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Nine reasons Lion Air 737 Max crashed Final report

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On Friday, air crash investigators in Indonesia released their final report, detailing the list of events that caused the Lion Air jet to plunge into the Java Sea. "From what we know, there are nine things that contributed to this accident," Indonesian air accident investigator Nurcahyo Utomo told reporters at a news conference. "If one of the nine hadn't occurred, maybe the accident wouldn't have occurred." (www.bbc.com) עוד...

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tjd1969
Tim Duggan 24
It was a sad loss of life, surely. But a quick scan tells me that the pilots were poorly trained and ill-equipped to deal with the emergency. Sorry to be so stark. Some pilots in (NOT the USA or Europe) are too complacent, and rely too much on automation. There is an adage, and I am paraphrasing: "Fly the effing airplane". Any good pilot knows this. Here's another tragic example: Air France 447. THAT airplane was perfectly fine, but icing caused conflicting indications to the Flight Crew. Basic FLY THE AIRPLANE using the Standby instruments would have resulted in a safe recovery. I shake my head....
ghstark
Greg S 7
I did a more thorough read, though not every page. Like many crashes there were many contributors to the disaster, including the pilots. The captain (PF) did a very poor job, and the first officer (PM) was plainly incompetent and unqualified. But Boeing's MCAS system was a disaster waiting to happen, and it deserves calling out for its incredibly dangerous and undocumented design.
richardorgill
Richard Orgill 7
Actually, you are semi-correct in your statement that they relied too much on automation. The FAA, Human Factor Division, is looking into that very bullet point. There is now documented proof that today's flight crews rely too much on automation vs. the aging and retiring pilots who learned to fly the bird, the FAA is using 80% flying and 20% on automation.

The pilot's of today are trained with 80% automation v. 20% flying ability. The figures used in my post come from the FAA recent news release. They are exploring various ways to enforce more training among flight crews.
tjd1969
Tim Duggan 8
Thank you for that response...I am a pilot. I know how to use automation. BUT? I know how to actually FLY an airplane....
mwerlein
Mark Werlein 3
Stick and rudder. There’s no replacing those skills.
speshulk99
john kilcher -2
Surely you were correct to state the lack of sufficient training with regards to the flight commander and the first officer. But as a pilot I would expect you to hold Boeing more responsible on the rush to put this bird into flight knowing fully well that the MCAS was an add on to hide the unusual potential for disaster due to the more powerful engines mounted higher thereby altering the airworthiness of the Max8. Also as a pilot you must also question the explicit ignoring of the MCAS in the Emergency manual. The fact that the pilot were ill trained IMO doesn't count: I would question any pilot flying this plane in the same flying conditions and recovering.
JMARTINSON
JMARTINSON 5
"MCAS was an add on to hide the unusual potential for disaster due to the more powerful engines mounted higher"

False. https://youtu.be/KB4lCbT5oX8?t=620


"thereby altering the airworthiness of the Max8"

That's like saying it was dark so I altered the light switch. It is or isn't (it is, see link above).


"the explicit ignoring of the MCAS in the Emergency manual"

False. Boeing 737-7/8 System Differences Training Manual, Jan 2017, Page 748


"The fact that the pilot were ill trained IMO doesn't count"

You're entitled to your opinion, but the the flying public is glad it doesn't count.
Quirkyfrog
Robert Cowling 2
Keep defending Boeing, but in the congressional testimony, it was pointed out that AIRLINES< not Boeing, pushed for more documentation, and demanded to know what else they didn't know about the plane.

Boeing took a 'shortcut', and it cost the planet almost 400 lives. Boeing screwed up. If MCAS wasn't there, and they hadn't rushed that plane into service, the accidents would not have happened.
JMARTINSON
JMARTINSON 0
I'm not defending anybody Was there something I said that you disagree with?
Quirkyfrog
Robert Cowling 1
Even in my ground school, the instructor told us to engage the autopilot if we were in a situation, and needed help.

