that would have to bend,” he

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What’s worse, it appeared to Dickson that the FAA was complicit in the effort. Increasingly, he said, airplanes came with an “IOU,” as managers at both the FAA and Boeing agreed to table disagreements about technical issues in order to avoid delays. “That culture is new, and that culture is toxic,” he said. “It’s putting profits ahead of real compliance.”

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August 2018, Muilenburg and Jennifer Lowe, a vice president in Boeing Government Operations who had helped plan the ceremony for Reagan’s funeral in a previous job as a Republican congressional staffer, were at Trump National Golf Club in Bedminster, New Jersey. They had the prime seats next to Trump and his wife, Melania, at a dinner for business leaders. “We’re going to build a record number of airplanes this year thanks to the policies of this administration,” Muilenburg said. Trump cut in, “Boeing is doing very well. I think Boeing has to like me a lot. Right? You’re doing very well. Yeah, I think everybody, frankly, in this room likes me. We’ll keep it that way.”

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On October 22, Boeing collected the Robert W. Campbell Award for leadership in safety from the National Safety Council, then led by the former NTSB chairwoman who had investigated the Dreamliner battery fires. On October 24, just days before a single fateful vane on an Indonesian plane would malfunction and go undetected, Boeing reported that third-quarter free cash flow jumped 37 percent to $4.1 billion, more than double analyst estimates, sparking a 3 percent jump in its share price. “The cash is the cash, you can’t deny it,” said Ken Herbert, an analyst with Canaccord Genuity.

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experts to discuss what had gone wrong. The shocking accident involving a nearly new plane had sent the company’s shares down 7 percent that Monday. It wasn’t a long discussion, as Hamilton described it later to congressional investigators. “We quickly identified that this MCAS activation could have been a scenario,” he said. “And, once the flight data recorder came up later in the week…we started working on a software change immediately.”

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The Boeing deputy who’d vetted the software design had categorized the risk of a failure as relatively minor. But the documents on file reflected the software’s earlier design (Revision C), not the more powerful version later added in flight tests (Revision E). They showed the stabilizer had the capacity to adjust a plane’s ascent or descent by only 0.6 degrees—in its final form, it had been given the authority to make adjustments at four times that angle. “When they changed the design it drastically changed the potential criticality of the MCAS feature,” one FAA specialist said. “And that was not communicated

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Boeing’s Safety Review Board, a formal gathering of engineers and pilots to go over recent safety incidents, discussed the Lion Air crash in early November. Among themselves, they had quickly acknowledged some of the software’s flaws. Their expectation that a pilot could safely untangle the chaos of confusing alerts and intervene to turn off the stabilizer had been challenged.

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an omertà in aviation accidents, and it applied here. Partly this is for self-protection: if someone writes openly about a flaw, it exposes the manufacturer to additional liability for having known about the issues in advance. In the wrangling over the Boeing rudder design blamed for two crashes back in the 1990s, litigation had eventually turned up a memo titled “We Have a Problem,” in which engineers acknowledged—even before a second

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There was another reason for the reluctance to push back against Boeing’s stated assumptions—one that involved race, not cost. The empathy that Boeing’s aviators might have had for a pilot who looked like them wasn’t being extended to Suneja and Harvino. Conversations at Boeing kept focusing on how Harvino, once he took over the controls, hadn’t been able to trim the plane with the thumb switch. Boeing’s pilots, predominantly older white men, had long had private jokes about the incompetent crews they ran into overseas. “Too dumb to spell 737,” went a frequent refrain of one pilot. Another trainer would ask rhetorically if “Chung Fo Ho” could handle a certain procedure.

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emergency situations (itself adapted from the even thicker Flight Crew Operations Manual, running more than a thousand pages). Pilots have to analyze the many varieties of mechanical ailments the way a doctor might parse physical ones. A half dozen separate procedures, for instance, cover anomalies involving the flaps, each of which presents slightly differently in flight.

