ARFF Daily News

Monday the 10th of March, 2025

Here are the stories to start the new week...

Of note, our lead story regarding the cancellation of classes at the National Fire Academy.

Be safe out there!

Tom

‘This is a travesty’: Fire service leaders react to National Fire Academy training cancellations

Several leaders urge reaching out to elected officials about the importance of National Fire Academy programs

By FireRescue1 Staff

FEMA’s announcement on Friday that all in-person training offered by the National Fire Academy is canceled sparked immediate pushback from many members of the fire service community, while others defended the administration’s actions as part of its wider efforts to evaluate agency programs and spending. Naturally, many debates played out on social media, including FireRescue1’s own Facebook post breaking the news.

Fire and EMS providers as well as other first responders from across the country travel to the NFA’s Emmitsburg, Maryland, campus for the federally funded institution’s free training programs. Former U.S. Fire Administrator (October 2021-January 2025) Dr. Lori Moore-Merrell shared background information about the role of the USFA and NFA to put this news in context: “The USFA is under the auspices of FEMA but is not part of the FEMA mission proper. USFA has a separate but parallel mission that focuses on preparing first responders. The USFA specifically is an entity of the U.S. Department of Homeland Security’s FEMA with the mission to support and strengthen fire and EMS to prepare for, prevent, mitigate and respond to all hazards. The NFA is a principal part of that mission.”

Additionally, Dr. Moore-Merrell shared a list of some of the classes canceled this week and in the coming weeks for hundreds of firefighters: Executive Fire Officer; Hazardous Materials and Weapons of Mass Disaster Incident Command; Fire Investigations: First Responders; Fire and Emergency Services Training Program Management; Fire Inspection Principles; and Emergency Medical Incident Command.

FireRescue1 reached out to its editorial advisory board, contributors and other fire service leaders to share their initial reactions to the news, what this could mean for the fire service, and hopes for next steps. Read these reactions below, including additional notes from Dr. Moore-Merrell.

Dr. Lori Moore-Merrell: Former U.S. fire administrator

“The U.S. Fire Administration’s National Fire Academy (NFA) is the premier professional training institution for America’s structural, industrial and wildland firefighters (both career and volunteers) from local, state, tribal and federal agencies. It is the American fire service war college. [The canceled] courses and many others offered at the NFA are critical for firefighters and their communities. The longer the NFA is shutdown, the greater the gap in professional development for firefighters and paramedics in the U.S. The NFA instructors also train arson investigators for all levels of government, including the ATF. It is a travesty that there is an interruption in these trainings, and no one knows for how long. When did firefighter training for the safety and well-being of the public and communities become misaligned with this administration so that it needs evaluation? The decision to shut down the NFA is a huge overstep given the clear establishment of the academy and its purpose in the 1974 Fire Prevention and Control Act. It is time for our friends in the House and Senate to step up.”

Related information:

• ‘Don’t let USFA go back in the shadows’: Dr. Lori Moore-Merrell’s message to fire service leaders
• USFA: Tracking changes at the agency during a presidential transfer of power

Frank Leeb: Deputy assistant chief (ret.), FDNY; managing director, First Responder Center for Excellence

“Regardless of political affiliation, we can all agree that firefighter training must remain a priority. Simply put, safety is a byproduct of training. The more we train, and the more opportunities we have to train, the better prepared we are to save lives – both our own and those of the communities we serve. … This is not just a fire service issue—it is a public safety issue. We must urge policymakers to recognize the National Fire Academy’s critical role and advocate for its continued funding and support. Our safety – and the safety of the communities we serve – depends on it.”

• Read more: ‘Firefighter safety transcends politics’

Marc Bashoor: Chief (ret.); FireRescue1 senior fire advisor

“I can only hope this is a temporary setback that will be followed with a restart of all the valuable programs offered by the NFA. It is more important than ever that you communicate with your elected officials about the effectiveness of NFA programs. It is critical that we continue to train at all levels locally as we navigate temporary or permanent changes occurring at the NFA. We must not allow these changes to translate into chaos in our training or in our performance of duty. Our mission of service remains the same, whether our training mission is supported by the federal government or not. Furthermore, I have no idea why anybody would think that the NFA programs would not align with the administration’s priorities. This is all about public safety, and the president has indicated he supports public safety ardently, so I’m not sure what the NFA would not be supporting in the public safety mission.”

