What The Lion Air Report Tells Us About MAX, Crew And Maintenance Errors
Boeing
This is an abbreviated version of the 1,600 word Aviation Daily article 'Lion Air Report Implicates MAX, Details Crew, Maintenance Errors'.
The final report on last year’s Lion Air Flight 610 (JT610) 737 MAX 8 accident concluded that inherent flaws in the aircraft’s flight control system set the stage for the crash and provides new details on both flight-crew and maintenance errors that played roles in the accident.
Indonesia’s National Transportation Safety Committee (NTSC) listed nine contributing factors in the accident sequence—eight of which cite Boeing's and FAA's work developing and approving the MAX, including the aircraft’s maneuvering characteristics augmentation system (MCAS) flight-control law. The ninth cites how the pilots managed the unfolding scenario, triggered by an incorrectly maintained angle-of-attack sensor that fed faulty data to the flight-control computer, which activated the MCAS.
JT610’s crew faced immediate difficulties when they departed Jakarta on Oct. 29, 2018, operating PK-LQP, a three-month-old 737 MAX 8. The left-side angle-of-attack (AOA) vane, replaced the day before, was not correctly calibrated—an issue investigators said was “most likely” due to errors at Florida-based repair station Xtra Aerospace. Xtra supplied an AOA sensor that was installed on PK-LQP the previous day.
Find out what else went wrong at the start of the flight in the full article here.
About 10 min. into the 11-min. flight, the captain transferred control of the aircraft to the first officer (FO). The MCAS—still receiving faulty AOA data—continued to activate, leading to a final, fatal dive into the Java Sea.
Investigators found multiple indications of deficiencies in the FO’s training records, including “difficulties to control aircraft during manual flight” on a 2016 ILS approach proficiency check, and “application exercise for stall recovery is difficult due to wrong concept of the basic principal for stall recovery in high or low level” during a 2017 observation.
Poor communication exacerbated the situation on JT610’s flight deck. When transferring control to the FO, the captain did not discuss the difficulty controlling the aircraft or the need for repeated nose-up trim inputs.
The JT610 crew did not refer to the runaway-stabilizer checklist or toggle center pedestal-mounted cutout switches that would have stopped the automatic stabilizer movements. Boeing assumed an uncommanded MCAS activation would be quickly diagnosed as runaway stabilizer, leading pilots to use the cutout switches. The report noted that Boeing’s assumptions were wrong.
Discover the other details provided by investigators on a series of maintenance-related errors that contributed to the accident in the full article.
The operational issues magnified numerous problems with the MAX’s design and certification, investigators said. The NTSC’s report includes a series of recommendations. Among them, it urged the FAA to reviews of assumptions of how pilots will react to non-normal situations; how the agency delegates certification tasks to manufacturers; and that “Boeing include a larger tolerance in the design is required [sic] to allow operability by a larger population of flight-rated pilots.”
The 385-aircraft MAX fleet has been grounded since mid-March, shortly after the crash of Ethiopian Airlines Flight 302, also a 737-8. Investigators quickly drew links between the two accidents, leading to the grounding. Boeing is nearing completion of modified MAX flight-control software that address the MCAS-related issues. It also is updating manuals and training to include the MCAS.
Meanwhile, the FAA on Oct. 25 announced that it reached a settlement agreement with Xtra that includes revoking the company’s repair station certificate. “Xtra failed to comply with requirements to repair only aircraft parts on its list of parts acceptable to the FAA that it was capable of repairing,” the agency said. “The company also failed to comply with procedures in its repair station manual for implementing a capability list in accordance with the Federal Aviation Regulations.”
Ingen kommentarer:
Legg inn en kommentar
Merk: Bare medlemmer av denne bloggen kan legge inn en kommentar.