mandag 12. november 2018

Lion Air

Airlines to be ordered to follow Boeing safety advice after Lion Air tragedy

Fatal Lion Air crash of 737 Max off Indonesian coast spurs Federal Aviation Authority to enforce bulletin directive on how to handle false cockpit readings


Indonesian rescuers sort recovered debris of Lion Air flight JT610 before loading onto a truck for investigation by the National Transportation Safety Committee at Tanjung Priok port in Jakarta, Indonesia, 02 November 2018. Lion Air flight JT-610 lost contact with air traffic controllers soon after takeoff then crashed into the sea on 29 October. The flight was en route to Pangkal Pinang, and reportedly had 189 people onboard. EPA/MAST IRHAM

US aviation regulators plan to order airlines to follow Boeing's advisory on how pilots should handle false readings from a plane sensor that authorities linked to last week's deadly 737 Max jet crash off the coast of Indonesia.

The Boeing bulletin combined with statements by Indonesian investigators suggest that the pilots on the Lion Air 737 Max 8 were battling the plane as its computers commanded a steep dive. The issue is easily solved - Boeing's notice said crews should follow an existing procedure to combat it - but can be difficult to address if pilots become confused.

The so called angle-of-attack sensor failed on Lion Air Flight 610 and had been replaced the previous day after earlier faults, the Indonesia National Transportation Safety Committee said in a briefing. The malfunction can cause the plane's computers to erroneously register an aerodynamic stall, causing the aircraft to abruptly dive to regain the airspeed it needs to keep flying.

The US Federal Aviation Administration (FAA) last week said it would issue an airworthiness directive on the issue and "will take further appropriate actions depending on the results of the investigation". The FAA also notified regulatory counterparts around the world, which typically follow the US agency's lead on safety matters.

The Boeing bulletin only reminds operators of the plane to follow existing procedures and doesn't require any physical fixes that could disrupt service. It's still possible the FAA may order the Chicago-based plane maker to redesign the Max's flight computers in the wake of the October 29 accident, which left 189 people dead.

The Lion Air jetliner plunged into the Java Sea minutes after takeoff from Jakarta airport, nosing downward so suddenly that it may have hit speeds of 950kph before slamming into the water, Bloomberg said.

Moments earlier, the pilots radioed a request to return to Jakarta to land, but never turned back toward the airport, according to Indonesia's National Transportation Safety Committee and flight-tracking data. The committee said the pilots were dealing with an erroneous airspeed indication.

Boeing said it is cooperating fully and providing technical assistance as the investigation continues.

Indonesia authorities said on Saturday they had stopped the search for victims of the crash but would keep looking for the Lion Air flight's second black box, the cockpit voice recorder.

"There is nowhere left to search and we have stopped finding victims' bodies," Muhammad Syaugi, the head of the national search and rescue agency (Basarnas) told Reuters. "We will limit our operations to monitoring."

Authorities have downloaded data from one of the black boxes found last week, the flight data recorder, but are still looking for the cockpit voice recorder.

Soearjanto Tjahjono, the head of the transportation safety committee (KNKT), said finding the voice recorder would be critical to understanding the cause of the crash.

"From the black box data, we know about 70 to 80 per cent of what happened but to 100 per cent understand the cause of the accident ... we need be able to know the conversation that took place in the plane's cockpit," he said, declining to elaborate on what the flight data recorder had revealed.

He said authorities were searching for 15 aircraft parts, including an "angle of attack" sensor on the aircraft, which helps the plane's computers understand if the aircraft is stable. Investigators have said one of these sensors had provided erroneous data.

An wrong angle-of-attack reading while pilots are flying manually can cause the plane's flight computers to command the Max models to dive, Boeing said in the bulletin to airlines. While planes like the Max fly mostly on autopilot, pilots can fly manually if they're dealing with unusual situations like the malfunctions that occurred on the Lion Air flight.

Pilots can override the nose-down movement by pushing a switch on their control yoke, but the plane's computers will resume trying to dive as soon as they release the switch, the manufacturer said.

Pilots should follow a separate procedure to halt the potentially dangerous action by the plane, the bulletin said. Flight crews are taught to handle "uncommanded nose-down stabiliser trim" by memorising a procedure to disengage the angle-of-attack inputs to the plane's computer system.

That angle-of-attack sensor is intended to measure the direction of air flow over wings so that they maintain lift. If the flow is disrupted by a plane going too slow or climbing too steeply, that can cause an aerodynamic stall and a plane will plummet. However, if the sensor malfunctions, it can cause the plane's computers to erroneously think it is in a stall - which can then command the aircraft to abruptly dive.

