What Went Wrong with the Boeing 737 Max?

9 Sep 2026 · 26 min · 12 chapters

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In short

Leadership and culture failures behind the Boeing 737 MAX crashes, using the Lion Air (Oct 2018) and Ethiopian Airlines (Mar 2019) disasters to examine crisis response, cost pressure, and the MCAS software design.

Guest backgrounds

Professor Bill George, leadership scholar and former CEO/chairman of Medtronic; teaches and writes business cases on leadership and crisis.

Key claims

Boeing’s culture shifted after the McDonnell Douglas acquisition toward cost over engineering/safety; the 737 MAX was rushed as a modification to meet certification constraints and win customers quickly; MCAS could take control away from pilots, and pilots weren’t properly trained; Boeing’s early response to Lion Air lacked CEO accountability and made premature “safest aircraft” claims; FAA oversight was weakened by budget cuts and Boeing involvement in review.

Notable examples

MCAS “self-driving car” loss of control; CEO crisis communication examples from Tylenol (Jim Burke) and BP (Tony Hayward).

Written by AI. May contain mistakes. Listen to the episode to check what was said.

Chapters

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The History of Boeing 737

1:15 to 2:15

Explore the legacy of the Boeing 737 and its significance in aviation.

“The team at Boeing thought they had a winner on their hands, and they were right.”

Crisis Leadership and Judgment

2:38 to 4:42

Delve into the pressures faced by leaders during crises, specifically in Boeing's case.

“Sometimes they're looking at historic figures like Martin Luther King Jr.”

Understanding Root Causes of Crises

4:42 to 6:06

Learn about the long-term issues leading to crises and their complexities.

“And it's the real test of a leader is how you respond in crisis.”

Boeing's Cultural Shift

6:06 to 8:06

Examine the cultural changes at Boeing and their impact on safety and engineering.

“And the pressures are quite different from a supplier, a customer, an FAA, or frankly, Muhlenberg had testified for Congress and the pressures you get testified for Congress.”

Corporate Decisions and Their Implications

8:06 to 9:26

Analyze the decisions made during Boeing's history that affected its safety protocols.

“There was a clear implication they were trying to blame it on the pilots.”

737 MAX Design Decisions

9:26 to 14:00

Discuss the design choices made for the 737 MAX and their implications on safety.

“acquired McDonnell Douglas, who was the premier fighter jet pilot, I used to work with them when I was in the Pentagon in the 60s.”

Initial Discussion on Boeing's Design Choices

14:00 to 14:30

Explore the reasons behind Boeing's decision to modify rather than redesign the 737 Max.

“So that was the start of everything in the case.”

Safety vs. Cost in Aircraft Design

14:56 to 16:42

Discuss the critical importance of safety over cost in aircraft design and decision making.

“This is a job for Indeed sponsored jobs.”

MCAS System and Pilot Control Issues

16:43 to 18:18

Delve into the design changes, particularly the MCAS system and its implications for pilot control.

“Well, they had to move the engines because it was a heavier plane, but then they couldn't raise the height like they normally would.”

Role of the FAA and Internal Approval Process

18:19 to 19:12

Analyze the FAA's role and Boeing's internal processes during the aircraft approval phase.

“for approval and Boeing paid engineers reviewing it as FAA officials.”
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CEO Responsibilities During Crises

19:13 to 21:46

Examine the crucial role of CEOs during crises and the need for public communication.

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Lessons Learned from the Boeing Case

21:47 to 23:32

Identify key takeaways regarding leadership and culture from the Boeing 737 Max crisis.

“Bill, this has been a fascinating conversation.”
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Transcript

Automatic transcript. May contain errors.

0:00Hey friends, Olivia from OLLI. Between new routines and the ultimate group project known as parenting, you need science-backed solutions that work with your life. That's where OLLI comes in. Start your mornings off right with Maltese made to support nutrition and immune health. Choose from our lineup of gut-supporting probiotics, and we've got occasional sleep support to help the whole fam chase their big dreams. Head back to class with the number one gummy supplement brand. Stock up on OLLI.com today. These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

0:30Bill George:When you need to build up your team to handle the growing chaos at work, use Indeed Sponsored Jobs. It gives your job post the boost it needs to be seen and helps reach people with the right skills, certifications and more. Spend less time searching and more time actually interviewing candidates who check all your boxes. Listeners of this show will get a$75 sponsored job credit at Indeed.com slash podcast. That's Indeed.com slash podcast. Terms and conditions apply. Need a hiring hero? This is a job for Indeed Sponsored Jobs. On January 17, 1967, aviation history was made when Boeing unveiled the very first Boeing 737 aircraft at King County International Airport outside of Seattle.

