Downfall - Il caso Boeing

[Fewwy]

Il Comandante Sully prende posizione contro Boeing (vero è che lui era un uomo Airbus, ma la sua autorevolezza penso travalichi queste inezie).

https://simpleflying.com/captain-su...IBnNEUUoRhV5kEZQ3AMwBn3cC8#Echobox=1666027523

Captain Sully Opposes Extension To Boeing 737 MAX Equipment Exemption
Captain Sully opposes exempting the Boeing 737 MAX 7 and MAX 10 from having EICAS. But is EICAS truly necessary?

The legendary pilot Captain Chesley “Sully” Sullenberger has added his name to those lobbying to deny the Boeing 737 MAX 7 and MAX 10 an exemption to the upcoming federal requirement to install Engine Indication and Crew Alerting System (EICAS) into their cockpits. Per Jon Ostrower of The Air Current, Sullenberger is concerned about the “startle effect” Allied Pilots Association mentioned in their October 5 statement, which can delay a pilot's response to any in-flight event, much less an emergency.

Introducing Captain Chesley “Sully” Sullenberger

First, let’s introduce Captain Sully. This is the pilot famed for the “Miracle on the Hudson,” after he successfully ditched an Airbus A320-214 (registration N106US) with no loss of human life. Sullenberger is a former military pilot who had total flying hours of almost 20,000 at the time of the bird strike and subsequent ditching, including 4,756 hours on the A320.

It's worth noting that Sullenberger’s A320 did have Electronic Centralized Aircraft Monitor (ECAM), which, as explained below, has many similarities to EICAS. The above photos are of an A320 cockpit and an ECAM display for reference.

Reviewing the transcript of Captain Sullenberger's cockpit transmissions from Tailstrike.com, the Captain and his Co-Pilot Jeff Skiles appear to have not relied on ECAM systems, but rather their experience and other resources. As per Tailstrike.com, Sullenberger told his copilot to "Get the QRH... [Quick Reference Handbook] loss of thrust on both engines," where the copilot got out the paper document of their in-cockpit references. Meanwhile, the cockpit was abuzz with audio and visual warnings of the A320's diminished condition. Ultimately, the two pilots and cabin crew teamed up to save all souls aboard with a successful ditching and evacuation.

Furthermore, one should note that Captain Sullenberger was very critical of installing the Maneuvering Characteristics Augmentation System (MCAS). As regular readers may recall, MCAS is an attempt to use software to address the inherent aerodynamic issues of adding modern, efficient but large engines on the same airframe designed in the 1960s for smaller engines. The problems were that MCAS was highly automated and, at the time of the accidents, relied on one angle of attack sensor rather than two. The 737 MAX aircraft were grounded until MCAS software was thoroughly fixed and a sufficient number of pilots received simulator training on the 737 MAX.

Allied Pilots Association's concerns

Nonetheless, Allied Pilots Association (APA), the pilot's union for American Airlines - the airline that acquired US Airways, the airline Captain Sullenberger flew for - issued a statement quoting APA President Capt. Edward Sicher on October 5;

“Boeing needs to proceed with installing modern crew alerting systems on these aircraft to mitigate pilot startle-effect and confusion during complex, compound system malfunctions. Once these systems are installed and pilots have been properly trained on them, our crews will be better able to identify system failures and prioritize corrective actions that could save lives. ... By equipping these aircraft with modern crew alerting systems, Boeing can maintain a strong order book for them, which will, in turn, protect the jobs of the thousands of hard-working men and women who build the airplanes.”

Before there was EICAS

First, as per the above YouTube, there already are and have been cockpit warning systems for all variants of the Boeing 737. For instance, preceding a stall, the aircraft yoke shakes to warn the pilot. The 737 cockpit packs aural and visual warnings for, among other things, fire, low fuel, overspeed, terrain, and wind shear.

Granted, with the Boeing 737 MAX accidents, a runaway horizontal stabilizer triggered by faulty sensors and MCAS was the primary cause. The pilots were insufficiently trained to handle the MCAS failures as a secondary cause.

What is ECAM & EICAS?

As per the above YouTube explanation, Engine Indication and Crew Alerting System, or EICAS, is installed on many modern aircraft, such as the Boeing 787 Dreamliner. EICAS is coupled with and supplements formal warnings such as flashing lights, audible alarms, a stick shaker, and alerts on the head-up display (HUD).

Furthermore, as you can see above, Airbus installs a similar cockpit alerting system called Electronic Centralized Aircraft Monitor or ECAM into Airbus aircraft. This system still has traditional blinkers and warnings on the cockpit to display the issue.

Regardless if the warning system is called EICAS or ECAM, the concept of warning pilots of issues from instruments is the same. Onboard instruments pick up a fault, transmit the fault information to the cockpit, and the cockpit also displays the checklist item or items to resolve the fault. This way, the pilots do not need to rely on memory or consult the manual under the startle factor.

Why no EICAS in the Boeing 737?

The 737 MAX 10 cockpit. Photo: Justin Hayward | Simple Flying
So one wonders, why would the Boeing 737 not have EICAS installed? The general answer is that installing EICAS would require different and more training – and with Southwest Airlines alone having a 9,800-member Southwest Airlines Pilots Association (SWAPA) to train, there’s a substantial cost to airlines providing that training.

Furthermore, it has been widely published that Southwest Airlines management – and worth emphasizing not their pilots’ union SWAPA – insisted on a penalty to Boeing of $1 million per 737 MAX if additional training was required to fly the type. Southwest Airlines subsequently has ordered no less than 543 aircraft of the 737 MAX family to restock its 737 fleet - and some of those 737 MAX 8s are flying for Southwest Airlines today.