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It was especially rare to have to deal with conditions so jarring in the midst of a takeoff or a landing, the most critical moments of any flight. Boeing had reports of the stick shaker activating at or shortly after takeoff only thirty times between 2001 and 2018, during which hundreds of millions of flights had taken place. Of those instances, twenty-seven were on 737s.

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Pilots that November began registering their concerns in the anonymous Aviation Safety Reporting System maintained by NASA. “I think it is unconscionable that a manufacturer, the FAA, and the airlines would have pilots flying an airplane without adequately training, or even providing available resources and sufficient documentation to understand the highly complex systems that differentiate this aircraft from prior models,” one wrote. “The fact that this airplane requires such jury rigging to fly is a red flag. Now we know the systems employed are error prone—even if the pilots aren’t sure what those systems are, what redundancies are in place, and failure modes. I am left to wonder: what else don’t I know?” Another captain called the MAX flight manual “inadequate and almost criminally insufficient.”

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attached the story in an email to Muilenburg and said crisply, “I am sure you have already read…and will brief the board.” Muilenburg had conversations with both Ken Duberstein, the former Reagan chief of staff who’d been the longtime lead director after coming over from the McDonnell Douglas board, and Dave Calhoun, who had only recently transitioned into the lead role, according to records unearthed in

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She asked what happened, and he essentially blamed the pilots. The airplane “has the ability to handle” a bad sensor like the one suspected in the Indonesian crash, he said. Boeing, he stressed, had already issued a bulletin pointing pilots to “existing flight procedures.” Over footage of rescue boats picking wreckage out of the water, Bartiromo asked him if he regretted not telling pilots more about the system. “No, again, we provide all the information that’s needed to safely fly our airplanes,” he answered, hewing to the script again. Bartiromo pressed: But was that information available to the pilots? “Yeah, that’s part of the training manual, it’s an existing procedure,” he said. “Oh, I see,” she said, apparently mollified. MCAS, of course, wasn’t in the manual—not unless you counted the glossary, which defined the term but didn’t explain

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Air matter,” that he would send a formal update to the board. “Press is terrible,” Duberstein replied, taking a staccato, man-of-the-world tone. “Very tough. Lots of negative chatter I’m picking up. Not pleasant.” Muilenburg told him the FAA had put out a “helpful” statement clarifying it wasn’t doing a probe of its own, and that Tim Keating, who ran Government Operations in Washington, was “engaged on [the] political side too.” The pilot unions, he told Duberstein, just wanted to

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stir up doubt so that the MAX might be classified as a new airplane type requiring “more pay” to fly. “On it, and working all angles,” Muilenburg concluded. His intentions were the opposite, but the email, in six crisp sentences, crystallized the captured regulators, the outsized political influence, and anti-union rhetoric that had made Boeing blind to its own faults.

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One stunning instance came in April, when Boeing acknowledged that some of its managers had known for a year before the first crash that the aoa disagree warning, alerting crews to a bad angle-of-attack vane, wouldn’t work for most airlines, who had acquired models that didn’t include the corresponding indicator. Boeing’s concession pointedly excluded “senior company leadership” (like Muilenburg and Luttig) from the group in the know.

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One asked if he’d resign; another began pressing him to explain why he hadn’t disclosed more about MCAS earlier. Dominic Gates, the Seattle Times beat reporter who would win a Pulitzer Prize for his reporting that year on Boeing, asked in his cutting Irish accent why Boeing couldn’t just admit it had made a mistake. “Never mind the processes,” he said. “What you came up with was flawed, was it not?” Muilenburg again couldn’t muster an answer that sounded human or reflective. “We followed exactly the steps in our design and certification processes that consistently

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produce safe airplanes,” he said. A Boeing representative cut the press conference short after fifteen minutes. Another reporter called out: “Three hundred and forty-six people died, can you answer a few questions here about that?” Muilenburg walked offstage, jaw clenched.

