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Ethiopian airliner down in Africa

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Ethiopian airliner down in Africa

Old 15th Mar 2019, 10:32
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Originally Posted by oldchina
Rated De said "As year after year business schools pump out MBA graduates the only thing they conceive is cost and lowering it"

Stop and think whether this is not utter nonsense.
You imagine Airbus gave the A320 a seven inches wider fuselage than the 737 to save operating cost?
Did they build the MCAS?
MCAS saved re-certification cost. It appears increasingly likely that a system considered necessary for safety wasn't explained and trained to the pilot. Why do you think that would be?

Post graduate courses are indeed pumping out the said graduates.
When did Airbus actually design the A320?

Go and listen to the opinions of the Boeing engineers who actually used to build the product.
Listen to what they say changed. Then have a look at any Ivy league business school, read the curriculum, look at the individual modules and see what the graduate is focused upon.

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Old 15th Mar 2019, 10:39
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Originally Posted by calypso
Three crews managed the above but the fourth got overwhelmed in the Lion Air case. The Ethiopian on the face of it looks quite similar but there isn't enough data yet to even have a guess. A bit of a mess but where I tend to agree with Boeing is in which way is this any different from a classic runaway stabiliser? Ok there is more distractions going on but bottom line is if the stabiliser starts to run and you dont get on those disconnect switches soon enough you will end up in the same place.
Two crashes and 3 near crashes, that means that only above average (or more lucky) pilots can avoid a crash after a single AOA sensor failure...

It would be interesting to know whether the MCAS ever was activated and avoided a stall in nominal conditions

Last edited by deltafox44; 15th Mar 2019 at 10:39. Reason: typo
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Old 15th Mar 2019, 10:49
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"The normailization of deviance." This. Exactly this. Shown to be a factor in many disasters, including Challenger. Sober thinking, smart people advised against certain actions and designs, and were shut down by others worried more about short term costs or schedule pressure.
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Old 15th Mar 2019, 10:52
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Originally Posted by CONSO
Bird strike or ramp rash or software error are three most obvious- the point is to alllow a SINGLE sensor to directly override pilot input and not be documented that it even exists is as close to criminal as one can imagine.
There is no such thing as 100% reliable sensor. You can vote in software, but in case of two sensors you dont know, which value is OK and which is bad, you need at least three to have confident voting system. There are much better options sw engineer can use, if he knows something about the subject and phisical reality it deals with. I'm just plain earth based industry programmer, but can imagine some verification methods that works even with one sensor. The basic method is to observe sensor behavior in time, just as you watching if it works by your own eyes, in many phases of flight.
- during the takeoff run just before plane goes airborne, you can assume that values AoA should be close to zero. If not, sensor is stuck or misaligned.
- after that should the values change to positive normal range, if not, the sensor is stuck. This is also the case of normal in/flight behavior, values in acceptable range, that change slowly and possibly with small difference between two sensors according to actual flight conditions. So you can tell its still living and not stuck somewhere.
And the most significant, dont check for value constantly over the set threshold. You should check if value rises from accepted range dynamically and in one moment oversets it, then act.
Programmers working for Boeing or component manufactors should have known this. I'm somewhat surprised they obviously dont. Or maybe the flight computer is totally out of resources after mods.

Last edited by Prag; 15th Mar 2019 at 12:19.
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Old 15th Mar 2019, 10:58
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Originally Posted by deltafox44
The FR24 data do NOT show that.

After about 45" roll (05:38:45.798) and for 5 seconds the ground speed is stable at 182/183 kts while the vertical speed is positive, reaching 2368 ft/mn. Though the pressure altitude is not consistent with the speed and vspeed evolution, speed and vspeed indicates the aircraft is already airborne and climbing at 182 kts (about 170 kts IAS). And one minute later it has gained 1000 ft and speed (250 kts). Then only the problems begin, may be after retracting the flaps.
The first thing I would normally do with FR24 data, after correcting for QNH, is to throw away transmitted VS values.

The aircraft climbed fairly steadily before levelling off at approximately 1050' AAL just over 60 seconds after rotation, so 2000+ fpm at any point seems a tad unlikely.
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Old 15th Mar 2019, 11:11
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Originally Posted by deltafox44
The FR24 data do NOT show that.

