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What the Lion Air Pilots May Have Needed to Do to Avoid a Crash

118 points by uger 8y ago

hhanesand 8y ago
Blows my mind that Boeing decided not to include this new system in the “updated” manual.
- JshWright 8y ago
  To be fair, this procedure is not "new". There is a condition known as "stabilizer runaway" that can occur when there is a failure in the automatic systems that control the stabilizer trim (for the autopilot, etc). This procedure is exactly what you would do in that situation to address this issue. The problem is the MCAS addition to MAX adds a new failure mode that the pilots weren't expecting, and it occurred during a very busy phase of flight.
- slededit 8y ago
  You can’t advertise no new training if you update the training material.
snowmaker 8y ago
It's not in this NYT article, but from this one (https://www.cnn.com/2018/11/15/business/boeing-lion-air-crash-stock/index.html https://www.cnn.com/2018/11/15/business/boeing-lion-air-cras...) apparently Boeing's stock has slid 8% likely because investors worry that it will have a huge liability associated with this.
- londons_explore 8y ago
  Doubt it. As a non-USA incident on a non-USA airline, compensation will probably end up being a new plane for the airline and a thousand dollars per passenger for funeral expenses.
WalterBright 8y ago
Shutting off power to the stab trim system is not complex, and it's why the switches are right there on the console. The wheel and the sound it makes are right there and make it obvious when the stab trim system is running.
- DuskStar 8y ago
  And ten minutes should certainly be enough to do that. For that matter, if you're constantly pulling back the yoke to stay level... Wouldn't you try setting the trim manually?
  - AWildC182 8y ago
    Yea, runaway trim is a failure pilots are aware of. That big wheel spins whenever the trim changes so they would notice the huge wheel turning, unprompted, while pulling back on the yoke. This doesn't seem like the whole story though. They clearly were able to control it for a while and were probably making trim inputs so why the sudden descent? They probably didn't turn off the trim motors as the article suggests but should have been able to keep re-trimming the aircraft indefinitely.
    - WalterBright 8y ago
      There's definitely more to the story, as the information we have just doesn't add up. Investigation of the wreckage should clearly show what position the stab trim was at. It's a large nut on a jackscrew, the disintegration of the airplane should leave that intact. The nut/jackscrew is built out of incredibly strong steel.
      - tyingq 8y ago
        Maybe this? Pilots have long been taught that pulling back on a 737's control column can arrest that condition – a fix pilots call a "breakaway", says the APA. Indeed, American's runaway stabiliser checklist, dated 10 July, says, "stabiliser trim commands are interrupted when the control column is displaced in the opposite direction". But the APA has now learned that the 737 Max is apparently different. https://www.flightglobal.com/news/articles/airline-industry-rushes-to-understand-nuances-in-737-453602/ https://www.flightglobal.com/news/articles/airline-industry-...
gok 8y ago
These articles make it sound like settled fact that this crash was caused by the anti-stall system. Is that really the expert concensus?
- tyingq 8y ago
  "Investigators and experts are uncertain why Lion Air Flight 610 plummeted...But they are focusing on an automatic system designed to keep..." That's the opener. Seems reasonable to me.
throwaxx 8y ago
Is it too cynical to wonder if the NTSB had been more involved with the investigation, that we’d be hearing pilot suicide explanations to protect Boeing?
- admax88q 8y ago
  Yes
Someone1234 8y ago
Great article, unfortunate choice of title and opening image. A lot of people are going to skip reading it, and assume this is an article blaming the pilots for this accident, rather than pointing out that neither the airline nor pilots were informed about Boeing's new systems and so couldn't have been trained to counteract it. Boeing's new system wasn't even in the updated manual. And therefore it wasn't in their QRH, which is likely what they were using while attempting to resolve the issue. > With only fragmentary data available, Mr. Hansman said he suspects that a runaway of the M.C.A.S. system played a central role in the crash. “The system basically overrode the pilot in that situation,” Mr. Hansman said. Every thread so far about this topic however have managed to find a way to blame Lion Air, or simply point out how much they suck while glossing over the actual facts.
- cft 8y ago
  Replacing/overriding humans by shoddy AI will become bigger and bigger problem. From the Gmail auto-suggestions to the labyrinth of voice recognition options when you call your credit card or an airline this is all a part of an unfortunate trend.
  - Someone1234 8y ago
