The crash site of Ethiopian Airlines flight ET302 on March 11, 2019 in Bishoftu, Ethiopia. Photo / Getty Images
Ethiopian Airlines appeared to foresee the deadly confusion its pilots would face if flawed software in the Boeing 737 Max failed. Boeing chose not to provide the guidance that the carrier was seeking.
In late 2018, Ethiopian Airlines’ chief pilot sent an urgent message to Boeing, the manufacturer of the 737 Max airliner.
Barely a month earlier, a 737 Max operated by Lion Air of Indonesia had plunged into the sea, killing everyone on board. The cause appeared to be a problem with the plane’s flight control system.
The Ethiopian carrier also flew the 737 Max, and the chief pilot wanted more information from Boeing about the emergency procedures to follow if the same problem that doomed the Lion Air flight should recur. At the time, Boeing was providing detailed briefings to pilots in the United States who were asking the same types of questions about how to respond.
But Boeing chose not to answer the Ethiopian pilot’s questions beyond referring him to a public document it had already issued after the Lion Air crash. Boeing said in its response that it was prohibited from giving additional information because it was providing technical support to Indonesian authorities investigating that crash.
Instead, Boeing briefly summarised the document, which is dated November 6, 2018, and is called an operations manual bulletin, according to email exchanges between the chief pilot and Boeing made public after The New York Times initiated legal action to unseal filings in a related criminal case.
Three months after the request by Ethiopian Airlines, one of its 737 Max jets nosedived into the ground after takeoff from Addis Ababa, Ethiopia’s capital, killing all 157 people on board. The main cause was found to be the same flawed flight control system responsible for the Lion Air flight crash, a failure that presented the Ethiopian Airlines pilots with the very same kinds of life-or-death decisions about how to respond that the chief pilot had asked about months earlier.
While it is unclear whether the Ethiopian Airlines pilots could have avoided crashing had Boeing provided a more detailed response, aviation experts said the lack of additional information most likely contributed to the inability of the pilots to pull themselves out of a fatal nosedive once the flight control software system malfunctioned.
“Who knows what they would have done with the information, but not having it seals the deal,” said Dennis Tajer, a spokesperson for the Allied Pilots Association, which represents American Airlines pilots.
“Any information given to the Ethiopian pilots, like we had, could have made the difference between life and death,” said Tajer, who is also a pilot who flies the 737 Max and another 737 model.
After the Lion Air crash, Boeing executives sought out US pilots to brief them on topics that were not discussed with the Ethiopian pilots, including long-term strategies for improving flight safety, a recording of the briefing shows.
The briefing for American pilots included a detailed explanation of the flight control system that failed, known as MCAS. Boeing executives touched on its operational role and spoke about technical issues vital to pilots, including how the system interacts with the angle-of-attack data, or the angle at which the wind strikes the wing. They aimed to enhance pilots’ comprehension of the system and to underscore the system’s complexity.
The company’s representatives highlighted efforts to address and clarify what they called misunderstandings related to MCAS. They pushed for training that would extend beyond routine checklists, focusing instead on equipping pilots with a thorough understanding of system behaviours and potential failures.
Despite the constraints Boeing described in the response to the Ethiopian chief pilot, Boeing officials discussed numerous details of the Lion Air crash.
According to the email exchange with Ethiopian Airlines around the same time, the chief pilot happened to be seeking guidance similar to what was shared in the briefing. A few days after attending a teleconference Boeing held for all users of the 737 Max, or a fleet call, the pilot emailed to ask what to prioritise in the event of multiple emergencies involving MCAS and angle-of-attack data. Such emergencies could overwhelm pilots with caution lights, audible sounds and seemingly conflicting warnings.
Tajer, who attended the meeting Boeing held with American pilots and who put several questions to Boeing representatives himself, said: “Our meeting with Boeing covered the same questions that the Ethiopian pilots were asking. It’s clear that they had the same questions we had but did not get the answers that we got from Boeing.”
The emails obtained by the Times are being used by families of the victims of the crash as they pressure the Justice Department to take a harder line with Boeing over its culpability and to convince a federal judge to not accept a plea agreement reached between the company and federal prosecutors. And the emails support some of the conclusions of an investigation by the Ethiopian Government into the crash.
The Ethiopian report, released in December 2022, found that if Boeing had provided more information to the carrier’s pilots about how to respond in the event of a software malfunction, they might have been able to regain control of the aircraft.
“The investigation found the questions raised by the airline to be safety critical, and if Boeing had answered the questions raised by the training department either directly or indirectly,” the report said, the outcome might have been different.
The Ethiopian investigators also had access to the emails between the chief pilot and Boeing and included them in their report. But Boeing’s unwillingness to provide the airline with more detailed guidance went largely unnoticed at the time.
