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.

Comments

So, pilot error?

[OffTheLip]

Is this a 737 Max 8 problem or a training problem?

Re:So, pilot error?

[Anonymous Coward]

Yes.

Re:So, pilot error?

[Anonymous Coward]

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.

Re:So, pilot error?

[doug141]

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.

Re:So, pilot error?

[Anonymous Coward]

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.

Re:So, pilot error?

[jellomizer]

It is both.
There is a problem with the 737 Max 8, because it is putting the airplane in bad state. Such conditions shouldn't be the case. While a pilot manually can make split second decisions, the onboard computer suppose to do split microsecond decisions. This flaw is making the computer to make a bad decision.
Now that stated, you NEVER PUT FULL FAITH IN A COMPUTER. When there is a problem, you should know how to force override the computer in a moment and take over, once you feel uncomfortable about the computer decision.

My work environment which isn't as fast pace as flying an aircraft has downtime procedures, for nearly all the IT Functions, in case the software doesn't work. When the software doesn't work, there is an IT Problem that needs to be fixed, however the people we support, still need to do their job, and cannot excuse the computers being down for not doing their work.

Re:So, pilot error?

[SlaveToTheGrind]

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.

Re: So, pilot error?

[Anonymous Coward]

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')

Re:So, pilot error?

[darkmeridian]

It's a training problem. Run-away trim (which an MCAS malfunction essentially is) can be fixed by hitting the auto-trim cut-out. There's a video about the issue on the 737 Classic (which is before the 737 NG and the 737 MAX). At the same time, Boeing should have told pilots that MCAS will move the trim automatically, and will progressively move the trim more and more dramatically each time it activates. However, the pilots should have known that there was a trim problem (because they were fixing the problem by moving the trim up only to have the system push it back down), and turn off auto-trim.

https://www.youtube.com/watch?...

Re: So, pilot error?

[drinkypoo]

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...

Re: So, pilot error?

[ceoyoyo]

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.

Re: So, pilot error?

[0100010001010011]

Boeing intentionally [re]worded parts of how the system behaves so that the "FAA" (themselves) wouldn't have to recertify.

Aerospace has a huge recycling problem where once something is certified they'll just reuse it as "COTS" (commercial off the shelf) so that they don't have to recert.

It also leads to incredibly stupid decisions that are more political than engineering.

I just ditched a gig at a Tier1 vendor because they picked a Coldfire (68k) processor because it was "in production". They had no dev boards. They can't find dev boards. But the whole project was stuck with the decision because of politics that happened far away from where I was.

Re:So, pilot error?

[Der Huhn Teufel]

Training. Hundreds of 737M flights each day in the states, not one crash or report of an issue. Both crashes happened in third world countries. That's not a coincidence.

Re:So, pilot error?

[bobbied]

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.

Re:So, pilot error?

[Anonymous Coward]

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.

Re:So, pilot error?

[bluefoxlucid]

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.

Re:So, pilot error?

[ArchieBunker]

Thats like one specific model of car jerking the wheel into oncoming traffic for no reason. Completely unacceptable.

Re:So, pilot error?

[Anonymous Coward]

I agree that more information about this new system should have been included in training. I disagree that a properly trained pilot would have any issues with responding to this MCAS trim issue without that information. There seem to be enough occurrences of the problem being effectively handled by other pilots to demonstrate that. It should have been immediately recognized as a trim problem and the proper response taken. The response for trim problems are the same for this MCAS problem. Pilots are required in training to respond to runaway trim by memory, without resorting to a checklist. The training for runaway trim is already in place, this is a variation on that, it should have been recognized by any properly trained pilot. It would be interesting to know more details about the training the accident pilots had. Runaway trim should be in the syllabus and failure to properly respond should be a fail item.

Re: So, pilot error?

[Type44Q]

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??

Re: So, pilot error?

[bondsbw]

I don't believe it and I don't really want it to happen. Killing the company would be like saying NASA should have been killed after Challenger.

A better response to both, which keeps us flying and fixes future fuckups, is to hold the people who authorized bypassing such reasonable procedures criminally liable.

