Now that we have seen the Lion Air final report I think it's back more in the court of #1.
#1 The Pilot did not review the issues from the Previous Flight - that is a huge No-no. If he had he probably would have had the knowledge that would have saved everyone on board.
#2 The Co-Pilot was cited as basically being incompetent and did not even have a mastery over the basics of Manual flight (did not know how to even use Manual Electric Trim properly) therefore should not have even be licensed as a pilot but kept getting passes through the Lion Air system.
#3 While the Pilot missed the review of the previous flight and showed relatively okay skills in the cockpit - it's one thing to look at the traces and see him counteracting MCAS activation 22 times - it's another thing to read about it in the timeline and say - why the hell didn't he throw the switches?
Then you read in the detailed CVR transcript that he admitted having the flu - which makes the fact he missed it 22 times and didn't brief his co-pilot properly on handover more understandable - but there is no way in hell he should have been in a cockpit. The Flu would have made him functionally impaired and possibly no better than drunk off his ass.
It's an incredibly detailed report - but after reading it you still think the pilots actions were not egregiously bad - symptomatic of a very broken training system I don't know what to say.
Boeing is still the root cause - but neither of those pilots should have been in that cockpit that day.
Indeed. Problem number one is still the aircraft. Of all the holes in the Swiss cheese, the Boeing hole is still the most egregious. While this flight had problems with the company’s crew and maintenance, not to mention an improperly factory-calibrated AOA sensor, absolutely every single MAX had the MCAS problem.
This report does nothing to diminish Boeing’s responsibility in the matter. It certainly doesn’t affect the legitimacy of the grounding.
It is right to expect proper maintenance, responsible crew behaviour, properly calibrated parts, and well-trained crews. It is right to expect crews to be the backstop against unforeseeable or non-preventable emergencies, and for that, I’m all in favour of better training. It is wrong to expect the pilots to be the backstop against a bad design.
Is this unreasonable?
Also, just a friendly reminder that Boeing is the party most opposed to any difference training. I’m sure WN doesn’t mind, as long as Boeing is willing to pay for it.
I don't know how you rank the egregious-nous of one over the other. At least In the case of Lion Air 610 they were all bad. The jury is still out on ET 302 - however I will be really surprised if we will see the same level of detail or admission of things that were done wrongly in that report.
Kudos to Indonesia for providing the detail and disclosure they did.
I'll give you the grounding though as it should never have been certified this way and obviously pilots don't have the assumed skill - however I'll stick with my belief that no one had to die if the rest of the system had been working like it should have.
Is it wrong to expect Pilots to be a backstop against bad design? That depends - I think MCAS really falls into the grey area where properly trained pilots should have been able to catch it - it was close enough to runaway stabilizer that the required runaway stabilizer memory checklist should have come immediately to mind or at least be tried one of the 22 times - but then again the pilot had the Flu and it seems like the Co-pilot couldn't recall any of the required memory checklists.
It was painful reading the transcript and all the times Pilot properly counteracted MCAS and for it never to occur to him to turn off the electric trim. Rereading with the knowledge that he had the flu and he was the equivalent of drunk made it a lot more understandable.
I'm not sure difference training really would have made much difference in this case - this was a failure of procedures (never fly when you have the Flu - remember to review the problems from the previous flight) and basic training.
Well… the likely truth is that the same crew, in the same personal circumstances, in an NG, with an improperly calibrated AOA sensor, probably would not have crashed. The other likely truth is that the same crew, in the same personal circumstances, in a future ungrounded and updated MAX, with an improperly calibrated AOA sensor, probably would not crash.
So yes, it may seem harsh, especially in shadow of the massive loss of life, but I still feel that Boeing’s failure is the most egregious. You yourself have acknowledge that the poor design is the root cause.
Humans are fallible. A plane just has two pilots. Only one of them needs to fail, and that can cause a tragedy. Even the best training can’t guarantee that humans will always perform as well as a situation asks. On the other hand, a large organization with many brains working on a design, and a certifying agency to oversee them, and with a century of aviation knowledge behind us, there ought to be way more than sufficient human redundancy to have prevented MCAS 1.0, and prevented this tragedy.
Now, as regards training. One of the problems is that nobody knew about MCAS, and nobody understood how much it increased the risk of a runaway stabilizer. On top of that, Boeing’s own literature is far too vague on what a runaway stabilizer even means. We would not have so much debate here, if Boejng’s literature were actually clear on this matter. In any case, it would have been proper to recommend that runaway stab be trained as regularly as loss of an engine on takeoff. Of course, Boeing didn’t even want to inform pilot’s about the existence of MCAS, let alone recommend proper training for it. They were trying to say that the MAX is the same as an NG, and required no better/different training than an NG.