I was astounded by the information in the thorough explanation of the Max crashes. Corruption, money, and power continue to work their evil effects on unsuspecting consumers.
13
Something bothers me about the logic of the author’s conclusion that it was the incompetence of the pilots from the third-world countries of Indonesia and Ethiopia in their handling of the similar MCAS-related in-flight emergencies successfully, due to their “lack of airmanship”...
Forgetting for a moment that Ethiopian Airlines owns and operates a dedicated B737 MAX simulator, whereas no U.S. major airline has one; forgetting for a moment that NO 737 PILOT ON ANY AIRLINE IN THE WORLD knew what the MCAS was prior to the LionAir accident; forgetting for a moment that the Boeing-conceived required 45-minute iPad “differences training” video didn’t mention the MCAS at all, and nor did it mention the fact that opposite pressure on the pilot control column would no longer stop runaway trim, as that pressure had done on all previous versions of the 737 since 1967; forgetting for a moment that the RUNAWAY STABILIZER TRIM procedures for a secret trim system that no one knew about, that jerks the nose over at warp speed — but that stops intermittently — might not be interpreted as a true stabilizer trim runaway, but something else, which it truly was... forget all that, and forget the single sensor and the selling of the cockpit warning light to only those airlines that could afford it... forget it, they say...
If the author’s theory of incompetence and lack of airmanship held up, third-world country airliners would be falling out of the sky every day, and they’re not.
69
"The worst of them are intimidated by their airplanes and remain so until they retire or die." Just as, by definition, the worst practicing doctor in the country is still seeing patients (often with a long trail of complaints), the worst pilots haven't been grounded yet. The system in both cases is supposed to stop them almost immediately, but a system only works if those responsible go by their own rules and procedures. Sadly, industry politics creep into it: often there is a reluctance to shut down someone, especially if they're not a white male in a profession long dominated by them. The nuclear power industry, scorned by many of both the left and right. has an outstanding safety record, partly as a result of Three Mile Island, but also from a long tradition of procedural zeal. That's what we need in the airlines.
6
Let’s pause for moment and recall how Boeing got here: They had a hardware issue, ie outdated plane design. Instead of redesigning the 737 fuselage and gear to accommodate modern jet engines, they chose a much cheaper (or so they thought) software fix. However, instead of a fully integrated fly-by-wire solution, which just might have worked, they opted for an even cheaper, secondary add-on system (MCAS) that second-guesses both pilot and autopilot. Unbelievably, and against even the most minimal standards, the MCAS was able to critically interfere with flight control based on a single sensor input alone. In a modern integrated system, the necessary calculations would have been done by the main computer (like the ECU in your car), which has access to dozens of sensor readings. Such a system would have readily identified sensor malfunction by checking consistency against other flight parameters, and would have easily recognized and intervened when the “fix” was about to bring the plane into a dangerous situation.
Obviously, Boeing is decades behind the state-of-the-art, and no quick fix will change that. I don’t know what they are cooking up right now, but something tells me that they won’t go back to the drawing board and do it right from ground up.
21
"The worst of them are intimidated by their airplanes and remain so until they retire or die. It is unfortunate that those who die in cockpits tend to take their passengers with them."
Says who? These two gratuitous sentences stopped me cold.
9
OK, let's assume they fly by rote. Had Boeing told pilots about MCAS and what happens when MCAS fails, pilots would know how to handle it -- even if they were flying by rote. So in these 2 accidents, flying by rote, even if true, *is irrelevant*.
Even American pilots simulating MCAS failure had serious difficulty. Even with 20-20 hindsight -- and knowing that MCAS was going to hit -- they came away shaken. This reality means more than pages of text and conjecture.
There are other errors and false conclusions in the article. Basically the author selectively picks facts and creates a story around it. Astonishing arrogance.
20
Well researched with one shortcoming; it did not clarify the origin of the cockpit chaos, the root cause of which the surviving experts don’t want to acknowledge.
Boeing issued no "memory items" for “Angle of Attack (AOA) Disagree”, the initial fault that led to both MCAS tragedies. This is despite the fact ON THE MAX ONLY, AOA Disagree always results in the following: Airspeed Unreliable and (if the crew retract the flaps) Stabilizer Runaway. Both of these consequential failures have memory items which the crew have been criticized for not following effectively. AOA disagree also generates Stall Warning and Altitude Disagree but without memory items.
Everyone (Boeing, the FAA, all airline operators of the Max who are also responsible by regulation to ensure proper guidance/documentation) failed to recognize the fact that had there been memory items (RECALL) for “Angle of Attack Disagree”, both accidents could have been avoided.
In an otherwise brilliant piece of reporting, William Langewiesche has not only shot the messenger by putting most of the blame on the pilots, but failed to recognize that those responsible for mandating rote responses (pilot procedures) have an equal responsibility to ensure unambiguous direction for flight critical events while not hiding behind an easy get out of jail card, the crews lack of airmanship.
But that would have required MCAS to be . . . .
15
Beautiful work, sir. Well thought-out, well-written and accessible for the non-flying public. As the designer, builder and pilot fo a well-know experiemental jet I have to agree with your central thesis: failure in airmanship, failure to fly the airplane.
9
Amen, Larry from Boston. Amen.
2
The complaints about this article blaming the victims doesn't make sense to me. The victims were the passengers, not the manufacturer nor the operator. Blame was given where blame was due, to Boeing and corner-cutting training operations.
I've admired Langewiesche's writing for the Atlantic, a monthly, and am pleased to see that he is writing for the Times, a daily newspaper. It was news to me that the training of passenger jet pilots was so scant and miserly in so much of the world.
8
Kamikaze plane tries to crash into ground, unsound aerodynamic design, software attempt to cover up for engineering shortcomings, software not disclosed to pilots, Etc etc. But those pilots!!!!
12
Wow this author is full of himself isn't he?
16
This article reeks of poor quality journalism. Can NYT confirm the authors are neutral and don’t have any vested interest in Boeing?P
20
I just finished watching a news story on YouTube from 60 Minutes Australia regarding pilots getting sick because the cockpit air and cabin air are drawn from the engines. Pilots are suffering from symptoms outlined in a internal Boeing memo if hydraulic engine oil is vaporized and fed into the cockpit air. Their producers took samples from the fold down tables and found traces of these chemical compounds from engine hydraulic oil. I've never heard of these charges before and wonder if any pilots out there have heard of this.
5
A clever and thoughtful article which also happens to blur Boeing’s responsibilities. It feels like a reference point in the below article about Boeing blaming pilots. This was a horrific corporate failure in its specifics and a broader corporate culture shift driven by financial wizardry over humanity.
https://newrepublic.com/article/154944/boeing-737-max-investigation-indonesia-lion-air-ethiopian-airlines-managerial-revolution
18
I read this terrific article in the Sunday hardcopy and was so impressed that I went online to contact the author with congratulations. I then came upon this demi-monde of comments with its astounding variety of interpretations of the same words that I read. There has to be a whole Ph.D. study here. So many are offended at the author’s light treatment of Boeing. Really? I thought that the author cast plenty of blame on Boeing. One “Times-pick” commenter called the pilots “highly-experienced? Wut?! The lead Indonesian pilot was 31 and Ethiopian pilots were 29 and 25! I could go on and on. Thank you, William Langewiesche and the NYT, for reminding me that reporting can still be produced in the age of Trump.
22
Just tell me how to reliably evaluate the airline safety record, the pilots and maintenance before I buy my tickets. Every time.
6
Avoid LCC outside the US. Learn what a union does inside a highly technical field. Learn what ASAP is and why it does not exist in other countries. Ask why Republicans really hate unions.
10
This article seems to be trying to get Boeing off the hook. If pilot training is as bad as the author states, then Boeing should have doubled down on safety by announcing the existance of MCAS and what to do if there were a problem with it. The fact that only one sensor for MCAS was built into the plane, and a second one given only as an option which adds additional costs indicates to me that Boeing's concern for safety was way behind its quest profits in their priorities.
Even if the pilots can be faulted for their reactions, it's Boeing's calamitous decisions which set it all in motion.
18
So much for superior airmanship: 45 minutes in a parked 737 max is what you get as US-pilot. The „third world pilots“ at least had max simulator training. Their US colleagues: None
https://qz.com/1584233/boeing-737-max-what-happened-when-one-us-pilot-asked-for-more-training/
5
Please stop pointing fingers at other people.
5
Better trained pilots in US?
Not really:
https://www.google.de/amp/s/qz.com/1584233/boeing-737-max-what-happened-when-one-us-pilot-asked-for-more-training/amp/
4
The impossibly difficult task of quickly turning off Boeing's computer safety system with a sequence of steps that the pilots were never shown has not been adequately addressed. Airmanship cannot save the plane if the computer does not let the pilot control the plane. I hope one outcome of these crashes is that flight training routines are updated to include scenarios where the autopilot and safety systems need to be disengaged against their will.
11
There is a great article in the IEEE Spectrum, by Gregory Travis, that points out that Boeing attempted to apply a software fix to a hardware problem. Mr. Travis has decades of experience as a pilot and software developer. It's a very credible read.
8
I lost a great friend in the last crash. The Captain was a great, respected, extremely smart, and well trained, friend.
Before the crash we called him a hero, cause he scored excellent marks. His knowledge, combined with his skills, during PT and PC always perfect.
Now, that he is gone, and that he can't defend himself, we are blaming him for the accident.
Indeed.
Just imagine if this was a war between Boeing vs Capt. Yared; the result would have been obvious, Boeing would have won.
This is no longer a war between the skills the pilots had vs Boeing, but rather Boeing vs engineering vs business ethics.
If the pilots are to be blamed, then why is the MAX still grounded, and costing Boeing in billions? If the aircraft is flawlessly designed and and perfectly build, then how come it isn't flying today?
21
This is a terrific article about a complex and gruesomely fascinating issue, but I expected a more balanced conclusion.
Completely downplaying Boeing's responsibilities as a harmless technical glitch and putting all the blame on pilots and companies (although they obviously have a huge role in the story) is deeply disturbing.
20
The author starts and ends as an apologist for Boeing, but his description of the accidents seems to refute his argument. As suggested in the article, and as with any occupation, among pilots deemed competent, there is a wide range of skills and abilities. Surely, a manufacturer should not design a plane that only the top 1% of pilots with the most airmanship can operate safely. Boeing's choice to sell what seem to be essential functions as an optional package at extra cost was irresponsible.
12
The author is being accused by commentators here of biases against the third world not evident in earlier writings.
His defense of Boeing, however, is less than persuasive because of the way Boeing reacted to the crashes. I have a sense, however, that more weight should be given to the defects inherent in a sweetheart relationship between the FAA and the aviation industry.
7
From 60,000 ft, so to speak, the problem described here is another example of the failure of a loose definition of artificial intelligence. The human brain is still the most intelligent computer, but in the greedy, amoral, world of high corporate decision-making, computerized decision-making is cheaper, and "close enough". After all, Lion Air and Boeing have made millions and billions in profit, and nobody is going to jail, and no executives will be impoverished. In the corporate world, the crashes are win- wins, as the passenger lives lost are meaningless financially, which is the only meaning that exists in the air industry. Welcome to the modern world. Get used to it, or destroy it.
4
I think this article just shows that accidents never have just one cause but several things have to happen in the right order. The MAX was badly designed and the pilots made errors but it was combination of these things which caused the crashes. The MAX isn't unsafe but then Boeing should told the crews about MCAS and there was no back up for the faulty air speed sensor on the captains side of the flight deck. Those who say Boeing gest no blame in this article haven't read it properly. It gives the facts of what the pilots did and how easily they can get overloaded with warnings when things are going wrong. Which is a lack of airmanship skills they should turn off the automation and fly the plane. But so many don't know how to.
7
Was this guy paid by Boeing? It's clear that the Boeing management culture is what "really brought the Boeing 737 down." Outsourcing. Hiding changes that might effect it's bottom line. Moving engineers to the sidelines. It wasn't those pilots. It was Boeing. Boeing is to blame.
8
An informative and very interesting read by the same author "Should Airplanes be Flying Themselves?" September 17, 2014 (Vanity Fair). Easily found through a google search.
I think it noteworthy to mention that at almost twenty-five years as a flight attendant for a regional and international North American carrier I don't recall a front end crew with a captain under forty.
8
Quite the article. Thorough. The politics are worthy of note. " You must say it could have been Israel's fault." No courage at the UN. Government cover ups, with France as a willing participant. Nothing new here.
At the end of the day though, I do see Boeing taking shortcuts in trying to pass off the plane as a 737, which it is clearly not.
I heard a comment recently that Boeing has suggested that airlines not identify the plane as a 737 max when it returns to service. I would hope that rumor is false.
I am not comfortable putting my kids on this place.
2
Boeing should not have placed the Max's engines in a more forward position. This necessitated software to monitor the instability this caused so that less experienced pilots could fly the Max 737. Fact: the Max is inherently unstable.
A classic case of a "structural" problem. No pun intended.
1
What would the writer make of pilot training at, say, Ryanair and Easyjet? They get trained very quickly there too. (Would-be pilots at these carriers actually pay the airlines for their flight training.) And carriers like BA also recruit and train their pilots from high school, without any flying experience. There is a difference in outcome, of course, but the writer seems to favor only the US model.
Also, the writer rather injects himself into the story so much that it reads a little like an op-ed.
4
My family and I were living in London when the time came to keep the promise I'd made to my son to send him to a flying school in Florida to obtain a private pilot's license.
I then paid half the cost for him and a Brit classmate to 'build hours' by flying a one-engine Cessna 2-seater for a US tour with stops in East Texas & Palo Alto before returning to Florida. The plane's instruments were 'basic' - as in a compass from a Cracker Jack box :-) - so the boys got a whole lot of 'seat-of-the-pants' experience.
He soon joined RyanAir, where he spent 13 years, the last three as a Training Captain at that airline's big simulator center near Nottingham in the UK.
I learned how enthusiastic and very skillful a pilot he'd become when he took me for a ride in one of the sims (737-800) and, high above Salzburg, showed me what a Hammerhead is. (I had no idea how realistic those multi-million-$$$ simulators are; I felt extremely queasy and utterly terrified.)
It's more than a dad's pride speaking when I say there's no pilot I'd rather have in the left seat up front in the case of a mechanical or other sort of incident.
For the past two years he has been captaining Boeing 787s for Qatar Airways in Doha.
Needless say, the recent escalation of tensions in that neighbor have significantly magnified my fears that he might soon have to put all his fabulous flying intuitions and learned technical skills to the test.
Fellow readers: feel free to keep your fingers crossed for him.
5
Boeing’s senior management could not have obtained a better piece of propaganda in its effort to conceal its guilt for killing over 300 people than if it had paid the author handsomely to write it.
The 1930 era’s romantic perception that a well-trained hero pilot can be relied upon to overcome the consequences of a defective design was thankfully buried decades ago. Now is not the time to return to that dangerous mindset and the carnage it wrought.
8
Not one word about the origin of the flight control problem, the possibility that the airplane will stall under what would otherwise be a "normal" flight regime.
Why? Because the new engines change the center of gravity of the aircraft. At every decision point on how to build the 737 MAX, Boeing, pushed by it's customers (the airlines) went to the limits (or beyond) what was possible, seeking to lower the magic seat mile cost.
Thus the need for the MCAS.
And quit defending the Pilots. They would be dangerous flying puddle jumper commuter aircraft, five hull loss accidents at Lion Air? Even with no casualties, because they involve runway accidents, that is a shocking total.
2
@OzarkOrc Ethiopian was a highly respected airline with no accidents. One of the few airlines in the world with a 737 MAX simulator. And yet, it crashed.
You can't blame this on poor pilots and poor training.
2
What a sad state of affairs. NYT, please do a follow-up article on how a consumer can know whether they are engaging with an airline that follows best practices of the industry.
Look at that picture of the cockpit. Who designed this user interface? Maybe Boeing should consider letting APPLE design their next cockpit.
5
Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect.
Captain A. G. Lamplugh
1
It's about time for an article like this one to appear. I was excited when I saw the name Langewiesche, and was not disappointed. Fate is indeed the hunter.
5
William Langewiesche is a national treasure. The Times was wise to take him on.
5
Takeaway:
1. Planes aren't perfect. If (when) something goes wrong, a real pilot takes care of the problem, while a paint-by-numbers one crashes the plane.
2. As everywhere else in life, politics plays a part.
3. Throw in a couple of pro-forma denunciations of Boeing as corrupt, to please the leftist readership. See #2.
4
So, unless it's an American manufactured plane and the pilots are American citizens, or have been fully trained and certified in America, the reason for any plane crash is pilot incompetence, or outright ignorance. Never is it the plane's fault. Second, had these crashes been Airbus planes, the fault most definitely would have been the plane. Third, never in the field of journalism, has so much smoke-screening befuddled writing been devoted to avoiding the truth.
8
I was captivated by the content of this article but I'm surprised by how many people are calling it well written. I couldn't believe the NYT would publish an essay with so many needless, puffed-up, pseudo-academic phrases such as "That is a simplification, but one that will do," "we will return to it later," "let's explore them briefly now." The condescending prose style of this piece was a real turnoff.
10
Whether William Langewiesche has received payment from Boeing needs to be investigated.
9
This is the very definition of a "puff piece" article, written in a leading magazine on behalf of Boeing!
The typist's intentions are clear - deflect, deflect, deflect!
Third world pilots of planes are now the scapegoats for a greedy corporations cutting corners at the expense of human lives! The blame part.
Hey, it is easier and cheaper to pay the penalty than take the precautions; a page taken from Iacocca's K-cars! All of that happened in the leading, proudly so, First World nation.
6
What an article! The harshest word used for Boeing is "bewildering". The mildest for the pilots is "dumb".
Forgiving me for concluding that the author started with a clear agenda...
12
Quick: you are experiencing 1g of force and being tossed about. You have to figure out in 1 minute what went wrong and fix it before you all die.
Look at that panel in the picture. Can you pick out what it is you need to press among the 300 or so buttons, switches and dials?
3
Weak pilots will crash a plane the moment something goes wrong, as happened with these two flights, and also happened when 50 souls perished in Buffalo, NY.
Sully Sullenberger would have landed this thing with one arm behind his back.
1
@VCuttolo Not so. Sully himself flew a flight in a simulator and testified about it in Congress on June 21st. He said: "Even knowing what was going to happen, I could see how crews could have run out of time an altitude before they could have solved the problems." He also testified: "It is clear that the original version of MCAS was fatally flawed and should never have been approved." He did not say "except for US pilots, who would have landed this thing with one arm behind their backs."
8
@Mot Juste
It is true that he testified that the MCAS as originally designed and implemented was unsafe. It is also true that a good pilot would have handled it well, as previous pilots did with the 737 Max. Even the Indonesian pilots landed it safely, aside from the one time they didn't. There is no question that Sully would have been just fine in that situation.
2
Disappointing to see the NYT trumpet an article so obviously written to advance the interests of Boeing. After smearing the pilots' "airmanship," and downplaying the havoc created in both cockpits by Boeing's "unannounced" but "innocuous" MACS, what independent, objective investigation justifies the author's assertion that "[t]he Max's creation took place in suburban Seattle among engineers and pilots of unquestionable if bland integrity, including supervising officials from the FAA"? Or that "[a]lthough Boeing's designers were aware of timetables and competitive pressures, the mistakes they made were honest ones, or stupid ones, or maybe careless ones, but not a result of an intentional sacrifice of safety for gain."
8
There was also the Asiana crash at SFO where the pilot clipped a seawall. He was tired from a long flight and was apparently too accustomed to the airplane flying itself. In my opinion there needs to be more hands-on flying in order to keep skill levels high. I believe the airplane should be flown manually all the way from taxi to cruising altitude. Only then should automation take over. Ditto for the end of a flight.
6
These excellent letters by readers balance any biases the author might have. There is clearly plenty of blame to go around, from the bottom-line focused corporate types and the political forces in all of the countries involved, to pilot training and the shortcomings of ground crews. It is not a reassuring picture for the flying public, despite the statistical likelihood of surviving any particular flight. Harrowing though the picture is, I'd rather see it clearly than have it be hidden away. Thanks to all who wrote so carefully and well.
9
Having flown on several budget carriers in SE Asia through the years, I can attest that many pilots here fly in ways that leave passengers shaking. Steep takeoffs, abrupt landings, and tight turns are fairly routine. So when I read about the lift provided by 737 Max engines placed forward of the wings when the nose points up steeply, those sometimes harrowing small airport takeoffs came to mind with no stretch of the imagination. This being the case, activation of the MCAS seems more probable in some parts of the world than Boeing allowed when they decided the system need not be mentioned to pilots, or when they decided the enhancements that cause a steeper autocorrection than in the FAA approved design need not be mentioned to the FAA. This being the case, it seems disingenuous for Boeing to first ignore the reality that flying styles differ across regions in their world market, and then to suggest pilots were to blame. The public, and perhaps more than a few industry professionals rightfully wonder what else Boeing might be ignoring or keeping secret. One last note: Given a choice, avoid the low cost carriers. They might skimp on purchasing optional pilot 'convenience' features.
10
Reading the comments here it seems there is a desire to pin the blame on one thing or the other while it would seem to me pretty obvious that when disasters occur - especially when they are a rare exception to the great safety record of modern aviation - that multiple factors were at play and that improvements should continue, as they have over many years.
Clearly pilot training was lacking, and the design of the systems on the 737 had some flaws under certain specific circumstances and if these two states did not occur together we would not be reading this piece.
The logical outcome is
1) Don't expect aviation to be 100% safe - it's close but it isn't
2) Boeing should revise the software and training around the MCAS system - and they are
3) Pilot training needs to include more flying hours, and especially more hours that are unassisted by technology and low cost flight schools such as Lion's need to revise their practices
7
@Mark Marks Good advice on pilot training. Can we realistically expect the airlines with weak pilot training to reinvent their safety culture?
@Bill: It’s been done. Korean Air went from a severely safety-challenged airline over 20 years ago to being one of the safest airlines in the world by taking a clear look at itself and its culture and adopting Crew Resource Management (CRM) to replace their “the Captain is God” culture. They made the decision to do this and got help from Delta Airlines... a great success story.
3
Basically, this article says a corporation that builds passenger aircraft cut corners but didn't tell pilots. Not only did they not tell the pilots on the far end of the bell shaped curve of airmanship ability, they didn't even tell the airmanship worthy ones - you know, the ones in the bubble of the bell shaped curve. As the author writes, "Indeed, Boeing "believed the system to be so innocuous...that the company did not inform pilots of its existence or include a description ... in the airplane's manuals."
As a member of the flying public with more than a million or two miles riding as a passenger on domestic and international flights, of course I fantasize - and desire - that every pilot is a hero and will save us from all manner of disasters. In my more rational mind, I know that sometimes they can't save us because stuff happens - but I also know flying is extremely safe in our time in history. Still, because stuff happens, I text my family before the flight takes off to make sure they know that I love them. I'm sure every other person on my flight is doing pretty much the same thing. I don't know what my point is exactly except I will now add to my thoughts before take off that I hope Boeing told the pilots about any potential system risks that could doom us all - no matter how innocuous they believe the risk to be.
6
The 737 MAX incorporates major design flaws, heavier engines placed forward on its wings, and relies on a faulty computer program to compensate for the design flaws. Boeing needs to recall the plane and go back to the drawing board to design an air worthy plane.
12
@an observer I think this fact about the heavier engines placed forward on its wings is missing from this article? That was the reason for the MCAS installation. It was a flawed design from the get go as I understand it.
3
The article gives a very good explanation of the failure of modern pilot training and how it can be deadly. However, I think it misses the issue that in part pilot training has become what it is because of a reliance and trust placed in the planes being sold to airlines. I'd argue that Boeing failed to provide a sufficiently reliable aircraft, even with its known pilot oriented culture. The design failures were not trivial and have exposed serious problems with FAA regulation. I think you do the industry an injustice by not accepting joint responsibility; inadequate pilot training and inadequate aircraft design. The cost of cheap flights for everyone has never been clearer.
In a digression I note that autopiloted automobiles will eventually create the same issues as drivers, like pilots, lose their skill to automation.
7
As a pilot friend of mine stated---it is never one thing that brings down a plane, but a cascade of bad decisions. In this case, the author focuses on the bad decisions made in the cockpit, forgetting that the bad decisions began years before in Boeing's corner offices. No plane should be designed with the assumption that the Red Baron would be flying every plane.
25
Thank you for a thought-provoking article.
After reading it, I checked the safety record of the next airline I will be flying, on a different version of the 737. Fortunately, that airline has one of best in the industry.
1
Excellent journalism, to the point, obsessed with details and highly critical of a bunch of actors in aviation. Please keep up the good work and continue to publish such articles that defy the Twitter age. AWESOME!
12
So much for Atul Gawande's Checklist Manifesto. I practiced surgery for almost forty years. I was taught how to operate. I was taught anatomy and how to cut and sew. I am concerned by the change in surgical training due to residency work hour rules and increased supervision. I think young surgeons are now taught operations but not how to operate. It's the difference between being taught how to follow a recipe and how to cook. What does a recipe (checklist) focused chef do when he/she needs a boneless chicken breast but all they have is a skin on bone in whole chicken? It seems like flight training is having the same issues. Scary stuff.
7
@Sandy Kaplan Respectfully, the surgical checklist ensures preparations for surgery have been done correctly to account for human error. It is not a checklist for doing an operation. I also take your point that skill requires years of experience.
2
I have known many people who worked for Boeing. The stories they tell. Boeing has always been very customer oriented. One airlines would always reject a new aircraft unless Boeing threw in enough carpet so that the airline could re-carpet the aircraft. Another airline when an aircraft was nearing the end of its warrenty would send all the black boxes they could find regardless how long the airline had then back to Boeing claiming that this was part of the warrenty. Many airlines are frequently trying to cheat Boeing out of something. Aircraft are very expensive.
As you pointed out in your article, airlines aret trying to get as much as possible out of their pilots. Some pilots make only $20,000 per year. Pilots are only paid for their time in the air not for the time on the ground getting the plane ready to fly. This can lead to highly fatigued pilots who should not be in a cockpit.
Airlines wanted an aircraft in the 737 Max that did not require recertification nor pilot retraining. Boeing gave them what they wanted with disasterous results. Is Boeing at fault? Are the airlines at fault? Is the FAA at fault for not providing proper oversight? I think that it is a combination of all these. I spent 25 years in aircraft maintenance, so I have seen many corners cut on maintenance and operational safety. Maybe we need a little more regulation of the airline industry.
11
My family and I were living in London when the time came to keep the promise I'd made to send my son to a flying school in Florida to obtain a private pilot's license.
I then paid half the costs for him and a Brit classmate to 'build hours' by renting a single-engine Cessna 2-seater for a major US tour with stops in inter alia East Texas (free lodging with his maternal grandmother), Palo Alto (ditto with a college roommate of mine and his wife) and eventually back to Florida.
He eventually got hired by RyanAir, where he spent 13 years, the last three as a Training Captain at that airline's big simulator center near Nottingham in the UK.
I learned how good and enthusiastic a pilot he'd become when he took me for a ride in one of the sims and, high above Flughaven Salzburg, showed me what a Hammerhead is. (I had no idea how realistic those multi-million-$$$ simulators are; I felt more than a little queasy and - I can't deny it - utterly terrified.)
It's more than a dad's pride speaking when I say there's no pilot I'd rather have in the left seat up front in the case of a mechanical or other sort of incident.
For the past two years he has been captaining Boeing 787s for Qatar Airways in Doha.
Needless say, the recent escalation of tensions in that neighbor have significantly magnified my fears that he might soon have to put all his fabulous flying intuitions and learned technical skills to the test.
Fellow readers: feel free to keep your fingers crossed for him.
9
Are there cases of European or North American air disasters where voice recorder transcripts were not released? Why are insecure and (likely at least partly) at-fault governments accorded that right without severe regulatory consequences?
7
The tragedy will be if the industries involved fail to heed the lessons learned here in this tragedy. There is plenty of room for improvement in all directions, lets hope we move on all of them so no more mothers, fathers, sons daughters, etc lose their lives in a preventable disaster.
The goal should be that we prevent further loss of life.
1
Riviting article filled with numerous areas for furher investigation.
The politics of resolution of the two crashes is abhorrent.
Trust Bill Boeing's kids to prevail.
I am underwhelmed.
Nowhere this tomb does the author address the primary cause of the Max difficulties.
Oversized engines fitted to an ancient airframe. Claiming it's just another Mark in order to avoid pilot training and recertification.
Boing must stand trial for its greed and Corporate criminality.
Boing greed knows no bounds.
16
I have read some articles about this. One aspect really missing is the poor passengers on the flights.
7
@Ravi
That wasn't the focus of this piece. Different article.
I recently read a long comment in Aviation Week about the crash that was written by a retired Boeing aeronautical engineer.
The theme of his comment is that the 737 MAX is inherently longitudinally unstable and that this was not sufficiently appreciated by Boeing. His point is that the MCAS system was not the proper answer to that problem.
As to the failure of the pilots is concerned, decades ago over North Vietnam I flew in the right seat with a very experienced pilot who had no combat experience. A plane ahead of us received some anti-aircraft damage whereupon my pilot "lost" it. My point is that until you are in a true emergency, you don't know how you will react. No amount of time in a simulator can train you for that moment.
As for the quality of training in India, that is well known to be suspect or worse. The same probably applies to Indonesia and most of Africa.
To put all the blame on the pilots is erroneous.
Nonetheless, I will fly the Boeing 737 MAX anytime with American, Canadian, and most EU airlines.
2
A quote from the CEO of the risk-laden airline in the context of many lives lost on his planes. Is this his excuse or justification or just his background rhetoric? Identity politics abounds.
“They look down on my airline and my country,” he told Reuters. “They treat us as third-world.”
1
Judging from the reaction to this article it's open scapegoat season, and the sound of lawyers happily barking in the chase is unmistakable and refreshing in the morning air.
The article makes a lot of sense, but it points fingers to parties which, while probably responsible for the situation, have few assets.
Who you' gonna call? Plane Busters!
5
While the research and analysis in the article in is in depth and illuminating, as far as the assessment of the Indonesian airlines and procedures, and I can understand the author's view on the rote learning and decline of actual flying skills, and how dangerous this is, it is not a balanced account of the bigger picture, one that takes into account the shortcomings in the design of the plane. Other readers have commented on the definition of airmanship, but the contrast too the way the author discussed technical issues is revealing. If you look at the way the author glossed over flaws in the MACS, from premise to function (little mention of the single point of failure in the system, the lack of the disagree light, the modifications to the system to increase the number of times it acted, and the angle at which it deflected the stabilizers etc.) it is far from a complete picture - it almost looks like technical details were cherry-picked, and the failings in the system are incidental to the events in the cockpit that led to crash.
13
Face the reality.
In the past, Boeing's success was based on flight engineers and plane designers who always based their decisions on the reality that their planes could fly based on the safety of the flight crews and passengers.
Then, the culture of Boeing became completely based on Sales executive, who could "massage" the reality to get their planes sold and getting government regulators to rubber stamp that reality.
Planes dropped out of the sky and hundreds died.
And you have a federal government staffed with pro-Boeing lobbyists.
Corporate greed always "Trump" passengers' needs.
Ironic about the term "Trump".
Connect the dots
6
An incredibly well written article. The explanations are well crafted and provide clarity to complex issues in aerodynamics and flight controls in simple and accurate terms. I spent my entire working life in fields aerospace engineering and aircraft flight testing. Although I may not completely agree with all of your assertions it has certainly given me food for thought, and altered my perception of the entire fiasco. Bravo Sir. Well done.
2
I believe the root cause of the 737 MAX problem is that the plane is unstable.
Until now, civil aviation airplanes have been intrinsically stable and can be flown using manual controls only -- without interference from additional systems like MCAS.
Military fighter jets, on the other hand, are unstable by design and are flown by a computer, with input from the pilot. They are un-flyable without the computer support. The computer (I presume) has access to all sensors and makes decisions based on the totality of its information.
The MCAS was a hack, originally added to pass a required high speed test maneuver and then made more aggressive because of a low speed issue that was discovered later.
It seems to me that if we move to unstable passenger planes, like the 737 MAX, we should use a control system that has all the information it needs to properly control the airplane. In addition to the angle-of-attack sensor, it should have access to position, speed, height, yaw, pitch, roll, etc. This, plus pilot/autopilot input, should be used to control the aircraft.
I believe that we should not introduce such unstable planes -- at least not without massive multi-year testing. After all, fighter planes crash regularly, which is why they are equipped with ejection seats. I don't see that as practical for commercial airliners.
15
My background includes 22 years in the Air Force flying fighters, training fighter pilots, training foreign pilots, investigating aircraft crashes, and flight testing aircraft. Additionally I have 20 years of commercial airline aviation experience including 737 max experience.
This article exposes facts that need to be considered every bit as much as Boeing designs failures. An inexperienced minimally trained pilot will quite easily get himself and his passengers killed regardless of the aircraft being flown. That is why the standards are so high in the US and Europe, and why the safety records of the countries mentioned are so poor.
To be a competitive applicant and future new hire at major US airlines typically requires the applicant to to have between six and 10,000 flight hours, and several thousand turbine pilot in command hours. While US pilots may be somewhat generic, the minimally trained pilots from the countries mentioned in this article share little in common with western pilots.
Would anyone have flown on either of the two airlines involved in these crashes had they known how inexperienced and poorly trained the pilots were? Of course not.
Airline pilots are responsible for the safety of their passengers. That is their number one priority. Pilots by definition are expected to be able to intervene in emergency situations. Very low time, poorly trained, and inexperienced pilots should not be airline pilots entrusted with the lives of others.
