All language subtitles for Ten.Steps.to.Disaster.Series.1.Part.3.737.Max.1080p.HDTV.x264.AAC.MVGroup.org.eng

Narrator: Two plane
crashes just months apart.

There are no survivors.

Both involve the same
plane, the 737 max.

Why do we have not one but
two crashes that were caused

Essentially by the same thing?

There is a problem here
that we need to look into.

Narrator: How could a brand new
plane just fall out of the sky?

The nose of the
plane was pushed

Down, resulting in this
nosedive into the sea

At 450 miles an hour.

Narrator: Now experts who
investigated the crashes--

Why did boeing design the
plane the way they designed it?

I'm at a loss.

Narrator: --And those
connected to them

Reveal a series of
catastrophic failures.

If only that data
had been looked at,

Then that crash would
have been averted,

And my friend's granddaughter
would be alive today.

Narrator: From potentially
lethal design problems--

There were efforts to bring
to light serious concerns

With the max, and those efforts
were either unsuccessful

Or not taken seriously.

Narrator: --To
inadequate regulation--

The faa delegated its
authority to boeing employees.

There's an immediate
conflict of interest.

Narrator: --And investigations
uncovering a failure

To disclose key information.

Just trying to blame the pilot
or blame the user

Does nothing to solve
the systemic problems that

Will lead to future accidents.

Narrator: 10 fatal mistakes
that lead to the tragedy

Of the 737 max crashes.

I see an example of what
can happen to any company

When they lose track of
paying attention to safety.

[music playing]

January 17, 1967.

The world's press gathers to
witness the launch of boeing's

Latest commercial jet, the 737.

It is a global hit, and over
the next 50 years becomes

Boeing's biggest earner.

Throughout its history, it has
flown an estimated 180 million

Flights, amounting to around
100 billion miles and nearly 17

Billion passengers.

It's very, very easy to fly.

I think it's a wonderful
airplane.

And it's had an amazing
safety record.

It's the most successful
production aircraft in history.

Narrator: But five decades on,
shortly after boeing

Releases its latest
evolution, the 737 max,

The fairy tale
becomes a nightmare.

October 29, 2018.

Lion air flight 610 crashes into
the java sea near indonesia.

Less than five
months later, March

10, 2019, ethiopian
airlines flight 302

Nosedives into the ground.

The 346 passengers and crew on
board the two flights are dead.

The entire 737 max fleet is
grounded around the world.

Global investigations begin.

There's a problem here that we
need to look into much further.

Narrator: Over the
next two years,

Congressional investigations
trace the first mistake

On the road to tragedy,
back to the very beginning

Of the 737 max story.

Boeing's decision
to update the 737

Is fast tracked in response
to commercial competition.

The boeing 737 max was
a knee jerk reaction.

Ultimately, in this case,
I strongly

Feel that competition
is clearly to blame

For these two incidents.

Narrator: Spring 2011.

Boeing's ceo
receives an alarming

Phone call from one
of its most loyal

Customers, american airlines.

For more than a decade, american
has only bought boeing.

But now it's jumping
ship and about

To purchase its new planes
from boeing's

Main competitor airbus.

When you lose an
airline customer,

They don't usually come back
because an airline that goes

With airbus versus
goes with boeing

Has now made real commitments
to training their pilots

Over the long term.

Narrator: Boeing
knows it needs to move

Fast to stay competitive.

Just months later
in August 2011,

It announces the launch of a
brand new plane, an evolution

Of its trusty 737, the 737 max.

Suddenly boeing had a
good response to airbus.

Narrator: Since the launch
of the original 737,

Boeing has created two more
generations of its best seller.

By remodeling it once again,
boeing is back in the game.

Not having to design
a whole new plane also

Makes commercial sense, saving
the company around $7 billion.

Creating a brand new
airplane from scratch

Is at least a five
year, six year endeavor.

Very expensive, a lot
of engineering time,

A lot of original work.

Narrator: Modifying the
highly successful 737

Seems the perfect solution.

But it is this decision that
sets it on the path to tragedy.

In the us, all aircraft
must be certified

Under regulations laid
down by the federal

Aviation administration.

But a plane modified from a
design already in operation

Can be certified
far more quickly.

