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Ethiopian Airlines Crew Followed Procedures Before Boeing Max Crash, Early Report Says (latimes.com)

The pilots of a doomed Ethiopian Airlines jet followed all of Boeing's recommended procedures when the plane started to nose dive but still couldn't save it, according to findings from a preliminary report released Thursday by the Ethiopian government. From a report: The plane crashed just six minutes after taking off from Addis Ababa, killing all 157 people on board. The report, based on flight data and cockpit voice recorders on the Boeing 737 Max 8, was not released in full. Boeing declined to comment pending its review of the report on the March 10 crash. The Max 8 has been under scrutiny since a Lion Air flight crashed off the coast of Indonesia under similar circumstances in October. Thursday's revelations raise questions about repeated assertions by Boeing and U.S. regulators that pilots could regain control in some emergencies by following steps that include turning off an anti-stall system designed specifically for the Max, known by its acronym, MCAS. Investigators are looking into the role of MCAS, whose functions include automatically lowering the plane's nose to prevent an aerodynamic stall. The Max has been grounded worldwide pending a software fix that Boeing is rolling out, which still needs to be approved by the Federal Aviation Administration and other regulators. Further reading: Flawed Analysis, Failed Oversight: How Boeing, FAA Certified the Suspect 737 MAX Flight Control System.

27 of 193 comments (clear)

  1. Next up: by Narcocide · · Score: 2, Interesting

    They find out that some completely different bug causes the MCAS override to stay on even if you shut it off.

    Either that or that it is susceptible to external control.

    1. Re:Next up: by lgw · · Score: 2

      They find out that some completely different bug causes the MCAS override to stay on even if you shut it off.

      Either that or that it is susceptible to external control.

      Possible, but also possible the procedures were bad. Given these planes weren't falling out of the sky left and right, I suspect switching off the MCAS works (assuming it's done while the plane is still recoverable).

      --
      Socialism: a lie told by totalitarians and believed by fools.
  2. Boeing Deserves to Pay for This by EndlessNameless · · Score: 5, Interesting

    So, to summarize:

    1. Boeing self-certified that pilots certified in type did not require additional training. (Prior to the recent deregulation, they weren't allowed to self-certify.)

    2. Pilots had to break out the manual during an emergency to properly control a system they were not trained to use.

    3. The system either did not disengage properly, or else it reengaged automatically, contrary to well-established norms for this aircraft type.

    Boeing screwed up, but it also happened because of relaxed oversight. The previous level of oversight seems more appropriate.

    Perhaps the FAA Administrator who made these changes should be forced to resign. This administration has had enough turnover that the President should be capable of appointing new leadership quickly.

    --

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    According to the latest ruleset, this post should be modded as Vorpal Flamebait +5.
    1. Re:Boeing Deserves to Pay for This by Streetlight · · Score: 4, Insightful

      Perhaps the FAA Administrator who made these changes should be forced to resign. This administration has had enough turnover that the President should be capable of appointing new leadership quickly.

      The replacement administrator would likely be the Boeing's chief lobbyist.

      --
      In a time of universal deceit, telling the truth is a revolutionary act. George Orwell
    2. Re:Boeing Deserves to Pay for This by Talderas · · Score: 4, Informative

      Perhaps the FAA Administrator who made these changes should be forced to resign. This administration has had enough turnover that the President should be capable of appointing new leadership quickly.

      The administrator of the FAA at the time of the certification of the 737 Max was Michael Heurta, who was appointed by President Obama. He took the position in December of 2011 and held it until January 2018. The 737 Max was certified in March of 2017.

      --
      "Lack of speed can be overcome. In the worst case by patience." --Znork
    3. Re:Boeing Deserves to Pay for This by Anonymous Coward · · Score: 5, Interesting

      There seems to be a lot of confusion around how the MCAS system is "disabled" in the case of problems. The MCAS system itself can't be disabled. The procedure for dealing with runaway trim adjustment, a larger umbrella under which problems with MCAS fall, is to turn off power to the electric motors that turn the trim adjustment wheels. These are physical switches that can't be turned on or off without physical contact by someone in the cockpit. The plane can't restore this power, only a person can flip the switches.

