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.

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

How do you incorrectly operate a system you don't know about?

[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

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

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?

Still laughing, not at you... well said. married life, and the will to live.

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.

5 MONTHS AFTER THE MCAS BULLETIN AND NOBODY REALLY UNDERSTOOD IT AT ET.

Better training might have been the answer, but many airlines chose not to do anything about it.

Good point.

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. 😳

[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.

Hi retired guy,

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.

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.

[QUOTE=568;10670031]
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 !

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 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.

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.

@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.

But that isn't right is it? It was the FAA who "followed suit" in grounding the airplane, after CAAC and EASA and others did so, and after FAA had just said that "Thus far, our review shows no systemic performance issues and provides no basis to order grounding the aircraft".

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.

The trigger for MCAS to resume is that a pilot made a trim input. Otherwise it was a one-shot. So it only restarted in response to manual input. And it moved continuously over that finite subset interval of time. It did not change speed or direction.

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.

So you agree that MCAS is not continuous, and therefore it is entirely reasonable not to characterise its operation as continuous/runaway, so not applying the runaway stabiliser QRH procedure is a reasonable (non) response?

The Runaway Stabiliser QRH characterises 'Runaway Stabiliser' as:

"Condition: Uncommanded stabilizer trim movement occurs continuously."

MCAS can be 'one-shot' or continual, interrupted by Stab Trim operations, and operating again if the MCAS trigger conditions still apply 5 seconds later. It is not, as you point out, continuous, which is enough to put doubt into the mind of a cognitively overloaded pilot whether the Runaway Stab QRH is appropriate.

It doesn't help that STS operates by executing uncommanded stabiliser movements, so pilots regard that as normal operations. Seeing and hearing the trim wheels move is normal flight deck background, which is part of the reason why MCAS was so insidious.

So, think back to that first takeoff you made in the -300. I assume you made AND trim inputs as you accelerated, because that would be normal. Likewise, I assume that the STS made ANU trim inputs, as it was designed to do, as the aircraft accelerated. And since those inputs were not manual, by you, nor were they made by the autopilot, because it was not engaged, you, that very first time the STS made a trim input, uncommanded by either you or the autopilot, did an IMMEDIATE RECALL action, and cut the stab trim switches to OFF. Please tell me that is so.

This fact has been ignored for too long.

737 pilots have been trained, by constant repetition, to ignore relatively short, uncommanded (by either the pilot or the autopilot) trim inputs.

Does STS require 60 pounds on the control wheel to maintain the desired pitch? I'm confused why you think that STS performance has anything to do with this. Some pilots have commented that they have to unwind some STS inputs via the trim switches; why would they not do the same for MCAS?

At what point should a pilot refuse to make trim inputs while pulling 60 pounds on the wheel when trim is available to them? After how many uncommanded adverse trim inputs should a pilot assume that the trim system has failed?

OTOH MCAS operated continuously long enough that when it was not offset the plane crashed. You would not close your eyes for a full 9 seconds driving on a crowded highway, so pick the amount of time the pilots should ignore an adverse trim increasing the control forces.

I have previously recommended that it change from trim blah-blah-blah to adverse trim forces, but I would have assumed that most pilots would know to trim the plane against high control loads. It turns out that it is a bad assumption and that training allows for pilots who try to overcome such forces with their own musculature.

As you want to be a language pedant you are welcome to it.

Lets see...lets say an average of three per takeoff, and I've done maybe 5000 takeoffs, and watched another 5000, I guess that would mean at least 30,000, in my case. YMMV

As for the wheel trim, the Ethiopian crew tried it, and stated that it didn't work. We still don't know why.

Could be because they let the speed build up so much by not reducing power.
Perhaps they pulled the levers back without disconnecting AT , took their hands off the TLs to pull back on the yoke, but thrust levers then moved back to TOGA because AT was still connected.
Just a theory.

Who is paying?

MechEngr
Thank you for the discussion, which I am sure will be of interest to others, even if we continue to cordially disagree.

I hope you have a good weekend.

This is drifting way off-topic. This thread is supposed to be about alleged whitewashing of Boeing's share of responsibility in the cited 2009 AMS crash.

Also, we're in the deja-vu-all-over-again realm where some folks simply insist that the MAX crashes were substantially due to pilot error. It's fine for those who want to believe that to do so, of course -- everyone is entitled to her or his own opinion. However, it should be recognized that virtually everyone and every entity responsible for aircraft certification, around the world, has agreed for nearly a year that the MAX, as it was introduced and initially flown, had engineering/design defects sufficiently serious to justify its grounding, for many months. And grounded is where it is now. The blame-the-pilots narrative has been overwhelmingly rejected.

That narrative is still in place from the manufacturer, hopeful operators, and most of their pilots. It has been rejected here, but I don't know if that counts for much.

It has been rejected by the world's CAAs (including, apparently reluctantly, by the FAA). That counts.

