The final report of the Indonesian investigators says the design and development of the MCAS system by Boeing was the main cause for the crash of Lion Air Boeing 737 MAX flight JT610 on October 29, 2018, that killed 189 passengers and crew. Improper certification, training, and maintenance issues were also pointed at as contributing factors.
The Indonesian National Transportation Safety Committee (KNKT) found out that a failure of the MCAS system resulting in a loss of control of the aircraft was not sufficiently taken into account during design and certification, blaming both Boeing and the U.S. Federal Aviation Administration (FAA). The manufacturer and the authority should “more closely scrutinize the development and certification process for systems whose malfunction has the ability to lead to loss of control of the airplane,” states the report, adding that “the MCAS function was not a fail-safe design and did not include redundancy”.
Inconsistencies were found in the MACS certification report: the system is known for correcting the angle of the stabilizers by 2.5°, yet FAA documents stated the maximum was only 0.6°. “It caused a much greater movement of the stabilizer than was specified in that original safety analysis document,” is noted in the report.
The investigators estimate that FAA delegated too much of its responsibility to Boeing engineers under the Organization Designation Authorization (ODA) program that allowed the manufacturer to conduct safety inspections and certification of its aircraft using its own engineers certified by the authority.
It had already been called into question by the Joint Authorities Technical Review, (JATR) conducted by a committee regrouping the FAA, the European Aviation Safety Agency (EASA), and aviation authorities from Australia, Brazil, Canada, China, United Arab Emirates, Indonesia, Japan, and Singapore, as well as NASA, published on October 14, 2019.