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

[derjodel]

With all the information we have now, I‘m sure that a number people knew exactly what was going on after lion air crash. They knew. There is no way they would not.

Yet, all of them let Etiopian happen. That‘s manslaughter.

[ST Dog]

Some interesting takes on the report...
I haven't finished it, but what I've read so far doesn't really correlate with many of the comments so far.

I do appreciate the more in-depth report of the earlier flight, LNI043.
Clears up a lot of previous questions.

[Diavel]

Only one way to adress this calamity

MCAS= Might Crash Again Soon

I have absolutely no confidence in the Boeing management. Boring has very capable engineers, but they have been overruled by the ignorant suits in Corporate HQ for far too long. For quite a while we have all talked about the ” race to the bottom” when it comes to the pay/ conditions for the aircrews. Boeing seems to have picked up this trend

[BDAttitude]

Anyone having a clue what this means?




How could the left stick shaker activate? I thought left vane Cptn stick shaker, right vane FO stick shaker.

[DaveReidUK]

Originally Posted by ST Dog

Some interesting takes on the report...
I haven't finished it, but what I've read so far doesn't really correlate with many of the comments so far.

Do elaborate, please.

[Zeffy]

Seattle Times

https://www.seattletimes.com/busines...ees-this-year/

No bonuses for white-collar Boeing employees this year
Oct. 25, 2019 at 11:56 am Updated Oct. 25, 2019 at 12:04 pm

Dominic Gates By Dominic Gates
Seattle Times aerospace reporter

Boeing will not pay annual bonuses to its management, executives or unionized engineers and white-collar workers next February, payouts that for many years have pumped millions of extra dollars into the accounts of employees in the Puget Sound region and beyond.

The internal announcement Thursday followed release of its third quarter results.

“With only one quarter left in the year, the grounding since March of the 737 MAX and the associated financial effects have severely impacted the company’s performance by limiting the ability to deliver planes and collect on customer contracts,” Boeing told employees on its internal website. “The company does not see a path to achieving an incentive payout for 2019.”

Heidi Capozzi, Boeing’s senior vice president of human resources, acknowledged the news would be “disappointing.”

Last February Boeing employees across Washington state received incentive bonuses totaling nearly $429 million out of a total companywide payout of $886 million. That meant an average bonus of $6,800 per employee here.

The year before, the February payout total for Washington state employees was a record $600 million, for an average of more than $9,000 per employee.

The company incentive plan calculates the bonuses based on three financial metrics: revenue (25%) which for 2019 had a target of $110.5 billion; core earnings per share (25%), which had a target of $20; and free cash flow (50%), which had a target of $15 billion.

The company’s internal notice to employees cited the cost so far of the 737 MAX grounding at $9.2 billion. As of the end of September, the company’s nine-month revenue was only $58.6 billion and the other two scores were negative: core earnings per share showed a loss of $1.13 per share and free cash showed an outflow of $1.6 billion.

The internal message makes clear that the Annual Incentive Plan (AIP) that applies to executives will be equally zeroed out. However, for Boeing’s top executives that plan provides just a small part of their overall bonus.

Boeing’s annual proxy filing that details executive compensation for the top leadership states that the AIP makes up only 17 percent of total compensation. Another 10 percent is base salary and the remaining 73 percent comes from a separate “Long Term Incentive Plan” that pays out based partly on cumulative financial results over a three-year period and also upon the stock price and the return to shareholders.

This long-term incentive plan will be reduced by the financial hit from the MAX grounding and by Boeing’s the cut to the share price, which has lost a fifth of its value since March. But because of the way the incentive plan is structured, it will take up to three years for the full reduction to work through the system.

For this year, Boeing’s leaders will still receive bonuses under the long-term plan, even as their employees get zero.

Boeing Machinists earn bonuses under a separate incentive plan that assesses their performance based on measures of quality, productivity and safety. The Machinists have continued to build 737 MAXs even though they cannot be delivered and so it’s unclear how their bonuses will be affected by the financial hit to the company.

Connie Keliher, spokeswoman for the International Association of Machinists union said Boeing has declined to release numbers on the quality, productivity and safety metrics while the MAX crisis continues. She said the final figure for the IAM incentive plan is always determined in January based on the full-year performance.

Ray Goforth, executive director of Boeing’s engineering union, the Society of Professional Engineering Employees in Aerospace (SPEEA), declined to comment.

The company’s internal message, acknowledging that the loss of the bonuses “may cause concern among employees about Boeing’s long-term financial health,” offered employees the assurance that management “continues to invest in the business, its people and its future.”

