Incident 3: Crashes with Maneuvering Characteristics Augmentation System (MCAS)

Description: A Boeing 737 crashed into the sea, killing 189 people, after faulty sensor data caused an automated manuevering system to repeatedly push the plane's nose downward.

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Alleged: Boeing developed and deployed an AI system, which harmed Airplane Passengers and Airplane Crew.

Incident Stats

Incident ID
3
Report Count
19
Incident Date
2018-10-27
Editors
Sean McGregor

CSETv1 Taxonomy Classifications

Taxonomy Details

Harm Distribution Basis

none

Sector of Deployment

transportation and storage

Possible fault in Lion Air plane similar to a cause of Air New Zealand Airbus A320 France crash
nzherald.co.nz · 2018

Possible faulty equipment that led to the crash of Lion Air Flight 610 was the same sort of sensing gear that contributed to the crash of an Air New Zealand A320 off Perpignan 10 years ago.

A failure of air flow monitoring pitot tubes on bo…

Lion Air Jet Had Airspeed Sensor Failure on Previous Flight
time.com · 2018

(Bloomberg) — The Lion Air jet that crashed into the Java Sea off Indonesia earlier this week had experienced problems with the sensors used to calculate altitude and speed on its previous flight, an issue that could help explain why the pl…

Boeing issues bulletin for pilots after Lion Air sensor data error
reuters.com · 2018

ZHUHAI, China, Nov 7 (Reuters) - Boeing Co said on Wednesday it had issued a bulletin to airlines reminding pilots how to handle circumstances where there was erroneous data from “angle of attack” sensors, in the wake of the Lion Air crash …

Lion Air plane had angle of attack sensor replaced prior to crash; Boeing issues safety reminder
abc.net.au · 2018

Lion Air plane had angle of attack sensor replaced prior to crash; Boeing issues safety reminder

Updated

A crucial sensor that is the subject of a Boeing safety bulletin was replaced on a Lion Air jet the day before it plunged into the Java…

New Clues to Lion Air 737 Max Crash Revealed in Boeing, FAA Warnings
insurancejournal.com · 2018

A Boeing Co. warning to 737 Max operators around the globe provides the first clues about how bad data from an airflow sensor might have contributed to the deadly crash of an Indonesian airliner last week.

The bulletin and statements by Ind…

Lion Air Plane Crash: Crucial 'Angle Of Attack' Sensor Replaced Before Crash
iafrica.com · 2018

A crucial sensor was replaced on a Lion Air jet the day before it plunged into the Java Sea, and that sensor replacement may have exacerbated other problems with the plane, Indonesian investigators said on Wednesday.

That sensor, known as t…

Lion Air Flight JH 160 Crash Sensor Replacement
popularmechanics.com · 2018

The FAA has issued an emergency directive to anyone flying the Boeing 737 MAX, the type of plane that crashed in the Lion Air Flight JH 610 incident, related to the faulty sensors that reportedly fed bad information to the pilots. Meanwhile…

Lion Air: Sensor was replaced day before crash but problems persisted
edition.cnn.com · 2018

(CNN) Problems were reported on a Lion Air jet that crashed into the sea off Jakarta even after technicians replaced a sensor on board the aircraft, investigators said.

Indonesian authorities confirmed Wednesday that the angle of attack (AO…

Crash Of Lion Air 737 MAX Raises Questions About Autopilot And Pilot Skills
forbes.com · 2018

AFP/Getty Images

[Updated: Nov. 13]

The FAA issued an emergency airworthiness directive Wednesday to airlines operating the new Boeing 737 MAX, calling on them to better instruct pilots on how to deal with a potential faulty reading from a …

Indonesian officials: Problems with sensor found on crashed Lion Air jet
news.cgtn.com · 2018

Indonesia's National Transportation Safety Committee said on Wednesday that a crucial sensor had been replaced on a Lion Air jet the day before it plunged into the Java Sea, killing all 189 people on board.

That sensor, known as the "angle …

Southwest replaced flight-control sensors of the kind implicated in Lion Air crash
marketwatch.com · 2018

During the three weeks before Lion Air Flight 610 plunged into waters off Indonesia, Southwest Airlines Co. LUV, +0.25% replaced two malfunctioning flight-control sensors of the same type that has been publicly implicated in the crash, acco…

Pilots struggled against Boeing’s 737 MAX control system on doomed Lion Air flight
seattletimes.com · 2018

Data from the fatal Oct. 29 flight that killed 189 people, and from the prior day's flight of the same jet, raises questions about three factors that seem to have contributed to the crash.

A key instrument reading on Lion Air flight JT610 w…

In Indonesia Lion Air Crash, Black Box Data Reveal Pilots’ Struggle to Regain Control
nytimes.com · 2018

Investigators have yet to recover the cockpit voice recorder, which could provide further insight into the steps taken by the pilots and whether they followed the correct procedures.

