
What Really Brought Down the Boeing 737 Max? - xmmrm
https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-crashes.html
======
miketery
"If you repeat a lie often enough, people will believe it, and you will even
come to believe it yourself." \- Dr Joseph Goebbels.

My god, the PR on behalf of Boeing by The NY Times is embarrassing. The
accidents were the result of various actions which increased the risk and
decreased safety. All beginning with moving the engines forward and up which
changed the flight envelope, requiring more complex systems. Followed by not
informing pilots of said new systems, and additionally selling as an add on
(for profit reasons) indicators which would have informed pilots whether this
system was activated.

Imagine your cruise control automatically was turning on in your car, but you
had no idea, and hitting the brake pedal did nothing. This is what those
pilots were experiencing.

Planes aren’t hard to fly if you follow basic principles, take appropriate
safety measures, and know the physics.

Responsibility for these deaths rests with Boeing.

~~~
zaroth
I like the brake pedal analogy. It's not perfect, but it makes the point well.
To add insult to injury, when the driver flipped a cut-out switch to disable
the cruise control, the brakes were useless, the manual brake adjustment lever
failed, and the only documented procedure to fix them at that point (for that
model plane, err, car) was to turn cruise control back on.

~~~
dsfyu404ed
As someone who's driven a lot of vehicles in various states of mechanical
failure I don't. Once you stop treating a vehicle as a magical black box where
everything affects everything the analogy falls apart.

Vehicles have predictable failure mode and systems that are integrated with
each other in known and fairly standardized ways. Short of catastrophic
mechanical failure (i. e the front fell off) someone with sufficient
experience to recognize what is going on should be able to disable systems
until some level of basic control is restored. Your brakes have nothing to do
with cruise control other than having a little switch on them (usually two
switches) to tell cruise control to turn off when you press them. I feel like
airline pilots should in theory have that level of understanding of the
systems in their aircraft since they are trained professionals and the stakes
are very high so they need to be able to handle failures gracefully.

And before anyone puts words in my mouth I'm not saying Boeing isn't the most
at fault party in all of this.

~~~
CaptainZapp
_I feel like airline pilots should in theory have that level of understanding
of the systems in their aircraft since they are trained professionals and the
stakes are very high so they need to be able to handle failures gracefully._

I agree. But you need to knowe that a system exists in the first place.

Something the manufacturer failed to document to begin with.

------
pytester
This reads like yet another PR attempt by Boeing execs to shift the blame for
the deaths away from their chronic mismanagement to pilot error.

~~~
wayoutthere
I would actually _still_ place this failure directly at Boeing's feet.

Games like the ones Boeing was trying to play (overhauling an entire aircraft
without having to change type rating and retrain pilots) directly lead to
situations like this. Yes, the FAA / NTSB should have been more effective, but
regulatory capture like this is common. It's ultimately Boeing's job to manage
the risk: losing 2 airframes in a matter of months because pilots weren't
trained on the aircraft _as a result of Boeing 's mismanagement_ has done
catastrophic damage to their reputation that will take decades to repair. They
will now be under a microscope for everything they do, which means they can't
use a lot of the less risky cost-cutting they were likely doing before.

The net result of Boeing's machinations to keep the 737-Max at the same type
rating led directly to a situation where pilots were not sufficiently trained
in the functionality of the aircraft. So I have zero sympathy for the view
that Boeing is not entirely responsible for this situation.

~~~
pytester
Yes, I'm surprised that more shareholders and more of Congress haven't been
calling both for Dennis Muilenburg's head and the end to self certification.

~~~
sseveran
It might make everyone feel better if he was fired, but little else. He became
CEO one month before the first fuselage was completed and six months before
the first flight, having been in charge of the defense unit. Perhaps a better
but less satisfying target would be Ray Conner
([https://en.wikipedia.org/wiki/Raymond_Conner](https://en.wikipedia.org/wiki/Raymond_Conner))
who was head of commercial aviation from 2012 to 2016, or perhaps Jim Albaugh,
his predecessor. Crucial engineering decisions would have been made during
these years.

------
SolaceQuantum
_" Even more pernicious was the F.A.A.’s longstanding delegation of regulatory
authority to Boeing employees — a worry that is perennially available to chew
on if you like and may indeed be related to the configuration of the
troublesome system as it was installed. Nonetheless, in Seattle, at the level
where such small choices are made, corruption, like cynicism, is rare."_

This is really embarassing to read, due to the intense naivete to have these
two sentences side by side.

------
VBprogrammer
> before reverting to a perfectly capable parallel system of manual trim

I don't have time to read the article in detail at the moment but suffice to
say that this is subject to considerable debate.

~~~
Filligree
Suffice also to say that, under heavy aerodynamic load, manual trim requires
enough physical force to be the next thing to impossible.