What is reviewed
by the regulator

Is mostly the modifications,
and how the modifications affect

The airplane as
opposed to starting

From a totally new airplane.

The manufacturer
of the airplane

Is not on the hook to jump
through the same number

Of hoops as you
would if the airplane

Was designed from scratch.

Narrator: This type of
certification process

Is known as the
changed product rule.

It's a long established
industry standard.

But in the case of the 737 max,
assessing modifications rather

Than the whole aircraft allowed
potentially dangerous faults

To enter the design.

In any process designed
and operated by humans,

Things can slip through the net,
and they obviously did here.

The change product rule
in this case enabled that.

Narrator: Investigations later
suggest the decision to modify

The old 737 is what set
the 737 max on the road

To tragedy because the
modifications signed off

Under the changed product rule
were considered in isolation,

And the effect on the
overall handling of the plane

Was not adequately scrutinized.

September 2011, development
begins on the modifications

Of the old 737.

Almost immediately,
boeing is looking

At a mountain of sales
for their new 737 max

From airlines across the globe.

Right from the start,
boeing management

Makes it very clear to
employees that time means money.

In the investigation report,
they

Mention this countdown timer.

And they actually call it
an excitement generator.

Understandable, maybe.

But what does it really do?

What it really does is put
pressure to meet the deadline

Front and center, therefore
putting quality and safety

Slightly in the background.

Narrator: After the crashes,
investigations

Suggest that time and money
pressures drove decisions that

Ultimately led to disaster.

It certainly has
the overarching appearance

That at every step
of the way, decisions

Are being made to prioritize
profits over safety.

But in the long run,
it costs far more, which is

What we see in this accident.

Narrator: By 2012, the
development stage of the 737

Max is well underway.

But in that same year,
boeing begins

To slash money and testing
time on the project.

A congressional investigation
after the crashes

Highlights this series of
cuts as an area of concern,

Suggesting it compromised
the future safety

Of the flying public.

Boeing has historically had
a very strong safety record.

The tragedy is that those
principles weren't put in place

In the design of this aircraft.

Narrator: In 2012, boeing
conducts a financial review

Of the 737 max.

Another project has already cost
the company billions in delays.

To save money,
the decision is made

To reduce a key testing process
during the aircraft's

Development.

So each time we
add something new,

We test not only that
the new feature works

But the old ones still do.

It seems obvious, but it's
all too easy to actually cause

The thing to go backwards.

Narrator: This testing is
critical throughout production

To make sure failings do
not creep into the design.

But to speed up production
and reduce costs,

Boeing cuts the testing
time by 2,000 hours.

A house transportation committee
hearing suggests some boeing

Employees were
feeling exhausted,

And some stated they
feared consequences if they

Spoke up about the pressure.

There was at
least one engineer

Who spoke up forcefully with his
concerns about the situation.

And he had a background in the
military where he was quite

Used to the invitation
to be very clear

When something's going wrong.

You are obligated to speak up.

And he was told, when
he spoke up at boeing,

That this is not the military.

This is a profit making
enterprise.

Narrator: Despite concerns
raised by boeing employees,

The performance record of the
previous generations of the 737

Gives us aviation authority,
the faa, enough confidence

To approve
the remodeling project.

But the faa's approval
is a grave error.

It certainly has the
overarching appearance

That at every step
of the way, decisions

Are being made to prioritize
profits over safety.

Narrator: If time and money
had not been such a priority,

Then identified problems
with the modifications

To the original 737
might have been solved

Before going any further.

Instead, one of the biggest
modifications

Goes on to be the root cause
of the fatal crashes,

Putting new larger engines
on the 737 body that

Change its behavior in the air.

The issue was,
essentially what happens is

The aircraft pitches upwards.

It is at such a steep
angle that the wing

Can't produce lift anymore,
and so the airplane stalls.

Narrator: To launch their
737 max into the 21st century

And make it more fuel efficient
than its airbus rival,

Boeing needs to change the
existing engines on the 737.

So the physics dictates
better fuel efficiency

Requires bigger engines.

Narrator: But fitting larger
engines to the 737 air frame

Isn't an easy job.

This is an airplane that
sits very low to the ground.

Its engines sit somewhere in
the order of about 17 inches

Off the ground.

