What happened after the 737 MAX crashes

Indeed, more widely, air safety in Indonesia has been viewed with some suspicion internationally at the level of oversight by Indonesian regulators, and Lion Air has been perhaps understandably tarred with the same brush.

In 2007, the European Union Air Safety Committee placed all Indonesian airlines on its Air Safety List, a blacklist banning airlines from EU airspace. The ban on Lion Air was lifted in 2016 following improvements, while the EU lifted the Indonesia-wide ban in June 2018, four months before the crash of flight 610.

With the release of the final report of the Indonesian transportation safety agency’s investigation into the Lion Air crash, some of this suspicion has since proven justified, but some has not. Critics have alleged that the Indonesian-led investigation has covered up failings at Lion Air, and that “revolving door” relationships of personnel from airline to regulator are problematic, but these accusations remain unproven.

This skepticism of the airline was particularly strong in Australia, where there is a strong domestic industry, where the Civil Aviation Safety Authority is a bellwether regulator in the region, and where aviation safety around its near neighbours is something of a concern.

Indeed, shortly after the crash of flight 610, the Australian Department of Foreign Affairs and Trade instructed government officials and contractors not to fly on the Lion Air group’s airlines.

The government lifted the ban on those Lion Air group flights to and from Australia later that week, but at the time of writing the department’s Smartraveller website still reads: “Following the fatal crash of a Lion Air plane on 29 October 2018, Australian government officials and contractors in Indonesia have been instructed not to fly on Lion Air or its subsidiary airlines that operate outside of Australia. This decision will be reviewed when the findings of the crash investigation are clear.“

Aspersions were initially cast on Lion Air…

Early investigation results and safety directives fingered the AOA sensors, but didn’t mention MCAS
Preliminary accident investigation findings in early November 2018 came from Indonesia’s National Transport Safety Committee, assisted by the US National Transportation Safety Board and other international partners, highlighting erroneous angle-of-attack (AOA) input as an area of focus for investigators.

On 6 November, Boeing issued Flight Crew Operations Manual Bulletin number TBC-19 addressing the AOA issues but, crucially, this bulletin did not mention the existence of MCAS at all.

The next day, 7 November the US Federal Aviation Administration issued an Emergency Airworthiness Directive (AD), number 2018-23-51, requiring operators to modify their aircraft flight manual to highlight that “if an erroneously high single angle of attack (AOA) sensor input is received by the flight control system, there is a potential for repeated nose-down trim commands of the horizontal stabilizer.”

Noted the FAA, “We are issuing this AD to address this potential resulting nose-down trim, which could cause the flight crew to have difficulty controlling the airplane, and lead to excessive nose-down attitude, significant altitude loss, and possible impact with terrain.”

The investigations, which were essentially seeking to discover the whether the balance of the crash of JT610 were with the pilots, the aircraft, its maintenance — or, as is the norm with aviation incidents, how these multiple factors combined — were ongoing on 10 March 2019, when Ethiopian Airlines flight ET302 crashed after takeoff from Addis Ababa.

BOEING 737 MAX OPERATORS
The airlines and private companies operating the worldwide fleet of 387 Boeing 737 MAX 8 and MAX 9 aircraft at the time of its grounding were:

9 Air, Aerolineas Argentinas, Aeromexico, Air Canada, Air China, Air Italy, American Airlines, Arkefly, Britannia Airways AB, Cayman Airways, China Eastern Airlines,
China Southern Airlines, Comair, COPA Airlines, Corendon Airlines, Eastar Jet, Enter Air, Ethiopian Airlines, Fertitta Enterprises, Fiji Airways, flydubai, Fuzhou Airlines, Garuda Indonesia, Gol Linhas Aereas, Hainan Airlines, Icelandair, Jet Airways, Jet Aviation Business Jets, SCAT (JSC Aircompany), Kunming Airlines, Lion Air, Globus Airlines, LOT Polish Airlines, Lucky Air, Mauritania Airlines, Mongolian Airlines (MIAT), Norwegian Air International, Norwegian Air Norway, Norwegian Air Shuttle, Norwegian Air Sweden, Okay Airways, Oman Air, Qatar Airways, Royal Air Maroc, Shandong Airlines, Shanghai Airlines, Shenzhen Airlines, SilkAir, Smartwings, Southwest Airlines, SpiceJet, Sunwing Airlines, Thai Lion, TUI Airlines Belgium, TUI Airways, Turkish Airlines, United Airlines, WestJet, and Xiamen Airlines.
DATA: US FEDERAL AVIATION ADMINISTRATION
The second crash stunned the world and shattered the safety regulation framework
It is difficult to overstate the level of shock from the world’s aviation community at the loss of a second Boeing 737 MAX in relatively short order, so soon into the programme’s operational life, in circumstances that seemed so familiar from the crash of Lion Air flight JT610.

Ethiopian Airlines acted immediately, grounding its fleet of 737 MAX aircraft the same day as ET302 went down, Sunday 10 March.