Re:So, pilot error?

[Anonymous Coward]

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).

Re:So, pilot error?

[Solandri]

The plane doesn't exactly need extra special training. People need to understand that similarity to older systems (backwards compatibility) is not always a good thing. It can also be a detriment when it causes people to assume things in the new system work the same as they did in the old system. According to TFA, the procedure the pilot used used to clear the problem is actually in Boeing's 737 Max checklist (steps the pilots are supposed to take when a problem occurs - like your ISP has you unplug and plug in your network cables, power cycle your cable modem,etc.)

The so-called dead-head pilot on the flight from Bali to Jakarta told the crew to cut power to the motor in the trim system that was driving the nose down, according to the people familiar, part of a checklist that all pilots are required to memorize.

Unfortunately, because of the similarity of the 737 Max to the older 737, two aircrews apparently assumed the new plane operated the same as the old one, and they apparently didn't follow the new checklist (likely didn't realize the new checklist differed) to clear up the problem. Resulting in two plane crashes. That would make it a training problem. But culpability still falls upon Boeing for not making it clear enough to pilots that the system had changed, and for designing a sensor which fails frequently enough to cause multiple incidents in only months of operation, and for designing a flight system which made it so difficult for the pilots to override a malfunctioning automated system.

Re:So, pilot error?

[Anonymous Coward]

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.

Re:So, pilot error?

[geoskd]

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.

Boeing is absolutely guilty for using a single point of failure.

The number one rule for safety critical systems is: Never, ever, EVER have a single point of failure in a safety critical system. That is why commercial planes have THREE hydraulic systems, two people in the cockpit, at least two engines, multiple fuel tanks and fuel pumps, etc. Anything that can affect the control surfaces or engines on an aircraft in motion is, by any reasonable definition, Safety Critical. The engineer who designed this thing, the manager who approved it, and the FAA regulator who signed off on it should all be put in prison for criminally negligent homicide.

Even our system of oversight is supposed to have redundancy built in, so when the FAA starts abdicating its oversight responsibilities, disaster is one step closer. Anyone who thinks that regulation is bad needs only look to this accident to see what inadequate regulation does.

Re:So, pilot error?

[dgatwood]

Bear in mind that it was the first crash caused by this system that we're talking about, not the second. At that point, nobody knew that there was a design flaw in that system, and the problem had been mitigated before it became actively dangerous, so there was no reason to assume that a future failure would result in loss of the aircraft. Also, the failure was reported, and servicing was performed after that failure.

The only thing that wasn't reported was that the presence of a third pilot was what made the difference. No doubt Lion Air did not report that out of fear that it would look like a pilot training problem, when they believed otherwise. This came out only after another crash on a different airline made that concern largely moot.

It is unlikely that full disclosure would have prevented the next accident. If anything, it might have caused all blame to be placed on the pilots, in which case Boeing might not have bothered to even start working on a workaround for the MCAS problems.

Re:So, pilot error?

[Anonymous Coward]

MCAS: It can't be bargained with. It can't be reasoned with. It doesn't feel pity, or remorse, or fear. And it absolutely will not stop, ever, until you are dead [or you disable it].

Re:So, pilot error?

[sjames]

It really is both. Initially, Boeing did not document the existence of MCAS. Some pilots may have stumbled over it's existence and applied a checklist for similar failures in documented systems.

Later, Boeing was required to document the existence of MCAS and state clearly that the runaway trim checklist should be followed when it malfunctions. Apparently not all pilots got that memo (so also a training problem).

Re: So, pilot error?

[Anonymous Coward]

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??

Isn't in the summary, the dead-head pilot was simply going through a crisis checklist that all pilots should have memorized.

Re:So, pilot error?

[drinkypoo]

At that point, nobody knew that there was a design flaw in that system

There's only two sensors and they're not cross-checked. Everyone involved with that system knew there was a flaw, it was inadequate by design.

Re:So, pilot error?

