Ch4 Doc tonight 20th Nov: Boeing's Killer Plane

Banzai600

In case anyone interested......Tonight, 9pm

Myself , I know nout about aircraft, but i think this whole situation with the Boeing Max is a farce, hundreds of dead ppl and yet they still keep banging the drum this aircraft is safe , even renaming it ??!!!

When does passenger safety take president over money / stockholders.....or am i missing something? Are they flogging a dead horse repeatedly?

See if this CH4 doc uncovers anything else. Who wants to fly in one, not me. No choice with Ryanair now , their Boeing order still on.



CHANNEL 4

" Boeing's Killer Plane: What Went Wrong?

Unravelling the events that led to two modern passenger jets falling out of the sky, and why the story of the fastest-selling aircraft in Boeing's history ended in tragedy. On 29 October 2018, Lion Air Flight 610 crashed into the Java Sea, and all 189 people on board died. Less than five months later, on 10 March 2019, an Ethiopian Airlines 737 MAX also crashed, and the 157 people on board were all killed. The documentary examines the crash reports to explore how these catastrophes could have been avoided, using state-of-the-art flight simulation and vivid CGI sequences to chart the flights' final moment"

Irish Steve

I'm not expecting this to be particularly good or informative, in as much as the process of fixing the MAX is still ongoing, and has not been finalised, so it's unlikely that this evening's programme will have much in the way of real detail, my fear is that it will be long on hype, repeatedly show badly produced simulations that will only cause people to fear flying in general, and there is also the distinct possibility that if it's been produced by an American company, they will be beating the drum of "badly trained pilots who didn't know how to fly the aircraft", which is not the case.

Boeing have a very clear case of massive deception to answer, and the one thing that is very clear now is that there will have to be significant training changes, and changes to the documentation, Boeing will no longer be allowed to pretend that the MAX is just a renamed NG, which was the way it was introduced.

Irish Steve

Well, I have to admit to being more than surprised by the quality of the program that has just been shown.

The focus of the program did not veer towards sensationalism, and only used simulation segments to highlight the very real difficulties that the crews of the 2 fatal flights experienced, with very appropriate comments from people who were able to interpret what had been happening during the fatal flights.

Boeing have wriggled considerably, and they tried to blame operators for their lack of understanding of the MCAS system, and sought to minimise the clearly demonstrated shortcomings of the MCAS system as it was installed in the fatal crash airframes. They did not come out of the program with any real credibility remaining, and were severely criticised in a number of places.

What was very much missing from the program was any meaningful input from the regulators, and their role in what happened, and what is now happening to make sure that it does not happen again, the emphasis was very much on the 2 fatal crashes, and the effects on the families of the people that died, and their very understandable anger at the way in which Boeing acted initially after the Lion Air crash, and subsequently after the Ethiopian crash.

The very real problem that has emerged of not being able to manually trim a badly out of trim aircraft has been highlighted, and it was made clear that the Ethiopian crew did do what Boeing had recommended subsequent to the Lion Air crash, but despite that, they were still unable to regain control of the aircraft due to the amount of excess nose down trim that MCAS had put into the scenario before it was switched off.

This happened as Boeing had made fatal assumptions about how quickly a crew dealing with an MCAS problem would analyse it, and disable the trim motors, the time "allowed" by Boeing was way too short, the result being that by the time the crew had made an analysis of the problem, and removed power from the trim motors, the MCAS system had already put in more trim than the crew were able to remove using the manual trim wheel, the problem being made worse by the excessive effort required due to the forces being experienced as a result of attempting to correct the nose down moment being applied by moving the control yokes.

The flight crew that did the simulator work were both highly experienced 737 pilots, and it was clear that despite their experience, what happened to them was outside of anything they had experienced in a long flying career. It made for uncomfortable viewing, I did a lot of research work in a number of Level D simulators a long time ago now, where we were deliberately exploring the limits and beyond of the certified flight envelope of a number of different types, so we encountered responses that were unexpected in several situations, but we never had the sort of problems that were evident during the simulations that were shown this evening, it was frighteningly clear that the malfunction of MCAS basically rendered the aircraft unflyable, and even delaying the crash was difficult, due to the inability of the crew to change the massive out of trim situation that MCAS had presented them with as a result of the malfunction.

When in desperation to recover stable flight, they tried to re enable and use the electric trim system to assist them getting it back into trim, the MCAS system made the problem worse by winding in even more nose down trim, due to the nature of the problem with the input to the MCAS system from the damaged AOA sensor.

