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Boeing Board to Call for Safety Changes After 737 Max Crashes

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Boeing Board to Call for Safety Changes After 737 Max Crashes

Old 20th Sep 2019, 04:09
  #41 (permalink)  
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Originally Posted by pilotmike
Some quotes"from the great aviation writer, William Langewiesche"...








"William Langewiesche is a newly named writer at large for the magazine. He is a former national correspondent for The Atlantic and international correspondent for Vanity Fair, where he covered a wide variety of subjects throughout the world. He grew up in aviation and got his start as a pilot before turning to journalism. This is his first article for the magazine."

Shocking. I hope this might be his last article.
You may be on to something there...

Dear FAA STDS person, I was reviewing my PQS document for a student, and my copy is missing the PQS details for the required strapping on of an aircraft. I found the spurs to be removed before flight and the requirement to fly only when there is lift in the air, but somehow my copy from the printer was missing the strap on performance standard. Please rectify at your earliest convenience,

Yours faithfully,
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Old 20th Sep 2019, 08:31
  #42 (permalink)  
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Langewiesche.articles ( remember the AF447 one) are written like mini-novels , with drama, adding personal " human " quotes, and therefore they are well received by the public . The problem here , like in the AF447 and the MH270 ones , is that he speculates a lot and present some of his ideas , or even rumors as kind of facts.
That said , his audience is the general public, not aviation professionals.
To his defense, he knows aviation and goes on to location to interview people ( or try to ) to write his pieces, something many other journalists fail to do.

His piece about the kids school in Jakarta is correct , yes it is just like this. I have been there and talked to the people running this "academy" which is run like a military camp. Yes those kids will be in the RHS of a 737 or 320 a year later after max 75h or real flying in a TB20. . But same in other parts of the world including Europe.
One thing that he does not emphasize in his piece is that the very poor accident rate in the country is vastly due to equatorial weather conditions and extremely poor infrastructure, lack of nav aids, etc.. Add corruption at all levels preventing any oversight, plus everybody else working around the system receiving extremely low salaries , forcing them to get a second , or sometimes 3rd job to sustain a family, and you get the environment .
The actual quality of the pilots is not the real problem in Indonesia, as this article would want the public to believe. I think this article is just preparation work to reassure the US public that it will be safe to fly again in the max in the coming months because they will be operated by US pilots. .
Clever.
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Old 20th Sep 2019, 12:51
  #43 (permalink)  
 
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Originally Posted by ATC Watcher
Langewiesche.articles ( remember the AF447 one) are written like mini-novels , with drama, adding personal " human " quotes, and therefore they are well received by the public . The problem here , like in the AF447 and the MH270 ones , is that he speculates a lot and present some of his ideas , or even rumors as kind of facts.
That said , his audience is the general public, not aviation professionals..........The actual quality of the pilots is not the real problem in Indonesia, as this article would want the public to believe. I think this article is just preparation work to reassure the US public that it will be safe to fly again in the max in the coming months because they will be operated by US pilots. .
Clever.
Agree, that article looks like a softening up prep for the public in North America. I feel for the flight crew who will have to fly the damn things or walk away from their job. It plays on the meme of ‘foreign pilots bad, our pilots good’ especially when you read the last line of that article.
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Old 20th Sep 2019, 15:10
  #44 (permalink)  
 
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The Langewiesche piece is taking 14000 words to sell the same message as some forum members here tried to sell: that real "airmanship" would have saved the day. But in the process the writer:

- downplays or simply ignores the fact that AoA-failure-induced MCAS action doesn't look like runaway trim, because it responds to cancellation with the yoke switches
- skates over the fact that a condition with failed power trim, AND trim and high speed can rapidly become very difficult to handle, hence the "roller-coaster" maneuver
- simply doesn't mention the simple fact that this particular failure was fatal two out of three times it occurred, and that once an erroneous MCAS action kicked in, the crew had become test pilots,

Now, maybe Langewiesche simply believes that flight training standards are inadequate and that pilots need experience in manual-control airplanes that they'll never fly professionally. But the missing bits of the story - including no "I asked Boeing to comment on XYZ and they declined", which is boring narrative but good practice - makes it sound consciously pro-Boeing to those familiar with the issues. On the other hand, even an attentive layman reader, or a general-interest editor, will not be aware of what was left out of the story.

I would think Boeing would be crazy to try to plant a story like this, because of the blowback should any linkage be revealed. But there is crazy - and there is desperate.
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Old 20th Sep 2019, 15:44
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I am cautious about wading into the commentary about the Langewiesche NYT article, but I'm going to suggest that there is a middle ground here.

