NTSB Comments on Ethiopian 737 MAX investigation

Albany Tom said:
I did think that MCAS had input to auto throttle as well as trim, and that does change my opinion a bit about recovery. But in terms of what caused the accident, it seems clear that two different crews were not able to recover from the failure, even with notices going out after the previous crash. To me that's strong evidence that those pilots just couldn't do it...either they didn't know how, or they couldn't react quickly enough.

I read NTSB as including pilot error as part of the cause if it is POSSIBLE for a crew to recover. But I think it's clear that not every crew is going to be capable of doing that in this case. To me the question is, could the average crew recover the aircraft when presented with the failure during an actual flight? For non US trained pilots, I think the answer here is "no", based on the two crashes.
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Not every pilot is a great or even good pilot. But there was corrective action the pilots here could have taken, but did not. And not some Haynes or Sullenberger thinking-outside-the-box action, a documented procedure. **** happens, and maybe (probably) the system should have been designed so this particular **** didn't happen, but it did, and the pilots didn't do the--documented--right thing. If they had, the plane likely would not have crashed. So how can their failure to do the right thing not be part of the probable cause?
 
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Albany Tom said:
I read NTSB as including pilot error as part of the cause if it is POSSIBLE for a crew to recover. But I think it's clear that not every crew is going to be capable of doing that in this case. To me the question is, could the average crew recover the aircraft when presented with the failure during an actual flight? For non US trained pilots, I think the answer here is "no", based on the two crashes.
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Let me ask you this: Do you think that the crew performance was acceptable? Do you think the training by the Ethiopian Air was sufficient?

Let's forget about running the check list for a second which would have led them to disconnect the electric trim or to disable auto throttle and reduce power. Is it really too much to expect a commercial pilot rated to fly passengers (regardless of whether in the U.S. or elsewhere) upon experiencing an un-commanded nose down trim input to use the electric trim to manually trim it back out?
 
Here are my 2 cents.

MCAS was the probable cause of these accidents, no doubt about it. Boeing added a new system that had a glaring single failure point (using a single AOA) and introduced a new failure mode that pilots were not adequately trained on in order to avoid developing a new type rating for the aircraft. Boeing doesn't care about type rating requirements, but their customers sure do. That's why Boeing keeps reinventing the 737, and Airbus the A320, its what the airline customers want.

However, it would be remiss to not include as contributing factors the pilot training and standards in the countries that the accidents occurred in, and the pilots' actions and inactions in responding to this particular failure mode, which was not unlike other similar trim malfunction failure modes. MCAS aside, these crashes could have been caused by a runaway trim fault just as easily. I do not find it a coincidence both accidents occurred in lesser developed countries with lower levels of aviation safety standards.

One thing I've been curious about, not entirely relevant to this report, is how these small foreign nations and their national airlines had such brand new aircraft, when domestic carriers were just beginning to receive them as well? Historically those nations would receive hand me downs from the more developed world.
 
midwestpa24 said:
Boeing added a new system that had a glaring single failure point (using a single AOA) and introduced a new failure mode that pilots were not adequately trained on in order to avoid developing a new type rating for the aircraft.
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The 737-8/-9 MAX does not meet certification requirements without MCAS even as a separate type. MCAS wasn't installed to keep the airplane under the same type rating. Extra training can not eliminate the need for MCAS.
 
Dig deeply enough and I think you'll find the root cause to be Boeing's corporate culture.

I recently finished reading the book Flying Blind by Peter Robison ( https://www.amazon.com/Flying-Blind-Tragedy-Fall-Boeing-ebook/dp/B08P98854S/ref=sr_1_1?crid=20CHW867P09RV&keywords=book+flying+blind&qid=1672435463&sprefix=book+flying+blind,aps,434&sr=8-1 ). I recommend it to anyone interested in the 737-MAX crashes.

The book is not technical in nature, and if you read it from a pilot's or an engineer's viewpoint you will find technical errors, but that is not really the point of the book. Flying Blind details Boeing's history and the cultural shift that took place over many years. That shift took them away from placing a high value on engineering and on product integrity and moved them toward a myopic focus on financial performance.

