Indonesian Investigators Release Final Report on Lion Air Crash

"ttyymmnn" (ttyymmnn) 10/25/2019 at 10:19 • Filed to: wingspan, Planelopnik, Boeing 737 Max

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And the news is not good for Boeing, though there are no blockbuster new revelations. The 737 MAX saga continues to be a story of lax FAA regulation, pressure to get the plane certified, a lack of coordination on Boeing’s part between divisions, and reliance on a single sensor to make MCAS do its thing. But the report also shares some blame to the flight crew. It notes a captain who was sick with the flu, a first officer who was awoken at 4:00 am to fill in and was shown to be deficient in piloting skills and unable to recall procedures that should have been memorized. The captain failed to understand exactly what was happening, though a lack of training on MCAS, and no mention of it in the manuals, surely added to his confusion. Blame is also placed on Lion Air maintenance personnel who cleared the plane to fly, and the Florida company who serviced the failed sensors.

I think the report highlights that the 737 MAX debacle has plenty of blame to spread around. !!!error: Indecipherable SUB-paragraph formatting!!! have tried to place at least equal blame on the flight crew, and admittedly, it took the first officer a full four minutes to locate a checklist while the pilot fought with MCAS. But I believe that the lion’s share of blame must be placed on Boeing, who designed a single-point of failure system and either neglected to tell regulators about it or outright covered it up. Blame must also be laid on the FAA who allowed the fox to guard the henhouse and left much of the regulatory oversight to Boeing, who cut corners and pressured engineers to get the MAX in the air as soon as possible in the face of mounting competition from Airbus.

For Boeing’s part, they have rewritten the software that drives MCAS to make it much less aggressive. The system also takes into account information from more than one sensor, and optional warning lights that would have alerted the crew to a disagreement between sensors has been made standard. The manuals have been updated, training has been augmented, and there shouldn’t be a single 737 pilot in the world who won’t know how to turn MCAS off. When the MAX carries passengers again (ferry and test flights have been ongoing for months now), it should be as safe as any airliner in the skies. However, this sort of rigorous testing and training should have taken place routinely long before the MAX was ever cleared to fly. It shouldn’t have taken 346 deaths to get to this point.

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The Seattle Times article is a good read. They have some of the best reporting on aviation in general, and Boeing specifically.

just-a-scratch > ttyymmnn 10/25/2019 at 10:33

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Your t ake seems accurate to me. One would be hard pressed not too put a big share of blame on Boeing. 

S eattle is Boeing country. If you don’t work for Boeing, you probably know someone who does.

Rusty Vandura - www.tinyurl.com/keepoppo > just-a-scratch 10/25/2019 at 10:43

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It's a Boeing badge on the grille, after all.

WilliamsSW > ttyymmnn 10/25/2019 at 10:56

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Sounds like a pretty balanced and thorough report. There are almost always a LOT of factors that contribute to an airliner crash, and we can learn from each one of those factors.

Our ADD culture wants a sound bite that casts all of the blame onto 1 party, but that’s not how reality works.

What Boeing did (didn’t do?) was egregious- yet perhaps a flight crew that was ready could have gotten the aircraft on the ground safely anyways. Maybe.   Doesn’t excuse Boeing AT ALL, but hopefully Lion Air and Indonesia take this to heart to improve their processes and procedures too.

ttyymmnn > WilliamsSW 10/25/2019 at 11:10

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perhaps a flight crew that was ready could have gotten the aircraft on the ground safely anyways.

Remember there was a mystery jump seat pilot who leaned in and saved the Lion Air plane the day before it crashed. And US pilots reported problems in the months before the two MAX crashes but were able to fly and land safely. I agree that better airmanship might have saved those two airliners, but the chain started with Boeing, and those pilots should never have been put in that position in the first place. IMO, the chain of failure began when Boeing pushed to get the MAX certified under a 50-year-old certificate.

