NYT: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’
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The most recent variant of the 737 is a debacle, one that Boeing will carry the burden for years to come. It’s predecessor, albeit another cut & paste job, isn’t. Its not without its limitations however fundamentally it remains a basic aeroplane that rarely leaves you in a state of overwhelming WTF. The reason why this aircraft crashed was that three people let it crash. One of the basics of flying is airspeed. This accident was a nonsense and remains nothing more than a lesson in poor airmanship & monitoring.
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Herod
can I second or “third”:that? Hurrah- I detect more posts supporting that view.
We refer of course to the need for basic flying skills/CRM/Airmanship, being retained and trained, or in some airlines, re-trained. or even trained for the first time in these skills. Quite a challenge isn’t it?
There seem to be two camps here in these forums. - “engineer-out” the pilots because they can no longer be expected to emulate the extraordinary skills of people like Eric Moody who’s crew saved the Jumbo over Jakarta. Eric would say, and has done , that he was just doing his job, like Sully. He was an average pilot in that airline. He never claimed to be a Tex Johnson or Chuck Yeager.
Or train them to handle the plethora of multiple failures that can occur on any plane with a cascading domino effect Non-normal procedures with confusing and sometimes contradictory annunciations.. like stick shaker rattling at the same time as the high speed warning. (look at the pitch,power and GPS for a clue would be good start).
QF A380 ex SIN was a classic example of the need, on even the very latest equipment, to be able to access a wide range of high level skills to prioritise the 50+ warnings they had with a partially crippled aircraft.
The lack of skills and training on AF447 was not a mile away from recent events. So it’s not just entry level startups that need these skills. We all need to hone them. Even some legacy airlines where perhaps we need to get back to basics.
The big question for the industry remains “ who is going to do this training?”
it is not unusual in start ups & LCC to have trainers as young as 25, who then train the 20 year old cadets , who 5 years later become trainers. There is every opportunity with that model for a sort of aeronautical inbreeding, with no wise heads to guide them. Add in the airline starting up its own Flight Academy and we’re all set to mark our own homework.
i guess my question is this- why are there so many on these forum topics who object to thorough pilot training?
if you’re a CFO counting the beans then I can see that it would frighten you to the core. But most commentators here seem to be either pilots or passengers who it would seem to me should be crying out for intensive training which has now finally been mentioned as a causal contributing factor in the two Max crashes.
Just curious. best wishes
R Guy
can I second or “third”:that? Hurrah- I detect more posts supporting that view.
We refer of course to the need for basic flying skills/CRM/Airmanship, being retained and trained, or in some airlines, re-trained. or even trained for the first time in these skills. Quite a challenge isn’t it?
There seem to be two camps here in these forums. - “engineer-out” the pilots because they can no longer be expected to emulate the extraordinary skills of people like Eric Moody who’s crew saved the Jumbo over Jakarta. Eric would say, and has done , that he was just doing his job, like Sully. He was an average pilot in that airline. He never claimed to be a Tex Johnson or Chuck Yeager.
Or train them to handle the plethora of multiple failures that can occur on any plane with a cascading domino effect Non-normal procedures with confusing and sometimes contradictory annunciations.. like stick shaker rattling at the same time as the high speed warning. (look at the pitch,power and GPS for a clue would be good start).
QF A380 ex SIN was a classic example of the need, on even the very latest equipment, to be able to access a wide range of high level skills to prioritise the 50+ warnings they had with a partially crippled aircraft.
The lack of skills and training on AF447 was not a mile away from recent events. So it’s not just entry level startups that need these skills. We all need to hone them. Even some legacy airlines where perhaps we need to get back to basics.
The big question for the industry remains “ who is going to do this training?”
it is not unusual in start ups & LCC to have trainers as young as 25, who then train the 20 year old cadets , who 5 years later become trainers. There is every opportunity with that model for a sort of aeronautical inbreeding, with no wise heads to guide them. Add in the airline starting up its own Flight Academy and we’re all set to mark our own homework.
i guess my question is this- why are there so many on these forum topics who object to thorough pilot training?
if you’re a CFO counting the beans then I can see that it would frighten you to the core. But most commentators here seem to be either pilots or passengers who it would seem to me should be crying out for intensive training which has now finally been mentioned as a causal contributing factor in the two Max crashes.
Just curious. best wishes
R Guy
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Originally Posted by retired guy
– this including possibilities of incorrect pilot operation in regard of the MCAS flight control system that is judged to be the main issue behind both incidents.
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[QUOTE=RetiredBA/BY;10668681].....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.[/QUOTE]
BA
On the money, literally, with that post. Saving money on safety will always end in tears. “ if you think safety is expensive, try having two accidents!” Ask Boeing , even though they were not entirely to blame as there were many other factors.
