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Indonesia to Fault 737 MAX Design, U.S. Oversight in Lion Air Crash Report

The Wall Street Journal. logo The Wall Street Journal. 9/23/2019 Andy Pasztor, Andrew Tangel
a group of people standing in front of a crowd © adi weda/epa-efe/rex/Shutterstock

Indonesian investigators have determined that design and oversight lapses played a central role in the fatal crash of a Boeing 737 MAX jet in October, according to people familiar with what is expected to be the first formal government finding that the design and U.S. regulatory approval were flawed.

The draft conclusions, these people said, also identify a string of pilot errors and maintenance mistakes as causal factors in the fatal plunge of the Boeing Co. plane into the Java Sea, echoing a preliminary report from Indonesia last year.

Misfires of an automated flight-control feature called MCAS on the MAX fleet led to the nosedive of the Lion Air jet and a similar crash of an Ethiopian Airlines MAX shortly after takeoff from Addis Ababa in March. The two crashes took 346 lives, prompted the grounding of all 737 MAX planes and disrupted the global aviation industry.

Details of the Indonesian report, which haven’t been reported previously, are subject to change and further analysis. Indonesian investigators declined to comment, except to say the final document is likely come out in early November.

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A Boeing spokesman said the plane maker continues to work with Indonesian authorities as they complete the report.

U.S. air-crash investigators are preparing to announce a handful of separate safety recommendations, ranging from bolstering the manual flying skills of pilots to enhancing FAA vetting of new aircraft designs.

The U.S. National Transportation Safety Board is expected around the end of the month to call for improvements to cockpit training and crew decision making, according to industry and government officials.

The goal is to ensure pilot proficiency when automated systems are malfunctioning or turned off, to help ensure appropriate responses to contradictory cockpit warnings such as those that occurred prior to the MAX crashes, the officials said. The board also is expected to emphasize the importance of setting priorities when executing emergency checklists.

In addition, the NTSB is expected to focus on potential changes to certification of new airliners. The board is poised to recommend re-evaluation of FAA procedures that give the industry authority to sign off on certain safety matters, the officials said. The aim is to make such approvals more transparent, with the goal of greater predictability and more-consistent federal oversight across various types of onboard systems.

Neither the U.S. nor Indonesian recommendations will be binding on the FAA, though the agency already faces escalating congressional and public pressure to change certification procedures. More than half a dozen outside inquiries, including a Justice Department criminal probe and various blue-ribbon advisory panels, are delving into the FAA’s 2017 approval of MCAS. Earlier this month, a Senate appropriations subcommittee backed legislation that would require FAA officials to address recommendations from ongoing investigations and audits.

The FAA has said it welcomes the independent reviews, will carefully consider their results and doesn’t have a firm timetable for allowing MAX jets back in the air. Boeing has said it is collaborating with U.S. and foreign officials to safely return the MAX to service.

Steve Dickson, the FAA’s new head, and top lieutenants are scheduled to meet Monday in Montreal with some four dozen foreign regulators to provide a closed-door update on anticipated fixes to the MAX’s flight-control software and computers.

The FAA is urging a core group of regulators—from Canada, Australia, Brazil and New Zealand—to approve the fixes around November, which would be roughly in tandem with informal U.S. timelines. FAA leaders also are trying to persuade aviation authorities in Europe and other regions to follow by lifting their grounding orders shortly afterward, according to U.S. government and industry officials familiar with the deliberations.

But such coordination efforts are running into significant hurdles. Canadian aviation regulators have signaled to the FAA that they expect to require pilots to undergo simulator training before they can start flying the MAX, something the FAA is unlikely to mandate. It could take until March for Air Canada to phase the bulk of its MAX aircraft into regular schedules, according to a person briefed on the details, months later than projected for U.S. operators.

In Europe, regulators previously said they won’t accept the FAA’s technical verifications of fixes and intend to perform their own certification analyses, possibly adding weeks or months to the timetable.

Meanwhile, FAA officials in recent weeks said that Boeing hasn’t provided all of the requested details laying out the description and safety assessments of the MAX’s redesigned flight-control system.

The latest version of Indonesia’s accident report has been shared with the FAA and NTSB for comment. U.S. officials are expected to visit Indonesia around the end of this month to finalize the document. People familiar with the process said NTSB experts don’t appear to have major disagreements with the draft. Boeing and the FAA, on the other hand, are concerned the final report will unduly emphasize design and FAA certification missteps, some of these people said.

Unlike NTSB reports that identify the primary cause of accidents and then list contributing issues determined to be less significant, Indonesia is following a convention used by many foreign regulators of listing causal factors without ranking them. Instead, the report is expected to list more than 100 elements of the crash chronology, according to a person briefed on the details. Many of those points are likely to refer to missteps by pilots and mechanics initially revealed last year in Indonesia’s preliminary report.

Indonesian authorities now are asking for comments on the draft conclusions dealing with those missteps, as well as findings that investigators have determined constitute engineering shortcomings, including reliance on a sole sensor in the original design of MCAS, according to people familiar with the matter.

Write to Andy Pasztor at and Andrew Tangel at


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