There was no in depth discussion of the changes that are being made by Boeing to resolve the problems, probably because those changes are not yet final, and looking at the manner in which the problems are manifested, I can see why the resolution is not the quick fix that was first anticipated, and that is probably because the manual trim problems have introduced a second and more intractable problem into the required resolution, it's now not just a case of preventing MCAS from putting too much trim in, they also have to resolve how to get it out if somehow the aircraft does become massively out of trim.

It was very clear that even with the fixes that are required, the manuals and training for the MAX are going to have to be significantly expanded and enhanced to ensure that flight crew are fully aware of what is happening to the aircraft, and the original concept of only 2 hours additional differences training for an experienced 737 pilot is not going to be acceptable for the future, despite the complaints that will come from the operators.

There was no indication in the program of when Boeing expect to be able to resume operations and deliveries of the MAX, my own feeling is that there may still be issues that are unresolved, and it may not be possible to get the aircraft back in the air as a 737 derivative, due to the problems that have been introduced by the changes that made the MAX, and required MCAS in the first place, and whatever about the FAA being unwilling or unable to force Boeing to make major changes, I think we can rely on EASA and other regulators world wide to insist that there can be no chance of another crash as a result of the changes from the NG family.

All in all, a very disturbing and thought provoking programme.

AlekSmart

The Birdstrike on the AoA probe was a new angle to me.
It is also,yet another "Sully" moment,when the value of Seat of the Pants manual flying training & experience,has to be underlined and maintained ?

Cloudio9

Anyone Know if it’s being shown again?

conor_ie

Cloudio9 wrote: »

Anyone Know if it’s being shown again?

Should be available on the All4 streaming service

Wanderer78

Unfortunately the world of large corporations and their ultimate goal of maximising profits at all costs, will always put our lives at risk, and not only in the aviation industry, it's a difficult conundrum, but our world needs companies such as Boeing doing what they do. Looking forward to seeing this documentary

banie01

@Irish Steve, good analysis.

Regarding the lack of input from the regulators.
Given that it's an FAA baby, do you feel they either weren't approached or refused to make a contribution?

The issues around the MAX are well known in Professional and aviation geek circles, they presentation of those issues in the C4 programme was quite even handed IMO.

The F.A.A would IMO be best served by avoiding comment until their liability is settled.
It could well be the case that Boeing's survival at this point hinges upon shifting some degree of liability to them and securing a settlement that can help offset Boeing's mounting costs.

Popeleo

Cloudio9 wrote: »

Anyone Know if it’s being shown again?

If you don't wish to register for all4, it is repeated on their 4seven channel a few times this week, including tonight at 22:00.

Banzai600

yeah, it was an interesting piece by CH4 , glad i alerted ppl it was on now.



as i said, im not a pilot, but Boeing expected pilots to make the "trim" adjustment within 4 seconds of the alarms going off - seriously 4 secs ? Then if you look at winding the trim in the cockpit how long it takes too. Who signed off on this, just nuts!


the angle of decent as they fought it during simulation seem to fight back and get stronger , for every move they made, the plane made 3 opposite moves, almost like the plane was in suicide mode imo. One crash, the aircraft was at 500 knots on impact, scary beyond belief :eek:

also worth noting , Boeing had 4700 orders at 100milion dollars a piece, hows that for incentive eh...money money money.

how can the public trust Boeing now, i dont want to next to near a max regardless of that they say,even if regulators say its ok. its a duff aircraft and that's that.

i hope the families get some recourse, but nobody will be held accountable / negligent for the deaths :rolleyes:


@ irishsteve , agree with op, good analysts.

Tow

This they cover the other 'grandfathered' in issues which the FAA are now looking at. Such as the flight control computer and control lines been too close together.

Irish Steve

The 2 things that did come as "new" to me were the insane timing from Boeing to respond to an MCAS failure, 4 seconds to analyse correctly and then respond to the problem is insane, and unachievable, and the other thing that I'd not already heard on the grapevine was that the AOA issue for Ethiopian was most likely a birdstrike. While I'm no longer at the sharp end of aviation, I still have a lot of contacts who are very much aware of the rumour mill that's ongoing with the MAX, and there are still some issues that are not yet in the public domain, but it's not my place to be revealing them.

What is going to be a challenge is how they deal with the now widely known issue of the excessive load on the trim wheel, while it may have been known about with the earlier NG and previous generations, it was a theoretical possibility, but unlikely, as there was no MCAS driving the aircraft way out of trim as a result of a failure. Yes, an electric trim runaway was possible on the earlier airframes, but as an isolated event, the crew would be very quickly aware of it, due to the noise from the trim wheel, and could respond to it very quickly. Trim runaway can happen on any aircraft that has electric trimming, had it happen to me once in a PA39, and dealing with it wasn't fun in a single crew situation, as it only showed up when the autopilot was disengaged, but the addition of MCAS on the MAX has changed the dynamic and the significance of the trim issues.

