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 primarily caused by the Boeing 737 Max's Maneuvering Characteristics Augmentation System (MCAS), which was triggered by faulty data from a newly installed, misaligned angle of attack indicator.
- Boeing received strong criticism for institutional failures, including flawed MCAS design and certification processes, inadequate safety analyses, and failing to implement critical alerts like the "AoA Disagree" alert.
- Lion Air and its crews also contributed to the accident through maintenance errors (installing the faulty sensor), a prior flight crew's failure to report critical warnings, and the accident crew's failure to notice conflicting instrument readings and communication issues amidst numerous cockpit alerts.
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