When Boeing acquired McDonnel Douglas, part of the deal placed MD executives into key positions at Boeing. Stonecipher was one, of course, but not the only one. Many of these managers, including Stonecipher, were disciples or even proteges of Jack Welch, and they brought to MD and to Boeing that Welch style of cutthroat management that values stock performance over product quality. Slash & burn cost-cutting, extreme levels of outsourcing, and product development shortcuts became common.

One impartial mediator described the new executives from MD as "hunter-killer assassins" and the legacy Boeing executives as "boy scouts."

That type of management might work (for a while) when a company is producing lightbulbs or toaster ovens. It is wholly inappropriate for producing airplanes.

Furthermore, if the management was driving toward a disaster-prone culture, the engineering organization at Boeing was equally at fault for not fulfilling their professional obligations to public safety. They allowed themselves to be seen and treated as labor rather than as professionals, forming a union and engaging in strikes over wages instead of going through professional channels and raising hell to the public and to the airlines about the issues with Boeing's products.

In the end, if it hadn't been the MAX it would have been some other disaster. What happened, from poor design to misleading the FAA and the airlines about the need for training and simulator updates, was the inevitable result of a rotted culture.

And it won't be fixed anytime soon. It took a new management team a few decades to create this problem. Unless Boeing cleans out the management ranks top to bottom, makes a true shift in company philosophy, and somehow engenders an engineering organization that takes their responsibilities seriously and exercises a degree of autonomy, the problem will never be fixed.
 
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Larry in TN said:
The 737-8/-9 MAX does not meet certification requirements without MCAS even as a separate type. MCAS wasn't installed to keep the airplane under the same type rating. Extra training can not eliminate the need for MCAS.
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Maybe my post was not clear enough. You are correct, MCAS was installed to make the aircraft meet certification requirements. The existence of the MCAS was minimized in the training syllabus in an attempt to avoid a new type rating or additional transition training for pilots. That is where Boeing really screwed up, not the creation of MCAS, but not disclosing it in the differences training.
 
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Half Fast said:
The book is not technical in nature, and if you read it from a pilot's or an engineer's viewpoint you will find technical errors, but that is not really the point of the book. Flying Blind details Boeing's history and the cultural shift that took place over many years. That shift took them away from placing a high value on engineering and on product integrity and moved then toward a myopic focus on financial performance.
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This seems to be a problem with many large corporations these days. The same things are being discussed about Southwest Airlines recent meltdown. Companies have forgotten that the quality of their product and service is what made them successful, and are blinded by the share price. You'd think eventually even these financial wizards would figure that out.

This could easily lead into another topic, big business CEOs. How many of these big shot, multi-millionaire CEOs actually have little value they contribute to the organization? They get paid millions, work for a company for a few years, then move on to another business or industry they have no knowledge of.
 
FYI, I posted the following three years ago in a POA 737-MAX thread. Nothing I've read or heard since (and that's been a lot) has changed my previous opinion. Rather, that opinion has been reinforced.


Half Fast said:
But from what I've read, that rot has led to a weakened engineering organization. If engineers don't feel a deep, in-the-gut, personal obligation regarding the correctness and safety of the products, and more importantly believe they have the authority to speak up and have their concerns taken seriously, the problem still persists. Those attitudes have their source in how the engineers see themselves, the profession, and their roles. Such attitudes and perceptions take time, coupled with lots of positive reinforcement, to change.

I'm speculating about how deep the problem may be at Boeing, but what I'm saying about the effects of such a problem and the difficulty in addressing it is not idle speculation. I've been a practicing engineer at Lockheed for over 35 years, about 20 years in engineering management. Today I manage the chief engineer dept for my business unit (aka "chief of chiefs"). Our culture, at least in my little corner of the company, is quite different from Boeing and I still have to reinforce to my folks their obligations, their responsibility to make their voices heard and to listen to the engineers working for them, and that they work for the engineering organization and not program managers.

