The NTSB is providing ongoing support under International Civil Aviation Organization Annex 13 to Indonesia’s Komite Nasional Keselamatan Transportasi (KNKT) investigation of the Oct. 29, 2018, crash of Lion Air flight 610 in the Java Sea and the Aircraft Accident Investigation Bureau of Ethiopia’s investigation of the crash of Ethiopian Airlines flight 302 near Ejere, Ethiopia.
Java Sea, Indonesia
On October 29, 2018, Lion Air flight 610, a Boeing 737 MAX 8, PK-LQP, crashed in the Java Sea shortly after takeoff from Soekarno-Hatta International Airport, Jakarta, Indonesia. The flight crew had communicated with air traffic control and indicated that they were having flight control and altitude issues before the airplane disappeared from radar. The flight was a scheduled domestic flight from Jakarta to Depati Amir Airport, Pangkal Pinang City, Bangka Belitung Islands Province, Indonesia. All 189 passengers and crew on board died, and the airplane was destroyed.
The Indonesia National Transportation Safety Committee (NTSC) has notified the NTSB of an accident involving a Boeing 737 that occurred on October 29, 2018. The NTSB has appointed a U.S. Accredited Representative to assist the NTSC's investigation under the provisions of ICAO Annex 13 as the State of Manufacture of the airplane.
All investigative information will be released by the NTSC.
Ejere, Ethiopia
On March 10, 2019, Ethiopian Airlines flight 302, a Boeing 737 MAX 8, Ethiopian registration ET-AVJ, crashed near Ejere, Ethiopia, shortly after takeoff from Addis Ababa Bole International Airport, Ethiopia. The flight was a scheduled international passenger flight from Addis Ababa to Jomo Kenyatta International Airport, Nairobi, Kenya. All 157 passengers and crew on board died, and the airplane was destroyed.
The government of Ethiopia has notified the NTSB of an accident involving a BOEING 737 that occurred on March 10, 2019. The NTSB has appointed a U.S. Accredited Representative to assist the government of Ethiopia's investigation under the provisions of ICAO Annex 13 as the State of Manufacturer of the airplane.
All investigative information will be released by the government of Ethiopia.
Related Information
ASR1901 - Safety Recommendation Report: Assumptions Used in the Safety Assessment Process and the Effects of Multiple Alerts and Indications on Pilot Performance
US Comments on Draft Aircraft Accident Investigation Report
As a result of these investigations, the National Transportation Safety Board makes the following new safety recommendations.
To the Federal Aviation Administration
- Require that Boeing (1) ensure that system safety assessments for the 737 MAX in which it assumed immediate and appropriate pilot corrective actions in response to uncommanded flight control inputs, from systems such as the Maneuvering Characteristics Augmentation System, consider the effect of all possible flight deck alerts and indications on pilot recognition and response; and (2) incorporate design enhancements (including flight deck alerts and indications), pilot procedures, and/or training requirements, where needed, to minimize the potential for and safety impact of pilot actions that are inconsistent with manufacturer assumptions. (A-19-10)
- Require that for all other US type-certificated transport-category airplanes, manufacturers (1) ensure that system safety assessments for which they assumed immediate and appropriate pilot corrective actions in response to uncommanded flight control inputs consider the effect of all possible flight deck alerts and indications on pilot recognition and response; and (2) incorporate design enhancements (including flight deck alerts and indications), pilot procedures, and/or training requirements, where needed, to minimize the potential for and safety impact of pilot actions that are inconsistent with manufacturer assumptions. (A-19-11)
- Notify other international regulators that certify transport-category airplane type designs (for example, the European Union Aviation Safety Agency, Transport Canada, the National Civil Aviation Agency-Brazil, the Civil Aviation Administration of China, and the Russian Federal Air Transport Agency) of Recommendation A-19-11 and encourage them to evaluate its relevance to their processes and address any changes, if applicable. (A-19-12)
- Develop robust tools and methods, with the input of industry and human factors experts, for use in validating assumptions about pilot recognition and response to safety-significant failure conditions as part of the design certification process. (A-19-13)
- Once the tools and methods have been developed as recommended in Recommendation A-19-13, revise existing Federal Aviation Administration (FAA) regulations and guidance to incorporate their use and documentation as part of the design certification process, including re-examining the validity of pilot recognition and response assumptions permitted in existing FAA guidance. (A-19-14)
- Develop design standards, with the input of industry and human factors experts, for aircraft system diagnostic tools that improve the prioritization and clarity of failure indications (direct and indirect) presented to pilots to improve the timeliness and effectiveness of their response. (A-19-15)
- Once the design standards have been developed as recommended in Recommendation A-19-15, require implementation of system diagnostic tools on transport-category aircraft to improve the timeliness and effectiveness of pilots’ response when multiple flight deck alerts and indications are present. (A-19-16)
