Go Back  PPRuNe Forums > Flight Deck Forums > Rumours & News
Reload this Page >

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

Rumours & News Reporting Points that may affect our jobs or lives as professional pilots. Also, items that may be of interest to professional pilots.

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

Old 25th Oct 2019, 11:32
  #3421 (permalink)  
 
Join Date: Jan 2008
Location: Reading, UK
Posts: 11,032
KNKT Press Conference:

DaveReidUK is offline  
Old 25th Oct 2019, 11:34
  #3422 (permalink)  
 
Join Date: Jan 2008
Location: uk
Posts: 793
Originally Posted by fizz57 View Post
So we've come full circle, from "if the plane is playing up fly it manually" to "if the plane is playing up engage the autopilot"

Did the Lion Air crew know this? Specifically, did Boeing tell them?
No, but the ET crew might have done, and I believe there were comments about other crews, before ET, briefing early autopilot engagement to protect against MCAS.

Of course, after ET it's clear that the autopilot can screw you up too and then drop out leaving MCAS to trim you nose down while GPWS warning is going off. I really don't understand why that comment is in LionAir report - we all know now that engaging autopilot to fight MCAS also ends in a smoking crater.
infrequentflyer789 is offline  
Old 25th Oct 2019, 11:50
  #3423 (permalink)  
 
Join Date: Jan 2007
Location: Liverpool
Posts: 26
Originally Posted by infrequentflyer789 View Post
No, but the ET crew might have done, and I believe there were comments about other crews, before ET, briefing early autopilot engagement to protect against MCAS.

Of course, after ET it's clear that the autopilot can screw you up too and then drop out leaving MCAS to trim you nose down while GPWS warning is going off. I really don't understand why that comment is in LionAir report - we all know now that engaging autopilot to fight MCAS also ends in a smoking crater.
Surely it only ends in a smoking hole depening upon which side is showing incorrect airspeed, which is why it stated as such. Presumably in this case, the side with the incorrect airspeed would not have affected the AP and all would have been rosy.
Ben_S is offline  
Old 25th Oct 2019, 11:52
  #3424 (permalink)  
 
Join Date: Jan 2008
Location: Reading, UK
Posts: 11,032
Boeing statement:

“On behalf of everyone at Boeing, I want to convey our heartfelt condolences to the families and loved ones of those who lost their lives in these accidents. We mourn with Lion Air, and we would like to express our deepest sympathies to the Lion Air family,” said Boeing President & CEO Dennis Muilenburg. “These tragic events have deeply affected us all and we will always remember what happened.”

“We commend Indonesia’s National Transportation Safety Committee for its extensive efforts to determine the facts of this accident, the contributing factors to its cause and recommendations aimed toward our common goal that this never happens again.”

“We are addressing the KNKT’s safety recommendations, and taking actions to enhance the safety of the 737 MAX to prevent the flight control conditions that occurred in this accident from ever happening again. Safety is an enduring value for everyone at Boeing and the safety of the flying public, our customers, and the crews aboard our airplanes is always our top priority. We value our long-standing partnership with Lion Air and we look forward to continuing to work together in the future.”
https://www.apnews.com/PR%20Newswire...c675819dc9783c

Six of the 25 Safety Recommendations in the Final Report are directed at Boeing.
DaveReidUK is offline  
Old 25th Oct 2019, 12:38
  #3425 (permalink)  
 
Join Date: Nov 2018
Location: Vancouver
Posts: 67
Lion Air crash report raises issues over design, maintenance and crew errors
Indonesian investigators have found that the flight crew on a Lion Air plane that crashed, killing all 189 people on board, struggled to quickly react to a malfunction that caused the plane's nose to go down.

The fatal crash, followed less than five months by another at Ethiopian Airlines, led to a global grounding of the Boeing 737 MAX and a crisis for the world's biggest plane maker, which this week ousted its commercial aeroplanes chief.

In its final report on the October 29, 2018 crash, Indonesia makes recommendations to Boeing, the airline, the US Federal Aviation Administration (FAA) and other agencies.

