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par13del
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 3:26 pm

So you want to create a new potential conflict where companies are not only accused of "bribing" politicians with campaign donations but also of influencing the knowledgeable experts who will meet in smoke filled rooms to determine what is said in public?
Where exactly do you think the existing politicians got their talking points from?
 
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AirlineCritic
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 6:36 pm

Revelation wrote:
Overall I do find the apparent lack of end-to-end testing very disappointing.

I would have thought the test matrix would have had to have had a "take off with incorrectly calibrated AoA sensor" test case as a primary requirement given the reliance on one AoA sensor.

I've seen in my (non-aviation) engineering career many cases where lots of individual engineers put their changes into a system in isolation, and no one does end to end analysis or testing with real world scenarios.


Agree 100%

(Not that I would personally volunteer for those test flights, but I'm not paid the big bucks to be a test pilot either.)
 
VV
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 8:06 pm

I know this link has been posted many times and I know a lot of people hate it because tells something credible, but I think it explains well the trim runaway procedure.

https://www.nytimes.com/interactive/201 ... ckpit.html
 
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zeke
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 8:20 pm

airtechy wrote:
A runaway trim is controllable. You stop it with the kill switches on the console. I was warned about this in the 70's when I first flew a plane with electric trim .


I think such a comment fails to acknowledge that this is not a “trim” in the traditional sense being a tab placed on the trailing edge of a elevator, aileron, or rudder. This is changing the angle of attack of the all moving horizontal stabilizer, and at times attitudes that will make the elevator ineffective. Being an all moving tailplane, it generates much greater forces than a trim tab.


morrisond wrote:
.

I'm quite aware that Lion Air did not have the FCOM bulletin. So what is ET's excuse?


The ET crew did follow the bulletin, suggesting they didn’t is denigrating their loss of life. They got to the stage after following the procedure where the force of both pilots pulling on the control column could not move it, the only additional assistance they could get was from the electric trim motors.

The procedure did not tell the pilots what actions to take if they could not move the controls after applying the procedure.

morrisond wrote:
.Zeke - I've asked you this following one before - but you have never replied.

You are flying along with the AP engaged and it tries to put you into a 30 Degree bank without your input but you noticed the bank and corrected it with the controls but then it did it again.

How many times would that have to happen before you would consider it your fault for not turning off the offending system and flying using the manual controls?

2-3 times? 4-5 times? 22 times? or is 23 times the magic number - anything below that and the Pilot holds no responsibility for shutting off the bad system?


I probably didn’t reply as it’s a dumb scenario and had nothing to do with the thread in question. MCAS only activates when manually flying, the pilots have already “turned things off” or have “not turned things on”.

MCAS was an undocumented flight control law which overrode pilots commands in manual flight. There is no actual way to turn MCAS off, it is embedded software in the FCC. The procedure that was published as part of the emergency AD does not turn MCAS off, it turns the electric trim off. MCAS is still commanding the electric motors nose down, if for whatever reason the relays for the electric trim failed to open when turning the switches off, MCAS will continue to trim nose down. To disable it you would need to do the non intuitive action and select flap.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
airtechy
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 8:23 pm

My question to any pilot would be if they found themselves needing to hold a lot of pressure on the yoke to maintain level flight .. what would be the first control you would reach for .. and what would be the second?
 
airtechy
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 8:32 pm

Lighter planes move a trim tab. Heavier planes like the 737 move the stabilizer. The effect is the same. And the effect is the same whether you roll the trim wheel by hand or have a motor do it for you. And all planes I'm aware of have a means to disable the motor trim as if it "runs away" as in these two cases the result can be very bad.
 
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zeke
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 8:41 pm

airtechy wrote:
Lighter planes move a trim tab. Heavier planes like the 737 move the stabilizer. The effect is the same. And the effect is the same whether you roll the trim wheel by hand or have a motor do it for you. And all planes I'm aware of have a means to disable the motor trim as if it "runs away" as in these two cases the result can be very bad.


The effect is not the same. For a trim tab on the trailing edge to go to the full travel position it will not greatly impact the airflow over the tail-plane and elevator. Full travel of a all moving tail-plane can blanket the airflow over elevator leaving the aircraft with no pitch control, somewhat similar to a deep stall on a T tail aircraft.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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zeke
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 8:51 pm

airtechy wrote:
My question to any pilot would be if they found themselves needing to hold a lot of pressure on the yoke to maintain level flight .. what would be the first control you would reach for .. and what would be the second?


Your first thought would be trim, if that was not working and being fairly soon after takeoff I would be thinking more along the lines of a CG issue, either loaded incorrectly (Air Midwest Flight 5481) or a CG shift (National Airlines Flight 102), not an undocumented flight control law.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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smithbs
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 8:57 pm

I read the report. It was a good product - many thanks to the Indonesian team, and like the Ethiopian report it was informative and objective.

There's been a lot of flame on the forum toward the FO. I think this is a bit undeserved, and I'll bring these points out from the report:

* The FO was more verbally engaged at the beginning of trouble than the Captain. However, the Captain would either not answer him, countermand his suggestions, or quiz him in a cryptic manner. To this last point, the FO ran his memory items but the Captain just said "memory item" and left the FO wondering. If the Captain knew something the FO missed, he should have said so explicitly instead of leaving it at a confusing and open-ended comment. I can't find one instance of the Captain doing a useful favor for the FO for the whole transcript.

* Yes, the FO took about two minutes to find the Unreliable Airspeed checklist. To his defense, I'd point out that ATC was on his back and the QRH did not list that procedure on the Quick Action Index - he had to go find it.

* ATC was on his back and giving him instructions that the Captain's flying was not complying with. ATC wanted to help, but they also did the FO no favors.

