Indonesian Investigators Release Final Report on Lion Air Crash

Boeing 737 MAX 8 (PK-LQP) at Soekarno–Hatta International Airport in September 2018, a month before it crashed off the Indonesian coast with the loss of 189 passengers and crew. (PK-REN)

And the news is not good for Boeing, though there are no blockbuster new revelations. The 737 MAX saga continues to be a story of lax FAA regulation, pressure to get the plane certified, a lack of coordination on Boeing’s part between divisions, and reliance on a single sensor to make MCAS do its thing. But the report also shares some blame to the flight crew. It notes a captain who was sick with the flu, a first officer who was awoken at 4:00 am to fill in and was shown to be deficient in piloting skills and unable to recall procedures that should have been memorized. The captain failed to understand exactly what was happening, though a lack of training on MCAS, and no mention of it in the manuals, surely added to his confusion. Blame is also placed on Lion Air maintenance personnel who cleared the plane to fly, and the Florida company who serviced the failed sensors.

I think the report highlights that the 737 MAX debacle has plenty of blame to spread around. Recent articles have tried to place at least equal blame on the flight crew, and admittedly, it took the first officer a full four minutes to locate a checklist while the pilot fought with MCAS. But I believe that the lion’s share of blame must be placed on Boeing, who designed a single-point of failure system and either neglected to tell regulators about it or outright covered it up. Blame must also be laid on the FAA who allowed the fox to guard the henhouse and left much of the regulatory oversight to Boeing, who cut corners and pressured engineers to get the MAX in the air as soon as possible in the face of mounting competition from Airbus.


For Boeing’s part, they have rewritten the software that drives MCAS to make it much less aggressive. The system also takes into account information from more than one sensor, and optional warning lights that would have alerted the crew to a disagreement between sensors has been made standard. The manuals have been updated, training has been augmented, and there shouldn’t be a single 737 pilot in the world who won’t know how to turn MCAS off. When the MAX carries passengers again (ferry and test flights have been ongoing for months now), it should be as safe as any airliner in the skies. However, this sort of rigorous testing and training should have taken place routinely long before the MAX was ever cleared to fly. It shouldn’t have taken 346 deaths to get to this point.

The Seattle Times article is a good read. They have some of the best reporting on aviation in general, and Boeing specifically.

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