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Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

bbc.co.uk

251–260 of 285 posts

Re: Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

#251
post #243

Earlier quoted context omitted.

It sounds like they did almost everything right. There are two fateful moments: >At 05:41:46, the Captain asked the First-Officer if the trim is functional. The First-Officer has replied that the trim was not working and asked if he could try it manually. The Captain told him to try. At 05:41:54, the First-Officer replied that it is not working At this point they were in stable flight and the trim wasn't that extreme…

When they did that final electric trim up, the right (more reliable) ASI indicates 365 knots. VMO is 340, so they were already in real trouble. It's not at all clear that even electric trim could overcome the air loads at that point to trim up, though it does look from the graph like it responded slightly.

At 05:40:30 you can see that the trim did change in response to pilot inputs at roughly the same speed. It should have been able to respond when they re-enabled electric trim unless there was some other failure. It will be interesting to see the full report with more detail about what the pilots did and why.

Re: Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

#252
post #46

Every time I read about these plane accidents, I wonder why planes don't have any emergency features to save these people. Couldn't you build a plane that would eject the cabin as a parachute module or something. Yes, I'm sure this is naive, but why? Edit: My point is that almost anything is better than crashing down with the plane.

I think zero-zero ejection seats are a good point of comparison here. These are the state-of-the-art ejection seats used by US fighters and bombers, designed to function from a dead stop on a runway. That's what you'd need for this to be useful in the flight regime most accidents occur in.

Unfortunately, ejection seats suck to use. Like, mild chance of killing you, very high chance of breaking bones, almost certain to make you a few inches shorter from compressing your spine levels of suck. This is assuming that you don't hit anything on the way out, of course - and don't land in the fireball. And that's with trained, fit pilots who are expecting the ejection. Can you imagine what happens to Grandma who's started to lose bone density? Or the baby on their mother's lap? And that's before you start considering the issues with having that many parachutes and rockets in close proximity, or the weight.

So that's why planes don't have features to save these people.

Re: Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

#253
post #7

Will be interesting to see the details when the report is actually public. It does sound like the scenario that Mentourpilot explored in the simulator is close to what happened, namely: Bad AoA probe causes MCAS to trim down, and also to indicate IAS disagree. Pilots increase throttle as per non-normal checklist to reduce the risk of stalling due to unreliable airspeed. Pilots disable electric stabilizer trim, as per…

Official report is now out: http://www.ecaa.gov.et/documents/20435/0/Preliminary+Report+... This scenario does indeed appear to be what happened. It just looks like when they re-enabled electric trim, they didn't trim up enough, and then left it turned on. 5 seconds later, MCAS kicked in again, and then it was all over.

The other noteworthy thing is that it does look like the angle of attack sensor failed catastrophically. It was reading 10ish degrees before immediately jumping to 75. Boeing really screwed the pooch here. A 75 degree AoA is obviously impossible and should be disregarded. Let alone a situation where it goes from 10 to 75 in seconds.

Re: Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

#254

Earlier quoted context omitted.

If someone connected a big industrial stop switch to a solenoid and pointed that solenoid at the trigger of a rifle aimed at the person pressing the button I don't think you would expect anyone to look particularly hard at the person who manufactured the switch. If it was indeed a bird strike which took out the sensor then they seem to be completely beyond all possible blame. Even if it wasn't I'm sure they could poi…

So you are saying this was probably not spec'd for this criticality? I guess I'm curious for more information on this. Obviously don't blame the sensor manufacturer without cause but why are these things so buggy?

Yes and no.

Yes, the sensor is appropriate for use as an input to a safety critical system.

No, it is not appropriate for a safety critical system to behave in such a manner where if that one vane failed, to kill everyone on board.

While the sensor caused the cascade via it's input, it was the implementation of the listening system that allowed the rest to happen.

Safety critical systems are designed with graceful degradation in mind. The fewer sources of information the system has, the more conservative it's contribution to the overall state of the system should become.

There should have been integration with the second AoA sensor, pilot notification of disagree, and a lessening of the authority of the system in favor of the pilots.

The pilots could then have turned the plane around, and landed it.

Boeing is also on the hook for not highlighting the compounding risk presented by an airspeed unreliable failure compared with a stab trim runaway.

I'd also wager they should have had an MCAS disable separate from the stab trim cutout as a result.

Re: Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

#255

This is a software screwup. It's buggy software due to rush to market. I hope they do an analysis of the whole project. We can all learn from it.

Software is involved, yes, but the problems are ultimately of management, risks (both underestimated and externalised on airlines, pilots, passengers, and the public), cutting corners, and complexity debt.

Re: Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

#256
post #218

Earlier quoted context omitted.

>The original comment you were replying to referenced Boeing's smear of the pilots, not Lion Air the company. I responded to: >the Lion Air crash (they were busy smearing the airline an the pilots instead) Which clearly references Lion Air the company. >You're absolutely correct that Lion Air might have had the opportunity to prevent Boeing's design failure from bringing down this plane (this time). That still leaves…

> Which clearly references Lion Air the company. Ah, yep, I misread that (can I blame the typo...? ;) ) My point is that is that it is appropriate to call out Boeing for their attempt at deflecting blame. The pilots apparently did not take an action that _may_ have saved the plane (we now know it may not have). That doesn't change the fact that the issue they failed to correct was a faulty design in the first place,…

>My point is that is that it is appropriate to call out Boeing for their attempt at deflecting blame.

Sure, but that doesn't mean going the other way and deflecting blame from Lion Air and the pilots.

>The pilots apparently did not take an action that _may_ have saved the plane (we now know it may not have).