I was kind of surprised. He also said, in difficult conditions, it's better to drop our hands from the yoke, and allow the plane to 'steady itself'. The dihedral angle design of the plane will cause it to settle down on its own.

Hmm...
bentwing60
bentwing60 2
Your instructor was sorta correct if talking about a 172 or Cherokee in a very limited situation. But many in my early days didn't have an autopilot. Do that, (drop the hands) in a V35 or T210 in a true LOC (loss of control) situation and you are dead when the airplane comes apart or hits the ground in a graveyard spiral. X's 10 in a transport category jet. IMHO MCAS morphed into something it was never intended to be with lead engineer, code writer replacements, (H1B's), the story is all there for those who choose to do the homework. Boeing fail! The FAA is complicit and will be held unaccountable. And Bill Babis said it right, "It seems Boeing thought the system may be needed in case of poor pilots and that is exactly who they trapped".
bbabis
Bill Babis 1
There is a huge difference between light aircraft and transport category aircraft. My instructor taught that if you were trapped above an undercast and unable to fly instruments, to just put the aircraft in a spin and recover when you saw the ground. We practiced it and it worked great. It was much safer than loosing control and entering a spiral and was possibly survivable if you hit the ground but certainly not doable in a transport aircraft.
airuphere
airuphere 8
Your completely correct. What are they gonna say in the Ethiopian crash.. where the right seat had under 250Total Time as a “cadet” - Lion Air has the same program but wasn’t in that flight.

And everyone forgets that LIon Air flight, same plane had the exact same issue on the previous flight - Except there was a check pilot in the jump seat who commanded the runaway trim procedure saving them all. These things mixed with the issues on the Boeing side made a perfect storm for these crashes.
JMARTINSON
JMARTINSON -1
France is in Europe.
tjd1969
Tim Duggan 5
I know. France is in Europe. I am saying, here, that NOT all airline pilots are well trained. Some slip through. An A-330 is an incredible machine, of course. BUT if one or two pitot tubes get iced over? The computers that display info to the pilots can go "haywire", to use a collequial phrase. EVERY modern air;iner has a set of "Stand-By instruments. Air France 447? THOSE pilots should have used them ....PITCH, POWER, AIRSPEED....these are basics.
bentwing60
bentwing60 4
If the world doesn't realize that "everything" these days is tied to the ADC's, either upstream or down, then they ain't payin attention. The loss of a single AOA probe, twice, is the cause of all this? How many did you lose, besides heat? The crews were ill prepared to deal with either occurrence and that is a huge part of the camels nose under the tent. They don't wanna talk about it. In the US, the airlines have exhausted the once endless supply of ex-military, ex corporate, part 135, part 91 guys on a mission to an airline job with a rich daddy. Hence, the airlines in the US are doing ab initio. Worldwide. So, yes on crew culpability, recognized or not, and no, we will never know all that Boeing knows because there was more to it than that! But in this uber political world, I will ever wonder, why didn't they pull the Throttles Back!
tjd1969
Tim Duggan 6
You know what you're talking about. The A-330, like all commercial airliners, have a STANDBY set of flight instruments. "Pitch. Power. Airspeed" I was a Flight Instructor before I was an airline pilot. Control the damn airplane FIRST!!! Fly it. The tragic loss of Air France 447? A few pilots did not learn that lesson....
ssobol
Stefan Sobol 2
It's all well and good to fly the plane first. However, the 737 has mechanical controls unlike an A-330. It is possible for the control forces to get so high that the pilots are simply not strong enough to fly the plane or fly it for long.
bbabis
Bill Babis 2
Yes! That last line says it all. We don't know what was going through their minds but pulling the power back should have been primary. Aerodynamic forces would not have locked the manual trim and they could possibly have figured it out.

[This comment has been downvoted. Show anyway.]

