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NYT: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

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NYT: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Old 22nd Jan 2020, 08:07
  #61 (permalink)  
 
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Originally Posted by safetypee View Post
Captain Biggles 101, and RetiredBA/BY, Herod, - just disconnect the autos - click click -

The operator needs sufficient information to trigger the point at which to act. Reliance on deduction or situational feedback of aircraft motion - when the aircraft is flying as expected, is not tolerable mitigation for (known) weakness in design. cf Aisiana.
Instead of looking at people as a hazard, to be guarded against; see them as an asset, a help in managing unusual situations as they do very successfully in operations every day. With such a view, then rare misjudgments in challenging situations are best answered by considering what more can be done in the operational environment, including automation, to assist people manage a wider range of situations.

HPSOV L, #44, 46, PJ2 # 49
I totally agree, aircraft design should not hide failures and surprise crews especially at critically low level. My point is, crews cannot be relied upon at all times to react properly when startled and little time available. Essentially we agree.

System design on the 737 NG is lacking EICAS and well thought out crew alerting. Just look at the master caution recall system that is ancient and very frequently failing on many aircraft to even display the intended annunciation when failed. Reality is that the machine design is old and lacks modern clear unambiguous system alerting when compared to Airbus or later Boeing models. If only crew had EICAS to clearly state what had failed and action to take, we wouldn't be having this discussion. Better system design, combined with flight crew more readily supported to maintain better manual piloting skills and monitoring, would improve the outcome of many of these serious accidents we now see.

One thing is for sure, there will be more technical failures putting huge reliance on flight crew to react timely in an appropriate manner to prevent accidents. The question is, do you want children of the magenta in the run up to the system failure or high energy approach prevention/recovery, or experienced crew who have been supported and encouraged to regularly practice full manual raw data with polished skills able to maintain full SA at same time to deal with faults?

We need to balance and reduce the notion of purely concentrated systems monitors and maintain a key focus on the basics first, that of core piloting skills and airmanship. The industry is now waking up to the excellent improved upset recovery training, better stall awareness and recovery techniques etc. We now need to wake the industry up the huge issue of preventing professional crew from flying completely manually without flight directors at sensible controlled times in order to maintain skills. This is a huge issue, seriously affecting piloting skills and safety. We are the last line in defence for the inevitable system failures yet the industry takes away the very necessary opportunities for crew to maintain needed skills that they are there to demonstrate within seconds should there be need. We need to stop and curtail the children of magenta trends, and insist upon higher standards being encouraged, demonstrated and maintained by flight crew and training departments. Some of the standards on flight decks are just not up to the necessary standards. Mostly self regulated industry training and lenient standards on checks is not correcting the issue, and is leading to the kinds of severe accidents that we now see.

The industry just keeps dragging in low experience, prioritises profits, and does not see the real value in retaining highly skilled time served aviators. Its time that standards were increased, and airlines truly took a cold hard look at experience levels and true standards on the flight deck. Then those professionals need better support and encouragement to practise and retain those skills. Flying is generally basic, but we've made it too complicated now by developing complex systems which have now made it complicated in relation to the human machine interaction. We need to concentrate on the basics.

Last edited by Captain Biggles 101; 22nd Jan 2020 at 08:38.
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Old 22nd Jan 2020, 08:36
  #62 (permalink)  
 
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Originally Posted by safetypee View Post
Captain Biggles 101, and RetiredBA/BY, Herod, - just disconnect the autos - click click -

The operator needs sufficient information to trigger the point at which to act.
Shouldn't the MEL have been sufficient information to not use the autothrust?

As a known complaint, with two succesful flights before, surely they had that information if they did their job?


Last edited by the_stranger; 22nd Jan 2020 at 15:19.
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Old 22nd Jan 2020, 09:24
  #63 (permalink)  
 
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Originally Posted by Twitter View Post
So it is. When you have presidents and their cohorts talking in thug speak and acting thug act, you mustn’t be surprised to see that behaviour further down the ranks.

