April 29, 2019, © Leeham News: Boeing got roundly thumped for blaming the pilots in the Lion Air flight 610 crash involving the 737 MAX last October.
It took months before Boeing CEO Dennis Muilenburg issued a video in which, among other things, he said, “We own it.” He was referring to safety of the MAX.
This was widely interpreted as Boeing stepping up and taking responsibility for at least some of the causes of the Lion Air and Ethiopian Airlines crashes.
Last Wednesday, he took it all back.
On the first quarter earnings call, Muilenburg denied there was any “technical slip or gap” in designing the now famous MCAS system. He said “actions not taken” contributed to the crash, a thinly veiled reference once again to pilot error. (More on this below.)
Aerospace analyst Ron Epstein asked Muilenburg on the earnings call the obvious question: How could this happen. Muilenburg’s reply:
There is no technical slip or gap here. Again, as I mentioned, we know that both accidents were a series of events, and that is very common to all accidents that we’ve seen in history. And what we know is that in this case, there was erroneous angle-of-attack information that came into the airplane from multiple causes. We know that at some point during the flight, that activated the MCAS control laws, and we know that ultimately there were actions or actions not taken that contributed to the final outcome.
I can tell you with confidence that we understand our airplane, we understand how the design was accomplished, how the certification was accomplished, and we main fully confident in the product that we put in the field. But we also know there are areas that we can improve, and that is the source of the software update here. But there was no surprise or gap or unknown here or something that somehow slipped through a certification process. Quite the opposite. We know exactly how the airplane was designed. We know exactly how it was certified. We have taken the time to understand that. That has led to the software update that we’ve been implementing and testing, and we’re very confident that when the fleet comes back up, the MAX will be one of the safest airplanes ever to fly.
Industry consultant Richard Aboulafia told The Seattle Times that Muilenburg’s statements were a clear indication Boeing’s lawyers are in charge of the messaging.
Aviation Week’s reporters were no less critical in a podcast. The Seattle Times outlined in a March 19 report a damning history of how MCAS was developed and certified.
But, in fairness, Muilenburg’s statement is not wrong. Every accident is a series of events. It’s axiomatic that if one link in a chain of events doesn’t happen, the accident doesn’t happen.
There have been press reports that US pilots, citing superior training here vs overseas, believe pilot error is the principal cause of the two accidents. I wrote a column April 15 on this very topic. I’ve talked with the flight safety director of a US airline who is adamant the pilots should have successfully flown through the incidents had training been better.
On LinkedIn, there is a Boeing 787 captain for a major US airline whose career includes flying the 737. He published three long articles about the crashes. He believes pilot error is the prime cause of both accidents, with Boeing’s own culpability contributing factors.
The articles are here:
Cordell’s case for pilot error is a little light on assessing the automation part of the accidents (auto throttles, for example), but he goes step-by-step about what the pilots should have been doing. Among the issues: with the auto throttles keeping the thrust at take off power, this created flow over the horizontal stabilizer, rendering them impossible to move.
This “blow back” is something LNA’s Bjorn Fehrm wrote about on March 22.
Returning to Muilenburg’s statement that there was no technical gap in the MCAS system.
Linking MCAS to one angle of attack sensor is, arguably, the key technical gap in the system. It is a rule in aviation you don’t have a single point of failure. Boeing argued the pilots were the back-up, but in upgrading the MCAS (or “fixing” it might be another term), MCAS is now being linked to the second AOA indicator on the 737.
The tug of war between MCAS and the pilot might, arguably, be another technical gap. This, too, is being upgraded (fixed).
Failing to tell airlines and the pilots about MCAS may not be a technical gap, technically speaking. It nevertheless is a serious gap that has drawn embittered fire from the unions at Southwest and American airlines. The flight safety director I spoke with is also angry Boeing didn’t reveal MCAS to his carrier.
It was Boeing that didn’t tell Southwest Airlines (and presumably others) that the AOA disagree feature on the 737 NG was turned off on the 737 MAX.
Boeing said it didn’t want to “inundate” pilots with information. Yet it also said MCAS training would take half an hour on an iPad or similar device.
My view: Boeing’s decision to link MCAS to a single AOA and point of failure, the repetitive engagement of MCAS and not telling airlines and pilots about MCAS started the chain of events that gave pilots a situation about which they didn’t know what was happening or how to react. Training was inadequate and pilot errors occurred, even if they were “trapped” into making them. The chain links start with Boeing.
I’m reminded of Robert Crandall’s reaction after an American Airlines Boeing 757 flew into a mountain in Colombia, killing all aboard. Crandall was CEO of American. In a move that was unprecedented, Crandall acknowledged shortly after the accident it was American’s fault. No excuses. No buts. The pilots simply mis-programmed the flight computer for approach to the airport.
Muilenburg’s video statement, We own it, seemed like Crandall’s example of manning up. Instead, I’m reminded of the “I’m sorry, but,” syndrome.
A city councilman of the Seattle suburb of Sammamish (where I used to live) recently was found to have sent a highly inflammatory text message to another councilman. In it, Jason Ritchie used a vulgar sexist term, followed by a comment with racial overtones and ended with a political threat.
