I wonder if someone using a cellphone during the flight may have caused the erroneous data? I was recently on a flight where the passenger behind me kept talking on a cellphone during taxiing for takeoff. They finally hung up when I and other passengers started yelling and threatening to call the attendants. I cited this crash as a possible consequence of data interference!
15
Flying these planes is flying by instrument. Pilots getting misinformation are doomed, as are passengers.
10
This was a very good article about the 737MAX M.C.A.S.. There are 2 types of emergency checklist airlines employ. The first most dire checklist is the Memory Items Checklist, also can be called Boxed Items or Immediate Action Items, the name varies among airline's procedures or regulative overseeing agency. These item are on a QRC, Quick Reference Card. Then there is the QRH for Quick Reference Guide, this is a thick book with many procedures and performance tables. If pilots are encountering a problem and it's not a Memory Item or on the QRC, then you reference the QRH. In the last 5-6 years, airlines have gone back to the Boeing Checkilists, for legal reasons. You don't want to have an accident and use the airline procedure that didn't fully follow the Boeing Procedure. Back to the first level of emergency checklists, Memory Items, as the name implies these are committed to memory. Stab Trim Runaway was a Memory Item up to 5-6 years ago and was removed from the Memory Item Checklist. If you had a runaway stabilizer, one of the steps was to turn off the Stab Trim Cut-Off Switches on the forward pedestal. This procedure now in the QRH. Long time 737 pilots have memorized this procedure and new pilots are not aware of it. Experience is everything in this profession.
34
There is no much hyped MCAS installed on the B-737 Max. Here is a link for the Type Certificate Data Sheet (TCDS) issued by FAA. It includes all minor/major modifications on the aircraft but the MCAS is not listed anywhere.
http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgMakeModel.nsf/0/179cdacd213801658625832a006b2e37/$FILE/A16WE_Rev_64.pdf
2
What is disturbing is that FAA goes with the Boeing and sacrifices safety for profit. Then even European Safety agency is clearly forced to do the same. I’m sure it’s all “to save the jobs”, but now that we have a pile of dead bodies the questions about this strategy better be asked and answered.
23
So, in the interest of cost reduction, a plane is designed that is fundamentally unstable in its operation and requires a system of sensors and computers to maintain normal flight. Testing for emergency behavior, such as a failed sensor or some very unusual disturbance, is minimal and unimaginative. And human intervention in the event of some system malfunction is rendered inadequate because pilot education and training was deliberately omitted to reduce costs and encourage buyers.
All of this reflects a company run by bean counters eying only the bottom line. And regulators played along!
Sounds like an Ayn Rand novel, eh?
42
This article about Boeing is another reason why regulations are needed and necessary and the government, especially the trump administration, needs to stop trying to deregulate everything possible and regulators need to hold companies completely accountable for their actions. We need a constitutional amendment requiring that all cabinet members have to be nonpartisan experts within the field that they run. An former oil executive, banker, lobbyist or any other business industry leader has no business running the FAA, EPA, FCC, SEC or any other part of the government whose sole responsibility is to protect the welfare of the people or the environment in which they live. Regulations are mostly put in place to protect people and not industry. The cost of something should have no bearing upon human lives or health. You don’t deregulate to protect the wealth of the top 1% and trump’s supporters really need to learn that lesson. The health and lives of people should matter more than how big or small the government is. It is very disconcerting when a farmer is complaining about the cost of making sure the poisonous chemicals they use don’t run off into the water supply, or a coal company is complaining about the cost of preventing toxins from entering the atmosphere that cause cancer, or an oil company complaining about the cost of making sure oil doesn’t spill and contaminate the soil or water. Money should never trump, no pun intended, the safety of people’s lives.
43
I am left wondering if MCAS is actively correcting a airliners angle of attack why that isn't visibly indicated in the cockpit?
Wouldn't a pilot want to know that an automated system is correcting the pitch of the plane?
The only way to tell is the position of a couple of switches?
15
everything is wrong
Boeing designed the MCAS with good intention of maintaining commonality and or increasing safety but in this case the assumption they use was not right when it was faced in situations where many things are less than ideal like Lion.
Obviously when designing the MCAS Boeing was assuming that the airline’s maintenance is reasonably good. The fact that it was written on the tech log by the previous pilot and was realized for flying is proof of the opposite.
Lion Air expanded really fast from about 30 airplanes in 2006 to having more than 115 in 2018. This can only be translated into recruitments and fast track career for all pilots, engineer, cabin crew, etc. meaning the average level of experience goes down. low experience is more prone to make error.
It is exciting time for employees. One who have been copilot for only 3 years (and flying for lion only since finished training) find them selves pushed by the manager to upgrade for captain. New captains, copilot, cabin crew, engineer, ground staff. You don’t need to be good. The airline needs you to be in charge because they need to fly the airplanes.
It’s not unknown new engineers just clean the connector and do a BITE on the computer to clear the error message and released the airplane
Now the chairman is acting angry with Boeing while actually he needs to cancel hundreds of firm airplane order that is too many for current Indonesian market where all airlines are struggling to survive.
14
Isn't corporate greed a wonderful thing? Remember the El Faro that sailed straight into the hurricane back in 2015 costing 33 mariners their lives? TOTE (owner of El Faro) played a big part in its demise, but did we learn any lessons from that? At the end of day, the ultimate objective is the profit to be made, not the lives to safeguard.
11
Unfortunately, the standard fallacies listed below are usually in play and may lead to error in these types of cases:
1) Profit may be maximized at the expense of all other considerations,
2) Adhering to #1 above, administrators' decisions usually override engineering concerns, and
3) Corporate structure always protects the administrators (referenced above) from the consequences of their poorly researched decisions.
12
@Hugh Hobbs "Profit may be maximized at the expense of all other consideration"
As in comfort. As in width of seats.
10
I see a lot of controversy in the comments section but one thing is absolutely clear here: safety was adressed on a “market driven” supply-demand base in this case. Let’s make no mistake, safety is not a commodity, it never was and it should never be. Boeing and the FAA simply dropped the ball and now they are rushing to “explain” it.
27
As a programmer, I'm shocked any programmer would have written code that didn't include the possibility of faulty sensor data - Boeing programmers have no excuse, they have blood on their hands.
I write code for industrial control, first priority, operator safety, second is protect the equipment. They could have easily checked the other sensor to ensure the data was correct.
29
Boeing has said that the crew of the fatal flight should have known to follow the "Runaway Stabilizer" checklist. However, Boeing's own checklist for defines the condition as "Uncommanded stabilizer trim movements occurs continuously."
The Lion Air 610 flight did not face continuous trim movements, they faced intermittent trim movements.
Boeing's own checklist---as written---doesn't apply to the situation these pilots encountered. Yes, some systems knowledge would have helped the pilots know to use the cut-out switches. And that's why the pilots should have had the information in the manuals and training.
13
The deadly control system failure of the 737 MAX can be traced to, of all things, a purchase decision by American Airlines.
In 2010, Airbus launched the A320neo that used new innovative engine designs. Even though the launch was accompanied by 40 firm orders, Boeing ignored it because it had a new competing plane on the horizon known as the New Small Airplane (NSA) and the fact that airlines tend to buy new aircraft from suppliers that already are major parts of their fleets.
Boeing's complacence was shaken when the A320neo initial sales success was punctuated by an order from American Airlines, a formerly all Boeing user, for purchasing options for 280 A320neo family aircraft, along with a slew of A319 and A321ceos. With a key customer essentially in danger of jumping to Airbus, a scrambling Boeing decided to reengine their current 737NG and to push back the NSA launch to 2030.
Scramble they did to produce the 737 MAX (18 months later), but in that scramble they had to squeeze the development cycle that would have likely disclosed the aircraft control problem that flight certification agencies noted.
Boeing's scramble paid off for them commercially but at the cost of 189 lives on Lion Air Flight 610.
17
From my experience in years of developing and maintaining computer software, I know that any new release of software is prone to errors. Knowing what changed was one of my problem-solving techniques that I shared with many of my associates. "Bugs Bernie".
7
@bnc Airplane pilots do not have the benefit of time that I had to make critical changes and take corrective action. They must be trained to know what to expect and know how to correct it. It is ironic that one of the customers I supported was Boeing and that they were sticklers for the quality of our products. Why weren't they sticklers for the quality of theirs?
9
My background is in Medicine and I find it gobsmacking that the airline industry is allowed to be so far behind!
It is unthinkable that FDA would be allowed to introduce a new drug without making sure doctors are aware of all side effects. Here in Europe there are further strict rules for CE marking of new medical devices and software tools.
How come in the 21st century the airline giants still are allowed to write their own rules for safety standards?
9
Really? The rate of errors in medicine is exponentially higher than in commercial aviation.
8
@Mark Marks
You seem to confuse human errors with procedures. My note is about the poor certification processes in the aviation industry and that they are allowed to approve their own technical inventions.
(On the note of human errors though, Martin Makary and Michael Daniel, at the Johns Hopkins University’s school published figures suggestion that possible 25000 deaths out of 2.7M per year in America could be avoided with better care. I guess the statistical conclusion from that would be that it is more dangerous to live than to fly.)
7
I worked for the Federal Railroad Administration as an inspector for a long time. The FRA essentially does the same kind of monitoring that the FAA does, except it works to make railroads safer. Unfortunately, the FRA falls prey to the industry which fights against additional regulations. Example: look how long it has taken for Positive Train Control to be implemented across the nation. Yes, it has been a great expense, but the number of lives and money saved in the long run more than compensates for the expense. However, like the FAA, the FRA too often is instructed by politicians to hold regulations back when the hue and cry from the railroads gets too loud in the offices of our our senators and members of the House. The result: accidents.
11
I believe Boeing made decisions based on the assumption that airlines and pilots behind the yoke are all competent. Doing the same correction over and over for 10 minutes without exhausting all possible corrective courses of action (like a checklist) is truly frightening. The previous pilots reacted correctly, reported the problem and yet the plane was allowed to fly again. It’s easy to jump on the corporate-bashing wagon, however the only capable villain here is Lion Air - their operational track record paved the way for this tragedy.
6
So it appears step number two in over-riding MCAS was to switch off electricity to tail stabilizers and manually crank the adjust wheel. And there has been already incidents where the pilots had to switch to emergency procedures on the same plane. As some pilots suggested here in the comments, "I'd switch to manual in one second", the question is... the crank, has it been working? Even without any training switching to pulls and levers means "cut off the power first". Has it been done??
5
'The story of the change to that system, ..., shows how safety on modern jetliners is shaped by a complex combination of factors ...
No it doesn't. It shows exactly what happens when marketing overrules well-established pilot training procedures. People die. It's that brutally direct. The rest of the story confirms this.
6
So you've just taken delivery of your new car and gotten up to speed on the freeway. You've engaged the cruise control, but unfortunately neither the manufacturer or the dealer has seen fit to warn you that on page 34 of the operation manual there is a footnote in the cruise control instructions which states "in this model drivers should be aware that pushing the brake pedal no longer disengages the cruise control system......"
20
Except a 737 is not a car, it's an aircraft, and pilots are supposed to know their aircraft inside out. Trying to pin this Boeing and the FAA is desperate - it was the fault of a dangerously incompetent airline and inadequately trained pilots.
5
This was essentially a "runaway trim" situation that wasn't dealt with by the pilots. Whether from a malfunctioning MCAS, auto-pilot, or servo motor -- cutting off the trim with switches/breakers is the response across many aircraft, even single engine piston aircraft (trainers).
If you are looking for a bigger picture, it's that pilot failure to manage automation malfunction is increasing due to over-reliance on technology. This is very avoidable.
But this incident is not a complex web of anything, despite what this article (and others) suggest. I am a pilot.
12
One hundred and eighty-nine families are bereaved. One hundred and eighty-nine human beings died after a harrowing ordeal of terror, panic, utter agony.
Boeing's flimsy excuses are embarrassing.
The fact is: Boeing cut corners. In the aviation industry, when you cut corners, people die.
