GT says fatal 737 MAX crashes caused by 'incompetent crew.'
A level of experience would have gone a long way to fixing this issue, as was done many times in the US by highly experienced crews that applied the memory items for runaway stab trim quickly and correctly. Without it seems any knowledge of this MCAS system.
Thats the way it is.......
Thats the way it is.......
Post ..... and that is the way it is - your expected to back it up.
GT is a f*****g idiot.
Have we really gone back to the bad old days of accidents simply being blamed on “pilot error” with no acknowledgment of the systemic problems that lined up the holes in the Swiss cheese and lead to that error?
The guy is an embarrassment to journalism and aviation.
Ignore.
Have we really gone back to the bad old days of accidents simply being blamed on “pilot error” with no acknowledgment of the systemic problems that lined up the holes in the Swiss cheese and lead to that error?
The guy is an embarrassment to journalism and aviation.
Ignore.
I wouldn't even classify him as a journalist... just look at his one foray into 'Air Crash Investigation' where he used the most sensationalist and exaggerated language to describe Garuda both before and after it's 'rebirth' and restructure after the Jogjakarta overrun. That is not journalism, it's big noting, big noting is fine as long as the person has the basic knowledge with which to big note... I roll my eyes every time I see him trotted out by 7 News or someone else as an 'expert'... 'CEO of Airline Ratings'... Airline Ratings is a website and not much else. I'll give him one thing, he has managed to rise to make money in the era of weasel words and BS, an era where expertise is brushed over and the ability to bull--it is what gets people up the ladder... the era of the Dunning-Kruger take-over...
I have to somewhat agree with the expert.
Listen guys.
Re: Lion Air. The guys didn't really have all the knowledge regarding MCAS but how comes an off duty Lion Air pilot occupying the jump seat managed to save the aircraft on the previous sector?
Re: Ethiopian. These guys were very inexperienced and it showed. They had so much information available to them regarding MCAS because of the Lion Air tragedy. These guys were just overwhelmed by the whole situation. They did not apply the proper memory items and procedures despite Boeing introducing them months earlier! They simply forgot to fly the plane and even switched the MCAS back on (talk about breaking SOPs!)
Any Canadian, US, European or Aussie crew would have dealt with the situation immediately.
Unfortunately it has to be said. I am not current on the 73M but a lot of my friends are and they have even said that Boeing has received too much negativity surrounding this. Unfortunately it comes back to the piss poor media.
Listen guys.
Re: Lion Air. The guys didn't really have all the knowledge regarding MCAS but how comes an off duty Lion Air pilot occupying the jump seat managed to save the aircraft on the previous sector?
Re: Ethiopian. These guys were very inexperienced and it showed. They had so much information available to them regarding MCAS because of the Lion Air tragedy. These guys were just overwhelmed by the whole situation. They did not apply the proper memory items and procedures despite Boeing introducing them months earlier! They simply forgot to fly the plane and even switched the MCAS back on (talk about breaking SOPs!)
Any Canadian, US, European or Aussie crew would have dealt with the situation immediately.
Unfortunately it has to be said. I am not current on the 73M but a lot of my friends are and they have even said that Boeing has received too much negativity surrounding this. Unfortunately it comes back to the piss poor media.
True and my experience of the issue as well.
GT may well be correct however it begs the question about why otherwise competent crew members become incompetent in this Boeing aircraft!
If an independent safety assessment had been done to support this iteration of the B737 then my non-airline pilot safety training would have detected a couple of hazards (see emails released to the public for evidence) which would require mitigation/barriers:
1. There is a single point of failure in the MCAS, the AOA sensor. The only mitigation being (correct me if I am wrong) that one AoA sensor was for the captain and the other for the FO;
2. There was, however, to be no mention of the MCAS during crew training. The mitigator being that it was automatic and would recover the aircraft without crew input. (is this true?) and that for point 1 that the crew would realise that the two AOA vanes were disagreeing even though they did not know this was a potential hazard (is this true?)
