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MAX’s Return Delayed by FAA Reevaluation of 737 Safety Procedures

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MAX’s Return Delayed by FAA Reevaluation of 737 Safety Procedures

Old 24th Sep 2019, 13:44
  #2581 (permalink)  
 
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Originally Posted by OldnGrounded View Post
Sure, it could be trained, but there would be no need for such training if the system didn't do that. Presumably, going forward and assuming that the MAX gets back in the air, it won't do that.
I quite agree. Personally, I think it is very unlikely that MCAS will ever cause another aircraft accident. However, I think it is almost certain that in the not too distant future there will be another novel malfunction on another aircraft with another crew, and the specific training issues that I mentioned will be a factor in how well that crew responds.
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Old 24th Sep 2019, 13:57
  #2582 (permalink)  
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Originally Posted by Tomaski View Post
I quite agree. Personally, I think it is very unlikely that MCAS will ever cause another aircraft accident. However, I think it is almost certain that in the not too distant future there will be another novel malfunction on another aircraft with another crew, and the specific training issues that I mentioned will be a factor in how well that crew responds.
No disagreement with that. I just wanted to say that some malfunctions -- notably those related to automatics not understood by pilots -- can be very difficult to recognize and react to, and that training to deal with those is especially likely to be inadequate.
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Old 24th Sep 2019, 14:17
  #2583 (permalink)  
 
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Fly Aiprt, #2572, and comments / diagrams thereafter, tomaski et al.

‘AoA Disagree’ was an option in those aircraft with ADCs which use AoA for internal corrections, e.g. 737 NG. Thus the AoA alert can provide some supporting understanding of an ADC sensor disagree, Speed, Alt, but where all of these systems have an abnormal procedure to compare indications with the appropriate stand-by indicator - use best 2 out of 3, the AoA alert is superfluous in those instances.

The stick shake is similar, but it is very poor practice (not suitable for certification ?) to use an ‘associated’ AoA Disagree alert to deduce the reason for the stick shake. An AoA malfunction is equally likely to be a low value opposed to a high one (MCAS excepted?), thus providing opportunity for a true stick shake to be falsely deduced as an AoA problem - similarly with the display of AoA.

The optional display of AoA value may have be an operational requirement, thus AoA Disagree required. AoA information is already within the EFIS speed display of low speed awareness.

A major weakness of a stand alone AoA display is that with dual system sensors, if one malfunctions it is impossible to identify which of the two is correct (the MCAS saga), additionally many other systems can be ’confused’; irrespective of the disagree alert.
Both EFIS displays should be removed with a disagreement to prevent incorrect interpretation.


Re ‘MCAS active’ - red indication. This display would be unacceptable for certification as it violates the requirement to only use ‘red’ level alerting for failures requiring urgent attention or action (see trim below). The alert also violates recommended principle of not to annunciate normal operation of background systems, e.g. STS.
Alerting for MCAS unavailability could be required if it’s absence affects flight handling.

We can assume that MCAS failure, continuous trim operation as in the accidents, must not happen again (within certification probability) - OnG #2580, but the unrelated trim runaway could occur as the system is unchanged from previous aircraft.
Thus the lesson is that any unwarranted trim operation - ‘PITCH TRIM’ should be alerted in Red for urgent action to isolate the trim system. Alternatively the trim system integrity should be improved (ongoing delay?). This could be a challenging task due to the many inputs and modes of trim operation.
This is aside from the problems of moving the trim wheel to restore a trimmed condition.

The central issue involves awareness, perception, and comprehension, thus display improvements must aid these. Be careful what you assume, what you wish for, or think that can be trained.


Last edited by PEI_3721; 24th Sep 2019 at 15:53.
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Old 24th Sep 2019, 14:17
  #2584 (permalink)  
 
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Originally Posted by Tomaski View Post
Real life does not go by script, nor is there any prohibition against multiple or ambiguous malfunctions.
Nice thoughtful post.

Not only is there no prohibition against multiple or ambiguous malfunctions, but in some case
their occurrence is by-design (intentional or not). Naively as SLF I assumed that this would
be identified by some sort of dependency-tree analysis at design-time, and their occurrence
identified and prevented if possible, or at least allowed for in operating procedures.

