
What the Lion Air Pilots May Have Needed to Do to Avoid a Crash - uger
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
======
Someone1234
Great article, unfortunate choice of title and opening image.

A lot of people are going to skip reading it, and assume this is an article
blaming the pilots for this accident, rather than pointing out that neither
the airline nor pilots were informed about Boeing's new systems and so
couldn't have been trained to counteract it.

Boeing's new system wasn't even in the updated manual. And therefore it wasn't
in their QRH, which is likely what they were using while attempting to resolve
the issue.

> With only fragmentary data available, Mr. Hansman said he suspects that a
> runaway of the M.C.A.S. system played a central role in the crash. “The
> system basically overrode the pilot in that situation,” Mr. Hansman said.

Every thread so far about this topic however have managed to find a way to
blame Lion Air, or simply point out how much they suck while glossing over the
actual facts.

~~~
cft
Replacing/overriding humans by shoddy AI will become bigger and bigger
problem. From the Gmail auto-suggestions to the labyrinth of voice recognition
options when you call your credit card or an airline this is all a part of an
unfortunate trend.

~~~
Someone1234
Honestly if the aircraft just communicated what automated actions it was
taking better, it may not have been so fatal.

"STALL AVOID - STABILIZER ADJUSTED - STALL AVOID - STABILIZER ADJUSTED" would
be kinda hard to ignore. Even if they forgot to put it in the manual.

~~~
ganeshkrishnan
Then on most modern aircrafts, these alarms would be going off all the time.
It's more important to know why the computer received incorrect data on the
angle of the plane.

Usually there are three or more sensors reading it and the master computer
uses the voting mechanism to arrive at the correct reading. So in this case
probably the master computer had erred?

~~~
TheSpiceIsLife
I don't understand. Do most modern aircraft fly right at the edge of their
ability to stay in the air?

~~~
ganeshkrishnan
Engine "Stalling" is not a big issue at all. As a part of training we
purposefully stall engines and recover from it. And as angle of attack
increases due to increase/decrease in wind speed, engine stalls can be more
frequent that usual.

~~~
makeset
You are conflating two separate things. Stalls in the aerodynamic sense
(angle-of-attack above critical) have nothing to do with the engine "stalling"
(engine-out) which is a mechanical failure.

~~~
ganeshkrishnan
I should have used better terminology. The article here describes aircraft
stalls and I was talking about the same.

Aircraft stalls are not extra-ordinary events and with auto pilot on the
computer is always adjusting the angle, speed , preventing stall etc.

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WalterBright
Shutting off power to the stab trim system is not complex, and it's why the
switches are right there on the console. The wheel and the sound it makes are
right there and make it obvious when the stab trim system is running.

~~~
DuskStar
And ten minutes should certainly be enough to do that. For that matter, if
you're constantly pulling back the yoke to stay level... Wouldn't you try
setting the trim manually?

~~~
AWildC182
Yea, runaway trim is a failure pilots are aware of. That big wheel spins
whenever the trim changes so they would notice the huge wheel turning,
unprompted, while pulling back on the yoke. This doesn't seem like the whole
story though. They clearly were able to control it for a while and were
probably making trim inputs so why the sudden descent? They probably didn't
turn off the trim motors as the article suggests but should have been able to
keep re-trimming the aircraft indefinitely.

~~~
WalterBright
There's definitely more to the story, as the information we have just doesn't
add up.

Investigation of the wreckage should clearly show what position the stab trim
was at. It's a large nut on a jackscrew, the disintegration of the airplane
should leave that intact. The nut/jackscrew is built out of incredibly strong
steel.

~~~
tyingq
Maybe this?

 _Pilots have long been taught that pulling back on a 737 's control column
can arrest that condition – a fix pilots call a "breakaway", says the APA.

Indeed, American's runaway stabiliser checklist, dated 10 July, says,
"stabiliser trim commands are interrupted when the control column is displaced
in the opposite direction".

But the APA has now learned that the 737 Max is apparently different._

[https://www.flightglobal.com/news/articles/airline-
industry-...](https://www.flightglobal.com/news/articles/airline-industry-
rushes-to-understand-nuances-in-737-453602/)

~~~
Syconious
Some aircraft have yoke aft limit switches that disable electrical stab trim I
believe.

As has been stated above, stab trim runaway is common knowledge and an
emergency procedure (EP) that is trained for. Arresting the descent with yoke
while activating the electrical stabilizer trim cutout and having the pilot-
not-flying manually rotate the stabilizer wheel in the opposite direction or
at least attempting to hold it from adding more trim if cutout is not working.

Many pilots will position a knee or shin on the stabilizer wheel so they are
aware when trim is being run. The yoke itself holds a trim adjustment
mechanism so the pilots can adjust trim while retaining arrest authority on
the yoke as well, though in the case of runaway trim the cutout would be used
and manual operation of the wheel would be required.

I believe another commentator mentioned the jack screw, this will very likely
have survived the crash and investigators will be able to tell exactly where
the nut was positioned (trim setting) when impact occurred.

With stab trim runaway being such well trained for EP [assumed as its common
in my circles] I would be surprised if that were the root cause unless pilot
error is attributed to suspecting another fault mode.

I am not familiar with commercial aviation as much, is it common place to
transition from the critical phase of flight during take off to autopilot (AP)
climb at such a low altitude? If they were not on some sort of AP mode I can't
see how they wouldn't notice the trim being added as a serious issue.