[wisnoskij]

Its a Pilot Training problem, but not a simple, "we just need to teach them about this one problem 737s have sometimes". It's that again and again, for decades now, we have perfectly functioning planes that have one sensor out of 50 go bad and the pilots will line the nose of the plane up directly with the ground, and proceed to fly directly into it.

It does not matter if some plane in particular has a minor software error or something has to be modified by 1 degree. It is that their are many pilots flying commercially that have no idea how to fly if even one gauge is off. Am I wrong, or did people used to be able to fly planes by pointing the nose above the horizon?

Re:So, pilot error?

[kaatochacha]

Its still a training problem, if the knowledge of the system and how to turn it off would resolve the issue.
To use your example "Your car is going to suffer a deadly crash unless we tell you about the magic button that disables the crash system.Proper training would allow you to know about this magic button and save the car.".
Just because it's a training issue doesn't mean its the pilots fault: They just weren't trained.

Re:So, pilot error?

[bobbied]

No no no, Boeing is 100% guilty of having manufactured an inherently aerodynamically unstable airplane.

Then EVERY low wing aircraft with engines UNDER the wings suffer from the same design flaw to varying degrees. Something tells me that there is nothing really wrong with this configuration given the huge numbers of successful models that share the same configuration and the same tendency to pitch up when adding thrust. In fact, just about every commercial aircraft flying today, with very few exceptions, share this same basic design and suffer from the same thing.

Are you saying that this configuration is at fault? Because the 737 MAX isn't any more unstable than a whole host of other aircraft that use the same basic design and like it or not I think you are really arguing for grounding just about every low wing jet liner with under wing engine mounts which would shut down about 90 - 95% of commercial flying done today.

Re:So, pilot error?

[sjames]

It seems that part of the problem is that the system effectively wrestles with the pilot over who is in charge of the trim. MCAS trims the nose down, pilot re-trims it up, 5 seconds later MCAS trims it back down, loop forever until pilot figures it out and disables MCAS or the plane crashes.

Re: So, pilot error?

[sjames]

The class of problem, "runaway trim" can be caused by a few different systems malfunctioning. Most of those systems also exist on the old 737, but MCAS is new to the MAX and behaves a little differently, though if you figure that out, the remedial action is the same.

Re:So, pilot error?

[Anonymous Coward]

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.

Re:So, pilot error?

[chaboud]

I recently had a rental car with lane-keeping suddenly jerk the wheel towards a barrier at an off ramp.

And, yes, it was completely unacceptable. I disabled that stuff ASAP.

Re: So, pilot error?

[squiggleslash]

"Should we tell them that if the plane starts plummetting towards the ground they should turn off the engines or die?"

"No, that's just what they'd expect us to do"

Seriously though, why didn't Boeing release this somewhat important bit of information? You say it's purposely, but why?

Re:So, pilot error?

[Xylantiel]

The problem is that Boeing effectively lied about the strength of the MCAS system. According to the previous article, Boeing's critical documents claim the MCAS can only change the tail by 0.6 degrees. The lack of required redundancy is based on this number. However, it turns out, the system can actually change the tail by 2.5 degree increments an infinite number of times. That some pilots figured out how to work around this behavior does not change the fact that a fundamentally unsafe system was approved for production due to Boeing's rush to market. The 0.6 degrees was changed during flight testing, and the necessary safety re-evaluation was not re-done until after the Lion Air crash. The previous article says that the 0.6 degrees still appeared in safety documents submitted by Boeing to foreign regulators despite being false.

Re: So, pilot error?

[ceoyoyo]

They didn't want to confuse "the average pilot."

Boeing didn't want pilots to have to go through a full training course for the new 737 as they would for a new aircraft, so they had to convince the FAA that it was just a variant, meaning only abbreviated training was required. The MCAS system is designed to reduce the differences in flying characteristics between the new and old planes, and intervene only when the plane is approaching a dangerous part of its flight envelope. That should never happen unless the pilot has screwed up, and if it does happen, the MCAS just gives a little tap and makes it all better. If something were to go wrong, the fix is the same as an existing procedure anyway.

