.jpg) ET-AVJ, the aircraft involved in the accident, pictured in February 2019 | |
| Accident | |
|---|---|
| Date | 10 March 2019 (2019-03-10) |
| Summary | Loss of control in flight |
| Site |
|
 | |
| Aircraft | |
| Aircraft type | Boeing 737 MAX 8 |
| Operator | Ethiopian Airlines |
| IATA flight No. | ET302 |
| ICAO flight No. | ETH302 |
| Call sign | ETHIOPIAN 302 |
| Registration | ET-AVJ |
| Flight origin | Addis Ababa Bole International Airport, Addis Ababa, Ethiopia |
| Destination | Jomo Kenyatta International Airport, Nairobi, Kenya |
| Occupants | 157 |
| Passengers | 149 |
| Crew | 8 |
| Fatalities | 157 |
| Survivors | 0 |
| This article is part of a series about the |
| Boeing 737 MAX |
|---|
| Accidents |
| 737 MAX groundings |
Ethiopian Airlines Flight 302 was a scheduledinternational passenger flight fromBole International Airport inAddis Ababa,Ethiopia, toJomo Kenyatta International Airport inNairobi, Kenya. On 10 March 2019, theBoeing 737 MAX 8 aircraft which operated the flight crashed near the town ofBishoftu six minutes aftertakeoff. All 149 passengers and 8 crew members on board died.
It isEthiopian Airlines' deadliest accident to date, surpassing the fatal hijacking ofEthiopian Airlines Flight 961 resulting in a crash near theComoros in 1996 that killed 125.[2][3] It is also the deadliest aircraft accident to occur in Ethiopia, surpassing the crash of an Ethiopian Air ForceAntonov An-26 in 1982, which killed 73 people on board.[4]
The accident was the second involving a MAX 8 in less than five months after the crash ofLion Air Flight 610 in the Java Sea that killed 189.[2][5][6] The crashes prompted a two-yearworldwide long term grounding of the jet and an investigation into how the aircraft wasapproved for passenger service.
The aircraft was a brand-newBoeing 737 MAX 8, withserial number 62450 andregistered as ET-AVJ. It was manufactured byBoeing Commercial Airplanes in 2018 and was delivered toEthiopian Airlines on 15 November. It had logged 1,330.3 airframe hours in 382 takeoff and landing cycles. It was also powered by twoCFM International LEAP-1B28B1G05 engines.[7][8]
In command was 29-year-oldCaptain Yared Getachew who had been flying with the airline for almost nine years[9] and had logged a total of 8,122 flight hours, including 4,120 hours on the Boeing 737.[a] He had been aBoeing 737-800 captain since November 2017; he started flying the Boeing 737 MAX since July 2018.[10] At the time of the accident, he was the youngest captain at the airline.[11] His co-pilot was 25-year-oldFirst Officer Ahmednur Mohammed who was a recent graduate from the airline's academy with 361 flight hours logged, including 207 hours on the Boeing 737.[b][10][11]
Flight 302 was a scheduled international passenger flight fromAddis Ababa, Ethiopia, toNairobi, Kenya. The flight departed Addis Ababa at 08:38:34local time (05:38:34UTC) with 149 passengers and 8 crew on board.[5][8]: 21
Seconds after takeoff at 05:38:44, the left and rightangle of attack (AOA) sensors immediately started disagreeing on each others data. Due to the AOA's erroneous and unstable data, the leftstick shaker immediately activated. The airspeed indicators on both sides also disagreed with each other and themaster caution and the anti-ice lights illuminated.[8]: 21
Approximately one minute into the flight, the first officer, following the captain's instructions, retracted the flaps. Within 10 seconds of this action, the autopilot disengaged, and the aircraft started to descend. The captain directed the first officer to report a "flight control" problem to the control tower.[13]
By the second minute, the MCAS had angled the horizontal stabilizer sharply downward, pitching the aircraft into a dive. Although the pilots managed to briefly counteract the nose-down attitude, the aircraft continued to lose altitude.[14]
The first officer, correctly identifying that they were experiencing a runaway MCAS activation, called out "Stab trim cut-out!" The pilots toggled switches to disable the aircraft's electricaltrim tab system, which also deactivated the MCAS software. Unlike previous 737 models, both switches disabled all electrical control of the stabilizer.[15] Without the electric trim system, the other possible way to move the stabilizer is by cranking thetrim wheel by hand, but because the stabilizer was located opposite to theelevator, strong aerodynamic forces were acting on it due to the pilots' inadequate thrust management.[16][17] At the plane's high speed, there was further pressure on the stabilizer. The pilots' attempts to manually crank the stabilizer back into position failed.[17]
