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10 March 2019 - Ethiopian Airlines 302

On March 10, 2019, at 05:38 UTC, Ethiopian Airlines flight 302, Boeing 737-8(MAX), ET-AVJ, took off from Addis Ababa Bole Int. Airport bound to Nairobi, Kenya Joma Kenyatta Int. Airport. Shortly after takeoff, the Angle of Attack sensor recorded value became erroneous and the left stick shaker activated and remained active until near the end of the flight. In addition, the airspeed and altitude values from the left air data system began deviating from the corresponding right side values. Due to flight control problems, the Captain was unable to maintain the flight path and requested to return back to the departure airport.
The crew lost control of the aircraft which crashed at 5: 44 UTC 28NM South East of Addis Ababa near Ejere village.

The following is based on the preliminary analysis of the DFDR, CVR and ATC communications. As the investigation continues, revisions and changes may occur before the final report is published.

At 05:37:34, ATC issued take off clearance to ET-302 and to contact radar on 119.7 MHz.

Takeoff roll began from runway 07R at a field elevation of 2333.5 mat approximately 05:38, with a flap setting of 5 degrees and a stabilizer setting of 5.6 units. The takeoff roll appeared normal, including normal values of left and right angle-of-attack (AOA). During takeoff roll, the engines stabilized at about 94% Nl, which matched the Nl Reference recorded on the DFDR. From this point for most of the flight, the Nl Reference remained about 94% and the throttles did not move. The Nl target indicated non data pattern 220 seconds before the end of recording. According to the CVR data and the control column forces recorded in DFDR, captain was the pilot flying.

At 05:38:44, shortly after liftoff, the left and right recorded AOA values deviated. Left AOA decreased to 11.1°then increased to 35.7° while value of right AOA indicated 14.94°. Then after, the left AOA value reached 74.5° in¾ seconds while the right AOA reached a maximum value of 15.3°. At this time, the left stick shaker activated and remained active until near the end of the recording. Also, the airspeed, altitude and flight director pitch bar values from the left side noted deviating from the corresponding right side values. The left side values were lower than the right side values until near the end of the recording.

At 05:38:43 and about 50 ft radio altitude, the flight director roll mode changed to LNAV.

At 05:38:46 and about 200 ft radio altitude, the Master Caution parameter changed state. The First Officer called out Master Caution Anti-Ice on CVR. Four seconds later, the recorded Left AOA Heat parameter changed state.

At 05:38:58 and about 400 ft radio altitude, the flight director pitch mode changed to VNAV SPEED and Captain called out "Command" (standard call out for autopilot engagement) and an autopilot warning is recorded.

At 05:39:00, Captain called out "Command".

At 05:39:01 and about 630 ft radio altitude, a second autopilot warning is recorded.

At 05:39:06, the Captain advised the First-Officer to contact radar and First Officer reported SHALA 2A departure crossing 8400 ft and climbing FL 320.
Between liftoff and 1000 ft above ground level (AGL), the pitch trim position moved between  4.9  and 5.9 units in response to manual electric trim inputs. At 1000 ft AGL, the  pitch trim  position was at 5.6 units.

At 05:39:22 and about 1,000 feet the left autopilot (AP) was engaged (it  disengaged  about  33 seconds later), the flaps were retracted and the pitch trim position decreased to 4.6 units.
Six seconds after the autopilot engagement, there were small amplitude roll oscillations accompanied by lateral acceleration, rudder oscillations and slight heading changes. These oscillations continued also after the autopilot was disengaged.

At 05:39:29, radar controller identified ET-302 and instructed to climb FL 340 and when able right turns direct to RUDOL and the First-Officer acknowledged.

At 05:39:42, Level Change mode was engaged. The selected altitude was 32000 ft. Shortly after the mode change, the selected airspeed was set to 238 kt.

At 05:39:45, Captain  requested  flaps  up  and  First-Officer  acknowledged.  One  second  later,  flap handle moved from 5 to O degrees and flaps retraction began.

At 05:39:50, the selected heading started to change from 072 to 197 degrees and at the same time the Captain asked the First-Officer to request to maintain runway heading.

At 05:39:55, Autopilot disengaged,

At 05:39:57, the Captain advised again the First-Officer to request to maintain runway heading and that they are having flight control problems.

At 05:40:00 shortly after the autopilot disengaged, the FDR recorded  an  automatic aircraft  nose down (AND) activated for 9.0 seconds and pitch trim moved from 4.60 to 2.1 units. The climb was arrested and the aircraft descended slightly.

At 05:40:03 Ground Proximity Warning System (GPWS) "DON'T SINK" alerts occurred.

At 05:40:05, the First-Officer reported to ATC that they were unable to maintain SHALA lA and requested runway heading which was approved by ATC.

At 05:40:06, left and right flap position reached a recorded value of 0.019 degrees which remained until the end of the recording.
The column moved aft and a positive climb was re-established during the automatic AND motion.

At 05:40:12, approximately three seconds after AND stabilizer motion ends, electric trim (from pilot activated switches on the yoke) in the Aircraft nose up (ANU) direction is recorded on the DFDR and the stabilizer moved in the ANU direction to 2.4 units. The Aircraft pitch attitude remained about the same as the back pressure on the column increased.

At 05:40:20, approximately five seconds after the end of the ANU stabilizer motion, a second instance of automatic AND stabilizer trim occurred and the stabilizer moved down and reached 0.4 units.

From 05:40:23 to 05:40:31, three Ground Proximity Warning System (GPWS) "DON'T SINK" alerts occurred.

