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Death Due to a Lack of Diligence

KNKT Report: Lion Air JT 610 Crash Report Lays Blame on Poor Maintenance and Faulty Boeing Design

As reported by The Jakarta Globe, the preliminary report from the National Transportation Safety Committee (KNKT) on the crash of Lion Air JT610 on October 29, 2018, states that the aircraft was not-airworthy with the problem causing the crash reported on earlier flights, including the flight on the night immediately preceding the crash.

The report issued on Wednesday, November 28, 2018, mentioned in detail maintenance protocols at Lion Air and pilot training issues that led to the crash that killed 189 passengers and crew.

The last words spoken by the Captain of the Boeing 737-MAX 8 jet was when he reported “five thou” or 5,000 feet as he struggled with “flight control problems” that sent the airplane into a steep, high sped dive culminating in a devastating crash in the ocean northeast of Jakarta, only 13 minutes after departing Soekarno-Hatta Airport in Cengkareng en route to Pangkal Pinang in Bangka, Belitung.

Reports paint a picture in which the pilots’ control stick shook violently suggesting the plane was in an imminent stall condition despite being in a nose-down high speed dive - the very opposite condition of an imminent stall. The pilot responded by trying to raise the nose by pulling back on the wheel, while a computerized system fought him and was pushing the nose down increasing its perilous descent towards the ocean.

The KNKT report said that a flight one day earlier from Denpasar, Bali to Jakarta using the same aircraft reported similar malfunctions during which the pilot disengaged automated systems in order to maintain control over the aircraft's attitude.

Quoting from the reports: "The flight from Denpasar to Jakarta experienced stick shaker activation during the takeoff rotation and remained active throughout the flight. This condition is considered as un-airworthy condition and the flight should have been discontinued.”

Despite the fact that the mechanical problems were reported upon landing to Lion Air’s maintenance team, the Airplane was nonetheless cleared to be flown the following day. That maintenance team reportedly reviewed the malfunction before declaring the aircraft safe and ready for another flight. 

The KNKT report stopped short of blaming the crash on either the pilot or maintenance crew.

Boeing is insisting that procedures to countermand the anti-stall system were in place and were used by the pilot on the penultimate flight of the doomed aircraft. It is not clear if the pilot of the doomed flight took the steps to override the stall system or knew of the design fault and any remedial steps.

Both US and Indonesian pilots have been critical of Boeing's claim, saying the aircraft manufacturer failed to issue revised instruction for the anti-stall system.

Meanwhile, some of the surviving families of the Lion Air flight have filed legal suit in the USA against Boeing Corporation.

The KNKT report has made a number of recommendations for suggested improvements on safety to Lion Air and Boeing.  Some of these recommendations have already been implemented by Boeing in ther operating manuals.

KNKT indicated that the review of the air crash is still in its early days and has yet to determine what, if any, role the defective anti-stall system played in the air tragedy.

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