Lion Air Report

[Ciaphas]

Yes, very odd.  Always made sense to make sure it was pinned and safe before sitting on one or getting up off it.  Has a pilot ever explained why?

They're pilots, they don't have to explain (enter the culture of arrogance).

At Columbus afb, we had a seat fire on the hammerhead. It injured some MX (egress) guys. The pilot said his initiators were partially pulled. He also stated the only thing he did was turn to look over his shoulder and   when he returned to forward position his initiator were in  an unsafe config. The odd thing about this incident is it takes roughly 35 lbs of force to unseat the ejection control handle and up to 55lbs of force to unseat the initiator firing sears(sp?).  turning to look over your shoulder is not going to produce that kind of force. This was in a Talon with a MK16 ESUP seat installed.

We have numerous pilots calling unsafe seat conditions because they cannot get their seat pin installed. Every incident has been caused by the pilot slouching in his seat putting forward force in the control handle which prevents proper alignment of safety pin holes. Once we get them to sit back in their seats, the pins slide right in.


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[FLS]

- a system whose failure was eventually qualified as 'hazardous' could have a single point of failure (a single AOA vane)

It's a redundant system. You can turn it off and fly the airplane.


- documentation of the system was minimal (before the 1st crash)

Minimal does not mean insufficient.

- 737 MAX simulators couldn't adequately replicate MCAS activation

The simulators can still train the correct response without the actual force feedback.

- after the 1st crash, a service bulletin informing airlines was released stating that the MCAS could deflect the tail in increments up to 2.5°, up from the 0.6° told to the FAA in the safety assessment

The speed was increased later, the speed given the FAA was correct at the time.


- MCAS could reset itself after each pilot response to repeatedly pitch the aircraft down

There are two switches. One that resets and one that turns it off. Training is to turn it off.

- no provision to deactivate the MCAS system was made other than by completely shutting down the non-malfunctioning electrical trim system

The MCAS is a part of the trim system just like the malfunctioning AOA gauge is part of the system. Regardless of which part fails you deal with it by turning it off.

There is no reason to blame Boeing for anything except a lame PR response.

[Busher]

There is no reason to blame Boeing for anything except a lame PR response.

I agree. It confused me from the beginning why Boeing behaved like the guilty party - especially in the absence of a detailed professional investigation. It's fine to be sympathetic that people died in your product but wait until all causal elements are determined before letting the PR Department talk.

[saggs]

Can somebody explain to me how somebody that lacks basic skills can up and land several hundred times. Shouldn't they have had crashed the first time?

Look at the Asiana 214 crash.  With the routes they flew the crew was far to dependent on automation. When the SFO ILS was down and they had to actually fly a visual approach... they crashed.  Reports was that that crew had never actually flown a visual approach in that type.

[Mister Fork]

Look at the Asiana 214 crash.  With the routes they flew the crew was far to dependent on automation. When the SFO ILS was down and they had to actually fly a visual approach... they crashed.  Reports was that that crew had never actually flown a visual approach in that type.

And that correlated to my previous point. Third world airlines are hiring mindless monkeys to fly their airplanes, completely dependent on the automated flight control systems. One issue - they have ZERO experience in how to actually fly the damn plane without the automated nanny FCS. Push button monkeys.

[Oldman731]

And that correlated to my previous point. Third world airlines are hiring mindless monkeys to fly their airplanes, completely dependent on the automated flight control systems. One issue - they have ZERO experience in how to actually fly the damn plane without the automated nanny FCS. Push button monkeys.

Which is sad, of course.  But Langewiesche the Younger, in his article on the Lionair crash, points out that it's a reality that will be with us for a long while, as air travel increases and the number of experienced pilots decreases.  For example, I know a young lawyer in over in New Jersey who had been a first officer on a small airline.  I asked him what it was like to fly the big planes.  He replied that he was pretty good at working the autopilot, and that was about it.  Bottom line seems to be that the automated nanny equipment is increasingly vital.

- oldman

[Busher]

Some North American airlines, recognizing that the automation is not fail safe, have instituted training programs to enhance basic operating skills - stick and rudder flying. Unfortunately that policy does not yet seem to be widely encouraged by managements nor by ALPA.

[Vraciu]

For the Nth times: it is possible to raise eyebrows at Boeing's implementation of the MCAS in the 737 MAX (*) while acknowledging that other factors played key roles in both crashes, and that the Lion Air's report is biaised.

So yes, with competent crews and an adequate safety culture (more to that later), the AOA vane incidents wouldn't probably have turned into disasters.

But Boeing decided that:

- a system whose failure was eventually qualified as 'hazardous' could have a single point of failure (a single AOA vane)
- documentation of the system was minimal (before the 1st crash)
- 737 MAX simulators couldn't adequately replicate MCAS activation
- after the 1st crash, a service bulletin informing airlines was released stating that the MCAS could deflect the tail in increments up to 2.5°, up from the 0.6° told to the FAA in the safety assessment
- MCAS could reset itself after each pilot response to repeatedly pitch the aircraft down
- no provision to deactivate the MCAS system was made other than by completely shutting down the non-malfunctioning electrical trim system

which is not demonstrating a stellar 'safety culture' at their level. Safety Culture was coined in INSAG-1 summary report of Chernobyl's disaster. In this report, and in the INSAG-7 update report, you'll find this sentence: "Nuclear plant designs must be as far as possible invulnerable to operator error and to deliberate violation of safety procedure". So, a safe design must plan for stupidity and incompetence. Not to allow it to thrive, but to shield from it when (not if) it happens.

