Lion Air Flight 610

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Lion Air Flight 610
Lion Air Boeing 737-MAX8; @CGK 2018 (31333957778) .jpg

Accident machine PK-LQP
Accident summary
Accident type System or component failure (SCF)
place Western Java Sea Indonesia 5 ° 46 ′ 15 "  S , 107 ° 7 ′ 16"  E Coordinates: 5 ° 46 ′ 15 "  S , 107 ° 7 ′ 16"  E
IndonesiaIndonesia 
date October 29, 2018
Fatalities 189
Survivors 0
Aircraft
Aircraft type Boeing 737 MAX 8
operator Lion Air
Departure airport Jakarta / Soekarno-Hatta , Indonesia
IndonesiaIndonesia 
Destination airport Pangkal Pinang , Indonesia
IndonesiaIndonesia 
Passengers 181
crew 8th
Lists of aviation accidents

Lion Air flight 610 (flight number JT610) was a domestic flight of the Indonesian low-cost airline Lion Air from Soekarno-Hatta Airport in Jakarta to Depati Amir Airport in Pangkal Pinang , on which the machine was on October 29, 2018 shortly after take-off at 6:20 am pm local time (00:20 CET ) crashed . All 189 inmates were killed. Wreckage of the aircraft was found in the sea off the island of Java .

plane

The machine was a new Boeing 737 MAX 8 with the aircraft registration number PK-LQP , delivered from the factory on August 13, 2018 , which had been transferred to Indonesia two months before the crash and had completed around 800 flight hours before the accident. It had a seating configuration that offered 180 people.

Victim

In addition to the two pilots, there were six flight attendants and 181 passengers on board, including three children. The captain had 6,000 hours of flight experience , the copilot 5,000 hours. The passengers included 20 employees of the Indonesian Ministry of Finance, ten employees of the Indonesian Court of Auditors, seven members of a regional parliament, three judges of the Indonesian Supreme Court, three employees of the Indonesian Ministry of Energy and Natural Resources and an employee of the state electricity company PLN. Among the victims were two foreign nationals, including former Italian professional cyclist Andrea Manfredi .

nationality Passengers crew total
IndiaIndia India 0 1 1
IndonesiaIndonesia Indonesia 180 7th 187
ItalyItaly Italy 1 0 1
total 181 8th 189

Course of events

Flight history

Flight route

The aircraft took off at 6:20 a.m. local time (11:20 p.m.  UTC ) and was scheduled to land in Pangkal Pinang at 7:20 a.m. local time (00:20 a.m. UTC). It took off in a westerly direction and then turned in a northeastern direction, which it maintained until it plunged into the sea at around 6:33 a.m. local time (11:33 p.m. UTC) northeast of Jakarta. The crash site is about 34 nautical miles off the coast of the Karawang Regency . The Java Sea has a water depth of up to 35 m at the crash site.

Altitude and speed profile in the course of the flight

Publicly available data from Automatic Dependent Surveillance (ADS-B, a system for displaying flight movements in the airspace) shows that the aircraft at an altitude of approximately 2100  feet (700 m) and within approximately 5000 feet (1700 m) made several steep, irregular descents for six minutes. The last of these descent (and crash) took about a minute.

particularities

The radio signals from the emergency beacon were not received, which is why the crash was initially not known to the Indonesian national search and rescue authority. The reason may be that the buoy did not stay on the surface of the water.

Less than a day before the crash, the aircraft reported an unspecified technical problem, which, however, did not result in the take-off ban. Incorrect or uneven speed and altitude data of the ADS-B had already been observed. However, the data had stabilized after eight minutes. According to the media, this only happened when a pilot flying as a passenger deactivated the automatic trim system.

During the flight involved in the accident, the pilots requested a return to the airport.

Accident investigation

The rescue of the flight data recorder (FDR) was reported on November 1, 2018 . The voice recorder (CVR) was recovered on Monday, January 14, 2019 at around 9:00 a.m. local time in about 30 meters water depth in 8 meters deep mud, about 50 meters from the point where the flight data recorder was recovered. The ultrasonic locating signal from the CVR- ULB was still being sent 73 days after the crash, albeit weaker. On January 19, 2019, it was reported that 124 minutes of good quality audio could be downloaded from the CVR.

On 7 November 2018, the Federal Aviation Authority published FAA due to the first results a Airworthiness with extreme urgency (emergency airworthiness directive, AD) for the Boeing models 737 MAX 8 and MAX 9, prompting the aircraft operators, aircraft manuals of the relevant To update models within three days according to the safety bulletin published by Boeing . As a result of the instruction, Boeing published a security bulletin in which attention is drawn to the handling of incorrect data from the angle of attack sensor.

