Alaska Airlines flight forced to make an emergency landing (Part II)... 26

[1503-44]

Speaking of spiders, it is getting a bit creepy with the whistle-blower death.

--Einstein gave the same test to students every year. When asked why he would do something like that, "Because the answers had changed."

 

[SWComposites]

Yeah, my money is on a NJ mob hit rather than suicide.

The entire BoD and C-suite execs need to be replaced.

 

[TugboatEng]

Reminds me of the Clinton body count. This guy retired at an unusually young age. It's probably wise to be skeptical about all of your assumptions here. Drug addiction is very likely.

 

[3DDave]

If the BoD and C-suite execs are replaced, who will do the interviews? Certainly not the spineless underlings they hired to keep them out of the loop. It would also be bad if anyone who thought they were suitable were to find similar people, so scratch HR.

 

[waross]

Well the front line managers do what the upper managers want them to or they may be gone.
And the upper managers do what the senior executives want them to do or they may be gone.
The top executives do what the BoD wants them to do or they may be gone.
The Board of Directors do what the majority stock holders want them to do or they may be gone.
I have thought for some time now that Boeing won't change until ownership changes.
A $2.5 Billion fine apparently was not enough to change the company culture.
Too Big to Fail or Too Big to admit Failure?


--------------------
Ohm's law
Not just a good idea;
It's the LAW!

 

[3DDave]

If loss drove change then Musk would be an entirely different person. If a $25B personal writedown isn't enough to question ones's choices, nothing will.

 

[1503-44]

I just said it was creepy. Let's don't take the character defamation route just yet. High stress has been known to occasionally cause untimely death.

Right. Fines and penalties are not going to make them flinch. 471 is a pretty big number too and that didn't even produce a "Geeze we're sorry".

Extreme sociopaths have their hands running a lot of stuff that they shouldn't even be let to go have a look at. They are always right, no matter what the damages are.


--Einstein gave the same test to students every year. When asked why he would do something like that, "Because the answers had changed."

 

[Brian Malone]

https://youtu.be/Z76YpCz9N2Y?si=Oxpi3Mi6or-tbA4x

I have seen some opinions posted strongly pointing to errors of the Ethiopian Air pilots. Certainly, there may be some errors that can easily be pointed out in hindsight, but this Frontline report says to me, engineering choices were made to minimize the presence of MCAS and minimize required pilot training to preserve business plans. In the chaos of a runaway plane the pilots tried to regain control over a system that was surreptitiously implemented and later revealed only by necessity and its full power was not truly revealed. The FAA was ineffective in their oversight of the Boeing development process by not being given knowledge of the MCAS system, and by being too cozy with Boeing employees assigned to be FAA representatives. The failures at Boeing are not by the make up of the staff. Boeing's failures are quality and design lapses driven by business choices and direction by the senior management (many who are engineers) and abetted by lax oversight by the FAA. Boeing has been working the regulatory loopholes and the additive errors compound.

 

[1503-44]

Pilot error has been pretty much totally discounted. So far its following the BP narrative just about to the letter. But first the innocent must be punished to divert attention from the number of golden parachutes touching down in the lush green meadows.

The consensus so far is that Stock market opium "OPM", the most powerful drug out there, is what caused this.

--Einstein gave the same test to students every year. When asked why he would do something like that, "Because the answers had changed."

 

[Brian Malone]

Other People's Money . . . very powerful and useful if you can get it and control it.

 

[Alistair_Heaton]

The Ethiopian captain was 2000 pic and over 9000 hours total.

He was young but not inexperienced.

The first officer was fresh out of school and new on type and wouldn't be much use trouble shooting something like that.

There is a group that do still put forward it was pilot incompetence. But it's way passed that now in certification and regulation authority.

 

[1503-44]

That supposition was just a tad too convenient for far too many reasons. Not the least was it came, was it just an hour after it happened?, or was it before, and they just printed and mailed it afterwards?

--Einstein gave the same test to students every year. When asked why he would do something like that, "Because the answers had changed."

 

[3DDave]

Brian, look at the FDRs. The Ethiopian pilots were provided a game plan that said, if there is a stall warning, but no stall, do not retract the flaps, turn off the autopilot and the autothrottle, set pitch and power and return to land.

This was obvious from the Lion Air preliminary report roughly 4 months before the ET-302 crash.

They were also to follow the stall warning procedure - also shut off autopilot, disable autothrottle. They turned on autpilot and did not disable autothrottle.

Their performance got worse from there. There is no indication they were panicked, they simply had not bothered to prepare, nada. The only thing they recalled was to disable the trim motor, but they forgot that the step before that is to trim the airplane and before that to disable the autopilot and the autothrottle. Aside from that their performance was perfect. But wait - there was a highlighted instruction in the FCOM and Emergency AD - never re-enable the trim motor if it's been disabled. They did that. Because they wanted to get the autopilot operating. The autopilot they are supposed to disable during a stall warning, which has been the case for over 30 years and has nothing to do with the MCAS software.