-Sorry I had meant to post this as a response above and not directly to your post

~~~
sokoloff
Most APs are certified for use from 400' above-ground-level on departure and
on a complex departure procedure or in weather, that's not an uncommon
engagement level.

There's a fair number of people who think that pilots are relying on
"George/Otto" too much and should do more hand flying, but I'd imagine if you
peered into 100 airliners on departure, that 95 or more of them are on
autopilot somewhere below 5000' AGL.

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snowmaker
It's not in this NYT article, but from this one
([https://www.cnn.com/2018/11/15/business/boeing-lion-air-
cras...](https://www.cnn.com/2018/11/15/business/boeing-lion-air-crash-
stock/index.html)) apparently Boeing's stock has slid 8% likely because
investors worry that it will have a huge liability associated with this.

~~~
londons_explore
Doubt it. As a non-USA incident on a non-USA airline, compensation will
probably end up being a new plane for the airline and a thousand dollars per
passenger for funeral expenses.

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hhanesand
Blows my mind that Boeing decided not to include this new system in the
“updated” manual.

~~~
JshWright
To be fair, this procedure is not "new". There is a condition known as
"stabilizer runaway" that can occur when there is a failure in the automatic
systems that control the stabilizer trim (for the autopilot, etc). This
procedure is exactly what you would do in that situation to address this
issue.

The problem is the MCAS addition to MAX adds a new failure mode that the
pilots weren't expecting, and it occurred during a very busy phase of flight.

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gok
These articles make it sound like settled fact that this crash was caused by
the anti-stall system. Is that really the expert concensus?

~~~
tyingq
_" Investigators and experts are uncertain why Lion Air Flight 610
plummeted...But they are focusing on an automatic system designed to keep..."_

That's the opener. Seems reasonable to me.

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iwiririwo
Slightly off-topic:

This is an ATC recording where pilots lost control over the aircraft. Figuring
out what to do when the aircraft goes to random directions, they ask for the
direction of the ocean to ditch in. Because of low visibility they have no
idea where they are going.

The description suggests that during maintenance, some steering control was
attached in the wrong way.

[https://youtu.be/kIc8Rr-cKd8](https://youtu.be/kIc8Rr-cKd8)

In this case, the pilots have like an hour to figure out how to control the
aircraft.

~~~
salex89
If they actually reached the sea they would ditch it sooner. Because of the
faulty controls they couldn't orient themselves, and more important, the
airplane did not turn the way they wanted it to, and kept jumping altitudes.
Because of that, at some point they kinda started to figure out how to
manhandle the jet, while waiting the Portuguese F16s to come and help orient
them. If I read correctly somewhere, the autopilot had enough life in it to
keep the plane basically flying. If they were closer to water, maybe this
would not be such a happy story.

The fighter pilot(s) and ATC did a whole lot actually, they seemed willing not
to give up and let them just ditch. The fighter pilots obviously new the local
conditions and airports very well and led them to land.

Sadly, the Lion Air had a different malfunction, they did not have time to
react. Maybe, just maybe, another crew would, but that's not the point. It is
pointless to sorrow about people not doing something they were not trained
for, and possibly not even aware, in a profession heavily dependent on
training and procedures.

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sehugg
Reminds me of the Air France Flight 447 crash, where a unexpected manual mode
leads to confusion and cognitive overload with no time to recover.

~~~
justboxing
> and cognitive overload with no time to recover.

I don't think the Lion Air Pilots would've been able to recover at all, even
if they didn't experience a cognitive overload.

> These steps were not in the manual, and the pilots had not been trained in
> them.

Source: OP

~~~
sokoloff
These steps are most certainly in the manual. Here's the QRH page from a
[different dash number] 737. "No new training" strongly suggests that this QRH
procedure is in the 737-Max as well.

NNC 9.1 (non-normal checklist "Runaway Stablizer") here:
[http://jira.icesoft.org/secure/attachment/21680/qrh%20rev36%...](http://jira.icesoft.org/secure/attachment/21680/qrh%20rev36%20-800%2027k.pdf)

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bredren
Am I missing the interactive part of this article? Seems like a bunch of
static images. Would be cool if it let you perform the operations in some way.

~~~
DonHopkins
Oh the humanity! The NYT has established themselves such a great reputation of
publishing high quality interactive data driven articles, that now people
expect them to include a fully functional flight simulator that lets you
relive the doomed pilot's last few minutes, like the Kobayashi Maru!

That sure would be cool, but some readers might find it a bit too shocking.

~~~
userbinator
To be fair, the URL does have "interactive" in it so expecting some form of
interactivity would not be unusual.

~~~
DonHopkins
You have to open up the JavaScript debugger console to see the interactive job
ad, where you can interactively evaluate JavaScript expressions like:
document.location =
'[https://developers.nytimes.com/careers';](https://developers.nytimes.com/careers';)

    
    
               0000000                         000        0000000
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          00000            0000  00000000       1                00000
        11111            000 00    000000      000                 11111
          00000          0000      000000     00000              00000
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             000        00000      000000       1               000
             000        000000     10000        1     0         000
             000        1000000 00              1    00         000
             000         1111111                1 0000          000
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             111111111        111111111111100000          111111111
               0000000              00000000              0000000
    
    
    
        NYTimes.com: All the code that's fit to printf()
        We're hiring: developers.nytimes.com/careers
    

To their credit, they've come up with an unobtrusive way around AdBlocker that
selectively targets web developers.

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known
Last week I saw the Pilot putting the plane in Autopilot instead of handing
over to copilot/trainee pilot when he went to loo.

