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Ethiopian airliner down in Africa

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Ethiopian airliner down in Africa

Old 26th Apr 2019, 06:10
  #4341 (permalink)  
 
Join Date: Nov 2015
Location: Bay Area, CA
Posts: 65
Reading the back and forth on the conundrum of “Pilots completely at fault for being stupid” as set against “Pilots completely not at fault because Boeing designed a $hit system,” and I’ve decided to take a stand. Apologies in advance as this is long, but trust me- it is worth it.

Of all of you out there who have posted here- whether with a desire to blame the pilots entirely or the opposite, how many of you have actually experienced an imminent, binary and life-threatening emergency in your airplane?? One that is so explicit you will either get it right or you will die?? And you have maybe 30 seconds to make that choice.

My guess is the list of aviators who can answer honestly that they have been at that threshold of death is very very small.

I am on that list. And I survived, despite making bad choices along the way.

I share this story because I want people to understand once and for all that while it is fine to offer that the pilots could have done better (they totally could have) the root cause of the MAX crashes was one of design, and human failures only built on that edifice to achieve the final outcome.

I also share this story because I want to try to explain to everyone here, in terms we can all understand, what it is really like when your known world explodes and you have to improvise in order to survive.

In June of 1996 I was in a very high performance unlimited category biplane named the Goshawk. (N345RM) I had departed Livermore CA several minutes earlier and was headed to a legal practice box adjacent to the Tracy airport. While over the Altamont hills at an indicated altitude of 4000MSL I began warming up by pulling to a 45 degree upline and doing snap rolls to the right. I did this once or twice. On the third attempt, once again at approximately 4000+MSL I initiated the snap roll to the right and hit hard left rudder as the wings returned to level to stop the autorotation. When I did this the left rudder pedal/bar shot away from my foot instead of providing actual resistance. The left rudder cable had snapped.

The airplane (which was by design dynamically unstable) paused its rotation for a moment and then began again violently to the right, probably at about 360 degrees per second. And here’s where the chair-jockeys don’t get it. I probably went two or three full revolutions before my mind could accept what I already knew had happened. I immediately pulled power, but the aircraft was already entering a nose-down spin- at a rotational rate of at least 360 degrees per second.

The ROD of a spinning aerobatic biplane is pretty steep, probably on the 1500-2000FPM range. I checked my altimeter, saw I was descending through 4,000 feet and decided to try to recover the airplane before bailing out. AND HERE IS THE IMPORTANT POINT: BECAUSE I REFUSED TO ACCEPT THAT THE AIRPLANE WAS COMPLETELY EFFED I would nearly die. My mind knew before then, as it knows now, that if you put a Pitts-like airplane into an autorotational state the only thing that is going to get it out is opposite yaw. With no rudder THERE CANNOT BE ANY OPPOSITE YAW!! I had thousands of hours in similar aircraft, I was an unlimited category competition aerobatic pilot and instructor, and yet when faced with the obvious I could not process it quickly enough, despite having the evidence staring me squarely in the eye, to react quickly enough to prevent me from nearly dying.

So I frittered away precious moments trying to use opposite yaw via ailerons, shots of engine thrust, hell I might have even prayed, I don’t know. What I know now is I could have done better. What I also know now, and somehow managed to forget then, was that I was over the Altamont. When I saw 4000’MSL and thought “OK, I’ve got time to play with this” the reality was I was over a hill- that was 2134’ high. Tracy- just 20 miles away and where I was headed sits at 193’ MSL.

In my mind, because I was stupid overwhelmed, or just unable to process everything being thrown at me I had maybe 3500-4000’ to play with. So I could spend 30 seconds fighting the airplane to try to recover it before I had to bail.

In reality I had less than 2000’ before I would be dead.

I spent probably ½ to ¾ of the real time I had to get out of the airplane in it- fighting to try to save it, and I did this by deliberately ignoring what I already knew (I had lost rudder control completely) what I should have known (I was over the Altamont) and what I should have accepted (I had to go- the Goshawk was not going to survive this, the only real question was would I??)