Additionally, as “Flying Blind: The 737 MAX Tragedy and the Fall of Boeing” by Peter Robison explained, a 2012 meeting between Federal Aviation Administration (FAA) engineer Richard Reed and Boeing managers saw Reed becoming upset that the 737 would remain,

“The last big commercial jet flying without an electronic crew alerting system”

The 737 having no EICAS is contrary to the EICAS that is found in the rest of the Boeing jetliner family, most Airbus aircraft, and most commuter planes like the Embraer 175 and de Haviland of Canada Dash-8-400 (aka Bombardier Q400), for starters. But as the 737 MAX was working off of a circa 1967 type certificate, there was no requirement to upgrade in 2012.

But as a result of the 737 MAX's troubles in 2020, the US Congress passed the Aircraft Safety and Certification Reform Act, updating the FAA oversight process. The act requires that any airplane certified after December 31, 2022, must comply with the latest FAA crew alerting regulation. The latest regulation requires EICAS, ECAM, or a similar system.

There are ongoing efforts to get an exemption for the 737 MAX 7 and MAX 10, as certification will not happen in time. A leading proponent for this, SWAPA President Casey Murray, explained why lobbying to prevent changing alert systems in the 737 MAX is ongoing, as reported by the Seattle Times;

“Switching from one to another and back and then back again is the issue. Having significant differences between the aircraft can cause confusion in moments of high stress.”

Any such confusion can delay pilot responses, create two groups of pilots in airlines that fly exclusively the Boeing 737, and other such major problems. This creates serious questions as to the efficacy and need of EICAS in the Boeing 737.

So is EICAS truly necessary to manage a 737 in-flight emergency?

All of this does not answer the key question - is EICAS truly necessary to address a serious in-flight emergency? EICAS was not on Southwest Flight 1380 - the flight where a 737-700's left engine had a fan blade failure. A listen to the above 737 Talk podcast by two 737 flight instructors who run b737training.org shows that Southwest Airlines Captain Tammie Jo Shults and First Officer Darren Ellisor were able to manage an in-flight emergency without EICAS.

Their 737-700 had a fan blade failure that punctured the fuselage, depressurizing the cabin within 5.5 seconds. The pilot and co-pilot managed the emergency to a safe landing, only losing one passenger from the initial fan blade failure. A transcript of the podcast is linked below under sources.

Captain Jo Shults explains both the importance of two well-trained professional pilots in the cockpit and how both pilots were able to manage to execute a safe landing in the Southwest Airlines 737-700.

In Captain Shults' memoir "Nerves of Steel: How I Followed My Dreams, Earned My Wings, and Faced My Greatest Challenge," Shults did explain her 737-700 in-flight emergency went by faster than all the checklists her co-pilot wanted doing could be completed.

“Darren and I had a number of emergency-procedure checklists that we were trying to run. There was the rapid-depressurization checklist, the engine severe-damage checklist, and the emergency-descent checklist. We were leaking fuel as well as hydraulic fluid and had lost our hydraulic A system engine-driven pump. Each of these situations was an emergency in itself and had associated checklists.

“The time for checklists was over. Darren told her that we would be on the ground soon and to prepare the cabin for landing. We had to turn toward the airport now and would just have to focus on getting the checklist items that were absolutely required for a safe landing done within the limited time we had available.”

The lack of time was, in part, due to the 737-700's condition, and also because a passenger had been pulled out a window and passed away from her injuries, despite the aircrew's and passengers' noble efforts fighting to save her life during the emergency approach and landing. EICAS' ability to prioritize checklists may have slightly helped, but could well have gotten stuck with conflicting priorities of the two pilots going off of a paper checklist and years of training and experience. Nonetheless, without ruining the book, Captain Shults was able to stick the landing.

 

[straniero]

quindi in pratica
'why would the Boeing 737 not have EICAS installed? The general answer is that installing EICAS would require different and more training – and [...] there’s a substantial cost to airlines providing that training. '
?

 

[Roland]

quindi in pratica
'why would the Boeing 737 not have EICAS installed? The general answer is that installing EICAS would require different and more training – and [...] there’s a substantial cost to airlines providing that training. '
?

che è poi lo stesso motivo per cui Boeing non ha dichiarato lo MCAS che ha causato 2 incidenti.

 

[ally01]

sospetto che il danno sia costato decisamente di piu' rispetto al costo di training degli equipaggi...qualcuno ha dati in merito?

 

[Paolo_61]

sospetto che il danno sia costato decisamente di piu' rispetto al costo di training degli equipaggi...qualcuno ha dati in merito?

Dati ovviamente no, ma è abbastanza evidente che il management di Boeing non ha brillato per lungimiranza (e il mercato, giustamente, punisce)

 

[ally01]

https://simpleflying.com/boeing-doesnt-plan-to-launch-a-new-airplane-any-time-soon/

Calhoun’s New Jet Delay Threatens Boeing’s Future In Airliner Business

Calhoun's rationale for waiting till the mid-2030s to launch a new airliner is based on a misunderstanding of how the commercial jet market has worked. It gives Airbus a free path to gaining over 70% market share — and perhaps knocking Boeing out of the business.

www.forbes.com

boeing nessun nuovo aereo prima del 2035...

 

[Seaking]

https://simpleflying.com/boeing-doesnt-plan-to-launch-a-new-airplane-any-time-soon/

Calhoun’s New Jet Delay Threatens Boeing’s Future In Airliner Business

Calhoun's rationale for waiting till the mid-2030s to launch a new airliner is based on a misunderstanding of how the commercial jet market has worked. It gives Airbus a free path to gaining over 70% market share — and perhaps knocking Boeing out of the business.

www.forbes.com

boeing nessun nuovo aereo prima del 2035...

Mossa azzardata, se non fosse per il settore militare Boeing sarebbe davvero in una posizione delicata nel lungo termine.
Sono davvero curioso di vedere come si configurerà il segmento narrow body da qui al 2035 (che poi se 2035 è il piano, nella reltà sarà magari più vicino al 2040...).

