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The Probable Cause of the Lions Air and Ethiopian Air Crashes

Author:

Mike has a keen interest in aviation safety as his son is a 747-400 Captain for Atlas Air Cargo.

Wreckage

Wreckage

Disclaimer and Sources

This article is based on information from the following sources:

  • Wikipedia
  • The Seattle Times
  • Washington Post
  • The Air Current
  • A conversation I had with my son, who is a seasoned captain for Atlas Air Cargo and flies 747-400s to destinations around the world

This article is published prior to the FAA, NTSB, DOT, and FBI investigations having been completed. Every effort will be made to update this article to the latest information once those agencies have completed their investigations.

Factors That May Have Caused the Crashes

After doing my research and analysis, I have come to the conclusion that the following factors were at work to cause the Lion Airlines and Ethiopian Airlines to crash shortly after take-off:

  • The variations of the 737 airliner.
  • The FAA giving Boeing permission to approve and certify the airworthiness of their own design modifications.
  • The failure of the MCAS system.
  • The airline industry's lack of sufficient training for pilots, because time is money.

The Variations of the 737 Airliner

In the late 1960s, the Boeing 737-100 was rolled out as a narrow-body airliner that was intended for use as a regional carrier and to be competitive with other narrow-body aircraft manufactures of that time. It was not built to be used as a long-haul passenger carrier. But as the years passed, it was modified to haul more passengers and add more power, so it became the workhorse of many airliners around the world. The following are the model numbers of each of the variants:

737-100, 200, 300, 400, 500, 600, 700, 800, 900, MAX -8, 9, 10.

As one can see, there have been many variations of the same basic aircraft design. The 737-100 fuselage length is 94 feet; the fuselage length of the MAX 10 is 143.7 feet. That is a difference of almost 50 feet. Of course, with all that increase in length, it means that more passengers could be accommodated as well. The -100 has a maximum passenger capacity of 85, while the MAX -10 has a maximum capacity of 188 passengers.

More powerful engines were also added as it was modified to handle the longer fuselage and passenger weight. The MAX series has much bigger engines than the other variants, so they mounted the bigger engines forward from where the early variants were mounted and increased the landing gear strut height as well.

The Maneuvering Characteristics Augmentation System (MCAS)

Boeing was concerned the additional weight and bigger engines, changes the center of gravity of the airplane and under certain conditions it could stall. So, they designed what they thought would be a fail system that would take over at the instant the airplane started to stall and automatically push the nose down by moving the horizontal elevator down, causing the tail to pitch up and the nose to move down. The system is designed to operate without the crew knowing that it is activated and to behave with the same flight characteristics as the 737-800 that they are familiar with.

How the MCAS system should work.

How the MCAS system should work.

MCAS Theory

The MCAS works on the input from two tiny wing like devices called Angle of Attack Sensors (AOS) mounted on both sides of the nose of the airplane.

Figure 1 shows If the airplane is sitting on the ground both of those sensors are supposed to be aligned with the wing and provide zero input to the MACS.

Figure 2 shows the airplane is in flight with the nose up, the sensor is supposed to indicate a positive angle of attack. If the angle of attack is too positive it will indicate a stall condition. (A stall is created when the nose of the airplane is so high that the wings have lost lift and the airplane has lost the ability to fly.)

Figure 3 shows the AOS sensor indicating a stall condition and the MCAS rotating the horizontal elevator to raise the tail and lower the nose of the airplane. If the AOS is sending faulty information to the MCAS, the system will go into a dive because it thinks the plane has stalled. I have found evidence that there is an override however, but it is very difficult to operate when the system fails as it will return control back to the MCAS every five seconds and cause a porpoising effect of the flight path.

The preliminary data from the flight data recorder of Lion Air indicates the AOS as being faulty. The AOS on the Ethiopian Air was supposed to have two AOS', but only one of them was providing input to the MCAS.

My son's experience during departure is the crew is very busy and that is when the MCAS takes over and tries to nose the plane down at a very high speed. The crew then has to figure out what when wrong at a low altitude and there is not enough time to recover from that steep high-speed, uncontrolled dive, thus resulting in disaster.

Lack of Training on MCAS

Because the MCAS system is integrated into the flight control systems and is autonomous, there is no pilot intervention required. Therefore, the reasoning is that only minimal pilot training is required to provide an overview of the system. Some airlines gave their pilots a one-hour overview on an iPad. Airlines like Southwest that uses the 737 series exclusively are always concerned about time and money for additional training, so they thought this was a great feature for the MAX series of 737s.