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So much cash had been shoveled back to shareholders—not to mention Boeing’s board members and executives—that there was little left when MAX deliveries stopped and revenue dried up. Under Greg Smith, the chief financial officer, Boeing had even started pulling GE-like financial maneuvers to beat Wall Street’s quarterly targets for cash, agreeing with some customers to pull forward anticipated payments for future deliveries in exchange for later concessions. By one analyst’s measure, these “Houdini moments” had accelerated as much as $1.5 billion of payments in a single year.

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Of course, the plane maker still had plenty of allies in Congress, and its almost fraternal relationship with the FAA held strong. At a hearing in May, Republican lawmakers led by Sam Graves, a representative from Missouri, suggested that it was foreign pilots rather than Boeing who were most to blame for the crashes. “You have to know how to fly the plane!” said Graves, a private pilot himself. He added that the Ethiopian pilots “were simply going too fast” and followed “no operating procedure that I know of or have ever heard of.”

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“Absolutely,” Elwell replied to Graves’s criticisms of the pilots, saying he planned to “take a hard look at the training standards globally.” The Republican congressman defended Boeing much as other lawmakers had after the Dreamliner fires, suggesting it would be a mistake to change anything about the way the FAA regulated Boeing. His rationale added a barely concealed nationalism. “It just bothers me that here we are, we just—we continue to tear down our system based

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Michael and Nadia had met Paul Njoroge, the father from Toronto who lost his entire family, through a WhatsApp chat thread the families started within days of the crash. They’d learned about it in Addis Ababa’s Ethiopian Skylight Hotel, where the mourning relatives had gathered, sobbing on the lobby’s purple couches. Veering between moments of bottomless despair and intense focus, Njoroge had been obsessively reading about Boeing—news stories, press releases, annual reports, quarterly financial statements. Consuming information was part of his job as an investment

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Once he’d finished his investigation, the issues seemed so clear: The dangerous flaw revealed by the Lion Air crash. The pattern of rewarding shareholders and top executives while skimping on investments. The neutering of the FAA. It sent him into an even deeper depression, certain that he could have saved his family if only he had paid better attention. Representative Sam Graves’s remarks at the May hearing, laying blame on the pilots, further disgusted him. “I felt that the reason why my family died was because when the first crash happened in October of 2018 it happened in Indonesia and not in the U.S. or Canada or the U.K., where lives matter more than in other places,”

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Paul began accompanying Michael, Nadia, and other relatives of victims on visits to congresspeople, walking the cold marble floors in the Cannon House Office Building or the Dirksen Senate Office Building amid the throngs of purposeful young staffers and lobbyists. Sometimes they only saw aides, but in many cases the members of Congress themselves sat and talked with them. They made it to fifty offices, Nadia eventually bowing out because the conversations brought such pain.

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At the Transportation Department, another of their stops, Elaine Chao and her staff were in tears, too; they had to send out for more Kleenex. The FAA appointed its first-ever family liaison to handle their requests for meetings and information, a manager named Michael O’Donnell. “They’re not used to dealing with the very people they’re supposed to protect,” Stumo said.

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To Tarek, the FAA managers were a crowd of dim bulbs, mindlessly repeating what Boeing had told them and promoting half-baked methods of statistical analysis, like the spreadsheet meant to calculate the risk of keeping the MAX flying. He couldn’t believe the FAA had treated a very rough estimate—the guess that one out of one hundred pilots would struggle with the new checklist—as if it were a definitive, observed rate. When he raised his concerns in emails to FAA officials, the conversations went nowhere. “They say ‘data-driven,’ but they have no clue what it means,” he said. “These are people who talk about science as though it’s some type of magic power you sprinkle on things.” As he tried to understand what went wrong at Boeing, he kept thinking about an engineering colleague of his father’s. The man’s pregnant wife had complained when her belly kept hitting the steering wheel. He cut the wheel

