Ethiopian ET302 Crash.

[oil_film_movies]

Originally Posted by DoubleWasp
Most of us would have never heard of Lion Air had somebody said "this plane has a problem. maybe let's fix it correctly."
As a flight conrol engineer for many years, any dissension from what senior management wants or believes is not allowed. Its the business world. They can always come up with intellectual arguments to support rushing the cert out the door.

I'm certain someone did say "this plane has a problem, maybe let's fix it correctly." There is a long history of disagreement with management in the engineering field. The power & risk management is with the execs though, make no mistake. Their call, not engineers who might sow discord being too careful and too risk averse.
----> Boeing simply thought pilots would hit the cut-out switches, kinda a simple thing.... or maybe not, as we know now.

 

[4WD]

Collected a fair number of these on KLM MD-11's … always good flights …

 

[Astro14]

Swiss Air 111 is a very misunderstood, and misrepresented, accident.

The airplane was improperly wired by the IFE vendor. The IFE should never be on the essential bus. Circuit breakers should not be used as switches. MPET insulation gives off toxic fumes when it burns.

It was 21 minutes from the first odor in the cockpit to water impact.

21 minutes.

The crew responded quickly, and correctly, to the emergency, but they didn't have the time. They never held, or dumped fuel, though it was discussed with approach control. They didn't have the time to land the airplane because the fire continued to worsen, and the kapton wiring insulation was poisoning them as well as

Shutting down cabin power left the IFE energized, though the wiring was arcing and shorting out, and killed the cabin fans, allowing the smoke to worsen. But they were following book procedure.

If the CBs had worked properly, the arcing might not have happened (arc faults are different than shorts, and often won't trip CBs, but in this case, the CBs had been used as switches so many times, that they didn't trip when they should have.)

If the IFE was on the Galley bus (where it should be) then killing cabin power would stopped the arcing and removed the source of the fire.

If the IFE wiring didn't penetrate the cockpit bulkhead by the ventilation duct, the fire couldn't have spread so quickly to the cockpit.

The toxicology on the crew was inconclusive, but they may have been poisoned by the fumes. Even though they were wearing their oxygen masks, the smoke was thick enough for them to absorb the toxins through their exposed eyes. They likely lost their primary flight displays in a cokpit so filled with smoke that they couldn't see outside.

Had they headed straight for Halifax when smoke was first detected, they still may not have made it.

They had no time.

And the wiring route, arcing wires, CBs, and essential bus all worked together to create a fire that had easy access to the cockpit and could not be put out.

http://www.tsb.gc.ca/eng/rapports-reports/aviation/1998/a98h0003/a98h0003.pdf

 

[fdcg27]

I've read that the Swissair crew spent at least some time loitering while thinking of dumping fuel.
That was apparently wrong.
A third of an hour to get the airplane turned around, an approach flown and landed isn't much.
Who approved this vintage car audio style install?

 

[Astro14]

It's a long, but interesting, read.

So many factors in that one...

 

[john_pifer]

Originally Posted by fdcg27
I've read that the Swissair crew spent at least some time loitering while thinking of dumping fuel.
That was apparently wrong.
A third of an hour to get the airplane turned around, an approach flown and landed isn't much.
Who approved this vintage car audio style install?


Good question. If the IFE was connected to the entirely wrong bus, I'm just wondering how in the world that happened.

 

[BusyLittleShop]

Some pilots can't even handle a routine flight and here Tex Johnson performs
aerobatics in a Ford Trimotor the best commercial aircraft America had
in 1929 and here he barrel rolls the 707 prototype to impress perspective
buyers not to mention startled an unsuspecting Boeing president, Bill Allen.

We know if Tex Johnson was flying the 737 that day he could have not only
saved everyone on board but barrel rolled the whole mess without spilling
anyone's beverage.. he was highly skilled at managing an aircraft energy
without going negative G... he was one of the most sought after engineering
and development test pilots in our history not to mention he died of natural causes...

 

[Shannow]

Originally Posted by BusyLittleShop

Some pilots can't even handle a routine flight and here Tex Johnson performs
aerobatics in a Ford Trimotor the best commercial aircraft America had
in 1929 and here he barrel rolls the 707 prototype to impress perspective
buyers not to mention startled an unsuspecting Boeing president, Bill Allen

Wright brothers, Admiral Bird, and Lindburgh never had such issues...

