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Ethiopian airliner down in Africa

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Old 21st March 2019 | 08:27
  #2221 (permalink)  
 
Joined: Apr 2009
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From: Hotel Gypsy
Originally Posted by rmac2
Yes Boeing did screw up with their design concept...

BUT after reading a lot of the to and fro here I have only three words to offer for when it's all going south on the panel

PITCH
POWER
TRIM

If she won't trim to the attitude you need for the known power setting that's a pretty BIG clue which system is not playing ball, particularly in day VMC which was the conditions for both accidents
Since Pontius was a pilot we've had trim runaways. Smart people train for that. REALLY smart people engineer away the problem. This thread, and others, according to CGB:

1. Boeing think they're going to get the hinds whipped by 320NEO. They dust-off some old drawings and add a couple of efficient engines.
2. Pesky certification requirements identify a force feedback issue at high AOA.
3. Boeing introduce a mechanism to falsely provide that feedback (basically trimming away from the pilot's input). Let's just think about that - a (hidden) automated mechanism that intentionally takes an aircraft out of trim.
4. Boeing don't put anything in the 'book' as they don't want to confuse pilots.
5. Crash 1.0
6. Crash 0.1 crew had something similar the day before. Jump-seat Hero sorted it (Why couldn't two crew figure the problem? Overload?)
7. Crash 0.1 crew and engineers didn't fully articulate and/or understand the issue. Did an occurrence report end-up on a Boeing database somewhere?
8. Boeing "Oh we have something called MCAS. It looks as if the logic may need a bit of tweaking but in the interim shove this extra page in your AFM."
6. US Government shutdown for 5 weeks - MCAS 2.0 is delayed.
7. Crash 2. "Hmmm, is this related?"

I don't see any point in specifically pointing fingers at a Seattle software engineer, a Government shutdown or under-trained, under-aroused crews - I see failures at numerous steps (Swiss cheese). There appears to be a lot of people/agencies who should be spending less time running around worrying about litigation and more time pulling-up their socks.

Last edited by Cows getting bigger; 21st March 2019 at 09:26. Reason: Typo's
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Old 21st March 2019 | 08:27
  #2222 (permalink)  
 
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From: Hyderabad
Indeed Fizz.

And right there is the root of the problem.

And you know, if the nose keeps going down, and the only thing that's bringing it back up for you is the stab trim, there might be some reluctance to turn it off!
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Old 21st March 2019 | 08:38
  #2223 (permalink)  
 
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From: Modena, Italy
Which certification FAR?

Speaking of pedantic and in the old SAT tradition of "select the BEST answer among the choices given" ...

Is FAR Chapter 25, Sec. 25.203(a) more directly controlling, since it addresses "longitudinal control force" in approaching stall and does not combine the tactile feedback requirement with trim speed issues?

Surely not an important quibble. I'm just a non-pilot software engineer who's trying to follow the causal chain here and I may need to correct an assertion I have made elsewhere.
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Old 21st March 2019 | 08:54
  #2224 (permalink)  
 
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From: dublin
Originally Posted by Nomad2
Indeed Fizz.

And right there is the root of the problem.

And you know, if the nose keeps going down, and the only thing that's bringing it back up for you is the stab trim, there might be some reluctance to turn it off!
Nomad
The thing that levels the plane is the yoke. You turn off the STAB. trim manually. Fly the plane. All before the STAB gets out of GREEN ZONE and into danger zone.
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Old 21st March 2019 | 09:02
  #2225 (permalink)  
 
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From: Hyderabad
yanrair.
Thanks for the reminder on how to fly. I remember exercise 1, "effects of controls" although it's some 13,000 hours ago for me.

Two crews were overwhelmed by these aircraft, so clearly it's not quite as simple as you suggest.

Shame you weren't in command I guess, it would all have been sorted out in a few seconds....,
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Old 21st March 2019 | 09:04
  #2226 (permalink)  
fdr
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From: 3rd Rock, #29B
Originally Posted by Rated De
Normailisation of deviance.

