Another (2nd) 737 Max 8 crash

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#2320995 20-Sep-2019 10:15

Technofreak:

frankv:

No airline pilot's total experience "consists of catering to passengers who flinch in mild turbulence", no matter what nationality. They've *all* got to the airliner captain's seat by way of thousands of hours of flight experience, with several hundred hours in light aircraft and commuter airlines, with plenty of experience in solo flight, turbulence, and steep turns. And the vast majority of airline pilots are there because they love to fly, and therefore when not carting people to and from their holidays, they *do* fly aerobatics, fly sailplanes, or fly to out-of-the-way airstrips. It's not extraordinary efforts, it's just what they *want* to do.

This might be normal for the US, Canada, Australia, and New Zealand and one or two other parts of the world but for a lot of Europe, Asia etc this isn't the case.

A lot of Europe? For Western Europe, which is by far the larger part in terms of aviation, the standards are similar to US, NZ, etc.

There is no General Aviation and very little in the way of Commuter Airlines. Cadets are going into the right hand seat as a First Officer with virtually no experience with around 200 hours total flight time. From here on in the only flying they will do before they become a Captain is the flying they do as a First Officer.

For many of these pilots it is a fact, their only real flying experience is "catering for passengers who flinch in mild turbulence".

There may not be much GA, but the whole point of that first 200 hours is to learn airmanship.

And you don't mention the recurrent simulator training that pilots are required to do, precisely to be able to handle uncommon emergencies. And the biennial flight review, aka check-rides.

Sadly it is likely to get even worse. An MPL or Multicrew Pilot Licence has been introduced and is being used in some parts of the world to fast track pilot training. You may be surprised (shocked) as to how little actual flying experience some pilots will have before they sit in the right hand seat of a jet as a First Officer (Co-pilot). As little of 30 hours in an aircraft with at a guess no more than 10 to 15 hours solo flight time.

A commercial pilot's license is 150 hours minimum. For an ATPL, the pilot must have at least 1500 hours of experience in aircraft, including 250 hours as pilot in command (PIC) and be at least 23 years old. In the UK, an ATPL is needed for PIC of any aircraft carrying 9 or more passengers. https://en.wikipedia.org/wiki/Airline_transport_pilot_licence

I do agree that, particularly in Asia and Africa, there are countries and airlines that cut corners on pilot qualifications (and pretty much everything else). If you choose to fly on one of these airlines, caveat emptor.

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#2321509 20-Sep-2019 18:55

frankv:They've *all* got to the airliner captain's seat by way of thousands of hours of flight experience, with several hundred hours in light aircraft and commuter airlines, with plenty of experience in solo flight, turbulence, and steep turns. And the vast majority of airline pilots are there because they love to fly, and therefore when not carting people to and from their holidays, they *do* fly aerobatics, fly sailplanes, or fly to out-of-the-way airstrips.

When I wrote "This might be normal for the US, Canada, Australia, and New Zealand and one or two other parts of the world but for a lot of Europe, Asia etc this isn't the case." I was responding to the portion of your post I have quoted above.

It very much applies to much of Europe where cadets get into the right had seat with around 200 hours and will build virtually no Pilot in Command time. The MPL also been used in Europe much more so than in the US, Canada, Australia or New Zealand.

Based on my personal experience, I very much doubt the vast majority of airline pilots in any part of the world "*do* fly aerobatics, fly sailplanes, or fly to out-of-the-way airstrips" as you suggest they do .

frankv:

There may not be much GA, but the whole point of that first 200 hours is to learn airmanship.

And you don't mention the recurrent simulator training that pilots are required to do, precisely to be able to handle uncommon emergencies. And the biennial flight review, aka check-rides.

