The full docket is here.
The final report is here.
tl;dr version: Deepwater Horizon all over again – multiple contributing factors. They all did it.
Earl
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That is usually the case with mishaps like this. It’s never one thing and generally involves technical, managerial, logistical, organizational, ethical and moral failures up and down the line, perpetuated by inertia, group think, and cognitive dissonance.
Another case in point: the space shuttle Challenger disaster. The main whistleblower, Morton Thiokol engineer Roger Boisjoly, wrote papers and lectured all over the world about such organizational failures.
Some people remember where they were when Kennedy was shot, as do I. I also remember exactly where I was at when the shuttle disaster happened. Outbound from the jetties in Lake Charles ship channel on a clear but crisp day. What a shock. This 737 debacle adds to one of the many reasons I have not flown since 2003.
beginner crew flew into the ground at overspeed conditions…
Had they of not done that the autopilot would have saved them ( allowed themselves to get in to an overspeed condition that is)
The Challenger disaster? We were just off of Key West, in ballast headed back to the Gulf Coast. The day before, we were off of Canaveral and thought that we were going to get a front row seat for the launch before it was scrubbed for that day.
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Failure of airmanship was probably more than 50 percent of the cause.
Simply pulling the power levers back might have given them a chance to save themselves.
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As I have mentioned before, we have met at sea and/or on land and did it safely… Cool shit sir. What a small world we live in. We are still here on this earth after the shit we’ve been through. Offshore tugs ain’t easy folks.Wouldn’t change a thing. Loved it, except for the flying part
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Get your hands dirty Steamer and try it out. LOL
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Been there done that PNW - Alaska - Bering Sea wire boats.
So maybe you know what I am talking about. Ain’t no party sir. Thinking you didn’t stay long in that business. With the flying and all.
I am guessing we may have crossed paths while I was with ABS. Did you ever do any surveys in Galveston/Freeport/Texas City in the 90s?
Yes. More than a few in all the ports mentioned. We were vetted constantly for new work, and ABS inspection was required by the customer.
So the pilots had several years flying experience on 737s, Boeing’s own test pilot wasn’t able to recover from the same crash scenario years prior, and the alarm that would have alerted the pilots to a sensor issue was knowing inoperable when Boeing sold the planes, and by the way this alarm was associated with a new system that Boeing didn’t want to call new so they wouldn’t have to spend money training pilots on…but you think it was just an issue of a “beginner crew”?
captain of Lion Air flight 610 had accumulated over 5,100 hours of flight time on Boeing 737 airplanes, and the 41-year-old first officer had more than 4,200 hours on Boeing 737 models, indicating that they were seasoned pilots.
it took one of Boeing’s own test pilots more than 10 seconds during a simulator test to respond to MCAS activation. The pilot, “found this catastrophic[.]” Boeing did not inform the FAA about this test data and appears to have discounted the test results, falsely assuming that pilots would quickly recognize and respond to uncommanded MCAS activation.
Boeing intentionally sought to ensure MCAS was not defined as a new function in order to avoid increased costs and greater certification and pilot training impact.
Boeing continued to produce and deliver its MAX aircraft to customers before the Lion Air crash knowing the AOA Disagree alert was inoperable on most 737 MAX aircraft without informing them of this non-functioning component.
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The Ethiopian flight hit the ground at 600 knots … about 350 knots more than it should have been flying. They never pulled the power off, they panicked and died 6 minutes after wheels up with the aircraft still at takeoff power.
The Lion Air crew managed to last for 12 minutes. The captain had 3000 hours less than the captain of the Ethiopian flight but the first officer had about 5000 more than the Ethiopian FO who only had a couple of hundred hours total … a complete beginner who did not have a clue.
They still let the plane go into overspeed, thats a beginner mistake.
Dont confuse, ‘being doing to for years’ versus ’ skilled pilot’
To be clear, it was 12min from clearance to take off until time of crash. They had several real or perceived issues for the first 6 min of flight before the MCAS started activating 20times in the final 6min of flight.
Well yeah, when the control system is automatically and continuously trying to aim a level aircraft at a downward angle due to an AOA sensor error of 21 degrees I’d have to assume they could have cut the engines off all together and they still would have accelerated into the earth.
Are you saying Boeing’s own test pilot who crashed in the simulator for the same reason wasn’t a skilled pilot?
The two quotes in the reports intro should carry weight, that the plane can’t be designed only for the most skilled seasoned pilots, it will necessarily be flown by pilots all over the world. And if Boeing hadn’t hidden a known flaw, hidden the novelty of the system, not enabled the alarm they were required to have enabled, and provided appropriate training, this might not have happened.
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No one is defending Boeing or the FAA for their actions and failures. Boeing management left Seattle for reasons that some might say are the root cause of both of these accidents and the company’s miserable condition.
The statements about “overspeed” are a reflection of the pilot’s ability to deal with the situation - or not.
Boeing is not at fault because a 200 hour first officer did not realize that maintaining maximum power from takeoff to impact is not standard operating procedure and a poorly trained and overloaded captain did not follow Boeing’s emergency directive that was issued after the Lion Air crash, or even understand why trim forces were so high.
What amazes me in the Lion Air timeline, the crew knew that when flaps were down the problem went away. They tried it twice and saw the result. Why did they not stay below flap speed and go back to the airport with flaps down?
No pilot here nor claim to have the knowledge, Something is not right with these planes. People with a lot of experience have had trouble with them. Doesn’t give that warm fuzzy feeling about flying ANYWHERE.
Boeing built a plane that the cheap arse budget airlines asked them to build.
They had to get around no pilot training.
The cheap arse airlines bought the planes in the 3rd world whereas the ones in the USA said wait a minute, we need a few more items in the cockpit to make them safe.
The airlines are responsible to train pilots not Boeing.
My 737 mate that does lots of sim work said the dodgy airlines were not even telling their crew the MAX had a few extra features.
They got a download onto their tablets explaining it, so whether they studied that or not is up to them.
Agreed you cant fly out of the single aoa sensor error unless you switch the autopilot on which is explained in the downloadable instructions.
The FAA allowing such a system to pass in my mind put them as liable as the dodgy airlines.
Can a DP2 vessel have a single sensor failure that causes a catastrophic failure, well no.
I guess we are all lucky the FAA are not involved in vessels.