Lion Air 610 Archives - Flight Safety Foundation

NTSB Urges Changes in Aircraft Design Assessments

Citing ongoing investigations of two Boeing 737 MAX accidents that killed 346 people, the U.S. National Transportation Safety Board (NTSB) today issued seven recommendations that call on the Federal Aviation Administration (FAA) to incorporate into its aircraft design safety assessments an evaluation of how pilots will respond to multiple alerts.

The new safety recommendations were developed through an examination of the safety assessments that were conducted as part of the original design of the maneuvering characteristics augmentation system (MCAS), which, according to preliminary investigations, activated in response to erroneous information about the airplane’s angle of attack.

All Boeing MAX airplanes have been grounded since March 13, following the March 10 crash of Ethiopian Airlines Flight 302 after takeoff from Addis Ababa. The earlier accident involved Lion Air Flight 610, which crashed after takeoff from Jakarta, Indonesia, on Oct. 29, 2018. The crashes killed all passengers and crew on both airplanes.

“We saw in these two accidents that the crews did not react in the ways Boeing and the FAA assumed they would,” said NTSB Chairman Robert Sumwalt. “Those assumptions were used in the design of the airplane and we have found a gap between the assumptions used to certify the MAX and the real-world experiences of these crews, where pilots were faced with multiple alarms and alerts at the same time.”

The NTSB’s recommendations were included in Aviation Safety Recommendation Report 19-01. In an accompanying statement, the agency said it was “concerned that the accident pilots’ responses to unintended MCAS operation were not consistent with the underlying assumptions about pilot recognition and response that were used for flight control system functional hazard assessments as part of the Boeing 737 MAX design.”

The statement added that the FAA allows such assumptions “without providing clear direction about the consideration of multiple flight-deck alerts and indications in evaluating pilot recognition and response.”

The NTSB said that, taken together, the safety recommendations to the FAA are intended to “ensure system safety assessments for the 737 MAX (and other transport-category airplanes) that used certain assumptions about pilot response to uncommanded flight control inputs, consider the effect of alerts and indications on pilot response and address any gaps in design, procedures, and/or training.”

The recommendations also call for development and use of “robust tools and methods for validating assumptions about pilot response to airplane failures as part of design certification” and “incorporate system diagnostic tools to improve the prioritization of and more clearly present failure indications to pilots to improve the timeliness and effectiveness of their response.”

The FAA said it would review all seven recommendations.

“The FAA is committed to a philosophy of continuous improvement,” the agency said. “The lessons learned from the investigations into the tragic accidents of Lion Air Flight 610 and Ethiopian Airlines Flight 302 will be a springboard to an even greater level of safety.”

FSF Editorial Staff. September 26, 2019

News, Safety Oversight

Boeing Names New Safety Panel

Boeing said today that it has established a new Aerospace Safety Committee — to be chaired by retired Adm. Edmund Giambastiani Jr. — that will be responsible for safety oversight in the design, development, manufacture and delivery of Boeing aerospace products and services.

In separate action, the Boeing Board of Directors amended the company’s governance principles to include safety-related experience as a factor in the selection of future members of the board.

Both actions followed a five-month-long independent review of airplane design and development policies in the aftermath of two crashes involving Boeing 737 MAX airplanes — the October 2018 crash of Lion Air Flight 610 and the March 2019 crash of Ethiopian Airlines Flight 302. Together, the two crashes killed all 346 people in both airplanes.

The review also resulted in a number of recommendations, including creation of a product and services safety organization to review all aspects of product safety, realignment of Boeing’s engineering function, reexamination of flight deck design and operation, and establishment of a design requirements program. The recommendations are being reviewed by senior company officials.

“The independent committee review was extensive, rigorous and focused on delivering specific recommendations to ensure the highest levels of safety in Boeing airplanes and aerospace products and services and for all who fly on Boeing airplanes,” Giambastiani said. “The committee and the board believe these recommendations, along with actions already taken by the board, will strengthen engineering at the company, bolster the safety policies and procedures for the design, development and production of Boeing products and services, and further improve board and management oversight and accountability for safety not only at Boeing but throughout the global aerospace industry.”

FSF Editorial Staff. September 25, 2019

News, Flight Training

Enhanced Training Needed for MAX Pilots, Committee Hears

Pilots are concerned about whether new training methods proposed by Boeing for pilots of its 737 MAX airplanes are adequate to “ensure that pilots across the globe flying the MAX fleet can do so in absolute, complete safety,” the head of an airline pilots union told a U.S. congressional hearing.

