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Ethiopian airliner down in Africa

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Ethiopian airliner down in Africa

Old 30th Apr 2019, 08:48
  #4621 (permalink)  
 
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Fortissimo, that is a mind-warping read. It reminds me of a scene from Yes Minister!
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Old 30th Apr 2019, 08:54
  #4622 (permalink)  
 
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Originally Posted by Cows getting bigger View Post
Fortissimo, that is a mind-warping read. It reminds me of a scene from Yes Minister!
Boeing know full well the future of the company is on the line here, and one mis-spoken phrase could be the nail in the coffin. This is a can of worms with more to come, that's why B is scared.

Last edited by groundbum; 30th Apr 2019 at 09:21.
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Old 30th Apr 2019, 09:22
  #4623 (permalink)  
 
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Originally Posted by Fortissimo View Post
Interesting and very carefully chosen words in Boeing's statement...



It goes on to state that if you did not opt for the AOA display, your disagree alert was "not operable". However, there will be an optional service bulletin to tell you how to make it operable on aircraft already delivered. So that's OK then.
How does that square with the previously-stated position that the AOA disagree was an extra cost option?
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Old 30th Apr 2019, 09:56
  #4624 (permalink)  
 
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Originally Posted by 737mgm View Post
Almost 5000 posts later it is clear it doesn't matter what professional 737 pilots will say about this issue. You guys have made up your mind and no facts will get in the way of that opinion. Nonetheless I will give it another try even though what I am about to write has probably already been mentioned several times:

The MCAS system obviously should have been designed better but the press makes it seem as if Boeing knew the system created great risks but they went ahead with it anyway in order to make more profit. That thought in itself is so absurd that arguing with anyone who believes it, is basically pointless. If Boeing had thought these accidents were likely to occur they would have designed the system differently.

What does this MCAS monster as you call it actually do? It lowers the nose of the aircraft by changing the position of the horizontal stabilizer. It doesn't make the wings fall off, it doesn't set the plane on fire... it only moves the horizontal stabilizer. There is a switch on the pilots control column which moves the horizontal stabilizer and it overrides MCAS each time. I know you guys do not want to face it, but it really is that simple. Now if someone is reading this, thinking if it was that simple why didn't the pilots just do it? First of all they did. The Lion Air Captain did it at least twenty times. And the Ethiopian Captain did trim out the MCAS induced movement completely the second time it activated. So we could already talk a lot about why they didn't do it the whole time, then lower the flaps for landing (MCAS deactivates) and land. Aside from the fact that they did use the trim switch a little bit at least. please have a look at Asiana flight 214, Emirates 521, or Turkish 1951. These are only a few examples of flights were pilots failed to do the most basic thing: flying the aircraft. There were other causes as well and in the case of Turkish and Asiana the flights were not stabilized at 1000 Feet which means they should have carried out a go around preventing both accidents even before the mistake of not flying the aircraft (speed control) was made.


What these accidents show you is that pilots will crash aircraft even though it would have been very easy not to. In the case of Asiana and Emirates there were not even any system failures. Why these things happen is a completely different issue and the answers are to be found in the human factors involved when people fly aircraft. The Fact is, planes crash because pilots do not carry out the basic steps involved in flying an aircraft.

Now one important point I would like to make to all the posters with their Skygod and hindsight comments: First of all, it isn't about blaming the pilots. It is about stating facts. If I or others state that the crew did not carry out the unreliable airspeed memory items when in fact Boeing requires a crew to so in the situation they were in, then that is stating a fact and has nothing to do with hindsight or blame. Stick shaker only on one side, several caution lights going on, differing airspeed indications create a very confusing situation. For exactly that reason there are memory items in order to deal with that situation and they must be carried out. This procedure is a life saver because in that situation it is nearly impossible to figure out which system is malfunctioning and what is actually going on. For that reason: AP off, AT off, FD both off, flaps extended 10° pitch 80% N1. This will set the airplane on a safe flight path and you will continue to climb away from the ground. Now you have time to figure out the problem. This is what we are trained for. This is our job. Carrying out these procedures in that situation has nothing to do with being a skygod and pointing out that the crew did not do it doesn't make us armchair pilots with hindsight. If there is an engine fire on take off I carry out my memory items, if there is a rapid depressurization I carry out my memory items. Again this is what we are trained for.

