Boeing, acting without adequate oversight from U.S. regulators, failed to grasp risks in the design of cockpit software on its 737 Max airliner, sowing the seeds for a Lion Air crash that also involved errors by airline workers and crew, Indonesian investigators found.

The fatal crash, followed less than five months by another at Ethiopian Airlines, led to a global grounding of the Boeing 737 Max and a crisis for the world's biggest plane-maker, which this week ousted its commercial airplanes chief.

In its final report into the Oct. 29, 2018, Lion Air crash that killed all 189 people on board, Indonesia made recommendations to Boeing, the airline, the U.S. Federal Aviation Administration (FAA) and other agencies.