~~~
me_me_me
Correct me if I am wrong, the pilot also need to be is specific position to
have maximum leverage - ergo its not pilots its the plane that is the issue
(or in that case Boeing's management).

------
chmaynard
The author has done a great deal of thoughtful investigative work and that's
always a good thing. However, in his attempt to reach conclusions and assign
blame he has diluted the effectiveness of the article. I'm very interested in
this topic, so I skimmed through it (a very long read) and get a sense of
whether it's worth further study. I decided to move on.

~~~
swasheck
Exactly. It reads like an attempt to validate a foregone conclusion using
components of thorough investigation. The author threw in a few gratuitous
statements about how "maybe MCAS wasn't the best idea" so that the they
couldn't really be accused of blindly supporting Boeing.

It sounds like Lion Air were victims of not knowing the systems in place.
Ethiopian Air didn't seem to have the altitude to figure things out in a
timely manner.

This isn't to say that there's not corruption and other things going sideways
in these investigations, but to lay blame squarely on the countries and the
airlines is really disingenuous.

------
cdumler
Can someone validate my thinking here, please? I’ve been watching this saga
for a while and there is something that doesn’t seem to be said that really
bothers me about this whole situation: the failure mode is negative, not
neutral. Here is what I mean.

An aircraft has a flight envelop that defines its flight characteristics. Not
only does it define in how fast or slow or high it can operate, but how that
operation changes if something changes in performance. For instance, engines
under the wing and on the tail cause differences as power is gained or lost.
Under the wing, an increase in power will push the nose up, and a loss in
power will cause the nose to drop. This is the opposite of tail mounted
engines. The whole point of training a pilot is make it instinctive to expect
what the plane will do when things go wrong, ie. if you are in a tail engine
plane and loose suddenly power, expect that you are moving closer to a stall.
The plane will both be raising the nose and losing speed. Again, vice versa
for wing mounted engine. There is also another important point. If the pilot
kills/loses the engine, is a neutral failure: the flight envelope does not
change. The engine is no longer providing thrust so the plane orients merely
to a new position in its flight envelope. But, failure in the flight system
for the Max does something totally different.

The whole point of the MCAS flight computer is make the plane appear as though
it has a different flight envelope. The computer automagically adjusts the
flight services, notably by moving the trim. What really bothers me about the
idea of using software to alter the flight characteristics is that any failure
results in the plane not only falling back on a fight envelope that isn’t what
the pilot trained on, but also to a point in the flight envelope that the
pilot didn’t even choose (ie. trim being in some arbitrary position). Worse
than that, an MCAS failure is negative. The very point of the computer system
is “out guess” and compensate for the pilot’s expectations of his or her
trained flight envelop; thus, if the computer believes it is operating
correctly but is not, it is actively making an arbitrary flight envelope that
could be constantly changing. The pilot must deduce the MCAS software is at
fault while the MCAS software is deducing the pilot is at fault.

Everything I have ever seen is that the whole point of airplane design and
pilot training is to reduce flight problems to known solutions as to resolve
the problem as quickly as possible. The very design of MCAS is failure must
put the pilot into an unknown position and likely be actively combating the
pilot’s understand of the situation. If this logic is correct, I cannot fathom
how any of this is acceptable.

~~~
swasheck
> Everything I have ever seen is that the whole point of airplane design and
> pilot training is to reduce flight problems to known solutions as to resolve
> the problem as quickly as possible. The very design of MCAS is failure must
> put the pilot into an unknown position and likely be actively combating the
> pilot’s understand of the situation. If this logic is correct, I cannot
> fathom how any of this is acceptable.

This is the salient paragraph in this comment. It's ridiculous to blame pilots
for figuring out recovery conditions when they can't be certain of the
parameters in which they're operating.