 

[Astro14]

Originally Posted by Shannow
Originally Posted by BusyLittleShop

Some pilots can't even handle a routine flight and here Tex Johnson performs
aerobatics in a Ford Trimotor the best commercial aircraft America had
in 1929 and here he barrel rolls the 707 prototype to impress perspective
buyers not to mention startled an unsuspecting Boeing president, Bill Allen

Wright brothers, Admiral Bird, and Lindburgh never had such issues...


People hear the word "pilot" and presume stick and rudder skills ala Wolfgang Langewiesche, or Tex Johnson.

But I'm pretty certain that's true anymore.

When flying a round-dial, (in my case, a very high-performance) airplane, particularly one without autopilot, the integration of flight data and aircraft performance into situational and flight awareness took place between the pilot's ears.

Now, that integration takes place in the computers that power glass displays, which present everything at once. The autopilot and flight management computer provide the situational awareness.

I see a kid with 1,500 hours applying for an airline job, and wonder, how many hours were flown without all the aids? without autopilot? without even a flight director?

Single digit hours, at best, in my experience. Click the autopilot on at 500 feet on climbout, there's a minute of actual flight experience. Click it off at 500 feet on approach, and, oooh, anouthe whole minute of actual flying. So, what, 2 minutes of real flight time on every leg? It, perhaps, adds up to a few hours of actual flying in a 1,500 hour experience.

We measure flight hours as experience, but it's a completely specious measure.

When I applied for a job at a major airline (in 1996-1997), I had 2,200 hours in the USN. I had not one moment with an autopilot on. Every minute of those hours was spent in actual control of the airplane. We will skip the part about how the aircraft handling was subjugated to the mission and it was taken for granted that I could put the airplane on parameters at every moment, particularly while landing on the ship, and we will skip the part about my (sometime foolish) exploration of the flight envelope, which gave me a real sense of how airplanes fly, the practical application of aerodynamics, energy, and performance.

The point is: every minute of those flight hours was spent in actual control of the airplane.

Now, today, in training programs and in airline operations, in the few minutes out of hours in flight that a pilot spends in control, the flight director is still on, and the pilot is simply following the commands of the computer (a child of the magenta). We've engineering flying into systems management and oversight of a set of computers. That is the environment in which pilots operate, from flight training, through their career progression up to the left seat of an airliner full of people.

But we still expect pilots to be able to react as pilots, to immediately understand what's happening with the airplane, to integrate the data that is presented when some of the data is false, and to develop an internal mental model of what is happening with the airplane.

We expect them to have situational awareness when they have almost no practice in developing situational awareness on their own.

We expect them to have feel and understanding when they've had near-zero experience in feeling or understanding the airplane.

Frankly, that set of expectations is completely unrealistic in the context of what we've done to flying.

It's like taking an infant, who has just learned to walk, and strapping them into wheel chair for the next 25 years, not allowing them to walk, ever, until suddenly, one day, without warning, in difficult circumstances, we kick the wheelchair over and yell at them, "run!" "You have to run now, or everyone on board will be killed!".

And then being surprised that they don't know how to walk, let alone run...

 

[DoubleWasp]

I was actually more on the events of a previous flight where the same exact thing happened (although successfully defeated by the crew), but yes, more was at play than simply that.

 

[DoubleWasp]

Now that's one [censored] of a sobering statement. Also explains a lot about how many of these situations get so out of hand. You are correct. I always assumed that commercial pilots were kind of flying aces. But the only pilots I ever knew were military pilots from generations ago. Had an uncle who left the AF to fly TriStars when I was a kid, but that's about as much as I ever knew a commercial pilot.




Also, where SA111 is concerned, I remember reading that the final conclusion was that they never would have made it even if they would have immediately beat it to an airport at the first warning. 21 minutes from smell to water. But how many before the crew was in too bad a shape to pull off a landing?

Report says aluminum in the cockpit was melted. That's terrible. I truly feel for those guys.

 

[PimTac]

Originally Posted by Astro14
Originally Posted by Shannow
Originally Posted by BusyLittleShop

Some pilots can't even handle a routine flight and here Tex Johnson performs
aerobatics in a Ford Trimotor the best commercial aircraft America had
in 1929 and here he barrel rolls the 707 prototype to impress perspective
buyers not to mention startled an unsuspecting Boeing president, Bill Allen

Wright brothers, Admiral Bird, and Lindburgh never had such issues...


People hear the word "pilot" and presume stick and rudder skills ala Wolfgang Langewiesche, or Tex Johnson.

But I'm pretty certain that's true anymore.

When flying a round-dial, (in my case, a very high-performance) airplane, particularly one without autopilot, the integration of flight data and aircraft performance into situational and flight awareness took place between the pilot's ears.

