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Ethiopian Airways flight crashes (10/03) + 737 MAX grounding

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LOL The Irony

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It's come out that the day prior to it's crash, Lion Air PK-LQP had the same issue and a travelling Pilot in the jumpseat told them how to switch MCAS off, saving the plane. https://www.telegraph.co.uk/news/20...d-doomed-lion-air-boeing-737-max-penultimate/
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.

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, two people familiar with Indonesia’s investigation told Bloomberg.

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 November 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 memorise.


“All the data and information that we have on the flight and the aircraft have been submitted to the Indonesian NTSC. We can’t provide additional comment at this stage due the ongoing investigation on the accident,” Lion Air spokesman Danang Prihantoro said.

The Indonesia safety committee report said the plane had had multiple failures on previous flights and hadn’t been properly repaired.

Representatives for Boeing and the Indonesian safety committee declined to comment on the earlier flight.

The safety system, designed to keep planes from climbing too steeply and stalling, has come under scrutiny by investigators of the crash as well as a subsequent one less than five months later in Ethiopia. A malfunctioning sensor is believed to have tricked the Lion Air plane’s computers into thinking it needed to automatically bring the nose down to avoid a stall.


Boeing’s 737 Max was grounded on March 13 by US regulatorsafter similarities to the Oct. 29 Lion Air crash emerged in the investigation of the March 10 crash of Ethiopian Airlines Flight 302. In the wake of the two accidents, questions have emerged about how Boeing’s design of the new 737 model were approved.

The Transportation Department’s inspector general is conducting a review of how the plane was certified to fly and a grand jury under the US Justice Department is also seeking records in a possible criminal probe of the plane’s certification.


The FAA last week said it planned to mandate changes in the system to make it less likely to activate when there is no emergency. The agency and Boeing said they are also going to require additional training and references to it in flight manuals.

“We will fully cooperate in the review in the Department of Transportation’s audit,” Boeing spokesman Charles Bickers said. The company has declined to comment on the criminal probe.

After the Lion Air crash, two US pilots’ unions said the potential risks of the system, known as the Maneuvering Characteristics Augmentation System, or MCAS, hadn’t been sufficiently spelled out in their manuals or training. None of the documentation for the Max aircraft included an explanation, the union leaders said.

“We don’t like that we weren’t notified,’’ Jon Weaks, president of the Southwest Airlines Pilots Association, said in November. “It makes us question, ‘Is that everything, guys?’ I would hope there are no more surprises out there.’’

The Allied Pilots Association union at American Airlines Group Inc. also said details about the system weren’t included in the documentation about the plane.

Following the Lion Air crash, the FAA required Boeing to notify airlines about the system and Boeing sent a bulletin to all customers flying the Max reminding them how to disable it in an emergency.


Authorities have released few details about Ethiopian Airlines Flight 302 other than it flew a “very similar” track as the Lion Air planes and then dove sharply into the ground. There have been no reports of maintenance issues with the Ethiopian Airlines plane before its crash.


If the same issue is also found to have helped bring down Ethiopian Airlines Flight 302, one of the most vexing questions crash investigators and aviation safety consultants are asking is why the pilots on that flight didn’t perform the checklist that disables the system.

“After this horrific Lion Air accident, you’d think that everyone flying this airplane would know that’s how you turn this off,” said Steve Wallace, the former director of the US Federal Aviation Administration’s accident investigation branch.

The combination of factors required to bring down a plane in these circumstances suggests other issues may also have occurred in the Ethiopia crash, said Jeffrey Guzzetti, who also directed accident investigations at FAA and is now a consultant.

“It’s simply implausible that this MCAS deficiency by itself can down a modern jetliner with a trained crew,” Guzzetti said.

MCAS is driven by a single sensor near the nose that measures the so-called angle of attack, or whether air is flowing parallel to the length of the fuselage or at an angle. On the Lion Air flights, the angle-of-attack sensor had failed and was sending erroneous readings indicating the plane’s nose was pointed dangerously upward.
 
