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Ethiopian Airlines 737 Max crashes killing 157

Nueces River Rat

By Nueces River Rat
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Your Mom

Your Mom 4849

Posted
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25 minutes ago, Onboard 2.0 said:

High speed/high altitude barrel role maneuvers to avoid incoming SAM's ??  Cause that would be cool as shit....

Damn near. Upset recovery included 120 degree bank at 30 degrees nose down. Full stalls from FL400, past the stick shaker, until full back pressure and trim still results in a 1000fpm descent before recovery. Lost almost 6000 feet in the recovery.  Airspeed Unreliable and Runaway Stab Trim were on the non-jeopardy observation days to check the box. Headed back for low vis cat III stuff, wind shear, gpws, and single engine work today. 

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Bobby_Batronic
Bobby_Batronic

Incorrect. MCAS didn’t kill two planes worth of people. Pilots failing to react to an inadvertent nose down pitch input correctly as per their MEMORY ITEMS, killed two planes worth of people. Someone

Ghost of LL
Ghost of LL

Oh, my everloving fucking god, will you please stop trying to make some innane political point with every fucking post on every fucking topic?  It's exhausting.  It's exhausting to an absolute mortify

Gatorubet
Gatorubet

“Could you make sure that the bolts to the side panel are fastened so I don’t blow out the plane?” “Sure….that will be an extra $23.”

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Hagbard Celine

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14 hours ago, Onboard 2.0 said:

High speed/high altitude barrel role maneuvers to avoid incoming SAM's ??  Cause that would be cool as shit....

The last commercial airliner that could possibly barrel role at cruise altitude was probably the Convair 880.  Maybe the 727-100 could have.  With no pax, no cargo and about 5000 pounds of jet-A.  And after Tex Johnson in 1954, I don't know that it was ever attempted again.

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RPM

RPM 26342

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4 hours ago, Onboard 2.0 said:

That's a big roger on the reference.

Talk about a film series that went progressively downhill along with completely unbelievable continuity. Joe Patroni went from chief mechanic to airline president to Concorde co-pilot.

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elfenix

elfenix 34331

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Posted (edited)

so, because boeing didn't want to build a new small/mid single aisle plane to take over the 7/8/9 size 737s and the 757, they now have huge legal liabilities, owe the airlines who purchased the max a shit ton of money, are selling a plane no one wants to fly on, and getting their lunch eaten by the 321XLR.  and what were the airlines going to do, not buy it?  airbus can't make more 320s. 

good job, guys.

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GringoSalado

GringoSalado 1651

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19 minutes ago, Leeroy Jenkins said:

I would bet that the airlines didn't want Boeing to build another class so they would have to train and get new type ratings for their pilots.  That was market driven, not Boeing driven.  

both IMO. Airlines need cockpit standardization to be efficient, Boeing needs fuselage standardization to be efficient.

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elfenix

elfenix 34331

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Posted (edited)
28 minutes ago, Leeroy Jenkins said:

I would bet that the airlines didn't want Boeing to build another class so they would have to train and get new type ratings for their pilots.  That was market driven, not Boeing driven.  

 

7 minutes ago, GringoSalado said:

both IMO. Airlines need cockpit standardization to be efficient, Boeing needs fuselage standardization to be efficient.

i know the airlines don't want to do it, but again, what were they going to do?  wait 6 years for an order slot to come up with 320s?

edit: not to mention it looks like they need significantly more retraining for the max than it was billed for.

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Your Mom

Your Mom 4849

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 When the it comes back on line, and who knows when that will be, my guess winter, there will not be much more training to fly it. Training will take place on the iPad again. There’s no MAX simulator out there available to any airline yet.   I think Boeing has one and there might be one in Canada. Even if each airline got one of those simulators today you’re talking about running 10,000 pilots through one simulator.    Most simulator sessions go about four hours, two per pilot.  Running 24/7 365 days a year it would take over 2 years to train every pilot. That’s just at SWA,  I don’t know how many 737 pilots the other airlines have but you’re talking several tens of thousands total.

 There’s not much new to train on it anyway. Boeing is fixing the software but the procedures for flying the airplane aren’t really going to change much at all.    There have been checklists and procedures for Airspeed Unreliable and Runaway Stab Trim, and for unloading the stab for manual trim at high speeds for 30+ years.  Those procedures aren’t changing. The only thing to be retrained is how the system works and why you might need to run those checklists that you’ve been training on for many years. 

 

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RPM

RPM 26342

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2 hours ago, Your Mom said:

There’s no MAX simulator out there available to any airline yet.

How long could it take to build them? A week? The program is all they need to change, right? Isn't the cockpit the same?

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Your Mom

Your Mom 4849

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13 minutes ago, RPM said:

How long could it take to build them? A week? The program is all they need to change, right? Isn't the cockpit the same?

Its a little different.  Important stuff is in the same place but the screens are set up a little different.   The thing is, for a sim to be an acceptable way to train it has to look, feel, and perform just about exactly like that model.  The 737-700 and 737-800 are both NGs with identical cockpits but each has it's own dedicated sims.  One sim can't be both because they fly a little different from each other, different characteristics.  

NG on top, MAX below.

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Your Mom

Your Mom 4849

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Posted (edited)

Y'all got gypped.  We got two cup holders in every plane.  Of course we were years behind  the rest of the industry with VNAV... probably never gonna have autoland. 

And don't get me started on our 20 year old apps for nonrev listing.  Takes me 10 minutes and 50 clicks to check loads on a flight and I still don't know how to see the standby list.  Gotta log in to the customer website separately for that.

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RPM

RPM 26342

Posted
Posted

I used to hang out on another board with a Boeing guy that worked his way into management. He was a supreme dick. If I was interested in schadenfreude I'd sign back up just to hear him make excuses and justify the cost cutting for profit's sake.