Compared to, for example, a
boeing 757, which is about 26,

27 inches off the ground.

Narrator: When the original
737 was designed 50 years ago,

The low slung body was a
design feature, not a flaw.

It was designed to be an
aircraft that could go around

The world, including into
developing countries that would

Lack the infrastructure
that would be

Available in some other
airports so that you

Have easy passenger loading.

Narrator: But the
737's low slung body

Means there's not enough room
to fit the newer, larger engines

In their previous position.

Instead, the new engines
are placed further forward

And higher up on the wings, and
this leads to a major problem.

Wind tunnel testing reveals the
relocation of the bigger more

Fuel efficient engines
has changed the way

The plane behaves in flight.

In some rare instances,
at cruising altitude,

It could push the plane's
nose upwards.

So the problem with
the nose pitching up

Is if the aircraft starts
to be at too steep an angle,

It can lose the ability
to remain aloft.

At that point,
boeing could have

And should have stopped to think
whether it was worth continuing

With the design.

Narrator: Had boeing scrapped
the project at this point,

The fatal crashes would
never have happened.

Instead, engineers are tasked
with finding a solution

To keep both the 737 body and
the new fuel efficient engines.

What they come up with
is arguably the biggest

Single mistake on the road
to the fatal crashes,

The addition of software
to overcome the problem

And make the plane fly
like the previous 737.

But this has unintended
consequences.

There have been reports that
suggest that the shear force

With which it pushed the
airplane into a downward spiral

Made it virtually impossible
for pilots to effectively

Recover from what was a dive.

Narrator: In 2012
software called

Mcas is added to the 737 max.

It's designed to ensure the
larger engines won't affect

The handling of the plane
during a specific and very rare

High speed maneuver.

The software gathers information
from different sensors,

Which monitor the plane's
g-force and pitch.

If the sensors show the
plane's nose rising rapidly,

The software will react
and push the nose back down.

On paper, the mcas makes
perfect technical sense.

If the nose pitches up
past a certain angle,

You rely on a piece of
technology to lower the nose.

Narrator: The new software
is a clever solution

That solves this extremely
rare handling problem.

And this is what is
included in the plans

That boeing originally
submits to the faa.

But then flight testing
reveals another issue.

The nose of the max
can also pitch up

At lower speeds after takeoff.

And unlike the high
speed maneuver,

This isn't a rare event.

It could happen any time
the plane flies.

So boeing uses
the same mcas software

To solve this problem as well.

That's a totally
different environment

To take a high speed
device and put

It in a low speed environment.

And that's when you
have to be very,

Very vigilant about your
underlying assumptions.

Do those assumptions
for the high speed regime

Still fit in the
low speed regime?

Those details were not
adequately addressed.

Narrator: Due to the relatively
low speeds after takeoff,

There would not be enough
g-force to trigger

The g-sensor.

This would prevent
mcas functioning in

This new low speed environment.

So boeing reprograms
this software to trigger

Without the g-sensor.

Two sensors were also originally
needed to trigger mcas.

But the 737 max
software now relies

On just a single pitch sensor.

Boeing says it did tell
the faa about this change,

But the house committee
on transportation

And infrastructure concluded
it had not been properly

Highlighted, allowing
it to go through

Without sufficient scrutiny.

Powerful software should
never rely on one sensor.

I am convinced that if the
right people on either side

Had known about that problem,
the faa would

Never have let it go
out of the factory

Door with only one sensor.

Narrator: Tragically,
both crashes

Reveal the danger of relying
on a single pitch sensor.

If it develops a fault,
the software

Has no way to tell
that it is now responding

To false information.

Imagine you looked
at a thermometer

And it's minus 30 one moment and
it's plus 20 the next moment.

If in 3/4 of a second, you saw a
thermometer change like that, I

Don't think you
would immediately

Throw your clothes
on and say, gee,

I guess it got
very cold outside.

I think you would say,
well, something's

Wrong with the thermometer.

Narrator: In both crashes, mcas
responded to faulty sensor data

Suggesting the planes
were about to stall.

Less than two minutes into the
first doomed lion air flight,

The 737 max's software
reacts to the erroneous data

And pushes the
plane's nose down.