      Removal of power to the motors prevents MCAS from being able to continue to add more nose-down trim. Unfortunately, most 737 pilots do not turn the trim adjustment wheels by hand when flying, because it is slow and awkward process. They usually use a small thumb joystick on the control yoke to adjust trim, which is carried out by the same electric motors used by MCAS. My guess is that with a bunch of nose-down trim, the pilots turned the power back on so they could make a large trim adjustment with the thumb joystick. But as the pilots add nose-up trim with the electric system, MCAS was again able to counteract that with nose-down trim.

      Basically, MCAS can add so much nose-down trim, and do it so rapidly, that even disabling the system leaves the plane in such a nose-down trim that it is unrecoverable. The pilots can't crank the trim wheels fast enough by hand, and turning the electric motors back on gives MCAS the advantage again.

    4. Re:Boeing Deserves to Pay for This by michelcolman · · Score: 2

      The pilots disengaged the electric trim which was causing the plane to pitch down. However, since it had already trimmed the nose down so much, they were unable to pull the nose back up using only the elevators (i.e. the stick). They could trim manually by turning the big trim wheels by hand, but that wasn't fast enough while they were continuing to dive towards the ground. So they decided to reengage the electric trim, hoping they could trim the nose back up. But instead, the MCAS immediately started to trim down even further.

    5. Re:Boeing Deserves to Pay for This by Anonymous Coward · · Score: 5, Interesting

      Here is an article that states that when the jackscrew that adjusts the horizontal stabilizer is under load from aerodynamic pressure, the manual trim requires too much force to adjust trim. https://leehamnews.com/2019/04/03/et302-used-the-cut-out-switches-to-stop-mcas/

      They turned the electric trim back on because the manual trim could not be used.

    6. Re:Boeing Deserves to Pay for This by Darinbob · · Score: 2

      But who was the administrator at the time the regulations were weakened?

    7. Re:Boeing Deserves to Pay for This by slacktide · · Score: 2

      The change which greatly expanded delegated certification was mandated by Congress, not the FAA. It was a part of HR 2115 "Vision 100--Century of Aviation Reauthorization Act" in 2003. Refer to section 227 - DESIGN ORGANIZATION CERTIFICATES. https://www.congress.gov/bill/...

    8. Re:Boeing Deserves to Pay for This by slacktide · · Score: 5, Informative

      The Speaker of the House was Dennis Hastert (R–Illinois). The change which greatly expanded delegated certification was mandated by Congress, not the FAA. It was a part of HR 2115 "Vision 100--Century of Aviation Reauthorization Act" in 2003. Refer to section 227 - DESIGN ORGANIZATION CERTIFICATES. https://www.congress.gov/bill/...

    9. Re:Boeing Deserves to Pay for This by labnet · · Score: 2

      737 pilots are actually trained for this circumstance and even the flight simulators simulate the jackscrew load on the trim wheels. They are taught to duck dive to release pressure to adjust elevator trim. The problem with the Ethiopian flight, was not enough height.... but once they had re-enabled the electric trim system, had they kept manually trimming up (then cutout the trim system again), they likely would have saved themselves.

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      46137
  3. Where is the link by jeremyp · · Score: 3, Informative

    I'd like to RTFA, but there's no link to it. There's no link to the source of the quotation.

    --
    All I want is a secure system where it's easy to do anything I want. Is that too much to ask ~~ Randall Munroe
    1. Re:Where is the link by jeremyp · · Score: 4, Informative

      Found it. It's from the LA Times.

      https://www.latimes.com/busine...

      --
      All I want is a secure system where it's easy to do anything I want. Is that too much to ask ~~ Randall Munroe
    2. Re:Where is the link by ilguido · · Score: 4, Informative
    3. Re:Where is the link by Xylantiel · · Score: 5, Informative

      Yeah, some the articles don't really give the necessary details. The one I found that really discussed it is this.