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Bobby_Batronic

Bobby_Batronic 1994

Posted
Posted
20 hours ago, Your Mom said:

Its a little different.  Important stuff is in the same place but the screens are set up a little different.   The thing is, for a sim to be an acceptable way to train it has to look, feel, and perform just about exactly like that model.  The 737-700 and 737-800 are both NGs with identical cockpits but each has it's own dedicated sims.  One sim can't be both because they fly a little different from each other, different characteristics.  

NG on top, MAX below.

maxresdefault.jpg

2gdj77c-mr.jpg

So are y’all scrounging for NG’s while waiting on the Max’s to become available or just holding serve until this comes to a conclusion?

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Your Mom

Your Mom 4849

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Just waiting it out I think. When they were grounded we had 34 but by years end we’ll have 70ish. We aren’t taking delivery of them of course, but they will all show up as they become airworthy.  Until then we’re just over-staffed and under-airplaned.  We did delay some -700 retirements but not many because most were already committed to buyers. 

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retread

retread 2951

Posted
Posted
On 6/28/2019 at 5:34 PM, RPM said:

I used to hang out on another board with a Boeing guy that worked his way into management. He was a supreme dick. If I was interested in schadenfreude I'd sign back up just to hear him make excuses and justify the cost cutting for profit's sake.

Link?

Does anyone have specifics on the what the second problem is with the MCAS? Is it just another set of unusual conditions that have to be accounted for?

https://time.com/5615292/boeing-737-max-software-problem/

Quote

Boeing said Wednesday that the FAA “identified an additional requirement” for software changes that the aircraft manufacturer has been working on for eight months, since shortly after the first crash.

“Boeing agrees with the FAA’s decision and request, and is working on the required software to address the FAA’s request,” Boeing said in a statement.

Government test pilots trying out Boeing’s updated Max software in a flight simulator last week found a flaw that could result in the plane’s nose pitching down, according to two people familiar with the matter. In both Max crashes, the plane’s flight-control software pushed the nose down based on faulty readings from one sensor.

The people said fixing the issue might be accomplished through software changes or by replacing a microprocessor in the plane’s flight-control system. One said the latest setback is likely to delay the plane’s return to service by an extra one to three months. Both spoke on condition of anonymity to discuss aspects of the review process that are not public.

 

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Nueces River Rat

Nueces River Rat 5539

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On 6/28/2019 at 4:24 PM, happyfunball said:

 

Would these be the same guys who spam call you from Eldorado, Texas saying ( in a slight accent) they are Mircrosoft tech support and they need get into your computer?  

I think when I started this thread it was noted this had a potential to be a  real clusterfark for Boeing.... Sure enough.

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Homercles

Homercles 10206

Posted
Posted
 

 

Some of the aviation nerd forums seem to posit that it’s the flight control computer getting overwhelmed during MCAS activation and slowing down the reversion to manual trim...sorta like Apollo 11 with the radar that was left on.

 

Edit: https://leehamnews.com/2019/06/28/bjorns-corner-new-pitch-trim-issue-forces-further-changes-to-737-max-software/

 

 

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Captainant

Captainant 27741

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On 6/28/2019 at 11:45 AM, Leeroy Jenkins said:

I would bet that the airlines didn't want Boeing to build another class so they would have to train and get new type ratings for their pilots.  That was market driven, not Boeing driven.  

Fuck that noise. Boeing wasn't forced into building a dangerously unstable plane and covering up flaws during inspection/certification. Just because the market is clamoring for something doesn't mean that it's incumbent on the producer to meet every demand at any cost.

That's like saying consumers are at fault for VW's diesel emissions fraud because they wanted a clean and fuel efficient vehicle. 

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Fozzz

Fozzz 152

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Posted

This company should be nuked from orbit or something, imo.  Put those aging minutemen to use and just vaporize every office building, warehouse, and any other facility in which their business is conducted.

Quote

This disregard for engineering integrity and safety had come from the Wall Street driven financialization of the 1990s, through General Electric’s McNerney, but also from military procurement culture. Current CEO Dennis Muilenburg, for instance, has presided over a series of problematic projects in the defense division, from the X-32, the losing entry in the F-35 joint strike fighter contract, to the Airborne Laser system. Muilenburg has handled the 737 Max problem the way a defense official would, through public relations and political channels rather than the way a civilian engineer would, which would be through an aggressively honest review of engineering choices.

The net effect of the merger, and the follow-on managerial and financial choices, is that America significantly damaged its aerospace industry. Where there were two competitors - McDonnell Douglas and Boeing, now there is one. And that domestic monopoly can no longer develop good civilian aerospace products. Hundreds of people are dead, and tens of billions of dollars wasted.

Boeing now has a rocky situation ahead of it. There is little trust in the current leadership of the company, and it will face significant liability from airlines who bought the jet, as well as mass cancelations of orders. There is a criminal investigation into the company, as there should be. This like likely to have significant and severe financial consequences.

The right policy path would be Congressional hearings to explore what happened to this once fine company, followed by a break-up of the company into a civilian and military division, or if possible, find a way to create multiple competitors out of this fiasco. Muilenburg should be fired, his compensation clawed back, and the Department of Justice should clean house and indict every relevant executive who empowered what looks like fraud at the core of the 737 Max fiasco. Congress should expand the FAA so it can once again do its job. With a new leadership team in place, Boeing could fix the 737 Max and begin planning great aircraft again.

https://mattstoller.substack.com/

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Wally Pryor

Wally Pryor 5262

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WASHINGTON (AP) - American Airlines said Sunday that it will keep the Boeing 737 Max plane off its schedule until Nov. 3, which is two months longer than it had planned.

