Downfall, Netflix documentary
Unfortunately the situation that Boeing got themselves into is quite typical in the high end corporate world these days, and aviation isn’t immune to this type of attitude that directly impinges on how the core people within that business go about their daily tasks. When shareholders and senior management are only focused on one thing that isn’t SAFETY, ala the stock price and their remuneration package, things go pear shaped very quickly.
Look what happened when Boeing reduced a large majority of their quality control people from the factory floor, why did they do this? $$$$$$$$ Nothing to do with maintaining or improving safety standards.
Just look at the effect this type of corporate influence has had on the industry in Australia recently and currently. Every major Part 121 operator in Australia has been directly effected by corporate takeovers that have directly effected how people on the front line in these organisations do their daily tasks.
CASA are in the process of implementing Safety and Quality Management System requirements for GA operators, and some operators aren’t happy about this as it’s going to cost them money to set up and maintain the system. It certainly will initially, however a well run Safety and Quality Management System will in fact save a lot of money, if it’s got the right people running it and they are allowed to do so. If they can’t, it will certainly cost a lot of money. If you don’t believe this, use the Boeing story as an example!
Safety comes at a high cost, however have an accident and one will quickly learn that safety isn’t really that expensive if you have the right people managing it.
Look what happened when Boeing reduced a large majority of their quality control people from the factory floor, why did they do this? $$$$$$$$ Nothing to do with maintaining or improving safety standards.
Just look at the effect this type of corporate influence has had on the industry in Australia recently and currently. Every major Part 121 operator in Australia has been directly effected by corporate takeovers that have directly effected how people on the front line in these organisations do their daily tasks.
CASA are in the process of implementing Safety and Quality Management System requirements for GA operators, and some operators aren’t happy about this as it’s going to cost them money to set up and maintain the system. It certainly will initially, however a well run Safety and Quality Management System will in fact save a lot of money, if it’s got the right people running it and they are allowed to do so. If they can’t, it will certainly cost a lot of money. If you don’t believe this, use the Boeing story as an example!
Safety comes at a high cost, however have an accident and one will quickly learn that safety isn’t really that expensive if you have the right people managing it.
Technical discussions aside. How is it that a company can go from a beleaguered cash strapped airplane maker who had to hide certain elements of its design from the FAA in order to avoid new type rating status, to one who can afford to pay a multi billion dollar fine in order to avoid criminal charges? And remain in business? Let us not forget the guy who was at the helm, the captain of the company you could say, got a golden handshake in return for overseeing the culpable homicide of a few hundred people. Corporate filth masquerading as leaders pedalling profits disguised as safety, I’m glad we are above all that down under.
Corporate greed, incompetence, arrogance all caused the Max to be rolled out with a flaw.
However a pilot with a left seat type rating in the 737 should know that when faced with an aircraft that has a trim wheel moving forward that the corrective action is to first use electric trim and if it's still trimming forward to do the Memory Items that you are paid to do.
Prior to the fatal Lion Air 610 flight one of the AoA sensors was replaced with another sensor which was repaired by a facility in Florida (XTRA) that had no approval to repair this part. It was shown that this particular sensor had already caused a stick shaker event on another aircraft but Lion Air used it anyway. There was no documented calibration check after installation thus the 21 degree difference between the two sensor readings was never picked up. The difference was discovered when the DFDR data was checked after the crash. A 21 degree difference between angle of attack sensors? No wonder MCAS detected a stall event ffs. You guys need to read more and stop watching sensationalist Netflix crap.
Ultimately this sensor precipitated a chain of events that exposed other factors that ultimately caused the fatal crash. Cheese anybody.
Ultimately this sensor precipitated a chain of events that exposed other factors that ultimately caused the fatal crash. Cheese anybody.
that exposed other factors that ultimately caused the fatal crash.
Unfortunately the situation that Boeing got themselves into is quite typical in the high end corporate world these days, and aviation isn’t immune to this type of attitude that directly impinges on how the core people within that business go about their daily tasks. When shareholders and senior management are only focused on one thing that isn’t SAFETY, ala the stock price and their remuneration package, things go pear shaped very quickly.
Look what happened when Boeing reduced a large majority of their quality control people from the factory floor, why did they do this? $$$$$$$$ Nothing to do with maintaining or improving safety standards.
Look what happened when Boeing reduced a large majority of their quality control people from the factory floor, why did they do this? $$$$$$$$ Nothing to do with maintaining or improving safety standards.
