Boeing - Design Issues...

Discussion in 'Rules and Regulations / Flight Safety / Better Pil' started by TXFlyGuy, Apr 11, 2019.

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  1. Oct 26, 2019 #341

    davidb

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    After reviewing the flight data, I now see the pilot was controlling the throttles and was mostly respecting the flap and aircraft speed limitations. I was wrongly confusing the data from the second crash with this one.

    This captain’s initial actions were within the range of responses of average pilots, IMO. No, he didn’t do or know the immediate actions for airspeed unreliable but he was controlling pitch and power. His performance was below average and his decision to fly while suffering flu symptoms probably didn’t help. However, he probably could have eventually figured out how to recover the aircraft to a safe landing, but...

    Compound emergencies present challenges that make it hard to predict a typical pilot response. The MCAS effectively required this crew to perform two separate emergency checklists; airspeed unreliable and runaway stab trim. Confusion with the first effectively masked the need for the second.

    The captain (at a subconscious level) knew of the trim malfunction. Yeah, it’s simple enough to just flip the switches off per memory items but human factors of multiple or compounded emergencies muddies the water.

    FWIW, at least one airline sampled crew response to the same scenario in the simulator. In keeping with “first look” criteria, no prior discussion or training was provided before surprising the crews. While crew performance varied, all were able to recover and land safely.
     
  2. Oct 26, 2019 #342

    BBerson

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    I only got to page 45 of the report so far. Seems maintenance faults could be a partial cause. I don't think the maintenance was adequate in repair or reporting the seriousness of the situation to unlucky pilots and authorities and Boeing. That aircraft had serious control issues from the first time and should not fly with passengers after a simple reset by a mechanic.
    In the U.S.A., immediate notification of a flight control system malfunction or failure is required (49CFR 830)
    Just my opinion of a contributing factor.
     
  3. Oct 27, 2019 #343

    davidb

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    Take it slow and don’t hurt yourself. Hundreds more pages of OMGs and contradictions to go.
     
  4. Oct 27, 2019 #344

    BBerson

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    That cockpit voice recording transcript was quite upsetting. The captain kept some control for several minutes. It wasn't a "run away trim". It was a repeated intermittent down trim that he fought with no prior knowledge of the system.
     
  5. Oct 27, 2019 #345

    davidb

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    That he fought successfully but then transferred control to the first officer who wasn’t afforded a clue.
     
  6. Oct 27, 2019 #346

    BBerson

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    Well the first officer was giving some up trim (Aircraft Nose Up) just like the captain. I don't know why he didn't give more up trim? But he was holding 95 pounds back pressure on the yoke. Shouldn't that be enough?
     
  7. Oct 27, 2019 #347

    Vigilant1

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    Thinking a bit more about this, the public will always be at a knowledge disadvantage in this scenario, and consumer advisory rating services have spotty records (Exhibit A: Bond rating agencies (Moody's, S&P, and Fitch) and their failure to properly report bond risks before the 2007-2008 financial crisis. So dirty that somebody should have gone to jail).
    Ya know which watchdogs really work? Insurance companies. The companies that insure those fleets of airplanes have a direct interest in crew training, maintenance, operational procedures, etc. They will make it their business (literally) to know that the crews are safe and the maintenance isn't pencil whipped. Higher risk = higher rates, or cancelled policies--and there are only so many insurers. Now, if an airline is big enough to underwrite their own hulls, then that's a different story. But airlines that pop up out of nowhere (which are a major source of safety issues) can't do that, and they also can't lease or get financing for their jets unless they can get insurance. Underwriters know risk and they are very hard to fleece.
    Were does this fall apart? Look at some of the most unsafe airlines, dig around a little, and you'll find a government re-insurance program. Often there's some corruption or questionable activity at the establishment of these programs, and they have the effect of vastly limiting the liability of the private insurers (or they eliminate the insurers entirely, with direct government insurance of the fleets). Voila! The airline's problem is solved, those pesky insurance folks are a lot less concerned about training, maintenance, etc. if they aren't on the actual hook for the actual risk.
     
    Last edited: Oct 27, 2019
  8. Oct 27, 2019 #348

    flyboy2160

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    V, can you give an example or two, or do we have to re-investigate it? Thanks.
     
  9. Oct 27, 2019 #349

    Vigilant1

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    The Lion Air situation is a good example.
    -- Many of their aircraft are owned by others and leased by Lion Air. For example, the Boeing 737 that crashed last Oct (Flight JT610). From here:
    Here's a snapshot of CMIG, they are on shaky ground (not due to the airliner crash, but due to other business practices). Ostensibly a private company, they are heavily intertwined with the Chinese government and Chinese Communist party, and not exactly private. Let me know if you ever find out who insured the hull on that crashed B737--if it is a truly private insurer with someone's private money at stake, I'll eat my hat.
    What about the compensation to victims? Was there a private insurer on the hook for that, an entity that might be very concerned with air safety at Lion Air? Nope. All of the (paltry) compensation came from an Indonesian state insurer.

    In the case of the Ethiopian Airlines 737 crash, it looks like private insurers are on the hook, though they will work hard to spread the costs to Boeing. Ethiopian Airlines has a good safety record overall (something few would say about Lion Air).
     
  10. Oct 27, 2019 #350

    BBerson

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    If you are saying the captain neglected to advise the first officer about the need for constant repeated up trim, then I strongly agree that was a big mistake on the part of the captain. He was not strong on communication.

    And the captain of the first incident flight was negligent in not advising mechanics about the trim switch being turned back on after landing.
     
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  11. Oct 27, 2019 #351

    Speedboat100

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    SVSU Steve is absolutely correct on this matter.
     