28
This article would have benefited from mechanical drawings so that the lay public could understand the technical problems better.
The article is, however, an argument for incorruptible government oversight. Too bad the FAA has been outsourced to the corporations.
11
Look, if you don't want to blamed for 'dumb pilots' crashing your planes, either stop selling your planes there or require Boeing-controlled training.
What you don't do is build in a secret computer which overrides human control, pushes the nose down and then blame pilots for reaching a height of 0 feet.
Where's a call for engineermanship and ethics over at Boeing headquarters?
35
Thank you Times for an article investigating facts about a topic.
This article has biases but details the opposing arguments well enough that even without being an expert on the topic I can make up my own mind based on the presented facts as opposed to the opinions. Could we please get more articles like this?
10
As my brother, a former airline pilot, always says, "They always blame the pilots, because they're already dead."
25
Wow. Thank you Mr. Langewiesche, for writing about these plane crashes in context. I have appreciated your in-depth analyses of plane crashes, especially the crash of AF447. I have also read just about every article on the 7-3 MAX in the NYT, and read way too many semi-hysterical reader comments based the little bit of information that has trickled out so far. This is the most balanced I have seen to date. You hit the nail on the head. Please come back with more as the information trickles in.
Kudos to NYT. My picayunish comment is that the article could use a little more judicious editing.
13
There are pilots and then there are systems operators.
7
There is another article about these 737 MAX crashes. This is to be found at
https://newrepublic.com/article/154944/boeing-737-max-investigation-indonesia-lion-air-ethiopian-airlines-managerial-revolution
That article puts most of the blame on Boeing. This article may be more realistic, but it seems to me that ultimately this is a Boeing problem, and iti s up to Boeing to fix the problem.
To be really nasty, ask yourselves what the FAA and Boeing response would have been if the two crashes had occured in the USA.
12
@toom If it had been those pilots in the US it would have been the same. US pilots have better training.
If the Indonesian and Ethiopian authorities did not release the full flight recorder data how did the author write such a detailed narrative of the doomed actions of the pilots? He seems to have written a biased account.
6
@MCC They didn't release the voice recorder. They did release the flight data recorder.
4
Wow. Riveting article. Well done
4
While I'm sure there's always room for improvement as regards the safety records of airlines, this article is full of unsubstantiated rumours, allegations, and assumptions. Furthermore, there's a highly unpleasant tone of casting aspersions by inference: So, Lion Air's owner penny-pinched by designing the airline logo and crew uniforms himself. What of it? I think we can all agree that Boeing's millions-of-dollar-pinching in order to avoid having to re-register the Max as an entirely new aircraft (which is what it is to all intents and purposes), and being less than forthright about this to its customers has proven far more costly. Boeing should just have done what any honest businessman would have done: taken the economic hit by spending the time (10 years) and money really required to come up with a competitive alternative to AirBus Neo. Shame on Boeing for not doing so.
18
Incredibly detailed and still comprehensible article that reads like a report. Great job!
5
Aviate, Navigate, Communicate!
4
I'm not a pilot but worked in aviation (helicopters) for 36 years and was able to visualize the author's descriptions of cockpit protocol and aerodynamic events. What struck me most was this aircraft wasn't dynamically stable with the larger engines and it was necessary to add complex enhancements (MCAS) to overcome that fundamental fault. Much was said of pilots lacking ''airmanship'', but what about engineers ignoring fundamental aerodynamic stability? The understanding between engineers and pilots is crucial and failed on this aircraft. Otherwise, great reading; give this man a Pulitzer.
14
By far one of the best NYT articles I've read in a long, long time. It's replete with technical know-how, acerbity, and insight beyond the surface.
7
Great article keep up the good work
4
I don't buy the pilot error explanation. It may be true that more skillful pilots could have prevented those 2 crashes but that does not change the fact that "the 737 Max was fatally flawed and should never have been approved" as pointed out by Retired Captain Sullenberger when he testified before Congress in June or the fact that "safety begins at the top, and the top officials at Boeing and the Federal Aviation Administration have let us down" as pointed out by a former chairman of the National Transportation Safety Board and a former managing director in this paper in July. I consider Mr. Langewiesche's story to be one of the most artful pieces of industry propaganda and shifting of responsibility ever printed in this newspaper.
27
@Mark. I tend to believe Sully (and all the other career pilots who essentially said the same.). I’m also quite surprised, given the quality and unbiased extensive prior coverage in this newspaper, that they felt a pompous, seemingly paid-for, piece like this to be featured, without at least a preface indicating that the author is dispensing opinion, essentially racist or xenophobic and very selective about the known facts. Thankfully, the Times opened this for comments, which largely trend toward the same analysis.
Also unsettling is the hubris of experienced pilots to believe that they would have had no trouble in these circumstances: something also belied by later simulator testing with excellent pilots. Hubris in the air may be common, but happens to be a primary cause of general aviation crashes, and with pressure to complete schedules, has to be operative in the airlines. Overconfidence can kill as surely as inexperience.
14
Totally agree about this being propaganda. Straight out of Boeing's PR department?
19
Exactly right. Industry propaganda is spot on.
8
An extremely well written and thorough article on this subject devoid on the nonsense and accusations you normally see. It is clear the pilots were not capable of handling the situation due to the training and culture of these third world airlines. Boeing also blew it with this system not including it in the manuals and emergency procedures. The ultimate engineering failure was using a sole source of information to activate the system. Thank you for this information.
4
I would tend to think the best pilots in commercial aviation would be those from the military who have been in combat and those who are crop dusters.
There is a saying however : There are old pilots and there are bold pilots but the numbers of old bold pilots are fewer.
2
Don’t these two quotes from the article really sum up what has been going on here: “Even more pernicious was the F.A.A.’s longstanding delegation of regulatory authority to Boeing employees — a worry that is perennially available to chew on if you like and may indeed be related to the configuration of the troublesome system as it was installed.” And “On the corporate level, the company is the worst sort of player — a corrosive agent that spreads money around Washington” In other words an ostensible “regulatory agency” that functions more like an Industry Trade Group, or is at least held hostage to those it is supposed to have oversight, combined with a regulated company that “has friends in higher places”? I lived in Seattle during the 1970's when the infamous "Will the last Person to Leave Seattle, Please Turn out the Lights" billboard was supposedly put up during Boeing's crash during the first "Oil Crisis". I understand their importance to the local and national economy. This is different and is a self inflicted wound that in addition to the tragic loss of life represents a terrible "miscalculation" at best if not criminal negligence or worse, by many.
2
The very last paragraph; “Boeing has grown largely silent, perhaps as much at the request of its sales force as of its lawyers. To point fingers at important clients would risk alienating not only those airlines but others who have been conditioned to buy its airplanes, no matter how incompetent their pilots may be.”, speaks to what Boeing should have done from the start, requiring that all the raw data associated with the accidents, (saved from the black box) be held as “owned by Boeing”. There could not have been any way that Boeing could have foreseen such accidents as that have occurred by these two tragic events , nor to have known both Indonesian and Ethiopian authorities would hold back the data! But now they must have the data for their own investigations, for future safety concerns and should write this “ownership” into future contracts! They must be bold as Farragut who said; “Dam the torpedoes, full steam ahead.”
2
There is much dispute on this board about the import of this article by people qualified to opine about the causes of these disasters that could have been averted. Many think that the article's pointing up of the contribution of the pilots is a snow job for Boeing (and the FAA). Others take a supposedly more nuanced view that it was pilot error coupled with the ignoring of basic training and design and testing protocols by Boeing to beat its competitors to market.
The latter view shows that the Times has been successful in muddying the waters, which of course favors Boeing, by disingenuously insinuating (but never saying outright) that there was in some vague sense an equivalent contribution between the pilots and the company.
This vacant perspective is clever but pernicious, because it tends to divert thinking about the company's (and its executives') responsibility away from the rubric of corporate criminal liability, which is the umbrella under which it ought to be analyzed in the first instance, given what the company knew and turned loose on unsuspecting innocent people, and the catastrophic results of this brazen pursuit of profit at the expense of public safety. The Times is good at this "well it's hard to say, you know" tale, or (another version of the same story), "it was everybody's fault", especially when it favors the wealthy and powerful and serves to protect them from real accountability.
6
I am currently a Boeing 767 Captain and have been flying for a major US airline for almost 20 years.
This was a very good article and one of the best aviation articles I’ve read in a long time, however you seem to assume that the “airmanship” problem is isolated just to third world countries. But the truth is, it’s a WORLDWIDE problem. You never mentioned Colgan Air or the recent Atlas 767 crash outside of Houston, both accidents involved lack of airmanship and improper unusual attitude recovery procedures. These problems exist in the US too. In fact our airline, including other major US airlines, have taken measures to ensure that our pilots are trained to handle “unusual attitudes” and implemented ways to improve our situational awareness(airmanship).
Finally, to increase automation or make planes more “robotic” as you suggest is NOT the solution. That just makes this problem worse. The accident pilots’ heavy reliance on automation and failure to just FLY the airplane is what really caused these unfortunate tragedies. The more automated an airplane is, the more airmanship, situational awareness and flying skills deteriorate. After almost 30 years of flying military and commercial airplanes, I’ve learned when things don’t look right and start getting ugly, turn off the automation and FLY the airplane. Unfortunately, these pilots were not trained to do that, their over reliance on automation doomed their flights.
15
Mr bigdaddy, You are mistaken. MCAS is not part of the "automation". It was operating in the background full time, not something that could be deselected before takeoff.
2
Wow - just wow. Certainly makes me think about what airline I fly.
3
There is a lot of good info in this article. I disagree with the author mostly blaming the pilots. The author has ignored the numerous and erroneous readings and alarms which were created by MCAS incorrectly interpreting readings from a single sheered off or malfunctioning AOA vane. For ET302, it definitely was a bird strike which occurred 6 seconds after zero WOW at 50 feet altitude above the runway and at 3/4 of the length of the runway. The sheered off AOA vane scenario is proven in the last several seconds of data shown in the ET302 preliminary report. In both crashes, MCAS caused the stick shaker to active on only one side of the cockpit, and MCAS caused other wildly inaccurate instrument readings which would make any pilot think that they were having FCC issues. In both crashes, there were no indications of a runaway stab scenario.
To the author: Opposing elevator control column force is ignored on the MAX in terms of automatically disengaging the autopilot and MCAS. On the MAX, the functions of the stab cutout switches were changed. A MAX pilot no longer has the option of killing the FCC's control of stab trim while retaining electric stab trim. It has been shown that the autopilot can take several seconds to disengage after flipping the stab trim cutout switches, that the MAX's FCCs are subject to unchecked bit flipping by cosmic rays, and that MCAS can cause the FCCs to report inaccurate data. The latter is obvious in the ADS-B data for both flights.
7
In the time since the 737 Max crashes, Boeing should have been required to retrain ALL foreign flight crews flying Boeing aircraft and maintenance crews concerning the electronics. Yes, it might have cost a pretty penny to fly some hundreds or thousands of these foreign personnel to Seattle or to a centralized airport in Asia. Too many of these low budget airlines should be blocked by Boeing by taking it upon itself by NOT certifying that the planes, flight crews and maintenance crews are qualified to put THEIR planes in the sky without Boeing Certified Training.
3
As far as the people are concerned, airplanes, their pilots and maintenance staff form a complex system. Airplane designers must take into account what is already known about the range of competencies of pilots and maintenance crews in the airlines to whom they sell the planes. If a design is good enough to be flown by, say, top 50 percent of the pilots and maintained by the top 50 percent of the mechanics at their current level of training and competencies, we are in big trouble. The article misses the point.
2
I agree for the most part with the author. Bottom line the pilots were not qualified to western standards. They did not have quality training nor quality maintence. The airline was trying to make money for "whom" and cut corners where they should not have. Ex. the airplane had the same problem with the angle of attack on it immediate prior flights. The cheapest replacement was used on the fourth flight. The AOA problem in the airplane was not corrected. That particular airplane shouid have been grounded.
The pilots were essentially untrained. The Air Lion culture did not seem to entertain cross cockpit discussion of things. When the pilots encountered the problem they seem to have no concept of disabling the auto trim and fly the airplane first and then see about fixing it. Things happen to an airplane but the basics beyond all is fly the plane fix it later.
The author did not recount how many flights the 737s with the advanced trim system had flown in the US and other countries without a crash. None were cited in the article.
The bottom line is quality training - pilots and maintainers.
7
Excellent article. I have two comments:
1. I recognized the author's last name - Langewiesche - immediately. His father, Wolfgang, wrote one of the classics of aviation that should be on every pilot's bookshelf: "Stick and Rudder." It was written in the early 1940's, but is still completely relevant today. It applies to these crashes and the pilots involved (even though their airmanship and training are only part of the problem). My copy is on the shelf next to me as I type this. I am a private pilot with an instrument rating and, while not very experienced, I know what it is like to be confused by a system failure in an airplane. It is not a good feeling, believe me.
2. Many comments on this article talk about the cause of the crashes as being the fault of only one part of the system: "It was the pilots! No! It was Boeing! No! It was the airlines! You're all wrong. It was the assembly line training that rushed pilots into service!"
I believe it was all of those elements.
Going forward, we should improve and monitor all of the elements of this system to minimize tragedies like these in the future. We can do it, but it's going to be hard. Harder if we insist on pinning all of the blame on only one part of the system.
8
My 30000 plus safe piloting flight hours and graduate of USN aviation safety officers school (when it was 3 months long, not one month as it is today) tell me that any machine that requires computer input just to be aerodynamically safe, simply put, ain’t safe. U will never see me on an 800 Max. Boeing did nearly the same thing with the 720. At high qfactors and high altitudes it reversed flight. They kept that info mostly quiet but quit producing them. The 787 Dreamliner is actually the finest machine ever built and with proper pilot training in my opinion it is totally safe
6
Historically, great airplanes have been great since the first day they flew. That's why the DC-3, 747 and the F-15 are still flying. Poorly engineered airplanes are troublesome from the first day and remain problematic until production is finally killed. As the article states, the problem of the stall characteristics could have been corrected aerodynamically but that was too expensive and time consuming. If Boeing can't build aircraft with the correct aerodynamics, they should get out of the business. Incidentally, the new Joint Strike Fighter F-35, has been a continuous problem from day one. The F-35 is a black hole of federal money for what is basically an ill conceived design. Aviation history is littered with the wreckage of badly designed airplanes.
4
Gosh, what a well written piece from an incredibly knowledgeable subject matter expert. Thank you! And it’s a great reminder that there is always a second point of view - all this time we had been blaming MCAS and Boeing. Thank you for this additional perspective!
6
Respectfully, is it standard practice in Boeing’s P.R. Department (or among its legion P.R. subcontractors in this thread) to use exclamation points when populating a comments section with empty kudos? Asking for a friend.
It has already been reported that MCAS had a single point of failure and that Boeing kept the presence and operation of the system secret from operators so they could *avoid* having to factor in the cost of extra training when considering the new Max variant for purchase. So who’s fault is that?
3
@Dale, I have no affiliation with Boeing whatsoever. I assume you are a PR plaintiffs lawyer going after the big pockets of Boeing because of the standard nature of your reply. Assumptions are great aren’t they!
Well written article, excellent read, tons of detail presented in a clear and engaging manner.
I am a software engineer and have read way too much about MCAS from various sources.
I understand and appreciate the concerns about pilot training in some countries. By all means we should do what we can to improve that as it appears to have been done in China.
But I simply don’t understand why any of the following gets a pass when the price tag is so high on these new planes:
1. Only one AOA used for input to MCAS.
2. MCAS trim adjustment lasts for 10s then stops but not necessary to mention it in the manual. This seems like a clear behavior change from any previous runaway trim and from how autopilot works.
3. MCAS operational at 5000 feet where a stall would be unrecoverable anyway?
4. MCAS operational at high speeds where nose down becomes unrecoverable or places airplane outside of known operational limits.
5. MCAS continues to the absolute limit of trim adjustment instead of stopping at a level which would allow full elevator to fully counter it.
6. AOA disagreement alert as an option with additional cost. If I understand correctly this is an option enabled via software and costs Boeing nothing. Talk about penny wise and pound foolish.
Sorry but the pilots either make the correct call or die, while Boeing management only has to make adjustments to their spreadsheets.
14
@Dave These are such incredibly astute observations. This is really a black and white issue that the article manages to complicate. It's like the smoking issue. The airplane is a lemon
3
As a retired avionics technician (US Air Force) who has worked on Boeing planes, this author is placing too much blame on the pilots. As even the Boeing CEO stated, these accidents were from a "chain of events". Nothing beats safety than knowledge and training. To treat an MCAS misfire as a "runaway trim" is very misleading. A "runaway" trim is just that, the trim wheels at the center console CONTINUOUSLY moving, hence the term "runaway". MCAS doesn't "runaway", it actually resets and triggers again, a characteristic that all runaway trim problems may not exhibit. So it's not fair to blame the pilots on this. Also, was the author aware of all the nuisances that could have been problematic for any pilot during the time of these accidents? The AOA sensor triggered false alarms - the stick shaker activated showing an impending stall while conflicting annunciators such as OVERSPEED activated. So if you're stalling, does cutting throttle the first thing in your mind if it is perceived there isn't enough airflow going over the wings? As I read in a book once about making great pilots, two key words are paramount: SITUATIONAL AWARENESS. Had the pilots at least known about some of the automated systems that could trigger such conditions, situational awareness could have been another element to avert disaster. Even our cars have lights for cruise control when we activate them. They run in the background only when we tell it to. Boeing failed their pilots.
16
@John G: This is the best, most well-reasoned feedback letter I’ve read on the subject article.
5
@john and @john,
Maybe you should read up on the author and his numerous awards for articles relating to deadly flights. Even his dad was a famous aviator and author. Then you would understand why I am going to rely on the author’s perspective rather than yours.
1
An illuminating disclosure of the root cause of both tragic crashes, Mr. Langewiesche. I was enthralled 40 years ago by your father’s classic book, and to our great benefit the apple didn’t fall far from the tree.
3
Every swept wing jet transport ever built is inherently unstable in parts of its flight envelope. Since the beginning of the jet age, many devices have been used to give acceptable handling qualities over the wide speed ranges these airplanes operate. These include yaw dampers to maintain directional control, mach trim systems to counter nose down tuck at high speed, feel computers to manage control forces, stick shakers for stall warning, stick pushers to provide positive feel at the stall, vortex generators & stall strips to control airflow, & numerous other tweaks to maintain acceptable handling qualities for the pilot. The 737 MAX is no more unstable than any other transport & probably better than most, but it needed a little help to maintain acceptable control feel at low speed with flaps up, hence the software enhancement called MCAS, sort of a computer version of the stick pusher long used on many aircraft. In hindsight, Boeing should have made MCAS more fault tolerant, but remember MCAS only works with flaps up & all take offs & landings are made with flaps down. In both fatal crashes, the stall warning "stick shaker" activated on take off & remained active for the entire flight. The last thing any competent crew would do is retract flaps with an active stick shaker since that would increase minimum stall speed some 40 mph. Even if the crew flubbed up & did retract flaps, MCAS could be disabled in less than 5 seconds if proper procedures were followed.
2
@Bobm Does the altitude of the airport play a role for an experienced 737 pilot? Do pilots taking off from high altitude airports in an aircraft that traditionally uses a lot of runway normally retract flaps earlier and defer to full throttle?
1
@Steve
In my day, normal flap retract was at 1,000 ft above ground regardless of airport altitude. Every take off is analyzed for aircraft weight, density altitude, wind, runway length, runway gradient, etc to achieve what is known as a balanced field take off. This means you have enough performance & runway to stop on the remaining length if take off is rejected at or before V1 speed & enough performance to meet the minimum climb gradient with an engine failed after V1. Flaps & take off thrust are set accordingly.
1
Even though I followed the MCAS story, it was only by reading this article that I got the complete picture. Outstanding work.
An example of pilots keeping calm in an emergency is the Air Transat Flight 236 that run out of fuel on a trans atlantic flight from Toronto to Lisbon in a Airbus 330 on August 24, 2001. The pilots without engine power glided the aircraft to a landing on a military airfield on a small island in the Azores. Everyone survived. Can only imagine if they panicked and started paging through the aircraft user manual.
3
Langewiesche is a great writer. I can't think of any other writer where I can not understand about 85% of what I'm reading, yet I'm still absolutely riveted.
2
Interesting article, well written and well documented. The author seems to nosedive at the end though, with his near-exoneration of Boeing, even though Boeing was clearly at fault, both technically and culturally, as he describes well in the article. Relying on airmanship while knowing that many pilots out there are not up to the grade is at best naive, not informing them adequately of any changes in the configuration of the plane borders on the criminal. It's clear Boeing tried to reduce costs, both for itself and the airlines it deals with, it knows its markets well, and is therefore part of the whole circus to maximise profits at the lowest costs. The name given to the new model of the 737 seemed to imply it. As to countries not keeping to regulations, it's clear to me that the rules need to be enforced. That could and should be a task of the countries around the world that adhere to them, and given the scope of air travel this day and age sanctions should be used. Last remark to the author: given your involvement in this industry, wouldn't it have been better to choose a different subject for your first contribution to the Times?
@Zefer, do some research. The author has written about every deadly crash for the past 20 years or so - first one was Valuejet in 1999 - and won numerous awards for each one of his stories. Why wouldn’t he write about a deadly crash for the NYT?
2
These sorts of details are no doubt relevant for tweaking a system in its death throes, but the root cause of this is unfettered greed and profiteering. This, an economic system gone wild, destroying everything in its path for a mindless, programmed and immoral goal, is the elephant in the room, and without addressing it, however impossible this may seem, we will forever be playing catchup, and failing. Well, not exactly forever, if you catch my drift.
3
When corporations lose their values and substitute a bottom line for a good product at a good price for the consumer, and then a corrupt government gets involved and deregulates and industry, disaster follows.
4
The piece, regardless of its quick caveats about not defending Boeing, functions as one. It falls back on a tried and true Americanism: Blame the victim. And what’s easier when error can be affixed to the “other;” foreign, of a different race, religion and culture? Besides, the others are conveniently dead.
So ample published evidence of Boeing’s responsibility (a weary design pushed past its limits to beat a rival to market, constrained testing, peculiarly sunny assumptions about how a new layer of complexity would operate in an emergency, new design flaws found after the accident), is brushed past by the author.
Instead, the author argues that the pilots and their aviation institutions failed. Well, it’s likely they did not perform as efficiently as pilots with thousands of hours of experience on previous iterations of 737’s and ample simulator time. However, we will never know conditions in that cockpit. We will never know if a grizzled veteran resembling Tom Hanks could have gotten that Lion flight back safely. Most catastrophes on air or ground are not averted because of Hollywood skill sets, but blind luck; intervening variables over which we have no control. The dice that were rolled this time left the factory weighted against any pilot.
183
@SMB wrong a lot of catastrophes are averted because of skill and training. But it appears many are just wanting to destroy Boeing or any other company and even people for that matter. This is a complex situation, mistakes were made by Boeing, by the pilots, by the Lion Air Mechanics, it was perfect storm ending tragically in the deaths of many innocent people.
30
@SMB It seems like flight crews should purposely be placed in flight simulators with potentially dire situations, that may result in a crash and see if they can fly from the seat of their pants just in case. They should be required to fly a glider and/or a single-engine Piper Cub or learn to fly a plane upside down.
24
@SMB "Well, it’s likely they did not perform as efficiently as pilots with thousands of hours of experience on previous iterations of 737’s..."
And that's not Boeing's fault, is it?
20
Boeing's "High Volatage" leadership of today undid decades of manufacturing acomplisment, discipline and brand reputation. What amatures.
5
This article deserves the Pulitzer Prize for investigative reporting.
5
Finally, The NY Times prints the whole story! As a former Naval Aviator whose pals who have worked at the finest of flight simulator companies attest: '...we've warned the Asian airlines that their pilots can't fly an airplane without the autopilot.'
I asked SW Airlines crew about the Max after the crash of the second plane. They offered up the following: 'SW Airlines has logged 90,000 hours without any problems. But our crews can fly by manually operating the plane AND our maintenance crews identify and fix problems as they arise...without postponement.'
The Korean Airlines plane that crashed short of the runway in San Francisco is the poster child example of this short outline ignored until this well written article.
All of this is not to exonerate Boeing's inept decision to withhold from flight crews about the new autopilot on board the 737 Max. But you don't need an autopilot to fly a jet...any jet!
5
@Jim Berg: It was Asiana Airlines that crashed in SFO, not Korean Air. Korean Air, in fact, Westernized their whole philosophy of flying a while back (the captain is not God), and is now one of the world’s safest airlines. So you owe them an apology. Also, the MCAS on the MAX will not engage with the autopilot on (read the article), so, by definition, the MCAS is not part of the Autopilot system.
4
Such a true comment about the reliance of Korean pilots on rote and autopilot (both major airlines- it was Asiana who crashed in SF, but Korean has had a long history of crashes due to hierarchy and poor airmanship) - in the days after the crash a friend told me of his experience assessing Asiana pilots, and their deficiencies in the simulator. He failed one senior Captain in a sim training, and because of this was removed from his position, while that Captain was given a second chance, and went on to do check rides as a training Captain - that was the situation in the SF crash, 3 captains failed to recognize what was happening.
2
While the author makes an extremely harsh judgement about the admittedly very inadequate reactions of the pilots, he is pretty much neglecting Boeing, the “publisher” of those technical difficulties and consequently the perpetrator of both crashes, and thus gives the impression of being closer to Boeing than one would wish a transparent and neutral journalist to be.
- Not a single word about the fact that MCAS was only needed to protect the hastily modernized aircraft from itself now that the repositioned engines were able to generate a "nose-up" moment far from any certification criteria. Instead, MCAS was designed in such a way that if a single sensor failed, it seemed determined to plunge all occupants to their deaths.
- Not a single word about the fact that Boeing secretly made serious changes to MCAS even after the 737 Max had been certified.
- only a casual reference at best to the fact that Boeing, despite the apparent risk, has deliberately renounced the principle of redundancy; and this despite the fact that competitor Airbus already had difficulties of the same kind in 2014, even using 3 AOA sensors (LH 1829), and to this day prominently points to this circumstance in the "Operations Engineering Bulletin".
- and also not a word about which corrections have now been made to the MCAS, which let the author decide that we can now all again climb into a 737 Max without worrying and that the ongoing worldwide grounding is completely exaggerated.
4
Extraordinary account about an anything but ordinary or isolated problem. Boeing is hardly the only example of where regulators all but handed over their lawful responsibilities to a company that should have been accountable to them and through them the public at large. Indeed, lack of adequate, even basic regulatory oversight of industries over the last two to three decades--from automotive, banking, and chemicals to health care, insurance and pharmaceuticals--is rampant. Somewhere along the way, prevailing propaganda during both Republican and Democrat administration's have convinced too many of us that deregulation is a panacea to what ails business when just the opposite is more often true. The dismantling of once fairly effective regulatory oversight here in the US merits much more media scrutiny and remedial action by all three branches of government.
3
I am not in the aviation industry but I have worked in engineering fields my entire working life. Good design does not need 'patches' after the fact. Airliners are not fighter aircraft that can be unstable to boost performance. With no software at all, an airliner should exhibit stable flight characteristics in all possible flight envelopes. Software can then be employed to improve efficiency, safety, and reduce fatigue for the pilots. My experience with bugs in software tells me that no product should rely solely on software to operate properly and safely. The 737 Max is an aerodynamically flawed design that needs to be completely overhauled.
8
@Mike Pasemko
That's completely wrong, Mike. Every swept wing jet transport ever built is inherently unstable in parts of its flight envelope. Since the beginning of the jet age, many devices have been used to give acceptable handling qualities over the wide speed ranges these airplanes operate. These include yaw dampers to maintain directional control, mach trim systems to counter nose down tuck at high speed, feel computers to manage control forces, stick shakers for stall warning, stick pushers to provide positive feel at the stall, vortex generators & stall strips to control airflow, & numerous other tweaks to maintain acceptable handling qualities for the pilot. The 737 MAX is no more unstable than any other transport & probably better than most, but it needed a little help to maintain acceptable control feel at low speed with flaps up, hence the software enhancement called MCAS, sort of a computer version of the stick pusher long used on many aircraft.
1
The underlying problem is one that plagued many industries: Technology has gotten complex, you have to modernize, but modernizing means you have to retrain and educate your product users. If the you have an old product (such as a 737) and retraining your users is going to be more work for them than simply learning how to use a new product (such as an A320), you’re going to lose market share.
This is a relatively trivial problem when you’re talking about smart phones and home appliances. It’s a life-and-death scenario when you’re talking about vehicles and heavy machinery.
Brain lock.
When you are panicking, what can you do?
Pilots are trained to fall back upon the basics. The basics here included turning off the electric trim. The basics also include reverting to a known-good state when you get into a bad state.
So yes, the pilots were at fault. Indeed, part of the problem was that this failure was tolerated and managed too many times by too many pilots.
But from a human-factors standpoint, if Boeing designs for level-headed pilots, it needs to provide a reliable training filter designed to select those pilots.
In this and other domains, engineering is being overwhelmed by politics, of business and regulation. Boeing pursued factories in China and Tennessee mainly for negotiating power, and is outsourcing as many parts as it can. The Miami "FAA Approved" parts suppliers come and go so quickly no one can track them. Regulation works in a good-faith context; with business and political influence at stake, only direct control works. Since that's not viable, the FAA does what regulators have to: put the fear of God into violators by making an example of Boeing.
The organization man is more at issue than the pilot.
3
If feels like this is the PR Release from Boeing. If it was an Airmanship problem, then why did they ground the planes in the US? They could have continued to keep them flying, given that there seems to be a strong culture of airmanship? If it was a training problem, why did they not specify the minimum hours or training to be completed for certification? For the Commander and Co-pilot? Why didn't the iPad training program cover these situations earlier?
The training needs to match the maximum complexity of the aircraft or the aircraft needs to match the minimum competency of the pilot. Looks like the both didn't meet.
If Boeing is targeting to sell to Lion Air and knows about the lax training (though this is an experienced pilot with 6K+ flying hours), doesn't the product need to meet the specifications or don't they need to insist on the purported "airmanship"?
It looks like Boeing put in a hurriedly designed product and is trying to develop a theory on pilot incompetence. That might be the perfect ploy to win the PR battle but also the perfect recipe to build unsafe aircraft.
6
As is frequently the case, many of the commentors are wiser than the author, IMHO.
It seems to me that the 737 Max is not aerodynamically stable through the entire range of flight operation. According to the article, the Lion Air pilots had over 6,000 flight hours, but couldn't fly this plane by hand.
I don't think this can be fixed by software. The problem causing these two crashes might be fixed, but then that does not assure that new problems will emerge in the future.
I feel like the 737 Max should not fly in passenger service again.
5
"will emerge" should be: will not emerge.
Sorry for that.
I was a search and rescue pilot for the U.S. Coast Guard. I retired from Alaska Airlines after 30 years. For adventure, I then flew for Jet Airways in India and Ethiopian Airlines in Addis. My experience as an expat comports almost exactly with Mr. Langewiesche's article. We are very lucky indeed to have someone with his writing skills explaining extremely complex aerodynamics to laypersons. I loved the young men and women I flew with in India and Ethiopia. They were without exception smart and eager. I wish them all safe landings.
4
Fantastic and thorough piece. When a medical issue ending my pilot in command days, I had more hours of actual flight time than some of the pilots in the accident aircraft. Thank goodness nobody offered me an airline job, or put me in charge of hundreds of lives. There is no substitute for actual solo flight in a non-automated aircraft facing small but unexpected problems. That is what develops airmainship.
3
The basic principles of emergency training are: keep it simple; leave as few decisions as possible to be made at the time of the emergency; and remember that people don't think well under stress. Compared to, say, self-defense training and first aid training, the "simple" things Mr. Langewiesche describes look like playing chess while being shot at.
Pilots need to be those rare people who actually get calmer in emergencies--and even they need extensive training. I doubt that there enough people like that to fly all the airliners even in the US. As a frequent passenger, I find all this disturbing.
5
Thank you for this excellent and insightful discussion. I was reminded of what Richard Feynman said at the end of his observations on the Challenger failure, "For a successful technology, reality must take precedence over public relations, for nature cannot be fooled."
11
Not mentioned in this riveting analysis is another element in the competition between Boeing and Airbus AE that may have led to the "under the radar" inclusion of the MCAS system in the design of the 737 Max. At the dawn of that battle, Boeing designed a simpler landing gear system, which meant that on the ground the 737 sat closer to the Tarmac. That wasn't important UNTIL the A320 Neo, when the newest engines just wouldn't FIT under the 737's wings. Boeing could have re-engineered for this, but that would have required a new type certification. So, instead they revised the engine pylons, mounting the MAX's engines farther forward and higher under the wings. THAT, in turn, changed the strap-on "airmanship" feel of the plane that Mr. Langewiesche describes so eloquently. Boeing thought they could counteract this with the MCAS system—and perhaps that explains Boeing's reluctance to make its presence known.
I'm not a pilot. However, I think I've articulated an exposition of how Boeing may have contributed to these tragedies. If Mr. Langewiesche is correct, Boeing risks paying the ultimate price (losing its very existence) for a problem that will remain after it's gone. However, if the "it flies differently" exposition IS correct, then blaming poorly trained pilots is exactly the WRONG thing to do because Mr. Langewiesche's complaint about lack of transparency among foreign flag carriers could be considered a knock against his own piece as well.
7
@Jim Robertson .