It's a nice little chain of small misjudgements and unforeseen consequences, putting bandaids on little problems and then forgetting how they can add up. I imagine the whole thing will be a case study in systems integration and engineering courses in the future.

Re: So, pilot error?

[c6gunner]

Yep, that does seem to be the bigger issue. The Air France crash was - for a long time - suspected to be a problem with the software overriding the pilot. Once we found the CVR it turned out the plane had a single sensor temporarily ice over, the pilot panicked, started to climb for no reason, continued to climb until it hit max altitude and stalled, and then continued to hold the stick full-back for about 4 minutes while the plane plummeted some 40,000 feet and smashed into the ocean.

Perfectly functional plane, brought down because a pilot panicked over losing a single sensor and did the one thing which every pilot should know not to do.

Re: So, pilot error?

[jrumney]

Because they want to sell more planes. Telling airlines they can use the same pilots they've been using for 50 years with no additional training required was the selling point. Telling them that because they just tacked on bigger engines to a 50 year old design instead of designing a new plane, they have a tendancy to pull up into a stall, but don't worry we've got a new automated system to correct it, but just in case it goes wrong here's what you need to do... might have put a few buyers off.

Re: So, pilot error?

[c6gunner]

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?

They didn't; according to info released by Lion Air, the plane was taken in for maintenance and the AOA vane was replaced. This however did not fix the problem.

My question would be why the hell did the technicians not realize that the problem was still there. This kind of system almost certainly requires an op-check after maintenance. Had they actually tested it they would have known it was still malfunctioning.

Re: So, pilot error?

[c6gunner]

No, Boeing was trying to avoid the training necessitated by the aircraft having new handling characteristics as compared to the previous model. The MCAS itself required zero training.

The "training" to go from a previous 737 to the 737 MAX consists of a 1 hour video and some short reading. They could have added a section to it which said "yeah, btw, we put this new box in, if your trim starts acting up just follow your standard runaway-trim checklist", and that would have been it. Not exactly a big hit to the budget there. Leaving it out was just dumb, not greedy.

Re:So, pilot error?

[HornWumpus]

Old movies...Who's had a tire 'blow out' in there lifetime?

Remember 'sawing on' the steering wheel to take-up linkage slack?

If you do, you're either older than dirt or a car collector.

Re: So, pilot error?

[HornWumpus]

The thing being missed is the sensor fault _causing_ runaway trim (with the new system) and disabling auto trim not being part of the 'inconsistent sensor' emergency checklist.

That should have been recognized as a potential killer and documented to hell and back the first time it was noticed and averted. Which it clearly was, at least once.

Re:So, pilot error?

[HornWumpus]

Disable auto trim is on the MAX's inconsistent sensor emergency checklist?

It is now...

This wasn't undisclosed

[Anonymous Coward]

We just don't know how to use the search button anymore

https://www.news.com.au/travel/travel-updates/incidents/lion-air-crash-pilot-on-previous-flight-made-distress-call-before-continuing-to-fly/news-story/7fa1bd3b49f4dbe76444f27cc52bca41

Date: Nov 2, 2018

Imagine if that had been Frank Abagnale

[Lucas123]

Abagnale would pose as a pilot to sit in airline jump seats and get a free ride. I don't know why, but the image of the pilot turning to him for help just crossed my mind.

Re:Imagine if that had been Frank Abagnale

[Calydor]

And yet he might go, "Holy shit, we're all gonna die if I don't do something! What kind of fixes do I know about for electronics? Alright. Turn it all off and back on."

And judging from the summary that just might have worked.

Sounds a lot like United Airlines Flight 232

[Software]

United Airlines Flight 232 was also saved by a dead-heading pilot who assisted the cabin crew.

What's remarkable in the Lion Air flight is that the company didn't ground the plane until the angle-of-attack sensor problem was resolved.

Holy cow!

[Camel Pilot]

I dunno manually removing power to a motor that a control system is erroneously commanding you and 300 people to die should be something that gets raised for serious review and corrective action. Someone really missed an opportunity to save a lot of lives.

