Indonesian Investigators Blame Boeing Max Design and Pilot Failures in Lion Air Crash

Indonesian investigators found sweeping problems and missteps in connection with last year’s fatal Lion Air crash, including design flaws in Boeing Co.’s 737 Max jet, certification failures by the U.S. regulator and a raft of errors at the airline by pilots and mechanics.

In a much-anticipated report released Friday, the National Transportation Safety Committee listed its findings and recommended fixes to Boeing, Lion Air and aviation authorities in the U.S. and Indonesia. The findings focused on a flight-control feature called the Maneuvering Characteristics Augmentation System, which has also been implicated in an Ethiopian Airlines crash in March. But it also painted a damning picture of Lion Air, where numerous actions also helped lead to the tragedy.

The conclusions add to the pressures on Boeing, which is finalizing fixes to its grounded best-selling jet and attempting to manage a public-relations crisis that has cost the company billions of dollars. While this closes one chapter on the saga, it’s not over. Boeing Chief Executive Officer Dennis Muilenburg, who was stripped of his role as chairman earlier this month, is due to face questions from lawmakers in Washington next week.

Boeing fell less than 1% to $341.54 at 1:29 p.m. in New York. Through Thursday, the shares had fallen 18% since the Ethiopia crash, the second-biggest drop on the Dow.

The wide-ranging report found ample blame to go around, from an obscure repair station in Florida to Boeing and the U.S. Federal Aviation Administration, whose failures have undermined the agency’s credibility as a leading aviation regulator.

The 737 Max was grounded March 13, three days after the crash in Ethiopia, costing Boeing $9.2 billion and counting. While Boeing says it has made significant progress in returning the 737 Max to service, no date has been set.

In response to the findings, Muilenburg said the company is addressing the Indonesian investigator’s safety recommendations. Boeing engineers have been working with the FAA and other regulators to make software updates and other changes, according to the statement.

The FAA said it welcomed the recommendations from Indonesia and would carefully consider them in its review of the 737 Max. “The aircraft will return to service only after the FAA determines it is safe,” the agency said in an emailed statement. Lion Air said in a statement it’s “essential to determine the root cause and contributing factors to the accident and take immediate corrective actions to ensure that an accident like this one never happens again.”

Separately, the FAA on Friday revoked the repair station certificate for Miramar, Fla.-based Xtra Aerospace LLC, which repaired the sensor that was later installed in the jet and malfunctioned, triggering MCAS.

The sensor was miscalibrated when it was refurbished at Xtra’s facility, the report said. It was supposed to be checked after it was installed on the plane, but investigators said that the problem went undetected by the airline mechanic.

“We have been cooperating closely with the FAA throughout its investigation and though we have reached a settlement with the FAA, we respectfully disagree with the agency’s findings,” Xtra said in a statement. The FAA’s enforcement action was separate from the Indonesian investigation “and is not an indication that Xtra was responsible for the accident,” the company said.

Minutes after taking off from Jakarta for Pangkal Pinang on the morning of Oct. 29, Lion Air Flight 610 nosedived into the Java Sea, killing all 189 people on board. It was the second-deadliest airline disaster in Indonesia’s aviation history, following a 1997 crash near Medan that killed 234 people.

During testing, Boeing determined that malfunctions involving MCAS weren’t deemed serious enough — hazardous or catastrophic failures — for a more rigorous analysis, which could have identified significant problems with its design, according to the report. Boeing also erroneously assumed that the crew would be able to correctly deal with malfunctions within three seconds, even though they were unaware of the existence of the flight-control system, it said.

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