Boeing 737 Max: One year after fatal Ethiopian Airlines crash, did planemaker put profits ahead of safety?

“Today is Sam’s birthday,” wrote Mark Pegram on 20 February this year.

“We should be celebrating with him. Instead I am sat here trying to summon the strength to visit his memorial tree.

“This is just part of the true cost of the 737 Max.”

Sam Pegram, a 25-year-old aid worker from Lancashire, was one of 157 passengers and crew who died aboard Ethiopian Airlines flight 302 from Addis Ababa to Nairobi.

On 10 March 2019, they boarded an almost-new Boeing 737 Max, the latest variant of a plane type that has been flying since the late 1960s.

ET302 was a routine service from the airline’s home base to the Kenyan capital Nairobi.

But within minutes of take-off, the aircraft crashed at high speed with the loss of all on board.

Five months earlier, a Lion Air Boeing 737 Max had come down soon after it left Jakarta airport in Indonesia, killing all 189 passengers and crew.

But according to the regulators who signed off the redesign of the 737, the fact that the Max was the aircraft lost in both crashes was simply a tragic coincidence.

“Our review shows no systemic performance issues and provides no basis to order grounding the aircraft,” insisted the Federal Aviation Administration (FAA), even as other safety regulators – including Britain’s CAA – were ordering their airlines to ground the 737 Max.

Accident investigators quickly revealed a struggle between the pilots of ET302 and their aeroplane that paralleled the Lion Air crash – forcing a 180-degree turn by the FAA.

The plane that Boeing believed would deliver billions in profits has not flown a single paying passenger since.

For over a century, aeronautical engineers have designed out risk to a degree unmatched in any other industry. They work to eliminate as much danger as possible from mechanical failure or human frailty.

Boeing’s engineers inadvertently wired in potential for disaster into the very heart of the Max.

While the basic appearance and key dimensions of the very first Boeing 737 remain, the Max’s engines and flight control system have changed radically.

Larger engines are much more efficient. But because the distance between the wing and the ground is unchanged from the early days, when much thinner “cigar-shaped” engines were used, for the Max they had to be hoisted up and forward – until they are blended with the wings.

Early on in the 737 redesign, Boeing engineers identified a theoretical aerodynamic problem with this arrangement. In some unusual circumstances, they concluded, there was a risk of stall – in which the wings do not generate sufficient lift to keep the plane aloft.

The engineers devised an electronic correction that would impose the correct response – to tip the nose downwards – should the pilots failed to do so.

The new software came with innocuous-sounding name of “Maneuvering Characteristics Augmentation System” (MCAS).

It relies on the “angle of attack”: the angle between the wing and the airflow, measured by a vane just below the flight deck.

If MCAS detects that the angle is getting dangerously steep, it operates an elevator in the tail to nudge the nose downwards – and continues to do so, for as long as the perceived perilous condition persists.

The designers accepted that they were pushing the Boeing 737 to its engineering limits. They aimed to protect passengers and crew against inept pilots with a system that overruled their commands.

But the system was built with two flaws that twice proved fatal.

The wisdom of redundancy has served aviation well: the life-saving principle of having multiple systems in case one fails is long-established in aviation. Yet it was inexplicably ignored by Boeing.

MCAS could be, and was, triggered by a single faulty sensor. And once it had automatically kicked in, MCAS was trained to force down the nose with such pressure that humans could not overpower it.

On 29 October 2018, the Boeing 737 Max operating as Lion Air flight 610 took off from Jakarta. A single faulty angle-of-attack sensor woke up MCAS, which initiated a fatal struggle between the pilots and the anti-stall system.

While there is a procedure to deactivate MCAS, the two pilots of the Indonesia plane were unable to identify it before they plunged into the Java Sea at an unsurvivable angle and speed.

The profile of the short flight revealed a bizarre series of ascents and descents. The two black boxes confirmed that MCAS deployed in response to a faulty sensor, and the relatively inexperienced pilots were unable to cope.

The FAA issued an Emergency Airworthiness Directive, circulated to 737 Max pilots worldwide.

MCAS, it warned, “could cause the flight crew to have difficulty controlling the airplane, and lead to excessive nose-down attitude, significant altitude loss, and possible impact with terrain”.

As the families of the Lion Air victims grieved, Boeing kept making the 737 Max at a prolific rate to meet an order book of around 5,000 jets.

