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

[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]

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.

[flashcrash]

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

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

[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).

[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]

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]

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.

Of course, I agree completely. My concern is that Boeing (through their media minions) is trying to deflect some of the blame. Yes, the crash couldn't have happened without pilot error, but the confusing scenario they created is highly conducive to pilot error. Pilot's don't just commit errors because they are bad or poorly trained pilots. They also commit errors because they lose their grasp of very stressful situations.

I think there is reason to think that these pilots would handle a conventional trim runaway correctly. I agree that they needed better training.

[elaw]

Well of course they're trying to deflect blame! The first reaction of any corporation when caught with their hands in a cookie jar is to claim their hands were not in the cookie jar, and also that they don't have hands and that cookie jars don't actually exist but if they did it would greatly benefit society if all corporations had their hands in cookie jars.

However the fact Boeing is trying to deflect blame does not mean they were 100% to blame for what happened. Don't get me wrong, I'm not trying to claim they were 0% to blame either (though the tone of some of my earlier posts may have sounded that way).

My feeling is that any professional pilot should be prepared to deal with a trim runaway when flying a plane that can experience that, which is almost all non-FBW airliners. But... Boeing put pilots in a plane that had an additional failure mode not found in many airliners (including earlier 737s) that could cause trim runaway, and would do it in a confusing fashion - meaning that when the pilots did certain things, the runaway would stop, only to resume moments later.

So IMHO Boeing and the pilots each deserve some of the blame.

[Evan]

However the fact Boeing is trying to deflect blame does not mean they were 100% to blame for what happened.

I have to disagree. Boeing put these pilots into a very disorienting, difficult to diagnose (if not impossible to diagnose, if they weren't even aware of MCAS) situation. That changes everything. They can't then suggest that the crew should have been able to treat it as a typical emergency. HIghly trained and proficient crews might have managed it. Less proficient crews might not have. Are there less proficient crews up there? Oh yes. Especially at airlines with a worrisome record for these things, like the ones to which Boeing agressively marketed the 737-MAX. It's a bit hypocritical to sell these airlines an airplane that depends so heavily on flawless pilot performance under the most confusing and stressful circumstances, and then try to shift the blame there in the aftermath.

The Ethiopian crew left the thrust in TOGA the entire time. Obviously, they were distracted from flying the plane due to the situation they were trying to understand. Boeing did that.

This is interesting and prophetic: An article titled Pitch Trim Runaway Right after takeoff, it’s a recipe for disaster, from 2017. Prior to either crash, there was a Cessna Citation being flown by a very experienced ATPL pilot that crashed into Lake MIchigan. The NTSB believe it was the result of a trim runaway. The plane should have been controllable, but the crew let the speed get too high while being distracted with troubleshooting. Sound familiar?

The NTSB cited the crew’s “haphazard and poorly coordinated troubleshooting efforts” as having “allowed an abnormal situation to escalate to an emergency” and concluded that “if the pilots had simply maintained a reduced airspeed ... the aerodynamic forces on the airplane would not have increased significantly” and “the pilots should have been able to maintain control of the airplane.”

https://www.aopa.org/news-and-media/all-news/2017/july/pilot/turbine-pitch-trim-runaway

[elaw]

Well I'm going to have to disagree with your disagreement. I don't always agree with the criticism you get here re "black-and-white reasoning" but in this case I concur with it.

Where to start... how about at the beginning?

You say the pilots were put into a disorienting situation (yes I know there were other words but bear with me). Flying into a cloud is disorienting... many many accidents over the years have proved that. Yet competent instrument-rated pilots can handle flying into clouds without crashing... millions of successful flights over the years have proven that. Competency is a thing, and can affect the outcome of many situations, especially in aviation. And to quote a wise ex-coworker of mine, "competency varies".

A "typical emergency"... what exactly is that? You mention another trim runaway incident that ended up with dead aviators, presumably to prove the point that runaway trim kills people. However there are many documented cases of trim runaways being successfully dealt with by pilots, and numerous people failing to die as a result. Does this sound a little like the cloud situation I describe above? Competent pilots usually handle encounters with clouds successfully, non-competent pilots and non-pilots generally don't. Competent pilots have handled trim runaways successfully, non-competent pilots (and some who were probably just having a bad day) have not.

Let me give a few more illustrating examples. Suppose you're piloting a DC-10 and a compressor disk explodes in the #2 engine, taking out all the hydraulics. A pretty clear-cut case of a plane trying to kill its inhabitants, yet in UA232 many survived due to the exceptional piloting and teamwork of a few individuals. On the other hand there are a lot of recorded cases of airplanes doing absolutely nothing wrong, and damage to aircraft/property/persons taking place due to the actions of incompetent/complacent/half-asleep/etc. pilots... landing with the gear up, landing long and running off the end of the runway, flying into weather the aircraft can't handle (or flying improperly even when the plane *can* handle the weather, resulting in a crash), etc. etc. Once again, competency affects the outcome.

The bottom line is I am not going to say the aircraft is 100% to blame in an emergency situation the pilots were trained to handle. If the aircraft lends some nuance to the situation that the pilots were not trained for, sure that's the aircraft's fault. And yes if the aircraft fails at all in any way that contributes to the accident, it's partly at fault. But cases like this are why the NTSB and others say those factors contribute to the accident (blame on aircraft < 100%) rather than causing the accident (blame on aircraft = 100%).

[Gabriel]

I disagree with both of you. Boeing has 100% of the blame. The FAA has 100 of the blame. The pilots have 100% of the blame. The airlines have 100% of the blame. And the local regulatory agencies have 100% of the blame. It took all of them to screw up for these accidents to happen. Blame is one of the things (together with love and knowledge) that you don't lose a bit when you share some.

[elaw]

Are you one of those people that asks for a pizza to be cut into 6 slices because you can't eat 8?

[Gabriel]

Are you one of those people that asks for a pizza to be cut into 6 slices because you can't eat 8?

No, because you do eat less pizza if you share some.

It's like having 6 bulbs in a serial connection saying that you have 1 amp flowing through the circuit and asking "ok but what fraction of the 1 amp does each bulb take?"

[elaw]

It's like having 6 bulbs in a serial connection saying that you have 1 amp flowing through the circuit and asking "ok but what fraction of the 1 amp does each bulb take?"

Or... is it like having 6 bulbs in a parallel connection saying that you have 1 amp flowing through the circuit and asking "ok but what fraction of the 1 amp does each bulb take?"

Oh and two of the bulbs are not lit because someone pulled the circuit breaker.

[elaw]

Okay I'm a little slow and realized your light bulb analogy was probably meant in the "Swiss cheese" sense, that if any one factor were not present the accident would not happen.

But I think that analogy is kind of like saying that in a bank robbery, the bank and the robber are both 100% at fault because if neither was present, the robbery would not have happened. If you go out and survey 100 people on the street, I doubt you're going to find one that feels the bank was 100% at fault. You might find a few that think it was 10% at fault because it had a poorly-maintained security system or something like that, and I think that kind of reasoning has value because it allows you to compare the magnitude of each factor and respond appropriately.

Take my UA232 example... IMHO saying the engine failure and the pilots are both 100% responsible for the deaths that occurred is absurd. The engine failure clearly was the proximate cause of the crash, a lot of resources were dedicated to diagnosing that problem and preventing it from recurring, and IMHO a lot of benefit was derived from that. Putting an equal amount of resources into trying to train every pilot to perform as well as or better than Al Haynes and company would be a fool's errand. Mostly in the sense that trying to teach them to fly an aircraft severely damaged in a very edge-case way would divert resources from training them to deal with much more likely scenarios. Trim runaway, for example.