The author presents a complex situation and does not, as you say, blame the pilots. He lays responsibility on Boeing, the training of pilots, the change from a previous skill set (airmanship) to one that is overly dependent on software, corporate greed and shoddy, dishonest mechanics. I don't understand how it could possibly serve truth finding when you make it politically incorrect to find fault with any of those elements.
2
"One of Boeing’s bewildering failures in the MCAS design is that despite the existence of two independent angle-of-attack sensors, the system did not require agreement between them to conclude that a stall had occurred".
The author highlights what appears to be a fundamental problem with the airline system and yet ends the article by proclaiming how safe and faultless the Max is. I'm having a hard time consolidating the two statements. Sure airmanship should be a major factor of consideration, but the airplane needs to function correctly too. He should have concluded the article by describing it as a perfect storm of issues that contributed to multiple tragedies. Boeing and airplane manufacturers should do better. Airlines and pilot training programs should do better. And governments and regulators should do better.
10
This is an incredibly written piece that breaks down the technical details in a lyrical way. The understanding of the crises (many within this decades-long, global saga) is amplified by the genius writing. What a feat, unearthing the layers of the story with such nuance.
8
I had the exact opposite reaction to this. Thought the writing was clunky. What is bland integrity? And does that mean there’s electric integrity? And the line “that worry is perennially available to chew on”. Freshman English gone very wrong
The article lays the blame at the feet of the pilots. It points out other issues but then circles back with the dagger. Which is trash. Feels disgusting. The fact is is that the company built a plane with flawed design concept, covered it with software, and failed to disclose it. The KNOWN inexperience of the pilots is the exact reason why this seems so egregious. And Boeing made the safety options that would have safeguarded against this add-on options for extra cost. Great idea for less wealthy customers as in this case. So let’s perennially chew on those ideas. If American pilots are the only ones who can safely fly Boeing planes then stop exporting planes.
3
Boeing faced losing sales to the A320neo.
Boeing decided to abandon the planned redesign of the 737 and instead re-engine the NG, as it would be faster to market and cheaper to implement.
Boeing needed to relocate the larger, more fuel efficient engines forward on the wings due to lack of ground clearance in the 737 design.
Boeing implemented a software "solution" to the changing pitch characteristics of the new engine placement, purely to avoid pilots having to recertify, which would be a barrier to sales.
Boeing tied this system to a single AoA vane, ignoring the redundancy of reading multiple sensors that is a basic tenet of aviation safety.
Boeing didn't tell anyone that this software solution existed, and could result in extreme, intermittent but repeated, pitch-down events in certain flight situations.
But let's blame "airmanship" for why the pilots of two different airlines were unable to diagnose a problem with a system they didn't know existed, and unable to make the connection to a similar, but crucially very different, runaway trim event.
29
@Nick Govier Indeed Boeing made some perplexing errors. But it was the panicked neophyte assembly line pilots that killed the passengers. That "third pilot" on the Indonesian plane gave that special independent opinion that saved the panicked pilot. It was sheer greed that falsified the data for the next flight and a good reason never to fly any substandard airlines.
3
@analyst and @Chasseur Americain need to get in the real world. No aircraft design is perfect. Boeing relies on pilots to make up the gap, Airbus uses computers. Neither will give 100% desired results.
I have about 472 hours TT in aircraft up to a B58 Beechcraft Baron. I could not imagine myself in the right seat of such a complex aircraft as a 737. And yet, the right seat in the Ethiopian Air 737 had less than 200 hours TT when he took the position.
Flying is STILL NOT a video game.
Excellent Article, Many Thanks Mr. Langewiesche
14
Boeing does not get to pretend that the pilots are to blame here. The failures and malfunctions have time and again been demonstrated to be difficult for seasoned pilots to overcome.
But, when it comes to responsibility in the face of tragedy it is always in a corporation's best interest to shirk as much of it as they can.
13
@Tyler
Well, I'd agree except that the author makes a pretty solid sounding case (to me; complete non-expert) that pilot training leaves an awful lot to be desired in some places.
3
One of the contributing factors to the overall poor "airmanship" among non-US ATPs is the fact that there is no robust General Aviation (private flying) outside much of the US. Unlike the US, where most non-military pilots spend bulk of the 1,500 flight hours required to be an ATP flying small airplanes (many doing flight instruction as a way to build time), the non-US way is minimal seat-of-the-pants flying, followed by the procedural trading in the simulator. I know that in some countries, pilots go straight from the sim to the cockpit of an airliner while their American counterparts have hundreds of hours dealing with real-word weather, equipment failures, human factors, and even in-flight emergencies. In short, there is no substitute for real flying experience, best of which is gained in small aircraft.
For the record, I work in the aviation industry making components for flight simulators but as a pilot, I know that simulator training definitely has its limitations. It is an awesome tool for practicing instrument flying, procedures, and emergencies, and is awesome for "testing" a maneuver before replicating it in the real-world but in no way it can be a substitute for a real airplane training, especially for at the primary training level.
11
@Bart You nailed it. America is the heart of aviation, and most pilots started out on farm strips and backwater airports as teenagers. Boeing forgot about all the dolts that the greedy nations with no coherent culture of skill are producing to "Fly" airplanes.
2
I doubt that many people will read this long and technical article to the end, unless they are pilots or have background in science or engineering. That is a shame, because I cannot recall reading a more riveting exploration of the intersection of technology, economics and humanity.
I have long been of the opinion that humans are now replaceable by machines only because they have been reduced to machine-like behavior - 'flying by rote' to use the author's phrase - by years of conditioning. That conditioning was for the benefit of modern corporate ideology, which abhors variation, and especially resents the idea that special respect must be given to any PARTICULAR human beings for their skills and experience - their 'airmanship'. Everyone (expect the executives) are to be part of the same faceless 'team', everyone executing their assigned script.
To this non-pilot, it seemed inconceivable that anything like this held true in the world of professional aviation. When the stories of these crashes came out, my tendency was to blame the computerized control system. I saw the images of the trim cutoff switches, the big mechanical wheels for manual trim control - surely no pilot would fail to immediately use those?
Now I have a clearer picture, and it is worse than anything I imagined. My thanks to Mr. Langewiesche for this eloquent glimpse into our bleak future, where our only hope for survival is to have our remaining humanity eradicated.
19
@zauhar Excellent points, but at least for America with its culture of pilots driven by desire and a well honed skill set, the future of aviation is bright.
2
Having thought about this article, I wonder about the two crew model in the cockpit.
It may work well enough when both pilot and copilot ave experienced. But when only the captain has substantial hours of experience, the inexperienced copilot becomes a serious liability when problems occur. He can't be very helpful in figuring out what is necessary and if he does have something useful to contribute, he is too hesitant to speak up to a very senior captain.
And as the article demonstrates, even experienced pilots when stressed may overlook important details (like reducing the thrust level from takeoff). (Although I wonder whether the pilot training actually schooled him in the control risks of excessive speed.)
Having a third crew member in the cockpit can save the airplane, as evidently happened on the Malaysian flight leg immediately preceding the accident where the "passenger" in the cockpit suggested turning off the electric trim.
While it would be impractical to mandate that all copilots have significant real experience (for how would they get it), perhaps regulators in rapidly expanding countries might consider requiring a third pilot where there is no experienced copilot.
Of course, you could just mandate that manufacturers make planes so simply any cabdriver can fly it and simply accept the loses that occur when the unanticipated happens.
5
@Mac
A third person in the cockpit - sure, but this won't happen. Costs. (Profits. etc.).
1
The author describes two accidents in detail. Both occur with the throttles set at full. Yet this was not explored as possible major cause of the accident.
The 737-8 (MAX) design incorporated larger and more powerful engines than the original design. The geometry changes increased the lift force of the engines which is foreword of the center of gravity. At some high speed this lift can overcome the lift from the stabilizer and elevator leading to "mushing" , deep stalling and collision with the ground.
I am sure this is being reviewed and it would be appropriate to make the review public.
6
Lets say you drive a car with cruise control and it starts lurching. You hit the breaks and it stops.
But the Indonesian pilot of the Boeing jet was so poorly trained that he did not hit the breaks when the runaway trim system lurched - a procedure so simple that a passenger could work it. And a passenger did just that on an earlier flight. (All according to the author).
He lacked "Airmanship" - the ability to fly airplanes. He watched others fly the Boeing simulator, the author suggests, and did not fly it himself. He was trained to put the jet on autopilot, and that's all he knew. Thus Indonesian jets are banned in the US and Europe.
The Boeing MCAS system is a bit of a kludge, a work around to ease the regulatory process. But its safe when real pilots fly the jet. MCAS failures are just like runaway trim failures, and fixed by pilots the same way.
They key ideas from the detailed, excellent article. The author seems to know his way around the airline industry.
8
I think the article is too quick to dismiss a faulty design as one of the main reasons for the accidents. Principles of the design of dependable embedded systems dictate that a system, such as MCAS, that can cause loss of airplane and cannot be controlled by pilots, need to be part of flight control. Instead it was part of the autopilot. Flight control is designed so that no single failure can lead to the loss of an airplane. Autopilot is designed so that in case of failure pilots can take over. But pilots could not detect MCAS malfunctioning. Therefore making MCAS part of the autopilot instead of part of flight control was a design error.
8
"One of Boeing’s bewildering failures in the MCAS design is that despite the existence of two independent angle-of-attack sensors, the system did not require agreement between them to conclude that a stall had occurred. Inside the cockpit, none of the pilots knew any of this or had ever heard of the MCAS.
...
...
What we had in the two downed airplanes was a textbook failure of airmanship. In broad daylight, these pilots couldn’t decipher a variant of a simple runaway trim, and they ended up flying too fast at low altitude, neglecting to throttle back and leading their passengers over an aerodynamic edge into oblivion."
Due to inconsistent logic your piece doesn't fly.
Furthermore, when trying to look at the big picture, you failed to note from 2012 to 2017, the time span of the development for the 737 Max, Boeing laid off 20% of it's work force, outsourcing overseas functions such as the software control for the MCAS. Profits and share prices flew, now the plane does not.
13
Blaming pilots on the crashes of a substandard designed aircraft is utter nonsense. These pilots had enough experience to fly this aircraft.
Boeing has not made an effort in keeping with modern aircraft design for this type. The fuselage design heritage is from 1955, the cockpit overhead panel from the sixties. The implications are as follows: no ergonomics go into the build of any 737 cockpit, systems are incrementally updated, until they are frankensteined and the Quick Reference Handbook is an abomination. When buying a Boeing everything is an option, because when Boeing decides that an annunciation light or a single data source which can determine flight control position is all that is needed for safety of flight, then that is all they will install it in the aircraft, unless the client wants to pay for more safety equipment. Too many items to list here, which make a B737 not 21st century jet.
However in this case we are speaking about THE worst case of visible corporate greed for some years now in the form of lost human life!
Why hasn't the CEO resigned? Why isnt the company being driven to the brink of extinction?
On top of that the FAA failed the public which is essentially their employer and instead relied on Boeing and it's beancounters to make sound design decisions.
Stepping into the cockpit of a B737, is like going back 20-30 years. Fix it and fix it now Boeing! Your attitude and your product.
20
I agree with you completely. Boeing, knowing what the level of competence was of the pilots that would be flying this aircraft, released it with a serious defect and no training on a system that was essentially kept secret. Boeing went the cheap and fast way instead of creating a new and safer design.
Overall, I thoroughly enjoyed the article and the information provided. My only concern would be some of the language used to describe the pilots and their actions being "dumb". I do agree that they were poorly trained and ill-prepared to handle the situation presented to them, but I consider that to be more of a symptom of the training requirements than their intelligence.
12
This is journalism at its best. Thank you, NYT!
5
The Computer Science definition of the MAX 8, is it's a kludge, it's the airborne equivalent of spaghetti code.
Boeing's handling of the MAX-8 debacle by tweaking MACS, reminds me of that old joke. Getting married to the spouse you divorced is like putting sour milk in the fridge at night, then drinking it in the morning assuming it will be fresh.
The MAX was built for profit, not safety. Also, the author's blaming 3rd world pilots' lack of'how-to-trim bona fides is flatout silly.
There is a solution though. Scrap 'em one. Scrap 'em all. Eat them.
Then design it PROPERLY from scratch.
8
Impressive first article. Since the Sullenberger incident it has become clearer that the ability to fly the plane is of utmost importance in corner cases, and the difference between life and death in those corner cases. With poorer training, the scope of deadly corners get larger as pointed out in this article. It is a pity one can't obtain the pilot rating before the flight leaves the ground.
12
This was one of the best articles i have ever read! the details, the explanations, the flow of the story, kept me intrigued throughout. While lengthy, it was required to cover everything that was critical to understanding this story. Cudos to the author and thank you for such a great read!
13
Given the hard cold facts in this article, the human character defects of greed , laziness and taking short-cuts have sadly contributed to these mishaps. It's so characteristic to blame the hardware and software makers as an easy way out. Boeing is unfortunately taking too much " heat ". Their products are superb. No complex product is always perfect. Human error and judgment in operating a transportation product, be it a car, truck, aircraft or boat is a constant challenge. What Langewiesche has illuminated h is the higher risk percentage factor attributable to pilots with suspect training. Appears that an oversight entity needs to be established to preclude these events. Not put the blame game on the aircraft maker. From all bad things come good things. Major aircraft insurers after reviewing the true facts will undoubtedly implement quality training and training audit oversight.
4
From a retired 30 year airline pilot with a lot of B737NG time... it is too easy to lay the entire blame on the pilots involved in these accidents. Airmanship and experience are real and are valid determiners of outcomes in extremis situations, to be sure. I have had runaway trim non-normals before in my career flying the line that I trained for in the simulator. These incidents were not accompanied by a super-aggressive trim “hard-over” or stick shaker that were caused by design by people who never told these pilots that they had that system (MCAS) on their airplane (the MAX), what activated it, or how to counter it, other than the standard runaway trim procedures. It starts with the Boeing design and lack of dissemination of knowledge of its new system.
26
Yet another bleak and alarming prognosis for the airline traveler. Surely the time has come to transition from today's airline shambles. The fact is that a viable and much safer option exists namely RPA or remote piloted aviation . Thanks to the Afgan war and the US Air Force. the technology is mature and highly reliable. Indeed next year ICAO will introduce similar satellite based RPA type systems( called Automatic Dependant Surveillance) which will provide real time monitoring of aircraft on a world wide basis . Clearly an RPA via ADS linkup could provide direct aircraft remote control. Indeed , given the scary state of airline piloting these day , it not only could BUT IT SHOULD ! and do so ASAP
Any relation to Wolfgang Langewiesche of "Stick and Rudder" fame?
3
I cannot help but wonder if this article was a pre-emptive strike against another one in the New Republic (“Crash Course”), which exposes Boeing’s negligent or worse actions surrounding the redesign of the 737.
From that article:
“I get so mad at Boeing trying to tar this captain when he was actually the most proficient pilot of all of them,” said Bjorn Fehrm, a former Swedish air force pilot whose technical blog on the aviation web site Leeham News is a 737 MAX must-read. “He was mastering this wild animal— [the plane nosedived] 22 times and he kept it in check!”
You want to write about the need for better pilots? Fine. Just keep it distinct from a plane that isn’t airworthy.
19
@Valerie
36 yr Airline pilot here. I agree with your post, but replied specifically to thank you for the reference to "Leeham News". I have read most of the author's articles, and his book about the A320 (which I flew for 5 years), he is deeply disrespectful and demeaning to airline pilots.
4
Great Article !
5
I missed my subway stop-twice-I was so engrossed in reading this remarkable piece of journalism. The complexity that has been teased out here deepens our understanding and shows why it is critical that we have (and pay for) well-researched journalism, and that we be patient before passing judgment.
6
I have never been a fan of the new low cost airlines. I know they pay their pilots the least and push every aspect of operations to the limit in order to cut costs. Flying is dangerous, it’s only safe when you have well engineered aircraft with redundant systems and well trained , experienced pilots that are appropriately compensated for their skills.
Considering that pilots are responsible for many lives , you would think they would be highly compensated, but most are not.
8
Seems to me the author is minimizing the conflicting vectors of profit pressures and sound, safe aeronautical engineering integrity inadequately addressed by Boeing management. They were decided short-sightedly (but understandably in the context of the uber-capitalism afflicting mankind) by Boeing in favor of its profit/market share imperative and "shareholder value" (so much for that now). As seen from Lion Air's general management, public safety is a fungible accounting line item, merely a matter of often-poor pro forma risk assessment.
Also seems that Boeing's engineering culture missed the memo on the customer service side of Boeing's longstanding concern about pilot adequacy. Engineering still assumed flying skills - as opposed to piloting function - that didn't exist in reality. That is a management deficiency.
The pilot qualification problem is well presented. Civilian pilot training, particularly in cultures where airmanship arising from more pervasive military and civilian recreation or business aviation involvement is not as widespread, is woefully behind the extent and standards - of military pilot training and is insufficient. The system is producing corporate "pilots," not airplane fliers.
Both the pilot training aspects and the corporate engineering tunnel vision contributed greatly, and pretty much equally imo. Langewiesche leans too heavily on pilot deficiency. And saying one was worse than the other is missing the point. They were both fatally flawed.
13
Excellent writing. Lengthy. Worth reading. Crux of matter appears to be Boeing understands and benefits from aggressive industry growth where pilot quality is an issue. Still they choose to operate in a manner where pilot quality can be required to avert deadly disasters. For me this means Boeing remains the actor most at fault.
In that vein I found this article insight useful.
"Boeing is aware of the decline, but until now — even after these two accidents — it has been reluctant to break with its traditional pilot-centric views. That needs to change, and someday it probably will; in the end Boeing will have no choice but to swallow its pride and follow the Airbus lead."
The life of a loved one is an unacceptable price to pay for someone else's pride.
How do we change "probably will" to "has" in a timely manner.
5
William clearly cuts to the core issues. I would expect nothing less him. He demonstrated the same insights when I knew him as a young aviator at Trenton in the 1970s.
Although he is correct about the issues, these issues are not limited to Asia or Africa. As a manufacturer test and training pilot, pilot examiner and technical advisor I saw similar behaviors in many areas of the world. It is long past the time when we need to address both the gross lack of airmanship and the equally gross lack of “maintenancemanship.”.
9
This article reminds me of the NYT "Diagnosis" column.
At least there the eventually successful diagnosis and proper treatment outcome of an unique individual were presented, but overall failures in similar cases that ignored critical but rare signals are not usually available for retrospective analysis.
In these plane crashes or other historical disasters, how much more valuable are meticulous and unbiased investigations, analysis of comprehensive information, and reporting to the public, as well as periodic updates on multi-dimensional efforts to correct and improve, with ever rising conflicts of interests and diluting of safeguards.
2
There may be hope in the news today: Colt, as much an American manufacturing icon as Boeing, decided to stop selling assault rifles to the civilian market. Probably just an ordinary business decision, as they said, but there’s the ‘handing a loaded weapon to a child is a bad idea’ vibe as well. Somebody at Boeing must have a job description that involves deciding if a potential airline can’t use the product safely. You know, the guy who refuses orders. I wish.
Meanwhile, those Maxes are still on the ground because, folks, software and whitewash is not, so to speak, flying.
4
As a lay person who has flown extensively, but will not claim to be able to do it myself, this informed write-up by William Langewiesche about not just the situation but also about the industry overall is illuminating. Thank you sir for the cogent exposition! It certainly opened my eyes.
John~
American Net'Zen
2
It's not about blaming the pilots. They didn't know what they didn't know. It's about third world countries and a trend in the industry to automate aircraft. Air France is a perfect example of pilots who no longer know how to fly the aircraft when the auto systems fail.
4
And so begins the rehabilitation of the reputation of a major advertiser.
5
Well, there is literature and there is reality:
„Canaccord Genuity analyst Ken Herbert, just back from a big aviation conference in Europe, said consensus in the industry is that, while the FAA might un-ground the Max before the end of the year, Europe’s regulator is expected to take about three months longer — and could require Chicago-based Boeing to make additional changes to the plane. Regulators in Canada and India have also indicated they could break with the FAA.“
https://www.seattletimes.com/business/faa-chief-meets-boeing-officials-tries-out-max-simulator/
1
Boeing's manual was simplified so that it omitted information about how to avoid crashing the plane in the case of the malfunction the two planes' pilots couldn't handle.
3
Boeing. Greed. Is what brought those planes down.
Boeing. Behind Airbus. In technology. In orders. Just behind, period. In both engineering and manufacturing ability. Is what brought those planes down.
Boeing. Trying to stay ahead of Airbus. Cutting corners. Saving a few pennies. Is what brought those planes down.
Boeing. Incompetent management. Incompetent engineering and manufacturing ability. Inadequate managerial oversight. Is what brought those planes down.
Boeing. Political pressure to allow corners to be cut. Political pressure to allow safety to be compromised. Political pressure to avoid oversight. Political pressure brought to bear. Is what brought those planes down.
Boeing. Political closeness. To the Obama administration. To FAA regulators. Is what brought those planes down.
Boeing. Is what brought those planes down.
8
@Brewster Millions
let's also include: Boeing. Anti-labor, union busting. Is what brought those planes down.
2
Those who comment here and criticize the author's view of airlines' weaknesses are doing a real disservice. It seems entirely obvious that both design and training issues can and do co-exist. To exonerate these corner-cutting airlines because of very real gaps at Boeing is to reduce their likelihood of straightening up and flying right.
12
The evidence calls for a publically available, independent evaluation of airline and pilot training and other indicators of competence. That way, airlines' customers would have a way to make choices based on an airline's and a particular pilot's rating. Could such a rating system actually offer "independent," apolitical information? I don't know enough to answer that question. However, the evidence as stated does warrant such an effort. And, it would clarify if pilots of any particular nationality demonstrate safer levels of ability than an article in a national/international newspaper can.
2
This MAY not be relevant, however, two things come to my mind when reading this article. First, before I could answer even one phone call working for AA Air Cargo in the 60s, I was trained for one entire month (and had to pass a test). Secondly, an airline story regarding floor bearing weight. Before computers, air cargo controllers had to understand this concept and figure it manually to instruct the loading of the specific aircraft (I also had to understand this concept and sometimes explain it to would be shippers of cargo). After computers, airline cargo controllers, in many cases, had no clue as to what the concept was, since the computer did it all. If not figured correctly, it can bring down an airplane. AA training for me was indispensable and I value it to this day.
5
Maybe you get what you pay for? Flying at rock bottom prices might raise your risk of death by some quantifiable percent. The U.S. has some very low priced carriers that I avoid. I'm particularly wary of the small regional connecting carriers whose pilots are reportedly low paid.
7
I was horrified by the snarky tone of the piece. Statements suggesting that half of every random grouping graduated in the bottom half of its class are not helpful and certainly not exculpatory. They may even call for tougher sanctions against Boeing. Other comments have been made about the illogic of trying to blame dead men who can't speak in their own defence with respect to their ability to fathom what was going on when a system they hadn't been urged to focus on and wasn't in the checklist kicked in. It is almost irresponsible to second guess these men who, let's remember, had flown these planes many many times without incident.
16
@Kfblanko
Thank you for pointing out the "snarky" "Bottom half of the class" comment. I was amazed that it was included in the article, and it called into question the objectivity of the author. I know from much reading of this persons work, and my 36 yrs of airline piloting, that he is very dismissive of the profession.
4
Aviation is much like healthcare, education and others who claim concern for the wellbeing of their customers. Big joke. Shoddy workmanship and training in that industry is manifested by the occasional mass killings such as those in this piece. Drop out rates and other failures of education are often ignored because of bright shiny objects being waived alongside such as free education and so called equal opportunity access. Healthcare is another story with their overuse of dangerous procedures and drugs. Insufficient or no research and the overpricing of established life preserving therapies. All of these malfeasances occur under the watchful eyes of a democratically elected, bribe taking Congress and Senate. God bless the USA!
2
As a former Navy pilot, NATOPS officer and flight instructor this article is spot on. The grievous failure of the pilots to simply TURN OFF the runaway trim shows a lack of airmanship that is simply appalling.
These accidents reminded me of the Asiana Airways 777 crash in San Francisco when the pilot FAILED to consult / oversee the approach landing speed and, as a result, crashed short of the runway. Again, a TOTAL lack of the most basic airmanship. Personally I would have charged the Captain of the Asiana Airways flight with murder - or, at the very least, manslaughter.
If an airline cannot properly train their pilots they have no business being in business.
15
@James Thurber Asiana -- the pilots assumed that Boeing's Auto Throttle would maintain the speed. It has many modes and in some modes it does NOT maintain speed.
The problem in Asiana is a very weak Use Interface that Boeing has.
It is sad NYT is publishing an admittedly well written, but an elaborate defense of Boeing by shifting the blame.
Boeing, as the piece itself claims, knows its customers, the planes and pilots who will fly them pretty well. Yet it pushes half-baked, slap-on systems that endanger passenger lives, only to keep the planes under the re-certification radar.
Don't even need to discuss the convenient trick of 'self-certification'.
We are supposed to pretend corruption and expediency are skills unheard of in Seattle.
21
Boeing corruption flourishes in boardrooms in Seattle and Chicago.
Connect the dots.
3
This is a well written article that focused on the total lack of a safety culture in Lion Air and poor training of their line pilots. But the article started with an agenda from the beginning to lay the blame solely with the pilots at the controls and not Boeing. How can you explain adding a feature that you fail to mention to pilots yet when it is among the factors that contributed to the downing of two airplanes you absolve Boeing and FAA of any responsibility but blame the dead pilots for the life's lost. That is just unconscionable. You are no different from the former acting head of FAA and some members of congress who blamed the pilots and praised Boeing. I would like to know if you were at the controls with no knowledge of MCAS, would you have been able to save the airframe?
16
@Alpha The horizontal stab trim system on the 737max is a 50+ year old system found on the 707, 727 and all 737 models. The disconnect switches and trim wheels are in the same location.
MCAS created a condition of runaway stab trim for which an emergency procedure has been outlined in all model aircraft flight manuals.
These pilots lack the training to fly these airplanes. It's not their fault. They thougth they did. Boeing doesn't oversee customer training, that's the responsiblity of the airline.
2
And that is where you and the author are 5 months behind. Since then it is common knowledge that macs kicking in is completely different from a stab trim runaway, since it is intermittent and therefore disguised and not nearly as easy to handle.
3
What a great article Mr. Langewiesche, the way you have broken down the sequence of events that led to this tragic accidents, is nothing but commendable. What I didn't appreciate though was the characterization of (especially) the Ethiopian pilots as 'dumb' and somewhat reckless. It was clear from my reading of this article - however intriguing -that there was a clear bias towards Boeing and how it mismanaged a 'true design flaw' with the MAX, which was ultimately the real root cause of these tragedies.
14
Excellent article... I would like to draw everyone's attention to the incident with the Airbus that finally became public recently . An accident totally unforeseen occurred on a transatlantic flight , where pilot and co pilot had so much smoke in the cockpit , they literally had to take turns leaving for air . Cause of the fire ? Pilot spilled his coffee on the console. He wasn't supposed to . He was supposed to place his beverage in a cup holder . He put it on the tray every plane has for the pilot and co pilot have in front of them .Directly above the console. Sure , the chances of anyone in a cockpit ever spilling any beverage ever again are billions to one .... but still . Ummmmm... liquid proof switches ?
1
This article is a great example of what should absolutely matter in high-risk professional fields: standards. The insistence on excellence and the recognition of the need for thorough (and at times, lengthy) training is something that seems to be fading from several fields as corporate interests take over . (Health care comes to mind; a new shortcut degree to play doctor seems to arrive every week).
As the author says, let’s not engage in a race to the bottom. Let’s have standards, people. I support Boeing in its underlying business model of requiring pilots to actually know how to be pilots. Who else will save us when the automation fails?
6
I am a retired airline pilot with approximately 30,000 hours of flying time. I have the B727, DC8, L1011, A320, A330,A340 and B777 on my license. This is a very well researched and written article. I had over 3000 hours of flying time with smaller airlines and held an Airline Transport rating before I was hired by a major. It took another 20 years before I had the seniority to consider bidding as a captain. This is typical of major airlines in North America, Western Europe and Australia. Not so much in some others around the world. Something as simple as a runaway stab trim is a yawner and should be handled very easily by anyone properly qualified and properly trained. Training is continuously under pressure to streamline and cut costs and this needs to be monitored closely by industry, regulatory bodies and pilot associations.
17
I agree with others who feel this is a thorough, fascinating and well-researched story. I also agree with the commenters who notice a Boeing PR flavor here; in brief, the argument is MCAS wasn’t adequately explained and that was dumb, but the pilots should have known how to bypass the (unknown) MCAS and so ultimately it’s their fault and the fault of poor training in the respective countries. A lot of effort is made to discredit Ethiopia and Indonesia, and while that information may be true, the percentage of the discrediting seems suspiciously high. I found the story fascinating and I look forward to more of Mr Langewiesche’s work, but he’s produced what has a fairly Boeing PR-like aftertaste.
17
@David Law In fact I wonder if he is trading on Wolfgang Langewiesche's name - this is no Stick and Rudder. He is related, have the aviation genes be passed on?
2
Superb writing style! I’ll look for more of Mr. Langewiesche’s articles in your publication. My experience is not in aviation, but I could easily follow the technical details. The themes in his story parallel those in commercial nuclear energy production in the ‘70s & ‘80s in this country (my experience). The 1986 Three Mile Island accident resulted in new symptom-based guidelines for nuclear plant operators, guidelines which hopefully prevented other accidents that could have resulted from operator rote-mindset, as well as from shoddy quality control practices.
3
Excellent article. I find it maddening that he is also dismissive of Boeing’s decisions to keep pilots out of the loop, to think more of getting it out than being transparent etc he does cover all tha5 as well as in depth history of the airlines involved and what info is known.
2
A key component of any manufacturing operation is Management of Change. This could be change in the way a product is manufactured, a change in personnel, or a change in the product itself. This is necessary to ensure an orderly transition to the new way of doing things such that risks are identified and managed, personnel affected by the change are aware and have the necessary training, etc. The concept of changing the underlying systems of an aircraft in such a (supposedly invisible) way that the jet appears to behave the same way as previous versions, thus avoiding extensive pilot retraining, is absolutely perverse.
I believe Boeing’s quality management system has been corrupted, with other product lines also affected including the 787 and the new refueling tanker recently sold to the Air Force.
7
This article tackles the toughest part of this whole narrative. Standards. I'm glad you've taken the argument to the true issue. American's mostly trust that airlines have done their due diligence to accommodate safe travel, but as this article tackles, other countries have "flexible" standards for safety. The production line pilot training academies are only part of the problem. The sketchy maintenance and paid oversight from foreign authorities are also to blame. Great job with the story...probably my best read from the NYT in a while!
11
I have enjoyed Langewiesche's writing in the past and this is a great first piece for the TImes. I look forward to more.
16
amazing article. I cant believe this is his first article.
7
@Anil Prabha
Only his first with the Times. Langewiesche has many aviation pieces out there - all as stellar as this one.
5
@Anil Prabha It is not his first article, you may find this one interesting as well. https://www.theatlantic.com/magazine/archive/2019/07/mh370-malaysia-airlines/590653/
2
That article is a disgrace to the its author. To blame the dead pilots is a little too easy, isn't it? And not only them, also their companies, the air controllers and the mechanics? Seriously? But in meantime, Boeing has absolutely no problem selling those planes to the same companies for billions and certifying their pilots and ground personal.
Everybody who has followed the story knows already that the situation in the cockpit was much more complicated and that the pilots were confused about what the actual problem is. By the time they figured it out, it was already way too late to manually trim the plane because of the speed.
And I find one thing very curious - how is it even possible to add a new system to the plane and not bother to inform pilots. Pilots are supposed to know how every major system on their plane function. You give a system more trim authority than the pilots, but you don't inform them about it? Hmm.
If there is any justice on this world, Boeing should pay to the victims and to the companies. Because this was an error that could have been avoided. If 4 qualified pilots couldn't assess the situation and safely handle the plane, then it shouldn't be allowed to fly. And I think that passengers will make sure it doesn't fly. That's what you get when you become "too big to fail".
20
@jane Boeing doesn't certify pilots... the stab trim system on the 737max is a 50+ year old system. It's on the 707, 727 and all 737 models.
MCAS was added and when the AOA vane failed caused Runaway Stab Trim for which every aircraft model has an emergency memory checklist item for.
I don't think the author blamed the pilots anymore than I would. They don't know what they don't know. The airlines are responsible for not providing the required training for their pilots. Training is expensive and one of the first things cut by third world countries.
The author is completly correct as demostrated by the Lion Air flight prior to the accident flight. That flight had a third pilot on the flight deck that had proper training and told the flying crew to simply turn the system off. They did and continued to their destination.
5
@Jeff Maybe on that first Lion Air problem flight, the third person was able to see through the mayhem in the cockpit of multiple conflicting warning. This same chaos was addressed by Sully Sullenberger, who said he had a hard time recovering a simulator and he already know what problem he was addressing. One more thing. It seems that the simulators are not calibrated to true life when it comes to manipulating the manual trim wheels on the Max and NG. It's not sure that trim could have been recovered with them at any speed.
3
@Jeff
“MCAS was added and when the AOA vane failed caused Runaway Stab Trim”. Not so. MCAS when activated is designed to mimic the behavior of an older-model 737 approaching stall. Pilots, knowing (how?) that the plane is not about to stall, are supposed to (mis-)attribute this behavior to a runaway-trim fault. Did Boeing ever conduct human-in-the-loop testing to establish that pilots would in fact treat this as runaway trim?
