Lionair Flight 610 737 Max Crash

Lion Air flight 610 crashed on October 29, killing all 189 people on board. Also, one rescue diver involved in the recovery drowned.

Having flown in Jakarta, Indonesia before, I can comment on the challenges that airlines face there:

  1. hazy visibility due to the tropical location, with marine conditions over Jakarta Bay. Often no horizon, just grayness. Some airports, like Surabaya, are often unsafe due to standing water from torrential rains.
  2. as a nation of over 13,000 islands (“Tanah Air” or “Land and Water”) and 250+ million people, there’s a lot of flight operations. Lionair is one of the busiest airlines in the world
  3. English is not the pilots’ native language, making training more challenging, especially advanced systems training
  4. Indonesia is literally “the end of the world.” Getting and maintaining parts inventories is a challenge, resulting in parts cannibalization rather than flight cancellations (Lionair has a policy of “only full flights” so a cancellation is a big deal)
  5. even small planes carry a lot of pax

When you combine the above with an advanced, new aircraft type like the 737 MAX, you get an accident like this.

It appears that the AOA sensor was faulty, requiring disengagement of both the AP and the autothrottles to override, then manual flying using an AI indicator. Update 2018-11-13: Boeing appears to have made a change to the autopilot to push the nose down without documenting it for pilots, even with the autopilot disengaged. Possibly this was to increase the appearance of commonality, thus reducing training requirements.

The average North American airline pilot can easily handle this situation, as they have significant VFR pilotage and systems knowledge.

Fantastic presentations by American Airlines Training Captain Warren VanderBurgh:

  1. Levels of Flight Deck Automation and how to avoid task saturation, “Children of the Magenta” (1997)
  2. Control Malfunctions & Flight Instrument Anomalies (1997)
  3. CFIT – Advanced Aircraft Maneuvering Program (1997)
  4. Unusual Aircraft Recovery Procedures (1997)

aviationtoday.com: FAA Issues Boeing 737 AOA Directive After Lion Air Crash
avweb.com: Lion Air Investigation Continues
W: Boeing 737 MAX
pprune.org: Indonesian aircraft missing off Jakarta
ainonline.com: Indonesian Airlines Draw More Scrutiny in Wake of Latest Crash
Obituary: Captain Warren “Van” Vanderburgh
Revealed: The 21 ‘worst’ airlines in the world
Indonesian plane grounded after passengers complain about stinky durian
ainonline.com: Boeing Guidance on 737 Max Stall Protection System Under Fire
wsj.com: Boeing Withheld Information on 737 Model, According to Safety Experts and Others
cnn.com: Lion Air: Some are looking where to place the blame, others wonder if their pilot can fly their plane
ainonline.com: Report on Lion Air Flight 610 Raises More Questions

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