 

[Fewwy]

https://www.seattletimes.com/busine...rid.com&utm_medium=email&utm_campaign=website

Cantwell pushes to clear Boeing’s final 737 MAX models, with conditions
Nov. 29, 2022 at 6:29 pm Updated Nov. 30, 2022 at 2:33 pm
By Dominic Gates
Seattle Times aerospace reporter

In what could be good news for Boeing, U.S. Sen. Maria Cantwell on Tuesday circulated draft legislation that would clear the way for the final two Boeing 737 MAX models to enter service without changes to the Renton-assembled aircraft.

The Washington Democrat’s legislative amendment would remove the deadline in a 2020 law that threatens to force Boeing to substantially change the crew alerting systems on the MAX 7 and MAX 10 models to get them certified to fly passengers.

In an interview, Cantwell said her amendment, while letting the MAX 7 and MAX 10 move forward, also includes conditions that would require all airlines to retrofit two significant safety enhancements on the MAX 8 and MAX 9 models currently in service.

She said the amendment puts no deadline on certification of the MAX 7 and 10, and will require the retrofit probably within two to three years.

Cantwell said her aim is to head off attempts by Republicans to insert alternative amendments into the National Defense Authorization Act, or NDAA, that would give Boeing “a clean extension and call it a day” without any conditions attached.

“Mitch McConnell, I know for a fact, asked three or four times in the recent NDAA negotiations if he could move a straight extension,” Cantwell said.

That politicians are scrambling to get some amendment through in the end-of-year legislative rush to relax the law signals imminent relief for Boeing.

The MAX 7, the smallest variant, is crucial to the plans of the biggest 737 customer, Southwest Airlines. And the MAX 10, the largest variant, has won multiple orders from Alaska Airlines, Delta, United and others.

Whether Cantwell’s or competing amendments will become law is unclear.

The ranking Republican on her Senate Commerce Committee, Sen. Roger Wicker, R-Miss., filed an amendment to the NDAA in September that would have extended the deadline for Boeing until September 2024, with no conditions.

According to sources on Capitol Hill, amendments with the same or similar wording — a no-strings extension of the deadline for Boeing — were being discussed in Congressional backrooms as recently as last week.

Rep. Peter DeFazio, D-Ore., who currently chairs the U.S. House Transportation and Infrastructure Committee, remains opposed to any change to the current deadline, his spokesperson Peter True said Tuesday. Rep. Sam Graves, R-Mo., who will take over that committee in January, said at a conference last month that he would do everything he could to clear the MAX 7 and 10 for certification.

Ansley Lacitis, Cantwell’s deputy chief of staff, said, “We kept on seeing that this clean extension was still there and we didn’t want to get rolled.”

Cantwell’s move was immediately denounced by family members of the victims of the two fatal 737 MAX crashes that killed 346 people.

Wanting to force Boeing to upgrade its systems more substantially, they have lobbied strongly against any amendment that would change the current law.

Michael Stumo, whose daughter Samya Rose Stumo died in the crash of Ethiopian Airlines Flight 302, said “crash families around the world are upset about this.”

He said U.S. legislators passed the law in 2020 as a result of the MAX accidents, but that already “their memory is fading again from the blood of the victims.”

What’s at stake for Boeing
The Aircraft Certification, Safety and Accountability Act, passed in 2020 following the two MAX crashes, states that all planes certified after the end of this year must have crew-alerting systems designed to the latest safety regulations, a standard the MAX doesn’t meet.

Certification of the MAX 7, interrupted by the crashes and the prolonged grounding of the MAX worldwide, is likely in the first quarter of next year, past the deadline. Boeing says the MAX 10 won’t now be certified until late 2023 at the earliest, 2½ years after its first test flight.

A congressional amendment is the only relief available to Boeing that would allow it to certify the MAX 7 and MAX 10 so they can join the 8 and 9 in service with the current crew alerting design unchanged.

U.S. pilot unions are divided on relaxing the law for the MAX.

The Allied Pilots Association, representing the 15,000 pilots at American Airlines and one of the largest pilot unions in the U.S., opposes clearing the MAX 7 and 10 and wants the crew-alerting system upgraded to make it safer.

Lining up with Boeing, the Air Line Pilots Association, which represents more than 66,000 pilots in North America, issued a statement that “we are confident in the safety” of the MAX.

And the Southwest Airlines Pilots Association, representing the 10,000 pilots at Southwest — the largest MAX customer, with 234 of the MAX 7 variant on order — explicitly asked Congress to grant Boeing the relief.

The stakes of Congress’ decision are enormous for Boeing.

CEO Dave Calhoun in July hinted at canceling the MAX 10 rather than incurring the expense of a system upgrade and having to revise the pilot training for the model.

And at a conference in October, Casey Murray, president of the Southwest pilots union, suggested that if Boeing is forced to upgrade the crew-alerting system on the MAX 7, Southwest might no longer want it — presumably because of the expense of additional pilot training.

“I don’t know the market for it at that point,” Murray said of the MAX 7. “I don’t know that it’ll be Southwest.”

Besides Southwest, only a couple of airlines have committed to that variant, with about 50 jets between them. If Southwest were to back out, the MAX 7 would be dead.

Mandating European safety enhancements
The conditions in Cantwell’s provision would require the Federal Aviation Administration to mandate a retrofit on all MAX models of two safety enhancements Boeing developed and is currently testing on the MAX 10, the final and largest MAX jet.

The first is a third measure of the jet’s angle of attack, a key data point that feeds the flight computer the angle between the wing and the oncoming air stream.

The MAX has two physical angle-of-attack sensors. This would be a virtual cross-check of that measure calculated by the flight computer from a variety of other sensors and inputs.

The second retrofit requirement is for a switch that would enable the pilot to silence an erroneous “stick shaker” — a stall warning that vigorously vibrates the control column and is a big distraction if it’s a false alarm.