Thanks for your input ! 
Very likely this detail has been discussed before, but what is the reason that causes Boeing to be so afraid that the Max gets into a stall situation, to the point that they came up with MCAS ?
Goes into something similar to a super stall situation, that is impossible to get out of it, or is it something else ?
It's been a very long time since I last studied stability
Very likely this detail has been discussed before, but what is the reason that causes Boeing to be so afraid that the Max gets into a stall situation, to the point that they came up with MCAS ?
Goes into something similar to a super stall situation, that is impossible to get out of it, or is it something else ?
It's been a very long time since I last studied stability
The "fear" is that an aerodynamic solution would be expensive - adding weight, drag, cost, structural modifications. Instead they adapted the speed trim system (STS), which already modifies the trim to alter the control wheel forces, to do this. No doubt Airbus already does this to adapt; it's just less noticeable on Airbus as the only force feedback is a spring in the sidestick and they change elevator and trim to match that force.
If I were to guess why it didn't get more notice, it's because the correction it was to provide is small with far less influence during normal operation than STS. Tragically, no pilot should ever have had MCAS operate - it's only for manual flight, flaps up, far from normal AoA. Further, any malfunction in the trim system produces the same symptoms and corrective procedures were already in place.
Like a car manufacturer using a 1960s design for a new vehicle, and not even going down the retro pathway. Putting systems in place to allow for 1960s design standards 50 years later isn’t smart engineering. Might be ok for a light aircraft manufacturer, however certainly not for a modern day airliner.
And yet you consider that the pilots were of a lesser standard that they couldn't cope with the flaw that ultimately kept the type grounded for years.
Absolutely agree but with the caveat that they are flying any other type of 737 and not the Max. If it was that simple then the Max would not have been grounded. MCAS added a level of complexity to your simple runaway stab procedure that would have seen many crashes occur had the flawed design been allowed to continue operating. Line pilots are not test pilots yet thats what Boeing (and the SH 737 jocks that never flew a Max) expected of them.
Absolutely agree but with the caveat that they are flying any other type of 737 and not the Max. If it was that simple then the Max would not have been grounded. MCAS added a level of complexity to your simple runaway stab procedure that would have seen many crashes occur had the flawed design been allowed to continue operating. Line pilots are not test pilots yet thats what Boeing (and the SH 737 jocks that never flew a Max) expected of them.
The initial application of rudder to counter an engine failure is very different and employs the same rapidly deployable muscle memory that a pilot has used on all twin types from the start of their twin flying.
Well, in 1995 I flew a new version of the CH47 which had just such a design fault - a single data source for the altimeter. Flying along at 4000’, fortunately VMC, I became aware that we had gradually descended to more like 2000’. I informed ATC of our problem and they replied that they still had our Mode C at 4000’. Boeing (belatedly) then added a second data source. Good job we weren’t IMC, eh?
Last edited by kintyred; 22nd Feb 2022 at 21:03.
And yet despite some legends on here saying well all they had to do was Switch Off the Stab Trim Cutout switches the aircraft was still grounded for 2 years. Maybe not that simple after all.
A trim runaway is not immediately obvious and requires a brief analysis of the situation prior to implementing a recall item that can easily be delayed with startle effect.
The initial application of rudder to counter an engine failure is very different and employs the same rapidly deployable muscle memory that a pilot has used on all twin types from the start of their twin flying.
The initial application of rudder to counter an engine failure is very different and employs the same rapidly deployable muscle memory that a pilot has used on all twin types from the start of their twin flying.
Moderator
That's weird, I could have sworn I did this in my NG type rating 15 years ago
And, likewise, on my Classic rating in the 80s.
A trim runaway is not immediately obvious
Suggest, like most training sequences I have been exposed to (from both ends of the sim), for "trim runaway", read something like "if it's not doing what you want/expect and you can't make it behave" then do something (turn it off) rather than just sitting there staring into space and wondering what's going on ! If, perchance, you over-reacted and jumped the gun, you can always go back a step with this one. A bit similar (if not all that closely related) to the standard TP approach - if you just did something and something unpleasant happens, undo that which you just did and see if the two might have been related.
the aircraft was still grounded for 2 years. Maybe not that simple after all.
There were certification considerations which needed to be addressed. Two different, albeit related, matters.
And, likewise, on my Classic rating in the 80s.
