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Pilot Who Hitched a Ride Saved Lion Air 737 Day Before Deadly Crash (bloomberg.com) 353

As the Lion Air crew fought to control their diving Boeing 737 Max 8, they got help from an unexpected source: an off-duty pilot who happened to be riding in the cockpit. Bloomberg reports: That extra pilot, who was seated in the cockpit jumpseat, correctly diagnosed the problem and told the crew how to disable a malfunctioning flight-control system and save the plane, according to two people familiar with Indonesia's investigation. The next day, under command of a different crew facing what investigators said was an identical malfunction, the jetliner crashed into the Java Sea killing all 189 aboard.

The previously undisclosed detail on the earlier Lion Air flight represents a new clue in the mystery of how some 737 Max pilots faced with the malfunction have been able to avert disaster while the others lost control of their planes and crashed. The presence of a third pilot in the cockpit wasn't contained in Indonesia's National Transportation Safety Committee's Nov. 28 report on the crash and hasn't previously been reported. The so-called dead-head pilot on the earlier flight from Bali to Jakarta told the crew to cut power to the motor driving the nose down, according to the people familiar, part of a checklist that all pilots are required to memorize.
Further reading: Flawed Analysis, Failed Oversight: How Boeing, FAA Certified the Suspect 737 MAX Flight Control System.
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Pilot Who Hitched a Ride Saved Lion Air 737 Day Before Deadly Crash

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  • So, pilot error? (Score:5, Interesting)

    by OffTheLip ( 636691 ) on Wednesday March 20, 2019 @11:06AM (#58304630)
    Is this a 737 Max 8 problem or a training problem?
    • Re: (Score:3, Insightful)

      by Anonymous Coward

      Yes.

      • by Anonymous Coward on Wednesday March 20, 2019 @11:45AM (#58304846)

        No.

        If you depend on some knowledge that's both obscure to pilots, and hidden from them by Boeing, that is not a "training problem".

        "Your car is going to suffer a deadly crash unless you know how to disable some system that GM did not tell you about, while in the midst of trying to deal with an uncontrollable car, and you were intentionally prevented from even knowing that system exists."

        Sorry. No. Just no.

        • Re: (Score:3, Insightful)

          by Anonymous Coward

          There's a checklist the pilots were supposed to know and follow in response to this emergency situation. The pilots didn't know, or at least, didn't follow the checklist (training problem) and crashed.

          Many things can go wrong during flight. It is a pilot's job to know and follow the checklists when one exists for a situation. Flying is all about checklists.

          With that said, having to perform emergency procedures should not be a standard part of flying a particular plane model (737 Max 8 problem).

          • Re:So, pilot error? (Score:5, Interesting)

            by sjames ( 1099 ) on Wednesday March 20, 2019 @12:48PM (#58305214) Homepage Journal

            It really is both. Initially, Boeing did not document the existence of MCAS. Some pilots may have stumbled over it's existence and applied a checklist for similar failures in documented systems.

            Later, Boeing was required to document the existence of MCAS and state clearly that the runaway trim checklist should be followed when it malfunctions. Apparently not all pilots got that memo (so also a training problem).

        • Its still a training problem, if the knowledge of the system and how to turn it off would resolve the issue.
          To use your example "Your car is going to suffer a deadly crash unless we tell you about the magic button that disables the crash system.Proper training would allow you to know about this magic button and save the car.".
          Just because it's a training issue doesn't mean its the pilots fault: They just weren't trained.

    • by Anonymous Coward on Wednesday March 20, 2019 @11:10AM (#58304646)

      Is this a 737 Max 8 problem or a training problem?

      It seems like all of the above. If you have a bad problem the day before that the main pilots didn't know how to solve and you continued flying those aircraft without making damn sure all the rest of your pilots knew how to solve it, then that's just wrong.

    • by doug141 ( 863552 ) on Wednesday March 20, 2019 @11:11AM (#58304650)

      It's both. They made a frankenstein plane that needs extra special training to not die, and failed to adequately train the people who would be flying them.

