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Jetty
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How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 7:33 pm

After a Boeing 737 crashed near Amsterdam more than a decade ago, the Dutch investigators focused blame on the pilots for failing to react properly when an automated system malfunctioned and caused the plane to plummet into a field, killing nine people.

The fault was hardly the crew’s alone, however. Decisions by Boeing, including risky design choices and faulty safety assessments, also contributed to the accident on the Turkish Airlines flight.

https://www.nytimes.com/2020/01/20/busi ... gin-google

This article makes it clear that Boeings poor design choices far predate the MAX, but until recently they managed to hide the consequences.

What's it with Boeing repeatedly making automated systems dependent on just 1 sensor even when 2 are available? :?
 
GalaxyFlyer
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 7:50 pm

Again, the crew mishandles a pretty obvious autothrottle failure and it is Boeing’s fault. The RA displayed incorrectly, the A/T showed “RETARD” indicating it thought it was within landing parameters, all missed by three “experienced” crew.

The NYT isn’t an engineering document.

GF
 
Jetty
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 7:53 pm

GalaxyFlyer wrote:
Again, the crew mishandles a pretty obvious autothrottle failure and it is Boeing’s fault. The RA displayed incorrectly, the A/T showed “RETARD” indicating it thought it was within landing parameters, all missed by three “experienced” crew.

The NYT isn’t an engineering document.

GF

More than one factor can be at fault, and mostly is when anything serious happens. Regardless on how many blame you can put on the pilots, why make it a habit to rely on 1 sensor when there are more available? Because they kept updating a plane from the 60’s instead of using state of the art design and technology because it was cheaper? The NG might already have been a generation too much. That’s where Boeing’s responsibility comes into play.
 
speedbird52
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 8:59 pm

Jetty wrote:
GalaxyFlyer wrote:
Again, the crew mishandles a pretty obvious autothrottle failure and it is Boeing’s fault. The RA displayed incorrectly, the A/T showed “RETARD” indicating it thought it was within landing parameters, all missed by three “experienced” crew.

The NYT isn’t an engineering document.

GF

More than one factor can be at fault, and mostly is when anything serious happens. Regardless on how many blame you can put on the pilots, why make it a habit to rely on 1 sensor when there are more available? Because they kept updating a plane from the 60’s instead of using state of the art design and technology because it was cheaper? The NG might already have been a generation too much. That’s where Boeing’s responsibility comes into play.

What? What are you talking about? Every airplane in the sky has an RA. It doesn't matter if it's a 737 Classic or a 787 or an A350. Every autothrottle system will retard the throttles at a certain altitude. If every radio altimeter can fail, and every autothrottle system retards the throttle based off of radio altimeter indications, then when a radio altimeter fails, the autothrottle will retard at an incorrect altitude. As for your statement about the autothrottle being dependent on one sensor, it is possible to switch between the CA and FO RAs. Any competent pilot would have noticed the inconsistency between the two RAs and the BAs, and ether disengaged the autothrottle or switched it over. An autothrottle failing is no where near to being the same thing as an airplane trying to fly itself into the ground.

If an A380 gave an auditory "retard" warning 1000 feet above the ground, and the pilots pulled the throttle back, would the subsequent crash be Airbus's fault? If anything "state of the art design and technology" is one of the root causes behind the crash, because it lulled the pilots into a false sense of security when it was their responsibility to monitor the aircraft's systems.
 
kalvado
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 9:21 pm

speedbird52 wrote:
Jetty wrote:
GalaxyFlyer wrote:
Again, the crew mishandles a pretty obvious autothrottle failure and it is Boeing’s fault. The RA displayed incorrectly, the A/T showed “RETARD” indicating it thought it was within landing parameters, all missed by three “experienced” crew.

The NYT isn’t an engineering document.

GF

More than one factor can be at fault, and mostly is when anything serious happens. Regardless on how many blame you can put on the pilots, why make it a habit to rely on 1 sensor when there are more available? Because they kept updating a plane from the 60’s instead of using state of the art design and technology because it was cheaper? The NG might already have been a generation too much. That’s where Boeing’s responsibility comes into play.

What? What are you talking about? Every airplane in the sky has an RA. It doesn't matter if it's a 737 Classic or a 787 or an A350. Every autothrottle system will retard the throttles at a certain altitude. If every radio altimeter can fail, and every autothrottle system retards the throttle based off of radio altimeter indications, then when a radio altimeter fails, the autothrottle will retard at an incorrect altitude. As for your statement about the autothrottle being dependent on one sensor, it is possible to switch between the CA and FO RAs. Any competent pilot would have noticed the inconsistency between the two RAs and the BAs, and ether disengaged the autothrottle or switched it over. An autothrottle failing is no where near to being the same thing as an airplane trying to fly itself into the ground.

If an A380 gave an auditory "retard" warning 1000 feet above the ground, and the pilots pulled the throttle back, would the subsequent crash be Airbus's fault? If anything "state of the art design and technology" is one of the root causes behind the crash, because it lulled the pilots into a false sense of security when it was their responsibility to monitor the aircraft's systems.

At least one other article quotes relevant part of investigation, commenting that "few pilots out there actually know how that works". Thanks for the confirmation.
FYI, they say that AT in 737NG is left side RA only.

UPD: https://www.msn.com/en-us/money/compani ... ar-BBZ8Saf
What the pilots couldn’t have known was that the computer controlling the engine thrust always relied on the left sensor, even when the controls on the right were flying the plane. That critical information was nowhere to be found in the Boeing pilots’ manual, Dr. Dekker learned.

Erik van der Lely, a 737 NG pilot and instructor for a European airline who studied under Dr. Dekker, told The Times that he had not known about this design peculiarity until he read a copy of the study. “I’m pretty sure none or almost none of the 737 pilots knew that,” he said.
 
IWMBH
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 9:36 pm

This is just the NY-times exploiting the MAX hype to get the attention of readers. If you read the report you'll see that Boeing was partly blamed for the crash and that they did issued a bulletin how pilots should handle these issues in the future.

Furthermore, it doesn't matter which plane you fly equipment can fail and pilots should be able the react accordingly. And unfortunately, because they where late with their checklists the Turkish Airlines-crew made a mistake and failed to notice the airspeed of the plane. I think it is a bad thing that the press starts mentioning these kind of things, it's just painful for the relatives of the victims.
 
speedbird52
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 10:08 pm

kalvado wrote:
speedbird52 wrote:
Jetty wrote:
More than one factor can be at fault, and mostly is when anything serious happens. Regardless on how many blame you can put on the pilots, why make it a habit to rely on 1 sensor when there are more available? Because they kept updating a plane from the 60’s instead of using state of the art design and technology because it was cheaper? The NG might already have been a generation too much. That’s where Boeing’s responsibility comes into play.

What? What are you talking about? Every airplane in the sky has an RA. It doesn't matter if it's a 737 Classic or a 787 or an A350. Every autothrottle system will retard the throttles at a certain altitude. If every radio altimeter can fail, and every autothrottle system retards the throttle based off of radio altimeter indications, then when a radio altimeter fails, the autothrottle will retard at an incorrect altitude. As for your statement about the autothrottle being dependent on one sensor, it is possible to switch between the CA and FO RAs. Any competent pilot would have noticed the inconsistency between the two RAs and the BAs, and ether disengaged the autothrottle or switched it over. An autothrottle failing is no where near to being the same thing as an airplane trying to fly itself into the ground.

If an A380 gave an auditory "retard" warning 1000 feet above the ground, and the pilots pulled the throttle back, would the subsequent crash be Airbus's fault? If anything "state of the art design and technology" is one of the root causes behind the crash, because it lulled the pilots into a false sense of security when it was their responsibility to monitor the aircraft's systems.

At least one other article quotes relevant part of investigation, commenting that "few pilots out there actually know how that works". Thanks for the confirmation.
FYI, they say that AT in 737NG is left side RA only.

UPD: https://www.msn.com/en-us/money/compani ... ar-BBZ8Saf
What the pilots couldn’t have known was that the computer controlling the engine thrust always relied on the left sensor, even when the controls on the right were flying the plane. That critical information was nowhere to be found in the Boeing pilots’ manual, Dr. Dekker learned.