JMARTINSON
JMARTINSON -1
I know you know France is in Europe. I thought you were about to get jumped by the this-is-all-Boeing's-fault (and if you disagree you're a racist) internet outrage street gang, so I took a swing at you hoping they would be satisfied with that and move on (like in the movies). To tell you the truth, I'm really surprised that it worked.
airuphere
airuphere 3
FROM REPORT: THIS SAYS IT ALL
The installed left AOA sensor had a 21° bias which was undetected during the installation test in Denpasar. The erroneous AOA resulted in different indications during the flight from Denpasar to Jakarta, including IAS (indicated airspeed) DISAGREE, ALT (altitude) DISAGREE, FEEL DIFF PRESS (feel differential pressure) light, activations of Maneuvering Characteristics Augmentation System (MCAS) and left control column stick shaker which were active throughout the flight. The flight crew was able to stop the repetitive MCAS activation by switched the stabilizer trim to cut out.
After landed in Jakarta, the flight crew reported some malfunctions, but did not include the activation of stick shaker and STAB TRIM to CUT OUT. The AOA DISAGREE alert was not available on the aircraft therefore, the flight crew did not report it. The reported problem would only be able to rectify by performing tasks of AOA Disagree.
ghstark
Greg S 1
Yeah, I read that. The pilots of that flight should be drawn and quartered for not even mentioning the uncommanded stabilizer movements.
bettiem
bettiem 3
This particular situation prompts my general concern. I've read that, unlike in the past, demand for pilots now far exceeds the number of people who have a real vocation to be a pilot. Thus the number of those who are hired who have any instinctive reactive ability to "fly the damn airplane" when necessary are precious few. Therefore must civil aviation overall, including airplane designers, urgently adjust so the the airplane by default "flies its damn self" with the flight crew being simply educated on-site caretakers of the automation?
E1craZ4life
Edward Bardes 0
A gentler barrier to entry money-wise would turn less new trainees off.
anlusome
Andre Melgaço 5
A huge 300 pages final report on flight LNI610 repeats scaring issues already in the preliminary report. In summary, a show of mixed imprudence, negligence and lack of competence. Plane had already "told the guys": hey, i'm not ok to fly! Maintenance people did a sucking job and the pilots... well, they died. Nobody is innocent. A show of horrors! A similar report? Flight AF447 (Rio-Paris) that crashed in Atlantic ocean...
steerts
Ron Streetenberger 7
Having spent 31 years with American Airlines at their flight academy as the #1 simulator massager, I knew that the crews of both Max 80 accidents had to be the main contributing factors. If you need to have the auto pilot hooked during takeoff, you don't belong in a cockpit of anything with wings. Runaway stabilizers were ALWAYS part of of A.A's simulator training. To sit there and watch that big stab trim wheel nosing the aircraft down while pulling the yoke back in response is the action of a complete idiot. Never once did I hear anything about an inoperative ADI, nor was anything said about pre-stall warnings or buffet. GOOD GRIEF!
ghstark
Greg S 3
The big problem is that the stabilizer didn't "run" away, rather it "squirreled" away, like the squirrel that teases my dog by always staying just out of reach. This made the problem much harder to recognize. The captain was able to correct the stabilizer position a couple times but each time MCAS would wait until he was finished and then move the stab 2.5 degrees nose down in its quickest mode. Warning lights for seemingly different problems were all illuminating and the PF's stick shaker was activated almost the entire time. The workload was simply too great, and, yes, the first officer was completely incompetent and unqualified. MCAS made this different that a normal runaway stabilizer, MCAS made this an intelligent and devious stabilizer that waited until the pilots weren't looking to move the stabilizer significantly nose down. And don't forget that the pilots didn't even know MCAS was there because Boeing intentionally avoiding documenting it so pilots would not have to train to recover from sensor fault-induced MCAS failure. Yes, the pilots were shit, the report makes that clear, but Boeing bears a *huge* responsibility for a clearly defective design that was not up to anybody's (including their own) robustness standards and for failing to require training or even inform the pilots for/of MCAS's failure modes.
JMARTINSON
JMARTINSON 1
"The pilots didn't even know MCAS was there because Boeing intentionally avoiding documenting it so pilots would not have to train to recover from sensor fault-induced MCAS failure"