Re: Holy cow!

[Type44Q]

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.

Re: Holy cow!

[geoskd]

Another way is to say that someone seized the opportunity to lose a lot of them.

Fortunately, our legal system considers both the same, and even has a handy expression for it:

Criminally Negligent Homicide.

189 Counts

We should probably throw in a conspiracy charge for good measure.

Re:checklist that all pilots are required to memor

[Calydor]

Not really. You also memorize a whole bunch of things for exams, but that doesn't mean you have actually learned how to put that knowledge to use in a real scenario. It's the whole problem at the core of teaching to the test.

Airbus A330/340 had similar issues. 727 also.

[Anonymous Coward]

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.

Boeing 737 MAX Hidden Settings

[Anonymous Coward]

https://i.imgur.com/YwuKQkp.png

Re:Boeing 737 MAX Hidden Settings

[shanen]

Extremely rare case. Not only were you modded into visibility, but you have a legitimate reason for anonymity.

If you were blowing the whistle on an actual settings page, your reason would be impeccable, but I have to peck at the satire defense and even lament that I was lucky to see the joke.

Han Solo instead Of Clippy.

[Zorro]

Pilots instead of Computers should fly the damn plane.

Re:Collection of errors

[0100010001010011]

The smoking gun for this incident isn't going to be what the final report says. It'll be on some notes by some engineer when this project started saying everything above. There isn't a way that this project made it this far without some intelligent engineers speaking up and getting over ruled by management.

I lasted exactly 45 days in Aerospace and it was terrifying, they picked a "COTS" architecture that hasn't been "COTS" since the Macintosh moved away from 68k. I was told to 'deal with it'. Other people quipped that "this wasn't the worst design decision he's seen". The schedule was everything because customers had already bought what we were working on.

But everything HAD to move forward according to THIS timeline because someone already bought it. In those 45 days I had to work on trial versions of everything, they couldn't figure out how to get us licensed in to their network. Everyone else on the project had always been in aerospace, so this was 'par for the course'. I came from automotive where we actually did put safety first (at least where I worked).

I want to see the MIL/SIL/HIL reports. This should have been caught in the plant model long before it came to market. There should be a high-fidelity model that shows this exact scenario and how it plays out. It was buried for some reason or another. If there isn't then they didn't test as comprehensively as they should have (because of rushing to market).

There are a lot of people, that have been coming to similar conclusions about the MAX8. It's an 'unstable pendulum' that they thought they could just 'fix it in software'. Good hardware design is crucial to a good controllable system.

Someone spoke up, either they have an e-mail in a safe (like Audi's Dieselgate) or they're no longer with Boeing (or one of their subcontractors like GE, or GE's subcontractors) because they did speak up and were told they were 'toxic to the project'.

This is the boring un-sexy parts of engineering. But 'Failure Mode and Effects Analysis (FMEA)s' are important. We literally sit down and go "What happens if this fails" and then write out a full plan in software. Plus a full test plan.

dSpace makes aerospace hardware-in-the-loop (HIL) test benches. They make them for automotive and off highway too. We literally 'drive' around a vehicle for thousands of hours for software releases.

I don't have a doubt this was caught by someone somewhere. Management got involved and now this is going to be another Challenger O-Ring example for freshmen engineers.

Is ignoring a plugged sensor a bad idea? Absolutely. Should the failure mode be plowing into the ground an full tilt after fighting the pilots? No.

A blow to US civil aviation influence

[wired_parrot]

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.

Re:A blow to US civil aviation influence

[im_thatoneguy]

Of course the Chinese grounded the plane. The Chinese want every Chinese Airline to buy exclusively Chinese built aircraft. Of course they would jump at the chance to ground their competitor. That's like saying "Airbus led the way in grounding all Boeing planes." The Chinese government needs to be viewed like a corporation not a certification authority.

Re:A blow to US civil aviation influence

[evil_aaronm]

Counter-point: In this case, were they wrong? The FAA and Boeing effed up and were initially reluctant to do the right thing. If left to themselves, would either the FAA or Boeing have taken corrective action? Regardless of their motives, China stepped in to save passenger lives.