If you want it to be great again, much work is required.

May I remind you that the president hinted at here was nowhere near being one when the turkish accident happened.
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Old 22nd Jan 2020, 09:27
  #64 (permalink)  
 
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Cap'n Biggles Sir,

Your excellent post about the need for the industry to give pilots the chance to hone their skills in everyday operations is very much to the point. When the automatics start doing something that is not as intended, we need not only better annunciation, but even more important, to have pilots who are sufficiently confident and well-practiced in their handling skills that they can immediately detect a departure from the intended flight path/configuration/speeds/altitudes/etc using the primary flight instruments, and then be able and confidently to handfly until the problem has been sorted.

From what I read, these days at a distance, current airline SOPs actively discourage the development and maintenance of these skills.
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Old 22nd Jan 2020, 09:58
  #65 (permalink)  
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Originally Posted by the_stranger View Post
Shouldn't the MEL have been sufficient information to not use the autothrust?

As a known complaint, with two siccesful flight before, surely they had that information of they did their job?
MMEL:

22-04 Autothrottle Systems C/1/0.
May be inoperative provided approach minimums do not require its use.

34-20-01 Radio Altimeter Systems

20-01-03. C/2/1 (M)(O) May be inoperative deactivated provided:
a) Approach minimums or operating procedures do not require its use,
b) Associated autopilot is not used for approach and landing,
c) Autothrottle is not used for approach and landing, and
d) Associated flight director is not used for approach and landing.
NOTE: During takeoff with one radio altimeter inoperative, the flight directors and autopilot should be controlled by the FCC on the same side as the valid radio altimeter (i.e., the first flight director and/or autopilot to be engaged must be receiving valid radio altitude data).

TK1951's fault was an airborne fault, and the MEL (a subset of the MMEL above) is not specifically applicable at that time, any NNCL or abnormal checks would apply. The MMEL hints to the interaction of an RA and the AT, but it isn't a glaringly obvious relationship when encountered at 500' AGL.
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Old 22nd Jan 2020, 11:00
  #66 (permalink)  
 
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Originally Posted by HPSOV L View Post

That’s why, in this age of system complexity and monitoring automation, it is vitally important that manufacturers keep improving cockpit ergonomics and don’t get let off the hook.
.....and even more important that basic handling skills are improved by many operators.

I have never flown a. NG but we had none of the current electronics in a -200, we managed perfectly
well but the arrival of the -300 made life even easier.

Sad to see the decline in basic skills of so many operators, almost all cost driven.
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Old 22nd Jan 2020, 11:27
  #67 (permalink)  
 
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Originally Posted by FlexibleResponse View Post
Very well researched, analyzed and presented, by Sidney Dekker. A belated well done sir!
A shame that the report has taken 10 years to surface. It is still as valid today as it was then.

Just read pages 117-121 "Findings and Conclusions" if you are time constrained.

https://www.onderzoeksraad.nl/nl/med...t_s_dekker.pdf
Indeed. And the second to last sentence should be hanging in any office of engineers designing and developing automation systems. Not only in aviation. But especially on the left coast of the US (Yes I'm looking at you Boeing & Tesla!).
The only defense against a designed-in single-failure path, in other words, are the pilots who are warned to mistrust their machine and to stare at it harder. Such a reminder, oriented only at the human operator in the system, is hardly credible after three decades of in-depth research into automated airliner flying and the subtle and pervasive ways in which automation on the flight deck (and particularly its subtle failure) affects human performance (e.g. Wiener & Curry, 1980, Sarter et al., 1997).
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Old 22nd Jan 2020, 12:09
  #68 (permalink)  
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Originally Posted by Captain Biggles 101 View Post
Well, here's the real problem. Put simply, there are far too many pilots that cannot perform and fly aircraft properly within its normal flight envelope well in all normal conditions, let alone with complex demanding technical issues when least expected and possibly fatigued. Talk to most long term sim TREs and they will tell you they have witnessed terrible things. The real question is how did we get to this? What lowered the standards? Who permits this? Are we heading in the wrong direction with children of the magenta just obsessed with the OFDM improved event safety stats, whilst we now witness terrible crashes where crews handle some serious events badly creating crashes? Look at Air France the crews pulling back for an eternity not recognising the stall; look at Turkish, not monitoring speed and thrust; look at several airliners below stall speed 85-100 kts with severe upsets following high power go arounds badly handled by crew. The writings in the wall, we need higher standards, and less self regulated back slapping.