Had this happened 20 years after Lion Air and no intervening crashes or incidents, sure, people forget. This was 4 months. Hubris, stupidity, over confidence, they thought Boeing and the FAA were lying about "memory items". Personally that Emergency AD should have been taped to their leg until the promised software update was released, but they decided to try to wing it. The first officer was the one who recalled the switch; a recall that ultimately killed them.

The PIC should have known both the stall warning and the trim problem procedures without hesitation. He did not know them at all. Why did he think he was safe to fly? Why did the chief pilot think he was safe to fly? Why did their CAA think they were safe to fly? Why did the airline management think they were safe to fly?

There is a reference to training, but the CAA certainly would not want to take blame for their failure. I recall the conditions of the captain's training were suspiciously vague. There was no evaluation of how, if he was trained, the training failed so badly that in a few months there was zero retention of the material.

 

[Alistair_Heaton]

They said the same thing about the rudder hard over.

It's a well trodden road for dealing with any design fault.

 

[LittleInch]

3D Dave,

You have been very consistent in your view over the second 737 crash and the pilot actions, but this ignores the results of the later simulator tests that Alastair referred to some time back where they took a selection of pilots trained in different parts of the world and ran the same scenario, also apparently the FAA director. Most of them also crashed apparently.

Trying to blame the pilots for not reacting to a plane which was going mental, with alarms, over speed clackers, movement up and down would be a whole heap different to reviewing this later from the comfort of our living rooms with plenty of time to decide what the root cause was. Remember this was only the third incident in many many flights and the whole point is that the system was set up to fail the pilots. IMHO.

Also as far as I know there are no instances of any flight actually happening where this system failed and where the pilots managed to control the aircraft back to base, other than the very first one where they were very fortunate that they had a third independent pair of eyes and arms to assist them. Even then they didn't know why the plane had reacted that way. This was an incredibly serious error by Boeing and the FAA. Blaming the pilots doesn't work for me.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

 

[Brian Malone]

3DDave, you see the details as you see them. I see Boeing should not have been able to implement a flight control system that has such extreme control and power over a plane's behavior without having a detailed description in the original operations manuals/instruction and training and prominence in the diclosure to the FAA. Their FMEA and risk analysis for this highly critical system (that relied on the input from a single AOA sensor) seems poorly planned/weighted and the original decisions made seem driven more by minimization of disclosure of the new flight control system rather than concern for passenger safety and ease of pilot awareness. MCAS and the plug door debacle (and every other issue the media puts in the news, whether truly Boeing-specific or not) are going to test Boeing to re-engineer their quality, production, and engineering practices. The FAA has some oversight retooling in order, too.

 

[Alistair_Heaton]

To note it was Boeing who wanted the SIM sessions outcomes silenced.

I can't find any details about that first crew that survived.

There have been other situations and crashes where a third set of eyes has saved the day in a cockpit.

The ability to only process the information displayed and not have to think about the flying is a collosal capacity increase.

There isn't alot of detail what went on on that first flight. I suspect a captain's foot was applied to the trim wheel which was applied by the pilot in the jump seat. Getting your hand near the 737 trim wheel when it's running takes some "balls" to be honest.

 

[LittleInch]

The first flight I think they managed to control the trim by the switches, but then 5 seconds later it went into another dive. It took the jump pilot to see what was happening and I think he actually disabled the trim motors once the plane got nearly level. Not sure how they managed to deal with all the other alarms etc going off due to the incorrect AoA indicator. Think they just went with whichever side was showing the correct altitude etc and not stick shaking.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

 

[3DDave]

No details were released on what was attempted in the simulator. Nothing at all says Boeing wanted the sim results silenced. Friend of a friend on the internet isn't a source.

The only possible test would be the last 10 seconds, after the pilots had fully stuffed it up. Competent pilots would know not to force autopilot on and would disable autothrottle. There is a difference between getting to a situation that is unrecoverable and avoiding one that is entirely avoidable.

The last 10 seconds of PIA 8303 and AF447 were also unrecoverable. The first due to Airbus hammering pilots 99% of the time that they cannot ever be stalled, and the latter from failure of CRM. Sure AF447 was also because Air France and Airbus had not issued an order to ground all the planes they knew had defective airspeed sensors, but that was corporate greed in action right there. They already had a safer replacement part, but chose to risk lives for corporate profits while they slowly rolled out the fix to a failure they had rushed into production with.

The overspeed clackers came long after they failed to perform the stall warning procedure. It's the sound of rods being shot from an engine 20 minutes after the oil light comes on. If they cannot think anymore about anything at all when a warning goes off they should not be in those seats. Or maybe no plane should ever have warnings so as to not cause the pilots any undue stress.

The second flight was under control until a failure in CRM and experience differential led the captain to turn over control to his newbie. That crew did follow the stall warning memory item list as did the first and did not overspeed in level flight.

Note that the first flight went 90 minutes with the stick shaking and stall warning. They even re-enabled the trim in cruise, got another MCAS increment, and immediately shut it back off - hence the guidance to never re-enable the trim motors. They used the hand cranks that "didn't work" for pilots in the sims because in the sims they let trim go a great departure from trim before going to manual. The possible "third set of eyes" was essentially the report that the Ethiopians had in hand when going over the Emergency AD and FCOM update.

