By 2007, Garuda, the national airline, had a notoriously bad safety record. Two weeks after Adam Air’s bent-airplane episode in Surabaya, a Garuda captain at the controls of a 737 bound for another airport on the island of Java allowed the airplane to get too high on the approach and tried to resolve the problem by pointing the nose down and diving at the runway despite the co-pilot’s calls to abort the approach and circle around. The captain got the airplane going so fast that when he called for flaps to configure for landing, the co-pilot did not dare extend them for fear of structural damage and did not communicate his doubts to the captain. Investigators later criticized the co-pilot for poor teamwork, specifically for not taking control of the airplane, but short of clubbing the captain into submission, there wasn’t much he could do. The airplane landed long, touched down going 100 miles an hour too fast, bounced three times and went careering off the far end of the runway, slicing through an airport perimeter fence and sliding across a road, a ditch and an embankment before coming to rest in a rice paddy and bursting into flames. Because rescue vehicles could not cross the ditch, firefighters could not get their equipment close enough to suppress the flames effectively, and the fire burned for more than two hours. The captain and the co-pilot were not hurt, but 21 people died and others were severely injured.



Garuda was the last straw. From 2003 to 2007, the Indonesian accident rate as measured by fatal flights per million departures had grown to be 15 times as high as the global average. The United States Embassy in Jakarta advised Americans to avoid travel on Indonesian airlines, though within Indonesia that was practically impossible to do. As usual, the numbers worked in favor of individual travelers: Even on the worst Indonesian airlines in the worst of times, the chances of being killed were minuscule. But for foreign governments that had become the self-anointed guardians of their citizens worldwide, the exposure was similar to that of the airplane manufacturers, though less consequential: Inevitably, accidents would continue to occur in Indonesia, and foreigners would die, and it would be hard for their officials to duck accountability unless the officials had registered concern in advance.

In 2007, the European Union and the United States permanently banned all Indonesian airlines from their national territories. This was done for reasons of safety. The ban was largely symbolic, because the Indonesians were focused on their expanding regional markets and had no immediate plans to open such long-distance routes, but it signaled official disapproval of Indonesia’s regulatory capabilities and served as a public critique of a group of airlines, some of which were out of control. Residents of Europe and the United States generally did not know or care, but many of the ordinary Indonesians who had grown to hate their airlines were in favor of the ban simply as a form of punishment. Deregulation had transformed Indonesia into a complicated Wild East of flying, inhabited by consumers who were immune to prestige, just as Lion Air’s Kirana had predicted.

The ban put Boeing and Airbus into a delicate position. They would now be selling airplanes to officially declared unsafe airlines that the American and European authorities expected would keep killing and injuring their passengers at a rate that would be unacceptable in the West. By 2007, the biggest of those airlines was Lion Air. That year, it placed a new order for 40 additional 737s, and Boeing happily agreed to fill it. In 2011, Lion Air returned to the table with what at the time was the largest commercial order in aviation history, a $22 billion deal for 230 units of the 737, including 201 units of the coming 737 Max. The deal was finalized during an Asean summit meeting in Bali that was attended by President Barack Obama. Photographs show Obama looking on approvingly as Kirana and a senior Boeing executive signed the contract. No mention was made in the associated news reports that Lion Air was considered to be a dangerous airline and that it was banned from the United States.

Lion Air had been contributing to the casualties almost since its inception. By the time of the signing ceremony in Bali, it was responsible for 25 deaths, a larger number of injuries, five total hull losses and an unreported number of damaged airplanes. An old truth in aviation is that no pilot crashes an airplane who has not previously dinged an airplane somehow. Scratches and scrapes count. They are signs of a mind-set, and Lion Air had plenty of them, generally caused by rushed pushbacks from the gates in the company’s hurry to slap airplanes into the air. Kirana was once asked why Lion Air was experiencing so many accidents, and he answered sincerely that it was because of the large number of flights. Another question might have been why, despite so many crashes, the death toll was not higher. The answer was that all of Lion Air’s accidents happened during takeoffs and landings and therefore at relatively low speed, either on runways or in their immediate obstacle-free vicinities. These were the brief interludes when the airplanes were being flown by hand. The reason crashes never happened during other stages of flight is most likely that the autopilots were engaged.

Boeing knew it had a problem. A widespread culture of corruption lay at the core, but that was beyond anyone’s ability to reform. Instead, Boeing decided to intervene at its own expense to raise standards at Lion Air and try to reduce its contributions to the accident rate. Both Boeing and Airbus had taken larger such actions before. Foremost were their epic interventions in China that gathered speed in the late 1980s and endured for years. At the start, civil aviation in China was a mess, with one of the highest accident rates in the world.

Dave Carbaugh, the former Boeing test pilot, spent his first 10 years with the company traveling the globe to teach customers how to fly its airplanes. He mentioned the challenge of training pilots in Asia. “Those were the rote pilots,” he said, “the guys standing up in the back of a sim. They saw a runaway trim. They saw where and how it was handled in the curriculum — always on Sim Ride No. 3. And so on their Sim Ride No. 3, they handled it correctly, because they knew exactly when it was coming and what was going to happen. But did they get exposed anywhere else? Or did they discuss the issues involved? No. It was just a rote exercise. This is Step No. 25 of learning to fly a 737. Period.” I asked about China specifically. He said: “The Chinese? They were probably the worst.” He spent every other month in China for years. He said: “They saw flying from Beijing to Tianjin as 1,352 steps to do. Yet if they flew from Beijing to Guangzhou, it was 1,550 steps. And they didn’t connect the two. It would get so rote that they just wouldn’t deviate. I remember flying with a captain who would never divert no matter how many problems I gave him. I asked him, ‘How come?’ He said, ‘Because the checklist doesn’t say to divert.’ ”