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 Lion Air flight 610 crash was attributed to multiple interacting human and technological failures, not a single cause, as detailed in the Indonesian NTSC report.
- The primary technical factor was the Boeing 737 Max's MCAS software, which was triggered by faulty data from a misaligned angle of attack indicator installed just prior to the accident flight.
- Boeing was faulted for design flaws in MCAS, inadequate safety analyses and oversight during its development, and failing to correct known software errors like the "AoA Disagree" alert.
- Lion Air personnel contributed through faulty maintenance (installing the misaligned sensor), a previous flight crew failing to report critical warnings, and the accident flight crew failing to notice significant instrument discrepancies and exhibiting poor coordination amidst numerous alerts.
Key takeaways sponsored by Aviator Pro | Start Your Training ->
See a mistake? Contact us.