And if Boeing were an airline that suffered two related crashes, or even unrelated, it’s bye bye. Billions of dollars and years of investment gone in a few weeks maybe. No jobs. So sad.
And the cost of real safety v lip service to safety is not high. Maybe 2\5 % of turnover. Measured against the cost of Armaggedonn as faced by Boeing currently its an easy form of insurance.
look fwd to any views on that sort of thing.
Safe flying
RvGuy
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.[/QUOTE]
BA
On the money, literally, with that post. Saving money on safety will always end in tears. “ if you think safety is expensive, try having two accidents!” Ask Boeing , even though they were not entirely to blame as there were many other factors.
And if Boeing were an airline that suffered two related crashes, or even unrelated, it’s bye bye. Billions of dollars and years of investment gone in a few weeks maybe. No jobs. So sad.
And the cost of real safety v lip service to safety is not high. Maybe 2\5 % of turnover. Measured against the cost of Armaggedonn as faced by Boeing currently its an easy form of insurance.
look fwd to any views on that sort of thing.
Safe flying
RvGuy
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Hi Old Dogs
My guess is because after the AD post Lionair, it was known about and Boeing said “;treat it like a runaway stab” which most assuredly it is. “ Continuously” means without stopping, or a quick succession of similar events.
“my wife nags we continuously “. Presumably she draws breath between each bout of nagging? But it will eventually cause you to lose the will to live. And vice versa for the PC types. Men can nag too.
similarly a stabilizer which runs AND , over and over , always in the same direction, with a very short pause is by any definition in the dictionary “:Continuous” yes?
Especially since we all studied that AD assiduously post Lionair to make sure a similar fate would not befall us.
thats how we stay safe. Learn from others. These days more than ever we need to learn from the published errors which are available on line every day on the likes of of AV HERALD and AEROINSIDE free of charge.
Everyday I read about maybe 15/major incidents. Some handled brilliantly. Others leave something that might have been done much better. FYI every day there are around three engine failures and a rising number of smoke fume events- some really nasty. Loads of learning free of charge.
Safe Flying
R Guy
My guess is because after the AD post Lionair, it was known about and Boeing said “;treat it like a runaway stab” which most assuredly it is. “ Continuously” means without stopping, or a quick succession of similar events.
“my wife nags we continuously “. Presumably she draws breath between each bout of nagging? But it will eventually cause you to lose the will to live. And vice versa for the PC types. Men can nag too.
similarly a stabilizer which runs AND , over and over , always in the same direction, with a very short pause is by any definition in the dictionary “:Continuous” yes?
Especially since we all studied that AD assiduously post Lionair to make sure a similar fate would not befall us.
thats how we stay safe. Learn from others. These days more than ever we need to learn from the published errors which are available on line every day on the likes of of AV HERALD and AEROINSIDE free of charge.
Everyday I read about maybe 15/major incidents. Some handled brilliantly. Others leave something that might have been done much better. FYI every day there are around three engine failures and a rising number of smoke fume events- some really nasty. Loads of learning free of charge.
Safe Flying
R Guy
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So, during the training of the Lion Air and Ethiopian crews they were never taught that an MCAS system was installed on the MAX (unlike the NG they were used to flying), how the MCAS system worked and trained in MCAS normal/abnormal use?
Can we assume all the Southwest, et al, and other American crews were trained on the MCAS system?
I ask because my buddy who flew MAX's for WestJet had no idea MCAS was installed.
Just another dumb Canadian pilot, I guess.
And one must wonder, if the problem is just dumb aircrew why is the MAX still on the ground?
Surely the fix for dumb aircrew is better training, not rebuilding the complete MCAS system?
Can we assume all the Southwest, et al, and other American crews were trained on the MCAS system?
I ask because my buddy who flew MAX's for WestJet had no idea MCAS was installed.
Just another dumb Canadian pilot, I guess.
And one must wonder, if the problem is just dumb aircrew why is the MAX still on the ground?
Surely the fix for dumb aircrew is better training, not rebuilding the complete MCAS system?
Hi Old Dogs
My guess is because after the AD post Lionair, it was known about and Boeing said “;treat it like a runaway stab” which most assuredly it is. “ Continuously” means without stopping, or a quick succession of similar events.
“my wife nags we continuously “. Presumably she draws breath between each bout of nagging? But it will eventually cause you to lose the will to live. And vice versa for the PC types. Men can nag too.
similarly a stabilizer which runs AND , over and over , always in the same direction, with a very short pause is by any definition in the dictionary “:Continuous” yes?
Especially since we all studied that AD assiduously post Lionair to make sure a similar fate would not befall us.
thats how we stay safe. Learn from others. These days more than ever we need to learn from the published errors which are available on line every day on the likes of of AV HERALD and AEROINSIDE free of charge.
