What went wrong with the 737 Max? Ex-Boeing factory manager speaks out

It’s a cold and wet day in Renton, but spirits are high as Boeing’s newest plane, the 737 MAX, readies for its first flight to cheers and applause. The latest version of the venerable family of airliners takes off into the leaden sky. The people watching that day could never have imagined the controversy and concern the jet would create.

But on that January day in 2016, it was all smiles and backslapping as the MAX was put through its paces.

Craig Bomben, Boeing’s chief test pilot, said at the event, “Well, if you haven’t figured it out, this is our first effort, our first airplane of our second century and I just have to say, wow, I mean, what an amazing machine.”

Little did he know that less than ten years down the line, the Boeing company would be pleading guilty to criminal fraud conspiracy following two fatal MAX crashes and at least one serious incident that risked the lives of passengers.

With the first delivery to a customer in 2017, it was just 18 months until the plane’s first deadly accident.

A 737 MAX operating a Lion Air flight from Jakarta, Indonesia, mysteriously crashed into the sea shortly after takeoff. Initial reports rumored pilot error, and Boeing quickly defended the new airliner. Just a couple of months later, an aircraft operated by Ethiopian Airlines crashed in similar circumstances soon after takeoff. The two accidents claimed the lives of 346 passengers and crew. Investigators soon realized this was no coincidence, and the finger was pointed at the plane’s onboard systems.

Specifically, the culprit was the Maneuvering Characteristics Augmentation System, or MCAS. The plane had been designed with the heavy engines further ahead of the center of gravity, and in certain parts of the flight envelope, it tended to nose up.

The MCAS system was supposed to automatically aid pilots by trimming the aircraft to pull the nose down to prevent a stall. However, when the system took control of the aircraft, it relied on just one sensor with no backup. So if it malfunctioned, MCAS could fly the plane to disaster. Allegedly, plane pilots weren’t officially aware of MCAS and its capability until after that first crash.

Immediately after that crash, aviation regulators worldwide started grounding the 737 MAX. Still, it wasn’t until two days later that the Federal Aviation Administration (FAA) in the United States reluctantly followed suit.

FAA administrator Steve Dickson remarked at a news briefing , “I will not approve the plane for return to passenger service until I’m satisfied that we’ve adequately addressed all of the known safety issues that played a role in the tragic loss of 346 lives aboard Lion Air flight 610 and Ethiopian Airlines flight 302.”

Rushed design and compromised safety

How could a world-renowned aircraft maker allow its new flagship airliner to fail so dramatically?

Ed Pierson, a former senior manager at Boeing’s 737 Factory in Renton, now director of the Foundation for Aviation Safety, says in an exclusive interview with Interesting Engineering :

“There’s been a well-documented list of problems. It started with the pre-design of the airplane, all the way through the design development, production of the plane, and now into operations. There have been repeated examples of rushed work, and shortcuts being taken, all in the effort to try to get the planes out the door and delivered as soon as possible so the company can make money.”

Pierson had a long career in military aviation before Boeing. He has given evidence to the US Congress on several occasions regarding corporate and governmental responsibility surrounding the safety of the 737 MAX.

The Boeing 737 is a venerable aircraft. It’s been around since the 1960s. The original 737s could be distinguished by being low to the ground with the engines mounted in pods underneath the wings.

The second generation, the Classic, still sat closer to the ground than its competitors. Still, its bigger engines had to be accommodated by being moved slightly ahead of the wing. The 737 design’s third iteration, the Next Generation model, arrived at the end of the 1990s. Its engine positioning is similar to the Classic’s, but the plane was getting bigger.

At this time, the airliner market was a duopoly: Boeing, the 737, Airbus, and the A320. When Airbus announced its latest version, Boeing was caught on the hop. The Airbus A320 Neo would provide better fuel efficiency and range using new technology engines. The Airbus stands higher, giving plenty of ground clearance for the new engines, which the 737 didn’t have.

Production woes

Boeing’s answer was to place the engines further forward than any other variants and rely on software to improve the flying characteristics, pushing the plane’s flight envelope.

Pierson describes the result: “Everybody knows that they were feeling pressure because of Airbus and the Neo series of planes, and they knew that they were gonna lose market share. Instead of doing it right and taking the time to do it right, they shortcutted the situation. They slapped on the engines and made a couple of modifications to the plane. They went through that, even though it took years. If you talk to the people involved in the certification, they’ll say, ‘well, it took five years’.”

