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Ethiopian airliner down in Africa

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Ethiopian airliner down in Africa

Old 27th Apr 2019, 16:49
  #4441 (permalink)  
 
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Originally Posted by Chu Chu View Post
I find it fascinating to watch highly qualified and experienced folks take nearly opposite views of the crews’ and Boeing’s respective contributions to the accidents.

I wonder if folks might get closer to consensus if the judged the crews based on what did happen, and Boeing on what could have happened. As SLF, I have to accept that the chaos in the cockpit would have been beyond anything I’m capable of imagining. But I’m still skeptical that a crew trapped in a tug-of-war with the control column shouldn’t have worked out that they should apply nose-up trim – and keep applying it until things got better or it became completely obvious that it wasn’t working.

At the same time, I’m assuming that the AOA probe failure could have happened in IMC. At least I haven’t seen anyone explain why it couldn’t. It seems perfectly reasonable that a crew faced with a stick shaker for no obvious reason and a display showing the horizon rising above the flight path for no obvious reason might hesitate before making major nose-up control and pitch inputs. And it sounds like it could have become too late pretty quickly.

Am I missing something?
I raised the possibility of faulty AOA and MCAS activation during night IMC conditions many pages ago, but there were no bites to my suggestion. If you throw in somatogravic illusion, the outcome could only have been more difficult than the two (three) actual cases that occurred in daytime VMC conditions. Juggling flight controls, instrument displays and spatial orientation at once would a real handful.

You comment raises a broader issue: With hindsight we know that both aircraft were flyable, with the right sequence of control inputs. At the time the pilots could not have known this for sure, and may have wasted energy on many mental scenarios, most of which did not lead to the small number of escape steps. They did not know for certain if there was any kind of mechanical malfunction (parts of the horizontal stabiliser or elevator fell off, control systems jammed), computer gone rogue (we know the cutoff switches are supposed to work, but are you really sure). In addition they might conceivably avoid doing things that might make the situation worse, or provoke the computer systems into more nose-down trim?

As several personal anecdotes have reminded us, when things go seriously wrong, rational thought sometimes goes right out the window. My understanding is that passenger jet pilots do not wake up in the morning expecting to face imminent death. The training process does not emphasise this kind of life or death situation, and the selection process does not specifically weed out those that would fail to meet test-pilot or astronaut standards.
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Old 27th Apr 2019, 17:04
  #4442 (permalink)  
 
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Originally Posted by Smythe View Post
B 737 driver....In regards to the MCAS and AP, there seems to be some differences noted.
From Pilot reports:

Wind and mechanical turbulence was noted. Careful engine warm times, normal flaps 5 takeoff in strong (appeared almost direct) crosswind. Departure was normal. Takeoff and climb in light to moderate turbulence. After flaps 1 to "up" and above clean "MASI up speed" with LNAV engaged I looked at and engaged A Autopilot. As I was returning to my PFD (Primary Flight Display) PM (Pilot Monitoring) called "DESCENDING" followed by almost an immediate: "DONT SINK DONT SINK!"
I immediately disconnected AP (Autopilot) (it WAS engaged as we got full horn etc.) and resumed climb.


Another report:

After verifying LNAV, selecting gear and flaps up, I set "UP" speed. The aircraft accelerated normally and the Captain engaged the "A" autopilot after reaching set speed. Within two to three seconds the aircraft pitched nose down bringing the VSI to approximately 1,200 to 1,500 FPM. I called "descending" just prior to the GPWS sounding "don't sink, don't sink." The Captain immediately disconnected the autopilot and pitched into a climb. The remainder of the flight was uneventful.
I haven't seen the original reports (would appreciate a pointer to the source if someone has it), but I saw this discussed elsewhere. It had been pointed out that this is likely two reports for one incident - one by the Captain and one by the FO. It is quite common for both pilots to fill out separate reports.

This does not appear to be a MCAS issue, since the A/P was engaged. It is more likely an autopilot issue. Not knowing the detail of how the crew had the A/P set up or the maintenance history, I couldn't really comment beyond that. I've seen A/P doing wonky things before on engagement which is why I keep my thumb near the disengage button when turning the ship over to HAL.
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Old 27th Apr 2019, 17:34
  #4443 (permalink)  
 
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I say again, Fly The Aircraft!