Dominic Gates: 206-464-2963 or [email protected]; on Twitter: @dominicgates.

[Takwis]

Originally Posted by Zeffy

" However, for Boeing’s top executives that plan provides just a small part of their overall bonus.... For this year, Boeing’s leaders will still receive bonuses under the long-term plan, even as their employees get zero."

Now there's some incentive!

[568]

Originally Posted by Maninthebar

From the report

Thanks for posting the text.
I am aware of the various aspects of autopilot engagement/technical details as I was an instructor on the 737 (all series) and have over 25 years flying and training on type as well as other Boeing types.

My point is that the FCTM refers to the aircraft being "trimmed" before engagement;

Quote from FCTM:

Autopilot Engagement.
The autopilot is FAA certified to allow engagement at or above 400 feet AGL after takeoff. Other NAA regulations or airline operating directives may specify a different minimum altitude. The airplane should be in trim, and the flight director commands should be satisfied before autopilot engagement. This prevents unwanted changes from the desired flight path during autopilot engagement.

[Tomaski]

Originally Posted by Takwis

Let me rephrase my question. I don't think that following that particular checklist would get them "home free"...I was asking about the assertions of the "hot shots". I seem to remember a whole lot of people (to include Boeing) insisting that if they had only followed that checklist, all would be well. I suppose I could go back through something like 14 closed posts and 10,000 plus comments, and figure it out myself. I was just wondering if anyone else remembered it that way.

Let me rephrase my answer. You asked:

It's been a year, with lots of conflicting information. But I seem to remember Boeing (and many hotshot pilots) insisting that if the Airspeed Unreliable checklist had been done, they would have been home free. Is that correct?

I'm going to ignore the "hotshot pilots" comment because quite frankly there was a valid point to be made here. Prompt and accurate execution of the Airspeed Unreliable would have significantly changed how this scenario played out. No one can prove whether it would have changed it enough to prevent the ultimate accident, but it would have decreased a certain amount of the confusion and provided a more stable platform from which to deal with the MCAS activation.

Before I continue, I want to emphasize that I do not believe this to be "crew performance" problem. Rather, this is a training problem. ​​​​​​It is highly probable that this crew was never trained to properly execute this procedure during the takeoff phase. This training failure exists across the entire industry and I am frankly surprised and dismayed that it has not gotten more attention.

Except for a brief moment when the flaps were retracted and then extended again (causing a single MCAS activation), the only malfunction the crew was dealing with during the first five minutes was a faulty AOA - which then generated the Airspeed Unreliable event and associated annunciations. Just about everything we see happening in those first minutes can happen TODAY on a 737NG and will continue to happen on the MAX after MCAS is fixed.

Within four seconds of liftoff, the FO correctly pointed out the "IAS Disagree" annunciation. Less than a minute later, the Captain instructed the FO to perform the memory items for Airspeed Unreliable (why the CA couldn't do it himself is beyond me). They knew what they were dealing with. Yet it then took approximately four minutes for the FO to locate this "memory item" in the QRH, and the Captain did not execute any of the appropriate steps. During this time, the Captain is struggling with aircraft control with altitude excursions and the airspeed becoming unreasonably high. Why? His power is still up, and the F/D is still on and is directing him to lower the pitch to break the "stall". Ultimately, someone raised the flaps again (probably due to overspeed condition), MCAS starts activating and the FO continues to read the Airspeed Unreliable checklist while the Captain is now pre-occupied with countering the MCAS inputs.

If the Airspeed Unreliable procedure had been executed when the Captain first called for it, at a minimum we would expect that the autothrottles and flight directors would have been turned off, N1's set to 80%, and pitch to 10%. If the crew had been properly trained in this procedure, they would have also been exposed to all the additional warnings and annunciations that go along with this malfunction (to use the engine failure analogy, no one is surprised when you lose a generator and hydraulic pump when you lose an engine because you see it all the time in the sim). These pitch and powers setting should have been maintained at least to flap retraction altitude. With these steps accomplished, the aircraft would have been in a slow but stable climb and the overspeed clackers would not be active.

What happens next depends on what you think the crew would have done with the flaps. There are reasonable arguments for both retracting the flaps and for leaving them extended (Boeing does not offer explicit guidance that I'm aware of). If the flaps were not retracted, MCAS would never have activated. If the flaps were retracted, then the aircraft would have been relatively stable with one of the pilots attempting to hold a fixed pitch and power setting according to the Airspeed Unreliable procedure. I think that it is entirely reasonable to speculate that if the crew had gotten to this point with a stable aircraft, a stable pitch and power setting, no F/D instructing them to dive, and no overspeed clacker, then yes, they may well have just handled any MCAS activation better.