      • by Anonymous Coward

        To be fair (at least as fair as possible given the circumstances), while the plane design is certainly Boeing's fault, the training issue is not. As I understand it, the airlines balked at the prospect of retraining the pilots, which is why the current system was put into place to make the plane bahave more like the older planes). Of course there still needed to be additional training to deal with overriding the system. And clearly some pilots received it (as evidenced by the pilot in this article). I'm jus

        • by drinkypoo ( 153816 ) <drink@hyperlogos.org> on Wednesday March 20, 2019 @11:35AM (#58304788) Homepage Journal

          To be fair (at least as fair as possible given the circumstances), while the plane design is certainly Boeing's fault, the training issue is not.

          Some have said (including in a response to one of my comments) that Boeing didn't share the information until after the first crash...

        • Re: So, pilot error? (Score:5, Informative)

          by ceoyoyo ( 59147 ) on Wednesday March 20, 2019 @11:35AM (#58304790)

          Boeing specifically and purposely left any mention of the new systems out of the difference training course that is required to be certified to fly the new 737.

          • Comment removed based on user account deletion
            • by ceoyoyo ( 59147 )

              They didn't want to confuse "the average pilot."

              Boeing didn't want pilots to have to go through a full training course for the new 737 as they would for a new aircraft, so they had to convince the FAA that it was just a variant, meaning only abbreviated training was required. The MCAS system is designed to reduce the differences in flying characteristics between the new and old planes, and intervene only when the plane is approaching a dangerous part of its flight envelope. That should never happen unless

            • by jrumney ( 197329 )
              Because they want to sell more planes. Telling airlines they can use the same pilots they've been using for 50 years with no additional training required was the selling point. Telling them that because they just tacked on bigger engines to a 50 year old design instead of designing a new plane, they have a tendancy to pull up into a stall, but don't worry we've got a new automated system to correct it, but just in case it goes wrong here's what you need to do... might have put a few buyers off.
      • Re:So, pilot error? (Score:5, Informative)

        by Solandri ( 704621 ) on Wednesday March 20, 2019 @12:17PM (#58304998)
        The plane doesn't exactly need extra special training. People need to understand that similarity to older systems (backwards compatibility) is not always a good thing. It can also be a detriment when it causes people to assume things in the new system work the same as they did in the old system. According to TFA, the procedure the pilot used used to clear the problem is actually in Boeing's 737 Max checklist (steps the pilots are supposed to take when a problem occurs - like your ISP has you unplug and plug in your network cables, power cycle your cable modem,etc.)

        The so-called dead-head pilot on the flight from Bali to Jakarta told the crew to cut power to the motor in the trim system that was driving the nose down, according to the people familiar, part of a checklist that all pilots are required to memorize.

        Unfortunately, because of the similarity of the 737 Max to the older 737, two aircrews apparently assumed the new plane operated the same as the old one, and they apparently didn't follow the new checklist (likely didn't realize the new checklist differed) to clear up the problem. Resulting in two plane crashes. That would make it a training problem. But culpability still falls upon Boeing for not making it clear enough to pilots that the system had changed, and for designing a sensor which fails frequently enough to cause multiple incidents in only months of operation, and for designing a flight system which made it so difficult for the pilots to override a malfunctioning automated system.

        • Disable auto trim is on the MAX's inconsistent sensor emergency checklist?

          It is now...

    • by Anonymous Coward on Wednesday March 20, 2019 @11:20AM (#58304680)

      I am a pilot although not type rated in 737. This is a pilot training issue primarily. Secondary there appears to be a failure to fully explain the behavior of the new MCAS trim mode so it can be differentiated from runaway trim. The response to the problem would be the same as runaway trim, turn off trim power, re-trim the aircraft manually. Indication of this new MCAS trim problem is almost identical to runaway trim. The difference is MCAS runs briefly and will repeat until it reaches its limit, whereas runaway trim will run continuously until it hits the stops. Turning off trim and manually re-trimming restores normal flight control in both cases.

      • I agree with you, this is solved by training..

        However, Boeing does have to answer for the lack of documentation, to regulators, to pilots, to maintenance people about this system, it's failure modes and how to disable it. Had Boeing been up front with documentation, everybody would have known (or should have known) what to do and a bunch of folks would be alive today.

