Ethiopia softens report on ’19 crash
Boeing 737 Max design, inadequate pilot training cited
Ethiopian investigators found Boeing Co.’s design of the 737 Max and inadequate pilot training led to a deadly crash a year ago, but dropped formal conclusions about the cause in an interim report after pressure from other nations.
A 136-page report, released by the country’s ministry of transport on Monday, said a new flight control safety system known as the maneuvering characteristics augmentation system on the Ethiopian Airlines Group plane was central to why it crashed into a field near Addis Ababa on March 10 last year, killing all 157 people on board.
The once top-selling Max was grounded by global regulators days after the accident, plunging Boeing into a crisis. The crash, which also featured the flight control system, followed a similarly deadly Lion Air Max jet crash in Indonesia that killed 189 people about four months earlier. Work to redesign the software and to address additional safety issues still isn’t complete and the U.S. manufacturer doesn’t expect the jet to return until summer at the earliest.
Memorial services are planned today at the crash site for family members of the victims as well as one in Addis Ababa.
A draft of the interim crash report had originally included a probable cause and contributing factors focusing on the plane’s design, said two people familiar with
the situation who asked not to be named while discussing the sensitive matter. The interim report included six recommendations and 16 “findings,” several of which pointed at Boeing, but no formal conclusion of what caused the disaster.
Conclusions about the cause and any contributing factors would be included in a final report. Ethiopian authorities haven’t said when they expect to finish such a report.
Boeing, the U.S. Federal Aviation Administration, the U.S. National Transportation Safety Board and the French Bureau of Inquiry and Analysis for Civil Aviation Safety all weighed in with concerns about how the original draft was written, said the people.
Helping to explain what the Ethiopian aviators were doing is key to gaining a full
understanding as to what happened, yet the new report from the country’s Aircraft Accident Investigation Bureau does little to address the pilots’ behavior.
The FAA alluded to that in a statement.
“We believe it’s important to have the full final report to evaluate it against other independent reports so that we might fully understand all of the factors — both mechanical and human — that played a role in this tragic loss of life,” the agency said.
The report’s conclusions focus on Boeing, including issues with flight control system, training and the plane’s reliance on only a single sensor.
“Boeing continues to provide technical assistance in support of the investigation,” a company spokesman said in an emailed statement. “We look forward to reviewing the full details and formal recommendations.”
The Ethiopian investigators’ assessment differs from
Indonesia’s final investigation report on the Lion Air crash. The Indonesian report cited a number of factors, including aircraft design, the flight crew’s response and a lack of documentation on the plane’s flight and maintenance history.
In Ethiopia’s case, investigators found that the aircraft had “a valid certificate of airworthiness,” had no known technical problems before departure, and had weight and balance “within the operating limits.”
But they said faulty sensor readings and automatic commands that did not appear on the flight crew operation manual had left the crew unable to control the plane, resulting in the fatal crash. The report also said Boeing’s reliance on a single sensor for the 737 Max “made it vulnerable to undesired activation.”
The transportation safety board sent “general comments” on the interim report to Ethiopia, said spokesman Eric Weiss, declining to specify
what was said. The practice in international investigations is that safety board represents Boeing’s and FAA’s views.
Outside input on accident investigators is generally included in a final report, but not in an interim report such as what Ethiopia released.
Training requirements for the 737 Max were set by the FAA and Ethiopian authorities. Boeing had insisted that the Max was so similar to earlier models that only limited training was needed to move from one to the other, and made that a selling point for the plane.
The plane maker this year recommended that Max pilots get simulator training. The FAA hasn’t weighed in on that issue.
Last week, a preliminary report by the U.S. House Committee on Transportation and Infrastructure said that production pressures and a “culture of concealment” at Boeing had contributed to both plane crashes. The report also found a conflict of interest with regard
to oversight, highlighting instances in which Boeing employees responsible for representing the FAA’s interest “failed to take appropriate actions” to safeguard passengers on commercial flights.
The aftermath of the Ethiopian crash highlighted the sizable influence that Boeing has over regulators and oversight procedures, said Githae Mwaniki, an aviation expert with Aviation Information Consultants in Nairobi, Kenya.
“That whole area of certification and modification of existing aircraft requires a total overhaul,” Mwaniki said.
Boeing, which is based in Chicago, now faces a $20 million fine from the FAA, and lawsuits filed by victims’ families are seeking tens of millions of dollars in damages. Information for this article was contributed by Alan Levin and Samuel Gebre of Bloomberg News and by Simon Marks and Abdi Latif Dahir of The New York Times.