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SQ22
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Updated: Final report of Lion Air JT610 has been released

Wed Oct 23, 2019 9:51 am

Reuters is reporting that Lion Air told victims' families that mechanical and design issues contributed to the crash. This has happened before the final report has will be released. Another contributing factor to the crash were deficiencies in the flight crews communication and manual control of the aircraft. These deficiencies have been identified during training according to the article.

Final report will be released on Friday.

https://www.reuters.com/article/us-indo ... SKBN1X20EJ

Link to the thread of the crash:

viewtopic.php?f=3&t=1407217
Last edited by SQ22 on Fri Oct 25, 2019 3:32 pm, edited 3 times in total.
Reason: Title updated
 
cedarjet
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Re: Reuters: Lion Air families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 10:09 am

To be fair, it’s a totally accurate statement
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Re: Reuters: Lion Air families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 10:25 am

Some other news about the JT610 final report from https://news.mb.com.ph/2019/10/23/lion-air-families-told-737-max-design-flaws-linked-to-deadly-crash/

JAKARTA – Mechanical and design issues contributed to the crash of a Lion Air 737 MAX jet last October, Indonesian investigators told victims’ families in a briefing on Wednesday ahead of the release of a final report.

Contributing factors to the crash of the new Boeing (BA.N) jet, which killed all 189 on board, included incorrect assumptions on how an anti-stall device called the Maneuvering Characteristics Augmentation System (MCAS) functioned and how pilots would react, slides in the presentation showed.

The briefing slides showed that a lack of documentation about how systems would behave in a crash scenario, including the activation of a “stick shaker” device that warned pilots of a dangerous loss of lift, also contributed.

“Deficiencies” in the flight crew’s communication and manual control of the aircraft contributed as well, the slides showed, as did alerts and distractions in the cockpit.

The deficiencies had been “identified during training,” the slides said, without elaborating.

Reliance on a single angle-of-attack sensor made MCAS more vulnerable to failure, while the sensor on the plane that crashed had been miscalibrated during an earlier repair, according to the slides.

The final report will be released on Friday.

The only real new information to me is that the AoA failure seem to have been identified to a "miscalibrated during an earlier repair". I wonder how a such error could have passed all the quality tests..
 
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Re: Reuters: Lion Air families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 10:45 am

PixelFlight wrote:
The only real new information to me is that the AoA failure seem to have been identified to a "miscalibrated during an earlier repair". I wonder how a such error could have passed all the quality tests..


didnt they tell before that calibration is done at the manufactor and not at the airliner MX

maybe that info was false ...?
 
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Re: Reuters: Lion Air families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 12:42 pm

asdf wrote:
PixelFlight wrote:
The only real new information to me is that the AoA failure seem to have been identified to a "miscalibrated during an earlier repair". I wonder how a such error could have passed all the quality tests..


didnt they tell before that calibration is done at the manufactor and not at the airliner MX

maybe that info was false ...?


Are you saying Lion Air MX can "calibrate" AOA vane?? How...??

I thought the whole defective "certified" Rosemount Aerospace-made AOA vane thing had been discussed to death before...?? No??

Get with it..., man??

Read here...

Faulty 737 sensor in Lion Air crash linked to US repairer

And..., while at it..., go to this thread and the specific post...

- viewtopic.php?t=1407217&p=21727967
 
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Re: Reuters: Lion Air families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 1:09 pm

patplan wrote:
asdf wrote:
PixelFlight wrote:
The only real new information to me is that the AoA failure seem to have been identified to a "miscalibrated during an earlier repair". I wonder how a such error could have passed all the quality tests..


didnt they tell before that calibration is done at the manufactor and not at the airliner MX

maybe that info was false ...?


Are you saying Lion Air MX can "calibrate" AOA vane?? How...??


no
it actually was a question

because not only here in the forum but anywhere it was told for months that the lion air MX is at fault for the crash

and now they tell about a wrong calibration what would fit into that picture
but if calibration can only be done in the workshop of the manufactor .... then Lion Air MX isnt at fault, is it?
 