3. MCAS can only be over-ridden by switching the system off, unlike runaway trim. The crews, however, were not informed therefore no mitigator existed;
4. MCAS only operates when the auto-pilot is disengaged. Mitigator is therefore to leave auto pilot engaged.
5. Auto-pilot will not however not engage if aircraft is outside of flight envelope (is this true?). Therefore hazard above not mitigated if the aircraft is in a stalled condition, or thinks it is due erroneous AOA indications.
6. It cannot be assumed that all pilots are equally competent and the lead operator has a sub-optimal safety record. Mitigator - hope nothing goes wrong!
I won't bore you to death with more but regardless of whether the aircraft design is faulty or Lion/Ethiopian pilots are poorly trained, these factors should have been considered by the Boeing Safety Management System (mandated by the FAA) and appropriate mitigators put in place to return the risk to as low as reasonably practicable. (For definitions see: NOPSEMA Guidance Note: ALARP, N-04300-GN0166, Australia, Revision 4, December 2012. Regulatory Guidance). In Australia the High Court has said "if a measure is practicable and it cannot be shown that the cost of the measure is grossly disproportionate to the benefit gained, then the measure is considered reasonably practicable and must be implemented."
.
If an independent safety assessment had been done to support this iteration of the B737 then my non-airline pilot safety training would have detected a couple of hazards (see emails released to the public for evidence) which would require mitigation/barriers:
1. There is a single point of failure in the MCAS, the AOA sensor. The only mitigation being (correct me if I am wrong) that one AoA sensor was for the captain and the other for the FO;
2. There was, however, to be no mention of the MCAS during crew training. The mitigator being that it was automatic and would recover the aircraft without crew input. (is this true?) and that for point 1 that the crew would realise that the two AOA vanes were disagreeing even though they did not know this was a potential hazard (is this true?)
3. MCAS can only be over-ridden by switching the system off, unlike runaway trim. The crews, however, were not informed therefore no mitigator existed;
4. MCAS only operates when the auto-pilot is disengaged. Mitigator is therefore to leave auto pilot engaged.
5. Auto-pilot will not however not engage if aircraft is outside of flight envelope (is this true?). Therefore hazard above not mitigated if the aircraft is in a stalled condition, or thinks it is due erroneous AOA indications.
6. It cannot be assumed that all pilots are equally competent and the lead operator has a sub-optimal safety record. Mitigator - hope nothing goes wrong!
I won't bore you to death with more but regardless of whether the aircraft design is faulty or Lion/Ethiopian pilots are poorly trained, these factors should have been considered by the Boeing Safety Management System (mandated by the FAA) and appropriate mitigators put in place to return the risk to as low as reasonably practicable. (For definitions see: NOPSEMA Guidance Note: ALARP, N-04300-GN0166, Australia, Revision 4, December 2012. Regulatory Guidance). In Australia the High Court has said "if a measure is practicable and it cannot be shown that the cost of the measure is grossly disproportionate to the benefit gained, then the measure is considered reasonably practicable and must be implemented."
.
Training
GT may well be correct however it begs the question about why otherwise competent crew members become incompetent in this Boeing aircraft!
If an independent safety assessment had been done to support this iteration of the B737 then my non-airline pilot safety training would have detected a couple of hazards (see emails released to the public for evidence) which would require mitigation/barriers:
1. There is a single point of failure in the MCAS, the AOA sensor. The only mitigation being (correct me if I am wrong) that one AoA sensor was for the captain and the other for the FO;
2. There was, however, to be no mention of the MCAS during crew training. The mitigator being that it was automatic and would recover the aircraft without crew input. (is this true?) and that for point 1 that the crew would realise that the two AOA vanes were disagreeing even though they did not know this was a potential hazard (is this true?)