Culture likely punitive.
Surely you jest sir! This is the best industry that money can buy. There is 40 years of rapacious investor appetite being counterbalanced by technical improvements in the operation and systems, and we hit a plateau some time back when it became noticeable to passers by that the pilots cannot fly planes any longer. The last 20 years we have poked smoking holes in the ground, punters have exclaimed in shock and indignation and then gone and paid the lowest amount that arbitrage of safety can buy.

Upshot is, the management system became reliant on unwavering compliance with procedures that sometimes help and sometimes hinder the task at hand. Consider the last time that you as an operating crew member had full compliance with all the rules that exist for your operation. Before anyone exclaims that we (you) are better than that, consider the last long haul flight you did out of say, JFK, where there were 165 pages of NOTAMS, and the crew had at least 10 minutes to plan for a 16 hour flight across the pole, in ETOPS or EDTO, in LVTO, with diversion fields in Siberia etc... The rules are meaningful when they can be applied readily, not requiring a QC to interpret the FDTL, FCL, and the rest of the BS that adds to the ZFW of the plane.

Considering how many operations out there are punitive, a long time back a disgruntled resident showed his/her displeasure with the local government by planting a rather large fireworks/ stick of gelignite outside of the govt chambers at night. The next morning, the doors were well askew. The local police were soon on the crime scene, and after a short while, the mayor asks the investigators if he has any suspects. The investigator leant over a counter and grabbed the local phonebook, handed to the mayor and said, "anyone between the covers".

Punitive culture is what the industry has developed. CRM, TEM, MEDA, and the rest of the acronyms are lipstick on the pig, there for show.

Wish the world was different, but there it is. Aviation is big money flows, with low margins, and the culture is a consequence of the reality.
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Old 21st March 2019 | 09:24
  #2227 (permalink)  
 
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From: dublin
Dear Fizz57
But you're not left with a Cessna - the 737's (the later ones at least) do not meet certification requirements with the bells and whistles turned off. That's why they were put in in the first place.
I think I am one of the few on this forum who has flown the real 737, not a sim. - later variants up to the -800 still in production (pre MAX obviously ) with pretty much everything turned off except the battery.
No hydraulics. No AC power. No anything but me and some 12mm wire joining me to the controls. And yes, I still have the STAB because is is trimmed MANUALLY!
I don't get your comment "not certified". A 737 can fly with no computers or indeed no pretty much anything working, and this is demanded on the FAA test flights which I have conducted to make sure it works. If this has changed on the MAX then that is something to ponder most seriously. But I doubt it.
So as a previous thread says" PITCH& POWER" and that is the key. If you fly 6 nose up and 60% power you can fly all day and it will not crash. Well, until you run out of fuel. That gives you loads of time to sort out all the other stuff going on. If you suffer total loss of airspeeds, multiple stick shakers, one airspeed saying 500 and the other saying zero and lots of horrible noises and verbal alerts going on - how do you decide which is right and which is wrong?. [Not sure it was a anything like as bad as this on these two by the way, but that is the worst case]. You level the wings, 6 deg pitch and set the power midway. Calm is restored. Switch off the offending systems. Fly manually. Re-engage any working automatics.


Cheers and thanks for the chat folks
Yanrair


I have been finding it hard going, we all have, with the to and fro of highly complex technical jargon and solutions. The solution is to fly the plane. If AF 744 had done this, and many many others, we would have had far fewer accidents.
Are modern pilots good enough to do this? Well, I have a view on that.

