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MANY MORE
GEOFF’S TAKE

FACTORS WERE

AT PLAY IN THE

ETHIOPIAN

AIRLINES

BOEING 737

MAX AIR CRASH

Geoffrey Thomas

is often said that the first casualty of an The EAIB’s failure to follow ICAO regulations Annex 13, whereby
It air crash is the truth as lay media scramble countries participating in the investigation are allowed to review
for an instant cause and a responsible party. the draft report and provide comments to the investigative
authority and those comments to be included is disturbing. Not
Sadly, every now and then, in the past, that only did the NTSB publish its comments in a nine-page 5000-
saying can be applied to crash investigations word document it was joined by France’s Bureau of Enquiry
and a classic case that of the loss of an Air and Analysis for Civil Aviation Safety (BEA) which agreed with
New Zealand DC-10 at Mount Erebus in 1979, the concerns and added some of its own and also published its
where the Royal Commission which correctly observations.
laid the blame with the airline was overturned
by the Government till 1999. The EAIB provided the NTSB with its first draft of the report in
late 2021. The NTSB reviewed the report and provided com-
Another case was more recent with the loss ments on several aspects of the accident the NTSB believed were
of a Silk Air 737 at Palembang, Indonesia, insufficiently addressed in the draft report. The NTSB said that
in 1997, where the US National Transport the comments were primarily were focused on areas related to
Safety Board was forced to add a 48-page human factors. The NTSB said that after the EAIB reviewed the
addendum to the report essentially saying comments, it provided the NTSB with a revised draft report for its
that the Indonesia findings that the shutdown review. The NTSB said it determined the revised report failed to
of the Cockpit Voice Recorder and Flight Data address its comments sufficiently. As provided by the ICAO Annex
Recorder were caused by short circuits not 13 process, the NTSB provided the EAIB with more expansive and
pilot actions to mask human factors causes. detailed comments.

Incredibly the Indonesian crash report could The NTSB said that “instead of incorporating the most recent and
not determine the cause, which set off vari- expanded comments into their report, or appending them as had
ous unsuccessful lawsuits against Boeing and been requested, the EAIB included a hyperlink in their final report
Parker Aerospace, supplier of the 737’s rudder to an earlier and now outdated version of the NTSB’s comments.”
flight control system. In its document the NTSB said “we agree that the uncommanded
nose-down inputs from the airplane’s MCAS system should be
Now the NTSB has taken what is an unusual part of the probable cause for this accident.
step of publishing its comments on its website
after Ethiopia’s Aircraft Accident Investigation But the NTSB adds that “we believe that the probable cause
Bureau (EAIB) failed to include its comments also needs to acknowledge that appropriate crew management
in its final report into the March 10, 2019, of the event, per the procedures that existed at the time, would
crash of Ethiopian Airlines flight 302, a Boeing have allowed the crew to recover the airplane even when faced
737-800 MAX. with the uncommanded nose-down inputs.”

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