Erik van der Lely, a 737 NG pilot and instructor for a European airline who studied under Dr. Dekker, told The Times that he had not known about this design peculiarity until he read a copy of the study. “I’m pretty sure none or almost none of the 737 pilots knew that,” he said.

My only experience with the 737 is Zibo and the NGX in flight sim, and I know how it works. It doesn't matter if they didn't know which sensor was controlling the engines because they have something called the "autothrottle disengage button"
 
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NYPECO
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 10:39 pm

Jetty wrote:
GalaxyFlyer wrote:
Again, the crew mishandles a pretty obvious autothrottle failure and it is Boeing’s fault. The RA displayed incorrectly, the A/T showed “RETARD” indicating it thought it was within landing parameters, all missed by three “experienced” crew.

The NYT isn’t an engineering document.

GF

More than one factor can be at fault, and mostly is when anything serious happens. Regardless on how many blame you can put on the pilots, why make it a habit to rely on 1 sensor when there are more available? Because they kept updating a plane from the 60’s instead of using state of the art design and technology because it was cheaper? The NG might already have been a generation too much. That’s where Boeing’s responsibility comes into play.


What does a malfunctioning radar altimeter have to do with the aircraft design when it's the same instrument used on modern aircraft?
 
spacecadet
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 10:50 pm

You have to be able to expect pilots to actually fly the plane. For every post we have here and elsewhere about how pilots have lost basic airmanship skills due to automation, we're now getting seemingly an equal number saying basic airmanship shouldn't be required and the automation should be infallible. These are incompatible philosophies.

The philosophy the entire industry has always operated under, continues to, and should continue to in the future, is that the pilots need to be able to fly the plane. If your speed drops 40 knots below Vap on final approach, it doesn't matter why - fix it! It was well within these pilots' capability to do so, and they didn't. That is why the plane crashed.

What should have come out of this accident is not more or better automation, but better piloting. Complacency is an issue with automation and that's what happened here. More training is needed to mitigate or even eliminate that complacency, because it's only going to get worse the more pervasive and reliable automation gets. It's kind of a paradox that the safer you make the automation, the more dangerous you make it when it fails. But that's the paradox we constantly need to deal with. In all cases, though, the ones in control of the plane are the pilots, not the automation. If the speed is decaying, the pilots need to see it and do something about it.
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Revelation
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 10:51 pm

From what I've seen, "jedi mind tricks" that avoid corporate liability are not only appreciated but actively encouraged by the management types. Entire layers of management spend the bulk of their time trying to lay jedi mind tricks on others. I'm not sure why people would find it unusual for Boeing to push back on accepting blame. We can find cases of them doing so back to the days of the 707, and I'm sure even further if we look back even further.
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keesje
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 10:52 pm

Not surprising, I pointed similarities in the design and Boeing tactic on Turkish 1951 last year. Similar to specially the Lionair crash.

search.php?keywords=Keesje+1951&t=1432067&sf=msgonly

Dismissing rumours, wait of the official investigation report, while blaming pilots, playing with public pre-occupations, buying time.

The 737 emergency warning system and systems fighting the pilot, giving incorrect information. Low redundancy, too much reliance on pilot reaction.

Grandfathered requirements allowed based on a safety record that excluded this crash and 2 other 737NG where the confusing emergency warning system played a role.

Please stop defending bad practices. Blind loyalty ends you up on the wrong side of the line.
Last edited by keesje on Mon Jan 20, 2020 11:03 pm, edited 1 time in total.
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kalvado
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 11:01 pm

speedbird52 wrote:
kalvado wrote:
speedbird52 wrote:
What? What are you talking about? Every airplane in the sky has an RA. It doesn't matter if it's a 737 Classic or a 787 or an A350. Every autothrottle system will retard the throttles at a certain altitude. If every radio altimeter can fail, and every autothrottle system retards the throttle based off of radio altimeter indications, then when a radio altimeter fails, the autothrottle will retard at an incorrect altitude. As for your statement about the autothrottle being dependent on one sensor, it is possible to switch between the CA and FO RAs. Any competent pilot would have noticed the inconsistency between the two RAs and the BAs, and ether disengaged the autothrottle or switched it over. An autothrottle failing is no where near to being the same thing as an airplane trying to fly itself into the ground.

If an A380 gave an auditory "retard" warning 1000 feet above the ground, and the pilots pulled the throttle back, would the subsequent crash be Airbus's fault? If anything "state of the art design and technology" is one of the root causes behind the crash, because it lulled the pilots into a false sense of security when it was their responsibility to monitor the aircraft's systems.

At least one other article quotes relevant part of investigation, commenting that "few pilots out there actually know how that works". Thanks for the confirmation.
FYI, they say that AT in 737NG is left side RA only.

UPD: https://www.msn.com/en-us/money/compani ... ar-BBZ8Saf
What the pilots couldn’t have known was that the computer controlling the engine thrust always relied on the left sensor, even when the controls on the right were flying the plane. That critical information was nowhere to be found in the Boeing pilots’ manual, Dr. Dekker learned.

Erik van der Lely, a 737 NG pilot and instructor for a European airline who studied under Dr. Dekker, told The Times that he had not known about this design peculiarity until he read a copy of the study. “I’m pretty sure none or almost none of the 737 pilots knew that,” he said.

My only experience with the 737 is Zibo and the NGX in flight sim, and I know how it works. It doesn't matter if they didn't know which sensor was controlling the engines because they have something called the "autothrottle disengage button"

Think about it in such a way: you're making certain statement from the position of being in the know - and then I point out that a specific fact you used as part of the reasoning is wrong, and lack of information about that very feature is discussed as a potential contributing factor in a crash. So, what is the take home message here?
 
kalvado
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 11:07 pm

JayinKitsap wrote:
The aviation systems around the world have done an amazing job making commercial aviation far safer, like over a 10 fold increase in miles flown without accident. But we really need all that ripped apart and let the lawyers sue everyone into collapse.

Lawer talk is the only language Wall street types understand. Apparently, technical reasoning is not being heard at Boeing...
And getting safer.. I wouldn't be surprised if the trend is to be reversed. People obviously getting used to things being safe - where it takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that! Read Rogers commission report as an example of how that works
 
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Aesma
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Mon Jan 20, 2020 11:57 pm

I remember reading the Helios crash report and getting out of it that the 737 cockpit is badly outdated, with tons of little confusing things. After that crash changes were mandated to the pressurization panel.

We all have one airline to thank for this...and Boeing pandering to it, of course.
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dangle
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 12:12 am

IWMBH wrote:
This is just the NY-times exploiting the MAX hype to get the attention of readers. If you read the report you'll see that Boeing was partly blamed for the crash and that they did issued a bulletin how pilots should handle these issues in the future.

Furthermore, it doesn't matter which plane you fly equipment can fail and pilots should be able the react accordingly. And unfortunately, because they where late with their checklists the Turkish Airlines-crew made a mistake and failed to notice the airspeed of the plane. I think it is a bad thing that the press starts mentioning these kind of things, it's just painful for the relatives of the victims.


This jumped out at me from the NYT article, that not just was the Turkish Airlines crew late on their checklist, but that "As the plane dipped to 1,000 feet, the pilots had not yet completed their landing checklist. Strict adherence to airline procedure would have meant circling around for another try, but violations were commonplace at the busy runway, investigators later determined."

While it is clear that pilots need to be the final arbiters of the safety of their aircraft, it is concerning that modern commercial flight may be becoming too complex for humans to quickly correct within the "four second rule."

Yes, it seems inexcusable that a pilot is not aware of their airspeed, but what if this is in the context of multiple other factors distracting them, perhaps at an airport where it is not uncommon to be faced with landing without having completed the checklist. It doesn't matter if each individual factor is easily managed by a competent pilot if too many issues arise too quickly.
 
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kanban
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 12:39 am

every week we see one airline or another experiencing flight deck personal skipping checklist items, not paying attention, being unaware of the aircrafts position, or not understanding the procedures for flying safely and generally being stupid (I'll just set my coke here on the control stand while I deal with this turbulence"). the scenario hasn't improved or devolved with the two person cockpit. the OEM always takes the first hit from the press, then the legal sharks seeking a feeding frenzy stir up the press in hopes of a big payoff. Those two items are the reasons no OEM accepts responsibility immediately, if ever, until the facts are discovered.

