Originally Posted by
wonkazoo
When I shared what I did last night it wasn't to expiate the guilt of the crews, but instead to try and get people to realize that "blaming" people who are no longer here to defend themselves is a bit disingenuous, and equally it distracts us from the very real root causes of the two incidents.
I suspect one of the reasons this is such a difficult topic is this concept of "blame." Watching some of the occasional "blame game" at my company, I've sometimes opined sardonically that it apparently wasn't really necessary to fix the problem as long as you could fix the blame. That is, as long as you could point to someone else's mistake, you didn't have to take personal responsibility to address the issue at hand. It is a natural human reaction, and it definitely plays out in the aftermath of these accidents.
There is one huge difference between my position and that expressed most recently by 737 Driver, and that is to the responsibility for the outcome of what happened. Note that I say responsibility and not blame.
I am more than happy to replace the word "blame" with "responsibility" (though I don't think I actually used the b-word in any of my posts). It certainly does not carry the same emotional connotation. But I will state again that my position, and I think pretty much the position of the entire aviation safety community, is that aviation accidents are rarely the result of a single cause. There are many links in the chain of causation. Yes, you can point to one link and say if this or that hadn't happened, then the accident would not have happened. However,
if the goal is to make aviation safer, then you have to look at every link in the chain and address each problem on its own merits.
The result of this sad effort was a system that, if it failed, would basically try to kill the pilot and everyone on board. I say again: MCAS will try to kill everyone on board if it fails.
I would simply point out that there are a number of other system and components on every commercial aircraft flying today that fit this criteria. Engine failures, high altitude pressurization failures, smoke/fume/fire events would all be fatal if not for the timely intervention of the flight crew. The flawless aircraft simply does not exit. They will malfunction, and sometimes they malfunction in novel ways.
I simply cannot recall (but am inviting others here to fill in the blanks if you can) another system on a transport category aircraft with a failure mode that defaulted to "I'm going to try to fly the airplane into the ground.
Well, I could probably come up with a few more examples, but at my airline we had one aircraft land short of the threshold and rip off the gear when the autopilot went wonky on short final during a Cat II operation. I've personally experienced a sudden nose down departure on one of my previous aircraft during a practice autoland, though fortunately I was able to disengage the A/P and recover before anything nasty happened. I'm pretty sure that if an engine failed on takeoff and the pilots did not respond with the proper control inputs, the likely result would be a big smoking hole off the end of the runway. Once again, aircraft will malfunction, and it is incumbent on the pilots to be sufficiently vigilant (or maybe just constructively paranoid) to do whatever it takes to keep that aircraft flying.
These incidents, indeed the entirety of MCAS' existence are a failure of corporate responsibility aided and abetted by a complete abrogation of regulatory responsibility. All in the pursuit of profits for shareholders..........Those are the responsible parties, and that is what I hope people will look carefully at. It starts with the airplane. Build a safe one and operators will still find a way to muck things up, and crews will still make mistakes. But step one, the most important step, is build an effing safe airplane.
I'm not cutting Boeing, the FAA, or the airlines any slack for their role in these accidents. They all need to address their lapses. But as I've already stated, this is not a forum for Boeing. Or for the FAA. Or for airline managers. We don't really have the power to address their issues. We do have the power to address
ours.
This is a forum for professional pilots. Yes, we could sit back, point fingers, and opine about how badly
someone else screwed up. Or we could take a hard look at our profession and ask why multiple crews had such difficulty and/or reluctance in applying some very basic airmanship techniques to resolve an aircraft malfunction that, while being unique and baffling, ultimately did not render the aircraft unflyable.