1:14Baby Boeing, as it was called, had a greater seating capacity than any plane in its class and sported wing-mounted engines that provided a more balanced center of gravity. The team at Boeing thought they had a winner on their hands, and they were right. The Boeing 737 is the top-selling commercial aircraft of all time and holds its own entry in the Guinness Book of World Records. It's operated by more than 5 ,000 airlines in over 200 countries, and at any given moment, there are roughly 1 ,200 737 airliners in the sky. In over three decades of operation, the plane was involved in 19 fatal accidents, which equates to about one accident for every 4 million departures.

1:55So when a brand new Boeing 737 MAX fell from the sky in October of 2018, killing all 195 souls on board, the aviation world took notice. Today on Cold Call, we welcome Professor Bill George to discuss his case entitled, What Went Wrong with Boeing 737 MAX? I'm your host, Brian Kenney, and you're listening to Cold Call on the HBR Presents Network. Bill George is an expert on leadership, a topic he teaches and writes about extensively, including numerous books, articles, and business cases. He's also the former chairman and chief executive officer of Medtronic, and he's a repeat guest here on Cold Call.

2:37Bill, we're so happy to have you back. Thanks for joining us today. Thanks for having me back, Brian. We always love your cases. They're super relatable. Sometimes they're looking at historic figures like Martin Luther King Jr. We had a conversation about that case. And then sometimes they're more sort of ripped from the headlines, and this falls into that category. I think these incidents are pretty fresh on people's minds. We're going to dig into some of the cultural issues at Boeing, and I think people will really like to hear your thoughts on where there might have been lapses in judgment or leadership.

3:05Let me ask you to start by telling us what's your cold call to start the case when you walk into the classroom or when you tune in on Zoom, I guess, these days is how we're doing it. Brian, here's how I start. It's now March 9, 2019. You're Dennis Muhlenberg, the CEO of Boeing. You're asleep in your apartment in Chicago. Are your families back in St. Louis at your home? You get a call from your chief safety officer at Boeing. Dennis, we've had bad news. A second Boeing 737 MAX has crashed outside Addis Adabi Airport in Ethiopia just a few minutes after takeoff. We just don't know anything at this stage.

3:46You're Dennis Muhlenberg. I want you to walk in his shoes. What are you going to do right now? That's a tough, tough question, but it's the kind of thing that these leaders have had to face. Tell me, you know, you've written so many cases on leadership. Why did this one strike you as one that was worthwhile? And how does it relate to the things that you write about and teach as a scholar? Well, I think this captures both the crucibles that the CEO and all the executive of Boeing felt about these two planes crashing from the air and how they led through this crisis. And this really illustrates leading in crisis, which a lot of us are facing these days.

4:25But it's an understanding of all the pressures that come to bear because you have not only the internal pressure, you have the customer pressures, you have the government pressure or the FAA. You have the media pressures. You have investor pressures. I have pressures from your board of directors. Well, I know what's happened. And all these things come to bear. And it's the real test of a leader is how you respond in crisis. That's what I was trying to capture and really examine how this leader dealt with this crisis. Give us a sense before we really dive into the details, what are the sort of key learning points that emerge out of these cases?

4:59I asked this.

5:29Bill George:jobs. For a limited time, you can get a Big Mac meal for just$8. That's a burger, fries, and a drink. They don't call it an extra value meal for nothing. Get a Big Mac meal only at McDonald's. Price and participation may vary. Promotion pricing may be lower than meal pricing. Students, after they describe how they would deal with this situation, what's the root cause of this problem? That's at the start of the class. The other learning that comes out of it is a lot of times crises have very long roots. And if you only deal in the immediacy of it, you don't kind of understand the depth and complexity of the problem.