Now, that integration takes place in the computers that power glass displays, which present everything at once. The autopilot and flight management computer provide the situational awareness.

I see a kid with 1,500 hours applying for an airline job, and wonder, how many hours were flown without all the aids? without autopilot? without even a flight director?

Single digit hours, at best, in my experience. Click the autopilot on at 500 feet on climbout, there's a minute of actual flight experience. Click it off at 500 feet on approach, and, oooh, anouthe whole minute of actual flying. So, what, 2 minutes of real flight time on every leg? It, perhaps, adds up to a few hours of actual flying in a 1,500 hour experience.

We measure flight hours as experience, but it's a completely specious measure.

When I applied for a job at a major airline (in 1996-1997), I had 2,200 hours in the USN. I had not one moment with an autopilot on. Every minute of those hours was spent in actual control of the airplane. We will skip the part about how the aircraft handling was subjugated to the mission and it was taken for granted that I could put the airplane on parameters at every moment, particularly while landing on the ship, and we will skip the part about my (sometime foolish) exploration of the flight envelope, which gave me a real sense of how airplanes fly, the practical application of aerodynamics, energy, and performance.

The point is: every minute of those flight hours was spent in actual control of the airplane.

Now, today, in training programs and in airline operations, in the few minutes out of hours in flight that a pilot spends in control, the flight director is still on, and the pilot is simply following the commands of the computer (a child of the magenta). We've engineering flying into systems management and oversight of a set of computers. That is the environment in which pilots operate, from flight training, through their career progression up to the left seat of an airliner full of people.

But we still expect pilots to be able to react as pilots, to immediately understand what's happening with the airplane, to integrate the data that is presented when some of the data is false, and to develop an internal mental model of what is happening with the airplane.

We expect them to have situational awareness when they have almost no practice in developing situational awareness on their own.

We expect them to have feel and understanding when they've had near-zero experience in feeling or understanding the airplane.

Frankly, that set of expectations is completely unrealistic in the context of what we've done to flying.

It's like taking an infant, who has just learned to walk, and strapping them into wheel chair for the next 25 years, not allowing them to walk, ever, until suddenly, one day, without warning, in difficult circumstances, we kick the wheelchair over and yell at them, "run!" "You have to run now, or everyone on board will be killed!".

And then being surprised that they don't know how to walk, let alone run...





Spot on.

We are in this transition era between the human interface and a computer interface doing the work for us. It creates a new level of distraction or curiosity. Those may not be the best words to describe it. Most of us wonder why a computer is doing what it is doing. In some of these accidents that trait is very clear. The Asiana crash at SFO is a prime example.

This applies to driving as well. In a new tech filled automobile the driver might waste a second or two wondering why the car isn't slowing down just before it slams into the vehicle in front of it. The emergency braking surely had to kick in, right?

 

[Astro14]

Thanks - it IS sobering.

But (despite my myriad of typos), it's what I've observed recently.

I commute to EWR from ORF. I am generally on the jumpseat of a commuter airplane (E-145 typically), so I see the young pilots in the industry.

They're smart. They're eager.

But most of them, when presented with a situation that's only slightly out of normal, aren't able to think and respond.

My most egregious/serious example: I was on the jumpseat going into BTV, on an overcast day. Now, we were cleared the ILS 15, which comes in over the lake, then over the UVM campus. BTV, for those of you who haven't been there, is about 300' MSL. 325, I think, but close enough...

Which means, that for an ILS with a 3 degree glideslope, the airplane should be about 300 feet above that altitude for every mile distant from the field. So, at 4 miles, we should be about 1,500', (1,200 + field elevation) and at 3 miles, we should be about 1,200' (900 feet + field elevation).

At 3 miles from the field, while still IMC, we were at 900 feet. MSL. That's 300 feet LOW.

I said to the crew, "Am I the only one who feels low?" The FO, who was flying, said, "the glideslope shows us right on." I said, "I know, I can see that, but we're three miles out and only 600 feet above the field, that's wrong. We ARE too low."

Just then, BTV Tower says, "XXXX we have an altitude warning, you are too low on approach."

FO says, "We are right on glideslope" (it's a magenta bug on the right side of the flight display, by the way...).

CAPT Says, "he (meaning me) is right, we are too low".

Then, we break out. PAPI (a visual glideslope indicator adjacent to the runway) shows us well below glideslope. All four red, if you're familiar with a PAPI. That's really not good...

FO says, "I don't understand"

Captain says, "Just fly the PAPI".