The Aftermath

The confluence of these factors at the same time may have caused the Lion Air and Ethiopian Air Disasters. This raises many questions:

  • Should the FAA allow aircraft manufactures to certify their own designs and modifications?
  • Should autonomous systems be integrated into aircraft without a means to override those systems?
  • Should more training be provided to crews who are responsible for the lives of their passengers and others?
  • Did Boeing try to hide the MCAS system from operators of the MAX series aircraft because they thought the operation would be foolproof?

The BP Oil Spill

The BP oil spill in the Gulf of Mexico was caused by the same lack of oversight and allowed the prime contractor to certify their own equipment and operations. It turns out the readings they reported were out of specification for safe operation of the rig and were the root cause of the blow-out of the rig. This is what happens when authorities who are responsible for the safety of others allow self-certification of equipment and processes.

Thanks for reading this article, and stay tuned as more information becomes available.

Update: March 22, 2019

Boeing has plans to modify the MCAS to receive inputs on both Angle of Attack Sensors and an indicator that will signal when the two sensor inputs are in disagreement. A digital display option will also be made available.

This content reflects the personal opinions of the author. It is accurate and true to the best of the author’s knowledge and should not be substituted for impartial fact or advice in legal, political, or personal matters.

© 2019 Mike Russo

Comments

bradmaster on July 07, 2019:

Mike

Yes, trying to beat Airbus outweighed the safety of the plane.

Mike Russo (author) from Placentia California on July 07, 2019:

Brad: I agree with you they should have an override control built into the MCAS. Boeing was trying to beat airbus to the market place. Time is money backfired on them.

Mike Russo (author) from Placentia California on July 07, 2019:

Jack: I agree with you. I think they pushed the envelope to its limits on the 737 air frame.

bradmaster on July 07, 2019:

It was apparently the new more powerful engine on the 737 Max that caused the nose to go up, and the need for the MCAS. The real problem was lack of training for the pilots, and that the system was invisible to the pilots, and wouldn't let the pilots in when MCAS was in control. Pilots were trained on IPADs and not real simulators.

Boeing cared more about their bottom line and not so much for the people, and they had zero sales of the Max after the two accidents. They do have some airline orders to be delivered in 2023.

Jack Lee from Yorktown NY on July 07, 2019:

I agree, it is taking too long for Boeing to respond to this crisis. That is why the stock has taken a dive. It has been over 4 months since accident. They should have been working on this since the first accident. Apparently, pilots have been complaining about the MAX for some times...

It is too late now but thinking back, the problem may have originated when they decided to modify an old successful plane and redesign it for another purpose. They should have created a new line called the 797 instead of the 737MAX...

Mike Russo (author) from Placentia California on July 07, 2019:

Hi Jack: Thanks for stopping by. I think the issue is the MCAS only had a single point of failure. It was only receiving inputs from on the angle of attack sensors. It they had used inputs from the other sensor, they could make a comparison. They are supposed to be working on that, but I don't know what is taking so long. It seems like a simple software fix.

Jack Lee from Yorktown NY on July 06, 2019:

Very informative. Thanks for the info. Before final conclusions are drawn, I cannot say for sure what was the cause of these crashed. From history, I do know automatic systems without human intervention is a bad idea. The Airbus had similar problems in the past and had to redesign their aircraft after serious crash.

Also, it was reported that Boeing made some of the safety features as optional items. It was up to the airlines to buy the extra features if they choose. This is another sore point with me. Any safety feature, no matter how minor, should be included in the base price of the plane. I can’t believe someone order a 100 million dollar plane and skipped over a safety feature for a small fraction of the total cost.

Bradmasteroccal on March 20, 2019:

Miebakagh

It was a good idea for Port Harcourt, sorry that politics is a problem. I am looking forward to reading your historical points.

Miebakagh Fiberesima from Port Harcourt, Rivers State, NIGERIA. on March 20, 2019:

Hello, Brad Masters, thanks for the quotation. But Port Harcourt, during the period, has experienced more than 27 killings due to the recent governorship election.

At the moment, I regret to say that does involve and their boys are prominent governors from the same ethnic group, the Ikweerres. Both governors are my facebook friends. They are fighting for the soul of the Rivers State. The statement should not be taken literally. It is more of doublespeak! Thank you.

Thank you for your interest in my Port Harcourt.

I am at present writing some historical cultural pieces that will culminate into this Port Harcourt.