Three minutes into the flight, with the aircraft continuing to lose altitude and accelerating beyond its safety limits, the captain instructed the first officer to request permission from air traffic control to return to the airport. Permission was granted, and the air traffic controllers diverted other approaching flights. Following instructions from air traffic control, they turned the aircraft to the east, and it rolled to the right. The right wing came to point down as the turn steepened.[17]
About five minutes into the flight, having struggled to keep the plane's nose from diving further by manually pulling the yoke, the captain turned the electrical trim tab system back on in the hope that it would allow him to put the stabilizer back into neutral trim. However, in turning the trim system back on, he also reactivated the MCAS software, which reactivated nine seconds later and pushed the nose further down. The captain and first officer attempted to raise the nose by manually pulling their yokes, but the aircraft continued to plunge toward the ground, crashing 25 seconds after MCAS was reactivated and 34 seconds after the captain flipped the stab trim switches.[17][14]
The aircraft disappeared from radar screens and crashed at 08:43:45, about six minutes after takeoff.[12][2][7][18] Flight tracking data showed that the aircraft's altitude and rate of climb and descent were fluctuating.[19] Several witnesses stated the plane trailed "white smoke" and made strange noises before crashing.[20] The aircraft impacted the ground at nearly 700 miles per hour (610 kn; 1,100 km/h).[17] There were no survivors.[5]
It crashed in the district ofGimbichu,Oromia Region,[21] in a farm field near the town ofBishoftu, 62 kilometres (39 mi; 33 nmi) southeast ofBole International Airport.[22] The impact created a crater about 28 metres (92 ft) wide, 40 metres (130 ft) long, and wreckage was driven up to 10 metres (33 ft) deep into the soil.[10] Wreckage was strewn around the field along with personal effects and body parts.[17][23][24]
Shortly after the crash, police and a firefighting crew from a nearbyEthiopian Air Force base arrived and extinguished the fumes on the crash site.[25] Police cordoned off the site, andEthiopian Red Cross personnel and air crash investigators moved in. Together with local villagers, they sifted through the wreckage, recovering pieces of the aircraft, personal effects, and human remains. Trucks and excavators were brought in to assist in clearing the crash site. Human remains found were bagged and taken to Bole International Airport for storage in refrigeration units typically used to store roses destined for export, before being taken toSt. Paul's Hospital in Addis Ababa for storage pending identification.[23][26] Personnel fromInterpol and Blake Emergency Services, a private British disaster response firm contracted by the Ethiopian government, arrived to gather human tissue for DNA testing, and anIsrael Police forensics team also arrived to assist in identifying the remains of the two Israeli victims of the crash.[27][28] The Chinese railway construction firmCRSG, later joined by another construction firm,CCCC, brought in large scale equipment includingexcavators andtrucks. They recovered bothflight recorders on 11 March, with the first being found at 9 am and the second flight recorder found at 1 pm.[c][29][30] The black boxes were given to Ethiopian Airlines and were sent toParis for inspection by theBEA, the French aviation accident investigation agency.[31]
The airline stated that there were 35 different nationalities among the 157 occupants on board.[32] Crash victim positive identification was announced on 13 September 2019. Nearly a hundred disaster victim identification (DVI) experts from 14 countries supported the Interpol Incident Response Team (IRT) mission.[33]
| Nationality | Deaths |
|---|---|
| Kenya | 32 |
| Canada | 16 |
| Ethiopia | 9[d] |
| China | 8[e] |
| Italy | 8 |
| United States | 8 |
| France | 7 |
| United Kingdom | 7 |
| Egypt | 6 |
| Germany | 5 |
| India | 4 |
| Slovakia | 4 |
