Indonesia issues final report on 737 MAX crash – highlights multiple errors including Boeing design fault

Indonesian investigators have released their final report into the October 29, 2018 crash which killed all 189 passengers and crew on board Flight 610, a Boeing 737 MAX 8 jet. While the report highlighted the fact that Boeing had acted without adequate oversight from U.S regulators and as a consequence had failed to grasp risks in the cockpit software of its now grounded 737 MAX jet, the report also made it clear that errors by the crew and airline workers were also a contributing factor.

Indonesia has consequently made recommendations to Boeing, Lion Air, the U.S. Federal Aviation Administration (FAA) and additional agencies. The report stated that:  “The design and certification of the MCAS did not adequately consider the likelihood of loss of control of the aircraft,” while also stating that “deficiencies” in the flight crew’s communication and manual control of the aircraft contributed to the crash, along with alerts and distractions in the cockpit. Commenting on the report, Indonesian air accident investigator Nurcahyo Utomo said: “From what we know, there are nine things that contributed to this accident. If one of the nine hadn’t occurred, maybe the accident wouldn’t have occurred.” The report made it clear that a critical angle of attack (AOA) sensor providing data to the MCAS anti-stall system had been mis-calibrated by Florida-based Xtra Aerospace without the recommended equipment, and that there were strong indications it had not been tested during installation by Lion Air maintenance staff.

According to Reuters news agency, the FAA, also faulted by the report for its oversight of Xtra, formally revoked the maintenance firm’s repair station certificate following the report’s publication. Xtra responded in a statement that it had been cooperating closely with the FAA “and though we have reached a settlement with the FAA, we respectfully disagree with the agency’s findings.”

The investigators also found that Lion Air should have grounded the jet following faults on earlier flights, adding that 31 pages were missing from the airline’s October maintenance logs. The report pointed out that Boeing’s safety assessment assumed pilots would respond within three seconds of a system malfunction but on the fatal flight, and one which had experienced the same problem the previous evening, it took both crews about eight seconds to respond. The report consequently made a recommendation for the systems to be designed not just for highly skilled test pilots, but for regular commercial airline pilots as well.