Polot wrote:

mjoelnir wrote:

After the constant attacks on the pilots of JT610, I have to ask, did some people realy read the report?

Perhaps posters here should read beginning on page 314 about JATR´s findings related to MCAS.
It finds a whole row of things wrong with the MAX and Boeing.

In sum, the JATR found that the Boeing 737 MAX aircraft should not have been certified as airworthy....

I want to quote a few points in regards to maintenance and pilots

B. Lion Air's pilots, engineers, and maintenance personal should not be faulted for their reasonable attempts to detect, diagnose, and correct an unknowable defect.

and

1. The Lion Air flight JT610 crew should not be faulted for their response to a latent and unknowable defect.

It is very clear were this accident report puts the blame, straight at Boeing's feet. Nowhere else.

You need to reread that section again a bit more critically. Those quotes are Lion Air’s comments on the final report (section 6.10). They quote some of JTAR’a findings which is why that header is on page 314, but only the indented bulleted parts are from JTAR. Your quotes are not words that JTAR or the the accident investigation team wrote. It is not surprising that Lionair is saying Lionair should hold no responsibility. JTAR was not investigating the Lion air crash, they were investigating the 737MAX controls and certification process and would not (and do not) talk about fault in the crashes because that was not their job to investigate. In fact the JTAR report states: Observation O11.2-C: Maintenance and ground handling errors have contributed to several accidents and multiple incidents, and maintenance issues might also be relevant to the Lion Air B737 MAX accident based on the preliminary report.

An investigative team is not going to spend pages detailing failures with Lionairs mechanics and pilots that allowed holes in the Swiss cheese to line up and then write ‘but hey can’t fault them for anything!’ Reports like this in general try to minimize talking about blame period, they just stage the factors that lead to the crash.

You are right. Only that the 737MAX was not certifiable as airworthy is according JTAR.

planecane wrote:

Just because this crash wouldn't have happened if not for MCAS does not mean another crash won't happen on an aircraft without design flaws due to shoddy maintenance and/or a borderline incompetent flight crew member.

The real facts hit your claim really hard, because actually the next major deadly crash after JT610 in the worldwide aircraft safety record is ET302, precisely caused by the same MCAS v1 design on the 737-8/9 MAX. https://aviation-safety.net/statistics/period/barometer.php

PixelFlight wrote:

planecane wrote:

Just because this crash wouldn't have happened if not for MCAS does not mean another crash won't happen on an aircraft without design flaws due to shoddy maintenance and/or a borderline incompetent flight crew member.

The real facts hit your claim really hard, because actually the next major deadly crash after JT610 in the worldwide aircraft safety record is ET302, precisely caused by the same MCAS v1 design on the 737-8/9 MAX. https://aviation-safety.net/statistics/period/barometer.php

Sure, if you ignore the Atlas Air crash (which looks like it crashed due to some shoddy crewmanship) and the point of his comment entirely.

dtw2hyd wrote:

JT601 was the perfect storm. Sloppy design, sloppy oversight, and sloppy repair shops came together.

I don't believe we've yet seen any evidence that shows the AOA sensor on either flight was bad, uncalibrated, or incorrectly installed. IIRC, the JT610 report incorrectly stated a uncalibrated sensor, based on their mis-interpretation of the NTSB report.

The FAA conveniently shut down the Florida repair shop that serviced the AOA crash sensor, but they fell short in formally stating the repair shop - Xtra Aerospace - mis-calibrated or failed to calibrate the specific crash sensor. Keep in mind they shut down Xtra just days before Boeing CEO's scheduled testimony.

Why is this important? Because there's still the possibility that the root cause of the bad AOA data is a malfunctioning or incorrectly installed ADIRU, which is now supported by a plant manager's email warning of compromised production processes due to exhausted and fatigued workers.

So what's the latest? Does anyone know when these birds will start flying again?

PixelFlight wrote:

Chemist wrote:

"Boeing screwed up. It's the vast majority Boeing's fault. The MAX was fatally flawed. There are big problems in Boeing and FAA that need to be addressed. And the crew responded poorly and we should improve crew training where basic airmanship seems to be poor, as that's important, too"

All the officials reports and reviews are mainly about why the design is not safe enough, and how the crew situation was not addressed correctly in the design, not documented, and not trained. In that specific context of this exact design error, I found inappropriate to evaluate the "crew training" and "basic airmanship" on how "crew responded" to an erratic design not documented and not trained. My disagreement is on term like "the crew responded poorly" supporting the view that the crew was expected to respond better to Boeing erratic design. I can't support that view because according to the officials reports and reviews, the Boeing expectations/assumptions on the crew response are identified as the fundamental error that flawed the safety analysis and allowed the erratic design to exists. The crew response to Boeing errors was a consequence of the Boeing errors on the crew response.

Unrelated to the Boeing design error on the 737-8/9 MAX that need to be fixed before returning to service, the official report did identify crews training issues that need to be addressed.

I agree with much of your statement, but they were trained to use checklists, they should know how to use trim, and they should know to reduce power when going over max speed. Those are basic airmanship items. Sot it's not just about untrained items (which is valid), it's also about the basics. Which is why I said the crew responded poorly and that's also a training issue for the things that they should have been trained for.

StTim wrote:

No crash results in a single recommendation and rarely will ever identify a single cause.

This one is no different.

This thread however is about the grounding.

I find it hard to understand why anyone is not supportive of the grounding considering what we know about MCAS 1.0

Blaming the deceased pilots for the grounding is just plain wrong and certainly shouldn't be on this thread.

I've not seen anybody say that the plane shouldn't be grounded.

DIJKKIJK wrote:

So what's the latest? Does anyone know when these birds will start flying again?

The latest is that American Airlines flight crews demand an active role in bringing the MAX back into operation … as they are scared flying on it

https://uk.reuters.com/article/uk-boein ... sinessNews

https://www.businessinsider.com/boeing- ... ?r=US&IR=T

planecane wrote:

mjoelnir wrote:

planecane wrote:

If you don't apportion blame elsewhere safety will suffer. It's only a matter of time before shoddy maintenance at Lion Air does something that causes another crash where the design was fine. It's only a matter of time before a Lion Air pilot who fails simulator checks constantly and shouldn't be in a cockpit fails to perform a procedure properly that has been trained for and crashes a plane.

Yes, Boeing's design and decisions are what created the conditions for these two crashes. However, for sure in the Lion Air case, if a runaway stabilizer had been caused on an NG by shoddy maintenance, that crew on that day still would have crashed.

No safety will mainly suffer by diverting attention from the terrible Boeing design and terrible Boeing actions.

Boeing designed the MCAS with complete disregard for standard practices regarding safe design for safety critical applications.

Boeing actions:
- Boeing did hide MCAS so no pilot could train for it or know about it.
- After the Lion Air crash, Boeing tried to divert attention (as you try to do now) away from the MAX, pointing to pilots and maintenance, while knowing that their design was responsible. The right action would have been to ask the FAA to ground the MAX
- Second crash, rinse and repeat. Even trying to appeal to the president of the USA to influence the FAA to not ground.

No, through this catastrophic events, the tendency to divert from the real problem, the negligent deadly design of the 737MAX, has slowed the necessary actions and is responsible for the second crash.

There is no basis for your claim, that a 737NG would have crashed that day.

Some of you are truly unbelievable in your mission to get Boeing. Nobody (at least I'm not) is diverting from the issue with the MCAS design and related decisions.

You are diverting from other issues that were discovered in the investigation. To avoid addressing those issues before they cause a crash is irresponsible.

Will you be happy if Lion Air maintenance screws something up on an A330 and the pilots are not skilled enough to recover and it crashes?

Just because this crash wouldn't have happened if not for MCAS does not mean another crash won't happen on an aircraft without design flaws due to shoddy maintenance and/or a borderline incompetent flight crew member.

But this thread is about grounding not any of the other issues around the crashes.

planecane wrote:

mjoelnir wrote:

planecane wrote:

If you don't apportion blame elsewhere safety will suffer. It's only a matter of time before shoddy maintenance at Lion Air does something that causes another crash where the design was fine. It's only a matter of time before a Lion Air pilot who fails simulator checks constantly and shouldn't be in a cockpit fails to perform a procedure properly that has been trained for and crashes a plane.

Yes, Boeing's design and decisions are what created the conditions for these two crashes. However, for sure in the Lion Air case, if a runaway stabilizer had been caused on an NG by shoddy maintenance, that crew on that day still would have crashed.

No safety will mainly suffer by diverting attention from the terrible Boeing design and terrible Boeing actions.

Boeing designed the MCAS with complete disregard for standard practices regarding safe design for safety critical applications.

Boeing actions:
- Boeing did hide MCAS so no pilot could train for it or know about it.
- After the Lion Air crash, Boeing tried to divert attention (as you try to do now) away from the MAX, pointing to pilots and maintenance, while knowing that their design was responsible. The right action would have been to ask the FAA to ground the MAX
- Second crash, rinse and repeat. Even trying to appeal to the president of the USA to influence the FAA to not ground.

