What could the crew know? The Lion Air 610 evidence lesson

Public record

The documented accident and safety reviews

On 29 October 2018, Lion Air flight JT610, operated using Boeing 737 MAX 8 PK-LQP, crashed into the Java Sea after departure from Jakarta. All 189 people aboard died. The Australian Transport Safety Bureau’s public record confirms that Indonesia’s NTSC released its final report on 25 October 2019. [1]

A separate NTSB safety recommendation report, dated 19 September 2019 and based on preliminary accident information, examined assumptions about pilots’ responses to unintended Maneuvering Characteristics Augmentation System (MCAS) operation. It reported that Boeing’s simulator evaluation had not reproduced the additional alerts associated with an erroneous angle-of-attack input. The NTSB concluded that the assessment inadequately accounted for the combined indications’ effect on pilot response. This was a safety assessment, not a criminal verdict. [2]

The subsequent FAA review, dated 18 November 2020, documented changes for return to service, including flight-control software using both angle-of-attack sensor inputs and additional training requirements. Its account matters here because the original configuration and later revised configuration must be kept separate. A reconstruction of the 2018 event should not silently import later safeguards. [3]

365 ALTERAM analysis

The forensic question: whose information are we reconstructing?

An investigator can review several recordings, technical diagrams and an established failure explanation at leisure. A crew must interpret indications as they arrive while managing an aircraft. Those are different information environments. Our methodological question is whether an opinion about a decision has been tested against what was available at that moment, rather than against the completed investigation.

Begin by separating three propositions: a condition existed; an indication of it reached the crew; the crew recognised its meaning. A recorded sensor value may support the first without proving the other two. Conversely, a clear recorded communication may support recognition. The task is to identify the evidence for each step without assuming either incompetence or an unavoidable outcome.

365 ALTERAM analysis

Build the timeline around available cues

In an analogous authorised review, preserve the supplied recorder material, decoding documentation, maintenance history, relevant manuals and training records. Identify the aircraft and software configuration applicable to the event. Lawful access and restrictions on recorder material must be addressed before specialist work begins; publicly available summaries cannot substitute for material that has not been examined.

Synchronise relevant recordings using documented reference events and state the remaining timing uncertainty. Distinguish the time a system recorded a condition from the time an indication was presented or a statement was made. If an apparent delay is comparable to the uncertainty in aligning the sources, a precise reaction-time claim needs qualification.

For each material interval, record what cues are established, what competing tasks are supported by the record and which response is actually evidenced. Do not equate silence in a transcript with the absence of an action. Equally, do not invent an unrecorded action to complete an attractive explanation. Mark the difference between an observation, a specialist interpretation and a gap.

365 ALTERAM analysis

Test whether the comparison is fair

A simulator exercise is useful only for the question it can answer. Before relying on one, document which cues, timing, configuration and prior knowledge were represented. Participants who already know the failure being tested may solve a different recognition problem from an unwarned crew. A simplified exercise can still test a narrow proposition, provided its limits remain visible.

Use appropriately qualified aviation and human-factor specialists to define the comparison and evaluate its significance. Independent review may find that the relevant indication was clear, training addressed it and the available response was feasible. It may instead identify an unsupported assumption, or insufficient material for a conclusion. Apply the same scrutiny to each possibility; workload is a question to examine, not an automatic explanation.

365 ALTERAM analysis

Give counsel an inspectable account of the decision

The practical deliverable is a chronology linking each disputed decision to established indications, communications, applicable documentation and uncertainty. Add a comparison schedule showing where an expert’s test reproduced the event and where it differed. That enables counsel to distinguish a disagreement about facts from a disagreement about the interpretation of human performance.

365 ALTERAM can coordinate that evidential review within an agreed instruction, with technical opinions assigned to qualified specialists. In serious proceedings, a single unsupported assumption about recognition or timing can materially affect the assessment. Correcting it may strengthen, weaken or leave the allegation unresolved. Qualified counsel determines legal strategy; a safety finding does not itself establish individual criminal responsibility.