A copy was seen by Reuters and it is due to be released publicly later on Friday.

Boeing, acting without adequate oversight from US regulators, failed to grasp risks in the design of cockpit software on its 737 MAX airliner.

Design flaw
Indonesian regulators criticise the design of the anti-stall system known as MCAS, which automatically pushed the plane's nose down, leaving pilots fighting for control.

"The design and certification of the MCAS did not adequately consider the likelihood of loss of control of the aircraft," the report says.

Boeing has been working on a redesign of MCAS, although it has yet to certified by the FAA.

The report says "deficiencies" in the flight crew's communication and manual control of the aircraft contributed to the crash, as did alerts and distractions in the cockpit.

The accident was caused by a complex chain of events, Indonesian air accident investigator Nurcahyo Utomo told reporters at a news conference.

During the flight, the first officer was unable to quickly identify a checklist in a handbook or perform tasks he should have had memorised, it says, adding he had also performed poorly in training exercises.

The captain did not properly brief the first officer when handing over control just before the plane entered a fatal dive.

A critical angle of attack sensor providing data to the MCAS anti-stall system had been miscalibrated by a company in Florida and there were strong indications it was not tested during installation by Lion Air maintenance staff.

Lion Air should have grounded the jet following faults on earlier flights, the reports says, and adds that 31 pages were missing from the airline's October maintenance logs.

Lion Air declined to comment.

Boeing said it was addressing Indonesia's safety recommendations and taking actions to enhance the safety of the 737 MAX.

FAA said it welcomed the report's recommendations and would carefully consider them.
==========

- https://7news.com.au/news/disaster-a...rrors-c-523415
patplan is offline  
Old 25th Oct 2019, 13:07
  #3426 (permalink)  
 
Join Date: Nov 2018
Location: Vancouver
Posts: 67
Additional tidbits from NTSC's Lion Air Flight JT610 Crash Investigation Final Report, as mentioned by a different news source:


...
Missed Opportunity

The report said problems with flight-data readings were initially reported on an Oct 26 flight from Tianjin in China to the Indonesian city of Manado. An examination of the angle-of-attack sensor showed it became unreliable in cold temperatures. An engineer in Manado suggested the crew continue to Denpasar in Bali for repairs.

"This indicated that the aircraft was released with known possible recurring problem," the report said.

On a flight from Denpasar the day before the crash, the crew on the 737 Max ignored malfunctioning indicators, according to the NTSC. It said the pilot was confident about continuing because the aircraft was controllable and the weather along the route was good. The decision to keep flying was "highly unusual" after getting warnings for an imminent stall, the report said.

Previous reports have shown that an off-duty pilot traveling in the cockpit of that flight helped disable the malfunctioning control system. The NTSC said Friday that the captain had asked for the deadheading flight crew's assistance, and kept the fasten seat-belt sign on.

"These actions indicated that the captain was aware of the need to use all available resources to alleviate the matter to complete the flight to the destination," it said.

The problems encountered weren't properly detailed in the post-flight report, which was filed outside office hours and not processed until the following day, the NTSC said. "The incomplete report became a hazard as the known or suspected defects were not reported which might make the engineer unable to properly maintain the airworthiness of the aircraft."


The Crash

The crew on the doomed flight, who might not have been aware of the previous problems, failed to complete checks on the aircraft due to distractions from the flight system, increasing their stress levels, the report said. They also didn't declare an emergency or asked for special handling, which would have helped to reduce their workload.

There seemed to be a lack of communication among the flight crew, with the captain not explicitly saying how much difficulty he was experiencing controlling the aircraft, it said. Most of the components of effective crew coordination were not achieved, resulting in failure to achieve the common goal of flying the aircraft safely...