I obviously did reach the (already foregone but stubbornly ignored by me) conclusion that the airplane was unrecoverable and decided to bail out- which is an interesting concept in a stable spinning airplane. I undid my harnesses as I had practiced, and I fought my way out of the airplane- pinned against the left side of the cockpit coaming by the rotational g-forces before eventually getting enough of my upper body into the slipstream that I was basically yanked out of the airplane. I was falling in a fetal position, thought about waiting to pull the ripcord, said eff-it and pulled, and after the shocking introduction to my first and (so far) only canopy opening was struck by the sound of the airplane smacking into the ground just a second or two later. Future calculation efforts would show that my chute opened between 134 and 200 feet above the ground, which at that rate of descent equaled a couple of seconds at best.

Surviving that incident has given me some small window of insight into what happens when your comfy world devolves in seconds into one where you know you are about to die.

The biggest lesson, and the greatest ego-killer was simple: I didn’t respond nearly as I would have hoped I would. It took me countless seconds to register the fact of the failure. I knew as soon as the pedal fired away from my foot what had happened. But my mind simply refused to accept that reality for some short period of time. The second error was equally simple: I thought I was the hero pilot (Neil Williams etc…) who would bring my crippled plane back to the airport, thereby saving the day. That thought nearly cost me my life, as I wasted precious seconds performing an absolutely useless dance of fancy “airmanship” that did nothing but allow my airplane to bring me closer and closer to the ground with every moment.

And now to the main point of this entirely too-long post: For those of you who suppose you will see everything clearly and “FTFA” when your own fatal opportunity presents itself please hear me when I say this: YOU WILL NOT!! The question that will determine your survival is how quickly will you move past that initial shock and be able to function properly again. In my case it was a single (albeit fatal) failure. I was extremely well trained, averse to panic-driven responses, and well-able to handle the emergency I had been presented with. Yet I wasted probably a full minute in an airplane I had no business being in any longer.

In the 737 crashes it was a cascade of failures. My own- very rare life experience tells me that those pilots had little chance given the stressors they were working under, as would the rest of you. These are not the words of someone who doesn’t know what it’s like. I’ve been there. I lived. So please trust me when I tell you that your vaunted talents will wither to nothing if someday you are in this unfortunate position. At best you will be semi-functional, at worst you will be functionally useless.

What you will not be, in any context, is a hero who defies these realities.

Final note: This isn’t about placing blame on anyone. Boeing designed an airplane with a crap system that had random and unmonitored control over the single most important control surface of the aircraft. The FAA paved the way for certification of the airplane, and once in the hands of pilots that airplane not once, but twice flew itself into the ground. (The pilots didn’t- it was MCAS that did, and that’s an important fact to take note of…) You can blame the pilots all you want, but it was the airplane itself that had a failure mode that required the pilots to be perfect or die. Boeing had years to create a functioning system that would not put the pilots in this position and they failed to create one. So the two (six really) pilots were left to defend themselves against an airplane that was trying to kill them. Four failed in that endeavor, and they have my utmost respect and gratitude.

Only those who have walked the path and survived can understand the fine line between winning and dying- which is why I have posted this ridiculously long post tonight.

Sorry for the sermon, just tired of reading the constant back and forth about who we should blame.

Link to the Final on my incident: Well despite being a member for years I haven't reached the vaunted 10-post threshold for posting URLs. Search "NTSB June 17, 1996 N345RM" for the final report.

Regards,
dce
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Old 26th Apr 2019, 06:26
  #4342 (permalink)  
 
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Dce

that is an excellent post and so true
Jetman346 is offline  
Old 26th Apr 2019, 06:51
  #4343 (permalink)  
 
Join Date: Oct 2017
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Originally Posted by wonkazoo View Post
Reading the back and forth on the conundrum of “Pilots completely at fault for being stupid” as set against “Pilots completely not at fault because Boeing designed a $hit system,” and I’ve decided to take a stand. Apologies in advance as this is long, but trust me- it is worth it.