Everyday I read about maybe 15/major incidents. Some handled brilliantly. Others leave something that might have been done much better. FYI every day there are around three engine failures and a rising number of smoke fume events- some really nasty. Loads of learning free of charge.
Safe Flying
R Guy
My guess is because after the AD post Lionair, it was known about and Boeing said “;treat it like a runaway stab” which most assuredly it is. “ Continuously” means without stopping, or a quick succession of similar events.
“my wife nags we continuously “. Presumably she draws breath between each bout of nagging? But it will eventually cause you to lose the will to live. And vice versa for the PC types. Men can nag too.
similarly a stabilizer which runs AND , over and over , always in the same direction, with a very short pause is by any definition in the dictionary “:Continuous” yes?
Especially since we all studied that AD assiduously post Lionair to make sure a similar fate would not befall us.
thats how we stay safe. Learn from others. These days more than ever we need to learn from the published errors which are available on line every day on the likes of of AV HERALD and AEROINSIDE free of charge.
Everyday I read about maybe 15/major incidents. Some handled brilliantly. Others leave something that might have been done much better. FYI every day there are around three engine failures and a rising number of smoke fume events- some really nasty. Loads of learning free of charge.
Safe Flying
R Guy
So the pilots are supposed to be the fault, even after the SB was raised, which of course added all the information that was needed to manage the defect, except, did anyone mention the manual trim would be unable to be overpowered? Ooops, nope, weasel legal terms applied, fly to trim speed.... yep, about 500KIAS, How about the fact that the trim rate of MCAS was 1/2 an order of magnitude greater than the rate of manual trim? Nope. Not a word of that. Why? as the manufacturer didn't know what had been done or the impact operationally. Yet, our reporters at large blame a 300hr pilot for... what? being a young pilot? Is that a compliance issue? is there a law out there that you cannot be a pilot until you have 10,000 hours command on... whatever? You have to be 101 years old in order to have the experience necessary to make up for a goatF&#@ in the design of the aircraft by experts?
We assume that Boeing, FAA, EASA and the rest have some skills, so how come the fault is the pilot when everyone else missed the issue?
GT needs to learn about causation, or get a pacifier and go sit in a corner.
As mentioned previously, if it was just the pilot then the plane would already be flying... and we would have a training program implemented for GT's incompetent crews. If there is a god, then perhaps that god will give GT the pleasure of dealing with a unknown flight control problem airborne. From my experience, it will give some clarity to your religious beliefs promptly. Try being in a life threatening situation dealing with a system that does not respond to your training, or the sage advice just provided by the OEM which just happens to be missing a couple of salient points.
So, during the training of the Lion Air and Ethiopian crews they were never taught that an MCAS system was installed on the MAX (unlike the NG they were used to flying), how the MCAS system worked and trained in MCAS normal/abnormal use?
Can we assume all the Southwest, et al, and other American crews were trained on the MCAS system?
I ask because my buddy who flew MAX's for WestJet had no idea MCAS was installed.
Just another dumb Canadian pilot, I guess.
And one must wonder, if the problem is just dumb aircrew why is the MAX still on the ground?
Surely the fix for dumb aircrew is better training, not rebuilding the complete MCAS system?
Can we assume all the Southwest, et al, and other American crews were trained on the MCAS system?
I ask because my buddy who flew MAX's for WestJet had no idea MCAS was installed.
Just another dumb Canadian pilot, I guess.
And one must wonder, if the problem is just dumb aircrew why is the MAX still on the ground?
Surely the fix for dumb aircrew is better training, not rebuilding the complete MCAS system?
Better training might have been the answer, but many airlines chose not to do anything about it.
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Many years ago I had a main rotor blade delamination in a Bell 212 (twin Huey).
The aircraft rolled upside down, wouldn't respond to the controls properly and was bangin' like h$ll.
I had NO CLUE what was wrong - but I knew it was bad.
Irish luck got the rocket back on the ground and it was determined that the inflight damage was so severe the aircraft was totalled.
Never wanna do anything like that again. 😳
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[QUOTE=retired guy;10669859]
With respect,
Since you have never flown the NG, and by your account only the -200, then these two variants are world's apart from the MAX.
I don't know if you have read the entire threads on the ET accident or the Lion Air, but in the flight envelope the crew were faced with they couldn't manage to control the pitch down movements of the stab provided by MCAS due to it's incorrect triggering.
Because of the lack of technical information provided by Boeing to pilots of the MAX, one would assume that no matter where you were trained or from what part of the world that you reside, fundamentally the airplane didn't react in the same way a normal NG would.
There were additional "nuisance cautions" sounding off (and other warnings) which weren't normal for a "stab" runaway situation as compared with the NG or earlier series.
Many human factors and cockpit design errors will come to light from these two tragedies and make modern transport planes even more safer and user friendly.
