A design flaw, inadequate pilot training and poor flight crew performance contributed to a Boeing jet crash in Indonesia last year, killing all 189 people on board. Investigators announced this yesterday in a report that an aviation analyst called “damned”. The Lion Air disaster was followed months later by a second crash – involving the same aircraft model – when an Ethiopian Airlines plane carrying 157 people crashed, causing the entire Boeing 737 MAX fleet to land worldwide.
The crashes put the MAX model’s Maneuvering Characteristics Augmentation System (MCAS) in the spotlight, an anti-stall mechanism that pilots on both planes found difficult to control during the jets’ downward career. On Friday, the Indonesian National Transportation Safety Committee said Boeing’s design of the anti-stall system and its certification by US regulatory authorities were “inadequate”. The MCAS was vulnerable to a single sensor it relied on for inputs and 737 MAX pilots were not properly advised on how to deal with a malfunction, according to its final report on the crash.
“The aircraft flight manual and flight crew training did not contain any information about MCAS,” it said. A sensor in the doomed jet’s system was “incorrectly calibrated” and the problem was not recognized by Lion Air’s maintenance teams after the aircraft’s previous flight had also lost control issues. The emergency was not “effectively managed” by the crew, who previously had performance issues, she added.
‘Heartfelt condolences’
An earlier report from international regulators said the U.S. Federal Aviation Administration (FAA) lacks the staff and expertise to fully assess the jet’s MCAS when certifying the aircraft. Yesterday’s report comes after Boeing – faced numerous legal disputes – replaced the head of its aircraft division this week. This marked the most significant executive exit since the 737 MAX was founded seven months ago.
Boeing underwent a new exam following the exposure of text messages from 2016 in which a test pilot described the MCAS as “rampant” and “egregious” during a simulation. On Friday, Boeing expressed “deep condolences” to the families of the victims and said it has since repaired the flight control system software. “These software changes will prevent the flight control conditions that were encountered in this accident from ever occurring again,” said Dennis Muilenburg, Boeing CEO, in a statement.
NTSC chairman Soerjanto Tjahjono told reporters on Friday that all the factors highlighted were “related” to explain why the crash happened. But aviation analysts said much of the blame can be traced back to Boeing. “What the Indonesians wrote here is damned,” said Stephen Wright, professor of aircraft systems at Tampere University in Finland. “(Lion staff) did their job based on the information they were given … Everything points to the manufacturer and how it was (MCAS) approved,” he added. Another expert said the aircraft’s design problems exceeded all others.
“Pilots can make mistakes – they are human, but the root of the problem is design,” said Jakarta-based aviation analyst Gerry Soejatman. “The MCAS was designed to be able to react only on the basis of a single input from a computer. (And) there was no cross-checking system to confirm whether the entry was correct or not. That’s the problem. ”
“My only son”
Lion Air, Southeast Asia’s largest airline by fleet size, said Friday’s report was “essential in determining the root cause and contributing factors to the accident and taking immediate corrective action”. The FAA said the grounded single-aisle jet would not be returned to service until the model was determined to be safe.
After briefing the report this week prior to its release, some relatives of the victims expressed their disappointment. “However, we have no choice but to accept the report,” said Epi Syamsul Qomar, who lost his son after families met with investigators in Jakarta. “People keep telling me to let go, stay strong, but how do I do that? It’s not that easy. He was my only son and I miss him every day. “
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