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mig17
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Re: Updated: Final report of Lion Air JT610 has been released

Sat Oct 26, 2019 2:39 pm

I read a lot of discussion about the AoA sensor, but I feel it misses the target. A malfunctionning sensor is not supposed to bring down an aircraft. Or we would have more more much accidents.
Like in the Air France 447 case, a faulty sensor began a chain of event that is not supposed to happen. In AF case, the FO stall the plane in the ocean, in the max case, the MCAS did ... twice now.
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Planetalk
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Re: Updated: Final report of Lion Air JT610 has been released

Sat Oct 26, 2019 2:44 pm

ikramerica wrote:
Planetalk wrote:
Somewhere outside the rather dull posts by people telling us they were right there's an interesting discussion to be had.

As was to be expected by anyone who's ever read an accident report, blame is shared around amongst all parties, although it is perhaps most unusual to see the aircraft manufacturer receive so much of it, actual design and certification flaws are rarely one of the root causes. It's not surprising that Lionair's training was found wanting, and this FO probably would have been weeded out some time ago in many airlines. Some points I would note:

- The FO also had over 5000 hours total and 4000 ours on type which is food for thought for those who seem to think 1500 hours provides some magical shield against pilot error. I personally feel far more comfortable with a well trained cadet up front than a guy with 1500 hours dusting crops.
- Of course, training systems worldwide need to improve (no s**t Sherlock), I don't think many would have disagreed with that before either of these crashes, it's really not some great revelation. We come back again to the point that it was Boeing who withheld information from pilots and the FAA and ensured these guys knew nothing of MCAS. That wasn't some dodgy third world airline skimping on training, it was a very deliberate, considered, decision by Boeing.
- Boeing well knows the standard of pilots worldwide, and they remain happy to sell planes to these airlines, and were quite happy to reduce training requirements. Boeing are as guilty as anyone for any deficiencies in the standards of pilots.
- There is a question of the intent behind people's actions. It is unlikely the FO deliberately tried to be bad at handling a plane and wasn't fussed if that led to him dying. It is sadly more likely that he lacked some of the skillset to be a good pilot, coupled with a system letting him down. I cannot cut such slack to those in Boeing who made quite deliberate decisions. And if you think there aren't people in management in corporations who don't care if their decisions end up costing lives somewhere down the line, you're being very naive. This guy paid for his mistakes with his life, many of those at Boeing will walk away from all this rich enough never to need to work again. That's why I feel rage at Boeing, and only sympathy for the FO.

Some here seem to think the fact the pilot made some mistakes vindicates their opinion that really MCAS wasn't all that bad as long as you had a half decent pilot. Which is nonsense but you have to admire their persistence. I don't think anyone thought the pilots made no mistakes. What people find unedifying, and frankly ignorant, are statements like 'any half decent pilot could have saved this', 'MCAS should never have led to a crash' and so on ad infinitium the last few months, which are still not backed up by a shred of evidence, and don't seem to be the opinion of anyone whose opinion has any significance in the industry

That this FO made mistakes does not somehow mean only bad crews would have crashed the plane. Indeed, we have plenty of real pilots as opposed to armchair warriors on the internet who have quite unequivocally stated that the pilots should not be blamed. We have the evidence from simulator sessions after the Ethiopian crash when even pilots who knew what was coming struggled or even lost the plane. We have Sully himself who has flown the scenario and came out defending the pilots. We have the public anger of pilots at US airlines towards Boeing for this. I personally, will take those as my references, rather than an anonymous guy on the internet who's never flown a 737 and apparently has nothing to do with their life but smear dead pilots.

Its a very very sad situation and there is a lot to earn all round. One hopes everyone learns from it. And one certainly hopes that no-one in Boeing is today reacting in the same way as some posters here. There is no victory in any of this for anyone, except perhaps any future lives saved by lessons learned.

Absolve the airline all you want.

The design was problematic. There was a major problem that could have crashed the plane that was not understood by Lion and not taken seriously.

It should not have been dispatched without a proper repair and documentation and without the crew also knowing what to expect in a failure.

But through a series of errors by the airline and their crew, the squirrelly, improperly repaired plane crashed. A plane that was not properly dispatched.

ET is a different accident. Had JT not crashed, ET definitely would have. But ET wasn’t in a vacuum. We shall see what the investigation reveals. Then you can absolve them.


Please quote a single thing I wrote that could be construed as absolving the airline. I said 'its no surprise Lionair's traning was found wanting'. You for some reason are inventing positions for people to start a fight. I'm not playing that game.

I can quite happily say Lionair were at fault. Boeing were at fault.The FAA were at fault. Noone absolved.

A quick note for you, a design that is deemed unairworthy is more than 'problematic'.

I can easily not fly Lionair, however it is very hard for me not to fly Boeing. So on a personal level, Boeing designing non-airworthy planes and then hiding what they've done from regulators and pilots, is what worries me most. That doesn't mean I absolve anyone else.

What it means is I expected better from Boeing, but if it makes you happy, to be clear yes Lionair are terrible. And since you want everyone to be treated fairly and eqyally, the conclusion is that Boeing are on their level. Does it make you proud?
 
zoom321
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Re: Updated: Final report of Lion Air JT610 has been released

Sat Oct 26, 2019 3:08 pm

PixelFlight wrote:
zoom321 wrote:
Does the report indicate if the maintenace issues were due to Lion mechanics not following boeing manual or is it the boeing manual that is inadequate ?

The report has detailed explanations how the FAA certified (well, not anymore) Xtra Aerospace mis-calibrated the AoA sensor and certified it for operation.


Not the AoA sensor per se but the questions about the trouble shooting done by Lion mechanics and how they cleared the max for flight. Were the mechanics just following Boeing manual ?
Many say the max was not airworthy.
 
dtw2hyd
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sat Oct 26, 2019 3:15 pm

Finn350 wrote:
They didn't follow the approved installation procedure! The engineer should have checked and recorded the angle deflection test values of AOA sensor via the SMYD to ensure that test results were within tolerance. See p. 38 of the report.


The report says engineer didn't record the values, it doesn't say engineer didn't check the values.

Two possibilities
1) The engineer did the test ie., checked the values but failed to document the values.
2) The engineer didn't perform the test, ie., didn't check the values.

You seem to jump to #2
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Finn350
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sat Oct 26, 2019 3:32 pm

dtw2hyd wrote:
Finn350 wrote:
They didn't follow the approved installation procedure! The engineer should have checked and recorded the angle deflection test values of AOA sensor via the SMYD to ensure that test results were within tolerance. See p. 38 of the report.


The report says engineer didn't record the values, it doesn't say engineer didn't check the values.

Two possibilities
1) The engineer did the test ie., checked the values but failed to document the values.
2) The engineer didn't perform the test, ie., didn't check the values.

You seem to jump to #2


Part of the correct procedure is to record the test values. The engineer didn't record the values. The engineer showed photos purportedly showing the test, but they were determined to be from a different aircraft (see p. 36).

The engineer in Denpasar provided the investigation several photos including of the Captain’s PFD that was claimed to be taken after the AOA sensor replacement and of the SMYD during the installation test. However, the time shown on the Captain’s PFD was the time before arrival of AOA sensor spare part and the investigation confirmed that the SMYD photos were not of the accident aircraft.
 
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Polot
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Re: Updated: Final report of Lion Air JT610 has been released

Sat Oct 26, 2019 3:41 pm

zoom321 wrote:
PixelFlight wrote:
zoom321 wrote:
Does the report indicate if the maintenace issues were due to Lion mechanics not following boeing manual or is it the boeing manual that is inadequate ?

The report has detailed explanations how the FAA certified (well, not anymore) Xtra Aerospace mis-calibrated the AoA sensor and certified it for operation.


Not the AoA sensor per se but the questions about the trouble shooting done by Lion mechanics and how they cleared the max for flight. Were the mechanics just following Boeing manual ?
Many say the max was not airworthy.

Even if Lionair completely follow approved procedures the severe problems encountered on the previous flight should have set off alarm bells that something was wrong and the aircraft should have been pulled from service to investigate. That is why many say it was not airworthy even before we learned the reasons behind the AOA issues.
 
frmrCapCadet
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Re: Updated: Final report of Lion Air JT610 has been released

Sat Oct 26, 2019 3:46 pm

What it means is I expected better from Boeing, but if it makes you happy, to be clear yes Lionair are terrible. And since you want everyone to be treated fairly and eqyally, the conclusion is that Boeing are on their level. Does it make you proud?


For the many of us who our aviation fans and even (were?) fans of Boeing this is indeed the pain. I suspect a lot of Boeing workers feel the same. And as well the FAA.
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shmerik
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sat Oct 26, 2019 5:42 pm

morrisond wrote:
zeke wrote:
Finn350 wrote:
What is the point to check SMYD readouts if not to check whether there is a gross disagreement.


Because that is the computer the sensor is connected to.


So you are saying it's okay to ignore the approved installation procedure?

What if the Vane had been damaged since being repaired?

Zeke - as an airline Pilot I can't believe you would be okay with this.

Are you saying you would be fine dispatching with a part that was not installed using the approved procedure?

How the hell is Boeing supposed to design around that?


How about some sort of redundancy and sanity checks when reading the AOA values in the MCAS logic?

Pretty straightforward and standard thing to design around...
 
dtw2hyd
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sat Oct 26, 2019 5:54 pm

Finn350 wrote:
Part of the correct procedure is to record the test values. The engineer didn't record the values. The engineer showed photos purportedly showing the test, but they were determined to be from a different aircraft (see p. 36).

The engineer in Denpasar provided the investigation several photos including of the Captain’s PFD that was claimed to be taken after the AOA sensor replacement and of the SMYD during the installation test. However, the time shown on the Captain’s PFD was the time before arrival of AOA sensor spare part and the investigation confirmed that the SMYD photos were not of the accident aircraft.


I agree with you AMT did a sloppy job of documenting the work. It doesn't prove that the engineer didn't check the values. AMT did document two other tests.

It may be that their process is to take pictures and do the paperwork later.

I wish the report spelled out more clearly what actually happened. Let's hope NTSB will dig deeper into this.

This may be final from Indonesia, but NTSB has to agree with their findings and conclusions. This is not the end of this investigation.
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Revelation
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sat Oct 26, 2019 6:17 pm

dtw2hyd wrote:
Finn350 wrote:
Part of the correct procedure is to record the test values. The engineer didn't record the values. The engineer showed photos purportedly showing the test, but they were determined to be from a different aircraft (see p. 36).

