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NTSB investigators on the Lion Air 737 MAX crash

Featured Replies

34 minutes ago, w6kd said:

Based on how badly and repeatedly they miss the mark on the sampling on 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. 

I don't think it's as much "missing the mark" as deliberately playing up the more sensational aspects because that's what get them their readership - a tactic that politicians have also cottoned on to, but that's beside the point.

The reality is that poor pilot performance has brought to light objective engineering flaws and certification slackness that otherwise wouldn't have become evident - but try selling that in todays sound-bite world.

 

It seems to me that we've been here before with all this and we probably will do so again when the next new type comes along and pilot familiarity and skill is not addressed.

Recall if you will the era when the A320 first came on the scene. It too had a (somewhat radical for the time) control system which pilots were not used to and sometimes failed to understand, and the result was a few well-publicised incidents and accidents which led to some people calling the A320 the 'Scarebus'.

Oh how the tables turn. Fast forward to today and now you have people paraphrasing the saying born back when the A320 was having its difficult adolescence: 'if it ain't Boeing, I ain't going' to now be 'if it IS Boeing, I ain't going' and now actually preferring to go on an A320, when they wouldn't have gone near one back when they were dropping out of the skies with depressing regularity. Was there anything wrong with the basic design of the A320 back then? Sure there were some very minimal things in its ergonomics and haptics which didn't help, but basically there was nothing wrong with it, as is the case with the MAX too, providing you know about its features.

In both cases, basically the issue boiled down to pilots not knowing about a system or function of the aeroplane they were flying, leaving them saying 'why's it doing that?!' as the thing plummeted toward the ground. Add in a bit of too much reliance on automation and a lot less basic stick and rudder skills which we see these days (I'm looking at you AF447, but not just you), and you've got your perfect storm for any aeroplane to crash, from a Cessna 150 upwards..

Like most aircraft accidents, it's rarely one thing which is the cause, but a cascade of them which lead to catastrophe. But at the end of the day and barring technical failures, it is a pilot skill and knowledge issue, because if it wasn't, every MAX which ever took off, and back in the day, every A320 which took off, would have fallen out of the skies. The fact that they didn't is a lot more telling than to simply focus on the ones which did.

There are five TUI 737 MAXs parked up at my works which have been there since that grounding order, but they didn't get there by magic, they were flown there and landed safely. Contrast this with that podcast analysis of the aircraft in the Lion Air crash, which quite evidently had some maintenance issues and some other stuff going on which was less than ideal.

Edited by Chock

Alan Bradbury

Check out my youtube flight sim videos: Here

  • Author
12 hours ago, W2DR said:

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

I think it's even more clear in the case of the Ethiopian crash. The crew identified the situation and that MCAS was starting to erroneously kick in. They followed the procedures correctly and, among other things, cut out the electric trim system. Now MCAS was disabled and, apart from the faulty AOA vane sending wrong information to only the Captain's PFD, they were climbing and "fine" at this point. Except that they weren't because they had completely disregarded thrust and airspeed and the aircraft was now flying well past the operational speed limit. As a result, they couldn't trim manually because of the huge aerodynamic loads on the horizontal stabilizer. At this point they deviated from the previously correctly followed procedures by turning the electric trim system back on, likely in the hopes it would help them trim the aircraft. Still receiving false information the AOA vane, MCAS began again to push the aircraft down and this time it was too late.

As you can see from the FDR data from the Lion Air crash, it is very much possible to counteract MCAS and keep the airplane under full control even when it's active. The Captain even seems to have had some awareness as to how to stop the trim inputs because he commanded flaps down again which there wouldn't be much of a reason for normally. Now MCAS only gets activated again in the final minute and the Captain hands over control to the F/O without telling him about the trim issue at all. Even when the F/O mentioned the "plane wants to fly down" the Captain merely said "it's okay". The FDR data then shows that the F/O didn't trim for as many seconds per MCAS trim input as the Captain did which was not enough to keep MCAS from gradually increasing the nose down pitch attitude.