In this case Boeing has learned it's lesson and has taken steps to correct both the problem and the culture that created it. So why the F*** do we have imbeciles with no substantive knowledge wanting another pound of flesh or 30 seconds of fame? Get over it.
 
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ClipperMonsoon
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 12:58 am

keesje wrote:
Not surprising, I pointed similarities in the design and Boeing tactic on Turkish 1951 last year. Similar to specially the Lionair crash.

search.php?keywords=Keesje+1951&t=1432067&sf=msgonly

Dismissing rumours, wait of the official investigation report, while blaming pilots, playing with public pre-occupations, buying time.

The 737 emergency warning system and systems fighting the pilot, giving incorrect information. Low redundancy, too much reliance on pilot reaction.

Grandfathered requirements allowed based on a safety record that excluded this crash and 2 other 737NG where the confusing emergency warning system played a role.

Please stop defending bad practices. Blind loyalty ends you up on the wrong side of the line.


Pot meet the kettle, doesnt sound to me like you've ever piloted a large aircraft
The true Queen of the Skies has an HF antenna probe atop the stabilizer, the Boeing 707-321B
 
speedbird52
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 12:59 am

kalvado wrote:
speedbird52 wrote:
kalvado wrote:
At least one other article quotes relevant part of investigation, commenting that "few pilots out there actually know how that works". Thanks for the confirmation.
FYI, they say that AT in 737NG is left side RA only.

UPD: https://www.msn.com/en-us/money/compani ... ar-BBZ8Saf

My only experience with the 737 is Zibo and the NGX in flight sim, and I know how it works. It doesn't matter if they didn't know which sensor was controlling the engines because they have something called the "autothrottle disengage button"

Think about it in such a way: you're making certain statement from the position of being in the know - and then I point out that a specific fact you used as part of the reasoning is wrong, and lack of information about that very feature is discussed as a potential contributing factor in a crash. So, what is the take home message here?

That I made a mistake in my argument. Also, I don't know if a flight simulator nerd counts as "someone in the know". It seems more like that (with all due respect) you are just clueless and I have basic knowledge of the subject. For arguments sake lets assume I was right and there was a way to switch the autothrottles radio altimeter to the FO: It isn't exactly relevant because, and I must stress this, the autothrottle failing did not crash the plane.[i] What caused the crash was [i]the pilots failing to notice the autothrottle had malfunctioned.
 
hivue
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 1:03 am

Boeing is a cheap target these days. I suppose next in line we'll see some publication retrospectively placing the preponderance of blame on them for OZ214 due to the "flight level change mode trap" they built in with no regard at all for human life.
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kalvado
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 1:25 am

kanban wrote:
In this case Boeing has learned it's lesson and has taken steps to correct both the problem and the culture that created it. So why the F*** do we have imbeciles with no substantive knowledge wanting another pound of flesh or 30 seconds of fame? Get over it.

In this case, Boeing behaved exact same way as after JT crash - so no lessons learned after all.
 
morrisond
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 1:45 am

hivue wrote:
Boeing is a cheap target these days. I suppose next in line we'll see some publication retrospectively placing the preponderance of blame on them for OZ214 due to the "flight level change mode trap" they built in with no regard at all for human life.


Or it will be Boeing's fault that an 737 NG crashed in the ET409 incident because the plane couldn't figure out that the Pilot couldn't fly and should have turned the Autopilot on automatically.
 
zippy
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 2:43 am

morrisond wrote:
Or it will be Boeing's fault that an 737 NG crashed in the ET409 incident because the plane couldn't figure out that the Pilot couldn't fly and should have turned the Autopilot on automatically.


That is a very curious position to take considering that Boeing didn't (correctly) document how the radio altimeters worked and actively discouraged additional pilot training.
 
Cubsrule
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 3:49 am

zippy wrote:
morrisond wrote:
Or it will be Boeing's fault that an 737 NG crashed in the ET409 incident because the plane couldn't figure out that the Pilot couldn't fly and should have turned the Autopilot on automatically.


That is a very curious position to take considering that Boeing didn't (correctly) document how the radio altimeters worked and actively discouraged additional pilot training.


Help me with “didn’t (correctly) document how the radio altimeter worked.” Doesn’t any competent pilot of any transport category aircraft have an acceptably comprehensive idea of how the RA works?

This really isn’t any different from Atlas 3591 or Air France 447. When the airplane does something the pilot isn’t expecting, it’s his or her job to fly the airplane.
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GalaxyFlyer
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 3:53 am

Or simpler still, a competent airline pilot should be able to comprehend what “RETARD “ means in reference to the A/T system. Especially when he asks for more thrust due to low airspeed and the throttles snap back. I swear we are dumbing down flying.
 
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zeke
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 4:24 am

GalaxyFlyer wrote:
Again, the crew mishandles a pretty obvious autothrottle failure and it is Boeing’s fault. The RA displayed incorrectly, the A/T showed “RETARD” indicating it thought it was within landing parameters, all missed by three “experienced” crew.

The NYT isn’t an engineering document.

GF


This reply disappointing considering the number of people that died, this was completely preventable by the aircraft. Like the MCAS issue Boeing and their supporters are saying the last line of defense when things go wrong is the pilots. However like MCAS this accident has highlighted that a single sensor failure has unintended outcomes that pilots are not made aware of, however Boing was fully aware of this issue at least 5 years before the accident.

This autothrottle anomaly has been known to Boeing for some time, in 2004, Boeing was made aware that a faulty radio altimeter could cause the autothrottle to enter retard flare mode when it should not. At that time five cases of this had been reported. Boeing’s tests found that a faulty altimeter reading would not necessarily be flagged as such inside the computer system. In 2006, it rolled out a solution to the problem in the form of a software update to all new 737s built from 2006 onward, which prevented the autothrottle from entering retard flare mode if the two radio altimeter readings didn’t agree. However, the autothrottles on 737s built before 2006 (including the accident airplane) ran a different operating system that couldn’t support the new software, so they didn’t receive the update. (Testing after the crash showed that the update was not 100% effective anyway.) This was not considered a safety issue because, if retard flare mode engaged erroneously, the pilots could simply disable the autothrottle and continue the flight, as they had done in all reported incidents up to that time, and indeed as they did in seven more incidents that occurred after that.

There was nothing on the 737 at the time to warn pilots of an impending low energy state, that low energy state could be as a result of external factors like wind shear or in this case a single sensor failure. Low energy states is a predictable state, many aircraft over the years have got themselves into low energy states for various reasons, often resulting in a loss of life.

In contrast on the A320 you will have a LOW ENERGY WARNING A low energy aural warning “SPEED SPEED SPEED” repeated every 5 s indicates to the pilot that the aircraft energy becomes lower than a threshold under which to recover a positive flight path angle through pitch control, the thrust must be increased. The low energy warning is triggered during deceleration before alpha floor (unless alpha floor is triggered by stick deflection), the delay between the two warnings depends on deceleration rate. If the speed decay continues, autothrust will command TOGA. The system does not care what precipitated to get to the low energy state, a failure of the aircraft systems, environmental conditions, or the pilots, it will maintain a safe energy state.

This fix resulting from this accident is very similar to the A320, Boing added a low speed aural warning to pilots, but only rolled that out to the 737. So they had over a dozen low speed events on the 737 and somehow through the it’s was restricted to that fleet only. Then Asiana Flight 214 crashes in SFO, which could have been totally preventable if they had rolled out the low speed warning to all fleets, not just the 737. That however would cost money.

You claim that the pilots should have seen the RETARD on the FMA, the pilots did talk about the -8 feet being on the PFD, they did talk about the unsafe gear warning. However there is a philosophical shift between Boeing and Airbus training when it comes to FMAs. Airbus are strict on knowing the FMA at all times, and calling out any changes to the FMA. Boeing does not have the same philosophy.

What up you failed to mention is that these pilots are performing a glide slope intercept from above. The reason why the RETARD was missed, it came right when they expected thrust to decrease anyway. When intercepting the glide slope from above. altitude must be lost quickly, and a high descent rate was selected. The crew fully expected the autothrottle to decrease thrust to achieve this high descent rate. None of the three pilots noticed that the autothrottle mode on their displays had changed to “retard,” and that the decrease in thrust was actually because the computer thought they were landing.

