Boeing 737 Max8 Aircraft Crashes and Investigations [Part 8] 24

[Sparweb]

This post is the continuation from this series of previous threads:

thread815-445840
thread815-450258
thread815-452000
thread815-454283
thread815-457125
thread815-461989
thread815-466401

This topic is broken into multiple threads due to the length to be scrolled, and 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.

Some key references:
Ethiopian CAA preliminary report (Link from Ethiopia is now broken. See link from NTSB Investigations below)

Indonesian National Transportation Safety Committee preliminary report

NTSB Investigations

NTSB Safety Recommendation Report: Assumptions Used in the Safety Assessment Process and the
Effects of Multiple Alerts and Indications on Pilot Performance

A Boeing 737 Technical Site

Washington Post: When Will Boeing 737 Max Fly Again and More Questions

BBC: Boeing to temporarily halt 737 Max production in January

Pulitzer Prize, For groundbreaking stories that exposed design flaws in the Boeing 737 MAX that led to two deadly crashes and revealed failures in government oversight.

http://www.sparweb.ca

 

[Alistair_Heaton]

The stuff that used to go on in the 70/880's to get through the certification was utterly horrendous. As you say it was a load of young males who had a bonus if it worked. Broken bones were common.

737 is particularly bad because it doesn't have wing slides. The evacuation drill needs the crew to select flaps to create a slide down to the ground. But that still levels a 6ft drop to the ground. In real life pax try and go back inside because they don't like the drop. If they forget to put the flaps out then its 10ft drop.

But they banned that shenanigans and its now a mix load with some variation in gender and age distribution in the cabin, well it is with EASA anyway.

In real life a lot of the time the under carriage has given way so things are lower. Or there isn't that much of a rush and people can just use the fore and aft doors.

 

[LittleInch]

I've never fancied getting out the overwing exits on a 737, but at least now the door hinges upwards so you don't end up with 20kg of door in your lap.

It always looked a rather err exciting way to exit the air plane.

and the 800 and Max have two doors on each wing!

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

 

[Alistair_Heaton]

I used to struggle with those wing exits during the yearly door training never mind the cabin crew. If you got the angles wrong you pulled a muscle in your back.

 

[waross]

I always got the take-away from the pre-flight announcement that;
"We will be flying almost 4 miles high.
There are six exits, two in the rear, two in the front and two over the wings."
I always thought;
"Great.
If anything goes wrong we can get out and walk on the wings."

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

 

[Sparweb]

Last year an intern at my company was being shown the cockpit of a Dash 8. Various features were being pointed out and the "guide" pointed to the ceiling that there's an emergency exit hatch there. He actually reached up and pulled the handle. Well the thing dropped into his arms and there was a struggle with the mass of it in a confined area, and his guide trying to regain control of the situation. A very red-faced young man walked out of the plane (the point where I saw that something was up). And he was required to accompany his guide to the maintenance chief to explain what had happened and that the door would have to be reinstalled and checked.

http://www.sparweb.ca

 

[Alistair_Heaton]

i got told in no uncertain terms to never touch it unless we were going to exit via it. It has a ventilation possibility which 50% of the time ends up with it dropping out. The guy was lucky he didn't hurt himself...

 

[dik]

It's back...

https://www.cnn.com/videos/business...-pkg-vpx.cnn/video/playlists/top-news-videos/

Rather than think climate change and the corona virus as science, think of it as the wrath of God. Feel any better?

-Dik

 

[Alistair_Heaton]

And as soon as they have one thing finished then another one turns up.

https://ad.easa.europa.eu/ad/AIR-20-19

its a similar issue that airbus had when one went into the woods thinking it was in landing mode and refusing to come out of it apparently.

 

[LittleInch]

Alistair - Do you mean AF296? There was a lot of talk about this and I know certain things are disputed, but in that one the pilots really screwed it up and didn't initiate go around fast enough for the engines to spool up given that they were at idle for a long time before that. Or so says airbus and the accident investigators.

But this one sounds not that good....

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

 

[Alistair_Heaton]

There is loads of disputed over that one

And claims that the back box's had been tampered with. There is alleged to be 4 seconds missing. And if that 4 seconds involves a none responsive command for power. Then history would have been somewhat different.