| Austria | 3 |
| Russia | 3 |
| Sweden | 3 |
| Israel | 2 |
| Morocco | 2 |
| Poland | 2 |
| Spain | 2 |
| Belgium | 1 |
| Chile | 1 |
| Djibouti | 1 |
| Indonesia | 1 |
| Ireland | 1 |
| Mozambique | 1 |
| Nepal | 1 |
| Nigeria | 1 |
| Norway | 1 |
| Peru | 1 |
| Rwanda | 1 |
| Saudi Arabia | 1 |
| Serbia | 1 |
| Somalia | 1 |
| Sudan | 1 |
| Togo | 1 |
| Uganda | 1 |
| Yemen | 1 |
| Total | 149 |
Many of the passengers were travelling to Nairobi to attend the fourth session of theUnited Nations Environment Assembly (UNEP).[36] A total of 22 people affiliated with theUnited Nations (UN) were killed, including 7World Food Programme staff, along with staff of the United Nations office in Nairobi, theInternational Telecommunication Union, and the office of theUnited Nations High Commissioner for Refugees.[37][38] The Deputy Director of Communications for the Kenya National Commission forUNESCO, two staff ofGeneral Electric,[39] a retired Nigerian diplomat and senior UN official who was working on behalf ofUNITAR, and a staff member of the Sudan office of theInternational Organization for Migration were also among the dead.[40][41] The airline stated that one passenger had aUnited Nations laissez-passer.[32] The flight was nicknamed a "UN shuttle" as it connected theAfrican Union headquarters as well as other UN offices in Addis Ababa to theUnited Nations Office at Nairobi, the organisation's headquarters in Africa.[42][43][44][45] The Addis Ababa-Nairobi route is also popular with tourists and business people. An employee of theNorwegian Red Cross, a British intern with theNorwegian Refugee Council, an environmental agent for theAssociation of Arctic Expedition Cruise Operators, fourCatholic Relief Services staff, and a senior Ugandan police official on assignment with theAfrican Union peacekeeping force inSomalia were also killed.[46][47]
Notable victims on-board included the Italian archaeologist and Councillor for Cultural Heritage of Sicily,Sebastiano Tusa,[48] and Nigerian-Canadian academicPius Adesanmi.[49][50] Slovak politicianAnton Hrnko lost his wife and two children in the crash.[2] Other notable victims includedChristine Alalo, a Ugandan police commissioner and peacekeeper serving with theAfrican Union Mission in Somalia.[51]
Ethiopian Prime MinisterAbiy Ahmed offered his condolences to the families of the victims.[5] Ethiopian Airlines CEOTewolde Gebremariam visited the accident site, confirmed that there were no survivors and expressed sympathy and condolences.[52] Boeing issued a statement of condolence.[53]
The Ethiopian parliament declared 11 March as a day of national mourning.[54] During the opening of the fourth United Nations Environment Assembly in Nairobi, a minute of silence was observed in sympathy for the victims.[55]PresidentMuhammadu Buhari of Nigeria, in his condolence message on behalf of the government and the people of Nigeria, extended his sincere condolences to Prime Minister Abiy Ahmed of Ethiopia, the people of Ethiopia, Kenya, Canada, China and all other nations who lost citizens in the crash.[56]
On 11 March, the FAA commented that the Boeing 737 MAX 8 model wasairworthy. However, due to concerns on the operation of the aircraft, the FAA ordered Boeing to implement design changes, effective by April. It stated that Boeing "plans to update training requirements and flight crew manuals in response to the design change" to the aircraft'sManeuvering Characteristics Augmentation System (MCAS). The changes would also include enhancements to the activation of the MCAS and theangle of attack signal.[57] Boeing stated that the upgrade was developed in response to theLion Air crash but did not link it to this accident.[58]
On 19 March, theU.S. Secretary of Transportation,Elaine L. Chao, sent a memo to the U.S. Inspector General asking him to "proceed with an audit to compile an objective and detailed factual history of the activities that resulted in the certification of the Boeing 737 MAX 8 aircraft."[59]
Flight International commented that the accident would likely increase unease about the Boeing 737 MAX felt in the aftermath of theLion Air Flight 610 accident on 29 October 2018, which similarly occurred shortly after take-off and killed all 189 occupants on board.[60] Boeing shares dropped 11% over the weekend;[61] by 23 March, Boeing had lost more than $40 billion in market value, dropping some 14% since the crash.[62]
