Amtrak saftey officer? And there safety record is...?

Thanks for the pointer.

And only one is a former FAA chief counsel, and so on.

Also, effectively, they are all political appointees, although, if you re-read what I wrote, you'll see that I speculated that the political ideology of high-level political appointees in the DOT (e.g., Elaine Chao, Secretary of Transportation and wife of Mitch McConnell) drove the formation and mission of the committee. It's really quite likely; these are people who believe government regulation is to be avoided whenever possible and minimized when it can't be avoided.

I shall. Thanks, again.

The report said that aviation safety experts it interviewed agreed that the FAA's decision to certify the Max as an update to previous generation 737s rather than a new type of aircraft didn't affect the Max's safety
"Each said a new TC (aircraft type certificate) would not have produced more rigorous scrutiny of the 737 Max 8 and would not have produced a safer airplane," the report said.

Is not it a new requirement for better not confusing cockpit warnings that would have been required on new Aircraft Type Certificates?

Is it not true that changes in compliance standards (the grandfathering was used for) are higher standards more safety intended + safer aircraft or were they introduced for fun?

In the FAA process, every major design change to be approved is required to be considered for application of "changed product rule", which has the theme that a change to an aircraft approved to an older standard may be required to be approved to a newer, or the most recent standard, if doing so is practical, and would improved safety. Basically, you can't keep modifying an old plane to still be old. But, this, as the certification exercise itself, requires correct application by FAA staff and delegated industry people, or it doesn't work well.

A lot of talk about the global aviation community in this report. Hmm. More “blame the pilots” as far as I can read.

We western pilots have been known to wreck perfectly good airplanes as well.

:rolleyes: <—— that’s how I feel after reading that report.

Dear Alf
agree with al of that. It’s a multi disciplinary approach that is required to see where this Industry is headed.
My concern is that it takes years to change some things. And we’ve been dumbing down training for a decade now. Train “just enough”.
R Guy

Hi Tuffy
in the last ten years out of all major accidents, only one was “western”- AF447. Two were Malaysian , missile and suicide. Then of course Germanwings. Western yes, but bizarre suicide. Two were the MAX , definitely not “western “ by location. 90%were in places that most people couldn’t place on a globe, with airlines that most of us have never heard of, and in what is politely called ‘developing ‘ world.
So I’m not sure what your point is but if you fly on “western airlines” and I won’t define that because there are plenty of “eastern airlines”:with excellent flight safety, QANTAS being a great example, you are historically much safer.
The threat is this. The world needs 500,000 pilots over next 25 years, mainly in the developing world and many are startups. No DNA on how to operate a safe airline. That is a massive challenge. There are two schools of thought
1/ train them to cope with the full spectrum of degraded airplane non normal situations including multiple failures sometimes escalating.rapidly out of control. Ie when computers fail, it’s easy for the pilots to fall back on basic flying skills and airmanship.
or
2/ Automate the problem -out so it can’t happen, and the pilots are there to conduct routine mundane tasks. So they don’t need to be extraordinarily skillful or even moderately so. Even better, set up your own flight academy to generate a constant flow of pilots. It’s a bit like marking your own homework though!
Interesting thread this! Thanks for raising this valid point.
R Guy

I'm guessing cargo aircraft accidents don't count as major accidents?
Atlas Air 3591 and UPS 1354 springs to mind as perfectly good aircraft being crashed in the last 10 years.

You guess correctly.

It would appear, that regardless of 'Western' or not, crew failures revolve around the same human factors everywhere.
This is not to say that aircrew training isn't to be improved in some areas, but Western operators are not immune from inadequate training or crew performance, as recent runway excursions, AF447 and those cargo mishaps seem to show.

retired guy, #168, we think alike. :ok:
However, take care in not slipping into the ‘ditch of solutions’ - training for the front line operators.The industry trains for the perceived threat, with today’s equipment.
Who trains the trainers, who oversees that - how.
Who trains the regulators, designers, managements, governments; how to improve HF application, the human perspective in their decision making.
Who asks the questions.
Takes time - yes, but also time to change viewpoint, our thinking, in a highly reliable industry in the aftermath of an accident.
- - - -
Re ‘appropriate and effective’ certification process - new / grandfather. An important question is who created the processes, checked them, learnt from evaluation and use.
Even with adequate oversight, human judgement is the final arbiter, but that is more with hindsight than foresight.

Social media forums thrive on hindsight, foresight is just ‘uninteresting’ opinion. Alternatively with ‘facts’ interpreted after the event, they, and with debatable comparisons of others’ opinion, can be rejudged - but to what point.

The required ‘process’ is to consider what can be learnt, and what can be done which might effect the future. We cannot change the past, even with debated hindsight; but we can consider what might be changed now so that this might influence and improve behaviour - everyone, so that future operations will remain safe.

Meanwhile in completely unrelated news airbus demonstrates automated takeoffs and plans for automated landings will follow all they need to do is automate taxi-in and nobody touches the controls. Beware the beancounters' love of autonomy. Scratch the Max issues and the beancounters scurry out be it in design, testing, simulators, training

You are very observant and quite right. I do safety talks to nervous passengers a lot and I use stats that only include passenger airliners since those are the ones that are of interest to the travelling public. I flew with Dan Air once and flew the 707 that crashed the soon after in Lusaka when the tail fell off - cargo, and lost a good friend in that one.
It is a fact that cargo flights are often badly or not reported unless they hit a block of flats in Amsterdam and take out lots of people on the ground.
So yes I did exclude cargo flights and I also exclude military ones since most of my listeners are not likely to be in an F15 any time soon.
But that is why this forum is good. You don't get away with anything inaccurate or murky so thanks for bringing it up. Hope that clarifies matters
Cheers
R Guy
The list below is all major crashes on passengers planes with multiple fatalities in the last ten years sorted in the left two columns by region and the right two by airline.
It is interesting how most of them are in less well know places or with airlines that I have never heard of (my ignorance) and that I would be very unlikely to fly on in the normal course of events. The yellow ones are the exceptions. Lionair AF 447, Germanwings, the two Malaysians and Ethiopian.
If I have left out any please let me know folks because I keep updating this list.

https://cimg5.ibsrv.net/gimg/pprune....54a4388fe3.png

https://en.wikipedia.org/wiki/1977_D...eing_707_crash

737 MAX MCAS
 

This was for the Ethiopia crash thread, now closed, so I'm posting it here:

Originally Posted by Gegenbeispiel
Quote:
Originally Posted by SLFstu
Hi
Thanks for noting why avionics logic can look/behave counter-intuitively.
I guess it was because in my previous job type there was the need to PRACTICALLY explain all observed actions.
Mind you, if Boeing ever did add some sort of MCAS ACTIVE annunciation then in the case I pointed out it would be a tad misleading if power to the trim motor is set to CUTOUT.
But in the overall scheme of things with this accident - 6 minutes until death - I was nitpicking about the minutest trivia.
Stay safe.

Stew
You're welcome, and thanks.
IMO, any MCAS activation is a very big deal. Boeing was wrong to try to hide MCAS from the crew.
The proper way, IMO, to annunciate MCAS ACTIVE would be as a master warning or master caution, with its own text on the warning panel. The signal for for that would be something like (((FCC1_SELECTED and FCC1_MCAS_ACTIVE) or (FCC2_SELECTED and FCC2_MCAS_ACTIVE)) and ELECTRIC_STAB_TRIM_ENABLED ) , probably implemented as hardware discrete logic. That would be an expensive modification. All the best. Arthur
PS do you mind if I put this msg exchange on the thread? I think I should.

The fundamental issue Gegenbeispiel is that any warning would violate or jeopardise the common type endorsement without simulator training with previous 737 family members. Boeing had contracted to accept a $1 million dollar penalty if simulator training was required for some 250++ jets with one operator. It also enhanced the sales pitch with other operators.

Subsequent revelations (Forkner chats logs) have revealed Boeing actively "Jedi Mind Tricked" Lionair into not requiring simulator for their own crews as Boeing were concerned other operators would be influenced to do this for their own crews, leaving the perception for potential purchasers that it was best practice to require training. This would increase the costs, and thus reduce the attractiveness of the 737-MAX relative to the Airbus A32x Neo family.

It was mentioned at one point the cost was about $2000 (assumed USD) per pilot was the cost if a training simulator was required.

$2,000 per pilot does not seem anywhere near correct - a break down of that would be great if anyone has one?

The emails had some redacted stuff but that was mostly redacted.

https://www.bbc.co.uk/news/business-51153286

Have to agree with the family.

An alternative interpretation of the report is that the use of either process could result in a flawed outcome; same outcome, no difference, equally deficient.
The effectiveness of either process was only as good as the bounding system allowed, and apparently no one questioned the overall organisational system - FAA or Boeing.

Similarly the report could suffer flaws or influences of the larger system; who holds the responsibility for overseeing the totality of the regulatory system: - the highest levels of the governing administration, throughout and to each and every individual in that system.

The report was downwards focussed; whereas looking upwards might have provided a better balance in the findings.

“...no matter how hard they try, humans can never be expected to out perform the system which bounds and constrains them. Organisational flaws will, sooner or later, defeat individual human performance.”
Gary Parata of Air Nelson

“Responsibility lies with those who could act but do not, it lies with those who could learn but do not, and for those who evaluate it can add to their capacity to make interventions which might make all our lives the safer.”
Phillip Capper – ‘Systems safety in the wake of the cave creek disaster.’

Hi Bendalot. It’s hard to cost sim per hour.
I know I can rent a local 737 sim for something like 1000 per hour- maybe less pro rata for four.
First you have the cost of the sim at say 12million. Then the building rent etc. utilization. Is it generating income from third parties? But the cost that scares airlines is the time off flying the line involved and impact on rosters. And the need for more training pilots- it’s a big overhead. In a LCC it’s not uncommon for pilots to have to travel a whole day from home base to a sim in day UK . Say Poland to UK? Three flights?
For a one hour Max refresher that would be the same. And then Hotac overnight. For some airlines that’s a cost too - not all!
Two days gone. And annual duty hours affected maybe. Oh dear. And FTL or roster agreement might mean he now can’t fly next day. Is the cost of this training worth it? A thousand times yes.

I would add a whole day annually onto every pilot if I were running the train set. ( Any finance guy reading this, and maybe others, will be saying “thank God the idiot is too old) One day devoted to flying in degraded modes. No autopilots. Multiple failures. Failures that are ambiguous. Raw data. Visual approaches. The works and no pilot would join who hadnt been been trained in those skills at flight school. Somewhere like Oxford or Jerez or equivalent.
Capt G Khan over and out
aka R Guy

does anyone have a link to the actual full report?
Yes our hearts go out to the families.
r Guy

Official Report of the Special Committee to Review the Federal Aviation Administration's Aircraft Certification Process

Yes indeed , a family always look at the accident in different light and I really feel sorry for them . . But basically the conclusions of the report could not have been any different for one simple reason ; it would put in question all previous similar certification processes done around that time by the same people and would probably affect the KC-46 and 787 certifications . An a grounding of those 2 aircraft would probably end Boeing , putting 100 thousand jobs in danger plus the economic impact and the loss of leadership in aviation , this is simply not an option for the US.

Thanks Dave
That will keep me out of the pub for the weekend.
Have a good one
R Guy

The Dep't of Transportation / FAA advisory panel's report appears certain to complicate matters in several ways. To start, the pub, r guy, will have one more seat vacant here too.

While it seems pretty evident that the report was a result of a studied and determined effort to protect the status quo especially regarding delegation in a broad sense, there are too many other wheels in motion, for it really to be effective. Just as an example when I (SLF + att'y) conclude my weekend reading will I have seen, let alone found logical satisfaction with, this panel's rebuttal of the JATR?

Quickly to note the panel is made up (as far as I can tell) of heavy worthies. Usually it's worth noting a gap between "expertise" - which typically is for sale - and "authoritativeness" - which is earned most often the old-school way. But in this instance what matters is the full set of substantive issues, and questions, not anyone's career history to date.

One reported assertion by the panel is that policies were adhered to, that things were done appropriately and effectively. But compliance with the status quo process hardly warrants approval - if the current system is flawed, let alone deeply so. I'll not insult the dignity of the families by commenting on "appropriate" or "effective".

A second reported assertion is that certification as a new type wouldn't have improved the overall safety of the airplane. I'm going to plead dumbfoundedness on this....new type, but no bare airframe testing without MCAS? No revealing its inclusion to pilots, no simulator training? One AoA sensor only? I must be missing something (again, just SLF + att'y). At the very least, this is a stark counter-factual -- the panel is a roster of heavies but they don't have magic portals for seeing into what "would have happened" either.

Third and almost last, regarding the scheme of delegating areas of the certification process, for now my response is, "but of course the status quo will counter-attack, and this is part of that." Some other worthies on Capitol Hill are obviously angling to re-reconfigure the delegation scheme, and those efforts now have one more obstacle.

Last, and most tentative until back in the pub, I've reached the conclusion that the court got it wrong in the case brought by British Caledonian when Langhorne Bond pulled the certificate of the DC-10 after the crash in Chicago, 25 May 1979. There's a lot of lip service paid to the Chicago Convention of 1944 with regard to reciprocal acceptance of certification, and obviously after 737 Max this scheme too will need a review. (At the time the Ten was grounded the real accident causal analysis was not yet known, but the court ruled the U.S. had acted in violation of law, based on what one could call "legal-paperwork-technicalities." Which are still operative....for now.)

WillowRun, fair points.

Had grandfathering not been available, then the conditions precedent would likely have been vastly different. The plane would not have need of the geometry that the MAX assumed, gear length would have been able to balance weight/cost of gear to development potential and optimised airframe configuration. That would have also permitted TBC to establish a fuselage section that permits LD loading which would permit the TBC product a cargo capability that it sorely misses out on in its 737 design. MCAS would not have been needed, however lord knows what else would come about out of a fresh design. Certification would be in the 10B+ range and that would add directly about 2M for 5000 airframes, and double that for the cost of finance for the sunk costs of development and certification. An aircraft such as the A330 was developed with relatively modern revisions of CS 25, and yet following a well thought out design (beauty in the eye of the beholder) and testing, the A330-300 ended up a hole in the ground doing a OEI GA on automation. Any design can have issues, old ones warmed over or new ones, and time exposes the strengths and weaknesses that are missed in the relatively exhaustive certification process.

A fresh start design has "unknown unknowns".

FAA delegation is not a scheme dreamt up by the FAA to circumvent the regulatory oversight, the FAA lags behind EASA in the establishment of DOA. Any delegation is dependent on the ethical standards of the delegate, and that is always going to be a point of contention; Chinese firewalls only work so well, as was exhibited by the investment banking communities. The issue of conflicting demands exists within a system that doesn't use delegation, where the regulator is responsible for both regulation development, certification and enforcement, as is being suggested, the back to the future scenario. In all cases, the certification of designs eats up talent, and that is scarce in all areas, with regulators disadvantaged usually to the commercial end of town in maintaining and developing talented people.

A continuing concern is the marginalisation of the quality processes, which are a stain on the industry. It is a specific part of the ODA/DOA system that the system is underpinned by effective QA, and there are examples abounding on systems disregarding and in fact silencing QA personnel going about their duties. As long as that is an accepted situation, there are dark clouds on the horizon. If an entity abuses the QA staff, or whistleblowers trying to get an urgent message to responsible managers or regulators, as long as they are treated the way they are, then any process is going to be inherently unbounded and heading towards badness.

Daily Telegraph (UK) carrying a report that “Staff emails claim that Boeing 777X shares Max problem”.

🙁

..

I found this report strained credulity and to be patronising in the extreme.

Part of a campaign to convince Americans Boeing and the FAA are trustworthy?

If you can’t make planes that foreigners can fly and operate safely, don’t sell planes to foreigners!

Special Committee Report
 

On first look, the report is reminiscent of a missive by Sir Humphrey, of "Yes, Minister". There is some careful wording that results in a generally favourable view, all is well in the realm... That doesn't appear to be consistent with the holes in the ground.

Page 35, a description of MCAS is included, which is the final problematic variant, not what was presented. It was a surprise to the test teams what it had been morphed into. That alters the complexion of effectiveness of the processes. That change occurring was a process failure for various reasons, what was expected to be certified was not what existed.

I would suggest that these paragraphs don't pass muster to the situation that occurred. If they are actually correct, then the aircraft certification was non compliant as the fault mode is not annunciated, 25.203 and 25.672 appear to remain problematic to the MCAS as built.

Blaming the crew for being the global outcome of their training programs and what is acceptable to ICAO, doesn't fix the shambles. There is hubris in assumption of superiority on recent history, stuff comes around and bites, liek driving a serviceable B763F into the bayou, dropping a 738 off piste into the local river, and the northern neighbours trying to snag the tail of 3 jets on the taxiway at KSFO, or dumping 40 toms of wide cut over the local school grounds. Europe has had it's days where there is scuffing of the shoe in the dust, like a 744 in the lagoon at Tahiti, various others parked off in the rough, and 447 highlighting the issue that there but for the grace of god go a whole bunch of operators. We appear to have an observer bias that is close to hubris. As I have said before, the very best pilot I have ever known was from Ethiopia. The best helicopter instructors were from Japan, the best applied CRM was from a Russian pilot ex Aeroflot.

The report is disappointing, and does a disservice to all, even TBC and the FAA, as well as the dearly departed.

The average pilot is exactly that, AVERAGE. They are not Yeagers or Armstrongs, or Eric Moody nor can they be reasonably expected to be. The internal emails that show how hard the OEM pushed to stop the operator from having specific training appears incongruous to complaints that foreign crew were inadequately trained... that sticks in the throat.

§ 25.203 Stall characteristics.


§ 25.672 Stability augmentation and automatic and power-operated systems.

From FDR
The average pilot is exactly that, AVERAGE. They are not Yeagers or Armstrongs, or Eric Moody nor can they be reasonably expected to be.

