Boeings Oversight and the Lion Air Crash: An Examination of MCAS System Mismanagement

Introduction

The catastrophic Airlines crash with Lion Air Flight 610 in October 2018, which led to the loss of 189 lives, has raised critical questions about Boeing's practices, specifically regarding the MCAS (Maneuvering Characteristics Augmentation System) and the training provided to pilots. This incident highlighted significant gaps in the company's approach to safety and communication with its aviation partners.

The MCAS System: An Unforeseen Challenge

The MCAS was intended to address potential aerodynamic issues, particularly the #6 (stall) and #7 (pitch trim) in the 737 MAX series. However, the system's complexity, coupled with insufficient communication and training, contributed to a series of tragic events.

Why Boeing Failed to Prioritize Extensive Training

Focused on Cost Efficiency: Boeing's focus on cost efficiency and the promotion of the 737 MAX as merely a minor update to previous models led to a significant oversight in training. The MCAS system required additional training, which added expenses that Boeing sought to minimize.

Overconfidence and Cost Considerations: The company's belief in the 737 MAX's robustness and the assumption that pilots would easily adapt to the new system without additional training were misguided. This overconfidence is a common issue in large corporations where bean counters often take precedence over safety considerations.

Manufacturers and Pilot Briefing Practices

Manufacturers commonly program a multitude of control laws into aircraft control systems but do not always brief pilots on the details of these laws. This practice is not uncommon, necessitating a balance between efficiency and safety. The Lion Air crash demonstrated that even these controlled and hidden laws can have grave consequences when flawed.

Hider of Flaws: While some control laws are kept secret for operational and competitive reasons, the presence of such laws can be a double-edged sword. When these laws are flawed, they become accident triggers rather than safety aids.

Hubris and Underestimation: There was also a hubristic element at play, where Boeing believed the pilots would be able to intuitively handle the system, assuming it was similar to the Next-gen models. This underestimation of pilot training needs was a significant misstep.

The Role of Pilot Override and System Reliability

Even highly skilled and trained pilots can become powerless when a system malfunctions and resists their inputs. The MCAS system, in its flawed state, created an environment where the pilots were unable to correct the aircraft's attitude, leading to the tragic stall at low altitude.

Both of the pilots of the Lion Air Flight 610 fought vigorously against the MCAS's nose-down command, but the system's refusal to accept pilot override proved fatal. The stall following takeoff was corrected but the system's engagement at a critical point in the flight path further complicated the situation.

Lessons Learned and Future Implications

The Lion Air crash serves as a stark reminder of the crucial role that pilot training and comprehensive system awareness play in aviation safety. This incident highlights the need for more transparent and thorough communication between manufacturers and airlines, as well as the necessity for comprehensive pilot training that addresses the unique characteristics and potential flaws of new systems like MCAS.

Call for Reform: The accident has led to numerous regulatory changes and safety improvements within the aviation industry. It is imperative for Boeing to reexamine its procedures, prioritize safety, and ensure that all necessary training and documentation are provided to pilots. Transparency and accountability in the development and deployment of new systems are essential moving forward.