Ethiopian airliner down in Africa

[Sublogic]

So, why do the two cutout switches in the MAX work differently than before? The NG had one for disabling AP trim plus (?) SpeedTrim and one to cut all electric trim, meaning the thumb switches’ input too.
Max has both switches cutting all.
Why:

(1) Was there a perceived danger that one needs to make double sure to cut MCAS out otherwise it would fly the ac in the ground? Which it did anyway but for other reasons. But that switch choice shows that someone saw the danger.

(2) Troubleshooting what goes wrong with the stabilizer trim takes too long. Better cut out everything right away but keep the appearance of two switches to ensure continuity. That choice must then have been based on somebodies analyses that nobody uses the sequential cutout approach. Meaning AP and SpeedTrim never failed. That must have been documented.

(3) Disabling MCAS input together with the AP could not have been allowed due to certification issues. Having a switch for AP & SpeedTrim and one for thumb switches & MCAS was considered as too complicated, so two switches cutting out all seemed the best choice while keeping the layout.

It seem to me that whoever made that design choice was aware that MCAS could be dangerous and he/she tried a last minute fix.

[L39 Guy]

It remains an inescapable fact, meaning as in the sense of a reality, that the introduction of a software based modification became a necessary in order to get this plane certified. That must have been considered as the most optimal solution to achieve the commercial aims of introducing a plane that could be competitive to others on the market, namely the Airbus offerings. The B737 had to be kept alive to do that. But how could it be possible to keep a plane designed half a century ago may still be fit for today`s world of aviation. The Douglas DC10 was also an all time winner, but can you imagine kitting it out with the latest high ratio by pass turbo fans of today, installing some fancy computers and software in it and saying here is the answer to short haul commuter, so long as you can get your pax to don their oxy masks if we hit some bad wx. Not really all that much different to saying the B737 MAX is more than safe as is, but just to make sure no airline has sat a pair of morons up front, we have with our clever MCAS thingy tell the computer how to handle them. Now if that does not make sense as to why they put in this MCAS thingy majig, then why did they do it in the first place. That of course takes us back to where we started, which then means we got nowhere and that is the whole purpose of the whole exercise.
With the exception of the hull, the MAX is an entirely different aircraft than the original B737-100 or even the NG’s. Different wing, engines, avionics, APU, landing gear, etc. If they called it a B797 would that makes things better?

The same can be said of the B747. Today's 800 series ain’t the B747-100 of 1969. Same thing, new engines, wing, avionics, APU, etc. Is anyone trashing Boeing for that? And, for all we know, the B747-800 might have the odd bandaid too for some obscure issue just like the MAX.

[L39 Guy]

With respect, I think there may be a breakdown in communication here that may be in large part responsible for the ongoing disagreement. When people say "human factors", they don't mean "the human element", they mean Human Factors*, i.e., the study of how the human mind and body interacts with designed systems.

The human mind does not, ironically, work in the ways most people think it does - it has well-documented limitations and sources of error plumbed into its design. A human factors expert can I believe pretty trivially design a scenario where most (if not all) humans will consistently fail to correctly solve even relatively trivial problems, regardless of their competence under normal conditions.

Thus, when asking "why didn't they just fly the plane?", one possible answer is undoubtedly some variant on "they were incompetent". But another possible answer is "they were put into a scenario in which any human being would consistently fail to solve the problem, regardless of competence". Probably the truth is somewhere between those two points.

*See Wikipedia article "Human factors and ergonomics"
That’s a fair point. My response and likely that of my “cohorts” is this: what was presented to the three crews upon lift-off was a classic Unreliable Airspeed (UAS) scenario which is a an emergency that any B737 type rated pilot ought to have seen in a simulator complete with all the bells, whistles and other distractions. The fidelity of simulators is really quite amazing.

So how is it that 1/3 crews did the drill and saved the aircraft (by controlling and flying the aircraft including a managing its speed thanks to doing the UAS drill) while the other 2 crews did not do the drill which ultimately lead to an uncontrollable aircraft as speed was so high that no human could manually trim the aircraft?

Once we have addressed that issue then the next one is how is it that the successful Lion Air crew needed a jumpseat pilot to point out that they had a runaway stab trim and the fatal Lion Air crew was thumbing through the checklist looking for a memory item when they lost control of the aircraft.

To me, this points to a serious training issue at both of these airlines.

[ottorot8]

With the exception of the hull, the MAX is an entirely different aircraft than the original B737-100 or even the NG’s. Different wing, engines, avionics, APU, landing gear, etc. If they called it a B797 would that makes things better?

The same can be said of the B747. Today's 800 series ain’t the B747-100 of 1969. Same thing, new engines, wing, avionics, APU, etc. Is anyone trashing Boeing for that? And, for all we know, the B747-800 might have the odd bandaid too for some obscure issue just like the MAX.

Sorry, but your wrong. I’ve been flying 737’s for the last 28+ years. That covers the 200, 300, 500, 700, 800 and I have about a dozen flights in the Max8. You could take about 70-80% of just the -200 cockpit and use it for spare parts on a Max8. Same switches, gauges, lights, etc. The list goes on.

[568]

With the exception of the hull, the MAX is an entirely different aircraft than the original B737-100 or even the NG’s. Different wing, engines, avionics, APU, landing gear, etc. If they called it a B797 would that makes things better?

The same can be said of the B747. Today's 800 series ain’t the B747-100 of 1969. Same thing, new engines, wing, avionics, APU, etc. Is anyone trashing Boeing for that? And, for all we know, the B747-800 might have the odd bandaid too for some obscure issue just like the MAX.Not the same as the 747-400 that's for sure. Boeing will have to address this, perhaps! (Flown both BTW).

[EDLB]

To me, this points to a serious training issue at both of these airlines.

If we talk about human factors we should start at the Boeing management decision making. They had years to think about that safety case, and figured, that the two chaps in row zero would always solve this problem in seconds.
May be we need for the MAX a third mandatory jumpseat pilot which only looks for weirded trim movement to get the MAX into the air again...

[Dave Therhino]

ie is the Boeing Ops Manual Bulletin TBC-19 entirely accurate... namely:

In the event of erroneous AOA data, the pitch trim system can trim the stabilizer
nose down in increments lasting up to 10 seconds. The nose down stabilizer trim
movement can be stopped and reversed with the use of the electric stabilizer trim
switches but may restart 5 seconds after the electric stabilizer trim switches are
released.

If this is true then it would be possible (not desirable) to use electric trim to override MCAS without using the cutout switches. MCAS could be interrupted and corrected every time it kicked in. I suspect it is not entirely accurate... I wonder if anyone has an authoritative answer?


MCAS can be interrupted with the electric trim switches on the yoke each time it activates, and trim can be returned to a low/zero column force state each time if the pilot puts in adequate opposite trim inputs. That is what the Lion Air crew did for approximately 2 dozen cycles of MCAS before the final few cycles, where the pilot flying at that point failed to put in an adequate amount of opposite trim in those final cycles, allowing the out of trim condition to increase to the point where they couldn't recover in the altitude available.

[L39 Guy]

Air

If we talk about human factors we should start at the Boeing management decision making. They had years to think about that safety case, and figured, that the two chaps in row zero would always solve this problem in seconds.
May be we need for the MAX a third mandatory jumpseat pilot which only looks for weirded trim movement to get the MAX into the air again...

This “problem” didn’t have to be solved in seconds. It’s not as if the aircraft is on fire. As pointed out earlier, the ET aircraft flew for almost two minutes with UAS before the flaps were selected up and MCAS kicked in. That was two minutes to do the UAS drill. Same thing for the fatal Lion Air aircraft. You could have given them all day and I don’t think it would have got ‘er done.

As I and others of my “cohort” have stated, Boeing’s mistake was to assume that B737 type rated pilots were trained to handle a basic emergencies like UAS and Stab Trim Runaway. If either of the fatal flights had done at least UAS the aircraft would have been controllable and bought them time to figure out the stab trim issue and, once they determined that, be able to manually trim the aircraft. This is what happened in the successful Lion Air case. In fact, they completed the flight (1 1/2 hours) with UAS and MCAS disabled.

Instead, neither of the accident aircraft crews did that drill, they failed to control the aircraft as it was going way too fast for manual trim. I don’t think it’s too much to ask of professional pilots to know and do memory drills and also to fly the damn aircraft at a speed where one can manually trim and not at the barber pole.

And, to be clear fault for this lies squarely on the airlines that employ and train them, the national CAA’s that regulate them and, to a lesser extent, the aircraft manufacturers that sell them aircraft with their brand on the side of the aircraft. And, yes, MCAS needs to be toned down too.

[derjodel]

MCAS can be interrupted with the electric trim switches on the yoke each time it activates, and trim can be returned to a low/zero column force state each time if the pilot puts in adequate opposite trim inputs. That is what the Lion Air crew did for approximately 2 dozen cycles of MCAS before the final few cycles, where the pilot flying at that point failed to put in an adequate amount of opposite trim in those final cycles, allowing the out of trim condition to increase to the point where they couldn't recover in the altitude available.

An undocumented system of which the pilots have no clue it even exists can interrupt airplane trim. If the pilot doesn't want to end in a coffin corner, they need to figure out on the spot that:
- this is not STS
- because it's not STS it must be either a bug or an undocumented system
- to save their lives they need to return the trim manually to a low/zero column force each time the undocumented command is triggered.

Despite facing those conditions, the Lion Air crew managed to react appropriately about 2 dozen cycles. Fighting the unknown system raised pilot's adrenaline and fear and induced panic. Thus, incapacitated by stress put on them, they no longer managed to manually correct the erroneous system input that was trying to - and succeeded to - kill them.

[L39 Guy]

An undocumented system of which the pilots have no clue it even exists can interrupt airplane trim. If the pilot doesn't want to end in a coffin corner, they need to figure out on the spot that:
- this is not STS
- because it's not STS it must be either a bug or an undocumented system
- to save their lives they need to return the trim manually to a low/zero column force each time the undocumented command is triggered.

Despite facing those conditions, the Lion Air crew managed to react appropriately about 2 dozen cycles. Fighting the unknown system raised pilot's adrenaline and fear and induced panic. Thus, incapacitated by stress put on them, they no longer managed to manually correct the erroneous system input that was trying to - and succeeded to - kill them.

A stab trim runaway affecting the fly ability of the aircraft is no time to “figure out “ anything. The figuring out happens back on terra firma. Whether the source of the runaway is a short circuit in a switch or motor, MCAS or anything other source, when the aircraft experiences uncommanded flight control movements in pitch it’s a stab trim runaway for which there is a clear and simple memory drill. The instinctive thing would to pull or push to restore the desired path then trim for it with the electric trim switches, even if it means long burst of trim. Whatever it takes. If the trim continues to be uncontrollable, turn it off and manually trim with the wheel, however one has to be flying at something less than Vmo to do that which means controlling the thrust or, in other words, flying the airplane.

[derjodel]

A stab trim runaway affecting the fly ability of the aircraft is no time to “figure out “ anything.


Stabilizer Trim Runaway. a malfunction which occurs when the Trimmable Horizontal Stabiliser (THS), or tailplane, on the aircraft tail fails to stop at the selected position and continues to deflect up or down.


Was it? By this definition, isn't any STS operation a trim runaway?

[CurtainTwitcher]

A stab trim runaway affecting the fly ability of the aircraft is no time to “figure out “ anything. The figuring out happens back on terra firma. Whether the source of the runaway is a short circuit in a switch or motor, MCAS or anything other source, when the aircraft experiences uncommanded flight control movements in pitch it’s a stab trim runaway for which there is a clear and simple memory drill. The instinctive thing would to pull or push to restore the desired path then trim for it with the electric trim switches, even if it means long burst of trim. Whatever it takes. If the trim continues to be uncontrollable, turn it off and manually trim with the wheel, however one has to be flying at something less than Vmo to do that which means controlling the thrust or, in other words, flying the airplane.

In the isolation of a simulator session where the sim instructor selects a runaway trim malfunction, fully agree with you.

Press play below before reading on...

https://youtu.be/TrjTUvhpBlE

This was not a classic runaway trim. No trim issues were encountered until the flaps were retracted. Retract flaps, now some forward trim starts, trim back with the electric trim and everything is good for 5 seconds, just enough time to start thinking about else, there goes the trim again, fix it with electric trim, all good for 5 seconds, repeat until end of sequence. You are also dealing with an airspeed unreliable. Not easy with that racket going on the background.

To the pilots in all three event flights, this was a trim fight, not a continuous runaway in the QRH condition statement for a Runaway Stabilizer. Judge for yourself from a current in-service document:

Condition: Uncommanded stabilizer trim occurs continuously

The trim worked as they expected, sort of. If English was not your first language, it would be even more difficult.

The Lion Air crews were in the worst position, they had no prior knowledge of the subtle system changes and faults that had led them to trim fight, not a runaway.

[Uplinker]

I am not disagreeing with you but if it was a trim fight, then why could they not keep the aircraft flying (albeit very untidily), and keep on feeding opposing trim inputs to return to land?

Why were the pilots in fear and panicked? Why did they not run their memory drills?

I would like to think that faced with this problem, I would think right bugger this : “pitch - power - speed”, now what the hell is going on? But would I ?

I think SIM training needs to be seriously looked at. UAS (and trim runaway) drills are pre-briefed, and the actions explained. Then into the SIM and a UAS event occurs. Unsurprisingly, the pilots do the drill and recover the aircraft. Tick. Next item.

But UAS is not done every SIM visit every 6 months. It might only be done once every 2 or 3 years, as the training cycle rotates. Even then, it will be one of several training elements the pilots will do in that SIM session, and each pilot will typically fly just one of each exercise each, then move on to the next training item.

Just as we always have to do an engine failure at take-off, a single engine ILS to a go-around, then a single engine NPA, I think that we should always practice situations where we have to revert to basic pitch - power - speed. No autopilots, no flight directors, no auto-thrust, no speed reading/UAS. And it should be sprung on us with no prior warning. Recovery from UAS or unusual aircraft behaviour needs to be an instinctive reflex.

(For Single engine, read OEI.)

[CurtainTwitcher]

I am not disagreeing with you but if it was a trim fight, then why could they not keep the aircraft flying (albeit very untidily), and keep on feeding opposing trim inputs to return to land?

Why were the pilots in fear and panicked? Why did they not run their memory drills?

I would like to think that faced with this problem, I would think right bugger this : “pitch - power - speed”, now what the hell is going on? But would I ?

I think SIM training needs to be seriously looked at. UAS (and trim runaway) drills are pre-briefed, and the actions explained. Then into the SIM and a UAS event occurs. Unsurprisingly, the pilots do the drill and recover the aircraft. Tick. Next item.

But UAS is not done every SIM visit every 6 months. It might only be done once every 2 or 3 years, as the training cycle rotates. Even then, it will be one of several training elements the pilots will do in that SIM session, and each pilot will typically fly just one of each exercise each, then move on to the next training item.

Just as we always have to do an engine failure at take-off, a single engine ILS to a go-around, then a single engine NPA, I think that we should always practice situations where we have to revert to basic pitch - power - speed. No autopilots, no flight directors, no auto-thrust, no speed reading/UAS. And it should be sprung on us with no prior warning. Recovery from UAS needs to be an instinctive reflex.

(For Single engine, read OEI.)
The enormous elephant in the room is training. Luckily I was from the old school where we had to hand fly a lot, it was trained and encouraged, I still practice. Our organisation recently decided to do away with circling approaches because the GNSS will always be available... until it isn't because of traffic, ATC requiring a visual approach or circuit etc. Circuits are now back on the menu in sims, after an absence of 5 or 6 years as line crews are actually having to do them instead of having a runway aligned VNAV path to 500' or less. We had been deskilled, and it was recognised we needed to bring these skills back.

Unfortunately executive level management across the industry have seen automation as their nirvana, it reduces training costs if you get a pilot to stick in an autopilot at 500' and disconnect at the minima. It can be a measured skill, and therefore converted into a KPI for automated compliance monitoring, which equates to a the safest possible operation in the executives mind. The issue is the industry has deskilled it's pilots in the quest for the minimum training footprint. It works until those rusty or non-existent skills are required on a dark and stormy night. Loss of control is the major source of fatalities in the industry. Until there is a genuine commitment to keeping up the basic flying skills, these type of accidents will occur. Boeing didn't help with the MAX.

[SystemsNerd]

That’s a fair point. My response and likely that of my “cohorts” is this: what was presented to the three crews upon lift-off was a classic Unreliable Airspeed (UAS) scenario which is a an emergency that any B737 type rated pilot ought to have seen in a simulator complete with all the bells, whistles and other distractions. The fidelity of simulators is really quite amazing.

So how is it that 1/3 crews did the drill and saved the aircraft (by controlling and flying the aircraft including a managing its speed thanks to doing the UAS drill) while the other 2 crews did not do the drill which ultimately lead to an uncontrollable aircraft as speed was so high that no human could manually trim the aircraft?

Once we have addressed that issue then the next one is how is it that the successful Lion Air crew needed a jumpseat pilot to point out that they had a runaway stab trim and the fatal Lion Air crew was thumbing through the checklist looking for a memory item when they lost control of the aircraft.

To me, this points to a serious training issue at both of these airlines.




"How is it that...?" is exactly the right question IMO, but the answer may be "they were physiologically incapable under the circumstances" rather than "they didn't know how".

Like, the first step in response is probably to ensure that pilots' rational minds do indeed know how to recover the aircraft in a classroom setting. If that's missing then yeah, incompetence, basic training issue, needs fixing immediately. It's possible that this was missing in all three of these cases. It's also possible, based on available evidence, that it wasn't; in this scenario, we proceed to the next step.

If the pilots' rational minds have the solution but they're not applying it, then my understanding of human factors suggests that the likely problem is that their reacting minds - Mark Levy's "chimpanzee brain" from the video linked earlier - is siezing control, in keeping with a few billion years of evolutionary training, and letting the aircraft fly itself into the ground, because chimpanzees can't fly jet aircraft.

There's a couple of obvious approaches to deal with this scenario. The first is to figure out what stimuli are causing the chimpanzee to take over, and removing those stimuli. This is classic human factors work. For example, the stick shaker is AIUI a nice bit of human factors design that is intended to reliably break the pilot's concentration and draw attention to the fact that the aircraft is approaching a stall. Probably there is an amount of time it needs to run before 99.9% of humans have consciously noted it, and that's probably single-digit seconds. Having it drop down to an insistent throb after that point might maintain the information while allowing the pilot to concentrate again. (Maybe this is the wrong fix; the point is that this is the *class* of solution you'd be looking for.)

The second one is to actively train the chimpanzee to sit down and shut up, which probably requires replicating the systems' conditions more faithfully in training. Yes, a simulator captures the aircraft system's condition very accurately, I'm not disputing that, but it's not obvious that it's capturing the human system's condition. Specifically, I would imagine that the chimpanzee learns very quickly that the simulator is essentially safe and it has nothing to worry about, so it doesn't flip out if it suspects the simulator is about to crash. In a real in-flight emergency, that's not going to be the case, so pilots probably should be explicitly trained to manage their own minds and bodies in emergency situations to prevent the chimp from taking over.

One possible solution (on which there is probably a bunch of research that may show it to be a very poor idea) would be to hook crews up to an IV line in sim training, and give them a massive slug of adrenaline when they first realise something is wrong. Their body is then going to want to drop into a classic fight-or-flight response; given that a stall can neither be run away from nor punched to death, this is unproductive, so you'd want to train pilots to manage this physiological process so they can get back to applying their rational-mind training as quickly as possible, and fly the damn plane. If they don't have this training, it's not surprising that they're failing at this in real life, and if that's the case then all the sim time and process-knowledge in the world isn't going to save them.

[rubik101]

I confess I have not read ALL the previous posts. I trust I am not treading on anyone's toes here. Pitch-power-speed is the go-to mantra for most of us who learned to fly with an AVGAS engine, a fixed pitch propeller in front of us and an instructor to our right. However, when the aircraft misbehaves in an unexpected fashion not mentioned in any QRH or training manual then the sense of disorientation, surprise, incredulity, inadequacy, anger, and frustration will swamp the brain and preclude all rational thought. Disengaging the auto-pilot, leveling the wings, looking for the horizon, and applying 75% of available power will still appear to the observer as a failed exercise and lead to further confusion etc, intensifying the cycle until utter hopelessness swamps the poor pilot. Imho, these two MAX 8 crashes were design faults and Boeing is squarely to blame for the failure to engage with owners regarding the subtle changes to the anti-stall system. I am glad I was not on board because even though we can all sit here and imagine that we would have done it differently, many of us might not.

[Dave Therhino]

An undocumented system of which the pilots have no clue it even exists can interrupt airplane trim. If the pilot doesn't want to end in a coffin corner, they need to figure out on the spot that:
- this is not STS
- because it's not STS it must be either a bug or an undocumented system
- to save their lives they need to return the trim manually to a low/zero column force each time the undocumented command is triggered.

Despite facing those conditions, the Lion Air crew managed to react appropriately about 2 dozen cycles. Fighting the unknown system raised pilot's adrenaline and fear and induced panic. Thus, incapacitated by stress put on them, they no longer managed to manually correct the erroneous system input that was trying to - and succeeded to - kill them.

I want to be clear I was simply answering a previous poster's question about how MCAS worked, and not attempting to defend the system design.

Regarding your last paragraph, one theory is that for some reason the pilot who had been successfully countering MCAS for 24 cycles transferred control to the other pilot, who did not put in sufficiently large opposite trim inputs and lost it in three cycles.

[L39 Guy]

Sorry, but your wrong. I’ve been flying 737’s for the last 28+ years. That covers the 200, 300, 500, 700, 800 and I have about a dozen flights in the Max8. You could take about 70-80% of just the -200 cockpit and use it for spare parts on a Max8. Same switches, gauges, lights, etc. The list goes on.

Yes, the overhead panel is 1960’s but the cockpit displays, FMS, engines, wings, and other major components sure aren’t. The point is not a part by part count but the major components of the MAX are completely different than the -100 even to the extent that one could legitimately not call it a B737.

[L39 Guy]

Was it? By this definition, isn't any STS operation a trim runaway?

Runaway Stabilizer: Uncommanded stabilizer trim movement occurs continuously. (Source B737 NNC)

[GordonR_Cape]

@SystemsNerd
One possible solution (on which there is probably a bunch of research that may show it to be a very poor idea) would be to hook crews up to an IV line in sim training, and give them a massive slug of adrenaline when they first realise something is wrong. Their body is then going to want to drop into a classic fight-or-flight response; given that a stall can neither be run away from nor punched to death, this is unproductive, so you'd want to train pilots to manage this physiological process so they can get back to applying their rational-mind training as quickly as possible, and fly the damn plane. If they don't have this training, it's not surprising that they're failing at this in real life, and if that's the case then all the sim time and process-knowledge in the world isn't going to save them.

That kind of intensive training was used for early astronauts (The Right Stuff), since the risks were very high, but the dropout rate was very high. Some of today's veteran pilots with military fast-jet experience, might also have gone through that process. In the current era of widespread passenger jet transportation, I don't think that kind of training is viable.

[Lost in Saigon]

In the isolation of a simulator session where the sim instructor selects a runaway trim malfunction, fully agree with you.

Press play below before reading on...

https://youtu.be/TrjTUvhpBlE

This was not a classic runaway trim. No trim issues were encountered until the flaps were retracted. Retract flaps, now some forward trim starts, trim back with the electric trim and everything is good for 5 seconds, just enough time to start thinking about else, there goes the trim again, fix it with electric trim, all good for 5 seconds, repeat until end of sequence. You are also dealing with an airspeed unreliable. Not easy with that racket going on the background.

To the pilots in all three event flights, this was a trim fight, not a continuous runaway in the QRH condition statement for a Runaway Stabilizer. Judge for yourself from a current in-service document:


Condition: Uncommanded stabilizer trim occurs continuously



The trim worked as they expected, sort of. If English was not your first language, it would be even more difficult.

The Lion Air crews were in the worst position, they had no prior knowledge of the subtle system changes and faults that had led them to trim fight, not a runaway.




Runaway Stabilizer: Uncommanded stabilizer trim movement occurs continuously. (Source B737 NNC)






In November 2018, after Lion Air, some (or all) operators, changed the checklist list and removed the word “continuous”.


https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/1080x945/thumbnail_1__449026ad328407a08e31559260fd80457a716771.jpg












https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/1080x1177/thumbnail_03dc14b910e0b79951314db9c04969b942057c2b.jpg

[A0283]

Hard to keep up ...

But this comes from the Wall Street Journal:

Boeing test pilots lacked key details of 737 MAX flight-control system

Boeing limited the role of its own pilots in the final stages of developing the 737 MAX flight-control system implicated in two fatal crashes, departing from a longstanding practice of seeking their detailed input, people familiar with the matter said.


As a result, Boeing test pilots and senior pilots involved in the MAX’s development didn’t receive detailed briefings about how fast or steeply the automated system known as MCAS could push down a plane’s nose, these people said.

[GordonR_Cape]

Hard to keep up ...

But this comes from the Wall Street Journal:

Boeing test pilots lacked key details of 737 MAX flight-control system Boeing limited the role of its own pilots in the final stages of developing the 737 MAX flight-control system implicated in two fatal crashes, departing from a longstanding practice of seeking their detailed input, people familiar with the matter said.

As a result, Boeing test pilots and senior pilots involved in the MAX’s development didn’t receive detailed briefings about how fast or steeply the automated system known as MCAS could push down a plane’s nose, these people said.

I already posted this article link in one of the parallel threads, and since the overall story is quite profound. Even though most of the information is not new, it is worth skimming, to be reminded of some of the details: https://www.theverge.com/2019/5/2/18518176/boeing-737-max-crash-problems-human-error-mcas-faa

Summary:
- Mistakes began nearly a decade ago when Boeing was caught flat-footed after its archrival Airbus announced a new fuel-efficient plane that threatened the company’s core business. It rushed the competing 737 Max to market as quickly as possible.
- In developing the Max, Boeing not only cut corners, but it touted them as selling points for airlines. Since the 737 Max was the same plane type as its predecessors, pilots would only need a 2.5-hour iPad training to fly its newest iteration.
- MCAS is the new software system blamed for the deadly Lion Air and Ethiopian Airlines crashes. But its failure in both crashes was the result of Boeing and the Federal Aviation Administration’s reluctance to properly inform pilots of its existence or to regulate it for safety.
- The FAA has admitted to being incompetent when regulating software, and, as a policy, it allows plane manufacturers to police themselves for safety. Nowhere in its amended type certification of the 737 Max is MCAS mentioned.
- Even still, Boeing only recommends a 30-minute self-study course for pilots on MCAS, rather than additional simulator or classroom instruction.
- Despite the two crashes, neither Boeing nor the FAA believes they’ve done anything wrong. A Boeing spokesperson said the company believes the system is still “a robust and effective way for the FAA to execute its oversight of safety.”

Nothing specific to test pilots, but these comments are telling:
And many pilots felt that, for the first new 737 in over 20 years, Boeing seemed to be oddly reluctant to prep them for it.

Captain Laura Einsetler, who’s flown for over 30 years, including on 737s, considers an all-computer-based course to be completely inadequate as an introduction to a new airplane.

“I don’t have the schematics. I don’t have the cockpit panels. I don’t have an instructor that I can ask questions to,” she says. “You’re hoping that the first time you see the Max is on a nice clear day. But sometimes it’s not, and you’re showing up at night or in bad weather into an airplane that has all these changes.”

The subtext: pilots were on a need-to-know basis about MCAS, and until the Lion Air crash, Boeing felt that they hadn’t needed to know.

Einsetler strongly disagrees. “We need to have the understanding and knowledge of how everything works on the jet, so that we can command the jet to do what we need it to do, not just be along for the ride,” she says.

“Not a lot of information got out there in a timely fashion,” concurs Juan Browne, a 777 pilot with over 40 years of flying experience. “It almost makes me wonder, did Boeing engineers themselves really understand how much power and authority they built into this system?”

[Ian W]

Quote:Originally Posted by SystemsNerd https://www.pprune.org/images/buttons/viewpost.gif (https://www.pprune.org/showthread.php?p=10461329#post10461329)Thus, when asking "why didn't they just fly the plane?", one possible answer is undoubtedly some variant on "they were incompetent". But another possible answer is "they were put into a scenario in which any human being would consistently fail to solve the problem, regardless of competence". Probably the truth is somewhere between those two points.

​​​​​​Thank you so much for this This is why I cannot accept the analysis of those that pile with unwavering assertiveness on the pilots' performance. We have only a partial view of what they experienced. We simply cannot know what the average crew would do in their shoes, vs what some hypothetical post-hoc average response should be, as evident as it may seem. Even so, are they at fault for the training they received? That's why when someone can't come back to tell their version, I prefer unanswered questions to "sure" answers.

As stated by SystemsNerd, the human cognition has limitations and foibles that many people are unaware of. One of these is the limited number of 'cognitive channels' also known as multiple resource theory. (see papers by Christopher Wickens and Erik Hollnagel) Simply you cannot read this posting and recite a something you have learned like NNC memory items at the same time - both use verbal cognition - if you are reading and someone says something you may hear them but you will not understand what they said and you will stop reading and ask them to repeat what they said. If you have to read, talk and listen at the same time you can only really do one at a time (we have all had to read a paragraph again as we stopped understanding what we were reading and listened instead).
So if you are running through memory items of an NNC - and you read the EICAS you may miss NNC items or not understand the EICAS - if the PM is shouting at you it may just be noise - if there is sufficient noise that channel stops completely and you do not even hear/comprehend the PM or that cavalry charge.

Mixed into this is the effect of the level of stress/alertness. This is normally referred to as an 'inverted U'.

https://cimg2.ibsrv.net/gimg/pprune.org-vbulletin/460x335/inverted_u_diagram_c1224187b9e0446c4516be2dd9863ef39ab92d63. jpg
from MindTools.com

So when you are bored with low stress your performance is actually poor, A little pressure / stress and your performance is ideal, but too much high stress and your performance will drop off rapidly.

Putting all that into an aviation perspective, A well trained pilot with experience of things going pear shaped and operating under pressure will not feel so much stress and concentrate on one item at a time and a lot of what will be done will be (what is called here ) muscle memory - innate training like stamping on a brake or steering a bike to stay balanced - or trimming an aircraft - it requires no thought as it is second nature. This is the importance of training - with not so much training it is easy to get into the overstressed very low performance state and 'get behind the aircraft'. The more inputs you are given the higher the stress and the less you are able to process and the normal human reaction to that is what is known as attentional or cognitive tunneling - a concentration on one aspect of what is happening that you _do_ think you can control and a total disregard of anything else. Everyone is different in this regard and the only way to avoid getting into the wrong side of the U is training, repeated training to get that muscle memory. Unfortunately, there is always a beancounter standing in the way of that.

[PEI_3721]

Yo gums,
Further to my comments on your additional request for ‘aero’ explanation ( https://www.pprune.org/showpost.php?p=10461386&postcount=4755 (https://www.pprune.org/showpost.php?p=10461386&postcount=4755)) see the following:-

‘During design of the MAX, Boeing added two more leading-edge vortilons [generating vortices over the top of the wing at high AOA] in 2018, for a total of six per side and also lengthened and raised the inboard leading-edge stall strips to assure stall behavior would be as docile as that of the NG’.
(https://www.twu557.org/index.php/news-main/course-comments/260-aviation-week-max-new-software)

This suggests that Boeing had identified issues earlier than I suggested; also because of the nature of the changes the aero effects were more significant than currently being discussed for MCAS.
The use of vortilons might be a simple alternative to adding many more vortex generators, but stall strips to reinforce the inner-wing stall before outboard sections, opposing pitch up, is more like ‘a new aircraft’ fix.
A very crude comparison of the effects of nacelle lift might be made with military blended wing / fuselage, or leading edge extensions; what ever these provide for the fighter world then its not helpful in commercial aviation - or at least a same type rating for the 737 MAX.

Also, Boeing ‘Commenting on criticism of the single string failure potential of the AOA input to MCAS, a Boeing official said the original design was based on a standard industry process of hazard classification which defined the potential failure as one that could be mitigated “very quickly performed by a trained pilot using established procedures”.

Add to that, a remarkable comment from the FAA; “Pilots of large aircraft are trained from Day 1. When the pitch of the aircraft is doing something you’re not telling it to do, you do a runaway pitch trim checklist,” Acting FAA Administrator Dan Elwell, a former airline pilot …
This does not add confidence that the FAA have a good understanding of training, nor the much wider safety aspects of loss of control (for wind-shear / turbulence pitch up - do we always inhibit trim ! )
https://www.twu557.org/index.php/news-main/course-comments/221-aviation-week-max-human-factors

Then re the training discussion:-
‘Pilots for three U.S. air carriers tell … that during their sim training they had never been exposed to extreme and continuous AOA indication errors, they’ve not experienced AOA induced airspeed and altitude deviations on PFDs and have not had to deal with continuous stall-warning stickshaker distractions. They also note that they have never been required to fly the aircraft from the point at which a runaway stab trim incident occurred all the way to landing using only the manual trim wheels. “We’re just checking boxes for the FAA (http://awin.aviationweek.com/OrganizationProfiles.aspx?orgId=31159),” says one Seattle-based pilot’.

P.S. some web links may be transposed, or changed by the host site - search news items (I’m working on it).

[Cows getting bigger]

I have no doubt that this is true, but it is also largely irrelevant from a procedural viewpoint. The pilots don’t need to be able to read a wiring diagram and tell you all the things that happens when they throw the cutout switches. They just need to know when they need to throw the cutout switches - as in the case of the runaway stab trim procedure.





737 driver, I have an itch and please take this comment with the best of intent.

When I was taught to fly, PPL through CPL etc, it was instilled in me to understand what every switch/knob did before I played with it (initial thanks to Norman Buddin, ex Hunter pilot and CFI). We were not in the business of altering things without understanding the impact.

So, please correct me if I am wrong, but earlier versions of the 737 had two distinct outcomes associated with the two stab trim switches whilst the Max basically has two switches in series? Somewhere along the line a change operating procedures seem to have pre-dated the wiring change. I’m trying to understand why pre-Max pilots didn’t know, or weren’t told about, the difference between the switches. Isn’t it better airmanship to understand why, what and how when managing aircraft systems, or are we witness to the pre-cursor of ‘Children of the Magenta’ in pilots who never questioned why they threw two switches and what each did?

[Takwis]

"In November 2018, after Lion Air, some (or all) operators, changed the checklist list and removed the word “continuous”."

"By this definition, isn't any STS operation a trim runaway? "

“Pilots of large aircraft are trained from Day 1. When the pitch of the aircraft is doing something you’re not telling it to do, you do a runaway pitch trim checklist,” Acting FAA Administrator Dan Elwell, a former airline pilot …"

Cool. Looks like we're finally going to get my F/Os some experience in using the manual trim wheel.


When I was taught to fly, PPL through CPL etc, it was instilled in me to understand what every switch/knob did before I played with it (initial thanks to Norman Buddin, ex Hunter pilot and CFI). We were not in the business of altering things without understanding the impact.




Cows Getting Bigger (best username ever!), I agree with you 100%...and would add my thanks to Swede Gamble ("Know Gamble in Aviation").

[wheelsright]

MCAS can be interrupted with the electric trim switches on the yoke each time it activates, and trim can be returned to a low/zero column force state each time if the pilot puts in adequate opposite trim inputs. That is what the Lion Air crew did for approximately 2 dozen cycles of MCAS before the final few cycles, where the pilot flying at that point failed to put in an adequate amount of opposite trim in those final cycles, allowing the out of trim condition to increase to the point where they couldn't recover in the altitude available.

That is the assumption that is at question (my emphasis). If your suggestion is correct then the crew did not apply sufficient opposite trim inputs. It remains in doubt as to whether it is possible to apply sufficient opposite trim inputs. If Boeing is to be believed the Lion Air pilots casually flew the aircraft into the sea and did not attempt to apply sufficient opposite trim inputs. I do not buy into this theory. I suspect that the only solution is to use the cutout switches at an early stage. There may be multiple reasons that sufficient opposite trim is not possible. What is raising doubt is that the Lion Air pilots were trying to do just what you suggest and did not succeed. Granted, that they should have taken a different path, but it remains they were trying to trim nose-up and apparently were unable. There is a lot more to this story, I suspect that many assumptions being made are not entirely correct. People are trying to reverse engineer from Boeing publications that may not be entirely accurate and are too brief to give a full explanation of the systems. So far it does not seem to make sense. I could be wrong, but my bull**** meter is quivering.

