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Air Transport Digest

French, U.S. Investigators: Ethiopian 737 MAX Accident Report Downplays Human Factors Issues

Sean Broderick January 04, 2023

Credit: Jemal Countess/Getty Images

The Ethiopian Airplane Accident Investigation Bureau (EAAIB) final report on the March 2019 fatal Boeing 737 MAX accident that triggered the model’s global grounding leans on erroneous information in analyzing how the pilots reacted and does not dig deeply enough into pilot-performance issues, investigators from France and the U.S. said.

EAAIB’s report on Ethiopian Airlines Flight 302 (ET 302), released Dec. 23, sheds little new light on the 737 MAX saga. The agency concluded that faulty data from a broken angle of attack (AOA) sensor activated the aircraft’s automated maneuvering characteristics augmentation system (MCAS) that directed the horizontal stabilizer to repeatedly point the 737-8’s nose down, and the pilots did not maintain control. Ten contributing factors focus on flaws in MCAS’s design and Boeing’s incorrect conclusion that pilots would respond appropriately if the system activated erroneously, with one blaming Boeing for inadequate responses to questions raised following the first 737-8 fatal accident, Lion Air Flight 610, in October 2018.

France’s BEA and the U.S. NTSB generally agree with EAAIB’s analysis of MCAS’s role in the accident. But the 330-page report sheds little light on why the ET302 pilots were not better prepared for an MCAS-related malfunction, despite significant communication about the system—including how to counteract it—following the Lion Air accident. Both agencies contend that EAAIB’s lack of focus on flight deck human factors aspects paints an incomplete picture of the ET302 accident and, more importantly, short-changes broader efforts to improve pilot training and competency.