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I thought Boeing blamed it on a combination of poor maintenance practices by the relevant airlines, poor handling and response to inflight error messages and ma

I thought Boeing blamed it on a combination of poor maintenance practices by the relevant airlines, poor handling and response to inflight error messages and maintenance requests on previous flights that left the issue unaddressed, and then weaknesses on the pilot side during the accident flights? I personally think they went a bit overboard with the revised procedure memory items.

smnrchrds 5y ago
I am no expert, but I remember the main culprit was that Boeing had insisted no further training is required for pilots to avoid some sort of expensive recertification. Weakness of pilots was the direct result of this. Pilots having experience with previous 737 planes were told in no uncertain terms that they can fly this new plane the exact same as the previous one and no further training or testing is required or even available. They did just that, but actions which would have saved the plane in previous generations ensured its crash in the MAX generation. And Boeing had the audacity of blaming the pilots when they inevitably died in crashes. > In vivid detail, the documentary pieces together what Boeing knew about the potential for disaster with the 737 Max and when the company knew it. Pasternak says in the film that in 2012, a “Boeing test pilot was flying the MAX in a flight simulator and trying to respond to an activation of MCAS, and that resulted in what he described as a catastrophic event. It showed that if that had been in real life, he [could] have lost the airplane. They realize from that moment on, even a Boeing test pilot may have trouble responding to MCAS.” > Yet internal communications explored in the film show that Boeing was determined to maintain the status quo: avoiding potential scrutiny by the Federal Aviation Administration that would add costs; keeping new simulator training for pilots to a minimum; and even requesting that MCAS be removed from pilot training manuals. https://www.pbs.org/wgbh/frontline/article/video-clip-boeing-737-max-crashes-fatal-design-flaw-documentary/ https://www.pbs.org/wgbh/frontline/article/video-clip-boeing...
- sokoloff 5y ago
  > Boeing had the audacity of blaming the pilots when they inevitably died in crashes. That wasn’t a great look, but Boeing is correct that if the pilots had followed the existing checklist memory items for stab trim runaway, the airplanes would not have crashed. The difficulty is that prior generations had breakout switches which would inhibit the stab trim from running in a direction counter to the control column deflection. That obviously won’t work for the intended purpose of MCAS (to give flight control feel in opposition to excessive pitch up). The checklist item for runaway trim is not “stop stab trim by deflecting control column” but rather “stop stab trim by throwing the stab trim cutout switches”. Pilots who used the “deflect control column” technique contrary to the checklist would have gotten away with the error in non-Max 73s, but not in the -Max edition. That’s pretty far from “0% pilot contribution” to the mishap IMO.
  - slownews45 5y ago
    Excellent point. A lot of focus is on pilots, but the safety chain was also weak. Maint, communication with flight dept, communication to subsequent pilots etc, training dept and required experience / education to fly. Not a good combo. Someone with 200 hrs of time, plane badly maintained, no good handoff around prior issues etc. I still think Boeings safety model with humans as the backup for computers probably doesn't work in a world where a large majority of pilots lean on fully fly by wire (computerized) planes. Someone with 240 hours, a bunch of that just sim time - can they hand fly a plane in its entire envelope? This is where Boeing sounded really tone deaf. They built a model around humans as backup, a very US centric model (ie, folks with tons of general aviation experience just as a hobby from young ages, military flight experience etc) which was not really appropriate here.
    - sokoloff 5y ago
      There’s a genuine question as to whether someone with 240 hours should be holding the yoke of a jet airliner. For me, that answer is “hell no!” as we saw in Colgan 3407 (and others) which led to the FAA 1500-hour minimum for an ATP. At 240 hours, I couldn’t be trusted with a Bonanza.
