
US pressured Dutch Safety Board to downplay tech faults in 2009 Boeing 737 crash - BurnGpuBurn
https://nltimes.nl/2020/01/21/us-pressured-dutch-safety-board-downplay-tech-faults-2009-turkish-airlines-crash-report
======
DCKing
Worth noting in Dutch news that the safety board chairman confirms US
pressure, but denies that they altered the report or that the report downplays
the tech faults in the first place [0].

[0]: [https://nos.nl/artikel/2319562-van-vollenhoven-vaker-druk-
ui...](https://nos.nl/artikel/2319562-van-vollenhoven-vaker-druk-uitgeoefend-
maar-we-bleven-altijd-onafhankelijk.html)

------
laydn
From Chernobyl (TV series):

"When the truth offends, we lie and lie until we can no longer remember it is
even there, but it is still there. Every lie we tell incurs a debt to the
truth. Sooner or later, that debt is paid."

~~~
arethuza
I guess there are people who really believe that reality is malleable and if
you say something often enough it becomes "true", as O'Brien explains in 1984:

 _" I tell you, Winston, that reality is not external. Reality exists in the
human mind, and nowhere else. Not in the individual mind, which can make
mistakes, and in any case soon perishes: only in the mind of the Party, which
is collective and immortal. Whatever the Party holds to be the truth, is
truth."_

~~~
clauderoux
We do not talk about reality anymore. This is so 20th century stuff... We talk
about alternate facts...

------
tda
Relevant comment from yesterday:
[https://news.ycombinator.com/item?id=22101953](https://news.ycombinator.com/item?id=22101953)

"Even a fix now proposed for the Max has similarities with the past: After the
crash near Amsterdam, the F.A.A. required airlines to install a software
update for the NG that compared data from the plane’s two sensors, rather than
relying on just one. The software change Boeing has developed for the Max also
compares data from two sensors.

Critically, in the case of the NG, Boeing had already developed the software
fix well before the Turkish Airlines crash, including it on new planes
starting in 2006 and offering it as an optional update on hundreds of other
aircraft. But for some older jets, including the one that crashed near
Amsterdam, the update wouldn’t work, and Boeing did not develop a compatible
version until after the accident."

~~~
ShamelessC
I don't know anything at all about aviation, but if redundancy of sensors is
so crucial to these systems then why don't they have like 10 of them on there
just in case? Are they particularly expensive? Do they need to be in certain
locations on the plane to work properly?

I'm obviously thinking about this from a software point of view where
redundancy is cheap but I am curious if it's just greedy cost cutting or if
there are legitimate reasons for this stuff.

~~~
Anarch157a
Because that would add several million dollars to the airplane's price. An
angle of attack sensor (the sensor MCAS relies on) for a small, twin-engine
private jet can cost nearly $50,000. The ones in the MAX cost a lot more.

Even if cost wasn't an issue, space and weight are. There are just so much
stuff you can tackle on the fuselage or inside the engine cowling before it
starts affecting the airplanes ability to fly.

------
_-___________-_
It's really easy to pile on and see every single 737 crash from the past as
somehow related to the MAX crashes now.

There are actually very few similarities between this crash and the MAX
crashes. The failure was in one part of a highly redundant system with
additional warning systems. The pilots failed to correctly react to the
failure and failed to do basic airmanship like monitor their speed until it
was too late.

Whereas the MAX failures may well have required well-above-average piloting
skills and instincts to successfully recover from, this one simply required
basic competence and attention.

~~~
blub
Why are you focusing on the technical dissimilarities instead of the poor
design based on one sensor and "blame the pilot" similarities?

~~~
_-___________-_
I don't believe the concept of "blame" has any place in air accident
investigation. Pilots should be able to report their mistakes without fear of
prosecution or internet mobs, and investigations should be able to highlight
errors on the part of pilots where they exist without the same kind of fears.

This is not an automatic system relying on a single sensor, as MCAS was. An
airliner in flight is a complex system of which the two pilots are a very
significant part. There were multiple failures here, and the technical failure
was not particularly unusual. What was quite unusual was a failure of basic
airmanship on the part of the pilots. A good investigation would (and did)
look at how that situation came about so that training or human-machine
interface can be improved to prevent it happening again. It's not about
blaming, it's about understanding.

~~~
iknowalot
That sounds interesting, but I still blame Boeing, liability is about blame
and Boeing has been bending over backwards to blame pilots for its own
technical failures.