As mentioned, there are also some other issues, related to damage as a result of uncontained failures, and that could also prove to be a challenge.

Fabio

Did any of the findings on the programme coincide with what William Langeweische wrote in the New York Times Magazine: https://www.nytimes.com/2019/09/18/magazine/boeing-737-max-crashes.html

From my reading of that he seems to place the blame firmly at the door of the pilots.

Noxegon

That was a good watch. Thanks for sharing.

Irish Steve

I've just looked at the NYT article again, and while there is some validity in the assertion of a decline of airmanship across the industry, and I have seen examples where it resulted in thought provoking results in some outside the normal envelope simulator sessions, the thrust of the NYT article is to try to exonerate Boeing, and that is just not an appropriate route for this discussion to be taking. Boeing were very much at fault for putting in a system that was undocumented, and has the potential to massively unbalance the airframe in a way that has resulted in the loss of 2 airframes.

Airmanship. Historically, a significant number of pilots came to commercial aviation after a career in the armed forces, flying high performance aircraft in a single crew situation, and in many cases, in a combat scenario, where damage was a real possibility, so the way to counter that was to make sure that the training outcome was that they really knew how the aircraft operated, and how to deal with a potentially seriously degraded aircraft. The downside of that situation was that many military pilots were not skilled in delegating or using multi crew resources, which is a fundamental part of commercial aviation, and that was only resolved by the introduction of the multi crew cooperation training concept.

In more recent times, the flow of military pilots has massively reduced, so the airlines have had to find ways to replace that experience and skill set, and the result has been a change in how the airlines operate. Now, what used to be relatively uncomplicated check lists that were used as aide memoires for critical stages of a flight have been replaced by all embracing and complex standard operating procedures that mean everyone has the same basic level of knowledge and understanding of how the aircraft operates. The problem has been made more complex by the reduction in the number of flight crew, and the resultant increase in the workload on the (now) 2 crew, who have to deal with much more than used to be the case, and more crowded skies and higher operating speeds have also added to that issue.

In some respects, the changes have been accomplished, but where it fails is in the name, "Standard" operating procedures, which can and do result in difficulties for all involved when the fault, or problem, for what ever reason is outside of the "standard" definition, and in the absence of underlying airmanship experience, the result is flight crew who cannot recognise what's wrong, and don't know enough about the aircraft to be able to work out what to change to resolve the problem. To compound the problem, the pressures on cost control have resulted in a reduction in the time in simulators to only allow such sessions to deal with meeting the absolute minimum standards required for regulatory certification of the flight crew, so the opportunity to expand one's understanding and knowledge of the aircraft in the safe environment of the simulator is no longer available, the spare slots are no longer there, and a pilot seeking to expand the knowledge of the type is more likely to be suspected of trying to deal with a problem rather than broadening their experience. To make it worse, the old concept of doing significant solo flying in a small analog instrument single engine aircraft has been deemed inappropriate preparation for multi crew flying of a digital aircraft, but what's been lost in among that revolution has been the experience of having to work out what's happening without being able to discuss it with another crew member, while continuing to fly and resolve whatever problem has occurred.

Another issue that I have seen is that senior experienced pilots are not being used as simulator captains, in some cases, relatively junior first officers were used to act as instructors, as simulator sessions became more of a box ticking exercise to ensure that SOP's were being assimilated rather than a safe environment in which to learn and expand knowledge. The problem for me with this is that if an instructor is really good, they are probably only going to be able to impart 80% of their knowledge to their students. When they are moved on, and new instructors come on stream, they too will hopefully impart 80% of their knowledge, but over time, 80% of 80% over a number of iterations suddenly becomes an awful lot less knowledge than was in place when the system first started.

The end result, combined with massive pressures on costs from the beancounters has been a subtle but significant change in the way that the structure and conduct of flight operations now happens. SOP's are now mandatory, and if a pilot goes outside of that framework, even if the result is a "success", they are likely to be asked some very awkward questions, the result being that initiative to expand knowledge has effectively been programmed out of the system. For 99.9 recurring %, that's not an issue, but when something like the MCAS scenario bites without warning, the result is often fatal. Another very clear example was the AF 330 crash into the Atlantic, the crew in charge at the time has been inadequately trained, so didn't know how to respond to a problem that should not have ended in the way that it did.

