Breaking news: Ethiopian Airlines flight has crashed on way to Nairobi

[Gabriel]

It takes an incendiary environment to make a fire. Boeing engineered an incendiary environment. That can never be tolerated because the ignition source is human nature.

Not sure if I wasn't clear. The design of the MCAS was a disaster. The design needs to be fixed and Boeing and the FAA need to be fixed. No dispute on that.

Now, with these pilots behind the wheel, do you feel more comfortable flying a 737 NG than a MAX? Because I don't think we would survive a runaway trim of the NG flavor either (no MCAS involved).
(acknowledged, the MCAS adds another failure mode for the trim runaway to happen, and one of unacceptable probability of occurrence, but trim runaways do happen for other reasons too)

Boeing needs to be fixed. But it is not the only thing that needs to be fixed.

[Evan]

My 2 cents: It takes fuel, oxygen and an ignition source to make a fire. It took a very bad design, bad pilots, horrible airline culture (especially Lion Air's) and corrupt regulatory agencies to create these accidents. Remove any of them and these accidents would not have happened. Yes, the MCAS design is a disaster, but it looks that these pilots would have not survived a "legacy" (not MCAS related) trim runaway in a 737 (MAX, NG, classic or the 1969's -100).

It takes an incendiary environment to make a fire. Boeing engineered an incendiary environment. That can never be tolerated because the ignition source is human nature.

[Gabriel]

My 2 cents: It takes fuel, oxygen and an ignition source to make a fire. It took a very bad design, bad pilots, horrible airline culture (especially Lion Air's) and corrupt regulatory agencies to create these accidents. Remove any of them and these accidents would not have happened. Yes, the MCAS design is a disaster, but it looks that these pilots would have not survived a "legacy" (not MCAS related) trim runaway in a 737 (MAX, NG, classic or the 1969's -100).

[flashcrash]

Boeing to pay bereaved 737 MAX crash victims $144,500 each:

https://www.bbc.com/news/business-49803068

[Evan]

https://www.nytimes.com/2019/09/18/m...x-crashes.html

long, interesting read. anxious to see evan's response to this....

It's well-written. I learned a few things from it. But it certainly seems biased toward Boeing's obsolete philosophy of reliance on airmanship as a first line of defence. The issue of deficient airmanship (either due to poor training or human factors or both) definitely played a role in the crashes, no doubt about that, but it sidesteps the larger point, which is that Boeing made an airplane that would challenge even proficient airman in this failure situation—designed with safety as a secondary priority and apparently certified through subterfuge, providing no instruction or procedure on the system that malfunctioned, and, once the malfunction threat revealed itself, failed to recall or ground the aircraft. So why are we talking about airmanship? Boeing cannot use airmanship as the only form of redundancy on a system like this. Commercial flights cannot be a test of a pilot's airmanship under such unusual scenarios. Those scenarios must, to the greatest possible extent, never occur. They can be and must be designed out. In designing any system that can disrupt flight control, the question "what could go wrong" must be fully explored and answered with solutions that are not airmanship alone. The author says it himself when he points out the "growing population of more than 300,000 airline pilots of variable and largely unpredictable skills". So, airmanship alone is off the table.

Boeing’s reticence allowed a narrative to emerge: that the company had developed the system to elude regulators; that it was all about shortcuts and greed; that it had cynically gambled with the lives of the flying public; that the Lion Air pilots were overwhelmed by the failures of a hidden system they could not reasonably have been expected to resist; and that the design of the MCAS was unquestionably the cause of the accident.

That "narrative" is true and accurate.

The twist is that Kirana could have built his airline on the Airbus 320, an airplane that is less challenging to fly, but instead chose the equivalent Boeing 737, which counts on pilots as the last resort if something mechanical or otherwise goes wrong.