AoA-high failure seems to be a perfect example, leading to the triggering of things like UAS,
autopilot drop-out, stall-warnings, and inappropriate MCAS activation (in the absence of flaps
and other blocking states).
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Old 24th Sep 2019, 14:48
  #2585 (permalink)  
 
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Originally Posted by PEI_3721 View Post

The optional display of AoA value may have be an operational requirement, thus AoA Disagree required. AoA information is already within the EFIS speed display of low speed awareness.

A major weakness of a stand alone AoA display is that with dual system sensors, if one malfunctions it is impossible to identify which of the two is correct (the MCAS saga), additionally many other systems can be ’confused’; irrespective of the disagree alert.
Both EFIS displays should be removed with a disagreement to prevent incorrect interpretation.


That's why I drew the AOA indication with a big red bar on it , showing it is no longer available or reliable.
It seems general aviation EFIS industry is ahead on this matter.

Originally Posted by PEI_3721 View Post
Re ‘MCAS active’ - red indication. This display would be unacceptable for certification as it violates the requirement to only use ‘red’ level alerting for failures requiring urgent attention or action (see trim below). The alert also violates recommended principle of not to annunciate normal operation of background systems, e.g. STS.
Alerting for MCAS unavailability could be required if it’s absence affects flight handling.
Agreed. I drew it in red because some times ago, MCAS activation was synonymous with "this aircraft is trying to kill you".
Any color would do.
As to not annunciate normal operation etc., disagree.
When STS operates, wheels do turn, clicks and white bars have been provided to make the crew aware of the activation.
Most every variation on the theme of "the crew should have identified" relies on this signal of activation.
Except that having something clearly in the field of vision is far more ergonomic.
Same for the MCAS, which should show when it activates, if only to signal some corner of the flight/AOA envelope is being entered.
Just like the bars for low speed on the speed ribbon.

One must not reason in terms of "we've always done it that way".
Obviously things are to be changed in ergonomics and training.
Presenting AOA indication at a useful place is viewed as an improvement. If pilots disagree, they are free to not include it in their scan. Or ask for more and better training ;-)
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Old 24th Sep 2019, 14:52
  #2586 (permalink)  
 
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Originally Posted by Fly Aiprt View Post
Wasn't aware of this version of the document - or had forgotten it - on Leeham News.
Even without clear units, control column forces seem no trifle, as expected with mistrim, hence the notion of fatigue.
Can't comment on that. I'm not familiar with the force required at any stage to correlate to.
And don't know his physical condition to say how long he could hold such force.
(I know today I could pull with 25 lbs of force a lot shorter time than I could 20 years ago)
The split between the yokes occurs when one pilots pulls (or push) harder than the other. Posted a drawing of the mechanism long ago.
F/O pull drop : with the aircraft finally doing a bunt, the acceleration goes negative and the pilots are thrown from their seats. If not very tightly restrained, keeping pulling on the yoke might be difficult.
Maybe, but I'd assume when the F/O was looking in the QRH he wasn't pulling, yet the 2 graphs follow closely.
When the captain started looking the F/O's force goes much higher than his side. That's the oddity.
Hoping the report sheds light on that too.

I am concerned that the focus on MCAS has overlooked other issues. Some is covered by EASA's requests, but they may be more.
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Old 24th Sep 2019, 15:02
  #2587 (permalink)  
 
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Any pilot used to hand flying would then instinctively wind in back trim to lighten the control load. As Tomaski said above, why they did not do this is a germane point.
How many revs of the trim wheel to ' wind in " say 2 degrees AND in say 5 seconds? AT 200 kts?

Previous threads and comments seem to say perhaps 50 turns-while at negative G assuminy you can reach handle, and apply enough torque

Of course, realizing that system was fubar, you had switched off all electric to kill a system you didn't know existed, and that HAL would repeat forever, or until you were vertically/ parked.
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Old 24th Sep 2019, 15:26
  #2588 (permalink)  
 
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Exclamation FAA lack of Candor to Congress

From WAPO

WASHINGTON – Investigators examining a whistleblower complaint have concluded that safety inspectors who worked on training requirements for Boeing 737 Max pilots were themselves “underqualified” – and that the Federal Aviation Administration provided misleading information about the issue to Congress.