There is an old saw that goes something like, "What you see depends heavily on where you stand." Different people can look at the information surrounding the MAX crashes through different lenses and come away with different viewpoints. That's not necessarily a bad thing. Accident investigations provide the opportunity to identify multiple ways in which the aviation system can be improved, even if there is disagreement regarding the primary causes.

I read the article through several times and I'll admit that I don't agree with everything Langewieshe says, but I don't disagree with all of it either. Clearly, Boeing fell far short of everyone's expectations in how they rushed through the MAX design and production process. Just as clearly, these accidents demonstrated that there is significant room for improvement in regulatory oversight, aircrew training, aircraft maintenance, and overall corporate (both airline and manufacturer) attitudes toward safety. All of these areas need work, so there is no need to pick and choose. Boeing absolutely needs to step up and fix their design process. The FAA and other certificate authorities absolutely need to step up and improve their oversight. By the same token, airlines also need to re-evaluate their aircrew training and aircraft maintenance practices with an particular eye toward improving safety as opposed to minimizing costs. It all needs work, so I really don't think it is necessary to emphasize one problem area at the expense of another.
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Old 21st Sep 2019, 18:53
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Sorry fdr

But it has been a while since Boeing was a market leader,even without the MCAS calamity, B737 is badly overdue for a replacement. The B787 has a “ cheap charlie” feel to it. As a pilot I much prefer the A 330 to the B787, having flown both.
If Boeing wants to be a market leader again, they need to go ahead with a 737 replacement. It was a very bad idea to scrap the 757 tooling.
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Old 23rd Sep 2019, 09:13
  #47 (permalink)  
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Originally Posted by Diavel
But it has been a while since Boeing was a market leader,even without the MCAS calamity, B737 is badly overdue for a replacement. The B787 has a “ cheap charlie” feel to it. As a pilot I much prefer the A 330 to the B787, having flown both.
If Boeing wants to be a market leader again, they need to go ahead with a 737 replacement. It was a very bad idea to scrap the 757 tooling.
Can't argue on the 737 or the 757. Having also flown both the 330 and 787, would say the choice, as beauty lies in the beholder. The flight deck setup of the 787 is better. As I have said often, I prefer the control C* of Airbus over C*U of Boeing, but when there is a crosswind, fault or other anomaly ill take the Boeing every day of the week. The 757 was a great pilots plane, and had a great performance mix but the financial didn't make much sense. Boeings rationale for the continuation of the 737 is not entirely of their making.

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Old 24th Sep 2019, 05:23
  #48 (permalink)  
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When we focus on 'human error' as the cause of an accident rather than the error being the consequence of a deeper flaw, we fail to look for the conditions which caused the undesired outcomes, and or behaviour. Boeing may well have helped create these conditions. Leave these conditions in place, and the same bad outcomes may happen again no matter how many posters, articles, or pilots we blame with fancy phrases such as loss of situational awareness, lack of proficiency etc. All we are doing is giving 'human error' a nice name, but we are not explaining why this happened, and we are not removing the conditions. A few well trained pilots during WWII regardless of skill, and or experience reported that they sometimes made errors using cockpit controls. The airforce did not blame them, rather they got the manufacturer to design better equipment in accordance with human requirements. Pilot behaviour on the two doomed aircraft is just the symptom of the trouble, not the cause of it. It has been proven time and time again, that skill and experience is not enough, but changing the conditions is, so lets focus on that rather on blaming the pilots with fancy error names.
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Old 24th Sep 2019, 07:11
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HFP,

Well stated; a much needed reminder, a refocusing of safety prioritises for the industry.

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Old 25th Sep 2019, 08:16
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Originally Posted by DaveReidUK
Not forgetting The Atlantic Dusts Off Discredited Conspiracy Theory to Accuse MH370 Pilot of Hijacking

Suicide-murder by the captain, in case anyone was wondering, according to Langewiesche.
A writer needs credentials and credibility, not popular acclaim. MH370 and the two Max accidents are among the most controversial in aviation history when it comes to separating fact from fiction, in spite of, or maybe because of, the evidence that appears to support whatever side of the argument you happen to be on. Who are we to look to for the real truth? CNN? The current culture of partisan political correctness has almost cleared the field of true investigative journalists, so let’s give this one the credit he deserves. He may not have all the answers, but I am willing to bet we are closer to the truth now than we were before he wrote his articles on all three of those accidents.
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Old 26th Sep 2019, 16:01
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Looks like another Board is also calling for safety changes.