~~~
_-___________-_
This kind of absolutism really doesn't help.

Air travel has made absolutely enormous strides in safety mostly because of
rational investigations that don't focus on one party but try to understand
all the factors that lead to an incident. The irrational, emotional response
to the MAX incidents is eroding that.

Boeing and the FAA definitely have significant issues in culture and
oversight. They should be resolved so that Boeing can continue to build safe
aircraft and the FAA can effectively oversee the US aviation industry.

At the same time, not every pilot in every flight deck is the same. Some are
more capable than others. Some have been trained better than others. Some come
from a culture where the "power gradient" between captain and first officer is
hard to overcome in order to provide effective CRM. Some come from a culture
where they're afraid they'll lose their job if they accurately report
incidents. All of these things, and more, are factors in air safety.

Focusing on one factor or one company really doesn't help.

~~~
DrScientist
Hmm.

Agree willingness to own up and discuss errors is critical to long term
airline safety.

However you only seem to be applying this to pilots and not to Boeing!

Isn't the issue with the MAX, and potentially now earlier episodes, that for
perhaps perfectly understandable commercial reasons, Boeing and even the FAA
haven't been upfront and honest about engineering issues and how to improve
stuff - ie _they_ have been guilty of playing the blame game - on to pilots -
who are often conveniently dead.

~~~
_-___________-_
I think I've been quite clear that I see significant issues within Boeing and
the FAA and that they should be resolved.

If you ignore the shrill media and look at the actual investigative work going
on, I don't think anybody is seriously suggesting that the pilots were the
sole cause of the MAX issues, and certainly nobody is "blaming" them.

At the same time, I don't know anyone working in aviation who thinks it's 100%
a coincidence that the first crashes happened with those two airlines. There
are always multiple factors in play.

My personal view on it is: the MAX was a flawed design due to the expectations
it placed on pilot training, competency and in particular, instinct in a
surprising situation. That's it. The aircraft was still capable of flying if
the pilots reacted correctly to the failure, and the reaction was one that
they were in theory trained for, but it's not reasonable to expect an average
pilot to be able to do that instinctively in the time available.

Talking about "cost-cutting" or whether a certain engineering decision was
made to save money is irrelevant, because engineers make trade-offs every day
- that's an important part of their job - and every single aircraft flying
(yes, including Airbus!) has a design that involves trade-offs, even in
safety-related things. For reasons that are now being explored, Boeing's
engineers made faulty assumptions when evaluating those trade-offs, probably
augmented by pressure to avoid mandated additional training of pilots, and the
regulatory oversight didn't catch it, or didn't want to due to being in a too-
close relationship with Boeing. Those are the problems that need to be solved
on the aircraft side.

I'm sure that given enough time you would have seen MAX crashes from other
airlines, but it's no surprise to me that the first crashes (and, in an
alternate reality where the MAX continued to fly, likely the majority of the
crashes) were with airlines that are well-known in the industry to have lower
standards of hiring, training and maintenance. Digging into that might well
find some problems that need to be solved on the human side.

~~~
DrScientist
> and certainly nobody is "blaming" them.

Not now the facts have come out, but originally - how about:

Congressman Sam Graves:

"In May, Graves insisted that “facts in the preliminary report reveal pilot
error as a factor”. He went on to claim that “pilots trained in the US would
have successfully been able to control this situation”.

[https://www.bbc.co.uk/news/extra/sd9LGK2S9m/battle_over_blam...](https://www.bbc.co.uk/news/extra/sd9LGK2S9m/battle_over_blame)

> At the same time, I don't know anyone working in aviation who thinks it's
> 100% a coincidence that the first crashes happened with those two airlines.

And here you are effectively repeating that.....

You basic premise is ridiculous. The idea that because some airlines/pilots
aren't as good as others, then it absolves Boeing.

Boeing should not be selling a plane into a market that don't cover markets
natural variant in pilots and airlines. That's like selling a car only F1
drivers can safely drive to the general public ( and crucially without telling
them it's really F1 driver only... ) and claiming it's perfectly safe despite
lots of crashes because Lewis Hamilton doesn't have a problem with it.

You could also argue the second crash happened because of the blaming of the
airline/crew on the first crash.

Sure there are other factors - it's a question of how many times do you have
to roll the dice before you get a crash - clearly far too few in this planes
case - and that is _entirely_ Boeing's fault.

