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NTSB cites competing pilot warnings

Old 09-26-2019, 06:49 AM
  #1  
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Default Boeing Underestimated Cockpit Chaos...

https://www.nytimes.com/2019/09/26/b...core-ios-share


Boeing Underestimated Cockpit Chaos on 737 Max, N.T.S.B. Says
By Natalie Kitroeff
Sept. 26, 2019, 10:10 a.m. ET
The National Transportation Safety Board said Thursday that Boeing made faulty assumptions during the development of its 737 Max jet.
The National Transportation Safety Board said Thursday that Boeing made faulty assumptions during the development of its 737 Max jet.Ruth Fremson/The New York Times
The National Transportation Safety Board released the results of a monthslong review of potential lapses in the design and approval of Boeing’s 737 Max on Thursday, faulting the company for making erroneous assumptions during the development of the jet and calling for broader changes in the way airplanes are certified.

The agency said Boeing had underestimated the effect that a failure of new automated software in the aircraft could have on the environment in the cockpit. When activated, the system, known as MCAS, automatically moves the Max’s tail and pushes its nose down. The system contributed to two crashes in less than five months that killed 346 people and caused regulators around the world to ground the plane.

Results of an internal review by Boeing, which its board made public on Wednesday, recommended changes to the design of cockpits and the company’s organizational structure to improve safety.

Also on Wednesday, in a hearing on Capitol Hill, the deputy director of the Federal Aviation Administration faced questions from senators about allegations that it misled Congress about the qualifications of inspectors who helped determine the training that pilots received. A task force composed of several international regulators is expected to submit a report this month regarding how the plane was certified.

Two investigators handled the bulk of the work for the National Transportation Safety Board, reviewing thousands of pages of documents, interviewing officials at Boeing and the F.A.A., and studying black-box data from the two crashes, in Indonesia and Ethiopia. They focused on MCAS, which sent both planes into nose dives.

When Boeing developed the Max, it assumed that if MCAS activated erroneously, pilots would immediately react by performing a standard emergency procedure. But the company had tested the possibility of an MCAS failure only in isolation, failing to account for just how chaotic the cockpit would become when the activation caused other malfunctions.

On the doomed Lion Air and Ethiopian Airlines flights, a faulty sensor triggered MCAS, which produced a cascading number of warnings that may have overwhelmed the pilots.

“They did not look at all the potential flight deck alerts and indications the pilots might face,” said Dana Schulze, the director of the Office of Aviation Safety at the safety board. “Multiple alerts and indications have been shown through years of research to have potentially an impact where pilots will not respond as perhaps you might have intended.”

Ms. Schulze said the agency would like the F.A.A. to review Boeing’s safety assessment of MCAS before allowing the plane to fly again. The plane is grounded while Boeing works on a software update and other changes intended to make it safer.

The safety board also recommended that the F.A.A. require Boeing and other manufacturers to consider the effect of multiple cockpit warnings when assessing how quickly pilots will respond to a malfunction. It also suggested that the agency direct plane makers to develop technology that could diagnose a problem during flight and tell pilots what procedure to follow.

“We are committed to working with the F.A.A. in reviewing the N.T.S.B. recommendations,” a Boeing spokesman, Gordon Johndroe, said. An F.A.A. spokesman, Lynn Lunsford, said the agency “will carefully review these and all other recommendations as we continue our review of the proposed changes to the Boeing 737 Max.”

The F.A.A. continues to face criticism for its handling of the Max certification.

This week, the United States Office of Special Counsel sent a letter to President Trump and Congress saying the F.A.A. provided incomplete information about a complaint made by a whistle-blower who claimed that inspectors at the agency weren’t fully qualified to determine pilot training on the Max.

In response to a request this year by Senator Roger Wicker of Mississippi, Republican chairman of the Senate Commerce Committee, the F.A.A. said that the complaint concerned officials working on a Gulfstream aircraft, not the Max, and that it had determined that inspectors evaluating pilot training on both planes were competent.

At the Wednesday hearing, top F.A.A. officials defended their comments. “Any insinuation that the F.A.A. misled Chairman Wicker in our reply to his inquiry is not what happened,” said Daniel K. Elwell, the deputy director of the agency. He called the special counsel’s allegation “simply inaccurate.”
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Old 09-26-2019, 07:13 AM
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The agency said Boeing had underestimated the effect that a failure of new automated software in the aircraft could have on the environment in the cockpit
Welcome to the 2020s. IMHO that is becoming more and more if a problem as planes are manually flown less and less. And it’s not just Boeing that has underestimated the problem, it’s the whole world.