        • Re: (Score:2, Interesting)

          by Anonymous Coward

          I agree that more information about this new system should have been included in training. I disagree that a properly trained pilot would have any issues with responding to this MCAS trim issue without that information. There seem to be enough occurrences of the problem being effectively handled by other pilots to demonstrate that. It should have been immediately recognized as a trim problem and the proper response taken. The response for trim problems are the same for this MCAS problem. Pilots are required

      • by dgatwood ( 11270 )

        I am a pilot although not type rated in 737. This is a pilot training issue primarily. Secondary there appears to be a failure to fully explain the behavior of the new MCAS trim mode so it can be differentiated from runaway trim. The response to the problem would be the same as runaway trim, turn off trim power, re-trim the aircraft manually. Indication of this new MCAS trim problem is almost identical to runaway trim. The difference is MCAS runs briefly and will repeat until it reaches its limit, whereas runaway trim will run continuously until it hits the stops. Turning off trim and manually re-trimming restores normal flight control in both cases.

        On the other hand, out of single-digit cases of this failure happening, nearly all of them resulted in loss of AF. If the extra training after the previous crash had resulted in this problem being successfully mitigated by pilots with that extra training several times before the next loss, then maybe I could see this as a training problem, but it seems like the only successful mitigation was in the one rare case where there happened to be a third pilot on board who was able to assess the problem without th

      • Its a Pilot Training problem, but not a simple, "we just need to teach them about this one problem 737s have sometimes". It's that again and again, for decades now, we have perfectly functioning planes that have one sensor out of 50 go bad and the pilots will line the nose of the plane up directly with the ground, and proceed to fly directly into it.

        It does not matter if some plane in particular has a minor software error or something has to be modified by 1 degree. It is that their are many pilots flying c

        • Yep, that does seem to be the bigger issue. The Air France crash was - for a long time - suspected to be a problem with the software overriding the pilot. Once we found the CVR it turned out the plane had a single sensor temporarily ice over, the pilot panicked, started to climb for no reason, continued to climb until it hit max altitude and stalled, and then continued to hold the stick full-back for about 4 minutes while the plane plummeted some 40,000 feet and smashed into the ocean.

          Perfectly functional

    • It is both.
      There is a problem with the 737 Max 8, because it is putting the airplane in bad state. Such conditions shouldn't be the case. While a pilot manually can make split second decisions, the onboard computer suppose to do split microsecond decisions. This flaw is making the computer to make a bad decision.
      Now that stated, you NEVER PUT FULL FAITH IN A COMPUTER. When there is a problem, you should know how to force override the computer in a moment and take over, once you feel uncomfortable about the

      • by sjames ( 1099 )

        It seems that part of the problem is that the system effectively wrestles with the pilot over who is in charge of the trim. MCAS trims the nose down, pilot re-trims it up, 5 seconds later MCAS trims it back down, loop forever until pilot figures it out and disables MCAS or the plane crashes.

    • by SlaveToTheGrind ( 546262 ) on Wednesday March 20, 2019 @11:25AM (#58304714)

      Based on what I've heard so far it strikes me as a marginal design (at best), coupled with inadequate training on how to work with that marginal design to stay safe.

      But this now adds a third layer: inadequate reporting by the pilots and/or resolution by the airline of a known severe problem, which allowed the plane to continue in service and experience the second failure. That's particularly over the top for those of us who routinely sit on the tarmac for hours while the airline tries to scrape up a technician to come in and change something as minor as an exit sign lightbulb.

      • by dgatwood ( 11270 )

        Bear in mind that it was the first crash caused by this system that we're talking about, not the second. At that point, nobody knew that there was a design flaw in that system, and the problem had been mitigated before it became actively dangerous, so there was no reason to assume that a future failure would result in loss of the aircraft. Also, the failure was reported, and servicing was performed after that failure.

        The only thing that wasn't reported was that the presence of a third pilot was what made

        • At that point, nobody knew that there was a design flaw in that system

          There's only two sensors and they're not cross-checked. Everyone involved with that system knew there was a flaw, it was inadequate by design.