      - slownews45 5y ago
        Yes, in the US we (now) think of 250 as too low. 1,500 is pretty dang high. Persoanlly, 500 - 1000 wouldn't be unreasonable in my view. Major airlines might still be at 3,000+ hours. Remember, it used to be in the US you could also fly as a FO with a commercial pilots license at 250 hours! FAA Commercial Pilot is 250 (50 of which need to be in powered airplane). https://www.aopa.org/training-and-safety/active-pilots/safety-and-technique/operations/commercial-pilot-certificate https://www.aopa.org/training-and-safety/active-pilots/safet... 50 hours behind the actual yoke? 200 lives 30,000 feet in the air? Overseas, some of the cadet / local pilot programs - you get pretty low time and/or connected pilots into the seat. "The committee noted that these deficiencies had been identified previously in training and reemerged during the accident flight. When the MCAS activated, it took the first officer four minutes to locate the proper checklist because he wasn’t familiar with required memory items. During training, the same pilot had shown unfamiliarity with Boeing and airline standard operating procedures and had weak aircraft handling skills, the report revealed. His training record reflected numerous deficiencies, including “major problems” controlling the aircraft." There is a reason Boeing initially said there might have been some pilot factors. They look at that memory item checklist, and think, trim problem, stab cutout memory item. In the US they have Capt Sully (glider / fighter pilots, lots of experience, with a strong FO) gliding a plane with two engines out to a safe landing. So human in the loop kind of works in the US. Could you program a computer for that? Probably, but not there yet. That said, I still blame Boeing to a large degree. If you are going to sell new planes to countries that have this type of system, you must design the plane for purpose. Ie, low time pilots who struggle / are connected / can't be fired etc - you don't then design the plane assuming the human in the loop will have hand flying ability to step in. That was pure greed, roll out this type of plane in the US / EU / UK etc. Good maintenance, good safety reporting systems (ASAP etc) work out the kinks, then go overseas. First Max 8 to Malindo air!!? Really?? They really need to get to airbus and beyond envelope protection etc in these markets. I'm also curious about checkrides overseas. Stuff like engine out on takeoff etc is just hammered into folks in the US.
- slownews45 5y ago
  The old procedure was Control Column - Hold Firmly Autopilot - Disengage. Do NOT re-engage. Control pitch attitude manually with column and electric trim. If runaway continues, stab trim cutout (both) to cutout. http://www.b737.org.uk/images/runawaystab2000.jpg http://www.b737.org.uk/images/runawaystab2000.jpg The new procedure is not that much different. With PK-LQP - previous flight it took 6 minutes for them to get to this procedure - and it was suggestion of a dead-heading pilot. This resolved things. Despite going through this exact issue on previous flight, the next flight takes off, same issue develops because of underlying maintenance issue, they were dealing with this for 8 minutes, 28 activations of incorrect trim but with a fatal outcome. Yes, MCAS was a bad design, yes it increased risk. I'm not sure it was a "nothing could be done" type situation. Better maintenance? Better communication between flights? Stab trim cutout earlier if you don't like how the automatic trim is working? Airbus has historically pushed more automation / flight protection. My own suspicion is Boeing will go that way as well, ie, human in loop model they had (where human fixes the computer going crazy) just doesn't work well especially for folks flying these big jets without much earlier GA / manual flying time. For example, in the US, a pilot would have done lots of manual flying on small planes first, and so might be a bit less automation dependent and better able to take over when computers go crazy. Also more hours before you fly the big jets (think 1,500 hours flight time). Usually a 4 year degree. Overseas, you can come off the street and be flying a jet with 200 - 240 hours of time including sim time? That is a TON less flying time, probably very very little manual stick and rudder flying. A fair number of saves in the US have come from folks with great stick and rudder flying experience, even things like glider experience you just don't have overseas. There usually is something called differences training for variants like this. Wouldn't cover MCAS, and is usually brief, but not normally zero. I'm surprised they did zero differences training if that was the case - that is very unusual. You've got to do normally at least an hour or two. A new variant is not unheard off, 737 probably has something like 12 variants under one type certificate. I would check your source there that no differences training came up.
