Boeing Statement on Lion Air Flight 610 Investigation Final Report
(Source: Boeing Co.; issued Oct. 25, 2019)
"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," said Boeing President & CEO Dennis Muilenburg. "These tragic events have deeply affected us all and we will always remember what happened."
"We commend Indonesia's National Transportation Safety Committee for its extensive efforts to determine the facts of this accident, the contributing factors to its cause and recommendations aimed toward our common goal that this never happens again."
"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. 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. We value our long-standing partnership with Lion Air and we look forward to continuing to work together in the future."
Boeing experts, working as technical advisors to the U.S. National Transportation Safety Board, have supported the KNKT over the course of the investigation. The company's engineers have been working with the US Federal Aviation Administration (FAA) and other global regulators to make software updates and other changes, taking into account the information from the KNKT's investigation.
Since this accident, the 737 MAX and its software are undergoing an unprecedented level of global regulatory oversight, testing and analysis. This includes hundreds of simulator sessions and test flights, regulatory analysis of thousands of documents, reviews by regulators and independent experts and extensive certification requirements.
Over the past several months Boeing has been making changes to the 737 MAX. Most significantly, Boeing has redesigned the way Angle of Attack (AoA) sensors work with a feature of the flight control software known as Maneuvering Characteristics Augmentation System (MCAS). Going forward, MCAS will compare information from both AoA sensors before activating, adding a new layer of protection.
In addition, MCAS will now only turn on if both AoA sensors agree, will only activate once in response to erroneous AOA, and will always be subject to a maximum limit that can be overridden with the control column.
These software changes will prevent the flight control conditions that occurred in this accident from ever happening again.
In addition, Boeing is updating crew manuals and pilot training, designed to ensure every pilot has all of the information they need to fly the 737 MAX safely.
Boeing continues to work with the FAA and other regulatory agencies worldwide on the certification of the software update and training program to safely return the 737 MAX to service.
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Final Aircraft Accident Investigation Report
(Source: Indonesian National Transportation Safety Committee; issued Oct. 25, 2019)
The aircraft impacted the water in Tanjung Karawang, West Java, all person on board perished and the aircraft destroyed.
On 26 October 2018, the SPD (speed) and ALT (altimeter) flags on the Captain’s primary flight display first occurred on the flight from Tianjin, China to Manado, Indonesia. Following reoccurrence of these problems, the left angle of attack (AOA) sensor was replaced in Denpasar on 28 October 2018.
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.
The following morning on 29 October 2019, the aircraft was operated from Jakarta with intended destination of Depati Amir Airport, Pangkal Pinang. According to the DFDR and the CVR, the flight had same problems as previous flight from Denpasar to Jakarta.
The flight crew started the IAS DISAGREE Non-Normal Checklist (NNC), but did not identify the runaway stabilizer. The multiple alerts, repetitive MCAS activations, and distractions related to numerous ATC communications contributed to the flight crew difficulties to control the aircraft.
The MCAS was a new feature introduced on the Boeing 737-8 (MAX) to enhance pitch characteristics with flaps up during manual flight in elevated angles of attack. The investigation considered that the design and certification of this feature was inadequate. The aircraft flight manual and flight crew training did not include information about MCAS.
On 10 March 2019, similar accident occurred in Ethiopia involved a Boeing 737-8 (MAX) experiencing erroneous of AOA.
As the result of the investigation, safety actions have been taken by related parties. KNKT issued safety recommendations to address safety issues identified in this investigation to Lion Air, Batam Aero Technic, Airnav Indonesia, Boeing Company, Xtra Aerospace, Indonesia DGCA, and Federal Aviation Administration (FAA).
Click here for the full report (322 PDF pages), on the KNTK website.
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