NYT: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’
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Asiana in SFO kind of springs to mind. Still in VNAV PTH, so autothrottles sort of in but not really, and no ILS so not tracking the glideslope when the autothrottles would have definitely been in like every other approach always. But the handling pilot somehow didn’t know what was going on, nor did the other three notice, where hands on throttles would have helped and there should have been been, and always should be an obsessive focus on airspeed. And vertical speed for that matter.
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Asiana in SFO kind of springs to mind. Still in VNAV PTH, so autothrottles sort of in but not really, and no ILS so not tracking the glideslope when the autothrottles would have definitely been in like every other approach always. But the handling pilot somehow didn’t know what was going on, nor did the other three notice, where hands on throttles would have helped and there should have been been, and always should be an obsessive focus on airspeed. And vertical speed for that matter.
As in the Turkish case the situation was coincidentally masked by intercepting the glide path from above and it occurred at the end of a long duty.
Now years later Boeing is fixing the HOLD trap in new aircraft, but a simple EICAS caution should have been introduced years ago.
Ditto the Dubai 777 crash due to TOGA confusion. They should’ve introduced aural feedback for inactive switch selection but they haven’t.
So, given FOQA fear g/a are the norm these days this accident will happen again. In fact it came damn close a couple of weeks ago.
The airmanship argument is a distraction that gives the manufacturers a free pass.
Last edited by HPSOV L; 21st Jan 2020 at 22:30.
Perhaps I have been missing something, BUT in my experience of the 737 ( a delightful aircraft)
as a TC with 7000 hours on type I used to teach that if the automatics are not doing exactly what you require, or you dont quite understand a particular aspect of the system, disconnect the AP and AT and FLY the damned thing.
It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,
If you cant do that you should not be in airliner cockpit.
as a TC with 7000 hours on type I used to teach that if the automatics are not doing exactly what you require, or you dont quite understand a particular aspect of the system, disconnect the AP and AT and FLY the damned thing.
It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,
If you cant do that you should not be in airliner cockpit.
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Perhaps I have been missing something, BUT in my experience of the 737 ( a delightful aircraft)
as a TC with 7000 hours on type I used to teach that if the automatics are not doing exactly what you require, or you dont quite understand a particular aspect of the system, disconnect the AP and AT and FLY the damned thing.
It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,
If you cant do that you should not be in airliner cockpit.
as a TC with 7000 hours on type I used to teach that if the automatics are not doing exactly what you require, or you dont quite understand a particular aspect of the system, disconnect the AP and AT and FLY the damned thing.
It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,
If you cant do that you should not be in airliner cockpit.
I’ve sat in many flight safety and CRM sessions and bar talk over the years where old hands tut-tutted and said “how could they do that?”. And years later the same get caught out themselves in similar circumstances.
The subtle point is that in all these cases the aircraft state wasn’t recognised due to masking or distraction. Humans take time to perceive and comprehend an unexpected situation when they have a preconceived mental plot. It took Sullenberger 30 seconds.
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.
"Mildly" Eccentric Stardriver
It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,
If you cant do that you should not be in airliner cockpit.
If you cant do that you should not be in airliner cockpit.
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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.
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.
Perhaps I have been missing something, BUT in my experience of the 737 ( a delightful aircraft)
as a TC with 7000 hours on type I used to teach that if the automatics are not doing exactly what you require, or you dont quite understand a particular aspect of the system, disconnect the AP and AT and FLY the damned thing.
It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,
If you cant do that you should not be in airliner cockpit.
as a TC with 7000 hours on type I used to teach that if the automatics are not doing exactly what you require, or you dont quite understand a particular aspect of the system, disconnect the AP and AT and FLY the damned thing.
It is, after all, just an aeroplane, fly the jet as such, using the yoke and thrust levers, simple.,
If you cant do that you should not be in airliner cockpit.
"What you think should have happened does not explain people's behaviour." - Sidney Dekker, Ch. 5, "They Should Have . . .", p.39, The Field Guide to Understanding Human Error;
Re PJ2 ref to S Dekker # 49;
the very apt publication of Dekker's report below to the Dutch Authorities which the NYT cites as being dismissed following Boeing intervention, # 1.
Only read the summary so far, but … concluding …
"A breakdown in CRM (Crew Resource Management) cannot be substantiated for TK1951."
"The length of B737 type training at THY, as well as procedural compliance at THY, appear to at least match industry standard."
"Post-accident manufacturer recommendations that, in effect, tell flight crews to mistrust their machine and to stare harder at it not only mismatch decades of human factors and automation research, but also leave a single failure pathway in place."