~~~
_-___________-_
I'm not claiming that anything absolves Boeing, and I can't see how any of my
words can be interpreted in that way. I encourage you to read what I'm
actually writing rather than imagine what I'm thinking.

There are serious issues to be resolved by Boeing and the FAA. There are
issues to be resolved around airline company culture. There are issues to be
resolved around pilot training and other human factors.

This " _entirely_ Boeing's fault" stuff just encourages a blinkered view of
the situation and is exactly the absolutism I was referring to in my
grandparent post.

This absolutism is encouraged by the media (just look at that BBC headline:
"Battle over blame") and is thankfully absent from the actual investigative
work.

While I have no idea why hot air from a congressman is relevant here, the
first quote from Graves is accurate. Pilot error was identified _as a factor_
in the preliminary report, and every subsequent report has also identified it
_as a factor_. Obviously there are far more important factors, but it's still
a factor, and every factor should be considered and possibly acted upon. As I
mentioned in a grandparent comment, the multi-factor approach to accident
investigation is one of the reasons air travel is so safe today.

The second quote is pretty much impossible for him to back up and should
probably be treated as the usual political noise -- he is, after all, a
congressman.

~~~
DrScientist
I said:

> Sure there are other factors - it's a question of how many times do you have
> to roll the dice before you get a crash - clearly far too few in this planes
> case - and that is entirely Boeing's fault.

You said:

>This "entirely Boeing's fault" stuff just encourages a blinkered view of the
situation and is exactly the absolutism

You haven't understood what I wrote.

Let's say there is a dice - that represents the chances of a combination of
different factors occurring ( weather, pilot experience, plane maintenance,
chance of debris hitting sensor, cosmic ray hitting computer - whatever )

What numbers that dice rolls is _entirely_ _out_ of Boeing's control.

However what is _entirely_ _in_ it's control is what happens when particular
combinations, represented by the numbers, come up.

So if there is a plane that crashes only when you roll a six, and a plane that
crashes when you roll a five or a six, clearly the second plane is 100% worse
and yes the individual crash depends on what the dice rolled - but the
relative safety of the plane doesn't!!!

Do you understand now?

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ecliptic_pole
The fact remains that this crash was 99% pilot error. The A/T displaying
"RETARD" for something like 60 seconds and the airspeed got down to something
stupid like 80 knots (airspeed is prominently displayed in at least 3 places
right in front of both pilot's faces) so it was pretty obvious that the auto
approach was not correctly configured, but what did the pilots do? Nothing.
They just sat there gormlessly for over a minute, oblivious to dozens of
warning signs right in front of them. No pilot should rely on the radio
altimeter so much that they literally fall out of the sky when it fails.

Every single Boeing plane has two buttons called "autopilot disconnect" and
"autothrottle disconnect", and when you press them, then you can fly the plane
and it will do exactly what you tell it to do. I mean _fly_ the plane, i.e.
left hand on yoke, right hand on throttle, feet on pedals. If those systems
fail, then yes, blame the manufacturer. But those systems basically never
fail.

~~~
tapland
When landing there is a lot going on. I don't know how airliners do it but at
those airspeeds and especially when landing an audio readout of airspeed for
every 10 knots dropped would be very useful.

~~~
ecliptic_pole
Boeing planes do have some features like that, one is called GPWS ("Ground
Proximity Warning System") and it yells things like "Sink Rate, Pull Up"! and
then it makes obnoxious "Whoop! Whoop!" noises. There's also the "stick
shaker" which literally starts violently vibrating the stick (which is
basically in between your legs so it's impossible not to notice) and also
makes a lot of noise. But I don't believe any amount of aural warnings will
help a pilot who has decided to leave the autopilot on below 1000 feet when
it's perfectly obvious the plane isn't correctly configured at all.

