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Ethiopian airliner down in Africa

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Ethiopian airliner down in Africa

Old 6th May 2019, 18:35
  #5021 (permalink)  
 
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Originally Posted by Lord Farringdon View Post
FWIW from and ex non-pilot military aircrew viewpoint, I have been in a few crappy situations when the day has just gone bad. In mil ops we operated close to the envelope in unfamiliar environments and it's the nature of these ops that means that sometimes, on thankfully very rare occasions, guys didn't come home. We all read the accident reports and make mental notes to ourselves...must be wary of that...must not do that ...must make sure I communicate that better...take another look at that checklist etc etc. But when it happens, the engine fire, the stuck main landing gear, the assymetric flap, the loss of hydraulics, smoke and fume, lightening strikes, severe CAT in the middle of an otherwise smooth moonlit cruise, flapless over the fence on short runway at 160 kts etc etc, there is a startle factor, there is time when you hear nothing and see nothing or can't make sense of anything, there is puzzlement and a fear that your event could well be the subject of the next accident report, and yes, a not unnatural fear that this could be your last flight. There is no immediate recall capacity because your senses are so overwhelmed with incoming information that you just can't assemble any course of action except whats right in your face and that leads to target fixation, like trying to control and uncontrollable wildly spinning aircraft, like trying to select the autopilot on, again and again and again!. It takes a few moments, but eventually, the haze clears. The airplane is still flying, (not in Wonkazoos case) new information is not coming and it seems like time has slowed down. Things start switching back on, you start to interpret the sounds you are hearing, the things you can see and thankfully, you start to recall memory actions. In Wonkazoos case the information didn't stop coming. Excessive and continuous G force is an overwhelming inhibitor to clear thinking. But fortunately he broke the target fixation and bailed. Everyone who has experienced hypoxia training will have experienced target fixation and how difficult it is to self recognise it let alone break it. Unlike Wonkazoos rather more desperate situation, my personal experiences were the type of things you might train for in a simulator. So much so that once you are over the startle and the haze, the immediate actions are almost routine. Importantly, you burst into pre-trained action safe in the knowledge that the event didn't kill you, that the bird still has its feathers and is flying and that if everyone does exactly as they are trained to do we'll get this thing on the ground even if the aircraft may not be reusable afterwards!

Wonkazoo and 737 Drivers' positions are so far apart but can easily be explained by the entirely different nature of events these guys have experienced and/or trained for. My experiences would lead me to agree with 737 Drivers view. That is, you get a scare, the event stabilises, you shake yourself off and go to memory recall. All going well, you, rather than someone else gets to write the event report afterwards. But now we come to ET. This should have been non-threatening 'routine' emergency. I know, using 'routine' and 'emergency' together is an oxymoron but you are trained for this right? That's why we are checked to fly. We are supposed to know what to do in these circumstances in the air because for all those recall items we maintain 100 percent recall training for them on the ground. The ET Captain would have been living under a rock and the airline grossly negligent if he wasn't aware of the Lion Air accident and what Boeing subsequently directed was his best and only courses of action to avoid disaster.

So why didn't he handled it correctly? Why didn't he just manage the UAS, turn back and land? My belief is that he didn't feel he was experiencing a routine UAS, or shall we call this a 737 Driver type of emergency, but rather that this nasty MCAS beast, that he only relatively recently become aware of, presaged by a UAS event had selected him that day. I believe there was too much information coming in for him to get out of startle mode and that this was aggravated by an early immediate assessment that he was in a fight for survival with MCAS right from the get go. He was thinking too far down track, to something that hadn't even happened yet but which led to target fixation on selecting auto pilot and his subsequent cognitive inability to deal with flaps, Vmo or cutout switches. He was not experiencing a 737 Driver "do the checklist your trained for" type of emergency but rather the "Oh no, not this" or Wonkazoo type of emergency where a fight to the death was about to start.

If the ET Captain had never heard of MCAS, he probably would have carried out the UAS and landed safely. Basically, his mere knowledge of MCAS but lack of full understanding of it may have scared the c##p out of him. How many reports have their since been of pilots that wont fly the airplane again until they are satisfied Boeing's fix and training solutions are 100 percent and in some cases others saying they just wont fly it again regardless. The ET Captain would have been deeply concerned about the possibility of a MCAS event and this self - fulfilling prophecy may have led him into the clutches of MCAS from which there was no escape.

