
In Lion Air Crash, Black Box Data Reveals Pilots’ Struggle to Regain Control - tysone
https://www.nytimes.com/2018/11/27/world/asia/indonesia-lion-air-crash-.html
======
danso
> _In the aftermath of the crash, pilots have expressed concern that they had
> not been fully informed about the new Boeing system — known as the
> maneuvering characteristics augmentation system, or M.C.A.S. — and how it
> would require them to respond differently in case of the type of emergency
> encountered by the Lion Air crew._

There's still more to learn about this disaster played out. But if what we've
learned so far holds up -- that Boeing added a significant feature without
proper communication or obvious way to override it -- I hope Lion Air 610
becomes part of the ethics curriculum in engineering classes, along with
Therac-25 and the Hyatt Regency walkway collapse [0].

[0]
[https://en.wikipedia.org/wiki/Hyatt_Regency_walkway_collapse](https://en.wikipedia.org/wiki/Hyatt_Regency_walkway_collapse)

~~~
aeternus
Documentation may have helped, but any pilot that has used an autopilot should
know how to deal with runaway trim. Fighting any trim issue via yoke pressure
is wrong, and flight instructors typically drill that into students.

Dealing with this is relatively simple:

1) Hold the trim wheel. Autopilots are designed so that humans can easily
override just by holding the control.

2) Disable the autopilot / M.C.A.S. via switch.

3) Pull the circuit breaker. Even if they pull the wrong breaker(s), flying
with a partial panel is safer than flying without controls.

~~~
thisrod
> Disable the autopilot / M.C.A.S. via switch.

The version of the article that I read says:

"The pilot of Flight 610 appears to have [pressed that switch] repeatedly to
bring the nose up, but the MCAS reactivated each time, as it was designed to
do, forcing the nose back down, and the pilot had to repeat the process again
and again."

This is getting quite wierd. The captain had 6000 hours of experience, the
pilots knew what the problem was, they had ten minutes to solve it, and they
had started to do the right things. All good so far. Then, something went
wrong. But what?

~~~
dx034
That it was not the autopilot misbehaving but the MCAS. The pilot probably
assumed it was the autopilot (and therefore deactivated it) but didn't know
about MCAS in this situation.

I wonder if the system showed a warning that was active to give the pilots a
hint of why the aircraft behaved the way it did. Even if they didn't know
about MCAS, a warning that it is active would've at least triggered further
responses (e.g. cut off power to the systems to return to manual control).

------
setquk
More relevant information at Reuters: [https://www.reuters.com/article/us-
indonesia-crash-boeing-ex...](https://www.reuters.com/article/us-indonesia-
crash-boeing-explainer/explainer-unraveling-the-boeing-737-max-lion-air-crash-
idUSKCN1NK2BE)

Couple of interesting excerpts:

 _Lion Air’s flight manual did not contain information about the new anti-
stall system, according to investigators and an airplane flight manual seen by
Reuters. U.S. pilots were also not made aware in training courses, pilot
unions say._

 _Pilots can stop the automated response by pressing two buttons if the system
behaves unexpectedly, the FAA says._

 _Pilots on a flight from Jakarta to Bali the day before the crash experienced
a similar sensor issue but managed to land safely by turning off the system,
the New York Times reported._

This sounds like a communication failure rather than an explicit technical
failure as the system was overridable. Lion Air wasn't exactly well known for
not being dodgy here so there was a possibility in the 10 minute flight window
they couldn't resolve the issue.

~~~
A2017U1
Communication probably isn't the right word. The pilots are given the logs for
all recent issues.

The prior flight called in a panpan distress signal for the exact same sensor
failure and subsequently disabled the system to continue flying.

No one is really meant to communicate this to a commercial pilot, they're
expected to read it themselves pre-flight.

~~~
talltimtom
... you are suggesting that information about new systems should be
communicated to pilots only through self study of near crash reports? So if
someone updates the system they just sit back and wait for the first time the
system crashes or almost chrashes a plane in order for pilots to learn about
it?

~~~
bgirard
No, you read that wrong.

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Someone1234
Very strange how the NY Times "Times Pick" comment (in the middle of the
article) literally makes claims that the article itself contradicts:

> If the Boeing emergency manual dictates that there are cut off switches to
> disable the system and return to manual control, it would be a training
> issue with the flight crew. Boeing obviously added this flight
> characteristic to the planes for a specific reason and also documented how
> and what it could do after their own test flights. Wondering how many
> airlines are not going through the entire aircraft's training publication to
> understand this system.

Which is a little odd as the article itself said that Boeing's new M.C.A.S.
system was not in the manual and or training documentation. Boeing's very
carefully worded statement is a deflection, they're essentially arguing that
even though they added a new undocumented system, that existing protocols for
other problems (runaway stabilizer trim) could be used to resolve this one.

How do the NY Times pick the "Times Pick" comment? Is reading the article
you're commenting on not a prerequisite?

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Rooster61
I'm really trying my best to see this from a perspective that Boeing ISN'T
guilty of negligence here, but it's proving pretty difficult. Their defense so
far as to how this should have been dealt with basically boils down to "RTFM,
we explicitly put it in the emergency checklist that yoke pressure won't fix
this, so bad on you if you didn't read it".

I understand that it probably SHOULD have been read, but I'd imagine that a
line about this particular scenario could easily be overlooked even if one did
review the emergency procedures for the MAX aircraft before piloting it. That
is still a pretty flimsy excuse even if there is a grain of truth. This isn't
some Monday detail that will cause a redeploy next week. A large number of
people are dead as a result of this accident.

How a system that can so stubbornly keep overriding manual input made it onto
a modern aircraft is concerning. I will admit that I am not in the industry
and am speaking from a platform of ignorance, but it's less than comforting
knowing that I may go up in a plane with such technology in place.

~~~
gumby
Certain industries, like air transport, pharmaceutical manufacturing etc have
developed protocols for which "RTFM, we explicitly put it in the emergency
checklist that yoke pressure won't fix this, so bad on you if you didn't read
it" actually _is_ not just a reasonable response but the _right_ one. There's
a whole infrastructure of update notices, how updates are published, and a set
of protocols for making sure people are up on the latest SOPs (and tracking
who is, who is authorized to do X and Y, etc. This bureaucracy is specifically
designed to prevent events of this type.

Hell, every aircraft is slightly different and the pilots and/or service
people don't treat them as such (although in practice typically the
differences may be negligible for the pilots -- but they will check).

So based on that it is absolutely the airline's responsibility to make sure
that the people operating any equipment are checked out on it.

So it is _possible_ (though pretty unlikely) that Boeing failed to follow
their protocol, e.g. didn't send out the right notices on a timely bases or
something, and if so they would be responsible. But with all the airframes
they've shipped over the decades that's pretty unlikely.

~~~
Rooster61
> So it is possible (though pretty unlikely) that Boeing failed to follow
> their protocol, e.g. didn't send out the right notices on a timely bases or
> something

From what I have been reading in other articles (sources available if you
wish), most of the comments from folks in the industry have been that Boeing
DIDN'T give the normal, proper notice to airlines. The prevailing sentiment is
that most everyone was caught relatively unaware that this feature had been
shipped on the new airframe. Mind you this is mostly hearsay from mainstream
media, so I am taking this with a grain of salt. Oversights tend to get
sensationalized.

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GreaterFool
I won't be flying 737-MAX. Hell no.