Of all of you out there who have posted here- whether with a desire to blame the pilots entirely or the opposite, how many of you have actually experienced an imminent, binary and life-threatening emergency in your airplane?? One that is so explicit you will either get it right or you will die?? And you have maybe 30 seconds to make that choice.

My guess is the list of aviators who can answer honestly that they have been at that threshold of death is very very small.

I am on that list. And I survived, despite making bad choices along the way.

I share this story because I want people to understand once and for all that while it is fine to offer that the pilots could have done better (they totally could have) the root cause of the MAX crashes was one of design, and human failures only built on that edifice to achieve the final outcome.

I also share this story because I want to try to explain to everyone here, in terms we can all understand, what it is really like when your known world explodes and you have to improvise in order to survive.

In June of 1996 I was in a very high performance unlimited category biplane named the Goshawk. (N345RM) I had departed Livermore CA several minutes earlier and was headed to a legal practice box adjacent to the Tracy airport. While over the Altamont hills at an indicated altitude of 4000MSL I began warming up by pulling to a 45 degree upline and doing snap rolls to the right. I did this once or twice. On the third attempt, once again at approximately 4000+MSL I initiated the snap roll to the right and hit hard left rudder as the wings returned to level to stop the autorotation. When I did this the left rudder pedal/bar shot away from my foot instead of providing actual resistance. The left rudder cable had snapped.

The airplane (which was by design dynamically unstable) paused its rotation for a moment and then began again violently to the right, probably at about 360 degrees per second. And here’s where the chair-jockeys don’t get it. I probably went two or three full revolutions before my mind could accept what I already knew had happened. I immediately pulled power, but the aircraft was already entering a nose-down spin- at a rotational rate of at least 360 degrees per second.

The ROD of a spinning aerobatic biplane is pretty steep, probably on the 1500-2000FPM range. I checked my altimeter, saw I was descending through 4,000 feet and decided to try to recover the airplane before bailing out. AND HERE IS THE IMPORTANT POINT: BECAUSE I REFUSED TO ACCEPT THAT THE AIRPLANE WAS COMPLETELY EFFED I would nearly die. My mind knew before then, as it knows now, that if you put a Pitts-like airplane into an autorotational state the only thing that is going to get it out is opposite yaw. With no rudder THERE CANNOT BE ANY OPPOSITE YAW!! I had thousands of hours in similar aircraft, I was an unlimited category competition aerobatic pilot and instructor, and yet when faced with the obvious I could not process it quickly enough, despite having the evidence staring me squarely in the eye, to react quickly enough to prevent me from nearly dying.

So I frittered away precious moments trying to use opposite yaw via ailerons, shots of engine thrust, hell I might have even prayed, I don’t know. What I know now is I could have done better. What I also know now, and somehow managed to forget then, was that I was over the Altamont. When I saw 4000’MSL and thought “OK, I’ve got time to play with this” the reality was I was over a hill- that was 2134’ high. Tracy- just 20 miles away and where I was headed sits at 193’ MSL.

In my mind, because I was stupid overwhelmed, or just unable to process everything being thrown at me I had maybe 3500-4000’ to play with. So I could spend 30 seconds fighting the airplane to try to recover it before I had to bail.

In reality I had less than 2000’ before I would be dead.

I spent probably ½ to ¾ of the real time I had to get out of the airplane in it- fighting to try to save it, and I did this by deliberately ignoring what I already knew (I had lost rudder control completely) what I should have known (I was over the Altamont) and what I should have accepted (I had to go- the Goshawk was not going to survive this, the only real question was would I??)

I obviously did reach the (already foregone but stubbornly ignored by me) conclusion that the airplane was unrecoverable and decided to bail out- which is an interesting concept in a stable spinning airplane. I undid my harnesses as I had practiced, and I fought my way out of the airplane- pinned against the left side of the cockpit coaming by the rotational g-forces before eventually getting enough of my upper body into the slipstream that I was basically yanked out of the airplane. I was falling in a fetal position, thought about waiting to pull the ripcord, said eff-it and pulled, and after the shocking introduction to my first and (so far) only canopy opening was struck by the sound of the airplane smacking into the ground just a second or two later. Future calculation efforts would show that my chute opened between 134 and 200 feet above the ground, which at that rate of descent equaled a couple of seconds at best.