6:06And the third learning point is to understand what pressure CEOs are under from external forces as well as internal forces and how they have to not only balance, but integrate and satisfy and deal with each of these forces. And the pressures are quite different from a supplier, a customer, an FAA, or frankly, Muhlenberg had testified for Congress and the pressures you get testified for Congress. That was an extremely embarrassing situation because the families of the victims of these crashes came with pictures of their loved ones on a board that was about 16 inches high and eight inches wide. And they held these pictures up behind them at a certain point in time and dramatic point.

6:48They all held him up, and the congressman asked him to turn around and look and ask him how he was feeling. Pressure-packed. It's a high-pressure job, I'll say that. And I think few people understand the multiple pressures CEOs are under, and they wonder, why do they behave in the ways they do? You talked about the Ethiopian Airlines disaster. I teased in the intro the Lion Air flight that crashed in 2018, and that was the first 737 Air Max to go down. I wonder if you could maybe talk a little bit about that flight, but I also want to talk about Boeing and its history. They've been around for a long time, sort of a storied history in aviation.

7:23So tell us what happened with Lion Air first, maybe as a starting point. The interesting thing about that is how Boeing responded. There was no statement from the CEO. Instead, there was a statement from the public relations department saying, we are very sad this happened and we are deferring all increase to the National Transportation Safety Board that's going to investigate it. Basically, not stepping up to any level of responsibility. And then about a week, 10 days later, Boeing published a statement saying the 737 MAX is the safest aircraft that's ever been flown. Boy, that's a risky statement when you don't have all the information.

8:03The pressure people are under, you don't know what happened. There was a clear implication they were trying to blame it on the pilots. But you really don't know what happened. And you're making these very strong statements. And they aren't coming from a person, the CEO, they're coming from a press department. And I think that's significant to examine. They did not shut the planes down. They let the others do the investigation for them. And then eventually they started their own investigation. But planes continued to fly. In your opinion, is this consistent with sort of the culture at Boeing? Talk a little bit about the origins of Boeing and the culture that was there, let's say prior to the merger with McDonnell Douglas?

8:43Well, Boeing, founded by William Boeing, was really the premier aviation company for the last, you know, 110 years. And it's an amazing company. I've visited many times out in Seattle, and it's an amazing company. And they have these huge bays where they produce the planes in Renton, Washington. Of course, you know, they're the ones that produced the original 707. They produced the 727, and then they had a huge Bonanza with a 747, which, of course, a gargantuan airplane to hold up to 450 passengers. So they were the premier company, and they were an engineer's company. They were a company where every engineer would fight to get a job there.

9:21You mentioned McDonnell Douglas. There are pretty clear indications in the case and in all my studies that when they acquired McDonnell Douglas, who was the premier fighter jet pilot, I used to work with them when I was in the Pentagon in the 60s. the F-4, a very, very popular aircraft, that the culture changed and became much more, if you will, cost-oriented and less safety.

9:45Bill George:When you need to build up your team to handle the growing chaos at work, use Indeed Sponsored Jobs. It gives your job post the boost it needs to be seen and helps reach people with the right skills, certifications, and more. Spend less time searching and more time actually interviewing candidates who check all your boxes. Listeners of this show will get a$75 sponsored job credit at indeed.com slash podcast. That's indeed.com slash podcast. Terms and conditions apply. Need a hiring hero? This is a job for Indeed sponsored jobs. For a limited time, you can get a Big Mac meal for just$8. That's a burger, fries, and a drink.

10:22They don't call it an extra value meal for nothing. Get a Big Mac meal only at McDonald's. Price and participation may vary. Promotion pricing may be lower than meal pricing. And design-oriented. We've seen this happen to a number of American companies. It happened to General Motors in the 20th century. General Electric, too, started focusing less engineering, more on cost reduction. And so Boeing did that. And it also had a rather difficult succession of CEOs. Phil Condit was the CEO and had to resign over an ethical scandal. He actually moved the headquarters from Seattle to Chicago for something like$60 million in subsidies, spread over 20 years.