We’ll soon be getting people in CA positions who really haven’t flown anything without an FMS since the got their CPL, and got a lot of their time from there on until they got hired by a regional being a SIC in aircraft that didn’t actually even require a SIC and, oh yes, had an FMS.

Don’t get me wrong I am not a Luddite, I think automation is great. It allows us to do our job more efficiently and oftentimes more precisely, but when those who have grown up knowing nothing else get in a stressful situation where they need to use their OWN brains AND the muscle memory built from a lot of hand flying, it’s going to be real difficult for a fair number of them.
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Old 09-26-2019, 07:53 AM
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Default NTSB cites competing pilot warnings

https://www.washingtonpost.com/local/trafficandcommuting/ntsb-cites-competing-pilot-warnings-and-flawed-safety-assumptions-on-boeing-737-max/2019/09/25/72291a2e-dfa6-11e9-be96-6adb81821e90_story.html

NTSB cites competing pilot warnings and flawed safety assumptions on Boeing 737 Max
Michael Laris

An aerial photo shows Boeing 737 MAX aircraft at Boeing facilities at the Grant County International Airport in Moses Lake, Wash., on Sept. 16. (Lindsey Wasson/Reuters)
September 26 at 10:40 AM
After an automated feature on a Boeing 737 Max failed in the skies above Ethiopia in March, repeatedly forcing the plane’s nose downward, the pilots were bombarded with a cacophony of alarms that shook, clacked and lit up throughout the cockpit.

Boeing did not sufficiently consider the effect that such a barrage would have on those flying the plane when it designed the Max, according to the National Transportation Safety Board, which released its first wave of recommendations Thursday in response to the crash in Ethiopia and one in Indonesia under similar circumstances in October.

The Federal Aviation Administration should require Boeing to make a more rigorous analysis of how its warning systems might overwhelm pilots, the NTSB said. The safety board also said the same problem could affect other passenger planes beyond the Max, and recommended that the FAA address such shortcomings broadly.

“They’re getting all these different alerts. That’s the actual scenario that never got evaluated in the simulator,” said Dana Schulze, director of the NTSB’s Office of Aviation Safety.

The FAA should require that safety assessments consider the effect of multiple alerts, she said, adding, “Clearly, if the underlying process has a deficiency, it’s going to affect more than just potentially one aircraft.

“What we’re not saying is that there’s broadly a safety issue in all these airplanes. We’re saying, ‘This is an opportunity to improve the process to ensure that the human aspect is considered,’ ” Schulze said.

Paul Njoroge, 35, of Toronto — who lost his wife, Carolyne Karanja, his three young children and his mother-in-law in the Ethiopian Airlines crash — holds photos during a vigil in front of the Transportation Department headquarters in Washington on Sept. 10, six months after the crash. (Sarah L. Voisin/The Washington Post)
The two crashes killed 346 people and left the management and safety practices of both Boeing and the FAA under intense scrutiny and the subject of numerous inquiries. The company and regulator have both said they followed the same safety practices for the Max that have for years produced trustworthy airplanes.

Boeing declined to answer questions about the NTSB findings, and was noncommittal about what actions it will take to address them, saying it will work with the FAA to review the recommendations. “The safety of our airplanes, our customers’ passengers and crews is always our top priority,” the company said in a statement Thursday.

The company’s board of directors on Wednesday recommended a number of actions to “bolster the safety policies and procedures” of the company. They included the creation of a “Product and Services Safety organization” that would report to senior company leaders and would review “all aspects of product safety, including investigating cases of undue pressure and anonymous product and service safety concerns raised by employees.”

Boeing’s board also recommended that the company “re-examine assumptions around flight deck design and operation . . . to anticipate the needs of the changing demographics and future pilot populations.” And it called for more pilot training where needed.

The FAA said in a statement that it appreciates the recommendations, which it will review, and that the agency is “committed to a philosophy of continuous improvement.” Lessons learned from crashes “will be a springboard to an even greater level of safety,” it said.