  - Symbiote 5y ago
    > Overseas ... in the US It's a bad habit to split the world into US/overseas. Canada and Western Europe are clearly much closer to the US than Indonesia and Pakistan, and Eastern Europe / CIS states have a history of ex-military/experienced pilots too.
- WalterBright 5y ago
  The Frontline episode is a mess of misinformation and omission of crucial facts. I submitted on the Frontline site a list of omitted facts and corrections supported by cited FAA documents. The moderators refused to post it. I used to watch Frontline regularly. Although they had an obvious left wing bias, I thought they made good faith efforts to present the facts. No more. I no longer watch Frontline nor consider them a reliable source of news. BTW, the "Aviation Disasters" did an episode on the 737MAX that was pretty decent (although a bit shallow due to time constraints), so it is possible to do a good story on it. Recommended.
WalterBright 5y ago
The problems were: 1. poor MCAS design 2. poor maintenance 3. pilots not following runaway trim emergency procedures The media pretty much never mentions (3). Note that 3 flights experienced the MCAS malfunction. 1 applied runaway trim emergency procedures, continued with the flight, and landed safely. https://theaircurrent.com/wp-content/uploads/2018/11/B737-MAX-AD-1107.pdf https://theaircurrent.com/wp-content/uploads/2018/11/B737-MA... 2018 - 035 - PK-LQP Final Report http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2018%20-%20...
- WalterBright 5y ago
  For those who don't like what I wrote, I encourage you to read the cites, which are official documents, rather than what journalists who literally know nothing about flying, piloting, or aircraft design, imagine is true.
  - kayfox 5y ago
    I think the biggest lie I have seen the news on the MAX make "true" has been that MCAS exists to make the MAX fly like previous 737s and that it could have been omitted if the aircraft were a new type... Of course: 1. The MAX can't be a new type, it would have to be clean-sheet at that point just from all the grandfathered items. 2. That view grossly oversimplifies how type ratings work for pilots. 3. MCAS exists to conform to the FARs (control force curves), not some "make it fly like a 737NG" thing.

smnrchrds 5y ago

I am no expert, but I remember the main culprit was that Boeing had insisted no further training is required for pilots to avoid some sort of expensive recertification. Weakness of pilots was the direct result of this. Pilots having experience with previous 737 planes were told in no uncertain terms that they can fly this new plane the exact same as the previous one and no further training or testing is required or even available. They did just that, but actions which would have saved the plane in previous generations ensured its crash in the MAX generation. And Boeing had the audacity of blaming the pilots when they inevitably died in crashes. > In vivid detail, the documentary pieces together what Boeing knew about the potential for disaster with the 737 Max and when the company knew it. Pasternak says in the film that in 2012, a “Boeing test pilot was flying the MAX in a flight simulator and trying to respond to an activation of MCAS, and that resulted in what he described as a catastrophic event. It showed that if that had been in real life, he [could] have lost the airplane. They realize from that moment on, even a Boeing test pilot may have trouble responding to MCAS.” > Yet internal communications explored in the film show that Boeing was determined to maintain the status quo: avoiding potential scrutiny by the Federal Aviation Administration that would add costs; keeping new simulator training for pilots to a minimum; and even requesting that MCAS be removed from pilot training manuals. https://www.pbs.org/wgbh/frontline/article/video-clip-boeing-737-max-crashes-fatal-design-flaw-documentary/ https://www.pbs.org/wgbh/frontline/article/video-clip-boeing...