* The Captain never communicated what he was doing to fly the airplane. This included large amounts of nose up trim, and messing with the flaps. The Captain seemed to hold his own in the "pilot vs MCAS pitch battle." But then he dumped the whole situation into the FO's lap without a word of how the aircraft was flying. To not brief the FO about the flying characteristics was bad on his part.

* The FO seemed surprised at the aircraft handling when he took control, but the Captain still didn't mention, "Oh yeah, you need to apply nose up trim in huge amounts." It was fatal because the simulations after the crash showed that a) two uncorrected applications of MCAS was enough to overcome the control column and b) the worst way to fly against MCAS was to apply short trim bursts, but that's what the FO unwittingly did - he seemed to rely on column movement and not so much with pitch control, but that is not how to play against MCAS.

In the training records, we see elements of what happened:

* Captain had write-ups on communication and CRM.

* FO had write-ups on fixation, missing details and being not so great at stick-and-rudder flying.

About the AoA Disagree light, there's been debate on this for months now. The report says it was discussed and would not have helped this situation. I agree - the AoA Disagree light would not have helped this flight crew. The AoA Disagree light just means your altitude and speed readings may be jacked, which this flight crew knew already and was working down that path. Their major problem is that the Captain never realized he had a major pitch problem going on in addition to the immediate indications.

That said, I think they did okay under the circumstances. They were working down the issues that they knew about. If they were in a NG, they would have landed and been fine. The fact that the manufacturer had a bug hidden away that would essentially add a runaway stab to the crisis was the fatal aspect. Boeing expected flight crews to recognize a runaway stab and hinged their cert justification on that, and to a degree that's correct - but the cause of the runaway stab was still their fault.

The AoA sensor problem was certainly an issue too, and could be construed to be the root cause. But component failure is a fact of life. A great chunk of my engineering career has been spent designing around the "what if's" of component failure than what I wanted the device to do when everything was normal. A component failure shouldn't create a sympathetic problem whose severity is even worse.

The report also went through the 737 MAX in great detail. I actually feel better about the airplane after reading it. Some aspects are a bit antiquated, but as engineers we have to balance older approaches under the "proven in use" argument as opposed to the "state of the art" argument. Both carry advantages and problems.

Thanks again to Indonesia for publishing this report. It is a credit to the KNKT.
 
morrisond
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 9:00 pm

zeke wrote:

morrisond wrote:
.

I'm quite aware that Lion Air did not have the FCOM bulletin. So what is ET's excuse?


The ET crew did follow the bulletin, suggesting they didn’t is denigrating their loss of life. They got to the stage after following the procedure where the force of both pilots pulling on the control column could not move it, the only additional assistance they could get was from the electric trim motors.

The procedure did not tell the pilots what actions to take if they could not move the controls after applying the procedure.

morrisond wrote:
.Zeke - I've asked you this following one before - but you have never replied.

You are flying along with the AP engaged and it tries to put you into a 30 Degree bank without your input but you noticed the bank and corrected it with the controls but then it did it again.

How many times would that have to happen before you would consider it your fault for not turning off the offending system and flying using the manual controls?

2-3 times? 4-5 times? 22 times? or is 23 times the magic number - anything below that and the Pilot holds no responsibility for shutting off the bad system?


I probably didn’t reply as it’s a dumb scenario and had nothing to do with the thread in question. MCAS only activates when manually flying, the pilots have already “turned things off” or have “not turned things on”.

MCAS was an undocumented flight control law which overrode pilots commands in manual flight. There is no actual way to turn MCAS off, it is embedded software in the FCC. The procedure that was published as part of the emergency AD does not turn MCAS off, it turns the electric trim off. MCAS is still commanding the electric motors nose down, if for whatever reason the relays for the electric trim failed to open when turning the switches off, MCAS will continue to trim nose down. To disable it you would need to do the non intuitive action and select flap.


On the first one you are conveniently ignoring they left the AT engaged at TOGA and were flying over Vmo. No wonder they couldn't move the elevator. You would probably not fault them for reducing thrust to zero either and pull up into a stall as the procedure didn't tell them to not do that either.

On #2 - I'll take that as you would consider a pilot stupid to not turn off the AP in my scenario by your deflection on your answer. You sound like a politician and not a Pilot.
 
airtechy
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 9:09 pm

Zeke. You are splitting hairs. Trim tab trim results in drag unless the desired trim is exactly in line with the fixed stabilizer. Stabilizer trim will result in the elevator in line with the stabilizer...no drag. Plus stabilizer trim allows a wider CG range to be corrected.

Boeing made many technical errors in the
MCAS design, but probably the worse mistake they made was assuming the average pilot would recognize what was clearly a trim issue if MCAS failed and correct it.

I since that in addition to an overhaul of MCAS the accident report and subsequent hearings will probably result in another failure alert warning. Maybe a hand pointing at the trim wheel would be helpful.

Edit .. typo
 
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Revelation
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 9:33 pm

AirlineCritic wrote:
Revelation wrote:
Overall I do find the apparent lack of end-to-end testing very disappointing.

I would have thought the test matrix would have had to have had a "take off with incorrectly calibrated AoA sensor" test case as a primary requirement given the reliance on one AoA sensor.

I've seen in my (non-aviation) engineering career many cases where lots of individual engineers put their changes into a system in isolation, and no one does end to end analysis or testing with real world scenarios.

Agree 100%

(Not that I would personally volunteer for those test flights, but I'm not paid the big bucks to be a test pilot either.)

Something interesting from the Congressional hearings, hopefully not being taken out of context:

Image

Ref: https://twitter.com/davidshepardson/sta ... 6092291072
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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zeke
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 9:36 pm

morrisond wrote:
You would probably not fault them for reducing thrust to zero either and pull up into a stall as the procedure didn't tell them to not do that either.