The ensuing firestorm prompted Ritchie to apologize on Facebook, followed by nearly 800 words of 16 months of grievances against his fellow council members for setting his mood and frustrations, leading to his text message outbursts.
It was the classic case of, “I’m sorry, but.”
Muilenburg’s is, “We own it, but.”
‘But, in fairness, Muilenburg’s statement is not wrong. Every accident is a series of events. It’s axiomatic that if one link in a chain of events doesn’t happen, the accident doesn’t happen.’
If you read his message to investors it is consistent with previous communications by giving a headline comment ‘own it’ with a subtext that in reality they did not. If you read the latest letter you will find in the offending paragraphs that there is a simple technique being used. There is a statement of fact that no one can disagree with followed by an observation for which there is a degree of subjectivity, fact, observation and repeat.
I suppose the proof is in the fact that Boeing are suffering a 4-5 month grounding whilst they make their ‘already safe’ aircraft safe.
I guess every word a Boeing representative says regarding MCAS is back-checked 10 times with lawyers. So, I wouldn’t blame any Boeing representative currently for using “water-proof wording”, at least not personally.
Boeing needs to fully own this. I have no problem at all blaming the CEO for allowing lawyers to own the messaging. This shows a profound lack of leadership on his part and the part of the board of directors. It is time for a clean sweep of the senior leadership to change the culture and help Boeing regain credibility.
Muilenburg “we’re very confident that when the fleet comes back up, the MAX will be one of the safest airplanes ever to fly.” Isn’t that an admission that its original safety could have been better?
Of course BA never makes a mistake- but it was just a non deliberate / or inadvertant issue . .
“” Boeing Statement on 737 MAX Disagree Alert
We want to provide a response to several news stories yesterday and today reporting on the disagree alert on the 737 MAX.
Boeing included the disagree alert as a standard feature on the MAX, although this alert has not been considered a safety feature on airplanes and is not necessary for the safe operation of the airplane. Boeing did not intentionally or otherwise deactivate the disagree alert on its MAX airplanes.
The disagree alert was intended to be a standard, stand-alone feature on MAX airplanes. However, the disagree alert was not operable on all airplanes because the feature was not activated as intended.
The disagree alert was tied or linked into the angle of attack indicator, which is an optional feature on the MAX. Unless an airline opted for the angle of attack indicator, the disagree alert was not operable.
On every airplane delivered to our customers, including the MAX, all flight data and information needed to safely operate the aircraft is provided in the flight deck and on the flight deck display. This information is readily accessible to pilots, and it always has been.
The air speed, attitude, and altitude displays, together with the stick shaker, are the primary flight information indicators in the flight deck. All recommended pilot actions, checklists, and training are based upon these primary indicators, not on the AOA disagree alert or the angle of attack indicator.
As the MAX safely returns to the air after the software modifications are approved and certified, all MAX production aircraft will have an activated and operable disagree alert and an optional angle of attack indicator. All customers with previously delivered MAX airplanes will have the ability to activate the disagree alert per a service bulletin to airlines.
We are confident that when the MAX returns to the skies, it will be one of the safest airplanes ever to fly.
WE return you now to why HAL said ” I’m sorry dave .. ..”
“The disagree alert was intended to be a standard, stand-alone feature”, I thought that airlines still had to pay for it to be installed / activated as an option, i.e. not ‘standard’.
“The disagree alert was tied or linked into the angle of attack indicator” didn’t someone write a software specification, was it not reviewed, and then verified against the end product at UAT (User acceptance testing) ?
“… has not been considered a safety feature on airplanes and is not necessary for the safe operation of the airplane.” but now “… all MAX production aircraft will have an activated and operable disagree alert … ”
“But there was no surprise or gap or unknown here or something that somehow slipped through a certification process.” and “That has led to the software update that we’ve been implementing and testing …”
So if there were no problems, why are you fixing (sorry upgrading) them ?
Why was MCAS 1.0 so forceful, and repetitive when MCAS 2.0 is much less so, and MCAS 2.0 is deemed acceptable, why was MCAS 2.0 not implemented to begin with if that’s what is acceptable now ?
“I am left to wonder: what else don’t I know?”
well A slight automaic tweak to the spoilers while landing to keep the nose wheel high …
and possibly a tweak to the flap/leading edge system whil landing
Boeing product in use problems are always pilot error.
Boeing production problems are invariably subcontractors under performing.
Nothing new to see here.
It is Colombia, not Columbia.
Fully agree with your assessment, Scott.
In recent years, Boeing showed that it was mis-firing badly strategically. The KC fight, the WTO squabble, the Bombardier issue and now this- all points to a company not focusing on its strengths, which is engineers building planes. It seems that the lawyers and accountants are influencing the board to the detriment of its focus.
No, the CEO and the Board are screwing up royally in managing the company and they are using the lawyers and bean counters to try to make it look good.
Sometimes referred to as closing the barn door after the cows have fled.
Any pilot of an aircraft with a classic flight control system and underwing engines knows that, with a fixed elevator trim setting, if you reduce thrust the nose drops, and that when the speed decreases the nose drops further. So I would leave the power setting alone while I’m struggling to not hit the ground, whatever the consequences.