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 1:54 pm

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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 4:49 pm

From reuters summary:

“ 7. The investigation could not determine that the installation test of AOA sensor was perform(ed) properly; however the mis-calibration was not detected.

8. Lack of documentation in the aircraft flight and maintenance log about the continuous stick shaker and use of the Runaway Stabilizer NNC meant that information was not available to the maintenance crew in Jakarta nor was it available to the accident crew, making it more difficult for each to take the appropriate actions.

9. The multiple alerts, repetitive MCAS activations and distractions related to numerous ATC communications were not able to be effectively managed. This was caused by the difficulty of the situation and deficiencies in manual handling, NNC execution and flight crew communication, leading to ineffective CRM application and workload management. These deficiencies had previously been identified during training and reappeared during the accident flight.”

This is what I’ve saying since day 2 when the questions were raised.

Given: aircraft design fault led to dangerously erratic behavior THE NIGHT BEFORE, the FAULT was due to Boeing’s design, but the CRASH was due to 7,8 and 9. Especially 8. The previous crew seemed to handle 9 fine. But the crew the next day seemed to have no idea what happened.

If the crew of the doomed flight knew what the crew before did to recover from 1-6 (boeing design flaw, sensor repair flaw), 9 would not have happened. Without 8 there is no 9.

It’s even worse for ET because they had over 3 months to understand the problems and either ground the fleet or train all pilots correctly, implement extra protocols for AoA faults, etc.

I would love to hear from 737 pilots to find out whether their airline implemented any changes after the JT crash and/or if they personally spent time learning about and understanding what was known at the time.
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 5:02 pm

ikramerica wrote:
9. The multiple alerts, repetitive MCAS activations and distractions related to numerous ATC communications were not able to be effectively managed. This was caused by the difficulty of the situation and deficiencies in manual handling, NNC execution and flight crew communication, leading to ineffective CRM application and workload management. These deficiencies had previously been identified during training and reappeared during the accident flight.”


While of course the excessive MCAS corrections were the root issue, the cockpit conditions have been on my mind regularly when thinking about the Lionair crash in particular, because they at one point resolved the immediate issue - by extending the flaps again to 5 degrees.

2-1/2 minutes later, they retracted the flaps once more, and MCAS activated again. During the remaining 6 minutes, it does not seem they realized what they had done previously that had halted the MCAS trim.
 
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 5:16 pm

iamlucky13 wrote:
ikramerica wrote:
9. The multiple alerts, repetitive MCAS activations and distractions related to numerous ATC communications were not able to be effectively managed. This was caused by the difficulty of the situation and deficiencies in manual handling, NNC execution and flight crew communication, leading to ineffective CRM application and workload management. These deficiencies had previously been identified during training and reappeared during the accident flight.”


While of course the excessive MCAS corrections were the root issue, the cockpit conditions have been on my mind regularly when thinking about the Lionair crash in particular, because they at one point resolved the immediate issue - by extending the flaps again to 5 degrees.

2-1/2 minutes later, they retracted the flaps once more, and MCAS activated again. During the remaining 6 minutes, it does not seem they realized what they had done previously that had halted the MCAS trim.

There where not 737 pilots to discover an unknown information on a recovery. The fact that the MCAS is enabled when the flaps are up was only known when the EAD was published. And even that EAD failed to instruct that flaps down is the most safe and effective action to disable MCAS, without disabling the manual electric stab trim. Retrospectively it seem obvious, but how many did write that solution before the EAD ?
 
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 6:03 pm

PixelFlight wrote:
Retrospectively it seem obvious, but how many did write that solution before the EAD ?


Yes. That's my only point. Not second guessing.

I'm just struck by how close they were to avoiding that crash.
 
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 6:37 pm

PixelFlight wrote:
[The fact that the MCAS is enabled when the flaps are up was only known when the EAD was published. And even that EAD failed to instruct that flaps down is the most safe and effective action to disable MCAS, without disabling the manual electric stab trim. Retrospectively it seem obvious, but how many did write that solution before the EAD ?