    • It's a training problem. Run-away trim (which an MCAS malfunction essentially is) can be fixed by hitting the auto-trim cut-out. There's a video about the issue on the 737 Classic (which is before the 737 NG and the 737 MAX). At the same time, Boeing should have told pilots that MCAS will move the trim automatically, and will progressively move the trim more and more dramatically each time it activates. However, the pilots should have known that there was a trim problem (because they were fixing the problem

      • by bluefoxlucid ( 723572 ) on Wednesday March 20, 2019 @11:46AM (#58304854) Homepage Journal

        Be that as it may, why the fuck would you put the plane and crew back in the air the next day without an investigation? As soon as this irregularity occurred, the plane and crew should have been grounded. Determining the cause, the response, and the obvious (not likely, but observable without projecting other possibilities) outcome without the irregular situation which corrected the issue, an immediate action would become visible.

        That action may be preventative (fix the problem) or contingency (ensure all pilots have training for familiarity with the situation and its appropriate response).

        When an irregularity occurs as such, you immediately don't know that the individual plane is unsafe. You may discover by investigation that the entire fleet is unsafe; but you don't know if the plane or its pilots are unique to the failure. You ground that whole damned set of factors, examine the situation, quickly identify the contributing parameters, and decide if you need to ground all planes, issue new training, or just deal with the specific set involved.

        That's just basic risk management. It has nothing to do with airplanes.

        • Re: (Score:2, Insightful)

          by Anonymous Coward

          Management loves to gamble with other peoples' lives and money. It's true of every industry. It is a fundamental problem with our system (of economics and governance in a general sense, as exported to many other nations) that enables regulatory capture.

          Regulatory capture is the best government money can buy.

          And it's a pretty shit one.

        • Be that as it may, why the fuck would you put the plane and crew back in the air the next day without an investigation?

          They didn't; according to info released by Lion Air, the plane was taken in for maintenance and the AOA vane was replaced. This however did not fix the problem.

          My question would be why the hell did the technicians not realize that the problem was still there. This kind of system almost certainly requires an op-check after maintenance. Had they actually tested it they would have known it was still malfunctioning.

      • by ceoyoyo ( 59147 )

        That's a nice easy explanation, but I'm not sure it's true. I just read an interesting post from a pilot on a pilots' forum about a procedure that used to be mentioned in the original 737 flight manual. Apparently, if you had a runaway trim situation that got too out of hand, it could be very difficult or impossible to turn the trim wheels by hand (even with both pilots) due to aerodynamic loading. The recommended procedure was called the "rollercoaster maneuver" and involved inputing elevator control to ac

    • Training. Hundreds of 737M flights each day in the states, not one crash or report of an issue. Both crashes happened in third world countries. That's not a coincidence.
    • Probably both. Why this first incident did not, at the minimum, result in a post-in note stuck to the control column for the next pilot is unpardonable.

      At the same time, any aircraft should disengage all automatic pilot behaviors, with a suitable audible indicateion, if a human in the cockpit moves a control axis through more than 50% of its range within one second's time.

    • Is this a 737 Max 8 problem or a training problem?

      Those are in the "other factors" category. Primary reason is the Boeing is a profit-based company and decided, on this occasion anyway, that profit was more important than other factors. I foresee a large fine and class-action lawsuits....

  • by Anonymous Coward

    We just don't know how to use the search button anymore

    https://www.news.com.au/travel/travel-updates/incidents/lion-air-crash-pilot-on-previous-flight-made-distress-call-before-continuing-to-fly/news-story/7fa1bd3b49f4dbe76444f27cc52bca41

    Date: Nov 2, 2018

  • by Lucas123 ( 935744 ) on Wednesday March 20, 2019 @11:10AM (#58304648) Homepage
    Abagnale would pose as a pilot to sit in airline jump seats and get a free ride. I don't know why, but the image of the pilot turning to him for help just crossed my mind.
  • by Software ( 179033 ) on Wednesday March 20, 2019 @11:22AM (#58304696) Journal
    United Airlines Flight 232 [wikipedia.org] was also saved by a dead-heading pilot who assisted the cabin crew.

    What's remarkable in the Lion Air flight is that the company didn't ground the plane until the angle-of-attack sensor problem was resolved.