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AoA sensors instead of one. In any cases of disagreement, it would shut down. De Luis listened in disbelief. Even the space shuttle, developed in the 1970s, had five redundant computers. Airbus planes typically used three sensors. The solution also seemed shockingly clunky: If the software was necessary to keep the plane’s nose from pitching up in certain situations, what would happen in a flight that encountered one of those rare situations and didn’t have MCAS available? “If a student came in with this design, I wouldn’t pass him,” de Luis told them. With officials still privately signaling the plane’s imminent reapproval, testing of various scenarios continued at the Systems Integration Laboratory near Boeing Field that summer. The FAA was running through all of the contingencies that hadn’t been considered in the first version of the MCAS software. They wanted to see, for instance, how the pilots would react to the rare possibility that the plane’s microprocessor

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maneuver he’d done probably hundreds of times over the years in the FAA’s repetitive tests of various scenarios. Despite the coaching from Boeing, however, the airline veteran needed sixteen seconds. He was dead. It was pure chance, and evidence of Tarek Milleron’s point about the ridiculously small sample sizes and gut instincts ruling the FAA’s supposedly rigorous decision making. But it made all the difference.

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Paul Njoroge appeared before the U.S. House Transportation and Infrastructure Committee on July 17, 2019, his eyes haunted, methodically turning the pages of a statement recounting the pain of a man who’d lost everything. Except his voice. Though it cracked when he talked about knowing that “my family’s flesh is there in Ethiopia mixed with the soil, jet fumes, and pieces of the aircraft,” it was clear and strong when he asked for a thorough investigation of the crashes. Congress,

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he said, should return the FAA to the system of oversight that had existed before the manufacturers co-opted it. He asked for criminal prosecution of Boeing and its executives, who, he pointed out, “have been the primary beneficiaries of this strategy to extract wealth from this storied company.”

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Minutes before the testimony began, Boeing had announced that the lawyer Ken Feinberg would handle distributing $50 million it had allocated for “near-term financial assistance to families.” Famous for managing the payments to September 11 victims, Feinberg had since become something of a go-to mediator in corporate scandals, from the BP oil spill to the Volkswagen emissions scandal. The families—and much of the media—portrayed it as a ham-handed effort to shape the public relations battle to Boeing’s benefit. The money amounted to $144,500 per victim. It was part of a larger $100 million fund that Boeing had announced earlier that month, which was supposed to pay for community programs and economic development in addition to direct family payments. Boeing’s initial statement on July 3 noted that it had created the fund “ahead of Independence

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before the Senate. He spoke in the peculiar argot of lifelong bureaucrats, using two or three words—or five or six—when one would do. He had a fondness for, and seemed to enjoy explaining, the intricacies of processes. A sentence rarely passed his lips without the use of an obscure acronym. But there was an assuredness and a machismo to his delivery. Pressed on why the agency hadn’t grounded the plane after the first crash, he answered the question just like the big dogs he regulated might: “Frankly, that’s what I get paid for,” he said. “That’s what managers get paid for. To look at the facts and make decisions.” Finally, he was asked to say plainly why the FAA had only issued an advisory to pilots and given Boeing months to modify the MCAS software, when its own internal

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assessment found such a high risk of another incident. This time he gave a fuller answer, before trailing off into one more process. “We knew that [the] eventual solution would be to have the modification and based on our risk assessment, we felt that this, that we have sufficient time to be able to do the modification, ah, you know, and get the final fix,” he said. “Which—what that means typically—we refer to it as ‘closing action.’ ”

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and forty-six people are dead because of what these chief pilots described as ‘egregious’ and ‘crazy’—that’s their language, that’s Boeing’s internal language.” In the audience, one woman wiped away tears, her husband rubbing her back. “Now what I find truly stunning,” Cruz went on. “Boeing handed this exchange over to the Department of Justice in February. In March, I chaired a hearing of the aviation subcommittee on these two crashes. Boeing did not see fit to give us that exchange—nor did it give it to the FAA. Your testimony here today is that you first learned of this exchange a couple of weeks ago. I’ve practiced law a lot of years. Your lawyers read, after the crashes, your senior leaders saying they lied to the regulators. How in the hell did nobody bring this to your attention in February when you produced this to the Department of Justice? How did you just read this a couple of weeks ago?” Muilenburg said he was made

