‘Boeing played Russian roulette with people’s lives’

The crash site is empty now condoned off by a row of wooden posts

The crash site is empty now condoned off by a row of wooden posts

After being grounded for more than a year and a half, Boeing’s 737 Max has been cleared to fly once again.

Boeing insists it has learned hard lessons from two deadly crashes - but families of the victims say unanswered questions remain.

It was still dark when the plane came in to land. Mark and Debbie Pegram, and their younger son Tom, looked out towards the runway from the deserted terminal building.

When they saw the tell-tale red writing down the side of the aircraft, and the elongated green, yellow and red triangles on its tail, they were overcome with emotion. 

It was the only Ethiopian Airlines plane arriving into Manchester that October morning, and on board was the coffin of 25-year-old Sam Pegram.

The family knew this was going to be a painful moment. However, it had been seven months since Sam had died. So, amid the intense loss and heartbreak, they also felt relief that it had finally arrived.

The humanitarian worker from Penwortham in Lancashire boarded an Ethiopian Airlines plane in the Ethiopian capital Addis Ababa, on 10 March 2019. Six minutes after take-off, the Boeing 737 Max aircraft crashed. No-one survived. 

It took investigators six months to match DNA samples taken from the family and Sam’s belongings, to remains recovered from the crash site. 

Sam Pegram

Sam Pegram

Sam Pegram

Sam Pegram

Earlier, his family had shown their passports and had been escorted through security at Manchester Airport. 

Family liaison officers were with them, along with someone from the UK Foreign Office, an inspector from Sussex Police and a representative from the coroner’s office.

As they stood overlooking the gate where the plane would park, officials stood back to give them some space.

An airline official carried the family’s single yellow rose and another bunch of flowers down to the plane. 

A union flag was draped over the shipping crate containing the coffin. As ground crew formed a guard of honour, it was moved to a waiting ambulance, and taken to clear customs.

It wasn’t until later that morning, at the undertakers, that Debbie, Mark and Tom were finally able to spend time with Sam in a private room.

The premature end to Sam’s life and that of 156 others could have been avoided. 

The Boeing 737 Max aircraft they were travelling on had fatal design flaws – and it was not the first to be involved in such a tragedy.  

A near-identical 737 Max had crashed off Indonesia five months earlier, in chillingly similar circumstances.

But tragically, after that crash, the aircraft was not grounded.  

And that was why “gentle” Sam, who his family remember as a kind, energetic young man, was able to board the Ethiopian Airways flight that morning.

Debbie believes it was Boeing’s “greed” that took him from her. “We want someone from Boeing to look us in the eye and explain why our son isn’t here.”

She says she will never again feel her son’s infectious energy nor receive his caring text messages. 

 “It’s all about money. They played Russian roulette with people’s lives.” 

“Nobody should have been on those planes.” 

The 737 Max was grounded worldwide for 20 months. Now, regulators in the US have finally given it permission to fly again. They insist it has been made safe. 

Nevertheless, the families feel distraught that it is being allowed back in the air.

The crash site in March 2019

The crash site in March 2019

Since the 737 Max was grounded, its design and construction have been pored over in minute detail by investigators and regulators from several different countries.

To fly again, each plane will have to undergo significant modifications, although the changes will not be visible from the outside and passengers will not notice any difference.

Before the grounding, the company had already delivered 385 aircraft from the 737 Max family to airlines.  About 450 have been built and are awaiting delivery.

Grounded 737 Max

The biggest alterations concern the flight control software known as MCAS – or Maneuvering Characteristics Augmentation System.

It was originally installed on the Max because of handling problems caused when large modern engines were installed on the existing 737 airframe.

It was meant to make the plane more stable, and to make the controls feel more familiar and predictable to pilots used to older versions of the 737.

The system was only ever meant to operate when the plane was flying at a high angle of attack, with its nose up and wings at a relatively steep angle relative to the airflow, approaching a stall.

It worked by using the horizontal stabiliser – the small wings at the tail of the aircraft either side of the tailfin – to push the nose of the aircraft downwards, countering an aerodynamic quirk that made it want to rise further.

But MCAS was deeply flawed. In both accidents, the system became active when it should not have done.

It became, for the pilots, a malevolent force – repeatedly pushing the nose of the plane down, when they were desperately trying to gain height. It was simply too powerful and too persistent for them to overrule.

This happened because MCAS relied on data from a single external sensor to determine the angle of attack of the plane, even though there were two of them available. When that sensor malfunctioned, it received bad data, and deployed at the wrong time.

Meanwhile, pilots were initially unaware the system even existed – US lawmakers later alleged Boeing had deliberately concealed the fact from them – and had not been trained to recognise or deal with failures.

