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Indonesian aircraft missing off Jakarta

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Indonesian aircraft missing off Jakarta

Old 25th Nov 2018, 12:02
  #1641 (permalink)  
 
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Bergerie, #1647; a key question.
I fear the answer involves a cheap and cheerful solution to a shortfall in meeting certification requirements, particularly if late in the program, where alternative arguments for equivalent safety were unacceptable. i.e. everything from the forgotten NASA lesson ‘Faster, Better, Cheaper’, isn’t.
Therein lies the underlying assumptions about the likely outcome of an AoA failure, and particularly that a crew will both understand and manage the situation; unfortunately in parallel, the understanding and management guidance were absent.
Furthermore the discussions in this thread suggest that even with descriptions and checklists the situation which pilots might face could be beyond their capability - understanding and strength.
Thus although we have the EAD drill, significant risk exists which pilots are expected to manage.

Add to the AoA issue, my previous question about the display of AoA, an option which Lion did not have.
If the DISAGREE a message does not remove the AoA display then pilots are presented with misleading, probably hazardous information (judged by the esteem by which AoA is held by PPRuNe).
Add to this, the question whether the associated alerts IAS, stickshake, and erroneous low speed awareness (AoA dependent) would be apparent as soon as the AoA was in error (disagree). If not why should these be subject to the MCAS inhibit conditions for trim operation (flap up), prior to which the AoA display would be showing conflicting information?

Re 2 out of 3 sensor comparison logic, there is a debatable area between using an automated a triple system, and the alternative of using human judgement of dual comparison and then selection of the third system. If nothing else the human is directed (Comparator) to the erroneous system opposed to the confusion of many consequential system alerts.

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Old 25th Nov 2018, 12:04
  #1642 (permalink)  
 
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Originally Posted by safetypee View Post
#1644: Except that MCAS does not have any ‘grandparents’.


Oh, MCAS has many famous granparents.

... It had a 727 with rear engines, that allowed the gear to be short and the wing low.
... Then the 737 antique, with the same short gear low wing design, so the engines were shoved right up next to the wing.
... Then the classic and NG, with ever larger and more powerful engines, giving a greater pitch up moment both in their thrust, their thrust line, and their forward of CofL aerodynamic effects. Now thrust was more powerful than max elevator input, and you could go ballistic if you were not careful. (Which is why the stall recovery advice says reduce power.)
... Then the Max, with even bigger and more powerful engines delivering an even greater pitch up moment.

Houston, we have a problem - we need a system to stop the aircraft going vertical, if too much power is added at the stall. Enter MCAS, stage left, to much applause and adulation. Hurrrah....! Except the new starlet was untried and untested....

As someone here said - Ford is not producing the Mk1 Cortina, with a new engine, dashboard, and a host of bolt-on fixes, because nobody would buy it. So why is anyone buying a 1962 aircraft, with new engines, a new dashboard, and a host of bolt-on fixes??

Silver
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Old 25th Nov 2018, 13:20
  #1643 (permalink)  
 
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Originally Posted by silverstrata View Post

Oh, MCAS has many famous granparents.

... It had a 727 with rear engines, that allowed the gear to be short and the wing low.
What was it called on the 727?
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Old 25th Nov 2018, 14:04
  #1644 (permalink)  
 
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Lightbulb

Originally Posted by aterpster View Post
What was it called on the 727?
"Flight Engineer" ?
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Old 25th Nov 2018, 14:27
  #1645 (permalink)  
 
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What was it called on the 727?
He meant that's where the short undercarriage and low wing came from... grandfathered from the 727.
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Old 25th Nov 2018, 14:57
  #1646 (permalink)  
 
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MCAS has the same grandparents, different DNA. What was once a primitive failsafe is now called “enhancement”?
The lineage is more direct? Engine placement makes the 727 a distant cousin, not a grandparent?

The march to economy should include added safety, not instability?
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Old 25th Nov 2018, 15:14
  #1647 (permalink)  
 
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Originally Posted by safetypee View Post
#1644: Except that MCAS does not have any ‘grandparents’. The ideas behind this ‘single-failure prone system’ may have its origins in modern aircraft with their high integrity stability enhancements based redundant architecture. Perhaps this is the shadow of grandfather designing, test and certification, and dated regulatory practice. Time to dust off James Reason’s views on organisational accidents.

Irrespective of what the Indonesian authorities identify in their investigations, the deficiencies in disseminating knowledge and crew checklists must be investigated.
I doubt that Indonesia alone would be able to pursue an investigation involving the FAA and Boeing in the US; according to Annex 13 they should, but …

The NTSB should be sufficiently independent to look at the FAA and delegated regulatory process, minimising any of criticism of an internal coverup.
An investigation would be in everyone’s interest worldwide. Without understanding where the design and certification process failed the confidence in aviation safety remains open to question, particularly for Boeing and all their aircraft types.
A separate investigation might also enhance the need for other regulators to review the integrity of their certification processes, and consider the effectiveness of the oversight of joint international approvals.
“Trust, but verify.”

