Lion Air Boeing 737MAX crash investigation final report faults Boeing design, pilot errors and maint


The final investigation report of the Lion Air 737 MAX flight JT610, critique the design and certification of Boeing’s new flight-control system, MCAS on the 737MAX airplane. “The design and certification of the MCAS (Maneuvering Characteristics Augmentation System) did not adequately consider the likelihood of loss of control of the aircraft,”…“A fail-safe design concept and redundant system should have been necessary for the MCAS.” states the report. Lion Air 737MAX flight 610 crashed into the Java Sea on Oct. 29, 2018, shortly after taking off from Jakarta Airport., all eight crew members and 181 passengers onboard were killed. The 353-page report released on Friday found that nine factors worked together to cause the Lion Air jet crash. The nine factors included the wrong assumptions by Boeing about how pilots would respond to the Maneuvering Characteristics Augmentation System (MCAS), lack of training for pilots in the new system, faulty angle of attack sensor, “These items were connected to each other. If one of them was not occurring on that day, the accident may not have happened,” said Nurcahyo Utomo, an investigator at the National Transportation Safety Committee. Three days before the crash on 26 October 2018, the SPD (speed) and ALT (altimeter) flags on the Captain’s primary flight display first occurred on the flight from Tianjin, China to Manado, Indonesia. Following reoccurrence of these problems, the left angle of attack (AOA) sensor was replaced in Denpasar on 28 October 2018., but the AoA sensor installed on the aircraft on 26 Oct, was a secondhand unit repaired and supplied by a Florida company, was faulty, and the Lion Air maintenance crew failed to test during installation prior to the flight. The installed left AOA sensor had a 21° bias which was undetected during the installation test in Denpasar. “One [angle of attack sensor] affected the whole system,” Nurcahyo said. A false reading on that sensor activated the MCAS and redirected the plane to pitch down, leaving the cockpit crew unable to override the auto­pilot commands. The MCAS was a new feature introduced on the Boeing 737-8 (MAX) to enhance pitch characteristics with flaps up during manual flight in elevated angles of attack The investigation considered that the design and certification of this feature was inadequate. The aircraft flight manual and flight crew training did not include information about MCAS. Indonesian investigators, however, stressed that their report was aimed to ensure the passenger safety and to prevent similar accidents., and cannot be used for liability or compensation issues in court. 


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