Lion Air Boeing 737 MAX Crash Was Result Of Nine Failings

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Days before the one year anniversary of the fatal Lion Air Boeing 737 MAX crash, the Indonesian National Transportation Safety Committee has released its final report into the accident. The accident claimed 189 lives as the brand new Boeing 737 MAX plunged into the sea.

Boeing 737 MAX, Lion Air, Crash
On the 29th of October 2018, a brand new Boeing 737 MAX 8 was lost in a fatal crash. Public Domain Photo

The Boeing 737 MAX has now been grounded for over half a year. The aircraft’s grounding came as a result of both the Lion Air crash, as well as a similar Ethiopian Airlines crash in March of this year. Following a year of investigation into the occurrences of the 29th of October 2018, the Indonesian National Transportation Safety Committee has released its final report.

What happened?

On the 29th of October 2018, a Lion Air Boeing 737 MAX registered as PK-LQP was scheduled to fly from Jakarta to Depati Amir Airport in Pangkal Pinang City. The aircraft had been delivered to the airline just 77 days prior to the accident.

At 06:20, the aircraft began its takeoff roll from the airport in Jakarta. Around 30 seconds later, the aircraft rotated, lifting off of the runway. The aircraft’s MCAS system then erroneously became activated. This led to the aircraft trimming itself in a pitch down configuration. Just 10 minutes later, the aircraft’s flight data recorders stopped recording as the aircraft collided with the sea below.

Boeing 737 MAX, Lion Air, Crash
The Boeing 737 MAX’s MCAS system contributed to the accident. Photo: Boeing

What contributed to the incident?

The BBC reports that Indonesian air accident investigator Nurcahyo Utomo told how “there are nine things that contributed to this accident”. He adds that “If one of the nine hadn’t occurred, maybe the accident wouldn’t have occurred.”

But what are the contributing factors to the crash? Firstly, the report found that the aircraft should not have taken off for the fatal flight, as an issue in the cockpit should have grounded it. However, the issue was incorrectly recorded.

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United Boeing 737 MAX
MAX Aircraft across the globe have now been grounded for more than six months. Photo: United Airlines

Additionally, a sensor feeding to the MCAS system was found to not have been tested properly by the repair station that supplied it. The repair station, Xtra Aerospace of South Florida, today had its certificate publicly revoked by the US Federal Aviation Administration.

A representative of Xtra Aerospace contacted Simple Flying with the following statement:

We have been cooperating closely with the FAA throughout its investigation and though we have reached a settlement with the FAA, we respectfully disagree with the agency’s findings. The FAA’s enforcement action is separate from the KNKT’s investigation and report of the Lion Air Boeing 737 Max accident and is not an indication that Xtra was responsible for the accident. Safety is central to all we do, and we will continue cooperating with the authorities. We would like to express our deep sadness and sympathy for all those who have lost loved ones in the Lion Air Flight 610 accident.”

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Fourthly, Indonesian investigators found flaws in the design of the MCAS software, which is behind the 737 MAX’s grounding. This was tied to deficiencies in training which were identified concerning the MCAS system.

Boeing 737 MAX, Lion Air, Crash
Nine contributing factors have been identified by investigators in the build-up to the accident. Photo: Boeing

The aircraft’s first officer had been flying the aircraft just before its fatal crash. The cockpit voice recorder identified that he failed to recall memory items from necessary procedures. In addition to this, he had not been properly briefed by the captain as the aircraft’s controls were handed over. Finally, a total of 31 pages of the aircraft’s maintenance records were missing at the time of the accident.

All of these contributing factors worked together to lead to the fatal flight on the 29th of October 2018.

Boeing’s response

Boeing issued a public response to the completed investigation earlier. The American Aerospace manufacturer’s CEO, Dennis Muilenburg said:

“On behalf of everyone at Boeing, I want to convey our heartfelt condolences to the families and loved ones of those who lost their lives in these accidents. We mourn with Lion Air, and we would like to express our deepest sympathies to the Lion Air family”

Boeing 737 MAX, Lion Air, Crash
Boeing’s CEO expressed deepest sympathies in a response to the report this morning. Photo: Boeing

He went on to add,

“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.” Before addressing the company’s relationship with Lion Air: “We value our long-standing partnership with Lion Air and we look forward to continuing to work together in the future.”

The investigation into a similar accident involving an Ethiopian Airlines Boeing 737 MAX in March is still ongoing.

This article was updated at 18:18 UTC to reflect a statement received from an Xtra Aerospace representative. 

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