To understand why the auto throttle went into retard mode, it is necessary to understand the logic. The retard flare mode can only activate when the autothrottle is engaged, the radar altimeter detects less than 27 feet above the ground, the flaps are extended beyond 12.5 degrees, and no target altitude is selected. When all of these conditions are met, this tells the autothrottle that the plane is seconds from touchdown, so retard flare mode engages thrust is brought back to idle. As it happened, during the glide slope intercept from above, all three logic gates were met with the faulty rad alt.

You also failed to mention when the crew received the stick shaker, The FO as PF increased thrust on both engines and pushed his control column forward to prevent the stall from occurring. But within a second or two, Capt, said “I have control,”. During the handover of controls the FO removed their hands from the throttles, with the “retard flare” mode is still engaged, manual power inputs are not allowed, so the autothrottle simply rolled both engines back to idle and the aircraft stalled.

speedbird52 wrote:
What? What are you talking about? Every airplane in the sky has an RA. It doesn't matter if it's a 737 Classic or a 787 or an A350. Every autothrottle system will retard the throttles at a certain altitude. If every radio altimeter can fail, and every autothrottle system retards the throttle based off of radio altimeter indications, then when a radio altimeter fails, the autothrottle will retard at an incorrect altitude. As for your statement about the autothrottle being dependent on one sensor, it is possible to switch between the CA and FO RAs.


This is not true, the autothrottle behaviors on a Boeing and autothrust on an Airbus which there to achieve similar end goals are implemented differently.

On an Airbus in the flare the autothrust DOES NOT bring the thrust back to IDLE when manually flying (it announces RETART at 20 ft to remind the pilots to manually do so), it will only reduce thrust to IDLE when under a fully automatic autoland Ask any instructor pilot who trains pilots coming across from a Boeing, they will tell you about flying along the runway at 10 ft at approach speed as the pilot under training is waiting for the the autothrottle to bring thrust back to IDLE. To land an Airbus manually the pilot has to physically bring the thrust levers back to IDLE. The Airbus philosophy when manually flying, the pilots must manually land, when doing an autoland it is the autopilot doing the landing.

When manually flying or during an autoland, the Boeing will bring the throttle back to IDLE.
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 4:30 am

JayinKitsap wrote:
We really need to design a plane with a minimum safety factor of 2.0, than can stop missiles, perform a 10g landing while not exceeding 2 g on any passenger, has the controls to prevent stalls or tail strikes, and sufficient automation that pilots are not needed. Further, any accident is to compensate each victim with $10M. Aviation accidents following that mandate will tend toward ZERO. But that is because aviation ceases.

The aviation systems around the world have done an amazing job making commercial aviation far safer, like over a 10 fold increase in miles flown without accident. But we really need all that ripped apart and let the lawyers sue everyone into collapse.


Not just accidents - expand the settlements to also include "pain and suffering" for any emergency landing LMAO.
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 4:37 am

Bad reporting by journalist
 
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 5:48 am

zeke wrote:

speedbird52 wrote:
What? What are you talking about? Every airplane in the sky has an RA. It doesn't matter if it's a 737 Classic or a 787 or an A350. Every autothrottle system will retard the throttles at a certain altitude. If every radio altimeter can fail, and every autothrottle system retards the throttle based off of radio altimeter indications, then when a radio altimeter fails, the autothrottle will retard at an incorrect altitude. As for your statement about the autothrottle being dependent on one sensor, it is possible to switch between the CA and FO RAs.


This is not true, the autothrottle behaviors on a Boeing and autothrust on an Airbus which there to achieve similar end goals are implemented differently.

On an Airbus in the flare the autothrust DOES NOT bring the thrust back to IDLE when manually flying (it announces RETART at 20 ft to remind the pilots to manually do so), it will only reduce thrust to IDLE when under a fully automatic autoland Ask any instructor pilot who trains pilots coming across from a Boeing, they will tell you about flying along the runway at 10 ft at approach speed as the pilot under training is waiting for the the autothrottle to bring thrust back to IDLE. To land an Airbus manually the pilot has to physically bring the thrust levers back to IDLE. The Airbus philosophy when manually flying, the pilots must manually land, when doing an autoland it is the autopilot doing the landing.

When manually flying or during an autoland, the Boeing will bring the throttle back to IDLE.

I am aware of this crucial difference and highlighted it in a separate post. My bad for not bringing it up again.
 
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 7:20 am

speedbird52 wrote:
kalvado wrote:
speedbird52 wrote:
My only experience with the 737 is Zibo and the NGX in flight sim, and I know how it works. It doesn't matter if they didn't know which sensor was controlling the engines because they have something called the "autothrottle disengage button"

Think about it in such a way: you're making certain statement from the position of being in the know - and then I point out that a specific fact you used as part of the reasoning is wrong, and lack of information about that very feature is discussed as a potential contributing factor in a crash. So, what is the take home message here?

That I made a mistake in my argument. Also, I don't know if a flight simulator nerd counts as "someone in the know". It seems more like that (with all due respect) you are just clueless and I have basic knowledge of the subject. For arguments sake lets assume I was right and there was a way to switch the autothrottles radio altimeter to the FO: It isn't exactly relevant because, and I must stress this, the autothrottle failing did not crash the plane.[i] What caused the crash was [i]the pilots failing to notice the autothrottle had malfunctioned.

But you don’t have basic knowledge of the subject, quite evidently I might add.

It’s incorrect to say every plane in the sky has a radio altimeter. Some very old aircraft may not (many do receive it when they install and aftermarket FMS like Universal’s UNS or something like that), very many GA aircraft do not have them, and sometimes normal transport aircraft do not have them when they fail. Normally when the radio altimeter fails it’s just an inconvenience because you expect those callouts and one day they’re not there and it throws off your landing technique, otherwise it shouldn’t impact your operation in good visibility; however, the 737 has shown that with it this is not always the case.

You compare this to a pilot manually retarding the throttle on the A380 if it calls for it 1000 feet off the ground. That’s a faulty comparison and your logic is purely non sequitur here. It just doesn’t equate.

I can vouch for using the PMDG NGX because I have tried it out in my spare time a considerable amount and one thing I have always criticized about it, though I understand why they do it, is that it is not realistic to not be able to ever influence the position of the thrust levers when AT is armed and in a functioning mode. If you force them they will move, but they’ll then reassume their computer commanded position. As well I am under the impression that if it is in “ARM” mode it could be moved, yet this is not modelled in that simulation. I have to say from the things I hear even the multi million dollar simulators aren’t a perfect representation of what an aircraft is actually like, most extreme case being the infamous “MAX” simulators. Flying an NGX or NGXu for that matter helps for learning some things because it is a well made emulation of a 737NG, but there are a few inaccuracies or things left out and most customers of that product use it so badly wrong anyway that it doesn’t matter. It’s not a product that will allow you to have qualified knowledge or opinion on the interplay between radio altimeter sources and the autothrottle system.

Similar to the MAX, main causal event so I understand here was the auto throttle erroneously going into RETARD due to lack of redundancy in data... just like MCAS. I would agree with someone that between pilot error and engineering error/corporate wrongdoing this is a little more of an in between shared fault than MCAS for example is, but let’s be real here, if this error occurs and the pilots offer no input whatsoever, the aircraft will crash by itself. This requires them to perform actions to stop something the aircraft started itself. The design is the primary cause here. An example of human error crash would be more along the lines of Asiana where the aircraft didn’t really do anything by itself that would cause it t crash or otherwise be unstable; rather, it was guided into an unstable approach situation but the crew (partly due to their confused knowledge of the systems). You see the difference? It’s all about what started the chain of events and what sort of action is required to correct it.

