
Boeing 737 Max Hit Trouble Right Away, Pilot’s Tense Radio Messages Show - alanwong
https://www.nytimes.com/2019/03/14/world/boeing-737-max-ethiopian-airlines.html
======
jcims
Narrative from ASRS 1555013:

I had my first flight on the Max [to] ZZZ1. We found out we were scheduled to
fly the aircraft on the way to the airport in the limo. We had a little time
[to] review the essentials in the car. Otherwise we would have walked onto the
plane cold.My post flight evaluation is that we lacked the knowledge to
operate the aircraft in all weather and aircraft states safely. The
instrumentation is completely different - My scan was degraded, slow and
labored having had no experience w/ the new ND (Navigation Display) and ADI
(Attitude Director Indicator) presentations/format or functions (manipulation
between the screens and systems pages were not provided in training materials.
If they were, I had no recollection of that material).We were unable to
navigate to systems pages and lacked the knowledge of what systems information
was available to us in the different phases of flight. Our weather radar
competency was inadequate to safely navigate significant weather on that dark
and stormy night. These are just a few issues that were not addressed in our
training.I recommend the following to help crews w/ their introductory flight
on the Max:Email notification the day before the flight (the email should
include: Links - Training Video, PSOB and QRG and all relevant
updates/FAQ's)SME (Subject Matter Expert) Observer - the role of the SME is to
introduce systems navigation, display management, answer general questions and
provide standardized best practices to the next generation
aircraft.Additionally, the SME will collect de-identified data to provide to
the training department for analysis and dissemination to the line pilots
regarding FAQs and know systems differences as well best practices in fly the
new model aircraft.

~~~
dredmorbius
What's the source of this and is there a URL? Found, James Fallows at _The
Atlantic_ ;

[https://www.theatlantic.com/notes/2019/03/heres-what-was-
on-...](https://www.theatlantic.com/notes/2019/03/heres-what-was-on-the-
record-about-problems-with-the-737-max/584791/)

~~~
blattimwind
You can't link to these on the ASRS site but that's the primary source.

[https://titan-
server.arc.nasa.gov/ASRSPublicQueryWizard/Quer...](https://titan-
server.arc.nasa.gov/ASRSPublicQueryWizard/QueryWizard_Filter.aspx) put in ACN
= 1555013.

~~~
moftz
That was a terrible experience trying to search for that report.

~~~
blattimwind
I have no idea why many government websites (not just US) are like this;
making things that are _obviously_ not stateful (like viewing a report or
search criteria) session-wide state. It almost feels somewhat intentional to
prevent linking to resources.

------
thedoctor79
The facts so far are that two new aircraft of the same model have crashed in a
very short period of time, in the same stage of flight and exhibiting the same
problem as evidenced by ATC recordings: loss of flight control. We should not
focus only on the software aspect, even though a very questionable (and
dangerous in my opinion) decision was made to not communicate to the pilots
the existence and operation of the software with no additional pilot training.

The software relied on input from sensors at least in the Lion Air crash and
the fact is the sensors failed on new aircraft.

I would trust the NTSB as much as the European counterparts. I have read some
of their reports and they are very dilligent and fair.

We should avoid placing blame now on anyone whether it is Boeing, pilots,
national agencies, until the full reports are available. The grounding of the
aircraft was perfectly justified with the available data from a security point
of view. The air industry has been focused on avoiding a blame culture. Even
I, as a passenger sometimes look for the lowest price, so the pressure for
cost cutting may come from us as well.

~~~
dubbel
> Even I, as a passenger sometimes look for the lowest price, so the pressure
> for cost cutting may come from us as well.

Of course you do, and that is not your fault. This is why we have independent
regulation organizations like FAA or EASA, to not have matters of security
solely in the hand of the free market.

~~~
Tsubasachan
Reminds me of a story of a budget airliner cutting costs by buying used parts
and patching them up. Now nobody had actually tried to do something so
nuts/genius before so there weren't any clear cut regulations. Eventually
there was an accident and the FAA started to put screws under the microscope
and interrogate maintenance crew.

Thankfully the aviation industry nowadays out of self interest cares about
safety.

~~~
amyjess
The usual way I've heard aviation regulations described is that every single
regulation is written in blood.

That is, every one of these regulations exist because somebody died as a
direct result of that regulation not existing.

------
tuna-piano
In the likely event that this is another MCAS related crash, I see only two
possible reasons:

1\. Boeing's suggested process (including flipping the two trim switches and
spinning a wheel) does not work for some reason.

-or-

2\. The Ethiopian pilots did not follow this process.

I see #1 as putting a huge, huge amount of blame on Boeing and the FAA -
especially given their months of "safe plane" reaction after Lion Air and
their cavalier few days after Ethopian.

I see #2 as still keeping a good deal of blame on Boeing, but also adding a
significant training+capability element to Ethiopian and the pilots. Since
Lion Air, how much had Boeing done to specify that the 737-MAX and the 737-NG
are not the same plane and require different things to be aware of? Could a
737-MAX pilot really not have run through in their head a thousand times what
MCAS related issues look like and what they would do if they started having
those issues?