There were some major changes to the AT logic afterwards and changes to the pilot training.

I think there was a Mayday episode on it.

The main pilot issue is show boating and going below 500ft when not intending to land. The chain of events after that could have been stopped there. Even doing 500ft flyby with pax onboard wouldn't have passed my personal risk assessment of acceptable.

 

[LittleInch]

Without going too far off tangent that crash (AF296) was a real balls up from the start.

But it's when you realise that they had the engines on idle for a long time (>30secs) and basically scrubbed off speed and height by gradually lifting the nose until they ran out of air speed then somehow expected the engines to give full power instantly. They lined up initially on the wrong runway, were too high and over confident. The engines were spooling up when they hit the trees but they take a few seconds and with a large bunch of trees at the end of the runway they didn't have those few seconds.

I don't know what happens on a normal landing / go around but I would be surprised if the engines were at complete idle as you glide in or how long the power on from throttle movement to actually doing something takes. In a crash situation time slows down to a remarkable event for the participant to the extent that it is a known issue that people think something isn't happening as fast as they think it should (e.g. engines spooling up) and so either add more force or start doing something else before the machine responds as it should (reportedly moving the throttles back to idle then full power again).

I would imagine the extra training went along the lines of don't fly a large passenger aircraft full of passengers at close to its stall speed 100 ft above the ground ( they actually did it a 30ft(!!) along a grass runway you've never been to before which has a large bunch of trees at the end of it.

And the clear grass bit between the trees is only 1100m long. So at the reported air speed of 120kts, that's 18 seconds max. Realistically probably 12 seconds from when he levelled the plane off. The whole thing was madness. IMHO.

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

 

[Alistair_Heaton]

Its a stabilisation criteria that they are above idle at 1000ft....

No the training was 3 days worth of know your airbus fight modes and how to know which one your in and how to get into climb like an angle mode. There was also a pretty major fight system update 9 months later.

These days the first airbus type rating has nearly double the amount of ground school that other type ratings have. Most of it is avionics and the FBW system. If you then go to other types in the airbus range is barely a week ground school and a couple of sessions in the sim.

That's the thing the pilot said he had put the power on and nothing happened. And something only happened when he moved the levers full travel and then hit TOGA.

There is a smell of the aircraft thought it was landing and went into flare mode so disregarded the power demands. It only kicked out of that mode when they hit TOGA. but by then it was too late with the spool up times.

The main way to avoid this one is not to get involved with this sort of nonsense fly by's in the first place. they have been banned to my knowledge this side of the Atlantic.

The AT system is seen as a major flaw in the airbus system. The power levers don't move and when your in manual they sense the position then send it to the flight controller that then demands the power from the engine. To my knowledge all FBW systems since airbus have the flight controllers sending demands to the power lever servo's which then move and then the engine controllers sense the position from there for demand. So if you over power the servo's then all the engine controller see's is the power levers in the firewall and gives you that.

As i have said a few times in these threads my personal belief is that the airbus system needs requalified with modern standards as well. Its 40 years old now and quiet a few major flaws are being grandfathered and never fixed.

I have been reading that Air France want a stretched version of the A220-300 and the driving force behind that is the fresh sheet FBW and cockpit which I must admit is great and the ex proper airbus pilots say is streets ahead of what they have flown ranging from A320 through to A380 and everything in-between.

 

[LittleInch]

He had also disabled a lot of the protection devices, but maybe forgot about that one... As we've seen with MCAS, there can be things written deep into the code that no one really knows about or should be overridden but wasn't. but as said, maybe something was starting to happen but in the growing panic as he's looking a row of trees he didn't know were there that his brain started going faster than normal and the engines didn't keep up.

So in the AB the power changes but the levers don't move?? Oh.

You're probably right that something designed 40 years ago should be re-done and not just continually patched up.

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

 

[Alistair_Heaton]

you normally put them into a gate and then they stay there until you land or decide to go manual power levers.

That feature is pretty much universally hated by the Ab pilots as far as I can tell.