Interesting that ferry flights for MAX aircraft have been specified by some CAAs only to be conducted with flaps extended. Eg the Silkair ferry flights from Singapore to Alice Springs.
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 6:42 pm

ikramerica wrote:
It’s even worse for ET because they had over 3 months to understand the problems and either ground the fleet or train all pilots correctly, implement extra protocols for AoA faults, etc.

What? Maybe I am wrong but as far as I know ET is an airline, not an organization to investigate crashes.

And how do you calculate the three months? JT was in October 2018 and ET in March 2019. Based on which findings should they have grounded the fleet two months after the JT-crash? Based on the discussions here on a.net or other forums? :-/

And on top of it: if you think it’s „even worse for ET they had over 3 months to understand the problems ...“, what about the OEM?
 
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 8:23 pm

zeke wrote:
PixelFlight wrote:
[The fact that the MCAS is enabled when the flaps are up was only known when the EAD was published. And even that EAD failed to instruct that flaps down is the most safe and effective action to disable MCAS, without disabling the manual electric stab trim. Retrospectively it seem obvious, but how many did write that solution before the EAD ?


Interesting that ferry flights for MAX aircraft have been specified by some CAAs only to be conducted with flaps extended. Eg the Silkair ferry flights from Singapore to Alice Springs.


It is interesting that there seem to different approaches. Air Canada flights seem to show pretty typical flight profiles for their ferry flights, here is an example:
https://www.flightradar24.com/data/airc ... v#22445be4
 
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Re: Reuters: Lion Air families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 8:28 pm

cedarjet wrote:
To be fair, it’s a totally accurate statement



Yup. It isn't the SOLE issue, but it is a major contributing part.
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 11:25 pm

ikramerica wrote:
From reuters summary:

“ 7. The investigation could not determine that the installation test of AOA sensor was perform(ed) properly; however the mis-calibration was not detected.

8. Lack of documentation in the aircraft flight and maintenance log about the continuous stick shaker and use of the Runaway Stabilizer NNC meant that information was not available to the maintenance crew in Jakarta nor was it available to the accident crew, making it more difficult for each to take the appropriate actions.

9. The multiple alerts, repetitive MCAS activations and distractions related to numerous ATC communications were not able to be effectively managed. This was caused by the difficulty of the situation and deficiencies in manual handling, NNC execution and flight crew communication, leading to ineffective CRM application and workload management. These deficiencies had previously been identified during training and reappeared during the accident flight.”

This is what I’ve saying since day 2 when the questions were raised.

Given: aircraft design fault led to dangerously erratic behavior THE NIGHT BEFORE, the FAULT was due to Boeing’s design, but the CRASH was due to 7,8 and 9. Especially 8. The previous crew seemed to handle 9 fine. But the crew the next day seemed to have no idea what happened.

If the crew of the doomed flight knew what the crew before did to recover from 1-6 (boeing design flaw, sensor repair flaw), 9 would not have happened. Without 8 there is no 9.

It’s even worse for ET because they had over 3 months to understand the problems and either ground the fleet or train all pilots correctly, implement extra protocols for AoA faults, etc.

I would love to hear from 737 pilots to find out whether their airline implemented any changes after the JT crash and/or if they personally spent time learning about and understanding what was known at the time.



you DO realize that 7, 8 and 9 are the LAST points of failures?
and that point 1 up to 6 show a complete other picture of whom has to take the blame ....
 
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Wed Oct 23, 2019 11:55 pm

364 days approx from crash to final report is a very quick turnaround for an accident investigation isn’t it?

Understandably it would have been expedited due for the groundings of course.
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 12:50 am

Interesting that in effect the crash is attributed to several causes, only some of which were Boeing, although those faults can properly be seen as the primary ones. Per philosophy and moral theology - and maritime law fault is multiplied - not divided.
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 3:08 am

TheWorm123 wrote:
364 days approx from crash to final report is a very quick turnaround for an accident investigation isn’t it?

Understandably it would have been expedited due for the groundings of course.