    Last edited: Oct 27, 2019
  12. Oct 27, 2019 #352

    Himat

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    I have not yet read all of the report but started with looking at the analysis and conclusion. From that and following this and other treads on certification and safety I do see one regulatory problem at the very start.

    The possibility for airplane manufacturers to make new versions of old designs without a full recertification for what to me look like an infinite time. Combined with a large cost difference in certifying a “modification” to certify a new design, there is a strong incitement to just “modify”. It does not get any better when the operators have the same incitement to keep all aircraft “similar” to cut training cost.

    A start would be that all aircraft had had to comply with the certification criteria at the time of assembly. Every time there is a new rule the manufacturers get one or two years to comply to new regulations.
     
  13. Oct 27, 2019 #353

    Wanttaja

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    Traditionally, Boeing employees received a bonus of 10-15% every year.

    News announcement this week: No bonuses, this year.

    Probably separate from executive bonuses, though....

    Ron Wanttaja
     
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  14. Oct 27, 2019 #354

    flyboy2160

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    I read the Lion Air report cited above. The piling on Boeing is being done by people justifying a previous prejudice, not based on the facts.

    The performance of the previous flight crews in not reporting their treatment of runaway stab and the shoddy lack of proper testing and lying by the maintenance crews are shockingly negligent.

    The crew that lost the plane performed very poorly. The previous crew correctly dealt technically with this exact problem.

    I can't to see how a failure of the Evil Deadly Cause of All The Earth's Problems MCAS is going to be treated any differently that a 'normal' runaway stab. In the end, it's just another computer flight control error. If the pilots have to keep thumbing the manual trim, shouldn't that immediately indicate a computer controlled trim problem? Don't they train for stuff like that?

    I can only hypothesize that there is a lot pressure at Lion Air to not report things that ground a plane and lose revenue - and safety be damned. That seems to be more of the root cause of this than a failure by Boeing.
     
  15. Oct 27, 2019 #355

    PagoBay

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  16. Oct 27, 2019 #356

    davidb

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    We need to see the next investigation and final report on the second crash. This one has so many factors, some of which seem ignored in the recommendations. The second one will probably help in establishing the best way to enhance safety.

    I mentioned earlier the issue of compound/multiple emergencies that this scenario presented. I believe a “stick shaker during rotation” checklist/procedure should be incorporated into the flight manual and training syllabus for all models of 737. Had such a checklist existed, the Max version would have likely included a note of action should unwanted trim occur. It’s much more effective to put the important information in a checklist than to bury a discussion of MCAS in a system section of the flight manual.
     
  17. Oct 28, 2019 #357

    davidb

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    To add background information and justification for my above post suggesting a stick shaker on takeoff checklist, I offer the following.

    Boeing has stated their justification for not including MCAS information in the flight manual. This justification has been widely refuted by many to include expert pilots. I maintain that any such information buried in the many pages of systems differences would likely not be absorbed as useful to the pilot. Boeing and and many pilots believe the current checklists for runaway stab trim and airspeed unreliable are sufficient for dealing with the Lion Air event. I personally have maintained that I am confident in being able to handle the scenario this crew faced. The crew before them did handle it. The fatal crew did not. The final report concluded Boeing’s assumptions were false. One event proves Boeing’s position. The second event disproved it.

    I am not God’s gift to aviation. I consider myself average and any competency I have comes from training and experience. One thing I remember from my military flight training from decades ago was we used to practice stick shaker on takeoff. I can’t remember if it was a checklist or just a procedure. There is no checklist or procedure for stick shaker on takeoff for the 737 but it has occurred many times I’m told. Perhaps that it has always been handled successfully by pilots in the past is justification for not having a checklist or trained procedure but I suggest we need one now that the facts are in on Lion Air. The indications accompanying stick shaker (which is triggered by AoA sensor) have become quite confusing for someone not knowing what to expect.

    What we need is an all inclusive checklist for stick shaker on takeoff. We have all inclusive checklists for others malfunctions that effectively take you through all actions and considerations all the way to landing. They start with immediate action memory items and then you reference the checklist. Had such a checklist been in place, as part of the Max certification, that checklist would have included the information about possible runaway trim if/when flaps are retracted. The hidden MCAS issue would have been in there by virtue of the process that goes into developing such all inclusive checklists.

    The mere existence of a checklist means you have to be exposed to it in training to get the type rating.

    There you have it. One checklist. No multiple compound emergency. No confusing situation to challenge those on the low end or those having a bad day. We can all safely fly the Max in its original state.
     
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  18. Oct 28, 2019 #358

    Vigilant1

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    The stick shaker on TO sounds like a great idea. Still, I don't think we'll see the Max back in the air "in its original state." The changes to MCAS that have already been announced. Comparisons between both SoA sensors for activation, limited MCAS trim authority, and limited MCAS persistence after being overridden, etc all address the issues we've seen and will make the plane safer. Also, andpolitically,procedures a "training and procedures only" fix won't be acceptable at this point.
     
  19. Oct 28, 2019 #359

    davidb

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    Yeah, I know that. The part you quoted was more of a tic comment. The Max won’t be back in service before the second crash final report is out and not before any and all recommendations are addressed and all parties are satisfied.

    My point with the checklist idea is it actually mitigates all concerns brought up in the report. The plane was/is airworthy and controllable in the hands of any pilot with the proper training and tools, just like all planes. It’s not like the wings fall off.
     
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  20. Oct 28, 2019 #360

    BBerson

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    The plane was not airworthy according to the report. It had a defective or improperly calibrated AOA sensor that caused a flight control malfunction.
    The standard definition of airworthy is compliance with the Type Certificate and other standards and in a condition for safe operation.
     

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