Lion Air Boeing Crash Final Report 737 MAX

It was made púfinal report of the Lion Air accident in a Boeing 737 MAX happened on 29 October 2018 extinguishing the life of 189 people.

The 29 October 2018, the flight 610 de PT Lion Mentari Airlines (Lion Air), a boeing 737 MAX 8, PK-LQP, crashedó in the Java Sea shortly afterés of takeoff from Soekarno-Hatta International Airport, She fought, Indonesia. The flight was a sun flightéscheduled flight from Jakarta to Depati Amir Airport, Pangkal Pinang City, Bangka Belitung Islands Province, Indonesia. The 189 passengers and crewón on board died and the planeón was destroyed.

almost añor undresséand why is it a girl?ídic accident that put into doubt the Boeing 737 MAX and what will comeífollowed by the Ethiopian accident, the National Transportation Committee of the RepublicúIndonesian war has made públic the report of meás de 300 págassed, which resolves and demonstrates the already confirmed doubts that generated this accident.

Final report

You can read the full report below, It takes time to load given its sizeñO:

Conclusions

The report is comprehensive in every sense, as a final report should be., but we will highlight in this summary some of the más important research discoveriesónot finished:

• MCAS isá diseñDesigned to operate only during manual flight (auto pilotáuncommitted attic), with the airplane flapsón raised, at a high AOA. As the development of 737-8 (MAX) progresó, the functionón MCAS was expanded to númere low Mach and increased to MCAS command máximo límeasure 2.5° stabilizer movement.
• During the AnáFunctional Risk Analysis (FHA), Undesired stabilizing movement by MCAS was considered a conditionóNo. of failure with greatest effect on the normal flight envelope. The evaluationón of Major no
  require Boeing to analyze más strictlyóno security failureálysis using failure modes and analysisáeffects lysis (FMEA) and the áfault tree Análysis (FTA), since these are only necessary for dangerous risks or cadastróspecific failure conditions.
• The crewóflight number no reactionó on activationón of MCAS but to the increasing force in the control column. Since the crewóflight number initially counteró the MCAS command using the control column, response time más long to do theéelectrical stabilizer adjustment inputs were understandable.
• During the FHA, the simulator test has neveríhas considered a scenario in which the activationón of MCAS allowedó that the movement of the stabilizer reached the máXimo Límite MCAS from 2.5 degrees. Repeated activations of MCAS without adequate reactionócrew adjustmentóhar flight numberífor the stabilizer to move to the máximo divert and increase crew workloadóflight number and, Thus, the effects of duty failureíto have been reconsidered. Therefore, their combined flight deck effects were not evaluated.
• The runaway stabilizer procedure was not reintroduced during the transition.óno training and noítell usóImmediate availability for crewón of flight to be able to directly correlate the nose down stabilizer without controls with the procedure. Therefore, I guessóno reliance on crew proceduresón trained to implement memory elements was inappropriate.
• During the accident flight, m were producedúltiples alerts and indications that increaseó crew workloadóflight number. This obscuredó the problem and the flight. The crewón could not come to a solutionón during the autoáinitial or subsequent nose-down stabilizer inputs of the aircraft, how to perform the stabilizer runaway procedure or continue using the adjustmentéelectric to reduce spinal forces and maintain level flight.
• pull backás in the column normally interrupts any avión stabilizer theénose down electric, but for him 737-8 (MAX) with MCAS running, the functionócontrol column cutting no.á disabled.
• He saysñor of the aircraft must provide the crew withóflight number informationón and alerts to help them understand the system and know howóhow to solve potential problems.
• Boeing consideró that the functionón MCAS is automaticáethics, the procedure is required to respond to any functionón MCAS was not different from existing procedures and crews were not expected to encounter MCAS under normal operating conditions.ón, For this Boeing did not consideró the failure scenario seen in the accident flight. The investigationón believes that the effect of MCAS erróneo with the función it was surprising for the flight crews.
• The investigationón believes that the crewóflight number dutyíhaving been informed of the MCAS that they will haveíhas provided knowledge of the system and increased your chances of being able to mitigate the consequences of múmultiple activations at the accident scene.
• Without understanding MCAS and reactivationón laterés to release the systeméelectric, the crewóThe flight attendant was running out of time to find a solution.ón before repetitive MCAS activations without fully re-controlling the aircraftón, what i putó the aircraft in an extreme nose-down attitude that the crewóflight n could not recover.