After about 45" roll (05:38:45.798) and for 5 seconds the ground speed is stable at 182/183 kts while the vertical speed is positive, reaching 2368 ft/mn. Though the pressure altitude is not consistent with the speed and vspeed evolution, speed and vspeed indicates the aircraft is already airborne and climbing at 182 kts (about 170 kts IAS). And one minute later it has gained 1000 ft and speed (250 kts). Then only the problems begin, may be after retracting the flaps.
You must be looking at different data then.
The vertical speed is positive but nothing happens to the altitude till 207 knots is reached. The other possible scenario, which is probably more likely, may be that the aircraft was carrying out a Flaps 1 takeoff, which would be consistent with the speeds reached on the runway at rotate and the gear up call, (the 182 knots). The brand new FO, who at 200 hours may have been doing his first line sector, then inadvertently selected flap up instead of gear up. The aircraft settled back on to the runway and the captain rotated again at 207 knots, which would be a normal recovery, but now the MCAS is activated in a hot and high, extremely low altitude situation.

We will know soon anyway. The flight recorders are being looked at now in Germany.
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Old 15th Mar 2019, 11:15
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Originally Posted by Capt Kremin
You must be looking at different data then.

We will know soon anyway. The flight recorders are being looked at now in Germany.
I thought that they were in France.

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Old 15th Mar 2019, 11:16
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I think that Capt Kremin is out of touch!
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Old 15th Mar 2019, 11:22
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Originally Posted by jsypilot
I thought that they were in France.
They are. Presumably at Le Bourget, HQ of the BEA.

I don't buy the "double rotation" scenario either.
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Old 15th Mar 2019, 11:22
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Wondering if / when was AP engaged on ET302 - FDR will tell

Last edited by N600JJ; 15th Mar 2019 at 12:25.
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Old 15th Mar 2019, 11:25
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Originally Posted by bud leon
It's utter nonsense for many reasons, not least because of this odd idea that getting an MBA turns humans into sociopaths. All this rhetoric about bean counting, criticism of an aviation culture that has become one in which the industry doesn't care if people die, that pilots can't fly planes any more, and that technology has made planes unsafe, flies in the face of aviation safety statistics which show a continuous reduction in fatality frequency that any industry would be immensely proud of.

We simply do not live in a world in which humans don't make mistakes. To err is human. We must always learn from mistakes, and the history of aviation safety is an exemplar of that. Excluding malicious acts, every single death in the history of travel has occurred because one or more people made a mistake in strategy, decision making, design, or operation. It's quite possible that the Max story is going to become a classic safety case study. But witch hunting doesn't get us anywhere.

So the statistics of which you speak saw the Challenger launch successfully 10 times.
So the statistics of which you speak saw the 737 MAX fly successfully until it didn't last year. Statistically, extrapolating the hull loss of the 737 MAX indicates that the hull loss rate is now intolerable.
So which statistical data set is the valid sample?

The focus of the post graduate program in the modern age is to be relevant to business. Perpetual profit in a finite world is utter nonsense, yet every graduate is taught grow revenue and cut cost. Seemingly inexhaustible right?
How low can cost be cut before it matters? An endless loop question?
Nobody stated the graduates were sociopaths, that is alarmist. What is obvious to those of us who witness it is that these graduates know little of process, know little of design. Their skill set can be readily applied to any corporate endeavour. After all it is marketed as an Masters of Business Administration (Generic) One size fits all.

The normalisation of deviance is not a witch hunt, it is a scientific investigation into acceptance of deviance from safe practice.
The deviation takes place an increment at a time. Boeing engineers foretold their concerns about Boeing. The very people charged with building the product stated the process had been compromised.
Their focus was not to be quality, rather schedule and self evidently cost.

Management documents state that clearly, deviation from accepted quality was permitted to protect schedule. Not the 737 MAX program incidentally, it was the 787.
Similarly, the NASA engineers had their concerns with O-Ring by pass. As did the engineers of Morton Thiokol.
Progam management dismissed their concerns, focused on schedule and budget.

Sound familiar?
Program cost, budgets, schedule and commercial viability overcame opposition from concerns for launch integrity. Everybody knows what happened next.

The case study of which you speak need not have been the 737 MAX. People made mistakes in design, strategy, decision making and operation.
The Boeing 787 program had all the hallmarks, the engineers in Boeing noticed the change, they called out the deviance. Statistically they have gotten away with it so far.

Perhaps the 737 MAX need not be a case study, the Challenger Launch Decision shows the template to anybody bothered enough to read it, having read it, the similarities are stark.

If this horrible loss of life was triggered by the same system that is believed responsible for the Lion Air accident, then statistically Boeing is going to have a hard time pointing to their statistics.












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Old 15th Mar 2019, 11:29
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Originally Posted by bud leon
It's utter nonsense for many reasons, not least because of this odd idea that getting an MBA turns humans into sociopaths. All this rhetoric about bean counting, criticism of an aviation culture that has become one in which the industry doesn't care if people die, that pilots can't fly planes any more, and that technology has made planes unsafe, flies in the face of aviation safety statistics which show a continuous reduction in fatality frequency that any industry would be immensely proud of.