Boeing has a history of shifting the blame & even orchestrating cover-ups. North America Aviation, which eventually was merged into Boeing, engaged in a cover-up after a nuclear accident in California, in 1959, that affected all of Southern California & especially Moorpark. I lived in Moorpark (2009-2010); had I known, I wouldn't have. Food is grown in the area. It was only much later that I watched a documentary about the 1959 disaster ("Nuclear Cowboys: LA's Secret Meltdown"). You can read about this tragedy, that had adverse health impacts, on Wikipedia in the article entitled "Sodium Reactor Experiment."
Flying is inherently risky. We need to have aviation companies that do not cut corners & do not shift the blame. Training pilots may be expensive. Paying for deaths is even more expensive. If you can't handle the responsibilities of building flying machines, don't even try to.
10
This information could destroy Boeing, but it is important to let it out. Knowing is what preserves democracy. Very sad that the European Union uses its basis of DATA Protection to keep this kind of reporting out. One small reason for Britain to leave it. No one talks about it though.
It is business and politics, a sometimes fatal combination.
Boeing wanted to sell more aircraft than its rival and had, still has, an inferior product.
Boeing has pursued a different idea than Airbus for a long time, and that is that an aircraft has to be flown primarily by its pilots while Airbus has put its money early on on computerized systems that take over most of the pilot's work load.
As Boeing found out that its approach wasn't that successful when compared to Airbus, it decided to switch to a system similar than the one from Airbus but did not want to lose face.
So Boeing made a few changes that it did not announce and the F.A.A, went along as this was an issue of national pride.
Politics at its worst.
"Boeing first" and against the competition of Airbus, never mind the safety and required training, after all, it is only passengers that are at stake which is nothing compared to profits.
And then a number of incidents and an accident happened.
Now what?
Will we see the same years of litigation we have seen with other notable Boeing crashes like the B767 over Thailand?
Where Boeing tried to blame the accident to faulty maintenance while in fact it was another design flaw?
It is the US approach to design, to implement changes and see what happens while others, European and Asian developers, would test, re test and then test again to make certain that flaws are ironed out before a customer will get the product.
And that US approach has - again - caused lives.
3
@Thomas
As a seasoned European pilot of Boeing aicraft, I can assure you that they are much more intuitive than their Airbus counterparts.
It's not that the Airbus family isn't safe - it is - and, in fact, they're easier and less stressful to operate on a day-to-day basis than their Boeing counterpart. It's when it goes wrong that the Airbus will become a handful and the Boeing will be pretty straightforward.
The 737max story is utterly horrific and blends regulatory failures, cost-cutting, maintenance criminality and lack of crew awareness.
It's not the philosophy that's wrong here - it's the product, the company, the airline, the management, the FAA. Airbus have been equally guilty in the past.
This does not absolve Boeing for the 737max which appears to be a triumph of accounting over accountability, but I prefer their approach to flight deck automation and crew integration.
They need to ensure this 'no cost, no crew training' scenario never happens again.
(777 pilot - 757/767/A320/A321 in the logbook)
15
@Zoe, I knew that this discussion was about to happen :-)
My pilots, I'm only a PPL and rated for smaller aircraft, are of the "Airbus brotherhood" and fly me around the world in an A-319.
They usually tell me that flying the Airbus is more like "driving a bus" as the computer takes most of the operation.
So for them, Airbus is, just like you say, a tool that will keep you from flying but keeps you looking at your screens and which, in case of an emergency, will become an entirely different item.
One I hope they can handle in any situation, but that is what these guys are good at.
At the same time, my company is also involved in airline business, some of our B737 Pilots tell me that they prefer their aircraft over the Airbus because it is still more in terms of flying the aircraft than being a computer operator.
So it is about personal preferences which aircraft to fly.
On the other side, the producer side and the regulatory side, the story is a different one as here some form of politics is playing a huge part.
There is no one more aggressively selling aircraft than Boeing and they usually have a "Buy American Pride" approach that is less appealing then a "Buy Quality" approach to our clients.
Boeing and Airbus could not be much different than they are and that is what is causing Boeing to take more risks.
It is only a question of time when then next crash will happen because of this aggressive sales pitch not driven by engineering but by marketing, not if.
3
While Boeing's drive to cut costs left a reduced margin for error, the Lion Air management decisions to forego basic maintenance on an aircraft once pilots has logged problems on previous flights pushed events over the cliff.
Unfortunately, Lion Air has long had form in this regard. It's hard to imagine designing any aircraft that could be considered safe to fly in such a comprehensively corrupted safety culture. Stronger regulatory action, both in the US and Indonesia, is clearly needed to keep aircrew and the flying public safe from the inevitabke result of raw and unchecked capitalism.
3
Once again Europe is ahead of the US in regulating capitalism. Just not far enough ahead to save these flyers, who are in effect guinea pigs in a live test of a regulatory system thus shown to be complacent and lax. A system that allows corporations to put profits (avoiding training costs) and market forces (getting that new model out into service quickly) ahead of safety. The invisible hand is sometimes deadly.
11
There is no evidence that Boeing did flight-testing of M.C.A.S. with erroneous sensor data, and it is not clear whether the F.A.A. did so.
Don't want to sound too critical, but if this is true, then Boeing and its engineers - developers and testers combined has a lot to reflect upon. And FAA must account for it as well. There seems to be a big disconnect with the basic best practices of engineering and software development.
14
I don’t know why you’d be concerned about “sounding too critical” of these & other obvious failures on the part of Boeing, the FAA et. al.
While many are uncomfortable with criticism, the ability to critique others is a key part of working together to maintain the health, welfare, safety & security requirements of our increasingly inter-connected global societies.
I’ve read that Brazil is at least a somewhat corrupt nation, it would be fascinating to learn why they were allegedly one of the few nations that bucked the trend in this matter. Perhaps the “incentives” their agencies, etc. required to ok the MAX were insufficiently satisfied.....
2
Who knew Brazil led the world in flight safety? I didn’t.
12
Boeing is accountable. End of argument.
11
A reputable airline would never have let that plane takeoff for that flight after what had happened earlier.
2
Oddly enough, at terrible cost, the 737MAX has now become the safest aircraft to fly for at least the next year.
2
I am an avionics systems engineer.
This is my worst nightmare.
However, what is equally nightmarish is the failure by management. They learn all they can about schedule risk and cost risk while getting their MBAs or PMPs, but they never ever think of safety risk or learn the valuable lessons of safety taught by history such as the shuttle disasters. Or, worse, they ignore those lessons because they are inconvenient truths.
It is frustrating as an avionics systems engineer to be obsessed with safety, yet management throws all that away just to save cost or put more money in their pockets with performance bonuses.
Managers need to be held criminally liable for their choices. Adults take responsibility for the consequences of their actions.
54
@VJR
This is why imo there should be professional engineers at all management levels in your industry - and similar industries - as well as MBAs, who seem to have only cost issues as their primary concern.
25
Where did that faulty sensor of the Boeing MCAS system make ?
2
Net-net, bottom-bottom line, is the 737 MAX safe for a passenger to fly in? I would like to know soon. Thank you so much....
6
I suspect there are message boards/website, etc. dedicated to the discussion & analysis of the issues surrounding this crash. I imagine that at one of those locations, at least one individual would likely be more than happy to to supply you with their opinion.
I have the feeling that the NYT comments section may not be the ideal place to make your request, for multiple reasons.
2
When there are errors at every level, from manufacturer to FAA to airline to pilot, an investigator would try to find out how the system failed to catch the problem somewhere along the chain.
This accident should lead to a systemic investigation in how change in airplane design is implemented. Everything should be on the table.
13
Deception is too mealymouth to describe the blood that Boeing and the FAA have on their hands as a result of their decisions to save money at the expense of human lives. May G-d rest the souls of those pilots who fought to their death, and the innocent souls aboard that plane. I am old enough to remember the carnage of the Boeing DC-10s and the lies Boeing told to sell jets to Turkish Air.
11
@CactusHugger For precision sake, DC-10 were McDonnell Douglas planes, not Boeing. Nothing to do with your comment however.
5
FAA budget cuts--a good idea?
10
@The Poet McTeagle
They get plenty of money - from campaign contributions to their boss's boss.
3
The aircraft flight control systems failed due to faulty input and caused this crash. Blaming pilot error is hindsight bias and counterfactual motivated reasoning.
Experienced pilots crashed this plane because they didn't understand what was going on. Can anyone really claim that pilots didn't need to be briefed and trained on this system when it has clearly caused a crash? If competent operators fail despite their best efforts, this is the fault of the system and blaming the pilots is against the fundamental insights the aviation industry has pioneered. Human being have limits and the systems must be designed to anticipate this. I predict that the investigators will be clear about this when the results come out. This is going to be a costly mistake for Boeing.
42
A great piece of investigative reporting - thank you.
29
This is a classic example of what happens when Boeing, FAA cut corners on safety to save on training cost to be competitive.
The pilot Mr Tajer is right when he was quoted: "a pilot needs to know what systems are aboard so that they become “a part of your fiber as you fly the aircraft.”." The dead Lion Air pilots were no aware of the MCAS nor the previous bewildered pilots who managed to land the same plane safely earlier. Those pilots were put in a position where they could not understand or control the plane.
This should never have happened and everyone should push back against the slow, secret n imperceptible slide in safety standards and culture of the plane manufacturer in cahoots with the regulator. To retain the public trust, their safety and not the profits of Boeing must come first. The FAA as the last bulwark against defective planes has failed in it's duties. There must be accountability from Boeing down the chain of liability otherwise the slide will continue and become the culture, i.e. the acceptable way of how new planes are made.
29
We used to say “it it’s not Boeing, I ain’t going.” We may have to reconsider.
15
I remember when companies large and small were invested in their employees and regularly sent them to training on company time. Those days ended a long time ago when they decided to put profits above all else at the expense of their employees. None of us are better off for this change in the equation from health insurance to retirement to outsourcing and now our lives are at all risk because of it.
17
The entire focus is on MCAS and how the pilots were not informed about it. The information on MCAS as a system has still not been shared with the pilots. Read my blog on "B737 Safety or Ethics" published in mindFly.blog highlighting the legal immunity that the manufacturer had enjoyed for known design defect. The same has been upturned by the court in early 2018. In the B787 battery fire incident investigations, NTSB has documented that FAA and Boeing are responsible for the defects.
What we forget is that there is an existing system in the B737 called"Speed trim system (STS)" which is monitored and has a fail light. If one channel fails, the Minimum Equipment List requires that second channel to be operational for the dispatch of the aircraft. STS also helps in automatically and autonomously, trimming down of the stabilizer if the aircraft nears a stall. How many people know that? MCAS does a similar function but the difference is that it is not monitored by a system to ensure that it is operational and there is no FAIL light in the cockpit as is given for the STS. What if MCAS fails in between a series of flights, which any system can fail and the aircraft keeps flying? This is against the design objective of the MCAS and certification. Moreover, MCAS is not listed in the Type Certificate Data Sheet issued by FAA. This document lists all the minor or major changes, modifications in the new aircraft.
30
I had a job that required weekly travel by air. I was married to a professional pilot. I never selected airlines based on price, always went for the ones with the best paid, most experienced crews. And if the weather was ifffy, I didn't fly
15
When the Ad tells you, this craft practically flies itself! beware, it means the human pilot is being push out of the loop little by little, and is unable to cope when necessary. I hope at least the affected get a big chunk$$$. What do you call totally avoidable accidents, the carrier is responsible for its pilots must pay.
5
Well I guess by now, 737 Max pilots are aware of MCAS. But go back. Why not inform their intuition? Aren't pilots the kind of aficionados who would absorb this, let it inform them?
1
As a VERY nervous flyer, I have to admit that reading all the comments obviously written by very experienced U.S.-based pilots is very reassuring. My heart breaks for those who lost their lives on this ill-fated flight; however, as evidence mounts that perhaps this disaster was largely the result of human error, I can’t help but thank my lucky stars to have the good fortune of routinely flying American carriers piloted by the world’s best, brightest, and most experienced. Thank you so much for delivering us safely: flight after flight, year after year.
