Training is a factor in the MAX crashes


By Scott Hamilton

April 15, 2019, © Leeham News: This column will no doubt light up the blog-o-sphere.
There’s been a major debate going on since the crash of Lion Air JT610, the Boeing 737-8 MAX that immediately became a huge controversy.

Boeing immediately blamed the pilots. So did some pilots of some US airlines, who said if the Lion Air crew had just flown the airplane, it wouldn’t have crashed. It was a training issue, some said.

Having got tremendous blow back over Lion Air, Boeing publicly held its tongue when Ethiopian Airlines flight ET302 crashed five months later.

Still, Boeing officials quietly still said there was nothing wrong with the airplane.
Some US and Canadian pilots maintained, publicly and privately, that a lack of training and pilot skills in the Third World was responsible.

They’re not entirely wrong.

Root cause

It’s pretty clear that the root cause of the two accidents can be traced to MCAS, the automation feature that provide stall protection for the MAX. In this case, automation fought the pilots (or the other way around, depending on your viewpoint) and the pilots lost.
Linking MCAS to a single Angle of Attack sensor rather than two created a single point of failure.

This is supposed to be an anathema in aviation.

Designing MCAS to be a repetitive engagement also proved a mistake.

Boeing is correcting these with its software upgrade.

But for those who want to exonerate the pilots in both crashes, well…those who criticized the four pilots have some pretty solid ground.

Aviation Week last week published a summary of the initial report for the Ethiopian Airline crash. The findings point to the pilots. The article is here; free registration is required.

Trapped into mistakes

It’s fair to say that the four pilots were probably trapped into making mistakes. Boeing didn’t tell the airlines about the MCAS, so no training was possible. But mistakes were made by pilots, nevertheless.

In late-March, there was enough information about the two accidents for me to have an email exchange in which I wrote:

Broadly, the following points appear to be contributory factors to the two accidents:

  1. Bad MCAS design.
  2. Single point of failure—linking to one AOA instead of two.
  3. Failure to tell the airlines/pilots of the MCAS.
  4. Failure to have warning systems as standard equipment in cockpit.
  5. Possible poor maintenance at Lion Air.
  6. Possible poor communication at Lion Air between the crew on the preceding flight and subsequent crews.
  7. Pilot actions at Ethiopian.

I also wrote that national pride will probably minimize the pilot contributions to the accidents.

Automation can lead to degraded skills

Those who pointed to poorer training in Third World countries aren’t wrong.

Pilot skills and training in the First World are extraordinary. The accident rates in the US, Canada and First World Europe have been lower than anywhere else since the dawn of modern aviation.

Automation helps, too. But it can lead to complacency.

Airbus adopted Flight Envelope Protection and sophisticated computer control over the airplane. Boeing preferred more direct pilot control, even as it moved toward automation.

Airbus essentially took the approach to prepare the airplane for the lowest common denominator. Boeing’s approach was for the average pilot, however this was defined.

Concerns over increasing automation aren’t new. When Boeing introduced the 737 NG in 1997, with more automation than the 737 Classic, I remember at the time Southwest Airlines was concerned about automation leading to a degradation of pilot skills. Then, there was a conscious decision that the pilots still needed to fly the planes.

I’ve talked with a United Airlines pilot who flew Boeing aircraft and who was a captain on the A320 at the time of our discussion. This was years ago. He said that despite the automation, he’d manually fly the airplane often to maintain his skills.

Automated accidents

There are two notable accidents in which auto-throttles played a key role. One was the Asian Airlines Boeing 777 accident at San Francisco. Another was the Turkish Airlines Boeing 737 crash in Amsterdam. In neither case were the auto-throttles the sole cause but these contributed to the accident.

Auto-throttles were an element—one of many—of the two MAX accidents.

On the other hand, the A320’s flight envelope protection system was a contributing factor to the successful water ditching for US Airways flight 1549.

A major difference between Western training and that in the Third World is Cockpit Resource Management. Culture also plays a role.

CRM has been around Western airline training for decades. It has contributed to successful outcomes of many emergency situations. CRM encourages cooperation between the captain and subordinate cockpit crew members.

CRM tends to be lacking in other areas, in part because many cultures place a high premium on deference to authority. There are several accidents in Asia where this deference played a deadly role.

Partner airlines

Delta Air Lines is a founder of the international alliance SkyTeam, which includes many airlines outside the First World.

Ed Bastian is CEO of Delta. I asked him at the Aviation Week MRO Americas conference last week about the different levels of pilot training and whether Delta takes a lead in standardizing training among SkyTeam partners.

“We do have a safety panel within SkyTeam and we have investments in partners around the world [which are not SkyTeam members],” he said. “Safety is one of the things we do partner with. We share insight, we share observations, we share training protocols, we’re always looking to learn from each other.”

Redefining the average pilot

That the definition of the “average pilot” may need a rethink is a thesis that has emerged from these two MAX accidents.

It looks like a thesis that has merit.


164 Comments on “Training is a factor in the MAX crashes

  1. You are probably right to some degree,but are you that confident in the skills of below average ability western pilots?Southwest has stated that they have had no problems with MCAS whatsoever, so we have no idea how any of their pilots would have reacted never mind the below average ones.Africas accident rate is higher, but in general they seemed to cope well enough with the NG.

    • agreeed.

      Unless the pilots did something really stu9pid like loose their situational awareness (failure to follow instruments ) its been a very good record on the NG>

    • You have to laugh don’t you, well you would if it were not so serious. MCAS, who ever heard of such junk. Look, Boeing wanted to stuff oversized engines on a low slung plane, the thing tilts upwards now👍

      Best suited to pot bellied pilots who can augment MCAS in adding some counterbalance 😁

    • SWA never had a failed alfa probe on a heavy loaded MAX at low altitude “a hot day in Denver” so we really don’t know how they would handle it at the time of the first incident.

  2. Cross-cultural issues also play a role. Many airlines in new markets (I rather use this expression than the patronizing “Third World”) have grown very rapidly. They need to source pilots from all over the world. Do they have enough focus in specific CRM and communications issues in a multi-language and multi-cultural environment while scrambling to manage rostering issues brought in by the rapid expansion?

    • Not wanting to be the “PC Police”, however, could we drop “First & Third” world designations and use Developing countries instead? It is arrogant and condescending.

      • And the Developing countries don’t have the resources (money) the developed countries do but they have the desperate need for commerce

        Maybe Boeing and Airbus should help them out? (like in monetary and structure assistance !)

      • Hi Lloyd, the term “Third World” actually has a positive connotation. Its origins lie in the times the Non-Aligned Movement emerged as a counterpart to the Western and Eastern blocs during the Cold War. Although mostly initiated by authoritarian regimes, the NAM had an emancipatory and empowering impact on countries that were colonies before.

        The term “developing countries”, on the contrary, can be perceived as arrogant and condescending as it is used to sum up countries that may have a cultrural heritage spanning way further into the past than, say, that of the US. “Developing” implies that ‘they’ are behind and have to catch up, which conveniently covers up the fact that it was and is Western policy that is mainly responsible for the social and economic status of the described countries.

        Sorry for the OT, Scott. Also not trying to be PC police as well, just wanted to add that perspective.

  3. Not only third world, Korean had a huge cockpit CRM problem. Almost all pilots came from the military, very hierarchical, respectful, following orders, Alpha’s. FAA required a total culture change, hired lots of foreign pilots, reduced defense influence, retrained everybody.

    I think authorities will look into how it is possible the Single point of failure sensor, MCAS overpowering the pilot, lack of training apparently passed some (grandfathered?) requirements and how come, nobody raised a flag (including EASA as far as I’m concerned). It probably more about the process than technical solution.

  4. In my view – the degradation of pilot manual flying skills/ ‘children of the magenta line’ debate is unprovable either way. Correct, we have seen acccidents where lack of manual flying skills/ CRM was an issue (and the poster example is a Western flight – AF447) But it is impossible to say the number of incidents that automation stopped occuring in the first place.

    Again, in my view, the global reduction in accident rates over the last generation shows we are doing something right – how much of that can be allocated to improved training, and how much to improved automation, is difficult to say.

    Anecdotally, in the airline I worked for, the adherence to SOP/ ‘flying by the book’ did see a culture shift, and the slightly cowboyish attitudes of the 1980’s that put a premium/ pride on ‘flying skills’ (aka being able to land from an unsuitable approach) replaced by a much more systematic approach 30 years later. I remember my first jump seat ride in a EU carrier in the early 90’s, and being surprised how they were glad/ happy to fly an automated approach, vs the attitude we had at the time that ‘real pilots fly manual approaches’

    • A good, and interesting, point.
      How many “incidents”out there that automation kept to a “near misses” instead of an accident?

      An answer that is probably not easy in finding.

      Like the A320 that was not supposed to fly in the woods, there will be people who say on one side that the pilot should have final authority over the aircraft, and all within it, and others who believe that the aircraft should save some pilots, and hence their passengers, from the pilot’s follies.

      • Oddly some may find, I am an advocate of Envelope protection ala Airbus.

        It does have its downsides, it was over sold (google Aircoup) but for the pilots in the World, Western, Eastern, Africa, Asia you name it, its a better system.

        I am not sure where Boeing got the notion that pilots needed to overcome the automation because the reality is the vast majority of the pilots are not fighter pilots nor aerobatic pilots and those are the ONLY ones who have any understanding of what the limits really are.

        In short, any pilot who thinks he can fly an aircraft to the limits better than a computer is wrong.

        At best a brief override might be allowable, but other than that, Airbus and BBD (now A220) etc have the right idea.

        Pilots for the most part are bus drivers (note the Air bus?) – yes its an honorable profession.

        Its nothing more than a learned skill. Its not inherent Chuck Yeager if you can fly.

        I was NOT a natural pilot. I was a decent one. I have seen those gifted pilots and they have my hat off, but they are not the norm.