If the crew had done this on any of these flights we wouldn't even be talking about MCAS. I am not blaming the crew when I say they did no do this. The crew is always just a product of the training department and the general procedures of the airline they fly for. For example, in the case of the Emirates crash, the crew wanted to fly a go around. They only pushed the take off/go around button but did not actually move the thrust lever forward in order to increase thrust on the engines. These pilots were not idiots. I can completely understand how this could happen. Normally as long as the automatic thrust control is engaged, pushing the TOGA button will increase thrust. However, shortly after touch down the automatic thrust control is automatically disengaged. Emirates is an airline with procedures that will not allow pilots to fly manually with the flight directors off for example. I can understand how a crew that is trained to rely on automation will not think to actually move the thrust levers and will not check if the thrust is increasing, despite procedures to do so. Basic skills are lost if one does not use them regularly.

The 737 MAX is grounded and will continue to be grounded for a long time because people think the airplane is unsafe. Furthermore the press reported the Ethiopian pilots carried out all the required procedures and yet they crashed. Why are people like me writing on this forum? It simply isn't true that the 737 MAX is inherently unsafe even with the "old" MCAS and it isn't true that the crew carried out the required procedures. That is not my opinion. That is a fact (again why they did not do it is another issue). If the established procedures had been carried out the planes would not have crashed. There was not one procedure done wrong but several done wrong. Each one of these procedures would have saved the aircraft. Carrying out the unreliable airspeed memory items is one procedure. If the pilots do not do this they are already entering an area where they are not flying the airplane according to procedure anymore but even in that case, carrying out the stab trim runaway memory items correctly once MCAS engaged (please stop these ridiculous comments that the MCAS activation cannot be recognized as a stab trim runaway) would also have saved the plane. If the pilots decide for whatever reason to not even do that, they still have the option of just trimming out the control forces each time MCAS activates (basic flying skills). Again when I am stating what they should have done according to procedure I am not blaming the pilots but only stating the facts of what Boeing says pilots must do in these situations and what we are trained for in our manuals and in the simulator. These recommended procedures would have saved the plane and please realize that there was a flight that had exactly the same problems and they did land safely (and they did not carry out unreliable airspeed mem items and also did not accurately carry out the stab trim mem items and still they saved the plane proving there are several options and it is not a react quickly or die situation).

Final comment: In my opinion crews that are not trained well and are lacking basic skills of flying the aircraft due to company policies are a far greater threat to aviation safety than any system design. I believe we still have a long way to go until we will design systems that never fail (if ever). So it will continue to be up to the pilots to save the day when systems malfunction. There needs to be a focus on enabling pilots to do so a lot more than focusing on how MCAS can be improved.

After what 5000 posts - can you answer why :- At 05:42:54 - Both pilots call out "left alpha vane"

This is 4 minutes and 12 seconds after WOW (take off) and they did not have the AoA disagree option I believe - pretty strange for a reasonable time Captain and low total time cadet to have a "snap" on exact words at that stage of flight.
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Old 30th Apr 2019, 11:18
  #4625 (permalink)  
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'Damaged wiring' ( quote from somewhere) and a CB popping out?

If the CB was labelled 'Left Alpha Vane', that would clinch it, I'd guess.
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Old 30th Apr 2019, 11:18
  #4626 (permalink)  
 
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Originally Posted by Bend alot View Post
After what 5000 posts - can you answer why :- At 05:42:54 - Both pilots call out "left alpha vane"

This is 4 minutes and 12 seconds after WOW (take off) and they did not have the AoA disagree option I believe - pretty strange for a reasonable time Captain and low total time cadet to have a "snap" on exact words at that stage of flight.
The Alpha Vane warning light is part of the anti-ice system. It illuminates if the AOA heat malfunctions. It has no bearing on an actual AOA signal failure, only a failure of the vane heating system.
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Old 30th Apr 2019, 11:40
  #4627 (permalink)  
 
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Why don't they just admit it and get on with fixing their problems?!

That is a very good question indeed.
With respect, it's not. Its a very naiive question.

