MAX takes to the skies again

[Gabriel]

Lay off the acronyms, Evan. Spewing obscure acronyms is similar to claiming credentials.

Boeing was known as “the plane where the pilot had ultimate authority”.

Pilots used to have to know the brake lining thickness...so maybe knowing that the new engines cause more pitch up and that there’s an automatic pitcher-downer system isn’t too much to ask...

You can’t compare that to knowing the computer code.

We have OFTEN seen pilots list nuances that are much more insidious than an automatic trimmer-downer...

DC-9 pilots had to learn that pulling a cabin pressure CB at the wrong time also popped the ground spoilers. That pilot was chastised for not knowing “how things work”.

Again, a system that applies nose-down trim when you get slow MIGHT be worth knowing about...Not the code, but that such a system exists.

That system was not mentioned in the manuals, nor the light-duty type-specific computer training module.

I am not necessarily defending leaving the Maneuver Characteristics Augmentation System out of the books. I am seriously questioning whether it would have made any difference.

It didn't make a difference for the 1st LionAir crew that successfully handled the situation following the "normal" trim runaway procedure despite the system not being known.

And it didn't make a difference either for the Ethiopian crew that crashed the plane after the system, its vulnerabilities and how to deal with its failures had been disseminated all over the place in Tele Vision, newspapers, internet fora, a preliminary accident report, a Boeing service bulletin and a Federal Aviation Agency's Emergency Airworthiness Directive (there, no acronyms).

DC-9 pilots had to learn that pulling a cabin pressure CB at the wrong time also popped the ground spoilers.

The Direct Current 9 pilots took off, the airplane stayed in ground mode (due to the nose struts not extending completely) so the airplane would not pressurize, so they pulled the ground mode CumulonimBus and the plane changed to "air" mode, which permitted pressurization. Shortly before landing they connected the CumulonimBus again and the plane went of course to ground mode again, so the plane said "touchdown" and extended the spoilers that had been armed by te crew to extend at touchdown.

The spoilers system and the air-ground mode system where described in the manual and it was deductible from the explanation in the manual that this would happen. Add they still did it.

Which kinda proves my point.

[3WE]

Which kinda proves my point.

40 years, it’s in the manual and DC-9s operate without issues, until someone deviates from procedure (Yes, Evan, it’s me) and prangs some lights and makes an excellent landing.

Less than 40 months and TWO crews can’t figure out that the new dive-causing augmentation system, THAT ISN’T IN THE BOOK, is diving the plane.

Now, it’s in the book, and I’m guessing 99.9% of 737-MinLav pilots understand it inside out and upside down.

Kind of proves your point badly.

Don’t forget that my point here is systems that make control surfaces do very big things (Not_every line of code)...I’d like ATLCrew to understand them the way he understands them...and everyone else, too.

[Evan]

Seriously? You mean that the Ethiopian crew didn't know what was happening? If they didn't, shame on them! If they did(and still lost it), shame on them!

Seriously? Shame? They're all dead Gabriel. They're dead because they fell into a trap that requires flawless pilot responses under bewildering circumstances to survive. Pilots, all of them, are prone to misjudgment and error but they become even more so when high workload and time compression bring human factors into play. They messed it up, certainly. But we have to anticipate that when we are developing our aircraft, because it absolutely will occur, even to the so-called best pilots. That remains a hard pill for many so-called best pilots to swallow. Fortunately, it isn't a hard one for investigators, engineers and certification authorities to swallow.

Or, as you put it:

I would argue that that is the correct approach in aviation. You asume that systems will fail, that things will go wrong, that pilots will make mistakes, and work out a system that is as robust as possible around that.

Or, as you put it:

Boeing relied on the trim runaway procedure for the pilots to handle these MCAS malfunctions, but the trim runaway procedure didn't factor the distractions caused by a false stickshaker, airspeed disagree, altitude disagree, and NOT having an AoA disagree indication that would explain all that (all of which are NOT factors in the "traditional" trim runaway), plus it described the trim runaway condition as "uncommanded stabilizer trim movement occurs continuously", which is not what happens in this MCAS failure (was now updated to "... or in a manner not consistent with the flight condition). And also it had "downgraded" (in 1982) the FCOM in the explanation of how the trim wheel can become too hard to move by hand and how to resolve it, which the Ethiopian crew could have used to try to trim the plane when they finally (way too late) attempted to use the manual wheel but it was stuck:

Shame on the dead pilots for not aceing that in real life on their first attempt in a compressed, misleading, panic-prone scenario? You might want to walk that back a bit.

