- 6/19/2025
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TVTranscript
00:01Just minutes after takeoff from Jakarta, Indonesia...
00:04Flying 610, I have no reliable altitude information.
00:07All instruments disagree.
00:09...pilots fight to control one of the world's newest airliners.
00:12Fly up!
00:13The Boeing Max 8.
00:15They never really figured out what was going on.
00:18...and end up crashing into the Java Sea.
00:22This was a very serious accident.
00:24What does the tracking data show?
00:26Investigators follow an erratic flight path.
00:29They're off course.
00:30There are altitudes all over the place.
00:32A history of maintenance issues.
00:34Did we have problems?
00:35I bet we did.
00:36And learn about a treacherous piece of hidden software.
00:39Looks like the MCAS kicked in.
00:41What's that?
00:42What they uncover shocks the world...
00:44...and grounds an entire fleet.
00:47The 737 MAX story will clearly be a watershed event in aviation history.
00:54Mayday, mayday!
00:55Let's go!
00:56Let's go!
00:57Oh, hop!
00:58310, too heavy-ass rigging up in my car,
01:00let's keep going!
01:02It's just after 5 a.m. in Jakarta, Indonesia.
01:29As 181 passengers settle in for a short domestic flight.
01:39In the cockpit, First Officer Harvino performs pre-flight procedures.
01:46Fuel pumps are on.
01:49The captain on this flight is Bhavya Suneja, who has more than 6,000 flying hours.
01:54The passengers are on board the latest version of the renowned Boeing 737, known as the MAX 8.
02:06David Karbaugh is a former Boeing test pilot.
02:12The MAX is the fourth iteration of the 737.
02:17One of the most successful airliners ever.
02:21And it was basically born out of a need to improve efficiency and performance.
02:26The MAX 8 has quickly become Boeing's fastest-selling airplane, with more than 300 already in the skies and almost 5,000 in the order books.
02:39The one being used on today's flight was delivered to Lion Air two months ago.
02:46Lion 610, you are cleared to runway 25L via Sierra Charlie 1.
02:51All clear, no traffic, let's run before take-off.
03:05Flaps?
03:07Flaps 5.
03:09If I've indicated.
03:12Lion Air Flight 610 is a 90-minute journey from Jakarta, over the Java Sea, to Banker Island.
03:21The low-cost airline operates hundreds of these short flights every day.
03:27Indonesia is the fourth most populous country in the world.
03:32And with 17,000 islands, you've got to have an easy way to do short-range transportation to get to those places.
03:40And the MAX is the ideal airplane for that kind of operation.
03:46Lion 610, cleared for take-off.
03:48Runway 25, contact terminal, East Wind Airborne.
03:51Lion 610, cleared for take-off.
04:11At 6.20, the MAX 8 lifts off the runway at Jakarta.
04:15But immediately there's trouble.
04:23The captain's control yoke starts shaking.
04:27A warning that the plane is about to stall.
04:30Take off, config.
04:32Okay, but what?
04:34The pilots can't identify the source of the problem.
04:37They have no choice but to continue climbing.
04:43The passengers are unaware that the pilots are dealing with anything unusual.
04:51Lion 610, fly heading 248.
04:55Follow standard instrument departure.
04:58Lion Air 610.
04:59The air traffic controller has no idea that there's an issue in the cockpit.
05:09The pilots get a warning that their airspeed indicators do not agree.
05:13The airspeed disagree.
05:14What's going on?
05:17Should we request a return to Jakarta?
05:18Landing gear up.
05:26Lion 610, climb to flight level 270.
05:31Still unaware of any trouble, the controller instructs the crew to continue climbing to 27,000 feet.
05:38Altitude disagree.
05:44The first officer now notices that the altimeters also show conflicting readings.
05:50Acknowledged altitude, disagree.
05:53Lion 610.
05:55Confirm our current altitude, please.
05:58Lion 610, your present altitude is...
06:02900 feet.
06:03The pilots are getting conflicting data about their altitude and their airspeed.
06:14Captain Sunezha expects his first officer to carry out the procedure for this situation.
06:19Canemory items, airspeed unreliable.
06:23What altitude should I request?
06:25Yeah, request...
06:27Proceed.
06:28The situation is deteriorating quickly.
06:37Climbing above 1,000 feet, the pilots are still unsure of their airspeed.
06:42If they fly too slowly, the plane could stall and fall from the sky.
06:47Request clearance to any holding point.