For Sweden > ttyymmnn 10/25/2019 at 11:11

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Citing the pilots as a contributing factor is appropriate, but I am infuriated to see articles blaming the pilots. An airline’s flight control system should be resilient enough to handle a somewhat compromised pilot.

ttyymmnn > For Sweden 10/25/2019 at 11:14

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Did you read that NYT piece? I agree with a lot of what the author had to say, but he also comes across as a Boeing apologist. I was also interested in his argument that Airbus designs their planes for pilots who only monitor the autopilot, and that Boeing perhaps  should have gone a similar route.

For Sweden > ttyymmnn 10/25/2019 at 11:17

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He was a complete Boeing apologist, which baffled me. I thought the NYT writers were all about speaking truth to corporate power, backing unionized employees, etc.

ttyymmnn > For Sweden 10/25/2019 at 11:17

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#Fair and Balanced

WilliamsSW > ttyymmnn 10/25/2019 at 11:42

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Oh I completely agree with that, and I’m not absolving Boeing of anything. Boeing deserves the scorn they’re getting, and flight crews should not be put into positions where they have to be heroes.

It’s just that there is more than 1 learning to be had from this tragedy. 

someassemblyrequired > ttyymmnn 10/25/2019 at 11:44

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I wanna know why the AOA indicator had to be replaced on a nearly new airplane.

someassemblyrequired > For Sweden 10/25/2019 at 11:46

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The modern NYT is pay-for-play.   They’re a large advertorial at the moment.   Only Boeing reporting I trust is Dominic Gates in the Seattle Times.

ttyymmnn > someassemblyrequired 10/25/2019 at 11:55

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It had been damaged in flight. It’s my understanding that such damage is not uncommon. That particular AOA sensor had already been damaged once and been repaired. That is why scrutiny has fallen on the FL company that effected the repair. I have read that that company, and others like it, function as a sort of mill to crank out repaired parts, with little oversight or quality control. 

WilliamsSW > For Sweden 10/25/2019 at 12:03

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I haven’t seen the article, but I’ll go out on a limb and guess it was Langewische?

His dad was a great writer though. 

Grindintosecond > ttyymmnn 10/25/2019 at 12:04

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.........aaaaaaaaaaaaa....I’m gonna keep my mouth shut on this. The group probably already knows my feelings on it.

For Sweden > WilliamsSW 10/25/2019 at 12:06

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yep

Grindintosecond > ttyymmnn 10/25/2019 at 12:06

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chain of failure was when foreign airlines put 200 hour autopilot cripple kids to be babysat in the right seat of those planes. Then they threw money at Boeing to get a new plane done up fast. Now, it’s boeings fault?

Long view needs glasses when politicians try to see it.

ttyymmnn > Grindintosecond 10/25/2019 at 12:30

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That is certainly a link in the chain, yes. And Boeing owns a few of those links as well. 

WilliamsSW > For Sweden 10/25/2019 at 12:52

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He’s both a Boeing apologist and someone who thinks pilots need to be “All the Right Stuff” guys.

And his dad wrote one of the best books ever written on flying .

For Sweden > someassemblyrequired 10/25/2019 at 12:52

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Always, always trust local reporting first.

For Sweden > WilliamsSW 10/25/2019 at 12:54

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If you’re not literally Bob Hoover you have no place flying this CRJ-200, bub.

WilliamsSW > For Sweden 10/25/2019 at 12:55

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He'll make an exception for Jimmy Doolittle, Al Haynes and Sully, but everyone else can GTFAC.

For Sweden > WilliamsSW 10/25/2019 at 13:21

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I think trusting an F-4 driver like Sully is risky tbh

WilliamsSW > Grindintosecond 10/25/2019 at 13:38

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It’s both - fix MCAS *AND* keep the rank amateurs out of the right seat.

f86sabre > ttyymmnn 10/25/2019 at 22:32

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Repair stations are more rigorously regulated, inspected and controlled    than most original product manufacturers.  Still, things happen. Also, the carrier is always responsible for the quality and serviceability of the parts that go on their aircraft regardless of who is turning the wrenches. Audits of the repair stations and understanding the tech data they are using are critical. Not all carriers fully carry that burden. 

ttyymmnn > f86sabre 10/25/2019 at 23:35

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Thanks for the clarification. I’m trying to remember where I read that...

f86sabre > ttyymmnn 10/26/2019 at 07:09

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Most likely in OEM marketing materials.