The engineer in Denpasar provided the investigation several photos including of the Captain’s PFD that was claimed to be taken after the AOA sensor replacement and of the SMYD during the installation test. However, the time shown on the Captain’s PFD was the time before arrival of AOA sensor spare part and the investigation confirmed that the SMYD photos were not of the accident aircraft.

I agree with you AMT did a sloppy job of documenting the work. It doesn't prove that the engineer didn't check the values.

We have no proof that he did record the values, and that's what the procedure demands the engineer does!

The whole reason why the procedure says to record the values is to PROVE that (a) you did the test, and (b) the equipment returned sensible values.

Of course the act of recording the values should force you to ask yourself if the values make sense or not, unless you are asleep or incompetent.

If he had just followed the documented procedure the point would be moot, as it was for the other two tests you cite.
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dtw2hyd
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sat Oct 26, 2019 6:49 pm

Revelation wrote:
dtw2hyd wrote:
Finn350 wrote:
Part of the correct procedure is to record the test values. The engineer didn't record the values. The engineer showed photos purportedly showing the test, but they were determined to be from a different aircraft (see p. 36).


I agree with you AMT did a sloppy job of documenting the work. It doesn't prove that the engineer didn't check the values.

We have no proof that he did record the values, and that's what the procedure demands the engineer does!

The whole reason why the procedure says to record the values is to PROVE that (a) you did the test, and (b) the equipment returned sensible values.

Of course the act of recording the values should force you to ask yourself if the values make sense or not, unless you are asleep or incompetent.

If he had just followed the documented procedure the point would be moot, as it was for the other two tests you cite.


He/She didn't record the values that is a stated fact in the report.

What I was trying to inter is did he/she checked/read the values.

AMT has to put the vane in one of the three positions go back into the cockpit and read and record value. Repeat three times. It seems to be a cumbersome process if working alone. Easy to skip the test completely

There are two bad practices in MX world, 1) Sloppy Documentation and 2) Pencil Whipping. Sloppy documentation gets an earful but pencil whipping is really dangerous.
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SheikhDjibouti
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sat Oct 26, 2019 6:49 pm

Revelation wrote:
dtw2hyd wrote:
Finn350 wrote:
Part of the correct procedure is to record the test values. The engineer didn't record the values.

I agree with you AMT did a sloppy job of documenting the work. It doesn't prove that the engineer didn't check the values.

We have no proof that he did record the values, and that's what the procedure demands the engineer does!

The whole reason why the procedure says to record the values is to PROVE that (a) you did the test, and (b) the equipment returned sensible values.

Of course the act of recording the values should force you to ask yourself if the values make sense or not, unless you are asleep or incompetent.

In a previous existence my OH serviced and calibrated assorted monitoring equipment related to water quality.
Not quite in the same league as aircraft repairs, but there are statutory regulations governing performance, and $$$substantial government fines for transgressions.

Some of her colleagues couldn't be ar$ed with driving 50 miles to particularly remote outstations and fiddling around in a tech cabinet on a rainy day, so they would enter bogus readings in the work log to "prove" they had done their job. :liar:
She would frequently catch up with them when it was her turn to visit the same site two weeks later.
Or by casually perusing the work log and seeing data written to three decimal places for a piece of kit that only displayed two d.p. :roll:

Of course whenever I falsified data, I made damn sure it passed the sniff test. Which is why I was never caught. :rotfl:

It seems as if the Lion Air techies were so awful they couldn't even come up with falsifying records as a workaround..... :banghead:
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AirlineCritic
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Re: Updated: Final report of Lion Air JT610 has been released

Sat Oct 26, 2019 7:42 pm

I've been silent because I feel I need to read the report... and it takes time. Still reading.

So far, I haven't seen too many real surprises. Swiss cheese gains another victim. As someone said, sad, because that means there were so many opportunities for avoiding the accident. (Although perhaps conversely, there's been many other accidents that were avoided because not all holes lined up... mind boggles.)

The list of nine contributing factors seems fair. Please do not lift only your favourite items and celebrate that you were right; one needs to consider the whole.

Maybe the only main surprise for me has been pulling the repair facility's license and their role in the accident; I wasn't expecting that and thought that either repair procedures or the particular repair job was done badly. Turns out the part was bad and the job was done badly. More cheese holes.

I do agree that the FO's abilities seemed substandard, and while some of that was expected, this went further than I thought.

All that being said, a transport category aircraft should not have easily correctable failure modes that lead to serious situations, unless those situations are clearly identified and trained for (such as engine loss). Because if you do, you eventually will hit a combination of cheese holes where, for instance, mechanical factors lead to a situation that someone can handle but isn't quite at his or hers best game that day, and then the backup doesn't work. This seems to have happened twice now, which to me indicates that some of the cheese slices are quite a full of holes (e.g., AoA sensor reliability, design that relies on one input, co-pilot proficiency in emergencies). Question: how much do crews train in sim for "xmas warning light" situations? Seems like a generic triage capability would be essential for these situations. Which sometimes do occur.
 
mjoelnir
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Re: Updated: Final report of Lion Air JT610 has been released

Sat Oct 26, 2019 8:28 pm

In regards to the AoA sensor, we have at least three holes in Swiss cheese.

- the sloppy repair shop, that should have lost it´s FAA certification a while ago
- the sloppy mechanic (s) that did not check the sensor after installing it and hoppfully looses his/her certification
- but als Boeing, that did not tell anybody, that the certified AoA disagree warning was not present, contrary to what the manual said
 
airtechy
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Re: Updated: Final report of Lion Air JT610 has been released

Sat Oct 26, 2019 9:00 pm

I would be very surprised if the mechanics at Lion didn't have a test set to independently check the AOA subassembly. This is "not" a calibration tool but a verification tool. It would have a mating electrical connector to supply power to the assembly, a method to read the output, and maybe a mechanical mount as vane angle is important here. The advantage here is that you can isolate a false reading to an individual assembly rather than a string of assemblies that are giving a bad output. The test could be as simple as holding the vane against the cw stop ..read the meter, hold against the ccw stop .. read the meter, align the the vane with the mark on the mount .. read the meter , and record and check the values against the required limits.

I'll bet there are "many" test boxes for various assemblies on the 737. Now what Lion Air's requirement is to "use" the test boxes is another story. What this report does seem to show is that in this case the fault was in the AOA assembly and not the electronics that followed. It will be interesting to see if the ET sensor went through the same repair house. You can bet there a lot of sensors being retested if they flowed though this calibration house. :shock:

Jim
 
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zeke
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sat Oct 26, 2019 10:55 pm

Finn350 wrote:

Part of the correct procedure is to record the test values. The engineer didn't record the values. The engineer showed photos purportedly showing the test, but they were determined to be from a different aircraft (see p. 36).


The actual procedure from Lion Air is not listed in the report, so I don’t know what they are supposed to record. When I see mechanics perform tests on aircraft I only see them record the result of the task, ie “carried out test IAW AMM task xxxx-xxx-xxx”. Each individual step in the within task is not recorded.

What is known is a normal sensor in the zero angle of attack position does not output zero degrees, it is designed to output 45 degrees +/-5 degrees. The normal tolerances allowed are +/- 5 degrees. I would suggest when they tested the probe through the range of movement e were would have seen between +/-105 to 95 degrees and seen it as being normal.

The SYMD is looking to see the output waveform is smooth sinusoidal in nature. It would fail the probe when moved through the range of motion if the output waveform from the sensor was not smooth sinusoidal.

The report also states the random bias could remain undetected during return to service testing.

“ In February 2019, Collins Aerospace repeated the Peak API offset demonstration at its facility. The test was repeated for the benefit of NTSB and FAA personnel who did not witness the original demonstration at Xtra Aerospace. The procedures followed during the February 2019 demonstration were fundamentally the same as those performed at Xtra Aerospace in December 2018. The conclusions were identical. First, that an equal offset could inadvertently be introduced to both resolvers. Second, that the magnitude of the offset is essentially random. And third, that the offset could go undetected through the CMM return-to-service tests.
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morrisond
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sat Oct 26, 2019 11:19 pm

SheikhDjibouti wrote:
Revelation wrote:
dtw2hyd wrote:
I agree with you AMT did a sloppy job of documenting the work. It doesn't prove that the engineer didn't check the values.

We have no proof that he did record the values, and that's what the procedure demands the engineer does!

The whole reason why the procedure says to record the values is to PROVE that (a) you did the test, and (b) the equipment returned sensible values.

Of course the act of recording the values should force you to ask yourself if the values make sense or not, unless you are asleep or incompetent.

In a previous existence my OH serviced and calibrated assorted monitoring equipment related to water quality.
Not quite in the same league as aircraft repairs, but there are statutory regulations governing performance, and $$$substantial government fines for transgressions.

Some of her colleagues couldn't be ar$ed with driving 50 miles to particularly remote outstations and fiddling around in a tech cabinet on a rainy day, so they would enter bogus readings in the work log to "prove" they had done their job. :liar:
She would frequently catch up with them when it was her turn to visit the same site two weeks later.
Or by casually perusing the work log and seeing data written to three decimal places for a piece of kit that only displayed two d.p. :roll:

Of course whenever I falsified data, I made damn sure it passed the sniff test. Which is why I was never caught. :rotfl:

It seems as if the Lion Air techies were so awful they couldn't even come up with falsifying records as a workaround..... :banghead:


It sounds like that's what ET might have done though - it will be interesting if a bird strike was actually heard on the CVR - maybe the same workshop that supplied Lion Air supplied ET as well - pure speculation - but you never know.
 
morrisond
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Re: Updated: Final report of Lion Air JT610 has been released

Sat Oct 26, 2019 11:21 pm

AirlineCritic wrote:
I've been silent because I feel I need to read the report... and it takes time. Still reading.

So far, I haven't seen too many real surprises. Swiss cheese gains another victim. As someone said, sad, because that means there were so many opportunities for avoiding the accident. (Although perhaps conversely, there's been many other accidents that were avoided because not all holes lined up... mind boggles.)

The list of nine contributing factors seems fair. Please do not lift only your favourite items and celebrate that you were right; one needs to consider the whole.

Maybe the only main surprise for me has been pulling the repair facility's license and their role in the accident; I wasn't expecting that and thought that either repair procedures or the particular repair job was done badly. Turns out the part was bad and the job was done badly. More cheese holes.