06:50Captain Sunezha wants to get the plane to a point where he can circle and solve the problem.
06:55Lion 610, request clearance to some holding point due to our current condition.
07:01Lion 610, what's the nature of your problem, please?
07:06We are experiencing a flight control problem.
07:09Lion 610.
07:16Where's the...
07:18Airspeed, airspeed.
07:22There's no airspeed unreliable.
07:23It's there.
07:24Got it.
07:29Autopilot if engaged, disengaged.
07:32Not every failure is a major emergency.
07:36And checklists are designed to grade or evaluate the severity of a system failure.
07:43So pilots are trained to methodically go through each step by step.
07:49Autopilot if engaged, disengaged.
07:51Disengaged.
07:52But the checklist isn't helping.
07:59Okay, okay.
08:01Now flying 5,000 feet above the sea, Captain Sunezha struggles to keep the plane's nose up.
08:08Flight path vector may be unreliable.
08:10Lion 610, turn right heading 070 to avoid traffic ahead.
08:15Set the pitch attitude.
08:17Roger.
08:18Heading 070.
08:24Lion 610, you're now descending.
08:27We're having flight control problems and are flying manually.
08:30The cabin would have realized that the airplane was not climbing as normal and that it had leveled off and there was probably some up and down sensations.
08:46Captain Sunezha has been fighting to keep the plane's nose from pitching downwards.
08:54Please take control for a moment.
08:56He now assigns that task to his first officer.
08:59I have control.
09:00So he can troubleshoot the problem himself.
09:04Oh, it's very...
09:06The first officer is also having difficulty keeping the aircraft level.
09:11There was a wide variety of problems that they had to sort out.
09:18And the first thing was what's common between all of these failures because that's how you start to sort through the problems.
09:24Flight 610 is flying erratically over the Java Sea and becoming increasingly more difficult to control.
09:35The lives of everyone on board now depend on the pilots figuring out the problem.
09:41I don't know where we are.
09:43And getting the plane to the ground safely.
09:46Lion 610, I have no reliable altitude information. All instruments disagree.
09:51Roger, Lion 610, no restrictions.
09:53When an aircraft declares an emergency, the controller's number one job is to provide assistance to that airplane.
10:01The controller allows Flight 610 to fly at any altitude the pilots choose.
10:07Please clear 3,000 above and below of traffic.
10:10Okay, we'll do. What altitude would you like?
10:14Five, five. It's diving.
10:16It's diving.
10:16It's okay. It's okay.
10:18Flight 610 is now speeding towards the sea.
10:21Here's me.
10:22And the pilots are out of options.
10:24Tr increase.
10:24Hold, hold, hold, hold, hold.
10:27Fly up. Up. Up. Up. Up.
10:30Up. Up. Up. Up. Up. Up. Up. Up. Up. Up. Up.
10:43Line 610. Up. Up. Up. Up. Up. Up. Up. Up. Up.
10:48Lion Air 610, control.
10:52CityLink 882, please hold on current position.
10:57Do you have visual on Lion 610, a Boeing 737 MAX 8?
11:03Negative. No other planes in sight.
11:0530 minutes after crashing into the Java Sea, the wreckage of Lion Air Flight 610 is located.
11:20There are no survivors.
11:24Relatives of the passengers are flown to Jakarta for trauma counseling.
11:30While they wait for the recovery of the bodies of their loved ones,
11:33investigators from Indonesia's accident investigation branch KNKT
11:38need to understand why one of the best-selling new aircrafts in the world fell from the sky.
11:52Okay, what does the tracking data show?
11:55Working with data from air traffic control,
11:59KNKT investigators focus on the flight path of Lion Air 610.
12:03They're off course.
12:08There are altitudes all over the place.
12:13From this data, we learned that this plane's altitude was fluctuating.
12:19It kept going up and down.
12:22We wanted to find out why the pilot couldn't keep the plane at a constant altitude.
12:26Investigators need to know if the controller can shed any light on the problems the crew was facing.
12:36They reported that they were having a control issue.
12:41Lion 610, what's the nature of your problem, please?
12:46We are experiencing a flight control problem.
12:49Lion 610?
12:50That's all he said.
12:52A flight control problem.
12:56Soon after that, they reported that their instruments were unreliable.
13:01Lion 610 have no reliable altitude information.
13:04All instruments disagree.
13:06Roger, Lion 610, no restrictions.
13:09That was about it.
13:10From the information we received from the air traffic controller,
13:19we didn't get the impression that the pilot was under pressure.