13 minutes after takeoff, the
plane plummets into the java

Sea at 450 miles per hour.

189 passengers and
crew are killed.

Less than five months later,
the pitch sensor

On an ethiopian airlines
737 max also fails.

After a terrifying six minutes
for all on board,

Flight 302 nose dives
into the ground.

Again, there are no survivors.

Why couldn't mcas have
had that amount of design

To be intelligent enough
to disregard

And ignore the bad data?

Then that crash would
have been averted

And my friend's granddaughter
would be alive today.

Narrator: In January 2021, two
years after the fatal crashes,

The us justice department
brings criminal charges of fraud

Against boeing for the failure
of two of its key employees

To be completely transparent
with the regulator about mcas.

But this situation
was compounded by

Another huge error of judgment.

This is the
equivalent of letting

The fox guard the chicken pen.

Narrator: During development
of the 737 max,

Boeing introduces software
to overcome handling issues.

Critical changes are made
to the system

And are not highlighted
to the industry regulator.

These are directly
responsible for the deaths

Of 346 passengers and crew.

But the regulator itself is
also part of the problem.

It makes a huge mistake,
giving boeing

The power to effectively sign
off much of the 737 max design.

The real glaring standout
fact in all this

Is that the faa, the regulator,
delegated its work

And its authority to boeing
employees, which in my view

Should never have happened
and should never happen again.

Narrator: In the united states,
all new plane designs

Must be green-lit by america's
aviation regulator, the federal

Aviation administration.

They regulate all
aspects of aviation--

Big planes, small planes,
planes in between,

Pilots, manufacturers.

Every aspect of aviation
is regulated for safety

By the federal
aviation administration

In the united states.

Narrator: Although the faa is
responsible for the final sign

Off on any new project,
it routinely

Delegates large
parts of this process

To the aircraft manufacturers.

The aircraft
manufacturers have

Been able to in some sense self
certify much of their process.

Not just boeing, but
any manufacturer in order

That the faa not become a
bottleneck for that process,

Because otherwise that could
slow it down to a standstill.

Narrator: At the time of
the 737 max development,

The faa didn't have
the staffing capacity

To monitor the entire program.

So by the time the 737 max was
green-lit to fly commercially,

It had delegated
so much authority,

Boeing had responsibility
for 87% of the checks

Needed to certify the plane.

Boeing of course
turns around and says,

"our plane is fit to fly.

Why would we say
any differently?"

In any situation where an
organization can self certify,

There's an immediate
conflict of interest.

Why on earth would an
organization not certify their

Own project as fit for purpose?

Narrator: Later investigations
report there are signs

That the staff members
delegated by the faa

Are put under undue
pressure by boeing.

If individuals feel it's not
in their interest to report

Problems or that, worse,
that they're not heard or even

Intimidated,
then the aircraft itself

Becomes an object of concern.

Narrator: The failure to
highlight key information

About mcas results in the
737 max leaving the factory

With fatal design flaws.

But a further decision
signed off by the faa results

In another devastating mistake.

Pilots don't go through
simulator training

Before flying the new 737 max.

They didn't have
the training to be

Able to diagnose the problem
when it was happening.

They didn't have
the information.

And so they were really
operating in the dark.

Narrator: By 2016, the first
737 max is about to roll

Off the production line.

Boeing is now looking
at a bulging order book.

One of the max's key selling
points is its fuel efficiency.

The other is that it flies
in exactly the same way

As the old favorite 737.

Boeing was trying to increase
the attractiveness

Of their aircraft to airlines
by saying, hey, this is a 737,

Therefore you can have pilots
be able to hop in the pilot seat

Very easily and fly this plane.

This is a really big deal
because it wouldn't necessitate

Additional training,
additional flight

Simulator time, all of which
is costly to the airlines.

Narrator: Instead of expensive
flight simulator training,

Boeing offers up a more cost
effective and quicker approach.

If they were already used
to flying the 737 version,

Pilots were encouraged
to use ipads to train

Up for the new 737 max.

Narrator: In 2011,
indonesian carrier lion air

Buys 230 planes at a
cost of over $20 billion.

17 months prior to
the lion air crash,

Lion air actually requested from
boeing if their pilots could

Have flight simulator
training on arrival

Of the new max models.