No, through this catastrophic events, the tendency to divert from the real problem, the negligent deadly design of the 737MAX, has slowed the necessary actions and is responsible for the second crash.

There is no basis for your claim, that a 737NG would have crashed that day.

Some of you are truly unbelievable in your mission to get Boeing. Nobody (at least I'm not) is diverting from the issue with the MCAS design and related decisions.

You are diverting from other issues that were discovered in the investigation. To avoid addressing those issues before they cause a crash is irresponsible.

Will you be happy if Lion Air maintenance screws something up on an A330 and the pilots are not skilled enough to recover and it crashes?

Just because this crash wouldn't have happened if not for MCAS does not mean another crash won't happen on an aircraft without design flaws due to shoddy maintenance and/or a borderline incompetent flight crew member.

Lion air maintenance has a limited danger it can only screw up few frames. Boeing has the possibility of screwing up hundreds of frames.

How do you compare having perhaps botched up the check after installing a repaired and newly certified AoA sensor, with designing a non airworthy frame, with deadly failure modes.

Will you be happy if more negligent designed Boeing frames will be the cause for more accidents?

DIJKKIJK wrote:

So what's the latest? Does anyone know when these birds will start flying again?

Somehow silence is getting deafening. Boeing promised "early Q4", FAA wants a month after formal submission of modifications for review - so until that submission had happened very quitely, latest estimates are gone and no new ones emerged.
My personal impression, EASA-FAA sync is the issue, with EASA demanding no-MCAS handling evaluation (trivial task according to a.net experts), and Boeing being not willing to risk. Probably they know things wouldn't work nicely. If that is the case, "if MAX would ever fly again" becomes a totally legitimate hundred billion dollar question.

DIJKKIJK wrote:

So what's the latest? Does anyone know when these birds will start flying again?

Boeing hasn't made a public statement on the submittal. It came in the form of statements from the FAA on Oct 22, 2019:

Dickson said at a conference of air traffic controllers in Washington that the agency had received the “final software load” and “complete system description” of revisions to the plane, which was grounded in March.

https://www.reuters.com/article/us-ethi ... SKBN1X11MM

3 takeaways from the congressional hearings:

1) Boeing Knew MCAS Had a Problematic Single Point of Failure Two Years Before Max Was Cleared To Fly

2) Boeing Knew Its Assumptions About Pilot Reactions To MCAS Could Be Wrong

3) After First Crash, Boeing Knew Of Internal MCAS Concerns But Refused To Ground Max Planes

https://www.npr.org/2019/11/02/77555337 ... l-hearings

sgrow787 wrote:

https://www.npr.org/2019/11/02/77555337 ... l-hearings

"I've talked to a lot of pissed off pilots," Transportation Committee Chair Peter DeFazio (D-Oregon) told Boeing CEO Muilenburg at the hearing Wednesday. "They said, 'We were the backup system? How can we be back up if we don't know something's going to take over our plane'."

"I think it highlights our engineers do raise questions, in an open culture. They question things," Hamilton said, adding the company "followed our thorough process,"

Now there is evidence that several months before the first 737 Max plane crash, Boeing knew that some pilots would need 10 seconds or longer to figure out what was happening, and taking that much time to react could have "catastrophic" results.

and on the fact that Muilenburg was sent emails about concerns over MAX... he told lawmakers he didn't fully read the messages. He turned them over to company lawyers and only recently became fully aware of their content.

He didn't even read them, turning them over to lawyers. Why is a lawyer the first person to be sent documents raising valid safety concern?

I'm gobsmacked.

A concerted effort to undermine and damage the reputation of Boeing and the MAX remains much the agenda of this thread.

If the MAX design was really NOT so broken, would it really have taken this long to get it back in the air? This is ridiculous as this point.

I am so glad America is not having an Apollo 13 moment because with this generations engineers, bureaucrats, managers, and scientists... our ASTRONAUTS would already be dead.

And you people want to take us to Mars! I don’t think so.

KlimaBXsst wrote:

A concerted effort to undermine and damage the reputation of Boeing and the MAX remains much the agenda of this thread.

It would be rather difficult to damage it any further than it already is.

PixelFlight wrote:

planecane wrote:

Just because this crash wouldn't have happened if not for MCAS does not mean another crash won't happen on an aircraft without design flaws due to shoddy maintenance and/or a borderline incompetent flight crew member.

The real facts hit your claim really hard, because actually the next major deadly crash after JT610 in the worldwide aircraft safety record is ET302, precisely caused by the same MCAS v1 design on the 737-8/9 MAX. https://aviation-safety.net/statistics/period/barometer.php

Explain AirAsia8501 on an A320

KlimaBXsst wrote:

A concerted effort to undermine and damage the reputation of Boeing and the MAX remains much the agenda of this thread

I think a famous John McEnroe reaction is appropriate here.

Boeing are responsible for the damage to the reputation of the MAX and BCA.

morrisond wrote:

PixelFlight wrote:

planecane wrote:

Just because this crash wouldn't have happened if not for MCAS does not mean another crash won't happen on an aircraft without design flaws due to shoddy maintenance and/or a borderline incompetent flight crew member.

The real facts hit your claim really hard, because actually the next major deadly crash after JT610 in the worldwide aircraft safety record is ET302, precisely caused by the same MCAS v1 design on the 737-8/9 MAX. https://aviation-safety.net/statistics/period/barometer.php

Explain AirAsia8501 on an A320

Lion Air flight 610 on the 29th of October 2018, Ethiopian Airlines Flight 302 19th of March 2019, how is AirAsia flight 8501 28th of December 2014 the next crash after Lion Air flight 610?

Does one have to buy you a calendar?

sgrow787 wrote:

3 takeaways from the congressional hearings:

1) Boeing Knew MCAS Had a Problematic Single Point of Failure Two Years Before Max Was Cleared To Fly

2) Boeing Knew Its Assumptions About Pilot Reactions To MCAS Could Be Wrong

3) After First Crash, Boeing Knew Of Internal MCAS Concerns But Refused To Ground Max Planes

https://www.npr.org/2019/11/02/77555337 ... l-hearings

That’s what happens to companies sometimes. Their “fear” of losing money to address a potentially damaging issue leads to suboptimal decisions which eventually not only results in them losing a lot of money, but also their reputation, the careers of some, occasionally their freedom (if one/some of them are found guilty of a crime), maybe even the company itself. Now, it’s Boeing’s turn and it’s really a shame that this happened. More than that for the families of the people who died.

art wrote:

KlimaBXsst wrote:

A concerted effort to undermine and damage the reputation of Boeing and the MAX remains much the agenda of this thread

I think a famous John McEnroe reaction is appropriate here...

I agree... about the John McEnroe reaction.
I at no way fault traditional Boeing.

Once the early Baby Boomers Generation set sail into retirement at Boeing, we were left with this warped, self entitled, rude, do it half-assed, you owe me something Generation of Dairy Flakes, who can’t seem to get off their Facebook Instagram butts long enough to put their minds together to solve a problem with their middle leaders unless everyone is made to “feel good diversely and inclusively.”

Time to get off the stick Generation Xers wanting to be Millennials and again produce planes. QUICKLY and thoroughly regrouping and fix shortcomings when things go amiss, and again revolutionize air travel like Boeing’s Baby Boomers and their fathers did.

T-tail deep stall can be solved by correct programming, tunnel testing, and engineering. MAX issues can be too.

Now just do it!

KlimaBXsst wrote:

T-tail deep stall can be solved by correct programming, tunnel testing, and engineering. !

on a FBW plane yes

on a manual control plane maybe if you can change units regardless of grandfathering

in all other cases, no

Polot wrote:

PixelFlight wrote:

planecane wrote:

Just because this crash wouldn't have happened if not for MCAS does not mean another crash won't happen on an aircraft without design flaws due to shoddy maintenance and/or a borderline incompetent flight crew member.

The real facts hit your claim really hard, because actually the next major deadly crash after JT610 in the worldwide aircraft safety record is ET302, precisely caused by the same MCAS v1 design on the 737-8/9 MAX. https://aviation-safety.net/statistics/period/barometer.php

Sure, if you ignore the Atlas Air crash (which looks like it crashed due to some shoddy crewmanship) and the point of his comment entirely.

https://www.ntsb.gov/investigations/pages/DCA19MA086.aspx
Atlas Air 5Y3591 captain had had about 11,000 hours total flight experience and first officer 5,000 hours total flight experience, not exactly "borderline incompetent flight crew member". And I can read no information about that accident that actually conclude that "it crashed due to some shoddy crewmanship". Quite the contrary, the initially "and then rapidly pitched nose down to about 49° in response to column input." was later edited by the NTSB "then pitched nose down over the next 18 seconds to about 49° in response to nose-down elevator deflection" that seem to indicate that the elevator did not deflect according to a column input. In addition the "FDR data indicated that the airplane gradually pitched up to about 20 degrees nose down during the descent" that could to indicate that the pilots tried to avoid the crash. At this point, aircraft malfunction is not out of the possibilities, so a bit early to use adjective to qualify the crewmanship, especially since no crew error and no crew issue was observed in the FDR and CVR.

and on the fact that Muilenburg was sent emails about concerns over MAX... he told lawmakers he didn't fully read the messages. He turned them over to company lawyers and only recently became fully aware of their content.

