What really brought down the Boeing 737 MAX?

[Aloha_Shooter]

One of the better written articles I've seen in the NYT.
https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-crashes.html


It's written more for laymen than https://seekingalpha.com/instablog/398764-vaughn-cordle-cfa/5290930-boeing-737-max-8-crashes-case-pilot-error

which I also recommend but the latter article is targeted more toward pilots or people familiar with operational analysis.

I still prefer Boeing's pilot-centric design philosophy over Airbus' robotic approach but that only works if airmen are at the controls -- in both seats. Ethiopian Airlines apparently has a decent reputation in the industry but I can't fathom putting someone in the right seat with 154 hours of experience. Would you hand the keys for a Ferrari to a new driver who had driven to the mall a hundred or more times?

[Gman]

I still prefer Boeing's pilot-centric design philosophy over Airbus' robotic approach but that only works if airmen are at the controls -- in both seats.

I'm in violent agreement with this. Build a durable aircraft and let the pilots do what they need to save their and their passengers' lives (BOEING). Don't have the computer fly the plane with suggestions from the crew up front (AIRBUS).

From what I've been able to determine, the FAA required Boeing to put the MCAS in place due to the engine relocation. The idea of using a single sensor and providing MCAS the ability to override the pilot input to the point of crashing the aircraft never should have happened.

(I'm not creating a login to read the NYT article)

[asystejs]

The NYT article did not require a logon for me and is a good read

[Gman]

78982
78981

[def90]

I'm able to read it without logging in or creating an account..

[Hoser]

We have seen many of the reports on these two crashes. This is the first mention of the Lion Air having a jump seating pilot on board.

Planes are getting bigger, faster and more complicated. They require more heads down. In the old days you had a dude to manage systems called a flight engineer. But they replaced him with a computer and lost of an extra set of eyes up front.

[Gman]

...an example of when an extra set of eyes, hands, and a brain made a difference:
https://en.wikipedia.org/wiki/United_Airlines_Flight_232


http://youtu.be/1d0thAVFsnY

[Aloha_Shooter]

We have seen many of the reports on these two crashes. This is the first mention of the Lion Air having a jump seating pilot on board.

Planes are getting bigger, faster and more complicated. They require more heads down. In the old days you had a dude to manage systems called a flight engineer. But they replaced him with a computer and lost of an extra set of eyes up front.

The jump seating pilot was on the flight that took off and landed successfully the night before. Reports of him helping save that flight came out some months ago but may have gotten lost in the rush to blame Boeing. As both articles I linked to point out, there were some pretty fundamental errrors in airmanship in all three flights (2 crashes and 1 near-crash). That doesn't mean Boeing is blameless but it sure seems to me that Indonesia, Ethiopia, and others would like to heap all the blame on Boeing and avoid questions about their standards.

[Gman]

The idea of selling safety systems (indicators that the angle of attack sensors were in disagreement and that the MCAS was engaged) as expensive options was pretty short-sighted and seems greedy on the part of Boeing:
They didn’t buy the DLC: feature that could’ve prevented 737 crashes was sold as an option (https://arstechnica.com/information-technology/2019/03/boeing-sold-safety-feature-that-could-have-prevented-737-max-crashes-as-an-option/)

From what I recall, the simulators also weren't accurate as to what a pilot could experience with the 737 MAX. This was intentional as the 737 operators and Boeing didn't want to require significant retraining with the new platform.

The entire episode indicated short-comings in manufacturing, FAA oversight, and pilot training and experience.

[Gman]

I think this is the same info with a link that I can actually read:
What Really Brought Down the Boeing 737 Max? (https://www.msn.com/en-us/news/world/what-really-brought-down-the-boeing-737-max/ar-AAHtnDu)

[ruthabagah]

Corporate greed and terrible QA?

[vossman]

Wow.

[Gman]

Crash Course: How Boeing's Managerial Revolution Created the 737 Max Disaster (https://newrepublic.com/article/154944/boeing-737-max-investigation-indonesia-lion-air-ethiopian-airlines-managerial-revolution)


Nearly two decades before Boeing?s MCAS system crashed two of the plane-maker?s brand-new 737 MAX jets, Stan Sorscher knew his company?s increasingly toxic mode of operating would create a disaster of some kind. A long and proud ?safety culture? was rapidly being replaced, he argued, with ?a culture of financial bullshit, a culture of groupthink.?


Sorscher, a physicist who?d worked at Boeing more than two decades and had led negotiations there for the engineers? union, had become obsessed with management culture. He said he didn?t previously imagine Boeing?s brave new managerial caste creating a problem as dumb and glaringly obvious as MCAS (or the Maneuvering Characteristics Augmentation System, as a handful of software wizards had dubbed it). Mostly he worried about shriveling market share driving sales and head count into the ground, the things that keep post-industrial American labor leaders up at night. On some level, though, he saw it all coming; he even demonstrated how the costs of a grounded plane would dwarf the short-term savings achieved from the latest outsourcing binge in one of his reports that no one read back in 2002.* >Snip

[ruthabagah]

Crash Course: How Boeing's Managerial Revolution Created the 737 Max Disaster (https://newrepublic.com/article/154944/boeing-737-max-investigation-indonesia-lion-air-ethiopian-airlines-managerial-revolution)

Yep. Now, this is serious BUT not out of the ordinary. The real problem is the level of collusion between the FAA and Boeing.... We rely on these agencies to "protect" the public interest and avoid this kind of accidents. Having a manufacturer run their own tests is pretty common in any industries, but it is baffling to me that no audit/qa was performed on such an important feature of a commercial aircraft.

