Lion Air: Black box report faults Indonesian airline's safety measures in crash

Geraldine Edwards
November 29, 2018

"During (that) flight, the plane was experiencing a technical problem but the pilot made a decision to continue", Nurcahyo Utomo, aviation head at the National Transport Safety Committee, told reporters.

The report said that the plane was "automatically trimming" on the previous flight - that is, the computer was adjusting the aircraft's angle - so the pilots switched to manual trim and, as their safety checklists didn't recommend an emergency landing, they continued to Jakarta.

"This is the basis of our recommendation to Lion Air".

Pilots at American Airlines and Southwest Airlines complained this month that they had not been given all information about the new system on the MAX.

In a statement following release of the report, US-based Boeing declared that the MAX, its newest plane, is safe.

Parts of an engine of the ill-fated Lion Air flight JT 610 are recovered from the sea during search operations in the Java Sea. It is activated when angle of attack (AOA) sensors indicate that the airframe is in a dangerously high angle and attempts to correct it by pushing the plane nose down.

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Utomo said the agency had not determined if the anti-stall system, which was not explained to pilots in manuals, was a contributing factor.

Apart from the stick shaker, the pilot of the Denpasar flight noted several other warning signs that appeared on the flight display, including one concerning the difference in the indicated airspeed. The information can be critical in preventing an aircraft from stalling.

However, during flight JT610, the plane's automatic anti-stalling system repeatedly forced the plane's nose down, even when the plane was not stalling - possibly due to a faulty sensor.

The APA, a USA airline pilots union, said that carriers and pilots had not been informed by Boeing of certain changes in the aircraft control system installed on the new MAX variants of the 737. They were able to complete the flight and land the plane safely.

The tragedy was the first involving Boeing's latest model of the 737 series, 737 MAX, which entered service a year ago.

In response to initial findings from the jet's flight data recorder, Boeing issued a bulletin to airlines reiterating procedures and advising them to add information on MCAS to flight manuals, which was followed by a US Federal Aviation Administration directive making that mandatory.

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The report unveiled fresh details of efforts by pilots to steady the 737 MAX jet as they reported a "flight control problem", including the captain's last words to air traffic control asking to be cleared to "five thou" or 5,000 feet.

"There were four flights that experienced problems with the airspeed indicator", Tjahjono said. Jagged lines in graphs contained in a preliminary report crash investigators are preparing to release Wednesday show the airplane's nose being pushed down at least two dozen times, the pilots pulling it back up each time, before its final, fatal nose-dive into the Java Sea. "A lot" could be attained by investigators from the voice recorder, Utomo said.

The findings will heighten concerns there were problems with key systems in one of the world's newest and most advanced commercial passenger planes.

Members of the National Transportation Safety Committee lift a box containing the flight data recorder from a crashed Lion Air jet.

Boeing said Tuesday that it "continues to work closely with the U.S. National Transportation Safety Board as technical advisers to support the ongoing investigation" by the Indonesian authorities.

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