13:23The pilot's tone was normal.
13:26It didn't seem that he was stressed.
13:27Since the pilots of flight 610 reported flight control problems and unreliable instruments,
13:39investigators wonder if recent maintenance records could explain what brought down the MAX 8
13:44only 11 minutes after takeoff.
13:50This flight had some problems with control.
13:54At that point, we needed to learn more about the plane's maintenance history.
13:58The angle of attack sensor was replaced the day before.
14:03There are two angle of attack sensors on the 737 MAX 8.
14:08The sensors calculate the angle between the plane's wing and the oncoming air.
14:13Their data helps determine if the plane's wings are providing sufficient lift.
14:19It's a very important piece of information.
14:21The pilots need to have some kind of warning that they are approaching stall,
14:25and so the angle of attack sensor is what gives that.
14:29For several days, the left side sensor had been giving faulty readings.
14:35It was finally replaced before the plane flew from Bali to Jakarta,
14:39one day before the accident.
14:44Investigators interview the crew who flew the same plane just hours before the crash
14:49to determine if there were any problems with the replacement sensor.
14:54Did we have problems?
14:56Yeah, we did.
15:00We conducted an interview with the crew of Flight 043.
15:04We learned from them that after takeoff, the crew was also having problems.
15:07What investigators hear next is chilling.
15:16The captain explains that when he lifted off from Bali,
15:20there were simultaneous warnings that his airspeed and altitude indicators had failed.
15:26Airspeed disagree, altitude disagree.
15:29A few seconds later, the MAX 8 stick shaker activated,
15:32indicating that a stall was imminent.
15:34Keep climbing.
15:36You're up.
15:38All the modern airliners have three sets of independently powered essential flight instruments,
15:45airspeed and altitude, and also the attitude of the airplane.
15:50If there is a discrepancy, you can determine which is providing inaccurate data.
15:56Your instruments are correct.
15:57You have control.
16:00The failure was on my side, so I hand it off.
16:03Flaps up.
16:04The captain adjusts his faulty instruments,
16:09so they display data from the first officer's side.
16:13We're diving.
16:14Pitch up.
16:14Keep trimming.
16:15That's when the plane started diving over and over.
16:19The captain reports that the plane began a series of uncommanded dives.
16:23Use your trim.
16:26That's it.
16:26In order to keep the plane climbing at a constant angle,
16:33the pilots set the position of their horizontal stabiliser at take-off
16:37and make minor adjustments during the flight.
16:40That's called trim.
16:41Trim can either be adjusted by the autopilot or manually by the crew.
16:45But every time the first officer tries to trim the nose up,
16:51the automated system pushes it back down.
16:54The first officer is finding it almost impossible to keep the plane climbing.
16:58The trim system on a modern jet has to be very powerful.
17:04The trim, in many cases, is actually more powerful than the control column.
17:09For some reason, the MAX 8 stabiliser continues to move independently,
17:16pushing the plane's nose down despite the first officer's commands.
17:21Let's see what's in the book.
17:23When the automated system moves the stabiliser,
17:26it also spins a large wheel that's located between the two pilots.
17:31This tells them that the system is adjusting the trim on its own.
17:34When the captain bent down to look at the checklist manual
17:42to solve the problem during this flight,
17:44the third crew was the one notifying the pilot
17:46that the trim was moving abnormally.
17:51Runaway stabiliser.
17:53Moving switches to cut out.
17:55The crew realises the stabiliser's automatic trim system is malfunctioning.
18:01It's continually pushing the nose down.
18:04Disengaging the system resolves the issue.
18:08When they cut out the trim switches,
18:10the system stopped doing nose down trim.
18:14Moving the switch to cut out pretty much solved it.
18:16The investigators learn that the previous crew
18:19then did something astonishing.
18:22So, we kept going.
18:26You kept going.
18:28If they had decided to return and land in Denpasar,
18:34it would have taken only 5 to 10 minutes,
18:37and they could have landed safely.
18:40But they decided to continue flying to Jakarta.
18:44Line Air 43 will continue on to Jakarta.
18:48Following a near catastrophe,
18:50with unreliable instruments and the stick shaker blaring,
18:53the crew elected to continue the 90-minute flight to Jakarta.
18:59It surprised all of us that they continued the flight.
19:04The crew managed to make a safe landing at Jakarta
19:07and reported the problem to maintenance personnel.
19:10I reported the issue and filled out the flight maintenance log.