A long time ago I worked in manufacturing for public transportation's equipment and the level of government scrutiny (both at the local and federal level) made me nauseous.... I guess it's safer to ride the bus than a 737Max. For the record, I am NOT anti Boeing, the 787 is one of my favorite plane ever.

[Aloha_Shooter]

I've got a different take-away from the two articles I cited. Boeing's management was short-sighted but the real problem is that Boeing's aircraft development and FAA's regulations are predicated on an American model where pilots didn't get into the cockpit on majors -- in either left- or right-hand seats -- until they had significant air time experience and extensive training but other countries are NOT requiring that level of proficiency or airmanship. Is it any surprise they get into situations that Boeing or the FAA didn't envision simply because they assumed the pilot(s) know basic procedures (like reducing throttle when the airspeed klaxon goes off)? I shouldn't have to tell the bus driver to ease off the gas when coming down a steep spiral off-ramp (I WOULD tell the new student in Drivers Ed but one presumes basic competence from someone licensed to drive a commercial bus).

Runaway stabilizer procedures aren't new and so far, it appears the MCAS repeated-cycling issue wouldn't even have come up if they'd been executed promptly. Manual trim on the ET flight would have had more of a chance of being effective if 1) it had been dialed in the correct direction and 2) throttles had been reduced from take-off power.

I for one would have no problems getting on a 737 MAX today as long as the pilots -- BOTH of them -- had American standards of training and experience. I don't want to get on any plane where the airline puts someone in the right-hand seat with 361 (much less 154) hours of flight experience and gets his/her simulator training by watching someone else sit in the seat and go through the motions.

[ruthabagah]

"Boeing presented highly trained test pilots only with a single alert indicating a condition known as runaway stabilizer trim, which can be triggered by the MCAS anti-stall system, safety board officials said. They said Boeing failed to consider that an underlying problem like sensor failures — which triggered MCAS in both Max crashes — would set off several alarms.

In the Lion Air and Ethiopian Airlines crashes , they said, the pilots’ control columns would have shaken to warn of an impending stall, they would have gotten several visual and sound alerts about things like altitude and speed.

“That’s the actual scenario that never got evaluated in the simulator,” said Dana Schulze, the board’s director of aviation safety."

It seems the ntsb Also believes that wrong assumptions and bad qa are to blame...


https://www.marketwatch.com/story/federal-officials-say-boeing-underestimated-pilots-ability-to-react-to-simultaneous-warning-alerts-2019-09-26

[Duman]

It's the same cancer permeating other corporations. You can write about the symptoms from many different perspectives, the narrative is the same.

The wheel keeps turning.

[Wolfshoon]

I for one would have no problems getting on a 737 MAX today as long as the pilots -- BOTH of them -- had American standards of training and experience. I don't want to get on any plane where the airline puts someone in the right-hand seat with 361 (much less 154) hours of flight experience and gets his/her simulator training by watching someone else sit in the seat and go through the motions.

Agreed, getting on some foreign carriers poses a larger than normal risk. Dont even think about getting on any african airline and russian carriers arent too much better. Most European are pretty decent with their version of the FAA (called the JAA) having decent oversight on the western side of things, eastern european starts getting back into murky waters. Most Asian airlines were also pretty good as they literally had no indigenous pilots and relied on western sourced pilots for their airlines. That has since changed with several countries sourcing pilots from within and reduced reliance on western pilots. Safety and training standards vary by country.

FAA ATP requirements bumped way up after several crashes by regional airlines back in circa 2010-2012. Used to be you could get on with a major with 350+ hours total time and a multi rating with IFR. Now it is 1500 hours PIC and a current ATP prior to even being interviewed. This has effectively just about killed off civilian training of aircrew as cost skyrocketed over $200k , leaving the military as the major source of trained pilots now. They are having their own issues retaining aircrew as well. If you want a well paying career, airline pilot is moving back up the charts as demand is climbing.

I cant stand regional airlines , between crew staffing and parts problems they are lucky to have a 65% release rate at the gate. They also account for a lot of mishandled baggage making the mainline airlines that contract with them look worse than what they really are. It is however, a self solving problem. Because of the huge increase in hiring requirements driven by the FAA there is a huge shortage of pilots coming on the horizon, with it peaking around 2028. The regional airlines literally cant hire pilots due to competition with the mainline legacy carriers.

[Duman]

Just finished watching 'Chernobyl' on HBO. It's a good parallel to the Boeing 737 situation.

[ruthabagah]

Just finished watching 'Chernobyl' on HBO. It's a good parallel to the Boeing 737 situation.

And just like Chernobyl we are witnessing a meltdown....

“This airplane is designed by clowns, who are in turn supervised by monkeys,” one Boeing pilot wrote to another in a 2017 exchange."


https://www.seattletimes.com/business/boeing-aerospace/boeing-internal-documents-reveal-culture-of-deceit-to-keep-down-costs-of-737-max/

Now, there is a rumor out there that they that they are seriously considering pulling a "757 max" project that was shelved due to cost. The 757 is a great plane.