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Ethiopian airliner down in Africa

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Ethiopian airliner down in Africa

Old 15th Apr 2019, 11:02
  #4041 (permalink)  
 
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Originally Posted by A0283 View Post
I previously posted this on the related software thread - it might provide some additional context to the discussions that are going on here:
Did Sully not turn on the APU early to save the day?
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Old 15th Apr 2019, 11:21
  #4042 (permalink)  
 
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Originally Posted by oggers View Post
... it doesn't speak to me of an issue with the stick shaker interfering with the operation of the electric trim switch.
If you look closely at the FDR traces, the Lionair captain who faithfully trimmed back up umpteen times did loose the trim switch ever now and then. There are off-blips in almost every long nose-up trim command. Therefore, I do believe, that the ergonomics of the yoke with shaker and high feel forces can make it difficult to actuate the thumb switch continuously. Maybe they had to cradle the column for prolonged high force, hands not in standard position.
Try thumb typing on your phone after you attached a 50 pound brick, while a friend is rattling it...
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Old 15th Apr 2019, 11:21
  #4043 (permalink)  
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Originally Posted by rog747 View Post
As the starter of this evocative thread of the first early morning report of a 737 accident in Africa, I have of course followed it all closely - The shock that morning that it was a 2nd new 737 MAX that actually had crashed in astonishingly similar circumstances to Lion Air has rocked the aviation world, and the public.

I do think most of you now need to go have have a nice cup pf tea and try to stop pontificating on weird and wonderful graphs, text and charts, (I do not of course mean the revealed readouts we know of so far) and to really now stop putting blame on the crews that simply were trying to save their aircraft due to unknown phenomena seemingly trying to kill them, which has seen 2 brand new jets of a design from the early 1960's dive into the ground at high speed minutes from take off.

This is unprecedented in our industry in many years - Last seen when the DC-10 was in service 40 years ago - Also long before social and digital media, and the likes of PPRuNe and YouTube and the freedoms of getting information quickly.

Many of the posts on here have shown much sense and empathy even at such an early stage in the investigations, and of course many pilots and crews are worried, however, we have descended somewhat that some here will brush it off as if the crews should have done this, and done that, or ''I could have saved the plane''...

No one knows as yet as to why these 2 new jets dived into the ground and lost over 300 lives.

The 3 Comet 1 structural failure crashes claimed 99 lives - those investigations were undertaken at a time when FDR or CVR data was not available -
How we have evolved from 65 years ago.

Can we calm down a wee bit over the MAX theories - except we do know that MCAS was implicated and functioned each time -

As I see it 2 have been lost (another 1 was an almost lost) and in all 3 the flight crews were faced with, and then all were startled with rapidly unfolding, and unknown dilemmas as to why their aircraft was trying to kill them just after lift off trying in vain to save it.

At this stage none of us know for sure why.

edited 11.43
Generally sensible post, however, it is absolutely reasonable to ask whether pilot skill / training was a factor.

The LionAir pre accident crew defused the situation with the help of a jump seat pilot. Once they had the aircraft under control, they re-enabled electric trim only to discover it attempting to nose the plane down again, before disabling it again and flying manually to destination.

That crew defeated AoA-failure-induced MCAS twice, not once.

One lesson which the industry has to learn from this is that all flight crews must know how to restore orderly flight and disable all automation in the case of misbehaving flight control systems. If that's not possible, the cockpit is no longer a place for human beings.
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Old 15th Apr 2019, 11:42
  #4044 (permalink)  
 
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Adding to my post Ethiopian airliner down in Africa

If we assume that pilots make such errors (as described in that study) regularly, then we might say that,

considering the overall high level of safety of commercial aerospace,

- we might conclude that the system is 'robust' enough to deal with such pilot errors,
- that airplanes might be so 'solid' that few situations arise that require the use of such checklists,

and,

that the question in these two cases would not be if errors were made (if they turn out to be real human errors or airplane induced errors), but why these errors may or may not have contributed to the chain of events that created two all fatal accidents,

The essence of aerospace accident investigation is not the apportioning of blame. We still have to go through the process of further fact finding, analysis, concluding, recommending. Now is not the time for blame ... yet ... I guess that those who want to should still be patient.
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Old 15th Apr 2019, 12:00
  #4045 (permalink)  
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A0283's post

I'm not so much worried by the poor checklist selection as I am about so much time footling around looking up sets of rules while still in the 'Aviate' phase of an emergency.