  5. I don’t see how designing an airliner for the ‘average’ pilot can ever be justified unless that average also respresents the capability of the least capable pilots. Otherwise you are condemning many pilots/passengers/familes/friends/aircraft/airlines etc to an unreasonably elevated risk of failure.

    Regarding the culture (and I guess you may get requests to use Developed/Developing Nations etc rather than expired terms First/Third World), are you suggesting Scott that it is the culture of the individuals or airlines operating aircraft that you feel needs to change as opposed to the culture of (it seems specifically) Boeing in designing for an ‘average’ pilot?

    Also, you list only the US, Canada and “First World Europe” as having low accident rates throughout aviation history. Really? Throughout aviation history (and I’ve never seen any statistics so have no way to judge at all. I’d simply want to see statistical evidence to justify such an assertion)? Specifically for the sentence, I’m not aware of any notable difference in accident rates in Europe pre-WWII and even if there has been any since then that is surely down to the political environment post-WWII. Beyond that, what about Australasia, Japan….?

    Regarding the average itself, what type of average is referred to? Mean, median or modal?

    • Wait. If you design the plane for the “average pilot”, aren’t you saying the half the pilots out there are dangerously underskilled for that plane?

      After all, half of all doctors are below average….

      • Precisely. Depends of course on mean, median or modal and distribution. But in the real world it is almost impossible for there not to be pilots whose capabilities are below this average.

        If the usage of the term average is more akin to the legal ‘average man on the street’ then maybe not.

      • And Doctors have a large percentage of General Aviation crashes.

        You might want to look at statistics of death in the US due to the medical field.

        Its not good

  6. Thank you for highlighting this issue. Healthy CRM and a shallow authority gradient in the modern flight deck is THE most important tool available to pilots. Forget about the different design features incorporated by either Boeing or Airbus. The automated systems in both are capable of giving you a hard time. Communicating with each other, being open for suggestion, having the ability to speak up and learning how to effectively manage stressful situations are key to modern airliner cockpit problem solving.

    My technical knowledge of aircraft systems isn’t as thorough as my counterparts had 30 years ago but I am a believer that this isn’t necessary anymore. Knowing how to tackle problems in the CRM sphere is not just fashionable but necessary with our modern day airliners. I’m grateful my sky team founding airline provides me with great training for this. I acknowledge the fact that some airlines or cultures outside the first world have some catching up to do. Those mindsets need changing.

    Relating all this to the Ethiopian crash though I a missing where the breakdown in CRM happened?

  7. Dear Scott, you tend to assume, in some sort of degree, the first arguments by Boeing and US pilots: that third world pilots are not prepared to fly safely the new plane. Well, if this is part of the conclusion, then Boeing has a really, really big problem. The vast mayority of the backlog of the 737 is from “third world” countries. If the companies of these countries come to the same conclusion as you, then it will be very plausible that they switch to Airbus, that can be handled by these pilots. On the other hand, the fact that the 737 NG was perfectly safe in the hands of these pilots doesnt make much a favour to the max. Finally, in my opinion, Boeing screw it up. They had a plan for a new narrowbody, but pressures by AA and Southwest made them changed their mind. They were financially strained by the debacle of the 787 and thye approved these cheap alternative. simply, they went cheap and and not long term.

  8. The only relevant words in this article are national pride. The article suggests it’s the national pride of Ethiopia and Indonesia but perhaps this article is about the national pride of America.

    The fact is, the 737 MAX has significant mechanical short-comings. Let’s hope regulators outside of America are willing to address them for America won’t even admit they exist.

    • Let us just say the 737 does have significant mechanical shortcomings (manual trim leverage)

      I have not problem admitting it and have said so.

      That said I have seen the European and US authorities allow aircraft to fly with serious issues for 5 years while they take their merry time about fixing them (well its not continent but at the first D check we will take care of it)

      As we have seen with the various engine fixes that did not work so good, maybe its time to make this test protocols and time critical rather than the same oh same oh.

      You will fix it and fix it NOW.

      You will test it a LOT – you can’t insert a change into a (XXX) unless it undergoes full test.

  9. How can pilots be trained into MCAS drills if MCAS is not part of the official aircraft specification and there are no or very few simulators available, whereof none with built-in MCAS software ? This situation is the result of Boeing’s programme planning and not one that stems from customer Operations doing or not doing.

    • The first info related to the preliminary report was given at a press conference arranger by the Ethiopian political authorities; such as the minister of transport. They had chosen their words carefully; the pilots followed Boeing’s instructions to the letter, – the pilots did everything correct. That was what the journalists around the world told their audience, and what became ‘the truth’ about the Ethiopian Airlines accident; for many ‘the truth’ even today.

      Somewhat later came the 30+ pages of the preliminay report, – who most of the mentioned journalist didn’t read (and wouldn’t have understood if they did!?). But some, including this site, studied the preliminary report in great detail, and their findings where not as conclusive as the press conference. gives the most detailed report walk-through I have seen (it’s recommended).

      Did the politicians have a motive with what they did; – i.e. conlude so much in favour of the pilots. I don’t know, – I may guess.

  10. Comparing pilot skills means you would have to exclude accidents due solely to equipment failure(s). For example, no matter how skilled the pilots were flying those early Comets, when they exploded due to a structural failure, the outcome would be the same always be the same.

    • Indeed. The first non training flight loss of a 707 was Sabena SN548 which crashed after a go around at Brussels airport in 1961. In an eerie throwback from the current Max crashes :
      “The FAA commented that the most plausible hypothesis was a malfunction of the stabilizer adjusting mechanism permitting the stabilizer to run to the 10.5deg nose-up position.”
      Plenty of aircraft malfunctions in early jet airliner crashes

  11. In an earlier article, someone suggested that the 737 MAX has limited hot and high performance.

    Takeoff roll at MTOW, 737 MAX = 8300 ft
    Takeoff roll at MTOW, A320 = 6900 ft

    Source: Wiki

    Perhaps the suggestion is right.

    Perhaps there is a need to concentrate on the average airplane as opposed to the average pilot. The first is science, the second is opinion.

    • Both runways at Addis Ababa are over 12,000 ft long and the altitude is 7600ft.
      Johannesburg airport is 5500ft and their longest runway is over 14,000ft.
      The only real problem for ‘hot and high’ is when the runway is limited length.
      GE has high power versions of the Leap-1B engines available , the possible options are 24,000- 30,000lbs take off thrust ( not all power options might be available for all Max variants).

      With 12,000 ft runways and high power engine options the Max 8 doesnt have any issues at Addis Ababa

      • MCAS seems to be so poorly designed I’m not sure how well boeing tested the combination of MCAS and high altitude takeoff with a failing sensor.

  12. I am interested in your nuanced argument Scott. In simple terms you are arguing that less experienced/trained crews will have had some impact on the accidents. I don’t think you are saying that they are the main factor behind them. What interests me is your stance in the wider argument.

    As far as I am concerned the more flight protection the better for me. To suggest that flight protection is inherently a bad thing goes against all the data. Whether FBW encourages perverse behaviour ie a loss of flying skills is a wholly separate matter. Could we not mandate more drills, training, peer reviews and updates for pilots? Could we not require pilots to have a ‘handfly’ Requirement built into their hours including numbered takeoff and landings?

    Getting back to the MAX issue we clearly have an issue of conflicting controls where a standard of flying higher than that which could reasonably be expected is needed. In its short life the Max has killed two pairs of pilots and scared a lot more.

  13. If you replace “first world” pilots with “pilots with an ATP” rating .. I think the statistics would show up better. After the Colgen Air crash, the FAA changed the rules for all ATP pilots in 121 operations, and needing 1500 hours for an ATP, along with added stall simulator training. If Ethiopian Air had that same requirement, the co-pilot would have had over 1000 hours more experience. Would that have saved the day? I’d really like to hear more from the 3 pilots (especially the jumpseat pilot), who did manage to fly out of the AOA failure successfully. He did have full focus on solving the problem, rather than trying to fly the plane at the same time, and may have had a better view, or been more focused on the trim wheel running away, than the ‘front seat’ pilots. With 1000’s of pilots retiring in the next few years, where will new pilots get the required hours to become ATP certified?

  14. I think there is an organized move to bailout Boeing. There are a few articles on the same lines as yours – trying to pin the blame on pilots.
    Yes, the pilots could have done better – such an inference can be made after most accidents and incidents.
    If the first world is that good in aviation, how come such a dodgy design come from Boeing and pass through FAA?. In aviation you cannot dig a hole and expect that no one will fall in it.
    Boeing is very lucky that one of the two unfortunate incidents did not involve American planes and it’s citizens.
    Such a design would not have come from any stable before the advent of low cost airlines, who insist on minimizing cost and expenditure on training. One hopes that a change comes in the first world so that such souped up aircraft are not sold to airlines in future.

    • I second that. But who would be surprised to find that Boeing is pulling all strings possible to push the attention away from the really dangerous questions. This makes it even more important for the independent media to nut buy into that diversionary tactic but keep digging away at the substancial problems.

      Maybe Scott or Björn can clarify if every airliner must be designed aerodynamically stable to receive a certificate.

      The next question is if the Max is aerodynamically stable over the entire normal flight envelope or not.

      In case it is not, then why did it receive a certificate? And would this certificate have to be revoked?

      • Let me try this again:

        Is it obligatory that an airliner is aerodynamically stable over the entire normal flight envelope?

        Is the 737 Max aerodynamically stable in that sense?


        • Yes it is stable. But more than just stability is required, it is also required that the higher you want to point the nose the further and HARDER you need to pull back on the yoke. This gives pilots consistent feedback on pitch angle.

          For the un-augmented MAX this is not the case. After some high pitch angle getting close to stall and beyond what is normally encounter, say 16 degrees, the force needed to raise the nose further begins to decrease. Say it takes 50lb pull to keep the nose at 16 degrees, then to raise it to 18 may only take 40. The plane is still stable, if the pilot lets go of the yoke it will level off, but the feedback is wrong.