At 05:40:27, the Captain advised the First-Officer to trim up with him.

At 05:40:28 Manual electric trim in the ANU direction was recorded and the stabilizer reversed moving in the ANU direction and then the trim reached 2.3 units.

At 05:40:35, the First-Officer called out "stab trim cut-out" two times. Captain agreed and First­ Officer confirmed stab trim cut-out.

At 05:40:41, approximately five seconds after the end of the ANU stabilizer motion, a third  instance of AND automatic trim command occurred without any corresponding motion  of  the  stabilizer, which is consistent with the stabilizer trim cutout switches were in the "cutout" position

At 05:40:44, the Captain called out three times "Pull-up" and the First-Officer acknowledged.

At 05:40:50, the Captain instructed the First Officer to advise ATC that they would like to maintain 14,000 ft and they have flight control problem.

At 05:40:56, the First-Officer requested ATC to maintain 14,000 ft and reported that they are having flight control problem. ATC approved.

From 05:40:42 to 05:43:11 (about two and a half minutes), the stabilizer position gradually moved in the AND direction from 2.3 units to 2.1 units. During this time, aft force was applied to the control columns which remained aft of neutral position. The left indicated airspeed increased from approximately 305 kt to approximately 340 kt (VMO). The right indicated airspeed was approximately 20-25 kt higher than the left.

The data indicates that aft force was applied to both columns simultaneously several times throughout the remainder of the recording.

At 05:41:20, the right overspeed clacker was recorded on CVR. It remained  active  until the  end of the recording.

At 05:41:21, the selected altitude was changed from 32000 ft to 14000 ft.

At 05:41:30, the Captain requested the First-Officer to pitch up with him and the First-Officer acknowledged.

At 05:41:32, the left overspeed warning activated and was active intermittently until the end of the recording.

At 05:41:46, the Captain asked the First-Officer if the trim is functional. The First-Officer has replied that the trim was not working and asked if he could try it manually. The Captain told him to try.

At 05:41:54, the First-Officer replied that it is not working.

At 05:42:10, the Captain asked and the First-Officer requested radar control a vector to return and  ATC approved.

At 05:42:30, ATC instructed ET-302 to turn right heading 260 degrees and the First-Officer acknowledged.

At 05:42:43, the selected heading was changed to 262 degrees.

At 05:42:51, the First-Officer mentioned Master  Caution Anti-Ice. The Master  Caution  is recorded on DFDR.

At 05:42:54, both pilots called out "left alpha vane".

At 05:43:04, the Captain asked the First Officer to pitch up together and said  that  pitch  is  not enough.

At 05:43:11, about 32 seconds before the end of the recording, at approximately 13,4002 ft, two momentary manual electric trim inputs are recorded in the ANU direction. The stabilizer moved in the ANU direction from 2.1 units to 2.3 units.

At 05:43:20, approximately five seconds after the last manual electric trim input, an AND automatic trim command occurred and the stabilizer moved in the AND direction from 2.3 to 1.0 unit in approximately 5 seconds. The aircraft began pitching nose down. Additional simultaneous aft column force was applied, but the nose down pitch continues, eventually reaching 40° nose down. The stabilizer position varied between 1.1 and 0.8 units for the remainder of the recording.

The left Indicated Airspeed increased, eventually reaching approximately 458 kts and the right Indicated Airspeed reached 500 kts at the end of the recording. The last recorded pressure altitude was 5,419 ft on the left and 8,399 ft on the right.

 

The FULL preliminary report can de downloaded HERE

 

 

AIRCRAFT FLIGHT AND MAINTENANCE LOG

The Maintenance Log Book (MLB) was reviewed in detail for the last 39 flights from 26 February 2019 until 09 March 2019 (previous flight to the accident flight). In addition, the records were reviewed for the 1A check conducted in early February.

Over the previous 39 flights, the MLB cited in particular: Captain's flight compartment PC power outlet has no power; the crew oxygen cylinder was replaced due to low pressure; and  the APU would not start. All three issues led to maintenance actions and did not reoccur.

In addition, the MLB was reviewed at a higher level for all flights back to the delivery flight in November 2018. Maintenance actions of relevance occurred in early December 2018 and involved several write-ups involving  temporary  erratic airspeed  and  altitude fluctuations  as well as  a report of the aircraft rolling during autopilot operation and  altitude and vertical speed  indication  on  the PFD showed an erratic and exaggerated indication. Maintenance actions were performed and none were reported to have reoccurred.

 

INITIAL FINDINGS

On the basis of the initial information gathered during the course of the investigation, the following facts have been determined:

  • The Aircraft possessed a valid certificate of airworthiness;
  • The crew obtained the license and qualifications to conduct the flight;
  • The takeoff roll appeared normal, including normal values of left and right angle-of-attack (AOA).
  • Shortly after liftoff, the value of the left angle of attack sensor deviated from  the  right one and reached 74.5 degrees while the right angle  of  attack sensor  value  was 15.3 degrees;  then after; the stick shaker activated and remained active until near the end of the flight.
  • After autopilot engagement, there were small amplitude roll oscillations accompanied by lateral acceleration, rudder oscillations and slight heading changes; these oscillations also continued after the autopilot disengaged.
  • After the autopilot disengaged, the DFDR recorded an automatic aircraft nose down (AND) trim command four times without pilot's input. As a result, three motions  of  the  stabilizer trim were recorded. The FDR data also indicated that the crew utilized the electric  manual trim to counter the automatic AND input.
  • The crew performed runaway stabilizer checklist and put the stab trim cutout switch to cutout position and confirmed that the manual trim operation was not working.

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