After the Ethiopian Airlines crash, China and most othercivil aviation authorities grounded the airliner over safety concerns. Other jurisdictions, including the U.S., followed suit as new evidence revealed similarities between both crashes. The groundings were ordered despite Boeing CEODennis Muilenburg's public assurances that the airplane was safe and a phone conversation with President Trump in which he "reiterated to the President our position that the MAX aircraft is safe", according to a Boeing statement.[63] In response to increasing domestic and international pressure to take action,[64][65][66] the U.S.Federal Aviation Administration (FAA) grounded the aircraft on March 13, 2019, reversing aContinued Airworthiness Notice issued two days prior.[67] About 30 MAX aircraft were flying in U.S. airspace at the time and were allowed to reach their destinations.[68] By March 18, every single Boeing 737 MAX plane (387 in total) had been grounded, which affected 8,600 weekly flights operated by 59 airlines across the globe.[69] Severalferry flights were operated with flaps extended to circumvent MCAS activation.
TheEthiopian Civil Aviation Authority (ECAA), the agency responsible for investigating civil aviation accidents in Ethiopia, investigated the accident. The aircraft manufacturer, Boeing, stated that it was prepared to work with the United StatesNational Transportation Safety Board (NTSB) and assist Ethiopian Airlines.[53] The United StatesFederal Aviation Administration (FAA) also assisted in the investigation.[70]
Both thecockpit voice recorder (CVR) and theflight data recorder (FDR) were recovered from the crash site on 11 March.[71] The FrenchBureau of Enquiry and Analysis for Civil Aviation Safety (BEA) announced that it would analyze the flight recorders from the flight.[72] BEA received the flight recorders on 14 March.[73] On 17 March,Ethiopia's transport ministerDagmawit Moges announced that "the black box has been found in a good condition that enabled us to extract almost all the data inside" and that the preliminary data retrieved from the FDR showed a clear similarity with those of Lion Air Flight 610.[74]
On 13 March 2019, the FAA announced that new evidence found from the crash site and satellite data on Flight 302 suggested that the aircraft might have experienced from the same problemLion Air Flight 610 was facing. Investigators discovered the jackscrew that controlled the pitch angle of thehorizontal stabilizer of Flight 302, was in the full "nose down" position. The finding suggested that, at the time of the crash, Flight 302 was configured to dive, similar to Lion Air Flight 610.[75] Due to this finding, some experts inIndonesia suggested that the IndonesianNational Transportation Safety Committee (NTSC) should cooperate with Flight 302's investigation team.[76] Later, the NTSC offered assistance to Flight 302's investigation team, stating that the committee and theIndonesian Transportation Ministry would send investigators and representatives from the government to assist with the investigation of the crash.[77]
On 4 April 2019, the ECAA released the preliminary report.[12] The preliminary report does not specifically mention theMCAS, but rather states "approximately five seconds after the end of the ANU (aircraft nose up) stabilizer motion, a third instance of AND (aircraft nose down) automatic trim command occurred without any corresponding motion of the stabilizer, which is consistent with the stabilizer trim cutout switches being in the "cutout" position".[12]
Approximately one minute into the flight, an airspeed of 238 knots (441 km/h; 274 mph) was selected. About 12 seconds later, theautopilot disengaged. The preliminary report asserts that the thrust remained at takeoff setting (94% N1) and the throttles did not move for the entire flight.[12][78] In the next 30 seconds thestabilizer trim moved 4.2 degrees nose down, from 4.6 to 0.4 units.[79] In the next 10 seconds, the trim moved back up to 2.3 units as a result of pilot input. The pilots agreed on executing the stabilizer trim cut-out procedure, cutting power to the trim motor operated by theMCAS.[12]