    • Lion Air likely didn't know there was a serious problem with the sensor. If TFA is correct, the dead-head pilot followed the correct procedure which cleared up the problem. All Lion Air's mechanics would've gotten was a note about the system malfunctioning (nobody knew the sensor was at fault until after the crash and the black box data was analyzed). And since the official resolution procedure cleared up the problem, that would've made it a low-priority fix, probably put off until the plane's next sched
  • by Camel Pilot ( 78781 ) on Wednesday March 20, 2019 @11:22AM (#58304698) Homepage Journal

    I dunno manually removing power to a motor that a control system is erroneously commanding you and 300 people to die should be something that gets raised for serious review and corrective action. Someone really missed an opportunity to save a lot of lives.

  • If there was an issue with the aircraft one day, I would do a lot of investigation before I would fly it again. This appears to be caused by a aircraft safety feature being set off by defective hardware and the pilots weren't informed of it or trained to handle it. Still, if something goes wrong one day, why would you fly the aircraft the next day?
    • Still, if something goes wrong one day, why would you fly the aircraft the next day?

      Because if you did that, planes would hardly ever be flying.

      lots are correcting for all kinds of crap, all the time.

      This is just one of the worse cases, where training mattered more than most other times...

  • by Anonymous Coward

    Only difference was the the faulty sensors on the Airbus usually screwed up at altitude.

    They still lost one however.

    727 had similar pilot training issues losing several right off the bat (two within three days of one another). Difference was that it was a completely new type, not advertised as being the same plane.

  • by Anonymous Coward on Wednesday March 20, 2019 @11:26AM (#58304724)

    https://i.imgur.com/YwuKQkp.png

    • by shanen ( 462549 )

      Extremely rare case. Not only were you modded into visibility, but you have a legitimate reason for anonymity.

      If you were blowing the whistle on an actual settings page, your reason would be impeccable, but I have to peck at the satire defense and even lament that I was lucky to see the joke.

  • So, why didn't the aircrew from the previous day's flight pass that incredibly valuable information along to the next crew? Leave a note in the cockpit? Tape over the auto-trim disable switch in the Off position? Talk with someone responsible for staffing on the ground to pass along the details of the problem and the solution? I'm sure it was discussed with maintenance -- as evidenced by the work done on one of the angle-of-attack sensors overnight before the fatal flight -- but was anyone else made aware o
    • They did write it down into the maintenance log [uploadhouse.com], as they should have.

      They have written about "IAS and ALT Disagree shown after Take Off" and "Feel Differential Pressure Light Illuminated".

      The tech crew flushed the left pitot tube and static port, cleaned the connector of the elevator force feedback unit and quickly tested both system on the ground, finding nothing wrong.

      So the aircrew didn't really write about the runaway stabiliser and the tech crew didn't bother to run comprehensive checks because it woul

  • Investigators listen to 'black box' cockpit recordings of planes that crash - why don't they do that for ANY report of a significant malfunction that looks like it might cause a crash under different circumstances? Hell, it doesn't even have to be "the" black box - they could have secondary recorders whose data are more accessible.

    I also wonder why there isn't an 'airline pilots only' social media platform that would spread news of this kind of incident far faster than 'official' channels. If pilots were re

    • by ceoyoyo ( 59147 )

      "I also wonder why there isn't an 'airline pilots only' social media platform that would spread news of this kind of incident far faster than 'official' channels."

      There are. They're fascinating.

    • I believe an employee (pilot here) won't be allowed to share on-job details on a public or outside company channels. Because it may affect the reputation of the company and its partners [eg Lion Air may look bad if it bought a bad plane; and boeing looks bad for engineering a bad plane / not requiring better pilot training]. And all these may affect the corporate's bottom line.
  • by Zorro ( 15797 ) on Wednesday March 20, 2019 @11:38AM (#58304806)

    Pilots instead of Computers should fly the damn plane.

  • by wired_parrot ( 768394 ) on Wednesday March 20, 2019 @11:48AM (#58304872)

    One of the bigger long-term consequences of these MAX-8 incidents will be the impact on the FAA's influence in the civil aviation world. One little commented fact is that when the MAX-8s were grounded it was the Chinese civil aviation authorities who led the world in grounding the 737 MAX. This was unprecedented, as most civil aviation authorities have tended to follow the lead certification authority of the manufacturer, the FAA in this case, before issuing a grounding. This was the case in previous grounding - the 787 dreamliner in 2013 and DC-10 groundings in 1979 were both led by the FAA.