Among aviation safety regulators worldwide, though, the response created a shocking change in the way that they act. Rather than largely being coordinated in decisions on aircraft airworthiness, as was the previous norm, the world’s regulators spent the four days between the crash on 10 March 2019 and the eventual grounding of the 737 MAX by the US FAA on 13 March taking a never before seen series of unilateral actions.

In an unprecedented move, the Civil Aviation Administration of China (CAAC) was the first major global regulator to move on groundings. The CAAC “issued a notice at 9 am on March 11 requiring domestic airlines to suspend the commercial operations of Boeing 737-8 aircraft”, citing “the similarities between the two accidents that the aircraft involved in both crashes were newly delivered Boeing 737-8 and both happened during take-off.”

This led to a flurry of speculation, largely around why China’s regulator, which was not lead investigating agency into either of the two crashes, would be the first to take action.

The Indonesian transportation authorities also issued a grounding order on 11 March, but this also faced some speculation from the international aviation community given the country’s historical weakness in aviation safety, previous total and selective airline bans like EASA’s, and criticism of Lion Air’s safety record.

Later that same day, on 11 March, the US Federal Aviation Administration (FAA) issued a Continued Airworthiness Notification to the International Community (CANIC), reaffirming that it believed the aircraft was still safe to fly.

A day later, the UK grounded the MAX on 12 March, with its regulator stating that “the UK Civil Aviation Authority has been closely monitoring the situation, however, as we do not currently have sufficient information from the flight data recorder we have, as a precautionary measure, issued instructions to stop any commercial passenger flights from any operator arriving, departing or overflying UK airspace.”

EASA, too, grounded the MAX “as a precautionary measure”, which the agency said was part of “taking every step necessary to ensure the safety of passengers”, with both an Airworthiness Directive prohibiting operations in Europe and Safety Directive prohibiting third-party operators operating the MAX to, from or within the EU.

The UAE forbade the MAX from flying through its airspace effective at one minute past midnight UTC on 13 March, the day when everything changed.

On Wednesday 13 March, Transport Canada, the regulator of the US’ northern neighbour, effectively grounded Canadian MAXes and any others overflying the country.

A statement from transport minister Marc Garneau, himself a former astronaut, explained that the decision “restricts commercial passenger flights from any air operator, both domestic and foreign, of the Boeing 737 MAX 8 and 9 aircraft – from arriving, departing, or overflying Canadian airspace”.

The impetus for the Canadian decision was a new set of data from a US company called Aireon, whose satellite aircraft tracking via ADS-B (Automatic Dependent Surveillance – Broadcast) using Iridium satellites had gone into final testing before official launch only the month before, in February 2019.

It remains unclear as to what exact ADS-B data was received, but Airservices Australia notes that ADS-B may include:
– Flight identification (flight number or call sign)
– ICAO 24-bit aircraft address (globally unique airframe code)
– Position (latitude/longitude)
– Position integrity/accuracy (GPS horizontal protection limit)
– Barometric and geometric gltitudes
– Vertical rate (rate of climb/descent)
– Track angle and ground speed (velocity)
– Emergency indication (when emergency code selected)
– Special position identification (when IDENT selected)

In essence, the tipping point for the Canadians was that the data received from Aireon’s systems regarding ET302 was so similar to the data from JT610 that Transport Canada felt it appropriate to ground the aircraft.

Crucially, it seems that the US FAA had the same data that their Canadian counterparts did. Yet it took until much later that same day, 13 March, for the US to act, with an announcement from US President Donald Trump.

GROUNDING THE MAX

Timelines of overflight bans, safety directives and other regulatory interdictions against the 737 MAX following the ET302 crash

10 March
ET302 crashes; Ethiopian grounds fleet

11 March
China, Indonesia, Mongolia (US FAA issues CANIC reaffirming safety of MAX)

12 March
Australia, European Union, India, Malaysia, Singapore, South Korea, Turkey

13 March
Canada, the United Arab Emirates, United States, and numerous other regulators

14 March
Japan, Russia and others
The politicisation of aviation safety and cosy complex relationships give much pause
One of the basic tenets of decades of aviation safety, and one of the reasons why flying has become substantially safer over time, is that every accident, incident or near-miss is analysed, its causes identified and changes made as a result.

To work effectively, it is becoming increasingly clear that this system of regulators and investigators must be well-funded, independent, non-politicised and free to work without interference. It is a disappointing reality of our modern political culture that it is necessary to say so, and equally disappointing that the response to the grounding of the Boeing 737 MAX so starkly showed how this is not the case in the United States.

Concerns about the capacity and funding of the US Federal Aviation Administration, the key commercial aerospace regulator in the US, are not new. Over recent years it has been at best a political football for the uninformed and inexpert, and at worst subject to work stoppages from government shutdowns, lacking for years a head official (the Administrator of the agency) as the political system demonstrates its inability to function.

One of the checks and balances in what is largely a consensus-based system of international civil aviation regulation is that the regulator from the jurisdiction of manufacture — the FAA for Boeing, EASA for Airbus, and so on — is trusted by other regulators to be doing an adequate job of regulating its manufacturers. Trust is also extended to those manufacturers through a system of delegation and self-certification, and that trust was broken in the 737 MAX’s case.