“The engine took over ten years to design and develop and still doesn’t meet engineering standards. The engines, to this day, are not meeting safety standards, like an anti-icing system. It’s crystal clear they rushed the design and development of the plane, and it is absolutely 100 percent clear they rushed it through production and they’re still rushing it through production,” Pierson continued.

After the Lion Air and Ethiopian Airlines crashes, the 737 MAX was grounded for 20 months .

During that time, Boeing faced canceled orders, and no deliveries could be made. The airliner was eventually re-certified as safe to fly, and flights and deliveries resumed in early 2021. Publicly, the 737 MAX appeared to have a clean bill of health. The troubles with the plane seemed solved, and it could get back to ferrying fare-paying passengers around the globe.

That is until the Alaska Airlines flight 1282 in January 2024. Soon after takeoff, part of the cabin structure detached, causing a rapid decompression and forcing the aircraft to make an emergency landing. This aircraft had what is known as a ‘plug’ where other airlines would have an exit.

As the aircraft pressurization kicked in, the plug gave way. Luckily, nobody was killed, as passengers were still required to be wearing seatbelts at the time of the incident. But this highlighted an underlying problem with the way the planes are manufactured.

“In the United States, there are four airlines that fly the MAX airplane: American, United, Alaska, and Southwest,” says Pierson.

“Those airlines are required to submit reports when there are aircraft systems malfunctions that could potentially lead to an unsafe condition. What we’ve seen is a lack of reporting. Alaska was reporting; they were doing a good job of reporting before their accident. They reported over 1,200 aircraft system malfunctions on brand new planes, 53 brand new planes, which should be horrifying to people. How do you have all these aircraft system problems? I can trace all this back to that dangerously unstable factory environment that I was trying to get the general manager and the CEO and the board of directors to shut down before the crashes. Unfortunately, I was not successful at that,” explains Pierson.

Leadership failures and structural changes

In its heyday, the Boeing company was one of the leaders in aviation engineering and had a long history of achievement.

The B-17 was the most produced bomber aircraft during the Second World War. The 307 was the first fully pressurized airliner to see service in the 1940s. The Boeing 707 and later 747 were synonymous with the glamor of air travel. However, the company has changed over the years, and the most seismic was the merger with rival McDonnell Douglas in 1997.

It’s been argued that this was when the ethos within Boeing changed, but Pierson disagrees: “I didn’t work at the Boeing company in 1997. But my father-in-law worked there and he said that it was obviously a change of leadership, a change of priorities. But any time you have a change of leadership, there’s a change of priorities. But in this case, it was fairly dramatic, is the way it was explained to me. But I don’t buy ‘the company went bad as soon as the McDonnell Douglas merger occurred’ and all these Jack Welch financial principles.”

“The merger occurred in 1997. Since 1997, the Boeing company has hired hundreds of thousands of employees, thousands of executives, they’ve had multiple different people in the C suite. So I don’t believe that this merger was so critical that it set the stage for everything else. I don’t think this was a foregone conclusion,” continues Pierson.

The Boeing employees are very smart, he says, “so it’s not like they’re just a bunch of lemmings and they’re following the Pied Piper over the cliff. This is clearly leadership failures at all levels, not just the senior level, all the way down to the person on the floor who’s building the plane, who has to make decisions on quality and whether or not their work is satisfactory or not.”

However, the merger resulted from a divorce of senior management at Boeing from the shop floor.

In 2001, the corporate headquarters moved from its traditional home of 80 years, Seattle in Washington State, to Chicago, only to move again in 2022 to Virginia to be closer to the Pentagon. The corporate headquarters and the production center could not be further apart, potentially leading to a lack of oversight and leadership.

“I don’t think Boeing intended this to happen,” says Pierson. “I think this has just been a gigantic colossal failure of leadership at all levels. Obviously at the senior level, the board of directors, and the C Suite, you know, they set the tone for the entire company and my personal opinion is they’re really out of touch, they really don’t understand what’s happening in the factories of the Boeing company. And it’s evident by their actions and the inactions that occur.”

“The pressure to get the planes out the door. If you can imagine, you hear the company talk about their stock prices all the time and how many projected deliveries they’re gonna have. And even though at the same time they’re talking about safety and quality, it’s almost an afterthought. And then they talk about it all the time when an incident happens, but then it reverts back to the same old way of doing business,” says Pierson.

