Lion Air Boeing Crash Final Report 737 MAX

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The final report of the Lion Air accident was made public in a Boeing 737 MAX happened on 29 October 2018 extinguishing the life of 189 people.

The 29 October 2018, the flight 610 de PT Lion Mentari Airlines (Lion Air), a boeing 737 MAX 8, PK-LQP, crashed into the Java Sea shortly after takeoff from Soekarno-Hatta International Airport, She fought, Indonesia. The flight was a scheduled domestic flight from Jakarta to Depati Amir Airport, Pangkal Pinang City, Bangka Belitung Islands Province, Indonesia. The 189 Passengers and crew on board were killed and the plane was destroyed.

Almost a year after this fateful accident that questioned the Boeing 737 MAX and that would be followed by the Ethiopian accident, The National Transportation Committee of the Republic of Indonesia has made public the report of more than 300 pages, which resolves and demonstrates the already confirmed doubts that generated this accident.

Final report

You can read the full report below, It takes a while to load given its size:

Conclusions

The report is comprehensive in every sense, as a final report should be., but we will highlight in this summary some of the most important discoveries of the completed research:

• MCAS is designed to operate only during manual flight (unengaged autopilot), with the airplane flaps raised, at a high AOA. As the development of 737-8 (MAX) progress, The MCAS function was expanded to low Mach numbers and increased to the maximum MCAS command limit of 2.5° of stabilizer movement.
• During the Functional Risk Analysis (FHA), Undesired stabilizer movement by MCAS was considered a failure condition with greatest effect on the normal flight envelope.. Major's assessment does not
  require Boeing to more rigorously analyze the failure condition in safety analysis using failure modes and effects analysis (FMEA) and fault tree analysis (FTA), as these are only necessary for hazardous or catastrophic failure conditions.
• The flight crew did not react to the activation of MCAS but to the increasing force in the control column. Since the flight crew initially countered the MCAS command using the control column, the longest response time to make electric the stabilizer adjustment inputs were understandable.
• During the FHA, The simulator test had never considered a scenario in which activating MCAS allowed the stabilizer movement to reach the maximum MCAS Limit of 2.5 degrees. Repetitive MCAS activations without adequate flight crew adjustment reaction would cause the stabilizer to move to maximum deflection and increase flight crew workload and, Thus, the effects of failure should have been reconsidered. Therefore, their combined flight deck effects were not evaluated.
• The stabilizer runaway procedure was not reintroduced during the training transition and there was no immediate indication available to the flight crew to be able to directly correlate the nose-down stabilizer without controls with the procedure.. Therefore, the assumption of relying on trained crew procedures to implement memory elements was inappropriate.
• During the accident flight, multiple alerts and indications occurred which increased the workload of the flight crew. This obscured the problem and the flight. The crew was unable to reach a solution during the initial or subsequent automatic nose-down stabilizer inputs of the aircraft., such as performing the stabilizer runaway procedure or continuing to use power trim to reduce spinal forces and maintain level flight.
• Pulling back on the spine normally disrupts any nose-down electric stabilizer aircraft, but for him 737-8 (MAX) with MCAS running, control column cutoff function is disabled.
• The aircraft design must provide the flight crew with information and alerts to help them understand the system and know how to resolve potential problems..
• Boeing considered the MCAS function to be automatic, The procedure required to respond to any MCAS function was no different than existing procedures and that crews were not expected to encounter MCAS under normal operating conditions., For this, Boeing did not consider the failure scenario seen in the accident flight.. Research believes effect of erroneous MCAS function was surprising to flight crews.
• The investigation believes that the flight crew should have been informed of the MCAS which would have provided them with knowledge of the system and increased their chances of being able to mitigate the consequences of multiple activations at the accident scene..
• Not understanding MCAS and reactivation after releasing the electrical system, the flight crew was running out of time to find a solution before repetitive MCAS activations without fully returning the aircraft to control, which placed the aircraft in an extreme nose-down attitude that the flight crew was unable to recover.

