Families of the 157 people who were killed when Ethiopian Airlines flight 302 crashed a year ago this week are memorializing their loved ones. A report by the Ethiopian government blames Boeing, specifically its dangerous design of the 737 MAX and the lack of adequate training provided to pilots. The Federal Democratic Republic of Ethiopia Ministry of Transport Aircraft Accident Investigation Bureau published a preliminary report of its year-long investigation of the crash, although the agency noted that its investigation continues and it will issue a final report later this year.
“We’ve watched Boeing’s lies unravel on a very public stage for over a year now,” said Beasley Allen’s Mike Andrews who focuses much of his practice on aviation litigation and currently represents families of Ethiopian Airlines flight 302 victims. “While the findings are not surprising, it is important to remember lives were needlessly taken, families changed forever and the lynch pin of this debacle was the corruption and culture of deception generated within Boeing and fostered by the FAA.”
The planes have been grounded since the Ethiopian crash. It was the second of two deadly crashes. The first crash, Lion Air flight 610, suffered similar problems that caused a parallel sequence of events leading to the deadly outcome of both flights.
The Ethiopian investigators’ report noted “[t]here were no known technical problems before departure.” It also noted that the weight and balance of the aircraft were within operating limits and that “takeoff roll and lift-off was normal, including normal values of left and right angle-of-attack (AOA).”
The problem began shortly after lift-off when the left and right AOA data began to differ. The faulty readings erroneously activated the MCAS, which was a new feature of the aircraft’s flight control system.
The MCAS was incorporated into the newest 737 design to address aerodynamic problems created by changes in the aircraft’s design – heavier engines moved closer to the aircraft’s nose. Those changes could push the aircraft’s nose too high, causing it to stall. The MCAS was incorporated to help push the nose back down in those instances. However, conditions that triggered the malfunction or the uncommanded nose-down scenario were never properly tested or addressed before the MAX was approved for service, the report explained. Further, the MCAS was designed to be hidden and separate from the autopilot system. Pilots were never made aware of the system, contributing to their difficulty in handling the challenges it created during the flight.
The Ethiopian report explained that the MCAS activated four times during the short flight. The pilots, just like those operating the doomed Lion Air flight, began a tug-of-war with the MCAS trying to regain control of the plane. Through a flood of alerts and warnings triggered by the uncommanded aircraft nose-down scenario, the pilots initially followed Boeing’s protocol for handling such an MCAS occurrence. They turned off the system but could not slow the plane’s speed, which was necessary for the next step in the protocol – manually trim the stabilizer. Manually trimming the stabilizer required the pilots to turn a wheel that would change the position of the tail stabilizer, allowing the nose to point up once again without reactivating the MCAS. According to the report, the speed placed too much pressure on the wheel, making it nearly impossible for one person to operate it correctly. Since the crew couldn’t get the aircraft to climb by using the manual trim procedure, they were forced to turn on the system back again. They were still unable to regain control of the plane before it crashed.
The investigators reported that in the last MCAS activation “the pitch angle dropped from 0.5 degrees to -7.8 degrees and the descent rate increased from -100 ft/min to -5,000 ft/min.” Further, it said that “despite recorded forces of up to 180 lbs., the pitch continued decreasing” while “[t]he descent rate and the airspeed continued increasing.”
These preliminary findings echo those of other inquiries involving both the Ethiopian Airlines and the Lion Air crashes. The Indonesian National Transportation Safety Committee and the National Transportation Safety Board (NTSB) issued similar findings last fall after the Lion Air crash investigation. At that time, the NTSB issued seven safety recommendations regarding its findings throughout the investigations of the crashes as it worked with the governments of Indonesia and Ethiopia. In addition to their recommendations, Ethiopian investigators adopted the NTSB’s recommendation ASR-19-10. The recommendation addresses improved MAX pilot training to accurately recognize and respond to flight deck alerts and indications, as well as improve training to “minimize the potential for and safety impact of pilot actions that are inconsistent with manufacturer assumptions.”
Additional recommendations from Ethiopian investigators include:
- The design of MCAS should consider the use of data from both AOA and/or other independent systems for redundancy.
- The regulator shall confirm all probable causes of failure have been considered during functional hazard assessment.
- The manufacturer shall insure sic the minimum operational speed computed by the SMYD to be within logical value. There should also be logic to validate the computation.
- The difference training should also include simulator sessions to familiarize with normal and non-normal MCAS operation. The training simulators need to be capable of simulating AOA failure scenarios.
- The manufacturer should confirm the AOA DISAGREE alert is functional whether the optional angle of attack indicator is installed or not.
Beasley Allen lawyer Mike Andrews focuses much of his practice on aviation litigation and currently represents families of Ethiopian Airlines flight 302 victims. In addition to his Ethiopian Airlines crash clients, Mike has represented people seriously injured in a variety of aviation crashes, and the families of those killed in both civilian and military airplane crashes and helicopter crashes.
Ethiopian Government (The Federal Democratic Republic of Ethiopia Ministry of Transport Aircraft Accident Investigation Bureau)
National Transportation Safety Board