Ethiopia’s final report on Boeing 737 MAX crash sparks international dispute over pilot error

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Ethiopia’s final report on Boeing 737 MAX crash sparks international dispute over pilot error
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French aviation safety authorities this week joined U.S. investigators in a harsh critique of the final report by Ethiopian authorities into the March 2019 crash of a Boeing 737 MAX.

In this March 11, 2019, file photo, wreckage is piled at the crash scene of an Ethiopian Airlines flight crash near Bishoftu, Ethiopia.

The French and American critiques — a rare fracture among the safety authorities participating in an air accident investigation — don’t dispute Boeing’s role, but present a fuller picture of the tragedy’s cause. He said “it smacks of their attempts to sweep under the carpet some clear deficiencies by the flight crew and the airline.”

In this March 11, 2019, photo, rescuers work at the scene of an Ethiopian Airlines flight crash outside of Addis Ababa, Ethiopia. Both the NTSB and France’s Bureau of Enquiry and Analysis agreed with the Ethiopian agency’s conclusion that the design of Boeing’s new flight control software that repeatedly pushed the jet’s nose down — the Maneuvering Characteristics Augmentation System, or MCAS — was a major cause of the accident.

Both agencies suggest that Ethiopian Airlines failed to ensure its pilots were adequately trained in the measures that Boeing recommended to counter an erroneous MCAS activation after the first MAX crash. To ensure independence from the U.S. manufacturer, the Ethiopian agency sent the plane’s black box to Paris, where the BEA performed the technical analysis on the jet’s flight data and cockpit voice recorders.

“There’s no doubt in my mind MCAS played a major role in this accident,” said Guzzetti, the former NTSB investigator. “In the public perception, Boeing got hammered because of these accidents, and they deserved to get hammered. I think the stain on Boeing is just as visible was it always was.” Pilots are supposed to memorize the response to an “Airspeed Unreliable” message: Disengage the automatic systems that control flight position and speed, and fly manually.

Meanwhile the autothrottle was stuck at full takeoff thrust. Soon the jet was moving much too fast, beyond its maximum design speed. The first officer, who should have been helping the captain figure out what was going on, had only 361 hours of total flying experience. He appeared “overwhelmed by the events on board from the moment the stick shaker triggered,” the BEA said.

“After a crash that just killed an entire planeload of people in Indonesia, you would think that they would offer a little bit more detail as to what to do if this were to happen again,” said de Luis. “The procedures were clearly written to minimize any sort of liability.”The NTSB and BEA assert that Ethiopian Airlines didn’t provide hands-on training to its pilots to execute Boeing’s instructions.

The Ethiopian report notes that Boeing’s bulletin didn’t mention that MCAS activates only when the flaps are retracted. Still, with the Lion Air crash scenario surely at the forefront of their minds, the captain seems to have realized MCAS was the problem. Confused, he tried to execute Boeing’s instructions, but messed up the sequence.

Perhaps panicking, he cut power to the horizontal tail prematurely, with the plane still in a nose-down posture. What caused that initial sensor failure that started this awful sequence of events? The French and U.S. agencies differ with the Ethiopian authority, which suggested some quality problem.

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