Contributing factors

• During the design and certification of the Boeing 737-8 (MAX), Assumptions were made about the flight crew's response to malfunctions that, despite being consistent with current industry guidelines, turned out to be incorrect.
• Based on incorrect assumptions about flight crew response and an incomplete review of the associated effects of multiple flight deck, MCAS reliance on a single sensor was deemed appropriate and met all certification requirements.
• MCAS was designed to rely on a single AOA sensor, which makes it vulnerable to erroneous input from that sensor.
• Lack of guidance on MCAS or more detailed use of trim in flight manuals and flight crew training, made it more difficult for flight crews to properly respond to uncommanded MCAS.
• AOA DISAGREE alert was not activated correctly during Boeing development 737-8 (MAX). As a result, did not appear during flight with poorly calibrated AOA sensor, the flight crew was unable to document it and, Thus, was not available to help maintenance identify the miscalibrated AOA sensor.
• The replacement AOA sensor installed on the accident aircraft was miscalibrated during a previous repair. This incorrect calibration was not detected during the repair.

security recommendations

As in every report, the idea is not to find guilty, otherwise, find solutions to prevent these events from recurring in the future, Thus, the researchers generate the following recommendations, among other:

Lion Air

• Investigation found that Lion Air manuals were not updated in a timely manner and the content has several inconsistencies, incomplete and unsynchronized procedures.
  Therefore, KNKT recommends establishing a system to ensure that company manuals are updated in a timely manner.
• Flight LNI043 which experienced multiple failures was considered to have caused or could have caused difficulties in controlling the aircraft. According to the Annex 13 from ICAO, CASR part 830 and OM-part A, The flight is classified as a serious incident requiring investigation by KNKT in accordance with the Aviation Law Number 1 from 2009 and Government Decree Number 62 from 2013.
  Therefore, KNKT recommends that Lion Air improve the management of its hazard report by allowing the hazard to be identified and providing appropriate mitigation.

AirNav Indonesia

• The LNI610 flight crew requested the controller for the altitude of the aircraft detected on the ATC radar screen., which could be an effort to obtain another source of information. The aircraft altitude request to the controller will not obtain additional information as the ATC radar display receives data from the aircraft transponder which transmits cockpit indications.
  Therefore, KNKT recommends providing information to the flight crew that the altitude indication on the ATC radar display was repeating aircraft data.

Boeing

• during the accident, multiple alerts and indications occurred which increased the workload of the flight crew. This obscured the problem and the flight crew was unable to come up with a solution during the initial and subsequent automatic entry of the Y stabilizer., such as performing the stabilizer runaway procedure or continuing to use power trim to reduce spine forces and maintain level flight.
  Therefore, KNKT recommends that the aircraft manufacturer consider the effect of all possible flight deck alerts and indications on flight crew recognition and response.; and incorporate the design, flight crew procedures and / or training requirements when necessary to minimize the potential for flight crew actions that are inconsistent with the manufacturer's assumptions.
• During the certification phase, flight test pilots demonstrated compliance, who typically have exceptional skills and experience. Flight test pilots generally have more knowledge about aircraft design features than regular pilots. This level of proficiency generally cannot be translated to most pilots.. Nevertheless, test pilots are trained to replicate the average flight crew. The pilots of the Aircraft Evaluation Group, who have operational flight history, They also evaluate the aircraft during the certification phase. These pilots establish the pilot type qualification requirements, training, verification and currency as part of the Flight Standardization Board process (FSB). The FSB process also uses airline pilots to help ensure that requirements are operationally representative.. The FAA and OEMs should reevaluate their assumptions for what constitutes the basic skill of an average flight crew and what level of systems knowledge a “properly trained average flight crew” has when they encounter failures..
  Therefore, KNKT recommends that Boeing include greater tolerance in the design that is required to allow the operation of a larger population of flight-rated pilots..
• The flight crew should have received information and alerts to help them understand the system and know how to resolve potential problems. Flight crew procedures and training should be appropriate.
  Therefore, KNKT recommends Boeing develop guidance for information criteria to be included in flight crew and engineer manuals.
• The aircraft should have functionally included the intended AOA DISAGREE alert message, which was installed on the aircraft 737 of. Boeing and the FAA must ensure that the new and modified aircraft design is described, analyze and certify appropriately.
  Therefore, KNKT recommends that Boeing ensure that certified and delivered aircraft have the intended system functionality.

This is a summary of the long final report, You can read all the conclusions and details in it..

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