Them moving gives you tactile feedback what the machine power state is even when you can't see them during fumes and smoke. The smoke generator in our sim seems to be some turbo powered zero viz machine. Way more effective than the one in the Q400 sim. I ended up with my mask 10cm away from DU3 and couldn't see the engine instruments last week in the sim doing that exercise. let it do an auto land and basically it looked after itself including speed reduction and the only thing we did was put the flap out and gear down after pointing it at the final approach fix and arming the approach mode.

I am not saying the should be redone just a complete big picture assessment in relation to modern norms. But things that have been highlighted as issues 40 years before shouldn't be allowed to continue. There is stuff on the 737 that has been bitched about and is still a feature on the MAX after 60 years.

 

[dik]

Sounds like a real fire...

Rather than think climate change and the corona virus as science, think of it as the wrath of God. Feel any better?

-Dik

 

[Alistair_Heaton]

Good training then.... And not cheap to provide. its a CAE 7000XR sim with CAE Tropos™ 6000XR visual system.

We had it on the ground and evacuated in under 10 mins. The fire and smoke checklist on all types is notorious for taking ages. Once you start it you set things up for ram air and venting as much as possible and then go through a series of tests to try and find out which system is on fire. Which is the various electrical systems then the air conditioning system. It takes about 30-40 mins to do it completely with 3 min pauses to see if the smoke decreases every time a system is isolated. We just got the ventilation going and got it on the ground. Which gave us full autoland capability because all the electrics were still online. But apparently if we had run the checklist until we had got to the 4th power system it would have cleared the smoke but then we would have been doing a manual approach with masks on which is not pleasant at the 25 min point after it started.

It took 15 mins coffee break for the air blowers to clear it ready for the next exercises. All in all a productive 4 hours worth of training. We were doing the new RNP AR procedures for the new curved approaches into the likes of Salzburg. From 18 miles out flying a slalom course down to the runway. Much less stressful than doing a visual circling approach.

If your interested

https://safetyfirst.airbus.com/app/...ased-navigation-rnp-and-rnp-ar-approaches.pdf

 

[Alistair_Heaton]

A pretty sobering read so far and i have only got to page 13....

https://www.commerce.senate.gov/services/files/FFDA35FA-0442-465D-AC63-5634D9D3CEF6

 

[waross]

I.Executive SummaryIn April of 2019, weeks after the second of two tragic crashes of Boeing 737 MAX aircraft, U.S. Senate Committee on Commerce, Science, and Transportation staff began receiving information from whistleblowers detailing numerous concerns related to aviation safety. Commerce Committee Chairman Roger Wicker directed staff to begin an oversight investigation. The scope and breadth of the investigation quickly expanded beyond the first allegations inspired by the 737 MAX tragedies. Information received from fifty-seven whistleblowers revealed common themes among the allegations including insufficient training, improper certification, FAA management acting favorably toward operators, and management undermining of frontline inspectors. The investigation revealed that these trends were often accompanied by retaliation against those who report safety violations anda lack of effective oversight, resulting in a failed FAA safety management culture.

It doesn't get any better as far as page 28 out of 102 pages.

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

 

[Alistair_Heaton]

Just finished it.

Feel quiet sorry for the grunts on the coal face,

Although quiet how you would "fix" it I have no clue. Similar investigations with NASA did change things for while but then history repeated itself years later with the Shuttle.

Its going to need serious amounts of money. And this is only the aircraft certification side of things. I suspect the air traffic part of the FAA has similar issues.

Only silver lining is that for world certification other authorities will now be requiring compliance separately from the FAA.

VIII.Conclusion
The FAA is responsible for the regulation and oversight of the U.S. aviation industry with
safety as the primary goal. The Committee’s twenty month investigation incorporated
information from fifty-seven whistleblowers, thousands of pages of documents, and numerous
interviews. Committee investigators discovered numerous systemic deficiencies in FAA
oversight. These deficiencies included ineffective or complete lack of oversight, resulting in
unnecessary risk to the flying public. In many cases FAA management appears to be aware, and
in some cases complicit in thwarting the very oversight they are charged with directing and
supervising. In the most alarming cases, whistleblowers have warned of tragedies before they
occur only to be retaliated against by managers. Unfortunately, much of what has been detailed
in this report has been well known and reported on for decades.

 

[dik]

Speaks volumes...

Rather than think climate change and the corona virus as science, think of it as the wrath of God. Feel any better?

-Dik