8
@NurseKaoru. Don't get too America-is-best about this. Non-American airlines have equally well-trained crew, and many countries have more stringent regulations because they are less beholden to corporate interests. I would never fly an Asian or African "low cost" airline. In fact, I avoid all low cost airlines. But if we're talking Singapore, Qantas, Air France, Emirates, Air New Zealand, KLM, Cathay Pacific, and those kinds you get the good training and even better service than American carriers.
13
@Stevenz Spot on ; and, even if the Indonesian company has not an impeccable safety record, nothing says the pilots of this doomed flight were inexperienced rookies.
Stab Trim Cutout covered immediate action item. However pilots and mechanics must know all differences and changes.
Usually handled in recurrent training during model introductions. Sometimes a course of few hours. Other times a handout or page change.
3
There is a one-way traffic sign near my home, which had been with tiny characters "except bikes" (a sort of common exception). One day they removed those tiny characters, probably because of some accident, and I was stopped by the police after a while. They released me only with a warning, but what they said was "there is no hide in the sign."
In the US, in the past twenty years, company profits have been driven largely by cost cutting. R & D budgets have been cut in every industry across the board, discounting innovation, good design, and providing value to the consumer, and disregarding the good sense of a robust product pipeline.
Boeing reacted to the market in developing the 737 with MCAS; the market was also paramount in their decision to work toward no additional pilot training. Companies decide whether they will be an innovative organization or a “first adopter,” always following the industry leader and saving cost in the process. Boeing has apparently chosen to be a first adopter—a cost-cutter. The needs of humanity/the consumer are secondary; cost-cutting as the primary means of realizing profit will always give short shrift to considerations like safety and environmental protection that are, in a long view, far more important to mankind.
Until $30M CEO comp becomes a thing of the past, companies like Boeing will continue to make light of other factors—even the sanctity of human life—in favor of increasing profits, meeting financial goals, and increasing the incomes of the greedy. Safety, integrity, and job security are no longer valued beyond their potential for financial liability, driven by the unbridled greed in the C-suite, from whence the political contributions that decide our governmental direction come, now that corporations are citizens of the US. The bean counters are their closest allies.
28
QATAR CEO Al Baker, known for his straight talk, coined a very famous statement at an IATA General Meeting some years ago. In front of all the heavy breathers of the Industry he said: “Boeing is a Company run by bean counters and lawyers” LOL...
17
With all the attention that medical costs are getting, cost cutting consultants have been roaming the halls of US hospitals.
1
Unconscionable action and non action in the name of expediency. Designing a passenger aircraft that is less stable than its predecessors is wrong. Compensating for that baked-in design flaw by devising inadequately margin-tested control laws and absent test-as-you-fly discipline is grossly unprofessional.
Compounding this malfeasance is single string design in a critical application. Multiple sensors were installed but their combined use ruled out for data verification. Just this flaw alone caused the plane to repeatedly plummet to Earth despite multiple attempts by the pilot(s) to maintain flight.
Even more damning was the disabling of the decades-long methodology of using the yoke to override an autopilot. In this case, that only temporarily overrode MCAS before it reasserted authority. How confusing that must have been to those pilots with all that goes on in a cockpit during take-off when there is little room for error and scant time for complex situational evaluation. The subsequent needed implementation of unfamiliar responses requiring multiple actions by both flight officers who were purposefully kept in the dark was a prescription for disaster. Expediency, just to save a buck at the flying public’s peril.
Where were our regulators one might ask? The final word on “similarity/in-family” and hence the requirements for flight certification ultimately rest with the FAA or have they abrogated that role and assigned it to the industry they purport to regulate?
25
@Sal Norman For me, best comment so far. Congrats.
1
So let's see if I've got this straight...Boeing tried to squeeze more fuel efficiency out of a "mature" design by using engines that didn't fit, so they changed their position in a way that mucked up weight-and-balance...then tried to compensate for it in software. Then they disabled one of the override provisions and didn't tell the pilots anything about it.
And the FAA rolled over and said "That's OK."
Now Boeing's announced that they've "automated" their quality-control system and laying off a bunch of inspectors, in full expectation that the FAA will roll over on that as well.
I don't know about the rest of y'all, but I don't think I'm going to be flying much anymore.
41
@Art Marriott Certainly not a Boeing 737 at any rate. This is appalling.
7
You mean the 737 Max. This problem isn’t present on any other 737 variant.
9
In real time, all pilots would probably do exactly what their training and experience has shown to work in the past. By not telling the pilots of this very important add on to the control systems, the pilots do not understand what they are flying. It would be like getting into a self driving car and not being told about the new braking system and what to do in case of malfunction of this system. Toyota had a similar software malfunctioning the runaway accelerations experienced in some Toyota vehicles: the fix was the foot mat pressing on the accelerator not the costly software.
When errors accumulate they do so exponentially and in this case, the FAA regulators caved under pressure from Boeing, Boeing sells planes not life insurance and can cover the fines from FAA and lawsuits, pilots are mum when the Brazilians should have talked to them or their union about this problem and unions must have known about the European hesitation and the Brazilian training. Until we arrest engineers who keep quiet knowing the system is bad, until we arrest CEOs for criminal manslaughter because they knew the system was flawed and until we hire more FAA regulators to truly inspect these new planes, we will see more crashes.
22
Sometimes it sounds like an advertisement for a “brand new, totally redesigned…” automobile . And my head is still swimming with all those inter-agency and intercompany decisions to not/make changes to costly training procedures e.g. total re-immersion in a simulator versus just a couple mentions (or not, as with the MCAS).
But what really gets me, is that Boing is sticking to it’s guns and saying that “established emergency procedures are sufficient” But pilots have disagreed stating that it “understates the complexity of responding to a crisis in real time, pilots said.”
Sounds more like it! And just look at the picture of that monstrous engine (2 usually) on that “newly redesigned” airplane, it’s humongous and then there’s two of them and for some reason they couldn’t mount it in the same place of the old 737, Without somehow designing new landing struts and wheels to make it NOT look like some knuckle dragging behemoth.... oh industry
9
@Nasty Pipsqeak Boeing have to say that or it opens them up for legal liability. Many years ago a company called Beechcraft made a beautiful, IMO, aircraft called a B200 King Air. It "allegedly" had a problem with the wing spar. A Canadian company provided a $20,000 fix for this alleged issue by attaching a strap to the wing spar that extended the life of the spar. Beechcraft could not be seen to rectify this alleged issue since it would have been admitting there was an issue with their wing spar and opened them up to legal liability and a possible mass of company destroying lawsuits.
Please note that I am NOT saying the Beechcraft B200 King Air did have a wing spar issue or that the aircraft was unsafe. To my knowledge there was never any legal action to prove this alleged issue. I do however wish I had gotten the chance to fly that magnificent aeroplane.
Boeing really need to build a totally new 737 replacement where there will be room to hang larger sized power plants under the wing. They are stuck with the P&W JT8D "slimline" turbojet of the 1960 and don't have the room for the hi-bypass turbofans of today. A problem that the 80s designed Airbus doesn't suffer from.
6
@Joseph King The new 737 most definitely *does not* use JT8D's. ALL new jet aircraft use high bypass turbofans. The 737 Max uses the CFM International LEAP engine, an improved version of the CFM 56. This is easy information to find.
2
@Stevenz Please read my last paragraph again, especially the last half of the second sentence starting after 1960. I should have worded it better but I mention the JT8D of the 1960s (missed the s in 1960 first time round). Apologies for any confusion caused. The 737-300 with the larger powerplant didn't arrive on the scene until the mid 1980. Do you remember why the bottom of the engine cowl was flattened and not a full "circle" like most, if not all, other turbofan cowls?
The problem with the MAX having to have the engines mounted higher and further forward and therefore the "need" for MCAS is because the initial 737 didn't have long enough undercarriage struts to allow for the larger turbofans. They didn't need to at the time because the JT8D was a much small diameter (slimline was my wording) turbofan so longer undercarriage struts were not needed. I don't think Boeing thought this aircraft would ever be as popular as it became so the short undercarriage struts were not an issue at the time. It was the 300 series when this became interesting hence the question about the bottom of the engine cowl. If they had designed it with a longer undercarriage struts then the MAX engine could have been mounted in the optimal place under the wing and MCAS may likely not have been needed.
1
Airbus began applying this philosophy with the A320, 330 & 340: „improving“ undesirable inherent characteristics of an airframe with software. This has advantages, flying skills are not so much of an issue except in emergencies and you can force an A380 to fly more or less like an A330 (or even better), hence less transition time for the pilots, savings in the certification process & fuel savings as you can squeeze the flight envelope closer to instability. Boeing long resisted this trend and rightly so, ultimately the commercial pressure was too high and Boeing had to give in. The FAA is subservient to Boeing and EASA to Airbus. The certification process for new airframes is always a joint effort between the Authorities which in many ways makes sense. The inconvenience is that nobody wants to hurt „the other guy“ fearing retaliation such that critical issues are not always handled with the necessary thoroughness. (Remember the battery issue on the 787?!). Flying, even with sophisticated control laws, is all too human...
6
There will come a time in my grandchildren’s futures when self driving cars may have similar issues—safety issues overshadowed by commercial interest—and the idea of not relying on the programming is beyond the memory of most drivers. I still enjoy knowing how to parallel park but I am grateful for cruise control and power steering and braking. There is a fine balance between augmenting technologies and human command. The trick is knowing where that balance lies and being able to choose for yourself. And oh yes—power windows are a blessing in old age.
14
Why that’s one of the first things I put in my Volvo GT 242, was a passenger side power window (since it didn’t make sense to put one on the driver side)
1
Do we know whether or not the pilots, if they had known of M.C.A.S., would have been able to save the plane? No. However we do know that, not knowing of the system, they were unable to save the plane and the lives of 189 people. It seems that the gamble of not retraining the pilots carries too high a risk to continue.
8
So Boeing made a deadly tradeoff. To save a few drops of gas, it appears they traded away inherent stability in the aircraft, or a tendency for it to fly straight and level on its own even with nobody touching the controls. Now to compensate for the tendency of the plane to pitch up out of control, they added a rudimentary software control loop based on angle of attack sensors and the trim system, but failed to do a full fault tree analysis, and failed to tell anyone about this MCAS "hack." From a pure engineering and safety point of view, this is a lousy way do design anything. And now lives were lost because of it.
25
I compliment this excellent report.
I am not a Boeing engineer ot a pilot but I fly a lot for business and pleasure. And I love airplanes and flying. I have flown in a Max but had no idea of some of these changes.
Right off the bat - it is not clear to me why a different positioning of these new engines is leading to a stall. To me, if these engines are more forward - if any thing - I would think aircraft would normally be in a nose down position. But that's a different matter.
I worked in the oil patch for 43 plus years and towards the end, became a Subject Matter Expert in our operations integrity engineering - which designs work processes so humans operate equipment safely and efficiently to it's designed specifications.
One critical process is Management of Change - so called MoC.
This process ensures that any change is fully communicated, explained and folks are trained if need be.
To me, this incident is a poster child of failure of MoC process.
Remember the Macondo incident - one of the root causes of that incident was failure in MoC process. Last minute changes were not fully analyzed and no risk analysis was performed.
Ditto here.
Hard to believe that a change of this type was not fully communicated to pilots and all other personnel including maintenance crew.
Now, one thing also stands out is why these pilots were not informed of observations made by the last crew. That's another failure of a system.
15
@Neil
The engines are generally forward of the aircraft's CG (center of gravity) on the 737, and on the MAX even more so. During flight the nacelles are capable of generating lift (the fuselage itself can also generate lift) but normally not enough to make any difference, unless the plane is already in a maneuver with some higher angle of attack. In that case, the increased lift generated far forward of the CG leads to pitch up, which leads to more lift, and more pitch, up and well, that's why it's extremely dangerous and needs prevention by a (properly functioning) automated system.
4
So, the Boeing thinking was if they told about it , pilots would have to be trained on it ? So just incorporate it , and forget about it ...FAA ? I guess when a corporation makes a decision, you cant expect a government agency to go against it ! That is why America votes republican , to get rid of pesky rules .
17
"The story of the change to that system, and how it came to play a central role in the Lion Air crash, shows how safety on modern jetliners is shaped by a complex combination of factors"
Its MUCH more than just jetliners. In the mid-80's Charles Perrow wrote a book that is still timely, "Normal Accidents." His thesis is modern systems have become so complicated that accidents are inevitable from unforeseen interactions. Ironically safety systems are often implicated like in this crash; they may protect against the intended harm but be activated in in situations the designers never anticipated.
Human progress is like that, and not just in technology. We love the Cathedrals from the Middle Ages but they are the ones that didn't have design flaws; those collapsed. Indeed many still standing benefit from lessons learned from those that fell, or reflect repair after partial collapse like Beauvais Cathedral. We walk across bridges today with nary a concern (at least outside of Italy), but the integrity of today's design is built upon the lessons learned from those that fell.
Failure is far from a flaw only present "back in the day" before present engineering and physics. As Perrow shows there are still unknowns and surprises. It doesn't help those on the unfortunate plane, but its the way it is. Prudent people will avoid self-driving cars, hovercraft, Musk's underground high-speed transit, and the like.
14
The two crucial things pointed out in this reporting are:
1) ..... decisions ultimately prompted the company (Boeing), regulators and airlines to conclude that training or briefing pilots on the change to the flight control system was unnecessary for carrying out well-established emergency procedures.
2) Among the many unanswered questions raised by the crash is the degree to which Boeing and the F.A.A. considered what would happen in the event that M.C.A.S. — or the sensors that fed the system information about the plane — were to malfunction.
My opinion is that the fault here lies with Boeing and the FAA. One can almost hear the stakeholders arguing endlessly over 1) and never considering putting 2) to a test, even a small, but pivotal one. And after all, isn't that a key benefit of simulations.
One could easily see a suggestion being made to Boeing, that they pick 5 or 6 crews at random, put them in a simulator and watch what happened when the MCAS malfunction is simulated. I bet, after 5 of the 6 experimental simulations ended in failure, that is a "fatal" crash, the count of almost 1,000 virtual coffins would strongly suggest a different decision and conclusion from the one in 1).
9
I bet you my bottom dollar it would be 6-out-of-6 safe landings. People need to understand, this same fault happened on the 3 flights prior to this one, and each time the crew reacted properly and continued the flights without incident. What these two pilots did - or didn’t do, as the case may be - is inexplicable.
5
@Mike
The red flag here is that the aircraft was not repaired after the first incident. Inevitably some tired, unfamiliar or relatively inexperienced crew was going to climb into the cockpit of something that wasn't fit to fly.
This is the bit that boils my blood. I have worked for many airlines, most of which had utterly uncaring, verging on incompetent management but even they didn't skimp on safety or maintenance.
Lion Air has a history of this neglect but there are plenty of Indonesian carriers who are as safe as any Western airline now.
As the information has dripped out I've just been staggered by the cost-cutting and the regulatory failure; it's reminiscent of the 1970s, not 2019.
(777 pilot)
13
The conflict between safety and costs permeates all aspects of the aviation industry. The FAA does a good job of suppporting safety regulations, but everybody seems to push back, everyone from private pilots to business jets to the airlines. Nobody wants to spend money, and safety does not sell very well. As a former professional pilot, it pains me to have seen this and to see it continue. And one other thing: there is no substitute for a professional in control of the aircraft, with a yoke that is actually connected to the control surfaces.
270
@DocSteve
As a pilot for 65 years (non-professional) I can say that nothing is more terrifying than having a run-away of the trim. It's like having an invisible demon wresting control from you. My late model Cessna has virtually every feature as the 737Max. But on the yoke it also has a little red button. Push it and all of the automatic control functions are disconnected and you get a loud squawk to let you know that you did it. Then you are flying a plane as simple as a 1945 Piper Cub. In other words you are back to really flying the machine. Two conclusions: 1. Every aircraft, no matter how sophisticated, needs to have a trim disconnect that operates instantaneously without rummaging around a check list. 2. Pilots needs to be trained in basic airmanship so they can FLY THE AIRPLANE in any circumstance.The landing on the Hudson was no miracle. Sully instantly reverted to his extensive experience flying gliders and other basic aircraft. Modern pilots seem to be trained to be button pushers who never look out the window.
242
@DocSteve ... Redundancy is having two sensors ...but the bean counters get to pick which one you use for the control system ? This is what happened to the Air France flight that crashed mid Atlantic , from Rio to Paris ... Multi pitot tubes ...but one input for speed indication ...tube freezes ...crash.
23
@DocSteve
Obviously there is a lot of safety with automation, but as someone that travels, I would like my pilots to be able to fly the plane with minimal computer assistance if needed. I asked a seasoned commercial pilot which was his favorite plane to fly. He replied, but not to my question: the last plane he HAD to fly was the DC-9 but that was in the late 1980s and early 1990s.
25
The responsibility for informing a pilot about the M.C.A.S. operation rests on: (a) Boeing, (b) the Indonesian regulators who approved the aircraft for use, (c) Lion Air, and (d) the pilots' profession generally. It is obvious that all of these parties, at some level, knew how the system worked (or should have worked). According to the article: "Boeing did not hide the modified system. It was documented in maintenance manuals for the plane, and airlines were informed about it during detailed briefings on differences between the Max and earlier versions of the 737."
The first duty of all the parties is to prevent another accident that might be caused by the same problem. Other than that we're seeing the classic scenario of assigning blame and liability. And right now everybody is pointing fingers in order to deflect blame. If this were a medical device instead of an aircraft, the final authority would rest with the regulators, who have a ministerial duty to the protect the public. Boeing protects its product, he airline protects its stockholders, and the pilot's profession protects their own people.
Certainly this was the case in Brazil. According to the article: "...regulators in Brazil broke with the F.A.A. and required that pilots be made familiar with the change." The Indonesian regulators have to act independently, and can't simply act as 'yes men' with a rubber-stamp.
50
@W A while back was discussing airline safety with a friend and he said that planes always have a backup emergency safety plan for any emergency plan. Now it seems that pilots were not even briefed on a possible malfunction of automatic system on the plane's computer. How could the pilots figure out what was malfunctioning if they didn't even know that the system was even there?
There were parties who were charged with over- looking the safety of the plane, Boeing, the country's regulators, the company that bought the plane and the pilots' union.
I am getting fed up with these organizations that are supposed to be a watchdog for the pubic and not only don't do their job but cause fatal injuries. It seems like we need a regulating body to supervise those other agencies that are overlooki
18
@W Dont forget ...in the USA , pilots DO NOT get trained in this procedure ... Boeing and FAA agreed ...
10
If the pilots had read the Aircraft Technical Log, they would have know the previous crew had simply flipped two switches to deactivate auto trim and regain control of the airplane. Hubris and faith in technology is a cultural issue with modern pilots that was the root cause of AF 447 also falling into the sea. Pilots need better training and clearly Boeing is moving a too fast allowing airlines to skimp on training. Bottom line is the crew lost control of the airplane due to pilot error. How do you not see a trim wheel spinning like a top and and want to stop that from happening by turning off automation? I have experienced several auto pilot discrepancies and each time I disconnected the autopilot in less than a second. But maybe I am just old school.
122
@topcamera Since we don't have access to the actual log-book write-up, we can't say if it, or the answering maintenance sign-off, showed the problem clearly, or perhaps led the new pilots down another garden path. I agree, however, that hubris and faith are and have been a continuing problem in many aircraft accident over many years.
However, the AF 447 accident was a direct result of basic pilot: failure to fly using basic attitude and power control inputs, and not be fooled by airspeed indications-the result of which was a classic upset/high-speed stall. This precise issue was the subject of a FAA Training film in the mid 1960s. !!! This film was entitled "Upset; Loss of Control of High Speed Jet Transports".
After flying for over a half century and training hundreds of pilots in "runaway trim" situations, I can assure you that while a high-speed trim motor "runaway" would indeed be spinning like a top, a small (but effective) low-speed un-commanded trim motor runaway, would not be anywhere nearly as noticeable, and therefore NOT trigger the classic "runaway trim-checklist procedure. And, this situation would have occurred whether or not the autopilot was involved, which further confused the situation.
23
And how would you react if you didn't know the automation existed in the first place? My understanding is this wasn't an 'autopilot discrepancy' because the MACS continues to operate with the autopilot off. Rather, this was a fly-by-wire system failure, compounded by the Flight Crew having no knowledge that the system even existed. In their wisdom, Boeing chose not to mention the new MACS addition in the Flight Crew Operating Manual. Applying the B737 'Runaway Stablizer' non-normal checklist might have prevented this accident, but more certainly, knowledge of MACS and its affect on the aircraft's performance might have too.
35
@topcamera @topcamera You have obviously never experience sensory overload caused by task saturation.
Airbus have suffered from software "surprises" since their tree trimming demonstration on 26 June 1988 (AF 296) and now it looks like Boeing is playing "follow the leader".
An Airbus avionics tech (that's one from the Airbus factory) was examining an avionics issue at an airline. As he examined the code he was heard to exclaim, "I didn't know it did that". Software should NOT fly/control aeroplanes, pilots should but then I'm biased.
30
Bottom line is that the pilots didn't follow procedure but they should have been told that pulling back on the yoke wouldn't work. You'd think that after a couple attempts, they'd figure out that it didn't work and move on to the checklist. They tried it more than two dozen times.
Despite what many people here say, money is an object. Almost everyone buys tickets based mostly on price so airlines must focus on cost or they'll go broke. It's the regulators responsibility to make sure safety isn't compromised. With the exceptionally safety of air travel, it's not unexpected that regulators might be too complacent.
82
@roseberry As I understand it, pulling back on the yoke DID work, until the "system" overrode it AGAIN. How is an untrained (on this particular scenario) pilot to know which one is not working properly while it's happening?
16
@roseberry So, to your mind, no responsibility accrues to Boeing for designing a system totally dependent on a single input sensor, or to the FAA for being "beholden" to Boeing around what, at least to lay eyes, looks like a clear case of an obligation to inform & train pilots who carry the lives of passengers in their hands?
24
@Dave I think there is a case to be made obviously that the regulators should have required extra training and that Boeing should have told pilots that the system nixed the pulling back of the yoke feature to disengage auto-trim. But I can also see Boeing's point that the prescribed procedure for dealing with run away auto-trim would work just like it always has.
7
It would seem that there's plenty of blame for everyone involved. But it's not clear why the system wasn't designed to allow manual over-ride without compelling the pilot to consult the flight manual. This has been a fairly consistent rule through the history of technology and throughout every industry. It's often difficult to accomplish, for design decisions have to take every conceivable circumstance into account, and there's no room for any sort of hubris: machines can and will fail, as will humans. To paraphrase Dr Asimov: every robot should have a clearly-marked on-off switch.
172
Exactly --the airplane should have clearly indicated via a visual and audible alarm that MCAS was firing. The pilots should have been trained (and tested) to respond to this and to know what MCAS was. The plane should have a manual override of MCAS and a off switch --and the manuals, training, and simulations should have ensured that the pilots knew how to turn the system off.
Not to say that the plane's software should have been fully capable of realizing a high likelihood of faulty data --which sould have become child's play if the second sensor would've been used.
24
@Mark Kinsler This robot (the aircraft) does have a clearly marked on-off switch. It's called the trim cutout switch. It's even big and red.
The pilots should have flipped it. They did not.
This article is misleading.
15
@Yoandel
Exactly. No ifs ands or buts about it.
Thanks Yoandel
7
The airline industry in general should be commended for the procedural systems put in place that have made flying one of the safest activities one can undertake.
That said, as an engineer myself, I am stunned that for their automated control system a single faulty sensor is enough to take a plane down. Sure we can blame pilot error, but that’s not really root cause is it ?
This situation seemed entirely preventable from the get go. Why is such a critical part not duplicated or better yet have some redundancy where the redundant parts are unlikely to all fail in the same way under the same conditions.
When we design medical devices we are required to assure that no single point failure whatever it might be can cause the device to become unsafe. Boeing should perhaps take a page from that playbook.
377
@Paul I totally agree, but like the automobile industry, it is cheaper to pay out wrongful death suits then to make the system failproof. Case in point, Boeing 737 hardover rudder issue.
18
@Paul As a private pilot, I have followed this story since the tragedy occurred. To me, the fundamental problem was insufficient pilot training by Lion Air. Technologically advance avionic systems have multiple cut-offs to disable auto-pilot systems. My single engine plane has an advance Garmin avionics package. It also have five separate methods to immediately disable the auto pilot. Major American airline companies and other major international airliners provide pilots with recurrent, sophisticated training. In my opinion these airliners are decidedly safer to fly. Travelers flying internationally should exercise extra caution and consideration when buying a bargain priced ticket from a low cost carrier.
10
@Paul I agree with you about redundancy. It was vital to the operation of the fuel cells that were used in the early Apollo missions. FEMA - Failure mode and effect analysis was the key to the over-all mission reliability, much truer today when missions take years; in 1966, we were fortunate to have mission times in hours..
10
Having flown on Lion Air, I was surprised that they didn't take an international credit card for payment. I had to take my reservation number to a 7-11 and pay in cash by noon the next day.
Talk about cutting corners.
7
@Michael And I bet you thought the airfare cost too much as well. What is having to pay cash for a ticket got to do with this air accident? I had an American company refuse to accept my Australian issued credit card due to many fraudulent card emanating from the country at the time. Were they cutting corners to?
2
While installation of the MCAS on the 737 MAX was reasonable and needed, the failure to inform Lion Air pilots of it existence is egregious. It is not at all evident that much additional aircrew training on the MCAS would have been necessary. A simple computer assisted training session would have been adequate. It would not have been necessary to immediately modify the existing 737 simulator and have aircrews go through additional simulator sessions. Simply knowing what the MCAS was in the 737 Max and what it was designed to do would have been adequate. Of course a discussion of an AoA malfunction - which occurred in the accident - and its impact on the MCAS would have been included in this additional aircrew instruction.
11
This tragedy (and others involving our reliance on continually-advancing technology) brings to mind a rather prescient (and still very relevant) piece of dialog from the 1962 novel "Fail-Safe," by Eugene Burdick and Harvey Wheeler (and the equally superb 1964 film directed by Sidney Lumet):
KNAPP: "The more complex an electronic system gets, the more accident-prone it is. Sooner or later, it breaks down... A transistor blows, a condenser burns out. Sometimes they just get tired, like people..."
GROETESCHELE: "But Mr. Knapp overlooks one thing. The machines are supervised by humans. Even if the machine fails, the human being can always correct the mistake."
KNAPP: "I wish you were right. The fact is the machines work so fast; they are so intricate; the mistakes they make are so subtle that very often a human being can't know if a machine is lying or telling the truth."
Again, that was in 1962; machines (and systems) are just a bit more complex, not to mention faster, today... .
(There is also the 1966 science fiction novel "Colossus," by Dennis Feltham Jones, which became the film "Colossus: The Forbin Project" in 1970 — another harrowing cautionary tale of advanced technology.)
7
The pilots should have read the manual for the new aircraft. Their boss, Lion Air, should have required the reading. This isn’t something that Boeing or FAA can require. A simulator requirement would have been too much...complaints would ensue. The pilots and maintenance crews made a series of errors that led to this tragedy, though I acknowledge how the new anti-stall feature should be easier to override.
3
Not sure what you’re talking about, Chris. I fly the 737Max for a major carrier and prior to this accident, there was absolutely NO mention of MCAS in my manuals. The FAA didn’t require it - it wasn’t there. That’s the whole point of this article.
34
@Chris McClure I have the Flight Manual for a 737, admittedly it is for the 300 Series, but it has 2,129 pages. Just a bit of light reading after a fatiguing 4 sector day. I think War And Peace would have been a shorter and less mind numbing read.
4
And yet Airbus still uses side-sticks that are not mechanically linked after Air France 447 crashed and killed 228 people 10 years ago. Where is the NYTimes article about this design issue? And criticism of the Airbus "the computer is always right" design philosophy?
I would encourage those writing here about Boeing to read about Air France 447 (an Airbus A330), where an instrument failure and arguably very poor design by Airbus contributed to pilot error. Some of the main contributing factors being the Airbus side-stick design that is not mechanically linked between the pilot and co-pilot, provides no feedback, and no "stick shaking". That mixed with poor training, bad displays, and the Airbus design philosophy that prioritizes the flight control computer resulted in this crash.
Air France 447 was almost 10 years ago, and Airbus still uses almost all these designs. I cannot find a NYTimes article criticizing Airbus.
Finally, while an argument could be made that Boeing should have included MCAS more clearly in training. Given the Lion Air pilots were so poorly trained to begin with that they did not read the flight log from the previous flight, and repeated the same action 12 times with the same result before crashing instead of following the known safety procedure and turning off two switches. -- Would that training have even made a difference?
9
@adam "Understanding Air France 447" by Bill Palmer provides an excellent in depth look at causal factors for the accident. Airbus may not have a "stick shaker" but does have aural annunciations when approaching a stall.
Aircraft logbooks don't always have succinct/in depth write ups from pilots about an aircraft's issue, so the Lion Air pilots may not have known that the previous crew, when presented with the abnormal, had disabled the electric trim switches. That said, from a pilot's perspective, would there be a "down side" to training on the MCAS differences?
(Having flown both the Airbus and Boeing extensively, each were a complete joy!)
1
@adam Yes, the training would have made a difference IMO. The brain is an incredible organ and its capabilities a wonder to behold. If you read the book by the pilot of BA 38, it takes him 6 pages to describe the actions that took him 2 SECONDS to perform. In the only real emergency I ever had flying, I am still astounded at my reactions and the multiple actions I took in the little amount of time I had to accomplish them. It seemed to me during that event that time slowed down. Those who have experienced it will know what I mean.
4
"The F.A.A. said that "other countries base their standards on conditions specific and unique to each nation.""
Apparently a unique condition of Brazil is that they prefer their airplanes not to crash.
25
This is what happen when you’re core competency is switched from making airplanes to “large system integration” . Too many MBAS and PMs and not enough engineers.
7
These fine, complex articles would benefit from a summary. But let me see if I understand.
With the new design and software, the plane would handle somewhat differently during an emergency (or, since they didn’t do flight tests with a malfunctioning system, did they not know how the plane would behave?) In any event, the emergency procedures would be the same, therefore they decide pilot re-training is not necessary. OK, that may or may not be reasonable. But how does it get from “no need for re-training” to “let’s not tell the pilots something is different” (even though the FAA, airlines. and maintenance officials were informed)?
6
The MCAS software utterly failed to maintain situational awareness and acted based on faulty data from a single sensor. That's not robust software ..... it's the exact opposite. It's very deficient software.
The MCAS software could have easily determined that the angle of attack data was incorrect by checking the data from the second sensor. Why did the software trust just one sensor ? One was providing valid data the other bad data ... when such an information conflict exists the software should NOT assume the extreme data from the malfunctioning sensor is valid. Secondly, there can be no aerodynamic stall when the nose is pitch down 30 degrees in a dive .... multiple gyroscopic pitch indicators would have confirmed a very steep nose down pitch. Coupling that with high airspeed and vertical down speed indicator readings would completely rule out an aerodynamic stall.
The software had NO situational awareness and acted stupidly and in total conflict with pilot nose up inputs. This is literally a disastrous design of a so called "safety system".
Yes clearly the pilots deserve some blame for not knowing how to shut down the MCAS system, but the root cause of this tragedy is very deficient software.
13
Year ago I was working in flight test at Douglas on the DC8-63 series. We were working on automated approaches, but the electronic signals from the ground systems could be unreliable at times. So there was a disconnect button for the automatic flight control. We still had the needle and ball indicators which are controlled by a gyro system. Pilots had to learn to fly these p[lanes manually, when you took flying lessons, you learned needle, ball, airspeed, how to do a spin and stall and recover.
If the instrumentation and the autopilot operations did not match, you disconnected the AP. I am not familiar with the attitude detection systems on the 737, but it seems to me a gyro stabilizing system would be more effective that the external detector shown in the above example.
3
I will leave technical and operational matters to other commenters. Instead, I think there is a process flaw that the article alludes to but doesn't quite nail.
There is something called "abundance of caution." Since this issue was flagged as a possible source of confusion and discussed so much among relevant parties, they should have defaulted to the most conservative response which would have been to require training. That's what regulators are for. But when regulators are captured by the industries they regulate, they don't have as much latitude as they are supposed to. They should not have to consider a company's finances or marketing issues when reviewing the safety of a product, but politics demands otherwise.
11
Whenever a new system like this is introduced, pilots who are, after all, the ultimate decision makers during flight, should be informed about and trained on what it is, what it does, and what impact the changes can have on the behavior of the plane, especially in emergency situations. I am stunned that the regulatory agencies let Boeing cut that corner so Boeing could sell the airlines on the cost savings in form of waived requirements for pilot retraining.
12
It appears that all this was just because Boeing wanted to make adoption of the new model less costly in order to boost sales.
Instead, they have suffered a PR disaster and massive lost of trust that will cost them many times more than the lost sales they might have suffered by putting safety first and demanding that pilots be retrained.
13
@TJ To think and extra $5 per ticket could have covered the cost of this training but Joe Public want the cheapest fare yet complain when they have to pay for a glass of water on-board the aircraft at FL360. These same people will happily pay the cost of some of these cheap tickets for a night on the town and the resulting hangover in the morning but $5 extra for a 90+ minute flight and they think they are being ripped off.
1
The issues here are technical in nature and frankly I don’t think many non technical people will get through it. Using “so-called” or “also called”, does not add clarity for those that don’t understand and mindless distraction for those that do.
4
I for one will refuse to fly with a Boeing 737Max. Senior executives, the CEO and the Board of Boeing should have known about the risk and taken adequate action. If they didn't it would be equally bad and in either case they should be held accountable.
15
That the effects of an MCAS with bad data were not tested was bad. To DISABLE the pull-yoke-disable-auto-stabilizer was WORSE. It is like not telling a driver that tapping the brake NO LONGER disengages auto-throttle (cruise control).
The quest for profit may have not been responsible for the loss of these souls, but NOT informing the pilots about the change is negligence.
How many US and European regulators are pilots? Did ANYONE ask current 737 pilots their opinion?
56
@Jonathan Jaffe
Your harangue suggests that you believe that the issues involved will somehow be decided on the basis of personal opinions in the N.Y. Times. Well, they won't.
Before arguing any causal factor you have to weigh the evidence. Ultimately, the outcome will reside with the insurers. They will decide whether to insure Boeing, Lion Air, or any airline based in Indonesia. As for Boeing and the rest of the aircraft industry, if they (collectively) feel that Boeing has been wronged in the investigation, then collectively they may not sell any new aircraft to the Indonesians in the future.
3
@W
Your harangue suggests that you believe that the issues involved will somehow be decided by you.
Well, they won't.
Before arguing any causal factor you have to weigh the financial risks. Ultimately, the outcome will reside with the insurers and the Boeing board. They will decide whether the lives lost are of greater value than the cost of training pilots. As for Boeing and the rest of the aircraft industry, if they (collectively) feel that Boeing has been wronged in the investigation, then collectively they may find their incentive for profit outweighs selling any new aircraft to the Indonesians in the future.
4
@Michael
Very, very well harangued, Michael - after weighing all the evidence.
2
Well, thanks to this article (and considered followup) I learned the name Roger Boisjoly. History repeats.
3
The article fails to properly discuss the critical factor of "angle of attack" which is the relationship of the wing to the relative wind over it. "(the acute angle between the direction of the relative wind and the chord of an airfoil;" Merriam Webster).