Cantwell said her amendment tells airlines “you have to make these retrofits and Boeing has to pay for them.”

A false angle-of-attack input and a distracting stick shaker were both contributing elements in the two fatal MAX crashes.

As a result, these specific improvements on the MAX 10 were required by two foreign regulators — the European Union Aviation Safety Agency and Transport Canada — as a condition of letting the MAX return to service in Europe and in Canada.

Furthermore, EASA said it expected Boeing to offer these enhancements as a retrofit to all prior MAX models.

“These modifications will be embodied in the 737-10 from the start of production and retrofitted on in-service MAX airplanes,” the agency stated in January 2021 when it allowed the MAX to return to service.

A source familiar with Boeing’s position, who spoke on condition of anonymity because of the sensitivity of the ongoing negotiations in Congress, said the company has agreed to offer these retrofit enhancements as an option.

“We’ll make it available to our airline customers,” the person said. “If they want them retrofitted on the rest of their fleet, absolutely.”

Cantwell’s amendment would make that mandatory. It would require the FAA to take enforcement action against any U.S. airline that doesn’t incorporate the retrofits.

The conundrum for Congress
When Boeing in 2014 certified the first version of the MAX, it convinced the FAA that upgrading the jet’s 1960s-era crew-alerting system would be too costly for too little benefit.

Boeing internal presentations made public during congressional investigations into the MAX crashes elaborated on the company’s motives.

They reveal Boeing’s concern that upgrading the system would be expensive, would slow the MAX development schedule and would add to pilot training costs for airline customers.

Still, when Congress passed the 2020 law it was intended to apply to all future airplane designs, not actually to the MAX.

The first two MAX models, the MAX 8 and MAX 9, were already certified before the crashes. After the grounding that lasted 21 months while Boeing developed extensive fixes, the FAA then recertified those aircraft to return to service.

Congress provided two years’ grace before the 2020 law took effect on the assumption that the MAX 7 and MAX 10 would also be certified as safe to fly by then.

That proved false. That’s partly because the COVID-19 pandemic slowed Boeing’s certification plans. Beyond that, the 2020 legislation also made the FAA process to certify an airplane much stricter — and slower.

Boeing is now required to more thoroughly test how a flight crew might respond to every malfunction of the plane’s systems. That, along with the FAA’s more rigorous oversight, considerably lengthened the certification process.

Today the 8 and 9 models are flying in passenger service around the U.S. and the world. Since the grounding was lifted, they have safely flown more than 1 million flights.

The source familiar with Boeing’s position said that in each of the five fatal crashes of 737 airplanes where the planemaker has acknowledged some failure of the crew-alerting system was a factor, it has introduced system upgrades to address the specific failures.

“The airplane has already through the decades demonstrated itself a safe product across a varied pilot demographic,” he added: “The sheer volume of flights where there weren’t accidents and there weren’t issues means something.”

Boeing statistics show that historically the 737 NG aircraft, the model before the MAX, suffered less than 1 fatal accident per 10 million flights.

Boeing declined to comment about Cantwell’s proposed legislative change, as did the FAA.

 

[Fewwy]

Ed infine, la montagna ha partorito il topolino.

https://www.aerotime.aero/articles/...g-737-max-strings-attached-deadline-extension

US lawmakers grant Boeing 737 MAX strings-attached deadline extension
Dec. 20, 2022
by Rytis Beresnevicius

In a recently published bill, the United States (US) Senate has granted approval to Boeing and, subsequently, the Federal Aviation Administration (FAA) to continue working on certifying the 737 MAX-7 and MAX-10.

The Fiscal Year 2023 Omnibus Appropriations Bill, released on December 20, 2022, includes changes to the 49 US Code Chapter 447. Lawmakers included amendments to the Flight Crew Alerting section (§ 44744), essentially giving the FAA and Boeing the go-ahead to continue working on certifying the two 737 MAX types that have yet to enter commercial service.

Changes to 737 MAX-7 and 737 MAX-10 alerting systems
While the bill reiterated that following the December 27, 2022 deadline aircraft would not be certified without a modern flight crew alerting system, it did include a provision for the exemption of aircraft where certification work began prior to the deadline. However, the exemption comes with strings attached.

“The prohibition in subsection (a) shall not apply to any application for an original or amended type certificate that was submitted to the Administrator [The FAA’s Administrator – ed. note] prior to December 27, 2020,” the Senate stated in its latest bill.

The Aircraft Certification, Safety, and Accountability Act (ACSAA), which goes into effect on December 27, 2022, will require aircraft to feature modern flight crew alerting systems. According to the document, such a system will, at a minimum, need to have displays and showcase differences among warnings, cautions, and advisories and include “functions to assist the flight crew in prioritizing corrective actions and responding to systems failures”.

Still, Boeing will have to make changes to the Engine Indicating and Crew Alerting System (EICAS) on all 737 MAX aircraft, including the 737 MAX-8 and MAX-9, which were cleared by the FAA to fly in November 2020.

The bill will mandate Boeing to retrofit all 737 MAX family aircraft with FAA-approved safety enhancements one year after the 737 MAX-10 is certified. Otherwise, the administrator will not be able to issue an airworthiness certificate to newly produced aircraft of the type. Furthermore, three years after the 737 MAX-10 certification, airlines will not be able to operate any of the 737 MAX aircraft unless they meet two conditions.

Firstly, the aircraft must include “safety enhancements approved by the Administrator” and secondly, they must either be produced or retrofitted with the FAA-approved design changes.

Boeing will also have to bear the costs of these modifications per the latest proposal.

Quarterly 737 MAX progress report
In addition to monitoring and certifying the design changes, the FAA will also have to brief the US Congress on the continuing progress of the certification of the 737 MAX-7 and MAX-10, the bill added.