I know PNF's task, but is it not a time even they should be soaking up technical details - facts about just what is going on and applying immediate assistance when possible? I'm dreaming, aren't I? It just doesn't seem to happen anymore, except I get the feeling the older crews still demand to know just how things work while the newer generation seem more content with 'just fly the thing'. Does that go with the 'magenta line' kids, or is it only some people have a natural need to know every nut, bolt and washer?
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Old 15th Apr 2019, 12:24
  #4046 (permalink)  
 
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“The boat equipment was in accordance with the Board of Trade requirements.” The Board of Trade was the regulator of British registered ocean going vessels. Board of trade regulations did not require enough life boats to carry all passengers off a vessel in distress. Thus the Titanic only had enough life boat capacity for ½ of the passengers she carried, in complete compliance with the then current regulations. The Titanic went down 107 years ago today.

The Max was certified for flight by aviation regulators world wide. These same regulators decreed no additional simulator training was required, (and if they did what would they have trained in that additional sim? Certainly not Left AOA vane failure at low altitude...). While I will point a big finger at the FAA’s head, I will also ask where were the other world wide regulators? Did they simply outsource their job to the FAA? And how much pressure was placed on Boeing by 737 operators world wide to minimize training costs associated with introducing the Max? Some of these operators have a very long history of operation of the 737 series. Did that experience cloud their judgement? Did other operators world wide without that historical knowledge simply accept what Boeing offered as adequate - training by bulletin?

And what about airline training departments? What is the quality of classroom and simulator training? What is the quality of the classroom and simulator instructors, Standards Captains, and Check Airmen? Lastly we need to take a hard, honest look at ourselves. We need to look in the mirror and see the pilot we are, not the pilot we think we are.

Sure I’ll throw bricks at Boeing and the FAA, but any honest assessment wouldn’t stop there.
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Old 15th Apr 2019, 12:52
  #4047 (permalink)  
 
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Originally Posted by spornrad View Post
Therefore, I do believe, that the ergonomics of the yoke with shaker and high feel forces can make it difficult to actuate the thumb switch continuously. Maybe they had to cradle the column for prolonged high force, hands not in standard position.
I think we can agree that it is easier to hold the trim switch with the stick shaker off. Nonetheless, the data shows clearly that the thumb switch can be held closed with the stick shaker on.

If you look closely at the FDR traces, the Lionair captain who faithfully trimmed back up umpteen times did loose the trim switch ever now and then. There are off-blips in almost every long nose-up trim command.
But the Lion Air data also shows "off-blips" during automatic trim every now and then, so based on that you can't attribute it to the thumb switch. Also, none of these "off-blips", as you call them, appear on the ET302 data which suggests they have more to do with how the two different investigations have processed the data into the graphics we see..

Try thumb typing on your phone after you attached a 50 pound brick, while a friend is rattling it...
Because you really really believe that holding down the trim switch is like typing on a phone
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Old 15th Apr 2019, 13:21
  #4048 (permalink)  
 
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Originally Posted by gmx View Post

If that's not possible, the cockpit is no longer a place for human beings.
Nor is the cabin.

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Old 15th Apr 2019, 13:44
  #4049 (permalink)  
 
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Originally Posted by rog747 View Post
This is unprecedented in our industry in many years - Last seen when the DC-10 was in service 40 years ago - Also long before social and digital media, and the likes of PPRuNe and YouTube and the freedoms of getting information quickly.
I remember the DC-10, though I was a child at the time. There are some similarities and some differences. The cargo door design was closest to the MCAS situation today. A poorly engineered design was certified; after the first accident, the problem was discovered, but there was no grounding order, and no AD issued, due to a close relationship between the heads of the FAA and MD. Following the second nearly identical disaster, there was a congressional investigation into the FAA's certification of the design, and an AD was issued mandating changes.