The 1 year delay for a final report is the usual delay recommended by ICAO annex 13 https://www.emsa.europa.eu/retro/Docs/marine_casualties/annex_13.pdf
6.6 Recommendation.— The State conducting the investigation should release the Final Report in the shortest possible
time and, if possible, within twelve months of the date of the occurrence. If the report cannot be released within twelve months,
the State conducting the investigation should release an interim report on each anniversary of the occurrence, detailing the
progress of the investigation and any safety issues raised.

The grounding was not in the control of the investigation team. The certification process to ground and return to service is the responsibility of each respective local aircraft safety authorities.
At least the EASA have expressed concerns that there did not have access to the investigation and depend only on Boeing and the FAA to get facts. This is probably one of the point that will be negotiated in the future.
 
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 3:13 am

frmrCapCadet wrote:
Interesting that in effect the crash is attributed to several causes, only some of which were Boeing, although those faults can properly be seen as the primary ones. Per philosophy and moral theology - and maritime law fault is multiplied - not divided.

Per ICAO annexe 13:
OBJECTIVE OF THE INVESTIGATION
3.1 The sole objective of the investigation of an accident or incident shall be the prevention of accidents and
incidents. It is not the purpose of this activity to apportion blame or liability.
 
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 1:43 pm

I perhaps should have said cause is multiplied, but think my meaning was clear. And the point I and others were making is that multiple factors were involved in the crash. Does that disagree with your ICAO quote?
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 2:31 pm

Oh boy, the phone calls are already started to come in... and tomorrow is going to be hell I guess...
Now something similar to points 1 to 4 would probably appear in the ET report too whenever that comes out... Now without 5-9, ET would have still happened.
All I want now is the bloody MCAS fix to come out . Boeing owes it to everyone, including its customers whose planes are now grounded.
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 2:38 pm

ikramerica wrote:
This is what I’ve saying since day 2 when the questions were raised.


So you're completely ignoring points 1 through 6? :confused:
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 4:14 pm

frmrCapCadet wrote:
I perhaps should have said cause is multiplied, but think my meaning was clear. And the point I and others were making is that multiple factors were involved in the crash. Does that disagree with your ICAO quote?

No, that fine :thumbsup:
(the word "fault" in early post was my motivation to quote the ICAO).
 
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 4:50 pm

This doesn't say anything we didn't expect or heard from them tbh. MCAS was primary cause, with CRM breakdown as a contributing factor. I wonder if the ET302 crash has a similar cause, and the question of how that AoA failed still remains. I also heard that apparently the captain of that flight was sorta able to maintain flight, but when he handed control over to the FO to try to diagnose the problem he wasn't prepared for how agressive MCAS was being, and it ended up how we all know. Can anyone confirm if that's true or if it's just a rumor?
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 5:42 pm

TheWorm123 wrote:
364 days approx from crash to final report is a very quick turnaround for an accident investigation isn’t it?


They must been reading Anet as well . . .
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 5:42 pm

mandala499 wrote:
Oh boy, the phone calls are already started to come in... and tomorrow is going to be hell I guess...
Now something similar to points 1 to 4 would probably appear in the ET report too whenever that comes out... Now without 5-9, ET would have still happened.
All I want now is the bloody MCAS fix to come out . Boeing owes it to everyone, including its customers whose planes are now grounded.


Well, that's a good way to describe and distinguish between Root Cause(s) and Contributing Cause(s) . . . .
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Thu Oct 24, 2019 9:54 pm

scbriml wrote:
ikramerica wrote:
This is what I’ve saying since day 2 when the questions were raised.


So you're completely ignoring points 1 through 6? :confused:

No. 1-6 made a very scary plane to deal with.

7 and 8 led to 9 being a factor.

The night before, there was no 9, and no crash.

As for ET, 1-6 are very serious, but somewhere along the line the pilots or the airline didn’t treat them seriously enough.

I can’t wrap my head around the ET pilots flying the aircraft without knowing FULLY what to do if the JT fault repeats. They clearly didn’t. I know I would have been studying the heck out of the crash if my life and the lives of customers depended on it.