[A0283]

@PEI_3721 (https://www.pprune.org/members/136812-pei_3721) - I was looking at a MAX video and noticed, next to the usual big strake at about 10 o'clock on the center of the cowling, a set of 2 smaller longitudinal white painted vanes/strakes on the inside of the engine on the sliding part of the thrustreversers. When the reversers slid back after TD, the vanes/strakes did not hit the leading edge of the wing, because a kind of small 'trapdoor' opened upward to let them pass through. On sliding forward the vanes/strakes became visible again and the 'trapdoor' closed behind them. Would be interesting to hear from you what their purpose is in the aerodynamic context that you were just posting about ;-)

[Sucram]

Yes, the overhead panel is 1960’s but the cockpit displays, FMS, engines, wings, and other major components sure aren’t. The point is not a part by part count but the major components of the MAX are completely different than the -100 even to the extent that one could legitimately not call it a B737.
Yes but it's still an old generation design with old generation aircraft failings.
No EICAS , no FBW (with resultant large pitch /power couple, defo not good news on manual go arounds), only two hydraulic systems, no effective autopilot go around (Cat3 excepted) etc etc, not even auto generator switching!
Most of the design changes apart from maybe the nice big screens seem to be all about economic improvements, not safety improvements, ie thinner more efficient but less speed stable wing, longer fuselage with resultant higher approach speed to prevent tail strikes on landing.
I could list more, it's a real shame they didn't build a new modern aircraft from the ground up (like the 777/787) but that would have really hit profits in the short term, I'm sure Boeing wish they had now.

[737 Driver]

With respect, I think there may be a breakdown in communication here that may be in large part responsible for the ongoing disagreement. When people say "human factors", they don't mean "the human element", they mean Human Factors*, i.e., the study of how the human mind and body interacts with designed systems.

The human mind does not, ironically, work in the ways most people think it does - it has well-documented limitations and sources of error plumbed into its design. A human factors expert can I believe pretty trivially design a scenario where most (if not all) humans will consistently fail to correctly solve even relatively trivial problems, regardless of their competence under normal conditions.

Thus, when asking "why didn't they just fly the plane?", one possible answer is undoubtedly some variant on "they were incompetent". But another possible answer is "they were put into a scenario in which any human being would consistently fail to solve the problem, regardless of competence". Probably the truth is somewhere between those two points.


I pretty much agree with everything you say except for the "any human" reference in the second to last sentence. I think that there is broad, though not unanimous, agreement that the accident crews made some serious errors that led to the final loss of aircraft control. Where I and some other participants here differ is that I strongly believe that much of the human factors element you refer to is amenable to training. One only has to look at the performance of the crew on the Lion Air 610 flight the day prior to the original accident. Despite being presented with a novel malfunction, one of the pilots kept flying the aircraft. IMHO, that crew took a bit too long to get to the trim cutout switches, but the takeaway is that every time MCAS made an input, the flying pilot took it right out again. At no time was there evidence that they were losing that fight.

It has been suggested that this crew would have ultimately crashed if not for the jumpseater suggesting that they try the cutout switches, but frankly that is an unwarranted assumption. Having been both in the flying seat and the jumpseat on many occasions, it is absolutely true that the jumpseater may catch something quicker, but that does not mean the flying crew will not catch it at all. There definitely appears to been a limited understanding of the stab trim system by both the Lion Air and Ethiopian crews (very much amenable to training), but it did not prevent the crew above from maintaining aircraft control.

I will agree that any human pilot at some stage in their training will be easily overwhelmed by even the most basic aircraft emergency scenarios. That is why we train so extensively for them. I had previously posted that in the Ethiopian accident, the Captain did fly the aircraft after a certain fashion, and that he had defaulted to his training. The problem was that he defaulted to the wrong training. Just about all of the ET302 Captain's initial actions can be understood in the context of a normal takeoff profile. Unfortunately, a normal takeoff profile left him in a highly unstable position from which dealing with the ultimate stab trim problem became a bridge too far.

When I and other posters keep saying that the pilots should have kept FLYING THE AIRCRAFT, we do not say this from a perspective that operating a malfunctioning aircraft is some inborn capability that every person has. Heck, walking isn't even an inborn capability. However, it is a skill that is amenable to training. That is, as long as you get the right kind of training. As has been already discussed extensively, training in modern commercial airliners has largely devolved into a process of following scripts. Pilots are presented with known problems with known solutions. Even at my airline, there is much less of the relatively unscripted training that really drove home the need to set aside any distractions and focus on the basics of flying the aircraft without the benefit of any automation until the situation was stabilized.

There are multiple links in the chain of causation leading to these accidents. I don't think anyone is questioning that MCAS needs to be fixed, or the FAA needs to step up its oversight, or that airlines need to review their internal training and operations policies. The professional pilot corps, however, needs to look at what we can do to correct the airmanship deficiencies that were exposed by these accidents.

[Takwis]

I was looking at a MAX video and noticed, next to the usual big strake at about 10 o'clock on the center of the cowling, a set of 2 smaller longitudinal white painted vanes/strakes on the inside of the engine on the sliding part of the thrustreversers. When the reversers slid back after TD, the vanes/strakes did not hit the leading edge of the wing, because a kind of small 'trapdoor' opened upward to let them pass through. On sliding forward the vanes/strakes became visible again and the 'trapdoor' closed behind them. Would be interesting to hear from you what their purpose is in the aerodynamic context that you were just posting about ;-)

It's not aerodynamics, its just a physical way to keep the reverser sliding cowl from hitting the leading edge devices...been there since the Classics.

[PEI_3721]

A0283,
Simple answer, I don’t know.
I’m looking for photos - found (Aerospaceweb.org | Ask Us - Nacelle Vortex Generator (http://www.aerospaceweb.org/question/aerodynamics/q0255.shtml)), but as you describe this does not fit my experience with vortilons - underwing leading edge with sharp/ pointy bits protruding forward. Nor any experience with engine cowl / nacelle strikes, attachments, bent metal, etc (my ‘jet’ although using stall breakers and stick push, had no vortex generators or other aero adjustments at all - match that).

https://en.m.wikipedia.org/wiki/Vortilon

Aerospaceweb.org | Ask Us - Wing Vortex Devices (http://www.aerospaceweb.org/question/aerodynamics/q0228.shtml)

Takwis -I doubt your explanation; see photo above

[A0283]

@Takwis - Thanks for responding :ok:. So no aerodynamic impact. Solved. @PEI_3721 thanks for your time.

Edit1: After PEI's response to Takwis's post I tried to dig up one of my images to put us on a level 'playing field'.

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/588x514/a0283_to_pei_3721_302dea3363303945d90c3cdcbe88bc5b3e2f2bc9.j pg
A0283

Edit2: In PEi's http://www.aerospaceweb.org/question/aerodynamics/q0255.shtml the dual strakes are visible on its 1st photo. The article says the big strake is on the -600 upto -900.

@Takwis - Could you tell me what the names of the big strake, the small strips, and the trapdoor are in 'Boeing speak'.

[SystemsNerd]

I pretty much agree with everything you say except for the "any human" reference in the second to last sentence. I think that there is broad, though not unanimous, agreement that the accident crews made some serious errors that led to the final loss of aircraft control. Where I and some other participants here differ is that I strongly believe that much of the human factors element you refer to is amenable to training. One only has to look at the performance of the crew on the Lion Air 610 flight the day prior to the original accident. Despite being presented with a novel malfunction, one of the pilots kept flying the aircraft. IMHO, that crew took a bit too long to get to the trim cutout switches, but the takeaway is that every time MCAS made an input, the flying pilot took it right out again. At no time was there evidence that they were losing that fight.

It has been suggested that this crew would have ultimately crashed if not for the jumpseater suggesting that they try the cutout switches, but frankly that is an unwarranted assumption. Having been both in the flying seat and the jumpseat on many occasions, it is absolutely true that the jumpseater may catch something quicker, but that does not mean the flying crew will not catch it at all. There definitely appears to been a limited understanding of the stab trim system by both the Lion Air and Ethiopian crews (very much amenable to training), but it did not prevent the crew above from maintaining aircraft control.

I will agree that any human pilot at some stage in his training will be easily overwhelmed by even the most basic aircraft emergency scenarios. That is why we train so extensively for them. I had previously posted that in the Ethiopian accident, the Captain did fly the aircraft after a certain fashion, and that he had defaulted to his training. The problem was that he defaulted to the wrong training. Just about all of the ET302 Captain's initial actions can be understood in the context of a normal takeoff profile. Unfortunately, a normal takeoff profile left him in a highly unstable position from which dealing with the ultimate stab trim problem became a bridge too far.

When I and other posters keep saying that the pilots should have kept FLYING THE AIRCRAFT, we do not say this from a perspective that operating a malfunctioning aircraft is some inborn capability that every person has. Heck, walking isn't even an inborn capability. However, it is a skill that is amenable to training. That is, as long as you get the right kind of training. As has been already discussed extensively, training in modern commercial airliners has largely devolved into a process of following scripts. Pilots are presented with known problems with known solutions. Even at my airline, there is much less of the relatively unscripted training that really drove home the need to set aside any distractions and focus on the basics of flying the aircraft without the benefit of any automation until the situation was stabilized.

There are multiple links in the chain of causation leading to these accidents. I don't think anyone is questioning that MCAS needs to be fixed, or the FAA needs to step up its oversights, or that airlines need to review their internal training and operations policies. The professional pilot corps, however, needs to look at what we can do to correct the airmanship deficiencies that were exposed by these accident.

When you say that you "strongly believe" the issue is amenable to training, is that based on research or on intuition? I ask because my understanding of the broad sweep of behavioural research is that actual human behaviour is often deeply unintuitive, and in a safety-critical environment I'd be very wary of relying on any assumptions about human behaviour that haven't been rigorously validated.

(I fully agree that pilots need to do their part in correcting any systemic errors contributing to these incidents; my concern is that treating them as "human error" or "poor training" passes up an opportunity to better understand how and why people actually make mistakes, and how to avoid falling into the same traps. Like, I read wonkazoo's underlying point about his crash as being "I knew exactly what to do and I *still* almost killed myself, because a real incident is not like a simulated one", and that seems like it argues against more of the same sort of training as a solution to that class of problem.)

[737 Driver]

737 driver, I have an itch and please take this comment with the best of intent.

When I was taught to fly, PPL through CPL etc, it was instilled in me to understand what every switch/knob did before I played with it (initial thanks to Norman Buddin, ex Hunter pilot and CFI). We were not in the business of altering things without understanding the impact.

So, please correct me if I am wrong, but earlier versions of the 737 had two distinct outcomes associated with the two stab trim switches whilst the Max basically has two switches in series? Somewhere along the line a change operating procedures seem to have pre-dated the wiring change. I’m trying to understand why pre-Max pilots didn’t know, or weren’t told about, the difference between the switches. Isn’t it better airmanship to understand why, what and how when managing aircraft systems, or are we witness to the pre-cursor of ‘Children of the Magenta’ in pilots who never questioned why they threw two switches and what each did?






If it hasn't already become evident, I am also a product of the old school philosophy of pilot training. That being said, there were plenty of times where even I thought we were being required to know far too much technical knowledge than was necessary.

Somewhere along the way, our training started to change. There was far less emphasis on understanding the systems and far more emphasis on following the written procedures. Our training has become highly scripted, and we almost always know the sim training scenarios in advance. I suspect that this change has largely been driven by costs, with modern airlines being reluctant to provide anything other than the minimum training required by the FAA. (You've probably heard the saying, "If the minimum wasn't good enough, it wouldn't be the minimum!")

Frankly, some pilots welcomed this change because it is less work and less threatening. There has always been lip service to the concept that, in some circumstance, the pilot may not have a well-defined checklist or procedure to follow and was expected to use their best judgement. Unfortunately, that sentiment has rarely been backed up with any kind of training. Unfortunately, I think we have seen enough accidents and incidents to in the last decade to show that there is a real, if unaccounted for, cost to this approach to training. Sadly, I still don't see any motivation to make the needed changes to the typical industry training regime. We apparently haven't produced a high enough body count to justify it.

As to your specific question, I have gathered from some of the other posters here that there was no change to their runaway stab trim procedure, that they always used both cutout switches. All I know is that at my airline, we used to be allowed to use them separately. This procedure was changed a few years back (can't remember exactly when, and I don't have any of the old manuals). At the time, I remember being told that this was a Boeing-preferred change driven by a larger trend of removing most types of troubleshooting activities from our non-normal procedures. In my current 737NG manual, there is no longer a reference to the functionality of the two cutout switches. I only know because my experience predates the change. Since current 737NG pilots aren't taught how these switches are wired, I guess there would be little point to telling them how the MAX switches are wired, and as I have previously stated, there is absolutely no difference in the aircraft from a procedural perspective.

[MurphyWasRight]

I will agree that any human pilot at some stage in his training will be easily overwhelmed by even the most basic aircraft emergency scenarios. That is why we train so extensively for them. I had previously posted that in the Ethiopian accident, the Captain did fly the aircraft after a certain fashion, and that he had defaulted to his training. The problem was that he defaulted to the wrong training. Just about all of the ET302 Captain's initial actions can be understood in the context of a normal takeoff profile. Unfortunately, a normal takeoff profile left him in a highly unstable position from which dealing with the ultimate stab trim problem became a bridge too far.


The ET pilot possibly followed the Boeing UAS flow chart I posted earlier that covered AoA failure as a 'false' positive ending with "pilot with correct display becomes pilot flying" which apparently did not happen.

He was able to engage autopilot for 30 seconds (again a questionable move). Until the AP disconnected as flaps were retracted the situation was not extreme, I will leave it to others how 'normal' the profile was.

At 05:40:00 the first MCAS input occurs followed by insufficient re-trim, surprise, lack of training experience with magnitude of MCAS input? This led to rapid speed increase

At 05:40:20 the second MCAS input occurs, interrupted by pilot trim at 04:40:27.
The crew carried out the runaway stab procedure at 05:40:35. From the trace it appears that the pilot may have been trimming at this point and was interrupted by the cutout switches.
Had they waited until AC was in trim we likely would not be discussing this..

Looking at the sequence above: At 05:40:00 the AC was not in extreme state By 05:40:35 they were left with likely inoperable manual trim and approaching, but not yet at VMO.
Things went from "interesting to extreme" in 35 seconds during which the crew followed the runaway trim procedure, albeit without first fully trimming the AC.

From other posts they may not have seen the update procedure with the 'note' about first trimming.

That is 35 seconds with only 2 MCAS inputs to get to an extreme state.

One thing that the prelim report does not cover is what was going on during the two and a half minutes until the final sequence. Surely they were not just sitting there with a couple of ATC exchanges.

Here is one scenario:

Trim cutout, both switches as per procedure

Attempts to use manual trim are not successful due to loading (speed still < VMO)

Pilot remembers 737NG had 2 cutout modes, auto and all, depending on slide ware version he "trained" with the change in MAX may not have been mentioned, even if it was it was not stressed.
They try first one then the other switch, no electric trim.
Further attempts to use manual trim?
Next relevant snip from the report:
At 05:41:46, the Captain asked the First-Officer if the trim is functional. The First-Officer has replied that the trim was not working and asked if he could try it manually. The Captain told him to try.
At 05:41:54, the First-Officer replied that it is not working.

Final puzzle is why only brief trim inputs after they re-enabled trim.

[737 Driver]

Since we have seemingly now moved onto a focus on the human factor element (i.e. the why behind the flight crew errors), I think it might be worthy to expand this topic a bit.

Clearly, these accidents have exposed a case where some presumably highly-trained and experienced professionals were put in a position where that training and experience did not rise to the task. Obvious errors were made that had fatal consequences. Since most of us would like to assume that this wasn't a case of malicious or negligent behavior, then presumably there were some significant human factor element behind these lapses.

I am referring, of course, to the various engineers, technical and supervisory staff that designed and approved MCAS for service.

Imagine, if you will, a parallel online forum in which aircraft-related engineer specialties debate over the various elements of these accidents from their perspective. One could imagine certain individuals saying, "Why didn't they just design the friggin' software/hardware correctly?!" Others might defend their tribe by saying the design was sufficient, it was just that the operators weren't sufficiently skilled/trained to handle a malfunction. Still others might concede that, while yes, errors were made, the individuals who had their hands on the design/approval process were working under various constraints and pressures and that their errors were perfectly understandable from a human factors perspective. They would plead that, please, everyone take a breath and quit trying to blame the engineers when it is obvious they were doing the best they could under the circumstances.

What would we make of such a conversation?

What I am trying to point out is that while some of us like to say "Boeing" messed up or "the FAA" messed up, the reality is that these organizations are simply made up of human beings who respond to their training, experience, and environment. Being human, they are just as much subject to the fallibilities of the human mind as were the pilots. There is even one study that lists precisely 188 types of cognitive errors that the human mind is subject to (click here (https://www.visualcapitalist.com/wp-content/uploads/2017/09/cognitive-bias-infographic.html) to read). These errors may be different than the ones the pilots were exposed to, but they were ultimately human errors.

At some point, we will have two final accident reports detailing a list of primary and secondary causes to these accidents. Behind a fair number of these causes will be a human being who was not acting out of malicious intent or neglect. They were simply performing according to their training, experience, and environment. In the discussions on this and related threads, there quite often the refrain, "Stop blaming the pilots!" I don't have any problem with that sentiment since the act of "blaming" is largely an emotional response that tends to avoid getting to the root of the problem. That being said, identifying the root causes and proposing remedies isn't the same as blaming (unless someone chooses to interpret it that way).

So yes, how about we all stop blaming everybody who had a hand in these accidents, understand that behind every error there was likely a human factor element, and support those efforts to address and/or remediate those issues?

[ATC Watcher]

Final puzzle is why only brief trim inputs after they re-enabled trim.
I think ( but not sure and wait to be corrected ) what the FDR data published shows is 2 briefs trims movements , .If this is the case , it does not show the actual inputs physically made , it could have been a continuous trim input by the Capt but it only worked twice briefly , possibly because the aerodynamic load on the stab was already very high ? just an attempt to understand it . I do not think the actual trim switches positions are recorded , but as I said, waiting to be corrected .

[Takwis]

A0283, the "Trapdoor" is a leading edge flap. The dual "strakes" physically push it up out of the way of the reverser door. They might be intentional vortex generators (they surely produce some vortices), and that may even be their purpose...none of my documentation over the last 20 odd years has mentioned them...but they definitely lift the leading edge flap out of the way when the reverser is moving. The ones in the picture are of a freshly painted aircraft...on a plane that has been is service for a little while, the paint gets rubbed off the top of them.

[MurphyWasRight]

One could imagine certain individuals saying, "Why didn't Still others might concede that, while yes, errors were made, the individuals who had their hands on the design/approval process were working under various constraints and pressures and that their errors were perfectly understandable from a human factors perspective.
...
So yes, how about we all stop blaming everybody who had a hand in these accidents, understand that behind every error there was likely a human factor element, and support those efforts to address and/or remediate those issues?
Totally agree with your post, nicely stated.
I snipped a couple of lines and added bolding.

There are parallel themes of degrading of pilot training to save money and Boeing management pushing for "in family" certification for MAX to save money and market share.

I would posit that neither of these decisions were made by people with hands on experience.
I will leave it at that.

[GordonR_Cape]

Since we have seemingly now moved onto a focus on the human factor element (i.e. the why behind the flight crew errors), I think it might be worthy to expand this topic a bit.

Clearly, these accidents have exposed a case where some presumably highly-trained and experienced professionals were put in a position where that training and experience did not rise to the task. Obvious errors were made that had fatal consequences. Since most of us would like to assume that this wasn't a case of malicious or negligent behavior, then presumably there were some significant human factor element behind these lapses.

I am referring, of course, to the various engineers, technical and supervisory staff that designed and approved MCAS for service.

Imagine, if you will, a parallel online forum in which aircraft-related engineer specialties debate over the various elements of these accidents from their perspective. One could imagine certain individuals saying, "Why didn't they just design the friggin' software/hardware correctly?!" Others might defend their tribe by saying the design was sufficient, it was just that the operators weren't sufficiently skilled/trained to handle a malfunction. Still others might concede that, while yes, errors were made, the individuals who had their hands on the design/approval process were working under various constraints and pressures and that their errors were perfectly understandable from a human factors perspective. They would plead that, please, everyone take a breath and quit trying to blame the engineers when it is obvious they were doing the best they could under the circumstances.

What would we make of such a conversation?

What I am trying to point out is that while some of us like to say "Boeing" messed up or "the FAA" messed up, the reality is that these organizations are simply made up of human beings who respond to their training, experience, and environment. Being human, they are just as much subject to the fallibilities of the human mind as were the pilots. There is even one study that lists precisely 188 types of cognitive errors that the human mind is subject to (click here (https://www.visualcapitalist.com/wp-content/uploads/2017/09/cognitive-bias-infographic.html) to read). These errors may be different than the ones the pilots were exposed to, but they were ultimately human errors.

At some point, we will have two final accident reports detailing a list of primary and secondary causes to these accidents. Behind a fair number of these causes will be a human being who was not acting out of malicious intent or neglect. They were simply performing according to their training, experience, and environment. In the discussions on this and related threads, there quite often the refrain, "Stop blaming the pilots!" I don't have any problem with that sentiment since the act of "blaming" is largely an emotional response that tends to avoid getting to the root of the problem. That being said, identifying the root causes and proposing remedies isn't the same as blaming (unless someone chooses to interpret it that way).

So yes, how about we all stop blaming everybody who had a hand in these accidents, understand that behind every error there was likely a human factor element, and support those efforts to address and/or remediate those issues?

The article that I just posted got lost in a flurry of comments, but is worth reading. It carefully describes the chain of human decisions involved in the design of MCAS, without apportioning blame: https://www.theverge.com/2019/5/2/18518176/boeing-737-max-crash-problems-human-error-mcas-faa

So MCAS was designed to compensate. It would use an angle of attack (AoA) sensor to detect when the airplane entered a steep climb. It would activate the airplane’s pitch trim system, which is routinely used to help stabilize the airplane and make it easier to control, especially during climb and descent. And it would trim the airplane in modest increments for up to nine seconds at a time until it detected that the airplane had returned to a normal AoA and ended its steep climb. It seems simple enough — on paper, that is.

MCAS received a “hazardous failure” designation. This meant that, in the FAA’s judgment, any kind of MCAS malfunction would result in, at worst, “a large reduction in safety margins” or “serious or fatal injury to a relatively small number of the occupants.” Such systems, therefore, need at least two levels of redundancy, with a chance of failure less than 1 in 10 million.

Worse still: the FAA did not catch the fact that the version of MCAS actually installed on the 737 Max was much more powerful than the version described in the design specifications. On paper, MCAS was only supposed to move the horizontal stabilizer 0.6 degrees at a time. In reality, it could move the stabilizer as much as 2.5 degrees at a time, making it significantly more powerful when forcing the nose of the airplane down.

But why had nobody caught it in the first place? The answer might be infuriatingly simple: nobody read the paperwork.

Although the FAA is responsible for the safety of any airplane manufactured in the United States, it delegates much of the certification to the manufacturers themselves.

So had anyone checked, they might have flagged MCAS for one of several reasons, including its lack of redundancy, its unacceptably high risk of failure, or its significant increase in power to the point that it was no longer just a “hazardous failure” kind of system.

In a strange way, the 737 Max’s story is less about what did happen and more about what didn’t. Nobody did anything criminal. Nobody did anything malicious. Nobody did anything wrong, in a strictly technical sense.

It’s a perfect example of the cross purposes at which business, technology, and safety often find themselves. With its bottom line threatened, Boeing focused on speed instead of rigor, cost-control instead of innovation, and efficiency instead of transparency. The FAA got caught up in Boeing’s rush to get the Max into production, arguably failing to enforce its own safety regulations and missing a clear opportunity to prevent these two crashes.

[737 Driver]

They might be intentional vortex generators (they surely produce some vortices), and that may even be their purpose...none of my documentation over the last 20 odd years has mentioned them...

The engine strakes generate vortices that energize the airflow going over the leading edge devices immediately behind and help delay airflow separation over the wing as the angles of attack increases.

[ams6110]

So yes, how about we all stop blaming everybody who had a hand in these accidents, understand that behind every error there was likely a human factor element, and support those efforts to address and/or remediate those issues?

I agree. This is how commercial aviation has become as safe as it is. When accidents happen, we seek not to blame individuals, but to understand root causes, and prevent or reduce the chance of the same thing happening again by correcting design or materials defects, augmenting training, changing procedures, improving regulatory oversight, documentation, and communication, or all of those things.

Sadly it seems there is a trend in society (I call it "outrage culture") where the response to any calamity is one driven by anger and blame, and not one seeking to solve actual problems. Or maybe I'm just getting old.

[Takwis]

The engine strakes generate vortices that energize the airflow going over the leading edge devices immediately behind and help delay airflow separation over the wing as the angles of attack increases.

Yes, they do. I have a picture of an Engine Strake for you; have to figure out how to post it. It is many times larger than the little roller ramps.

Can't post urls, can't post pictures.Try https://i.ytimg.com/vi/_vkgXtuEN34/maxresdefault.jpg (https://i.ytimg.com/vi/_vkgXtuEN34/maxresdefault.jpg(/img)


https://cimg5.ibsrv.net/gimg/pprune.org-vbulletin/1280x720/maxresdefault_54786382cea2f4c60d4e68d7853236c28b3b92e7.jpg

[Tobin]

In November 2018, after Lion Air, some (or all) operators, changed the checklist list and removed the word “continuous”.

As a programmer, I really like this checklist a lot more. Besides scrapping the misleading word "continuous", it also tells pilots to control pitch with electric trim as an explicit step prior to using the CUTOUT switches, rather than having it be an apparently conditional substep of disengaging the autopilot if it is engaged.

As a tangent to that, it seems to me that it is difficult to establish a definition of "runaway stabilizer" that includes erroneous MCAS but doesn't include normal STS. Words like "continuous" apply to neither, nor do phrases like "cannot be stopped by pilot electric trim". I'm not at all happy to have Potter Stewart writing emergency checklists; "I know it when I see it" seems not enough for something this critical.

[737 Driver]

Can't post urls, can't post pictures.Try https colon //i.ytimg.com/vi/_vkgXtuEN34/maxresdefault dot jpg
.


Not off probation yet? ;) Let's see if I can assist:

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/708x391/strake_94a61d2dcfec8ea6f0526aae2a65df941e296b6f.jpeg
Inboard engine strake

For the non-aero types, the need for the strake is due in large part to the disruption of airflow over the wing caused by the engines themselves, particularly as the AOA increases. The strake creates a vortex that adds energy to the airflow and helps delay airflow separation over the wing.

[PEI_3721]

Takwis,
Thanks for the further explanations clarifying your previous answer, which I now accept.
At least until I understand the Boeing logic of using two vanes to lift a LE flap ;)
A simple mechanical solution vs the electronic logic of MCAS ?!!

The use of a large (larger) engine cowl strake adds questions to the originating theme of the extent aerodynamic changes.
If the overall change requires additional inner-wing stall strips, then why use an aerodynamic cowl ‘fence’ to isolate the inner wing, normally achieved by the stall strip.

[737 Driver]

There are parallel themes of degrading of pilot training to save money and Boeing management pushing for "in family" certification for MAX to save money and market share.

I would posit that neither of these decisions were made by people with hands on experience.
I will leave it at that.
.


I will posit that for every person connected to these accidents, from the lowly technician or pilot all the way up to the Boeing CEO or FAA Administrator, we could construct a "training, experience, and environment" description that explains the choices they made. The takeaway is that once these elements are identified, then a concerted effort should be made to change whatever it was in their training, experience or environment that led to those choices in the first place.

[A0283]

Takwis Re your remark about fresh paint - good observation ;-) it was freshly painted aircraft indeed ... was an Ethiopian MAX delivery flight.

737 Driver the image you posted has only one of the smaller strakes ... so when was the second strake introduced ... my guess based on Takwis answer and PEI's post is the -600 to -900 ... so you would expect a reason for that... do you know what 737-model that KLM plane was?

737 Driver in the image that I posted I indicated the difference between the 'trapdoor' and the 'leading edge' ...IIRC the trapdoor opens down and forward and is as far as I could see not a part of the moveable leading edge/slats ... it would require a detailed picture of a MAX to clear that up I guess (would be nice to see one),

PEI_3721 could it still be that these 2 strakes have both a mechanical and an aerodynamic function ? ... it appears that there where enough aerodynamic issues to solve, even going from Classic to NG and on to MAX, so you could expect some changes in these area's ... like difference in size and position of the big strake (it looked increased in size on the images that I had) ...

[737 Driver]

737 Driver the image you posted has only one of the smaller strakes ... so when was the second strake introduced ... my guess based on Takwis answer and PEI's post is the -600 to -900 ... so you would expect a reason for that... do you know what 737-model that KLM plane was?

737 Driver in the image that I posted I indicated the difference between the 'trapdoor' and the 'leading edge' ...IIRC the trapdoor opens down and forward and is as far as I could see not a part of the moveable leading edge/slats ... it would require a detailed picture of a MAX to clear that up I guess (would be nice to see one),


The picture was found online by Takwis, and there was no explanation of its context. I was merely assisting him with posting it. As far as your other queries, I have reached the extent of my expertise in these matters except to say that apparently someone thought these devices were necessary to accommodate the changes in airflow around the new engines.

[wheelsright]

I agree. This is how commercial aviation has become as safe as it is. When accidents happen, we seek not to blame individuals, but to understand root causes, and prevent or reduce the chance of the same thing happening again by correcting design or materials defects, augmenting training, changing procedures, improving regulatory oversight, documentation, and communication, or all of those things.

Sadly it seems there is a trend in society (I call it "outrage culture") where the response to any calamity is one driven by anger and blame, and not one seeking to solve actual problems. Or maybe I'm just getting old.

"This is how commercial aviation has become as safe as it is" I suspect that it is rather an Alice in Wonderland perspective. Every accident that involves loss of life, ultimately requires the investigation and apportionment of blame. Nothing has significantly changed in that respect. Air accident investigation does its best not to make legal findings because that is for the courts. Liability for mistakes is an important part of concentrating the mind... not just in the aviation world. Improving safety standards is largely due to commercial necessity. Public trust goes hand in hand with passenger volume. It is the breach of trust that can harm aviation. Countries have laws and hopefully those laws are respected and enforced when appropriate. Negligence, criminal negligence, dishonesty and corruption are possible in aviation as with every other walk of life. If individuals knowingly allowed or concealed unsafe systems being incorporated into the 737 MAX they will be be culpable. It is not a witch-hunt for the law to be enforced. The criminal test is an actus reus combined with mens rea. It is a high bar but one that could be reached. There are already signs that there have been some concealment and lack of candor. The circumstances demand that there will be further criminal and civil investigation to properly apportion blame. It may be that there were a series of innocent mistakes but that does not seem to be the most likely. Regardless of innocence, blame will still have to be apportioned to calculate compensation claims.

[Lonewolf_50]

"This is how commercial aviation has become as safe as it is" I suspect that it is rather an Alice in Wonderland perspective. Every accident that involves loss of life, ultimately requires the investigation and apportionment of blame. . Spoken like a lawyer, not an accident investigator.
In blame there is profit - and a payday for a lawyer. :p The criminal test is an actus reus combined with mens rea. If you want people not to speak freely during an accident investigation, keep that attitude foremost.

[derjodel]

That is 35 seconds with only 2 MCAS .

35 seconds. That is exactly the time "wasted" by captain Sullenberger's reaction time - he could have landed at La Guardia had he reacted "properly"!

In other words, Sully would have crashed this airplane, too. Must be a terrible pilot with no skills and no aviation safety insight.

[JLWSanDiego]

A big part of our problems today is that many if not most of our politicians are in fact lawyers

[slacktide]

And, for all we know, the B747-800 might have the odd bandaid too for some obscure issue just like the MAX.

All aircraft experimental flight test campaigns uncover issues which were not expected during the design of the aircraft, and require some sort of change to rectify. In the case of the 747-8, it was outboard aileron flutter, which was corrected with a *GASP* software fix. The engineering team was lauded for creating a software-only fix which required no hardware changes.

https://www.seattletimes.com/business/in-person-fitzgeralds-fix-for-boeing-747-8-earns-aviation-honors/

[737 Driver]

35 seconds. That is exactly the time "wasted" by captain Sullenberger's reaction time - he could have landed at La Guardia had he reacted "properly"!

In other words, Sully would have crashed this airplane, too. Must be a terrible pilot with no skills and no aviation safety insight.

Okay, Sully wasn't piloting a 737, but let's say he did. Somehow I just don't think Sully would have allowed his stab trim to run for 9 continuous seconds (that would be 37 spins of the trim wheel) before doing something about it, say like hitting the yoke trim switch with his left thumb. I certainly don't think he would let that happen twice. Maybe we should also note that Sully wasn't piloting Lion Air 610 the day before the accident (same aircraft, different crew in the very first documented case of the MCAS malfunction), and yet they still managed to figure out that when an automated system puts in some stab trim you don't want, it is entirely possible to take it right back out again.

[Lonewolf_50]

A big part of our problems today is that many if not most of our politicians are in fact lawyers The problem more related to this thread is that the industry seems to have established a trend, and built momentum in that direction, of dumbing down the flight deck positions and only retaining them so that there is someone to blame. (Yes, very cynical view, but that "Children of the Magenta Line" theory didn't arrive out of nowwhere).

[Phantom Driver]

737 Driver--
Okay, Sully wasn't piloting a 737, but let's say he did. Somehow I just don't think Sully would have allowed his stab trim to run for 9 continuous seconds (that would be 37 spins of the trim wheel) before doing something about it, say like hitting the yoke trim switch with his left thumb. I certainly don't think he would let that happen twice. Maybe we should also note that Sully wasn't piloting Lion Air 610 the day before the accident (same aircraft, different crew in the very first documented case of the MCAS malfunction), and yet they still managed to figure out that when an automated system puts in some stab trim you don't want, it is entirely possible to take it right back out again.

First, let me congratulate you ( like others have done ) on comprehensive and insightful analysis of this sad episode in aviation . It is just a pity that your observations /advice seem to be falling on so many deaf ears . Hence this thread continues to go round in ever widening circles , with no apparent end in sight .
There is an old saying -" a good workman never blames his tools " ; to that end , we can add the mantra--" Safety is a well trained pilot " .

Continuing on the same path of quotations , there is the favourite from Shakespeare --" Man has oft more need to be reminded than informed " . We forget past lessons easily .

Which brings me to the final , main point , (which you have stressed , in bold type , goodness knows how many times )--FLY THE AIRCRAFT. This is drummed into every pilot from day one . Sadly , this fairly simple piece of advice often falls by the wayside in the heat of the moment . The basics have been forgotten . Now , why this is so is another matter entirely .

[MemberBerry]

Obvious errors were made that had fatal consequences. Since most of us would like to assume that this wasn't a case of malicious or negligent behavior, then presumably there were some significant human factor element behind these lapses.

I am referring, of course, to the various engineers, technical and supervisory staff that designed and approved MCAS for service.


I would like to assume they were not malicious or negligent too. But unfortunately a certain percentage of the population consists of sociopaths and psychopaths. And studies have shown that percentage is higher for people in senior executive positions, going as high as 20% psychopaths among CEOs, for example: https://www.washingtonpost.com/news/on-small-business/wp/2016/09/16/gene-marks-21-percent-of-ceos-are-psychopaths-only-21-percent/?utm_term=.549ab86d739e. With that in mind, I tend to be very suspicious when I hear a large company has made a "mistake", especially when that "mistake" has the potential to increase the profits of the company. At least until the public becomes aware of it.

You can look at the Volkswagen emissions scandal for example. A lot of people conspired to disregard the regulations to increase profits. I see no reason something similar wouldn't be possible at Boeing. It wouldn't surprise me at all if it turns out Boeing ignored or even deliberately covered up the MCAS safety issues, hoping they wouldn't get caught.

[coaldemon]

So you are saying that Boeing was on the same path as Volkswagen and had specifically designed software that operated when it was tested. Wow you really have no idea of the people in Boeing. I don't work for them but I have had a lot to do with them and that is not what they are about culturally.