      Basically it is possible for the MCAS, in combination with other things, to put the airplane in a situation that is not easily recoverable without turning the system that the MCAS is part of back on. This is because the system that bypasses the MCAS isn't strong enough to turn the tail back to the right position. But when the electrical stabilizer system is turned back on, the MCAS just kicks in again and puts it right back in nose-down. There are ways to work it out but they require "non-checklist actions" as the article says. There is no way pilots can figure this out in less than a minute while the MCAS is driving them into the ground. So basically the whole idea that "they could just switch it off" only works in some circumstances. So now we see that it appears even the instructions to pilots were not properly tested.

  4. Authority by Anonymous Coward · · Score: 2, Interesting

    The word "Report" has such an authoritative tone. According to the report...
    And then you read who wrote the report. Of course they would conclude that their country, their people, their pilots were not at fault.
    You see this legal positioning stuff play out over and over.

    And all you can do is try to backpedal and say, no, the Ethiopian government isn't a reliable authority on the correct operation of a Boeing airplane. Then the argument goes to, well then who is?

  5. Re:Terrible plane by TigerPlish · · Score: 4, Insightful

    should have bought AirBus

    AF 443.

    The Paris Air Show lawnmower, AF 296 (And in that one, investigators allegedly altered blackbox data to frame the pilot because heavens no, we can't have FBW impuned in the international spotlight after crashing 1 of 3 at the world's biggest airshow. Vive la France!)

    The sad truth is that now Boeing is just as shitty as Airbus, because Boeing now behaves like McDonnel Douglas did. Why? It's Douglas "leadership" that took over Boeing post-merger, and now Boeing is accountant-driven, not engineer-driven. Anytime you subjugate engineering to the beancounters this happens.

    I am so dissapointed with Boeing ever since the slippage started on the 787. The rollout for that one was of an empty shell, unlike all other rollouts before it. Shameful. Live it up, shareholders, live it up, your short-term greed fucked up what was America's best, most visible product.

    Maybe it's time to buy Sukhoi. Or maybe Lockheed can be persuaded, they've not built any jetliners since the L1011.

    --
    The "Civilized World" jumped the shark ca. 1973.
  6. BAD AD by ghoul · · Score: 5, Interesting

    The AD which went out after the Lion Air Crash said disable the MCAS using cutoff switches. What it did not consider is that if the plane is already nose down then the aerodynamic forces are too strong to use the manual wheels to make it nose up. The AD should have specified use your electric trim yoke switches to make the trim up and then cut out the electric trim so MCAS cannot make it nose down again.
    Also why is the MCAS triggering 6 minutes into a flight. Takeoff by definition is close to stall. It should be off during takeoff. If this plane cannot takeoff without MCAS then this plane is not safe. This is not a fighter jet where the pilot can eject if the software screws up or the plane goes unstable.

    --
    **Life is too short to be serious**
    1. Re:BAD AD by wired_parrot · · Score: 5, Interesting

      The AD which went out after the Lion Air Crash said disable the MCAS using cutoff switches. What it did not consider is that if the plane is already nose down then the aerodynamic forces are too strong to use the manual wheels to make it nose up. The AD should have specified use your electric trim yoke switches to make the trim up and then cut out the electric trim so MCAS cannot make it nose down again..

      This is a good explanation of the difficulty in trimming the aircraft in a mistrim condition by a former senior Boeing engineer. The short of it is that in the mistrim condition encountered by ET302, with stab nose down and the pilots pulling elevator nose up, the combined tail loads would've produced high jackscrew load opposing nose stab up trim that would be impossible to overcome with manual trim.

      Boeing did publish guidance for older 737 models on recovering on a severe nose out-of-trim condition, which would have required taking the aircraft into a roller-coaster maneuver to relieve the horizontal stabilizer loads. But given that they were already close to the ground, this was not an option. The other suggestion was to extend flaps, but given that the aircraft was above the minimum flap speeds, this was also not possible.

      In short, it looks like the fix to the problem was as much to blame as the problem itself

  7. Clunky system? by CaptainDork · · Score: 2

    I was in the Navy aboard an aircraft carrier. I worked on the avionics but never serviced or knew about the anti-stall systems.

    That said, I do not recall two blades on either side of the nose cones.