The NTSB is participating in ongoing investigations of the two crashes led by aviation authorities in Jakarta and Addis Ababa. NTSB investigators delayed making other recommendations until those inquiries are completed, leaving many key questions unaddressed for now.

The safety board, for instance, did not publicly describe which Boeing failures led to the design and sale of the automated feature implicated in both crashes, known as the Maneuvering Characteristics Augmentation System (MCAS). The feature was designed to work based on data from a single sensor, and was given the power to push the plane’s nose down, again and again, which essentially overpowered pilots who struggled to regain control before the Indonesia and Ethi*o*pia crashes.

Nor did the NTSB recommend how Boeing should fix flaws in its operations or how the FAA might reform its controversial Organization Designation Authorization program, which gives Boeing broad power to oversee its own safety. And the NTSB investigators, Schulze said, did not “address specific issues looking at the pilot performance in these particular accidents.”

[Long before the Max disasters, Boeing had a history of failing to fix safety problems]

But the safety board outlined several concerns about “human factors,” a broad area that covers the interface of person and machine.

“The lessons of the past need to be plowed into the designs of the future,” said Evan Byrne, who heads the NTSB’s Human Performance and Survival Factors division focused on aviation safety. “This isn’t necessarily a new airplane problem. The concept of saturation, in terms of alarms, warnings and crews maybe going down the wrong path for troubleshooting, has occurred with very simple airplanes. Research at NASA shows that crew response to abnormal situations can not be perfect.”

Byrne said the goal now is to take what has been learned in crashes regarding “how pilots actually perform” and make sure those lessons are reflected in the way airplanes are certified in the future.

NTSB officials said Boeing made assumptions in its safety analysis of a potential failure of the MCAS system that proved off base.

“Every design you need to make assumptions, but you want to validate that that’s going to work,” Schulze said.

In building its original safety assessment for the Max, Boeing had assumed that “the pilots would immediately identify” that the plane was being pushed downward without their input, she said.

Boeing also assumed that “after immediately identifying these control forces, they would immediately take action,” and if problems persisted, they would resort to an existing emergency checklist on how to deal with a “runaway” horizontal stabilizer on the plane’s tail, which makes the aircraft climb or descend, Schulze said.

But Schulze said that when NTSB investigators delved into the details, they found that Boeing’s assumptions did not reflect the type of failure that eventually occurred with MCAS.

When Boeing had test pilots face an “unintended MCAS activation,” the simulator pushed the plane’s nose down by 2.5 degrees at a certain speed, she said. The pilots were able to handle that situation safely.

[With its ties in Washington, Boeing has taken over more and more of the FAA’s job]

But in Indonesia and Ethiopia, there was “a deeper failure” — an external probe provided faulty information to MCAS. That added to the series of competing alerts, even as MCAS repeatedly pushed the nose down. And Boeing “did not look at all the potential flight deck alerts and indications the pilots might face when this specific failure” happened, she said.

In comments to Congress earlier this year, Capt. Chesley B. “Sully” Sullenberger III said he thought it was “unlikely that other crews would have had very different experiences or performed very differently than these crews did on their accident flights. . . . I can tell you firsthand that the startle factor is real, and huge.”

The NTSB made seven recommendations Thursday to address certification and safety issues, and investigators expect to add more later. They called on the FAA to:

●Guarantee that Boeing has reexamined certain safety assessments for the Max. In cases where the company “assumed immediate and appropriate pilot corrective actions” in response to “uncommanded” movements of the plane, the FAA should ensure that Boeing “consider the effect of all possible flight deck alerts and indications on pilot recognition and response.”

Boeing also should be required to “incorporate design enhancements (including flight deck alerts and indications), pilot procedures, and/or training requirements, where needed, to minimize the potential for and safety impact of pilot actions that are inconsistent with manufacturer assumptions,” the NTSB said.

●Require that similar reassessments and improvements be done on most other passenger planes.

●Notify international authorities that they should consider the same issues.

●Develop “robust tools and methods” for “validating assumptions” used during the certification process, specifically assumptions on how pilots will handle dangerous failures of airplanes’ systems.

● Revise FAA regulations and guidance to use those new tools for certifying the design of airplanes, and to reexamine the “validity” of assumptions the FAA allows regarding how pilots will recognize and respond to problems.

●Develop design standards, with help from experts and industry, for diagnostic tools that will improve the “prioritization and clarity” of the various warnings and indications pilots are subjected to, with an eye toward improving the “timeliness and effectiveness” of their response.