Boeing won't fix this by replacing just the CEO, especially not by replacing him with the chairman. A major house cleaning, coupled with explaining what must change and why, is necessary. And then time, with lots of modeling good examples.
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midwestpa24 said:
Maybe my post was not clear enough. You are correct, MCAS was installed to make the aircraft meet certification requirements. The existence of the MCAS was minimized in the training syllabus in an attempt to avoid a new type rating or additional transition training for pilots. That is where Boeing really screwed up, not the creation of MCAS, but not disclosing it in the differences training.
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I don’t recall where I heard it, but to reinforce your point, I believe Boeing also faced an agreed 1mil/airplane penalty with one airline (Southwest maybe?) if the MAX ended up requiring that airline to put crews through new ratings, etc.
 
midwestpa24 said:
The existence of the MCAS was minimized in the training syllabus in an attempt to avoid a new type rating or additional transition training for pilots.
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MCAS isn't complex and as it is an additional function added to the existing speed-trim system. It could have been added to the differences training that each of us (qualified 737 NG pilots) had to do before flying a MAX. Adding it to the differences training would not have created the need for a different type rating. MCAS training was not included because it wasn't thought to be unnecessary as MCAS wasn't designed to activate in the normal flight envelope and, if it did, the crew would use the existing RUNAWAY STABILIZER procedure to mitigate.

Whenever something is changed or added to an aircraft, the foreseeable failure modes are analyzed to classify the risk that each threat would present to a flight. The risk level assigned to an unscheduled MCAS activation was relatively low because the existing procedure would mitigate.

On the 737, the air-data, navigation, flight control computers, and autoflight systems are dual systems. Each side is independent of the other so that a failure on one side won't affect the other side which is still working with valid data. The Captain's flight instruments use the left air-data inputs (pilot, static, AoA, IRU, etc), left ADIRU, left FCC, etc. If a data source, or component, on the left side fails, the data displayed on the Captain's side will be wrong while the data and functions on the F/O's side will remain unaffected. The only interconnect is that there are some comparators which will display an alert that the two sides disagree. i.e. IAS DISAGREE, ALT DISAGREE, etc.

MCAS was designed in the same manner. When the Captain was flying, it would use the left AoA data, left FCC, left ADIRU data, etc. When the F/O was flying, it would use the right data sources. The separation was maintained to prevent creating additional opportunities for a single failure disabling functions, or corrupting data, on both sides.

After the second accident, the risk assessment was reevaluated and changed since they now had real-world examples showing that two-thirds of the crews exposed to an unscheduled MCAS activation failed to perform as expected by accomplishing the RUNWAY STABILIZER procedure. That necessitated the redesign of how MCAS operated. This redesign required combining data from both the left and right systems which created new failure modes which each had to be evaluated and, if necessary, mitigated. That is why the fix took so long to accomplish. The result was a system that is now more complex than the original.
 
midwestpa24 said:
Companies have forgotten that the quality of their product and service is what made them successful, and are blinded by the share price.
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:yeahthat:

Some years ago I read an article about Hewlett-Packard in which one of the founders (I forget which) explained it this way (paraphrasing): "Profit to a corporation is like food to the body. Food is necessary to sustain life, and quite enjoyable, but food itself is not the purpose of life. If a corporation stays true to its purpose, profits will follow, but if a corporation makes profit its focus and loses sight of its purpose, its products will fail and the corporation will fail."

Sadly, that happened at HP. It seems that many corporations end up with executives who only view their jobs as stepping stones and don't really give a rip about the company and its products.
 
midwestpa24 said:
how these small foreign nations and their national airlines had such brand new aircraft, when domestic carriers were just beginning to receive them as well? Historically those nations would receive hand me downs from the more developed world.
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The historical side changed years ago depending on the country and their financial situation. And also their national market. For example, Ethiopia Airlines is one of the few African based airlines approved to fly various ex-pat governmental employees based partly on the new models they fly. You started to see new model aircraft in the smaller countries back in the 90s. Besides the target market for the MAX and NEO was overseas and not domestic prior to covid. However, the MAX performance was so exceptional it became popular everywhere.
midwestpa24 said:
but their customers sure do.
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And its the customer who can exert the most pressure. Its that pressure which led to the NEO then the MAX. With the projected growth through 2030, no operator was willing to wait for Boeing's or Airbus's new clean sheet design. While everyone wants to pile on Boeing, the operators and the FAA are right up there with them in terms of the probable cause of these accidents. Its how the system has worked for years and unfortunately fails dramatically at times.
 
The chain of events includes lack of oversight of the release of that aircraft, with that software and with the same training requirements. So the additional person, in my view, is the FAA. Not the pilots.