Contributing factors

• During the designñor and the certificationón del Boeing 737-8 (MAX), Assumptions were made about the crew's response.ón flight to malfunctions that, despite being consistent with current industry guidelines, turned out to be incorrect.
• Based on incorrect assumptions about the crew's responseóflight number and a reviewóincomplete n of associated flight deck effects múltiple, the dependence of MCAS on a single sensor was consideredó appropriate and compliantó with all certification requirementsón.
• MCAS was designedñdesigned to rely on a single AOA sensor, which makes it vulnerable to err inputóno sensor.
• The absence of guidanceón about MCAS or the use máDetailed adjustment information is provided in flight manuals and crew training.óflight number, made it más difíeasy for flight crews to respond appropriately to uncommanded MCAS.
• AOA DISAGREE alert did not activateó correctly during the development of the Boeing 737-8 (MAX). As a result, I didn't show upó during flight with miscalibrated AOA sensor, the crewóflight number could not document it and, Thus, was not available to help maintenance identify the miscalibrated AOA sensor.
• The replacement AOA sensor that was installedó the accident aircraft was calibratedó bad during a repairón anterior. This calibrates usóincorrect n was not detectedó during the repairón.

security recommendations

As in every report, the idea is not to find guilty, otherwise, find solutions to prevent these events from recurring in the future, así The researchers generate the following recommendations, among other:

Lion Air

• The investigationón foundó that the Lion Air manuals were not updated in a timely manner and the content has several inconsistencies, incomplete and unsynchronized procedures.
  Therefore, KNKT recommends establishing a system to ensure that company manuals are updated in a timely manner.
• The flight LNI043 that I experiencedó múltiples fallos are consideredó caused the rotíto have caused difficulties in controlling the aircraftón. According to the Annex 13 from ICAO, CASR part 830 and OM-part A, the flight isá classified as a serious incident requiringó researchón by KNKT in accordance with the Aviation Lawón Número 1 from 2009 and Government Decree Número 62 from 2013.
  Therefore, KNKT recommends that Lion Air improve managementón of your hazard report allowing the hazard to be identified and providing mitigationón appropriate.

AirNav Indonesia

• The crewóLNI610 flight number requestedó to the controller the altitude of the aircraft detected on the ATC radar screen, what caníto be an effort to obtain another source of informationón. The aircraft's altitude request to the controller will not obtainá informationón additional since the ATC radar display receives data from the aircraft transponder which transmits cockpit indications.
  Therefore, KNKT recommends providing informationón to the crewóflight number that the indicationón altitude on radar screen ATC was repeating aircraft data.

Boeing

• during the accident, m were producedúmultiple alerts and indications that increased the crew's workloadóflight number. This obscuredó the problem and the crewóflight team could not come to a solutionón during initial and subsequent automatic entryáY stabilizer pen, how to perform the stabilizer runaway procedure or continue using the trim theéelectric to reduce spinal forces and maintain level flight.
  Therefore, KNKT recommends that the aircraft manufacturer consider the effect of all possible flight deck alerts and indications on crew recognition and response.óflight number; and incorporate the designñO, crew proceduresóflight number and / or training requirementsón when necessary to minimize the potential for crew actionsón of flight that are inconsistent with the manufacturer's assumptions.
• During the certification phaseón, flight test pilots demonstrated compliance, who typically have exceptional skills and experience. Flight test pilots generally have más knowledge about the charactersídesign aestheticsñor the aircraft that normal pilots. This level of competence generally cannot be translated to the greatestíto the pilots. Nevertheless, the test pilots areán trained to replicate the crewóaverage flight number. The pilots of the Evaluation GroupóNo. of Aircraft, who have operational flight history, spaghettién evalúthe aircraft during the certification phaseón. These pilots establish the qualification requirementsópilot type number, trainingón, checkón and currency as part of the Normalization Board processóFlight number (FSB). The FSB process alsoén uses l pilotsínever aéarea to help ensure that requirements are operationally representative. The FAA and OEMs must reevaluate their assumptions for what constitutes b-ability.áphysics of a crewóaverage flight number andé level of systems knowledge has a «crewóProperly trained average flight number» when you find faults.
  Therefore, KNKT recommends that Boeing include greater tolerance in the designñor what is required to allow the operation of a populationón más large number of qualified pilotsóflight number.
• The crewóflight number dutyíto have received informationón and alerts to help them understand the system and know howóhow to solve possible problems. Crew procedures and trainingóflight number dutyístill be appropriate.
  Therefore, KNKT recommends Boeing to develop the guía for the information criteriaón that should be included in the crewón flight and engineer manuals.
• The aircraft mustíto have functionally included the intended AOA DISAGREE alert message, that was installedó on the aircraft 737 of. Boeing and the FAA must ensure that the designñor new and modified aircraft described, analyze and certify appropriately.
  Therefore, KNKT recommends that Boeing ensure that certified and delivered aircraft have the intended system functionality.

This is a summary of the long final report, all the conclusions and details you will be able toán read in it.