Daniel Carey, a 35-year captain with American Airlines and president of the 15,000-member Allied Pilots Association, told the Aviation Subcommittee of the House Committee on Transportation and Infrastructure on Wednesday that before two fatal crashes, there was an “absence of robust pilot training” on how to respond in case of a failure of the MAX’s Maneuvering Characteristics Augmentation System (MCAS).

MCAS failures factored in the fatal crashes of two 737 MAX airplanes, according to preliminary investigations. The first accident involved Lion Air Flight 610, which crashed into the Java Sea after takeoff from Jakarta, Indonesia, on Oct. 29, 2018, killing all 189 passengers and crew; the second accident involved Ethiopian Airlines Flight 302, which crashed after takeoff from Addis Ababa, Ethiopia, on March 10, killing all 157 passengers and crew. In both cases, the accident airplane was a 737 MAX 8. Both accidents are still under investigation.

The entire MAX fleet has been grounded worldwide since soon after the second crash.

Carey told the subcommittee that he believes Boeing engineers have made “significant positive changes” in MAX software to help avert similar MCAS failures in the future.

“However, at [the Allied Pilots Association] we remain concerned about whether the new training protocol, materials and method of instruction suggested by Boeing are adequate to ensure that pilots across the globe flying the MAX fleet can do so in absolute complete safety.”

Chesley Sullenberger, the (since retired) US Airways captain who landed his Airbus A320 in the Hudson River after a Jan. 15, 2009, bird strike caused a loss of all engine power, reiterated Carey’s call for improved training, including simulator training, on how to handle MCAS failures.

“We should all want pilots to experience these challenging situations for the first time in a simulator, not in flight with passengers and crew on board,” Sullenberger told the subcommittee.
J. Randolph Babbitt, former administrator of the U.S. Federal Aviation Administration, added that today’s pilots need training that is constantly being improved.

“We have the technology to expand training with the use of [virtual] reality and high-fidelity simulation so that no pilot should ever be surprised by [an] event that takes place in an aircraft in which they are certified,” Babbitt said.

FSF Editorial Staff. June 20, 2019

News, Safety Oversight

Nine CAAs to Join FAA in 737 MAX Review

Representatives from nine civil aviation authorities from around the world will join the technical review panel established by the U.S. Federal Aviation Administration (FAA) to review the certification of the Boeing 737 MAX’s automated flight control system.

The FAA said Friday that the Joint Authorities Technical Review (JATR) team — announced in the aftermath of the second fatal crash of a 737 MAX in five months — would “evaluate aspects of the 737 MAX automated flight control system, including its design and pilots’ interaction with the system, to determine its compliance with all applicable regulations and to identify future enhancements that might be needed.”

The first of the two accidents involved Lion Air Flight 610, which crashed into the Java Sea after takeoff from Jakarta, Indonesia, on Oct. 29, 2018, killing all 189 passengers and crew; the second accident involved Ethiopian Airlines Flight 302, which crashed after takeoff from Addis Ababa, Ethiopia, on March 10, killing all 157 passengers and crew. In both cases, the accident airplane was a 737 MAX 8.

Civil aviation authorities worldwide subsequently grounded all MAX airplanes while Boeing worked on a software update intended to help prevent another similar crash.

In both accidents, preliminary information indicated that the airplanes experienced what Ethiopian accident investigators called multiple “uncommanded nose-down conditions” and that the pilots were unable to pull the aircraft’s nose back up. Preliminary findings focused on a new feature known as the maneuvering characteristics augmentation system (MCAS), which was designed to enhance the airplane’s pitch stability.

The JATR’s first meeting is scheduled for April 29, and the panel’s work is expected to continue for 90 days.

In addition to representatives of the FAA and the U.S. National Aeronautics and Space Administration, other experts on the JATR will include participants from Australia’s Civil Aviation Safety Authority, Brazil’s Agência Nacional de Aviação Civil, Transport Canada Civil Aviation, the Civil Aviation Administration of China, the European Union Aviation Safety Agency, the Japan Civil Aviation Bureau, the Indonesia Directorate General of Civil Aviation, the Civil Aviation Authority of Singapore, and the General Civil Aviation Authority of the United Arab Emirates.

FSF Editorial Staff. April 22, 2019

News, Accident/Incident Investigation

Ethiopia Releases Preliminary Accident Report in Flight 302 Crash

Ethiopia’s Aircraft Accident Investigation Bureau today released a preliminary accident investigation report into the March 10 crash of Ethiopian Airlines Flight 302 shortly after takeoff from Addis Ababa on a scheduled flight to Nairobi, Kenya. All 157 passengers and crew on board the Boeing 737 MAX 8 aircraft were killed in the crash.

