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Cockpit voice recorder of Lion Air jet depicts pilots' frantic search for fix

reuters.com

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Re: Cockpit voice recorder of Lion Air jet depicts pilots' frantic search for fix

#221

Post by js2 »

VBprogrammer wrote: post #206
_s wrote: post #188

Earlier quoted context omitted.

I think context is what helps - - I’ve just taken off, and am going through the after take off checklist: Set the airspeed, power, climb rate, heading, talking to ATC, planning the next stage of the flight - Perhaps I’ve just raised the flaps and the plane starts behaving erratically - My first / immediate thought is that my previous action led to an undesired aircraft state. - I work from that point on - I touch the…

> - My first / immediate thought is that my previous action led to an undesired aircraft state. FYI This is shown in the Lion air preliminary report. They select flaps 0 (from flaps 5) and a few seconds later reselect flaps 5. Unfortunately a while after that they decide to go to flaps 0 again. With any flaps selected the MCAS system is disabled.

This must have been mighty confusing without knowing about MCAS. It’s like trying to fly a black box instead of flying a plane.

Re: Cockpit voice recorder of Lion Air jet depicts pilots' frantic search for fix

#222

Post by [deleted] »

rsync wrote: post #168
bookofjoe wrote: post #55

Best book I've ever read on the root cause ("tight coupling") of accidents: https://en.wikipedia.org/wiki/Normal_Accidents From its Wikipedia entry: >"Normal Accidents: Living with High-Risk Technologies" is a 1984 book by Yale sociologist Charles Perrow, which provides a detailed analysis of complex systems from a sociological perspective. It was the first to "propose a framework for characterizing complex technolog…

I cannot recommend this book enough. I will also point out that some sections of it are highly entertaining. In fact, the tanker collision chapter is laugh-out-loud funny.

[deleted]

Re: Cockpit voice recorder of Lion Air jet depicts pilots' frantic search for fix

#223

Post by gojomo »

michaelt wrote: post #60
gojomo wrote: post #7

Earlier quoted context omitted.

That's the most amazing revelation to me so far. The same plane had an identical uncontrolled-dive problem the day before, which required an emergency power cut to the improperly-engaged motor, and somehow that incident didn't ground the plane or even result in any effective advisory to the next crew. Further, the Bloomberg story reports: "The Indonesia safety committee report said the plane had had multiple failures…

The same plane had an identical uncontrolled-dive problem the day before, [...] and somehow that incident didn't ground the plane or even result in any effective advisory to the next crew. This is the problem with the Boeing blame-the-pilots-for-not-switching-the-stab-trim-cutout-switches approach. If the pilots fear near misses will be called pilot error, and they'll be called incompetent/dangerous or punished for e…

Not sure that follows, either theoretically or practically. Non-reporting of any observed aircraft issues puts their fellow pilots, and all other passengers, in grave risk.

A tiny shred of mutual respect for other flight crews, or for human life of passengers in general, should easily overwhelm any concern an anomaly report will harm their record.

In this case, the prior crew could've reported the problem, and their successful resolution. There's little risk of an actual malfunction requiring the emergency disengagement of normal systems being mislabeled "pilot error", especially when they made a proper recovery according to trained procedures.

For all I know, the crew did make this report, but the report failed to have the necessary impacts, in either grounding/fixing the plane or reminding followup crews of relevant emergency procedures. If that incident or prior failures weren't reported, or were reported but not acted upon, then the fault for that lies with some mix of the crews, the airline, and relevant regulators – in addition to any other failures by Boeing.

Re: Cockpit voice recorder of Lion Air jet depicts pilots' frantic search for fix

#224

Post by anigbrowl »

cal5k wrote: post #117
mjburgess wrote: post #65

Earlier quoted context omitted.

I think this perspective on accidents needs far more emphasis. Many accidents are unavoidable and not the result of some person failing to do some thing. The world isn't a story, people don't have much agency, and events do not happen because people want them to. These "narrative explanations" are mythological just-so stories that attribute the complex interaction of systems to individuals, organizations, etc. in nai…

This is the issue I have with the media - moreso than any particular bias, media loves to paint a narrative when, in truth, random events are more likely to blame (though in fairness this is a human flaw borne from the heuristic value of narrative). Accidents happen in complex systems - rather than burning the people involved at the stake, we should recognize the inherent complexity of safety hurtling an aluminum tub…

Oh, let's be calm and sober about this, and passively accept the existence of accidents rather than re-examine organizational, business, or economic premises. So much easier to blame the media.

Craven excuse-making and responsibility avoidance at its worst.

Re: Cockpit voice recorder of Lion Air jet depicts pilots' frantic search for fix

#225

Post by kayfox »

cal5k wrote: post #117
mjburgess wrote: post #65

Earlier quoted context omitted.

