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

[Bend alot]

Originally Posted by ozaub

A small correction please to my post at #3317. I suggested that foreign validations of FAA Type Certification would have detected deficiencies in design of MCAS. KNKT report at 1.17.8 tells us that Indonesian DGCA did validate TC and did discuss MCAS. Implies that DGCA saw nothing amiss

Given that was the virgin version of MCAS that FAA had information on - certainly nothing amiss, other than the steroid version took it's place in the back ground without FAA being informed.

You can only validate on what you are given - simple answer, every regulator must over see every aircraft development in every detail.
Practical answer has manufacturer of aircraft development satisfactorily oversee all aspects of aircraft development by home regulator - outsourcing that for the developers to do is a option, but a very bad one.

[Tomaski]

Originally Posted by rog747

So if the Lion crew had switched everything off AP AT etc etc and flown and trimmed the a/c manually to a safe speed (using thrust setting) and safe height with pitch & power (assume flaps up) to sort things out,
it was always going to be impossible for them because MCAS would over ride anything they did and still put the nose down, leaving the guys in a complete muddle
(Thinking why is it doing this?)

Re the comment made above ''This crew was not well-prepared to handle the AOA malfunction and subsequent warnings'' -
I thought that Lion Air had not purchased the AOA disagree display option?
So with all the other startle factors and warnings going off how would the crew recognise an AOA disagree was the sole issue here?

Am I correct in thinking this?
Thanks

Re MCAS overriding the crew - it was, in fact, the opposite. The Main Electric Trim (MET) overrode MCAS ever time it was used. As we saw when the Captain was the PF, aggressive MET inputs could counter MCAS inputs. That said, it is apparent from the report that while the Captain was actually making these inputs, he was not articulating what was happening with the trim, likely because of cognitive overload. When he transferred control to the FO, it was without any warning that the stab trim was acting in a peculiar manner. The FO was not nearly as aggressive in making MET inputs. This is not surprising since those types of inputs were outside his normal experience. The FO got increasingly behind the MCAS inputs and ultimately lost control.

Re the AOA DISAGREE annunciator. The AOA DISAGREE function was not operational on the accident aircraft, but its presence would likely have made no difference except for adding yet another warning light to the mix. By design, this annunciation, if working, would not have come on until 400' AFE. During the accident flight, the FO announced the IAS DISAGREE warning within one second of liftoff and the ALT DISAGREE warning within 30 seconds. At the time the ALT DISAGREE annunciation appeared, the Captain's altimeter read 340 feet and the FO's altimeter read 560 feet (Jakarta is very near sea level). Thus an AOA DISAGREE message would have been approximately concurrent with the ALT DISAGREE annunciation.

There is an AOA DISAGREE non-normal procedure, but it is not a memory item. That non-normal checklist, if consulted, would simply directs the crew to the IAS DISAGREE and ALT DISAGREE non-normals. The IAS DISAGREE non-normal directs the crew to the Airspeed Unreliable non-normal. Thus, if the AOA DISAGREE warning was operative, it would not have added any useful information from a procedural standpoint as ultimately the checklists direct the crew to the Airspeed Unreliable procedure. The Captain called for this procedure less than one minute after the IAS DISAGREE call by the FO. If the AOA DISAGREE had illuminated, and the crew had consulted the associated non-normal before doing anything else, it would have potentially delayed their response to the Airspeed Unreliable event.

[Tomaski]

Originally Posted by CurtainTwitcher

My intuitive "feel" on this is the crews faced very complex scenarios that they were untrained for, and this contributed to the two MAX accidents.

However, the raw data of the accident rates suggests that the 737-NG operation globally is remarkable immune to a catastrophic outcome bases on the exact AoA failures, the consequent cacophony of warnings and noise, even though they share the same sensors and architecture with the sole exception of the MCAS system. As far as I am aware, there have been no hull losses due to flight control issues for the NG.

Globally, NG crews have dealt with these failure modes and landed the aircraft safely in 22 years and 100+ million flights.

The final accident report mentions that there have been 16 known cases of inadvertent stick shaker activations on the 737NG fleet. It does not detail the underlying cause of these activations. All but two of these events resulted in an immediate return to the departure airport. I have seen second-hand reports of two of these incidents. In both cases, the crews were VMC and got the stick shaker on takeoff. The bad side was quickly identified, control was transferred as appropriate, followed by a quick trip around the pattern. The Airspeed Unreliable NNC was not performed in either of these two cases. So yes, this can be a relatively benign malfunction on the 737NG in VMC without any other complicating factors.

