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Ethiopian airliner down in Africa

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Ethiopian airliner down in Africa

Old 28th Apr 2019, 16:59
  #4501 (permalink)  
 
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Originally Posted by HundredPercentPlease View Post

Your mic may be stuck.
I will keep repeating the first commandment of aviation - FLY THE AIRCRAFT, first, last, and always - as long as there is a single aviator out there who denies that this was not the crew's primary responsibility and does not make a credible argument that the tools to do so were unavailable to them.

​​​​​​If I asked WHY the crew just did not "fly the aircraft" in the Eastern 401 accident, everyone knows the answer. So WHY did it happen here?
And this is precisely the direction that I believe the conversation should go.

I find several things unacceptable about these accidents (your list may be different):

1. It is unacceptable that Boeing designed MCAS in such a way that it produced such a hazardous failure mode,
2. It is unacceptable that the FAA and various certification authorities delegated so much of the oversight,
3. It is unacceptable that the airlines, in conjunction with Boeing and the certificate authorities, were too focused on minimizing the training rather than maximizing the safe introduction of the MAX, and
4. It is unacceptable that the flight crews, given everything we know about the malfunction, were ultimately unable to FLY THEIR AIRCRAFT into a stabilized state and land safely.

Now, of these four items, which one does the professional pilot corps have the most power to address?

Rightly done, the goal of a post mortem into the crew response is not an exercise in assigning blame. It is an exercise in determining what went wrong and what can be done so that future crews do not meet such an ill-fated end.

Germane inquiries would look at the background and experience of the crews, training policies and standards, hiring standards, and corporate policies and culture. While it may be a delicate subject, the individual backgrounds of the accident pilots should be looked at to see if they had any history indicating problems with airmanship skills or discipline.

We can also hold up a mirror and look at our own experiences. Have we become too complacent? After all, aviation is very, very safe. Most of the time, the manufactures get it right, the regulators get it right, the dispatchers get it right, the weather forecasters get it right, the maintenance folks get it right, Air Traffic Control gets it right, and the trainers get it right. Most of the time. Checking, re-checking and employing a high degree of vigilance is a lot of work. Turning off the magic and hand-flying is work. Insisting on a high standard for yourself and your flying partner is work.

Engaging the automation and letting HAL do all the work is seductive. How many of us know someone who bids the easy wide-body flying because they want to sit back, chill and not really fly? How many of us spend most of our sim prep time trying to learn the script (and the answers) rather than digging into some aspect of our aircraft or operation that we've become a bit rusty on? How many of us spend more effort on planning our layovers than planning our flights? Are we becoming handmaidens to some future accident/incident that should have seen coming?

I've been guilty of all these sins and more at one time or another. Fortunately, some external event will usually come along and remind me of my obligations. The MAX/MCAS debacle has been one of those events.

I don't think anyone of us ever wants to see another accident like Lion Air or Ethiopian. So yes, Boeing needs to build better aircraft, the certificate authorities needs to exercise better oversight, and the airlines need to stop trying to get by with minimum training at a minimum cost. And we need to do everything in our power to become better aviators.

Last edited by 737 Driver; 28th Apr 2019 at 17:10.
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Old 28th Apr 2019, 17:31
  #4502 (permalink)  
 
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I think I agree with nearly all of that.

However... why (do you think) on this occasion, were the ET crew unable to continue stabilised flight? You have stated that it is unacceptable (which is obvious)... but why couldn't they? Nice simple question!

Also, as an aside:

It is unacceptable that the flight crews, given everything we know about the malfunction
You have to consider what they knew.
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Old 28th Apr 2019, 17:32
  #4503 (permalink)  
 
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Salute!

