NYT: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

[slfool]

After a Boeing 737 crashed near Amsterdam more than a decade ago, the Dutch investigators focused blame on the pilots for failing to react properly when an automated system malfunctioned and caused the plane to plummet into a field, killing nine people.The fault was hardly the crew’s alone, however. Decisions by Boeing, including risky design choices and faulty safety assessments, also contributed to the accident on the Turkish Airlines flight. But the Dutch Safety Board either excluded or played down criticisms of the manufacturer in its final report after pushback from a team of Americans that included Boeing and federal safety officials, documents and interviews show.

https://www.nytimes.com/2020/01/20/business/boeing-737-accidents.html

[Twitter]

Same story on BBC news page quoting NYT concerning "suppressed data" from the Turkish NG, AMS Feb 2009 investigation.

They talk of a "single sensor" having had an input into the ATS - as far as I can see they mean the RA input.

Interestingly the left RA input was used for ATS speed control whether R or L system is selected. In the initial report BBC says that the crew may have discounted the Left RA failure, thinking it irrelevant while using ATS from the right side. Doesn't excuse monitoring IAS of course. Apparently the source of RA input was not made clear in the FOM.
I know it was on the MD-80. Left RA was mandatory for a Cat 111 approach for that reason.

They are hitting the single sensor aspect and drawing "striking" parallels to the Max AoA input case.

[CW247]

Boeing tech is rudimentary at best. Airline CEOs and shareholders really ought to wake up to this fact.

[fdr]

There is a fair bit of commonality with the gap between expected performance and actual performance of the crew in the THY1951 accident and the MAX losses. At first blush a simplistic view is that it has to be a deficient crew, and yet, these crews are correctly certificated by their respective regulators, as was the crew of AF447.

The emphasis and reliance on automation may benefit accuracy but it does increase response time when a fault occurs while in a monitoring state. For the MAX cases, the crew were specifically hand flying the aircraft in an abnormal condition, for which an argument may be made that the ability to manually operate the aircraft in the abnormal case was adversely affected due to the extent of reliance in normal ops on automation. I actually don't believe that is a strong coupling, would expect that the fundamental problem is the underlying variability of humans to cope with an anomaly that is not within their direct recognition primed responses and associated decisions. Analysis of a new condition takes time, and sods law is that a defensive mechanism for surprise events will be good on most occasions, but sometimes it will be inadequate or compounding of the problem. Consider the AA DC 10 accident at KORD, AA191; the Co pilot recognised the basic condition of a severe engine failure, and entered into his trained response, which was problematic on that day, as the LH slat had lost hydraulics, and had retracted, so diligently flying V2 as a target resulted in loss of control. In Amsterdam, the crew were conducting training which is an elevated risk condition, and were given a high and close pattern that preoccupied them. Yes, they had IAS indicators, noise and various cues to the fact that the automatics were not functioning as expected (loss [ramping to zero] of LH RALT resulted in the ATR entering the idle function which is unannunciated, and as the throttles were already back at idle, the crew were unaware that the throttle was not going to wake up and maintain commanded approach speed when the sink rate reduced on capturing the glide path). In AMS, the event deteriorated quite rapidly, and the crew did not recognise the signs of decaying energy. Essentially the crew were outside the loop (Boyd's OODA) For the MAX, both crews were outside the loop, and circumstances resulted in their attempts to get to grips with the problem being unsuccessful. As an industry we have spent a lot of time on warm fuzzy CRM issues, but have had inadequate emphasis on SA maintenance, recognition of SA loss, and associated training, including strategies to recover SA. The basic problem is akin to taking a knife to a gun fight. In the case of the MAX, uniquely, the actual failure mode was novel to the crews experience, it wasn't even a known system, and while the OEM suggests that the response would be consistent with a runaway trim system, that is only partially true, running away at 4 times the recovery trim rate is a surprise package, as is the removal of the yoke limit switch cutouts. Having an intermittent runaway is not something that occurs in the world otherwise of trims, and for the ET case, the recovery process added a new surprise with the problems of manual trim being effectively frozen by the elevator loads, which resulted in the crew putting the stab cutout switches back to normal, with disastrous results.

The average pilot is not well equipped today to cope with a novel, time critical, highly dynamic event. Much like Chernobyl reactor technicians. Working out what is trying to kill you in the absence of information is a challenge, and those occasions need to be minimised, with crews given training in SA matters. The good news is that these are exceptional events when the underlying engineering issues are resolved. There is no simple panacea to the issue of improving reliability of the human-machine system performance.

[alf5071h]

Hindsight itself is not painful; it is the subsequent realisation that lessons were not learnt, advice not heeded, nor actions taken.
The NYT article is timely, and ‘unusually’ accurate and to the point, in comparison with some media reviews.

Full accident report: http://reports.aviation-safety.net/2009/20090225-0_B738_TC-JGE.pdf
Appendix B: Comments of parties involved - NTSB / Boeing, (Page 140) provides insight to the review process and particularly the theme of blame the pilots, checklists, procedures; ‘we have flow this in the M Cab and our pilots were able to recover the aircraft’. ~ Walter Mitty.

The response to remark #1 - was a timely ‘put down’ of the NTSB / Boeing’s opening distraction that reporting format reduces safety impact and lessons learnt, even more so for the Max. ~ Delusion.

Appendix M: Simulator Tests (after this accident), (Page 201)
‘Evaluation of the aerodynamic performance data showed that once the aircraft stalled (approximately 5 seconds after the onset of stick shaker) there was insufficient altitude for the airplane to be successfully recovered. Therefore, the post stall recovery flight regime was not investigated during the M-Cab simulation tests.’

The NYT article, and the accident report, should reinforce the wake up call emerging from the Max saga. Not specifically directed Boeing, FAA, NTSB, but for world manufacturing, regulation, investigation and operations.

Woods and Dekker, http://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2002_and_before/WoodsDekker2001.pdf

http://www98.griffith.edu.au/dspace/bitstream/handle/10072/46628/70230_1.pdf?sequence=1

and for info: https://pure.uvt.nl/portal/files/7737432/Pupulidy_The_transformation_01_09_2015.pdf
“case studies to show the interweaving of organizational and individual journeys, each of which began with the strength to inquire and to challenge assumptions.”

Is it possible to get a copy, or at least view the ‘Dekker report’. Noting its intended confidentiality, perhaps via PM.
Alternatively as a bold safety statement, publishing the report anonymously with the objective of learning and changing even at this late stage.

[ARealTimTuffy]

The average pilot is not well equipped today to cope with a novel, time critical, highly dynamic event. Much like Chernobyl reactor technicians. Working out what is trying to kill you in the absence of information is a challenge, and those occasions need to be minimised, with crews given training in SA matters.

I would argue that the average pilot was never equipped to cope at any point in history, not just today’s pilot. Pilots are humans and suffer broadly the same natural response when faced with a novel, time critical, highly dynamic event.

The way to mitigate that is to include the human style responses into the training and develop systems to minimize the effect startle factor. Eg. We train for V1 engine failures, but rarely do we train for the bird strike, compressor stall at v1 failure. So the first time you hear the massive bang is when it happens in real life. But look at the reports and videos. The evidence points to this type of failure as a primary way an engine will fail at takeoff. Not just a flameout or fadec rollback.

[568]

The RA was mentioned in the FCOM but it was very easy to miss. The same single source issue is also relevant to the 737 autobrake system in that it uses the L IRS for deceleration rates. Again the cut to training foot prints across type ratings ensures less systems understanding compared with the way type ratings used to be taught.

It is time safety was placed at the top of the Corporate tree instead of huge operating profits. Training is expensive but accidents aren't cheap either and then there is the loss of life ,which can never be replaced with money from law suits.

[Peter H]

I always wondered why there was no real discussion about the s/w using an RA reading that was basically "off scale".
As a s/w engineer I always felt a sense of professional guilt that that the developers missed that one.

[TLB]

Bottom line on this accident folks: three pilots allowed the airspeed to fall 34 KIAS below the selected reference speed (110 vs 144 at 500 feet AGL). Don't blame the automatics folks, it is the pilots' responsibility to maintain a safe airspeed.

[Semreh]

The average pilot is not well equipped today to cope with a novel, time critical, highly dynamic event. Much like Chernobyl reactor technicians. Working out what is trying to kill you in the absence of information is a challenge, and those occasions need to be minimised, with crews given training in SA matters. The good news is that these are exceptional events when the underlying engineering issues are resolved.

Chernobyl was, in part, caused by the operators being instructed/required to run an experiment, outside the normal operating parameters, which they had not been trained on. In principle they 'should' have refused.

This article (https://www.cnet.com/news/chernobyl-miniseries-by-hbo-and-sky-prompts-searches-on-nuclear-explosion-fission/) gives a good overview of the facts immediately preceding the Chernobyl accident, this article (https://www.world-nuclear.org/information-library/nuclear-fuel-cycle/nuclear-power-reactors/appendices/rbmk-reactors.aspx) gives a bit more background on RMBK reactors, and this (https://www-pub.iaea.org/MTCD/publications/PDF/Pub913e_web.pdf) is a rather long official report (in English) into the matter.

There is a telling quotation from that last report:

1-5.2. The misguidedness of the practice of transferring emergency protection functions to the human operator owing to the lack of appropriate engineered safety features was highlighted by the accident itself: the combination of design deficiencies and the non-total reliability of human operators brought about the disaster.

The personnel were unaware of some of the dangerous features of the reactor and, therefore, did not realize the consequences of the violations. This fact in itself demonstrates the lack of safety culture, not so much on the part of the personnel, but rather on the part of the reactor designers and the operating organization.

And, quoted within this report from the 3-Mile Island report:

"An operator must never be placed in a situation which an engineer has not previously analysed. An engineer must never analyse a situation without observing an operator's reaction to it"

I think, mutatis mutandis, the same applies for pilots operating aircraft.

[donotdespisethesnake]

Bottom line on this accident folks: three pilots allowed the airspeed to fall 34 KIAS below the selected reference speed (110 vs 144 at 500 feet AGL). Don't blame the automatics folks, it is the pilots' responsibility to maintain a safe airspeed.

As long as we have placed the blame on the "right" people, that is all that matters. That is Level 1 thinking.

Level 2 thinking means considering why those people made a mistake, and how to prevent it.

[Brian Pern]

Perhaps the level 2 thinking involves a bit of 'airmanship. Many years ago I was taught to guard the controls below Fl100/10,000ft. Also when approaching level off certainly within 1000 ft. If you.put your hand on the thrust levers you will feel them move, similarly with the yoke. Its all basic stuff, when you fly a light aircraft you guard the throttle, so why oh why don't we do it on large aircraft these days.
I see every day young and not so young modern pilots ignoring the controls, because the autopilot is in. Is it really that hard.
Training has to change as we really are becoming Children of the Magenta line.

[Old Dogs]

Bottom line on this accident folks: three pilots allowed the airspeed to fall 34 KIAS below the selected reference speed (110 vs 144 at 500 feet AGL). Don't blame the automatics folks, it is the pilots' responsibility to maintain a safe airspeed.
It is also the aircraft manufacturer's responsibility to be forthright about the aircraft systems. 😏

[Old Dogs]

As long as we have placed the blame on the "right" people, that is all that matters. That is Level 1 thinking.

Level 2 thinking means considering why those people made a mistake, and how to prevent it.
Very well said.

[Brian Pern]

Bottom line on this accident folks: three pilots allowed the airspeed to fall 34 KIAS below the selected reference speed (110 vs 144 at 500 feet AGL). Don't blame the automatics folks, it is the pilots' responsibility to maintain a safe airspeed.
Could not agree more, I've had too much wine so apologies, but....someone should be monitoring what IThe aircraft is doing, if you don't like what you see do somthing about it. Jesus .....people this is basic airmanship, I am driven insane by the lack of it I see every day both on the Sim and on the line. The 737 is a doodle to fly, it's not complicated, so why make it. Stop playing with the f@@@ing FMC fly the bloody thing. 3 times table is not that hard is it? Today's sky gods are so full of themselves with all the latest shimmy kit, they don't have an inkling of airmanship.
right rant over.

[Australopithecus]

Perhaps the level 2 thinking involves a bit of 'airmanship. Many years ago I was taught to guard the controls below Fl100/10,000ft. Also when approaching level off certainly within 1000 ft. If you.put your hand on the thrust levers you will feel them move, similarly with the yoke. Its all basic stuff, when you fly a light aircraft you guard the throttle, so why oh why don't we do it on large aircraft these days.
I see every day young and not so young modern pilots ignoring the controls, because the autopilot is in. Is it really that hard.
Training has to change as we really are becoming Children of the Magenta line.

Word of advice: don’t bid for an Airbus job.

[retired guy]

Could not agree more, I've had too much wine so apologies, but....someone should be monitoring what IThe aircraft is doing, if you don't like what you see do somthing about it. Jesus .....people this is basic airmanship, I am driven insane by the lack of it I see every day both on the Sim and on the line. The 737 is a doodle to fly, it's not complicated, so why make it. Stop playing with the f@@@ing FMC fly the bloody thing. 3 times table is not that hard is it? Today's sky gods are so full of themselves with all the latest shimmy kit, they don't have an inkling of airmanship.
right rant over.

Dear Brian
you May have guzzled too much plonk ,but you speak the honest truth. In vino veritas.
i have been reading this thread with a growing sense of alarm. I have observed that exercise in the sim over and over with cadets barely more than children and they handle it flawlessly. You have to ignore six warnings to stall, and then screw up the stall recovery to crash. It’s so very basic airmanship and basic training that when I first saw the replay of the Turkish crash I thought somebody was leaving something out. It can’t have been that they sat there and ignored all the pre stall warnings and then the stall warnings. But it seems they did.
i think that what is becoming increasingly obvious is that there are plenty of folk out there who think that when things go wrong the pilots can’t really be expected to cope.
Its late and I need some wine. Zzz well
R Guy

[retired guy]

Bottom line on this accident folks: three pilots allowed the airspeed to fall 34 KIAS below the selected reference speed (110 vs 144 at 500 feet AGL). Don't blame the automatics folks, it is the pilots' responsibility to maintain a safe airspeed.

That’s three people on this thread who seem to understand that you fly the plane- not let it fly you.
were getting there.
R Guy

[retired guy]

Word of advice: don’t bid for an Airbus job.

In airlines I know well that fly the 737 , the pilots are right there behind the thrust and controls throughout the approach. Any thing not right and the hands take over. During final approach you track the thrust levers to ensure they deliver the power required. During GA you press TOGA and then track the movement
to GA thrust. If it fails you just set it yourself. I’m sorry but this is so basic that I’m not quite sure why we are talking about it. Now I am talking Boeing here where the controls actually work in the normal way and the thrust levers move in line with thrust changes. Airbus? No you are right. None of this applies. Which is why the pilots on AF447:had no idea where the controls or thrust were set and what effect they were having.
Its why some people don’t like that design philosophy.
Youve guessed it. I’m pro Boeing.
R Guy

[retired guy]

It is also the aircraft manufacturer's responsibility to be forthright about the aircraft systems. 😏

In what way was Boeing not forthright about 737 at Amsterdam design please? Not being picky- just don’t get the point.
Thanks
R Guy

[OldnGrounded]

In what way was Boeing not forthright about 737 at Amsterdam design please? Not being picky- just don’t get the point.
Thanks
R Guy

There was no information in the FCOM to indicate that the AT was always controlled based upon inputs from the left RA, even when the right FCC was active.

[Old Carthusian]

It is an uncomfortable fact that automation has made flying safer. Another uncomfortable fact is that in the days when pilot's 'flew' the plane the accident and fatality rates were far higher than now. The issues with pilots responding appropriately to unforeseen circumstances are unfortunately not due to the increase in automation of the flight envelope. If one studies the accident reports of the past one recoils in horror at the mistakes made by pilots hand flying aircraft. We need to avoid rose-tinted spectacles about the past and focus on the real issue here. There will always be pilots who are unable to respond effectively in an emergency or anomalous situation just as there are pilots who can do so successfully. The question is what to do about these pilots as short of putting them in an emergency it is often difficult to tell who falls into this category. This is where the aircraft manufacturer comes into play - designing aircraft which are robust and easy to fly and putting safety above profits. There seems to be a failure of risk management and ability to appreciate that aviation accidents are all 'black swans' in the ranks of Boeing. Analogies have been drawn with the nuclear industry and these I think are appropriate. Cutting corners on safety is not an appropriate response and trying to bury or influence the results of a safety report so it is more favourable to the company is particularly abominable.

OC

[OldnGrounded]

There will always be pilots who are unable to respond effectively in an emergency or anomalous situation just as there are pilots who can do so successfully.

No. There will always be emergencies in which pilots respond effectively, as well as emergencies when pilots do not do so. And the very same pilots might find themselves in either situation on any given flight.

Life is complicated and humans are all human.

[Old Carthusian]

No. There will always be emergencies in which pilots respond effectively, as well as emergencies when pilots do not do so. And the very same pilots might find themselves in either situation on any given flight.

Life is complicated and humans are all human.

I very much see your point - however, a detailed reading of accident reports unfortunately tends to reinforce the proposition that it is mostly pilots who create emergencies. Your emphasis is very much the lesser cause of accidents but I think we can say of the MAX affair that the pilots were the victims of badly designed and conceived software and a rather perverted desire to put saving money above safety.

OC

[wonkazoo]

This thread has sparked a thought, one that has lingered through the MAX saga.

What is "airmanship??"

I know what I think it means, and I know what a lot of posters here on PPRuNE think it means, but in concrete terms what exactly is airmanship??

Before you answer with a concrete definition let me share my day with you. This morning started at 0400 in Fountain Valley, CA where I was staying with my son for a hockey tournament. Come 1100 we were on our way home to Half Moon Bay, through the entirety of the LA basin, the Grapevine, the endless expanse of Rt 5 to the Pacheco pass etc. When we started I was reasonably coherent and my usual race-car driver (for real) self. By the time it started to rain five hours later on Rt. 5 just before Los Banos my eyes were blurry with fatigue and I had to use every ounce of energy I had to maintain focus on the road and the copious (and insane) traffic around me. Was I unsafe?? I do not think so. (If I did think so I would have stopped) But could I have responded to a series of life-threatening events occurring in quick sequence with the same level of reaction time and cognition that I had five hours earlier in LA?? Nope. Not a chance.

