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

[3DDave]

"That might well be true, but how many other airlines actually did do that?"

It's an EMERGENCY AD and a Memory Item update to the FCOM.

If they chose to ignore it in spite of the relation to a recent fatal accident it does not fall on Boeing.

All the airlines looked at it and all of them accepted it as did all the pilots and all the CAAs - because it had worked. Demonstrably. In recent memory, so one would think they would examine it carefully.

The reason these instructions don't tell them that pulling back may not stop the trim (aside from it being plainly obvious when it does stop trim, and only works -during- some particular trim event and ) is that this is not a procedure solely for MCAS. It why it refers to "relaxing the column" and not puling back.

This is a procedure for the control fault of runaway stabilizer - which could be caused by a wire breakthrough or switch failure providing unexpected power or control signal that would also not respond to pulling back, or a melted relay or a software fault other than MCAS; maybe due to a dead transistor in a memory chip. There would be no "5 seconds" for a mechanical or electrical fault, so no need to mention it. It might be intermittent or it might be continuous.

The pilots are there to deal with symptoms - the symptom is "runaway stabilizer" not "MCAS due to SMYD/..."

The pilots, the airlines, the CAAs also did not push back on the term "runaway stabilizer" but I've seen too many who claim it cannot be "runaway" if it stops after some interval. "That's not runaway, it stops after a while" they write, as if it matters. Since there is a stop at the end of the jackscrew, by that definition, there can never be trim runaway.

Maybe it should have been called "excess trim force on the control wheel"

Do pilots need a kindergarten class on how to trim a plane? Maybe they do, as the Captain in ET-302 did apply the electric trim but did not trim the plane. Should it be explained as if to a five year old instead of a multi-thousand hour Captain?

"Initially, higher control forces may be needed to overcome any stabilizer nose down trim already applied.
Electric trim can be used to neutralize control column pitch forces before moving the STAB TRIM CUTOUT switches to CUTOUT"

Does that not say what is to be done? It said "Electric trim can be used to neutralize control column pitch forces" and that was true - electric trim continued to function. "neutralize control column pitch forces" is that unclear as the reason to use the electric trim? "neutralize control column pitch forces before moving the STAB TRIM CUTOUT" is what is to be done "before" cutout.

When the Captain read these new instructions what did the Captain think it meant? We don't know because his airline never asked him or the FO (first officer.) We also don't know because there is no record his Chief pilot or the CAA had talked to them either.

From the FDR it is clear this crew was beyond desperate to get the autopilot running even during the non-MCAS related event for which they are trained and given clear instructions to disable the autopilot and autothrottle. ET-302 was gaining altitude and was in a stable climb, when they decided to try to re-engage the autopilot. They turn on the thing they are told to turn off and keep off to try the autopilot and, when that failed, they left turned on the thing they are told to turn off and keep off.

It was that experimentation that lost them all control of the plane. Per the FDR, until they tweaked the trim switch to see if the trim motor worked, MCAS had issued no recent trim commands and MCAS stopped moving the stab the instant any electric trim command was used.

It is more imperative to find out why the training failed so miserably and why their airline and CAA failed to ensure they were capable of handling what is a trivial physical action. Planes can be examined to see if the software is good, but what of the thousands of pilots who may be just as poorly trained?

 

[Alistair_Heaton]

try 100's of thousands, of pilots.

These information letters are a weekly if not daily downloads on to the ipad. You can and do get saturated with all the updates. Especially when you have been on vacation for a couple of weeks.

You do get tick tests with a few questions after reading them but in reality how long retention they have is debatable. For me they don't sink in until there is an exercise in the sim. And I am lucky I get an extra 4 hours bring it up to 16 hours from 12 which is the legal min per year.

"It is more imperative to find out why the training failed so miserably "

100% agree on this one and the issue has been known about as long as I have been flying. But its all part of this risk matrix and cost analysis.

But if the 737 MAX risk matrix V training required is increased V other types then the aircraft type is as dead as a dodo.

I think you would be surprised how little we actually manually trim the plane outside the sim. Its maybe a couple of dips of the trim switch after the AP is out for landing and that's it per flight. In nice weather months I won't touch it for weeks.

 

[AZPete]

3DDave, what's motivating the ferocity of argument? The detail with which the analysis is broken down and rebutted indicates some strong feelings on the matter, as though an egregious wrong has been committed by the pilot/airline while the manufacturer and regulator have met their burden. Is that the essence of the argument?

