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Indonesia to Fault 737 MAX Design...

Old 09-22-2019, 04:47 PM
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Default Indonesia to Fault 737 MAX Design...

Indonesia to Fault 737 MAX Design, U.S. Oversight in Lion Air Crash Report

First formal government finding on crash also likely to detail pilot and maintenance missteps; NTSB preparing separate safety recommendations

By Andy Pasztor and Andrew Tangel Sept. 22, 2019 4:54 pm ET

The Lion Air crash and a similar crash of an Ethiopian Airlines MAX in March together took 346 lives. Photo: adi weda/epa/Shutterstock
Indonesian investigators have determined that design and oversight lapses played a central role in the fatal crash of a Boeing 737 MAX jet in October, according to people familiar with the matter, in what is expected to be the first formal government finding of fault.

The draft conclusions, these people said, also identify a string of pilot errors and maintenance mistakes as causal factors in the fatal plunge of the Boeing Co. plane into the Java Sea, echoing a preliminary report from Indonesia last year.

Misfires of an automated flight-control feature called MCAS on the MAX fleet led to the nosedive of the Lion Air jet and a similar crash of an Ethiopian Airlines MAX shortly after takeoff from Addis Ababa in March. The two crashes took 346 lives, prompted the grounding of all 737 MAX planes and disrupted the global aviation industry.

Details of the Indonesian report, which haven’t been reported previously, are subject to change and further analysis. Indonesian investigators declined to comment, except to say the final document is likely to come out in early November.

A Boeing spokesman said the plane maker continues to work with Indonesian authorities as they complete the report.

U.S. air-crash investigators are preparing to make public a handful of separate safety recommendations, ranging from bolstering the manual flying skills of pilots to enhancing FAA vetting of new aircraft designs.

The U.S. National Transportation Safety Board is expected around the end of the month to call for improvements to cockpit training and crew decision making, according to industry and government officials.

The goal is to ensure pilot proficiency when automated systems are malfunctioning or turned off, to help ensure appropriate responses to contradictory cockpit warnings such as those that occurred prior to the MAX crashes, the officials said. The board also is expected to emphasize the importance of setting priorities when executing emergency checklists.

0:00 / 8:58


Why the Agency That Regulates Boeing Is Under Scrutiny
Why the Agency That Regulates Boeing Is Under Scrutiny
Is the Federal Aviation Administration too close to the industry it regulates? In the wake of the Boeing 737 MAX 8 crashes in Indonesia and Ethiopia, The Wall Street Journal examines why the FAA is facing renewed scrutiny into its aircraft certification process.
In addition, the NTSB is expected to focus on potential changes to the certification of new airliners. The board is poised to recommend re-evaluation of FAA procedures that give the industry authority to sign off on certain safety matters, the officials said. The aim is to make such approvals more transparent, with the goal of greater predictability and more-consistent federal oversight across various types of onboard systems.

Neither the U.S. nor Indonesian recommendations will be binding on the FAA, though the agency already faces escalating congressional and public pressure to change certification procedures. More than half a dozen outside inquiries, including a Justice Department criminal probe and various blue-ribbon advisory panels, are delving into the FAA’s 2017 approval of MCAS. Earlier this month, a Senate appropriations subcommittee backed legislation that would require FAA officials to address recommendations from ongoing investigations and audits.

The FAA has said it welcomes the independent reviews, will carefully consider their results and doesn’t have a firm timetable for allowing MAX jets back in the air. Boeing has said it is collaborating with U.S. and foreign officials to safely return the MAX to service.

Steve Dickson, the FAA’s new head, and top lieutenants are scheduled to meet Monday in Montreal with some four dozen foreign regulators to provide a closed-door update on anticipated fixes to the MAX’s flight-control software and computers.


The crashes prompted the grounding of all 737 MAX planes and disrupted the global aviation industry. Photo: lindsey wasson/Reuters
The FAA is urging a core group of regulators—from Canada, Australia, Brazil and New Zealand—to approve the fixes around November, which would be roughly in tandem with informal U.S. timelines. FAA leaders also are trying to persuade aviation authorities in Europe and other regions to follow by lifting their grounding orders shortly afterward, according to U.S. government and industry officials familiar with the deliberations.

But such coordination efforts are running into significant hurdles. Canadian aviation regulators have signaled to the FAA that they expect to require pilots to undergo simulator training before they can start flying the MAX, something the FAA is unlikely to mandate. It could take until March for Air Canada to phase the bulk of its MAX aircraft into regular schedules, according to a person briefed on the details, months later than projected for U.S. operators.

In Europe, regulators previously said they won’t accept the FAA’s technical verifications of fixes and intend to perform their own certification analyses, possibly adding weeks or months to the timetable.

Meanwhile, FAA officials said in recent weeks that Boeing hasn’t provided all of the requested details laying out the description and safety assessments of the MAX’s redesigned flight-control system.