Watch this scene from "Glory". https://www.youtube.com/watch?v=90x6kAcVP54 and identify the difference between the 737 Driver correct actions and satisfactory outcomes and the Wonkazoo actions and outcomes. The soldier considers himself a pretty good shot but it doesn't take much to imagine the Colonel as MCAS and the soldier as the ET Captain. You see the soldier startle, you see his fumbling attempts to do a simple task, that previously he had done with aplomb and you see the utter disbelief at the outcome.

So sorry for the long opinionated post but I hope it provoked some thought. 737 Driver and Wonkazoo had an interesting, lively and ultimately respectful discussion some posts back from which I learnt a lot. I think ultimately they are both right..but for different reasons.
Thank you for finding a way to articulate one of the primary differences between my views and those of 737 Driver. (and as a consequence between two disparate groups here and probably around the world...) I've spent some time trying to noodle out a way to express them coherently and you have done better than I could have by far.

To be clear: I am agreement with most of what Mr. Driver says about training and the industry. The only real point where we diverge is on the reactions of the crews and the culpability of them or on them for the outcomes as they happened. As far as I can tell we are in agreement that industry across the board has set the stage for incidents like these, as well as that there is a ton of shared responsibility, from manufacturer to regulator to commercial operators and training systems down to (in a very minor way) the crews themselves. The difference between us is (I think) that I give the crews a pass because if all the previous people (or even some of them) had done their jobs even half competently then those six pilots would not have been sitting on a hot seat in the pointy end in the first place.

No, you cannot design an idiot-proof or perfectly safe airplane, but you can design one that won't try to kill the crews flying it if one of your data devices goes south. If you do design (and certify!!) such a contraption, no matter the cause, you should be held to very high account indeed.

Warm regards,
dce
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Old 6th May 2019, 18:47
  #5022 (permalink)  
 
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Originally Posted by wheelsright View Post
Sorry to push you on this, but that is not a clear answer. What precisely is the procedure that the ET302 pilots should have followed? ie What would you have done? That is not in any way suggesting the the ET302 followed the correct procedure.
This has been covered before, but here it is again. This particular malfunction (AOA failure generating an erroneous stall signal) first presents itself as an unreliable airspeed event. The 737 has a procedure called "Airspeed Unreliable" which if properly followed, would have put the aircraft in a stabilized configuration at a safe altitude. An important point is that the flap configuration should not have been changed (i.e. flaps left extended) until the "Airspeed Unreliable" checklist had at least proceeded far enough to identify if either pilot actually had a reliable airspeed. In theory, the ET302 crew should have also been in possession of the information on MCAS that came out after the Lion Air 610 accident, and given this information they should have left the flaps extended and returned to the departure airport for landing. In this case, MCAS would never had activated.

There is some suggestion that the information on MCAS was not properly distributed to the crews. However, in this case I still question whether the flaps should have been retracted given the nature of the malfunction. Even so, if the crew had first completed the Airspeed Unreliable checklist, they would have been in a stabilized aircraft at a higher altitude. Once the flaps were retracted, the erroneous MCAS activation would have presented itself as runaway stab trim. Those procedures have already been discussed, but they were not followed either. So in short, there were two well-established procedures that were not used, and if used would have had a decidedly different outcome.
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Old 6th May 2019, 19:02
  #5023 (permalink)  
 
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No, you cannot design an idiot-proof or perfectly safe airplane, but you can design one that won't try to kill the crews flying it if one of your data devices goes south. If you do design (and certify!!) such a contraption, no matter the cause, you should be held to very high account indeed.
Succinct.

Whatever happened to the once proud and accountable philosophy driving human endeavour?
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Old 6th May 2019, 19:09
  #5024 (permalink)  
 
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Wheelsright, #5014

Re Old MCAS. We cannot assume that crews knew of MCAS interaction with trim, (Boeing did not publish details).
With some knowledge (ET), the procedure called for use of trim and / or deduction of trim malfunction. See discussions on time assumed to recognise malfunction - MCAS active/quiescent cycle would take at least 13 sec of dedicated observation, thus probably much longer; then follow the trim runaway drill.
(5 sec could have been the value used in certification for trim runaway - but MCAS is not continuous)
An AoA alert only adds to the general confusion of several alerts consequential to AoA malfunction.