●Require that those diagnostic tools are installed on passenger planes to help pilots better deal with multiple alerts.
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Old 09-26-2019, 10:06 AM
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Originally Posted by docav8tor View Post
https://www.washingtonpost.com/local/trafficandcommuting/ntsb-cites-competing-pilot-warnings-and-flawed-safety-assumptions-on-boeing-737-max/2019/09/25/72291a2e-dfa6-11e9-be96-6adb81821e90_story.html

NTSB cites competing pilot warnings and flawed safety assumptions on Boeing 737 Max
Michael Laris

An aerial photo shows Boeing 737 MAX aircraft at Boeing facilities at the Grant County International Airport in Moses Lake, Wash., on Sept. 16. (Lindsey Wasson/Reuters)
September 26 at 10:40 AM
After an automated feature on a Boeing 737 Max failed in the skies above Ethiopia in March, repeatedly forcing the plane’s nose downward, the pilots were bombarded with a cacophony of alarms that shook, clacked and lit up throughout the cockpit.

Boeing did not sufficiently consider the effect that such a barrage would have on those flying the plane when it designed the Max, according to the National Transportation Safety Board, which released its first wave of recommendations Thursday in response to the crash in Ethiopia and one in Indonesia under similar circumstances in October.

The Federal Aviation Administration should require Boeing to make a more rigorous analysis of how its warning systems might overwhelm pilots, the NTSB said. The safety board also said the same problem could affect other passenger planes beyond the Max, and recommended that the FAA address such shortcomings broadly.

“They’re getting all these different alerts. That’s the actual scenario that never got evaluated in the simulator,” said Dana Schulze, director of the NTSB’s Office of Aviation Safety.

The FAA should require that safety assessments consider the effect of multiple alerts, she said, adding, “Clearly, if the underlying process has a deficiency, it’s going to affect more than just potentially one aircraft.

“What we’re not saying is that there’s broadly a safety issue in all these airplanes. We’re saying, ‘This is an opportunity to improve the process to ensure that the human aspect is considered,’ ” Schulze said.

Paul Njoroge, 35, of Toronto — who lost his wife, Carolyne Karanja, his three young children and his mother-in-law in the Ethiopian Airlines crash — holds photos during a vigil in front of the Transportation Department headquarters in Washington on Sept. 10, six months after the crash. (Sarah L. Voisin/The Washington Post)
The two crashes killed 346 people and left the management and safety practices of both Boeing and the FAA under intense scrutiny and the subject of numerous inquiries. The company and regulator have both said they followed the same safety practices for the Max that have for years produced trustworthy airplanes.

Boeing declined to answer questions about the NTSB findings, and was noncommittal about what actions it will take to address them, saying it will work with the FAA to review the recommendations. “The safety of our airplanes, our customers’ passengers and crews is always our top priority,” the company said in a statement Thursday.

The company’s board of directors on Wednesday recommended a number of actions to “bolster the safety policies and procedures” of the company. They included the creation of a “Product and Services Safety organization” that would report to senior company leaders and would review “all aspects of product safety, including investigating cases of undue pressure and anonymous product and service safety concerns raised by employees.”

Boeing’s board also recommended that the company “re-examine assumptions around flight deck design and operation . . . to anticipate the needs of the changing demographics and future pilot populations.” And it called for more pilot training where needed.

The FAA said in a statement that it appreciates the recommendations, which it will review, and that the agency is “committed to a philosophy of continuous improvement.” Lessons learned from crashes “will be a springboard to an even greater level of safety,” it said.

The NTSB is participating in ongoing investigations of the two crashes led by aviation authorities in Jakarta and Addis Ababa. NTSB investigators delayed making other recommendations until those inquiries are completed, leaving many key questions unaddressed for now.

The safety board, for instance, did not publicly describe which Boeing failures led to the design and sale of the automated feature implicated in both crashes, known as the Maneuvering Characteristics Augmentation System (MCAS). The feature was designed to work based on data from a single sensor, and was given the power to push the plane’s nose down, again and again, which essentially overpowered pilots who struggled to regain control before the Indonesia and Ethi*o*pia crashes.