That said, throw in some IMC, high terrain and/or other complications, then this can develop into a fairly challenging malfunction. Keep in mind that one of the potential causes of an Airspeed Unreliable event could be a multiple bird strike during takeoff in which the crew could be dealing with more than a single sensor failure.

[ARealTimTuffy]

Originally Posted by Tomaski

I will again make the observation that, with the exception of a single MCAS cycle (after which the crew extended the flaps) the ONLY malfunction that this crew was dealing with for the first five minutes was a malfunctioning AOA sensor. That's it. Almost all of the confusing elements that presented themselves during that time could happen TODAY on any 737NG currently flying. These things can happen again on every MAX once they are flying again. Every. Single. One. None of the proposed remedies changes this reality.

No, the crew shouldn't be buried in the checklist. They should perform the memory items and fly the aircraft to a safe altitude where they can stabilize the aircraft, prioritize their actions, and then run the appropriate checklists. That did not happen.

Forget MCAS for the moment. This crew was not well-prepared to handle the AOA malfunction and subsequent warnings, annunciations and divergent instrument readings. They were not prepared because they were never properly trained to handle this malfunction even though it was, in theory, a high priority memory item procedure. There has been a massive training failure, and it has occurred at airlines across the board. Yet, has anything really changed in this regard since these accidents? Among the 737NG pilot community that participates here, I would ask if any of you have seen any significant changes in your company's training regime that would better prepare you for an AOA malfunction on takeoff? I've seen nothing at my airline.

Unfortunately the discussion around MCAS and Boeing's liability tends to suck most of the oxygen out of the room when examining these tragic events. There are other lessons here, and I'm greatly concerned that those lessons are going to be lost because so many people are looking at the bright shining object that is known as MCAS.

Although my airline is in a unique position, our crews have been through a flight control malfunction sim highlighting trim runaways, manual trimming highlighting the forces required, and IAS Disagrees. Most valuable sim I have every done. I believe we will be adding this to the initial training course curriculum.

[gums]

Salute!

Great points, on the whole, Tom. Especially about instinctive use of that trim button/switch that seems to be missing from some of the newbie pilot bag of tricks.
I was taught from day one to roll that wheel in the Champ or Taylorcraft so I would not have to hold stick pressure. Later, my first IP when I went to jets told me if I didn't wear a hole in the thumb of my flying glove then I wasn't trimming enuf. paid off big time for next 4,000 hours.
More about the findings later, as we have severe wx rolling in here on north Gulf coast. Plus, a really big game over in Baton Rouge.
Gums sends...

[568]

Originally Posted by Grebe

Boeing ups its ' safety ' optics- add a submariner - gives new meaning to ' dive dive dive "

Your post was really funny.
Seems that Boeing will soon be making subs.

How on earth is this new person going to fix the current state of affairs at Boeing? I don't know if he has any experience in flying Navy or commercial jets; I personally think this isn't going to help put the train wreck back on the track.

[GemDeveloper]

Actually, given the apparently parlous state of Boeing's safety culture, it is more than possible that someone coming in from outside the industry will be best placed to instill the necessary change, as they will be asking some pretty searching questions of the current guardians of the processes and won't be easily fobbed off with any "we've always done it like this" answers.

A retired senior Naval Officer who has been brought up in the safety culture of nuclear submarines where there are two very key safety threads running through his daily life... the first the safe operation of the reactor power plant and the second the safe operation of the boat itself... may be the breath of fresh air that Boeing needs. There is the need to operate and be seen to operate any nuclear installation to the highest standards of safety because of the searching questions that always are asked if there is even the most insignificant incident. There's roughly the same number of souls on board one of the SSNs or SSBNs as there are on a short haul aircraft, and the consequences of a serious safety issue could easily be just as fatal.

[OldnGrounded]

Originally Posted by 568

Your post was really funny.
Seems that Boeing will soon be making subs.

How on earth is this new person going to fix the current state of affairs at Boeing? I don't know if he has any experience in flying Navy or commercial jets; I personally think this isn't going to help put the train wreck back on the track.

Apparently, the gentleman will be joining the board of directors' safety committee. It's a very long way from the deliberations and suggestions of such an entity to the real world of design and manufacture. As Grebe indicated, this move is probably at least as much about optics as it is about real change.