I've spent roughly 4,400 hours of my life at the pointy end of flying objects in full responsibility for returning them to the ground in the same state that they left it. I failed to do this once- and I have the caterpillar pin to prove that on that day my "airmanship" was enough to at least keep my ass from dying, even if it could not save the airplane. So do I have "airmanship??" I honestly have no idea, but if I do I also know that given enough fatigue, distraction or illness it can be erased in a heartbeat.

Anyway I return to the question: What the heck is "airmanship" and why is it so great at saving airplanes that have been poorly designed??

Warm regards- apologies for the length- as stated the day started quite awhile ago.
dce

[Ascend Charlie]

Airmanship is the safe and efficient operation of an aircraft, both in the air, and on the ground.

[maxxer]

As slf that article gives me shivers and i think this thread should be deleted asap.
we all know that the airplane had an issue with this aensor because the airplane gave a silly warning while it was still perfectly fine to fly manually.
The turkish became very aggressive to clear the crew of any mistakes but this accident is purely on the crew they had the time to figure out why the machine was complaing about configuration before they let the machine land itself.
There is in our world no other way of automation possible then we currently have.
Sensors which need air to flow passed them or use some magnetic interference measurements it is how it is we will not get the super robots you see in hollywood movies no auto healing of the machines , pilots should learn to deal with that.
This article is just Boeing bashing but an airbus would crash just as well if you dont troubleshoot the fault and let the faulty sensor fly it

[fox niner]

Bottom line on this accident folks: three pilots allowed the airspeed to fall 34 KIAS below the selected reference speed (110 vs 144 at 500 feet AGL). Don't blame the automatics folks, it is the pilots' responsibility to maintain a safe airspeed.

True. However.
Why didn’t the 737 get any “fundamental” upgrade since it was initially designed??? It has sooo many KNOWN design flaws, it is almost funny. Almost, because they are deadly. To name a few:
-split cockpit, wherein the left side does not know where the righthand side is going.
-airco switches design, whereby it is very difficult to see/determine how they are positioned(helios crash)
-single channel determines deceleration of the autobrakes. (Left irs only)
-single channel auththrottle, with input of single RALT. (Turkish at AMS)
-identical wailer for T/O config, OR cabin ALT. What the hell. Seriously.
-Recall system knob is prone to mishandling. Do NOT push it too hard or it will not indicate anything.
-Probably many more.

The reason for keeping all these stupid design flaws in there, is Boeing’s attempt to maintain one type rating. So according to Boeing, it is better for THEM to keep it cheap and competitive, while some people die in some third world country because of their incompetence.
Glad I dont fly it anymore. Later models of Boeing are better.
The only up-side of flying a 737, is that it makes you a better-than-average pilot. If you can fly a 737, than you can fly ANY Boeing airplane.

[retired guy]

There was no information in the FCOM to indicate that the AT was always controlled based upon inputs from the left RA, even when the right FCC was active.

Thanks. That’s true. The manuals should of course be accurate. That said the majority of pilots I have known wouldn’t have derived any benefit from that knowledge in the AMS situation . Ask any pilot, if you know any, without warning “ How does speed trim work”. “Describe the hydraulic system A and what services it supplies”, or any question that goes just a little deeper than superficial. You might be surprised at the response. Fact is that it wasn’t that the crew didnt understand the wiring diagram for the Rad Alt and it’s relationship to the FCC and the avionics related to Autothrottle/ RA interface. Very few would, even if it were in the manuals in bold underline. What they didn’t know what to do was fly the plane, which I would argue is their primary function when things don’t work as expected. So in this case the autothrottle didn’t “wake up”, as it didn’t in ASIANA SFO 777. Both planes crashed due to pilot inability to recognize that the plane was deviating seriously from the desired flight path and did not initiate a manual recovery in time.
Thats my view and I’m not alone. Clearly, from some of the comments earlier.
It is very good we’re discussing these issues because they lie at the heart of the future of aviation safety.
Best wishes
R Guy

[Twitter]

As slf that article gives me shivers and i think this thread should be deleted asap.
we all know that the airplane had an issue with this aensor because the airplane gave a silly warning while it was still perfectly fine to fly manually.
The turkish became very aggressive to clear the crew of any mistakes but this accident is purely on the crew they had the time to figure out why the machine was complaing about configuration before they let the machine land itself.
There is in our world no other way of automation possible then we currently have.
Sensors which need air to flow passed them or use some magnetic interference measurements it is how it is we will not get the super robots you see in hollywood movies no auto healing of the machines , pilots should learn to deal with that.
This article is just Boeing bashing but an airbus would crash just as well if you dont troubleshoot the fault and let the faulty sensor fly it

Sorry Maxxer, I couldn’t make head nor tail of that. Must have been a long night?

[retired guy]

True. However.
Why didn’t the 737 get any “fundamental” upgrade since it was initially designed??? It has sooo many KNOWN design flaws, it is almost funny. Almost, because they are deadly. To name a few:
-split cockpit, wherein the left side does not know where the righthand side is going.
-airco switches design, whereby it is very difficult to see/determine how they are positioned(helios crash)
-single channel determines deceleration of the autobrakes. (Left irs only)
-single channel auththrottle, with input of single RALT. (Turkish at AMS)
-identical wailer for T/O config, OR cabin ALT. What the hell. Seriously.
-Recall system knob is prone to mishandling. Do NOT push it too hard or it will not indicate anything.
-Probably many more.

The reason for keeping all these stupid design flaws in there, is Boeing’s attempt to maintain one type rating. So according to Boeing, it is better for THEM to keep it cheap and competitive, while some people die in some third world country because of their incompetence.
Glad I dont fly it anymore. Later models of Boeing are better.
The only up-side of flying a 737, is that it makes you a better-than-average pilot. If you can fly a 737, than you can fly ANY Boeing airplane.

The “issues” you describe are easily sorted through SOPS. Example Aircon switching. Helios didn’t follow SOPS. It was truly shocking to read the report on that.

But to move on, you are right. If you can fly a 737 you are on one of the most robust and delightful planes ever built and a combination of that long safety record and good pilot skills makes the 737 a very safe plane indeed but you do have to know how to fly I accept. And that’s our problem isn’t it.
I think this is coming up more and more as we unravel the Max issues. It seems that Boeing do indeed seem to expect a solid level of pilot training and ability. Hence just an AD post Lionair reminding everyone that when the stab wheel runs unexpectedly- just do the procedure. And we now know that ET still didn’t do that 5 months later. So the debate must now be about “is it reasonable to expect pilots to have the same skill levels as the previous generation”. It’s going to be a long and interesting battle. Airbus just said freighters with no pilots (one pilot ?) in 5 years. Others saying train the pilots! I hope I’m around long enough to see how this unR Guy

[alf5071h]

TLB, there is a significant difference between being responsible and being able to exercise responsibility. Thus, neither automation or pilots, but the combination, interacting with the situation being experienced - context.
See appendix N of the report - previous incidents. The outcome of all of these was success, but the context differed - more altitude, alternative alerting - situation awareness, and thus time available.

“...no matter how hard they try, humans can never be expected to out perform the system which bounds and constrains them. Organisational flaws will, sooner or later, defeat individual human performance.”
Gary Parata of Air Nelson

- - - - - -

wonkazoo, Ascend Charlie, et al,

“Airmanship is a personal attitude to flying, why we do it, how we do it. Airmanship must grow with training, experience, and personal exposure. It is not just about staying alive or not bending the airplane or yourself, it is about walking off the airfield knowing that you have both performed and crafted an activity. You have been totally aware of what you have done and why you enjoyed it, and a that point you owe nothing to anyone.” Slide 13
https://www.dropbox.com/s/bhpin7se6mea6vj/Airmanship%20Professionalism%20in%20Flight.ppt?dl=0

fdr, average pilot, :=
No such thing as an average pilot. ;)

[Snyggapa]

No such thing as an average pilot. ;)

statistically, there must be. And also statistically, nearly half of your pilots will be below average.

Don't design products to be safe only if used by the average pilot

Serious question - has anyone ever come off a long duty period and into a sim to see how their fatigued self reacts in an emergency?

[fdr]

Chernobyl was, in part, caused by the operators being instructed/required to run an experiment, outside the normal operating parameters, which they had not been trained on. In principle they 'should' have refused.

This article (https://www.cnet.com/news/chernobyl-miniseries-by-hbo-and-sky-prompts-searches-on-nuclear-explosion-fission/) gives a good overview of the facts immediately preceding the Chernobyl accident, this article (https://www.world-nuclear.org/information-library/nuclear-fuel-cycle/nuclear-power-reactors/appendices/rbmk-reactors.aspx) gives a bit more background on RMBK reactors, and this (https://www-pub.iaea.org/MTCD/publications/PDF/Pub913e_web.pdf) is a rather long official report (in English) into the matter.

There is a telling quotation from that last report:





And, quoted within this report from the 3-Mile Island report:



I think, mutatis mutandis, the same applies for pilots operating aircraft.


Chernobyl and the MAX (and THY @ EHAM) share common features of unintended behaviour by the system which the operators were not aware of. For Chernobyl, the paradoxical effect of hitting the scram button ("AZ-5") which would cause a displacement of water from the control rod channel, removing a neutron absorption mechanism, and replacing that initially with the graphite tip acting also as a moderator, leading to a massive spike in power output, many orders of magnitude above rated power output. The management of the team did not permit concerns of operators to the precipitous drop in power output from xenon-135 poisoning to terminate the test, and the consequences of the RBMK control design became known after the event. The decision making in the process was made without all the information to hand that was necessary to make a safe determination. Humans, experts and non experts don't have great batting averages with decision making under uncertainty, experts reach a position in a shorter period of time, that may be important, but the decision merit is still hit and miss. OTOH, computer systems are effective where the actual conditions are as envisioned by the programmer, any part out of round gets an poor outcome, and that is the benefit of the human in the loop; humans can ponder anomalies, and given time, can establish a counter measure. Temporal constraints have severe consequences; given time, an tentative intervention can be assessed for merit, whether the outcome is being achieved. Without time, statistics come into play. For THY at AMS, had the flightpath been at 10,000' AGL when encountering the loss of SA, then recovery would have been likely. getting to hover in a 737 at a couple of hundred feet has a high probability of ending badly. Yes, the crew missed a stack of cues as to the energy state of the aircraft that appears remarkable in the cold light of reflection, much like the splashdown of AZ-214, but that is what happened on the day, to crews that woke up expecting to have another boring day.

Recovery from a loss of SA is a challenge, and all humans suffer from SA losses at various times in their activities.

[Ben_S]

It seems that Boeing do indeed seem to expect a solid level of pilot training and ability.

Seems an odd statement given they wanted no additional training and hid the existance of MCAS.

Odd that the wave of new posters keep turning up with nothing but an agenda to blame the pilots, as one seems to disappear a new one turns up.

[OldnGrounded]

Thanks. That’s true. The manuals should of course be accurate. That said the majority of pilots I have known wouldn’t have derived any benefit from that knowledge in the AMS situation.

It might have been beneficial for them to know that the recognizably-faulty data from the left radio altimeter was actually feeding the autothrottle logic. As it was, they knew the reading from that RA was bogus, but they thought it didn't matter.

[alf5071h]

Synggapa, #35,
'statistically' most issues can be identified as having an average. The important point is if this is meaningful; useful in achieving a specific objective.
Failures in aircraft components can be quantified - counted and divided; human performance is qualitative - a judgement which might at best be classified. Interpreting opinions as hard numbers defies meaning. Note rating assessments for CRM.

This inability to quantify humans creates uncertainty which challenge assessors and designers, who may be biased towards numerical techniques. The industry does not design for 'average' people, everyone has to be considered in context. Thus context - those situations which could challenge people and equipment have to be considered.

Recent accidents suggest that Boeing resorted to a numerical view of pilots (blame according to an arbitrary 'averge') when defending their products, deflecting suggestions of poor design. Their product design could have been well designed according to their ground rules, but then either human judgement or the range of situations considered were mistaken; work as conducted was not as imagined.
Perhaps this reflects erroneous cultural (organisational) beliefs; everyone should be the same as us - false consensus bias; - not considering the realities in a rapidly changing world.
https://www.dropbox.com/s/7425e8yykgkxpi3/Dominant%20and%20minority%20culture%20%2B.pdf?dl=0

Statistical Thinking: http://iase-web.org/documents/intstatreview/99.Wild.Pfannkuch.pdf

https://www.stat.auckland.ac.nz/~wild/StatThink/images/99.Measurement.pdf

[retired guy]

It might have been beneficial for them to know that the recognizably-faulty data from the left radio altimeter was actually feeding the autothrottle logic. As it was, they knew the reading from that RA was bogus, but they thought it didn't matter.

I wasn't aware of that to be honest. Let me read the report again. I wasn't aware that the crew had any idea what was going wrong, let alone diagnose the effects of an RA failure at around 1500 feet. I think from memory that the first inkling they had that something was wrong was when the stick shaker went off but I may be wrong.
Remember that by that time the plane was in takeoff attitude of around 12-15 degrees and the airport would have disappeared from view out of the window.
But I think my point remains - the AT can malfunction at any time and it it does (SFO 777) you need to take over the power immediately and if necessary fly the plane to safety. `I don't think I would have known what an RA failure at a 1500 meant except that it precludes at CAT 111 approach and auto land. But as the speed started falling below Vref +15 (approach speed) and long before the other six warning kick in, I hope I would have seen the speed falling below the desired value and applied power.
Anyway good point and I will have a look at the recording again.
Many thanks
R Guy

[OldnGrounded]

I wasn't aware of that to be honest. Let me read the report again. I wasn't aware that the crew had any idea what was going wrong, let alone diagnose the effects of an RA failure at around 1500 feet. I think from memory that the first inkling they had that something was wrong was when the stick shaker went off but I may be wrong.
Remember that by that time the plane was in takeoff attitude of around 12-15 degrees and the airport would have disappeared from view out of the window.
But I think my point remains - the AT can malfunction at any time and it it does (SFO 777) you need to take over the power immediately and if necessary fly the plane to safety. `I don't think I would have known what an RA failure at a 1500 meant except that it precludes at CAT 111 approach and auto land. But as the speed started falling below Vref +15 (approach speed) and long before the other six warning kick in, I hope I would have seen the speed falling below the desired value and applied power.
Anyway good point and I will have a look at the recording again.
Many thanks
R Guy

I don't think anyone is arguing that the Turkish Airlines crew wasn't largely responsible for the AMS crash. The point is simply that Boeing also had some responsibility and worked hard, apparently along with US regulators, to keep references to that out of the investigative reports.

[Final 3 Greens]

As long as we have placed the blame on the "right" people, that is all that matters. That is Level 1 thinking.

Level 2 thinking means considering why those people made a mistake, and how to prevent it.

I'm only a bug smasher former pilot, but letting the speed decay to 110kts against a ref of 134 is just not acceptable and to allow it at low altitude is .....

Working in domains where thinking is highly valued, I'm always an advocate of systems thinking, but such a basis transgression of the principles of airmanship is surely not a topic for deep thinking? One pilot flying, one monitoring - even on a training flight, surely there are procedures to maintain this safeguarding?

I remember having a safety pilot onboard to keep a lookout when I was under the hood in a PA28 and there was a very clear briefing from the instructor/pic about R&R during critical phases of flight.

[bunk exceeder]

Asiana in SFO kind of springs to mind. Still in VNAV PTH, so autothrottles sort of in but not really, and no ILS so not tracking the glideslope when the autothrottles would have definitely been in like every other approach always. But the handling pilot somehow didn’t know what was going on, nor did the other three notice, where hands on throttles would have helped and there should have been been, and always should be an obsessive focus on airspeed. And vertical speed for that matter.

[HPSOV L]

Asiana in SFO kind of springs to mind. Still in VNAV PTH, so autothrottles sort of in but not really, and no ILS so not tracking the glideslope when the autothrottles would have definitely been in like every other approach always. But the handling pilot somehow didn’t know what was going on, nor did the other three notice, where hands on throttles would have helped and there should have been been, and always should be an obsessive focus on airspeed. And vertical speed for that matter.

That’s not quite what happened. The trainee was slightly high on approach and had selected FLC mode to increase the descent rate. When he then input the Missed App Alt into the MCP the aircraft started to climb to the new, higher altitude. He disconnected the autopilot and closed the thrust levers manually to regain the profile from above. In doing so the auto throttle did an indirect mode change from speed controlling to HOLD which, as we all know in hindsight, will not wake up.
As in the Turkish case the situation was coincidentally masked by intercepting the glide path from above and it occurred at the end of a long duty.
Now years later Boeing is fixing the HOLD trap in new aircraft, but a simple EICAS caution should have been introduced years ago.
Ditto the Dubai 777 crash due to TOGA confusion. They should’ve introduced aural feedback for inactive switch selection but they haven’t.
So, given FOQA fear g/a are the norm these days this accident will happen again. In fact it came damn close a couple of weeks ago.

The airmanship argument is a distraction that gives the manufacturers a free pass.

[RetiredBA/BY]

Perhaps I have been missing something, BUT in my experience of the 737 ( a delightful aircraft)
as a TC with 7000 hours on type I used to teach that if the automatics are not doing exactly what you require, or you dont quite understand a particular aspect of the system, disconnect the AP and AT and FLY the damned thing.

It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,

If you cant do that you should not be in airliner cockpit.

[HPSOV L]

Perhaps I have been missing something, BUT in my experience of the 737 ( a delightful aircraft)
as a TC with 7000 hours on type I used to teach that if the automatics are not doing exactly what you require, or you dont quite understand a particular aspect of the system, disconnect the AP and AT and FLY the damned thing.

It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,

If you cant do that you should not be in airliner cockpit.

Well that’s what the Asiana guy thought he was doing.

I’ve sat in many flight safety and CRM sessions and bar talk over the years where old hands tut-tutted and said “how could they do that?”. And years later the same get caught out themselves in similar circumstances.

The subtle point is that in all these cases the aircraft state wasn’t recognised due to masking or distraction. Humans take time to perceive and comprehend an unexpected situation when they have a preconceived mental plot. It took Sullenberger 30 seconds.

That’s why, in this age of system complexity and monitoring automation, it is vitally important that manufacturers keep improving cockpit ergonomics and don’t get let off the hook.

[Herod]

It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,

If you cant do that you should not be in airliner cockpit.

Well said that man

[Twitter]

Actually it’s not so simple in the Max case - flying manually allows MCAS to run - AP on inhibits MCAS.

