Willy Kurniawan Reuters
JAKARTA — Design flaws in Boeing Co.’s 737 Max, false assumptions on pilots’ responses to new systems, and regulatory lapses combined to cause last year’s fatal Lion Air crash, Indonesian investigators said Friday, as they released a final report that pinpointed faults in a flight-control feature intended to prevent the aircraft from stalling.
The accident prompted Boeing to make changes to the 737 Max, the manufacturer said in a statement Friday as the report was released, including redesigning the angle-of-attack sensors that feed information to the cockpit, improving crew manuals and pilot training.
“These software changes will prevent the flight control conditions that occurred in this accident from ever happening again,” Boeing said.
Lion Air flight 610 crashed into the Java Sea on Oct. 29, shortly after taking off from Jakarta. All eight crew and 181 passengers were killed.
The crash was soon tied to a new automated feature Boeing had included on the 737 Max, a new version of its popular jet with larger, more fuel-efficient engines. Investigators say the feature was mistakenly triggered by faulty information from an external sensor.
Similar problems were blamed for the crash of an Ethiopian Airlines flight in March that killed 157 people. The Max has been grounded worldwide since shortly after that crash.
On Friday, officials from Indonesia’s transportation-safety regular said nine factors worked together to doom the Lion Air jet.
“These items were connected to each other. If one of them was not occurring on that day, the accident may not have happened,” said Nurcahyo Utomo, an investigator at the National Transportation Safety Committee.
[Widow of pilot on doomed Lion Air flight says direct appeals made to ground Boeing model]
Those factors included incorrect assumptions by Boeing about how pilots would respond to the new flight-control system, known as Maneuvering Characteristics Augmentation System, or MCAS. Investigators highlighted how the MCAS design relied on a single sensor, and was therefore vulnerable to errors.
“One [angle of attack] affected the whole system,” Nurcahyo said. A false reading on that sensor redirected the plane’s nose downward, leaving the cockpit crew unable to override the autopilot commands.
Other fatal mistakes included a lack of training for pilots in the new system, a lack of documentation about problems in previous Lion Air flights involving the same jet, and ineffective coordination between flight crews. Investigators concluded that the plane should have been grounded after an earlier fault.
The report called for improved oversight by the Federal Aviation Administration, the U.S. regulator, and included suggestions for Boeing as well as Lion Air.
Indonesian investigators, however, stressed that their report was not aimed at pinpointing culpability, but ensuring passenger safety and preventing a similar accident. The report cannot be used for liability or compensation issues in court.
In a statement, Lion Air said it was essential to take “immediate corrective actions to ensure that an accident like this one never happens again.”
[NTSB cites competing pilot warnings and flawed safety assumptions on Boeing 737 Max]
Charles Herrmann, a Seattle attorney representing the families of 46 Lion Air crash victims, said the crash anniversary and the release of the report are “a double wounding” for his clients.
“This is a devastating experience for these people,” Herrmann said. “It involves not only tremendous sorrow and grief. There’s a lot of anger.”
Since the crashes, Boeing’s decision to adopt MCAS, and the FAA’s role in certifying the plane have come under intense scrutiny from the Justice Department, congressional investigators and lawyers representing the families of dozens of those who died.
Ahead of Friday’s release of the crash investigation report, a review by the U.S. National Transportation Safety Board found that Boeing underestimated the risk posed by MCAS and made bad assumptions about how pilots would respond to a barrage of alerts in the cockpit if something went wrong.
And an international group of aviation regulators and U.S. experts concluded that Boeing shared information with the FAA in a fragmented way, leading to the new feature not being subjected to sufficient scrutiny.
Tatan Syuflana
AP
Navy personnel in Jakarta removed recovered parts of the Lion Air jet that crashed into the sea last year, in a file photo from Nov. 1, 2018.
MCAS was designed to kick in when pilots were flying manually, repeatedly pushing the plane’s nose if sensor data indicated that it was at risk of stalling. But the data it received in both the Lion Air and Ethiopian Airlines flights was faulty, causing the feature to kick in repeatedly while the pilots struggled to regain control of the aircraft.
[Boeing and FAA faulted in oversight breakdowns that contributed to 737 Max failure]
The protracted grounding of the Max has battered Boeing’s finances and its stock price. This week the company reported that its revenue fell to $20 billion in the third quarter, down 21 percent from a year earlier. Profits were down 51 percent to $1.17 billion.
The company also announced the resignation this week that Kevin McAllister, the head of the Boeing division that made the Max.
The company’s fortunes rest on it winning approval from aviation regulators in the United States and abroad for the Max to resume flights.
Boeing has redesigned the feature in a way that it says is safer and the changes are being reviewed by aviation authorities. FAA officials say they still have several more weeks’ work to do and airlines have said they’re keeping the Max off their schedules into January and February.
Boeing’s chief executive Dennis Muilenberg, who was stripped of his role as chairman of the company’s board this month, is scheduled to testify about the Max before Senate and House committees next week. Lawmakers are weighing whether there ought to be changes to a FAA program that turns over to industry much of the responsibility for certifying that safety standards are being met.
FAA discovers new safety concern during Boeing 737 Max test]
Lion Air is Indonesia’s largest budget airline, operating in a fast-growing industry across an archipelago where air travel is a necessity. But even before October’s crash the country had a spotty safety record and its carriers were banned from flying to the United States between 2007 and 2016.
The Max involved in the crash had entered service just months before. Lion Air was a major international customer for Boeing.
The pilot, 31-year-old Bhavye Suneja, was a native of India who had logged 6,000 flight hours. He was joined in the cockpit by a first officer who used only the single name Harvino and who had 5,000 hours of experience.
Vini Wulandari, Harvino’s sister, said the investigation reinforced her family’s belief that her brother was not to blame for the crash, and demanded Boeing take more responsibility for the loss of life.
“From the beginning, I'm sure that Harvino was innocent because he had done everything according to procedure," Vini said in an interview Friday. Her family is among those suing Boeing.
“Someone must be held responsible for what has happened,” she added.
Mahtani reported from Hong Kong.
Read more
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FAA discovers new safety concern during Boeing 737 Max test
Long before the Max disasters, Boeing had a history of failing to fix safety problems
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https://www.washingtonpost.com/world/asia_pacific/investigators-fault-boeing-737-maxs-flight-control-system-regulatory-lapses-and-pilot-training-in-lion-air-crash/2019/10/25/e8143d06-f69c-11e9-b2d2-1f37c9d82dbb_story.html
2019-10-25 09:28:00Z
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