We simply do not live in a world in which humans don't make mistakes. To err is human. We must always learn from mistakes, and the history of aviation safety is an exemplar of that. Excluding malicious acts, every single death in the history of travel has occurred because one or more people made a mistake in strategy, decision making, design, or operation. It's quite possible that the Max story is going to become a classic safety case study. But witch hunting doesn't get us anywhere.
You should read the book "Managers, not MBA's" by McGill's Henry Mintzberg to understand what he is getting at. Training people to hit quarterly eps targets so that you make your bonus deters from long term planning and encourages short term fixes.
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Old 15th Mar 2019, 11:56
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gums thanks for the reply jimtx i did not read all the pages so excuse me.. i was just wondering if there was something more to this. just wanted to know if the MCAS system has its own non controllable trim motors that we cant shut off in the cockpit!!! I know how its is supposed to work based on what I have been trained on. I flew one on tuesday and had NO issues. And by the way 20k plus years and hours in the 737!
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Old 15th Mar 2019, 11:58
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Originally Posted by WHBM
This seems a poor FAA perspective. By definition, 50% of pilots will be below that average skill level.

Particularly when they only have 200 hours total.
It is what is written in part 14 of the electronic code of federal regulations. And while youre looking there, take a look at chapter 25. 672

Ttfn
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Old 15th Mar 2019, 12:04
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Originally Posted by Capt Kremin
One options suggested by the FR data is that there was no flap set for takeoff.

The data shows a 63 second ground roll followed by a rotation at 207 knots. At this point the MCAS may have simply been doing its job.

Hard to believe this would happen, but it's happened before.
1. I don‘t think it is possible to survive a flapless T/O at this density altitude and take off mass.
2. Even if they did - after reaching 1000ft and 300kt everything is fine and they could have continued the flight. However, here the disaster started at this point of the flight.
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Old 15th Mar 2019, 12:16
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Would the reported high speed of the aircraft in the latter stages (383 kts, as cited upthread) go to explain the 'falling debris' mentioned by eyewitnesses? Could that speed have started to initiate hull breakup, or detaching of some other components?
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Old 15th Mar 2019, 12:24
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Originally Posted by silverstrata


Sure about that? Someone new to the aircraft, captain average, and a bit tired.

At 3,000 ft, the stick shaker starts going like mad, causing a hell of a racket, and you think you have an airspeed problem and might be stalling. Sure, the controls are getting heavier and heavier, and you trim a bit for that, but this is caused by the aircraft stalling - isn’t it? (You cannot hear the trimmer, over the din of the stick-shaker.) So you have to let the nose drop, untill you are sure you have enough airspeed.

Ok, you are getting a bit low now, time to pull back. Ahh, but the aircraft will not respond - pull as hard as you like, but the stick feels jammed (you need 60 kg of force to counter full stab-trim). You shout to the f/o to help pull, but the ground is coming up fast.... End of short story...

Silver
I guess that could be plausible if you overlook 3 airspeed indicators, moving trim wheels, control force on the yoke, aircraft attitude. Someone who does all that has failed at his primary job of being a pilot. I have had several incorrect stall warnings including two at rotation. A 1 second cross check showed they were in error.
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Old 15th Mar 2019, 12:35
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Originally Posted by WHBM
If that is the case then there is likely only one version of the code (eases management of it), but a flag set Yes or No if the fee has been paid or not.

If so, and the right code to avoid the issue was actually installed in the aircraft but deliberately switched off, lawyers for the pax, especially those from the second accident, will have a field day.
The display options that Southwest and others purchased provides digital readout of AOA as sensed by each of the AOA vanes and a light bringing attention to significant disagreement between those two measurements. It is my understanding that the pair of digital displays and the disagree light may be fitted or just the disagree light. The operation of the control laws and the stick shakers that are driven by the AOA vane sensors are the same whether or not these display options are included on the flight deck.
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Old 15th Mar 2019, 12:45
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Originally Posted by FCeng84
The display options that Southwest and others purchased provides digital readout of AOA as sensed by each of the AOA vanes and a light bringing attention to significant disagreement between those two measurements.
Are you referring to the AoA display on the PFD, or to a separate annunciator that isn't present at all on non-equipped aircraft?

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Old 15th Mar 2019, 12:47
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For comparison, Volkswagen lost over 60% due to their emission scandal. But this could be, and should be big if it's due to MCAS.
A ridiculous comparison. VW set out to deceive and cheat the emission testing for commercial gain. Boeing added a function to enhance safety when operating at the edge of the envelope, somewhere most crews should and will never be but perhaps a faulty sensor and lack of a second input has caught them out.
Just remember that the crew who flew the affected Lion Air aircraft the day before the fatal managed to land safely. There are trim cut outs, manual trim and electric trim all of which override MCAS inputs.
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