19:16If the airplane experience is an abnormal
19:19or an unusual system failure,
19:21it goes into the maintenance log.
19:24Airspeed and altitude disagree,
19:26but not a word about the stabilizer problem.
19:30Investigators are surprised to learn
19:32that the captain of the previous flight
19:34said nothing about the out-of-control stabilizer
19:37or the action he took to correct it.
19:41Runaway stabilizer.
19:42Moving switches to cut out.
19:45The lives of the passengers and the crew that follows you
19:49is basically dependent on you
19:52filling out the paperwork correctly.
19:56Good morning.
19:58Good morning.
19:59They're done loading,
20:01so we should be able to get out of here on time today.
20:03A few hours later,
20:04the passengers and crew of Flight 610
20:07boarded the aircraft
20:08with no knowledge or warning
20:11of the potential problems
20:12faced by the previous crew hours earlier.
20:15Fuel bumps?
20:17Fuel bumps are on.
20:20Did a repeat of the problem on this aircraft
20:23result in the deaths of the 181 passengers
20:26and eight crew?
20:34It takes three days for search and rescue teams
20:37to lock on to the signal
20:38coming from the MAX 8's flight data recorder.
20:41Divers recover it from a depth of 115 feet.
20:47The recorder has preserved data
20:49from the accident flight
20:50and 18 previous flights
20:52covering almost 1,800 different parameters.
20:56Master caution goes off
20:58as soon as they leave the ground.
20:59probably because airspeed
21:02and altitude don't agree.
21:06Stick shaker
21:07activates here.
21:10The data shows a repeat
21:11of the problem on the previous flight.
21:15Faulty readings
21:16caused by a discrepancy
21:17between the left and right
21:19angle of attack sensors.
21:20From the FDR data we received,
21:26we learned that this plane
21:27had faulty angle of attack readings
21:29that affected both flights similarly.
21:31The two planes are very similar.
21:34Left and right angle of attack values
21:37are off by 21 degrees
21:39for the entire flight.
21:41We suspected the new angle of attack sensor
21:46installed in Bali
21:47was either faulty
21:48or the installation process
21:50was done incorrectly.
21:52That's why.
21:54The mechanic who replaced the sensor
21:56before the flight
21:57from Bali to Jakarta
21:59failed to ensure it was calibrated,
22:01which resulted in faulty readings.
22:04There's a procedure
22:05that would have shown
22:07it was erroneous
22:08and that it was bad.
22:10They signed off that they did it.
22:12They could not have done it.
22:14On the MAX 8,
22:16the angle of attack sensor
22:17doesn't just measure the airplane's angle.
22:20Altitude disagree.
22:21It helps calculate
22:23precise airspeed and altitude.
22:26That explains why
22:28airspeed and altitude
22:30disagreed throughout the whole flight.
22:32The malfunctioning sensor
22:34on the captain's side
22:35resulted in a difference
22:36between the left and right side's
22:38speed and altitude displays.
22:40Then there's this.
22:43The data clearly shows
22:44that for every nose-up trim input,
22:46there was a corresponding
22:48automatic nose-down trim input.
22:51Sounds like what the crew
22:53of Flight 43 described.
22:55The data shows investigators
22:56that for some reason,
22:58the plane's automated trim system
23:00was repeatedly dropping
23:01the plane's nose
23:02while the pilots
23:04fought to lift it.
23:0526 separate nose-down commands.
23:12This doesn't look like
23:13a runaway stabilizer to me.
23:15Runaway stabilizer
23:17is a common malfunction
23:18of the trim system,
23:20usually resulting in
23:21one continuous uncommanded
23:22movement of the stabilizer.
23:24The NTSB brought a representative
23:30from Boeing
23:30to help us
23:31in our investigation.
23:33We asked them to explain
23:34why, in both flights 610
23:36and 043,
23:37the same plane
23:38continued to pitch down.
23:46We're trying to understand
23:47these automatic inputs.
23:50Looks like the MCAS kicked in.
23:54What's that?
23:56Boeing points to an obscure
23:58automated system
23:59known as MCAS,
24:01the Maneuvering Characteristics
24:03Augmentation System.
24:06That's when we first learned
24:07about the MCAS.
24:10To understand
24:11what could have caused
24:12the crash of Flight 610,
24:15investigators need to go back
24:16seven years to 2011,
24:19when Boeing first announced
24:21the development of the MAX 8.
24:24The 737 MAX
24:25was basically born
24:27out of a need
24:28to improve
24:30the performance
24:31and sales
24:32of the 737.