Thanks, 737, a great list

I find several things unacceptable about these accidents (your list may be different):

1. It is unacceptable that Boeing designed MCAS in such a way that it produced such a hazardous failure mode.
2. It is unacceptable that the FAA and various certification authorities delegated so much of the oversight.
3. It is unacceptable that the airlines, in conjunction with Boeing and the certificate authorities, were too focused on minimizing the training rather than maximizing the safe introduction of the MAX.
4. It is unacceptable that the flight crews, given everything we know about the malfunction, were ultimately unable to FLY THEIR AIRCRAFT into a stabilized state and land safely.
And then
of these four items, which one does the professional pilot corps have the most power to address?
As Richard Bach posted long ago in "Flying" or maybe the EAA magazine, all crashes are "loss of control".
- pilot/crew is negligent - CFIT, poor pre-flight and elevator locks are not removed, etc
- pilot/crew is completely unprepared for even the smallest problem - incompetent
- pilot/crew performs incorrect procedure for an emergency, e.g.shuts down the wrong engine ( one good thing for we single-seat, single engine types)
- mechanical/computer failures that cannot be overcome by pilot/crew, e.g. Wonk's problem 20 years ago,
- catastrophic failure of major parts of the plane, e.g. TWA800, terrorist bomb, SAM over Crimea

737 is correct: This is the best forum to deal with the rhetorical question - PPRuNe aircrew. And although I am inactive, I had a super career as a "professional pilot" and faced/overcame more than a few hairy episodes. Only came close to the nylon letdown two or three times. I didn't fly passengers or have a crewmember except for VIP joy rides in the family model and a few hundred hours in an interceptor early on.

So imagine, if you will........How many successful resolutions to problems or prevention of same have resulted from a pilot peeking at these forums between flights? Huh?

Gums sends...
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Old 28th Apr 2019, 18:06
  #4504 (permalink)  
 
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Originally Posted by 737 Driver View Post
...
That being said, except for your initial takeoff setting, you don't operate the trim by reference to the index. You operate by feel. If you are holding in any sustained control pressures around any axis (pitch, roll, yaw), you would normally trim away those pressures until the controls were neutral. I say "normally" because there are some flying techniques that involve leaving in some control pressures in certain situations, but that is beyond the scope of this discussion. So in reality, you could tape over the index, and as long as you trimmed out the control pressures, then maintaining aircraft control should pose no problem. Again, this is assuming that you do not have an aircraft that is loaded outside its C.G. envelope.
...
.
Thanks for confirming my impression that the crew would not be referencing the absolute trim numbers.
One puzzling feature of the ET (and to some extent LionAir) traces is the failure to fully trim after MCAS inputs.

I wonder if part of this could be due to a 'muscle memory" illusion that after having to pull with a lot of force to counteract the ND trim the relaxed force after the partial re-trim felt less out of trim than actual situation.

The report does not have a collum force trace, just position. Can anyone hazard a guess as to what force might have been required.






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Old 28th Apr 2019, 18:13
  #4505 (permalink)  
 
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I find the following text very interesting, a safety report written in Nov 18 by a captain who cleary was on his game and wary of a potential MCAS trap:

It was day three of six for me and day three with very good FO (First Officer). Well rested, great rapport and above average Crew coordination. Knew we had a MAX. It was my leg, normal Ops Brief, plus I briefed our concerns with the MAX issues, bulletin, MCAS, stab trim cutout response etc. I mentioned I would engage autopilot sooner than usual (I generally hand fly to at least above 10,000 ft.) to remove the possible MCAS threat.
So, he had the post-Lion Air FCOM and had clearly thought about it. His solution was to minimise exposure to MCAS territory in order to reduce risk. Great airmanship but not exactly the answer to the problem.
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Old 28th Apr 2019, 18:29
  #4506 (permalink)  
 
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Originally Posted by HundredPercentPlease View Post
However... why (do you think) on this occasion, were the ET crew unable to continue stabilised flight? You have stated that it is unacceptable (which is obvious)... but why couldn't they? Nice simple question!

Also, as an aside:

You have to consider what they knew.
As long as we agree this is speculation, based on the limited evidence presented in the accident report, I'll be happy too.