    It sounds clunky to me. Shit that sticks out is subject to damage. Apparently, the two blades could be out of sync. There is a "double-vote yes," system that indicates when the blades are not reporting the same conditions, and a "disagree," warning light Boeing apparently provided as an "in-app," purchase.

    Small-revenue airlines did not opt for the expansion pack and didn't get the fucking memo as to how to deal with a cray cray "AI" system that can fly the goddam plane better than a human.

    "Stall," has a well-established definition and whatever method of detection works on other airlines is not the one Boeing uses.

    --
    It little behooves the best of us to comment on the rest of us.
    1. Re:Clunky system? by jabuzz · · Score: 2

      The problem is the two sensors. You need three is a safety critical system like this so one bad sensor can be out voted by the remaining two good sensors.

      Boeing have two options. Redesign the whole system to have three sensors which means retrofitting it on all delivered planes. That's going to be costly and time consuming.

      The second option is just to disable the MCAS and have all pilots flying the MAX variants of the 737 type certify. This will take time and makes the 737 MAX a much less attractive plane for airlines as they have to type certify their pilots for the new plane.

      The best Boeing can do with the current hardware is have the software disengage on differential sensor input and turn on the indicator light (which presumably will need retrofitting on all planes without it). However at this point the pilots won't be trained/certified for a plane which now has different stall characteristics. Consequently you are back at having to type certify your pilots for the MAX variant.

      Boeing are completely and totally screwed. Further the person or persons who signed off on using just two sensors need to find themselves in the dock on corporate manslaughter charges.

    2. Re:Clunky system? by ceoyoyo · · Score: 2

      Two sensors is fine, because it isn't really a safety critical system. All engine-under-wing airliners have the same instability problem in a stall, and the MAX isn't that much worse. If the system turned off on failure, it would be fine.

      Whoever approved using only one sensor was an idiot.

  8. Re:Capitalism again by Mr.+Dollar+Ton · · Score: 2, Informative

    It's a shame that the market position of Boeing and Airbus has very little to do with capitalism and everything to do with cronyism.

    You say that like "cronyism" sprang up all by itself from the vacuum. Cronyism is the expected result of the operation of a capitalist economy without effective and strong oversight, the result of which operation is always and invariably capitalism taking over politics, democratic or otherwise. The economic mechanisms are also well understood by the economic theory: when investing in bribes and government subversion creates better returns than investing in production, a capitalist will invest in bribery and not in production. This case is a perfect illustration of the phenomenon - it was a lot more effective for Boeing to subvert the certification process than to ensure quality aircraft design. Boeing boss even had the temerity to call Trump and ask that grounding of the dangerous planes be delayed for PR reasons.

    The result of the right-wing(nut) policies of oversight removal in the US are well known. Corporations have for a long time had a say over politics that the ordinary citizens don't. Even science says so:

    Multivariate analysis indicates that economic elites and organized groups representing business interests have substantial independent impacts on U.S. government policy, while average citizens and mass-based interest groups have little or no independent influence. The results provide substantial support for theories of Economic-Elite Domination and for theories of Biased Pluralism, but not for theories of Majoritarian Electoral Democracy or Majoritarian Pluralism.

    The worst part is that US is exporting this model worldwide, damaging and weakening democratic governments all over the place.

  9. Re:Terrible plane by michelcolman · · Score: 5, Informative

    AF 443

    Pilot error, and a hair raising one at that

    Simultaneous overspeed and stall warnings (making the pilots believe they were in a high speed stall). Stall warning that shut up at low speed (below 60 kts) but came back on precisely when the pilots were temporarily taking the correct action, making them believe that pushing the stick was the wrong thing to do. Pilots that cannot feel what the other pilot is doing with the stick. With all the simultaneous warnings and inconsistent indications, they had no idea what information to trust anymore. Sure, with perfect hindsight it's easy to see what they did wrong, but it wasn't as clear cut as some seem to believe.

    The Paris Air Show lawnmower, AF 296

    Ah, I see, you are a conspiracy nut. The envelope protection saved almost all lifes back then when the pilot actively tried to kill everyone by stalling the aircraft. Without the protection the plane would have fallen from the sky like a bloody brick, not slowly gliding on the top of the trees.