The other big issue with the DC-10 was the improvised maintenance procedures at AA that were the cause of the AA 191 disaster, though that accident did also reveal some design flaws, as did the UAL 232 accident ten years later.

In none of the major DC-10 crashes and incidents could the pilots have employed some simple recognition and standard procedures to save the aircraft. Yet despite significant physical damage and loss of flight controls, in the case of AA 96 the pilots were able to return and land using the limited working control surfaces that they still had. And the pilots were able to bring UAL 232 back to the runway using only engine thrust of the two wing engines after the uncontained failure of the tail engine caused total loss of hydraulic pressure. I consider both of those incidents to be beyond Sully-level performances by the pilots, yet nobody could have realistically blamed them if they had failed. Had PPRuNe existed at that time, I don't think anyone would be here posting "Why didn't they just perform the memory items for the cargo door blowing out and collapse of the cabin floor onto the control cables." And yet in those two cases the crews were able to maintain awareness, figure out what still worked and what didn't, and fly the aircraft with what they had.

As a (now grown adult) passenger, I don't have a loss of confidence in the MAX. They are not blowing out doors, or shedding engines. They are 100% physically intact and completely flyable, even with the flawed MCAS system, which is now understood, and will be fixed. I don't blame the pilots so much as I recognize the difference that in theory it seems that it should have been possible to run a few simple memory procedures, flip a few switches, and fly back and land. I don't see exceptional piloting skill being required there, in contrast to what some of the DC-10 crews were facing.

Whether the public at large will see it that way, especially given today's outrage-oriented media, remains to be seen.
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Old 15th Apr 2019, 13:46
  #4050 (permalink)  
 
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One lesson which the industry has to learn from this is that all flight crews must know how to restore orderly flight and disable all automation in the case of misbehaving flight control systems. If that's not possible, the cockpit is no longer a place for human beings.
The other lesson would be why on earth are pilots having to do this in the first place? Why are manufacturers building 1960 era aircraft?? Why did Boeing hide knowledge of the MCAS? Nothing else in the world would be built to a 50 year old design yet somehow in aviation it is acceptable.
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Old 15th Apr 2019, 13:50
  #4051 (permalink)  
 
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Originally Posted by gmx View Post
Generally sensible post, however, it is absolutely reasonable to ask whether pilot skill / training was a factor.

The LionAir pre accident crew defused the situation with the help of a jump seat pilot. Once they had the aircraft under control, they re-enabled electric trim only to discover it attempting to nose the plane down again, before disabling it again and flying manually to destination.

That crew defeated AoA-failure-induced MCAS twice, not once.
...snipped...
That one in bold and underlined meant:
1. The crews got lucky they found temporary solution to their "STS running the opposite way" problem.
2. Then they realized they needed an electric motor to trim after all. So, they turned it back on.
3. When the "STS running the wrong way trouble" showed up again, they killed off the electric motor for good.

The crew DIDN'T actually perform the so-called "Runaway Trim NNC", otherwise they'd written about that on their log and/or the ASHOR. They didn't even mention about the stick shaker incident which had consumed their entire flight until they'd landed safely at destination.

As written on the preliminary accident report:
Page 22 KNKT Preliminary Report


AFML
To the MX, they'd written: "IAS (Indicated Air Speed) and ALT (altitude) Disagree and FEEL DIFF PRESS (Feel Differential Pressure) light problem" on the Aircraft Flight Maintenance (AFML).
Page 9 KNKT Preliminary Report

The mystery is the pilot claimed they'd performed the "Runaway Trim NNC" to the Indonesian crash investigator when infact they'd just killed the motor directly without even following any known procedure. As explained here...