First, let's look at the First Officer. He had 361 hours total, and 207 hour in the 737 of all types. Most notable, those 207 hours had all occurred in the previous 90 days. He had 56 hours in the MAX. I do not know how much switching around between the MAX and the NG he did, so it is not possible to say from the data provided how much recent currency he had in the MAX. Taken as a whole, you have a pilot who was given about 150 hours of total time before he was put into commercial airliner, and he had been on the job for about three months prior to the accident. This simply boggles my mind that this is even possible. The First Officer could have been the best stick alive, but there simply is no substitute for experience, both in time and years, particular as it relates to aircraft emergencies. As a result, the Captain was handicapped from the start. When things start going south, and the pilot flying has his hands full of airplane, having an experience and trusty partner who can feed you information, prompt you on actions, and help you maintain situational awareness is worth its weight in gold. This wasn't exactly a single-pilot operation, but it was pretty close.

Looking at the Captain's background (and I'll say right here some of this is second hand), it appears he went from the Ethiopian Training Academy into the right seat of the wide-body pretty quickly. His 737 time as an FO is not split out, but doing some triangulating it appears that much of his 8122 hours was gained as a wide-body First Officer. As you probably know, lots of wide-body time does not necessarily translate into lots of flying in critical phases, and even less with the automation turned off. Looking to the Captain's immediate attempts to engage the automation when it was inappropriate to do so combined with some poor aircraft handling skills points to a case of significant automation dependency. Forced to hand-fly an aircraft when he was uncomfortable with doing so and facing a significant distraction in the form of the stick shaker, he appears to have fallen back on default behaviors like trying to fly a "normal" takeoff profile (A/P @ 400', climb to 1000', retract the flaps) when it was not appropriate (particularly retracting the flaps given what was known about MCAS). The aircraft was never really stabilized when MCAS kicked in, and by that time it appears the Captain had achieved cognitive overload making the remainder of his attempts to control the situation ineffectual. I think the FO did the best that he could, but I really don't know how assertive a three-month 360 hour First Officer could be in this situation.

To go deeper into the question of WHY this crew was so unprepared would require additional specifics regarding the training environment, airline policies and procedures (particularly in regards to the use of automation), and crew management issues that I do not currently possess. Maybe some others can chime in here.

Again, this is just speculation. I'm sure the accident investigators will be looking into all of these issues and will hopefully shed some light in subsequent installments on their findings.
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Old 28th Apr 2019, 18:29
  #4507 (permalink)  
 
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Originally Posted by 737 Driver View Post
You can be forgiven your unfamiliarity with the 737 cockpit layout, so let me help here. There is a direct reading of the stab position right next to the trim wheel:




This is the view from the First Officer side, but there is an identical trim wheel and index on the Captain's side. You can also see the stab trim cutout switches just aft of the trim index.

.


737 driver, looking at the TO greenband, on the 738, (and all other NG that I can remember)it is 1.5 to 6.5, while on the MAX it is 3 to 8...this is a significant difference. Thoughts?
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Old 28th Apr 2019, 18:32
  #4508 (permalink)  
 
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Originally Posted by Water pilot View Post
There is evidence from the voice recorder (of the second accident) that the co-pilot was unable to move the stabilizer.
...still not clear that was the case as meleagertoo alluded to earlier, but even if so this is with the other pilot hauling back on the yoke with airspeed well above Vmo. Not exactly within the realm of normal certified operation.

Anyone else here have an instructor that would demand you "let go of the controls" when it was obvious you were using the elevator instead of trimming out to maintain a flightpath?
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Old 28th Apr 2019, 18:42
  #4509 (permalink)  
 
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Originally Posted by 737 Driver View Post
I will keep repeating the first commandment of aviation - FLY THE AIRCRAFT, first, last, and always - as long as there is a single aviator out there who denies that this was not the crew's primary responsibility and does not make a credible argument that the tools to do so were unavailable to them.