The findings of the U.S. Office of Special Counsel, which independently investigates whistleblower complaints, have added to questions about the effectiveness and transparency of safety oversight at the FAA, which has come under scrutiny after two new 737 Max jets it had certified as safe crashed in Indonesia and Ethiopia, killing 346 people.

Boeing and the FAA have faced intense criticism for failing to make sure pilots had the information and training necessary to handle any problems with a new automated safety feature on the Max, known as the Maneuvering Characteristics Augmentation System, or MCAS. Investigators say the feature, fed by faulty data from a sensor, repeatedly misfired, forcing the nose of both planes down before they crashed.

In a letter to President Donald Trump on Monday, Special Counsel Henry Kerner wrote that “FAA’s official responses to Congress appear to have been misleading in their portrayal of FAA employee training and competency.”

Information provided by the FAA “obfuscates” concerns about the preparation of safety inspectors and “diverts attention away from the likely truth of the matter: that they were neither qualified under agency policy to certify pilots flying the 737 Max nor to assess pilot training on procedures and maneuvers.”

“The FAA is entrusted with the critically important role of ensuring aircraft safety,” Kerner added in a statement. “The FAA’s failure to ensure safety inspector competency for these aircraft puts the flying public at risk.”

In a statement, the FAA said: “We are reviewing the Special Counsel’s letter. We remain confident in our representations to Congress and in the work of our aviation safety professionals. Aviation safety is always our foremost priority, and we look forward to responding to the concerns that have been raised.”

On April 2, Sen. Roger Wicker, R-Miss., chairman of the Senate Committee on Commerce, Science and Transportation, queried the acting FAA administrator about claims from whistleblowers “that numerous FAA employees, including those involved in the Aircraft Evaluation Group (AEG) for the Boeing 737 Max, had not received proper training and valid certifications.”

Wicker also wrote that some of those employees may have been part of an FAA group, known as a Flight Standardization Board, formed to “develop minimum training recommendations” – specifically for the new Max jets – and ensure that pilots have all the necessary information to safely fly them.

Wicker wrote that the FAA “may have been notified about these deficiencies as early as August 2018” and that the committee “is led to believe that an FAA investigation into these allegations may have been completed recently.”

There had indeed been such an investigation by the FAA’s Office of Audit and Evaluation, which considers whistleblower cases and other internal and external reports of aviation safety violations. That office is meant to provide an “independent venue for the conduct or oversight of objective, impartial investigations and evaluations,” according to the FAA, and it reports to the FAA’s top official.

On April 4, then-acting FAA administrator Daniel Elwell responded to Wicker, saying, “we can confirm that all of the flight inspectors who participated in the Boeing 737 Max Flight Standardization Board certification activities were fully qualified for these activities.”

On May 2, Elwell added that “It is not accurate . . . to suggest that this whistleblower disclosure and investigation implicated the qualifications of the Boeing 737 Max Flight Standardization Board (FSB) and the FSB’s evaluation of the Maneuvering Characteristics Augmentation System.”

In a letter dated June 3, the Trump administration’s top lawyer at the Transportation Department, Steven Bradbury, wrote to Kerner saying that the “FAA has confirmed” that qualifications of Max inspectors were not an issue. Bradbury said the whistleblower’s “allegations have already been investigated.”

But Kerner, whom Trump appointed in 2017, said his investigators “obtained internal FAA communications and conducted employee interviews, which adduced credible information directly contradicting the [FAA’s] assertions” to the Senate Commerce Committee.

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The information “specifically concerns the 737 Max and casts serious doubt on the FAA’s public statements regarding the competency of agency inspectors who approved pilot qualifications for this aircraft,” wrote Kerner, who served on the House Oversight Committee under Republican chairmen Darrell Issa of California and Jason Chaffetz of Utah, and also worked on investigations for the late senator John McCain, R-Ariz.