Page 20 "Preliminary Aircraft Accident Investigation Report" KNKT

When they declared that they performed three NNC's, including the Runaway Stabilizer one, to the investigator, they had just exaggerated some of their actions and/or had obscured certain details after the fact. Indeed, they conveniently omitted a very important fact: a dead head sitting on jumper seat had been the one suggesting to kill the trim motor during the cockpit's highly tense full-of-warning-and-alarm episode. We now know about this "dead head hero" because there was a leak from the media.

The Indonesian accident investigators need to get to the bottom of these discrepancies, among other things, before reaching their final conclusion within the next 3-4 months.

Last edited by patplan; 15th Apr 2019 at 13:58. Reason: format
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Old 15th Apr 2019, 14:43
  #4052 (permalink)  
 
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As a life-long apostle of Boeing (I am just a private pilot), I feel betrayed by this MCAS fiasco. They abandoned their bedrock principle that pilots can take over complete control if and when they want it.

My suspicion that Boeing is going to get off the hook frustrates me even more.

But, history shows that Boeing will survive this. Remember 737 rudder hardovers?

1. March 1991, United585 in Colorado Springs. It rolled to the right on approach and crashed. What shocked everybody was that the NTSB could not figure out the cause. Their final report (December 1992) guessed that it might be: (i) loss of directional control, or (ii) turbulence.
2. September 1994, USAir427 in Pittsburg. It rolled to the left on approach and crashed. While the second investigation was still underway, there was a third incident. In June 1996, Eastwind517 experienced two episodes of rudder reversal while on approach to Trenton, New Jersey. With the help of a live pilot and a malfunctioning aircraft still in one piece, the NTSB had some clues. Their final
report (March 1999) implicated the PCU servo.

It's long since forgotten now (that's the point of my post), but the 737 was thought to be dangerous. Even the travelling public knew that it could without warning fly you into the ground.

The MCAS crashes will be easier for the public to digest. There is no unknown to fear. Boeing made a big mistake, but at least they knew what they were doing.
Pilots who were more experienced, or faster with their NNCs, or better trained to carry through the action items on the checklists, might have saved the day.
As soon as the public hears that Boeing has fixed their mistake and believes that all pilots know how to handle the fix, the re-branded MAX will be airborned once again.

But, I still feel B-trayed. Growing within me is a little more willingness to look at A's design philosophy.
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Old 15th Apr 2019, 15:01
  #4053 (permalink)  
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Originally Posted by CaptainMongo View Post
. . .
The Max was certified for flight by aviation regulators world wide. These same regulators decreed no additional simulator training was required, (and if they did what would they have trained in that additional sim? Certainly not Left AOA vane failure at low altitude...). While I will point a big finger at the FAA’s head, I will also ask where were the other world wide regulators? . . .
Long-time operators of the B737, the Brazillians examined the type and created 3 types for the B737 in their 2018 ANAC Report.

First, the FAA FSB Report, then the Brazillian Report:

From the FAA FSB Report 2018



--------------------------------

From the ANAC, Agência Nacional de Aviação Civil
GRUPO DE AVALIAÇÃO DE AERONAVES – GAA
BRAZILIAN AIRCRAFT EVALUATION GROUP

Operational Evaluation Report - B737

From the ANAC Report, pg. 8 - 9:The Boeing 737 series have been in service for many years in Brazil, even before the ANAC Aircraft Evaluation Group (GAA) was established. For that reason, this is the first Operational Evaluation conducted by ANAC on the B-737, specifically the B-737-8MAX. An operational evaluation was conducted by ANAC Aircraft Evaluation Group (GAA) in Miami, FL, USA, during October 2017, where the proposed differences training for the B-737-8MAX was evaluated, considering the B-737-800 as the base aircraft. The evaluation was conducted using the methods described in ANAC IAC 121-1009.

The results presented here for the previous B-737 models (737-200, 737-300, 737-400, 737-500, 737-600, 737-700 and 737-800) are based on the Boeing 737 FAA FSB Report revision 14.