He didn't even read them, turning them over to lawyers. Why is a lawyer the first person to be sent documents raising valid safety concern?

I don't recall that section of the congressional questioning, but I'll assume you're citing it properly. That means that Mullenberg lied to Congress. Why? If he read these emails well enough to realize that they needed to be sent to the lawyers, then he realized what was in them, and their import. He can sidestep and extemporize all he wants, but that's really what it means. He knew enough about what was in them to realize that they were of legal importance, so he knew precisely what was in them.

I'm not trying to say that Mullenberg is an evil so and so who needs to go to a dark, dank place for the rest of his life. There's so much more here that we just don't know, yet. However, I do believe that Mullenberg was aware of the MAXs many problems far longer than he is claiming, and more than likely possessed very in depth knowledge, as one would expect for someone in his position. It will be interesting to see if the Justice Department's criminal investigation does anything regarding this.

Chemist wrote:

PixelFlight wrote:

Chemist wrote:

"Boeing screwed up. It's the vast majority Boeing's fault. The MAX was fatally flawed. There are big problems in Boeing and FAA that need to be addressed. And the crew responded poorly and we should improve crew training where basic airmanship seems to be poor, as that's important, too"

All the officials reports and reviews are mainly about why the design is not safe enough, and how the crew situation was not addressed correctly in the design, not documented, and not trained. In that specific context of this exact design error, I found inappropriate to evaluate the "crew training" and "basic airmanship" on how "crew responded" to an erratic design not documented and not trained. My disagreement is on term like "the crew responded poorly" supporting the view that the crew was expected to respond better to Boeing erratic design. I can't support that view because according to the officials reports and reviews, the Boeing expectations/assumptions on the crew response are identified as the fundamental error that flawed the safety analysis and allowed the erratic design to exists. The crew response to Boeing errors was a consequence of the Boeing errors on the crew response.

Unrelated to the Boeing design error on the 737-8/9 MAX that need to be fixed before returning to service, the official report did identify crews training issues that need to be addressed.

I agree with much of your statement, but they were trained to use checklists, they should know how to use trim, and they should know to reduce power when going over max speed. Those are basic airmanship items. Sot it's not just about untrained items (which is valid), it's also about the basics. Which is why I said the crew responded poorly and that's also a training issue for the things that they should have been trained for.

Actually the JT610 used the trim very extensively, so there definitely know how to trim, but no against the MCAS v1 unknown to them. As for the speed, the report allow to understand that in addition to multiple alarms, disagreement indications, stick shaker, and MCAS repetitive actions, the speed was not easy to figure out due to incoherent information from the aircraft:

"At 23:23:00 UTC, the aircraft EGPWS sounded “AIR SPEED LOW – AIR SPEED
LOW”. The TE controller responded that the ground speed of the aircraft, shown on
the radar display, was 322 knots. The DFDR recorded the indicated airspeed on the
Captain’s PFD indicated as 306 knots and on the FO’s PFD indicated 318 knots."

"At 23:23:08, the DFDR recorded on the Captain’s PFD low speed barber pole and
overspeed barber pole merged. On the FO’s PFD, the overspeed barber pole
appeared with the bottom of the pole about 340 knots and the low speed barber pole
did not appear."

The real overspeed did not occurred until the last 4 seconds before the crash, and the report did not list the overspeed as a contribution to the crash.

So based on your "they should know how to use trim" and "they should know to reduce power when going over max speed" argumentation, I still disagree that pilots can be blamed for a "response" to the erratic Boeing 737-8/9 MAX. Technically there was possibilities to saved the flight, but it was a Boeing erratic assumption to expect that there would "respond" in a way to save the flight in the context of was there experienced into the cockpit. You can maybe find a better argument, but I doubt that it can work with me if it's about a pilot "response" to Boeing erratic design.

PixelFlight wrote:

Chemist wrote:

PixelFlight wrote:

All the officials reports and reviews are mainly about why the design is not safe enough, and how the crew situation was not addressed correctly in the design, not documented, and not trained. In that specific context of this exact design error, I found inappropriate to evaluate the "crew training" and "basic airmanship" on how "crew responded" to an erratic design not documented and not trained. My disagreement is on term like "the crew responded poorly" supporting the view that the crew was expected to respond better to Boeing erratic design. I can't support that view because according to the officials reports and reviews, the Boeing expectations/assumptions on the crew response are identified as the fundamental error that flawed the safety analysis and allowed the erratic design to exists. The crew response to Boeing errors was a consequence of the Boeing errors on the crew response.

Unrelated to the Boeing design error on the 737-8/9 MAX that need to be fixed before returning to service, the official report did identify crews training issues that need to be addressed.

I agree with much of your statement, but they were trained to use checklists, they should know how to use trim, and they should know to reduce power when going over max speed. Those are basic airmanship items. Sot it's not just about untrained items (which is valid), it's also about the basics. Which is why I said the crew responded poorly and that's also a training issue for the things that they should have been trained for.

Actually the JT610 used the trim very extensively, so there definitely know how to trim, but no against the MCAS v1 unknown to them. As for the speed, the report allow to understand that in addition to multiple alarms, disagreement indications, stick shaker, and MCAS repetitive actions, the speed was not easy to figure out due to incoherent information from the aircraft:

"At 23:23:00 UTC, the aircraft EGPWS sounded “AIR SPEED LOW – AIR SPEED
LOW”. The TE controller responded that the ground speed of the aircraft, shown on
the radar display, was 322 knots. The DFDR recorded the indicated airspeed on the
Captain’s PFD indicated as 306 knots and on the FO’s PFD indicated 318 knots."

"At 23:23:08, the DFDR recorded on the Captain’s PFD low speed barber pole and
overspeed barber pole merged. On the FO’s PFD, the overspeed barber pole
appeared with the bottom of the pole about 340 knots and the low speed barber pole
did not appear."

The real overspeed did not occurred until the last 4 seconds before the crash, and the report did not list the overspeed as a contribution to the crash.

So based on your "they should know how to use trim" and "they should know to reduce power when going over max speed" argumentation, I still disagree that pilots can be blamed for a "response" to the erratic Boeing 737-8/9 MAX. Technically there was possibilities to saved the flight, but it was a Boeing erratic assumption to expect that there would "respond" in a way to save the flight in the context of was there experienced into the cockpit. You can maybe find a better argument, but I doubt that it can work with me if it's about a pilot "response" to Boeing erratic design.

One of the perhaps differentiators in airmanship is that one person has memorized everything they should know, and the other person *understands* what they should know. When you are pointing down, with flaps and gear up, in an aircraft with as much power as a 737 MAX, then you are going to be overspeed in really short order. There is an important set of descending (no pun intended) priorities, and not overspeeding is right up at the top. The "understanding" pilot would know this immediately. The "memorizing" pilot would be racking their brain for all the memorized items that they ought to be doing, trying to assess relative priorities - all while taking critical seconds. There is a differentiator and that's all basic training and understanding.
Also, the CRM is trained, and we know that the LionAir captain did a poor handoff. He'd been maintaining control with 20-some up trim activations, yet in passing control somehow didn't mention that very unusual detail to the FO. Another critical item not managed.
Yes, Boeing was the root cause. But I don't understand why you won't agree that the crews had plenty of room for improvement, well beyond whether MCAS was trained.

Chemist wrote:

PixelFlight wrote:

Chemist wrote:

I agree with much of your statement, but they were trained to use checklists, they should know how to use trim, and they should know to reduce power when going over max speed. Those are basic airmanship items. Sot it's not just about untrained items (which is valid), it's also about the basics. Which is why I said the crew responded poorly and that's also a training issue for the things that they should have been trained for.

Actually the JT610 used the trim very extensively, so there definitely know how to trim, but no against the MCAS v1 unknown to them. As for the speed, the report allow to understand that in addition to multiple alarms, disagreement indications, stick shaker, and MCAS repetitive actions, the speed was not easy to figure out due to incoherent information from the aircraft:

"At 23:23:00 UTC, the aircraft EGPWS sounded “AIR SPEED LOW – AIR SPEED
LOW”. The TE controller responded that the ground speed of the aircraft, shown on
the radar display, was 322 knots. The DFDR recorded the indicated airspeed on the
Captain’s PFD indicated as 306 knots and on the FO’s PFD indicated 318 knots."