-

Re ground inhibit of AoA. As reported the logic appears reasonable. AoA vane requires airflow thus is inaccurate until xxx kts, but it is required soon after rotate for the critical stick-shake function.
Disagree provides no benefit in this, but even with contrary arguments, inhibition of superfluous alerts below 400 ft is reasonable.

I suspect that the AoA mess originates from dominant customers request for AoA display (gauge), similar to 757 option. Their reasoning driven by cost to meet the then emergent upset recovery training - we have AoA display thus less / no additional training. Boeing said yes, but possibly added the disagree alert to overcome the ‘misleading’ information certification aspect with AoA malfunction - gauges show different values but not which is incorrect.
The better engineering solution is to remove the display - AoA Disagree not required, MCAS inhibited, … no additional training, install new alert that MCAS is inoperative.

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Old 6th May 2019, 19:18
  #5025 (permalink)  
 
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Originally Posted by 737 Driver View Post
Uh...., no. I could go into all the reasons why one shouldn't, but can you just take my word for it?
What does TBC-19, the Boeing Flight Crew Operations Manual Bulletin, say you should do when there is an AOA disagreement?

Not that I agree, but they make no mention of an unreliable airspeed checklist...they jump right into fixing the trim problem.
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Old 6th May 2019, 19:23
  #5026 (permalink)  
 
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Originally Posted by MemberBerry View Post
I understand that the memory items are so time critical that you need to be able to perform them immediately. However, when such a procedure contains "ifs" that require you to check if the problem stopped before progressing to the next step, even if you do everything in complete silence without any communication 5 seconds doesn't seem enough.

I found a study called "LINE PILOT PERFORMANCE OF MEMORY ITEMS" on the FAA's site that discusses among other things two conflicting concerns regarding performance under stress: doing things as fast as possible vs doing things as accurately as possible:

https://www.faa.gov/about/initiative...mory_items.pdf

This was also demonstrated in the Ethiopian flight, with the pilots forgetting to disable the auto throttles as part of the runaway stabilizer memory items.

The entire study is a very interesting read. Sorry if it has been posted here before, I searched the thread and I couldn't find it.
I have not read that particular study before, but there are several focusing on errors in checklist processing. This one is quite thorough. Summary version, and full paper:
https://flightsafety.org/asw-article...er-error-trap/
https://human-factors.arc.nasa.gov/p...010-216396.pdf
Checklist deviations clustered into six types:
flow-check performed as read-do;
responding without looking;
checklist item omitted, performed incorrectly, or performed incompletely;
poor timing of checklist initiation;
checklist performed from memory;
and failure to initiate checklists
(in order of number of occurrence)
The first two types accounted for nearly half of the checklist deviations observed.
Monitoring deviations grouped in three clusters:
late or omitted callouts,
omitted verification,
and not monitoring aircraft state or position
Although this study focused mainly on checklist use and monitoring deviations, additional data on
primary procedure deviations provide context and allowed us to examine how effective checklists
and monitoring were at trapping primary procedure errors
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Old 6th May 2019, 19:27
  #5027 (permalink)  
 
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safeteepee #5039

Do not disagree with anything in your post.

But do you think that it is possible to use electric trim to counteract MCAS before using the cut-out switches? I feel there is something being missed here. Clearly, it is intended by Boeing that you can, and that is the information that has been provided. Given, two crews appear to have failed to apply sufficient nose-up trim, I have a niggling doubt it is the whole story. I want a reason they failed to apply sufficient nose-up other than they were stupid. I realise there may not be a reason...
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Old 6th May 2019, 19:28
  #5028 (permalink)  
 
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Rogue Boeing 737 Max planes ‘with minds of their own’ | 60 Minutes Australia


Compelling interviews with Chris Brady ( The Boeing 737 Technical Site ), Dennis Tajer, Peter Lemme, David Learmount and Dominic Gates.
43 minutes...