1.2. Objective

The objective of this report is to present the results from the operational evaluation of the B-737 series aircraft.
The content of this report is applicable to operations under the framework of ANAC.

1.3. Purpose
The purpose of this report is to:

Determine the Pilot Type Rating assigned for the B-737 series;
Recommend the requirements for training, checking and currency applicable to flight crew for the B-737 series, and functionalities; and
Present the compliance of the B-737 series with the requirements of the RBHA 91 and RBAC 121.

1.4. Applicability

This report is applicable to:

Brazilian operators of the B-737 series under RBHA 91 and RBAC 121 requirements;
Approved Training Organizations certified under RBAC 142 (Training Centers);
Civil Aviation Inspectors related to safety oversight of the B-737 series;
ANAC Principal Operations Inspectors (POIs) of the B-737 series operators.

2.PILOT TYPE RATING The GAA stablished [sic] 3 (three) different type ratings for the B-737 series aircraft and recommends the update of publication “Instrução Suplementar – IS 61-004” (ANAC type rating list) with the following information:


Last edited by PJ2; 15th Apr 2019 at 15:06. Reason: [sic] denotes that the word "stablished" is in the original document and it is taken to be the word, "established"
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Old 15th Apr 2019, 15:21
  #4054 (permalink)  
 
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Originally Posted by PJ2 View Post
Long-time operators of the B737, the Brazillians examined the type and created 3 types for the B737 in their 2018 ANAC Report.

First, the FAA FSB Report, then the Brazillian Report:

From the FAA FSB Report 2018



--------------------------------

From the ANAC, Agência Nacional de Aviação Civil
GRUPO DE AVALIAÇÃO DE AERONAVES – GAA
BRAZILIAN AIRCRAFT EVALUATION GROUP

Operational Evaluation Report - B737

From the ANAC Report, pg. 8 - 9:The Boeing 737 series have been in service for many years in Brazil, even before the ANAC Aircraft Evaluation Group (GAA) was established. For that reason, this is the first Operational Evaluation conducted by ANAC on the B-737, specifically the B-737-8MAX. An operational evaluation was conducted by ANAC Aircraft Evaluation Group (GAA) in Miami, FL, USA, during October 2017, where the proposed differences training for the B-737-8MAX was evaluated, considering the B-737-800 as the base aircraft. The evaluation was conducted using the methods described in ANAC IAC 121-1009.

The results presented here for the previous B-737 models (737-200, 737-300, 737-400, 737-500, 737-600, 737-700 and 737-800) are based on the Boeing 737 FAA FSB Report revision 14.

1.2. Objective

The objective of this report is to present the results from the operational evaluation of the B-737 series aircraft.
The content of this report is applicable to operations under the framework of ANAC.

1.3. Purpose
The purpose of this report is to:

Determine the Pilot Type Rating assigned for the B-737 series;
Recommend the requirements for training, checking and currency applicable to flight crew for the B-737 series, and functionalities; and
Present the compliance of the B-737 series with the requirements of the RBHA 91 and RBAC 121.

1.4. Applicability

This report is applicable to:

Brazilian operators of the B-737 series under RBHA 91 and RBAC 121 requirements;
Approved Training Organizations certified under RBAC 142 (Training Centers);
Civil Aviation Inspectors related to safety oversight of the B-737 series;
ANAC Principal Operations Inspectors (POIs) of the B-737 series operators.

2.PILOT TYPE RATING The GAA stablished [sic] 3 (three) different type ratings for the B-737 series aircraft and recommends the update of publication “Instrução Suplementar – IS 61-004” (ANAC type rating list) with the following information:

And in that Brazilian OER you will see that they identified MCAS as a category B training item. The question is what training the operators in Brazil implemented. GOL grounded their fleet after the Ethiopian crash even though they would have had training on MCAS.*
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Old 15th Apr 2019, 15:29
  #4055 (permalink)  
 
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Published on Monday, April 15, 2019