.....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.[/QUOTE]
BA
On the money, literally, with that post. Saving money on safety will always end in tears. “ if you think safety is expensive, try having two accidents!” Ask Boeing , even though they were not entirely to blame as there were many other factors.
And if Boeing were an airline that suffered two related crashes, or even unrelated, it’s bye bye. Billions of dollars and years of investment gone in a few weeks maybe. No jobs. So sad.
And the cost of real safety v lip service to safety is not high. Maybe 2\5 % of turnover. Measured against the cost of Armaggedonn as faced by Boeing currently its an easy form of insurance.
look fwd to any views on that sort of thing.
Safe flying
RvGuy
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.[/QUOTE]
BA
On the money, literally, with that post. Saving money on safety will always end in tears. “ if you think safety is expensive, try having two accidents!” Ask Boeing , even though they were not entirely to blame as there were many other factors.
And if Boeing were an airline that suffered two related crashes, or even unrelated, it’s bye bye. Billions of dollars and years of investment gone in a few weeks maybe. No jobs. So sad.
And the cost of real safety v lip service to safety is not high. Maybe 2\5 % of turnover. Measured against the cost of Armaggedonn as faced by Boeing currently its an easy form of insurance.
look fwd to any views on that sort of thing.
Safe flying
RvGuy
Since you have never flown the NG, and by your account only the -200, then these two variants are world's apart from the MAX.
I don't know if you have read the entire threads on the ET accident or the Lion Air, but in the flight envelope the crew were faced with they couldn't manage to control the pitch down movements of the stab provided by MCAS due to it's incorrect triggering.
Because of the lack of technical information provided by Boeing to pilots of the MAX, one would assume that no matter where you were trained or from what part of the world that you reside, fundamentally the airplane didn't react in the same way a normal NG would.
There were additional "nuisance cautions" sounding off (and other warnings) which weren't normal for a "stab" runaway situation as compared with the NG or earlier series.
Many human factors and cockpit design errors will come to light from these two tragedies and make modern transport planes even more safer and user friendly.
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HI BD
I think the three basic fixes to MCAS were developed long ago. It’s just that loss of confidence in FAA is slowing down approval. Past tense is appropriate because by the time it’s recertified, which it will be, the Max Will be the most tested airplane ever- maybe more than Concorde. You have no evidence that it’s “vapour ware”- apart from a hunch?
here is some well reasoned commentary from a couple of sources. Looks good to me.Boeing’s worst ever nightmare just got even worse with an announcement from the company yesterday that its own best estimates for ungrounding of the plane by the FAA have been shifted back to mid-2020.
...
I know that there has been some extensive work done on MCAS, but I am also aware that there are still sitting 600+ aircraft sitting on the ground with MCAS V1 loaded on their FCC. The term "vapor ware" is assigned in the software world to software releases that are announced but then delayed again and again which is a which is pretty good description on what happens with the FCC software release containing the MCAS fix.
Further, until now, there is still lacking an official description of exact system behaviour of MCAS V2 - only rumors - or did I miss something here?
I do know there are rumors about latching so a single trigger event and reduced authority but nothing detailed. But I would have some very detailed questions here. E.g. what would be the conditions to allow triggering for second MCAS event. What does happen in case of a AOA disagree in flight or even worse, during active MCAS intervention - software wise and procedure / check-list wise. Until now, no information whatsoever. Also no information about the position of regulators on the sufficiency of these measures. However we do know some regulators were critical about the two vane design. While there has been reports of "new" problems, like trim forces, cable position and initialization hick-ups, it is still hush-hush about the actual status of the "not-an-anti-stall"-system.
So if this entire sad story - by first estimations the planes should have been back flying since June last year - shows one thing: There is no fix until the plane is ungrounded, not only in the US but also in Europe and in China.
I am still sure this will happen - but calling the affair settled and refering to it in past tense is still a bit early in my humble opinion.
Recent posts deviate, distract from the thread subject. Perhaps if Dr Dekker were to publish a similar report on the Max incidents there would be substantiated opinion to discuss opposed to raking over dead coals.
Whereas the AMS HF report could have political ramifications, there is far greater value in the explanation of HF in the reality of operations, which we can all learn from.
If only we might learn or understand what should, could be learnt; but that's difficult for closed minds.
Whereas the AMS HF report could have political ramifications, there is far greater value in the explanation of HF in the reality of operations, which we can all learn from.
If only we might learn or understand what should, could be learnt; but that's difficult for closed minds.
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Hi Old Dogs
My guess is because after the AD post Lionair, it was known about and Boeing said “;treat it like a runaway stab” which most assuredly it is. “ Continuously” means without stopping, or a quick succession of similar events.