In a statement, American said the action will result in the cancellation of about 115 flights per day. It said it "remains confident" that the Boeing plane will be recertified this year. But some airline executives are growing doubtful about that timetable.

United has 14 Max jets while American has 24 of them. Southwest Airlines, which has 34 Max jets - more than any other carrier - is canceling about 150 flights per day.

 

How far in advance is Southwest giving notification given on cancelled flights ?

 

https://www.wsbtv.com/news/national/american-airlines-extends-boeing-plane-flight-cancellations/966882006

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Wally Fairway

Wally Fairway 5575

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Posted (edited)
8 hours ago, DaysOff said:

https://www.flightglobal.com/news/articles/a321neo-operators-alerted-over-excessive-pitch-ano-459718/?fbclid=IwAR0OqhQs-YSsJEn8YrUQd9XSsvKouAFXv6P8aieeVpEp7e8SCJXw9TTUIr8

Ground em

Start your own damn scAirbus thread, this one is full up on Boeing issues.

Edited by Wally Fairway
typo/spelling
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Wally Fairway

Wally Fairway 5575

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WSJ article today about the 737 Maxx

Quote

By 

Andrew Tangel, Andy Pasztor and Mark Maremont

Aug. 16, 2019 10:43 am ET

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TEXT

180 RESPONSES

Almost as soon as the wheels of Ethiopian Airlines Flight 302 spun free from the runway March 10, the instruments in front of Capt. Yared Getachew went haywire.

The digital displays for altitude, airspeed and other basic information showed dramatically different readings from those in front of his co-pilot. The controls in Capt. Getachew’s hands started shaking to warn him the plane was climbing too steeply and was in imminent danger of falling from the sky.

Soon, a cascade of warning tones and colored lights and mechanical voices filled the cockpit. The pilots spoke in clipped bursts.

“Command!” Capt. Getachew called out twice, trying to activate the autopilot. Twice he got a warning horn.

Another powerful automated flight-control system called MCAS abruptly pushed down the jet’s nose. A computerized voice blared: “Don’t sink! Don’t sink!”

The pilots wrestled with the controls, desperate to raise the nose of their Boeing 737 MAX. Three times Capt. Getachew instructed co-pilot Ahmed Nur Mohammed, “Pull up!”

At the same time, a loud clacking warned the preoccupied pilots that the plane was flying too fast.

Four minutes into the flight, the pilots finally touched on the source of their problems, simultaneously calling out “Left alpha vane!”

Fatal Emergency

A jumble of loud and contradictory warnings confronted the captain and his co-pilot of Ethiopian Airlines Flight 302 shortly after takeoff on March 10.

Air Traffic Control granted Ethiopian Airlines Flight 302 clearance to take off. About a minute after takeoff, the airplane’s left and right ‘angle of attack’ vanes recorded different values, unbeknownst to the pilots. Investigators believe a bird strike damaged the captain-side vane.

Stick shaker control vibrates

A stall-warning known as a ‘stick shaker’ causes the captain's controls to start vibrating. Different altitude, air speed and pitch-related readings appear on the captain’s and first officer’s displays.

Captain: ‘Command’—a standard call-out for autopilot engagement—is called out twice.

Autopilot warning audible warning

The crew twice attempted to engage autopilot, but hear an autopilot warning instead, signaling that system wouldn’t activate.

The pilot’s autopilot was engaged, followed by the plane slightly rolling and accelerating sideways.

Captain: Advised first officer to request to maintain runway heading, noting flight-control problems.

Autopilot disengaged again.

MCAS, which stands for the Maneuvering Characteristics Augmentation System, misfired for nine seconds, using the horizontal stabilizer to push down the plane’s nose, arresting the climb and causing the jet to descend slightly.

‘DON’T SINK’ alerts by the plane’s Ground Proximity Warning System (GPWS) sounded.

A few seconds later, the pilots pulled back the controls and the airplane began to climb.

Three more GPWS ‘DON’T SINK’ alerts occurred from 8:40:23 to 8:40:31 a.m.

The pilots used electric trim switches on the yoke to order the plane’s nose up, but its angle remained largely unchanged. Eight seconds later, MCAS automatically misfired for a second time.

Captain: Asked first officer to work with him to raise the nose.

First-officer: Called out ‘stab trim cut-out’ twice. Captain agreed.

Electric trim commands counteracted the stabilizer’s movement pushing the plane downward, before the crew hit the trim cut-out switches that disable electric motors that control the horizontal stabilizer.

Captain: Called out ‘pull up’ three times.

First-officer: Acknowledged.

MCAS tried but failed to push down nose, because the pilots had disabled the automated feature.

First-officer: Made request to air-traffic controllers to maintain 14,000-feet altitude and reported flight-control problems.

For roughly the next two and a half minutes, the stabilizer position gradually moved the aircraft in the nose-down direction. The pilots were pulling back on the yoke to raise the nose the entire time. The captain's indicated airspeed increased from approximately 351 mph to approximately 391 mph. The first officer's indicated airspeed was approximately 26 mph higher than the captain's.

Captain: Pitch up.

First-officer: Acknowledged.

Overspeed clacker audible warning

The first officer's overspeed clacker was recorded on the cockpit voice recorder (and remained active until the end of the recording). Shortly thereafter, the captain's overspeed warning activated (and was intermittently until the end of the recording).

Captain: Asked if the ‘trim’ system that controls the horizontal stabilizer was functional.

First-officer: Responded the trim wasn't working and asked if he could try it manually.

Captain: Told first officer to try it.

First-officer: Reported it isn't working. Requested a vector to return from Air Traffic Control, which was approved.

Captain: ‘Left alpha vane.’ Told the first officer pitch up together, and that pitch is not enough.

First-officer: ‘Left alpha vane.’

The first officer mentioned ‘Master Caution Anti-Ice,’ noting an alert that prompts pilots to look up at indicators on an overhead panel.

Two momentary manual electric trim inputs from the pilots are recorded in the nose-up direction. The stabilizer moved the aircraft in the nose-up direction.

MCAS misfired for the third and final time – pushing the plane’s nose down for five seconds – indicating the pilots had turned the automated system and associated electric trim motors back on. The aircraft began pitching nose down. Additional manual pulls on the control columns failed to stop the nose from eventually reaching a 40-degree downward angle. 

Seconds later, Flight 302 crashed, killing all 157 people on board.

‹›

RETURN TO BEGINNING

Note: All times are local and correspond to at least one event in each panel.

Sources: Ethiopian air-safety investigators, pilots and safety experts; Photos: Mulugeta Ayene/Associated Press (plane); Dimas Ardian/Bloomberg News (cockpit)

Erroneous signals from that malfunctioning sensor tricked the onboard computers into believing the jetliner’s nose was angled too high, causing MCAS to push it down again and again.

It was too late. Flight 302 nose-dived at nearly the speed of sound, hitting the ground with such force that an airliner with 157 people aboard was largely reduced to fragments no bigger than a man’s arm.

Five months earlier, Lion Air Flight 610 had plunged into the Java Sea, killing 189 people, under similar circumstances.

Regulators have focused since the crashes on MCAS, its reliance on a single sensor andBoeing BA 0.54% ’s decision not to tell pilots about the new system. At the root of the miscalculations, though, were Boeing’s overly optimistic assumptions about pilot behavior.

In designing the flight controls for the 737 MAX, Boeing assumed that pilots trained on existing safety procedures should be able to sift through the jumble of contradictory warnings and take the proper action 100% of the time within four seconds.

That is about the amount of time that it took you to read this sentence.

Boeing bet nearly everything on those four ticks of the clock. The company’s belief in its engineering, and its reliance on pilots to be flawless cogs, enabled Boeing to speed the latest iteration of its most important airliner to market and ultimately saved money for its customers.

Now, the aerospace giant is sorting through the consequences: two crashes, a global grounding of the MAX fleet, frustrated airlines and the gravest threat to Boeing in its modern history.

The company is under investigation by federal prosecutors, securities regulators, aviation authorities and lawmakers. It faces more than 100 lawsuits from families of the 346 dead. It may have to further slow or temporarily halt production of the MAX if flight restrictions last much longer. And its troubles are disrupting travel for passengers as well as clouding the outlook for airlines, aerospace suppliers and their tens of thousands of workers.

A Boeing 737 Max 8 in production at Renton, Wash. PHOTO: GARY HE/EPA/SHUTTERSTOCK

Interviews with current and former Boeing employees, pilots, airline officials, federal regulators and documents reviewed by The Wall Street Journal show that Boeing repeatedly minimized the risks posed by MCAS, without detailed scrutiny or pushback from U.S. regulators. Engineers assumed pilots would be able to almost instantly counteract an MCAS malfunction, like the ones on the two doomed flights, by executing a long-established emergency procedure for a similar problem.

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The assumptions dovetailed with a vital company goal. To make the plane as inexpensive as possible for airlines to adopt, Boeing was intent on persuading regulators that pilots of earlier 737s should be allowed to start flying the MAX without simulator training. That training would have been required if there were substantial safety differences between the models, boosting the plane’s cost to airlines since training cuts into time flying paying passengers.

“Our marching orders are no training impact on this airplane. Period,” Richard Reed, a former Federal Aviation Administration engineer, recalled a senior Boeing official telling him during a meeting in the early years of the MAX’s development.

The company had promised its biggest customer for the MAX, Southwest Airlines Co. , that it would pay it $1 million per plane ordered if pilots needed to do additional simulator training, according to Rick Ludtke, a Boeing engineer who worked on the jet’s cockpit systems, and another person who had been involved in the airplane’s development.

A Boeing spokesman said the design and certification of MCAS, including reliance on pilots as the ultimate safety net, were part of a methodical six-year effort that followed accepted industry practices. He also said overall approval of the MAX met “stringent standards and requirements” set by federal regulators.

“We will continue to learn from the reviews and the lessons from these accidents to continue improving safety,” the spokesman said, citing the continuing investigations.

Boeing CEO Dennis Muilenburg (lower left) joining test pilots for an April flight of updated MCAS software on a 737 MAX 7. PHOTO: PAUL WEATHERMAN/BOEING/AGENCE FRANCE-PRESSE/GETTY IMAGES

In trying to get the MAX flying again, Boeing will now rely on two sensors, give pilots information it had withheld about the existence of MCAS and lessen the system’s authority. It will also turn on safety alerts that had only operated in a small number of the planes and make emergency procedures no longer dependent upon textbook pilot reactions.

The FAA is reassessing some of its key assumptions. The agency said certification procedures are “well-established and have consistently produced safe aircraft designs,” but it is rethinking reliance on average U.S. pilot reaction times as a design benchmark for planes that are sold in parts of the world with different experience levels and training standards.

Related Video

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0:00 / 4:36

How Boeing’s 737 MAX Troubles Ripple Through the Industry

Two crashes and the global grounding of Boeing’s 737 MAX commercial airliner led to extensive disruption in the international aerospace industry. WSJ’s Robert Wall explains the continuing effects of the plane’s grounding. Photo: Getty Images

Boeing began developing the MAX in 2011 as bitter rival Airbus SE began making inroads with its A320neo. Boeing, needing a fuel-efficient single-aisle airliner to avoid losing market share, rushed to lock in deals before its board approved building the jet.

To use less fuel, the design called for larger engines that would be moved forward and higher than in the previous model. The changes affected how the plane handled, though. Its nose pitched up in certain high-altitude conditions, risking a stall, the term for a sudden loss of force called lift that keeps planes aloft.

Engineers developed MCAS, which stands for Maneuvering Characteristics Augmentation System, to manage that. The system operated behind the scenes, pushing down the plane’s nose by moving the horizontal stabilizer on the tail by small increments of 0.6 degree.

Boeing officials were focused on making the MAX fly as similarly as possible to earlier 737s. The fewer differences, the less likely the FAA would require pilots to undergo retraining.

Mr. Ludtke, the former Boeing cockpit engineer, said company managers put pressure on engineers to avoid tweaks in designs that could result in pilots needing to learn new maneuvers in a simulator.

Financial Fallout

The protracted grounding of Boeing's 737 MAX has prevented the aerospace giant from delivering its most popular jet, costing it sales, dragging down profit and shrinking its market value amid competition with rival Airbus.

At one point around 2013, Boeing officials fretted the FAA would require simulator training, the person involved with the plane’s development said. But the officials, including chief MAX engineer Michael Teal, opted not to work with simulator makers to simultaneously develop a MAX version because they were confident the plane wouldn’t differ much from earlier 737s.

“It was a high-stakes gamble,” this person said.

The Boeing spokesman said that as with any new version of an existing airplane, minimizing differences was a goal for the MAX. “But this design objective was only that—an objective—and was always subordinate to other requirements, including safety.” Boeing always had a plan to help develop a MAX simulator and didn’t delay it out of concerns the FAA might require pilot training, he said.

Some Boeing engineers who worked on the MAX said MCAS wasn’t seen as an important part of the flight-control system. They focused on other functions they deemed to be more critical to safety, such as an auto-landing system.

In meetings with Boeing officials at an FAA office in the Seattle area around 2013, the plane maker described the system as simply a few lines of software code, according to Mr. Reed, the former FAA engineer who participated in those discussions.

The company outlined how a single sensor that measured the angle of the plane’s nose would trigger MCAS, Mr. Reed recalled, but argued a failure wasn’t likely and the system would kick in only in extreme conditions.

“Let’s quit messing around about the chances of this happening being rare,” Mr. Reed remembered saying. “If it can happen, it’s going to happen.”

Boeing assigned MCAS a technical-hazard rating of “major” during everyday operations, meaning its failure was unlikely to result in death or the loss of the plane. Multiple sensors aren’t required by the FAA for that designation, on the assumption that the crew could handle any failure. Boeing said another sensor would have added unneeded complexity. Other systems on earlier 737s relied on single sensors, according to former Boeing engineers and others familiar with the designs.

Pilots Craig Bomben, left, and Ed Wilson stepping out a Boeing 737 Max in January 2016 after its first flight at Boeing Field in Seattle. PHOTO: ELAINE THOMPSON/ASSOCIATED PRESS

The Boeing spokesman said a single sensor “satisfied all certification and safety requirements,” and potential additional training wasn’t considered when assessing MCAS hazards.

From the start, safety-assessment documents Boeing provided to the FAA assumed pilots would be able to handle misfires.

Regulators endorsed that determination, along with the single sensor. The FAA certification rules under which the MAX was allowed to fly assume pilots react correctly to certain emergencies 100% of the time.

As part of its calculus, Boeing decided it didn’t need to tell cockpit crews about MCAS or how it worked. During early design phases, Boeing referred to the system by name in a draft manual, parts of which were reviewed by the Journal, and explained generally what it was supposed to do. Those references disappeared before it was issued to airlines.

The company reasoned that pilots had trained for years to deal with a problem known as a runaway stabilizer that also can force the nose of the plane to dip. The correct response to an MCAS misfire was identical. Pilots didn’t need to know why it was happening.

Late in the design process, however, Boeing gave MCAS greater authority. Test pilots for the company and FAA discovered that the MAX’s controls didn’t stiffen as needed during certain lower-speed maneuvers, according to people familiar with the MCAS design. They suggested MCAS be expanded to work at lower speeds so the MAX could meet FAA regulations, which require a plane’s controls to operate smoothly, with steadily increasing amounts of pressure as pilots pull back on the yoke.

To adjust MCAS for lower speeds, engineers quadrupled the amount the system could repeatedly move the stabilizer, to increments of 2.5 degrees. The changes ended up playing a major role in the Lion Air and Ethiopian crashes.

After increasing the system’s potency, though, Boeing didn’t submit a new safety assessment to the FAA, according to people familiar with the matter. While a top FAA pilot knew about the changes, other officials were in the dark and some now say an updated safety assessment could have provided a chance to find problems.

The system’s evolution and lack of an updated safety assessment were earlier reported by the Seattle Times. The FAA has said Boeing wasn’t required to update the document.

The assumptions about pilot reaction stayed the same even though a misfire could now lead to a fatal battle between pilot and machine.

The Boeing spokesman said engineers determined the changes didn’t affect the overall hazard assessment, saying the company briefed the FAA and international regulators on MCAS, including its final configuration, several times.

Ethiopian Airlines pilots and crew members attended a service for crash victims at Holy Trinity Cathedral in Addis Ababa in March. PHOTO: EPA/SHUTTERSTOCK

Those specifics, including the system’s expanded authority at lower speeds, were mentioned in a letter and in a number of Boeing presentations to FAA officials monitoring the MAX, according to people briefed on the communications. But senior FAA officials in Washington weren’t told, and many others inside the agency continued to depend on Boeing’s initial descriptions of MCAS.

FAA training experts, unaware MCAS had been made more potent, ultimately decided the MAX’s handling characteristics were close enough to those of previous 737s that pilots could learn changes in a few hours on a laptop or tablet. It went into service in 2017.

Southwest Airlines, the jet’s first and biggest customer, followed Boeing’s lead and deleted MCAS from the manuals and emergency procedures it devised for its pilots. Other carriers didn’t mention it, either.

On Oct. 28, 2018, an alarm called a stick shaker went off on a Lion Air 737 MAX flight from Denpasar, Indonesia, to Jakarta, causing one of the pilots’ controls to vibrate heavily, warning of an aerodynamic stall.

MCAS pushed down the plane’s nose. Faulty data from a malfunctioning sensor had set off a false-stall alarm and caused MCAS to misfire.

The puzzled cockpit crew checked a quick reference handbook, running through other emergency steps before successfully regaining control of the plane by executing the checklist for a runaway stabilizer. That turned off MCAS and the crew flew manually for the rest of the trip.

Indonesian aviation officials said the pilots had difficulty finding a solution because they had trouble diagnosing the problem. “It’s instinct. Not in the book,” said Avirianto, the Transportation Ministry’s director of airworthiness and aircraft operations, who uses one name, like many Indonesians.

The cockpit crew and mechanics didn’t note the severity of the issue in maintenance logs. The next day, the same aircraft took off from Jakarta as Lion Air Flight 610 with the faulty sensor.

The flight crew immediately faced the same problem. The nose repeatedly pushed down. The crew counteracted the system some two dozen times, using thumb switches on the controls. But the pilots never ran the full emergency procedure that would have turned off MCAS.

After 11 minutes in the air, the crew lost control, and the plane crashed into the sea.

Several days after the crash, Kevin Greene, the FAA’s chief engineering test pilot for the MAX, told about a dozen agency officials on a conference call that MCAS was suspected of having played a role in the accident, according to a person familiar with the agency’s response.

“What’s MCAS?” one FAA official asked, according to people familiar with the call. The FAA declined to make Mr. Greene available for comment.

Shoes found during a search for victims of the ill-fated Lion Air flight 610, collected at the Jakarta International Container Terminal on Oct. 31, 2018. PHOTO: BAY ISMOYO/AGENCE FRANCE-PRESSE/GETTY IMAGES

Agency officials were surprised to learn documents on file at its Seattle-area office failed to mention how the souped-up version of MCAS worked, according to people familiar with the matter. Those papers described MCAS as having one-fourth the control it now had and made no mention that it fired repeatedly.

Around the same time, an internal FAA assessment determined the brawnier MCAS posed an unreasonably high safety risk, one that could result in a similar malfunction on another MAX within months.

Boeing decided for the first time to detail MCAS’s function in a bulletin to airlines. The manufacturer and the FAA also reminded pilots of the emergency procedure. This was supposed to buy Boeing time to work on a permanent solution: a software fix that would include comparing data from both onboard sensors.

Despite the confusion that enveloped the Lion Air cockpit, FAA leaders still backed Boeing’s reliance on swift, unerring pilot response, according to an FAA official who was part of the deliberations. The company and the FAA assured the public the MAX was meanwhile safe to fly.

In the weeks after the crash, outside pilots, FAA officials and U.S. safety investigators were brought in to help Boeing engineers recheck their assumptions about pilot response, people familiar with the matter said.

Simulator tests revealed that an MCAS misfiring produced more alarms than pilots would see with a typical runaway stabilizer, the person familiar with the FAA response said.

What surprised FAA officials, this person said, was a demonstration that showed what happened if pilots failed to take action as expected under Boeing’s design assumptions—more than two MCAS misfires could push the plane’s nose down so much that it became uncontrollable and likely to end in catastrophe.

“It made us realize that this was pretty serious,” the person said.

Still, the pilots in those simulator sessions responded as expected, people familiar with the results said, executing Boeing’s emergency procedure properly and in time.

“Nobody…walked away saying, ‘There’s a mistake here,’” one of the people familiar with the MCAS design said. Still, the tests left company officials with the feeling: “OK, we see that that is confusing, and somehow we got two flight crews who responded differently than we would have expected.”

The FAA agreed no urgent changes were required. The MAX fleet kept flying without restrictions or additional pilot training.

Historically, Boeing’s engineering philosophy has put aviators at the center of every new design—ensuring pilots could override computer commands—while simultaneously embracing automation to reap the safety benefits. The year before the Lion Air crash was the safest world-wide in the history of commercial air travel. U.S. airlines suffered a single passenger fatality over roughly a decade.

From 747 jumbo jets in the 1970s through the latest wide-body 777 and 787 models, the concept thrived. Boeing prided itself on building airliners that allowed crews to overcome almost any automated function without having to take extra steps to disable underlying systems. Even as automation helped pilots cope with problems from engine failures on takeoff to excessive speed during landings, they retained ultimate control.

Since the late 1990s, though, U.S. accident investigators have recognized that real-world reactions by pilots don’t always measure up to FAA expectations.

“No consideration is…given to imperfect human performance,” Benjamin Berman, a former National Transportation Safety Board staffer who investigated the 1994 crash of a USAir 737 near the Pittsburgh airport, argued in a 2003 paper.

Crash Consequences

FAA rules typically assume “the human will intervene reliably every time,” Mr. Berman added, calling it “an unrealistic assumption for human performance.”

In 1996, an FAA study of a subset of experienced propeller-plane pilots found that only one out of 26 reacted to a similar stabilizer emergency within four seconds.

A 2008 study for the FAA, one of the most recent, found commercial pilots in simulator tests sometimes became confused when confronted with unfamiliar failures and reiterated that certification standards were unrealistic.

