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Thread: Lion Air Flight 610 Crash

  1. #361
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    The Indonesian National Transportation Committee has released the final report on Lion Air flight 610. They spread the blame around and found nine issues that contributed to the accident. The report also lists 89 findings.

    To download the report PDF:
    http://knkt.dephub.go.id/knkt/ntsc_a...l%20Report.pdf

    Contributing factors:

    Contributing FactorsContributing factors defines as actions, omissions, events, conditions, or acombination thereof, which, if eliminated, avoided or absent, would have reducedthe probability of the accident or incident occurring, or mitigated the severity of theconsequences of the accident or incident. The presentation is based onchronological order and not to show the degree of contribution.

    1. During the design and certification of the Boeing 737-8 (MAX),assumptions were made about flight crew response to malfunctions which,even though consistent with current industry guidelines, turned out to beincorrect.

    2. Based on the incorrect assumptions about flight crew response and anincomplete review of associated multiple flight deck effects, MCAS’sreliance on a single sensor was deemed appropriate and met all certificationrequirements.

    3. MCAS was designed to rely on a single AOA sensor, making it vulnerableto erroneous input from that sensor.

    4. The absence of guidance on MCAS or more detailed use of trim in the flightmanuals and in flight crew training, made it more difficult for flight crews toproperly respond to uncommanded MCAS.

    5. The AOA DISAGREE alert was not correctly enabled during Boeing 737-8(MAX) development. As a result, it did not appear during flight with themis-calibrated AOA sensor, could not be documented by the flight crew andwas therefore not available to help maintenance identify the mis-calibratedAOA sensor.

    6. The replacement AOA sensor that was installed on the accident aircraft hadbeen mis-calibrated during an earlier repair. This mis-calibration was notdetected during the repair.

    7. The investigation could not determine that the installation test of the AOAsensor was performed properly. The mis-calibration was not detected.

    8. Lack of documentation in the aircraft flight and maintenance log about thecontinuous stick shaker and use of the Runaway Stabilizer NNC meant thatinformation was not available to the maintenance crew in Jakarta nor was itavailable to the accident crew, making it more difficult for each to take theappropriate actions.

    9. The multiple alerts, repetitive MCAS activations, and distractions related tonumerous ATC communications were not able to be effectively managed.This was caused by the difficulty of the situation and performance in manualhandling, NNC execution, and flight crew communication, leading toineffective CRM application and workload management. Theseperformances had previously been identified during training and reappearedduring the accident flight.

  2. #362
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    Well those nine points do not say much about pilot error and a lot about “inappropriate” design and information. Away from the report more robust language would be appropriate, i think, and class actions seem likely now.
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

  3. #363
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    The 89 findings include several points about crew actions including the FO failing on memory items in the midst of the mess, and spotty communication between the Captain and FO.

  4. #364
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    Quote Originally Posted by profloater View Post
    Well those nine points do not say much about pilot error and a lot about “inappropriate” design and information. Away from the report more robust language would be appropriate, i think, and class actions seem likely now.
    Lawsuits began a while ago. Boeing has settled 11 of 17 from just one firm.

    This probably isn’t a case to justify taking a class-based approach. The plaintiffs who have filed can clearly demonstrate a harm vs. a class of those who may have experienced a harm (e.g. the Roundup class action). Put another way, the pool of plaintiffs is very well-defined.

    More litigation may come once Ethiopia releases its final report.

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    My takeaway is they pretty much spelled out the more obvious issues, and all that was added was some indication that there was previous training evidence that this flight crew might not handle a desperate crisis terribly well (that might be said for a lot of people). Also, it now appears that the AOA sensor did not break in flight, it was messed up from the start by the maintenance crew. Apparently, not only was the flight crew not well informed about this potentially catastrophic failure mode, neither was the maintenance crew. It would be easy to imagine whoever put that AOA in there saying they regret screwing up the sensor installation but they had no idea that one sensor, mounted incorrectly and avoiding detection of the miscalibration, could fly that plane into the ground. A lame excuse for incompetence, I grant you, but yet again it seems to have been Boeing's tendency to sweep under the rug the potential dangers designed into the MCAS that was as much at fault as the design flaws themselves. If you are going to opt for a questionable design, the worst thing you can do is try to distract attention from its shortcomings to avoid objections-- I would say that is the core lesson here.

