Ethiopian Air ET302, Boeing 737 crashes - 157 souls - 10 March 2019

The black box from the doomed Ethiopian Airlines plane showed 'clear similarity' to the Lion Air crash near Indonesia in October last year, Ethiopia's transport minister has revealed.

While declining to give details today, Dagmawit Moges said the parallels would be the 'subject of further study during the investigation,' with a preliminary report issued in '30 days'.

Ethiopians hold mass funeral for plane crash victims as 17 empty caskets are escorted through street | Daily Mail Online

This is not good news for Boeing.
 
Flawed analysis, failed oversight: How Boeing, FAA certified the suspect 737 MAX flight control system

SBM

Current and former engineers directly involved with the evaluations or familiar with the document shared details of Boeing’s “System Safety Analysis” of MCAS, which The Seattle Times confirmed. The safety analysis:
  • Understated the power of the new flight control system, which was designed to swivel the horizontal tail to push the nose of the plane down to avert a stall. When the planes later entered service, MCAS was capable of moving the tail more than four times farther than was stated in the initial safety analysis document.
  • Failed to account for how the system could reset itself each time a pilot responded, thereby missing the potential impact of the system repeatedly pushing the airplane’s nose downward.
  • Assessed a failure of the system as one level below “catastrophic.” But even that “hazardous” danger level should have precluded activation of the system based on input from a single sensor — and yet that’s how it was designed.
The people who spoke to The Seattle Times and shared details of the safety analysis all spoke on condition of anonymity to protect their jobs at the FAA and other aviation organizations.

Both Boeing and the FAA were informed of the specifics of this story and were asked for responses 11 days ago, before the second crash of a 737 MAX last Sunday.

SBM
 
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Flawed analysis, failed oversight: How Boeing, FAA certified the suspect 737 MAX flight control system

SBM

Current and former engineers directly involved with the evaluations or familiar with the document shared details of Boeing’s “System Safety Analysis” of MCAS, which The Seattle Times confirmed. The safety analysis:
  • Understated the power of the new flight control system, which was designed to swivel the horizontal tail to push the nose of the plane down to avert a stall. When the planes later entered service, MCAS was capable of moving the tail more than four times farther than was stated in the initial safety analysis document.
  • Failed to account for how the system could reset itself each time a pilot responded, thereby missing the potential impact of the system repeatedly pushing the airplane’s nose downward.
  • Assessed a failure of the system as one level below “catastrophic.” But even that “hazardous” danger level should have precluded activation of the system based on input from a single sensor — and yet that’s how it was designed.
The people who spoke to The Seattle Times and shared details of the safety analysis all spoke on condition of anonymity to protect their jobs at the FAA and other aviation organizations.

Both Boeing and the FAA were informed of the specifics of this story and were asked for responses 11 days ago, before the second crash of a 737 MAX last Sunday.

SBM

Wow. Law$uit$!
 
I hit a paywall at the WSJ link but Fox is covering it too:
Each time the MCAS is triggered, it can be overridden by a pilot. However, the MCAS can reset itself each time, too, which allows it "unlimited authority," one current FAA safety engineer said, according to the Seattle Times.
Boeing, FAA questioned about safety of 737 MAX safety system days before Ethiopian Airlines crash
Which we already knew. But there was a procedure to stop the process. In the Lion Air crash pilots flying that same plane the day before had been able to override the MCAS.

Boeing's Bulletin TBC-19 from November 6 (regarding the Lion Air crash) stated the system could be disengaged by the cutout switches:
Repetitive cycles of uncommanded nose down stabilizer continue to occur unless the stabilizer trim system is deactivated through use of both STAB TRIM CUTOUT switches in accordance with the existing procedures in the Runaway Stabilizer NNC. It is possible for the stabilizer to reach the nose down limit unless the system inputs are counteracted completely by pilot trim inputs and both STAB TRIM CUTOUT switched are moved to CUTOUT.
So are officials saying that the procedure failed in the Ethiopian Air crash? Or are they saying the pilot failed to disengage both cutout switches?

In any case I'm glad to see this investigation into Boeing and the FAA. As I understand it the redesigned 737 was nose heavy so Boeing compensated by installing the MCAS which ultimately led to the FAA certifying the MAX.

A little history on the MAX test flights:
2017 https://www.bizjournals.com/seattle...halts-737-max-testing-cfm-leap-1b-engine.html
March 2018 Boeing's new 737 MAX 7 completes first successful test flight
In depth article (regarding the Lion Air crash) from November 2018 Boeing’s New Jet Hit Problem in Tests Before Fatal Crash
 
I hit a paywall at the WSJ link but Fox is covering it too:
So are officials saying that the procedure failed in the Ethiopian Air crash? Or are they saying the pilot failed to disengage both cutout switches?
Thanks for the informative post. In regards to the Ethiopian crash, it might be too early to tell as I don't think the black box has been fully analyzed.