As said elsewhere the 737 at that point should have had an aural low air speed warning like the A320 has always(?) had; in fact, all these aircraft should have an aural warning for that and it should not be optional. Treat it much like the dual input side stick warning, which proved to be a necessity. Another problem on the 737 is it’s auto throttle design and logic is actually pretty counterintuitive to human nature. So in an example like this one’s first response when airspeed is low when they are training to be a pilot is to reach over and add power if putting the nose down isn’t an option or will not reach desirable outcome. On a Boeing, particularly the 737, you do not do this. It will alloy you to increase thrust, but then it will resume what it wants, in this case being idling out the engines so it seems. You can see in this video exactly this as they perform a go around seemingly without selecting the correct auto throttle mode to do so: https://www.youtube.com/watch?v=VmtoqsfCyXo

Of course, the AT arm switch or the super convenient buttons. can be used to stop all of this nonsense and they should have known to use that knowing the 737’s auto throttle, hard to dispute that, but that doesn’t exonerate Boeing from making a suboptimal design yet again. The auto throttle logic does not follow the same logic the rest of the auto flight does (same criticism that MCAS gets and you’ll see why). If something goes wrong with STS or with the autopilot, simple counteracting column force will disengage the automation without needing to use switches. These systems are designed like this for a very good reason. Why is this not the case for the auto throttle? Why does it not engage like the other auto flight systems when you intentionally override it? Why did they think the same good reason did not apply to it that did to all the other auto flight systems? This is where I will argue to my grave that if Airbus clearly did one thing right it was the auto thrust design they have. Far simpler to understand what you are asking from the automation and understand how to correct it if it is wrong. On an Airbus there are typically 3 positions (actually basically the same positions the CRJ has surprisingly enough). There’s the idle position, the range in between where you can manually manipulate the thrust up to the climb position. This position functions as the position you leave it in after takeoff until you want to shut it off much like when you select VNAV, FLCH, or Speed on a Boeing and it behaves mostly the same just being more centric around the mode you select on the thrust lever rather than the MCP. It can do climb, speed, or idle which is more simple than what Boeing offers in the same range while achieving the same goal. This is the selection where auto thrust truly operates in the traditional “auto throttle” sense. Beyond that is FLX/MCT depending on whether you entered a flex temperature or not. In this range auto thrust is armed but it does not have authority to change anything. Beyond that is the final TO/GA setting which works the same as the previous setting but is just basically max power. Then if it’s an A320 there’s also the reverse thing but that’s not important. So let’s say on an Airbus the auto thrust is in an incorrect mode and the airspeed is getting dangerously low. To correct one can simply firewall the levers and the automated mode is fully overridden. Auto thrust I believe remains armed and if so they can deal with that after crisis is averted. It follows the similar logic as if it the autopilot is misbehaving and you manipulate the control to override and correct, you just still have to disarm the system despite it already being inactive. Of course, this is all without assuming alpha protection doesn’t kick in first. Is just far more intuitive considering this is basically what is done on the smaller aircraft that are not automated. This is not to be an A vs B comparison even though it is more so than to show that this is once place where automation, in the Boeing, has over complicated the situation (unusual for me to wholeheartedly admit). To Airbus’s credit here they made a system that you treat far more more like an aircraft that lacks automation and also a system that yields itself to the most instinctual reaction any human would have in order to correct the issue. In the case of this flight, if all else were equal, it would likely have changed the outcome. Of course not to say they didn’t put that disarm button in a good place on the 737 because they actually did, it just shouldn’t need to rely on one. It’s simply not consistent with the override logic of all the other automated flight functions. It’s a design that does work so many times every day perfectly fine, it’s not nearly as bad as MCAS, but it could be better and even if it saved one life it would be that much better as one human life is worth infinitely more than Boeing (or Airbus) and their billions as far as I’m concerned.

Of course there still is that issue of Boeing defaulting to thinking its good enough to rely on a single input of sensor data... a reoccurring theme. This is truly where there is something to blame them for.

As for the news article, I am definitely no Boeing apologist, but I feel like they ran out of MAX news to run so they ran this. This is not even close to the MAX and it’s problems. The only thing relevant here like I said was that whole relying on a single sensor thing. That should never have been allowed... After how many times I’ve said that in the past year.
 
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 9:42 am

zeke wrote:
GalaxyFlyer wrote:
Again, the crew mishandles a pretty obvious autothrottle failure and it is Boeing’s fault. The RA displayed incorrectly, the A/T showed “RETARD” indicating it thought it was within landing parameters, all missed by three “experienced” crew.

The NYT isn’t an engineering document.

GF


This reply disappointing considering the number of people that died, this was completely preventable by the aircraft. Like the MCAS issue Boeing and their supporters are saying the last line of defense when things go wrong is the pilots. However like MCAS this accident has highlighted that a single sensor failure has unintended outcomes that pilots are not made aware of, however Boing was fully aware of this issue at least 5 years before the accident.

This autothrottle anomaly has been known to Boeing for some time, in 2004, Boeing was made aware that a faulty radio altimeter could cause the autothrottle to enter retard flare mode when it should not. At that time five cases of this had been reported. Boeing’s tests found that a faulty altimeter reading would not necessarily be flagged as such inside the computer system. In 2006, it rolled out a solution to the problem in the form of a software update to all new 737s built from 2006 onward, which prevented the autothrottle from entering retard flare mode if the two radio altimeter readings didn’t agree. However, the autothrottles on 737s built before 2006 (including the accident airplane) ran a different operating system that couldn’t support the new software, so they didn’t receive the update. (Testing after the crash showed that the update was not 100% effective anyway.) This was not considered a safety issue because, if retard flare mode engaged erroneously, the pilots could simply disable the autothrottle and continue the flight, as they had done in all reported incidents up to that time, and indeed as they did in seven more incidents that occurred after that.

There was nothing on the 737 at the time to warn pilots of an impending low energy state, that low energy state could be as a result of external factors like wind shear or in this case a single sensor failure. Low energy states is a predictable state, many aircraft over the years have got themselves into low energy states for various reasons, often resulting in a loss of life.

In contrast on the A320 you will have a LOW ENERGY WARNING A low energy aural warning “SPEED SPEED SPEED” repeated every 5 s indicates to the pilot that the aircraft energy becomes lower than a threshold under which to recover a positive flight path angle through pitch control, the thrust must be increased. The low energy warning is triggered during deceleration before alpha floor (unless alpha floor is triggered by stick deflection), the delay between the two warnings depends on deceleration rate. If the speed decay continues, autothrust will command TOGA. The system does not care what precipitated to get to the low energy state, a failure of the aircraft systems, environmental conditions, or the pilots, it will maintain a safe energy state.

This fix resulting from this accident is very similar to the A320, Boing added a low speed aural warning to pilots, but only rolled that out to the 737. So they had over a dozen low speed events on the 737 and somehow through the it’s was restricted to that fleet only. Then Asiana Flight 214 crashes in SFO, which could have been totally preventable if they had rolled out the low speed warning to all fleets, not just the 737. That however would cost money.

You claim that the pilots should have seen the RETARD on the FMA, the pilots did talk about the -8 feet being on the PFD, they did talk about the unsafe gear warning. However there is a philosophical shift between Boeing and Airbus training when it comes to FMAs. Airbus are strict on knowing the FMA at all times, and calling out any changes to the FMA. Boeing does not have the same philosophy.

What up you failed to mention is that these pilots are performing a glide slope intercept from above. The reason why the RETARD was missed, it came right when they expected thrust to decrease anyway. When intercepting the glide slope from above. altitude must be lost quickly, and a high descent rate was selected. The crew fully expected the autothrottle to decrease thrust to achieve this high descent rate. None of the three pilots noticed that the autothrottle mode on their displays had changed to “retard,” and that the decrease in thrust was actually because the computer thought they were landing.

To understand why the auto throttle went into retard mode, it is necessary to understand the logic. The retard flare mode can only activate when the autothrottle is engaged, the radar altimeter detects less than 27 feet above the ground, the flaps are extended beyond 12.5 degrees, and no target altitude is selected. When all of these conditions are met, this tells the autothrottle that the plane is seconds from touchdown, so retard flare mode engages thrust is brought back to idle. As it happened, during the glide slope intercept from above, all three logic gates were met with the faulty rad alt.