There are many accidents where “pilots theoretically should have been able to save the day, but they took the wrong action, or no action,” said Tony Lambregts, a retired FAA engineer who studied the interaction between people and machines.

Boeing compounded the problem with the MAX, he said, by initially not notifying pilots MCAS existed. “The pilots were hopelessly unprepared to deal with that,” Mr. Lambregts said. “They hadn’t been adequately instructed and trained for it.”

One thing Boeing failed to account for, pilots and some FAA officials said, is that there are different methods for straightening up a jetliner whose nose is pointed too far down. Some pilots use switches on the controls in different ways, and many may instinctively pull back on the yoke to bring the nose up.

In earlier 737s, pulling back on the yoke also turned off a different automated flight-control system and allowed the pilots to manually fly. Boeing didn’t tell pilots that the MAX was different: When they pulled back on the controls, the nose could rise, but it didn’t shut off MCAS, which could keep misfiring, pushing the nose down. MCAS’s design required the change, according to people familiar with the matter.

As details of the Lion Air crash trickled out, pilots pressed Boeing about why they had been kept in the dark.

In late November, Boeing officials, including Mike Sinnett, the vice president for product strategy, Craig Bomben, a senior pilot, Allan Smolinski, sales director for the Americas, and John Moloney, director of transportation policy, visited American Airlines’ pilot union in Fort Worth, Texas.

The pilots wanted to know why Boeing had excluded MCAS from their manuals, except for a mention in the glossary, when they were expected to be the ultimate, non-automated backstop for the system.

Ethiopian Airlines Captain Yared Getachew fought without success to correct the glide path of Flight 302 on March 10.

“We are the human element,” Capt. Mike Michaelis, then-chairman of the union’s safety committee, told them, according to a recording.

Mr. Sinnett asked the pilots why they needed to know whether MCAS or another problem was pushing down the plane’s nose.

“We struggle with this,” Mr. Sinnett said. “If there are three or four or five things that could cause a runaway stabilizer, why do you need to know which one it is before you operate the procedure?”

“This particular one is masked by so many other distractions,” one pilot responded. “I think it’s very unique.”

With no mention of MCAS, or the ways it could fail, in the manual, many pilots might have a difficult time coming up with the correct response in an emergency.

Four months after the meeting, Ethiopian Airline Flight 302 would prove the point in deadly fashion.

In warning airlines about MCAS after the Lion Air crash, Boeing and the FAA made note of the alerts that could help diagnose a malfunction, including one alert that was a feature on earlier 737 models, called the “AOA Disagree.”

It was supposed to tell pilots when the MAX’s two “angle-of-attack” sensors showed different readings. Even though MCAS used data from only one, other onboard systems could compare both and warn pilots.

“Please be informed that if there are any other associated message like AOA DISAGREE or there is an airspeed difference the runaway stabilizer checklist must be done first before proceeding to the other checklists,” Capt. Theodros Asfaw Tilahun, a management pilot for Ethiopian Airlines, emailed colleagues on Nov. 8, shortly after the Lion Air crash.

Trouble was, that alert feature wasn’t activated on MAX jets operated by Ethiopian and many other airlines. A contractor had made mistakes in software meant to activate them, but Boeing had told only certain airlines.

Boeing, which maintains the alerts aren’t critical safety items, instead billed them as part of an optional package. The Boeing spokesman said Ethiopian didn’t purchase it, noting that one of the plane maker’s bulletins, after the Lion Air crash, indicated the alerts would only work with that package. The airline didn’t respond to requests for comment.

Among the recipients of the email about the nonexistent alert was Mr. Getachew, the captain who wrestled with a misfiring MCAS on March 10. During that desperate struggle, the crew turned off MCAS, only to later switch it back on.

About five minutes after takeoff, the doomed 737 MAX slammed into the brown earth of a farm near Bishoftu, Ethiopia, at more than 550 miles an hour.

The crater caused by the March crash of Ethiopian Airlines Flight 302. PHOTO: BAZ RATNER/REUTERS

—Alison Sider, Robert Wall, Daniel Michaels, Ben Otto, Gabriele Steinhauser, Elisa Cho and Jim Oberman contributed to this article

https://www.wsj.com/articles/the-four-second-catastrophe-how-boeing-doomed-the-737-max-11565966629?mod=hp_lead_pos5

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bschoolprof

bschoolprof 6271

Posted
Posted
2 minutes ago, Wally Fairway said:

WSJ article today about the 737 Maxx

https://www.wsj.com/articles/the-four-second-catastrophe-how-boeing-doomed-the-737-max-11565966629?mod=hp_lead_pos5

I was just about to post that.  I don't know if poors can see it, but they give a nice breakdown of the accident sequence with graphics and what the pilots did.

Here are the verbal descriptions without the graphics.  Maybe some of the pilots could weigh in?

8:37:34 a.m.

Air Traffic Control granted Ethiopian Airlines Flight 302 clearance to take off. About a minute after takeoff, the airplane’s left and right ‘angle of attack’ vanes recorded different values, unbeknownst to the pilots. Investigators believe a bird strike damaged the captain-side vane.

8:38:44 a.m.

A stall-warning known as a ‘stick shaker’ causes the captain's controls to start vibrating. Different altitude, air speed and pitch-related readings appear on the captain’s and first officer’s displays.

8:38:58 a.m.

The crew twice attempted to engage autopilot, but hear an autopilot warning instead, signaling that system wouldn’t activate.

 

The pilot’s autopilot was engaged, followed by the plane slightly rolling and accelerating sideways.

8:39:55 a.m.

Captain: Advised first officer to request to maintain runway heading, noting flight-control problems.

Autopilot disengaged again.

8:40:00 a.m.

 

MCAS, which stands for the Maneuvering Characteristics Augmentation System, misfired for nine seconds, using the horizontal stabilizer to push down the plane’s nose, arresting the climb and causing the jet to descend slightly.

8:40:03 a.m.

‘DON’T SINK’ alerts by the plane’s Ground Proximity Warning System (GPWS) sounded.

A few seconds later, the pilots pulled back the controls and the airplane began to climb.

8:40:12 a.m.

Three more GPWS ‘DON’T SINK’ alerts occurred from 8:40:23 to 8:40:31 a.m.

The pilots used electric trim switches on the yoke to order the plane’s nose up, but its angle remained largely unchanged. Eight seconds later, MCAS automatically misfired for a second time.

8:40:27 a.m.

 

Captain: Asked first officer to work with him to raise the nose.

First-officer: Called out ‘stab trim cut-out’ twice. Captain agreed.

Electric trim commands counteracted the stabilizer’s movement pushing the plane downward, before the crew hit the trim cut-out switches that disable electric motors that control the horizontal stabilizer.

8:40:41 a.m.

 

Captain: Called out ‘pull up’ three times.

First-officer: Acknowledged.

MCAS tried but failed to push down nose, because the pilots had disabled the automated feature.

8:40:42 a.m.

 

First-officer: Made request to air-traffic controllers to maintain 14,000-feet altitude and reported flight-control problems.

For roughly the next two and a half minutes, the stabilizer position gradually moved the aircraft in the nose-down direction. The pilots were pulling back on the yoke to raise the nose the entire time. The captain's indicated airspeed increased from approximately 351 mph to approximately 391 mph. The first officer's indicated airspeed was approximately 26 mph higher than the captain's.

8:41:30 a.m.

 

Captain: Pitch up.

First-officer: Acknowledged.

Overspeed clacker audible warning

The first officer's overspeed clacker was recorded on the cockpit voice recorder (and remained active until the end of the recording). Shortly thereafter, the captain's overspeed warning activated (and was intermittently until the end of the recording).

8:41:46 a.m.

 

Captain: Asked if the ‘trim’ system that controls the horizontal stabilizer was functional.

First-officer: Responded the trim wasn't working and asked if he could try it manually.

8:41:54 a.m.

 

Captain: Told first officer to try it.

First-officer: Reported it isn't working. Requested a vector to return from Air Traffic Control, which was approved.

8:42:54 a.m.

Captain: ‘Left alpha vane.’ Told the first officer pitch up together, and that pitch is not enough.

First-officer: ‘Left alpha vane.’

The first officer mentioned ‘Master Caution Anti-Ice,’ noting an alert that prompts pilots to look up at indicators on an overhead panel.

8:43:11 a.m.

 

Two momentary manual electric trim inputs from the pilots are recorded in the nose-up direction. The stabilizer moved the aircraft in the nose-up direction.

8:43:20 a.m.

 

MCAS misfired for the third and final time – pushing the plane’s nose down for five seconds – indicating the pilots had turned the automated system and associated electric trim motors back on. The aircraft began pitching nose down. Additional manual pulls on the control columns failed to stop the nose from eventually reaching a 40-degree downward angle. 

Seconds later, Flight 302 crashed, killing all 157 people on board.

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bschoolprof

bschoolprof 6271

Posted
Posted

So my layman understanding is that they cut the switches to prevent the MCAS nose down inputs (which is what was talked about a ton on this thread), but the stabilizer was still trimmed to a nose down position (presumably because it just stayed where it was) and the manual trim adjustments weren't working, perhaps in part because the plane was going too fast.  So they turned the automated trim system back on, MCAS took over, and then they crashed.  What should they have done? Slowed down? 

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Brisketexan

Brisketexan 105285

Posted
Posted

This is the part that bothers me the most:

Quote

8:40:41 a.m.

 

Captain: Called out ‘pull up’ three times.

First-officer: Acknowledged.

MCAS tried but failed to push down nose, because the pilots had disabled the automated feature.

8:40:42 a.m.

 

First-officer: Made request to air-traffic controllers to maintain 14,000-feet altitude and reported flight-control problems.

For roughly the next two and a half minutes, the stabilizer position gradually moved the aircraft in the nose-down direction. The pilots were pulling back on the yoke to raise the nose the entire time. The captain's indicated airspeed increased from approximately 351 mph to approximately 391 mph. The first officer's indicated airspeed was approximately 26 mph higher than the captain's.

So....it seems that these guys did what you're supposed to (disable the MCAS)....and the stabilizer was still pushing the plane nose-down?

At this point, I'm pretty comfortable saying nope, no, no fucking way will I ever fly on a 737 Max, no matter what the FAA ends up saying.  I think there's a damned good chance this whole fiasco drives Boeing to bankruptcy.

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retread

retread 2951

Posted
Posted (edited)
45 minutes ago, bschoolprof said:

So my layman understanding is that they cut the switches to prevent the MCAS nose down inputs (which is what was talked about a ton on this thread), but the stabilizer was still trimmed to a nose down position (presumably because it just stayed where it was) and the manual trim adjustments weren't working, perhaps in part because the plane was going too fast.  So they turned the automated trim system back on, MCAS took over, and then they crashed.  What should they have done? Slowed down? 

The pilots can correct me if I'm off, but I think turning the stab trim cut-out switches off early enough is the key. If you don't, the factors you list play against you.

I think Lion Air tried to use the thumb switch on the yoke (electric trim adjust) more than the Ethiopian flight. Still, they didn't turn of the stab trim switches soon enough. MCAS' actions were more influential than the thumb switch used by the pilot.

Lion Air FDR https://static.seattletimes.com/wp-content/uploads/2018/11/LionAir-BlackBox-WEB-1560x1040.jpg

Edited by retread
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