Boeing 737 Max Recertification Testing - Finally.
Thread Starter
NTSB formally disputes Ethiopian report on the MAX crash:
Ethiopian Max Crash Report Made False Claims on 737, US Says (msn.com)
Ethiopian Max Crash Report Made False Claims on 737, US Says (msn.com)
The US National Transportation Safety Board accused the Ethiopian Accident Investigation Bureau of making claims “unsupported by evidence” in conclusions belatedly published late last year.
“The final report does not provide any details to support the EAIB’s statements about the existence of an electrical problem,” the NTSB wrote on Tuesday.
US investigators said they agreed generally with Ethiopia’s findings that a flawed design in the 737 Max pushed the nose down automatically and was at least part of the cause of the March 10, 2019 crash that killed 157 people.
But the Ethiopians ignored numerous other factors, the NTSB said. In particular, the Ethiopian Airlines Group crew had been told how to counteract a failure of the flawed software known as Maneuvering Characteristics Augmentation System, or MCAS, after a crash off the coast of Indonesia about four months earlier. But they failed to follow the procedure, the NTSB said.
“This is unprecedented in our view,” NTSB Chairwoman Jennifer Homendy said in an interview. “They were not operating in good faith with ICAO rules and we feel that we have to be very public where we think there were inaccuracies in the report and where we think it could be more comprehensive.”
“The final report does not provide any details to support the EAIB’s statements about the existence of an electrical problem,” the NTSB wrote on Tuesday.
US investigators said they agreed generally with Ethiopia’s findings that a flawed design in the 737 Max pushed the nose down automatically and was at least part of the cause of the March 10, 2019 crash that killed 157 people.
But the Ethiopians ignored numerous other factors, the NTSB said. In particular, the Ethiopian Airlines Group crew had been told how to counteract a failure of the flawed software known as Maneuvering Characteristics Augmentation System, or MCAS, after a crash off the coast of Indonesia about four months earlier. But they failed to follow the procedure, the NTSB said.
“This is unprecedented in our view,” NTSB Chairwoman Jennifer Homendy said in an interview. “They were not operating in good faith with ICAO rules and we feel that we have to be very public where we think there were inaccuracies in the report and where we think it could be more comprehensive.”
What payback does a lawyer want in this case? Seems like billions in settlements and crashing their sales and stock prices aren't enough. Meanwhile those in charge of the airline, knowing the plane was flawed, knowing their pilots weren't trained, and still sold tickets, walk away with a huge cash windfall and a discount on new planes from a source they put all the blame on. No justice in that.
Psychophysiological entity
During the intensive period of posting on PPRuNe, I mentioned the possible adverse effects of knowing a little about the previous crash but being nowhere near to having a clear picture of MCAS. As unlikely as it sounds, during those chaotic minutes, having some fuzzy recollection of technical memos might just have been worse than not having been briefed at all.
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Every part of the indictment you either stated or implied against the Ethiopian airline or the government of that country, or both, may be valid and true, MechEngr.
That having been said though, why shouldn't NTSB have taken issue with the accident report, or done so in such a formal manner? Or is your point not that NTSB should have merely shrugged it off, but rather are you trying to impress upon those readers here who might be a ton less cynical and world-wise, the more enlightened understanding of the true state of affairs?
That having been said though, why shouldn't NTSB have taken issue with the accident report, or done so in such a formal manner? Or is your point not that NTSB should have merely shrugged it off, but rather are you trying to impress upon those readers here who might be a ton less cynical and world-wise, the more enlightened understanding of the true state of affairs?
Psychophysiological entity
Since the ET302 crew failure started before MCAS was involved, it's not a simply a problem of failing to have a clear picture of a technical memo.
I've long wondered if the power was left high because of being in a bewildered state, or if they imagined pulling the power back would exacerbate the pitch problem.
Psychophysiological entity
I've just been reading a 4 hour old BBC news item on the reintroduction of charges against Boeing. What kind of justice comes up with "deferred prosecution agreement". I was generally aware but hadn't realised it was so blatant.
Embedded in the post is a long sub thread which has wondrous graphics but it leaves the reader with the usual over-simplified ideas.
https://www.bbc.co.uk/news/business-64390546
Reading on, and on, and on, I have to say that it would be churlish to nit pick this news item. In one of the sub-sub sections, it really gives a good overview of the Boeing/FAA self regulation issues. The inner link is a long read.