"At 23:23:08, the DFDR recorded on the Captain’s PFD low speed barber pole and
overspeed barber pole merged. On the FO’s PFD, the overspeed barber pole
appeared with the bottom of the pole about 340 knots and the low speed barber pole
did not appear."

The real overspeed did not occurred until the last 4 seconds before the crash, and the report did not list the overspeed as a contribution to the crash.

So based on your "they should know how to use trim" and "they should know to reduce power when going over max speed" argumentation, I still disagree that pilots can be blamed for a "response" to the erratic Boeing 737-8/9 MAX. Technically there was possibilities to saved the flight, but it was a Boeing erratic assumption to expect that there would "respond" in a way to save the flight in the context of was there experienced into the cockpit. You can maybe find a better argument, but I doubt that it can work with me if it's about a pilot "response" to Boeing erratic design.

One of the perhaps differentiators in airmanship is that one person has memorized everything they should know, and the other person *understands* what they should know. When you are pointing down, with flaps and gear up, in an aircraft with as much power as a 737 MAX, then you are going to be overspeed in really short order. There is an important set of descending (no pun intended) priorities, and not overspeeding is right up at the top. The "understanding" pilot would know this immediately. The "memorizing" pilot would be racking their brain for all the memorized items that they ought to be doing, trying to assess relative priorities - all while taking critical seconds. There is a differentiator and that's all basic training and understanding.
Also, the CRM is trained, and we know that the LionAir captain did a poor handoff. He'd been maintaining control with 20-some up trim activations, yet in passing control somehow didn't mention that very unusual detail to the FO. Another critical item not managed.
Yes, Boeing was the root cause. But I don't understand why you won't agree that the crews had plenty of room for improvement, well beyond whether MCAS was trained.

And LionAir completely failed the information handoff from crew to maintenance, from maintenance to crew, and from crew to log and log to crew.

If LionAir is competent, this plane doesn’t crash. Which of course means that ET would be left in the dark completely (does anyone think Lion would try to let anyone know of their incidents had there been no crash?). So either way, ET would have crashed if JT hadn’t.

I just find it hard to accept that after having 3 months to digest the JT information that ET as a whole did everything right and crashed anyway. I have a feeling the ET report, if honest, will reveal a host of missteps by ET similar in severity to JT. But who knows?

ikramerica wrote:

If LionAir is competent, this plane doesn’t crash. Which of course means that ET would be left in the dark completely (does anyone think Lion would try to let anyone know of their incidents had there been no crash?). So either way, ET would have crashed if JT hadn’t.

This touches an interesting topic, so interesting to me that I even, years ago, wanted to start a thread about it: how do airlines „process“ aircraft crashes internally?

I guess it’s human nature or maybe it’s just me, I can learn from mistakes much better than from learning how it should work (... had some semesters structural design and loved my professor for reporting about his investigations on bridge collapses and what specific design mistakes had been made...). So one would think the airlines, in parallel to the flight training, provide their pilots with huge books about crash investigations, look them firmly in the eyes and say „read it and don’t make such mistakes!“

And what happens at major airlines shortly after a crash of an aircraft type they operate by themselves, in particular new aircraft types? Would love to read they simply send an e-mail to all pilots „hey, we canceled all your flights tomorrow, let’s get together at our HQ to discuss a little bit about that crash yesterday“ but I have the feeling it doesn’t work that way... :-/

ikramerica wrote:

I just find it hard to accept that after having 3 months to digest the JT information that ET as a whole did everything right and crashed anyway. I have a feeling the ET report, if honest, will reveal a host of missteps by ET similar in severity to JT. But who knows?

You wrote something similar in another thread. The question that comes to my mind is: why is it ET that should have done something after the JT-crash? If it is common practice within the industry to somehow take actions after a crash, wouldn’t you expect that „non-third-class-airlines“ (... not meant to be offensive ... :-; ...) such as UA and AC take the lead?

Which leads again to the question of how airlines „process“ aircraft crashes of other airlines.

kalvado wrote:

Revelation wrote:

kalvado wrote:

Thing is, engineering qualification is another weak link in MCAS situation.
You can blame a lot of things on management pressure - but two things in present situation that are very hard to justify by external influence: multiple actuations and no input sanitation.

I don't find it hard to blame engineering management pressure for that kind of result. Typically managers will partition the work by department and by engineer so an individual engineer only considers the impact over a small scope, then they can say their work is done. No manager will want to be responsible for the big picture since that's too much pressure, and they won't want to push back on lower level managers to get them to expand the scope of the work. No one wants to be the long pole in the tent. We see lots of evidence of "it worked well enough in the past, why reconcider the big picture" thinking in the article I linked above, along with https://www.seattletimes.com/seattle-ne ... afeguards/

Again, hard to believe. There should be a single document, request for coding of a MCAS procedure. Are you saying the document was not put together by someone in engineering position nor checked by an engineer? Then blanket scrap order is really overdue...

I can back up the point that this is very hard to believe. There's surely more than even just the order to code MCAS. I used to work as a software dev for an aerospace contractor and even at our tiny company EVERYTHING is documented. All design documents are kept and related to each other in matrices and any change to either was recorded in a table at the top with what was changed and what the reasoning behind it was, along with how the change would effect other related systems.

I hadn't seen this mentioned before until reading the NPR article just now (https://www.npr.org/2019/11/02/77555337 ... l-hearings) but not only were there the emails about the safety of the authority of MCAS in 2015, and the chat logs about the simulator in 2016, but even shortly before the Indonesia crash Boeing was still concerned about it in 2018.

DeFazio released a document showing that in June of 2018, after airlines had begun flying the new 737 Max planes, but months before the Lion Air crash, Boeing employees were raising concerns about how much time it would take for pilots to react to a potential MCAS failure. The document, called a "coordination sheet" and dated June 11, 2018, suggested some pilots would take more time than four seconds to react, and "A slow reaction time scenario, (greater than) 10 seconds, found the failure to be catastrophic."

And then even after the crash they decided that it was OK to continue to allow pilots to fly the plane up until a second MCAS related incident. Even after at least 3 years of internal discussion over it, and then you have the CEO playing dumb like he skimmed the communications and had no idea that any of this was going on.

I get that there is a point that pilot training standards could be better but how is anyone surprised that people are angry about Boeing's actions in all of this?

From a software engineering perspective the entire saga is appalling and absurd. I was holding out hope that somehow Boeing's engineering teams somehow changed one aspect of the system and missed the downstream effects elsewhere but after the revealed communications from 2015, 2016, and 2018 I just can't see it being the case anymore. The tone in Folkner's chat logs makes MCAS sound like a well-known pain point in the program, almost like an inside joke.

The lack of redundancy, error checking, sanity checking, and any semblance of graceful failure modes in MCAS make it look like a failing grade into level computer science class project in freshman year of college. Say what you will about the performance of the pilot's who had to react to it without having a clue about its existence but Boeing's engineering performed much, much worse, and over a longer period of time.

So, when will we start blaming airlines for being too cheap to provide at least 3 days class and two or three simulator sessions for conversion to MAX and asked Boeing to develop a plane that only requires 1 hour iPad reading? We blamed Boeing, and yes Boeing did something wrong, and we blamed airlines for providing less training (yes they did that too). But shall we consider that airlines are the force behind this too? Airlines are trying to give less and less training for conversion just because it's cheaper, and Boeing agreed.

Revelation wrote:

It's interesting how some posters here used ugly terms like racist when people had questions about how the pilots responded to the conditions they were presented with, but those same people now are showing very little concern about the fact that disadvantaged people are still being flown around by an airline whose training and maintenance shortcomings have been so vividly displayed.

Riddle me this, why isn't the other Boeing 737's having the same issues as the MAX with Lion Air? They are maintained by the same engineers and same processes that has clear shortcomings as what affected the MAX. That counts for the pilots as well. Also, for a airline that has such bad practices and shoddy airmanship from its pilots, why did Boeing allow them to launch the 739ER? The reputational damage a crash from an airline that is obviously not fit to carry "disadvantaged passengers from the third world" of a new model would surely come into consideration for Boeing. Does Boeing not do checks and balances to ensure its reputation isn't harmed by airlines that have shortcomings in training and flying skills? Or does making money count for more?

shmerik wrote:

And then even after the crash they decided that it was OK to continue to allow pilots to fly the plane up until a second MCAS related incident. Even after at least 3 years of internal discussion over it, and then you have the CEO playing dumb like he skimmed the communications and had no idea that any of this was going on.

Another failing for Muilenberg that he didn't read email about the MCAS and only skimmed them. Now you could forgive some bean counter CEO who doesn't have the technical education or experience and may not want to get bogged down in the minute details of engineering systems that would confuse him, but for an engineer to not take an interest seems, well criminal.

benbeny wrote:

So, when will we start blaming airlines for being too cheap to provide at least 3 days class and two or three simulator sessions for conversion to MAX and asked Boeing to develop a plane that only requires 1 hour iPad reading? We blamed Boeing, and yes Boeing did something wrong, and we blamed airlines for providing less training (yes they did that too). But shall we consider that airlines are the force behind this too? Airlines are trying to give less and less training for conversion just because it's cheaper, and Boeing agreed.