On 9 March 2020, the ECAA released an interim report. This report stated that the left and right angle of attack (AOA) values deviated by 59°. The AOA disagree message did not appear. The left minimum operating speed and left stick shaker speed was computed to be greater than the maximum operating speed without any invalidity detection. The pitchFlight Director bars disappeared then reappeared with left and right displaying different guidance. The left stick shaker then activated. The nose-down trim was triggered by the MCAS four times. The right over-speed clacker activated. On the third MCAS trigger, there was no corresponding motion of the stabilizer, which is consistent with the stabilizer trim cutout switches being in the "cutout" position at that moment. The MCAS design relied on a single AOA sensor inputs making it vulnerable to undesired activation and unreliable data. The difference training from B737NG to B737 MAX was inadequate.[80]
![[icon]](/mt/?noimg=&dark=on&url=http%3a%2f%2fen.wikipedia.org%2fwiki%2fFile%3aWiki_letter_w_cropped.svg) | This sectionneeds expansion with: more details from the final report and the ECAA's analysis of the event are needed as this section is composed mostly of differing views. You can help byadding missing information.(November 2024) |
On 23 December 2022, the ECAA released the final report in the crash, which stated:[10]
Repetitive and uncommanded airplane-nose-down inputs from the MCAS due to erroneous AOA input, and its unrecoverable activation system which made the airplane dive with the rate of -33,000 ft/min [−170 m/s] close to the ground was the most probable cause of the accident.
On 27 December 2022, the NTSB released its comments on the accident separately from the final report, saying that the Ethiopian authorities failed to include them in or append them to their report.[81] The NTSB's comments read in part:[16]
Overall, the US team concurs with the EAIB's investigation of the MCAS and related systems and the roles that they played in the accident. However, many operational and human performance issues present in this accident were not fully developed as part of the EAIB investigation. These issues include flight crew performance, crew resource management (CRM), task management, and human-machine interface. It is important for the EAIB's final report to provide a thorough discussion of these relevant issues so that all possible safety lessons can be learned.
The NTSB further detailed:[16]
Appropriate crew management of the event, per the procedures that existed at the time, would have allowed the crew to recover the airplane evenwhen faced with the uncommanded nose-down inputs.
TheBEA also submitted comments to the draft final report, in which it disagrees with some aspects of the Ethiopian findings, specifically regarding crew performance. The introduction to the BEA's comments reads in part:[82]
The BEA globally agrees with the analysis of the crew performance for phases 4 and 5 of the accident scenario. However, the BEA considers that some aspects of the analysis of the crew performance in the first phases of the flight are insufficiently developed and could improve the understanding of what could have been done by the crew which could have modified the outcome of the flight.
The report continues in documenting the pilots' errors:[82]
During the accident flight, the flight crew did not make appropriate use of theassociated applicable procedures on which he [sic] had received training in the preceding months.
The Captain's attempts to engage AP was in contradiction with the Approach to Stall or Stall Recovery maneuver check list, which was expected to be applied in reaction to the stick shaker activation.
Degradation of the CRM which started immediately after the AOA vane failure and which didn't help the crew take the necessary actions to keep the plane under control although they had received an adequate recurrent training on situations that occurred in the accident flight.
Ethiopian Airlines said theMCAS was "to the best of our knowledge" activated when the aircraft crashed.[83][84] According to Ethiopian transport ministerDagmawit Moges, the crew "performed all the procedures repeatedly provided by the manufacturer but was not able to control the aircraft".[85][86][87] Bjorn Fehrm from Leeham News stated the preliminary report confirms "the Flight Crew followed the procedures prescribed by FAA and Boeing in AD 2018-23-51",[79] released shortly after theLion Air crash.