24:35In 2010,
24:37Boeing's main competitor,
24:39Airbus,
24:40unveiled the A320neo,
24:43a fuel-efficient,
24:44short-haul airplane.
24:45It was an immediate hit
24:47with airlines
24:47at a time of rising fuel costs.
24:49Boeing was caught
24:52by surprise.
24:54The A320neo
24:56was significantly
24:57more fuel-efficient.
24:59So,
25:00all of a sudden,
25:00they were faced
25:01with a dilemma.
25:02Do you design
25:03a new airplane,
25:04a four- or five-year project,
25:06or do you modify
25:07the existing 737?
25:11But there were problems
25:13with taking a plane
25:14that was designed
25:14in the 1960s
25:16and turning it
25:17into a fast
25:18and fuel-efficient aircraft.
25:21To improve
25:22the performance
25:23of the MAX,
25:24they decided
25:25to install
25:26more fuel-efficient,
25:28larger engines.
25:30The only way
25:31to make those
25:32larger engines fit
25:33was to slide them
25:35forward on the wings.
25:36The design engineers
25:37had a problem
25:38with the ground clearance
25:39from the engines.
25:40and on 737,
25:42you can't increase
25:43the size
25:44of the main landing gear
25:45because of the size
25:46of the wheel wells.
25:47It has to fit there.
25:48So,
25:49the only thing
25:49they could do
25:50was to move
25:51the engines
25:51further forward
25:52and up.
25:53That solved
25:54one problem,
25:55but created another.
25:58It caused the 737
25:59to pitch up
26:00at low speeds,
26:02particularly
26:02when it was already
26:03in a nose-up position
26:04like during take-offs.
26:06So,
26:07they created
26:08software
26:09that would recognize
26:10the airplane
26:11approaching stall
26:12and artificially
26:14force the nose down
26:16and logically
26:17they turned
26:18to the trim system
26:20to do that.
26:21And that's the problem
26:22you solved with MCAS?
26:23Yes,
26:24it made the MAX
26:24handle like any other 737.
26:27MCAS
26:28was designed
26:30for a very low
26:31probability event.
26:34It's diving.
26:35It's diving.
26:36It's okay.
26:37How are they
26:37trained to respond?
26:39Well,
26:39they weren't.
26:40Not specifically.
26:41Fly up.
26:42Up.
26:43Up.
26:44Could Boeing's
26:46high-tech solution
26:47to a design problem
26:48have inadvertently
26:49put thousands
26:50of passengers
26:51around the world
26:52at risk?
26:57In order to
26:58eliminate the need
26:58for costly pilot training,
27:01Boeing had to
27:01convince authorities
27:02that the MAX 8
27:03handled the same way
27:05as all previous
27:06737s.
27:08Different handling
27:09characteristics
27:09will automatically
27:11require time
27:12in the simulator
27:13and extra training.
27:16Boeing argued
27:16that since MCAS
27:17operated in the background
27:19without the need
27:20for any pilot input,
27:21it didn't affect
27:22the airplane's handling.
27:25Not a word
27:26about MCAS here.
27:28Boeing never included
27:30mention of MCAS
27:31in the flight control
27:32manuals.
27:34They argued that
27:35since the system
27:36was not under control
27:37of the crew,
27:38it should not be included.
27:41It's like the system
27:42doesn't even exist.
27:45Boeing thinks
27:48that it's an automatic
27:49system for safety purposes
27:50and has nothing to do
27:52with pilot operation.
27:55According to Boeing,
27:56the MCAS software
27:58would automatically
27:59move the plane's stabilizer
28:00to push the plane's nose down
28:02if it started to pitch up
28:04under very specific circumstances.
28:09It only kicks in
28:10when these three conditions
28:11are met.
28:14Boeing explains
28:15that MCAS only activates
28:16when it senses
28:17that the angle of attack
28:18is excessive,
28:19when the autopilot
28:22is off
28:23and when the flaps
28:25are retracted.
28:26An extremely rare combination.
28:29Professional pilots
28:30don't typically
28:32stall airplanes,
28:33so the likelihood
28:35of an MCAS activation
28:37was thought
28:37to be extremely low.
28:40This is the data
28:41of both flights.
28:43Tragically,
28:43the data shows
28:44that because of
28:45the faulty maintenance
28:46on the angle of attack sensor,
28:48flight 610
28:49ended up meeting
28:50all three conditions.