Why? Unless the airlines are the ones making the decision if training is required I don't see how they are to blame in any way. As a customer you can ask any salesperson for a discount, but they are not mandated to give it to you.

benbeny wrote:

So, when will we start blaming airlines for being too cheap to provide at least 3 days class and two or three simulator sessions for conversion to MAX and asked Boeing to develop a plane that only requires 1 hour iPad reading? We blamed Boeing, and yes Boeing did something wrong, and we blamed airlines for providing less training (yes they did that too). But shall we consider that airlines are the force behind this too? Airlines are trying to give less and less training for conversion just because it's cheaper, and Boeing agreed.

So the airlines are to blame for not providing training for a feature that they weren't even aware of?

They never asked Boeing to create a plane that only requires iPad training, they just stipulated that they pay less if training was required, which makes sense since they take on the cost of the training

ikramerica wrote:

If LionAir is competent, this plane doesn’t crash.

And if Boeing is competent, neither MAX would have crashed. Do you see, where the big leverage is?

ikramerica wrote:

I just find it hard to accept that after having 3 months to digest the JT information that ET as a whole did everything right and crashed anyway.

There was nothing to digest. I have heard a MAX pilot saying after the Lionair crash: "There is no officially confirmed new information beside the AD. MCAS does not exist. It must have been something else. The published FDR data does not provide any information about an automatic trim system." Pilots, who wanted to rely on official information simply were put on a fasting cure by Boeing. There was nothing to digest! Now if you say, that they should have learned from the press how to handle their aircraft, that would also be putting the cart before the horse.

ikramerica wrote:

I just find it hard to accept that after having 3 months to digest the JT information that ET as a whole did everything right and crashed anyway. I have a feeling the ET report, if honest, will reveal a host of missteps by ET similar in severity to JT. But who knows?

The misteps by JT in the report are only a few, which are strongly put into perspective by a much larger number of exonerating findings.

planecane wrote:

seahawk wrote:

planecane wrote:

I was inventing a highly unlikely scenario to show a way that there could be a runaway stabilizer where electric trim would still work.

You said that it was impossible. I'm sure there are other ways for it to happen but I'm not an expert on the trim system fault tree so I can't give specific examples.

However the NNC, after saying to disengage autopilot and trim with the manual electric trim says to move the cutout switches IF RUNAWAY CONTINUES. That indicates a scenario is possible where the autopilot wasn't the cause and electric trim functioned but there was a runaway stabilizer.

I said there is no scenario in which manual electric trim would work and the stick override for nose down trim movement would not work.

If the stick override works there is no runaway stabilizer situation as the trim will stop moving. Explain why the NNC is written the way it is if these scenarios can't exist.

First the override only stops nose down trim movement not nose-up and secondly you can still have the old style runaway trim where manual electric also does not work. And thirdly it would be bad airmanship to stop a runaway trim through the stick override, as you would be flying seriously out of trim.

Chemist wrote:

PixelFlight wrote:

Chemist wrote:

I agree with much of your statement, but they were trained to use checklists, they should know how to use trim, and they should know to reduce power when going over max speed. Those are basic airmanship items. Sot it's not just about untrained items (which is valid), it's also about the basics. Which is why I said the crew responded poorly and that's also a training issue for the things that they should have been trained for.

Actually the JT610 used the trim very extensively, so there definitely know how to trim, but no against the MCAS v1 unknown to them. As for the speed, the report allow to understand that in addition to multiple alarms, disagreement indications, stick shaker, and MCAS repetitive actions, the speed was not easy to figure out due to incoherent information from the aircraft:

"At 23:23:00 UTC, the aircraft EGPWS sounded “AIR SPEED LOW – AIR SPEED
LOW”. The TE controller responded that the ground speed of the aircraft, shown on
the radar display, was 322 knots. The DFDR recorded the indicated airspeed on the
Captain’s PFD indicated as 306 knots and on the FO’s PFD indicated 318 knots."

"At 23:23:08, the DFDR recorded on the Captain’s PFD low speed barber pole and
overspeed barber pole merged. On the FO’s PFD, the overspeed barber pole
appeared with the bottom of the pole about 340 knots and the low speed barber pole
did not appear."

The real overspeed did not occurred until the last 4 seconds before the crash, and the report did not list the overspeed as a contribution to the crash.

So based on your "they should know how to use trim" and "they should know to reduce power when going over max speed" argumentation, I still disagree that pilots can be blamed for a "response" to the erratic Boeing 737-8/9 MAX. Technically there was possibilities to saved the flight, but it was a Boeing erratic assumption to expect that there would "respond" in a way to save the flight in the context of was there experienced into the cockpit. You can maybe find a better argument, but I doubt that it can work with me if it's about a pilot "response" to Boeing erratic design.

One of the perhaps differentiators in airmanship is that one person has memorized everything they should know, and the other person *understands* what they should know. When you are pointing down, with flaps and gear up, in an aircraft with as much power as a 737 MAX, then you are going to be overspeed in really short order. There is an important set of descending (no pun intended) priorities, and not overspeeding is right up at the top. The "understanding" pilot would know this immediately. The "memorizing" pilot would be racking their brain for all the memorized items that they ought to be doing, trying to assess relative priorities - all while taking critical seconds. There is a differentiator and that's all basic training and understanding.
Also, the CRM is trained, and we know that the LionAir captain did a poor handoff. He'd been maintaining control with 20-some up trim activations, yet in passing control somehow didn't mention that very unusual detail to the FO. Another critical item not managed.
Yes, Boeing was the root cause. But I don't understand why you won't agree that the crews had plenty of room for improvement, well beyond whether MCAS was trained.

I did wrote this a bit early and still think it's the best I can do to date:
"Unrelated to the Boeing design error on the 737-8/9 MAX that need to be fixed before returning to service, the official report did identify crews training issues that need to be addressed."

I think it's fair to clearly separate the two points as unrelated because, as the EASA viewpoint, the pilot training is not to compensate an erratic safety design. But Boeing did an erratic safety design _AND_ did not require pilot training. From that point, the accident was only a matter of time. Of course the accident will hit with greater probability the crews under the average performance, and this is exactly what happened. So yes, the crews needed improvements, but this was unrelated to the Boeing erratic design and this need to be addressed with a training improvement program unrelated to the 737-8/9 MAX improvement program. The only link between the two points is the Boeing wrong assumptions about the pilots performance in a cockpit context that Boeing did not even analyse correctly, so it's absurd to blame the pilots in that precise cockpit context and wrong assumptions. This only feed endless debate like about measuring something with an inappropriate setup. The two points will be improved separately. Once you realize that, you understand how useless is to blame the pilots "response" to the erratic design. Boeing and pilots have both there set of unrelated improvements to do.

PixelFlight wrote:

I think it's fair to clearly separate the two points as unrelated because, as the EASA viewpoint, the pilot training is not to compensate an erratic safety design. But Boeing did an erratic safety design _AND_ did not require pilot training. From that point, the accident was only a matter of time. Of course the accident will hit with greater probability the crews under the average performance, and this is exactly what happened. So yes, the crews needed improvements, but this was unrelated to the Boeing erratic design and this need to be addressed with a training improvement program unrelated to the 737-8/9 MAX improvement program

Now that we have started including the MAX 9 in our postings, why have we excluded the 7 and the 10, surely the reason why we switched in this version of the grounding thread is for safety reasons to ensure that the 9 is included in any fixes?
In the earlier versions the focus was on the model that crashed and there were discussions of whether MCAS was on the 9, I assume it has been confirmed, so what about the 7 and 10, for safety reasons it should not be relevant that they are not yet in service, they are versions of the MAX.

shmerik wrote:

kalvado wrote:

Revelation wrote:

I don't find it hard to blame engineering management pressure for that kind of result. Typically managers will partition the work by department and by engineer so an individual engineer only considers the impact over a small scope, then they can say their work is done. No manager will want to be responsible for the big picture since that's too much pressure, and they won't want to push back on lower level managers to get them to expand the scope of the work. No one wants to be the long pole in the tent. We see lots of evidence of "it worked well enough in the past, why reconcider the big picture" thinking in the article I linked above, along with https://www.seattletimes.com/seattle-ne ... afeguards/

Again, hard to believe. There should be a single document, request for coding of a MCAS procedure. Are you saying the document was not put together by someone in engineering position nor checked by an engineer? Then blanket scrap order is really overdue...

