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after take-off and before the first MCAS reduction aggravated the difficulties encountered by the crew
activation, the Approach to Stall or Stall to control the aircraft throughout the remainder of the flight.
Recovery Manoeuvre and the Airspeed
Unreliable Non-Normal Checklist. “During this phase, besides the destabilizing cockpit environment
linked to the activation of the stick shaker and a Master Caution
2.Captain’s insistence on engaging the A/P, immediately after take-off, the coordination and the communi-
contrary to the Approach to Stall or Stall cation between the captain and the F/O were very limited and
Recovery manoeuvre procedure. insufficient.

3.Insufficient use of the electric trim to relieve “There was no discussion nor diagnosis with respect to the nature
the high control column forces after the of the events on board. The situational awareness, problem solv-
MCAS nose down orders. ing, and decision making were therefore deeply impacted. “The

4.Captain’s lack of thrust reduction when F/O’s lack of proactivity, which comes out from the CVR tran-
the speed became excessive, which in scripts, seems to show that he was overwhelmed by the events
combination with insufficient trim, caused on board from the moment the stick shaker triggered. His low
an increase of the forces which became flight experience (300 hours total) may have accounted for this
unmanageable on both the control column situation.
and the manual trim wheel.
“The BEA regrets that the parts of the CVR transcript which
5.The use of the Logipad system by the airline allow to show the difficulties encountered by the F/O have been
as the sole means to disseminate informa- removed from the extracts of the CVR transcript published in
tion on new systems and/or procedures, the report.”
which doesn’t allow the evaluation the
crews’ understanding and knowledge acqui- The BEA’s closing remarks sum up the final tragedy in this dev-
sition on new systems and procedures. This asting air crash. It states, “it is regrettable that the report does
system was used to disseminate the infor- not include a thorough analysis of the reasons for the behaviours
mation related to the MCAS system issued observed, in relation with their training, their experience and the
following the previous 737 Max accident company organization with regard to the training and knowledge
and did not allow the airline to ensure that acquisition principles.”
the crews had read and correctly under-
stood this information. If the BEA and NTSB had not spoken up the report would have
solely blamed Boeing, whereas there were many at fault in this
The BEA added that “the lack of thrust tragic accident.

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