"Shortly after the accident, Boeing issued a bulletin to all 737 operators and announced that it “will warn crews about fundamentals like flying the aircraft, monitoring airspeed, [and] monitoring altitude” (Learmount, 2009).
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). For flight crews of Boeing 737’s, like the crew of TK1951, there is no sufficient training, no written guidance or documentation, and no likelihood of line experience that would insulate them from the kind of automation surprise that happened near Amsterdam on the 25th of February."
https://www.onderzoeksraad.nl/nl/med...t_s_dekker.pdf
the very apt publication of Dekker's report below to the Dutch Authorities which the NYT cites as being dismissed following Boeing intervention, # 1.
Only read the summary so far, but … concluding …
"A breakdown in CRM (Crew Resource Management) cannot be substantiated for TK1951."
"The length of B737 type training at THY, as well as procedural compliance at THY, appear to at least match industry standard."
"Post-accident manufacturer recommendations that, in effect, tell flight crews to mistrust their machine and to stare harder at it not only mismatch decades of human factors and automation research, but also leave a single failure pathway in place."
"Shortly after the accident, Boeing issued a bulletin to all 737 operators and announced that it “will warn crews about fundamentals like flying the aircraft, monitoring airspeed, [and] monitoring altitude” (Learmount, 2009).
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). For flight crews of Boeing 737’s, like the crew of TK1951, there is no sufficient training, no written guidance or documentation, and no likelihood of line experience that would insulate them from the kind of automation surprise that happened near Amsterdam on the 25th of February."
https://www.onderzoeksraad.nl/nl/med...t_s_dekker.pdf
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Meanwhile Airbus is doing A350 fully automated take off trials - one step closer to make a significant improvement to the flight safety by eliminating the weakest link...
CargoOne, re your 'weakest link' # 51,
See # 50, read the report, then reconsider where the weakest link is.
Human, most probably, but not those flying the aircraft, nor requiring elimination.
See # 50, read the report, then reconsider where the weakest link is.
Human, most probably, but not those flying the aircraft, nor requiring elimination.
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statistically, there must be. And also statistically, nearly half of your pilots will be below average.
Don't design products to be safe only if used by the average pilot
Serious question - has anyone ever come off a long duty period and into a sim to see how their fatigued self reacts in an emergency?
Don't design products to be safe only if used by the average pilot
Serious question - has anyone ever come off a long duty period and into a sim to see how their fatigued self reacts in an emergency?
your maths is of course correct. There must be an average pilot half way between the best and the worst. Now the worst has to exceed the minimum requirement, and in a good airline that minimum will be above the CAA bar by some good margin. So your worst pilot is still pretty good. Your average pilot, a bit like me , somewhat better. and while not the best in the world, still hitting high ratings with no fail points and minor debriefing areas.And then the best pilots way up there much higher and probably get 100% in proficiency. Every time. So you can let your average pilot fly anything you can throw at him. Then there are the 200 airlines that aren’t allowed to fly in EU AIRSPACE. They clearly lie below the minimum EU. EASA requirement and their average pilot must have a lot difficulty passing checks etc.
as for being tired after a long day, yes I have and once or twice had to do my OPC after, on following morning. . Can’ t remember outcome so must have been ok.
doe that cover what you wanted.
R Guy
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Dutch regulators have just published the study cited in yesterday's NY Times story:
A Decade Later, Dutch Officials Publish a Study Critical of Boeing
After a Boeing 737 crashed near Amsterdam more than a decade ago, an expert study that sharply criticized the manufacturer was never published by the Dutch safety authorities, and its key findings were either excluded or played down in their accident report.
On Tuesday, the Dutch Safety Board, which had commissioned the study, reversed course — publishing it a day after The New York Times detailed the findings.
The Times’s review of evidence from the accident, which killed nine people on a Turkish Airlines flight in 2009, showed the study’s conclusions were relevant to investigations into two more recent crashes of Boeing aircraft that killed 346.
[Read The Times’s investigation here.]
The study, by Sidney Dekker, acknowledged that the pilots made serious errors but also found that Boeing bore significant responsibility. It accused the company of trying to deflect attention from its own “design shortcomings” with “hardly credible” statements drawing attention to the pilots’ mistakes.
A spokeswoman for the board had told The Times last week that Dr. Dekker’s study was confidential. But in a statement on Tuesday, Jeroen Dijsselbloem, chairman of the Dutch board, said the study had been posted online because the board’s “current practices” had changed. “We now publish as much as possible,” he said.
The board also defended its investigation of the 2009 crash, which involved a 737 Next Generation, or NG, a predecessor to the 737 Max. The more recent accidents involved the Max, which has been grounded since last year as investigations continue.
Mr. Dijsselbloem noted “the key question” for those investigations was whether lessons from 2009 “were sufficiently learned by Boeing and the American authorities.”