NTSB Issues 7 Safety Recommendations to FAA related to Ongoing Lion Air, Ethiopian Airlines Crash Investigations

9/26/2019
​WASHINGTON (Sept. 26, 2019) — The National Transportation Safety Board issued seven safety recommendations Thursday to the Federal Aviation Administration, calling upon the agency to address concerns about how multiple alerts and indications are considered when making assumptions as part of design safety assessments.

Aviation Safety Recommendation Report 19-01 was issued Thursday stemming from the NTSB’s ongoing support under International Civil Aviation Organization Annex 13 to Indonesia’s Komite Nasional Keselamatan Transportasi (KNKT) investigation of the Oct. 29, 2018, crash of Lion Air flight 610 in the Java Sea and the Aircraft Accident Investigation Bureau of Ethiopia’s investigation of the crash of Ethiopian Airlines flight 302 near Ejere, Ethiopia. All passengers and crew on board both aircraft – 346 people in all – died in the accidents. Both crashes involved a Boeing 737 MAX airplane.


The seven safety recommendations issued to the FAA are derived from the NTSB’s examination of the safety assessments conducted as part of the original design of Boeing’s Maneuvering Characteristics Augmentation System (MCAS) on the 737 MAX and are issued out of the NTSB’s concern that the process needs improvement given its ongoing use in certifying current and future aircraft and system designs.

“We saw in these two accidents that the crews did not react in the ways Boeing and the FAA assumed they would,” said NTSB Chairman Robert Sumwalt. “Those assumptions were used in the design of the airplane and we have found a gap between the assumptions used to certify the MAX and the real-world experiences of these crews, where pilots were faced with multiple alarms and alerts at the same time. It is important to note that our safety recommendation report addresses that issue and does not analyze the actions of the pilots involved in the Lion Air and Ethiopian Airlines accidents. That analysis is part of the ongoing accident investigations by the respective authorities.”

The NTSB notes in the report that it is concerned that the accident pilots’ responses to unintended MCAS operation were not consistent with the underlying assumptions about pilot recognition and response that were used for flight control system functional hazard assessments as part of the Boeing 737 MAX design.

The NTSB’s report further notes that FAA guidance allows such assumptions to be made in certification analyses without providing clear direction about the consideration of multiple, flight-deck alerts and indications in evaluating pilot recognition and response. The NTSB’s report states that more robust tools and methods need to be used for validating assumptions about pilot response to airplane failures in safety assessments developed as part of the U.S. design certification process.

The seven recommendations issued to the FAA urge action in three areas to improve flight safety:
  • Ensure system safety assessments for the 737 MAX (and other transport-category airplanes) that used certain assumptions about pilot response to uncommanded flight control inputs, consider the effect of alerts and indications on pilot response and address any gaps in design, procedures, and/or training.
  • Develop and incorporate the use of robust tools and methods for validating assumptions about pilot response to airplane failures as part of design certification.
  • Incorporate system diagnostic tools to improve the prioritization of and more clearly present failure indications to pilots to improve the timeliness and effectiveness of their response.
NTSB investigators continue to assist the KNKT and AAIB in their ongoing investigations. The NTSB has full access to information from the flight recorders, consistent with standards and recommended practices for the NTSB’s participation in foreign investigations.

The KNKT’s accident report is expected to be released in the coming months, and their analysis of the Lion Air accident may generate additional findings and recommendations.

Aviation Safety Recommendation Report 19-01 is available online at https://go.usa.gov/xVv7P.









https://www.ntsb.gov/news/press-rele...R20190926.aspx

Last edited by Airbubba; 26th Sep 2019 at 16:40.
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Old 26th Sep 2019, 16:33
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For anyone else who can't get those links above to work, here are the 7 Safety Recommendations made to the FAA:

Require that Boeing (1) ensure that system safety assessments for the 737 MAX in which it assumed immediate and appropriate pilot corrective actions in response to uncommanded flight control inputs, from systems such as the Maneuvering Characteristics Augmentation System, consider the effect of all possible flight deck alerts and indications on pilot recognition and response; and (2) incorporate design enhancements (including flight deck alerts and indications), pilot procedures, and/or training requirements, where needed, to minimize the potential for and safety impact of pilot actions that are inconsistent with manufacturer assumptions. (A-19-10)

Require that for all other US type-certificated transport-category airplanes, manufacturers (1) ensure that system safety assessments for which they assumed immediate and appropriate pilot corrective actions in response to uncommanded flight control inputs consider the effect of all possible flight deck alerts and indications on pilot recognition and response; and (2) incorporate design enhancements (including flight deck alerts and indications), pilot procedures, and/or training requirements, where needed, to minimize the potential for and safety impact of pilot actions that are inconsistent with manufacturer assumptions. (A-19-11)