[Evan]

Here's a tragic story of one of the best pilots, an EL AL captain, 59, 25,000 hours including combat flying. Did he know how to fly? Damned right he did.

Similar story to that of Captain Olsen's: 1992, Schippol, 747 freighter, a fuse pin failure resulted in a #3 pylon failure. The engine broke away to the right ripping the #4 engine away as well. It also took out 33 feet of leading edge, a portion of the right wing and knocked out all hydraulics. Flying at 260kts, there was still enough lift generated by the damaged right wing to control the roll tendency. The FE restored some hydraulics and the crew requested a return to Schippol. But the pilot, one of the best, was unaware that the engines had departed or that the wing had suffered structural damage. He was aware that some flaps were inop and increased thrust on the remaining engines to reduce sink rate. The combination of increased thrust and slat assymetry at a higher pitch angle resulting from less flaps made the roll very hard to control. Slowing to approach speed was the nail in the coffin, as the right wing could no longer generate the lift needed to overcome the assymetry. The airplane rolled over into a dive, impacting a high-rise apartment complex and killing a number of people on the ground. The investigation concluded that a survivable landing in this condition was nearly impossible. Attempting one over a populated area in that condition was unthinkable. Shame on the pilot? No, despite all of his years of flying, he was unaware of the condition that day. He did what any good pilot would do, and ended up killing a score of people as a result.

My point? Crack airmanship is not some sort of immunity from bad situational awareness. Whereas bad situational awareness can overcome the best airmanship.

[ATLcrew]

Here's a tragic story of one of the best pilots, an EL AL captain, 59, 25,000 hours including combat flying. Did he know how to fly? Damned right he did.

Similar story to that of Captain Olsen's: 1992, Schippol, 747 freighter, a fuse pin failure resulted in a #3 pylon failure. The engine broke away to the right ripping the #4 engine away as well. It also took out 33 feet of leading edge, a portion of the right wing and knocked out all hydraulics. Flying at 260kts, there was still enough lift generated by the damaged right wing to control the roll tendency. The FE restored some hydraulics and the crew requested a return to Schippol. But the pilot, one of the best, was unaware that the engines had departed or that the wing had suffered structural damage. He was aware that some flaps were inop and increased thrust on the remaining engines to reduce sink rate. The combination of increased thrust and slat assymetry at a higher pitch angle resulting from less flaps made the roll very hard to control. Slowing to approach speed was the nail in the coffin, as the right wing could no longer generate the lift needed to overcome the assymetry. The airplane rolled over into a dive, impacting a high-rise apartment complex and killing a number of people on the ground. The investigation concluded that a survivable landing in this condition was nearly impossible. Attempting one over a populated area in that condition was unthinkable. Shame on the pilot? No, despite all of his years of flying, he was unaware of the condition that day. He did what any good pilot would do, and ended up killing a score of people as a result.

My point? Crack airmanship is not some sort of immunity from bad situational awareness. Whereas bad situational awareness can overcome the best airmanship.

I don't think that's the best example of "bad situational awareness". That crew did the best they could with the information they had.

[Gabriel]

Seriously? Shame? They're all dead Gabriel. They're dead because they fell into a trap that requires flawless pilot responses under bewildering circumstances to survive. Pilots, all of them, are prone to misjudgment and error but they become even more so when high workload and time compression bring human factors into play. They messed it up, certainly. But we have to anticipate that when we are developing our aircraft, because it absolutely will occur, even to the so-called best pilots. That remains a hard pill for many so-called best pilots to swallow. Fortunately, it isn't a hard one for investigators, engineers and certification authorities to swallow.

Shame on the dead pilots for not aceing that in real life on their first attempt in a compressed, misleading, panic-prone scenario? You might want to walk that back a bit.

Evan, come on. They were 737 MAX pilots. The first 737 MAX crash had happened a few months ago.

A crew took, a false stickshaker activated immediately. Upon flap retraction, they started getting nose-down inputs. But these pilots don't crash. The pilots disconnect the electric trim and use the manual trim wheel and continue fly to their destination.

