Ethiopian airliner down in Africa

[MemberBerry]

Originally Posted by 737 Driver

All that “troubleshooting” takes less than 5 seconds.

Actually it can take longer than 40 seconds. For just the 2 first steps out of 3. From one of my previous posts:

17:59 - F/O - "auto pilot - disengage"
18:01 - Mentour - "autopilot is disengaged"
18:04 - F/O - "auto throttle - disengage"
18:07 - Mentour - "if you can do that for me please"
18:09 - F/O - "disengaged"
18:11 - F/O - "if it continues, I will go with the stab trim cutout switches"
18:13 - Mentour - "ok, let's evaluate this to see if it's moving"
18:20 - F/O - "memory items for the runaway stabilizer complete"
18:21 - Mentour - "yeah, let's evaluate"
18:25 - Mentour - "I have no authority of the trim at the moment"
18:29 - F/O - "roger"
18:32 - Mentour - "I can't control it manually, so it doesn't really work, so if you can continue with the memory items please"
18:37 - F/O - "memory items - stab trim cutout switches to cutout"
18:40 - Mentour - "Continue"
18:41 - F/O moves the switches to the cutout position
18:42 - F/O: "Cutout"

You could do all 3 steps in 5 seconds if you had no communication with the other pilot and didn't wait at all between the steps. But that doesn't sound very wise.

Later edit, actually I think that's one of the mistakes of the Ethiopian crew. They executed this checklist too hastily and they skipped the step about disabling the auto-throttles. If they did that, they probably would have payed more attention to their speed and adjusted it manually as needed. Instead, the engines remained at 94% until VMO, when from the FDR trace it seems the A/T lowered that to around 90%.

[FrequentSLF]

Originally Posted by 737 Driver

All that “troubleshooting” takes less than 5 seconds.

5 seconds for troubleshooting, so if you do not recognize a runaway trim in 4 seconds, you will be 2.5 units out of trim... when you turn off magic...(i.e. electrical trim)... exactly the same position of et302...
Probably can be recognized it in 2 seconds, plus 5 to troubleshoot..still almost in same situation
Would be interesting to see how many pilots in a SIM will react in less than 4 seconds

[wetbehindear]

737 Driver " I just don't think Sully would have allowed his stab trim to run for 9 continuous seconds (that would be 37 spins of the trim wheel) before doing something about it, "

Let us remember that Sully let the speed decay below Vsub Ls and became aware of it when the fdr data shown to him.

[MurphyWasRight]

Originally Posted by MemberBerry

The first step in your mantra is "turn off the magic". What Boeing did by implementing MCAS severely undermines that first step, because they added an additional bit of "magic", that can't be turned off using the old procedures (A/P off, A/T off, FD off). Instead, turning off this bit of "magic" requires disabling manual electric trim as well, with the cutout switches.

I think it wouldn't hurt if Boeing would implement some way to disable automatic trim independently from manual electric trim. Something that can disable both STS and MCAS without forcing you to use the trim wheels for the rest of the flight.

Since making significant changes to the cockpit like adding switches is probably out of the question, maybe there should be a way to completely disable automatic trim, using existing switches. For example using the existing cutout switches. Placing them in the cutout position, waiting a few seconds, then switching them back to normal could be used as a way to disable automatic trim, but leave manual electric trim functional. That would require just a software change.

No need for new switches or fancy logic:
All 737 up to 737NG have 2 switches, the right one disables auto trim, the left one disables pilot electric trim, and probably all electric trim.

For as yet unexplained reasons this was changed on 737MAX so that either switch disables all electric trim.

The switches were relabeled to primary and backup.

[Mac the Knife]

I can't quite understand why the function of the two switches was changed.
Previously, if I've read it right, one turned off MCAS etc. The other one turned off manual electric trim (on the yoke)

On the MAX, both switches have the same function (in series nogal!), ALL electrical trim is turned off,
leaving only a teeny-weeny wholly manual wheel that would take something like ten
minutes of hard winding (from a difficult position) to get the stabiliser back to even neutral.

That doesn't seem very sensible. Perhaps I've got it wrong.