You also failed to mention when the crew received the stick shaker, The FO as PF increased thrust on both engines and pushed his control column forward to prevent the stall from occurring. But within a second or two, Capt, said “I have control,”. During the handover of controls the FO removed their hands from the throttles, with the “retard flare” mode is still engaged, manual power inputs are not allowed, so the autothrottle simply rolled both engines back to idle and the aircraft stalled.

speedbird52 wrote:
What? What are you talking about? Every airplane in the sky has an RA. It doesn't matter if it's a 737 Classic or a 787 or an A350. Every autothrottle system will retard the throttles at a certain altitude. If every radio altimeter can fail, and every autothrottle system retards the throttle based off of radio altimeter indications, then when a radio altimeter fails, the autothrottle will retard at an incorrect altitude. As for your statement about the autothrottle being dependent on one sensor, it is possible to switch between the CA and FO RAs.


This is not true, the autothrottle behaviors on a Boeing and autothrust on an Airbus which there to achieve similar end goals are implemented differently.

On an Airbus in the flare the autothrust DOES NOT bring the thrust back to IDLE when manually flying (it announces RETART at 20 ft to remind the pilots to manually do so), it will only reduce thrust to IDLE when under a fully automatic autoland Ask any instructor pilot who trains pilots coming across from a Boeing, they will tell you about flying along the runway at 10 ft at approach speed as the pilot under training is waiting for the the autothrottle to bring thrust back to IDLE. To land an Airbus manually the pilot has to physically bring the thrust levers back to IDLE. The Airbus philosophy when manually flying, the pilots must manually land, when doing an autoland it is the autopilot doing the landing.

When manually flying or during an autoland, the Boeing will bring the throttle back to IDLE.


Thanks Zeke for the clear explanation. This is not a new topic at all, it was just surpressed as irrelevant, Boeing bashing, off topic. We had a discussion about it last year, because the similarities, systems, involved institutions and follow up are so clearly the same. Indications of big company powerplay & weak safety culture IMO.
"Never mistake motion for action." Ernest Hemingway
 
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 2:14 pm

Again the similarity between two cars, the one I have has great automatic safety features, but it is difficult to understand just what those features are doing, and if and when they are doing it. Kid's Tesla has the same features but has them integrated with the steering wheel, accelerator, and brakes, he seldom has to think about what the car is also doing.

Boeing has put pilots in the position of not knowing just what the plane is doing, and in at least 3 cases relying on a single sensor which has failed. So as well as flying and relying on instruments, add to the workload sensitivity as to whether or maybe a single altimeter/AoA is failing.

ps - my next car may be a Tesla, Toyota arrogantly does not update computers on its cars. They think they are good enough. They aren't, only almost good enough.
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 3:30 pm

kanban wrote:
every week we see one airline or another experiencing flight deck personal skipping checklist items, not paying attention, being unaware of the aircrafts position, or not understanding the procedures for flying safely and generally being stupid (I'll just set my coke here on the control stand while I deal with this turbulence"). the scenario hasn't improved or devolved with the two person cockpit. the OEM always takes the first hit from the press, then the legal sharks seeking a feeding frenzy stir up the press in hopes of a big payoff. Those two items are the reasons no OEM accepts responsibility immediately, if ever, until the facts are discovered.

In this case Boeing has learned it's lesson and has taken steps to correct both the problem and the culture that created it. So why the F*** do we have imbeciles with no substantive knowledge wanting another pound of flesh or 30 seconds of fame? Get over it.

Yes, there are different ways to look at this.

OEMs trying to minimize damage and shed blame should not be news. PR and crisis management firms exist for this purpose. Accident reports do take several rounds of inputs from many different parties, one being the OEM. Edits based on this input are normal. Reporters trying to create links come across as piling on.

OEMs at best threading the needle and at worse playing "jedi mind tricks" when interacting with regulators is IMO far worse since it impacts every plane built by that OEM under that certificate, and every pilot trained to fly it, etc.

Boeing's claims of changing culture seem to be platitudes and window dressing. We've seen some of the top managers walk the plank, but what about all the mid and lower level manager trained under that regime, how do you get them to rewire their value system to break away from groupthink when some major high level initiative such as no sim training no longer makes sense? What more do we have to suggest culture is changing other than email from the newly appointed crony capitalist CEO?
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 3:40 pm

GalaxyFlyer wrote:
Or simpler still, a competent airline pilot should be able to comprehend what “RETARD “ means in reference to the A/T system. Especially when he asks for more thrust due to low airspeed and the throttles snap back. I swear we are dumbing down flying.

https://twitter.com/Satcom_Guru/status/ ... 6622727168 is a tweet from Peter Lemme (Satcom Guru), someone well known from 737 MAX reporting:

Saying every system on the airplane must be fail-safe, that the pilot is not part of the response to failure and malfunction, is much bigger than voting sensor inputs.
Pilots should be accountable for airspeed and altitude.
Pilots should be accountable to mode display.


Seems sensible to me, but it also seems discussion of pilot accountability gets overly simplified down to "blame the pilots".
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 3:48 pm

The pilots are the safety mechanism in an aircraft. Want to make aviation safer, train them better. Much more efficient than making the plane more and more complex.
 
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 5:19 pm

Not providing redundant sensors aside, I really wonder about Boeing's Human Factors Engineering capabilities. These incidents all seem to involve crews misreading ques or not understanding the state of the aircraft. Some of that maybe training (part of which is also Boeing's responsbility). But part of it is absolutely how information is collated and presented inside the cockpit.
 
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 5:52 pm

seahawk wrote:
The pilots are the safety mechanism in an aircraft. Want to make aviation safer, train them better. Much more efficient than making the plane more and more complex.


removing/fixing UI traps is NOT making it more complex. ( actually you have a chance to make it less complex.)

What increases complexity exponentially is adding onion layers for changing UI paradigms.
If you introduce a UI interface paradigm it must work consistently and not show its bones unexpectedly.
737 by way of its development path is the grandmother of all deformed onions. gene splicing and all :-)
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 6:17 pm

Revelation wrote:
Boeing's claims of changing culture seem to be platitudes and window dressing. We've seen some of the top managers walk the plank, but what about all the mid and lower level manager trained under that regime, how do you get them to rewire their value system to break away from groupthink when some major high level initiative such as no sim training no longer makes sense? What more do we have to suggest culture is changing other than email from the newly appointed crony capitalist CEO?


Two things to remember
1) Boeing does not publicly pillory the lower and middle range employees, they reassign them, send them to re-education classes, subject them to more frequent performance reviews. Most were doing their job as described by their management. The various reward systems unfortunately were driven by conformance to managers desire good or bad. these things are changing. Had one manager reassigned to managing a facilities maintenance crew when his gross incompetence was realized.

2) Boeing has a long history of "Can DO" unfortunately where it was appropriate during the B-17 manufacture, it continued to the present day where we say newbie managers using it as an excuse to bypass the processes and procedures of the company. These newbie MBA's see them selves as saviors and invariably start their careers wanting to change things with out enough comprehension of the process and the regulatory requirements. Many of the newbie MBAs also want a fast track to the top without ever touching the ground so they consciously become Yes men and enablers. this won't change with the next crop of newbies unless they are subject to some intense training and grunt work before being made managers. I recall when Condit and Mullaly first arrived at the company. They spent several years learning/working in each site and department before moving up.
 
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 6:46 pm

Microsoft always had answers to its bugs and blue screens of death. A great operating system but it depends on talented operators to understand its operation, in particular when it goes sideways.

In contrast, Apple and Google Android both have an interface that is far more intuitive, more likely to be operated properly in a panic.

We are making planes that are far more automated, but then its operators (the pilots) are not 'coders' but often an individual just getting its required hours. Are those hours actually operating the plane when the autopilot has tripped out due to an issue, or watching the plane fly itself.
 
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 6:49 pm

Aircraft shouldn't forcefully push down the nose or idde engines close to stall speed at a few hundred feet, fighting the pilots, crashing the aircraft. That's bad design.

The pilots are not there to correct design errors, outdated requirements or incomplete manuals. Thats up the manufacturers and certifying body. Having the pilot in full control of the aircraft sounds good, unless it is a lame excuse to not implement the latest, safest technology complying to the latests requirements.

It pisses me off watching people selling their souls & principles defending their fav company. Muilenburg apologized & was fired. Further investigations are ongoing.
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 7:01 pm

JayinKitsap wrote:
Microsoft always had answers to its bugs and blue screens of death. A great operating system but it depends on talented operators to understand its operation, in particular when it goes sideways.