11:03Personally, I felt at the time it was a terrible mistake, and I think history has proven it was indeed a very poor decision because you separate yourself now from the people running the company, from the engineers, the marketers, the people engaged every day in the business, production people. You can't walk out in the factory. They have no interest in Chicago. Gary Stonecipher came in. He actually was called out of retirement when Condit was terminated. And he actually did quite a good job reviving the commercial aircraft business because they were losing out to Airbus and always complaining about Airbus's subsidies.

11:36But Stonecipher was the cost guy. And he openly said, we're going to cut the cost. This has got to be a more business-oriented company, less of an engineer's company. Stonecipher also, unfortunately, was caught in a sexual scandal and had to resign. That's a tough stretch. And they had the obvious candidate to become Stonecipher's successor right there in place, who had revived the commercial aviation business, a man named Alan Mulally. But Mulally was passed over for Jim McNerney, who at the time was CEO of 3M. He had been a General Electric, very famous executive, had only been at 3M for three years, He even got a call from the President of the United States urging him to take the Boeing job in the national interest.

12:17So they've had quite a succession of CEOs. And Muhlenberg comes in later on, 2013, as CEO. But he really didn't become CEO or in charge in 2016 when McNarnie retired. So let me just jump in for a second because I'm hearing words like cost-cutting, downsizing, whatever sort of euphemisms we want to use. Cost-cutting and aircraft manufacturing, you know, there seems to be a tension there. And I'm wondering if what we started to see was a change in emphasis in the way that they went about designing and developing aircraft that may have caused them to not be as thorough as they were in the earlier days when they first developed the 737.

12:53Is that fair to say? It's always hard to prove that if you're not working there, but that certainly is the impression one has. So there's huge cost pressure in the industry. You know, we know that. Why does Boeing make the decision to redesign or rather modify, I guess might be the right word, the 737, rather than just designing an entirely new aircraft? Now you got to the, that's the, bingo, that's the root cause of the case. It takes people a while to get there. You got there a little bit faster, Brian. That's the key question. They were losing out to Airbus and American Airlines was about ready to shift away from them.

13:28So they put together a modification of the 737 that can hold American Airlines business. Point of fact, it was late and it took five, five and a half years to get there. But they did everything to avoid the type certification that you referenced back in 1968. Think about all the advances in technology and aviation. You know, they had to stay within this type certification. That meant they couldn't make any changes. They couldn't make it higher. They couldn't add things. They couldn't change their training manuals. And so they really couldn't describe the differences to the pilots that were flying it or even train them on those differences to stay within this type certification.

14:05So that was the start of everything in the case. I believe that predetermined every design decision was based on not designing a whole new aircraft, which might have taken five to nine years. So is that the key issue there then? Because I'm wondering what the benefits are of constraining yourself in this way by using a modification approach rather than a completely new design. Are they saving money or time or both? Speed. Get there fast. You have money.

14:31Bill George:When you need to build up your team to handle the growing chaos at work, use Indeed Sponsored Jobs. It gives your job post the boost it needs to be seen and helps reach people with the right skills, certifications, and more. Spend less time searching and more time actually interviewing candidates who check all your boxes. Listeners of this show will get a$75 sponsored job credit at Indeed.com slash podcast. That's Indeed.com slash podcast. Terms and conditions apply. Need a hiring hero? This is a job for Indeed sponsored jobs. For a limited time, you can get a Big Mac meal for just$8. That's a burger, fries, and a drink.

15:07They don't call it an extra value meal for nothing. Get a Big Mac meal only at McDonald's. Price and participation may vary. Promotion pricing may be lower than meal pricing. Don't spend the kind of money you did on the 787. Get there fast and hold the customer. They were responding to the short-term competition and frankly made a lot of short-term decisions that proved to be fatal. I was in the safety business at Medtronic and we knew that one failed defibrillator could cost someone their life. And if we had a software problem that went across all of our different layers, they'd all have to be pulled out of people's bodies or corrected.

15:41Safety was paramount. To me, there can be, and you're talking about a plane that's flying with 150, 200 people in the air and maybe 300. You can have no compromise on safety. There is no such thing as a trade-off between cost and safety. Safety has to be paramount, everything you do, because the cost of a failure, I'm not even going to talk the cost of this, just the cost of one plane going down, so far exceeds any savings you get in designing the aircraft that you wouldn't ever want to consider compromising. But these things are very subtle. See, there's no one that goes out and says, we're putting cost over safety.