So yes, some air companies in some part of the world operate under standards not acceptable in the western world, and the rate of accidents demonstrates the difference. However, even if not quite so often, some grave operator errors happen in the western companies too: American Airlines 587, Air France 447, Colgan Air 3407... In some of those crashes, disaster would have been avoided if the crews had just left the plane fly by itself. This was not a solution in the situation leading to both MCAS related crashes.

Instead of fuming at the 'unfair' treatment of poor little Boeing, I personally hope that this will kick the company back on the track towards the safety level it was renowned for. And I also hope that the selection and training of flight crews will improve and not be allowed to deteriorate further.

(*) a previous and different form of MCAS is installed on the KC 46. This system takes input on dual redundant angle of attack sensors; it will disengage with stick input by the pilot.

It was a stab trim runaway.   The cause is irrelevant.   An AOA vane “issue” isn’t required for it to occur.  The solution remains the same.   

Also, Lion Air equipped the airplane that way when additional equipment was available.   They didn’t want it.   They cheap-ass their airplanes just like they cheap-ass their training and maintenance.    Had they not dispatched an airplane with a known defect we wouldn’t be having this discussion.    However, in Africa, broken airplanes are accepted as SOP.   Until you fix that culture all the AOA vanes in the world won’t help you. 


Also, the notion it can’t be trained is crap.   I just finished a 737 NG SIC course and one of the training events included a surprise nose down trim runaway on takeoff caused by the STS, which is the poor-man’s MCAS.   Follow the procedure and it’s a piece of cake. 

[Busher]

Vraciu, if you don't mind me asking, did you make a career change leading to the Boeing type endorsement?

[Vraciu]

Vraciu, if you don't mind me asking, did you make a career change leading to the Boeing type endorsement?

I did, however, I may wind up making another one shortly.  This industry is insane right now.   I could wind up on anywhere from one to three airplane types at once.  I'm working to catch up on my retirement now that I am finally out of debt.

[Busher]

I did, however, I may wind up making another one shortly.  This industry is insane right now.   I could wind up on anywhere from one to three airplane types at once.  I'm working to catch up on my retirement now that I am finally out of debt.

I never had the chance..... too old when they went nuts for pilots.... but I would have liked to go to Emirates International. 2 F/O's I mentored went there. They'll retire in a couple of years, still under 50 and multi millionaires. Have you considered them?

[Vraciu]

I never had the chance..... too old when they went nuts for pilots.... but I would have liked to go to Emirates International. 2 F/O's I mentored went there. They'll retire in a couple of years, still under 50 and multi millionaires. Have you considered them?

I'm too much of a Texan to go to Emirates I think.   I have fought my entire career to stay close to home.  My roommate from flight school (I'm in my mid-forties and he is a bit younger so I acted as a mentor through most of his career) is a 777 Captain there.   Guy is loaded but he's also flying his tail off.   I don't want to fly 1000 hours a year.  Anything more than about 250 is too much work from my standpoint.  LOL 

If I could find a good gig flying a Legacy 650 full-time I'd jump at that over anything the airlines are offering.   Unfortunately, the average Corporate/Charter job lasts about three years before you get laid off so if stability is the goal then the airlines probably offer that better than anyone else.

I'm rambling.   I still don't know what I want to be when I grow up.    I guess I'm holding out for that dream job--again.   I've finally decided to stop chasing rainbows and this 737 thing is definitely not what I want to do for the rest of my career, so I am throwing hooks into the water to see what bites.   

I'll actually be up in Montreal next week to pick up a Legacy for its conformity/demo flights.   Really looking forward to that.

[Busher]

I'm too much of a Texan to go to Emirates I think.   I have fought my entire career to stay close to home.  My roommate from flight school (I'm in my mid-forties and he is a bit younger so I acted as a mentor through most of his career) is a 777 Captain there.   Guy is loaded but he's also flying his tail off.   I don't want to fly 1000 hours a year.  Anything more than about 250 is too much work from my standpoint.  LOL 

If I could find a good gig flying a Legacy 650 full-time I'd jump at that over anything the airlines are offering.   Unfortunately, the average Corporate/Charter job lasts about three years before you get laid off so if stability is the goal then the airlines probably offer that better than anyone else.

I'm rambling.   I still don't know what I want to be when I grow up.    I guess I'm holding out for that dream job--again.   I've finally decided to stop chasing rainbows and this 737 thing is definitely not what I want to do for the rest of my career, so I am throwing hooks into the water to see what bites.   

I'll actually be up in Montreal next week to pick up a Legacy for its conformity/demo flights.   Really looking forward to that.

I feel your pain Sir. In the 1960's I chased airplanes across this continent; did the Corporate Flying thing a little (usually until the Boss's latest squeeze decided she liked yachts more than Lear jets); and finally to the airline to do as you say, 1000 hours a year for 32+ years.
All in all, a good career but in hindsight, I should have gone to veterinary school

[Vraciu]

I feel your pain Sir. In the 1960's I chased airplanes across this continent; did the Corporate Flying thing a little (usually until the Boss's latest squeeze decided she liked yachts more than Lear jets); and finally to the airline to do as you say, 1000 hours a year for 32+ years.
All in all, a good career but in hindsight, I should have gone to veterinary school

You said it all right there, my friend.   Looks like history repeats itself.   

[Toad]

All in all, a good career but in hindsight, I should have gone to veterinary school

LOL! I was pre-med in college with vet school in mind. But I was also AFROTC and wanted to fly jets. Like you, I should have gone to vet school.

But yeah, I had a fairly good career, so...whatever. Sliding down the backside now. Tis what it tis.