Additionally, Bashoor shared the following with the Associated Press: “The NFA is a powerhouse for the fire service. It’s not a ‘nice to have.’ It is the one avenue we have to bring people from all over the country to learn from and with each other. If we want to continue to have one of the premier fire services in the world, we need to have the National Fire Academy.”

Jason Caughey: Fire chief, Laramie County (Wyo.) Fire Authority; FireRescue1 senior fire advisor

“The cancellation of classes at the NFA marks a significant disruption in the professional development and training of our nation’s firefighters. The NFA has long served as a cornerstone for advancing fire service leadership, offering high-level educational opportunities to help individuals enhance their skills, knowledge and effectiveness in the field. It is more than just an academic institution; it is a place where future leaders of the fire service are molded, equipped to face increasingly complex and dangerous fire-related challenges.

“While there may be unforeseen circumstances that lead to the temporary suspension of classes, it is essential that the value of such training is not underestimated. The fire service is an ever-evolving field, and those in it need continuous education to stay prepared for new challenges. We must ensure that the NFA remains a robust and resilient institution, capable of adapting to challenges while continuing to provide critical training to the men and women who dedicate their lives to protecting our communities. The fire service deserves no less.

“It is unfortunate that the NFA is currently caught in the middle of politics. I hope that the president will acknowledge its importance and reopen it as soon as possible.”

Rocco Alvaro: Deputy chief, Fairfax County (Va.) Fire & Rescue

“The closure of in-person class offerings at the NFA presents a significant loss to leadership development, networking and collaboration opportunities within the fire service. These programs have long served as a cornerstone for fostering future leaders, allowing individuals to exchange ideas, develop strategic solutions and build relationships that strengthen emergency response capabilities across the fire service landscape. Without these in-person interactions, the ability to cultivate leadership, share best practices, and engage in dynamic discussions that drive progress within the fire service is diminished. Fire departments nationwide rely on these professional development opportunities to prepare their personnel for the evolving challenges of emergency response, resource management and public safety leadership.

“Beyond professional growth, in-person NFA courses reinforce the fire service’s deep-rooted commitment to our communities and our oath to protect and serve. Firefighters and emergency responders do more than respond to calls; they lead, train, educate, develop and innovate to enhance public safety. The ability to collaborate face-to-face with peers from diverse backgrounds fosters a collective approach to addressing the struggles facing today’s fire departments, from recruitment and retention to emerging threats and resource constraints. As we navigate these challenges, we must remain steadfast in our dedication to lifelong learning and professional excellence, ensuring we uphold the trust placed in us by the communities we serve.

“This beacon and shining light within our industry has now been diminished.”

Eric Linnenburger: Deputy chief of operations, Westminster (Colo.) FD

“I’m disappointed by this news, as I was looking forward to returning to campus this month to continue learning alongside my peers from across the nation in the Executive Fire Officer Program –but I’ll get over that. My real concern is for those whose jobs and livelihoods are at risk and the broader impact on our fire service. Federal employees, contractors and private businesses on and off campus now face fear and uncertainty. Anyone who has attended knows the value of the education and relationships built at the NFA – there is nothing frivolous about it. In recent years, the USFA has made great strides in unifying the fire service around a shared mission and priorities, and the NFA is central to that success. This is a disruptive and unnecessary setback, but I have no doubt our U.S. fire service will remain resilient and emerge stronger than before.”

Rommie Duckworth: Captain, Ridgefield (Conn.) FD

“As both a graduate and instructor for the NFA, I am deeply dismayed by the sudden cancellation of all in-person training. These programs are essential – not optional – for developing and maintaining the expertise our nation’s firefighters and fire service leaders need to protect their communities. The NFA provides unparalleled opportunities for firefighters to gain specialized knowledge, exchange vital information, and return to their communities equipped to handle increasingly complex emergencies.

“This disruption affects not only individual firefighters who had committed time, energy and resources to advance their skills, but it also impacts our collective mission of public safety. While we understand fiscal responsibility, cuts that undermine critical training ultimately compromise safety for both first responders and the communities we serve.

