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Ethiopian airliner down in Africa

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Ethiopian airliner down in Africa

Old 29th Mar 2019, 23:47
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WSJ: The Final Minutes of Ethiopian Airlines’ Doomed Boeing 737 MAX

The Final Minutes of Ethiopian Airlines’ Doomed Boeing 737 MAX

The Final Minutes of Ethiopian Airlines’ Doomed Boeing 737 MAX

By Matina Stevis-Gridneff and Yonathan Menkir Kassa
March 29, 2019 12:18 p.m. ET

ADDIS ABABA, Ethiopia—It took less than six minutes to deepen one of the gravest crises in the history of Boeing Co.

At 8:37 a.m. on March 10, Captain Yared Getachew and First Officer Ahmed Nur Mohammed were accelerating an Ethiopian Airlines Boeing 737 MAX along runway 07R of Addis Ababa’s highland airport.

The flight conditions were perfect—warm and cloudless—at 8:38 as the jet lifted above the hills to commence the one hour and 40 minute shuttle to Nairobi.

Something almost immediately went wrong. At 8:39, as the jet reached an altitude of 8,100 feet above sea level, just 450 feet above ground, its nose began to pitch down.

Mr. Mohammed radioed the control tower, his crackling voice reporting a “flight-control problem.” The tower operators asked for details as Mr. Getachew, a veteran with 8,000 flight hours, fought to climb and correct the glide path. By 8:40, the oscillation became a wild bounce, then a dive.

“Pitch up, pitch up!” one pilot said to the other, as the Boeing jet accelerated toward the ground. The radio went dead.

At 8:44, the airliner crashed into a field just 30 miles from the runway. All 157 people on board were killed instantly.

This reconstruction of the final moments of Ethiopian Airlines Flight ET302, described in new detail by people close to the crash investigation, airline executives and pilots, paints a picture of a catastrophic failure that quickly overwhelmed the flight crew.

It appears to support a preliminary conclusion reached by Ethiopian officials and international investigators, who believe an automated flight-control feature activated before the plane nose-dived into the ground, according to people familiar with the matter.

This emerging consensus—relayed during a high-level briefing at the Federal Aviation Administration on Thursday and reported later the same night by The Wall Street Journal—represents the first findings based on data retrieved from the flight’s black boxes. It is the strongest indication yet that Boeing’s misfiring system was at the heart of both the Ethiopian Airlines crash earlier this month and a Lion Air flight in Indonesia, which crashed less than five months earlier. Both doomed jets were Boeing 737 MAXs. The two disasters claimed 346 lives. A report from Ethiopian authorities is expected within days.

The Justice Department and other U.S. federal agencies are investigating whether Boeing provided incomplete or misleading information to regulators and airline customers about the 737 MAX aircraft to get the jetliner certified as safe to fly. The focus on disclosures is part of a broader investigation into how the plane was developed and certified.

Pilots flying the 737 MAX around the world were only alerted to the stall-prevention system after the Lion Air crash, and saw almost no mention of it in manuals, according to the pilots and industry officials. Most didn’t have visible cockpit warnings that would have alerted pilots to a malfunctioning sensor, and they had no access to simulators that could replicate the kinds of problems that doomed Lion Air flight 610.

In that crash, the stall-prevention system, based on erroneous sensor information, repeatedly pushed the plane’s nose down and, according to a preliminary report, the pilot battled the flight controls while facing a cacophony of alarms before losing control and plunging into the Java Sea, killing all 189 people on board.

Boeing said it is updating the MCAS software and making safety alerts that had been optional a standard feature. The fix has been undergoing flight trials since Feb. 7, Boeing said, before the Ethiopian airliner crashed.

Ethiopian Airlines—Africa’s largest carrier—is fighting to defend its record. Across this vast nation of 105 million people, the state-owned airline has in recent years become emblematic of, and indispensable to, Ethiopia’s ascent from one of the world’s poorest countries to a regional powerhouse. The closely-linked fates of carrier and country are now under the spotlight, raising the stakes for the airline to effectively manage the fallout of the accident.

Minutes after the plane crashed, Ethiopian Airlines chief executive officer felt a buzz in his pocket. Tewolde Gebremariam was attending Sunday service with his family at the Medhane-Alem Cathedral close to the airport when his phone rang.

It was the number for the airport’s “collaborative decision-making system,” a task force of airline, air-traffic control and airport officials who work together to ensure flight traffic is managed efficiently.