Multiple aviation experts who had read Dr. Dekker’s study told The Times its findings had not been sufficiently incorporated into the final Dutch accident report. In addition, the Times learned, the Dutch removed or minimized criticisms of Boeing after pushback from a team of Americans that included the manufacturer and federal safety officials.
Jan Paternotte, a member of the Dutch House of Representatives, praised the study’s release but called for a hearing of those involved, saying he believed he would secure the necessary support during a committee meeting on Wednesday. “Boeing has been capable of strong-arming outside parties if it serves the short-term interest of the company,” he said. “When safety is at stake, that is a problem.”
The Dutch board on Tuesday acknowledged that it had changed portions of its draft report after the Americans raised objections, but called that “standard procedure” and noted that the Americans’ comments were included in an appendix.“The Dutch Safety Board does its work in strict independence,” Mr. Dijsselbloem said. “The Board decides independently on the outcome of its investigations, the content of its reports and its conclusions and recommendations.”
A Boeing spokesman referred questions to the National Transportation Safety Board, which led the American team that commented on the Dutch draft report. An N.T.S.B. spokesman declined to comment.
The Federal Aviation Administration, which was also a member of the American team participating in the 2009 inquiry, said in a statement that it was “following a thorough process for returning the Boeing 737 Max to passenger service.” The agency added that it was working with international safety regulators to review “proposed changes to the aircraft” as well as “recommendations from safety experts who have examined our certification processes.”
The Dutch board’s final report, released in 2010, focused blame on numerous mistakes by the pilots, including their failure to notice a dangerous drop in speed and their incorrect response to an alert warning of an impending stall. The report contained statements — some nearly verbatim and without attribution — that were originally written by the American team and further emphasized crew errors.
The Times found striking parallels between the accident and the 737 Max crashes. In both cases, design decisions by Boeing allowed a single faulty sensor to activate a powerful computer command. In both cases, Boeing had known of the potential sensor failures but determined that pilots would react correctly and recover the plane. And in both cases, Boeing didn’t include information in the pilots’ manual that could have helped them respond to the malfunctioning automation.
Boeing, the F.A.A and the N.T.S.B. noted that the system involved in the earlier accident differed significantly from the one blamed in the Max crashes. But aviation safety experts, including a senior F.A.A. official who was not authorized to speak publicly, told The Times that the similarities were noteworthy.
Dr. Dekker’s report “should have woken everybody up,” one said. Instead, “the issue got buried.”
After a Boeing 737 crashed near Amsterdam more than a decade ago, an expert study that sharply criticized the manufacturer was never published by the Dutch safety authorities, and its key findings were either excluded or played down in their accident report.
On Tuesday, the Dutch Safety Board, which had commissioned the study, reversed course — publishing it a day after The New York Times detailed the findings.
The Times’s review of evidence from the accident, which killed nine people on a Turkish Airlines flight in 2009, showed the study’s conclusions were relevant to investigations into two more recent crashes of Boeing aircraft that killed 346.
[Read The Times’s investigation here.]
The study, by Sidney Dekker, acknowledged that the pilots made serious errors but also found that Boeing bore significant responsibility. It accused the company of trying to deflect attention from its own “design shortcomings” with “hardly credible” statements drawing attention to the pilots’ mistakes.
A spokeswoman for the board had told The Times last week that Dr. Dekker’s study was confidential. But in a statement on Tuesday, Jeroen Dijsselbloem, chairman of the Dutch board, said the study had been posted online because the board’s “current practices” had changed. “We now publish as much as possible,” he said.
The board also defended its investigation of the 2009 crash, which involved a 737 Next Generation, or NG, a predecessor to the 737 Max. The more recent accidents involved the Max, which has been grounded since last year as investigations continue.
Mr. Dijsselbloem noted “the key question” for those investigations was whether lessons from 2009 “were sufficiently learned by Boeing and the American authorities.”
Multiple aviation experts who had read Dr. Dekker’s study told The Times its findings had not been sufficiently incorporated into the final Dutch accident report. In addition, the Times learned, the Dutch removed or minimized criticisms of Boeing after pushback from a team of Americans that included the manufacturer and federal safety officials.
Jan Paternotte, a member of the Dutch House of Representatives, praised the study’s release but called for a hearing of those involved, saying he believed he would secure the necessary support during a committee meeting on Wednesday. “Boeing has been capable of strong-arming outside parties if it serves the short-term interest of the company,” he said. “When safety is at stake, that is a problem.”