Indeed, if crews cannot perform to the highest standards, they should not be on the flight deck. We cannot just blame solely aircraft design. This is a job for professionals to be just that.

The sooner we bring back respect for experienced professional flight crew the better. Right now there is a constant race to the bottom, whereby financial incentives push airlines to constantly favour inexperience pulling in at the bottom end, to the detriment of experience and safety. Then the self regulated training and checking just pushes crew through onto line. We need higher standards of training, experience and ability on the flight deck, then we must support those standards to be practised and maintained ready for any eventualities requiring that full demonstrated competence. Get rid of children of the magenta and get back to the important basics.

Not sure about that. There were plenty of accidents on steam powered aircraft that were due to loss of SA and lack of professionalism in the old days.
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Old 22nd Jan 2020, 12:55
  #69 (permalink)  
 
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Originally Posted by retired guy View Post
Ok point taken and apologies for missing your well made argument.
R Guy
No problem. We're all just trying to sort out a truly complex and confusing situation.

FYI, here's the relevant finding re: inadequate documentation, item 6 of Dekker's findings and conclusions:

Based on their training and documentation, the TK1951 crew would have believed that they had protected their aircraft and its flight from any pre-existing problems with the left RA. The right autopilot (known as Autopilot B or CMD B) had been selected on, and the right Flight Control Computer (known as FCC B) was giving it inputs.

Boeing pilot training materials and documentation do not reveal that the autothrottle always gets its height information from the left Radio Altimeter, that, on pre-2005 737NG models, it doesn’t cross-check its RA input data with other RA data; and that the right RA does not provide input to the autothrottle—even when FCC B has been selected as Master and Autopilot B is flying (which was the case for TK1951).

Last edited by OldnGrounded; 22nd Jan 2020 at 13:15. Reason: Format messy text from PDF.
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Old 22nd Jan 2020, 14:47
  #70 (permalink)  
 
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Originally Posted by alf5071h View Post
The NYT article, and the accident report, should reinforce the wake up call emerging from the Max saga. Not specifically directed Boeing, FAA, NTSB, but for world manufacturing, regulation, investigation and operations.
Alternatively as a bold safety statement, publishing the report anonymously with the objective of learning and changing even at this late stage.
Uh-huh. It was the world's company that designed and built 737-800. It was the world's certifying authority that rubber-stamped it. It was the world's investigation organization that put the pressure on the Onderzoeksraad to play down the technical aspects of the disaster so it seems that the world was quite responsible. I wish there were some way we could narrow down the responsibility, at least to the country level or so.

Originally Posted by Brian Pern View Post
Today's sky gods are so full of themselves with all the latest shimmy kit, they don't have an inkling of airmanship.
Safety statistics do not corroborate your claim.

Originally Posted by Old Carthusian View Post
There will always be pilots who are unable to respond effectively in an emergency or anomalous situation just as there are pilots who can do so successfully.
So, in which group falls the captain of FlyDubai 981? Could he fly the missed approach or not?

Originally Posted by wonkazoo View Post
What the heck is "airmanship" and why is it so great at saving airplanes that have been poorly designed??
The greatness of airmainship lays in the fact it is cheaper than properly designing the aeroplanes plus you can always count on the (volunteer) army of fans to berate the pilots killed in the poorly designed aeroplanes for the lack thereof, thereby moving the focus from design to pilot.