MCAS was only activated for very short periods of time during the accident flights and when it is, it's possible to counteract and keep the nose in a normal position and the aircraft under full control. What comes into play now is that on the Lion Air flight the crew was just not capable to even deal with the situation of one side displaying wrong information when the other side as well as the standby instruments are showing normal parameters. The Ethiopian pilots had already cut out and dealt with MCAS but put themselves in the situation of high overspeed by forgetting power and speed and then deviated from procedures which re-induced the initially cut out problem.

For the 100th time, no one is trying to take away due blame from Boeing or put undue blame on the pilots. It's just a fact at this point that there was less MCAS involvement and more pilot error than most think. You don't have to work for Boeing to point that out.

 

 

  • Author

I also think it's concerning that when experienced airline pilots as well as seasoned investigators who are pilots themselves and investigated tons of aircraft accidents in their career come to this conclusion and people act like even they are talking nonsense or are working for one of the involved parties in a conflict of interest.

    If I recall, Lion Air initial news reports focused on both prior maintenance problems, and pilot inexperience with the MCAS system for the crash.  Then, as the weeks past, although fully warranted, media outlets sunk their teeth in a much juicier story:  Corporate greed involving the cover-up of a perhaps flawed system (MCAS), and undo influence on U.S. government Agencies to approve it.   

   But I rely on one undeniable fact:  There were thousands of flights around the world using the 737 MCAS.  There were scattered accounts of problems with it, but I believe, not one fatality prior to Lion Air.  

Pilot error and the possibility of two crews literally flying an airplane into the ground isn't as juicy of a story as corporate greed. 

Especially when the corporate greed angle helps to push certain political movements. 

It's pathetic. The lion air crash should have never happened. 

I have flown on the MAX quite a few times and I'll be doing it again...however you won't catch me on a lion air flight no matter what airplane it is because it's very apparent that the airline culture regarding maintenance and airworthiness is a joke at best.

FAA: ATP-ME, 737 CA, enough time in the 757/767 to be dangerous 🤠

Matt Kubanda, 7950X3D, 64GB RAM, RTX 5090@4k, MSFS 2024

 

 

 

35 minutes ago, ahsmatt7 said:

you won't catch me on a lion air flight no matter what

Hey, that means you'll be implementing a Lion Bar:wink:

Edited by Chock

Alan Bradbury

Check out my youtube flight sim videos: Here

  • Author
8 hours ago, ahsmatt7 said:

however you won't catch me on a lion air flight no matter what airplane it is because it's very apparent that the airline culture regarding maintenance and airworthiness is a joke at best.

In the podcast they also talk about how Lion Air have a policy of not paying flight deck and cabin crew if they don't arrive at the planned destination. Which means any turn around to the origin airport or diversion for safety reasons won't be paid and as a crew member you're basically punished for that. The investigators discuss how this may incline pilots to decide to go on to the destination rather than playing it safe when they're uncertain if safety is compromised.

9 hours ago, ahsmatt7 said:

Pilot error and the possibility of two crews literally flying an airplane into the ground isn't as juicy of a story as corporate greed. 

Especially when the corporate greed angle helps to push certain political movements. 

It's pathetic. The lion air crash should have never happened. 

I have flown on the MAX quite a few times and I'll be doing it again...however you won't catch me on a lion air flight no matter what airplane it is because it's very apparent that the airline culture regarding maintenance and airworthiness is a joke at best.

If this is still a debating point, I wonder if the aircraft regulators around the world who banned the use of these aircraft are all as naive and easily influenced by the world's press as you seem to be implying. You seem also to be implying that corporate greed is an invention of the press or some other interested party. Why there should be a political motive escapes me.There have been many occasions where pilots have flown aircraft into the ground but not so many of them resulted in a worldwide ban of the use of the aircraft in question. There have also been occasions where a design fault has flown pilots into the ground, a previous model of the 737 is one.