I agree with some of the posts above: If the Aircraft is not doing what you want then make it do what you want. Take out the automation and hand fly it if need be but take control of it.

Have a look at the data released in the preliminary report for ET302 and see if you can work out what they were doing in the 2 minutes before MCAS came in. That would also be the MCAS they were supposed to have been informed about after the release of the bulletin by Boeing. There are a lot of factors to this one and although MCAS is a flawed concept and has to be fixed the aircraft around it is fine and actually very nice to operate.

As for psychopaths in corporate structures I have meet some definite candidates over the years as well as some in Pilots uniforms.

[MemberBerry]

So you are saying that Boeing was on the same path as Volkswagen and had specifically designed software that operated when it was tested. Wow you really have no idea of the people in Boeing. I don't work for them but I have had a lot to do with them and that is not what they are about culturally.


I didn't say that MCAS operated only when tested, but still a lot of parallels can be drawn between the two situations. I have no reason not to believe that MCAS works properly when the AOA sensors work properly, which was not what was going on at Volkswagen. But I still believe it is highly likely that in both cases there some unethical people ignored that their products can kill people, to increase profits.

And I don't mean to blame all the Boeing employees, or even a majority of Boeing's employees. I'm sure many of them are fine people that do their best every day, and are sickened and angry about the situation. But it's enough to have a few dozens of people in key positions being unethical. It doesn't matter if 99% of the employees are not like that, the final outcome can be the same.

[FrequentSLF]

I agree with some of the posts above: If the Aircraft is not doing what you want then make it do what you want. Take out the automation and hand fly it if need be but take control of it.


Hello,

will you explain how to take out the automation, in this case MCAS, unless you mean indeed to crank the wheels?
i might missed the switch to do so, would appreciate if you can point it to me

[Matt48]

As stated by SystemsNerd, the human cognition has limitations and foibles that many people are unaware of. One of these is the limited number of 'cognitive channels' also known as multiple resource theory. (see papers by Christopher Wickens and Erik Hollnagel) Simply you cannot read this posting and recite a something you have learned like NNC memory items at the same time - both use verbal cognition - if you are reading and someone says something you may hear them but you will not understand what they said and you will stop reading and ask them to repeat what they said. If you have to read, talk and listen at the same time you can only really do one at a time (we have all had to read a paragraph again as we stopped understanding what we were reading and listened instead).
So if you are running through memory items of an NNC - and you read the EICAS you may miss NNC items or not understand the EICAS - if the PM is shouting at you it may just be noise - if there is sufficient noise that channel stops completely and you do not even hear/comprehend the PM or that cavalry charge.

Mixed into this is the effect of the level of stress/alertness. This is normally referred to as an 'inverted U'.

https://cimg2.ibsrv.net/gimg/pprune.org-vbulletin/460x335/inverted_u_diagram_c1224187b9e0446c4516be2dd9863ef39ab92d63. jpg
from MindTools.com

So when you are bored with low stress your performance is actually poor, A little pressure / stress and your performance is ideal, but too much high stress and your performance will drop off rapidly.

Putting all that into an aviation perspective, A well trained pilot with experience of things going pear shaped and operating under pressure will not feel so much stress and concentrate on one item at a time and a lot of what will be done will be (what is called here ) muscle memory - innate training like stamping on a brake or steering a bike to stay balanced - or trimming an aircraft - it requires no thought as it is second nature. This is the importance of training - with not so much training it is easy to get into the overstressed very low performance state and 'get behind the aircraft'. The more inputs you are given the higher the stress and the less you are able to process and the normal human reaction to that is what is known as attentional or cognitive tunneling - a concentration on one aspect of what is happening that you _do_ think you can control and a total disregard of anything else. Everyone is different in this regard and the only way to avoid getting into the wrong side of the U is training, repeated training to get that muscle memory. Unfortunately, there is always a beancounter standing in the way of that.

I would like to see a stick shaker attached to a judges chair and then watch him make some complicated judgement with all that racket and distraction going on, but he won't die if he gets it wrong.

Where the MCAS trim runaway becomes difficult to deal with is it's transient nature, kind of like a partial engine failure in a single, oh, the engine has died, ok look for a landing area, good, got that, oh it's going again, so I'll turn a 180 and try to head back to the strip, oh no, it's failed again, now where was that grassy field, but if it was a straight out constant trim runaway, it would most likely have been caught sooner as there was training for that scenario.

[MurphyWasRight]

Have a look at the data released in the preliminary report for ET302 and see if you can work out what they were doing in the 2 minutes before MCAS came in. That would also be the MCAS they were supposed to have been informed about after the release of the bulletin by Boeing. There are a lot of factors to this one and although MCAS is a flawed concept and has to be fixed the aircraft around it is fine and actually very nice to operate.
.

OK. here is my take, where possible times are from the text of report, assumed to be more accurate than reading the chart:
Takeoff roll began from runway 07R at a field elevation of 2333.5 m at approximately 05:38,
Everything looks nominal.
At 05:38:44, shortly after liftoff, the left and right recorded AOA values deviated
This was first indication of trouble, stick shaker and UAS indications.
Although the prelim report does not contain details it is possible the crew determined the UAS to be due to AoA; from Boeing flow chart someone posted a while back. Double quoted so my comments stand out better:
If AoA sensor is failed high,stick shaker on failed side will activate on rotation accompanied by IAS/ALT disagree warning flags
If the pitch power and config are consistent with takeoff and the good side ASI agrees with the Standby ASI,then it is a false warning ----------- >If in any doubt execute the UAS NNC
The symptoms match exact;y and there was not a huge difference in airspeed so they likely did not have a doubt. Anyone know what the standby ASI would show?
The pilot with good side data becomes PF
That did not happen as shown by pilot side AP warnings. The 360 total hours FO just might have something to do with that.
Land immediately
Appears they were not planning an immediate landing, although some of the ATC requests might have been from an 'automatic script' they were used to following.

There were a couple of attempts to engage auto pilot. ending in success at:
At 05:39:22 and about 1,000 feet the left autopilot (AP) was engaged (it disengaged about 33 seconds later),
At this point one could say they were flying the aircraft as they were trained/used to doing. Whether that is a good thing is a different discusion.
At 05:39:42, Level Change mode was engaged. The selected altitude was 32000 ft. Shortly after the mode change, the selected airspeed was set to 238 kt.
More normal procedure, this is probably the last time anyone thought about airspeed, at least until the clackers went off.
At 05:39:45, Captain requested flaps up and First-Officer acknowledged. One second later, flap handle moved from 5 to 0 degrees and flaps retraction began.
Still a surprisingly 'normal day at the office, although they would not be the first crew to ignore stick shaker and complete a flight, and no I am not referring to Lion air but a US crew report in safety database.
At 05:39:55, Autopilot disengaged,

And this is when MCAS kicked in 5 seconds later. So about 75 seconds from first fault to MCAS, with about half of that with a working autopilot leading them to believe things were basically OK, which in a 737NG they would have been. They were possibly even intending to complete flight for 'commercial' reasons.

[RobertP]

ICAO Annex 13 and the associated manual of accident/incident investigation clearly define the responsibilities and dissemination requirements for information including CVFDR Data. Ethiopea is a signatory to this (and all other) annexes to the convention. The international “aviation” community effectively “own” this information although it does of course imply that all States comply in full regarding these requirements.

[737 Driver]

will you explain how to take out the automation, in this case MCAS, unless you mean indeed to crank the wheels?
i might missed the switch to do so, would appreciate if you can point it to me

A MCAS failure presents itself as runaway stab trim. This uncommanded motion can be caused by a number of different malfunctions, MCAS being only one of them. The runaway stab trim procedure is agnostic as to the underlying cause of the the malfunction.

The procedure itself calls for disengagement of the Autopilot, use of Main Electric Trim (yoke trim switch) as necessary, disengagement of the Autothrottles, and if the runaway has not ceased, use of the stab trim cutout switches. Once all electric trim has been terminated, you would use manual trim as needed until landing.

Though it is not currently procedure, if you had a good idea that the problem really was MCAS (presumably because of an erroneous AOA or airspeed input), you could extend the flaps and restore the electric trim since MCAS only works with the flaps up. Technically, engaging the autopilot would also cause MCAS inputs to cease, however, our manuals contain warnings that the autopilot may not stay engaged with an erroneous AOA or airspeed.

[Matt48]

A big part of our problems today is that many if not most of our politicians are in fact lawyers
Both occupations are interchangeable, they are equal parts public debating, show biz, and BS, i.e. convincing that black is white.

[Matt48]

A MCAS failure presents itself as runaway stab trim. This uncommanded motion can be caused by a number of different malfunctions, MCAS being only one of them. The runaway stab trim procedure is agnostic as to the underlying cause of the the malfunction.

The procedure itself calls for disengagement of the Autopilot, use of Main Electric Trim (yoke trim switch) as necessary, disengagement of the Autothrottles, and if the runaway has not ceased, use of the stab trim cutout switches. Once all electric trim has been terminated, you would use manual trim as needed until landing.

Though it is not currently procedure, if you had a good idea that the problem really was MCAS (presumably because of an erroneous AOA or airspeed input), you could extend the flaps and restore the electric trim since MCAS only works with the flaps up. Technically, engaging the autopilot would also cause MCAS inputs to cease, however, our manuals contain warnings that the autopilot may not stay engaged with an erroneous AOA or airspeed.

I'm not sure if this has been discussed already and I've missed it, but is it possible for the electric stab trim to become stalled or overwhelmed by aerodynamic forces when there's a combination of a bit of speed and full stab deflection.

[GordonR_Cape]

All aircraft experimental flight test campaigns uncover issues which were not expected during the design of the aircraft, and require some sort of change to rectify. In the case of the 747-8, it was outboard aileron flutter, which was corrected with a *GASP* software fix. The engineering team was lauded for creating a software-only fix which required no hardware changes.

https://www.seattletimes.com/business/in-person-fitzgeralds-fix-for-boeing-747-8-earns-aviation-honors/

Thanks for the interesting article. However it is ironic in many ways, highlighting the difference between the development of the B747-8 and the B737 MAX.

The other difference is corporate culture. The 2nd most read article on the Seattle Times website is the appointment of a legal czar to deal with the B737 MAX fallout: https://www.seattletimes.com/business/boeing-aerospace/boeing-appoints-legal-czar-to-oversee-fallout-from-fatal-max-crashes/ (https://www.seattletimes.com/subscribe/signup-offers/?pw=redirect&subsource=paywall&return=https://www.seattletimes.com/business/boeing-aerospace/boeing-appoints-legal-czar-to-oversee-fallout-from-fatal-max-crashes/)

The first article celebrates the achievement of a young engineer, the second is all about hiding behind layers of corporate accountability, As the saying goes: success has a thousand fathers, but failure is an orphan.

[wheelsright]

Spoken like a lawyer, not an accident investigator.
In blame there is profit - and a payday for a lawyer. :p If you want people not to speak freely during an accident investigation, keep that attitude foremost.

Of course you are right that in the context of an air accident investigation it is better not to approach the matter with the view to assigning blame or liability. But it is naive to assume that every person is not aware that they could be held liable or that misleading Federal investigators is criminal. Lawyers are a little like dentists... overpaid and to be avoided if possible. But sometimes they are necessary.

Obviously, from the perspective of people that have lost family and friends they want to know why it happened and may need compensation for their loss. if you are face to face with a victim it is rather harder to be dismissive of their needs. The enforcement of law should be just and proportionate. I suspect that failure to enforce the law would be an invitation to abuse it. I doubt it would serve the culture of safety to avoid justice. Without justice, it is likely that people would be less candid rather than more candid. The enforcement of law is a natural and necessary part of air safety. Therefore, I do not think it could be right that the assignment of blame in any way impedes candor or safety; quite the reverse in fact. Cost is quite a different issue...

[737 Driver]

I'm not sure if this has been discussed already and I've missed it, but is it possible for the electric stab trim to become stalled or overwhelmed by aerodynamic forces when there's a combination of a bit of speed and full stab deflection.

This was actually one of the first issues that I checked into when I started looking at these accidents. To date I have found no evidence to suggest that the electric motor could stall under the loads present in the accident scenarios. If you think about it, in the final stages of the Ethiopian crash the stab motor was perfectly able to move the stab to near its limit against the opposing forces.

[FrequentSLF]

A MCAS failure presents itself as runaway stab trim. This uncommanded motion can be caused by a number of different malfunctions, MCAS being only one of them. The runaway stab trim procedure is agnostic as to the underlying cause of the the malfunction.

The procedure itself calls for disengagement of the Autopilot, use of Main Electric Trim (yoke trim switch) as necessary, disengagement of the Autothrottles, and if the runaway has not ceased, use of the stab trim cutout switches. Once all electric trim has been terminated, you would use manual trim as needed until landing.

Though it is not currently procedure, if you had a good idea that the problem really was MCAS (presumably because of an erroneous AOA or airspeed input), you could extend the flaps and restore the electric trim since MCAS only works with the flaps up. Technically, engaging the autopilot would also cause MCAS inputs to cease, however, our manuals contain warnings that the autopilot may not stay engaged with an erroneous AOA or airspeed.
i am not a pilot, but if i remeber well, the last memory item for a runaway trim stabilizer is grab and hold...not crank
I do not want to argue, please correct me if I am wrong

[Matt48]

This was actually one of the first issues that I checked into when I started looking at these accidents. To date I have found no evidence to suggest that the electric motor could stall under the loads present in the accident scenarios. If you think about it, in the final stages of the Ethiopian crash the stab motor was perfectly able to move the stab to near its limit against the opposing forces.

Thanks for that 737 driver.

[737 Driver]

i am not a pilot, but if i remeber well, the last memory item for a runaway trim stabilizer is grab and hold...not crank
I do not want to argue, please correct me if I am wrong

Well, not exactly the last step, but close. I know of no instance where the cutout switches haven't worked. Among my colleagues on the 737, the most often technique discussed if one were to ever to be exposed to this situation is for the non-flying pilot to place his foot firmly on the trim wheel. Works much better than the hand. The trim system is designed such that if the cockpit trim wheel is stopped, the stab itself will not move because of a clutch mechanism that favors the trim wheel.

[slacktide]

I would like to see a stick shaker attached to a judges chair and then watch him make some complicated judgement with all that racket and distraction going on, but he won't die if he gets it wrong.

Still a surprisingly 'normal day at the office, although they would not be the first crew to ignore stick shaker and complete a flight, and no I am not referring to Lion air but a US crew report in safety database.

Cognitive dissonance... So, is the stick shaker so startling and confusing that we should expect pilots to loose the ability to make rational judgements and control the aircraft when it is active, or is it a just normal day at the office, set FL 320 and continue?

Either way you slice it, the pilots had airspeed disagree and stickshaker immediately after takeoff. None of memory items on the UAS NNC checklist were executed. Counter to multiple instructions in that checklist, they continued to attempt to engage the autopilot when their training taught them they should not have. MCAS was no factor for the first one minute, fifteen seconds of the flight. Startle factor does not last a minute and fifteen seconds.

[slacktide]

i am not a pilot, but if i remeber well, the last memory item for a runaway trim stabilizer is grab and hold...not crank
I do not want to argue, please correct me if I am wrong

First - there is an IF statement before that action. You only do it if the runaway continues after having selected STAB TRIM CUTOUT.

Second - that is the last memory item on the checklist, but it is not the last item. After finishing the memory items, the crew, using the QRH, should execute the non-memory (reference) items. The first reference item is "Stabilizer - Trim Manually." Note - this excerpt is from an NG, but I believe that we earlier had compared it to MAX in one of these threads and found no or negligible differences.

https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/429x671/capture_319df63ab096e24e15c12d5e602d70ace565a602_95a97c4f3b2 9406e3b3fe55ff66ec806394fc7fa.png

[Akali Dal]

I’m sure when slacktide has his vibrator go off and slacks up, he would his have thumbs twiddling, fingers groping and setting 70% Ann one and pitch down to 4 degrees��

[wonkazoo]

Startle factor does not last a minute and fifteen seconds.

Second dumbest statement I've seen this week. (Apologies for the harsh tone, I'm just done with superheroes who fail to understand cognitive impairment at times of unexpected and excessive stressors.)

For all you freaking hero pilots out there who would have just flown the effing airplane away from the troubles:

I wrote, probably a week ago now, of my own experience, as an eminently qualified, level-headed and relatively "calm when the crap hits the fan" type. For the heroes here who cannot understand cognitive stress-induced impairment I suggest you go back and read it- you might learn something.

You (yes you guys and all of us) simply cannot predict the cognitive impairment you will suffer (and we all suffer some form of it- unless one of us is God, in which case hallelujah!!) when the **** really really hits the fan. You cannot simulate this in a simulator, and most of you who have had to deal with emergencies of one form or another have also never dealt with it.

It is what happens when a big neon sign lights up your entire brain at once, screaming "YOU ARE ABOUT TO DIE!!" The fact that you might be able to overcome that knowledge will still not dampen your body's reaction to that realization, and you will, as a result, function at a fraction of your normal rate.

I know most of you- even the ones sympathetic to this reality, are certain you won't fade for even a moment, that your professional work and pride will keep you from ever experiencing such a complete disconnect from events.

I'm here to tell you that you are wrong.

No one will ever accurately depict what happened in either of those two cockpits. An audio tape reveals nothing of what is going on inside the minds of those four pilots. People pontificating here about their personal traits would be well-advised to consider that fact, and the one that says they are equally as likely, independent of their training, to suffer cognitive impairment when faced with a similar circumstance.

Regards, sorry for the rant-
dce

[slacktide]

dumbest freaking effing hallelujah **** DIE rant

Temper your emotion. The startle response has been studied and documented for decades, and the results are used as a part of the design and certification of aircraft around the world. Instead of resorting to profanity, which may feel powerful to you but adds no value, I suggest that you read some of the original research and publications of Dr. Michael Gillen, PhD. Dr. Gillen also happens to be an ATP and is/was a 737 line check airman at United Airlines. His research indicates that impairment can last for up to 30 seconds following a strong startle event. He also published a great paper a few years ago (based on a study involving 40 different crews) comparing the effect of training recency on response to startle effect. This paper was used by the FAA as part of defining the new UPRT training requirements, which the FAA now requires as a result of the unacceptable pilot performance demonstrated on AF447. He found that crews who did not have recency in UPRT training consistently failed to meet ATP minimum standards, while crews who did have recent training, met the ATP standards.

The Ethiopian crew did not perform to standards. If, instead of flying a revenue flight on a 737MAX, they happened to be in a simulation session on an 737NG, and they were given stick shaker and airspeed disagree at rotation, how do you think the check airman would have rated the subsequent performance? Would he have said "Gee, too bad that stick shaker was annoying you. I'll forgive your failure to execute any of the required checklist items. You're cleared for another 6 months."

[alf5071h]

Excellent rant wonkazoo, :ok:
Startle, long or short duration, according to the perceived situation, according to personal disposition, experience; Experience, again questioning where this came from and how formed.

Startle can be reinvigorated, even continuous, particularly in situations where action taken for the situation does not improve conditions; not cure a ‘problem’, because the problem is more often unknown in startling situations. Then … if you follow procedures, (the essential items; don’t quibble about SOPs, nothing is standard when startled) the aircraft / system does not respond as you, design, or regulator expected.

http://www.icao.int/Meetings/LOCI/Presentations/Managing%20Startle%20Individual%20Crew%20and%20Organizationa l%20Strategies.pdf

http://pacdeff.com/pdfs/W%20Martin%20Queenstown%20Presentation.pdf

http://www.flightsafetyaustralia.com/2015/08/without-warning-the-startle-factor/

http://safetyforum.alpa.org/LinkClick.aspx?fileticket=S4dMWfWy%2bSU%3d&tabid=1004

[catch21]

I suppose if Boeing "did everything right" they'll have a hard job justifying firing anyone for "doing something wrong" here?

[LEM]

Fact is that even if your brain is short circuited by fear of death, that's exactly in those moments that pilots should be real pilots, I mean resource to INSTINCTS, BASIC INSTICTS.
A "pilot" who hears the tremendous noise of 500 knots (!) and doesn't even touch those tho things in the middle of the pedestal (also called trust levers) to pull them back.... well, should be doing another job (and I put it nicely)....

[Ancient Mariner]

All this grandstanding makes me wonder if some of you have been in an emergency, a real emergency?
I've been fortunate/unfortunate enough to have been in a few, albeit maritime, not aviation related.
Everytime I was surprised to see "highly trained professionals", and I mean highly trained, we had realistic training once a week for these eventualities, totally break down and be unable to function. I not talking 30 seconds, 90 seconds, but unable, period.
Aviation is of course a totally different ballgame. :hmm:
Per

[A0283]

slacktide @ His research indicates that impairment can last for up to 30 secs following a strong startle event.

When you discuss research or complex engineering it would be necessary to share and discuss definitions first. That by itself is not simple thing in a forum format. In order to do it right I imagine that you would need a constant exchange of combinations of 'post+attachments'. Most research has a strict scope. So I sincerely wonder what your definition of "startle" is (how it combines with other effects). And it would be interesting to have a link to a public document of your Dr.

"Startle" basically suggests a 'short duration' experience/event. Your answer and that research does not seem to cover short and longer duration 'freezes'. And short and longer duration 'confusion'. Let alone other short, mid and long term effects.

Some of the other posters have shared and explained experiences that indicate that there is more than what you seem to suggest.

What strikes me in some posts on this thread is the absolute 100% conviction that some seem to reflect. I have been in situations where my life was directly threathened and also in situations where people got a heart attack while driving. In all cases I reacted very good ... did a number of the right things and did them right ... But what I saw around me made it clear to me that there is a lot of grey in between the black and white. And that when such a situation would happen again that I myself included and others should and could not expect to react in the same manner. I think that is what some of the posters appear to want to share. And the apparent or even clear rejection of that experience may explain some of their emotion.

We would all agree that training is at the least very important. But, I also note that there are things that can be improved by training but not to a 100% success. An interesting old example used to be research in the military. You train infantry soldiers with 100% heavy loads. But when they fired rounds over their heads they could only lift 50%. It is well researched that the body can take over. Elite soldiers are trained in more challenging and dangerous settings, so training helps a lot. But even elite soldiers die,both in training (even SAS) and in daily and combat ops. So no 100%. Planes are designed toward 100% safe but I never heard an experienced designer say that he is 100% sure.

[JCviggen]

Fact is that even if your brain is short circuited by fear of death, that's exactly in those moments that pilots should be real pilots, I mean resource to INSTINCTS, BASIC INSTICTS.
And how do you suppose we *should* go ahead and make sure we got people with the "right stuff" up front? Are you suggesting we simply strap trainees into an actually crashing plane and see if they can save it by using their superior instincts? You can't know things that cannot be effectively tested and anyone who thinks they will certainly keep functioning rationally and effectively in an incident is kidding themselves.

[fdr]

Fact is that even if your brain is short circuited by fear of death, that's exactly in those moments that pilots should be real pilots, I mean resource to INSTINCTS, BASIC INSTICTS.
A "pilot" who hears the tremendous noise of 500 knots (!) and doesn't even touch those tho things in the middle of the pedestal (also called trust levers) to pull them back.... well, should be doing another job (and I put it nicely)....

LEM, with the greatest stretch of the imagination, I just don't see any part of Part 61 or the MOS that requires heroic competency to be present in all aviators seated forward of Row 1. It may be nice to find, and it does occur occasionally, but the system cannot depend on heroic intervention to make up for stupidity in the fundamental design. Part 25 expressly demands that extreme levels of competency, heroics etc must not be relied on to save the day, and that is the fundamental problem with where the industry finds itself with JT610, and ET302. I don't object to people maintaining skills at a high level, in fact that he highly desirable, but it is not what the industry has achieved or demands, and on occasion, it has bitten back, as it did with AA587.

The industry has a bit of a problem, and that is not going away anytime soon. The explosive growth of the industry and the nonsensical regulatory environment result in the current training and recurrent matrices, that cover the obligatory requirements but are not going to achieve exceptional levels of competency leading to legendary aerial feats; the training, system and design needs to be robust enough to achieve an acceptable level of risk for the industry, and that is the problem at present.

[Bergerie1]

Per,

Both you and wonkerzoo speak the truth with the authority of having been there. I was subjected to a particularly nasty emergency very early in my flying career. Although we did a number of things wrong, we survived. It made me re-think many things about aviation, the most important being how one may react when something totally unexpected, outside any previous normal training regime, suddenly 'hits one in the face'.

It not only made me study much more diligently everything I could find out about the aircraft I was flying and about aviation in general, but it also led me to studying all the books I could find on the psychology of human reactions to fear and excessive workloads. The so-called 'startle effect' was not known by that name in those days, but my reading made very clear the way in which the primative part of the human brain can take over in extremis. Good training definitely helps to combat this, but, as Per has said, even the best trained individual can falter.

However much we study and behave and train as professionals, even the coolest skygod may find he has feet of clay.

[GordonR_Cape]

Excellent rant wonkazoo, :ok:Startle, long or short duration, according to the perceived situation, according to personal disposition, experience; Experience, again questioning where this came from and how formed.

Startle can be reinvigorated, even continuous, particularly in situations where action taken for the situation does not improve conditions; not cure a ‘problem’, because the problem is more often unknown in startling situations. Then … if you follow procedures, (the essential items; don’t quibble about SOPs, nothing is standard when startled) the aircraft / system does not respond as you, design, or regulator expected.

http://www.icao.int/Meetings/LOCI/Presentations/Managing%20Startle%20Individual%20Crew%20and%20Organizationa l%20Strategies.pdf

http://pacdeff.com/pdfs/W%20Martin%20Queenstown%20Presentation.pdf

http://www.flightsafetyaustralia.com/2015/08/without-warning-the-startle-factor/

http://safetyforum.alpa.org/LinkClick.aspx?fileticket=S4dMWfWy%2bSU%3d&tabid=1004
Thanks for the interesting links, which together shed some light on the current discussion.

I would add another factor, the difference between procedural memory and semantic memory. Pilots will have been repeatedly trained to do certain procedural operations on NG simulators, which become part of ingrained muscle memory. With the introduction of the B737 MAX, there were insufficient simulators. Differences training was done on a computer, which became part of factual recall memory.

IMO the combination of procedural training on a B737 NG, plus semantic training of the MAX differences, may create a mental conflict in determining the right choice of actions. The addition of stress factors, would make the failure to respond correctly much higher.

Reference: Declarative Memory (Explicit Memory) and Procedural Memory (Implicit Memory) - Types of Memory - The Human Memory (http://www.human-memory.net/types_declarative.html)

[Uplinker]

UAS recovery in particular needs to be a reflex response, (like trimming, or immediately dipping the nose if the stall warning goes off), but it is not trained sufficiently in my view. I don’t always monitor both speed tapes when PM as we climb out on busy or complicated departures but I definitely should.

In the light of this accident and other fatal accidents in the last few years; every SIM session should have a mandatory event which requires ignoring everything else and reverting to basic pitch and power - not pre-briefed or even mentioned; just sprung on every crew at any moment, any phase of flight.

Regarding surprise reaction; We once had the overspeed warning go off in a Dash 8, because PM had missed bringing the flaps up owing to radio calls and a very busy departure. This beeping was going on for about 40s before we both realised what it was. Not proud to admit that at all, but these things happen.

I’m sure this will have been mentioned, so apologies but, is there an AoA disagree warning on the 737?

[Loose rivets]

uplinker #4860

I’m sure this will have been mentioned, so apologies but, is there an AoA disagree warning on the 737?


The $80,000 upgrade, and the warning that got lost in the mystery of not having that upgrade, will, I hope, become a courtroom issue.

[wheelsright]

All this grandstanding makes me wonder if some of you have been in an emergency, a real emergency?
I've been fortunate/unfortunate enough to have been in a few, albeit maritime, not aviation related.
Everytime I was surprised to see "highly trained professionals", and I mean highly trained, we had realistic training once a week for these eventualities, totally break down and be unable to function. I not talking 30 seconds, 90 seconds, but unable, period.
Aviation is of course a totally different ballgame. :hmm:
Per

I agree with your observation. I think we all aspire to function well under severe pressure or danger. The truth is even we cannot predict how we will operate under intense pressure let alone how somebody else will perform. Training does help, provided it is sufficient to make the actions required second nature but still does not recreate the pressure of facing death. I have been in a number of high stress situations and in hindsight performed reasonably well in two but failed miserably in another resulting in the death of a friend. My father was an resistance fighter during WWII and was accustomed to life and death situations for over 4 years of his life continuously. I always admired his ability to function under the most intense danger and pressure... but there is no training that can replace experience. Many people luckily do not have the benefit of observing themselves in the most extreme of circumstances.

I too have witnessed well trained peoples minds become empty and acknowledge all the training in the world cannot predict a poor reaction to the ultimate stress. From my own experience I can say that in the two circumstances that I performed well, I immediately had a clear crystalized understanding of what was required. In the event that I did not perform well, I was unsure of the best course of action at the time. What I find difficult to read in this thread are people that have assumed what happened and assumed that it was immediately clear to the pilots what was required. Flying pitch and power is a little more stressful when you are a few feet AGL. I will reserve judgment on the pilots until further information is available and even then do not believe that Boeing should have ever placed them in that situation.

[PaxBritannica]

I accept that pilots are trained to react to certain situations in a manner that does not require them to make nuanced decisions. This seems eminently sensible. However, it seems to me that this requires pilots to be sure that they're reacting to the right problem. If you get UAS, along with a bunch of other anomalies you wouldn't normally expect, I think the human brain might hesitate to diagnose. The fact that performing the UAS memory items may have saved the day does not mean that this was clear to the ET crew in the moment.

In the Lion Air cases, crews had no idea MCAS existed, and struggled to make a diagnosis. The first crew 'happened' on a solution. The second crew had to factor in the plane's behaviour AS WELL AS the underlying knowledge that the a/c had misbehaved in a mysterious way the flight before.

The Ethopian crew were in a position to know that MCAS existed, although it seems their company had not provided them with much information. Like most MAX pilots, they would have had to think through for themselves - on their own time - how an MCAS anomaly might present. In the moment, with the cockpit screaming at them, they were - in real time - having to work out if this was an MCAS problem and whether this affected what they should do. Runaway MCAS is not quite the same as runaway stabiliser. Remember: at that time, MCAS had caused problems only once; Boeing had downplayed the seriousness of the issue and subtly blamed the third-world airline; despite the hull loss Boeing had not rushed to put a correction in place. The situation was foggy and confusing.

The crew was highly motivated to keep this plane safe. I'm sure we all agree on that? But Boeing's poor handling of the MCAS bad news may itself have contributed to the ET crash. The fact that, with their own lives on the line, these pilots were not able to work out what to do, suggests that crews needed proper training in how to incorporate MCAS issues into their diagnostic triggers. Pilots depend on training that reduces their startle response and allows them to diagnose quickly. Some pilots will need that more than others.

[KRUSTY 34]

Thanks for the interesting links, which together shed some light on the current discussion.

I would add another factor, the difference between procedural memory and semantic memory. Pilots will have been repeatedly trained to do certain procedural operations on NG simulators, which become part of ingrained muscle memory. With the introduction of the B737 MAX, there were insufficient simulators. Differences training was done on a computer, which became part of factual recall memory.

IMO the combination of procedural training on a B737 NG, plus semantic training of the MAX differences, may create a mental conflict in determining the right choice of actions. The addition of stress factors, would make the failure to respond correctly much higher.

Reference: Declarative Memory (Explicit Memory) and Procedural Memory (Implicit Memory) - Types of Memory - The Human Memory (http://www.human-memory.net/types_declarative.html)

Sounds perfectly rational to me.

Over the years I have been witness to some truly ignorant behavior by senior managers, and in turn the organizations they control. In basic terms, the one contributing factor to this baffling loss of corporate intellect, has been the AGENDA!

Did something similar happen at Boeing and the FAA?

[Loose rivets]

I said a bazillion posts ago that there's a chance some pre-knowledge of the Lion Air accident had a negative effect on the ET skipper's actions. Firstly a greater shock factor - due to realising a very specific and serious danger was confronting him. It may even explain, in those frantic moments, why he went for the AP. He may have picked up on the fact it would stop this mysterious MCAS, a problem he thought would not become an issue again in a million years. When at last the AP engaged, it would be only moments before his worst fears were realised. He was replaying the Lion Air accident, and things would be becoming surreal.

I've also mentioned finishing a flight with the stick-shaker going. I was in ink black chop and the noise seemed to suck at my mind, despite being one who loved a challenge to relieve the boredom.

Being in a 1-11 at Palma - V1 Rotate, and seconds later hovering over some buildings to the left. Zero on one ASI, and VMO on the other. We just kind of sopped over these grey hanger-like structures and then climbed away. I issued a met warning and company aircraft all went to Barcelona. And that was it. Nothing ever said about the incident. Even hopping over a bowser in Naples never got a single request for clarification. The bowser appeared out of the heat haze when we were very near V1. No worries, it'll be gone, and then the aaaaaaaagh moment. It was towing an even bigger bowser. Yes, another notch of flap on takeoff works. A bit of nervous laughter and we got on with our day. Different world back then.

The thing is, machines are machines, and they do much what we expect them to do - until one day they don't. But even then, minds world-wide can dig and dig at the probabilities as we're doing here. The mechanical side will make sense eventually, however unpalatable. However, the human side may never make sense. As I look back at my life, human behaviour has been the greatest mystery, and outside of war, my observation of unexplainable behaviour has not surprisingly been in the aviation industry. Bewildering, even unconscionable . . . I can't find a more suitable adjective, much of it to do with keeping the show on the road, or should I say, in the air.

If they do dig deep into Boeing and the FAA, it's probable I won't live long enough to see the last act of the performance. But the fact is, I could leave the theatre early because nothing would surprise me.

[737 Driver]

I accept that pilots are trained to react to certain situations in a manner that does not require them to make nuanced decisions. This seems eminently sensible. However, it seems to me that this requires pilots to be sure that they're reacting to the right problem. If you get UAS, along with a bunch of other anomalies you wouldn't normally expect, I think the human brain might hesitate to diagnose. The fact that performing the UAS memory items may have saved the day does not mean that this was clear to the ET crew in the moment.



Which is precisely why I and others have stated ad nauseum that when a pilot is presented with an undesired aircraft state, ambiguous warnings, or loss of situational awareness, they must be able to, at a minimum, Turn off the magic, Set the pitch, Set the power, Trim the aircraft, Monitor the performance, and Move to a safe altitude, i.e. FLY THE AIRCRAFT. This is the default response to any emergency or non-normal situation when a pilot is unclear as to what he/she should do next. And yes, it is a trainable response.

Performing these actions is no more difficult than executing the procedures for an engine fire/failure at V1, and we should not expect any less from a trained and competent commercial flight crew.

[GlueBall]

What I find difficult to read in this thread are people that have assumed what happened and assumed that it was immediately clear to the pilots what was required. .
What's immediately clear and overwhelmingly obvious is that when I'm pulling the control column to climb and the jet's not climbing but trimming nose down, is to stop the forward moving trim wheel either with my right hand or my right thigh/knee and simultaneously order the copilot to cut the stab trim switches. Just like that. Instinctively when the jet is not responding to my control inputs. Because for the moment I don't need to THINK nor to KNOW whether it's MCAS or just a runaway trim. It's elementary, instinctive hands-on flying reaction by an experienced pilot. The 29 year old purported 8000 hour captain seemed to be weaned on automation over-dependence and obviously lacked depth in manual flying skills. Turning on A/P with stick shaker, oblivious to approaching VMO at low altitude... Sad.

[safetypee]

737Driver, Matt48,
‘… evidence to suggest that the electric motor could stall under the loads …’
This may depend on the direction of applied load. MCAS ‘nose down’ could be easier than a resorting ‘nose up’ crew trim switch input. Similar problems for manual trim wheel, particularly if the elevator is deflected to demand aircraft nose up.
Also see the discussions about deliberate electric trim inhibition - https://www.satcom.guru/2019/04/what-happened-on-et302.html diagram of electric trim limit. Was MCAS wired through this restriction or not ?
The basic point was identified in the EASA certification query, which was answered as the alternative trim wheel input would be available

[737 Driver]

737Driver, Matt48,
‘… evidence to suggest that the electric motor could stall under the loads …’
This may depend on the direction of applied load. MCAS ‘nose down’ could be easier than a resorting ‘nose up’ crew trim switch input. Similar problems for manual trim wheel, particularly if the elevator is deflected to demand aircraft nose up.
Also see the discussions about deliberate electric trim inhibition - https://www.satcom.guru/2019/04/what-happened-on-et302.html diagram of electric trim limit. Was MCAS wired through this restriction or not ?
The basic point was identified in the EASA certification query, which was answered as the alternative trim wheel input would be available



Again, no evidence from either of these accidents or from historical data that the electric stab trim motor could stall under load. The matter of the electric trim inhibition discussed in the link above is a completely separate issue. That inhibition prevents main electric trimming (pilot actuated) into a certain region of forward trim, but it does not prevent the use of electric trim to move out of that region.