    Honestly if the aircraft just communicated what automated actions it was taking better, it may not have been so fatal. "STALL AVOID - STABILIZER ADJUSTED - STALL AVOID - STABILIZER ADJUSTED" would be kinda hard to ignore. Even if they forgot to put it in the manual.
    - ganeshkrishnan 8y ago
      Then on most modern aircrafts, these alarms would be going off all the time. It's more important to know why the computer received incorrect data on the angle of the plane. Usually there are three or more sensors reading it and the master computer uses the voting mechanism to arrive at the correct reading. So in this case probably the master computer had erred?
sehugg 8y ago
Reminds me of the Air France Flight 447 crash, where a unexpected manual mode leads to confusion and cognitive overload with no time to recover.
- justboxing 8y ago
  > and cognitive overload with no time to recover. I don't think the Lion Air Pilots would've been able to recover at all, even if they didn't experience a cognitive overload. > These steps were not in the manual, and the pilots had not been trained in them. Source: OP
  - sokoloff 8y ago
    These steps are most certainly in the manual. Here's the QRH page from a [different dash number] 737. "No new training" strongly suggests that this QRH procedure is in the 737-Max as well. NNC 9.1 (non-normal checklist "Runaway Stablizer") here: http://jira.icesoft.org/secure/attachment/21680/qrh%20rev36%20-800%2027k.pdf http://jira.icesoft.org/secure/attachment/21680/qrh%20rev36%...
bredren 8y ago
Am I missing the interactive part of this article? Seems like a bunch of static images. Would be cool if it let you perform the operations in some way.
- DonHopkins 8y ago
  Oh the humanity! The NYT has established themselves such a great reputation of publishing high quality interactive data driven articles, that now people expect them to include a fully functional flight simulator that lets you relive the doomed pilot's last few minutes, like the Kobayashi Maru! That sure would be cool, but some readers might find it a bit too shocking.
  - userbinator 8y ago
    To be fair, the URL does have "interactive" in it so expecting some form of interactivity would not be unusual.
    - DonHopkins 8y ago
      You have to open up the JavaScript debugger console to see the interactive job ad, where you can interactively evaluate JavaScript expressions like: document.location = 'https://developers.nytimes.com/careers'; https://developers.nytimes.com/careers'; 0000000 000 0000000 111111111 11111111100 000 111111111 00000 111111111111111111 00000 000000 000 1111111111111111111111111100000 000 000 1111 1111111111111111100 000 000 11 0 1111111100 000 000 1 00 1 000 000 00 00 1 000 000 000 00000 1 000 00000 0000 00000000 1 00000 11111 000 00 000000 000 11111 00000 0000 000000 00000 00000 000 10000 000000 000 0000 000 00000 000000 1 000 000 000000 10000 1 0 000 000 1000000 00 1 00 000 000 1111111 1 0000 000 000 1111111100 000000 000 0000 111111111111111110000000 0000 111111111 111111111111100000 111111111 0000000 00000000 0000000 NYTimes.com: All the code that's fit to printf() We're hiring: developers.nytimes.com/careers To their credit, they've come up with an unobtrusive way around AdBlocker that selectively targets web developers.
princetontiger 8y ago
dont fly third world airlines. western pilots win wars and dominate the skies.
iwiririwo 8y ago
Slightly off-topic: This is an ATC recording where pilots lost control over the aircraft. Figuring out what to do when the aircraft goes to random directions, they ask for the direction of the ocean to ditch in. Because of low visibility they have no idea where they are going. The description suggests that during maintenance, some steering control was attached in the wrong way. https://youtu.be/kIc8Rr-cKd8 https://youtu.be/kIc8Rr-cKd8 In this case, the pilots have like an hour to figure out how to control the aircraft.
- salex89 8y ago
  If they actually reached the sea they would ditch it sooner. Because of the faulty controls they couldn't orient themselves, and more important, the airplane did not turn the way they wanted it to, and kept jumping altitudes. Because of that, at some point they kinda started to figure out how to manhandle the jet, while waiting the Portuguese F16s to come and help orient them. If I read correctly somewhere, the autopilot had enough life in it to keep the plane basically flying. If they were closer to water, maybe this would not be such a happy story. The fighter pilot(s) and ATC did a whole lot actually, they seemed willing not to give up and let them just ditch. The fighter pilots obviously new the local conditions and airports very well and led them to land. Sadly, the Lion Air had a different malfunction, they did not have time to react. Maybe, just maybe, another crew would, but that's not the point. It is pointless to sorrow about people not doing something they were not trained for, and possibly not even aware, in a profession heavily dependent on training and procedures.
known 8y ago
Last week I saw the Pilot putting the plane in Autopilot instead of handing over to copilot/trainee pilot when he went to loo.