3. MCAS can only be over-ridden by switching the system off, unlike runaway trim. The crews, however, were not informed therefore no mitigator existed;
4. MCAS only operates when the auto-pilot is disengaged. Mitigator is therefore to leave auto pilot engaged.
5. Auto-pilot will not however not engage if aircraft is outside of flight envelope (is this true?). Therefore hazard above not mitigated if the aircraft is in a stalled condition, or thinks it is due erroneous AOA indications.
6. It cannot be assumed that all pilots are equally competent and the lead operator has a sub-optimal safety record. Mitigator - hope nothing goes wrong!
I won't bore you to death with more but regardless of whether the aircraft design is faulty or Lion/Ethiopian pilots are poorly trained, these factors should have been considered by the Boeing Safety Management System (mandated by the FAA) and appropriate mitigators put in place to return the risk to as low as reasonably practicable. (For definitions see: NOPSEMA Guidance Note: ALARP, N-04300-GN0166, Australia, Revision 4, December 2012. Regulatory Guidance). In Australia the High Court has said "if a measure is practicable and it cannot be shown that the cost of the measure is grossly disproportionate to the benefit gained, then the measure is considered reasonably practicable and must be implemented."
.
If an independent safety assessment had been done to support this iteration of the B737 then my non-airline pilot safety training would have detected a couple of hazards (see emails released to the public for evidence) which would require mitigation/barriers:
1. There is a single point of failure in the MCAS, the AOA sensor. The only mitigation being (correct me if I am wrong) that one AoA sensor was for the captain and the other for the FO;
2. There was, however, to be no mention of the MCAS during crew training. The mitigator being that it was automatic and would recover the aircraft without crew input. (is this true?) and that for point 1 that the crew would realise that the two AOA vanes were disagreeing even though they did not know this was a potential hazard (is this true?)
3. MCAS can only be over-ridden by switching the system off, unlike runaway trim. The crews, however, were not informed therefore no mitigator existed;
4. MCAS only operates when the auto-pilot is disengaged. Mitigator is therefore to leave auto pilot engaged.
5. Auto-pilot will not however not engage if aircraft is outside of flight envelope (is this true?). Therefore hazard above not mitigated if the aircraft is in a stalled condition, or thinks it is due erroneous AOA indications.
6. It cannot be assumed that all pilots are equally competent and the lead operator has a sub-optimal safety record. Mitigator - hope nothing goes wrong!
I won't bore you to death with more but regardless of whether the aircraft design is faulty or Lion/Ethiopian pilots are poorly trained, these factors should have been considered by the Boeing Safety Management System (mandated by the FAA) and appropriate mitigators put in place to return the risk to as low as reasonably practicable. (For definitions see: NOPSEMA Guidance Note: ALARP, N-04300-GN0166, Australia, Revision 4, December 2012. Regulatory Guidance). In Australia the High Court has said "if a measure is practicable and it cannot be shown that the cost of the measure is grossly disproportionate to the benefit gained, then the measure is considered reasonably practicable and must be implemented."
.
The trim speed of MCAS being 4 times faster than the pilot trim rate at the speed that the event occurs was not known less briefed in the OEB.
At exactly what age and experience level do we expect an unsuspecting crew to make up for the deficiency of the system, from the regulator, designers, certification that gave them a shoddy system?
If the crew are the cause, then feel free to book a flight on the max this day, obviously the grounding is unnecessary, and we can all feel happy blaming the deceased, after all, victimising victims is a grand sport of ours.
GT... Really?
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The information to the ET crew was only partially that needed to handle the event. The manual trim problem was only alluded to, not briefed. It remains deficient to this date.
The trim speed of MCAS being 4 times faster than the pilot trim rate at the speed that the event occurs was not known less briefed in the OEB.
At exactly what age and experience level do we expect an unsuspecting crew to make up for the deficiency of the system, from the regulator, designers, certification that gave them a shoddy system?
If the crew are the cause, then feel free to book a flight on the max this day, obviously the grounding is unnecessary, and we can all feel happy blaming the deceased, after all, victimising victims is a grand sport of ours.