All this being said, one of the causal factors of these accidents is that the pilots let the aircraft so far out of trim in the first place. It is absolutely clear from the data (both ET302, and both LA610 flights) that the pilot actuated stab trim stopped and reversed the MCAS trim input every time it was used. As powerful as MCAS was, it could not overcome the strength inherent in the Captain's left thumb - if he had chosen to use it.

[alf5071h]

737 Driver,
Ad nauseam is a Latin term for argument or other discussion that has continued to the point of nausea. … indicating that the topic has been discussed extensively and those involved have grown tired of it.

Repetition does not change the accuracy or value of a statement or argument.
People, aviation, the world is not absolute, thus by considering the in-between ‘grey’ area opens the possibility of identifying something to learn. It is up to us to take these possibilities, accept that there is always something new to learn.

Avoid ‘what is’, and consider ‘what might be’; accept that no single view is absolute, not applicable to all situations, particularly those which you did not attend.

[737 Driver]

737 Driver,
Ad nauseam is a Latin term for argument or other discussion that has continued to the point of nausea. … indicating that the topic has been discussed extensively and those involved have grown tired of it.

Repetition does not change the accuracy or value of a statement or argument.


Perhaps it's worth noting that repetition and practice are core drills behind many learned skills, including aviation. It seems that certain reminders are very much in order here.

"People need to be reminded more often than they need to be instructed." - Samuel Johnson

[MemberBerry]

Fact is that even if your brain is short circuited by fear of death, that's exactly in those moments that pilots should be real pilots, I mean resource to INSTINCTS, BASIC INSTICTS.
A "pilot" who hears the tremendous noise of 500 knots (!) and doesn't even touch those tho things in the middle of the pedestal (also called trust levers) to pull them back.... well, should be doing another job (and I put it nicely)....

If you bothered to read the preliminary report you would have seen that they were not at 500 knots (!!!????!!!!). They only reached 500 knots immediately before impacting the ground, after diving for 20 seconds following the final MCAS activation.

Before that however:

"From 05:40:42 to 05:43:11 (about two and a half minutes), the stabilizer position gradually moved in the AND direction from 2.3 units to 2.1 units. During this time, aft force was applied to the control columns which remained aft of neutral position. The left indicated airspeed increased from approximately 305 kt to approximately 340 kt (VMO). The right indicated airspeed was approximately 20-25 kt higher than the left."

Which is consistent with the FDR IAS trace.

[James7]

The first crew 'happened' on a solution. .

The crew did not happen on anything, It was a jump seat pilot from a different airline that told them what to do and saved the day.

[PaxBritannica]

The crew did not happen on anything, It was a jump seat pilot from a different airline that told them what to do and saved the day.
I believe that's a pretty good definition of 'happening on a solution'. They tried other things unsuccessfully and then tried the suggestion of a third party, and it happened to work.

[fdr]

Forgive me but I don't believe this has been asked or answered before, so maybe I'm missing the basics but...

At stick shaker upon or immediately after take-off

Would raising the flaps be expected even when past V2 and apparently accelerating and climbing normally.
Surely an immediate return might be anticipated whilst I acknowledge a desire to cleanup and find a stable and mentally comfortable flight regime.

So surprised not to see this action directly criticised... I can see theres a conflict or choice between wanting adequate speed/thrust setting and sticking with a speed limiting flap setting (i assume).

Well, Yes & No.

The crew have 3 independent IAS indications, and the AOA information in passing by the lower limit speeds on the IAS tape. The AOA is incorrect, and that is triggering an erroneous correction to the Capt's IAS and triggers the disagree messages, the AOA already triggering the stall warning erroneously. The crew understand the aircraft is flying, and a cross check of power/attitude as well as comparison of the Capt/FO and the integrated standby would indicate that the Capts display is erroneous, and using the other sources, cleaning up would be possible. it is also possible that the crew were following established routine and raised the flaps. Once that was done the headaches multiplied rapidly. Either scenario is quite possible. Frequently, a crew will raise the gear after takeoff following a tyre failure or other issue that would contraindicate that procedure. We do tend to follow entrenched routine, even though such routines can be quite easily interrupted.


​​​​​​​

[Bend alot]

Which is precisely why I and others have stated ad nauseum that when a pilot is presented with an undesired aircraft state, ambiguous warnings, or loss of situational awareness, they must be able to, at a minimum, Turn off the magic, Set the pitch, Set the power, Trim the aircraft, Monitor the performance, and Move to a safe altitude, i.e. FLY THE AIRCRAFT. This is the default response to any emergency or non-normal situation when a pilot is unclear as to what he/she should do next. And yes, it is a trainable response.

Performing these actions is no more difficult than executing the procedures for an engine fire/failure at V1, and we should not expect any less from a trained and competent commercial flight crew.
With respect-

You were the only pilot that responded to what "would you do" that maintained the flying pilot position. You gave very little tasks to the non flying pilot and you even did not acknowledge the input that they would have given you. Your feed back was of a one man crew.

Both others that replied handed over to the FO to fly, I expect as they had the accurate instruments not just air speed but pitch - the pilots pitch was incorrect!

Again the pilots pitch was incorrect.

[Loose rivets]

I recall a mention of the electrical motor running while clutches changed the drive from one authority to another. Is the stopping of the wheel reliant on a clutch slipping? It seems from this thread that the smaller diameter wheel might be a bit of a challenge.

I asked before, but does anyone know how long the motor runs on for? I find it hard to believe it is powered down after every single pulse of the thumb switches, so I assume a lag in the power-down.

[FrequentSLF]

I recall a mention of the electrical motor running while clutches changed the drive from one authority to another. Is the stopping of the wheel reliant on a clutch slipping? It seems from this thread that the smaller diameter wheel might be a bit of a challenge.

I asked before, but does anyone know how long the motor runs on for? I find it hard to believe it is powered down after every single pulse of the thumb switches, so I assume a lag in the power-down.
is a brushless motor, therefore it will be powered on and off for every blip. Practically not lag

[fdr]

Performing these actions is no more difficult than executing the procedures for an engine fire/failure at V1, and we should not expect any less from a trained and competent commercial flight crew.

Ordinarily I would agree, however, the problem here is that there was a fundamental SA failure in the process of all of these events.

In the flight prior to JT610, the crew did not initially comprehend what was happening, perception was initially missing. The crew did eventually recover from that state when there was intervention by the 3rd flight deck person drawing attention to the trim behaviour. SA-1 Perception Failure. Thereafter the crew went for a 2 hour transit with the stick shaker running in the background...

On JT610, the crew had an SA-1 Perception failure to start with as well, and arguably detected the uncommanded stab motion and thereafter had an SA-2 Comprehension failure, which occurred with the handover to the FO of the aircraft while the Capt commenced further investigation. The Captains handover resulted in the effective termination of intervention from corrective trim input by the FO. Arguably there was an SA-3 type failure at the same time, as the Capt did not project forward the implications of not continuing the intervention of the trim input by MCAS, which led directly to the aircraft being so far out of trim that the dark knowledge of the potential for the trim being defeated without a specific manoeuvre to unload the stab was not realised. The FCOM is underwhelming on the subject, and the Capt ran out of ideas, time, altitude and elevator authority promptly.

ET had some information provided per the EAD, however, the crew had SA-2 failure once again.

Training of runaway stab is not a common item, and training for severe out of trim cases is effectively non-existant, and the FCOM hardly suggests that the matter may end up being critical for recovery time/altitude. If the crews are to be expected to respond appropriately, then sufficient knowledge and training is necessary so that the crew can make a decision based on recognition (RPDM) or if time permits, by analysis. As the crew were still ill informed that control loss was quite possible, and that a recovery would need a procedure that was not meaningfully described and not trained, it is difficult to shoot the messenger, the crew in question.

The SA failures that occurred here occurred in a period of dynamic operations and with high levels of stress on the decision makers. The truth is that people will respond differently with the set of cues that were in play on these occasions, and training to improve the likelihood of a desirable outcome is necessary. Keeping pertinent information from the flight crew was unhelpful, and the FCTM discussion on out of trim events fails to indicate the criticality of the situation, one that raises questions on the basis of certification of the aircraft in the first place.

The crew did try to fly the plane, they didn't recognise the problem, they didn't comprehend what the situation was promptly, and when breaking the manual trim process they did not project the state forward as a result of that action, due to inadequate information and training. Were they flying the plane? they were, but they didn't know they had brought a knife to a gun fight.

The FCTM is a bland understatement of a potentially catastrophic situation.

[wheelsright]

Again, no evidence from either of these accidents or from historical data that the electric stab trim motor could stall under load. The matter of the electric trim inhibition discussed in the link above is a completely separate issue. That inhibition prevents main electric trimming (pilot actuated) into a certain region of forward trim, but it does not prevent the use of electric trim to move out of that region.

All this being said, one of the causal factors of these accidents is that the pilots let the aircraft so far out of trim in the first place. It is absolutely clear from the data (both ET302, and both LA610 flights) that the pilot actuated stab trim stopped and reversed the MCAS trim input every time it was used. As powerful as MCAS was, it could not overcome the strength inherent in the Captain's left thumb - if he had chosen to use it.

"No evidence" is a commonly used phrase used to justify all manner of absurdity (usually by politicians). The absence of evidence does not rule in or rule out anything.

"It is absolutely clear from the data (both ET302, and both LA610 flights) that the pilot actuated stab trim stopped and reversed the MCAS trim input every time it was used. As powerful as MCAS was, it could not overcome the strength inherent in the Captain's left thumb" It is not absolutely clear at all. The FDR does not track the thumbswitch position as far as I know. Thus, it cannot be said with certainty that there were not additional electric trim up inputs that had no effect. Your assumption seems to be based on the accuracy of Boeings publications. I do not think that any pilot, even a very bad pilot, would not make further electric trim up corrections under the circumstances. For these reasons there remain doubts in my mind. In the case of ET302 it seems the crew reactivated electric trim in desperation... following that action it is difficult to believe that they did not do so to apply constant electric trim up via the thumb switch. It is a puzzle what actually happened, but unless you KNOW what the pilots ACTUALLY did it is mere speculation rather than being "absolutely clear".

[infrequentflyer789]

All this being said, one of the causal factors of these accidents is that the pilots let the aircraft so far out of trim in the first place. It is absolutely clear from the data (both ET302, and both LA610 flights) that the pilot actuated stab trim stopped and reversed the MCAS trim input every time it was used. As powerful as MCAS was, it could not overcome the strength inherent in the Captain's left thumb - if he had chosen to use it.

What do you make of this from ET:

05:40:27 - the Captain advised the First-Officer to trim up with him

Bearing in mind preceding it is an ineffective (in timing and duration compared to 1st MCAS input) period of manual ANU trim, and following it is a period of manual trim that both interrupts the 2nd MCAS input, is constant/continuous and reverses it (but doesn't reverse the first MCAS input).

It sounds (to this non-pilot engineering type) awfully like the Captain's left thumb (or it's switch) does not have the Captain's confidence, and not at all like he has just not "chosen to use it".

Or, put another way, under what circumstances as a 737 driver would you ask your co-driver to "trim up (or down) with you"? If the answer is "don't know any circumstances " or "would never do that", then WTF was going on in the ET cockpit to trigger that request?

[FrequentSLF]

What do you make of this from ET:

05:40:27 - the Captain advised the First-Officer to trim up with him

Bearing in mind preceding it is an ineffective (in timing and duration compared to 1st MCAS input) period of manual ANU trim, and following it is a period of manual trim that both interrupts the 2nd MCAS input, is constant/continuous and reverses it (but doesn't reverse the first MCAS input).

It sounds (to this non-pilot engineering type) awfully like the Captain's left thumb (or it's switch) does not have the Captain's confidence, and not at all like he has just not "chosen to use it".

Or, put another way, under what circumstances as a 737 driver would you ask your co-driver to "trim up (or down) with you"? If the answer is "don't know any circumstances " or "would never do that", then WTF was going on in the ET cockpit to trigger that request?
Very good point!
i would also ask to the experts, what the FDR records? The thumb switch? The manual command to the brushless motor? Or the effective running of the motor?
Furthermore, since the MAX was the first aircraft with MCAS which agency should oversight the FDR signals recording? Spoilers are FBW, MACS is lingering in the background... how difficult will be for investigators to interprete recordjngs?

[737 Driver]

With respect-

You were the only pilot that responded to what "would you do" that maintained the flying pilot position. You gave very little tasks to the non flying pilot and you even did not acknowledge the input that they would have given you. Your feed back was of a one man crew.

Both others that replied handed over to the FO to fly, I expect as they had the accurate instruments not just air speed but pitch - the pilots pitch was incorrect!

Again the pilots pitch was incorrect.

With respect -

As prelude, we need to correct one misunderstanding here. There was nothing wrong with the attitude indicators. The only manner in which the Captain’s pitch was incorrect or not was whether he established the correct pitch or not on his fully functioning attitude indicator.

There is no single right answer to this malfunction. Much depends on how quickly the crew perceives what is actually transpiring, what is working, and what isn’t. The major test of what responses were acceptable is whether those actions ultimately resulted in the safe landing of the aircraft.

The setup for this scenario was what would I have done if I were placed in the Ethiopian Captain’s position. May I remind you that he was given not only a malfunctioning aircraft but also a 350-hour First Officer? One of the important decisions a Captain must make, once the situation is stabilized, is to designate the flying and non-flying pilot. Yes, with a reasonably experienced First Officer, it would have been prudent to designate that person as the flying pilot once it was determined that he had the better instruments. However, it should be stated that there are certain real challenges to flying an aircraft with an AOA that is generating an erroneous stall signal due to the various ancillary system effects (I won’t detail them here, so you just need to accept my word on that). Unless this particular 350-hour FO had previously demonstrated to me that he had strong hand flying skills, then it is very likely that I would have continued to fly the aircraft for much of the remaining flight.

[737 Driver]

"No evidence" is a commonly used phrase used to justify all manner of absurdity (usually by politicians). The absence of evidence does not rule in or rule out anything.

"It is absolutely clear from the data (both ET302, and both LA610 flights) that the pilot actuated stab trim stopped and reversed the MCAS trim input every time it was used. As powerful as MCAS was, it could not overcome the strength inherent in the Captain's left thumb" It is not absolutely clear at all. The FDR does not track the thumbswitch position as far as I know. Thus, it cannot be said with certainty that there were not additional electric trim up inputs that had no effect. Your assumption seems to be based on the accuracy of Boeings publications. I do not think that any pilot, even a very bad pilot, would not make further electric trim up corrections under the circumstances. For these reasons there remain doubts in my mind. In the case of ET302 it seems the crew reactivated electric trim in desperation... following that action it is difficult to believe that they did not do so to apply constant electric trim up via the thumb switch. It is a puzzle what actually happened, but unless you KNOW what the pilots ACTUALLY did it is mere speculation rather than being "absolutely clear".

The DFDR traces show not only pilot and automation inputs on separate tracks, they also show whether the stab moved in response. There is even one example where MCAS is shown trying to make an input but the stab does not move because the stab trim switches were in the cutout position. Otherwise, every time that either the pilot or the automation made a stab trim input, then the stab moved as one would expect. I do not know whether the DFDR picks up the pilot trim signal directly from the switch or from somewhere else, but there were plenty of pilot inputs that corresponded to a stab movement. To conclude that the yoke trim switch suddenly stopped working requires a much greater leap of faith than a conclusion that it was used ineffectually.

[737 Driver]

What do you make of this from ET:

05:40:27 - the Captain advised the First-Officer to trim up with him

Bearing in mind preceding it is an ineffective (in timing and duration compared to 1st MCAS input) period of manual ANU trim, and following it is a period of manual trim that both interrupts the 2nd MCAS input, is constant/continuous and reverses it (but doesn't reverse the first MCAS input).

It sounds (to this non-pilot engineering type) awfully like the Captain's left thumb (or it's switch) does not have the Captain's confidence, and not at all like he has just not "chosen to use it".

Or, put another way, under what circumstances as a 737 driver would you ask your co-driver to "trim up (or down) with you"? If the answer is "don't know any circumstances " or "would never do that", then WTF was going on in the ET cockpit to trigger that request?

There is abundant information here to show that this crew was absolutely overwhelmed by the circumstances they faced. There are many, many head scratchers that simply defy explanation if your going in assumption is that the crew was in control of the situation. They were not. Rather, the situation was clearly in control of them. So you must pardon me if I do not attempt to provide a rational explanation for many of their actions.

[MemberBerry]

Earlier I was comparing Boeing's MCAS with Volkswagen's emissions test defeat device. I found this old New Yorker article, from 2015, hypothesizing how Volkswagen may have got there:

https://www.newyorker.com/business/currency/an-engineering-theory-of-the-volkswagen-scandal

They say it may not have necessarily been an explicit management decision saying "let's cheat", but many small incremental changes that individually didn't seem a big deal (normalization of deviance):

If the same pattern proves to have played out at Volkswagen, then the scandal may well have begun with a few lines of engine-tuning software. Perhaps it started with tweaks that optimized some aspect of diesel performance and then evolved over time: detect this, change that, optimize something else. At every step, the software changes might have seemed to be a slight “improvement” on what came before, but at no one step would it necessarily have felt like a vast, emissions-fixing conspiracy by Volkswagen engineers, or been identified by Volkswagen executives. Instead, it would have slowly and insidiously led to the development of the defeat device and its inclusion in cars that were sold to consumers.

Initial reports mentioned that at least 30 Volkswagen managers were involved. And now, 4 years later, some of them have already been sentenced to jail time. So, at least in Volkswagen's case, it seems it was a bit more than just "normalization of deviance".

[737 Driver]

The crew did try to fly the plane, they didn't recognise the problem, they didn't comprehend what the situation was promptly, and when breaking the manual trim process they did not project the state forward as a result of that action, due to inadequate information and training. Were they flying the plane? they were, but they didn't know they had brought a knife to a gun fight.



Which is precisely why, when presented with an undesired aircraft state, unknown or ambiguous malfunction, or a loss of situational awareness, the flying pilot must be ready and able to Turn off the magic, Set the Pitch, Set the Power, Trim the aircraft, Monitor the performance, and Move the aircraft to a safe altitude. You do not have to know what is going on. You do need to know how to stabilize the aircraft and place it in a safe position so you then have the time to figure out what is going on.

[MemberBerry]

Which is precisely why, when presented with an undesired aircraft state, unknown or ambiguous malfunction, or a loss of situational awareness, the flying pilot must be ready and able to Turn off the magic, Set the Pitch, Set the Power, Trim the aircraft, Monitor the performance, and Move the aircraft to a safe altitude. You do not have to know what is going on. You do need to know how to stabilize the aircraft and place it in a safe position so you then have the time to figure out what is going on.

The first step in your mantra is "turn off the magic". What Boeing did by implementing MCAS severely undermines that first step, because they added an additional bit of "magic", that can't be turned off using the old procedures (A/P off, A/T off, FD off). Instead, turning off this bit of "magic" requires disabling manual electric trim as well, with the cutout switches.

I think it wouldn't hurt if Boeing would implement some way to disable automatic trim independently from manual electric trim. Something that can disable both STS and MCAS without forcing you to use the trim wheels for the rest of the flight.

Since making significant changes to the cockpit like adding switches is probably out of the question, maybe there should be a way to completely disable automatic trim, using existing switches. For example using the existing cutout switches. Placing them in the cutout position, waiting a few seconds, then switching them back to normal could be used as a way to disable automatic trim, but leave manual electric trim functional. That would require just a software change.

Then your mantra would work just fine, if you include this additional sub-step of "Auto-Trim Off" as part of "turn off the magic".

[FrequentSLF]

Which is precisely why, when presented with an undesired aircraft state, unknown or ambiguous malfunction, or a loss of situational awareness, the flying pilot must be ready and able to Turn off the magic, Set the Pitch, Set the Power, Trim the aircraft, Monitor the performance, and Move the aircraft to a safe altitude. You do not have to know what is going on. You do need to know how to stabilize the aircraft and place it in a safe position so you then have the time to figure out what is going on.





with all respect, Sir
turn off magic... that was possible on previous 737, before max... lets do not talk about AB.
MAX is different from any other 737, you cannot turn off magic... in case of trim stab... you turn off power! Not magic, Sir, turn off power, and manual wheel is smaller than in the 400s...hence higher force required to crank.
still with all due respect Sir, how hard is to move the trim manually on a MAX? (If you ever tried)

[737 Driver]

The first step in your mantra is "turn off the magic". What Boeing did by implementing MCAS severely undermines that first step, because they added an additional bit of "magic", that can't be turned off using the old procedures (A/P off, A/T off, FD off). Instead, turning off this bit of "magic" requires disabling manual electric trim as well, with the cutout switches.

I think it wouldn't hurt if Boeing would implement some way to disable automatic trim independently from manual electric trim. Something that can disable both STS and MCAS without forcing you to use the trim wheels for the rest of the flight.

Since making significant changes to the cockpit like adding switches is probably out of the question, maybe there should be a way to completely disable automatic trim, using existing switches. For example using the existing cutout switches. Placing them in the cutout position, waiting a few seconds, then switching them back to normal could be used as a way to disable automatic trim, but leave manual electric trim functional. That would require just a software change.

Then your mantra would work just fine, if you include this additional sub-step of "Auto-Trim Off" as part of "turn off the magic".

I assume that you are aware that there are other potential sources of uncommanded and undesired stabilizer trim movement besides MCAS? We do not have separate disconnects for them either. The runaway stab trim procedure is completely and absolutely agnostic as to the source of the uncommanded movement, nor should the flight crew waste precious time trying to diagnosis the source.

As to the mantra, you may have noted that one of the steps was “Trim the Aircraft.” At all times, the MCAS input could be stopped and reversed by the use of Main Electric Trim. The flying pilot was fully capable of countering every MCAS input until such time that the crew got around to executing the runaway stab trim procedure.

BTW, it is not procedural to fiddle with the cutout switches once they have been used.

[737 Driver]

with all respect, Sir
turn off magic... that was possible on previous 737, before max... lets do not talk about AB.
MAX is different from any other 737, you cannot turn off magic... in case of trim stab... you turn off power! Not magic, Sir, turn off power, and manual wheel is smaller than in the 400s...hence higher force required to crank.
still with all due respect Sir, how hard is to move the trim manually on a MAX? (If you ever tried)

Please read and heed the entire mantra. The first step is to turn off the magic. A few steps later is “Trim the Aircraft”. That step is sufficient to take care of MCAS until the runaway trim procedure is executed. The manual trimming has always been a problem on multiple Boeings - if you let it get grossly out of trim. The crew had the ability to not let it get there.

I’m sorry, but this is too much like the story of the kid who killed his parents and then requested mercy before the Court because he was an orphan. The lack of application of basic airmanship skills placed this aircraft in a situation where basic airmanship skills were no longer sufficient to save the ship. Too many people are looking at the five minute mark and declaring the aircraft to be unflyable without much regard as to what happened in the previous 4 minutes and 59 seconds.

[FrequentSLF]

Please read and heed the entire mantra. The first step is to turn off the magic. A few steps later is “Trim the Aircraft”. That step is sufficient to take care of MCAS until the runaway trim procedure is executed. The manual trimming has always been a problem on multiple Boeings - if you let it get grossly out of trim. The crew had the ability to not let it get there.

I’m sorry, but this is too much like the story of the kid who killed his parents and then requested mercy before the Court because he was an orphan. The lack of application of basic airmanship skills placed this aircraft in a situation where basic airmanship skills were no longer sufficient to save the ship. Too many people are looking at the five minute mark and declaring the aircraft to be unflyable without much regard as to what happened in the previous 4 minutes and 59 seconds.
grossly out of trim? I do not the FDR traces, but if i recall well was 2 MCAS events and trim was at 2.1. So 2 degrees, max 3 out of trim...
your mantra says turn off magic first.., so... how long before you decide to trun off? 9 seconds? 2.5 degress of trim... of you saying that you so brilliant that in 1 second can decide is a runaway trim and hit the cut off?
9 seconds and ypu are grosssly out of trim, and no power. You stated earlier, before cut off trim back...but how that works with turn off magic? Those are your words...turn off magic, but before cutting off power trim back... that is impossible on max.
maybe you need a new mantra

[MemberBerry]

I assume that you are aware that there are other potential sources of uncommanded and undesired stabilizer trim movement besides MCAS? We do not have separate disconnects for them either. The runaway stab trim procedure is completely and absolutely agnostic as to the source of the uncommanded movement, nor should the flight crew waste precious time trying to diagnosis the source.

As to the mantra, you may have noted that one of the steps was “Trim the Aircraft.” At all times, the MCAS input could be stopped and reversed by the use of Main Electric Trim. The flying pilot was fully capable of countering every MCAS input until such time that the crew got around to executing the runaway stab trim procedure.

BTW, it is not procedural to fiddle with the cutout switches once they have been used.


I'm aware there are other sources, like the A/P, but turning off the A/P is already possible, so I didn't mention it. I already mentioned STS, and suggested that there should be a way to disable both STS and MCAS, since they are still functional even when the A/P is off. And you should be able to do that without affecting anything else.

Of course you could also have a stabilizer runaway involving the manual electric trim, that would require disabling it with the cutout switches to stop it. But from what I read such a runaway is less likely compared to an MCAS runaway. I didn't hear anyone here saying they experienced such a stabilizer runaway on the 737.

As to not wasting time troubleshooting, actually the existing trim runaway memory items involve troubleshooting. First they tell you to turn off the A/P and A/T. If that doesn't work, use the cutout switches. If that doesn't work, hold and grasp the trim wheels. If they didn't want you to troubleshoot, they would just tell you to do all 3 steps immediately, without waiting after each step to see if it fixes the issue.

As to fiddling with the cutout switches after being used, it might not be procedural, although the memory items do not mention that explicitly. They do explicitly mention not reenabling the A/P and A/T. If not fiddling with them is so important, it should have been explicitly mentioned.

And, in any case, procedures are written by humans, and can and have been modified a lot of times in the past to make them better.

[Uplinker]

Which is precisely why, when presented with an undesired aircraft state, unknown or ambiguous malfunction, or a loss of situational awareness, the flying pilot must be ready and able to Turn off the magic, Set the Pitch, Set the Power, Trim the aircraft, Monitor the performance, and Move the aircraft to a safe altitude. You do not have to know what is going on. You do need to know how to stabilize the aircraft and place it in a safe position so you then have the time to figure out what is going on.




+1 Very well put :ok:

But this needs training and reinforcement in the SIM. It is not enough - in these days of CBTs and multiple choice exams - to assume that all pilots are capable of this without training. Sad but true. So much time is taken up with other things in SIM details that the basics are being assumed to be present rather than being actually tested and practised.

[737 Driver]

As to not wasting time troubleshooting, actually the existing trim runaway memory items involve troubleshooting. First they tell you to turn off the A/P and A/T. If that doesn't work, use the cutout switches. If that doesn't work, hold and grasp the trim wheels. If they didn't want you to troubleshoot, they would just tell you to do all 3 steps immediately, without waiting after each step to see if it fixes the issue.
.

All that “troubleshooting” takes less than 5 seconds.

[capngrog]

"05:40:27 - the Captain advised the First-Officer to trim up with him"

The above quote is from frequentflyer789's Post #4882; however, the quote itself is merely a narrative account of cockpit conversations and is not from a transcript of the actual cockpit conversations. Has anyone seen/read a transcript of the CVR tapes? Will such a transcript be forthcoming?

Cheers,
Grog

[VFR Only Please]

The Ethiopian Captain (…) was given (…) a 350-hour First Officer.

Apparently there are 200-hour pilots out there flying nuclear-armed aircraft. So I've heard. Simulators have come a long way, thousands of hours of teaching people to fly single-engine airplanes really isn’t the greatest preparation for airline flying, and the CVR shows it was the Ethiopian FO’s suggestion to hit the cutout switches in the first place.

It is not procedural to fiddle with the cutout switches once they have been used.

It also isn’t procedural having the terrain fast rising up out the window to smite thee. Desperate times maybe explain desperate measures.

At all events, there's 0.6% of the worldwide Max fleet gone in the space of five months. No survivors. My two cents: Boeing finally broke the 737 but good by dint of finally overtweaking it. Having done that, they took the stall-happy result and -- on the cheap -- hastily stuck a bandaid on it. Now they and their furious customers are wedded to this Frankenplane, so Boeing is working on a New & Improved Extra-Special Bandaid.
Onion News defined MCAS as "software designed to place all the blame on airline pilots".

[derjodel]

Okay, Sully wasn't piloting a 737, but let's say he did. Somehow I just don't think Sully would have allowed his stab trim to run for 9 continuous seconds (that would be 37 spins of the trim wheel) before doing something about it, say like hitting the yoke trim switch with his left thumb. I certainly don't think he would let that happen twice. Maybe we should also note that Sully wasn't piloting Lion Air 610 the day before the accident (same aircraft, different crew in the very first documented case of the MCAS malfunction), and yet they still managed to figure out that when an automated system puts in some stab trim you don't want, it is entirely possible to take it right back out again.

Perhaps one day Sully would offer his perspective. All we know with certainty is that he claims there is a „human factor“ which needs to be takin into account.

i wonder, in case he crashed, how many pilot s here would badmouth him to not turn to la guardia the second after the birdstrike. Well, luckily we won‘t know that.

but in case of ET, it‘s not exactly fair to say they did nothing. Captain called control problems immediatelly and pulled the stick back to counter the trim. At 5:39:55 AP disengaged and mcad kicked in. At 5:40:35 trim cotout was done. Not 35, but 40 seconds. Ok, their human factor was worse than Sullys. But it is nontheless, human factor. Humans are not machines and machines need to be designed in a way to anticipate delayed corrective response.

Btw, Sully switched APU on although it was NOT on the checklist. ET crew tried to re-engage AP. In case Sully failed, i bet he would have been crucified for not following the ckecklist.

very interesting thing, human bias.

[Kerosene Kraut]

Blaming the pilots for some imperfect systems layout sounds a bit unfair to me.

[derjodel]

Blaming the pilots for some imperfect systems layout sounds a bit unfair to me.

for the pilots, it helps building the (false?) self- confidence. “Can’t happen to me”. The alternative is to develop fear of flying. So it‘s an understandable subconscious strategy.

for some other entities, the reason is simply monetary.

[MemberBerry]

All that “troubleshooting” takes less than 5 seconds.

Actually it can take longer than 40 seconds. For just the 2 first steps out of 3. From one of my previous posts:


17:59 - F/O - "auto pilot - disengage"
18:01 - Mentour - "autopilot is disengaged"
18:04 - F/O - "auto throttle - disengage"
18:07 - Mentour - "if you can do that for me please"
18:09 - F/O - "disengaged"
18:11 - F/O - "if it continues, I will go with the stab trim cutout switches"
18:13 - Mentour - "ok, let's evaluate this to see if it's moving"
18:20 - F/O - "memory items for the runaway stabilizer complete"
18:21 - Mentour - "yeah, let's evaluate"
18:25 - Mentour - "I have no authority of the trim at the moment"
18:29 - F/O - "roger"
18:32 - Mentour - "I can't control it manually, so it doesn't really work, so if you can continue with the memory items please"
18:37 - F/O - "memory items - stab trim cutout switches to cutout"
18:40 - Mentour - "Continue"
18:41 - F/O moves the switches to the cutout position
18:42 - F/O: "Cutout"


You could do all 3 steps in 5 seconds if you had no communication with the other pilot and didn't wait at all between the steps. But that doesn't sound very wise.

Later edit, actually I think that's one of the mistakes of the Ethiopian crew. They executed this checklist too hastily and they skipped the step about disabling the auto-throttles. If they did that, they probably would have payed more attention to their speed and adjusted it manually as needed. Instead, the engines remained at 94% until VMO, when from the FDR trace it seems the A/T lowered that to around 90%.

[FrequentSLF]

All that “troubleshooting” takes less than 5 seconds.
5 seconds for troubleshooting, so if you do not recognize a runaway trim in 4 seconds, you will be 2.5 units out of trim... when you turn off magic...(i.e. electrical trim)... exactly the same position of et302...
Probably can be recognized it in 2 seconds, plus 5 to troubleshoot..still almost in same situation
Would be interesting to see how many pilots in a SIM will react in less than 4 seconds

[wetbehindear]

737 Driver " I just don't think Sully would have allowed his stab trim to run for 9 continuous seconds (that would be 37 spins of the trim wheel) before doing something about it, "

Let us remember that Sully let the speed decay below Vsub Ls and became aware of it when the fdr data shown to him.

[MurphyWasRight]

The first step in your mantra is "turn off the magic". What Boeing did by implementing MCAS severely undermines that first step, because they added an additional bit of "magic", that can't be turned off using the old procedures (A/P off, A/T off, FD off). Instead, turning off this bit of "magic" requires disabling manual electric trim as well, with the cutout switches.

I think it wouldn't hurt if Boeing would implement some way to disable automatic trim independently from manual electric trim. Something that can disable both STS and MCAS without forcing you to use the trim wheels for the rest of the flight.

Since making significant changes to the cockpit like adding switches is probably out of the question, maybe there should be a way to completely disable automatic trim, using existing switches. For example using the existing cutout switches. Placing them in the cutout position, waiting a few seconds, then switching them back to normal could be used as a way to disable automatic trim, but leave manual electric trim functional. That would require just a software change.


No need for new switches or fancy logic:
All 737 up to 737NG have 2 switches, the right one disables auto trim, the left one disables pilot electric trim, and probably all electric trim.

For as yet unexplained reasons this was changed on 737MAX so that either switch disables all electric trim.

The switches were relabeled to primary and backup.

[Mac the Knife]

I can't quite understand why the function of the two switches was changed.
Previously, if I've read it right, one turned off MCAS etc. The other one turned off manual electric trim (on the yoke)

On the MAX, both switches have the same function (in series nogal!), ALL electrical trim is turned off,
leaving only a teeny-weeny wholly manual wheel that would take something like ten
minutes of hard winding (from a difficult position) to get the stabiliser back to even neutral.

That doesn't seem very sensible. Perhaps I've got it wrong.

Mac

[MurphyWasRight]

Actually it can take longer than 40 seconds. For just the 2 first steps out of 3. From one of my previous posts:



You could do all 3 steps in 5 seconds if you had no communication with the other pilot and didn't wait at all between the steps. But that doesn't sound very wise.

Later edit, actually I think that's one of the mistakes of the Ethiopian crew. They executed this checklist too hastily and they skipped the step about disabling the auto-throttles. If they did that, they probably would have payed more attention to their speed and adjusted it manually as needed. Instead, the engines remained at 94% until VMO, when from the FDR trace it seems the A/T lowered that to around 90%.
To be fair the mentour pilot video was done in a "teaching/demonstration" mode, a real crew would have probably done it twice as fast.

Skipping autothrottle off step is significant, although much earlier on some pilots posted that simply chopping the throttle in their condition could have undesired effects and had to be done with some fitness.
In any case they were still under VMO when the cutout switches were actuated, have not seen any hard facts on what speed would allow manual trim given the trim state.

The real problem was using cutout before the AC was in trim. It is possible that once the FO called runaway trim the pilot jumped to that thought even though he was successfully trimming at the time.
It is not clear that the ET pilots were fully aware of the revised procedure, yet another painful hole in the cheese.

[VFR Only Please]

The Ethiopian crew (...) skipped the step about disabling the auto-throttles. If they did that, they probably would have payed more attention to their speed and adjusted it manually as needed. Instead, the engines remained at 94% until VMO,

I read in the aviation press a remark from a guy with 12,000 hours on the 737, a sim instructor, who said he'd often seen airspeed drop off a crew's scan in circs far less stressful -- and confusing -- than these.