The latest version of Indonesia’s accident report has been shared with the FAA and NTSB for comment. U.S. officials are expected to visit Indonesia around the end of this month to finalize the document. People familiar with the process said NTSB experts don’t appear to have major disagreements with the draft. Boeing and the FAA, on the other hand, are concerned the final report will unduly emphasize design and FAA certification missteps, some of these people said.

Unlike NTSB reports that identify the primary cause of accidents and then list contributing issues determined to be less significant, Indonesia is following a convention used by many foreign regulators of listing causal factors without ranking them. Instead, the report is expected to list more than 100 elements of the crash chronology, according to a person briefed on the details. Many of those points are likely to refer to missteps by pilots and mechanics initially revealed last year in Indonesia’s preliminary report.

Indonesian authorities now are asking for comments on the draft conclusions dealing with those missteps, as well as findings that investigators have determined constitute engineering shortcomings, including reliance on a sole sensor in the original design of MCAS, according to people familiar with the matter.

—Kim Mackrael
and Ben Otto
contributed to this article.

0:00 / 4:36


How Boeing’s 737 MAX Troubles Ripple Through the Industry
How Boeing’s 737 MAX Troubles Ripple Through the Industry
Two crashes and the global grounding of Boeing’s 737 MAX commercial airliner led to extensive disruption in the international aerospace industry. WSJ’s Robert Wall explains the continuing effects of the plane’s grounding. Photo: Getty Images
Write to Andy Pasztor at [email protected] and Andrew Tangel at [email protected]
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Old 09-24-2019, 12:37 AM
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You mean the probable cause isn't unqualified brown pilots? Shocking I say! JohnBurke is gonna be pi$$ed.
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Old 09-24-2019, 05:31 AM
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Originally Posted by ShyGuy View Post
You mean the probable cause isn't unqualified brown pilots? Shocking I say! JohnBurke is gonna be pi$$ed.

Along those lines, it's also Boeing's fault for the Asiana B-777 crash in SFO. I'd imagine that the contributing factor was that the ILS was out of service, the beautiful day VFR weather notwithstanding, of course.
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Old 09-24-2019, 07:02 AM
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Boeing outsourcing critical work is the cause of these accidents, I said it a week after the second accident.
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Old 09-24-2019, 07:08 AM
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Originally Posted by Mesabah View Post
Boeing outsourcing critical work is the cause of these accidents, I said it a week after the second accident.


The cause?

I’d say “the cause” would be two crews unable to handle an emergency due to extremely poor and scripted training, and no opportunity to develop airmanship skills before getting into an airline cockpit. They were set up for failure.

As for the contributing factors, carry on with your bashing of Boeing.
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Old 09-24-2019, 08:10 AM
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Originally Posted by RJSAviator76 View Post
Along those lines, it's also Boeing's fault for the Asiana B-777 crash in SFO. I'd imagine that the contributing factor was that the ILS was out of service, the beautiful day VFR weather notwithstanding, of course.
Not the same thing.



The primary cause needs to be Boeing’s decision to design a single point of failure for a critical flight control feature, the FAA’s certification of a said system whose failure modes were not properly studied or understood, along with Boeing’s willful act of hiding any information about this new system in the manuals. Contributing to the accident are the pilot errors like leaving thrust levers in climb, etc.

RJS, if you operate under a PC/PT training scenario here, you are not allowed to be given “multiple failure” scenario for a jeopardy event. You don’t get a V1 cut at the same time with a cargo fire going off. The problem with Boeing is they assumed any activation of MCAS would simply be recognized as a trim runaway. What they never realized (because they rushed and had time compression due to their NEO competition) is that a single failure of the CA side AOA sensor or probe would trigger MCAS, but only after the CA stick shaker goes off and loses potential altitude/airspeed information on the CA side. The pilot receives what looks like a false approach to stall warming (stick shaker) along with potential unreliable airspeed information. Now MCAS kicks in. Not just kicks in, but keeps kicking in an infinite amount of times because of the false AOA readings, instead of just kicking on once and stopping. No one at the FAA or Boeing envisioned this type of failure mode.


It’s a little tiring to read reports that blame dead pilots only, while the system that allowed the accident to happen changes without being acknowledged as at least a contributing factor. Colgan was a good example. No doubt the crew screwed up and the probable cause stands. Still. Fact remains until 2009 if you were flying at 121 airlines, with gear and flaps down we were told to power out of stalls and minimize altitude loss (which in most cases) meant pulling slightly back into the shaker. The industry taught altitude loss and an approach to stall as a speed/altitude problem, instead of an AOA problem. After the plane crashes the entire industry changes training and stall scenarios so now at the first indication of stall, you must apply nose down input to reduce AOA. The previous training methodology should have been cited as a contributing factor to Colgan. “FAA’s insistence of an approach to stall be treated as an altitude/speed problem, instead of an AOA problem, and the ensuing negative training pilots received that prioritized altitude.”