And this is precisely the direction that I believe the conversation should go.
I think in the attempt to be artful the other night one of the main reasons I wrote what I wrote wasn't communicated clearly enough. (I am referring to my post about bailing out of the Goshawk in 1996...) It occurs to me now that in that failure lies a lot of the disconnect between me and 737 Driver on this one issue, and many others as well.

What I was trying to convey that night was the complete and total disconnect that happens when a very real, very lethal emergency is presented to someone who just seconds before was sitting comfortably doing the same thing they had done hundreds or thousands of times before with predictable outcomes every time. So for those who fall back on the tried and true mantra of FTFA (I'm from New York, you can't say anything without at least one eff being in there...) to fault the crews I hope you can begin to understand that in order to FTFA you have to have a functioning intellect able to process complex and copious inputs and in the short time that each crew had they almost certainly never got past the startle-factor and confusion (I hate to use this word, but let's say paralysis) that the events inflicted on them.

For those of you who think you are super-human and will never flinch when the bullet heads your way I am here to tell you that you will, and the only thing that will determine whether or not you survive is partly luck and partly how quickly you are able to return to a quasi-functional state- if in fact you are able to do so before the clock runs out on your life experiences. 40 seconds (as reported by media) is a stupidly short period of time to be startled, shocked, scared, and thence to recover and take decisive action. I would argue it is a nearly impossible window to react effectively.

Perhaps the most frustrating thing for professional pilots (because it implies that you are not in fact in control of your entire domain...) is that you cannot train this away, you cannot tell which pilots will be totally paralyzed and incapacitated vs. those who will shrug and go on piloting vs. those who will recover quickly and get about their business. I smile when I read the pilots who write here in obscene terms about how the crews should have done this and that (specifically not referring to 737D here) because I know full well, and from experience, that they are as likely as anyone to be incapacitated if one day things really do go far south.

If your hands are shaking so hard you can barely hold on to something like a yoke from all the adrenaline pumping through your system FTFA becomes not a mantra but an unattainable goal. THAT'S WHY THEY CRASHED. THEY RAN OUT OF TIME BEFORE THEIR BRAINS COULD NORMALIZE TO THE POINT THAT THEY COULD FTFA.

One more quickie- to 737 Driver's point about no control failures- I would argue that a horizontal stab that cannot be moved due to overpowering control forces (while still in the envelope BTW) is a totally incapacitating failure and will be a significant part of the finding on why ET crashed. In other words: It was far from a perfectly flyable airplane. The crew did what they were supposed to do- they stopped MCAS from trimming down any longer. But they could not rewind the trim to an operable setting.

Warm regards,
dce

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Old 28th Apr 2019, 18:47
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Originally Posted by 737 Driver View Post
Forced to hand-fly an aircraft when he was uncomfortable with doing so and facing a significant distraction in the form of the stick shaker, he appears to have fallen back on default behaviors like trying to fly a "normal" takeoff profile (A/P @ 400', climb to 1000', retract the flaps) when it was not appropriate (particularly retracting the flaps given what was known about MCAS). The aircraft was never really stabilized when MCAS kicked in, and by that time it appears the Captain had achieved cognitive overload making the remainder of his attempts to control the situation ineffectual. I think the FO did the best that he could, but I really don't know how assertive a three-month 360 hour First Officer could be in this situation.
.
The report does state that the FO called trim runaway so he was not totally inert.
There is a saying in medicine that rare conditions are most likely to be diagnosed by bright interns or very experienced doctors. The intern does not have the experience to reject improble diagnoses while the very experienced are more likely to pick up on the "something does not fit" observations. From your description one would have to say the Captain was in the moderately (at best) experienced category.

The other possible trap is that the since Captain was able to engage the autopilot before he selected flaps up he may have thought things were better than they were, false stick shaker only moderate airspeed disagree.
Does anyone know the likely reading of the backup (uncorrected for AoA) air speed indicator in these conditions?
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Old 28th Apr 2019, 18:59
  #4511 (permalink)  
 
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Thank you for having a stab at answering.