          Giving the pilot the correct force-feedback is a certification requirement and is why MCAS was added.

          • Why not just adjust the forces on the yoke then instead moving stabilizers?

          • @Matth

            Adjusting force on the “yoke” is what modern fly-by-wire solutions do, for example the A220, for example from Bjorn Fehrm flight of the cseries “Then I pulled the side-stick to the hard stop which decelerated us to 95kts. It required quite some extra force (which is as it should be).”

            But adding synthetic force feedback was not an option for the 737 without many more changes. But they already had a motor driven trim system so it was duel purposed.

  15. What we need before condemning the dead is proof that good pilots could have avoided crashing.We (the general public) know of only one case where the pilots beat the trap,and they had the unfair advantage of a spare non flying pilot.You can’t assert that US pilots would have done better without a significant number of them ever having been faced with the problem.

    • I for one would love to know whether the incident the day before the Lion Air crash is comparable to the incident the day before.

      In particular we know that bedlam occurred during the Lion Air crash with every reading inconsistent, every sound inconsistant and of course asymmetric stick shake. In other words, the pilots were subject to a game of chance – take your pick as to what to believe. In fact nothing could be believed for the FCC went into meltdown

      Was the same true of the incident the day before, or was the third pilot able to isolate the issue as trim stabiliser runaway for I don’t think the third pilot knew about MCAS.

      With regard to the Ethiopian crash, the pilots were subject to the same bedlam. They chose to execute the trim stabiliser runaway procedure but it didn’t work. But we are now told that they should not have done that. Instead they should have executed the air speed data conflict procedure.

      With regard to the air speed conflict procedure. The airplane was 50ft off the ground when the air speed conflict occurred. Reduce N1 to 80%, decrease alpha from 15° to 10° at just 50ft off the ground. I don’t think the airplane would remain airbourne with two engines providing thrust. But I’m absolutely sure the airplane wouldn’t remain airbourne if there was an engine failure.

      Others have offered different procedures. They all involve reducing thrust to the engines, but only at a safe altitude and with a greater airspeed.

      This raises a question? When there is complete bedlam on the flight deck, with the FCC in complete meltdown, which procedure is the correct procedure to use, for my guess is that there are dozens to choose from.

      The game of chance. If you choose wrong you die, if you choose right you live.

      What interests me is that Boeing and the FAA have not this time issued the right procedure or the right sequence of procedures to prevent a repeat of the Ethiopian Airline crash.

      With regard to the Lion Air crash, the ‘right’ procedure was issued within 24 hours – at least we were told it was the ‘right’ procedure.

      • Survival became a game of chance? That’s probably correct. Dealing with problems procedurally is fine, it’s what pilots are encouraged and trained to do. But it they’re given no information at all (what’s MCAS?) or unworkable procedures (er, the trim wheels cannot be turned manually) we shouldn’t be at all surprised if a crash occurs.

        Could an air force trained pilot with thousands of hours hand flying all sorts of aircraft successfully improvise their way out of an MCAS event? Maybe. But if that’s the level of training that it would require to safely fly the MAX then that should be reflected in the training requirements Boeing puts into their manuals.

        It’s this failure to match reasonable human factors to the potential behavior of the aircraft which, in my opinion, is the greatest failing of Boeing and the FAA. First, it seems clear that they’ve not really assessed human factors as a part of deploying MCAS, especially related to foreseeable faults. Second, given that the emergency AD said “use manual trim” which turned out to be impossible, it seems that Boeing don’t even know the behavior of their own aircraft adequately. Given that, what outcome other than a tragedy could reasonably be expected?

        Another thing I find distasteful in this debate; all these pilots had (AFAIK) time on the NG, and some of them quite a lot of it. Pilots do not turn into useless jellies simply because they’re flying a new aircraft, especially one that’s been sold as being “the same as an NG”.

        MCAS made the MAX unpredictably and viciously different to the NG, with one of the nastiest failure paths imaginable. Boeing put it there, and the FAA (sorta) approved it, and didn’t tell pilots about it. That should be the starting point of any and all conversations about the MAX, and really everything else (including pilot skill levels) is a very distant secondary consideration.

        • My thoughts precisely. But I will respond more precisely because it is becoming more clear. There is a lot more to be said about the 737 Max.

          Scott: The science or the people. You have the right to ask the question. I think it is the science not the people

    • Ethiopian pilots failed to execute unreliable airspeed checklist. This is elementary and pilots that do not know how to do this should not be flying. Crew also failed to re-trim the aircraft. The stabilizer runaway checklist’s second step directs pilots to “control aircraft pitch attitude manually with control column and main electric trim as needed”. In any case the aircraft would have been difficult to control in its overspeed situation, an overspeed that resulted from pilot failure to throttle back.

  16. By your definition Scott, I’d say Boeing is even more culpable. If it sells planes to “Third world” airlines that have poorer training protocols. That is as dangerous a practice as putting in software that has inadequate backups and failing to tell anyone about it. Both set your customer up to fail.

    Either way it doesn’t stack up for Boeing. Lest we forget, this is the second product in a row that Boeing has rushed to market, which has forced regulators to ground them. First the 787 and now the Max. The latter, regrettably, with many unnecessary fatalities.

    What’s the saying about the workman and the tools? I wonder which is which as far as the Max is concerned?

  17. If autothrust/automation generally, CRM, and control laws for aircraft design are the intended topics, I would note that AF47 would also be a pertinent data point. With 3 western pilots on a mainline legacy route, in the A330 confusion reigned in the cockpit until about 10 seconds prior to the plane smacking into the ocean.

    Boeing’s underlying systems, including the newer variants of it’s control/training systems on the 777 and 787, are very sound. MCAS was a royal failure in implementation/training, full stop.

    • Not quite sure what your point is beyond attempting to equate AB and BA. I think the difference is that as a flying novice (32 hours in my youth) I could understand that holding back the stick continuously for minutes at a time is a foolish move. AF447 required quite a ridiculous lack of airmanship to crash an aircraft because full flight envelope protection was lost. In fact the cause was so foolish that the captain did not figure his co-pilot could be so stupid until too late. Should the controls be cross linked? Probably yes, but this is at one end of the protection interface spectrum.

      With the MAX put me in a cockpit with stickshaker going, alarms ringing having just taken off and with the aircraft trying to bury itself in the ground this is quite another matter. This is at the other end of the control interface spectrum, the aircraft itself would have appeared to have a deathwish and would have tried again and again to counter reasonable flight inputs in a very limited timeframe.

      So no, not a pertinent data point, more of a contrived attempted equivalence.

      • No, there are real similarities. Disengaging MCAS and then repeated electric trim is all that was required. Point is, flight envelope protection is always up to the pilot in reality to execute responsibly, and the implication on this post that 737 automation (or Boeing broadly) can lead to complacency vs. the Airbus full envelope protection seems erroneous.

        If anything, the 737 is less automated than its competitors (220, SSJ, 320, E2), but flying the aircraft shouldn’t be difficult for non-western pilots to figure out; it’s the same basic rules Boeing has used since the 707, broadly.

        Pilot errors can lead to disaster even in cruise today, no matter where the plane was assembled, or by whom.

        • “Pilot errors can lead to disaster even in cruise today, no matter where the plane was assembled, or by whom.”

          Both the MAX 8 incidents were at take off, not at cruise.
          That makes a tremendous difference, don’t you think!?

        • Erm, no, there are superficial similarities at best. I will agree that the MAX should not be difficult for (non western) pilots to figure out, the trouble is that it was. There is a debate on automation to be had but to have it off the back of this debacle is hardly helpful.

          Simply it is fudging the fact that it is not automation that killed here, it was poor and incomplete implementation of that automation. Let’s be frank, the Airbus system is not everyone’s favourite but we don’t see that design philosophy being grounded. The MCAS design has been

          • Sowerbob:

            When your instruments show you have full nose up and your Vertical Speed is negative at 10,000 feet per minute you are stalled.

            The AF447 captain never was in a pilots seat during that crash, he was behind the two pilots (not sure how soon but not there are the start)

            Why he did not do the instrument scan or understand them I have not a clue. But clearly no one in that cockpit had one either.

          • “Automation” is 3 of Scott’s section headlines (bold). You can make an argument that it is an improper subject, ok, but it’s not my choice, it’s what he chose for this piece.

            Automation will only increase with new designs moving forward, and often to a safety advantage (this also ties into the subscription piece today). As with any automation that requires a powerful machine to do something without human input, though, errors can be fatal, whether it’s in a machine shop, a car, or a plane.

            The AF296 A320 crash was another one where the pilot disputed, through the present day, if the software/automation did what it should have. Or Air Inter 148, where the autopilot increased the rate of descent, or the compression value issues that led to the LH2904 loss, or the numerous organizational/training factors cited in Gulf Air 072.

            Whenever you have new systems, miscommunication/inadequate training/implementation are a risk. The enormous bashing of Boeing here (in comments) is only partly deserved, imho. Training, and automation are the main/primary issues in both crashed in question for a new type. Yes, Boeing blew it, but Leeham’s analysis is pretty fair here over all.

          • Texl1649,

            The point about training and the MAX is that Boeing said nine was needed, then said hardly any was needed after a fatal crash, and is even today saying that it’ll take a couple of minutes with an iPad. Yet everyone who’s saying that the pilots lacked the necessary skills is saying that Boeing is getting the training requirements badly wrong. So what’s it to be? Military test pilot school, or an iPad?

  18. No pilot should be put in a dangerous situation by some bad design made by some big company. It s just a job, it s not war, „we don t need another hero… ”. At best this scenarios must happen in a simulator, but never in real life with so many souls on board. It s like a driver must prove to the world that he has F1/Nascar skills from time to time, just not to be confounded to regular/boring driver. But why?

