Friday, 25 October 2019

Lion Air's Boeing 737 Max caused by a series of failures including design flaws, pilot errors and maintenance missteps


It was a catalogue of failures that lead to the Lion Air Boeing 737 Max crash that claimed the lives of 189 people last October, the official report says. 

On Friday 25th October the Indonesian Air Crash investigators released their final report into the disaster which listed a series of issues that caused the crash. "From what we know, there are nine things that contributed to this accident," Nurcahyo Utomo, part of the air accident investigation team told a press conference.  "If one of the nine hadn't occurred, maybe the accident wouldn't have occurred."


Those nine failures include a previous cockpit error should have grounded the dommed jet, yet the report says wasn't recorded properly, so the aircraft was allowed to keep on flying.  A critical sensor recently purchased from a repair centre in Florida, had not been tested properly.   That sensor, the single one, fed information to Boeing's Manoeuvring Characteristics Augmentation System - the special software developed to prevent the aircraft stalling, following aerodynamic issues resulting from Boeing moving the larger engines closer to the fuselage than on previous generations of the 737 aircraft.  


The Indonesian investigators said issues with MCAS repeatedly pushed the nose down, while the pilots were battling for control. Boeing has made incorrect assumptions about how the MCAS control system would behave leading to deficiencies during training. There were also issues with the flight deck crews performance during the flight, lack of full communication and briefings. The report said that investigators discovered 31 pages were missing from the aircraft's maintenance log.

"On behalf of everyone at Boeing, I want to convey our heartfelt condolences to the families and loved ones of those who lost their lives in these accidents. We mourn with Lion Air, and we would like to express our deepest sympathies to the Lion Air family," said Boeing President & CEO Dennis Muilenburg. "We commend Indonesia's National Transportation Safety Committee for its extensive efforts to determine the facts of this accident," he said, adding "We are addressing the KNKT's safety recommendations, and taking actions to enhance the safety of the 737 MAX to prevent the flight control conditions that occurred in this accident from ever happening again."






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