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Old 6th Apr 2019, 09:46
  #3435 (permalink)  
coaldemon
 
Join Date: Jan 2004
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I feel for the crew in these circumstances as they appear to have been overloaded to the extreme. Everyone is looking back with hindsight but a couple of things that I have seen in the Preliminary report:
1. It looks like a bird has hit and sheared off the AoA vane. It settles at 75 degrees Up and the aircraft is 15 nose up so the counterweight is holding it down. Then repeatedly trying to put in the Autopilot with Stick shaker going was only going to make a bad situation go even worse. Not a recommended procedure I have found anywhere in the Boeing Manuals for any aircraft. Very similar to a Ryanair event a few years ago in an 800. Crew manually flew it around and landed it.
2. I can't see where any complete checklists were done. None at all. Just the Stab Trim cut-outs thrown to cut-off by the FO when the Captain was trimming the aircraft back to neutral. If the FO had waited for the call for the checklist and actioned it with the Captain they may have been in a better position closer to neutral. Remember that MCAS in the old software form stops when you start to trim it back with the electric trim. When you stop you have 5 seconds so then is a good time to do the checklist and throw the switches. From what I can see there were two full applications of MCAS prior to them putting the Stab motors back on.
3. It appears that while in manual mode the Stab was trimmed even further nose down. I think this may have been inadvertent by the FO but made a bad situation even worse. It also made it more difficult to then manually trim back and they gave up. As someone has already mentioned you need to put a lot of force (around 50 lbs from memory) and have some coordination to wind it back at high speed. Or you pull the power back and slow down which brings us to
4. The Take off power was not at any stage pulled back and they went through VMO within about 2 minutes. From there they kept accelerating. All the way to 500 kts
5. Then to put the system back to normal then meant that MCAS was still inputting to the circuit. That was it. No chance of recovery

One of the things that Manufacturers need to realise is that a lot of their customers do not have English as their first language. (Frankly some of the Airbus manuals I have had to read with Franglish take this to another level as well). If the guys had read all the info on MCAS and understood it would things have been different? With stick shaker going on during departure in the Heavier machines you never select flaps up until you confirm what has happened and you are well clear of terrain. To take the Flaps up at 1000 ft in this situation knowing that the shaker was going was an interesting move most likely reflex to the quickly accelerating aircraft.

As someone else has said that is why Airline Crew get paid well and why training should be more about the things that will cause you large harm and how you react rather than some of the tick the box exercises.

Does the aircraft need to be redesigned. Nope. The software does need to be changed and Boeing need to be a lot more rigorous in how they approach these critical systems. I have flown the MAX and it is a nice aircraft to fly. Lets see where the media take the world with this one.
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