Only to find out that the last resort manual elevator trim system doesn’t work…
Regulators need to take a long hard look at the 737 elevator system.
For ET302 it’s a hot, and high climb out, they’re not very far off the ground when it all starts going pear shaped, they’re getting ‘Don’t sink’ messages, and people are saying they should have retarded the throttles ?
MCAS now kicks in, and you’re nose down trying to find a way to get the nose up again, what would happen if you retard the throttles with the nose already down? Any US trained 737 drivers here to comment please ? (Genuine query !, only 737 pilots please.)
There needs to be a better measure of a pilot’s skill, 2000 hours vs 400 hours doesn’t mean much, 50 hours on a 737, and 1950 hours on a 152 are not the same as 400 hours solely on a 737 !
* ““DON’T SINK”
alert in the cockpit—an aural ground alert for potentially hazardous flight conditions that could result in the aircraft hitting the ground.” – Cordle Case for Pilot Error
I thought the ET flight CVR hadnt been released ?
“In Addis Ababa, a source who has listened to the air traffic control recording of the plane’s communications said Flight 302 had an unusually high speed after take-off before the crew reported problems and asked permission to climb quickly.” Only the Tower recording.
Addis Abbaba is of course very high altitude by american standards, even higher than Aspen , which doesnt allow 737s even with 8000ft runway.
At 05:40:03 Ground Proximity Warning System (GPWS) “DON’T SINK” alerts occurred.
That was just 18 seconds after the Captain requested flaps up. Check Appendix 1 for altitude, and airspeed. MCAS appears to have kicked in at 05:40:00
Can you imagine a surgeon saying such BS if there is a patient problem? I don’t care what Mühlenberg says because a jury is going to decide. And this lawyer speak might really piss a jury off. When you look at the numbers on the Roundup cases where damages were debatable and causation was not clear one has to think Boeing is going to have a problem where there is no debate to a level of probability.
Felix 47: Sorry to tell you that they do. Look up the data of hospital caused deaths with the subset of surgeon caused deaths.
When was the last time you saw a doctor of any kind voluntarily give up their license to practice?
Yep, lawyer standing their by their side in every case.
If fact, the only way to get the worst gone is for State action.
There was an interesting article on a Dentist who bought out a practice,e his income dropped by 80%.
He did extensive spread sheets, the original owner had done thousands of unneeded crowns and root canals.
Ergo, high income with a standard patient load (and crown only last 15 years or so, so for each good tooth you now have a future problem and cost)
“Muilenburg denied there was any “technical slip or gap” in designing the now famous MCAS system.”
Instead of “famous MCAS”, wouldn’t “infamous MCAS” be more accurate?
“The chain links start with Boeing.”
Scott is perfectly right, everything is said in this sentence.
Saving boeing’s reputation will sooner or later be the result of Muillenburg’s resignation. There are now too many informations coming from airlines or whistleblowers to help him avoid to do what he should already have done, for the sake of this company and its employees. The chain links start with Boeing and the Boeing’s reputation recovery starts with a boss who stops shifting the responsibility on others, bad luck or an unfortunate chain of events. He must resign, the sooner the better. When you’re paid millions of dollars, many times more than the Boeing’s average employees, you have this kind of duty.
Funny how you pay out all the money for superior talent and don’t get it.
Sounds like a 5 year old arguing about why it was not their fault.
I believe that the international airworthiness authorities may well demand a more in depth study of the issue.
The Boeing solution is a new patch on the original wound.
You co flate two differetn aspect.
1. MCAS was done and done badly but the fixes look to fully correct that.
2. How Boeing got there is not directly a AHJ issue, its a legislative issue as well as an AHJ management issue (FAA).
From the first ‘defensive’ words he uttered, he lost me. I thought it totally disrespectful to defend anything when people had lost their lives. He should have expressed sympathy and then shut-the-F-up.
I think he should have been fired as he likely had cost Boeing a lot of extra litigation/fodder in future cases by first defending, and then (in video) ‘owning it’ [corporate BS we hear so often – some MBA program retoric no doubt].
Muilenburg’s response to the questions above during their earnings call should ‘too’ have been deflected neutrally.
Technically taking data from only one AOA sensor, and only having 2 (as opposed to Airbuses 3) introduces a probability difficulty in any software (which one is correct… More likely correct… Best out of 3) – is a failure. The fact the MCAS is not (but now will be) visually integrated into flight controls and feedback systems is a failure in terms of human factors.
The fact these have now been remedied in the new software update is indicative of those failures, as is the time taken to roll out the fix. It could be debated/argued in legal terms that these were indeed failures in a modern day sense.
Muilenburg needed to and needs to stop talking… He’s adding insult to injury.
For the most part I agree spot on
However, reality is the 737 is not a 2 out of 3 voting system as that is part of FBW architecture not a mechanical control system aircraft like the 737.
Airbus had to go with 3 when they went with FBW and envelope protection.