By the way there is another theme here on this topic. That everything needs to be automated out. What about landing in 60 knots of wind with bad turbulence in 300 metres visibility and 200 foot cloud base in pouring rain? That is a challenge and is done manually every time, since no autopilot can get anywhere near dealing with the complexity of such conditions and the endless permutations required to achieve a safe touchdown. Windshear Go Arounds are manual. Get it wrong and we are in God's Parlour. GPWS terrain impact avoidance is flown manually using the stick shakers to fly right into the stall, but not beyond, to safety fly over the obstacle.
There are so many of these we can't deal with them now but one thing they are not is automated.
Yanrair



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Old 21st March 2019 | 09:30
  #2228 (permalink)  
 
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From: dublin
yanrair.
Thanks for the reminder on how to fly. I remember exercise 1, "effects of controls" although it's some 13,000 hours ago for me.

Two crews were overwhelmed by these aircraft, so clearly it's not quite as simple as you suggest.

Shame you weren't in command I guess, it would all have been sorted out in a few seconds....,


That is a cheap shot. Sully and hundreds of pilots like him have achieved things I could maybe not have achieved, but I do know how to!! Al Haines, Sioux City - look at that one on tube. BA 747 over Jakarta All four engines flamed out. Safe landing. Not in the "book" that some of you guys are referring to. Lots of stuff in not in any book. These two were. STAB RUNAWAY.
BA 777 Heathrow couple of years ago. Saved 400 lives using pure flying skills. Double engine failure like Sully. I have been involved in training a major airline recently and all these skills are taught and practised including landing with no engines.
Cheers
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Old 21st March 2019 | 09:36
  #2229 (permalink)  
ZAZ
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From: Victoria
Speaking of the books
Cockpit voice recorder alleges capt and FO both flying plane for nine minutes each trying to look up stuff in the flight ops books.
Last heard saying goodbye.
not that it helped.
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Old 21st March 2019 | 09:50
  #2230 (permalink)  
 
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From: Hotel Gypsy
yanrair, for every Hero, there's a Zero - that's the law of averages. Pilots are no longer heroes, nor should they be. A safe system is one that reduces risk as low as reasonably practical and, whether we like it or not, a human being brings a huge pile of risk to any system. Pilots are not masters of the system, we are a part of it. For sure, these two crashes may have been avoided by the flick of two switches. But that wasn't the way it worked out and many of us think it rather disingenuous to pile the overwhelming burden of responsibility on the Zeros pilots.

"Just flick the switches and revert to manual" - that is confirmation bias at it's worst, being indicative of an industry that no long takes an active role in looking at itself.
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Old 21st March 2019 | 10:04
  #2231 (permalink)  
 
Joined: Sep 2017
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From: Europe
Originally Posted by fdr
Surely you jest sir! This is the best industry that money can buy. There is 40 years of rapacious investor appetite being counterbalanced by technical improvements in the operation and systems, and we hit a plateau some time back when it became noticeable to passers by that the pilots cannot fly planes any longer. The last 20 years we have poked smoking holes in the ground, punters have exclaimed in shock and indignation and then gone and paid the lowest amount that arbitrage of safety can buy.

Upshot is, the management system became reliant on unwavering compliance with procedures that sometimes help and sometimes hinder the task at hand. Consider the last time that you as an operating crew member had full compliance with all the rules that exist for your operation. Before anyone exclaims that we (you) are better than that, consider the last long haul flight you did out of say, JFK, where there were 165 pages of NOTAMS, and the crew had at least 10 minutes to plan for a 16 hour flight across the pole, in ETOPS or EDTO, in LVTO, with diversion fields in Siberia etc... The rules are meaningful when they can be applied readily, not requiring a QC to interpret the FDTL, FCL, and the rest of the BS that adds to the ZFW of the plane.

Considering how many operations out there are punitive, a long time back a disgruntled resident showed his/her displeasure with the local government by planting a rather large fireworks/ stick of gelignite outside of the govt chambers at night. The next morning, the doors were well askew. The local police were soon on the crime scene, and after a short while, the mayor asks the investigators if he has any suspects. The investigator leant over a counter and grabbed the local phonebook, handed to the mayor and said, "anyone between the covers".

Punitive culture is what the industry has developed. CRM, TEM, MEDA, and the rest of the acronyms are lipstick on the pig, there for show.

