NTSB Addresses Unexpected Pilot Behavior, Multiple Alarms

The NTSB issued a report on Thursday asking the FAA to ensure aircraft regulators and designers consider the effects of multiple cockpit alarms and what can happen when pilots don’t react as expected to emergency situations. According to the NTSB, the report's seven recommendations stem from its support of the ongoing investigations by Indonesia’s Komite Nasional Keselamatan Transportasi (KNKT) and the Aircraft Accident Investigation Bureau of Ethiopia into the fatal crashes of Ethiopian Airlines Flight 302 on March 10 and Lion Air Flight 610 on Oct. 29, 2018, both Boeing 737 MAX aircraft.

“We saw in these two accidents that the crews did not react in the ways Boeing and the FAA assumed they would,” said NTSB Chairman Robert Sumwalt. “Those assumptions were used in the design of the airplane and we have found a gap between the assumptions used to certify the MAX and the real-world experiences of these crews, where pilots were faced with multiple alarms and alerts at the same time.” Sumwalt emphasized that the report (PDF) does not analyze the actions of the accident pilots.

The recommendations include ensuring that system safety assessments for transport-category airplanes “consider the effect of all possible flight deck alerts and indications on pilot recognition and response” and incorporate design enhancements, pilot procedures, and training requirements to “minimize the potential for and safety impact of pilot actions that are inconsistent with manufacturer assumptions.” The board also recommended the development and incorporation of tools and methods “for use in validating assumptions about pilot recognition and response to safety-significant failure conditions as part of the design certification process” along with development and implementation of design standards for “aircraft system diagnostic tools that improve the prioritization and clarity of failure indications (direct and indirect) presented to pilots to improve the timeliness and effectiveness of their response.”