The next day, another crew in the same plane experiments exactly the same thing. False stickshaker immediately after liftoff. Uncommented nose-down trim inputs immediately after flaps retraction. The pilot reacts to each uncommanded nose-down trim input with nose-up trim thumb switch which has the effect of: a) immediately interrupting the nose-down uncommanded input, b) command nose-up trim and c) avoid further uncommanded nose-down trim inputs for the next 5 seconds after releasing the thumb switch. The crew manages to keep the plane more or less in trim doing this TWENTY THREE TIMES over the next couple of minutes. Until, for some obscure and ununuderstandable reasons, they stop doing that. The uncommanded nose-down trim inputs continue but now the pilots either don't react to them, or react to them with late and much shorter manual trim inputs. The airplane becomes increasingly nose-down out-of-trim (why on Earth a pilot would not react to that with nose-up trim always baffled me, that doesn't require situational awareness, it is instinctive for a pilot to try to remove excessive control column with trim) until the point where they just cannot hold it anymore and they go into an uncontrollable dive.

Shortly thereafter, the MCAS comes to light and gets heavy exposure in the specialized and not-specialized media. Boeing issues a service bulletin and the FAA makes it a EAD. While the MCAS is not mentioned by its name, it is explained. We learn that it inhibited on AP or with flaps not fully up, that it works on a single-AOA sensor, that it will add nose-down trim inputs in increments of 10 seconds separated by 5 seconds of "silence", that using the thumb switch will override it and keep it off for 5 seconds, that this system can be killed by killing the electric trim with the cutout switches, that if the plane became quite out-of-trim the thumb switch can be used to completely trim out the plane before killing the electric trim, that the trim wheel can and should be manually used to trim the plane after killing the electric trim.

You knew all that before the Ethipioan crash. I knew all that before the Ethiopian crash.
Did the Ethiopian pilots knew all that before the Ethiopian crash?

If they didn't know it, YES, SHAME ON THEM!!!! And I cannot believe that you disagree with that. I am sure that you, as a passenger, expect your pilot to be aware arond the circumstances of the latest crash of the type he flies, what caused it and how it could have been prevented from the pilot perspective. If you don't expect that, SHAME ON YOU TOO.

If they did know it, it kind of proves my point that having the MCAS fully disclosed and explained in the manuals from the get go would have not necessarily help prevent these crashes. The first LionAir crew didn't need need that information to save the plane (and complete the flight to their destination). The availability and widespread of this information didn't prevent the Etiopian crash.

Now, please, please PLEAASE understand this:
That I say "shame on [the Ethiopian pilots]" (if they didn't know all that you and I knew about the MCAS) doesn't mean that I don't blame the Ethipian for not properly training their pilots, Boeing for the incredibly crappy and dangerous design of the MCAS, and both Boeing and the FAA for how they managed the certification process and for the eroded culture that they had been driving for the last decades.

It is not one-or-the-other. It is all of them.

I do understand and agree that the systems in a plane must be designed to avoid confusion and excessive workload and must be robust to some degree (and not minor) of pilot mistake and loss of awareness. The MCAS clearly did not meet that and it was more than a minor contributor in both accidents.

Now, that a system is designed to be robust to sub-par performance, when sub-par pilot performance occurs it is still sup-par pilot performance and needs to be called out because it needs to be addresses TOO (not exclusively) to make the system at great safer.

Both crews could have saved the day without resorting to a lot of creativity or a deep understanding of the MCAS (pretty much like the first LionAir crew did, which would be ridiculous to compare to the El-Al accident in Amsterdam).

For the LionAir crew... The plane keeps trimming down? Keep trimming up in response (as you did 23 times and for more than 2 minutes) At some point it would be nice to think that this is a strange version of intermittent trim runaway and apply the trim runaway procedure (which includes memory items that the pilots should know and apply before resorting to the QRH).