On #2 - I'll take that as you would consider a pilot stupid to not turn off the AP in my scenario by your deflection on your answer. You sound like a politician and not a Pilot.


The answer to the first part I have already made clear in the many ET threads, this thread is talking about "Final report of Lion Air JT610 has been released".

The second part is irreverent as the autopilot was not engaged, MCAS is an undocumented flight control law that only is active when manually flying. If they had the autopilot on, MCAS would not have activated, however the could not activate the autopilot due to the airspeed and altitude disagree.

airtechy wrote:
Zeke. You are splitting hairs. Trim tab trim results in drag unless the desired trim is exactly in line with the fixed stabilizer..


I am not splitting hairs. Having a trim tab at full deflection will not blanket the stabilizer or elevator with turbulent flow to stop it from working. However a stabilizer at the full travel position possibly can blanket the elevator leaving the aircraft with no pitch control, like a deep stall in a T tail..Tail-plane stall drastically reduces the downward force it produces, creating a rapid aircraft nose-down pitching moment. The impact of a tail-plane stall include the difficulty in trimming in pitch, reduction in elevator force required for control in the forward sense, elevator control oscillation or pulsing with forward movement of the yoke much lighter than a corresponding aft movement and reduction in elevator effectiveness. When a tail-plane stall occurs it will result in an abrupt and/or un-commanded nose down pitching manoeuvre that may be preceded or accompanied by sudden forward control column movement or snatch. There is no cockpit indications of an approaching tail-plane stall such as airframe buffet or activation of stall warning systems.

That is one of the reasons why the recovery altitude needed is so high, it is to allow time to manually move the stab back to a position where the elevator can once again be aerodynamically effective.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
hivue
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 9:37 pm

airtechy wrote:
Zeke. You are splitting hairs. Trim tab trim results in drag unless the desired trim is exactly in line with the fixed stabilizer. Stabilizer trim will result in the elevator in line with the stabilizer...no drag. Plus stabilizer trim allows a wider CG range to be corrected.


Someone please correct me if I am wrong since I'm no aeronautical engineer, but the purpose of a trim tab is to move the elevator. The elevator accomplishes the trim. Thus if the tab moves up the elevator is forced down and the airplane is trimmed nose down. I would think the elevator causes much more drag than the tab. The only time "the desired trim is exactly in line with the fixed stabilizer" is when the desired trim is no trim.
"You're sitting. In a chair. In the SKY!!" ~ Louis C.K.
 
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zeke
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 9:41 pm

Revelation wrote:
Something interesting from the Congressional hearings, hopefully not being taken out of context:


The next side was more damming, it was known to have "“catastrophic” impact if pilots did not react within 10 seconds"
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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zeke
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 9:45 pm

hivue wrote:
Someone please correct me if I am wrong since I'm no aeronautical engineer, but the purpose of a trim tab is to move the elevator. The elevator accomplishes the trim. Thus if the tab moves up the elevator is forced down and the airplane is trimmed nose down. I would think the elevator causes much more drag than the tab. The only time "the desired trim is exactly in line with the fixed stabilizer" is when the desired trim is no trim.


The 737 has no elevator trim, essentially the elevator can be thought as a is a big trim tab for the stabilizer. Pilots will move the elevator to obtain the pitch they require, then move the stabilizer so the elevator force returns to neutral.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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smithbs
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 9:51 pm

hivue wrote:
airtechy wrote:
Zeke. You are splitting hairs. Trim tab trim results in drag unless the desired trim is exactly in line with the fixed stabilizer. Stabilizer trim will result in the elevator in line with the stabilizer...no drag. Plus stabilizer trim allows a wider CG range to be corrected.


Someone please correct me if I am wrong since I'm no aeronautical engineer, but the purpose of a trim tab is to move the elevator. The elevator accomplishes the trim. Thus if the tab moves up the elevator is forced down and the airplane is trimmed nose down. I would think the elevator causes much more drag than the tab. The only time "the desired trim is exactly in line with the fixed stabilizer" is when the desired trim is no trim.


For 737 stab and trim, see here, Section 1.6.5.3.

http://knkt.dephub.go.id/knkt/ntsc_avia ... Report.pdf
 
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PixelFlight
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 9:55 pm

Revelation wrote:
AirlineCritic wrote:
Revelation wrote:
Overall I do find the apparent lack of end-to-end testing very disappointing.

I would have thought the test matrix would have had to have had a "take off with incorrectly calibrated AoA sensor" test case as a primary requirement given the reliance on one AoA sensor.

I've seen in my (non-aviation) engineering career many cases where lots of individual engineers put their changes into a system in isolation, and no one does end to end analysis or testing with real world scenarios.

Agree 100%

(Not that I would personally volunteer for those test flights, but I'm not paid the big bucks to be a test pilot either.)

Something interesting from the Congressional hearings, hopefully not being taken out of context:

Image

Ref: https://twitter.com/davidshepardson/sta ... 6092291072

The NTSB report explain that a failure analysis was done for the MCAS, but:

"Un-
commanded MCAS was documented as a potential consequence of erroneous AOA,
but was not identified as a factor contributing to the catastrophic rating in any of
these."

"Boeing
considered that the loss of one AOA and erroneous AOA as two independent events
with distinct probabilities. The combined failure event probability was assessed as
beyond extremely improbable, hence complying with the safety requirements for
the Air Data System."

"During the single and multiple failure analysis from the air data system worst case
scenario of “failure of one AOA followed by erroneous AOA”, Boeing concluded
that the effect would be hazardous until the flight crew recognized the problem and
took appropriate action to mitigate it. Boeing recognized that training would
improve flight crew recognition and response."