Surviving that incident has given me some small window of insight into what happens when your comfy world devolves in seconds into one where you know you are about to die.

The biggest lesson, and the greatest ego-killer was simple: I didn’t respond nearly as I would have hoped I would. It took me countless seconds to register the fact of the failure. I knew as soon as the pedal fired away from my foot what had happened. But my mind simply refused to accept that reality for some short period of time. The second error was equally simple: I thought I was the hero pilot (Neil Williams etc…) who would bring my crippled plane back to the airport, thereby saving the day. That thought nearly cost me my life, as I wasted precious seconds performing an absolutely useless dance of fancy “airmanship” that did nothing but allow my airplane to bring me closer and closer to the ground with every moment.

And now to the main point of this entirely too-long post: For those of you who suppose you will see everything clearly and “FTFA” when your own fatal opportunity presents itself please hear me when I say this: YOU WILL NOT!! The question that will determine your survival is how quickly will you move past that initial shock and be able to function properly again. In my case it was a single (albeit fatal) failure. I was extremely well trained, averse to panic-driven responses, and well-able to handle the emergency I had been presented with. Yet I wasted probably a full minute in an airplane I had no business being in any longer.

In the 737 crashes it was a cascade of failures. My own- very rare life experience tells me that those pilots had little chance given the stressors they were working under, as would the rest of you. These are not the words of someone who doesn’t know what it’s like. I’ve been there. I lived. So please trust me when I tell you that your vaunted talents will wither to nothing if someday you are in this unfortunate position. At best you will be semi-functional, at worst you will be functionally useless.

What you will not be, in any context, is a hero who defies these realities.

Final note: This isn’t about placing blame on anyone. Boeing designed an airplane with a crap system that had random and unmonitored control over the single most important control surface of the aircraft. The FAA paved the way for certification of the airplane, and once in the hands of pilots that airplane not once, but twice flew itself into the ground. (The pilots didn’t- it was MCAS that did, and that’s an important fact to take note of…) You can blame the pilots all you want, but it was the airplane itself that had a failure mode that required the pilots to be perfect or die. Boeing had years to create a functioning system that would not put the pilots in this position and they failed to create one. So the two (six really) pilots were left to defend themselves against an airplane that was trying to kill them. Four failed in that endeavor, and they have my utmost respect and gratitude.

Only those who have walked the path and survived can understand the fine line between winning and dying- which is why I have posted this ridiculously long post tonight.

Sorry for the sermon, just tired of reading the constant back and forth about who we should blame.

Link to the Final on my incident: Well despite being a member for years I haven't reached the vaunted 10-post threshold for posting URLs. Search "NTSB June 17, 1996 N345RM" for the final report.

Regards,
dce

Thanks for sharing your brush with the dark side.

A couple of serious questions if you do not mind.

During your event did pitch and power enter your mind?

Were you a airline pilot or just aerobatics?

How long did you actually spend trying to fight it, and how long did it feel like you fought it (I expect they are not the same answer).
Bend alot is offline  
Old 26th Apr 2019, 06:53
  #4344 (permalink)  
 
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Originally Posted by wonkazoo View Post
Link to the Final on my incident: Well despite being a member for years I haven't reached the vaunted 10-post threshold for posting URLs. Search "NTSB June 17, 1996 N345RM" for the final report.
Final report.






Attached Files
File Type: pdf
N345RM Final Report.pdf (88.6 KB, 137 views)
DaveReidUK is offline  
Old 26th Apr 2019, 07:06
  #4345 (permalink)  
 
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Originally Posted by Bend alot View Post
Thanks for sharing your brush with the dark side.

A couple of serious questions if you do not mind.

During your event did pitch and power enter your mind?

Were you a airline pilot or just aerobatics?