Hello, Brad Masters, thanks for the quotation. But Port Harcourt, during the period, has experienced more than 27 killings due to the recent governorship election.

At the moment, I regret to say that does involve and their boys are prominent governors from the same ethnic group, the Ikweerres. Both governors are my facebook friends. They are fighting for the soul of the Rivers State. The statement should not be taken literally. It is more of doublespeak! Thank you.

I am at present writing some historical cultural pieces that will culminate into this Port Harcourt.

Thank you for your interest in my Port Harcourt.

Brad on March 20, 2019:

Miebakagh

Thanks again for your kind words.

I thought this was very interesting

"Port Harcourt, Nigeria. Friday, March 15, 2019 ... "Our goal is to make Rivers State a land of peace and prosperity with boundless opportunities and possibilities ..."

Miebakagh Fiberesima from Port Harcourt, Rivers State, NIGERIA. on March 20, 2019:

Hi, Brad Masters, I agreed. Mike is a professional in his right. The safety of every person onboard a plane is important. Life is precious. It should be protect always. Thanks again for weighing in. Have nice day.

Brad on March 19, 2019:

Miebakagh

You are welcome, but Mike did most of it.

I do agree the lives of all people that fly including the flight crew should get the best protection possible. That is why I don't understand why the FAA is not essential in ongoing investigations.

Miebakagh Fiberesima from Port Harcourt, Rivers State, NIGERIA. on March 19, 2019:

Hello, Mike, the link is noted.

Miebakagh Fiberesima from Port Harcourt, Rivers State, NIGERIA. on March 19, 2019:

Hello, Brad Masters, "If the lives of the passengers that will fly on the 737 are not important enough for the FAA to work on the fix under current guidelines then Congress needs to fix it.” Thank you for explaining that the government agency has to be there in order to do its work. This is the most important factor in any accident or faulty systems that can warrant a serious accident.

But the government agent being silent or looking the other way round amount to the negligence of duties. Thank you for employing your experiences to inform as well. Have a wonderful time.

Mike Russo (author) from Placentia California on March 19, 2019:

Brad: I just read this article which states there are two Angle of Attack sensors on the MAX series, but only one of them is used to provide input to the MCAS. That provides only a single point of failure with no redundant backup. The investigations in both crashes point to faulty input from the senor the single sensor input.

Here is the link to the article:

https://jalopnik.com/recent-boeing-737-max-crashes...

Brad on March 19, 2019:

Mike

Thanks for the info. I have found that working on government contracts, as well as commercial contracts that money and time to market have always been an issue. With most products that isn't a life or death issue, but aircraft that is a problem.

I understand the aerodynamics of what was described as what the software does, but I didn't understand why the software didn't know it was doing the wrong thing. Maybe giving back the controls to the pilot might not have saved the day.

What is also surprising is that the aircraft simulator programs have done all of the possible, or least known problem for aircraft flight. Maybe if the FAA and Boeing had a different relationship with each other, one of the two of them might have seen the problem. Maybe not singularly but asking questions. Many of the government agencies that govern industries are filled with workers from the same companies they are monitoring. You would have thought that some one what have at least asked the right questions about this feature. Also, one of the most important features of real time software, and firmware are the diagnostic programs to make sure that the hardware is functioning properly. Not that it was an issue, I don't know, but it checks the equipment.

Does your son have any insight to this particular problem?

Anyway, looking forward to any updates here.

Mike Russo (author) from Placentia California on March 19, 2019:

Brad: I asked my son, if Boeing would run any flight worthiness test on the MCAS system during its development. He said they probably would have, but if it is working properly, there would be no indication of a malfunction. I don't know how many changes they made to the software and whether they did regressive testing.

My son also said, Boeing and the airlines are always concerned about how time and money affects their bottom line. Boeing wants to beat their competition to the market place and the airlines want to incur as little cost as possible to changes in equipment. They make business decisions based on risk/reward ratios. In this case the risk was much higher than the reward.

Mike Russo (author) from Placentia California on March 19, 2019:

Brad: It was a surprise to me as well.

Brad on March 19, 2019:

Mike

Feel free to del any of my comments, as it is your article.

I am just voicing my opinion.

Brad on March 19, 2019:

Mike

Thanks for the update.

"Brad and Miebakagh: I talked to my son about the five week shutdown and the effect it had on the fix. He countered with, the Lion Air crash happened in October of last year. The evidence now shows both crashes were due to the same malfunction of the MCAS system.