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After the second crash, Barr told subordinates he was skeptical about the basis for a criminal investigation of Boeing, according to a person familiar with the matter. He relayed multiple questions to the line attorneys in the fraud section, who feared their probe would be shut down, this person said. By July, however, Barr had recused himself, citing his past ties to Kirkland & Ellis. (A Justice Department spokesman declined to comment.) None of that was of any help in the moment to Muilenburg, squirming under the cross-examination by Cruz as to why he didn’t investigate the pilot’s concerns in the simulator. The CEO went on to explain that Forkner no longer worked at Boeing, as if that were another barrier to obtaining information. This argument was particularly feeble because the pilot on the other end of those messages, Patrik Gustavsson, still worked at Boeing—in Forkner’s old job. Cruz immediately

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family members—killed, they said, because of the company’s greed and callousness. Paul Njoroge brought pictures of four coffins instead of the faces of his wife, Caroline, and their children, Ryan, Kelli, and Rubi. Muilenburg knew the plane was flawed, Njoroge told him, and still he blamed foreign pilots; he hadn’t seen the victims in Ethiopia and Indonesia as people just like his own children. “They’re not human beings to you,” Njoroge said, “so you can only see their coffins.” He wanted to watch Muilenburg crack, to make the imperturbable engineer feel the weight of guilt. But as Njoroge talked about the daily pain his life had become, the anguish Boeing had caused, he broke down himself. What he got from Muilenburg was a look that in that moment, to him, felt pitying. It wasn’t what he wanted at all.

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Muilenburg kept invoking the values he’d learned on an Iowa farm, to the point that it brought groans from Nadia and others in the rows of seats where the victims’ family members sat, many of them leaning on each other or clasping hands. Her farm was a real place, where she’d raised her children. Muilenburg’s was pure symbolism, a trick meant to invoke ethics and integrity and even the long-lost ghost of Boeing legend T. Wilson, another Iowa State graduate. None of that registered in his actions.

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Afterward, Nadia again approached Muilenburg. His security guard moved to body her away, but he leaned in to listen. She took the opportunity to ask about the MCAS software: Would it really be safe once Boeing finished making all of the changes? He assured her it would. Then she offered a review of his performance. “You talked about Iowa just one too many times and the whole group said, ‘Go back to the farm, go back to Iowa,’ ” she said. “Do that!”

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Dickson said he’d look into it, without committing to anything. Muilenburg read that as a green light, and Boeing put out a statement saying “it is possible” that deliveries would resume in December. The FAA chief felt manipulated. He sent a memo to safety chief Ali Bahrami telling his team to “take whatever time is needed” and, for good measure, recorded an unusual video message to all FAA employees that soon hit YouTube. “I know there’s a lot of pressure to return this aircraft to service quickly,” Dickson said from his desk in Washington, the monuments in soft focus behind him. “I’ve got your back.”

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Muilenburg’s watch. The board met the next Sunday, December 22, and voted to fire him. Luttig followed Muilenburg out the door; he retired the day after Christmas. Walking away with $59 million, he had earned more than enough to afford those college expenses for his children that he had fretted about in his letter of retirement from the federal bench. With Muilenburg’s ouster, Calhoun was installed as CEO. A board member since 2009, he had collected $3.4 million in compensation and served through every stage of the MAX’s fraught birth and frenzied development. An old friend of Jim McNerney’s, he used to play a regular foursome of golf with Jack Welch at GE. The face at the top of Boeing may have changed, in other words, but the playbook had not.

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Asked that question on CNBC January 29, Calhoun answered vaguely. “We found out way too late,” he said. On a call with analysts that day, he suggested Muilenburg had duped him and Boeing’s board, in addition to the public. “I get a lot of media attention around the idea that I am somehow an insider,” he said. “What if I changed that a little bit? What if I told you I simply had a front-row seat to everything you saw?”

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