The approach for a legacy system like the 737 is different as the manual back up is the third (not exactly but close)
Any 737 programing is done by two different software teams into each side of the control system (pilot/co pilot)
Boeing has made a series of so many avoidable mistakes in the recent past (Sonic aircraft, 787 delays and grounding, ill-fated 747-8 program, over-budget KC-46 tanker, reactive instead of proactive launch of 60’s design 737-MAX, pushing Bombardier C-series program into the lap of Airbus, NMA with flimsy business case etc.) that I have begun to wonder if there is something fundamentally “rotten in Denmark.” Stepping back a bit from the current MAX debacle, and looking at the overall picture, one cannot but worry about the current state of Boeing.
It would be informative to find out how and why a decision to use a single AOA sensor to activate MCAS was made. Every aerospace engineer knows not to build in a single-point failure into a vital system. Did the engineers make a mistake? Or were they overruled? If so by whom? Answers to these questions will tell us a lot about who is in charge at Boeing.
To provide a rough analogy:
Suppose I design a car that under certain conditions can activate a runaway accelerator. I assume the probability of that happening is so small that I don’t tell the customer about it. My goal is to sell the car first and foremost. Also let us say tapping the brake pedal twice in succession or pulling on the hand brake would deactivate the accelerator, but after a lapse of time the runaway accelerator kicks in again. I mention all this in the car manual but don’t highlight it. Then after some time, a couple of accidents happen killing passengers. Who is to blame here? The answer is quite obvious. Most drivers in panic would step on the brakes as hard as they could to stop the car. That is a natural reaction, but the car keeps accelerating. Perhaps some drivers might have the presence of mind to pull on the hand brakes too. But not everyone would. When your car is about to crash into another at high speed with fatal consequences, you don’t have time to calmly analyze the problem and come up with a solution. The human brain just does not work that way.
Now suppose I blame the driver for not being skillful enough to engage the hand brake or for not following instructions in the manual. Does that sound right? It was my fault to build in such a failure in the first place and also override the driver.
Boeing needs to explicitly say that they made a mistake and apologize, instead of using lawyer-crafted language. That would be the right thing to do.
Scott is right here. The chain link started with Boeing!
This actually happened with Toyota stuck accelerator issue about a decade ago, in which a vehicle would continue to accelerate despite the driver hitting the brakes and/or hand brake.
For what it’s worth, pressing the brake did not slow the car and turning off the car would make a bad situation even worse due to the loss of power steering. The emergency solution is to put the car into neutral, and then brake to a stop safely.
In the meantime, despite incident after incident, toyotas remained on the roads. Ultimately, the solution was found to be both a software update to prevent any acceleration if a brake pedal is ever depressed, and improved securing of the floor mat.
You can search for news coverage, but here’s a sample link
Don’t pile it on, the Sonic Cruiser was a good idea but customers re-directed Boeing to better economics as preferable to the small reduction in trip time, nothing wrong with that – listening to customers is a good practice. The 787 was that more economical airplane.
For me there are basically two way to interpret this “un-owning” by Muilenberg:
1) The lawyers came to the conclusion that Boeing as a company or worse some people inside the company committed a crime.
2) The Max “hardware” doesn’t comply with fundamental FAA rules and the MCAS is a double-patch that covers up this failed design but wont remedy it.
In both cases there they have to push away all blame and guilt as hard as they just might.
Any other explanation?
I agree with the first part.
I disagree with the second part as the MCAC Ver 2.0 has all the features that should have been in 1.0.
Its not a kludge patch on top of a problem.
They wrote a new program for MCAS that only has a name in common.
Rev 1.0 was not a patch. It was software written to a requirement. Bloody awful and as badly written software as you will find.
Note software nor the goal MCAS goal is a problem and does not violates any standard.
Where it went off the rails and into the Grand Canyon (ocean and plains of Ethiopia respectively ) was how it was written which again was beyond grossly flawed.
MCAS 2.0 doesn’t have the features of a full FCC. But then it can’t. The aerodynamics are very, very compromised
Perhaps it is due to the guy in the grassy knoll.
Or maybe Castro was behind it.
Well I for sure nor did most of the posters here buy it that he owned it.
Lip service is not owning it.
People talked about tone, that is pure BS. What counts are actions and those tell you exactly who and what someone is.
I don’t think Wall Street had the issue right (can’ read the full thing).
The Disagree was made an options. I don’t know when it was made an option.
I believe SW paid for that option.
And its irrelevant in that unless you know about MCAS its not something that is going to concern you.
Kind of so what, then the shaker and squawks hit and you may have a brief, ok, then the MCAS kicks in and you no longer care you have a different problem (or so you think)
Follow up looks like SW did not know it became an option and did not know they had to pay for it.
They activated (indicates they too can adjust the software) when it came out.
It now looks like the NG did have it without any disabling.
What a great way to treat your customers. All those Airline ops types will go onto long careers with their Airlines or others.
Good time for SW to start negotiation for A220-300 to keep prospect open for the future and twist Boeing’s arm on discounts. Benefit to SW and a message.
Long term its going to be corrosive to Boeing – their best bet would be to wipe out the upper management, apologize and start over again, this time with real actions not fake ones.