The first report must be provided no later than March 1, 2023, and after that date, the FAA’s Administrator will have to appear before Congress on a quarterly basis. The current FAA Acting Administrator is Billy Nolen, a former American Airlines pilot. Nolen, or any other head of the government agency, will be required to provide detailed information on how the certification of the 737 MAX-7 and MAX-10 is progressing, “including any design enhancements, pilot procedures, or training requirements resulting from system safety assessments”. They will also have to brief US lawmakers on the implementation of the safety enhancements for the 737 MAX family.

The safety enhancements, which include a synthetic Angle of Attack (AoA) system, the ability for pilots to turn off stall warnings and overspeed alerts, were mandated following the two fatal crashes of the Boeing 737 MAX-8 aircraft in Indonesia and in Ethiopia. The two accidents, which occurred in October 2018 and March 2019, respectively, claimed the lives of 346 people. However, the bill also reiterated that additional design changes deemed appropriate by the FAA could be added.

AeroTime approached Boeing for comment.

 

[Michele]

Uscito il report finale:

Aircraft Accident Investigation Report B737- MAX 8, ET-AVJ December 2022 (havkom.se)

 

[Jambock]

L'NTSB ha pubblicato alcuni commenti che l'Autorità Etiope non ha incluso nel report finale.

NTSB Releases Comments on Ethiopia’s Investigation of the Boeing 737-8 Max Accident

www.ntsb.gov

Vorrei trovare il tempo per leggere tutto con calma...


Questo articolo indica alcuni punti elencati dal NTSB:

NTSB Challenges Ethiopian Aviation Authority On Max Crash Final Report

NTSB calls out crew, airline mismanagement in Ethiopian Airlines Max disaster.

www.avweb.com

“We agree that the uncommanded nose-down inputs from the airplane’s MCAS system should be part of the probable cause for this accident. However, the [EAIB’s] draft probable cause indicates that the MCAS alone caused the airplane to be ‘unrecoverable,’ and we believe that the probable cause also needs to acknowledge that appropriate crew management of the event, per the procedures that existed at the time, would have allowed the crew to recover the airplane even when faced with the uncommanded nose-down inputs. We propose that the probable cause in the final report present the following causal factors to fully reflect the circumstances of this accident:

• uncommanded airplane-nose-down inputs from the MCAS due to erroneous AOA values and

• the flight crew’s inadequate use of manual electric trim and management of thrust to maintain airplane control. In addition, we propose that the following contributing factors be included:

• the operator’s failure to ensure that its flight crews were prepared to properly respond to uncommanded stabilizer trim movement in the manner outlined in Boeing’s flight crew operating manual (FCOM) bulletin and the FAA’s emergency airworthiness directive (AD) (both issued 4 months before the accident) and

• the airplane’s impact with a foreign object, which damaged the AOA sensor and caused the erroneous AOA values.”

 

[OneShot]

Quindi hanno messo a terra un aeroplano per tutti quei mesi per nulla?

 

[Farfallina]

Quindi hanno messo a terra un aeroplano per tutti quei mesi per nulla?

In realtà la messa a terra del B737 Max è andata incontro alle cause individuate dall'NTSB. Poi è comprensibile che l'ente etiope focalizzi il problema sull'errore del software glissando sul mancato addestramento dei piloti al recupero di emergenza e sulla causa del danno al sensore, così come si sta che l'NTSB che sottolinei la serie di cause coincidenti che ha portato al disastro perché solo rendendosene conto compiutamente si può evitare che possa succedere nuovamente.

 

[ally01]

non al disastro ma ai disastri. Per due punti passa sempre una retta, forse biosgnava aspettare un terzo incidente per chiarire che il MAX andava rivisto?

 

[belumosi]

Quindi hanno messo a terra un aeroplano per tutti quei mesi per nulla?

Andrò controcorrente, ma secondo me la risposta è si.
Le varie CAA hanno messo a terra il MAX nei giorni immediatamente successivi all'incidente di Ethiopian, senza alcuna evidenza sulle cause dello stesso.
Una volta individuato il MCAS tra le concause, la CAA etiope ha pensato bene di scaricare le intere responsabilità sull'aereo.
Quando in realtà sembra proprio che siano stati i piloti a non rispettare le prescrizioni emesse da Boeing dopo l'incidente del Lion Air.
E se così fosse, sarebbe corretto affermare che nessun MAX pilotato secondo le prescrizioni emesse dal costruttore dopo il primo crash, ha avuto incidenti.
Sia chiaro che le mie parole non intendono sminuire la porcata fatta dal costruttore americano in fase di progettazione e certificazione del nuovo 737, ma secondo me se ci si fosse limitati a valutare i fatti reali, non sarebbe stato necessario mettere a terra l'aereo e le opportune modifiche si potevano fare gradualmente sull'intera flotta senza particolari problemi.
Poi posso capire anche la reazione istintiva delle varie CAA nell'imporre un grounding per motivi prudenziali (e un po' paraculi, diciamolo pure), ma secondo me sul piano strettamente logico (c'è un incidente - indago - trovo le cause - adotto provvedimenti), un provvedimento così drastico poteva essere evitato.

 

[B77W]

Le varie CAA hanno messo a terra il MAX nei giorni immediatamente successivi all'incidente di Ethiopian, senza alcuna evidenza sulle cause dello stesso.
Una volta individuato il MCAS tra le concause, la CAA etiope ha pensato bene di scaricare le intere responsabilità sull'aereo.
Quando in realtà sembra proprio che siano stati i piloti a non rispettare le prescrizioni emesse da Boeing dopo l'incidente del Lion Air.
E se così fosse, sarebbe corretto affermare che nessun MAX pilotato secondo le prescrizioni emesse dal costruttore dopo il primo crash, ha avuto incidenti.