In fault mode, switching off the automatics - or thinking you have, leads to this Gotcha, where you still have a rogue system fighting you.

As it happens, leaving flap out and or AP engaged would have enabled an approach to land - but who could know that at the time?

So the macho just fly it method has its limits.

[PJ2]

Perhaps I have been missing something, BUT in my experience of the 737 ( a delightful aircraft)
as a TC with 7000 hours on type I used to teach that if the automatics are not doing exactly what you require, or you dont quite understand a particular aspect of the system, disconnect the AP and AT and FLY the damned thing.

It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,

If you cant do that you should not be in airliner cockpit.
It is surprising and somewhat disappointing that "holier than thou" hindsight & blame statements still have credibility among aviation people.

"What you think should have happened does not explain people's behaviour." - Sidney Dekker, Ch. 5, "They Should Have . . .", p.39, The Field Guide to Understanding Human Error;

[alf5071h]

Re PJ2 ref to S Dekker # 49;
the very apt publication of Dekker's report below to the Dutch Authorities which the NYT cites as being dismissed following Boeing intervention, # 1.

Only read the summary so far, but … concluding …

"A breakdown in CRM (Crew Resource Management) cannot be substantiated for TK1951."

"The length of B737 type training at THY, as well as procedural compliance at THY, appear to at least match industry standard."

"Post-accident manufacturer recommendations that, in effect, tell flight crews to mistrust their machine and to stare harder at it not only mismatch decades of human factors and automation research, but also leave a single failure pathway in place."

"Shortly after the accident, Boeing issued a bulletin to all 737 operators and announced that it “will warn crews about fundamentals like flying the aircraft, monitoring airspeed, [and] monitoring altitude” (Learmount, 2009).
The only defense against a designed-in single-failure path, in other words, are the pilots who are warned to mistrust their machine and to stare at it harder. Such a reminder, oriented only at the human operator in the system, is hardly credible after three decades of in-depth research into automated airliner flying and the subtle and pervasive ways in which automation on the flight deck (and particularly its subtle failure) affects human performance (e.g. Wiener & Curry, 1980, Sarter et al., 1997). For flight crews of Boeing 737’s, like the crew of TK1951, there is no sufficient training, no written guidance or documentation, and no likelihood of line experience that would insulate them from the kind of automation surprise that happened near Amsterdam on the 25th of February."

https://www.onderzoeksraad.nl/nl/media/inline/2020/1/21/human_factors_report_s_dekker.pdf

[CargoOne]

Meanwhile Airbus is doing A350 fully automated take off trials - one step closer to make a significant improvement to the flight safety by eliminating the weakest link...

[safetypee]

CargoOne, re your 'weakest link' # 51,
See # 50, read the report, then reconsider where the weakest link is.
Human, most probably, but not those flying the aircraft, nor requiring elimination.

[retired guy]

statistically, there must be. And also statistically, nearly half of your pilots will be below average.

Don't design products to be safe only if used by the average pilot

Serious question - has anyone ever come off a long duty period and into a sim to see how their fatigued self reacts in an emergency?

Hi Synggapa
your maths is of course correct. There must be an average pilot half way between the best and the worst. Now the worst has to exceed the minimum requirement, and in a good airline that minimum will be above the CAA bar by some good margin. So your worst pilot is still pretty good. Your average pilot, a bit like me , somewhat better. and while not the best in the world, still hitting high ratings with no fail points and minor debriefing areas.And then the best pilots way up there much higher and probably get 100% in proficiency. Every time. So you can let your average pilot fly anything you can throw at him. Then there are the 200 airlines that aren’t allowed to fly in EU AIRSPACE. They clearly lie below the minimum EU. EASA requirement and their average pilot must have a lot difficulty passing checks etc.

as for being tired after a long day, yes I have and once or twice had to do my OPC after, on following morning. . Can’ t remember outcome so must have been ok.
doe that cover what you wanted.
R Guy

[OldnGrounded]

Dutch regulators have just published the study cited in yesterday's NY Times story:

A Decade Later, Dutch Officials Publish a Study Critical of Boeing (https://www.nytimes.com/2020/01/21/business/boeing-737-crashes.html)

After a Boeing 737 crashed near Amsterdam more than a decade ago, an expert study that sharply criticized the manufacturer was never published by the Dutch safety authorities, and its key findings were either excluded or played down in their accident report.

On Tuesday, the Dutch Safety Board, which had commissioned the study, reversed course — publishing (https://www.onderzoeksraad.nl/nl/media/inline/2020/1/21/human_factors_report_s_dekker.pdf) it a day after The New York Times detailed the findings.

The Times’s review of evidence from the accident, which killed nine people on a Turkish Airlines flight in 2009, showed the study’s conclusions were relevant to investigations into two more recent crashes of Boeing aircraft that killed 346.

[Read The Times’s investigation here (https://www.nytimes.com/2020/01/20/business/boeing-737-accidents.html).]

The study, by Sidney Dekker, acknowledged that the pilots made serious errors but also found that Boeing bore significant responsibility. It accused the company of trying to deflect attention from its own “design shortcomings” with “hardly credible” statements drawing attention to the pilots’ mistakes.

A spokeswoman for the board had told The Times last week that Dr. Dekker’s study was confidential. But in a statement on Tuesday, Jeroen Dijsselbloem, chairman of the Dutch board, said the study had been posted online because the board’s “current practices” had changed. “We now publish as much as possible,” he said.

The board also defended its investigation of the 2009 crash, which involved a 737 Next Generation, or NG, a predecessor to the 737 Max. The more recent accidents involved the Max, which has been grounded since last year as investigations continue.

Mr. Dijsselbloem noted “the key question” for those investigations was whether lessons from 2009 “were sufficiently learned by Boeing and the American authorities.”

Multiple aviation experts who had read Dr. Dekker’s study told The Times its findings had not been sufficiently incorporated into the final Dutch accident report. In addition, the Times learned, the Dutch removed or minimized criticisms of Boeing after pushback from a team of Americans that included the manufacturer and federal safety officials.

Jan Paternotte, a member of the Dutch House of Representatives, praised the study’s release but called for a hearing of those involved, saying he believed he would secure the necessary support during a committee meeting on Wednesday. “Boeing has been capable of strong-arming outside parties if it serves the short-term interest of the company,” he said. “When safety is at stake, that is a problem.”

The Dutch board on Tuesday acknowledged that it had changed portions of its draft report after the Americans raised objections, but called that “standard procedure” and noted that the Americans’ comments were included in an appendix.“The Dutch Safety Board does its work in strict independence,” Mr. Dijsselbloem said. “The Board decides independently on the outcome of its investigations, the content of its reports and its conclusions and recommendations.”

A Boeing spokesman referred questions to the National Transportation Safety Board, which led the American team that commented on the Dutch draft report. An N.T.S.B. spokesman declined to comment.

The Federal Aviation Administration, which was also a member of the American team participating in the 2009 inquiry, said in a statement that it was “following a thorough process for returning the Boeing 737 Max to passenger service.” The agency added that it was working with international safety regulators to review “proposed changes to the aircraft” as well as “recommendations from safety experts who have examined our certification processes.”

The Dutch board’s final report, released in 2010, focused blame on numerous mistakes by the pilots, including their failure to notice a dangerous drop in speed and their incorrect response to an alert warning of an impending stall. The report contained statements — some nearly verbatim and without attribution — that were originally written by the American team and further emphasized crew errors.

The Times found striking parallels between the accident and the 737 Max crashes. In both cases, design decisions by Boeing allowed a single faulty sensor to activate a powerful computer command. In both cases, Boeing had known of the potential sensor failures but determined that pilots would react correctly and recover the plane. And in both cases, Boeing didn’t include information in the pilots’ manual that could have helped them respond to the malfunctioning automation.

Boeing, the F.A.A and the N.T.S.B. noted that the system involved in the earlier accident differed significantly from the one blamed in the Max crashes. But aviation safety experts, including a senior F.A.A. official who was not authorized to speak publicly, told The Times that the similarities were noteworthy.

Dr. Dekker’s report “should have woken everybody up,” one said. Instead, “the issue got buried.”

[zerograv]

In what way was Boeing not forthright about 737 at Amsterdam design please? Not being picky- just don’t get the point.
Thanks
R Guy

A few paragraphs from what the NYT wrote. Link is at the very begining of this thread.

Critically, in the case of the NG, Boeing had already developed the software fix well before the Turkish Airlines crash, including it on new planes starting in 2006 and offering it as an optional update on hundreds of other aircraft. But for some older jets, including the one that crashed near Amsterdam, the update wouldn't work, and Boeing did not develop a compatible version until after the accident.


Five years before the Turkish Airlines crash, Boeing was aware that a sensor malfunction could idle the engines improperly, but the company decided it wasn't a safety concern, the Dutch investigators wrote.


The safeguard was available in 2006, but the change wouldn't work on some 737 NG models, like the Turkish Airlines plane, that used an autothrottle computer made by a different company. After the 2009 crash, Boeing developed a version of the update compatible with those computers, and the F.A.A. required airlines to install it.

[Old Dogs]

https://www.cbc.ca/news/business/boeing-fifth-estate-costs-safety-1.5426571

[FlexibleResponse]

Very well researched, analyzed and presented, by Sidney Dekker. A belated well done sir!
A shame that the report has taken 10 years to surface. It is still as valid today as it was then.

Just read pages 117-121 "Findings and Conclusions" if you are time constrained.

https://www.onderzoeksraad.nl/nl/media/inline/2020/1/21/human_factors_report_s_dekker.pdf

[Old Dogs]

Very well researched, analyzed and presented, by Sidney Dekker. A belated well done sir!
A shame that the report has taken 10 years to surface. It is still as valid today as it was then.

Just read pages 117-121 "Findings and Conclusions" if you are time constrained.

https://www.onderzoeksraad.nl/nl/media/inline/2020/1/21/human_factors_report_s_dekker.pdf
The fact that it was buried is criminal, in my view, but it shows the power of Boeing, ..... and America.

[safetypee]

Captain Biggles 101, and RetiredBA/BY, Herod, - just disconnect the autos - click click -

The operator needs sufficient information to trigger the point at which to act. Reliance on deduction or situational feedback of aircraft motion - when the aircraft is flying as expected, is not tolerable mitigation for (known) weakness in design. cf Aisiana.
Instead of looking at people as a hazard, to be guarded against; see them as an asset, a help in managing unusual situations as they do very successfully in operations every day. With such a view, then rare misjudgments in challenging situations are best answered by considering what more can be done in the operational environment, including automation, to assist people manage a wider range of situations.

HPSOV L, #44, 46, PJ2 # 49 :ok:

[alf5071h]

fdr, #58 :ok: No such thing as an average pilot.

A valuable list of regulatory references.

Many countries and individuals should heed the chastisements, but the most important language, that written in American English ( NW manufacture and regulation, and South Side Mall DC dialects ), is absent.

Even after stating a 'truth', it has to be recognised and heeded as important. Furthermore, 'truths' have to withstand legal advice as how to design, certificate, document, and present training requirements.
The industry has to be increasingly reminded of the challenges on its integrity; the need for safety above protectionism.

Well done to the Dutch Investigators in openly posting the 'Dekker report'; something more significant than the original accident report, and which raises the standards for investigation, reporting, and acting on recommendations.

Similarly for Dr Dekker; the HF report should be promoted as an HF primer - not detracting from the excellence of his books.
His report must be required reading for people at all levels of manufacture and regulation, especially bean counters and lawyers, and not least ourselves.
A gateway for change, improving our industry.

[retired guy]

I don't think anyone is arguing that the Turkish Airlines crew wasn't largely responsible for the AMS crash. The point is simply that Boeing also had some responsibility and worked hard, apparently along with US regulators, to keep references to that out of the investigative reports.

Ok point taken and apologies for missing your well made argument.
R Guy

[the_stranger]

Captain Biggles 101, and RetiredBA/BY, Herod, - just disconnect the autos - click click -

The operator needs sufficient information to trigger the point at which to act.
Shouldn't the MEL have been sufficient information to not use the autothrust?

As a known complaint, with two succesful flights before, surely they had that information if they did their job?

[sleeper]

So it is. When you have presidents and their cohorts talking in thug speak and acting thug act, you mustn’t be surprised to see that behaviour further down the ranks.

If you want it to be great again, much work is required.


May I remind you that the president hinted at here was nowhere near being one when the turkish accident happened.

[Bergerie1]

Cap'n Biggles Sir,

Your excellent post about the need for the industry to give pilots the chance to hone their skills in everyday operations is very much to the point. When the automatics start doing something that is not as intended, we need not only better annunciation, but even more important, to have pilots who are sufficiently confident and well-practiced in their handling skills that they can immediately detect a departure from the intended flight path/configuration/speeds/altitudes/etc using the primary flight instruments, and then be able and confidently to handfly until the problem has been sorted.

From what I read, these days at a distance, current airline SOPs actively discourage the development and maintenance of these skills.

[fdr]

Shouldn't the MEL have been sufficient information to not use the autothrust?

As a known complaint, with two siccesful flight before, surely they had that information of they did their job?

MMEL:

22-04 Autothrottle Systems C/1/0. May be inoperative provided approach minimums do not require its use.

34-20-01 Radio Altimeter Systems

20-01-03. C/2/1 (M)(O) May be inoperative deactivated provided:
a) Approach minimums or operating procedures do not require its use,
b) Associated autopilot is not used for approach and landing,
c) Autothrottle is not used for approach and landing, and
d) Associated flight director is not used for approach and landing.
NOTE: During takeoff with one radio altimeter inoperative, the flight directors and autopilot should be controlled by the FCC on the same side as the valid radio altimeter (i.e., the first flight director and/or autopilot to be engaged must be receiving valid radio altitude data).

TK1951's fault was an airborne fault, and the MEL (a subset of the MMEL above) is not specifically applicable at that time, any NNCL or abnormal checks would apply. The MMEL hints to the interaction of an RA and the AT, but it isn't a glaringly obvious relationship when encountered at 500' AGL.

[RetiredBA/BY]

That’s why, in this age of system complexity and monitoring automation, it is vitally important that manufacturers keep improving cockpit ergonomics and don’t get let off the hook.

.....and even more important that basic handling skills are improved by many operators.

I have never flown a. NG but we had none of the current electronics in a -200, we managed perfectly
well but the arrival of the -300 made life even easier.

Sad to see the decline in basic skills of so many operators, almost all cost driven.

[BDAttitude]

Very well researched, analyzed and presented, by Sidney Dekker. A belated well done sir!
A shame that the report has taken 10 years to surface. It is still as valid today as it was then.

Just read pages 117-121 "Findings and Conclusions" if you are time constrained.

https://www.onderzoeksraad.nl/nl/media/inline/2020/1/21/human_factors_report_s_dekker.pdf
Indeed. And the second to last sentence should be hanging in any office of engineers designing and developing automation systems. Not only in aviation. But especially on the left coast of the US (Yes I'm looking at you Boeing & Tesla!).
The only defense against a designed-in single-failure path, in other words, are the pilots who are warned to mistrust their machine and to stare at it harder. Such a reminder, oriented only at the human operator in the system, is hardly credible after three decades of in-depth research into automated airliner flying and the subtle and pervasive ways in which automation on the flight deck (and particularly its subtle failure) affects human performance (e.g. Wiener & Curry, 1980, Sarter et al., 1997).

[BRE]

Well, here's the real problem. Put simply, there are far too many pilots that cannot perform and fly aircraft properly within its normal flight envelope well in all normal conditions, let alone with complex demanding technical issues when least expected and possibly fatigued. Talk to most long term sim TREs and they will tell you they have witnessed terrible things. The real question is how did we get to this? What lowered the standards? Who permits this? Are we heading in the wrong direction with children of the magenta just obsessed with the OFDM improved event safety stats, whilst we now witness terrible crashes where crews handle some serious events badly creating crashes? Look at Air France the crews pulling back for an eternity not recognising the stall; look at Turkish, not monitoring speed and thrust; look at several airliners below stall speed 85-100 kts with severe upsets following high power go arounds badly handled by crew. The writings in the wall, we need higher standards, and less self regulated back slapping.

Indeed, if crews cannot perform to the highest standards, they should not be on the flight deck. We cannot just blame solely aircraft design. This is a job for professionals to be just that.

The sooner we bring back respect for experienced professional flight crew the better. Right now there is a constant race to the bottom, whereby financial incentives push airlines to constantly favour inexperience pulling in at the bottom end, to the detriment of experience and safety. Then the self regulated training and checking just pushes crew through onto line. We need higher standards of training, experience and ability on the flight deck, then we must support those standards to be practised and maintained ready for any eventualities requiring that full demonstrated competence. Get rid of children of the magenta and get back to the important basics.


Not sure about that. There were plenty of accidents on steam powered aircraft that were due to loss of SA and lack of professionalism in the old days.

[OldnGrounded]

Ok point taken and apologies for missing your well made argument.
R Guy

No problem. We're all just trying to sort out a truly complex and confusing situation.

FYI, here's the relevant finding re: inadequate documentation, item 6 of Dekker's findings and conclusions:

Based on their training and documentation, the TK1951 crew would have believed that they had protected their aircraft and its flight from any pre-existing problems with the left RA. The right autopilot (known as Autopilot B or CMD B) had been selected on, and the right Flight Control Computer (known as FCC B) was giving it inputs.

Boeing pilot training materials and documentation do not reveal that the autothrottle always gets its height information from the left Radio Altimeter, that, on pre-2005 737NG models, it doesn’t cross-check its RA input data with other RA data; and that the right RA does not provide input to the autothrottle—even when FCC B has been selected as Master and Autopilot B is flying (which was the case for TK1951).

[Clandestino]

The NYT article, and the accident report, should reinforce the wake up call emerging from the Max saga. Not specifically directed Boeing, FAA, NTSB, but for world manufacturing, regulation, investigation and operations.
Alternatively as a bold safety statement, publishing the report anonymously with the objective of learning and changing even at this late stage.Uh-huh. It was the world's company that designed and built 737-800. It was the world's certifying authority that rubber-stamped it. It was the world's investigation organization that put the pressure on the Onderzoeksraad to play down the technical aspects of the disaster so it seems that the world was quite responsible. I wish there were some way we could narrow down the responsibility, at least to the country level or so.

Today's sky gods are so full of themselves with all the latest shimmy kit, they don't have an inkling of airmanship.
Safety statistics do not corroborate your claim.