While the alerts and workload are overwhelming in a vacuum, ET were not operating in a vacuum. Sadly, the JT pilots seemed to be, but should not have been.
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Fri Oct 25, 2019 6:07 am

Is there any indication if the pilots even saw the trim wheel turning?
 
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Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Fri Oct 25, 2019 12:11 pm

[ Found no thread on the report being issued, please merge if one exists ]

Good summary at https://www.reuters.com/article/us-indo ... SKBN1X401G

Boeing, acting without adequate oversight from U.S. regulators, failed to grasp risks in the design of cockpit software on its 737 MAX airliner, sowing the seeds for a Lion Air crash that also involved errors by airline workers and crew, Indonesian investigators found.

As expected, most of the attention is on Boeing, but JT's crew, maintenance and training received some attention too, along with FAA's lack of supervision.

One quote I found interesting:

The accident had been caused by a complex chain of events, Indonesian air accident investigator Nurcahyo Utomo told reporters at a news conference, repeatedly declining to be drawn on providing a single dominant cause.

“From what we know, there are nine things that contributed to this accident,” he said. “If one of the nine hadn’t occurred, maybe the accident wouldn’t have occurred.”

To many of us, this is exact kind of report we expected.
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Fri Oct 25, 2019 12:17 pm

As expected, and as usually is the case, not one single thing was responsible for bringing down JT610 but a sequence of events.
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sxf24
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Fri Oct 25, 2019 12:21 pm

I agree this is as expected.

After reading exerts from the report and other reporting, I’m surprised at the Seattle Times very different conclusions. I guess Dominic Gates is still pissed off he didn’t get called on on Boeing’s last call.
 
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Fri Oct 25, 2019 12:32 pm

sxf24 wrote:
I agree this is as expected.

After reading exerts from the report and other reporting, I’m surprised at the Seattle Times very different conclusions. I guess Dominic Gates is still pissed off he didn’t get called on on Boeing’s last call.

Found his report at https://www.seattletimes.com/business/b ... ot-errors/

It does go much more directly at Boeing.

It also raises the specter of fake evidence presented by JT to try to get their maintenance team off the hook and that 31 pages were missing from the crashed plane's October logs.

Bloomberg ( https://www.bloomberg.com/news/articles ... rash-probe ) goes more directly at it:

Weeks after a Lion Air jet crashed in the Java Sea, killing all 189 aboard, an airline employee gave investigators photographs meant to show that a crucial repair had been properly performed the day before the disaster.

Yet the pictures may not show what was claimed.

The time displayed in photos of a computer screen in the cockpit of the Boeing Co. 737 Max indicated they had actually been taken before the repair was performed, according to a draft of the final crash report being prepared by Indonesia’s National Transportation Safety Committee, portions of which were reviewed by Bloomberg News.

Investigators were similarly unable to confirm the authenticity of other pictures in the packet, which were supposed to show how a piece of equipment near the jet’s nose had been calibrated, according to the report. There were indications that the pictures depicted a different plane, according to two people familiar with the investigation.

The last thing you want to do is mislead accident investigators, IMO.
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Fri Oct 25, 2019 1:22 pm

There was also these nuggets from the Guardian https://www.theguardian.com/world/2019/ ... ilot-error

"The final report said the first officer onboard was unfamiliar with procedures and had shown issues handling the aircraft during training."

And ABC

"The statement released Friday outlined various missteps. The aircraft, only in use for two months, began having problems a few days before it crashed. A new angle of attack sensor was installed while the aircraft was on the Indonesian island of Bali a day before the crash, but it had been mis-calibrated during an earlier repair, leaving it 21 degrees out of alignment. The problem was missed when it was installed, and the investigators said they were unable to find out if the new sensor was properly tested."
 
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Fri Oct 25, 2019 1:30 pm

I tried to Google but couldn't find a link to the actual report. Has it been published yet?
 
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Fri Oct 25, 2019 1:32 pm

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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Fri Oct 25, 2019 1:33 pm

dtw2hyd wrote:
I tried to Google but couldn't find a link to the actual report. Has it been published yet?