Your sources also demonstrate errors in a previous article. The article gave the impression that once the system engaged itself, the pilot needed to constantly over ride the system, thus increasing the possibility of a pilot verse auto pilot "war" over control of the plane. Rather, it seems possible to totally disengage the system and that Boeing informed airlines of this ability.

I think there is a good possibility of the plane being inherently safe in the hands of well trained flight crews whose training includes a lot of access to advanced simulators, follow on training, and mentoring from senior pilots long experienced with the plane design. And, of course, their airline timely informs pilots of all safety bulletins and amendments to flight manuals- then provides training to the new standard etc.

But.... the level of pilot training and technical expertise of Boeing customers can vary considerably. There seems to be a chance that the autopilot / sensors can be very unforgiving in the hands of lesser trained flight crews and technicians.

If this is the case, the primary responsibility would seem to be with the customer to operate the purchased equipment safely. Yet it would also seem that Boeing also has a duty to be aware of these variances in training and to design auto pilots and automated safety features accordingly with clearly explained over rides and clear indicators of what automated feature is engaged and what sub feature is doing what.
 
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Pilots complained to authorities about issues with the Boeing 737 Max for months before the deadly Ethiopian Airlines crash

"At the heart of the controversy surrounding the 737 Max is MCAS, the Maneuvering Characteristics Augmentation System," Business Insider transportation correspondent Benjamin Zhang wrote.

"To fit the Max's larger, more fuel-efficient engines, Boeing had to redesign the way it mounts engines on the 737. This change disrupted the plane's center of gravity and caused the Max to have a tendency to tip its nose upward during flight, increasing the likelihood of a stall," Zhang said.

"MCAS is designed to automatically counteract that tendency and point the nose of the plane downward."

Catching up.

Holy crud. Now it makes more sense why they had installed the automatic anit-stall feature (that is causing issues in itself).

After reading the above I am never flying one of these ever. In the last disaster I have always felt they just need to disconnect the new anti-stall feature because its causing so much trouble but after reading above I now see why they put it in. They hid that fact from us in the first crash because they made it sound like a neat cool new feature but now I am learning it was put in because the whole plane is not balanced right to begin with.

Good grief. Im staying away from these planes at booking time. Even if it means I have to fly with another airline or pay more or go out of my way.

This is unbelievable.

As I have said in the past.
"The new anti-stall feature that kills".

Permanently disconnect the darn new feature and then rebalance that plane. Let pilots do their job and fly the plane like they are supposed to.
 
Flawed analysis, failed oversight: How Boeing, FAA certified the suspect 737 MAX flight control system

SBM

Current and former engineers directly involved with the evaluations or familiar with the document shared details of Boeing’s “System Safety Analysis” of MCAS, which The Seattle Times confirmed. The safety analysis:
  • Understated the power of the new flight control system, which was designed to swivel the horizontal tail to push the nose of the plane down to avert a stall. When the planes later entered service, MCAS was capable of moving the tail more than four times farther than was stated in the initial safety analysis document.
  • Failed to account for how the system could reset itself each time a pilot responded, thereby missing the potential impact of the system repeatedly pushing the airplane’s nose downward.
  • Assessed a failure of the system as one level below “catastrophic.” But even that “hazardous” danger level should have precluded activation of the system based on input from a single sensor — and yet that’s how it was designed.
The people who spoke to The Seattle Times and shared details of the safety analysis all spoke on condition of anonymity to protect their jobs at the FAA and other aviation organizations.

Both Boeing and the FAA were informed of the specifics of this story and were asked for responses 11 days ago, before the second crash of a 737 MAX last Sunday.

SBM

Wow. Just wow.

So the plane is not balanced right to begin with because of the different engines used, and instead of fixing that balance problem and designing the plane properly to handle the new engines, they instead create a "patch" and call it a new anti-stall feature to hide the fact it was put on to fix the known balancing issues they encountered with the new engines .

How in the world did any of this get approved is beyond me. I have lost all faith in this particular aircraft.
 
Thanks for the informative post. In regards to the Ethiopian crash, it might be too early to tell as I don't think the black box has been fully analyzed.

Your sources also demonstrate errors in a previous article. The article gave the impression that once the system engaged itself, the pilot needed to constantly over ride the system, thus increasing the possibility of a pilot verse auto pilot "war" over control of the plane. Rather, it seems possible to totally disengage the system and that Boeing informed airlines of this ability.

I think there is a good possibility of the plane being inherently safe in the hands of well trained flight crews whose training includes a lot of access to advanced simulators, follow on training, and mentoring from senior pilots long experienced with the plane design. And, of course, their airline timely informs pilots of all safety bulletins and amendments to flight manuals- then provides training to the new standard etc.

