Alaska Airlines flight forced to make an emergency landing... 82

[JohnRBaker]

Yes, Wichita, Kansas was the center for the manufacture of civil aircraft and they've repurposed the old airport terminal into an air museum, most of which is dedicated to the history of civil aviation and the various manufactures of small aircraft. They also had an outstanding display of engines, again, most of them from civil aircraft from over the years.

Here's a shot of the old terminal:

August 2017 (Sony a6000, 16-50mm)

John R. Baker, P.E. (ret)
Irvine, CA
Siemens PLM:

The secret of life is not finding someone to live with
It's finding someone you can't live without

 

[Alistair_Heaton]

its on my bucket list to visit if I ever go back to the USA

 

[Sparweb]

This is pretty bad:

https://www.faa.gov/newsroom/review...ion-designation-authorizations-oda-design-and

To give some context, the FAA set up this review board in March last year (before the doors blew off, so to speak) to examine Boeing's organization with respect to how delegated "Unit Members" are being respected. Unit Members are supposed to represent the FAA and provide oversight from within the company. It seems Boeing's culture roused their ire the whole time. They don't come right out and call it "sandbagging" but you get the idea.

The emphasis of this report is more focused on management of their engineering personnel than a review of their production system, which would speak more about "quality control". Instead this review looked at "safety management systems" or SMS which is the aviation term for building a workplace culture that upholds safety at all levels.

 

[3DDave]

Is the unfavorable interaction based on FAA/review board member statements or is this word on the street? Not doubting the conclusion, just looking for substantiation.

Simply, I can accept the push-back and resistance is true as I have been subject to similar "We are here to fix your problem" investigators before when the investigators had a solution in mind before arriving, usually a solution they had developed as a way to solve all problems everywhere. With the variety of members on this review board I would expect there were multiple different mutually exclusive such solutions.

One would think if a safety management system was the way to go the FAA would have created one for all of US aviation to use. US General Aviation kills around as many people every year as both MAX crashes did, and have been killing people at that rate for decades. Perhaps the FAA would consider fixing deaths in the US?? Dunno.

I am sure if the Boeing response is just as vague as the request for an SMS (like, give everyone an additional thing to hang with their badge that says "SMS - Use It" or maybe woven into new lanyards, that's the ticket)is no one on the committee or in Congress will be more or less favorably impressed than if Boeing rolls out a 50,000 page document in 5 point single spaced text with quarter inch margins on legal sized paper that covers 25,000 possible circumstances. Whatever Boeing publishes or does, I bet there are memos already written, maybe attached to scheduled e-mails, expressing displeasure with the approach in extremely vague terms, but certainly bombastic.

 

[Alistair_Heaton]

Spar how long do you think SMS takes to implement time wise?.

My personal experience with airlines which is the basic level is it takes years to actually function as intended.

There are people that never really buy into it and have to find other jobs otherwise it kills the process of the whole buying into it.

It also seems to me that getting consultants in to dictate processes is only the first box ticking stage. It actually working as intended takes years and a hard core of "locals" that are on it every single working day.

My work I did the induction courses and thought this is too good too be true... it didn't quite work as it sounded with the Q400. There was still do a power reset and don't put it in the techlog by some technicians.

COVID layoffs and transition to single A220 fleet have made a colossal difference. No small part is due to the philosophy of the health management of the aircraft and the inability to reset faults by technicians or crew without documentation trails that the reset has been done.

The known argumentative technicians never came back after covid.

 

[dik]

This was a natural consequence of withdrawing FAA oversight in the first place... when you live in a glass house...

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

-Dik

 

[Alistair_Heaton]

FAA's funding runs out in March this year.

I can understand why FAA and the OEM's want the cost base moved away from Political variable funding arguments.

Projects put on hold because of some political drama unfolding.

What happens when all the inspectors and certifiers stop getting paid?

 

[SWComposites]

re Spar’s post,
Yep, the report is pretty bad.
Any tool, whether it is SMS or something else, is just that, its a tool. If its not backed up by real management commitment, then its useless. Or worse.
Since the merger its clearly apparent that the management focus has been on stock price and share buybacks. Go read the history since 1997.
The excessive outsourcing and decimation of parts of the Boeing engineering workforce prior to the 787 program led to significant problems, delays and huge cost over runs. That in turn delayed any spending on a 737NG replacement. And when the A320neo started to sell very well, Boeing panicked and launched the “just stuff some new engines on and don’t change anything else” Max.
And then in order to sell the less capable and flawed Max they had to greatly reduce the price. Which led to extreme pressures on the suppliers and factory to pump out airplanes fast and cheap.
The Covid induced layoffs and retirements greatly reduced the manufacturing experience level.
So here we are.
Boeing can either somehow completely turn the management focus, or risk crashing and burning. Not sure buying Spirit (the Boeing bits; Airbus isn’t going to allow Boeing to be a supplier to them) is really going to help.