I've been looking but can't find it - it may have a press embargo.
 
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Fri Oct 25, 2019 1:57 pm

morrisond wrote:
dtw2hyd wrote:
I tried to Google but couldn't find a link to the actual report. Has it been published yet?


I've been looking but can't find it - it may have a press embargo.

Jon O's tweet gives us https://t.co/9sfXMpBFTn?amp=1

It worked for me...
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Wake now, discover that you are the song that the morning brings
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Revelation
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Fri Oct 25, 2019 2:03 pm

One outcome: Xtra's repair station certificate was yanked by the FAA:

https://twitter.com/jonostrower/status/ ... 9826110464
Wake up to find out that you are the eyes of the world
The heart has its beaches, its homeland and thoughts of its own
Wake now, discover that you are the song that the morning brings
The heart has its seasons, its evenings and songs of its own
 
morrisond
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Fri Oct 25, 2019 2:21 pm

Another shocker - look on Page 79 - apparently the Pilot had the Flu. Perfect shape to be in when flying.
 
morrisond
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Joined: Thu Jan 07, 2010 12:22 am

Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Fri Oct 25, 2019 2:43 pm

The report is not kind to the pilots at all.

"The FO was unable to control the
aircraft as the repetitive MCAS activations were not countered by adequate trim up
input. The common flight crew reaction to a heavy control column is by providing
adequate trim. This suggests that while the Captain’s training or experience enabled
him to recognize the need for sustained nose up trim, the FO’s training and
experience did not.
This condition was also in agreement with the FO’s training records that showed
several comments indicating that the FO had difficulty in aircraft handling. The
Lion Air policy for such deficiencies was that the flight crew would be treated with
additional briefings or rehearsal. The reappearance of difficulty in aircraft handling
indicated that the treatment was not effective."

Seriously - the FO didn't even know how to use the electric trim right?
 
morrisond
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Fri Oct 25, 2019 2:47 pm

They didn't follow proper procedures in determining the condition of the airplane before flying it.

"During the LNI610 flight preparation, the CVR recorded flight crew discussion
related to the Deferred Maintenance Item (DMI) but the flight crew did not discuss
any issue related to previous aircraft problem recorded in the AFML. The OM-part
A subchapter 2.1.14.3 describes that one of the Captain responsibilities is to
examine the AFML to inquire about the technical status of the aircraft before the
flight.
The absence of flight crew discussion of the previous problem suggests the flight
crew might not be aware of aircraft problems that might reappear during their flight.
This was different compared to the flight crew of the LNI043 flight, who had
awareness of the aircraft condition after discussion with the engineer about the
aircraft problem and the rectification prior to the flight which may have helped the
flight crew to immediately identify the problem correctly.
Being unaware of multiple problems that occurred on the previous flight, including
the stick shaker activation and uncommanded AND trim lead to the inability of the
flight crew to predict and be prepared to mitigate the events that might occur."
 
Etheereal
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Fri Oct 25, 2019 2:52 pm

frmrCapCadet wrote:
Interesting that in effect the crash is attributed to several causes...

Plane accidents/crashes dont happen that often due a single issue, but a chain of errors/mistakes.
 
BEG2IAH
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Fri Oct 25, 2019 3:00 pm

Aside from obvious Boeing, FAA, Xtra Aerospace, Lion Air maintenance, etc. negligence and borderline criminal behavior... What the hell is this?!?

At 23:21:37 UTC, the Captain instructed the FO to perform memory items for
airspeed unreliable. The FO did not respond to this request.

At 23:23:09 UTC, the Captain commanded “memory item, memory item”.

At 23:24:31 UTC, the FO advised the Captain that he was unable to locate the
Airspeed Unreliable checklist.

At 23:25:11 UTC, the FO repeated the TE controller instruction to the Captain to
fly heading 350°, then informed him that there was no airspeed unreliable checklist.