Originally Posted by HundredPercentPlease View Post
We get it. You think they were sub-standard. You would have used your greater "airmanship" to keep the basic parameters in line and therefore the aircraft flying. Your lack of appreciation of human factors in a real scenario with real line pilots in the real world is what you should address.
Applying the steps I have outlined is not "greater" airmanship. It is basic airmanship. These steps have been preached in aviation circles pretty much since the Wright Brother days. I really don't understand why this is such a difficult or controversial topic.

I definitely appreciate the human factors issue. The crew performance is one HUGE human factors issue. And that issue is this: What were the factors impacting these crews (experience? training? environment? stress?) that kept them from applying basic airmanship skills to stabilize the aircraft so they could then successfully deal with the malfunction?


In my model, the captain wanted to get the thing cleaned up, then reduce the workload, then work out what was wrong. They cleaned up - he used the a/p to reduce the workload, and as they were starting to diagnose the aircraft bit them. His workload reduced his SA (along with the stick shaker) to a critical point. The pilot failed due to excess workload, not due to lack of "airmanship".
Here's the hard reality: "Your" model (or the ET Captain's model, if you rather) resulted in the deaths of all the passengers and crew. There is not a single universe in which selecting A/P at low altitude was the right choice with an active stick shaker. Raising the flaps prior to properly diagnosing the problem is also highly suspect. What I see instead is a Captain who was so unclear as to what was going on that he simply reverted to what he did on every previous takeoff - engage the A/P at 400', climb to 1000', retract the flaps. Trimming was handled poorly because he had not hand-flown sufficiently to wire this skill into procedural memory. This was not airmanship, this was rote behavior.

In comparison the "model" I have repeated flogged, a model that has been around for probably a century of aviation, a model that has saved many an aircraft when followed and doomed quite a few when not, would have at a minimum allowed this crew to stabilize the aircraft and get it to a safe altitude. Whether they would then have correctly resolved a subsequent problem with MCAS is impossible to say, but they would have been dealing with it from a stabilized platform at a much higher altitude.

Last edited by 737 Driver; 27th Apr 2019 at 17:46.
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Old 27th Apr 2019, 18:13
  #4444 (permalink)  
 
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737 Driver:
What you say (and keep on saying) makes manifest sense. Basic competency is an absolute requirement for this gig.
Don't let the bastards get you down!
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Old 27th Apr 2019, 18:31
  #4445 (permalink)  
 
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Trying to add a bit of balance here, there are clearly polarised views regarding Boeing vs. a few pilots. Surely professional aviators, certainly those operating a $100M aircraft, realise that they are a layer in the system? What would you prefer, no changes to the technical side and continued reliance on pilot skills/airmanship, or perhaps a more comprehensive review and upgrade of the entire system (note, pilots are part of the system)? To bang-on about a lack of basic airmanship sort of misses the point and reminds me of the 1980s Air Force I joined. Things have moved on. If it were my train set(s), I would:

Start designing the 737 replacement
Bin the MCAS 'kludge' and put in a system that is far more comprehensive and capable.
Ensure people are trained properly (a joint manufacturer, regulator and operator responsibility)
Communicate.

We all have positives to offer here and that should be a good thing about aviation. Unfortunately, money drives the world; the open & honest environment we require will always be influenced by the bean-counters and lawyers.




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Old 27th Apr 2019, 18:41
  #4446 (permalink)  
 
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Originally Posted by Cows getting bigger View Post
Trying to add a bit of balance here, there are clearly polarised views regarding Boeing vs. a few pilots. Surely professional aviators, certainly those operating a $100M aircraft, realise that they are a layer in the system? What would you prefer, no changes to the technical side and continued reliance on pilot skills/airmanship, or perhaps a more comprehensive review and upgrade of the entire system (note, pilots are part of the system)? To bang-on about a lack of basic airmanship sort of misses the point and reminds me of the 1980s Air Force I joined. Things have moved on. If it were my train set(s), I would:

Start designing the 737 replacement
Bin the MCAS 'kludge' and put in a system that is far more comprehensive and capable.
Ensure people are trained properly (a joint manufacturer, regulator and operator responsibility)
Communicate.

We all have positives to offer here and that should be a good thing about aviation. Unfortunately, money drives the world; the open & honest environment we require will always be influenced by the bean-counters and lawyers.
As an engineer, I would say that MCAS was not a money issue, it was a management/corruption issue.