There will always be pilots who are unable to respond effectively in an emergency or anomalous situation just as there are pilots who can do so successfully. So, in which group falls the captain of FlyDubai 981? Could he fly the missed approach or not?

What the heck is "airmanship" and why is it so great at saving airplanes that have been poorly designed??The greatness of airmainship lays in the fact it is cheaper than properly designing the aeroplanes plus you can always count on the (volunteer) army of fans to berate the pilots killed in the poorly designed aeroplanes for the lack thereof, thereby moving the focus from design to pilot.

As slf that article gives me shivers and i think this thread should be deleted asap.You might be able to stop the PPRuNE, but in the grand scheme of the things, PPRuNe is insignificant compared to the New York Times and it's the one you can't stop. Reporters have smelled the blood.

The only up-side of flying a 737, is that it makes you a better-than-average pilot. If you can fly a 737, than you can fly ANY Boeing airplane.I am glad to read that, as I have found 738 to be far easier to fly than Q400 and maybe I'll be searching for another type rating pretty soon.


wonkazoo, Ascend Charlie, et al,

“Airmanship is a personal attitude to flying, why we do it, how we do it. Airmanship must grow with training, experience, and personal exposure. It is not just about staying alive or not bending the airplane or yourself, it is about walking off the airfield knowing that you have both performed and crafted an activity. You have been totally aware of what you have done and why you enjoyed it, and a that point you owe nothing to anyone.” If we go by this definition, that leans heavily on the pilot's self-appraisal instead of the consequences of his or her actions, well then late Arthur "Bud" Holland would be one of the airmanshipest pilots that have ever walked the Earth. If we conveniently edit Czar 52 flight out of his biography, that is.

Put simply, there are far too many pilots that cannot perform and fly aircraft properly within its normal flight envelope well in all normal conditions, let alone with complex demanding technical issues when least expected and possibly fatigued.Safety statistics do not corroborate your claim.

Talk to most long term sim TREs and they will tell you they have witnessed terrible things. Pilots who perform terrible things are retrained until they do their flying in non-terrible way or are washed out.

The real question is how did we get to this? We got to what? To humongous discrepancy between real world's flying safety and PPRuNeload of claims we are doomed because pilots today can't fly? I would guess that huge holes in understanding how the modern aviation works and unwillingness to face the fact that air travel has never been safer were filled and compensated by industrial quantities of imagination and self-righteousness. Whether psychotropic substances played part, I can't speculate at the moment.

Are we heading in the wrong direction with children of the magenta just obsessed with the OFDM improved event safety stats, whilst we now witness terrible crashes where crews handle some serious events badly creating crashes? If there is really a plot to improve safety stats by killing less passengers and crew, I will gladly join it.

We cannot just blame solely aircraft design. You as "we" don't matter at all. FAA is blaming design enough that it grounded it and keeps it grounded.

Right now there is a constant race to the bottom, whereby financial incentives push airlines to constantly favour inexperience pulling in at the bottom end, to the detriment of experience and safety. There are no statistics or studies to corroborate your claim that safety is somehow diminished through the lack of experience. Personally, as someone who has flown with quite a few MPLs, ex-fast jet jocks and wobble to planks, I find the claims that the training standards are getting lower or that MPL is the doom of us all fairly ridiculous. Actually, those who tried hardest to kill me, themselves, our cabin crew and our passengers were the graybeards in the LHS who picked up all the wrong habits through experience.

[flash8]

We have been here before have we not, albeit many, many years ago with the THY DC-10 at ermenonville, a senior Convair engineer (subcontractor) on the project warned of a "fundamental failure mode" with the cargo door latching mechanism, which for reasons that remain murky to this day were never actually fixed on the fateful aircraft (ship 29) resulting in catastrophe.

That was the time the FAA chief admitted (wouldn't happen today) they were "Fat, dumb and happy" (verbatim) in oversight, a remarkable statement, they were the only party to come out with a little self-respect from the whole tawdry affair.

That there were no emails, social media or such back then of course, and the stamp on the forms that said the door work had been carried out seemingly falsified (again this was never resolved) with all and sundry denying everything (although the smoking gun was the Applegate memorandum) shows that today, hiding is far more difficult.

There are certainly parallels even though the cases are forty five years apart.

Incidentally the lawsuits that followed were the largest in history at that time (mid 1970's) with McDD never (I believe) admitting full culpability.

[Old Carthusian]

So, in which group falls the captain of FlyDubai 981? Could he fly the missed approach or not?

Tragically the evidence indicates not and the clue is in the conduct of the Aeroflot flight.

OC

[OldnGrounded]

So, in which group falls the captain of FlyDubai 981? Could he fly the missed approach or not?

I think that captain falls into the group of exhausted pilots repeatedly fatigued by inhuman rostering. Among other things.

[Clandestino]

You got it in one, OldnGrounded, now let me help our friends with somewhat Manichean worldview that separates pilots into sharply defined categories of "good" and "bad" by reminding them that the official report of A6-FDN catastrophe (https://mak-iac.org/upload/iblock/1e8/report_a6-fdn_eng.pdf) is full of references to successful first windshear escape and go-around, before the second, fatal one. So if we go by the philosophy that there are good and bad pilots (and its quite sinister implication, pervading the MAX threads that the bad pilots destroyed the good aeroplanes) , we would be at loss to explain how the good pilots turned into the bad in the matter of hours.

[RetiredBA/BY]

Actually it’s not so simple in the Max case - flying manually allows MCAS to run - AP on inhibits MCAS.

In fault mode, switching off the automatics - or thinking you have, leads to this Gotcha, where you still have a rogue system fighting you.

As it happens, leaving flap out and or AP engaged would have enabled an approach to land - but who could know that at the time?

So the macho just fly it method has its limits.


Excuse my ignorance but isnt the MCAS switched off by the stab.trim cutout switches ?

Trimming by the handwheel.

Nothing macho ( or holier than thou etc.,) about flying a 737 manually, just basic flying skill, which should be possessed by EVERY pilot.

[Old Carthusian]

You got it in one, OldnGrounded, now let me help our friends with somewhat Manichean worldview that separates pilots into sharply defined categories of "good" and "bad" by reminding them that the official report of A6-FDN catastrophe (https://mak-iac.org/upload/iblock/1e8/report_a6-fdn_eng.pdf) is full of references to successful first windshear escape and go-around, before the second, fatal one. So if we go by the philosophy that there are good and bad pilots (and its quite sinister implication, pervading the MAX threads that the bad pilots destroyed the good aeroplanes) , we would be at loss to explain how the good pilots turned into the bad in the matter of hours.

Clandestino

I would say that 'bad' and 'good' are being used to create unrestricted generalizations. Even though it is the case that there are indeed such 'types' and that certain people are indeed trying to smear the pilots in the MAX accidents to protect Boeing you make your point poorly. The example chosen is a case of a pilot getting it horribly wrong and the first successful go around is irrelevant to the outcome apart from being one of the links in the causal chain which led to a lot of unnecessary deaths. I am all in favour of greater automation as it is likely that it would eliminate accidents like this one but to my mind the issue is more to do with corporate irresponsibility and the moral bankruptcy reigning at Boeing. A pilot should have all the information he needs about his aircraft to be able to fly it successfully. Unfortunately it is an aspect of American corporate life that uncomfortable facts, flaws in the product and developments are hidden if they impact the bottom line. The Boeing behaviour in the Turkish accident is regrettably not unusual and will continue, if not at Boeing, at other companies. It is always thus where money is placed on a pedestal.

The answer is that the regulatory authorities resist this kind of pressure and remain pure. However, this is perhaps a pipe dream.

OC

[OldnGrounded]

Excuse my ignorance but isnt the MCAS switched off by the stab.trim cutout switches ?

Trimming by the handwheel.

Nothing macho ( or holier than thou etc.,) about flying a 737 manually, just basic flying skill, which should be possessed by EVERY pilot.

Actually, it may well be that trimming with the hand wheels could take as much or more strength than could be mustered, together with some rather fancy (and untrained) flying skills, at some attitudes and dynamic loads. This issue has been part of the discussion since soon after ET 302 went down. Here's a starting point:

https://www.satcom.guru/2019/04/stabilizer-trim-loads-and-range.html

[Twitter]

Excuse my ignorance but isnt the MCAS switched off by the stab.trim cutout switches ?

Trimming by the handwheel.

Nothing macho ( or holier than thou etc.,) about flying a 737 manually, just basic flying skill, which should be possessed by EVERY pilot.

No point in going over it all again R Baby but briefly those switches don’t switch off MCAS - they switch off the Stab trim, which MCAS attempts to operate. MCAS can only be disabled by Slats out or and AP on.

My poorly made point was that disconnecting AP/AT and flying manually will not on it’s own get you out of this mess, as it would out of most others. Indeed, leaving the AP engaged would be beneficial in the special case of MCAS rogue operation. Problem is the Speed Disagree situation / Stall warning preventing this.

As recommended by Oldn’ see early threads for more on this and Trim wheel diameter problems.

Manual flying is of course not macho (some commentators are.) It is one of the most satisfying things to do and probably why we became pilots.

[Ian W]

No point in going over it all again R Baby but briefly those switches don’t switch off MCAS - they switch off the Stab trim, which MCAS attempts to operate. MCAS can only be disabled by Slats out or and AP on.

My poorly made point was that disconnecting AP/AT and flying manually will not on it’s own get you out of this mess, as it would out of most others. Indeed, leaving the AP engaged would be beneficial in the special case of MCAS rogue operation. Problem is the Speed Disagree situation / Stall warning preventing this.

As recommended by Oldn’ see early threads for more on this and Trim wheel diameter problems.

Manual flying is of course not macho (some commentators are.) It is one of the most satisfying things to do and probably why we became pilots.

Switching off stab trim (Stab Trim Cut Out Switches) prevents any stab trimming and that stopped Version 1 MCAS having any effect. So it may have been running inside the STS subsystems - but it could not do anything to affect the operation of the aircraft. From reports the updated MCAS will not repeatedly operate so the main problem of MCAS re-initializing and repeating a ND trim after any electric trim input has been removed in the Max from now on. The initiation of the problem caused by the single point of failure of only using one AoA vane has also been removed by the MCAS being linked to both AoA vanes. In other words the direct MCAS threat has been removed.
So your post should really use the past tense.

[BDAttitude]

Switching off stab trim (Stab Trim Cut Out Switches) prevents any stab trimming and that stopped Version 1 MCAS having any effect. So it may have been running inside the STS subsystems - but it could not do anything to affect the operation of the aircraft. From reports the updated MCAS will not repeatedly operate so the main problem of MCAS re-initializing and repeating a ND trim after any electric trim input has been removed in the Max from now on. The initiation of the problem caused by the single point of failure of only using one AoA vane has also been removed by the MCAS being linked to both AoA vanes. In other words the direct MCAS threat has been removed.
So your post should really use the past tense.
We haven‘t seen the updated version life, have you? Just vapour ware. Can‘t see why past tense should be mandatory.

[retired guy]

[QUOTE=BDAttitude;10669672]We haven‘t seen the updated version life, have you? Just vapour ware. Can‘t see why past tense should be mandatory.[/QUOTE

HI BD
I think the three basic fixes to MCAS were developed long ago. It’s just that loss of confidence in FAA is slowing down approval. Past tense is appropriate because by the time it’s recertified, which it will be, the Max Will be the most tested airplane ever- maybe more than Concorde. You have no evidence that it’s “vapour ware”- apart from a hunch?
here is some well reasoned commentary from a couple of sources. Looks good to me.Boeing’s worst ever nightmare just got even worse with an announcement from the company yesterday that its own best estimates for ungrounding of the plane by the FAA have been shifted back to mid-2020.

Updating 737 MAX customers and the investment community yesterday Boeing said that:

“We are informing our customers and suppliers that we are currently estimating that the ungrounding of the 737 MAX will begin during mid-2020. This updated estimate is informed by our experience to date with the certification process. It is subject to our ongoing attempts to address known schedule risks and further developments that may arise in connection with the certification process. It also accounts for the rigorous scrutiny that regulatory authorities are rightly applying at every step of their review of the 737 MAX's flight control system and the Joint Operations Evaluation Board process which determines pilot training requirements.

Returning the MAX safely to service is our number one priority, and we are confident that will happen. We acknowledge and regret the continued difficulties that the grounding of the 737 MAX has presented to our customers, our regulators, our suppliers, and the flying public. We will provide additional information about our efforts to safely return the 737 MAX to service in connection with our quarterly financial disclosures next week”.

Having fallen 5.5% on the back of media reports Boeing shares were suspended ahead of the formal announcement. With close to 5,000 737 MAX planes ordered and so far, 387 of the grounded planes delivered to airline customers and maybe close to 400 currently stored awaiting delivery the next six months will be crucial to Boeing as they also will to airline customers that had hoped the aircraft would have been ungrounded this month and to those that had planned on receiving new aircraft.

In respect of ungrounding the airplane Boeing remains in the hands of the FAA just as it also does internationally with other global regulators that have followed suit in grounding the airplane. Additional software related issues announced by the company earlier this month relating to the power-up monitoring function that verifies some system monitors are operating correctly will likely be a partial cause of the additional delay in ungrounding but with the FAA having been found wanting in the manner in which certification of the 737 MAX was conducted there can be little doubt that regulators are not prepared to allow the aircraft to fly again until they are satisfied on each and every issue involved including airline pilot training is deemed perfect.

Boeing has itself worked extremely hard to ensure that when the 737 MAX is allowed to return to airline service that each and every issue has been resolved. The change in CEO from Dennis Muilenburg to David Calhoun has had a dramatic impact right across the company and led to some radical changes. This is very evident in the more honest, open and transparent manner in which that Boeing is keeping its customers, investors and airline community involved. There may of course be other issues that we may never know about and that relate to how the two tragic incidents occurred – this including possibilities of incorrect pilot operation in regard of the MCAS flight control system that is judged to be the main issue behind both incidents. But the point is that Boeing has put its hands up, taken full responsibility for what occurred and to ensure that when the 737 MAX flies again it will begin the long process of earning a reputation of being a very safe plane.

Speculation as the whether the 737 MAX will fly again is nonsense – it will and my personal view is that while the next couple of years are going to be tough as Boeing reverses the negative profile that has been attached to 737 MAX since the grounding. Boeing has taken all the many negative aspects surrounding the 737 MAX on the chin and it is in my view nonsense to suggest that it might walk away from 737 MAX and, as I heard suggested earlier today, possibly move back to producing 737-800’s.

The cost of 737 MAX accidents and subsequent grounding has been put at around $9.2 billion so far. Undoubtedly this will rise further still in the months ahead. Nevertheless, Boeing is a strong company and it will in my view pull through this crisis in its affairs albeit that there remain many bumps for the company over the next year.

In respect of order Boeing has said that number of 737 MAX planes ordered since the grounding roughly match the number of cancellations received. Airlines continue to have confidence that together Boeing and the FAA regulators will get this right and that 737 MAX will have a good future.

Getting the 737 MAX airplane back in the air is not just an issue for Boeing but also one for its competitors. Growth this year will have been negatively impacted by the 737 MAX grounding and while it is only Boeing’s reputation that has suffered, I venture to suggest that the whole industry has suffered as a result.

As to speculation as to whether Boeing might begin the process of designing a replacement aircraft, for the 737 MAX soon, I would say that this is no more likely today than it was two years ago. 737 MAX just as the main and hugely successful Airbus A320 NEO family of aircraft have evolved from their predecessor aircraft. To design, research, develop and build a completely new aircraft and take it through to certification is a ten-year process. However, I venture to suggest that the next generation single aisle/ narrow body replacements for 737 MAX and the highly successful competing Airbus A320 NEO family of aircraft will be very different from those that we fly in today.

Boeing will not allow itself to fall behind its competitors but I do not believe that it is ready to move into a single aisle replacement process yet. The commercial aircraft industry isn’t built like any other – new aircraft today have to be designed to accommodate not only the needs of the airline industry customer, technological and potential cost advantage but in this day and age, acceptance of greatly increased environmental pressures placed on the manufacturers and which translates to achievement of greatly improved fuel efficiency and ultimately, making greater use of non-fossil fuels.

The bottom line is that the next generation of commercial aircraft will be very different from those of today and it just maybe that while the commercial aircraft industry will continue to grow as those continents such as Africa and South America that have not enjoyed the benefits that we have provide new areas of growth whilst those of us in mature markets place even greater emphasis on environmental issues and cost. Whatever, just as Airbus undoubtedly will, I also believe that when it has moved through this dreadful crisis in its affairs, Boeing will also prosper.

[alf5071h]

Translation from
https://www.telegraaf.nl/nieuws/1151995056/kamer-wil-boeing-topman-spreken-over-vliegcrash-turkish-airlines

THE HAGUE - On 6 February, the House of Representatives wants to question Boeing's chief executive David Calhoun about a plane crash at Schiphol in 2009. The central question will be whether pressure has been exerted from the United States on investigations by the Dutch Safety Board (OVV). It remains to be seen whether Calhoun will come.

The committee has also invited, among others, OVV chairman Jeroen Dijsselbloem and researcher Sidney Dekker, who was involved in the investigation. Former OVV chairman Pieter van Vollenhoven is also on the guest list.
A Boeing 737 from Turkish Airlines crashed on 25 February 2009 shortly before landing at Schiphol. Nine passengers were killed. The OVV investigated and concluded that the crash was caused by a defective altimeter, in combination with crew errors.

Minister Cora Van Nieuwenhuizen (Infrastructure) said on Tuesday that she cannot assess whether the story is correct. "The OVV itself must state that," said the minister. In her view, it is common for the parties involved to be able to comment on the findings of the Research Council, as long as that is limited to factual inaccuracies. "There must of course never be any influence on recommendations or conclusions."

There must of course never be any influence on recommendations or conclusions.

[Callsign Kilo]

The most recent variant of the 737 is a debacle, one that Boeing will carry the burden for years to come. It’s predecessor, albeit another cut & paste job, isn’t. Its not without its limitations however fundamentally it remains a basic aeroplane that rarely leaves you in a state of overwhelming WTF. The reason why this aircraft crashed was that three people let it crash. One of the basics of flying is airspeed. This accident was a nonsense and remains nothing more than a lesson in poor airmanship & monitoring.

[retired guy]

Well said that man

Herod
can I second or “third”:that? Hurrah- I detect more posts supporting that view.