~~~
cjbprime
I think both end up with blame on Boeing. If a discussion in world news isn't
enough to prepare an experienced 737 pilot (ten years!) to counteract spurious
MCAS, then nothing is, at least to the level of safety expected in airline
travel.

A plausible explanation for (1) that I've seen discussed is that, after
disabling the auto trim, it may be impossible to manually re-trim while the
yoke's pulled back, without first relieving aerodynamic stress on the elevator
-- in this case by pointing the nose even farther down temporarily, which no
sane pilot is going to want to do close to the ground.

(I don't know whether it could actually happen this way.)

~~~
VBprogrammer
I think it's unlikely that this crash will be attributed to the same set of
circumstances as the lion air crash. I don't find it credible that an
experienced pilot would fail to catch what, in essence, is a trim runaway
event. There is a reason trim runaway is a memory item on almost all aircraft.
Even in the Lion air case the previous flight experienced difficulty with the
system and dealt with it. This was before the publication and a great deal of
publicity of the details around MCAS. I don't think we've heard anything yet
to suggest this particular aircraft had a fault in previous flights. Another
failure in the AoA sensor on a brand new aircraft seems unlikely.

I don't find 1 particularly compelling, it would have been noted by now if it
was impossible to trim the aircraft using the manual trim wheels. Unless this
is very specific to the MAX.

That said, I think it's entirely possible there is something else wrong in the
control of the MAX.

~~~
cjbprime
> I don't find 1 particularly compelling, it would have been noted by now if
> it was impossible to trim the aircraft using the manual trim wheels.

It has been noted:

737 Flight Crew Training Manual, chapter Non-Normal Operations/Flight
Controls, sub heading Manual Stabilizer trim:

"Excessive air loads on the stabilizer may require effort by both pilots to
correct mis-trim. In extreme cases it may be necessary to aerodynamically
relieve the air loads to allow manual trimming. Accelerate or decelerate
towards the in-trim speed while attempting to trim manually."

In this case the excessive air load would be caused by the yoke control
pulling the elevator up while the trim controlled stabilizer is doing the
opposite.

Like you say, it's hard to know whether this actually happened.

~~~
VBprogrammer
I've seen that before. It certainly doesn't say it's impossible. I need to
have look in the certification requirement but I'm pretty sure it would be
uncertifiable if the trim couldn't be neutralised.

~~~
cjbprime
> It certainly doesn't say it's impossible.

What would it have to say? It says you might have to do X before Y, where Y is
a thing that you need to do quickly while at low altitude to avoid dying and X
is a thing that gives you even less time to do it in and makes the problem
worse.

~~~
mannykannot
Let's work through an example. You are in level, trimmed, manual flight and
the trim system suddenly starts pitching the nose down. As a consequence, the
aircraft will begin descending and accelerating. Your first response, even
before you have recognized that you have a trim runaway situation rather than
just some turbulence, is to pull back, to restore level flight level and bring
the speed down to where it is supposed to be. In other words, you are
decelerating towards the in-trim speed, which is precisely what the quoted
section of the manual is saying you should do.

~~~
VBprogrammer
Unfortunately I think you may be misinterpreting that section in the manual.

From your senario when the trim moves nose down. You apply nose up on the
elevator which makes the trailing edge of the elevator go up which applies a
downwards force on the trailing edge of the stabilizer. In order to move the
trim back towards neural you need to lift the trailing edge against this
force.

If the trim is extreme you may have to relax back pressure to reduce that
force.

By in trim speed they mean the speed at which the aircraft would naturally
settle at given the current trim setting.

~~~
mannykannot
You have a point, but I am not sure that this is a complete analysis of the
situation, because it does not consider the changing moments as the centers of
pressure of the wing and stabilizer move in response to the changing airspeed.
Furthermore, when one moves the elevator of a subsonic airplane, it does not
just change the force generated by the elevator, but also the force generated
by the stabilizer it is attached to (by affecting the airflow over it), so
that is another potential source of changing moments.

Perhaps the phrase "aerodynamically relieve the air loads" means to minimize
the aerodynamic force generated by the stabilizer? The stabilizer of a
conventional airplane will invariably generate a downwards force when the
aircraft is in pitch equilibrium at high speed, but it may be upwards at low
speed, even with the C of G within limits. In such cases, the speed at which
it has no load will be an intermediate one, and therefore could be either
above or below the speed to which the airplane is currently (mis-)trimmed.

The quoted passage says it is referring to correcting what it calls a mis-
trim, so if your interpretation is correct, then where it says "in-trim
speed", it actually means "the speed to which the airplane is mis-trimmed",
while the general usage of the term "in trim" means trimmed to fly at the
intended speed, and I would take the phrase "in-trim speed" to refer to that
speed - the speed that the pilots intend to fly at, or, in other words, the
speed that this out-of-trim airplane would tend to fly at when put back in
trim.

Furthermore, if things are as you describe, then the rule could have been more
simply and clearly phrased as "reduce your pressure on the control yoke".
Maybe your interpretation is correct, but if so, it seems to me to be an
unnecessarily confusing way to describe it.

