Report: Lion Air Boeing 737 Max Crash Caused by a Series of Failures

By Jesse Sokolow on 25 October 2019
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IMG_7743The investigation by Indonesian authorities into the crash of Lion Air Flight 610 held that design flaws in Boeing’s 737 Max aircraft, maintenance issues, regulatory lapses, and false assumptions about pilots’ responses to new systems were to blame.

The aircraft crashed in part because pilots were never trained on how to respond to a malfunction of the Boeing 737 Max’s new flight control system, the Maneuvering Characteristics Augmentation System, or MCAS.  In a news conference on Friday, investigators pointed to nine critical issues that they said came together to bring about the crash.

“The items were connected to each other,” said chief investigator Nurcahyo Utomo.  “If one of the nine hadn’t occurred, maybe the accident wouldn’t have happened,” he added.

The factors cited by investigators included incorrect assumptions made by Boeing about how pilots would respond to the MCAS, and they focused on how the system relied on a single sensor and was therefore vulnerable to errors.

Other factors included a lack of pilot training on the new system, a lack of documentation about problems in prior Lion Air flights of the airliner involved in the crash, and ineffective coordination between flight crews relating to such issues.

Investigators said that the aircraft should have been grounded after an earlier flight in which a similar incident occurred with the flight control system.

“We are addressing the KNKT’s safety recommendations, and 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,” Boeing said in a statement following the release of the findings.  “Safety is an enduring value for everyone at Boeing and the safety of the flying public, our customers, and the crews aboard our airplanes is always our top priority.”

(Photo: Accura Media Group)

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