Disabling electric trim would have absolutely saved the Lion Air flight just like it did when the same issue cropped up on the previous flight. Some speculated (which appears to be incorrect) that the Ethiopian Air flight was in a situation that they couldn't recover from, but the Lion Air flight was not in that situation.

The Lion Air pilots identified that the trim was incorrect and reset it at least 20 times. It's fair to fault them for not coming to the conclusion that the electric trim system was malfunctioning and that they should disable it.

Re: Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

#257

I thought this was a software failure initially, but upon following the case, I have come to realize it's not. I still see plenty of people saying this is a software failure in this thread. This is not a software failure. This is a system/process failure on many level. The plane was rushed to beat a competitor. A mismatch between the plane & engine happened which can cause it to be off balance. A system was added in…

This has been just about my exact conclusion. I've just been checking things off as the evidence rolls in.

Re: Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

#258

Earlier quoted context omitted.

Totally agree. Some of the sentiments expressed here was borderline racist. (badly trained, overworked cluelless third world pilots not even capable to follow a checklist). One of the worst smear jobs was actually by the New York Times accusing the captain of the Ethiopian plane not having trained in a 787-MAX simulator. Hello? Wasn't that the whole sales pitch that the plane requires no training at all for certified…

The first officer on that flight was extremely inexperienced. He only had 200 hours of total flight time. In the U.S., you need 1500 to sit in the right seat of an airliner in scheduled service. While I would not put the blame on the pilots for the accident, it's impossible to know if it might have turned out differently had there been two experienced pilots in the cockpit.

There were two experienced pilots in Lion Air 610.

In the case where prescribed procedures are followed, and don't work well enough (i.e. you're still stuck in a bad situation that continues to degrade), you're basically asking for experience to manufacturer an alternative on the spot. That's rather like a Hail Mary pass, in terms of logic. It's a 'well maybe maybe not'.

I'm not sure how that progresses the conversation, and yet people on HN keep bringing this up as if it's relevant without actually showing any new dots let alone connecting them. Setting aside hard evidence proving experience is a factor, you don't even have a hypothesis of how it might be a factor.

He had only 200 hours of flight time. Well so fucking what? You have to make the case. It doesn't make its own case. The reason why the U.S. has a higher regulatory requirement for experience is because of Colgan Air 3407, in part, even though the experienced pilot in command showed the same incorrect response to stall warning as the second in command, both of which were contrary to training, and also the training itself was inadequate.

I've got quite a lot more total time experience than the second in command of the Ethiopian airlines pilot. I can't tell you with any meaningful certainty I would have done anything different.

I'd say my life experience is more relevant than my flight hours experience. And my life experience when encountering either human or computer confusion at only 1000 feet above the ground, is to consider it somewhere between incompetency and sabotage. I would not be diagnosing that shit either way, I'd disconnect all of it.

And I would be irate at discovering a form of autopilot (MCAS is a safeguard, or control law) that I was not previously informed of by either my airline, or regulator, or the airplane manufacturer. And in fact, U.S. pilots are pissed at exactly that. Including or even in particular the ones with 1500+ hours.

Re: Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

#259

Earlier quoted context omitted.

The explanation put forward (which seems reasonable) is that the cutouts were disengaged because the aerodynamic forces were stronger than could be overcome by the manual control, so they had to turn the electrics back on in an attempt to move it (which allowed the MCAS to continue pushing the stabilizer to the extreme)

Ah. They'd have had to "roller coaster" the airplane (pitch up, then move the elevator surface towards neutral [so a net nose down]) to get the trim to move manually [the last step on the checklist]. Repeat as needed until the stab is trimmed within a range where it can move manually in unaccelerated flight. That's an interesting possibility, which if they didn't know about it (I don't blame them), they may have felt…

They never had the altitude to do that...

Re: Ethiopian Airlines Boeing 737 pilots 'could not stop nosedive'

#260
post #224

Earlier quoted context omitted.

Agreed. After the Lion Air crash, Boeing basically asserted the plane was perfectly safe, and that the pilots should have followed the runaway trim process - this means turning off the electric motor which moves the trim, and having the pilots move it manually using a wheel provided for the purpose. Boeing has tried to imply that in the midst of an emergency which looks very different from a runaway trim, pilots shou…

There's a major difference between the Lion Air and Ethiopian Airlines crashes though - altitude and incident duration. Things that are recoverable from 5000' AGL might not be from 1000' AGL. Speed is life, and altitude is life insurance after all. From my reading, the Lion Air pilots could have disabled electronic trim anytime after those 26 recoveries and been fine. But the Ethiopian Airlines pilots only had 1000'…

Could have disable it, but didn't? We don't actually know yet whether they did or when they did, and if they did if it was already too late. Critically we don't know their mental state, as we don't have transcripts yet.

If the pilots are reactive or even panicked at the unexpected uncommanded pitch behavior, they may have been doomed right from that moment. The previous flight, Lion Air 34, the pilots likewise did not immediately cutoff autotrim. We have no transcript from that flight either. None of these pilots have been told of, or simulator trained, an MCAS upset scenario. Startle factor is relevant and can cause total cockpit breakdown. The 737 PCU design flaw and subsequent accidents show this. Can problem specific training mitigate crashes? Sure. How would these pilots have received MCAS upset training when they don't even know MCAS exists and the simulators didn't have such an failure option? And should they now be required to have such training? Including simulator training?

As for why MCAS is triggered below 1500' AGL in the Ethiopian Airlines case, that is a very good question. I have not seen the altitude above which MCAS is supposed to apply, and I haven't discovered how that trigger altitude is determined, radar altimeter?

Most of the facts we still don't know.

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