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edwin_m

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If the deadheading pilot knew the solution and at least four others didn't, that suggests a briefing/training failure.
 

cjp

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If the deadheading pilot knew the solution and at least four others didn't, that suggests a briefing/training failure.
Agreed but look at how this was sold as a tweak of the existing 373 with just 45 minutes or so on an Ipad to go over the differences, no need for any sim time and the flight manual was silent on the new gimmick from Boeing so as not to overload pilots. Of course after the Lion Air crash Boeing put out an advisory but it clearly was not effective enough to allow all pilots to recognise the problem.
I am sure that now it is every Max8 pilot's mind.
But until it is fixed by Boeing I can understand why the CAA banned the 737Max8 from UK airspace.
 

Swanny200

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Theoretically are you as a pilot for an airline like Lion Air forced to fly different planes or are you just on the one type i.e would one week a pilot be put on a 737NG and the next be flying a 737 Max8 because this to me would open a whole new can of worms, the two planes Boeing are saying are practically the same in the cockpit but the Max-8 has a major difference in flying characteristics, can pilots have that momentary lapse where they think they are flying another plane?
 

Bletchleyite

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Theoretically are you as a pilot for an airline like Lion Air forced to fly different planes or are you just on the one type i.e would one week a pilot be put on a 737NG and the next be flying a 737 Max8 because this to me would open a whole new can of worms, the two planes Boeing are saying are practically the same in the cockpit but the Max-8 has a major difference in flying characteristics, can pilots have that momentary lapse where they think they are flying another plane?

Generally a pilot is only type-certified on one aircraft to avoid precisely this. Common types are quite valued for that reason, e.g. A318-321 are I think considered one type.
 

Swanny200

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Generally a pilot is only type-certified on one aircraft to avoid precisely this. Common types are quite valued for that reason, e.g. A318-321 are I think considered one type.

I did wonder if once you migrated to type, you stayed on type, which then begs the question why did Boeing decide not to make sure that all pilots knew how to handle their aircraft?
 

edwin_m

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I think the idea was that the MAX would be similar enough to previous 737s that it didn't need any type conversion, which would also imply being able to swap between different versions without any problem (as someone suggested above was possible with A319-A320).
 

Swanny200

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I think the idea was that the MAX would be similar enough to previous 737s that it didn't need any type conversion, which would also imply being able to swap between different versions without any problem (as someone suggested above was possible with A319-A320).
That was the point I was trying to say earlier, the cockpit's are exactly the same from what I have heard so if you don't look out the window or had a momentary lapse of attention then you wouldn't know if you were flying a 737NG or a 737 Max-8, it has happened plenty of times before where pilots have got confused for instance the Kegworth incident a few posts back.
 

edwin_m

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That was the point I was trying to say earlier, the cockpit's are exactly the same from what I have heard so if you don't look out the window or had a momentary lapse of attention then you wouldn't know if you were flying a 737NG or a 737 Max-8, it has happened plenty of times before where pilots have got confused for instance the Kegworth incident a few posts back.
I'd say not so much confused about what they were flying, more forgetting or never knowing in the first place that the new version has some subtle differences. At least in the case of the MAX and possibly at Kegworth too.
 

WatcherZero

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Oh dear! There are of course many paths this could take, but I think some of them begin to point at the end of Boeing.

Doubtful it could threaten a company the size of Boeing but could lead to at the extreme end multibillion dollar fines and one or two executives having a short prison stay. Boeing is likely to suffer more from the reputational damage and loss of custom of airlines cancelling orders in response. They have about 2600 orders for the type and so far customers collectively accounting for about 500 have said they are or are close to cancelling orders. Its hard on the airlines though because the main competitor, Airbus A320Neo already has 5,814 orders and a Backlog in delivery running close to a decade.
 

Bald Rick

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Doubtful it could threaten a company the size of Boeing but could lead to at the extreme end multibillion dollar fines and one or two executives having a short prison stay. Boeing is likely to suffer more from the reputational damage and loss of custom of airlines cancelling orders in response. They have about 2600 orders for the type and so far customers collectively accounting for about 500 have said they are or are close to cancelling orders.

Indeed, the latest development hasn’t affected the share price too badly: up 1% today.

Although I do think if a major carrier does cancel an order, then it will get interesting.
 