Wish the world was different, but there it is. Aviation is big money flows, with low margins, and the culture is a consequence of the reality.
As Captain Sullenberger recalled reading an article written by a retiring airline pilot (paraphrasing) : "Once we were recruited and trained for our judgement, now we are selected for our compliance"

Precisely correct. Anybody who doesn't understand where the blame will rest, ought familiarise themselves with "Strict Liability" and why it is in the Crimes Act. It is attached to all regulation with respect to those things the Pilot In Command carries the barrow for...
Over time, there has been a lot of distance placed (legally speaking) between senior management and liability. Strangely despite 165 pages of NOTAMS and the like the PIC must still sign stating the aircraft is correctly loaded...

Last edited by Rated De; 21st March 2019 at 10:27.
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Old 21st March 2019 | 10:14
  #2232 (permalink)  
 
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From: Leeds, UK
EASA ahead of the curve

March 2018, EASA already concerned about FBW aircraft and the algorithms contained within

In a 'Safety Emphasis Items list' first drafted in March 2018 and last revised in December, EASA notes that it may move to increase scrutiny of electronic flight control laws.

EASA states, “On fly-by-wire aeroplanes the flight controls are implemented according to complex control laws and logics. The handling qualities certification tests usually performed on conventional aircraft to demonstrate compliance..are not considered sufficient to cover the flight control laws behaviour in all foreseeable situations that may be encountered in service.”

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Old 21st March 2019 | 10:21
  #2233 (permalink)  
 
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From: what U.S. calls ´old Europe´
"Once we were recruited and trained for our judgement, now we are selected for our compliance"
Once aircraft were designed to meet the certification requirements, now authorities struggle to keep their rules current with all the new inventions of industry incompatible with existing regulation...
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Old 21st March 2019 | 10:24
  #2234 (permalink)  
 
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From: Florida and wherever my laptop is
Originally Posted by mm43
The above quoted post got no reaction, as it unfortunately appeared in between a series of tit for tat posts. Succinctly written, it describes the background to this problem in what appears to be a completely valid manner.

Therein lies the problem, as Boeing have hung MCAS on the tail of the STS, which has for many years operated quietly in the background to effectively neutralize long period elevator demand, and thereby providing the full range of elevator control when required on demand. Its the extra lift generated by the engine nacelles, now further forward and higher than those on the NG, that needed to be neutralized to maintain the correct feedback forces on the control column in high AoA situations.

As described by StuntPilot, MCAS is a reconfiguration sub-system relying on non validated air data, and steps across the safety critical barrier in an insidious way.
What is described is actually classic 'Automation Surprise' (What's it doing now?) that is followed by attentional (cognitive) tunneling as the human's mind grasps at straws to try to understand what is going on.
The suggestion that the machine tells the pilot what is happening is good- except that if there is not sufficient thought a small subsystem like AoA used by a LOT of systems can result in alert messages scrolling on displays all sorts of sounds and alerts and haptics like stick shakers and pushers -- all for just an AoA disagree. I think that there is a major human factors failure in modern aircraft where not sufficient thought has been given to the multiplicity of warnings that can come from a small event - and the warnings themselves create problems rather than assistance. There needs to be something like an Failure Modes Effects Analysis that flags up that at this point there are multiple separate warnings being displayed in various ways that will consume the entire cognitive resource of the pilot and not allow his primary AVIATE task any resource. This effect is often seen where something VERY obvious is disregarded as the pilot's cognitive resources are completely saturated.
Another aspect of the automation surprise is that the workload can literally explode from routine to overload in a second. This takes a lot of training to cope with and an MPL with less than 100 hours live flying is not going to be of any use in one of these incidents and indeed may panic and make extra work for the experienced pilot - effectively the aircraft is being flown by one pilot,

There will be a raft of lessons to be learned from these incidents. Let's hope that the beancounters learn them too. .
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Old 21st March 2019 | 10:31
  #2235 (permalink)  
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From: Welsh Marches
New York Times has an article saying that Ethiopian Airways had a Max 8 simulator but the pilot of ET302 hadn't trained on it.