Originally Posted by 737 Driver View Post
retract the flaps) when it was not appropriate (particularly retracting the flaps given what was known about MCAS).
How did he know he was going to have an MCAS event? He was dealing with a stall warner that shouldn't have been warning.

I would advocate asking "why" to every conclusion. And writing "because..."

There are two lines of thinking here: it was a poor aircraft and they were poor pilots. Let me explore both, using the "why" system:
1. The aircraft had hidden killer behaviour because it was a financial requirement to have a common TR because the regulator allowed this because the regulator is weak.
2. The crew performed poorly because they were inadequately trained because it was a common TR which was allowed because the regulator is weak.

If we boil this down, it doesn't really matter whether you subscribe to pilot error or Boeing error or both. Ultimately this has arisen through inadequate regulation. The regulator should have stepped in with the whole instability issue, the MCAS fix, the lack of documentation and the lack of training.

This month it's the FAA, but it so easily could have been any other national authority. The industry is in a mess due to inadequate regulation - and it's Boeing, the airlines, the pilots and the passengers are suffering.

I would avoid making assumptions about the skills of the crews. In Europe it's easy to do too - we hear incompetent sounding fat cigar chewing fools who don't know that you can have a flight level of 90, but we try to remember that judging ability by nationality or assumed education is very, very wrong.

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Old 28th Apr 2019, 19:09
  #4512 (permalink)  
 
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Thumbs up

Originally Posted by HundredPercentPlease View Post
There are two lines of thinking here: it was a poor aircraft and they were poor pilots. Let me explore both, using the "why" system:
1. The aircraft had hidden killer behaviour because it was a financial requirement to have a common TR because the regulator allowed this because the regulator is weak.
2. The crew performed poorly because they were inadequately trained because it was a common TR which was allowed because the regulator is weak.

If we boil this down, it doesn't really matter whether you subscribe to pilot error or Boeing error or both.
Both. Congrats. You have won the Internet for today.
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Old 28th Apr 2019, 19:18
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Originally Posted by Organfreak View Post
Both. Congrats. You have won the Internet for today.
Lol!

I would suggest then that every party bar one wants better regulators:

Manufacturers, so the pilots are well trained and don't destroy their aircraft.
Pilots, so the manufacturers make safe aircraft.
Passengers, for both the above reasons.

The only party who wants poor regulators is the airlines - and that's for greed reasons.
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Old 28th Apr 2019, 19:28
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Originally Posted by HundredPercentPlease View Post

The only party who wants poor regulators is the airlines - and that's for greed reasons.
Quite. Welcome to 2019. So I would submit that, given the environment in which we find ourselves, it's no wonder that 737 Driver insists that we know how to fly the damn plane. Seems pragmatic and very healthy. This debate doesn't need to be so polarized.
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Old 28th Apr 2019, 19:46
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Originally Posted by 737 Driver
retract the flaps) when it was not appropriate (particularly retracting the flaps given what was known about MCAS).
How did he know he was going to have an MCAS event? He was dealing with a stall warner that shouldn't have been warning.
Auto pilot was also a 'known' protection against MCAS as mentioned in one of the safety reports a page back or so.
Had the auto pilot stayed engaged another couple of minutes we might not be having this discussion.

Btw: I am not faulting the auto pilot (probably the only thing that is mostly innocent) or agree with decision to engage it given stick shaker etc.
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Old 28th Apr 2019, 19:49
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Originally Posted by Organfreak View Post
Quite. Welcome to 2019. So I would submit that, given the environment in which we find ourselves, it's no wonder that 737 Driver insists that we know how to fly the damn plane. Seems pragmatic and very healthy. This debate doesn't need to be so polarized.
I only disagree with 737 Driver over his assertion that flying the aircraft in those circumstance was always achievable. I maintain that for many crews it would have been unachievable, owing to the combined human factor issues that saturate the environment, inhibiting the execution of normal flying skills. In my experience of major failures in real life, getting over the hill is harder than you think. Much harder. And very low hour FOs are very, very useful. Controversial, I know (especially to US pilots), but that's what I discovered for real.
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Old 28th Apr 2019, 20:50
  #4517 (permalink)  
 
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meleagertoo

Originally Posted by meleagertoo View Post
No, of course I don't.