In an ideal world, the regulator and the manufacturer, FAA and Boeing would have sat down for a discussion of how to solve the issue MCAS addresses, stated requirements, a proposed solution, and a validation path to ensure the adequacy of the solution. Because MCAS is ABOUT EXTENDING AN EXISTING TYPE CERTIFICATE.

In the corrupt world which has set in, the FAA said nudge nudge wink wink "just make a fig leaf to cover that patch", Boeing designed a fig leaf, flight tested it and found it inadequate, quickly modded it and shipped it. No dialogue and honest verification took place.

Now the FAA, and thus the US government is involved in covering up the process inadequacy "in the name of competing with Airbus".

What a joke. Don't congressmen and women have families who fly on US-made airframes?

Edmund
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Old 27th Apr 2019, 19:29
  #4447 (permalink)  
 
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So as this thread continues towards the five-grand mark, how many of these posts have been a version of "well, if this had happened to me and my F/O, we'd have done this, that and those other things and everyone would have been fine because FLY THE AIRPLANE and BASIC AIRMANSHIP and we're not children of the magenta line, we're hairy-armed master aviators."

But let's get this straight. It never happened to you.

There are three pilots alive to whom this failure (AoA failure arms MCAS, which kicks in as flaps retract) actually happened. Four others are dead along with their passengers, The failure caused two fatal accidents less than two years after service introduction. Compare this to anything in the past 25 years of aviation and tell me that's not unusual, that the AoA/MCAS sequence is something that should be handled with normal training.

Bull!
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Old 27th Apr 2019, 19:43
  #4448 (permalink)  
 
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Originally Posted by LowObservable View Post
Compare this to anything in the past 25 years of aviation and tell me that's not unusual, that the AoA/MCAS sequence is something that should be handled with normal training.

Bull!
What about the 737 rudder problems [hardovers from defective actuators]? IIRC, that problem, besides a mechanical one, had to be "trained" for a technique to avoid going splat.

But the guy you're railing against, the one who keeps on saying, "Fly the airplane," DOES acknowledge the design problem generated by Boeing, in every post, while criticizing the pilots. That IS a balanced view.

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Old 27th Apr 2019, 19:57
  #4449 (permalink)  
 
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I just saw this on The Aviation Herald:

On Apr 27th 2019 it became known, that four independent whistleblowers, current and former Boeing employees, had called the FAA hotline for whistleblowers regarding aviation safety concerns on Apr 5th 2019. The concerns reported were wiring damage to the AoA related wiring as result of foreign object damage as well as concerns with the TRIM CUTOUT switches. The FAA believes these reports may open completely new investigative angles into the causes of the two crashes in Indonesia and Ethiopia.
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Old 27th Apr 2019, 19:59
  #4450 (permalink)  
 
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Originally Posted by 737 Driver View Post
By the numbers then: Stick shaker. WTF?! Check my power (increase as necessary), check my attitude, check my configuration. Is it flying or is it wallowing? If it is wallowing, keep the nose down and accelerate. If its flying, probably a false indication, continue the climb, call for the gear. Cross check instruments. I've got my hands full, so ask my FO to read off what he sees on all three airspeeds. At 400 feet check my roll mode, have FO ask for straight ahead if appropriate and declare emergency. If by now I've determined we have unreliable airspeed, memory items except I'm going to keep takeoff power and 15 degrees pitch until 1000' where I set 10 degrees and 80% N1.
Very convincing, well written, and no-one can argue that following that recipe would have saved the aircraft.

There are two problems with it. The pilot seems to have done rather a lot by 400ft. And leaving flaps down seems a bit too convenient. If you just add a bit of delay in pulling the stick shaker CBs, and you happen to clean up (which would be perfectly good airmanship), then the MCAS genie is out of the bottle and you're in test pilot mode.

Reality is more complex, time is more flexible, cognitive skills are worse than the scripts that we write after the event.

A competent pilot showing good airmanship would most likely have activated mcas pre lion air, and quite possibly post. Once in the mcas trap I'd say it's 50/50 they'd get out of it at low altitude. See my previous post for why. So your constant assertions of 'just fly the plane' don't really cut it.

Again I think everyone agrees with you that there needs to be more emphasis on hand flying skills throughout the whole industry and that 200h is ludicrous for a FO.