Boeing denies deliberately concealing any information from its customers.

Now, Boeing has made significant changes to the MCAS software. For a start, it will have to use data from both “angle of attack” sensors. If those sensors give significantly different readings, the system will not activate at all. And a warning light on the flight deck, to alert the crew of a potential sensor failure, will have to be operational.

When MCAS does activate, it will only do so once – rather than deploying repeatedly, as it did on the crashed planes. And it will be less powerful. The crew must be able to override it simply by pulling back on their control columns.

The regulator in charge of ensuring aviation safety in the US, the Federal Aviation Administration (FAA), has demanded changes to cockpit procedures, and has mandated new training requirements for pilots. This will include specific training linked to MCAS and “associated failure conditions”, which will involve time in a simulator.

There will also be a change unrelated to MCAS, to counter a separate potential hazard found during the FAA’s review of the 737 Max design. Two sets of wiring for controls at the rear of the aircraft, including the horizontal stabiliser, were found to be too close together, in breach of FAA rules.

These wires will have to be rerouted, to prevent a possible short-circuit causing the stabiliser to move on its own, potentially causing a crash – although the risks of that happening are understood to be very remote, and Boeing resisted the change.

The revised design is the result of a huge engineering effort, which has included some 1,300 test flights. The FAA has estimated the cost of carrying out the changes at more than $1m (£754,000) for each aircraft that needs to be modified.

So will all this be enough to make the 737 Max a safe aircraft? Pilots spoken to by the BBC believe it will. They say the design has been changed, crews know how the system works and will be properly trained to deal with failures. They know, too, that the scrutiny of the 737 Max’s design has been unprecedented.

Others are more sceptical. Lawyers representing the families of victims of the ET302 crash claim the plane has a fundamental flaw that has not been addressed. They say the position and size of its engines mean it is “inherently aerodynamically unstable” and it remains potentially dangerous.

Boeing rejects that suggestion. 

Its view is supported by Bjorn Fehrm, an aeronautical analyst at consultants Leeham News. “The aircraft is perfectly flyable without the MCAS software,” he says - pointing out that the system is not actually meant to deploy during normal flight. 

The FAA itself says that “with MCAS inoperative, the Boeing 737 Max is capable of continued safe flight and landing”.

Meanwhile, critics of Boeing and the FAA claim the flawed design of the 737 Max was merely a symptom of a much wider disease. They believe that a corporate culture at Boeing prioritised profit at the expense of safety, and that the regulatory culture failed to keep the aerospace giant in check.

Airteam Images

Airteam Images

The sheer, obscene violence of a plane crash can be hard to imagine.  When Ethiopian Airlines flight ET302 hit the ground just minutes after takeoff,  it was travelling at more than 500mph.

The massive impact simply obliterated the aircraft, forming a crater some 10m deep. Heavier parts, such as the engines, buried themselves in the dark earth, while lighter pieces were scattered across the surrounding fields. Months later, they were still lying there.

Remote as it was, the crash site was rapidly besieged by investigators, government officials and people from surrounding villages. Diggers set to work retrieving wreckage. And soon, the families of the victims gathered at the site to grieve.

In the US, politicians launched a far-reaching investigation.

The official inquiry, led by the Ethiopian authorities, quickly homed-in on the MCAS software as the probable immediate cause of the disaster.

The House Committee on Transportation and Infrastructure in the US Congress had a different brief, however. Led by Democrats Peter DeFazio and Rick Larsen, it decided to investigate the entire process of design, development and certification of the 737 Max itself, to find out why an apparently flawed aircraft had been cleared to fly passengers in the first place.

What went wrong inside Boeing's cockpit?

The committee released its final report in September this year, and its conclusion was scathing.  The Max crashes, it said, were not the result of a single failure, technical mistake or mismanaged event. They were instead:

 “…The horrific culmination of a series of faulty technical assumptions by Boeing’s engineers, a lack of transparency on the part of Boeing’s management, and grossly insufficient oversight by the FAA.”

The report painted a picture of Boeing as a business under intense financial pressure - first to get the 737 Max in the air, and then to maximise production at all costs. The desire to meet these goals, it said, had jeopardised the safety of the flying public.

The FAA, meanwhile, had become the victim of “regulatory capture” by the very company it was meant to be overseeing. In other words, it was acting in Boeing’s interests rather than protecting the public.

“It’s mind-boggling,” said Congressman DeFazio afterwards. “Both the FAA and Boeing came to the conclusion that the certification of the Max, which killed 346 people in two accidents just a few months apart, was ‘compliant’ – that’s the bureaucratic word, it was compliant.

“But the problem was, it was compliant, and not safe. And people died.”

