tency necessary to reliably survive the events with the knowledge the crews had at that time is not that trained by airlines, selected by HR, a standard obliged by the national regulators, ICAO or Iata, nor is it evident that passengers are prepared to pay to assure such standards
The rules require unexceptionalism.... And the planes issues definitely exceeded any reasonable level of that criteria.
Those cockpits were difficult environments in order to cope with what amounts to compound critical failures. It remains unreasonable to blame the messenger of the systemic failings that deregulation naturally result in
The gods of aviation have never assured pilots fair skies or flawless equipment, yet we are still commanded to keep the blue side up if humanly possible. The penultimate Lion Air crew (both Captain and FO in turn) without even an iota of information about MCAS demonstrated that the tools were available to keep the aircraft under control until the malfunction itself could be contained. The Captain of the Lion Air accident flight performed the same feat, again with no knowledge of MCAS (though the previous day's write-ups provided clues). Apparently the Captain thought his FO would have a similar level of skill at the controls, but sadly he failed to adequately monitor. Thus three out of four Lion Air pilots pretty much lay to rest the contention that this was a malfunction that rendered the aircraft uncontrollable. Challenging maybe, but not impossible.
Ethiopian 302 was another case entirely. By this time, information regarding MCAS had been disseminated. Granted Boeing published this information in a rather lawyerly, mealy-mouthed way that was far from sufficient. However, there was enough there to read between the lines that the pilots at my airline understood a few key pieces of information: if operating a MAX, an erroneous stick shaker should be considered a serious event; the unreliable airspeed and runaway trim NNC were the go-to procedures; if encountered on liftoff, do not under any circumstances retract the flaps. This knowledge was, in theory, available to the Ethiopian pilots as well.
If one were paying attention, there have been a number of troubling reports regarding Ethiopian's pilot training and certification standards and overall operating culture. The Ethiopian 409 crash into the Mediterranean back in 2010 should had been a harbinger. The accident investigation concluded, in part:
"the probable causes of the accident were the flight crew's mismanagement of the aircraft's speed, altitude, headings and attitude through inconsistent flight control inputs resulting in a loss of control and their failure to abide by CRM principles of mutual support and calling deviations"
It would be comforting to think that Ethiopian took this report to heart and poured resources into improved crew training. Instead, they blasted the findings and attempted to blame the crash on either sabotage, a shoot-down by unknown party, or a lightening strike. Not surprisingly, then we have this (largely ignored) piece from the Washington Post last April:
Ethiopian pilots raised safety concerns years before fatal crash, records show
These reports date back to 2015 (a mere five years after the ET409 accident). Quoting from the article:
One pilot said the airline didn’t “have the infrastructure” to support the fleet of Boeing and Airbus jets it ordered, and alleged the airline had a “fear-based” management culture in which “safety is being sacrificed for expansion and profit margin.” The pilot also accused the airline of failing to update pilot manuals and leaving out certain checklists designed to help pilots respond to “non-normal” situations. Another pilot criticized Ethiopian regulators for maintaining lax standards with respect to crew flight and rest time.
One pilot accused the airline of employing flight simulator trainers that are not knowledgeable about “aircraft systems, Boeing procedures, or company procedures,” and failing to follow a syllabus for a pilot training course.
The pilot also noted that “non-normal checklists in the cockpit are not kept current, including complete omission of certain checklists,” referring to documents that instruct pilots on how to respond to “non-normal” equipment behaviors that can become dangerous.
Fast forward to a time period after Lion Air but prior to the ET302 accident, we have this item published by Bloomberg, also largely ignored:
Long Before Boeing 737 Max Crash, Ethiopian Air Pilot Warned of Dangers
Quoting from the article:
An
Ethiopian Airlines pilot told senior managers at the carrier months before one of its
Boeing Co. 737 Max jets crashed that more training and better communication to crew members was needed to avert a repeat of a similar disaster involving a
Lion Air flight.
