B38M, en-route, northeast of Jakarta Indonesia, 2018

B38M, en-route, northeast of Jakarta Indonesia, 2018

Summary

On 29 October 2018, a Lion Air Boeing 737-MAX 8 crew had difficulty controlling the pitch of their aircraft after takeoff from Jakarta and after eventually losing control, a high speed sea impact followed. The Investigation found that similar problems had also affected the aircraft s previous flight following installation of a faulty angle-of-attack sensor and after an incomplete post-flight defect entry, rectification had not occurred. Loss of control occurred because the faulty sensor was the only data feed to an undisclosed automatic pitch down system, MCAS, which had been installed on the 737-MAX variant without recognition of its potential implications.

Description

On the morning of 29 October 2018, a Boeing 737-MAX 8 (PT-LQP) being operated by Indonesian carrier Lion Air on a scheduled domestic passenger flight from Jakarta Soekarno-Hatta to Pangkal Pinang as LNI 610 impacted the sea northeast of Jakarta approximately 11 minutes after its daylight takeoff. The pilots had reported a flight control problem to ATC radar and had requested and initially begun a return to Jakarta because of it, but no declaration of urgency or emergency was made. Evidence indicating a high speed impact was found soon after the last recorded transmission to ATC. The aircraft was destroyed and none of the 189 occupants survived.

Investigation

An Investigation was carried out by the Indonesian NTSC. The DFDR was recovered on 1 November 2018 but the CVR was not located and recovered - detached from its ‘pinger’ - until 14 January, despite an intensive effort in what was at times very poor underwater visibility. A separate report ‘Underwater Search for Flight Recorders' was subsequently published and is included as Appendix 6.1 on pps 232-244 of the Final Report. Relevant data were subsequently recovered from both recorders. No signals were heard from the ULB installed on the forward side of the nose pressure bulkhead and it was not recovered.

Initial progress in the Investigation was provided in a Preliminary Report which was published on 28 November 2018 and included two Safety Recommendations:

The full content of this page is available to registered users only.
Please Log in or Register

SKYbrary Partners:

Safety knowledge contributed by: