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

[Evan]

- The PIC also reported the flight condition through the electronic reporting system of the company A-SHOR.

Would that include the pitch trim issues?

- The engineer performed flushing the left Pitot Air Data Module (ADM) and static ADM to rectify the IAS and ALT disagree followed by operation test on ground and found satisfied. The Feel Differential Pressure was rectified by performed cleaned electrical connector plug of elevator feel computer. The test on ground found the problem had been solved.

Because the problem hadn't been identified. There was probably nothing wrong with the ADM's. AFAIK, an incorrect AoA value will give an incorrect onside IAS and ALT value as well.

When they say 'test on ground'. I'd like to know what that means. A full test of air data sensors and readings should have revealed the AoA data discrepency. I think any healthy maintenance culture would have checked them all before signing off on it.

[Chris K]

You don't always see the next crew, but yes if you do get to hand the aircraft over to the next crew you would normally let them know if the airplane is good or if there has been a problem(s).

Thank you - I appreciate the insight!

[Chris K]

Sort of. Unfortunately these some pilots did NOT do their professional job and reported just IAS disagree and feel system light. They sort of "forgot" to include the little details like, I don't know, let me see, oh yes: The stick-shaker activated immediately after take off and the plane wanted to go down and was trimming down all the time without our intervention and it nosed over and we almost crash and we first fought back applying nose-up trim with the yoke switch but the plane would trim down again shortly afterwards so we ended up turning the trim motors off with the cutout switches and used the manual trim wheel for the rest of the flight. Not to mention that they decided to still do the 1:50 flight flight instead of returning to base, because, you know, the abnormal checklists that they used didn't indicate to do so (so you know, don't breath unless there is a procedure that tells you to do so) (and the checklists didn't say to continue to the intended destination either, but somehow they still were able to make that decision).

Talk about completely unacceptable.

This is additional detail I didn't know about - thanks. Crazy bad stuff ....

[Gabriel]

Initial report out.

http://avherald.com/files/2018%20-%20035%20-%20PK-LQP%20Preliminary%20Report.pdf

Here some drops (and this part is regarding just the previous flight):

- On 28 October 2018, a Boeing 737-8 (MAX) aircraft registered PK-LQP was operated as a scheduled passenger flight from Denpasar to Jakarta. Prior to the flight, the Angle of Attack (AoA) sensor had been replaced and tested.

- The DFDR showed the stick shaker activated during the rotation and remained active throughout the flight. About 400 feet, the PIC noticed on the Primary Flight Display (PFD) that the IAS DISAGREE warning appeared.

- The PIC cross checked both PFDs with the standby instrument and determined that the left PFD had the problem. The flight was handled by the SIC.

- The PIC noticed that as soon the SIC stopped trim input, the aircraft was automatically trimming aircraft nose down (AND). After three automatic AND trim occurrences, the SIC commented that the control column was too heavy to hold back. The PIC moved the STAB TRIM switches to CUT OUT.

- The pilot performed three Non-Normal Checklists (NNCs) consisting of Airspeed Unreliable, ALT DISAGREE, and Runaway Stabilizer. None of the NNCs performed contained the instruction “Plan to land at the nearest suitable airport”.

- After parking in Jakarta, the PIC informed the engineer about the aircraft problem and entered IAS (Indicated Air Speed) and ALT (altitude) Disagree and FEEL DIFF PRESS (Feel Differential Pressure) light problem on the Aircraft Flight Maintenance Log (AFML).

- The PIC also reported the flight condition through the electronic reporting system of the company A-SHOR.

- The engineer performed flushing the left Pitot Air Data Module (ADM) and static ADM to rectify the IAS and ALT disagree followed by operation test on ground and found satisfied. The Feel Differential Pressure was rectified by performed cleaned electrical connector plug of elevator feel computer. The test on ground found the problem had been solved.

The flight from Denpasar to Jakarta experienced stick shaker activation during the takeoff rotation and remained active throughout the flight. This condition is considered as un-airworthy condition and the flight shall not be continued.

KNKT recommend ensuring the implementation of the Operation Manual part A subchapter 1.4.2 in order to improve the safety culture and to enable the pilot to make proper decision to continue the flight.

According to the weight and balance sheet, on board the aircraft were two pilots, five flight attendants and 181 passengers consisted of 178 adult, one child and two infants. The voyage report showed that the number of flight attendant on board was six flight attendants. This indicated that the weight and balance sheet did not contain actual information.

[Gabriel]

But that's not what we seem to have here. What we seem to have is an aircraft that had a serious issue that some pilot(s) did their professional job and brought the beast down safely.

Sort of. Unfortunately these some pilots did NOT do their professional job and reported just IAS disagree and feel system light. They sort of "forgot" to include the little details like, I don't know, let me see, oh yes: The stick-shaker activated immediately after take off and remained active the whole flight and the plane wanted to go down and was trimming down all the time without our intervention and it nosed over and we almost crash and we first fought back applying nose-up trim with the yoke switch but the plane would trim down again shortly afterwards so we ended up turning the trim motors off with the cutout switches and used the manual trim wheel for the rest of the flight. Not to mention that they decided to still do the 1:50 flight flight instead of returning to base, because, you know, the abnormal checklists that they used didn't indicate to do so (so you know, don't breath unless there is a procedure that tells you to do so) (and the checklists didn't say to continue to the intended destination either, but somehow they still were able to make that decision).

Talk about completely unacceptable.

[BoeingBobby]

A breath of common sense IMO.

Serious question, what type of communication takes place between pilots when you all are handing off the aircraft to a new crew? Is anything required or are you just looking at the log books and such? I would think this would be tremendously valuable and yet I can see where logistically it may not always be feasible.

You don't always see the next crew, but yes if you do get to hand the aircraft over to the next crew you would normally let them know if the airplane is good or if there has been a problem(s).

[Chris K]

So what do you expect? Never ever a death? Is that a reasonable expectation?

Definitely not my expectation as there will always be acts of god and things that happen that are completely unavoidable, up to and including pilots making mistakes as they are of course human.

But that's not what we seem to have here. What we seem to have is an aircraft that had a serious issue that some pilot(s) did their professional job and brought the beast down safely. But instead of learning from a win, the gun was pointed at the foot and the trigger pulled. Just a completely unacceptable sequence of events given what should have been an easily avoidable set of circumstances.

[Chris K]

There should be a "flight test requested before signoff" box for the pilot to tick on the maintenance log. the previous flight crew would have checked that box as they flew the whole flight manually with the stick shaker going off the entire time... bzzzzzzzzzzzz……..

A breath of common sense IMO.

Serious question, what type of communication takes place between pilots when you all are handing off the aircraft to a new crew? Is anything required or are you just looking at the log books and such? I would think this would be tremendously valuable and yet I can see where logistically it may not always be feasible.

[BoeingBobby]

If you really are a line pilot.

Oh I am willing to bet big $$ he is!

[Black Ram]

At this point there seems general agreement that the pilots screwed the pooch but I go back to my original point/post which is that a test flight should have been conducted given the circumstances. I've read on av-herald both a mechanic and pilot saying the plane should have been rejected to being returned to service given the circumstances. (For me, "test flight" and "rejected to return to service" are synonymous.)

It seems to me, as a lowly passenger, we're being asked to be guinea pigs with insufficient knowledge of the circumstances, at the mercy purely of the pilots skills, thereby eliminating a ginormous mountain of potentially mitigating safeguards. As I said before, if you give me Sulley or Boeing Bobby or Neil freaking Armstrong, I'll buckle up and take my chances, and same for a nearly brand new properly functioning plane with pilot(s) I assume are competent. But a "who knows?" pilot with an aircraft coming off a serious maintenance event? Very few people would sign up for that and rightfully so.

Like I said before, even if this plane was sorted out before its fateful flight, or if that flight never took place, the fact remains that the plane's automation acted out on the false indications of only one AoA vane, and that pilots flying this plane did not know about the plane's automation. This crash could have happened on any other given time. What's to say this exact failure can't occur spontaneously when the plane is in the air?

I also think you shouldn't ever take your chances, no matter who is the pilot. Sulley also made a mistake, and worse, he denies it to this day, instead blaming the plane and making up facts, contradicting the NTSB report. He absolutely did his job that day, but good pilots are not gods, nor are they angels. They are human beings, like everyone else.

[Evan]

And yet again I ask which airlines and "watchful authorities" do you mean? You did let now-defunct Air Berlin slip out in one post, which I still don't find credible.

Yes, yet again.

If you really are a line pilot, the answer should be well-known to you. When you look at crashes and incidents in this decade involving gross pilot error and/or shoddy maintanance, certain airlines and nations stand out. Indonesia stands out quite blatantly. There has also been a fair amount of press exposing institutional problems. Yet even in regions with corrupt oversight, you will find operators with a sound, internal safety tradition. It involves a certain amount of research and initiative to determine which airlines might be the ones you want to avoid. If your life is worth the trouble, you will do this.

The principle lesson I've learned in ten years of studying this stuff is that it all comes down to the safety culture of the airline and the civil aviation authority. When those things are sound, crashes are extremely rare. When they aren't: good luck, you'll need it.

[orangehuggy]

There should be a "flight test requested before signoff" box for the pilot to tick on the maintenance log. the previous flight crew would have checked that box as they flew the whole flight manually with the stick shaker going off the entire time... bzzzzzzzzzzzz……..

[ATLcrew]

Airlines with a proper safety culture, under the watchful eye of civil aviation authorities with a proper safety culture, ensure that their pilots and maintenance personnel are familiar with the procedures that prevent lowly passengers from ending up as dead guinea pigs.

And yet again I ask which airlines and "watchful authorities" do you mean? You did let now-defunct Air Berlin slip out in one post, which I still don't find credible.

[Evan]

It seems to me, as a lowly passenger, we're being asked to be guinea pigs with insufficient knowledge of the circumstances, at the mercy purely of the pilots skills, thereby eliminating a ginormous mountain of potentially mitigating safeguards.

The decision to be a guinea pig is yours to make. You want to fly on a corner-cutting Indonesian airline with an atrocious safety record, climb aboard, Mr. Guinea Pig.

Airlines with a proper safety culture, under the watchful eye of civil aviation authorities with a proper safety culture, ensure that their pilots and maintenance personnel are familiar with the procedures that prevent lowly passengers from ending up as dead guinea pigs. Most of that never requires test flights. Just proper ground tests.

It appears that the AoA vane here didn't fail due to a mechanical issue that would have only been revealed in flight, so it must have been either installed incorrectly, miscalibrated or something was off in the logic. Any of those things could have be detected on the ground, if, of course, anyone bothered to check these things properly.

[Gabriel]

Yes -- "almost" being the key word. Semantics indeed ....

So what do you expect? Never ever a death? Is that a reasonable expectation?