[Flapsupbedsdown]

Originally Posted by 568

Whilst I agree with what you say, I would like to add the following:

Most of the worlds NAA's do not train "outside the box". Companies see the cost of training as "expensive" which reduces their overall profit, per the bean counters, thus reducing quality training time. This reduction fails to address proper system knowledge and procedures, an important aspect in operating a commercial jet aircraft.
Years ago Boeing reduced the "training footprint" in reaction to Airbus's training footprint!

The crew of the fatal flight had many different caution messages and warnings.

1) Stall warning
2) IAS disagree
3) Elevator feel
and so on.

So what checklist, would they run and what was covered during their transition course?

Most NAA's adopt the Boeing type rating course and tailor the course to the requirements of their respective NAA's (not FAA) to meet the standard for issuance of the type rating.
The adopted "Boeing" course covers "runaway stabilizer" and "airspeed unreliable" (without stall warnings, feel diff, IAS disagree etc). During the transition course stalls and UPRT are part of the type course but are not included with other cautions and warnings, such as the accident crew were faced with. Current flight simulators are basically programmed to a level which covers basic malfunctions, so any "deeper" system integrated faults attached to other systems cannot be selected by the Instructor.

The crew had no exposure in training to all of the other cautions and warnings (that they received during the flight) during their initial (transition) course.

Question: if you are faced with an IAS disagree at "say 200 ft agl" ( there is a memory item for this) why would you retract flaps and accelerate? MCAS wouldn't even come into play. Not defending manufacturer or controlling agency. In my very humble opinion even Sully's most appreciated comments are not appropriate.

[Tomaski]

Originally Posted by Flapsupbedsdown

Question: if you are faced with an IAS disagree at "say 200 ft agl" ( there is a memory item for this) why would you retract flaps and accelerate? MCAS wouldn't even come into play. Not defending manufacturer or controlling agency. In my very humble opinion even Sully's most appreciated comments are not appropriate.

How a flight crew would respond in the situation will be a function of what they know about the underlying system and how they have been trained to execute this procedure. There are major deficiencies in both areas.

Prior to Lion Air, information on MCAS was not available to flight crews, so they could not base any decision on what to do with the flaps on information they did not have. In the case of Ethiopian 302, the information regarding flap extension inhibiting MCAS was available, but there are serious questions as to whether this was adequately communicated to the Ethiopian pilots.

The Airspeed Unreliable procedure is very generic, and it does not provide much in the way of takeoff-specific guidance. In particular, there is no firm guidance on whether to leave the flaps extended while the checklist is being run or whether to retract the flaps at the normal point (while setting appropriate pitch and power settings from the tables). Given the available information, reasoned arguments can be made for either choice regarding the flaps.

More to the point, I strongly suspect that neither of the accident crews had ever been exposed to an Airspeed Unreliable event in training, and therefore were not aware of all the various warnings and indications, nor were they provided with specific guidance on how to execute this procedure. I will speculate that they all ultimately chose to retract the flaps because 1) they had accelerated past the flap placard speed (generating an overspeed clacker), and 2) they were used to raising the flaps in absence of any guidance to do otherwise.

[pettinger93]

The senior retired naval person will certainly have an enhanced safety culture: submarines operations are far less forgiving than modern aircraft, with equal, or worse, catastrophic outcomes when things go wrong. However, I fear that the admiral will be used to working in a far less financially constrained atmosphere than Boeing operates. Bradly speaking, what the submarine service wants, the submarine service gets, in safety terms, which, from the reports in this thread I doubt will have been the norm in Boeing up til now.

[568]

Originally Posted by Flapsupbedsdown

Question: if you are faced with an IAS disagree at "say 200 ft agl" ( there is a memory item for this) why would you retract flaps and accelerate? MCAS wouldn't even come into play. Not defending manufacturer or controlling agency. In my very humble opinion even Sully's most appreciated comments are not appropriate.

At 200 ft AGL given the caution, I would fly the aircraft in the current configuration. Of course it is all to easy to make these comments now that we have an official report of the accident.

The IAS disagree (not a memory item) check list will direct the crew to airspeed unreliable.