Mac

[MurphyWasRight]

Originally Posted by MemberBerry

Actually it can take longer than 40 seconds. For just the 2 first steps out of 3. From one of my previous posts:



You could do all 3 steps in 5 seconds if you had no communication with the other pilot and didn't wait at all between the steps. But that doesn't sound very wise.

Later edit, actually I think that's one of the mistakes of the Ethiopian crew. They executed this checklist too hastily and they skipped the step about disabling the auto-throttles. If they did that, they probably would have payed more attention to their speed and adjusted it manually as needed. Instead, the engines remained at 94% until VMO, when from the FDR trace it seems the A/T lowered that to around 90%.

To be fair the mentour pilot video was done in a "teaching/demonstration" mode, a real crew would have probably done it twice as fast.

Skipping autothrottle off step is significant, although much earlier on some pilots posted that simply chopping the throttle in their condition could have undesired effects and had to be done with some fitness.
In any case they were still under VMO when the cutout switches were actuated, have not seen any hard facts on what speed would allow manual trim given the trim state.

The real problem was using cutout before the AC was in trim. It is possible that once the FO called runaway trim the pilot jumped to that thought even though he was successfully trimming at the time.
It is not clear that the ET pilots were fully aware of the revised procedure, yet another painful hole in the cheese.

[VFR Only Please]

Originally Posted by MemberBerry

The Ethiopian crew (...) skipped the step about disabling the auto-throttles. If they did that, they probably would have payed more attention to their speed and adjusted it manually as needed. Instead, the engines remained at 94% until VMO,

I read in the aviation press a remark from a guy with 12,000 hours on the 737, a sim instructor, who said he'd often seen airspeed drop off a crew's scan in circs far less stressful -- and confusing -- than these.

As for Sully-upon-Hudson, he's big into number of flying hours as a measure of competence. Free country. But to sound off publicly (as he did in the case of the Addis crash) does him no credit. I'm no airline pilot, but people I know, who are, resent Sully's near-deification by the media. Yes he refused to return to La Guardia, realized he couldn't make Teterboro, and instead chose that extremely long and wide, dead-calm liquid runway just off to his left. (Switching on the APU was an admirable brainwave.) They insist that any competent crew could have done what he and Skiles did, given the excellent conditions. (Imagine wind, choppy waves, lousy visibility --- or worse, that + mountains.)

derjodel is bang on that "machines need to be designed in a way to anticipate delayed corrective response". The Max looks fundamentally flawed. That new bandaid had better be Absolutely Perfect.

[737 Driver]

Okay, given the flurry of a certain type of comment, I think it would be useful to provide some advice here.

I know some of you have some strongly held positions, and that’s okay. However, some of those positions are based on a theoretical framework, or perhaps something you read somewhere or something someone told you. When those positions stray off into technical matters regarding the 737 or airline operations, please consider the following.

I do not tell my auto mechanic how to fix my car. I do not tell the surgeon how to operate on my body. I do not tell the professional golfer how to perform a tricky shot out of the bunker. I do not do this even if I can tell that the end result was less than optimum. So if you have never actually flown a 737, please do not try to educate me as to how the systems function, how a checklist should be run, or how difficult the aircraft is to operate under certain conditions. It does nothing to add credibility to your position. I have more than 10 years cumulative experience in this aircraft plus another 15+ in other related Boeing products. I have been trained in countless abnormal and emergency situations in that time, and I have experience quite a few real ones in the air. I am quite familiar with the all the psychological and environmental factors that can come into play.

I offer my technical expertise here, in part, so that the commentary doesn’t go off into the weeds on some point that is fundamentally incorrect. In doing so, I may provide information in a simplified fashion to cater to the non-Boeing and non-pilot members of this forum. If you wish to argue the placement and use of switches and controls, whether this step should be done before that step, or whether something can be done in 5 seconds or 5 minutes, please have that discussion with someone else.

The bottom line is that the accident pilots made serious errors and did not meet the expectation of a professional airline flight crew. This statement should be no more controversial than saying that the various engineers and technical staff at Boeing made serious errors in the design of MCAS and did not meet the expectations of their profession. If you wish to label this as “blaming,” there is nothing I can do to stop you. Personally, I’ve seen enough of the culture of blame, and it does little to get to the root of the problem.