Nonsense! Neither aircraft is 'challenging to fly', nor should it be. (Exception: runaway trim is a bit of a challenge. So why is this happening on a 21st century aircraft? Because Boeing placed short term shareholder value over progress and safety enhancement.) The A320 differs from the 737 in that the pilots do not have to trim the aircraft and cannot exceed the safe flight envelope. If 'something mechanical or otherwise' goes wrong, the pilots absolutely need to be counted on. Especially if that 'something' removes the envelope protections. Just ask AirAisa...

Airbus did not create the A320 as "a robotic new airplane that would address the accelerating decline in airmanship and require minimal piloting skills". FBW provided protections against pilot error by pilots with exceptional piloting skills. It's purpose, however, was to reduce pilot workload and improve flight handling and efficiency. I'm sure ATL will concur that a pilot with minimal piloting skills is not welcome in the A320 cockpit.

Some [engineers] at Boeing argued for an aerodynamic fix, but...

But Boeing placed expedience over safety. Full stop.

He spends ample time pointing out how Boeing considered a runaway trim scenario to be easily handled by a competant crew, and thus removed any concern about an MCAS failure, but he then points out the reality:

But there were two differences that may have confused them. The first was the severity of the pitch-down trim, which ran twice as fast a regular runaway — hence the praying in the cabin. The second was that it lasted about only 10 seconds, then stopped for five seconds, then started again.

The issue here is confused situational awareness at low altitude in a time-compressed emergency. "Ambushing" is the word he uses in the article. Boeing should have recognized how disorienting and dangerous this scenario would be.

Nowhere is there any suggestion of the more effective procedure I suggested for this failure: 'get under flap speed / get out some flaps'. However, it is revealed here that Horvino did prompt Suneja to do exactly this and he did and it solved the problem. The author calls this "The best move of the morning". Unfortunately, Suneja retracted them again 30 seconds later. Why didn't Boeing issue this procedure, which does not sacrifice the utility of electrical trim, when they first identified the threat? Because a new procedure might have drawn the attention of regulators and triggered a new type certification?

One interesting new revelation for me was that, in the Ethiopian crash, the pilots were attempting to re-engage the autopilot in the final moments. That goes a long was to explaining their actions (and inactions).

Here is his summary:

What we had in the two downed airplanes was a textbook failure of airmanship. In broad daylight, these pilots couldn’t decipher a variant of a simple runaway trim, and they ended up flying too fast at low altitude, neglecting to throttle back and leading their passengers over an aerodynamic edge into oblivion. They were the deciding factor here — not the MCAS, not the Max.

Yes, the deciding factor was the airmanship and situational clarity of the pilots. And it can never be that. Because that is not a reliable thing in such situations. You need a reliable form of redundancy for any single-point failure that affects flight control. Boeing decided not to bother with that. They were the deciding factor here.

And then Boeing sold these aircraft to airlines with known, well documented airmanship and maintenance failings, unsafe airlines that were banned in the United States. That should be illegal.

Yes, there was a failure of airmanship here. That is irrelevant. Yes, Indonesia is a snakepit of corruption. That is irrelevant. The only thing that is relevant is the story of the 737-MAX, why such an anachronistic aircraft was extended (and rushed) into the 21st century, why Boeing placed report order to marketing over engineering and why they took a cavelier attitude to the potential danger of a new flight control system. And, of course, why the FAA let them.

But really nice try.

[TeeVee]

https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-crashes.html

long, interesting read. anxious to see evan's response to this....

[Evan]

This is funny, do you both not see that at this point, safety does align with profitability? Before it did not. Now it does only because a bunch of people died. Money drives safety when it matters, and now it matters.

When did governments actually address health concerns with smoking? When they started to lose lawsuits associated with safe workplaces. Then they sued all the tobacco companies. Sometimes, money and health, or money and public safety align, and now we are in an era (we'll see how long it lasts) where they align in the aircraft industry.

I think we have to distinguish between safety and safety theatre, but the steps suggested in flipping the order of reports is a step in the right direction. The elephant in the room is, however, the B737, which doesn't belong in the 21st century. The decision to crutch it along, which is a much higher-level strategic decision by senior management tied with the decision to postpone the replacement airframe, is where all this began. That decision wasn't profitability driving safety. It was profitability impeding progress.

[Schwartz]

Dilatory tactics. At some point, it will become impossible to ignore the fact that Boeing's senior executive management is the core problem and that will hopefully result in a purge that restores the company's public trust.

total horseshit. a committee run by executives who themselves have nothing but PROFIT as their main concern and a former admiral who was hired by boeing "In a statement, Boeing chairman and chief executive Jim McNerney indicated that the addition of Giambastiani, who was the second-highest ranking officer in the U.S. military, is intended to bolster strategic thinking on the defense side of the company and to boost Boeing's influence with the Pentagon." (http://old.seattletimes.com/html/bus...ngboard08.html)

This is funny, do you both not see that at this point, safety does align with profitability? Before it did not. Now it does only because a bunch of people died. Money drives safety when it matters, and now it matters.

When did governments actually address health concerns with smoking? When they started to lose lawsuits associated with safe workplaces. Then they sued all the tobacco companies. Sometimes, money and health, or money and public safety align, and now we are in an era (we'll see how long it lasts) where they align in the aircraft industry.

[TeeVee]

total horseshit. a committee run by executives who themselves have nothing but PROFIT as their main concern and a former admiral who was hired by boeing "In a statement, Boeing chairman and chief executive Jim McNerney indicated that the addition of Giambastiani, who was the second-highest ranking officer in the U.S. military, is intended to bolster strategic thinking on the defense side of the company and to boost Boeing's influence with the Pentagon." (http://old.seattletimes.com/html/bus...ngboard08.html)

[Evan]

https://www.theglobeandmail.com/busi...7-max-crashes/

Notable:

Dilatory tactics. At some point, it will become impossible to ignore the fact that Boeing's senior executive management is the core problem and that will hopefully result in a purge that restores the company's public trust.

[Schwartz]

https://www.theglobeandmail.com/business/international-business/article-boeing-board-to-call-for-safety-changes-after-737-max-crashes/

Notable:

The recommendations will include that Boeing change aspects of its organizational structure, calling for the creation of new groups focused on safety and encouraging the company to consider making changes to the cockpits of future airplanes to accommodate a new generation of pilots, some of whom may have less training.

...

One of the report’s most significant findings concerns the reporting structure for engineers at the company. At Boeing, top engineers report primarily to the business leaders for each airplane model, and secondarily to the company’s chief engineer.

Under this model, engineers who identify problems that might slow a jet’s development could face resistance from executives whose jobs revolve around meeting production deadlines. The committee recommends flipping the reporting lines, so that top engineers report primarily to Boeing’s chief engineer, and secondarily to business unit leaders.

...

Boeing has more than 100,000 employees and, like many large companies, at times struggles with information flow. In particular, there has been inadequate communication within the engineering department, and from Boeing’s commercial airplanes division, based in the Seattle area, to Boeing corporate offices in Chicago.

The new safety group will work to ensure that the company’s various efforts have adequate independence and are working together and sharing information effectively. The new group will report to senior Boeing leadership, as well as to a new permanent committee on the board focused on aerospace safety.

...

The board committee is expected to recommend that Boeing re-examine cockpit design and operation to ensure that new Boeing planes are accessible for the next generation of pilots, including those with less training.

Boeing’s chief executive, Dennis A. Muilenburg, established the committee in April, calling on it to review “companywide policies and processes for the design and development of the airplanes we build.” The group included four Boeing directors familiar with complex industrial systems, as well as highly regulated industries.

Adm. Edmund Giambastiani Jr., a former nuclear submarine officer and the former vice chairman of the Joint Chiefs of Staff, was the committee chairman. The other members were Lynn Good, the chief executive of Duke Energy and a board member of the Institute for Nuclear Power Operations; Edward Liddy, the former chief executive of the insurance company Allstate; and Robert Bradway, the chief executive of Amgen, a pharmaceuticals company.

To conduct its review, the committee interviewed dozens of Boeing employees about their work. The committee also hired independent safety experts who had experience with industrial accidents including the Deepwater Horizon explosion, the Columbia space shuttle disaster and the Fukushima nuclear power plant accident. Among the experts was Sean O’Keefe, the former NASA administrator.

...

The FAA and international regulators are similarly frustrated with Boeing, a sentiment that became apparent at a meeting last month.

In August, Boeing met with officials from the FAA and other global aviation agencies to brief them on its efforts to complete fixes on the Max. Regulators asked detailed questions about adjustments to the Max’s flight control computers, which the Boeing representatives there were not prepared to answer.

Instead, the company representatives began to display a PowerPoint presentation on their efforts, according to people briefed on the meeting who spoke on the condition of anonymity because it was not public.

At that point, the regulators ended the meeting. Weeks later, Boeing has still not answered all their questions.

[Gabriel]

Or was it that Boeing didn't want to risk triggering a new type certification (or a significant delay in time-to-market) and thus decided not to present the changes? Boeing knew a type-certication or delay would doom them in this segment of the market. Management led them into that corner.

I don't think that a new type certification was at stake. But extra cost, a delay in launch, and perhaps more importantly, a more extensive training requirement for the pilots (which would have added extra cost and transition time for the airlines and breached Boeing's promises to them) was.

[Evan]

Yup, I red that one yesterday. I like this article.

The article further explains why that happened.
It says "paraphrasing" that in the beginning the MCAS has a limited functionality for high-speed high-G maneuvers and the authority was limited to a fraction of 1 degree (0.6 degree IIRC). Boeing presented to the FAA a safety evaluation of that MCAS. Then, later in the development, they expanded the function to work at slow speeds which increase its maximum deflection to 2.5 degrees... AT A TIME (with possible repetitions) but considered the change minor and not involving increased risks so they didn't present a new safety evaluation to the FAA. Incredible.

Or was it that Boeing didn't want to risk triggering a new type certification (or a significant delay in time-to-market) and thus decided not to present the changes? Boeing knew a type-certication or delay would doom them in this segment of the market. Management led them into that corner.

[Gabriel]

A better and more focused article perhaps (and not an opinion piece):

https://www.nytimes.com/2019/07/27/b...l?action=click

One quotation: "The safety review in their [FAA] files didn’t mention that the system could aggressively push down the nose of the plane and trigger repeatedly"

Yup, I red that one yesterday. I like this article.

The article further explains why that happened.
It says "paraphrasing" that in the beginning the MCAS has a limited functionality for high-speed high-G maneuvers and the authority was limited to a fraction of 1 degree (0.6 degree IIRC). Boeing presented to the FAA a safety evaluation of that MCAS. Then, later in the development, they expanded the function to work at slow speeds which increase its maximum deflection to 2.5 degrees... AT A TIME (with possible repetitions) but considered the change minor and not involving increased risks so they didn't present a new safety evaluation to the FAA. Incredible.

It also discusses other instances of the development where the FAA engineers questioned safety aspects of the 737 and the FAA management sided with Boeing using time and budgets constrains (that is, Boeing's bottom line) as a factor in the decision.

And many other things in the behavior of the FAA, both internally and in their relationship with Boeing.

I cannot vouch for the accuracy, objectivity and overall "truth" of that article, but I didn't find anything obvious and it is worth reading.

[flashcrash]

That is misleading to say the least and it is redacted in a way not to be plain lie but to fit a position. The position can be justified with accurate information.

A better and more focused article perhaps (and not an opinion piece):

https://www.nytimes.com/2019/07/27/b...l?action=click

One quotation: "The safety review in their [FAA] files didn’t mention that the system could aggressively push down the nose of the plane and trigger repeatedly"