The Justice Department investigated Boeing’s role in both the Lion Air and the Ethiopian Airlines crashes. It learned of the emails before reaching a 2021 deal that allowed Boeing to avoid criminal prosecution, a person familiar with the investigation said. The 2021 deal required that Boeing pay more than US$2.5 billion ($4.1b) to resolve a criminal charge of conspiring to defraud the federal government, specifically the Federal Aviation Administration. The terms of the 2021 settlement also required Boeing to abstain from any misconduct for three years.
The emails – which were not made available to congressional investigators in the United States and only came to the attention of some families of those killed in the crash last year – are now part of an effort by the families to block the plea deal.
The families argue that the agreement does not do enough to hold Boeing and its executives responsible for the crashes or to address what they see as deep-rooted problems in Boeing culture and operations that are leaving air travellers at risk.
The Justice Department will defend its proposed criminal plea agreement with Boeing on Friday in front of a federal judge in Texas. The judge is set to hear argument from all parties before deciding whether to accept the agreement.
The emails stand in sharp contrast to Boeing’s initial efforts to suggest that the Ethiopian crash was partly the result of pilot error.
“We will never forget the lives lost on these flights and their loved ones,” Boeing said in a statement in response to questions about the emails. “Their memory and the hard lessons we learned from these accidents drive us every day to uphold our responsibility to all who depend on the safety and quality of our products. Boeing cooperated fully and transparently with all investigations into the accidents.”
Ethiopian Airlines did not respond to a request for comment.
Boeing is facing several other federal investigations into safety and quality issues in the wake of an incident on January 5, when a door plug on an Alaska Airlines 737 Max 9 jet blew off during a flight. The Justice Department, FAA and National Transportation Safety Board have all opened inquiries into the incident.
Earlier this year the Justice Department found that Boeing violated the 2021 agreement reached after the Max crashes, saying the aircraft manufacturer failed to create and maintain a programme to detect and prevent violations of US anti-fraud laws.
As a result, the Justice Department reinstated the felony charge of conspiracy to defraud the federal Government. The department and Boeing ultimately reached a proposed agreement where the company could plead guilty to the conspiracy charge and avoid a public trial.
The families have asked the federal judge who must decide whether to approve the revised plea deal to consider evidence including the questions Ethiopian Airlines posed to Boeing before the crash.
“It’s outrageous that Boeing refused to answer direct questions from the Ethiopian airlines pilots,” said Paul G. Cassell, a lawyer representing families of victims of the fatal plane crashes. “That was vital safety information that would have saved 157 lives. Boeing put continuing its conspiracy of concealment ahead of passenger safety, killing all those on board.”
In retrospect, the questions being asked by Ethiopian Airlines were frighteningly prescient.
During the doomed Ethiopian flight, pilots appeared to struggle with some of the same issues for which the chief pilot requested clarification. For example, the first set of warnings had not been resolved by the time a new set began flashing as the MCAS glitch kicked in. That led to debate over whether the pilots could have cut through that confusion and saved the plane if they had been given more effective guidance about how to respond.
With only minutes to react when the MCAS, short for Maneuvering Characteristics Augmentation System, erroneously pitched the nose of the plane down after takeoff, the pilots were not able to disable the system quickly enough, and the plane plunged into the ground.
In declining to answer some of the specific questions from the Ethiopian chief pilot, Boeing cited a provision, known as Annex 13, which governs crash investigations and was established by the International Civil Aviation Organisation, a United Nations agency.
The provision’s main goal is to provide safety information and data to help avoid future accidents. It makes clear that investigations should not be about figuring out who is to blame. Boeing has argued that its decision not to share more information was validated by the NTSB, though the board has disputed Boeing’s characterisation of its position.
“I am not aware of any incidents where that article has been used to prevent the transfer of critical safety information,” Jim Hall, a former chair of the NTSB, said of Annex 13.
Naoise Connolly Ryan, who lives in Ireland with her two young children, lost her husband, Mick Ryan, in the Ethiopian crash. She is among those leading the push to halt the plea agreement reached between Boeing and the Justice Department.
Ryan criticised Boeing for holding back safety information from airlines, calling it criminal and suggesting it could have prevented the Ethiopian crash. She said Boeing had no right to use the investigation as an excuse for not sharing what she called crucial information.
Ryan said she did not know why the Justice Department had not dug deeper into the matter.
“If someone had decided to do the right thing, and someone had a conscience and someone put lives and safety above their own corporate interests, then my husband, I believe, would have been alive today,” Ryan said.
Erin Applebaum, a lawyer who represents 34 of the families who lost loved ones in the Ethiopian Airlines crash, said the families want accountability, not money, from Boeing.
“They want the public to know what happened between those two crashes, what the executives knew and when they knew it,” she said. “Could they have prevented the second crash, did they purposely choose not to take action, and did 346 die as a result?”
“The only way to achieve true accountability is through a public trial,” she added. “That is the only satisfactory outcome for the families: Boeing executives being put on trial and held accountable for what they did.”
This article originally appeared in The New York Times.
Written by: Mark Walker and James Glanz
Photographs by: Lindsey Wasson
©2024 THE NEW YORK TIMES
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