For the Ethiopian crew.... You know or should know all that you need to know about the MCAS. They seem to have correctly identified the situation as a MCAS case (given the information already available and the fact that they had the stickshaker on one side immediately after liftoff and that the MCAS starting actuating immediately retracting the flaps, EXACTLY as in the previous 2 LionAIr MCAS incident & accident) or AT LEAST as a trim runaway, since after the 2nd MCAS activation they used the cutout switches to kill the electric trim (and the MCAS with it). Unfortunately the plane was quite out of trim by then and they did not se the thumb switch to trim it out before killing the electric switch. But no big deal, you just killed the electric trim, I hope you understand that the thumb switch will not work anymore, right? The plane is out of trim, what will you do? Use the manual wheel of course, it is not only part of the trim runaway procedure and in the Boeing SB and FAA's EAD, but is totally reasonable and what, I don't know, Cessna pilots do. But no, let's better keep talking with the ATC asking them for latitude clearances, headings, thinking of navigation, waypoints, etc... They totally reversed the "aviate-navigate-communicate". They were overloaded and understandably forgot the throttles in the take-off setting. A little bit less understandably they didn't detect that the speed (disagreeing or not) was going off the charts, or if they detected it they didn't react to it (I mean, one of the pilots should be FLYING the plane, no?) And they didn't even detect / react to it when the overspeed warning activates. At some point, with the force required and the pilot fatigue both increasing, the situation starts to become desperate. So finally it occurs to the FO that it may be a good idea to try to use the trim wheel, which by then is stuck due to the aerodynamic forces caused by the significant out-of-trim condition, big pull-up force in the elevator, and overspeed. Yet (and yes, this part is in hindsight), they still had a few options to save the day. One was to make a last effort to pull together, point the nose significantly more up, and in this way reduce the airspeed which in tour would have reduced the pull up force and the force needed on the wheel. The second one would have been the roller coaster maneuver: let go a bit on the elevator and let the nose go down to reduce the aerodynamic forces and be able to turn the wheel (almost nobody knew about this technique that had been off the manuals since about 1982). A third option was to re-engage the electric trim, trim the plane with the thumb switch and then, when the plane back in trim, kill the electric trim again and keep using the trim wheel afterwards. They seem to go this route because they reconnect the electric trim and use the manual thumb switch to trim up, twice, split second clicks that barely move the stabilizer at all. And then they stop. 5 seconds later, as expected, the MCAS kicks in again, this time for the last time since the plane crashes seconds later in an uncontrollable dive.

Controlling these situations did require something more from the pilots than normal operation,
BUT IT DID NOT REQUIRE FLAWLELSS ACE PERFORMANCE. It should have been within the realm of an "average +/- a couple sigmas" crew to control this, even with the crappy horrible, irresponsible, criminal design of the MCAS and the equally horrible certification process. In particular, it did not require the level of awareness and creativity that would have been needed to save the El-Al at Amsterdam, or that was required to save the United DC-10 at Sioux Citi.

Both crews were sub-par. The Ethiopian one in particular because they already had all the hindsight of the first 2 LionAir MCAS cases and the SB and EAD and all the talks that were going around this subject in the industry.

And no, that doesn't make the original MCAS design any better.
But as you expect more robustness to human factors in the design on the system, and I fully agree with that (there is a reason why you respond to me by quoting myself) and saying "Or as you put it"), I also expect some level robustness in pilot performance so 100% of the awareness doesn't go overboard at the first occurrence of a known, well documented, controllable, and well procedurized abnormal situation. That is what things training, procedures, CRM, division of tasks, and concepts like "FLY THE PLANE FIRST" are there for.

IT IS NOT ONE THING OR THE OTHER. IT IS BOTH (at least until we have automated planes that do not rely on human performance to manage abnormal situations).

Pilot performance like this one, or AF 447, or Colgan, should be trained or screened out of the system. Or at least (because you are not going to ever eliminate it), call it off when it happens to see what can be improved on the human side of the business instead of defending such subpar performance and understandable and almost acceptable.

[Evan]

I don't think that's the best example of "bad situational awareness". That crew did the best they could with the information they had.

No. I agree. It isn't and they did. But they were not aware of the situation beyond the loss of power. I chose it because it is an analogue to Captain Olsen's story of pylon failure and exceptional pilot skill. Again, my point is... well, read the last sentence again.

[Evan]

If they didn't know it, YES, SHAME ON THEM!!!! And I cannot believe that you disagree with that. I am sure that you, as a passenger, expect your pilot to be aware arond the circumstances of the latest crash of the type he flies, what caused it and how it could have been prevented from the pilot perspective. If you don't expect that, SHAME ON YOU TOO.

