Boeing 737 Max8 Aircraft Crashes and Investigations [Part 4] 28

[Sparweb]

This is the continuation from:

thread815-445840
thread815-450258
thread815-452000

This topic is broken into multiple threads due to the long length to be scrolled, and many images to load, creating long load times for some users and devices. If you are NEW to this discussion, please read the above threads prior to posting, to avoid rehashing old discussions.

Thank you everyone for your interest! I have learned a lot from the discussion, too.

My personal point of view, since this falls close to (but not exactly within) my discipline, is the same as that expressed by many other aviation authorities: that there were flaws in an on-board system that should have been caught. We can describe the process that "should have happened" in great detail, but the reason the flaws were allowed to persist is unknown. They are probably too complex to reveal by pure reasoning from our position outside of the agencies involved. Rather, an investigation of the process that led to the error inside these agencies will bring new facts to light, and that process is under way, which will make its results public in due time. It may even reveal flaws in the design process that "should have" produced a reliable system. Every failure is an opportunity to learn - which is the mandate of the agencies that examine these accidents.

Some key references:

Ethiopian CAA preliminary report

Indonesian National Transportation Safety Committee preliminary report

The Boeing 737 Technical Site


No one believes the theory except the one who developed it. Everyone believes the experiment except the one who ran it.
STF

 

[Alistair_Heaton]

Thought some might find this interesting..

http://newsinflight.com/2019/07/10/engine-spinner-came-loose-in-flight-on-delta-airlines-plane/

Bag of luck took a hammering with this one.

 

[thebard3]

Oh, the luxury of being a NON aircraft software engineer. Mazdas would be falling from the sky...

https://abcnews.go.com/Business/wir...58?cid=clicksource_4380645_null_headlines_hed

Brad Waybright

It's all okay as long as it's okay.

 

[Lou Scannon]

On the topic of simulators, training, and proficiency checking, some might find this interesting, from a historical perspective.
Link

"Schiefgehen wird, was schiefgehen kann" - das Murphygesetz

 

[Lou Scannon]

Oh, the luxury of being a NON aircraft software engineer. Mazdas would be falling from the sky...

Never mind that, it's already completely obvious that we have game programmers on the loose with no clue about physics, hard real time or other serious engineering disciplines such as in the loop validation, writing mission critical code for Tesla, Uber et al wannabe autonomous vehicles, with predictably disastrous results. Not faulting the programmers directly, but the organizations they work for that think they've got the bull by the horns, when the opposite is the case.

"Schiefgehen wird, was schiefgehen kann" - das Murphygesetz

 

[waross]

I know a top gaming programmer.
He works for a top game producing company.
When I saw him last year he was supervising about 300 programmers.
I think that the pay may be better than at Tesla.
He did work for awhile for a company owned by Mr. Musk. (Not Tesla. Another property.)
He's gone back to gaming.
Talking to him about his past projects, I suspect that he does have a clue.
I guess if a game programmer can't get a good job with a game company there is always Tesla.
But I accept your point of view as it applies to Tesla programmers but not all game programmers.

Bill
--------------------
"Why not the best?"
Jimmy Carter

 

[human909]

Talking to him about his past projects, I suspect that he does have a clue.

I don't think anybody was suggesting that there are not excellent programmers and intelligent people in these industries. But you have to realise the required standard of quality control is COMPLETELY different.

It is often commented that modern software be it games, productivity software or operating systems has vastly more bugs than older software. Part of that is complexity. But also with online hotfixes and bugfixes the pressure to get it perfect on the first release isn't as great.

 

[IRstuff]

Nothing to do with gamers, per se. FCS had world-class systems engineering, but no one at the prime understood military vehicles.

TTFN (ta ta for now)
I can do absolutely anything. I'm an expert!

https://www.youtube.com/watch?v=BKorP55Aqvg

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[Sparweb]

On the topic of simulators,

There's a lot that's out of date in that 45-year old article. Have you been inside a modern full-motion, wraparound-vision flight simulator? It's pretty intense.
I worked at CAE Electronics for a summer internship. In the 90's it was already getting pretty good. It doesn't have to convince you it's real to give you the visual cues to your orientation (or disorientation, depending).

No one believes the theory except the one who developed it. Everyone believes the experiment except the one who ran it.
STF

 

[3DDave]

I guess the FCS systems guys failed to do their requirements work and AoA evaluations correctly. Would they blame materials guys for not making aluminum as stiff as boron? Obviously a flaw with those terrible engineers.

 

[Alistair_Heaton]

I think the initial remit was correct because it had the G limitation included as a dual trigger which is why it got past the test pilot sign off.

It was after they started playing with it to sort out other issues that the consequences of the changes to the failure modes was not caught.

