A Batik Air Boeing Co. 737 Max 8 aircraft, operated by Lion Air, downtown, sits on the tarmac at Soekarno-Hatta International Airport in Cenkareng, Indonesia, Tuesday, March 12, 2019.
Dimas Ardian | Bloomberg | Getty Images
Indonesia has recommended closer review of automated control systems, better design of flight deck alerts and accounting for a more diverse pilot population in the wake of a Boeing 737 MAX crash, according to a copy of a final report seen by Reuters.
The report of the crash of the Lion Air jet jet on October 29, 201
Less than five months after the Lion Air crash, an Ethiopian Airlines 737 MAX crashed, leading to a global anchoring of the model and triggered a business crisis at Boeing, the world's largest planner.
Indonesian investigators on Wednesday told the victims' families that a mix of factors contributed to the crash, including mechanical and design issues and a lack of documentation on how systems would behave.
"Deficiencies" in the flight crew's communication and manual control of the aircraft contributed to the crash, as did all the peas and distractions in the cockpit, according to the slides presented to families.
The final report stated that the first officer was unfamiliar with procedures and had shown problems handling the aircraft during training.
The report also found that a critical sensor providing data to an antitrust system had been mis-calibrated by a Florida workshop and that there were strong indications that it was not tested during installation by Lion Air maintenance personnel.
Lion Air is said to have grounded the jet after failures on previous flights, the report said, adding that 31 pages were missing in the airline's maintenance logs in October.
Lion Air did not respond to a request for comment.
In the report, Indonesian regulators recommended a redesign of the anti-stall system known as the MCAS that automatically pushed the aircraft's nose down, leaving pilots fighting for control.
Boeing has already stated that it would redo the system and provide more information about it in pilot manuals.
According to the report, Boeing's safety assessment assumed that pilots would respond within three seconds of a system failure, but at the accident rate and one experiencing the same problem before nightfall, it took both crews about eight seconds to respond.
Boeing has said it cannot comment before the release of the report.
A panel of international aviation safety regulations this month also stated Boeing for assumptions it made in designing the 737 MAX and found areas where Boeing could improve processes.