B: Don't you think that Boeing could have been forth coming after the first crash, that they put a user hidden feature, and that there was no manual override. If the FAA knew about it, then that puts the FAA in the hot seat.

Bottom line, with automated systems for aircraft, and the 100 years of aircraft, and the experience of both the FAA and Boeing they would have found this flaw early on. Whenever that change to MCAS was made, their had to be at least Boeing engineers, and management involved in the risk. Yes, it is a nice feature when it works, but what about when it doesn't? That should have been a big decision when it was made. I would like to have congress look at those decisions and how they were made. Not to search for the guilty but to prevent these kind of results in the future, Not just the 737, not just Boeing but across all aircraft.

-------------------------------------

He also said the reason the FAA did not get involved is because of what is called a Type Rating Certification. The MAX series of 737's is supposed to have the same type of flight characteristics as the -800 aircraft. Therefore, it is the same Type Rating and does not require any further certification.

Boeing and the FAA reasoned if the MCAS was working properly, no one including the pilots would know about it and the Type Certification and very minimal training would have sufficed. But the MCAS malfunctioned and that is why it was exposed. Now we have to see what happens from this point forward."

B:

While I appreciate your son's input and I am impressed with his qualifications my further comment is about Boeing and the FAA. The FAA and Boeing reasoning was totally wrong, not that it malfunctioned but that they could justify it that way.

My point is that the FAA shouldn't be thinking is just reactive measures when accidents happen. Although this wasn't an accident, it was a design error that was going to happen at some point.

Quality has to be designed into a product, and Six Sigma and other defect management works best when the defect is found at its earliest time. In the MCAS, this seems to me that time was when someone at Boeing said, here is what where are going to do about MCAS. This is not Monday morning quarterbacking, it is just good design. It is one thing to have this be hidden from the pilot, but it is another thing when the MCAS doesn't recognize that it is going to crash, and it won't notify and release the control to the pilot. Do you think your son would agree with that.

These are my opinions, and the concern of a person that uses air travel.

---------------------------------------

Thanks and feel free to del for any reason, it is your article.

Brad on March 19, 2019:

Mike

Thanks for the comment.

BTW. I have worked on several defense project as a contractor, and while the government requires Defect management data, which has many names like zero defect, and Six Sigma they didn't seem to do it themselves, it was mainly for their vendors. .

The projects that I did for private companies put the defect management into the design process, That way it catches the defect whether is a manufacturing or programming process at its earliest time. I even worked on the Boeing 777, but only a tiny tiny part. They still used the government documentation and processes even though the 777 isn't military.

As I recall, any computer programming for aircraft is Class A and that is about the most stringent requirement for programming.

Finding out about the Boeing self monitoring was a surprise to me.

Mike Russo (author) from Placentia California on March 19, 2019:

Brad and Miebakagh: I talked to my son about the five week shutdown and the effect it had on the fix. He countered with, the Lion Air crash happened in October of last year. The evidence now shows both crashes were due to the same malfunction of the MCAS system.

He also said the reason the FAA did not get involved is because of what is called a Type Rating Certification. The MAX series of 737's is supposed to have the same type of flight characteristics as the -800 aircraft. Therefore, it is the same Type Rating and does not require any further certification.

Boeing and the FAA reasoned if the MCAS was working properly, no one including the pilots would know about it and the Type Certification and very minimal training would have sufficed. But the MCAS malfunctioned and that is why it was exposed. Now we have to see what happens from this point forward.

Mike Russo (author) from Placentia California on March 19, 2019:

Diane: I agree with you totally. Before I retired, I worked for Toshiba for 10 years. Every employee at our facility was required to take a quality program called Six Sigma training. It was a quality control program that strives to lower defects to one part in 1 million. The process was called DMAIC: Define the root cause of the problem; Measure it; Analyze it; Improve the process; and Control the process. It didn't matter if you were a secretary or an engineer, everybody was required to take the training.

Mike Russo (author) from Placentia California on March 19, 2019:

Brad: Yes, Congress should form a committee to investigate the process.

Brad on March 19, 2019:

Miebakagh Fiberesima

9 hours ago from Port Harcourt, Rivers State, NIGERIA.

"Hi, BradmmasterOCcal, does the crash warrant congress investigation? Is the takeoff from the American soil, or is it because the plane was en route to the United States? You may correct me where I am wrong. Many thanks."