“We’ve lost ET302 from the radar,” the voice on the other end of the line said in Amharic, Ethiopia’s national language.

By the time Mr. Gebremariam reached the airport, it was becoming clear the plane had crashed.

“Right there, immediately,” Mr. Gebremariam thought of the Lion Air crash, he said in an interview. “The similarities were very striking. The impact, both were brand-new airplanes, both were MAX, and [they both crashed] in a short time, quickly after takeoff.”

As two air force helicopters prepared to lift off to search for ET302, pilots on the airport runway were getting restless.
Lazarus Kuol was in line for departure, preparing to take off on his single-engine turboprop aircraft on a medevac flight to the southwestern city of Jinka. He was due to collect two Chinese patients and bring them back to Addis Ababa for treatment.

The waiting pilots, listening to the control tower’s shared frequency, heard the operators discuss an emergency and order all aircraft to remain grounded, while two incoming planes were told to delay landing. The tower had lost contact with ET302. Maybe it was a communication problem, Mr. Kuol thought, or maybe they made an emergency landing on the flat farmlands southeast of the capital.

The minutes passed with no word from the missing aircraft or the search-and-rescue mission, and Mr. Kuol began to fear the worst.

He was given clearance to take off at 09.50, the second aircraft to depart Bole International Airport after ET302 went missing, and began to listen to the exchange between two radio frequencies, “Addis Center,” the main control-tower, and “Harar Meda,” the air force base.

“We can’t see it in the lowland,” said one of the two air force helicopter pilots dispatched to search for ET302. “We’ll climb on the highlands to look.”

In fact, the helicopters were circling over the crash site without realizing. The dive had been so fast and so steep that the aircraft had bored a crater into the ground and fractured into thousands of pieces. It was hardly visible from air.

“When I went to the site, the plane was completely below ground,” said Mr. Gebremariam, the CEO. He took off in another helicopter as soon as the crash site had been identified. “At that time, we knew there were no survivors.”

He notified the country’s Prime Minister, Abiy Ahmed, who first tweeted about the crash in Amharic at 10.48am local, just over two hours after the doomed flight had taken off.

At 10.50am, the news broke abruptly into the quiet Sunday mornings of the families of the 157 on board, and the rest of the world.

“The Office of the PM, on behalf of the Government and people of Ethiopia, would like to express [its] deepest condolences to the families of those that have lost their loved ones on Ethiopian Airlines Boeing 737 on regular scheduled flight to Nairobi, Kenya this morning,” a tweet from his official account said.

—Robert Wall, Andy Pasztor and Andrew Tangel contributed to this article.

Write to Matina Stevis-Gridneff at [email protected]

Appeared in the March 30, 2019, print edition as '‘Pitch Up, Pitch Up!’ The Final Minutes of an Ethiopian Jet.'

Last edited by airman1900; 31st Mar 2019 at 11:29. Reason: added print edition reference
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Old 29th Mar 2019, 23:55
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Originally Posted by Bleve
In the aftermath of the AF447 accident, Boeing (and Airbus) substantially changed the Unreliable Airspeed non-normal checklist (NNC). The message that has since been repeatably reinforced is that if there are ANY abnormalities related to airspeed, pilots should NOT make any assumptions as to what indication is right and what is wrong. They should simply run the Unreliable Airpeed NNC methodically until the correct indications are determined. So a stick shaker activating after takeoff (due to a faulty AOA signal) will be treated (and reported to ATC) as 'Unreliable Airspeed'.

The accident scenario that we are discussing might run something like this:
- At rotation stick shaker activates (due to a faulty AOA signal).
- You see normal speed indications.
- Stick shaker at normal indicated airspeeds is NOT logically consistent. Post AF447, that is an Unreliable Airspeed event. (You are NOT jumping to any conclusions at this stage that the IAS is correct and the Stick Shaker is wrong).
- Climb to a safe height and begin the Unreliable Airspeed NNC.
- Report to ATC that you have Unreliable Airspeed (because that is the NNC that you are now working through).
- Manually set a known power and attitude for level flight (the NNC requires the autopilot to be disconnected).
- Unbeknownst to you, MCAS has now been activated because of the faulty AOA signal.
- Your efforts to trim the aircraft for straight and level flight are proving difficult (because of the hidden MCAS intervention). Confusion increases because you can't even establish straight and level flight to continue the NNC.
- You are soon overwhelmed.
bleve
my understanding was that the STAB running fully nose down wasn’t “hidden”_ the pilot tried repeatedly to trim the other way for ten minutes- isn’t that correct? It’s just that every time he trimmed nose up the STAB trimmed nose down and was winning the tug of war. Apart from that your analysis seems entirely plausible. Yes- we revert to pitch power for safe flight once normal speed indications become unreliable. 15 deg pitch in initial climb. 6 deg pitch straight and level.
When all indications fail you pitch power are always valid. And of course GPS which is largely ignored in these discussions but is a life saver
cheers
Y
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Old 30th Mar 2019, 00:01
  #2743 (permalink)  
 
