February 2023 – The poor quality of African accident investigation reports is once again in the spotlight.
THE FALLOUT FROM THE TWO Boeing Max crashes has been enormous – not just in the 346 lives lost, but in the inestimable damage to the once proud Boeing reputation for engineering excellence.
Now the pendulum is beginning to swing back – and Ethiopia is firmly in the sights of the American establishment.
African aviation regulators have an ongoing struggle to produce quality accident reports. The South African CAA has sporadic bouts of quality, but the Ethiopians have failed dismally in the two investigations that really matter – the Ethiopian 737 Max and the SACAA’s own Citation crash in George.
The National Transportation Safety Board (NTSB) has undiplomatically criticised the Ethiopian Aircraft Accident Investigation Bureau’s (EAIB) final report on the 737 Max crash. Further, the NTSB’s comments come soon after it criticised ‘the investigation’s insufficient attention to the human performance aspects of the accident’. (A euphemism for poor pilot skills).
AIN Online reports that the Ethiopian report ‘contains findings not supported by evidence. For example, the NTSB specifically cites the EAIB’s conclusion that aircraft electrical problems caused erroneous angle-of-attack (AOA) output. In its final report, the EAIB claimed that electrical problems stemming from the aircraft’s construction caused the AOA sensor’s heater to fail.’ As a result, the AOA sensor provided bad data that caused the MCAS to repeatedly pitch the nose of the plane downward until it impacted the ground.
‘A euphemism for poor pilot skills’
In direct contradiction, the NTSB found that “… a foreign object, most likely a bird, resulted in the separation of the AOA sensor vane, causing erroneous readings.” The NTSB added that it provided the EAIB with evidence that supports the finding of a foreign object strike, but the EAIB failed to include it in its final report.
The EAIB also claimed that; “an open circuit, wire fatigue, .. unexplained electrical/electronic anomalies, and the loss of heater power led to the failure of the AOA sensor.” The NTSB says that an electrical failure of the AOA sensor did not occur before the vane’s impact with a foreign object.
It is hard to disagree with the NTSB. The chances of ‘wire fatigue’ in an almost new plane must be almost nil, and the need for an AOA heater was irrelevant, as it was far from freezing.
Also – the flight data recorder showed no indication of an electrical issue with the resolvers, the NTSB added.
The NTSB also criticised the EAIB’s finding about the lack of MCAS documentation for flight crews. After the Lion Air 737 Max crash, Boeing had provided the information to all 737 Max operators – four months before the Ethiopian crash.
The NTSB says the EAIB issued its final report without giving the FAA the chance to review and comment, as stipulated by the ICAO Annex 13.
For this key investigation the EAIB has been found badly lacking – and it casts African aviation standards in a bad light.
