Indonesia’s safety report identifies failures in deadly Lion Air accident
Airlines, aviation officials, design flaws among sweeping factors that led to crash
Indonesian JAKARTA/WASHINGTON investigators found sweeping problems and missteps in connection with last year’s fatal Lion Air crash, including design flaws in Boeing Co.’s 737 Max jet, certification failures by the U.S. regulator and a raft of errors at the airline by pilots and mechanics.
In a much-anticipated report released Friday, the National Transportation Safety Committee listed its findings and recommended fixes to Boeing, Lion Air and aviation authorities in the U.S. and Indonesia. The findings focused on a flight-control feature called the Maneuvering Characteristics Augmentation System, which has also been implicated in an Ethiopian Airlines crash in March. But it also painted a damning picture of Lion Air, where numerous actions also helped led to the tragedy.
The conclusions add to the pressures on Boeing, which is finalizing fixes to its grounded best-selling jet and attempting to manage a public-relations crisis that has cost the company billions of dollars. While this closes one chapter on the saga, it’s not over. Boeing chief executive Dennis Muilenburg, who was stripped of his role as chairman earlier this month, is due to face questions from lawmakers in Washington next week.
Boeing shares were down 1.37 per cent to close at US$339.83 in New York on Friday. Through Thursday, the shares had fallen 18 per cent since the Ethiopia crash, the second-biggest drop on the Dow.
The wide-ranging report found ample blame to go around, from an obscure repair station in Florida
to Boeing and the U.S. Federal Aviation Administration, whose failures have undermined the agency’s credibility as a leading aviation regulator.
The 737 Max was grounded March 13, three days after the crash in Ethiopia, costing Boeing US$9.2 billion and counting. While Boeing says it has made significant progress in returning the 737 Max to service, no date has been set.
In response to the findings, Muilenburg said the company is addressing the Indonesian investigator’s safety recommendations. Boeing engineers have been working with the FAA and other regulators to make software updates and other changes, according to the statement.
The FAA said it welcomed the recommendations from Indonesia and would carefully consider them in its review of the 737 Max. “The aircraft will return to service only after the FAA determines it is safe,” the agency said in an emailed statement.
Lion Air said in a statement it’s
“essential to determine the root cause and contributing factors to the accident and take immediate corrective actions to ensure that an accident like this one never happens again.”
Minutes after taking off from Jakarta for Pangkal Pinang on the morning of Oct. 29, Lion Air Flight 610 nosedived into the Java Sea, killing all 189 people on board. It was the second-deadliest airline disaster in Indonesia’s aviation history, following a 1997 crash near Medan that killed 234 people.
During testing, Boeing determined that malfunctions involving MCAS weren’t deemed serious enough — hazardous or catastrophic failures — for a more rigorous analysis, which could have identified significant problems with its design, according to the report. Boeing also erroneously assumed that the crew would be able to correctly deal with malfunctions within three seconds, even though they were unaware of the existence of the flight-control system, it said.
“The flight crew should have been made aware of MCAS which would have provided them with awareness of the system and increase their chances of being able to mitigate the consequences,” the report said. “Training would have supported the recognition of abnormal situations and appropriate flight crew action.”
During simulator testing, Boeing never considered the scenario that occurred in the Lion Air flight, in which the flight-control system kicked in multiple times and repeatedly pushed down the plane. The Lion Air crew reacted differently to what Boeing anticipated, according to the report.
Indonesian investigators also highlighted some problems in the certification process of the 737 Max, saying the aircraft manufacturer didn’t submit required documentation and the FAA didn’t adequately oversee the overall design.
Meanwhile, Boeing is in the final stages of completing its software fix application to the FAA, and is preparing for a certification flight. It said this week it still expects regulatory clearance during the fourth quarter to return the 737 Max to service. Approvals in other regions are likely to come after. In Europe, regulators plan to do their own flight tests, though they have said they will try to keep any delays as short as possible.
Airline customers have been cautious on the Max’s return. Air Canada is keeping the Boeing 737 Max off its flying schedule until Feb. 14, citing “regulatory uncertainty” that will affect thousands of passengers. Westjet announced in September it was removing the 737 Max from its schedule until Jan. 5.
Southwest Airlines Co.’s CEO said on Thursday he isn’t sure whether the FAA will sign off this year, and after that it will take as long as two months to train pilots and get aircraft ready to fly. Norwegian Air Shuttle ASA said this week it expects the Max to remain idle until at least late March.
The flight crew should have been made aware of MCAS which would ... increase their chances of being able to mitigate the consequences.