- The final report into the Lion Air Boeing 737 Max crash that killed 189 people blamed Boeing’s design of the plane, as well as pointing to errors by the airline and its crew.
- It said that the design of the controversial MCAS software, which continually pointed the plane’s nose down “did not adequately consider the likelihood of loss of control of the aircraft,” and that Boeing should have added a fail safe system.
- The report also criticized Boeing for not telling pilots about the system and for failing to notice that an alert in the plane was not working, as well as for making the MCAS system more powerful without telling regulators.
- The report also pointed to pilots, saying that the crew responded poorly to a series of alerts and that the first officer could not recall a checklist that he should have memorized.
- It said that Lion Air should have grounded the plane after similar issues were found on a previous flight, that 31 pages were missing from the plane’s maintenance logs that month.
- Lion Air did not appear to have inspected a key sensor that turned out to be faulty, it also noted.
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The final report by investigators of the Lion Air Boeing 737 Max plane that crashed and killed 189 people in October 2018 said that Boeing’s design of the plane contributed to the crash, alongside the actions of the airline and its pilots.
The Indonesian investigators pointed to the plane’s anti-stall software, called MCAS, which the preliminary report identified as the reason the plane’s nose continually pointed down out of the pilots’ control, causing it to nosedive into the sea.
Flight JT 610 crashed into the sea 13 minutes after it took off from Soekarno-Hatta International Airport in Jakarta, Indonesia on October 29, killing everyone on board.
“The design and certification of the MCAS did not adequately consider the likelihood of loss of control of the aircraft,” the report said.
“A fail-safe design concept and redundant system should have been necessary for the MCAS.”
The report also highlighted that Boeing ultimately gave MCAS more power in the plane compared to what it had originally told regulators, a development first reported by the Seattle Times in March.
The report said that this meant the US Federal Aviation Administration “would not be able to reassess the safety of the design change.”
Reuters, The Seattle Times, and The Associated Press have seen the report, but at the time of publication, Business Insider has been unable to obtain a full copy of the report.
The preliminary report into the crash in April found that the MCAS system had misfired in the Lion Air plane that crashed — as did the preliminary report into the Ethiopian Airlines 737 Max that crashed and killed 157 people in March. Boeing is currently updating the plane, which has been grounded since March, but has defended its design as safe.
The updates have not yet been approved by the US Federal Aviation Administration or its equivalent regulators around the world.
The final report, released today, criticized Boeing for not including details about the MCAS system in manuals and training for the plane’s pilots.
“The absence of information about the MCAS in the aircraft manuals and pilot training made it difficult for the flight crew to diagnose problems and apply the corrective procedures,” the report said.
An audio recording from a meeting between American Airlines pilots and Boeing executives after the Lion Air crash that was shared with Business Insider showed the pilots confronting Boeing for not sharing details about the system.
“I would think that there would be a priority of putting explanations of things that could kill you,” one pilot then said.
Boeing’s CEO defended not telling pilots about the system in April, saying that it is “fundamentally embedded in the handling qualities of the airplane” and that it is “not a separate system to be trained on.”
The report also criticized Boeing for failing to notice an error that meant a warning light about the plane’s angle in the sky did not work.
In a statement after the release of the report, Boeing CEO Dennis Muilenburg said it was “addressing” the investigator’s safety recommendations.
He added that Boeing is “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.”
“We commend Indonesia’s National Transportation Safety Committee for its extensive efforts to determine the facts of this accident, the contributing factors to its cause and recommendations aimed toward our common goal that this never happens again.”
Boeing is facing lawsuits from the families of those killed on the flight, as well as the families of those killed on the Ethiopian Airlines plane.
Investigators also pointed to the pilots and the airline
The report was also critical of the action of Lion Air and its pilots, citing poor communication and solutions to previous issues with the same plane.
It said that the crew did not coordinate their responses to the issues in the plane and the associated alerts, and said that the first officer, who had performed poorly in training, was not able to recall a checklist that he should have memorized.
The captain had been wrestling with the plane’s controls, managing to pull it up from a nose-down position more than 20 times, before he handed them over to the first officer, the report said. Soon after, the plane crashed into the sea.
A March report in The New York Times said that the pilots were unaware of the steps they needed to take to stop the crash.
The report also said that Lion Air failed to ground the plane after its previous flight, when the plane had the same malfunction but an off-duty pilot managed to solve the problem. The April preliminary report found that that information was not passed onto the crew of the fatal flight.
Friday’s report said that the previous flight “experienced multiple malfunctions was classified as a serious incident and should have been investigated.”
The report said that 31 pages were missing from the plane’s maintenance logs from October, the month of the crash.
The report also said that a critical sensor in the plane, supplied by a Florida company, was faulty during the fatal flight.
It said that Lion Air appeared not to have tested the sensor when installing it as a replacement the day before the crash.
Maintenance records do not include any record of this sensor — an angle of attack sensor, which measures the plane’s angle in the sky —being tested by the maintenance engineer who installed it, the report said, though the engineer claimed that it had been.
The report said that “the investigation could not determine with any certainty” that the installation was “successful.”