The role of novel on-board systems

In a broader sense, the urgent airworthiness instruction relates to the Maneuvering Characteristics Augmentation System (MCAS), which is intended to recognize and correct critical flight situations in the MAX series of the Boeing 737; among other things, it obtains the data from the angle of attack sensor. MCAS became necessary because the enlarged engine housings, which have been moved forward, generate strong lift at high angles of attack. This lift created in front of the wing's center of gravity also causes a moment that pulls the aircraft's nose upwards. This means that the control behavior is different from that of the 737-NG series ("Next Generation") . The MCAS intervenes in the flight control by automatically adjusting the trim of the horizontal stabilizer and pushing the nose down without the pilot having to do anything. In this way it protects against a stall if the angle of attack is too high. It is only active when the landing flaps are retracted and during manual flight. (Extended flaps shift the center of lift to the rear, which dampens the effect of the engine casing being shifted forwards.) If the autopilot is active, there is sufficient protection against difficult flight situations; however, the autopilot fails as a protective measure and cannot be switched on again if sensors provide inconsistent measurement data.

Although the MCAS intervenes directly in the flight control, Boeing had deliberately concealed the existence of the system - and its possible malfunctions - in order to simplify the retraining of the NG pilots on the MAX series. According to pilots, MCAS wasn't even mentioned in the manuals.

In addition, in all previous 737 versions, the electrical trimming of the horizontal stabilizer - regardless of whether it causes the aircraft nose to be raised or lowered - always stops as soon as the pilot gives the opposite command with the control stick. However, this is not the case with MCAS, because - as long as it detects a critical flight situation and no manual opposite trimming is carried out via switches on the control horn - it still leads to lower nose commands to the tail trim. If the pilot has no knowledge of MCAS, the flight behavior of the Boeing 737MAX is in direct contradiction to its training content. It is believed that this confusion prevented problem resolution on Flight 610. The effect of the MCAS can be blocked using the runaway trim procedure - see the airworthiness instructions - but the MCAS remains active in the background and tries to intervene again later. If the procedure is followed, however, there is no longer any protection against critical flight situations. A pilot who expects the flight behavior of an NG version based on his training and experience could then be overwhelmed.

The US aviation authority FAA has ordered an investigation into these developments; it deals with the safety analyzes of Boeing engineers, with the retraining of the pilots and with how the FAA can appropriately test and approve the electronic components installed by the manufacturer. Some of the questions are why MCAS only uses the data from one of the two angle of attack sensors (lack of redundancy and plausibility check), and how Boeing was able to certify the aircraft type - because the possible failure of MCAS directly worsens the stability of the aircraft, and must the flaps are extended to improve stability, this in turn limits the range of the aircraft, which can be a problem with ETOPS authorizations. Another complication is this: Switching off an on-board system in the event of unexpected flight behavior can be life-saving. However, a system that ensures the required flight stability must not simply be deactivatable - and in critical flight situations (for example shortly after take-off, at low altitude) there is no time to consider whether an active on-board system is now endangering safety or not. The basic assumption behind all on-board systems is that they work correctly. If you deviate from this, dangers arise from the higher workload of the crews.

A general aspect of the accident is the advanced automation of modern airliners to the point where the pilots are overwhelmed in the increasingly rare exceptional situations, even if the automation has made air traffic overall safer - for example EGPWS , which is known as CFIT - Has greatly reduced accidents. It should also be emphasized that the Boeing 737, due to its history (first flight in 1967), is not designed for electronic fly-by-wire control, which makes the integration of flight envelope protection systems such as MCAS more difficult. In contrast, the much younger Boeing 777 and Airbus 320 were designed for the use of such systems.

According to Spiegel Online, the airline had requested flight simulator training for its pilots before using the machine. Boeing employees successfully tried to dissuade the airline from this idea. Retraining of older models would not be planned and necessary. Training on a flight simulator would not have been of any use in this specific case either, since the Boeing flight simulator software did not take the MCAS function into account at all. The flight simulator software was only upgraded after the crash. In internal e-mails at Boeing, Boeing employees described the desire for simulator training for pilots of the 737 Max as an idiotic idea.

