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.
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.
So, pilot error? (Score:5, Interesting)
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Yes.
Re:So, pilot error? (Score:5, Insightful)
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.
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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)
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).
Re: So, pilot error? (Score:4, Informative)
The class of problem, "runaway trim" can be caused by a few different systems malfunctioning. Most of those systems also exist on the old 737, but MCAS is new to the MAX and behaves a little differently, though if you figure that out, the remedial action is the same.
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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.
Re: So, pilot error? (Score:4, Interesting)
No, Boeing was trying to avoid the training necessitated by the aircraft having new handling characteristics as compared to the previous model. The MCAS itself required zero training.
The "training" to go from a previous 737 to the 737 MAX consists of a 1 hour video and some short reading. They could have added a section to it which said "yeah, btw, we put this new box in, if your trim starts acting up just follow your standard runaway-trim checklist", and that would have been it. Not exactly a big hit to the budget there. Leaving it out was just dumb, not greedy.
Re:So, pilot error? (Score:5, Insightful)
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.
Re:So, pilot error? (Score:4, Insightful)
Thats like one specific model of car jerking the wheel into oncoming traffic for no reason. Completely unacceptable.
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Old movies...Who's had a tire 'blow out' in there lifetime?
Remember 'sawing on' the steering wheel to take-up linkage slack?
If you do, you're either older than dirt or a car collector.
Re:So, pilot error? (Score:5, Insightful)
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.
Re: So, pilot error? (Score:2, Insightful)
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
Re: So, pilot error? (Score:5, Insightful)
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)
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.
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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
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The thing being missed is the sensor fault _causing_ runaway trim (with the new system) and disabling auto trim not being part of the 'inconsistent sensor' emergency checklist.
That should have been recognized as a potential killer and documented to hell and back the first time it was noticed and averted. Which it clearly was, at least once.
Re: So, pilot error? (Score:5, Interesting)
I don't believe it and I don't really want it to happen. Killing the company would be like saying NASA should have been killed after Challenger.
A better response to both, which keeps us flying and fixes future fuckups, is to hold the people who authorized bypassing such reasonable procedures criminally liable.
Re:So, pilot error? (Score:5, Informative)
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.
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Disable auto trim is on the MAX's inconsistent sensor emergency checklist?
It is now...
Re:So, pilot error? (Score:4, Funny)
Re:So, pilot error? (Score:5, Insightful)
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.
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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.
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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
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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
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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
Re: So, pilot error? (Score:3)
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
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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
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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.
Re:So, pilot error? (Score:4, Insightful)
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.
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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
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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.
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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
Re:So, pilot error? (Score:5, Insightful)
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.
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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.
Re: So, pilot error? (Score:3)
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.
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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
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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.
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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....
Re: So, pilot error? (Score:4, Interesting)
Boeing intentionally [re]worded parts of how the system behaves so that the "FAA" (themselves) wouldn't have to recertify.
Aerospace has a huge recycling problem where once something is certified they'll just reuse it as "COTS" (commercial off the shelf) so that they don't have to recert.
It also leads to incredibly stupid decisions that are more political than engineering.
I just ditched a gig at a Tier1 vendor because they picked a Coldfire (68k) processor because it was "in production". They had no dev boards. They can't find dev boards. But the whole project was stuck with the decision because of politics that happened far away from where I was.
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I just ditched a gig at a Tier1 vendor because they picked a Coldfire (68k) processor because it was "in production". They had no dev boards. They can't find dev boards. But the whole project was stuck with the decision because of politics that happened far away from where I was.
This is the same reason that we're not ready to go to Mars, yet. The human problem has yet to be solved by technology, and so the human problem poisons technology.
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Re:So, pilot error? (Score:5, Insightful)
Yes.
Boeing is guilty for using a single sensor for a critical flight function.
Um.. Not really.. Boeing is guilty of being a bit short sighted about the failure modes of the MCAS and not effectively communicating critical information to anybody, the pilots, their trainers, and likely the certification inspectors.
This story shows that the aircraft is fully airworthy without the MCAS system functioning. You don't need it to control the aircraft, it's just there to "help" and you can turn it off if you correctly diagnose the issue and pull the right breaker.