Lot of details starting from page 270 of the JT610 final report. And the scandalous part is:

"Boeing advised that after the accident, they reviewed how the case of single
erroneous AOA would have been categorized if included in the original review.
Boeing concluded that had the case of “Erroneous AOA from a single source” been
included in the S&MF document, the same assumption about pilot response to un-
commanded MCAS as used in the FHAs (which was based on regulatory guidance
in AC 25-7C) would have been used, and it is unlikely that any design changes
would have resulted
from including this case in the S&MF analysis. As noted in
section E.1, Boeing did conduct a similar, less formal analysis of the effects of
erroneously high AOA on MCAS and concluded that no redesign was needed."
: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:
 
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smithbs
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 10:06 pm

PixelFlight wrote:
"Boeing advised that after the accident, they reviewed how the case of single
erroneous AOA would have been categorized if included in the original review.
Boeing concluded that had the case of “Erroneous AOA from a single source” been
included in the S&MF document, the same assumption about pilot response to un-
commanded MCAS as used in the FHAs (which was based on regulatory guidance
in AC 25-7C) would have been used, and it is unlikely that any design changes
would have resulted
from including this case in the S&MF analysis. As noted in
section E.1, Boeing did conduct a similar, less formal analysis of the effects of
erroneously high AOA on MCAS and concluded that no redesign was needed."


What part of this strikes you as scandalous? The KNKT report's findings are full of how Boeing assumed the flight crew would respond properly (or in an intended fashion). In this paragraph, you are seeing how that assumption drove the design and cert. The findings of the report indicate that this assumption was incorrect, and so if you re-do Boeing's analysis with a modified paradigm of flight crew response, the outcome with respect to design and cert would be different.
 
AABusDrvr
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 10:32 pm

smithbs wrote:
I read the report. It was a good product - many thanks to the Indonesian team, and like the Ethiopian report it was informative and objective.

There's been a lot of flame on the forum toward the FO. I think this is a bit undeserved, and I'll bring these points out from the report:

* The FO was more verbally engaged at the beginning of trouble than the Captain. However, the Captain would either not answer him, countermand his suggestions, or quiz him in a cryptic manner. To this last point, the FO ran his memory items but the Captain just said "memory item" and left the FO wondering. If the Captain knew something the FO missed, he should have said so explicitly instead of leaving it at a confusing and open-ended comment. I can't find one instance of the Captain doing a useful favor for the FO for the whole transcript.

* Yes, the FO took about two minutes to find the Unreliable Airspeed checklist. To his defense, I'd point out that ATC was on his back and the QRH did not list that procedure on the Quick Action Index - he had to go find it.

* ATC was on his back and giving him instructions that the Captain's flying was not complying with. ATC wanted to help, but they also did the FO no favors.

* The Captain never communicated what he was doing to fly the airplane. This included large amounts of nose up trim, and messing with the flaps. The Captain seemed to hold his own in the "pilot vs MCAS pitch battle." But then he dumped the whole situation into the FO's lap without a word of how the aircraft was flying. To not brief the FO about the flying characteristics was bad on his part.

* The FO seemed surprised at the aircraft handling when he took control, but the Captain still didn't mention, "Oh yeah, you need to apply nose up trim in huge amounts." It was fatal because the simulations after the crash showed that a) two uncorrected applications of MCAS was enough to overcome the control column and b) the worst way to fly against MCAS was to apply short trim bursts, but that's what the FO unwittingly did - he seemed to rely on column movement and not so much with pitch control, but that is not how to play against MCAS.

In the training records, we see elements of what happened:

* Captain had write-ups on communication and CRM.

* FO had write-ups on fixation, missing details and being not so great at stick-and-rudder flying.

About the AoA Disagree light, there's been debate on this for months now. The report says it was discussed and would not have helped this situation. I agree - the AoA Disagree light would not have helped this flight crew. The AoA Disagree light just means your altitude and speed readings may be jacked, which this flight crew knew already and was working down that path. Their major problem is that the Captain never realized he had a major pitch problem going on in addition to the immediate indications.

That said, I think they did okay under the circumstances. They were working down the issues that they knew about. If they were in a NG, they would have landed and been fine. The fact that the manufacturer had a bug hidden away that would essentially add a runaway stab to the crisis was the fatal aspect. Boeing expected flight crews to recognize a runaway stab and hinged their cert justification on that, and to a degree that's correct - but the cause of the runaway stab was still their fault.

The AoA sensor problem was certainly an issue too, and could be construed to be the root cause. But component failure is a fact of life. A great chunk of my engineering career has been spent designing around the "what if's" of component failure than what I wanted the device to do when everything was normal. A component failure shouldn't create a sympathetic problem whose severity is even worse.

The report also went through the 737 MAX in great detail. I actually feel better about the airplane after reading it. Some aspects are a bit antiquated, but as engineers we have to balance older approaches under the "proven in use" argument as opposed to the "state of the art" argument. Both carry advantages and problems.

Thanks again to Indonesia for publishing this report. It is a credit to the KNKT.



Figure 31, on page 108 of the report is the quick action index of the Lion Air QRH. The airspeed unreliable checklist is the second one listed.

From Page 179 of the report:

"The Airspeed Unreliable procedure is one of the checklists which are listed on the Quick Action Index. The Quick Action Index is available on the cover page of the QRH and the Airspeed Unreliable is on the second line of the list. The inability for the FO to perform memory items and locate the checklist in the QRH in a timely manner indicated that the FO was not familiar with the NNC. This condition was reappearance of misidentifying NNC which showed on the FO’s training records."

ATC being "on his back" is no excuse at all for a professional pilot. "Standby" fixes that problem 100%, and should have been the first thing one of them said to ATC if they felt at all distracted by ATC.
 
