Originally Posted by
slacktide
................ Pointing out that the pilot's actions were seriously deficient in no way exonerates Boeing. .............. This could include the regulations that the aircraft is designed to, the oversight of the certification and change management process by the regulator, the content and method of delivery of the NG to MAX transition training, the schedule, recency, and frequency of any recurring training, the service bulletin and FCOM/QRH deployment procedures at the airline, and the maintenance and post-maintenance test procedures at the airline. (Lionair - so far there have been no indications that Ethiopian performed maintenance on the AOA or ADIRU)
Agreed! It's called "Systems Engineering" and, in their System Safety Assessment, Boeing assumed a level of performance of the 3 elements of their system Hardware, Software and Humanware all of which was deficient
in that all elements did not meet Boeings assumed performance levels on several occasions - hence the holes lining up twice in the Safety Assessment. The holes are meant to line up once every x,000,000 hrs - but they lined up twice in quick succession - the assumed performance levels (reliability) did not provide the level of Safety required - or that it was not fully assessed - a point
SFLstu notes above with that quote "
I don't think we appreciated the ramifications of a failure of an AOA probe." That is a worry if true! Irrespective of "Well, they [the crew] should have been able to....." I personally suspect the next alignment of all 3 elements failing (one could argue MCAS worked as designed but the design was too "severe") would not have been far away - hence the grounding so we'd have time to consider what needs fixing - as you say, more than just a bit of code. The fact that, IMHO, (and that of at least a couple of other people in recent Posts) that the solution was applied in the wrong area worries me too!
As you say, all elements of the "system" need to be addressed - but, if the Q-system is where the solution should by rights be - sadly that does not seem to be likely. So, the other elements will have to be able to mitigate a bigger Risk(?) posed by MCAS solution than by a Q-system change. Would "Best of a bad job!" be too strong a phrase? And, as you say, not only do we have to make the MAX "system" safe (which we can do), we have to (re)learn how it could have been done
better. Using 2 dreadful crashes to decide we as an Industry had got things wrong is not the way to do things. We should all think long and hard where, in our own jobs, what the effects could potentially be if we don't play our part in whatever we are involved in (see the thread in the Military forum dealing with Airworthiness for example). Been in aviation 41 years now and the only progress I've made is, each year, I realise that I know even less than I thought I knew last year!
Off to find a non-asbestos fire blanket to hide under so as avoid the flaming I'm sure I'll Rx over this! Oh, and decide whether I'm just so "unsafe" I should retire immediately!