I do agree that the FO's abilities seemed substandard, and while some of that was expected, this went further than I thought.

All that being said, a transport category aircraft should not have easily correctable failure modes that lead to serious situations, unless those situations are clearly identified and trained for (such as engine loss). Because if you do, you eventually will hit a combination of cheese holes where, for instance, mechanical factors lead to a situation that someone can handle but isn't quite at his or hers best game that day, and then the backup doesn't work. This seems to have happened twice now, which to me indicates that some of the cheese slices are quite a full of holes (e.g., AoA sensor reliability, design that relies on one input, co-pilot proficiency in emergencies). Question: how much do crews train in sim for "xmas warning light" situations? Seems like a generic triage capability would be essential for these situations. Which sometimes do occur.


Generic triage is a great idea - something happens that you don't understand - turn off all the automation or the system that is acting up and fly the plane - we need the big red button.
 
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Classa64
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sun Oct 27, 2019 12:14 am

Revelation wrote:
dtw2hyd wrote:
Finn350 wrote:
Part of the correct procedure is to record the test values. The engineer didn't record the values. The engineer showed photos purportedly showing the test, but they were determined to be from a different aircraft (see p. 36).


I agree with you AMT did a sloppy job of documenting the work. It doesn't prove that the engineer didn't check the values.

We have no proof that he did record the values, and that's what the procedure demands the engineer does!

The whole reason why the procedure says to record the values is to PROVE that (a) you did the test, and (b) the equipment returned sensible values.

Of course the act of recording the values should force you to ask yourself if the values make sense or not, unless you are asleep or incompetent.

If he had just followed the documented procedure the point would be moot, as it was for the other two tests you cite.


As I am still reading the report and only work in Automotive the fact he never recorded the values baffles me as a Technician. When I adjust forward collision Radars I have to adjust it vertically and horizontally to +/-0.1 degree in both directions but on my Tablet I can see it in real time. Going back and forth if alone to check values I think would lead someone to just say its good and checked but not write anything down other than Ya i checked it.

But if it had not crashed and the sensor was found to be out of spec he has nothing to prove that he did anything really.

Also I can't even fathom why the hell he would try and pass off pics that were not even of what he was working on. Writing everything down for me is habit and sometimes time consuming but when the crap hits the fan I always point and say, see I told you so its written right there.

I am seeing though there is a lot more to the puzzle sadly

C
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airtechy
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 1:35 am

The NTSB section of the report has a very good description of the certification history of the MAX and MCAS including the interaction between the FAA and Boeing, a very technical description of how all the hardware and software elements tie together, and how changes in MCAS authority were not adequately analysed. Also and excellent description of how one sensor failed and the other was mis-calibrated.

I do find it hard to understand how a trim system has the range to drive the stabilizer to a position that can cause forces in excess of the ability to be counteracted by yoke forces ... regardless of how the trim is driven.Hard to believe that the CG range would require that travel.

Unless I missed it (entirely possible), I also saw nothing that said that the force at trim extremes would require more force on the manual trim wheel than could be managed by the pilots. Also noted was that a AAA test fixture was available, but not at the location where the mechanic troubleshooting the failures was located. So he used an alternate procedure.

Jim
 
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 2:46 am

morrisond wrote:
AirlineCritic wrote:
I've been silent because I feel I need to read the report... and it takes time. Still reading.

So far, I haven't seen too many real surprises. Swiss cheese gains another victim. As someone said, sad, because that means there were so many opportunities for avoiding the accident. (Although perhaps conversely, there's been many other accidents that were avoided because not all holes lined up... mind boggles.)

The list of nine contributing factors seems fair. Please do not lift only your favourite items and celebrate that you were right; one needs to consider the whole.

Maybe the only main surprise for me has been pulling the repair facility's license and their role in the accident; I wasn't expecting that and thought that either repair procedures or the particular repair job was done badly. Turns out the part was bad and the job was done badly. More cheese holes.

I do agree that the FO's abilities seemed substandard, and while some of that was expected, this went further than I thought.

All that being said, a transport category aircraft should not have easily correctable failure modes that lead to serious situations, unless those situations are clearly identified and trained for (such as engine loss). Because if you do, you eventually will hit a combination of cheese holes where, for instance, mechanical factors lead to a situation that someone can handle but isn't quite at his or hers best game that day, and then the backup doesn't work. This seems to have happened twice now, which to me indicates that some of the cheese slices are quite a full of holes (e.g., AoA sensor reliability, design that relies on one input, co-pilot proficiency in emergencies). Question: how much do crews train in sim for "xmas warning light" situations? Seems like a generic triage capability would be essential for these situations. Which sometimes do occur.


Generic triage is a great idea - something happens that you don't understand - turn off all the automation or the system that is acting up and fly the plane - we need the big red button.

You’ve repeated this MANY times in the grounding thread. Such a button would be to disable what you’ve described as nannies, yes?

A non-FBW plane shouldn’t need nannies. But, when you depart significantly from the initial design, in pursuit of efficiency, suddenly the plane needs nannies to fly properly. So, these are the nannies you wish to disable? But then, the safety of the plane actually becomes questionable, doesn’t it? Of course, those pesky regulations aren’t really there for safety, are they? <sarcasm off>

In reality, the only plane out there that could possibly want a “big red button” is the MAX. Literally everything else out there, in its size range or larger, is a proper, modern FBW plane. They all have proper redundancies built-in, including their own automatic “big red buttons” where they automatically revert to more and more direct control laws, depending on the gravity of the situation.

The MAX is the only Frankenstein aircraft that could even have a reason to possess a big, red button.

Or, they could just design the MAX systems correctly, as they have in all of Boeing’s other currently manufactured designs (excluding the 787 battery, of course). Or, do they all need big red buttons too? :roll:
 
Chemist
Posts: 723
Joined: Tue Oct 20, 2015 4:46 am

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 3:35 am

I've done work in the Pharmaceutical industry. where documentation is critical and I assume is pretty similar to the airline industry. The FDA is the regulatory industry in the US for Pharmaceuticals, just like the FAA is for aircraft.
Regarding documentation, and looking/inspecting that documentation during audits, there is a saying "If it wasn't written down, it didn't happen". That's why recording of the information is so important. There is no proof that anything happened if it wasn't written down. And recording false info or backdating is a termination offense.
 
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Finn350
Posts: 1601
Joined: Tue Jul 09, 2013 4:57 am

Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sun Oct 27, 2019 4:03 am

zeke wrote:
Finn350 wrote:

Part of the correct procedure is to record the test values. The engineer didn't record the values. The engineer showed photos purportedly showing the test, but they were determined to be from a different aircraft (see p. 36).


The actual procedure from Lion Air is not listed in the report, so I don’t know what they are supposed to record. When I see mechanics perform tests on aircraft I only see them record the result of the task, ie “carried out test IAW AMM task xxxx-xxx-xxx”. Each individual step in the within task is not recorded.

What is known is a normal sensor in the zero angle of attack position does not output zero degrees, it is designed to output 45 degrees +/-5 degrees. The normal tolerances allowed are +/- 5 degrees. I would suggest when they tested the probe through the range of movement e were would have seen between +/-105 to 95 degrees and seen it as being normal.

The SYMD is looking to see the output waveform is smooth sinusoidal in nature. It would fail the probe when moved through the range of motion if the output waveform from the sensor was not smooth sinusoidal.

The report also states the random bias could remain undetected during return to service testing.

“ In February 2019, Collins Aerospace repeated the Peak API offset demonstration at its facility. The test was repeated for the benefit of NTSB and FAA personnel who did not witness the original demonstration at Xtra Aerospace. The procedures followed during the February 2019 demonstration were fundamentally the same as those performed at Xtra Aerospace in December 2018. The conclusions were identical. First, that an equal offset could inadvertently be introduced to both resolvers. Second, that the magnitude of the offset is essentially random. And third, that the offset could go undetected through the CMM return-to-service tests.


That is related to then return to service testing. On p. 87-89 "1.16.1 Installation Test AOA Sensor with Known Bias" you will find that on-aircraft testing will detect bias:

On 15 November 2018, with approval from KNKT and under direction and supervision of the NTSB, Boeing and the NTSB conducted an installation test of an AOA sensor on an exemplar Boeing 737-7 (MAX) located at the Boeing Field Flight Line. This test was intended to demonstrate if the AMM installation test, task 34-21-05-400-801, was robust enough to ensure that a bias in an AOA sensor could be identified/detected using the installation and alternate test procedure.


Conclusion:
1. With the serviceable (original) AOA sensor installed on the aircraft, the results of the alternative installation test indicated that the left AOA sensor met the AMM requirements.
2. With the biased AOA sensor, the test found that the vane angle values exceed the limits as follows:
a. When the vane was at its zero position, the SMYD displayed -31.9° (the misalignment angle) instead of 0° ± 5°
b. When the vane positioned at its maximum upper stop, the SMYD displayed +67.6° instead of +100° ± 5°.
c. When the vane positioned at its maximum lower stop, the SMYD displayed the text “AOA SENSR INVALID”.
3. The alternative method of the installation test in the AMM will successfully detect a mis-calibrated AOA sensor.


There are several photos of the AOA sensor and corresponding SMYD readouts on p. 88 to demonstrate the on-aircraft test.
 
morrisond
Posts: 2648
Joined: Thu Jan 07, 2010 12:22 am

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 4:15 am

aerolimani wrote:
morrisond wrote:
AirlineCritic wrote:
I've been silent because I feel I need to read the report... and it takes time. Still reading.

So far, I haven't seen too many real surprises. Swiss cheese gains another victim. As someone said, sad, because that means there were so many opportunities for avoiding the accident. (Although perhaps conversely, there's been many other accidents that were avoided because not all holes lined up... mind boggles.)

The list of nine contributing factors seems fair. Please do not lift only your favourite items and celebrate that you were right; one needs to consider the whole.

Maybe the only main surprise for me has been pulling the repair facility's license and their role in the accident; I wasn't expecting that and thought that either repair procedures or the particular repair job was done badly. Turns out the part was bad and the job was done badly. More cheese holes.

I do agree that the FO's abilities seemed substandard, and while some of that was expected, this went further than I thought.