We refer of course to the need for basic flying skills/CRM/Airmanship, being retained and trained, or in some airlines, re-trained. or even trained for the first time in these skills. Quite a challenge isn’t it?

There seem to be two camps here in these forums. - “engineer-out” the pilots because they can no longer be expected to emulate the extraordinary skills of people like Eric Moody who’s crew saved the Jumbo over Jakarta. Eric would say, and has done , that he was just doing his job, like Sully. He was an average pilot in that airline. He never claimed to be a Tex Johnson or Chuck Yeager.

Or train them to handle the plethora of multiple failures that can occur on any plane with a cascading domino effect Non-normal procedures with confusing and sometimes contradictory annunciations.. like stick shaker rattling at the same time as the high speed warning. (look at the pitch,power and GPS for a clue would be good start).

QF A380 ex SIN was a classic example of the need, on even the very latest equipment, to be able to access a wide range of high level skills to prioritise the 50+ warnings they had with a partially crippled aircraft.
The lack of skills and training on AF447 was not a mile away from recent events. So it’s not just entry level startups that need these skills. We all need to hone them. Even some legacy airlines where perhaps we need to get back to basics.

The big question for the industry remains “ who is going to do this training?”
it is not unusual in start ups & LCC to have trainers as young as 25, who then train the 20 year old cadets , who 5 years later become trainers. There is every opportunity with that model for a sort of aeronautical inbreeding, with no wise heads to guide them. Add in the airline starting up its own Flight Academy and we’re all set to mark our own homework.
i guess my question is this- why are there so many on these forum topics who object to thorough pilot training?
if you’re a CFO counting the beans then I can see that it would frighten you to the core. But most commentators here seem to be either pilots or passengers who it would seem to me should be crying out for intensive training which has now finally been mentioned as a causal contributing factor in the two Max crashes.
Just curious. best wishes
R Guy

[Old Dogs]

– this including possibilities of incorrect pilot operation in regard of the MCAS flight control system that is judged to be the main issue behind both incidents.


How do you incorrectly operate a system you don't know about?

[retired guy]

.....and even more important that basic handling skills are improved by many operators.

I have never flown a. NG but we had none of the current electronics in a -200, we managed perfectly
well but the arrival of the -300 made life even easier.

Sad to see the decline in basic skills of so many operators, almost all cost driven.

BA
On the money, literally, with that post. Saving money on safety will always end in tears. “ if you think safety is expensive, try having two accidents!” Ask Boeing , even though they were not entirely to blame as there were many other factors.
And if Boeing were an airline that suffered two related crashes, or even unrelated, it’s bye bye. Billions of dollars and years of investment gone in a few weeks maybe. No jobs. So sad.
And the cost of real safety v lip service to safety is not high. Maybe 2\5 % of turnover. Measured against the cost of Armaggedonn as faced by Boeing currently its an easy form of insurance.
look fwd to any views on that sort of thing.
Safe flying
RvGuy

[retired guy]

How do you incorrectly operate a system you don't know about?

Hi Old Dogs
My guess is because after the AD post Lionair, it was known about and Boeing said “;treat it like a runaway stab” which most assuredly it is. “ Continuously” means without stopping, or a quick succession of similar events.
“my wife nags we continuously “. Presumably she draws breath between each bout of nagging? But it will eventually cause you to lose the will to live. And vice versa for the PC types. Men can nag too.

similarly a stabilizer which runs AND , over and over , always in the same direction, with a very short pause is by any definition in the dictionary “:Continuous” yes?
Especially since we all studied that AD assiduously post Lionair to make sure a similar fate would not befall us.
thats how we stay safe. Learn from others. These days more than ever we need to learn from the published errors which are available on line every day on the likes of of AV HERALD and AEROINSIDE free of charge.
Everyday I read about maybe 15/major incidents. Some handled brilliantly. Others leave something that might have been done much better. FYI every day there are around three engine failures and a rising number of smoke fume events- some really nasty. Loads of learning free of charge.
Safe Flying
R Guy

[Old Dogs]

So, during the training of the Lion Air and Ethiopian crews they were never taught that an MCAS system was installed on the MAX (unlike the NG they were used to flying), how the MCAS system worked and trained in MCAS normal/abnormal use?

Can we assume all the Southwest, et al, and other American crews were trained on the MCAS system?

I ask because my buddy who flew MAX's for WestJet had no idea MCAS was installed.

Just another dumb Canadian pilot, I guess.

And one must wonder, if the problem is just dumb aircrew why is the MAX still on the ground?

Surely the fix for dumb aircrew is better training, not rebuilding the complete MCAS system?

[fdr]

Hi Old Dogs
My guess is because after the AD post Lionair, it was known about and Boeing said “;treat it like a runaway stab” which most assuredly it is. “ Continuously” means without stopping, or a quick succession of similar events.
“my wife nags we continuously “. Presumably she draws breath between each bout of nagging? But it will eventually cause you to lose the will to live. And vice versa for the PC types. Men can nag too.

similarly a stabilizer which runs AND , over and over , always in the same direction, with a very short pause is by any definition in the dictionary “:Continuous” yes?
Especially since we all studied that AD assiduously post Lionair to make sure a similar fate would not befall us.
thats how we stay safe. Learn from others. These days more than ever we need to learn from the published errors which are available on line every day on the likes of of AV HERALD and AEROINSIDE free of charge.
Everyday I read about maybe 15/major incidents. Some handled brilliantly. Others leave something that might have been done much better. FYI every day there are around three engine failures and a rising number of smoke fume events- some really nasty. Loads of learning free of charge.
Safe Flying
R Guy

Still laughing, not at you... well said. married life, and the will to live.

So the pilots are supposed to be the fault, even after the SB was raised, which of course added all the information that was needed to manage the defect, except, did anyone mention the manual trim would be unable to be overpowered? Ooops, nope, weasel legal terms applied, fly to trim speed.... yep, about 500KIAS, How about the fact that the trim rate of MCAS was 1/2 an order of magnitude greater than the rate of manual trim? Nope. Not a word of that. Why? as the manufacturer didn't know what had been done or the impact operationally. Yet, our reporters at large blame a 300hr pilot for... what? being a young pilot? Is that a compliance issue? is there a law out there that you cannot be a pilot until you have 10,000 hours command on... whatever? You have to be 101 years old in order to have the experience necessary to make up for a goatF&#@ in the design of the aircraft by experts?

We assume that Boeing, FAA, EASA and the rest have some skills, so how come the fault is the pilot when everyone else missed the issue?

GT needs to learn about causation, or get a pacifier and go sit in a corner.

As mentioned previously, if it was just the pilot then the plane would already be flying... and we would have a training program implemented for GT's incompetent crews. If there is a god, then perhaps that god will give GT the pleasure of dealing with a unknown flight control problem airborne. From my experience, it will give some clarity to your religious beliefs promptly. Try being in a life threatening situation dealing with a system that does not respond to your training, or the sage advice just provided by the OEM which just happens to be missing a couple of salient points.

[MechEngr]

So, during the training of the Lion Air and Ethiopian crews they were never taught that an MCAS system was installed on the MAX (unlike the NG they were used to flying), how the MCAS system worked and trained in MCAS normal/abnormal use?

Can we assume all the Southwest, et al, and other American crews were trained on the MCAS system?

I ask because my buddy who flew MAX's for WestJet had no idea MCAS was installed.

Just another dumb Canadian pilot, I guess.

And one must wonder, if the problem is just dumb aircrew why is the MAX still on the ground?

Surely the fix for dumb aircrew is better training, not rebuilding the complete MCAS system?

5 MONTHS AFTER THE MCAS BULLETIN AND NOBODY REALLY UNDERSTOOD IT AT ET.
https://www.youtube.com/watch?v=5fVVqfJnNIY

Better training might have been the answer, but many airlines chose not to do anything about it.

[Old Dogs]

Try being in a life threatening situation dealing with a system that does not respond to your training, or the sage advice just provided by the OEM which just happens to be missing a couple of salient points.

Good point.

Many years ago I had a main rotor blade delamination in a Bell 212 (twin Huey).

The aircraft rolled upside down, wouldn't respond to the controls properly and was bangin' like h$ll.

I had NO CLUE what was wrong - but I knew it was bad.

Irish luck got the rocket back on the ground and it was determined that the inflight damage was so severe the aircraft was totalled.

Never wanna do anything like that again. 😳

[568]

.....and even more important that basic handling skills are improved by many operators.

I have never flown a. NG but we had none of the current electronics in a -200, we managed perfectly
well but the arrival of the -300 made life even easier.

Sad to see the decline in basic skills of so many operators, almost all cost driven.

BA
On the money, literally, with that post. Saving money on safety will always end in tears. “ if you think safety is expensive, try having two accidents!” Ask Boeing , even though they were not entirely to blame as there were many other factors.
And if Boeing were an airline that suffered two related crashes, or even unrelated, it’s bye bye. Billions of dollars and years of investment gone in a few weeks maybe. No jobs. So sad.
And the cost of real safety v lip service to safety is not high. Maybe 2\5 % of turnover. Measured against the cost of Armaggedonn as faced by Boeing currently its an easy form of insurance.
look fwd to any views on that sort of thing.
Safe flying
RvGuy

With respect,
Since you have never flown the NG, and by your account only the -200, then these two variants are world's apart from the MAX.
I don't know if you have read the entire threads on the ET accident or the Lion Air, but in the flight envelope the crew were faced with they couldn't manage to control the pitch down movements of the stab provided by MCAS due to it's incorrect triggering.
Because of the lack of technical information provided by Boeing to pilots of the MAX, one would assume that no matter where you were trained or from what part of the world that you reside, fundamentally the airplane didn't react in the same way a normal NG would.
There were additional "nuisance cautions" sounding off (and other warnings) which weren't normal for a "stab" runaway situation as compared with the NG or earlier series.
Many human factors and cockpit design errors will come to light from these two tragedies and make modern transport planes even more safer and user friendly.

[BDAttitude]

HI BD
I think the three basic fixes to MCAS were developed long ago. It’s just that loss of confidence in FAA is slowing down approval. Past tense is appropriate because by the time it’s recertified, which it will be, the Max Will be the most tested airplane ever- maybe more than Concorde. You have no evidence that it’s “vapour ware”- apart from a hunch?
here is some well reasoned commentary from a couple of sources. Looks good to me.Boeing’s worst ever nightmare just got even worse with an announcement from the company yesterday that its own best estimates for ungrounding of the plane by the FAA have been shifted back to mid-2020.

...

Hi retired guy,

I know that there has been some extensive work done on MCAS, but I am also aware that there are still sitting 600+ aircraft sitting on the ground with MCAS V1 loaded on their FCC. The term "vapor ware" is assigned in the software world to software releases that are announced but then delayed again and again which is a which is pretty good description on what happens with the FCC software release containing the MCAS fix.
Further, until now, there is still lacking an official description of exact system behaviour of MCAS V2 - only rumors - or did I miss something here?
I do know there are rumors about latching so a single trigger event and reduced authority but nothing detailed. But I would have some very detailed questions here. E.g. what would be the conditions to allow triggering for second MCAS event. What does happen in case of a AOA disagree in flight or even worse, during active MCAS intervention - software wise and procedure / check-list wise. Until now, no information whatsoever. Also no information about the position of regulators on the sufficiency of these measures. However we do know some regulators were critical about the two vane design. While there has been reports of "new" problems, like trim forces, cable position and initialization hick-ups, it is still hush-hush about the actual status of the "not-an-anti-stall"-system.
So if this entire sad story - by first estimations the planes should have been back flying since June last year - shows one thing: There is no fix until the plane is ungrounded, not only in the US but also in Europe and in China.
I am still sure this will happen - but calling the affair settled and refering to it in past tense is still a bit early in my humble opinion.

[safetypee]

Recent posts deviate, distract from the thread subject. Perhaps if Dr Dekker were to publish a similar report on the Max incidents there would be substantiated opinion to discuss opposed to raking over dead coals.

Whereas the AMS HF report could have political ramifications, there is far greater value in the explanation of HF in the reality of operations, which we can all learn from.

If only we might learn or understand what should, could be learnt; but that's difficult for closed minds.

[Semreh]

Hi Old Dogs
My guess is because after the AD post Lionair, it was known about and Boeing said “;treat it like a runaway stab” which most assuredly it is. “ Continuously” means without stopping, or a quick succession of similar events.
“my wife nags we continuously “. Presumably she draws breath between each bout of nagging? But it will eventually cause you to lose the will to live. And vice versa for the PC types. Men can nag too.

similarly a stabilizer which runs AND , over and over , always in the same direction, with a very short pause is by any definition in the dictionary “:Continuous” yes?
Especially since we all studied that AD assiduously post Lionair to make sure a similar fate would not befall us.
thats how we stay safe. Learn from others. These days more than ever we need to learn from the published errors which are available on line every day on the likes of of AV HERALD and AEROINSIDE free of charge.
Everyday I read about maybe 15/major incidents. Some handled brilliantly. Others leave something that might have been done much better. FYI every day there are around three engine failures and a rising number of smoke fume events- some really nasty. Loads of learning free of charge.
Safe Flying
R Guy
Actually no. The behaviour you describe, in a dictionary definition, is continual, not continuous. https://grammarist.com/usage/continual-continuous/
The behaviour of MCAS in the crash flights was not continuous, but continual. The trigger for MCAS was a continuous incorrect signal from the AoA indicator relied upon by the MCAS software, but the effect was continual pitch down commands to the stabiliser, some of which, to complicate matters, were ignored/unactioned in the periods during which the stab trim was deselected manually.
The difference, in English, is important. Certainly, I would expect a technical manual to be written carefully and for the writer to understand the difference between continuous and continual when writing a diagnostic procedure.

[RetiredBA/BY]

[QUOTE=retired guy;10669859]

With respect,
Since you have never flown the NG, and by your account only the -200, then these two variants are world's apart from the MAX.
I don't know if you have read the entire threads on the ET accident or the Lion Air, but in the flight envelope the crew were faced with they couldn't manage to control the pitch down movements of the stab provided by MCAS due to it's incorrect triggering.
Because of the lack of technical information provided by Boeing to pilots of the MAX, one would assume that no matter where you were trained or from what part of the world that you reside, fundamentally the airplane didn't react in the same way a normal NG would.
There were additional "nuisance cautions" sounding off (and other warnings) which weren't normal for a "stab" runaway situation as compared with the NG or earlier series.
Many human factors and cockpit design errors will come to light from these two tragedies and make modern transport planes even more safer and user friendly.


Read my post again.

I did not say I had flown ONLY the 200 I was one if the first captains checked out on the -300 whose automatics were probably the start of those on the NG and MAX !

I did my -200 course at Boeing with Chet Ekstrand as my instructor. I seem to remember, but it was 40 years ago, that the teaching was that if the trim wheel was rotating and not because of manual trim inputs or autopilot trimming, then you had a trim runaway and the IMMEDIATE, RECALL, action was stab trim switches to OFF.

With prompt action the aircraft would probably not be far out of trim and could be trimmed manually.

That said, perhaps I am more “sensitive” than most to stab. Runaways which the MCAS effectively was.

Back in 1964 I was posted to 207 squadron as part of the crew to replace those killed in the Valiant crash at Market Rasen, believed to have been caused by a TPI runaway.

We then had a drill rammed into us that a TPI runaway required IMMEDIATE action by both pilots as the tailplane could JUST be overcome by elevator input but required the full strength of both pilots. That remained with me for the rest of my career. I spent some time on the Canberra , too, which had a number of tailplane runaways leading to fatal ground or sea impact, in its early days, not forgotten by those of us who flew it.

My apologies if my memory is failing me !

[Semreh]

It is interesting reading the full report in the light of the MCAS involved crashes, especially the Lion Air crash.

The Dutch report on the crash of Turkish TC-JGE, 25 Feb 2009 (http://reports.aviation-safety.net/2009/20090225-0_B738_TC-JGE.pdf) made a point of asking Boeing about the procedure when an instrument is identified as inoperative during the flight (Section 1.2.4 on page 18), but in Appendix N, Similar Occurrences (p 204)
TC-JGE was involved in two similar occurrences, which became known by the flight data recorder.

Incident A
TC-JGE made an ILS approach for runway 27L with two autopilots engaged at London Heathrow airport in England on 23 February 2009. The captain’s radio altimeter system (left) displayed a negative value and both autopilots disengaged when an altitude of 500 feet was passed. The auto-throttle ‘retard flare’ mode was activated and at this point the throttles moved aft. The airspeed dropped below the selected speed. After four seconds the crew disengaged the autothrottle and manually brought the throttles forward. Subsequently, the aircraft landed safely.

Incident B
TC-JGE made an ILS approach for runway 23R with the right autopilot engaged at Damascus air-port in Syria on 24 February 2009. The captain’s radio altimeter system (left) specified a negative value when an altitude of 4000 feet was passed. After the flaps were selected at approximately 2500 feet, the autothrottle activated the ‘retard flare’ mode. The airspeed at this time was 209 knots and the selected speed was set on 155 knots. After having flown at 1500 feet for 74 seconds, the airspeed went below the selected speed. The speed was 16 knots below the selected speed at 1400 feet. The throttles were moved forward; a nose up movement ensued with an increase in alti-tude and speed. Subsequently, the crew reduced the selected speed to 138 knots. A few seconds later the crew disengaged the autothrottle and autopilot. The ‘retard flare’ mode had been activate for 94 seconds.

So, much like the problems associated with the AoA indicator in Lion Air, there was a history of problems with the RA, and the third pilot in the cockpit even mentioned the RA fault on the crash flight - but in this case, the flight continued to have problems that were not solved in time to prevent the crash.

Like many crashes, there are a lot of holes leading up to the final incident. I do not wish to fan the 'pilot error' flames by providing an example where two previous crews resolved the issues successfully and thus saying the third set were deficient: rather this seems to point to a systemic fault that was not identified and relied on humans to solve the problem: which, as we know, will not work every time.

It is also worth underlining that the pilots on the fatal crash did not know that the autothrottle would continue to rely on the faulty radio-altimeter. The information was available to Boeing, and published in documentation not available to the pilots, as described by Decker's (https://www.onderzoeksraad.nl/nl/media/inline/2020/1/21/human_factors_report_s_dekker.pdf) report on page 36.

The human factors failures here are glaring.

[alf5071h]

The Dutch review #83 could get very messy:-

- Boeing do not attend … unlikely scenario.

- Boeing submits a formal denial which might deflect the issue towards the NTSB - they were the 'accredited representative', Boeing was only a 'party' in the investigation. Avoids difficult questions.