You were talking about "several hundred hours in light aircraft and commuter airlines, with plenty of experience in solo flight, turbulence, and steep turns". I never mentioned simulator training as recurrent simulator training isn't designed to make up for any of this kind of flying

frankv:

A commercial pilot's license is 150 hours minimum. For an ATPL, the pilot must have at least 1500 hours of experience in aircraft, including 250 hours as pilot in command (PIC) and be at least 23 years old. In the UK, an ATPL is needed for PIC of any aircraft carrying 9 or more passengers. https://en.wikipedia.org/wiki/Airline_transport_pilot_licence

Correct, but none of this is related to the MPL which is another licence entirely and was what I was discussing in respect to your response about the hours required to hold a CPL and ATPL. The MPL is designed for beancounters as it significantly reduces costs. It is a convenient way for airlines to crew up with First Officers.

If you think the environment that lead to how the MCAS was certified was bad, I'd suggest waiting to see where the MPL goes. In the past the role of the First Officer to a large extent was seen as a Captain in training. The old adage applies is airlines don't employ First Officers they employ future Captains.

The question has been asked as to how an MPL holder can transition to be a Captain for which he/she will need an ATPL. However the MPL doesn't give the holder the prerequisites for holding an ATPL. The only way forward is to send them back to flight school (a costly exercise) or create a pathway to an ATPL through relaxing the requirements and giving credits towards the ATPL licence that currently don't exist (lower the bar).

Based on how the MPL came about (by lowering the CPL bar) which path do you think will be followed? I'm afraid the beancounters who know the cost of everything but the value of nothing will win the day.

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#2321516 20-Sep-2019 19:03

Varkk:

Finally it doesn't matter how corrupt or lacking the airlines training scheme was if the vital information about the system was left out of the training material from Boeing.

I would argue that without any training on the MCAS the pilots should have been able to safely recover the aircraft. The emergency procedures for the fault symptoms they experienced were already in existence.

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#2328988 3-Oct-2019 11:50

Boeing 737 Max Safety System Was Vetoed, Engineer Says

New York Times, By Natalie Kitroeff, David Gelles and Jack Nicas

...The engineer ... Curtis Ewbank [lodged] a formal complaint and calling out the chief executive for publicly misrepresenting the safety of the plane.

During the development of the 737 Max, Mr. Ewbank worked on the cockpit systems that pilots use to monitor and control the airplane. In his complaint to Boeing, he said managers had been urged to study a backup system for calculating the plane’s airspeed. The system, known as synthetic airspeed, draws on several data sources to measure how fast a plane is moving.

Such equipment, Mr. Ewbank said, could detect when the angle-of-attack sensors, which measure the plane’s position in the sky, were malfunctioning and prevent other systems from relying on that faulty information. A version of the system is used on Boeing’s 787 Dreamliner, a new plane model.

In both crashes of the Max, an angle-of-attack sensor is believed to have failed, sending bad data to automated software designed to help prevent stalls. That software, known as MCAS, then activated erroneously, sending the planes into irrecoverable nose dives.

Mr. Ewbank noted in the complaint, “It is not possible to say for certain that any actual implementation of synthetic airspeed on the 737 Max would have prevented the accidents” in Ethiopia and Indonesia. But he said Boeing’s actions on the issue pointed to a culture that emphasized profit, in some cases, at the expense of safety.

Throughout the development of the Max, Boeing tried to avoid adding components that could force airlines to train pilots in flight simulators, costing tens of millions of dollars over the life of an aircraft. Significant changes to the Max could also have required the more onerous approval process for a new plane, rather than the streamlined certification for a derivative model.

...Mr. Ewbank said he hadn’t filed a complaint during the development of the Max because, in part, the “fear of retaliation is high.”

He stepped forward this year, he explained in the complaint, because of the “ethical imperative of an engineer — to protect the safety of the public.”

“Boeing is not in a business where safety can be treated as a secondary concern,” Mr. Ewbank wrote in the complaint. “But the current culture of expediency of design-to-market and cost cutting does not permit any other treatment by the work force tasked with making executive management’s fever dreams a reality.”

https://www.nytimes.com/2019/10/02/business/boeing-737-max-crashes.html

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#2336818 14-Oct-2019 14:29

Boeing’s Board Acted After Months of Mounting Pressure

New York Times

By Natalie Kitroeff and David Gelles

Early Friday morning, Boeing’s board gathered on a conference call that had been hastily arranged the day before. Dennis A. Muilenburg, the company’s chief executive and the chairman of the board, was not invited.

By the end of the day, a decision had been reached: Mr. Muilenburg would lose his title as chairman, a rebuke from a board that has defended Boeing’s senior leadership after two crashes of its 737 Max jet killed 346 people. The board elevated its lead independent director, David L. Calhoun, to replace Mr. Muilenburg as chairman.

For months, the Boeing board had resisted stripping Mr. Muilenburg of the chairmanship. In April, a shareholder proposal to split the chairman and chief executive roles was voted down, though by a smaller margin than last year. Mr. Calhoun said in an interview with The New York Times in May that the board regularly discussed splitting the roles, but felt confident in Mr. Muilenburg.

“We think we’ve got the right guy,” Mr. Calhoun said at the time.

But since then, the outlook for Boeing has worsened. The 737 Max, its best-selling jet and one of its biggest sources of revenue, remains grounded after seven months. New problems with the plane have continued to crop up, causing repeated delays, although the company says it expects the plane will be cleared to fly again by the end of the year. The company has struggled to persuade international regulators that it has developed an adequate fix for the automated system that contributed to both fatal accidents.

Boeing recently announced more than $8 billion in costs tied to the crashes, and its stock price has declined by about 15 percent since early March.

Boeing customers have lost hundreds of millions of dollars because of the grounding and are becoming increasingly impatient. They complain of inconsistent updates from the company about the status of the plane.

Executives at the company fear there will be long-term damage to their relationship with airlines, who may be tempted to defect to Airbus, Boeing’s biggest competitor.
...
...With the Max still grounded and questions swirling about Mr. McAllister, Boeing must now proceed with a chief executive who has been stripped of some of his power.

“People will read this as a little loss of confidence that the board has in Dennis,” Mr. Sonnenfeld said. “And rightly so.”

https://www.nytimes.com/2019/10/13/business/boeing-board-dennis-muilenburg.html

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#2343812 26-Oct-2019 15:17

Official Indonesian Crash Report published

Excerpt: [from the aviation Herald http://www.avherald.com/h?article=4bf90724/0010&opt=0]

Contributing factors defines as actions, omissions, events, conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduced the probability of the accident or incident occurring, or mitigated the severity of the consequences of the accident or incident. The presentation is based on chronological order and not to show the degree of contribution.

- During the design and certification of the Boeing 737-8 (MAX), assumptions were made about flight crew response to malfunctions which, even though consistent with current industry guidelines, turned out to be incorrect.

- Based on the incorrect assumptions about flight crew response and an incomplete review of associated multiple flight deck effects, MCAS’s reliance on a single sensor was deemed appropriate and met all certification requirements.

- MCAS was designed to rely on a single AOA sensor, making it vulnerable to erroneous input from that sensor.

- The absence of guidance on MCAS or more detailed use of trim in the flight manuals and in flight crew training, made it more difficult for flight crews to properly respond to uncommanded MCAS.

- The AOA DISAGREE alert was not correctly enabled during Boeing 737-8 (MAX) development. As a result, it did not appear during flight with the mis-calibrated AOA sensor, could not be documented by the flight crew and was therefore not available to help maintenance identify the mis-calibrated AOA sensor.

- The replacement AOA sensor that was installed on the accident aircraft had been mis-calibrated during an earlier repair. This mis-calibration was not detected during the repair.

- The investigation could not determine that the installation test of the AOA sensor was performed properly. The mis-calibration was not detected.

- Lack of documentation in the aircraft flight and maintenance log about the continuous stick shaker and use of the Runaway Stabilizer NNC (Non-Normal Checklist) meant that information was not available to the maintenance crew in Jakarta nor was it available to the accident crew, making it more difficult for each to take the appropriate actions.

- The multiple alerts, repetitive MCAS activations, and distractions related to numerous ATC communications were not able to be effectively managed. This was caused by the difficulty of the situation and performance in manual handling, NNC execution, and flight crew communication, leading to ineffective CRM application and workload management. These performances had previously been identified during training and reappeared during the accident flight.