In contrast, Apple and Google Android both have an interface that is far more intuitive, more likely to be operated properly in a panic.

We are making planes that are far more automated, but then its operators (the pilots) are not 'coders' but often an individual just getting its required hours. Are those hours actually operating the plane when the autopilot has tripped out due to an issue, or watching the plane fly itself.


Intuitive!!! may be to the team, not to users if they keep changing user interface without warning.

Are you saying coders are better than pilots? My first Fortran 84 program crashed because loop didn't have an exit condition and ran out of allocated memory. No coder should put 2.5 degree nose down every 10 seconds indefinitely and expect an reasonable outcome, not someone who writes flight control system software.
All posts are just opinions.
 
PdC
Posts: 1
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 7:08 pm

Original report published by Dutch safety Authority. Interesting read...
https://www.onderzoeksraad.nl/nl/media/inline/2020/1/21/human_factors_report_s_dekker.pdf
 
WIederling
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 8:22 pm

JayinKitsap wrote:
Microsoft always had answers to its bugs and blue screens of death.

Same for Boeing : "Pilot Error" :-))
Will any other accidents classified as "Pilot Error" be revisited?
( The report on the Korean 777 crash already holds a bag of NTSB hints that were muted, ignored)

A great operating system but it depends on talented operators to understand its operation, in particular when it goes sideways.
.


Then Microsoft Windows has the same characteristics that the 737 ( and Boeing ) shows.
to wit:
32 bit extensions and a graphical shell [on top of] a
16 bit patch to an
8 bit operating system originally coded for a
4 bit microprocessor, written by a
2 bit company, that can't stand
1 bit of competition."

Must be a Seattle thing? :-))

( I still await the moment someone finds out that Microsoft broke the GPL and stealthily runs a Linux Kernel under the hood
to get away from all their design mistakes.)
Murphy is an optimist
 
WPvsMW
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 9:10 pm

Gotta love that binary math, and Edge is now a Chromium fork....
"We adopted the Chromium open source project in the development of the new Microsoft Edge to create better web compatibility for our customers, and less fragmentation of the web for all web developers."
https://www.microsoftedgeinsider.com/en-us/
 
Cubsrule
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 9:19 pm

keesje wrote:
Aircraft shouldn't forcefully push down the nose or idde engines close to stall speed at a few hundred feet, fighting the pilots, crashing the aircraft. That's bad design.

The pilots are not there to correct design errors, outdated requirements or incomplete manuals. Thats up the manufacturers and certifying body. Having the pilot in full control of the aircraft sounds good, unless it is a lame excuse to not implement the latest, safest technology complying to the latests requirements.

It pisses me off watching people selling their souls & principles defending their fav company. Muilenburg apologized & was fired. Further investigations are ongoing.


I agree with the sentiment, but with the autothrottle/RA issue, how does this work in practice? What's the correct autothrottle response when the autothrottle receives bad RA information? By the way, this really isn't a one sensor/two sensor issue; with two sensors, disagreement likely results in some sort of reversion to a different/inferior control mode.
I can't decide whether I miss the tulip or the bowling shoe more
 
WayexTDI
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 9:29 pm

Cubsrule wrote:
keesje wrote:
Aircraft shouldn't forcefully push down the nose or idde engines close to stall speed at a few hundred feet, fighting the pilots, crashing the aircraft. That's bad design.

The pilots are not there to correct design errors, outdated requirements or incomplete manuals. Thats up the manufacturers and certifying body. Having the pilot in full control of the aircraft sounds good, unless it is a lame excuse to not implement the latest, safest technology complying to the latests requirements.

It pisses me off watching people selling their souls & principles defending their fav company. Muilenburg apologized & was fired. Further investigations are ongoing.


I agree with the sentiment, but with the autothrottle/RA issue, how does this work in practice? What's the correct autothrottle response when the autothrottle receives bad RA information? By the way, this really isn't a one sensor/two sensor issue; with two sensors, disagreement likely results in some sort of reversion to a different/inferior control mode.

And that's why there is usually 3 sensors in critical systems; but Boeing seem to think that 2 is enough on 737s (see the MAX)
 
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PW100
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 10:05 pm

The Dutch Accident Investigation Board has replied to the NYT accusations with respect to the TK1951 Accident Report.
Some interesting parallels occur with the Max crisis:



The only defence against a designed-in single-failure path [is] the pilots who are warned to mistrust their machine and to stare at it harder.

Such a reminder, oriented only at the human operator in the system, is hardly credible after three decades of in-depth research into automated airliner flying and the subtle and pervasive ways in which automation on the flight deck – and particularly its subtle failure – affects human performance.

Crews would not have been insulated from the “automation surprise” which emerged on the Turkish Airlines, owing to an absence of sufficient training, written guidance or documentation, or line experience.




The “automation surprise” reflects several issues, but primarily the fact that the autothrottle continued to use the Left Radio altimeter, despite FO being pilot flying and right-hand autoilot active:



The first officer, who was flying, was following his primary flight instruments including height measured by the right-hand radio altimeter.

But the left-hand radio altimeter, while reading incorrectly, did not categorise its reading as an error – which meant that, critically, it maintained control over various aircraft systems including the autothrottle. The crew was unaware of this and could not have known about it.

The human-factors analysis states that the crew, which had switched to the right-hand autopilot and right-hand flight-control computer, “would have believed that they had protected their aircraft” from any problems with the left-hand radio altimeter.

What is not in Boeing 737 documentation and training available to pilots is that the autothrottle always gets its height information from the left radio altimeter.

The knowledge available through training and pilot documentation is so underspecified that it in fact can create a false or buggy mental model about the inter-relationships between the various automated systems and their sensor input.

This is a relic from the Boeing 737, certificated long ago, which in the original design prioritised the provision of information to the [captain, seated on the left side].

It is noticeable that this subject cannot be found in any of the Boeing 737 manuals or training documents for pilots. Pilots therefore do not have the correct knowledge about links between the control systems and data input for their own aircraft.
Immigration officer: "What's the purpose of your visit to the USA?" Spotter: "Shooting airliners with my Canon!"
 
GalaxyFlyer
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Tue Jan 21, 2020 11:42 pm

zeke wrote:
GalaxyFlyer wrote:
Again, the crew mishandles a pretty obvious autothrottle failure and it is Boeing’s fault. The RA displayed incorrectly, the A/T showed “RETARD” indicating it thought it was within landing parameters, all missed by three “experienced” crew.

The NYT isn’t an engineering document.

GF


This reply disappointing considering the number of people that died, this was completely preventable by the aircraft. Like the MCAS issue Boeing and their supporters are saying the last line of defense when things go wrong is the pilots. However like MCAS this accident has highlighted that a single sensor failure has unintended outcomes that pilots are not made aware of, however Boing was fully aware of this issue at least 5 years before the accident.

This autothrottle anomaly has been known to Boeing for some time, in 2004, Boeing was made aware that a faulty radio altimeter could cause the autothrottle to enter retard flare mode when it should not. At that time five cases of this had been reported. Boeing’s tests found that a faulty altimeter reading would not necessarily be flagged as such inside the computer system. In 2006, it rolled out a solution to the problem in the form of a software update to all new 737s built from 2006 onward, which prevented the autothrottle from entering retard flare mode if the two radio altimeter readings didn’t agree. However, the autothrottles on 737s built before 2006 (including the accident airplane) ran a different operating system that couldn’t support the new software, so they didn’t receive the update. (Testing after the crash showed that the update was not 100% effective anyway.) This was not considered a safety issue because, if retard flare mode engaged erroneously, the pilots could simply disable the autothrottle and continue the flight, as they had done in all reported incidents up to that time, and indeed as they did in seven more incidents that occurred after that.

There was nothing on the 737 at the time to warn pilots of an impending low energy state, that low energy state could be as a result of external factors like wind shear or in this case a single sensor failure. Low energy states is a predictable state, many aircraft over the years have got themselves into low energy states for various reasons, often resulting in a loss of life.