Re: checklist that all pilots are required to memo

[omnichad]

I'd love it if people were more willing to be methodical when the situation demands it, but most pilots will not get out a paper checklist while in the middle of a nosedive.

Re:Distinct lack of communication

[dunkelfalke]

They did write it down into the maintenance log, as they should have.

They have written about "IAS and ALT Disagree shown after Take Off" and "Feel Differential Pressure Light Illuminated".

The tech crew flushed the left pitot tube and static port, cleaned the connector of the elevator force feedback unit and quickly tested both system on the ground, finding nothing wrong.

So the aircrew didn't really write about the runaway stabiliser and the tech crew didn't bother to run comprehensive checks because it would have taken too much time and some specialised equipment they probably didn't have at hand.

And here you have it all coming together - a crappy airplane, dilettante pilots and overworked technicians, resulting in a crash.

Flight Envelopes are not squares

[Bryansix]

This system should be using a myriad of sensors to activate, not the least of which is the air speed indicator, backed up by GPS, the altimeter, also backed up by GPS, and the bank indicator. For one thing, the stall angle of attack is completely different at one speed versus another. This is because flight envelopes are not squares. Second of all, if altitude or GPS show the plane about to go below the ground level for the specific location, it shouldn't be driving the nose down.

Re:Flight Envelopes are not squares

[dunkelfalke]

Because GPS shows ground speed but the airplane is not on the ground. With a headwind the ground speed goes down, but the airspeed goes up. With a tailwind it is the other way around. It is useless for flying. An airplane with a lightly loaded wing can actually hover in the wind, having sufficient airspeed to stay in the air, but a groundspeed of zero.

Responsibility?????

[sgt_doom]

Although I haven't been in the aviation arena for some years, I recall that this should have been disseminated in a NOTAMN (notice to airmen) --- why didn't that aircrew spread that correction to others within the airport and airlines????? If they did not, it displays a massive show of irresponsibility on their part!

Re:I'm just wondering...

[yes-but-no]

I believe an employee (pilot here) won't be allowed to share on-job details on a public or outside company channels. Because it may affect the reputation of the company and its partners [eg Lion Air may look bad if it bought a bad plane; and boeing looks bad for engineering a bad plane / not requiring better pilot training]. And all these may affect the corporate's bottom line.

What about a runaway throttle?

[Anonymous Coward]

Toyota had a runaway throttle caused by recursive software. People died as a result.

Toyota's response - replace the floormats!

Someone should have gone to prison over this.

Lionair is at fault!!

[Pyramid]

The fact that an aircraft that almost crashed because of a fault wasn't immediately grounded and instead was allowed to fly the next day IS ABSOLUTELY UNCONSCIONABLE!

They had a procedure

[Sqreater]

So they knew about the problem, and instead of fixing it, they created a "procedure,' one that had to be memorized and remembered or you and your crew and every person on the plane would surely die. Sound right to you?

how did they keep on flying after initial "save"?

[4wdloop]

After a "near crash" accident like this, how come all the plains were not grounded?

I suppose this "Fight Club" scene may be relevant?

https://www.youtube.com/watch?...

What maintenance actions did tech data call for?

[couchslug]

Former avionics troop here. Given a malfunction, tech data directs appropriate troubleshooting and maintenance. If AOA sensor replacement is in the fault/troubleshooting tree, you replace that sensor. When a sensor is replaced follow-on maintenance like self tests and operational checks is required. The replacement sensor may have passed causing the techs to assume the problem was fixed, but they were ON THE GROUND.
What tech data error permitted the aircrew to fly with an AOA or other malfunction? What idiot permitted the aircraft to fly after REPEATED malfunctions and on what grounds?
Not every malfunction grounds an aircraft nor should they, but AOA is important enough for grounding and if in-flight verification of a fix is required or desired, a functional check flight is performed by aircrew, not "aircrew and fucking passengers".

So,

[BitztreamNotARealNam]

How's life in the hypocrite lane?