  6. #366
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    I agree as an engineer, in fact I am amazed that a trim system could be allowed to depend on a mechanical flap that is known to be vulnerable with a second one not automatically alarmed when disagreeing. When aircraft rely on one primary system component, it is designed to be very unlikely to fail. Moving flaps that can be hit by birds or runway debris are just not in that class.
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

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    And are not even routinely tested for miscalibration! I can only conclude the maintenance crew was not informed about the essential nature of that equipment. Of course they should know that an instrument that tells you your angle of attack is a key system, but there are two such sensors, so they may have thought the system was redundant and that miscalibrations would be immediately known to the pilots. Sadly, such was not the case. That's what bothers me the most about all this, it's not just how badly the MCAS is undesigned, which one can argue is easy to say in hindsight-- it is the seemingly intentional effort to avoid detection of its underdesign. "Nothing to see here folks" seems to be Boeing's strategy about MCAS. I could wildly speculate that there is a memo somewhere that is a smoking gun in regard to the intention to conceal the issue. Something like that could be much worse for Boeing than just the grounded fleet.

  8. #368
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    AoA sensors have never been part of the core instrumentation. Pilots fly with a pitot, a gyro and baro. That's why some if the AoA functionality was an added extra. Boeing is certainly on the block for massively increasing its importance while trying to bury that change.

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    NPR (2 November, 2019): 3 Takeaways From 2 Days of Tense Boeing Congressional Hearings

    Chilling (though not entirely new):

    1) Boeing Knew MCAS Had a Problematic Single Point of Failure Two Years Before Max Was Cleared To Fly:

    It appears that one of the most glaring missteps in the design of the new flight control system was relying on information from just a single angle of attack (AoA) sensor for MCAS to activate. AoA sensors are small vanes on the nose of the plane that measure the pitch of the aircraft as moves into the headwind. If the the AoA senses that plane is pitched up too high, MCAS will automatically and repeatedly force the nose of the plane down. And that's exactly what happened to both planes that crashed, except the sensor was wrong. Indonesian investigators found a Lion Air maintenance crew installed a new, but faulty AoA sensor the day before the doomed flight, and failed to recalibrate it and test it.

    Experts say relying on just one sensor for a safety critical system is unheard of in aviation engineering.

    The House Transportation Committee released a redacted email during Wednesday's hearing showing Boeing knew this was a potential problem back in 2015, two years before the plane was cleared to fly by the FAA and three years before the first Max plane crash, as one engineer raised concerns about relying on just one sensor to trigger the system, writing "Are we vulnerable to single AOA sensor failures with the MCAS implementation or is there some checking that occurs?"

    Despite the concern, Boeing decided to stay with the single-sensor design, with no backup to prevent MCAS from forcing the plane into a nose dive.
    Will any senior Boeing heads roll? It seems unlikely ...

  10. #370
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    Quote Originally Posted by Jean Tate View Post
    NPR (2 November, 2019): 3 Takeaways From 2 Days of Tense Boeing Congressional Hearings

    Chilling (though not entirely new):

    Will any senior Boeing heads roll? It seems unlikely ...
    Happening already in form or another:

    VP of Commercial Airplanes Division ousted
    SEATTLE/WASHINGTON (Reuters) - Boeing Co on Tuesday ousted the top executive of its commercial airplanes division, Kevin McAllister, marking the first high-level departure since two fatal crashes of its 737 MAX jets.
    The company named veteran Boeing executive Stan Deal to succeed McAllister effective immediately as president and chief executive of Boeing Commercial Airplanes (BCA). Deal had led Boeing’s recently formed Global Services division.
    President Dennis Muilenberg loses chairmanship of Boeing
    With pressure mounting on the Boeing board and increased public concern about a need to revamp the company’s safety culture, the board on Friday took away Dennis Muilenburg’s role as company chairman, separating that position from his chief executive role.

    Muilenburg will remain CEO and president, and will stay on the board of directors, while lead director David Calhoun was elected to replace him as chairman.

    The move falls short of what some analysts have called for: Muilenburg’s ouster, along with some of the board, to give the company a jolt that would mark a culture shift away from the constant focus of recent years on the share price and cost cutting.
    And keep in mind that big companies often shuffle executives into roles with few - or no - responsibilities. A lot of that may be going on but not reaching the level of "news". That kind of shuffle is a way to not get sued by a company's own executives but is still a demotion. This may be an example:

    In March, Boeing said John Hamilton, formerly both vice president and chief engineer in Boeing's Commercial Airplanes division, will focus solely on the role of chief engineer.
    If you are expecting any kind of criminal proceedings against executives that is quite unlikely in the US.