At 23:25:17 UTC, the FO stated “10.1” and began reading the Airspeed Unreliable
checklist. Note: The Airspeed Unreliable checklist is on page 10.1 of the QRH.

It took FO 3 minutes and 40 seconds to find a checklist that's a memory item? Wow!

So captain could fight MCAS successfully, but FO, as soon as he took over the control, basically crashed the plane. Isn't that what happened with ET 302 as well? Lack of communication from the captain to FO to let him know how much manual trim he (the captain) was doing and as soon as the FO took over, nose dive and crash...
Flying at the cruising altitude is (mostly) boring. I wish all flights were nothing but endless take offs and landings every 10 minutes or so.
 
Etheereal
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Fri Oct 25, 2019 3:24 pm

BEG2IAH wrote:
fly heading 350°, then informed him that there was no airspeed unreliable checklist.

At 23:25:17 UTC, the FO stated “10.1” and began reading the Airspeed Unreliable
checklist. Note: The Airspeed Unreliable checklist is on page 10.1 of the QRH.

It took FO 3 minutes and 40 seconds to find a checklist that's a memory item? Wow!

What a surprise . there was no checklist .. but there was a checklist!
 
ikramerica
Posts: 14936
Joined: Mon May 23, 2005 9:33 am

Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Fri Oct 25, 2019 3:43 pm

BEG2IAH wrote:
Aside from obvious Boeing, FAA, Xtra Aerospace, Lion Air maintenance, etc. negligence and borderline criminal behavior... What the hell is this?!?

At 23:21:37 UTC, the Captain instructed the FO to perform memory items for
airspeed unreliable. The FO did not respond to this request.

At 23:23:09 UTC, the Captain commanded “memory item, memory item”.

At 23:24:31 UTC, the FO advised the Captain that he was unable to locate the
Airspeed Unreliable checklist.

At 23:25:11 UTC, the FO repeated the TE controller instruction to the Captain to
fly heading 350°, then informed him that there was no airspeed unreliable checklist.

At 23:25:17 UTC, the FO stated “10.1” and began reading the Airspeed Unreliable
checklist. Note: The Airspeed Unreliable checklist is on page 10.1 of the QRH.

It took FO 3 minutes and 40 seconds to find a checklist that's a memory item? Wow!

So captain could fight MCAS successfully, but FO, as soon as he took over the control, basically crashed the plane. Isn't that what happened with ET 302 as well? Lack of communication from the captain to FO to let him know how much manual trim he (the captain) was doing and as soon as the FO took over, nose dive and crash...

Well yes. It’s what many have been pointing out since day 2. And we routinely get slammed for even suggesting that despite the situation that MCAS was creating, the handoff to the incompetent FO crashed the plane. Due to both failure of the FO to know how to fly a plane without automation, and failure of the captain to tell him what he was doing to keep the plane aloft.

And worse, the captain seems relatively competent, and had Lion notified him that the previous pilot had to turn off the switches to recover from the same situation, there is no doubt in my mind that he would have done that.

Then again, had that happened, the ET flight would have crashed no matter what since they still would have been unaware of what to do, with the same 2nd seat pilot unfit to be there situation.
Of all the things to worry about... the Wookie has no pants.
 
ikramerica
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Fri Oct 25, 2019 3:49 pm

morrisond wrote:
There was also these nuggets from the Guardian https://www.theguardian.com/world/2019/ ... ilot-error

"The final report said the first officer onboard was unfamiliar with procedures and had shown issues handling the aircraft during training."

And ABC

"The statement released Friday outlined various missteps. The aircraft, only in use for two months, began having problems a few days before it crashed. A new angle of attack sensor was installed while the aircraft was on the Indonesian island of Bali a day before the crash, but it had been mis-calibrated during an earlier repair, leaving it 21 degrees out of alignment. The problem was missed when it was installed, and the investigators said they were unable to find out if the new sensor was properly tested."

If an airline in CYA mode can’t produce documentation of a proper repair, even after the fact with, at minimum, sworn statements by the mechanics, it means that the repair wasn’t done properly.
Of all the things to worry about... the Wookie has no pants.
 