“My sincere hope is that the administration resolves this issue and reinstates these invaluable courses, reaffirming their commitment to public safety and the professionals dedicated to protecting lives across the country.”

Keith Padgett: Chief (ret.); fire and EMS academic program director, Columbia Southern University

“Ensuring the responsible use of taxpayers’ dollars is essential, but so is the continued support of the U.S. Fire Administration. The NFA has provided valuable training to thousands of emergency responders in Emmitsburg, and they have taken that knowledge back to their local organizations and made a difference. We must continue to uphold this level of education to protect lives and property across the nation.”

Andrew Beck: Training officer, Mandan City (N.D.) FD

“The NFA provides more than training classes. It’s a place to develop a professional network and learn from other fire service leaders. It is important to allow us to collectively work to solve problems and better serve our individual jurisdictions. A great example of this is the Executive Fire Officer (EFO) Program. This program allows departments of all sizes and resources to provide graduate-level training to future fire service leaders. This level of coordination and training will not be possible or accessible for agencies across the county in the private sector.”

Trevor Frodge: Bureau chief of training, West Chester (Ohio) FD

“The NFA and the USFA work diligently to ensure the safety of first responders and citizens in times of disaster and terror. By shuttering the doors of the NFA, the government’s pursuit to uncover fraud, waste and abuse has in essence stalled the education and training of America’s heroic first responders and impacted local communities. I hope that the analysis by the Department of Government Efficiency on the USFA comes to a swift and decisive end soon.”

This is an evolving story, and we will continue to share new information and insights from fire service leaders.

https://www.gov1.com/public-safety/this-is-a-travesty-fire-service-leaders-react-to-national-fire-academy-training-cancellations

Wreckage of Lancaster County plane crash under investigation

LANCASTERONLINE | Staff

An acrid smell lingered in the air around Brethren Village in Manheim Township on Monday morning, the wreckage of a crashed plane still visible behind police tape in a parking lot. 

Nearby, several smashed and burned vehicles were under and around the plane, which likely skidded more than 100 feet after hitting the ground, Manheim Township chief of police Duane Fisher said Sunday.

The Beechcraft Bonanza, a single-engine aircraft which seats six, had been scheduled to take off from the Lancaster Airport at 3:15 p.m. Sunday for a flight to Springfield, Ohio. At 3:15, Lancaster Countywide Communications dispatch got a call of a plane down. 

The Bonanza, with five people onboard, crashed shortly after 3 after taking off from Lancaster Airport, officials from the Federal Aviation confirmed. According to the aircraft’s FAA registration, the plane was owned by Jam Zoom Yayos LLC in Manheim. 

All five were injured, officials reported at a press conference Sunday afternoon, which the FAA confirmed in a preliminary report Monday. They were transported by local EMS agencies to local hospitals for treatment. No one on the ground sustained any injuries, though Brethren Village residents were asked to shelter in place as a precaution.

"I don't know if I'd consider it a miracle, but the fact that we have a plane crash where no one on the ground was hurt is a wonderful thing," Fisher said.

A person on the aircraft was heard reporting that a door on the aircraft was open before requesting a landing at the airport, the Associated Press reported. An air traffic controller had cleared the plane to land before saying "Pull up!"

Manheim Township fire rescue/emergency management director Scott Little stated they will now transition into the discovery and investigation phase. Additional info from federal agencies on next steps are to be determined. 

A dozen vehicles on the ground sustained additional damages, with five being severe. No structural damage was reported at Brethren Village. Salvation Army Emergency Disaster Service was seen on site to assist in recovery efforts.

Little said Monday that Civil Air Patrol is securing the scene for federal investigators from the FAA and National Transportation Safety Board. 

'It just nosedived'

Brian Pipkin, a Lititz resident who was visiting Brethren Village at the time of the crash, said he was driving on Airport Road when he saw the plane flying low. 

“I don’t know what played into it but it veered left,” Pipkin said. “It just nosedived.” 

Pipkin said he couldn’t tell if the plane struck a parking lot at Brethren Village or a building. He called 911. 