A trim runaway is not immediately obvious
Suggest, like most training sequences I have been exposed to (from both ends of the sim), for "trim runaway", read something like "if it's not doing what you want/expect and you can't make it behave" then do something (turn it off) rather than just sitting there staring into space and wondering what's going on ! If, perchance, you over-reacted and jumped the gun, you can always go back a step with this one. A bit similar (if not all that closely related) to the standard TP approach - if you just did something and something unpleasant happens, undo that which you just did and see if the two might have been related.
the aircraft was still grounded for 2 years. Maybe not that simple after all.
There were certification considerations which needed to be addressed. Two different, albeit related, matters.
The early part of the program mentions the McDonnell Douglas management method; those of us who flew the DC10 will remember the design philosophy influenced by accountants that led to the Chicago, Paris and Sioux City accidents. The hydraulic system and slat system designs along with the supposedly non standard engine maintenance procedures. The most shocking and crooked part was that the Turkish crash was initially blamed on a Paris mechanic eventually it was discovered that a mandatory modification had not been carried out but MD falsified the work and it’s inspection paperwork.
IIRC the MD11 was certified on the back of the DC10 as a full certification process would have involved substantial modification and expense. There is also the question as to how much Kapton and the insulation materials were part of the SR111 loss.
IIRC the MD11 was certified on the back of the DC10 as a full certification process would have involved substantial modification and expense. There is also the question as to how much Kapton and the insulation materials were part of the SR111 loss.
This is a quote from one of my colleagues on BeechTalk:
I found the documentary one-sided in many respects. I'm not debating that the MCAS system was poorly designed, and that the pilots should have been informed and trained in the system. However the show relied heavily on common biased media/political tropes:
- Boeing tried to defend itself publicly - therefore they must be guilty
- Boeing has lobbyists on staff - therefore they must be guilty
- Boeing made decisions intended to improve profitability and reduce cost - anyone who does this is guilty
- Boeing did not release publicly the millions of pages of internal documents ordered by the government overnight - so they must be guilty
- Boeing pointed out that the crews did not follow the complete trim runaway procedures - clearly they were shifting blame and must be guilty
- The Boeing CEO did not call each family personally - so Boeing must be guilty. It would have been nice if the producers discussed that every call would have been recorded, posted to the internet, and used to suggest Boeing knew it was guilty.
- When Boeing officials met with the pilot's union they didn't provide documents, reports, and presentations - so they must have been hiding something (their guilt). Of course Boeing, in the middle of an investigation, probably felt anything they provided would be published out of context and used against them. I think this was a good supposition considering the pilot's union surreptitiously taped the meeting, edited the tape, and released it publicly to make Boeing look bad (and the pilots look good).
There were also a number of statements made which I have trouble with:
- 'Boeing concluded that if the pilots did not respond to an MCAS failure within 10 seconds, in every case the plane would be lost'. And repeated by the 'experts' on the show several times: 'it is physically impossible for a crew to respond in 10 seconds'. I seriously doubt that was the extent of the Boeing conclusion, and that it is physically impossible to intervene or respond within 10 seconds.
- 'Boeing knew that MCAS failures were likely, that they would doom the planes, and that they "conspired" to keep this information from pilots and operators'. Again I suspect this is a gross oversimplification or exaggeration.
I also thought the Airbus comparison was interesting. It was strongly implied that Airbus is a remarkable aircraft manufacturer, they build virtually perfect planes, much better than Boeing, and that because Boeing tried to compete by building an improved and very economic airframe/engine package Boeing is clearly a shoddy manufacturer with no concern for safety.
The show never adequately delved into two key factors which were Boeing's main defense: the normal procedure requiring disconnecting the speed trim system, and of reducing throttle to avoid an over-speed situation. The first was mentioned but little was said about why the first crew didn't disconnect the system (as they were trained). In the second crash, the crew did disconnect the system (this was demonstrated in the show), and it was shown that they were far above the safe airspeed which prevented manual trim from working, but the show did not question why the pilots didn't reduce the throttle while in a steep descent with excess airspeed. Of course the assumption is that with all the alarms going off the crews were distracted, still I think the show could have acknowledged that if the normal Boeing procedure had been followed the crashes would not have occurred. The show then could have then discussed in more detail the factors that would have made application of the proper procedures difficult or less likely (lack of training in MCAS failure modes, possible lack of training provided on speed-trim runaway, alarm overload, etc.