 

[SWComposites]

Alistair - implementing an real working SMS into a big OEM is even more difficult and will take a lot longer than in an airline.

 

[SWComposites]

And back to the report, the only thing that will really fix the identified issues is to yank the ODA and go back to FAA appointed and managed DERs. I’ve posted before about how Boeing lobbying Congress got the ODA system created.

 

[EdStainless]

And congress did it because they didn't (and still won't) fund the FAA to do the assigned job.
There are two parties at the root of this, The Boeing BOD and Congress.
Everyone else is dealing with the fallout from them.

= = = = = = = = = = = = = = = = = = = =
P.E. Metallurgy, consulting work welcomed

 

[3DDave]

The "don't change anything" part of MAX was because that's what the customers demanded. Boeing could keep the price the same as the 320neo and still be cost effective as a result of the airlines not having to change any operations at all.

If you mean by "flawed" that foreign airlines had been reducing pilot hand-flying training, coupled with a flawed public relations response to the false narrative put out by the responsible-for-the-second-crash airline operator, then yes. How was Boeing to understand that the airlines were lying to them about pilot qualifications?

Build "flawless" planes and you get PIA 8303.

If Boeing re-integrates with Spirit they also get the benefit of running only one management burden instead of paying for two; that includes having only one quality management system, which seems to be the core of the latest problem.

I have yet to see any sign that the ODA was the source of any problem to the extent that FAA involvement would have made one bit of difference. The FAA already had the tools to understand and analyze MCAS, which they originally failed to do, as did every other airline and CAA on the planet after the Lion Air crash, because that crash was correctly identified as a pilot based crash. Or maybe all the rest did and not the second crash operation.

Notice who did not get dragged before Congress - the company that miscalibrated the Lion Air AoA sensor nor was the FAA for not ensuring that company had processes in place to prevent that miscalibration and detect that miscalibration.

 

[Alistair_Heaton]

SWComposites that's why I referred to it as basic.

It takes long enough with just an end user setup. Which is why I asked the question.

 

[Sparweb]

Spar how long do you think SMS takes to implement time wise?.

Hi Alistair,
My experience is a lot like yours - SMS takes a long time. For those old-timers who've been there done that, the shift in thinking is hard. For the young it can seem like the normal way to do business. Then and there the friction starts. It is really hard to implement, too. Management doesn't just have to buy in, they have to be involved in the deployment of the system, which literally takes years. For executives who answer to quarterly reports, that's hard. So top-to-bottom everyone in the organization tends to struggle. Including the engineers.

The engineering struggle with SMS in my particular experience is the change from decision making to decision accountability. When people in certification have been examining regulatory compliance for decades, and somebody comes along with a SMS plan, it's easy to respond "yeah I already do that, go away". When you've been authorized to make a finding of compliance for long enough that you know the requirement by heart, it's hard to allow people into your decision process asking questions about how and what you chose. And then they expect you to report on your activity in minute detail. "Get outta my hair." It took a while for me, and I needed a boss who had bought into this to steer me straight. I am now reaping benefits from a system that should be used to build trust.

One way I've found it useful is that I've been able to self-report on slip-ups in our department's work using SMS. Reporting the mistake itself can come across as embarrassing at best or an urgent safety concern at worst. In the non-critical cases, having a SMS system already in place and self-reporting helps. In my experience (of only 2 cases) I found that reporting by SMS and letting the SMS system steer the resolution, that put an end to the issue with our regulator. They trusted our people to find and implement the solution, and we reported progress all the way until it was closed. No further action, no follow up, no red-flag to be picked on for the next audit. That's what it looks like when your organization has earned the trust of the regulators.

So while I don't believe SMS is perfect, and my company's deployment of SMS is also not perfect, we keep getting better at it, and there are benefits when it is used right. So I was disappointed to read the report, but it is consistent with what I have been told by some current and former Boeing employees I've met.

 

[Sparweb]

the only thing that will really fix the identified issues is to yank the ODA and go back to FAA appointed and managed DERs. I’ve posted before about how Boeing lobbying Congress got the ODA system created.

Do you think they would?

Your view of the USA's aerospace industry may be different from mine. From here it seems like there's Boeing and then there's everyone else. Only one of them is "too big to fail" thus the FAA isn't likely to make such moves. In the past decade or two the political support for the FAA to make bold moves has literally vanished. Just look at how they were thrown on the back foot by the FCC over 5G frequency deployment, today dealing with a rash of near-misses, and the number of times their budget was cut, suspended, or simply wasn't renewed. They didn't come out of the MAX scandal looking clean and white either.

 

[Alistair_Heaton]

I self report all the time and it seems to throw people out because they presume pilots are trying to cover up and make excuses.

Just being honest and saying I messed up I need to do xyz to ensure it doesn't happen again takes all the wind out of their sails.

This machine I learned very early on it was pointless trying to hide anything. Every problem is recorded and gets sent to 3-4 places 2 of which are external to the company.