[WillowRun 6-3]

Safety culture "Board-C-Suite Disagree" Annunciator

Disclaimer 1st: the boards I've advised directly, and those whose affairs I've sometimes followed, don't compare at all to Boeing (and there's no claim even implied in what follows, otherwise).
Boardroom changes in the weather can happen quite rapidly. While top management is structured in linear hierarchies and linear arrays, a board of directors (or college trustees) is structured as a cohort. While there are gradations around seniority, the most potent force for understanding how directors manuever is how well they intuitively account for the views of - as well as questions held by - the directors as a whole.
Of course group dynamics gets into political games, personalities matter, and so on.
But as almost a forecast, this new board member isn't going to sit quietly and see what happens. Expect to see instead stridently pro-active moves to shorten that distance from board actions to the design and plane-building realms.
Throw the optics label if it suits you; Boeing very obviously created the mess it's in (with help from FAA, yes, and the Congress, and....). But count one attorney who keeps at least a few seats in one row of the mind open, as after all, do any of us have anything like the responsibilities of the U.S. Navy CNO on our c.v.s.?

[Flapsupbedsdown]

Originally Posted by 568

At 200 ft AGL given the caution, I would fly the aircraft in the current configuration. Of course it is all to easy to make these comments now that we have an official report of the accident.

The IAS disagree (not a memory item) check list will direct the crew to airspeed unreliable.

First 4 actions on the "airspeed unreliable" QRH nnc are memory items and include "pitch and power", it is not anywhere suggested to clean up, at a point the checklist says "set pitch and thrust for the current configuration of flight" and warns of possible multiple warnings.
Extracts from FCTM:.. The current flap position should be maintained until the memory pitch and thrust setting have been set and the airplane stabilized. If further flap extension/retraction is required refer to PI-QRH Airspeed unreliable table.
​​​​​​. Settings are provided for flight with and without flaps extended. The crew should use the setting for the condition they are in to keep the airplane safe while assessing the checklist etc...
Toghether with ET flight, it is the third fatal accident involving "unreliable airspeed" in recent times including a FBW aircraft.
​​​​

[Tomaski]

Regarding questions as to what the crew should have done in response to the initial indications associated with the AOA malfunction......

FWIW, beginning on page 91 of the final accident report, the investigation team reports findings from several test scenarios performed in Boeing's E-Cab engineering simulator. These scenarios were conducted to better understand the malfunction, the indications presented to the flight crew, and the crew workload. This is a description of one of these scenarios:

The first case objective of the third scenario was to observe an “ideal” response to stick shaker and IAS and ALT DISAGREE messages after takeoff. Crews were instructed to maintain takeoff flap configuration (MCAS function will not engage with flaps extended), complete the Airspeed Unreliable and Altitude Disagree NNC and return for landing at Jakarta. There was no significant issue regarding the first case.

The report does not say how or by whom this "ideal response" was crafted. That is, we do not know if this was hindsight or if this would have been the "Boeing approved" solution if asked before these accidents ever happened. Nor does the report say if this is the ideal response going forward with the redesigned MCAS system.

Personal opinion..... this "ideal response" should have been made part of the original emergency AD that Boeing put out after the Lion Air accident rather than the lawyerly-type language that was used. It might have made a difference.

[OldnGrounded]

Originally Posted by WillowRun 6-3

But as almost a forecast, this new board member isn't going to sit quietly and see what happens. Expect to see instead stridently pro-active moves to shorten that distance from board actions to the design and plane-building realms.
Throw the optics label if it suits you; Boeing very obviously created the mess it's in (with help from FAA, yes, and the Congress, and....). But count one attorney who keeps at least a few seats in one row of the mind open, as after all, do any of us have anything like the responsibilities of the U.S. Navy CNO on our c.v.s.?

If the admiral makes those proactive moves I'll be very impressed -- and grateful and relieved. And far be it from me to question the competence of a guy who has succeeded in the career path he chose.

I've just seen so many of these board-seat shuffles, almost always for the purpose of placating the press, customers and shareholders and so seldom resulting in real change in the trenches, that I tend to be suspicious.

[PJ2]

WillowRun 6-3, I concur with your views on "boards" of all natures; I have seen sea changes in at least one airline when a pair of new glasses are available and used. Before coming to terms with a serious problem, it must first be defined, (QED!) Leadership and the modelling of behaviours and prioritizing of corporate values, like the quality and "wholeness" of a symphony's music, always comes from the conductor. I know you're keenly aware of this and I hope the following contributes to this aspect of an important discussion.

In thinking about corporate culture at Boeing, NASA and the Challenger / Columbia accidents came to mind, and Dianne Vaughan's sociological study of the culture at NASA, "The Challenger Launch Decision", well worth reading in the present context. It was the B787 grounding that was the seed here and I wondered if anyone had written about corporate culture, specifically at Boeing.