sokoloff 5y ago
> Boeing had the audacity of blaming the pilots when they inevitably died in crashes. That wasn’t a great look, but Boeing is correct that if the pilots had followed the existing checklist memory items for stab trim runaway, the airplanes would not have crashed. The difficulty is that prior generations had breakout switches which would inhibit the stab trim from running in a direction counter to the control column deflection. That obviously won’t work for the intended purpose of MCAS (to give flight control feel in opposition to excessive pitch up). The checklist item for runaway trim is not “stop stab trim by deflecting control column” but rather “stop stab trim by throwing the stab trim cutout switches”. Pilots who used the “deflect control column” technique contrary to the checklist would have gotten away with the error in non-Max 73s, but not in the -Max edition. That’s pretty far from “0% pilot contribution” to the mishap IMO.
- slownews45 5y ago
  Excellent point. A lot of focus is on pilots, but the safety chain was also weak. Maint, communication with flight dept, communication to subsequent pilots etc, training dept and required experience / education to fly. Not a good combo. Someone with 200 hrs of time, plane badly maintained, no good handoff around prior issues etc. I still think Boeings safety model with humans as the backup for computers probably doesn't work in a world where a large majority of pilots lean on fully fly by wire (computerized) planes. Someone with 240 hours, a bunch of that just sim time - can they hand fly a plane in its entire envelope? This is where Boeing sounded really tone deaf. They built a model around humans as backup, a very US centric model (ie, folks with tons of general aviation experience just as a hobby from young ages, military flight experience etc) which was not really appropriate here.
  - sokoloff 5y ago
    There’s a genuine question as to whether someone with 240 hours should be holding the yoke of a jet airliner. For me, that answer is “hell no!” as we saw in Colgan 3407 (and others) which led to the FAA 1500-hour minimum for an ATP. At 240 hours, I couldn’t be trusted with a Bonanza.
    - slownews45 5y ago
      Yes, in the US we (now) think of 250 as too low. 1,500 is pretty dang high. Persoanlly, 500 - 1000 wouldn't be unreasonable in my view. Major airlines might still be at 3,000+ hours. Remember, it used to be in the US you could also fly as a FO with a commercial pilots license at 250 hours! FAA Commercial Pilot is 250 (50 of which need to be in powered airplane). https://www.aopa.org/training-and-safety/active-pilots/safety-and-technique/operations/commercial-pilot-certificate https://www.aopa.org/training-and-safety/active-pilots/safet... 50 hours behind the actual yoke? 200 lives 30,000 feet in the air? Overseas, some of the cadet / local pilot programs - you get pretty low time and/or connected pilots into the seat. "The committee noted that these deficiencies had been identified previously in training and reemerged during the accident flight. When the MCAS activated, it took the first officer four minutes to locate the proper checklist because he wasn’t familiar with required memory items. During training, the same pilot had shown unfamiliarity with Boeing and airline standard operating procedures and had weak aircraft handling skills, the report revealed. His training record reflected numerous deficiencies, including “major problems” controlling the aircraft." There is a reason Boeing initially said there might have been some pilot factors. They look at that memory item checklist, and think, trim problem, stab cutout memory item. In the US they have Capt Sully (glider / fighter pilots, lots of experience, with a strong FO) gliding a plane with two engines out to a safe landing. So human in the loop kind of works in the US. Could you program a computer for that? Probably, but not there yet. That said, I still blame Boeing to a large degree. If you are going to sell new planes to countries that have this type of system, you must design the plane for purpose. Ie, low time pilots who struggle / are connected / can't be fired etc - you don't then design the plane assuming the human in the loop will have hand flying ability to step in. That was pure greed, roll out this type of plane in the US / EU / UK etc. Good maintenance, good safety reporting systems (ASAP etc) work out the kinks, then go overseas. First Max 8 to Malindo air!!? Really?? They really need to get to airbus and beyond envelope protection etc in these markets. I'm also curious about checkrides overseas. Stuff like engine out on takeoff etc is just hammered into folks in the US.