In contrast on the A320 you will have a LOW ENERGY WARNING A low energy aural warning “SPEED SPEED SPEED” repeated every 5 s indicates to the pilot that the aircraft energy becomes lower than a threshold under which to recover a positive flight path angle through pitch control, the thrust must be increased. The low energy warning is triggered during deceleration before alpha floor (unless alpha floor is triggered by stick deflection), the delay between the two warnings depends on deceleration rate. If the speed decay continues, autothrust will command TOGA. The system does not care what precipitated to get to the low energy state, a failure of the aircraft systems, environmental conditions, or the pilots, it will maintain a safe energy state.

This fix resulting from this accident is very similar to the A320, Boing added a low speed aural warning to pilots, but only rolled that out to the 737. So they had over a dozen low speed events on the 737 and somehow through the it’s was restricted to that fleet only. Then Asiana Flight 214 crashes in SFO, which could have been totally preventable if they had rolled out the low speed warning to all fleets, not just the 737. That however would cost money.

You claim that the pilots should have seen the RETARD on the FMA, the pilots did talk about the -8 feet being on the PFD, they did talk about the unsafe gear warning. However there is a philosophical shift between Boeing and Airbus training when it comes to FMAs. Airbus are strict on knowing the FMA at all times, and calling out any changes to the FMA. Boeing does not have the same philosophy.

What up you failed to mention is that these pilots are performing a glide slope intercept from above. The reason why the RETARD was missed, it came right when they expected thrust to decrease anyway. When intercepting the glide slope from above. altitude must be lost quickly, and a high descent rate was selected. The crew fully expected the autothrottle to decrease thrust to achieve this high descent rate. None of the three pilots noticed that the autothrottle mode on their displays had changed to “retard,” and that the decrease in thrust was actually because the computer thought they were landing.

To understand why the auto throttle went into retard mode, it is necessary to understand the logic. The retard flare mode can only activate when the autothrottle is engaged, the radar altimeter detects less than 27 feet above the ground, the flaps are extended beyond 12.5 degrees, and no target altitude is selected. When all of these conditions are met, this tells the autothrottle that the plane is seconds from touchdown, so retard flare mode engages thrust is brought back to idle. As it happened, during the glide slope intercept from above, all three logic gates were met with the faulty rad alt.

You also failed to mention when the crew received the stick shaker, The FO as PF increased thrust on both engines and pushed his control column forward to prevent the stall from occurring. But within a second or two, Capt, said “I have control,”. During the handover of controls the FO removed their hands from the throttles, with the “retard flare” mode is still engaged, manual power inputs are not allowed, so the autothrottle simply rolled both engines back to idle and the aircraft stalled.

speedbird52 wrote:
What? What are you talking about? Every airplane in the sky has an RA. It doesn't matter if it's a 737 Classic or a 787 or an A350. Every autothrottle system will retard the throttles at a certain altitude. If every radio altimeter can fail, and every autothrottle system retards the throttle based off of radio altimeter indications, then when a radio altimeter fails, the autothrottle will retard at an incorrect altitude. As for your statement about the autothrottle being dependent on one sensor, it is possible to switch between the CA and FO RAs.


This is not true, the autothrottle behaviors on a Boeing and autothrust on an Airbus which there to achieve similar end goals are implemented differently.

On an Airbus in the flare the autothrust DOES NOT bring the thrust back to IDLE when manually flying (it announces RETART at 20 ft to remind the pilots to manually do so), it will only reduce thrust to IDLE when under a fully automatic autoland Ask any instructor pilot who trains pilots coming across from a Boeing, they will tell you about flying along the runway at 10 ft at approach speed as the pilot under training is waiting for the the autothrottle to bring thrust back to IDLE. To land an Airbus manually the pilot has to physically bring the thrust levers back to IDLE. The Airbus philosophy when manually flying, the pilots must manually land, when doing an autoland it is the autopilot doing the landing.

When manually flying or during an autoland, the Boeing will bring the throttle back to IDLE.


Watch thy airspeed, lest the Earth rise up and smite thee

I learned those words 53 years ago and it’s never been less true. Has aviation training sunk to the point that we do not teach, and do not expect, pilots to be aware of their energy state (airspeed and altitude) and correct gross deviations? That we expect the airplane to save the crew? This situation wasn’t unapparent or difficult to interpret. I’m saddened by that outcome over the past five decades.

This crew even added thrust, let the throttles come back to idle and DID NOTHING to correct the situation by disconnecting the A/T system. They weren’t plunging to the ground, the plane wasn’t furiously adding AND trim making the plane uncontrollable as in the two MAX crashes. I’m no Boeing fanboy, it’s a hot mess and the 737 is way past its “sell by” date at least a generation ago, but really piloting does require a certain duty of care and attention to the basics. Airspeed and altitude are as basic as it gets.

I’ve read the Dutch report when it came out and used it in a presentation on A/T basics; I didn’t feel it necessary to go through the details as you aptly did. Thanks.

GF
 
speedbird52
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Wed Jan 22, 2020 12:50 am

spacecadet wrote:
You have to be able to expect pilots to actually fly the plane. For every post we have here and elsewhere about how pilots have lost basic airmanship skills due to automation, we're now getting seemingly an equal number saying basic airmanship shouldn't be required and the automation should be infallible. These are incompatible philosophies.

The philosophy the entire industry has always operated under, continues to, and should continue to in the future, is that the pilots need to be able to fly the plane. If your speed drops 40 knots below Vap on final approach, it doesn't matter why - fix it! It was well within these pilots' capability to do so, and they didn't. That is why the plane crashed.

What should have come out of this accident is not more or better automation, but better piloting. Complacency is an issue with automation and that's what happened here. More training is needed to mitigate or even eliminate that complacency, because it's only going to get worse the more pervasive and reliable automation gets. It's kind of a paradox that the safer you make the automation, the more dangerous you make it when it fails. But that's the paradox we constantly need to deal with. In all cases, though, the ones in control of the plane are the pilots, not the automation. If the speed is decaying, the pilots need to see it and do something about it.

Agreed 100%. I would like to revise my original opinion and say that I do think that a better ui or aural warnings would have been helpful. But I do not see how the 737 NG being a 737 variant would have prevented the implementation of such a system. OP Seemed to think that because the NG didn't have aural or better visual indications of autothrottle modes, it was somehow evidence that Boeing shouldn't have developed the NG?? Autothrottle failure should never result in death. I still cannot comprehend why a crew of 3 in a 737 couldn't have just looked at the airspeed indicator. Could better aircraft design have prevented the TK crash? Yes. But the main cause of that accident is absolutely poor CRM. No amount of warning systems can fix that problem.
 
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CALTECH
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Wed Jan 22, 2020 3:55 am

Jetty wrote:
GalaxyFlyer wrote:
Again, the crew mishandles a pretty obvious autothrottle failure and it is Boeing’s fault. The RA displayed incorrectly, the A/T showed “RETARD” indicating it thought it was within landing parameters, all missed by three “experienced” crew.

The NYT isn’t an engineering document.

GF

More than one factor can be at fault, and mostly is when anything serious happens. Regardless on how many blame you can put on the pilots, why make it a habit to rely on 1 sensor when there are more available? Because they kept updating a plane from the 60’s instead of using state of the art design and technology because it was cheaper? The NG might already have been a generation too much. That’s where Boeing’s responsibility comes into play.


NG was a generation too much ? Please explain how it is safer than the preceding 737 generation, and, OMG airbus fanboys, safer than the A-3XX narrow bodies of Airbus ?

Yes, Boeing should be made to use more sensors and have cross talk between computers, which seems to be happening for the return to service of the MAX.


Airliner models with the five lowest non-zero crash rates were, 2017; Revised: 8 January 2020
1. 0.03 - Embraer 170/190
2. 0.06 - Boeing 747-400
3. 0.07 - Boeing 737-600/700/800/900 (737NG)
4. 0.08 - Airbus A320 (includes A318, A319, A321)
5. 0.14 - Boeing 737-300/400/500**
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WIederling
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Re: How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’

Wed Jan 22, 2020 12:21 pm

dtw2hyd wrote:
Are you saying coders are better than pilots?


The thing with software is that you can fix it afterwards ( at least that is the perception
by management and they work with that concept. ) in an easy way. "Just update
I do that on my desktop computer all the time ".

With everything today being diffused by software/computer stuff
the "Mythical Man Month" bible has expanded its reach.
Murphy is an optimist

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