Well, shame on me then because I don't. I hope. I don't expect. I try to fly on airlines where there is a good reason to hope. If I had to fly on Lion Air, I might even pray. There is a great and growing demand for pilots out there (2020 aside) and some of them are going to be marginal under stress. Ask anyone who ever led an army.

(why on Earth a pilot would not react to that with nose-up trim always baffled me, that doesn't require situational awareness, it is instinctive for a pilot to try to remove excessive control column with trim)

Is it not instinctive for pilots to reduce take off thrust after leveling off? Yet they didn't. Is it not instinctive for pilots to avoid overspeed, yet they didn't. Everything they did indicates mental confusion, task overload, inability to focus, panic.

Is it not instinctive for pilots to fly by instruments in IMC? Yet, they sometimes don't. They sometimes defer t their senses and fly into the ground or the sea. Why do we have GPWS callouts with suggestions like TOO LOW GEAR. Is it not instinctive for pilots to put the gear down before landing? And yet...

You have always resisted one dark reality that contributes to plane crashes: the human mind is not always reliable. It is fallible. It can be treacherous under certain circumstances. I think most pilots probably resist this reality. Accepting it would make the job a lot less comfortable. But that is the reality. The defense is everything we do to prevent confusion and disorientation in the cockpit. Some of that is through design and, to the greatest practical extent, no design can ever cause pilot confusion or disorientation. That bold clause is the 'law' that MCAS broke.

I am aware that you agree with that.

But shame should be reserved for pilots who do intentionally risky things, like monkey with circuit breakers, improvise procedures or skip procedures or fly into red returns or proceed with unstabilized approaches. Shame on the lot of them. But you can't seriously place shame on pilots who simply failed to contend with confusion and disorientation. Low marks, if you must, but if I say "there but for the grace of god goes Gabriel", how do you know, until it happens, that that isn't true?

A dose of humility is essential to getting safety to where it is today. Apparently. a second dose is still needed.

[Gabriel]

Less than 40 months and TWO crews can't figure out that the new dive-causing augmentation system, THAT ISN'T IN THE BOOK, is diving the plane.

Now, it's in the book, and I'm guessing 99.9% of 737-MinLav pilots understand it inside out and upside down.

Incorrect. It was ONE crew that couldn't figure it out when it wasn't in the book.

One other crew could figure it out even when it wasn't in the book
And one other crew couldn't figure it out even when it was already in the book (and 99.9% of the MAX pilots should have known it inside out).

So the correlation between being / not being in the books and the crew figuring / not figuring it out is quite inexistent.

[Gabriel]

Well, shame on me then because I don't. I hope. I don't expect.

Semantics

Is it not instinctive for pilots to reduce take off thrust after leveling off?

No, it is not. Instinctive is something you do automatically without thinking. That is what you do with the trim in manual flight. That is not what you do with the thrust reduction after take-off.

Is it not instinctive for pilots to avoid overspeed?

Again, no, for the same reasons as above.

Everything they did indicates mental confusion, task overload, inability to focus, panic.

I agree. Surely being concerned for getting clearance before busting altitudes, getting heading vectors, and talking about standard departures with ATC instead on focusing on flying the plane didn't help to focus on flying the plane.

Is it not instinctive for pilots to fly by instruments in IMC?

No, it isn't it takes quite a bit of intelectual effort and focus to hand-fly in IMC. That is almost the opposite to an instinct.

Why do we have GPWS callouts with suggestions like TOO LOW GEAR. Is it not instinctive for pilots to put the gear down before landing?

No, it is not. Or maybe it is, borderline. It would be instinctive if when you do the landing checklist you found the landing gear down without remembering having lowered it, which may happen. But I would say that, in general, lowering the landing gear is a conscious decision that you take and execute at a certain point during the approach.

You have always resisted one dark reality that contributes to plane crashes: the human mind is not always reliable. It is fallible.

No, I have never resisted that. Human factors have always been very present in my mind and I am fully aware that there is a correlation between the strong improvement in aviation safety and the time where we stopped putting "pilot error" as a probable cause in accident reports.

But while "pilot error" is not an acceptable cause of accident, pilot hiring practices, pilot training practices (pre- and during- airline job), pilot performance monitoring (like FOQA) company culture, and, why not, pilot material (which includes reaction under pressure, self-discipline, an attitude of interest and commitment, and just raw coordination between brain function and motor skills) CAN be valid root causes. And this is a part were, in my opinion, the industry needs to focus more.