GT... Really?
The trim speed of MCAS being 4 times faster than the pilot trim rate at the speed that the event occurs was not known less briefed in the OEB.
At exactly what age and experience level do we expect an unsuspecting crew to make up for the deficiency of the system, from the regulator, designers, certification that gave them a shoddy system?
If the crew are the cause, then feel free to book a flight on the max this day, obviously the grounding is unnecessary, and we can all feel happy blaming the deceased, after all, victimising victims is a grand sport of ours.
GT... Really?
That is the most erudite and constructive element.
That the fail safe is the pilot gives them all an out.
Or it did until it happened twice.
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Same crews globally, Same training, Same AoA vane.
Boeing have done a unfortunate "natural experiment" between the NG and the MAX. Almost everything remained constant, the only really significant change was the inclusion of additional software and larger engines. The engines have not been directly implicated in either accident.
Same crew training on the NG and the MAX, yet the fatality rate is 3.08 per million departures compared to 0.06 per million on the NG. Not only that, the NG has more than 100+ x the flights. This is a massive sample size of NG departures, I will also concede the sample size is relatively small for the MAX.
Everything is as constant as we could reasonably expect to perform a valid scientific comparison between two models.
Why did the MAX crash at more than 100 times the rate of the NG when they were almost indistinguishable from a crew perspective?
I posted on another thread #2891
Boeing has been undone by this high degree of commonality. The difference in the accident rates with almost identical systems was too stunning to ignore. When investigation reveal there was a new MCAS system (previous rebuke for calling it software accepted in post #2459 ) there was nowhere for Boeing to hide. A single system change related to flight controls could be pin pointed as the single cause of the accidents. Sure there were plenty of other factors (training, experience, organisational, SOPs), but they were all held constant between the NG and the MAX.
Pilots have been dealing with AoA vane failures and faults since 1997 at the same rate as the MAX with the introduction of the NG without a fatality. MCAS is the only significant variable that has been implicated in these accidents. It simply could not be ignored.
I posted earlier, Boeing's October 2018 own data, that attested to the safety of the NG. Some 100+ million flights without flight control issues, and then 0.65 million MAX departures with two flight control fatal accidents. It was not the AoA vane failure that was the cause, it was the MCAS system, and only the MCAS system that the airworthiness authorities could not sweep under the rug and dismissed as pilot error and ignore because everything was so common with the NG.
Put yourself in the shoes of a senior CAA official looking at these figures comparing the max to the NG. Could you honestly let it fly in your airspace? Because I would be certain, this is the data that each CAA would have had compiled very quickly
As an aside, I keep thinking that this whole failure is looking more similar to the first computer accident, the Therac-25 accident X-Ray machine as documented by Nancy Leveson.
In that accident, a sequence of models of new software dose control were held constant, and a physical interlock preventing a lethal does of radiation to the patient was eventually removed. This interlock was from the previous non-computerised model where the operator could accidentally overdose a patient. What the company failed to understand, was the software was actually faulty right from the start, the interlock was saving patients for years without the company understanding the fault.
To me, the MAX accidents have a similar theme, engineering assumptions made on the basis of almost identical systems, with small iterative flawed changes that lay dormant until the accident sequences.
Here is Boeing's own data
Source: Boeing Statistical Summary of Commercial Jet Airplane Accidents Worldwide Operations | 1959 – 2017
Boeing have done a unfortunate "natural experiment" between the NG and the MAX. Almost everything remained constant, the only really significant change was the inclusion of additional software and larger engines. The engines have not been directly implicated in either accident.
Same crew training on the NG and the MAX, yet the fatality rate is 3.08 per million departures compared to 0.06 per million on the NG. Not only that, the NG has more than 100+ x the flights. This is a massive sample size of NG departures, I will also concede the sample size is relatively small for the MAX.
