The National Transportation Safety Board (NTSB) has just released its Aviation Safety Recommendation Report 19-01, stemming from its ongoing cooperative investigation of the October 29, 2018 crash of Lion Air flight 610 in the Java Sea and the Ethiopian Airlines flight 302 crash near Ejere, Ethiopia on March 10, 2019.
As both fatal accidents infamously involved the Boeing 737 MAX-model airplane, which is undergoing a safety-systems overhaul by the manufacturer, the NTSB has closely examined the certification process and safety assessments involved in the original approval of Boeing's Maneuvering Characteristics Augmentation System (MCAS) design aboard the 737 MAX.
One of the specific concerns outlined in the report relates to Federal Aviation Administration (FAA) regulations and guidance during the safety-systems certification process that currently allow for underlying assumptions to be made about pilots' real-world recognition and response to multiple flight-deck alerts and hazard indications.
"We saw in these two accidents that the crews did not react in the ways Boeing and the FAA assumed they would," said NTSB Chairman Robert Sumwalt. "Those assumptions were used in the design of the airplane and we have found a gap between the assumptions used to certify the MAX and the real-world experiences of these crews, where pilots were faced with multiple alarms and alerts at the same time.
Because that same safety evaluation process is still being used to certify current and future flight systems and aircraft designs, the NTSB is strongly suggesting the need for improvement of diagnostic tools and methods used in the design certification process, in order to prioritize and clarify the failure indications being presented to pilots.
In conclusion, the NTSB issued seven safety recommendations to the FAA, urging it to implement improvements in three areas:
- Require that manufacturers of all US type-certificated transport-category airplanes consider the effect of all possible flight-deck alerts on actual pilot recognition and response, abandoning assumptions that pilots will prioritize and respond to hazard indications as intended by the manufacturer, and address accordingly any gaps in design, procedures, and/or training.
- As part of the design certification process, develop and implement more robust tools and methods, using input from industry and human-factors experts, to validate assumptions about pilot recognition and response to safety-significant failure indications.
- Develop design standards for aircraft system diagnostic tools that improve the prioritization and clarity of failure indications being presented to pilots to improve the timeliness and effectiveness of their response when multiple flight-deck alerts and indications are present.
NTSB continues its ongoing support of the Indonesian organization, Komite Nasional Keselamatan Transportasi (KNKT), and the Aircraft Accident Investigation Bureau of Ethiopia in their investigations into the 737 MAX crashes. Authorities expect the KNKT's accident report to be released in the coming months and its analysis of the Lion Air accident may uncover additional findings or fuel further recommendations.
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