  19. Assume a normal distribution in pilot skill, a plane designed for “Average pilots” would mean there are 50% pilots who can’t handle flying them. Given the size of Boeing fleet around the world and the amount of pilots flying Boeing aircraft in any given moment, that seems to be begging for problems to occur.

  20. There is rarely a single cause of an accident. The pilots are the last line of defence. Presenting them with an plane that isn’t working as expected very close to terrain is a nasty thing to do.

    All elements will need to shoulder some of the blame.

  21. Scott if we go down that road, Perhaps the safety regulators should limit the markets that Boeing sells to and not the plane itself. It’s safe to fly in “first world” markets but a death trap in the third world because of the quality or lack thereof of the pilots.

  22. I would like to ask: Is it just undertrained pilots? It doesn’t matter if third, second or first World, as you put it. Actually, I know of some “third world” pilots who, with just a couple hours of trainig, were able to do what a “first world” pilot was unable, like landing a Galaxy in a very short, high and hot airplane with a mountain at the end.
    I think thant the issue here has, on the other hand, several different contributors:
    -Corrupt Authorities (ala LAMIA crash in Colombia a couple of years ago, where Bolivian authorities allowed a flight that was beyound the maximun possible endurance of the aircraft being used)
    – The “Low Cost Carrier” culture. If you start monitoring it, there have been several Ryanair flights that declared “fuel emergency”. And those were, as you put it “First Wold European” flights with an European carrier. That culture stresses pilots too much into “wrong decissions”. That culture, within a “corrupt environment”, is a recipe for a very awful situation
    – Culture clash, as you have already said. Whether form the military (Fly the mission without regard of your life! training), or a very hyerarchical society, perhaps the “average pilot” has diverged a lot.
    – But also, the need to reimagine the aviation world. Not that long ago, Pilots where Captains in the full term of the world, “Master and Commander of the Ship, The Crew, The Passengers and Cargo”. Nowadays, I see that pilots are referred as “aiplane drivers”. And passengers are treated like cattle. That is also a degradation of the human factors. Perhaps driven by the LCC culture?

  23. Scott, Thank you for an excellent, thoughtful analysis of the two disasters. As someone with extensive experience actually flying the different derivations of the 737, I have to agree that Boeing made unforgivable errors of judgement in not disclosing MCAS to the flight crews and in the development of the software that implemented it.

    However, the crews in both cases had the ability and should have had the system knowledge to recover from the failure. Speed Trim, a precursor to MCAS operates in a similar vein, that is high angle of attack, slow speed, A/P off. The response to unwanted stab trim operation is the same for all: Stab Trim Cutout to Cutout.

    As a former Test Pilot, Check Pilot and APD, no pilot under my observation would get a ‘pass’ if unable to recite the response and take proper action in the event of an unwanted stab trim operation.

    One other element which you touched upon is crew experience and CRM. With a 200 hour First Officer, ET302 was at a great disadvantage in any emergency. The minimum experience for crews in the west is 1500 hrs in order to qualify for the ATP and SIC status.

    Students of air transport disasters know that it is nearly always a chain of events that causes the tragedy and this case is no different.

    • Would you just please do me the favor and state that the 737 Max is a fine plane and there is nothing substantial wrong with it?

      And while you are at it that the MCAS is just an unimportant tiny little thing added for the comfort of the pilots, but in reality unnecessary. That wiring this system to only one OAO sensor is not really a problem. That the idea of giving that system total control overriding the pilot is just a little mishap.

      Seriously? The only error was that it was not disclosed and the software has a glitch or two?

      • Mr. Webber:

        Did you train in the locked up Stabilizer mode?

        The one where you have to unload the aircraft to allow the manual trim wheel to work.

        Was this done with a runaway trim that has the nose dumped way down?

        Was this done at a high and hot airport?

        • In support of TransWorld’s response:

          Capt. Webber,

          In your post, you mention “The response to unwanted stab trim operation is the same for all: Stab Trim Cutout to Cutout.”

          However, in Peter Lemme’s informative post (“What Happened on ET302”, he states:

          “The cutout switch function was changed with the 737MAX from all prior 737 models. The legacy switch combination was one switch to cutout electric trim altogether, the other to cutout the autopilot trim commands. MCAS and Speed Trim System are both commands from the “autopilot”. With the legacy switch configuration, the flight crew can disable the autopilot commands and retain electric trim.

          “With the 737MAX, the flight crew lose both electric trim and autopilot trim with the cutout switch.”

          (He posts photos of the trim cutout switches on the MAX versus “legacy” 737’s–not sure of the model.)

          Is it possible that the ET302 pilots didn’t have the option of trimming electrically after the cutout switches were thrown, leaving only the manual trim system that was likely locked up due to aerodynamic forces that could only be unloaded by pointing the nose down at low altitude? (Also well described in another Peter Lemme post:

          That would be a situation that would not be as simple to handle as you describe.

          • Thank you, I read his article but missed that aspect.

            Are there one or two trim motors ?

            I believe the function of the full after Yoke switch was also changed.

            If I have it right (????) it cut out the auto trim before and did not in MCAS.

    • The minimum experience for crews in the west is 1500 hrs in order to qualify for the ATP and SIC status.

      Not true. Europe, Australia, New Zealand Canada, Japan – none of them have 1500 hour requirement. I think you will find it is just the USA (and that safety rates in those countries are as good as, or better than the US)

      200 hours in a LH sponsored apprenticeship with clear wash out criteria or 1500 hours in a collection of random seats with no structured training, and ‘buying hours’? And the apprenticeship approach is how military train.

  24. I think Boeing take is for the ABOVE AVERAGE not average pilot.

    Fleshing that out, the idea is a pilot is skilled enough to know when they can take the aircraft to the limit and for very short periods beyond.

    That is not average pilot skill, that is in the 80%.

    And as we saw with the C0-17 crash at Elmendorf, that skilled pilot took it further and further and crashed.

    I agree the pilot and the skill level had some bearing on this.

    But keep in mind, those same pilots were lead to believe that they had full control of the aircraft and in fact the philosophy was turned 180 degrees and when something does not work the way its supposed to, the fog of war comes into full play.

    The opposite could be said for the Asiana crash, the pilot was used to the bottom of the envelope protection that was not there as a result of an unrelated action with the FLCH mode.

    So flip this around and when was the last problem pilots had controlling a 737NG?

    MCAS broke the pilots back, and while its worth discussing pilots and training, to me that puts 100% of it on Boeing.

    • Should an aircraft that will be produced in large numbers flying in countries all over the globe flown by pilots of various training backgrounds and skills be made so difficult to fly generally by “Junior” commercial pilots?

      Design flaw or focus on the US market but with bulk of sales to “3rd World” countries outside of the US!!!

  25. There must be a huge incentive to spread responsibility, or even only the perception of it. We have to watch out.

  26. And there was a rash of crashes, wrong airport landings, in the US the last few years.

    A300 UPS crashed into a hilltop on approach

    767 dumped into a Bayous in Houston.

    FedEx has lost how many MD-11s in crashes (3-4?)

    Lufthansa an MD-11 in Saudi Kingdom.

    And how are Western pilots better?

    • I have a bad feeling about lately delivered 767 freighters. USAF found debris in its tanker aircraft from the same line as the freighters.

    • Fedex DC10/MD10/MD11 hull losses ?
      ( they have changed name over the years from Federal Express to Fedex then to Fedex Express!)

      Seven hull losses

    • Just a few there. The Dana air MD83 2012 crash in Nigeria. American Captain.

  27. I think to expect a pilot to creatively troubleshoot the problem off the checklist is asking far too much. A sully is 1 in 10000 pilots. Yeah he probably woulda saved both planes. If et 302 left throttle at 75% vs 94% would it have changed the outcome? Doubt it. So they would have had to respond with 40% throttle. Speed brakes flaps 1 and the trim enable and retrim….is that anywhere in the checklist or simulator training? Maybe we should set this up in a simulator and see how many pilots make it before we draw conclusions. Of course now they all know what happened to et302….

    • Mark: I would still bet a lot of pilots would not get it, Ethiopian had an idea of what needed doing (according to Boeing) and it was not working.

      I can tell you that once what you know quits working (backup or not) then you have to wing it and that si a really bad thing.

  28. With respect to the takeoff roll distances listed earlier, Wiki does not define TAKEOFF as either ground roll or the actual FAR takeoff distance. The conditions Wiki lists for the 737 MAX are “ISA, SL, MTOW.” Wiki does not list any conditions for the A320neo. Hence it is not clear if an apples to apples comparison can be made.

  29. Is it possible to use GPS speed as a 3rd input for unreliable speed indication? If one were to target a min 300 knots gps below 10000 feet that should be. A safe speed no? I think the checklist of speed indication combined with MCAS is wrong. The MCAS should be flaps 1 not disable trim. This way they can still use electric trim. Runaway trim does not affect speed indication while AOA failure affects speed and triggers MCAS.

    • Mark: There are so many added corrections to MCAS that its not longer the same creature from the black Lagoon it was.

      I believe the 787 uses a solid state gyro for backup speed.

      Keep in mind the 737 (and A320) as well as all others have a complete independent backup Speed System that displays on the alternative instrument cluster.

      Its the unit dead in the middle above the white handle that has an Artificial Horizon on it.

      I think its in a poor location but ……

      • Is that backup speed a completely different data feed? If so from.what source?

        • Mark: It is. It has its own Pitot and its own static sensor.

          I don’t like it in the center when it should be in each pilots center area as backup check.

          While I was only an average pilot aerial maneuvers wise (no Chuck Yeager ) (landing as well) I was killer on instruments.

          A key to that was the constant cross check of ALL the instruments (backup and main) with each other and sorting out if one was off.

          To me that central backup looses a part of the purpose of having your backup instruments in the normal scan area.