You can’t fix a problem until you recognize a problem exists. These accidents, among others, have provided clear evidence that there is a problem with the level of pilot skills in this industry. We can either ignore it, or we can do something about it.

[737 Driver]

Originally Posted by Kerosene Kraut

Blaming the pilots for some imperfect systems layout sounds a bit unfair to me.

Let’s again dispose of this canard.

It is interesting how the “Let’s not blame” defense only seems to apply to the flight crew. I don’t see anyone saying “Let’s not blame Boeing,” or “Let’s not blame the FAA.” In fact, the whole “blame” defense is utterly useless, because all it does is say that you don’t want to look at the errors that were made by a particular group. Well, that is not how aviation safety investigations work. Every link in the chain of causation is examined. This is not done to assign “blame,” but rather to identify causes and propose remedies.

Finally, absolutely no one is laying the MCAS design errors at the feet of the pilots, just as no one faults the pilots when any of their other systems go haywire. However, we absolutely should examine if those same pilots handled a particular malfunction to the standards expected of them as professional aviators.

[L39 Guy]

Fly the damn airplane...

Ancient Mariner: All this grandstanding makes me wonder if some of you have been in an emergency, a real emergency?
I've been fortunate/unfortunate enough to have been in a few, albeit maritime, not aviation related.
Everytime I was surprised to see "highly trained professionals", and I mean highly trained, we had realistic training once a week for these eventualities, totally break down and be unable to function. I not talking 30 seconds, 90 seconds, but unable, period.
Aviation is of course a totally different ballgame.
Per

You are correct, aviation is (or should be) a different game. During the selection, training and ongoing check rides during one's career as a professional pilot the individual is constantly evaluated and tested. In an ideal world, if they don't cut the mustard they are cut loose - I have seen this happen a few times but unfortunately I have seen too many marginal pilots given complimentary passes on various sim rides, line checks, etc. Unions fighting back is probably why some of the marginal pilots get through; I suppose the corporation also calculates the probability of an event, the probability of two weak pilots being paired together and decides to take that risk. I would submit, however, that any one that totally breaks down and unable to function would not (or should not) hold a commercial pilot license.

As far as emergencies, I have had plenty...three engine failures, a couple of hydraulic system failures, blown tires, etc. I am no hero, I just do what I have been trained to do.

During a few day hiatus while on vacation the discussion pivoted to human factors which is undoubtedly an issue and particularly the "startle factor". I know of few emergency situations where the voice of a lovely lady comes over the speaker and says "Standby for xxxx" with xxx being a UAS, stab trim runaway, engine fire, etc. The startle factor is always there and it is accounted for in the certification of the aircraft, i.e. crew recognition and reaction time.

But after that "startle factor" period is over, it's time to get down to work and deal with the problem, usually with an emergency checklist and sometimes without (double engine failure, volcanic ash (BA flight in the 1980's), a complete hydraulic failure (UAL Sioux City), etc.). It is the job, the responsibility, of the professional aviator to react to the problem startle factor or not. If the professional pilot as an individual cannot get past the startle factor and focus on the problem and deal with it, then they should not have a license or type rating. If professional pilots collectively cannot manage the startle factor and deal with emergencies anymore then it's time to shut down the industry entirely as the traveling public cannot be guaranteed their safety in the even of an emergency.

Yes, there was a startle factor at lift-off on the two accident flights and one incident flight. In the case of the incident flight, they dealt with the startle factor, called for the UAS checklist, controlled the speed of the aircraft (i.e. flew the aircraft) and that allowed them to diagnose the MCAS issue when the flaps were raised. The dealt with MCAS by flying the damn airplane (trim and speed control) with a little help from a "friend" and carried on to destination with the stick shaker, UAS and manual trim. Bravo!

Yet the accident crews had the same startle factor and couldn't even get to first base, i.e. UAS drill. And they had almost two minutes to execute that simple, memory checklist. And had they done just that, they would not have been racing around at 340 kts, making manual trim and hand flying with nose down trim impossible due to control forces. Instead, they could have manhandled that aircraft while they sorted out the trim including using the manual trim wheel and could have flown all day long in that condition, just like the Lion Air incident flight.