I'll spare you the cockpit debrief, but here's the point: the FO was blindly flying the magenta bug, showing him that the airplane was on path. He had no clue that something was wrong, because the magenta bug was right on. There was no fusion of information taking place, just acceptance of what was presented.

I was just watching from the jumpseat. It didn't look right to me, even though I don't fly that particular airplane. I spoke up, gently at first (because I thought that barking out the observation would've engendered resistance and confrontation and I needed them to accept what I was seeing, not argue with me) and then I was backed up by Tower.

There was situational awareness on the jumpseat, but not from the flying seats.

The Captain was quick to understand. The FO really wasn't. He couldn't see what was wrong, because the magenta bug was right where it was supposed to be, even though the airplane was not where it was supposed to be.

When I flew back up there two weeks later, the ILS for RWY 15 was NOTAM out of service.

Yeah, no kidding. We were the flight to discover that it was broken and provided faulty vertical guidance.

The situational awareness provided by the flight guidance system (flight computers, flight director, etc.) was wrong. The data presented was wrong because the ground station was providing faulty data.

But without the ability to fuse that data (using the little grey cells between the pilot's ears) with other information, like barometric altitude, or radio altimeter and displayed distance, thereby reaching a different conclusion, there was simple, blind acceptance of the presented information.

A child of the magenta, indeed...

 

[john_pifer]

Originally Posted by Astro14
Thanks - it IS sobering.

But (despite my myriad of typos), it's what I've observed recently.

I commute to EWR from ORF. I am generally on the jumpseat of a commuter airplane (E-145 typically), so I see the young pilots in the industry.

They're smart. They're eager.

But most of them, when presented with a situation that's only slightly out of normal, aren't able to think and respond.

My most egregious/serious example: I was on the jumpseat going into BTV, on an overcast day. Now, we were cleared the ILS 15, which comes in over the lake, then over the UVM campus. BTV, for those of you who haven't been there, is about 300' MSL. 325, I think, but close enough...

Which means, that for an ILS with a 3 degree glideslope, the airplane should be about 300 feet above that altitude for every mile distant from the field. So, at 4 miles, we should be about 1,500', (1,200 + field elevation) and at 3 miles, we should be about 1,200' (900 feet + field elevation).

At 3 miles from the field, while still IMC, we were at 900 feet. MSL. That's 300 feet LOW.

I said to the crew, "Am I the only one who feels low?" The FO, who was flying, said, "the glideslope shows us right on." I said, "I know, I can see that, but we're three miles out and only 600 feet above the field, that's wrong. We ARE too low."

Just then, BTV Tower says, "XXXX we have an altitude warning, you are too low on approach."

FO says, "We are right on glideslope" (it's a magenta bug on the right side of the flight display, by the way...).

CAPT Says, "he (meaning me) is right, we are too low".

Then, we break out. PAPI (a visual glideslope indicator adjacent to the runway) shows us well below glideslope. All four red, if you're familiar with a PAPI. That's really not good...

FO says, "I don't understand"

Captain says, "Just fly the PAPI".

I'll spare you the cockpit debrief, but here's the point: the FO was blindly flying the magenta bug, showing him that the airplane was on path. He had no clue that something was wrong, because the magenta bug was right on. There was no fusion of information taking place, just acceptance of what was presented.

I was just watching from the jumpseat. It didn't look right to me, even though I don't fly that particular airplane. I spoke up, gently at first (because I thought that barking out the observation would've engendered resistance and confrontation and I needed them to accept what I was seeing, not argue with me) and then I was backed up by Tower.

There was situational awareness on the jumpseat, but not from the flying seats.

The Captain was quick to understand. The FO really wasn't. He couldn't see what was wrong, because the magenta bug was right where it was supposed to be, even though the airplane was not where it was supposed to be.

When I flew back up there two weeks later, the ILS for RWY 15 was NOTAM out of service.

Yeah, no kidding. We were the flight to discover that it was broken and provided faulty vertical guidance.

The situational awareness provided by the flight guidance system (flight computers, flight director, etc.) was wrong. The data presented was wrong because the ground station was providing faulty data.

But without the ability to fuse that data (using the little grey cells between the pilot's ears) with other information, like barometric altitude, or radio altimeter and displayed distance, thereby reaching a different conclusion, there was simple, blind acceptance of the presented information.

A child of the magenta, indeed...


Pretty fascinating anecdote. Thanks for sharing that.

It's too bad there's not a real-time news source of things like this happening, that all commercial pilots would periodically look at (like a website or email that would go out), that would detail near-misses and keep everyone on his toes. Or, is there?

