Paul Njoroge sat up late on the evening of March 9, 2019, tracking a flight from Toronto, Canada, to Ethiopia’s capital, Addis Ababa.
This was the first leg of his family’s journey to visit relatives in Kenya. It was to be the trip of their lifetime.
Njoroge told the US House Committee on Transportation and Infrastructure that investigated the Boeing 737 Max aircraft that he went to bed after his family arrived safely at their layover in Addis Ababa.
He was to check in again the next day.
As he slept, his wife Carolyne, their three children — six-year-old Ryan, four-year-old Kelli, and nine-month-old Rubi — and his mother-in-law, Ann, continued their journey by boarding Ethiopian Airlines flight 302 from Addis Ababa to Nairobi, Kenya.
“It was a crystal-clear day, but within minutes of take-off the unthinkable happened; the Boeing 737 Max, a brand new aircraft with 157 passengers and crew members on board, began to dive back towards the ground as the pilots fought to force the plane’s nose back up toward the sky,” the committee says in its final report released on Wednesday. The battle did not last long.
Six minutes after take-off, Ethiopian Airlines flight 302 crashed. The jet’s impact left a massive crater in a field just a few miles from the airport. Not a single soul survived.
More than one year later, Njoroge told the committee that he is still haunted by the image of his children’s final moments.
“I have nightmares about how they must have clung to their mother, crying, seeing the fright in her eyes as they sat there helplessly. And there was nothing I could do to save them,” he said.
“I miss their laughter, their playfulness, their touch.”
His testimony is captured in the 18-month long investigation of the design, development, and certification of the 737 Max aircraft report, and related matters by the United States Congress.
Unknown to the public, on March 1, 2019, the Federal Aviation Authority (FAA) had reminded Boeing that the original level of differences training proposed in 2016 by Boeing — before the Lion Air crash — was Level B. The FAA informed Boeing that the software changes to the Manoeuvring Characteristics Augmentation System (MCAS) “may not meet the definition of Level A differences” training and advised Boeing that the company’s “evaluation is proceeding at risk. Nine days later, Ethiopian Airlines flight 302 crashed, killing Mr Njoroge’s entire family and dozens of other passengers.
Now the US Congress has issued a damning 245-page report that puts the blame of the Ethiopian and Lion Air crashes on the steps of Boeing. The report, marks the culmination of 17 months of investigations, involving five public hearings, 24 interviews and 600,000 pages of documents.
Technical design flaws, faulty assumptions about pilot responses, and management failures by both Boeing and the FAA played instrumental and causative roles in the chain of errors that led to the crashes of Lion Air flight 610 in October 2018, and Ethiopian Airlines flight 302 in March 2019, that resulted in the tragic and preventable deaths of 346 people, it said.
“[The two crashes] were 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 Federal Aviation Administration,” reads the report in part.
Mr Njoroge would soon learn that his family members were the victims of not the first, but the second Boeing 737 Max aircraft that was involved in a catastrophic, crash killing everyone on board — an extraordinary fact given the significant advances in aviation safety over the past two decades, and the fact that the 737 Max was a newly certified aircraft.
Boeing 737 Max
“The story of the Boeing 737 Max was never expected to be associated with catastrophe,” notes the report.
It adds that the aircraft was supposed to be a story of American ingenuity and technological success — a modern, more fuel-efficient airplane that had already become the manufacturing giant’s best-selling jet in its history prior to the first Max crash of Lion Air flight 610 in Indonesia in 2018.
Ethiopian Airlines flight 302 crashed five months later, just two years and two days after the FAA had certified the new 737 derivative aircraft as safe to fly. Clearly, it was not.
“The facts laid out in this report document a disturbing pattern of technical miscalculations and troubling management misjudgements made by Boeing. It also illuminates numerous oversight lapses and accountability gaps by the FAA that played a significant role in the 737 Max crashes,” the report said.
In its damning conclusion, the Congress report fingers Boeing for failing in its design and development of the Max.
The US Aviation agency, FAA, is also put on the spot for having failed in its oversight of Boeing and its certification of the aircraft.
The report also, for the first time, revealed allegations about the two airlines (Ethiopian and Indonesian) maintenance records regime and possible cover-ups after the crashes.
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“… a whistleblower with knowledge of Ethiopian Airlines’ actions in the aftermath of the March 2019 crash alleged that staff of the carrier accessed the airplane’s maintenance records the day after the accident. Such action is contrary to protocols that call for records to be immediately sealed following a crash,” it said.
The report notes that Boeing, in several critical instances, withheld crucial information from the FAA, its customers, and 737 Max pilots. The plane maker was also accused by Congress of making faulty assumptions about critical technologies on the 737 Max, most notably with MCAS.
The manufacturer is also accused of rushing through the aircraft’s production programme to compete with Airbus’ new A320neo aircraft.
This pressure, says the report, among other things, resulted in extensive efforts to cut costs, maintain the 737 Max programme schedule, and avoid slowing its production line.
The 737 Max is now the subject of multiple investigations and lawsuits around the world and will be forever associated with the tragic deaths of 346 people killed in two separate crashes, as well as one rescue diver who died attempting to recover bodies from the Lion Air crash in the Java Sea.