118 points by uger 8y ago

hhanesand 8y ago

Blows my mind that Boeing decided not to include this new system in the “updated” manual.

JshWright 8y ago
To be fair, this procedure is not "new". There is a condition known as "stabilizer runaway" that can occur when there is a failure in the automatic systems that control the stabilizer trim (for the autopilot, etc). This procedure is exactly what you would do in that situation to address this issue. The problem is the MCAS addition to MAX adds a new failure mode that the pilots weren't expecting, and it occurred during a very busy phase of flight.
slededit 8y ago
You can’t advertise no new training if you update the training material.

snowmaker 8y ago

It's not in this NYT article, but from this one (https://www.cnn.com/2018/11/15/business/boeing-lion-air-crash-stock/index.html https://www.cnn.com/2018/11/15/business/boeing-lion-air-cras...) apparently Boeing's stock has slid 8% likely because investors worry that it will have a huge liability associated with this.

londons_explore 8y ago
Doubt it. As a non-USA incident on a non-USA airline, compensation will probably end up being a new plane for the airline and a thousand dollars per passenger for funeral expenses.

WalterBright 8y ago

Shutting off power to the stab trim system is not complex, and it's why the switches are right there on the console. The wheel and the sound it makes are right there and make it obvious when the stab trim system is running.

DuskStar 8y ago
And ten minutes should certainly be enough to do that. For that matter, if you're constantly pulling back the yoke to stay level... Wouldn't you try setting the trim manually?
- AWildC182 8y ago
  Yea, runaway trim is a failure pilots are aware of. That big wheel spins whenever the trim changes so they would notice the huge wheel turning, unprompted, while pulling back on the yoke. This doesn't seem like the whole story though. They clearly were able to control it for a while and were probably making trim inputs so why the sudden descent? They probably didn't turn off the trim motors as the article suggests but should have been able to keep re-trimming the aircraft indefinitely.
  - WalterBright 8y ago
    There's definitely more to the story, as the information we have just doesn't add up. Investigation of the wreckage should clearly show what position the stab trim was at. It's a large nut on a jackscrew, the disintegration of the airplane should leave that intact. The nut/jackscrew is built out of incredibly strong steel.
    - tyingq 8y ago
      Maybe this? Pilots have long been taught that pulling back on a 737's control column can arrest that condition – a fix pilots call a "breakaway", says the APA. Indeed, American's runaway stabiliser checklist, dated 10 July, says, "stabiliser trim commands are interrupted when the control column is displaced in the opposite direction". But the APA has now learned that the 737 Max is apparently different. https://www.flightglobal.com/news/articles/airline-industry-rushes-to-understand-nuances-in-737-453602/ https://www.flightglobal.com/news/articles/airline-industry-...

gok 8y ago

These articles make it sound like settled fact that this crash was caused by the anti-stall system. Is that really the expert concensus?

tyingq 8y ago
"Investigators and experts are uncertain why Lion Air Flight 610 plummeted...But they are focusing on an automatic system designed to keep..." That's the opener. Seems reasonable to me.

throwaxx 8y ago

Is it too cynical to wonder if the NTSB had been more involved with the investigation, that we’d be hearing pilot suicide explanations to protect Boeing?

admax88q 8y ago
Yes

Someone1234 8y ago

Great article, unfortunate choice of title and opening image. A lot of people are going to skip reading it, and assume this is an article blaming the pilots for this accident, rather than pointing out that neither the airline nor pilots were informed about Boeing's new systems and so couldn't have been trained to counteract it. Boeing's new system wasn't even in the updated manual. And therefore it wasn't in their QRH, which is likely what they were using while attempting to resolve the issue. > With only fragmentary data available, Mr. Hansman said he suspects that a runaway of the M.C.A.S. system played a central role in the crash. “The system basically overrode the pilot in that situation,” Mr. Hansman said. Every thread so far about this topic however have managed to find a way to blame Lion Air, or simply point out how much they suck while glossing over the actual facts.

cft 8y ago
Replacing/overriding humans by shoddy AI will become bigger and bigger problem. From the Gmail auto-suggestions to the labyrinth of voice recognition options when you call your credit card or an airline this is all a part of an unfortunate trend.
- Someone1234 8y ago
  Honestly if the aircraft just communicated what automated actions it was taking better, it may not have been so fatal. "STALL AVOID - STABILIZER ADJUSTED - STALL AVOID - STABILIZER ADJUSTED" would be kinda hard to ignore. Even if they forgot to put it in the manual.
  - ganeshkrishnan 8y ago
    Then on most modern aircrafts, these alarms would be going off all the time. It's more important to know why the computer received incorrect data on the angle of the plane. Usually there are three or more sensors reading it and the master computer uses the voting mechanism to arrive at the correct reading. So in this case probably the master computer had erred?