  30. Can anyone tell me what is the documented response to an asymmetric stick shaker activation right after leaving the ground? This is clearly when the pilots were first aware of a problem, but from what I’ve read they followed normal take off procedures until MCAS first activated. They activated full autopilot (did it engage w/ the stick shaker going?) then raised the flaps. Take off thrust was set throughout. Were they supposed to do something different prior to MCAS activation?

  31. The article promises controversy, but I don’t see it. It really doesn’t offer anything new, either.

    I’m surprised to find a lack of emphasis on the original 0.6 degrees per cycle as compared to the final 2.5 (and now proposed drastic reduction). This is a point which truly veers into the absurd on the part of Boeing and greatly amplified any pilot errors.

    Tajer said, that’s the difference between controlled flight and uncontrolled flight.

    • Clearly you are an engineer. Welcome to the problem. What you have said is the first indication of the problem. I’m not there yet, but I’m trying. Many others are trying. Boeing are keeping secrets. Any help I and others will be happy with.

    • Agreed on the vastly excess authority which goes with the moronic single sensor.

      But you can now add in Stabilize not moving with manual trim when speeds get up and its not in the book apparently either (nor trained on?)

      What kind of a backup system is it if you have to unload Stabilizer to have it work?

      You don’t think that if you need it you don’t have enough problems that you need to use it?

  32. Scott & Bjorn,
    there was an article in Business Insider indicating that, beyond the MCAS software issue, there is a second software fix now required by the FAA to an existing routine on the MAX affecting the control of flaps in certain conditions. The article was not clear but the inference was again that some type of un commanded and undesired control input could occur randomly without pilot intervention or awareness.
    Have you any further information on this item? It could perhaps tie in with the unexplained problems reported on the database by US pilots.

  33. A problem with using “averages” is that they almost never correct. Useful in first-order approximations but deadly in real world scenarios. A more appropriate definition would be if Boeing defined the aircraft to fit 95% (99%, pick your number) of all pilot skills instead of just “average”.

  34. Bjorn has been clear he does not feel the pilots are at fault.

    Interesting to see Scotts take and maybe a debate between them?

    • Like many others I am suspicious of a Boeing deflection media campaign,maybe just misplaced patriotism.Boeing is in a good position to make Scott’s job hard/easy.

      • That came out a bit wrong ,I don’t think leeham can be bought that easily, but I would be interested to hear whether subtle pressure is being applied. I would be surprised if it wasn’t, if Boeing’s CEO thought that it was a good idea to try and get the president to personally intervene in a safety issue

      • @Grubbie: Boeing and Leeham have been at odds for 15 years, ratcheting up from 2007 when we began reporting delays about the 787. It’s been up and down ever since. We say what we think, and we don’t drink the Kool aid. We don’t buy into the Boeing narrative all their airplanes are good and all Airbus airplanes are bad. The idea that Boeing is in a good position to make our job easy or hard is, in the abstract, true but the idea we’ve been “bought” or have “misplaced patriotism” is nonsense. Bjorn draws his conclusions and I draw mine based on engineering and flight expertise and market intelligence.

        • As a mechanic/tehcnial/engineer I am more inclined in Bjorns direction.

          That does not mean Scott is wrong, makes for a healthy debate. Which is a good thing.

          What kills me is the Lion 610 pilots put the flaps down again and it stopped – been there done that and limped back in a non desirable per norm but its working ok mode and it stopped its b ad stuff lets not make it worse again.

          • Let’s be sure readers understand something: I am not saying the accidents were pilot error. I said training is a factor. I said if the pilots did err, they probably were trapped into error by Boeing.

          • Scott:

            Training being on Boeing as well as MCAS, I can agree with that.

            Training on 737 in general without a training process that address stabilizer lock up in high speed and not longer in the manual.

            Ethiopian looks to have made a Stab at it, but did not understand all he ramification involved.

            We can add in a non MAX type Simulator that you are now training in a sort of look alike. One that does not even closely duplicate the aspects of MAX and MCAS changed function not just in the stabilizer but eh Yoke cutout as well.

            The lack of Fidelity is appalling.

  35. TransWorld

    “Mark: I would still bet a lot of pilots would not get it, Ethiopian had an idea of what needed doing (according to Boeing) and it was not working.
    I can tell you that once what you know quits working (backup or not) then you have to wing it and that is a really bad thing.”

    But the final culprit was turning the trim cutout back to “on” without realizing this would bring back the same thing they were trying not to have.

    Yes they did have a major problem manually trimming, but it was exacerbated by the unusual high speed as such low altitude.

    One thing is a bit off for me, if you have problem as soon as you lift off and you want to get back to the airport, wouldn’t the “flaps” be left out a bit to help with lift? The whole MCAS thing would probably have not come up at all then, but I guess you would have to put yourself in their shoes to understand everything that’s going on at that particular moment.

    Lastly, don’t understand why the “unstable plane” stuff is mentioned time and time again. The Max does not need the MCAS to flight, Boeing added it to make it fly more like the 737NG. Bad decision maybe and worse implementation on their part for sure, but it is not like it needs as long as the pilot are trained to watch for those instances where a high speed AOA pitch would make the MAX nose come up a bit faster than the NG.

    If the engines by being bigger would create such an unstable airplane, there are plenty of airplanes out there with bigger engines (the 777 would be an-flyable)

    • I’m a bit confused by the multiple references

      One item though, Boeing was told to put it in per the FAA.

      Flaps are a drag after a certain point speed wise, its also a drill to clean up the aircraft.

      Yes speed continues to haunt this, but high, hot and Ethiopian Airlines training may all factor in.

      I did an unintentional spin one time. The control no longer work at all, nada. Affect wise its a shock and it would be and is confusing (the Sun rising in the West) –

      I recovered but I was extremely lucky I had enough altitude to get over my panic and confusion and then even more extremely remember what the remedy was and execute it with no more training than having read the books on spins.

      If you run out of altitude before you figure it out its a pile of aluminum. Nothing doing what it should, procedures not working the way they said (and no acualy training in a Similar acualy setup for it) no training on the Manuel Trim let alone it not responding..,..


    • Oscar, by the time they turned the trim system back on they were already doomed. They were in a badly out of trim aircraft pointed at the ground at low level with unreliable airspeed indication and had no documented options left to try, having just discovered that the manual trim was unmovable. AFAIK there aren’t any reliable ways out of that situation.

      Regarding the necessity or otherwise of MCAS, if the airframe doesn’t need it why did Boeing feel the need to configure it to add 2.5° of down trim, repeatedly? That’s not a minor adjustment to a flight characteristic, that’s a major intervention. So for what reason is such a major intervention necessary?

      • Precisely.

        The fact is that kind of force – the force applied by MCAS – is not nessary if the airplane is naturally stable. So the only interpretation is that the airplane is not natually stable.

        With regard to the pilots, they were thinking out of the box for what Boeing and the FAA told them to do didn’t work.

        • Philip: Again, it is not naturally unstable.

          If its trimmed full nose down its got severe issues.

          The only unstable aspect is at a stall and that is not defined as Unstable.

          Its defined as an undesirable excessive pitch up.

          The rest is trim. Trim any Stabilizer wrong and no aircraft is going to fly right.

          Bad software in an A320 would do the same thing.

          While for the most part Airbus works well, I define bad software what occurred on AF447, as there are two actions that can occur other than revert to degraded control laws.

          Like MCAS, bad software triggers a reaction, in this case a totally incomprehensible reaction . At leas the 737 MAX pilots realized it was an issue even if not the nuances of it to stop it.

          The AF447 pilots with a lot less serious software input mucked it up beyond belief.

          • Transworld, AFAIK no public information says just how bad that pitch up is. Given the magnitude of the MCAS trim input it’s reasonable to assume that the pitch up it’s trying to prevent is really quite significant.

            That seems perfectly plausible, given that there’s a lot more engine nacelle, further forward of the pressure centre, etc. It’s going to be acting as a much stronger “lever” once the airstream catches hold of it.

            One can consider this to be unstable if the rate of pitch-up accelerates with increasing pitch; the aircraft would be running away from the pilot’s control. Again we don’t know if that’s what happens.

            However, Boeing seem dead set against actually letting pilots know what it feels like for themselves. That in itself is pretty bad PR optics, and I’m amazed that this isn’t causing more concern amongst the flying community than is apparent.

  36. Possibly, is my response. I note that in your list of contributory factors the crew features as #6 & 7 of 7. Items 1 – 4 sheet home squarely to Boeing, so I think that your list prioritises the issues well (subject to the final reports).

    • Read my comments elsewhere. The airplane wants to stall. That is the reason why 0.6 became 2.5 as @tem reminded everybody not understanding we are going round in circles.

      The 737 MAX uses severe trim stabiliser even in ‘normal’ operation. During climb out with power up it gets worse. Hence the brutal reaction of MCAS if it perceives anything wrong.

      Anyway we have flogged it to death, so let’s leave it there

  37. The key point for me has always been that MCAS performs a trim stabiliser AND (airplane nose down) deflection which it doesn’t neutralise. This means the nose will continue to rotate down until the deflection is neutralised.

    It’s the same as pushing the yoke forward. The nose will rotate down until the yoke is returned to a neutral position.

    Time is therefore of the essense for the longer it takes to disengage MCAS and reverse the trim stabiliser AND deflection the more the nose is pointing down.

    I’ve always thought of a 737 MAX at 35000 ft and 450 knots cruise. The left alpha vane goes north. MCAS thinks a stall is imminent and performs a trim stabiliser AND deflection, putting the airplane into a dive.

    The pilots are gods gift to humanity, so it only takes them 5 to 10 seconds to realise what is happening and disengage MCAS. Trim is set to manual.

    But live or die depends on manual trim remaining operative and the elevators remaining operative. I think we are being told neither is likely at 450 knots and above.