(And yet, regardless, the manufacturers need to keep designing systems that are more and more robust to shortcomings in those departments, because we know that no matter how good the industry is there in the human factors it will never be perfect, bad apples will slip through the gaps from time to time and god apples will have very bad days from time to time too).

The defense is everything we do to prevent confusion and disorientation in the cockpit. Some of that is through design and, to the greatest practical extent, no design can ever cause pilot confusion or disorientation. That bold clause is the 'law' that MCAS broke.

I agree, especially not after a single point of failure that can be cause for something as a bird strike.
That said, you will never get rid of situations that can cause pilot confusion either. That's why the industry has to work on both ends of the story.

But shame should be reserved for pilots who do intentionally risky things. [...] You can't seriously place shame on pilots who simply failed to contend with confusion and disorientation.

And I don't. Read again:

You knew all that before the Ethiopian crash. I knew all that before the Ethiopian crash.
Did the Ethiopian pilots knew all that before the Ethiopian crash?

If they didn't know it, YES, SHAME ON THEM!!!!

Do you REALLY disagree with that?

[Evan]

The defense is everything we do to prevent confusion and disorientation in the cockpit. Some of that is through design and, to the greatest practical extent, no design can ever cause pilot confusion or disorientation. That bold clause is the 'law' that MCAS broke.

I agree, especially not after a single point of failure that can be cause for something as a bird strike.
That said, you will never get rid of situations that can cause pilot confusion either. That's why the industry has to work on both ends of the story.

We are in agreement on this, which is the essence of the MCAS debacle.

You knew all that before the Ethiopian crash. I knew all that before the Ethiopian crash.
Did the Ethiopian pilots knew all that before the Ethiopian crash?

If they didn't know it, YES, SHAME ON THEM!!!!

Do you REALLY disagree with that?

I would if it were true, although I would direct the shame more to the operator and the aviation authority. But their actions indicate awareness, and that shifts the shame to another place.

Boeing and the FAA failed to ground the 737MAX based on the conceit that a procedural instruction could suffice in dealing with the threat of a design that can cause pilot confusion or disorientation.

You knew about human factors before the Ethiopian crash. I knew about human factors before the Ethiopian crash. Both Boeing and the FAA were well aware of human factors before the Ethiopian crash.

SHAME ON BOEING AND THE FAA! For me, that's where it begins and ends.

[Gabriel]

I would if it were true, although I would direct the shame more to the operator and the aviation authority. But their actions indicate awareness, and that shifts the shame to another place.

Well, this is the first time I used the word "shame" in this thread

Either of the fatal crash crews would have avoided upset if they had known what was happening and why.

Seriously? You mean that the Ethiopian crew didn't know what was happening? If they didn't, shame on them!

So you think that they knew or that they didn't? You seem a little bit contradictory.
We will never know what they knew. We know that Ethiopian limited their training on the subject to distributing the SB/EAS among pilots. Yes, shame on them.
And there was more to be known. Things that you and me knew.
A pilot worth their epaulette should have enough interest and curiosity as to research a fatal crash that just happened in the type of plane he is flying.
Again, that doesn't remove an inch of responsibility on the airline, Boeing and the FAA for their actions.
Responsibility (accountability), unlike liability, is one of the few things that you have any less when you share it.

My initial post was about how there were many opportunities that could and should ave stopped the Ethiopian accident to happen.
And the Ethiopian pilots were ONE of them.
Remember, it is VERY EASY to train someone to take-off, turn the autopilot climbing through 400ft and turn it off descending through 400ft and land.
The real value of the pilot is not for what they do when all is on but for what they do when things go wrong. If we are not training the pilots to handle the situation when things go wrong, we are not training pilots, we are training airplane drivers. (the same could be said about the flight attendants). And the MCAS situation was not so difficult to handle, especially it should have not been for the Ethiopian crew who knew everything that there was to know about the MCAS, this failure and how to handle it. (or should have known, shame on them if not). It was not like the DC-10 at Sioux City where a lot of creativity was required or even like Sully's US Air where some tough decisions had to be made ("Should we try to reach an airport or we go for the river?").