 

[3DDave]

There has been no rebuttal. There has been taking the initial ET-302 claims at face value.

The putting of sole blame has moved from MCAS to the Board room, but not a single analysis has looked at the step by step operations in the cockpit as recorded on the FDR.

The maker met their burden with the Emergency AD.

Would anyone here would accept a situation where a minor malfunction of a piece of equipment, an adequate and already proven adaptation is given, and subsequent use by an informed operator that ignores every part of that adaptation resulted in an unwanted outcome is blamed on the maker?

And the "startled" excuse looks really weak compared to the door departure response. Alistair is apparently pulling to have pilots that are feinting goats.

When I say they failed to follow the stall warning procedure - where is the breakdown and rebuttal?
When I say they failed to follow the stabilizer runaway procedure - where is the breakdown and rebuttal?
When I say their Chief pilot did not ensure the pilots under his care understood with absolute clarity how those procedures were to be followed - where is the breakdown and rebuttal?
When I say their CAA did not ensure the pilots in that country did not ensure the pilots understood with absolute clarity how these procedures were to be followed - where is the breakdown and rebuttal?
When I say the false stall warning is the initiator - where is the breakdown and rebuttal?

The rebuttal has been "it's the fault of greed" Yeah - the pilots were greedy and wanted to fly. The airline was greedy and wanted to sell tickets. The CAA and government were greedy for political power and wanted to operate their national pride and joy; their President said operating this particular brand new top-of-the line jet would be a way to provide a slap in the face to Western powers who he claimed said his country was incapable.

Had concentration been placed on pilot performance as the core factor gets to the underlying problem that crashed PIA 8303 and AF 447 and many others. Even after Lion Air, when the core of the report and the resulting AD said that the crash was preventable by simply understanding how to trim and how to use a switch, the ET-302 crew said - naw, we're so good we don't have to read it. I am not sure Alistair is getting Emergency ADs and updated FCOM pages for memory item procedures every day - but his attitude towards them is a problem.

Anyway, reducing the complex sequence of events to "Boeing Bad" doesn't offer a way to preventing future problems.

 

[AZPete]

Is the grounding of the aircraft warranted?

 

[waross]

You have made your point, Dave.
Most here do not agree with you.
If, as your position seems to imply, we must choose between;
A. Boeing Bag.
and
B. Pilots Bad.
Most will choose to disagree with you and vote for "A. Boeing Bad."
But the world is not that simple and those are not the only choices.

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

 

[3DDave]

If that's the conclusion it's incorrect.

My position remains, Boeing had a flawed development that missed a critical problem, but it was a problem that could be overcome by the pilots; Boeing incorrectly evaluated pilot training. But for pilot inaction or incorrect action the planes still allowed full control and both crashes were entirely avoidable and needless. The FAA and all airlines said the Emergency AD was sufficient.

All bad.

 

[hokie66]

To the extent that I understand, 3DDave has made his arguments much better than those who just want to bash Boeing.

 

[TugboatEng]

Conspiracy Alert:

China is making major developments with its COMAC C919. Perhaps they are pushing all of these smaller stories of failures in our media in an attempt to destabilize Boeing.

 

[dik]

Boeing's motive was profit at any cost!

-----*****-----
So strange to see the singularity approaching while the entire planet is rapidly turning into a hellscape. -John Coates

-Dik

 

[TugboatEng]

So your a fan of COMAC? Because they work directly for the government they can produce the safest airplane as profit is no longer an influence on design?

 

[SWComposites]

C919 uses a lot of western components. Engines, avionics, etc. I’ve met some of the COMAC engineers; they seemed pretty capable.

Sadly Boeing is doing a fine job of looking bad all by themselves.

 

[3DDave]

Not going to a labor camp because they missed delivery targets might be a more adverse incentive.

Looks at China's tofu cities.

Have to wait and see.

 

[Alistair_Heaton]

3DDave is not wrong.

The startle effect is a lot more powerful than he realises though. Older aircraft types had more issues and you were conditioned to deal with it. These modern ones hardly ever throw up time critical situations.

You could argue the point that airbus and JAR/EASA set things up with pilot training to ensure that pilots were not setup to flying this type of machine competently. Its been a steady process since the 1990's

We just don't have the GA infrastructure to get the hours in on basic aircraft types. The rest of the world followed EASA because it was cheaper and they just didn't have the number of pilots to meet demand. The stats showed accidents were not increasing in fact they have decreased.

