I just listened to this podcast done by former NTSB investigators Greg Feith and John Goglia on the Lion Air 737 MAX crash. They cite the Indonesian accident report and read directly from it as well as from FDR and CVR data. This is telling a significantly different story than what you keep reading and hearing about the Lion Air crash and the role that MCAS played in it.

https://www.podbean.com/eu/pb-w9bnw-cfcd9b

It is best if you listen in yourself but I'll cite the most significant parts:

• The airplane was not only unairworthy in the accident flight but also for two flights prior and was still cleared to fly every time.
• The airplane was flyable and under full control by the Captain for about 10 minutes of the 11 minute flight.
• Of the 11 minutes of flight, MCAS was activated only for about 1 minute: after flap retraction briefly for 10 seconds before the Captain commanded flaps 5 which shut MCAS off again and in the last moments before impact when the flaps fully retracted for unknown reasons (no command by either pilot) which enabled MCAS again.
  • For 10 of 11 minutes, until the final moments, this was entirely an unreliable airspeed situation due to a faulty AOA vane with MCAS completely shut off due to flaps.
• When MCAS was actually activated, the Captain successfully countered the automatic trim inputs and the stab trim stayed in the green takeoff band for as long as he was pilot flying.
• The F/O did not only not know the unreliable airspeed memory items but he also wasn't able to find them in the QRH after flipping through the pages for several minutes. As a result of this and of the Captain not taking action in this regard either, no memory items or checklists were ever performed and the unreliable airspeed was never taken care of (no power and pitch technique either).
  • On the CVR you can actually hear the sound of paper pages (of the QRH) being flipped (!) for minutes. The only warnings that were present were the stick shaker (not for the entire time) and visual warnings on the Captain's PFD. So much for the common theory that there was a lot of noise from all kinds of warnings.
• Despite the Captain recognizing the uncommanded trim inputs and repeatedly counter acting manually, neither pilot turned off the automatic trim system or even mentioned this.
• The Captain handed over control to the F/O in the moments before impact without briefing him on what he had been doing to control the airplane.
• At this point the aircraft had reached a speed close to 400 knots because the autothrottle was still engaged (similar to the Ethiopian crash).
• The F/O then didn't trim enough to counteract MCAS and the airplane's nose attitude was increasing downward until impact.
• Throughout the whole flight there was poor CRM and coordination between the pilots and only little actual discussion with regards to the abnormal flight situation.

This is simply the flight data verbally recited. This by no means clears Boeing of any blame but it is astonishing how MCAS played far less of a role in this accident than it's widely alleged that it did. It's a bit shocking how much misinformation is floating around about the crashes and about how much MCAS actually contributed. The blame with regards to human factors I think should not be put onto the pilots but rather on the training they received because like the investigators said, the poor airmanship and at times plain incompetence to deal with the situation is likely the result of poor training.

Edited February 8, 20206 yr by threegreen

I’ve been saying it since this crash. The MCAS might be a broken system that needs to be fixed. But it is hardly the reason the crashes occurred.  Use whatever accident investigation model you want it was only one part of many that lined up to the unfortunate end.  Most of these crews and that includes Ethiopian and Asiana 777 SFO incident don’t have that much hands on flying experience. They are trained to their commercial and thrown into the right seat and instructed to turn the automation on.  In the case of the 777 incident the Capt had 10000 hours of flying but how much of that was actually hands on? From my personal experience I can tell you, I was my most proficient when I was hand flying a Beech 1900 with no autopilot down to CAT I. Mins day in and day out. Not when I had 250 hrs and a CPL. not when I had 800 hrs as a CFI. But after I had 4500 more hours of hand flying.