This value is displayed by the aircraft instrumentation and has been used by the Navy since the 1960's as a primary flight instrument for carrier landings, where being on speed is critical. The 737 aircraft's computer system utilizes both airspeed and angle of attack inputs. It's the pilots responsibility to observe discrepancies and follow the correct indications when one system fails.
The airline industry and the FAA have never widely embraced and trained pilots to use this method of staying at the correct air speed for the weight of the aircraft. This value can easily be displayed on the windscreen as well with the HUD (heads up display). Cross checking between air speed and angle of attack gives the pilot the information to fly the aircraft safely and efficiently.
There is broad responsibility for this unnecessary crash.
14
@Skywarrior
In civilian aviation with large jet transports, if it all goes horribly wrong, you set a pitch and a power and most experienced crews would do this by feel, refining from the tables in the manual when the aircraft was stable if necessary.
Even a fully-developed stall shouldn't be a drama; a hats-on, standing-up interview with no tea and biscuits, yes, but easily identifiable without AoA information.
AoA is critical to carrier operations but it's not to us. Both Airbus and Boeing will complain on the ADI if you're approaching Alpha floor (usually occurs on approach when the aircraft is a lot heavier than advertised on the load sheet!) but the automatics will take care of it. If it's in manual and you need a constant path - more thrust. Not exactly difficult.
Where I feel for this crew is that they were essentially in an unannounced stab trim runaway situation. The system that allowed them to intuitively override it by pulling/pushing the yokes had been removed (no one had told them) and every person on here criticising the crew for not reaching for the cutoff switches has probably never had to endure the gruesome shift patterns of airline work.
At dark o'clock on day six would I have overlooked it? Maybe.
I don't actually know why we don't get AoA - there's room for it on most glass cockpit screens, even legacy ones, but imagine the millions to certify it...)
(777 pilot - previously 757/767/320/321)
9
The fact is that not all pilots were “kept in the dark” with regard to MCAS, as an article from Forbes (Nov 16, 2018) quoted below makes clear. This raises questions that are not answered by pointing blame towards the manufacturer and regulator.
United Pilots Say They Were Already Trained To Override Boeing 737MAX Automatic Stall Recovery
Sisk (chairman of the central air safety committee for the United ALPA chapter) said the United 737 MAX differences bulletin already referred to situations where nose-down trim is automatically applied as airspeed decreases toward a stall. For such a situation, he said, the bulletin advises that “If MCAS were to fault, forcing an undesirable nose down attitude or continuing inappropriate nose down trim, using the cutout switches on the pedestal will stop the trim runaway.”
In an MCAS malfunction, “You will do exactly as you have been trained – you will fly the airplane, stop the runaway trim, and then continue to fly the airplane until you have landed safely,” Sisk said.
13
"... one of the primary theories is that the system was receiving faulty data about the angle of the plane from what is known as an angle of attack sensor, [that measures] how much the plane’s nose is pointing up or down. "
Wrong. Completely wrong. Epically wrong. As in what the heck are your fact checkers doing besides drinking on the job wrong.
The angle of attack sensor measures the angle between the wing and the relative wind. An airplane going slowly in level flight will have a higher angle of attack than the same airplane going faster in level flight. An airplane going straight up can have zero angle of attack.
Instead, roughly speaking, angle of attack is a measure of how much work the wing *is* doing, compared to how much it *can* do.
"By limiting the differences between the models, Boeing would save airlines time and money by not putting their 737 pilots in simulators for hours to train on the new aircraft, making a switch to the Max more appealing."
This called "differences training." At most, that would be worth a day of academics, and one simulator period. Chump change.
“Regardless of cause,” the company said, the flight crew should go through the checklist, “which is contained in existing procedures.”
Exactly. When things go wrong, pilots deal with effects. Later, it is up to maintenance to determine the causes. There was a checklist for the pilots to follow, regardless of cause.
They didn't.
I'm an airline pilot with 40 years experience.
32
@Jeff Guinn
And if you didn't even know about the existence of the M.C.A.S. and a crisis arose, I'm sure you wouldn't miss a beat and would perform flawlessly. After all, you're a pilot with 40 years of experience, and powerful, hidden software overriding you is absolutely nothing to worry about during those precious seconds.
11
@Jeff Guinn: You can make your point without insulting fact checkers, who are doubtless sober.
6
@Jeff Guinn An airplane going straight up can have zero angle of attack.
An aircraft going straight up still has a relative airflow (RAF) (or wind for American trained pilots) and an angle of attack (AoA). Admittedly other forces must be applied to stop the aircraft from going over on its back like pushing forward on the elevator or changing the horizontal stabiliser to keep the nose pointing up. Even going vertical the wing is producing lift on the usually top surface of the wing and the Chord Line is still from the Leading Edge to the Training edge of the wing irrelevant of its physical direction. The AoA is still measured between the Chord Line and the RAF which in your example is still initiating contact with the wing on the LE.
Going vertical may give you a ZERO AoA but it is still an AoA albeit producing zero net lift. In your example, the only thing overcoming weight is the thrust from the engine and not the wing as in normal level, climbing, descending or turning flight conditions.
3
Very sad. Just a small amount of required additional pilot training on the MCAS could have saved 189 lives. I hope and assume all pilots flying the 737 Max have now had that training.
7
I could not get through this article because the reporter kept saying the same thing over and over again. Had to abort.
4
At the end of the day, it is the pilots responsibility to understand the systems aboard the aircraft and how to use them, even in an emergency. Every pilot should know how to disable the automated systems and fly that plane by hand. Unfortunately pilots and unions tend to blame Boeing and others for their own laziness.
6
@DEWaldron
Yes, but if they are not made aware of them, how can they know to disable them?
5
If I were a the judge in this case I would share the culpability of the crash between Lion Air and Boeing. Neither is completely at fault and neither is completely innocent.
1
Compare Lion Air 610 and Air France 447 and what do you see. Pilots with low airmanship quotients who failed to follow the procedures designed to prevent an accident.
The Airbus airplane involved in Air France 447 had a standard procedure for bad data in the system and the pilots failed to follow it. They held the airplane in a nose high stall all the way to the ocean.
The Boeing airplane involved in Lion Air 610 had a standard procedure for dealing with bad data entering the MCAS system. The pilots failed to follow it and turn the system off.
When I got my pilot license I had one phrase drilled into me, "First fly the airplane". Regardless of the emergency you cannot allow yourself to be distracted from this basic tenet. EVER.
The crews of these two flights failed to do this. They had an emergency procedure that would have saved the aircraft. They failed to execute that procedure with tragic results.
33
@Rick Girard Errr, the LionAir pilots were "flying the plane". The issue was that the plane didn't let them, and they couldn't figure out why because they hadn't been trained properly.
To my mind there is a parallel with my car. It has a sophisticated anti-lock breaking system which requires that when I need to stop in an emergency, regardless of road surface conditions, I stamp on the brakes as hard as I can, and also actively steer the vehicle. In a car of even 10 years ago, or any car without an anti-lock system, this behaviour would exacerbate the incident because the vehicle would skid, any steering input would be moot, and I would travel in a straight line faster than if I were cadence braking towards my accident. I have been trained at collision avoidance with an anti-lock system. I would need to be completely re-trained to do the same in an older car.
13
@Rick Girard What did your Instructor tell you to do if you lost your tailplane (not your elevator, just the tailplane)? I am not being pedantic or sarcastic, I am just asking a question to make a point, ok.
This is basically what happened to these guys. Yes there was a solution for it but they tried their known and trained for solutions but didn't action the untrained for procedure that would have saved their passengers, crew, aircraft and themselves and boy, I bet they were trying their best to save themselves.
6
Boeing is all about the bottom line. The 737 was designed in the 1960's, how many products do we use today based on 1960 technology? Boeing changes the engines and makes minor changes to the interior and systems. It has a cross section that is tight and uncomfortable to fly. The Airbus 320 family is newer and has a wider cross section. Boeing should have launched a new aircraft to replace the 737 but that would have given the Airbus 320NEO all the orders at American Airlines and a narrow-body monopoly for 7 to 10 years. Boeing management is falling into the same trap like GE, they think they are invincible. When the commercial airplane markets enters another recession, they with be facing huge losses since the are building a high percentage of each aircraft in-house. They will not have suppliers to eat a large portion of the losses like was did on the 787 program. The Boeing performance on the USAF KC-46 refueling tanker is a disgrace. DOD has awarded Boeing two new development contracts for the MQ-25 Navy tanker drone and T-X trainer. It demonstrates having the Secretary of Defense being a former Boeing employee helps!
6
Personally, I would love to see an analysis written by, or at the very least reviewed by, a pilot, preferably an airline pilot, preferably a 737 pilot, preferably a 737 Max pilot.
In a complex situation like this, it is easy to generate controversy, and the reality is that news organizations, even reliable news organizations such as NYT, live on controversy.
Controversy then excites the normal confirmation bias that exists in everyone. In this case, as I read the comments, it seems to me that this incident has degenerated into a full-fledged Rorschach test. I read conclusions about the cause of this accident from people who have never sat in a pilot's seat, and have never actually thought about what it takes to fly an aircraft.
I would be remiss if I didn't add my prejudices to the mix. While I think that the existence of MCAS, incomplete documentation, and incomplete training are all contributing factors, there are SEVERAL factors with much, much higher influence and contribution. First among those is that the pilots did not fly the aircraft. Rule #1 in flying: AVIATE.
12
Unfettered capitalism strikes again. Caveat emptor, indeed. Beware, beware, and beware.
10
the pilots had probably just a few seconds to decide, the flight was barely 4k feet from the ground n flying at 400mph,
i feel sad for the crew n passengers. even if the pilots made all the correct decisions, time wasn't on their side. if you see the flight path as it went nose down the plane's last recorded speed actually increased dramatically. u can bet boeing is going to pay heavily for this and someone shud to stop this duopoly of boeing/airbus has to end
10
I once saw an ad in a newspaper. I don't remember the product or service being touted, but the ad said "if you think training is expensive, consider the cost of ignorance".
16
@Steve C. Agreed. We're learning that everyday with the current white house resident.
4
The proximate cause of the loss of Lion Air's 737 Max was a failure of a simple sensor that relayed erroneous data about the aircraft's attitude to the flight control system. That failure started a cascade of events that led to the loss of the aircraft.
But there are two such sensors on the 737 Max: one on port one on starboard. If one was reporting properly, as pilots on the next-to-last-flight reported, why did the control system not detect the conflict with the failing sensor and alert the crew?
7
Boeing has long seemed to take the stance of, “Don’t say we didn’t warn you.” What I cannot understand is: why were they against supplemental training/guidance, as the article seems to suggest? It appears that it will take the deaths of 189 people to bring this about. Kudos to the NYT for staying on top of this.
11
@blondiegoodlooks
Why? Because additional training equals added expense, and companies like Boeing think only about dollars and cents. It's capitalism. Lives are an inconvenience to be factored into the cost/benefit.
9
Just recently, a viral “woman acting terribly on a flight” story reminded me that the FAA allows plane manufacturers and airlines to shove the flying public into seats that are too small for the average American adult and too close to permit passengers to exit quickly or take safe braced crash positions. They know what they are doing. 170 pounds is a laughable assumed average weight. The distance between seats is known to be too short. They are knowingly sacrificing safety for dollars.
10
@Heather
Heather it is the airlines ONLY who choose the size of the seat and leg room.
But you have to understand the Airlines are VERY concerned about this space issue.
American Airlines is Ordering planes without any entertainment system (now BYO tablet)
and
Most all have ended Meals, Snacks, Pillows, Blankets and recently on one flight even Drinks
ALL in the NAME of creating SPACE for its customers (LOL)
3
@chimanimani
The aircraft manufacturer determines the width of the seats. The aisle has to be so wide, leaving a fixed dimension to fit in six seats. Pitch is determined by the airline. If they gave us three more inches of fore and aft room they would lose a few rows of seats. That costs money and could be a make or break proposition.