The NTSB recognizes this type of need for independence - though the illustration of this comes from a recent incident which likely is less complicated than this accident (not only because it was *only* a very close call).

The chairman of the Board, in response to a question from someone in the audience at a guest lecture the chairman delivered about a year ago, stated that in its recommendations in the aftermath of the AC 759 San Francisco incident, NTSB was keenly aware of the need to protect, as well as exercise, its independence. No doubt the Annex 13 process for this accident is largely but not totally different kind of situation. (And that's without heaving irony, about Indonesia as the centre of the Annex 13 process.)

(Whether NTSB report after KSFO in fact manifested independence, and then how effective follow-ups have been (and where), is another question - possibly instructive for the tasks ahead now.)
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Old 25th Nov 2018, 16:03
  #1648 (permalink)  
 
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There were some questions about the status of the identification process.

Official status on 23nov2018 was 90 male and 35 female for a total of 125.

Unofficial - based on both official and public data - not possible to completely verify this yet - includes 3 of 5 cabin crew, the 1 mechanic, 1 pilot (Capt). There have been at least 2 people identified from seat-rows 2-34, but zero from row14, from row13 only 1 person. If you look at the present status that I have, the least number of identifications are from rows 2-14 the CDEF seats.

Note1: I dont know the exact Lion Air cabin layout. Thought the seating total was 189, which requires 31.5 rows of seat. Rows 2-34 are mentioned in the passenger manifest/list. If row 13 and 14 are not used, we have 31 rows if 2-34 are used.
Note2: If you would only have this information (not going into detail here) you would estimate that you are dealing with a - very high speed, steep angle, banked right (or left if inverted) - impact. We will probably know by 30nov2018 if that estimate points in the right direction.

Last edited by A0283; 25th Nov 2018 at 16:29.
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Old 25th Nov 2018, 16:14
  #1649 (permalink)  
 
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Originally Posted by A0283 View Post
There were some question on the status of the identification process.

Official status on 23nov2018 was 90 male and 35 female for a total of 125.

Unofficial - based on both official and public data - not possible to completely verify this yet - includes 3 of 5 cabin crew, the 1 mechanic, 1 pilot (Capt). There have been at least 2 people identified from seat-rows 2-34, but zero from row14, from row13 only 1 person. If you look at the present status that I have, the least number of identifications are from rows 2-14 the CDEF seats.

Notes: I dont know the exact Lion cabin layout. Thought the seating total was 189, which requires 31.5 rows of seat. Rows 2-34 are mentioned in the passenger manifest/list. If row 13 and 14 are not used, we have 31 rows if 2-34 are used.
So. Aircraft impacted starboard side “first”.



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Old 25th Nov 2018, 16:26
  #1650 (permalink)  
 
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Originally Posted by safetypee View Post
#1644: Except that MCAS does not have any ‘grandparents’. The ideas behind this ‘single-failure prone system’ may have its origins in modern aircraft with their high integrity stability enhancements based redundant architecture. Perhaps this is the shadow of grandfather designing, test and certification, and dated regulatory practice. Time to dust off James Reason’s views on organisational accidents.

Irrespective of what the Indonesian authorities identify in their investigations, the deficiencies in disseminating knowledge and crew checklists must be investigated.
I doubt that Indonesia alone would be able to pursue an investigation involving the FAA and Boeing in the US; according to Annex 13 they should, but …

The NTSB should be sufficiently independent to look at the FAA and delegated regulatory process, minimising any of criticism of an internal coverup.
An investigation would be in everyone’s interest worldwide. Without understanding where the design and certification process failed the confidence in aviation safety remains open to question, particularly for Boeing and all their aircraft types.
A separate investigation might also enhance the need for other regulators to review the integrity of their certification processes, and consider the effectiveness of the oversight of joint international approvals.
“Trust, but verify.”

I would be concerned if the NTSB would enter into any kind of assessment regarding the adequacy of a regulatory process (e.g. reviewing "integity", and "effectiveness" ) as that is entirely delegated to the regulator body. However the burden of an impartial investigations and recommendations may simply point out the failure circumstances against any standards in the regulation as written.
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Old 25th Nov 2018, 16:30
  #1651 (permalink)  
 
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Since we're talking about grandparents, here's some context:

https://www.flightglobal.com/pdfarch...0-%200302.html

The MAX is twice as heavy and powerful as the original. (The heaviest A321 seems to be about one-third heavier than the initial standard A320.) The Flight piece describes a very simple airplane, with mostly duplex systems, that could withstand the failure of almost anything powered, short of the loss of two engines, and had no stab-aids other than a stick-shaker and a yaw damper.