Notify other international regulators that certify transport-category airplane type designs (for example, the European Union Aviation Safety Agency, Transport Canada, the National Civil Aviation Agency-Brazil, the Civil Aviation Administration of China, and the Russian Federal Air Transport Agency) of Recommendation A-19-11 and encourage them to evaluate its relevance to their processes and address any changes, if applicable. (A-19-12)

Develop robust tools and methods, with the input of industry and human factors experts, for use in validating assumptions about pilot recognition and response to safety-significant failure conditions as part of the design certification process. (A-19-13)

Once the tools and methods have been developed as recommended in Recommendation A-19-13, revise existing Federal Aviation Administration (FAA) regulations and guidance to incorporate their use and documentation as part of the design certification process, including re-examining the validity of pilot recognition and response assumptions permitted in existing FAA guidance. (A-19-14)
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Old 26th Sep 2019, 16:42
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Originally Posted by DaveReidUK
For anyone else who can't get those links above to work, here are the 7 Safety Recommendations made to the FAA:
I've attempted to patch the NTSB typo in the last link and I've attached the Safety Recommendation Report to this post.
Attached Files
File Type: pdf
ASR1901.pdf (141.5 KB, 26 views)
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Old 26th Sep 2019, 17:35
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Originally Posted by DaveReidUK
For anyone else who can't get those links above to work, here are the 7 Safety Recommendations made to the FAA:
From my view this is not just a Boeing problem, but applies throughout the industry.

In my simplistic view, somehow we can no longer assume that the man machine interface will stop arguing to the point where the recovery is impossible. What does it take to teach the man otherwise?
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Old 26th Sep 2019, 18:32
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Very interesting report, which reinforces several comments made in this thread!

One minor technical point which was argued (inconclusively) in previous threads, seems to have been definitively stated as a fact:
As originally delivered, the MCAS became active during manual flight (autopilot not engaged) when the flaps were fully retracted and the airplane’s AOA value (as measured by either AOA sensor) exceed ed a threshold based on Mach number. When activated, the MCAS provided automatic trim commands to move the stabilizer AND. Once the AOA fell below the threshold, the MCAS would move the stabilizer ANU to the original position.
This stabilizer reset process never took place in the accident cases with a stuck AOA. The consequences of this part of the fault-tree was not examined properly at the design stage.
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Old 26th Sep 2019, 19:35
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Originally Posted by GordonR_Cape

This stabilizer reset process never took place in the accident cases with a stuck AOA. The consequences of this part of the fault-tree was not examined properly at the design stage.
Not really - at the design process is was assumed that if the stab trim started doing anything the pilots didn't like, they'd immediately disable it. However it was also assumed that the pilots would be trained to know about MCAS so they could recognize if it wasn't acting properly. This lead to a malfunction of MCAS being classified as no worse than Major. Everything downstream was a result of those two flawed assumptions - including MCAS using a single AOA sensor - since that was all consistent for a system that wasn't judged to be flight critical.

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Old 26th Sep 2019, 19:54
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So nobody thought what would happen when the duty AoA sensor misbehaves for some reason, like getting stuck at lets say 25 deg. Multiple warnings and an activated MCAS. Maybe all primary sensors should be analysed.
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Old 26th Sep 2019, 21:19
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Originally Posted by Aihkio
So nobody thought what would happen when the duty AoA sensor misbehaves for some reason, like getting stuck at lets say 25 deg. Multiple warnings and an activated MCAS. Maybe all primary sensors should be analysed.
I'm uncertain what to make of this, in the NTSB report:

As originally delivered, the MCAS became active during manual flight (autopilot not engaged) when the flaps were fully retracted and the airplane’s AOA value (as measured by either AOA sensor) exceeded a threshold based on Mach number.
Emphasis added.
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Old 26th Sep 2019, 21:45
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Originally Posted by OldnGrounded
I'm uncertain what to make of this, in the NTSB report:

" (as measured by either AOA sensor)"

Emphasis added.
I'm pretty sure that's just a compressed version of a much longer paragraph, and not literally true as written. The original interpretation could be that either AOA value could trigger MCAS, depending on which side FCC was active (alternating between flights).
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Old 27th Sep 2019, 00:44
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Originally Posted by GordonR_Cape
I'm pretty sure that's just a compressed version of a much longer paragraph, and not literally true as written. The original interpretation could be that either AOA value could trigger MCAS, depending on which side FCC was active (alternating between flights).
OK, you're probably right. If not, the system is even stranger than we thought.
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