But.... the level of pilot training and technical expertise of Boeing customers can vary considerably. There seems to be a chance that the autopilot / sensors can be very unforgiving in the hands of lesser trained flight crews and technicians.

If this is the case, the primary responsibility would seem to be with the customer to operate the purchased equipment safely. Yet it would also seem that Boeing also has a duty to be aware of these variances in training and to design auto pilots and automated safety features accordingly with clearly explained over rides and clear indicators of what automated feature is engaged and what sub feature is doing what.
I think you hit the nail on the head across the board. The story seems to go:

Airlines wanted more fuel efficient planes. Airbus came out with one (Airbusneo) and Boeing decided to compete with it by redesigning a 737.

Boeing's design called for bigger, heavier engines that had to be placed differently, in part because the ground clearance is small to begin with so the new engines had to be moved up. This created a stability issue.

The airlines don't like paying for pilot training so Boeing thought the MAX was close enough to prior 737s that little or no training would be required. The airlines liked that.

In order for the FAA to certify the MAX Boeing had to incorporate the MCAS. In their wisdom they felt all that was needed to to make a note in the manual without flagging it to pilots' attention.

Competent pilots were able to handle it, including when it made errors. Other pilots, who were basically fast-tracked on simulators and very little hands-on (manual) flight experience had a problem. The Lion Air crash was an example.

So after the Lion Air crash Boeing issued Bulletin TBC-19 to further explain the procedure to cut off the stabilizer trim and began "considering" whether a software update would be needed; if so then it would take 6-8 weeks to complete. That would put it to about the end of January.

However:
Boeing and federal officials have denied reports that a software update started after the October crash and now set to be released as soon as April was delayed because of the government shutdown earlier this year.
The Seattle Times says it identified flaws in an internal safety analysis of the 737 Max's MCAS software and had presented them to Boeing and the Federal Aviation Administration four days before the second fatal crash in five months involving the plane model.
Boeing and the FAA were reportedly told about issues with the 737 Max software 4 days before the plane's 2nd deadly crash

Here's the Seattle Times article - a definite must read. They notified Boeing and the FAA after a safety analysis they had done before the Ethiopian Air crash.
Flawed analysis, failed oversight: How Boeing, FAA certified the suspect 737 MAX flight control system
There's so much more but it would take a novella to cover it all.
 
“In the aftermath of the crash, officials at the unions for both American and Southwest Airlines pilots criticized Boeing for providing no information about MCAS, or its possible malfunction, in the 737 MAX pilot manuals.

An FAA safety engineer said the lack of prior information could have been crucial in the Lion Air crash.

Boeing’s safety analysis of the system assumed that ‘the pilots would recognize what was happening as a runaway and cut off the switches,’ said the engineer. ‘The assumptions in here are incorrect. The human factors were not properly evaluated.’”

“Boeing also plans to update pilot training requirements and flight crew manuals to include MCAS.

These proposed changes mirror the critique made by the safety engineers in this story. They had spoken to The Seattle Times before the Ethiopian crash.”

Flawed analysis, failed oversight: How Boeing, FAA certified the suspect 737 MAX flight control system
 
Flawed analysis, failed oversight: How Boeing, FAA certified the suspect 737 MAX flight control system

SBM

Current and former engineers directly involved with the evaluations or familiar with the document shared details of Boeing’s “System Safety Analysis” of MCAS, which The Seattle Times confirmed. The safety analysis:
  • Understated the power of the new flight control system, which was designed to swivel the horizontal tail to push the nose of the plane down to avert a stall. When the planes later entered service, MCAS was capable of moving the tail more than four times farther than was stated in the initial safety analysis document.
  • Failed to account for how the system could reset itself each time a pilot responded, thereby missing the potential impact of the system repeatedly pushing the airplane’s nose downward.
  • Assessed a failure of the system as one level below “catastrophic.” But even that “hazardous” danger level should have precluded activation of the system based on input from a single sensor — and yet that’s how it was designed.
The people who spoke to The Seattle Times and shared details of the safety analysis all spoke on condition of anonymity to protect their jobs at the FAA and other aviation organizations.

Both Boeing and the FAA were informed of the specifics of this story and were asked for responses 11 days ago, before the second crash of a 737 MAX last Sunday.

SBM
Hey, squid!

I see I duplicated what you had already posted. Sorry. I did a St. Patrick's gig last night and apparently was too bleary-eyed this morning to properly read the new posts.

But that Seattle Times article is worth mentioning twice. NPR also did an interesting interview with a pilot from the Allied Pilots Association:
American Pilots Union Assesses Boeing's Ability To Keep Its Planes Safe

I read a well-informed post written by a longtime 737 pilot but I don't think I can put a link here since it was on another forum. But one thing he wrote about was the time it could take to make corrections and how that could be difficult to impossible when the plane is so close to the ground. It gave me some food for thought.
 