On 29 April 2019, Boeing's CEODennis Muilenburg said that if "you go through the checklist...it calls out actions that would be taken around power management and pitch management of the airplane. It also refers to the cutout switches, that after an activation that was not pilot-induced, that you would hit the cutout switches. And, in some cases, those procedures were not completely followed".[88][89][90]
A data spike in the flight data[12] led to speculations about a bird or other debris hitting the plane as it was taking off, shearing away the airflow sensor.[91] These speculations were dismissed by Ethiopian Airlines, and Chief investigator Amdye Ayalew Fanta stated there was no indication of such damage.[91][92][93][94]
On 25 April 2019,The Aviation Herald submitted 25 questions that have arisen in the aftermath of the accident to theFAA's Flight Standardization Board (FSB) regarding their draft for certification of the Boeing 737 MAX aircraft.[1] Earlier, it stated that a copy of the version of section 2.6 of the Flight Operations Manual, "Operational Irregularities", in use by Ethiopian Airlines at the time of the crash was dated 1 November 2017 and did not include material from the Operator's Bulletin issued by Boeing on 6 November 2018.[1]
Based on the preliminary report,The Aviation Herald comes to the conclusion: "Neither of the three crews" (JT-43,JT-610, ET-302) "would have been forced to react under time pressure in order to prevent a crash, [...] without the technical malfunctions [of theangle of attack sensors] and the nose down trim inputs."[1]
According toThe Air Current aviation journal andThe Seattle Times, the preliminary report shows that while the pilots initially followed the correct procedure to disable runaway trim, they did not complete the checklist fully, and consequently, the recovery effort did not succeed.[95][96] Pilots have demonstrated in simulators that the trim wheels cannot be moved in severe mis-trim conditions combined with a high airspeed.[97] As the pilots on Flight 302 pulled on theyoke to raise the nose, the aerodynamic forces on the tail's elevator would create an opposing force on the stabilizer trim jackscrew that would prevent the pilots from moving the trim wheel by hand.[91][96][98]
The Air Current reported that the resolution for this jammed trim issue was not part of Boeing's then-current 737 manual.[95]The Seattle Times reported that pilots on the737-200 were trained for this failure, but later models became so reliable that Boeing had dropped mention of this procedure, deeming it no longer necessary for the 737.[95][96]
Experts theorise that the difficulty to trim made it necessary for the flight crew to release the cutout, and try to use electronic trim in an effort to correct the out-of-trim configuration.[79][99] According to Bjorn Fehrm (Leeham News) and Peter Lemme, the airplane was flying "at 375kts and MCAS was never designed to trim at these Speed/Altitude combinations".[79][99]
John Cox, a former 737 pilot and pilots' union safety representative, andChesley Sullenberger, who successfully ditchedUS Airways Flight 1549 in theHudson River, both didflight simulator replications of Flight 302. Cox described the rapid onset of unforeseen events as a "...breeding ground for confusion and task saturation." Sullenberger commented that "Even knowing what was going to happen, I could see how crews would have run out of time and altitude before they could have solved the problems."[100] While defending the pilots' actions, Sullenberger was also highly critical of allowing someone with only 200 hours of flight experience to be first officer.[101]
737 Model Summary Through January 2019 Model Series Orders Deliveries Unfilled {...} 737 MAX 5011 350 4661
Local residents of Gimbichu Woreda (district), where ET 302/10 March accident happened,[...]
Among those killed on the flight were 22 United Nations staff members, according to CNN. The outlet went on to note that the flight has been nicknamed a "UN shuttle," owing to its route between Ethiopian capital Addis Ababa, where the African Union headquarters are located, and Nairobi, Kenya, home of the UN's headquarters in Africa.
Analysis of preliminary report: timeline and human factor
Difficulty to trim
Summary of the 737 Max crashes