Kerner wrote that emails reviewed by his office “show serious concerns” within the Office of Audit and Evaluation “regarding the veracity of the agency’s public statements, particularly after the FAA’s final response was transmitted to the Committee.”

The FAA’s Office of Audit and Evaluation “determined” that safety inspectors for the Max “had not met qualification standards. Specifically, these [inspectors] had not received formal classroom training as required by” two FAA orders, Kerner wrote. Another FAA division agreed with that interpretation, but “this information does not appear in the final” Office of Audit and Evaluation report on inspector training issues, according to Kerner.

An attorney with the Office of Special Counsel said the office “will not speculate as to why this information does not appear.”

A point of disagreement has been whether FAA orders require aviation safety inspectors to have both formal classroom training as well as on-the-job training to do their jobs. Elwell, for example, had argued that were “ambiguities in the FAA’s policy” regarding training requirements for safety inspectors and said the whistleblower’s concerns “provided the FAA with an opportunity to improve our internal systems and procedures.”

An April memo prepared for Elwell by Ali Bahrami, the FAA’s top safety official, argued that while FAA officials at a key division “believe formal training should be required, the current guidance language allows either formal training” or on-the-job training.

The Office of Audit and Evaluation reported in February that it had reviewed training records for all aviation safety inspectors assigned to an office in Seattle, where the Boeing 737 Max was evaluated, and in Long Beach, where questions about inspector training were first raised by the whistleblower concerning a separate Gulfstream aircraft.

The FAA auditors “found 16 of 22 (73%) have not completed the required formal training course. Worse yet, at least 11 of the 16 do not qualify to enroll in the course because they do not hold a Certified Flight Instructor certificate,” they wrote.

Among those were the three members of the Flight Standardization Board for the Boeing 737 Max, according to the Office of Special Counsel.

As the investigation into the Max crashes continues, the FAA met Monday in Montreal with dozens of international aviation regulators. Although U.S. officials had hoped for broad global agreement on when to allow the plane to fly again, FAA Administrator Stephen Dickson seemed to acknowledge that will come in phases, saying the agency is primed to help “as you make your own decisions about returning the Max to service.”

Noting that “accidents in complex systems rarely are the result of a single cause,” Dickson also said international regulators will need to target “improvements in standards and approaches for not just . . . how aircraft are designed and produced, but how they are maintained and operated.”
ImagIne that - lack of candor = in simple terms they lied
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Old 24th Sep 2019, 15:28
  #2589 (permalink)  
 
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Originally Posted by Tomaski View Post
The underlying presumption in this particular case is that the pilots could have used the fully functioning Main Electric Trim to return the aircraft to somewhere close to an in-trim state before turning off the electrics. Yes, we know that didn't happen, and the reason why that didn't happen is an important discussion. However, we need to first recognize that the capability was actually there.
That presumption is an assumption that might not turn out to be valid. Absent reports of actual flight tests with MCAS (as it was) triggering, and knowing the the sims are now being found to be inaccurate in this area (e.g. trim wheel forces) there are only three crews who have tested this assumption, two of them crashed.

First LionAir flight seems to have managed, but not sure we know who was flying. Second LionAir flight the Captain appeared to be losing but only gradually, but it appears (although I'm not sure it's been confirmed) that he handed over to the FO who didn't seem to have the capability.

ET flight, in contrast, the Capt appeared to be losing but after one MCAS asks the FO to "trim up with him" which seems to result in much longer period of Main Electric Trim followed by call to cut-out (why? maybe MET stopped working? - they certainly weren't back in trim).

What does this mean? - I don't know. Any 737 driver ever asked colleague to help with the trim switches, ever? (and if so, why). After Lion I would have absolutely agreed with you, from an engineering point of view the capability is there. But after ET report, I don't know any more. That call for assistance in trimming up needs investigating.
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Old 24th Sep 2019, 15:31
  #2590 (permalink)  
 
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Originally Posted by NutLoose View Post
Compensation being offered by Boeing over family losses is a pittance USA wise, I would have expected at least a naught on the end.

https://www.bbc.co.uk/news/business-49803068
Kind of sparse on details. How was the number derived from the $50m in the fund? What is the rest of the fund to be used for?
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Old 24th Sep 2019, 15:40
  #2591 (permalink)  
 
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Originally Posted by Speed of Sound View Post
Why in god’s name was this offered as an optional extra?
The AoA indicator was the option, not the disagree warning. The disagree warning was supposed to be standard. It was a mistake, due to be fixed in the next update. It was not considered serious enough to warrant a special release for just that.