As for Sully-upon-Hudson, he's big into number of flying hours as a measure of competence. Free country. But to sound off publicly (as he did in the case of the Addis crash) does him no credit. I'm no airline pilot, but people I know, who are, resent Sully's near-deification by the media. Yes he refused to return to La Guardia, realized he couldn't make Teterboro, and instead chose that extremely long and wide, dead-calm liquid runway just off to his left. (Switching on the APU was an admirable brainwave.) They insist that any competent crew could have done what he and Skiles did, given the excellent conditions. (Imagine wind, choppy waves, lousy visibility --- or worse, that + mountains.)

derjodel is bang on that "machines need to be designed in a way to anticipate delayed corrective response". The Max looks fundamentally flawed. That new bandaid had better be Absolutely Perfect.

[737 Driver]

Okay, given the flurry of a certain type of comment, I think it would be useful to provide some advice here.

I know some of you have some strongly held positions, and that’s okay. However, some of those positions are based on a theoretical framework, or perhaps something you read somewhere or something someone told you. When those positions stray off into technical matters regarding the 737 or airline operations, please consider the following.

I do not tell my auto mechanic how to fix my car. I do not tell the surgeon how to operate on my body. I do not tell the professional golfer how to perform a tricky shot out of the bunker. I do not do this even if I can tell that the end result was less than optimum. So if you have never actually flown a 737, please do not try to educate me as to how the systems function, how a checklist should be run, or how difficult the aircraft is to operate under certain conditions. It does nothing to add credibility to your position. I have more than 10 years cumulative experience in this aircraft plus another 15+ in other related Boeing products. I have been trained in countless abnormal and emergency situations in that time, and I have experience quite a few real ones in the air. I am quite familiar with the all the psychological and environmental factors that can come into play.

I offer my technical expertise here, in part, so that the commentary doesn’t go off into the weeds on some point that is fundamentally incorrect. In doing so, I may provide information in a simplified fashion to cater to the non-Boeing and non-pilot members of this forum. If you wish to argue the placement and use of switches and controls, whether this step should be done before that step, or whether something can be done in 5 seconds or 5 minutes, please have that discussion with someone else.

The bottom line is that the accident pilots made serious errors and did not meet the expectation of a professional airline flight crew. This statement should be no more controversial than saying that the various engineers and technical staff at Boeing made serious errors in the design of MCAS and did not meet the expectations of their profession. If you wish to label this as “blaming,” there is nothing I can do to stop you. Personally, I’ve seen enough of the culture of blame, and it does little to get to the root of the problem.

You can’t fix a problem until you recognize a problem exists. These accidents, among others, have provided clear evidence that there is a problem with the level of pilot skills in this industry. We can either ignore it, or we can do something about it.

[737 Driver]

Blaming the pilots for some imperfect systems layout sounds a bit unfair to me.

Let’s again dispose of this canard.

It is interesting how the “Let’s not blame” defense only seems to apply to the flight crew. I don’t see anyone saying “Let’s not blame Boeing,” or “Let’s not blame the FAA.” In fact, the whole “blame” defense is utterly useless, because all it does is say that you don’t want to look at the errors that were made by a particular group. Well, that is not how aviation safety investigations work. Every link in the chain of causation is examined. This is not done to assign “blame,” but rather to identify causes and propose remedies.

Finally, absolutely no one is laying the MCAS design errors at the feet of the pilots, just as no one faults the pilots when any of their other systems go haywire. However, we absolutely should examine if those same pilots handled a particular malfunction to the standards expected of them as professional aviators.

[L39 Guy]

Ancient Mariner: All this grandstanding makes me wonder if some of you have been in an emergency, a real emergency?
I've been fortunate/unfortunate enough to have been in a few, albeit maritime, not aviation related.
Everytime I was surprised to see "highly trained professionals", and I mean highly trained, we had realistic training once a week for these eventualities, totally break down and be unable to function. I not talking 30 seconds, 90 seconds, but unable, period.
Aviation is of course a totally different ballgame. :hmm:
Per

You are correct, aviation is (or should be) a different game. During the selection, training and ongoing check rides during one's career as a professional pilot the individual is constantly evaluated and tested. In an ideal world, if they don't cut the mustard they are cut loose - I have seen this happen a few times but unfortunately I have seen too many marginal pilots given complimentary passes on various sim rides, line checks, etc. Unions fighting back is probably why some of the marginal pilots get through; I suppose the corporation also calculates the probability of an event, the probability of two weak pilots being paired together and decides to take that risk. I would submit, however, that any one that totally breaks down and unable to function would not (or should not) hold a commercial pilot license.

As far as emergencies, I have had plenty...three engine failures, a couple of hydraulic system failures, blown tires, etc. I am no hero, I just do what I have been trained to do.

During a few day hiatus while on vacation the discussion pivoted to human factors which is undoubtedly an issue and particularly the "startle factor". I know of few emergency situations where the voice of a lovely lady comes over the speaker and says "Standby for xxxx" with xxx being a UAS, stab trim runaway, engine fire, etc. The startle factor is always there and it is accounted for in the certification of the aircraft, i.e. crew recognition and reaction time.

But after that "startle factor" period is over, it's time to get down to work and deal with the problem, usually with an emergency checklist and sometimes without (double engine failure, volcanic ash (BA flight in the 1980's), a complete hydraulic failure (UAL Sioux City), etc.). It is the job, the responsibility, of the professional aviator to react to the problem startle factor or not. If the professional pilot as an individual cannot get past the startle factor and focus on the problem and deal with it, then they should not have a license or type rating. If professional pilots collectively cannot manage the startle factor and deal with emergencies anymore then it's time to shut down the industry entirely as the traveling public cannot be guaranteed their safety in the even of an emergency.

Yes, there was a startle factor at lift-off on the two accident flights and one incident flight. In the case of the incident flight, they dealt with the startle factor, called for the UAS checklist, controlled the speed of the aircraft (i.e. flew the aircraft) and that allowed them to diagnose the MCAS issue when the flaps were raised. The dealt with MCAS by flying the damn airplane (trim and speed control) with a little help from a "friend" and carried on to destination with the stick shaker, UAS and manual trim. Bravo!

Yet the accident crews had the same startle factor and couldn't even get to first base, i.e. UAS drill. And they had almost two minutes to execute that simple, memory checklist. And had they done just that, they would not have been racing around at 340 kts, making manual trim and hand flying with nose down trim impossible due to control forces. Instead, they could have manhandled that aircraft while they sorted out the trim including using the manual trim wheel and could have flown all day long in that condition, just like the Lion Air incident flight.

As a professional aviator (and a person that flies in the back of aircraft a lot), it is my expectation that the aviators I work with or whom I have entrusted by life and that of my family to be competent enough to get over the startle factor and do what they are expected to - fly the damn aircraft and deal with the emergency. In the case of the MAX, the emergencies are known and have published procedures. This was not a double engine failure, volcanic ash, total hydraulic failure but a simple UAS. That is not asking too much.

As 737 Driver and others have been stating on this thread, this may sound harsh and hard-ass but that it is the professional responsibility of the a professional aviator. There is no denying that MCAS needs rework and there is not disagreement about that. But what we are arguing is that aircraft do have system failures and startle factor is a fact-of-life, but the pilots must have the training and experience to deal with it. They have to wear the big boy pants because they are the last line of defense.

As I mentioned a couple of thousands of post ago, the airline industry has been whistling past the graveyard for many years but now the chickens are coming home to roost (sorry about the mixed metaphors). It just takes some unexpected event now to cause an aircraft to crash - MCAS, no ILS approach available (Asiana SFO), an engine failure (ATR 42 TPE), a go-around (Emirates 777 DBX) and airplanes crash when trained and competent crews could have and should have avoided the loss of life and aircraft.

These events should be a call to action by the entire industry - manufacturers who have hithertofore relied on experienced and trained pilots to save the day, regulators who are not demanding higher standards of pilot training and experience (i.e. actually hand flying and not watching the autopilot), airlines (for the same reasons) and pilot unions who have to own part of the responsibility for insuring their members uphold high professional standards which may mean actually hand flying aircraft.

Boeing erred with MCAS but the fault for these accidents are the result of failure of the players noted above.

[safetypee]

737 Driver, Uplinker,
‘Loss of situational awareness’

How do you know that you have lost awareness; compare this with an illusion. Awareness exists, unfortunately it doesn’t match the real situation, nor therefore the actions required.
Do you have an illusion of understanding these accidents.
If you have lost something, what was ‘this’ which you already had. How did you acquire it in the first instance.

Reduce power shortly after take off - compare with other emergencies where the climb is continued to a safe altitude, e.g. fire.
It’s a hazardous option to reduce power early in the climb, particularly with a ‘don’t sink’ alert - ET.

L 39 Guy,
When quoting 777 SFO and 777 DBX, consider the particular systems contributions, lest you start agreeing with 737 Driver.

[MurphyWasRight]

Yet the accident crews had the same startle factor and couldn't even get to first base, i.e. UAS drill. And they had almost two minutes to execute that simple, memory checklist. And had they done just that, they would not have been racing around at 340 kts, making manual trim and hand flying with nose down trim impossible due to control forces. Instead, they could have manhandled that aircraft while they sorted out the trim including using the manual trim wheel and could have flown all day long in that condition, just like the Lion Air incident flight.

Can you comment on the possibility that the ET crew diagnosed the UAS as a a false warning per the Boeing flow chart that was posted a while ago. My bolding'

If AoA sensor is failed high,stick shaker on failed side will activate on rotation accompanied by IAS/ALT disagree warning flags
Ifthe pitch power and config are consistent with takeoff and the good side ASI agrees with the Standby ASI,then it is a false warning
------------ If in any doubt execute the UAS NNC

The pilot with good side data becomes PF

Land immediately


Even if they did diagnose it as false warning it does appear they were continuing on rather than "land immediately"

It is possible that the real "startle factor" moment was the combination of autopilot disconnect followed by first MCAS trim, up till then it might have been in the 'understood and handled' category. The speed was about 250 knots at time of first MCAS input.

Another way of framing this is what if the bird strike (or whatever the cause) had happened at 05:39:55 after the flaps had been retracted following an uneventful takeoff, this would have left them in same state: Autopilot disconnect immediately followed by MCAS ND trim.

Note: I agree with much of what has been said on condition of pilot training/competency, seems to have devolved into a 'tick the checkbox' multiple choice exercise.

[L39 Guy]

Your ferocious ego is diminishing any points you may have. Even though it's unlikely (even given your join date), you are sounding like a Boeing shill.

Clearly they didn't meet your expectations. As you know, you can overload anyone in the sim - to the point of failure. Others here, myself included, believe that this crew were overloaded and suffered cognitive difficulties as a result. If they had been trained, or at least made properly aware of what would happen with a single AoA failure on takeoff, then their cognitive position may have been different. But stall, UAS and then MCAS is a triple-nasty that appears to have beaten every crew faced with it.

You also seem to believe that the ET crew didn't know that if all else fails, fly the aircraft. What you will not accept is that they knew that that was what they had to do, but couldn't - due to overload.

Finally - the answer to the problem is either to remind everyone to prioritise the flying of the aircraft (because they didn't know that), or fix the aircraft so it's no killer. Which may prove tricky, now the limitations of the manual (hand crank) trim system are being revealed.

Please, let's not personalize this and attack individuals. 737 Driver has invested a lot of time and effort in addressing a lot of issues raised on this thread and for that he deserves everyone's respect whether you agree or disagree with him.

The crews of the accident aircraft did not meet the expectations of 737 Driver, myself and, most importantly, the passengers that bought tickets on those flights. While there are multiple events involved in these accidents, let's break this down to the first event which lasted up to 2 minutes before the flaps were selected up:

Explain to me how and why, long before MCAS reared its ugly head, that these crews could not recognize an UAS (stick shaker, IAS DISAGREE, etc) and not set an attitude and power setting per the NNC?
Explain to me how and why a professional flight crew would let the speed of the aircraft hit Vne (340 kts plus) while supposedly hand flying an aircraft?
Explain to me why one would engage the autopilot at 400 ft while in stick shaker (stall) or UAS?

This is a UAS event, pure and simple at this stage of the game. And they couldn't even do that! If they had an engine failure at V1 there is not a hope in hell that they could fly the aircraft if they couldn't even manage a UAS event. And, by the way, an engine failure before, during or after V1 has a startle factor too.

Explain to me how and why the crew of the Lion Air incident flight was able to do the UAS drill and also control the speed of the aircraft such that manually trimming the aircraft was possible and, indeed, were able to fly to destination with UAS, stick shaker and manual stab trim?

With respect to limitations of the manual trim of the B737, I know of no aircraft that can be flown at Vne with full nose down trim. No aircraft, flown by a professional, should be allowed to get into that corner. How about pulling those two levers between the pilots back to idle rather than leaving it at take-off power? That will quickly bring the speed of the aircraft into a regime where one can manually trim the aircraft. But that involves flying the damn airplane, a basic skill that the industry seems to have lost in this and other accidents/incidents recently.

[L39 Guy]

L 39 Guy,
When quoting 777 SFO and 777 DBX, consider the particular systems contributions, lest you start agreeing with 737 Driver.

It's true that the 777 had some quirks with the auto-throttle that contributed to these (non-fatal) accidents but nevertheless in the case of SFO four pilots in the cockpit watched the speed decay to a stall and in the case of DBX, nobody noticed that the thrust levers did not advance to go around after hitting the TOGA switches. This points to training (doing a visual approach in the case of SFO) and basic flying skills, i.e. monitoring the aircraft performance in the both cases.

It also points to way too much dependence on automation which, as many of us have pointed out on this thread, is a big, big problem in the airline industry today.

[VFR Only Please]

It does nothing to add credibility to your position.

I have Zero credibility LOL. My handle on this forum is designed to be upfront about that.

No quarrel with L39 Guy's post. Even this: "Boeing erred with MCAS but the fault for these accidents are the result of failure of the players noted above."

I'll just repeat what I said earlier about 0.6% of the worldwide Max fleet disappearing (poof!) in five months owing to survivorless crashes. If we're admitting that Boeing erred with MCAS (and indeed part of that error was hiding the very existence of MCAS from crews and pretending to airlines that this airplane required no expensive stuff like like time-consuming training) then we're admitting that the Max accentuates normal human failings among crews and turns them into Lethal Errors, which somehow don't occur on other aircraft (ETH somehow has managed to operate the 777, A350, whatever, so far without incident). What does this tell us about the fundamental realities of the Max?

[Takwis]

I would add to your question the further evidence of Muilenberg continually asserting that there is nothing wrong with the airplane, and it is 100% the fault of the pilots. I think even Boeing die-hard fans here have admitted that there is something that needs to be fixed on the airplane,

[737 Driver]

I have Zero credibility LOL. My handle on this forum is designed to be upfront about that.


This is one of those times that you need to read what I actuallly wrote instead of what you think I wrote.

To be precise, when a non-737 or even non-Boeing pilot wants information on 737 systems or procedures, I am happy to oblige. When that same person then wants to argue over technical details and suggest that they know more about the aircraft I been flying for over 10 years, then yes, they take a hit in credibility both in my eyes and the eyes of others who notice such things.

Don’t try to tell me how to fly the 737 and don’t make assertions that are poorly supported by the evidence, and we will get along just fine.

[moosepig]

I would add to your question the further evidence of Muilenberg continually asserting that there is nothing wrong with the airplane, and it is 100% the fault of the pilots. I think even Boeing die-hard fans here have admitted that there is something that needs to be fixed on the airplane,
Muilenberg HAS to say that. Can you imagine the company lawyers or shareholders suggesting he say otherwise? One sniff of an admission of liability and Boeing would be sued out of existence.

[737 Driver]

737 Driver, Uplinker,
‘Loss of situational awareness’

How do you know that you have lost awareness; compare this with an illusion. Awareness exists, unfortunately it doesn’t match the real situation, nor therefore the actions required. Do you have an illusion of understanding these accidents. If you have lost something, what was ‘this’ which you already had. How did you acquire it in the first instance.


Okay, those last two questions border on some deep metaphysical issues, so let’s just say that when a flight crew first steps into the cockpit at the gate that they should have a good sense of where they are, what day it is, where they are going, what they had for breakfast, etc. Otherwise, we are all pretty much screwed.:uhoh:

Let’s start again with the mantra: When presented with an undesired aircraft state, unknown malfunction or ambiguous warning, or a loss of situational awareness, the flying pilot should be ready and able to: Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude.

Loss of situational awareness is just one of the entry conditions, though it is an important one. You don’t even need to have an active aircraft malfunction. Many years ago, a crew at my airline was doing a descent and arrival into a South American airport in a non-radar environment with high terrain and thunderstorms in the area. This was in the days before EGPWS and navigation display screens. At some point while trying to maneuver around the weather, the Captain realized that he no longer knew what his position was in relation to the surrounding the terrain, so he immediately disconnected the autopilot and autothrottles, set the pitch and power for a max performance climb, and climbed to a safe altitude. Once there, they reestablished SA and started the arrival anew. It is very possible that this Captain saved the lives of everyone onboard.

Back to the mantra. The preamble is “When presented with an undesired aircraft state, an unknown malfunction or ambiguous warning, or a loss of situational awareness...” These are conditional statements joined by the word “or”. You only need one of them to apply the mantra.

The mantra continues, “the flying pilot should be ready and able to...” It does not actually say the flying pilot must do the following. If the flying pilot has enough SA to apply a different and more appropriate procedure, then that is what he/she should do. Now this leaves open the possibility that the pilot misidentifies the malfunction and applies the wrong corrective action. Hopefully, this is where the non-flying pilot steps in with a sanity check. There is no evidence in this accident that the crew misidentified the malfunction and were applying the wrong non-normal procedure.

However, if the flying pilot is 1) presented with an undesired aircraft state, and 2) does not know what the cause of that aircraft state is (i.e. unknown malfunction or ambiguous warning), then that person has pretty much met the definition of loss of situational awareness whether they know it or not. In that case, in the absence of any other procedure that would apply, the flying pilot should Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude.

Somewhere along the way, they may either come to realize that they have lost SA, or better yet, they will regain SA so that they can properly address the situation. Either way, by applying the steps above (i.e. FLY THE AIRCRAFT), they will have greatly improved their position.

[mangere1957]

Original post deleted due to having totally screwed up.

My error.

Great comments from B737 Driver and L39 Guy. Agree 100%.
Good work guys.

[wonkazoo]

If I have to read "Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude" one more time my head is going to explode like a pimple on a teenage girls nose.

I have no idea why a few very well-invested individuals here are pounding this drum so loudly and consistently, but for the umpteenth time your incredibly abrasive repetition ignores the fact that in order for your hypothesis to work (If airplane is doing something you don't expect, like, etc...) you need a rational fully functioning mind to interpret the data and act the way you want them to act. Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude only works with a human mind that hasn't been incapacitated or significantly diminished.

Someone else has properly offered here that the ET incident may well be traced at it's most basic human factors core to the impairment the pilots experienced due to the previous Lion Air crash. In other words: Their consciousness knew how the last one went down, so their bodies responded accordingly, which left them poorly equipped to actually perform the steps you have been seemingly demanding that they do since shortly after they in fact died.

I shared my own experience in the hope that people would gain some insight into pilot (human) incapacitation and cognitive impairment, but obviously those words were lost in translation. (If you are new to this discussion search on my username for a post roughly a week ago...) I have no idea what particular windmills the small group of devout believers in Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude.
are tilting at, but I can say I wish you would go away and find somewhere else to haunt, or at the very least find some other new expression to convey your "opinion." (Quotes because to me the words express ignorance, but I know they are offered as informed opinion...)

We get it- (we got it a week ago actually) you think the pilots crashed perfectly flyable airplanes. (You've said nearly exactly that...) Let's move on...

Regards-
dce

[headshrink]

thank you, dce. Fear can incapacitate you completely for a long time. "my mind goes blank" is what I heard many times from my patients.
hh

[maxter]

Please, let's not personalize this and attack individuals. 737 Driver has invested a lot of time and effort in addressing a lot of issues raised on this thread and for that he deserves everyone's respect whether you agree or disagree with him.

'The crews of the accident aircraft did not meet the expectations of 737 Driver, myself and ...(Boeing)'…....

The solution is surely simple. Boeing only sell MAX to US customers where the skills and training are all exceptional and let Airbus sell to the lower level.

That 'them and us' bias creeps in much to regularly in these threads. Accept that not all pilots have your magnificent skills yet they still get hired. That is todays world, but even US pilots crash sometimes.

Surely you have to design to the standard that the lowest skilled that may get posted to the MAX left seat is able to survive without exceptional skills or you just pick your customers.

[mangere1957]

L 39 Guy,
When quoting 777 SFO and 777 DBX, consider the particular systems contributions, lest you start agreeing with 737 Driver.

There was NOTHING wrong with the Asiana 777 in SFO, there was LOTS wrong with two useless pilots. If an aeroplane is EVER doing, or not doing(in 777 DBX) what you want then the pilot's job is to MAKE it do what you want. To make it simple for you, if you expect the auto-throttle to be increasing power and it doesn't then you DIY. Seesh. Are you a pilot?

Oh and there is nothing wrong with agreeing with 737 Driver because he, just like L39 Guy, knows what he's talking about.

[Bend alot]

I wonder if Ethiopian Airlines youngest Captain, was reluctant to hand over flying to such a low time FO - that had the correct reading instruments.

Then taking on the job to fix the problem/s solo, rather than as a crew. Was the last hole to line up and that overload him?

Was the FO scared to "suggest" things to the Captain due to respect or fear until it was left too late to speak up? There are a couple of pilots on here that come across as people that I would have second thoughts about speaking freely, and think I would pause before speaking.

[FrequentSLF]

Okay, given the flurry of a certain type of comment, I think it would be useful to provide some advice here.

I know some of you have some strongly held positions, and that’s okay. However, some of those positions are based on a theoretical framework, or perhaps something you read somewhere or something someone told you. When those positions stray off into technical matters regarding the 737 or airline operations, please consider the following.

I do not tell my auto mechanic how to fix my car. I do not tell the surgeon how to operate on my body. I do not tell the professional golfer how to perform a tricky shot out of the bunker. I do not do this even if I can tell that the end result was less than optimum. So if you have never actually flown a 737, please do not try to educate me as to how the systems function, how a checklist should be run, or how difficult the aircraft is to operate under certain conditions. It does nothing to add credibility to your position. I have more than 10 years cumulative experience in this aircraft plus another 15+ in other related Boeing products. I have been trained in countless abnormal and emergency situations in that time, and I have experience quite a few real ones in the air. I am quite familiar with the all the psychological and environmental factors that can come into play.

I offer my technical expertise here, in part, so that the commentary doesn’t go off into the weeds on some point that is fundamentally incorrect. In doing so, I may provide information in a simplified fashion to cater to the non-Boeing and non-pilot members of this forum. If you wish to argue the placement and use of switches and controls, whether this step should be done before that step, or whether something can be done in 5 seconds or 5 minutes, please have that discussion with someone else.

The bottom line is that the accident pilots made serious errors and did not meet the expectation of a professional airline flight crew. This statement should be no more controversial than saying that the various engineers and technical staff at Boeing made serious errors in the design of MCAS and did not meet the expectations of their profession. If you wish to label this as “blaming,” there is nothing I can do to stop you. Personally, I’ve seen enough of the culture of blame, and it does little to get to the root of the problem.

You can’t fix a problem until you recognize a problem exists. These accidents, among others, have provided clear evidence that there is a problem with the level of pilot skills in this industry. We can either ignore it, or we can do something about it.
i agree, myself have digressed from my field of expertise and apologize for that, said so I think there are only 4 pilots that could comment properly, unfortunately they are unable to do so...

[RickNRoll]

If I have to read "Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude" one more time my head is going to explode like a pimple on a teenage girls nose.

I have no idea why a few very well-invested individuals here are pounding this drum so loudly and consistently, but for the umpteenth time your incredibly abrasive repetition ignores the fact that in order for your hypothesis to work (If airplane is doing something you don't expect, like, etc...) you need a rational fully functioning mind to interpret the data and act the way you want them to act. Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude only works with a human mind that hasn't been incapacitated or significantly diminished.

Someone else has properly offered here that the ET incident may well be traced at it's most basic human factors core to the impairment the pilots experienced due to the previous Lion Air crash. In other words: Their consciousness knew how the last one went down, so their bodies responded accordingly, which left them poorly equipped to actually perform the steps you have been seemingly demanding that they do since shortly after they in fact died.

I shared my own experience in the hope that people would gain some insight into pilot (human) incapacitation and cognitive impairment, but obviously those words were lost in translation. (If you are new to this discussion search on my username for a post roughly a week ago...) I have no idea what particular windmills the small group of devout believers in Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude.
are tilting at, but I can say I wish you would go away and find somewhere else to haunt, or at the very least find some other new expression to convey your "opinion." (Quotes because to me the words express ignorance, but I know they are offered as informed opinion...)

We get it- (we got it a week ago actually) you think the pilots crashed perfectly flyable airplanes. (You've said nearly exactly that...) Let's move on...

Regards-
dce

Turning off the magic is what activates MCAS when the AoA is faulty.

[Bend alot]

Turning off the magic is what activates MCAS when the AoA is faulty.

Boeing and FAA last documentation prior to ET crash was "indicating" that it could be a good idea NOT to turn off the magic - until the aircraft was trimmed electrically first. Then you turn off the magic.

[capngrog]

If I have to read

Someone else has properly offered here that the ET incident may well be traced at it's most basic human factors core to the impairment the pilots experienced due to the previous Lion Air crash. In other words: Their consciousness knew how the last one went down, so their bodies responded accordingly, which left them poorly equipped to actually perform the steps you have been seemingly demanding that they do since shortly after they in fact died.


Regards-
dce

Wonkazoo:

Your above statement indicates to me that you think that all pilots are a bunch of folks who turn to jelly at the first sign of something amiss. I have to respectfully disagree. The extensive training that pilots are supposed to undergo, is to primarily reduce the effects of the "startle factor" and allow the so-called "muscle memory" to take over in the event of an emergency. Of course that is only if the pilots have been trained to fly the airplane instead of wonder: "Why is it doing that?" All too many recent (in the past decade or so) accidents/incidents have involved pilots trouble shooting the computer generated warnings instead of looking out the window and flying the aircraft. I can't necessarily fault pilots for that, because that seems to be what is currently being taught. Pilots need to develop a feel for flying and to understand that it is a very complicated, yet do-able balancing act. I still like 737 Driver's mantra: " Turn off the magic, set the pitch, set the power, trim the aircraft, monitor the performance and move the aircraft to a safe altitude".

Cheers,
Grog

[wonkazoo]

Wonkazoo:

Your above statement indicates to me that you think that all pilots are a bunch of folks who turn to jelly at the first sign of something amiss. I have to respectfully disagree. The extensive training that pilots are supposed to undergo, is to primarily reduce the effects of the "startle factor" and allow the so-called "muscle memory" to take over in the event of an emergency. Of course that is only if the pilots have been trained to fly the airplane instead of wonder: "Why is it doing that?" All too many recent (in the past decade or so) accidents/incidents have involved pilots trouble shooting the computer generated warnings instead of looking out the window and flying the aircraft. I can't necessarily fault pilots for that, because that seems to be what is currently being taught. Pilots need to develop a feel for flying and to understand that it is a very complicated, yet do-able balancing act. I still like 737 Driver's mantra: " Turn off the magic, set the pitch, set the power, trim the aircraft, monitor the performance and move the aircraft to a safe altitude".

Cheers,
Grog

Grog,

Your above post indicates to me that not only did you not read my previous post, you have not read any of my other posts either, including the one where I (a 4,400 hour commercial pilot- with the hours earned the hard way) describe a near (as in within a second or two of being dead) death experience as PIC in an airplane. Added to that I once held a zero level (ground) waiver for aerobatic demonstrations so I'm going to go out on a limb and suggest that with few exceptions you will not find a more qualified person here on PPRuNe to comment on hand-flying at aerodynamic limits within 300' of the ground. Thus telling me that "Pilots need to develop a feel for flying" is like the dumbest thing I have been told in quite a while.

Please go read- and then you can edit your comment to appropriately reflect what I have written, what my experience is, and you understanding of same.

Warm regards,
dce

[capngrog]

Grog,

Your above post indicates to me that not only did you not read my previous post, you have not read any of my other posts either, including the one where I (a 4,400 hour commercial pilot- with the hours earned the hard way) describe a near (as in within a second or two of being dead) death experience as PIC in an airplane. Added to that I once held a zero level (ground) waiver for aerobatic demonstrations so I'm going to go out on a limb and suggest that with few exceptions you will not find a more qualified person here on PPRuNe to comment on hand-flying at aerodynamic limits within 300' of the ground. Thus telling me that "Pilots need to develop a feel for flying" is like the dumbest thing I have been told in quite a while.

Please go read- and then you can edit your comment to appropriately reflect what I have written, what my experience is, and you understanding of same.

Warm regards,
dce

Wonkazoo:

Are you really saying that an accomplished pilot such as yourself has had no need to develop a feel for flying?

Cheers,
Grog

[Bend alot]

Wonkazoo:

Are you really saying that an accomplished pilot such as yourself has had no need to develop a feel for flying?

Cheers,
Grog
No the way I read his first post here was that in the real event he froze, he knew that he should be getting out but continued to fight the unwinnable event - that almost cost him his life.

Some years ago I witnessed a helicopter crash.
The pilot was very experience fixed wing survey pilot most of his time at 247 feet AGL, recently got his helicopter licence and just converted to a very new type turbine helicopter. This day he was just building hours on type, so I did not interrupt him on his pre-flight when I arrived at work.

I watched him take off then start to fly away. Soon I saw a "puff" come from near the rear of the helicopter { brain - did I see that? that seems not normal}.
Some time later I saw the "puff" again {brain - I saw that, it is not normal. ------------------------------------- If I see that again I need to act --------------------------- The tug is just there I will use the radio and TELL him to land}

I did indeed see the third "puff" but I had no chance of using the radio, the "puff" in a fraction of a second was a massive fire covering the entire rear 3/4 of the helicopter.

I froze and watch it crash in a massive fireball - F***K Pat's dead I said as the others looked to that direction, I jumped on the tug and headed to the crash site. Most the way there a army car was heading toward me with Pat in the middle eyes like dinner plates but he acknowledged me, so I turned around and went back to the hangar.

To this day I can not put a time line on any stages of the above events but the flight was around 600 m in length - Pat was seen jumping out of the helicopter before impact by the army guys, so certainly he was in overload at that time. Jumping probably prolonged Pat's life and he gave us the clue to the crash, but the burns won soon after.

I knew that I did see that first "puff" and I knew it was not normal - I was in a safe environment. I took too long to respond - I was listening to my brain.

[Uplinker]

...................
I have no idea why a few very well-invested individuals here are pounding this drum so loudly and consistently, but for the umpteenth time your incredibly abrasive repetition ignores the fact that in order for your hypothesis to work (If airplane is doing something you don't expect, like, etc...) you need a rational fully functioning mind to interpret the data and act the way you want them to act.....................only works with a human mind that hasn't been incapacitated or significantly diminished.

Someone else has properly offered here that the ET incident may well be traced at it's most basic human factors core to the impairment the pilots experienced....................... I have no idea what particular windmills the small group of devout believers in Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude.
are tilting at, but I can say I wish you would go away...........

Regards-
dce

Human factors are very relevant and the point is surely that when the automation or aircraft is misbehaving and/or the pilots are overloaded and have no idea what the fxxk is going on, the reflex response - when overloaded - needs to be to go back to basics : set a pitch, set a power and check altitude, attitude and vertical speed* This by itself will unload the pilots and enable the recovery phase: “Right the flight path is safe. Now, what the hell is happening to this aircraft?”

Everyone expects all pilots to do this but training and testing no longer ensures this basic requirement - witness the crashes and botched go-arounds of recent years. For more years’ than I can remember the (Airbus) SIM briefing is to use the automation to help reduce your workload. (Although to be fair the Airbus automatics are a lot better than the 737’s, and yes I have flown both).



*I would like to think that I would do this with stick shakers and warnings going on but I don’t know for sure. I for one would welcome much more UAS and misbehaving automation practice.

[RickNRoll]

Boeing and FAA last documentation prior to ET crash was "indicating" that it could be a good idea NOT to turn off the magic - until the aircraft was trimmed electrically first. Then you turn off the magic.

But then you have changed the mantra. By turning off the magic another form of magic is turned on that then has to be turned off. Not only that, if you thought you had turned off the magic and just needed to fly pitch and power it was affecting pitch more than you ever would.

[Cows getting bigger]

Beoing's original FCOM


https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/1108x735/005a_df504822cfd83368285cf165d09a74eb48a20fdc_1ee7cbcbe5e8f3 c77564836cc92bd1988801d7fb.jpg


A couple of thoughts.

Firstly, the only bit in bold says that this event occurs "during manual mode only". Perhaps, cognitively, the ET captain zoomed-in on this highlighted bit of text at 400ft climbing-out and tried to duck the issue by engaging A/P (if he had ever actually seen this FCOM). Not a defence, just trying to understand thought process.

Secondly, the FCOM specifically points pilots towards considering not turning off the magic immediately - "electric trim can be used to neutralise control column pitch forces before moving stab trim cutout switches". I'm not a 737 driver but one wonders how much time (MCAS iterations) one would spend trying to balance the forces before switching off. Prior to MCAS, did the NNC include this note?

PS. I tend to agree that leaving thrust at 94% (or whatever it was) would have brought increased complications.

[GordonR_Cape]

But then you have changed the mantra. By turning off the magic another form of magic is turned on that then has to be turned off. Not only that, if you thought you had turned off the magic and just needed to fly pitch and power it was affecting pitch more than you ever would.

In a recent post I pointed out that the training on the B737 NG simulator that all pilots get, plus the brief computer knowledge about the MAX differences, produce different kinds of memory. Adding the somewhat ambiguous emergency AD, means it is not immediately obvious what the correct procedures are to fly the aircraft, and recall during stressful situations is diminished.

The cascading series of failures triggered by faulty AOA, is particularly insidious. Once past the initial startle factor, and when MCAS activates, controlling pitch is no longer just flying the aircraft as previously trained. When the computer starts fighting the pilot, the crew have to switch back to diagnostic mode, and this is when sensory overload really sets in.

I appreciate some of the comments made by 737 Driver , but IMO repeating the "mantra" does no justice to a complex and rapidly evolving flight emergency. I am not a pilot, and have little to teach 737 Driver , but must point out that this discussion has been going on for many months, long before (he) became a forum member.

[Bend alot]

In a recent post I pointed out that the training on the B737 NG simulator that all pilots get, plus the brief computer knowledge about the MAX differences, produce different kinds of memory. Adding the somewhat ambiguous emergency AD, means it is not immediately obvious what the correct procedures are to fly the aircraft, and recall during stressful situations is diminished.

The cascading series of failures triggered by faulty AOA, is particularly insidious. Once past the initial startle factor, and when MCAS activates, controlling pitch is no longer just flying the aircraft as previously trained. When the computer starts fighting the pilot, the crew have to switch back to diagnostic mode, and this is when sensory overload really sets in.

I appreciate some of the comments made by 737 Driver , but IMO repeating the "mantra" does no justice to a complex and rapidly evolving flight emergency. I am not a pilot, and have little to teach 737 Driver , but must point out that this discussion has been going on for many months, long before (he) became a forum member.
Yes much credit needs to be given to the 737 pilots posting on this thread, possibly mostly 737 Driver.

But now this thread seems over till the final report/s are given - we have waffled on for too long now the power beyond control decides time is up. Who reset the cut out switches that let the machine takeover?

Some very knowledgeable folk posted here, keep up your great work.

[KRUSTY 34]

I’m not sure if there is a link as yet, but 60 Minutes Australia...

Nailed it!

[GordonR_Cape]

I’m not sure if there is a link as yet, but 60 Minutes Australia...

Nailed it!

There is a link in the Australian sub-forum: https://www.pprune.org/australia-new-zealand-pacific/621184-60-minutes-boeing-tonight.html

I am not in Oz, and have not seen the TV program, but assume you are being sarcastic. The promo-link popped in my news-feed earlier today, and looked like rubbish.

Edit: There is a preview online, but it is only available to those with the right IP address: https://www.9now.com.au/60-minutes/2019/extras/clips/clip-cjv4w3c7l00070glb07twvhug

Edit: https://tvtonight.com.au/2019/05/60-minutes-may-5-2.html
Tonight on 60 Minutes Liz Hayes fronts a special investigation into Boeing following recent aviation failures.