All that being said, a transport category aircraft should not have easily correctable failure modes that lead to serious situations, unless those situations are clearly identified and trained for (such as engine loss). Because if you do, you eventually will hit a combination of cheese holes where, for instance, mechanical factors lead to a situation that someone can handle but isn't quite at his or hers best game that day, and then the backup doesn't work. This seems to have happened twice now, which to me indicates that some of the cheese slices are quite a full of holes (e.g., AoA sensor reliability, design that relies on one input, co-pilot proficiency in emergencies). Question: how much do crews train in sim for "xmas warning light" situations? Seems like a generic triage capability would be essential for these situations. Which sometimes do occur.


Generic triage is a great idea - something happens that you don't understand - turn off all the automation or the system that is acting up and fly the plane - we need the big red button.

You’ve repeated this MANY times in the grounding thread. Such a button would be to disable what you’ve described as nannies, yes?

A non-FBW plane shouldn’t need nannies. But, when you depart significantly from the initial design, in pursuit of efficiency, suddenly the plane needs nannies to fly properly. So, these are the nannies you wish to disable? But then, the safety of the plane actually becomes questionable, doesn’t it? Of course, those pesky regulations aren’t really there for safety, are they? <sarcasm off>

In reality, the only plane out there that could possibly want a “big red button” is the MAX. Literally everything else out there, in its size range or larger, is a proper, modern FBW plane. They all have proper redundancies built-in, including their own automatic “big red buttons” where they automatically revert to more and more direct control laws, depending on the gravity of the situation.

The MAX is the only Frankenstein aircraft that could even have a reason to possess a big, red button.

Or, they could just design the MAX systems correctly, as they have in all of Boeing’s other currently manufactured designs (excluding the 787 battery, of course). Or, do they all need big red buttons too? :roll:


I'm not familiar with it but I believe Airbus has a button you can push to put it into Direct Law. No idea if that turns off AT but I assume it would turn off AP.

That wouldn't be a bad idea on the MAX - really all it needs is a switch to turn off anything that can affect the electric trim just like the NG has - then you have a AP switch and an AT switch.

However one big red button would be simpler and wouldn't be a bad idea on all aircraft. It would probably be a lot simpler to understand under stress and you would now what you had vs trying to remember what systems were still working.

Hit the big red button - take manual control and then have maintenance remote diagnose the problem with you and run you through how to fix it.

Lufthansa 1829 is a great example of this.
 
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PixelFlight
Posts: 1018
Joined: Thu Nov 08, 2018 11:09 pm

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 4:36 am

aerolimani wrote:
morrisond wrote:
AirlineCritic wrote:
I've been silent because I feel I need to read the report... and it takes time. Still reading.

So far, I haven't seen too many real surprises. Swiss cheese gains another victim. As someone said, sad, because that means there were so many opportunities for avoiding the accident. (Although perhaps conversely, there's been many other accidents that were avoided because not all holes lined up... mind boggles.)

The list of nine contributing factors seems fair. Please do not lift only your favourite items and celebrate that you were right; one needs to consider the whole.

Maybe the only main surprise for me has been pulling the repair facility's license and their role in the accident; I wasn't expecting that and thought that either repair procedures or the particular repair job was done badly. Turns out the part was bad and the job was done badly. More cheese holes.

I do agree that the FO's abilities seemed substandard, and while some of that was expected, this went further than I thought.

All that being said, a transport category aircraft should not have easily correctable failure modes that lead to serious situations, unless those situations are clearly identified and trained for (such as engine loss). Because if you do, you eventually will hit a combination of cheese holes where, for instance, mechanical factors lead to a situation that someone can handle but isn't quite at his or hers best game that day, and then the backup doesn't work. This seems to have happened twice now, which to me indicates that some of the cheese slices are quite a full of holes (e.g., AoA sensor reliability, design that relies on one input, co-pilot proficiency in emergencies). Question: how much do crews train in sim for "xmas warning light" situations? Seems like a generic triage capability would be essential for these situations. Which sometimes do occur.


Generic triage is a great idea - something happens that you don't understand - turn off all the automation or the system that is acting up and fly the plane - we need the big red button.

You’ve repeated this MANY times in the grounding thread. Such a button would be to disable what you’ve described as nannies, yes?

A non-FBW plane shouldn’t need nannies. But, when you depart significantly from the initial design, in pursuit of efficiency, suddenly the plane needs nannies to fly properly. So, these are the nannies you wish to disable? But then, the safety of the plane actually becomes questionable, doesn’t it? Of course, those pesky regulations aren’t really there for safety, are they? <sarcasm off>

In reality, the only plane out there that could possibly want a “big red button” is the MAX. Literally everything else out there, in its size range or larger, is a proper, modern FBW plane. They all have proper redundancies built-in, including their own automatic “big red buttons” where they automatically revert to more and more direct control laws, depending on the gravity of the situation.

The MAX is the only Frankenstein aircraft that could even have a reason to possess a big, red button.

Or, they could just design the MAX systems correctly, as they have in all of Boeing’s other currently manufactured designs (excluding the 787 battery, of course). Or, do they all need big red buttons too? :roll:
:checkmark: :thumbsup:
An additional note: The MCAS is a function within the STS and the STS exists also in the 737-x00 NG, so technically the 737 NG + 737 MAX have automation when the autopilot is not engaged. Boeing started the 737 in that Frankenstein FBW route in manual flight mode since the NG. :stirthepot:

JT610 report 1.6.5.4 MCAS Functional – Detailed Description:
"Similar
to the Speed Trim Function, the MCAS function is also a flight control law
contained within each of the two FCCs."
"Specific to the MCAS, the control law commands the stabilizer trim as a function of
the following: Air/Ground, Flap position, Angle of attack, Pitch rate, True Airspeed
and Mach"
"In the FCC software
version current at the time of the accident, if the original elevated AOA condition
persists for more than 5 seconds following an MCAS flight control law reset, the
MCAS flight control law will command another stabilizer nose down trim input
(with the magnitude based on the AOA and Mach sensed at that time)"

JT610 report 2.5.1.3 Decision to Rely on Single Sensor:
"The Speed Trim System (STS), including
the MCAS function, is a flight control law contained within each of the two FCCs."

NTSB report D.1 Speed Trim Function:
"The Speed Trim function, which is implemented as a control law within the flight
control computer (FCC 28 ), commands incremental stabilizer trim through the
automatic trim control system circuitry."

NTSB report D.2 MCAS Functional – Detailed Description:
"Similar
to the Speed Trim Function, the MCAS function is also a flight control law
contained within each of the two FCCs."
There is a footnote:
"MCAS is an open loop flight control law."

NTSB report E.1.1 Requirements Generation and Traceability:
"The MCAS function is a control law (software) contained within the Flight Control
Computer (FCC), which was developed by Rockwell Collins Inc to meet the design
specifications contained within a Specification Control Drawing (SCD) provided to
them by Boeing."

Now, a flight control law have absolutely no way to be anything but a design under the safety catastrophic (level A software) requirement on all FBW design aircrafts, yet Boeing managed to escape that and wrongly classified his Frankenstein FBW design as safety major (level C software) requirement. The JT610 and NTSB reports goes very deep into how the Functional Hazard Assessment (FHA) was wrong, and consequently wrongly expect the pilots as a mitigation of the 737 Frankenstein FBW design, without even informing the pilots about that !

A "big red button" is not the proper solution for a wrong Functional Hazard Assessment.
:stirthepot: 737-8 MAX: "For all speeds higher than 220 Kts and trim set at a value of 2.5 units, the difficulity level of turning the manual trim wheel was level A (trim wheel not movable)." :stirthepot:
 
AABusDrvr
Posts: 139
Joined: Sat Dec 03, 2016 6:48 am

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 4:58 am

morrisond wrote:
aerolimani wrote:
morrisond wrote:

Generic triage is a great idea - something happens that you don't understand - turn off all the automation or the system that is acting up and fly the plane - we need the big red button.

You’ve repeated this MANY times in the grounding thread. Such a button would be to disable what you’ve described as nannies, yes?

A non-FBW plane shouldn’t need nannies. But, when you depart significantly from the initial design, in pursuit of efficiency, suddenly the plane needs nannies to fly properly. So, these are the nannies you wish to disable? But then, the safety of the plane actually becomes questionable, doesn’t it? Of course, those pesky regulations aren’t really there for safety, are they? <sarcasm off>

In reality, the only plane out there that could possibly want a “big red button” is the MAX. Literally everything else out there, in its size range or larger, is a proper, modern FBW plane. They all have proper redundancies built-in, including their own automatic “big red buttons” where they automatically revert to more and more direct control laws, depending on the gravity of the situation.

The MAX is the only Frankenstein aircraft that could even have a reason to possess a big, red button.

Or, they could just design the MAX systems correctly, as they have in all of Boeing’s other currently manufactured designs (excluding the 787 battery, of course). Or, do they all need big red buttons too? :roll:


I'm not familiar with it but I believe Airbus has a button you can push to put it into Direct Law. No idea if that turns off AT but I assume it would turn off AP.

That wouldn't be a bad idea on the MAX - really all it needs is a switch to turn off anything that can affect the electric trim just like the NG has - then you have a AP switch and an AT switch.

However one big red button would be simpler and wouldn't be a bad idea on all aircraft. It would probably be a lot simpler to understand under stress and you would now what you had vs trying to remember what systems were still working.

Hit the big red button - take manual control and then have maintenance remote diagnose the problem with you and run you through how to fix it.

Lufthansa 1829 is a great example of this.



There isn't a "button" to put an airbus into direct law. And there is a switch (actually two) to turn off anything that can affect the electric trim on a MAX, just like the NG.
 
User avatar
zeke
Posts: 14890
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sun Oct 27, 2019 5:19 am

Finn350 wrote:
There are several photos of the AOA sensor and corresponding SMYD readouts on p. 88 to demonstrate the on-aircraft test.


I didnt find any of that section conclusive as it was not representative of the conditions found on the aircraft.

The bias the introduced with that sensor was 57% larger than on the accident aircraft, it does not show the raw SYMD values (as zero angle of attack should show +45 degrees from the sensor, not zero degrees), and third, we don’t know the content of the task card the airline used.

You keep making blanket statements regarding what the airline didn’t do, when it is clear that the tests done at the repair facility and at the sensor manufacturer have established that a sensor can slip through the calibration and testing process without a bias being detected.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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zeke
Posts: 14890
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 5:21 am

AABusDrvr wrote:

There isn't a "button" to put an airbus into direct law. And there is a switch (actually two) to turn off anything that can affect the electric trim on a MAX, just like the NG.