Comes back to the FHA/FMECA and the criticality of the AoA sensor, MCAS, and a host of other systems.

Originally Posted by Peter H View Post
Naively as SLF I assumed that this would be identified by some sort of dependency-tree analysis at design-time, and their occurrence identified and prevented if possible, or at least allowed for in operating procedures.


FHAs/FMECAs only look at single faults. They do look at how that fault propagates through the system, though it is up to humans to determine the likelihood of a given fault and how critical the effects are.

What they don't do is look at multiple faults. There are just too many possible combinations.

Just like exhaustive testing is impossible (at least impractical) on complex systems.
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Old 24th Sep 2019, 16:16
  #2592 (permalink)  
 
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Fly Aiprt,
we debate the same issues, but from differing viewpoints.

Your disagreements about alerts, colour, etc, would have to be compared with existing certification requirements or changed via a time consuming alternative means of compliance.

Re … must not reason in terms of “we have always done it that way”
Yet, many of the 737 Max MCAS problems stem from alternative reasoning; attempting to mimic a modern protected flight control system in an old aircraft design.

Similarly applying modern training assumptions and technique to an aircraft which did not have sufficient similarity to precious versions.

Presenting AOA indication at a useful place is viewed as an improvement. If pilots disagree, they are free to not include it in their scan.”
I strongly disagree on both counts; the ‘ignore’ view promotes a cluttered display. Having to disregard an ‘irrelevant’ display feature is as mentally demanding as looking at and understanding an indication.
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Old 24th Sep 2019, 16:51
  #2593 (permalink)  
 
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Originally Posted by PEI_3721 View Post
Presenting AOA indication at a useful place is viewed as an improvement. If pilots disagree, they are free to not include it in their scan.”
I strongly disagree on both counts; the ‘ignore’ view promotes a cluttered display. Having to disregard an ‘irrelevant’ display feature is as mentally demanding as looking at and understanding an indication.


PEI, that was addressing the statements of some pilots as to an AOA indication being of no use. Or course they should be trained - or re-trained.
Re cluttered display, I do not know what to make of a small dial with AOA in the upper right corner, and a small additional "AOA disagree" message in the left lower corner.
Would this really fit seamlessly into the standard scan, and not be mentally demanding ?
Displaying a big red bar or cross over unavailable information has become pretty standard in non-certified aviation.

Last edited by Fly Aiprt; 24th Sep 2019 at 23:53.
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Old 25th Sep 2019, 05:57
  #2594 (permalink)  
 
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Changed training regime

Originally Posted by Tomaski View Post
  • Overly-scripted training. Pretty much every where, training has become a series of scripted malfunctions that are known in advance. Multiple malfunctions are not presented. There is little, if any, use of surprise or ambiguity. Real life does not go by script, nor is there any natural law prohibiting multiple or ambiguous malfunctions.
I don't disagree, but I suspect that as soon as check rides changed to be unscripted with potential for multiple malfunctions, a significant proportion of pilots would fail.
At best, they would then need (possibly significant) retraining before they passed a re-check.
At worst, some might never pass: they either lack the natural talent or are too deeply engrained with the 'old stuff' to cope with the 'new stuff'.
Either way, it would hugely increase training costs and put a constricting bottleneck in the pilot supply chain, and would therefore be furiously opposed by the airline companies.
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Old 25th Sep 2019, 07:38
  #2595 (permalink)  
 
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Any pilot used to hand flying would then instinctively wind in back trim to lighten the control load. As Tomaski said above, why they did not do this is a germane point.
How many revs of the trim wheel to ' wind in " say 2 degrees AND in say 5 seconds? AT 200 kts?
Why not use the electric trim which halts MCAS trim input?
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Old 25th Sep 2019, 09:42
  #2596 (permalink)  
 
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Some of the Federal Aviation Administration inspectors who worked on training requirements for the troubled Boeing 737 Max planes and other aircraft were underqualified and the air safety agency misled lawmakers about it, federal investigators said Tuesday.