The views of "Sully" Sullenburger and the Danial Carey, the president of the Allied Pilot's Association, are informative on this:
https://www.npr.org/2019/06/19/734248714/pilots-criticize-boeing-saying-737-max-should-never-have-been-approved
15
@Nicholas. Sully is definitely an airman. As are all those pilots who were astounded when the technical details came out and they realized they’d been deliberately been cut out of any chance to control their planes. Pilots generally believe that they know how to fly.
6
It's unbelievable how little training can get you into a cockpit.
5
For anyone trying to really understand what the pilots of ET302 where going through:
https://medium.com/@dawalk6/accident-timeline-of-ethiopian-302-ed20e33f900a
3
stupid engineers who think a computer can fly an airplane better than a pilot. they are doing the same with cars and trucks.
3
This article is racist and incoherent. Indeed, it is rationally impossible to reconcile the seat the pants idea of "airmanship" to the skills necessary to counteract the rogue effects of a software "patch" that are still not fully known and that, like all software, do not obey the "laws of nature." Sully Sullenberger, who faced the stress and chaos of a catastrophic moment refused to second guess or criticize the dead pilots. But this author not only second guesses them, he berates and insults them with adjectives such as "weak" and "dumb." I was surprised not to find him calling them "woolly headed." There is so much unknown about the 737 Max and the crash. And it's easy to second guess. But how could Yared Getachew of Ethiopian airlines be sure the plane wasn't encountering a stall? Would his own experience, airmanship and familiarity with 737 performance have governed his decisions concerning flaps and speed while lifting off from a high altitude airport such as Addis Ababa? Were there other, unknown effects of the LEAP engines on performance at low speeds that might have involved control surfaces on the tail? As for third-world corruption: What is the word for the cozy relationship between Boeing and the FAA, or for the money Boeing is now spending to spin the news and blame the pilots? Only a white supremacist attitude hidden behind a word like "airmanship" can explain the smug, simple and simplistic meanness of this article.
Yared Getachew
20
You are on the spot! Interesting how „back seat pilots“ will always try to outguess the accident report. Whilst many of the statements made in this article appear accurate at the anecdotal level it remains to be seen how relevant they might have been to both accidents. Blaming the Indonesian Authorities for their lack if oversight is a no brainer, suffice to consult the IATA & ICAO statistics. But,...whether the Indonesians (respectively Ethiopians) bear the brunt of the blame for their lack of oversight or maybe the almighty FAA remains to be seen and in this context the author exhibits a pronounced lack of humility and objectivity. As to the widely praised „airmanship“, the author be reminded that it is not considered a factor that can objectively be included in the accident/incident ICAO/IATA classification criteria as its definition is extremely vague and hence statistically widely irrelevant. BTW, in this respect the Hudson case represents an ideal combination of „airmanship“ and adherence to SOP‘s.
5
Mr. Langewiesche -- If it was pilot error, why is Boeing redesigning the system? You can't say on one hand, the pilots screwed up, and on the other say, we need to do a complete redesign. If it was truly pilot error, Boeing should say, "The system is perfectly safe, the pilots just need more skill."
7
I think the article is spot-on, and I wish that some of the mainstream media (and politicians) who have been fueling the mass hysteria would sit down and read it. I think the article is also fair. There is blame on both sides of the coin.
Yes, Boeing screwed up big-time and they need to explain how something that could have been better designed by a college engineering student (in an afternoon) could have ever gotten past an initial design review.....much less make it into a production airplane. Do they still do design reviews? Scary.
That said, the folks on these two airplanes didn't have to die. When the airplane suddenly and aggressively starts trimming against the desired flight attitude, a pilot cannot allow that situation to persist. There is no time for checklists. The procedures for some emergencies, such as runaway stab trim, must be committed to memory. Unfortunately, as the author describes, the pilot shortage is driving the industry to believe they can short-cut experience requirements with rote training. We are training a generation of button-pushers, instead of REAL pilots. Just read through the accident reports on Air France 447 and Asiana 214 and it will become obvious that there was a complete lack of airmanship or "air-sense" in both cockpits. If the media an the politicians want to stir up some hysteria, they should focus on that, because THAT is truly scary.
The most valuable safety system in any airplane is a well-trained pilot.
11
I suggest interested readers consult "IEEE Spectrum" for an April 18, 2019 article by Gregory Travis entitled, "How the Boeing 737 Max Disaster Looks to a Software Developer". Travis has been a pilot for 30 years, a software developer for more than 40. His bottom line appears as the article's subtitle: "Design shortcuts meant to make a new plane seem like an old, familiar one are to blame."
In brief - and as mentioned by William Langewiesche - Boeing's competitor, Airbus, introduced a new plane that was more enticing to operators because it was more fuel efficient and therefore cheaper to operate. In response, Boeing installed larger engines in the 737 and mounted them in a new configuration. This change made the 737 Max's operating characteristics somewhat different from its predecessor.
In order to avoid costly "hardware" re-designs, Boeing introduced a software "fix": the contentious MCAS. The 737 group considered this so inconsequential (and the FAA delegated significant oversight to the company), it was omitted from the pilot manual. Also, Boeing only offered dual sensor monitoring as an "upgrade" package so, for many airlines, the software relied on only one AOA input.
Since Langewiesche neglected to mention some of these factors altogether and only tangentially noted others, the piece - while provocative - seems somewhat tendentious. In light of Travis' analysis, published in an engineering journal, the 737 problem is more nuanced than described herein.
16
@KAC What happened with Bombardier should also be noted. They designed, from the bottom up, a far superior, cutting edge aircraft -- the C series. What did capitalist Boeing do? They tried to drive Bombardier out of business with a lawsuit accusing them of dumping planes on the market -- selling them to Delta. And Bombardier nearly went under before savvy Airbus invested in them, and bought rights to the C series, rebranding it the Airbus A220. And I think American, United, and Southwest would be lying if they said they wouldn't switch places with Delta which doesn't own any 737 Maxes.
2
Im reading this article as BOEING spin. "Phew, that takes some of the pressure off us," they would be saying.
8
It seems clear that there is plenty of blame to assign, deservedly so. My question is, why are builders like Boeing not held to standards such as are required of auto makers? They design vehicles knowing that the greenest 16 - 18 year-olds will be getting behind the wheel, and barring overwhelming physical forces, those cars had better be designed to keep them alive when they make a mistake. Recalls happen regularly when safety issues are discovered, usually at the manufacturer's expense.
In short, car makers are required to make their vehicles as idiot-proof as possible, and given the relatively low fatality ratio/millions of cars and trucks on the road, they succeed pretty spectacularly. Airbus clearly is taking a similar approach in the construction of their planes.
The author, obviously a pilot with decades of experience, notes that Boeing is, "on the corporate level...the worst sort of player"; that the FAA habitually cedes regulatory oversight to Boeing; that Boeing has been aware for years that commercial pilot training in some countries is minimal and/or very poor; and notes that despite this, Boeing continues to design and sell planes around the world, like the MAX with its MCAS workaround, which require a degree of airmanship to fly safely that just can't be acquired quickly. Those undertrained, undoubtedly panicked young pilots who paid for their lack of experience with their lives are just as innocent as the passengers who died on Boeing's planes.
4
They called it NASA mgt. group think when two shuttles went down. NASA knew the shuttles designs were unsafe, and yet the kept launching them.
Two Max's went down, and the FAA in a group think effort with Boeing said they were safe. The FAA did not want to bring the MAX to a screeching halt after the first crash and didn't.
The Challenger and the Columbia have an eerie and almost identical failure of the the FAA and NASA federal agencies.
The Max and the Space Shuttles both have or had catastrophic design failures.
4
@tomjoe. Appreciate the analogy, but NASA missions are and always were, high risk. Most of the Shuttle’s flights had military components, plus an overlay of political purpose. It was only we, the public, who focused on the drama, especially when civilians and high school science projects were on board. And even though both tragic events had warning signs, and even if the Shuttle missions were scientifically unrewarding from the get-go, long before Challenger, I’d say the program was only on a par with military test flight in the balance of risk and reward. Different context.
3
I read this again today, after reading it last night and commenting, where I referred to my Opinion I wrote on this issue published in the NYTimes this August (https://www.nytimes.com/2019/08/07/opinion/letters/faa-boeing-crashes.html).
There is otherwise something uncomfortable about this article, and not just the odd English usage and style, but the expository narrative that contains intimate detail, either incredibly prescient or from privileged information, but with no references. The writer, and the Times byline, appear to indicate or imply that he is related to the infamous Wolfgang Langewiesche who wrote "Stick and Rudder" that nearly every pilot from my generation (Embry Riddle Aeronautical University, '78, ATP, 10,000 hours multiple jet ratings; CFI) read as the "Bible" of flying skills. It is exclusively centered in a pro-pilot skills-based argument, which would partly explain this author's perspective (which I don't disagree with, per se). He also provided important context about 3rd-world aviation standards (quite accurate, although occasionally too speculative), labor markets and pilot training philosophy in them. But it still reads overall like a paid advertisement, a public relations position paper or even a litigation expert testimony exhibit. Interesting, but too many questions as to its journalistic integrity and apparent opportunism. The bottom line: read a professional accident report when or if it is publicly disseminated and verified in US law.
16
In the cockpit of all commercial planes (and perhaps some private planes), the manufacturer should install a video camera, two-way audio, and a help button. The audio and video feeds, and requests for help made by pilots, would all be transmitted live to a central location, perhaps called a Pilot Assistance Center (PAC), where aviation experts could provide immediate guidance to the pilots in the cockpit of a troubled plane. (It would be like “the ghost in the jump seat” sitting behind the Bali captain and co-captain three days before the tragedy of Lion Air 610, who recommended “shutting off the electric trim by flipping the cutout switches.”) In addition, some or all of the information from a plane’s instruments should be transmitted in real time to a PAC, where it would be stored.
Doing the above would hopefully achieve three things:
1. Help pilots handle challenging situations.
2. Make it possible to give pilots better training and feedback.
3. Provide information after crashes, dings, and near misses.
Each PAC would need to handle multiple models of planes and the languages spoken by pilots flying those planes. Boeing could build, equip, and staff a PAC for their planes, and Airbus could do the same.
Why is all of this necessary? Because teaching “airmanship” is extraordinarily difficult and simply not feasible across the entire airline industry, and because equipment failure and unforeseen conditions will always require timely interventions by human pilots.
5
Pulitzer worthy.
7
What scares me the most is the assumption of the author and many of the commenting „I would have saved the plane“ pilots, that the ET 302 Pilots just should have taken the throttle down. For any interested person it’s no secret that the take off happened from one of the highest altitude airports in the world with a full load. Where is the airmanship in not taking the absolute flying basics into account?
7
@DJ 11. Like some auto racing expert saying that ‘I’d never slam on the brakes in a four-wheel skid on ice’, their comments simply do not apply to everyone licensed to pilot a car. Sure we would, it’s the base response to velocity without control. We mandate these days that the car not let us make things worse. We do not say that several hundred million drivers should not be on the road. In my extremely limited flying experience, my ex-Navy instructor put the plane in awkward conditions on purpose, but shutting the engine in a climb right off the runway wasn’t one.
4
There are many Pilots who would take issue this articles assessment that airmanship would have avoided this loss of life , Chesley Sullenberger for one.: https://www.nytimes.com/2019/06/19/business/boeing-737-max-hearing.html
Improved “Airmanship” MAY HAVE saved these Crews & Passengers while overcoming a flawed MACS design. Avoiding fundamental design errors, documenting and providing training of MCAS WOULD HAVE prevented these Crews & Passengers being placed in hams way. As this article correctly points out Boeing is fully aware of the lack of Airmanship within much of the world’s flight crews. With this knowledge Boeing’s failures on the 737 MAX design/documentation/training and reaction after Flight LNI-610 are even more insupportable.
It would be a service to the flying public to publish an article that delves as deeply into the design errors, the motivations behind NOT informing flight crews of MCAS and why explicit training for MCAS false positives was not offered?
10
Moon of Alabama is all over this, documenting several wrong statements by this author.
5
@Bartolo thank you for this reference!
The future of aviation certainly holds extensive risks resulting from inexperienced pilots, airlines cutting cost to maximise return, which ultimately drives poor safety management, ineffective training programmes etc. Ironically, safety management has seen the introduction of poor regulatory oversight with reliance on operators to manage risk as opposed to continuing compliance and oversight practices. Regulations and compliance should make up 90% of the overall operation.
Although there are some good points in this article, I strongly disagree with the comments made in respect to the pilot actions – “it was the decisions made by four of those pilots, more than the failure of a single obscure component, that led to 346 deaths and the worldwide grounding of the entire fleet.”. A sorely incorrect statement. I do not disagree that their response and actions are questionable, but this is why we investigate the causes which result in these actions or inaction's. You focus a lot on the active failures with little emphasis on the deeper issues. This accident was certainly caused by a failure at a much higher level.
I highly doubt the scenario was presented itself as a “simple” runaway trim but a much more complicated beast. As you pointed out, stick shaker activation, unreliable airspeed and altitude. 10 second burst of nose down input is not an indication of a "simple" trim failure. A lot of challenges for the investigators I'm sure to identify what truly occurred.
3
this article seems to a hit piece aiming to absolve Boeing and shift the blame to airlines. how to train their pilots to handle the design flaws of MAX if Boeing did not highlight to the airlines that the plane may stall and the pilots need to learn how to overcome the design flaws.
7
As encompassing as this article may be, some arguments are questionable and need clarification. The sidekick towards line pilots whereas they would be “afraid” of turbulence and bank angles in excess of 30 deg. is just nonsense. A line pilot’s main task is to fly 200-500 souls safely, reliably and comfortably over thousands of miles from A to B, day in and day out, in a wide variety of circumstances. It is obvious then, that turbulence is a factor and a matter of concern. Apart from flight envelope considerations, bank angles in excess of 30 deg. and deck angles in excess of 25/-10 deg. are not always appreciated by all passengers.
The opinion of test pilots, many of whom I have known personally and admire and respect, is not always relevant to line flying. The worlds of test flying, and line flying, both of which I’ve experienced thoroughly, have many commonalities but also significant differences which I will not explain here for brevity.
Finally, on “airmanship” there are about as many (or even more) opinions as there are pilots. The author, if he has consulted a.o. the excellent material on safety IATA has regularly published over decades, must be well aware that the main cause of “pilot error” and hence incidents and accidents, even today, is non adherence to SOP’s (Standard Operating Procedures). In this respect, strict adherence to SOP’s (except in emergencies), is the bread and butter of the line pilot and has saved more lives than “airmanship heroes” have.
7
This article is a red herring - largely true but a distraction from the real issue.
Yes, modern pilots are largely deficient in airmanship, and this is going to be an ever-increasing problem. Modern airline pilots log hours for sitting in their seats and doing nothing, like a Tesla driver. Then, when something *really* bad happens, they are not on top of their game enough to deal with it. Like a Tesla driver.
All of the above does not change the fact that Boeing packed an undocumented time bomb into the Max, and it went off. The thing that was *really* bad that happened and which the pilots could not deal with was Boeing's fault.
15
Thank you New York Times for adding William Langewiesche as a writer-at-large. I have read his aviation investigations for many years; there is simply no one that come close to his expertise and singular writing style.
13
Great article Mr. Langewiesche. I have been a pilot for 30+ years. In my mind the lack of redundant angle of attack sensors feeding the MCS is unfathomable.
Then again so is the fact that airline pilots did not realize it was a runaway trim problem.
9
Best article so far explaining all the intricacies of mechanicals aircraft pilot confusion and the reasons for — airmanship, an excellent term... Feel sorry for those people who have to fly in Africa and island Asia countries
7
I'm just not sure I understand the argument here. Are you saying that unless one of those pilots had "airworthiness" that the plane was going to crash? That's a big jump. Airworthiness seems to come from a lot of experience, which would mean a pilot would have to be older, and also an exceptionally talented person. You cite it as a rarity. I'm assuming ( I believe correctly) that there are many pilots from all over the world who had about the same amount of experience as Mr. Suneja and Harvino, most of whom do not have airworthiness. I applaud the expertise of pilots, but Boeing gave no instruction to them about how to use the MCAS, pilots weren't even told about the new system, and Boeing never bothered to put it into the instruction manual, and purchasers of the MCAS had to pay extra for additional safety devices, (No greed there) Only Brazil chose to buy the add-ons. You keep saying that Boeng does all these greedy, pretty disgusting things but those things have nothing to do with the crashes. Of course they did. It's the mindset.
9
A truly amazing article! The author and the NYT are to be congratulated on it. I worked at Boeing after Harry Stonecipher bought Boeing with its own money and introduced the 'Douglas' culture. This seems to be the end result. I certainly hope the America's largest supplier of foreign currency can weather the storm.
7
Absolutely riveting article- crackerjack writing! Langewiesche made a complicated subject not only clear, but writes with such immediacy that one feels one is in the cockpit with the hapless pilots- harrowing!
6
Doesn't it all come down to greed?
1
Very interesting reading! As a Private Pilot who only fly small single-engine machines, I can only guess how it is feel to fly 737, and how properly trained pilots would react on this problem. Obviously, Boeing made mistakes, very serious ones, first to implement the system that can crash the machine and then, by keeping it obscure. However the problem raised here is very important and much broader. It is how responsible (or not) the airlines approach to the pilot qualification. Both Boeing and Airbus make great aircraft, which is very difficult to crush, but, as saying goes, "impossible to design100% fool-prof system because fools are very smart". It is very revealing that both tragedies happen with airlines that are notorious with their neglect for pilots training. Ethiopian crew was (or at least should be) aware of the issue, but under the stress they fail the "First Commandment" that every student pilot learns on his first flying lesson :"whatever happen - fly the plane!". This is all what you need to know about pilots qualification at this airline and airline attitude to the safety.
May be one day we will be riding self-driving cars and flying self-flying planes, but before that it is the guy at the cockpit who guaranties our safety.
Very good article! Respect to author.
5
A dramatic, but deeply flawed story. Too many items to even try to address.
But if the author really knows how airplanes fly into the air, he ought to learn about the Bernoulli effect. Not "tilted up wings".
5
I have no expertise in this area so my comments must be viewed in that light. Nonetheless, if the author of this article is correct that there are pilots in other countries that are sub optimally trained then this information was known to Boeing. So with that knowledge why design an aircraft that you will sell into markets where pilot training is not ideal? The conclusion is inescapable; Boeing made a decision to rush production to meet Airbus' neo design. An airplane is a complex feat of engineering so when you are selling to an international market you have to know to whom you are selling.
7
Why was the MCAS system designed to respond so aggressive?
3
@Bal. The reason has been documented in some of the published documents that have surfaced so far. Boeing’s simulations indicated that the MCAS’s two reasons for being added would not provide adequate response unless they increased it. The decision to make the response incremental every 5 seconds, even after being shut off and restarted, is just fatally stupid. Last thing I read is that Boeing is backing off on the magnitude of the effect, but that possibly won’t work in that it can provoke an actual FAA recertification, which is what they tried to avoid. How they got away with the other cost-cutting, like the single AOA reference, lack of indicators, or connection to the rest of the flight computer, IMHO is not just error, it’s culpable.
It appears the Federal Gov't is bound and determined to put an unsafe airplane back into the sky. It was not the pilots, it was the Boeing Corp trying to save a buck and the FAA going along. And now, NYT joining in on the group think.
Remember NASA and Morton Thiokol and the Challenger? We must launch at all costs. The Columbia? Chunks of insulation had fallen off during liftoff on nearly every launch.
And now two identical plane failures. The FAA did not want to take the 737 Max out of service after the first failure. Then the second identical failure....Only it is not NASA Mgt. and Morton Thiokol group think. It is now FAA and Boeing group think, they and others are saying the planes are safe.
Are the planes safe now, or should the plane have had its engines relocated, rather than depend on a computer and a sensor and a hail mary from the FAA training department fall victim to group think?
4
Fantastic article!
5
An excuse of Boeing
1. It was "Malfunctions" that caused the crash. It was
Engineering Design Errors
2. The Pilots were unprepared because
Boeing intentionally withheld information
3. The Max 8 is an inherently flawed aeronautical
design.
Here is a picture of the original 737
https://airwaysmag.com/wp-content/uploads/2016/07/737-and-787.jpg
See how the engine fits directly under wing.
That is the weight of the engine is below the
point of lift
And here as a picture of the Max 8
https://inteng-storage.s3.amazonaws.com/images/MARCH/sizes/Boeing_max_8_resize_md.jpg
See how the engine is now in front of the wing ?
Have you ever seen another airplane with the engine this far forward ?
No you haven't. Boeing , to save money, hung too big an engine on an airframe that was not designed to take such a big engine.
6
Good pilot requirement explanation but contradicts himself on one point, disingenuous on another to bolster his story. Says solution to runaway trim is simple and easy: turn off trim switch. But that didn't work in Ethiopia (for complex reasons.)
Says media blamed new MCAS but he must have read at least the NYT. Media consistently faulted multiple problems, short term profit and consistently flaunting a basic engineering principle: KISS. Keep it simple stupid to avoid complex problems. They blamed taking a decent 1967 design and continually bloating it till it was imbalanced and unstable. (A '67 bug is less safe than a new car, but install a hemi?)
Boeing knew a newly redesigned 797 would be better.
Bloating a '67 plane seemed less short term financial risk. But greater passenger risk, which is greater financial risk.
3
Many seem to be reading this article with the notion that blame is singular, that there is a single cause - so pointing to poor pilot training takes Boeing off the hook. That's not the culture in air accident investigation - there are often, especially with modern airplanes, multiple causes and all of them should be investigated.
As this article clearly shows, there's a combination of causes here, and while the Boeing engineering failures, the regulatory failures, have been much discussed, the context behind them, and the pilot training angle are relevant and important not to ignore. All of these causes created the accident, take away any of them and there's very good odds that this would not have happened. All of the causes are at fault, to think that you should pick only one, that blaming poor pilot training absolves Boeing or the FAA is not true.
7
I knew this article was by William Langewiesche. I have read his other amazing articles on other airplane problems. I hope the FAA and all of the aviation industry reads his work and uses it to resolve problems. Thank you sir!
5
I very much enjoyed this article. Whether you come down on the side of Boeing or the pilots, the frustration is palpable over our disagreement with the nature of technology and human interfaces. The author is no doubt correct to say, “the pilots should have been better.” And no question the decisions made by Boeing are culpable for characteristics built into the airship that require airmanship. Change or die seems to be the lesson for all people and corporations. The economics of faster, more and bigger demand it. What seems missing is an acknowledgement that greed in all it’s forms is at play here. And simply demanding humans to acquiesce to change beyond their abilities either in the cockpit or the corporate office is leading us into a very terrifying future indeed.
5
In sharp contrast to last week's Kavanaugh hit piece, this story is authoritative, well-researched and solidly-documented. Its author's agenda is clear -- find and shine a light on the unvarnished truth - and it succeeds while leaving room for each of us, as readers, to draw our own conclusions. Well done.
5
Thank you. The flying public needs this kind of factual detail with explanation. Apparently both regulators and aircraft manufacturers also need to read - and heed. And voters in this day of "roll back those nasty, intrusive federal regulations" ought think hard about how much political control of FAA is in the national interest. Maybe that's why I always pause to say "Thanks for a safe flight." each time I exit an aircraft.
7
This is the accident chain:
Business pressure > FAA’s certification process > Boeing not communicating with pilots > faulty parts/maintenance procedures > inadequate pilot training/experience
I’m a big fan of the author and have been flying small planes for decades.
9
@Elvis
Exactly. Using functional parts would have broken the chain, better communication of the faults of the airplane by maintenance - these in particular combine badly with a late introduced software that bases it's decision making on a single instrument rather than comparing both inputs.
3
MCAS was the primary contributor. The real problem was that the new design did not allow the pilots to choke back to bring the nose up as a means to automatically disengage the MCAS. That was a new design and a flawed one. First instincts would be to pull back on the yoke but that would do you no good. Another fact the author omits is that the trim cutoff switches, when both were disengaged, did not necessarily bring you in the clear. If the plan was already at a dangerous pitch and velocity when the cutoff was engaged this would make manual trim of the aircraft very difficult. The cutoff switches, when activated, would also disengage the electronic trim, so no help there either. Poor design was my far the most substantial contributor.
8
The author's own, very interesting article, demonstrates that the 737 Max isn't "safe to fly", it's flyable with great care by experienced pilots with proper training and good judgment in a crisis. Yet there are large numbers of pilots flying who can't be described that way. Given who the pilots are, the article makes clear that the plane isn't "safe to fly".
5
Thank you for writing this article.
It is much needed.
Clearly written and informative.
About the interacting dynamic, multidimensionality of potential and actual failure.
Human and nonhuman.
It unashamedly notes how personal unaccountability, by a
range of people, at different types, levels and qualities,
either caused or were associated with documentable
temporary as well as more permanent failure,
in addition to the almost institutionalized Barriers to “Fail better.”
Barriers to learning from outcomes and integrating them into new realities are the necessary road to needed improvement.
Not to do so, for what ever the reason(s), and
whoever the individual or systemic stakeholders, and
their agenda(s), is to be complicit. To BE failure-blind.
The author notes a list of “unaccountables.”
People. Companies. Government agencies.
Anchored values enabling violating...
Hints at flaws in ethics such inadequate oversight. Monitoring.
The human costs in life and limb to toxic, unreasonable profit.
What is not hinted at is that the behaviors documented in this “report,” when repeated over and over, are
enabled in various ways by each of US. By our choices.
Choosing to be complacent.
Choosing to BE and remain willfully blind to what IS and should not BE.
Choosing to BE, and remain, willfully deaf about...
Choosing to be willfully indifferent.
Choosing to be willfully ignorant when generalizable facts are both available and accessible.
1
In all of the discussion about how much of the culpability for the tragic crashes to assign Boeing, FAA, shoddy maintenance, or poor pilot training (all of which get get their share of blame in Langeweische's article) there remains a key element of misunderstanding regarding how quickly a trained pilot should be able to recognize a fault and turn off the electric trim and revert to manually trimming. Answer: 10 seconds.
As opposed to theoretical or especially rote learning, training implies sufficient time physically practicing and rehearsing of the steps to solve a fast developing and dynamic problem be conducted. This produces correct responses that do not involve reading a checklist, or recalling where to look up data or instructions. This repeated rehearsal leads to success and is part of airmanship.
I may be crucified for saying so, but a huge advantage that American (and perhaps western European) pilots have over much of the rest of the world is that we have a General Aviation industry which allows building of vital flight experience -including rehearsing handling runaway trim scneraios in dozens of different airplanes before a pilot becomes an airline pilot.
There is no substitute for varied flight experience and problem solving on your own which General Aviation experience provides. It is no wonder that the US passenger airlines are currently stupendously safe. Pilots come with 1,000 hours or more of flight experience, not 196 hours of academy experience.
6
This is such a brilliantly written expose on the complexities of flight and all of the third party vendors that scarily contribute to plane safety all I want to know is when is the book out? BRAVO!
3
I neglected to note who the author was as I took in each sentence. He wrote an engrossing book titled: Into The Sky. Highly recommend it to anyone with an armchair passion for piloting.
3
Even if we accept the premise of the article about the dearth of airmanship, these are the pilots the industry now has - and yet accident rates have gone down, down, down in the age of less fancy flying and better safety systems.
Boeing is still the culprit because it didn't plan the plane for the pilots who were likely to be flying it.
5
Timing of this article recycling the six months old meme about pilot error and bad third world airlines terrifies me. It means Boeing has not learned its lessons and is trying to fix the MAX by PR.
If Ethiopean are considered an inadequate fleet, most airlines in the US should shut down.
6
@Philip Lingard "trying to fix the MAX by PR." This is the best summary of the entire debacle that I've read.
1
In an otherwise excellent article, I’m not sure why Mr. Langewiesche decided to offer this – “That is not meant as a blanket defense of Boeing. On the corporate level, the company is the worst sort of player — a corrosive agent that spreads money around Washington, pushes exotic weapons on Congress, toys with nuclear annihilation, sells all sorts of lesser instruments of death to oppressive regimes around the world and dangerously distorts American society in the ways that President Dwight D. Eisenhower warned against in his prescient 1961 farewell address. But hardly any of that matters in the story of the 737 Max.” But, he is right. Hardly any of it matters, nor does his over-the-top diatribe regarding Boeing matter either.
1
As flying becomes more software-mediated, calling for a return to "airmanship" is naive. If an engine fails, a pilot can anticipate the physical impact to her flight demands. However, nothing about our intuitions about the physical world can help us figure out a software bug. In the case of the 737 Max's MCAS, even its designers didn't anticipate that it could move the stabilizer 10x more than intended. It's hard to predict what a computer does when it goes insane. Pilots cannot be expected to deal with rogue software when that software has become so enveloping of the piloting task, from data presentation to control surface adjustments.
I heard of a fighter jet that would have flipped upside down whenever it crossed the equator, due to a bug in its flight control software. The problem was caught in a simulator and root caused to a sign inversion issue in the software when crossing zero latitude. How would even the best pilot be able to handle this in flight?
5
Kudos to Mr. Langewiesche for such a well-written piece. He grasps the problem at hand and has the courage (that too few have) to say what needs to be said concerning aviation safety.
I was right with him until the very end.
The solution is not more automation to lessen the need for better pilots. The solution is to invest in making better pilots. (And all other people involved in aviation.) It sounds expensive (because it is). Until you compare the cost that the industry is suffering now.
We've seen this movie before and it always ends the same way. Safety is expensive. But not nearly as expensive as failures caused by lack of safety.
Don Brown
5
The three major variables in flight safety are aircraft, pilot and weather. Faulty aircraft and bad weather place a greater premium on airmanship. In this case the demands on the pilots were significant and probably beyond even many well trained and experienced pilots. No doubt some of the best could safely deal with these events, but as a passenger I want my aircraft to challenge my pilots as little as possible.
9
A runaway trim tab is one of the most common malfunctions that pilots train for. Responding to this condition is routinely performed during recurrent training which US pilots do every 6 to 12 months in a full motion simulator. The correct response to this condition is to merely disconnect the trim motor, which can be accomplished through multiple pathways: Push the auto pilot disengage button which resides under the pilot’s thumb; Throw the panel switch; Pull the circuit breaker.
Pilots do not practice flying the airplane during recurrent training; they practice responding to emergencies. US standards require that a pilot respond to a runaway trim tab in three seconds in order to pass the test.
While the Boeing design made it possible for the MCAS system to respond incorrectly to an incompetently maintained angle of attack indicator, the failure to fly the planes properly with subsequent crashes were purely pilot error. The chain of events was initiated by incompetent maintenance. This is a criticism of 3rd world foreign airlines. It is not a criticism of the US airline industry.
5
This article does an excellent job summarizing the abysmal state of international pilot training and capability. The conclusions that the crashes were primarily pilot error, however, is flawed, because it fails to recognize Boeing management's failure to maintain safety as a primary priority, sabotaged by financial and competitive pressures. I spent 37 years in Boeing Commercial Airplanes, and have seen first hand the deterioration of safety-focused management. The very idea of relying on one sensor in a critical flight system violates basic engineering design criteria, and while I was not privy to this particular model's design, I'd be VERY surprised not to find Engineering overruled by management to get the airplane in service before it was ready. As with most airplane accidents, there are a number of factors that combine to cause the problem, but if one looks at the timelines of the crashes, the first problem was the flawed design and how it was implemented. And Boeing management must shoulder all of the responsibility for that problem - had that design been adequately addressed, neither of these accidents would have happened.
8
Ok, the detail here is onerous. However, I detect the 'test pilot attitude'. From reading "the Right Stuff" pilots in general always believe that they could have avoided the crashes that other pilots experienced. I guess it is a survival mechanism, to believe that you are in control of the airplane. Also, machismo. Anyway, I disagree with his conclusion. The plane should not be able to detect a non-existent problem and then crash the plane unless over-ridden. The plane was retro-fitted with an engine with different characteristics than it was defined for. Fixing a physical problem with software is always a mistake.
13
William Langewiesche does a suburb job in explaining the probable causes of the Boeing 737Max crashes. Unfortunately, until greed is not a player in the Aviation Industry, I'm afraid more crashes may occur, especially in areas where oversight is non existent. I trained 'Ab Inicios" (means from the beginning) years ago with Crossair Airlines in Switzerland, and unless I asked the co- pilot "look out the window and fly the airplane" he had is head inside doing rote procedures he had memorized. Flying does not come naturally to some people. A lot of those First Officers went on to become good pilots, but a lot did not. W. Langewiesche is spot on. (Any chance he is related to Wolfgang Langewiesche author of "Stick and Rudder"?) Thanks for a great piece of writing, accurate and informative.
7
An excellent description of the pilot errors and some of Boeing's. But one big failure remains, as far as I can see - the decision that rather than accept that a flight issue might result in a less severe G force change, in order to duplicate flight characteristics of the prior generation, they altered the software (MCAS) to produce an artificial shock to the pilots to mimic the real one.
This is just as much damaging 'rote' behavior as the pilot training. If the aircraft doesn't match specs, tweak until it does, even if introducing a negative behavior.
The all-or-nothing of the certification process - where they had to match all prior behavior or go through a very heavy process to recertify could be a part of the problem - an incremental certification process might also be worth considering, for the future - or eliminating the ability to do a partial certification.
7
Thanks for the great article. Very enlightening. I am just not so sure recovering from a runaway trim is easy, even for a well trained pilot. Seems to be heavy work and involves a lot of coordination between pilot and copilot.
2
As a former aviation employee turned lawyer, I have always been fascinated and interested in aviation and its events. Thank you so much for this very informative and well written article.
5
The next time my flight is delayed or grounded because of "mechanical difficulties," maybe I'll be a little less angry.