Ovviamente (e purtroppo) è interesse dell'ente etiope scaricare le responsabilità su Boeing, così come gli Egiziani si inventarono la storia dell'elevatore difettoso sul 767 che precipitò nell'Atlantico per mascherare l'atto suicida del FO, ed è il motivo per il quale in certi paesi l'aviazione è indietro anni luce, nonostante le stelle gentilmente concesse da SkyTrax e le black list idiote.
Per quanto riguarda le prescrizioni emesse da Boeing, però, è vero che i piloti dell'Ethiopian hanno commesso degli errori (alcuni secondo me comprensibili nel contesto specifico, altri meno), ma non mi sentirei di affermare che con quelle indicazioni non si sarebbe ripetuto l'incidente, perché la comprensione dell'accaduto e relativo addestramento erano i veri tasselli che mancavano (all'epoca).
Boeing pensava di cavarsela suggerendo l'ovvio, ovvero che bastava escludere il motore elettrico del trim e usare i muscoli per contrastare il MCAS: approccio quantomeno discutibile, visto lo scenario leggermente più complicato del previsto.

 

[belumosi]

@777W

Non ho la competenza per giudicare, ma se quanto dichiarato dal NTSB risponde al vero, ho l'impressione che anche i piloti abbiano una parte di responsabilità.
Questo è il riassunto fatto da FG.


US investigators dismayed as 737 Max crash probe skips analysis of crew's actions

By David Kaminski-Morrow28 December 2022

US investigators have dissented over findings of an Ethiopian inquiry into the fatal Boeing 737 Max 8 crash outside Addis Ababa nearly four years ago, arguing that the conclusions focus on technical design issues and fail to take sufficient account of human factors and inadequate pilot responses to the loss of control.
The accident, involving Ethiopian Airlines flight ET302 in March 2019, was the second to involve a 737 Max in less than five months and led to a worldwide grounding of the type, over concerns that failure of a single angle-of-attack sensor could generate false air data and lead the horizontal stabiliser trimming system to push the aircraft into a rapid descent.
Ethiopia’s aircraft accident investigation bureau has concluded that the trimming system, known as MCAS, was responsible for the crash, echoing the Indonesian Lion Air 737 Max accident in October 2018.
It claims that a defective angle-of-attack sensor exposed the vulnerability of MCAS, which would have otherwise remained as a “hidden threat”.

It claims that a defective angle-of-attack sensor exposed the vulnerability of MCAS, which would have otherwise remained as a “hidden threat”.

The US National Transportation Safety Board fully concurs that the MCAS behaviour was part of the accident sequence.
But it disagrees that the angle-of-attack sensor was defective, arguing instead that a bird-strike on the instrument, causing its vane to break away, was more likely.
Crucially it also contests the Ethiopian inquiry’s suggestion that the aircraft was “unrecoverable” by the crew.
“We believe that the probable cause also needs to acknowledge that appropriate crew management of the event, per the procedures that existed at the time, would have allowed the crew to recover the airplane even when faced with the uncommanded nose-down inputs,” says the NTSB.


It has separately published its dissention over the draft report after it was not attached to the final report newly issued by the Ethiopian bureau.
The Ethiopian inquiry found that the aircraft’s throttle levers remained at take-off thrust, and that the stick-shaker activated as the jet became airborne from Addis Ababa.
Its captain attempted to engage the autopilot, despite this being inconsistent with stick-shaker procedures, but the crew “did not discuss any issue” relating to the stick-shaker, it states. The autopilot activated at the third attempt.
According to the inquiry the false angle-of-attack sensor data led to incorrect calculation of a minimum operational airspeed – which exceeded the maximum operational airspeed of 340kt – and also prevented the flight-management computer from detecting a threshold altitude at which thrust would have automatically reduced.

As the aircraft climbed, the crew retracted the flaps, but shortly afterwards the autopilot disconnected. The combination of manual flight, retracted flaps, and the false angle-of-attack data triggered MCAS to adjust the horizontal stabiliser and lower the nose.
Although the crew attempted to counter this nose-down tendency with manual input, the continuing high-thrust acceleration meant the pilots had to apply excessive forces in response.
MCAS triggered for a second time, and the pilots responded by activating the trim cut-out switches – a correct response, advised after the Lion Air accident – which effectively prevented MCAS from adjusting the stabiliser when it triggered for a third time.
At this point the aircraft was travelling at 332kt, at 9,100ft altitude, and gradually climbing but the crew was having to counter the out-of-trim stabiliser with substantial force.
The crew advised air traffic control of the flight-control difficulties, and aimed to reach the minimum safe altitude of 14,000ft in order to start diagnosing the problems.
But the “unbearable” manual forces needed to trim the aircraft and maintain the climb were too much for the pilots, and the captain called, “Put them up” – an apparent command to disconnect the trim cut-out switches which, critically, would also re-activate MCAS.
“It most likely appears that the flight crew were trying to find other means to relieve the force,” says the inquiry, in an explanation for the decision. MCAS subsequently commanded a fourth nose-down shift in the stabiliser, pushing the aircraft into its final fatal dive.
After the cut-out switches were restored a fourth MCAS activation resulted in the fatal descent
The inquiry says MCAS and a lack of pilot training “did not trigger” the accident, but that it was initiated by flawed data from the angle-of-attack sensor.
But the NTSB believes the analysis of the pilots’ performance is “not sufficiently developed” by the inquiry which, it adds, focuses “heavily” on system design issues instead.
“Absence of flight crew performance information limits the opportunity to address broader and equally important safety issues,” it states, pointing out that evaluation of the crew’s actions “would not have been particularly difficult” given the amount of information available.
“Design mitigation must adequately account for expected human behaviour [in order] to be successful,” the NTSB adds, and demands a “thorough understanding” of crew performance – not only for design purposes but also operational and training safety improvements.
The NTSB disputes a conclusion that airspeed and altitude ‘disagree’ messages were not presented to the crew, and says the inquiry should have explored the pilots’ “lack of conversation or action” in response to the messages.
According to the NTSB, the aircraft was not uncontrollable, but the inquiry neglects to state that a manual reduction of thrust and appropriate use of manual electric trim would have allowed the pilots to maintain control despite the uncommanded MCAS inputs.
“The flight crew’s failure to reduce thrust manually and the excessive airspeed that resulted played a significant role in the accident sequence of events,” the NTSB insists.
It says the activation of the stick-shaker or the annunciation of an ‘airspeed disagree’ message should have prompted an “expected” crew response to disengage the autothrottle.
Instead the autothrottle remained active and responsive to the erroneous angle-of-attack data, and failed to order a thrust reduction. Despite an aural ‘overspeed’ warning as the aircraft accelerated towards 340kt, at high thrust, the NTSB says the crew did not notice the autothrottle’s unusual behaviour, or take action to manually control thrust, leaving the pilots to deal with excessive forces on the control column and manual trim-wheel.
Countering the uncommanded nose-down inputs with manual nose-up electric trim – as described in operating manual documentation – would have enabled control forces to remain in a “controllable regime”, it says.
It adds that the draft report “did not examine” the pilots’ understanding of the relationship between airspeed and necessary control forces, and says it “misses and opportunity” to evaluate the effectiveness of airline training on this matter.
Evidence from the inquiry, the NTSB states, shows the crew did not carry out appropriate non-normal procedures in response to annunciations relating to unreliable airspeed, stall warning and runaway stabiliser.
Flight-data recorder information shows only “minimal” use of manual electric trim, which would have reduced control forces, while performing memory items for unreliable airspeed or runaway stabiliser would have led the crew to disengage the autothrottle. Such actions should have been carried out before the crew activated the trim cut-out switches.
But even after activating the trim cut-out, says the NTSB, the crew subsequently disconnected the switches – a decision which was “contrary” to procedures which directed crews to ensure that the cut-out remained in place for the rest of the flight.
“Available evidence for this accident did not indicate why the crew performed this action,” it adds.
“By not evaluating the human factors associated with this crew action, the report provides a limited understanding of the circumstances leading to the airplane’s nose-down pitch before impact.”