The internal emails that show how hard the OEM pushed to stop the operator from having specific training appears incongruous to complaints that foreign crew were inadequately trained... that sticks in the throat.

There is extensive discussion on Boeing's interaction with the investigation into the 737 accident at AMS in:- NYT: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

The conclusions in the 'suppressed' HF report are summarised, with a link to the report at:- https://www.pprune.org/10668326-post50.html

In addition, the final conclusion notes the following about design and training, and hazardous out of trim conditions; - relevant to the 737 Max.

Back in 1996, the FAA Human Factors team recommended the creation of interim certification policy guidance, which would fill the gap until design and training guidance material would be complete. It said:
"Specifically, the HF Team believes that the following areas should be addressed by interim guidance: Pilot/autopilot interactions that create hazardous out of trim conditions; Autopilots that can produce hazardous energy states and may attempt maneuvers that would not normally be expected by a pilot; and improved airplane flight manual wording regarding the capabilities and limitations of the autopilot.”

This is not the same as all pilots from Ethiopia being the best pilots in the world. Clearly Ethiopian management did not ever ascertain if their pilots could fluidly cope with the Lion Air scenario before putting passengers into the seats. Ethiopian CAA did not ascertain if Ethiopian Airline had done that check. The pilots of the accident craft did not memorize the steps even though the prior crash should have been fresh in their minds.

I believe the pilot who was there at the time, that Ethiopian was avoiding doing anything about that training. https://www.bloomberg.com/news/artic...-737-max-crash

It's not a matter that Ethiopian nationals are innately incapable, that's absurd; it's a matter that these pilots, their management, and their CAA were all unmotivated to cease 737 Max operations before understanding how to deal with MCAS. Except for Bernd Kai von Hoesslinm who apparently resigned rather than be associated with them.

See the thread here on that story for news that the Dutch Safety Board has now published the cited report.

https://www.pprune.org/rumours-news/...ot-buried.html

When I had interest in the matter, the training at ET was done by.... Alteon, who were a subsidiary of Boeing, and which was later renamed as... Boeing. Whether that is the case still is unknown.

Trainer on 737 and 747. I/we trained to select the attitude using the elevator, then trim the forces out. The 737 took a little practice as the electric trim is fast and powerful. You could always tell if someone was trying to fly using the STAB TRIM... the aircraft would poipoise all over the sky, enlisiting the shout of "stop doing that."

Yes so $1K just for the unit (sim only)for one hour, then the pilot needs to be paid as does his replacement and then the ancillary costs.

$2K seems way of the mark in most cases.

There really aren't two schools of thought there is only one.

Automate it.

There are people who may disagree with that approach, but that does not remove this is what is inevitably being pursued.

There used to be people who disagreed the earth being round. Folk even disputed gravity. That isn't a school of thought. It's just denial.

Whether or not automation is the ultimate outcome simply isn't in question. It is.

What is at challenge is whether the negative slope on training and experience is suitably aligned with the positive slope on the capabilities of automation.

Automation is not the complete answer, it's a system designed by fallible humans, this very thread is about the failed attempt to automate a system. There have been at least one accident cause by automation where the aircraft was written off (an A320 where the automation wouldn't permit the aircraft to flare for landing) and a number of incidents, without dredging up the reports notable events in Oz have been to a 777 and 330.

Turb 70, automate it,
As per megan, automation is not a complete answer; even if there is an 'answer' at all.
Increasing caution is required with single focus solutions, or extreme alternatives - black or white, man or machine.

Resolving situations like the Max has to consider the middle ground; the messy grey areas of uncertainty which humans dislike and tend to avoid. Depending on viewpoint, the Max issue was a breakdown of man and machine; good people, but asked to do more than their capability (design / pilots), good technology, in theory, but poorly implemented and certified. Consider the grey areas, man and machine together as one, the processes of design and certification, but don't expect a quick or easy way forward.

So far the FAA has kept their heads down and have escaped most of the criticism, but their responsibility and oversight of the certification was equally flawed as Boeing's contribution.

In the pursuit of increased safety, both parties have a role, but which one might might lead. FAA (with other world regulators) indicate acceptable means of man and machine implementation - how much credit to be given to the human. But regulations do not design aircraft.

Boeing could propose advanced man and machine concepts; learning from research, but requiring proof of concept for regulation, which involves 'educating' the FAA. Can, or what might the FAA learn.

With a well balanced man and machine concept, the human must be seen as an advantage, not as a hazard,

The approach integrating man and machine might not be that difficult to achieve, but the necessary functions within FAA and Boeing might be more difficult as both depend on world views of the their much dented capabilities. As much as the industry needs man and machine, they need FAA and Boeing.