A memorial for the victims of the Ethiopian Airlines crash

A memorial for the victims of the Ethiopian Airlines crash

Among those called to testify was Boeing’s now former chief executive Dennis Muilenburg.

Visibly deeply uncomfortable as he faced unremitting harsh questioning while sitting yards away from relatives of those lost aboard ET302, he admitted that Boeing had “made some mistakes” on his watch and “discovered some things we didn’t get right”.

He brushed off calls for his resignation – but within a few weeks he had left the company anyway.

And although Mr Muilenburg insisted that safety had always been a core value for Boeing, lawmakers later heard allegations that the company had ignored emphatic warnings about problems with the 737 Max programme.

Dennis Muilenburg testifies before the Senate committee

Dennis Muilenburg testifies before the Senate committee

Boeing’s factory in Renton, some 13 miles (21km) from Seattle, is the beating heart of the US aviation industry. According to the company, some 11,600 planes have rolled out of its gargantuan hangars over the years. This is where each generation of the 737 has been built - including the Max. At its peak, it can build an entire aircraft in just 10 days.

But such speed, according to insiders, has its dangers. And in 2018, a senior manager on the production line, Ed Pierson, emailed the head of the 737 programme to warn that the rush to produce new aircraft was causing serious problems.

“I know how dangerous even the smallest of defects can be to the safety of an airplane. Frankly right now all my internal warning bells are going off. And for the first time in my life, I’m sorry to say that I’m hesitant about putting my family on a Boeing airplane,” he said.

The email was sent on the 9 June 2018 – nearly five months before Lion Air Flight 610 plunged into the Java Sea. 

In December 2019 Mr Pierson found himself a star witness before the congressional committee.  

A navy veteran with decades of experience in aviation, he told lawmakers how he had become deeply concerned about the “chaotic” and “dysfunctional” state of the factory – to the point where he had asked for the entire 737 Max production line to be shut down. But his request got nowhere, and he left the company soon afterwards.

Boeing factory, Renton, Washington

Boeing factory, Renton, Washington

Mr Pierson had been working in the Renton factory for three years. By mid 2018, it was producing 47 aircraft every month - and was about to increase that number to 52. But the pressure to build at such a rate was already taking a heavy toll.

“We were having horrible supply chain problems,” he now remembers. “We had a huge backlog, thousands of jobs behind schedule.”

Tasks which would normally be carried out in a rigidly-planned order on the production line were being done out of sequence. Unfinished aircraft were standing on the tarmac outside the factory, while employees were being asked to work huge amounts of overtime. Many were simply exhausted.

“Everything was indicating to me professionally that this was not safe at all, and we needed to stop the line temporarily, fix the problems,” he says.

“But there was this tremendous schedule pressure to get these airplanes out the door.”

Mr Pierson says he told the head of the 737 programme, Scott Campbell, that he had seen operations in the military shut down over less substantial safety issues.

“The military isn’t a profit-making organisation,” Mr Campbell allegedly replied.

Mr Pierson retired soon afterwards. But following the Lion Air crash he took his concerns back to Boeing, even writing directly to the chief executive and board – urging them to investigate conditions at Renton.

He was subsequently told the company had seen nothing “that would suggest the existence of embedded quality or safety issues”.

Boeing later said it had taken Mr Pierson’s concerns seriously, and had devoted significant resources to maintaining production quality. But it insisted that the suggestion of a link between production conditions at Renton and the two accidents was “completely unfounded”. It emphasised that none of the authorities investigating the crashes had found any such link.

Mr Pierson got a similar response when he took his concerns to the US National Transportation Safety Board, the US agency which was assisting with the investigation into ET302. Its response was that they fell “outside the scope of the NTSB’s role in the 737 Max investigations”.

But Mr Pierson says this misses the point. He still believes that conditions at Renton were highly relevant to the Max investigation, not least because, he claims, they showed a profit-driven corporate mentality at Boeing.

And he emphasises that the failure of sensors originally fitted in the factory were a major part of the chain of events leading to the crashes.

US lawmakers were shocked at his testimony – and ordered the FAA to investigate conditions at Renton. But while officials did subsequently speak to him, Mr Pierson insists they failed to follow-up on his allegations. Almost a year later, he feels deeply disappointed.

“I feel like they’re paid by tax dollars to do their job. But they resisted, they delayed, they blocked,” he says

“I’m not happy. I think all of us have been let down.”

The FAA says it has inspectors on site at Renton on a daily basis - a situation that predated Mr Pierson’s testimony. And it points out that for much of this year, the 737 Max production line was shut down after Boeing decided to suspend building the plane.

But Mr Pierson is not the only former Boeing employee to claim that production and cost pressures may have undermined safety standards at the company – and concerns are not confined to the 737 production line.