In those areas, I agree with the NYT article, but where I have problems with it is that subsequent to the crashes, 737 pilots with massive experience, in the simulators, with hindsight, were unable to achieve a different result to the Lion Air or Ethiopian crews, despite their 20K plus hours worth of experience. Even allowing for the discount of the time that the aircraft is flying on automation, 20K hours of experience and being unable to recover means that the way the airframe had been configured by MCAS meant that it had been rendered unflyable, the area they ended up in, massively out of trim and outside of the certified operating environment, was a fatal combination that could not be recovered, and the fact that MCAS was able to put the airframe into that situation has to be attributed to the decisions made by Boeing, and the crews of both fatal flights were placed in situations that could not be resolved by any SOP, or even by some incredibly inventive airmanship.

Yes, the fatal crash crews made mistakes that did not help, but some of that can be attributed to them being overwhelmed by the severity of the handling problems, and the number of warnings and alerts they were being subjected to, their lack of old fashioned airmanship, and the fact that their experience was so far outside of "standard", they had no point of reference to use to try and resolve the problems they were experiencing. Compounding the problems was the failure of Boeing to tell them about how MCAS worked, and the penny pinching absence of a warning about the AOA discrepancy situation only added to the severity of the problems. For me, that is the area of discrepancy between the NYT article and last night's documentary

What is very clear is that this level of failure can never be allowed to happen again. That means that some of the changes that have crept into the design and certification of aircraft have to be unwound, and somehow, the box ticking concept that has taken over training procedures has to be changed to ensure that all pilots have a better understanding of the job they are doing, and appropriate experience of flying that enhances the airmanship experience.

If that means we can no longer fly from Dublin to London for 9.99, and the minimum cost becomes 19.99, so be it, and while it may not be fully understood by the people who fly in the future, a better level of safety has to be worth that premium.

cson

banie01 wrote: »

It could well be the case that Boeing's survival at this point hinges upon shifting some degree of liability to them and securing a settlement that can help offset Boeing's mounting costs.

Boeing are quite literally too big to fail for the US so I could see that happening. They're way to intertwined with the US DoD for them to go out of business. Look at how the 767 ended up being the USAF tanker vs the A330.

cson

https://theaircurrent.com/aviation-safety/new-document-in-737-max-investigation-points-to-chaos-pressure-in-mcas-development/

Jon Ostrower has a number of very insightful articles on it, he's been pretty consistently critical of Boeing throughout the whole affair.

Turbulent Bill

To see where aviation has come from in terms of safety, check out https://upload.wikimedia.org/wikipedia/commons/2/24/1970-2018_fatalities_per_revenue_passenger_kilometre_in_air_transport_%28cropped%29.png as an example. Essentially a 30-fold decrease in deaths over a 50-year period. Obviously multiple factors contribute to this, but I'd guess that automation and SOPs had a large part to play. I'd be extremely wary of rolling back on any of this.

In the MAX case, it's clear that the MCAS automation and SOPs were just wrong. However, it doesn't diminish their value as safety tools, given the millions of lives they save compared to the unfortunate few that are caught by corner cases or (in this case) corporate greed.

murphaph

It became received wisdom that the aircraft manufacturers would put safety first above all else. Boeing has shown that not necessarily to be the case. The MCAS issue is the highest profile story but this has been going on for years. The revelations of angle grinders and hammers being used on inaccurately manufactured frame parts at Boeing suppliers should have been enough to stop this rot when they came out but people had to die first.

Hotblack Desiato

Popeleo wrote: »

If you don't wish to register for all4, it is repeated on their 4seven channel a few times this week, including tonight at 22:00.

Wed 27 Nov 2019 23:05 GMT 104 Channel 4
Thu 28 Nov 2019 00:05 GMT 121 Channel 4 + 1
Tue 03 Dec 2019 02:20 GMT 127 4seven
Tue 03 Dec 2019 23:05 GMT 127 4seven

(Channel numbers are for Freesat)

Fritzbox

murphaph wrote: »

The revelations of angle grinders and hammers being used on inaccurately manufactured frame parts at Boeing suppliers...

What revelations? And what problems did they cause?

Stovepipe

Allegedly, workers were using hammers to drive in "podgers" to align fuselage barrels, before bolting or riverting the barrels together. Nothing unusual or particularly dangerous about that, as long as you are careful but, if you start using angle grinders to cut off excess aluminium, then it gets a bit shaky..........allegedly.

murphaph

I admit that I would have been sceptical of these allegations myself before all the MCAS stuff came out. It's not about what happened exactly but about the managerial culture that allowed it to happen.