The jet reported a discrepancy in its angle of attack sensor during a flight from Bali to Jakarta the day before it crashed. The device was replaced after pilots reported a problem with the airspeed reading, the Indonesian transportation safety regulator said on Wednesday.


A Lion Air passenger jet was flying from Jakarta to an island off Sumatra when it crashed into the sea.

Boeing has delivered 219 Max planes - the latest and most advanced 737 jets - since the models made their commercial debut last year with a Lion Air subsidiary. Boeing has more than 4,500 orders for the airliners, which feature larger engines, more aerodynamic wings and an upgraded cockpit with larger glass displays. The single-aisle family is Boeing's biggest source of profit.

Aircraft and engine manufacturers routinely send bulletins to air carriers noting safety measures and maintenance actions they should take, most of them relatively routine. But the urgency of a fatal accident can trigger a flurry of such notices.

After an engine on a Southwest Airlines plane fractured earlier this year over Pennsylvania, killing a passenger, CFM International issued multiple bulletins to operators of its CFM56-7B power plants.

Aviation regulators such as the US FAA and the European Aviation Safety Agency often follow such actions by mandating that carriers follow the bulletins.

Pilots raise and lower the nose of Boeing jetliners by pushing and pulling on a yoke in the cockpit, which controls panels at the tail known as elevators. In addition, a system known as pitch trim can be changed to prompt nose-up or nose-down movement.

The angle of attack readings are fed into a computer that in some cases will attempt to push down the nose using the pitch trim system. In the early days of the jet age, the pitch trim system was linked to several accidents. If pilots aren't careful, they can cause severe nose-down trim settings that make it impossible to level a plane.

Such an issue arose in 2016 at Rostov-on-Don Airport in Russia when a FlyDubai 737-800 nosed over and slammed into the runway at a steep angle, according to an interim report by Russian investigators. That case didn't involve the angle-of-attack system. One of the pilots had trimmed the plane to push the nose down while trying to climb after aborting a landing, the report said. All 62 people on board died.

Lion Air's latest crisis illustrates the challenge relatively new carriers face as they try to keep pace with unstoppable demand for air travel in developing nations while striving for standards that mature markets took decades to reach.

Retired air force chief of staff Chappy Hakim, an adviser to the transport ministry, said he avoided flying with Lion Air or other Indonesian airlines, with the exception of Garuda, which has not had a fatal crash since 2007.

"I know Garuda," he said of the national carrier. "The other airlines, I don't believe they do the maintenance and training properly." He declined to elaborate further.

Lion Air managing director Daniel Putut disputed any laxity in the airline's safety culture, stressing that it conducted maintenance in accordance with manufacturer guidelines.

The Directorate General of Civil Aviation, the Indonesian aviation authority, did not respond to multiple requests for comment about Lion Air's safety record.




Deadly Lion Air Crash Puts Spotlight on Safety Culture Within Indonesia's Airlines


In April 2013, a Lion Air Boeing 737 missed the runway on the Indonesian resort island of Bali in bad weather and plowed into the sea, cracking its fuselage open on the rocks.

All 108 on board survived. But a September 2014 report by Indonesia's air crash investigators highlighted errors and poor training, saying the 24-year-old co-pilot had failed to adhere to the "basic principles of jet aircraft flying."

Lion Air, struggling to get off a European Union blacklist because of "unaddressed safety concerns," asked Airbus, which supplies part of its fleet, to help improve training.

The EU removed the privately owned budget airline from the list in 2016 after it determined Lion Air met international safety standards. None of Indonesia's roughly 100 airlines - most of them tiny - remain on the EU blacklist, with the last few coming off in June. All were banned in 2007; the national carrier, Garuda Indonesia, was the first to be removed in 2009.

The crash of a Lion Air jet on Oct. 29 into the sea off Jakarta has put a spotlight back on the airline's safety record, although the cause remains undetermined. None of the aircraft's 189 passengers and crew survived.

Lion Air's latest crisis illustrates the challenge relatively new carriers face as they try to keep pace with unstoppable demand for air travel in developing nations while striving for standards that mature markets took decades to reach.

Retired air force chief of staff Chappy Hakim, an adviser to the transport ministry, told Reuters he avoided flying with Lion Air or other Indonesian airlines, with the exception of Garuda, which has not had a fatal crash since 2007.

"I know Garuda," he said of the national carrier. "The other airlines, I don't believe they do the maintenance and training properly." He declined to elaborate further.

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Lion Air Managing Director Daniel Putut disputed any laxity in the airline's safety culture, stressing that it conducted maintenance in accordance with manufacturer guidelines.

The Directorate General of Civil Aviation, the Indonesian aviation authority, did not respond to multiple requests for comment about Lion Air's safety record.