How long did you actually spend trying to fight it, and how long did it feel like you fought it (I expect they are not the same answer).
As I wrote- I tried to use thrust (power) to bump it out of it's spin. When a dynamically unstable airplane is in auto-rotation pitch alone doesn't have the ability to recover the aircraft. It can tighten or loosen the auto-rotation by virtue of decreasing or increasing the AOA (Hmmm, have I read about AOA recently??), but pitch authority alone (of which there was tons in this airplane) cannot overcome the autorotative state as it does not affect yaw, which is the critical factor in a stabilized spin. (Inside wing stalled, outside wing flying...) I did try pro-spin and anti-spin aileron with the power changes. Frankly I genuinely thought I could bump it out of it's stable autorotative state. Which was my pilot-ego speaking louder than my science-pilot self.

"Airline pilot or just aerobatics?" Well that's an interesting question, but I've never flown heavy iron, nor have I suggested I have. But I did somehow survive roughly 4400 hours of PIC time in an immense variety of airplanes and helicopters, each of which obeys the same exact physics as a 737 Max-8.

I cannot tell you how long I spent trying to recover the airplane (as opposed to fighting it). IN round numbers when I realized what had happened I looked at the altimeter, saw something around 4000' MSL and thought "I have some time." Roughly speaking I was on the ground a minute or a minute and a half later.
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Old 26th Apr 2019, 07:11
  #4346 (permalink)  
 
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Wonkazoo

Don't apologise for the length, really excellent post, thank you.

Regards - and respect.

Alchad
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Old 26th Apr 2019, 07:17
  #4347 (permalink)  
 
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Originally Posted by DaveReidUK View Post
Final report.
There is also a summary of the accident here: https://aviation-safety.net/wikibase/wiki.php?id=133835

Edit: The dry report contains nothing like the first-hand version in this thread:
attempts at regaining control were unsuccessful
GordonR_Cape is offline  
Old 26th Apr 2019, 07:22
  #4348 (permalink)  
 
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One more quick note before I totter off to bed.

We all like to think of ourselves as calm and cool. The Chuck Yeager persona etc.

I really hope you all hear what I am trying to say here- more than I ever have before.

When I landed awkwardly, (I tried to flare my round chute) I was then dragged for a couple hundred feet or so as the winds were blowing around 15KT and a chute is alas a big kite. I finally got it collapsed enough to unbuckle the harness and stop the whole sad circus in its tracks.

And there I lay, in the dry grass of a California summer, on the container of my parachute and harness, panting like a dog who has run miles, and looking at my hands as my pulse thudded through my fingers in a way I've never felt before or since.

My mind would take years to process that I had just been in a knife fight for my survival, but my body knew exactly what had happened. I am known for being calm, especially when stuff gets silly. What most people don't know is that I have lain helpless on my stomach, with three fractured vertebra, staring at my hands all while panting uncontrollably.

Because despite being calm I almost ran out of answers. (Actually I did run out of answers- which helped as the only option was to bail out- much to my family's presumed happiness.)

We like to see ourselves as heroes- who will always do the right thing when the chips are down.

The reality as far less noble. Which is why compassion for those who were put in a situation just like mine, but who were so minutely less fortunate, is completely appropriate,

Cheers-
dce
wonkazoo is offline  
Old 26th Apr 2019, 07:26
  #4349 (permalink)  
 
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Originally Posted by wonkazoo View Post
As I wrote- I tried to use thrust (power) to bump it out of it's spin. When a dynamically unstable airplane is in auto-rotation pitch alone doesn't have the ability to recover the aircraft. It can tighten or loosen the auto-rotation by virtue of decreasing or increasing the AOA (Hmmm, have I read about AOA recently??), but pitch authority alone (of which there was tons in this airplane) cannot overcome the autorotative state as it does not affect yaw, which is the critical factor in a stabilized spin. (Inside wing stalled, outside wing flying...) I did try pro-spin and anti-spin aileron with the power changes. Frankly I genuinely thought I could bump it out of it's stable autorotative state. Which was my pilot-ego speaking louder than my science-pilot self.