I can back up the point that this is very hard to believe. There's surely more than even just the order to code MCAS. I used to work as a software dev for an aerospace contractor and even at our tiny company EVERYTHING is documented. All design documents are kept and related to each other in matrices and any change to either was recorded in a table at the top with what was changed and what the reasoning behind it was, along with how the change would effect other related systems.

I hadn't seen this mentioned before until reading the NPR article just now (https://www.npr.org/2019/11/02/77555337 ... l-hearings) but not only were there the emails about the safety of the authority of MCAS in 2015, and the chat logs about the simulator in 2016, but even shortly before the Indonesia crash Boeing was still concerned about it in 2018.

DeFazio released a document showing that in June of 2018, after airlines had begun flying the new 737 Max planes, but months before the Lion Air crash, Boeing employees were raising concerns about how much time it would take for pilots to react to a potential MCAS failure. The document, called a "coordination sheet" and dated June 11, 2018, suggested some pilots would take more time than four seconds to react, and "A slow reaction time scenario, (greater than) 10 seconds, found the failure to be catastrophic."

And then even after the crash they decided that it was OK to continue to allow pilots to fly the plane up until a second MCAS related incident. Even after at least 3 years of internal discussion over it, and then you have the CEO playing dumb like he skimmed the communications and had no idea that any of this was going on.

I get that there is a point that pilot training standards could be better but how is anyone surprised that people are angry about Boeing's actions in all of this?

From a software engineering perspective the entire saga is appalling and absurd. I was holding out hope that somehow Boeing's engineering teams somehow changed one aspect of the system and missed the downstream effects elsewhere but after the revealed communications from 2015, 2016, and 2018 I just can't see it being the case anymore. The tone in Folkner's chat logs makes MCAS sound like a well-known pain point in the program, almost like an inside joke.

The lack of redundancy, error checking, sanity checking, and any semblance of graceful failure modes in MCAS make it look like a failing grade into level computer science class project in freshman year of college. Say what you will about the performance of the pilot's who had to react to it without having a clue about its existence but Boeing's engineering performed much, much worse, and over a longer period of time.

Hard to believe but not impossible. The NTSB SYSTEM SAFETY AND CERTIFICATION SPECIALIST’S REPORT give some details about how the 737-8/9 MAX project was documented on subjects where the MCAS matter. My understanding of that report is that it give me the feeling that it was a management configuration where only the good news was documented. The bad news look ignored in the project documentation and traces are only found in some emails or chats, without much consequences at that time. The first need of MCAS was early on the project and relatively well documented, the second need for the MCAS was late on the project and this was here that the documentation inside Boeing was not coherent anymore to ensure safety.

PixelFlight wrote:

Boeing and pilots have both there set of unrelated improvements to do.

I actually agree with this last statement. As the skills the Pilots didn't display on the MAX is not unique to the 737 MAX.

For example some of the Major Air disasters of the recent past that probably would not have happened with better manual skills/better CRM.

ET409 - 737 NG crash - Lack of Manual Flying Skills
AF447 - A330 Crash - Manual Flying Skills/Bad CRM/Minor design issues but really the crew
Colgan 3407 - Bombadier Dash 8-400 - Lack of Manual Skills, BAD CRM
AirAsia 8501- A320 - Bad Maintenance - Lack of Manual Flying Skills/Bad CRM
JT 610 - 737 MAX - Design Mistake/Bad CRM - Lack of Manual Flying Skills
ET302 - 737 MAX - Design Mistake/Bad CRM - Lack of Manual Skills

If you look through the list of Major Air disasters excepting for things like Terrorist Bombs there is a common thread. Lack of Manual flying skills and bad CRM. It is not Design.

https://en.wikipedia.org/wiki/List_of_a ... fatalities

Once we get past Boeing's problems this is a Worldwide Pilot Training issue that needs to be addressed. Due to automation and lack of time to practice Pilots have lost this critical ability and seem to be way less sharp than they need to be. We need to do this if we want to improve safety further - a lot of the crashes on the list above would not have happened with even average crews.

Airlines exist in a very competitive industry and will only spend the basic minimum on training as defined by regulation. In recurrent and/or primary training that is barely enough to keep up with all the automated systems - manual flight is rarely practiced.

Regulation needs to change to compel airlines to spend more on training. It won't happen unless they are compelled to do it.

As I showed before a doubling in training hours may add maybe $2-3 to an airline ticket.

Planes need to be designed as safe as possible - but who doesn't like the above idea?

On the MAX let's call Boeings crappy design A and the pilots bad CRM/poor piloting skills B.

The pilots would have never been put in the position they were without A. But the crashes need not have happened if B were what it is supposed to be.

Better design is critical - but at this point it will not do much more to improve safety (once the MAX is fixed) until we are able to replace Pilots with new designs and probably AI in 20-30 years and we have to remember the aircraft that are currently flying and coming off the assembly lines will need pilots to fly them for another 25-30 years.

Until then Improving training on Manual skills/Better CRM will be the primary determinant on how many fatal crashes we have in the future. Significant safety design changes (probably more redundancy) will not enter the fleet in significant numbers for quite some time.

Training(and better maintenance practises) are key.

shmerik wrote:

Even after at least 3 years of internal discussion over it, and then you have the CEO playing dumb like he skimmed the communications and had no idea that any of this was going on.

My first thought is that people think CEOs are supermen that know in great detail the minutia of things going on within an organization, but they don't. Clearly mid level managers do not want negative things flowing up the chain, they try to manage them at their level. In the case of Boeing, the CEO has to watch over airliners, space and defense divisions. I'd be pretty surprised if he had heard of the challenges with MCAS before the first crash.

My second thought is once the crash happened he did need to make himself aware of the minutia. Maybe he leaned on the BCA President to do this work too much? Maybe he wanted to maintain 'plausible deniability' so he didn't get hands-on with the problem? Maybe he thought it would be better to have someone else take the lead so they could serve as a 'fall guy'? Regardless, he owns the crisis management aspects of the MAX tragedy, and it's pretty clear to me that he's done a poor job and will pay for it with his job. No big deal for him, there will be plenty of other cushy opportunities for him to pursue after, plus he's been making and presumably banking massive amounts of money already.

enzo011 wrote:

Riddle me this, why isn't the other Boeing 737's having the same issues as the MAX with Lion Air? They are maintained by the same engineers and same processes that has clear shortcomings as what affected the MAX.

How do we know they don't? It took the major MCAS issue to get the 'holes in the Swiss Cheese' to line up, but that doesn't mean there aren't other holes waiting for some other event that would cause them to line up. Isn't a preemptive shutdown called for, ala ValuJet in the 90s?

ValuJet was grounded by the FAA on June 16, 1996, and was allowed to resume flying again on September 30, but never recovered from the crash.[

Ref: https://en.wikipedia.org/wiki/ValuJet_F ... estigation

shmerik wrote:

benbeny wrote:

So, when will we start blaming airlines for being too cheap to provide at least 3 days class and two or three simulator sessions for conversion to MAX and asked Boeing to develop a plane that only requires 1 hour iPad reading? We blamed Boeing, and yes Boeing did something wrong, and we blamed airlines for providing less training (yes they did that too). But shall we consider that airlines are the force behind this too? Airlines are trying to give less and less training for conversion just because it's cheaper, and Boeing agreed.

So the airlines are to blame for not providing training for a feature that they weren't even aware of?

They never asked Boeing to create a plane that only requires iPad training, they just stipulated that they pay less if training was required, which makes sense since they take on the cost of the training

Yet we in here complained a lot about less and less training. Training is costly, so does the airplane. It's a cost of doing business. Why don't we ask airlines to give more training? Why does regulators worldwide agree with required trainings?

benbeny wrote:

shmerik wrote:

benbeny wrote:

So, when will we start blaming airlines for being too cheap to provide at least 3 days class and two or three simulator sessions for conversion to MAX and asked Boeing to develop a plane that only requires 1 hour iPad reading? We blamed Boeing, and yes Boeing did something wrong, and we blamed airlines for providing less training (yes they did that too). But shall we consider that airlines are the force behind this too? Airlines are trying to give less and less training for conversion just because it's cheaper, and Boeing agreed.

So the airlines are to blame for not providing training for a feature that they weren't even aware of?

They never asked Boeing to create a plane that only requires iPad training, they just stipulated that they pay less if training was required, which makes sense since they take on the cost of the training

Yet we in here complained a lot about less and less training. Training is costly, so does the airplane. It's a cost of doing business. Why don't we ask airlines to give more training? Why does regulators worldwide agree with required trainings?

Good question. But why do not point it into the right direction, at Boeing.

One of the main push by Boeing was in regards to the MAX were the minimum training requirements. They sold to Southwest and I assume other airlines, the promise of no simulator training requirement for on million USD per frame.
They than went to hide the changes from NG to MAX and got the FAA to underwrite the minimum training requirement.

If we do not expect Boeing to put the foot down, as they put shareholder's satisfaction before safety, as a good corporation does, we should expect the FAA to act. But they failed miserably.