US investigators dismayed as 737 Max crash probe skips analysis of crew's actions

US investigators have dissented over findings of an Ethiopian inquiry into the fatal Boeing 737 Max 8 crash outside Addis Ababa nearly four years ago, arguing that the conclusions focus on technical design issues and fail to take sufficient account of human factors and inadequate pilot responses...

www.flightglobal.com

 

[B77W]

se quanto dichiarato dal NTSB risponde al vero, ho l'impressione che anche i piloti abbiano una parte di responsabilità.

Dispiace doverne parlare in questi termini visto l'accaduto, ma è vero: i piloti hanno dimostrato lacune tecniche importanti. Su questo non ci piove e sì, tutto assolutamente vero quanto riportato dal NTSB (manco a dirlo).
Però, ed è quello che vorrei fosse chiaro, fra teoria e pratica passa un oceano. Nessuno aveva provato al simulatore uno scenario del genere, che sostanzialmente unisce due fra le avarie più serie che si possano incontrare in volo, e in decollo soprattutto: la prima è la perdita delle indicazioni di velocità (che rimanda ad una checklist) e la seconda è lo stabilizzatore che va per i fatti suoi (che rimanda ad un'altra checklist). Certo, qualunque pilota (e ingegnere) sa che non è possibile pensare a e ricreare a priori qualunque possibile scenario, ed è il motivo per il quale spesso e volentieri si parla di esperienza ed airmanship, oltre che capacità tecniche. Ma pensare di cavarsela (dal lato Boeing) suggerendo che esista già una checklist apposita, no, non è accettabile. Si doveva eviscerare tutta la storia del MCAS, si dovevano provare al simulatore vari scenari che rendessero chiaro al pilota medio (che non è il test pilot della Boeing, per ovvie ragioni) come lavorava il MCAS e come contrastarlo in caso di problemi al sensore (al di là della checklist che tutti dovremmo, e sottolineo dovremmo, conoscere), e tutto questo non è stato fatto.
Per questo non posso, nel mio piccolo, sposare la tesi che se si fosse semplicemente seguito quanto detto da Boeing non sarebbe successo nulla. Certo, magari con due piloti diversi l'incidente non sarebbe avvenuto, chi lo sa? Ma il costruttore non può basarsi su queste considerazioni di "se" e "forse" per lavarsene le mani, questo voglio dire.

 

[belumosi]

Anche il BEA francese condivide le considerazioni del NTSB.
E secondo me acquisiscono un peso ben più rilevante, in quanto vengono da un paese sul quale è difficile ipotizzare l'ombra del protezionismo nei confronti di un Boeing.

French BEA Concurs with NTSB on Gaps in ET Max Crash Report
by Gregory Polek
- January 3, 2023, 2:00 PM

France’s Bureau d'Enquêtes et d'Analyses (BEA) on Tuesday followed the U.S. National Transportation Safety Board (NTSB) in calling for Ethiopian authorities to amend the final report on the March 10, 2019, crash of an Ethiopian Airlines Boeing 737 Max 8 to reflect human factors considerations and flight crew shortcomings. Ethiopia’s Aircraft Accident Investigation Bureau (EAIB) led the investigation with the help of the French and U.S. authorities, both of which said that the report failed to sufficiently address operational and crew performance in its finding that a malfunction in the airplane’s Maneuvering Characteristics Augmentation System (MCAS) caused the accident.
“Shortcomings relating to the crew’s actions, particularly in the first phase of the flight, is not accompanied by a thorough analysis of the reasons for the behaviors observed, in relation with their training, their experience and the company organization with regard to the training and knowledge acquisition principles,” said the BEA.
In summary, the BEA concluded that the crew’s inadequate actions and insufficient cockpit resource management played a role in the chain of events that led to the accident, in particular before the first MCAS activation.
The French authority has called for the EIAB to add five contributing factors related to the crew’s actions in the report, including the flight crew’s failure to apply the Approach to Stall or Stall Recovery Maneuver and the Airspeed Unreliable Non-Normal Checklist immediately after takeoff and before the first MCAS activation and the captain’s insistence on engaging the autopilot, contrary to the Approach to Stall or Stall Recovery maneuver procedure.
In its Tuesday statement, the French authority described how the crew did not fully follow the procedure for addressing the activation of the left stick shaker because of an erroneous angle-of-attack value, most likely caused by a bird strike.