Clip

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On me phone but this story basically says Boeing made you pay extra for important safety features like the stuff which would've helped this plane- allegedly
https://www.nytimes.com/2019/03/21/business/boeing-safety-features-charge.html

Story now added as per forum rules and to assist those who use screen readers

As the pilots of the doomed Boeing jets in Ethiopia and Indonesia fought to control their planes, they lacked two notable safety features in their cockpits.

One reason: Boeing charged extra for them.

For Boeing and other aircraft manufacturers, the practice of charging to upgrade a standard plane can be lucrative. Top airlines around the world must pay handsomely to have the jets they order fitted with customized add-ons.

Sometimes these optional features involve aesthetics or comfort, like premium seating, fancy lighting or extra bathrooms. But other features involve communication, navigation or safety systems, and are more fundamental to the plane’s operations.

Many airlines, especially low-cost carriers like Indonesia’s Lion Air, have opted not to buy them — and regulators don’t require them.



Federal prosecutors are investigating the development of the Boeing 737 Max jet, according to a person briefed on the matter. As part of the federal investigation, the F.B.I. is also supporting the Department of Transportation’s inspector general in its inquiry, said another person with knowledge of the matter.

The Justice Department said that it does not confirm or deny the existence of any investigations. Boeing declined to comment on the inquiry.

https://www.nytimes.com/2019/03/15/...on=CompanionColumn&contentCollection=Trending

The jet’s software system takes readings from one of two vanelike devices called angle of attack sensors that determine how much the plane’s nose is pointing up or down relative to oncoming air. When MCAS detects that the plane is pointing up at a dangerous angle, it can automatically push down the nose of the plane in an effort to prevent the plane from stalling.

737 Max planes, according to a person familiar with the changes, who spoke on condition of anonymity because they have not been made public. Boeing started moving on the software fix and the equipment change before the crash in Ethiopia.

The angle of attack indicator will remain an option that airlines can buy. Neither feature was mandated by the Federal Aviation Administration. All 737 Max jets have been grounded.

“They’re critical, and cost almost nothing for the airlines to install,” said Bjorn Fehrm, an analyst at the aviation consultancy Leeham. “Boeing charges for them because it can. But they’re vital for safety.”

[After a Lion Air 737 Max crashed in October, questions about the plane arose.]

Earlier this week, Dennis A. Muilenburg, Boeing’s chief executive, said the company was working to make the 737 Max safer.

“As part of our standard practice following any accident, we examine our aircraft design and operation, and when appropriate, institute product updates to further improve safety,” he said in a statement.

Boeing jet has come under scrutiny.]

Boeing charges extra, for example, for a backup fire extinguisher in the cargo hold. Past incidents have shown that a single extinguishing system may not be enough to put out flames that spread rapidly through the plane. Regulators in Japan require airlines there to install backup fire extinguishing systems, but the F.A.A. does not.

“There are so many things that should not be optional, and many airlines want the cheapest airplane you can get,” said Mark H. Goodrich, an aviation lawyer and former engineering test pilot. “And Boeing is able to say, ‘Hey, it was available.’”

But what Boeing doesn’t say, he added, is that it has become “a great profit center” for the manufacturer.


Both Boeing and its airline customers have taken pains to keep these options, and prices, out of the public eye. Airlines frequently redact details of the features they opt to pay for — or exclude — from their filings with financial regulators. Boeing declined to disclose the full menu of safety features it offers as options on the 737 Max, or how much they cost.

But one unredacted filing from 2003 for a previous version of the 737 shows that Gol Airlines, a Brazilian carrier, paid $6,700 extra for oxygen masks for its crew, and $11,900 for an advanced weather radar system control panel. Gol did not immediately respond to a request for comment.


The three American airlines that bought the 737 Max each took a different approach to outfitting the cockpits.

American Airlines, which ordered 100 of the planes and has 24 in its fleet, bought both the angle of attack indicator and the disagree light, the company said.

Southwest Airlines, which ordered 280 of the planes and counts 36 in its fleet so far, had already purchased the disagree alert option, and it also installed an angle of attack indicator in a display mounted above the pilots’ heads. After the Lion Air crash, Southwest said it would modify its 737 Max fleet to place the angle of attack indicator on the pilots’ main computer screens.

