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Pilot Who Hitched a Ride Saved Lion Air 737 Day Before Deadly Crash (bloomberg.com)
As the Lion Air crew fought to control their diving Boeing 737 Max 8, they got help from an unexpected source: an off-duty pilot who happened to be riding in the cockpit. Bloomberg reports: That extra pilot, who was seated in the cockpit jumpseat, correctly diagnosed the problem and told the crew how to disable a malfunctioning flight-control system and save the plane, according to two people familiar with Indonesia's investigation. The next day, under command of a different crew facing what investigators said was an identical malfunction, the jetliner crashed into the Java Sea killing all 189 aboard.
The previously undisclosed detail on the earlier Lion Air flight represents a new clue in the mystery of how some 737 Max pilots faced with the malfunction have been able to avert disaster while the others lost control of their planes and crashed. The presence of a third pilot in the cockpit wasn't contained in Indonesia's National Transportation Safety Committee's Nov. 28 report on the crash and hasn't previously been reported. The so-called dead-head pilot on the earlier flight from Bali to Jakarta told the crew to cut power to the motor driving the nose down, according to the people familiar, part of a checklist that all pilots are required to memorize. Further reading: Flawed Analysis, Failed Oversight: How Boeing, FAA Certified the Suspect 737 MAX Flight Control System.
The previously undisclosed detail on the earlier Lion Air flight represents a new clue in the mystery of how some 737 Max pilots faced with the malfunction have been able to avert disaster while the others lost control of their planes and crashed. The presence of a third pilot in the cockpit wasn't contained in Indonesia's National Transportation Safety Committee's Nov. 28 report on the crash and hasn't previously been reported. The so-called dead-head pilot on the earlier flight from Bali to Jakarta told the crew to cut power to the motor driving the nose down, according to the people familiar, part of a checklist that all pilots are required to memorize. Further reading: Flawed Analysis, Failed Oversight: How Boeing, FAA Certified the Suspect 737 MAX Flight Control System.
Yes.
Is this a 737 Max 8 problem or a training problem?
It seems like all of the above. If you have a bad problem the day before that the main pilots didn't know how to solve and you continued flying those aircraft without making damn sure all the rest of your pilots knew how to solve it, then that's just wrong.
It's both. They made a frankenstein plane that needs extra special training to not die, and failed to adequately train the people who would be flying them.
I am a pilot although not type rated in 737. This is a pilot training issue primarily. Secondary there appears to be a failure to fully explain the behavior of the new MCAS trim mode so it can be differentiated from runaway trim. The response to the problem would be the same as runaway trim, turn off trim power, re-trim the aircraft manually. Indication of this new MCAS trim problem is almost identical to runaway trim. The difference is MCAS runs briefly and will repeat until it reaches its limit, whereas runaway trim will run continuously until it hits the stops. Turning off trim and manually re-trimming restores normal flight control in both cases.
Based on what I've heard so far it strikes me as a marginal design (at best), coupled with inadequate training on how to work with that marginal design to stay safe.
But this now adds a third layer: inadequate reporting by the pilots and/or resolution by the airline of a known severe problem, which allowed the plane to continue in service and experience the second failure. That's particularly over the top for those of us who routinely sit on the tarmac for hours while the airline tries to scrape up a technician to come in and change something as minor as an exit sign lightbulb.
Only difference was the the faulty sensors on the Airbus usually screwed up at altitude.
They still lost one however.
727 had similar pilot training issues losing several right off the bat (two within three days of one another). Difference was that it was a completely new type, not advertised as being the same plane.
Someone really missed an opportunity to save a lot of lives.
Another way is to say that someone seized the opportunity to lose a lot of them.
To be fair (at least as fair as possible given the circumstances), while the plane design is certainly Boeing's fault, the training issue is not. As I understand it, the airlines balked at the prospect of retraining the pilots, which is why the current system was put into place to make the plane bahave more like the older planes). Of course there still needed to be additional training to deal with overriding the system. And clearly some pilots received it (as evidenced by the pilot in this article). I'm just not sure whose responsibility that part was (Boeing's, airline's, or pilots')
To be fair (at least as fair as possible given the circumstances), while the plane design is certainly Boeing's fault, the training issue is not.
Some have said (including in a response to one of my comments) that Boeing didn't share the information until after the first crash...
"You're right," Fisheye says. "I should have set it on 'whip' or 'chop.'"
Yes.
Boeing is guilty for using a single sensor for a critical flight function.
Um.. Not really.. Boeing is guilty of being a bit short sighted about the failure modes of the MCAS and not effectively communicating critical information to anybody, the pilots, their trainers, and likely the certification inspectors.
This story shows that the aircraft is fully airworthy without the MCAS system functioning. You don't need it to control the aircraft, it's just there to "help" and you can turn it off if you correctly diagnose the issue and pull the right breaker.
The problem Boeing caused here is not fielding a faulty aircraft, but not communicating the necessary safety information to flight crews, maintenance personnel, and authorities. They didn't tell pilots about this system, what it does, what happens if it fails and how to disable it. It simply wasn't in the pilot's manual, didn't make it into the training process. They didn't tell the maintenance folks so they could diagnose the faulty AOA sensor correctly and return the system to full functionality.. AND Most damaging, Boeing didn't tell the certification authorities about this new feature so they could be sure all the interested parties, pilots, trainers, and maintenance where apprised of the system, knew how to use it, bypass it and repair it. THAT is what's on Boeing here.