“my wife nags we continuously “. Presumably she draws breath between each bout of nagging? But it will eventually cause you to lose the will to live. And vice versa for the PC types. Men can nag too.
similarly a stabilizer which runs AND , over and over , always in the same direction, with a very short pause is by any definition in the dictionary “:Continuous” yes?
Especially since we all studied that AD assiduously post Lionair to make sure a similar fate would not befall us.
thats how we stay safe. Learn from others. These days more than ever we need to learn from the published errors which are available on line every day on the likes of of AV HERALD and AEROINSIDE free of charge.
Everyday I read about maybe 15/major incidents. Some handled brilliantly. Others leave something that might have been done much better. FYI every day there are around three engine failures and a rising number of smoke fume events- some really nasty. Loads of learning free of charge.
Safe Flying
R Guy
My guess is because after the AD post Lionair, it was known about and Boeing said “;treat it like a runaway stab” which most assuredly it is. “ Continuously” means without stopping, or a quick succession of similar events.
“my wife nags we continuously “. Presumably she draws breath between each bout of nagging? But it will eventually cause you to lose the will to live. And vice versa for the PC types. Men can nag too.
similarly a stabilizer which runs AND , over and over , always in the same direction, with a very short pause is by any definition in the dictionary “:Continuous” yes?
Especially since we all studied that AD assiduously post Lionair to make sure a similar fate would not befall us.
thats how we stay safe. Learn from others. These days more than ever we need to learn from the published errors which are available on line every day on the likes of of AV HERALD and AEROINSIDE free of charge.
Everyday I read about maybe 15/major incidents. Some handled brilliantly. Others leave something that might have been done much better. FYI every day there are around three engine failures and a rising number of smoke fume events- some really nasty. Loads of learning free of charge.
Safe Flying
R Guy
The behaviour of MCAS in the crash flights was not continuous, but continual. The trigger for MCAS was a continuous incorrect signal from the AoA indicator relied upon by the MCAS software, but the effect was continual pitch down commands to the stabiliser, some of which, to complicate matters, were ignored/unactioned in the periods during which the stab trim was deselected manually.
The difference, in English, is important. Certainly, I would expect a technical manual to be written carefully and for the writer to understand the difference between continuous and continual when writing a diagnostic procedure.
[QUOTE=568;10670031]
With respect,
Since you have never flown the NG, and by your account only the -200, then these two variants are world's apart from the MAX.
I don't know if you have read the entire threads on the ET accident or the Lion Air, but in the flight envelope the crew were faced with they couldn't manage to control the pitch down movements of the stab provided by MCAS due to it's incorrect triggering.
Because of the lack of technical information provided by Boeing to pilots of the MAX, one would assume that no matter where you were trained or from what part of the world that you reside, fundamentally the airplane didn't react in the same way a normal NG would.
There were additional "nuisance cautions" sounding off (and other warnings) which weren't normal for a "stab" runaway situation as compared with the NG or earlier series.
Many human factors and cockpit design errors will come to light from these two tragedies and make modern transport planes even more safer and user friendly.
Read my post again.
I did not say I had flown ONLY the 200 I was one if the first captains checked out on the -300 whose automatics were probably the start of those on the NG and MAX !
I did my -200 course at Boeing with Chet Ekstrand as my instructor. I seem to remember, but it was 40 years ago, that the teaching was that if the trim wheel was rotating and not because of manual trim inputs or autopilot trimming, then you had a trim runaway and the IMMEDIATE, RECALL, action was stab trim switches to OFF.
With prompt action the aircraft would probably not be far out of trim and could be trimmed manually.
That said, perhaps I am more “sensitive” than most to stab. Runaways which the MCAS effectively was.
Back in 1964 I was posted to 207 squadron as part of the crew to replace those killed in the Valiant crash at Market Rasen, believed to have been caused by a TPI runaway.
We then had a drill rammed into us that a TPI runaway required IMMEDIATE action by both pilots as the tailplane could JUST be overcome by elevator input but required the full strength of both pilots. That remained with me for the rest of my career. I spent some time on the Canberra , too, which had a number of tailplane runaways leading to fatal ground or sea impact, in its early days, not forgotten by those of us who flew it.
My apologies if my memory is failing me !
With respect,
Since you have never flown the NG, and by your account only the -200, then these two variants are world's apart from the MAX.
I don't know if you have read the entire threads on the ET accident or the Lion Air, but in the flight envelope the crew were faced with they couldn't manage to control the pitch down movements of the stab provided by MCAS due to it's incorrect triggering.
Because of the lack of technical information provided by Boeing to pilots of the MAX, one would assume that no matter where you were trained or from what part of the world that you reside, fundamentally the airplane didn't react in the same way a normal NG would.
There were additional "nuisance cautions" sounding off (and other warnings) which weren't normal for a "stab" runaway situation as compared with the NG or earlier series.