Originally Posted by maxxer View Post
As slf that article gives me shivers and i think this thread should be deleted asap.
You might be able to stop the PPRuNe, but in the grand scheme of the things, PPRuNe is insignificant compared to the New York Times and it's the one you can't stop. Reporters have smelled the blood.

Originally Posted by fox niner View Post
The only up-side of flying a 737, is that it makes you a better-than-average pilot. If you can fly a 737, than you can fly ANY Boeing airplane.
I am glad to read that, as I have found 738 to be far easier to fly than Q400 and maybe I'll be searching for another type rating pretty soon.

Originally Posted by alf5071h View Post
wonkazoo, Ascend Charlie, et al,

Airmanship is a personal attitude to flying, why we do it, how we do it. Airmanship must grow with training, experience, and personal exposure. It is not just about staying alive or not bending the airplane or yourself, it is about walking off the airfield knowing that you have both performed and crafted an activity. You have been totally aware of what you have done and why you enjoyed it, and a that point you owe nothing to anyone.
If we go by this definition, that leans heavily on the pilot's self-appraisal instead of the consequences of his or her actions, well then late Arthur "Bud" Holland would be one of the airmanshipest pilots that have ever walked the Earth. If we conveniently edit Czar 52 flight out of his biography, that is.

Originally Posted by Captain Biggles 101 View Post
Put simply, there are far too many pilots that cannot perform and fly aircraft properly within its normal flight envelope well in all normal conditions, let alone with complex demanding technical issues when least expected and possibly fatigued.
Safety statistics do not corroborate your claim.

Originally Posted by Captain Biggles 101 View Post
Talk to most long term sim TREs and they will tell you they have witnessed terrible things.
Pilots who perform terrible things are retrained until they do their flying in non-terrible way or are washed out.

Originally Posted by Captain Biggles 101 View Post
The real question is how did we get to this?
We got to what? To humongous discrepancy between real world's flying safety and PPRuNeload of claims we are doomed because pilots today can't fly? I would guess that huge holes in understanding how the modern aviation works and unwillingness to face the fact that air travel has never been safer were filled and compensated by industrial quantities of imagination and self-righteousness. Whether psychotropic substances played part, I can't speculate at the moment.

Originally Posted by Captain Biggles 101 View Post
Are we heading in the wrong direction with children of the magenta just obsessed with the OFDM improved event safety stats, whilst we now witness terrible crashes where crews handle some serious events badly creating crashes?
If there is really a plot to improve safety stats by killing less passengers and crew, I will gladly join it.

Originally Posted by Captain Biggles 101 View Post
We cannot just blame solely aircraft design.
You as "we" don't matter at all. FAA is blaming design enough that it grounded it and keeps it grounded.

Originally Posted by Captain Biggles 101 View Post
Right now there is a constant race to the bottom, whereby financial incentives push airlines to constantly favour inexperience pulling in at the bottom end, to the detriment of experience and safety.
There are no statistics or studies to corroborate your claim that safety is somehow diminished through the lack of experience. Personally, as someone who has flown with quite a few MPLs, ex-fast jet jocks and wobble to planks, I find the claims that the training standards are getting lower or that MPL is the doom of us all fairly ridiculous. Actually, those who tried hardest to kill me, themselves, our cabin crew and our passengers were the graybeards in the LHS who picked up all the wrong habits through experience.








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Old 22nd Jan 2020, 18:54
  #71 (permalink)  
 
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We have been here before have we not, albeit many, many years ago with the THY DC-10 at ermenonville, a senior Convair engineer (subcontractor) on the project warned of a "fundamental failure mode" with the cargo door latching mechanism, which for reasons that remain murky to this day were never actually fixed on the fateful aircraft (ship 29) resulting in catastrophe.

That was the time the FAA chief admitted (wouldn't happen today) they were "Fat, dumb and happy" (verbatim) in oversight, a remarkable statement, they were the only party to come out with a little self-respect from the whole tawdry affair.