The KNKT provided an extensive analysis spanning 31 pages. The KNKT provides a key analysis which indicates that normal, intuitive and logic crew reactions actually trigger the accident sequence when they state:

In the event of an MCAS activation with manual electric trim inputs by the flight crew, the MCAS function will reset which can lead to subsequent MCAS activations. With an MCAS command due to an erroneous high AOA signal, and flight crew inputs that do not fully return the aircraft to a trimmed state, subsequent MCAS commands can result in the aircraft becoming significantly miss-trimmed.

The KNKT concluded: "The aircraft design should not have allowed this situation."

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#2343816 26-Oct-2019 15:35

PolicyGuy:

Official Indonesian Crash Report published

Excerpt: [from the aviation Herald http://www.avherald.com/h?article=4bf90724/0010&opt=0]

Contributing factors defines as actions, omissions, events, conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduced the probability of the accident or incident occurring, or mitigated the severity of the consequences of the accident or incident. The presentation is based on chronological order and not to show the degree of contribution.

- During the design and certification of the Boeing 737-8 (MAX), assumptions were made about flight crew response to malfunctions which, even though consistent with current industry guidelines, turned out to be incorrect.

- Based on the incorrect assumptions about flight crew response and an incomplete review of associated multiple flight deck effects, MCAS’s reliance on a single sensor was deemed appropriate and met all certification requirements.

- MCAS was designed to rely on a single AOA sensor, making it vulnerable to erroneous input from that sensor.

- The absence of guidance on MCAS or more detailed use of trim in the flight manuals and in flight crew training, made it more difficult for flight crews to properly respond to uncommanded MCAS.

- The AOA DISAGREE alert was not correctly enabled during Boeing 737-8 (MAX) development. As a result, it did not appear during flight with the mis-calibrated AOA sensor, could not be documented by the flight crew and was therefore not available to help maintenance identify the mis-calibrated AOA sensor.

- The replacement AOA sensor that was installed on the accident aircraft had been mis-calibrated during an earlier repair. This mis-calibration was not detected during the repair.

- The investigation could not determine that the installation test of the AOA sensor was performed properly. The mis-calibration was not detected.

- Lack of documentation in the aircraft flight and maintenance log about the continuous stick shaker and use of the Runaway Stabilizer NNC (Non-Normal Checklist) meant that information was not available to the maintenance crew in Jakarta nor was it available to the accident crew, making it more difficult for each to take the appropriate actions.

- The multiple alerts, repetitive MCAS activations, and distractions related to numerous ATC communications were not able to be effectively managed. This was caused by the difficulty of the situation and performance in manual handling, NNC execution, and flight crew communication, leading to ineffective CRM application and workload management. These performances had previously been identified during training and reappeared during the accident flight.

The KNKT provided an extensive analysis spanning 31 pages. The KNKT provides a key analysis which indicates that normal, intuitive and logic crew reactions actually trigger the accident sequence when they state:

In the event of an MCAS activation with manual electric trim inputs by the flight crew, the MCAS function will reset which can lead to subsequent MCAS activations. With an MCAS command due to an erroneous high AOA signal, and flight crew inputs that do not fully return the aircraft to a trimmed state, subsequent MCAS commands can result in the aircraft becoming significantly miss-trimmed.

The KNKT concluded: "The aircraft design should not have allowed this situation."

sorry lay people like me don't understand the salient points!

it reads to me like the sensor wasn't calibrated properly?

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#2343841 26-Oct-2019 18:03

Batman:

PolicyGuy:

Official Indonesian Crash Report published

Excerpt: [from the aviation Herald http://www.avherald.com/h?article=4bf90724/0010&opt=0]

[snip]

The KNKT concluded: "The aircraft design should not have allowed this situation."

sorry lay people like me don't understand the salient points!
it reads to me like the sensor wasn't calibrated properly?

In my opinion, this is about as bad as an accident report can get: pretty much everybody who could do so just plain fouled up.