The next player, airlines, want also to cut training expenses down, see again shareholders satisfaction. I do not see why USA posters are so satisfied with their system, those USA airlines do not want to train pilots from scratch, they want to get them ready made with somebody else having paid for the training.

Outside of the USA you see some airlines starting to set up their own programs to train pilots from scratch, or have done that for a while. But that is hardly done out of compassion, but it gets to be the only way those airlines can get enough well trained pilots.

I would like to see airlines running training programs, like European companies in many industries having run apprenticeship programs. It is the fastest and safest way to a skilled work force.
Of course one should do away with the 1,500 hours requirement. If there would be sense in that requirement you would see a serious Air Force like in the USA use a similar time frame, non does.
The training programs should be similar to apprenticeship programs in not putting the cost on the trainee. Rigorous requirements with wheezing out the inefficient and hopeless, do not go well with taking money from the trainee, you set up a conflict of interest.
Letting a pilot pay for being allowed to start off at in airline in the right seat, should be absolutely banned.

KlimaBXsst wrote:

A concerted effort to undermine and damage the reputation of Boeing and the MAX remains much the agenda of this thread.

If the MAX design was really NOT so broken, would it really have taken this long to get it back in the air? This is ridiculous as this point.

I am so glad America is not having an Apollo 13 moment because with this generations engineers, bureaucrats, managers, and scientists... our ASTRONAUTS would already be dead.

And you people want to take us to Mars! I don’t think so.

After reading the ongoing replies to this thread,
My impression is the MAX design system is what is broken almost as much as the MAX itself.

WHY it has taken so long to get the MAX back in the air shows, how bureaucratically political our aeronautical societal’s assumed computational processing and managerial engineering systems have almost been paralyzed and hamstrung by a design; puzzle pieced together by those who don’t necessarily understand the whole concept of flight.

A corporation of “sub-contractorees,” doesn't necessarily make for a Corporation that has a grip on it’s technology.

This should be yet another wake up call, for those concerned about Ai (artificial intelligence) in the age of robotics going awry.

If people don’t know or understand what capabilities the parts they separately build into the machines they are producing, DO; how are operators of these machines suppose to.

Thus when these very same machines start making the decisions over the humans; the whole aviation world sure becomes a lot more scary and in a sense aviators become the “first canaries in the coal mine of Ai out of control,” as they and Boeing have become with the MAX.

shmerik wrote:

kalvado wrote:

Revelation wrote:

I don't find it hard to blame engineering management pressure for that kind of result. Typically managers will partition the work by department and by engineer so an individual engineer only considers the impact over a small scope, then they can say their work is done. No manager will want to be responsible for the big picture since that's too much pressure, and they won't want to push back on lower level managers to get them to expand the scope of the work. No one wants to be the long pole in the tent. We see lots of evidence of "it worked well enough in the past, why reconcider the big picture" thinking in the article I linked above, along with https://www.seattletimes.com/seattle-ne ... afeguards/

Again, hard to believe. There should be a single document, request for coding of a MCAS procedure. Are you saying the document was not put together by someone in engineering position nor checked by an engineer? Then blanket scrap order is really overdue...

I can back up the point that this is very hard to believe. There's surely more than even just the order to code MCAS. I used to work as a software dev for an aerospace contractor and even at our tiny company EVERYTHING is documented. All design documents are kept and related to each other in matrices and any change to either was recorded in a table at the top with what was changed and what the reasoning behind it was, along with how the change would effect other related systems.

I hadn't seen this mentioned before until reading the NPR article just now (https://www.npr.org/2019/11/02/77555337 ... l-hearings) but not only were there the emails about the safety of the authority of MCAS in 2015, and the chat logs about the simulator in 2016, but even shortly before the Indonesia crash Boeing was still concerned about it in 2018.

DeFazio released a document showing that in June of 2018, after airlines had begun flying the new 737 Max planes, but months before the Lion Air crash, Boeing employees were raising concerns about how much time it would take for pilots to react to a potential MCAS failure. The document, called a "coordination sheet" and dated June 11, 2018, suggested some pilots would take more time than four seconds to react, and "A slow reaction time scenario, (greater than) 10 seconds, found the failure to be catastrophic."

And then even after the crash they decided that it was OK to continue to allow pilots to fly the plane up until a second MCAS related incident. Even after at least 3 years of internal discussion over it, and then you have the CEO playing dumb like he skimmed the communications and had no idea that any of this was going on.

I get that there is a point that pilot training standards could be better but how is anyone surprised that people are angry about Boeing's actions in all of this?

From a software engineering perspective the entire saga is appalling and absurd. I was holding out hope that somehow Boeing's engineering teams somehow changed one aspect of the system and missed the downstream effects elsewhere but after the revealed communications from 2015, 2016, and 2018 I just can't see it being the case anymore. The tone in Folkner's chat logs makes MCAS sound like a well-known pain point in the program, almost like an inside joke.

The lack of redundancy, error checking, sanity checking, and any semblance of graceful failure modes in MCAS make it look like a failing grade into level computer science class project in freshman year of college. Say what you will about the performance of the pilot's who had to react to it without having a clue about its existence but Boeing's engineering performed much, much worse, and over a longer period of time.

I'm not an industry insider or expert, but have worked in corporate American for almost 25 years and understand corporate behavior. I've been following these posts for over a year and am surprised at how few posts (other than the attached and a few others) relate to what I believe is at the heart of the matter: Boeing had to hide the unacceptable pitch up characteristics from the FAA and the airlines or else - frankly - the entire justification for the plane would be at risk and significant cancellations could have resulted.

Boeing promised the airlines a cost-effective, fuel efficient, grandfathered airplane to compete with the A320NEO with entry in service 2016/2017. They delivered on this mission by designing larger engines for the airframe than ever before, and then to accommodate their size, moving them forward and upward to slightly above the wing.

At some point during development, they learned that the airplane had unacceptable aerodynamics at high speed / high altitude and during certain maneuvers that significantly increased its pitch up tendencies beyond 737NG and outside FAA standards. Hence MCAS was born, and based on their assessment of the rarity of these high speed pitch up situations, MCAS had limited authority. It was shared with FAA, but determined to be of such limited risk that a failure was not deemed catastrophic. Boeing convinced FAA that such rarity also made any special notifications or training for pilots unnecessary.

Then, they discovered that the airplane had further dangerous pitch up tendencies at low speed / low altitude. So they modified MCAS by significantly increasing its authority. But, by all accounts they didn't fully disclose that to the FAA, and definitely not prominently to the airlines. Ask why that is: because the FAA would have had to require further testing, putting their EIS and grandfathering at risk. Plus, had FAA evaluated and considered MCAS failure a catastrophic risk, then they would likely have had to modify hardware, also putting EIS and grandfathering at risk. Boeing couldn't have these EIS delays, as they'd just come off similar delays for the 787. What we now see, as some of these emails are being uncovered, there were those inside who were trying to raise red flags, but to no avail - whether that was Boeing Executive management (C Suite) or project management, it becomes evident these concerns were discounted or ignored due to the impact addressing them would have had on the delivery timeframes and even the plane itself. This is typical corporate behavior so it's not unreasonable to believe they'd not want to impact their 737 MAX project.

In my mind, these were not mistakes of Boeing - this was an intentional effort to maintain grandfathering and limited training in light of the mounting evidence that the plane as designed couldn't meet FAA standards or their commitments to their airline customers.

Further, ask why Boeing is now against having the airplane tested without MCAS. I believe they know FAA would find its unacceptable pitch up tendencies and Boeing would need to make significant hardware changes. But they've now got 200? 300? planes that they continued to build that would be unusable without major changes. Boeing is doing everything it can to keep that from happening.

Finally, given there is a criminal investigation underway by the Department of Justice, does anyone believe that the FAA will unground the plane until the investigation is completed? Wouldn't the FAA - or at least the airlines - want to know there was no criminal conduct involved in the certification process before restarting flying. I think the AA flight attendants are just the beginning of the pushback on Boeing and FAA, and even if cleared, I'm not sure there will be much flying for a while.

morrisond wrote:

PixelFlight wrote:

Boeing and pilots have both there set of unrelated improvements to do.

I actually agree with this last statement. As the skills the Pilots didn't display on the MAX is not unique to the 737 MAX.

Cool

morrisond wrote:

Better design is critical - but at this point it will not do much more to improve safety (once the MAX is fixed) until we are able to replace Pilots with new designs and probably AI in 20-30 years and we have to remember the aircraft that are currently flying and coming off the assembly lines will need pilots to fly them for another 25-30 years.

Until then Improving training on Manual skills/Better CRM will be the primary determinant on how many fatal crashes we have in the future. Significant safety design changes (probably more redundancy) will not enter the fleet in significant numbers for quite some time.

Training(and better maintenance practises) are key.

