Lion Air crash: Airline should improve safety culture

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"In our view the plane was not airworthy".

The Boeing 737 MAX 8 crashed into the Java Sea less than 15 minutes after its October 29 takeoff, killing 189 people.

Lion Air had insisted after the crash that the plane, which was manufactured this year and had been in operation only since August, was airworthy.

Nurcahyo Utomo, aviation head at the National Transport Safety Committee, told the BBC that "several problems occurred simultaneously" during the flight, including problems with measuring air speed and altitude, and with the stick shaker.

Indonesia's aviation safety record has improved since its airlines, including national carrier Garuda, were subject to years-long bans from U.S. and European airspace for safety violations, although the country has still recorded 40 fatal accidents over the past 15 years.

KNKT has not yet said what caused the crash and the recommendations are an indication of areas of focus, but not necessarily the ultimate cause.

Problems were noted with that system on reports of earlier flights of the plane that crashed.

However, Nurcahyo Utomo told the BBC: "We haven't found the information in the manual relevant to the new feature to the 737- MAX, related to the feature for the stall prevention system".

New details of Flight JT610's final moments were also included in the report.

The preliminary report relies on data recovered from the plane's onboard flight recorder. His last words captured were "five thou", as he asked to be cleared to 5,000ft (1,500m).

Lemme said he was troubled that the pilots of the plane were not warned about the problems of earlier flights. It is equipped with an automated system that pushes the nose down if a sensor detects that the nose is pointed so high that the plane could go into an aerodynamic stall.

The pilot of the same Boeing 737 reported similar issues the day before the Lion Air crash.

This same issue had plagued the crew on Flight JT43, which made a rocky trip from Bali to Jakarta on Oct 28.

Pilots who flew the aircraft before the crash told investigators that the anti-stall system engaged due to erroneous airspeed and altitude indicators, but the flight crew managed to adjust the plane's pitch manually by shutting the automated system off. The crew disabled the aircraft's electric stabilizer trim and continued the flight, with the first officer flying on what the crew deemed to be more reliable instruments.

Boeing, in a statement released after the report's publication, said the company appreciates KNKT's efforts to investigate the cause of the accident, and is "taking every measure to fully understand all aspects of this accident".

Boeing's statement did not make any reference to a revised anti-stall system introduced on the 737 MAX which US pilots say and Indonesian investigators say was missing from the operating manual.

Revelations about the doomed Lion Air flight, released Wednesday in a preliminary report by Indonesian investigators, also exacerbated long-standing debates over what degree of automation is safest for airplanes - and how human pilots should be able to take full control.

Lion Air Flight JT610 plunged into the sea less than half an hour after taking off on a routine flight to Pangkal Pinang city.

Black box data showed the plane also had an airspeed indicator issue on multiple earlier flights, said investigators, who have yet to locate the cockpit voice recorder on the sea floor.

According to the preliminary report, this is what happened after the plane took off.

Coming from an aviation family, she said that Suneja's sister wanted to follow in his footsteps, but that the fatal accident had shaken her faith in the technology.

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