First of all they very clearly are 'getting on with fixing their problems'. What on earth would make anyone dream otherewise?

But more to the point, everything Boeing says and everything they do is governed by lawyers. Every word they utter in public is scrutinised by lawyers before it is spoken or printed. Every action or modification or design approval is swarmend over by lawyers because of the insane levels of liability involved.

A moment's thought would tell you that Boeing cannot admit fault even if it wanted to, because that would render them exposed to unlimited liability. They know they are in for reparations of epic proportions but they must try to limit them out of simple fiancial survival.

In the past Boeing have, I'm told, not changed ambiguous or unclear wording in manuals because doing so would be a legal admission of fault in the original wording, and render them liable post-correction had anyone ever been damaged by the original! That is the sort of legal idiocy Boeing are up against, and I daresay they'd love to be more open - as any decent person would - were they able to. The point is they simply cannot be as open as some would wish, and though their reticence may not be entirely down to this aspect I have no doubt that a great part of it is which leads to statements that appear mealy-mouthed. You have the shysters - and a grossly overdeveloped liability-obsessed legal system - to thank for that.

Last edited by meleagertoo; 30th Apr 2019 at 12:03.
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Old 30th Apr 2019, 12:08
  #4628 (permalink)  
 
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Originally Posted by Escape Velocity View Post
The Alpha Vane warning light is part of the anti-ice system. It illuminates if the AOA heat malfunctions. It has no bearing on an actual AOA signal failure, only a failure of the vane heating system.
This sort of thing could be significant. If the Alpha vane had been knocked off in a birdstrike I wonder how long it takes to trigger an overheat if there is no vane left to dissipate it? You can bet someone has found out, and if that figure is close to 4min 12 sec it's an indication that might point to the alpha vane physical loss theorey.
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Old 30th Apr 2019, 12:27
  #4629 (permalink)  
 
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Why don't they just admit it and get on with fixing their problems?!

Why don't they just admit it and get on with fixing their problems.
Perhaps Boeing does not know which particular aspect fix. The proposals so far limit the effects of an errant AoA value on trim (MCAS issue), but without specifically identifying the source of error: - ‘well whatever it is, the output is limited’.
But the other systems which use AoA appear not to be protected.
How can you prove (certification) that a system is now reliable if the orrigionating source of the problem is unknow, unreplicatable.
Boeing 737 Max Software Fixes Due to Lion Air Crash Delayed


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Old 30th Apr 2019, 12:53
  #4630 (permalink)  
 
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Originally Posted by meleagertoo View Post
This sort of thing could be significant. If the Alpha vane had been knocked off in a birdstrike I wonder how long it takes to trigger an overheat if there is no vane left to dissipate it? You can bet someone has found out, and if that figure is close to 4min 12 sec it's an indication that might point to the alpha vane physical loss theorey.
This was discussed at length somewhere around post 4000 (3000?), a lot of details can be lost in a massive thread, a brief recollection:
The DFR shows initial AoA fault occurs at 5:38:45 followed shortly after by "Primary AOA Heat L" going to off.
Quotes are from the prelim report:

At 05:38:46 and about 200 ft radio altitude, the Master Caution parameter changed state. The First Officer called out Master Caution Anti-Ice on CVR. Four seconds later, the recorded Left AOA Heat parameter changed state.
The heater is in the vane so when the vane departs the circuit would open, this would cause the above.

At 05:42:51, the First-Officer mentioned Master Caution Anti-Ice. The Master Caution is recorded on DFDR.
At 05:42:54, both pilots called out “left alpha vane”.
I don't know the system but assume there was a display of Anti ice caution cause.
This was the second master caution, I will leave it to those with more knowledge whether this was a simple repeat of the first (unacknowledged?) or was re-triggered by other events. Totally reasonable for the crew to not prioritize an anti ice caution at takeoff given the conditions, this would only matter at high altitudes.

The other evidence that strongly supports vane departure theory is the last part of the DFR plot where the left AoA sensor can be seen closely following G forces, caused by the internal (vane) counterweight acting as a pendulum.

Last edited by MurphyWasRight; 30th Apr 2019 at 13:07. Reason: Note on anti ice at takeoff.
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Old 30th Apr 2019, 13:26
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Originally Posted by meleagertoo View Post

With respect, it's not. Its a very naiive question.