As a professional aviator (and a person that flies in the back of aircraft a lot), it is my expectation that the aviators I work with or whom I have entrusted by life and that of my family to be competent enough to get over the startle factor and do what they are expected to - fly the damn aircraft and deal with the emergency. In the case of the MAX, the emergencies are known and have published procedures. This was not a double engine failure, volcanic ash, total hydraulic failure but a simple UAS. That is not asking too much.

As 737 Driver and others have been stating on this thread, this may sound harsh and hard-ass but that it is the professional responsibility of the a professional aviator. There is no denying that MCAS needs rework and there is not disagreement about that. But what we are arguing is that aircraft do have system failures and startle factor is a fact-of-life, but the pilots must have the training and experience to deal with it. They have to wear the big boy pants because they are the last line of defense.

As I mentioned a couple of thousands of post ago, the airline industry has been whistling past the graveyard for many years but now the chickens are coming home to roost (sorry about the mixed metaphors). It just takes some unexpected event now to cause an aircraft to crash - MCAS, no ILS approach available (Asiana SFO), an engine failure (ATR 42 TPE), a go-around (Emirates 777 DBX) and airplanes crash when trained and competent crews could have and should have avoided the loss of life and aircraft.

These events should be a call to action by the entire industry - manufacturers who have hithertofore relied on experienced and trained pilots to save the day, regulators who are not demanding higher standards of pilot training and experience (i.e. actually hand flying and not watching the autopilot), airlines (for the same reasons) and pilot unions who have to own part of the responsibility for insuring their members uphold high professional standards which may mean actually hand flying aircraft.

Boeing erred with MCAS but the fault for these accidents are the result of failure of the players noted above.

[safetypee]

737 Driver, Uplinker,
‘Loss of situational awareness’

How do you know that you have lost awareness; compare this with an illusion. Awareness exists, unfortunately it doesn’t match the real situation, nor therefore the actions required.
Do you have an illusion of understanding these accidents.
If you have lost something, what was ‘this’ which you already had. How did you acquire it in the first instance.

Reduce power shortly after take off - compare with other emergencies where the climb is continued to a safe altitude, e.g. fire.
It’s a hazardous option to reduce power early in the climb, particularly with a ‘don’t sink’ alert - ET.

L 39 Guy,
When quoting 777 SFO and 777 DBX, consider the particular systems contributions, lest you start agreeing with 737 Driver.

[MurphyWasRight]

Originally Posted by L39 Guy

Yet the accident crews had the same startle factor and couldn't even get to first base, i.e. UAS drill. And they had almost two minutes to execute that simple, memory checklist. And had they done just that, they would not have been racing around at 340 kts, making manual trim and hand flying with nose down trim impossible due to control forces. Instead, they could have manhandled that aircraft while they sorted out the trim including using the manual trim wheel and could have flown all day long in that condition, just like the Lion Air incident flight.

Can you comment on the possibility that the ET crew diagnosed the UAS as a a false warning per the Boeing flow chart that was posted a while ago. My bolding'

If AoA sensor is failed high,stick shaker on failed side will activate on rotation accompanied by IAS/ALT disagree warning flags
Ifthe pitch power and config are consistent with takeoff and the good side ASI agrees with the Standby ASI,then it is a false warning
------------ If in any doubt execute the UAS NNC

The pilot with good side data becomes PF

Land immediately

Even if they did diagnose it as false warning it does appear they were continuing on rather than "land immediately"

It is possible that the real "startle factor" moment was the combination of autopilot disconnect followed by first MCAS trim, up till then it might have been in the 'understood and handled' category. The speed was about 250 knots at time of first MCAS input.

Another way of framing this is what if the bird strike (or whatever the cause) had happened at 05:39:55 after the flaps had been retracted following an uneventful takeoff, this would have left them in same state: Autopilot disconnect immediately followed by MCAS ND trim.

Note: I agree with much of what has been said on condition of pilot training/competency, seems to have devolved into a 'tick the checkbox' multiple choice exercise.

[L39 Guy]

Originally Posted by HundredPercentPlease

Your ferocious ego is diminishing any points you may have. Even though it's unlikely (even given your join date), you are sounding like a Boeing shill.