28:55The series of problems
28:56occurred
28:57when the left angle
28:58of attack sensor
28:59was replaced in Bali.
29:05Investigators dig deeper
29:06into the data
29:07and discover
29:08the MCAS system
29:09had no fail safe.
29:13The MCAS installed
29:15in the plane
29:15relied on only one sensor.
29:19The MCAS only took data
29:21from one angle
29:22of attack sensor,
29:23not both.
29:26Most protection systems
29:28are designed
29:28with redundancies.
29:30Your instruments
29:30are correct.
29:31You have control.
29:32So a single failure
29:33doesn't result
29:34in catastrophe.
29:36Flaps up.
29:37What Boeing did not
29:39adequately do
29:40was assess
29:42all of the other failures
29:43that that single component
29:45would have.
29:46The faulty angle
29:47of attack sensor
29:48wrongly showed
29:50the plane pitching up steeply.
29:52The autopilot
29:53was disengaged
29:54for the entire flight.
29:55And then right here
29:57they retract the flaps.
30:00Exactly the same
30:01as the previous flight.
30:06That's when
30:07MCAS kicks in
30:09and starts pushing
30:12the nose down.
30:15Up to this point
30:16the crew only had
30:17a minor instrument problem.
30:18By raising the flaps
30:22the pilots unknowingly
30:24triggered a much
30:25more serious problem.
30:29We assumed
30:30the pilots
30:31would know
30:31how to respond.
30:34Boeing made
30:35the assumption
30:35that pilots
30:36would respond
30:37to the uncommanded
30:38MCAS inputs
30:38by disengaging
30:40the automatic trim.
30:41The Boeing assumptions
30:44were that the pilots
30:45would instantly
30:46recognize
30:47the inadvertent
30:48MCAS activation
30:50and treat it
30:51within three seconds.
30:54Investigators examined
30:55the flight data
30:56of the previous
30:57Lion Air flight
30:58to see how that crew
30:59reacted to the
31:00MCAS activation.
31:02The first MCAS input
31:04on flight 43
31:05is here.
31:07The captain
31:08pulls back
31:09on his control column
31:10and applies
31:10manual trim
31:11then fights
31:12against the MCAS
31:14for three minutes
31:15and 40 seconds
31:15before hitting
31:16a cutout switch.
31:18I think the assumption
31:18that they were going
31:20to recognize
31:20and act
31:22within three seconds
31:23was very optimistic
31:25if not unrealistic.
31:29Lion 610
31:30I have no reliable
31:31altitude information
31:32all instruments disagree.
31:34Unlike the previous crew
31:36the pilots
31:37of flight 610
31:38struggled with the problem
31:39for more than
31:4010 minutes
31:41and never made
31:44the connection
31:45to a runaway stabilizer.
31:53Investigators need
31:54to understand
31:54why two crews
31:56facing an identical problem
31:57reacted so differently.
32:04Investigators struggle
32:05to understand
32:06and why the pilots
32:07of Lion Air flight 610
32:09lost control
32:10of the aircraft.
32:11After nearly three months
32:13of searching
32:13the ocean floor
32:14the cockpit voice recorder
32:16is finally recovered
32:17and taken for analysis.
32:21The CVR was the key
32:23to our investigation.
32:25Together with the FDR data
32:26the CVR could reveal
32:28all the mystery
32:29in our investigation.
32:30All right, 610 cleared for takeoff.
32:37Investigators hope
32:38the recording
32:38will help to explain
32:40why the crew
32:40of flight 610
32:42couldn't identify
32:43the problem
32:43and take corrective action
32:45to fix it.
32:46Rotate.
32:50Takeoff, don't fake.
32:53Okay, but what?
32:53The faulty angle
32:56of attack sensor
32:57triggers a series
32:57of warnings
32:58as soon as the plane
32:59lifts off.
33:03Airspeed disagree.
33:04What's going on?
33:07Should we request
33:08a return to Jakarta?
33:11Landing gear up.
33:16After takeoff
33:17the MCAS system
33:18was activated
33:19and their plane
33:20started to pitch down.
33:21The captain has noticed
33:24that the plane's stabilizer
33:25is now automatically
33:26trimming the nose down
33:28and does what
33:29Boeing assumed he would.
33:31He pulls back
33:32on the control column
33:33and uses manual trim
33:35to counteract
33:36the computerized inputs.
33:39Okay.
33:40Boeing was right about that.
33:42But the captain
33:43never mentions
33:44the trim problem.