Who ramped this up to "LEGAL", this isn't a court of law. Or are you changing the rules midstream?

No kangaroo court - back to hysterical overstatement again! The evidence for pilot's actions? The preliminary reports and the data traces are all we have to go on but they're enough to tell a great deal. Or do you hold them discredited due to some hitherto unsuggested collusion or corruption?

I'm surprised you even need to ask that question...
I wasn't changing the rules just seeking to separate which things I should give more weight. I added "LEGAL" to mean officially sanctioned findings that have considered all available evidence rather than subjective personal, opinions which, however qualified the authors may be as pilots or whatever are merely that - subjective. The preliminary reports and data are just that, preliminary. My (your view) "hysterical overstatement " comment about a kangaroo court was simply trying to draw the distinction between judgments made with full evidence and those which are personal opinions.

My original question to you was trying to point out the contradiction between your "Despite the amount of unequivocal evidence of misdeeds by the pilots" and your wish for evidence to be present evidence and discuss it rationally. My reading of the posts on this thread by qualified pilot does lead me to conclude that everyone is of that opinion and I merely suggesting that before making such a statement you should provide evidence of such.

Finally, as for your "hysterical overstatement" remark, you might like to go back and re-read your post where phrase such statements abound "hysteria ramps up and wild totally unsubstantiated accusations of bodgery etc etc", "shrill and baseless . nothing short of scurrilous etc etc". You might also like to check out other posts on this thread (eg FAA getting comments on their whistleblower phoneline) which suggest that these unsubstantiated accusations are less than unsubstantiated.

Sorry that I had to take up your time explaining this again.
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Old 28th Apr 2019, 21:24
  #4518 (permalink)  
 
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wonkazoo, I have sent you a PM
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Old 28th Apr 2019, 21:26
  #4519 (permalink)  
 
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Originally Posted by MurphyWasRight View Post
Auto pilot was also a 'known' protection against MCAS as mentioned in one of the safety reports a page back or so.
Had the auto pilot stayed engaged another couple of minutes we might not be having this discussion.
Just to clarify something which was discussed previously: Enabling the autopilot would certainly inhibit MCAS. However this is only true if there were no other factors in play. In the accident scenarios the problems cascaded, and AOA disagree triggered unreliable airspeed, which limited the possibility that the autopilot could be used to inhibit MCAS.

Analysing all of this in a short period of time, would have required exceptional knowledge, and in the absence of an AOA value or AOA disagree display, an understanding of the links between the sensors and the flight systems may have been beyond the scope of the crew.
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Old 28th Apr 2019, 21:43
  #4520 (permalink)  
 
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Originally Posted by GordonR_Cape View Post
Just to clarify something which was discussed previously: Enabling the autopilot would certainly inhibit MCAS. However this is only true if there were no other factors in play. In the accident scenarios the problems cascaded, and AOA disagree triggered unreliable airspeed, which limited the possibility that the autopilot could be used to inhibit MCAS.

Analysing all of this in a short period of time, would have required exceptional knowledge, and in the absence of an AOA value or AOA disagree display, an understanding of the links between the sensors and the flight systems may have been beyond the scope of the crew.
My earlier point was that the autopilot was engaged for about 35 seconds, this could have tricked the pilot into thinking things were (more or less) ok spurious warnings only, this led to flap retraction.This is supported by the almost normal seeming events in cockpit at this time, selecting altitude etc

Flap retraction led to 2 things in short order:
1: Autopilot dropped off.
2:Mcas added it's first ND input.

So the pilot was dealing with 2 things at once.
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