------
mobilefriendly
Why was this flagged? It is a detailed New York Times article by a respected
aviation journalist. Its opinionated reporting but I was looking forward to
the Hacker News discussion.

~~~
lenocinor
I agree. I'm guessing that, at least for many folks, they didn't know the
context, and assumed that the more positive statements are the result of
naivete or ignorance.

------
hackerNoose
I think it was the first article I've read on the issue that actually
explained all the factors in a clear way. As it's a complicated issue it
needed to be long. Even though the pilots evidently were incompetent, I do
think he's too light on his criticism against Boeing. The failure mode on this
system was too drastic, and unnecessarily persistent. Combined with the fact
that all that was needed was one faulty sensor this was obviously shoddy
engineering.

------
sambull
Trying to get everything under the sun grandfathered in from the old air-frame
(from safety requirements and type rating) is what brought it down. Oh and
being in bed with the people who could have slowed them down and said hold up
here....

------
jmull
I read the whole article. It is long.

The TLDR is something like: the 373 max crashes are the result of a lack of
“airmanship” by pilots of the airlines of developing countries, a quality the
author acknowledges he can’t define. But he feels the pilots make many “really
dumb” errors and are incompetent. And the airlines that employ and often train
them are crappy.

Meanwhile, Boeing is mostly blameless. Sure, there were “bewildering” design
decisions but those didn’t have much to do with it. The article suggests
Boeing’s mistake may have been that, unlike Airbus, it failed to appreciate
how idiotic pilots have become.

Ok, I failed to make my TLDR short.

This article doesn’t go over very well with me. The problem with blaming the
problem on an unmeasureable quality (“airmanship”) is that it leaves no room
for a rational solution. He suggests the max should be ungrounded, but how can
you do that without improving airmanship, and how can you do that if you can’t
meaningfully quantify it?

While it does a great job of presenting many facts across several threads, it
reads like the author wants to minimize Boeing’s responsibility and interprets
all the facts through that lens.

------
qaq
How much does it cost to have an "article" like this posted on NYT?

------
g4d
That's a 14,000 word report with no concluding statement...

------
chmaynard
A friend of mine wrote:

"I don't know whether you recognized the name of the author. He is a well-
known aviation writer and journalist, and the son of Wolfgang Langeweische,
author of the book _Stick and Rudder_. _Stick and Rudder_ has been the bible
for pilots of how planes fly since its publication in the 1940s."

------
ecmascript
Wow, such a long article in what probably could be condensed into 1 a4 sized
page if you really are just about answering the question posed.

Who actually reads articles like this? I am genuinely curious. Comes off as
information overload to me and it's hard to know what to believe.

~~~
matthewtoast
I do. William Langewiesche is probably the best writer on aviation - if you
want really deep and detailed analysis.

~~~
ecmascript
Cool, you must honestly be one of a few. I could never bear myself to read
such a long article even if the topic was of interest.

I can listen to or view content that are hours long but in text format it's
kind of overwhelming to me. Mainly because I cannot do anything else than read
while I am reading which makes reading such a piece a very time-consuming
task. I'd rather do something else than read such an article but it's probably
for the best that there are people like you who like it as well.

~~~
lenocinor
I understand your point, but I read articles like this (and especially ones by
Langewiesche) because there are topics that, for me, I learn better about it
this way. I'm exactly opposite of you -- I generally can't bear to watch
videos or listen to podcasts about these kinds of nonfiction topics because
they feel way too long to me, whereas I can read an article faster and skip
the parts easily that I don't feel are good.

------
zelienople
Finally, one lone voice cuts through the hysteria and garbage and speaks the
unpopular truth.

The good old boy culture of training men inadequately so that they can, at
best, monitor an aircraft's systems, and then pretending that they are pilots
is what killed those people.

You don't like it, but it's the truth.

~~~
salawat
No... Not really.

I mean, I agree with you to a point. There is a delight taken by manufacturers
being able to ostensibly cut training costs.

But in this case, the fact was the plane itself was unsoundly engineered. Even
highly skilled pilots have failed to rescue the plane in a simulator. The
pilot cannot be the primary carrier of blame when the equipment in the best
hands available had only a 66% chance of having the pilot recover AFTER being
made aware of what to expect.

Boeing is definitely the right one on whom to shoulder the blame here.

EDIT: Okay, On further consideration, I do see where you're coming from with
the article's focus on "airmanship". My primary contention, however, remains.
You can put a dangerous plane in the hands of a good airman, and you still
have an airman flying a dangerous plane. That is the issue most seem to be
bothered by. Even if the "modern pilot" doesn't have that visceral connection
to their planes, that's no excuse for a manufacturer to produce one that
requires extreme levels of airmanship to divine the existence of a system they
couldn't admit the existence, severity, or implementation of to regulators for
fear of not meeting deadlines.

Again, I agree with you to a point, and believe you did make a good point.
Just wanted to make it clear that I don't think it should detract from
Boeing's clear malfeasance here.

~~~
zelienople
You wrote "Even highly skilled pilots have failed to rescue the plane in a
simulator".

This is utter nonsense that you either made up or obtained from some
unreliable source. It is categorically false.

The third pilot in the jump seat "rescued" the Lion Air accident aircraft on
the previous flight by simply telling the pilots to disengage the stabilizer
trim. This "rescued" aircraft continued 600 miles safely to Jakarta.

You know nothing and yet you have opinions, and this is now universally
accepted. You are therefore easily manipulated by those who would blame Boeing
instead of the gross and egregious negligence of the pilots, those who trained
them, the airline owners and executives, and the market conditions that forced
Boeing to make decisions in good faith that incorrectly assumed a level of
pilot competency that did not exist.