Despite Boeing’s insistence that the proper procedures we…

Faulty Lion Air sensor wasn’t fixed before crash, preliminary report finds
businesstimes.com.sg · 2018

A malfunctioning sensor at the centre of the investigation into the Oct 29 crash of a Lion Air jetliner into the Java Sea wasn't repaired before the fatal flight even though it had failed on the plane's previous trip, according to a prelimi…

Report: Lion Air pilots unable to correct for faulty sensor
mercurynews.com · 2018

JAKARTA, Indonesia – A malfunctioning sensor and an automated response from the aircraft’s software stymied pilots’ efforts to control a doomed Indonesian flight that went careening into the sea last month, according to a preliminary invest…

Report faults safety failures, defects in Lion Air crash
apnews.com · 2018

National Transportation Safety Committee investigator Nurcahyo Utomo holds a model of an airplane during a press conference on the committee's preliminary findings on their investigation on the crash of Lion Air flight 610, in Jakarta, Indo…

Report Faults Safety Failures, Defects in Lion Air Crash
courthousenews.com · 2018

JAKARTA, Indonesia (AP) — Pilots fought against an automated system that pitched a Boeing jetliner’s nose down repeatedly because of a faulty sensor until they finally lost control and plunged into the Java Sea last month, Indonesian invest…

What we've got here is a failure to communicate
usatoday.com · 2018

Why did the 737 Max plunge into the sea in Indonesia, killing all 189 on board? Pilots must know about every change on the jets they fly: Our view

Indonesians recover a plastic box containing the data recorder of Lion Air Flight 610 on Nov.…

medium.com · 2019

Present day Air travel is one of the safest modes of travel. Statistics from the US Department of Transportation show that in 2007 and 2016 there were 11 fatalities per trillion miles of commercial air travel. This is in stark contrasts to …

Variants

A "variant" is an incident that shares the same causative factors, produces similar harms, and involves the same intelligent systems as a known AI incident. Rather than index variants as entirely separate incidents, we list variations of incidents under the first similar incident submitted to the database. Unlike other submission types to the incident database, variants are not required to have reporting in evidence external to the Incident Database. Learn more from the research paper.
unreviewed
Incident Date:
2019-03-10
Description of Incident Circumstances

Ethiopian Airlines flight ET302 from Addis Ababa-Bole Airport (ADD/HAAB), Ethiopia to Nairobi-Jomo Kenyatta International Airport (NBO/HKJK), Kenya, a Boeing 737 MAX 8 registration ET-AVJ MSN 62450/7243, crashed about 6 minutes after takeoff from ADD near Bishoftu, Ethiopia, 8°52′37″N 39°15′04″E. There were no survivors among the 157 occupants. Accident investigation found that the causes were similar to those involved in the accident of Lion Air flight JT610 on 29-10-2018. Quoting from the official investigation report: [QUOTE 3.2Probable cause of the accident Repetitive and uncommanded airplane-nose-down inputs from the MCAS due to erroneous AOA input, and its unrecoverable activation system which made the airplane dive with the rate of -33,000 ft/min close to the ground was the most probable cause of the accident. [p. 255] [UNQUOTE [QUOTE The data from the flight data recorders, as summarized in reports of the ET 302 accident and the Lion Air Flight 610 accident, indicated that if a single erroneously high AOA sensor input is received by the flight control system, MCAS can command repeated Airplane nose-down trim of the horizontal stabilizer. This unsafe condition, if not addressed, could cause the flight crew to have difficulty controlling the Airplane , and lead to excessive Airplane nose-down attitude, significant altitude loss, and impact with terrain [p. 257] [UNQUOTE [QUOTE Safety Issue Summary On the previous Lion Air flight and the Lion Air and Ethiopian Airlines accident flights, the DFDR recorded higher AOA sensor data on the left side than on the right (about 20° higher in the previous Lion Air flight and the Lion Air accident flight and about 59° higher on the Ethiopian Airlines accident flight). As previously stated, the MCAS becomes active when the Airplane ’s AOA exceeds a certain threshold. Thus, these erroneous AOA data inputs resulted in the MCAS activating on the accident flights and providing the automatic AND stabilizer trim inputs. The erroneous high AOA sensor input that caused the MCAS activation also caused several other alerts and indications for the flight crews. The stick shaker was activated on both accident flights and the previous Lion Air flight. In addition, IAS DISAGREE and ALT DISAGREE alerts occurred on all three flights. Also, the Ethiopian Airlines flight crew received a Master Caution alert. Further, after the flaps were fully retracted, the unintended AND stabilizer inputs required the pilots to apply additional force to the columns to maintain the Airplane’s climb attitude. [p. 266] [UNQUOTE]

Sources:

  1. Ethiopian Airplane Accident Investigation Bureau (EAIB). "Aircraft Accident Investigation Report B737- MAX 8, ET-AVJ". Published 23-12-2022. URL: https://www.havkom.se/assets/reports/L-34_19-No-AI_01_18-ACCIDENT-FINAL-REPORT_compressed.pdf
  2. U.S. National Transportation Safety Board. "Response to Final Aircraft Accident Investigation Report Ethiopian Airlines Flight 302 Boeing 737-8 MAX, ET-AVJ". Published 13-01-2023. URL: https://www.ntsb.gov/investigations/Documents/Response%20to%20EAIB%20final%20report.pdf
  3. Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile. "Accident du Boeing 737 immatriculé ET-AVJ et exploité par Ethiopian Airlines survenu le 10/03/2019 près de Bishoftu [Enquête menée par EAIB / Ethiopie] — Observations du BEA". Published 03-01-2023. URL: https://bea.aero/les-enquetes/evenements-notifies/detail/accident-du-boeing-737-immatricule-et-avj-et-exploite-par-ethiopian-airlines-survenu-le-10-03-2019-pres-de-bishoftu-enquete-menee-par-eaib-ethiopie/
  4. Summary at Aviation Safety Network. URL: https://aviation-safety.net/database/record.php?id=20190310-0
Inputs / Outputs

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