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Lion Air 737-Max missing, presumed down in the sea near CGK (Jakarta)

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  • Originally posted by Gabriel View Post
    It did when the procedure was sort of applied in the Lion Air flight previous to the accident.
    For the 2 accident flights, no, it didn't.
    Therefore, the trim runaway procedure is not an effective form of redundancy for MCAS in the real world.

    Originally posted by Gabriel View Post
    And the reason why the procedure didn't work is that was either not applied at all or not applied correctly. And the reason why it was not applied correctly, well, in Lion Air they were clueless. The trim runaway is one of the few abnormal procedures that has memory items but instead of applying them they spent several minutes trying to find the correct procedure in the QRH. For Ethiopian it is less clear. Human factors of course played a role, and a big one, in both of them. Now, a properly trained and disciplined crew has a better chance to apply the procedure correctly.

    For these accidents to happen you need 3 ingredients:
    - The horrible and unacceptable MCAS design, testing and certification (blame on Boeing and the FAA).
    - The failure of the AoA sensor (For Lion Air, blame on the company in California that sold the spare AoA sensor who has just lost its FAA certificate, Lion Air maintenance, and the crew of the previous flight. For Ethiopian it is less clear but the sensor was working ok until it failed during rotation.)
    - The failure of the crew to apply the trim runaway procedure correctly (Airlines and application authority, and Boeing again for the human factors introduced by this failure mode)

    Remove ANY of these, and the accidents would have not existed.
    You left out some ingredients:
    • An aircraft manufacturer focused on short term stock performance and market capitalization in a 'casino' climate of chaos capitalism.
    • An inevitable investment in a new airframe development needed to mount the upcoming ultra-high-bypass turbofans postponed to maximize quarterly profits and short-term stock performance.
    • A key competitor who has just released a new airframe development needed to mount the upcoming ultra-high-bypass turbofans, capturing the interest of your long-term customer base.
    • A dose of sudden desperation and reactionary rather than strategic leadership.
    • A willingness to brush aside your tradition of safety and to corrupt the design and certification processes in order to fast-track a new product and retain market share (despite the documented concerns of your engineers).


    Remove ANY of these, and the accidents would have not existed.

    Saying these crashes were the result of pilots not applying a simple trim runaway procedure in a scenario that is very unlike a trim runaway is either very naive or very convenient. In any case, it didn't prevent crashes in 2/3's of the known instances of erroneous MCAS activations, and the reason for that is well known, extensively documented human factors that can and must be considered in design of modern aircraft. Once you understand that (and we've had two very stark lessons on this), there is absolutely no point in bringing up the trim runaway procedure here.

    Comment


    • Originally posted by Evan View Post
      You left out some ingredients:
      • An aircraft manufacturer focused on short term stock performance and market capitalization in a 'casino' climate of chaos capitalism.
      • An inevitable investment in a new airframe development needed to mount the upcoming ultra-high-bypass turbofans postponed to maximize quarterly profits and short-term stock performance.
      • A key competitor who has just released a new airframe development needed to mount the upcoming ultra-high-bypass turbofans, capturing the interest of your long-term customer base.
      • A dose of sudden desperation and reactionary rather than strategic leadership.
      • A willingness to brush aside your tradition of safety and to corrupt the design and certification processes in order to fast-track a new product and retain market share (despite the documented concerns of your engineers).


      Remove ANY of these, and the accidents would have not existed.
      All these fall under the 1st ingredient I listed.
      I just listed the high-level ingredients, not the hows and whys of each of them.

      You can produce similar lists for the other 2 items too.

      Saying these crashes were the result of pilots not applying a simple trim runaway procedure in a scenario that is very unlike a trim runaway is either very naive or very convenient.
      1st, I hope it is not me who you have in mind when you say "saying that these crashes where the result of pilots not following the trim runaway procedure". I mentioned that as ONE of the causes. Do you argue that? Do you argue that if the pilots would have followed the trim runaway procedure correctly these accidents would not have happened?