- Boeing attends or are represented; difficult questions to be answered, which again could be redirected to the NTSB.

- Dutch view "… it is common for the parties involved to be able to comment on the findings of the Research Council, as long as that is limited to factual inaccuracies." Implying that Boeing could have commented - which they did via NTSB, but apparently not on the HF report. See the accident report, appendix M, NTSB/Boeing comments ( page 140), without any reference to the Dekker report (did NTSB/Boeing see the Dekker report; hard to believe they did not).

- The Dutch investigators might have downplayed the HF report as not being sufficiently 'factual', HF is only soft science. Yet the industry accepts HF for training and knowledge to improve human behaviour and safety.

- There may have been decenting opinion, but not published.

- Alternative HF commentary could have been sought; more experts, greater opportunity for split opinions, but it would be difficult to overcome the weight of a world-renown HF investigator, type rated on the 737, who's report references world wide, and specifically US research.

A likely outcome; accept differing views and move on.
The Dutch House of Representatives could direct their investigators to treat HF as factual, a good example for other Nations and reinvigorate ICAO advice in Annex 13.

Keep lawyers, commerce, and manipulation of public opinion out of investigations.

Dr Dekker; please publish similar reports on 737 Max, 777 SFO, AF447, CRJ Sweden.

[MechEngr]

Actually no. The behaviour you describe, in a dictionary definition, is continual, not continuous. https://grammarist.com/usage/continual-continuous/
The behaviour of MCAS in the crash flights was not continuous, but continual. The trigger for MCAS was a continuous incorrect signal from the AoA indicator relied upon by the MCAS software, but the effect was continual pitch down commands to the stabiliser, some of which, to complicate matters, were ignored/unactioned in the periods during which the stab trim was deselected manually.
The difference, in English, is important. Certainly, I would expect a technical manual to be written carefully and for the writer to understand the difference between continuous and continual when writing a diagnostic procedure.
Nothing, therefore, in the flying of a plane is continuous. Every plane ends up on the ground and either in a smoking hole or, more often, the scrap yard.
Every. Single. Thing. Is. Intermittent.
I'm glad to explain how, in English, "continuous" has no meaning.

[Semreh]

@MechEngr

Nothing, therefore, in the flying of a plane is continuous. Every plane ends up on the ground and either in a smoking hole or, more often, the scrap yard.
Every. Single. Thing. Is. Intermittent.
I'm glad to explain how, in English, "continuous" has no meaning.

Does that mean continuous functions (https://en.wikipedia.org/wiki/Continuous_function) have no meaning?

If you can understand the concept of an expected duration of a process, you can talk meaningfully about the process being continuous if it is not interrupted within the expected duration, or continual if it is interrupted a number of times within the expected duration. If we talk about a 'runaway stabiliser', it would be expected to continue until it reached the end-stops unless a manual cut-out is performed. If a stabiliser movement ceases without manual input, then restarts without manual input later, one can talk about an interruption. If the stabiliser moves in a particular direction, stops, then continues to move again several times, then it is moving continually.

Obviously, but unhelpfully, in the limit, when time goes towards infinity, all processes can be expected to terminate at some point, so yes, in the perspective of unlimited time, no process is continuous. If you limit, or focus your view on a finite subset of time, then a process can be said to be continuous over that segment if there are no discontinuities/interruptions.

I hope that clarifies things sufficiently for you.

[Sallyann1234]

In respect of ungrounding the airplane Boeing remains in the hands of the FAA just as it also does internationally with other global regulators that have followed suit in grounding the airplane.

But that isn't right is it? It was the FAA who "followed suit" in grounding the airplane, after CAAC and EASA and others did so, and after FAA had just said that "Thus far, our review shows no systemic performance issues and provides no basis to order grounding the aircraft".

One might suppose that since the FAA was reluctant to follow the other regulators in grounding the aircraft, the others may also be slower in allowing it to fly again.

[MechEngr]

@MechEngr



Does that mean continuous functions (https://en.wikipedia.org/wiki/Continuous_function) have no meaning?

If you can understand the concept of an expected duration of a process, you can talk meaningfully about the process being continuous if it is not interrupted within the expected duration, or continual if it is interrupted a number of times within the expected duration. If we talk about a 'runaway stabiliser', it would be expected to continue until it reached the end-stops unless a manual cut-out is performed. If a stabiliser movement ceases without manual input, then restarts without manual input later, one can talk about an interruption. If the stabiliser moves in a particular direction, stops, then continues to move again several times, then it is moving continually.

Obviously, but unhelpfully, in the limit, when time goes towards infinity, all processes can be expected to terminate at some point, so yes, in the perspective of unlimited time, no process is continuous. If you limit, or focus your view on a finite subset of time, then a process can be said to be continuous over that segment if there are no discontinuities/interruptions.

I hope that clarifies things sufficiently for you.

The trigger for MCAS to resume is that a pilot made a trim input. Otherwise it was a one-shot. So it only restarted in response to manual input. And it moved continuously over that finite subset interval of time. It did not change speed or direction.

Awaiting a CVR transcript where the pilots are discussing continuous vs continual and that because it was continual, that the 60+ pounds of force required to hold the nose up required no trim to offset it.

[Semreh]

The trigger for MCAS to resume is that a pilot made a trim input. Otherwise it was a one-shot. So it only restarted in response to manual input. And it moved continuously over that finite subset interval of time. It did not change speed or direction.


So you agree that MCAS is not continuous, and therefore it is entirely reasonable not to characterise its operation as continuous/runaway, so not applying the runaway stabiliser QRH procedure is a reasonable (non) response?

The Runaway Stabiliser QRH characterises 'Runaway Stabiliser' as:

"Condition: Uncommanded stabilizer trim movement occurs continuously."

MCAS can be 'one-shot' or continual, interrupted by Stab Trim operations, and operating again if the MCAS trigger conditions still apply 5 seconds later. It is not, as you point out, continuous, which is enough to put doubt into the mind of a cognitively overloaded pilot whether the Runaway Stab QRH is appropriate.

It doesn't help that STS operates by executing uncommanded stabiliser movements, so pilots regard that as normal operations. Seeing and hearing the trim wheels move is normal flight deck background, which is part of the reason why MCAS was so insidious.

[Takwis]

... the teaching was that if the trim wheel was rotating and not because of manual trim inputs or autopilot trimming, then you had a trim runaway and the IMMEDIATE, RECALL, action was stab trim switches to OFF.

So, think back to that first takeoff you made in the -300. I assume you made AND trim inputs as you accelerated, because that would be normal. Likewise, I assume that the STS made ANU trim inputs, as it was designed to do, as the aircraft accelerated. And since those inputs were not manual, by you, nor were they made by the autopilot, because it was not engaged, you, that very first time the STS made a trim input, uncommanded by either you or the autopilot, did an IMMEDIATE RECALL action, and cut the stab trim switches to OFF. Please tell me that is so.

[Takwis]

It doesn't help that STS operates by executing uncommanded stabiliser movements, so pilots regard that as normal operations. Seeing and hearing the trim wheels move is normal flight deck background, which is part of the reason why MCAS was so insidious.

This fact has been ignored for too long.

737 pilots have been trained, by constant repetition, to ignore relatively short, uncommanded (by either the pilot or the autopilot) trim inputs.

[MechEngr]

So you agree that MCAS is not continuous, and therefore it is entirely reasonable not to characterise its operation as continuous/runaway, so not applying the runaway stabiliser QRH procedure is a reasonable (non) response?

The Runaway Stabiliser QRH characterises 'Runaway Stabiliser' as:

"Condition: Uncommanded stabilizer trim movement occurs continuously."

MCAS can be 'one-shot' or continual, interrupted by Stab Trim operations, and operating again if the MCAS trigger conditions still apply 5 seconds later. It is not, as you point out, continuous, which is enough to put doubt into the mind of a cognitively overloaded pilot whether the Runaway Stab QRH is appropriate.

It doesn't help that STS operates by executing uncommanded stabiliser movements, so pilots regard that as normal operations. Seeing and hearing the trim wheels move is normal flight deck background, which is part of the reason why MCAS was so insidious.

Does STS require 60 pounds on the control wheel to maintain the desired pitch? I'm confused why you think that STS performance has anything to do with this. Some pilots have commented that they have to unwind some STS inputs via the trim switches; why would they not do the same for MCAS?

At what point should a pilot refuse to make trim inputs while pulling 60 pounds on the wheel when trim is available to them? After how many uncommanded adverse trim inputs should a pilot assume that the trim system has failed?

OTOH MCAS operated continuously long enough that when it was not offset the plane crashed. You would not close your eyes for a full 9 seconds driving on a crowded highway, so pick the amount of time the pilots should ignore an adverse trim increasing the control forces.

I have previously recommended that it change from trim blah-blah-blah to adverse trim forces, but I would have assumed that most pilots would know to trim the plane against high control loads. It turns out that it is a bad assumption and that training allows for pilots who try to overcome such forces with their own musculature.

As you want to be a language pedant you are welcome to it.

[Takwis]

After how many uncommanded adverse trim inputs should a pilot assume that the trim system has failed?

Lets see...lets say an average of three per takeoff, and I've done maybe 5000 takeoffs, and watched another 5000, I guess that would mean at least 30,000, in my case. YMMV

As for the wheel trim, the Ethiopian crew tried it, and stated that it didn't work. We still don't know why.

[RetiredBA/BY]

Lets see...lets say an average of three per takeoff, and I've done maybe 5000 takeoffs, and watched another 5000, I guess that would mean at least 30,000, in my case. YMMV

As for the wheel trim, the Ethiopian crew tried it, and stated that it didn't work. We still don't know why.
Could be because they let the speed build up so much by not reducing power.
Perhaps they pulled the levers back without disconnecting AT , took their hands off the TLs to pull back on the yoke, but thrust levers then moved back to TOGA because AT was still connected.
Just a theory.

[Chris2303]

Dr Dekker; please publish similar reports on 737 Max, 777 SFO, AF447, CRJ Sweden.

Who is paying?

[Semreh]

MechEngr
Thank you for the discussion, which I am sure will be of interest to others, even if we continue to cordially disagree.

I hope you have a good weekend.

[OldnGrounded]

This is drifting way off-topic. This thread is supposed to be about alleged whitewashing of Boeing's share of responsibility in the cited 2009 AMS crash.

Also, we're in the deja-vu-all-over-again realm where some folks simply insist that the MAX crashes were substantially due to pilot error. It's fine for those who want to believe that to do so, of course -- everyone is entitled to her or his own opinion. However, it should be recognized that virtually everyone and every entity responsible for aircraft certification, around the world, has agreed for nearly a year that the MAX, as it was introduced and initially flown, had engineering/design defects sufficiently serious to justify its grounding, for many months. And grounded is where it is now. The blame-the-pilots narrative has been overwhelmingly rejected.

[Takwis]

That narrative is still in place from the manufacturer, hopeful operators, and most of their pilots. It has been rejected here, but I don't know if that counts for much.

[OldnGrounded]

That narrative is still in place from the manufacturer, hopeful operators, and most of their pilots. It has been rejected here, but I don't know if that counts for much.

It has been rejected by the world's CAAs (including, apparently reluctantly, by the FAA). That counts.

[Takwis]

That counts. It does. The recent governmental panel shook my faith in that, unfortunately. I could see pressure, threats of economic downturn, loss of a major manufacturer, jobs, suppliers, etc. further eroding my faith in the regulatory bodies. I could also see a "fill the squares" sort of solution getting the plane back into service more quickly than a completely satisfying one. We'll see, I guess.

[MechEngr]

Lets see...lets say an average of three per takeoff, and I've done maybe 5000 takeoffs, and watched another 5000, I guess that would mean at least 30,000, in my case. YMMV

As for the wheel trim, the Ethiopian crew tried it, and stated that it didn't work. We still don't know why.

Sorry, I should have emphasized how many trim events added 30 pounds of pull for each one in quick succession on a single flight.

But if you feel STS is adverse and compromising your ability to control the plane, perhaps you should write that up.

[MechEngr]

This is drifting way off-topic. This thread is supposed to be about alleged whitewashing of Boeing's share of responsibility in the cited 2009 AMS crash.

Also, we're in the deja-vu-all-over-again realm where some folks simply insist that the MAX crashes were substantially due to pilot error. It's fine for those who want to believe that to do so, of course -- everyone is entitled to her or his own opinion. However, it should be recognized that virtually everyone and every entity responsible for aircraft certification, around the world, has agreed for nearly a year that the MAX, as it was introduced and initially flown, had engineering/design defects sufficiently serious to justify its grounding, for many months. And grounded is where it is now. The blame-the-pilots narrative has been overwhelmingly rejected.

You will note that I've started the blame for the pilot side with the airline, the relevant CAA, and finally with the pilots who rejected training for the Ethiopian crash. I just remain puzzled and saddened that in the case of Lion Air, one pilot repeatedly responded to adverse trim by eliminating the trim problem and keeping the plane on speed and altitude while the other pilot seems to have been transfixed with the idea that making the ever increasing amount of trim stop was sufficient. As if he didn't notice the trim position was changing and instead just wanted to keep the trim wheel from moving all while the control loads were going up.

As to whitewashing, that is a bad thing. OTOH airlines failing to perform due diligence is also a bad thing. They had access to all 737 accident reports and could certainly quiz the maker about their approach to avoiding similar accidents.

So why did the Dutch Safety board give in? They are independent of the FAA and the US NTSB and not obligated to Boeing. In no way does the NY Times article explain how the Dekker report got buried.

The human factors concept for alerting pilots or training them, in this case, is flawed. Had either system gone with dual sensors or some other scheme to prevent an adverse result there would have been zero benefit to a distracting alert of the pilots to the discrepancy and therefore no human factor to be considered. It's far better to avoid involving humans in performance decisions. This appears to be what Boeing's software changes did and there were no more RA failure related crashes. LIke MCAS, the manufacturer problem isn't failing to train or alert pilots, it's not recognizing the potential combination leading to a bad outcome.

Let's face it - there are human factors engineers at Boeing. Bunches of them. Yet not a peep from them complaining that MCAS ran on a single sensor and that pilots would certainly crash the plane if that sensor misreported. At least so far - maybe there are more emails, but my experience with human factors engineers is they are outspoken on all sorts of things.

What it really was was a failure of Systems Architects, a relatively new and somewhat toxic addition to engineering. This bunch of hand wavers sit between management and promises made to customers and the actual engineers and are responsible for creating the performance specifications for the hardware and software. Which is exactly where flawed software like MCAS gets born. The good SAs are great - Kelly Johnson of the Skunk Works was one. Anyone living in PowerPoint land? View with great skepticism.

[Loose rivets]

Some pilots have commented that they have to unwind some STS inputs via the trim switches; why would they not do the same for MCAS?

The call, "It's like STS is working in reverse!" is a clue. They noticed it was an anomaly but that's the point, the knowledge it was wrong left them bewildered.

[RetiredBA/BY]

Got an answer for this one, RetiredBA/BY?
No I dont.

Perhaps I have an early onset of something but I have no memory of a STS on our very early -300s, which even had round instruments, and absolutely no memory of anything about it in the sim. Mach trim yes STS no. This worries me a little as the technicalities of my aircraft of all types were always of deep interest. No recall of ever seeing uncommanded trim movement, either.

Our - 300 “course”. Was very simple really just the FMS and autopilot operation, the rest we pretty much made up in the belief -300 airframe was pretty much as a - 200 with some tweaks.

My FO on my first -300 trip is coming on Friday, I will discuss his knowledge of the STS.

Just looked at my Boeing training notes. Runaway stab was practised on 7 sorties, manual trim operation alone on 2 and no discussion or even mention of the Yo Yo procedure, never heard of it on my time on the 73.

Intersting to see my ppl now shows my former types include all 737s up upto 900, never even sat in one !

[Peter H]

No I dont.

Perhaps I have an early onset of something but I have no memory of a STS on our very early -300s, which even had round instruments, and absolutely no memory of anything about it in the sim. Mach trim yes STS no. This worries me a little as the technicalities of my aircraft of all types were always of deep interest. No recall of ever seeing uncommanded trim movement, either.

Our - 300 “course”. Was very simple really just the FMS and autopilot operation, the rest we pretty much made up in the belief -300 airframe was pretty much as a - 200 with some tweaks.

My FO on my first -300 trip is coming on Friday, I will discuss his knowledge of the STS.

Just looked at my Boeing training notes. Runaway stab was practised on 7 sorties, manual trim operation alone on 2 and no discussion or even mention of the Yo Yo procedure, never heard of it on my time on the 73.

Intersting to see my ppl now shows my former types include all 737s up upto 900, never even sat in one !

No guarantee of accuracy, but see https://aviation.stackexchange.com/questions/65258/when-was-the-speed-trim-system-implemented-on-the-boeing-737

>Was the Speed Trim System implemented on the original Boeing 737 or just the Boeing 737 NG series?

Boeing's patent (US4676460A) for the STS was filed on 1984-11-28, the same day of the 737 Classic (3/4/500 series) entering service.

So since the addition of the bigger engines on the Classic, it's been there.

[OldnGrounded]

What it really was was a failure of Systems Architects, a relatively new and somewhat toxic addition to engineering. This bunch of hand wavers sit between management and promises made to customers and the actual engineers and are responsible for creating the performance specifications for the hardware and software. Which is exactly where flawed software like MCAS gets born. The good SAs are great - Kelly Johnson of the Skunk Works was one. Anyone living in PowerPoint land? View with great skepticism.

As a long-time systems guy, I certainly won't argue with that. In recent years, those slots have increasingly been filled by people who are better at impressing the suits than they are at real engineering -- and whose mission in life is to find easy jobs. But the good ones are invaluable.

There are, of course, HF people at Boeing, as there are at other aircraft manufacturers. There's a lot of evidence, however, that the products, in the end, often don't reflect the best current understanding of the discipline. If I design a system with the expectation that operators will act and react in particular ways, within some stated time frames, and that doesn't happen in the real world, it's not only the behavior of the operators that needs careful examination.

[MikeSnow]

No guarantee of accuracy, but see aviation.stackexchange.com/questions/65258/when-was-the-speed-trim-system-implemented-on-the-boeing-737

>Was the Speed Trim System implemented on the original Boeing 737 or just the Boeing 737 NG series?

Boeing's patent (US4676460A) for the STS was filed on 1984-11-28, the same day of the 737 Classic (3/4/500 series) entering service.