Source:
- https://www.chinadailyhk.com/article...?newsId=110524
patplan is offline  
Old 25th Oct 2019, 13:09
  #3427 (permalink)  
 
Join Date: Apr 2008
Location: Paris
Age: 70
Posts: 274
So now the report is out, the airline can blame Boeing, Boeing can blame the pilots and maintenance, and the FAA who are actually supposed to be the failsafe on design and training requirements can continue business as usual, with the congresscritters busily gorging themseves at the Boeing trough.

At least in China they would jail a couple of maintenance engineers, bureaucrats and company execs for show, which might discourage future recurrence of the same behaviors.

Edmund
edmundronald is offline  
Old 25th Oct 2019, 13:20
  #3428 (permalink)  
 
Join Date: Feb 2008
Location: UK
Age: 62
Posts: 288
Originally Posted by Ben_S View Post
Surely it only ends in a smoking hole depending upon which side is showing incorrect airspeed, which is why it stated as such. Presumably in this case, the side with the incorrect airspeed would not have affected the AP and all would have been rosy.
Mmm not so sure, meanwhile the stick-shaker is continuous, the GPWS alerts are going off and the a/c heading towards the ground PDQ, with no doubt other beeps chimes and alarms all sounding...Not quite so rosy I would have thought?
rog747 is offline  
Old 25th Oct 2019, 13:30
  #3429 (permalink)  
 
Join Date: May 2019
Location: UK
Posts: 24
Well, while we await the full report the (much expanded) Seattle Times piece has a few interesting bits. The AoA sensor on the fatal flight had been recently replaced:

The replacement AOA sensor was a secondhand component supplied by a certified aviation repair shop, Xtra Aerospace in Miramar, Florida.

The part was faulty. On the flight directly before the fatal flight, the replacement sensor was off by 21 degrees from the one on the other side of the plane.

The report states that this difference indicates that the sensor “was most likely inadvertently mis-calibrated” during test and calibration in Florida. Xtra Aerospace’s procedures did not include an extra check required to validate the calibration.

The report notes that the FAA, which is supposed to oversee quality control at component suppliers missed this, and concludes that its “oversight was not effective.”
On Oct. 28, the day before the crash flight, following a series of cockpit warnings about airspeed and altitude, a maintenance engineer installed a new angle of attack sensor.

Though he was supposed to do an installation test to ensure it was correctly calibrated and installed, the maintenance records show no such test, the report found. The engineer did produce several photos of the flight display, which he claimed showed the test had been performed. But investigators could not confirm that the photos were taken in the plane that crashed and clearly suspected they were not.

“The investigation could not determine with any certainty that the AOA sensor installation (was) successful,” the report states.
On the Oct. 28 flight, the 21 degree angle of attack sensor fault set off the same series of events that would show up again a day later on the accident flight. The captain’s stick shaker went off immediately, the airspeed and altitude warnings appeared.

And after the pilot retracted the flaps, MCAS — assuming the angle of attack was too high because of the input from that one bad sensor — activated and began to push the nose of the aircraft down.

Since Boeing hadn’t informed airlines or pilots about MCAS, the captain and his first officer didn’t understand what was happening. But they were lucky in that a third pilot, another Lion Air first officer, was along for the free ride, sitting in the jump seat in the cockpit. That third set of eyes seems to have been crucial in helping the crew troubleshoot, stay calm and find a way out of the situation.

After discussion among the three of them, the captain flipped a pair of switches that cut off electrical power to the tail. That allowed him to regain control. When he flipped them back and the nose-down movements resumed, he cut off power again.

According to procedures, the pilot should have turned the plane around and landed as soon as possible. Instead, the crew flew on to their destination.

Upon landing, the captain reported only the issues that had shown up on his flight display: the airspeed and altitude warnings and a light indicating a difference in the feel of the control column. Fatally, he did not report the activation of the stick shaker, the way the stabilizer had pushed the nose down or his use of the cutout switches to resolve the problem, resulting in an “incomplete report.”

That omission, the report found, was critical to the maintenance engineer not realizing how serious the state of the plane was. It should have been grounded. But the next morning it would take off on its next flight, with the same pattern of faults, a different crew, and a deadly outcome.