Southwest Airlines has 34 737 Max 8s; and about 246 Max 8s on order. They have 208 737-800s in service, and a whopping 513 737-700s in service. Boeing probably convinced them to up-gage since they knew the 737 Max 7s were not competitive with the Bombardier CSeries (A220-300s.) In “changing” Southwest’s business model of having 143 seats in one class in a smaller plane, Boeing may have over played their hand. If Southwest Airlines current management could channel Mr. Herb Kelleher (RIP,) I think he would give his approval and sound advice of adding a second or even a third type of aircraft to a fleet that now numbers over a whopping 754 aircraft (minus 34 MAXs) and flies thousands of miles over the ocean. But we are talking about fitting in. BTW, Alaska Airlines could hold onto those A321s…
Southwest has been up-sizing their fleet to larger planes for many years, it has nothing to do with the MAX program or the C Series (A220). Most of their deliveries of NG 737’s over the last few years have been 800’s not 700’s.
Before ungrounding, compensate each of the victims the 2018 pay and bonus of the CEO.
That has my vote, how about the last 5 years pay and bonuses and stock options?
Coming soon to a Boeing employee in seattle… Punishment of the innocent, promotion of the guilty. And a lower level manager is/will be toast. meanwhile, back at the ranch . ..
The Cordle “Max Viability” article makes for some interesting reading, particularly the best and worst outcome scenarios (p2).
While these best and worst outcomes detail various potential interactions between the US DOT and FAA in terms of certification and approval processes there is no attention paid to approvals by overseas airworthiness authorities – this is going to be a massive issue in getting the Max back into the air.
Similarly on page 3 a set of 6 milestones are described from the software fix (1) through to re-entry into service (5) and DOT investigation (6).
FAA approval is milestone number 2 – where are the approvals from overseas jurisdictions which have clearly stated that they will not accept FAA approvals ?
Aren’t these going to have a significant impact on the viability of the Max series ?
There is also no mention of simulator training for Max pilots – something that overseas airworthiness authorities may demand even if the FAA doesn’t see the need.
The entire article has been written for the (now past) world in which FAA approval and certification guaranteed operations (and sales) in all corners of the globe.
China is a vital market for the Max but it is almost certain that the Chinese will play politics in order to extract concessions in trade talks. Other countries may not be quite so belligerent but will certainly conduct their own investigations before approving any fix to the Mcas software. They will want to be seen by their constituents as filling any perceived gap or shortfall in certification and safety issues by Boeing and the FAA in relation to the 737 Max.
Translated, Owellian behavour. For example, MCAS is a ‘Stall Protection System’ but now it is a component of a ‘Speed Trim System’. As per previous commentary
This comes to Richard Davenport. Can I ask Richard Davenport to post again. The reason is that MCAS does not meet the FAA requirements of a stabilisation system. That’s why it is no longer a stall protection sytem, it’s something else. What it is we don’t really know.
Richard, great post. Can you do it again.
Does MCAS comply with the following FAR, considering that there is/was no indication of MCAS even being in the plane, never mind showing a failure. Was there any indication for an AOA sensor failure?
Sec. 25.672 — Stability augmentation and automatic and power-operated systems.
If the functioning of stability augmentation or other automatic or power-operated systems is necessary to show compliance with the flight characteristics requirements of this part, such systems must comply with §25.671 and the following:
(a) A warning which is clearly distinguishable to the pilot under expected flight conditions without requiring his attention must be provided for any failure in the stability augmentation system or in any other automatic or power-operated system which could result in an unsafe condition if the pilot were not aware of the failure. Warning systems must not activate the control systems.
(b) The design of the stability augmentation system or of any other automatic or power-operated system must permit initial counteraction of failures of the type specified in §25.671(c) without requiring exceptional pilot skill or strength, by either the deactivation of the system, or a failed portion thereof, or by overriding the failure by movement of the flight controls in the normal sense.
(c) It must be shown that after any single failure of the stability augmentation system or any other automatic or power-operated system—
(1) The airplane is safely controllable when the failure or malfunction occurs at any speed or altitude within the approved operating limitations that is critical for the type of failure being considered;
(2) The controllability and maneuverability requirements of this part are met within a practical operational flight envelope (for example, speed, altitude, normal acceleration, and airplane configurations) which is described in the Airplane Flight Manual; and
(3) The trim, stability, and stall characteristics are not impaired below a level needed to permit continued safe flight and landing.
[Amdt. 25–23, 35 FR 5675 Apr. 8, 1970]
“Southwest’s own manuals were wrong” about the status of the alerts, said Southwest pilots union president, Jon Weaks. Since Boeing hadn’t communicated the modification to the carrier, the manuals still reflected incorrect information.
Following the Lion Air crash, Southwest asked Boeing to reactivate the alerts on planes already in its fleet. This move, along with questions about why they had been turned off, prompted FAA inspectors overseeing Southwest to consider recommending that the airline’s MAX fleet be grounded while they assessed whether pilots needed additional training about the alerts. Those internal FAA discussions, however, were brief and didn’t go up the chain, according to documents reviewed by The Wall Street Journal.
here > https://ih.advfn.com/stock-market/NYSE/boeing-BA/stock-news/79781060/boeings-enduring-puzzle-why-certain-safety-featur
There was the assumption all around including FAA that such alerts would be active.