    I think we always need to remind ourselves that it’s not just MCAS that doesn’t wotk, manual trim and the elevators may not work either. And the nose continues to rotate down every second, making the dive steeper and steeper.

    I’ve never understood why MCAS uses the trim stabiliser to prevent stall in the first place. What’s wrong with the elevators? At least the pilots can reverse the elevator deflection by pulling back the yoke, provided the elevators still work!

    • The Times of London interviewed a 737 MAX pilot some time ago who made clear that there was a significant pitch up moment during climb out at high power. The video says the same. I think it is a slam dunk that it is true.

      • As I understand it a sudden application of power gives a pitch up.

        As a pilot if you know about both training and experience it its a non issue.

        MD-11 had far worse issues and its crash record confirms it.

        • Misread it as long as you want. It is not about a sudden application of power.

          The nose wants to go up because of what I said in a previous blog. You responded by making clear that Darwin was the gold standard. I decided not to respond, but so many things came to mind with regard to naturalism. Presumably you do know that Darwin was a naturalist.

          I won’t go into it again, but it is basic aerodynamics as to what will happen with the wing/engine mounting as it is. As I said soon after the Lyon Air crash, pylons are important. Engine/wing mountings need pylons or all airplanes would have engine/wing mounting like that (less metal).

          Anyway you have a right to think whatever you want to think. So I’ll leave it at that.

        • TransWorld, why don’t you take a look at the Max from the front? There you can see that the engine is indeed in front of the wing. At a relative high angle of attack (after takeoff, full load, hot and high,…) the airflow in the area behind the engine is disturbed, reducing lift. At the same time the engine created more lift. While the wing is behind COG, the engine is before it. This creates an nose-up moment.

          The resulting question is – was the MCAS implemented because there is a real danger of the Max to stall (fully loaded, max power, flaps in 0) or “only” because Boeing meant to retain the NG handling characteristics.

          I’m not convinced that it’s only the latter. My take is that this tendency to stall is real and dangerous. It would mean significant limitations to the performance of the Max, which again would make it a weak competitor to the A320.

          Boeing tried to square the circle with the Max and failed in the worst possible fashion.

          • Gundolf:

            I am not an aeronautical engineer. You say you can see all that, no one can.

            There are only two methods that can, one is flight testing and the other is computer modeling.

            Anything else is not an opinion its wild speculative conjecture based on nothing science or data drive.

            The FAA did not note any unusual characteristics in the MAX other than at stall, then it had a pitch up tendency.

            It is widely known that the 737NG and Classic likely would pitch up under full accelerations.

            As soon as non engineers hear pitch up, a sub group whigs out. Oh, the sky is falling, its the worst thing since the Corair (or Pinto with the exploding gas tank)

            All machinery has its characteristics. An operate is trained to know them and it is not a big deal as long as its consistent and you can counter it.

            I had the dubious privilege of experience and old Norton BSA one time. Holy mother of god, the thing was dangerous at 50 mph. Tens of thousands of riders owned that cycle. I was spoiled by the much better latter machines. Oblivious you could learn to ride it.

            The experts ran it over 100 mph and won races with it.

            The reality is as longs as the characteristic are known and consistent its not an issue. Pitch up is nothing more than the nose wanting to rise and you counter it. That is why we have Simulators (much lower cost than the real thing) , you train in those until you handle it (or get washed out)

            Nothing in any technical information released says anything about characteristics of the 737 Max having unaccepted per the standards handling.

            The information does say the FAA noted the pitch up at stall was beyond acceptable and told Boeing to correct it.

            The NG did not have it, Boeing elected to make it NG like (or supposed to) that is not a mandation by the FAA. It was in Boeing financial interest not to have more training or have a MAX type ratings needed (simulators would have to be modified or bought and costs for manuals etc. )

            Boeing threw a lousy fix at it and we know what happened.

            The next thing I expect is the flat earth or there is no climate change conspiracy to raise its head.

          • Denver in the summer is hot an high. United did not seem to have a problem flying their Maxes out of Denver International.

          • I will add there’s nothing wrong with continuous use of severe stabiliser trim. It’s just drag, but a lot of it. Except:

            We now know it causes manual trim to be inoperable and the elevators to be inoperable.

            If the above wasn’t happening then Boeing would be fine. They would just have a poor performing airplane, which we know is true.

          • @TransWorld, when the Norton BSA was built, I take it that most motorcycles of that era were similarly dangerous. As were cars and planes etc. Look at the number of casualties in relation to travelers and distances.

            We have introduced obligatory helmets, safety belts and significantly tighter safety standards on pretty much everything that moves in a possibly dangerous fashion.

            No you seriously advocate a return of standards to those bad old times? You have no problem with a plane that is inherently unsafe and must be kept in check by a perfectly trained pilot in good shape to bring it home? Sorry but I don’t buy that.

            I believe that when you in person enter a plane you want to be sure that even the least capable/experienced pilot of that airline on a bad day and under difficult circumstances (load, weather, traffic,..) will fly you 100% safe, just like in all the other modern planes.

          • No, what I am saying is most peole are handed stuff that simply works, and they do not get it has limitations.

            Your smart phone needs to be recharged and you think nothing g of it.

            That is an operational characteristics . Electric cars have very limited range. If you own one you need to know how far you have gone, how much power is being used (Winter in AK and a heater needed for you and the windows) etc.

            You know your low slung car with 2 wd will not go through the mud-hole, you simply do not try, that to is a operating characteristics.

            As time has gone on, we have gotten vastly better to the point people forget, there are limitations.

            In the case of an aircraft you have a machine that goes from 0 to 600 mph (more or less) and you want it to drive like a VW that does not exceed 100 mph typical and on a flat surface.

            Welcome to the real world, its extremely difficult. I have no idea how the A320 flies with the full envelope protection in no control law.

            So what you are saying is I have to dump my 95 pickup because it does not handle like a 2019?

            The A320 may or may not have aspect of control when the control laws are not there, no one talks about it. Anecdotally we do know the A380 that blew the engine the Pilots did not trust their ability to drive it, they kept trying to make auto pilot run it.

            So what if a 737 puts the nose up as power is advanced? As long as you know its there, its not a vicious random thing, its more than flyable. Perfect no, but your smart phone runs out of power does it not?

            Did you know each aircraft handles a bit different because they are not perfectly built and the assembly is shimmed a bit here and there and they all have personalizes?

            The only item at issue is the Manual Trim. That is indeed an aspect that is legacy and needs an answer.

            Making the MAX into a death trap on conjecture is simply ignorance at best.

            You do know all aircraft have a tendency to stall?

            AF447 was STALLED.

            Did you know until recently no one was TRAINED in commercial aircraft stalls?

            That is like a swimmer not knowing how to do the breast stroke (your basic max travel get there swimming move)

            Did you know that Simulators could not even MAKE A STALL until recently ?

            You ignore the simple fact of the sated aspect of how this occurred.

            1. The FAA noted a pitch up at stall and told Boeing to correct it.

            2. Boeing threw a crap fix in and the FAA approved it.

            Things went to hell in hand basket from there.

            No more, no less and factual.

          • @TransWorld, I have been developing products all my life, so please spare me this kind of [Edited] explanations that everything has a limit. I don’t think you can find a person here on this board that would not know that.

            So back to the point: It’s not about a plane having limits. It’s about a plane being compromised in its handling and safety to a level that is much below the standards that we enjoy today.

            No it’s not about your 90’s pickup. This is about a 60’s design public transport vehicle that would not pass certification if not for all those over-stretched grandfathering rights and self-certification.

            I used to fly gliders and part of the training were stalls and spins. I personally actually enjoyed that. Yes, I am very surprised to learn that this is not part of the training of an airline pilot, at least in the simulator. Very weird. You should think that a pilot would be able to handle all the extremes of flying. When you know how to handle a stall or a spin, it is really not so dangerous…

            Anyway, if I’d be responsible for purchasing planes at an airline, my shopping list would look pretty narrow now when it comes to single-aisles planes. Now that airlines know about this very unhealthy combination of features and functions of the Max, I would not be surprised to see this product suffer in the market.

    • That looks like the anticipation. Probably July and need to to list August to avoid schedule disruptions.

      Peak Traver season is having a serious impact with everyone’s schedules.

  38. Yes, training is a factor. But if you aren’t trained, what can you be blamed for. In this regard, who avoided pilot training, Boeing for commonality or the airlines?

    I have never piloted a plane. But running into a cockpit environment running wild on me seconds after take off, following procedures I have been told after the Lion Air Crash, without success, what exactly to we expect pilots to do? They tried.

    Hindsight. We all know better now. This is the plane and nothing else. We all agree the system is badly designed or programmed. A hot shot pilot might have managed. Might. But flying is common stuff now, not an elusive entertainment for the rich and hot. This is exclusively the fault of Boeing (including the lobbying). Not contributing factors. I am flying tons as pax and I have to rely that also not so hot shot pilots bring me to my destination safely. I trust planes, not airlines.

    Product safety. Anyone?

    • I had the misfortune to having been subjected to a Hot Shot just of of Vietnam army pilot in a helicopter. He tried to kills us twice.

      The guy was there before him was a solid conservative pilot. We never had a problem of any kind with him.

      And I told him so when he said the new guy is better than I am. You got us there and back nice and safely each time, you don’t get any better than that!

  39. This is a suggestion from one of AviationWeek readers. I support this line of thought. I would also add a pilot will need to do it each year.

    “Maybe it’s time to add 100 hours of WW1 era biplane flying to the basic pilot curriculum for “academy pilots”.”

    • Apparently most do not know that post AF447 there has been a significant change in how pilots are run through a Simulator.

      There are two aspects to it.

      1. Is the Aerobatics though its called unusual attitudes. I was trained extensively in that back in the day and I have no idea how anyone can have gotten a seat in a Regional let alone mainline without that.
      Regardless they are no putting pilots into steep dives, stalls (many Simulators had to be modifier to simulate a stall amazingly enough ) and teaching them how to recover.