The problem is that Boeing established the width of their cabins in the mid 50s with the 707. It hasn't changed for its single aisle planes. If memory serves, Airbus gives 8 more inches, but that's hardly a noticeable difference allocated over six seats. Until each manufacturer designs new aircraft with a different cross section, we're stuck with it, literally and figuratively.
As to the other things you mention, yes, the industry is intentionally making their products - aircraft and service - *less* desirable to the end user. It's the only industry that makes money by doing that.
6
Boeing and Airbus both make incredibly safe aircraft. In this case, it appears Boeing and the FAA did cut corners, creating the risk of a highly improbable but fatal accident. As with most fatal commercial air accidents, it takes a combination of errors to produce a fatal outcome, and that appears to be the case here. It wouldn't have taken much training time to alert pilots to the new system so they'd recognize what was going on in the situation faced by the Lion Air pilots.
9
I am a passenger who knows nothing of piloting an aeroplane. But the article does suggest that at least one factor contributing to a complex and immensely tragic emergency was Boeing's decision not to impose the burden of additional pilot training on its customer airlines, out of concern that Boeing might lose business to Airbus. Boeing's stock price over the past three years has climbed steeply from $100 to $400 per share or an average growth of 100% per year. To what extent were Boeing's decisions influenced, consciously or unconsciously, by its aggressive pursuit of profits on behalf of its shareholders?
86
@felix To what extent were the FAA's decisions influenced by Boeing's huge lobbying presence in Washington?
13
@Stevenz
Good point. Our corporate culture incubates bias at many levels, including that of the regulators who we pay (with our taxes) to ensure that products are safe. We should add that the current administration is anti-regulation. When I visit relatives in Arlington I drive by a Boeing headquarters which is directly across the highway from the pentagon.
7
Boeing is guilty here for introducing a serious code change without notifying pilots and airlines, in order to keep retraining costs down - it’s as simple as that.
The fact that Lion Air wasn’t the most honorable airline is immaterial.
The longer they hold out on admitting that, the more egregious the fault (and cost) become.
49
The 737 is a decades old design that is arguably past its sell-by date. The M.C.A.S is an attempt to address a fundamental design issue with aircraft. Over the years the large power increase of the low slung engines and the pitch up condition it can give rise to has made it imperative with the MAX to introduce a band-aid to the problem. Not addressing the basic aircraft design (not commercially viable?) but, add on M.A.C.S. instead.
Thanks for following this story and RIP all those who died.
23
@ John Krimugen. That’s like saying the Mercedes E350 is a decades old model. Yes, there has been a vehicle called a E350 and a plane called a 737 for decades. But just like with the Mercedes, the current 800 and the original 100 model of the 737 is light years different.
9
So by being dishonest with the FAA, Boeing was able to dupe its customers that no training was required for the new 737 Max, reducing its cost of adoption by airlines, increasing its competitiveness and therefore boosting sales relative to those of its competitor Airbus and thereby helping Boeing make its numbers on Wall Street.
One would encourage responsible airlines who bought the 737 Max on the basis of Boeing’s false representations to now sue Boeing for the cost of pilot retraining and for the FAA to order the retrofitting of redundant sensors at Boeing’s expense.
Shareholders should consider during Boeing directors and management for any impact of reputational damage on enterprise market valuation.
27
I am not an aeronautical engineer and am basing my thinking solely on the facts in the article but I think that Boeing and the FAA seem to have been wrong on at least two points.
1) They do not seem to have tested how the automatic system would react in a situation when the attitude sensor failed.
2) They disabled the mechanism whereby the pilot would get back control from the automated system by pulling back on the yoke and did not inform the pilots that this had been done.
There also seems possible to assign blame to Lion Air since their maintenance staff allowed this plane to be flown even after problems with the sensors and flight controls had been reported by the pilots of the earlier flights.
62
@Engineer Nor am I an aeronautical engineer, but I am a license pilot (albeit on aircraft much smaller than a 737). I do have plenty of time in advanced 737 simulators.
This article is, as is much of the Times' reporting on this issue, misleading at best, though it's not quite as bad as the designed-to-terrify pictorial they had a month or so ago.
There is an established procedure for trim runaway, no matter the cause (the Times itself notes there are multiple causes for a trim runaway besides MCAS). The pilots didn't follow it. If they had - like the crew on the same aircraft on the preceding flight - it almost certainly would have solved the problem.
Yes, Boeing should have done more to make pilots aware of the system, but I don't think you can make a credible argument that not knowing the system caused the crash. Failure to follow proper procedure caused the crash. Even if they HAD known about MCAS, they don't seem to have known what to do about a trim runaway. That's not acceptable.
30
@Engineer I believe your second point is key here. Yes, the pilots should have still followed the procedure to respond to trim failure, but even trained professionals can loose their head and not follow procedures by the book if their usual go-to solution (yoke correction) is disabled and they weren't told about it. That being said, it looks like pilot error made more likely to occur by failure to communicate the changes the new system implemented.
5
@Engineer "1) They do not seem to have tested how the automatic system would react in a situation when the attitude sensor failed."
Then they would have disabled the the automatic trim as indicated in the check list. That test would not have changed anything.
1
Cutting corners to protect profits isn’t always a great idea.
Ultimately, the problem boils down to the fact that money is speech.
21
It will be interesting to see if there is a lawsuit if Boeing will have to reveal exactly how much they projected an airline would save per pilot by not having to train a pilot for the new 737 version. It doesn't seem like it would be a critical factor in an airline picking the Boeing plane over the Airbus considering the costs of the two planes.
24
I would have thought that's is standard procedure to test every sensor going bad. Apparently not --
"There is no evidence that Boeing did flight-testing of M.C.A.S. with erroneous sensor data, and it is not clear whether the F.A.A. did so."
50
R. Ackoff quote: "When a mess, which is a system of problems, is taken apart, it loses its essential properties and so does each of its parts. The behavior of a mess depends more on how the treatment of its parts interact than how they act independently of each other. A partial solution to a whole system of problems is better than whole solutions of each of its parts taken separately."
8
I don't trust Boeing. I always check what type of plane I will be flying and if I can, avoid the new Boeing planes.
Personally, I love Airbus planes for international flights. Much nicer to coach passengers.
7
@Nina you may be surprised at the number of people who feel, with good reason, exactly the opposite. Airbus control systems are designed so that the computer has the final authority via numerous sets of control capabilities called “laws” . This enables a less rigorous and less expensive training program, and works fine - within the operating envelope of the system. Outside that envelope, or when the system gets bad data, it will fight - or confuse - the pilots all the way to the ground. Or water, as was the case in the Air France Flight 447 crash in 2009.
42
@Nina Before you get too entrenched in an “Airbus good/ Boeing bad” mindset, you might want to check out an Air France Airbus accident off the coast of Brazil. Then go back to find a Boeing 737 that landed safely after losing a huge portion of its upper skin in Hawaii, as well as a Boeing 727 that landed safely after a bomb blew a hole in its side.
As an airline pilot for over 35 years, I subscribe (along with MANY of my colleagues) to the phrase, “If it’s not Boeing, I’m not going”.
15
@Tradcarp That and the nickname Airbus pilots have for their own planes: the Scarebus! I totally agree - if it ain't Boeing, I ain't going.
4
Boeing, by its own analyses, clearly indicated that the MCAS system would only fire in not ordinary situations --i.e., that MCAS would play a role in emergencies and potential emergencies. Further, the positioning of the engines clearly affected the physical tendencies of the airplane in flight --and in situations that are far more complex (and dangerous).
Hence, the two facts above clearly and absolutely and forcefully mandate that pilots be re-trained, and that emergency maneuvers be simulated.
Furthermore, using only one sensor as opposed to both, thus introducing a single point of failure is an awful, terrible, engineering choice --which by itself mandates training as then only a human pilot could compensate for this engineered vulnerability.
Yet, that no engineering tests or simulations with bad data were performed is simply negligence, on part of Boeing --and that the FAA could have cleared this plane to fly without requiring this is also negligence of the highest order.
182
@Yoandel ~
"...using only one sensor as opposed to both, thus introducing a single point of failure is an awful, terrible, engineering choice...."
Absolutely! Redundancy makes for a safer aircraft. One of the classic examples is the DC10 vs Lockheed 1011.
The latter had more redundancy, was safer but was more expensive.
32
@Yoandel
How many corporate insiders make the FAA decisions?
8
@Yoandel
Totally concur. Heavens, even the engines aren't a single point failure instance, and they're really expensive.
It just should not be possible for a single sensor failure (and its cascading consequences) to take down an aircraft. This is basic professional engineering for life-critical systems.
9
Those responsible for the failure to provide the proper training for pilots should be criminally prosecuted. This might serve as a deterrent to the bean counters. Compensation for the families of those who died in the crash, though necessary, is wholly inadequate.
61
@Marvin
I too share your desire to have those responsible to be held accountable. Yet, time after time corporations are made to pay fines that are minimal amounts compared to the profits they make. And corporate executives continue to get their pay increases. Negligence is criminal and there should be criminal indictments.
22
Great topic.
Good information.
Very well phrased.
12
Couple things:
1. The runaway trim checklist doesn’t “suggest” anything; it tells you exactly what to do in case you run into the situation like these pilots faced.
2. They didn’t need to know a blessed thing about MCAS in order to be able to handle this emergency (as evidenced by the pilots on the previous flight handling the same issue just fine). The electric trim cutout switches have been in the same place since the 737-100 first rolled off the production line almost 50 years ago.
3. The ONLY thing I can fault Boeing and the FAA for is not telling pilots that moving the yoke no longer disengaged the autotrim. Still, even without knowing this, if you had a trim/elevator issue and you corrected with the yoke and encountered the same problem again, the obvious next move (without even looking at the checklist) would be hitting the cutout switches and manually adjusting the trim with the wheel.
The idea that these two guys sat there for 11 or 12 cycles of this problem over the course of 10 minutes and never consulted the checklist or hit the trim cutout switches is absolutely mind-boggling. My strong belief is that they would have had the same outcome flying a 737NG, or anything else for that matter.
At most I would say this is 5% Boeing’s fault and 95% the pilots not handling a very basic (albeit ill-timed) emergency.
Pro tip: do NOT fly on an airline in a developing country. Flown by an American or European-trained crew, this would’ve been a different outcome.
109
@Mike
But in previous version of the plane pulling back on the yoke disabled the trim. It didn't on the plane with the MCAS system. That was a change. On previous versions without MCAS the pilots would have flown the plane safely but on this one they could not.
Boeing cannot both claim that the plane is the same and then disable the previous well-known traditional safety system (pulling back on the yoke). That is a huge change that the pilots were unaware of.
50
Yeah, but rich corporation.
4
@JCReaves "On previous versions without MCAS the pilots would have flown the plane safely but on this one they could not."
Oh they certainly could have; I was just reading the preliminary accident report, and the airplane experienced the same issue on the previous 3 flights. All 3 landed ithout incident. It's actually infuriating reading the report. Three straight flights on the previous 2 days, the same issue. Three attempts at a solution by maintenance crews. The post-maintenance test always showed the fault as cleared, but the same problem would happen on the next flight. Don't you suppose at some point Lion Air should have stopped putting paying passengers in this particular plane until they got it squared away, including an error-free test flight (WITHOUT unwitting guinea pigs in the back)?
Further, you should see the readouts from the flight data recorder. The automatic trim would push the nose down, the pilot would trim it back up. Then the automatic trim would trim it down again, the pilot would trim it back up again. I count TWENTY-SIX TIMES the pilot retrimming to correct for the auto trim. Don't you think at some point you might think about disabling the auto trim? Holy cow!!!
And you have to understand, in the 737, you can see the trim wheel moving when the auto trim engages. The trim wheel by your knee physically moves. Not a real big mystery what was going on!
Absolutely infuriating.
35
Minor correction. The yoke (sometimes referred to the control yoke) is attached to the control column. The control column is pushed forward or pulled back by the pilot who is holding on to the yoke. A forward movement moves the elevator/stabilator which causes the nose to pitch down. An aft movement causes the nose to rise. Turning the yoke left or right moves the ailerons which enables the aircraft to turn by raising the aileron on one wing and lowering it on the other. And yes, even this is a simplification.
