An Indonesian investigation has found a Lion Air flight that crashed and killed 189 people a year ago was doomed by a combination of aircraft design flaws, inadequate training and maintenance problems.
A final accident report released on Friday said Lion Air flight 610, from Indonesia’s capital Jakarta to the island of Sumatra, crashed because the pilots were never told how to quickly respond to malfunctions of the Boeing 737 Max 8 jet’s automated flight-control system.
The jet plunged into the Java Sea just 13 minutes after its take-off on October 29 2018.
Indonesia’s National Transportation Safety Committee said the automated system, known as MCAS, relied on a single “angle of attack” sensor that provided erroneous information, automatically shoving the nose of the Max jet down.
The report also identified various missteps prior to the crash.
The aircraft, only in use for two months, had problems on its last four flights, including one the day before its fatal accident.
The Indonesian report followed another last month from US federal accident investigators who concluded that Boeing and the Federal Aviation Administration underestimated how a blizzard of visual and auditory warnings would slow pilots’ ability to respond quickly enough to avert crashes.
Just five months after the Indonesian crash, the same kind of malfunction caused a Max jet to crash in Ethiopia, killing all 157 people on board.
That led to the grounding of all 737 Max jets and put Boeing under intense pressure to explain problems associated with the MCAS system.
The aircraft still has not resumed flying.
Boeing recently reported its third-quarter earnings dropped 51% to 1.17 billion dollars in part because it added 900 million dollars more in costs for the Max.
Boeing issued a statement after the release of the final report on the accident.
Boeing’s president and chief executive Dennis Muilenburg said the company is addressing the committee’s safety recommendations and working to enhance the safety of the 737 Max jet “to prevent the flight control conditions that occurred in the accident from ever happening again”.
Mr Muilenburg said the aircraft and its software are receiving “an unprecedented level of global regulatory oversight, testing and analysis. This includes hundreds of simulator sessions and test flights, regulatory analysis of thousands of documents, reviews by regulators and independent experts and extensive certification requirements.”