    They were actually trying to demonstrate the stall protection, by flying extremely slowly right at the edge of the stall (which no pilot would ever attempt in a regular plane). The big problem was that the engines did not spool up as quickly as the pilots had expected. The conspiracy theory is about why the engines took so long to spool up: some say they got into ground idle due to a programming error, some say it was because the pilots had pulled certain circuit breakers, some say flight data recorder info was falsified, etc... I have never really dug in to the whole story, but the theories are not as nutty as they would seem at first sight.

  10. Re:Terrible plane by Anonymous Coward · · Score: 2, Informative

    The crew applied full power and the pilot attempted to climb. However, the elevators did not respond to the pilot's commands, because the A320's computer system engaged its "alpha protection" mode (meant to prevent the aircraft from entering a stall).

    Which was exactly the right action. Stalling would've been much, much worse and that's what would've happened if the computer hadn't saved the day to the extent that it could be saved. The aircraft did not have the speed to climb so all they would've managed to do was to gain a little altitude, loose all their speed and then fall like a brick. This argument has been done to death.

  11. Re:Terrible plane by Anonymous Coward · · Score: 3, Informative

    AF 443

    Pilot error, and a hair raising one at that

    Simultaneous overspeed and stall warnings (making the pilots believe they were in a high speed stall). Stall warning that shut up at low speed (below 60 kts) but came back on precisely when the pilots were temporarily taking the correct action, making them believe that pushing the stick was the wrong thing to do. Pilots that cannot feel what the other pilot is doing with the stick. With all the simultaneous warnings and inconsistent indications, they had no idea what information to trust anymore. Sure, with perfect hindsight it's easy to see what they did wrong, but it wasn't as clear cut as some seem to believe.

    First off, it's AF447 and not 443.

    There was no overspeed warning. The reason is quite simple: the first thing the pilot did when the autopilot disconnected was to pull on the stick. As any pilot will know, that will lower the speed. They never got it back.
    The stall warning sounded at this point, correctly, as a response to the pilot's commands. It's only after that the FBW disconnected, and the stall warning stopped.

    When it did resume, it's not like the pilot tried many times to push the nose down, triggering the stall warning as a result, as you seem to believe. The stall warning sounded for a whole minute during which the pilot flying kept increasing the nose up attitude. That's right at the top of the flying 101 don'ts. And all this while the alarm was screaming "don't do this".

    So, basically, the plane entered a stall _because_ of unnecessary pilot actions, and stayed in stall _despite_ a constant alarm from the computer.

    There's a valuable lesson here about the necessity of practising the basics of flying - when the computer can't deal. There's another one about managing panic: it still took 4 minutes for the plane to crash - there is time to think.

    Blaming the computer, or Airbus, is just the one that won't actually help with anything.

    The Paris Air Show lawnmower, AF 296

    Ah, I see, you are a conspiracy nut. The envelope protection saved almost all lifes back then when the pilot actively tried to kill everyone by stalling the aircraft. Without the protection the plane would have fallen from the sky like a bloody brick, not slowly gliding on the top of the trees.

    They were actually trying to demonstrate the stall protection, by flying extremely slowly right at the edge of the stall (which no pilot would ever attempt in a regular plane). The big problem was that the engines did not spool up as quickly as the pilots had expected. The conspiracy theory is about why the engines took so long to spool up: some say they got into ground idle due to a programming error, some say it was because the pilots had pulled certain circuit breakers, some say flight data recorder info was falsified, etc... I have never really dug in to the whole story, but the theories are not as nutty as they would seem at first sight.

    No they were actually trying to show the plane to a public that was quite incapable of understanding what "stall protection" means, during an airshow at an airport too small for the A320 to operate from (and not in Paris, as you seem to believe). Black boxes and a concurring audio analysis show that the engines spooled up as per spec. If the pilots "expected" them to do so faster, that's their mistake. In any case, while the 10m slow flyby might still have worked out, the nail in the coffin appears to be that the pilots didn't see the forest beyond the runway.