16:21General Motors had that problem back in the 90s. No one's saying that. It's that it's a slippery slope that people get to. And that's important for students in the class to understand how do you get on that slippery slope where all of a sudden decisions are being made that put costs over safety? You do that, you're going to have a fatal crash, which Boeing did. What were some of the design changes they made? Well, they had to move the engines because it was a heavier plane, but then they couldn't raise the height like they normally would. So the engines were going to be too low. The profile was too low.

16:53They ran into real problems early on and they had to redesign part of the electronic systems And so they put in a system called the MCAS system. And that was a software fix to correct this problem. What the MCAS did is it had sensors that if the sensor sensed something was going wrong, it would take over flying the aircraft. It would actually take it away from the pilots. It's like having a self-driving car and you can't regain control. And so the pilots had lost control, but no one told them this. So if you're trying to pitch it up and it's going down and you pitch it up and it goes down more because you don't have control.

17:32And that's exactly what happened in these two crashes. They had the same pattern problem. Meanwhile, they couldn't train the pilots on what this was all about. See, it's what I call in a classroom talked about Murphy's law, compound error. When you have one thing go wrong, if you don't fix the root cause, then you're going to have compound a series of problems because you make decisions based on that first flawed decision, and it can lead to a very negative situation. I would assume, Bill, that they must have tested these planes as they were building them. And the FAA plays some role, don't they, in approving the planes when they're done?

18:06Where was the FAA throughout this process? The FAA's budgets were being cut back severely during the early stages of this. And so Boeing agreed to put some of its people into the FAA. So in effect, you had Boeing presenting the product for approval and Boeing paid engineers reviewing it as FAA officials. There was no fraud or sham here that was very out in the open. It was a huge mistake. You talked a lot about the changes in CEOs that they went through. It sounds like it was a revolving door and maybe not with the most qualified people stepping into that role. What would you say, you know, in your experience working with CEOs in all industries, what would the role of the CEO be in a situation like this?

18:48How should they behave? Should they be advocating for the engineers and their employees? Should they be advocating for the customer? You know, what should they be doing? Well, I would say, First of all, I would disagree with one thing. I think they were qualified. Jim McDarnie was fully qualified to come in there. He had run the GE Jet engine business. Dennis Buellinger was fully qualified. He'd been with the company 22 years, an engineer. But he came in very late in the game. So what do you do when you're a CEO in 2016 and the planes are flying?

19:26made to support nutrition and immune health. Choose from our lineup of gut-supporting probiotics, and we've got occasional sleep support to help the whole fam chase their big dreams. Head back to class with the number one gummy supplement brand. Stock up on OLLI.com today. These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

19:46Bill George:When you need to build up your team to handle the growing chaos at work, use Indeed Sponsored Jobs. It gives your job post the boost it needs to be seen and helps reach people with the right skills, certifications, and more. Spend less time searching and more time actually interviewing candidates who check all your boxes. Listeners of this show will get a$75 sponsored job credit at Indeed.com slash podcast. That's Indeed.com slash podcast. Terms and conditions apply. Need a hiring hero? This is a job for Indeed sponsored jobs. You just don't go shut your production line down and abandon your customers.

20:20It could have been done after the first Lion Air crash. In fact, should have been done with the benefit at 2020. I say when you have that first trash, that's a good place to shut everything down. Yet in my experience, not saying something leads to real problems in a crisis. People want to hear from a human being. They want to hear from the CEO. So the role of the CEO, first of all, is he a spokesman. You remember, Brian, the famous Tylenol case with Jim Burke. And he was out there every day. He didn't have the information. He didn't know who would put cyanide in the Tylenol. He had no information, but he went out and reassured people, we're doing everything.

20:52He didn't say it's impossible this could happen again because he was scared to death it might happen again. You've got to be out there on the firing line. I remember in the case of the British Petroleum when they had that huge blow up in the Gulf of Mexico and it's leaking. It took over 90 days to shut it down. Tony Hayward didn't go down there for six weeks. The CEO, after six weeks, he goes there and they asked Mr. Hayward, what are you going to say about this? And he said, you know, actually, I just wish this whole situation to be over. I'd like my life back. And someone said, Mr. Hayward, you know that these 11 employees of yours are not getting their life back.

