Air
Safety
Reports
and details
Lion Air 737 MAX
Findings Released
of recent
incidents.
On October 22, 2019, a Boeing 737
MAX 8 destined for China Southern
Airlines touched down at Grant County
International Airport, joining 157 other
examples at the New Mexico facility.
B-20CT (c/n 65251) became the 300th
MAX aircraft to be stored pending
delivery once the type is recertificated.
While an unfortunate milestone, it was
a mere footnote in what was a week
to forget for the Seattle manufacturer
as it continues to plod through its
annus horribilis. That same day, Kevin
McAllister was the first executive head
to roll as part of the ongoing MAX saga.
The Boeing Commercial Airplanes
CEO was ousted and immediately
replaced with Stan Deal, the former
Boeing Services chief executive.
Three days later, with the first
anniversary of Lion Air flight
610 looming, the final report into the
October 29, 2018 accident was released
by the Komite Nasional Keselamatan
Transportasi (Indonesian National
Transport Safety Committee, KNKT).
The ill-fated Boeing 737 MAX 8,
PK-LQP (c/n 43000), was rostered to
operate a service between Jakarta’s
Soekarno-Hatta International and
Depati Amir Airport, Pangkal Pinang
with 181 passengers and eight crew on
board. The aircraft began its take-off
roll two minutes later, lifting off from
Runway 25L at 06.20.33. As the nose
landing gear lifted from the runway, the
88 AIRLINER WORLD JANUARY 2020
left column stick shaker – a warning
device that alerts the crew when the “We commend
aircraft is close to a wing stall condition Indonesia’s National
– activated and continued for most Transportation Safety
of the flight.
The MAX 8’s Digital Flight Data
Committee for its
Recorder (DFDR) noted a difference extensive efforts to
between the left and right angle of determine the facts
attack sensor readings of around 21°, of this accident, the
which continued until the end of the
recording. The first officer (FO) advised contributing factors
the captain of an indicated airspeed to its cause and
(IAS) disagreement 11 seconds after the recommendations
aircraft rotated – the DFDR recorded
the left IAS as 164kts and the right IAS
aimed toward our
as 173kts. A message regarding this common goal that this
discrepancy was displayed on the first never happens again…”
officer’s primary flight display (PFD) Boeing president and CEO
until the end of the flight. At 06.21.28, Dennis Muilenburg
the captain’s PFD indicated an altitude
of 790ft, while the FO’s system
displayed 1,040ft. Discrepancies in the
airliner’s height also continued – 15
seconds later the FO’s unit advised it
was 230ft higher than the 1,310ft shown
on the captain’s PFD. At 06.21.52, the
FO requested clearance to a holding
point in order to better diagnose the
“flight control problem” he reported
to the Terminal East controller.
However, the controller did not
acknowledge the request.
Over the next four minutes, the crew
attempted to reach and maintain
5,000ft. However, on two occasions
the aircraft descended at rates of

up to 3,750 feet per minute (fpm)
and 3,200fpm respectively. The FO
requested the controller to provide a
speed as indicated on the radar display
and was given a ground speed of
322kts, differing from the 306kts and
322kts shown on the left- and right-
hand PFDs respectively. At 06.24.43,
the DFDR recorded the altimeter on the
captain’s PFD indicated 5,310 feet and
the FO’s PFD suggested 5,570 feet with
a rate of climb of about 460fpm.
The aircraft’s Maneuvering
Characteristics Augmentation System
(MCAS) activated on 25 occasions
between 06.25.27 and 06.32.20, at
which time it disappeared from radar.
The three-month-old airliner crashed
into the Java Sea, close to the town of
Karawang, with the loss of all onboard.
Three days prior to the crash, the jet
had operated LNI2748 from Tianjin,
China, to Manado, during which
issues were recorded in the aircraft’s
flight maintenance log. The pilot had
detailed that speed and altitude flags
had appeared on his PFD rather than
normal airspeed and altitude indication.
An engineer in Manado, Indonesia,
completed the required checks, with
the aircraft passing the self-test and
being released back into service. The
same warnings appeared on the
left-hand PFD on three flights on
October 27-28 with ‘SPEED TRIM’ and
‘MACH TRIM’ lights illuminated on the
second and third rotations. The aircraft
was again withdrawn from schedules
and a replacement angle-of-attack
sensor – later found to be miscalibrated
– was fitted. Pilots subsequently saw a
20° difference between PFD values.
DATE REG'N C/N TYPE
Oct 26 C-GBTU 209 De Havilland Canada DHC-3T Turbine Otter
Oct 27 YI-BYO UNK Aircraft Industries (formerly Let Kunovice) L-410UVP
Nov 11 N619AE 145101 Embraer ERJ145
Nov 21 TC-AEH 284 Gulfstream G150
Nov 22 YV3012 23990 Boeing 737-400
Nov 24 9S-GNH 8030 Dornier 228-200
Air
Safety
Reports
and details
of recent
incidents.
In its findings, the Indonesian again… We are addressing the KNKT’s
authorities cited design, pilot error and safety recommendations and taking
Lion Air’s maintenance of the aircraft as actions to enhance the safety of the
contributing factors. Regarding MCAS, 737 MAX to prevent the flight control
it stated: “the investigation considered conditions that occurred in this accident
that the design and certification of this from ever happening again.”
feature was inadequate.” (Photos KNKT, Boeing, Flickr Creative
According to the KNKT: “The lack of Commons/Ikko Haidar Farozy)
MCAS information in the FCOM [flight
crew operations manual] and flight
crew training resulted in it being more
difficult for the flight crew to diagnose
the problem and find the corrective
procedure to solve it. Without prior
awareness of the MCAS function, it
would be more difficult for the flight
crew to understand the problem. It
would take them longer to understand
the situation and come to the correct
solution, putting them at a higher risk
than necessary.”
The report also found that: “Lion Air
manuals [were] not updated in a timely
manner and the content [had] several
inconsistencies, incompleteness,
and unsynchronised procedures.” It
continued: “The duration of hazard
identification topic on the SMS [safety
management systems] training syllabus
was insufficient. This may reduce the
ability of employees to define and
report a hazard.”
Responding to the Indonesian
authority’s report, Boeing president
and CEO Dennis Muilenburg said in a
statement: “We commend Indonesia’s
National Transportation Safety
Committee for its extensive efforts to
determine the facts of this accident, the
contributing factors to its cause and
recommendations aimed toward our
common goal that this never happens
OPERATOR FATALITIES LOCATION NOTES
Blue Water Aviation Services 3 Canada Crashed into lake
Abeer Air Services 0 South Sudan Forced landing
Envoy Air (opf American Eagle) 2 Brazil Crashed in mountainous terrain
Tahe Havacılık 0 Ukraine Nosegear broke away on landing
Avior – Aviones de Oriente 0 Colombia Right-hand gear collapse on landing
Busy Bee Congo 29 Democratic Republic of Congo Crashed into buildings after take-off (ten on ground killed)
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