The MCAS risk management was based on having the same response to a failed motor driver that would not shut off. Different cause, same symptom, hence same response. If that isn't true, then there should not have been the trim motor cutout switches.

"They said the same thing about the rudder hard over." Sure, because they didn't know the actual cause of those crashes and initially found nothing wrong with the post-crash hardware. All in spec, all functioned on the bench as required. Here all the control equipment was 100% functional the entire time. Nothing prevented the pilots from controlling the aircraft. The procedure was handed to ET-302 on a silver platter. No one investigated why their training failed, which is why two external agencies wrote independent sections that the Ethiopian CAA did not include in their report.

"There isn't alot of detail what went on on that first flight. I suspect a captain's foot was applied to the trim wheel which was applied by the pilot in the jump seat. Getting your hand near the 737 trim wheel when it's running takes some "balls" to be honest."

What the hell is that about? It's hardly a coherent sentence. The first one didn't require anyone putting a foot on the trim wheel. The second one didn't involve anyone grabbing the trim wheel as the trim was still functional and the Captain used it, just essentially unused by the FO. The third one might have but, again, they stuffed up every step so it didn't matter.

The capper is this - everyone could see the Lion Air report and decide if their pilots could follow the simple directions that came out of that or not. That decision was made by the airlines and the pilots and the various CAAs.

At that point, Boeing had committed to a software change.

If you own a product and you see someone in the news was killed while using it but the maker announces a replacement part that will prevent that happening who does the responsibility belong to if you use the product before that new part is installed? Not one pilot said one thing about the FCOM update or the Emergency AD before ET-302. It was accepted and it 100% worked because it had already been used successfully. No pilots quit, or refused to fly. Do we trust the thousands of experienced pilots to know their ability to cope and their CAAs and their Chief Pilots or is Boeing supposed to be a mind reader?

 

[LittleInch]

I came across this article on AF477 which makes fascinating reading and have copied a couple of key paragraphs.

https://hbr.org/2017/09/the-tragic-...y-but-catastrophic-consequences-of-automation

"Loss of control typically occurs when pilots fail to recognize and correct a potentially dangerous situation, causing an aircraft to enter an unstable condition. Such incidents are typically triggered by unexpected, unusual events – often comprising multiple conditions that rarely occur together – that fall outside of the normal repertoire of pilot experience. For example, this might be a combination of unusual meteorological conditions, ambiguous readings or behavior from the technology, and pilot inexperience – any one or two of which might be okay, but altogether they can overwhelm a crew. Safety scientists describe this as the “Swiss cheese” model of failure, when the holes in organizational defenses line up in ways that had not been foreseen. These incidents require rapid interpretation and responses, and it is here that things can go wrong.

Commercial aircraft fly on autopilot for much of the time. For most pilots, automation usually ensures that operations stay well within safe, predictable limits. Pilots spend much of their time managing and monitoring, rather than actively flying, their aircraft.

Automation provides massive data-processing capacity and consistency of response. However, it can also interfere with pilots’ basic cycle of planning, doing, checking, and acting, which is fundamental to control and learning. If it results in less active monitoring and hands-on engagement, pilots’ situational awareness and capacity to improvise when faced with unexpected, unfamiliar events may decrease. This erosion may lie hidden until human intervention is required, for example when technology malfunctions or encounters conditions it doesn’t recognize and can’t process."


I'm not in a position to criticise the pilots and decide whether they are "competent" or not. In many cases trying to reengage the autopilot is probably a good idea as many things are made worse by manual intervention. It's interesting on the AF incident that even without the A/P on, the reckoning is that the plane would have kept going relatively flat and level, but trying to correct a small roll with a small joystick and not much controllability at high altitude and high speed created a worse condition. Loss of anti-stall functionality didn't help, nor other issues like the stall warning hooter dropping out due to lack of forward speed...

As I recall the second flight, the aircraft was trimmed nose down and the second pilot was finding it hard to keep the nose up with all that trim. So he tried something which didn't work.

Runaway trim as a single issue is almost certainly a lot easier to figure out and the trim motors get cut out if you pull against it normally, but not in MCAS. So one taught method was now not correct.

And yes, to a certain extent Boeing is supposed to be a mind reader to figure out design and software that makes sense, doesn't go against previous "rules" of flying a B737 and can recognise faults or put in place features which prevent it destroying the aircraft. All the actual things they did later were inherently quite sensible and you have to wonder how come no one thought of this during the design and review process. Or maybe they did but it was too costly or too late to modify it. But failure to modify MCAS before selling the aircraft cost Billions and hundreds of lives.

Not ensuring QA procedure to allow four piddly bolts to not be fitted - more billions, thankfully no one got sucked out, but that was a lot more luck than design. Failure at 35,000 ft with people actually seated next to the door - nothing would stop you going out that huge hole. Probably 5-15 people out the plane is my guess.



Remember - More details = better answers
Also: If you get a response it's polite to respond to it.