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 737 Max's MCAS software, activated by faulty data from a misaligned angle of attack indicator installed by Lion Air maintenance.
- Boeing faced significant criticism for institutional failures, inadequate MCAS design and certification processes, and not addressing known software flaws like the disabled "AoA Disagree" alert.
- Additional contributing factors included Lion Air's maintenance installing the faulty sensor, a preceding crew failing to report critical warnings from a prior flight, and the accident flight crew's inability to notice instrument discrepancies and effectively coordinate during the emergency.
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