So since the addition of the bigger engines on the Classic, it's been there.

According to that answer on Stack Exchange, speed trim on the 737-300s without EFIS is different, it doesn't operate when the flaps are up.

[retired guy]

No I dont.

Perhaps I have an early onset of something but I have no memory of a STS on our very early -300s, which even had round instruments, and absolutely no memory of anything about it in the sim. Mach trim yes STS no. This worries me a little as the technicalities of my aircraft of all types were always of deep interest. No recall of ever seeing uncommanded trim movement, either.

Our - 300 “course”. Was very simple really just the FMS and autopilot operation, the rest we pretty much made up in the belief -300 airframe was pretty much as a - 200 with some tweaks.

My FO on my first -300 trip is coming on Friday, I will discuss his knowledge of the STS.

Just looked at my Boeing training notes. Runaway stab was practised on 7 sorties, manual trim operation alone on 2 and no discussion or even mention of the Yo Yo procedure, never heard of it on my time on the 73.

Intersting to see my ppl now shows my former types include all 737s up upto 900, never even sat in one !

Hi Retired BA/BY
I see some folk mixing you up with me Retired Guy.
Your posts are so coherent I don’t mind at all. As long as you don’t! I flew -300 and -400
and recently-800 and don’t remember speed trim being obvious in early days. Maybe during flap retraction. On -800
more active but because of my training whenever the trim wheel ran unexpectedly you would cop it straight away. Why is it doing that? Always on the alert. Think that’s been lost somewhere
cheers
R Guy.

[retired guy]

I don't think anyone is arguing that the Turkish Airlines crew wasn't largely responsible for the AMS crash. The point is simply that Boeing also had some responsibility and worked hard, apparently along with US regulators, to keep references to that out of the investigative reports.

Hi there again OldnGrounded
its oldnRetired here! Maybe we share a long and happy career somewhere back there when you pulled, the houses got smaller, but if you pulled too hard they got bigger again!

What alarms me here is that there are people here, and especially that long Dutch report that do seek to remove a lot of the responsibility onto a Rad Alt failure and away from a failure of the crew to monitor IAS and apply power manually the moment it fell
below V Ref. Never mind ignoring several blindingly obvious stall warnings culminating in stick shake and I imagine airframe buffet.
And so if I were Boeing I too would fight hard, not to
dissemble or “ keep references out” but to let the truth be known. That’s not the same thing. Boeing do seem to suffer from, what many here seem to see as an old fashioned delusion , probably not shared by Airbus ,
that pilots need to be well trained and maintain a standard of airmanship.
And so we now sit at that jumping off point. Will the two Max crashes re-energise training programs as well as seeing MCAS and other technical improvements.
or will we say MCAS fixed. It was the only cause. Job done.
Until the next one, and the next

[alf5071h]

Chris, #110, 'who is paying' - re request for Dr Dekker to publish similar reports on other accidents.

Why do we frame safety benefit with money first; cost benefit, a tradeoff between competing resources.
The request to Dr Dekker for other materials could enable a comparison with different situations, more recent technology, or alternative influences, with possibly different conclusions.
Other reports would provide a larger baseline from his point of view, from which we might consider the many other analyses of these accidents with their alternative conclusions (also the range of views in this thread).
Even so, or without more reports, we are required to think about these issues for ourselves, with biased views, without a baseline or measure by which we could provide reasoned argument; but then we don't - it costs too much in mental effort.

'Falling off my perch' into the real world, the issue of balancing commerce with safety is a threat which must be managed. The industry has put great effort into managing safety at the sharp end, but in a very safe industry the effects of commercial influence is increasingly important. If the balance is changing, then what are the disturbances - man, machine, or money; what are damping factors, or the mechanism of maintaining balance.

Did Boeing ask 'who is paying' as priority in their their designs, or in response to accidents like AMS; if so then the 737 Max has answered, but this does not immediately provide a better question.

If education is about learning to ask better questions opposed to stating answers, then Boeing could have learnt from their pilots advice 'the question is not can it be done, but should it be done.'
(https://www.pprune.org/10670407-post9.html Link to Boeing background document.)

There are many contributions to safety @ Papers | Sidney Dekker (http://sidneydekker.com/papers/) but none specific to this issue.

[Semreh]

What alarms me here is that there are people here, and especially that long Dutch report that do seek to remove a lot of the responsibility onto a Rad Alt failure and away from a failure of the crew to monitor IAS and apply power manually the moment it fell
below V Ref. Never mind ignoring several blindingly obvious stall warnings culminating in stick shake and I imagine airframe buffet.


I hope I am not speaking only for myself when I say that I am not seeking to devolve all, or even the majority of, the responsibility onto a Rad Alt failure. It is but one of the 'holes in the Swiss Cheese' that lined up on this occasion. It is, however, for designers and engineers (and many others) to remove as many holes as is reasonably possible (https://en.wikipedia.org/wiki/ALARP), and having the autothrottle depend on a single Rad Alt and not swap sides with the FMC, or indeed have a separate manual switch (which would affect certification) is a decision that seems to require justification.

I certainly regard good airmanship as valuable, and share with you considerable disquiet at the failure of the crew to monitor IAS. Automation should be a supplement to airmanship, not a replacement. Putting pilots in the invidious position of needing to understand the 'state' of the automation better than the aircraft understands itself really should not be allowed; yet pilots are expected to diagnose subtle failures in automation in the absence of full information, under time pressure. It is no wonder that some don't succeed. Pilots are human, and putting humans into safety-critical control loops with incomplete or inaccurate information will result in failures. Helpful automation should reduce the numbers of such failures.

[OldnGrounded]

I certainly regard good airmanship as valuable, and share with [retired guy] considerable disquiet at the failure of the crew to monitor IAS. Automation should be a supplement to airmanship, not a replacement. Putting pilots in the invidious position of needing to understand the 'state' of the automation better than the aircraft understands itself really should not be allowed; yet pilots are expected to diagnose subtle failures in automation in the absence of full information, under time pressure. It is no wonder that some don't succeed. Pilots are human, and putting humans into safety-critical control loops with incomplete or inaccurate information will result in failures. Helpful automation should reduce the numbers of such failures.

I can't possibly say it better than this. I'm pretty sure everyone agrees that the Turkish crew was "guilty" of multiple serious errors. However, that doesn't change the fact that the manufacturer had failed to let crews know that the left RA was feeding the autothrottle even when the right FCC was active -- a very significant hole in the cheese, all by itself. Remember, they noticed that the left RA reading was bogus, but they didn't think it mattered.

[Semreh]

By the way, if anyone is wondering why a radio-altimeter might display -8 as a legitimate reading on some aircraft types, this web-page gives some background:

https://www.flightdatacommunity.com/looking-closely-at-radio-altimeters/

[RatherBeFlying]

Remember, they noticed that the left RA reading was bogus, but they didn't think it mattered. because they thought they had bypassed the failed RA by switching FCCs.

This may be the third B accident where a single failed sensor resulted in an evil system response.

With A, there's two cases of multiple failed sensors resulting in accidents: AF447 and a test flight that fell into the Med when the good AoA sensor was outvoted by two bad ones.

[retired guy]

because they thought they had bypassed the failed RA by switching FCCs.

This may be the third B accident where a single failed sensor resulted in an evil system response.

With A, there's two cases of multiple failed sensors resulting in accidents: AF447 and a test flight that fell into the Med when the good AoA sensor was outvoted by two bad ones.

Hi Rather Be Flying
I don't think AF 447 went into The Atlantic because of multiple sensor failures. That was easily overcome through flying the plane in the correct manner - I think?
The tech failure was a catalyst or start of a chain of events, but not the cause.
Thats what seems to be the general consensus but I may be wrong.
I get your point is you are saying that several invalid inputs can confuse a computer I agree, as in this case, but here we go again, isn't that why we have pilots. Good luck to Airbus with their latest auto takeoff.
Cheers
R Guy

[RatherBeFlying]

Hi RG,

​​​​In AF447 all the pitots got clogged at some point which looks like a multiple sensor failure to me.
Caveat: haven't read the report recently.

[SteinarN]

Hi RG,

​​​​In AF447 all the pitots got clogged at some point which looks like a multiple sensor failure to me.
Caveat: haven't read the report recently.

And one other point;
had the pilots done absolutely nothing then the plane would have continued flying level and straight. It was the action from the pilots that actually brought it down. And even after the aircraft got deeply stalled, if the pilots had let go of the side stick the aircraft would have unstalled itself and regained controlled level flight.

So the AF447 has very significant differences compared to the B737 single sensor cases we are discussing. In all those cases the aircraft wanted to crash itself and the pilots needed to actively intervene in order to avoid the crashes, something they sadly did not succeed in.

[Twitter]

Posters berating flight crew reactions in the Max MCAS accidents really have literally no idea what they faced. Furthermore, I bet they have never flown the 737 NG/Max, and are current on modern complex jets. Armchair flight simmers need not interject and insult the abilities of those that perished.

The complexity of systems on modern EFIS jets, not only improves safety in some circumstances, but at times increases the complexity of failures to the point of being detrimental when such systems react to incorrect sensors. This was not a simple single failure necessitating manual flight and simple manual trim. Far far from, and how foolish of any professional pilot to consider this as such. This was a grace situation that enabled as little as 10 seconds to respond before entering an inevitable irrecoverable situation.

The crew were quite obviously fighting against many numerous simultaneous conflicting and confusing warnings and events. In brief, airspeed unreliable, altitude unreliable, stick shaker stall warning, master cautions, stabiliser trim motion and noise masked by stick shaker noise, aircraft out of trim, nose attitude dropping, and manual trim not working sufficiently. To say they would be slightly overloaded is an understatement.

These simultaneous events were untrained, not in the manual, and not foreseen. Before the pprune aviation gods berate these crews, just consider the reality of what these crews faced. You have no reason to comment berating these crews unless you have been in their exact situation, not forewarned, and have flown the 737 NG/Max.

The answer is to fix the systems, make them more reliable, train the crews properly in sims, insist on the very highest standards achievable, and for the industry to start to again support crew to maintain and practice manual flying skills as necessary in the right circumstances.

I’d agree with all of that. Of course it is normal that any thinking pilot would think “my God, what would I / could I have done?” And then gain knowledge and work out a plan.
This is the healthy reaction - doesn’t mean one has to instruct the world about the perceived or imagined failings of others.

[fdr]

Posters berating flight crew reactions in the Max MCAS accidents really have literally no idea what they faced. Furthermore, I bet they have never flown the 737 NG/Max, and are current on modern complex jets. Armchair flight simmers need not interject and insult the abilities of those that perished.

The complexity of systems on modern EFIS jets, not only improves safety in some circumstances, but at times increases the complexity of failures to the point of being detrimental when such systems react to incorrect sensors. This was not a simple single failure necessitating manual flight and simple manual trim. Far far from, and how foolish of any professional pilot to consider this as such. This was a grace situation that enabled as little as 10 seconds to respond before entering an inevitable irrecoverable situation.

The crew were quite obviously fighting against many numerous simultaneous conflicting and confusing warnings and events. In brief, airspeed unreliable, altitude unreliable, stick shaker stall warning, master cautions, stabiliser trim motion and noise masked by stick shaker noise, aircraft out of trim, nose attitude dropping, and manual trim not working sufficiently. To say they would be slightly overloaded is an understatement.

These simultaneous events were untrained, not in the manual, and not foreseen. Before the pprune aviation gods berate these crews, just consider the reality of what these crews faced. You have no reason to comment berating these crews unless you have been in their exact situation, not forewarned, and have flown the 737 NG/Max.

The answer is to fix the systems, make them more reliable, train the crews properly in sims, insist on the very highest standards achievable, and for the industry to start to again support crew to maintain and practice manual flying skills as necessary in the right circumstances.

So true.

Hindsight is 20/20, foresight is most often myopic.

As K said:

1500 years ago, everybody "knew" that the earth was the center of the universe. 500 years ago, everybody "knew" that the earth was flat. And 15 minutes ago, you "knew" that humans were alone on this planet. Imagine what you'll "know" tomorrow.

[LandIT]

Cap'n Biggles Sir,

Your excellent post about the need for the industry to give pilots the chance to hone their skills in everyday operations is very much to the point. When the automatics start doing something that is not as intended, we need not only better annunciation, but even more important, to have pilots who are sufficiently confident and well-practiced in their handling skills that they can immediately detect a departure from the intended flight path/configuration/speeds/altitudes/etc using the primary flight instruments, and then be able and confidently to handfly until the problem has been sorted.

From what I read, these days at a distance, current airline SOPs actively discourage the development and maintenance of these skills.

Bergerie, I wholeheartedly agree.
To me this means there should be indications (read status screens constantly on display) of what the automation is doing. Anything that automagically moves a control surface should be shown here. Especially AP functions should be shown, trim angle indication, autothrottle amount, rudder angle, you name the essentials. Furthermore, when the automatics have suddenly determined they will disconnect (as computers do, they just reach a criteria and pow!) this display should show the positions of all the essential control surfaces and engine power that the pilot will have to contend with. In other words, I object to the automatics doing things i know nothing about and then suddenly disconnecting and leaving essential things in unknown conditions for me to figure out within 10 seconds or so, or I die. I especially object to manufacturers who don't document automatic "features", when they occur, their effect, criticality and failure modes. I object to some of the automatics doing things without any indication, such as changing the thrust without moving the throttle levers or changing then not showing the trim amount. I object to reliance on one sensor for almost any of the automatics functions, but more importantly I object if the aircraft doesn't indicate when a sensor is not agreeing to its partner. There can be more. I don't want to use capitals, so manufacturers please hear me. Give me a chance to understand what is going on - why isn't it normal to provide all this indication of what your aeroplane systems are doing so that its obvious what it stopped doing when something goes wrong (as it always will).
Please give us pilots the complete picture of what's going on .. and when your automatic systems give us .. what's NOT going on!.

[fdr]

Hi Rather Be Flying
I don't think AF 447 went into The Atlantic because of multiple sensor failures. That was easily overcome through flying the plane in the correct manner - I think?
The tech failure was a catalyst or start of a chain of events, but not the cause.
Thats what seems to be the general consensus but I may be wrong.
I get your point is you are saying that several invalid inputs can confuse a computer I agree, as in this case, but here we go again, isn't that why we have pilots. Good luck to Airbus with their latest auto takeoff.
Cheers
R Guy


The sensors cleared, the back stick didn't.

If anyone can think of a plane other than an Ercoupe that you can hold full back stick all day, then that might be worth a beer. For all that though, assuming that the pilots had reason to live another day, there is a reason that a trained pilot thought that holding full back stick was a good idea, and releasing that as commanded by the captain when he got back was not accomplished. In the end, the pilot was human, and in a critical, high stress event, the pear shape ended up proving Newtons law of apples.

With no particular party intended, an observation of operational safety

We sit back in out comfortable chairs, and remark on the worst seconds of the worst day that these guys had, and remonstrate that a human had human frailties. We also contend that we would have done differently, and maybe we would, or maybe we would also be human. Will be glad never to have to find out that case in a tube filled with valuables.

Sure there is an appropriate passage in some well read tome that speaks to judgements, yes, I seem to recall that was written somewhere.

PS: Actually, I have experienced that type of problem, I assure you that being in command of an aircraft that you have 447 lives other than your own interested in your actions, and knowing that there is nothing you are able to do to alter the outcome at that very moment concentrates the mind. If it never happens again, then I would be a happy little camper. In my case, the situation had no causation from my actions, I can only imagine what it would be like to have an inkling that you have a bad day, and that you may have had input into that condition. That is a terrifying thought all of its own.

[vlieger]

https://www.marxist.com/capitalism-kills-new-revelations-highlight-boeing-s-criminal-negligence.htm


Boeing, the FAA and the NTSB (National Transportation Safety Board) try to wash their hands of this by simply saying that the system involved in the earlier accident differed significantly from the one blamed in the MAX crashes. In our view, this is a huge cop-out that ignores the essence of the problem: a design flaw as a result of insufficient redundancy, leading to unpredictable behaviour not explained in the manuals nor trained for in the simulator.
...
This latest revelation is slow to trickle through because of the technical and specialist nature of the matter. Regardless, the credibility of Boeing as “a company you can trust” has plummeted to historical lows all over the world. Trust tends to be a one-way street and once it has been broken, it is very hard to restore.
...Does this mean that Boeing will go bust? Unlikely. Its lobbyists have far too much power to keep this latest mismanaged design on the ground forever, technical issues or not. Boeing is the only major US commercial aircraft maker and is too integrated into the military-industrial complex of US imperialism. As the largest exporter in the United States, it has become a behemoth that is too big to fail.

Paradoxically for a country famed for espousing free market values, the “land of the free” has produced in Boeing a company that is heavily dependent on the largesse of the public sector. The “America First” mantra of Donald Trump has greatly benefited Boeing with lucrative government contracts and the protection of its de facto domestic monopoly from competitors like Airbus. Despite the recent losses and scandals, its planned acquisition of Brazilian aircraft manufacturer Embraer also seems to be going ahead.

Apart from benefiting greatly from public loan guarantees provided by the federal Export-Import Bank (nicknamed “Bank of Boeing”), Boeing is notorious for its exploitation of the tax code and for years has gotten away with paying a negative tax rate on its income. The company is now the country’s second-largest recipient of federal funding after Lockheed Martin, another company in the service of the US war machine. This means it is more dependent on the public purse than a number of federal agencies.

Within the aviation industry, with its massive infrastructural needs, the state has always played a big role. Perversely, after deregulation in the 1980s, Boeing was allowed to effectively become a public entity with private profits. It gladly accepted the money and the safety net from the American public. In return, it has made private shareholders and upper management fabulously rich, while producing aircraft that put the public at risk. The laws of capitalism have a logic of their own and after decades of “ripping up the rules” and cutting corners in search of profit, the chickens are coming home to roost.

[retired guy]

A commentary from a well known city analyst. It's just another view folks. Only the Pope claims to speak "ex cathedra" (and only then not very often!).Announcing a 4th Quarter loss per share of $2.33 and full year loss per share of $3.47 along with expectations that the cost of the 737 MAX crisis that has rocked the Chicago based company over the past ten months is now anticipated to grow to $18.6 billion surely make this one if not THE worst day in terms of financial reporting in the 104 year history of the Chicago based company. By the same token it may also be regarded as being a very good day for Boeing and the investment community as both results statement, approach and subsequent interviews show a welcome return of clarity, transparency and honesty. For this alone Boeing is deserving of applause.