2
Air crashes are almost always require multiple failures and the problems combine all at once.
7
I think Boeing will be exonerated by law but found morally suspect. This seems to be a case of lying by omission. Sure, if those pilots did everything right this tragedy may have been averted but it is really hard to be always right. Safety is not absolute and in this case the bottom line may have tipped the possibility of error in favor of a crash. This has tarnished Boeing's stellar reputation and I hope they learn from this.
11
Fascinating and well written article. The ability to overpower a stabilizer runaway by force in earlier models may very well have let pilots develop the wrong habits to buy time in dealing with a stabilizer runaway by overpowering the yoke (which is what the Lion Air pilots were trying to do). Clearly the removal of the override by force should have been communicated to everyone flying the Max.....
64
Like many old, established American private and public organizations, Boeing succumbed to the cognitive cancer that it knew more than anyone else, and a decision that minimized delay was always the proper decision. The same kind of cognitive cancer led to the Challenger disaster, the termination of the Bush-Gore recount, the decision to invade Iraq and a host of other bone-headed moves. Feedback from devil's advocates, and knowledgeable functionaries, such as pilots, astronauts, local politicians and soldiers is the best remedy for the cognitive cancer of smugness.
85
@OldProf
“...the cognitive cancer of smugness.”
I’m writin’ that one down.
12
The article stated the Pilots Union may also bear some blame but then never explains why that is so. Since the pilots had no idea that the system had been installed how would their Union be involved?
24
Greed. Simple greed.
Boeing wanted to match Airbus in 2010 to protect profits and market share. A fast certification needed to be acquired (bought?) to meet market goals.
Boeing wanted to avoid training pilots to save time and money, so engineering also had to satisfy a political goal.
The FAA concurred -- regulatory capture in action.
Fortunately, no Americans were hurt in the Lion Air disaster, just foreigners, so Boeing will probably scrape by just fine with some minor fines because the victims don't have the money to purchase justice in the US system.
Boeing's image, however, takes another huge hit. How many other clients will favour airlines that have Airbus equipment?
42
@Ed. In any case the failure of TBC and on down, to inform all parties, especially the flight crews of this MAJOR change to the flight control operations is totally inexcusable, BUT, it merely continues the practices which came in vogue with the 747/DC-10/L1011 in the late 60s, which was welcomed by the airlines and, sorry to say, some of the pilot unions, especially in the US. This trend of untrained pilots has been going on for half a century at least, due to $$$$ considerations. And, the more complex and automated that aircraft have become, the thinner and less detailed the pilot's flight manuals have become. How sad..... criminal, really.
2
"After the crash, Boeing told airlines that when M.C.A.S. is activated, as it appeared to have been on the Lion Air flight, pulling back on the control column will not stop so-called stabilizer runaway."
Not making pilots aware of above change by no-training-required-works-same-as-before messaging, Boeing is negligent. I hope they compensate the Indonesian families the same way they would if it was flight from Midway to Orlando.
28
If you read the article, it appears that the appropriate emergency response for the aircraft’s behavior in this situation was the exact same in the Pre-Max models and the Max model. The next-to-last flight pilots used that response to safely respond but the last-flight pilots did not. If that is the case, even if that crew had been flying a Pre-Max model, their lack of following the prescribed emergency response would have resulted in a crash. With the only variable being the pilots, wouldn’t this be a classic case of pilot error?
16
@William, although the "appropriate emergency response" for the Lion Air problem is the same as for a "runaway stabilizer"situation such as might have occurred on earlier 737 models, the symptom confronting the Lion Air pilots was different. The MCAS system allowed temporary overrides by pilot commands and then reasserted itself after a few seconds. This pattern occurred repeatedly and could have been very confounding to pilots not aware of how the system operates. It would not have looked the same as the runaway stabilizer situation pilots are trained for.
22
@William, although the "appropriate emergency response" for the Lion Air problem is the same as for a "runaway stabilizer"situation such as might have occurred on earlier 737 models, the symptom confronting the Lion Air pilots was different. The MCAS system allowed temporary overrides by pilot elevator commands and then reasserted itself after a few seconds. This pattern occurred repeatedly and could have been very confounding to pilots not aware of how the system operates. It would not have looked the same as the runaway stabilizer situation pilots are trained for.
2
@William
I would agree...Mike/NY, who seems to be an experienced pilot, supports this.
3
In this case, as in most other cases, an aviation accident/incident has more than one contributing cause. The Times article highlights several contributing factors but gives short shrift to what may be the most significant one.
The article states "The pilot of the plane’s next-to-last flight, in his entry into an electronic log, noted a variety of problems he had encountered ...". The fact that previous flight's pilot didn't or couldn't know what the cause of the malfunctions were is largely irrelevant. When something on the aircraft isn't working properly it is the responsibility of the airline through its maintenance infrastructure to determine the cause of the problem and resolve it.
Typical airline procedures require the pilot to enter into a log a description of the malfunction and the maintenance technician to log the corrective action. Although this system is the official way to deal with all aircraft maintenance problems, sometimes the pressure for "schedule reliability" has a way of rearing it's ugly head. Sometimes in stead of making a good faith effort to diagnose the problem, the log book will be cleared with a sign off such as "unable to reproduce symptoms on ground". Also, in some parts of the industry maintenance write ups are ignored until the aircraft is scheduled to go through a maintenance base.
I don't how big a factor any of the above played in this accident, but I think more attention should have been payed to it in the times article.
30
This is the FAA's mission statement: "Our continuing mission is to provide the safest, most efficient aerospace system in the world."
If you want to have the safest system, then the pilots need to have all information about changes to an aircraft and have training to familiarize themselves with how this might affect the operation of their aircraft. There is no excuse to skimp on training.
I've always liked and felt safe in Boeing aircraft. I am very disappointed that safety was given short shrift.
96
@Mary Ann Donahue The FAA epitomizes the relationship of many federal regulatory agencies to "regulated" large corporations - a wholly owned subsidiary. A captive agency in other words. It has been long-time common knowledge of the FAA.
31
@Rocky ~
I know that the FAA lets the bottom line influence their decision making, that the relationship with the industry they are supposed to regulate is too cozy.
It wasn't always thus. Maybe it is time for the FAA to live up to and adhere to its original mission--safety.
13
@Mary Ann Donahue, it's long past time the FAA lived up to its original mission. It *is* time for full transparency on who at the FAA owns stock in the major airline manufacturers, and who made the decision to ignore pilot training after a significant redesign of both the airframe and the automation.
4
Airplanes are very safe because designers and regulators have learned from past mistakes. This seems like a case when the bottom line overrode years of learned caution in order to sell a new version of a plane that wasn't ready for flight.
55
So the question I have for Boeing and the FAA is - what are 189 lives worth? There’s no good answer to that question, other than the lifetime pain that the families and friends of those who died are now facing.
If I get this right, it was a bottom line decision to not train the pilots, nor even make them aware of a major change in essentially the operating system of the plane. I don’t know much about aviation but don’t have to in this case. It comes down to criminal negligence, all in the interests of saving money and rewarding shareholders.
Certainly a court will decide how to compensate that which can’t be compensated. I am simply disgusted, and outraged, over the actions (or lack thereof) by Boeing and the FAA. At least Brazil got it right.
259
@HeyJoe I love these dramatic, emotional comments calling Boeing murderers by people who freely admit they have no idea what they're talking about.
Let me explain:
If your car could have 3 different reasons for the same problem, but the solution was the same, would you want to know the intricate details, or just what to do in an emergency? That's the case here. There are any number of possible reasons for a trim fault in this airplane. The solution always involves the same thing: hitting the cutout switches and taking manual control of the trim.
Also, in airplanes there are really complex emergencies, and very basic emergencies. In any airplane with electric trim, a runaway trim situation (like they experienced) is a very basic emergency. Every 737 pilot on earth knows how to handle it from rote memory. And those switches have been in the same place for 50 years. Literally.
This is the runaway trim emergency checklist for the 737:
1. Hold control column firmly
2. Disengage autopilot
3. Disengage autothrottle
4. STAB TRIM CUTOUT SWITCHES (both)
That's it. And the emphasis is not mine, it is in all caps in the checklist.
It is absolutely inconceivable that a trained, competent 737 crew, faced with repeated runaway trim, wouldn't hit the cutout switches. These guys never did.
If it makes you feel better to call Boeing a bunch of murderers, fine. But the same thing happened on the previous flight without issue. That's because the crew handled it properly.
54
The word “murderer” occurs nowhere in my comments. That’s a fiction you created. Try reading the entire comment next time before you respond.
15
@HeyJoe I read your comment. You were correct when you said you don't know anything about aviation. You were very, very wrong when you said you didn't have to in this case. Regardless of the cause, the solution was the same. A solution that these two pilots never even tried when it should have been the first thing on their minds. On the flight before this one, the very same thing happened, and the crew hit the trim cutoff switches and continued the flight without incident (which, incidentally, they should not have done - even with the symptom resolved, they should have landed immediately).
Three crews had the same issue on three consecutive flights. Neither of the first two had any problem dealing with it. What does that tell you? I feel bad jumping on these guys because this happened in a critical phase of flight, and it surely would have been startling. But it was perfectly manageable with no additional training. To hear people excoriate Boeing for this is ridiculous.
4
If Boeing had spent a fraction of the time in determining what was the optimal training program versus the time spend dodging liability maybe (just maybe) 189 people might still be alive. But understandably this seems an unusual confluence (obviously not impossible) of circumstances, but without admitting guilt it would make sense to me for Boeing to compensate the families of victims, and change training such that this is featured.
8
This complex situation reminds me of the dangers we take on when we put computers in control of decision making. In addition to the potential of incorrect action being taken because of faulty information flow, there is an added danger in making the decisions of humans more complex and perhaps confused.
What if the computer is right and I am wrong? How much time is taken in considering this issue during an emergency? This does not apply only to flying aircraft, but increasingly in driving a car and making decisions at work and in the household.
We are on the verge of turning a massive amount of decision making over to computers in regard to cars that, if not fully self-driving, make numerous decisions for the driver. This problem extends to almost every aspect of complex decision making, risking, as the science fiction writers have long imagined, reducing humans to victims of automated decisions and trying to reassert control over their lives.
Underlying this march to potential disaster is the belief by many engineers and computer programmers that computers can always make a better decisions by eliminating "the human factor" of error. While we rush to embrace new technologies, as a society we need to consider where we are going, how far into this we want to go and when the cry out, "Stop!".
Otherwise...
55
Good article and analysis.
Everyone involved (Boeing, Lion, FAA, etc) shares some blame and they know it. Boeing having made the lion’s share (sorry). Changes are being made and efforts to avoid falling into similar traps underway.
The arguments being made by Boeing and Lion are mainly about managing liability after the fact.
18
Yet, computers are fully able today of adapting and using this feedback, and even learning. If the computer brings the nose down, and the pilot up, and then back down, and the pilot up... modern computer systems can easily be programmed to prompt "Hmmm... I see you don't agree, should I stop default behavior?"
Additionally, such events (computer is overriden over and over) should give human operators the option to transfer control to the redundant computer (and sensor).
This tragedy is 1000% a result of human design choices --nothing of it is inherent to computers.
12
And the essence of your reply is magnified with the introduction of Artificial Intelligence, essentially, that computers can take the same data as a human and make a better (or optimal) decision.
A big problem with that (AI) is that it doesn’t, and can’t, factor in human emotion. In addition to this aviation disaster, I’m truly concerned with how “smart” cars are becoming. It wasn’t that long ago that BMW engineers wouldn’t put cup holders in cars because the drivers were supposed to be focused on driving. Seems they were on to something.
I just bought a new Lexus, and it’s loaded with stuff, usually under the catch-all term, “Infotainment”. And here I thought I was just supposed to get from point A to point B without killing myself or anyone else. Silly me.
12