Boeing completes nearly 100 test flights with new 737 Max software fix

Boeing says flight crews have already completed 96 flights without incident on 737Max jets with a new software update.
It has flown more than 159 hours in total.
No issues have been identified but Boeing will continue to operate test flights for several more weeks before applying for new approval from the FAA.
Southwest Airlines isn't too confident the Max will get the green light any time soon.
The airline will now keep the planes off its schedules until at least August 5.
That will result in about 160 flight cancellations a day during the busy summer season.
America Airlines said it will also ground its Max jets until August 19 at the earliest.
Meanwhile, Sen. Edward Markey and other lawmakers have introduced a bill that would require aircraft makers to provide all safety equipment as standard at no extra charge.
The Air Line Pilots Association has backed the bill proposal.
The planes involved in crashes in Indonesia and Ethiopia did not have the optional tools that may have been able to alert pilots to malfunctioning sensors which are thought to have played a role in the accidents.
https://www.travelmole.com/news_feat...ews_id=2037018
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Old 15th Apr 2019, 15:56
  #4056 (permalink)  
 
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Originally Posted by gmx View Post
Generally sensible post, however, it is absolutely reasonable to ask whether pilot skill / training was a factor.

The LionAir pre accident crew defused the situation with the help of a jump seat pilot. Once they had the aircraft under control, they re-enabled electric trim only to discover it attempting to nose the plane down again, before disabling it again and flying manually to destination.

That crew defeated AoA-failure-induced MCAS twice, not once.

One lesson which the industry has to learn from this is that all flight crews must know how to restore orderly flight and disable all automation in the case of misbehaving flight control systems. If that's not possible, the cockpit is no longer a place for human beings.
I , for one, don't want to fly in a plane flown by HAL. Someone previously said something about a big switch that turns Everything Automatic OFF and leaves the pilots in charge. This could work well provided pilots are well trained and have not been worked to fatigue and have plenty of hand flying experience that is kept up to date and all the systems of the aircraft still work at the pilots command. Trying to trim by hand being shown to be not effective (to put it lightly) as an example.

We have unmanned drones that are commanded from the ground. I don't want to fly in a unmanned drone flown by someone on the ground either. So let's get pilots working with all the tools available with a big ALL AUTOMATICS OFF switch but all flight controls , gauges, etc all working. Let's keep the pilots well practiced and well trained.

Better than HAL. At least until we fly regularly into SPACE because manual flight won't really be possible. When we do NYC to TOKYO in 90 mins by flying into space, pilots may still be in the cockpit but they probably will be pushing buttons . Me thinks.

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Old 15th Apr 2019, 15:59
  #4057 (permalink)  
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Originally Posted by jimtx View Post
. . . The question is what training the operators in Brazil implemented. . . .
Precisely. Did they follow their own advice...?

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Old 15th Apr 2019, 18:30
  #4058 (permalink)  
 
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Useful video on the MCAS software updates from pilot Juan Browne:

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Old 15th Apr 2019, 19:11
  #4059 (permalink)  
 
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Useful and informative, although we've heard most of this already. It was important that he emphasized keeping in practice with hand-flying, even for very experienced pilots, but in briefly mentioning why hand-flying isn't practiced more, he completely blew off what I thought was a major factor in that: airlines don't WANT you to hand-fly, one of the main reasons being, supposedly, better gas mileage. Is it time for regulators to mandate a certain amount of hand-flying by pilots so that they won't get fired for doing it? (Given the pilot shortage, it seems unlikely that ppl should lose their jobs for it.)
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Old 15th Apr 2019, 19:15
  #4060 (permalink)  
 
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Originally Posted by Takwis View Post
Stabilizer trim was not mentioned in my MAX training at all. The labels, or functions, of the cutout switches were not mentioned or noticed.
That's very interesting. WAAAAY back right after Lion Air first happened we were discussing the switch nomenclature change, and user TriStar_drvr posted this picture of his MAX computer-based training... so it was covered in at least some airline's training, in a very superficial manner.

Indonesian aircraft missing off Jakarta




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