“On the activation of the stick shaker, the flight crew must apply the Approach to Stall or Stall Recovery procedure, which is a memory item,” it said. “As described in the [Flight Crew Operating Manual/Quick Reference Handbook], the first steps in the Approach to Stall or Stall Recovery procedure are to hold the control column firmly, disengage the autopilot and autothrottle, and then smoothly apply a nose down input. Only the nose-down input was performed by the flight crew. The autothrottle remained engaged and the pilot later insisted on engaging the [autopilot].”
Other factors listed by the BEA include insufficient use of the electric trim to relieve the high control column forces after the MCAS nose-down orders and the captain’s lack of thrust reduction when the speed became excessive, which in combination with insufficient trim, caused an increase of the forces that became unmanageable on both the control column and the manual trim wheel.
Finally, the BEA faulted the airline’s use of the Logipad electronic flight bag system as the sole means to disseminate information related to the MCAS issued following the previous accident of a 737 Max—that of a Lion Air airplane on October 29, 2018. Because the Logipad system doesn’t allow the evaluation of the crew's understanding and knowledge acquisition on new systems and procedures, the airline could not ensure that the crew had read and correctly understood the information.

French BEA Concurs with NTSB on Gaps in ET Max Crash Report | AIN

France’s BEA joins call for Ethiopian authorities to amend final report on the March 2019 crash of an Ethiopian Airlines Boeing 737 Max.

www.ainonline.com

 

[speedbird001]

Anche il BEA francese condivide le considerazioni del NTSB.
E secondo me acquisiscono un peso ben più rilevante, in quanto vengono da un paese sul quale è difficile ipotizzare l'ombra del protezionismo nei confronti di un Boeing.

French BEA Concurs with NTSB on Gaps in ET Max Crash Report
by Gregory Polek
- January 3, 2023, 2:00 PM

France’s Bureau d'Enquêtes et d'Analyses (BEA) on Tuesday followed the U.S. National Transportation Safety Board (NTSB) in calling for Ethiopian authorities to amend the final report on the March 10, 2019, crash of an Ethiopian Airlines Boeing 737 Max 8 to reflect human factors considerations and flight crew shortcomings. Ethiopia’s Aircraft Accident Investigation Bureau (EAIB) led the investigation with the help of the French and U.S. authorities, both of which said that the report failed to sufficiently address operational and crew performance in its finding that a malfunction in the airplane’s Maneuvering Characteristics Augmentation System (MCAS) caused the accident.
“Shortcomings relating to the crew’s actions, particularly in the first phase of the flight, is not accompanied by a thorough analysis of the reasons for the behaviors observed, in relation with their training, their experience and the company organization with regard to the training and knowledge acquisition principles,” said the BEA.
In summary, the BEA concluded that the crew’s inadequate actions and insufficient cockpit resource management played a role in the chain of events that led to the accident, in particular before the first MCAS activation.
The French authority has called for the EIAB to add five contributing factors related to the crew’s actions in the report, including the flight crew’s failure to apply the Approach to Stall or Stall Recovery Maneuver and the Airspeed Unreliable Non-Normal Checklist immediately after takeoff and before the first MCAS activation and the captain’s insistence on engaging the autopilot, contrary to the Approach to Stall or Stall Recovery maneuver procedure.
In its Tuesday statement, the French authority described how the crew did not fully follow the procedure for addressing the activation of the left stick shaker because of an erroneous angle-of-attack value, most likely caused by a bird strike.

“On the activation of the stick shaker, the flight crew must apply the Approach to Stall or Stall Recovery procedure, which is a memory item,” it said. “As described in the [Flight Crew Operating Manual/Quick Reference Handbook], the first steps in the Approach to Stall or Stall Recovery procedure are to hold the control column firmly, disengage the autopilot and autothrottle, and then smoothly apply a nose down input. Only the nose-down input was performed by the flight crew. The autothrottle remained engaged and the pilot later insisted on engaging the [autopilot].”
Other factors listed by the BEA include insufficient use of the electric trim to relieve the high control column forces after the MCAS nose-down orders and the captain’s lack of thrust reduction when the speed became excessive, which in combination with insufficient trim, caused an increase of the forces that became unmanageable on both the control column and the manual trim wheel.
Finally, the BEA faulted the airline’s use of the Logipad electronic flight bag system as the sole means to disseminate information related to the MCAS issued following the previous accident of a 737 Max—that of a Lion Air airplane on October 29, 2018. Because the Logipad system doesn’t allow the evaluation of the crew's understanding and knowledge acquisition on new systems and procedures, the airline could not ensure that the crew had read and correctly understood the information.

French BEA Concurs with NTSB on Gaps in ET Max Crash Report | AIN

France’s BEA joins call for Ethiopian authorities to amend final report on the March 2019 crash of an Ethiopian Airlines Boeing 737 Max.

www.ainonline.com

A mio parere sarebbe successo comunque, se non li su un'altro MAX.
Come giustamente fa notare B77W i piloti non erano addestrati a simili scenari, provateci voi a risolverli in 2/3 minuti , con il culo sopra un aereo pieno di pax.
Gli è pure andata bene ( eufemisticamente) che sia successo nelle remota Etiopia e non su un MAX di Ryan Air o di qualche compagnia US.