In January 2021, the US Department of Justice (DoJ) charged Boeing with fraud. But the company was able to avoid going on trial, by agreeing to pay $2.5bn in fines and compensation, and promising to tighten up its compliance procedures.
This settlement - known as a deferred prosecution agreement - provoked intense anger among a number of the relatives of those who died aboard ET302.
They claimed, and continue to claim, that the deal was a "sweetheart agreement" which was concluded without their knowledge, violated their rights, and allowed the company to avoid being held fully accountable.
The Department of Justice defended its decision, insisting that the settlement was appropriate, because it could not prove beyond reasonable doubt there was a direct connection between Boeing's alleged crimes and the two crashes.
This settlement - known as a deferred prosecution agreement - provoked intense anger among a number of the relatives of those who died aboard ET302.
They claimed, and continue to claim, that the deal was a "sweetheart agreement" which was concluded without their knowledge, violated their rights, and allowed the company to avoid being held fully accountable.
The Department of Justice defended its decision, insisting that the settlement was appropriate, because it could not prove beyond reasonable doubt there was a direct connection between Boeing's alleged crimes and the two crashes.
https://www.bbc.co.uk/news/business-64390546
Reading on, and on, and on, I have to say that it would be churlish to nit pick this news item. In one of the sub-sub sections, it really gives a good overview of the Boeing/FAA self regulation issues. The inner link is a long read.
Last edited by Loose rivets; 26th Jan 2023 at 01:56.
Every part of the indictment you either stated or implied against the Ethiopian airline or the government of that country, or both, may be valid and true, MechEngr.
That having been said though, why shouldn't NTSB have taken issue with the accident report, or done so in such a formal manner? Or is your point not that NTSB should have merely shrugged it off, but rather are you trying to impress upon those readers here who might be a ton less cynical and world-wise, the more enlightened understanding of the true state of affairs?
That having been said though, why shouldn't NTSB have taken issue with the accident report, or done so in such a formal manner? Or is your point not that NTSB should have merely shrugged it off, but rather are you trying to impress upon those readers here who might be a ton less cynical and world-wise, the more enlightened understanding of the true state of affairs?
My agenda is to focus on all elements regarding safety and not to ignore major ones, an oversight which the NTSB and other ICAO participants attempted to rightfully correct when the flawed Ethiopian report skipped their own actions. I didn't suggest or imply the NTSB should shrug off anything, though I would have liked to see the investigation include the SMYD giving a false report; I don't recall seeing that mentioned.
If the airline were instead operated by a hedge-fund backed venture capital firm that got it via leveraged buyout and saddled it with insurmountable debt, would that make an ethical difference when they continued to fly? Would they be held blameless for operating in the face of a known fatal hazard after taking no steps to mitigate it?
Watch now how Boeing solves this problem:
- Step One: Forum Shop for the Best Jurisdiction
- Step Two: Inflate the Penalty
- Step Three: Finding a Scapegoat
- Step Four: Ignoring the Victims
- Step Five: A Final Footnote
Shortly after the Boeing DPA was signed on January 7, 2021 (the day after President Trump’s “rally” in Washington), the U.S. Attorney resigned (as is customary on a change of Administration), and months later, she joined a new firm as partner—Kirkland & Ellis. Well, it’s a small world
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The reply was to the situation in the cockpit regarding MCAS as the cause of the chaos. On that basis your response is nonsensical.
My agenda is to focus on all elements regarding safety and not to ignore major ones, an oversight which the NTSB and other ICAO participants attempted to rightfully correct when the flawed Ethiopian report skipped their own actions. I didn't suggest or imply the NTSB should shrug off anything, though I would have liked to see the investigation include the SMYD giving a false report; I don't recall seeing that mentioned.
If the airline were instead operated by a hedge-fund backed venture capital firm that got it via leveraged buyout and saddled it with insurmountable debt, would that make an ethical difference when they continued to fly? Would they be held blameless for operating in the face of a known fatal hazard after taking no steps to mitigate it?
My agenda is to focus on all elements regarding safety and not to ignore major ones, an oversight which the NTSB and other ICAO participants attempted to rightfully correct when the flawed Ethiopian report skipped their own actions. I didn't suggest or imply the NTSB should shrug off anything, though I would have liked to see the investigation include the SMYD giving a false report; I don't recall seeing that mentioned.