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Originally Posted by jimjim1

Do these computers have hardware memory protection such that one "process" cannot interfere with another? I suspect that they will not have such protection but I am not sure. I read somewhere that they were 80286 based . The 286 does not have integrated hardware memory protection although I suspect that an addition Memory Management Unit might be able to provide it.
With the caveat that I have no inside knowledge of Boeing's programs and so could be talking though my hat, I would be surprised if there were anything as complex as a 'process' in this control system. Even the most simple and minimal operating system introduces a heck of a lot of unnecessary complexity. It is likely that everything runs in the same memory space (especially if it is a 286) and looks like one large interrupt driven program. They probably have some sort of minimal 'frame' so they can compile together the various developer's work, but it is probably quite small and simple compared to the millions of lines of code (literally) that you will see in an operating system.
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Old 30th Mar 2019, 00:44
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Originally Posted by DaveReidUK
Discussed at length in one of the Lion Air threads.

No, it's not possible, by design.
I asked previously, with no meaningful reply, whether the unit can be opened in the field.
It seems that they are repairable at point of manufacture, but could a field tech get one open.
If they can be opened in the factory, what stops them from being opened in the field.

Installing a complete unit, correctly indexed for position, may be irrelevant if the unit has been opened and internal components incorrectly indexed.
How many splines hold the internal rotor onto the vane shaft?

I have spent a long time in Indonesia. I have a pretty good idea of what can happen in these here parts.
Murphy may have even been Indonesian, I suspect. Maybe "Murfi"?
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Old 30th Mar 2019, 00:49
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Originally Posted by WingNut60
If they can be opened in the factory, what stops them from being opened in the field.
Why would anyone want to do that ?

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Old 30th Mar 2019, 00:51
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Originally Posted by DaveReidUK
Why would anyone want to do that ?
Because "it's not working properly".
Because "we don't have a spare".
Because they can!
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Old 30th Mar 2019, 01:05
  #2747 (permalink)  
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Elephants

The details on the trigger event have blocked out the major issue in these events, that is, why the crew were unsuccessful in coping with the problems that they encountered?

Note: MCAS is not a stall prevention system, it is a system to achieve compliance with a static stability criteria for a part of the envelope.
The deficiency in the natural stability could lead to excessive g loading or inadvertent stalls etc as a consequence as attitude maintenance tasks need greater monitoring than with a compliant system. The rules themselves are not necessarily as relevant as they were in the days of early attitude displays, and with shorter body aircraft. The flight crew in a modern aircraft will notice the response on their coffee cup as they pull a bit harder on the prong, which is not simulated well in current 6-DOF FFS.

Two crews had issues that presented in such a way that what is obvious post fact was not at the time. Why? That is the question. While Bill Boeing needs to sort out his system that appears to have been based on various assumptions of response that did not occur as expected, the fundamental case remains that all conceivable failure modes of the total aircraft as a system are unlikely to be run down prior to experiencing the same in the air, and the crew response needs to be able to recover from unknown symptoms in a time critical period.

Lion Air is poignant where it appears the pilot during the fault finding attempted to apply human factor training concepts, and in doing so control was finally lost. Every time we push on a balloon it reshapes the balloon... actions have consequences. The fundamental tenets of priorities have not changed, nor does human factor training expect to do so, but on the day, the intervention that was holding ground and keeping the flight path managed was lost with the transfer of control. The transfer was undertaken to give the pilot more cognitive capacity to deal with the issue, however the preventive action was not maintained by the FO...

Control reversion with true FBW aircraft, alternate modes on Boeing FBW aircraft are quite different to Airbus, however as Boeing always uses a speed trim input from the trim switches, the reversion from full FBW to none on the Boeing is not a significant change. On the Airbus, the degradation of modes results in the introduced requirement to use manual trim, which is also displayed on the ECAM, however history shows that the crews in a high work load and stress environment do not always respond with manual trim inputs, resulting in loss of control.