    Additionally, it now appears both Transport Canada and EASA are no longer willing to accept FAA certification [globalnews.ca]. Other aviation authorities have in the past accepted FAA certification without challenge. if other authorities no longer trust the FAA to do its oversight properly Boeing will be forced to carry out multiple certification assessments for each civil aviation authority, and that will carry with it a considerable delay and financial burden.

    • Of course the Chinese grounded the plane. The Chinese want every Chinese Airline to buy exclusively Chinese built aircraft. Of course they would jump at the chance to ground their competitor. That's like saying "Airbus led the way in grounding all Boeing planes." The Chinese government needs to be viewed like a corporation not a certification authority.

      • Counter-point: In this case, were they wrong? The FAA and Boeing effed up and were initially reluctant to do the right thing. If left to themselves, would either the FAA or Boeing have taken corrective action? Regardless of their motives, China stepped in to save passenger lives.
  • These planes have been flying for quite a while, but only recently they've gone full stupid and are nosediving into the ground ?

    What's changed recently ?

    • It's only the newer models of the 737 MAX. The 737 was introduced in 1967 but the 737 MAX came in 2016.

      And even then, the older models apparently had an automatic override that would kick in if the pilot held the yoke back. The newer models require the pilot to manually shut off that sensor.

  • by Bryansix ( 761547 ) on Wednesday March 20, 2019 @12:15PM (#58304992) Homepage
    This system should be using a myriad of sensors to activate, not the least of which is the air speed indicator, backed up by GPS, the altimeter, also backed up by GPS, and the bank indicator. For one thing, the stall angle of attack is completely different at one speed versus another. This is because flight envelopes are not squares. Second of all, if altitude or GPS show the plane about to go below the ground level for the specific location, it shouldn't be driving the nose down.
  • Comment removed based on user account deletion
  • Responsibility????? (Score:5, Interesting)

    by sgt_doom ( 655561 ) on Wednesday March 20, 2019 @12:43PM (#58305190)
    Although I haven't been in the aviation arena for some years, I recall that this should have been disseminated in a NOTAMN (notice to airmen) --- why didn't that aircrew spread that correction to others within the airport and airlines????? If they did not, it displays a massive show of irresponsibility on their part!
  • Does anyone happen to know if the failure mode has been successfully recreated in an simulator?

  • by Pyramid ( 57001 ) on Wednesday March 20, 2019 @02:58PM (#58305926)

    The fact that an aircraft that almost crashed because of a fault wasn't immediately grounded and instead was allowed to fly the next day IS ABSOLUTELY UNCONSCIONABLE!

  • by Sqreater ( 895148 ) on Wednesday March 20, 2019 @03:11PM (#58306026)
    So they knew about the problem, and instead of fixing it, they created a "procedure,' one that had to be memorized and remembered or you and your crew and every person on the plane would surely die. Sound right to you?
  • by 4wdloop ( 1031398 ) on Wednesday March 20, 2019 @05:40PM (#58306916)

    After a "near crash" accident like this, how come all the plains were not grounded?

    I suppose this "Fight Club" scene may be relevant?

    https://www.youtube.com/watch?... [youtube.com]

  • by couchslug ( 175151 ) on Wednesday March 20, 2019 @05:58PM (#58307038)

    Former avionics troop here. Given a malfunction, tech data directs appropriate troubleshooting and maintenance. If AOA sensor replacement is in the fault/troubleshooting tree, you replace that sensor. When a sensor is replaced follow-on maintenance like self tests and operational checks is required. The replacement sensor may have passed causing the techs to assume the problem was fixed, but they were ON THE GROUND.
    What tech data error permitted the aircrew to fly with an AOA or other malfunction? What idiot permitted the aircraft to fly after REPEATED malfunctions and on what grounds?
    Not every malfunction grounds an aircraft nor should they, but AOA is important enough for grounding and if in-flight verification of a fix is required or desired, a functional check flight is performed by aircrew, not "aircrew and fucking passengers".

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