Is there a limit to evolutionary development?

PS - Does anyone know if there's anything MCAS-like on the P-8A? It's based on the NG, of course, but its mission involves the sort of maneuver where MCAS would kick in, and there are conditions where the aircraft might have more of an aft cg than the commercial airplanes, given the aft weapon bay and the heavy pressurized sonobuoy launchers in the back of the cabin.
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Old 25th Nov 2018, 17:05
  #1652 (permalink)  
 
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Originally Posted by Capn Bloggs View Post
He meant that's where the short undercarriage and low wing came from... grandfathered from the 727.
I don't quite follow that, seeing as the 727 didn't have wing-mounted engines. Then again, I flew them, didn't design them.
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Old 25th Nov 2018, 17:27
  #1653 (permalink)  
 
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“...Is there a limit to evolutionary development?...”

I would say no. So long as the evolved pilot keeps pace.....


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Old 25th Nov 2018, 17:53
  #1654 (permalink)  
 
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Originally Posted by safetypee View Post
The NTSB should be sufficiently independent to look at the FAA and delegated regulatory process, minimising any of criticism of an internal coverup.
An investigation would be in everyone’s interest worldwide. Without understanding where the design and certification process failed the confidence in aviation safety remains open to question, particularly for Boeing and all their aircraft types.
A separate investigation might also enhance the need for other regulators to review the integrity of their certification processes, and consider the effectiveness of the oversight of joint international approvals.
“Trust, but verify.”

NTSB published a scathing report on 787 battery certification process. FAA brushed aside. Same can happen here.

I am guessing the augmentation word is be the key. This is just for a smooth flight, not a critical component, 2.5 degrees stabilizer trim is not going to kill anyone. No big deal, Stamped and signed. Yours Truly.
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Old 25th Nov 2018, 18:10
  #1655 (permalink)  
 
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The 787 battery failed written rules posted in the Federal register. Related to “fire onboard”. Not allowed.

The fix was to “contain” fire. It still violated the rule, but the continued violation was ignored.

Only one fact Boeing will answer to, post “fire” becoming acceptable on board.....

”...We decided not to disclose the presence of MCAS. We did not wish to overwhelm the average pilot....”

Average has nothing to do with the final verdict. US jurisprudence values one pre requisite among all others.

”Non disclosure is a “species of fraud...” “

The shortest path to ruin is failing to disclose a material fact, that bears on a contract: Commercial Carriage is a contract. Every paid passage is an ironclad contract.
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Old 25th Nov 2018, 18:13
  #1656 (permalink)  
 
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Originally Posted by DaveReidUK View Post
IIRC, the NTSC stated that there had been four previous (not necessarily consecutive) flights during which similar problems had been encountered, and that at some stage during that sequence the AoA sensor had been replaced.
And here we arrive at a question about the MEL, and what the requirements are for a test flight if there is a flight control problem, one that repeated, to include a safety of flight sub system, stick shaker, malfunctioning (false positives, apparently) for an extended period of time.

Also the previous flight completed their sector with the stick shaker being active basically the whole flight.
Post of interest and Another post of interest.
That's a hole or three in the Swiss cheese lining up.

A separate concern is what is an apparent glossing over of that system in the difference training, and how well trained/taught aircrews are regarding systems That Move The Flight Control Surfaces in various degraded/malfunction modes. From the contributory causes perspective, there's seems to me a (tragic) synergy between three elements of the system that are not the flying-the-aircraft piece, or even designing and building it.

1. Known failure modes, and training pertaining thereunto
2. Documentation and difference training so that pilots know how the flight controls move, and when ...
3. The MEL, how to trouble shoot and fix a problem, and then release for flight for carrying passengers.

The bellowing about how the latest 737 is somehow not a fit aircraft I'll leave to others - been watching the A vs B bun throwing on PPRuNe for a decade, and it's pointless. The vast majority of the fleet seems to take off and land without issue on a daily basis. What concerns me are pilot training, maintenance procedures, and documentation. A few pages back there was a video by a flying Captain that raises a disturbing point in parallel with some issues raised in this discussion: how thorough is the difference training, and what "this is new" stuff is covered in the simulator sessions that introduce the new version to the aircrews.

Does this vary by company? If so, why?

Similar question about maintenance procedures, and what constitutes a defect that can be "fixed later" versus "can't fly until it's fixed' versus 'can't fly till it's fixed and a maintenance test flight completed.' That third thing appears, from what I've gleaned so far, to not have been done.