Last edited by medod; 25th Oct 2019 at 13:36. Reason: more
medod is offline  
Old 25th Oct 2019, 13:52
  #3430 (permalink)  
 
Join Date: Jan 2017
Location: UK
Posts: 21
Final report published

Final report appears to be here: http://knkt.dephub.go.id/knkt/ntsc_a...l%20Report.pdf
File dated 2019-10-25 12:12 UTC

Last edited by paulross; 25th Oct 2019 at 14:12. Reason: Fix link.
paulross is offline  
Old 25th Oct 2019, 14:05
  #3431 (permalink)  
 
Join Date: Jun 2019
Location: VA
Posts: 210
Originally Posted by edmundronald View Post
So now the report is out, the airline can blame Boeing, Boeing can blame the pilots and maintenance, and the FAA who are actually supposed to be the failsafe on design and training requirements can continue business as usual, with the congresscritters busily gorging themseves at the Boeing trough.

A gentle reminder that the purpose of the official accident report is to identify all the primary and secondary factors that contributed to an accident and recommend steps to mitigate those factors in the future. It is less about blame than about trying to make aviation safer.

Civil and criminal lawsuits on the other hand......
Tomaski is offline  
Old 25th Oct 2019, 14:07
  #3432 (permalink)  
 
Join Date: Nov 2000
Location: Cambridge, England, EU
Posts: 3,437
Originally Posted by paulross View Post
I get a 404
Gertrude the Wombat is offline  
Old 25th Oct 2019, 14:10
  #3433 (permalink)  
 
Join Date: Jun 2019
Location: VA
Posts: 210
I haven't had a chance to read the final report yet, but from the excerpts in the press I haven't seen anything that hasn't already been extensively discussed on this forum. No real surprises so far.
Tomaski is offline  
Old 25th Oct 2019, 14:11
  #3434 (permalink)  
Thread Starter
 
Join Date: Apr 2015
Location: Under the radar, over the rainbow
Posts: 625


Note that the headline on the Seattle Times story has changed as it was updated and expanded:

Indonesia’s devastating final report blames Boeing 737 MAX design, certification in Lion Air crash

NYSE trading opens in about 20 minutes.
OldnGrounded is offline  
Old 25th Oct 2019, 14:13
  #3435 (permalink)  
 
Join Date: Jan 2017
Location: UK
Posts: 21
Fixed link: http://knkt.dephub.go.id/knkt/ntsc_a...l%20Report.pdf
paulross is offline  
Old 25th Oct 2019, 14:16
  #3436 (permalink)  
 
Join Date: Feb 2006
Location: USA
Posts: 432
https://boeing.mediaroom.com/2019-10...n-Final-Report

Boeing Statement On Lion Air Flight 610 Investigation Final Report

CHICAGO, Oct. 25, 2019 /PRNewswire/ -- Boeing (NYSE: BA) issued the following statement regarding the release today of the final investigation report of Lion Air Flight 610 by Indonesia's National Transportation Safety Committee (KNKT):

"On behalf of everyone at Boeing, I want to convey our heartfelt condolences to the families and loved ones of those who lost their lives in these accidents. We mourn with Lion Air, and we would like to express our deepest sympathies to the Lion Air family," said Boeing President & CEO Dennis Muilenburg. "These tragic events have deeply affected us all and we will always remember what happened."

"We commend Indonesia's National Transportation Safety Committee for its extensive efforts to determine the facts of this accident, the contributing factors to its cause and recommendations aimed toward our common goal that this never happens again."

"We are addressing the KNKT's safety recommendations, and taking actions to enhance the safety of the 737 MAX to prevent the flight control conditions that occurred in this accident from ever happening again. Safety is an enduring value for everyone at Boeing and the safety of the flying public, our customers, and the crews aboard our airplanes is always our top priority. We value our long-standing partnership with Lion Air and we look forward to continuing to work together in the future."

Boeing experts, working as technical advisors to the U.S. National Transportation Safety Board, have supported the KNKT over the course of the investigation. The company's engineers have been working with the US Federal Aviation Administration (FAA) and other global regulators to make software updates and other changes, taking into account the information from the KNKT's investigation.