Wrong. Boeing 737-7/8 System Differences Training Manual, Jan 2017, Page 748

I'm on a mission.
ghstark
Greg S 3
Great, you have the manual. I notice you have conspicuously avoided including what it actually says on that page. So what does it say?
bettiem
bettiem 3
On the matter of AF447, I highly recommend the book "Understanding Air France" by Bill Palmer https://tinyurl.com/y2q49rc5 . It takes the reader on the flight as if an observer and, well, pilots also must have the guts to declare, "I'm not OK to fly" when that's the case.
cubpilot7
Pat McKinzie 5
MCAS is NOT an anti-stall system! It was intended to change the flight characteristics to make the Max feel the same as the NG avoiding costly training time for pilots. I expect to hear that the way MCAS contributed to these accidents is by mimicking an actual stall “un-commanded nose down” at a time when some but not all cockpit indicators were falsely reporting a stall. The angle of attack vain is used to provide warning of a stall, thus those warnings were activated by the faulty AOA sensor . This confused the pilots. Remember in an actual stall the pilots should leave the power in and further reduce attitude, or the opposite of the runaway trim, Boeing expected pilots to react to with an erroneous MCAS activation. Three attitude indicators combined with power all indicating normal would mean no stall, but there was apparently a discrepancy between the two airspeed indicators further confusing the issue. The airspeed indicators do not use input from AOA so something else was wrong with the Lion Air plane.
tbpera
Tom Pera 2
would love to see a big RED switch on the middle of the instrument panel

"ON" "OFF" off turns off all auto settings so the pilots can FLY THE AIRPLANE

yep...I'm a simpleton
bbabis
Bill Babis 1
Great idea Tom but that also implies that pilots be able to FLY THE AIRPLANE and not be automation managers.
sgbelverta
sharon bias 2
Seems the investigators looked at a number of things, and didn't just say the pilots or aircraft were at fault. I hadn't read previously that a part from Florida hadn't been tested, and the FAA just pulled that companies certification. Will have to see how the findings compare to the Ethiopian investigation.
BrorMonberg
Bror Monberg 2
346 deaths attributed to the 737 Max. Lessons need to be learned so these lost lives have purpose. I lost a family member to a commercial airlines crash killing 137. Much was learned from it but I don't wish this on any family.
AbieshanG13
Abieshan Ganeshamurthi 2
Boeing should've trained the pilots to use MCAS before hand so that the crash wouldn't have happened whatsoever.
jammen737
jammen737 8
HA! Airline should have made sure the pilots knew how to fly their airplane.
airuphere
airuphere 1
They did. It was called Runaway Trim. How else was the inbound flight to Jakarta saved by a different crew. If you read the transcripts this crew, god rest their soul, was way in over their heads.
airuphere
airuphere 1
LINK TO REPORT IN FULL
************************
http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf
bentwing60
bentwing60 1
Not to sound too suspicious of the publisher of the article, an ardent euro., EADS fan, and the NY Times of the east, the boiler plate and inaccurate description of the original intent of MCAS in said article seems a misdirect and the article is indeed not the Indonesian accident report, but a BBC journo. spin on it. The fact remains that an ab initio pilot is being taught to fly the automation, not a transport category jet and what is left when the automation breaks! An AB in alternate law (AF447) or a Max with a stab. trim runaway is not the training focal point for putting a novice in the right seat. Nor would I purport that the recurrent training for experienced pilots is failure mode dominant. Automation can be as ill equipped to save the day as are pilots who don't understand the failure modes of automation. Boeing screwed the pooch without doubt, but it's a long food chain.
lecompte2
lecompte2 1
Sad to see that even now, after all the information out about the 737 Max, a lot of confusion appears in the comments on this page. Proves to me that this plane should not fly again until all is cristal clear about it's design faults and how they are compensated for by systems and the crew. Again Boeing is still uncooperative to cover their you know what.
airuphere
airuphere 0
Most of the information out is by the misinformed media. Many here have read the reports in full. I suggest you do the same. Not debating what you’ve said, except a lot in these crashes has to do with the operation and maintenxe of the aircraft. Once the software is fixed - the plane is more than safe to fly. This is not the first time engine soE and placement has changed on a 737, 320, ejet.. that happens often. MCAS was used in this case, and designed poorly, but the aircraft is more that flyable - the mcas was to adjust for small lift from the engines for pilots USED to flying older 737... they’re not design faults - design challenges.
lecompte2
lecompte2 0
Did you know that since turbine engines exit, they have been placed under the wing and a fair distance from the cabin or behind the cabin. The simple reason for this is to protect the fuselage and the wing from a catastrophic failure where the engine falls apart. In the 737 Max the engine placement has compromised this basic principle by moving the engines high and ahead of the wing and closer to the passengers. Could this be a compromise on safety to save money and improve performance at any cost ?
airuphere
airuphere 2
Ok, and Airbus uses the SAME engine on the A320. Surely they’ve altered the placement as well, and made untold changes to the control laws of the FBW.