Interim report, November 2018

During the previous flight, the pilots had determined that two malfunctions had occurred: The captain then made two entries in the Aircraft Flight & Maintenance Log (book) on the page with the number B3042855. For the first item, IAS and ALT Disagree shown after Take Off were entered. FEEL DIFF PRESS LT ILL (Feel Differential Pressure Light Illuminated) was entered as a second separate complaint . This light indicates that a malfunction has occurred in the system, which changes the manual operation of the elevators depending on flight altitude and airspeed . In simple terms, the greater the altitude (altitude) and the velocity (airspeed), the higher the required force for operating the elevator, which by the action of so-called elevator feel and centering unit to the control wheel (engl. Control Column ) is intentionally .

On both sides of the aircraft are air pressure sensors - the one hand, pitot tubes ( pitot tubes ) which is the raw, uncorrected airspeed (engl. IAS for " I ndicated A ir S peed" ) measured and the static probes ( Static ports ) which is the raw, Register uncorrected altitude ( " Alt itude" ). The measurements of the left and right sides contradicted each other, which impaired the function of the on-board systems. The pilots worked through the checklist; landing soon was not recommended. In addition to other steps, they deactivated the automatic trimming of the horizontal stabilizer and flew on without any problems.

After landing, aircraft mechanics went on troubleshooting and checked some systems. They did not find any disruptions to prevent operations and therefore considered the aircraft to be airworthy.

On the accident flight ( "AOA sensor, engl. Speak, the two angle sensors A ngle o f A ttack ") values with a difference of 20 °. The automatic tailplane trimming continued until the crash and was temporarily interrupted when the pilots extended the landing flaps. The pilots were able to stop the descent initiated by on-board systems and gain altitude again 26 times.

Seattle Times report

The journalist Dominic Gates wrote in an article for the Seattle Times that due to the high time pressure - Airbus was just developing the Model 320neo - Boeing had urged the FAA in 2015 to carry out some safety analyzes themselves, including this one for the aforementioned MCAS system. The horizontal tail unit on the Boeing 737 can trim down by a maximum of 5 °; and the documents that Boeing had sent to the FAA say that MCAS only trims down 0.6 ° with each activation. Test flights showed, however, that MCAS should trim down by 2.5 ° in order to be sufficiently effective - and with this limit the MAX-8 aircraft were ultimately delivered without the FAA being notified of this change. MCAS was thus able to trim the tail unit up to the maximum 5 ° with just two successive activations.

According to the FAA document AC 25.1309-1A "Systems Design and Analysis", malfunctions of MCAS in a critical flight situation were classified as "hazardous failure", a classification between "major failure" (all occupants survive) and "catastrophic failure" (aircraft is irretrievably lost, most of the inmates are killed). If the failure of an on-board system means a "major failure", a redundant, fail-safe design is not yet required. Although MCAS represents a more critical on-board system according to this classification, it only obtained the angle of attack data from a single sensor.

JATR report

After the two crashes of Lion Air 610 and Ethiopian Airlines 302, the FAA, NASA , EASA and various national aviation authorities formed a committee, the Joint Authorities Technical Review . The report of the committee, which focuses on the on-board systems of the 737 MAX-8 and MAX-9, recommends, among other things:

  • Engineers employed by the manufacturer who work on aircraft systems should be able to contact FAA experts without fear of disadvantages.
  • Aircraft manufacturers should hire specialists who are independent of all design processes. You should work impartially and check the aircraft and on-board systems and their design for safety deficiencies.
  • Aircraft systems should be analyzed holistically and not fragmented. In the case of new or changed systems, all effects on all other on-board systems should be clarified.
  • The decision as to which on-board systems are described in which way in the manuals (Airplane Flight Manual, Flight Crew Operation Manual, Flight Crew Training Manual) should be justified and documented.

Final report

The final report was published on October 26, 2019. As in many aircraft accidents, this one also happened through a chain of errors:

An incorrectly working angle of attack sensor activated MCAS as soon as the landing flaps were retracted. MCAS led to control commands that overwhelmed the pilots until they finally lost control of the aircraft.

The following causes of the accident were identified:

Boeing
  • Possible malfunctions of MCAS were classified as major failure (see above), which did not require a rigorous clarification of possible sources of error and malfunctions - in contrast to the appropriate classification as hazardous or even catastrophic failure . As a result, it was decided that MCAS should only obtain data from one angle of attack sensor instead of two (lack of redundancy ).
  • Boeing found that the incorrect activation of MCAS could initially be counteracted effectively with the elevator alone. It was also assumed that in the event of an MCAS malfunction, the crew could react appropriately within three seconds and trim the horizontal stabilizer, even while maintaining the flight path. The possibility that the crew will only take off the horizontal stabilizer with a delay was not taken into account.
  • During the tests in the flight simulator, the possibility that MCAS would use the full 2.5 ° trim per activation was never run through. The workload caused by multiple triggering of MCAS was also not adequately considered.
  • During the last phase of the flight, the aircraft lost altitude and could no longer be controlled. The force required to pull the control horn exceeded 100 lbs (45.4 kg). A maximum of 75 lbs (34 kg) is allowed.
  • The pull on the control horn stops the lower nose trim of the tail unit in all aircraft, which was not the case with the 737 MAX 8. This had contributed to the confusion of the pilots.
  • Boeing did not fully inform the FAA of changes to the onboard systems, which may have prevented the timely detection of the problematic design.
  • Boeing followed the instructions in the aforementioned document AC 25.1309-1A. However, the aircraft manufacturer assumed that the crew would always act correctly in an emergency, which is not realistic. Possible incorrect reactions by the pilots must be integrated into the safety analysis of the on-board systems. However, MCAS and its possible malfunctions were never explained to the pilots, which made a false reaction by the crew likely.
  • The aircraft had two angle of attack sensors. The system, which shows deviating angle of attack values, was not installed as standard. This could have indicated the faulty sensor (see below).
Lion Air and their crews
  • After the flight from Manado to Denpasar (Flight 43, October 28), the aircraft should have been taken out of service because the automatic thrust control failed at takeoff; this is due to a very likely malfunction of the altitude and speed measurement. The aircraft accident investigation authority, which should have been involved, was not notified.
  • When the angle of attack sensor was reinstalled, it was misaligned by 21 °. However, this should have been noticed in tests; the test results were not documented.
  • Prior to flight 610, the issues encountered on the previous flight were not discussed.
  • On the flight involved in the accident, the pilots did not describe the problem in a clear manner (see Crew Resource Management ). The captain did not ask the first officer to counter the trim by MCAS with a separate, opposite trim. The tasks were not divided up in a meaningful way.
  • The captain was suffering from the flu ; the first officer received poor reviews during his training. It took him four minutes to find the relevant pages in the checklist.
Xtra Aerospace (USA)
  • The seller of the angle of attack sensor had not calibrated it correctly. There was no written procedure to be able to calibrate the sensor correctly and without errors.

context

It was the first total loss of a Boeing 737 MAX 8 since the introduction of this type in 2017.

The accident exceeds the number of victims on Air India Express flight 812 in 2010. This is the worst, most casualty incident involving a Boeing 737 - the best-selling type of passenger aircraft in the world.

It is the worst accident in Lion Air history and the airline's second fatal accident after 25 people were killed in a 2004 runway accident involving a McDonnell Douglas MD-82 . The incident is also Indonesia's second worst aviation disaster after the accident on Garuda Indonesia flight 152 .

Ethiopian Airlines Flight 302

During the investigation into the crash, a Boeing 737 MAX 8 crashed again on March 10, 2019. An Ethiopian Airlines plane crashed shortly after taking off from Addis Ababa, killing all 157 occupants. The course of the accident was similar to that of Flight 610, which gave the aviation authorities of numerous countries the reason for a flight ban (Engl .: Grounding) for aircraft of the type Boeing 737 MAX 8 or all 737 MAX variants. The reasons for this were similar, extraordinary fluctuations in the rate of climb and descent, in both cases an almost vertical fall at high speed and the trimming of the horizontal stabilizer on the wreck.

literature

  • Rainer W. During: FliegerRevue , Volume 67, No. 2/2019, pp. 12-14

Web links

Commons : Lion Air Flight 610  - Collection of Pictures, Videos and Audio Files

Similar incidents

Individual evidence

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  2. ^ Lion Air flight crashes in Indonesia (English) . In: Sydney Morning Herald , October 29, 2018. 
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  4. ↑ a b Euan McKirdy: Lion Air flight crashes en route from Jakarta to Pangkal Pinang . In: CNN , October 28, 2018. Retrieved October 29, 2018. 
  5. ↑ a b c Lion Air plane carrying 188 on board crashes into sea shortly after take-off from Jakarta (English) . In: The Straits Times , October 29, 2018. 
  6. ↑ Passenger plane crashed in Indonesia at: orf.at on October 29, 2018
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  9. ↑ 4 Nama Anggota DPRD Bangka Belitung di Manifes Lion Air JT-610 (Indonesian) , Kumparan News. October 29, 2018. 
  10. ^ Andi Saputra: Tiga Hakim Ada di Pesawat Lion Air yang Jatuh, MA Berduka (Indonesian) , Detik News. October 29, 2018. 
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  17. ↑ Divers rescue flight recorder , tagesschau.de, November 1st
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  27. ↑ Before the 737 Max crashes, Boeing employees made fun of the desire for simulator training
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