AOA gauges are great, and indexers of any type are good tools in achieving stable approaches. HUD's are also great, but neither of them is an absolute necessity to the safe flight of the aircraft. Given adequate funding, they are the first equipment on the options list to ask for. For these cases, the symptom of the problem was the out of trim case, and the inability to simply re-trim and cure the out of trim case. The trim system on any aircraft is not a Möbius loop, it will end at some point, and the continued demand to re-trim was inconsistent with normal operation of the trim on any aircraft.

Somewhere in the design architecture decision making, the necessity of a correct crew response to a fault was either not considered, or was considered and assumed that the crew would readily identify the problem symptom as a trim runaway, and intervene using the method that has been incorporated for more than 50 years. That a crew would not be able to recognise and respond appropriately shows that human factors are alive and well in the design and certification process. It is the human that may make an incorrect assumption on a design or certification matter who also intervenes and ensures that other matters that would not be caught purely by compliance with preexisting rules are mitigated. To err is human, but removing humans from decision making is a high risk game.
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Old 30th Mar 2019, 01:15
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Originally Posted by Water pilot
It is likely that everything runs in the same memory space (especially if it is a 286) and looks like one large interrupt driven program. They probably have some sort of minimal 'frame' so they can compile together the various developer's work
Thanks.

Oops too short pprunepadding.
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Old 30th Mar 2019, 02:39
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I tossed in my commercial licence 40 years ago for a rewarding and exciting career in finance and IT but flying was always in my blood so I have always been interested in aviation. In this 737 Max crash issue something seems totally wrong to me. Both here in Pprune and in other media I have see a number of times where it has been inferred that this is pilot error as a MCAS fault is like trim runaway and fixing that is a memory item and takes 15 secs. However if I understand it correctly with runaway trim when you go to trim nose up the automation keeps on trimming more nose up even though the pilot has stopped trimming. In this situation it is the exact opposite the pilot trims up and the automation pushes the nose down. But I cannot see where people have focused on this critical difference. I would have thought in a crisis situation which was the case in these two crashes the last thing you would train your pilots to do would be tho take actions contrary (or in this case opposite to) to the symptoms being experienced. The people including some people presented in the media as experts who say that this is the same or similar to trim runaway seem to be missing the point that it is the exact opposite and therefore totally confusing. Who is missing the point here? Me or the experts?
And for those who wonder how I could give up flying for a business career. I am now long retired but I think I was unsuitable. I would have been totally bored as a pilot and therefore eventually potentially unsafe. I had a career where nearly every day was different, regular crisis to keep my attention, lots of mentally challenging problems to solve, and where I got to be the rule maker and breaker rather than the follower.
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Old 30th Mar 2019, 03:43
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I'm attaching 3 normal flights profiles, 1 normal speed and altitude data vs the profile of the crashed Ethiopian and its speed and altitude readings.
The difference between them is obvious.
Could it be that being, maybe, early and first flight of the day the cover of the pitot tubes where not removed? It has happened before. The latest happened to a MH in Brisbane Australia. Poor preflight checks by engineers and pilots. They both missed it.
This could explain the lack of speed and altitude during almost 2 minutes of the doomed plane. Then in very short time speed of 250-383kts.
During take off roll they were caught by surprise and missed* the 80 kts callout. First reaction of a ill trained crew to fly Airspeed Unreliable Speed NNC or junior crew ( *FO had,its being said, 200hrs) was to level off to gain speed. Once speed increases rapidly he retract flaps to avoid exceed VMO placard. Speed jumps very fast. To control it commander pulls abruptly to control speed and then a real high AOA of attack is reached. Having a problem he requests to turn back...
MCAS kicks in when: High angle of attack, manual flight, flaps up and in a turn.
Assuming pilots did all this in sequence, it might triggered the MCAS. And sadly in this case, it worked exactly the way it was designed to work. To avoid an upset triggered by a unreasonable maneuver by pilots or environment.
Then they kept fighting MCAS, why? Investigation will tell the probable cause...






its just a thought...
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Old 30th Mar 2019, 05:24
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NYT has made the Max its cover story today. And they're not friendly.
https://www.nytimes.com/2019/03/29/b...gtype=Homepage
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Old 30th Mar 2019, 06:40
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apologies if posted prior

MCAS the Achilles Heel of the Max that has the potential to end the 737 line.
Lets hope Boeing gets the fix right and the Max flies on as a great final version of the robust and venerable 737.