Narrator: This is way beyond
the two hours of ipad training

Boeing has been pushing.

The minute boeing sets a
precedent suggesting that one

Group of pilots
requires training,

The concern would be that other
airlines, other customers would

Say we also need training.

And hang on a second,
we were promised an airplane

That required minimal training.

So why are we now
on the hook to pay for this?

Narrator: Boeing persuades
lion air that simulator

Training is unnecessary.

Pilot training is very, very
important, with the idea being

That when an emergency comes,
the instincts are correct,

The muscle memory is there.

So to go through a modern
approved training syllabus

Makes you completely
comfortable.

If you've got through
all the hurdles

And you climb into the airplane
after all that training,

You just feel
completely confident.

Narrator: If the pilots in both
crashes had simulator training,

They might have been
better prepared

When things went wrong.

But even then, another key
decision proves critical.

Boeing makes no mention at all
of the mcas software

In the 737 max flight manual.

I met with the head of
the accident investigation

Committee in jakarta.

And I was astonished when he
told me that the pilots were

Not even aware
of the mcas system,

This incredibly powerful
system that is figuring

Prominently in the crash.

It wasn't even in
their flight manual.

So when the lion air pilots were
experiencing these problems,

They didn't even
know mcas existed.

Narrator: January 2016, the 737
max makes its maiden flight.

Two months later, boeing
convinces the faa the plane's

Mcas software doesn't
need to be included

In the plane's flight manual.

The later congressional report
suggests this was to avoid mcas

Being seen as a new feature.

They were worried about
the specter of raising

The possibility that there
was something profoundly

Fundamentally new here
that pilots might

Need to know something about.

Narrator: Boeing's sales pitch
is that flying the new 737 max

Is exactly the same as
flying the previous 737.

But the two subsequent
plane crashes

Prove the reality of this claim
was very different.

October 29, 2018,
lion air flight 610

Is less than two minutes
into its journey

When the plane's nose
starts to be pushed down.

Because the pilots have no clue
the mcas software has been

Fitted to the plane,
they have no idea

How to stop this happening.

Within minutes, the control
of that aircraft

Was out of their hands.

They were not prepared for it.

The lion air pilots were
experiencing these problems.

They didn't even know
mcas existed.

They had no way to know
why the plane

Was acting erratically
for them and why

It wasn't easy to control.

This was a major problem.

Narrator: Ultimately, the pilots
can't pull the plane out

Of its final deadly dive,
and it crashes

Off the coast of indonesia.

Given that mcas wasn't mentioned
in the aircraft manual,

A post crash hearing suggested
it was a flawed assumption

The pilots would be able to
overcome the problems caused

By this software.

Had the pilots known about
the existence of the software,

They may have been able to
work out how to override it.

Tragically, had it not been
for yet another mistake,

The lion air flight
might have been prevented

From taking off altogether.

The day before,
the same aircraft

Experiences a similar problem,
but details of how

It was solved aren't passed on.

The information just
fell between the cracks,

And the next crew didn't know
how they solved it.

Narrator: October 28, 2018,
lion air flight jt043 takes off

On a two hour internal journey
to the indonesian capital,

Jakarta.

The aircraft was less
than six months old,

Less than 800 hours of
flying time, which is

Relatively new for an aircraft.

Narrator: Minutes after takeoff,
at an altitude of just 400

Feet, the control stick
in the cockpit

Begins to shake violently.

Some airliners
have stick shake

To artificially tell you when
you're approaching a stall.

Narrator: But unknown
to the pilots,

The plane is not in
danger of stalling.

The stick shaker is
vibrating in response

To a malfunctioning
external sensor,

The same single sensor that
feeds into the mcas software.

The mcas responds
to the false data

By forcing the plane
into a dive.

You do not want this
system functioning

When the airplane is trying
to maintain stable flight.

If the system kicks in
during these points in time,

The worst case scenario
is a crash.

Narrator: Unaware of the
existence of the mcas software,

The pilots send out
frantic mayday signals.

But three minutes later,
they manage

To regain control of the plane.

It's really interesting
to me that the crew that

Flew the airplane just
before the accident was

Able to stumble upon
the right cut out procedure.