No button, two rotary switches on any FBW Airbus.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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aerolimani
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 5:31 am

morrisond wrote:
aerolimani wrote:
morrisond wrote:

Generic triage is a great idea - something happens that you don't understand - turn off all the automation or the system that is acting up and fly the plane - we need the big red button.

You’ve repeated this MANY times in the grounding thread. Such a button would be to disable what you’ve described as nannies, yes?

A non-FBW plane shouldn’t need nannies. But, when you depart significantly from the initial design, in pursuit of efficiency, suddenly the plane needs nannies to fly properly. So, these are the nannies you wish to disable? But then, the safety of the plane actually becomes questionable, doesn’t it? Of course, those pesky regulations aren’t really there for safety, are they? <sarcasm off>

In reality, the only plane out there that could possibly want a “big red button” is the MAX. Literally everything else out there, in its size range or larger, is a proper, modern FBW plane. They all have proper redundancies built-in, including their own automatic “big red buttons” where they automatically revert to more and more direct control laws, depending on the gravity of the situation.

The MAX is the only Frankenstein aircraft that could even have a reason to possess a big, red button.

Or, they could just design the MAX systems correctly, as they have in all of Boeing’s other currently manufactured designs (excluding the 787 battery, of course). Or, do they all need big red buttons too? :roll:


I'm not familiar with it but I believe Airbus has a button you can push to put it into Direct Law. No idea if that turns off AT but I assume it would turn off AP.

That wouldn't be a bad idea on the MAX - really all it needs is a switch to turn off anything that can affect the electric trim just like the NG has - then you have a AP switch and an AT switch.

However one big red button would be simpler and wouldn't be a bad idea on all aircraft. It would probably be a lot simpler to understand under stress and you would now what you had vs trying to remember what systems were still working.

Hit the big red button - take manual control and then have maintenance remote diagnose the problem with you and run you through how to fix it.

Lufthansa 1829 is a great example of this.

Actually, no. I’m pretty damned sure you can’t just put an A320 into direct law by pressing a button. If you want to choose to go all the way into direct law, you have to actively disable functional parts of the system to force the plane into direct law. Considering there is no direct human to machine control of the plane, there must always be a computer between you and the controls. Things have to go very, very wrong before you’re in that situation, and the plane already knows you’re in that situation, and takes care of moving you into alternate law, or if things get really bad, direct law.

Anyhow… comparing an FBW aircraft to the MAX is so apples and oranges, it’s really a waste of time. Only the MAX could possibly benefit from a “big red button” because only the MAX is a Frankenstein which needs to marry automation with non-FBW.

Anyhow… that’s enough ridiculous off-topic pollution of this thread. If somebody reported and erased this entire conversation, I would not be upset. I would leave AirlineCritic’s reasonable post, but your cherry-picked “red button” response, and everything after it, is a waste of words on here.
 
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Finn350
Posts: 1601
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Re: Indonesia report on 737 MAX crash faults Boeing design, says Lion Air made mistakes

Sun Oct 27, 2019 6:47 am

zeke wrote:
Finn350 wrote:
There are several photos of the AOA sensor and corresponding SMYD readouts on p. 88 to demonstrate the on-aircraft test.


I didnt find any of that section conclusive as it was not representative of the conditions found on the aircraft.

The bias the introduced with that sensor was 57% larger than on the accident aircraft, it does not show the raw SYMD values (as zero angle of attack should show +45 degrees from the sensor, not zero degrees), and third, we don’t know the content of the task card the airline used.

You keep making blanket statements regarding what the airline didn’t do, when it is clear that the tests done at the repair facility and at the sensor manufacturer have established that a sensor can slip through the calibration and testing process without a bias being detected.


The installed left AOA sensor had a 21° bias which was undetected during the installation test in Denpasar. The on-aircraft test prodedure allows ± 5° bias. If the test was done correctly at Denpasar, it would have shown the miscalibration. The fact that "as zero angle of attack should show +45 degrees from the sensor, not zero degrees" is not relevant to the discussion.

If Lion Air AMM Task 34-21-05-400-801 somehow deviated from the Boeing recommendation, it surely would have been mentioned in the final report.
 
VV
Posts: 1702
Joined: Sat Feb 13, 2016 1:03 pm

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 7:09 am

mig17 wrote:
I read a lot of discussion about the AoA sensor, but I feel it misses the target. A malfunctionning sensor is not supposed to bring down an aircraft. Or we would have more more much accidents.
Like in the Air France 447 case, a faulty sensor began a chain of event that is not supposed to happen. In AF case, the FO stall the plane in the ocean, in the max case, the MCAS did ... twice now.


I fully agree with you. I have always been told that the pilots are the last line of defense when a system fails.
In this case it is still not certain whether the pilot even saw the trim wheel turning. If they did the case of trim runway would have been identified and the procedure applied.

I am not saying the MCAS had not any role in the two accidents.

Obviously the initial MCAS was not foolproof enough, but it does not mean the pilots should not do the right thing to prevent the accident to happen.
 
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AirlineCritic
Posts: 1752
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 9:04 am

I asked for training for pilots to handle "xmas warning lights" situations as a way for them manage their ability to effectively find out what the actual or most critical problems are. Seems like today's aircraft have been built with so many warning systems that you are likely going to get many if something happens.

Morrisond's suggestion was the big red button approach, to get the aircraft back to as manual mode as possible. Some others argued against it on the basis of the nature of the particular functions in the MAX.

I don't think the big red button approach is necessarily the right approach either, but for different reasons. There seems to be an underlying assumption that when something bad happens, it is an automation and computer system problem, or them getting bad input. And the correct result is to take manual control. Man up and fly the plane like real pilots! :-)

Of course that is not always like that, even if we have a string of accidents where confusion about what the plane is doing and why has been a central theme, with either the pilot (Air France) or plane (Lion Air, Ethiopian) flying the aircraft in the wrong direction. But there are also situations where there are a ton of alarms going on and the issue isn't that the automation is doing something funny (US Airways, Qantas).

So I think the right tool for the all-hell-breaks-loose situation is CRM and observation, not immediate hitting of some button. But I do agree that if after analysis, the problem seems to be that one can't make the plane go where the pilots want it to go, being able to turn off all automation would be useful.
 
VV
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 9:43 am

I understood the following.

1. the maintenance has not been done properly
2. the not-so-foolproof MCAS was triggered when in a situation where there was no need to pitch down the aircraft using the trim.
3. Pilots didn't see the trim wheel turned and thus didn't understand that they should have applied the trim runaway procedure.

It seems there has been a confusion in the cockpit during several minutes prior to the final plunge.
 
morrisond
Posts: 2648
Joined: Thu Jan 07, 2010 12:22 am

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 11:55 am

aerolimani wrote:
morrisond wrote:
aerolimani wrote:
You’ve repeated this MANY times in the grounding thread. Such a button would be to disable what you’ve described as nannies, yes?

A non-FBW plane shouldn’t need nannies. But, when you depart significantly from the initial design, in pursuit of efficiency, suddenly the plane needs nannies to fly properly. So, these are the nannies you wish to disable? But then, the safety of the plane actually becomes questionable, doesn’t it? Of course, those pesky regulations aren’t really there for safety, are they? <sarcasm off>

In reality, the only plane out there that could possibly want a “big red button” is the MAX. Literally everything else out there, in its size range or larger, is a proper, modern FBW plane. They all have proper redundancies built-in, including their own automatic “big red buttons” where they automatically revert to more and more direct control laws, depending on the gravity of the situation.

The MAX is the only Frankenstein aircraft that could even have a reason to possess a big, red button.

Or, they could just design the MAX systems correctly, as they have in all of Boeing’s other currently manufactured designs (excluding the 787 battery, of course). Or, do they all need big red buttons too? :roll:


I'm not familiar with it but I believe Airbus has a button you can push to put it into Direct Law. No idea if that turns off AT but I assume it would turn off AP.

That wouldn't be a bad idea on the MAX - really all it needs is a switch to turn off anything that can affect the electric trim just like the NG has - then you have a AP switch and an AT switch.

However one big red button would be simpler and wouldn't be a bad idea on all aircraft. It would probably be a lot simpler to understand under stress and you would now what you had vs trying to remember what systems were still working.

Hit the big red button - take manual control and then have maintenance remote diagnose the problem with you and run you through how to fix it.

Lufthansa 1829 is a great example of this.

Actually, no. I’m pretty damned sure you can’t just put an A320 into direct law by pressing a button. If you want to choose to go all the way into direct law, you have to actively disable functional parts of the system to force the plane into direct law. Considering there is no direct human to machine control of the plane, there must always be a computer between you and the controls. Things have to go very, very wrong before you’re in that situation, and the plane already knows you’re in that situation, and takes care of moving you into alternate law, or if things get really bad, direct law.

Anyhow… comparing an FBW aircraft to the MAX is so apples and oranges, it’s really a waste of time. Only the MAX could possibly benefit from a “big red button” because only the MAX is a Frankenstein which needs to marry automation with non-FBW.

Anyhow… that’s enough ridiculous off-topic pollution of this thread. If somebody reported and erased this entire conversation, I would not be upset. I would leave AirlineCritic’s reasonable post, but your cherry-picked “red button” response, and everything after it, is a waste of words on here.



It's not off topic at all - we are discussing the how things could have/should have been done better after seeing the Final Report from Lion Air.

See above - sorry on Airbus's its a Rotary switch. I'm quite aware that the Computer is still involved in Direct Law. Even in an Airbus ( or Boeing FBW) things can go wrong like on Lufthansa 1829 - where if they had gone straight to Direct Law they would have solved their control issues sooner. They did do a great job though of saving the plane - however it was almost a case of another co-pilot putting it into the ground.

Machines are not perfect. In addition to design issues parts do break (or two sensors can freeze).

The topic was general triage. What to do when things go wrong.

In triage the first thing is to Stabilize the patient. Then figure out what to do. It's a great suggestion by AirlineCritic.

I'm trying to suggest Cockpit procedures that would make it simpler for crews in highly stressed situations to save the plane by calming things down and have time to sort through things.

When you think back through almost all the fatals due to aircraft control issues - as planes have grown so Complex - what do you think is a better first reaction?

