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Old 6th May 2019, 17:35
  #5010 (permalink)  
wonkazoo
 
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Originally Posted by Lord Farringdon
FWIW from and ex non-pilot military aircrew viewpoint, I have been in a few crappy situations when the day has just gone bad. In mil ops we operated close to the envelope in unfamiliar environments and it's the nature of these ops that means that sometimes, on thankfully very rare occasions, guys didn't come home. We all read the accident reports and make mental notes to ourselves...must be wary of that...must not do that ...must make sure I communicate that better...take another look at that checklist etc etc. But when it happens, the engine fire, the stuck main landing gear, the assymetric flap, the loss of hydraulics, smoke and fume, lightening strikes, severe CAT in the middle of an otherwise smooth moonlit cruise, flapless over the fence on short runway at 160 kts etc etc, there is a startle factor, there is time when you hear nothing and see nothing or can't make sense of anything, there is puzzlement and a fear that your event could well be the subject of the next accident report, and yes, a not unnatural fear that this could be your last flight. There is no immediate recall capacity because your senses are so overwhelmed with incoming information that you just can't assemble any course of action except whats right in your face and that leads to target fixation, like trying to control and uncontrollable wildly spinning aircraft, like trying to select the autopilot on, again and again and again!. It takes a few moments, but eventually, the haze clears. The airplane is still flying, (not in Wonkazoos case) new information is not coming and it seems like time has slowed down. Things start switching back on, you start to interpret the sounds you are hearing, the things you can see and thankfully, you start to recall memory actions. In Wonkazoos case the information didn't stop coming. Excessive and continuous G force is an overwhelming inhibitor to clear thinking. But fortunately he broke the target fixation and bailed. Everyone who has experienced hypoxia training will have experienced target fixation and how difficult it is to self recognise it let alone break it. Unlike Wonkazoos rather more desperate situation, my personal experiences were the type of things you might train for in a simulator. So much so that once you are over the startle and the haze, the immediate actions are almost routine. Importantly, you burst into pre-trained action safe in the knowledge that the event didn't kill you, that the bird still has its feathers and is flying and that if everyone does exactly as they are trained to do we'll get this thing on the ground even if the aircraft may not be reusable afterwards!

Wonkazoo and 737 Drivers' positions are so far apart but can easily be explained by the entirely different nature of events these guys have experienced and/or trained for. My experiences would lead me to agree with 737 Drivers view. That is, you get a scare, the event stabilises, you shake yourself off and go to memory recall. All going well, you, rather than someone else gets to write the event report afterwards. But now we come to ET. This should have been non-threatening 'routine' emergency. I know, using 'routine' and 'emergency' together is an oxymoron but you are trained for this right? That's why we are checked to fly. We are supposed to know what to do in these circumstances in the air because for all those recall items we maintain 100 percent recall training for them on the ground. The ET Captain would have been living under a rock and the airline grossly negligent if he wasn't aware of the Lion Air accident and what Boeing subsequently directed was his best and only courses of action to avoid disaster.

So why didn't he handled it correctly? Why didn't he just manage the UAS, turn back and land? My belief is that he didn't feel he was experiencing a routine UAS, or shall we call this a 737 Driver type of emergency, but rather that this nasty MCAS beast, that he only relatively recently become aware of, presaged by a UAS event had selected him that day. I believe there was too much information coming in for him to get out of startle mode and that this was aggravated by an early immediate assessment that he was in a fight for survival with MCAS right from the get go. He was thinking too far down track, to something that hadn't even happened yet but which led to target fixation on selecting auto pilot and his subsequent cognitive inability to deal with flaps, Vmo or cutout switches. He was not experiencing a 737 Driver "do the checklist your trained for" type of emergency but rather the "Oh no, not this" or Wonkazoo type of emergency where a fight to the death was about to start.

If the ET Captain had never heard of MCAS, he probably would have carried out the UAS and landed safely. Basically, his mere knowledge of MCAS but lack of full understanding of it may have scared the c##p out of him. How many reports have their since been of pilots that wont fly the airplane again until they are satisfied Boeing's fix and training solutions are 100 percent and in some cases others saying they just wont fly it again regardless. The ET Captain would have been deeply concerned about the possibility of a MCAS event and this self - fulfilling prophecy may have led him into the clutches of MCAS from which there was no escape.

Watch this scene from "Glory". https://www.youtube.com/watch?v=90x6kAcVP54 and identify the difference between the 737 Driver correct actions and satisfactory outcomes and the Wonkazoo actions and outcomes. The soldier considers himself a pretty good shot but it doesn't take much to imagine the Colonel as MCAS and the soldier as the ET Captain. You see the soldier startle, you see his fumbling attempts to do a simple task, that previously he had done with aplomb and you see the utter disbelief at the outcome.

So sorry for the long opinionated post but I hope it provoked some thought. 737 Driver and Wonkazoo had an interesting, lively and ultimately respectful discussion some posts back from which I learnt a lot. I think ultimately they are both right..but for different reasons.
Thank you for finding a way to articulate one of the primary differences between my views and those of 737 Driver. (and as a consequence between two disparate groups here and probably around the world...) I've spent some time trying to noodle out a way to express them coherently and you have done better than I could have by far.

To be clear: I am agreement with most of what Mr. Driver says about training and the industry. The only real point where we diverge is on the reactions of the crews and the culpability of them or on them for the outcomes as they happened. As far as I can tell we are in agreement that industry across the board has set the stage for incidents like these, as well as that there is a ton of shared responsibility, from manufacturer to regulator to commercial operators and training systems down to (in a very minor way) the crews themselves. The difference between us is (I think) that I give the crews a pass because if all the previous people (or even some of them) had done their jobs even half competently then those six pilots would not have been sitting on a hot seat in the pointy end in the first place.

No, you cannot design an idiot-proof or perfectly safe airplane, but you can design one that won't try to kill the crews flying it if one of your data devices goes south. If you do design (and certify!!) such a contraption, no matter the cause, you should be held to very high account indeed.

Warm regards,
dce
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