For Concours77:
The "evolution" of the modern pilot still costs time and effort to train and educate on the complex system/aircraft he or she is flying. Getting off of your high horse about the 787 battery would be nice. I don't see it as relevant to a flight control malfunction.
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Old 25th Nov 2018, 18:28
  #1657 (permalink)  
 
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Originally Posted by lomapaseo View Post
I would be concerned if the NTSB would enter into any kind of assessment regarding the adequacy of a regulatory process (e.g. reviewing "integity", and "effectiveness" ) as that is entirely delegated to the regulator body. However the burden of an impartial investigations and recommendations may simply point out the failure circumstances against any standards in the regulation as written.
On the contrary, surely. The reason that an 'annex 13' investigation body should be entirely independent (of everyone and everything else) is precisely because it should be able to question any part of the system. Using your argument, there should be no assessment of the piloting process because that is delegated to the pilot in command, or of the maintenance process because responsibility for signing off the aircraft as fit to fly is delegated to the maintenance organisation, and so on).

Is there any reason that you believe that the FAA is, in some way infallible? Indeed, there are plenty of examples of accidents where regulatory oversight is identified as poor, either before or after the investigation. In some ways it surprises me that regulatory agencies are relatively rarely the focus of recommendations resulting from accident investigations.

Having worked in a regulatory agency, it was rather sobering on occasions to see how little knowledge or understanding that the regulator actually had of the organisations which it was supposed to oversee. And that was before any arguments that regulatory staff could never have cutting-edge industry competence (only the people at the sharp end, those developing new technologies could be expected to fully understand such things) and so regulators would only study and assess the adequacy of safety cases produced by manufacturers etc.(which would always be honest and complete, of course). Rather interestingly as I sit here writing this, I can't help thinking about a news story running on the BBC at the moment - albeit a different industry and well outside FAA jurisdiction - which might open some eyes to the way in which regulation can work - https://www.bbc.com/news/health-46318445.

The annex 13 type of investigation is not perfect, but it's better than many of the alternatives that some might prefer - and long may the NTSB look at the effectiveness of the FAA (and all of the local parallels as they apply), just as they look at any other part of the aviation system. That's the only way that the enviable safety performance that we see in the aviation industry will be maintained and improved.
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Old 25th Nov 2018, 18:29
  #1658 (permalink)  
 
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Originally Posted by Lonewolf_50 View Post
And here we arrive at a question about the MEL, and what the requirements are for a test flight if there is a flight control problem, one that repeated, to include a safety of flight sub system, stick shaker, malfunctioning (false positives, apparently) for an extended period of time.


Post of interest and Another post of interest.
That's a hole or three in the Swiss cheese lining up.

A separate concern is what is an apparent glossing over of that system in the difference training, and how well trained/taught aircrews are regarding systems That Move The Flight Control Surfaces in various degraded/malfunction modes. From the contributory causes perspective, there's seems to me a (tragic) synergy between three elements of the system that are not the flying-the-aircraft piece, or even designing and building it.

1. Known failure modes, and training pertaining thereunto
2. Documentation and difference training so that pilots know how the flight controls move, and when ...
3. The MEL, how to trouble shoot and fix a problem, and then release for flight for carrying passengers.

The bellowing about how the latest 737 is somehow not a fit aircraft I'll leave to others - been watching the A vs B bun throwing on PPRuNe for a decade, and it's pointless. The vast majority of the fleet seems to take off and land without issue on a daily basis. What concerns me are pilot training, maintenance procedures, and documentation. A few pages back there was a video by a flying Captain that raises a disturbing point in parallel with some issues raised in this discussion: how thorough is the difference training, and what "this is new" stuff is covered in the simulator sessions that introduce the new version to the aircrews.

Does this vary by company? If so, why?

Similar question about maintenance procedures, and what constitutes a defect that can be "fixed later" versus "can't fly until it's fixed' versus 'can't fly till it's fixed and a maintenance test flight completed.' That third thing appears, from what I've gleaned so far, to not have been done.

For Concours77:
The "evolution" of the modern pilot still costs time and effort to train and educate on the complex system/aircraft he or she is flying. Getting off of your high horse about the 787 battery would be nice. I don't see it as relevant to a flight control malfunction.
Everything we say here is impacted by flagrant malpractice by the regulator. Including training, and hardware.
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Old 25th Nov 2018, 18:34
  #1659 (permalink)  
 
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Right, Concours77: blame the same doctor for my hernia scar as for my wife's scar from her C section.(no, I've never been treated by her OB).
Your statement is so general as to be useless, as I see it.
You can write all of the rules that you want to write; following up on that to see that the rules are carried out, or that the rules themselves cause problems, costs money. Is that your point? Just how much transparency do you expect from the Indonesian regulator?
Culture has an impact on operations. (SFO, 777, et al)
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Old 25th Nov 2018, 18:39
  #1660 (permalink)  
 
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Money has nothing to do with it, not from my side. FAA delegated their remit to Boeing because “We Don’t have resources to retain experts....”

Guarding the Guardians is part and parcel of any honest exchange.... your failure (refusal) to see that precludes any further discussion...
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