April 05, 2019, ©. Leeham News: The preliminary accident report of the ET302 crash was released yesterday. It confirmed what we wrote about earlier in the week, the pilots followed the prescribed procedure to stop MCAS. Yet they didn’t make it.
Part of why we presented Wednesday. Here follows additional analysis after studying the information in the Preliminary Crash Report.
The report released by the Ethiopian Ministry of Transport is a preliminary report. It follows the structure of the Lion Air JT610 preliminary report.
It confirms what we wrote about earlier in the week, the Flight Crew followed the procedures prescribed by FAA and Boeing in AD 2018-23-51. And as predicted the Flight Crew could not trim manually, the trim wheel can’t be moved at the speeds ET302 flew.
The traces from the report is Shown in Figure 1 and 2 (click on them to make them larger).
Figure 1 shows the general Flight Information traces whereas Figure 2 shows the specific information around MCAS and the signals which affect MCAS.
I have decided to spend a minimum of time on basics, which we’ve gone through several times, and focus on what everyone is now asking themselves: Why did the Crew re-engage the trim and why didn’t they then trim more themselves to combat any MCAS trim?
First the basics.
The events are very similar to Lion Air JT610 but not identical. At rotation, everything is normal this time (the high AoA was present at rotation for JT610) but 10 seconds after rotation, at 05.38.45 in the traces, the left Angle of Attack (AoA) went high, Figure 2, 10 seconds after line A.
Observe the values are different from JT610. I assume we have the un-corrected AoA values (the Vane values) in this FDR (Flight Data Recorder) trace whereas we had the recalculated Wing AoA values presented in the JT610 FDR traces (raw angle values are higher for the Vanes as explained in previous articles. The airflow along a fuselage nose is curving upward at positive angle against the wind, more so than for the wing).
Stick shaker activates at A but the flight continues pretty normally until the Flaps are raised at B, Figure 2. The trim commands before Flaps up are normal trims from the Pilot Flying (PF, the Captain, Trim Man trace). Autopilot and finally Speed Trim System trims on the Automatic trim trace (to understand Speed Trim and the reason for MCAS, read here and select among the list of articles at the end of the text to learn more).
After Flaps up at B, you have the first MCAS nose down at 1 which stops at 2 (the FFC, Flight Control Computer, trim trace). Between 2 and 3, PF trims against. This causes MCAS to reset and trim again at 3 and it gets interrupted by PF trim at 4. Now MACS is identified and the Pilot Monitoring (PM, the First Officer) cuts trim with Cut Off switches after 5. We know this as the next attack from MCAS at 6 has no effect on Pitch trim units (the trace below FCC trim). Now the fight with MCAS is over and the crew starts turning back to the airfield after 05.40.45, Figure 1 Heading Disp (Displayed) trace.
The Crew finds however they can’t correct the nose heavy trim with the manual wheels, contrary to what is stated in the AD and in their Checklists. Speed is now at Vmo, the maximum design Indicated Air Speed (IAS) for the aircraft, 340kts.
The throttles are left at 94% thrust for the whole flight. This is higher than normal but this is a high takeoff. At 7,600ft it is a full 2,200ft higher than Denver, which is the US Benchmark for high takeoffs. And with Stick Shaker and IAS disagree you keep high thrust and fly a slow climb (the IAS disagree is present in the traces but not mentioned in the report specifically. We don’t have all the Crew callouts and discussions present in the report is my conclusion).
The high speed of 340kts indicated airspeed and the trim at 2.3 units causes the Stabilator manual trim to jam, one can’t move it by hand. The crew is busy trying to hand trim the next two minutes but no trim change is achieved.
At 7 the aircraft nose is dipping (see Pitch Attitude Disp trace) because PF can no longer hold against the Yoke forces we discussed Wednesday (Ctrl Column Pos L/R). PF decides he needs Electric Trim to stop the aircraft from diving. Cut Off switches are put to Electric Trim active. PF successfully trimmed against the last MCAS attack, he can do it again.
After 7 PF commands Electric Trim Nose Up in two short cycles. I asked my selves (as did others) why these short trims? They are fighting to get the nose up to the extent they risk switching in the Electric Trim again. Then why not trim nose up continuously or for at least long cycles once Electric Trim is there? It took me several hours to find an explanation. Here my take:
To understand the blip trims one must have flown fast jets at low altitude. At the speed ET302 is flying, 360kts, it’s hypersensitive to trim. The least trim action and the aircraft reacts violently. Any trimming is in short blips.
As PF holds the nose up with a very high stick force, now for a long time, he’s sensitivity to release stick with trim is not there (this is what Pilots do when they trim nose up, otherwise the aircraft pitches up fast). He trims therefore in short blips and has difficulty to judge the trim effect he has achieved. His is not flying on feel. He can’t, he is severely out of trim, holding on to the Yoke with a strong pull force.
Anyone who has flown a grossly out of trim aircraft at high speeds knows your feel is compromised. The sensors you have to rely on are your eyes, not your hands.
PF has the horizon glued to read the aircraft. The result is the short nose-up trims we see. The nose goes up and the stick force needed is reduced. His judgment is; this is enough for now, it was a powerful response. Any MCAS attack I now trim against, then I correct my trim if I need to.
But the aggressive MCAS, trimming with a speed 50% higher than the pilot and for a full nine seconds, kicks in at 8 with a force they didn’t expect. Speed is now at 375kts and MCAS was never designed to trim at these Speed/Altitude combinations. Dynamic pressures, which governs how the aircraft reacts to control surface movements, is now almost double it was when last MCAS trimmed (Dynamic pressure increases with Speed squared).
The Pilots are thrown off their seats, hitting the cockpit roof. Look at the Pitch Attitude Disp trace and the Accel Vert trace. These are on the way to Zero G and we can see how PF loses stick pull in the process (Ctrl Column Pos L). He can barely hold on to the Yoke, let alone pull or trim against.
His reduced pull increases the pitch down further, which increases the speed even more. At 05.45.30 the Pilots have hit the seats again (Accel Vert trace and Ctrl Columns force trace) and can start pulling in a desperate last move. But it’s too late. Despite them creating the largest Control Column movement ever, pitch down attitude is only marginally affected.
We have Control Column displacement this time, JT610 was Force. If the elevator reacts to these displacements, at the Dynamic Pressure we have, we should have seen the diving stop. The lack of reaction to the large Control Column displacement of two Pilots pulling makes me think we now have blowback. This is not a design fault, we are well beyond Vmo. But it explains the rapid dive, unhindered by the Pilots’ actions.
It’s easy to say “Why didn’t they trim then?”. Because they are going down at 20 degrees nose down (which is a lot, a normal landing approach is 3°) and at 400kts. Then you just pull for all you have. And the aircraft is not reacting to the largest Control Column displacement since takeoff. This makes them pull even harder, the aircraft is unresponsive and they are fighting for theirs and all the passenger lives.
A final reflection: Once again we have been given no elevator trace. Why? It’s there, why can’t we see it. It would have given us a better understanding of what’s happening in the last part of the flight.