The flaw is in the system/management not per say the individuals or teams doing the projects.


On a seperate note that article is way out of date. The Q400 the first time I landed it I had 70 pax down the back. This zero flight time rating is not an option for low experenced pilots or for that matter training through a normal training provider, You have to have 3000 plus hours in transport twin engined aircraft. It has to be through a company you are going to fly for. And the first 4 sectors need to be with a special training Captain/examiner. The sim used needs to be a level D sim. If you can't meet the requirements you need to do 4 or 6 takeoffs and landings in the real aircraft.

Its not a problem I found until several months down the line when I had a positioning sector empty landing with 700kg of fuel on board which gives a 19 ton landing weight. I was more used to landing with 26-28 tons. The Q400 is utterly horrible landing at sub 21 tons. I liken it to trying to land a shopping trolley getting taken off a curb empty trying to get the back wheels down first. It came as a bit of a shock to be honest. If i had done the circuits in the aircraft it would have been about the same weight. That said when you do your first sectors with pax in the back you have never flown the machine at max TO weight or landed at max landing weight. Loading it up with ballast half way through the circuits is not a realistic option.

 

[charliealphabravo]

I guess the FCS systems guys failed to do their requirements work and AoA evaluations correctly. Would they blame materials guys for not making aluminum as stiff as boron? Obviously a flaw with those terrible engineers.

It was after they started playing with it to sort out other issues that the consequences of the changes to the failure modes was not caught.

It is looking like these problems exist because top level Boeing executives made a smokey room deal with top level airline executives to deliver equipment with certain imagined specifications at a certain date/cost. They then used every corporate trick in the book to push it past engineering objections, engineering realities, test pilot sign-offs, and FAA approvals. The problems themselves are trivial and would have been easily caught and flagged by Boeing engineers and even Boeing's design guidelines.

This is a bit afield but it reminds me of how Vale was manipulating geotechs in the Brazil tailings dam failures or the way owners were gaming the system in the Elliot Lake Mall collapse. Engineers and conscientious individuals simply don't have the power to over-ride this type of corporate behavior. And by 'corporate' I don't really mean corporations per se but the corporate behavior of humans.

 

[waross]

I agree charliealphabravo.

It is looking like these problems exist because top level Boeing executives made a smokey room deal with top level airline executives to deliver equipment with certain imagined specifications at a certain date/cost. They then used every corporate trick in the book to push it past engineering objections, engineering realities, test pilot sign-offs, and FAA approvals. The problems themselves are trivial and would have been easily caught and flagged by Boeing engineers and even Boeing's design guidelines.

This is not an engineering failure.
This is a management failure.
Management telling engineering when they should be asking engineering.
There may be similarities here to the attempts to have the value of pi changed to 3 exactly by legislation.

It appears that management also carefully chose the design team to exclude any engineer with the knowledge and intestinal fortitude to slow the schedule by saying;
"No. This is not wise. This is not right."
One such engineer did slip through the net and did stand up to management on a point of safety and won his point.
He was quickly removed from the project.
Managements mind was made up and they would not allow anything to compromise an unrealistic schedule.
As part of the deal with airlines don't forget the $200,000,000 plus penalty if simulator training was needed.
When management, from the great height of ego and authority and through a smoky veil of hubris, issue orders contrary to good engineering practice, bad things often happen.



Bill
--------------------
"Why not the best?"
Jimmy Carter

 

[RVAmeche]

I wonder what the cost of initially certifying the Max as a new plane, while fully addressing design issues and updating its technology, compared to the costs associated with the grounding, investigation/repair(s), lawsuits, loss of consumer confidence, and loss of orders would look like.

 

[IRstuff]

It's not necessarily ego and hubris, since the execs in question are beholden to the board, and the board is driven by stock valuation. The bottom line, literally and figuratively, is that if any executive attempts to do the right thing and wind up spending profit, he's gone at the next board meeting.

TTFN (ta ta for now)
I can do absolutely anything. I'm an expert!

https://www.youtube.com/watch?v=BKorP55Aqvg

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[Alistair_Heaton]

Well it was 32 billion $ reportely for the 787 program.


According to JP Morgan the max grounding is costing currently 1 billion $ a month to boeing alone not including airline costs and penalty charges. I think there was a time limitaion on that as well that a new gear kicked in after a certain period and the 1 billion $ increased. By how much I don't know. In April Airlines had racked up 2 $ billion in costs in two months. Its something like 150 000$ per day per airframe. Not including maintenance and parking etc and replacement aircraft.

So a guess is 2 billion total per month Boeing and airlines. Alought the airline cost will start ramping up quiet rapidly after oct as NG's were due to be returned before D check. So 2 billion a month currently After Oct 3 billion after feb next year possibly 4 billion a month.