I don't think that has anything to do with it. The plane is manufactured by Boeing, and the FAA is responsible for air safety. One of the main questions I have is why the FAA is not deemed essential workers when a government shutdown occurs. The FAA was in the process of working with Boeing on the fix, but it was delayed because they stopped during the government shutdown. If the lives of the passengers that will fly on the 737 are not important enough for the FAA to work on the fix under current guidelines then congress needs to fix it.

Most important is that the head of a government agency is not the agency. That means that the structure, the processes, the infrastructure is where the work is done. The head of the government agency is responsible for the agency, but if as in the case of the FAA one is not in place, the agency should run just as effectively without them.

The fact, that the top FAA job has been empty for 14 months is something the public needs to have the information to understand why it isn't filled. But it shouldn't have contributed to the delay of the 737 fix.

"Enforcement fines against major U.S. airlines have dropped 88% in the past two years, even as three-hour tarmac delays have more than doubled.""

This enforcement is also not a result of a missing top of the FAA, and congress should exercise their oversight committee to determine what is the root cause.

In addition, government agencies should do their job, and in the case of the 737 it seems to be a big mistake that the FAA allowed Boeing to do its self monitoring. That was the job of the FAA.

It is the same with the FDA, because they only see the data from the drug companies that they monitor. The FDA doesn't have its own testing facility to do their job. There have been many FDA approved drugs that were bad, and the proof is following all the lawsuits that resulted from it.

Thanks Miebakagh

G. Diane Nelson Trotter from Fontana on March 19, 2019:

Trust BUT definitely verify. When people are allowed to self-monitor, they often have the built in self assurance that they did it right the first time. Quality Assurance systems have a purpose that can save lives. I was a property systems auditor at General Motors Hughes for about 12 years and can attest, "Self-monitoring can have deadly consequences." Mixing business and personal relationships puts product assurance in jeopardy.

Miebakagh Fiberesima from Port Harcourt, Rivers State, NIGERIA. on March 19, 2019:

Hi, all contributing significantly to the discussion in any small way are welcomed. Have a great day.

Miebakagh Fiberesima from Port Harcourt, Rivers State, NIGERIA. on March 19, 2019:

Hello, Mike, it is well appreciated. Thanks.

Miebakagh Fiberesima from Port Harcourt, Rivers State, NIGERIA. on March 18, 2019:

Hi, BradmmasterOCcal, does the crash warrant congress investigation? Is the takeoff from the American soil, or is it because the plane was en route to the United States? You may correct me where I am wrong. Many thanks.

Brad on March 18, 2019:

Mike

Do you think that someone in congress should investigate the FAA to find out why?

just a thought.

Mike Russo (author) from Placentia California on March 18, 2019:

Brad: This is what the Wall Street Journal said about the top job at the FAA:

"The top job at the Federal Aviation Administration has been open for 14 months. Enforcement fines against major U.S. airlines have dropped 88% in the past two years, even as three-hour tarmac delays have more than doubled."

This could have a bearing on why the FAA did not do their job properly on the 737-MAX airworthiness tests.

Thanks for your comments

Mike Russo (author) from Placentia California on March 18, 2019:

Brad: Thank you for your comment.

Brad on March 18, 2019:

Mike

Aircraft systems used to require triple redundancy before fly by wire. And, if it is true that the program didn't allow user override when it put the nose down, that is an error in programming design. That is also why I am against total auto drive cars.

Brad on March 18, 2019:

Mike

You didn't like it when I kept telling you how bad the government was in doing their job.

This is a perfect example of it.

As well as allowing a government shutdown, to delay the fix for the aircraft. The FAA should always be deemed essential workers during the shutdown.

Aircraft systems used to require triple redundancy before fly by wire. And, if it is true that the program didn't allow user override when it put the nose down, that is an error in programming design. That is also why I am against total auto drive cars.

You did a great job on the details of what went wrong, how MCAS works, and why it was the problem.

It was interesting to read.

Marietta Passero on March 18, 2019:

Enjoyed this extremely informative article...Good on ya Mr Russo!⭐️⭐️⭐️⭐️⭐️

Mike Russo (author) from Placentia California on March 18, 2019:

I'm glad I could shed some light on the disaster for you. Thank you for stopping by.

Miebakagh Fiberesima from Port Harcourt, Rivers State, NIGERIA. on March 18, 2019:

Hello, Mike, when I heard of the crash online, I had no information from my local newspapers and magazines. I was waching. But here you hve provide some useful information. Thanks for sharing.