Indonesia’s National Transportation Safety Committee has released the final report into the last year’s Lion Air Boeing 737 MAX 8 crash into the Java Sea which took the lives of 189 people.

The conclusions of the 353-page report point to a series of reasons, including Boeing’s failure in aircraft design, mistakes of the airline itself and poor qualification of the pilots.

“From what we know, there are nine things that contributed to this accident,” Indonesian air accident investigator Nurcahyo Utomo told reporters at a news conference. “If one of the nine hadn’t occurred, maybe the accident wouldn’t have occurred.”

The whole Boeing 737 MAX fleet was grounded in the aftermath of the second disaster involving 737 MAX aircraft, it was Ethiopian Airlines flight with 157 fatalities. The grounding should have taken place a way earlier, right after the Lion Air accident, or even earlier.

Deeper into the Findings

As it has been already mentioned, the accident was an accumulative result of many failures with even more what-ifs. First of all, maybe these 189 lives would have been saved if the aircraft which performed this fatal flight was grounded before the departure.

The issues related to certain technical errors were reported after some of the previous flights, however, inappropriate way of their record lead to irresponsible clearance for another flight without fixing the problems reported.

The flight, in turn, appeared to be the last for the aircraft that was built in 2018 and went into service just two months before crashing having only 800 hours of flight.

This responsibility falls on the airline, as it did not manage to control the maintenance process and adequately react to potential risks. Worth highlighting that the final document revealed 31 pages were missing from the plane’s maintenance log.

Of course, the report focused on the so many times discussed sensor which, according to the report, was not properly tested. Indonesian investigators identified issues with the plane’s Manoeuvring Characteristics Augmentation System – or MCAS, which repeatedly pushed the plane’s nose down, leaving pilots fighting for control.

That MCAS software was designed to help prevent the 737 MAX from stalling, however, the things went wrong, the other way than it was expected by Boeing.

“The investigation considered that the design and certification of this feature was inadequate,” the investigator’s summary of the report said. “The aircraft flight manual and flight crew training did not include information about MCAS.”

In response to the report, the planemaker said it was “taking actions to enhance the safety of the 737 MAX to prevent the flight control conditions that occurred in this accident from ever happening again”.

Although Indonesian investigators previously said mechanical and design problems were the key factors in the crash of the Lion Air 737 MAX, the final document found out some more key issues that contributed to the death of 189 people.

One of these is poor qualification of the first officer who struggled to run through a list of procedures as was barely familiar with it and had shown issues handling the aircraft during training.

Apart from that, the report pointed out that the captain had not briefed him properly when he handed over the controls as they struggled to keep the plane in the air.

As it follows, the accident was a chain of tragic events. There is no one person or one company to be blamed for it. The fault lies both with Lion Air and Boeing. The human factor is present here as well. The time will show what the report into the Ethiopian Airlines crash will bring to light.