“Fatal Flaw”
When aircraft manufacturer Boeing announced its brand-new passenger jet, the 737 MAX, it thought it was onto another winner. Airlines around the world – including Australia – ordered thousands. But Boeing was wrong, and the plane has turned out to be a catastrophic failure. In the last six months two of the jets have crashed and 346 people have been killed. In a special edition of 60 MINUTES, Liz Hayes reconstructs the final horrific moments of both Lion Air flight 610 and Ethiopian Airlines flight 302. In startling interviews with 737 pilots, aircraft engineers and a former Boeing insider, Hayes investigates the fatal flaw of the 737 MAX, and questions not only why Boeing designed a plane with the ability to override the control of the pilots, but also why the company didn’t tell the airlines buying the planes it was doing this. Boeing says it can, and will, fix the problem, but Hayes asks whether the damage has already been done. For decades Boeing has relied on the undisputed trust of pilots and millions of passengers flying worldwide. But now, has it all been lost?
Reporter: Liz Hayes
Producer: Gareth Harvey

8:40pm Sunday on Nine.

[KRUSTY 34]

Believe it or not Gordon, sarcasm was the furthest thing from my mind.

I didn’t see the promo link, but IMHO the program succinctly went to the heart of just about everything that is wrong with the MCAS fiasco.

And no, I have no affiliation with 60 Minutes, or the Nine Network.

[VFR Only Please]

Muilenberg HAS to say that (there is nothing wrong with the aircraft -- everything has been corrected with utmost perfection, and anyway it was all the pilots' fault). Can you imagine the company lawyers or shareholders suggesting he say otherwise? One sniff of an admission of liability and Boeing would be sued out of existence.

I think you're Bang On. Boeing is wedded (no, welded) to the Max and simply lacks the means to turn back now. Its only option is to forge ahead and utter no word that hasn't first been examined by its lawyers under a microscope.

[737 Driver]

To the several posters commenting that the "Turn of the Magic" piece of the mantra is inappropriate during this malfunction, let me make a couple of observations:
.

"Turn of the Magic" on the 737 refers specifically to the Autopilot, Autothrottles, Flight Director, and Flight Path Vector. Other aircraft may have a different list. It does not refer to turning off MCAS, because obviously, there is no off switch for MCAS. However, the "Trim the Aircraft" step will definitely override MCAS input until the crew has the time to execute the Runaway Stab Trim procedure.
The post-Lion Air 610 AD (posted above) says quite explicitly that the autopilot may not remain engaged, a fact demonstrated three times by the Ethiopian Captain. In this malfunction, the autopilot will not be there to save you. This critique also assumes that the flight crew was aware of MCAS and the items that inhibit its activation. If that were the case, the best recourse was not to engage the autopilot, but to leave the flaps extended.
To those who have said that the mantra is not the best way to handle an MCAS failure, I AGREE! The best way to have handled this malfunction was for the crew to execute the Airspeed Unreliable NNC and leave the flaps extended. They did not.

Read the preamble to the mantra again: "When presented with an undesired aircraft state, unknown malfunction or ambiguous warning, or a loss of situational awareness...,"

The going-in assumption is the crew DOES NOT KNOW what the correct procedure is because they haven't correctly identified the problem. I can't stress this strongly enough. You don't get to the mantra if you know what the malfunction is. You don't get to the mantra if you are already applying to the appropriate procedure. You get to the mantra when you don't understand what is going on. I think it is clear from the data that the ET302 crew did not understand their situation. In that case, if the Captain had simply:
.Turned off the Magic, Set the Pitch, Set the Power, Trimmed the Aircraft, Monitored the Performance, and Moved the Aircraft to a Safe Altitude,.
that is, if he had FLOWN THE AIRCRAFT until such time that he could determine what the malfunction and appropriate procedure was, we would not be having this conversation today.

[Takwis]

I think you're Bang On. Boeing is wedded (no, welded) to the Max and simply lacks the means to turn back now. Its only option is to forge ahead and utter no word that hasn't first been examined by its lawyers under a microscope..

All the more more reason to disbelieve every word out of his mouth.

[737 Driver]

Secondly, the FCOM specifically points pilots towards considering not turning off the magic immediately - "electric trim can be used to neutralise control column pitch forces before moving stab trim cutout switches". I'm not a 737 driver but one wonders how much time (MCAS iterations) one would spend trying to balance the forces before switching off. Prior to MCAS, did the NNC include this note?
.


Your reading of this AD is not quite correct. First, before you ever get to MCAS activation, you have a case of Unreliable Airspeed. That non-normal would have you disconnect the autopilot, autothrottles, and flight directors as a first step. The AD further goes on to say that the autopilot may disconnect if it is engaged. This was demonstrate quite clearly (three times) in the ET302 accident. Finally, if the autopilot was engaged, use of the Main Electric (pilot actuated) Trim would have caused the autopilot to disconnect.

As far as how much time one spends neutralizing the trim forces, basically as much time as you needed. Keep in mind that every time the pilot inputs any amount of stab trim, MCAS stops in its tracks for 5 seconds. Thus, as long as the pilot trim inputs were separated by less than 5 seconds, they could trim as long as they needed to return the control forces to neutral before using the cutout switches. From that point, they would use the manual trim wheel.

[737 Driver]

If I have to read "Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude" one more time my head is going to explode like a pimple on a teenage girls nose.

I have no idea why a few very well-invested individuals here are pounding this drum so loudly and consistently.....

You titled this post "Fate May be the Hunter, but Fear is the Killer."

Exactly! I could not agree more, and therein lies the key to understand where all this has been going.

FEAR. Gut-wrenching, mind-numbing FEAR. FEAR is the killer. FEAR is the enemy. FEAR is the obstacle to successfully navigating so many aircraft emergencies. So how do we overcome this very predictable human reaction?!

Think for a moment what transpires in military training. Military commanders know that their soldiers will be engaging with FEAR on the front lines, but they also know that paralyzing FEAR is the one thing most likely to doom them. How do they overcome this obstacle? Through training and repetition. Training and repetition. Training and repetition. One of those famous cliches you hear in military-themed movies when the battle is about to be joined, "Remember your training!" And yes, some number of soldiers will still forget their training and freeze at a critical moment, but that doesn't mean the training was useless.

To the uninitiated pilot in training, I can think of a lot of simulator events that can stimulate the fear reflex - Engine Fire at V1, uncommanded engine failure at high altitude leading to decompression and an emergency descent, low altitude windshear recovery. That is exactly why we train for them. You need to train, and you need the repetition of training so that the correct responses are drilled deep down into your reptilian brain. The current training practices at most airlines do an okay job at training for the KNOWN.

What the current training regime is failing to train for is the UNKNOWN.

Yes, paralyzing fear is one possible outcome when faced with an unknown emergency, particularly at low altitude. Since we know this, we ought to train for it. How? As I have amply described, you train for it by intentional subjecting the flight crew to the unknown and novel situations where the only correct answer is: "Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude." You do this literally again and again until their heads want to explode. The inborn FEAR response is usually described as: Fight, Flee, or Freeze. As aviators, we need to add a fourth - FLY THE AIRCRAFT.

To those who may say this is idealistic or somehow not possible, this grey-haired pilot will tell you that this is what we used to do. Somewhere along the way, the training environment stopped emphasizing one of our most important tasks - when all else fails, when the world is going to **** around you, when you feel the fear rise in your throat, FLY THE AIRCRAFT, first, last, and always. Yes, the crew's ineffectual response is ultimately a human factors issue, but it is a human factors issue that has a very definite fix.

The Ethiopian crew failed in their response to this malfunction because their training regime failed them first.

[Lonewolf_50]

@737 Diver:
The issue here, having just gone through the last 7 pages of this thread, remains a multi party setting up of this crew (as I see it).
1. Boeing and various companies were chasing a dollar/profit objective, and the AoA miscompare "alert" was apparently optional equipment.

2. A primary flight control is moved by an aircraft sub system with no pilot in put, but (as has been discussed at length) a number of ways of disabling it.

3. Training on this subsystem: of questionable quality. Doubly so due to wide variation between air line companies in how much (in terms of time and money) they invest in their crews, not just for the upgrade to Max but in general.

4. Crew training(??) / inexperience becoming an international norm.

5. Over-reliance on automation becoming an international norm.

6. Arriving at your points in your latest post (https://www.pprune.org/rumours-news/619272-ethiopian-airliner-down-africa-248.html#post10463632), (none of which seem unreasonable to me, but I don't fly 737) the above mentioned factors suggest that unless you are in a company who values crew competence, and puts money / time / resources toward that core value, your crews are open to being set up - not only for the startle factor increasing a challenge, but incomplete systems knowledge (and practice with it) getting in the way of timely and correct decision making when dealing with a systems malfunction. Years ago when I was running sim training the ability to do some "free play" at the end of a session to test where a crew got oversaturated with systems malfunctions/emergencies was good training, and a lot of crews really appreciated them.Meme/clue for the non pilots in the audience here: when a malfunction turns into an emergency (or a fatal crash) to simply blame the pilots is to overlook that layers of human endeavor and responsibility that got them to that point.

7. (Pax Britannica made some interesting points previous but I lost my train of thought). The cockpit gradient in a given cockpit does not develop in isolation from cockpit / corporate culture, which is also informed by larger cultural issues regarding authority. It is unclear how that played out for ET to me, and is one of those hard to quantify factors.

8. A company (be it ET, Lion, or perhaps if things had played out differently, United or American?) has a powerful financial motive to move the blame indicator arrow to point ONLY at the manufacturer. (And the single point of failure issue that looks to be a root causal factor gives them fair grist for that mill). Some of this is cultural, some of this is purely financial due to how litigation works.

9. In the time between Lion Air and ET: what training, what systems training, and what crew training with related malfunctions did this crew have? What are the effects of negative training, and how do those play out in a cockpit?

10. Recency and upset training was mentioned above. I'll offer an idea here: any malfunction that is related to the movement of primary flight controls is subject to a recency factor (as seen in the AF 447 accident).

Were they, the crew in ET, set up?
At least in part, I offer that the answer is yes. The system that set them up all of the world's airline companies are a part of, and are core players in. So too are regulators, and nations.

I can't disagree with the general point that the pitch and power chorus are making (this singing group is once again on stage was they were for most of the AF 447 discussion on PPRuNe) . Power plus attitude equals performance.
But are people really being trained that way anymore?
Are their behaviors being incentivized to ground their operation of aircraft with that fundamental principle foremost?
If not, why not?
The corporations who make their money in this business (be it manufacturing, operating, or training people to operate the equipment) need to answer that question. So who is holding them all to account?

Aside: I do not believe that there is now an international standard of what a professional pilot is - I have seen some appeal to that thought - no matter how badly I wish that were true.
There may once have been such a standard. (But hey, all that is now needed is a concierge, eh? Tech is magic! (/sarcasm off))
There's a lot of lip service paid to it, though, and professional pilots (those who are the real deal) are rightly dismayed to see the profession that learned hard lessons over the course of a century, under attack. The two dead men (and their passengers) from ET are casualties in a war that seems to be going on between price and professionalism, and the use of automation to replace human function.

[737 Driver]

But now this thread seems over till the final report/s are given -


Perhaps I have not been clear enough on this point. My participation here has very little to do with the last accident. It has everything to do with the next accident.

It is highly unlikely that the next major aircraft accident will be due to MCAS or even anything related to the MAX. It is reasonably probable that the next hull loss will have a flight crew related cause, and high on the list of potential causes is that someone forgot to FLY THE AIRCRAFT. Plain and simple.

Until we take this seriously enough to actually do something about it, we are just going to be back here someday discussing some other unlucky pilot who got caught at a time he didn't expect with a problem he didn't expect and who somehow forgot to FLY THE AIRCRAFT first, last, and always.

[Lonewolf_50]

Until we take this seriously enough to actually do something about it, we are just going to be back here someday discussing some other unlucky pilot who got caught at a time he didn't expect with a problem he didn't expect and who somehow forgot to FLY THE AIRCRAFT first, last, and always. I think you are right,and I don't want to be sitting in the back when that happens. (I have to fly to visit my parents next week.)
So who is incentivizing pilots all over the world to do as you say?
What are their company SOPs, norms, habits, training, and requirements doing to incentivize behaviors that is not defaulting to that core principle?

[A0283]

@ 737driver if he had FLOWN THE AIRCRAFT until such time that he could determine what the malfunction and appropriate procedure was, we would not be having this conversation today.

A normal (fatalities included) accident safety investigation (the path that I am trying to follow) roughly takes a year. Complex ones can take more years (the 737 rudder reversals took many more years). Your "100%" statement, if true, would make fools of the majority of accident investigators. Including US investigations. That can not be your intention.

My impression is that you create (unintentional) confusion on these pages by acknowledging failures of all parties in the system (you have written an excellent short post on this a number of pages back) . But then quickly and repeatedly focussing elaborately on the failure of the pilots. Which can give the general reader the idea that you are only bashing the heads of these four guys. The style of writing (for an international audience including non-native english speakers) could also be perceived by some as a bit (unintentional) arrogant and bullying. Which is something people dont expect from a (CRM) cockpit.

The viewpoint that I myself try to take in this accident thread is that of trying to understand facts and doings of all the parties involved. If you take that overall view, then Boeing and FAA actions appear to be (many many facts 'pending') 'unprecedented' and 'incomprehensible' and contra the long established Boeing culture (at least before the 787) ... with the FAA having mixed reviews over the last 60 years. It would also be interesting to get more facts about the impact that airlines have had here (collaborative design is also collective involvement). Therefore it is no surprise to me, and certainly a positive sign, that there are multiple (US) investigations running in parallel. Which is rather unusual by itself though. And only getting the facts in those areas will take at least one year (the DoT IG for example for his investigation said that they normally need 1 year but in this case he expects it to be longer). I would expect the NTSB to go beyond a more 'technical' investigation and include an extensive proper 'certification process and design process' investigation. It is not only a pilot thing or design thing anymore, the credibility of a significant part of US aerospace is at stake. Considering the size of US aerospace the global system has a stake in this as well.

So in your posts it would sincerely help me to better understand them, if you can make clear when you are talking about general or US standards of pilot training/hrs, or training/hrs specific to 'which' accident(s). And also, if the scope of your post covers all the parties involved or that you focus 'mainly' on the piloting aspects.

I would expect most here to agree with your statements about the importance of training and the worry about the training levels and low hour pilots. The question we are dealing with here is an accident where within that context we want to know how important the training/hrs of these pilots was in the overall picture.

[GordonR_Cape]

Believe it or not Gordon, sarcasm was the furthest thing from my mind.

I didn’t see the promo link, but IMHO the program succinctly went to the heart of just about everything that is wrong with the MCAS fiasco.

And no, I have no affiliation with 60 Minutes, or the Nine Network.

Text version: https://www.9news.com.au/national/60-minutes-inside-boeings-disaster-737-max-aircrafts/f5875c13-57d6-4957-8bf6-a0c47ddfe293

Edit: Skim read. Nothing new IMO.

[Organfreak]

I think you are right,and I don't want to be sitting in the back when that happens. (I have to fly to visit my parents next week.)
So who is incentivizing pilots all over the world to do as you say?
What are their company SOPs, norms, habits, training, and requirements doing to incentivize behaviors that is not defaulting to that core principle?

This issue emerged in bold relief (see what I did there?) after the AF447 crash report, and everybody freaked-out. Did it change anything? Maybe a bit of training to recognize a stall, but it is apparent the basic training problem was soon forgotten or blown-off.

[Organfreak]

I'm going to post a deeper link to today's Seattle Times article (the previously-posted link led me to another link with the headlines only).
Highly-recommended reading: It appears that this is a scandal that's way worse than we thought. Clear, mendacious malfeasance and misfeasance by Boeing. This should be a gigantic scandal!
https://www.seattletimes.com/business/boeing-aerospace/engineers-say-boeing-pushed-to-limit-safety-testing-in-race-to-certify-planes-including-737-max/

I wish everyone would quit with the hostile attacks on 737 Driver. He clearly knows exactly WTF he's talking about and he should be thanked for his continuing campaign! Remember AF447!

[User7861]

Excuse me if this was already mentioned before, but I have to ask:

Nobody seems to be disturbed about the fact that the Unreliable Airspeed memory items include two performance settings only, and none of those are suitable for an initial climb after take off.
80% 10 degress pitch is the one with flaps extended and gear up. Starting actions at 400 AGL would mean that somewhere around 1000' these values would be set if I happened to follow the memory items without thinking.
So then what? What about high terrain and MSA?
Why is there no initial thrust and pitch setting for take off?
My personal game plan would be to keep the take off thrust and an initial pitch somewhere 14-16 degrees up until MSA or in case of VMC to an altitude where I'm absolutely sure that there will be no terrain threat, then set the 80% 10 deg.
Can anybody here show me what am I missing? Is there any of you here, who would consider setting that pitch and power right after take off? Is there even any data about the actual climb rate at MTOW for that setting?

[Zeffy]

https://www.seattletimes.com/business/boeing-aerospace/engineers-say-boeing-pushed-to-limit-safety-testing-in-race-to-certify-planes-including-737-max/


Engineers say Boeing pushed to limit safety testing in race to certify planes, including 737 MAX
May 5, 2019 at 6:00 am

By Dominic Gates and Mike Baker
Seattle Times staff reporters

In 2016, as Boeing raced to get the 737 MAX certified by the Federal Aviation Administration (FAA), a senior company engineer whose job was to act on behalf of the FAA balked at Boeing management demands for less stringent testing of the fire-suppression system around the jet’s new LEAP engines.

That June he convened a meeting of all the certification engineers in his unit, who collectively agreed with his assessment. Management initially rejected their position, and only after another senior engineer from outside the MAX program intervened did managers finally agree to beef up the testing to a level the engineer could accept, according to two people familiar with the matter.

But his insistence on a higher level of safety scrutiny cost Boeing time and money.

Less than a month after his peers had backed him, Boeing abruptly removed him from the program even before conducting the testing he’d advocated.

The episode underscores what The Seattle Times found after a review of documents and interviews with more than a dozen current and former Boeing engineers who have been involved in airplane certification in recent years, including on the 737 MAX: Many engineers, employed by Boeing while officially designated to be the FAA’s eyes and ears, faced heavy pressure from Boeing managers to limit safety analysis and testing so the company could meet its schedule and keep down costs.

That pressure increased when the FAA stopped dealing directly with those designated employees — called “Authorized Representatives” or ARs — and let Boeing managers determine what was presented to the regulatory agency.

“The ARs have nobody supporting them. Nobody has their backs,” said one former Authorized Representative who worked on the 737 MAX and who provided details of the engineer’s removal from the program. “The system is absolutely broken.”

FAA-designated oversight engineers are supposed to enjoy protection from management pressure. Removing one who proves a stickler for safety regulations will inevitably produce a chilling effect on others who see the consequences of being too rigid about safety concerns, said John Goglia, former member of the National Transportation Safety Board (NTSB).

“It negates the whole system,” said Goglia. “The FAA should have come down on that really hard.”

Following two deadly 737 MAX crashes off the coast of Indonesia and in Ethiopia that killed 346 people, and the subsequent grounding of the airplane worldwide, the certification of the jet has come under intense scrutiny, including a slew of lawsuits, congressional hearings and a criminal investigation.

None of the people interviewed were involved in certifying the Maneuvering Characteristics Augmentation System, the flight-control software implicated in the two crashes. But one area of scrutiny is sure to be the delegated system under which Boeing employees, paid by the company but acting as FAA designees, did the detailed certification work. It may slow down plans by the FAA and Boeing for a future certification regimen that would further erode the FAA’s oversight.


https://mail.google.com/mail/u/0?ui=2&ik=750726b4e8&attid=0.1&permmsgid=msg-a:r8290025959865332112&th=16a88f25cdc7c19f&view=fimg&sz=s0-l75-ft&attbid=ANGjdJ_cPXKC-wmoLCt3qJswqpRZXHTzpgJvCApEtQmvkBp7Jx_qVhY0ZqLcp9hEKx5s2-gnB54B4cfACHZPEvdGx5pgTGFoHE85NTSDQkhV6ij_JCrPxalUQVOp70Q&disp=emb&realattid=ii_jvb68pfw0


Boeing, in a statement responding to Seattle Times questions, said that FAA procedures, including regular, FAA-mandated training, “ensure Boeing employees serving in this capacity act independently on behalf of the FAA.”

It added that “there are processes in place to carefully evaluate any concerns regarding the AR’s ability to act independently.” The company declined to comment on individual cases cited in this story.
Yet as the FAA has increasingly delegated certification tasks to Boeing itself, it’s also made changes to the reporting structure that leave its designees to fend for themselves inside the company.

While a few former employees involved in certifications said they handled the pressure as a regular part of the job, others described the work environment as hostile, focused on achieving FAA approval within schedule and cost targets. Some of those workers spoke on condition of anonymity to protect professional relationships or for fear of retribution.

This echoes the findings of a Seattle Times investigation in March of what happened on the FAA side of the MAX certification. Within the FAA, its safety engineers worked under constant pressure from their managers to delegate more and more work to Boeing itself, and to speedily approve the safety assessments the Boeing designees came up with.

On the Boeing side of that process, the removal of the senior engineer acting as an FAA Authorized Rep was an extreme example that highlights the broader negative impact of two changes: The FAA no longer appoints its own ARs, instead leaving that to Boeing. And these designees now rarely interact with the FAA directly, according to former Boeing ARs interviewed by The Times.

They said these changes have stripped them of protection and given managers more opportunity to push for shortcuts.

In a statement, the FAA said it oversees the Boeing certification system “to ensure procedures are followed.” The agency also said it has “received no whistleblower complaints or any other reports … alleging pressure to speed up 737 MAX certification.”

Boeing managers are supposed to undergo “undue pressure” training to ensure that they aren’t crossing boundaries with the FAA’s representatives. And some ARs said that, despite some tensions, their managers were respectful of the role.

Fred Stong, an AR who worked on electrical systems at Boeing, said his experience was that everyone works through differences to reach common ground. He said he was always assertive in his role and didn’t face any problems.

“At no time in my career would anybody dare to pressure me,” Stong said.

Yet the former AR on the MAX said managers overseeing that jet’s certification were “extremely aggressive” about anything that affected the program cost or schedule.

“Managers were pounding on the ARs to get what the company needs in terms of reduced testing,” he said. “If it costs the company time and money, they’d pound on you to change the test design.”

The radical shift from DERs to ARs
Before 2004, those Boeing technical employees who worked safety on behalf of the FAA were called “Designated Engineering Representatives,” or DERs. Though paid by Boeing, they were appointed by the FAA and reported directly to their technical counterparts at the FAA.

What changed since 2004 is that safety engineers, now called Authorized Representatives, are appointed by and report to Boeing managers.

The opaque bureaucratic name for this new structure — Organization Designation Authorization (ODA) — masks the significant change: Instead of having individual Boeing employees authorized as FAA reps, Boeing now has an entire organization within the company so authorized. The individual FAA Authorized Reps — Boeing engineers — report up the chain to their Boeing managers, not the FAA.

A veteran aviation-safety engineer who over the decades worked for long stints as a DER at Boeing and later as a Boeing AR on a variety of projects including the MAX, said there’s “nothing inherently wrong” with the FAA delegating safety certification — provided it retains oversight.

This consultant asked for anonymity to protect his current livelihood doing certification work for multiple aviation companies.

Working as a DER with smaller aviation companies that don’t have an ODA designation, it’s his job to ensure their products comply with all safety regulations. On those projects, he can consult directly with FAA technical people if any problem arises or if he needs advice on what exactly may be required to demonstrate compliance.

“If I need guidance, I call my FAA adviser,” he said. “I’m overseen directly by the FAA. And every year there is a pretty robust audit of my activity before the FAA will delegate me for the following year.”

His experience working as an AR at Boeing and other companies was quite different.

“Under ODA, the FAA no longer manages the people making the compliance findings,” he said. “They never even talk to them.”

And because Boeing appoints the representatives, he said, accountability is severely curtailed. “If the company is happy with their decisions, obviously, they’ll be kept in their jobs.”

Under the old system, “we knew we’d lose our livelihood if we didn’t maintain the integrity of making decisions the way the FAA would do it,” the consultant said. “That check is no longer there.”

The FAA, contradicting the accounts of the former Authorized Representatives interviewed, said that ARs “have frequent interaction and access to FAA personnel to communicate concerns directly.”

However, a copy of one version of the Boeing ODA manual, an internal document labeled proprietary but obtained by The Times, told ARs with concerns about their workload or pressure from managers to first report them to the AR administrator, who is a higher level Boeing manager.

The manual also states that AR performance will be judged in part by whether they are “completing their duties in a timely and cooperative manner.”

It’s a Boeing manager who determines if an individual representative’s performance is sufficiently cooperative, as evidenced by the experience of Mike Levenson, who has worked as an FAA representative at several companies and served in an AR role at Boeing for five years until 2013.

He said that while there’s always a pressure on FAA representatives in an aviation world full of deadlines and cost considerations, most industry managers are able to find a balance to ensure the ARs have independence. He said he didn’t find that to be the case at Boeing.

Levenson worked on certifying aircraft repairs at Boeing and said he certified more than 500 in his time there, though he did not work on the MAX. On three occasions, he declined to certify repairs. The first two times, Levenson said, he got called into a supervisor’s office.

On the third occasion, in June 2013, a proposed repair clearly did not meet all FAA requirements, he said. After he declined to approve it, Levenson said, his manager “told me to go back and find compliance or my contract would not be extended.”

Levenson agreed to do additional work and consulted with other colleagues but still couldn’t certify the repair’s compliance.

“When I reported this to my manager, I was told this was unacceptable and was summarily dismissed the following day,” Levenson said.

The FAA said it has no record of Levenson filing a complaint. Levenson said he talked to the agency but didn’t file anything formally.

MAX inherits 737 legacy issues
The removal from the MAX program of the FAA’s Authorized Rep who insisted upon stricter engine fire-suppression testing is briefly summarized in a February 2017 report obtained by The Seattle Times. The report does not name the engineer, and the two people who described what happened spoke on condition that he not be named.

In the report, prepared by the three unions that represent FAA technical staff, the incident was listed among a long series of problematic decisions made under the current system of delegating FAA certification and oversight to Boeing.

The engineer removed from the program had more than two decades of experience at Boeing doing certification work on behalf of the FAA. Managers transferred him to Boeing’s “Central Engineering” unit, with no particular job description, and appointed as his replacement on the MAX team an engineer with relatively little experience in certification.

Four additional concerns specific to the 737 MAX were listed in the 2017 report. All were related to certification of legacy systems inherited from the earliest 737 models that were found by FAA technical staff to be noncompliant with the latest safety regulations.

These involved a lack of redundancy in the rudder cables; a too-high surface temperature allowed in the fuel tank; insufficient fireproofing around the plane’s auxiliary power unit in the tail; and using high-power wiring to connect to a switch inside the fuel tank.

All these issues were flagged by safety engineers working at the FAA as requiring fixes before the MAX could be certified.

The MAX won certification anyway after managers on the Boeing side of certification insisted that these were non-issues and managers on the FAA side agreed to let it move ahead with these shortcomings unaddressed.

All were waved through by the Boeing ODA and signed off by FAA management, according to the union report.

The FAA, in its statement to The Times, said it ordered the findings to be investigated at the time but said it wouldn’t address the specific items “because of the ongoing investigations into the aircraft’s certification.”

A better oversight structure
When Acting FAA Administrator Dan Elwell appeared before the U.S. Senate subcommittee on aviation in March, he was asked if the FAA could pull the oversight of air safety back in-house instead of delegating it to Boeing and other manufacturers.

“It would require roughly 10,000 more employees and another $1.8 billion for our certification office,” Elwell told the senators.

But that’s assuming the FAA would end delegation of oversight completely and take back all the certification work for a new airplane. That’s impractical, not only for the lack of resources, but also because all the leading-edge technological expertise needed is concentrated inside Boeing and its suppliers.

Many of the FAA’s safety engineers formerly worked for Boeing. But when they leave industry to work for the government, after a few years they inevitably lose touch with the latest innovations.

As the former NTSB member Goglia puts it: “You can’t stay on the pointy end of the arrow and work for the government.”

The former Boeing Authorized Rep who described the current system as “broken” agrees.

“It’s impossible for someone sitting at a desk at the FAA to keep up with the technology,” he said. “Once you step out, it will bypass you really fast.”

Still, he said, there’s no need to contemplate a wholesale removal of delegation from industry. Instead, he said, what’s needed is to have the same Boeing engineers continue to do the safety evaluations, but to have them chosen by and reporting to the FAA — in other words, to revert to the old DER structure of oversight.

The former AR said that worked well because the FAA “was able to see into the design process from the beginning and have direct input as it was developed.”

“I’m not asking for the FAA to add 10,000 engineers,” he said. “Keep the same ARs as today. Just change who they report to, who is overseeing them. That doesn’t mean transferring the work to the FAA.”

John Cox, chief executive of Safety Operating Systems and formerly the top safety official for the Air Line Pilots Association, said that following the accidents and questions raised about how the errant flight control system on the MAX was certified, “there probably needs to be a review of the ODA system.”

“The (older) DER approach worked extremely effectively,” Cox said. “If engineers are working on behalf of the FAA, they should have a direct technical liaison with the FAA.”

And Goglia, the former NTSB member, said the AR system, with these engineers appointed by and reporting to Boeing, may need to be adjusted.

“I like the older system better than Boeing, or any manufacturer, having that kind of control,” Goglia said.

Moving toward complete self-certification
Yet before the MAX crashes, the FAA was heading in exactly the opposite direction: toward more delegation of oversight, with FAA participation reduced to a bare minimum.

A 2012 report to the FAA by a committee co-chaired by a Boeing representative and the FAA’s top aviation safety official, Ali Bahrami, recommended increased delegation of oversight to industry, working toward a “future state” beyond ODA with another deliberately obscure bureaucratic name: Certified Design Organization, or CDO.

If Boeing were to achieve CDO status, its employees could certify their own designs. Employees doing the certification work would not be designees technically working on behalf of the FAA, just Boeing engineers working for Boeing.

This would be true self-certification, but has not yet been implemented.

Levenson said such a shift would increase safety risks for the industry.

“It’s a horrible idea,” Levenson said. “There’s not enough oversight as it is now. That would remove almost all oversight.”

The former AR on the MAX who provided details of the engineer’s removal said he spoke to The Seattle Times because he hopes for action to reverse the industry’s direction.

He said the two crashes that claimed so many lives in Indonesia and Ethiopia starkly emphasize the need to force the FAA to go back to a DER-style structure, where those working at Boeing on behalf of the FAA are directly overseen by agency technical experts.

“Unfortunately, in our industry, the pendulum swings when people die,” he said. “Let those people’s deaths mean something.”

Seattle Times researcher Miyoko Wolf contributed to this story.

Dominic Gates: 206-464-2963 or [email protected]; on Twitter: @dominicgates.
Mike Baker: 206-464-2729 or [email protected]; on Twitter: @ByMikeBaker.

[GlobalNav]

Fit hitting shan on Boeing MAX certification and safety testing

From seattle times today 5 may-- article goes into great detail
https://www.seattletimes.com/author/dominic-gates/

Its this lack of true independence between the OEM and the certification specialists that makes the current form of Organizational Delegation Authority the problem. In addition, the increased resistance WITHIN FAA management to selective technical oversight by the certification authority, and diminished integration between FAA engineers and delegated engineers (DER, or AR) that puts the delegates in such tenuous position with their employer - the OEM. The article is spot on!

[L39 Guy]

Excuse me if this was already mentioned before, but I have to ask:

Nobody seems to be disturbed about the fact that the Unreliable Airspeed memory items include two performance settings only, and none of those are suitable for an initial climb after take off.
80% 10 degress pitch is the one with flaps extended and gear up. Starting actions at 400 AGL would mean that somewhere around 1000' these values would be set if I happened to follow the memory items without thinking.
So then what? What about high terrain and MSA?
Why is there no initial thrust and pitch setting for take off?
My personal game plan would be to keep the take off thrust and an initial pitch somewhere 14-16 degrees up until MSA or in case of VMC to an altitude where I'm absolutely sure that there will be no terrain threat, then set the 80% 10 deg.
Can anybody here show me what am I missing? Is there any of you here, who would consider setting that pitch and power right after take off? Is there even any data about the actual climb rate at MTOW for that setting?

I can’t speak for the 737 as I don’t fly it but I fly the 787 with a similar procedure.

Like everything else, common sense and airmanship. Boeing (or Airbus, etc) can’t write a procedure for every possible circumstance (weight, altitude, temperature, terrain) so if one or more of those items precludes you from setting 10 degrees/80% then stick with take-off power/15 degrees or so until you are clear of any threats then go to the recommended values.

[Bend alot]

Perhaps I have not been clear enough on this point. My participation here has very little to do with the last accident. It has everything to do with the next accident.

It is highly unlikely that the next major aircraft accident will be due to MCAS or even anything related to the MAX. It is reasonably probable that the next hull loss will have a flight crew related cause, and high on the list of potential causes is that someone forgot to FLY THE AIRCRAFT. Plain and simple.

Until we take this seriously enough to actually do something about it, we are just going to be back here someday discussing some other unlucky pilot who got caught at a time he didn't expect with a problem he didn't expect and who somehow forgot to FLY THE AIRCRAFT first, last, and always.

Sadly that day is today, and not a MCAS event as predicted.

[KRUSTY 34]

Text version: https://www.9news.com.au/national/60-minutes-inside-boeings-disaster-737-max-aircrafts/f5875c13-57d6-4957-8bf6-a0c47ddfe293

Edit: Skim read. Nothing new IMO.

Agree 100% Gordon. Everything in the program traces from the time Lion Air went down.

It’s just taken 5 months and another 157 lives for the mainstream media to finally join the dots.

[wonkazoo]

From the Seattle Times Article:

"Four additional concerns specific to the 737 MAX were listed in the 2017 report. All were related to certification of legacy systems inherited from the earliest 737 models that were found by FAA technical staff to be noncompliant with the latest safety regulations.

These involved a lack of redundancy in the rudder cables; a too-high surface temperature allowed in the fuel tank; insufficient fireproofing around the plane’s auxiliary power unit in the tail; and using high-power wiring to connect to a switch inside the fuel tank.

All these issues were flagged by safety engineers working at the FAA as requiring fixes before the MAX could be certified.

The MAX won certification anyway after managers on the Boeing side of certification insisted that these were non-issues and managers on the FAA side agreed to let it move ahead with these shortcomings unaddressed."

I'm sorry, I'm trying to pick my jaw up off the floor. The 737 has no redundancy in it's rudder control system?? I've had a rudder cable failure- trust me when I say it can end very badly!! Can any (ahem) 737 Driver confirm that this is in fact accurate, that there is either no or a lack of redundancy in the 737's rudder??

If that is true that is the most shocking thing I have read about aviation in a very long time- and that the airplane was granted its STC just three years ago makes this even more shocking.

If it is true.

Cheers-
dce

[Organfreak]

I'm sorry, I'm trying to pick my jaw up off the floor. The 737 has no redundancy in it's rudder control system?? I've had a rudder cable failure- trust me when I say it can end very badly!! Can any (ahem) 737 Driver confirm that this is in fact accurate, that there is either no or a lack of redundancy in the 737's rudder??

If that is true that is the most shocking thing I have read about aviation in a very long time- and that the airplane was granted its STC just three years ago makes this even more shocking.

If it is true.

Cheers-
dce

I'm no driver, but I can read:
The Rudder System (http://www.b737.org.uk/theruddersystem.htm) Hope this helps.
EDIT: Oh! I just realized this info is from 1997, but I'd be shocked if they'd since re-designed this to operate by cable and with no redundancies.

[737 Driver]

Excuse me if this was already mentioned before, but I have to ask:

Nobody seems to be disturbed about the fact that the Unreliable Airspeed memory items include two performance settings only, and none of those are suitable for an initial climb after take off.
80% 10 degress pitch is the one with flaps extended and gear up. Starting actions at 400 AGL would mean that somewhere around 1000' these values would be set if I happened to follow the memory items without thinking.
So then what? What about high terrain and MSA?
Why is there no initial thrust and pitch setting for take off?
My personal game plan would be to keep the take off thrust and an initial pitch somewhere 14-16 degrees up until MSA or in case of VMC to an altitude where I'm absolutely sure that there will be no terrain threat, then set the 80% 10 deg.
Can anybody here show me what am I missing? Is there any of you here, who would consider setting that pitch and power right after take off? Is there even any data about the actual climb rate at MTOW for that setting?