However one chooses to paint them, with full year revenue falling 24% to $76.6 billion and the company reporting a $1,975 million loss from operations combined with negative operating cash outflow of $2,446 million compared to a previous year positive cash flow of $15,322, suffice to say that these are an appalling set of numbers the like of which investors will hope never to see again.



Do FY19 results mark the end of the Boeing 737 MAX crisis – no they certainly don’t and the prospect of further bad news ahead cannot be ruled out. Will the 737 MAX fly again? Boeing believes so and that the downside risk of this is 10%. I for one believe that to be right and that 737 MAX will certainly fly again but clearly, there is more work to do before regulators will allow that to occur. Indeed, this isn’t just a story of Boeing achieving recertification of the 737 MAX sometime this year but also one of rebuilding its long and valued reputation for safety. I am no doubt that Boeing will achieve what it has set out to do but no-one should imagine that achieving that goal will not have been very hard earned.



Despite the seemingly appalling set of results presented by Boeing senior management today dig down into the message that is writ large throughout these results and you find a company that is taking a very different approach to its investor messaging. Humbled as the company has certainly been throughout this crisis, Boeing is providing a new insight that has clarity, transparency and honesty in abundance. This a new Boeing and it is one that investors should welcome despite the many problems that still lie ahead.



Boeing’s annual statement has the hand of its new Chairman, Dave Calhoun writ large across every piece of detail and information provided. Open, honest, transparent and full of clarity – there is to my mind a very visible and marked change in the attitude and approach being taken - one that is not only extremely welcome but long overdue.



Simplification and openness have been called for many times in the past and Boeing has responded by focussing on what really matters, not only in respect of openness in its messaging but importantly, in how that messaging relates across the wider company into the priorities of safety, quality, integrity and delivering on its programs and promises made.



Boeing will not only survive this but in my view will once again prosper. Maybe that is still a long way away but I take the view that the company remains fundamentally strong.



Not much talked about today but despite the massive problems that have hit the narrow bodied 737 MAX, Boeing’s widebody commercial aircraft segment is still doing very well. So too is Boeing Defense and its other activities including Space.



True, there are still some very muddied 737 MAX waters to clear a way through and there are almost bound to be more shocks ahead, but cut through the mountain of problems that Boeing is now working hard and facing up to resolve and one can clearly see that Dave Calhoun has already taken Boeing by the scruff of the neck and demanded radical change. He has in my view been absolutely right to demand significant change and there is much work to do to restore Boeing back to where it needs to be. This includes airline customers that have suffered as 737 MAX planes remain grounded and passengers alike. But the good news is that there can surely be no accusations from this results statement of lack of clarity, transparency, openness and honesty.



Another example of change of approach and that marks a departure from the past is that the media and analyst community have been given two separate call opportunities with CEO Dave Calhoun and CFO Greg Smith. Mr. Calhoun has also done his first TV interview as Chairman of Boeing with CNBC Squawk Box.



In the CNBC interview Mr. Calhoun confirmed that CEO Dennis Muilenburg had offered to give up any 2019 bonus and that he will not take any further short or long-term bonus or equity until the 737 Max is flying again. He said that Mr. Muilenburg “had done everything right” adding that he (Muilenburg) has set up the 737 MAX for return to service” and that Muilenburg has led a program to rewrite the MCAS related conditions that had led to the two tragic accidents. “Muilenburg” he said “remains the right man to get the 737 MAX back int the air” and that “he had the full confidence of the Boeing Board”. Mr. Calhoun also said that “we can and will improve safety” and that [Boeing engineering] process needed to change.



In respect of the 737 MAX future Mr. Calhoun said that getting the 737 MAX back in the air will be a “long process” adding that the regulators will decide when that occurs but he made very clear that he believed Dennis Muilenburg was the man to do it. The CNBC interview was a huge and important test for the new Boeing chairman and having listened to it in full I believe that he came through it very well.

[retired guy]

Bergerie, I wholeheartedly agree.
To me this means there should be indications (read status screens constantly on display) of what the automation is doing. Anything that automagically moves a control surface should be shown here. Especially AP functions should be shown, trim angle indication, autothrottle amount, rudder angle, you name the essentials. Furthermore, when the automatics have suddenly determined they will disconnect (as computers do, they just reach a criteria and pow!) this display should show the positions of all the essential control surfaces and engine power that the pilot will have to contend with. In other words, I object to the automatics doing things i know nothing about and then suddenly disconnecting and leaving essential things in unknown conditions for me to figure out within 10 seconds or so, or I die. I especially object to manufacturers who don't document automatic "features", when they occur, their effect, criticality and failure modes. I object to some of the automatics doing things without any indication, such as changing the thrust without moving the throttle levers or changing then not showing the trim amount. I object to reliance on one sensor for almost any of the automatics functions, but more importantly I object if the aircraft doesn't indicate when a sensor is not agreeing to its partner. There can be more. I don't want to use capitals, so manufacturers please hear me. Give me a chance to understand what is going on - why isn't it normal to provide all this indication of what your aeroplane systems are doing so that its obvious what it stopped doing when something goes wrong (as it always will).
Please give us pilots the complete picture of what's going on .. and when your automatic systems give us .. what's NOT going on!.

Hi LandiT

I think that some recent crashes didn't need any in depth knowledge of the systems other than "pull and the houses get bigger as long as you manually apply the power". Really. When things go wrong very low down, you just need to fly the plane if you know how. I am concerned that too much presentation of things like surface positions etc just lead to delays in flying the plane.
I remember the first pilots in our airline going on the then new A320. To a man they said - "but there is nothing in the manuals about how this all works". And "it is badly translated from French so that it is hard to understand".
The reply was of course "you don't need to understand it, and if you tried there would not be time in a critical situation to start trying to work it all out". You see it is all computerised.
I seem to remember that the fallback was "you can always fly it I direct law and then it becomes just a plane". To which the pilots said " but we won't have the practice to do that".
That was then.
So, this is all a long time ago when the A320 was quite new. What I would be interested to know is, has anything changed since those first few weeks?
Does the current training on the Airbus go into any depth or is it still largely on a need to know basis?
I speak as someone who has only flown down the back on Airbus and my only thought was "who could allow a plane to be sold with a pack of barking dogs in the hold, and think that was ok!
Cheers
R Guy

[vlieger]

So, this is all a long time ago when the A320 was quite new. What I would be interested to know is, has anything changed since those first few weeks?
Does the current training on the Airbus go into any depth or is it still largely on a need to know basis?


I would say the FBW system is designed a lot better and Airbus ironed out the main bugs over the years. The various laws are reasonably well documented and trained for.
I'd say the main difference is Boeing slapped on a piece of dodgy software on a conventional design going back to the 60s, and they were found out -- whereas Airbus started from scratch, as Boeing should have done.

[SamYeager]

Does the current training on the Airbus go into any depth or is it still largely on a need to know basis?

When the A350 was nearing EIS I read that Airbus were changing their training syllabus such that the initial training would be about gaining familiarity with flying the aircraft in direct law before later moving on to flying in normal law. I believe, but can't be certain, that the plan was that eventually the training for other aircraft would move to a similar method. No idea as to how detailed the training is into aircraft systems.

[RetiredBA/BY]

No I dont.

Perhaps I have an early onset of something but I have no memory of a STS on our very early -300s, which even had round instruments, and absolutely no memory of anything about it in the sim. Mach trim yes STS no. This worries me a little as the technicalities of my aircraft of all types were always of deep interest. No recall of ever seeing uncommanded trim movement, either.

Our - 300 “course”. Was very simple really just the FMS and autopilot operation, the rest we pretty much made up in the belief -300 airframe was pretty much as a - 200 with some tweaks.

My FO on my first -300 trip is coming on Friday, I will discuss his knowledge of the STS.

Just looked at my Boeing training notes. Runaway stab was practised on 7 sorties, manual trim operation alone on 2 and no discussion or even mention of the Yo Yo procedure, never heard of it on my time on the 73.

Intersting to see my ppl now shows my former types include all 737s up upto 900, never even sat in one !

Raised the issue of the speed trim system with my good friend, shortly after our first trip on the 300 together he gained his command. He was a very sharp guy but cannot recall a SPEED TRIM system Mach trim yes, but STS No, but jt was many years ago !

I will raise the issue with another old colleague soon but I am minded to think the STS was not fitted to our very early -300s ( the first) or like the MCAS, was not mentioned in the manuals.

Really curious about this, its not my nature to have been unknowing about a flight control system on a type which I flew and trained others.

Of course, at our age we could have an early onset !!

[xetroV]

I can't possibly say it better than this. I'm pretty sure everyone agrees that the Turkish crew was "guilty" of multiple serious errors. However, that doesn't change the fact that the manufacturer had failed to let crews know that the left RA was feeding the autothrottle even when the right FCC was active -- a very significant hole in the cheese, all by itself. Remember, they noticed that the left RA reading was bogus, but they didn't think it mattered.

Talking about cheese: did you know that the NG's autothrottle also uses the left airspeed / Mach reference, even when the right FCC is active? I discovered that by accident during an actual unreliable airspeed event (I'm actually not sure if this information was mentioned somewhere in the FCOM at that time - if it had, the "discovered" in this sentence should be replaced by "re-discovered", but the end result was the same regardless).

We were confronted with a blocked static port at cruising altitude (probably had something to do with excessive rain ingestion on the ground during storm conditions earlier that flight): we noticed a steadily increasing difference in altitude indications, which then exceeded the threshold for the Altitude Disagree flag to appear. Thus, we had to descend to a flight level below RVSM airspace. Starting the descent it became immediately apparent that the left-hand indicated altitude remained constant, even though the aircraft was very obviously descending. This, in turn, caused an erroneous overspeed annunciation on the left-hand PFD, plus the associated aural distraction of the clacker. But no immediate concerns with regard to flight-path control, as we already had autopilot B engaged and LVL CHG appeared to work flawlessly, with the throttle closed during descent - as one would expect. Then the surprise: no automatic throttle-up when levelling off at the new lower cruising altitude. The autothrottle speed control left the throttle closed as it was, relying on the erroneous left-hand airspeed value that was already indicating deep into the barberpole.

Boeing will probably argue that using a single source airspeed here is perfectly acceptible and completely safe. After all, my "superiour western piloting skills" obviously saved the day - we didn't stall the aircraft. :rolleyes:

Still, it would have been nice if the system had just disengaged the autothrottle automatically with the associated warnings...

[KRH270/12]

Weil 737 is easy, whenever the sh... hits the fan follow the SOPs:

A/P if engaged... disengage
A/T if engaged... disengage

That means TAKE CONTROL AND MAUALY FLY the aircraft.

Thats what we teach at our company, be able and willing to handfly the aircraft... anywhere​​​​...anytime!

That also means, the PF allways has his hands on the yoke and throttles/spedbrakes below 10.000ft
(exept CM1 between V1 and 400‘)

[Twitter]

Weil 737 is easy, whenever the sh... hits the fan follow the SOPs:

A/P if engaged... disengage
A/T if engaged... disengage

That means TAKE CONTROL AND MAUALY FLY the aircraft.

Thats what we teach at our company, be able and willing to handfly the aircraft... anywhere​​​​...anytime!

That also means, the PF allways has his hands on the yoke and throttles/spedbrakes below 10.000ft
(exept CM1 between V1 and 400‘)

There‘s an original idea. Now where have I read that before?

[KRH270/12]

There‘s an original idea. Now where have I read that before?

Well, its and old concept, long forgotten by many, but its never outdated...

[MathFox]

Boeing will probably argue that using a single source airspeed here is perfectly acceptible and completely safe. After all, my "superiour western piloting skills" obviously saved the day - we didn't stall the aircraft. :rolleyes:

Still, it would have been nice if the system had just disengaged the autothrottle automatically with the associated warnings...
I would say that you were luckily not distracted by ATC and landing checklists. And lucky having sufficient altitude to correct the automation induced problem.

[RetiredBA/BY]

Weil 737 is easy, whenever the sh... hits the fan follow the SOPs:

A/P if engaged... disengage
A/T if engaged... disengage

That means TAKE CONTROL AND MAUALY FLY the aircraft.

Thats what we teach at our company, be able and willing to handfly the aircraft... anywhere​​​​...anytime!

That also means, the PF allways has his hands on the yoke and throttles/spedbrakes below 10.000ft
(exept CM1 between V1 and 400‘)


Like I said earlier,

If the automatics fail or are giving confusing info., , disconnect and go back to basics and just FLY the damned thing !

My worst case scenario, like a de Crispigny, but with only two pilots:

Crossing the Atlantic in a 76 on a filthy night, 300 pax behind me sleeping soundly, 3 am, body temp. Low, engine blows taking a lot of electrics and automatics with it.

Wx at enroutes, I have never operated into before, on limits.

I was NOT then going to refresh my hand flying skills,

I was determined I would have the flying skills to make a non precision approach and hit the 1000 foot spot.

Only achievable, in my opinion as an ex RAF refresher QFI, with regular hand flying practice.

Ready for incoming !

[megan]

RetiredBA/BY, this any help re STS?

https://aviation.stackexchange.com/questions/65258/when-was-the-speed-trim-system-implemented-on-the-boeing-737

[alf5071h]

Re invitation for Boeing to attend Dutch parliament. # 82
https://www.pprune.org/showpost.php?p=10669834&postcount=82

Latest position via NYT
https://www.nytimes.com/2020/02/06/business/boeing-737-inquiry.html?partner=msn

Both NTSB and Boeing decline to attend:
NTSB hides behind Dutch investigators and Annex 13 - https://www.tweedekamer.nl/downloads/document?id=3d56ca91-13ca-4d74-b618-3665b5447d1c&title=Position%20paper%20NTSB%20t.b.v.%20hoorzitting%2Fronde tafelgesprek%20OVV-rapport%20over%20de%20vliegramp%20van%20Turkish%20Airlines%2 0bij%20Schiphol%20in%202009%20d.d.%206%20februari%202020.doc

Boeing hides behind NTSB, Dutch investigation, Annex 13, …, the American team in 2009 had been led by the N.T.S.B. and “we will follow the lead of the N.T.S.B.”
https://www.tweedekamer.nl/downloads/document?id=cbee2434-ad62-4822-9308-6f031ec9dcb3&title=Position%20paper%20The%20Boeing%20Company%20t.b.v.%20h oorzitting%2Frondetafelgesprek%20OVV-rapport%20over%20de%20vliegramp%20van%20Turkish%20Airlines%2 0bij%20Schiphol%20in%202009%20d.d.%206%20februari%202020.pdf

[safetypee]

The joint NTSB & Boeing approach might lower NTSBs reputation; trust in an independent investigation.

The FAA wisely keep their head down, after all they did certificate the particular radio altitude and alerting system.

[xetroV]

I would say that you were luckily not distracted by ATC and landing checklists. And lucky having sufficient altitude to correct the automation induced problem.
I fully agree - that was more or less the gist of my slightly sarcastic comment there. And even without those distractions my response was reactive, rather than pro-active, as I was clearly surprised by the system behaviour.

It just doesn't make sense that an autothrottle stubbornly continues to use erroneous sensor inputs when the autopilot still works fine on a correct set of data. And it sure is a sign of sloppy engineering that a flight control system does not degrade gracefully and unambiguously (e.g. by disengaging the autothrottle, coupled with the usual aural and visual cues) if an unacceptable discrepancy between two measurements is sensed (in our case IAS, in the Turkish case Radio Altitude and in the MAX case AoA). Well, actually that's the problem here: these systems didn't sense the discrepancy to begin with, because the system designers deliberatly chose to rely on one sensor only, even though multiple sensors were available.

[BDAttitude]

Well, actually that's the problem here: these systems didn't sense the discrepancy to begin with, because the system designers deliberatly chose to rely on one sensor only, even though multiple sensors were available.
See, no redundancy, no problem :O.
On another thread there was recently a comment, that VW commited fraud, whereas BA "just" misjudged the human handling capabilities of a tech defect.
This thread is nicely shows that there is culture of trying to get away with the cheapest solution, trying to hide it and upon beeing caught just updating the books and check lists, at max adding some alert to an already overloaded deprecated alerting system.
No wonder they thought they could get away with it one more time.

[radken]

I may have missed this in the mass of reporting lately about things “Max, but I’ve not recently read any more about EASA’s previous statement made a couple of months ago concerning their “insistence” they will fly the Max “bare airframe” before blessing this type to return to European skies. This mention of “bare airframe” performance does (it not?) go to the basic issue of what Schizoid characteristics the ship demonstrates in certain high speed power/attitude combinations, and which, if encountered by your “average” line pilot, just might be beyond their “average” ability to safely fly out of. Here in the U.S. the discussion about MCAS always devolves into “making the airplane safe by fixing the software.” This is the direction in which I believe Boeing Corporate purposely and successfully has directed the conversation since the “real fix,” the aerodynamic “flaw” fix, is impossibly expensive. Does anyone know a more recent update from EASA?

[safetypee]

radken, assuming that 'the bare airframe' refers to flying the Max without MCAS - predicted to be rare situations, then the piloting task is to manage the small parts of the flight envelope with reduced stability margin, and presumably all flight conditions with manual trim.
The latter, no trim, situation might not apply if the revised design and system switching enables reinstating the trim - note reported difficulties in following procedures after the last public sim evaluations.

The notion of an 'average pilot' is misleading; the acceptability for flight is a judgement based on agreed certification requirements - but words can be interpret differently. This might be at the root of the FAA's problem with other regulators - the FAA interpreted standards (failure case) in comparison with other worldly interpretations. Perhaps similar to abilities as imagined vs ability in reality - false interpretation of accidents occurring in different parts of the world equating to piloting standards, and not differentiating normal, abnormal operations, nor MCAS failure after training.

This thread is about AMS and Rad Alt failure and alerting, similar issues as with MCAS. These problem issues are in the assumptions and interpretation of the wording of regulations and piloting capability. The AMS accident indicated that the FAA / Boeing viewpoint did not have sufficient safety margin in real situations (Dekker report); thus if this design thinking was continued in the MAX, most likely, then the MAX failure case may also lack sufficient safety margin.

[safetypee]

Latest report on MAX from AWST 12 Feb
https://aviationweek.com/shownews/singapore-airshow/faa-narrows-issues-max-ungrounding

Discussion continues in 'Boeing and FAA oversight' thread.