FILE PHOTO: Lion Air’s Boeing 737 Max 8 airplane is parked on the tarmac of Soekarno Hatta International airport near Jakarta, Indonesia, March 15, 2019. REUTERS/Willy Kurniawan
October 25, 2019
(Reuters) – Indonesia has recommended closer scrutiny of automated control systems, better design of flight deck alerts and accounting for a more diverse pilot population in the wake of a Boeing Co 737 MAX crash, the Seattle Times reported http://bit.ly/2WbsSYR.
The newspaper received an advance copy of a final report on the crash of a Lion Air jet that killed all 189 people on board on Oct. 29, 2018.
Less than five months after the Lion Air accident, an Ethiopian Airlines 737 MAX crashed, leading to a global grounding of the model and sparking a corporate crisis at Boeing, the world’s biggest planemaker.
Indonesian investigators on Wednesday told families of the victims that a mix of factors contributed to the crash, including mechanical and design issues and a lack of documentation about how systems would behave.
“Deficiencies” in the flight crew’s communication and manual control of the aircraft contributed to the crash, as did alerts and distractions in the cockpit, according to slides presented to the families.
The final report said the first officer was unfamiliar with procedures and had shown issues handling the aircraft during training, according to the Seattle Times.
When the aircraft encountered airspeed reading problems after take-off, the first officer had to be asked twice by the captain to perform the checklist and it took him four minutes to find it in the quick reference handbook, the newspaper said.
The report also found that a critical sensor providing data to an anti-stall system had been miscalibrated by a repair shop in Florida and that there were strong indications that it was not tested during installation by Lion Air maintenance staff.
Lion Air should have grounded the jet following faults on earlier flights, the report said and added that 31 pages were missing from the airline’s October maintenance logs.
Lion Air did not respond to a request for comment.
FIGHTING MCAS
In the report, Indonesian regulators recommended a redesign of the anti-stall system known as MCAS that automatically pushed the plane’s nose down, leaving pilots fighting for control.
Boeing has already said it would remake the system and provide more information about it in pilot manuals.
According to the report, Boeing’s safety assessment assumed pilots would respond within three seconds of a system malfunction but on the accident flight and one that experienced the same problem the prior evening, it took both crews about eight seconds to respond, the Seattle Times said.
Boeing had reasoned that MCAS could be countered by a pilot pulling back on the control column alone, but events and subsequent tests showed that cut-out switches needed to be used, the paper cited the report as saying.
In December 2018, accident investigators and Boeing conducted a simulator test and found that after just two activations of MCAS, absent counteraction from the pilot, the control column became “too heavy” to move, the newspaper said.
The final report will be released publicly on Friday. Boeing has said it cannot comment before the release of the report.
A panel of international air safety regulators this month also faulted Boeing for assumptions it made in designing the 737 MAX and found areas where Boeing could improve processes.
(Reporting by Jamie Freed in Singapore; additional reporting by Bernadette Christina Munthe in Jakarta and Bhargav Acharya in Bengaluru; Editing by Himani Sarkar and Gerry Doyle)