First of all they very clearly are 'getting on with fixing their problems'. What on earth would make anyone dream otherewise?
Okay, perhaps my comment was a bit too subtle, because it really wasn't directed at Boeing.

Previously, I listed five broad causal links involving different groups:

1. Boeing
2. FAA and other certificate authorities
3. Maintenance/logistical chain (both the airline and possible third-party repair facility involved with Lion Air faulty AOA vane)
4. Airlines
5. Flight crew members

Let me restate my question differently, perhaps a bit more diplomatically.

Why don't each of these groups simply admit they had a role in these accidents and focus on addressing those issues?

I think that we all know that for legal reasons, anyone in the first four groups is going to be very reticent to say anything publicly that will increase their liability exposure. And to be fair, each of these groups is very likely working in the background to correct their lapses. One concern, of course, is that some of these players may not go far enough because they are concerned that comprehensive remedial action will be tantamount to an admission of guilt (i.e. the initial Boeing response to the Lion Air crash).

What about that fifth group? I'm not talking about the crew members who perished. I'm talking about the rest of the professional pilot corps who has just been handed a great, big warning sign that things may not be well in our collective house. I don't think anyone is going to try to sue anyone here, so we really don't have the same excuse as the others.

Yes, it get the the natural human tendency to defend one of our own. We really don't like contemplating that one of our brethren may have had anything to do with the deaths of hundreds of people. "There but for the grace of God," and so forth. All perfectly understandable sentiments, and all significant obstacles to making any changes to the way we do business.

You can't fix a problem until you recognize a problem exists. I humbly suggest that we collectively recognize the crew competency issues within our own ranks and devote our brain cells to addressing that problem rather than lobbing largely ineffectual grenades over the fence.

Last edited by 737 Driver; 30th Apr 2019 at 13:51.
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Old 30th Apr 2019, 13:38
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.
Shortly after takeoff, the data suggest that the Left AOA vane was damaged by some foreign object, likely a bird strike. This then likely caused a short in the heating element. This would have annunciated the Master Caution/Anti-Ice lights on the forward glareshield.
.
.



.
The Anti-Ice annunciation would have directed the pilots to the relevant area of the overhead panel which would have shown a "L Alpha Vane" light illuminated on the Probe Heat control panel.



So when both pilots say "Left Alpha Vane", what is going on is the very standard procedure of verbally announcing the particular annunciator that generated the Master Caution light in the first place. Not really a great mystery.
.
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Old 30th Apr 2019, 14:55
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Originally Posted by bill fly View Post
Unfotunately most people these days want a quick easy solution to life’s complex problems.
You can see it in politics and in daily life. It leads to repetitive emphasising of dogma and it led to Trump.
You can see it in these discussions.
The tragedy is that some of the items of dogma could be valid, if discussed reasonably but can’t be heard in the torrent.
Ethiopian airliner down in Africa

bill,
I agree with the above as a wider ranging overview. This is also reflected in reduced levels of experience and views of ‘Expertise’ *.
A wider concern is where these aspects apply to manufacturing design teams and regulators. These people, like pilots, are Children of The New Age’, many not even born before the 737 first flew.
With respect to older designs, is there sufficient expertise, experience in the skills for revising designs and checking levels of safety to justify retention of ‘grandfather rights’ aircraft.

* https://www.foreignaffairs.com/artic...aith-expertise


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Old 30th Apr 2019, 15:01
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Originally Posted by alf5071h
These people, like pilots, are Children of The New Age’, many not even born before the 737 first flew.

The 737 first flew 9 days after I was born so, at 52 years old, I'm rather pleased I fall on the right side of the line. However, my wife would probably agree with your 'children' sentiment.
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Old 30th Apr 2019, 15:06
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737 Driver, #4683
You can't fix a problem until you recognize a problem exists. I humbly suggest that we collectively recognize the crew competency issues within our own ranks and devote our brain cells to addressing that problem rather than lobbing largely ineffectual grenades over the fence.’