MIflyer12
Posts: 6070
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Re: Reuters: Lion Air JT610 families told 737 MAX design flaws and flight crew deficiencies linked to deadly crash

Fri Oct 25, 2019 4:05 pm

Revelation wrote:
One outcome: Xtra's repair station certificate was yanked by the FAA:

https://twitter.com/jonostrower/status/ ... 9826110464


That's been reported by Reuters, too.

https://www.reuters.com/article/us-xtra ... X41OB?il=0

The U.S. Federal Aviation Administration (FAA) on Friday revoked the repair certification of Florida-based Xtra Aerospace LLC, which fixed a sensor suspected of contributing to the catastrophic crash of a Lion Air 737 MAX a year ago.

"Xtra failed to comply with requirements to repair only aircraft parts on list of parts acceptable to the FAA that it was capable of repairing," the FAA said, which had opened an investigation soon after the October 2018 crash.
 
morrisond
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Re: Updated: Final report of Lion Air JT610 has been released

Fri Oct 25, 2019 5:57 pm

It's revealing after the report has been released how quiet it's gotten in here.

These are my main three takeaways in regards to the pilots actions:


#1 The Pilot did not review the issues from the Previous Flight - that is a huge No-no. If he had he probably would have had the knowledge that would have saved everyone on board.

#2 The Co-Pilot was cited as basically being incompetent and did not even have a mastery over the basics of Manual flight (did not know how to even use Manual Electric Trim properly) therefore should not have even be licensed as a pilot but kept getting passes through the Lion Air system.

#3 While the Pilot missed the review of the previous flight and showed relatively okay skills in the cockpit - it's one thing to look at the traces and see him counteracting MCAS activation 22 times - it's another thing to read about it in the timeline and say - why the hell didn't he throw the switches?

Then you read in the detailed CVR transcript that he admitted having the flu - which makes the fact he missed it 22 times and didn't brief his co-pilot properly on handover more understandable - but there is no way in hell he should have been in a cockpit. The Flu would have made him functionally impaired and possibly no better than drunk off his ass.

It's an incredibly detailed report - but after reading it you still think the pilots actions were not egregiously bad - symptomatic of a very broken training system I don't know what to say.

Boeing is still the root cause - but neither of those pilots should have been in that cockpit that day.
 
ikramerica
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Joined: Mon May 23, 2005 9:33 am

Re: Updated: Final report of Lion Air JT610 has been released

Fri Oct 25, 2019 6:12 pm

morrisond wrote:
It's revealing after the report has been released how quiet it's gotten in here.

These are my main three takeaways in regards to the pilots actions:


#1 The Pilot did not review the issues from the Previous Flight - that is a huge No-no. If he had he probably would have had the knowledge that would have saved everyone on board.

#2 The Co-Pilot was cited as basically being incompetent and did not even have a mastery over the basics of Manual flight (did not know how to even use Manual Electric Trim properly) therefore should not have even be licensed as a pilot but kept getting passes through the Lion Air system.

#3 While the Pilot missed the review of the previous flight and showed relatively okay skills in the cockpit - it's one thing to look at the traces and see him counteracting MCAS activation 22 times - it's another thing to read about it in the timeline and say - why the hell didn't he throw the switches?

Then you read in the detailed CVR transcript that he admitted having the flu - which makes the fact he missed it 22 times and didn't brief his co-pilot properly on handover more understandable - but there is no way in hell he should have been in a cockpit. The Flu would have made him functionally impaired and possibly no better than drunk off his ass.

It's an incredibly detailed report - but after reading it you still think the pilots actions were not egregiously bad - symptomatic of a very broken training system I don't know what to say.

Boeing is still the root cause - but neither of those pilots should have been in that cockpit that day.

I’m recovering from a bad flu and I still feel nervous driving a car. I have to pay extra attention to everything. But luckily I can pull over if something goes wrong.

As for the incompetent FO, it’s symptomatic of a fast growing, low cost company of any type.
Of all the things to worry about... the Wookie has no pants.

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