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The former head of France’s aviation accident investigation bureau told CNN that he saw flaws in the system. "I think the design of this system is not satisfactory as it relies on only one sensor. In case this sensor fails, of course the system doesn’t work. And in this case it could be difficult for the pilot to overreact to the system.”

Ethiopian Accident Investigation Bureau intends to release a preliminary report within 30 days.

Experts say there were similarities in the Ethiopian Airlines crash and the Lion Air crash. What were some of them? - CNN
 
Wow. Just wow.

So the plane is not balanced right to begin with because of the different engines used, and instead of fixing that balance problem and designing the plane properly to handle the new engines, they instead create a "patch" and call it a new anti-stall feature to hide the fact it was put on to fix the known balancing issues they encountered with the new engines .

How in the world did any of this get approved is beyond me. I have lost all faith in this particular aircraft.

Good way to describe it. I was thinking along the lines of "so they designed a crappy aircraft and threw some software on it to make it work" (MOO), but your description is a bit more mature. We fly a lot and I've never been scared of any aircraft, small to big. My eldest almost has her pilot's license. No way in H E double hockey sticks will I set foot on one of these ever. I'm very curious to see how this is all going to play out.

All JMO
 
Statement from Boeing CEO CEO Dennis Muilenburg

“We know lives depend on the work we do, and our teams embrace that responsibility with a deep sense of commitment every day. Our purpose at Boeing is to bring family, friends and loved ones together with our commercial airplanes—safely. The tragic losses of Ethiopian Airlines Flight 302 and Lion Air Flight 610 affect us all, uniting people and nations in shared grief for all those in mourning. Our hearts are heavy, and we continue to extend our deepest sympathies to the loved ones of the passengers and crew on board.

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. This overarching focus on safety spans and binds together our entire global aerospace industry and communities. We’re united with our airline customers, international regulators and government authorities in our efforts to support the most recent investigation, understand the facts of what happened and help prevent future tragedies. Based on facts from the Lion Air Flight 610 accident and emerging data as it becomes available from the Ethiopian Airlines Flight 302 accident, we’re taking actions to fully ensure the safety of the 737 MAX…

Boeing has been in the business of aviation safety for more than 100 years, and we’ll continue providing the best products, training and support to our global airline customers and pilots. This is an ongoing and relentless commitment to make safe airplanes even safer…

…Our entire team is devoted to the quality and safety of the aircraft we design, produce and support. I’ve dedicated my entire career to Boeing, working shoulder to shoulder with our amazing people and customers for more than three decades, and I personally share their deep sense of commitment. Recently, I spent time with our team members at our 737 production facility in Renton, Wash., and once again saw firsthand the pride our people feel in their work and the pain we’re all experiencing in light of these tragedies. The importance of our work demands the utmost integrity and excellence—that’s what I see in our team, and we’ll never rest in pursuit of it.”

Letter from Boeing CEO Dennis Muilenburg to Airlines, Passengers and the Aviation Community
 
That is terrible I thought the crash site was protected by the men with guns I saw.

Even if a plane crashed in the US where the authorities could not get to it quickly, there is no way anyone culturally here would even think about looting something like this. In other countries, especially ones where they are so poor, any opportunity to get something to sell is taken. Just a cultural and economic thing I think.

Sometimes the police squads are corrupt too.
 
Statement from Boeing CEO CEO Dennis Muilenburg

Typical corporate executive response to a major incident...carefully worded to acknowledge but avoid taking direct responsibility. Talks about the pride his "people feel in their work" when the investigation into this horrible tragedy has just kicked off. Totally self-serving IMO.
 
Typical corporate executive response to a major incident...carefully worded to acknowledge but avoid taking direct responsibility. Talks about the pride his "people feel in their work" when the investigation into this horrible tragedy has just kicked off. Totally self-serving IMO.

I agree with you entirely.
 
As the Lion Air crew fought to control their diving Boeing 737 Max 8 on Oct 28, they got help from an unexpected source: an off-duty pilot who happened to be riding in the cockpit.

That extra pilot, who was seated in the cockpit jumpseat, correctly diagnosed the problem and told the crew how to disable a malfunctioning flight-control system and save the plane, according to two people familiar with Indonesia's investigation.

However, the next day, under command of a different crew facing what investigators said was an identical malfunction, the jetliner crashed into the Java Sea, killing all 189 aboard.

Pilot who hitched a ride had saved Lion Air's 737 Max jet the day before its doomed flight

It is absolutely tragic that the people on this flight were saved and the people on the flight the next day were not. I just wish the plane had been grounded after this flight.
 

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