Pipkin said he saw two people laying in the grass nearby, covered in black marks. He wasn’t sure if they were ejected from the plane or not. 

https://lancasteronline.com/news/local/aircraft-crashes-at-brethren-village-in-manheim-township/article_4d97540c-fd21-11ef-bbe9-f7813ee350a2.html

Small aircraft makes emergency landing outside DeLand airport

Matt Leonard – WESH

DELAND, Fla. —

A small, single-engine plane safely made an emergency landing on International Speedway Boulevard outside the DeLand Airport on Saturday, according to the Volusia Sheriff's Office.

The Volusia Sheriff's Office said the plane reportedly experienced engine failure while on approach to DeLand Airport. The pilot was able to successfully land the plane on ISB just east of Kepler Road, near the DeLand Airport. No one was injured and the aircraft was undamaged.

Two people were aboard the plane at the time.

The plane's operator, Embry-Riddle Aeronautical University, provided the following statement to WESH 2: "Embry-Riddle is aware of the incident in the DeLand this morning. All occupants are accounted for and safe. The university is cooperating with all agencies and authorities on this matter."

The Volusia County Professional Firefighters Association warned drivers of traffic in the area.

https://www.wesh.com/article/aircraft-emergency-landing-outside-deland-airport/64102773

NTSB Final Report: Evolution Aircraft Inc Revo

Pilot Receiving Instruction Made “Reverse Command” Control Inputs Which Led To Side-To-Side Oscillations

Location: Carson City, Nevada Accident Number: ANC24LA024
Date & Time: April 16, 2024, 09:45 Local Registration: N976BG
Aircraft: Evolution Aircraft Inc Revo Aircraft Damage: Substantial
Defining Event: Loss of control on ground Injuries: 2 None
Flight Conducted Under: Part 91: General aviation - Instructional

Analysis: The flight instructor reported that it was the first takeoff in a weight-shift control aircraft for the pilot receiving instruction. During the takeoff roll, the aircraft veered left and then right, then rolled on its side and exited the runway. According to the flight instructor, the pilot receiving instruction made “reverse command” control inputs which led to side-to-side oscillations, which progressed without correction from the flight instructor. The pilot reported no pre-impact mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Probable Cause and Findings: The National Transportation Safety Board determines the probable cause(s) of this accident to be -- The pilot receiving instruction’s failure to maintain control of the weight-shift control aircraft, during takeoff, which resulted in collision with terrain. Contributing to the accident was the flight instructor’s delayed remedial action.

FMI: www.ntsb.gov

NTSB Final Report: Benjamin Pratt Bearhawk Patrol

Loss Of Engine Power As A Result Of Carburetor Ice

Location: Galena, Alaska Accident Number: ANC24LA014
Date & Time: February 18, 2024, 16:00 Local Registration: N406AK
Aircraft: Benjamin Pratt Bearhawk Patrol Aircraft Damage: Substantial
Defining Event: Fuel related Injuries: 1 None
Flight Conducted Under: Part 91: General aviation - Personal

Analysis: The pilot reported that while enroute, flying below a 1000-foot ceiling in 2 miles of visibility and light snow, he encountered various instances of carburetor icing which were resolved using the periodic application of carburetor heat. However, later in the flight, he encountered carburetor icing that wasn’t clearing with the application of carburetor heat. The pilot elected to make an off-airport landing and while performing a descending 180° turn, maneuvering to land, he reported that the airplane’s engine lost all power. The pilot leveled the airplane’s wings partway through the turn and landed straight ahead, in a small clearing. The airplane overran the landing area and impacted a clump of trees which resulted in substantial damage to the wings. 

According to the Carburetor Icing Probability Chart (FAA SAIB CE-09-35), the atmospheric conditions at the time of the accident were conducive to carburetor icing at cruise power and glide power.

According to FAA Advisory Circular 20-113, "To prevent accidents due to induction system icing, the pilot should regularly use [carburetor] heat under conditions known to be conducive to atmospheric icing and be alert at all times for indications of icing in the fuel system."

The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

Probable Cause and Findings: The National Transportation Safety Board determines the probable cause(s) of this accident to be -- A loss of engine power as a result of carburetor ice. Contributing to the outcome was the pilot’s failure to effectively use carburetor heat in conditions conducive to the formation of carburetor ice.

