Some important points from the PDF that show that it was not the problem with the pilots:

- In 2015, a Boeing AR raised the question of whether MCAS was “vulnerable to single AOA sensor failures….” Despite this, the aircraft was delivered with MCAS dependent on a single AOA sensor.

- After Boeing redesigned MCAS in 2016 to increase its power to move the aircraft’s stabilizer at low speed, Boeing never reevaluated a single- and multiple-failure analysis of MCAS.

- In March 2016, Boeing sought, and the FAA approved, removal of references to MCAS from Boeing’s Flight Crew Operations Manual (FCOM), ensuring 737 MAX pilots were unaware of this new software and its potential effect on the aircraft’s handling without pilot command.

- Boeing’s design of MCAS violated its own internal requirements which demanded that the system “not have any objectionable interaction with the piloting of the airplane” and “not interfere with dive recovery,” which occurred in both 737 MAX crashes.

- In August 2017, five months after the 737 MAX was certified by the FAA and three months after it entered revenue service, Boeing issued a problem report to its supplier complaining that the 737 MAX’s AOA Disagree alert was tied to an optional AOA Indicator display and therefore was not functioning on the vast majority of the 737 MAX fleet worldwide.

- Rather than immediately informing the FAA and Boeing customers about this issue, and advising Boeing to fix the problem via a software update as soon as possible, a Boeing AR consented to Boeing’s plan to postpone the software update until 2020 (...)

- Although Boeing prepared a “Fleet Team Digest” to inform its customers about the inoperable AOA Disagree alert, the company never sent it, keeping its customers in the dark about the inoperable alert.

- Boeing provided Lion Air a Flight Crew Operations Manual (FCOM) on August 16, 2018, one year after learning that the AOA Disagree alert was not functioning on most 737 MAX aircraft, highlighting the operation of the AOA Disagree alert. Boeing failed to indicate that it knew the AOA Disagree alert on the Lion Air 737 MAX aircraft was not operational.

- Boeing did not acknowledge that the AOA Disagree alerts on an estimated 80 percent of the 737 MAX fleet were inoperative until after the Lion Air crash in October 2018.

- Boeing’s own analysis showed that if pilots took more than 10 seconds to identify and respond to a “stabilizer runaway” condition caused by uncommanded MCAS activation the result could be catastrophic. The Committee has found no evidence that Boeing shared this information with the FAA, customers, or 737 MAX pilots.

- Boeing had tremendous financial incentive to ensure that no regulatory determination requiring pilot simulator training for the 737 MAX was made. This incentive included a Boeing contract with Southwest Airlines, its U.S. launch customer, that would have cost Boeing more than $1 million per aircraft it delivered to Southwest if pilot simulator training was required for Southwest pilots transitioning to the 737 MAX from the 737 NG. At the time of the Lion Air crash, Southwest had ordered or pre-ordered an estimated 280 737 MAX aircraft from Boeing.

- In March 2017, the month the 737 MAX was certified by the FAA, Boeing’s 737 Chief Technical Pilot responded to colleagues about the prospects of 737 MAX simulator training, saying: “Boeing will not allow that to happen. We’ll go face to face with any regulator who tries to make that a requirement.”