By your logic any plane flying a Turbine which is all aircraft turboprop and jet - are unsafe - which is untrue.

There are many factor that go into engine design to contain failures. All engines are turbine, the moves made on the 737M hardly compromise safety to the cabin. Despite what paranoid family members who no nothing about aviation tell Congress. I feel for their loss, but they should not be testifying.
airuphere
airuphere 2
Sorry I meant a320NEO has same engines
lecompte2
lecompte2 1
The engines on the 320 neo are below the wing of the aircraft. On the 737M part of the engine is just above and ahead of the wing. More specifically the bypass area is directly ahead of the leading edge, any break up usually goes out through there. So there.
JMARTINSON
JMARTINSON 1
The MCAS infographic looks straight out of a book called "Look At The Big Airplane Go!" Airplanes are big and loud.

Actually, make that the entire article:

"And if the captain, who'd successfully kept the plane in the air - despite the intervention of a rogue automated system he didn't understand - hadn't handed over to his less-capable first officer, disaster might still have been avoided".
tjd1969
Tim Duggan 10
"rogue automated system"??? Oh, brother...anyone with thousands of hours on the B-737 knows how to fly the damn thing!! I mean FLY, not just use the autopilot.
ghstark
Greg S 2
MCAS is not the autopilot. In fact, it doesn't engage when the autopilot is activated.
usrepeaters
Rob Palmer 1
Has everybody read what Capt. Sully has said about this in the New York Times magazine? He blames lack of training and lack of manufacturer and FAA proper supervision for the development of the whole device and calls it a "death trap" which should lead to a better system.
bkoskie
Billy Koskie 2
Capt. Sully also noted Airbus has an inherent design flaw, that being the 2 side sticks are not connected. So one pilot cannot look at his stick and visually tell what kind of stick inputs the other pilot is making. Having said that, it's still hard to believe Boeing made the decisions it did regarding MCAS and AOA. Particularly, the note of 'optional safety equipment' meaning a second AOA sensor. There is no such things as 'Optional' when safety is concerned. Geez
lecompte2
lecompte2 0
There are other problems with the Max not implicated here, that will appear eventually, for example engine size and placement.

[This comment has been downvoted. Show anyway.]

30west
30west 13
Robert, apparently you didn't read either this squawk or the Final Accident Reort by the Indonesian Government.

"From what we know, there are nine things that contributed to this accident," Indonesian air accident investigator Nurcahyo Utomo told reporters at a news conference. If one of the nine hadn't occurred, maybe the accident wouldn't have occurred."

Another quote from the Squawk: "Further, the report found that the first officer, who had performed poorly in training, struggled to run through a list of procedures that he should have had memorised. He was flying the plane just before it entered into the fatal dive, but the report said the captain had not briefed him properly when he handed over the controls as they struggled to keep the plane in the air."