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PixelFlight
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 10:33 pm

smithbs wrote:
PixelFlight wrote:
"Boeing advised that after the accident, they reviewed how the case of single
erroneous AOA would have been categorized if included in the original review.
Boeing concluded that had the case of “Erroneous AOA from a single source” been
included in the S&MF document, the same assumption about pilot response to un-
commanded MCAS as used in the FHAs (which was based on regulatory guidance
in AC 25-7C) would have been used, and it is unlikely that any design changes
would have resulted
from including this case in the S&MF analysis. As noted in
section E.1, Boeing did conduct a similar, less formal analysis of the effects of
erroneously high AOA on MCAS and concluded that no redesign was needed."


What part of this strikes you as scandalous? The KNKT report's findings are full of how Boeing assumed the flight crew would respond properly (or in an intended fashion). In this paragraph, you are seeing how that assumption drove the design and cert. The findings of the report indicate that this assumption was incorrect, and so if you re-do Boeing's analysis with a modified paradigm of flight crew response, the outcome with respect to design and cert would be different.

The scandal is that this definitively prove that this was not just a simple missing fault analysis, deep into a complex tree of possibilities. The flawed classification basically obliterated all design risk controls requirement because no fault analysis will ever result in a such requirement. Boeing accumulated hidden safety problems by using the pilots as unrealistic risk control, without telling them anything ! There found a breach in the regulation that makes the MAX==NG so more easy to do, that this was irresistible. This allowed Boeing to ignore any safety on the MCAS and blame the pilots if anything will happens. And this is still exactly the case today: Boeing and many peoples are still blaming the pilots for a design problem that Boeing deliberately chose to not handle knowing secretly that there could safely deny it and blame the pilots instead. This was just a disaster waiting to happen, and the probability was higher for pilots that have less experience.

Ignore the safety problem, take the money, and blame the others, especially the more vulnerable. Truly cynical evil.
: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:
 
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smithbs
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 10:50 pm

AABusDrvr wrote:
Figure 31, on page 108 of the report is the quick action index of the Lion Air QRH. The airspeed unreliable checklist is the second one listed.

From Page 179 of the report:

"The Airspeed Unreliable procedure is one of the checklists which are listed on the Quick Action Index. The Quick Action Index is available on the cover page of the QRH and the Airspeed Unreliable is on the second line of the list. The inability for the FO to perform memory items and locate the checklist in the QRH in a timely manner indicated that the FO was not familiar with the NNC. This condition was reappearance of misidentifying NNC which showed on the FO’s training records."

ATC being "on his back" is no excuse at all for a professional pilot. "Standby" fixes that problem 100%, and should have been the first thing one of them said to ATC if they felt at all distracted by ATC.


Ah, yes, you're right - second on the list. See, I missed it too. :oops:

Regarding ATC, I think the FO was not being helped because he was taking and confirming instructions from ATC, and then the Captain would not adhere to the instruction during his flying. So you have yet another piece of discontinuous operation in your mind, in addition to the instrumentation failures - all adds up to distraction. Sure, he could have said "standby," or ATC could have said "unrestricted operation" and then listened. But...it didn't happen. I don't think it contributed to the final outcome - just a finding, as the report indicated.
 
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smithbs
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 11:06 pm

PixelFlight wrote:
The scandal is that this definitively prove that this was not just a simple missing fault analysis, deep into a complex tree of possibilities. The flawed classification basically obliterated all design risk controls requirement because no fault analysis will ever result in a such requirement. Boeing accumulated hidden safety problems by using the pilots as unrealistic risk control, without telling them anything ! There found a breach in the regulation that makes the MAX==NG so more easy to do, that this was irresistible. This allowed Boeing to ignore any safety on the MCAS and blame the pilots if anything will happens. And this is still exactly the case today: Boeing and many peoples are still blaming the pilots for a design problem that Boeing deliberately chose to not handle knowing secretly that there could safely deny it and blame the pilots instead. This was just a disaster waiting to happen, and the probability was higher for pilots that have less experience.

Ignore the safety problem, take the money, and blame the others, especially the more vulnerable. Truly cynical evil.


This report reveals how much of the safety analysis rested on a "proper" flight crew response, and the excerpt you pulled in the above post shows how that mitigation flowed through the system. I've sat in FMEA's before and am very familiar with how such paradigms flow through like water. Then see report pg 227 - the KNKT says that the flight crew response paradigm needs to be shifted. That changes the FHA outcome and forces a more thorough FMEA.

See the report, page 219 - Boeing is fixing the problem. We see in the report how in late 2018 Boeing worked to identify and quantify the issue, and issued communications to operators accordingly as information came forth. I think your charges of Boeing secretly conspiring to screw the pilots over for the sake of money is off the deep end.
 
airtechy
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 11:11 pm

However a stabilizer at the full travel position possibly can blanket the elevator leaving the aircraft with no pitch control, like a deep stall in a T tail.

I agree. Why would you design a trim system with this much travel? What flight condition would require it? And are you saying that the 737 max has this extreme range? I'm not sure what this has to do with how stabilizer trim works, but if so it says you should never let the trim get this far off.. regardless of the cause. Fly the plane first!
 
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zeke
Posts: 14896
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 11:53 pm

airtechy wrote:
Why would you design a trim system with this much travel? What flight condition would require it?


The range of stab trim is there to account for the large range in
1) Speed
2) CG
3) configuration
4) thrust
5) ice
6) failure conditions
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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PixelFlight
Posts: 1018
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Re: Updated: Final report of Lion Air JT610 has been released

Wed Oct 30, 2019 11:59 pm

smithbs wrote:
PixelFlight wrote:
The scandal is that this definitively prove that this was not just a simple missing fault analysis, deep into a complex tree of possibilities. The flawed classification basically obliterated all design risk controls requirement because no fault analysis will ever result in a such requirement. Boeing accumulated hidden safety problems by using the pilots as unrealistic risk control, without telling them anything ! There found a breach in the regulation that makes the MAX==NG so more easy to do, that this was irresistible. This allowed Boeing to ignore any safety on the MCAS and blame the pilots if anything will happens. And this is still exactly the case today: Boeing and many peoples are still blaming the pilots for a design problem that Boeing deliberately chose to not handle knowing secretly that there could safely deny it and blame the pilots instead. This was just a disaster waiting to happen, and the probability was higher for pilots that have less experience.

Ignore the safety problem, take the money, and blame the others, especially the more vulnerable. Truly cynical evil.


This report reveals how much of the safety analysis rested on a "proper" flight crew response, and the excerpt you pulled in the above post shows how that mitigation flowed through the system. I've sat in FMEA's before and am very familiar with how such paradigms flow through like water. Then see report pg 227 - the KNKT says that the flight crew response paradigm needs to be shifted. That changes the FHA outcome and forces a more thorough FMEA.

See the report, page 219 - Boeing is fixing the problem. We see in the report how in late 2018 Boeing worked to identify and quantify the issue, and issued communications to operators accordingly as information came forth. I think your charges of Boeing secretly conspiring to screw the pilots over for the sake of money is off the deep end.

The analysis did not rested on a "proper" flight crew, but on assumptions that were incorrect about the flight crew response. This is not exactly the same.

"KNKT recommends that Boeing include a larger tolerance in the design
is required to allow operability by a larger population of flight-rated pilots."

Boeing did not understand the severity of the problem in 2018, as proved by the EAD that assert and confirm that at that time Boeing still expected the pilots to make the risk control of a failure condition. I don't think this was a conspiracy, but a company width macroscopic outcome resulting by highly challenging objectives to be solved in short time by peoples not exchanging enough safety information. This is not an hazard if the point where the regulation was abused by incorrect assumption from Boeing own standards is exactly what was required to terminate the 737 MAX more quickly and to match the priority goal MAX==NG. The cynical evil is Boeing as a company that pushed itself in a situation where there was actively searching for the minimal way to bypass the regulation that could risk the time to market and MAX==NG goals. And there found the amazing safety hack in the stab trim runaway risk control. It's why it's a company culture problem, mainly set by the top execs on purpose to own more money.
: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:
 
morrisond
Posts: 2648
Joined: Thu Jan 07, 2010 12:22 am

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

Thu Oct 31, 2019 12:09 am

PixelFlight wrote:
smithbs wrote:
PixelFlight wrote:
The scandal is that this definitively prove that this was not just a simple missing fault analysis, deep into a complex tree of possibilities. The flawed classification basically obliterated all design risk controls requirement because no fault analysis will ever result in a such requirement. Boeing accumulated hidden safety problems by using the pilots as unrealistic risk control, without telling them anything ! There found a breach in the regulation that makes the MAX==NG so more easy to do, that this was irresistible. This allowed Boeing to ignore any safety on the MCAS and blame the pilots if anything will happens. And this is still exactly the case today: Boeing and many peoples are still blaming the pilots for a design problem that Boeing deliberately chose to not handle knowing secretly that there could safely deny it and blame the pilots instead. This was just a disaster waiting to happen, and the probability was higher for pilots that have less experience.

Ignore the safety problem, take the money, and blame the others, especially the more vulnerable. Truly cynical evil.


This report reveals how much of the safety analysis rested on a "proper" flight crew response, and the excerpt you pulled in the above post shows how that mitigation flowed through the system. I've sat in FMEA's before and am very familiar with how such paradigms flow through like water. Then see report pg 227 - the KNKT says that the flight crew response paradigm needs to be shifted. That changes the FHA outcome and forces a more thorough FMEA.

See the report, page 219 - Boeing is fixing the problem. We see in the report how in late 2018 Boeing worked to identify and quantify the issue, and issued communications to operators accordingly as information came forth. I think your charges of Boeing secretly conspiring to screw the pilots over for the sake of money is off the deep end.

The analysis did not rested on a "proper" flight crew, but on assumptions that were incorrect about the flight crew response. This is not exactly the same.

"KNKT recommends that Boeing include a larger tolerance in the design
is required to allow operability by a larger population of flight-rated pilots."

Boeing did not understand the severity of the problem in 2018, as proved by the EAD that assert and confirm that at that time Boeing still expected the pilots to make the risk control of a failure condition. I don't think this was a conspiracy, but a company width macroscopic outcome resulting by highly challenging objectives to be solved in short time by peoples not exchanging enough safety information. This is not an hazard if the point where the regulation was abused by incorrect assumption from Boeing own standards is exactly what was required to terminate the 737 MAX more quickly and to match the priority goal MAX==NG. The cynical evil is Boeing as a company that pushed itself in a situation where there was actively searching for the minimal way to bypass the regulation that could risk the time to market and MAX==NG goals. And there found the amazing safety hack in the stab trim runaway risk control. It's why it's a company culture problem, mainly set by the top execs on purpose to own more money.


There seems to be a wide range of standards in terms of what a Flight-rated pilot should be expected to know/be.

Boeing/FAA standards, KNKT's which seem not bad and Anut's where as long as pilots are able to at least chew gum while standing are good to go in the cockpit.
 
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smithbs
Posts: 441
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Re: Updated: Final report of Lion Air JT610 has been released

Thu Oct 31, 2019 3:16 am

morrisond wrote:
There seems to be a wide range of standards in terms of what a Flight-rated pilot should be expected to know/be.

Boeing/FAA standards, KNKT's which seem not bad and Anut's where as long as pilots are able to at least chew gum while standing are good to go in the cockpit.