    Plus pressure from the Hill:

    WASHINGTON (Reuters) - The chairman of the U.S. House Transportation and Infrastructure Committee on Friday said Boeing Co must shake-up its management team and Congress must reform how new airplanes are certified following the disclosure of internal messages about the 737 MAX involved in two deadly crashes.

    Representative Peter DeFazio, a Democrat, sharply criticized the largest U.S. airplane manufacturer after instant messages between a former senior pilot and another employee suggested the company may have unintentionally misled regulators and experienced significant issues with a key safety system known as MCAS tied to the two fatal crashes that led to the grounding of Boeing’s best-selling plane.

    “It goes far beyond one individual. They can’t hang him and say he’s responsible. This was cultural,” DeFazio said in a Reuters interview on Friday. “Boeing’s got to clean up its culture and I don’t think you can clean it up with the people who were in charge when this all unfolded.”

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    I really think managers should talk to their employees every day. Employees will tell managers about problems. The little and the big problems need to be solved every day. If a manager isn't fixing at least one problem every day, they will soon fall behind. I don't know what Boeing does, but I abhor when purchasing agents get bonuses for reducing costs. Otherwise, engineers are generally way under paid for the work that they do. There are only so many people who are really talented enough to be engineers. Engineers are no longer valued, finding the lowest cost supplier is what is valued. We could also stop with all the stupid fads, SPC, six sigma, just in time, ISO, etc. All these fads just get in the way of the tedious work of continually fixing problems every day.
    Last edited by Copernicus; 2019-Nov-04 at 11:57 AM.
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    This always gets me, especially now that we know how long at least some of the fatal flaws in MCAS etc were known within Boeing: "Safety is at the core of who we are at Boeing, and ensuring safe and reliable travel on our airplanes is an enduring value and our absolute commitment to everyone." (no prize for guessing who said that, publicly; hint: Mull...).

    How can he sleep at night?

  13. #373
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    Quote Originally Posted by Copernicus View Post
    I really think managers should talk to their employees every day. Employees will tell managers about problems. The little and the big problems need to be solved every day. If a manager isn't fixing at least one problem every day, they will soon fall behind. I don't know what Boeing does, but I abhor when purchasing agents get bonuses for reducing costs. Otherwise, engineers are generally way under paid for the work that they do. There are only so many people who are really talented enough to be engineers. Engineers are no longer valued, finding the lowest cost supplier is what is valued. We could also stop with all the stupid fads, SPC, six sigma, just in time, ISO, etc. All these fads just get in the way of the tedious work of continually fixing problems every day.
    In the middle part of my career I was often troubleshooting in big companies between managers and engineers and it was amazing how often the problems could be solved just by asking the people who actually handled the equipment.The larger the company, in general, the bigger the barriers in upward communication partly for fear of reprisal and partly because of the strong “us and them” ethic which develops. The other frequent problem was an over emphasis of specialisms taking precedence over generalists. Once one specialist team has pinned their theory on another specialist team as to a problem, they kind of stop thinking. There are established ways to avoid these problems and it makes me very sad to realise that a great company like Boeing could have fallen so far from good practice, as I feel the evidence has demonstrated that they have.
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

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    Also notice that most of the "shakeup" is just swapping jobs around, and it's easy to see it as appeasement rather than real change, we shall see. In any case, I'm sure they're all still making millions per year in salaries to make these kinds of decisions. McAllister seems to be the only one to leave the company, and I'll bet he gets hired as CEO somewhere else quite soon. It sure sounds like an "old boy network" that cashes in on these companies, and it's not obvious what kinds of special qualifications they bring-- if this is a measure of the kind of leadership they provide.

