Air travel is fabulously safe, as thousands of flights take off and land without incident every day. But on January 5, 2024, when Boeing’s two-month-old 737 MAX 9 narrowly escaped disaster after a mid-cabin door plug blew out, causing explosive depressurization of the aircraft cabin on Alaska Airlines flight 1282, this was sadly not unexpected, given the story of the 737 MAX.

I have been investigating the Boeing 737 MAX ever since my friend’s granddaughter was in seat 16J on Ethiopian Airlines flight 302 on March 10, 2019 when it crashed, killing all 157 passengers and crew on board. Shortly thereafter, in a conversation with the victim’s great uncle, Ralph Nader, I became aware of the contributions of the corporate malfeasance of Boeing and the regulatory capture of the Federal Aviation Administration (FAA) to the 737 MAX crashes, and I have been investigating the Boeing 737 MAX ever since. Since Fall 2019, I have been teaching the course “Boeing 737 MAX: Money, Machines, and Morals in Conflict” at the University of California, Berkeley.

The tragedy of Ethiopian flight 302 involved a four-month-old 737 MAX 8 which dove uncontrollably to the ground, crashing in Ejere, Ethiopia, six minutes after takeoff from Addis Ababa. Just five months earlier, all 189 on board Lion Air 610 were killed when a five-month-old Boeing 737 MAX 8 plunged into the Java Sea, 13 minutes after takeoff from Jakarta on Oct. 29, 2018. It had been a mere 17 months since the 737 MAX had flown its first commercial flight on May 22, 2017.

Boeing 737 MAX incidents differ fundamentally from accidents that arise from unforeseen circumstances, such as the famous “Miracle on the Hudson” water landing of US Airways Flight 1549, necessitated by a flock of Canada geese that unexpectedly collided with the engines of Captain Chesley “Sully” Sullenberger’s Airbus A320, three minutes after takeoff from LaGuardia on a chilly January day in 2009.

Unfortunately, the Boeing 737 MAX airplane suffers from poor design, manufacturing, workmanship, inspection and oversight.

Just a week before the Alaska Airlines 1282 blowout incident, a nut was found to be missing in the rudder system of a 737 MAX in India, leading Boeing to find loose bolts in its new aircraft awaiting delivery. In August, the FAA warned that the anti-ice system overheats if used for more than five minutes at a time, which could lead to part of the engine breaking off. The FAA said that this “may cause fuselage and/or window damage, potentially resulting in decompression and hazard to window-seated passengers aft of the wing and/or impact damage to the wing, flight control surfaces, and/or empennage, which could result in loss of control of the airplane.”

In fact, the 737 MAX has had at least 20 serious production quality defects, most involving flight safety related systems, since it was ungrounded in November 2020, according to Ed Pierson, a former senior manager at Boeing’s 737 factory who is now the Executive Director for The Foundation for Aviation Safety.

Boeing has been prioritizing profits over safety, in both design and fabrication. Moreover, the Federal Aviation Administration (FAA) has been derelict in its duty as aviation safety watchdog, both before and after its initial certification of the 737 MAX in March 2017.

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When I met in Jakarta with the head of the Aviation Accident Investigation Subcommittee of Indonesia’s National Transportation Safety Committee (known as KNKT) about the first crash, I was amazed to learn that the pilots of that doomed flight had never even been informed about a new dangerous software system installed on the 737 MAX. It was this system, called the Maneuvering Characteristics Augmentation System (MCAS) which led to the crashes when it malfunctioned and overrode the pilots’ actions.

A few weeks after that crash, the FAA performed an internal analysis, calculating that if Boeing did not change the design of this problematic software system, they expected a staggering 15 fatal 737 MAX crashes over the 30-year lifetime of the fleet. With such an alarming conclusion, why did the FAA not ground the airplane at that time, rather than tragically waiting until after the second crash in Ethiopia five months later that took 157 innocent lives?

Both fatal crashes involved erroneous data being input to MCAS about the angle by which the airplane was tilted. The reading is provided by an angle of attack (AoA) sensor which is a little weather vane protruding precariously from the side of the fuselage, where it is susceptible to damage. It is incomprehensible that Boeing designed the software to take input from only a single vulnerable sensor; in fact, there was already a second AoA sensor on the aircraft, which sports one on each side of the nose. Why did Boeing ignore aviation’s time-honored principle of redundancy?