Boeing’s plant at North Charleston, South Carolina, makes the 787 Dreamliner, a popular long-haul airliner. John Barnett, a former quality control manager at the factory, has previously told the BBC he believes that a rush to get new planes out of the factory caused serious quality problems.

He claims, for example, that during his time at the plant, under-pressure workers deliberately removed substandard parts from scrap bins and fitted them to aircraft on the production line in order to save time – in at least one case with the knowledge of a senior manager.

He also alleges that procedures meant to track parts through the factory were not followed – allowing a number of defective items to be “lost”.

In 2017, following up on his claims, the FAA did identify a number of cases in which non-conforming parts had gone missing. Boeing insists that it has since fully resolved the situation and implemented corrective action.

Another former quality control employee at the plant, Cynthia Kitchens, has made similar allegations. In 2011, she complained to regulators about substandard parts being deliberately removed from quarantine bins and fitted to aircraft, in an attempt to keep the production line moving.

She also alleges employees were being told to overlook substandard work, and says defective wiring bundles, containing metallic shavings within their coatings, were deliberately installed on planes – creating a risk of dangerous short-circuits.

Aircraft with such wiring, she told the BBC, may still be flying today.

“It gets scarier every day I think about it,” she says.

Boeing has not responded to these specific allegations - but says Ms Kitchens resigned in 2016 “after being informed that she was being placed on a performance improvement plan”.  It points out that she subsequently filed a lawsuit against Boeing “alleging claims of discrimination and retaliation unrelated to any quality issues”.  The lawsuit was dismissed, and Ms Kitchens had to pay Boeing’s costs. 

Since the tragedies involving Lion Air 610 and ET302, the aviation world has changed beyond recognition. The Covid epidemic has had a catastrophic effect on air travel, forcing carriers to cut most of their flights and keep planes on the ground.

The booming market the 737 Max was designed for has disappeared - for the moment at least. It is not expected to recover for the next three or four years – meaning that airlines which once clamoured for new planes are trying to delay their orders. The pressure to produce planes as fast as possible has evaporated.

The crisis has been dreadful news for Boeing’s business. In the first nine months of the year, it lost $3.5bn, and it is in the process of cutting 30,000 jobs. But it has been able to focus on returning the Max to service – and the aircraft is likely to continue operating for decades.

Boeing headquarters, Chicago, Illinois

Boeing headquarters, Chicago, Illinois

Boeing headquarters, Chicago, Illinois

Boeing headquarters, Chicago, Illinois

Boeing insists it is a different company now. It commissioned a major review of its operations after the grounding of the Max, which was carried out by a committee of independent directors. The outcome was a 10-point plan to improve its safety procedures from design through to delivery.

Mr Muilenburg’s replacement David Calhoun has promised to hold the company to the highest standards of safety, quality and integrity. The FAA, meanwhile, says it remains “committed to continually advancing aviation safety”.

Yet doubts persist. In its final report, the House Transportation and Infrastructure Committee stated that:

“... producing a compliant aircraft that proved unsafe should have been an immediate wake-up call to both Boeing and the FAA that the current regulatory system… is broken.

“Unfortunately serious questions remain as to whether Boeing and the FAA have fully and correctly learned the lessons behind the Max failures.”

Critics of Mr Calhoun, who has been a director of Boeing for more than a decade, say he is the wrong man to lead a far-reaching cultural change at the company. They claim he is tainted by the failures of the past.

And the families of those who died on ET302 insist the plane should not be flying. Their campaign – known as #AxeTheMax –  is continuing.

They have already testified before the US Congress and met with regulators in the US and Europe. They are also suing Boeing, whose negligence and mistakes, they say, killed their loved ones.

They accept, however, that their efforts to get the 737 Max grounded for good never really had much chance of success. Adrian Toole, who lost his daughter Joanna, claims that the forces lined up against them were “just too powerful”.

Joanna Toole

Zipporah Kuria, whose father Joseph Waithaka was also killed, agrees. She believes the industry simply could not consider abandoning the design.

“The moment this plane is permanently grounded, it’s a form of defeat for them,” she says.

Joseph Waithaka and Zipporah Kuria

But although they know they cannot prevent the Max from returning to the skies, the relatives hope that their efforts will help prevent future tragedies.

In the meantime, says Ms Kuria, “I pray the plane is as safe as they say it is.”


Authors: Theo Leggett and Tom Burridge

Producer: James Percy

Photos: Warren Smith, Reuters, Getty Images, Family handout

Graphics: Lilly Huynh, Tom Housden, Gerry Fletcher, Salim Qurashi

Editor: Kathryn Westcott

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