"File to fit, pound to insert, paint to match" - Aircraft Maintenance 101
No.
If you depend on some knowledge that's both obscure to pilots, and hidden from them by Boeing, that is not a "training problem".
"Your car is going to suffer a deadly crash unless you know how to disable some system that GM did not tell you about, while in the midst of trying to deal with an uncontrollable car, and you were intentionally prevented from even knowing that system exists."
Sorry. No. Just no.
Be that as it may, why the fuck would you put the plane and crew back in the air the next day without an investigation? As soon as this irregularity occurred, the plane and crew should have been grounded. Determining the cause, the response, and the obvious (not likely, but observable without projecting other possibilities) outcome without the irregular situation which corrected the issue, an immediate action would become visible.
That action may be preventative (fix the problem) or contingency (ensure all pilots have training for familiarity with the situation and its appropriate response).
When an irregularity occurs as such, you immediately don't know that the individual plane is unsafe. You may discover by investigation that the entire fleet is unsafe; but you don't know if the plane or its pilots are unique to the failure. You ground that whole damned set of factors, examine the situation, quickly identify the contributing parameters, and decide if you need to ground all planes, issue new training, or just deal with the specific set involved.
That's just basic risk management. It has nothing to do with airplanes.
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Boeing specifically and purposely left any mention of the new systems out of the difference training course that is required to be certified to fly the new 737.
Correct.
And that is why this is going to end Boeing. That level of gross negligence and intentionally hiding safety-critical information has caused the deaths of hundreds of people.
Thats like one specific model of car jerking the wheel into oncoming traffic for no reason. Completely unacceptable.
Only the State obtains its revenue by coercion. - Murray Rothbard
One of the bigger long-term consequences of these MAX-8 incidents will be the impact on the FAA's influence in the civil aviation world. One little commented fact is that when the MAX-8s were grounded it was the Chinese civil aviation authorities who led the world in grounding the 737 MAX. This was unprecedented, as most civil aviation authorities have tended to follow the lead certification authority of the manufacturer, the FAA in this case, before issuing a grounding. This was the case in previous grounding - the 787 dreamliner in 2013 and DC-10 groundings in 1979 were both led by the FAA.
Additionally, it now appears both Transport Canada and EASA are no longer willing to accept FAA certification. Other aviation authorities have in the past accepted FAA certification without challenge. if other authorities no longer trust the FAA to do its oversight properly Boeing will be forced to carry out multiple certification assessments for each civil aviation authority, and that will carry with it a considerable delay and financial burden.
They didn't tell pilots about this system, what it does, what happens if it fails and how to disable it. It simply wasn't in the pilot's manual, didn't make it into the training process.
How did the dead-head Lion Air pilot know how to save the plane??
There's a checklist the pilots were supposed to know and follow in response to this emergency situation. The pilots didn't know, or at least, didn't follow the checklist (training problem) and crashed.
Many things can go wrong during flight. It is a pilot's job to know and follow the checklists when one exists for a situation. Flying is all about checklists.
With that said, having to perform emergency procedures should not be a standard part of flying a particular plane model (737 Max 8 problem).
Management loves to gamble with other peoples' lives and money. It's true of every industry. It is a fundamental problem with our system (of economics and governance in a general sense, as exported to many other nations) that enables regulatory capture.
Regulatory capture is the best government money can buy.
And it's a pretty shit one.
Not under stress, no tunnel vision. Probably just knowing that if your nose goes down your horizontal stabilizer is moving. Remove that movement and problem disappears. He didn't know the root cause, it was enough to break the chain of causality
It is both. In fact, it's a MAX problem, a training problem, and a documentation problem.
The MAX is defective by design because it has a computer than can override pilot commands autonomously based on false sensor data. It is defective because a) it has no sensor redundancy, b) has no way of determining when a sensor is faulty, and c) does not inform the pilot when the system is overriding her commands.
It is a training problem because Boeing was so eager to push a plane that could operate under the standard 737 type rating without any training, that it failed to create any training program. In essence, they marketed it (untruthfully) as a new plane that required no additional training, so they covered up this new system and did not provide a training program for it.
It is a documentation problem because Boeing did not create documentation on how to use the system. Because it was "idiot proof," they decided that documenting it would have created confusion.
In reality, Boeing is probably going to be found criminally negligent in these murders, because they:
a) Knew or should have known that the system as it was designed was defective;
b) knew or should have known that the system as it was designed was unsafe;
c) took deliberate and willful steps to conceal the fact that the system as it was designed was defective;
d) took deliberate and willful steps to conceal the fact that the system as it was designed was unsafe;
e) took deliberate and willful steps to deceive the FAA about the airworthiness of the aircraft when seeking type certification;
f) took deliberate and willful steps to deceive their customers about the additional training required to safely operate the aircraft;
g) took deliberate and willful steps to deceive the public about the safety and airworthiness of the aircraft; and
h) filed materially false statements with the FAA regarding the safety and airworthiness of the aircraft.
There are probably more that could be listed, but I believe Boeing is guilty of all of these. This is, of course, only my belief.