The rest of my posts revolved on where having the MCAS in the manual would have made a difference. Well, for Ethiopian, having the info available didn't make a difference. And also not having it available made a difference for the 1st LionAir incident. That means that out of 3 MCAS known MCAS pernicious activations, we know that it didn't make the difference in 2, and we don't know if it would have made any difference in one.

You knew about human factors before the Ethiopian crash. I knew about human factors before the Ethiopian crash. Both Boeing and the FAA were well aware of human factors before the Ethiopian crash.

SHAME ON BOEING AND THE FAA!

Yes. It is not one thing or the other. It is both (or all of them).

For me, that's where it begins and ends.

Oh, so it's not all of them?
Pilots, don't read about recent accidents in your type.
Airlines, don't train the pilots on the failures that happened in a recent crash on the same type you operate, how it happens, and how to manage it to a safe outcome.
It's all on Boeing and the FAA. You just trust that you will never face a situation that might be confusing.

[Evan]

So you think that they knew or that they didn't? You seem a little bit contradictory.

You know it's not the black and white. They probably had read the Boeing notice. I think they certainly knew about the Lion Air crash and that MCAS posed a threat. I think they knew that the SOP was to cut out the electric pitch trim, which they did. I think they knew about that much.

But I don't think they knew entirely what was happening and I don't think Boeing or the FAA (or you) should have expected them to. Again, the human mind, human factors, task overload, time compression. That is what I meant when I said 'not knowing what was happening and why'. Example: Can't move the pitch trim wheel. Why? Too much airload, too much airspeed, too much thrust. If they had known why, they would have reduced thrust, but that axis had been pushed out of mind by the human factors I am speaking of (also, it's counterintuitive to reduce thrust when the thing is pitching down against your will).

Pilots, don't read about recent accidents in your type.
Airlines, don't train the pilots on the failures that happened in a recent crash on the same type you operate, how it happens, and how to manage it to a safe outcome.
It's all on Boeing and the FAA. You just trust that you will never face a situation that might be confusing.

It begins with Boeing not designing and the FAA not certifying a system that, after a single point failure to an externally mounted sensor can cause confusion and disorientation in the cockpit.
It proceeds to Boeing and the FAA not grounding an aircraft with a system that, after a single point failure to an externally mounted sensor can cause confusion and disorientation in the cockpit.
And it ends there. If it doesn't get certified, or if it gets grounded and redesigned, the rest is unnecessary.

Look, the procedure to deal with this couldn't be simpler: 1) Restore flight path and retrim 2) Reduce thrust (if necessary to reduce airspeed below flap extension speed) 3) Extend flaps.

In most cases, step two isn't even needed.

This isn't about how simple it would have been to deal with an MCAS failure with a fully intact headspace. It's about human factors. Period.

[Gabriel]

It begins with Boeing not designing and the FAA not certifying a system that, after a single point failure to an externally mounted sensor can cause confusion and disorientation in the cockpit.
It proceeds to Boeing and the FAA not grounding an aircraft with a system that, after a single point failure to an externally mounted sensor can cause confusion and disorientation in the cockpit.
And it ends there. If it doesn't get certified, or if it gets grounded and redesigned, the rest is unnecessary.

There I strongly disagree.
Yes, A should have happened B should have happened, but then B, C and D (which would save the day if A and B didn't) are unnecessary?
That's not how aviation safety became so good.
Yes, it is good to cut the sequence of events that lead to a crash as soon as possible, in the first slices of swiss cheese. But having it escape the first layers and stopping it at another slice down the line is still much better than crashing.
Take AF447 for example.
Human factors do exist but they can and must be addressed too. That's why we have (or should have) FOQA, division of work/tasks, cross-checking, communication protocols between pilots, CRM, and training, training, training. They will never be perfect, but at the same time we cannot accept anything less than perfect, which means that we always need to work on improving them. If Ethiopian and the aviation industry at great don't take a lesson on human factors from the Ethiopian crash (and the LionAir too), shame on them!

That is what I meant when I said 'not knowing what was happening and why'. Example: Can't move the pitch trim wheel. Why? Too much airload, too much airspeed, too much thrust. If they had known why, they would have reduced thrust, but that axis had been pushed out of mind by the human factors I am speaking of.