Clearly they didn't meet your expectations. As you know, you can overload anyone in the sim - to the point of failure. Others here, myself included, believe that this crew were overloaded and suffered cognitive difficulties as a result. If they had been trained, or at least made properly aware of what would happen with a single AoA failure on takeoff, then their cognitive position may have been different. But stall, UAS and then MCAS is a triple-nasty that appears to have beaten every crew faced with it.

You also seem to believe that the ET crew didn't know that if all else fails, fly the aircraft. What you will not accept is that they knew that that was what they had to do, but couldn't - due to overload.

Finally - the answer to the problem is either to remind everyone to prioritise the flying of the aircraft (because they didn't know that), or fix the aircraft so it's no killer. Which may prove tricky, now the limitations of the manual (hand crank) trim system are being revealed.

Please, let's not personalize this and attack individuals. 737 Driver has invested a lot of time and effort in addressing a lot of issues raised on this thread and for that he deserves everyone's respect whether you agree or disagree with him.

The crews of the accident aircraft did not meet the expectations of 737 Driver, myself and, most importantly, the passengers that bought tickets on those flights. While there are multiple events involved in these accidents, let's break this down to the first event which lasted up to 2 minutes before the flaps were selected up:

1. Explain to me how and why, long before MCAS reared its ugly head, that these crews could not recognize an UAS (stick shaker, IAS DISAGREE, etc) and not set an attitude and power setting per the NNC?
2. Explain to me how and why a professional flight crew would let the speed of the aircraft hit Vne (340 kts plus) while supposedly hand flying an aircraft?
3. Explain to me why one would engage the autopilot at 400 ft while in stick shaker (stall) or UAS?

This is a UAS event, pure and simple at this stage of the game. And they couldn't even do that! If they had an engine failure at V1 there is not a hope in hell that they could fly the aircraft if they couldn't even manage a UAS event. And, by the way, an engine failure before, during or after V1 has a startle factor too.

1. Explain to me how and why the crew of the Lion Air incident flight was able to do the UAS drill and also control the speed of the aircraft such that manually trimming the aircraft was possible and, indeed, were able to fly to destination with UAS, stick shaker and manual stab trim?

With respect to limitations of the manual trim of the B737, I know of no aircraft that can be flown at Vne with full nose down trim. No aircraft, flown by a professional, should be allowed to get into that corner. How about pulling those two levers between the pilots back to idle rather than leaving it at take-off power? That will quickly bring the speed of the aircraft into a regime where one can manually trim the aircraft. But that involves flying the damn airplane, a basic skill that the industry seems to have lost in this and other accidents/incidents recently.

[L39 Guy]

Originally Posted by safetypee

L 39 Guy,
When quoting 777 SFO and 777 DBX, consider the particular systems contributions, lest you start agreeing with 737 Driver.

It's true that the 777 had some quirks with the auto-throttle that contributed to these (non-fatal) accidents but nevertheless in the case of SFO four pilots in the cockpit watched the speed decay to a stall and in the case of DBX, nobody noticed that the thrust levers did not advance to go around after hitting the TOGA switches. This points to training (doing a visual approach in the case of SFO) and basic flying skills, i.e. monitoring the aircraft performance in the both cases.

It also points to way too much dependence on automation which, as many of us have pointed out on this thread, is a big, big problem in the airline industry today.

[VFR Only Please]

Originally Posted by 737 Driver

It does nothing to add credibility to your position.

I have Zero credibility LOL. My handle on this forum is designed to be upfront about that.

No quarrel with L39 Guy's post. Even this: "Boeing erred with MCAS but the fault for these accidents are the result of failure of the players noted above."

I'll just repeat what I said earlier about 0.6% of the worldwide Max fleet disappearing (poof!) in five months owing to survivorless crashes. If we're admitting that Boeing erred with MCAS (and indeed part of that error was hiding the very existence of MCAS from crews and pretending to airlines that this airplane required no expensive stuff like like time-consuming training) then we're admitting that the Max accentuates normal human failings among crews and turns them into Lethal Errors, which somehow don't occur on other aircraft (ETH somehow has managed to operate the 777, A350, whatever, so far without incident). What does this tell us about the fundamental realities of the Max?