If people do 2-3 plus power resets about the same issue it triggers a huge flag somewhere. The only protection we have as crew is to make sure its recorded in the tech log.

You can see me change over the last 18 months in the captains seat. Last 6 months I have 2 flight data monitoring flags which were firm landings below level 1 out of phase inspection and a full folder of voyage report completions. And zero explain yourself from the boss or flight safety emails.

It takes a while though to get used to how to make the system tick.

I might add as Captain when I say "I" I refer to the crew as a whole as I am responsible for their actions.

So my two FDM the reports only triggered conformation that the process was completed correctly ie. identify a landing could be classed as firm, record it, inform maint control, data download performed, relevant requirements performed and aircraft released.

The triggering of the process post flight due to HMU trigger not flight crew apparently is a whole different level of phone calls and emails. The way I do it, two weeks after you submit the report you just get an email saying report complete saying procedures have been complied with.

As a note with this machine a straight G reading seems to bare no relation to what your bum feels. Pointing straight down the runway no wind and you ask for download because it feels ruff and they come back you were less than 1.6 your released.

Any lateral velocity and the G ramps up. So your bum might say nothing wrong with that and it triggers a level 1 inspection.

So I think the G disclosed is actually a load index which is a combination of a multiple number of variables some of which have way more loading effect than straight up down deceleration of a sexual assault of an innocent runway with a 50 ton plus aircraft.

 

[3DDave]

On being wrong | Kathryn Schulz

https://www.youtube.com/watch?v=QleRgTBMX88

SMS is great when you realize a mistake has been made. It may help avoid making that mistake again.

I don't see how it prevents a mistake being made in the first place. As the above video discusses, being wrong feels just like being right.

A response to a problem seems to me like it should include a detailed analysis of a typical problem it is intended to repair or avoid and show how it would have been effective in doing so. Like, what information was available to the participants that the response would have caused them to act differently? Not a fan of cure-alls that with clear hindsight into a problem isn't shown to clearly deal with that problem.

 

[Alistair_Heaton]

On the subject of SMS

As mentioned by 3DDave PIA 8303 accident report is an utterly disgusting chain of events,

https://avherald.com/files/(PUBLIC VERSION) FINAL INVESTIGATION REPORT PIA 8303 AP-BLD.pdf

The accident was actually just the very end of a long chain of faults spread over years and a serious management fault which has been there for the whole time i have worked as a pilot. PIA was on my no fly list before I trained to be a pilot 23 years ago now.

The next comment I won't expand on too much as it would be inappropriate to the individuals and company's.

In my social circle of pilots there have been several cases of none colleague pilots being removed from the responsibility of command due to the SMS system pulling data from multiple sources including training records. This has led to a trigger of a review of their suitability to command a multicrew public transport aircraft. This has happened in multiple different company's. From low cost carriers through to legacy full service airlines and not just in EASA.

So as an industry there does seem to be movement to remove the protection of "mates" sim checks and personal input to protect people who are not meeting the grade or are struggling.

And a personal conversation with someone that was downgraded due to this process was actually quite surprising to me. They don't work with me. It was a lay over crew using the same hotel.

They spoke of their feelings of relief about being removed from the role and just going back to flying the machine as a first officer.

I am seriously considering not running to the bitter end of my career as a Captain, down grade myself, get a CPL issued and not have to deal with all the crap. Just keep the flights safe and waggle the stick.

 

[Alistair_Heaton]

3DDave from what I am seeing is that its also being used to identify hidden trends before the fault occurs to be identified.

A220 heath management unit is point in case.

Lets face it pilots are pretty rubbish at feeding back quality data about the machine.

The HMU and FDR records colossal amounts of data far more than a human could even monitor never mind interpret.

Trends of method of operation and average skill base they seem to be able to work with and implement. And change relatively quickly without waiting for a smoking wreck in the ground to trigger the in depth investigation.

My last sim featured a lot of exercises in relation to dealing with high energy events. I am told that the data from which was recorded and sent to Canada. All A220 operators did similar exercises at the request of Airbus.

I have zero clue what will happen with such data, but it will be real operational data of what they can expect the airframe to be exposed to by real pilots. Or even if it was fleet wide or just my company.

Not some made up nonsense of presumption of "A properly trained pilot should be able to cope with this situation" in relation to presumption of a procedure filling a hole in the Swiss cheese model.

When in reality highly experienced test pilots when the situation is dumped on them had to go into make it up as they were going along mode. With less than 90% being able to save the day. Normal line pilots it would have been below 50%.

 

[3DDave]

So, was PIA 8303 a problem with the design of the plane?

The situation the pilots were started at had the plane over max velocity and maximum trim and likely after the trim system was renabled and MCAS retriggered.

Regular test pilots would recognize the need to follow the stall warning procedure straight away and properly retrimmed and not allowed it to go out of control, just like the first crew did and the captain of the second crew did.

Is trimming pitch forces just an option for pilots to learn? Can they skip that class and still pass the course?