Last edited by PerPurumTonantes; 27th Apr 2019 at 23:03.
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Old 27th Apr 2019, 20:09
  #4451 (permalink)  
 
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One thing is certain, the persons who are the main drivers of these accidents had a lot more time to consider the outcome of their actions than the pilots. They have a CPA, MBA and/or JD. They received large salaries and bonuses. They live in the suburbs of Chicago, and will be receiving far less scrutiny than the engineers and pilots. They will cost out the lives lost vs. the cost of doing things properly. Their profession will insulate them from their true share of the culpability. In the end a very few will get a golden handshake and pursue other interests. Let’s take a minute to remember them.

Last edited by dozing4dollars; 27th Apr 2019 at 20:56.
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Old 27th Apr 2019, 20:46
  #4452 (permalink)  
 
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.... and now, because this is a pilots forum, the subject of Airspeed. Although a lot was going on, it seems to me, sitting on my couch, that if A/S was controlled, the misbehaviour of the trim would have been easier to deal with at a lower A/S.

The previous LionAir flights controlled A/S (obviously). When we “hand fly” (flight directors and auto throttle on) it’s analogous to me on my couch. Fly toward the FD. Hell, I even have a Heads Up display. If you want to see the other guys squirm, turn off the AT Much of this so-called “hand flying” isn’t really. I think it would be very human to miss the AS during an event such as this. I think pulling the throttles back once unreliable AS was identified would be key to gaining some time to think. Hand flying with AT on isn’t doing much good and has made me less aware of flying using the throttles.

I also believe the MCAS was not adjusting its trim input for AS. From what I’ve read in the discription of MCAS, it shouldn’t have been using 2.5 degree ANU at higher AS
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Old 27th Apr 2019, 20:51
  #4453 (permalink)  
 
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200 hour FOs? A culture of maximum automation at all times with almost zero handflying experience and confidence?

Sounds more like Europe than Africa.

​​​
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Old 27th Apr 2019, 20:55
  #4454 (permalink)  
 
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Originally Posted by LowObservable View Post
But let's get this straight. It never happened to you.
True, none of us were there when the pins all lined up. Guilty as charged.

Might I also point out that none of us were there when the aircraft designers were designing, the project managers were managing, the regulators were regulating, and the airlines were training. Yet, there seems to be a pretty broad consensus in these parts that their were critical lapses in those parts despite the fact that no one here (at least that I've seen) has claimed to be current in qualified in those specialties. Odd, don't you think?

No, I was not there, and no I have never seen an MCAS failure in the sim or in life. However, over the course of 35+ years in aviation and perhaps a dozen different aircraft, I've dealt with more emergencies in the sim than I can count and more in the air than I ever wished to have had. I've encountered pilots of all different skill levels, and I've observed the traits that separate the good from the bad. Having reviewed perhaps hundreds, if not thousands, of incident reports over the years, I think I have a fairly good sense for what types of malfunctions should have been survivable without resort to extraordinary means, which ones required some combination of luck and superior skill, and which ones were pretty much hopeless from the start. In the case of Lion Air, I'd put that one somewhere between the first and second categories mainly due to the novelty. For Ethiopian, that one falls squarely in the first batch. Sorry you disagree, but I strongly suspect the final accident reports will fall closer to my position than yours.

Last edited by 737 Driver; 27th Apr 2019 at 22:57.
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Old 27th Apr 2019, 21:39
  #4455 (permalink)  
 
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Originally Posted by 737 Driver View Post
Having reviewed perhaps hundreds, if not thousands, of incident reports over the years, I think I have a fairly good sense for what types of malfunctions should have been survivable without resort to extraordinary means, which ones required some combination of luck and superior skill, and which ones were pretty much hopeless from the start. In the case of Lion Air, I'd put that one somewhere between the first and second categories mainly due to the novelty. For Ethiopian, that one falls squarely in the first batch. Sorry you disagree, but I strongly suspect the final accident reports will fall closer to my position than yours.
In the Ethiopian case unfortunately I would have to disagree with you, the chances of an unbiased look at pilot actions and training are low given the response to the prior (Lebanon) accident report which detailed numerous pilot errors, with a possibility of subtle PIC incapacitation to which Ethiopian authorities strongly objected and proposed unsupported by facts alternate theories.