And what was interesting there
was it wasn't the crew that was

Involved in flying the
airplane at the time,

But it was the pilot in
the jump seat behind them

That actually figured out
the right response.

He was able to perform
a procedure known

As the runaway stabilizer,
which is

A mechanical process to restore
the balance of the plane.

Narrator: The same problem
recurs throughout the journey.

But each time, the crew
manages to override

The deadly software.

Passengers later described the
flight as a terrifying roller

Coaster ride.

As soon as the plane lands,
the pilot reports the incident

To the ground maintenance
engineers,

But key information
isn't passed on.

There was no record
in the lion

Air logs of how they'd actually
gone about fixing this problem.

Narrator: Less than
24 hours later,

Flight 610's pilots
board the same 737 max

With no knowledge of what
they're about to face.

Had the runaway stabilizer
checklist procedure

Been reported as a solution in
that maintenance log, the pilot

The next day on that
tragic lion air crash

May have been in more of a
position to understand how

To tackle the mcas system,
despite not knowing it

Was installed on the aircraft.

Narrator: If that information
had been passed on,

Disaster might have been averted
less than 24 hours later.

Instead, the very same 737 max
crashes on its next flight.

Then tragically, less than five
months later, another 737 max

Falls from the skies.

When the second
accident happened,

It was a different ballgame.

Narrator: October 29,
2018, less than 24 hours

After a terrifying
roller coaster flight,

The same 737 max departs
from jakarta at 6:20 am.

Almost immediately,
the software mistakenly

Pushes the plane's nose down,
just as it did the day before.

This time, there is no off duty
pilot on board to save the day.

The plane crashes into
the java sea 13

Minutes after takeoff,
killing all 189 people on board.

The nose of the plane was
pushed down by the system

At an angle of
almost 40 degrees,

Resulting into this nose dive
into the sea at a speed

Of 450 miles an hour.

Narrator: Although flight
recordings highlight

Technical faults,
it is suggested

The real problem was
not with the plane,

The problem was pilot error.

This delays the real problem
from being

Fully investigated until after
the second 737 max crash.

Just trying to blame the pilot
or blame the user

Does nothing to solve
the systemic problems that

Will lead to future accidents.

Narrator: In the aftermath
of the lion air crash,

Boeing releases a press
statement saying that the 737

Max is as safe
as any airplane that

Has ever flown in the skies.

The finger of blame
is pointed at the pilots

Rather than the plane itself.

It goes with the job.

You accept it,
that the first person

That's going to be looked at
is you as the captain.

It's just how it is.

And would I call it a burden?

I just, I think
I have acceptance

That that's how it is.

Narrator: Blaming
the pilots means

Attention focuses on the
airline, not the 737 max.

If you start to even imply
that it might be partly

Your fault, your stock price
is going to take a hit,

There are going to be huge
financial consequences, maybe

Legal consequences as well.

Narrator: In this situation,
lion air makes an easy target.

Lion air had a dubious
safety record,

Large number of incidents
in the previous 20 years.

There were issues with
pilot training recorded.

There were issues
with maintenance

And general engineering
within the organization.

Narrator: Boeing
implies the solution

To the software problem is
simply a standard procedure.

It's called the runaway
stabilizer checklist

And is found in the manual.

In reality, the runaway
stabilizer checklist

Is a non-normal procedure.

And in that situation,
pilots will be looking

Through a physical
hard copy checklist,

Trying to identify what they
need to do in that situation.

And with minutes to
spare or even seconds

To spare in the cockpit,
that's not reality.

Narrator: Focusing on
the pilot's actions

Deflects attention away
from the real problem,

The plane's technical issues.

In the weeks that follow,
the company goes on

To highlight the information
that shows how to override

The deadly software problem, and
737 max sales continue to soar.

Then less than five months
after the lion air crash,

An ethiopian airline 737 max
nose dives into the ground

Six minutes after takeoff.

All 157 passengers
and crew are killed.

The plane's black box reveals
striking similarities

With the lion air crash.

When the second
accident happened,

It was a different ballgame
because ethiopian

Have a fantastic reputation,
and are very well thought

Of in the rest of the world.

And suddenly,
you couldn't blame,

You couldn't get away
with it anymore.