21:28But that kind of inability to respond in a crisis, I think many CEOs are not well-trained. You can be an engineer at Boeing for 25 years and get to be CEO, but that doesn't mean you're well-trained to deal in the public eye. So I think CEOs today must be out in front on very important issues because you're going to be challenged. That's a big learning from the case of how important it is to be prepared to do that. Bill, this has been a fascinating conversation. It's a great case and a disturbing one because you hope that these problems have been resolved, but I guess you don't really know for sure.

21:59Tell us if there's one thing you want listeners to take away from this case. What would it be? The importance of leadership in a crisis and why, as the leader, you need to be out in front. If there's a problem, you should be out there, first of all, apologizing and saying how sorry you are on behalf of your organization for what happened. Even if you don't know if you're culpable, express empathy. Because in the media, media is not about facts. It's about feelings. How do people feel? Do you care about them? And we had a great debate in the case discussion about is it leadership or culture? Well, it's both.

22:37But if the culture is not right, the leader has to change that culture. And that's a tough job. But that's so important that leaders take that role on. So they have the internal role and the external role. We've talked before about crucible moments, and this is something you've written quite a bit about. And it sounds like this is exactly what a crucible moment is, right, by definition? It sure is. And this is the test because you have no preparation for it. You can go through all the crisis training you want, but no one is going to actually put you in that situation. So that's why I think the Harvard Business School training is so important.

23:11We have a lot of people in this particular course who become CEOs. and this is a great preparation for them to realize, oh my gosh, these are the kind of things that could happen to me too. I better be emotionally and mentally prepared even if I'm going to have to work on the fly and decide what to do because the situation is constantly changing, the fact-based situation is changing. Like I said, this is a real test. Bill, it's a great case. Thank you for writing it and thank you for coming on to discuss it with us. Anytime, Brian. Thank you. If you enjoy Cold Call, you should check out our other podcasts from Harvard Business School, including After Hours, Skydeck, and Managing the Future of Work.

Read the full transcript

23:47Find them on Apple Podcasts or wherever you listen. Thanks again for joining us. I'm your host, Brian Kenney, and you've been listening to Cold Call, an official podcast of Harvard Business School brought to you by the HBR Presents Network.

From the publisher

What Went Wrong with the Boeing 737 Max?

19 Jul 2023

---

How did the evolution of Boeing’s organization and management lead to two tragic plane crashes within six months, in which a total of 346 people died?

Harvard Business School professor Bill George discusses the long roots that ultimately led to the crash of Lion Air flight 610 in October 2018 in Indonesia and the crash of Ethiopian Airlines flight 302 in March 2019 in Ethiopia. He discusses the role cost cutting, regulatory pressure, and CEO succession played in laying the foundation for these tragedies and examines how Boeing executives responded to the crises in his case “What Went Wrong with Boeing’s 737 Max?” (https://store.hbr.org/product/what-went-wrong-with-boeing-s-737-max/320104?sku=320104-PDF-ENG)

This episode originally aired on Cold Call on April 20, 2021.

You can also listen to this episode on HBR.org, and wherever you listen to podcasts:
- HBR.org (transcript available here): https://hbr.org/podcast/2021/04/what-went-wrong-with-the-boeing-737-max
- Apple Podcasts: https://podcasts.apple.com/us/podcast/what-went-wrong-with-the-boeing-737-max/id1156646189?i=1000517908277
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Series Description:
Harvard Business School’s legendary case studies, distilled into podcast form.

About Harvard Business Review:
Harvard Business Review is the leading destination for smart management thinking. Through its flagship magazine, books, and digital content and tools published on HBR.org, Harvard Business Review aims to provide professionals around the world with rigorous insights and best practices to help lead themselves and their organizations more effectively and to make a positive impact. Learn more at www.hbr.org.

Chapters:
00:00 – Intro
1:56 – What’s the Cold Call?
5:17 – The First Crash / History of Boeing
10:29 – Cutting Costs at the Expense of Safety
15:15 – The CEO’s Role
17:35 – Main Takeaway
19:24 – Outro

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