Nor did the NTSB recommend how Boeing should fix flaws in its operations or how the FAA might reform its controversial Organization Designation Authorization program, which gives Boeing broad power to oversee its own safety. And the NTSB investigators, Schulze said, did not “address specific issues looking at the pilot performance in these particular accidents.”

[Long before the Max disasters, Boeing had a history of failing to fix safety problems]

But the safety board outlined several concerns about “human factors,” a broad area that covers the interface of person and machine.

“The lessons of the past need to be plowed into the designs of the future,” said Evan Byrne, who heads the NTSB’s Human Performance and Survival Factors division focused on aviation safety. “This isn’t necessarily a new airplane problem. The concept of saturation, in terms of alarms, warnings and crews maybe going down the wrong path for troubleshooting, has occurred with very simple airplanes. Research at NASA shows that crew response to abnormal situations can not be perfect.”

Byrne said the goal now is to take what has been learned in crashes regarding “how pilots actually perform” and make sure those lessons are reflected in the way airplanes are certified in the future.

NTSB officials said Boeing made assumptions in its safety analysis of a potential failure of the MCAS system that proved off base.

“Every design you need to make assumptions, but you want to validate that that’s going to work,” Schulze said.

In building its original safety assessment for the Max, Boeing had assumed that “the pilots would immediately identify” that the plane was being pushed downward without their input, she said.

Boeing also assumed that “after immediately identifying these control forces, they would immediately take action,” and if problems persisted, they would resort to an existing emergency checklist on how to deal with a “runaway” horizontal stabilizer on the plane’s tail, which makes the aircraft climb or descend, Schulze said.

But Schulze said that when NTSB investigators delved into the details, they found that Boeing’s assumptions did not reflect the type of failure that eventually occurred with MCAS.

When Boeing had test pilots face an “unintended MCAS activation,” the simulator pushed the plane’s nose down by 2.5 degrees at a certain speed, she said. The pilots were able to handle that situation safely.

[With its ties in Washington, Boeing has taken over more and more of the FAA’s job]

But in Indonesia and Ethiopia, there was “a deeper failure” — an external probe provided faulty information to MCAS. That added to the series of competing alerts, even as MCAS repeatedly pushed the nose down. And Boeing “did not look at all the potential flight deck alerts and indications the pilots might face when this specific failure” happened, she said.

In comments to Congress earlier this year, Capt. Chesley B. “Sully” Sullenberger III said he thought it was “unlikely that other crews would have had very different experiences or performed very differently than these crews did on their accident flights. . . . I can tell you firsthand that the startle factor is real, and huge.”

The NTSB made seven recommendations Thursday to address certification and safety issues, and investigators expect to add more later. They called on the FAA to:

●Guarantee that Boeing has reexamined certain safety assessments for the Max. In cases where the company “assumed immediate and appropriate pilot corrective actions” in response to “uncommanded” movements of the plane, the FAA should ensure that Boeing “consider the effect of all possible flight deck alerts and indications on pilot recognition and response.”

Boeing also should be required to “incorporate design enhancements (including flight deck alerts and indications), pilot procedures, and/or training requirements, where needed, to minimize the potential for and safety impact of pilot actions that are inconsistent with manufacturer assumptions,” the NTSB said.

●Require that similar reassessments and improvements be done on most other passenger planes.

●Notify international authorities that they should consider the same issues.

●Develop “robust tools and methods” for “validating assumptions” used during the certification process, specifically assumptions on how pilots will handle dangerous failures of airplanes’ systems.

● Revise FAA regulations and guidance to use those new tools for certifying the design of airplanes, and to reexamine the “validity” of assumptions the FAA allows regarding how pilots will recognize and respond to problems.

●Develop design standards, with help from experts and industry, for diagnostic tools that will improve the “prioritization and clarity” of the various warnings and indications pilots are subjected to, with an eye toward improving the “timeliness and effectiveness” of their response.

●Require that those diagnostic tools are installed on passenger planes to help pilots better deal with multiple alerts.
Life could be rough for Boeing if foreign regulators simply implement the NTSB’s suggested requirements.
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Old 09-26-2019, 12:50 PM
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Originally Posted by tnkrdrvr View Post
Life could be rough for Boeing if foreign regulators simply implement the NTSB’s suggested requirements.
Hard to apply that just to Boeing. NTSB usually comes up with a Santa Claus list, regulators and politicians have to balance that with reality/economics. Remember, the safest plane is one which never flies...
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