In the Ethiopian Air crash, this angle of attack reading jumped from about 12° to 74.5° in less than a second, which would clearly be physically impossible for a flying machine weighing over 100,000 pounds. From my computer science perspective, it is unforgivable that MCAS was not designed to validate the plausibility of incoming data before it would force the aircraft into its deadly dive toward the ground.

Even after the second horrific crash, the FAA remained steadfastly against grounding the 737 MAX, despite the similarities of the two crashes. With Boeing touting its confidence in the airplane and even its CEO Dennis A. Muilenburg delivering the same message personally in a phone call with then President Trump, the obdurate FAA resisted calls to ground the airplane for more than 85 hours after the crash. It was only after 40 countries grounded the 737 MAX in an unprecedented worldwide show of no confidence in the FAA that the agency finally acquiesced and grounded the airplane, on the afternoon of March 13, 2019.

Nineteen months later, on November 18, 2020, the FAA ungrounded the 737 MAX, amid continuing concerns over its safety. This decision was based on secret data and testing. The nonprofit airline consumer organization Flyers Rights filed a federal Freedom of Information Act request for flight test protocols and results pertaining to the ungrounding decision. However, what they received was close to 10,000 pages with almost every page completely blacked out.

How did we get here? Boeing had maintained an esteemed engineering tradition in the 20th Century. But a seismic shift in corporate culture began immediately after Boeing acquired McDonnell Douglas Corporation in August 1997. The takeover was inverted insofar as it was the management of the smaller, struggling, more bottom line-oriented McDonnell Douglas who took the reins of Boeing.

Harry C. Stonecipher, the former McDonnell Douglas CEO who had become Boeing’s President and COO, boasted in a Feb. 29, 2004 Chicago Tribune interview, “When people say I changed the culture of Boeing, that was the intent, so that it’s run like a business rather than a great engineering firm.” Stonecipher was forced to resign after having an affair with a subordinate and was replaced on July 1, 2005 by W. James McNerney, Jr., from GE and 3M.

Meanwhile, later that year, on Nov. 14, 2005, the FAA established the Organization Designation Authorization (ODA) Program. This enabled certification of new aircraft to be performed by employees of the manufacturer — the proverbial fox guarding the hen house.

The stage was set for the 737 MAX saga. In Spring 2011, American Airlines CEO Gerard J. Arpey called McNerney, warning that American, an exclusive Boeing customer for a decade, was on the verge of ordering hundreds of a recently announced new airplane from Airbus. This was the A320neo, where the moniker “neo” held the key, designating “new engine option.” The new CFM International LEAP-1A engine would consume 15% less fuel to provide the same thrust. The increased fuel efficiency relied on having a larger fan diameter, a key fact which would prove problematic for Boeing.

Since the creation of a new aircraft requires a design and development process which takes many years, McNerney steered Boeing away from creating a modern airplane to compete with the A320neo; instead, he directed the company to revamp the oldest aircraft series still in commercial passenger service, its 737, which had been developed in the mid-1960’s.

The legacy design of the 737 airframe presented obstacles, leading to a compromised design. The primary challenge was that the wings were too low to accommodate a modern engine with large six-foot fan diameter necessary for fuel efficiency. Boeing found a workaround. It repositioned the engines further forward and higher at the front of the wing.

But this affected the aerodynamic characteristics of the airplane, causing the nose to pitch up at high angle of attack at high airspeed. This was the raison d'être of MCAS, which would automatically adjust control surfaces of the aircraft (the horizontal stabilizer on the tail) to push the nose down while in flight.

It subsequently became apparent that the pitch-up problem could also occur at low airspeeds, which would require that the horizontal stabilizer be adjusted farther to achieve a similar effect. Consequently, Boeing made MCAS more powerful and potentially dangerous, where it could activate at both low and high airspeed and would make large adjustments to the control surfaces.

Boeing was forging ahead, in an example of “escalation of commitment,” a term coined in 1976 by my business school colleague Professor Barry M. Staw, who specialized in organizational behavior.

The company did not inform the FAA about the significant expansion of MCAS, instead falsely conveying to the agency that it was benign, according to court testimony in March 2022 from Stacey Klein, head of the FAA Aircraft Evaluation Group (AEG) in Seattle, which was tasked with determining appropriate pilot training for the 737 MAX.