It's hard not to agree with the basic conclusion, but I get tired of "documentaries" that have a predetermined conclusion and without exception find that one player is totally guilty (evil in fact) and that no other party should share the blame. In this show the main theme was:
- Boeing is entirely guilty, knew the planes were doomed to crash, but sold them anyway to make an extra $5 bucks
- The government and FAA are great but were bamboozled by the evil corporate giant
- Congress is here to save you
- If a plane crashes it's the builder's fault, pilots never make mistakes, even if they do it's the plane builder's fault.
- But it's all good now because there's a whole new law on the books and Boeing was soaked by the gov for $2.5 Billion
- Boeing tried to defend itself publicly - therefore they must be guilty
- Boeing has lobbyists on staff - therefore they must be guilty
- Boeing made decisions intended to improve profitability and reduce cost - anyone who does this is guilty
- Boeing did not release publicly the millions of pages of internal documents ordered by the government overnight - so they must be guilty
- Boeing pointed out that the crews did not follow the complete trim runaway procedures - clearly they were shifting blame and must be guilty
- The Boeing CEO did not call each family personally - so Boeing must be guilty. It would have been nice if the producers discussed that every call would have been recorded, posted to the internet, and used to suggest Boeing knew it was guilty.
- When Boeing officials met with the pilot's union they didn't provide documents, reports, and presentations - so they must have been hiding something (their guilt). Of course Boeing, in the middle of an investigation, probably felt anything they provided would be published out of context and used against them. I think this was a good supposition considering the pilot's union surreptitiously taped the meeting, edited the tape, and released it publicly to make Boeing look bad (and the pilots look good).
There were also a number of statements made which I have trouble with:
- 'Boeing concluded that if the pilots did not respond to an MCAS failure within 10 seconds, in every case the plane would be lost'. And repeated by the 'experts' on the show several times: 'it is physically impossible for a crew to respond in 10 seconds'. I seriously doubt that was the extent of the Boeing conclusion, and that it is physically impossible to intervene or respond within 10 seconds.
- 'Boeing knew that MCAS failures were likely, that they would doom the planes, and that they "conspired" to keep this information from pilots and operators'. Again I suspect this is a gross oversimplification or exaggeration.
I also thought the Airbus comparison was interesting. It was strongly implied that Airbus is a remarkable aircraft manufacturer, they build virtually perfect planes, much better than Boeing, and that because Boeing tried to compete by building an improved and very economic airframe/engine package Boeing is clearly a shoddy manufacturer with no concern for safety.
The show never adequately delved into two key factors which were Boeing's main defense: the normal procedure requiring disconnecting the speed trim system, and of reducing throttle to avoid an over-speed situation. The first was mentioned but little was said about why the first crew didn't disconnect the system (as they were trained). In the second crash, the crew did disconnect the system (this was demonstrated in the show), and it was shown that they were far above the safe airspeed which prevented manual trim from working, but the show did not question why the pilots didn't reduce the throttle while in a steep descent with excess airspeed. Of course the assumption is that with all the alarms going off the crews were distracted, still I think the show could have acknowledged that if the normal Boeing procedure had been followed the crashes would not have occurred. The show then could have then discussed in more detail the factors that would have made application of the proper procedures difficult or less likely (lack of training in MCAS failure modes, possible lack of training provided on speed-trim runaway, alarm overload, etc.
It's hard not to agree with the basic conclusion, but I get tired of "documentaries" that have a predetermined conclusion and without exception find that one player is totally guilty (evil in fact) and that no other party should share the blame. In this show the main theme was:
- Boeing is entirely guilty, knew the planes were doomed to crash, but sold them anyway to make an extra $5 bucks
- The government and FAA are great but were bamboozled by the evil corporate giant
- Congress is here to save you
- If a plane crashes it's the builder's fault, pilots never make mistakes, even if they do it's the plane builder's fault.
- But it's all good now because there's a whole new law on the books and Boeing was soaked by the gov for $2.5 Billion
It seems that Boeing is no longer Boeing, It's McDonnell Douglas and this all sounds so much like the debacle that went on with McDonnell Douglas
and the FAA in getting the flawed DC-10 rushed through certification.
If you can find a copy, The Rise and Fall of the DC-10 is very interesting reading.
and the FAA in getting the flawed DC-10 rushed through certification.
If you can find a copy, The Rise and Fall of the DC-10 is very interesting reading.