In addition to pilot training, this article also highlights the importance of those men and women on the ground we never see--the maintenance crew. If they are sloppy or too fearful of management to call out errors, we are all at risk.
Airline travel in the US (and in some other countries) is highly regulated, which is why it has a good safety record, and crashes are meticulously investigated. This is not true everywhere. And with "budget" airlines, the pressure is probably a bit too tilted toward cost vs. safety. Know before you go...
9
Great article that provides important context on a very complex issue. It also helps realize the all-too-human tendency to oversimplify complexity, select information according to personal belief and be attracted by the suspicion of conspiracy. Airmanship is a must for pilots, and it's increasingly lacking, no about that. But so are integrity and safety first for any company that builds airplanes. Boeing tried to get away with yet another attempt to rejuvenate a dead body just because they were afraid of losing completely against Airbus. The FAA closed their eyes to put America first. These fundamental mistakes cannot be excused by lack of airmanship of pilots. The 737 Max must never take off again, regardless of what pilot is in the cockpit. Basic truth can be contextualized but not diluted or made disappear.
6
Great piece by the son of the man who wrote "Stick and Rudder,"--required reading for any pilot.
Most accidents are the result of a series or collection of smaller failures, not a single cause, and this seems to fit the bill.
But capping it all is the universal greed that drove Boeing to avoid new certification and drove the low-cost airlines to use marginally qualified pilots.
12
Among other things, the article makes me reconsider flying on any so called "budget" airline. The lower the budget, the lower the allocation for pilot training, salaries, maintenance, spare parts (new vs. used), etc. I no longer believe in assurances that "safety is never compromised...". What's even more disturbing is that "profit before safety" seems to become more and more the norm for the entire aviation industry. Unfortunately, I think, that will only change after a couple more accidents.
7
I find that Boeing should be designing down to the least competent pilots who will be flying their planes. Yes, it would be great if more training, skills, professionalism and pride could be instilled across the personnel operating these fleets. But as the author points out, this is wildly unlikely to happen when profit and price are the prime directives, demand is rising, pilots and techs are demoralized and there is a frenzy to keep rotating these airplanes into the sky 24/7. It seems like the Airbus “fly by wire” model comprehends the global operational realities of air travel far better than Boeing’s.
6
Words cannot begin how happy I am that I stumbled across that article that, in turn, had been impeccably-well written. I have personally acquired pretty deep insights into the industry correlating with airplanes. My major take away from this story is not the fact that there had been a good number of various malfunctions and countless mistakes made by a number of individuals, but the fact that some business companies put a great deal of emphasis on pursuing financial aspects, typically failing to provide society with the desirable and needed levels of work performance. The good news is there is always room for improvement. Finally, I am deeply sorry for ordinary people who became a part of the deadly stories .
8
Interesting article by the son of Wolfgang Langewiesche, the author of Stick and Rudder, the best book on how an airplane flies, and how to actually fly an airplane ever written.
10
As an active non-Boeing pilot with 39 years of experience in the industry, including Asia’s airline industry, I haven’t read an article like that before.
Chapeaux.
The author describes accurately and precisely the outcome of a combination of sloppy engineering and poor airmanship.
I think we will see more of it in the future. And it’s not about blaming pilots. It’s about the system of flight training and education of pilots in combination with low low costs in the airline industry.
353
@Countryman
Having flown the 737-200 as a young pilot and then moved onto many other types including the 777 and 380, I've got a decent understanding of what this is all about.
The new generation FBW aircraft are far more benign than the 737. As the last of the dinosaurs still in production, the MAX needs to be flown with some skill. Especially when things go wrong in unanticipated ways.
I agree with the author that the present training system does not adequately cover the MAX. It works fine for FBW types but the system fails when it come to the MAX.
This is a systemic problem and quite frankly I fail to see an easy solution.
34
@Countryman
Except, the pilots and their passengers perished, while the CEO’s remain in place, with politicians assisting with their greed.
Remember what China did to their CEO’s who tampered with milk ~
14
@Countryman
I disagree since FAA pilots failed this scenario, and since the FAA also discovered that the FCC and MCAS does not immediately give full control authority to the pilot after the stab cutout switches have been thrown.
12
The new design is a mistake. it's also a mistake to double down and try to stick with a bad design. Aircraft are not meant to be designed to be fragile in their environment. This design is fragile. It's tempting to rely on artificial intelligence and special training for the pilots. an aircraft should be able to be flown" by the wire" . If you can't do that, your craft is dangerous.
China is doing the right thing in refusing to accept this aircraft. Not only should they refuse to buy the aircraft but they should refuse to allow it to be landed in China.
159
@Analyst - no, people should refuse to travel on airlines who employ poorly trained pilots with insufficient experience.
There are no special skills required to fly the MAX, however sound airmanship is required to be safe in ANY aircraft. It is this quality which is the glaring deficiency in these accidents. As the article states, Boeing absolutely made mistakes - but that does not excuse the lack of airmanship by the crews. I make that statement as an airline pilot and simulator instructor for airline pilots (including those from various countries and cultures around the world).
26
@Analyst Boeing has taken the high ground and continued to build planes that require skill and deep dedication to knowing ones craft. Should they design planes that allow for assembly line pilots with no deep seated flying ability - "Airmanship"? If pilots become robots with little independent thought and skill sets, then any burp in a flight may lead to a cascade of failures that lead to a crash. Airbus still has pilots that have driven their planes into the ground. First world pilots don't make third world errors.
11
@Analyst I then assume you refuse to ride on an airbus then? Did you read the article?
6
"He grew up in aviation..."
That's one of those understatements. The author's father wrote "Stick and Rudder," which was responsible for training more pilots than any other *single* document and which is still read by pilots today. I read it when I trained a little more than a decade ago..
He is correct that airmanship would have saved these flights. He is a little light on his examination of Boeing and the FAA's role in presenting the situation which the pilots had to overcome, but he is correct that a well-trained pair of pilots, or even a single pilot, should be able to respond well. And they have, including the anonymous jumpseater.
11
"Even more pernicious was the F.A.A.’s longstanding delegation of regulatory authority to Boeing employees — a worry that is perennially available to chew on if you like." I would like. Do you think that if Boeing had not been regulating itself, that this might not have happened? Or if Boeing hadn't been spreading money around and selling toys and guns to to oppressive regimes, or paying off politicians....You say that this was not about greed. Perhaps it wasn't in this one particular instance. Or perhaps, it played a part in what happened, because your article paints a pretty grim picture of a company that seems pretty greedy.
8
The scary question is would the FAA be knowledgeable enough to restrict some foreign airlines entry into U.S airspace...?
1
What is bringing this plane down as a very bad design. It should not be flown.
4
What a dismal logic...
They do not build cars for only experienced drivers. Boeing should have known that pilots come with different level of experiences (btw, Boeing claimed that no additional training was necessary for the Max). A good company anticipates that all users are not 100% confident. The Max was born out of greed and some should go to jail for killing all those people. The plane is inherently unstable should not return to the service.
12
@Sam
This article makes the point that the remedy for the flaw in the Max was a standard one - if my car has a new autopilot that might over accelerate, how much training do I need to know to hit the brake like any other time I have too much speed?
That's a valid defense. And airline pilots are required to have substantial training, far more than a DMV test and a few hours of practice. This is not remotely like a car.
1
This piece would have been better had it been written by his father, Wolfgang Langewieche. Look him up; he wrote the bible, "Stick and Rudder", and that is one of the keys here. There is too much sim training and reliance on the autopilot and not enough training in the art of hand flying. This may get third world pilots into the flight deck sooner but at huge risk to the passengers. Also the big corporations are running the show in the US, not the regulators. We should be ashamed.
5
I couldn't finish reading this article. It is like Boeing is the author throwing up their hands - see not my fault.
Wasn't Boeing lazy? Add a new bigger engine to the body of an existing plane then slap a quick fix on the DEADLY FLAW.
So sad that North America couldn't follow the European example and ground planes immediately to protect people first vs protect $$ first.
3
Before pilots sit in the cockpit of an airplane, they should be required to take a RIGOROUS Pilot Ed Class for the airplane they are flying. The pilots of the doomed 737 Max Airplanes should have been able disengaged the auto pilot (MCAS) and piloted the airplanes.
“MCAS was therefore introduced to give an AUTOMATIC NOSE DOWN stabilizer input during steep turns with elevated load factors (high AoA) and during flaps up flight at airspeeds approaching stall.”
“it is believed that the MCAS used this erroneous AoA data to command nose down stabilizer which was NOT COUNTERACTED SUCESSFULLY BY THE CREW until the aircraft impacted the water.”
http://www.b737.org.uk/mcas.htm
1
This is a riveting and remarkable article. A few months ago, for some reason, I watched a series of YouTube videos documenting historical air crashes and near-crashes. One thing I remember about these is that yes -- the difference is often in having a pilot who is able to function at a high level while under tremendous stress. While I am not at all a military person and could never consider being asked to kill fellow human beings, I do respect the type of training that military pilots receive, and yes, I would feel safer on an airplane knowing that at least one of the pilots has had this kind of training.
6
Any automated system can develop a glitch. When the problem is more complex and will take time to resolve, a means of disengaging automation must be simple and fast. A single release button with a safety so it cannot be mistakenly activated would have saved both planes.
With driverless cars and other systems that can pose peril to life, there must always be a way to override a system. the problem for both pilots and drivers when automation is disconnected - do they have sufficient experience to operate the plane or car?
5
@Rodger Parsons
Read the Preliminary Reports (before commenting).
There is a cut-out switch (with a safety guard) on the center console, behind the throttles, within easy reach of both pilots.
The Lion Air crew never used it, for reasons unknown.
The Ethiopian Airlines crew did use it. Unfortunately, they failed to use manual electric trim to fully relieve control forces first. Also unfortunately, they later turned electric trim back on, allowing MCAS to once again activate. Also unfortunately, they then placed the switches in the CUT-OUT position and left it there without first using MET to relieve control forces.
2
Very interesting and well written article.
It would be interesting to know if somebody made a simulation test with what happened in the two crashes. How would other pilots react?
@Marc T. Respectfully, The New York Times has already published the article you are suggesting. . . on March 25, 2019. That article details how simulation tests were done with the NYT's headline concluding: "In Test of Boeing Jet, Pilots Had 40 Seconds to Fix Error." The the gist of the March 25 article was, quote: "The MCAS 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 737 Max simulator." These tragedies should not be pinned on pilot error as Mr. Langewiesche would have readers believe. You should review the simulator presentation that "60 Minutes Australia" did, showcasing on YouTube the challenges that the two flight crews faced against MCAS.
2
They ran simulations and the outcome wasn’t very different with the pilots expecting an MCAS attack.
As I board a plane I glance in the cockpit where I hope to see both an older pilot (for experience - airmanship here) and a younger pilot ( for reflexes)
3
As an international traveler, this is one of the most sobering things I’ve ever read.
8
I lost a close colleague and friend on Ethiopian 302. His remains are scattered amongst a 30-ft deep crater in an Ethiopian field. I cannot imagine how terrifying were the last 6 minutes of his life. I do know the pain and anguish of his loss, and the void that loss has created. So while I appreciate the painstaking recreation of events leading up to and during both flights, I do not appreciate the perjorative tone leveled against the pilots. It’s easy to blame them when you’ve had 6-12 months after the two crashes to pour over the data and delve into every nook and cranny. The pilots had no such luxury, rather, mere seconds after take off to ascertain the situation, process multiple inputs and make decisions that determined their fates and that of 342 others. If they were not properly trained that’s the fault of their employers, Lion Air and Ethiopian Airlines. If the design of the aircraft was flawed and too complicated, certain aspects of which were not disclosed to the customers, that’s the fault of the manufacturer, Boeing. Don’t let any of them off the hook.
32
You’re letting your emotion cloud a pretty simple fact. Pilots were untrained, inexperienced. The same plane in the hands of better trained pilots has also malfunctioned, but they have managed to steer it. Your grief is appreciated and you have everyone’s empathy. That doesn’t make for a coherent argument though.
12
@Nearly Normal No, I'm not, and you said it yourself … "better trained pilots." You cannot blame the pilots for being assigned to an aircraft they didn't have enough experience to fly. You also cannot blame them for the training they received, or for not receiving the training necessary to be able to respond properly. And you cannot, in the Lion Air case, blame them for shoddy maintenance and the falsification thereof. Whether you're cognizant or not, when you set foot on an airplane you do so with the understanding that you giving complete control of your well being to everyone -- from gate agents to baggage handlers, TSA, M&R, pilots, ATC and hundreds of others -- involved in that aircraft's safe passage. That's an incredible responsibility and leap of faith that happens hundreds of thousands of times every day. Whether you pay $99 for a discount ticket or $9,900 for first class, the airlines, aircraft and component manufacturers and regulating bodies cannot not allow corners to be cut or ethics to be compromised. I cannot set foot on a B737 MAX, nor will I allow anyone I care about to do so, as much as I can influence them.
7
It actually made for a coherent argument though. No pilot should have to deal with runaway trim right after takeoff especially when the new generation of pilots grew up playing video games rather than flying fighter planes in times of war. Boeing should know this, you should know this.
2
As a private pilot I have deep respect for the Langewiesche name. How father's book Stick and Rudder is required reading for budding pilots or flying enthusiasts.
I also loved his recent article on the MH370 disappearence. I can cant say the same about this article, however... Mr Langewiesche starts off (rightly IMO) being critical of the pilots and their choices. But then leads into a long diatribe into how third world countries dont deserve new toys, and absolves Boeing of all wrongdoing or negligence. There's plenty of blame to go around on all parties involved here and focusing on one country as the reason for the grounding of a jet around the world is unfair.
27
I don’t want to fly on a plane that should only be flown by the likes of captain Sully. I want to fly on a plane that could be flown by the average Joes and Jane’s. Boeing should fix the problems. Period.
28
@EPJP The point of this article is that pilots are NOT average Joes and Janes. Each and every one of them must be prepared, both through training and through harrowing experience, to handle a life-threatening emergency that very few of them will ever encounter in their careers.
5
@epjp. Sully testified that it was a nearly impossible recovery, borne out by simulator testing. I think Sully qualifies in ‘airmanship’
3
Poor airmanship is bean-counters' answer of Low-Cost Air travel explosion world wide and bean counters instead of pilots who run airlines. Ditto for Boeing's rush to certify a system designed to imitate Airbus automation. As an aerobatic flight instructor and airshow pilot, I pose one question: Do you want your kid's doctor and teachers to be at the best of their academic class and on the Varsity teams, of drops outs sitting on the bench? How about your pilot?
7
If this article doesn’t discourage hundreds of people from flying on airlines then they aren’t paying attention.
4
I, too, was impressed by the thoroughness of the article. But I think it downplays the understandable confusion in the cockpit from multiple warning indicators going off at once.
Once there is a stick-shaker stall warning going off, the author faults the pilots for not cutting power. Cutting power in the face of an impending stall? That doesn’t just require airmanship—it requires clairvoyant foreknowledge that the aircraft’s warning systems are defective.
If every pilot reflexively cut power in the face of a stall warning, as the author insists should have occurred in the second crash, planes would be crashing around the world on a daily basis.
14
Writing as a B757 Captain, this is the best, most authoritative article on the subject I have ever read in a mainstream publication.
By a long shot.
Yes, Boeing made mistakes. But the inescapable conclusion is that both crews managed to crash perfectly flyable airplanes. Complete failure to control airspeed is proof positive of fundamental incompetence.
28
As an engineer, it was always hammered into us to look for the Root Cause, the one that if removed, there is no symptoms anymore. In Boeing case, the root cause was shoddy design. Tens of thousands of airplane fly without a problem, part of them with incompetent pilots. Not many of them fall out of blue sky within a few months as the MAX did.
One of the main root causes is that boeing designed a critical system that uses only ONE sensor. This is a cardinal No No. Either they are incompetent, or they are criminals.
And as far as “airmanship”, It is probably lacking at most of the non MAX airplanes that are flying today, but they are still airborne. Boeing never stipulated that the MAX specifically can be flown by “airmanship” persons only.
The piece is full of non relevant information, but lacks logic.
22
>>> "But the inescapable conclusion is that both crews managed to crash perfectly flyable airplanes."
If the world's civil aviation authorities agreed with you, the MAX wouldn't be grounded worldwide.
9
@josh
You are wrong.
There are many systems on any complex airplane that can cause a crash if the pilots fail to respond correctly.
MCAS is no different in that regard. The proper response is easily executed for properly trained pilots.
Among professional pilots, there is essentially no disagreement on this issue.
4
As a pilot of everything from airplanes to hang gliders since 1976 and a airline industry professional I can't say this story is surprising.
The Boeing versus Airbus design philosophy has been fought over in airline cockpits for decades, I remember the first time I got the chance to fly an Airbus A320 sim decades ago I walked away thinking this thing is just to easy to fly and what will the pilots who grow up with this technology do when it fails. For my generation if it all fails we just revert to flying the airplane first, working the problem and then communicating with ATC. Since I know way more than an average passenger for decades there are airlines i would never fly.
I will say after the dust settles the Airbus design philosophy wins because they are building airplanes for the current generation of pilots (children of the magenta line) pilots know what this means or google it. Boeing is still building airplanes for my generation or my late fathers World War Two generation. You have to accept the way things are and not the way they were or how you want them to be.
10
I'm disappointed that many commenters here see this as a black or white issue, not one of the holes in Swiss cheese slices all lining up, which is the case in nearly all aircraft accidents. This article looks at the system as a whole, and is probably the best account published to date of the B737 MAX fiasco. It does not exonerate anybody. There is not a single fault, but many, all of which must be corrected but many of which will not. There are huge emotional, judicial, political and financial factors which make a rational discussion of the whole situation almost impossible. We owe a debt of gratitude to William Langewiesche, surely the most qualified person to have publicly written about this tragic affair.
18
This is one of the best aviation articles I've ever read. As a longtime pilot who recently retired rather than deal with the increasing malaise in the commercial aviation market, Mr. Langewiesche has accurately described the complex and competing forces pushing the industry in the wrong direction.
I spoke about the article to a senior trainer at my former airline (a leading(?) premium carrier based in Asia) and asked that it be required reading for pilots before their next simulator checks - which just happen to include upset recovery training.
Self-loading freight (aka passengers) have no idea how inexperienced the cockpit crews are becoming, and how their training and early experiences are leaving them completely unprepared for even simple, but unexpected malfunctions in increasingly capable but complex machines.
Well done William L., I look forward to more of your writing in the NYT.
22
The author harkens back to the days of "those magnificent men in their flying machines". His priority isn't safety, it's to maintain a high status and pay scale for operators of airplanes. As if somehow airplane drivers must be a different(and superior) breed. Nonsense. I foresee a day when airplanes will be flown the way military drones are today. Controlled remotely by technicians. At one time, boilers, elevators, radio transmitters, and railway trains all needed continuous skilled operators because of their inherent unpredictability. But progress dictated that for society to have more benefit of those technologies, they had to be more efficient in their use of human labor. The exact same applies to plane drivers. If air travel is to be available to the masses not restricted to the wealthy, it has to be affordable to the masses. Pilots aren't athletes with rare skills or creative thinkers. The work they perform can well be automated. Computers can remember the checklists and combinations of symptoms much better than any human. Even this article shows that the proper actions to take were "in the book". A book that a computer wouldn't take minutes to pore through to find the answer.
10
How’s that driverless car thing coming along? Forcing machines to make moral decisions is not a good idea. Machines are great a repetitive work (i.e. autopilots) but do you really want to rely on an IT staff on the ground? Airliners have millions of parts. They are not elevators. It takes a lifetime of learning to become a good pilot.
7
You should start an airline. Clearly you misunderstand what it takes to be a pilot in today's airline world. If it was so easy then a computer would be doing it today. Good luck with that.
3
Perhaps, "thinks lightly". (Not your fault, however.)
I am a retired, USAF fighter pilot / 747 capt. I started out when a lot of hard-won experience and judgment was required to be a good aviator.
We are now in a transition in all technical fields between human expertise and advanced forms of artificial intelligence. The transition will not be easy. "AI" has great potential once it can be relied on when the technology has matured.
Hang on as there are some rough but exciting times ahead.
2
The American General Aviation system encourages new pilots to learn learning on their own how to deal with the unexpected and unusual. To learn from one's mistakes, is critical, and the academy approach of rote learning and passively checking boxes is inadequate.
Invention of electric devices to trim airplanes made it clear that such systems could fail and that the the manual trim wheel must remain available to trim the airplane. Consequently all US pilots, when first introduced to an airplane with an electric trim (usually as a low time private pilot), are trained to to react to any uncommanded pitch change by immediately. Pilots are taught (typically on single engine or light twin small aircraft) not to worry about why the electric trim is activating, but to just IMMEDIATELY TURN IT OFF and trim manually! In America, the average pilot hired by an airline has been though this training dozens of times as he or she has transitioned into different small airplanes as an instructor or charter pilot.
This training is what Boeing engineers and the FAA assumed when the the Max was certified. With tens of thousands of Boeing aircraft it always had worked before. The problem is that training in much of the rest of the world does not have the luxury of a General Aviation industry to gain experience, and like Airbus, Boeing will have to introduce more computer control and redundancy to account for less competent pilots as the years go by. Sad but true.
13
@John H
Absolutely.
As a private pilot the first thing I learned was “fly the airplane.”
Meaning that you actually learn how an aircraft is supposed to feel with only you at the controls—rather than an autopilot—which any pilot should know to disengage when the airplane doesn’t feel right.
1
Thank you William Langewiesche,
For a well written and informative article on the myriad factors that contributed to these crashes.
Many have looked to blame a single cause, perhaps one that fits a convenient narrative, but we have so many contributing factors;
An improperly implemented MCAS
Failure of Boeing to initially inform pilots of MCAS
Poorly trained pilots
Shoddy maintenance
Poor record keeping
Defective replacement parts
Improper instructions from air traffic control
Cover ups by governments impeding investigations, etc.
What really lies underneath all of these factors is poor communication and that is why it is so important that a society can communicate truth among it's members. We must understand reality in order to improve our lives and it is no accident that in countries where the truth is hidden, the fatality rate is 15 times higher.
10
I am a retired Boeing engineer, as you may guess from the name on my post. I had no role in the design of the 737 MAX. I did participate in the design of the structure of previous version of the 737.
This article is by far the most informative I have read on the subject of the 737 MAX crashes. Although it concentrates on the actions of the pilots and their training (unsurprising since the author is a pilot) it also lays out the errors in the design of MCAS.
I have read a good many of the comments on the article and there are some recurring inaccuracies that may have sprung from earlier, less informed articles.
One misunderstanding is that the 737 MAX is inherently unstable and that MCAS was needed to compensate for that instability. On the contrary, it was intended to give the same control column "feel" as the previous 737s during a stall. It was to be inactive otherwise. The somewhat larger, somewhat more powerful engines of the MAX did not destroy the fundamental stability of the airplane, The change from turbojet engines (under the wing) to turbofan engines (ahead of the wing) with the introduction of the 737-300 in 1984 was a much more significant change in propulsion geometry than we see with the MAX, and it was accomplished with no harm to stability or safety.
Boeing is working to correct the design errors in MCAS. I hope the airlines with below-average safety records attack their deficiencies with equal vigor and oversight.
16
the MAX is MUCH more prone to stall. why did Boeing added the quick and overly aggressive system, if not to compensate for it? saying it was done for the stick "feel" is like designing a car with 3 wheels, and adding massive power steering to help the driver keep same "feel" (and not telling them they deal with 3 wheeled car).
8
@Aero Engineer
Yeah, that's what this article said - they made it have the same "feel" by diving more to have a bigger g-force change - solely in order to have the same characteristics as the 737. That's a bad decision, where the engineering is being forced (presumably by company management) to put in a feature that reduces the safety of the vehicle in order to save on costs and time. And it might also be an issue with the regulatory agencies, that there was such a disparity, such a requirement to have the precise same behavior, even when the new behavior was technically safer.
1
I'm not an aviation expert. However this was not a case of pilot error but a design issue where the airframe /engine combination meant the plane had inherently poor handling characteristics that were "overcome" by a badly designed and inherently unsafe control system. The solution needs to be an aerodynamic one and not a more reliable automated system. The root causes lie deeper in the organisations that allowed the design and it's approval to go ahead.
7
Great article, but Boeing already knew there was a pilot training problem when they sold the planes to Lion. I would think just as part of risk management Boeing would have gone the extra mile to ensure the specifics of the maneuver were clear in any training program or manual provided for the 737 Max.
7
The author points to a number of factors contributing to these accidents. Taken in their entirety, the one thing that could have resolved a lot of these issues are endemic to much of the transportation industry.
When automation was seen by Boeing as a way to correct a basic issue with the way the airplane handled, part of the problem was created. When pilots (and other operators) are not trained in ways that have them get a feel for what it is they're doing and when automation performs most of what they do, when emergencies strike, they don't respond appropriately because they don't have the necessary skills for the situation. I saw the same thing years ago in reading about the flight that went down over the Atlantic from Rio.
Another problem is when the people designing things don't have a lot of experience operating them. This is compounded when there isn't a real feedback loop to correct deficiencies because the operators don't see them as design problems and the designers don't see their connection to the accidents cause. Or can't correct it. Add to that the regulatory environment where people who should be enforcing regulations are leaving it to the companies to take care of or are being bought off.
If all the pilots actually knew how to fly under adverse conditions, had a lot more practice in doing this, and had a real understanding of the way all these systems interacted (airmanship, I believe he called it), a lot of these accidents could have been prevented.
6
I keep thinking about it and I realized that the real contradiction that isn't brought up here is that if Boeing is about pilot control, then the deployed version of MCAS is the opposite of that mission. You can't be for pilot control and deploy and defend this, it's one or the other.
14
@Jerko M. Astute comment: a hidden system to fake control feel is precisely what an ‘airman’ would not like. None of the pilots knew that their control feel was artificially bent, none of them knew it rebooted itself if turned off (on the yoke), or that each reboot would increase the fatal pitch. None of them could have called it the runaway trim, because it simply didn’t operate like that. The bottom line is that a pilot would not only have to be trained well and alert, but somehow clairvoyant, and all within a few seconds before a totally unrecoverable dive.
7
Thanks for this in-depth, knowledgeable report on the 737 MAX accidents. A key point emerges. Quoting the author:
"Boeing believed the system to be so innocuous, even if it malfunctioned, that the company did not inform pilots of its existence or include a description of it in the airplane’s flight manuals."
"Nonetheless, in Seattle, at the level where such small choices are made, corruption, like cynicism, is rare."
As the two accidents show, the MCAS software was anything but innocuous. Further, the introduction of MCAS was certainly not a "small choice", but rather a key performance feature that should have been integrated into the overall system design of the airplane (and subsequently into safety / reliability reviews and training regimens).
The distinction between Boeing (manual flight expertise) and Airbus (robotic control) was also interesting. Given the trends of modern education, which one is the safer bet?
6
All crashes are the result of many failures. Boeing's mistakes are critical:
The flawed design of the MCAS system.
Failing to document it properly.
Poor reaction to the 1st crash.
It seems negligent maintenance practices and communications as well as insufficient training (partially caused by Boeing's lack of documentation) and poor airmanship were also factors. However the fact that there were multiple accidents in such a short involving airplanes with just one minor failure is a huge red flag about the aircraft itself.
Unfortunately it seems that both "sides" of this argument are correct. The 737 Max is an unsafe airplane with MCAS as it was and there is a problem with piloting that contributed to these disasters.
Hopefully lessons are learned and the future is safer. Boeing's behavior following these events hasn't inspired much confidence in that though.
4
This is a very interesting and well thought-out article. It describes in good detail some of the complexities which include the planes' dynamics, the sensors, the controllers, the pilot interfaces, and the pilots. Complex, but as control systems engineers, we need to see through the complexity. My question is: given that any modern control system will have at its heart a state estimate of the plane (e.g. velocity, heading, pitch, roll, altitude) and a reasonable estimate of the terrain around the plane (i.e. that the ground doesn't have a big hole in it that the plane can fly into), why would the engineers allow, under any circumstances, the control system to fly the plane straight into the ground?
18
@Eric Jackson It would have been dead simple to compare the AOA sensors and disable MCAS and notify the crew if there is disagreement between them. The requirement to hide the system from pilots and not train them precluded that option though. A dedicated MCAS disable switch would have been a good addition as well.
10
@Eric. The simple answer is that the MCAS was a patch; not at all integrated with the rest of the system. It was autonomous, designed to bypass a FAA regulatory issue, mostly. There was absolutely nothing in the cockpit, or the manual, let pilots know that it was engaged, disagreed with other sensors, or to prevent it from engaging close to terrain. Plus, of course, the single sensor operation, which is forbidden. In this article’s way-out tribute to airmanship, and denigration of pilots worldwide, the simple fact was that the MCAS wasn’t creeping automation; it was just an invisible, fatal trip wire that neither the plane’s computer, or any pilot, could possibly know about.
4
As a lifelong pilot and student of the industry, I had been reading between the lines and concluding that Boeing was mostly to blame. Only because my familiarity with this writer and his work, I have to agree with his assessment. Well written and researched piece William L.
8
Oh those Indians and Indonesians!
Pilots without the “right stuff” to figure out, on the fly, aspects “unique” to the plane model they’re flying! That no pilot with no other plane ever has had to confront or think about. Why indeed should Boeing bother to even inform these losers about facets that no other airliner in the history of the planet has ever been vulnerable to? Cry babies!
That pilots of major American Airlines, in simulated similar situations (luxuriating in the absence of real life die or fly consequence), cannot deal with them rapidly enough to avoid a disastrous crash, is of no matter. Our pilots, even when drunk, are the “real thing.” Got that Indian and Indonesian pretenders?
What’s next?
The author of this tripe banging on Boeing’s door and demanding a high paying no consequence job.
Welcome to Trump world.
18
Ethiopia’s Aircraft Accident Investigation Bureau has released its preliminary report. www.ecaa.gov.et. I imagine that is where this author finds some of his data, yet he fails to cite the report and the initial findings: “The crew performed runaway stabilizer checklist and put the stab trim cutout switch to cutout position and confirmed that the manual trim operation was not working.” Had he cited this report or the authority who issued it, he probably would have attempted to discredit them in support of the poorly constructed conspiracy theory he is attempting to weave. Another fact left out: Boeing altered key switches in 737 MAX cockpit, limiting ability to shut off MCAS. www.seattletimes.com
The author is attempt to shift the narrative that Boeing is at fault or an inferior product, for NOT disclosing a system to pilots, for creating a system that takes input from one sensor and processes that data on one processor and forgoes redundancy. No, Boeing is guilty of selling planes to incompetent airlines, a difficult position for Boeing. This argument is bolstered mostly by shots at Lion Air and its’ pilots, not so skillfully leaving Ethiopian Airlines to less numerous digs but still lumping them in with what he characterizes as inexperienced and untrained foreign pilots who were “shepherding hapless souls through the sky.”
He refers to the AOA disagree light that will now be standard on the MAX as an "idiot light" and cites without source that the MCAS is fixed.
16
@T Condon, you misread the Seattle Times article. The “alteration” of the cockpit switches did not in any way “limit the ability [for pilots] to shut off MCAS. The procedure to disable MCAS (an automated trim system) is the same as the procedure for disabling a runaway trim as it has been on every model of 737 since the model was introduced: flip those two switches to cutoff, maintain airspeed within limits, and manually trim the airplane with the very large trim wheels located on both sides of the center pedestal (right next to each pilot’s inboard knee). The pilots in both the LionAir and Ethiopian crashes failed to do so.
8
@Airman. The pilots followed Boeing's procedure, and were unable to use manual trim.
The actual title of the article is "Boeing altered key switches in 737 MAX cockpit, limiting ability to shut off MCAS" https://www.seattletimes.com/business/boeing-aerospace/boeing-altered-key-switches-in-737-max-cockpit-limiting-ability-to-shut-off-mcas/
3
@Airman. One reason the crew could not use the manual trim is that the MCAS setting was deliberately large enough to put too much force on the stabilizer, something confirmed in later tests. This prompted them to desperately try to restart the electrics, not knowing (as apparently nobody did) that doing so rebooted the MCAS and added another big angle. A couple of these, and those trim wheels won’t do it, at least with human strength. Without any cockpit indicators it wouldn’t have looked like runaway trim since the wheels moved then stopped. Too bad Boeing removed mention from the manual.
3
Arrogant, colonialist attitude by writer! Why do Americans always think others (Asians, Africans and to lesser extent Europeans) are incompetent or not as well trained? In the last 50years what’s been the proportion of American pilots & American airliners that have failed? The Max is aerodynamically flawed! You don’t take bigger engines & stick it on the same airframe & then put an idiot computer program to compensate for the resulting stressed & flawed aerodynamics- any grade 12 Physics student could understand that!
18
Bring back Virgin Air!!! ...please?...
Ps. Don’t shame the pilots, if that were the case the 737’s would be up by now, stop your rubbish. That said, rote pilots are scary and my parachute will be my carry-on. Now to test exiting at 600mph in a 45 degree pitch. Wish me luck.
4
Just 2 more third world pilot suicides by passenger aircraft. No wonder they won't release the flight cockpit recordings to the investigators. Boeing is the real victim here.
3
I’m thinking this author has a soft spot in his heart for Boeing and hence this apologist piece for their lethal product.
12
One of the best articles I have read in ages. Informative, persuasive, well written. Looking forward to more from this author!
10
Flying commercial is for the birds. I fly private and my pilots go through a stringent vetting process. Most of these guys (and gals) I hire need off on Sundays to sing in their church choirs and they lead boring lives, unlike those yahoos flying commercial that are coming off of a bender.