The report contains a fight history based on preliminary analysis of the airplane’s digital flight data recorder (DFDR) and cockpit voice recorder and air traffic control (ATC) communications. In their initial findings, investigators found that shortly after takeoff, the value of the left angle of attack (AOA) sensor deviated from the right one, with the left AOA sensor reaching 74.5 degrees while the right sensor indicated 15.3 degrees. The stick shaker activated shortly thereafter. The flight crew twice reported flight control problems.

According to the report, the DFDR recorded an automatic aircraft nose down (AND) trim command four times without pilot input. The DFDR data also indicated the flight crew utilized the electric manual trim to counter the automatic AND input, and that the crew performed the runaway stabilizer checklist, put the stabilizer trim cutout switch to cutout position and confirmed the manual trim operation was not working.

Information in the preliminary report is subject to change as the investigation continues.

Following release of the report, Boeing issued a statement and then followed up with a recorded message from Dennis Muilenburg, chairman, president and CEO. In his message, Muilenburg says in part: “The full details of what happened in the two accidents [Lion Air Flight 610 and Ethiopian Flight 302] will be issued by the government authorities in the final reports, but, with the release of the preliminary report of the Ethiopian Airlines Flight 302 accident investigation, it’s apparent that in both flights the Maneuvering Characteristics Augmentation System, known as MCAS, activated in response to erroneous angle of attack information.

“The history of our industry shows most accidents are caused by a chain of events. This again is the case here, and we know we can break one of those chain links in these two accidents. As pilots have told us, erroneous activation of the MCAS function can add to what is already a high workload environment. It’s our responsibility to eliminate this risk. We own it and we know how to do it.”

Muilenburg said Boeing is “working to finalize and implement a software update that will ensure accidents like that of Lion Air Flight 610 and Ethiopian Airlines Flight 302 never happen again. … We’re nearing completion and anticipate its certification and implementation on the 737 MAX fleet worldwide in the weeks ahead.”

The two Boeing statements can be found here.

FSF Editorial Staff. April 4, 2019

News, Flight Training, Safety Review

U.S. Lawmakers Want Evaluation of Foreign Pilot Training

The U.S. House of Representatives Transportation and Infrastructure Committee and its aviation subcommittee want a federal investigation of cockpit automation and international pilot training standards in the wake of the Lion Air and Ethiopian Airlines Boeing 737 MAX 8 accidents.

In a March 29 letter to Department of Transportation Inspector General Calvin Scovel, the committee leaders requested a federal investigation of international pilot training standards and training for commercial pilots operating outside the United States, including training for the 737 MAX. The request also asks Scovel’s office to focus on how the Federal Aviation Administration (FAA) implemented recent cockpit automation management requirements to ensure that, in light of technology advancements in automation, pilots are capable of flying aircraft when automation fails or is deactivated.

The request was signed by Rep. Peter DeFazio, a Democrat from Oregon and chairman of the committee; Rep. Sam Graves of Missouri, ranking Republican on the committee; and Rep. Rick Larsen, a Democrat from Washington, who chairs the subcommittee.

Specifically, the committee leadership wants the Office of the Inspector General (OIG) to:

Review and evaluate training provided to pilots operating U.S. certificated commercial passenger aircraft in the United States compared to the training provided to pilots operating U.S. certificated commercial passenger aircraft outside the United States, including training on the Boeing 737 MAX (training provided both before and after the Lion Air accident in October 2018);
Review the requirements of the FAA, European Union Aviation Safety Agency and other civil aviation authorities’ regulations and the International Civil Aviation Organization’s standards regarding training for transport category pilots on cockpit automation, including training on the Boeing 737MAX (both before and after the Lion Air accident in October 2018); and,
Outline any recommendations developed or information discovered in the course of the review to improve international pilot training standards and training for pilots operating U.S.-certificated commercial passenger aircraft outside the United States, particularly in light of greater automation in the cockpit.

In addition, the OIG is to evaluate how FAA has implemented portions of the FAA Extension, Safety and Security Act of 2016 pertaining to cockpit automation management. The language in the act requires FAA to develop a process to verify that air carrier training programs incorporate measures to train pilots on monitoring automation systems; control the aircraft flightpath without auto pilot or autoflight systems; develop metrics or measurable tasks that carriers can use to evaluate pilot monitoring proficiency; issue guidance to safety inspectors responsible for oversight of the operations of air carriers on tracking and assessing pilots’ proficiency in manual flight; and issue guidance to air carriers and inspectors regarding standards for compliance with previously implemented requirements for enhanced pilot training.

FSF Editorial Staff. April 1, 2019

Safety Oversight

DOT Panel to Review FAA Aircraft Certification Process

The U.S. Department of Transportation (DOT) said today that it is establishing a special committee to review procedures used by the Federal Aviation Administration (FAA) in certifying new aircraft, including the Boeing 737 MAX, grounded earlier this month after two accidents.

