The Boeing 737 MAX 8 Crashes: The Case for Pilot Error
The Boeing 737 MAX 8 Crashes: The Case for Pilot Error
A Detailed Review of the Ethiopian And Indonesian Preliminary Accident Reports By Vaughn Cordle, CFA and Don McGregor, USAF Maj Gen (Ret.)
Pilot Errors in Ethiopian Airlines Flight 302
There are two critical and fatal pilot errors that were not properly identified and discussed in the Ethiopian preliminary report’s Initial Findings and Safety Recommendations. The report falls short in terms of properly identifying or prioritizing the primary causes and their relationship to the ultimate effect—the crash. We believe that our analysis of the report’s findings and “ET302 Preliminary FDR [Flight Data Recorder] (DFDR) Data” provides strong evidence that supports our view.
We divide our analysis of why ET 302 crashed into essential and critical arguments that identify the two fatal pilot errors.
Critical Arguments
1. The pilots (crew) mismanaged engine thrust and airspeed
2. Excessive airspeed rendered manual trim ineffective
3. The crew deviated from the emergency procedure
4. Crew experience and competency a major contributing factor
Pilot Errors
1. Mismanagement of engine thrust and airspeed
2. Deviation from company and Boeing procedures
What Ethiopian Airlines Already Knew—Lessons Learned from the Lion Air Flight 610 (LA 610) Accident
The Indonesian preliminary Aircraft Accident Investigation Report is a more thorough review of the accident and provides useful “Findings” and “Safety Actions”—critical information that can help any airline avoid an MCAS-related accident. However, this does not clear Lion Air of pilot or procedural culpability that led to the accident. Like our review of the Ethiopian report, we believe that our analysis of the report’s “Factual Information”, “Aircraft Flight and Maintenance Log” history, and “FDR [Flight Data Recorder] (DFDR) Data” provides strong evidence supporting the view that pilot error was the largest contributing factor.
Like the Ethiopian accident, we can divide our analysis of the LA 610 crash into critical arguments culminating into two fatal pilot errors. Even though the accidents of Lion Air and Ethiopian Airlines have similarities with respect to MCAS issues, they are significantly different in the circumstances leading up to and during the emergency. Because of this, the format used to support these arguments and errors will be presented differently—yet reach the same conclusion: pilot error was the largest contributing factor.
Critical Arguments
1. Previous Lion Air Flight 43 did not pass on critical aircraft information
2. Previous Captains or Maintenance did not ground the aircraft
3. The pilots (crew) identified the wrong checklist
4. The pilots misdiagnosed the runaway trim problem
5. Inappropriate transfer of aircraft control during a critical phase of the emergency
Fatal Pilot Errors
1. Misdiagnosed runaway trim
2. Inappropriate transfer of aircraft control
https://www.linkedin.com/pulse/boein...hn-cordle-cfa/