Last edited by Zeffy; 6th May 2019 at 20:13. Reason: added list of industry experts
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Old 6th May 2019, 19:44
  #5029 (permalink)  
 
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Threat and Error Management

PART 1

In the interest in moving the conversation along, and in particular to help transition this thread from a rearview, reactive mode to a more forward-looking proactive one, I would like to tee up a subject that is hopefully familiar to many aviators - the Threat and Error Management Model. I have some more thoughts to share that build upon this model, so it would be helpful to have some familiarity with it.

Briefly, the TEM model examines aviation safety through a lens that assumes that pilots will always be faced with threats (known and unknown) and errors. It is assumes that there are no perfect aircraft, environments or people, but it tries to devise a resilient system that is capable of identifying and mitigating threats and trapping errors. Rather than cut and paste a full description of the TEM model, I would ask you to look at the links below:

Introduction to Threat and Error Management

Wikipedia Threat and Error Management

Part of the TEM model is the concept of barriers. Barriers are those things that can be put in place to mitigate threats and trap errors. Some people refer this to the "Swiss Cheese" model because it assumes that no barrier is perfect either. Even though there will be holes in each barrier, the concept is to have enough of the right type of barriers so the "holes" do not line up and lead to either an undesired aircraft state or worse, an incident or accident.
.



The MAX accidents can be analyzed using the TEM model to identify not only the particular threats and errors, but also whether there were sufficient barriers and/or why the existing barriers did not ultimately prevent these accidents. Armed with this information, then the goal is to identify how those barriers can be improved to prevent future incidents and accidents.

Last edited by 737 Driver; 7th May 2019 at 14:22.
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Old 6th May 2019, 20:03
  #5030 (permalink)  
 
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Originally Posted by Takwis View Post
What does TBC-19, the Boeing Flight Crew Operations Manual Bulletin, say you should do when there is an AOA disagreement?

Not that I agree, but they make no mention of an unreliable airspeed checklist...they jump right into fixing the trim problem.
Had to go look up TBC-19. The information was incorporated into our company manuals a little differently, but it is essentially the same guidance. This supplement specifically discusses the impact of an erroneous AOA on the trim system. It does not address the effect of erroneous AOA (particularly of the "stall" variety) on other aircraft systems - of which there are quite a few. The crew still needs to deal with those problems, and we have existing procedures for most (but not all) of them. Unreliable airspeed is one of the outcomes of the AOA failure, but we have a NNC that is (mostly) suitable and thus did not need to be modified. Other than the erroneous stick shaker (for which there is no checklist) unreliable airspeed was the first manifestation of the AOA failure and should have been dealt with first.

A careful reading of TBC-19 basically states that a bad AOA input can create unwanted stab trim movement, and the proper response to the unwanted stab movement is to execute the Runaway Stabilizer Trim checklist. I might add that functionally while experiencing this malfunction in the air, we do not refer to this document (or its equivalent). We refer to the appropriate non-normal checklist.
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Old 6th May 2019, 20:07
  #5031 (permalink)  
 
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Originally Posted by wheelsright View Post
safeteepee #5039

Do not disagree with anything in your post.

But do you think that it is possible to use electric trim to counteract MCAS before using the cut-out switches? I feel there is something being missed here. Clearly, it is intended by Boeing that you can, and that is the information that has been provided. Given, two crews appear to have failed to apply sufficient nose-up trim, I have a niggling doubt it is the whole story. I want a reason they failed to apply sufficient nose-up other than they were stupid. I realise there may not be a reason...
It has pretty well been established on this thread that pilot electric trim will work in all conditions (does not stall under load) and interrupts MCAS if active as shown by ET trace at ~05:40:27. This pilot trim input was possibly then interrupted by cutout switches.

Other than 'deer in headlights' loosing it I see a few possible factors:

1: Pilot accustomed to short blips not comprehending amount truly needed, this fits Lion Air when the FO was ineffective at the end when PIC handed over control while the Captain was mostly successful.

2: Trimming by column feel not position: May seem that AC is closer to trimmed than it is. In other words if you have been pulling really hard then just slightly hard may feel like close to trimmed, I am sure the pilot did not want to over trim given all the alarms.
This might explain ET first retrim at 05:4-:15. Unfortunately we don't have the column force graph, just position.

3: Some as yet to be revealed flaw that interferes with pilot trim inputs; one possibility is biomechanical factors related to actuation switches after prolonged pulling.
This is unlikely but could explain the final seconds of both accidents.