If the airline were instead operated by a hedge-fund backed venture capital firm that got it via leveraged buyout and saddled it with insurmountable debt, would that make an ethical difference when they continued to fly? Would they be held blameless for operating in the face of a known fatal hazard after taking no steps to mitigate it?
Rather than again misunderstanding a post, and especially because it's not entirely certain (to this SLF, anyway) what outcomes you're comparing in the question with which your post ends, I'll wait to have the outcome of today's hearing - and related proceedings, if any - in the DPA matter to take into account. That said, and with that caveat, I'd say yes.... outright greed and purposeful manipulation of vulnerable safety regulatory processes would make an ethical difference, at least insofar as a jury's consideration of punitive damages is concerned.
The current outcome. The one that currently stands that greed and purposeful manipulation of a safety regulatory process captured by the owner/operator of an airline and the sole arbiter of its own safety analysis. The one that the NTSB complained about. That outcome.
Here's another ethics question: If an entity is entirely judgement proof and beyond all legal reach, is it ethical to ignore their contribution in assessment of blame?
Here's another ethics question: If an entity is entirely judgement proof and beyond all legal reach, is it ethical to ignore their contribution in assessment of blame?
The current outcome. The one that currently stands that greed and purposeful manipulation of a safety regulatory process captured by the owner/operator of an airline and the sole arbiter of its own safety analysis. The one that the NTSB complained about. That outcome.
Here's another ethics question: If an entity is entirely judgement proof and beyond all legal reach, is it ethical to ignore their contribution in assessment of blame?
Here's another ethics question: If an entity is entirely judgement proof and beyond all legal reach, is it ethical to ignore their contribution in assessment of blame?
I imagine the NTSB and whoever looks after aid handouts in Washington are now at daggers drawn.
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Standardization is a myth.
Okay, that's just an attention-getting device. First of all, this SLF/attorney lacks meaningful knowledge about the subject air carrier other than facts one would have to assume are valid about more-or-less any unspecified airline in a given size class and the flag carrier of a country similarly in a given category or class.
But the realization that selling airplanes to air carriers 'round the world has long entailed embracing, and more so, utilizing, flaws or weakness in the airline or national regulatory scheme relative to fidelity to safety matters - that adds another layer of cynicism and mistrust to the legacy of the 737 MAX and the company. Maybe that isn't really the biggest jolt.
So much of the international commercial aviation sector professes to operate under standardization, established and looked after by that U.N. affiliate with the wings and globe in its insignia. (For a current instance, on another thread the existence of an ICAO program seeking to address upgrades - or redoing entirely - of the Notam system was asserted as a reason explaining Congressional inaction on the same subject.) But if an air carrier, the country flagship no less, and the national government deviate significantly from both the letter of the standards and the results intended to be produced by the total set of standards (and RPs) - maybe it's time for the largest and most significant countries in the sector (int'l commercial aviation) to drop the pretense about standardization. I realize that economic issues were cut out of the proceedings in Chicago in 1944; maybe that decision has borne a bitter - and tragic - legacy.
Of course, the U.S. won't do this under current policy leadership and administration in Washington, and even if it wanted to, it could not be done without a Permanent Rep to ICAO and Council with Amb. rank (as capable as the current head-of-mission obviously is).
Okay, that's just an attention-getting device. First of all, this SLF/attorney lacks meaningful knowledge about the subject air carrier other than facts one would have to assume are valid about more-or-less any unspecified airline in a given size class and the flag carrier of a country similarly in a given category or class.
But the realization that selling airplanes to air carriers 'round the world has long entailed embracing, and more so, utilizing, flaws or weakness in the airline or national regulatory scheme relative to fidelity to safety matters - that adds another layer of cynicism and mistrust to the legacy of the 737 MAX and the company. Maybe that isn't really the biggest jolt.
So much of the international commercial aviation sector professes to operate under standardization, established and looked after by that U.N. affiliate with the wings and globe in its insignia. (For a current instance, on another thread the existence of an ICAO program seeking to address upgrades - or redoing entirely - of the Notam system was asserted as a reason explaining Congressional inaction on the same subject.) But if an air carrier, the country flagship no less, and the national government deviate significantly from both the letter of the standards and the results intended to be produced by the total set of standards (and RPs) - maybe it's time for the largest and most significant countries in the sector (int'l commercial aviation) to drop the pretense about standardization. I realize that economic issues were cut out of the proceedings in Chicago in 1944; maybe that decision has borne a bitter - and tragic - legacy.
