Originally Posted by
safetypee
#1644: Except that MCAS does not have any ‘grandparents’. The ideas behind this ‘single-failure prone system’ may have its origins in modern aircraft with their high integrity stability enhancements based redundant architecture. Perhaps this is the shadow of grandfather designing, test and certification, and dated regulatory practice. Time to dust off James Reason’s views on organisational accidents.
Irrespective of what the Indonesian authorities identify in their investigations, the deficiencies in disseminating knowledge and crew checklists must be investigated.
I doubt that Indonesia alone would be able to pursue an investigation involving the FAA and Boeing in the US; according to Annex 13 they should, but …
The NTSB should be sufficiently independent to look at the FAA and delegated regulatory process, minimising any of criticism of an internal coverup.
An investigation would be in everyone’s interest worldwide. Without understanding where the design and certification process failed the confidence in aviation safety remains open to question, particularly for Boeing and all their aircraft types.
A separate investigation might also enhance the need for other regulators to review the integrity of their certification processes, and consider the effectiveness of the oversight of joint international approvals.
“Trust, but verify.”
The NTSB recognizes this type of need for independence - though the illustration of this comes from a recent incident which likely is less complicated than this accident (not only because it was *only* a very close call).
The chairman of the Board, in response to a question from someone in the audience at a guest lecture the chairman delivered about a year ago, stated that in its recommendations in the aftermath of the AC 759 San Francisco incident, NTSB was keenly aware of the need to protect, as well as exercise, its independence. No doubt the Annex 13 process for this accident is largely but not totally different kind of situation. (And that's without heaving irony, about Indonesia as the centre of the Annex 13 process.)
(Whether NTSB report after KSFO in fact manifested independence, and then how effective follow-ups have been (and where), is another question - possibly instructive for the tasks ahead now.)