Everything is as constant as we could reasonably expect to perform a valid scientific comparison between two models.
Why did the MAX crash at more than 100 times the rate of the NG when they were almost indistinguishable from a crew perspective?
I posted on another thread #2891
This comes back to the natural experiment that Boeing have performed between the MAX and the NG. Same AoA vane (IIRC same part number), and almost everything identical. So if you want to assume constant component failure rate, why are there no NG accidents related to flight controls or instrument failures that I can recall?
Boeing has been undone by this high degree of commonality. The difference in the accident rates with almost identical systems was too stunning to ignore. When investigation reveal there was a new MCAS system (previous rebuke for calling it software accepted in post #2459 ) there was nowhere for Boeing to hide. A single system change related to flight controls could be pin pointed as the single cause of the accidents. Sure there were plenty of other factors (training, experience, organisational, SOPs), but they were all held constant between the NG and the MAX.
Pilots have been dealing with AoA vane failures and faults since 1997 at the same rate as the MAX with the introduction of the NG without a fatality. MCAS is the only significant variable that has been implicated in these accidents. It simply could not be ignored.
I posted earlier, Boeing's October 2018 own data, that attested to the safety of the NG. Some 100+ million flights without flight control issues, and then 0.65 million MAX departures with two flight control fatal accidents. It was not the AoA vane failure that was the cause, it was the MCAS system, and only the MCAS system that the airworthiness authorities could not sweep under the rug and dismissed as pilot error and ignore because everything was so common with the NG.
Put yourself in the shoes of a senior CAA official looking at these figures comparing the max to the NG. Could you honestly let it fly in your airspace? Because I would be certain, this is the data that each CAA would have had compiled very quickly
As an aside, I keep thinking that this whole failure is looking more similar to the first computer accident, the Therac-25 accident X-Ray machine as documented by Nancy Leveson.
In that accident, a sequence of models of new software dose control were held constant, and a physical interlock preventing a lethal does of radiation to the patient was eventually removed. This interlock was from the previous non-computerised model where the operator could accidentally overdose a patient. What the company failed to understand, was the software was actually faulty right from the start, the interlock was saving patients for years without the company understanding the fault.
To me, the MAX accidents have a similar theme, engineering assumptions made on the basis of almost identical systems, with small iterative flawed changes that lay dormant until the accident sequences.
Source: Boeing Statistical Summary of Commercial Jet Airplane Accidents Worldwide Operations | 1959 – 2017
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Surely one of the over arching aims of type certification is that the aircraft is benign enough to be safely operated by an average crew rather than a test pilot.
in the case of the B737 Max it would seem from much of the evidence presented this was not the case.
in the case of the B737 Max it would seem from much of the evidence presented this was not the case.
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There has never ever been a Boeing jet that puts Stabilizer trim commands in remotely. This is the crux of the deal, in a Boeing you fly it and don’t expect any computer inputs. Airbus fine that’s a given, but not in a Boeing. This is a big deal and especially as it uses one sensor a disaster in the making.
You can sell a high performance piece of kit to someone who has no experience of it without training or a warning but expect the lawyers to come calling if they kill anyone with it - applies to all industries
There has never ever been a Boeing jet that puts Stabilizer trim commands in remotely. This is the crux of the deal, in a Boeing you fly it and don’t expect any computer inputs. Airbus fine that’s a given, but not in a Boeing. This is a big deal and especially as it uses one sensor a disaster in the making.