Of course, the U.S. won't do this under current policy leadership and administration in Washington, and even if it wanted to, it could not be done without a Permanent Rep to ICAO and Council with Amb. rank (as capable as the current head-of-mission obviously is).
Fair comment, though there was plenty of time after MCAS played a role, for the mental chaos to become all-consuming.
I've long wondered if the power was left high because of being in a bewildered state, or if they imagined pulling the power back would exacerbate the pitch problem.
I've long wondered if the power was left high because of being in a bewildered state, or if they imagined pulling the power back would exacerbate the pitch problem.
From ET-302 Interim Investigation Report - p13
"At 05:39:42, the crew engaged Level Change mode and set MCP speed to 238kt"
Description taken from piece by Seattle Times, March 7th 2021
According to the interim investigation report released a year ago, the faulty Angle of Attack sensor on Flight ET302, even before it triggered MCAS to push the plane’s nose down, interfered with other sensor readings of altitude and airspeed. Registering the plane as still below 800 feet above the ground even after it passed that threshold, the jet’s computer had the autothrottle maintain full takeoff thrust for 16 seconds after it should have reduced the power for the climb phase. More significantly, seconds later the pilots set the jet’s speed target at 238 knots, but the autothrottle didn’t follow through. Again because of the faulty sensor on the left, the flight computer detected the discrepancy between the left and right airspeed values and flagged the data as invalid. Unable to validate the aircraft’s speed, the computer stopped sending thrust instructions to the autothrottle. As a result, the engines remained at maximum thrust for the rest of the fatal flight. The plane eventually exceeded the 737’s maximum design speed of 340 knots. This so increased the forces on the jet’s tail that the pilots couldn’t budge it manually.
Psychophysiological entity
Pulitzer Prize winners - The Seattle Times
https://www.seattletimes.com › pulitzersSeattle Times staffers have won journalism's highest honor 11 times since 1950, and have been finalists on 14 other occasions since 1982.
Seattle Times wins Pulitzer Prize for Boeing 737 MAX coverage
https://www.seattletimes.com › inside-the-times › seattle-ti...
4 May 2020 — The Seattle Times has been awarded a 2020 Pulitzer Prize for National Reporting for its yearlong coverage of the two deadly crashes of ...
Impressive stuff. I like to think there was a two way street between the Times and PPRuNe's multi-thousand posts.
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Not Guilty, is the plea
Meanwhile, in federal court in Texas, Boeing entered a plea of Not Guilty.
Reporting by Courthouse News Service follows via link. Note, Article includes link to court filing by the crash victims' families.
https://www.courthousenews.com/boein...37-max-safety/
Added: the court filing is..... the recitation it sets forth of the facts overall, as well as its withering contempt for the way the DPA was reached and for Boeing's criminal acts and omissions, it's really kick-out-the-jams.....
Reporting by Courthouse News Service follows via link. Note, Article includes link to court filing by the crash victims' families.
https://www.courthousenews.com/boein...37-max-safety/
Added: the court filing is..... the recitation it sets forth of the facts overall, as well as its withering contempt for the way the DPA was reached and for Boeing's criminal acts and omissions, it's really kick-out-the-jams.....
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Only when the not-documented secret button was pushed, the MCAS effects could be compensated for. In the pre-Indonesian crash, only the (experienced ?) engineer, monitoring the situation, managed to get to that stage.
So, yeah, for now, there are no reasons to assume, this crew would not have managed to get the MAX on the ground in one piece, with all participants in this MAX/MCAS experiment walking away unharmed, if the MCAS had been stayed at rest.
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......
So much of the international commercial aviation sector professes to operate under standardization, established and looked after by that U.N. affiliate with the wings and globe in its insignia. .... But if an air carrier, the country flagship no less, and the national government deviate significantly from both the letter of the standards and the results intended to be produced by the total set of standards (and RPs) - maybe it's time for the largest and most significant countries in the sector (int'l commercial aviation) to drop the pretense about standardization.
So much of the international commercial aviation sector professes to operate under standardization, established and looked after by that U.N. affiliate with the wings and globe in its insignia. .... But if an air carrier, the country flagship no less, and the national government deviate significantly from both the letter of the standards and the results intended to be produced by the total set of standards (and RPs) - maybe it's time for the largest and most significant countries in the sector (int'l commercial aviation) to drop the pretense about standardization.
It's more that the ICAO assumed (wrongly), that developing countries (in those days third-world countries), would be able to realize/implement the ICAO standards to the same level as the democracy lead first-world. The same issues the UN is also plagued with.
When a new power rises in a country in chaos, there are 2 options to stabilize and get all noses in the same direction: Discuss/negotiation among all parties or use force to do so. Western democracies obviously went the first road. Putin (and China as well), went the "force" road, and current history shows the result of regimes that use the force road: It needs more and more force and repression.
Looking how the world-wide money laundering is being handled (putting countries on a black/gray list, and softly punishing those countries violating the norms, by reducing their international monetary options), is something that might work too for ICAO violations. This issues with this is, though, that the number of incidents is that low, that results can only be "measured" using the validation of the implementation of laid out standards. Still a fishy judgement, though. There are so many countries violating the intended implementation. Think about the whole of the ME........
WideScreen,
They were, starting 1-10 seconds after take-off*, given a continuing stick shaker** - which AFAIK requires two memory item steps: Disable the Autopilot and Disable the Autothrottle. They did neither one. The reasons for the requirement is simple: either the automation has pushed the plane into a stall or the instrumentation the automation requires has failed; both make reliance on the automation a bad choice. The overspeed did not happen for a long time after that; there was no conflict at the time the stall warning memory items were to be done. Had they been done there would be no overspeed and therefore no additional warning for it.
They also had access to fresh knowledge of exactly how MCAS functioned and how to handle it. This is skipped over by the Final Report, leaving the industry without a firm base to analyze what steps are required to guarantee every pilot learns and understands the information that is available.
As evidenced by the Lion Air preliminary report, issued months ahead of ET302 one crew and a senior pilot found the plane completely flyable with MCAS nudging away; Lion Air crashed when a first officer did not continue the management the captain had been performing.
There is no "secret button." The trim runaway cutout switches are plainly visible and work as advertised; though earlier versions had separate channels to cutout separate inputs, the training was always (last 10-30 years AFAIK) to cut them both rather than spend time to diagnose the exact cause of the trim runaway.
Read the Final Report for both Lion Air and ET302, paying close attention to the events recorded by the FDR for all three flights.
I feel quite sad at the outcome as MCAS was not a system that failed in a way to guarantee a crash. There was a failure in human factors and it wasn't the amount or kind of alarms, but in failing to convey to the pilots what an MCAS event felt like and how they needed to always handle the stall warning immediately and never use Autopilot or Autothrottle with the stick shaker running. You might ask, why doesn't the automation shut itself off when the stick shaker is running? Because, if it's an automation failure the automation cannot be trusted to do anything correctly. At least the airplane computers cannot lock the pilots outside.
*They don't report the time the weight-on-wheels ended, just the time of positive climb which was at 50 foot altitude. Roughly 4 seconds after the stick shaker started the Anti-Ice and Master Caution indicators lit, which the F/O then announced to the Captain. A few seconds later, with the stick shaker hammering away, the Captain called for the Autopilot to be engaged, the first of three times before cutting out the trim. They re-enbled the trim and tried to engage the Autopilot a 4th time, the actions that allowed the MCAS its final trim increment.
** At some point there was also a speed/alt difference warning, but the stall warning should have the highest priority. Again, this should be covered by training, but the final report has no information on the proficiency of the pilots in prioritizing the stick shaker stall warning. The overspeed warning was at 5:41:21; the takeoff at roughly 05:38:43.
They were, starting 1-10 seconds after take-off*, given a continuing stick shaker** - which AFAIK requires two memory item steps: Disable the Autopilot and Disable the Autothrottle. They did neither one. The reasons for the requirement is simple: either the automation has pushed the plane into a stall or the instrumentation the automation requires has failed; both make reliance on the automation a bad choice. The overspeed did not happen for a long time after that; there was no conflict at the time the stall warning memory items were to be done. Had they been done there would be no overspeed and therefore no additional warning for it.
They also had access to fresh knowledge of exactly how MCAS functioned and how to handle it. This is skipped over by the Final Report, leaving the industry without a firm base to analyze what steps are required to guarantee every pilot learns and understands the information that is available.
As evidenced by the Lion Air preliminary report, issued months ahead of ET302 one crew and a senior pilot found the plane completely flyable with MCAS nudging away; Lion Air crashed when a first officer did not continue the management the captain had been performing.
There is no "secret button." The trim runaway cutout switches are plainly visible and work as advertised; though earlier versions had separate channels to cutout separate inputs, the training was always (last 10-30 years AFAIK) to cut them both rather than spend time to diagnose the exact cause of the trim runaway.
Read the Final Report for both Lion Air and ET302, paying close attention to the events recorded by the FDR for all three flights.
I feel quite sad at the outcome as MCAS was not a system that failed in a way to guarantee a crash. There was a failure in human factors and it wasn't the amount or kind of alarms, but in failing to convey to the pilots what an MCAS event felt like and how they needed to always handle the stall warning immediately and never use Autopilot or Autothrottle with the stick shaker running. You might ask, why doesn't the automation shut itself off when the stick shaker is running? Because, if it's an automation failure the automation cannot be trusted to do anything correctly. At least the airplane computers cannot lock the pilots outside.
*They don't report the time the weight-on-wheels ended, just the time of positive climb which was at 50 foot altitude. Roughly 4 seconds after the stick shaker started the Anti-Ice and Master Caution indicators lit, which the F/O then announced to the Captain. A few seconds later, with the stick shaker hammering away, the Captain called for the Autopilot to be engaged, the first of three times before cutting out the trim. They re-enbled the trim and tried to engage the Autopilot a 4th time, the actions that allowed the MCAS its final trim increment.
** At some point there was also a speed/alt difference warning, but the stall warning should have the highest priority. Again, this should be covered by training, but the final report has no information on the proficiency of the pilots in prioritizing the stick shaker stall warning. The overspeed warning was at 5:41:21; the takeoff at roughly 05:38:43.
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WideScreen,
They were, starting 1-10 seconds after take-off*, given a continuing stick shaker** - which AFAIK requires two memory item steps: Disable the Autopilot and Disable the Autothrottle. They did neither one. The reasons for the requirement is simple: either the automation has pushed the plane into a stall or the instrumentation the automation requires has failed; both make reliance on the automation a bad choice. The overspeed did not happen for a long time after that; there was no conflict at the time the stall warning memory items were to be done. Had they been done there would be no overspeed and therefore no additional warning for it.
They were, starting 1-10 seconds after take-off*, given a continuing stick shaker** - which AFAIK requires two memory item steps: Disable the Autopilot and Disable the Autothrottle. They did neither one. The reasons for the requirement is simple: either the automation has pushed the plane into a stall or the instrumentation the automation requires has failed; both make reliance on the automation a bad choice. The overspeed did not happen for a long time after that; there was no conflict at the time the stall warning memory items were to be done. Had they been done there would be no overspeed and therefore no additional warning for it.
My impression is, they would have found out (they had time, since the aircraft was perfectly flyable) and setup the return to the airport.
This issue is the conflicting indications together with the cacophony on alarms that got fired.
They also had access to fresh knowledge of exactly how MCAS functioned and how to handle it. This is skipped over by the Final Report, leaving the industry without a firm base to analyze what steps are required to guarantee every pilot learns and understands the information that is available.
There is no "secret button." The trim runaway cutout switches are plainly visible and work as advertised; though earlier versions had separate channels to cutout separate inputs, the training was always (last 10-30 years AFAIK) to cut them both rather than spend time to diagnose the exact cause of the trim runaway.
Read the Final Report for both Lion Air and ET302, paying close attention to the events recorded by the FDR for all three flights.
I feel quite sad at the outcome as MCAS was not a system that failed in a way to guarantee a crash. There was a failure in human factors and it wasn't the amount or kind of alarms, but in failing to convey to the pilots what an MCAS event felt like and how they needed to always handle the stall warning immediately and never use Autopilot or Autothrottle with the stick shaker running. You might ask, why doesn't the automation shut itself off when the stick shaker is running? Because, if it's an automation failure the automation cannot be trusted to do anything correctly. At least the airplane computers cannot lock the pilots outside.
I feel quite sad at the outcome as MCAS was not a system that failed in a way to guarantee a crash. There was a failure in human factors and it wasn't the amount or kind of alarms, but in failing to convey to the pilots what an MCAS event felt like and how they needed to always handle the stall warning immediately and never use Autopilot or Autothrottle with the stick shaker running. You might ask, why doesn't the automation shut itself off when the stick shaker is running? Because, if it's an automation failure the automation cannot be trusted to do anything correctly. At least the airplane computers cannot lock the pilots outside.
That way of thinking was "current", 50+ years ago. It's no longer applicable in today's busy commercial flying business. There are simply too many other (higher level) important items, to expect pilots to have to deal with something like the MCAS intricacies.
......
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