      2. The rote flying and training where pilots knew what the drill was made landings and takeoffs as the goal is now going away.
      Instead things like Sullenberger and two engines going out and what do you do? Airbus did not even have a checklist for that as it does not happen (repeat, does not happen).
      That would include run away stabs, the AF447 where you suddenly have no speed and the control system degraded to Alternative Control Law allowing you to stall the aircraft if you want to (and they did)
      Or two out of you three speeds freezing up and dumping you down on an Airbus as both said the same thing on that A320 and 2 out of three can’t be wrong.
      What they are teaching is the fall back to basics of piloting the aircraft in any and all scenarios that can go wrong and making sure you know the essentials of how to react correctly.
      For the 737 a loaded stabilizer now has to be added (or would have been there all along)

      • Sullenberger ?

        “Thirteen seconds after the plane struck birds, captain Chesley Sullenberger told first officer Jeff Skiles, “Get the QRH [Quick Reference Handbook] loss of thrust on both engines.” (Skiles had recently been to recurrent training, and so Sullenberger believed the first officer could find the QRH more quickly.)”
        Dual engine failure is a part of airliner simulator training as recommended by Airbus. There were some new features required about low altitude dual engine failure and ditching on water where optical illusions reduce hieght perception.
        ‘Dont make it up’ repeat ‘dont make it up’

  40. Has anyone came across the FAA’s Flight Standardization Board prelim report that came out today? If so please post the link. Looks like the software patch has been accepted.

    • All well and good, but as far as I am concerned, the Max line shouldn’t have been given an Airworthiness Certificate”, and I for one will never travel in a Max. Corporate profits over the protection of the passengers is unconscionable.

    • Im curious whether Boeing was listening too much to its biggest customers when it ‘decided’ how much extra training required
      These airlines only fly 737 NG planes

      Southwest 9100 pilots

      Ryanair 4800 pilots

    • “The proposal calls for stepped up training on the anti-stall system called MCAS that is linked to two fatal crashes, but stops short of requiring costly simulator training that could complicate the plane’s return to service.

      Boeing climbed as much as 2.5 percent on the news.“

      Pretty sure those two sentences tell you everything you need to understand why this is the “correct” decision.

  41. It is foolish for this blog and Boeing to blame pilots in the Max crashes.
    The flying public expects man & machine to work as one, consistently, in a safety-critical industry. I run maintenance in a Nuclear power plant.
    The group-think, that the Lion Air crash, occuring in a “third-world” country, lead to tardiness in investigations that could have saved the lives of Ethiopian Air passengers.
    I don’t want my flight flown by super-duper trained pilots from the “first world”, but I demand the plane makers to make equipments that ANYONE certified to use it, can use it safely.

    If Boeing doesn’t do it in future, their business is sunk.
    I still won’t fly in a Max from what I’ve heard so far. Software upgrade or not. Damn this attitude !

  42. I suspect Boeing is trying to get away from the present situation with an MCAS 3.0, ie a fix to the previously announced software fix to the original MCAS. Reformulated, Boeing expects one single and same black box to take care of essentially TWO distinct high AoA dangers : the coffin corner (nearing stall in high altitude cruise) and at low speed TOGA power (eg at the initial climb-out after take off, or in IAS disagree/AoA disagree occurrences, from FOD or otherwise). The question is : can Boeing redesign their MCAS so that it takes care satisfactorily of said two distinct flight envelope protections ??

    Given the way this complex issue was “solved” originally (after five years of MAX development + test flights) then thereafter simply with their revision dated 6 November 2018 to the MAX’ FCOM) then again five months after the Lion Air crash, revealing to the world the existance of MCAS coming forward with their MCAS 2.0 met with mitigated welcome by the profession, and now, given the time to FINALLY solve the issue (working under extreme pressure to get the MAX declared airworthy again ??) can we rely on the ability of these SAME systems designers to crack that nut ??

    Mayhaps it would be advisable to STOP a few moments and go BACK TO ESSENTIALS. Shouldn’t the malicious ‘black hole’ susceptibility of the MAX to a diverging AoA at higher AoA possibly preferably call for some radical – hardware – solution ? If a proper engine-to-pylon-to-wing rework probably would be too costly (it would kill the MAX ?), possibly a recowling of the engines to produce downlift or at least making the nacelles lift-neutral in cruise would be suitable ? Or at least put a well-pondered ballast in the nose, like in the old days ?

  43. Having extensively studied the preliminary crash report, the available black box data, a lot of analysis from various sources and the comments to those as well as Boeing Manuals and 737 Max data – I have come to the same conclusion as Scott Hamilton – Pilot error was one of the many elements in the chain of events that led to the ET302 crash.

    My current take on what went wrong with piloting the ET302 flight is that the pilots did not react – for lack of better wording I will call it – “instinctively correct” to the situation presented to them.

    What do I mean by “instinctively correct” and why would I consider an instinctive reaction to be best?

    By “Instinctively correct” I mean you are familiar with a situation and know instinctively how to react correctly to the situation without having to consciously think about it (This is more than following a mere checklist – Since checklists can not cover all thinkable situations). Instinctively correct actions can be achieved through training – and the more training the better.
    For example on a stall – if you trained this situation often – you will then instinctively know how to react correctly to counter the stall you are experiencing. Thus with enough training and the resulting instinctive reactions – you have a way better chance of saving the situation than if you had not had the chance to train for the situation.

    In extreme sports – where life threatening situations are the norm – instinctively correct actions/reactions (developed through training and experience) is what keeps the “masters” of these sports alive. I will confess that luck and natural talent also play a role of course – though these are not trainable.

    I used to do extreme sports myself and I did encounter life threatening situations. Within split seconds, you have to perform the right actions to save you from the looming catastrophe. Even the slightest mistake can be fatal. No time for fear or thinking. No room for mistakes.

    While I am not saying that commercial flying should be considered an extreme sport, I do think that in emergencies the same mechanisms come into play.
    Instinctively know when you are in danger and what to do – without having to look into any manual – and whatever needs to be done – do it immediately.
    After the situation is somewhat in control, the next step can be to pick up the manual and see what else needs to be done.

    Concluding it may be said that being qualified to fly a commercial airplane safely as pilot much more might be required than is currently the norm internationally. I know a lot of training is already done, but even more extensive training of recognizing and understanding dangers & correct responses to these dangers should be a top priority everywhere in the world. Not only to get the commercial pilot license, but also to maintain it. This means a lot of time in the simulator or even training airplanes throughout the whole career of the pilot.

    In a perfect world, an international body to check pilot qualifications could be established. This body would check pilots responses to random emergencies on their type of aircraft at least once a year. If the pilot would not know what to do, or take dangerous actions, the pilots license for commercial flying would be suspended until the pilot has achieved the required level of mastery of his airplane.

    Note: This post concentrates on the pilot training issue, but I am not letting the airplane producers of the hook – accidents usually happen through a chain of events where pilots, weather etc. are factors, as well as the plane and its controllability. The plane manufacturers responsibility is to provide as safe an airplane as possible, with transparency on shortcomings & dangers of the airplane as well as providing thorough training material & documentation and making sure accurate simulators of the airplane are available. In the case of the 737 MAx crashes the pilots and their training may not have been perfect, but neither did the airplane manufacturer do a very good job in providing everything needed for good training. Also both of the crashed airplanes clearly had malfunctions.

    • Extensively looking for pilot errors is pointless when the airplane should never have put them into that situation in the first place.
      Boeing built and fielded, and the FAA approved, a crappy airplane that overwhelmed TWO flight crews who clearly did not want to die.
      Maybe the rest of the world should leave the MAX to the exceptionally skilled American pilots.

    • Why don’t we try to weight the blame then?

      In this case I would put 95% of the blame on Boeing and 5% on each airline.

      I do understand extreme sports. I have put myself in dangerous situation more than once, include some bad accidents when all my training did not suffice or my luck simply ran out. That includes flying gliders as well as biking in the Alps, both on and off-road. I certainly understand you approach, but still have to disagree strongly. This is not sports, where people risk their health on free will.

      In public traffic we have to make sure to deliver the maximum safety to all involved. This means the maximum safety current technology can provide. And this has to have priority over profit every time.

      My take of the current situation is that we have many great and safe modern planes out there which all feature great aerodynamics, fly-by-wire systems with fantastic pilot support, and ONE ancient design that has been seriously over-stretched and should not be in service at all.

      • Flying an aircraft is not nor it ever should be extreme sports.

        Extreme Sports are another way of playing Russian Roulette. If you look at the data, those who do extreme sports either die in their endeavors or they get out before they die. Sooner or latter, regardless of the skill, they run into a situation that no one can overcome (think an Avalanche down on top of an extreme skier) – or as a mountain climber said at age 35, I stared out with 25 men in my group, I am the only one left alive.

        Instinct is also not nor should be in a Pilots lexicon. Instinct it a blind reaction to a situation that is biologic reaction (fight or flight) that may save you if you are eon the Veld, but it does not operate an aircraft. If all else fails Panic, you got nothing to loose (passengers do of course) .

        An aircraft is supposed to be tested to standards such that there is no question on how it reacts in any given situation.

        The systems that control it are purely technical and have know function and reactions.

        The two come together in the Sijmular (airline pilots) and you are trained on immediate reactions to the given failures an aircraft can throw at you.

        Thee is no instinct, its a mechanical thought out process. If you go by instinct you do not trust your instruments and you wind up upside down and in a spin, your “instincts” are telling you all the wrong thing because your instincts NEVER FLEW when they were developed., They were all ground (or tree) based.

        Its your training and your instruments you use, not instincts.

        Once you are through the emergency procedure, then you have a follow up checklist. You don’t try to commit it all to memory, just the immediate emergency reactions needed to resolve given flight conflict.

