Lion Air Crash Report Faults Boeing 737 MAX Design Flaws, Pilot Errors

Topline: Boeing, the world's largest plane maker, is undertaking "unprecedented" steps to overhaul its safety standards and software after a report by Indonesian aviation regulators found design flaws in the 737 MAX played a factor in the crash of Lion Air Flight 610 in 2018.

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• Indonesia's National Transportation Safety Committee found nine factors linked with Boeing, the airline and the pilots in the report that was initially leaked to the media before being released on Friday. The release of the findings comes nearly one year after the Lion Air 737 MAX nosedived shortly after taking off from Jakarta killing 189 people.
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• In a key finding the crash investigators criticized Boeing over the design of the anti-stall system known as the Maneuvering Characteristics Augmentation System (MCAS).
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• "The design and certification of the MCAS did not adequately consider the likelihood of loss of control of the aircraft," according to a copy of the report obtained by Reuters.
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• Investigators also found fault with the Indonesia low-cost carrier pointing to 31 pages missing for the aircraft's maintenance logs, and a key sensor in the anti-stall system was likely not tested after it was installed.
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• The report also found fault with the pilots of the aircraft with the captain not briefing his copilot prior to handing over control of the plane, while the copilot in command at the time of the crash had performed poorly in training, "tended to have 'press-on-itis'," also known as "get-home-itis," and struggled to run checks.
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• The report also says that Lion Air should have grounded the aircraft after a series of faults were detected on earlier flights.
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• Therecommendations to Lion Air, Boeing, the Federal Aviation Administration and Indonesian regulators include improving training measures and cockpit communication, testing new systems and redesigning the MCAS system, improving oversight of certification and maintenance, and establishing procedures for how to handle recurring faults on aircraft.

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• In a statement, Boeing CEO Dennis Muilenburg said the firm is improving the MCAS component, as well as updating its crew manuals and pilot training material.
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• Muilenburg said in a statement: "We mourn with Lion Air, and we would like to express our deepest sympathies to the Lion Air family. These tragic events have deeply affected us all and we will always remember what happened."
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• American aviation regulator FAA is considering the report's recommendations, Reuters reported, while last month, Boeing set up a safety committee to ensure the "safe design, development, manufacture, production, operation, maintenance and delivery" of Boeing products.

Crucial quote: In a press conference following the release of 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," Reuters reported.

Key background: All passengers and crew on the Lion Air plane died when a new 737 MAX crashed into the Java Sea shortly after take-off. Every 737 MAX aircraft was grounded in March after 157 people died when an Ethiopian Airlines plane traveling from Addis Ababa to Nairobi crashed. Aviation regulators and the U.S. Department of Justice are investigating what Boeing knew about problems with the crucial anti-stall system.

Last month Boeing reportedly settled with the families of Lion Air crash victims for $1.2 million each, for a single victim without dependents, according to Reuters. while almost 100 lawsuits have been brought over the Ethiopian Airlines crash. Boeing suffered substantial financial losses as a result of the grounding, while a number of former engineers and whistleblowers have emerged over recent months, claiming that Boeing knew of safety failings and accusing the company of rejecting safety upgrades in order to cut costs.

Tangent: This week, Boeing's head of commercial airplanes, Kevin McAllister, was ousted, making him the most senior executive to leave the firm after the two crashes. The 737 MAX aircraft are not expected to return to service until 2020 at the earliest.