And that won't include any mods that have to be rolled out to get them flying again or cost of getting them certified by EASA and the like.

A new plane would have taken 10 years to design and produce. By which point Boeing would only have a fraction of market share that it had before the NEO came out. I suspect time was the biggest pressure.

As a guess I reckon it must have cost over 10 billion $ so far for all concerned without the legal stuff and consumer confidence accounted for. By January it will be over 25 billion. Next April which is not unrealistic outside the USA should get it up to the cost of developing the 787.

Even when they get them flying again there will be a huge warranty part replacement hit. Expect daily gear issues and flap failures as seals go after sitting unused for months. It will take at least 6 months before those type of failures have worked thier way through. And the aircraft will invent new failure modes because its just not normal to have them sit for a month on the ground never mind a year. And your going to have well over 1000 of them in the air all in the same state of over 1 month mothballed at the same time. And a pilot is bound to screw up and crash one. And there will be a few that the pilot doesn't screw it up and they crash anyway because the gear won't go down and lock. And more than a few steering manifolds go taking the plane off runway. Every hour of the day somewhere in the world the pilots will have the QRH out. Which could have been a paperless setup with automatic ticking of items aka 787 and 777 but due grandfather issues it s a crap book which lives behind the captains seat which takes 100 times as long to find the right page to run never mind execute.

I suspect each airframe once everything is sorted will end up costing more than a 787. A max 8 is 117 million un-discounted. A 787-8 is 240 million. A 747-8 is 405 million. Its normal to get 10-40% discount on the list price depending on who you are and how many your buying. BTW that doesn;t include the powerplant cost. Which is mostly power by the hour.

I really have no idea how much the final bill will be....

 

[Lou Scannon]

A new plane would have taken 10 years to design and produce. By which point Boeing would only have a fraction of market share that it had before the NEO came out. I suspect time was the biggest pressure.

Agreed, but they had every opportunity to get the Max right if they would have let the engineers do their jobs and spend a *little* more money than originally budgeted.
Alternatively they could have taken a middle road and reactivate the 757. Of course that wouldn't meet the fleet commonality goal, but then neither would a new plane.

I really have no idea how much the final bill will be....

Indeed. Orders of magnitude more than management bargained for when launching the project, evidently. Heads rolling at the end of all this, anyone?

"Schiefgehen wird, was schiefgehen kann" - das Murphygesetz

 

[Alistair_Heaton]

https://samchui.com/2019/07/10/easa-identifies-737-max-autopilot-fault/

I have been told that "the" email was the instigator to this issue.

And although we do have our differences in opinion on pilot presume responses to the situation that occurred, in the cockpit in both accidents. In actual fact it was 3DDave who actually highlighted this issue with his comments on the FDR readouts which led me to see the issue and then pass it onto the tech EASA pilots which then took it further. Without his/her input an absolutely colossal swiss cheese hole could have been missed. BTW the tech pilot I passed it onto used to be a BAe structural engineer on the BAe 146, J41 and also work on Typhoon. I met him flying the BAe bus routes out of Warton when he was a PPL. He is a CEng and knows his poo both flying and building/fixing the things. He has a Phd in some materials bollocks none related to aviation.


I realise that it might cause some mixed feeling on the subject but in my world we are as open as we can be on our own performance and also information flow. Holding onto that info doesn't sit well with me. I want to congratulate 3DDave for adding to aviation safety but I realise that it might not sit well with them... Anyway as a pilot I thankyou for highlighting a real safety issue but can understand why that causes mixed feelings.


I really don't think money was the main concern it was time. Which had a knock on effect of market share.

 

[Lou Scannon]

Then again, time=money. Of course, some tasks are not amenable to getting compressed in time, such as gestation. Nevertheless, Boeing is effectively going to be way later to market than they anticipated, never mind all the money, and forfeit of their good reputation, with all stakeholders: passengers, customers, regulators, investors,... not to mention industry partners.

"Schiefgehen wird, was schiefgehen kann" - das Murphygesetz

 

[3DDave]

Umm, good. As long as the major issue of industry acceptance of poor pilot training to save a few bucks putting pilots in seats is dealt with also. I also hope it leads to a complete and thorough investigation of all aircraft control systems.

By-the-by - what information was gleaned from the FDR? It's an interesting claim and it would be good to see what the basis for it is.

 

[LionelHutz]

I don't see how it's something to be real proud of. You got it completely wrong writing an email about the autopilot not disconnecting when the stick shaker went off.

The accident report says it was connected while the stick shaker was going off and that it did disconnect itself.

That news report says it doesn't completely disconnect. There was nothing in the report about the autopilot remaining partially connected. I'm really curious what partially disconnecting even means. I always thought the autopilot was either on or off and didn't partially work.