The FAA’s Office of Audit and Evaluation in February said it found that 16 of 22 safety inspectors did not complete formal training while 11 of the 16 lacked flight-instructor certificates.

https://www.cnbc.com/2019/09/24/fede...qualified.html
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Old 25th Sep 2019, 12:22
  #2597 (permalink)  
 
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Originally Posted by kiwi grey View Post
I don't disagree, but I suspect that as soon as check rides changed to be unscripted with potential for multiple malfunctions, a significant proportion of pilots would fail.
At best, they would then need (possibly significant) retraining before they passed a re-check.
At worst, some might never pass: they either lack the natural talent or are too deeply engrained with the 'old stuff' to cope with the 'new stuff'.
Either way, it would hugely increase training costs and put a constricting bottleneck in the pilot supply chain, and would therefore be furiously opposed by the airline companies.
Sadly, I agree with your assessment. That's why the cynical side of me has on occasion opined that unofficially there is an "acceptable" hull loss rate in aviation. As long as we don't kill too many people too often, then the inadequacies built into the current training regime will remain largely unchanged.
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Old 25th Sep 2019, 12:33
  #2598 (permalink)  
 
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Question to pilots:
Don't you ever play the "what if" game with flying. I don't mean: lets pull that CB and see what happens, but more like: by procedures I can use all these configurations lets try the odd one. Or: I have no idea how that mechanism works lets dig the pic.
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Old 25th Sep 2019, 12:44
  #2599 (permalink)  
 
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​​​​​​
Originally Posted by Peter H View Post
Nice thoughtful post.

Not only is there no prohibition against multiple or ambiguous malfunctions, but in some case
their occurrence is by-design (intentional or not). Naively as SLF I assumed that this would
be identified by some sort of dependency-tree analysis at design-time, and their occurrence
identified and prevented if possible, or at least allowed for in operating procedures.

AoA-high failure seems to be a perfect example, leading to the triggering of things like UAS,
autopilot drop-out, stall-warnings, and inappropriate MCAS activation (in the absence of flaps
and other blocking states).

Quite correct. For my part, one of the significant takeaways from the MAX accidents is how quickly an AOA malfunction on a 737 can create a domino effect of faults that sets up a very challenging situation for the aircrews - and this is whether we are talking about an NG or a MAX. I won't parse out all the details, but if you step through everything that happens from the initial fault, there are multiple checklists to run and multiple systems that are degraded or rendered inoperative. In addition, a variety of erroneous fault conditions are generated which have the potential for misleading the crew if they do not clearly understand exactly why those faults are being generated. That being said, I don't believe this malfunction would be any more challenging than a takeoff engine failure, with the key difference being that we practice engine failures all the time. AOA failures, not so much.
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Old 25th Sep 2019, 12:57
  #2600 (permalink)  
 
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Originally Posted by Aihkio View Post
Question to pilots:
Don't you ever play the "what if" game with flying. I don't mean: lets pull that CB and see what happens, but more like: by procedures I can use all these configurations lets try the odd one. Or: I have no idea how that mechanism works lets dig the pic.
My sense is that some do and some don't, and their inclination is strongly affected by their background and training environment. Once upon a time, pilot training typically consisted of a lot of deep dives into systems and procedures where detailed knowledge was considered essential. Somewhere along the way (starting about 15-20 years ago at my airline, likely different elsewhere), systems knowledge became less important and more emphasis was placed on following the written procedures without necessarily knowing the "why's" behind each step. In the past when working through the non-normal checklists one would ask, "Why do I do this step here?", the answer would include particulars on how that step affected a particular system. Nowadays the answer is more likely to be, "Because that is how the procedure is written!" I suspect in some training environments, that last answer is deemed sufficient and thus further investigation is discouraged.
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