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Their lives ended in a nano-second, obliterated with the airplane.

It was the most violent kind of air crash: a nosedive into the sea at high speed with the engines running at full power.

There were 181 passengers aboard Lion Air Flight 610 on October 29, 2018. Of those, 178 were adults, one was a child and two were infants. All but one of them were Indonesian. The exception was an Italian adult. Of the eight flight crew who died, onethe co-pilotwas Indian and the remainder were Indonesian.

Many of the graves of the victims contain only body parts, painstakingly identified from their DNA; of many others there was no trace.

Over the year since then most of the reporting, including mine, has been focused on the deeply flawed machine involved, the Boeing 737-MAX, and on the culpability of Boeing and the regulator that cleared it as safe to fly, the Federal Aviation Administration (FAA). The worlds fleets of 737-MAX jets were not grounded until a second very similar crash on March 10 this year in Ethiopia that killed another 149 passengers and eight crew.

The fact that all but two of the victims of the Lion Air crash were Indonesian has a story to tell. Basically, its about geography. Indonesia is the worlds largest archipelago, spread over 3,200 miles (slightly more than the distance between New York and San Francisco) and includes more than 17,000 islands.

This meant that there was no way for Indonesia ever to embrace the two great 20th-century land-based unifiers of travelrailroads and highways. Nor was it possible for air travel to compensate for that absenceuntil the arrival of a new great leveler, the budget airline.

A new way of life became possible as part of the second great revolution in air travel.

Lion Air is one of Asias fastest growing budget carriers. Flight 610 was flying from Jakarta to Pangkal Pinanga distance of only 287 miles on what should have been a quick and routine flight. Regular flying is one of the biggest changes to the lives of Indonesians, giving them the ability to hop on a small jet and go to any of the countrys cities.

This new way of life became possible as part of the second great revolution in air travel. The first was the Jet Age, beginning in the late 1950s, that dramatically shrank the distances between continents. The second was the coming of the budget airline for domestic routes, which began in the 1970s.

And one airplane became the worlds workhorse for budget airlines, the Boeing 737. It was never part of Boeings original plan, conceived in 1964, for their smallest jet. It was intended for regularly (and excessively) priced domestic routes.

But when U.S. airlines were deregulated in 1978 the two things converged: cheap flights and the 737, which was ideally sized for intercity routes and capable of sardine-can tight seating.

And nowhere in the world has this business model been more keenly adopted than in Asia. The International Air Transportation Association, IATA, predicts that the number of passengers flying every year will grow from 4.6 billion now to 8.2 billion by 2037, and much of that growth will be driven by the huge appetite for air travel in Asia.


Airline business expert Craig Jenks describes this as a pumped-up version of the Wild West boom in jet travel that we saw in the U.S. after deregulation.

He told me, Budget airlines introduce a new level of freedom to travel that has a broad cultural impact, giving people who have previously been unable to afford to fly a broader world experience.

Jenks cites China as the prime example: In China new airports are appearing in progressively smaller cities, everybody wants an airport and a budget airline route. In China, he points out, a small city can have a population of five million.

As it caters to the pent-up appetite to fly, Beijing is the hungriest city on the planet. This September its new airport, Daxing, opened with a main terminal building of 11 million square feet, designed by the late Zaha Hadids team.

The FAA which was the last to act, two days after the Chinese grounding.

It is the largest single structure in the world. By 2025 Daxing will be handling 75 million passengers a year and is capable of swiftly doubling that by adding more runways.

All this means that the phenomenal growth in cheap flights will have to be matched by rigorously enforced standards of safety across the world.

And, indeed, it is significant that China was the first country to ground the 737-MAX after the second crash: of the 350 MAX jets then flying in the world 96 were flown by Chinese airlines and one fifth of the 5,000 MAX models so far ordered are bound for Chinese airlines.

Chinas regulators said they had a policy of zero tolerance for lapses in safety and their action contrasted strikingly with that of the FAA which was the last to act, two days after the Chinese grounding and only then after pressure from Canadian regulators.


The FAAs tardy response and subsequent revelations about its lax oversight of Boeing,allowing a death trap to be certified as safe to fly, has effectively ended a consensus that had for decades created a worldwide standard for air safetyled by the FAA. Now other regulatory agencies around the world, and particularly the European Aviation Safety Agency, EASA, are refusing to allow the MAX jets back in the air until they have satisfied themselves that its problems have been fixed. EASA is even sending its own pilots to Seattle to make their own test flights.

There is also the issue of the effect on passengers. One American survey has shown that 20 percent of travelers would avoid flying on a 737-MAX for at least six months after it is returned to service. And more than 40 percent said they would rather take a more expensive flight on a different airplane than book a cheap one on a MAX.