[Takwis]

I would add to your question the further evidence of Muilenberg continually asserting that there is nothing wrong with the airplane, and it is 100% the fault of the pilots. I think even Boeing die-hard fans here have admitted that there is something that needs to be fixed on the airplane,

[737 Driver]

Originally Posted by VFR Only Please

I have Zero credibility LOL. My handle on this forum is designed to be upfront about that.

This is one of those times that you need to read what I actuallly wrote instead of what you think I wrote.

To be precise, when a non-737 or even non-Boeing pilot wants information on 737 systems or procedures, I am happy to oblige. When that same person then wants to argue over technical details and suggest that they know more about the aircraft I been flying for over 10 years, then yes, they take a hit in credibility both in my eyes and the eyes of others who notice such things.

Don’t try to tell me how to fly the 737 and don’t make assertions that are poorly supported by the evidence, and we will get along just fine.

[moosepig]

Originally Posted by Takwis

I would add to your question the further evidence of Muilenberg continually asserting that there is nothing wrong with the airplane, and it is 100% the fault of the pilots. I think even Boeing die-hard fans here have admitted that there is something that needs to be fixed on the airplane,

Muilenberg HAS to say that. Can you imagine the company lawyers or shareholders suggesting he say otherwise? One sniff of an admission of liability and Boeing would be sued out of existence.

[737 Driver]

Originally Posted by safetypee

737 Driver, Uplinker,
‘Loss of situational awareness’

How do you know that you have lost awareness; compare this with an illusion. Awareness exists, unfortunately it doesn’t match the real situation, nor therefore the actions required. Do you have an illusion of understanding these accidents. If you have lost something, what was ‘this’ which you already had. How did you acquire it in the first instance.

Okay, those last two questions border on some deep metaphysical issues, so let’s just say that when a flight crew first steps into the cockpit at the gate that they should have a good sense of where they are, what day it is, where they are going, what they had for breakfast, etc. Otherwise, we are all pretty much screwed.

Let’s start again with the mantra: When presented with an undesired aircraft state, unknown malfunction or ambiguous warning, or a loss of situational awareness, the flying pilot should be ready and able to: Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude.

Loss of situational awareness is just one of the entry conditions, though it is an important one. You don’t even need to have an active aircraft malfunction. Many years ago, a crew at my airline was doing a descent and arrival into a South American airport in a non-radar environment with high terrain and thunderstorms in the area. This was in the days before EGPWS and navigation display screens. At some point while trying to maneuver around the weather, the Captain realized that he no longer knew what his position was in relation to the surrounding the terrain, so he immediately disconnected the autopilot and autothrottles, set the pitch and power for a max performance climb, and climbed to a safe altitude. Once there, they reestablished SA and started the arrival anew. It is very possible that this Captain saved the lives of everyone onboard.

Back to the mantra. The preamble is “When presented with an undesired aircraft state, an unknown malfunction or ambiguous warning, or a loss of situational awareness...” These are conditional statements joined by the word “or”. You only need one of them to apply the mantra.

The mantra continues, “the flying pilot should be ready and able to...” It does not actually say the flying pilot must do the following. If the flying pilot has enough SA to apply a different and more appropriate procedure, then that is what he/she should do. Now this leaves open the possibility that the pilot misidentifies the malfunction and applies the wrong corrective action. Hopefully, this is where the non-flying pilot steps in with a sanity check. There is no evidence in this accident that the crew misidentified the malfunction and were applying the wrong non-normal procedure.

However, if the flying pilot is 1) presented with an undesired aircraft state, and 2) does not know what the cause of that aircraft state is (i.e. unknown malfunction or ambiguous warning), then that person has pretty much met the definition of loss of situational awareness whether they know it or not. In that case, in the absence of any other procedure that would apply, the flying pilot should Turn off the Magic, Set the Pitch, Set the Power, Trim the Aircraft, Monitor the Performance, and Move the Aircraft to a Safe Altitude.

Somewhere along the way, they may either come to realize that they have lost SA, or better yet, they will regain SA so that they can properly address the situation. Either way, by applying the steps above (i.e. FLY THE AIRCRAFT), they will have greatly improved their position.

[mangere1957]

Original post deleted due to having totally screwed up.

My error.

Great comments from B737 Driver and L39 Guy. Agree 100%.
Good work guys.