Hopefully the final reports will fully address this question.
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Old 6th May 2019, 20:17
  #5032 (permalink)  
 
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737 Driver, TEM incorporates the whole system, not just pilots being faced with issues. So, in this case one could view MCAS trim runaway as the threat with AOA failures, inadequate training, crew responses etc as errors.

Without going over the apportionment argument again (that’s one for the lawyers), MCAS brought a new TEM ‘flow’ that was not properly thought through. The slightly worrying thing is a similar flow could apply to any trim runaway; in hindsight the number of layers in place may be too few or, more likely, some of the layers have rather large holes.

TEM works, as long as everyone involved recognises the importance their role in the system. Some thousands of posts back I postulated that the overall risk may have been (inadvertently) ‘shuffled’ too far in the direction of the crews.
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Old 6th May 2019, 20:21
  #5033 (permalink)  
 
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Originally Posted by MurphyWasRight View Post

3: Some as yet to be revealed flaw that interferes with pilot trim inputs; one possibility is biomechanical factors related to actuation switches after prolonged pulling.
This is unlikely but could explain the final seconds of both accidents.
Last time I was in the sim, doing stalls and falls, I had an unusual attitude recovery from somewhat inverted (120 degrees), nose low. There were several other stalls leading up to this, so the stick shaker had been going quite a bit. On this one, while trying to roll, push, get the speedbrakes out, and trim, my thumb slipped off the trim switch two or three times. I can easily see how hard it would be to pull with some force on the yoke, and keep your thumb on the trim, after a long period of stickshaker activation.
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Old 6th May 2019, 20:26
  #5034 (permalink)  
 
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Originally Posted by Cows getting bigger View Post
737 Driver, TEM incorporates the whole system, not just pilots being faced with issues. So, in this case one could view MCAS trim runaway as the threat with AOA failures, inadequate training, crew responses etc as errors.
You are correct. The TEM model can be applied to the entire chain including what went wrong during the design process. This model is so flexible that it is often used outside of aviation as well. However, as I have previously mentioned, my main interest is what can done at the flight crew level, so that is where my focus is.
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Old 6th May 2019, 20:28
  #5035 (permalink)  
 
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driver,

the flow of if/then logic in the system is lost with legacy and lack of a comprehensive logic flow chart.

As an example, the accident in DXB, when the pilots pressed TOGA, but then the ac bounced on the runway. The pilots had no idea of the logic switch in the system, and what was disabled with weight on wheels. The mantra, press TOGA, pull back...within 10 seconds the ac impacted the rwy.

The legacy commands, the if/thens, are lost in the FMS programming. Only on incidents, does the legacy and the myriad of if/then scenarios emerge.

MCAS was a poorly applied band-aid to a much larger problem. At least 3 different crews found the holes in the model, 2 of which, cant speak to the issues.

Last edited by Smythe; 6th May 2019 at 20:41.
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Old 6th May 2019, 20:34
  #5036 (permalink)  
 
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What, exactly, is the use of an "A of A DISAGREE" with no A of A indication to back it up? I can't see it tells you anything useful at all, in fact it merely adds an unquantifiable and unanswerable question into the mix. Had it been fitted it would have required a QRH action to go with it. What could tgat possibly tell you to do about it?
Add another A of A sensor and a triage system and it becomes another matter of course, but it seems unnecessarily harsh to criticise Boeing for not incorporating procedures that can only confuse and not help.

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Old 6th May 2019, 21:32
  #5037 (permalink)  
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Originally Posted by wonkazoo View Post
The Boeing whistleblower who is working with the FBI confirmed that making the MCAS flight control system reliant on only one sensor was a deliberate decision to avoid the need for expensive Level D or flight simulator training.

“MCAS was designed using data from only one of the sensors because we knew the FAA would not have certified a two-sensor system without Level D Training…”

https://www.youtube.com/watch?v=Qytf...ature=youtu.be at 35:30

Boeing is dead, at least the Boeing we all knew and loved. It’s sadly time to accept that reality.
Was this video done in a B737MAX simulator? If so, who's simulator, and if not, we need to know how an NG simulator re-produces MCAS behaviour such that the demonstration is a valid one.