33:46He and his first officer
33:47are focused entirely
33:49on their faulty
33:49airspeed and altitude
33:51readings.
33:52Where is the
33:52airspeed, airspeed?
33:55There's no airspeed
33:57unreliable.
33:57It's there.
33:59Got it.
34:02This is where
34:03we found significant
34:04differences
34:04between flight 043
34:06and 610.
34:08It takes
34:09first officer
34:10Harvino nearly
34:11two minutes
34:12to locate
34:12the appropriate checklist
34:13for mismatched airspeed.
34:15I think the first officer
34:16was pretty well
34:17task saturated.
34:18And one of the things
34:19that task saturation
34:20does in humans,
34:21it limits our ability
34:23to communicate.
34:24We don't hear well
34:25and we don't verbalize
34:26things very well.
34:28Raps up four degrees
34:29and 75% at one.
34:31There it is.
34:33When the automated
34:34trim system pushes
34:35the nose down,
34:37the large wheel
34:38makes a characteristic
34:39sound.
34:39when the trim wheel
34:42moves,
34:43it makes a sound
34:44like a freight train.
34:46It's meant
34:46to be noticeable.
34:49Following a reliable
34:50attitude,
34:52N1,
34:53ground speed,
34:55check.
34:57They still don't notice it.
35:00Wrong about that.
35:02He didn't put it together
35:03that every time
35:04he trimmed up,
35:05the MCAS system
35:06was trimming it
35:07back down.
35:0734 times.
35:11He applies nose-up trim
35:1234 times
35:13and doesn't think
35:15to wonder why.
35:18They did not recognize
35:20the problem
35:21and take the corrective
35:23action Boeing predicted
35:24they would.
35:25In this particular case,
35:27Boeing made assumptions
35:28about design
35:30and pilot experience
35:32and training
35:32that didn't add up.
35:36Please take control
35:38for a moment.
35:39I have control.
35:42Investigators now hear
35:43another crucial difference
35:45between flight 610
35:46and the previous flight.
35:47That's it.
35:49Please take control.
35:52Not a word
35:52about the fact
35:53that he's had to make
35:54more than
35:5430 trim inputs.
35:59I think the captain
36:00was very frustrated
36:01with the first officer.
36:03Oh,
36:04it's very...
36:05And I'm sure
36:06he didn't really
36:07want to hand it over
36:08to the first officer,
36:09but he felt
36:10that he needed to
36:11in order to figure out
36:12what was going on
36:13with the checklist.
36:14But because there's
36:16no mention of MCAS
36:17in the manual,
36:18there isn't a checklist
36:19for the crew to follow.
36:21It's diving.
36:22It's diving.
36:23Okay.
36:24With no warning
36:25from the captain
36:25about the need
36:26for repeated nose-up trim,
36:28the first officer
36:29quickly becomes overwhelmed.
36:32Sadly,
36:33this first officer
36:34was pretty well overwhelmed
36:35and as the system
36:37trimmed the nose down,
36:39he was not nearly
36:40aggressive enough
36:41in responding to that.
36:44In flight 610,
36:47the pilot didn't
36:48deactivate the automatic trim
36:49and the plane's nose
36:51kept coming down
36:51because of the MCAS
36:52and it didn't stop
36:54until the plane crashed.
36:56One minute
36:57after taking control,
36:59the first officer
37:00watches helplessly
37:01as the plane
37:02plunges towards
37:03the Java Sea.
37:07KNKT investigators
37:09discover that
37:09Boeing's assumptions
37:10of how pilots
37:11would recognize
37:12and overcome
37:13an uncommanded
37:14nose-down trim
37:15on the MAX 8
37:16were fatally flawed.
37:24They sure didn't act
37:26the way Boeing
37:26said they would.
37:28Here it is.
37:30Without requiring
37:32exceptional skill
37:33or strength.
37:35Investigators
37:36soon learn
37:36why Boeing's assumptions
37:38about how pilots
37:39would react
37:40were so wrong.
37:41to certify the MAX 8,
37:43Boeing assured
37:44the FAA
37:45that an average
37:46flight crew
37:47would be able
37:47to override
37:48the MCAS system.
37:49so were these guys
37:51average?
37:54Captain passed
37:55all his checks.
37:57Looks like
37:58a competent pilot.
38:03This guy
38:04has a whole
38:05different story.
38:08Investigators
38:08are surprised
38:09by the first officer's
38:10background.