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Captain Sully Sullenberger, is not what anyone would call an incompetent or poorly trained crew
He is one of the few who has actually flown the profile of the two fatal crashes, in a 737 max sim
He found the MCAS runaways to be completely different to a trim runaway, very insidious and dangerous in how they first present themselves, and how difficult they were to control
His conclusion was 100% opposite to Thomas's
I know who I'd rather believe
https://www.independent.co.uk/travel...-a9162386.html
He is one of the few who has actually flown the profile of the two fatal crashes, in a 737 max sim
He found the MCAS runaways to be completely different to a trim runaway, very insidious and dangerous in how they first present themselves, and how difficult they were to control
His conclusion was 100% opposite to Thomas's
I know who I'd rather believe
https://www.independent.co.uk/travel...-a9162386.html
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This accident was classic Swiss cheese. It is appalling to lay the blame on the crew who found themselves confused by a complex malfunctioning system they did not know existed. Boeing are liable certainly ethically and morally with a complete failure in management oversight and breakdown of traditional engineering principals. Shame on you, Thomas. It is beyond asinine to claim pilot error when there are so many other factors.
Lets be fair to Boeing. It was their customers that asked for similarity and no additional training from the 737NG. Boeing (or its subsidiaries) would have been more than happy to sell additional simulator time to cover 737 MAX differences. Adding an AOA disagree warning light to the baseline model would have required a procedure: What do we does that light mean and what do we do about it? And that means training. Even quietly handling the AOA sensor failure (with dual inputs) wouldn't work either, as changing the handling characteristics without notifying the flight crew would be unacceptable.
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Hang on, this would be a Boeing friendly "leak"* right GT?
This would be the same Boeing that mocked operators who actually wanted to give their pilots additional training (beyond the one hour iPad course): Bloomberg Report: Boeing Mocked Lion Air Calls for More 737 Max Training Before Crash.
Is this the same Boeing that would allow their own family to travel on the MAX and described the FAA thus:
my bold. Source :The Register What was Boeing through their heads? Emails show staff wouldn't put their families on a 737 Max over safety fears
again from the Boeing chat logs
The same Boeing who also had a hand in suppressing a 2009 Human Factors report on a fatal 737 accident that had a large degree of system design failure in addition to flight crew error and undocumented behaviour with a system relying on a SINGLE CHANNEL failure just like the MAX (Capt's RA triggered autothrottle flair mode causing idle thrust with the same annunciation RETARD that the crew would expect to see at that point in the configuration sequence), they were happy to see the pilots take all the credit for the accident: NYT: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’
Do I understand exactly who you are now carrying water for GT, the same Boeing? How can you sleep at night?
Source Documents
*Geoffrey Thomas, will you disclose any consideration or benefit in kind, directly or indirectly from Boeing?
This would be the same Boeing that mocked operators who actually wanted to give their pilots additional training (beyond the one hour iPad course): Bloomberg Report: Boeing Mocked Lion Air Calls for More 737 Max Training Before Crash.
Is this the same Boeing that would allow their own family to travel on the MAX and described the FAA thus:
my bold. Source :The Register What was Boeing through their heads? Emails show staff wouldn't put their families on a 737 Max over safety fears
again from the Boeing chat logs
The same Boeing who also had a hand in suppressing a 2009 Human Factors report on a fatal 737 accident that had a large degree of system design failure in addition to flight crew error and undocumented behaviour with a system relying on a SINGLE CHANNEL failure just like the MAX (Capt's RA triggered autothrottle flair mode causing idle thrust with the same annunciation RETARD that the crew would expect to see at that point in the configuration sequence), they were happy to see the pilots take all the credit for the accident: NYT: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’
Do I understand exactly who you are now carrying water for GT, the same Boeing? How can you sleep at night?
Source Documents
- 737 Max Chat logs US House Transportation Committee https://transportation.house.gov/imo...Production.pdf
*Geoffrey Thomas, will you disclose any consideration or benefit in kind, directly or indirectly from Boeing?
The same Boeing that fired the top boss, saying the company had “decided that a change in leadership was necessary to restore confidence in the company moving forward as it works to repair relationships with regulators, customers, and all other stakeholders”.
Whatever the range of facts and opinions, this is the same Boeing that has since then announced it will take longer than previously declared expectations to get the thing back in the air.
Incurring all that extra work doesn't suggest Boeing support for what Mr Thomas is saying.