Analysis & Opinions

Boeing 737 Max Crashes

| June 17, 2021

Examining the role of the NTSB in international investigations

Summary of the Incident

Lion Air flight 610 crashed into the Java Sea after departing from Jakarta, Indonesia on October 29, 2018. Less than a year later, on March 10, 2019, Ethiopian Airlines flight 302 crashed near Ejere, Ethiopia, six minutes after take off. Both flights were flying the Boeing 737 Max 8 plane. The Lion Air investigation was led by the National Transportation Safety Committee of Indonesia, and the Ethiopian Airlines investigation was led by the Ethiopia Accident Investigation Bureau. 

The key difference between the older Boeing 737 model and the 737 Max was the larger, updated engine. The Boeing 737 model was too low to the ground–a characteristic that made it able to service smaller airports with less landing equipment–to fit a new engine under the wings of the plane. Boeing’s solution was to fit the engine higher up on the plane. However, the new placement of the engine caused the nose of the plane to point too far up when the plane was in full thrust, as it is during take off. To resolve the issue, Boeing installed the Maneuvering Characteristics Augmentation System (MCAS) into the 737 Max. The MCAS was intended to lower the nose of the plane when sensors detected that the nose was pointed too far up. In both incidents, the MCAS received incorrect data from the sensors and forced the plane’s nose down. 

 

Investigations

Because the crashes happened abroad, the NTSB did not lead the investigations but it was an accredited representative to both investigations. As an accredited representative, the NTSB participated in the investigations. The Ethiopia Accident Investigation Bureau has released a preliminary investigation report. Recommendations in the preliminary report focus on the issues with the flight control system that caused the nose of the plane to dip down. The Indonesia National Transportation Safety Committee’s report was published October 29, 2018 and included recommendations for Boeing, the FAA, Lion Air and its subsidiaries, and the Indonesian civil aviation agency. 

The NTSB initiated a review of the crashes and recommended the FAA make changes to its assumption of pilot recognition and response, on which the FAA’s approval of Boeing’s MCAS software was based. In its analysis, the NTSB included the Lion Air flight that immediately preceded the accident flight. In the earlier Lion Air flight, the pilot also encountered issues with AOA alerts but was able to override the automatic responses through manual pilot commands. The fact that all three pilots responded to the multiple alerts differently led the NTSB to recommend that the FAA request that Boeing ensure that its safety systems adequately take into account the effect of multiple alerts on a pilot’s response. 

Multiple organizations conducted investigations into the safety of the Boeing 737 Max 8, including the U.S. Department of Transportation Special Committee, the U.S. Department of Transportation Office of the Inspector General, and the Joint Authorities Technical Review. The civil aviation authorities of Canada, China, the European Union, Indonesia, Japan, and the United Arab Emirates participated in the Joint Authorities Technical Review, which assessed the certification process for the Boeing 737 Max. The FAA considered the reports from the other reviews and investigations, as well as the NTSB’s recommendations, in its return to service review of Boeing’s safety adjustments. The FAA required that Boeing update MCAS to address the issues details in its report and that pilots be trained on operating MCAS. 

The European Union Aviation Safety Agency (EASA) conducted its own return to service review for the Boeing 737 Max. The EASA’s report determined that the changes Boeing had made to the 737 Max had made the plane safe but also specified changes that, although not related to issues immediately threatening the safety of passengers, Boeing would have to make before the plane would be allowed to service the EU. 

 

Policy Changes

Congressman Peter DeFazio introduced the Aircraft Certification Reform and Accountability Act in September 2019 to strengthen the FAA’s oversight powers, make changes to the certification process, and extend protections for whistleblowers. Provisions of the bill were later incorporated into H.R. 133: Consolidated Appropriations Act, 2021 [Including Coronavirus Stimulus & Relief], which was signed by President Trump December 27, 2020. 

The FAA proposed a $3.9 million civil penalty against Boeing for installing nonconforming equipment onto the 133 of its aircraft in December 2019, and later proposed an additional $5.4 million penalty for additional noncomforming equipment. 

The Department of Justice charged Boeing with conspiring to defraud the FAA, alleging that Boeing 737 Max Technical Flight Pilots deceived the FAA about the MCAS. Boeing agreed to pay a criminal monetary penalty of $243.6 million, $1.77 billion to Boeing’s airline customers, and $500 million to establish a beneficiary fund for the families of the passengers of Ethiopian Airlines flight 302 and Lion Air flight 610.

Reports

  • NTSB Report on Ethiopian Airlines and Lion Mentari Airlines Crashes

    Link to the report here

  • Preliminary Summary of the FAA’s Review of the Boeing 737 Max for Return to Service

    Link to the report here

  • Joint Authorities Technical Review

    Link to the report here

  • Audits Conducted by the Department of Transportation Office of the Inspector General

    Link to the report here

  • Official Report of the Special Committee to Review the Federal Aviation Administration Aircraft Certification Process

    Link to the report here

  • European Union Aviation Safety Agency Boeing 737 MAX Return to Service Report

    Link to the report here

  • Ethiopia Aircraft Accident Investigation Bureau Preliminary Report

    Link to the report here

  • Indonesia Komite Nasional Keselamatan Transportasi Investigation Report

    Link to the report here

  • Senate Committee on Commerce, Science, and Transportation Committee Investigation Report

    Link to the report here

  • House Committee on Transportation and Infrastructure Preliminary Investigative Findings

    Link to the report here

  • House Committee on Transportation and Infrastructure Final Report

    Link to the report here

Legislation

  • Consolidated Appropriations Act, 2021 [Including Coronavirus Stimulus & Relief]

    Link to the bill here

Hearings

  • House Committee on Transportation and Infrastructure Hearing, Status of the Boeing 737 MAX: Stakeholder Perspectives

    Link to the transcript here

Penalties

  • FAA Proposal of $3.9 Million Civil Penalty

    Link to the FAA press release here

  • FAA Proposal of $5.4 Million Civil Penalty

    Link to the FAA press release here

  • Department of Justice Penalty

    Statement from the Department of Justice here

General Resources

  • Explanation of the Crashes

    Vox video explaining how the Lion Air and Ethiopian Airlines crashes happened here

For more information on this publication: Belfer Communications Office
For Academic Citation: Ontiveros, Victoria.“Boeing 737 Max Crashes.” , June 17, 2021.

The Author