"Airline pilot or just aerobatics?" Well that's an interesting question, but I've never flown heavy iron, nor have I suggested I have. But I did somehow survive roughly 4400 hours of PIC time in an immense variety of airplanes and helicopters, each of which obeys the same exact physics as a 737 Max-8.

I cannot tell you how long I spent trying to recover the airplane (as opposed to fighting it). IN round numbers when I realized what had happened I looked at the altimeter, saw something around 4000' MSL and thought "I have some time." Roughly speaking I was on the ground a minute or a minute and a half later.
Cheers, was just some questions based on some posts on this thread.

Far from your experience, I have had a couple of near departed events in my life and thinking rationally at the time is somewhat fuzzy.

I have also witnessed a few fiery actual crashes both fixed wing and a rotary (I expect GF rights played a big part in the rotary one S269 C to D) - very strange how different we react at that time. The pilot that was in a bad way and passed soon after lead us to the problem.

Also involved very closely with a loss of aircraft (RIP) on a private fly away - again very different the way people acted and after recalled the event during personal chats and the ATSB investigation.

Thanks for detailing your account.
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Old 26th Apr 2019, 07:39
  #4350 (permalink)  
 
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Originally Posted by wonkazoo View Post
The reality as far less noble. Which is why compassion for those who were put in a situation just like mine, but who were so minutely less fortunate, is completely appropriate,

Cheers-
dce
Thanks Sir for this. Really.
TheEdge is online now  
Old 26th Apr 2019, 07:50
  #4351 (permalink)  
 
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Originally Posted by GordonR_Cape View Post
There is also a summary of the accident here: https://aviation-safety.net/wikibase/wiki.php?id=133835

Edit: The dry report contains nothing like the first-hand version in this thread:
One quick note/mea culpa:

The "Pushed himself back into his seat' charade was because I was (technically) (Well really) performing aerobatic maneuvers within 4NM of an airway. Which meant if I admitted to deliberately entering the maneuver I could be busted by the feds. Since I had to hike a couple of miles back to civilization (with one sneaker and a sock) I had plenty of time to find a rational explanation for how my airplane entered into an autorotative state without doing actual aerobatics.

Second note: The report is inaccurate and confusing when it says I was in the box when the failure occurred. A simple look at the map will tell you that the failure occurred over the Altamont.

Last Note, and a good one: Our family (Including my 10 and 12 year-olds) is going to go to the crash site on June 17th. The actual location is a bit unknown as it was in the middle of a ton of grass, some hillsides, two ponds, and a gazillion cows. But the image I first saw when I looked up from my hands will never leave me, and the wreck can't be far from there. Granted most pieces were removed 20 years ago, but the engine case was buried up the the middle of the last bank, so I'm betting if we look hard enough we'll find evidence of the event.

All of which is simply amazing. I went from seconds separating me from life, to a family and a life unknown.

Lucky am I...
dce
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Old 26th Apr 2019, 08:04
  #4352 (permalink)  
 
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Thank you so much Wonkazoo. If you don't mind, I will copy your post - and send it to some of my Hot Shot buddies - yeah, still buddies - who still are adament that they would have saved the Lion Air and ET flights. Thank you Sir. From a 16k hours Airline guy, who doesn't know if I could have done better...
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Old 26th Apr 2019, 08:36
  #4353 (permalink)  
 
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Great post dce. Should be mandatory reading on any human factors refresher
BleedingOn is offline  
Old 26th Apr 2019, 08:46
  #4354 (permalink)  
 
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Originally Posted by wonkazoo View Post
My guess is the list of aviators who can answer honestly that they have been at that threshold of death is very very small.
A small proportion but not a small number. Everyone who has ever ejected, bailed, or faced a major malfunction could be asked and most likely have a range of opinions on the human factors of ET302.
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Old 26th Apr 2019, 09:00
  #4355 (permalink)  
 
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Originally Posted by oggers View Post
A small proportion but not a small number. Everyone who has ever ejected, bailed, or faced a major malfunction could be asked and most likely have a range of opinions on the human factors of ET302.
With a common theme - it was not easy and I made mistakes and luck played a part in many of them - but any with ejection seats are never in the position of the ET 302 crew and even Wankazoo ( opps wonkazoo is correct - embarrassing mistake thanks for the PM's I will live with it.) had a "bail" option in real life.