No, you are not missing anything. I sent my Fleet Manager a long list of items that I felt were deficient in the current Airspeed Unreliable NNC, this being one of them. One of the more significant problems is that once you have stabilized the aircraft, there are all kind of ancillary system effects from a bad AOA or airspeed input, and the QRH doesn't do a good job of discussing them. He said that they would forward them to Boeing along with a bunch of other material they had been collecting, but he said not to expect any definitive answers soon. I suspect all correspondence with Boeing is being vetted through legal.

To answer your specific question, the consensus among folks I've discussed this with is to maintain takeoff power and 15 degrees nose up until reaching 1000', engine-out acceleration altitude, or obstacle clearance as appropriate. At that point, set 80% and 10 degrees and work the checklist far enough through to determine the good airspeed system before you retract your flaps. If you are in an area that requires special routing for terrain, follow whatever company procedures you have for engine out maneuvering. Keep in mind that 80% N1 on two engines is better thrust than one engine at MCT. This procedure also works for a Go-around/Missed approach from low altitude.

[737 Driver]

I'm sorry, I'm trying to pick my jaw up off the floor. The 737 has no redundancy in it's rudder control system?? I've had a rudder cable failure- trust me when I say it can end very badly!! Can any (ahem) 737 Driver confirm that this is in fact accurate, that there is either no or a lack of redundancy in the 737's rudder??

If that is true that is the most shocking thing I have read about aviation in a very long time- and that the airplane was granted its STC just three years ago makes this even more shocking.



This caught my attention as well. I'm not sure exactly which part of the system they are talking about. From my FCOM:

Each set of rudder pedals is mechanically connected by cables to the input levers
of the main and standby rudder PCUs. The main PCU consists of two independent
input rods, two individual control valves, and two separate actuators; one for
Hydraulic system A and one for Hydraulic system B. The standby rudder PCU is
controlled by a separate input rod and control valve and powered by the standby
hydraulic system. All three input rods have individual jam override mechanisms
that allows input commands to continue to be transferred to the remaining free
input rods if an input rod or downstream hardware is hindered or jammed.

My reading is that the Captain and First Officers rudder controls are completely independent (though linked) systems. As with virtual all controls in modern airliners, one side can override a jam on the other side.

That being said, Boeing's management of the MAX program is looking more dismal with each passing day.

[737 Driver]

Sadly that day is today, and not a MCAS event as predicted.

Too soon to say. I would like to think not. :(

[OldnGrounded]

From today's NYT:

Boeing Believed a 737 Max Warning Light Was Standard. It Wasn’t (https://www.nytimes.com/2019/05/05/business/boeing-737-max-warning-light.html).

When Boeing began delivering its 737 Max to customers in 2017, the company believed that a key cockpit warning light was a standard feature in all of the new jets.

But months after the planes were flying, company engineers realized that the warning light worked only on planes whose customers had bought a different, optional indicator.

In essence, that meant a safety feature that Boeing thought was standard was actually a premium add-on.

Boeing detailed its initial confusion about the warning light in a statement released on Sunday, adding new details to what was already known about the flawed design and introduction of the 737 Max, its best-selling jetliner.

AOA disagree, of course. Sheesh.

[737 Driver]

@ 737driver

A normal (fatalities included) accident safety investigation (the path that I am trying to follow) roughly takes a year. Complex ones can take more years (the 737 rudder reversals took many more years). Your "100%" statement, if true, would make fools of the majority of accident investigators. Including US investigations. That can not be your intention.

That is not my intention. I understand that it takes time to flesh out all the details in a final accident report. However, enough information may be present during the preliminary phase that indicates the need for immediate action. The obvious example in this case is that the certificate authorities did not wait for the final report to order the grounding of the MAX. Similarly, I would argue that there is enough evidence of crew member lapses, particularly when taken together with a trend that spans airlines and airframes, that we should not wait until the ink is dry on the final report before we do something about it.

My impression is that you create (unintentional) confusion on these pages by acknowledging failures of all parties in the system (you have written an excellent short post on this a number of pages back) . But then quickly and repeatedly focussing elaborately on the failure of the pilots. Which can give the general reader the idea that you are only bashing the heads of these four guys. The style of writing (for an international audience including non-native english speakers) could also be perceived by some as a bit (unintentional) arrogant and bullying. Which is something people dont expect from a (CRM) cockpit.

As I have already stated on several occasions, while there was a definite chain of causation, the people who populate this forum only really have the power to address the remedy for one link in that chain - the crew performance. We can bash Boeing all we want, but there is not a thing said on PPRuNe that is going to have a direct effect on Boeing. Personally, I'm not into complaining just to complain. If I'm going to invest my time and energy here, I would like to think that I might just move the needle some and get a reasonable number of the professional aviators who populate this forum thinking about how they can change how they approach their flying so that future accidents may be avoided. That starts with admitting, that yes, there really is a problem with the existing standards and expectations for professional pilots.

As far as my writing style, it is what it is. I am passionate about this subject, and I'm sure it comes through. I suspect I am also a bit irritating because I am uncompromisingly presenting a message that some people just do not want to hear. Boeing did not produce a resilient aircraft in the MAX. Likewise, the current pilot training pipeline is not producing resilient aviators. When the MAX is fixed, which one of those problems are we left with?

The viewpoint that I myself try to take in this accident thread is that of trying to understand facts and doings of all the parties involved. If you take that overall view, then Boeing and FAA actions appear to be (many many facts 'pending') 'unprecedented' and 'incomprehensible' and contra the long established Boeing culture (at least before the 787) ... with the FAA having mixed reviews over the last 60 years. It would also be interesting to get more facts about the impact that airlines have had here (collaborative design is also collective involvement). Therefore it is no surprise to me, and certainly a positive sign, that there are multiple (US) investigations running in parallel. Which is rather unusual by itself though. And only getting the facts in those areas will take at least one year (the DoT IG for example for his investigation said that they normally need 1 year but in this case he expects it to be longer). I would expect the NTSB to go beyond a more 'technical' investigation and include an extensive proper 'certification process and design process' investigation. It is not only a pilot thing or design thing anymore, the credibility of a significant part of US aerospace is at stake. Considering the size of US aerospace the global system has a stake in this as well.

I have no doubt that Boeing, the FAA, and a number of airlines are going to get the colonoscopy from hell in regards to how they all basically conspired to rush this program through at maximum speed and minimum costs. There are currently armies of lawyers besieging Fortress Boeing as we speak. It is an interesting spectacle to watch, and I'm sure we will learn a lot in the process. However, as I have said before, I'm not going to dwell on Boeing because Boeing doesn't really give a crap about anything I have to say. I think my energies are better directed toward people who I might actually be able to influence.

So in your posts it would sincerely help me to better understand them, if you can make clear when you are talking about general or US standards of pilot training/hrs, or training/hrs specific to 'which' accident(s). And also, if the scope of your post covers all the parties involved or that you focus 'mainly' on the piloting aspects.

Let be absolutely clear that I think that training standards and expectations have fallen across the board. I think we get away with it better in North America because we have a deeper pool of pilots to draw from than other areas of the world. It is rare to see a new hire at my airline with less than 4,000 hours, and by that time this pilot has probably seen a lot of interesting flying that did not involve engaging the autopilot at 500' on takeoff and clicking it off at 1000' on approach, if you know what I mean. Even so, I am sometimes dismayed to how much has been removed from our sim training and how much technical information has been removed from our manuals. We supposedly have on of the best airline training and safety programs in North America, yet I continually see cracks in the foundation. I suspect this is being driven by the constant race to the bottom in terms of delivering the product at the lowest possible cost.

[Dee Vee]

the company believed that a key cockpit warning light was a standard feature in all of the new jets.

Who is this "company" claiming it thought there was a light there, very convenient to use an airy fairy "company name" as an excuse.

Give us the name of the exec responsible who thought this, and what evidence they had to support it, and then tell us if it was the same exec who decided AoA redundancy wasn't required...

"companies" don't make decisions, individuals do, "companies" and they lawyers should be banned from trying to protect individuals making life and death decisions, when things go wrong.

[edmundronald]

When Boeing explained to pilots in one meeting how systems on the Max worked, the company said that the disagree alert would function on the ground. In the late November meeting, Boeing told pilots for American Airlines (which had bought the add-on) that their disagree alert would have notified them of problems before takeoff.

“We were told that if the A.O.A. vane, like on Lion Air, was in a massive difference, we would receive an alert on the ground and therefore not even take off,” said Dennis Tajer, a spokesman for the union representing American Airlines pilots. “That gave us additional confidence in continuing to fly that aircraft.”

But in the last several weeks, Boeing has been saying something different. Mr. Tajer said the company recently told American pilots that the system would not alert pilots about any sensor disagreement until the aircraft is 400 feet above the ground.



It just keeps getting worse. The NYT story cited above buried the lede. Even those who paid for and had an AoA disagree that worked had one that didn’t work during takeoff.

As an engineer SLF I feel this is becoming almost unbelievable. I predict Boeing will be making VERY LARGE political campaign contributions over the next few years.

Edmund

[737mgm]

Excuse me if this was already mentioned before, but I have to ask:

Nobody seems to be disturbed about the fact that the Unreliable Airspeed memory items include two performance settings only, and none of those are suitable for an initial climb after take off.
80% 10 degress pitch is the one with flaps extended and gear up. Starting actions at 400 AGL would mean that somewhere around 1000' these values would be set if I happened to follow the memory items without thinking.
So then what? What about high terrain and MSA?
Why is there no initial thrust and pitch setting for take off?
My personal game plan would be to keep the take off thrust and an initial pitch somewhere 14-16 degrees up until MSA or in case of VMC to an altitude where I'm absolutely sure that there will be no terrain threat, then set the 80% 10 deg.
Can anybody here show me what am I missing? Is there any of you here, who would consider setting that pitch and power right after take off? Is there even any data about the actual climb rate at MTOW for that setting?

A legitimate question that I have been asking myself as well. Adding to what other posters have said, you can find answers in the 737 flight crew training manual:

“Memory items for target pitch and thrust must be accomplished as soon as it is suspected that airspeed indications are incorrect. The intent of having memorized pitch and thrust settings is to quickly put the airplane in a safe regime until the Airspeed Unreliable checklist can be referenced. The memorized settings are calculated to work for all model/engine combinations, at all weights and at all altitudes. The flaps extended settings will be sufficient such that the actual airspeed remains above stick shaker and below the flap placard limit. The flaps extended pitch and thrust settings will result in a climb."

Accordingly setting 10° pitch and 80% N1 will result in a climb at all weights. If you have a look at the departure chart that ET 302 flew you will see that terrain was not a factor for them for at least 40NM if they continue on runway heading. Also they had good visibility. Therefore setting these values would not have been a problem. However as you said, it is also an option to keep the TO thrust setting a bit longer and the pitch atitude at 15° in order to climb quicker to an altitude where you feel more comfortable. Nonetheless you have no guarantee from Boeing then that you will not reach flap placard speed at some point. If terrain is actually a factor that is a risk I would be willing to take and as 737driver said, the best option then would be to fly your company's engine out procedure.

[737 Driver]

A legitimate question that I have been asking myself as well. Adding to what other posters have said, you can find answers in the 737 flight crew training manual:

“Memory items for target pitch and thrust must be accomplished as soon as it is suspected that airspeed indications are incorrect. The intent of having memorized pitch and thrust settings is to quickly put the airplane in a safe regime until the Airspeed Unreliable checklist can be referenced. The memorized settings are calculated to work for all model/engine combinations, at all weights and at all altitudes. The flaps extended settings will be sufficient such that the actual airspeed remains above stick shaker and below the flap placard limit. The flaps extended pitch and thrust settings will result in a climb."


Unfortunately, our company manuals don't go into that level of detail. It does have this little gem, though: "If the flight crew is aware of the problem, flight without the benefit of valid airspeed information can be safely conducted and should present little difficulty." Just a walk through the park.

I'm hoping this verbiage gets yanked with the next change.

[feueraxt]

https://www.smh.com.au/business/companies/boeing-left-airlines-authorities-in-dark-on-alert-linked-to-737-max-crashes-20190506-p51kcy.html

Boeing knew months before a deadly 737 Max crash that a cockpit alert wasn't working the way the company had told buyers of the single-aisle jetliner.

Questions have been raised about the company's lack of transparency.

But the planemaker didn't share its findings with airlines or the Federal Aviation Administration until after a Lion Air plane went down off the coast of Indonesia in October, according to a Boeing statement Sunday. The accident occurred after erroneous readings by a single angle-of-attack sensor triggered software that pushed the jet's nose down until pilots lost control.

Boeing's latest disclosure raises new questions about the 737 Max's development and testing - and the company's lack of transparency. The alert was supposed to flash when two angle-of-attack vanes sent conflicting data about the relation of the plane's nose to the oncoming air stream. Boeing had told airlines and pilots that the so-called AOA disagree warning was standard across the Max fleet, as on a previous generation of 737 jets.

The software delivered to Boeing linked the signal with a second cockpit gauge - available for a fee -that displayed the readings from the two vanes. As a result, the AOA disagree light, which warned pilots of issues with the sensors, functioned only for customers that purchased the optional indicator.

"The question I have is just like we asked them in Reno, 'Is that all there is?' That's the biggest question," said Jon Weaks, head of the Southwest Airlines Pilots Association, referring to a meeting union leaders had with Boeing after the Lion Air crash. "It's obviously troubling that here is something else Boeing didn't get to us."

FAA criticism

The inactive alert was later deemed to be "low risk" by the FAA's Corrective Action Review Board, the regulator said Sunday. "However, Boeing's timely or earlier communication with the operators would have helped to reduce or eliminate possible confusion," the FAA said.

Boeing engineers discovered the discrepancy "within several months" of the initial Max deliveries in May 2017, the company said as it provided additional details of an issue that first came to light last week. The disclosures followed criticism from airlines and crash victims' relatives that Boeing hasn't been forthcoming about issues with the 737 Max, which has been grounded since a second crash in March, in Ethiopia.

The two disasters killed 346 people.

The manufacturer's own experts reviewed the issue and "determined that the absence of the AOA Disagree alert did not adversely impact airplane safety or operation," according to the Boeing statement. The company's review board decided the setup was acceptable until the two alerts could be unlinked with the next planned software update for the plane's display system.

Airline discussions

Rockwell Collins, which was acquired last year by United Technologies Corp., provides the cockpit displays and flight-control computers for the 737 Max. Another United Technologies division makes the angle-of-attack vanes for the plane.

United Technologies referred questions to Boeing.

The Chicago-based planemaker said its senior leadership wasn't involved in the review and first became aware of the issue after the Lion Air accident. Boeing also broke the news of the glitch to Max operators such as Southwest Airlines Co. in the aftermath of the initial crash.

"Why weren't the manuals changed? Until after Lion Air, our manuals said that worked," Weaks said. "You can't blame Southwest because that's the information they had from Boeing. We don't know what we don't know."

Boeing said it also told the FAA that company engineers had identified the issue in 2017, along with the findings from their internal review process. In December, a safety review board convened by the manufacturer confirmed that the absence of a functional AOA disagree light didn't present a safety issue.

Software update

Boeing briefed the FAA's Seattle aircraft certification office in November, and the information was forwarded to the agency's Corrective Action Review Board for evaluation, an FAA representative said Sunday. The panel determined the issue to be "low risk," and said Boeing would have to fix it as part of an overall package of enhancements to the Max in response to the Lion Air accident.

Before the Max returns to service, Boeing plans to issue a software update that will allow the AOA disagree light to operate as a standalone feature.

Boeing has separately been working to finalise a redesign of the software, known as MCAS, that was mistakenly triggered by the faulty sensor readings. The last major milestone is an FAA certification flight that the company expects to conduct shortly.

[737 Driver]

Reference deactivated "AOA Disagree" alert.

Sloppy, sloppy, sloppy.

That being said, I think it is fair to say that prior to the MAX accidents, most of the pilots at my airline had no clue that there was such a thing as an "AOA Disagree" alert. I'm not sure it would have made any difference.

[Australopithecus]

As an experienced 737 pilot I am little bemused at the suggestion that an AoA disagree message would decisively help things one way or the other. Faced with a stick shaker on take-off you are either stalled or you are not. It takes about three seconds to assure yourself that you are not, thus the sensed AoA is in disagreement with reality. AoA disagree? Check!

While I agree with the thrust of 737 Driver's argument, I am also aware that human perceptions and reactions are a lot more complex than we wish them to be. Crew performance can vary across a broader spectrum than we assure ourselves is the case.

I have watched pilot experience levels and basic skill sets decline over the years. The industry would be in crisis if demonstration of old fashioned handling skill sets were suddenly required to be paid more than lip service.

With regard to Boeing: I wonder how they will keep their ODE status, and I wonder if the FAA will be required, under this administration, to return to a more hands-on oversight role.

I would expect other regulators, if not the FAA, to require Boeing to address those other system concerns flagged by the whistleblowers prior to the Max flying again.

[fdr]

737D;

your posts indicate that the crew of the flights were less than competent in essence, however, you also suggest that the training standards are deficient. One specific on competency is your statement that you would respond in the event that these crews encountered by recognising the problem, identifying the cause and completing the action within "5 seconds".

Okay.

You are currently a participant in an internet multi player demonstration of Schrödinger's cat gedankenexperiment, WRT observer impact on outcomes. You have knowledge that did not exist at the time of the events, and you have time to contemplate navels and determine a course of action, and by those factors alone, you are not able to replicate the conditions existant for the crews concerned. To judge the crews timeliness or lack of understanding is fundamentally flawed scientifically if you have any intent to understand what happened in these cases. Today, possibly the crews will respond effectively to this particular problem, but given the application of sods' law, someone on some dark night is going to brilliantly apply all the prompt response that will be gained from the establishment of the corporate knowledge of MCAS, and they are going to misapply it as a slip in SA will have occurred. That is the insidious nature of the world we live in, where unintended consequences are a real outcome.

On "5 seconds", that is of course 60% longer than the out of trim case that the aircraft is certified for, so presumably your "5 Seconds" is also potentially inadequate, however I assume that you would not consider your "5 Second" response time to be incompetent?

The Boeing OEB raised after the first accident is pretty darn silent on the fact that the aircraft can enter a condition where the airloads on the stab can exceed the crews ability to effect a recovery. For that gem, you have to read the FCTM and comprehend what the weasel words there mean in the real world, that in order to recover in the severe out of trim case, you may have to let the aircraft recover towards it's trim state sufficiently to unload the stab so that the trim can be actuated. That sounds all well and good if you are not confronted with planet earth in the upper windscreen at close proximity to achieve that condition. That is pretty much an existential threat to the crew, and I would hazard that they were indeed under some stress, that you as an observer from the sideline have not had to experience when making your "5 Second" judgement on competency.

I agree that training needs to be lifted around the industry, we dont necessarily need more training, we need training that is not wasteful fo the resources that exist, as they are to day. We are currently governed by the aviation industries own version of political correctness, A.K.A. as SMS, and QA. In order to give a simplified box ticking exercise to regulators and managers, we come up with matrices and checklists that are fantastic for showing compliance, but, that is all. There is no closure of the loop on the fact that the crew may comply with a procedure or policy that in itself increases operational risk, or is impossible to do as it conflicts with the real world. The other sort of failure (think false negatives, false positives) arise when the boxes get ticked, but the impact of implementation is not observed. Our roles, policies and procedures are developed usually as bandaids on top of bandaids to reduce the risks of something, either real risk, or showing compliance (another form of risk - commercial). In all cases, however it is unlikely that the 200 hr pilot sitting in the RHS seat of the plane was the cause of the competency issues, he/she cannot be other than the logical outcome of what the industry has accepted as a good solution to unfettered growth (a cancer in effect, sounds good until the consequences start being felt).

Sully gets mentions in the conversations. The NTSB acknowledged the human in the loop issues in the response time during the public hearings and that was factored into the analysis. I would suggest that the recognition aspects of a loss of all engines event while unpleasant, is simpler than the multiple failure cues that existed on the Lion Air and Ethiopian aircraft. Rather than acknowledge the human in the loop, you have indicated that "5 Seconds" is a competent response time. I would counter that the time you suggest is arbitrary and unreasonable, and does not reflect competency, it merely reflects the opportunity you have had to consider your hypothetical response to the scenario post hoc.

As an aside, long long ago etc... I was evaluating a checker and a trainer in a sim, while they collectively beat up on a student (a B7xx line captain). They were remarkably derisive of the pilots competency. At the end of the session, I asked these aces to hop in the seats and I was going to give them a single failure well within the realms of likelihood. With a modest cross wind, as the wheels left the ground, I failed the worst case engine, from the standpoint of applied rudder at that time, I declined to use crash override to make the point. On leaving the sim session, both checker and trainer apologised to the student for their lack of respect in their comments. Point is this, humans in the loop are a fact, and it is important to recognise and respect that. Sully made a difference to the outcome, as more often than not occurs every single day in countless anomalies that the industry encounters. Humans are the strength of the system while being a point of failure, and that needs to be accepted.

Over the years, I have listened to too many CVR's and looked at too many FDR/QAR outputs to expect that any crew will achieve much in 5 seconds on a normal flight, other than pavlovian responses for failures on a TO. The highly trained response on an RTO etc is however as often as not carried out incorrectly, so I wonder if the 5 Seconds is not just a bit harsh as a standard.

A final thought: The crews encountered an unusual trim case, the checklist is for a runaway trim, yet the problem did not actually present as such, there was a trim error that occurred, but the trim responded normally to the crews trim inputs, and then after a period of time was anomalous again. That is not a simple set of facts to decipher in short order. Given their time over, I expect that the crew would follow your advice and act within 5 seconds and cure the ills of the world.

kind regards,

FDR

[formulaben]

Turning off the magic is what activates MCAS when the AoA is faulty.

Do you make a habit of flying of turning on the autopilot when the stick shaker activates after takeoff?

[Dave Therhino]

From the Seattle Times Article:

"Four additional concerns specific to the 737 MAX were listed in the 2017 report. All were related to certification of legacy systems inherited from the earliest 737 models that were found by FAA technical staff to be noncompliant with the latest safety regulations.

These involved a lack of redundancy in the rudder cables; a too-high surface temperature allowed in the fuel tank; insufficient fireproofing around the plane’s auxiliary power unit in the tail; and using high-power wiring to connect to a switch inside the fuel tank.

All these issues were flagged by safety engineers working at the FAA as requiring fixes before the MAX could be certified.

The MAX won certification anyway after managers on the Boeing side of certification insisted that these were non-issues and managers on the FAA side agreed to let it move ahead with these shortcomings unaddressed."

I'm sorry, I'm trying to pick my jaw up off the floor. The 737 has no redundancy in it's rudder control system?? I've had a rudder cable failure- trust me when I say it can end very badly!! Can any (ahem) 737 Driver confirm that this is in fact accurate, that there is either no or a lack of redundancy in the 737's rudder??

If that is true that is the most shocking thing I have read about aviation in a very long time- and that the airplane was granted its STC just three years ago makes this even more shocking.

If it is true.

Cheers-
dce

The 737NG and Max have a single set of rudder cables running from the forward quadrants to the aft quadrant.

[568]

It just keeps getting worse. The NYT story cited above buried the lede. Even those who paid for and had an AoA disagree that worked had one that didn’t work during takeoff.

As an engineer SLF I feel this is becoming almost unbelievable. I predict Boeing will be making VERY LARGE political campaign contributions over the next few years.

Edmund



Regarding the "political contributions",depends how much money is left in the pot after litigation.

[wonkazoo]

The 737NG and Max have a single set of rudder cables running from the forward quadrants to the aft quadrant.

You must be $hiting me...

Single set meaning one set for left seat and one set for right?? (Which is still a bit shaky if you think about it) If there are two sets are they in close proximity at any point??

Any drawings, diagrams or photos??

Thx-
dce

[Rx7man]

On the subject of training, what I find quite unbelievable is that every airline seems to have their own training procedures for a specific aircraft... Shouldn't there be just standard training dictated by the manufacturer of the aircraft and that should cover everything required.. there should be no need for carrier specific training other than perhaps some company policies, but nothing related to operating the equipment.

[GordonR_Cape]

From today's NYT:
Boeing Believed a 737 Max Warning Light Was Standard. It Wasn’t (https://www.nytimes.com/2019/05/05/business/boeing-737-max-warning-light.html).

AOA disagree, of course. Sheesh.

Thanks for the link. It gets worse:
When Boeing explained to pilots in one meeting how systems on the Max worked, the company said that the disagree alert would function on the ground. In the late November meeting, Boeing told pilots for American Airlines (which had bought the add-on) that their disagree alert would have notified them of problems before takeoff.

“We were told that if the A.O.A. vane, like on Lion Air, was in a massive difference, we would receive an alert on the ground and therefore not even take off,” said Dennis Tajer, a spokesman for the union representing American Airlines pilots. “That gave us additional confidence in continuing to fly that aircraft.”

But in the last several weeks, Boeing has been saying something different. Mr. Tajer said the company recently told American pilots that the system would not alert pilots about any sensor disagreement until the aircraft is 400 feet above the ground.

My emphasis added. This is a critical point that was touched on previously. It is impossible to get a reliable AOA value until there is significant forward airspeed. Plus it takes time to compare the two values, and trigger the AOA disagree warning. By then the aircraft is airborne. Its a bit too late. If it was fitted and worked, which it didn't.

[Smythe]

Boeing just issued a statement on their website:

Boeing Statement on AOA Disagree Alert (https://boeing.mediaroom.com/news-releases-statements?item=130431)

Plus it takes time to compare the two values, and trigger the AOA disagree warning.

Getting confused here. Isnt it reported that MCAS only uses one AoA vane? If there is a disagreement, what does it matter if it relied on one? Add-on alert or not, didnt MCAS only use one?

[wonkazoo]

Boeing just issued a statement on their website:

Boeing Statement on AOA Disagree Alert (https://boeing.mediaroom.com/news-releases-statements?item=130431)

What a house of cards.

If you read the statement it goes to great lengths to show how they determined over and over again that the AOA disagree alert does not impact flight safety. Which, if there wasn't an autonomous flight control system that has full authority over the horizontal stabilizer based solely on the output of a single AOA vane, might actually be true.

Left unaddressed by the Boeing statement is that their determination is only operative until you have a previously unknown system that utilizes a single AOA input and can trim the horizontal stab down at 2.5 degree intervals all the way to the stops. Until the airplane is in an unrecoverable state should the crew not react quickly and accurately enough.

Oops!! We forgot about that one!!

I've got ten bucks that says Boeing ends up in bankruptcy to protect them from the various and numerous liabilities they are now facing. (Orders that won't be filled, dead people, lost revenues by airlines already in possession of the airframes, future liabilities, etc...)

I've got another tenner to donate if the MAX is flying again before the end of the year, and one more for it never flying again in passenger service.

That's my gambling quotient for this year- I hope it pays well!!

Regards,
dce

[Bend alot]

Boeing just issued a statement on their website:

Boeing Statement on AOA Disagree Alert (https://boeing.mediaroom.com/news-releases-statements?item=130431)



Getting confused here. Isnt it reported that MCAS only uses one AoA vane? If there is a disagreement, what does it matter if it relied on one? Add-on alert or not, didnt MCAS only use one?

Lion air flight had an AOA disagree of from memory of 40 degrees on the ground and in flight. So with this disagree warning the flight would not have happened - the fact the LH AoA was in error that would have activated MCAS then becomes irrelevant - the flight would not have happened.

NOTE - my understanding is that the LH aoa on Lion Air read 40 degrees different to the RH AoA in every position stationary or moving.

[fdr]

Regarding the "political contributions",depends how much money is left in the pot after litigation.

Boeing's current market capitalisation is 151B... with hard assets of 89.9B. I doubt that any litigation is going to meaningfully alter TBC's viability or future. Arguably, while there is an argument that they have liability for the accidents, in practical terms the world and the USA need Boeing to be active and successful, lest we have a global monopoly result which has never been desirable.

The FAA-OEM discussions on rules application is not nefarious, it arises as the aircraft has a right to legacy status, while experience has resulted in changes to the rules that would otherwise apply. The FAA may push and cajole, but the law is pretty straightforward as to the requirements and that is what TBC has likely complied with. That the rules that don't apply are more stringent is the way the world works. Legacy status is not unreasonable, it recognises that there is a long lead time in developing an aircraft, and there is a need to freeze the regulatory standard or no new product would ever be completed. On submission of a PSCP, a substantial amount of the process involves determining the rules revision status that applies to the design.

The FAA TAD and Boeing have good people within their programs, mistakes may occur, but so far, there has not been evidence of corporate irresponsibility, just lousy choices.
Rant follows:
[This is in contrast to the fiasco over the late 90's early 2000's supplier producing parts that were supposed to be CNC per the TC, but which were made literally by hand using templates and hand shears. That TBC sacked the whistleblowing QA engineers was unconscionable, just as the disgraceful behaviour to the whistleblower mechanic on the AS261 maintenance procedures, where many involved failed to act ethically. Trite words on ethics and morality are plentiful, from scripture, Sunday school, but the dirty little fact is that ethical stands usually end up with the whistleblower being punished. The most glaring example of that is still playing out today; Assange facilitates the disclosure of the simple fact that the US public were being fed false information on various subjects, in their name, specifically the video of the AH64 attack in Baghdad that killed a reporter and a number of other people through erroneous assessment of their combat status.This was the tape recording hi 5's on planting 30mike mike M789 rounds through the front windscreen of a van which was filled with civilians trying to provide aid to the dying, including in their midst a 2 Y/O child (deceased). The public get told post fact that the reporter was a terrorist. Assange is described as an enemy of the state, pilloried, and the VP, Biden suggests extrajudicial response (assassination of Assange). Years later, Snowden discloses illegal breaches of the US publics rights by No Such, breaching constitutional rights of Joe Citizen, and is branded a "traitor". The world ain't what it used to be, probably never was except in fairy tales. 200 years ago, people showing indignation would have ended up with schools, parks and roads named in their memory, today, they are the butt of derisive jokes.

Edmund Burke was right when he lamented in 1770 on what was necessary for evil to triumph in "Thoughts on the Cause of the Present Discontents" (https://books.google.com.my/books?id=kbouAAAAMAAJ&pg=PA106&redir_esc=y#v=onepage&q&f=false), but today it may be that Burke would be considered to be an optimist]

[FrequentSLF]

What a house of cards.

If you read the statement it goes to great lengths to show how they determined over and over again that the AOA disagree alert does not impact flight safety. Which, if there wasn't an autonomous flight control system that has full authority over the horizontal stabilizer based solely on the output of a single AOA vane, might actually be true.

Left unaddressed by the Boeing statement is that their determination is only operative until you have a previously unknown system that utilizes a single AOA input and can trim the horizontal stab down at 2.5 degree intervals all the way to the stops. Until the airplane is in an unrecoverable state should the crew not react quickly and accurately enough.

Oops!! We forgot about that one!!

I've got ten bucks that says Boeing ends up in bankruptcy to protect them from the various and numerous liabilities they are now facing. (Orders that won't be filled, dead people, lost revenues by airlines already in possession of the airframes, future liabilities, etc...)

I've got another tenner to donate if the MAX is flying again before the end of the year, and one more for it never flying again in passenger service.

That's my gambling quotient for this year- I hope it pays well!!

Regards,
dce
bring the matra... 737driver will fix it with it

[Mach2point7]

The "Boeing Statement on AOA Disagree Alert" tells us that the MAX has had an AoA disagree alert function from the outset, but in error, it was not displaying to the aircrew. There is a long and convoluted explanation/justification of why that deficiency may not have been critical.

Lets not be distracted by that argument. The real issue is that if the AoA disagree signal system was available " in keeping with Boeing’s fundamental design philosophy of retaining commonality with the 737NG" why on earth was it not used as a critical input to the MCAS activation logic ??

[GordonR_Cape]

@Mach2point7

Lets not be distracted by that argument. The real issue is that if the AoA disagree signal system was available " in keeping with Boeing’s fundamental design philosophy of retaining commonality with the 737NG" why on earth was it not used as a critical input to the MCAS activation logic ??

Valid point! This will be critical in lawsuits.

The "excuse" is a technical one IMO (not that Boeing has admitted anything). It is complicated to design a system such as MCAS that is both reliable and safe. The more inputs there are into a system, the more chance there is it will fail to carry out its intended purpose. In the case of MCAS, this would have severely delayed certification. Somewhere along the process, the urgency of reliable activation of MCAS became more important than the safety aspects, which were pushed onto the pilots, in the "unlikely" event of AOA failure.

[fdr]

@Mach2point7

in the "unlikely" event of AOA failure.

AOA probes have a statistical certainty of failure within the global fleet. There is a near statistical certainty as well that somewhere, a crew will stall the aircraft, that happens on occasions.

[HarryMann]

AOA probes have a statistical certainty of failure within the global fleet. There is a near statistical certainty as well that somewhere, a crew will stall the aircraft, that happens on occasions.

Maybe but less likely than an AoA disagree ?

[fdr]

Maybe but less likely than an AoA disagree ?
Not really, the highest likelihood would be of a disagree. To have failures and not have a disagree would come from multiple failures of identical types and outcomes. Now that more or less happened at perpignan IIRC but it may have still just been a single sensor failure, where 2 out of 3 vanes froze position literally due to servicing which didn't protect the vanes from water ingress. At altitude the vanes froze, and presumably the correct vane was voted out by the two stuck vanes. The vane is pretty reliable, but I replaced a couple on one B737 in fairly short order.
​​​​The conic-static pressure type on the westwind is reliable...

[Lord Farringdon]

Someone else has properly offered here that the ET incident may well be traced at it's most basic human factors core to the impairment the pilots experienced due to the previous Lion Air crash. In other words: Their consciousness knew how the last one went down, so their bodies responded accordingly, which left them poorly equipped to actually perform the steps you have been seemingly demanding that they do since shortly after they in fact died.

Regards-
dce




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.

[PaxBritannica]

There's no date on that Boeing statement. Was it issued before or after the Ethiopian crash?

In 2017, within several months after beginning 737 MAX deliveries, engineers at Boeing identified that the 737 MAX display system software did not correctly meet the AOA Disagree alert requirements.

I believe they started delivering the MAX in May 2017?

Accordingly, the review concluded, the existing functionality was acceptable until the alert and the indicator could be delinked in the next planned display system software update.

How long does that process take? By October 2018, nothing had happened. Boeing have been vague about exactly when the discrepancy was noticed, so let's say they had seventeen months to get the software fix designed and installed. Is seventeen months the standard kind of time it takes for aviation software fixes to get implemented? (And there's not much evidence the fix was even under design, prior to Lion Air.)

Everything I've read suggests a major schism between the engineering layers at Boeing and the commercial execs, with all the power in the hands of the execs. So I'm not surprised to read:

Senior company leadership was not involved in the review and first became aware of this issue in the aftermath of the Lion Air accident.

[ATC Watcher]

Lord Farringdon thank you for posting that video. very enlightening , and conform to what I personally witnessed and experienced during an aviation accident a few yeas ago. Like you I do not consider Wonkazoo and 737 Drivers' positions to be opposite, but rather complementary to one another. Very good to have both of them here .

Pax Britanica :
Senior company leadership was not involved in the review and first became aware of this issue in the aftermath of the Lion Air accident.
This looks to me as been a sentence dictated by lawyers rather than a fact, but I am sure that if it is not true we will see copies of emails surfacing in the Seattle Times or Wall Street Journal pretty soon ...:hmm:

[PaxBritannica]

.

Pax Britanica :

This looks to me as been a sentence dictated by lawyers rather than a fact, but I am sure that if it is not true we will see copies of emails surfacing in the Seattle Times or Wall Street Journal pretty soon ...:hmm:

Note the other distancing strategy:

The software delivered to Boeing linked the AOA Disagree alert to the AOA indicator, which is an optional feature on the MAX and the NG. Accordingly, the software activated the AOA Disagree alert only if an airline opted for the AOA indicator.

This suggests some contractor somewhere is being lined up to shoulder the blame, or at least allow Boeing to reduce their exposure.