These numbers are quite telling because normally price is the deciding factor for most people planning a flight.

Of course, flying has always engendered a greater anxiety than is justified by the statistics. According to IATA, in the most recent five year period the annual average is 75 accidents of which only 11 involve fatalities. And those deaths average out at 315 a year. In 2017, a banner year for air safety, only 19 people died worldwide on commercial flightsto get a sense of how low this is the number should be set against the more than four billion passengers flying every year.

In the case of Boeing, corporate greed entered and corrupted the process from the moment in 2011 when the 737-MAX program was launched.

The two 737-MAX crashes have broken this pattern of a steady, long and striking advance in aviation safety. That has been achieved in every part of the system that sustains airline operations: the technical leaps made in the design of the airplanes themselves, the interaction of those advances with the technology of air traffic control, the new regimes of security at airports, the rigor of maintenance checks, and the safety cultures of airlines and regulators.

The astonishing thing is that this system works as well as it does across a swathe of different cultures, including in countries with variable standards of political and commercial integrity.

And, make no mistake, what broke down here reflects a uniquely American problem brought about by egregious lapses, specifically by both Boeing and the FAA.

In the case of Boeing, corporate greed entered and corrupted the process from the moment in 2011 when the 737-MAX program was launched. Engineers in Seattle complained of unrealistic deadline pressures while top managers in the companys Chicago headquarters, more alert to Wall Street than airline safety, gave priority to stock buybacks and shareholder returns.

An extraordinary public relations debacle last week exposed another way in which the old Boeing of legendary quality has been replaced by a new Boeing.


It was widely reported that in 2016 the companys chief technical pilot, Mark Forkner, had discovered a serious problem with the controls of the MAX jet while running tests in a flight simulator. The implication was that his experiencethe airplane, he said, was behaving like crazyshould have forewarned that a new computerized control, Maneuvering Characteristics Augmentation System, MCAS, was capable of crashing the airplaneas it did in Indonesia and Ethiopia.

This revelation justified a new burst of outrage that included the response from the chairman of the House Committee on Transportation and Infrastructure, Peter De Fazio, who is in the middle of an investigation into both Boeing and the FAA.

It now turns out, however, thanks to reporting by the Seattle Times, that the problem Forkner reported was not in the airplane at all but was caused by a software glitch in the flight simulator.

This might seem to help Boeings case but for two things:

First, when Forkner had completed testing the MCAS system he not only said the airplane was safe to fly passengers but that pilots did not need to be informed that the system even existedeither in flight manuals or in their simulator training as they adapted to the new airplane. This would seem to implicate Forkner in the corporate policy to conceal a potentially lethal addition to the flight controls.

The test and evaluation pilots are mostly recruited from the Air Force and the Navy and arrive with a 'Top Gun' sense of superiority.

Secondly, in a texting exchange with the man who succeeded him as chief technical pilot, Patrik Gustavsson, Forkner made clear that everybody was so damned busy and getting pressure from the program that he was being kept out of the loop about changes being made to the control system.

Forkners attorney David Gerger has declined to address questions about his client, but told The Wall Street Journal: Mark flew the MAX. His Air Force buddies flew the MAX. He would never put himself, his friends or any passenger in an unsafe plane.

Behind the complaints about pressure lies a problem with the new Boeing culture that has so far received little attention: with the test pilots.

Two groups of pilots test a new airplane. One, the technical group that was led by Forkner, never leave the ground. They fly the airplane exclusively in simulators and their job is to prepare the flight manuals and training courses for airlines that buy the airplane. The others are from the flight test and evaluation group. These are test pilots as we normally think of themthey put a new jet through the whole flight envelope it is likely to encounter in airline use, lasting over a period of at least two years.

Forkners complaint about being left out of the loop reflects a cultural schism at Boeing between the two kinds of piloting.

The test and evaluation pilots are mostly recruited from the Air Force and the Navy and arrive with a Top Gun sense of superiority that grates on pilots with an exclusively airline background. One veteran Boeing pilot told me that the ex-military pilots look down on the simulator pilots as minionswhile the simulator pilots argue that they far better understand the difference between flying for the military and flying an airplane full of passengers.

This is not a conflict that helps anyone. And this is just one more sign that it has taken the 737-MAX catastrophes to reveal a lot about the shortcomings of the company that Boeing has become.

In a way, one detail in Forkners own account of his problems with the 737-MAX serves as a sadly defining picture: Im locked in my hotel room with an ice cold Grey Goose he told Gustavsson in an email. Ill probably fire off a few dozen inappropriate emails before I call it a night.

Read more: https://www.thedailybeast.com/inside-the-scandal-that-killed-346-people-and-destroyed-boeings-reputation