The Russian proverb доверяй, но проверяй is most often translated into English as trust, but verify, and was often quoted in the 1980s as part of the developing relationship between the Soviet Union and the United States. Regrettably, it seems that the FAA fell down substantially on the verify part, and it is already clear that this was for a variety of reasons, many of which are still under current examination by a variety of inquiries and investigations.

At the same time, the sequential, patchwork nature of the grounding of the 737 MAX showed starkly that the trust extended to the FAA by other regulators is not at a sufficient level to enable them to, in essence, take the FAA’s word for as much of the process as they have previously.

Perspectives among regulators and the industry vary, of course, but there are widespread concerns around the politicisation of the US regulator.

It is, at best, wildly inappropriate that a head of state should be making either decisions or announcements about aviation safety.

Yet, in the case of the Boeing 737 MAX, US President Donald Trump was in front of cameras rather than the Acting Administrator of the FAA (then Daniel Elwell, now Deputy Administrator) or, at the very least, Transportation Secretary Elaine Chao.

This is, of course, a unique administration, characterised by volatility and caprice, together with a lack of understanding of how complex international systems need to operate, a lack of regard for those systems, or all of the above. It is also one that is increasingly aligned with Boeing, even more so than previously, and even given the historical size of Boeing’s exports.

There are widespread concerns around the politicisation of the US regulator

Too much closeness is a far-reaching problem
To an extent, the manufacturer-regulator complex has been ever thus: as went the US, so went Boeing. But there was inherent trust, either explicit or implicit, in the norms and mores of the US political system under previous administrations. The often problematic closeness of the US and Boeing was thus downplayed, mitigated or occasionally brushed conveniently aside.

In another time, the way the “Air Force One” VC-25B decision was taken might have been a scandal in and of itself. So might the Patrick Shanahan affair. So might the delegation of MAX certification. So might the move of Nikki Haley, formerly US Ambassador to the United Nations and before that Governor of South Carolina, home to a Boeing plant, to the airframer’s board. So might the business interests of US Transportation Secretary Elaine Chao, who also happens to be married to US Senate Majority Leader Mitch McConnell. So might telephone calls from Boeing’s Dennis Muilenburg to the Oval Office, pleading the case not to ground the aircraft.

Altogether, the consensus — especially from overseas — is that there is substantial and problematic proximity between the US government, senior political appointees, and Boeing. Whether or not that closeness crosses the line into conflict of interest or even corruption is not for the WOFA to say, although investigations, including by the US Department of Justice, are ongoing.

But whether this closeness is officially rotten is, in some ways, neither here nor there: if it smells bad enough to a sufficiently large number of international stakeholders then that is a skepticism threshold that must raise red flags about whether the US aviation certification authorities are operating properly.

Indeed, being chummy with one’s government may also have other complicating consequences. In the event that the government decides to pick a trade war with a nation whose airlines are some of your primary customers, and where you are already comparatively weak in a competitive sense, you may end up getting caught up in tariffs, reprisals and, less measurably, a substantial loss of favour.

Aviation diplomacy is not new either, although consider Airbus’ substantial separation from EASA. While, yes, visits of or to the French Président or German Chancellor often come with orders or other partnership announcements stamped with Airbus’ logo on them, EASA is a European Union agency that works more widely than the union itself, independent of meddling from national governments and even, to an extent, from supranational government.

But even within aviation, a relationship that is too close between the regulator and regulated is a colossal problem, and one that is all too plain in statements from EASA and from Transport Canada, regulators that initially Boeing will need to have on side in order to get the aircraft back in the air. More widely, though, the FAA needs to regain the trust of those regulators in order to itself regulate, and to have its regulating be approved by others.

Positive noises are beginning to come out of Washington

There are some hopeful signs coming from FAA Administrator Steve Dickson, appointed since the MAX groundings. In a 14 November memo, Dickson explains, of the work to unground the MAX: “I want to underscore my commitment to our shared promise that this effort is not guided by a calendar or schedule. Safety is the driving consideration.”

“The FAA fully controls the approval process,” Dickson highlights, stating: “I unequivocally support the dedicated professionals of the FAA in continuing to adhere to a data-driven, methodical analysis, review, and validation of the modified flight control surfaces and pilot training required to safely return the MAX to commercial service. We will maintain that approach, and your team should take whatever time is needed to do that work. I am committed to backing you all up on this.”

“As you and I have said so many times, the FAA’s return-to-service decision for the MAX will rest solely on FAA’s assessment of whether Boeing’s proposed software updates and pilot training address the known issues for grounding the aircraft,” Dickson, a pilot himself, writes. “I am not going to sign off on this aircraft until I fly it myself and am satisfied that I would put my own family on it without a second thought.”

This will, for some time, be hyperbole. It would be a rare aviation industry regulator, executive, expert or observer who will not, for some years to come, hesitate over that mouse-click or finger tap to book a flight with that simple “737 MAX” designator on it.