A major malfunction is what an engine failure? every Tom Dick and Harry practice that on takeoff and very often!

Last edited by Bend alot; 26th Apr 2019 at 09:42. Reason: Explanation in the ()'s sorry Wonka - will buy you a beer.
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Old 26th Apr 2019, 10:41
  #4356 (permalink)  
 
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Originally Posted by Ian W View Post
Average professional pilots even below average professional pilots should note and correct out of trim flight. This is C-172 stuff and is not complicated.
Way back in training we were in a C172 about to take off. I'd skipped a checklist item - "autopilot off". Instructor came down on me hard for that one He told me the story of a fatal crash at Leicester UK where pilot left AP on.

"Initially, until about 100 feet agl the take-off appeared normal but then the aircraft adopted an ever increasing nose-high attitude which culminated in a gentle left roll at about 300 feet agl before the aircraft's nose dropped sharply. It seemed to the aero club witnesses that the aircraft had stalled in a markedly nose-up attitude. After what appeared to be an attempted stall recovery at about 100 feet
agl, it dived into the ground whilst rolling left with the engine still running"
...
"During the ground evaluation tests it was noticed that if the ALT button was pressed, the autopilot
engaged... About three to four seconds
later, the elevator trim commenced winding on nose-up trim until it reached maximum deflection;
this took about 18 seconds".

HAL can get at you even in a 172.

https://assets.publishing.service.gov.uk/media/5422ec04e5274a13170000d5/dft_avsafety_pdf_501522.pdf
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Old 26th Apr 2019, 11:33
  #4357 (permalink)  
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wonkazoo, thanks for a thought provoking break from the regular arguments. Refreshing to have one's mind taken so vividly to that scene. Talking of minds.


A couple of times I've posted about getting into the minds of the three MAX crews. I've tried to paint the picture of the chaos and mental confusion that was probably - and I mean, probably - taking place.

Strangely, if feel Could've done's and should've done's are fine for analytical discussion . Yes, they're often unkindly critical, but without them we don't have both sides of the most fundamental part of this long thread: the argument between both camps. More or less the performance of the four pilots, V FAA and Boeing's behaviour.

I protested that the months of hindsight invalidates any true judgement we may feel compelled to put forward against the pilots.

Getting into the mind of an average pilot, whatever that might be these days. One thing's for sure, it's not one that's had his senses sharpened by months of focussed discussion on this specific crisis, and not necessarily comparable to some of the pilots on here that have a wealth of experience on a wide range of Boeing products.
I further expressed some astonishment at what I described as the dichotomy of opinions between even the highly experienced PPRuNe posters.
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Old 26th Apr 2019, 12:43
  #4358 (permalink)  
 
Join Date: Apr 2009
Location: A place in the sun
Age: 80
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wonkazoo,

Thank you for your excellent post, no need to apologise for its length. Like you, I have been to 'the edge' very early on in my airline pilot career, it made me think a whole lot differently about flying - to my eventual benefit. Indeed, yes, the brain does become scrambled for a while when something startling, sudden and frightening occurs. Read my link and stop for a moment and think how foolish we all were to switch off the main flight instruments in the middle of what was probably a spiral dive.
IFR conditions on the flight deck

It takes time to collect your thoughts and start to react correctly. I was the co-pilot. We survived and it made me very humble about these things ever afterwards. Armchair quarter backs should spare a thought for those caught up in such events and say to themselves,"There but for the grace of God go I."

And it applies to Sky Gods too!