~~~
_-___________-_
Turkish does seem to have some kind of problem with the landing phase in
general:

* THY A333 at Port Harcourt on Dec 31st 2019, runway excursion, tyre damage

* THY B738 at Odessa on Nov 21st 2019, runway excursion and nose gear collapse on landing

* THY B738 at Lviv on Jan 6th 2019, runway excursion during backtrack

* THY A321 at Bucharest on Jun 22nd 2017, overran runway on landing

* THY B738 at Pristina on May 2nd 2016, runway excursion on landing

* THY A319 at Sochi on Sep 28th 2016, ATC prevented controlled flight into terrain

* THY B738 at Nice on Aug 27th 2016, went through extended centerline and descended below safe height

* THY A321 at Tbilisi on May 5th 2016, hard landing

* THY A343 at Antananarivo on Jan 9th 2016, touched down short of runway

* THY A333 at Kathmandu on Mar 4th 2015, runway excursion and nose gear collapse

* THY A320 at Istanbul on Apr 25th 2015, hard landing, go-around, engine problem, gear problem, gear collapse, runway excursion

I could go on...

------
acqq
> the _New York Times_ reports based on _its own research_.

The original NYT article, with only a few HN comments:

[https://news.ycombinator.com/item?id=22098270](https://news.ycombinator.com/item?id=22098270)

"Boeing’s Responsibility in a Deadly Crash ‘Got Buried’"

~~~
breakingcups
People probably assumed it was about 737 MAX crashes, not the older NG.

------
salawat
Hmmm. The only thing I wonder is whether there may be a fundamental
architectural issue with their approach to "Flight Computer in command".

From my understanding, every 737 has two flight computers, but only one is in
command at a time (I.e. generating commands to drive things like A/P, A/T). If
other hardware in the plane is connection-wise split between the two
computers, you will end up in situations where the two computers fundamentally
disagree on what reality is.

The only backup in that case is good airmanship to know that you are in an
anomalous condition, diagnose whether you have a set of gauges that you can
rely on, and finally, what to do about it. ATC could have been utilized to
cross-check instruments.

This is honestly non-trivial machine operation 101. Your sensors can be wrong.

A resolution I might suggest moving forward is an MFD function that allows
pilots to manually remap avionics data sources in flight. Structure it as a
Source->Sink system. Then again, I'm reluctant to drop that type of burden on
them as it sounds quite similar to the structure of certain other software of
I'll-repute; however, it would provide a remediatory mechanism a Pilot could
utilize in flight.

Though it doesn't help at all if everything is hosed. That's what A/T A/P
disconnect and stick and rudder skills are for though.

Overall, it does strike me as possibly being same in type in terms of
manufacturer philosophy playing a part; but in this case there was enough done
wrong by the pilotsthat it doesn't necessarily seem like a worthwhile hill to
die on to go after Boeing for it.

Interesting there was explicit pressure against doing so though. That raises
questions, but sufficient time has gone by that likely most documentation to
be investigated is long gone.

------
bolle
The Dutch Safety Board published the original technical report by Prof. Dekker
[0].

[0]: [https://www.onderzoeksraad.nl/en/page/16227/turkish-
airlines...](https://www.onderzoeksraad.nl/en/page/16227/turkish-airlines-
rapport-prof.-dekker)

------
dangjc
It's bad to rely on national champions like Boeing. Like Blackberry and Nokia,
their pride leads to their eventual fall, taking out thousands of jobs with
them when an upstart from outside (Apple) surges ahead. Better to have
multiple smaller active competitors.

------
LoSboccacc
sure it was an hardware fault that started the event, but now blaming the
whole thing on a system that has a warning system, duplicate readings to check
faults and bypasses to work around the issue is deeply misguided and ignores
simple facts about how safety is attained in aircrafts: trough redundancy and
training.

this is completely different from the mcas where the default configuration
lacked redundancy, the pilot lacked training and the bypass procedure
ineffective unless executed at low speed and high altitude before the dive
would lock the trims

~~~
blub
Boeing's cost-cutting design and their culture of covering their own ass and
blaming the pilot seem particularly relevant and relatable.

~~~
LoSboccacc
no, it's not relevant unless you can substantiate how the cost cutting was
related to the crash and it'd be an hard case to make, since the faulty system
were redundant and the warning themselves were redundant with lights, audibles
and whatnot. the hardware did all it could to get the pilot to go around and
reassess the situation.

------
rahuldottech
Because do human lives even really matter anymore? Nah, screw 'em, hurrrr
money!

