Originally Posted by
ST Dog
I'm looking at the 20+ times he did it, 5+ minutes if I read the FDR graphs right. And was above 5000ft through that (ASL I think. What was ground level?)
I think he had a good idea of the problem (AND trim when it shouldn't) and how to counter it. He was doing it. It was only when he handed off to get the manuals that it went to sh*t.
No, I don't know how the rest of the environment would have played here.
But I do think the Capt could have keep it up and then started trying things, eventually getting to cutouts or flaps. Instead he handed off to look in manuals instead of having the F/O do that.
Before anyone jumps, i'm not defending Boeing or blaming pilots. I'm saying it looks like the Captain had it under some control much like the prior crew did. The F/O couldn't maintain that. Don't know why or even imply that he should have been able too. The captain may have been exceptional or just lucky.
Not blaming the F/O either. I drive every day but I don't have the skills a cop/protection detail have for high speed chase/escape. I'm no Grad Prix driver either. They could easily avoid a crash that I couldn't. I don't expect every pilot to have such advanced skills anymore than the average driver is expected to have suck advanced skills.
The crew were reacting to a fault that presented as a compound series of symptoms, and for a period of time they maintained a level of control of the situation. If we are discussing JT610, then the captain followed global best practice in resource management to attempt to increase his knowledge. The Captain had been dealing with an unknown issue, and had been responding effectively without necessarily having all of the facts or knowing what parts of his actions were effective. As an automated response, it is conceivable that the captain didn't recognise his actions as being abnormal, he was responding to the trim demand of the aircraft. That may appear to be speculative, however, while the captain was flying, the aircraft was under control, shortly after handing over the aircraft control to the FO, trim condition deteriorated in the absence of effective counter inputs, while the captain was in the process of accessing further information.
- At the time of the handover, the Captain did not fully comprehend what the problem was, he handed over control in order to attempt to rectify that position.
- The Captain at handover appears to not have been fully aware of his own inputs and that those were anomalous, or would not be continued by the FO.
- The FO attempted a short period of trim interventions, and then got outside of the loop.
- The crew were trained by the system, and applied or attempted to apply best practices as trained in HF training. On the day it was not effective.
- Had the Captain known what was occurring with the trim, he would have had no need to hand over to the FO hand flying,
- Had the Captain known of the MCAS system, he would have been able to take a moment to bring the aircraft into trim using the pickle switches, and then connect the AP, which would remove the MCAS function from the equation.
- In the background the crew were dealing with a false stall warning, erroneous speed and altitude displays and those alone would make the crew hesitant to attempt to engage the AP.
The OEM altered the function of the MCAS in the certification program taking away one of the two required triggers that would have limited abnormal function.
The OEM didn't comprehend (certainly better not have....) the consequences of the changed primary function of the MCAS system and didn't undertake an effective fault analysis to determine the risk from the change in function.
The lack of comprehension of the OEM as to the consequences of the re functioned MCAS led to a continuation of the position that minimal or no information was needed to be provided to the crew, and that no training was needed for the crew.
MCAS was unknown to the crew
The AOA fault presented as a compound critical fault of instrumentation, IAS/ALT, and flight dynamics, stall warning, operation of an unknown aggressive auto trim function.
Confronted with a compound emergency, the Captain at a time where the aircraft appeared to be under some control, handed over control to the FO who was apparently unaware of the inputs the Captain had been applying to counter the MCAS trim inputs.
For the ET event, the inherent limitations of the manual trim system came to the fore, again, information that was not readily available to the crew was missing.
Post hoc, the handling of the aircraft is difficult, to highly undesirable with this latent defect, when it occurs, and the crews dealing with the problem have full prior knowledge of the issues, and the interventions that are necessary, information that was not available to the accident crews.
With a highly competent crew set, it is possible that a different outcome would have occurred. That is in the lap of the gods to know the truth of, and is speculative, as the facts are simply that the fault never occurred to a crew that would be classified as highly competent, who comprehended the issue to the extent that the aircraft would have been grounded on the spot as non airworthy. Now, the preceding flight to JT610 encountered the problem, and apparently from input from a 3rd pilot became aware of the trim running. The awareness did not get to the point where the crew thereafter removed all of the problems for the continued flight to WIII, they listened to the stall warning for an hour in the cruise. The write up in the logbook doesn't reflect comprehension of the enormity of their accidental discovery of the MCAS behaviour. Hopefully that was reported by some other means internally, but it would be as shocking to find a crew that recognise the import of the issue they have observed and take action to the extent to stop the operation of the aircraft. It took the regulators 6 months to take action... the prior crew had minimal opportunity to intervene. The prior flights composition in the cockpit was non standard, and it is revealing that the cognition of the trim activity came from the observers seat, not the front seats. Whether a highly competent crew of 2 pilots only, without an observer would have resolved the problem successfully as the first crew to encounter the problem remains speculative.
The standards required for the operation of RPT aircraft are established by ICAO SARPS, separately the certification of the aircraft explicitly requires normal levels of strength and competency of the flight crew in dealing with aircraft issues. The system cannot expect constant exceptionalism from all flight crew, it is logically irrational and unobtainable. It doesn't happen with astronauts, doctors, lawyers, and certainly not politicians, so why would crews that are on food stamps in some 3rd world banana republics be expected to meet a standard that is not expected by international SARPS, certification standards, PQS, or any other field of human endeavour. A group assuming they collectively would have always been successful in dealing with such problems due to their [heritage][training standards][haircut] etc is delusional. Confronted with unique problems, a human may well achieve a successful outcome, from applying effective decision making under uncertainty, applying appropriate heuristics, or by good luck. Being damned good or lucky are not requisite standards for operating aircraft.
When preparing for a test flight, a lot of effort goes into ascertaining the potential problems that may arise, and then based on that assessment, defences are established to reduce risk to an acceptable level. In testing, with rigorous risk management protocols, bad things still happen (the Gulfstream 650 crash Roswell, 2011, the A330-300 coupled G/A- engine failure, Toulouse, 1994 come to mind). Blaming a regular flight crew for being caught out by a critical and unknown fault seems to be unreasonable; if test pilots get caught out, how much more exceptional do we expect a line crew to be???
Are we expecting exceptionalism from 300hr CPL's?
Really?