Narrator: If the focus
had been on the plane

Rather than blaming the pilots,
the technical issues might have

Been solved and the
second crash averted

Because there was only
one real difference

Between the two crashes.

The pilots of the
ethiopian airlines 737 max

Did have knowledge of how to
deal with the software problem

If it occurred, but
the plane still crashed.

A key mistake made long before
the first 737 max rolled off

The production line meant
that whatever the pilots did,

The odds were
stacked against them.

When they designed the 737
max and assumed it would be safe

And safely operated
by pilots who

Are comfortable with
the 737, they didn't take

Into account the human factor.

They didn't take into account
what happens

In those very few seconds
when you're startled

By an unexpected event.

Narrator: March 10, 2019,
8:38 am,

Ethiopian airlines flight 302
is only seconds into its ascent.

Just like lion air
flight 610, the plane

Stick shaker begins
to vibrate violently

And the plane nosedives.

The black box recordings and
the details clearly show that

The pilot and the co-pilot
were frantic in their efforts

To try and stabilize the plane.

Narrator: Armed with knowledge
of how to override the problem,

The pilots manage
to regain control.

But seconds later, the plane
pitches down again.

The automated system
would kick back in,

Time and time again,
and that's ultimately

What led to the crashes.

Narrator: The ethiopian
air pilots lose

And regain control three times.

The fourth time they lose
control, they are not so lucky.

The plane crashes into the
ground with total loss of life.

They were overloaded
physically in trying

To handle the aircraft.

And then when they did try
to take over manual control,

They found it very,
very difficult to do so.

So they had, there
was a whole cascading

Series of events that happened
that led to this accident.

Narrator: The pilots struggled
to rectify the problem

For four terrifying minutes.

Regulators base their
certification on the assumption

That this sort of problem can
be solved in just four seconds.

If the airplane can't be
recovered after that four

Seconds without herculean
effort by the pilot,

Or without potentially
damaging the airplane,

Or hurting passengers,
then it doesn't pass.

Narrator: But later
investigations

Uncover internal documents
revealing boeing was not only

Aware of the problem,
but in one simulator test,

It took their pilot
10 seconds to resolve.

Boeing did not highlight
this catastrophic situation.

When a boeing employee raised
concerns about the ability

Of pilots to respond to mcas
activating repeatedly,

Those concerns
were not addressed.

Every human has a stress
performance curve

Depending on their experience,
their attitude, their training.

And there's a startle effect,
which we all have.

That is when intensive events
within the cockpit

Cause the pilot's
blood pressure to rise,

Their heartbeat rate
to increase.

Narrator: The startle effect
is found

To be one of the critical
human factors

Which was underestimated during
the development of the 737 max.

One of the tragedies
of these accidents

Were that the basic foundational
principles and procedures

Of human factors
engineering don't

Appear to have been applied
when they designed the 737 max.

If you want to reduce or even
eliminate human error,

Then you have to design
the technology

To be compatible
with how people operate.

Narrator: By March 13, 2019,
every 737 max around the globe

Has been grounded.

Following investigations,
the faa

Is criticized for its handling
of the max project.

The faa was asleep
at the wheel when

It comes to certifying the max.

It didn't carry
its job out properly.

Narrator: The justice department
charges boeing with conspiracy

To commit fraud for two
of its key employees

Concealing information
from the faa

About the operation
of its mcas software.

Under a deferred
prosecution agreement,

Boeing pays out $2.5 billion
in fines and compensation.

I think all of us who
were testifying very much

Felt that those people deserved
to have something come out

Of this accident that could
be used to improve

Air transportation safety.

Narrator: The company agrees to
be monitored by the fbi fraud

Department for three years.

In December 2020,
the 737 max is finally

Given permission to fly again.

But it's mcas software now
relies on two pitch sensors

And all pilots get full
simulator training before

Entering a 737 max cockpit.

Sometimes it's easy
to step back

And say, well, this thing
is just too complex.

It can't be preventable.

I don't agree with
that perspective.

These are not accidents
that just happen

Because some fluke thing.

But I think the bigger issue
is the tug of war

And the battle between
the financial goals

Of a corporation
and its ethical duties.

That's what we see here.

[music playing]