1
Recovery was made impossible by the fact that neither crew reduced thrust from full power. It would be like trying to control a car with bad steering while keeping the accelerator mashed to the floor the whole time, continuously accelerating. This is not planned for in any recovery procedures no matter how experienced the crew. You have to stay within the aircrafts envelope.
12
Boeing's behavior seems to be similar to that described by the article of all the relevant entities in Indonesia and Ethiopia. Unless Boeing adopts a policy of total transparency regarding its in-house behavior, its relationship with the FAA, with corrupt governments and fly by night airlines it deserves to be severely punished.
6
A safe voyage is depedent on a safe system devoid of technical malfunction.The hypothesis and allusion that a pilot’s experience is indepedent of safety standards is prevaricate, subjective and dead on arrival.
5
From time to time, the NYT translates articles of importance to non-English speakers into the local languages. To have any chance of fighting the local corruption, this article needs to be translated into Bahasa Indonesia and Amharic.
7
It's clear from the comments that many readers don't want to hear the truth about the repercussions of capitalist practices in the airline industry around the world, centering on chasing profit and what that means for employee training, but would rather find a single scapegoat in Boeing.
6
From the timeline established in this piece the Lion Air pilots who perished walked into an ambush. Specific pieces of info they needed to know about the plane were unknown to them. The previous pilots and mechanics left them in the dark, and the airline sounds like a shoddy operation. None of that is relevant if we're talking culpability.
Boeing may make a certain kind of plane, airmanship may be relevant, but the bottom line is that Pilot error is not the root cause.
Rather, Boeing introduced a new plane designed to avoid recertification. Pilot errors contributed, but greed and competition were the drivers of this plane wreck.
7
Amidst all the hysteria and anti Boeing rhetoric, it's important to examine some relevant figures - in the USA over the past decade there were approximately 350,000 fatalities in automobile accidents and exactly ZERO fatalities in Boeing passenger jet crashes.
4
This is why I subscribe to the NYT. Well written and engaging. To me, pilots are responsible for flying the plane, and when called upon must do their job!
5
I'm a pilot. 50 years since I soloed. I fly jets. To 50+ countries as captain so far.
The author is obviously experienced in the cockpit. He describes the cockpit thought process, or lack of, perfectly. As an industry insider, never have I read anything so well researched and as close to 100% accurate as possible. Many thanks to the author.
As he states, this was not by any means an overwhelming problem for competent pilots. It was not just pilot error. It was absolute total pilot incompetence.
Public beware; we have a generation of pilots who's experience solving problems is very weak, thanks to automation, manufacturers who will sell anything to anybody, and a public who has let their guard down, thinking that the FAA is worldwide.
26
Pilot error and country of origin negligence.
There hasn't been a fatal commerical airline accident in the United States in over 10 years. And even before that, they were extremely rare.
I'd not hesitate to get on a 737-MAX if it was a US carrier and flown by one of our experienced (and superior) pilots.
5
Sad as this is, it looks more reassuring than what the original story seemed to be, runaway control system is prone to trigger and be unrecoverable for reasonably competent crew. This is more of the classic multifactorial crash analysis, Boeing designed it the way they did for the cited reasons, with a major failure allowing it to trigger on one sensor failure. Another major failure- they didn't seem to understand the impact of figuratively and literally shaking up a mediocre crew with a cascade of surprises while low, slow and at full power. Boeing didn't imagine a crew that couldn't figure out in time they needed to shut off the power trim, leave it off, and slow down, not speed up as the false stall warnings goaded them to do.
7
As most pilots likely know, this article's author's father wrote the marvelous beginning flight manual and airmanship textbook, "Stick And Rudder". It was my bible while learning to fly 45 years ago. The author's point that, while Boeing made some inexplicable decisions regarding the flight control system, that there is a huge problem with pilots lacking basic airmanship skills is very well taken (see his analysis in the Sept, 2014 ed of Vanity Fair of Air France flght 447). Many current airline pilots come to the cockpit with very little time in airplanes that teach the pilot the skills and problem solving techniques that allow them to "strap the plane on" rather than merely sit in the cockpit. These skills take hundreds of hours solving issues (with or without checklists) at speeds and in equipment that allow the pilot to solve the problem using his/her own wits. My daughter is a captain for an airline and she describes the almost total disassociation from the plane and flying that modern automation effects on nearly all routine flights. The pilots are used mostly as system managers. Fortunately for her passengers she grew up in the family plane and spent her early years in the profession doing stick and rudder flying in the San Juan Islands. Boeing made mistakes, but there is, as Langewiesche so clearly illustrates, a growing problem with a lack of fundamental airmanship.
24
@Todd
"My daughter is a captain ...."
That phrase makes me happy!!!
1
Boeing, with its corrupting tentacles resisting oversight, regulation and accountability, is a rogue company who ought to be broken up. Fat chance of this with this rotten government. So tragic for the families.
This is magnificent journalism, bravo NYT. Mr. Langewiesche, your writing on aviation matters is at the pinnacle of the profession. I love your work...thank you.
4
I've enjoyed this authors writing over the years and this was another well written piece but as far as the substance (poor pilot training being the real cause of the crash) I found it magnificently unpersuasive. Boeing better have a better tale for its lawyers to present.
For a much more compelling story I would suggest this:
https://newrepublic.com/article/154944/boeing-737-max-investigation-indonesia-lion-air-ethiopian-airlines-managerial-revolution
6
One would have thought that the article would also tackle the Ethiopian Airlines crash. But this is really left out of the picture.
1
It's hard to believe that the NYT would go so far to misrepresent the twin tragedies that cost so many people their lives.
The Ethiopian pilot even knew about the earlier incident but he was deceived by Boeing's false representation of or lack of understanding for what had gone wrong in Indonesia.
Few pilots would have had the physical strength to resist the MCAS induced downward trim forces being applied by the plane for long enough to gain an understanding of what was happening. Gaining an understanding of what was happenning was clearly not obvious or intuitive, it took Boeing months and two crashes before they figured it out.
8
Did Boeing ghost-write this article for you? It should be under the header of "ADVERTISER-SUPPORTED CONTENT." The indictment of the MCAS system is based on the reading of the black boxes and the failure of FAA to properly regulate Boeing is based on facts and figures. Blaming these crashes on the pilots "who only go by single names" is pathetic. A modern jetliner should avoid crashing itself into the ground on a sunny day because of a solitary defective component.
14
Correction: the Rio to Paris accident happened around June 2009. Not 2015 as stated here. 2015 might have been the release of the results of the crash investigation after the necessary boxes had been recovered. As I recall it took a good couple years to find the boxes.
4
Boeing is corrupt and greedy and operating in a country where the government is owned by corporations. Lion Air is corrupt and greedy and operating in a Third World country. Nothing less than a perfect storm.
4
I agree with other commenters who think that this article must have been funded by Boeing. It is not up to your customer to make up for your product's shortcomings. I do not fly on Boeing airplanes any more.
11
It is, at its core, an extension of the war on facts perpetrated and embraced by what used to be a “Party” and what never was a “president” - Donald Trump, pseudo republican.
2
William Langewiesche, you have a real talent here. There are so many complexities associate with this event and you were able to lay them out in clearly readable fashion. Sure wish I had your writing talent.
Now, on viewing so many of the comments here, I can see how frustrating it must be for you read these and find yourself wishing they had read the full article rather than simply skimming, before commenting.
8
I can answer the title question! The author's incredible self-regard crashed the plane.
Seriously, is the piece enriched by the repeated tales of his personal bravery, amazing skills, and derring do? Or do they just put his disdain for the pilots of these flights in even less flattering lights?
7
The Max’s design is inherently unstable given Boeing’s decision to use new large engines on an old plane
The Times has written numerous articles about this
The software was designed to “balance” the plane
This article is disingenuous at best; blaming pilots for failing to control an unstable plane
The blame lies squarely with Boeing and the FAA
5
@Paul Incorrect. The aircraft is aerodynamically stable. The problem addressed by the software is not instability, but an unexpected relationship between control force and result.
An analogy: in most cars, when turning your steering wheel to the ends of of its travel, it gets harder to turn. This is so you don't unexpectedly run into the end of the steering travel. The MAX doesn't do this as much as other cars, so they designed some software to make it pretend to be harder to turn near those travel limits.
Now, that software was really, really, really stupidly designed and played a bigger role in these crashes that this article seems to suggest.
But the airplane itself is perfectly stable, just like a car that doesn't steer harder near the ends of travel won't suddenly veer off the side of the road.
1
The author points to a well-known deficiency in pilot training. As a former simulator instructor, I have seen this to a more limited degree with North American pilots lacking military or comparable experience in aircraft handling. But here we have the additional complication of a really stupid control system modification. You could not ask for a more lethal combination than an incompetent crew faced with the action of a really stupid, undocumented control system.
This is not the first time Boeing has employed an undocumented trim system. Just ask 767 pilots if their airplane has a mach trim system. They will search their aircraft operating manuals in vain.
Billy T
7
Chasseur Americain Apparently translates from french as 'American hunter' --no matter--it's still a fake name , and for all we know he might be one of the lawyers trying to break open the treasure chest of a multi billion dollar american corporation. (instead of chasing a jerk-water airline without any money) .
The two pilots who I talked with, fly this plane every week. Both said from the start , evidently the crew did not know how to manually trim their aircraft- try and find a crew-member of any major American airline that does not know that---Good luck.
2
This is a good story, though it lets Boeing off the hook a little. The author dances around the fact that something deep in the bowels of Boeing led to the decision to eliminate redundancy for a critical sensor. Just because Boeing has a history of excellence doesn't mean the current management carries the same torch.
In computer speak MCAS is a kludge, a workaround for a problem the doesn't exist with a clean sheet design. If MCAS was deployed specifically to "normalize" 737 characteristics in order to skirt regulations and to compensate for some errors made by under-trained pilots, then I would say this is a failed implementation.
In addition to the worst possible publicity of Boeing denying and obscuring, now every bump on a Max flight going over the Rockies is understandably gonna give passengers the jitters.
There was a lack of due care and due diligence, and for this you can only point to Boeing management.
8
95% of those students who show up with a high school diploma (hopefully) and $60,000 pass pilot training??!??! These pilots had no idea they couldn't fly, until lack of experience and muscle memory proved they couldn't. Corporate greed on all sides. Poor regulatory oversight. Inept air traffic control. They are the victims, not the fault.
3
The author acknowledges Boeing’s failures, without which these two crashes are avoided. Yet inadequate pilot training is an issue with all aircraft designs. The A330 Airbus that stalled all the way from cruising altitude into the Atlantic was mentioned. In that tragedy the stall warning blared while one pilot continued to pull up until it was too late. It gave me chills reading that account due to the basic lack of knowledge. I had the same feeling reading about the rote training today. Were these pilots taught to understand that exceeding design speed would not allow pitch control? How about requiring training as part of the aircrafts sale? It should include teaching fundamentals of aircraft stability and control.
5
A question for all the experts out there. Could additional training for pilots be developed that would minimize the chances for problems such as this one from occurring again? If so, how much additional training might be needed and how much would the associated costs add to the price of an airline ticket? If it didn't pose any threat to people on the ground, two classes of tickets should be sold. The lower priced one using pilots who have gone through the quick and cheaper training for folks who just have to fly but want to save some money, no matter what the risks involved. The more expensive tickets for those interested in walking away from the inevitable landing. You pays your money and take your chances.
2
Wow. I'm impressed by the thoroughness of the author. He made it very clear that knowing how to fly a plane and KNOWING how to fly a plane are two totally different things. This article has made me think twice about taking a low cost carrier in another country. It's scary to think that the lack of training and simple, rote memorization is all that is needed to control the lives of hundreds of innocent passengers. The article made me remember the time an Asiana (not a low cost carrier) crashed at SFO. IIRC, the pilot didn't know how to compensate for a variable and clipped the tail on landing.
6
In aviation as in surgery, we are told these days it is all science (and hence rote and/or suitable for automation). But in both, when the chips are down, success is pure art. And then, only a true artist will do. I am from an earlier generation when the artistry inherent in excelling at these professions was highly esteemed, rather than disavowed.
We are now in thrall to technology, and have pushed artistry aside. It is a great loss to our civilization.
8
I have been working as a Captain for national carriers in SE Asia for 5 years and can tell from experience that the article is spot on.
Corruption, lawlessness, bureaucracy, lack of oversight, lack of proper training, unmotivated maintenance crews, lack of spare parts, pressure from the Airlines on Instructors and Examiners to deliver pilots, and seriously unmotivated and inexperienced pilots are all jeopardizing flight safety in this region every day. Many incidents are not reported and when they are, the reports never reach the public.
I believe an important part of the problem is that this region never had the long Western history of accidents and incidents to learn from. And the lessons available from the West were mostly inaccessible due to the language barrier. So in the short history of Asian-Pacific aviation, using modern aircraft, there was never a sense of urgency to instill a safety culture.
The forces that suppress the accident rate are technology, the generally aviation-friendly climate, the hiring of experienced Western educated Captains and perhaps a bit of luck. That said, I must also say that I have seen improvements over the past 5 years and have worked with some great and motivated crews. It’s just a slow process.
23
The way I read this is that some fairly simple steps by calm, experienced pilots could have overcome the apparent failures (weaknesses) the the 737 MAX and MCAS systems:
1. Higher altitude would have allowed for more time to figure out the problem and recover.
2. The indication of excessive speed could and should have been responded to immediately.
3. The author suggests that the pilots found themselves in a whirlwind of confusion and took confused reactions which made the situation far worse. Good pilots do not let routine problems cause a nose dive in their mental states.
4. Still, we are left to wonder if Boeing had insisted that pilots be fully briefed and trained on MCAS whether these two tragedies would have occurred.
5. The author alludes to the fact that automated systems reduce airmanship but also indicates that more automation is not only coming but necessary. If the central issue was pilot training and experience, this seems contradictory because the more something is automated, the harder it becomes to understand and counteract and the more those who are supposed to be in control become accustomed to letting the computers do it.
6. The amount of training and flight experience received by Lion Air beginning pilots, if it is as described, seems horribly inadequate to be handling such a complex system as in any commercial airliner. This, to me, is the crux of the problem regardless of the systems used.
7. MCAS, once activated, attacks repeatedly, every 5 sec.
15
Are you spokesperson for Boeing? The plane was rushed into productoin with flawed design. Please dont blame the valiant pilots for this tragic loss of life. Corporate greed and arrogance killed those people.
2
Also, standing in the background during simulator training is not and should never be considered a substitute for actually sitting at the controls and resolving issues. This is a joke, but a sad, sick joke because of the human life involved.
5
I'm reminded of the wonderful book "Fate is the Hunter" by Ernest Gann. It tells the story of his life as an airline pilot in the late '30s and in transports in WWII as well. In one story he tells, he was a young pilot flying and learning with a grizzled veteran who didn't much value gentle mercy. One dark night, the old man started lighting matches right in Gann's face, coldly and repeatedly startling and blinding the young Gann as he strove to maintain control and composure. The older pilot never explained himself, and Gann wrote it off as innate cruelty.
Some long time later, Gann found himself flying through a hellish thunderstorm. The lightning was frequent, close, and blinding. Gann was suddenly reminded of the match-lighting ordeal, understood what that had been about, and calmed down, getting the plane through the storm.
That's the kind of training that can't be gotten through classrooms, books, or simulators.
17
I’m an English professor and not an engineer. What a fine piece of writing, with sentences with wit and panache! And I learned a lot about the 737Max situation that I did not know before.
38
While the article articulates faults from Boeing it ultimately concludes the critical problem lies with poor pilot training and experience, such that any good pilot would understand and correct runaway trim (even as MACS, unknown and not trained for, would under some circumstances repeatedly turn on to re-initiate the problem).
Am I the only one here wondering whether the impetus for this article, and any funding, came directly or indirectly from Boeing?
29
@FilligreeM Absolutely agree.
3
Terrific reporting, as much about the lack of training and thus lack of skill of airline pilots, as about the Max. The root cause of all of this: pressure to make money. The airlines to minimize cost and Boeing to compete with Airbus. Since childhood I have been a Boeing fan. I grew up with stories of the B17 in WW2 and the modern jet age of the 707 and the tri-jet 727 (which also had accidents early in its career because pilots were unfamiliar with the flight characteristics of its T tail.) As noted in the article Boeing made mistakes and these occurred because it was caught flat-footed by the Airbus Neo and had to play catch up. The MCAS was a shortcut. Redesign would have been the right call, as some in Boeing argued. Boeing compromised safety knowing full well the substandard pilot training around the world. I hope that the 737 Max eventually becomes a workhorse like the 727, but I think the more likely outcome is the Max becoming the 21st century version of the Comet and Lockheed Electra.
12
@Joe Smith
Agreed but there's a significant difference here; In the case of the 737 Max the probability of total loss of the aircraft and all aboard was not at all guaranteed and in the case of the Comet (mid-air breakups) it was absolutely guaranteed. Boeing's case is, to varying degrees, defensible whereas in de Havilland's case there is no defense at all.
1
re: "William Langewiesche is a newly named writer at large for the magazine. He is a former national correspondent for The Atlantic and international correspondent for Vanity Fair, where he covered a wide variety of subjects throughout the world. He grew up in aviation and got his start as a pilot before turning to journalism. This is his first article for the magazine."
I'm going to take a SWAG that William is the grandson--or great grandson--of the great Wolfgang Langewiesche, author of the pilot's bible 'Stick and Rudder: An Explanation of the Art of Flying.' Required reading for every pilot wannabe.
14
Amazing, and, that one of the first words he uses is AIRMANSHIP - the beginning, and in this case, the end of the pilots career.
2
I've unfortunately been in a few situations where I was so flooded with panic-terror that I probably couldn't have said what my name is. I gather that level of emotion played a role in the pilot's failure to flip that switch to turn off the electrics and thus disable the MCAS. Mr. Langewiesche says that in his own experiences with runaway trim he had 8 seconds of surprise and 2 seconds of flipping the switch. So I'm guessing the accident pilot went over the edge somewhere in that first eight seconds. I can picture him trembling as his finger slides down the pages of checklists, barely able even to read what he is seeing. Obviously it's easier for some people than for others to stay cool even in that kind of situation. How do you train the latter group to do it?
6
I'm an aerospace engineer and have worked in the industry for over 30 years. Yes, many pilots don't have enough training. That said when Boeing installs a software control system and doesn't tell anyone because it's "innocuous", that is a huge mistake and let's be clear it was done to save money. Save money on requiring pilots to receive additional training, save money on all the updates to documentation, save money by installing software instead of fixing a mechanical issue. Pilots, regardless of their training, cannot know how to react in a situation where they don't have the knowledge of what the plane is doing or supposed to do. If a pilot doesn't know about the MCAS, "Airmanship" doesn't help because the plane is not doing what the pilot is asking it to do
48
@debbie doyle
I was going to post something similar, but you stated the issue succinctly and clearly. Excellent post.
2
@glennmr Thanks
From what I've read in this article and the comments, it was the bizarre, unceasing exactness of the repeating 10-second pitch-down events followed by 5-second reprieves that put these situations out of the realm of what one could reasonably expect airmanship to handle. Nature doesn't act that way.
22
Very informative and very well written. Also misleading. Sure, pilots are not what they used to be, Air France 447, Colgan Air etc all proved that beyond any doubt, no new news there. Sullys are getting scarcer, he would be the first person to tell you that. All the more reason not to try to band-aid fix a cheap derivative airplane with a poorly designed and spectacularly poorly implemented automated system like the MCAS. MCAS was worse than I had thought based on this article; combined with the interacting limitations of the airplane described, it is terrifying. Remember, this follows on the heels of Boeing not enclosing the huge lithium batteries in the 787 in a fireproof box and the FAA allowing that to pass. In no time, they caught fire and threatened the planes. Yet now I can't take my Mac laptop onto an airplane due to the relatively tiny lithium battery.
14
The notion of "airmanship" is all well and good.
But there is enough blame here to go around.
Boeing, FAA, airlines, pilots, fly-by-night parts suppliers, air traffic control.
But how are pilots supposed to display "airmanship" when there are hidden systems embedded in their aircraft?
We all know that Boeing iterative design changes were intentional - to allow an ancient airworthiness certificate to stand.
We also know that they intentionally hid MCAS to allow their sales force to sell airlines on no needed added training.
Virtually all the players in this tragedy put profit / money savings before safety.
The chickens just come home to roost.
Unfortunately innocent passengers paid with their lives.
14
I'm astonished at the absence of outrage directed at Ethiopian Airline for putting an individual with 361 total hours of flight time in the cockpit of Flight 302. (Following the crash, Ethiopian Airlines stated on their website that First Officer Nur had a total of 200 hour of flight time. Apparently he was piloting Boeing 737s when he had 'merely 154 hours' of flight time.)
In an emergency, one pilot flies the plane while the other attempts to diagnose and manage the situation. Should we expect someone with as little experience as First Office Nur to successfully do either?
I'm fairly certain that middle-class U.S. parents would be outraged if they learned they were putting their child on a school bus driven by someone with just 200 hours of driving experience.
11
A fascinating study by a guy who knows how to fly. But he begins and ends the article by blaming pilots and presents plenty of evidence that lead me to the opposite direction.
Who hired the pilots and kept them in less than optimal training conditions? Who did not trust the pilots enough to inform them of the workings of the MCAS?
The author knows very well that in emergency conditions, some pilots will make correct decisions and that others will not.
But companies such as Boeing, tis suppliers, and the owners of Lion Air have years to make their design, engineering, and sales decisions.
It was obvious to many that the 737 Max should have been immediately grounded after the Lion Air incident. Because of LionAir's maintenance mistakes, immediately apparent after the crash, I advised the company I work for to stop flying on LionAir.
With the Air Ethiopia crash, it took the rest of the world t o force Boeing and the US Transportation Agency to ground the 737. Stop blaming the pilots, they are the last in a chain already full of weaker links.
13
I’m, in the Max you have a plane that Boeing is trying to keep tied to a 50 year-old airworthiness certificate, yet compared to the original, it has different wings, engines, cockpit, size, tail etc. even the bathrooms are different (much smaller). The Max might as well have the airworthiness certificate I gave my paper airplane this morning. Despite the author’s leather-jacket pilot bravado, Boeing and its complicit regulators sired this fiasco. It just took greedy airline execs to raise it.
14
This is one of the best articles written on the subject. I have not flown the Max, but I have several thousand hours in the 737-200, 800, and 900.
I am not a big 737 fan in that I think that it is about time for Boeing to design a new airplane and stop tweaking the 737. However, I would not hesitate to fly on a 737 Max even if no fix was implemented if it was flown by one of the US Carriers as well as several foreign carriers. I would hesitate to fly on any airplane from some other carriers, even if it was a completely redesigned 737 Max or even another airplane.
10
SUPERB, although deeply troubling, article that highlights serious issues with pilot training that have almost been forgotten in these tragedies. It must be remembered that the action to rectify a Runaway Stabilizer Trim is a MEMORY ITEM. Turn the system off. It is just that simple. And it is not as if the system is hidden. The two Stab Trim wheels are right beside the pilot's knees and when they move they are noisy. You simply can't miss it.
Geoffrey Thomas
Editor-in-Chief
AirlineRatings.com
3
Do ambulance chasers exist only in the US?
Millions are on the table here, where are the takers?
4
I dislike the level of blame this article places solely on the pilots. This article reads like the pilots received training only on a pony and were as such ill prepared when left unsupervised on a regular stock horse. From everything I have read the issue is closer to that they were trained on a pony and put on what they were told was a gentle stock horse but was in fact a hardened bucking bronco.
Also about 2/3rds the way through the article there is mention of a warning light "indicating disagreement between the two angle-of-attack sensors" that I take issue with. My understanding is that that light is one part of TWO safety packages Boeing made optional concerning MCAS but the light is non-functional without the second package added as well. I point this out because Boeing apparently did not mention this to any airline, Southwest reportedly bought the light package for all of their MAXs without opting for the second so the light doesn't activate to indicate when there is a problem. Even a pilot with airmanship could overlook a problem with MCAS if the system designed to indicate a discrepancy says there is none.
12
I didn’t read the article other than the headline, enough to make me throw in my opinion.
And here is where real justice is warped. In most countries senior executivesmaking decisions that lead to deaths like this would be held personally and professionally responsible. But not here in the USA...
Why are Boeing execs getting a free pass even with all of the evidence pointing to intentional effortsweru to mask the problems with their hot jet, intentionally failing to enforce pilot training and in the end chalking it up to systemic breakdowns.
These execs should be in jail for intentional homicide, Boeing should be penalized and suspended from building aircrafts for at least 5 years.
But since the rank and file were talking orders, their pay and benefits should be continued and guaranteed. The execs should be personally responsible for the costs involved aside from jail time.
Making decisions that save a few dollars but threaten innocent lives shouldn't be written off by corporate Mia culpas and granted free passes.
In China these execs either jump off tall buildings or disappear into labor camps. Hmmm, maybe there's truer justice to be had outside the USA.
I'm not an attorney but if there was a foreign citizen that went down in one of these planes then a foreign criminal case ought to be made against these Boeing fat cats..
8
What a grotesque exercise in blaming the victim. As a counterpoint, I recommend reading this article in EE times that reports the conclusions of miracle-on-the Hudson pilot Chesley Sullenberger:
https://www.eetimes.com/author.asp?section_id=36&doc_id=1334869
Sullenberger said, “Boeing designers also gave MCAS too much authority, meaning that they allowed it to autonomously move the horizontal stabilizer to the full nose-down limit.”
Sullenberger, a former USAF fighter pilot with more than 20,000 hours of experience was able to fly a Boeing 737 Max simulator that had been programmed with both the fatal flight profiles of the October 2018 Lion Air and March 2019 Ethiopia Airlines crashes. He said, “Even knowing what was going to happen, I could see how crews could have run out of time and altitude before they could have solved the problems.”
14
For a first article in NYT, not bad at all I would say!
Thank you for all the details and especially the differences between both crashes.
How did you get such detailed info about what happened in the cockpit if all the info has not been released...?
Thanks again
The 737 MAX was a plane reliant on software that lacked the most basic of software architecture premises - when a failure occurs on one side, check the other side.
In both cases, angle of attack sensors failed on one side, and MCAS, rather than cross check the other AOA sensor, trusted the faulty sensor and sent the plane into an uncontrollable and unstoppable nosedive.
In this day and age, when autopilot can fly plane safely across the earth with amazing success, to blame the pilots for fault when in fact the software flying the plane was not only overridable but when pilots were told “this is just like every other 737”, to then blame the pilots for the crash when the cause was clearly poor design coupled with lack of training to rush a faulty product into production in the name of saving money for shareholders is nothing short of unconscionable.
13
Really excellent analysis.
2
Interesting that this pilot-writer wants to make a point that Boeing's foreign buyers can't match U.S. Navy-trained fighter pilots. But, beyond painting non-G7-country flight crews as an Uber start-up experiment, what is the pilot-writer's point?
Don't Boeing executives know the difference? Because worldwide passengers of the 737 Max --- get pilots with 737 Max training, not U.S. Navy-trained fighter pilots.
Frankly, his whole Top Gun exercise was to create a stereotype of THOSE PEOPLE who Boeing's public can't believe have that "airmanship".
Both air crews FOUND GUILTY of "textbook failure of airmanship". If you say so, Ice Man.
Moving on. I found this explanation to be a self-serving, sales job:
"Boeing believed the (Maneuvering Characteristics Augmentation) system to be so innocuous, even if it malfunctioned, that the company did not inform pilots of its existence or include a description of it in the airplane’s flight manuals."
One.You hang heavier engines on an existing airframe and change its flight parameters SO MUCH -- that you augment the MCAS to force down the nose automatically & without pilot knowledge.
Two. You don't require redundancy in the angle of attack sensor that, when it misreads, continues to force down the nose of the plane.
Three. You discover that this sensor has more failures per flight hour (due to bird strikes, etc) than predicted.
Four. Engineers design planes; but, a test pilot will explain "so innocuous, even if it malfunctioned".
11
This summer I had the privilege of spending about 15 minutes in a Boeing 737-300 simulator at WestJet’s beautiful corporate headquarters in Calgary. Every knob and switch is exactly like the real McCoy. My respect for pilots and aviation couldn’t be higher.
I would gladly fly with the author in a 737 Max right now if I could. His perspective and polished writing on these tragedies is deeply satisfying. Langewiesche has a gift for writing about a complex subject on a level that is digestible for a Hooters Air passenger.
2
@Hollis. Would you? Booing hid this defect not only from airlines and pilots, but the defective behavior was also completely absent in the simulators. You could have simulated for 3000 hours and still have gained no experience with this engineering atrocity.
Your confidence is sorely misplaced.
3
YIKES!!! Sure we can discuss airlines that cut corners and don’t train pilots well, but seriously, the deaths of hundreds of individuals falls on Boeing.
3
I notice in the article that when the airplane's manufacturer does something dumb, the tone is something like "I don't know who or why they did it, but they did."
However, when the pilots in the middle of an emergency do something dumb, the tone is rife with how stupid they were. Maybe so, but my sympathy lies with anyone trying to puzzle out a ridiculous situation at 350 knots.
The article will no doubt appeal to our rugged individual, seat of your pants, Spirit of St. Louis, Hans Solo sense of ourselves here in the US but I'm left with the sense that Airbus builds a better, safer plane.
The problem with the Max is that in a sense it pivots to the past and expects pilots to be better when the company clearly knew they're getting worse.
Boeing ought to have designed a completely new plane. Furthermore, I don't buy the concept that 2/3rds of the company is rather nasty and the folks in commercial aviation have managed to remain untouched.
So, in deference to those who have died and Boeing's part in it, I will not fly on this plane.
7
92 deaths per day are attributed to cars in the US. The equilvent of a Max jet crashing everyother day for an entire year. World wide its 1,240,000 per year, almost 3,400 per day, the equilvent of almost 19 max jets crashing everyday for an entire year.
2
Pilot training can't make up for a poorly designed aircraft. The 737 Max is a poorly designed aircraft.
6
MCAS activates....
AoA input signal does not change... disable MCAS!
1
Thanks for this explanation of the real world. Beautifully done.
2
I'm a commercial pilot, not an airline pilot, rated to fly on instruments with 2,000 hours flying smaller airplanes. In both of these airlines, I'd be hired and frankly overqualified. It's quite easy to understand the high level of danger for most of the flying public in certain sections of the world.
4
It seems to me that if these crashes were the result of pilot error, the 737s would be flying. On the other hand, I can see where shortcuts by the airlines could explain this situation. I don’t think his explanation should be dismissed just because it’s not politically correct. I can see where the success of safety in the industry could lead to complacency, with pilots that aren’t ready for anything out of the routine. The routine was broken by equipment malfunction though, maybe, ideally, all pilots would be able to calmly figure the problem out in a few minutes, but I wouldn’t want to bet my life on that.
2
Sully, has issued the call out of inexperience. He stated an element of the problem, but not solutions.
1
Seems there's plenty of blame to go around. I think though that fixing the problem of corruption isn't going to happen right away. And since 10,000 hours of sitting without incident in a modern, mostly automated airliners isn't likely to develop great seat-of-the-pants flyers, it's a safe bet that panicked reactions of the pilots to emergencies is going to get worse, not better, even with training in simulators. Boeing needs to fix it's planes so that this almost never happens. That's the only reasonable fix that can actually happen now.
7
My impression was not that the author is excusing Boeing, but broadening the discussion.
Edward Tenner’s book, The Efficiency Paradox, came to mind as I was reading, and the unintended consequences and challenges of advancing automation.
6
A very excellent article aggregating all the various parts leading to a well supported conclusion: Pilot Error. However, Boeing will forever be responsible for pushing sales over and above flight safety. Furthermore, how will Boeing and the FAA EVER convince the flying public the 737 MAX is safe to fly.
I think Boeing will have to change the name of this airframe and engine combination to mover forward.
8
I’m not a pilot, engineer, or even a good video gamer. But I was awestruck – up until the last 3 paragraphs – of the depth, detail, and broad context of Mr. Langewiesche’s article. It describes a complex, tangled web of factors leading to these disasters, which I suspect is more widespread (e.g., the Florida grey-market parts suppliers) than just the profit-motivated shortcomings of “third world” airlines on which it appropriately focuses. Certainly, pilot training everywhere should devote substantial time to dealing with anomalous situations, and good simulations could easily accomplish this (I’m reminded of SCRAM for the old 1981 Atari…). But as for Boeing, who would design a demonic system that relentlessly overrides the pilots’ inputs, and when a problem inevitably arises, depends on the pilots to disable it. But more fundamentally, in my mind, is why the over-modified trying-to-keep-up-with-Airbus 737 MAX required the MACS in the first place.
13
If for no other reason than the surname of the author is Langewiesche, this article deserves a fair hearing. Ad hominem attacks that he's a Boeing stooge do us all no good.
Did Boeing design a plane that was an accident waiting to happen? A jury will decide, but my read of the consensus in the pilot's community is they did. Boeing and the FAA must root cause this design failure and ensure it never happens again. I take at face value that this article isn't intended to provide Boeing an out for the responsibility.
Is pilot training deficient in many, especially developing, countries? I don't think any fair observer would disagree. This article merely details those failings. There are certainly airlines I will never fly on and ones I wouldn't take my family on. The difference is my perception of pilot / maintenance quality.
Would a better trained pilot have saved either of those 737's? Only God knows.