Option A - something goes weird and you try to instantly diagnose what has gone wrong with one of the Sensors/Control Systems/Computers and recall which of the 10 memory procedures (I'm exaggerating but maybe not) is the right one or what page of the QRH to go to (Even the A320's is 238 pages) while making sure the plane doesn't crash.

or

Option B - Something happens you don't understand - turn off anything that can affect the flight path/ speed of the aircraft without your direct control and put the plane in straight and level flight (How to fly an plane straight and level is Lesson #1 when you are taking your Pilots license) within the normal operating speed range - Boeing and Airbuses 4 Degree nose up 75% thrust Airspeed Unreliable Procedure (it might be slightly different between the two) - facilitated by one button to make things simpler.

If Lion Air had option B - the big red button do you not think that the Co-pilot could at least remember that simple procedure if it was drilled and made mantra? Even the Pilot in his incapacitated state should have been able to remember that.

Sorry for trying to offer a suggestion that might make things safer so we don't repeat these tragedies and help account for design failures/parts failures and failure to train crews properly failures.

This probably would have produced different results on AF447 as well and definitely on ET302.
 
mjoelnir
Posts: 9391
Joined: Sun Feb 03, 2013 11:06 pm

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 12:53 pm

morrisond wrote:
aerolimani wrote:
morrisond wrote:

I'm not familiar with it but I believe Airbus has a button you can push to put it into Direct Law. No idea if that turns off AT but I assume it would turn off AP.

That wouldn't be a bad idea on the MAX - really all it needs is a switch to turn off anything that can affect the electric trim just like the NG has - then you have a AP switch and an AT switch.

However one big red button would be simpler and wouldn't be a bad idea on all aircraft. It would probably be a lot simpler to understand under stress and you would now what you had vs trying to remember what systems were still working.

Hit the big red button - take manual control and then have maintenance remote diagnose the problem with you and run you through how to fix it.

Lufthansa 1829 is a great example of this.

Actually, no. I’m pretty damned sure you can’t just put an A320 into direct law by pressing a button. If you want to choose to go all the way into direct law, you have to actively disable functional parts of the system to force the plane into direct law. Considering there is no direct human to machine control of the plane, there must always be a computer between you and the controls. Things have to go very, very wrong before you’re in that situation, and the plane already knows you’re in that situation, and takes care of moving you into alternate law, or if things get really bad, direct law.

Anyhow… comparing an FBW aircraft to the MAX is so apples and oranges, it’s really a waste of time. Only the MAX could possibly benefit from a “big red button” because only the MAX is a Frankenstein which needs to marry automation with non-FBW.

Anyhow… that’s enough ridiculous off-topic pollution of this thread. If somebody reported and erased this entire conversation, I would not be upset. I would leave AirlineCritic’s reasonable post, but your cherry-picked “red button” response, and everything after it, is a waste of words on here.



It's not off topic at all - we are discussing the how things could have/should have been done better after seeing the Final Report from Lion Air.

See above - sorry on Airbus's its a Rotary switch. I'm quite aware that the Computer is still involved in Direct Law. Even in an Airbus ( or Boeing FBW) things can go wrong like on Lufthansa 1829 - where if they had gone straight to Direct Law they would have solved their control issues sooner. They did do a great job though of saving the plane - however it was almost a case of another co-pilot putting it into the ground.

Machines are not perfect. In addition to design issues parts do break (or two sensors can freeze).

The topic was general triage. What to do when things go wrong.

In triage the first thing is to Stabilize the patient. Then figure out what to do. It's a great suggestion by AirlineCritic.

I'm trying to suggest Cockpit procedures that would make it simpler for crews in highly stressed situations to save the plane by calming things down and have time to sort through things.

When you think back through almost all the fatals due to aircraft control issues - as planes have grown so Complex - what do you think is a better first reaction?

Option A - something goes weird and you try to instantly diagnose what has gone wrong with one of the Sensors/Control Systems/Computers and recall which of the 10 memory procedures (I'm exaggerating but maybe not) is the right one or what page of the QRH to go to (Even the A320's is 238 pages) while making sure the plane doesn't crash.

or

Option B - Something happens you don't understand - turn off anything that can affect the flight path/ speed of the aircraft without your direct control and put the plane in straight and level flight (How to fly an plane straight and level is Lesson #1 when you are taking your Pilots license) within the normal operating speed range - Boeing and Airbuses 4 Degree nose up 75% thrust Airspeed Unreliable Procedure (it might be slightly different between the two) - facilitated by one button to make things simpler.

If Lion Air had option B - the big red button do you not think that the Co-pilot could at least remember that simple procedure if it was drilled and made mantra? Even the Pilot in his incapacitated state should have been able to remember that.

Sorry for trying to offer a suggestion that might make things safer so we don't repeat these tragedies and help account for design failures/parts failures and failure to train crews properly failures.

This probably would have produced different results on AF447 as well and definitely on ET302.


Nice rant and than we get to the Boeing 737MAX.

It´s pilot machine interface is that old, it needs exceptions from current FARs to get certified. No accommodation for Boeing developments in this area since the 757/767 something called EICAS. A more modern interface used on all Boeing frames, but the commercial 737, since. Even the P-8, a military 737, got EICAS.

The designers at Boeing designing MCAS, gave the pilots exactly 3 seconds to diagnose the problem of MCAS failure and react with the right action. They actually discussed the danger of multible activation of MCAS and the problem of overload through multible error alarms and they decided to leave it as they designed it.
Boeing designers accepted the possibility, that if you did not react very fast, averting the catastrophic events would be difficult.

Furthermore Boeing designed MCAS so that all usual ways for a pilot to stop it from working were excluded. No turn off button, but disabling all electrical trim. No turning off by pulling heavily on the column, like in the KC-46.

But Boeing´s care for pilots and their passengers did not end there. Boeing made sure that no pilot would know about MCAS, that nobody could train for MCAS if by chance they got wind of it, going so far as to exclude MCAS and its failure modes from the commercial available 737MAX simulators.
 
morrisond
Posts: 2648
Joined: Thu Jan 07, 2010 12:22 am

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 1:27 pm

mjoelnir wrote:
morrisond wrote:
aerolimani wrote:
Actually, no. I’m pretty damned sure you can’t just put an A320 into direct law by pressing a button. If you want to choose to go all the way into direct law, you have to actively disable functional parts of the system to force the plane into direct law. Considering there is no direct human to machine control of the plane, there must always be a computer between you and the controls. Things have to go very, very wrong before you’re in that situation, and the plane already knows you’re in that situation, and takes care of moving you into alternate law, or if things get really bad, direct law.

Anyhow… comparing an FBW aircraft to the MAX is so apples and oranges, it’s really a waste of time. Only the MAX could possibly benefit from a “big red button” because only the MAX is a Frankenstein which needs to marry automation with non-FBW.

Anyhow… that’s enough ridiculous off-topic pollution of this thread. If somebody reported and erased this entire conversation, I would not be upset. I would leave AirlineCritic’s reasonable post, but your cherry-picked “red button” response, and everything after it, is a waste of words on here.



It's not off topic at all - we are discussing the how things could have/should have been done better after seeing the Final Report from Lion Air.

See above - sorry on Airbus's its a Rotary switch. I'm quite aware that the Computer is still involved in Direct Law. Even in an Airbus ( or Boeing FBW) things can go wrong like on Lufthansa 1829 - where if they had gone straight to Direct Law they would have solved their control issues sooner. They did do a great job though of saving the plane - however it was almost a case of another co-pilot putting it into the ground.

Machines are not perfect. In addition to design issues parts do break (or two sensors can freeze).

The topic was general triage. What to do when things go wrong.

In triage the first thing is to Stabilize the patient. Then figure out what to do. It's a great suggestion by AirlineCritic.

I'm trying to suggest Cockpit procedures that would make it simpler for crews in highly stressed situations to save the plane by calming things down and have time to sort through things.

When you think back through almost all the fatals due to aircraft control issues - as planes have grown so Complex - what do you think is a better first reaction?

Option A - something goes weird and you try to instantly diagnose what has gone wrong with one of the Sensors/Control Systems/Computers and recall which of the 10 memory procedures (I'm exaggerating but maybe not) is the right one or what page of the QRH to go to (Even the A320's is 238 pages) while making sure the plane doesn't crash.

or

Option B - Something happens you don't understand - turn off anything that can affect the flight path/ speed of the aircraft without your direct control and put the plane in straight and level flight (How to fly an plane straight and level is Lesson #1 when you are taking your Pilots license) within the normal operating speed range - Boeing and Airbuses 4 Degree nose up 75% thrust Airspeed Unreliable Procedure (it might be slightly different between the two) - facilitated by one button to make things simpler.

If Lion Air had option B - the big red button do you not think that the Co-pilot could at least remember that simple procedure if it was drilled and made mantra? Even the Pilot in his incapacitated state should have been able to remember that.

Sorry for trying to offer a suggestion that might make things safer so we don't repeat these tragedies and help account for design failures/parts failures and failure to train crews properly failures.

This probably would have produced different results on AF447 as well and definitely on ET302.


Nice rant and than we get to the Boeing 737MAX.

It´s pilot machine interface is that old, it needs exceptions from current FARs to get certified. No accommodation for Boeing developments in this area since the 757/767 something called EICAS. A more modern interface used on all Boeing frames, but the commercial 737, since. Even the P-8, a military 737, got EICAS.

The designers at Boeing designing MCAS, gave the pilots exactly 3 seconds to diagnose the problem of MCAS failure and react with the right action. They actually discussed the danger of multible activation of MCAS and the problem of overload through multible error alarms and they decided to leave it as they designed it.
Boeing designers accepted the possibility, that if you did not react very fast, averting the catastrophic events would be difficult.

Furthermore Boeing designed MCAS so that all usual ways for a pilot to stop it from working were excluded. No turn off button, but disabling all electrical trim. No turning off by pulling heavily on the column, like in the KC-46.

But Boeing´s care for pilots and their passengers did not end there. Boeing made sure that no pilot would know about MCAS, that nobody could train for MCAS if by chance they got wind of it, going so far as to exclude MCAS and its failure modes from the commercial available 737MAX simulators.


Yes we know Boeing is evil I don't think anyone on here is refuting that - and you call mine a rant?

So what is your solution for making sure Lion Air 610's, Lufthansa 1829's, AF447 and Et302's don't happen again?

More bells and whistles going off in the cockpit and more automation, including more memory items and an expanded 300 page QRH?