The problem Boeing caused here is not fielding a faulty aircraft, but not communicating the necessary safety information to flight crews, maintenance personnel, and authorities. They didn't tell pilots about this system, what it does, what happens if it fails and how to disable it. It simply wasn't in the pilot's manual, didn't make it into the training process. They didn't tell the maintenance folks so they could diagnose the faulty AOA sensor correctly and return the system to full functionality.. AND Most damaging, Boeing didn't tell the certification authorities about this new feature so they could be sure all the interested parties, pilots, trainers, and maintenance where apprised of the system, knew how to use it, bypass it and repair it. THAT is what's on Boeing here.
Re: So, pilot error? (Score:5, Insightful)
They didn't tell pilots about this system, what it does, what happens if it fails and how to disable it. It simply wasn't in the pilot's manual, didn't make it into the training process.
How did the dead-head Lion Air pilot know how to save the plane??
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They didn't tell pilots about this system, what it does, what happens if it fails and how to disable it. It simply wasn't in the pilot's manual, didn't make it into the training process.
How did the dead-head Lion Air pilot know how to save the plane??
Isn't in the summary, the dead-head pilot was simply going through a crisis checklist that all pilots should have memorized.
So, (Score:3)
Comment removed (Score:4, Interesting)
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No no no, Boeing is 100% guilty of having manufactured an inherently aerodynamically unstable airplane.
Then EVERY low wing aircraft with engines UNDER the wings suffer from the same design flaw to varying degrees. Something tells me that there is nothing really wrong with this configuration given the huge numbers of successful models that share the same configuration and the same tendency to pitch up when adding thrust. In fact, just about every commercial aircraft flying today, with very few exceptions, share this same basic design and suffer from the same thing.
Are you saying that this configuration is
This wasn't undisclosed (Score:2, Informative)
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
Imagine if that had been Frank Abagnale (Score:5, Funny)
Re:Imagine if that had been Frank Abagnale (Score:5, Funny)
And yet he might go, "Holy shit, we're all gonna die if I don't do something! What kind of fixes do I know about for electronics? Alright. Turn it all off and back on."
And judging from the summary that just might have worked.
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What kind of fixes do I know about for electronics? Alright. Turn it all off and back on.
Millenial pilots do a scandisk and a defrag also. But that takes time, which there's precious little of at takeoff time - hence the crash
Sounds a lot like United Airlines Flight 232 (Score:5, Informative)
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.
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Holy cow! (Score:3)
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.
Re: Holy cow! (Score:4, Insightful)
Someone really missed an opportunity to save a lot of lives.
Another way is to say that someone seized the opportunity to lose a lot of them.
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Why did they fly the next day? (Score:2)
Because stuff happens all the time (Score:2)
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...
Airbus A330/340 had similar issues. 727 also. (Score:2, Insightful)
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.
Boeing 737 MAX Hidden Settings (Score:5, Funny)
https://i.imgur.com/YwuKQkp.png
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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.
Distinct lack of communication (Score:2)
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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
I'm just wondering... (Score:2)
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
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"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.
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Han Solo instead Of Clippy. (Score:3)
Pilots instead of Computers should fly the damn plane.
A blow to US civil aviation influence (Score:5, Insightful)
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.
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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.
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Okay so (Score:2)
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 ?
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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.
Flight Envelopes are not squares (Score:3)
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Because GPS shows ground speed but the airplane is not on the ground. With a headwind the ground speed goes down, but the airspeed goes up. With a tailwind it is the other way around. It is useless for flying. An airplane with a lightly loaded wing can actually hover in the wind, having sufficient airspeed to stay in the air, but a groundspeed of zero.
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Responsibility????? (Score:5, Interesting)
Simulator? (Score:2)
Does anyone happen to know if the failure mode has been successfully recreated in an simulator?
Lionair is at fault!! (Score:3)
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!
They had a procedure (Score:3)
how did they keep on flying after initial "save"? (Score:3)
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]
What maintenance actions did tech data call for? (Score:3)
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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Not really. You also memorize a whole bunch of things for exams, but that doesn't mean you have actually learned how to put that knowledge to use in a real scenario. It's the whole problem at the core of teaching to the test.
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All memory can end up being lost. Part of the problem is that autopilot has gotten too good. This both lowers the hiring standards for pilots and has also left them out of practice.
