Originally Posted by
Turb
Reading the whole document I found myself wondering why they need to tell people to train for these situations - I mean surely it's all standard training protocols - and then I look again at Tomaski's post and I find myself thinking it's time to stop trusting the civil aviation industry.
CAA SN–2019/005 is a direct response to the second B737 Max loss. It may be polite and encapsulated in vague discussion, but it is directly talking to the 737 trim system. Peripherally, it may remind some airbus operators of the implications of direct law and the need to remain in trim, but that is not the central theme.
"This is with particular reference to aircraft equipped with conventional trimming systems (i.e. non-fly-by-wire) and aircraft which use manual trim back-up systems in the event of an electronic trim system malfunction."
Until MCAS came along as a surprise in the MAX, the latent issues of the B737 trim system had been lost in the mists of time.
While giving warm fuzzies for effort, I rmain befuddled by the following comment:
"Utilising their Safety Management System (SMS)...". The industry had two exceptional events occur, which are the subject of major mishap investigations. Two airlines have SMS that would have applicable information in that area, the other 200+ IATA airlines and sundry other operators around the world, in 121, 125, 135 and 91 type ops would be wondering what they are referring to. As it is a UK CAA document, then presumably it is targeting the SMS programs of the handful of 737 operators that have the aircraft on their AOC's and which have not had events of note for the subject matter. Arguably the FCF manual reversion events from about a decade ago may at a pinch be considered to be the SMS items of note, however, that is not technically correct, the events in the manual reversion arise from an elevator position difference between power on and manual reverted conditions, which may indeed have led to an out of trim problem touching on the limitations of manual trim, but they didn't in the cases that occurred, so the SMS reference is, well, odd. Consider ICAO DOC9859 (latest revision 4, of 2018) which is the foundation of SMS systems. Within that document, it is hard to find a chapter that one would follow I.A.W the CAA's SN, Its not
Ch 3; Safety Culture,
Ch 4; Safety Performance Management
Ch. 5; Safety Data Collection and Processing Systems
Ch. 6; Safety Analysis
Ch. 7; Protection of Safety Data....
Ch.8; State Safety Management.
Ch. 9; Safety Management Systems
Out of all of those parts, how that fits into the SN suggestion to use the SMS... is lost on this observer. Possibly it is an urging of the airlines to become expert in the latent deficiencies of the aircraft they operate, to second guess the regulator and the certifying authority, but I doubt that is something that the airlines want to or should be doing. The fundamental problem with say Ch.5 and 6 which are the meat and potatoes (er, Yorkshire pud and gravy for Brexiteers) is that data doesn't exist to work with for the operators, unless they did have the problem on the Max. If they had, we would have heard about it in the Mirror, or other rag, or at least on PPrune. In the absence of data, how does a reactive linear/quasi linear system function to promote safety?
Paragraph 2.3 of the SN gives a list of suggested points of training to review and to reinforce manual flying skills. I contend the problem is not manual flying skills per se, it is loss of situational awareness. The ability for the pilots to push and pull is not in question except in a general sense that the pilots were defeated by events. Essentially, the pilots were taking a knife to a gun fight due to a lack on knowledge, and an inability on the day to get back to achieving SA, essentially they were booted outside the OODA loop at the very beginning, and never gained the bandwidth to regain SA. Does being able to hand fly an aircraft at a certain time give you that SA recovery opportunity? Possibly, but only in passing. the problem is recognition of the loss of SA, and then having strategies to recover SA.
- Manual Flight with and without Flight Directors including manual and automatic trimming scenarios, where applicable: Not the problem in the MAX event
- No autopilot, no auto thrust/auto throttle and at different control laws, where applicable, Not the problem in the MAX event
- and at different speeds (including slow flight) and altitudes •
- Steep turns using 45 degrees bank, 180 degrees to 360 degrees left and right • Not the problem in the MAX event , fun but not an issue, and usually considered as a precision flying requirement, gotta keep within xxx' etc etc etc... which is irrelevant for the purposes of recovery from out of control flight.
- Turns with and without spoilers • Not the problem in the MAX event
- Procedural instrument flying and manoeuvring including instrument departures and arrivals and visual approaches • Not the problem in the MAX event
- Prevention of and recovery from stall events • Not the problem in the MAX event. Yes they had false warning, but they never stalled. Had they recovered SA, then the aural CB would have been pulled at some point to stop the ringing in their ears.
- Thrust and pitch mode awareness in automatic, partial automatic and manual flight including pilot monitoring and crew coordination • Not the problem in the MAX event
- Automatic trim malfunctions, The MAX problem. Utterly unknown before the 1st event. inadequately understood before the 2nd event.
- associated crew actions and implications of manual intervention and lack of awareness of the aircraft’s trim state. As above. The crew advise prior to event #2 was inadequate, the problem of manual trim limitations was only referenced in legalistic weasel words, that defied the intent of being defensive in nature to the crew.
- This should include strategies to recover from an out-of-trim condition after an automated system failure and various energy states at different altitudes • The difficulty of manual trim intervention at high aerodynamic loads with applicable commercial air transport aircraft, particularly at lower altitudes and with consideration of crew coordination difficulties/techniques FINALLY That is 737 related, it is not directly airbus, CRJ, ERJ, Dassault, Gulfstream, Learjet etc... it is a 737 curiosity, that has existed for 1/2 a century and awoke from the mists of time with the advent of MCAS as produced.
- Pitch and power couple, in automatic and manual flight, with and without auto thrust. Warm fuzzy stuff, and contradictory to the MCAS out of trim case....
- Particular focus should be given to fly-by-wire aircraft, especially in the event of a control law downgrade • Flight control law downgrades, if applicable • Always worthwhile, refer to Perpignan, but again, not something arising from the ooze of most SMS data collections, only the exceptions exist and those were in.... ask your local AAIB/CAB etc.
- Unreliable airspeed events and crew co-ordination • Existing requirement, and not the primary issue in the MCAS events, it was a symptom and an increased workload issue.
- Reduction in automation levels and subsequent reinstatement of automatic systems; • Instrumentation failures and basic scan warm fuzzy stuff.
So... while always keen to spend coin on training in the simulator, I'm not sure that much of what is suggested here materially deals with the issues that are intended to be enhanced. The fundamental issue is loss of SA, with or without the recognition of the loss of SA, and the failure to implement a strategy to recover SA before making headlines.
The system does not need more bandaids on top of old bandaids, it needs to give simple training to ensure that crews can recognise when they are starting to lose the plot, and how to get back into a position where they can make sense of it all again. That can mean being able to fly on instruments, being able to pull an ejector handle, being able to read a checklist or being able to call for help from competent technical assistance. Both MCAS events placed the crews in positions where the workload and stress stopped them from regaining control of the situation, as they did not comprehend what their problem was. As went 447 for the RHS pilots full backstick input, as went the Perpignan splash, as went the A330-300 loss at Toulouse.
The simulator training proposed in the SN while all warm fuzzy stuff, and always fun to do, does not cure the fundamental problem.
ITS THE ECONOMY, S.A., STUPID
Now, HOT's, TM's etc, do what you need to do to tick the boxes, that is what regulation has devolved to, but if you want to reinforce your operational safety, work on S.A. issues, Stop the bandaids for the ulcers that we have within.
Now, I'm going off standby, and having a beer.