Bell206 said:
And its the customer who can exert the most pressure. Its that pressure which led to the NEO then the MAX. With the projected growth through 2030, no operator was willing to wait for Boeing's or Airbus's new clean sheet design. While everyone wants to pile on Boeing, the operators and the FAA are right up there with them in terms of the probable cause of these accidents. Its how the system has worked for years and unfortunately fails dramatically at times.
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I agree with adding FAA as part of the chain. I don't agree with adding the operators, though. Customers in just about any industry are going to ask for more features, lower cost, and faster delivery. The manufacturers have to decide how they're going to meet those requests, and how to balance the risk. If an aircraft manufacture goes to market too quickly, or with a poor product, they accept that risk. Boeing isn't the first to do it, and they won't be the last. NASA did it, trying to launch a shuttle based on extrapolated data and against engineering recommendation.
 
Albany Tom said:
Not the pilots.
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Albany Tom said:
I don't agree with adding the operators,
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Albany Tom said:
Customers in just about any industry
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I don't know what your background is, but the customer/operator in the aviation industry has a legal obligation to maintain and operate their aircraft after Boeing builds it and the FAA certifies it. In the Lion Air accident, the operators pilot did not write up all the discrepancies with the aircraft and their mechanics did not repair the aircraft properly prior to the accident the next day. That was not Boeings or the FAAs fault. In Flight 302, it was EA who assigned a 200 hour pilot as co-pilot and did not ensure their crews were properly equipped to handle the a runaway stabilizer per the latest guidance 4 months after the Lion Air accident. Which was again not Boeing or the FAAs fault. There are a lot of single point failure risks on aircraft but the system in place is only as good as the weakest link. Based on my experience in aviation, I put just as much blame on the operator as I do anyone else. As the old saying goes, anytime you point your finger at something there are always 3 fingers pointing back at you. ;)
 
Half Fast said:
:yeahthat:

Some years ago I read an article about Hewlett-Packard in which one of the founders (I forget which) explained it this way (paraphrasing): "Profit to a corporation is like food to the body. Food is necessary to sustain life, and quite enjoyable, but food itself is not the purpose of life. If a corporation stays true to its purpose, profits will follow, but if a corporation makes profit its focus and loses sight of its purpose, its products will fail and the corporation will fail."

Sadly, that happened at HP. It seems that many corporations end up with executives who only view their jobs as stepping stones and don't really give a rip about the company and its products.
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Not to mention vendors and consultants who sell your execs on the Newest Big Idea that will revolutionize your processes.
 
Half Fast said:
...

Sadly, that happened at HP. It seems that many corporations end up with executives who only view their jobs as stepping stones and don't really give a rip about the company and its products.
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or case about the customers.
 
Half Fast said:
Without having any knowledge about your existing processes, products, organization, or workforce.
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Isn’t that the job of the COO? If your COO is so out of touch that they sign off on buying some BS solution to a problem that doesn’t even exist for the company, it says more about the company buying than the company selling.
 
AKiss20 said:
Isn’t that the job of the COO? If your COO is so out of touch that they sign off on buying some BS solution to a problem that doesn’t even exist for the company, it says more about the company buying than the company selling.
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True but can be difficult with a huge corporation. Sometimes our place would try to roll out things across the entire corporation that worked in one segment but not others. It's hard to make one size that fits 140,000 people dispersed all around the world.

For example, I often saw process "improvements" that were good in a manufacturing environment getting shoved into R&D where they don't work at all. How do you schedule breakthroughs? Apply CPI/SPI metrics to inspiration? Estimate costs for an unknown number of trials?

That's sorta like trying to have Michelangelo make paintings on a production line. "Mr. Michelangelo, if you will paint all the reds first, then paint all the blues, then the greens, and so forth, you'll have less paint switching and save lots of manhours with less brush cleaning and paint mixing. Oh, and I need you to lay out earned value milestones for that Sistine Chapel job we quoted."
 
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Half Fast said:
That's sorta like trying to have Michelangelo make paintings on a production line. "Mr. Michelangelo, if you will paint all the reds first, then paint all the blues, then the greens, and so forth, you'll have less paint switching and save lots of manhours with less brush cleaning and paint mixing. Oh, and I need you to lay out earned value milestones for that Sistine Chapel job we quoted."
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Hapless project manager friend's company installed an always-on EV display in his office. Automatic eye roller it was.
 