Re: checklist that all pilots are required to memo (Score:2)
The article is worded poorly. The thing about a piloting checklist is... it's a checklist. As in, a real list on a laminated paper. The important thing is not that the pilotd memorized every item on the list but that they know list X is the one to go down when problem Y occurs. That's the real training failure here.
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I'd love it if people were more willing to be methodical when the situation demands it, but most pilots will not get out a paper checklist while in the middle of a nosedive.
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Apparently, "memorize" means something different there.
Check lists ARE memorized and pilots are tested on if they know them often. Pilots know them, it's part of their job to follow them from memory and safely flying *requires* you know them by heart. It's drudgery and boring work to memorize them, but your life depends on it.
NOBODY want's to be experiencing an engine out emergency between V1 and V2 and have the pilots fumbling around for the check lists. No, you need to be marching though the check lists by wrote because there is very little margin for doing
Re: Collection of errors (Score:2)
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There was one
https://www.youtube.com/watch?... [youtube.com]
Re:Collection of errors (Score:5, Interesting)
The smoking gun for this incident isn't going to be what the final report says. It'll be on some notes by some engineer when this project started saying everything above. There isn't a way that this project made it this far without some intelligent engineers speaking up and getting over ruled by management.
I lasted exactly 45 days in Aerospace and it was terrifying, they picked a "COTS" architecture that hasn't been "COTS" since the Macintosh moved away from 68k. I was told to 'deal with it'. Other people quipped that "this wasn't the worst design decision he's seen". The schedule was everything because customers had already bought what we were working on.
But everything HAD to move forward according to THIS timeline because someone already bought it. In those 45 days I had to work on trial versions of everything, they couldn't figure out how to get us licensed in to their network. Everyone else on the project had always been in aerospace, so this was 'par for the course'. I came from automotive where we actually did put safety first (at least where I worked).
I want to see the MIL/SIL/HIL reports. This should have been caught in the plant model long before it came to market. There should be a high-fidelity model that shows this exact scenario and how it plays out. It was buried for some reason or another. If there isn't then they didn't test as comprehensively as they should have (because of rushing to market).
There are a lot of people, that have been coming to similar conclusions about the MAX8. It's an 'unstable pendulum' that they thought they could just 'fix it in software'. Good hardware design is crucial to a good controllable system.
Someone spoke up, either they have an e-mail in a safe (like Audi's Dieselgate) or they're no longer with Boeing (or one of their subcontractors like GE, or GE's subcontractors) because they did speak up and were told they were 'toxic to the project'.
This is the boring un-sexy parts of engineering. But 'Failure Mode and Effects Analysis (FMEA)s' are important. We literally sit down and go "What happens if this fails" and then write out a full plan in software. Plus a full test plan.
dSpace makes aerospace hardware-in-the-loop (HIL) test benches [dspace.com]. They make them for automotive and off highway too. We literally 'drive' around a vehicle for thousands of hours for software releases.
I don't have a doubt this was caught by someone somewhere. Management got involved and now this is going to be another Challenger O-Ring example for freshmen engineers.
Is ignoring a plugged sensor a bad idea? Absolutely. Should the failure mode be plowing into the ground an full tilt after fighting the pilots? No.
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You caught the true root cause: cheaping out on fundamental design,
Boeing had a working airframe but knew they'd be out of the picture if they couldn't upgrade to a more efficient engine. There is no efficient engine physically compatible with the 737 airframe. Boeing used duct tape and hot glue to put the engine in a location which compromises flight stability (a LOT).
A correct, at least from an engineering and safety standard, would have been to put the new engines aft where they belong, perhaps either
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I don't have a doubt this was caught by someone somewhere. Management got involved and now this is going to be another Challenger O-Ring example for freshmen engineers.
It's already come out that the FAA allowed Boeing to produce their own safety assessment for the aircraft. Of particular note, it stated that the MCAS would only adjust .6 degrees. However in testing it was determined that .6 wasn't enough, it had to go to 2.5 degrees. This went unchanged in the safety assessment which allowed the MCAS system to be classified at a safety level that didn't require redundant input or systems. So it basically relied only on 1 AOA sensor. In the Lion Air crash, it was fou
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It's not a "stall recovery" system, it's a "stall avoidance" system. One of the top rules of flying is "don't stall it" to which I add that you NEVER want to stall a jet airliner. Where they are tested to have reasonable behavior when stalled, there is no guarantee that you can recover from a stall within the altitude and aircraft performance you have available.