Lion Air crash report raises issues over design, maintenance and crew errors
Indonesian investigators have found that the flight crew on a Lion Air plane that crashed, killing all 189 people on board, struggled to quickly react to a malfunction that caused the plane's nose to go down.
The fatal crash, followed less than five months by another at Ethiopian Airlines, led to a global grounding of the Boeing 737 MAX and a crisis for the world's biggest plane maker, which this week ousted its commercial aeroplanes chief.
In its final report on the October 29, 2018 crash, Indonesia makes recommendations to Boeing, the airline, the US Federal Aviation Administration (FAA) and other agencies.
A copy was seen by Reuters and it is due to be released publicly later on Friday.
Boeing, acting without adequate oversight from US regulators, failed to grasp risks in the design of cockpit software on its 737 MAX airliner.
Design flaw
Indonesian regulators criticise the design of the anti-stall system known as MCAS, which automatically pushed the plane's nose down, leaving pilots fighting for control.
"The design and certification of the MCAS did not adequately consider the likelihood of loss of control of the aircraft," the report says.
Boeing has been working on a redesign of MCAS, although it has yet to certified by the FAA.
The report says "deficiencies" in the flight crew's communication and manual control of the aircraft contributed to the crash, as did alerts and distractions in the cockpit.
The accident was caused by a complex chain of events, Indonesian air accident investigator Nurcahyo Utomo told reporters at a news conference.
During the flight, the first officer was unable to quickly identify a checklist in a handbook or perform tasks he should have had memorised, it says, adding he had also performed poorly in training exercises.
The captain did not properly brief the first officer when handing over control just before the plane entered a fatal dive.
A critical angle of attack sensor providing data to the MCAS anti-stall system had been miscalibrated by a company in Florida and there were strong indications it was not tested during installation by Lion Air maintenance staff.
Lion Air should have grounded the jet following faults on earlier flights, the reports says, and adds that 31 pages were missing from the airline's October maintenance logs.
Lion Air declined to comment.
Boeing said it was addressing Indonesia's safety recommendations and taking actions to enhance the safety of the 737 MAX.
FAA said it welcomed the report's recommendations and would carefully consider them.==========
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