Aviators understand that aircraft accidents seldom occur because of a single misstep in the human or technological chain. They usually occur when a flight crew is overwhelmed by multiple human or technological failures within a short time span.
NTSC Issues Final Report on Last Fall’s Lion Air Accident
Key Takeaways:
- The crash of Lion Air flight 610 was attributed to a complex interplay of multiple human and technological failures, rather than a single misstep.
- The primary technical culprit was the 737 Max's MCAS software, which was triggered by faulty data from a misaligned angle of attack indicator installed by Lion Air maintenance.
- The report highlighted significant institutional failures at Boeing, including design flaws and inadequate safety analyses, as well as insufficient oversight by the FAA.
- Both the accident flight crew and the crew of the preceding flight also contributed through failures in observing conflicting instrument data, coordinating during the emergency, and reporting critical warnings.
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