I do think that there is a lot of things that can be done at the design level to improve safety without having to replace the pilots. Fact is that we can't actually change how a human pilot is engineered, so the design and operation have to take in account the human weaknesses to ensure safety. Training is one of the point that can improve some human pilot performances, but this has also limitations in term of statistic effectiveness.

You are talking about an ideal future where the designs will not contribute anymore to fatal crash to show that in this case only the training will contribute to the crash. Ok, but the reality of the last dozen months have show a very different situation where a single erratic design contributed alone to two crashes with the highest fatalities in that period. This reality remain how important is to have safe design .

par13del wrote:

PixelFlight wrote:

I think it's fair to clearly separate the two points as unrelated because, as the EASA viewpoint, the pilot training is not to compensate an erratic safety design. But Boeing did an erratic safety design _AND_ did not require pilot training. From that point, the accident was only a matter of time. Of course the accident will hit with greater probability the crews under the average performance, and this is exactly what happened. So yes, the crews needed improvements, but this was unrelated to the Boeing erratic design and this need to be addressed with a training improvement program unrelated to the 737-8/9 MAX improvement program

Now that we have started including the MAX 9 in our postings, why have we excluded the 7 and the 10, surely the reason why we switched in this version of the grounding thread is for safety reasons to ensure that the 9 is included in any fixes?
In the earlier versions the focus was on the model that crashed and there were discussions of whether MCAS was on the 9, I assume it has been confirmed, so what about the 7 and 10, for safety reasons it should not be relevant that they are not yet in service, they are versions of the MAX.

JT610 final report page 246:
"The STS was
carried over to the 737-7/-8/-9 (737 MAX) family of aircraft. Additionally, on 737
MAX aircraft, the MCAS function was added to the STS to address the pitch
characteristics described above."

And footnote 27:
"Both the 737-8 and 737-9 were in service at the time of the accident. The 737-7 and 737-10 are planned future derivatives that have not yet entered service."

It's know since a long time that both the 737-8 and 737-9 have MCAS. It seem unavoidable that the 737-7 have MCAS too. The 737-10 is actually less visible, but since it's a derivative, it's probably the case too.

This raise an intriguing question: Since there are doubt that Boeing is willing to do a test flight to show the actual characteristics without MCAS, how that characteristics can vary between the MAX family range, mainly between the different length of the fuselage ? Maybe the problem is even worst for the 737-7 or for the 737-10 due to there shorter or longer fuselage.

KlimaBXsst wrote:

After reading the ongoing replies to this thread,
My impression is the MAX design system is what is broken almost as much as the MAX itself.

WHY it has taken so long to get the MAX back in the air shows, how bureaucratically political our aeronautical societal’s assumed computational processing and managerial engineering systems have almost been paralyzed and hamstrung by a design; puzzle pieced together by those who don’t necessarily understand the whole concept of flight.

A corporation of “sub-contractorees,” doesn't necessarily make for a Corporation that has a grip on it’s technology.

What I think is broken is that Boeing made a bunch of financial and marketing goals the primary focus of the MAX program, and everything else second.

As the old saying goes, "Good, Fast, Cheap: Pick Two".



They picked Fast and Cheap, and Good was left wanting.

Given how many MBAs are running around you would have thought they would have internalized this rule by now, but the "we want it all" culture is a powerful thing.

DC10LAXJFK wrote:

I'm not an industry insider or expert, but have worked in corporate American for almost 25 years and understand corporate behavior. I've been following these posts for over a year and am surprised at how few posts (other than the attached and a few others) relate to what I believe is at the heart of the matter: Boeing had to hide the unacceptable pitch up characteristics from the FAA and the airlines or else - frankly - the entire justification for the plane would be at risk and significant cancellations could have resulted.

This fits the "picking fast and cheap over good" notion pretty well. They chose fast (schedule pressure, must match competitor's timeline) and cheap (push back on any changes to the 737) over good. We now see fixing the major MCAS issues is taking about a year. We also see there were some questions about MCAS being raised internally, but weren't being acted upon, presumably because of the fast+cheap imperatives.

DC10LAXJFK wrote:

Finally, given there is a criminal investigation underway by the Department of Justice, does anyone believe that the FAA will unground the plane until the investigation is completed? Wouldn't the FAA - or at least the airlines - want to know there was no criminal conduct involved in the certification process before restarting flying. I think the AA flight attendants are just the beginning of the pushback on Boeing and FAA, and even if cleared, I'm not sure there will be much flying for a while.

I think the two issues are pretty independent of each other. The FAA has the JATR report and the KNKT accident report to inform its decision making. I don't think a criminal finding would change its approach much if at all.

DC10LAXJFK wrote:

Finally, given there is a criminal investigation underway by the Department of Justice, does anyone believe that the FAA will unground the plane until the investigation is completed? Wouldn't the FAA - or at least the airlines - want to know there was no criminal conduct involved in the certification process before restarting flying. I think the AA flight attendants are just the beginning of the pushback on Boeing and FAA, and even if cleared, I'm not sure there will be much flying for a while.

Yes, I think Boeing will have to articulate a promise of specific compensation for the victims, airlines, and aircraft crews in order to get cooperation and the aircraft flying again. It seems like they are avoiding the obvious hoping it will go away. Talking about settling up on compensation is on the critical path to return to service.

Revelation wrote:

[
What I think is broken is that Boeing made a bunch of financial and marketing goals the primary focus of the MAX program, and everything else second.

As the old saying goes, "Good, Fast, Cheap: Pick Two".



They picked Fast and Cheap, and Good was left wanting.

Except for MAX was neither cheap nor fast.
Development timeframe for MAX is longer than for NG, which was a bigger development. Cost of MAX program was on par with A320 NEO cost.
Which leaves us with neither cheap, nor fast - and apparently not good.

planecane wrote:

uta999 wrote:

I too have defended the dead pilots in the past on here. None of us were there on those two aircraft, having to deal with something very unusual, confusing, alarming, frightening and ultimately deadly. They probably knew quite early on that their actions would not save them.

The problem now is to not muddy the water so much, that Boeing get off so lightly, only partly to blame, the pilots bought it on themselves, they were useless etc etc. Boeing is completely to blame here. No other aircraft type would have done what the MAX did to them. That is all Boeing, not the pilots. If you apportion blame elsewhere, future safety will suffer.

If you don't apportion blame elsewhere safety will suffer. It's only a matter of time before shoddy maintenance at Lion Air does something that causes another crash where the design was fine. It's only a matter of time before a Lion Air pilot who fails simulator checks constantly and shouldn't be in a cockpit fails to perform a procedure properly that has been trained for and crashes a plane.

Yes, Boeing's design and decisions are what created the conditions for these two crashes. However, for sure in the Lion Air case, if a runaway stabilizer had been caused on an NG by shoddy maintenance, that crew on that day still would have crashed.

MCAS trim rate is considerably higher than any automatic trim rate on NG. But having read Peter Lemme's thorough analysis, one could arrive at the conclusion that a real trim-runaway on the NG would be quite a handful for an average NG crew, and safe landing would by no means be guaranteed.

Point in order: maintenance did not cause the MCAS-runaway, they did not prevent it would be better description. AoA was already defective, they just installed another defective one. During which there were of course several (missed) opportunities to detect that.

However it seems the NG system robustness has PROVEN to be so strong that these issues do not materially affect flight safety. Not so for the Max, sadly.


Also, we need to keep in mind the odds of these things happening. Yes, maintenance may have (eventually) caused a NG crash as you describe (though not likely), but by that time we would have seen dozens, hundreds, if not thousands of MCAS related accidents in the same time frame. Same for the pilot failing simulator check.

FAA categorizes events in four different categories for hazardous events:
* MINOR (like MMEL item, safe flight is not affected)
* MAJOR (reduced operating, some limitations; like engine In-Flight Shut Down)
* HAZARDOUS (significant risk for partial loss of life)
* CATASTROPHIC (significant risk for loss of all life)
Each higher category requires more redundancies and better system reliability.

The main problem on the Max, according to Peter's analysis, is that three different issues (each identified as MAJOR) happened at the same time:
* airspeed and altitude disagree = MAJOR 1
* false stall warning (stick shaker, minspeed/PLI anomoly, feel force increase) = MAJOR 2
* MCAS malfunction = MAJOR 3 (although Lemme argues that this could/should have been HAZARDOUS itself)

In his mind (I'm not sure if this is described by the regulations), if you have two simultaneous MAJOR events, they should be considered HAZARDOUS. Add a third MAJOR to it, it become CATASTROPHIC.
The associated safety assessments (FHA, SSA) failed to properly identify MCAS run-away risk (classifying it as MAJOR rather than HAZARDOUS), and did not take into consideration the stacked effects of three MAJOR events happening at the same time, which resulted in CATASTRPOHIC events.

Cockpit crew performance, as well as maintenance performance, should therefore not be part of the (un)grounding saga. However that does not mean that there are no lessons to be learnt in those areas.