The committee’s interim cochairs, pending the appointment of other members, will be retired Air Force Gen. Darren McDew, former head of the U.S. Transportation Command, and Capt. Lee Moak, a former president of the Air Line Pilots Association, International.

“Safety is the number one priority of the Department, and this review by leading outside experts will help determine if improvements can be made to the FAA aircraft certification process,” Transportation Secretary Elaine Chao said in announcing the appointments.

Today’s announcement came just over two weeks after a March 10 accident involving Ethiopian Airlines Flight 302, a 737 MAX 8 that crashed shortly after takeoff from Addis Ababa, Ethiopia, killing all 157 passengers and crew. On Oct 29, 2018, another MAX 8, Lion Air Flight 610, crashed into the Java Sea after takeoff from Jakarta, Indonesia, killing 189 passengers and crew. The FAA grounded MAX 8 and MAX 9 airplanes on March 13. Other civil aviation authorities worldwide have taken similar action.

The committee, to be known as the Special Committee to Review FAA’s Aircraft Certification Process, is an independent panel; its findings will be delivered to the transportation secretary and the FAA administrator.
The committee is being formed in accordance with a law passed in 2018 outlining criteria for the appointment of panels to provide advice and recommendations on issues involving FAA safety oversight and certification programs and activities, the DOT said. Members of the public who would like to be considered for membership must submit information being published in the Federal Register.

FSF Editorial Staff. March 25, 2019

News, Safety Oversight

Senate Subcommittee Schedules Oversight Hearing

The U.S. Senate Commerce, Science and Transportation Committee’s Aviation and Space Subcommittee has scheduled a hearing on federal oversight of commercial aviation for 3 p.m. Wednesday, March 27.

“In light of the recent tragedy in Ethiopia and the subsequent grounding of the Boeing 737 Max aircraft, this hearing will examine challenges to the state of commercial aviation safety, including any specific concerns highlighted by recent accidents,” the committee said in a news release.

Witnesses scheduled to testify include Robert Sumwalt, chairman of the National Transportation Safety Board; Daniel Elwell, acting administrator of the Federal Aviation Administration (FAA); and Calvin Scovel, inspector general of the Department of Transportation.

The committee said it intends to hold a second hearing on aviation safety in the near future to hear from industry stakeholders, including Boeing, other manufacturers, airline pilots and other stakeholders.

Ethiopian Airlines Flight 302 crashed shortly after takeoff from Addis Ababa, Ethiopia, on March 10. All 157 passengers and crew were killed. Lion Air Flight 610, also operated with a MAX 8, crashed into the Java Sea on Oct. 29, killing 189 passengers and crew. FAA grounded MAX 8 and MAX 9 airplanes on March 13.

Earlier this week, Transportation Secretary Elaine Chao ordered Scovel’s office to conduct an audit of the MAX 8 certification process.

Also this week, FAA issued another continued airworthiness notification to the international community (CANIC) providing an update on safety matters related to the MAX fleet.

In an earlier CANIC, FAA provided information regarding Boeing’s development of flight control system changes to address the Lion Air accident. In this week’s CANIC, FAA said it “is aware that Boeing is developing a service bulletin that would specify the installation of new flight control computer operational program software. Boeing has also developed flight crew training related to this software. The FAA’s ongoing review of this software installation and training is an agency priority, as will be the roll-out of any software, training or other measures to operators of the 737 MAX.”

FSF Editorial Staff. March 21, 2019

News, Safety Regulation

DOT Orders Audit of Boeing 737 MAX 8 Certification

U.S. Secretary of Transportation Elaine L. Chao on Tuesday ordered an audit of the Boeing 737 MAX 8 certification process. The aircraft, which the Federal Aviation Administration (FAA) grounded last week, has been involved in two fatal accidents in the past several months.

In a brief memo to Calvin L. Scovel, III, the Department of Transportation’s (DOT’s) inspector general, Chao asked the Office of the Inspector General to proceed with an audit to compile an “objective and detailed factual history of the activities that resulted in the certification” of the MAX. She said the intent of the audit was to help inform DOT’s decision making and the public’s understanding, and to “assist the FAA in ensuring that its safety procedures are implemented effectively.”

FSF Editorial Staff. March 20, 2019

News

Boeing Releases Letter from CEO to Public, Aviation Community

Boeing has released a letter from Dennis Muilenburg, chairman, president CEO of The Boeing Co., addressing the safety of the 737 MAX aircraft. The letter and accompanying video message can be found on the Boeing website.

FSF Editorial Staff. March 19, 2019

Podcasts