Oh, that is a very interesting report Busher.
For example, from the CVR of Lion Air 610:
22:25:39 The Captain advised the FO that he was having flu. The CVR recorded the Captain coughed about 15 times within an hour during the preflight.
Umm...flying while you are under the influence of the flu? Isn't that what sick time is for?
As for the dispatch of Lion Air 610, the report lays it off on the previous crew the night before. They acknowledge things were not right but blame that crew's inadequate reporting of the problem.
41.On the flight from Manado to Denpasar on 28 October 2018, the DFDR recorded the A/T disengaged on takeoff roll and the SPD and ALT flags on the captain’sPFD most likely had appeared after the engine start. The altimeter and speed indicator are airworthiness related instruments and must beserviceable for dispatch. The decision to continue the flight was contrary to the company procedure.
42.The engineer in Denpasar considered that the problem had appeared repeatedly and decided to replace the left AOA sensor. Replacement of AOA sensor proved to be the solution to rectify the SPD and ALT flags that were reported to have appeared on the Captain’s PFD, however the installed AOA sensor was misaligned by about 21° and resulted in different problems.
43.The Boeing test result indicated that a misaligned AOA sensor would not pass the installation test as the AOA values shown on the SMYD computer were out of tolerance and “AOA SENSR INVALID” message appeared in the SMYD BITE module. This test and subsequent testing verified that the alternate method of the installation test could identify a 20 or 21° bias in the AOA sensor.
44. Comparing the results of the installation test in Denpasar and Boeing, the investigation could not determine that the AOA sensor installation test conducted in Denpasar with any certainty.
45.The BAT LMPM required the engineer to record the test values to ensure that the test results were within tolerance. The engineer did not record the value of the AOA angle deflection during the AOA sensor installation test. Therefore, neither BAT nor Lion Air identified that the documentation had not been filled out.
LATER
56.The insufficient SMS training and inability of the employees to identify the hazard might also be indicated by the incomplete post-flight report of the problems that occurred on LNI043. The incomplete report became a hazard as the known or suspected defects were not reported which might make the engineer unable to properly maintain the airworthiness of the aircraft.
57.Content of the report did not trigger the Duty Management Pilot to assess this as a Serious Incident and enable a safety investigation. The risk of the problems that occurred on the flight LNI043 were not assessed to be considered as a hazard on the subsequent flight. TOAD: YGBSM!!
58.The LNI043 flight that experienced multiple malfunctions were considered caused or could have caused difficulties in controlling the aircraft. According to the ICAO Annex 13, CASR part 830 and OM-part A, the flight is classified as serious incident which required investigation by the KNKT in accordance with the Aviation Law Number 1 of 2009 and Government Decree Number 62 of 2013.
59.The definition of an aircraft repetitive problem was different between Lion Air CMM and BAT AMOQSM. This difference indicated that the Lion Air did not monitor the repetitive problem policy of the BAT as a subcontracted entity.
60.The requirement to report all known and suspected defects is very critical for engineering to be able to maintain the airworthiness of the aircraft.
