Netflix’s Boeing Documentary, Downfall…and all that it missed…
I teach writing and disaster analysis for the Math and Statistics department at Queen’s University in Kingston, Ontario. As part of the course, we do an in-class inquiry regarding the two crashes of the 737 MAX 8 aircraft. So, as it is something that my students will probably come across, I had to check out Downfall, the Netflix documentary on Boeing and the crashes that dropped today. And, it was…passable. Mostly.
In fairness, a documentary film is not an official crash report, or a proper crash investigation. It is a narrative, one that is streamlined to avoid as much unnecessary complexity as possible. Unfortunately, in the case of this documentary, this means that pertinent information was missed, left out, or in at least one case, outright misrepresented.
For background, part of the framework of accident investigation is that an incident such as an airliner crash has no single cause. The framework I teach, HFACS (Human Factors Analysis and Classification System) divides the causes into unsafe acts (errors and violations) and underlying conditions (an earlier form of this system, created by James Reason, was called “Swiss Cheese”). All must be present for the aircraft to crash — without multiple factors, the organizational layers of defence hold, and the plane lands safely.
To apply this to the documentary, there can be no doubt that Boeing created an aircraft that crashed very easily under a certain set of conditions. But a lot had to go wrong for these conditions to occur in the first place, and then even more had to go wrong for this to result in a crashed aircraft. So, where does the documentary go wrong in its presentation of the “Boeing entirely at fault” narrative?
The Misrepresentation of Lion Air 610
Of both of the MAX 8 crashes, Lion Mentari Air 610 was by far the most preventable. There was absolutely no reason that aircraft should have crashed. But, here the Netflix documentary engages in outright misrepresentation to avoid muddying the events with the fact that Lion Mentari Air bears quite a lot of its own responsibility for the crash.
You may have noticed that the cockpit recording recreation was “based on” the transcript of the actual crash flight cockpit recording. Why, you might wonder, did they not use the actual recording, or quote the transcript directly? Put simply, because in reality it was chaos in the cockpit.
The pilot and co-pilot did not work well together — the pilot was known to have weaknesses in crew management, and the co-pilot had trouble carrying out instructions (such as checking non-normal checklists) in chaotic situations. And the situation was chaotic. Because the pilot never declared a state of emergency, air traffic control sent them a a steady stream of navigation instructions. So, in the middle of trying to diagnose the problem, the flight crew was being interrupted over and over again. None of this comes out in the documentary, which presents the crash as a situation where the aircraft just nose-dives while the pilot tries to calmly diagnose the problem.
But the most damning indictment of Lion Mentari Air is that Lion Air 610 was allowed to take off at all. What the documentary doesn’t mention is that 610 was the SECOND flight in which that aircraft had erroneous MCAS activations. In the flight before, the aircraft nose-dived several times, but the flight crew correctly diagnosed the problem and safely landed the airplane. At this point in time, the plane should have been grounded. But, it wasn’t — the flight crew miscategorized the problem in their post-flight write-up, and despite how obvious it was that something was very, VERY wrong, the plane was cleared for flight.
This is far from the only damning role Lion Mentari Air played in the crash — according to the final report, the AOA sensor that failed was a refurbished one from another aircraft, in which it had also been faulty. Next to no oversight was exercised over the contractor who tested and installed the sensor in the crash plane, which was tested in a non-standard manner, and no results were recorded.
Boeing certainly created the situation in which a plane could crash due to an faulty AOA sensor — but if the final report of the Lion 610 crash teaches us anything, it is that not only was this a recoverable situation, but that there was ample warning and time in which the plane should have been grounded, which would have prevented the crash.
Ethiopian Air 310: Close Enough?
The documentary correctly presents Ethiopian Airlines 310 as a damning indictment of Boeing, in which the crash pilot followed the instructions to disable MCAS when it triggered, but the aircraft crashed anyway. Unfortunately, it doesn’t really talk about why the plane couldn’t be trimmed. The reason it gives is that the plane was travelling too fast, which is, well, not really the entire truth.
The entire truth, in fact, is far more damning towards Boeing.
The fact of the matter is that at just about any speed, there is no aircraft that cannot be trimmed using the manual trim. Now, there is a general exception: if the aircraft is going fast enough at too steep an angle, the air pressure against the stabilizer is so great that it becomes impossible for it to move and trim the airplane. This, however, is not what happened to Ethiopian Airlines 310.
The thing is that there is a specific exception to this rule, and that is if the aircraft is a 737. The 737 has a design “quirk” — if it is in mistrim (meaning the aircraft requires pressure to the control column to keep it in trim) and the electric trim is deactivated, the stabilizer locks up. This is a decades-old problem across most models of the 737, and one with a known solution: you take your hands off the column, allow the plane to trim to the angle it wants to go to (in the process freeing the stabilizer), and then manually trim the plane. Pilots called this variations on the “Rollercoaster” method.
This information, however, stopped being included in 737 manuals back around the mid-1980s.
So, what happened to the pilot of Ethiopian Airlines 310 was that he successfully diagnosed and troubleshot the MCAS activation, only to fall prey to an older, long-undocumented design issue in the plane that nobody had been trained on in around 30 years.
The Motivations of Boeing
If you watch the documentary, it would be very easy to come away with the impression that Boeing acted entirely on its own out of sheer corporate greed. But, the actual situation was far more complicated than that. As sworn evidence in the House Committee Final Report demonstrates, the 737 MAX 8 wasn’t originally supposed to exist at all. Boeing’s answer to Airbus upgrading an older aircraft was going to be designing and producing an entirely new aircraft, a replacement to the 737 (which would have, in turn, gone through an entirely new certification process). But this was then scuttled and a mad race to upgrade the 737 started instead.
So what happened?
In 2011 the CEO of Boeing received a phone call from the CEO of American Airlines — a company that had exclusively bought Boeing aircraft for the past ten years and one of Boeing’s biggest customers — which told them that American Airlines was about to move over to Airbus, and if Boeing wanted to keep them as a customer, they had to provide a competing aircraft, and fast. As a result, Boeing could either cancel its plans for a new small airliner and upgrade the 737, or lose yet another major customer.
But Boeing also had negotiated itself into a corner with at least one major customer. Making one of the major selling points of the MAX 8 the lack of any needed simulator training, they committed in the sale contract to a $2 million rebate per airplane sold if any simulator training proved to be necessary. Over hundreds of planes delivered, this would amount to hundreds of millions of dollars lost.
This is not all that is missing from the Netflix documentary, and all of this (with the exception of the links regarding the prior 737 stabilizer issue) can be found in the official crash and investigation reports. The role of the FAA, which is presented as near-blameless (outside of being slow to ground the aircraft), amounted to something bordering on, if not crossing into, outright collusion to get the aircraft certified. Ethiopian Airlines tampered with the crash plane’s maintenance log after the crash, and a whistleblower came forward alleging that the government-owned airline was going as far as to jail and torture maintenance workers who didn’t get aircraft back into the air regardless of airworthiness.
It’s not surprising that so much is missing — the 737 MAX 8 crashes are very complicated situations with a lot of moving parts. But, presenting this as solely the fault of Boeing does a massive disservice to understanding the MAX 8 crashes. Boeing is indeed guilty of putting out an unsafe aircraft and trying to cover up the existence of MCAS. But other factors were involved, without which these aircraft would not have crashed.