The Dutch board on Tuesday acknowledged that it had changed portions of its draft report after the Americans raised objections, but called that “standard procedure” and noted that the Americans’ comments were included in an appendix.“The Dutch Safety Board does its work in strict independence,” Mr. Dijsselbloem said. “The Board decides independently on the outcome of its investigations, the content of its reports and its conclusions and recommendations.”
A Boeing spokesman referred questions to the National Transportation Safety Board, which led the American team that commented on the Dutch draft report. An N.T.S.B. spokesman declined to comment.
The Federal Aviation Administration, which was also a member of the American team participating in the 2009 inquiry, said in a statement that it was “following a thorough process for returning the Boeing 737 Max to passenger service.” The agency added that it was working with international safety regulators to review “proposed changes to the aircraft” as well as “recommendations from safety experts who have examined our certification processes.”
The Dutch board’s final report, released in 2010, focused blame on numerous mistakes by the pilots, including their failure to notice a dangerous drop in speed and their incorrect response to an alert warning of an impending stall. The report contained statements — some nearly verbatim and without attribution — that were originally written by the American team and further emphasized crew errors.
The Times found striking parallels between the accident and the 737 Max crashes. In both cases, design decisions by Boeing allowed a single faulty sensor to activate a powerful computer command. In both cases, Boeing had known of the potential sensor failures but determined that pilots would react correctly and recover the plane. And in both cases, Boeing didn’t include information in the pilots’ manual that could have helped them respond to the malfunctioning automation.
Boeing, the F.A.A and the N.T.S.B. noted that the system involved in the earlier accident differed significantly from the one blamed in the Max crashes. But aviation safety experts, including a senior F.A.A. official who was not authorized to speak publicly, told The Times that the similarities were noteworthy.
Dr. Dekker’s report “should have woken everybody up,” one said. Instead, “the issue got buried.”
Last edited by OldnGrounded; 21st Jan 2020 at 23:37. Reason: Formatting
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Critically, in the case of the NG, Boeing had already developed the software fix well before the Turkish Airlines crash, including it on new planes starting in 2006 and offering it as an optional update on hundreds of other aircraft. But for some older jets, including the one that crashed near Amsterdam, the update wouldn't work, and Boeing did not develop a compatible version until after the accident.
Five years before the Turkish Airlines crash, Boeing was aware that a sensor malfunction could idle the engines improperly, but the company decided it wasn't a safety concern, the Dutch investigators wrote.
The safeguard was available in 2006, but the change wouldn't work on some 737 NG models, like the Turkish Airlines plane, that used an autothrottle computer made by a different company. After the 2009 crash, Boeing developed a version of the update compatible with those computers, and the F.A.A. required airlines to install it.
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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
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
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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
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
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
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
Last edited by safetypee; 22nd Jan 2020 at 07:37.
fdr, #58 No such thing as an average pilot.
A valuable list of regulatory references.
Many countries and individuals should heed the chastisements, but the most important language, that written in American English ( NW manufacture and regulation, and South Side Mall DC dialects ), is absent.
Even after stating a 'truth', it has to be recognised and heeded as important. Furthermore, 'truths' have to withstand legal advice as how to design, certificate, document, and present training requirements.
The industry has to be increasingly reminded of the challenges on its integrity; the need for safety above protectionism.
Well done to the Dutch Investigators in openly posting the 'Dekker report'; something more significant than the original accident report, and which raises the standards for investigation, reporting, and acting on recommendations.
Similarly for Dr Dekker; the HF report should be promoted as an HF primer - not detracting from the excellence of his books.
His report must be required reading for people at all levels of manufacture and regulation, especially bean counters and lawyers, and not least ourselves.
A gateway for change, improving our industry.
No such thing as an average pilot.A valuable list of regulatory references.
Many countries and individuals should heed the chastisements, but the most important language, that written in American English ( NW manufacture and regulation, and South Side Mall DC dialects ), is absent.
Even after stating a 'truth', it has to be recognised and heeded as important. Furthermore, 'truths' have to withstand legal advice as how to design, certificate, document, and present training requirements.
The industry has to be increasingly reminded of the challenges on its integrity; the need for safety above protectionism.
Well done to the Dutch Investigators in openly posting the 'Dekker report'; something more significant than the original accident report, and which raises the standards for investigation, reporting, and acting on recommendations.
Similarly for Dr Dekker; the HF report should be promoted as an HF primer - not detracting from the excellence of his books.
His report must be required reading for people at all levels of manufacture and regulation, especially bean counters and lawyers, and not least ourselves.
A gateway for change, improving our industry.
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I don't think anyone is arguing that the Turkish Airlines crew wasn't largely responsible for the AMS crash. The point is simply that Boeing also had some responsibility and worked hard, apparently along with US regulators, to keep references to that out of the investigative reports.
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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.