There is far, far more data available to today's investigators, in many cases almost instantly and the days of allowing aircraft types to fly on during a four year investigation into a fault that continues to kill passengers and crew are over.

Given that apparently all those involved in the manufacturing and use of these aircraft have concluded that there is a design problem, not yet solved to everyone's satisfaction, I wonder at your conclusion that there is not.

 

 

Edited by Reader

  • Author
5 hours ago, Reader said:

If this is still a debating point, I wonder if the aircraft regulators around the world who banned the use of these aircraft are all as naive and easily influenced by the world's press as you seem to be implying. [...]

After the first crash it was clear MCAS was a broken software that needed to be fixed and when the second aircraft went down in similar fashion, I think it was reasonable to keep it on the ground while investigating what was going on because there was obviously a problem with the aircraft. I don't think that was a decision made by every regulatory authority simply because of media and/or public pressure.

5 hours ago, Reader said:

Given that apparently all those involved in the manufacturing and use of these aircraft have concluded that there is a design problem, not yet solved to everyone's satisfaction, I wonder at your conclusion that there is not.

I'm not who you are replying to but no one ever denied MCAS was a flawed design. I don't know why this allegation keeps coming up.

Incidentally, it has been fixed some time ago and last I read was that re-certification flights were planned to begin within the next weeks.

Edited by threegreen

7 hours ago, Reader said:

If this is still a debating point, I wonder if the aircraft regulators around the world who banned the use of these aircraft are all as naive and easily influenced by the world's press as you seem to be implying. You seem also to be implying that corporate greed is an invention of the press or some other interested party. Why there should be a political motive escapes me.There have been many occasions where pilots have flown aircraft into the ground but not so many of them resulted in a worldwide ban of the use of the aircraft in question. There have also been occasions where a design fault has flown pilots into the ground, a previous model of the 737 is one.

There is far, far more data available to today's investigators, in many cases almost instantly and the days of allowing aircraft types to fly on during a four year investigation into a fault that continues to kill passengers and crew are over.

Given that apparently all those involved in the manufacturing and use of these aircraft have concluded that there is a design problem, not yet solved to everyone's satisfaction, I wonder at your conclusion that there is not.

 

 

Where in the post that you quoted did I say that there was nothing wrong with the airplane? I never said that. 

I could argue that there have been so many other knee jerk reactions that have done nothing for safety except put a band aid on things instead of solving the real problem.

 

The MCAS system is flawed, but to completely blame it for both crashes is stupid. 

FAA: ATP-ME, 737 CA, enough time in the 757/767 to be dangerous 🤠

Matt Kubanda, 7950X3D, 64GB RAM, RTX 5090@4k, MSFS 2024

 

 

 

Hello,

thanks for replying.

To a complete outsider such as myself, it does not make sense to fit such a device which could so easily go wrong and indeed did, which could take control of the aircraft and then rely only on the pilot knowing exactly what to do next and to do it exactly right and immediately, to prevent the certain death of all on board. I understand that a pilot needs to be able to fly but don't they also need their aircraft to be reliable and predictable? I can see that with hindsight, the pilots could have saved the day but under such pressure, are their actions not at the very least understandable if not also excusable?

I expect that there is a different view among professionals such as yourself and I would be very interested in knowing what the "inside" opinion is.

 

It is not a zero sum game where if the plane is faulty, the pilots are exonerated or if it is pilot error, the plane is perfect. You CAN have both a faulty plane and pilot error. What stands out to the professional, is that the pilots did not do what they were trained and expected to do. Take the transcript of the ethiopean crash. Nowhere is there any evidence that they called for memory items, qrc’s and qrh’s. Simple markers of a crew that has activated their abnormals response. If they had remembered to do what they were trained to do, they may have seen the note that implores them not to turn the trim back on. Maybe they would be alive. If you had family on that plane, you would hope they exhausted all that they were trained to do before crashing it. Otherwise, you’re left with a lot of woulda shoulda coulda. Maybe nothing would have saved them, but at least call for a memory item on the cvr so that they know you followed your training.

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