Last edited by Bergerie1; 26th Apr 2019 at 13:02.
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Old 26th Apr 2019, 13:07
  #4359 (permalink)  
 
Join Date: Apr 2019
Location: USA
Posts: 217
Wonkazoo,

Appreciate the comments. Understanding the human reaction to an aircraft emergency is a very important part of examining these incidents. You're right, that it really isn't a case of Boeing messed up or the pilots messed up or the regulators messed up or the maintenance folks messed up. All those parts came together at the same time to cause these accident. However, by they same token, we can't simply sit back and say Boeing needs to fix their design, the FAA needs to strengthen their oversight, the airlines have to do a better job at training, and then turn a blind eye to what, we as professional pilots, ought to be doing to address obvious shortcomings in airmanship. And we can't address those shortcomings unless we acknowledge that those shortcomings were present in these accidents.

In my aviation career, I've had three incidents where if I didn't make the right choices in a timely manner, then a very bad outcome would have resulted. The most notable was an engine failure in a single-engine aircraft that culminated in a deadstick ILS approach to the runway with 300-1 weather. Yes, luck was involved in that there was an airport close enough to navigate to, but luck didn't land the plane. I don't say this to pat myself on the back, but to simply to say that I've been there. You're right in that the initial wave of emotions and disbelief can be enormous and potentially paralyzing. I've also made some embarrassing mistakes in my career that if not caught by my trusty First Officer, could have devolved into something unpleasant. Mistakes happen and humans err, but that does not mean we just throw up are arms and say there's nothing to be done.

I've said before that when I was an instructor pilot, I could take just about any well-adjusted adult and teach them the basics of flying and that they would be safe enough on a VFR day if nothing went wrong. Similarly, there are lots of people who can be taught the systems management approach to flying, and as long as nothing happens too quickly and the problem is well-known or the solution is covered by some non-normal checklist, then they will do just fine.

Here's the cold reality of these accidents: Things will happen that aren't on the checklist. They can happen quickly. Crew competency matters, and I do mean "crew" because the Captain can't do it all himself when things go bad. Basic airmanship skills matter. The ability to think under pressure matters. The ability to prioritize matters. Ultimately, these planes were flyable using some pretty basic airmanship skills, but that did not happen. Perhaps one day the aircraft and all the processes that touch a flight will be made so completely fault tolerant that these things don't matter. However, when that future becomes reality, airlines won't need professional pilots anymore, will they?

Yes, I'm being hard on the crew, just as I'm being hard on Boeing and the FAA and the airlines. It can be a hard business, and people die when we don't get it right. That being said, I've seen no evidence that anyone was intentionally malicious or careless. The human factor element touches every part of these accidents from the aircraft designers, to the supervisors, to the regulators, to the airline managers, and all the way to the flight crew. We know that there were multiple mistakes by multiple humans, and now it is incumbent on us to ask what could have been done differently. We do not do this so we have the luxury to say WE could have prevented these accidents, but to make the entire chain of causation more resilient and safer.

PPRuNe is not an online forum for Boeing or the FAA or airline management. We can point fingers, but we can't really fix their issues. PPRuNe, however, is a forum for professional pilots, so we can certainly discuss what ought to be done when we see evidence that points to lapses in airmanship. If some of the participants want to take the position that there is nothing to be done, that we merely have to accept that some of our number are going to succumb to the pressures induced by an unexpected aircraft state, fail to execute well-established procedures and/or apply basic airmanship skills, I am not sure what else I can say.

IMHO, what I think would be more beneficials is to move past the shock and denials and the strong desire to defend one of our own and look at the particular chain of causation that led to these crews not being able to perform to the standards of a professional pilot when lives were at stake.

Last edited by 737 Driver; 26th Apr 2019 at 16:03.
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Old 26th Apr 2019, 14:31
  #4360 (permalink)  
 
Join Date: Apr 2009
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Age: 80
Posts: 1,047
737 Driver,

You are right too. Every part of that chain of human mistakes needs to be examined - manufacturers, regulators, airlines, trainers, accountants, managers and pilots. The pilots are the last link in that chain and in these last two accidents they were lacking too. As professional pilots we must strive for and achieve high standards, and, let's face it, most do.
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