5 ms·
Sorry, but this is a naive understanding of aviation safety. Have a look at "the Swiss cheese model" as a starting point to gain insight. Of course many accide
by erokar 7y ago
Sorry, but this is a naive understanding of aviation safety. Have a look at "the Swiss cheese model" as a starting point to gain insight.
Of course many accidents have a "pilot error" component, the central issue is what made the pilots do the wrong thing. This needs to be analyzed on a systemic level, i.e. was the training good enough, did the pilots receive adequate information, did the aircraft system provide the pilots understandable feedback, etc.
For the pilots to do the right thing, they first need to identify the problem. That can be very difficult when a lot of visual and auditory alarms -- sometimes contradicting each other -- goes off at the same time. The aircraft manufacturer has to account for the human factors.
Boeing failed miserably in this regard: 1) MCAS didn't work as intended, 2) they deliberately left out essential info about the system from flight manuals. In addition the FAA failed in their oversight of Boeing.
The deaths are on them, not the pilots.
- WalterBright 7y ago> Sorry, but this is a naive understanding of aviation safety. Very few aviation crashes are the result of a single failure. Usually, they are a combination of failures, all of which were required to produce the crash. These crashes are no different: 1. the design shortcomings of MCAS 2. the refurbished AOA sensor on the LA airplane was not calibrated properly 3. LA put the plane back in service despite the failed AOA sensor 4. The crew of the LA flight were not informed of the failed AOA sensor 5. The flight crews did not follow the memory runaway trim procedure All of these had to happen. A typical NTSB crash report dispassionately identifies all the contributing factors to an accident and issues corrective action recommendations for each of them.
- tempguy9999 7y agoI was curious about point 3; was lion air responsible for detecting the failed AOA sensor or someone else? I can't exactly say but a quick read comes up with some relevant points: "According to the reports presented to the Indonesian parliament, a Florida-based aerospace company performed the repair of the faulty AOA sensor." https://airlinerwatch.com/broken-aoa-sensor-in-lion-air-737-max-8-crash-linked-to-a-florida-based-aerospace-company/ https://airlinerwatch.com/broken-aoa-sensor-in-lion-air-737-... [from april 2019] So possibly it's not LA's fault, however "On Nov. 5, CNN published an update on the crash investigation from Capt. Nurcahyo Utomo of Indonesia's National Transportation Safety Committee (KNKT) noting that the FDR review also concluded that the aircraft's airspeed indicator had been malfunctioning on four consecutive flights prior to the crash. Utomo also indicated the pilots should have recognized the malfunction when it occurred on flight JT610." https://www.aviationtoday.com/2018/11/07/faa-issues-boeing-737-aoa-directive-amid-lion-air-crash/ https://www.aviationtoday.com/2018/11/07/faa-issues-boeing-7... [from nov 2018]
- WalterBright 7y agoThere's no excuse for LA putting the airplane back in service after the first crew had to cut off the stab trim, or even bothering to inform the next crew of the issue.
- tempguy9999 7y agoThat was my point (edit: and Nurcahyo Utomo's point). I was backing you up on this.
- WalterBright 7y agoI know, I was just concurring. Thanks for lending a hand here :-)
- EddieCPU 7y ago@WalterBright: “These crashes are no different” .. “1. the design shortcomings of MCAS” “5. The flight crews did not follow the memory runaway trim procedure” How would the pilots have switched off MCAS if they didn't know it was there?
- tzs 7y agoThey throw the switch that turns off automatic trim. That the automatic trim system is going nuts due to some new system (MCAS) they don't know about as opposed to it going nuts for one of the reasons it might do so on earlier planes doesn't matter.