Side comment to address this...
Yes, I agree. I don't think that they knew (or than many pilots would have known) why the trim wheel was stuck. That was not part of the LionAIr discussion at great, and it was not mentioned in the Boeing SB / FAA's EAD. The closest was this:

Initially, higher control forces may be needed to overcome by stabilizer nose down trim already applied. Electric stabilizer trim can be used to neutralize the control column forces before moving the STAB TRIM CUTOUT switches to CUTOUT. Manual stabilizer trim can be used before and after the STAB TRIM CUTOUT SWITCHES are moved to CUTOUT.

The 737 QRH for trim runaway didn't say anything about a stuck wheel wither. The 737 FCTM said only this:

Manual Stabilizer Trim
If manual stabilizer trim is necessary, ensure both stabilizer trim cutout switches are in CUTOUT prior to extending the manual trim wheel handles.
Excessive airloads on the stabilizer may require effort by both pilots to correct the mis-trim. In extreme cases it may be necessary to aerodynamically relieve the airloads to allow manual trimming. Accelerate or decelerate towards the in-trim speed while attempting to trim manually.

Which if you ask me is absolutely insufficient and worse, can be counterproductive. When the plane is trimmed to much nose-down but still for an AoA that would still generate 1G at a speed below overspeed, that would work. Now, if the plane is trimmed for an AoA that would not generate enough lift even at overspeed speeds, or even worse, trimmed for negative Gs, that would not work and you would have to use the roller coaster maneuver. I mean... accelerate towards the in-trim speed? How much more could have this crew accelerated? This required the old-fashioned roller coaster maneuver that disappeared from the FCTM at around 1982.

In addition, a stuck trim wheel was not involved (or mentioned) in the previous 2 LionAir events.

So for this part of the sequence of events, I think that these pilots were not, and many other pilots would not have been, equipped to deal with the situation, and we could not expect that they would have been from the information available to them and to the airlines.

And yet, at that point the crew had a moment of brilliancy that could (and should) have saved the day: They reconnected the electric trim. The trim runaway procedure doesn't have any provisions to reconnect the electric trim and, while it also says "do not re-engage the electric" (as it does say it for the autopilot in the same procedure), may consider that was a violation to the procedure.

I say screw that. Pilots have the authority to deviate from any procedure if they judge it necessary for the safety of the flight.
They were fighting increasing column loads to keep the nose from going down, they were getting physically exhausted, they were losing the battle against the control column and, while raising the nose even further (pulling together form the yokes) to slow down would have helped, that was not established anywhere or trained for and it just didn't occur to them. What were supposed to do? Say "ok, we lost" and stop fighting?

Nobody knows what they thought, who did it, and how aware the other one was. But the only reason I can think of for one of them to reconnect the electric trim is to be able to operate the electric trim with the thumb switch (given that they could not move the wheel manually). And yet, when they reconnected the electric trim, they did not operate the thumb switch except for 2 very brief clicks that barely moved the stabilizer at all, and then, 5 seconds after the last click, the MCAS kicked in for the last time (as they should have known it would).

We will never know and I will never understand why they did that, why they reconnected the electric trim only not to use it and leave it available for the MCAS. They were so close to save the day. It just required pressing a button, literally.

[Evan]

There I strongly disagree.
Yes, A should have happened B should have happened, but then B, C and D (which would save the day if A and B didn't) are unnecessary?
That's not how aviation safety became so good.

Ok, hold on, this is not how aviation safety got so good. First there is design and certification. Then there is operational safety. Both need their own dedicated layers of defense. The pilots cannot be considered the third line of defense for design and certification safety unless they are test pilots. Oh... right... there were test pilots who raised concerns... Didn't prevent two fatal outcomes, did it...

When the crew boards a revenue flight, they need to be boarding an aircraft that has already been made (and proven) safe by multiple layers of defense.

The comes the first line of operational defense: Familiarize pilots with the aircraft in its entirety and train them on how to deal with every system failure.

And yet, when they reconnected the electric trim, they did not operate the thumb switch except for 2 very brief clicks that barely moved the stabilizer at all, and then, 5 seconds after the last click, the MCAS kicked in for the last time (as they should have known it would).

And there you have it Gabriel: the breaking point in human cognitive performance. Probably due to a great deal of panic, frustration and bewilderment.

It's a place where investigators scratch their heads and write down 'human factors'. That is the place pilots must never arrive at.