I think this perspective on accidents needs far more emphasis. Many accidents are unavoidable and not the result of some person failing to do some thing. The world isn't a story, people don't have much agency, and events do not happen because people want them to. These "narrative explanations" are mythological just-so stories that attribute the complex interaction of systems to individuals, organizations, etc. in nai…

This is the issue I have with the media - moreso than any particular bias, media loves to paint a narrative when, in truth, random events are more likely to blame (though in fairness this is a human flaw borne from the heuristic value of narrative). Accidents happen in complex systems - rather than burning the people involved at the stake, we should recognize the inherent complexity of safety hurtling an aluminum tub…

The HN discussion of this issue is fairly revealing in that it points towards the people on this site wanting a simple explanation with a short list of people to punish, when it is more likely a long list of small details with many people who might have made relatively minor mistakes or simply not foreseen the issue in question. Working in IT (and also formerly at Boeing, so there's some crossover in experience), I find this unsurprising, as IT systems become more and more complex the answers are not "theres a bug in Vendor X's product" or "system Y was misconfigured" but a long litany of small errors, oversights or unforeseen issues that culminated in some larger issue. It does not help that many of these people are unwilling to adjust their conclusions based on emerging evidence. Fortunately in aviation there is a culture of understanding all the details of accidents, identifying all the possible improvements and implementing them. I suspect that the IT industry is on the verge of a crisis as I don't see this sort of attitude prevalent in it, which is funny because lots of the terminology and some of the techniques are common, just not the culture.

Re: Cockpit voice recorder of Lion Air jet depicts pilots' frantic search for fix

#226

Post by VBprogrammer »

js2 wrote: post #221
VBprogrammer wrote: post #206

Earlier quoted context omitted.

> - My first / immediate thought is that my previous action led to an undesired aircraft state. FYI This is shown in the Lion air preliminary report. They select flaps 0 (from flaps 5) and a few seconds later reselect flaps 5. Unfortunately a while after that they decide to go to flaps 0 again. With any flaps selected the MCAS system is disabled.

This must have been mighty confusing without knowing about MCAS. It’s like trying to fly a black box instead of flying a plane.

Yeah, I can imagine. I mentioned elsewhere, the previous flight managed to develop a reasonable mental model (they thought that the Mach Trim System was responding to a wrong airspeed input). Saying that, failing to guess what's going wrong shouldn't result in a big hole in the ground.

This is pretty interesting if you haven't seen it before:

https://vimeo.com/159496346

Re: Cockpit voice recorder of Lion Air jet depicts pilots' frantic search for fix

#228

Post by ericfrenkiel »

matt4077 wrote: post #42
CyberFonic wrote: post #10

One of the factors that has been quickly glossed over is the low level of experience of some of the pilots in both the Indonesian and Ethopian accidents. In the USA, due to much higher levels of experience pilots have been correcting for the MCAS actions effectively and complaining about it to NASA (in order to avoid being branded as whistle-blowers by their airlines).

How would it even be possible for US pilots to sustainably have „much higher levels of experience“? Do non-US pilots fly only two days a week? Do they all die before age 40? This stereotype of dingy third-world airlines with incompetent, untrained pilots borders on racism. At the very least, one should notice that flying the world’s newest airliner in significant numbers is incompatible with one‘s preconceptions.

I think your comment is out of line to accuse someone of racism. This airline has a bad record of aviation accidents, yet you would rather censure someone for simply not sharing your opinion.

Re: Cockpit voice recorder of Lion Air jet depicts pilots' frantic search for fix

#229

Post by cal5k »

anigbrowl wrote: post #224
cal5k wrote: post #117

Earlier quoted context omitted.

This is the issue I have with the media - moreso than any particular bias, media loves to paint a narrative when, in truth, random events are more likely to blame (though in fairness this is a human flaw borne from the heuristic value of narrative). Accidents happen in complex systems - rather than burning the people involved at the stake, we should recognize the inherent complexity of safety hurtling an aluminum tub…

Oh, let's be calm and sober about this, and passively accept the existence of accidents rather than re-examine organizational, business, or economic premises. So much easier to blame the media. Craven excuse-making and responsibility avoidance at its worst.

...except for the part where I say we should examine the root cause and make appropriate adjustments?

Or should we find every software developer who ever worked on the 737 MAX and throw them in jail?

Because brutal punishment of errors is what leads to a culture of quality improvement, right?

Re: Cockpit voice recorder of Lion Air jet depicts pilots' frantic search for fix

#230

Post by foldr »

jandrese wrote: post #219
foldr wrote: post #213

Earlier quoted context omitted.

I'm not sure where you're getting the "unbeknownst" from. In the cockpit voice recorder transcripts attached to the official accident reports, it seems that the pilots were aware of who had control at any given point in time.

I remember right before the impact with the water the captain finally realizing why his controls aren't doing anything and asking the co-pilot to finally let go of his stick. IIRC they never did throttle up however. Ultimately the co-pilot got tunnel vision and thought for some reason they were in an overspeed condition for most of the incident and failed to communicate that effectively with the rest of the crew. He…

The captain wasn't at the controls.

I'm not sure what you mean by "throttle up". They were at full TOGA thrust.

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