It does. The recent governmental panel shook my faith in that, unfortunately. I could see pressure, threats of economic downturn, loss of a major manufacturer, jobs, suppliers, etc. further eroding my faith in the regulatory bodies. I could also see a "fill the squares" sort of solution getting the plane back into service more quickly than a completely satisfying one. We'll see, I guess.

Sorry, I should have emphasized how many trim events added 30 pounds of pull for each one in quick succession on a single flight.

But if you feel STS is adverse and compromising your ability to control the plane, perhaps you should write that up.

You will note that I've started the blame for the pilot side with the airline, the relevant CAA, and finally with the pilots who rejected training for the Ethiopian crash. I just remain puzzled and saddened that in the case of Lion Air, one pilot repeatedly responded to adverse trim by eliminating the trim problem and keeping the plane on speed and altitude while the other pilot seems to have been transfixed with the idea that making the ever increasing amount of trim stop was sufficient. As if he didn't notice the trim position was changing and instead just wanted to keep the trim wheel from moving all while the control loads were going up.

As to whitewashing, that is a bad thing. OTOH airlines failing to perform due diligence is also a bad thing. They had access to all 737 accident reports and could certainly quiz the maker about their approach to avoiding similar accidents.

So why did the Dutch Safety board give in? They are independent of the FAA and the US NTSB and not obligated to Boeing. In no way does the NY Times article explain how the Dekker report got buried.

The human factors concept for alerting pilots or training them, in this case, is flawed. Had either system gone with dual sensors or some other scheme to prevent an adverse result there would have been zero benefit to a distracting alert of the pilots to the discrepancy and therefore no human factor to be considered. It's far better to avoid involving humans in performance decisions. This appears to be what Boeing's software changes did and there were no more RA failure related crashes. LIke MCAS, the manufacturer problem isn't failing to train or alert pilots, it's not recognizing the potential combination leading to a bad outcome.

Let's face it - there are human factors engineers at Boeing. Bunches of them. Yet not a peep from them complaining that MCAS ran on a single sensor and that pilots would certainly crash the plane if that sensor misreported. At least so far - maybe there are more emails, but my experience with human factors engineers is they are outspoken on all sorts of things.

What it really was was a failure of Systems Architects, a relatively new and somewhat toxic addition to engineering. This bunch of hand wavers sit between management and promises made to customers and the actual engineers and are responsible for creating the performance specifications for the hardware and software. Which is exactly where flawed software like MCAS gets born. The good SAs are great - Kelly Johnson of the Skunk Works was one. Anyone living in PowerPoint land? View with great skepticism.

The call, "It's like STS is working in reverse!" is a clue. They noticed it was an anomaly but that's the point, the knowledge it was wrong left them bewildered.

No I dont.

Perhaps I have an early onset of something but I have no memory of a STS on our very early -300s, which even had round instruments, and absolutely no memory of anything about it in the sim. Mach trim yes STS no. This worries me a little as the technicalities of my aircraft of all types were always of deep interest. No recall of ever seeing uncommanded trim movement, either.

Our - 300 “course”. Was very simple really just the FMS and autopilot operation, the rest we pretty much made up in the belief -300 airframe was pretty much as a - 200 with some tweaks.

My FO on my first -300 trip is coming on Friday, I will discuss his knowledge of the STS.

Just looked at my Boeing training notes. Runaway stab was practised on 7 sorties, manual trim operation alone on 2 and no discussion or even mention of the Yo Yo procedure, never heard of it on my time on the 73.

Intersting to see my ppl now shows my former types include all 737s up upto 900, never even sat in one !

No guarantee of accuracy, but see https://aviation.stackexchange.com/q...the-boeing-737

>Was the Speed Trim System implemented on the original Boeing 737 or just the Boeing 737 NG series?

Boeing's patent (US4676460A) for the STS was filed on 1984-11-28, the same day of the 737 Classic (3/4/500 series) entering service.

So since the addition of the bigger engines on the Classic, it's been there.

As a long-time systems guy, I certainly won't argue with that. In recent years, those slots have increasingly been filled by people who are better at impressing the suits than they are at real engineering -- and whose mission in life is to find easy jobs. But the good ones are invaluable.

There are, of course, HF people at Boeing, as there are at other aircraft manufacturers. There's a lot of evidence, however, that the products, in the end, often don't reflect the best current understanding of the discipline. If I design a system with the expectation that operators will act and react in particular ways, within some stated time frames, and that doesn't happen in the real world, it's not only the behavior of the operators that needs careful examination.

According to that answer on Stack Exchange, speed trim on the 737-300s without EFIS is different, it doesn't operate when the flaps are up.

Hi Retired BA/BY
I see some folk mixing you up with me Retired Guy.
Your posts are so coherent I don’t mind at all. As long as you don’t! I flew -300 and -400
and recently-800 and don’t remember speed trim being obvious in early days. Maybe during flap retraction. On -800
more active but because of my training whenever the trim wheel ran unexpectedly you would cop it straight away. Why is it doing that? Always on the alert. Think that’s been lost somewhere
cheers
R Guy.