United Airlines, which ordered 137 of the planes and has received 14, did not select the indicators or the disagree light. A United spokesman said the airline does not include the features because its pilots use other data to fly the plane.

Boeing is making other changes to the MCAS software.

When it was rolled out, MCAS took readings from only one sensor on any given flight, leaving the system vulnerable to a single point of failure. One theory in the Lion Air crash is that MCAS was receiving faulty data from one of the sensors, prompting an unrecoverable nose dive.

In the software update that Boeing says is coming soon, MCAS will be modified to take readings from both sensors. If there is a meaningful disagreement between the readings, MCAS will be disabled.

Incorporating the disagree light and the angle of attack indicators on all planes would be a welcome move, safety experts said, and would alert pilots — as well as maintenance staff who service a plane after a problematic flight — to issues with the sensors.


The alert, especially, would bring attention to a sensor malfunction, and warn pilots they should prepare to shut down the MCAS if it activated erroneously, said Peter Lemme, an avionics and satellite-communications consultant and former Boeing flight controls engineer.

“In the heat of the moment, it certainly would help,” he said.
 
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WatcherZero

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An indicator that your two sensors are providing contradictory data is an optional extra? sheesh.
 

TheEdge

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That's quite shocking. I'd always assumed that airliner cockpits were a standard part and all had the same safety equipment.
 

edwin_m

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I think the basic controls are fairly standard but the detail would depend on what particular gadgets were fitted to that aircraft. Aircraft have had some kind of stall warning for a long time that works a "stick shaker" to warn the pilot, but I don't think that sensor is duplicated because it should never come into play unless the aircraft is being flown in a way it never should be normally. The difference here is that the traditional stall warning is very distinctive and every pilot will know what to do in response*, but rather than giving an alert the MCAS takes action to bring the nose down and why that is happening is not immediately obvious to the pilot. Perhaps it would be safer to drive them off the same sensor or at least have the MCAS activate the stick shaker, so the pilot knows for certain that the plane thinks it is in a stall situation.

*There have been crashes due to faulty sensors/instruments where the crew get warnings that the airspeed is too high and too low simultaneously. So perhaps duplicating the stall sensor would be a good idea anyway.
 

YorkshireBear

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I must confess, finding out that some safety features on airlines are optional and Boeing make money out of them is quite concerning..... Such as secondary Fire Extinguishers as mentioned in that article. Maybe it's an overreaction but it seems dodgy to me and if this is a worldwide thing from all manufacturers to me that is a concern.
 

jellybaby

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I must confess, finding out that some safety features on airlines are optional and Boeing make money out of them is quite concerning..... Such as secondary Fire Extinguishers as mentioned in that article. Maybe it's an overreaction but it seems dodgy to me and if this is a worldwide thing from all manufacturers to me that is a concern.
Is that any different to cars where many safety features are optional extras, at a price?

You might argue that in a car the driver has the choice but that isn't the case when you are a passenger in a taxi or the pedestrian that is hit.
 

edwin_m

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Can't help thinking that for something as simple as a disagree light it would be cheaper for Boeing just to fit as standard than to go to all the trouble of making it optional.
 

TheEdge

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Is that any different to cars where many safety features are optional extras, at a price?

You might argue that in a car the driver has the choice but that isn't the case when you are a passenger in a taxi or the pedestrian that is hit.

What sort of safety systems are optional in a car now? Unless you are talking about the various assist systems, which I'd argue are different to something like an AOA indicator.
 

jellybaby

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What sort of safety systems are optional in a car now?
Electronic Stability Control is the first that springs to mind as something that used to be optional. In the early 2000s it was thought that it could prevent one third of fatal accidents. It's of course now mandatory in the US and EU.

I believe Intelligent Speed Assistance is likely to be mandatory soon but it could be saving lives today. There were plans to make Emergency Brake Assist mandatory but that doesn't seem to have happened.

To me these are all safety features even if they have assist in the name, which may in part be because many drivers don't like the idea of their car restricting what they can do.
 

WatcherZero

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Theres arguments over speed assistance, situations where at the drivers discretion breaking the speed limit may be necessary such as safe overtaking or collision avoidance (e.g. oncoming traffic), if implemented it could virtually kill off motorway overtaking.