1A) Boeing created a grossly deficient MCAS design and concealed MCAS’ existence, then
1B) The US Federal Aviation Administration (FAA's) lack of supervision allowed certification of the MAX when it shouldn’t have.

2) Boeing (through a subcontractor) inadvertently disabled the “AoA Disagree” error indicator & message, then themselves decided it was minor enough to wait until the next year’s routine software upgrade.

3) Lion Air put an inadequate copilot in the right-hand seat (“the FO’s training records that showed several comments indicating that the FO had difficulty in aircraft handling. The Lion Air policy for such deficiencies was that the flight crew would be treated with additional briefings or rehearsal. The reappearance of difficulty in aircraft handling indicated that the treatment was not effective”)

4) The outstation line maintenance engineer (an employee of a subcontractor) almost certainly didn’t test the new AoA indicator when he replaced the (first) faulty one. It was also faulty but he never tested it and …

5A) The maintenance organisation that repaired the AoA indicator was using unsuitable and inadequately documented equipment to calibrate the repaired AoA indicator. They shipped one out that was about 20 degrees misaligned, this was the replacement fitted in 4).
5B) The FAA (a different part of it to 1B) never noticed the repairer’s non-adherence to the FAA’s requirements.

6) The pilot of the previous flight pressed on when he should have turned back, so the repair required was done at an outstation, rather than main base. He also didn’t write up the fault completely – partly because the “AoA disagree” didn’t come on [see 2)], partly because he didn’t know about MCAS [see 1A)], partly because …?

So many slices of cheese, so many gaping holes.
😞 😞 😞

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#2343846 26-Oct-2019 18:21

Lawyers are going to get rich over this! That is for certain.

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#2352984 13-Nov-2019 20:55

Boeing's China Problem, The Boeing 737 Max

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#2377102 17-Dec-2019 15:26

Boeing halts 737 production

https://leehamnews.com/2019/12/16/boeing-halts-737-production/

After reducing B737MAX production from 52 per month to 42 per month early in this saga, Boeing will completely stop B737MAX production in January.
There are no more B737NGs to be built, just some P-8s for the USN, RAF & RAAF - it's not clear whether production of those will also stop.

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#2377338 17-Dec-2019 21:07

PolicyGuy:There are no more B737NGs to be built, just some P-8s for the USN, RAF & RAAF - it's not clear whether production of those will also stop.

The RNZAF also have four P-8 on order of course (and Norway)

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#2377368 17-Dec-2019 22:06

Poseidon are based on the classic -800 series it would seem

Although a NextGeN, not the -MAX changes. So I'd expect that to continue as a separate line

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#2377423 18-Dec-2019 07:51

FAA Chief Pushes Back On Boeing Pressure To Return 737 Max Jets To Service

NPR, By David Schaper, 12 December, 2019

The head of the Federal Aviation Administration has told Boeing's chief executive to back off the company's push to speed up the recertification of the troubled 737 Max airplane.

The warning happened in a meeting between FAA Administrator Stephen Dickson and Boeing CEO Dennis Muilenburg at the FAA's headquarters in Washington on Thursday, and comes just a day after Dickson faced intense questioning from Congress over what some lawmakers say is a too-cozy relationship between the FAA and the company it regulates.

Aviation authorities around the world ordered all 737 Max aircraft grounded last March, after the second of two deadly crashes that were primarily caused by a faulty flight control system on the planes. The crashes in Indonesia and Ethiopia together killed 346 people.

Ever since the grounding, Boeing officials have been predicting a quick return of the jets to passenger service. Company statements since September have been especially direct in predicting regulator approval for Max software fixes in the fourth quarter, and recent statements have suggested certification is imminent, happening before end of the year....

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#2377754 18-Dec-2019 13:13

Slightly off topic but my other half did BA Heathrow nervous flier course which is run by senior pilots with many many hours.

One person asked one of the pilots had they been nervous due to turbulence. I think he had 20k plus hours or something ridiculous flying wide body jets, and he said only once and that was for about 5 minutes. His comment was the planes are very over engineered.

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