The US National Transportation Safety Board issued 7 safety recommendations to the FAA today regarding the crashes of 2 737 MAX aircraft in November 2018 and March 2019. The safety recommendation report does not address the cause of either crash, which is the responsibility of the investigators in charge in Indonesia and Ethiopia, respectively. The recommendations stem from the NTSB’s review of the ‘safety assessments conducted as part of the original design of Boeing’s Maneuvering Characteristics Augmentation System (MCAS)’, which has emerged has a potential key factor in both crashes.
All 737 MAX remain grounded worldwide pending re-certification of the aircraft by the FAA and other authorities.
The Federal Aviation Administration (FAA) is responsible for rule making regarding the certification of aircraft in the United States. The NTSB’s report provides recommendations to ‘address concerns about how multiple alerts and indications are considered when making assumptions as part of design safety assessments.’ The NTSB is concerned that Boeing and the FAA did not take in to account how pilots would react to a situation where multiple warnings and alerts would provide pilots with cascading or conflicting information.
7 NTSB recommendations
Require that Boeing (1) ensure that system safety assessments for the 737 MAX in which it assumed immediate and appropriate pilot corrective actions in response to uncommanded flight control inputs, from systems such as the Maneuvering Characteristics Augmentation System, consider the effect of all possible flight deck alerts and indications on pilot recognition and response; and (2) incorporate design enhancements (including flight deck alerts and indications), pilot procedures, and/or training requirements, where needed, to minimize the potential for and safety impact of pilot actions that are inconsistent with manufacturer assumptions. (A-19-10)
Require that for all other US type-certificated transport-category airplanes, manufacturers (1) ensure that system safety assessments for which they assumed immediate and appropriate pilot corrective actions in response to uncommanded flight control inputs consider the effect of all possible flight deck alerts and indications on pilot recognition and response; and (2) incorporate design enhancements (including flight deck alerts and indications), pilot procedures, and/or training requirements, where needed, to minimize the potential for and safety impact of pilot actions that are inconsistent with manufacturer assumptions. (A-19-11)
Notify other international regulators that certify transport-category airplane type designs (for example, the European Union Aviation Safety Agency, Transport Canada, the National Civil Aviation Agency-Brazil, the Civil Aviation Administration of China, and the Russian Federal Air Transport Agency) of Recommendation A-19-11 and encourage them to evaluate its relevance to their processes and address any changes, if applicable. (A-19-12)
Develop robust tools and methods, with the input of industry and human factors experts, for use in validating assumptions about pilot recognition and response to safety-significant failure conditions as part of the design certification process. (A-19-13)
Once the tools and methods have been developed as recommended in Recommendation A-19-13, revise existing Federal Aviation Administration (FAA) regulations and guidance to incorporate their use and documentation as part of the design certification process, including re-examining the validity of pilot recognition and response assumptions permitted in existing FAA guidance. (A-19-14)
Develop design standards, with the input of industry and human factors experts, for aircraft system diagnostic tools that improve the prioritization and clarity of failure indications (direct and indirect) presented to pilots to improve the timeliness and effectiveness of their response. (A-19-15)
Once the design standards have been developed as recommended in Recommendation A-19-15, require implementation of system diagnostic tools on transport-category aircraft to improve the timeliness and effectiveness of pilots’ response when multiple flight deck alerts and indications are present. (A-19-16)
FAA response to NTSB safety recommendations
The FAA’s first priority is safety. We welcome and appreciate the NTSB’s recommendations. The agency will carefully review these and all other recommendations as we continue our review of the proposed changes to the Boeing 737 MAX. The FAA is committed to a philosophy of continuous improvement. The lessons learned from the investigations into the tragic accidents of Lion Air Flight 610 and Ethiopian Airlines Flight 302 will be a springboard to an even greater level of safety.