I think this is one of the big question marks coming out of the investigation. Clearly Boeing's safety analysis set the bar too high - we have two crashed airplanes as demonstration. But for those who say the FO was an unprofessional pilot and was never qualified to be in the cockpit...he had almost 4300 hours on type. How many pilots around the world are hovering around 5000 hours? Something to think about.
 
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AirlineCritic
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Re: Updated: Final report of Lion Air JT610 has been released

Thu Oct 31, 2019 8:06 am

smithbs wrote:
I read the report. It was a good product - many thanks to the Indonesian team, and like the Ethiopian report it was informative and objective.

There's been a lot of flame on the forum toward the FO. I think this is a bit undeserved, and I'll bring these points out from the report:

* The FO was more verbally engaged at the beginning of trouble than the Captain. However, the Captain would either not answer him, countermand his suggestions, or quiz him in a cryptic manner. To this last point, the FO ran his memory items but the Captain just said "memory item" and left the FO wondering. If the Captain knew something the FO missed, he should have said so explicitly instead of leaving it at a confusing and open-ended comment. I can't find one instance of the Captain doing a useful favor for the FO for the whole transcript.

* Yes, the FO took about two minutes to find the Unreliable Airspeed checklist. To his defense, I'd point out that ATC was on his back and the QRH did not list that procedure on the Quick Action Index - he had to go find it.

* ATC was on his back and giving him instructions that the Captain's flying was not complying with. ATC wanted to help, but they also did the FO no favors.

* The Captain never communicated what he was doing to fly the airplane. This included large amounts of nose up trim, and messing with the flaps. The Captain seemed to hold his own in the "pilot vs MCAS pitch battle." But then he dumped the whole situation into the FO's lap without a word of how the aircraft was flying. To not brief the FO about the flying characteristics was bad on his part.

* The FO seemed surprised at the aircraft handling when he took control, but the Captain still didn't mention, "Oh yeah, you need to apply nose up trim in huge amounts." It was fatal because the simulations after the crash showed that a) two uncorrected applications of MCAS was enough to overcome the control column and b) the worst way to fly against MCAS was to apply short trim bursts, but that's what the FO unwittingly did - he seemed to rely on column movement and not so much with pitch control, but that is not how to play against MCAS.

In the training records, we see elements of what happened:

* Captain had write-ups on communication and CRM.

* FO had write-ups on fixation, missing details and being not so great at stick-and-rudder flying.

About the AoA Disagree light, there's been debate on this for months now. The report says it was discussed and would not have helped this situation. I agree - the AoA Disagree light would not have helped this flight crew. The AoA Disagree light just means your altitude and speed readings may be jacked, which this flight crew knew already and was working down that path. Their major problem is that the Captain never realized he had a major pitch problem going on in addition to the immediate indications.

That said, I think they did okay under the circumstances. They were working down the issues that they knew about. If they were in a NG, they would have landed and been fine. The fact that the manufacturer had a bug hidden away that would essentially add a runaway stab to the crisis was the fatal aspect. Boeing expected flight crews to recognize a runaway stab and hinged their cert justification on that, and to a degree that's correct - but the cause of the runaway stab was still their fault.

The AoA sensor problem was certainly an issue too, and could be construed to be the root cause. But component failure is a fact of life. A great chunk of my engineering career has been spent designing around the "what if's" of component failure than what I wanted the device to do when everything was normal. A component failure shouldn't create a sympathetic problem whose severity is even worse.

The report also went through the 737 MAX in great detail. I actually feel better about the airplane after reading it. Some aspects are a bit antiquated, but as engineers we have to balance older approaches under the "proven in use" argument as opposed to the "state of the art" argument. Both carry advantages and problems.

Thanks again to Indonesia for publishing this report. It is a credit to the KNKT.


Spot on. Thank you for this, smithbs.
 
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Finn350
Posts: 1601
Joined: Tue Jul 09, 2013 4:57 am

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

Thu Oct 31, 2019 8:20 am

AirlineCritic wrote:
smithbs wrote:
I read the report. It was a good product - many thanks to the Indonesian team, and like the Ethiopian report it was informative and objective.

There's been a lot of flame on the forum toward the FO. I think this is a bit undeserved, and I'll bring these points out from the report:

* The FO was more verbally engaged at the beginning of trouble than the Captain. However, the Captain would either not answer him, countermand his suggestions, or quiz him in a cryptic manner. To this last point, the FO ran his memory items but the Captain just said "memory item" and left the FO wondering. If the Captain knew something the FO missed, he should have said so explicitly instead of leaving it at a confusing and open-ended comment. I can't find one instance of the Captain doing a useful favor for the FO for the whole transcript.

* Yes, the FO took about two minutes to find the Unreliable Airspeed checklist. To his defense, I'd point out that ATC was on his back and the QRH did not list that procedure on the Quick Action Index - he had to go find it.

* ATC was on his back and giving him instructions that the Captain's flying was not complying with. ATC wanted to help, but they also did the FO no favors.

* The Captain never communicated what he was doing to fly the airplane. This included large amounts of nose up trim, and messing with the flaps. The Captain seemed to hold his own in the "pilot vs MCAS pitch battle." But then he dumped the whole situation into the FO's lap without a word of how the aircraft was flying. To not brief the FO about the flying characteristics was bad on his part.

* The FO seemed surprised at the aircraft handling when he took control, but the Captain still didn't mention, "Oh yeah, you need to apply nose up trim in huge amounts." It was fatal because the simulations after the crash showed that a) two uncorrected applications of MCAS was enough to overcome the control column and b) the worst way to fly against MCAS was to apply short trim bursts, but that's what the FO unwittingly did - he seemed to rely on column movement and not so much with pitch control, but that is not how to play against MCAS.