You can be as humble as you like, but if the problem is within human thought, that there is a limit to human performance, then the competency issue resides with our (your) thoughts - Ethiopian airliner down in Africa

Hopefully you accept that there is a limit; then how is this defined, by whom. Can you enlighten us, where is the evidence of crew competency problems, particularly relating to these accidents.
Or do you use outcome - an accident, to judge competency after the fact.

How might we judge the competency of designers, regulators. With hindsight all appear deficient, but in reality everyone working as best they could, in the conditions they faced; how might they describe their conditions of work and change them.

What the industry requires is the wisdom to foresee how crews will react in extreme, rare, surprising, and life threading situations; without such vision, then crews require help in avoiding these extremes, avoid the situation, change the overall operating environment - change the aircraft system.

Heed the words of James Reason; “it’s very difficult to change the human condition, but you can change the conditions of work”.
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Old 30th Apr 2019, 15:17
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Originally Posted by alf5071h View Post
.
Can you enlighten us, where is the evidence of crew competency problems, particularly relating to these accidents.
I am just going to accept at face value that you haven't read my previous posts. Both I and other participants have commented on this extensively, perhaps too extensively for some people's tastes. Perhaps you should take a moment and review those posts?
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Old 30th Apr 2019, 15:37
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Originally Posted by Fortissimo View Post
Interesting and very carefully chosen words in Boeing's statement https://boeing.mediaroom.com/news-re...ts?item=130426, issued in response to media reports yesterday.



It goes on to state that if you did not opt for the AOA display, your disagree alert was "not operable". However, there will be an optional service bulletin to tell you how to make it operable on aircraft already delivered. So that's OK then.
Isn't it amazing how Boeing's engineering is never wrong, it is just that the customers do not understand it. I should look up and see if some of my old management colleagues work there, this BS is so familiar (although we did it better.)
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Old 30th Apr 2019, 16:13
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Originally Posted by Water pilot View Post
Isn't it amazing how Boeing's engineering is never wrong, it is just that the customers do not understand it. I should look up and see if some of my old management colleagues work there, this BS is so familiar (although we did it better.)
How did you arrive at that interpretation of the press release? Because I arrived at the exact opposite conclusion. Boeing has admitted that they screwed up by tying the activation of the AOA Disagree alert to the the selection of the AOA indicator customer option.

I don't see any language in the release that insinuates that this was in any way the customer's fault or that it is to a lack of the customer's understanding.
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Old 30th Apr 2019, 16:28
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Originally Posted by Cows getting bigger View Post
The 737 first flew 9 days after I was born so, at 52 years old, I'm rather pleased I fall on the right side of the line. However, my wife would probably agree with your 'children' sentiment.
Sometimes here we forget that the 737 basic design is actually 1950s since it’s a 707 with two engines missing. When I transferred from 707 to 737 you could nearly have done a differences course! Ok no flight engineer but systems almost the same including the STAB TRIM which is unchanged in basic concept for 60+
now. The 707 had no hydraulic controls except rudder boost and even that was not needed. We had no proper simulator so a lot of training was done on a real plane including stab runaway/ emergency descent from high level and engine failures.
So, when the Max returns to the skies and
ends up with a life of several decades, it will be a century old design with a few electronic add ons when it finally retires.
Y
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Old 30th Apr 2019, 16:51
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Originally Posted by slacktide View Post
How did you arrive at that interpretation of the press release? Because I arrived at the exact opposite conclusion. Boeing has admitted that they screwed up by tying the activation of the AOA Disagree alert to the the selection of the AOA indicator customer option.

I don't see any language in the release that insinuates that this was in any way the customer's fault or that it is to a lack of the customer's understanding.
Agreed that they dont blame the customer in this one, but they seem to just not be able to help themselves when it comes to trying to have it both ways, my bold in quote from release.

Boeing included the disagree alert as a standard feature on the MAX, although this alert has not been considered a safety feature on airplanes and is not necessary for the safe operation of the airplane. Boeing did not intentionally or otherwise deactivate the disagree alert on its MAX airplanes.

The disagree alert was intended to be a standard, stand-alone feature on MAX airplanes. However, the disagree alert was not operable on all airplanes because the feature was not activated as intended.
Reminds me of the classic "a mistake was made" in place of "i made a mistake".
As to safety it would have helped prevent Lion air since it would have flagged AoA on penultimate flight.
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