Many human factors and cockpit design errors will come to light from these two tragedies and make modern transport planes even more safer and user friendly.
Read my post again.
I did not say I had flown ONLY the 200 I was one if the first captains checked out on the -300 whose automatics were probably the start of those on the NG and MAX !
I did my -200 course at Boeing with Chet Ekstrand as my instructor. I seem to remember, but it was 40 years ago, that the teaching was that if the trim wheel was rotating and not because of manual trim inputs or autopilot trimming, then you had a trim runaway and the IMMEDIATE, RECALL, action was stab trim switches to OFF.
With prompt action the aircraft would probably not be far out of trim and could be trimmed manually.
That said, perhaps I am more “sensitive” than most to stab. Runaways which the MCAS effectively was.
Back in 1964 I was posted to 207 squadron as part of the crew to replace those killed in the Valiant crash at Market Rasen, believed to have been caused by a TPI runaway.
We then had a drill rammed into us that a TPI runaway required IMMEDIATE action by both pilots as the tailplane could JUST be overcome by elevator input but required the full strength of both pilots. That remained with me for the rest of my career. I spent some time on the Canberra , too, which had a number of tailplane runaways leading to fatal ground or sea impact, in its early days, not forgotten by those of us who flew it.
My apologies if my memory is failing me !
Last edited by RetiredBA/BY; 24th Jan 2020 at 14:47.
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Parallel with Lion Air
It is interesting reading the full report in the light of the MCAS involved crashes, especially the Lion Air crash.
The Dutch report on the crash of Turkish TC-JGE, 25 Feb 2009 made a point of asking Boeing about the procedure when an instrument is identified as inoperative during the flight (Section 1.2.4 on page 18), but in Appendix N, Similar Occurrences (p 204)
So, much like the problems associated with the AoA indicator in Lion Air, there was a history of problems with the RA, and the third pilot in the cockpit even mentioned the RA fault on the crash flight - but in this case, the flight continued to have problems that were not solved in time to prevent the crash.
Like many crashes, there are a lot of holes leading up to the final incident. I do not wish to fan the 'pilot error' flames by providing an example where two previous crews resolved the issues successfully and thus saying the third set were deficient: rather this seems to point to a systemic fault that was not identified and relied on humans to solve the problem: which, as we know, will not work every time.
It is also worth underlining that the pilots on the fatal crash did not know that the autothrottle would continue to rely on the faulty radio-altimeter. The information was available to Boeing, and published in documentation not available to the pilots, as described by Decker's report on page 36.
The human factors failures here are glaring.
The Dutch report on the crash of Turkish TC-JGE, 25 Feb 2009 made a point of asking Boeing about the procedure when an instrument is identified as inoperative during the flight (Section 1.2.4 on page 18), but in Appendix N, Similar Occurrences (p 204)
TC-JGE was involved in two similar occurrences, which became known by the flight data recorder.
Incident A
TC-JGE made an ILS approach for runway 27L with two autopilots engaged at London Heathrow airport in England on 23 February 2009. The captain’s radio altimeter system (left) displayed a negative value and both autopilots disengaged when an altitude of 500 feet was passed. The auto-throttle ‘retard flare’ mode was activated and at this point the throttles moved aft. The airspeed dropped below the selected speed. After four seconds the crew disengaged the autothrottle and manually brought the throttles forward. Subsequently, the aircraft landed safely.
Incident B
TC-JGE made an ILS approach for runway 23R with the right autopilot engaged at Damascus air-port in Syria on 24 February 2009. The captain’s radio altimeter system (left) specified a negative value when an altitude of 4000 feet was passed. After the flaps were selected at approximately 2500 feet, the autothrottle activated the ‘retard flare’ mode. The airspeed at this time was 209 knots and the selected speed was set on 155 knots. After having flown at 1500 feet for 74 seconds, the airspeed went below the selected speed. The speed was 16 knots below the selected speed at 1400 feet. The throttles were moved forward; a nose up movement ensued with an increase in alti-tude and speed. Subsequently, the crew reduced the selected speed to 138 knots. A few seconds later the crew disengaged the autothrottle and autopilot. The ‘retard flare’ mode had been activate for 94 seconds.
Incident A
TC-JGE made an ILS approach for runway 27L with two autopilots engaged at London Heathrow airport in England on 23 February 2009. The captain’s radio altimeter system (left) displayed a negative value and both autopilots disengaged when an altitude of 500 feet was passed. The auto-throttle ‘retard flare’ mode was activated and at this point the throttles moved aft. The airspeed dropped below the selected speed. After four seconds the crew disengaged the autothrottle and manually brought the throttles forward. Subsequently, the aircraft landed safely.