It turns out that there are at least two such works, written as cohort studies in 2010 & 2015. They are well researched, offering some helpful insights into Boeing's cultural changes over time, in-step with broader changes in the political economy. These two books concern themselves with the American worker and business cultural changes that gathered momentum in the early '70's from the energy of a growing speculation economy, increasingly-unbridled profit and the devolution of the value of employees. Some labelled this new economy, "neoliberalism". This is a sufficient digression off-topic to define the background from which these works emerged.

They are:

Edward Greenberg, Leon Grunberg, Sarah Moore and Patricia Sikora, "Turbulence", Yale University Press, 2010

Edward Greenberg, Leon Grunberg, Sarah Moore and Patricia Sikora, "Turbulence", Yale University Press, 2010

&

Leon Grunberg, Sarah Moore, "Emerging from Turbulence", Rowman & Littlefield, 2016

Leon Grunberg, Sarah Moore, "Emerging from Turbulence", Rowman & Littlefield, 2016

Both are available as ebooks.

PJ2

[OldnGrounded]

Before Deadly Crashes, Boeing Pushed for Law That Undercut Oversight

Before Deadly Crashes, Boeing Pushed for Law That Undercut Oversight

The government has been handing over more responsibility to manufacturers for years. The new law makes it even harder for regulators to review Boeing’s work.

With a few short paragraphs tucked into 463 pages of legislation last year, Boeing scored one of its biggest lobbying wins: a law that undercuts the government’s role in approving the design of new airplanes.

For years, the government had been handing over more responsibility to manufacturers as a way to reduce bureaucracy. But those paragraphs cemented the industry’s power, allowing manufacturers to challenge regulators over safety disputes and making it difficult for the government to usurp companies’ authority.

Although the law applies broadly to the industry, Boeing, the nation’s dominant aerospace manufacturer, is the biggest beneficiary. An examination by The New York Times, based on interviews with more than 50 regulators, industry executives, congressional staff members and lobbyists, as well as drafts of the bill and federal documents, found that Boeing and its allies helped craft the legislation to their liking, shaping the language of the law and overcoming criticism from regulators.

In a stark warning as the bill was being written, the Federal Aviation Administration said that it would “not be in the best interest of safety.”

More

[WillowRun 6-3]

Thanks very much PJ2 for the reading suggestions.

Recalling the 787 grounding, at the time it was occuring, I observed what appeared to be a divergence in the investigative processes conducted in the U.S. relating to the incident in Boston, when compared to the essentially same type of process conducted relating to the incident in Japan (or at least these appeared divergent on some superficial level). It wasn't just the practically contemporaneous postings by NTSB of inquiry documents on its website (for instance witness interview reports were posted promptly there). Without meaning or wanting to knock Japanese process in that incident, it seemed the U.S. Board was more comprehensive, and was digging deeper.

So another question for "the authorities" in this grounding situation (and crisis) is, was such a divergence, if it did exist to a material extent, a precursor for Annex 13 headaches when the current report by Indonesia's authorities will be contrasted with, eventually, the report by Ethiopia? As even casual observers have seen, press reports have questioned integrity factors around the Ethiopia investigation.

Trying to shed any taste for drifting a thread, I'm not cataloguing the list of "responsive action decision and implementation steps" now in sight (not cataloguing them here). Just to add, the fact that another retired highly ranked Navy admiral, a former Vice Chairman of the JCS, already has been directing the new Safety Committee, gives, or should perhaps give, some modest measure of optimistic view.

[568]

Originally Posted by Flapsupbedsdown

First 4 actions on the "airspeed unreliable" QRH nnc are memory items and include "pitch and power", it is not anywhere suggested to clean up, at a point the checklist says "set pitch and thrust for the current configuration of flight" and warns of possible multiple warnings.
Extracts from FCTM:.. The current flap position should be maintained until the memory pitch and thrust setting have been set and the airplane stabilized. If further flap extension/retraction is required refer to PI-QRH Airspeed unreliable table.
​​​​​​. Settings are provided for flight with and without flaps extended. The crew should use the setting for the condition they are in to keep the airplane safe while assessing the checklist etc...
Toghether with ET flight, it is the third fatal accident involving "unreliable airspeed" in recent times including a FBW aircraft.
​​​​

Agree with your comments and quotes from the FCTM.
My response was to another poster who had asked what actions would to do if IAS disagree caution appeared at 200 feet AGL. Fly the aircraft then assess, plan and act accordingly.