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Old 6th May 2019, 21:36
  #5038 (permalink)  
 
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Originally Posted by PJ2 View Post
Was this video done in a B737MAX simulator? If so, who's simulator, and if not, we need to know how an NG simulator re-produces MCAS behaviour such that the demonstration is a valid one.
It is an NG simulator. You could fake it by throwing in a bad AOA/stick shaker/unreliable airspeed and then introduce a runaway stab after flap retraction. Not what I would call "valid" but "illustrative."
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Old 6th May 2019, 22:02
  #5039 (permalink)  
 
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Originally Posted by PJ2 View Post
Was this video done in a B737MAX simulator? If so, who's simulator, and if not, we need to know how an NG simulator re-produces MCAS behaviour such that the demonstration is a valid one.
The simulation is meaningless and it is on an NG sim. The quote is purportedly from a Boeing whistleblower who is working with the FBI. IF from an accurate source it is not meaningless, it is instead a stunning indictment that Boeing put profit ahead of safety and knew it when they did.

Forget the demonstration- that was so much theater. Look at what the Boeing employee said- that is the important bit, which is why I posted it.

Regards,
dce
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Old 6th May 2019, 22:05
  #5040 (permalink)  
 
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Originally Posted by wonkazoo View Post
Reading the back and forth on the conundrum of “Pilots completely at fault for being stupid” as set against “Pilots completely not at fault because Boeing designed a $hit system,” and I’ve decided to take a stand. Apologies in advance as this is long, but trust me- it is worth it.

Of all of you out there who have posted here- whether with a desire to blame the pilots entirely or the opposite, how many of you have actually experienced an imminent, binary and life-threatening emergency in your airplane?? One that is so explicit you will either get it right or you will die?? And you have maybe 30 seconds to make that choice.

My guess is the list of aviators who can answer honestly that they have been at that threshold of death is very very small.

I am on that list. And I survived, despite making bad choices along the way.

I share this story because I want people to understand once and for all that while it is fine to offer that the pilots could have done better (they totally could have) the root cause of the MAX crashes was one of design, and human failures only built on that edifice to achieve the final outcome.

I also share this story because I want to try to explain to everyone here, in terms we can all understand, what it is really like when your known world explodes and you have to improvise in order to survive.

In June of 1996 I was in a very high performance unlimited category biplane named the Goshawk. (N345RM) I had departed Livermore CA several minutes earlier and was headed to a legal practice box adjacent to the Tracy airport. While over the Altamont hills at an indicated altitude of 4000MSL I began warming up by pulling to a 45 degree upline and doing snap rolls to the right. I did this once or twice. On the third attempt, once again at approximately 4000+MSL I initiated the snap roll to the right and hit hard left rudder as the wings returned to level to stop the autorotation. When I did this the left rudder pedal/bar shot away from my foot instead of providing actual resistance. The left rudder cable had snapped.

The airplane (which was by design dynamically unstable) paused its rotation for a moment and then began again violently to the right, probably at about 360 degrees per second. And here’s where the chair-jockeys don’t get it. I probably went two or three full revolutions before my mind could accept what I already knew had happened. I immediately pulled power, but the aircraft was already entering a nose-down spin- at a rotational rate of at least 360 degrees per second.

The ROD of a spinning aerobatic biplane is pretty steep, probably on the 1500-2000FPM range. I checked my altimeter, saw I was descending through 4,000 feet and decided to try to recover the airplane before bailing out. AND HERE IS THE IMPORTANT POINT: BECAUSE I REFUSED TO ACCEPT THAT THE AIRPLANE WAS COMPLETELY EFFED I would nearly die. My mind knew before then, as it knows now, that if you put a Pitts-like airplane into an autorotational state the only thing that is going to get it out is opposite yaw. With no rudder THERE CANNOT BE ANY OPPOSITE YAW!! I had thousands of hours in similar aircraft, I was an unlimited category competition aerobatic pilot and instructor, and yet when faced with the obvious I could not process it quickly enough, despite having the evidence staring me squarely in the eye, to react quickly enough to prevent me from nearly dying.

So I frittered away precious moments trying to use opposite yaw via ailerons, shots of engine thrust, hell I might have even prayed, I don’t know. What I know now is I could have done better. What I also know now, and somehow managed to forget then, was that I was over the Altamont. When I saw 4000’MSL and thought “OK, I’ve got time to play with this” the reality was I was over a hill- that was 2134’ high. Tracy- just 20 miles away and where I was headed sits at 193’ MSL.