In Cordell Case for Pilot Error, quote:
1. Mismanagement of engine thrust and airspeed
2. Deviation from company and Boeing procedures
I am not a pilot but if I remember well aren’t pilots encouraged to learn the counter-intuitive notion, that thrust manages altitude and pitch manages airspeed, right at their early career?
This would be consistent with the behaviour of the pilots in both crashes: in Lion Air’s the altitude at which MCAS activated was not an issue hence no pilot induced overspeed, in contrast, ET Flight 302 altitude margin was low which would lead the pilot to not favour anything that would trade against altitude, ie. reduce thrust.
MCAS appears to intervene counter to basic pilot skills, like it had been developed in a compartimentalized way divorced from the multiple considerations it should integrate with.
I find that Mr. Cordle has done a very thorough Investigation with the material he has at Hand. But I find he presents it with very many conditional Statements (“Having covered in detail the pilot’s mismanagement of airspeed and power, we should point out that one action might still have saved the day.”, “Whether this would have changed the outcome is uncertain, but it would have controlled the aircraft’s airspeed and eliminated one problem from the pilots’ frenetic agenda.”Running a lesser priority checklist and misdiagnosing the problem is serious enough, but the crew of the fatal crash did something that was highly unusual, which, if not done, might have saved their lives and the lives of everyone else on the aircraft.”
I would like to address the continuing debate about pilot error.
My own view is that if a pilot ignores false information then they are good pilots, which means they are not bad pilots.
This then comes to the Lion Air and the Ethiopian Airline crashes. In both cases the FCC went into meltdown meaning that all information delivered to the pilots was false. Any suggestion otherwise is false. The pilots were rendered blind and deaf. With regard to feel, they could not feel anything because the controls were unresponsive.
Even so the pilots worked out that the asymmetric stick shake as commanded by the FCC was false. But many keep saying they should have acted on it. Acting on bad information is bad piloting skills not good piloting skills.
Equally, even so the pilots worked out that the asymmetric air speed indication as commanded by the FCC was also false. But many keep saying they should have acted on it. Acting on bad information is bad piloting skills not good piloting skills.
And so on.
With regard to the Lion Air crash the pilots didn’t know. With regard to the Ethiopian crash the pilots did know. But the instructions given by Boeing and the FAA didn’t work.
Bottom line. Boeing and the FAA didn’t tell pilots. That was the cause of the first crash. After the first crash, what Boeing and the FAA said was wrong. That was the cause of the second crash.
Pilots can only act on what they know. That applies to everybody.
We could all play a wonderful game of “Bullshit Bingo” with Muilenburg. BS Bingo also uses a bingo card, but the numbers are replaced by typical BS/hot-air terms and phrases, such as “empowerment”, “core values”, “we own this”, etc. If one of the BS terms on your card is used in the media, you cross it off on your card…and you shout “bingo” when you get a full line or card. LNC gives some cotton candy to the first 10 winners 😏
American pilots say they will not fly the MAX alone in the world, so I assume that means US will not unground by itself. So who will they get to go along with them? Canada, Brazil, Europe? One of those agencies is the critical path to the MAX getting airborne again.
From my perspective, it was an engineering systems mistake and an organizational failure. The initial design with the resets and unlimited range of command. And after the LionAir crash, this was the reaction to the MCAS engineering by the best and the brightest at Boeing, or the best and the brightest were not redirected to go over it with a fine tooth comb? Either way there was a systemic breakdown for me, but I’m not Canada, Brazil, or Europe, so we’ll see what their take on it is.
In theory politics and emotion have nothing to do with it…. But Boeing annoyed Canada with the C-Series action and the US just kicked off an aviation trade dispute with Europe. So we’ll see how theory works out in practice.
There are a lot of subtle ways certification authorities could mess with Boeing. For example (and I’m not saying this is politically motivated, who knows) Canada’s transport minister has already indicated he thinks simulator training should be part of any return-to-flight. On the face of it sounds completely reasonable, and hard to argue with in a public forum. Moreover Boeing itself is hinting many pilots are not trained well enough. But given the dearth of simulators and large number of 737 pilots, that requirement alone would cause Boeing a lot of grief.
“Muilenburg describes flight simulator training as a “downstream” option available “where it makes sense” and based on airlines’ “individual needs”. “We will be providing enhanced training and supplemental materials to our airline… customers,” he says.”
Not sure this approach will work out for Boeing: ‘ “downstream” option available “where it makes sense”’. But if it may make sense downstream, why is it safe to fly without it initially? And when does it make sense?
Is he really saying simulator training may be needed but it is up to each airline to decide? On what basis do they decide? This sounds bit like an abdication of responsibility.
If not that at least awkward messaging.
Read that between the lines and he is following the mantra that only the US based airlines do not need flight simulator training because they are already so much better than everyone else.
By the way, I thought they had already provided all of their supplemental materials to the Airline customers (Ipad refresher and so forth).
He was speaking out of both sides of his mouth at the same time because the biggest 737 airlines Southwest (9100 pilots) and Ryanair (5000 or so pilots ) don’t want to hear anything about simulator conversion training.
The tail is wagging the dog.
