scorecardresearch Skip to main content
Michael A. Cohen

Boeing’s deadly crashes and the failure of American oversight

Inspectors look through the wreckage of Lion Air Flight 610.Associated Press

“IT’S VERY IMPORTANT we have strong government oversight,” or so said Boeing’s chief executive Dennis Muilenberg when he testified before Congress last week, summoned to explain how two of his company’s Boeing 737 Max planes crashed four months apart, taking the lives of 346 people.

But the story of Indonesian Lion Air Flight 610 and Ethiopian Airlines Flight 302 is one of a company — and too often, an American corporate culture — more focused on profits than safety and far too capable of thwarting regulatory oversight.

For Boeing, the 737 Max was a business imperative — a more fuel-efficient version of its traditional 737 plane, built to compete with the company’s increasingly formidable competitor, Airbus.


The new planes required larger engines, but such a change affected how the aircraft would handle during flight. So Boeing devised a software program called the Maneuvering Characteristics Augmentation System, or MCAS, that would make adjustments to the aircraft if the new engines caused the plane to pitch upward.

But Boeing was worried that installation of the MCAS software could force customers into costly and time-consuming training of pilots.

The company went to inordinate lengths to keep pilots and the FAA in the dark about MCAS. Pilots weren’t briefed about it, and Boeing even pushed the FAA to take MCAS references out of the plane’s flight manual.

In both the Lion and Ethiopian Air crashes, neither of the pilots knew about MCAS or appeared to understand why the nose of the plane was consistently being pushed down. In a report by Indonesian authorities, the MCAS system was judged the primary cause of the crash.

John Cox, the chief executive of Safety Operating Systems and a long-time accident investigator, told me Boeing fell victim to a corporate culture of “groupthink” and relied far too much on long-standing assumptions about pilot reactions in the cockpit — assumptions that turned out to be wrong.


It’s a view shared by Richard Aboulifia, vice president of aviation at Teal Group, who said that Boeing’s “culture is the biggest factor here.” He said Boeing’s failure to put people with engineering knowledge in leadership positions exacerbated the problem.

Some inside Boeing did raise concerns. In company emails, released this week, employees asked as early as 2015 if MCAS could malfunction because of a single faulty sensor, which was a factor in both crashes. Plans to include an MCAS warning alert in the cockpit were dropped. It was instead made optional.

Both Cook and Aboulfia warned of placing sole blame on Boeing for the crashes — or losing sight of how safe air travel has become. “There were,” says Cook, “numerous opportunities for the manufacturer, regulators, operator, pilot, maintenance technician, and repair facility to intervene.” Indeed, one of the more shocking elements of the Lion Air crash is that the plane had been having problems for several days and yet no alarm bells were raised inside the company.

Nonetheless, when assigning culpability, Boeing’s decision-making stands out. And it wasn’t just a matter of cutting corners in the development of the 737 Max.

Boeing had successfully lobbied Congress, over the years, to neuter regulatory agencies and give the company more responsibility to monitor its own safety procedures and, in effect, regulate itself. So when it came to MCAS, Boeing had almost complete control of its approval.


Had the FAA been better informed about the system, a recent report of US and international regulators suggested, the agency likely would have given the software far greater scrutiny.

Rena Steinzor, a law professor at the University of Maryland who studies the regulatory system, says the Boeing fiasco speaks to a larger problem.

The agencies that are responsible for conducting oversight and keeping Americans safe not only lack authority, they don’t have the institutional know-how to even understand the systems they are regulating. “They’ve been under attack and underfunded for so long,” are increasingly “demoralized and decimated,” and are watching their best employees depart, says Steinzor.

Rebuilding these agencies will probably take years — particularly after the deregulatory fever of the Trump administration. But Steinzor says that a federal criminal investigation, currently underway, could hasten change. While clearly Boeing didn’t intend to kill passengers, “willful blindness” or “grossly negligent” conduct can and should be prosecuted, says Steinzor.

The Justice Department has more aggressively pursued such prosecutions in recent years. And the simple threat of a criminal penalty, Steinzor says, could force the company to take health and safety more seriously.

However we get there, it’s clear that change is required — not just at Boeing, where Muilenberg made $23 million last year and stubbornly holds onto his job, but in corporate America writ large. The foxes can no longer guard the henhouse.


Michael A. Cohen’s column appears regularly in the Globe. Follow him on Twitter @speechboy71.