In the training records, we see elements of what happened:

* Captain had write-ups on communication and CRM.

* FO had write-ups on fixation, missing details and being not so great at stick-and-rudder flying.

About the AoA Disagree light, there's been debate on this for months now. The report says it was discussed and would not have helped this situation. I agree - the AoA Disagree light would not have helped this flight crew. The AoA Disagree light just means your altitude and speed readings may be jacked, which this flight crew knew already and was working down that path. Their major problem is that the Captain never realized he had a major pitch problem going on in addition to the immediate indications.

That said, I think they did okay under the circumstances. They were working down the issues that they knew about. If they were in a NG, they would have landed and been fine. The fact that the manufacturer had a bug hidden away that would essentially add a runaway stab to the crisis was the fatal aspect. Boeing expected flight crews to recognize a runaway stab and hinged their cert justification on that, and to a degree that's correct - but the cause of the runaway stab was still their fault.

The AoA sensor problem was certainly an issue too, and could be construed to be the root cause. But component failure is a fact of life. A great chunk of my engineering career has been spent designing around the "what if's" of component failure than what I wanted the device to do when everything was normal. A component failure shouldn't create a sympathetic problem whose severity is even worse.

The report also went through the 737 MAX in great detail. I actually feel better about the airplane after reading it. Some aspects are a bit antiquated, but as engineers we have to balance older approaches under the "proven in use" argument as opposed to the "state of the art" argument. Both carry advantages and problems.

Thanks again to Indonesia for publishing this report. It is a credit to the KNKT.


Spot on. Thank you for this, smithbs.


Agree, very good summary.
 
User avatar
smithbs
Posts: 441
Joined: Wed May 17, 2017 6:09 pm

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

Thu Oct 31, 2019 1:32 pm

AirlineCritic wrote:
smithbs wrote:
I read the report. It was a good product - many thanks to the Indonesian team, and like the Ethiopian report it was informative and objective.

There's been a lot of flame on the forum toward the FO. I think this is a bit undeserved, and I'll bring these points out from the report:

* The FO was more verbally engaged at the beginning of trouble than the Captain. However, the Captain would either not answer him, countermand his suggestions, or quiz him in a cryptic manner. To this last point, the FO ran his memory items but the Captain just said "memory item" and left the FO wondering. If the Captain knew something the FO missed, he should have said so explicitly instead of leaving it at a confusing and open-ended comment. I can't find one instance of the Captain doing a useful favor for the FO for the whole transcript.

* Yes, the FO took about two minutes to find the Unreliable Airspeed checklist. To his defense, I'd point out that ATC was on his back and the QRH did not list that procedure on the Quick Action Index - he had to go find it.

* ATC was on his back and giving him instructions that the Captain's flying was not complying with. ATC wanted to help, but they also did the FO no favors.

* The Captain never communicated what he was doing to fly the airplane. This included large amounts of nose up trim, and messing with the flaps. The Captain seemed to hold his own in the "pilot vs MCAS pitch battle." But then he dumped the whole situation into the FO's lap without a word of how the aircraft was flying. To not brief the FO about the flying characteristics was bad on his part.

* The FO seemed surprised at the aircraft handling when he took control, but the Captain still didn't mention, "Oh yeah, you need to apply nose up trim in huge amounts." It was fatal because the simulations after the crash showed that a) two uncorrected applications of MCAS was enough to overcome the control column and b) the worst way to fly against MCAS was to apply short trim bursts, but that's what the FO unwittingly did - he seemed to rely on column movement and not so much with pitch control, but that is not how to play against MCAS.

In the training records, we see elements of what happened:

* Captain had write-ups on communication and CRM.

* FO had write-ups on fixation, missing details and being not so great at stick-and-rudder flying.

About the AoA Disagree light, there's been debate on this for months now. The report says it was discussed and would not have helped this situation. I agree - the AoA Disagree light would not have helped this flight crew. The AoA Disagree light just means your altitude and speed readings may be jacked, which this flight crew knew already and was working down that path. Their major problem is that the Captain never realized he had a major pitch problem going on in addition to the immediate indications.

That said, I think they did okay under the circumstances. They were working down the issues that they knew about. If they were in a NG, they would have landed and been fine. The fact that the manufacturer had a bug hidden away that would essentially add a runaway stab to the crisis was the fatal aspect. Boeing expected flight crews to recognize a runaway stab and hinged their cert justification on that, and to a degree that's correct - but the cause of the runaway stab was still their fault.

The AoA sensor problem was certainly an issue too, and could be construed to be the root cause. But component failure is a fact of life. A great chunk of my engineering career has been spent designing around the "what if's" of component failure than what I wanted the device to do when everything was normal. A component failure shouldn't create a sympathetic problem whose severity is even worse.

The report also went through the 737 MAX in great detail. I actually feel better about the airplane after reading it. Some aspects are a bit antiquated, but as engineers we have to balance older approaches under the "proven in use" argument as opposed to the "state of the art" argument. Both carry advantages and problems.

Thanks again to Indonesia for publishing this report. It is a credit to the KNKT.


Spot on. Thank you for this, smithbs.


Thanks. I was wrong about details on the QRH reference though - it was on the first page index. Second line, smaller print.
 
XRAYretired
Posts: 870
Joined: Fri Mar 15, 2019 11:21 am

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

Fri Nov 01, 2019 3:47 pm

Another date for the diary.

“All recommendations will be followed-up in the next three months, until January 2020,” said Air Transportation Director-General Polana B. Pramesti during a press conference at Soekarno-Hatta Airport, Friday, Nov. 1.
https://en.tempo.co/read/1267108/lion-a ... n-3-months

Ray

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