12
Let me summarize:
Many (most?) third-world countries skimp on pilot training, plane maintenance and regulatory oversight (possibly include the FAA in the last one). Their pilots don't get enough flight hours and/or dedicated simulator training compared to American pilots. Boeing introduced an unpredictable, poorly documented control override system that an experienced (read: American) pilot, with his superior "airmanship," should nevertheless be able to deal with.
Accepting this as true makes the 737 Max situation even worse. If you have marginal pilots trying to keep things in the air, it is unpardonable why Boeing would then insert such an unstable control system that was likely known about and discussed among American pilots with their proximity to the manufacturer. Mentioning simulator training here is rather moot, as Boeing has yet to release the simulator for this system demanded by the pilots union before recertification -- something that is (was) routinely done before releasing a new system ready for flight.
I'm not a pilot, but I do have engineering training in control systems and their stability. I always thought of Boeing as an engineering-first kind of company. I can't believe that an actual Boeing engineer designed or approved this system. Those who participated should find another more appropriate line of work, like writing another food-delivery app in Silicon Valley.
6
Actually, no one knows per se, what caused these two aviation accidents, because a formal forensic accident investigation is not yet complete, nor yet assessed by Western standards. Pilot error (or incompetence) is however significantly probable in these two events; at least contributory in a causal chain; for a number of factual reasons. Readers may otherwise appreciate my opinion on this matter, recently in the New York Times: https://www.nytimes.com/2019/08/07/opinion/letters/faa-boeing-crashes.html
I am one of those pilots the author adores... Navy trained (flew upside down/taught students to enter and recover from spins), 34 years at a major airline, almost 20 as Captain, flying Boeing jets exclusively.
The most dangerous pilot is not one with little experience or one taught by rote... it is the pilot who speaks as if “it can’t happen to me”.
The author, who in an earlier work criticized Captain Sullenberger for not making a perfect landing in the Hudson, is one of those pilots.
74
Thanks for this, 767ER. The very scariest comments I've seen and heard, from the very beginning of this mess, have been from aircrew who are smugly certain that they are Sky Gods who would have handled the MCAS interventions without problem and that the fault lies with those (foreign!) incompetents who don't know how to "just fly the airplane."
Those are the pilots I don't want to fly with.
10
@767ER
Post hoc analysis will always seem more clear as in this article. But it really never gets the whole story...
The fact that many pilots are being trained by rote method is very disappointing to hear. Without being able to analyze any problem with deep knowledge of flight characteristics, bad issues can mount quickly. (I have seen such in a different industry--with high levels of complexity.)
thanks for commenting.
3
Let the rehabilitation of Boeing begin. I'm sticking with the comments made by engineers immediately following the second event.
6
Such a long time ago, air travel was so special. People dressed up to fly and most of the pilots were intelligent, experienced and downright brilliant. The stewardess were customer serviced oriented and you felt safe that they cared about your small child who was traveling alone would be protected till they reached there destination.
That was long ago and now we have airplanes whose safety upkeep is done in foreign countries to save money, pilots who dont have enough flying time, stewardess who cant be bothered to look after people in wheelchairs or ensure that little kids are looked after. We have a complete breakdown in the airplane system so it is obvious that e would have complete kaos in the skies. Each party lying about all of the hard work they do to cut costs. Major corporations just like the cigarette companies know what should have been done and deliberately didnt do it.
It is apparent that there is no industry safe from the power of the almighty dollar. The lives of citizens will never be valued as much as the profits that shareholders will make off of the known sale of defective airplanes. Airlines love their insurance companies victims not so much.
4
@Tony
If airlines were willing to compensate pilots, mechanics, and flight attendants what their services are worth, perhaps those golden days would return.
As it is, your demands for exceptional service on exceptionally poor pay seem problematic.
3
Hey, if the pilots were white, American men who'd graduated in the bottom half of their class, would that story have been newsworthy? Regardless of the author's experience (which he touts endlessly, often in contrast to that of dead pilots unable to defend themselves), would he have called them and their actions "dumb" had they been American pilots?American
A story that downplays Boeing's decision to override regulators and ignore programming flaws in order to heap derision on dead pilots troubles me in general. But I feel that the author's experience as a pilot blinded him to the disturbing and offensive ways he speaks of the pilots who had the bad luck to be assigned 737Max flights.
13
I have always enjoyed and appreciated the long pieces done by William Langewiesche, but this piece by him shocks me. I fail to understand how he went so far off the rails. His article is so riddled with technical mistakes and contains so much slander that it might just as well have been written by Boeing's public relations department. Perhaps, in spirit, it was. If this piece were submitted as "expert testimony" in a court of law, opposing counsel would make mincemeat of him.
23
If there are factual inaccuracies please elaborate. Otherwise your comment is a fact free dismissal of what appears to be a thoughtful and thoroughly researched piece.
6
@MFA
Research my foot :)
@Kenneth E. MacWilliams Is he related to Wolfgang and perhaps trading on name recognition?
Nicely written article by this new writer at large.
1
I've been saying this all along. If planes were to blame there would be many more crashes. That these crashes occurred in 3rd world countries is all we need to know.
5
@Kathy B
I fear your foregone conclusion obscures real information:
The crashes follow sensor failures. What is the rate of the sensor failures, and where have they occurred?
Are you tied to Boeing and in what way?
13
@Kathy B
I think any airplane that cannot withstand the test of safety in the "third world" as you say is not safe. Suffice to say that Boeing failed a cheap safety test that cost high in human lives.
And if you are selling planes to the third world and know that the standards there are different don't you think they should be built to meet those not so stellar standards?
22
Certainly racist and as the US becomes more inclusive we will have many more pilots of color with different accents. It is a disgrace that we have so few brown pilots.
I have been an air passenger since I was 7. I am now 71 I cannot count the number of air miles I might have flown. Until now, two things have been a consistent explanation of air tragedies: Pilot Error and other human error. I think it inevitable in the age of unbridled capitalism, that it has become impossible to blame an industry for malfeasance, misfeasance or nonfeasance. In this case, it is clear to all that a combination of malfeasance by the manufacturer and nonfeasance by government regulators caused the deaths of many and the financial loss to the corporation itself and the public in general
5
Amazing! It took the NYT an entire year to publish an article about the 737 MAX by someone with even a cursory understanding of aviation. And Mr. Langewiesche, frankly, is aviation royalty. His father, also William, wrote "Stick and Rudder" in 1944, which to this day is the best text available about flying an airplane.
I have said from day 1 that it is no accident (pardon the pun) that these crashes happened where they did. I am a pilot. I took my first plane ride in my father's plane on my first birthday. Do not EVER get on an Asian or African air carrier. Period. If you value your life, don't do it. Indonesia's safety record is absolutely abhorrent. And anyone who thinks Ethiopian Airlines is safe is out of their mind. They have had 25 times' the hull losses (i.e. major accidents) of American Airlines since 1980, flying 1/10th of the number of hours AA flies.
I'm not saying Boeing didn't make any mistakes here. But it is no coincidence that the pilot who saved the Lion Air plane that crashed on its previous flight the day before was a British pilot riding in the jumpseat. He pointed out to the Indonesian crew what was going on.
And the method for disabling the MCAS is the same in the MAX as t has been in the 737 since 1967: it involves flipping two switches. You don't have to know what MCAS is to do it properly.
I would have gotten on a 737 MAX the day after the Ethiopian crash and slept like a baby, so long as the crew was American.
46
@Mike
I would prefer a piece written by someone with enough humility not to tout his own self-reported expertise while speaking so ill of the dead. I found his egocentric asides jarring, deeply offensive, and troubling in their juxtaposition to his stereotyping and tone deafness when describing the deceased pilots - who, had they survived, would never be given several thousand words in the Times to celebrate their feat.
9
@Mike
I was surprised and disappointed to not find you close your whatever with - Make America Great Again! :)))
1
This article is subtly racist, if not overtly. The crash was caused by Boeing's management culture and its outsourcing sprees that enable a single point of failure to affect the outcome of a series of flights. Airplane systems must not cause emergencies - I think either the author shows how you can send expert influencers to fix a public mess or the author is being compensated. "Indian pilot" is not a root cause - don't scapegoat.
32
@Dante Agreed. It's simple: take away the MCAS and its single point of failure and neither flight would have crashed. Period.
9
@Dante - I'm sorry, I missed there the author "subtly, if not overtly", said, suggested, or implied that skin color was to blame. The author didn't say that poor quality pilot training in LDC's is the root cause. But he did say it was an important factor, resulting in these 4 pilots not flipping the stab cutouts which would have turned off MCAS, saving 346 lives.
6
@Dante, it is not at all racist - Did you read the article?
Indonesia had an accident rate 15x higher than normal. What you fail to grasp is that the airlines set the standards for training and experience, which can be a little or a lot, and with a pilot shortage worldwide, the ultra low-cost airlines are not going to pay enough to either (a) adequately train their flight crew; or (b) attract pilots with already great training and experience. That's a supply and demand thing. Quite a few pilots from the Americas and Europe go to the developing markets to build time and experience - and if they had the same poor training, I would expect the same poor performance. The developed world generally does a better job (invests more and attracts the best applicants globally) training professionals - whether doctors, engineers, or pilots. If you were having heart surgery tomorrow, would you choose a doctor trained in the US, or Indonesia? Not a knock on the Indonesian people at all, but a reality of the investment in and quality of training, developing safety procedures and culture, management oversight, etc.
9
If the author's airmanship argument had any weight at all he'd cite cases where airmanship saved a plane where sensors failed, the software made catastrophic choices and the plane was flyable by airmanship alone.
But the author didn't. The author doesn't even begin to address cases of sensor failure. Instead, the author makes reference to 3rd world airlines and insufficient pilot training as if that absolves Boeing from its catastrophic design flaws on the airframe, software and sensor choices. And as if BOEING even mentioned the system existed to pilots or even airlines! The author doesn't even begin to address cases of sensor failure.
Unconvinced.
FAIL
10
This article and the introduction of so much automation in aviation makes me view the coming autonomous vehicle "boom" with great trepidation... and I'm no luddite. I spent my entire career in IS.
11
I'm an electrical engineer specializing in embedded hardware/firmware Automatic Control Systems, precisely the kind of systems that an electronic autopilot uses for flight control. In my 15 years of work in medical instruments design, equipment that requires nearly as careful design as an aircraft as lives depend on them, at least two principles needed to be followed.
First, the user (the doctor or nurse) was not supposed to know how to maneuver the machine or it's working complexities, so as to deploy emergency procedures in case there is a malfunction during surgeries for example. Designs had to be smart to take care of minor user errors and had to be extremely intuitive/easy to use ("fool proof").
Second, extensive design reviews were conducted by a team of engineers, which would have- in the case of Boeing MAX 737 brought up the question that simply adding a second pitch sensor would not have solved the problem of single-sensor-failure because if one sensor said the aircraft nose was pointing up while the other said it was pointing down, the software would have no way to decide which one to obey while declaring the other failed. Typically, in life-critical designs where a proper decision is demanded in real time, this problem is solved by having an odd number of sensors (3) where the software looks at the "voting" of sensors, as it makes the likelihood of two simultaneous failures an extremely rare probability.
Looks like Boeing followed none of these two principles!
29
@4world I know this is a long article but it said that the plane did have 3 sensors. Unless I read it wrong.
1
@Billbo
Only one angle of attack sensor was used at a time as input into the MCAS system.
In addition, a sensor failure in an active 3-sensor system also enables reporting of the failure, and consequential replacement of the failed sensor upon the next landing, thus keeping all 3 sensors operational in 99.99% of flights.
2
I am afraid Langewiesche is too busy defending Boeing at the expense of the good name of the Ethiopian Airlines to tell you the FACTS which he is afraid would spoil the story he wants to sell you on behalf of Boeing.
So, I just want to let you know that Ethiopian Airlines is one of the best Airlines in Africa, known for its safety, connectivity and profitability.
Ethiopian is a Star Alliance Member that conducts DOZENS of DAILY flights to the United States alone.
19
Langewiesche's essay is a grotesque distortion. He has a history of disdain for what he perceives as squalor and as such enjoys shooting fish in that barrel all too much. This is the problem with knowing just part of the subject at hand, perhaps too well. If he is as good a pilot as he is a writer one would have no worries in the air with him. The problem is that he quite evidently is not very knowledgeable about airplane development and the 737 MAX in particular. This leaves him with basic errors such as "electrohydraulic" (the stabilizer is driven by an electric motor turning a jackscrew) and missing the obvious implications of his own conclusion about the many substandard pilots flying planes. He should have made the point early and then proceeded to examine the development process of the 737 MAX wherein Boeing made decisions that ultimately trapped the pilots. Boeing engineers did go eyes wide open into their design, which used zero statistically-valid human factors data to conclude that the pilots would, in seconds, recognize a malfunction of the MCAS system as a stabilizer runaway. Since they designed a single point of failure system, they also knew how often a malfunction would occur from angle-of-attack sensor failure data. As he writes, they knew all about varying pilot skills. This variation makes risk extremely hard to model and so Boeing knew plenty to provide more safeguards against a malfunction. This would have been the story to write had he been able to do so.
28
@Tarek Milleron
Thanks for the human-factors mention. I am a human-factors engineer with experience working in process-control and air-traffic control. Note that, when MCAS activates as intended, pilots are expected to perceive that the aircraft is approaching a stall. When it is activated by a (single-point!) sensor fault, pilots are supposed to ‘recognize’ the same perceived behavior as a runaway-trim condition - though the fault is not in the trim system. Presumably pilots have other sources of information to guide them to execute the appropriate recovery procedure in the different instances. That presumption certainly should have been tested in human-in the-loop simulation, and in flight tests.
Great article, even if it treated Boeing and its design kludge less harshly than it probably deserved. The adroit conflation of aviation expertise and top-notch journalism was welcomed in a world where aviation issues are often so misunderstood by the reporters as well as the general public.
The combination of and ambiguity with respect to culpability harkens me back 40 years to a cartoon placed outside my Dowling College aviation flight lab. A Cessna 172 was pictured beneath a cloud from which a lightning bolt had shot out and sheared off its wings. The caption read, "the NTSB has determined the cause of the accident was pilot error". This hyperbole reinforced in my mind that the pilot is always blamed for everything, sometimes unfairly. But later, much as this article raised my awareness, it was pointed out that small planes have no business flying near thunder clouds, implying that at the end of the day it was indeed an issue of airmanship.
11
"A Top Aviation Expert on What Really Brought Down the Boeng 737 Max."
Do I really need to be told that the writer is a top aviation expert? I wish I were left to come to my own conclusions about the airplane and its operation and not influenced by the attempted intimidation to believe whatever the author wants me to believe.
8
This could be one of the most horrifying articles I've ever read in NYT. Squarely labeling the pilots and the culture, in which they're trained to fly, as incompetent and somehow a stark resemblance of developing nations they're in, is not only horrible but outrageous.Investigators who, as part of the investigation after the accidents, simulated the exact conditions in a test flight 737 max simulator, faced the same fatal conclusions as those accidents. Never mind the fact that Boeing had to create this MCAS system specifically to counter the pitch issues that arose due to the unstable design of 737 max, was carefully omitted by the writer.
32
@PD,
So you would have no concerns about getting on a Lion Air flight so long as it wasn’t a Boeing 737 Max?
The ignorance and arrogance of this Langewiesche dude is mind-boggling. Let me just give you an example as to how he uses uninformed, inaccurate and misleading information to make a case where there is simply none to be made.
About the Ethiopian Airlines' plane that went down in Lebanon, he quotes someone who apparently says "no Israeli missile" has been found to be the cause.
Now, he is inaccurately and misleadingly implying as if the Ethiopians somehow tried to blame "an Israeli missile" for the accident. But THEY NEVER DID! You see, the guy has no clue how closely the Ethiopians work with the Israelis on security matters in the region.
Hezbollah secretly shipping arms to Africa? That's another matter, given the explosion witnesses reported to have seen just before the plane came down. But not to worry! Langewiesche assures us that a gifted ex-Lebanese pilot told him the pilots were to blame. Here, Langewiesche bizarrely makes it look as if it would have been easier for this Lebanese ex-pilot to blame Hezbollah instead of the dead pilots. Come on, be serious, this is the New York Times!
12
@daniel solomon
Ethiopia is the one country in Africa whose roots go back more to ancient Israel than to the rest of Africa.
I think that explains a few things—not least in aviation!
2
The article starts like one written by a writer with an objective mind. But it gradually expanded to focus on Indonesia in terms of aviation.
It's simply a deflection away from the FUNDAMENTAL design mistake made by Boeing in regard to the MAX 737.
That mistake is to make the MAX 737 rely on one SINGLE Angle-Of-Attack sensor. Instead of two.
'Angle-of-attack sensors are highly reliable and have been used on passenger jets for years, but like any aircraft component, they can fail. Given that, former Boeing and Rosemount engineers said it was surprising that Boeing would allow a single sensor to activate a crucial system that pushes the aircraft toward the ground'.
See: https://www.nytimes.com/2019/03/29/business/boeing-737-max-crash.html
It reminds me of the US blamed South Vietnamese for the loss in the war to northern Communist. Never mind the US PLANNED to withdraw from the war when nit longer suits its strategic objectives. It's a different topic, I know. But the tactic is eerily the same.
To allow this writer's spin in a feature article, but not as an opinion, is akin to treating readers like stupid and sheep like.
For a newspaper like The New York Times, disappointment would be an understatement.
15
@Life Traveller Two angle-of-attack sensors are just about as worthless as one. If the two sensors report measurements with significant disparities between them, how is the pilot (or autopilot) to know which one is correct and which one is incorrect ?
For critical systems (like airplanes, for example), there should be at least 3 sensors. If one sensor reports measurements that are in disagreement with the other two, then shut that sensor down and get it fixed as soon as you land.
For extra-critical, MUST NOT FAIL systems (like an airplane with me and/or one or more of my family members on board), the minimum number of sensors should be 5, although I'd greatly prefer 7. Or 9, or 11.
3
This article is a low point in the history of this newspaper, on par with your endorsement of the invasion of Iraq. It makes one wonder what forces are at work in the decision making process in your newsroom. Beginning with the headline this is a misleading and half baked propaganda piece that seems to devalue the victims of Boeing’s corporate greed and protect this corporation from the consequences of its criminal neglect. Their are also racist undertones in Langewiesche’s prose. Who is this guy and why does he come out of the woodwork with this ignorant thesis. The FAA, EASA, Boeing, hundreds of investigators and all involved airlines agree that the MAX is not fit to fly. Don’t blame the crashes on pilots who happen to have no white skin.
Shame on you, NYT!
35
@Jatta Don't bring race into this. My God, how absurd can you get? Developed countries have a hard enough time finding pilots nowadays. Imagine a low cost carrier in a developing country. Please.
8
@Jatta,
So please confirm: after reading this article, would you feel comfortable flying as a passenger on a Lion Air flight so long as you were on a different type of plane?
A former pilot myself. In the aviation world there is an old saying. In time of crisis, "fly the airplane." Now it seems to have morphed to "trust the airplane."
But I take extreme umbrage at this:
"The same cannot be expected of airline pilots who never fly solo and whose entire experience consists of catering to passengers who flinch in mild turbulence, refer to “air pockets” in cocktail conversation and think they are near death if bank angles exceed 30 degrees."
Military experience has never been a prerequisite for commercial aviation. In fact, there are disadvantages to a background that includes flying upside down and pulling G forces that would cripple passengers. They are extremely well trained but for a *very* different job than getting safely from ORD to LAX.
Most airline pilots, in the US at least, have considerable experience at developing airmanship skills through long training and progressive experience moving up the ratings ladder and experience in type. The author, as experienced a writer and pilot as he is and who I have respected for decades, can't show any evidence that that system has failed the flying public.
10
Boeing, the pilots, and the airlines are all at fault. To design MCAS to take control of the trim on the basis of data from just one sensor when others are available was almost an incredible blunder, though I believe it was a organizational screw-up and not due to greed. Until this happened, Boeing boasted an excellent safety record.
For Lion Air to not inform the pilots of what had occurred on the previous flight of the aircraft, and to use a shoddy replacement for the sensor, was unconscionable. And obviously, the Lion Air pilots should've been able to sort through the problem, because the pilots on the previous flight, including the 'ghost', had successfully dealt with the identical situation. The Ethiopian pilots had been informed of MCAS, and even more than the Indonesian pilots, they should've reacted more intelligently.
And yes, increasing automation does raise the question of how human operators can gain the experience to prepare for the rare situations where the software is in error. And yes, it is characteristic of some third world cultures to value saving face above facing uncomfortable facts.
12
Langewiesche paints a picture of willfully lax oversight, substandard training, grinding fatigue, abbreviated experience, and pilots’ goal of putting away enough hours that they can eventually secure a better job with a safer airline. Sounds like the US commuter airline industry.
15
There is plenty of blame to go around here. Partly these crashes were Boeing's fault, partly they were the maintenance crews' fault, and partly they were the pilots' fault.
The problem starts with the sensor vanes, which malfunctioned on the captain's side on both planes. If the sensors had not malfunctioned, the MCAS would not have engaged, because there would have been no indication of a stall. So Boeing's real problem is bad sensor vanes. This problem was compounded by having the MCAS engage when the sensors disagreed -- the copilots' vanes were fine in both cases. The system should not engage when data is discrepant.
The ground maintenance crews should have fixed the sensor problems, which they definitely knew about previously in the Indonesian plane, and it would not surprise me if the Ethiopian one had previous malfunctions too. They failed to fix the sensor problem, which started the fatal chain of events.
The pilots did make errors as well. No PC sentiments can change that. Failing to throttle back from takeoff thrust is not Boeing's fault. On top of that, other pilots, such as the "ghost," were able to figure out what was going on and take appropriate action. In the fatal flights, one bad decision or oversight led to another, and ended in a situation where saving the plane became impossible. The wouldn't have been in that situation if Boeing hadn't made mistakes, but neither the ground techs nor the pilots are blameless either.
14
@Nikki very well said, thank you
3
@Nikki being able to correct a problem in stayed flight at altitude is totally different than at takeoff. Those who have flown the unfixed software on takeoff all crashed their simulators.
2
This article is long on analysis of what the pilots did or did not do, and short on what they faced - unforeseen situations with multiple failures and warnings appearing. Having faced regulators myself, albeit in a different industry, it’s very easy for anyone to sit there afterwards and say ‘why didn’t you do x or y?’ as if that was the most simple thing in the world at the time. But real life isn’t slow motion.
7
Hard hitting article:
““Airmanship” is an anachronistic word, but it is applied without prejudice to women as well as men. Its full meaning is difficult to convey. It includes a visceral sense of navigation, an operational understanding of weather and weather information, the ability to form mental maps of traffic flows, fluency in the nuance of radio communications and, especially, a deep appreciation for the interplay between energy, inertia and wings. Airplanes are living things. The best pilots do not sit in cockpits so much as strap them on. The United States Navy manages to instill a sense of this in its fledgling fighter pilots by ramming them through rigorous classroom instruction and then requiring them to fly at bank angles without limits, including upside down.”
"If you were to choose a location in the developing world in which to witness the challenges facing airline safety — the ossification of regulations and in many places their creeping irrelevance to operations; ... Indonesia" William Langewiesche
Will read this in detail!
4
As an aerospace engineer, I would like to address some mischaracterizations of the MCAS system that I'm seeing in the comments:
MCAS is not designed to make the 737 MAX stable. No aerodynamically unstable passenger aircraft would ever be approved, and the 737 MAX is no exception. As Langewiesche states in the article, "pitching up into a stall is a characteristic of all jets with underslung engines," so the claim that this is a feature unique to the MAX is not true, though the MAX does pitch up slightly more in that scenario. The stabilizers, or horizontal wings on the back of the plane, are adjustable(trimmable) in large part to address the moment generated by the underslung engines on almost every passenger aircraft.
Rather, MCAS is designed to create the "necessary backpressure on the control column," more specifically to cause the force on the column to "increase in a conventional linear manner as they had in previous 737s and as certification standards required."
In other words, MCAS addresses the pilot's perceived force on the stick he is using to fly the plane, which should increase linearly as the plane approaches stall. This is not related to the plane's aerodynamic stability, which is a plane's tendency to return to level flight when a disturbance is applied.)
While the MCAS system is flawed, one should note that this is a subsystem level isse. The 737 MAX is not aerodynamically unstable, and does not require MCAS to operate normally.
9
Thank you for an in-depth and comprehensive piece about two very tragic aviation catastrophe. I thought it was well-balanced and delicate in casting the blame in a very wide, if not complicated, net.
6
@Robert B agreed
To me this article is simply a Boeing push/lobbying effort... it tells me just how much Boeing is in trouble. This is part a of a massive campaign to deflect their fundamental responsibility. I want to see exactly where else and to whom their money is flowing.
15
Indeed, one the best articles I have ever read in the NYT. Congratulations for this masterpiece!
11
Comments like this are absolutely unusual in NYT threads and there is a startling number of them in this one.
I, for one, am having a hard time seeing this as coincidental.
5
I find this article appalling. Blame the pilots the author says. How about a proper root cause discussion of why MCAS was required in the first place. The engines are locatec in the wrong place due to their additional size.
8
This reporting is dangerously unaware that the design of the airplane cannot and should not be corrected or compensated for by any combination of software, retrofitting, or pilot behavior. The design us fatally flawed, and there has been ample ink spilled on that topic. When will the NY Times recall its avowed mission to tell the truth above any corporate interest or other alliances?
9
Pilot inexperience is, to me, the single most frightening aspect of flying today. In contrast to years ago, when you had people with military training, like Sully Sullenberger and Al Haynes, flying, nowadays, with demand for pilots high and people like Sullenberger and Haynes hard to come by, you have pilots like this, not to mention those two who were piloting a Continental or United Express plane to Buffalo 10 years. The copilot was heard screaming on the cockpit voice recorder as the plane went down in flames and all were killed. (if the plane's going to crash, could you at least do us the favor of not screaming as it does so?)
4
Total nonsense that Boeing is to blame. I am a 737 pilot and this writer has it exactly correct. The pilots, their lack of experience and their over-dependence upon automation were directly to blame.
12
“Over-dependence on automation?” The pilots in these crashes didn’t even know the MCAS system existed. They were fighting the control surfaces of a rogue anti-stall system getting wrong information from a sensor with a single point of failure. If the pilots were actually in the wrong, why is the Max likely to still be grounded well into December?
Seems like the author is doing some rehabilitation PR work for Boeing.
While I believe there was no explicit corruption at work here and that "the mistakes ... made were honest ones, or stupid ones, or maybe careless ones, but not a result of an intentional sacrifice of safety for gain," the primary "culprit" here is Boeing.
Consider these points:
1. Boeing creates and distributes all the pilot training materials used by pilots worldwide that fly its aircraft.
2. Boeing creates the pilot training program for its aircraft.
3. Boeing wrote all of the flight management system software.
4. If Lion Air is a very important customer, surely Boeing's experience with Lion made them aware of the allegedly poor training of Lion Air pilots. Wouldn't a prudent manufacturer take into account the lower quality of the "users" operating their machines to make them more "idiot proof," especially taking into account the potential liability and/or poor training/experience of the "users"?
I regret that the Times reporters have decided to lean toward the manufacturer's favorite excuse ("blame the pilot") to move the focus away from a basic principle: Manufacturers are responsible for product defects, not owners or users. Boeing's failures in systems programming, training and documentation are solely Boeing's, not the pilots.
11
Just like @Chasseur American, I find the fact it disturbing that the tone of the article is for to blame the pilot for Boeings failings. I would go further and declare that the article in blaming pilots who are from elsewhere but are duly certified to fly these airplanes by Boeing as racist.
8
@Afam -- Please don't hurl accusations around. The fact is, pilots were from those places. Pointing that out, and pointing out that third world countries don't have the resources for building an aviation system like those in the west, is not racist, it's just reporting. Otherwise, you're arguing that only white people can be criticised.
7
One of the most pathetic articles I've ever read in NYT. Squarely labeling the pilots and the culture, in which they're trained to fly, as incompetent and somehow a stark resemblance of developing nations is not only horrible but outrageous.Test pilots who, as part of their investigation after the accidents, when simulated the exact conditions in a simulator were faced with the same fatal conclusions as those accidents.
Never mind the fact that Boeing had to create this MCAS system specifically to counter the pitch issues created by the unstable design of 737 max, carefully omitted by the writer.
14
One flaw with this article is that "airmanship" is being engineered out of modern aircraft.
Airmanship constitutes being able to sense an impending stall by mushy controls and hearing a "buffeting" airflow over the wings. If a stall is entered, even the most basic pilot rating has you recover from 2 types of stalls; power-on and power-off.
Boeing's MCAS system improperly sensed an impending stall and strongly over-reacted. My own belief is that intrinsic 737Max8 airframe characteristics make a stall unrecoverable. All new aircraft have to be stall tested and preferably spin tested as part of certification. Boeing did not certify the Max8; they only amended the older certificate.
It is hard to blame airmanship when undocumented software overrides the pilots skills. Even more alarming, MCAS is deemed necessary to avoid a stall that all commercial pilots have trained to avoid.
This may not even be an overreaction from Boeing. Airframe changes to gain fuel efficiency can lead to an aircraft that will not recover from a stall. Prior to the accidents, Boeing had a huge number of 737Max largely on the basis of fuel efficiency. Boeing claimed the Max had a 4% better fuel use than the AirBus 320Neo.
Those interested can read about aft Center of Gravity unrecoverable stall/spin accidents with an internet search.
9
This article is the best piece of investigative reporting in the Times in 2019. Thank you for the deep, nuanced exploration of changes in aviation over the last few decades. I'm in an unrelated industry, but I plan to share this article as required reading for my research group this month to facilitate a discussion on safety management.
11
The article emphasizes the pilots’ failures in the two accidents but it also calls out the system failures: poor pilot training, an outdated aircraft design patched by an obscure software program and Boeing’s aggressive tactic to sell airplanes to underperforming airlines. No matter how you spin it: Boeing had all the necessary knowledge to prevent these fatal accidents. The pilots failed but are not to blame. We have to be careful when looking at systems and singular actions within the system. We tend to think in narratives and not system analysis. In the narrative approach pilots seem to be the culprits but in the system approach they are the victims along with the passengers who trusted the air safety system.
8
All four pilots lacked experience and training. One requires the experience to understand one needs training. It appears Boeing was happy to advertise no training necessary when they had no idea of their responsibility. The FAA trusted Boeing to understand that responsibility. There is no downside to training. The operators did not supply pilots capable of managing a failure or even stabilizing the aircraft. Upper management for all involved treated the complex operation (flying) with distain. People are assigned jobs without proper training in all industries. Management in these cases consider training as an expense. The individuals who implied that sediment in these crashes should be held responsible. Boeing and both operators.
4
Increased engine power drives the nose upward and threatens a stall. The computers were designed to prevent a stall by keeping the nose down. The pilots did not know, we’re not trained and didn’t have a method to quickly disable the computer driving the nose downward. If pilots knew.... but it would have been a new plane, not an upgrade of an older model. Hence, more cost in training and FAA approval.
Saving money over safety and reputation.
16
I just read an article from today's New Republic on the same subjects, but with the opposite take.
It is much more fact-filled, detailing the history of Boeing's management--specifically its adaptation of financial strategies to replace engineering strategies (and the firing of 2000 engineers.)
It even details where and when the ït's the pilots" argument emerged within Boeing, surprisingly, prior to the MAX, with the 787, and how Boeing pushed it.
Fascinating reading. It completely demolishes these arguments based on "äirman" expertise. Just one example: American pilots have been told that with the extra software their airlines had bought, they would be aware that the two indicators disagreed before they got off the ground. Actually, the indicator of disagreement does not turn on until the aircraft attains an attitude of 400 feet.
30
There are some important details that get lost in what comes off as a pedantic expose of the authors knowledge:
Boeing released a system that provided automated input into the flight controls with a single point of failure - the angle of attack sensor. The system seems to rely on the pilots ability to make the correct decision based on discordant information, without any training on the specific case, in a few seconds which many lives depend on.
The author seems to cop-out on investigating this critical design decision by Boeing further.
While I think the background of airline development, flight operations and training is interesting - it doesn't add much information to why a very poor design decision was made.
I may have missed something in the process - there was a lot to get through.
11
The article appears to be a an attempt at rehabilitating the reputation of Boeing with misdirection to pilots training. Granted Pilot training could be improved, but that does not excuse Boeing's disregard for quality in all faucets of its products & production.
11
The article appears to be a an attempt at rehabilitating the reputation of Boeing with misdirection to pilots training. Granted Pilot training could be improved, but that does not excuse Boeing's disregard for quality in all faucets of its products & production.
1
I wonder if William Langwiesche and the NYT are on Boeing's payrolls. This article is insensitive to all the dead - the dead pilots cannot be expected to defend themselves. in fright we forfeited one nonrefundable Lion Air flight ticket but tha was worth a lot of peace of mind. THIS IS A DEFECTIVE PLANE MODEL AND THE ENTIRE FLEET SHOULD BE JUNKED AND PRODUCTION STOPPED AND PERMANENTLY DISCONTINUED. I WONDER IF BOEING OR THE CONCERNED REGULATORY AVAIATION AUTHORITIES CAN EVER BE TRUSTED AGAIN AND WILL BE BROUGHT TO JUSTICE. THE BOING MAX MAY VERY WELL BE A FLYING COFFIN AND NO SANE PASSENGER SHOULD EVEN DREAM OF STEPPING INTO ONE.
20
The author certainly seems to be carrying a very clear brief for Boeing! That happens! But, why is NYT playing the same game? My respect for NYT has been dented! Could this possibly be “fake news”?
6
The comments saying “brilliant article” and so on aren’t typical comments and are more than likely paid trolls.