sehugg 8y ago

Reminds me of the Air France Flight 447 crash, where a unexpected manual mode leads to confusion and cognitive overload with no time to recover.

justboxing 8y ago
> and cognitive overload with no time to recover. I don't think the Lion Air Pilots would've been able to recover at all, even if they didn't experience a cognitive overload. > These steps were not in the manual, and the pilots had not been trained in them. Source: OP
- sokoloff 8y ago
  These steps are most certainly in the manual. Here's the QRH page from a [different dash number] 737. "No new training" strongly suggests that this QRH procedure is in the 737-Max as well. NNC 9.1 (non-normal checklist "Runaway Stablizer") here: http://jira.icesoft.org/secure/attachment/21680/qrh%20rev36%20-800%2027k.pdf http://jira.icesoft.org/secure/attachment/21680/qrh%20rev36%...

bredren 8y ago

Am I missing the interactive part of this article? Seems like a bunch of static images. Would be cool if it let you perform the operations in some way.

DonHopkins 8y ago
Oh the humanity! The NYT has established themselves such a great reputation of publishing high quality interactive data driven articles, that now people expect them to include a fully functional flight simulator that lets you relive the doomed pilot's last few minutes, like the Kobayashi Maru! That sure would be cool, but some readers might find it a bit too shocking.
- userbinator 8y ago
  To be fair, the URL does have "interactive" in it so expecting some form of interactivity would not be unusual.
  - DonHopkins 8y ago
    You have to open up the JavaScript debugger console to see the interactive job ad, where you can interactively evaluate JavaScript expressions like: document.location = 'https://developers.nytimes.com/careers'; https://developers.nytimes.com/careers'; 0000000 000 0000000 111111111 11111111100 000 111111111 00000 111111111111111111 00000 000000 000 1111111111111111111111111100000 000 000 1111 1111111111111111100 000 000 11 0 1111111100 000 000 1 00 1 000 000 00 00 1 000 000 000 00000 1 000 00000 0000 00000000 1 00000 11111 000 00 000000 000 11111 00000 0000 000000 00000 00000 000 10000 000000 000 0000 000 00000 000000 1 000 000 000000 10000 1 0 000 000 1000000 00 1 00 000 000 1111111 1 0000 000 000 1111111100 000000 000 0000 111111111111111110000000 0000 111111111 111111111111100000 111111111 0000000 00000000 0000000 NYTimes.com: All the code that's fit to printf() We're hiring: developers.nytimes.com/careers To their credit, they've come up with an unobtrusive way around AdBlocker that selectively targets web developers.

princetontiger 8y ago

dont fly third world airlines. western pilots win wars and dominate the skies.

iwiririwo 8y ago

Slightly off-topic: This is an ATC recording where pilots lost control over the aircraft. Figuring out what to do when the aircraft goes to random directions, they ask for the direction of the ocean to ditch in. Because of low visibility they have no idea where they are going. The description suggests that during maintenance, some steering control was attached in the wrong way. https://youtu.be/kIc8Rr-cKd8 https://youtu.be/kIc8Rr-cKd8 In this case, the pilots have like an hour to figure out how to control the aircraft.

salex89 8y ago
If they actually reached the sea they would ditch it sooner. Because of the faulty controls they couldn't orient themselves, and more important, the airplane did not turn the way they wanted it to, and kept jumping altitudes. Because of that, at some point they kinda started to figure out how to manhandle the jet, while waiting the Portuguese F16s to come and help orient them. If I read correctly somewhere, the autopilot had enough life in it to keep the plane basically flying. If they were closer to water, maybe this would not be such a happy story. The fighter pilot(s) and ATC did a whole lot actually, they seemed willing not to give up and let them just ditch. The fighter pilots obviously new the local conditions and airports very well and led them to land. Sadly, the Lion Air had a different malfunction, they did not have time to react. Maybe, just maybe, another crew would, but that's not the point. It is pointless to sorrow about people not doing something they were not trained for, and possibly not even aware, in a profession heavily dependent on training and procedures.

known 8y ago

Last week I saw the Pilot putting the plane in Autopilot instead of handing over to copilot/trainee pilot when he went to loo.