(not enough posts to past link)
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Old 21st March 2019 | 11:04
  #2236 (permalink)  
 
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From: UK
Harry, Brandon,
You may wish to consider the question posed at the end of this post. Why fail high.
Boeing 737 Max Software Fixes Due to Lion Air Crash Delayed
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Old 21st March 2019 | 11:35
  #2237 (permalink)  
 
Joined: Mar 2019
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From: Sweden
Runaway Stabilizer training

Have you seen this 737 runaway stabilizer training on YouTube? OMG when that stab wheel is running there is not much time to react. Very scary. Look at the first officer trainee's reaction when the warning signals turn on and the plane dips. After seeing this I am so sad to see that these easy to access STAB TRIM switches could have saved both planes.

www.youtube.com/watch?v=3pPRuFHR1co
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Old 21st March 2019 | 12:33
  #2238 (permalink)  
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From: Herts, UK
Originally Posted by Ian W
What is described is actually classic 'Automation Surprise' (What's it doing now?) that is followed by attentional (cognitive) tunneling as the human's mind grasps at straws to try to understand what is going on.
The suggestion that the machine tells the pilot what is happening is good- except that if there is not sufficient thought a small subsystem like AoA used by a LOT of systems can result in alert messages scrolling on displays all sorts of sounds and alerts and haptics like stick shakers and pushers -- all for just an AoA disagree. I think that there is a major human factors failure in modern aircraft where not sufficient thought has been given to the multiplicity of warnings that can come from a small event - and the warnings themselves create problems rather than assistance. There needs to be something like an Failure Modes Effects Analysis that flags up that at this point there are multiple separate warnings being displayed in various ways that will consume the entire cognitive resource of the pilot and not allow his primary AVIATE task any resource. This effect is often seen where something VERY obvious is disregarded as the pilot's cognitive resources are completely saturated.
Another aspect of the automation surprise is that the workload can literally explode from routine to overload in a second. This takes a lot of training to cope with and an MPL with less than 100 hours live flying is not going to be of any use in one of these incidents and indeed may panic and make extra work for the experienced pilot - effectively the aircraft is being flown by one pilot,

There will be a raft of lessons to be learned from these incidents. Let's hope that the beancounters learn them too. .
Another excellent post...
It horrifies me that this area has not been addressed more intelligently (cognitive overload) although QRMs and their glass screen equivalents do prioritise and stack incoming errors in (pre-ordained) importance
The serious incident of the Qantas A380 engine explosion damaging many systems, requiring up to 3 extra buddying crew (?) to work successively (and tirelessly) through many pages to get that back on the ground safely is a case in point, and perhaps it's incidents like these that should not only be studied more widely but become industry exemplars of CRM.

However, we must not forget Company Communication and Systems Training which will almost certainly here to be found wanting?

Last edited by HarryMann; 21st March 2019 at 15:10.
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Old 21st March 2019 | 12:36
  #2239 (permalink)  
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From: Nantes
Originally Posted by Alchad
New York Times has an article saying that Ethiopian Airways had a Max 8 simulator but the pilot of ET302 hadn't trained on it.

(not enough posts to past link)
Ethiopian also said their 737 MAX full flight simulator is NOT designed to simulate MCAS problems. So it would not have changes anything if the pilot of ET302 had trained on it.
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Old 21st March 2019 | 12:44
  #2240 (permalink)  
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From: Sudbury, Suffolk
Originally Posted by deltafox44
Ethiopian also said their 737 MAX full flight simulator is NOT designed to simulate MCAS problems. So it would not have changes anything if the pilot of ET302 had trained on it.
That would be even worse then! You could train for x failure after take off and then when you ACTUALLY encounter x something quite different happens and the procedure you used successfully in the SIM winds up killing you.

Whose responsibility would the sim software be?
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