If the claims in this article are correct, that it was basically incompetent foreign pilots, the aircraft wouldn’t have been absent from American skies for so long.
10
@Glen I'm not a troll. And not paid, either.
1
Greed.
1
I hope the "Cockroach Corner" used airline parts shop is driven out of business.
Out of curiosity I googled that phrase, and to my astonishment came upon an Oct 8, 1980 UPI article that lays blame at their feet for the death of baseball legend Roberto Clemente and the Wichita State University football team:
https://www.upi.com/Archives/1980/10/08/New-safety-rules-for-Cockroach-Corner-aircraft/9184339825600/
39 years is a long time for something nicknamed "Cockroach Corner" to be in business in the airline industry, isn't it?
5
As with a lot of aviation tragedies it was not the forces of nature that crashed the 737MAXs, but human failings motivated by profit.
This article seems to be concentrating on only some of those involved and their profit motive; foreign airline operators. I trust the author shall, when the time comes, dedicate a similar level of effort reporting the consequences of the financial motives within Boeing, the FAA and the US political system (relevant because the FAA’s budget and Administrator are political decisions), and on whether or not their own judgements between finance and diligence are, given the high expectations fomented by the article, unquestionably a golden standard for all to aspire to. Let us hope so, otherwise there will be much quoting of John 8:7.
The author better hurry up, for Boeing may soon fall over the brink they are stumbling towards; there may be nothing left to report on. That would be a different sort of sadness, but many would say that it would be a result all of their own making.
That it's not Airbus in this situation is partly luck; Boeing didn't adapt to the changed dynamics of the small airliner market and operating practises caused by Airbus's FBW. Regardless, one or the other would still have eventually found themselves in this situation. Not even FBW is fool proof, foolishness tends to increase, no design is flawless and no engineering process is perfect or fully adhered to. Also the gap between recklessness and misfortune gets narrower.
4
That it’s not Airbus in this position, is truly fortuitous for Airbus! Mostly because they are now able with aforesight to clear up similar defects in their organisation structure and reporting lines, to prevent similar mishaps from creeping into design, and in the way design defects are rectified, especially by overriding venal profit motivations!
3
It always amazes me to see the ease with which Western writers tend to mindlessly and lazily dump all blame and maleficent intent on non-Western actors, even in cases where they happen to be the obvious victims.
In this case, the "expert" writer first gives a little lip service to Boeing's blatant corporate greed and arrogance that resulted in these two devastating disasters; and then thoughtlessly and callously dumps all the blame on the voiceless victims.
Why? Because he knows it's the easiest and safest thing to do, that (like always) he can get away with it. Sickening.
14
Boeing doesn't profit from crashed planes....it needs to sell hundreds of planes to break even, so this view that they are driven by this myopic view of short term sales is silly since they need long term equipment and aftermarket (i.e. service) sales to actually turn a profit
1
You design a plane for the pilots that are; not for the legendary “airmanship” pilots who used to be or should be. If a plane requires for safety a specially trained and certified pilot, then you make that a requirement in the sales contract to indemnify your corporation.
Boeing just killed several hundred human guinea pigs as part of their testing program to make their plane some day safe enough.
Why did Boeing pull their planes? Aren’t there 1st world pilots with the right stuff to qualify with an “airmanship” rating just in case; or are we all just risking foolishly our lives every time we fly?
Why was this article written and published in today’s New York Times? Does it benefit Boeing? Does it merely benefit the author’s ego or will he be testifying in Boeing’s defense for a fee?
19
If you’re asking, why don’t the Indonesians and the Ethiopians release the cockpit voice and flight data from that recorder. Yes, there is blame all around but slamming Boeing only is irresponsible.
11
Wondering if editors fact checked whether the author is a Boeing employee or troll. He is not a truly objective journalist versed in the peculiarities and technical flaws of the MCAS system and confusion it wreaked in the cabin of both crashes.
I've read every article here in this great paper about the two horrendous 737 Max crashes and the part MCAS played. The author really underplays it's impact on the crashes and instead shifts blame via a history lesson.
I'd recommend all interested in preventing future automation induced aircraft failures do a simple search here and read more about MCAS to get more understanding and more objective view.
An earlier article mentioned how hard and short a time our pilots fighting MCAS experienced in simulation as it repeatedly engaged. After two crashes, hindsight is perfect and all pilots knew to turn off electric trim.
13
The author makes an exacting, compelling, if not brilliant
case about pilot error. Please, nay-sayers, where can I read your exacting, compelling, & brilliant analysis to refute his conclusions? Also, the truth can hurt.... political correctness cannot possibly have relevance in catastrophes such as these.
7
I think that there is a tragic non-sequitur within this article. On the one hand, the author argues, persuasively, that these two accidents were largely the result of pilot incompetence. But towards the end he says that the way to minimize the likelihood of this happening again is not to insist on more stringent pilot training and selection processes, but rather to let the quality of pilots keep declining and give more control to automated systems. I am old fashioned, so I cannot see the logic of this. The captain who points out that half the pilots graduate in the bottom of their class hits the nail on its head. The solution is not to cater to that lower 50 % of pilots, but rather to raise the average, so that those 50% underperformers do not become pilots.
I know the counterargument - there are probably not enough people with the necessary degree of airmanship to fill all cockpit seats. Then reduce the number of cockpit seats. Make flying more expensive, allow sub-par carriers to go bankrupt, stop this crazy rush to the bottom that is affecting all of society. I am a (soon to retire) university professor in the physical sciences and see essentially the same thing happening in the dismal educational standards of today, compared to those that I was held up to almost 50 years ago.
I recommend the remarkably prescient science fiction story by C.M. Kornbluth, “The Marching Morons”.
6
I can't say here in the comment section what I really wanted to say to the writer of this rubbish. I tried to find him on twitter to say what's on my mind. But he doesn't have a twitter address. What is he afraid of?
4
Thank you....Spot On! Only thing I can't believe is that this is actually published in the NY Times. I have been waiting for someone to tell the truth. These accidents are the result of VERY POOR Airmanship...Period. From one pilot to another I say "Thank you for excellent journalism."
3
Pure, shameless propaganda for Boeing.
I wish the author the worst possible outcome. A 737 crash perhaps?
5
You blame the pilots? Shame on you!
All evidence is there
that it was Boeing and its crew
who simply did not care.
Often the pilots are to blame.
It is called “pilot error”.
This time you should not make that claim.
The MCAS spread the terror.
And what about the FAA?
There was no oversight!
Too many things here went astray.
The MAX is NOT alright!
5
The ignorance and arrogance of this Langewiesche dude is mind-boggling. Let me just give you an example as to how he uses uninformed, inaccurate and misleading information to make a case where there is simply none to be made.
About the Ethiopian Airlines' plane that went down in Lebanon, he quotes someone who apparently says "no Israeli missile" has been found to be the cause.
Now, he is inaccurately and misleadingly implying as if the Ethiopians somehow tried to blame "an Israeli missile" for the accident. But THEY NEVER DID! You see, the guy has no clue how closely the Ethiopians work with the Israelis on security matters in the region.
Hezbollah secretly shipping arms to Africa? That's another matter, given the explosion witnesses reported to have seen just before the plane came down. But not to worry! Langewiesche assures us that a gifted ex-Lebanese pilot told him the pilots were to blame. Here, Langewiesche bizarrely makes it look as if it would have been easier for this Lebanese ex-pilot to blame Hezbollah instead of the dead pilots. Come on, be serious, this is the New York Times!
4
Right from the Headline of the article to it’s narrative appear to have already concluded to Kill the messenger, in this case the Cockpit team.
I couldn’t understand some of the syntax where William takes literary help of words denigrating the crew to help paint readers’ opinion with some bias, where one of the reader comments generalized ‘third world’ airline to be incompetent of flying! How was a nationality of the Pilot was important in this piece, which otherwise could have been something researched and presented with pure objectivity! Alas, but it was not.
In the end it clearly sounded as an Advertorial of Boing Inc. Sorry, despite your best efforts to fly your point of view, your rationale is still grounded!
4
Starting off on the wrong foot. Poor article from a poor author.
2
Error alert. The anecdote regarding the crash of an Air France A330 on a flight from Rio to Paris is clearly a reference to the crash of Flight 447, which occurred in June 2009, not January 2015.
3
The ignorance and arrogance of this Langewiesche dude is mind-boggling. Let me just give you an example as to how he uses uninformed, inaccurate and misleading information to make a case where there is simply none to be made.
About the Ethiopian Airlines' plane that went down in Lebanon, he quotes someone who apparently says "no Israeli missile" has been found to be the cause.
Now, he is inaccurately and misleadingly implying as if the Ethiopians somehow tried to blame "an Israeli missile" for the accident. But THEY NEVER DID! You see, the guy has no clue how closely the Ethiopians work with the Israelis on security matters in the region.
Hezbollah secretly shipping arms to Africa? That's another matter, given the explosion witnesses reported to have seen just before the plane came down. But not to worry! Langewiesche assures us that a gifted ex-Lebanese pilot told him the pilots were to blame. Here, Langewiesche bizarrely makes it look as if it would have been easier for this Lebanese ex-pilot to blame Hezbollah instead of the dead pilots. Come on, be serious, this is the New York Times!
1
Langewiesche is not being honest in this peice at all. The whole thing reads more like an ad placement by Boeing than a seriously researched piece worthy of the NYT. Let me just give you an example as to how he uses uninformed, inaccurate and misleading information to make a case where there is simply none to be made.
About the Ethiopian Airlines' plane that went down in Lebanon, he quotes someone who apparently says "no Israeli missile" has been found to be the cause.
Now, he is inaccurately and misleadingly implying as if the Ethiopians somehow tried to blame "an Israeli missile" for the accident. But THEY NEVER DID! You see, the guy has no clue how closely the Ethiopians work with the Israelis on security matters in the region.
Hezbollah secretly shipping arms to Africa? That's another matter, given the explosion witnesses reported to have seen just before the plane came down. But not to worry! Langewiesche assures us that a gifted ex-Lebanese pilot told him the pilots were to blame. Here, Langewiesche bizarrely makes it look as if it would have been easier for this Lebanese ex-pilot to blame Hezbollah instead of the dead pilots. Come on, be serious, this is the New York Times!
4
As an Engineer this is a catastrophic single failure problem. One failure of the sensor in the control system of the aircraft causes a catastrophic dive of the airplane without other indicators or warnings. There is no check of sensor failure and no warning for the pilot to disable the autopilot. Finally a very severe dive of the aircraft, which is abnormal, should have been "checked" by the autopilot system computer and avoided giving the pilots a chance to "think" things thru and maybe disable the autopilot. Maybe the autopilot should automatically disable when "severe" dive conditions are "commanded". In the end the autopilot is an aide. It should not take severe actions and should leave it to the human pilots on the plane and give them a fighting chance to save the flight from a catastrophe. To me it looks like the engineers at Boeing trusted more in their own autopilot software and technology and non-failure rate of their sensors to make this happen.
The blame falls directly on Boeing. Nearly a year of grounding, proves this point. Boeing engineers had not thought this thru and as a result we are still waiting for these death machines to fly? I'll be damned if I fly in a 737 Max!
12
Fortunately, this article is far too long to attract enough readers to help Boeing’s Hail Mary coverup of a greedy attempt to cut oversight, training and cost. Their engineers did something absolutely forbidden, but it was the Board that decided to lie to the FAA, pilots, and potential customers. Then they put out the word to blame pilots. So, voila.
13
A fascinating report from an airline industry insider.
However, after all is said and done, it is important to realize that had these 737 Maxs not been equipped with the MCAS, all those people killed in the crashed would still be alive.
As an airline passenger, given a choice between a plane which even a concierge can fly and a plane which requires its pilots to have that nebulous quality called "airmanship", I would choose the former every time.
Boeing had better scrap the 737 Max and build a plane whose safety does not depend on the pilot as a last resort.
3
You do realize that the A330 crashed in the Atlantic because those pilots lacked airmanship?
2
Boeing’s problem is rooted in the fact that they desired to market an aircraft quickly to counter the A320neo. To do so competitively they increased payload and positioned engines to advantage that fact. To counter consequences of repositioning engines, they eventually devised MCAS! Then they felt it ok to ignore telling pilots about MCAS, as it would presumably work as designed. It didn’t! Hence these avoidable deaths. Sure there is pilot error. But MCAS is the fundamental issue here. Boeing better face it. Re Indonesia, sure there is much to blame them and Lion Air for! Corruption is mothers milk there!
Corporate greed is what brought those planes down. Pure and simple.
5
Explain...why would Boeing who needs long-term sales to generate a profit on its airplane resort to short-term cut corners...Boeing needs the plane to sell for a long time and fly for a long-time in order to make money...it doesn't turn a profit on a couple years of sales
I write as a onetime frequent flier (400K-500K miles a year) rather than any kind of expert on the technical issues. I once rode with a deadheading Qantas pilot from Frankfurt to Sydney, who told me, when I asked him what airlines to fly and avoid: Where possible, choose North American, northern European, South Asian (Malaysia, Thai, Singapore), and Australia/New Zealand flag carriers; second choice, southern European flag carriers; third choice, South American flag carriers, and walk or take the train rather than fly African or Soviet-bloc carriers (this is how old my information is) because the Sovs then flew the lethal IL-66. Global constraint: never, never ever, even think about flying Garuda, then the sole Indonesian carrier. This bloke was rather Anglo-centric and a tad racist, of course, but it sounds as though, 35 years on, he wasn't far off the mark.
1
It’s very difficult to wave fairly technical information into a general interest story, but this author managed it really well. I am not a pilot, but I still found the article fascinating. Well done!
5
How is it that no crashes have occurred when better trained pilots are flying the aircraft, in this case the 737MAX? Certainly aircraft have fallen out the sky since, well, the beginning of manned flight, but what are the criteria of criticism? Technical and easy to assume answers that cannot be articulated because we worry that someone or some nationality will be insulted because of stupidity, stubbornness, pride, hubris, politics, etc. Perhaps we should ask the passenger in Seat 3A, oh, they are shredded beyond recognition, the only real excuse there is to not answering the question(s) we all need to know to prevent this kind of tragedy from happening again.
1
A defense lawyer for Boeing could not have written a better piece.
Boeing's decision to remove one of two critical sensors from its MCAS system and then to bury the details of this decision is the reason for the two crashes.
Instead of blaming the pilots, the writer should have examined the dysfunctional relationship between Boeing and the FAA.
11
Here come the Boeing apologists, blaming the pilots of 3rd world countries not as well trained as American hot shots. As Boeing tried to whitewash its image, it instructed its minions to shift the narrative and tried to put the blame for a problem created by its own greed and pretended that that Boeing did not put its bottom line above the safety of the consumers of its products.
According to NY Times, June 26, 2019 article, "In at least one instance, an F.A.A. pilot was unable to quickly and easily follow Boeing’s emergency procedures to regain control of the plane." This of course is a few simulation tests done by the FAA, a Boeing apologist itself -- too late two accidents.
8
When I began my flight training in a T-6 primary trainer, on nearly every flight, including the first one, the instructor in the back seat created a fake emergency to which I was expected to respond. This continued throughout the 500 hours or so of training in a succession of aircraft — T-38, T-33, F-80, F-84E — before I was declared combat ready and sent off to Korea. I continued to "rehearse" emergency situations throughout my flying career.
It seems to me that the new breed of pilots described in this amazing article — that is, pilots trained by computer — aren't very well equipped to handle emergencies because they haven't been exhaustingly trained to manage them.
So, perhaps all airline pilots should be required to experience training in high-performance jets with a no-nonsense instructor in the back seat challenging them.
Remember the axiom:
Aviation in itself is not inherently dangerous.
But, like the sea, is terribly unforgiving of mistakes, or carelessness.
And:
Flying is hours and hours of boredom
Interspersed with moments of stark terror.
7
Finally a reporter with the will and knowledge to say what 737 pilots have known since the initial reports came out. I have 20 years of flying 737s including the MAX. I trained pilots for the US Navy for 10 years. This story is the most accurate and complete account yet published.
7
Author of this article needs to do go on some training courses on ARP4754, flight control systems, human factors and airworthiness. Once he’s done that, come back and rewrite the entire article, because the very premise of it is totally incorrect.
The notion that pilots must be hero-qualified and those not up to the job are lesser beings is a fantasy detached from the very real science of human factors and failure mode effects analysis, articles - no - essays like this one are unhelpful in the context of the goal of aircraft safety.
Stop trying to bamboozle the public with false theories about systems you don’t understand, please.
14
I still don’t want to set foot on a Max 8.
2
So, is each passenger supposed to interrogate the pilots on their training and to make a judgement as to their competence, upon entering a 737 Max, after it is flying again? Not I. I will not board that plane.
4
My friend flies a Cessna 172 for fun. She has more flight hours than the Ethiopian beginner co-pilot who, with 154 hours flight time, presumably not all in a large turbine 737, began to share responsibility for some 150 trusting passengers. What disastrous nonsense in the Ethiopian aviation administration. The US requires 1500 flying hours for commercial co-pilots (post-Colgan) (750 hours with military pilot experience).
5
The AoA (Angle of Attack) disagree "signal" was inadvertently disabled unless the customer purchased, for $80,000, the AoA display on the flight control display panel.
Why has no one pointed out that this, use of the AoA disagree "signal", is exactly what was needed to justify the otherwise sheer idiocy of using a single AoA sensor.
How else could the 2 sensors be used.... averaging..?
NOT!
5
What a long winded puff piece.
The author's summary that "What we had in the two downed airplanes was a textbook failure of airmanship." And "The paradox is that the failures of the 737 Max were really the product of an incredible success"
Err.... thanks for these words of reassurance - NOT
I and my family will certainly not be flying on a Boeing 737 Max.
Not sure Boeing's problems can be casually dismissed as "honest, stupid or maybe careless mistakes".
7
Give me an ex-Navy pilot as my pilot. Anyone that lands a speeding jet on a moving and rolling carrier in bad weather knows their stuff.
1
People go to jail for stealing trivial sums, or for punching someone else. Who will do time for killing these HUNDREDS of innocent victims? They knew the likely result, and did it for money.
If a person of color, or other marginalized person, had inflicted even 1% of this harm, they would be looking at life imprisonment.
2
Two questions about the 737 Max fleet:
Do we know how many times MCAS initiated improperly, and pilots did quickly and properly disengage the electric trim?
Do we know how many time MCAS initiated properly and performed as the designers intended?
3
Ok, pilots at fault. But when things can go wrong they will go wrong. So why do you absolve Boeing of co-responsibility when they clearly had faulty systems on the 747 Max?
2
You have to wonder whether any of these pilots, or others trained by rote, could have duplicated the calm cockpit skills of "Sully" Sullenberger as he landed his fully loaded plane in the Hudson River.
2
I am disturbed by the elements of racism that the author clearly demonstrates in this article. Ethiopian Air has always been regarded as one of the most professional airlines in the world. It is shameful that you allow Boeing to argue that its failure is due to the pilots and avoid fault because their greed led them to skip a proper introduction to the 737 Max for all pilots. The move in the placement and height of the engines was substantial. The decision by the EASA not to accept an automatic recertification nation by the FAA suggests a deep scepticism of Boeing.
5
Wow! Really good article. Nice job Mr. Langewiesche!
1
Seems to me that Boeing execs may be criminally liable. Many aspects of this article seem to contradict the narrative that is in the public domain and also contradict published air safety commentary from various national air safety regulators, including the FAA. There is a reason the 737 Max is still not cleared to fly by the US authorities. And there are reasons why foreign regulators are no longer prepared to accept the FAAs word on safety.
Given the circumstances, great care should be taken to avoid any errors of fact in reporting. One might otherwise prejudice potential criminal actions and the normal course of regulatory enforcement.
Cui Bono?
3
Boeing builds a product so complex that there is no room for error, both within its internal systems (harware, software, and on and on) and external systems (pilots, airports, weather, etc) interacting with the airplane. When there is an error hundreds of people die, which is no the case for most companies. When Amazon does not deliver a package on time, hundreds of people wont die.
People must understand that complex systems are risky. In this case, many factors came together to create the perfect storm. MCAS (in itself not the sole reason), incompetent pilots (itself not the sole reason), and other factors not the sole reason.
Investigations still ongoing, but the media, President Trump, and other organizations were wrong to prematurely blame Boeing. I look forward to see the conclusion and details of the investigation of the accidents. At worst for Boeing, it will be shared responsibility of the accidents. At best, the conclusion of this article.
2
@Jos If memory serves, complexity leading to “normal accidents” is exactly what Langewiesche concluded about the ValuJet 592 crash twenty years ago. It is curious he did not revisit this issue.
When we investigate aircraft accidents, there is always a chain of events that occur that contribute to the accident. And if any of these links in the chain are identified, we usually have a better outcome. Some of the links in this chain include:
Aircraft systems design
Pilot training
Economic pressure from Airbus
Pilot proficiency
Pilot experience
Airline culture
Maintenance procedures
Rarely is there an simple explanation to such tragedies.
We must do better.
7
The author makes a great case for holding the pilots at least partially responsible. In both cases, ample evidence is presented that the pilots in both crashes forgot very basic rules. One of those rules -- when the pilot side instrumentation indicated a problem and the co-pilot side and the backup instruments indicate normal, the pilots should ignore the offending instruments. These issues both presented before MCAS kicked in. MCAS made each worse. The pilots in both crashes only had to disengage the electric trim controls to save each plane. All the pilots froze. None of them remembered even the most basic rules of airmanship. It is unfortunate that many want to blame only Boeing. I believe this article exposed some important truths about flying in many countries outside the US, Europe and China. I find nothing disturbing about rooting out the real causes of these accidents, regardless of whose incompetence this exposes.
6
It appears that many readers have missed two fundamental points, which were clearly stated in the article:
1. MCAS is not designed to address a stability issue. It exists to make the pilot control column feel heavier at very high Angles of Attack, when approaching stall. The notion that it exists to address stability is simply not true, as the MAX is not longitudinally unstable.
2. The 737 MAX does not require MCAS to fly during normal operations but had to implement it to satisfy FAR 25, which specifies that the control column needs to feel heavier as AoA increases. MCAS is not constantly working to keep the plane in the air, and in fact should never activate unless in extremely adverse flight conditions or when sensors break.
Sure, the MCAS was implemented poorly without sufficient redundancy, but the 737 MAX at it's core is not unstable and doesn't require software to keep it flying normally. The idea that its engines are too large and have imbalanced the plane is completely wrong.
2
... To top it off, while the technical fixes to the MCAS have been accomplished....
So many thorough details but no mention at all of the need for MCAS in the first place necessitated by the Boeing's cost-saving decision to attach the new more powerful engines to the old 737 body design to save money. This was very well explained in a NYT article earlier this year.
The previous versions of 737 do not have and do not need MCAS.
1
If the device is / was so easy to cut out and flying the plane without it is simple why have it in the first place?
1
Regulatory requirements stating that the feel of the control column should be consistent through a stall, the max without the MCAS system did not provide the proper feel. It is important to note the plane is safely handleable without MCAS it is just temperamental at the margins.
@Patrick Sullivan - thank you.
On the road we blame cars for accelerating when the accelerator is pushed (Audi, Toyota etc.).
But in the air we blame pilots for pitching down when the stick is pulled back?
Strange.
4
No doubt, the pilots of these two aircraft made mistakes in attempting to address the problem. But their incompetence did not lead them to crash the earlier version of the 737. Nor do we have any evidence that these same conditions were encountered by other pilots who were able to overcome them. I think it is justifiable to conclude that, without the intervention of the MCAS system, these would not have become accident flights.
5
Interesting but irrelevant. Even US pilots had trouble with the system and had to disable it. Boeing ignored the problem until there was loss of life, and even then the CEO begged Trump not to ground the planes because of the financial loss, loss of prestige and trust and to give Boeing time to blame the pilots.
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I commented on the 03.23 Times article on 737 MCAS. Here's the comment again, edited slightly for clarity.
Seems like an obvious specification that, "if the plane has just taken off and is climbing steeply to altitude, then no matter what do NOT continue to point the nose of the plane at the all-too-nearby ground." But MCAS apparently did just that. It seems that MCAS was added as an afterthought and has not been integrated carefully and fully with what the airplane is currently DOING.
Boeing has historically NOT used formal mathematical methods to verify rigorously its flight-control software systems. The following aerospace organizations DO use formal logical methods to verify flight-control software: Airbus, European Space Agency, NASA, Bombardier, Embraer, Cessna, Gulfstream, Sikorsky, Dassault and Thales (source: Boulanger "Formal Methods" eye.eu 2012). Formal verification almost certainly would have caught the logical contradiction of pointing at the ground when the ground is only seconds below.
No matter what else was or wasn't done right, Boeing should be using formal methods on its flight-control software. The FAA has begun to mandate formal methods in DO-178C. The FAA should mandate full use NOW, period.
7
I don't think, as some commenters contend, that the article places too much blame at the feet of the pilots. The piece is careful to also point out the problems with the Max's design and Boeing's negligent lack of communication regarding the MCAS system. The main focus of the story is obviously on the actions of the pilots, but it also does an excellent job in describing that these crashes are also a result of a series of events outside of the cockpit.
5
While the author does point to significant errors made by the aircrews, this was under pressure, and the fact remains that without MCAS surely these planes would not have crashed.
2
I'm a passenger, not a pilot, but this article seems carefully researched, is exceedingly well written and carrys the smack of truth. He's not just commenting on the lack of pilot training and 'airmanship', or the culpability of Boeing in this mess. His real focus - quite rightly - is on the corruption, greed and worker exploitation underlying the whole airline business, particularly the low cost carriers. That's what happens when accountants and dodgy CEOs overrule the real experts in any field and bent politicians deregulate that industry to appease their donors and cronies.
4
A good article that really seems more of a "whitewash" than anything else. I'll have to read it again, but it seems no mention was made that the larger engines had to be moved forward and this changed the flight characteristics of the aircraft. Also that MCAS was not known by the Pilots who've flown this plane. Certainly improper pilot training might have compounded the problems. But the main fact is that major changes in flight behavior were not known by the Pilots. Boeing certainly has a major responsibility
2
Let us assume there is a new car similar to Tesla and this car does very well on auto pilot. At the time of purchasing the car we are instructed on how to use autopilot and how to switch it off by a very simple maneuver that even a novice can handle at all times. All is well so far. Suddenly the company installs new updates (by the way Tesla sends many updates to the car on their own) which requires you take a slightly different step to switch off autopilot on the car. No one tells you about it but it is in the manual on page 24 if you cared to download it. Now you crash the car. Do you blame me for depending on autopilot or the car company for changing procedures without informing anyone? That is what happened here.
3
This article has convinced me to fly only with airlines that provide proper training to their pilots and not to fly on a max even after it comes back.
Your article assigns disproportionate blame on Lion Air and its crew ( just like Boeing tried to deflect it totally to Indonesia doubting the skill or lack of it of the pilots).
Does the author believe that the Max 737 disaster would never have happened in the Western world because of its more competent flight staff? This tragedy could have happened any where in the world.It is clear that the bulk of the liability is on Boeing for its faulty equipment and the shoddy way they managed the training process.
3
Like most accidents, the ones picked apart in the article had multiple causes. It's wrong to place the entire blame on the pilots or on Boeing. Both are innocent and both are guilty.
I wish the NYTimes would limit technical responses to this article to those who have extensive experience designing or flying Boeing passenger aircraft, or those who are expert in safety management systems and human factors.
The more technical comments here from armchair experts and backyard pilots are less than helpful.
An interest in aviation does not an expert make.
1
What brought down these two 737 Max aircraft was not a lack of airmanship by the pilots but in fact greed by Boeing executives.
The 737 was never designed to handle the engines that were put on the Max and Boeing forced its engineers to design a system (MCAS) to compensate for this fact. Furthermore, they didn't share the final specifications for the MCAS system with the FAA and never told 737 Max pilots that the system existed.
The blase indifference the author shows to what was going on in those doomed planes' flight decks is reckless. To suggest the pilots should have just followed a runaway stabilizer procedure and used manual trim to right the situation ignores several important factors outlined in the air crash investigations.
First, this was not a runaway stabilizer. It was a new automated system the pilots didn't even know existed. The stabilizer was responding to their control inputs only later to be overridden by the MCAS system. It didn't present as a runaway stabilizer scenario.
Second, the Ethiopian pilots did as the author suggested and cut out the automatic trim. However, they were unable to manually trim the aircraft, most likely due to the amount of force present on the stabilizer, and had to re-enable automatic trim in order to recover from the MCAS induced dive.
The 737 Max is a plane that never should have been and the author's attempt at blame shifting is appalling.
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With over 25,000 hours in a 737 I can say this is the best written, most comprehensive, and most accurate article I have seen published on this subject.
5
As a captain at Southwestern, that's good to know.
I still won't be flying this plane.
6
"These crashes are demonstrable evidence that our current system of aircraft design and certification has failed us," ...Captain Chelsey Sullenberger (the miracle on Hudson pilot) before the Congressional hearing on June 19, 2019. During the hearing, Sullenberger strongly rejected the suggestion that pilot error was to blame for the accidents. "I'm one of a tall group of people who have experience such a sudden crisis. I can tell you the the startle-factor (MCAS) is real and it is huge. Within seconds, these crews would have been fighting for their lives," added Sullenberger.
So, unlike others who prefer to generalize about pilots skills in the developing countries, my instinct is to trust an independent voice of reason such as Sullenberger, a pilot who has actually faced death defying event, and tested the MCAS software, finding it wanting. For crying out aloud, I suppose aviation authorities in Canada, Europe, Asia, Africa, Latin America, Middle East, have all somehow "conspired" to shut down 737 Max 8 - totally impossible.
9
Thanks to the NYT for continuing to follow the 737Max/MCAS story.
The author assumes that some/many/most American/Western European 737 MAX pilots would have been able to successfully deal with the problems faced by these Indonesian and Ethiopian pilots.
Did any American/Western European 737MAX pilots ever face the same or similar problems these Indonesian and Ethiopian crews faced?
Was the root cause of these crashes deficient aircraft maintenance, hopefully never found in American/Western European 737MAX operations, so that American/Western European pilots never faced the situations these Indonesian and Ethiopian pilots faced?
I suggest that is a fit subject for further investigation.
2
With pilot training and airmanship problems acknowledged, when Nikki Haley and the rest of the Boeing Board fly regularly on the Max, I will start to give it consideration.
This is an excellent inside look at these tragedies. My thanks to NYT and the author. But the pilot error conclusion is a perspective call. The fact is the emergency the pilots encountered was caused by deficiencies and lack of redundancies in the Max design. It was a cacophony of causes. The new aerodynamic characteristics of the larger engine placement on the wings, the new MCAS software to compensate for the resulting stall characteristics, the new systems reliance on a single angle of attack sensor, and the lack of adequate notice and training concerning the new MCAS made the aircraft more difficult to fly than the earlier 737 models these pilots were used to. That is a fault and cause that rests with Boeing, even if the pilot errors referenced in this excellent piece are all well founded.
1
Whatever the case, I think The MCAS should have been highlighted rather than hidden. Also, Boeing should have required simulator training to fly the new 737 Max. But that would have cost the corporation money.
2
While I enjoyed this article, the author's certainty that HE would have handled the situation perfectly is a bit off-putting. As usual, one's ability to fly an airplane is inversely proportional to one's distance from the glareshield. Langewiesche's smug superiority is on full display here.
Boeing should not be excused, nor should the airlines that neglected to properly train their pilots. Pretending that it was solely the fault of the pilots is convenient but misguided.
2
While this is a very informative and interesting description of the two MAX tragedies, why is the author so sure of his facts while at the same time complaining that the actual data from the downed planes has not been made available to all investigators?
1
Horrifying to read this. And the experts, self described or otherwise) commenting can’t agree on the solution. Makes one want to stay home.
1
I'm no engineer, but putting more powerful engines on a plane not designed for them, and then cooking up a digital "fix" to cover for the inherent flying problem said engines cause sounds criminal to me. If it quacks like a duck...
2
if Boeing is manufacturing a 180 passenger commercial aircraft which requires a pilot with "airmanship" to fly safely, and it is known that "airmanship" is a disappearing skill few modern pilots now have, particularly those with certain airlines, and that unprepared pilots are the rule not the exception, how can Boeing sell these aircraft to these airlines?
Sorry, but it all comes back to Boeing.
2
Perhaps the author can explain the discrepancy between his statement of the maximum airspeed of the 737 as 360 knots which is far lower than the speeds at which this aircraft typically cruises.
Outstanding article. I'm reluctant to absolve the airplane. The author says, "The MCAS as it was designed and implemented was a big mistake.” It activates even when there's disagreement between the left- and right-side sensors and continues to fight even when the human makes contradictory inputs. Mr. Langewiesche writes, "the technical fixes to the MCAS have been accomplished,” but doesn't specify whether those fundamental flaws been eliminated. And he adds, "other barely related imperfections have been discovered....”
Nor is distrust of Boeing necessarily misplaced:
"In 2007, the [EU] and the [US] permanently banned all Indonesian airlines from their national territories...for reasons of safety.... The ban put Boeing and Airbus into a delicate position. They would now be selling airplanes to officially declared unsafe airlines that the American and European authorities expected would keep killing and injuring their passengers at a rate that would be unacceptable in the West. By 2007, the biggest of those airlines was Lion Air. That year, it placed a new order for 40 additional 737s, and Boeing happily agreed to fill it.”
There’s a constellation of problems here - woefully inadequate pilot training; design & cultural flaws at Boeing; and political considerations too: "He approached the Transportation Ministry to inquire about licensing the airline and was laughed off....But when the industry was deregulated shortly afterward, Kirana could not be denied."