We're expected to believe that Boeing specified the feature correctly, but did not assess the software that got returned, or test it exhaustively? Did the contractor also get to self-certify?

[groundbum]

Senior company leadership was not involved in the review and first became aware of this issue in the aftermath of the Lion Air accident.

This is the sound of low level engineers being thrown under the wheels of the bus.

The question should be asked; in a safety first company how come the leadership didn't hear? There should have been a well established high priority channel within the company where safety issues could not be ignored or neglected or hushed up. If they want the flying public's confidence, and even more important the pilots confidence in their products, they need to rectify this see no evil hear no evil culture they've created.

G

[737 Driver]

737D;

your posts indicate that the crew of the flights were less than competent in essence, however, you also suggest that the training standards are deficient. One specific on competency is your statement that you would respond in the event that these crews encountered by recognising the problem, identifying the cause and completing the action within "5 seconds".



If I recall correctly, the "5 second" remark was specifically in reference to a certain set of steps on the runaway stab trim checklist. Apparently there is a "demo" video on YouTube that gives the impression that it takes longer, and someone was under the impression that this length of time was one of the things working against the crew. I was simply pointing out that it could have been done quicker. In another post, however, I also pointed out that the crew could take all the time they needed to get the aircraft back to neutral trim as long as one of the pilots was, yes, FLYING THE AIRCRAFT and managing the trim using the yoke switch.

I agree that training needs to be lifted around the industry, we don't necessarily need more training, we need training that is not wasteful fo the resources that exist, as they are to day. We are currently governed by the aviation industries own version of political correctness, A.K.A. as SMS, and QA. In order to give a simplified box ticking exercise to regulators and managers, we come up with matrices and checklists that are fantastic for showing compliance, but, that is all. There is no closure of the loop on the fact that the crew may comply with a procedure or policy that in itself increases operational risk, or is impossible to do as it conflicts with the real world. The other sort of failure (think false negatives, false positives) arise when the boxes get ticked, but the impact of implementation is not observed. Our roles, policies and procedures are developed usually as bandaids on top of bandaids to reduce the risks of something, either real risk, or showing compliance (another form of risk - commercial). In all cases, however it is unlikely that the 200 hr pilot sitting in the RHS seat of the plane was the cause of the competency issues, he/she cannot be other than the logical outcome of what the industry has accepted as a good solution to unfettered growth (a cancer in effect, sounds good until the consequences start being felt).

I fully agree with this.

​​​​​​A final thought: The crews encountered an unusual trim case, the checklist is for a runaway trim, yet the problem did not actually present as such, there was a trim error that occurred, but the trim responded normally to the crews trim inputs, and then after a period of time was anomalous again. That is not a simple set of facts to decipher in short order. Given their time over, I expect that the crew would follow your advice and act within 5 seconds and cure the ills of the world.

Again, I think you are reading to much into that "5 second" comment. I agree that, at least to the Lion Air crew, this presented itself as a novel malfunction. There has been some questions raised about how clearly the post-Lion Air AD and related information was transmitted to the Ethiopian flight crews. However, I will also point out that in the history of aviation, there will always be someone who gets to experience a malfunction for the first time. That is why I keep harping on the mantra (I think you know it by now ;))

The mantra assumes that a flight crew may be presented with a novel situation that will require time to sort out. And I will say again, if either of the accident crews had done nothing but apply the mantra, particularly the "Trim the Aircraft" part, they would have bought themselves sufficient time - basically until fuel exhaustion - to figure out what was going on. That is way more than 5 seconds.

[NutLoose]

Sadly it seems to follow this example as to why

https://news.ycombinator.com/item?id=19389983

[737 Driver]

The "Boeing Statement on AOA Disagree Alert" tells us that the MAX has had an AoA disagree alert function from the outset, but in error, it was not displaying to the aircrew. There is a long and convoluted explanation/justification of why that deficiency may not have been critical.

The Boeing spokesperson is essentially correct. Again, I am not defending the overall sloppiness that this particular piece displays, and it is just another example in a growing list of how the MAX development program wasn't managed within the high standards that are normally expected of an aircraft manufacturer.

Strictly from a technical perspective, however, it needs to be pointed out that if a 737 crew were to receive an "AOA Disagree" message and go to the appropriate NNC, that checklist would simply direct them to the "IAS Disagree" checklist and/or the "ALT Disagree" checklist as appropriate. The "IAS Disagree" checklist would then direct the crew to the "Airspeed Unreliable" checklist, which has already been discussed extensively. In short, if the AOA disagreement becomes significant enough to impact the flight instruments or other systems, there will be plenty of other indicators for that problem (stick shaker, "IAS Disagree" alert) and so the "AOA Disagree" message is somewhat redundant in terms of directing the crew to the proper procedure.

The real issue is that if the AoA disagree signal system was available " in keeping with Boeing’s fundamental design philosophy of retaining commonality with the 737NG" why on earth was it not used as a critical input to the MCAS activation logic ??

Very good point, and I believe the MCAS update will do exactly this. I suppose the answer to why this wasn't done in the first place resides in the thinking that led to the MCAS design team using only one AOA input. This probably arose from the fact that the MCAS is considered to be an ancillary function of the Speed Trim System (STS). The STS has been around since the 737NG was launched and it has always relied on just one AOA input. The difference is that the STS respects the control column trim cutout switches (this is different than the pedestal cutout switches) and MCAS does not. The control column cutout switches prevent the STS from trimming nose down when the control column is moved aft. Apparently no one connected the dots that by removing the control column cutout switches from the circuit, MCAS was now set up to malfunction in a novel and hazardous manner.

[MurphyWasRight]

On UAS:
Unfortunately, our company manuals don't go into that level of detail. It does have this little gem, though: "If the flight crew is aware of the problem, flight without the benefit of valid airspeed information can be safely conducted and should present little difficulty." Just a walk through the park.
.
Does it include "land at nearest suitable airport".?
The Lion Air prelim report on the penultimate flight crew:
The pilot performed three Non-Normal Checklists (NNCs) consisting of Airspeed Unreliable, ALT DISAGREE, and Runaway Stabilizer. None of the NNCs performed contained the instruction “Plan to land at the nearest suitable airport”.
Seems to me with that much 'stuff hitting the fan' (polite form of a well known technical term) I think that pressing on was a bit of a gamble, that they did probably may relate to commercial pressure.
Interest to know what % of commercial pilots reading this would have pressed on.

737 driver
Reference deactivated "AOA Disagree" alert.
Sloppy, sloppy, sloppy.
That being said, I think it is fair to say that prior to the MAX accidents, most of the pilots at my airline had no clue that there was such a thing as an "AOA Disagree" alert. I'm not sure it would have made any difference.

Could have made a big difference in Lion Air if the penultimate crew had included it in the tech log. I say if because they seem to have left out using trim cutout.
ET might have been the first one in that case,

[cavuman1]

Here is a link to a Wall Street Journal article which claims that Boeing had withheld information about MCAS for more than a year before the Ethiopian accident: BOEING WITHHELD MCAS SAFETY INFORMATION (https://www.wsj.com/articles/boeing-knew-about-safety-alert-problem-for-a-year-before-telling-faa-airlines-11557087129)

- Ed

[737 Driver]

On the subject of training, what I find quite unbelievable is that every airline seems to have their own training procedures for a specific aircraft... Shouldn't there be just standard training dictated by the manufacturer of the aircraft and that should cover everything required.. there should be no need for carrier specific training other than perhaps some company policies, but nothing related to operating the equipment.

I do not disagree in theory, but IMHO, the reality is that the training standards dictated by Boeing have been catering to the lowest common denominator for years. They have a strong incentive to sell aircraft across the entire spectrum of airlines and countries regardless of the depth and quality of their aviation heritage. Requiring a higher level of demonstrated skills for the operator potentially translates into higher costs and lost sales.

Sadly, this thought process does not stop at Boeing. I recently had an opportunity to fly with FO who was relatively new to the 737. During our trip, we discussed a number of issues that had come out of the recent MAX crashes. During this conversation, he confessed that before these accidents, he did not even know the stab trim wheel had a stowable handle and had never been trained in its use. Think about that for a moment. Also consider that a freshly-minted 737 Captain would have received the exact same training.

After I picked my jaw up off the floor, I proceeded to personally give the FO the training he had missed. Afterwords, I shared my concerns with my Fleet Manager and told him in no uncertain terms that our training programs needed a thorough review. The Fleet Manager replied that this was already in progress, and stated that our training programs were constantly being reviewed for improvement. He added a telling remark, however, that stab trim malfunctions had never been a statistically significant problem at our airline, implying of course that the training events our pilots are exposed to constantly needed to be justified by historical data. I told him that if the MAX accident had occurred at our airline, the family of those who perished would have been rightfully angered if it had come to be known that the crew had not been properly trained in a runaway stab procedure because the airline considered it to be a statistically insignificant event.

The degradation of pilot training and standards is a worldwide problem. It is being driven in large part by the beancounter mentality that attempts to justify every cost. Unfortunately this approach forgets that there are some costs that cannot be easily quantified, and eventually a price will be paid in bent metal and broken bodies. Sadly, even if the industry will not openly admit it, there seems to be an underlying assumption that there is an acceptable hull loss rate and that little will change until the body count goes up.

[737 Driver]

.
On UAS:

Does it include "land at nearest suitable airport".?



No, it does not, a glaring omission in this operator's opinion. I am being told that our UAS procedures are going to be updated. I suspect this will take longer than necessary because of the liability issues (i.e. any change may be interpreted as an admission of fault). Personally, I don't think any of the crews at my airline would continue blissfully on with even one good airspeed indicator, much less none.

[rog747]

I do not disagree in theory, but IMHO, the reality is that the training standards dictated by Boeing have been catering to the lowest common denominator for years. They have a strong incentive to sell aircraft across the entire spectrum of airlines and countries regardless of the depth and quality of their aviation heritage. Requiring a higher level of demonstrated skills for the operator potentially translates into higher costs and lost sales.

Sadly, this thought process does not stop at Boeing. I recently had an opportunity to fly with FO who was relatively new to the 737. During our trip, we discussed a number of issues that had come out of the recent MAX crashes. During this conversation, he confessed that before these accidents, he did not even know the stab trim wheel had a stowable handle and had never been trained in its use. Think about that for a moment. Also consider that a freshly-minted 737 Captain would have received the exact same training.

After I picked my jaw up off the floor, I proceeded to personally give the FO the training he had missed. Afterwords, I shared my concerns with my Fleet Manager and told him in no uncertain terms that our training programs needed a thorough review. The Fleet Manager replied that this was already in progress, and stated that our training programs were constantly being reviewed for improvement. He added a telling remark, however, that stab trim malfunctions had never been a statistically significant problem at our airline, implying of course that the training events our pilots are exposed to constantly needed to be justified by historical data. I told him that if the MAX accident had occurred at our airline, the family of those who perished would have been rightfully angered if it had come to be known that the crew had not been properly trained in a runaway stab procedure because the airline considered it to be a statistically insignificant event.

The degradation of pilot training and standards is a worldwide problem. It is being driven in large part by the beancounter mentality that attempts to justify every cost. Unfortunately this approach forgets that there are some costs that cannot be easily quantified, and eventually a price will be paid in bent metal and broken bodies. Sadly, even if the industry will not openly admit it, there seems to be an underlying assumption that there is an acceptable hull loss rate and that little will change until the body count goes up.


737driver one of the most enlightening and concise posts in this thread recently

[Smythe]

There's no date on that Boeing statement. Was it issued before or after the Ethiopian crash?

It showed up on the website on May 05, 2019. at around noon.

Strictly from a technical perspective, however, it needs to be pointed out that if a 737 crew were to receive an "AOA Disagree" message and go to the appropriate NNC, that checklist would simply direct them to the "IAS Disagree" checklist and/or the "ALT Disagree" checklist as appropriate

Well, that was my question, if you did get the alert, what would you do? With MCAS, it appears that it uses one specific AoA vane? (or just one vane) I am unclear on this.
Cutting off MCAS does not solve the issue of the reason it was created in the first place, lift from the nacelles.

[Alchad]

Thanks for the link. It gets worse:

Quote extract...

But in the last several weeks, Boeing has been saying something different. Mr. Tajer said the company recently told American pilots that the system would not alert pilots about any sensor disagreement until the aircraft is 400 feet above the ground.

Unquote

My emphasis added. This is a critical point that was touched on previously. It is impossible to get a reliable AOA value until there is significant forward airspeed. Plus it takes time to compare the two values, and trigger the AOA disagree warning. By then the aircraft is airborne. Its a bit too late. If it was fitted and worked, which it didn't.

Im surprised this didn't attract more comments, perhaps it got missed in the flurry of recent posts? Just wondered how much of a "wow" comment it is, and also whether the 400 feet limit would presumably also apply to MCAS as it would suggest that an input check is performed before the AOA signal is allowed to be used? There was talk way way back about a height limit on MCAS intervention but don't think it ever got resolved.

Alchad

[MurphyWasRight]

During our trip, we discussed a number of issues that had come out of the recent MAX crashes. During this conversation, he confessed that before these accidents, he did not even know the stab trim wheel had a stowable handle and had never been trained in its use. Think about that for a moment. Also consider that a freshly-minted 737 Captain would have received the exact same training.
..
He (fleet manager) added a telling remark, however, that stab trim malfunctions had never been a statistically significant problem at our airline, implying of course that the training events our pilots are exposed to constantly needed to be justified by historical data.
...

This supports my impression that the manual trim system as originally designed has been continually degraded both by training and physical changes such as smaller wheel and removal of separate auto only cutout option.
At the same time the sources of runaway trim have increased as more automatic systems use the trim, NG sts and other? , MAX + mcas and other?.

Can not help but think that the safety analysis used a faulty evaluation of manual trim system, mechanical and pilot training, when assessing MCAS impact, falling back on grandfathered original analysis of effectiveness/useability.

[ws737]

@737 Diver:
The issue here, having just gone through the last 7 pages of this thread, remains a multi party setting up of this crew (as I see it).
1. Boeing and various companies were chasing a dollar/profit objective, and the AoA miscompare "alert" was apparently optional equipment.

2. A primary flight control is moved by an aircraft sub system with no pilot in put, but (as has been discussed at length) a number of ways of disabling it.

3. Training on this subsystem: of questionable quality. Doubly so due to wide variation between air line companies in how much (in terms of time and money) they invest in their crews, not just for the upgrade to Max but in general.

4. Crew training(??) / inexperience becoming an international norm.

5. Over-reliance on automation becoming an international norm.

6. Arriving at your points in your latest post (https://www.pprune.org/rumours-news/619272-ethiopian-airliner-down-africa-248.html#post10463632), (none of which seem unreasonable to me, but I don't fly 737) the above mentioned factors suggest that unless you are in a company who values crew competence, and puts money / time / resources toward that core value, your crews are open to being set up - not only for the startle factor increasing a challenge, but incomplete systems knowledge (and practice with it) getting in the way of timely and correct decision making when dealing with a systems malfunction. Years ago when I was running sim training the ability to do some "free play" at the end of a session to test where a crew got oversaturated with systems malfunctions/emergencies was good training, and a lot of crews really appreciated them.Meme/clue for the non pilots in the audience here: when a malfunction turns into an emergency (or a fatal crash) to simply blame the pilots is to overlook that layers of human endeavor and responsibility that got them to that point.

7. (Pax Britannica made some interesting points previous but I lost my train of thought). The cockpit gradient in a given cockpit does not develop in isolation from cockpit / corporate culture, which is also informed by larger cultural issues regarding authority. It is unclear how that played out for ET to me, and is one of those hard to quantify factors.

8. A company (be it ET, Lion, or perhaps if things had played out differently, United or American?) has a powerful financial motive to move the blame indicator arrow to point ONLY at the manufacturer. (And the single point of failure issue that looks to be a root causal factor gives them fair grist for that mill). Some of this is cultural, some of this is purely financial due to how litigation works.

9. In the time between Lion Air and ET: what training, what systems training, and what crew training with related malfunctions did this crew have? What are the effects of negative training, and how do those play out in a cockpit?

10. Recency and upset training was mentioned above. I'll offer an idea here: any malfunction that is related to the movement of primary flight controls is subject to a recency factor (as seen in the AF 447 accident).

Were they, the crew in ET, set up?
At least in part, I offer that the answer is yes. The system that set them up all of the world's airline companies are a part of, and are core players in. So too are regulators, and nations.

I can't disagree with the general point that the pitch and power chorus are making (this singing group is once again on stage was they were for most of the AF 447 discussion on PPRuNe) . Power plus attitude equals performance.
But are people really being trained that way anymore?
Are their behaviors being incentivized to ground their operation of aircraft with that fundamental principle foremost?
If not, why not?
The corporations who make their money in this business (be it manufacturing, operating, or training people to operate the equipment) need to answer that question. So who is holding them all to account?

Aside: I do not believe that there is now an international standard of what a professional pilot is - I have seen some appeal to that thought - no matter how badly I wish that were true.
There may once have been such a standard. (But hey, all that is now needed is a concierge, eh? Tech is magic! (/sarcasm off))
There's a lot of lip service paid to it, though, and professional pilots (those who are the real deal) are rightly dismayed to see the profession that learned hard lessons over the course of a century, under attack. The two dead men (and their passengers) from ET are casualties in a war that seems to be going on between price and professionalism, and the use of automation to replace human function.


I agree 100%...+1

[safetypee]

Alchad, https://www.pprune.org/10464568-post5008.html

No ‘wow’ response because an AOA Disagree alert has little value for pilots. There is no third system to resolve the ambiguity - which AoA is correct - not known; what can I do about it - nothing, info only (or distraction). Furthermore an alert could contribute to misdiagnosis in the UAS drill; stick shake + EFIS low speed awareness on the ‘left side’, this might incorrectly bias thoughts to the left, - speed correct - aircraft is slow.
Whereas the Air Data Disagree alerts for Speed / ALT each have a third, standby instrument which the crew can use to arbitrate and choose the most valid pairing; standby + right side = right Speed is best.
So without means of arbitration the AoA alert has little value.

From an engineering view, particularly with hindsight, AoA Disagree could have been used in the original MCAS design. It wasn’t because that design assumed that the effects in the accident would not occur - all of which were incorrect.
Limiting these problems using AoA Disagree provides an engineering solution. However for the crew, retaining the AoA alert would not clarify the accuracy of AoA - so don’t display the alert nor the optional gauge when there is disagreement.
The most important absence is the annunciation that MCAS is inoperative, which with a caution that flight in some (few) areas of the fight envelope requiring careful handing.

[wheelsright]

Among others, 737 Driver is getting a lot of flack in this thread because some people see his contributions as trying to deflect blame away from Boeing and on to the pilots. I would not be so harsh, but suggest that pilots tend to look at issues from a pilots perspective. There is little doubt that disabling electric trim at an early stage would have prevented these accidents. However, one could also suggest that disabling electric trim before all flights would have prevented these accidents or simply grounding the MAX series would have prevented the accidents.

A little flippant yes, but it is the reason for some emotional statements. None of the pilots could reasonably be accused of anything other than an innocent mistake. Boeing on the other hand did not make an innocent mistake they took a calculated risk... a risk that did not pay off. It was not an innocent mistake at all. It is the difference between doing something wrong and making a mistake. 737 Driver accepts that MCAS should not be enabled when AoA disagree (or so I understand). Boeing must have understood this issue long before Lion Air, and certainly after Lion Air.They should have grounded the MAX to resolve the matter. That is why a little emotion is creeping into this thread.

737 Driver is tending to argue pitch and power is the solution but underplaying that pitch cannot be achieved if it is running away. Earlier on in the thread, 737 Driver said runaway could be arrested by the knee of the pilot... not sure that is following procedure or is even possible. 737 Driver is insistent that electric trim can be used to counteract MCAS. If the publications of Boeing are accurate, that is true.

However, it is difficult to believe that the in the Lion Air and ET302 incidents that the pilots were not trying to use the thumb switches to counteract MCAS. Maybe they were not, maybe they, for some reason, thought that they could not. I still have some doubts because it does not seem to add up. What is certain is that had they reacted quicker and hit the cut-out switches earlier, they probably would have been in good shape. Of course, the FDR suggests that the pilots did not use much electric trim, but it is not conclusive because thumb switch input is not recorded.

I am a little skeptical why the voice transcripts of ET302 have not been published. I suspect some legal eagles have stuck their oar in. The transcript could be exculpatory or damning to some of the parties. Perhaps some parties do not want those kinds of conclusions made just yet. It is probably for the best to take a little more time to do a thorough investigation, despite the public desire to know what happened. All too much truth has come out already for Boeing's liking. Perhaps the tip of the iceberg?

[MemberBerry]

If I recall correctly, the "5 second" remark was specifically in reference to a certain set of steps on the runaway stab trim checklist. Apparently there is a "demo" video on YouTube that gives the impression that it takes longer, and someone was under the impression that this length of time was one of the things working against the crew. I was simply pointing out that it could have been done quicker. In another post, however, I also pointed out that the crew could take all the time they needed to get the aircraft back to neutral trim as long as one of the pilots was, yes, FLYING THE AIRCRAFT and managing the trim using the yoke switch.


I recall it a bit differently. It was a longer exchange starting with a comment about the first step in your mantra. I claimed that "turning off the magic" is made more difficult on the MAX, because it contains an additional bit of magic that can't be turned off without losing manual electric trim as well. As a solution I proposed introducing a software update (since a hardware change like rewiring the cutout switches differently would be more costly), which would allow the pilots to disable MCAS and other types automatic electric trim without losing manual electric trim. You replied that the new feature would involve more troubleshooting, and the philosophy is that pilots should not troubleshoot problems, and procedurally they shouldn't fiddle with the cutout switches. I replied that the runway stabilizer memory items already look a bit like troubleshooting, saying "do this, if that doesn't work do that, if that doesn't work finally do that". What I meant was that a bit more troubleshooting in addition to the existing troubleshooting steps wouldn't be the end of the world. For example the "fiddling" part could be added as deferred items. Especially since two sets of pilots experiencing MCAS did just that. They fiddled with the cutout switches after initially disabling stabilizer trim.

Then you replied that those "troubleshooting" steps in the memory items can be done in "under 5 seconds". I felt that sounded a bit like an exaggeration. First of all the pilot flying would have to hold firmly the control column. This means he would have to rely on the pilot not flying to actually execute rest of the memory items, since his hands are busy. I assumed the pilot not flying will not just do the rest of the items blindly and hastily, without confirming them with the pilot flying first, so I didn't see how that that can be done in under 5 seconds. So I replied with a partial transcript of a Mentour video, demonstrating the execution of the memory items, where the "troubleshooting" part took 43 seconds. Mentour is a captain with over 10000 hours experience on the 737. He is also a line training captain, type rating instructor, and type rating examiner.

I agree that in the demo video they were not executing the memory items as fast as possibile, and in a real emergency it would probably be wise to execute them faster. What I didn't mention was that, including problem identification, it actually took them 83 seconds between the start of the runaway and using the cutout switches, including the time needed to identify the problem. The full transcript and the link to the video by Mentour is in one of my older posts in this thread, here: https://www.pprune.org/rumours-news/619272-ethiopian-airliner-down-africa-174.html#post10440735

It is possible Mentour was exaggerating by making the execution of the memory items too long and too formal. Or you were exaggerating with your "under 5 seconds" claim. Or both. Alternatively there may be some misunderstanding on my part.

After your "don't tell me how to fly the plane" post I took a break from posting yesterday to allow the things to calm down. Even if I don't agree with everything you say, I appreciate your informed contributions to this forum, and that you are trying not to let the discussion go "into the weeds". As for me, I'm just a passenger that is interested in this MAX saga. I only post when somebody makes claims that are clearly wrong without anybody contradicting him (for example the "the pilots allowed the plane to reach 500 knots without doing anything" post, or the "pilots in the previous Lion Air flight immediately used the cutout switches"), or when I feel that the facts or opinions I post are valuable to the discussion.

Unfortunately I'm not very good at interacting with people, and I'm sorry if my posts may seem disrespectful, I am just giving my honest opinion.


Now to different topic, the AoA disagree light. First, we have the revelation that Boeing didn't know that it doesn't work if the AoA display optional feature was not installed. OK, that's understandable, it's a bug that has slipped through testing. It happens. Then they say they analyzed the impact and they concluded it doesn't affect the safety. OK, fair enough, a lot of pilots have expressed similar opinions.

But then there is decision to not inform either the FAA or the airlines about the problem. Hiding this information IS actually a safety issue, in my opinion. OK, let's say 95% of the pilots don't care about the AoA disagree light. But the remaining 5% might be confused in a AoA disagree situation, assuming the disagree light works correctly and there is nothing wrong with the angle of attack vanes. Instead those pilots may suspect issues with the pitot probes the static ports or some other issues when they get a false stick shaker.

And even the part about the disagree indicator itself not being a safety feature is debatable. For example, after the previous Lion Air flight, if this indicator worked properly its activation might have been recorded in the flight and maintenance log, and the maintenance crew might have tested replaced the faulty vane, and we wouldn't have the Lion Air accident.

But then, the cherry on top is Boeing not even knowing how their planes work. First claiming that when the related option is installed AoA disagree light can activate on the ground, then realizing after a few months that actually you need to be at least 400 feet above ground level for it to activate. I don't even know what to say about that. They didn't give the contractor that implemented that piece of software exact specifications about how it should work? If they did, how is it possible they didn't know? Did somebody later assume it works just like on the NG, without checking the documentation before telling the airlines? I assume it works on the ground for NGs, during the takeoff roll, otherwise I can't find any reasonable explanation for this surreal display of incompetence on Boeings part.

[wheelsright]

Alchad, https://www.pprune.org/10464568-post5008.html

No ‘wow’ response because an AOA Disagree alert has little value for pilots. There is no third system to resolve the ambiguity - which AoA is correct - not known; what can I do about it - nothing, info only (or distraction). Furthermore an alert could contribute to misdiagnosis in the UAS drill; stick shake + EFIS low speed awareness on the ‘left side’, this might incorrectly bias thoughts to the left, - speed correct - aircraft is slow.
Whereas the Air Data Disagree alerts for Speed / ALT each have a third, standby instrument which the crew can use to arbitrate and choose the most valid pairing; standby + right side = right Speed is best.
So without means of arbitration the AoA alert has little value.

From an engineering view, particularly with hindsight, AoA Disagree could have been used in the original MCAS design. It wasn’t because that design assumed that the effects in the accident would not occur - all of which were incorrect.
Limiting these problems using AoA Disagree provides an engineering solution. However for the crew, retaining the AoA alert would not clarify the accuracy of AoA - so don’t display the alert nor the optional gauge when there is disagreement.
The most important absence is the annunciation that MCAS is inoperative, which with a caution that flight in some (few) areas of the fight envelope requiring careful handing. Not really true. A MAX pilot should immediatley disable electric trim if AoA disagree, period. That is what we now know. We also know that the system should disable MCAS in the event off AoA disagree and Boeing did not provide that logical functionality. Otherwise agreed.

[hans brinker]

I do not disagree in theory, but IMHO, the reality is that the training standards dictated by Boeing have been catering to the lowest common denominator for years. They have a strong incentive to sell aircraft across the entire spectrum of airlines and countries regardless of the depth and quality of their aviation heritage. Requiring a higher level of demonstrated skills for the operator potentially translates into higher costs and lost sales.

Sadly, this thought process does not stop at Boeing. I recently had an opportunity to fly with FO who was relatively new to the 737. During our trip, we discussed a number of issues that had come out of the recent MAX crashes. During this conversation, he confessed that before these accidents, he did not even know the stab trim wheel had a stowable handle and had never been trained in its use. Think about that for a moment. Also consider that a freshly-minted 737 Captain would have received the exact same training.

After I picked my jaw up off the floor, I proceeded to personally give the FO the training he had missed. Afterwords, I shared my concerns with my Fleet Manager and told him in no uncertain terms that our training programs needed a thorough review. The Fleet Manager replied that this was already in progress, and stated that our training programs were constantly being reviewed for improvement. He added a telling remark, however, that stab trim malfunctions had never been a statistically significant problem at our airline, implying of course that the training events our pilots are exposed to constantly needed to be justified by historical data. I told him that if the MAX accident had occurred at our airline, the family of those who perished would have been rightfully angered if it had come to be known that the crew had not been properly trained in a runaway stab procedure because the airline considered it to be a statistically insignificant event.

The degradation of pilot training and standards is a worldwide problem. It is being driven in large part by the beancounter mentality that attempts to justify every cost. Unfortunately this approach forgets that there are some costs that cannot be easily quantified, and eventually a price will be paid in bent metal and broken bodies. Sadly, even if the industry will not openly admit it, there seems to be an underlying assumption that there is an acceptable hull loss rate and that little will change until the body count goes up.

Could not agree more.
A few companies and almost two decades ago I upgraded in a small company flying 50-seaters. Before they let you on the line there was extensive checking before upgrade started, and OE/line-training till every deficiency was corrected or you were send back to the right seat, SIM training was something different every half year, with a specific training syllabus send out a few weeks prior to prepare. I upgraded a few years ago on the A320, got 7(!) sectors of OE and was send on my way. In my first few months, and flying with new FOs (company growing fast) I had quite a few things I had never seen before: no FD take-off due to dispatched with the engines in N1 rated mode, FD deferred and several others I had never seen online or in the SIM. Most of the training now is checking the required boxes, same scenario every time, and there are so many items you are doing "250 to the marker" CATIII and OEI/SE because of time constraints.....
I am lucky my company lets me fly raw data/AP/AT off except when required by regulations (RNAV SID/LO-VIS/AUTO landing) so I have been able to stay current, and show a lot of "inexperienced" FOs all these things, but it really should be trained to proficiency before getting to the line.

Also, I really agree with your take on the automation dependency issue.
Boeing needs a company wide overhaul of their certification department, with much more regulatory oversight to rebuilt confidence. The massive mistakes made in certifying MCAS, (and all the other surrounding issues like AOA discrepancy warnings left inactive due to third party software (no excuse IMHO)) makes me believe heads should roll at every level.
Having said that, just because Boeing messed up. doesn't mean the pilots didn't. There have been more instances of LOC in-flight were the only crew action was a frantic attempt to re-engage the AP. If that is the best you can do, you are not trained/capable to be in the cockpit. Most of what the pilots did in the 3 flights we are talking about speaks to severe training/handling issues.
Continuing a flight with the stick shaker, and then only writing up reverse STS trim is IMO on of the primary causes for the first crash.
Using trim two dozen times to correct MCAS, but never interrupting the MCAS while it was trimming (so only re-active, never pro-active), and still not switching the trim off, or reducing power?
Switching the trim off while out of trim, but not reducing power, and no hand trimming till it was too late?
None of theses events had a single easy checklist that would have resolved everything, but it does still say in the manual, that there is no checklist for every conceivable problem, and pilots are expected to be able use their skills to control the aircraft, while handling unexpected situations.

[Smythe]

Not that simple, in a climbing turn, AoA will always disagree.

[hans brinker]

Not that simple, in a climbing turn, AoA will always disagree.

For all their blatantly obvious faults, I don't think Boeing is incapable of designing a working AOA disagree system. They set the threshold around 5deg I believe. I would think that is based on test/simulations showing "climbing turns" will not give an AOA disagree more than 5 degrees. (also don't think the it needs to be a turn, or climbing. The AOA disagree will get higher for higher AOA, especially in combination with un-coordinated flight).

[wheelsright]

Not that simple, in a climbing turn, AoA will always disagree.

IMHO it is that simple. There are ordinarily circumstance that there will be disagreement or unreliable data. For example, before the aircraft has sufficient speed before takeoff, AoA is meaningless. Boeing has included some other criteria that disable MCAS that is not thoroughly documented but touched on. The left and right FCC is a black box device that is programmed to take account of various factors. The magic of computers is that they can take account of many factors that humans will take longer periods to process. AoA/MCAS could be programmed to take account of many factors that could occur normally and fail-back in other circumstances. Boeing itself has published advice to disable electric trim under certain circumstance but left that that to the pilots. It is very doubtful that MCAS should continue to have authority when AoA is clearly unreliable.

What is the published procedure for AoA disagree notification when installed?

[Smythe]

More from Seattle Times:

Tajer said the American pilots were told in the meeting that on the flight deck of their 737 MAXs, the AOA disagree light would have lit up on the ground and so, because that’s a “no-go item,” the plane wouldn’t even have taken off. However, Tajer said that within the last two to three weeks, “we are now learning that, unlike Boeing told us in November, the warning light actually is inhibited on the ground.”

“We are being told by Boeing that the AOA Disagree Alert … is inhibited until 400 feet above ground level,” he said Sunday. “We are currently awaiting written confirmation of this AOA Disagree Alert limitation as it is not detailed in any 737 flight crew manual.”

https://www.seattletimes.com/business/boeing-aerospace/long-before-first-737-max-crash-boeing-knew-a-key-sensor-warning-light-wasnt-working-but-told-no-one/

At 400 feet, the light comes on, then what? (the 5 second memory rule?)

AoA/MCAS could be programmed to take account of many factors that could occur normally and fail-back in other circumstances.

It already does. AoA is never a direct reading from the vane, it passes through many levels of algorithms depending on circumstances and conditions.

[formulaben]

Then you replied that those "troubleshooting" steps in the memory items can be done in "under 5 seconds". I felt that sounded a bit like an exaggeration. First of all the pilot flying would have to hold firmly the control column. This means he would have to rely on the pilot not flying to actually execute rest of the memory items, since his hands are busy. I assumed the pilot not flying will not just do the rest of the items blindly and hastily, without confirming them with the pilot flying first, so I didn't see how that that can be done in under 5 seconds.

It is very clear you're unable to grasp the concept of how a memory item procedure is conducted; it is certainly not how you suppose it to be. You are conflating a NNC procedure and a memory item procedure. Stop wasting our time sharing your opinions on things you know nothing about. This is rubbish speculation and it is also happens to be 100% wrong.

[hans brinker]

More from Seattle Times:

Tajer said the American pilots were told in the meeting that on the flight deck of their 737 MAXs, the AOA disagree light would have lit up on the ground and so, because that’s a “no-go item,” the plane wouldn’t even have taken off.However, Tajer said that within the last two to three weeks, “we are now learning that, unlike Boeing told us in November, the warning light actually is inhibited on the ground.”

“We are being told by Boeing that the AOA Disagree Alert … is inhibited until 400 feet above ground level,” he said Sunday. “We are currently awaiting written confirmation of this AOA Disagree Alert limitation as it is not detailed in any 737 flight crew manual.”

https://www.seattletimes.com/business/boeing-aerospace/long-before-first-737-max-crash-boeing-knew-a-key-sensor-warning-light-wasnt-working-but-told-no-one/

That statement about the first meeting seems really wrong. The AOA won't work without the plane moving through the air (preferably in the direction the nose is pointed). Because the vane has a counterweight inside it will be more than happy to sit at a random angle, until somewhere during the T/O roll the will start indicating AOA. The 400' sounds more reasonable to me, as it will give time for factors as side-slip due to crosswind T/O to dissipate.
The biggest issue for me is that again there is a system that is incompletely in the Boeing FCM.

[yellowtriumph]

I am not a pilot, but I am curious. What is the technical reason for not having the AoA sensors on the same side of the aircraft? Be gentle, I am not a pilot.

[wheelsright]

More from Seattle Times:

It already does. AoA is never a direct reading from the vane, it passes through many levels of algorithms depending on circumstances and conditions.

Re your quote from my comment... I thought that is what I said, sorry if it was not clear. The AoA signal is routed to the FCC's; thereafter it is processed. For reasons that are not clear, MCAS was intended to remain active when AoA was unreliable. Part of the problem is that left and right is separated and the the left hand does not know what the right is doing, so to speak. Disagree seems to be separate from the FCC's but I stand to be corrected.

The signal from the AoA has to have all kinds of mapping and algorithms to provide clean data. Vibration, noise, sudden turbulence, inertia are but some of the issues that must be processed out. However, the question is why substantial disagreement between sensors was not regarded as an important factor in disabling MCAS automatically?

[737 Driver]

Not really true. A MAX pilot should immediatley disable electric trim if AoA disagree, period. That is what we now know. We also know that the system should disable MCAS in the event off AoA disagree and Boeing did not provide that logical functionality. Otherwise agreed.

Uh...., no. I could go into all the reasons why one shouldn't, but can you just take my word for it?