FMI: www.ntsb.gov

NTSB Prelim: Rockwell 112

A Mobile Phone Belonging To The Passenger Dialed 911 And Advised By Automated Voice Message That The Owner Was In A Severe Crash

Location: Covington, GA Accident Number: ERA25FA120
Date & Time: February 15, 2025, 23:00 Local Registration: N1423J
Aircraft: Rockwell 112 Injuries: 2 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

On February 15, 2025, about 2300, a Rockwell 112, N1423J, was destroyed when it was involved in an accident near Covington, Georgia. The private pilot and one passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

According to Federal Aviation Administration (FAA) air traffic control radio communication information, the pilot contacted Atlanta Terminal Radar Approach Control (TRACON) Departure Radar North (DRN) position for an instrument flight rules (IFR) clearance and release from Covington Municipal Airport to Valdosta Regional Airport, Valdosta, Georgia. At 2256, the pilot advised the controller he would be departing from runway 10 and was ready to depart. The DRN controller issued the clearance with an initial climb to 3,000 ft, as well as a departure frequency and transponder code, which the pilot correctly read back. The pilot was advised that the release for departure clearance was void if he had not departed within 10 minutes, which he acknowledged. There was no record that the pilot contacted the DRN controller after his last audio communication while on the ground.

A review of airport security cameras revealed that a light from the airplane came into view during the takeoff roll on runway 10 at 2259 and went out of view from that camera several seconds later. The airplane at the time when it went out of view was located about 1,800 ft down the runway. Another airport security camera with a view of where the airplane impacted trees and terrain recorded a very bright light filling the upper portion of the screen at about 1 minute later.

According to the Covington-Newton County Communications Center Call Detail Report, at 2303, a mobile phone belonging to the passenger dialed 911 and advised by automated voice message that the owner was in a severe crash and was not responding to their phone. The coordinates of the location that were given were about 34 ft northeast of the actual resting position of the main wreckage. Additionally, the Covington Police Department dispatch received a call from the FAA TRACON about 2322 reporting that the accident airplane was supposed to depart at 2259 and they had not heard from the pilot yet.

Law enforcement personnel responded to the airport and when they were at the north side of the airport from behind two chain link fences officers noted a fire erupting from a wooded area. The officers cut access points in both chain link fences, responded to the site with handheld fire extinguishers and attempted to extinguish the fire.

The accident site was located about 4,230 ft down and 620 ft north of the northern edge of runway 10. The cockpit and cabin were consumed by the postimpact fire. The wreckage was recovered and retained for further examination. 

FMI: www.ntsb.gov

Today in History

6 Years ago today: On 10 March 2019 Ethiopian Airlines flight ET302, a Boeing 737 MAX 8, crashed shortly after takeoff from Addis Ababa-Bole Airport, Ethiopia. There were no survivors among the 157 occupants.

Date: Sunday 10 March 2019

Time: 08:44

Type: Boeing 737 MAX 8

Owner/operator: Ethiopian Airlines

Registration: ET-AVJ

MSN: 62450/7243

Year of manufacture: 2018

Total airframe hrs: 1330 hours

Cycles: 382 flights

Engine model: CFMI LEAP-1B

Fatalities: Fatalities: 157 / Occupants: 157

Other fatalities: 0

Aircraft damage: Destroyed, written off

Category: Accident

Location: 50 km ESE of Addis Ababa-Bole Airport (ADD) -   Ethiopia

Phase: En route

Nature: Passenger - Scheduled

Departure airport: Addis Ababa-Bole Airport (ADD/HAAB)

Destination airport: Nairobi-Jomo Kenyatta International Airport (NBO/HKJK)

Investigating agency: AAIB Ethiopia

Confidence Rating:  Accident investigation report completed and information captured

Narrative:

Ethiopian Airlines flight ET302, a Boeing 737 MAX 8, crashed shortly after takeoff from Addis Ababa-Bole Airport, Ethiopia. There were no survivors among the 157 occupants.

Takeoff roll began from runway 07R at 08:38 hours local time, with a flap setting of 5 degrees and a stabilizer setting of 5.6 units.