Putut, a former pilot, also told Reuters during a visit to the airline's training center near the Jakarta airport that it complied with all regulatory requirements.

He said Lion Air had worked hard to install an attitude of "zero tolerance" for accidents after the Bali crash, making last week's disaster a painful eye-opener. Thousands of Lion Air flights have taken off and landed without serious incident since then.

"We are also looking into what went wrong - new aircraft, experienced crews, and we have applied the zero-tolerance culture, yet another accident happened," Putut said. "But we still don't know the cause, so we will wait for the investigation from NTSC (National Transportation Safety Committee)."

Safety Culture
Frank Caron, head of a risk consulting firm who served as Lion Air's safety manager from 2009 to 2011 after insurance companies requested a foreign expert, said that at the time he was troubled by what he regarded as the airline's attitude that accidents were inevitable.

"Safety is much more than running concepts and procedures," he said. "Safety is a spirit, a state of mind, a way of thinking, an attitude in the daily aspects of an operational life. And that is precisely what Lion never got. They would say, 'The airline has 250 flights a day, it is not abnormal that you have accidents.'"

For example, after the 2013 Bali crash, Lion Air co-founder Rusdi Kirana told local media who asked about the airline's safety record: "If we are seen to have many accidents, it's because of our frequency of flights."

Caron claimed he left Lion Air after some of his safety recommendations were not implemented. Lion Air's chief executive declined to comment on Caron's account of his departure or his other assertions.

Indonesian accident investigators made four recommendations after the Bali crash, including that Lion Air should "ensure that all pilots must be competent in hand flying" and teach proper cockpit coordination.

They also urged the aviation authority to ensure all airlines under its control did the same.

Putut said Lion Air embraced those recommendations.

Between the Bali crash and the one last week, Lion Air had three non-fatal accidents, including one in April in which a 737 skidded off a runway, according to Flight Safety Foundation's Aviation Safety Network database.

Since it began operating 18 years ago, Lion Air has seen a total of eight planes damaged beyond repair in accidents, two of which killed a combined 214 people, according to the Aviation Safety Network database.

During the same period, five jets from its chief rival, the national carrier Garuda Indonesia, were damaged beyond repair, and two accidents killed a combined 22 people, according to the database. Garuda declined to comment about its safety record.

Since the 2013 Bali crash, Lion Air has sought to improve safety by gaining European Aviation Safety Agency (EASA) certification for its pilot training and maintenance facilities.

EASA certifies its training center to instruct other airlines' pilots on A320 simulators and is seeking the same approvals for 737 jets and ATR72 turboprops, said Audy L Punuh, Lion Air's Angkasa Pilot Training Organisation Director.

Rapid Growth
Lion Air has expanded quickly since it started flying in 2000, overtaking national carrier Garuda by capturing more than half of the domestic market and establishing offshoots in Thailand and Malaysia.

It has ridden a wave of aviation growth in Indonesia, where air travel has become critical for the economy.

Domestic air traffic more than tripled in Indonesia over the past decade as prosperity and low fares made flying affordable for more people.

With 129 million passengers in 2017, the Southeast Asian country was already the world's 10th-largest aviation market and is projected to continue growing.

That growth has been accompanied by an air-accident rate that was twice the global average in 2017 and consistently higher than Indonesia's neighbors in the Association of Southeast Asian Nations, according to the United Nations' aviation agency.

Indonesian pilots are allowed to fly a maximum of 110 hours a month, which is more than the 100 hours in most other countries.

Last year seven commercial planes were damaged beyond repair around the world, according to Boeing data; two were in Indonesia, wrecked in non-fatal accidents involving Sriwijaya Air and Tri M.G. Airlines.

Latest Crash
Flight JT610 took off from Jakarta at 6:20 a.m. on Oct. 29, bound for Bangka island, off Sumatra, and plunged into the sea 13 minutes later. Just before the crash, the pilot asked to return to the airport.

The aircraft flew erratically on its previous flight and its airspeed readings were unreliable, according to an accident investigator and a flight tracking website.

Investigators on Monday said the flight data recorder from the downed jet showed an airspeed indicator had been damaged during its final four flights, raising questions about maintenance and mechanical problems.

Boeing said on Wednesday it had issued a bulletin to airlines reminding pilots about what it described as existing procedures for handling erroneous data from sensors.

The Federal Aviation Administration later issued a directive calling for revisions to "operating procedures of the airplane flight manual."

It is too early for regulators to decide whether to reconsider the decision to remove Lion Air from the EU blacklist, EU Ambassador to Indonesia Vincent Guerend told Reuters.

"The European Commission continues to monitor the situation on a regular basis," he said. "It is still too early to have any conclusive views on the causes of the accident."



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