The former manager said that they were in daily contact with Boeing employees, retirees, airline staff, and FAA personnel, both current and retired. Everyone is disheartened by the company’s decline. This deterioration is largely due to failures at the senior levels and the absolute breakdown of oversight by the Department of Transportation and the FAA, says Pierson.

Following the accident, the FAA conducted audits and a safety culture survey. The findings were alarming, and the FAA acknowledged the severity of the issues. Pierson says that this should not have been a surprise to the FAA. “If they were properly doing their job, they would have identified these problems first, rather than us discovering them through incidents like door blowouts on airplanes.”

The illusion of safety

In the United States, airlines report issues with aircraft to the FAA, and the Foundation for Aviation Safety reported on the MAX data in November 2023.

Pierson describes: “We highlighted Alaska, and in a way, we complimented them because at least they were submitting the reports. They were submitting boatloads of reports, over 1200 on 53 airplanes in a two-year span of time. And I’m not talking about seat trays and minor stuff. I’m talking about flight management computer, stab trim motor, speed trim hydraulics, brakes, pressurization, autopilot, auto throttle, systems stuff that are failing. And we stated in there that this is very concerning, and what’s really concerning is, airlines overseas, like Ryanair, for example, they don’t submit reports to the FAA. The FAA really has no idea how Ryanair is performing.”

Pierson says that this is part of the illusion of safety: people believe that regulators are all-knowing, but they aren’t. For example, in the US, Southwest Airlines operates about 210 MAX airplanes, four times as many as Alaska Airlines, yet they report significantly fewer issues. It’s statistically impossible for a problem to affect only one airline’s planes

But how can all these faults appear in relatively new aircraft?

Pierson explains: “So all this data, you combine it with the removals of quality control inspections. Individual planes had thousands of inspections removed because of some idea of accelerating production, and even though a lot of those inspections were clawed back by the union, the union was able to reinstate them, there are still hundreds of airplanes, unfortunately, that left the factories without those thousands of inspections. And we’re seeing lots of evidence of these manufacturing problems, and it all stemmed back to pre-MAX crashes and the decision by the regulators not to do their damn jobs.”

There could also be an underlying issue with the value of talent in building the aircraft, which could have caused the problems. “I think it’s a wicked brew of a lack of valuing people, pressuring people, putting them under intense pressure, and misguided priorities,” says Pierson. Instead of saying we’re going to deliver 30 planes a month, we should say we’re going to deliver as many high-quality planes as we can.”

The 737 MAX fiasco has undoubtedly hurt the reputation and respect the Boeing company had earned over 100 years in the aircraft industry.

Pierson has a radical suggestion on how to win back that trust: “Well, I think that’s relatively straightforward. First of all, they need to completely change out the leadership. And what I mean by that is not just the CEO, but the C suite because those individuals in the C suite were picked by the CEO. They’ve had plenty of time to fix things, and they’ve done nothing but make things go further south. They need to admit failures, they need to admit things, instead of denying them, instead of downplaying them, they deny and downplay whenever there’s an incident. It’s always like, oh, this is kind of a one-off and really, this is unique or we’re gonna investigate it. That’s bullshit. They freaking know these issues are continuing to happen, and they need to be honest and tell the truth because you can’t fix problems unless you tell the truth. And they should welcome the FAA in and have the FAA do no-notice audits.”

Part of that wish has come true as Boeing has lost two CEOs since the crashes. Dennis Muilenberg resigned in January 2020 over his handling of the affair, and his replacement, Dave Calhoun, stepped down at the end of 2024.

Investigations by the Federal Aviation Administration have been highly critical of Boeing’s lack of quality control in manufacturing the 737 MAX.

In an interview with CNBC in January 2024, Boeing president and CEO David Calhoun said, “We will engineer answers and be certain it can never happen again. We will look everywhere around the MAX, around the Spirit factories, our own factories, our inspection processes, and we will make sure that we take steps to ensure that it never, never can happen again.”

The authorities have implemented stricter monitoring to catch potential problems. But what can you say about a once-proud company that admitted to a fraud charge against the FAA by not upholding an agreement to make safety changes following the two crashes?

The new CEO and their team face a monumental task in addressing the manufacturing and systems issues that have plagued the plane, and rebuild public trust in its aircraft and engineering.