slownews45 5y ago
The old procedure was Control Column - Hold Firmly Autopilot - Disengage. Do NOT re-engage. Control pitch attitude manually with column and electric trim. If runaway continues, stab trim cutout (both) to cutout. http://www.b737.org.uk/images/runawaystab2000.jpg http://www.b737.org.uk/images/runawaystab2000.jpg The new procedure is not that much different. With PK-LQP - previous flight it took 6 minutes for them to get to this procedure - and it was suggestion of a dead-heading pilot. This resolved things. Despite going through this exact issue on previous flight, the next flight takes off, same issue develops because of underlying maintenance issue, they were dealing with this for 8 minutes, 28 activations of incorrect trim but with a fatal outcome. Yes, MCAS was a bad design, yes it increased risk. I'm not sure it was a "nothing could be done" type situation. Better maintenance? Better communication between flights? Stab trim cutout earlier if you don't like how the automatic trim is working? Airbus has historically pushed more automation / flight protection. My own suspicion is Boeing will go that way as well, ie, human in loop model they had (where human fixes the computer going crazy) just doesn't work well especially for folks flying these big jets without much earlier GA / manual flying time. For example, in the US, a pilot would have done lots of manual flying on small planes first, and so might be a bit less automation dependent and better able to take over when computers go crazy. Also more hours before you fly the big jets (think 1,500 hours flight time). Usually a 4 year degree. Overseas, you can come off the street and be flying a jet with 200 - 240 hours of time including sim time? That is a TON less flying time, probably very very little manual stick and rudder flying. A fair number of saves in the US have come from folks with great stick and rudder flying experience, even things like glider experience you just don't have overseas. There usually is something called differences training for variants like this. Wouldn't cover MCAS, and is usually brief, but not normally zero. I'm surprised they did zero differences training if that was the case - that is very unusual. You've got to do normally at least an hour or two. A new variant is not unheard off, 737 probably has something like 12 variants under one type certificate. I would check your source there that no differences training came up.
- Symbiote 5y ago
  > Overseas ... in the US It's a bad habit to split the world into US/overseas. Canada and Western Europe are clearly much closer to the US than Indonesia and Pakistan, and Eastern Europe / CIS states have a history of ex-military/experienced pilots too.
WalterBright 5y ago
The Frontline episode is a mess of misinformation and omission of crucial facts. I submitted on the Frontline site a list of omitted facts and corrections supported by cited FAA documents. The moderators refused to post it. I used to watch Frontline regularly. Although they had an obvious left wing bias, I thought they made good faith efforts to present the facts. No more. I no longer watch Frontline nor consider them a reliable source of news. BTW, the "Aviation Disasters" did an episode on the 737MAX that was pretty decent (although a bit shallow due to time constraints), so it is possible to do a good story on it. Recommended.

WalterBright 5y ago

The problems were: 1. poor MCAS design 2. poor maintenance 3. pilots not following runaway trim emergency procedures The media pretty much never mentions (3). Note that 3 flights experienced the MCAS malfunction. 1 applied runaway trim emergency procedures, continued with the flight, and landed safely. https://theaircurrent.com/wp-content/uploads/2018/11/B737-MAX-AD-1107.pdf https://theaircurrent.com/wp-content/uploads/2018/11/B737-MA... 2018 - 035 - PK-LQP Final Report http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2018%20-%20035%20-%20PK-LQP%20Final%20Report.pdf http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2018%20-%20...

WalterBright 5y ago
For those who don't like what I wrote, I encourage you to read the cites, which are official documents, rather than what journalists who literally know nothing about flying, piloting, or aircraft design, imagine is true.
- kayfox 5y ago
  I think the biggest lie I have seen the news on the MAX make "true" has been that MCAS exists to make the MAX fly like previous 737s and that it could have been omitted if the aircraft were a new type... Of course: 1. The MAX can't be a new type, it would have to be clean-sheet at that point just from all the grandfathered items. 2. That view grossly oversimplifies how type ratings work for pilots. 3. MCAS exists to conform to the FARs (control force curves), not some "make it fly like a 737NG" thing.