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Old 30th Mar 2019, 08:24
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Originally Posted by WingNut60
Because "it's not working properly".
Because "we don't have a spare".
Because they can!
I'm assuming you have never worked in an airline maintenance environment.
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Old 30th Mar 2019, 08:33
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Originally Posted by VONKLUFFEN
I'm attaching 3 normal flights profiles, 1 normal speed and altitude data vs the profile of the crashed Ethiopian and its speed and altitude readings.
The difference between them is obvious.
Could it be that being, maybe, early and first flight of the day the cover of the pitot tubes where not removed? It has happened before. The latest happened to a MH in Brisbane Australia. Poor preflight checks by engineers and pilots. They both missed it.
This could explain the lack of speed and altitude during almost 2 minutes of the doomed plane. Then in very short time speed of 250-383kts.
During take off roll they were caught by surprise and missed* the 80 kts callout. First reaction of a ill trained crew to fly Airspeed Unreliable Speed NNC or junior crew ( *FO had,its being said, 200hrs) was to level off to gain speed. Once speed increases rapidly he retract flaps to avoid exceed VMO placard. Speed jumps very fast. To control it commander pulls abruptly to control speed and then a real high AOA of attack is reached. Having a problem he requests to turn back...
MCAS kicks in when: High angle of attack, manual flight, flaps up and in a turn.
Assuming pilots did all this in sequence, it might triggered the MCAS. And sadly in this case, it worked exactly the way it was designed to work. To avoid an upset triggered by a unreasonable maneuver by pilots or environment.
Then they kept fighting MCAS, why? Investigation will tell the probable cause...

its just a thought...
Do you mean that a blocked pitot caused erroneous AoA that in turn triggered repeated applications of MCAS ?

Or that those were two independent, simultaneous failures ?

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Old 30th Mar 2019, 08:45
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Originally Posted by DaveReidUK
Do you mean that a blocked pitot caused erroneous AoA that in turn triggered repeated applications of MCAS ?

Or that those were two independent, simultaneous failures ?
I think VONKLUFFEN is flogging a dead horse. That theory has been supersed by the leaked preliminary accident investigation report, which confirms that MCAS was activated in the Ethiopian crash. The rest of the explanation does not make sense in view of the known ADS-B speed and altitude data points.
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Old 30th Mar 2019, 09:03
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I'm assuming you have never worked in an airline maintenance environment.
I’ve worked in airline maintenance environments that were so cowboy by nature that my local car wrecker would blush if he saw some of the practices.
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Old 30th Mar 2019, 09:34
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Originally Posted by DaveReidUK
I'm assuming you have never worked in an airline maintenance environment.
Correct. But I have worked in Indonesia for most of the last forty years.
You may think that what I suggested could not happen because of procedures, checks and balances.
I assure you that it can.

Just remember, it's the same environment that recently saw a PIC fly for an hour and a half on stick-shaker and not report it.

My query asks "is it possible to open the AoA vane unit body in the field."
If the answer is Yes, then don't discount the possibility that it could happen, overnight in Jakarta.
It is very possible.
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Old 30th Mar 2019, 09:50
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Originally Posted by WingNut60
My query asks "is it possible to open the AoA vane unit body in the field."
If the answer is Yes, then don't discount the possibility that it could happen, overnight in Jakarta.
It is very possible.
"Captain, would you mind testing our unauthorised, undocumented repair to the LH AoA sensor on the next sector?"

"No, we don't have an Overhaul Manual for it - it's not a field-serviceable item - but, hey, how hard can it be?"

"You might find that it reads a bit high (or possibly low) afterwards as we have no idea how to calibrate it, but we can tweak it again if necessary until it's reasonably accurate"

No, I don't think so.
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Old 30th Mar 2019, 10:11
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Originally Posted by DaveReidUK
"Captain, would you mind testing our unauthorised, undocumented repair to the LH AoA sensor on the next sector?"

"No, we don't have an Overhaul Manual for it - it's not a field-serviceable item - but, hey, how hard can it be?"

"You might find that it reads a bit high (or possibly low) afterwards as we have no idea how to calibrate it, but we can tweak it again if necessary until it's reasonably accurate"

No, I don't think so.
Dave Reid, not possible in the UK. But we are talking Indonesia here.
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Old 30th Mar 2019, 10:15
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Originally Posted by DaveReidUK

No, I don't think so.
While we will have to agree to disagree over the possibility, I would like to see EXACTLY what the techs said they did in each instance.
I know that there have been previous references but I can't find them now.

I am really interested in what was recorded as having been done.
Verbatim, in Bahasa Indonesia, would be best, if anyone has it.

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