When I tagged Boeing, it's like "IF THIS, THEN THAT" in programming. "THIS" is Boeing. "THAT" is pilot mismanagement of an obscure system characteristic. Boeing comes first. The Big Chicken, as it were. Then the Egg splats on the ground.
 
Flying Keys said:
Not to mention vendors and consultants who sell your execs on the Newest Big Idea that will revolutionize your processes.
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I used to work at a place where this happened perhaps every 6-8 months. It was exhausting, and in the end, most of us just disregarded whatever initiative was being attempted, and just went about our jobs.
 
Larry in TN said:
Adding it to the differences training would not have created the need for a different type rating.
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This is purely opinion, and as stated in other posts above seemed to be Boeing/Southwest's primary motivation for attempting to ensure that that references to MCAS were minimized to FAA regulators in an effort to ensure that the plane didn't require a separate type rating.
 
Lowen Loftin said:
This is purely opinion
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It is an educated option based on flying the airplanes and having done many transition training courses throughout my career.

as stated in other posts above seemed to be Boeing/Southwest's primary motivation for attempting to ensure that that references to MCAS were minimized to FAA regulators in an effort to ensure that the plane didn't require a separate type rating.
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It's become the common mantra but that doesn't make it true.

Keeping the MAX under the same 737 type rating was the intention from the start, Boeing's goal, and the expectation of every 737 MAX customer. SWA did not have a larger interest in this than other other 737 operator.

737 MAX differences training consisted of a couple hours of training covering a very long list of differences between the MAX and NG. MCAS, as originally designed, was not a system that pilots had any control over, any indications from, or would ever encounter in the aircraft's normal flight envelope. An un scheduled MCAS activation had been classified as a low-threat failure due to it being mitigated by the existing RUNAWAY STABILIZER procedure. There is no reason why this system would have pushed the design past the threshold for requiring a separate type rating.

What the FAA does do is limit operators from keeping crews current on more than two of the major sub-divisions of the 737 at any one time. i.e. You can flight 737 Classics and 737 NG interchangeably but you must give up 737 Classics before adding 737 MAX. That's what drove SWA to park the last of their 737 Classics before the MAX introduction.

For context, have you ever looked at the differences between the 757, 767-200/300, and 767-400? They are significant. Much more significant than the NG to the MAX and they are all covered under a single type rating.
 
midwestpa24 said:
One thing I've been curious about, not entirely relevant to this report, is how these small foreign nations and their national airlines had such brand new aircraft, when domestic carriers were just beginning to receive them as well? Historically those nations would receive hand me downs from the more developed world.
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"Small foreign nations"? I think you need to get out more. Indonesia has a population of 276 million people and a GDP of over a trillion dollars. I think they can afford a few little Boeing jets just fine.
 
Katamarino said:
"Small foreign nations"? I think you need to get out more. Indonesia has a population of 276 million people and a GDP of over a trillion dollars. I think they can afford a few little Boeing jets just fine.
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Seriously. Ethiopian has an annual revenue of 5 billion. That’s just under a third of that of American Airlines. These weren’t exactly tiny carriers…
 
And yet, the FO had 271 hours. TOTAL time.
 
Half Fast said:
I wonder how much of that time was spent hand-flying a 737. Maybe 20 minutes?
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Boeing selling airliners to Ethiopian is like selling firearms to minors.
 
Half Fast said:
Nah. Bad analogy.

Heck, I gave firearms to a minor. Ask @2-Bit Speed . And owned firearms myself when I was a minor. Quite common around here.
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Yes, but the minors were trained and responsible where I grew up too. It was a cultural thing back then.
 
Piperonca said:
Yes, but the minors were trained and responsible where I grew up too. It was a cultural thing back then.
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Yep.

This is @2-Bit Speed 's growth chart: :)
upload_2023-1-6_16-56-46.png

Started with a Daisy BB gun when he was maybe 7 or so, culminated in a 12ga pump when he was in high school.
 
Piperonca said:
Yes, but the minors were trained and responsible where I grew up too. It was a cultural thing back then.
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Yup…we did firearm safety training, and when the day for shooting came around we loaded our rifles and ourselves on top of the instructor’s fuel delivery truck, and headed out to the gravel pit to shoot. :D
 
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