~~~
VBprogrammer
You make a couple of very good points. And your right, if it were that simple
they hopefully would have described it that way.

In general pitch trim runaway incidents are easiest to control at low speeds.
It gives you more aircraft configuration options available to try and reduces
the aero loads general.

But perhaps they were just not ruling out either.

~~~
mannykannot
I have asked around, and the consensus is that you are correct.

------
dogra
A key problem with Boeing is its complacency when things go wrong. I
personally remember the Lauda Air crash. Boeing's response to it was
unsatisfactory at least:
[https://en.wikipedia.org/wiki/Lauda_Air_Flight_004#Niki_Laud...](https://en.wikipedia.org/wiki/Lauda_Air_Flight_004#Niki_Lauda's_visit_with_Boeing)

------
SpaceInvader
I just hate such links which I could not read without logging in into nytimes
:(

~~~
neonate
Incognito window works for me.

------
neuronic
Let's preface this by saying I am aware that cause of the accident has not
been determined. Seeing reports of experienced pilots being assigned to 737
MAXs without prior flight experience of this precise model, prompts me to make
this comment.

As a passenger I expect pilots to fully know the plane they are flying and to
previously have flown this exact type and model of aircraft in training
sessions without any passengers whatsoever. 737 MAXs seem to have significant
differences compared to other 737 models and airlines appear criminally
negligent in the use of these aircraft.

I used to be a mere bus driver as a college job and I _had_ to train on all
models before transporting any sort of organism with a central nervous system.

But apparently, flying hundreds of people at hundreds of mph at several
thousand feet above the ground doesn't require this sort of familiarity with
the machine. Having flown other 737s and skimming a manual 20mins before
departure was often deemed sufficient, resulting in flabbergasted and
overwhelmed pilots.

Boeing, FAA, airlines... whoever is ultimately blamed in all of this, the
crash has revealed some scary stories in regards to aviation - all for the
sake of cutting costs because people demand to fly across continents for $100.

~~~
raverbashing
> this exact type and model of aircraft in training sessions without any
> passengers whatsoever

Nobody does that in a "live aircraft", that's what simulators are for (and the
whole flight training curriculum, from the first lesson to being able to fly a
commercial jet).

~~~
acqq
And in this case the Boeing's selling point of the MAX was "not even the new
simulator training is needed."

Then we read that the MAX was the "best selling model." It seems, based on the
false advertising, that included not acknowledging the differences. Even the
"less serious" ones:

[https://news.ycombinator.com/item?id=19374386](https://news.ycombinator.com/item?id=19374386)

"I had my first flight on the Max [to] ZZZ1. _We found out we were scheduled
to fly the aircraft on the way to the airport in the limo. We had a little
time [to] review the essentials in the car._ Otherwise we would have walked
onto the plane cold. My post flight evaluation is that we lacked the knowledge
to operate the aircraft in all weather and aircraft states safely.

The instrumentation is completely different - My scan was degraded, slow and
labored having had no experience w/ the new ND (Navigation Display) and ADI
(Attitude Director Indicator) presentations/format or functions (manipulation
between the screens and systems pages were not provided in training materials.
If they were, I had no recollection of that material)."

------
exodust
"You're in private mode" (no article for me).

Is there another way to view the text?

~~~
LeoPanthera
[http://archive.is/Qk7PU](http://archive.is/Qk7PU)

~~~
Moru
"Hmm. We’re having trouble finding that site."

Using cloudflares DNS 1.1.1.1. Seems that does not work since a while.

[https://community.cloudflare.com/t/1-1-1-1-does-not-
resolve-...](https://community.cloudflare.com/t/1-1-1-1-does-not-resolve-
archive-is/28059/10)

A lot of blame to and from who is responsible for the problem, still no
solution apparently.

~~~
dredmorbius
Try; [http://archive.fo/Qk7PU](http://archive.fo/Qk7PU)

The .is domain has been occasionally problematic.

~~~
Sylamore
archive.is/fo basically doesn't work with cloudflare DNS due to a
misconfiguration by whomever runs the archive.today service. It has been
reported by multiple people to the site operator and at this point it seems
likely intentional.

~~~
Moru
I just used my normal DNS server to get the correct IP and put that IP in my
pi-holes hosts file and now it works just fine.