That there were no emails, social media or such back then of course, and the stamp on the forms that said the door work had been carried out seemingly falsified (again this was never resolved) with all and sundry denying everything (although the smoking gun was the Applegate memorandum) shows that today, hiding is far more difficult.

There are certainly parallels even though the cases are forty five years apart.

Incidentally the lawsuits that followed were the largest in history at that time (mid 1970's) with McDD never (I believe) admitting full culpability.
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Old 22nd Jan 2020, 23:31
  #72 (permalink)  
 
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So, in which group falls the captain of FlyDubai 981? Could he fly the missed approach or not?

Tragically the evidence indicates not and the clue is in the conduct of the Aeroflot flight.

OC
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Old 22nd Jan 2020, 23:51
  #73 (permalink)  
 
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Originally Posted by Old Carthusian View Post
So, in which group falls the captain of FlyDubai 981? Could he fly the missed approach or not?
I think that captain falls into the group of exhausted pilots repeatedly fatigued by inhuman rostering. Among other things.
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Old 23rd Jan 2020, 04:56
  #74 (permalink)  
 
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You got it in one, OldnGrounded, now let me help our friends with somewhat Manichean worldview that separates pilots into sharply defined categories of "good" and "bad" by reminding them that the official report of A6-FDN catastrophe is full of references to successful first windshear escape and go-around, before the second, fatal one. So if we go by the philosophy that there are good and bad pilots (and its quite sinister implication, pervading the MAX threads that the bad pilots destroyed the good aeroplanes) , we would be at loss to explain how the good pilots turned into the bad in the matter of hours.
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Old 23rd Jan 2020, 08:45
  #75 (permalink)  
 
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Originally Posted by Twitter View Post
Actually it’s not so simple in the Max case - flying manually allows MCAS to run - AP on inhibits MCAS.

In fault mode, switching off the automatics - or thinking you have, leads to this Gotcha, where you still have a rogue system fighting you.

As it happens, leaving flap out and or AP engaged would have enabled an approach to land - but who could know that at the time?

So the macho just fly it method has its limits.

Excuse my ignorance but isnt the MCAS switched off by the stab.trim cutout switches ?

Trimming by the handwheel.

Nothing macho ( or holier than thou etc.,) about flying a 737 manually, just basic flying skill, which should be possessed by EVERY pilot.
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Old 23rd Jan 2020, 09:43
  #76 (permalink)  
 
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Originally Posted by Clandestino View Post
You got it in one, OldnGrounded, now let me help our friends with somewhat Manichean worldview that separates pilots into sharply defined categories of "good" and "bad" by reminding them that the official report of A6-FDN catastrophe is full of references to successful first windshear escape and go-around, before the second, fatal one. So if we go by the philosophy that there are good and bad pilots (and its quite sinister implication, pervading the MAX threads that the bad pilots destroyed the good aeroplanes) , we would be at loss to explain how the good pilots turned into the bad in the matter of hours.
Clandestino

I would say that 'bad' and 'good' are being used to create unrestricted generalizations. Even though it is the case that there are indeed such 'types' and that certain people are indeed trying to smear the pilots in the MAX accidents to protect Boeing you make your point poorly. The example chosen is a case of a pilot getting it horribly wrong and the first successful go around is irrelevant to the outcome apart from being one of the links in the causal chain which led to a lot of unnecessary deaths. I am all in favour of greater automation as it is likely that it would eliminate accidents like this one but to my mind the issue is more to do with corporate irresponsibility and the moral bankruptcy reigning at Boeing. A pilot should have all the information he needs about his aircraft to be able to fly it successfully. Unfortunately it is an aspect of American corporate life that uncomfortable facts, flaws in the product and developments are hidden if they impact the bottom line. The Boeing behaviour in the Turkish accident is regrettably not unusual and will continue, if not at Boeing, at other companies. It is always thus where money is placed on a pedestal.

The answer is that the regulatory authorities resist this kind of pressure and remain pure. However, this is perhaps a pipe dream.