Incident B
TC-JGE made an ILS approach for runway 23R with the right autopilot engaged at Damascus air-port in Syria on 24 February 2009. The captain’s radio altimeter system (left) specified a negative value when an altitude of 4000 feet was passed. After the flaps were selected at approximately 2500 feet, the autothrottle activated the ‘retard flare’ mode. The airspeed at this time was 209 knots and the selected speed was set on 155 knots. After having flown at 1500 feet for 74 seconds, the airspeed went below the selected speed. The speed was 16 knots below the selected speed at 1400 feet. The throttles were moved forward; a nose up movement ensued with an increase in alti-tude and speed. Subsequently, the crew reduced the selected speed to 138 knots. A few seconds later the crew disengaged the autothrottle and autopilot. The ‘retard flare’ mode had been activate for 94 seconds.
Like many crashes, there are a lot of holes leading up to the final incident. I do not wish to fan the 'pilot error' flames by providing an example where two previous crews resolved the issues successfully and thus saying the third set were deficient: rather this seems to point to a systemic fault that was not identified and relied on humans to solve the problem: which, as we know, will not work every time.
It is also worth underlining that the pilots on the fatal crash did not know that the autothrottle would continue to rely on the faulty radio-altimeter. The information was available to Boeing, and published in documentation not available to the pilots, as described by Decker's report on page 36.
The human factors failures here are glaring.
The Dutch review #83 could get very messy:-
- Boeing do not attend … unlikely scenario.
- Boeing submits a formal denial which might deflect the issue towards the NTSB - they were the 'accredited representative', Boeing was only a 'party' in the investigation. Avoids difficult questions.
- Boeing attends or are represented; difficult questions to be answered, which again could be redirected to the NTSB.
- Dutch view "… it is common for the parties involved to be able to comment on the findings of the Research Council, as long as that is limited to factual inaccuracies." Implying that Boeing could have commented - which they did via NTSB, but apparently not on the HF report. See the accident report, appendix M, NTSB/Boeing comments ( page 140), without any reference to the Dekker report (did NTSB/Boeing see the Dekker report; hard to believe they did not).
- The Dutch investigators might have downplayed the HF report as not being sufficiently 'factual', HF is only soft science. Yet the industry accepts HF for training and knowledge to improve human behaviour and safety.
- There may have been decenting opinion, but not published.
- Alternative HF commentary could have been sought; more experts, greater opportunity for split opinions, but it would be difficult to overcome the weight of a world-renown HF investigator, type rated on the 737, who's report references world wide, and specifically US research.
A likely outcome; accept differing views and move on.
The Dutch House of Representatives could direct their investigators to treat HF as factual, a good example for other Nations and reinvigorate ICAO advice in Annex 13.
Keep lawyers, commerce, and manipulation of public opinion out of investigations.
Dr Dekker; please publish similar reports on 737 Max, 777 SFO, AF447, CRJ Sweden.
- Boeing do not attend … unlikely scenario.
- Boeing submits a formal denial which might deflect the issue towards the NTSB - they were the 'accredited representative', Boeing was only a 'party' in the investigation. Avoids difficult questions.
- Boeing attends or are represented; difficult questions to be answered, which again could be redirected to the NTSB.
- Dutch view "… it is common for the parties involved to be able to comment on the findings of the Research Council, as long as that is limited to factual inaccuracies." Implying that Boeing could have commented - which they did via NTSB, but apparently not on the HF report. See the accident report, appendix M, NTSB/Boeing comments ( page 140), without any reference to the Dekker report (did NTSB/Boeing see the Dekker report; hard to believe they did not).
- The Dutch investigators might have downplayed the HF report as not being sufficiently 'factual', HF is only soft science. Yet the industry accepts HF for training and knowledge to improve human behaviour and safety.
- There may have been decenting opinion, but not published.
- Alternative HF commentary could have been sought; more experts, greater opportunity for split opinions, but it would be difficult to overcome the weight of a world-renown HF investigator, type rated on the 737, who's report references world wide, and specifically US research.
A likely outcome; accept differing views and move on.
The Dutch House of Representatives could direct their investigators to treat HF as factual, a good example for other Nations and reinvigorate ICAO advice in Annex 13.
Keep lawyers, commerce, and manipulation of public opinion out of investigations.
Dr Dekker; please publish similar reports on 737 Max, 777 SFO, AF447, CRJ Sweden.
Actually no. The behaviour you describe, in a dictionary definition, is continual, not continuous. https://grammarist.com/usage/continual-continuous/
The behaviour of MCAS in the crash flights was not continuous, but continual. The trigger for MCAS was a continuous incorrect signal from the AoA indicator relied upon by the MCAS software, but the effect was continual pitch down commands to the stabiliser, some of which, to complicate matters, were ignored/unactioned in the periods during which the stab trim was deselected manually.