Regardless, I doubt some of you will accept the Lion Air report and any blame on Boeing. You feel superior and think it couldn’t have happened to an American crew (re: white crews). That’s your right to believe that. Although I’m disappointed to hear stuff like that, I acknowledge that on average, pilots (because of their type A personality) tend to think highly of their own pilot skills versus their actual reality. Re: you’re not as good as you think you are.
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Old 09-24-2019, 08:18 AM
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Originally Posted by ShyGuy View Post
You mean the probable cause isn't unqualified brown pilots? Shocking I say! JohnBurke is gonna be pi$$ed.
Didn't really need to bring that to the conversation. There are many European pilots in the same boat. The US (and Oz and Canada) benefit from robust military and GA infrastructures, so our pilots learn to be pilots before they learn to be button pushers.

But for some reason real airplane flight time during training is just too expensive or terrifying some other countries.
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Old 09-24-2019, 08:26 AM
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Originally Posted by ShyGuy View Post
Regardless, I doubt some of you will accept the Lion Air report and any blame on Boeing. You feel superior and think it couldn’t have happened to an American crew (re: white crews). That’s your right to believe that. Although I’m disappointed to hear stuff like that, I acknowledge that on average, pilots (because of their type A personality) tend to think highly of their own pilot skills versus their actual reality. Re: you’re not as good as you think you are.
Blame is not mutually exclusive; it is not Boeing's fault or the pilots fault, it is Boeing's fault and the pilots fault. A reasoned analysis can be made given the details that are known.

https://www.nytimes.com/2019/09/18/m...s.html?sfns=mo
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Old 09-24-2019, 08:52 AM
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Originally Posted by RJSAviator76 View Post
The cause?

I’d say “the cause” would be two crews unable to handle an emergency due to extremely poor and scripted training, and no opportunity to develop airmanship skills before getting into an airline cockpit. They were set up for failure.

As for the contributing factors, carry on with your bashing of Boeing.
No, it's the other way around in this case. The MCAS system was not implemented as it was designed, or certified.
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Old 09-24-2019, 12:13 PM
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Originally Posted by ShyGuy View Post
Not the same thing.



The primary cause needs to be Boeing’s decision to design a single point of failure for a critical flight control feature, the FAA’s certification of a said system whose failure modes were not properly studied or understood, along with Boeing’s willful act of hiding any information about this new system in the manuals. Contributing to the accident are the pilot errors like leaving thrust levers in climb, etc.

RJS, if you operate under a PC/PT training scenario here, you are not allowed to be given “multiple failure” scenario for a jeopardy event. You don’t get a V1 cut at the same time with a cargo fire going off. The problem with Boeing is they assumed any activation of MCAS would simply be recognized as a trim runaway. What they never realized (because they rushed and had time compression due to their NEO competition) is that a single failure of the CA side AOA sensor or probe would trigger MCAS, but only after the CA stick shaker goes off and loses potential altitude/airspeed information on the CA side. The pilot receives what looks like a false approach to stall warming (stick shaker) along with potential unreliable airspeed information. Now MCAS kicks in. Not just kicks in, but keeps kicking in an infinite amount of times because of the false AOA readings, instead of just kicking on once and stopping. No one at the FAA or Boeing envisioned this type of failure mode.


It’s a little tiring to read reports that blame dead pilots only, while the system that allowed the accident to happen changes without being acknowledged as at least a contributing factor. Colgan was a good example. No doubt the crew screwed up and the probable cause stands. Still. Fact remains until 2009 if you were flying at 121 airlines, with gear and flaps down we were told to power out of stalls and minimize altitude loss (which in most cases) meant pulling slightly back into the shaker. The industry taught altitude loss and an approach to stall as a speed/altitude problem, instead of an AOA problem. After the plane crashes the entire industry changes training and stall scenarios so now at the first indication of stall, you must apply nose down input to reduce AOA. The previous training methodology should have been cited as a contributing factor to Colgan. “FAA’s insistence of an approach to stall be treated as an altitude/speed problem, instead of an AOA problem, and the ensuing negative training pilots received that prioritized altitude.”


Regardless, I doubt some of you will accept the Lion Air report and any blame on Boeing. You feel superior and think it couldn’t have happened to an American crew (re: white crews). That’s your right to believe that. Although I’m disappointed to hear stuff like that, I acknowledge that on average, pilots (because of their type A personality) tend to think highly of their own pilot skills versus their actual reality. Re: you’re not as good as you think you are.
You lost me at "white crews."

For the rest of you, this is a long read, but well-worth it.

https://apple.news/AHhKSVOlLS0GHBTAPJI9UXA
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