In my mind, because I was stupid overwhelmed, or just unable to process everything being thrown at me I had maybe 3500-4000’ to play with. So I could spend 30 seconds fighting the airplane to try to recover it before I had to bail.

In reality I had less than 2000’ before I would be dead.

I spent probably ½ to ¾ of the real time I had to get out of the airplane in it- fighting to try to save it, and I did this by deliberately ignoring what I already knew (I had lost rudder control completely) what I should have known (I was over the Altamont) and what I should have accepted (I had to go- the Goshawk was not going to survive this, the only real question was would I??)

I obviously did reach the (already foregone but stubbornly ignored by me) conclusion that the airplane was unrecoverable and decided to bail out- which is an interesting concept in a stable spinning airplane. I undid my harnesses as I had practiced, and I fought my way out of the airplane- pinned against the left side of the cockpit coaming by the rotational g-forces before eventually getting enough of my upper body into the slipstream that I was basically yanked out of the airplane. I was falling in a fetal position, thought about waiting to pull the ripcord, said eff-it and pulled, and after the shocking introduction to my first and (so far) only canopy opening was struck by the sound of the airplane smacking into the ground just a second or two later. Future calculation efforts would show that my chute opened between 134 and 200 feet above the ground, which at that rate of descent equaled a couple of seconds at best.

Surviving that incident has given me some small window of insight into what happens when your comfy world devolves in seconds into one where you know you are about to die.

The biggest lesson, and the greatest ego-killer was simple: I didn’t respond nearly as I would have hoped I would. It took me countless seconds to register the fact of the failure. I knew as soon as the pedal fired away from my foot what had happened. But my mind simply refused to accept that reality for some short period of time. The second error was equally simple: I thought I was the hero pilot (Neil Williams etc…) who would bring my crippled plane back to the airport, thereby saving the day. That thought nearly cost me my life, as I wasted precious seconds performing an absolutely useless dance of fancy “airmanship” that did nothing but allow my airplane to bring me closer and closer to the ground with every moment.

And now to the main point of this entirely too-long post: For those of you who suppose you will see everything clearly and “FTFA” when your own fatal opportunity presents itself please hear me when I say this: YOU WILL NOT!! The question that will determine your survival is how quickly will you move past that initial shock and be able to function properly again. In my case it was a single (albeit fatal) failure. I was extremely well trained, averse to panic-driven responses, and well-able to handle the emergency I had been presented with. Yet I wasted probably a full minute in an airplane I had no business being in any longer.

In the 737 crashes it was a cascade of failures. My own- very rare life experience tells me that those pilots had little chance given the stressors they were working under, as would the rest of you. These are not the words of someone who doesn’t know what it’s like. I’ve been there. I lived. So please trust me when I tell you that your vaunted talents will wither to nothing if someday you are in this unfortunate position. At best you will be semi-functional, at worst you will be functionally useless.

What you will not be, in any context, is a hero who defies these realities.

Final note: This isn’t about placing blame on anyone. Boeing designed an airplane with a crap system that had random and unmonitored control over the single most important control surface of the aircraft. The FAA paved the way for certification of the airplane, and once in the hands of pilots that airplane not once, but twice flew itself into the ground. (The pilots didn’t- it was MCAS that did, and that’s an important fact to take note of…) You can blame the pilots all you want, but it was the airplane itself that had a failure mode that required the pilots to be perfect or die. Boeing had years to create a functioning system that would not put the pilots in this position and they failed to create one. So the two (six really) pilots were left to defend themselves against an airplane that was trying to kill them. Four failed in that endeavor, and they have my utmost respect and gratitude.

Only those who have walked the path and survived can understand the fine line between winning and dying- which is why I have posted this ridiculously long post tonight.

Sorry for the sermon, just tired of reading the constant back and forth about who we should blame.

Link to the Final on my incident: Well despite being a member for years I haven't reached the vaunted 10-post threshold for posting URLs. Search "NTSB June 17, 1996 N345RM" for the final report.

Regards,
dce
Dear DCE, the only thing I disagree with is that Your "story" was too long. Not at all, it could not be shorter, though You are a talented writer.
//M
Marian Blacharski is offline  

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