Your Squawk is not based upon facts from the report, but upon your personal unfounded ideas.
lbhorton
Larry Horton 4
Exactly. Still too many people looking for the one main cause. I think it is a human failing to always do that with any problem. Had an instructor once who assigned homework. Read NTSB/FAA accident reports. It became glaringly obvious there are always mulitlple causes. Causes are cogs in a machine, the machine being the accident. Remove one and the machine does not work or the accident does not happen. I have applied that lesson to my personal and professional life solving problems. Boeing is a cog, the pilots are a cog the company in Florida was a cog training is a cog. The solution lies in addressing all these issues. On automation we are seeing it in all aspects of life. Self driving cars, trucks and even medical procedures. We try and cover the possible failure of automation by requiring human oversight. My question is how long does it take a human to come back from being lulled to recognizing that a problem is occurring, analyze the solution and react. I think that might be one of the key issues in the future of automation. The lead article in today's squawk was Garmin's new automated landing system. This is the future and humans place in it will have to be understood. Sorry I ran on.
ghstark
Greg S 1
Several of those nine things were related to the AOA sensor errors. Even if everything had been good with AOA sensors beforehand, if one of them broke during takeoff MCAS would've tried to kill them just the same. It's not a stretch to say that MCAS was a ticking time bomb, as the report makes abundantly clear.
bbabis
Bill Babis 2
Many many items and systems on all aircraft are “ticking timebombs” if they fail under certain conditions. That is where knowledge and training come in. The ticking timebomb in these accidents was the MAX, warts and all, being matched with marginal crews.
ghstark
Greg S 3
I think the focus on the failures of the pilots is proper and necessary. But it's also important to analyze how an average 737 NG pilot might've performed in the same circumstances. Knowledge and training are absolutely critical, and this is where Boeing's second unforgivable error comes in. They hid the knowledge of MCAS' function to intentionally avoid the need to train pilots on MCAS' unique failure modes. In fact, it'
s unthinkable to not let pilots learn about how MCAS works even when it works perfectly. These pilots were basically told this is just a updated version of the 737 NG, and in fact it was drastically different. When you pull back on the yoke of the NG in this critical phase of flight the stabilizer works with you. But on the MAX MCAS will fight you hard if it determines you are heading toward a stall. Given a very small window of time to diagnose and mitigate the problem the captain failed. After the second uncommanded stabilizer movement he should've activated the cutout switches. But he had a plethora of other problems that he was forced to prioritize. In retrospect he prioritized incorrectly. But would another 737 NG pilot have done it differently? That's the question I'd like to see an attempt to answer.
bbabis
Bill Babis 3
Well said Greg. The MCAS story will turn out to be a novel in itself. My feeling is that it was never needed in the first place because who is going to get a transport aircraft even near a stall unintentionally and then not be able to recover should they. It seems Boeing thought the system may be needed in case of poor pilots and that is exactly who they trapped.
cbuckley
cbuckley 7
I am not an aviator but after reading the news report its pretty clear pilot error or lack of training, skill, experience and Air Indonesias failures to ensure proper repair and maintenance procedures are the major contributing factors in this air crash.

I am guessing there are 1000's of these aircraft in service and only two have crashed at the hands of perhaps less than stellar performers in the airline industry. I know of no B737 crashes with Air canada, united, southwest, etc. I am inclined to believe that boeing have a industry leading aircraft with the B737 and is DEFINATLY not a "piece of shit".
MXE
Charlie Gibbs 5
No, the 737 isn't a "piece of shit". It's a venerable design that has stood the test of time - although it's probably been pushed about as far as it should go. MCAS, on the other hand...

I am a computer programmer who has written data collection software that is running 24/7 in a couple of thousand installations - so I know a bit about reliable, robust system design. There is no way that I would consider taking the kind of shortcuts that Boeing did, even though a failure of my software could never result in a smoking crater. Yes, there are other factors involved - but a system that can't deal with unexpected inputs isn't going to last long here in the real world.
tbpera
Tom Pera 1
definitely pushed way too far....
airuphere
airuphere 1
Read the report Bob. You fool

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