OC
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Old 23rd Jan 2020, 13:01
  #77 (permalink)  
 
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Originally Posted by RetiredBA/BY View Post
Excuse my ignorance but isnt the MCAS switched off by the stab.trim cutout switches ?

Trimming by the handwheel.

Nothing macho ( or holier than thou etc.,) about flying a 737 manually, just basic flying skill, which should be possessed by EVERY pilot.
Actually, it may well be that trimming with the hand wheels could take as much or more strength than could be mustered, together with some rather fancy (and untrained) flying skills, at some attitudes and dynamic loads. This issue has been part of the discussion since soon after ET 302 went down. Here's a starting point:

https://www.satcom.guru/2019/04/stab...and-range.html
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Old 23rd Jan 2020, 14:00
  #78 (permalink)  
 
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Originally Posted by RetiredBA/BY View Post
Excuse my ignorance but isnt the MCAS switched off by the stab.trim cutout switches ?

Trimming by the handwheel.

Nothing macho ( or holier than thou etc.,) about flying a 737 manually, just basic flying skill, which should be possessed by EVERY pilot.
No point in going over it all again R Baby but briefly those switches don’t switch off MCAS - they switch off the Stab trim, which MCAS attempts to operate. MCAS can only be disabled by Slats out or and AP on.

My poorly made point was that disconnecting AP/AT and flying manually will not on it’s own get you out of this mess, as it would out of most others. Indeed, leaving the AP engaged would be beneficial in the special case of MCAS rogue operation. Problem is the Speed Disagree situation / Stall warning preventing this.

As recommended by Oldn’ see early threads for more on this and Trim wheel diameter problems.

Manual flying is of course not macho (some commentators are.) It is one of the most satisfying things to do and probably why we became pilots.
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Old 23rd Jan 2020, 17:42
  #79 (permalink)  
 
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Originally Posted by Twitter View Post
No point in going over it all again R Baby but briefly those switches don’t switch off MCAS - they switch off the Stab trim, which MCAS attempts to operate. MCAS can only be disabled by Slats out or and AP on.

My poorly made point was that disconnecting AP/AT and flying manually will not on it’s own get you out of this mess, as it would out of most others. Indeed, leaving the AP engaged would be beneficial in the special case of MCAS rogue operation. Problem is the Speed Disagree situation / Stall warning preventing this.

As recommended by Oldn’ see early threads for more on this and Trim wheel diameter problems.

Manual flying is of course not macho (some commentators are.) It is one of the most satisfying things to do and probably why we became pilots.
Switching off stab trim (Stab Trim Cut Out Switches) prevents any stab trimming and that stopped Version 1 MCAS having any effect. So it may have been running inside the STS subsystems - but it could not do anything to affect the operation of the aircraft. From reports the updated MCAS will not repeatedly operate so the main problem of MCAS re-initializing and repeating a ND trim after any electric trim input has been removed in the Max from now on. The initiation of the problem caused by the single point of failure of only using one AoA vane has also been removed by the MCAS being linked to both AoA vanes. In other words the direct MCAS threat has been removed.
So your post should really use the past tense.
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Old 23rd Jan 2020, 17:57
  #80 (permalink)  
 
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Originally Posted by Ian W View Post
Switching off stab trim (Stab Trim Cut Out Switches) prevents any stab trimming and that stopped Version 1 MCAS having any effect. So it may have been running inside the STS subsystems - but it could not do anything to affect the operation of the aircraft. From reports the updated MCAS will not repeatedly operate so the main problem of MCAS re-initializing and repeating a ND trim after any electric trim input has been removed in the Max from now on. The initiation of the problem caused by the single point of failure of only using one AoA vane has also been removed by the MCAS being linked to both AoA vanes. In other words the direct MCAS threat has been removed.
So your post should really use the past tense.
We haven‘t seen the updated version life, have you? Just vapour ware. Can‘t see why past tense should be mandatory.
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