 

[Astro14]

John - There is a real-time dissemination vehicle for failed/inoperative field equipment in the NOTAMS.

Ostensibly, ASRS (Aviation Safety Reporting System, run by NASA) provides that kind of insight, but it requires the crew in question to submit the report and a curious pilot to go look it up.

Airlines analyze trends and publish bulletins, news letters, flight manual updates, crew communication messages, or whatever, to disseminate information to their pilots.

But there isn't a single, central, comprehensive source of information.

If I want to know more about a particular accident, I go to the NTSB website, or to Google. I would have no way of knowing if a crew had a failed ILS on approach to an airport unless I went digging.

It's frustrating as a pilot, to have to go digging for information, to have information presented in a myriad of formats, venues, and sources.

It's a challenge, that's for certain...

 

[BusyLittleShop]

Might as well had Chief pilot "Admiral Bird" and Co-pilot Big Bird at the controls...

 

[AdmdeVilleneuve]

There has been a steady stream of articles in my local newspaper regarding the 737MAX and two recent crashes, and today's news in the ST (and other sources) is not good. Dominic Gates has been on the Boeing/aerospace beat for over 20 years; does a good job in my opinion.
https://www.seattletimes.com/busine...max-may-have-failed-on-ethiopian-flight/

And, the hits just keep on coming. Not written in-house, but an article credited to Roll Call that appeared in the Times today says the USAF has suspended deliveries of KC-46 Pegasus tankers again.

 

[Shannow]

Originally Posted by Astro14
But we still expect pilots to be able to react as pilots, to immediately understand what's happening with the airplane, to integrate the data that is presented when some of the data is false, and to develop an internal mental model of what is happening with the airplane.

We expect them to have situational awareness when they have almost no practice in developing situational awareness on their own.

We expect them to have feel and understanding when they've had near-zero experience in feeling or understanding the airplane.

Frankly, that set of expectations is completely unrealistic in the context of what we've done to flying.

It's like taking an infant, who has just learned to walk, and strapping them into wheel chair for the next 25 years, not allowing them to walk, ever, until suddenly, one day, without warning, in difficult circumstances, we kick the wheelchair over and yell at them, "run!" "You have to run now, or everyone on board will be killed!".

And then being surprised that they don't know how to walk, let alone run...


I've been saying that for years, both in the workplace (power station control rooms), in aircraft threads, and what I'm more worried about autonomous (well "semi autonomous") vehicle threads.

The more that you remove the operator from operating, the less aware they are of what's really happening with their machine.

To then throw them into control in the event of a control system failure (or parameters out of range), expecting them to immediately identify
a) current state
b) how it got there; and

then take immediate, and correct action

Is grossly unfair to the human.

Tesla (and BITOGers) stating that "you are the one in control and responsible" is a demonstrable misunderstanding of what happens when you remove the human from the control system

 

[fdcg27]

A development in this accident came to light today in a leak of an interim report to be released by Ethiopian authorities tomorrow morning their time.
The AOA vane was apparently damaged by a bird or other object at some point in the flight.
The crew recognized the trim problem and removed power to it, although they apparently didn't first use the switches on the yokes to eliminate the nose-down trim induced by the MCAS system operating on erroneous data.
They then used the hand wheels to restore more favorable trim, although whether they had things trimmed hands-off isn't known at this time.
They then did something that beggars belief.
They turned the switches that power the electric stab trim motor back on. MCAS kicked back in with the erroneous data it was operating with and you know the rest.

 

[ZeeOSix]

Originally Posted by AdmdeVilleneuve
There has been a steady stream of articles in my local newspaper regarding the 737MAX and two recent crashes, and today's news in the ST (and other sources) is not good. Dominic Gates has been on the Boeing/aerospace beat for over 20 years; does a good job in my opinion.
https://www.seattletimes.com/busine...max-may-have-failed-on-ethiopian-flight/


From the article:
"The Wall Street Journal, citing people briefed on the crash investigation's preliminary findings, reported Tuesday night that the pilots hit the system-cutoff switches as Boeing had instructed after October's Lion Air MAX crash, but couldn't get the plane's nose back up. They then turned the system back on before the plane nose-dived into the ground.

It would suggest the emergency procedure that Boeing laid out for pilots worldwide after the Lion Air crash, and that the FAA alerted airlines to the next day, is wholly inadequate and failed the Ethiopian flight crew."

Turing the system back on is not part of the instructions. Taking control and flying the plane manually is the next step. The news tries to twist stuff up as much as possible, as can be seen by the last sentence in the quote above.