At 08:38:44, ten seconds after rotation, the left and right recorded Angle of Attack (AOA) values deviated. The left AOA decreased to 11.1° then increased to 35.7° while value of right AOA indicated 14.94°.

This resulted in the onset of the stick shaker followed by a master caution light. At the same time the captain’s primary flight display (PFD) showed a drop in indicated airspeed (IAS) from 170Kt to 156Kt.

The captain initially responded by reducing the pitch as a reaction to the stick shaker. This did not stop the stick shaker and the captain to stopped applying further nose down column input at a pitch angle of 7-8° above horizon

Approaching 400 ft, the captain attempted to engage the autopilot (AP) but it was not successful. A second attempt failed as well. Passing 1000 ft radio altitude, at the third attempt, the autopilot was successfully engaged.

The captain asked the first officer to advise ATC of the inability to follow the planned departure due to a flight control problem and to request runway heading and climb 14,000ft.

The left stall management yaw damper computer which was affected by inputs from a failed left AOA sensor calculated the left hand minimum operational airspeed erroneously above 340kt (VMO). This resulted in an overspeed warning.

At the same time, the auto throttle operation was affected by the erroneous left AOA sensor value and remained in the Arm mode and failed to transition to N1 mode, which would have reduced the take-off thrust to climb thrust automatically.

The auto throttle did not give a warning or a failure flag for the flight crew when its operation was affected by the failed AOA sensor value.

The first activation of the Maneuvering Characteristics Augmentation System (MCAS) system occurred within a second where the auto throttle was supposed to reduce from take-off thrust to climb trust. And in less than another second the GPWS aural alert "DON’T SINK" sounded twice.

The activation of MCAS followed by GPWS aural alert with already ongoing stick shaker coupled with no failure flag or warning from the auto throttle in an extremely high workload environment must have caused the auto throttle remaining in the ARM mode with take-off thrust set to remain unnoticed by the crew.

At 08:39:45, captain requested flaps up and the first officer moved the flap handle to position 0. The autopilot then disengaged and the flaps reached the up position.

At 08:40:00, because of the erroneous left AOA value, the MCAS activated the first automatic nose down trim for 9 seconds. At the end of the first MCAS activation the stabilizer position was 2.1 units with the captain pulling to pitch up the airplane, with a force of around 90 lbs (41 kg). At different times when the pilot applied electrical trim for short duration or longer duration the trim stopped at about 2.3 for unknown reasons.

At 08:40:20 the second MCAS activation, lasting 7 seconds, was interrupted by the captain’s electric trim up inputs. The captain applied a nine second electric trim-up input which fully counteracted the second MCAS input and stopped the GPWS warning but it did not bring the aircraft to a neutral trim condition.

When MCAS activated for the third time an automatic nose-down trim was commanded there was no corresponding motion of the stabilizer, which is consistent with the stabilizer trim cutout switches being in the ’cutout’ position.

The captain repeatedly requested the first officer to pull up with him on the control column with pitch values oscillating between 7° nose up and -2° nose down. Pitch increased when both pilots applied forces, pitch decreased when a single pilot applied force (force oscillated between 80

lbs and 110 lbs (36-50 kg)). The vertical speed variations followed the variations of the pitch angle, with vertical speed was oscillating between -2,500 ft/min and 4,400 ft/min.

The captain requested the first officer to try the manual trim wheel, and after seconds of intense efforts, the first officer told the captain that it was not working. This was due to the amount of force required to turn the trim wheel. At this moment the stabilizer trim was at 2.3 units with the IAS at 340 Kts.

At 08:42:10 the captain asked and the first-officer to request radar control a vector to return. ATC instructed ET302 to turn right heading 260 degrees. During the radio communications with the ATC, the first officer’s action on the control column was released which increased forces on the captain’s control column. The captain then requested the first officer to check the Master Caution. Then, they both announced "left alpha vane".

At this time the airplane was almost reaching the minimum safe altitude. After about 10 seconds the captain then told the first officer that they should pitch up together. The captain then told the first officer "pitch is not enough" and "put them up". A sound similar to stab trim cut-out switches being returned to normal was recorded on the CVR, thus the stab trim cut out switches were most likely turned back on at that moment.

