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Ethiopian airliner down in Africa

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Ethiopian airliner down in Africa

Old 26th Apr 2019, 07:11
  #4361 (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
  #4362 (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
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Old 26th Apr 2019, 07:22
  #4363 (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
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Old 26th Apr 2019, 07:26
  #4364 (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
  #4365 (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.
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Old 26th Apr 2019, 07:50
  #4366 (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
  #4367 (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
  #4368 (permalink)  
 
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Great post dce. Should be mandatory reading on any human factors refresher
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Old 26th Apr 2019, 08:46
  #4369 (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
  #4370 (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
  #4371 (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
  #4372 (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
  #4373 (permalink)  
 
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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
  #4374 (permalink)  
 
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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
  #4375 (permalink)  
 
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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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Old 26th Apr 2019, 14:50
  #4376 (permalink)  
 
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Originally Posted by 737mgm View Post
Another issue is, if these accidents were preventable by carrying out the required Boeing procedures or by applying basic flying skills respectively, despite MCAS activating.
When I was trained on the 737 (classic and NG), the stab trim runaway was a runaway - where the trim wheel ran continuously. We would identify it as a runaway, because it was continuously running, and flick the switches.

1. MCAS activation is not continuous, it's bursts.
2. The 737 trim system likes to provide bursts of random trim at certain times (STS) so bursts are considered normal.

This is why the Boeing excuse "they should have done the runaway stab QRH to fix the MCAS problem" is a load of utter nonsense. 737 Driver - pinning this on lack of airmanship will costs lives in the future.
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Old 26th Apr 2019, 14:56
  #4377 (permalink)  
 
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HundredPercentPlease,

I don't know the 737 but I used to fly 707s. The stab trim runaway drill was predicated on continuous movement as you say. I imagine the bursts of STS activity made these movements appear normal and thus mask the MCAS bursts too. All very confusing.
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Old 26th Apr 2019, 14:58
  #4378 (permalink)  
 
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Originally Posted by sky9 View Post
Can I just highlight that the F/O had 200hrs experience. I didn't get a commercial pilots licence until I had flown 230 hours and didn't fly jets until I had 1800hrs. The company that I flew 737's for in the UK in the early 1970's required 2000 hours before offering a job in the right hand seat.

This incident was to all intents and purposes a single pilot operation.
Absolutely spot on. At 200 (300 according to ET) hours, you are just along for the ride. The CA himself may have never flown anything outside of ET, certainly not old and broken airplanes from the past. It really bothers me that to this day, I sometimes look over at the FO for ideas or help in doing mental math, and he has nothing to contribute. These aircraft are certified for a minimum of two experienced pilots, not one instructor and one student. Ridiculous.

12,000 hours as captain of 727/57/67, I still rely on my highly experienced F/O's to feed me as much advice as they can.
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Old 26th Apr 2019, 14:59
  #4379 (permalink)  
 
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Originally Posted by HundredPercentPlease View Post
When I was trained on the 737 (classic and NG), the stab trim runaway was a runaway - where the trim wheel ran continuously. We would identify it as a runaway, because it was continuously running, and flick the switches.

1. MCAS activation is not continuous, it's bursts.
2. The 737 trim system likes to provide bursts of random trim at certain times (STS) so bursts are considered normal.

This is why the Boeing excuse "they should have done the runaway stab QRH to fix the MCAS problem" is a load of utter nonsense. 737 Driver - pinning this on lack of airmanship will costs lives in the future.
I think we disagree where a burst ends and continuously starts. Only been in the jumpseat of the 737, but I would be wildly surprised if STS would ever trim more than a second or two. Having the trim wheel run for ten seconds is way more than a burst. Having said that I can totally see the pilots not realizing what is going on amidst the whole set of stall warning/stick shaker/UAS indications. MCAS should never have been certified using only one AOA at a time, and I feel the same goes for the stall warning/stick shaker, there should at least be an easy way to cancel the alert if the warning is spurious.
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Old 26th Apr 2019, 15:04
  #4380 (permalink)  
 
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Originally Posted by sky9 View Post
Can I just highlight that the F/O had 200hrs experience. I didn't get a commercial pilots licence until I had flown 230 hours and didn't fly jets until I had 1800hrs. The company that I flew 737's for in the UK in the early 1970's required 2000 hours before offering a job in the right hand seat.

This incident was to all intents and purposes a single pilot operation.
This airline isn't alone in setting up that situation.
It does not help that the captain was only recently transitioned to the new aircraft, and the already-mentioned-a-few-hundred-times issues with "just what was in the differences training?" was hardly a robust aircraft systems course. That their best efforts were not good enough points, in my view, a finger at the system writ large: training, currency, company policies on training (and others) and of course the aircraft system itself. What is to me the most worrying is that with the comparatively recent Lion Air crash, this crew was, it seems, neither prepared nor trained on how to deal with that problem.
That right there, it seems to me, is where the entire system let these two pilots down. The "system" doesn't learn, and / or does a poor job of passing on "lessons learned."
Deni, a few pages back, points to the AoA signal getting to the flight computer as being a detail worthy of very thorough resolution. With the Lion Air ending up in the sea, some evidence of how that signal went sour may have been lost. In this crash, granted, there was a fire, perhaps some evidence of that signal's path, and it's possible sources of corruption, may be more clear.
I sincerely hope that Beoing's team is, along with their various test flights, putting a high magnification glass on the entire path of the AoA signal from vane to computer, and focues on how and where those signals can get dirty/contaminated. I experienced a variety of strange things happening in aircraft over the years due to electrical signals going astray or strange. Were stray trons a root cause?
We'll see.
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