2009 Crash of Boeing 737 NG Now Receiving New Scrutiny (orlandosentinel.com) 66
Slashdot reader JoeyRox shares a disturbing story about a Boeing 737 NG flight carrying 128 passengers that crashed in 2009, killings its three pilots, another crew member and five passengers. But "the Dutch investigators focused blame on the pilots for failing to react properly when an automated system malfunctioned and caused the plane to plummet into a field," the New York Times reported this week.
"The fault was hardly the crew's alone, however. Decisions by Boeing, including risky design choices and faulty safety assessments, also contributed to the accident on the Turkish Airlines flight." But the Dutch Safety Board either excluded or played down criticisms of the manufacturer in its final report after pushback from a team of Americans that included Boeing and federal safety officials, documents and interviews show. The crash, in February 2009, involved a predecessor to Boeing's 737 Max, the plane that was grounded last year after accidents in Indonesia and Ethiopia killed 346 people and hurled the company into the worst crisis in its history.
A review by The New York Times of evidence from the 2009 accident, some of it previously confidential, reveals striking parallels with the recent crashes — and resistance by the team of Americans to a full airing of findings that later proved relevant to the Max.
In the 2009 and Max accidents, for example, the failure of a single sensor caused systems to misfire, with catastrophic results, and Boeing had not provided pilots with information that could have helped them react to the malfunction. The earlier accident "represents such a sentinel event that was never taken seriously," said Sidney Dekker, an aviation safety expert who was commissioned by the Dutch Safety Board to analyze the crash.
Dekker's study accused Boeing of trying to deflect attention from its own "design shortcomings" and other mistakes with "hardly credible" statements that admonished pilots to be more vigilant, according to a copy reviewed by The Times.
[That 2009 study was never made public -- until Tuesday, after the New York Times had published its story.
The same day Boeing announced they'd stopped production on the 737 Max.]
The Times also reports that after the first fatal 737 Max crash in 2018, one Ohio State professor who has advised the FAA sent an email to a colleague citing research from the 1990s on automation-triggered disasters -- as well as Boeing's 2009 crash. "That this situation has continued on for so long without major action is not how engineering is supposed to work.
After the second fatal 737 Max crash, he told he Times he was appalled. "This is such of a failure of responsibility," he said. "We're not supposed to let this happen.
"The fault was hardly the crew's alone, however. Decisions by Boeing, including risky design choices and faulty safety assessments, also contributed to the accident on the Turkish Airlines flight." But the Dutch Safety Board either excluded or played down criticisms of the manufacturer in its final report after pushback from a team of Americans that included Boeing and federal safety officials, documents and interviews show. The crash, in February 2009, involved a predecessor to Boeing's 737 Max, the plane that was grounded last year after accidents in Indonesia and Ethiopia killed 346 people and hurled the company into the worst crisis in its history.
A review by The New York Times of evidence from the 2009 accident, some of it previously confidential, reveals striking parallels with the recent crashes — and resistance by the team of Americans to a full airing of findings that later proved relevant to the Max.
In the 2009 and Max accidents, for example, the failure of a single sensor caused systems to misfire, with catastrophic results, and Boeing had not provided pilots with information that could have helped them react to the malfunction. The earlier accident "represents such a sentinel event that was never taken seriously," said Sidney Dekker, an aviation safety expert who was commissioned by the Dutch Safety Board to analyze the crash.
Dekker's study accused Boeing of trying to deflect attention from its own "design shortcomings" and other mistakes with "hardly credible" statements that admonished pilots to be more vigilant, according to a copy reviewed by The Times.
[That 2009 study was never made public -- until Tuesday, after the New York Times had published its story.
The same day Boeing announced they'd stopped production on the 737 Max.]
The Times also reports that after the first fatal 737 Max crash in 2018, one Ohio State professor who has advised the FAA sent an email to a colleague citing research from the 1990s on automation-triggered disasters -- as well as Boeing's 2009 crash. "That this situation has continued on for so long without major action is not how engineering is supposed to work.
After the second fatal 737 Max crash, he told he Times he was appalled. "This is such of a failure of responsibility," he said. "We're not supposed to let this happen.