This illustrates yet another factor of national/corporate pride hindering global safety objectives, and yes Boeing/FAA are in same category.
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Old 27th Apr 2019, 22:04
  #4456 (permalink)  
 
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Originally Posted by dozing4dollars View Post
One thing is certain, the persons who are the main drivers of these accidents had a lot more time to consider the outcome of their actions than the pilots. They have a CPA, MBA and/or JD. They received large salaries and bonuses. They live in the suburbs of Chicago, and will be receiving far less scrutiny than the engineers and pilots. They will cost out the lives lost vs. the cost of doing things properly. Their profession will insulate them from their true share of the culpability. In the end a very few will get a golden handshake and pursue other interests. Let’s take a minute to remember them.
And ain't that the truth.
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Old 27th Apr 2019, 22:43
  #4457 (permalink)  
 
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Originally Posted by PerPurumTonantes View Post
There are two problems with it. The pilot seems to have done rather a lot by 400ft.
No more than I do on any other takeoff emergency. I get to practice several of these a year during recurrent training, and it’s a pretty standard drill to focus primarily on these basic parameters until you get some altitude under you.

And leaving flaps down seems a bit too convenient.
It’s more habit than convenience. My general practice on any takeoff emergency is to leave some flaps hanging unless a procedure calls for otherwise until such time that I determine that I will not be returning to the departure field. This slows things down considerably and burns fuel quicker.

If you just add a bit of delay in pulling the stick shaker CBs, and you happen to clean up (which would be perfectly good airmanship), then the MCAS genie is out of the bottle and you're in test pilot mode.
Sure, I’ll play along. Of course, you’ll have to assume I haven’t put on the A/P by now, and since I’ve pulled the stick shaker circuit breaker (not procedure, BTW, but I’d be inclined to do it anyway) and finished the Airspeed Unreliable NNC, there would be no reason not to ask HAL for some assistance. So, there I am hand-flying, bring the flaps up, and BAM!, MCAS kicks in. What MCAS will then attempt to do is run the trim nose down for 9 continuous seconds and spin the trim wheel about 37 times. I’ve asked this before, and I’ll ask this again: Starting from a stabilized, in-trim platform, exactly how long should a qualified 737 type-certified Captain who is hand-flying the aircraft let the trim run in one direction before he/she does something about it?

Therein lies your answer. What you have at this point is runaway stab trim. Our procedures really don’t care what the source of the runaway is. If you have an undesired and unexplained stab trim input, you are expected to intervene.

Reality is more complex, time is more flexible, cognitive skills are worse than the scripts that we write after the event.

Again I think everyone agrees with you that there needs to be more emphasis on hand flying skills throughout the whole industry and that 200h is ludicrous for a FO.
I do not disagree, but there really is a limit to how much befuddlement should be expected of a professional flight crew entrusted with the lives of 150+ souls. If a pilot cannot overcome the initial surprise factor in pretty short order, fall back on basic airmanship skills and execute known procedures, then perhaps they should reconsider their chosen career.



Last edited by 737 Driver; 27th Apr 2019 at 23:45.
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Old 27th Apr 2019, 22:56
  #4458 (permalink)  
 
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Originally Posted by 737 Driver View Post
So, there I am hand-flying, bring the flaps up, and BAM!, MCAS kicks in. What MCAS will then attempt to do is run the trim nose down for 9 continuous seconds and spin the trim wheel about 37 times. I’ve asked this before, and I’ll ask this again: Starting from a stabilized, in-trim platform, exactly how long should a qualified 737 type-certified Captain who is hand-flying the aircraft let the trim run in one direction before he/she does something about it? Therein lies your answer. What you have at this point is runaway stab trim. Our procedures really don’t care what the source of the runaway is. If you have an undesired and unexplained stab trim input, you are expected to intervene.



I do not disagree, but there really is a limit to how much befuddlement should be expected of a professional flight crew entrusted with the lives of 150+ souls. If a pilot cannot overcome the initial surprise factor in pretty short order, fall back on basic airmanship skills and executed known procedures, then perhaps they should reconsider their chosen career.
+100
Oh? Ten charaters minimum? +100,000,000 then
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Old 27th Apr 2019, 23:09
  #4459 (permalink)  
 
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I haven't seen the original reports (would appreciate a pointer to the source if someone has it)
737 Driver ASRS database link.. https://asrs.arc.nasa.gov/overview/database.html
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Old 27th Apr 2019, 23:43
  #4460 (permalink)  
 
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Originally Posted by Smythe View Post
737 Driver ASRS database link.. https://asrs.arc.nasa.gov/overview/database.html
Found them, thanks! The reports were misfiled with the 737NG's for some reason. They appear to be reporting the same anomaly. Report numbers are ACN 1597286 and ACN 159380 for anyone looking for them.
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