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Lion Air 610

Printed page xviii. PDF page 20.

DISAGREE Non-Normal Checklist (NNC), but did not identify the runaway stabilizer. The multiple alerts, repetitive MCAS activations, and distractions related to numerous ATC communications contributed to the flight crew difficulties to control the aircraft. The MCAS was a
Open final report at PDF page 20Aircraft Accident Investigation Report KNKT.18.10.33.04

Lion Air 610

Printed page 193. PDF page 195.

lbs. for long term application as required in 14 FAR 25.143(d). During the accident, multiple alerts and indications occurred which increased flight crew's workload. This obscured the problem and the flight crew could not arrive at a solution during the
Open final report at PDF page 195Aircraft Accident Investigation Report KNKT.18.10.33.04

Lion Air 610

Printed page 200. PDF page 202.

identify problems and respond quickly to mitigate them. However, during the accident flight multiple alerts and indications concealed the actual problem and made it difficult for the flight crew to understand and mitigate it. 14 FAR 25.672 further requires that
Open final report at PDF page 202Aircraft Accident Investigation Report KNKT.18.10.33.04

Lion Air 610

Printed page 205. PDF page 207.

procedures to implement memory items was inappropriate 12. During the accident flight, multiple alerts and indications occurred which increased flight crew's workload. This obscured the problem and the flight crew could not arrive at a solution during the initial or
Open final report at PDF page 207Aircraft Accident Investigation Report KNKT.18.10.33.04

Lion Air 610

Printed page 208. PDF page 210.

identify problems and respond quickly to mitigate them. However, during the accident flight multiple alerts and indications concealed the actual problem and made it difficult for the flight crew to understand and mitigate it. 36. The Flight Standardization Board (FSB)
Open final report at PDF page 210Aircraft Accident Investigation Report KNKT.18.10.33.04

Lion Air 610

Printed page 215. PDF page 217.

accident crew, making it more difficult for each to take the appropriate actions. 9. The multiple alerts, repetitive MCAS activations, and distractions related to numerous ATC communications were not able to be effectively managed. This was caused by the difficulty
Open final report at PDF page 217Aircraft Accident Investigation Report KNKT.18.10.33.04