I know the FAA is facing a lot of harsh criticism since the two Boeing 737 Max accidents less than six months apart: the Lion Air Flight 610 crash in Indonesia in October 2018 and the Ethiopian Airlines Flight 302 crash in March 2019. But those criticisms have focused on the FAA’s certification of the Boeing 737 Max and its oversight of Boeing. Some of that criticism is justified, in particular, allowing the aircraft to be certified with just one angle-of-attack (AOA) sensor for its MCAS—flight control software—system. One sensor for a critical component is a design failure that Boeing and the FAA should never have allowed. But there are more questions that the FAA needs to answer as a result of these accidents and their aftermath.
While Boeing and the FAA made their share of mistakes in certifying the 737 Max, my review of the available public information shines an even harsher light on Lion Air and its operation of revenue service flying passengers. And it begs the question, why has the Indonesian government failed to take strong action in light of the glaring maintenance and other errors revealed by its own accident report? And, if the accident report wasn’t enough, a New York Times investigation of the airline should be. If reporters could find these problems, one would hope the government agency entrusted with ensuring aviation safety in Indonesia could, as well.
First, the accident report prepared by the Komite Nasional Keselamatan Transportasi (KNNT)—the Indonesian equivalent of the U.S. NTSB—contains information that should call into question Lion Air’s qualifications to fly and Indonesia’s oversight of the airline. Most troubling for me, as a long-time airline mechanic and accident investigator, is the history of maintenance problems before the 737 crashed on October 29. Those problems, and the failures to properly document or correct them, indicate to me that the crew on the fateful flight was assigned an unairworthy aircraft. And no crew should have ever been given that aircraft to fly, let alone a scheduled airline flight with paying passengers.
According to the accident report prepared by the Indonesian government, the maintenance issues with the AOA sensor began almost a month before the accident. Thereafter, on multiple flights, there were indications of problems with this sensor, as well as with the flight control system. Maintenance actions based on these reported problems were incomplete, inadequate, or non-existent. For example, in one case where maintenance was unable to rectify the problems, the crew was told to just fly the aircraft—with paying passengers—to the next station. It is shocking that maintenance asked the crew to do this and even more shocking that the crew did this. And most of you have probably read of the problems on the flights immediately preceding the accident flight, with the crew fighting to control the aircraft.
In addition to the problems noted in the accident report, a subsequent investigative report by the NY Times found ”based on interviews with dozens of officials and airline employees, including pilots and members of maintenance teams…that Lion Air has a track record of working its pilots to the point of exhaustion, faking pilot training certification and forcing pilots to fly planes they worried were unsafe, including the plane that crashed.” The NY Times investigation further found that “just as the company does not seem pressed to adopt changes from the report…Indonesian officials were quick to defend a carrier that has had 11 accidents and incidents since its founding in 1999.” The report concluded, “after a crash, a company and a government deny problems, deflect blame, and drag their feet on improvements.” To date, there is no indication that Lion Air management or the Indonesian government are tackling the systemic problems that appear to exist at the airline.
Out of ICAO Compliance
It seems to me that from these reports that Lion Air is not planning to take significant action to correct its safety issues any time soon nor does it appear that the Indonesian government will force the airline to make necessary changes or shut the airline down until it does. If that’s the case, then Indonesia is not in compliance with its responsibilities as a member of ICAO, the International Civil Aviation Organization. Under ICAO, member countries are responsible for complying with international aviation safety standards and overseeing compliance with those safety standards by their air carriers.
Indonesia’s apparent reluctance to take on safety problems at Lion Air should cause the FAA to revisit its Category 1 designation for Indonesia under its International Aviation Safety Assessment (IASA) program. Indonesia was upgraded to Category 1 in 2016 after being designated Category 2 from 2007. According to the FAA, “while under a Category 2 rating, the country either lacked laws or regulations necessary to oversee air carriers in accordance with minimum international standards, or its civil aviation authority…was deficient in one or more areas, such as technical expertise, trained personnel, record-keeping, or inspection procedures.” Until the Indonesian government shows a willingness to take on Lion Air’s safety problems, it’s hard to imagine that it deserves to be rated a Category 1 country.
Under IASA, the FAA determines whether a country’s civil aviation authority maintains oversight of its air carriers consistent with international aviation safety standards developed by ICAO. And while those ratings may not seem important now since no Indonesian airliner is flying directly into the U.S., an airline like Garuda, the national airline of Indonesia that is majority-owned by the government, could begin service at any time. Also, travelers to Indonesia might well rely on the FAA’s ratings in deciding whether to fly Indonesian airlines—like Lion Air—domestically, especially since the U.S. State Department notes Indonesia’s FAA safety rating on its travel advisory page. “The U.S. Federal Aviation Administration (FAA) has assessed the Government of Indonesia’s Directorate General of Civil Aviation as being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for oversight of Indonesia’s air carrier operations.” The FAA owes it to American travelers to reassess Indonesia’s compliance with international safety standards.