According to emails and documents reviewed by Bloomberg News, the pilot in December urged his superiors to bolster training on a 737 Max flight-control feature so crews would be better prepared for what the
Lion Air pilots encountered in October before plunging into the Java Sea, killing all aboard.
“It will be a crash for sure” if pilots struggling with a malfunction of Boeing’s flight-control system on the 737 Max also encountered, for example, a cockpit warning that they were flying too close to the ground, the pilot, Bernd Kai von Hoesslin, wrote in a Dec. 13 email.
In the December email, von Hoesslin reminded managers that flight crews could be overwhelmed by multiple warnings and cockpit alerts that can sound during an errant activation of MCAS.
In a separate email in November, von Hoesslin asked airline managers to provide more detail about MCAS to “those Max pilots who are not fully or even aware of how the Max MCAS” system functions. The request came after a flight operations manager at the airline circulated Boeing’s November 6 service bulletin that described, without naming MCAS, how erroneous sensor data could cause the jet to pitch toward the ground automatically, and how pilots should respond.
In a statement released on Twitter Wednesday, the airline said it “strictly complies with all global safety standards and regulatory requirements.” It also said that allegations it didn’t specify “are false and factually incorrect,” and called the pilot a “disgruntled former employee” who was fired.
Darryl Levitt, an attorney for von Hoesslin, said the pilot was not fired. Rather, he resigned from the airline after he had “previously raised concerns with Ethiopian Airlines that in Capt. von Hoesslin’s opinion were not adequately addressed, and his concerns related to very serious matters of aircraft safety,” Levitt said.
Gotta like that "disgruntled former employee" line. Sounds like something Boeing would have said before their world came crashing down.
Next, we have this from an April 16th update in the Aviation Herald:
On Apr 11th 2019 The Aviation Herald received a full copy of the Flight Operations Manual (FOM), Revision 18B released on Nov 30th 2018, which is currently being used by Ethiopian Airlines (verified in April 2019 to be current). Although Boeing had issued an operator's bulletin on Nov 6th 2018, which was put into
Emergency Airworthiness Directive 2018-23-51 dated Nov 7th 2018 requiring the stab trim runaway procedure to be incorporated into the FOM ahead of the sign off of this version of the FOM (the entire document is on file but not available for publishing), there is no trace of such an addition in the entire 699 pages of the FOM.
Quite the opposite, in section 2.6 of the FOM "Operational Irregularities" the last revision is provided as Revision 18 dated "Nov 1st 2017".
According to information The Aviation Herald had received in March 2019, the Airline Management needed to be reminded to distribute the Boeing Operator's Bulletin as well as the EAD to their pilots, eventually the documents were distributed to the flight crew. However, it was never verified, whether those documents had arrived, were read or had been understood. No deeper explanation of the MCAS, mentioned but not explained in both documents, was offered.
It turned out, that only very cursory knowledge about the stab trim runaway procedure exists amongst the flight crew of Ethiopian Airlines even 5 months after the EAD was distributed. In particular, none of the conditions suggesting an MCAS related stab trim runaway was known with any degree of certainty. In that context the recommendation by the accident flight's first officer to use the TRIM CUTOUT switches suggests, that he was partially aware of the contents of the EAD and reproduced some but not all of the provisions and not all of the procedure, which may or may not explain some of the obvious omissions in following the procedure in full.
Finally, we have the knowledge that Ethiopian Airlines, backed by the Ethiopian Civil Aviation Authority, thought it was perfectly acceptable to put a pilot into the right seat of a 737 after a mere
160 hours of total flight time. As a point of reference, 160 hours equates to about
two months of experience at my airline.
Taken in full, these reports draw a fairly convincing picture that Ethiopian Airlines was an accident waiting to happen.
However, Boeing's cock-up with the MAX has been so huge, so amazingly stupendously perplexingly attention-grabbing, that it has literally sucked all the oxygen away from any discussion other than
BOEING BOEING BOEING, with perhaps a smidgen of FAA regulatory capture.
So when I say Ethiopian Airlines is getting a pass, I do mean they are getting a pass.