  15. #375
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    Quote Originally Posted by profloater View Post
    In the middle part of my career I was often troubleshooting in big companies between managers and engineers and it was amazing how often the problems could be solved just by asking the people who actually handled the equipment.The larger the company, in general, the bigger the barriers in upward communication partly for fear of reprisal and partly because of the strong “us and them” ethic which develops. The other frequent problem was an over emphasis of specialisms taking precedence over generalists. Once one specialist team has pinned their theory on another specialist team as to a problem, they kind of stop thinking. There are established ways to avoid these problems and it makes me very sad to realise that a great company like Boeing could have fallen so far from good practice, as I feel the evidence has demonstrated that they have.
    I don't really know if part of the problem isn't that there are very few manufacturers of commercial airplanes. Too easy to consolidate all companies into a few. Too easy for the CEO's to recommend board members, and board members to recommend CEO's.
    What are the ways to circumvent large corporation problems?
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  16. #376
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    Quote Originally Posted by Copernicus View Post
    I don't really know if part of the problem isn't that there are very few manufacturers of commercial airplanes. Too easy to consolidate all companies into a few. Too easy for the CEO's to recommend board members, and board members to recommend CEO's.
    What are the ways to circumvent large corporation problems?
    Given that secrecy is often important, the corporation needs a team which exists outside of the normal hierarchy structure, reports directly to the CEO and has the authority to make internal investigations. Obviously the choice of this team is critical, they need to be experienced within the company and they need to feel truly independent. Some might be retired or Others can be selected for their Maverick or general knowledge skills. In the end their reports can still get suppressed by the CEO. But the most important role these people have is to pick up issues from the shopfloor or in this case from the pilots and package them directly to the CEO bypassing the various vested interests so that more detailed investigations can be started. Consultants can often fill this role and meet the requirements of secrecy having the benefit of no career path within the large company. If the CEO Does not have the confidence to use an independent team or has issues to hide, then the company is in big trouble from the top. The adage, too big to fail, gets applied but cannot be relied upon in every case.
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

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    Oh no! Now questions about Oxygen on the Dreamliner from a retired engineer, says the BBC news today. Has this hit the USA news?
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

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    Ugh. The corporate culture there has really gone bad.
    Cum catapultae proscriptae erunt tum soli proscript catapultas habebunt.

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    More bad news for Boeing?
    https://www.dailymail.co.uk/news/art...ging-wing.html

    Fuselage skin ripped wide open just behind the 777X wing in September during a stress test at Boeing's Washington hub
    The plane's aluminum skin buckled and ruptured then due to 'depressurization of the aft fuselage, the structure that supports the door blew off' a source said
    Also,

    An FAA source said it's unlikely Boeing will have to do another test as the disaster occurred with only 1% of the stress test left
    They said the margin could be covered by using computer analysis to prove how they'll cover the vulnerability
    Surely it failed the test even if it was at 99% load. If there is a line drawn, what use is there in moving the line when you don't reach it?

    Apologies for the link to the daily wail.

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    Angry

    Quote Originally Posted by Copernicus View Post
    I want to mention that I work in healthcare now, and the quality standards in healthcare are magnitudes lower than manufacturing.
    Are you sure about that??
    Seems that at the end of 2019, it seems that the manufacturing standards are considerably lower...
    As in 'it got off the ground once, so it's perfect' from the management side...
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    Quote Originally Posted by Trebuchet View Post
    Just watched that. Very good, other than his annoying editing.

    I'm the guy that shrunk the wheels. Damn.
    (hugs)
    Although to be honest, the shrinking wheels didn't make any real difference- hell even if they had been 4ft in diameter, it is doubtful they would have been any better in pitching the nose up- those wheels were 'stuck' and stuck bad...
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    It is scary that it is now December- and the max is still months away from flying (and the delay makes non US regulators even more nervous- any attempt to 'push' a 'quick release' is likely to see it flying in in the US and there only... )
    plus the damage to the FAA is immense- many overseas are literally if it comes from the FAA, I want to see independent proof- for things as small as a simple battery charger for a Cessna, there is simply no trust anymore- its automatically assumed that a FAA approval is proof it IS probably defective- it just hasn't been found out yet...
    the fallout could remain for decades..
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  23. #383
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    Quote Originally Posted by boppa View Post
    It is scary that it is now December- and the max is still months away from flying (and the delay makes non US regulators even more nervous- any attempt to 'push' a 'quick release' is likely to see it flying in in the US and there only... )
    plus the damage to the FAA is immense- many overseas are literally if it comes from the FAA, I want to see independent proof- for things as small as a simple battery charger for a Cessna, there is simply no trust anymore- its automatically assumed that a FAA approval is proof it IS probably defective- it just hasn't been found out yet...
    the fallout could remain for decades..
    But a good part of the outcome is a shake up of FAA and other authorities. I hope it shakes up Boeing too, of all industries, the aircraft industry has been good at learning from crashes, usually in technology changes but this time in management structure, ranks and roles. There must be a role for engineering sign off which can resist the pressure of commercial needs.
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

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