Had I been taken at 250 hrs and thrown in a jet and told to let the automation do everything I wouldn’t have the tactile feel of flying I do today. How do I know this? Cause now I fly a 747 and I can tell you personally how fast it is you lose that touch.  Does that make me a bad pilot now? No, we do upset recovery training to help us get the feel for it again.  It take about a min or less I think before you get in the groove again. But it was still there.  
These guys didn’t have any of that because of the explosive growth of aviation in these regions.  They need pilots an they need them now.  There’s a long history of accidents in the US that follow this same trend. Colgan for example and more recently here at Atlas in the 767 IAH crash.  A person that should never have been operating an aircraft slipped thru cracks because someone needed bodies in seats.
But I digress.  The last barrier to prevent this crash was the crew.  They were the ones that should have been able to cope with a mechanical issue that still left the aircraft airworthy.  They could not and the aircraft was airworthy.  It was the case with both of the Max crashes.  In Ethiopians case they couldn’t think to pull back the power and impacted at max thrust. Because they didn’t slow the aircraft down they couldn’t get the air load off the horizontal stabilizer. They also deviated from Boeings procedures when they reactivated the electric trim.  It’s a shame really.

You said in your post that the blame in regard to human factors should not be out on the pilots but instead with their training. 

Being in the airlines myself, just reading your post and the bullet points you wrote, that's exactly what should be blamed in regards to human factors....the pilots. 

These were supposed to be professional pilots and it looks as if they didn't act in that capacity at all. It looks as though the leadership of the captain is abysmal at best. 

Its a text book case of poor CRM and threat and error management by the crew. It also show how human factors always tend to play a huge role with things like this.

The airline's training should be blamed as well but to completely excuse the pilots and say training is the issue is a terrible idea.  

It's a terrible cocktail of bad training and bad airmanship as well as bad leadership.

I used to fly in Indonesia in the early 90s. The local guys I flew with there were actually really good, sometimes exceptionally  good ,at VFR stick and rudder flying,, but the problem was with IFR and procedural flying.

One guy for example had successfully handled 17 !! Engine failures in his career,plus a rudder becoming partly detached on a DC3 which is quite remarkable . However the same chap was responsible for a basic error in IFR navigation  which then  lead to a fatal CFIT

Edited February 8, 20206 yr by jon b

2 hours ago, ahsmatt7 said:

The airline's training should be blamed as well but to completely excuse the pilots and say training is the issue is a terrible idea. 

Thanks for the input and I agree. Why I'm thinking about the training though is more because of the F/O than the Captain. Based on what the F/O was doing and what he was not doing it seems to me he was completely unable to cope with what was going on. It seems he was overwhelmed by a situation that, while obviously serious and stressful, is trained for (unreliable airspeed). I don't think he was a stupid person but rather that he wasn't able to recall what he learned and trained for. That training should of course be rigorous enough to know exactly what to do if you're caught completely off-guard.

Another thing that was mentioned is that the Captain said before the flight he was sick and he could be heard coughing all the time on the CVR. The F/O said he was called in at 4 am to jump in for someone when he was looking forward to some rest from duty in the previous days. So you have the whole fatigue discussion again.

Add to that the maintenance mentality of not performing tests (and trying to trick investigators when questioned) and telling pilots to take the unairworthy airplane somewhere else because we can't fix it and those pilots accepting that instead of refusing to fly an airplane with obvious failures and there are so many ways this could have and should have been prevent from happening.

Edited February 8, 20206 yr by threegreen

If it were "pilot error" you think Billions of dollars of aircraft would be on the ground? really. There is more going on than we all know or think we know.

3 minutes ago, Adrian123 said:

If it were "pilot error" you think Billions of dollars of aircraft would be on the ground? really. There is more going on than we all know or think we know.

Of course billions of dollars would be grounded.  Given the public outcry over the situation the almighty wise people in DC would excerpt whatever pressure they needed on the FAA to make it look like they were doing something.

No ones denying the MCAS system needs to be fixed but the aircraft have been grounded for nearly a year and the MCAS software fix has been available for awhile.  This is purely a punishment and PR job at this point. You can take the tin foil hat off.