So those who pointed to this procedure as an important aid in dealing with this malfunction were not wrong. Their primary error was assuming that the airlines had actually bothered to train their crews how to execute it.

[BDAttitude]

Do you remember the criticism Mentour recieved for simulating MCAS by trim input?
Turns out this is how BA did their Hazard Analysis:

[Tomaski]

Originally Posted by 568

For autopilot engagement the aircraft must be trimmed properly so maybe the autopilot (s) would not be available to the crew.

Autopilot engagement was specifically precluded due to the Airspeed Unreliable condition.

[Ian W]

Originally Posted by derjodel

With all the information we have now, I‘m sure that a number people knew exactly what was going on after lion air crash. They knew. There is no way they would not.

Yet, all of them let Etiopian happen. That‘s manslaughter.

They knew and they put out a detailed AD with the FAA. The supplied checklist which was almost identical to the runaway trim NNC, if followed, would have prevented the Ethiopian crash. It was not followed. Step 2 was to use MET to trim to neutral then the next step was switch off stab trim. AS shown by the Lion air flights MET stopped the initial version of MCAS and could recover the trim back to neutral. It seems that manual trimming is not second nature for 73 pilots. Nevertheless, it would have been better to self-ground the aircraft and issue the software fix to require both AOA vanes to match AND show the same high angle of attack for MCAS to operate.

AS one of the reports said the issue was flagged as 'Major' as it was considered a qualified crew could recover from an MCAS runaway; however, current crews should not have been expected to cope due to the training regimes at most airlines. Therefore the MCAS issue should have been flagged as catastrophic which would have required a far better and rapid fix to the problem.

[Takwis]

I'll try again, Tomaski, as right above me is a perfect example of what I am talking about. You detail the steps of the Airspeed Unreliable checklist as being "an important aid in dealing with this malfunction". Ian W says that "if followed", the Runaway Stab Trim checklist "would have prevented the Ethiopian crash". For a while, there were two factions of pilots (call them what you wish), with one group advocating one checklist, and the other group arguing for the other checklist. At times, Boeing spokesmen said that one was the solution, and at other times, to include the AD, insisting that the other was the one to follow. My point is that if a crowd of pilots and engineers sitting at their computers cannot make up their mind which was the proper checklist to use...if Boeing vacillated over time between the two as more facts were brought up, how can anyone expect even a well trained crew to make the "right" decision, hundreds of feet above the ground in an aircraft marginally in control?

[ST Dog]

Originally Posted by Tomaski

Within four seconds of liftoff, the FO correctly pointed out the "IAS Disagree" annunciation. Less than a minute later, the Captain instructed the FO to perform the memory items for Airspeed Unreliable (why the CA couldn't do it himself is beyond me).

I recall that the airline procedures were for the PM (FO here) to do the memory items/checklists while the PF flies the plane.


There was also commentary about the Captain not controlling the crew well and that the FO had notes about not knowing memory items and having trouble finding/executing checklists.

I think that it is entirely reasonable to speculate that if the crew had gotten to this point with a stable aircraft, a stable pitch and power setting, no F/D instructing them to dive, and no overspeed clacker, then yes, they may well have just handled any MCAS activation better.

Quite likely to have engaged the trim cutouts like the previous crew did.

[ST Dog]

Originally Posted by Takwis

I'll try again, Tomaski, as right above me is a perfect example of what I am talking about. You detail the steps of the Airspeed Unreliable checklist as being "an important aid in dealing with this malfunction". Ian W says that "if followed", the Runaway Stab Trim checklist "would have prevented the Ethiopian crash". For a while, there were two factions of pilots (call them what you wish), with one group advocating one checklist, and the other group arguing for the other checklist. At times, Boeing spokesmen said that one was the solution, and at other times, to include the AD, insisting that the other was the one to follow. My point is that if a crowd of pilots and engineers sitting at their computers cannot make up their mind which was the proper checklist to use...if Boeing vacillated over time between the two as more facts were brought up, how can anyone expect even a well trained crew to make the "right" decision, hundreds of feet above the ground in an aircraft marginally in control?

If the airspeed checklist was followed then you'd be in a better position to maintain control, especially before flaps-up.

Once past that, or if not done at all, executing the runaway stab check list, before trim got way out, would have stopped unwanted trim allowing for recovery.