Please provide a solution vs just ranting. At least I'm trying - mine applies to all aircraft types and if made a core in training could have prevented most of the air disasters of the past 20 years.
 
mjoelnir
Posts: 9391
Joined: Sun Feb 03, 2013 11:06 pm

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 1:50 pm

morrisond wrote:
mjoelnir wrote:
morrisond wrote:


It's not off topic at all - we are discussing the how things could have/should have been done better after seeing the Final Report from Lion Air.

See above - sorry on Airbus's its a Rotary switch. I'm quite aware that the Computer is still involved in Direct Law. Even in an Airbus ( or Boeing FBW) things can go wrong like on Lufthansa 1829 - where if they had gone straight to Direct Law they would have solved their control issues sooner. They did do a great job though of saving the plane - however it was almost a case of another co-pilot putting it into the ground.

Machines are not perfect. In addition to design issues parts do break (or two sensors can freeze).

The topic was general triage. What to do when things go wrong.

In triage the first thing is to Stabilize the patient. Then figure out what to do. It's a great suggestion by AirlineCritic.

I'm trying to suggest Cockpit procedures that would make it simpler for crews in highly stressed situations to save the plane by calming things down and have time to sort through things.

When you think back through almost all the fatals due to aircraft control issues - as planes have grown so Complex - what do you think is a better first reaction?

Option A - something goes weird and you try to instantly diagnose what has gone wrong with one of the Sensors/Control Systems/Computers and recall which of the 10 memory procedures (I'm exaggerating but maybe not) is the right one or what page of the QRH to go to (Even the A320's is 238 pages) while making sure the plane doesn't crash.

or

Option B - Something happens you don't understand - turn off anything that can affect the flight path/ speed of the aircraft without your direct control and put the plane in straight and level flight (How to fly an plane straight and level is Lesson #1 when you are taking your Pilots license) within the normal operating speed range - Boeing and Airbuses 4 Degree nose up 75% thrust Airspeed Unreliable Procedure (it might be slightly different between the two) - facilitated by one button to make things simpler.

If Lion Air had option B - the big red button do you not think that the Co-pilot could at least remember that simple procedure if it was drilled and made mantra? Even the Pilot in his incapacitated state should have been able to remember that.

Sorry for trying to offer a suggestion that might make things safer so we don't repeat these tragedies and help account for design failures/parts failures and failure to train crews properly failures.

This probably would have produced different results on AF447 as well and definitely on ET302.


Nice rant and than we get to the Boeing 737MAX.

It´s pilot machine interface is that old, it needs exceptions from current FARs to get certified. No accommodation for Boeing developments in this area since the 757/767 something called EICAS. A more modern interface used on all Boeing frames, but the commercial 737, since. Even the P-8, a military 737, got EICAS.

The designers at Boeing designing MCAS, gave the pilots exactly 3 seconds to diagnose the problem of MCAS failure and react with the right action. They actually discussed the danger of multible activation of MCAS and the problem of overload through multible error alarms and they decided to leave it as they designed it.
Boeing designers accepted the possibility, that if you did not react very fast, averting the catastrophic events would be difficult.

Furthermore Boeing designed MCAS so that all usual ways for a pilot to stop it from working were excluded. No turn off button, but disabling all electrical trim. No turning off by pulling heavily on the column, like in the KC-46.

But Boeing´s care for pilots and their passengers did not end there. Boeing made sure that no pilot would know about MCAS, that nobody could train for MCAS if by chance they got wind of it, going so far as to exclude MCAS and its failure modes from the commercial available 737MAX simulators.


Yes we know Boeing is evil I don't think anyone on here is refuting that - and you call mine a rant?

So what is your solution for making sure Lion Air 610's, Lufthansa 1829's, AF447 and Et302's don't happen again?

More bells and whistles going off in the cockpit and more automation, including more memory items and a 300 page QRH?

Please provide a solution vs just ranting. At least I'm trying - mine applies to all aircraft types and if made a core training could have prevented most of the air disasters of the past 20 years.


If you point to one comment I made about Boeing and the 737MAX that is not a fact, you can call my post a rant.

How dare you compare the other accidents with the terrible death trap Boeing produced knowingly with the 737MAX? Can you point to me where another air framer discussed possible catastrophic failures of an automation and decides to hide the automation?
This disaster is so far out of everything I once believed the airline industry to be about. Once upon a time Boeing was a beacon for safety conscious design of airplanes, but that was perhaps always a misconception.
 
dtw2hyd
Posts: 8233
Joined: Wed Jan 09, 2013 12:11 pm

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 1:54 pm

morrisond wrote:
Please provide a solution vs just ranting. At least I'm trying - mine applies to all aircraft types and if made a core training could have prevented most of the air disasters of the past 20 years.


The drawing board is the first line of defense and pilots are the last line of defense.

If I have to summarize your take on this topic.
I will pack the parachute and hid the real pull cord in an inconspicuous location and leave a dummy pull cord readily available, and the parachutist has to figure out while falling. If the parachutist fails to find the real pull cord in the few seconds, he/she is no good.
All posts are just opinions.
 
morrisond
Posts: 2648
Joined: Thu Jan 07, 2010 12:22 am

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 2:46 pm

dtw2hyd wrote:
morrisond wrote:
Please provide a solution vs just ranting. At least I'm trying - mine applies to all aircraft types and if made a core training could have prevented most of the air disasters of the past 20 years.


The drawing board is the first line of defense and pilots are the last line of defense.

If I have to summarize your take on this topic.
I will pack the parachute and hid the real pull cord in an inconspicuous location and leave a dummy pull cord readily available, and the parachutist has to figure out while falling. If the parachutist fails to find the real pull cord in the few seconds, he/she is no good.


Agreed - good aircraft design is the first line of defence. In this case it was a design failure.

In other cases it's parts that can fail or freeze up.

To use your parachute analogy - Modern Parahuting gives the parachutist the option of using many different types of chutes(ram air, rogallo, annular, etc..) - assuming you could carry them all with you would have the choice of pulling multiple cords depending on the atmospheric conditions and where you wanted to land that might be different than what you assumed before you jumped out of the plane.

When you get out of the plane - you are confused as you become disoriented in a tumble - pick the wrong one and you die as it won't deploy properly - pull the big red one on your chest and out pops the good old Round WW2 round one that will get you to the ground and you will walk away from it - it just may not be as elegant an landing.
 
morrisond
Posts: 2648
Joined: Thu Jan 07, 2010 12:22 am

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 2:49 pm

mjoelnir wrote:
morrisond wrote:
mjoelnir wrote:

Nice rant and than we get to the Boeing 737MAX.

It´s pilot machine interface is that old, it needs exceptions from current FARs to get certified. No accommodation for Boeing developments in this area since the 757/767 something called EICAS. A more modern interface used on all Boeing frames, but the commercial 737, since. Even the P-8, a military 737, got EICAS.

The designers at Boeing designing MCAS, gave the pilots exactly 3 seconds to diagnose the problem of MCAS failure and react with the right action. They actually discussed the danger of multible activation of MCAS and the problem of overload through multible error alarms and they decided to leave it as they designed it.
Boeing designers accepted the possibility, that if you did not react very fast, averting the catastrophic events would be difficult.

Furthermore Boeing designed MCAS so that all usual ways for a pilot to stop it from working were excluded. No turn off button, but disabling all electrical trim. No turning off by pulling heavily on the column, like in the KC-46.

But Boeing´s care for pilots and their passengers did not end there. Boeing made sure that no pilot would know about MCAS, that nobody could train for MCAS if by chance they got wind of it, going so far as to exclude MCAS and its failure modes from the commercial available 737MAX simulators.


Yes we know Boeing is evil I don't think anyone on here is refuting that - and you call mine a rant?

So what is your solution for making sure Lion Air 610's, Lufthansa 1829's, AF447 and Et302's don't happen again?

More bells and whistles going off in the cockpit and more automation, including more memory items and a 300 page QRH?

Please provide a solution vs just ranting. At least I'm trying - mine applies to all aircraft types and if made a core training could have prevented most of the air disasters of the past 20 years.


If you point to one comment I made about Boeing and the 737MAX that is not a fact, you can call my post a rant.

How dare you compare the other accidents with the terrible death trap Boeing produced knowingly with the 737MAX? Can you point to me where another air framer discussed possible catastrophic failures of an automation and decides to hide the automation?
This disaster is so far out of everything I once believed the airline industry to be about. Once upon a time Boeing was a beacon for safety conscious design of airplanes, but that was perhaps always a misconception.


Please point to the evidence where Boeing knowingly knew the design would kill people. They made some very bad assumptions about the current state of pilot proficiency and how they would react to MCAS failure.

You might be right - and there might be a smoking gun someone hasn't found yet - but so far all that has been shown is that they were stupid.
 
dtw2hyd
Posts: 8233
Joined: Wed Jan 09, 2013 12:11 pm

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 3:04 pm

morrisond wrote:
Agreed - good aircraft design is the first line of defence. In this case it was a design failure.

In other cases it's parts that can fail or freeze up.

To use your parachute analogy - Modern Parahuting gives the parachutist the option of using many different types of chutes(ram air, rogallo, annular, etc..) - assuming you could carry them all with you would have the choice of pulling multiple cords depending on the atmospheric conditions and where you wanted to land that might be different than what you assumed before you jumped out of the plane.

When you get out of the plane - you are confused as you become disoriented in a tumble - pick the wrong one and you die as it won't deploy properly - pull the big red one on your chest and out pops the good old Round WW2 round one that will get you to the ground and you will walk away from it - it just may not be as elegant an landing.


The presumption is MAX should behave like NG, but it didn't.

From Mr.Forkner to JT/ET crew learnt the hard way that is not the case.

Should we take "Granted, I suck at flying" message literally, or a jab at MCAS team? I am guessing Mr.Forkner is a good pilot.
All posts are just opinions.
 
planecane
Posts: 1555
Joined: Thu Feb 09, 2017 4:58 pm

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 3:23 pm

airtechy wrote:

I do find it hard to understand how a trim system has the range to drive the stabilizer to a position that can cause forces in excess of the ability to be counteracted by yoke forces ... regardless of how the trim is driven.Hard to believe that the CG range would require that travel.



I haven't finished reading the entire report yet, but, the way that the report describes the operation of MCAS, the intention was not to move the stabilizer to the point where it couldn't be counteracted by the elevator. One of the big screw ups in the design and implementation was not realizing that every time a pilot would counteract MCAS with the thumb switch, it would reset MCAS to be ready to trigger again. The maximum authority was intended to be 2.5 units. However, if counteracted but not quite completely, each successive activation is able to result in a nose down trim lower than the previous activation. It is only the cascading MCAS activations and subsequent counteractions that essentially gave MCAS unlimited authority.

