Ethiopia crash

[cowpatz 243]

59 minutes ago, KevinAu said:

1. I’ve got a wee bit of an idea how.

2. We’re not paid to be confused and terrified. The people in the back are counting on us not to be confused and terrified.

3. The trim wouldn’t have worked without someone turning it back on.

As I said ....read it....don't look at it....you really have no idea.

[cowpatz 243]

2 minutes ago, Garys said:

When we step onto a commercial airliner we are no longer armchair critics. I expect the aircraft to not go mechanical and I expect the flight crew to not turn a bad situation into a dire one if it does. As such I have just as much right to say how I feel about these events as everyone else. Instead of putting yourself in the pilots seat, instead put yourself in the passenger seat where 90% of us here would be sitting. It also seems to me that a lot of pilots putting the blame solely at Boeings feet fly with a joystick instead of a yoke. 

Doesn't really matter which seat you are in does it? This is a big Boeing screw up...and I have been flying only Boeings for 31 years.

[Garys 209]

Actually it does. Your skills, training and decision making which is out of  our control directly effects whether or not we make it home. Not every crew would have put this one in the dirt. To imply that would be insulting 737 crews all over the world.

You are right in that this software is a screw up. It should never have been installed as is. 

Edited April 10, 2019 by Garys

[John_Cillis 2,406]

30 minutes ago, Garys said:

Actually it does. Your skills, training and decision making which is out of  our control directly effects whether or not we make it home. Not every crew would have put this one in the dirt. To imply that would be insulting 737 crews all over the world.

You are right in that this software is a screw up. It should never have been installed as is. 

A quote which sums up this thread and what happened very well, as well as showing respect for the overall professionalism of flight crews and training in so many world airlines, including Ethiopian.  Accidents come down to reaction times, experience, software and hardware, and experience does not always guarantee a positive outcome as shown in Tenerife and other historical air, train and ground accidents. 

I was an experienced driver thinking I would never cause a fender bender, but I did once, thankfully I had good insurance, it was a non-injury accident, and his vehicle was bigger than mine and had the slightest of dents.  The police that gave me a minor infraction were affable and humorous, knowing I'd have to drive my damaged car, shaken as I was, back home so it could be taken to the body shop for repair.  The police officer told me not to fret, to take an online course since he knew I was a salaried worker who worked an odd schedule. 

The course was a great refresher, taught me about the habits I had picked up, and my ticket was removed from my record so in 30+ years of driving, I have no record of a ticket.  Experience helped me in that accident, even though the driver came out of my blind spot--even he said the accident was unavoidable, I managed OK. 

But in some airline accidents, the outcome is inevitably negative and experience and all the skills the pilots have just might not overcome what is happening given the timing for their reflexes to respond, and also the reaction and stress of the other flight crew and pax which can be sensed.  In other words, for me I cannot criticize flight crew because I was not there to apply my own reaction times, thinking, etc....

John

[KevinAu 441]

4 hours ago, cowpatz said:

As I said ....read it....don't look at it....you really have no idea.

Yeah, I have no idea what you’re getting at. We’ve already been going over that fdr readout for the last several pages of this thread. There’s nothing new in what you posted.

[threexgreen 3,142]

I for one am struggling to see how anyone is in this thread is being unfair to the pilots in any way. As others have pointed out, this thread is remarkably calm, professional and objective in discussing what happened and is happening. I also can't see any sign of wild speculation but instead, the bit of speculation that is going on here is well informed and remains within limits. I don't see a mantra of " Let's figure out how we can blame the pilots" at all. The pilots are undoubtedly one of the key factors in any aircraft operation and thus logically part of the investigation as well as this discussion. All I'm seeing that is said about the pilots is justified and fair reasoning as to what role the pilots played in the accidents. From the FDR data it seems like the pilots may have switched the automatic stab trim back on and when someone, including me, points out that if  they did they didn't follow procedures, that's nothing more than a logical conclusion that any investigator would come to make as well. When I say the FO was young and not very experienced I'm simply stating facts. In no way am I saying or implying that he wasn't qualified to do his job. In fact, if it weren't for some factors that made me change my mind when I was already enrolled in an ATPL flight school I would be sitting in an airliner cockpit today myself with much less experience (hours) than what is normal in the US waiting for my frozen ATPL to finally get 'melted'. But I surely wouldn't think, after successfully completing flight training and earning my license, that I'm not qualified to do that job.

I don't see why some suddenly seem to be so upset about armchair pilots. Let's keep this thread the way it is, calm and professional.

Edited April 10, 2019 by threegreen
Typo.

[AviatorMan 253]

So in this thread we seem to be saying that crew error is at least one of the cause of these two accidents.  It seems that if Boeing's objective was to create a new 737 model that would not require extensive retraining for pilots already familiar with the 737, then they did not achieve their objective. What they have in fact achieved is an aircraft that requires very little retraining for routine flying, but significant retraining seems to be required for dealing with MCAS related incidents such as those which led to these two crashes and the deaths of nearly 400 people. 

[KevinAu 441]

15 minutes ago, AviatorMan said:

So in this thread we seem to be saying that crew error is at least one of the cause of these two accidents.  It seems that if Boeing's objective was to create a new 737 model that would not require extensive retraining for pilots already familiar with the 737, then they did not achieve their objective. What they have in fact achieved is an aircraft that requires very little retraining for routine flying, but significant retraining seems to be required for dealing with MCAS related incidents such as those which led to these two crashes and the deaths of nearly 400 people. 

No, because the mcas failure is a design error. The plane is grounded and nobody is flying because of it. You’re assuming nothing is done to fix this. Once the software fix is tested, approved, and implemented, the plane will only then be allowed to fly. When it does fly again, the mcas should not do anything like this again, so all these mcas failure procedures would be moot. What will they have to train for? There would be no need for any training and it will even be removed from the checklist.

Edited April 10, 2019 by KevinAu

[Bob Scott 7,721]

13 minutes ago, AviatorMan said:

So in this thread we seem to be saying that crew error is at least one of the cause of these two accidents.  It seems that if Boeing's objective was to create a new 737 model that would not require extensive retraining for pilots already familiar with the 737, then they did not achieve their objective. What they have in fact achieved is an aircraft that requires very little retraining for routine flying, but significant retraining seems to be required for dealing with MCAS related incidents such as those which led to these two crashes and the deaths of nearly 400 people. 

Significant retraining?  No, not really...the corrective action for a trim runaway, regardless of cause, remains the same.  There will be some material added to help recognize the situation more quickly, such as the coincident indicators like an AoA disagree warning, and to make crews aware of the peculiarities of this mode of failure...but a runaway trim situation has been a critical memory response item since long before these two crashes.  This'll get a few minutes of classroom time amongst the many other potential issues that are already covered every time a pilot goes through recurrent training.  I'm sure there will be warnings added to the FM that reiterate the blindingly obvious--e.g. once you turn the trim off with the stab cutout, leave it off, and that maybe possibly leaving the power up throughout the recovery until you exceed Vmo might result in air loads on the stab that impede recovery...sort of like the warnings that now come with a steam iron, warning you to remove the clothes from your body before using the iron.

I still believe that an experienced crew (an FO with 200 hours total time does not meet that criteria) and one that was proficient in hand flying (vs autopilot monitoring) should/could have recovered either one of the mishap jets.

Regards

[Bobsk8 12,745]

9 minutes ago, w6kd said:

Significant retraining?  No, not really...the corrective action for a trim runaway, regardless of cause, remains the same.  There will be some material added to help recognize the situation more quickly, such as the coincident indicators like an AoA disagree warning, and to make crews aware of the peculiarities of this mode of failure...but a runaway trim situation has been a critical memory response item since long before these two crashes.  This'll get a few minutes of classroom time amongst the many other potential issues that are already covered every time a pilot goes through recurrent training.  I'm sure there will be warnings added to the FM that reiterate the blindingly obvious--e.g. once you turn the trim off with the stab cutout, leave it off, and that maybe possibly leaving the power up throughout the recovery until you exceed Vmo might result in air loads on the stab that impede recovery...sort of like the warnings that now come with a steam iron, warning you to remove the clothes from your body before using the iron.

I still believe that an experienced crew (an FO with 200 hours total time does not meet that criteria) and one that was proficient in hand flying (vs autopilot monitoring) should/could have recovered either one of the mishap jets.

Regards

There were three crews that had this problem, two of them crashed. The third crew was helped by a pilot in the jump seat.Were  all these pilots inept, or is it Boeing that gave their own design FAA approval? 

[KevinAu 441]

11 minutes ago, Bobsk8 said:

There were three crews that had this problem, two of them crashed. The third crew was helped by a pilot in the jump seat.Were  all these pilots inept, or is it Boeing that gave their own design FAA approval? 

Not so much inept as unprepared. The lionair crew was understandably unprepared. The mishap crew had almost no guidance on recognizing and dealing with the failure. I say almost because if they had enough wits to recognize the unwanted nose down trimming aspect of what was happening, they could have fallen back to what they already know about dealing with a runaway trim. But that part, as we know, is masked amidst a lot of other noise, clutter and extraneous warnings. The first crew to experience this unknown failure mode was fortunate to have a jumpseater who was sitting behind everybody and was able have an overview of everything that was happening, especially the trim wheel rolling down on them. That’s why they survived. That’s one of the reasons why we have fo’s takeover the flying during a problem nowadays, so the captain, with more experience, is given a chance to step back and take in an overview.

The Ethiopian crew, unlike the lionair crew, had warning of this potential failure scenario, how it would appear to them, what the danger is, and what to do and not do. Unfortunately, it still found them unprepared. Whatever fault Boeing and the faa is liable for in allowing this poorly conceived piece of software into the wild, a degree of fault will still be on the crew for not being prepared to deal with an emergency. The extent to which they were unprepared to deal with anything but a normal flight is evidenced by the lack of any acknowledgment and switching of ‘mental mode’ from normality to abnormality. If their training is anything like what US air carriers do, then what you should have seen evidence of in the report, would have been some type of mantra or cadence that shows that they were switching their mental gears into abnormality mode so that they would be prompting themselves for memory items and qrh procedures. None of that was evident in the report. There are supposed to very very specific actions and call outs the moment an abnormality is noticed. That is the training. None of that is shown there. What is apparent is that the captain is completely overwhelmed by the situation. If he was able reform the jelly that his mind had turned into back into the brain of a captain, he would have called for the qrh and the fo would have hopefully been able to get to the part that said leave the cutouts off and they may well be alive now. Instead, you see a complete lack of any of the discipline and procedures they supposedly had shown in the sim during their training. They’re flipping switches as it occurs to them, not under any kind of process as they are supposed to have been trained to. I’m not trying to just pin blame on them, but this is really the bread and butter of what we are paid to, expected to, and depended upon to, do in case of emergency. It’s important. It’s the difference between life and death. That responsibility to do as you’re trained should not be taken lightly.

[skelsey 765]

14 minutes ago, KevinAu said:

What is apparent is that the captain is completely overwhelmed by the situation. If he was able reform the jelly that his mind had turned into back into the brain of a captain, he would have called for the qrh and the fo would have hopefully been able to get to the part that said leave the cutouts off and they may well be alive now. Instead, you see a complete lack of any of the discipline and procedures they supposedly had shown in the sim during their training. They’re flipping switches as it occurs to them, not under any kind of process as they are supposed to have been trained to. I’m not trying to just pin blame on them, but this is really the bread and butter of what we are paid to, expected to, and depended upon to, do in case of emergency. It’s important. It’s the difference between life and death. That responsibility to do as you’re trained should not be taken lightly.

I'm not disagreeing with your assessment of the crew's performance at all - I think this is a very good summary of what they did and the problems with it. What happened is now reasonably (with the caveat that we haven't seen a full CVR transcript etc etc) well established.

The question, however, as I posed little while back is why they performed in this way?

As you say, they presumably demonstrated competence in failure management, CRM etc in the sim and unless they'd been living under a rock must have been aware of the Lionair incident. So why did they perform in the way they did when faced with this situation in reality?

Obviously that is a largely rhetorical question but hopefully one which the final report will address in depth and the aspect I am most interested in - as only by understanding why is it possible to make changes to prevent other crews from experiencing similar problems in different non-normal situations.

[Bob Scott 7,721]

2 hours ago, Bobsk8 said:

There were three crews that had this problem, two of them crashed. The third crew was helped by a pilot in the jump seat.Were  all these pilots inept, or is it Boeing that gave their own design FAA approval? 

They proved to be fatally incompetent, based on the information now available.  In the case of the Lion Air crash, it appears that maintenance was also fatally incompetent.  Aside from the problems with an AoA malfunction causing an MCAS activation, which Boeing is most definitely addressing, the reasons for the crews' inability to recognize and correct the resulting trim runaway also needs serious introspection.  Dismally low crew experience was most certainly a factor in the Ethiopian crash, and the declining hands-on proficiency of crews that log thousands of hours of autopilot time, but less and less actual hands-on flying, sure looks suspect to me as well. 

If an engine fails, and the pilots fail to recognize and handle it prior to slowing below Vmca, then roll inverted and plunk it in, there's an aircraft problem that's causal, but the crew's failure to recognize and correct a foreseeable and manageable problem is also causal in the crash.  We wouldn't just conclude that the crash occurred because the engine failed and leave it at that...not only did the equipment malfunction, but the ultimate failsafe--the crew--also failed.  Both the Lion Air and Ethiopian jets hit the ground in a flyable condition--the problem was correctable had the crews recognized and reacted to the problem with the existing critical-action procedures for a trim runaway.  We need to know why they failed as much as we need to know why the MCAS was activated.  I really do believe that there's an underlying danger being exposed here that's far more insidious and dangerous than this MCAS issue--crews that spend so much time on automation that they can't grab the yoke and throttle and do "pilot stuff' when the need arises.

Consider this...I have a friend that for years was barely senior enough to hold a line as a relief pilot on an augmented 3-pilot 777 crew for a major US carrier.  He had to repeatedly be sent to the simulator out of cycle because he logged so few approaches and landings that he couldn't even stay current as a 777 pilot, much less proficient at it.  The typical out-and-back flight was 20-24 hours of flying time, with two takeoffs and landings to be spread across three pilots.  He'd fly three or four of those flights in a month.  How would things go with a serious malfunction with him in the seat after years of that kind of "flying"??

Regards

[skelsey 765]

8 minutes ago, w6kd said:

If an engine fails, and the pilots fail to recognize and handle it prior to slowing below Vmca, then roll inverted and plunk it in, there's an aircraft problem that's causal, but the crew's failure to recognize and correct the problem is also causal in the crash.  We wouldn't just conclude that the crash occurred because the engine failed and leave it at that...not only did the equipment malfunction, but the ultimate failsafe--the crew--also failed.

Correct, but I'm not sure an EFATO is a good analogy to the MCAS-related incidents for the simple reason that EFATO, the challenges it presents, recognition and recovery are very well known and, indeed, trained for every single time the crew visit the sim.

MCAS, on the other hand, was a problem that the manufacturer had failed to tell pilots existed and was insidious in its appearance -- don't forget that the 737 does a lot of 'uncommanded' trimming (STS) in any case so pilots would be well used to the trim wheels whirring away in unexpected (and, to the pilot, apparently counter-productive) directions around this stage of flight.

If the manufacturer had said "look, we've put this new system in to the aircraft, this is what it does and where the inputs come from and here's some possible failure modes that you need to be conscious of" in their training package then that would be one thing. But they didn't -- and don't forget also that with so few 737 MAX simulators in existence most crews will never have had experience of non-normals in a MAX sim -- only in an NG, where the root cause, an AoA failure, would present in a completely different manner.

To extend the EFATO analogy -- what would your assessment be if an aircraft exhibited totally different flight characteristics and displayed compeltely different indications to another variant when an engine failed on takeoff but crews hadn't been told that or ever seen it in the sim? Would it be reasonable to expect them to diagnose the problem as quickly and perform to the same standard?

[KevinAu 441]

56 minutes ago, skelsey said:

I'm not disagreeing with your assessment of the crew's performance at all - I think this is a very good summary of what they did and the problems with it. What happened is now reasonably (with the caveat that we haven't seen a full CVR transcript etc etc) well established.

The question, however, as I posed little while back is why they performed in this way?

As you say, they presumably demonstrated competence in failure management, CRM etc in the sim and unless they'd been living under a rock must have been aware of the Lionair incident. So why did they perform in the way they did when faced with this situation in reality?

Obviously that is a largely rhetorical question but hopefully one which the final report will address in depth and the aspect I am most interested in - as only by understanding why is it possible to make changes to prevent other crews from experiencing similar problems in different non-normal situations.

Complacency. Getting so used to the normal hum drum of going from point a to b day in and day out without any problems. You are not mentally prepared to change gears into abnormal mode. I see this all the time. ‘Ding’ and some Eicas message pops up and my fo will start reaching for a button or switch on the overhead. He knows what the problem is, I know what the problem is, we all know what needs to be done, but we’re just ad hocing it. That’s when I say wait, then I say the first line in our abnormal procedure, the eicas message, then I say I or you have control, then I say memory items, then I say no memory items, then I say qrc. I steer them back into the abnormal procedure that we do in training and that we are supposed to fall back on for every abnormality. Once I remind them of what they did so many times in training, they fall back into what is known, comfortable, and proper. The captain of the Ethiopian jet was wandering in the woods with the shakers, and miscompares, and heavy yoke. But if he snapped out of the shock of it and reached backed into the first step of his trained abnormal procedure, ie declaring the problem, calling for memory items, etc, whatever steps Ethiopian had tried to hammer into him in the sim, then he would have found a safe space in his mind to step forward one step at a time along a path to handle the situation, utilize his fo, and comply with the procedure and not turn the trim back on. He didn’t do that. He never got past the shock of the noise and handling problems. 

Edited April 10, 2019 by KevinAu