      2nd, the trim runaway caused by the MCAS failure is not "very unlike a trim runaway". You have the trim moving uncommanded during manual flight and causing an out of trim condition that you have to fight against with increasing stick forces, when you use the thumb switch you can override it and when you release the trim switch it starts again. Yes, there are particularities... If you do nothing the trim runaway would stop by itself after 5 seconds (but I hope that by 5 seconds of continuous wheel spinning against your expectations and against your stick forces you already have the trim runaway picture in mind), it will wait 5 seconds to happen again after you release the thumb switch (that's unusual, but "traditional" trim runaways can be intermittent), and in these 2 accidents they had a stickshaker on one side since lift off (which they obviously disregarded as false since they both retracted flaps and slats BEFORE the MCAS activated). The Lion Air crew spent several MINUTES looking up for a procedure in the QRH. Which procedure do you think they were looking up? Why were they looking it up without applying the memory items? The Ethipoian crew had the advantage of foresight, or should have. The Lion Air accident had happened months earlier, the MCAS had been disclosed, the SB and EAD had been issued, and the thing was all over the place.

      Now, am I saying that that was THE cause? Or even the MAIN cause? Not so. I listed 3 ingredients. And I didn't invent that, it is in Lion Air's accident report.

      I am sorry, the crew COULD have acted better, but they couldn't. As a passenger, I do have higher expectations regarding the pilots. If you are going to argue that current airplane designs should be done not with PILOTS in uppercase but with undertrained and not-motivated-for-self-learning puppy-mill pilots in mind, I agree (so should Airbus by the way so another AF doesn't happen again), then perhaps you have a point. If you are going to argue that the MCAS design was horribly and acceptable regardless the quality and expertise of the flight crews, I fully agree. And you can take your analysis of the business context that affected the decisions at Boeing, yo can make a very similar analysis (even worse) of Lion Air (I don't know to what extent Ethiopian).

      --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
      --- Defend what you say with arguments, not by imposing your credentials ---

      Comment


      • Originally posted by Evan View Post
        Saying these crashes were the result of pilots not applying a simple trim runaway procedure in a scenario that is very unlike a trim runaway is either very naive or very convenient. In any case, it didn't prevent crashes in 2/3's of the known instances of erroneous MCAS activations, and the reason for that is well known, extensively documented human factors that can and must be considered in design of modern aircraft. Once you understand that (and we've had two very stark lessons on this), there is absolutely no point in bringing up the trim runaway procedure here.
        I understand that.
        But do you understand concurrent factors and causes?
        Do you realize that that after the 1st incident (that everybody walked away from) the 2nd incident should have never existed to begin with? And that after the 2nd incident the crew of the 3rd incident should have been EXPERTS in this and be able to easily recognize and address the situation?

        I do blame Boeing and the FAA. I do not blame ONLY Boeing and the FAA as you do.

        --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
        --- Defend what you say with arguments, not by imposing your credentials ---

        Comment


        • Originally posted by Gabriel View Post
          I do blame Boeing and the FAA. I do not blame ONLY Boeing and the FAA as you do.
          Here's how I would assess blame: If the pilots had recovered, I would say bravo for the pilots. If the pilots crashed whilst trying to recover, I would see them as victims, not as deserving blame. These erroneous MCAS events were too disorienting to carry a confident expectation of successful recovery. You would have responded perfectly of course, and BoeingBobby would have done it blindfolded with one hand and one foot tied behind his back, and every other pilot you might ask would have also done everything correctly without breaking a sweat, but in the real world, there are many pilots who would have met a similar fate. The event is centered around a symptom that is essentially trim runaway, but it DOES NOT behave like trim runaway. In addition to the stall warning (not a situation conducive to pulling up), the master caution, the intermittent ceasing and repeating, the stabilizer rate, the sudden nose-down upsets are disorienting and distracting. Again, Ethiopian did use the CUTOUT switches but why did they leave the thrust in TOGA? They were DISTRACTED and CONFUSED by the situation. Because Boeing built an airplane that can distract and confuse the pilots. We NEVER want an airplane to do that.