Electronic Stability Control was an optional extra because it was software built on top of the equipment used for ABS and traction control, while wildly fitted as standard they only became mandatory in the EU in 2004 and the US in 2013.
 

cjp

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It is not necessary to exceed the speed limit to overtake. The correct solution is not to overtake, to respect the speed limit, to have patience. Just because you can go fast does not mean you should.
Aircraft have both max manoeuvring speeds as well as VNE and one exceeds this at one peril although it is not to say one could not but .....
 

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The blame for the Ethiopian crash is going to explode everywhere.

- Boeing potentially having a flawed or even fraudulent safety case for MCAS
- Regulatory capture of the FAA
- Boeing not including proper details of the system in the operating manual
- Boeing charging $80,000 for an MCAS warning light
- Ethiopian not paying $80,000 for an MCAS warning light even following the Lion Air crash
- Ethiopian failing to train pilots on MCAS nuances even following the Lion Air crash
- Possible pilot error
- Further potential consequences over the faulty AOA sensor on the aircraft which crashed, perhaps a maintenance issue
- plus many more

Nobody will come out of this looking good.
 

WatcherZero

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Add in just emerged Boeing knew about the MCAS issues after the first crash and were already working on software update before the 2nd crash. Boeing also invited dozens of pilots to try out the same situation in their company Simulator, almost all the experienced pilots that tried that situation crashed within 40 seconds.
 

cjp

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Add in just emerged Boeing knew about the MCAS issues after the first crash and were already working on software update before the 2nd crash. Boeing also invited dozens of pilots to try out the same situation in their company Simulator, almost all the experienced pilots that tried that situation crashed within 40 seconds.
Knew about the first part but unaware of the second. What is the source for the second piece of information and were the sim flights before or after the advisory was sent out by Boeing?
 

WatcherZero

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https://www.nytimes.com/2019/03/25/business/boeing-simulation-error.html

During flight simulations recreating the problems with the doomed Lion Air plane, pilots discovered that they had less than 40 seconds to override an automated system on Boeing’s new jets and avert disaster.

The pilots tested a crisis situation similar to what investigators suspect went wrong in the Lion Air crash in Indonesia last fall. In the tests, a single sensor failed, triggering software designed to help prevent a stall.

Once that happened, the pilots had just moments to disengage the system and avoid an unrecoverable nose dive of the Boeing 737 Max, according to two people involved in the testing in recent days. Although the investigations are continuing, the automated system, known as MCAS, is a focus of authorities trying to determine what went wrong in the Lion Air disaster in October and the Ethiopian Airlines crash of the same Boeing model this month.

The software, as originally designed and explained, left little room for error. Those involved in the testing hadn’t fully understood just how powerful the system was until they flew the plane on a 737 Max simulator, according to the two people.

In the current design, the system engages for 10 seconds at a time, with five-second pauses in between. Under conditions similar to the Lion Air flight, three engagements over just 40 seconds, including pauses, would send the plane into an unrecoverable dive, the two people involved in the testing said.

That conclusion agreed with a separate analysis by the American Airlines pilots’ union, which examined available data about the system, said Michael Michaelis, the union’s top safety official.

At least some of the simulator flights happened on Saturday in Renton, Wash., where the 737 Max is built. Pilots from five airlines — American, United, Southwest, Copa and Fly Dubai — took turns testing how the Max would have responded with the software running as it was originally written, and with the updated version, known as 12.1.

In the simulations running the updated software, MCAS engaged, though less aggressively and persistently, and the pilots were also able to control the planes.
 

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I don't think much blame can go to Ethiopian, really, and lots can go to Boeing. After AF447 I can't believe anyone signed off a system that worked only off one sensor. And then there's the rumours that, even with the training and warning lights, the planes were uncontrollable in simulator testing.
 

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I don't think much blame can go to Ethiopian, really, and lots can go to Boeing. After AF447 I can't believe anyone signed off a system that worked only off one sensor. And then there's the rumours that, even with the training and warning lights, the planes were uncontrollable in simulator testing.
In the news tody, it looks like Boeing will be hit with enormous leasing and additional fuel costs caused by their grounding the entire fleet of 737 MAXs.
 
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