31 minutes ago, Adrian123 said:

If it were "pilot error" you think Billions of dollars of aircraft would be on the ground? really. There is more going on than we all know or think we know.

What I don't get is why so many people seem to be so allergic to the notion that pilot error played a significant role in the crashes. Yes, the MCAS design was screwed up and Boeing apparently have quite some quality and, in this case, safety issues that can't be excused. But it is proven by actual flight data and investigations that the crashes were avoidable and that in both cases the pilots did not perform as you would expect from trained, qualified airmen.

Have you listened to what the investigators are saying or read my post? MCAS had significantly less impact on this flight than most believe and even when it was active the Captain successfully counteracted and had the airplane under control. 90% of the flight was an unreliable airspeed situation which is nothing new and yet the pilots didn't even really address this issue. They couldn't even do the memory items or find the checklist. The Ethiopian pilots had already pretty much dealt with the situation when they followed procedures and turned off the electric trim system. The aircraft was actually climbing at that point. But they totally forgot about power management. They put themselves in the situation that they couldn't trim manually anymore.

I know the popular story is that the plane is a death trap and the pilots couldn't do anything about it but that's just not true.

 

Edited February 9, 20206 yr by threegreen

Maybe it's just me, but sounds like a couple of folks here work for Boeing............

2 hours ago, Adrian123 said:

If it were "pilot error" you think Billions of dollars of aircraft would be on the ground? really. There is more going on than we all know or think we know.

There is no question there was plenty of pilot error, it's just a matter of determining the fault line between that and how much the MCAS system and lack of training contributed: https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-crashes.html?smid=nytcore-ios-share

2 hours ago, Adrian123 said:

If it were "pilot error" you think Billions of dollars of aircraft would be on the ground? really.

Once you add ambulance chasers and bureaucrats to the mix, well, yes. 

At some point, public perception (formed in large part by a corrupt mass media that either doesn't know what it's talking about, is sensationalizing to generate profit, or is nefariously misinforming people to pursue an agenda) becomes reality, no matter how far divorced that perception may be from the facts.

 

1 hour ago, W2DR said:

Maybe it's just me, but sounds like a couple of folks here work for Boeing............

More like a couple of us here actually have some training and flight time experience.

3 hours ago, W2DR said:

Maybe it's just me, but sounds like a couple of folks here work for Boeing............

With all due respect, that is one of the most word not allowed comments I have seen about these incidents. If you haven't listened to the podcast, give it a listen. 

Secondly, please tell me you have extensive training and experience within airlines, because if you don't, it's going to be very very very hard to have any real educated opinions on this stuff. 

 

I train those 250h newbies into 737 in a major airline, within less than 2 month....

You can watch all sort of "funny" things they do in simulator...

18 hours ago, Adrian123 said:

Trumponian!

I'm sorry, but criticising the media for their long record of ridiculously inept reporting--in this case on subjects regarding aviation--has nothing to do with US presidential politics.

Just this last week I saw multiple news reports containing similar absurd misinterpretations of an SVFR clearance, characterized as some sort of special permission to circumvent the rules in the helicopter crash that killed an LA basketball star.  It was as if the oracle on high, the Master Pundit In The Sky, spoke and they all started to parrot the same--patently WRONG--baloney.  A Delta 777 that dumped fuel over land in SoCal was sensationalized like they had just sprayed Agent Orange on a school playground.  The CNN reporting on the Malaysian 370 disaster included such brilliant flashes of the obvious as a video capture of a simulation, captioned by a news flash statement that an aircraft will lose altitude when it runs out of fuel.  (No kidding??!!)  The media gets it wrong and stupid all the time, often in spectacular fashion.  They rush to be the first to fill air time, and in the early hours of a major story, they fill that time with misinformation rather than moving on to something else while they take time to gather some actual facts to report.

Based on how badly and repeatedly they miss the mark on the sampling of topics of which I have first-hand knowledge, it's clear to me that they are not to be trusted to get pretty much *anything* right.