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John_Cillis

Ethiopia crash

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2 hours ago, honanhal said:

If that's the case, and if the answer to whether totally flawless flying could have saved them is in fact "no," it seems a bit hard to understand why we're focusing so much on the crew mistakes -- though mistakes they were. That's not to say there isn't value for future training purposes in dissecting their actions and pointing out their mistakes, to an extent, the same way we do in those cases where the plane does avoid a catastrophic result following an issue. But that's very much not the same thing as establishing those pilot actions (or lack thereof) as a but-for cause of the crash.

Before I comment, a qualifier - or perhaps a dis-qualifier.  I am NOT an expert here and don't claim to be.  I am a licensed private pilot and former aircraft owner, but I have not a single hour of turbine time to my name.  I normally read with great interest the comments of those with real experience in topics such as this, but stay on the sidelines.

That said, this statement struck me a bit sideways.  Accident investigations are (or should be) about so much more than identifying one root cause for a crash and then focusing on that core factor. 

Let's say, strictly for the sake of argument that even with the best pilot responses this crash was inevitable, perhaps due to specific high altitude issues in this incident and/or the fact that it occurred so soon after takeoff, .  Do you really believe that renders an evaluation of the pilots' actions as irrelevant, even if pointing out the flaws in their collective responses could help in preventing crashes in similar, but not identical scenarios?  What if it happened again to a crew who were a few minutes later into their flight, and/or coming out of a sea-level airport, for example?

A good investigation is very much about determining all causative (and potentially causative) factors and then establishing the best next steps to prevent future occurrences in similar scenarios, by addressing all of these factors.

Scott

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1 hour ago, KevinAu said:

I don’t think their analysis of the manual wheel being turned the wrong way by the fo is correct. If he was turning it in the nose down direction, he would not have found resistance and declared that it wasn’t working. Instead, it seems more likely that he tried as hard as he could to turn it nose up, couldn’t budge it, and when he let go, the wheel rebounded further nose down. Just watch some of these videos that others have posted here of pilots trying to crank the wheel and losing. The tension rebounds it further nose down.

From what I've seen of the trim wheel, pulley/cable interconnect, and the stab jackscrew assemblies, I don't think that turning the trim wheel in either direction would be without heavy resistance at high air loads.  There's a tremendous amount of force being applied to the threads on the jackscrew.  That said, I'll have to leave that to the engineers and flight test folks to say definitively.  I'd surmise that there will soon be some additional FM data on trim wheel operation, forces etc as a result of all this.

Regards


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5 hours ago, w6kd said:

From all that I've read, yes.  After the MCAS-driven trim runaway, the aircraft was not unflyable until the crew made it unflyable, primarily by not controlling their airspeed, and by deviating from the abnormal checklist and returning the stab trim switches to normal and leaving them there.

And I think Ethiopian 302 did not make it down due to less than skilled, competent crew action following a serious, but recoverable emergency situation.

 

4 hours ago, KevinAu said:

Yes, there is a reasonable argument that the flight could have been definitely saved. The point I have made here before and will make again is that they should have followed their *basic* training. There was no need for flawless or superb piloting skills.

The moment they turned the trim back on, that was the moment the bomb blew the wing off. That was the do not pass go, do not collect $200, stop the checkride, you die in 5 seconds moment. And the only that would have stopped that bomb from going off was reading the checklist. All they had to do was just fall back to the process they demonstrated they learned in training for *any* abnormal. Then they would have pulled out a checklist. And lived.

Bob and Kevin: thanks for your replies, which are very illuminating. I don't know that I necessarily agree with your assessments based on balance on what I've seen, but it's telling all the same that you're both very confident that the fundamental cause of the Ethiopian crash was pilot error, not aircraft design flaws or a broken AOA vane. It's a pretty brave position to take, especially when there's still some major unknowns as to what happened, but you do both marshal some compelling arguments in its favor. 

2 hours ago, tttocs said:

That said, this statement struck me a bit sideways.  Accident investigations are (or should be) about so much more than identifying one root cause for a crash and then focusing on that core factor. 

Do you really believe that renders an evaluation of the pilots' actions as irrelevant, even if pointing out the flaws in their collective responses could help in preventing crashes in similar, but not identical scenarios?  What if it happened again to a crew who were a few minutes later into their flight, and/or coming out of a sea-level airport, for example?

A good investigation is very much about determining all causative (and potentially causative) factors and then establishing the best next steps to prevent future occurrences in similar scenarios, by addressing all of these factors.

I tried to be as clear as possible in my post that it's important to look at mistakes the pilots made for the sake of improving flying safety going forward, which is why I wrote this:

"That's not to say there isn't value for future training purposes in dissecting their actions and pointing out their mistakes, to an extent, the same way we do in those cases where the plane does avoid a catastrophic result following an issue."

I actually think we're in violent agreement about that, but with one caveat that bears explanation. In no way do I think what the pilots did is irrelevant to the question "how do we improve (across-the-board) flight safety?" I certainly hope all MAX pilots will learn the hard-won lessons these crews have given them about how NOT to respond to an MCAS issue. At the same time, there's a distinct question here that isn't exactly the same as that first question: "why did this plane crash?" My post was about whether what the pilots did is in fact ultimately irrelevant in answering that question, if we think no matter what they did it would still have crashed. I still honestly don't know, which is why I wanted to hear from people like Bob and Kevin who feel strongly that it's not only relevant, but decisive, in answering that question.

James

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18 minutes ago, honanhal said:

 

Bob and Kevin: thanks for your replies, which are very illuminating. I don't know that I necessarily agree with your assessments based on balance on what I've seen, but it's telling all the same that you're both very confident that the fundamental cause of the Ethiopian crash was pilot error, not aircraft design flaws or a broken AOA vane. It's a pretty brave position to take, especially when there's still some major unknowns as to what happened, but you do both marshal some compelling arguments in its favor. 

James

No, I still don’t think you understand. The fundamental causes are the mcas design flaw and failure to follow checklist. The factors that contributed to the crash are going to be birdstrike, pilot performance, pilot training, pilot experience. Like I said before, blame is like new cars at an oprah show. There is more than one to be given out. Just because I wanted to point our where the ethiopean transport minister made a statement that was obviously untrue does not mean that I am providing cover for boeing’s role. The vitriolic reaction from some here to the point being made that the pilot’s made mistakes was completely ridiculous. Pilot error does not preclude mechanical failure. The two can be cited together. Here is an example. Taken from the first ntsb report I randomly clicked on. Suppose a plane takes off and the engine fails and the plane crashes. Is it pilot error or engine failure? Well, it easily is both.

https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20030107X00031&AKey=1&RType=Final&IType=FA

In an accident, every factor has to be looked at and called. You don’t strike out one factor just because you want another one to take all the blame. This ethiopean crash was caused by design error and pilot error.

 

Edited by KevinAu
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Thanks for the clarification, Kevin. That’s actually a very reasonable position and I don’t disagree.

James

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19 hours ago, w6kd said:

From what I've seen of the trim wheel, pulley/cable interconnect, and the stab jackscrew assemblies, I don't think that turning the trim wheel in either direction would be without heavy resistance at high air loads.  There's a tremendous amount of force being applied to the threads on the jackscrew.  That said, I'll have to leave that to the engineers and flight test folks to say definitively.  I'd surmise that there will soon be some additional FM data on trim wheel operation, forces etc as a result of all this.

Regards

Bob, I watched a video several weeks ago where use of the manual trim wheel was being demonstrated under high-loading conditions. Neither the PIC or FO were able turn the wheel even using the fold-out hand crank, nor could they turn the thing with both of them attempting to crank together! :blush:


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No I still don't think you understand what people have been saying. And playing the victim/vitriol card is pretty silly. You are just as rude as others have been.

Anyway I do like that you are now starting to change your tune and admit that there design error was the largest factor.

But to reiterate nobody ever said that different pilots couldn't have saved the plane. 

I will try to explain it one more time because well god loves a trier... as myself and other pilots over on pprune have tried to explain to the 'would have happened to me crowd' is that without hindsight the number of conflicting factors facing them was not acceptable. The confusing and startling situation with undertrained pilots was an accident waiting to happen, the "errors" they made were exacerbated by Boeing failures

Boeing Failures

  • confusing and missing warnings 
  • unnecessary stick shaker
  • 1 input design for a system that can override pilot
  • ridiculous design of MCAS 2.5 degrees faster than switch trim can move
  • no memory items for AoA failure (new training)
  • no change to unreliable airspeed checklist (new training)
  • incorrect warnings (new training)
  • inability for 1 pilot to manually trim when out of trim at near VMax 
  • design of switches changed but insufficient training
  • 1hr iPad type conversion training 
  • 80k for the correct warning 
  • no way to cancel cacophony of stick shaker and klaxons 

All of these factors led to the pilot mistakes.

No they are not completely mutually exclusive.

Pilot

  • pilot not correcting trim switch fully during critical 1min period instead pulling back
    lets wait for the audio on this to hear what was happening, but as many have noted the pilot was probably cognitively saturated and in normal flight is not used to heavy re trimming like this (noted by several 737 pilots)
  • didnt instantly recall the full text of the 8 Nov MCAS Bulletin which stated not to re-engage the CUTOUT switches for remainder of flight
    Actually if you look at the data log, they did retrim quite a bit BEFORE flicking the CUTOUTs, this is impressive to recall that Note in the bulletin (2nd page small note about retrim before cutout) so perhaps he was focused on this action and again with all the noise and terror didnt see the part about re-engage.
  • used autopilot/autothrottle
    perhaps he thought this might be a way to disable MCAS, or because he wanted to read the checklist/bulletin again and didnt trust the junior pilot he used it.. or perhaps he thought I am happy to keep the power on to ensure that the plane climbed from a very hot and high airfield with 10k peaks near the plane.. a mistake in hindsight. 
  • failed to fully understand how he would be screwed if the plane got fast and they had flicked the CUTOUTS.
    So this is the new factor in the Ethiopia crash, we didn't really appreciate after Lion air even reading every page of pprune how much of a problem this was.
     

As I said nobody denies that these pilot actions were contributing factors. What I object to is the arrogant tone that oh if they just followed their training it all would have been fine. These pilots passed their training, this inadequate min training level was specified by Boeing.

I find it really scary that there are pilots who have no sympathy for such a confusing situation. I also find it really heartening that older pilots like old man with nearly 15000 737 hours (he once flew a 200/300/700 all in one day having never done a single type conversion course!) and pprune legends like gums (who flew some of the trickiest fighter aircraft) have loads of empathy and understanding of how Boeing let all these pilots and pax down so badly. I think the best pilots know it could happen to them.

The rebuttal made several times here seems to be they didn't follow checklists or bulletins. Firstly see all the points above but also I don't think the checklists or memory items cover the observed situation at all either directly or clearly, some parts of all of them would have been in hindsight the right action.

The bulletin is pretty long and the single sentence that says do not re-engage is a very small piece near the end. But even then as you known the training is do not follow checklists blindly, make decisions and adapt at all times, he may have even considered that but thought MCAS triggers again we have enough height to fight it or turn it off again.. but not having the comfy couch enabled power of internet hindsight nor having waded through 1000 pages of detail on MCAS/Jackscrews/ADIRU/AoA wiring/MCAS trim rotation speed vs trim switch speed didn't realise that at the speed they were going (too fast) it would be unrecoverable.

I find it so hard to fathom a fellow pilot even considering that the levels of culpability are even in the same galaxy let alone ball park. 

Boeing's years of cost cutting and poor designs while sitting in a comfy air-conditioned office in Seattle vs the pilots 3 mins of terror trying to keep everyone alive with inadequate tools and against the direct wishes of Hal.

Edited by DellyPilot
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Dellypilot, my sympathies lie with the passengers. They count on us two guys up front to do what we were trained to do. If those two did their abnormals drill, they would probably all be alive. Or at least they would not be having people saying they didn’t follow procedures afterwards. What’s scary is that I haven’t seen you mention the word ‘passengers’ once in any of your posts. Those were the first people I thought about. Not the pilots and trying to make rationalizations about why the pilots didn’t do this or that. I thought what a shame that they never pulled out their training, those poor passengers could all still be alive. Pilots owe it to their passengers to remember their training, use their qrhs, exercise some crm, and stay calm, especially when the plane is trying to kill them. If that is not a time to remember your training, when is it ever?

You’ve been and continue insinuating that I am a dangerous pilot because I am saying that this accident should be a reminder that we need to remember our abnormals drill when we are faced with an emergency. While at the same time you are lauding somebody on pprune for flying passengers around in different versions of a plane without any proper training. No wonder we disagree......

Edited by KevinAu

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1 hour ago, KevinAu said:

While at the same time you are lauding somebody on pprune for flying passengers around in different versions of a plane without any proper training. No wonder we disagree

No Kevin, apologies I wasn't clear, I was talking about 'my' old man, (my father) not some guy on pprune. He flew many 737 variants for nearly 30 years.

In no way does he or I laud this! The opposite, it is a direct criticism of Boeing's grandfathering policy that contributed to this crash. It allows pilots to fly any variant (back then with no training at all) with as little as a 1 hour session and zero sim time. 

On one flight he had to ask the captain where buttons were, can you imagine!  He complained to management (at significant risk to his career progression) but nothing was done as this was normal and 'legal'.

At least today Boeing require the 1 hour type conversion session. From now on I guess sim time will be required to practice key differences, such as MCAS malfunctions and new memory items.  

So no, I don't think this is why I (and many pilots like my father) disagree with you. 

I don't want to argue anymore, believe it or not I respect your opinion (especially as a current pilot on the brilliant E170, which by the way Boeing tried hard to kill off!).

I really do see where you are coming from and you make valid points but I think they are massively outweighed. Let's agree to disagree (very strongly 🙂)!

What we can agree on is that lessons will be learned on certification, training and grandfathering of 50 year old designs. I will always feel though that both crashes could have been avoided.

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5 hours ago, DellyPilot said:

From now on I guess sim time will be required to practice key differences, such as MCAS malfunctions and new memory items.

There is an updated, longer training course which now includes MCAS but Boeing's stance still is that actual sim training is not required. With the fix MCAS can't get anywhere near crashing the plane which is the argument against sim training. We'll see what regulators say about that.

Edited by threegreen

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9 hours ago, DellyPilot said:

I will always feel though that both crashes could have been avoided.

Isn't that precisely  why Boeing is introducing a redesigned MCAS system, along with updated pilot training, so that future crashes will be avoided?  :wink:

Edited by Bert Pieke

Bert

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3 hours ago, Bert Pieke said:

Isn't that precisely  why Boeing is introducing a redesigned MCAS system, along with updated pilot training, so that future crashes will be avoided?  :wink:

I guess there alternative would be to ignore the crashes, not fix the problem, and let the crashes continue...???????


 

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Amazing the extent of the delusion. 

From the New York Times article:

"

At a tense meeting with the pilots’ union at American Airlines in November, Boeing executives dismissed concerns. “It’s been reported that it’s a single point failure, but it is not considered by design or certification a single point,” said Mike Sinnett, a Boeing vice president, according to a recording of the meeting.

His reasoning? The pilots were the backup.

“Because the function and the trained pilot work side by side and are part of the system,” he said.

Four months later, a second 737 Max crashed in Ethiopia. Within days, the Max was grounded around the world.

"

So much for the backup.

Unbelievably hubris.

Cheers.

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