The difference, in English, is important. Certainly, I would expect a technical manual to be written carefully and for the writer to understand the difference between continuous and continual when writing a diagnostic procedure.
The behaviour of MCAS in the crash flights was not continuous, but continual. The trigger for MCAS was a continuous incorrect signal from the AoA indicator relied upon by the MCAS software, but the effect was continual pitch down commands to the stabiliser, some of which, to complicate matters, were ignored/unactioned in the periods during which the stab trim was deselected manually.
The difference, in English, is important. Certainly, I would expect a technical manual to be written carefully and for the writer to understand the difference between continuous and continual when writing a diagnostic procedure.
Every. Single. Thing. Is. Intermittent.
I'm glad to explain how, in English, "continuous" has no meaning.
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@MechEngr
Does that mean continuous functions have no meaning?
If you can understand the concept of an expected duration of a process, you can talk meaningfully about the process being continuous if it is not interrupted within the expected duration, or continual if it is interrupted a number of times within the expected duration. If we talk about a 'runaway stabiliser', it would be expected to continue until it reached the end-stops unless a manual cut-out is performed. If a stabiliser movement ceases without manual input, then restarts without manual input later, one can talk about an interruption. If the stabiliser moves in a particular direction, stops, then continues to move again several times, then it is moving continually.
Obviously, but unhelpfully, in the limit, when time goes towards infinity, all processes can be expected to terminate at some point, so yes, in the perspective of unlimited time, no process is continuous. If you limit, or focus your view on a finite subset of time, then a process can be said to be continuous over that segment if there are no discontinuities/interruptions.
I hope that clarifies things sufficiently for you.
Nothing, therefore, in the flying of a plane is continuous. Every plane ends up on the ground and either in a smoking hole or, more often, the scrap yard.
Every. Single. Thing. Is. Intermittent.
I'm glad to explain how, in English, "continuous" has no meaning.
Every. Single. Thing. Is. Intermittent.
I'm glad to explain how, in English, "continuous" has no meaning.
If you can understand the concept of an expected duration of a process, you can talk meaningfully about the process being continuous if it is not interrupted within the expected duration, or continual if it is interrupted a number of times within the expected duration. If we talk about a 'runaway stabiliser', it would be expected to continue until it reached the end-stops unless a manual cut-out is performed. If a stabiliser movement ceases without manual input, then restarts without manual input later, one can talk about an interruption. If the stabiliser moves in a particular direction, stops, then continues to move again several times, then it is moving continually.
Obviously, but unhelpfully, in the limit, when time goes towards infinity, all processes can be expected to terminate at some point, so yes, in the perspective of unlimited time, no process is continuous. If you limit, or focus your view on a finite subset of time, then a process can be said to be continuous over that segment if there are no discontinuities/interruptions.
I hope that clarifies things sufficiently for you.
One might suppose that since the FAA was reluctant to follow the other regulators in grounding the aircraft, the others may also be slower in allowing it to fly again.
@MechEngr
Does that mean continuous functions have no meaning?
If you can understand the concept of an expected duration of a process, you can talk meaningfully about the process being continuous if it is not interrupted within the expected duration, or continual if it is interrupted a number of times within the expected duration. If we talk about a 'runaway stabiliser', it would be expected to continue until it reached the end-stops unless a manual cut-out is performed. If a stabiliser movement ceases without manual input, then restarts without manual input later, one can talk about an interruption. If the stabiliser moves in a particular direction, stops, then continues to move again several times, then it is moving continually.
Obviously, but unhelpfully, in the limit, when time goes towards infinity, all processes can be expected to terminate at some point, so yes, in the perspective of unlimited time, no process is continuous. If you limit, or focus your view on a finite subset of time, then a process can be said to be continuous over that segment if there are no discontinuities/interruptions.
I hope that clarifies things sufficiently for you.
Does that mean continuous functions have no meaning?
If you can understand the concept of an expected duration of a process, you can talk meaningfully about the process being continuous if it is not interrupted within the expected duration, or continual if it is interrupted a number of times within the expected duration. If we talk about a 'runaway stabiliser', it would be expected to continue until it reached the end-stops unless a manual cut-out is performed. If a stabiliser movement ceases without manual input, then restarts without manual input later, one can talk about an interruption. If the stabiliser moves in a particular direction, stops, then continues to move again several times, then it is moving continually.
Obviously, but unhelpfully, in the limit, when time goes towards infinity, all processes can be expected to terminate at some point, so yes, in the perspective of unlimited time, no process is continuous. If you limit, or focus your view on a finite subset of time, then a process can be said to be continuous over that segment if there are no discontinuities/interruptions.
I hope that clarifies things sufficiently for you.
Awaiting a CVR transcript where the pilots are discussing continuous vs continual and that because it was continual, that the 60+ pounds of force required to hold the nose up required no trim to offset it.