Boeing withheld this information to persuade the FAA not to require specific MAX flight simulator training for pilots who were flying an earlier 737 model. Boeing convinced the FAA to require only training on an iPad for an hour. Boeing even offered Southwest Airlines a rebate of a million dollars per airplane if MAX simulator training were to be needed.

The company further convinced the FAA AEG to delete information about MCAS from the 737 MAX Flight Standardization Board Report, thereby preventing MCAS from being included in the pilot’s manual.

Boeing was subsequently charged with criminal wrongdoing related to its efforts to defraud the FAA about MCAS.

In the waning days of the Trump administration, the Department of Justice (DOJ) secretly negotiated a Deferred Prosecution Agreement (DPA) with Boeing pertaining to the criminal charges. The DPA enables Boeing to request that the pending criminal charges against it be dropped if it does not commit any crimes over the term of the agreement.

I noticed startling timing: The agreement was signed on the infamous date of Jan. 6, 2021. The Alaska 1282 door plug blowout occurred the Jan. 5, 2024, which is just a hair before the expiration of the three-year term of the DPA. Should Boeing have criminal responsibility in this blowout incident, then the earlier criminal charges arising from the Boeing’s deception of the FAA would no longer be eligible to be dropped.

The DPA specifies that Boeing pay $2.51 billion; however, the bulk of the settlement ($1.77 billion) goes to airlines, which probably would have recovered the money anyway from their own civil lawsuits. The actual criminal penalty is $243.6 million, which is less than one-tenth of the total settlement and is equivalent to the price tag of only two 737 MAX airplanes. The families of all the 346 victims share only $500 million of the settlement.

But the victims’ families were not included in the negotiation of the DPA. They filed a motion in the Northern District of Texas, where the DPA had been filed, asserting that the DOJ violated the Crime Victims’ Rights Act (CVRA) with this secret dealmaking.  In his February 2023 ruling, Federal District Court Judge Reed C. O'Connor agreed but did not nullify the agreement. The Fifth Circuit Court of Appeals ruled in December 2023 that although the lower court was not required to set aside the agreement, the families could in the future challenge an eventual motion by Boeing to dismiss the pending criminal charges against it on the basis of the DPA having been illegally negotiated. Perhaps this could open the possibility of a criminal trial with top Boeing management called as witnesses.

While Boeing CEO David L. Calhoun vowed “complete transparency” after the January 5th 737 MAX 9 door plug blowout, it should be brought to light that just six weeks before the accident, Boeing submitted a petition to the FAA for a safety exemption for its yet-to-be certified newest model of the 737 MAX family, a smaller version called the 737 MAX 7.

Boeing is requesting that the FAA proceed with certification despite the known problem of the overheating anti-ice system risking part of the engine flying off, as discussed above. A passenger was killed when pieces flew off an engine at 32,000 feet on Southwest 1380 on April 17, 2018, damaging the wing and breaking a window, which caused explosive depressurization.

Unfortunately, Boeing already succeeded in having Congress repeal the section of the Aircraft Certification, Safety and Accountability Act (ACSAA) that mandated future 737 MAX models to have an up-to-date pilot alerting system. The Engine Indicating and Crew Alerting System (EICAS) is “standard on essentially all modern airliners” according to the European Union Aviation Safety Agency (EASA). This consequential abrogation was buried on page 772 in a section entitled “Amendments to the Flight Crew Alerting Requirements” of the $1.7 trillion omnibus spending bill signed into law on December 29, 2022 by President Biden.

This is especially troubling because the requirement for the alerting system was established based on a recommendation to the FAA in September 2019 from the National Transportation Safety Board which identified the outdated alerting system as a contributing factor in the two 737 MAX crashes.

American Airlines Captain Dennis Tajer, who is the communications committee chair at the Allied Pilots Association (APA), the labor union which represents the pilots at that airline, recently commented to me that “The Boeing 737 MAX is an airplane built on executive excuses and requests for FAA exemptions from rules that keep other airplanes safe. Enough is enough. Stop this madness, fix your airplane and how you build it.”

Boeing should return to its former proud engineering tradition and cease prioritizing profits over the safety of the flying public. The FAA needs to regain its role as the global gold standard of civil aviation oversight. And Congress should not cater to the whims of the airline manufacturer in its lawmaking and must strengthen the Freedom of Information Act to ensure transparency in matters of health and safety.