I’ve heard recent reports that Ryan Air does want simulator training now
There is new “upset training” now required for US pilots .. (since March)
Here’s a neat Alaska Airlines training video, showing a sample, thanks to Aviation Week. https://www.youtube.com/watch?v=zCJco59tqoQ
I wonder if Boeing is concerned about how Pilots will react to the 737-MAX stall characteristics? or will MCAS be involved in the upset training, since it’s not a safety / stall warning device?
AoA disagree was optional until it was decided to make the “already safe aircraft safer”. Now simulator training will too be optional until they decide to make the “safer than already safe aircraft even more safer”.
I believe that all of the relevant Regulatory Authorities for each country will be taking a much closer look at the 737 MAX reintroduction to service scenario but they will all be also considering the Impact on the Airlines based in their jurisdictions. I hope this will provide the optimal balance between safety and service without letting politics and gamesmanship getting in the way.
I doubt there was any disagreement legally speaking between the earlier ‘own it’ video and any official Boeing statement since. I didn’t see any siginificant ownership in the original video and although the new tone may appear different the audiences are also different and will receive their own tailored messages.
The interesting thing for me is the choice of words “technical slip or gap” (or other words he used as I haven’t seen a transcript). Anyone know what the legal understanding of “technical slip or gap” is and also what this doesn’t cover and therefore what Boeing isn’t denying?
The press conference is here: https://www.pscp.tv/CNBC/1DXGyNzkagLJM.
Muilenburg got through most of it with serene irresponsibility for what had happened. The deflection flowed smoothly until the final question from Dominic Gates that somehow got to him. Gates put to it Muilenburg that MCAS was simply flawed. Muilenburg was having none of this and went on again about why MCAS was in the Max. But he looked beaten. His heart was no longer in it. He turned his back on the audience and walked out.
from Ralph Nader ..
1) Per Dominic Gates, and Scott, and most posters here, Muilenburg is saying that if it weren’t for pilot error, neither plane would have crashed.
2) Per Flight Global, Boeing is proposing additional training that may take as little as 15 additional minutes on a tablet or other computer
To summarize: the crashes were due to pilot error, but pilots need very little additional training.
So I guess Boeing thinks the new software is so good that it alone will prevent the kind of pilot errors that crashed the two planes? Regardless of which airline is flying the plane?
Sarcasm mode ON:
since MCAS is only there for making the pilots controls feel better, than just a short video on a tablet is needed. The obvious pilot error was not recognizing a simple runaway trim situation when only one stick shaker was going off.
Sarcasm mode OFF:
What was the error rate on the speed trim system prior to MCAS? How many times did it erroneously command the stab. up or down mulitple times? So, I would agree that the solution isn’t more training, it is to fix MCAS to the previous reliability rate of the speed trim system which was virtually failsafe.
I’d like to hear Boeing’s interpretation of Apollo 13. Not a design flaw, a series of unfortunate events, operator error. MCAS was not a flawed design? Houston, we have a problem.
Boeing’s official position amounts to “We didn’t make a mistake, and we’re correcting it as fast as we can.” That’s the lawyers playing defense, trying to minimize the financial damage to the company, and it’s a plate of oats that have passed through the horse. Mistakes were made — big mistakes, deadly mistakes, unforced mistakes — and so far it doesn’t appear than anyone at Boeing is being held to account for them. Heads should be rolling, but they are not. The Max can be fixed, but whether Boeing can be fixed is another matter. I’m no longer confident that the company culture that led to this debacle can be reformed. It’s deeply disheartening that one of America’s great aviation manufacturers is committing slow suicide.
Man versus machine? Dennis Muilenburg’s world of man versus machine:
The AoA reading is 75°, let’s act on it even though 75° is impossible. Specifically fly the airplane into the ground based on an impossible reading! Should the machine reject animpossible reading? Machines must never reject an impossible reading! Very, very bad engineering to reject impossible readings!
Asymmetric stick shake. Act on it even though it’s wrong! Asymmetric speed indication. Act on it even though it’s wrong! Why arn’t you acting on wrong information? Bad pilot, very, very bad pilot! Good pilots always act on wrong information!
Lion Air pilots: Nothing in the manuals. Don’t know what to do! Bad, bad pilot, good pilots know without telling them. But you are third world pilots, so it’s very easy to blame you!
Ethiopian Airlines pilots: They call left alpha vane. How dare you get it right! The procedure we have given you doesn’t work! So you must not get it right. Bad, bad pilot, good pilots never get it right. But you are third world pilots, so it’s very easy to blame you!
Increase the dividend by 20%. The shareholders will be happy with a 20% pay rise. I will keep my job. Two airplane crashes, 346 people dead. Just blame the pilots, they are third wotld pilots.
Actually, I cant see how the CEO can survive this.
The evidence is so clear and it has deep lying issues in the way Boeing constructs and certifies planes.
The B787 with it’s battery issues was close to disaster, really close. Already there you had to ask why this system was certified, and it was pure luck the started burning on the ground or close to an alternate.
The Max design has so many flaws, some that can’t be fixed at all.
The aerodynamic won’t change, no matter how much software Boeing writes.