Since this accident, the 737 MAX and its software are undergoing an unprecedented level of global regulatory oversight, testing and analysis. This includes hundreds of simulator sessions and test flights, regulatory analysis of thousands of documents, reviews by regulators and independent experts and extensive certification requirements.

Over the past several months Boeing has been making changes to the 737 MAX. Most significantly, Boeing has redesigned the way Angle of Attack (AoA) sensors work with a feature of the flight control software known as Maneuvering Characteristics Augmentation System (MCAS). Going forward, MCAS will compare information from both AoA sensors before activating, adding a new layer of protection.

In addition, MCAS will now only turn on if both AoA sensors agree, will only activate once in response to erroneous AOA, and will always be subject to a maximum limit that can be overridden with the control column.

These software changes will prevent the flight control conditions that occurred in this accident from ever happening again.

In addition, Boeing is updating crew manuals and pilot training, designed to ensure every pilot has all of the information they need to fly the 737 MAX safely.

Boeing continues to work with the FAA and other regulatory agencies worldwide on the certification of the software update and training program to safely return the 737 MAX to service.

Contact

Boeing Communications
312-544-2002
[email protected]
Zeffy is offline  
Old 25th Oct 2019, 14:17
  #3437 (permalink)  
 
Join Date: Jun 2019
Location: VA
Posts: 210
Originally Posted by OldnGrounded View Post

Note that the headline on the Seattle Times story has changed as it was updated and expanded:
In the online news trade, there is a separate staff who is in charge of writing the headlines with the object to attract as many "clicks" as possible. This article will probably be repeated on a number of different new sites, and it is likely the headline will change several times in the process, sometimes to make it look like fresh material.

Welcome to the world of online news reporting.....
Tomaski is offline  
Old 25th Oct 2019, 14:18
  #3438 (permalink)  
 
Join Date: Feb 2006
Location: USA
Posts: 432
https://www.faa.gov/news/press_relea...m?newsId=24314

Press Release – FAA Revokes Repair Station Certificate of Xtra Aerospace of South Florida

For Immediate Release
October 25, 2019
Contact: Kathleen Bergen
Phone: 404-305-5100; Email: [email protected]

WASHINGTON – The U.S. Department of Transportation’s Federal Aviation Administration (FAA) issued an order today revoking the repair station certificate of Xtra Aerospace, LLC, of Miramar, Fla.

According to the order, Xtra failed to comply with requirements to repair only aircraft parts on its list of parts acceptable to the FAA that it was capable of repairing. The company also failed to comply with procedures in its repair station manual for implementing a capability list in accordance with the Federal Aviation Regulations. Xtra is a repair station certificated under part 145 of the Federal Aviation Regulations.

The FAA began its investigation in November 2018. Investigators looked specifically at the company’s compliance with regulatory requirements that apply to its capability list, and records and work orders for aircraft parts it approved for return to service. The investigation determined that from November 2009 until May 2019, Xtra failed to complete and retain records in accordance with procedures in its repair station manual to support parts on its capability list. The company also did not substantiate that it had adequate facilities, tools, test equipment, technical publications, and trained and qualified employees to repair parts on its capability list.

The agency issued the order as part of a settlement agreement with the company. Under the agreement, Xtra waives its right to appeal the revocation to the National Transportation Safety Board or any court.

###
Zeffy is offline  
Old 25th Oct 2019, 14:24
  #3439 (permalink)  
 
Join Date: Nov 2018
Location: Vancouver
Posts: 67











patplan is offline  
Old 25th Oct 2019, 14:58
  #3440 (permalink)  
 
Join Date: Nov 2018
Location: Vancouver
Posts: 67














patplan is offline  

Thread Tools
Search this Thread

Contact Us - Archive - Advertising - Cookie Policy - Privacy Statement - Terms of Service - Do Not Sell My Personal Information

Copyright © 2018 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.