The deaths of 346 people would have been “avoidable” without the numerous design errors and the series of management and control irregularities during the development of the Boeing 737 Max also caused by the pressures caused by the competition from the Airbus A320neo. In a 245 page report published Wednesday after a year and a half of work, the US parliamentary commission of inquiry launches a harsh indictment against the aerospace giant and the FAA, the US federal regulator, on the latest generation aircraft involved in two accidents immediately after take-off, killing all passengers and staff on board.
The Boeing 737 Max del volo Lion Air 610 It took off from Jakarta, Indonesia on 29 October 2018 and sank as soon as it left the city, killing 189 people instantly. A few months later, on March 10, 2019, the dynamic is repeated with another aircraft of the same type when the volo Ethiopian Airlines 302 departed from Addis Ababa, Ethiopia, crashes to the ground (157 victims). It is at that point that within a few hours the local air transport safety authorities decide to stop the 737 Max which has not taken off with the passengers since then.
The debris of the 737 Max in Ethiopia
“Boeing failed in the design and development of the 737 Max and the FAA (the US federal aviation body, ed) did not play its role in Boeing’s oversight and certification of the aircraft, ”the report wrote. The parliamentary committee argues that the incidents “were not the result of a single failure, technical error or mismanaged event.” Worse still, those incidents “were the horrific culmination of a series of flawed technical assumptions by Boeing engineers, a lack of transparency from the company’s management and grossly insufficient oversight from the FAA.”
The role of “deep throats”
To arrive at today’s report, the commission browsed over 600,000 pages of documents requested from Boeing, FAA, airlines and other companies involved. During the investigation, several interviews were also carried out – in some cases actual interrogations – with dozens of Boeing and FAA employees. A crucial role was also played by the “deep throats” of both the aerospace giant and the regulatory body which, in addition to telling various details, also delivered emails that they considered important for the investigation.
The external sensor that supplied the data to the “Mcas” anti-stall system
The anti-stall system
The two incidents of 2018 and 2019 revolve around the role played by “Mcas”, the anti-stall computer system which, receiving information from a single external sensor, is able to bring the nose of the aircraft back to the right level. But on both flights that sensor received wrong data prompting the software to act accordingly and in a dangerous way by crashing the 737 Max shortly after takeoff. The pilots tried to react, but in the Lion Air flight they did not even know the existence of that anti-stall system, in the second case the “Mcas” required such physical strength that it would have been impossible for the pilots to bring up the nose.
“Crucial information omitted”
The document argues on this point that Boeing has made “incorrect design and performance assumptions”. Not only. Because the company has also “omitted crucial information” relating to the “Mcas” both to the FAA, and to customers and pilots. The very existence of the anti-stall system has not been included in the manuals for crews, thus convincing regulators not to require additional (and more expensive) simulator training for pilots to enable them to the 737 Max. to the FAA which according to the commission “has failed to ensure the safety of public transport”. The commission has proposed some reforms on certification procedures.
Last year the National transportation safety board (the body that investigates accidents in the transport sector, ed) explained that Boeing has “overestimated” the ability of pilots to handle a series of alarms during Mcas malfunctions. The company has introduced changes to the anti-stall system making it less powerful, giving pilots more control and the software more external data before being activated: all changes that are being considered these months as part of the re-certification procedures. of the aircraft. After the tests of the American regulators, in the past few days it was the turn of the Canadian and European colleagues in the skies of Canada.
Boeing replies to the report by claiming in a statement that it “cooperated fully from the start” and that it “learned many difficult lessons from the accidents and mistakes we made.” The company recalls having made “all the necessary measures to be able to return the 737 Max to flight safely”, having “changed the work of the engineers, giving them a more direct channel with top management (meanwhile changed, ed) to share their concerns “. From the FAA they let it be known that they intend to work “with the legislators to implement the improvements identified in the report”.
DOCUMENT: Read here the full investigation report of the US parliamentary commission (in English)
16 September 2020 (change September 16, 2020 | 16:21)
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