38:11The first officer
38:12on Lion Air Flight 610
38:14had had challenges
38:15in training.
38:16He had trouble
38:17staying up with
38:18the airplane
38:18understanding
38:19the complexities.
38:20His manual flying
38:21skills were not
38:22optimum
38:23and he required
38:25additional training.
38:26It's diving.
38:27It's diving.
38:28It's okay.
38:29Flight 610 proved
38:30that Boeing was wrong
38:32about how pilots
38:33would react
38:33to an MCAS failure.
38:35Fly up.
38:36Up.
38:36Up.
38:37They never really
38:42figured it out
38:42and then
38:44the captain
38:45gave control
38:45to someone
38:46whose manual
38:47flying skills
38:48were not going
38:49to save the day.
38:50As a result
38:52of the accident
38:52Boeing issues
38:53new guidelines
38:54for MAX 8 pilots
38:55informing them
38:57about MCAS
38:57and detailing
38:58the procedures
38:59to follow
39:00in the event
39:01it triggers
39:01an uncommanded
39:02nose down.
39:04The bulletin
39:05advises pilots
39:05to apply manual
39:06trim
39:07and to move
39:08the stabilizer trim
39:09switches to cut out.
39:11This was a
39:12reinforcement
39:12to the pilots
39:13that says
39:14there is a system
39:15on the airplane
39:16that can move
39:17the trim.
39:18If it does so
39:20treat it as a runaway
39:21stabilizer.
39:23Hey
39:24turn a TV on?
39:31Our breaking news
39:33an Ethiopian
39:34airlines has crashed
39:35shortly after takeoff
39:36from Addis Ababa.
39:38The belief
39:39that Boeing's advisory
39:40would prevent
39:41another similar accident
39:42is shattered
39:43four months later
39:44when another
39:45MAX 8 crashes.
39:46Dead.
39:48Flight tracking data
39:50shows that
39:50Ethiopian airlines
39:52flight 302's
39:53altitude fluctuated
39:54throughout the flight.
39:56There's immediate
39:57speculation
39:58that once again
39:59Boeing's MCAS
40:00software
40:01is to blame.
40:03In both accidents
40:04the MCAS
40:06activated
40:06causing this
40:07nose-down trim
40:08situation
40:09to occur
40:10repeatedly
40:11and in both cases
40:12the crews let the
40:13airplane accelerate
40:14far, far greater speed
40:16than it should have been.
40:17Put those two together
40:18and the controllability
40:19of the airplane was lost.
40:20This time
40:23the pilots knew
40:24about MCAS
40:25and what to do
40:26in case it activated
40:27yet they still
40:29couldn't control
40:29the airplane.
40:31Boeing realized
40:31well if this
40:32crew
40:33can't handle it
40:34then
40:35other crews
40:36won't.
40:38In spite of
40:38the FAA's assurance
40:40that the MAX 8
40:41is airworthy
40:41regulators around
40:43the world
40:43ground
40:44the global
40:45MAX 8 fleet
40:45until the problem
40:47with MCAS
40:47is fixed.
40:51The main thing
40:51in our mind
40:52was we worried
40:52that all of the
40:53Boeing 737 MAX 8
40:55that are currently
40:55flying all over
40:56the world
40:57might have the
40:58potential to
40:58suffer the same
40:59catastrophe.
41:01The FAA
41:03eventually
41:03follows suit.
41:06Our concern
41:07isn't with the
41:08mistakes
41:08A US
41:09congressional
41:09investigation
41:10determines
41:11that Boeing
41:11made faulty
41:12technical assumptions
41:13and errors in
41:14judgment
41:15which led
41:15to these accidents.
41:16I didn't know
41:17about this
41:18is unacceptable.
41:21Boeing insists
41:22it's learned
41:22from these incidents
41:23and is determined
41:24to make the
41:25MAX 8 safe
41:26and regain
41:27public trust.
41:28Boeing
41:29has committed
41:30to making it
41:30easier for pilots
41:32to override
41:33the MCAS system.
41:36Once that override
41:38is activated
41:38the system
41:40will not
41:41continue
41:42to re-engage.
41:43and
41:46they're developing
41:47a training
41:48program
41:48to familiarize
41:49pilots
41:50with MCAS.
41:56The
41:57737 MAX
41:58story
41:59will change
42:00forever
42:00how airplanes
42:01are certified
42:02and the
42:02737 MAX
42:04will clearly
42:04be a watershed
42:05event
42:06in aviation
42:07history.
Recommended
44:02
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