That's why MCAS 2.0 with proper logic and design care will only activate for one cycle per high AoA event. Even if both sensors failed simultaneously in a way that would cause a similar runaway, the cascading authority will no longer be possible and MCAS will be limited to the intended authority. This will ensure that the pilots will always have enough elevator authority to maintain level flight. If MCAS 1.0 had been limited to a single activation per high AoA event neither crash would have happened. It wouldn't have been able to command more than 2.5 units nose down and the counter trim (which both crews did early on), would not have been overridden by MCAS activating again. The single sensor design wouldn't have even come under scrutiny and the MAX would never have been grounded.
 
XRAYretired
Posts: 870
Joined: Fri Mar 15, 2019 11:21 am

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 3:48 pm

morrisond wrote:
mjoelnir wrote:
morrisond wrote:

Yes we know Boeing is evil I don't think anyone on here is refuting that - and you call mine a rant?

So what is your solution for making sure Lion Air 610's, Lufthansa 1829's, AF447 and Et302's don't happen again?

More bells and whistles going off in the cockpit and more automation, including more memory items and a 300 page QRH?

Please provide a solution vs just ranting. At least I'm trying - mine applies to all aircraft types and if made a core training could have prevented most of the air disasters of the past 20 years.


If you point to one comment I made about Boeing and the 737MAX that is not a fact, you can call my post a rant.

How dare you compare the other accidents with the terrible death trap Boeing produced knowingly with the 737MAX? Can you point to me where another air framer discussed possible catastrophic failures of an automation and decides to hide the automation?
This disaster is so far out of everything I once believed the airline industry to be about. Once upon a time Boeing was a beacon for safety conscious design of airplanes, but that was perhaps always a misconception.


Please point to the evidence where Boeing knowingly knew the design would kill people. They made some very bad assumptions about the current state of pilot proficiency and how they would react to MCAS failure.

You might be right - and there might be a smoking gun someone hasn't found yet - but so far all that has been shown is that they were stupid.

Knowingly Knew - total death toll = 189 souls.

'Days after the Lion Air crash, the agency invited Boeing executives to the F.A.A.’s Seattle headquarters, according to two people with knowledge of the matter. The officials sat incredulous as Boeing executives explained details about the system that they didn’t know.
In the middle of the conversation, an F.A.A. employee, one of the people said, interrupted to ask a question on the minds of several agency engineers: Why hadn’t Boeing updated the safety analysis of a system that had become so dangerous?'

search.php?st=0&sk=t&sd=d&sr=posts&keywords=dangerous&t=1426007&sf=msgonly&ch=-1&start=50

'Federal Aviation Administration officials Wednesday tried to defend the decisions they made after a 737 Max jet crashed in Indonesia last year. But in a Senate hearing, it was revealed they predicted a second malfunction was likely. Sadly, they were right, and the Max has been grounded ever since the deadly Ethiopian Airlines crash in March.
Senators demanded to know why the FAA didn't do more after the first 737 Max crash last October. They pointed to internal FAA analysis, done just days after the crash, predicting another emergency incident was likely within the next 10 months, due to the plane's troubled anti-stall system, known as MCAS.'

https://www.cbsnews.com/news/faa-knew-a ... air-crash/

Knowingly knew? = 'Dangerous', 'Likely', 'Within 10 months' = satisfied.

Total Death Toll = 346 souls.

Ray
 
User avatar
767333ER
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 3:50 pm

Just about what was expected. My point remains you can remove any of the factors from this crash and it still might have happened with the exception being MCAS because if you remove MCAS and the AOAs disagree they just don’t get autopilot, so what. Without MCAS this chain of events does not get into motion. Plenty of blame to go around but Boeing still deserves the most.
Been on: 732 733 734 73G 738 752 763 A319 A320 A321 CRJ CR7 CRA/CR9 E145 E175 E190 F28 MD-82 MD-83 C172R C172S P2006T PA-28-180

2 ears for spatial hearing, 2 eyes for depth perception, 2 ears for balance... How did Boeing think 1 sensor was good enough?!
 
mjoelnir
Posts: 9391
Joined: Sun Feb 03, 2013 11:06 pm

Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 3:57 pm

morrisond wrote:
mjoelnir wrote:
morrisond wrote:

Yes we know Boeing is evil I don't think anyone on here is refuting that - and you call mine a rant?

So what is your solution for making sure Lion Air 610's, Lufthansa 1829's, AF447 and Et302's don't happen again?

More bells and whistles going off in the cockpit and more automation, including more memory items and a 300 page QRH?

Please provide a solution vs just ranting. At least I'm trying - mine applies to all aircraft types and if made a core training could have prevented most of the air disasters of the past 20 years.


If you point to one comment I made about Boeing and the 737MAX that is not a fact, you can call my post a rant.

How dare you compare the other accidents with the terrible death trap Boeing produced knowingly with the 737MAX? Can you point to me where another air framer discussed possible catastrophic failures of an automation and decides to hide the automation?
This disaster is so far out of everything I once believed the airline industry to be about. Once upon a time Boeing was a beacon for safety conscious design of airplanes, but that was perhaps always a misconception.


Please point to the evidence where Boeing knowingly knew the design would kill people. They made some very bad assumptions about the current state of pilot proficiency and how they would react to MCAS failure.

You might be right - and there might be a smoking gun someone hasn't found yet - but so far all that has been shown is that they were stupid.


You just have to read the Reuters article. Boeing new that MCAS could activate several times. Boeing new that MCAS could activate while a Christmas tree of errors could confuse the pilots. Do you need to be hit with a four by two over the head, to get a clue.
 
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Revelation
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 4:01 pm

morrisond wrote:
Please point to the evidence where Boeing knowingly knew the design would kill people. They made some very bad assumptions about the current state of pilot proficiency and how they would react to MCAS failure.

You might be right - and there might be a smoking gun someone hasn't found yet - but so far all that has been shown is that they were stupid.

That to me is the interesting thing: how do you prove the root cause was managers putting excessive pressure on engineers due to greed, versus engineers making bad assumptions?

We're at point where Occam's Razor tells you that given we have documented proof of Boeing making so many decisions that favored Boeing's own bottom line over safety (going with 3 second recognition time, saying MCAS is not an anti-stall system so a single sensor is fine, deciding that pilots will recognize MCAS as runaway trim so no documentation or training changes are needed, testing MCAS in isolation with no end-to-end testing of bad AoA sensor scenarios starting from takeoff so no understanding of pilot's actual workload) that it must be an organizational influence (i.e. "culture") rather than individual engineers making bad assumptions.

Yet without a smoking gun (document saying Manager X told Engineer Y to do or not do Z), chances are that many of the same managers are still in similar positions of power, or even greater power and there won't be anything forcing them out.

We know Boeing itself is making some organizational reforms to give more power and independence to the safety teams and to protect whistle blowers, but also clearly doing all it can do to avoid getting tagged with criminal liability charges.

We don't see FAA doing much of anything to reform itself, nor Congress doing anything to give FAA back powers it once had nor increasing its budget at all.

All we see from Congress is "made for TV" hearings slagging Boeing and FAA without any attention to how it has acted to strip money and power from FAA at Boeing's behest.

Given the deck is stacked in Boeing's favor and Congress appoints the head of the FAA, neither Boeing or FAA are going to raise such points.

They'll just take their public lashing because they are happy with the status quo.

I hope I'm proved wrong, but I doubt I will be.
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 4:06 pm

mjoelnir wrote:
You just have to read the Reuters article. Boeing new that MCAS could activate several times. Boeing new that MCAS could activate while a Christmas tree of errors could confuse the pilots. Do you need to be hit with a four by two over the head, to get a clue.

In other words, you have no evidence that Boeing knowingly knew the design would kill people.

At best we have evidence of individuals at Boeing giving their company the benefit of the doubt on things that reduce the amount of change MAX needed.

We don't have documented evidence of a collective decision to accept a design that would kill people.
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mjoelnir
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 4:55 pm

Revelation wrote:
mjoelnir wrote:
You just have to read the Reuters article. Boeing new that MCAS could activate several times. Boeing new that MCAS could activate while a Christmas tree of errors could confuse the pilots. Do you need to be hit with a four by two over the head, to get a clue.

In other words, you have no evidence that Boeing knowingly knew the design would kill people.

At best we have evidence of individuals at Boeing giving their company the benefit of the doubt on things that reduce the amount of change MAX needed.

We don't have documented evidence of a collective decision to accept a design that would kill people.


Boeing knowingly accepted a automation that they new could bring the aircraft into trouble. You have to lean far out of the window to not call that knowingly accepting that people get killed. What you not seem to understand, that you do not need intent, negligence goes quite far enough.
 
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par13del
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 5:10 pm

So based on the last few post we can now accept the the release of the actual accident reports will not put this issue to rest, it may not be shocking if someone says Boeing paid off somebody to have something or someone other than Boeing listed as being at fault.
I looked forward to seeing the official Lion Air report just as much as I look forward to the Ethiopian report, I admit that I do not look forward to the discourse on A.Net when released....
 
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Re: Updated: Final report of Lion Air JT610 has been released

Sun Oct 27, 2019 5:17 pm

mjoelnir wrote:
Revelation wrote:
In other words, you have no evidence that Boeing knowingly knew the design would kill people.

At best we have evidence of individuals at Boeing giving their company the benefit of the doubt on things that reduce the amount of change MAX needed.

We don't have documented evidence of a collective decision to accept a design that would kill people.

Boeing knowingly accepted a automation that they new could bring the aircraft into trouble. You have to lean far out of the window to not call that knowingly accepting that people get killed.

In other words, you still have no evidence that Boeing knowingly knew the design would kill people.

There's a difference between "bring the aircraft into trouble" and "knowingly knew the design would kill people".

mjoelnir wrote:
What you not seem to understand, that you do not need intent, negligence goes quite far enough.

It depends on the forum: criminal court, civil court, or this forum.

In US criminal court you do need intent, in civil court you do not.

In this forum, you keep answering a question different than the one being asked and pretend that no one sees the difference.
Wake up to find out that you are the eyes of the world
The heart has its beaches, its homeland and thoughts of its own
Wake now, discover that you are the song that the morning brings
The heart has its seasons, its evenings and songs of its own

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