          The crashes could have been avoided by stellar piloting. The crashes could have been avoided by more robust parts and proper maintenance procedures. Are all pilots stellar? Do parts fail on occasion? You, me, Boeing and the FAA know the answers are yes. Especially in Indonesia where their launch customer operated. Aviation safety must have tolerance for this.

          The crashes are 100% the fault of Boeing and the FAA.

          *That does not mean Lion Air and Ethiopian are blameless for their maintenance and pilot training shortcomings. That's a separate issue, however. The important thing here is to remain focused on the issue of design, certification and management wrongdoings and not let that blame be diluted by the fact that Indonesia has a serious CAA problem, which we've all known for a long, long time.

          Comment


          • Boeing and the FAA are taking notice and taking action. Are these airlines and civil aviation authorities that oversee these airlines also taking notice and action? If so, they are doing it very silently.

            --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
            --- Defend what you say with arguments, not by imposing your credentials ---

            Comment


            • Oh, and by the way, I don't blame the pilots. I never do (and if I did I will admit it was a mistake). Pilots are victims (except in the few cases where they do it on purpose, "it" being either crashing the plane or the intentional disregard of procedures, and in the second case the airline has a lot to do too). Airlines are responsible to select and train pilots and monitor their performance. Pilots learn the basics of flight in flight schools. Airplane manufacturers design airplanes that are more or less pilot-friendly and more or less sensitive to pilot error (which is human error, part of human nature), airplane manufacturers and airlines make procedures that are more or less robust to pilot error, and so on.

              --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
              --- Defend what you say with arguments, not by imposing your credentials ---

              Comment


              • Originally posted by Gabriel View Post
                Boeing and the FAA are taking notice and taking action. Are these airlines and civil aviation authorities that oversee these airlines also taking notice and action? If so, they are doing it very silently.
                Unfortunately, I doubt these developing world CAA's are going to overcome corruption any time soon, so we can expect more pilot error and shoddy maintenance from the airlines they are overseeing. We need to sell them planes that are as forgiving as possible, or at least planes that don't help them crash...

                But, as I said, that is a separate issue. We can fix Boeing and the FAA and that is where the focus must remain.

                (Whether Boeing can fix their brand remains to be seen. A 737 replacement would certainly help.)

                Comment


                • You should all read this new report on AVHerald.

                  https://avherald.com/h?article=4b57c3dd/0000&opt=0

                  Even with extensive software and a lot of redundancy, we get this. They were very lucky not to crash.

                  Comment


                  • Originally posted by Schwartz View Post
                    You should all read this new report on AVHerald.

                    https://avherald.com/h?article=4b57c3dd/0000&opt=0

                    Even with extensive software and a lot of redundancy, we get this. They were very lucky not to crash.
                    Christ, I just flew (unwittingly) with Smartlynx last week. Easyjet is using them for ACMI wet lease. Yeah, the M is for maintenance... Ugh. (This brings up the subject again about requiring trusted airlines to disclose farmed-out flights to shady operators AT THE TIME OF BOOKING).

                    This one is deeply complex, but on the face of it it seems to come down to two big issues: improper maintenance and a cavalier attitude towards repeatedly resetting FCC's instead of servicing them. Sort of reminds me of the AirAisa debarcle. Similar level of stupidity. But at least these pilots seemed to know how to fly their way out of trouble once they got themselves into it.

                    When the seatback information in my white, unmarked A320 revealed it to be operated by Smartlynx, I did a bit of research on them. Estonian and/or Latvian with what appeared to be a good history and safety compliance culture.

                    Had I read this final report before that flight, I would have taken the bus. There's some seriously broken safety culture here.

                    Beware, your next Easyjet flight might be on Smartlynx.

                    Comment


                    • Originally posted by Evan View Post
                      Christ, I just flew (unwittingly) with Smartlynx last week.
                      Yeah, okay...

                      Comment

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