In the words of the Air France 447 pilot just before he died from his own
gross incompetence, “[Expletive], we’re dead.” And in this, I am referring to
the human species.

~~~
salawat
What you seem to mistakenly believe I'm referring to was the third pilot in
the Lion Air penultimate flight. I was not, but it is a testament to good Crew
Resource Management that he was able to pick out the right course of action
when other pilots were not.

I'm referring to the test pilots test flying the original proposed software
fix before they were forced to reclassify the FCC failure condition to
catastrophic severity due to one of them not successfully saving the aircraft
in a simulated single-event upset. Three pilots were tapped by the FAA to try
to recover from a single event upset which would result in erroneous MCAS
activation.

The two military pilots saved the plane. The civilian test pilot didn't,
resulting in an elevation of failure in the FCC on which MCAS runs to
catastrophic, requiring a fundamental redesign.

[https://www.seattletimes.com/business/boeing-
aerospace/newly...](https://www.seattletimes.com/business/boeing-
aerospace/newly-stringent-faa-tests-spur-a-fundamental-software-redesign-
of-737-max-flight-controls/?amp=1)

I assume the Seattle Times is an acceptable source?

>You know nothing and yet you have opinions, and this is now universally
accepted. You are therefore easily manipulated by those who would blame Boeing
instead of the gross and egregious negligence of the pilots, those who trained
them, the airline owners and executives, and the market conditions that forced
Boeing to make decisions in good faith that incorrectly assumed a level of
pilot competency that did not exist.

Okay. Just stop. I've been knee deep in the investigation and follow-up of
these disasters since about March, and had honed in on the most likely root
cause given a combination of information on motives (Southwest rebate),
culture issues (McDonnell Douglas management strategy from their merger),
fundamental hardware/software design (single AoA sensor, no cross-checking),
basic aerodynamics (consequences of the engines on end behavior), test
piloting (Royal Aeronautical Society, D. P. Davies interviews), experience
with control systems, and research into regulatory minutiae.

Take a spin back through my comment history if you'd like. I was working on
reverse engineering with only publically available information, and got to the
right conclusions within about a month. Got to sit back and check conclusions
off until the Seattle Times formally published their inside story in June.
Suffice it to say, I'm probably the absolute _last_ person you'd want to
accuse of "not knowing anything and being manipulable". The 737 MAX MCAS
fiasco was an absolute travesty from the get go, and any competent computer
scientist would have told them that a computer handling such a critical
function must be _very carefully designed, programmed, and clearly
communicated to the end user_.

I'm _very_ opinionated in this case, mainly because I've taken the time to
become informed enough to truly comprehend how badly Boeing screwed the pooch.
And considering they've had whistleblower testimony that the single AoA
sensor, no cross-check decision was made specifically to avoid having the FAA
refuse to certify the plane on time, that eliminates the idea this was "good-
faith", as good-faith would have been honoring your responsibility to the
public to design a fundamentally safe and well documented aircraft in full
compliance with all regulations.

Whistleblower testimony first mentioned here, in a 60 Minutes Expose on the
MAX.

[https://m.youtube.com/watch?v=QytfYyHmxtc](https://m.youtube.com/watch?v=QytfYyHmxtc).

Thank you muchly, sir, and kindly take your misinformed speculation about my
subject area knowledge elsewhere. It's my business to know why things fail,
even if everyone involved is trying to do their best from keeping me from
finding it. Physics don't lie. People, and especially businesses with
everything on the line, on the other hand, do.

I have a great deal of respect for pilots, but I'm enough of an engineer to
know when someone is putting an operator in serious danger. Boeing checked
_ALL_ the boxes.

I've said my piece. Good day, sir.

------
maxthrow22
>>Immediately after liftoff, the captain’s airspeed indication failed,
airspeed-disagreement and altitude-disagreement warnings appeared on his
flight display and his stick shaker began to rattle the controls in warning of
an imminent stall.

This simple fact has simply been ignored by the broder community on hackernews
who are not pilots. The airspeed indicator is tied into the AoA sensor. The
moment the AoA fails the pilots recieve an airspeed disagreement warning that
must be fixed using the unreliable airspeed checklist. If your analysis of
what happend on either of the accident flight ignores this critical fact you
are wrong.

Welcome to the Danning-Krueger effect in action

~~~
cmurf
What in the unreliable airspeed checklist would have saved the flight?

Once mistrim happens, there is no possible way to get either of the two
flights in question, to either 4 degrees pitch up and 75% N1, let alone 10
degrees pitch up and 80% N1. Any power reduction will cause a pitch down and
make the problem worse. All your advise would do is kill them faster. Mistrim
must be avoided at low altitude, and in these two cases MCAS induced mistrim
faster than it could be identified and avoided. It takes significant altitude
to recover from it, assuming you even know the procedure, which hasn't been in
the 737 FOM for decades. Neither flight had sufficient altitude for that
procedure.

If all of this were just about training and checklists, these airplanes
wouldn't be grounded around the world.

I also find it hilarious you misspell your insult.