Not telling pilots about MCAS is a serious flaw alone, how should a pilot understand whats’ existence he doesn’t even know.
Matters of fact Ethopian did proof that MCAS failure can’t be recovered with means and measures BOeing advices.
Training has been a flaw, checklists have been a flaw, there’s so much to blame on Boeing.
And the biggest shame is actually not admitting that Boeings flaws did cost 350 lives. How can any Pax or customer be sure Boeing did fix if they deny it’s broken?
I won’t fly any Max, that’s for sure, and I also avoid the dreamliner whenever I can.
And actually if i would have ordered the Max, this is the time where I would cancel the order and went straight to Airbus.
If I have to take A220 instead, so it is.
I can just hope the major customers, Lion Air, American, Southwest, Dubai, Gecas, ALC pressure Boeing hard and cancel their orders.
It’s their pilots and training Boeing is blaming now.
Today is May 1. I think yesterday the board and shareholders gave the CEO a vote of confidence? The bottom line, baby; the bottom line.
I’d like to see some instructor pilots, flying the 737-MAX, in the certified simulator for the new upset training. Showing us the ‘real’ stall characteristics that MCAS is put in to prevent. How difficult it is for a pilot to recover, from a stall, in the region that causes the pitch up that MCAS is protecting? I”m sure this has crossed the minds of 737-MAX pilots. There is a dearth of data outside of Boeing and the FAA to analyze on the 737-MAX in the MCAS, and stall flying ability. I’m not sure how many certified 737-MAX upset simulators there are now, but, here’s one company.
And if there is any way to quantify the chance of a 737-MAX vs a 737-previous to get into a stall, because of the new engines, that would be good to know also… Is the angle of attack to enter a stall that much different in a 737-MAX than a 737-previous etc Is there a way to demonstrate this using a simulator? Since we don’t have access to the wind tunnel testing, independent flight simulator testing seems to be the only way for airlines to find out for themselves what dangers may or may not lurk in the 737-MAX.
The question is: Have Boeing told TRU the truth about the stall characteristics or the 737 MAX or have they made it up?
Philip, You have a good point. The sim only works as well as the data points fed into it. I was wondering if any large airlines or national certification agencies would actually take a 737-MAX up and see what points actually trigger MCAS, or test the AOA disagree light on the ground etc. I’m rather surprised there isn’t a way to check out the AOA sensors easily before every flight along with the pitot sensor system. Of course I’m surprised they don’t have a way other than shutting down the entire electrics to the stab trim motor. The FCC/MCAS isn’t tied into the auto pilot cutout switch. I’d put in a MCAS cutout switch if it were my plane. My personal guess is that the foreign certification agencies will be running their own ground tests on the system, no matter what the FAA and Boeing certify. I can’t see them doing anything but, that now. They’ll probably set up a simulated AOA sensor they can adjust easily and put the plane through it’s paces on the ground.
Sure, almost every plane crach can be avoided by the correct actions of a pilot, but not all airlines pilots are gifted. If Boeing still says the system is not flawed then that deadly philosophy will continue on in its future products. It was deeply flawed, the specifications did not match what was certified, critical failure warnings were made optional. I will not fly one of these for a few years, I have very little confidence in Boeing or its management.
Under this circumstances.
Ofc most crashs can be avoided, but not all airline pilots are gifted with the right information and checklists by the manufacturer.
MCAS has been unknown to pilots till Lion Air, and Ethopian did show that MCAS failure is not recoverable by the means and action Boeing provides.
And these runaway stabilizer checklist is something you have to figure out first.
That’s the bottom line, the result.
The reason, the underlying is way more compliacted and goes deep into construction, certification, aerodynamics, business, training etc.
The truth is: Boeing did provide a airplane with major flaws.
And this is where I’m 100% with you: If they deny it’s on them, the won’t change the underlying issues.
Even if it would lower Boeings chances in getting away from lawyers and courts, I’m confident taking the responsibility on them would be the right way out of the MAx crisis.
Say you have made a misteak. Say it has cost lifes. Adress the issue, and ensure it will never, never happen again.
That’s how you win back trust.
Blaming the technican of Lion Air who changed the sensor, the pilots of both planes etc. will not restore trust in Boeings airplanes.
“actions not taken”
– engineering managers and project pilots asking questions about the wiseness of the design?
– updating the safety analysis?
The question for Muilenberg is:
Who was responsible for the unwise aggressiveness of the system and dependence on a single AOA vane plus failure to update safety analysis – a system that does not meet safey standards widely accepted including within Boeing, if not Boeing?
– The maker of the computer and software, normally in close liaison with Boeing and to an agreed set of requirements (specification)?
– The FAA, which has had pilots who want to overdo things, and likely engineers as well (I’ve encountered such with airlines and Boeing engineers)?
“Linking MCAS to one angle of attack sensor is, arguably, the key technical gap in the system. It is a rule in aviation you don’t have a single point of failure. Boeing argued the pilots were the back-up, but in upgrading the MCAS (or “fixing” it might be another term), MCAS is now being linked to the second AOA indicator on the 737.”
Scott, should be ‘second AOA sensor’.
“A city councilman of the Seattle suburb of Sammamish…”
Who votes for such idiots?