The Captain kept MCAS in check a long time. It was only when he handed off to the FO that it got out of hand.
The report faulted the Captain for a poor handover, not explaining what the plane was doing or what he was doing to counter. The FO for whatever reason did not instinctively trim against MCAS like the Captain did. (Or like both pilots on JTI043).

[ST Dog]

Originally Posted by BDAttitude

Do you remember the criticism Mentour recieved for simulating MCAS by trim input?
Turns out this is how BA did their Hazard Analysis:

And as the NTSB report stated, it ignored the rest of the flight deck effects.

A human factors failure in large part, but also an inherent problem with how FHAs and FMEAs are done (not just at Boeing either).

[568]

Originally Posted by Tomaski

Autopilot engagement was specifically precluded due to the Airspeed Unreliable condition.

Indeed you are correct
My response was a general comment about autopilot engagement.

[Tomaski]

Originally Posted by Takwis

I'll try again, Tomaski, as right above me is a perfect example of what I am talking about. You detail the steps of the Airspeed Unreliable checklist as being "an important aid in dealing with this malfunction". Ian W says that "if followed", the Runaway Stab Trim checklist "would have prevented the Ethiopian crash". For a while, there were two factions of pilots (call them what you wish), with one group advocating one checklist, and the other group arguing for the other checklist. At times, Boeing spokesmen said that one was the solution, and at other times, to include the AD, insisting that the other was the one to follow. My point is that if a crowd of pilots and engineers sitting at their computers cannot make up their mind which was the proper checklist to use...if Boeing vacillated over time between the two as more facts were brought up, how can anyone expect even a well trained crew to make the "right" decision, hundreds of feet above the ground in an aircraft marginally in control?

I'll remind you here that your question was about the Airspeed Unreliable procedure, which I answered specifically.

Beyond that, here is absolutely no requirement to make an either/or choice regarding which checklists to execute. However, there sometimes is a need to prioritize multiple checklists. Remove MCAS from the equation entirely, and this crew probably still had at least six different non-normal procedures to run through just because of the AOA malfunction. As I have said before, there is no fundamental natural law that prohibits the existence of multiple malfunctions. This is yet another training failure we see across airlines. Nowadays during training, malfunctions are presented one at a time and run to some kind of conclusion. Then the next, and then the next as the training events are checked off. Reality is not always so kind.

Pretty much everything I said about crews not being trained to execute the Airspeed Unreliable procedure applies to Runaway Stab Trim. Honestly, how many times have you seen this in your training? Again, its one of those "memory procedures." One would think that crews would see these on a routine basis.

So the full answer is, IF the accident crews had regularly been trained in Airspeed Unreliable procedures (particularly during takeoff) AND IF they had been regularly trained in Runaway Stab Trim, I think it is a good bet the outcome would have been different. But they weren't and here we are.

[Tomaski]

Originally Posted by ST Dog

I recall that the airline procedures were for the PM (FO here) to do the memory items/checklists while the PF flies the plane.

This is is what the report says about the Lion Air QRH procedures:

"When a non–normal situation occurs, at the direction of the pilot flying, both crew members do all memory items in their areas of responsibility without delay. "

In the case of Airspeed Unreliable, three of the four "memory" steps are actually performed by the PF, in this case the Captain. The FO would turn off the F/D switches. Afterwards, the PM would pull out the checklist and confirm, in coordination with the PF, that all the checklist items were accomplished.

So when the FO can't remember (or find) the "memory procedures," what's preventing the Captain from reciting the steps from.... ahem ..... memory and then executing them?


Excerpt from the QRH:

​​​​​​

When a non–normal situation occurs, at the direction of the pilot flying, both crew members do all memory items in their areas of responsibility without delay. The pilot flying calls for the checklist when:

• the airplane is not in a critical phase of flight (such as takeoff or landing)
• all memory items are complete.

The pilot monitoring reads aloud:

• the checklist title
• the airplane effectivity (if applicable) as needed to verify the correct checklist
• as much of the condition statement as needed to verify that the correct checklist has been selected
• as much of the objective statement (if applicable) as needed to understand the expected result of doing the checklist.
  
  The pilot flying does not need to repeat this information but must acknowledge that the information was heard and understood.
  
  For checklists with memory items, the pilot monitoring first verifies that each memory item has been done. The checklist is normally read aloud during this verification. The pilot flying does not need to respond except for items that are not in agreement with the checklist. The item numbers do not need to be read....

[ozaub]

Blame the pilots if you must.. Boeing will. But why was Boeing allowed to sell a new model of the 737 which was inherently less safe than earlier models? Grandfathering, ODA and self-regulation. Nothing Boeing does to MCAS will make MAX configuration as safe as NG..