A multi pilot license they only fly around 60 hours in an aircraft before hitting the sim on a multipilot jet. And those training aircraft are FADEC EFIS equipped.

There was a lot of dirty practises occurred when the A320 came to the market by both sides.

And they have continued to this day with the stupidity surrounding the A220. There will be loads out there giving pay back.

But realistically stretching a 1960's design to the MAX was a pretty stupid idea and playing the certification rules so that they never moved it forward with the alerting system has really bitten them.

I see it as an information overload while trying to diagnose what the hell is happening. The FBW protections not being there and the reliance on human memory items to fix things is flawed. Which is why the 777 and 787 don't have them for this issue. modern types you only have put the oxygen masks on.

I can't think of any other commercial aircraft that doesn't have a central annunciator panel for faults. Which is the basic system which has been in aircraft since the 70's. The latest ECAM fire up the relevant checklist and warn you if you have misconfigured the aircraft. But changing to that would have triggered a separate type rating for pilots so they just left it with the 1960's system. To be fair that was driven by the airlines as well not wanting to pay additional training costs.

 

[1503-44]

There are two basic design philosophies I like to follow.
1) Just because you can do it, doesn't necessarily mean you should.
2) If there is a safer way to do something, you probably should be doing it that way.

Alistair points those out.
"But realistically stretching a 1960's design to the MAX was a pretty stupid idea and playing the certification rules so that they never moved it forward with the alerting system has really bitten them."

But Alistair, I don't see any need to be fair. "But changing to that would have triggered a separate type rating for pilots so they just left it with the 1960's system. To be fair that was driven by the airlines as well not wanting to pay additional training costs." Customers always want their say every day. The Engineers job is to say yes sir, until they cross the line. Not wanting to pay training costs is one of the poorest excuses I've ever heard. Do training costs need to be included in the price of the aircraft to make it more acceptable to CEOs with private equity backgrounds to buy them? Paying 100s of millions for technology you can't operate because training is expensive is not an effective strategy. It's just short sightedness and false economics. It's not all about ROI. This is just the same failure principle adapted for the airlines business. The approach should be, Hey, if you can't afford the training costs, maybe we should go over there and have a look at that one. Yeah, it's not as bright and shiny as this one, but you won't spend hundreds of dollars on training costs. (Now I see the reason I have to pay extra to sit together. It's FU.) Once again we find the Engineer is sales driven and not taking the role of protecting his customer.

3DDave, you're paddeling upstream. Everything B did with the max was to avoid running off "Bad decision Road". This undercurrent runs the entire length of the river and we're still nowhere the ocean.

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

 

[Alistair_Heaton]

The to be fair bit, was that it wasn't just Boeing MBA's its was also Airline MBA's.

The big issue was the post MD merger put the MBA's in charge of the product. They sectioned the design to prevent the engineers talking to each other. There was nobody with a big picture view by plan. Even the test pilot community weren't given the big picture.

I suspect the MAX 10 and 7 are going to be 2027 or even 2030 before certified.

All the piss taking they did on the NG certification has now been found out.

 

[Alistair_Heaton]

BTW my boss is a pilot and oh Leary of Ryan Air is one.

Its the best airline I have every worked for Maint.

Ryan Air is well known to be solid when it comes to pilot training and SOP's. And its maint has also got an extremely good reputation and they don't fly on the MEL. It gets fixed ASAP like my boss insists on.

BTW the airlines in the USA with similar reputation for maint and pilot standards are all cargo. Run by pilots as the CEO.

 

[1503-44]

Ryan needs massive customer relations improvement. I guess there's always something. Their "Reduced ac deliveries means higher ticket price" narative of late is not helping. Makes them look very greedy. Its bad enough having to pay extra to sit together. I expect having to pay extra to sit will be next.

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

 

[Alistair_Heaton]

It has many faults, but the maint and the pilot training and ops is not one of them.

Personally I would only ever fly single sector without baggage with them. But its a business model that works for them.

 

[LionelHutz]

I agree with 3DDave that the accident pointed out a lack of pilot ability to fly the plane. I don't believe they did anything correctly when trying to handle the situation. I'm not impressed with the "blame it all on Boeing" stance that has happened since that stance is ignoring the other faults in the path between the plane type being designed and two of them torpedoing into the ground.

Boeing's motive was profit at any cost!

Same as the airline motive...

In hindsight, Boeing continuing to concentrate on a 737 replacement instead of trying to make the 737 a neo competitor would have been the smart move.