After a failed attempt to trim using the manual trim wheel as per the runaway stabilizer non-normal checklist and significant and unbearable amount of force on the control column, the flight crew were trying to find other means to relieve the force. The airplane was at 13800 ft; IAS was 367kt, pitch just below 1°, stabilizer at 2.3 units of trim, bank angle 21° right.

The crew was busy pulling on the controls with high muscular force trying to maintain airplane flight path control and reach 14000 ft, a target on which they remained focused. Trying to maintain flight path control was a very demanding task and represented here a high workload, physically and mentally, to the detriment of every other task.

An overspeed warning added another disruption and disturbance on board. The cockpit noise environment was unsettling and further impacted the flight crew’s concentration.

Immediately after the stab trim cut-out switches were put back in normal position, the crew attempted another unsuccessful autopilot engagement as the plane was approaching 14000 ft. At the same time, the captain applied two brief electric trim up inputs of 1 second each while pulling on the control with an average force of 100 Lbs (45 kg). The force on the controls remained between 75 and 100 Lbs.

At 08:43:20, five seconds after the trim-up inputs, the fourth MCAS triggered. The plane started to descend. During the 9-second MCAS activation, the stabilizer decreased from 2.3 units to 1 unit of trim. The captain repeatedly shouted to the first officer to pitch up. The forces were physically unmanageable by both flight crews. The aircraft began pitching nose down.

The airplane hit the ground eighteen seconds after the end of the 4th MCAS.

The investigation noted that intermittent flight control system abnormalities began well before the accident flight. Maintenance actions of relevance started occurring in December 2018 when the airplane was one month old and included several pilot write ups involving temporary fluctuations of vertical speed and altitude. There were also three reports of the airplane rolling during autopilot operation. Altitude and vertical speed indications on the PFD showed erratic and exaggerated indications.

From the maintenance log book report the airplane also suffered intermittent electrical/electronic anomalies in addition to the flight control system malfunctions. For example, three days before the crash the Auxiliary Power Unit (APU) Fault Light illuminated, and the APU had a protective shutdown. The onboard maintenance function computer message also indicated the Start Converter Unit (SCU) showed the APU’s start system was inoperative. The SCU is located in the electrical and electronics (E/E) compartment. The captain’s personal computer power outlet also had no power. The possibility of intermittent electrical/electronic system defects were an underlying issue.

The AOA sensor malfunction on the accident flight most likely occurred as the result of a power quality problem that resulted in the loss of power to the left AOA Sensor Heater. Evidence indicates the loss of power was likely due to a production related intermittent electrical/electronic failure involving the airplane’s Electrical Wiring Interconnection System (EWIS) and the AOA Sensor part.

Probable cause of the accident

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 close to the ground was the most probable cause of the accident.

Contributing Factors

1. The MCAS design relied on a single AOA sensor, making it vulnerable to erroneous input from the sensor;

2. During the design process, Boeing failed to consider the potential for uncommanded activation of MCAS, but assumed that pilots would recognize and address it through normal use of the control column, manual electric trim, and the existing Runaway Stabilizer NNC. The OMB and Emergency AD issued after the Lion Air accident included additional guidance but did not have the intended effect of preventing another MCAS-related accident;

3. While Boeing considered the possibility of uncommanded MCAS activation as part of its FHA, it did not evaluate all the potential alerts and indications that could accompany a failure leading to an uncommanded MCAS;

4. The MCAS contribution to cumulative AOA effects was not assessed;

5. The combined effect of alerts and indications that impacted pilot’s recognition and procedure prioritization were not evaluated by the Manufacturer;

6. Absence of AOA DISAGREE warning flag on the flight display panels (PFD);

7. The B737 MAX Crew difference CBT training prepared by Boeing and delivered to Pilots did not cover the MCAS system;

8. Failure by the manufacturer to design simulator training for pilots with regards to safety critical systems like MCAS with catastrophic consquences during undesired activation.

9. The manufacturer failed to provide procedures regarding MCAS operation to the crew during training or in the FCOM;

10. Failure by the manufacturer to address the safety critical questions raised by the airline which would have cleared out crew confusion and task prioritization.