In terms of numbers sold, the 737 is the world’s most successful airliner. This is the plane that, more than any other, helped to democratise aviation. Over the past half-century, more than 10,000 have been built – placing it well ahead of its main competitor, the Airbus A320.

Safety is an obsession in aviation, but two airlines stand out: Southwest and Ryanair. Both of them fly the 737 exclusively.

Until a freak accident aboard Southwest Airlines flight 1380 on 17 April 2018 cost the life of Jennifer Riordan, Southwest had flown around 2 billion passengers without a single fatal accident. Ms Riordan lost her life when she was partially sucked out of a window after part of an housing disintegrated and hit the fuselage.

After that tragedy, the mantle for the world’s safest airline passed to Ryanair – which has now flown around 1.5 billion people aboard 737s with zero deaths in crashes.

Both airlines are eager to fly the Boeing 737 Max. It has better fuel efficiency than current models, and – in Ryanair’s case – has eight additional seats within the same cabin profile.

Southwest is the largest customer for the Max, and was flying them safely and successfully until the worldwide grounding. Ryanair had scheduled the Max for the summer of 2019, but had not received any of the planes by the time the no-fly order was received.

At first Boeing confidently predicted that the jet would be flying commercially by the end of 2019. But while the company made software changes, conducted test flights and promised training enhancements, incriminating internal messages emerged.

They portrayed a toxic corporate culture that put profits, not passenger and crew safety, first when creating the 737 Max.

“Designed by clowns who in turn are supervised by monkeys,” wrote one Boeing employee in 2017.

The comment, whose writer also describes the plane as “piss poor,” is among hundreds of emails and text messages released to regulators and the US Congress.

To make the Max more appealing to existing Boeing 737 customers, the planemaker presented the differences between the Max and the previous “NG” version jet as minor.

“How about explaining why your pilots misled the FAA about the nature of the MCAS?” tweeted Mark Pegram.

Training pilots is expensive, and all the while they are in a flight simulator they are not flying profitably. So Boeing insisted that current 737 pilots required only a short tablet-based exercise rather than time in a simulator.

“I want to stress the importance of holding firm that there will not be any type of simulator training required to transition from NG to Max,” wrote one pilot working for the planemaker. “Boeing will not allow that to happen.

“Boeing does not understand what is to be gained by a three-hour simulator session, when the procedures are essentially the same.”

MCAS was glossed over. An Asian airline asking for simulator training was told that it would create “a difficult and unnecessary training burden for your airline, as well as potentially establish a precedent in your region for other Max customers”.

Boeing now recommends simulator training for 737 Max pilots when the jet finally returns to service. But there is no certainty about when that might be.

The FAA, wounded by accusations that it became too close to Boeing in a case of “regulator capture” is determined to play hardball. “The aircraft will return to service only after the FAA determines it is safe,” it declares.

During a year of intense scrutiny of the Max, other problems have come to light – including concerns over wiring bundles. They may need to be re-positioned in the hundreds of aircraft standing idle on airport aprons across the world – as well as the staff car park at the Boeing plant in Washington State.

Airlines no longer expect to be flying the Max during the summer peak – and, indeed, are suddenly glad to have the aircraft off their books. The coronavirus crisis has triggered an unprecedented slump in air travel worldwide, and carriers’ former desperation for capacity has vanished – replaced, in many cases, by a desperate battle for survival.

The planemaker says: “Boeing has made significant progress over the past several months in support of safely returning the 737 Max to service as the company continues to work with the FAA and other global regulators on the process laid out for certifying the 737 Max software and related training updates.

“These two tragic accidents continue to weigh heavily on everyone at Boeing.”

Even when demand returns, Boeing has a huge reputational battle to fight. If airlines find, as successive Independent polls have done, that a significant slice of the travelling public is anxious about the 737 Max, they will be in no rush to take delivery.

As the families of the victims of Ethiopian Airlines 302 and Lion Air 610 prepared for their first Christmas without their loved ones, Boeing’s CEO, Dennis Muilenburg, was sacked.

His replacement, David Calhoun, was tweeted by Sam Pegram’s father, Mark, on 22 February: “We are approaching the 1st anniversary of flight ET302 that cost the lives of 157 people including my son.

“Tonight I am going out with friends of Sam to toast his memory.”

The life of Sam Pegram, and every victim who perished in the Boeing 737 Max, deserves to be honoured with a vow to put people before profit.