        As for assigning blame, this is not a legal definition, its a perception.

        If the MCAS did not exist, those two aircraft would not have crashed.

        Plane and simple.

      • 100% Boeing, wouldn’t have happened if they were not flying a MAX. Boeing owns the whole thing.

  44. There are a lot of feelings, but I understand that – at least I think I understand it. Three points:

    Pilots were NOT told about MCAS on the grounds that the 737 MAX was no different to the 737 NG

    Pilots were NOT told that the elevators would become inoperable at certain deflections of the trim stabiliser and at certain airspeeds.

    Pilots were NOT told that the manual operation of the trim stabiliser would be become inoperable at certain deflections of the trim stabiliser and at certain airspeeds.

    The point I’m making is that if you tell the pilots then you can blame the pilots. But if you don’t tell the pilots you can’t blame the pilots.

    Training and education is about the information that you are given not about the information that you are not given.

    Scott, bad day at the office

    • Even if you tell the pilots, it’s still not really their fault.If you saturate anyone with enough non intuitive tasks with no warning, they won’t be able to cope. Whilst it’s possible that an ex fighter pilot like captain Shults would do better, there is no evidence.
      As Bjorn says “the worst pilot on a bad day”.However bad the dead pilots might have been, they didn’t seem to have a problem flying the NG.
      The bottom line for me to board a MAX is some sort of explanation for why Boeing went from 0.6 degrees to 2.5 and why it’s OK to downgrade it again. Until they do that I’m not prepared to believe anything they say.

      • Agreed. For the record, I think both sets of pilots did very well.

  45. I’ve got a friend who thinks it’s very suspicious that the last two Boeing Aircraft groundings (i.e., 787 and 737) were as a result of incidents ocurring at “foreign” airlines. My friend thinks it’s all some kind of international conspiracy to throw shade on the competency of Boeing and the FAA so that Chinese and Russian companies have the breathing room needed to finish their aircraft designs and start competing. In short, these aircraft groundings are a very slick Communist Plot. As a result, you either side with Boeing, or you are a Communist Sympathizer.

    Just saying.

    Does any one think my friend has a valid point?

    • No. You can find any sort of thing on the Internet to support any sort of belief or position. People have these attitudes before they even decide to express their opinions. More of a shrinking World that the 787 and Max went overseas. Where’d the 777 first go? BTW, the World is Flat.

    • I have a friend who thinks Boeing sell the poorly built aircrafts to foreign countries and keeps the best ones for american companies.
      Is that a valid point too?

      • No.
        The 737s are all the same, its a standardised production line
        for all the variants with the only different models being built for US military

  46. Bit late to the party but it has to be said …

    Very poor quality comment to blame the pilots for the Max crashes given what we currently know.

    As was noted previously the pilots and their abilities are No.5 on the list of issues, problems and causes — consequently they are very far down regarding the blame game and a period of reflective silence is in order as from what we know they tried their best to retrieve a catastrophic failure of the plane and the systems on it.

    What happens next — are we going to blame the deckhands on the Titanic for not getting all the boats away? I’m sure someone, somewhere could find issues with their performance on the night but that would be a fifth order issue in the face of the higher order failures regarding hull design, sailing instructions and lifeboat regulations.

    Very petty in the extreme would be one way of looking at it.

    • Or the fact that the Titanic bulkheads did not go up much past the waterline.

      • Captain Smith was going all ahead full in an ice field. Also, @ FBonT, deckhands don’t lower lifeboats, able seaman do…

      • Titanic, had the minimum number of lifeboat capacity, which was far less than the number of person onboard. In this accident they had in fact time to evacuate. Two years later came SOLAS/IMO with strong requirements for life-saving equipment. Then, later the same year, Empress of Ireland collided with a freighter when sailing out from St. Lawrence, very(!) close to land. The ship sank after 14 minutes; the same number AS on Titanic died.

        In technolgy nothing is 100% ‘safe’, we often learn as we go. In many occassions the price seems far too high. Perhaps we, to a greater extend, should follow the objectives of Annex 33 of the (ICAO) Chigago Convention ‘the sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents’. Using (flight) cycles as the baseline, the 737 model comes better out than the Concorde.

        So what do we do to make the MAX even better and safer?

    • This is not just some politician speaking out of turn. I this is Canada’s a hint to the FAA on how it will rule, perhaps even with some knowledge of what the Europeans and Chinese are thinking. Putting this out gives the FAA a chance to to change their mind before officially ruling.

      Because if the FAA rules no simulator training is needed but the rest of the world demands it that could result in a humiliating climb-down.

      • But Canada has such positive feelings for BA after the C Series actions. I’m sure they’ll be willing to do BA a solid and let this training issue slide.

  47. Planes need to be designed not for the average pilot, but for the worst pilot that might possibly sneak through the system. The worst crash in history was caused by the chief instructor of KL effin M. Need I say more?

    • All these comments about average pilots have it backward. Planes are not designed for pilots, average or otherwise, rather they are designed to require pilots with certain knowledge and the ability to deal with given workloads. The pilots are then trained to have that knowledge and tested to ensure they can handles the largest workload the aircraft will ever throw at them.

      Of course there may be exceptional situation where an exceptional pilot might save the day. But that should never be in the realm of what have been anticipated. If it is then the system has failed.

      • Does anyone know the makeup of the teams developing Boeing (esp. 737) flight controls/cockpits and training? Are they representative of the pool of commercial pilots who fly them? With the use of their airliners heavily skewed toward “First World” airlines, often piloted by former military pilots, in earlier generations the makeup may not have mattered. But things have changed.

        I’d be interested to see also how the approach at Airbus differs with its unavoidably more diverse background (which I think is largely a strength compared with Boeing).

        As an aside, I’ve found in the past a major weakness in many US companies is the lack of internationalism, especially when dealing with non-US customers, so have just had a look at the Boeing Exec biographies. Of the 33 people who are listed under either Chairman, Executive Council or Commercial Airplanes, only 1 (!) shows as having been educated outside the USA, VP IT Business Partners Vishwa Uddanwadiker, and even he only did his Bachelors elsewhere before doing his Masters in the USA. To me this is strongly indicative of a blinkered mindset.

        As an aside 2, the President of Boeing International is a lawyer/litigator. He may be excellent at his job and have the relevant experience and expertise but I don’t see any prior international business experience and his being a litigator seems to gel with the overly legal, confrontational way Boeing seems to behave to me. It is also consistent with the blinkered approach to anything non-US.

        • The legal side seemed to be quite distant to his executive experience which included China.
          “Previously, Allen served as president of Boeing Capital Corporation, a wholly owned Boeing subsidiary that arranges, structures and provides financing for Boeing’s commercial airplane, space and defense products. Prior to Boeing Capital, Allen served as vice president of Boeing International and president of Boeing China, responsible for leading the company’s business in China from its Beijing headquarters.”
          Seems to be a high flyer who would succeed in any field , just so happened to start career in law.
          Bill Allen , President of Boeing from 45 to 68,then Chairman to 72, was previously a Boeing lawyer.
          I have found some lawyers to be very good problem solvers and not ‘servants of the law’

  48. Below average pilots, or below average design process? First, the design seems to be so unsophisticated and simplistic to be unbelievable. If: high AOA, Then: command stabilizer down again and again. That’s the nuance that would make a MAX feel like an NG?? You’ve got to be kidding me. It was just high AOA protection with the stabilizer.

    Then, three big mistakes:
    -No limits on the range of the stab?
    -Single input vane?
    -Changing the switches and deleting autopilot? Which will create the same disaster if Speed Trim ever malfunctions, the pilots only option will be manual…

    But worst, where was the checking process???? Isn’t this design supposed to be triple checked, quadruple checked? That’s the systems breakdown that is most disturbing. One person makes a mistake or does a bad design, people are human, but there is supposed to be a process that eliminates that.

    Did one person just design MCAS with no checks?
    Single fault error AOA gauge is bad, single fault design process is unforgivable.

  49. Since MCAS is defined by seconds of operation and degrees, two questions for Boeing:
    -What is the angle (of attack) that initiates the MCAS function?
    -What is the new angle limit, for MCAS on the stabilizer, with the new version that retains elevator authority? 0 being full nose down, 17(?) being full nose up, MCAS is not operational between 0 and ? degrees.

  50. Below are two excerpts from the 4-26-19 FlightGlobal editorial at the link after the excerpt. Stick shaker going off? No problem! Just retract the flaps and engage the autopilot to climb to cruise altitude!

    “While Boeing has faced a public avalanche of scorn and scepticism – perhaps deservedly – the accident sequence does not easily divide into convenient ‘before’ and ‘after’ timelines, separated by a well-defined point, some 1min 21s into the flight, when MCAS wrote its trace onto the flight-data recorder like a harbinger of catastrophe.

    This boundary has instead been blurred by preliminary findings that raise awkward questions about airmanship and training, ones which are unlikely to sit easily with those who would prefer blame to be an exclusively external, rather than internal, affair.”

    “But the Ethiopian inquiry has not indicated whether either pilot recognised critical warning signs that emerged immediately after take-off, such as the one-sided stick-shaker and disagreeing instruments, or made a connection over the behavioural similarities with the ill-fated Lion jet.

    Procedures for unreliable airspeed indications typically require the autopilot and autothrottle to be disengaged. But the crew persisted with activating the autopilot on the unreliable side, proceeding with an intended climb to cruise altitude – apparently selecting 32,000ft rather than the cleared 34,000ft – and leaving the thrust at the take-off, rather than climb, setting. Despite the continuing stick-shaker activation, the flaps were retracted.

    Context is everything, of course, and the inquiry has months to run before a full explanation emerges. It has not yet released a full cockpit-voice recorder transcript.

    But the impression is less that of a well-conducted flight interrupted by a software system gone rogue, than an escalation of small problems into a major one.”

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