Classic example of shit hitting fan (Score:5, Interesting)
... and spreading the stink everywhere, too late now Boeing, , a world class reputation gone to shit, the senior people at Boeing need to go to jail, the shareholders should take a bath and the Max should be scrapped and Boeing sent back to the drawing board .. of course, if Boeing wasn't a corporation shielding the upper class from the consequences of their actions, it might happen, but we all know that the real criminals will walk away with millions ... and you still swear the system isn't completely evil and corrupt.
Sure.
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Heads roll uphill in corporate America.
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Tony Soprano said it best "Money rolls uphill and shit rolls downhill"
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At the time, "Trading Places" was just a funny movie. Now we have to wonder if Eddie Murphy got it exactly right.
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the shareholders should take a bath
You realize this means you, right? Your 401(k) probably has some Boeing stock, among others.
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It's called a poison pill, and it's why limited stock ownership by "the rest of us" hasn't been blocked.
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Even my Aunt who works as a cashier has a 401k with employer match.
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I guess most people you know don't have jobs.
How many American workers participate in workplace retirement plans?
https://www.pensionrights.org/... [pensionrights.org]
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Good. What your money is used for is your responsibility, even if you bundle it up with a bunch of other people and get someone else to deal with it for you.
Pilots weren't paying attention (Score:5, Informative)
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Look it is very simple to solve the Boeing crisis:
Only white American pilots should be allowed to fly their planes.
Only white American passengers should be allowed to travel on a Boeing.
It doesn't matter then who is right or wrong, and spin and lies won't have any further effect.
One way or another, the problem will solve itself and flying will become much safer.
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Re:Pilots weren't paying attention (Score:5, Informative)
Although the AP design, relying on a single altimeter as input, is questionable from an engineering standpoint, the fact is clear that in this particular case, the pilots simply weren't paying attention. If they had been paying attention, they simply could've avoided getting their plane into an irrecoverable situation.
That sounds logical, but with Boeing under such scrutiny over the 737 MAX failure I expect that this will take more than this to save them from blame.
The failure of MCAS is an entirely different beast. It actively steered the plane into an irrecoverable configuration, even if the pilots were paying attention. Also, in case of the first crash, they even purposely didn't inform the crew there was such a system, so the crew didn't even know what they were fighting against...
The problems with MCAS is in a class all its own. One major problem with the 737 MAX was that the MCAS and the power trim controls were on the same circuit breaker. If the MCAS set the trim too far then the manual trim control would have required superhuman strength to put back to a reasonable position. Turning the circuit on meant MCAS put the trim in a dangerous position, turning the circuit off meant there was no power to the motors needed to move the trim to a safe position. If the MCAS had limits on how much trim it could apply, as it was originally designed, then the pilots could still use the control column to overcome MCAS trim changes.
This failure to have separate circuit breakers for MCAS and the motors for stabilizer trim was the last straw. Of course there's many other failures on how MCAS was implemented on the 737 MAX that lead to this being deadly as opposed to merely hair raising and uncomfortable. There was the use of a single AoA sensor that gets mentioned often, but I'm not so sure this is as worthy of as much scrutiny as it is getting. I can agree, of course, that the failure of a single sensor should not be something that can bring down an aircraft. Where I see this as not much of an issue is that the MCAS was not a flight critical system and it's failure should have only resulted in a small addition of "mental bandwidth" for the pilots if this sensor failure required disabling the MCAS. The MCAS should not have been able to set the trim beyond what the pilots could overcome with control column input, but again even this would not have been a problem if disabling MCAS did not also disable the power trim motors.
I'm not even sure if knowledge of the presence of MCAS was necessary to prevent these deadly crashes. Pilots would have to know how to deal with a failure of the power trim and I'm speculating that by disabling the power trim the pilots might still have been able to recover from the MCAS failure. If MCAS had not been able to put the trim to a point in which both control column input could not counteract, and where the forces on the trim were too much to overcome manually, then by disabling the power trim the pilots could have recovered by either pulling back on the control column or by turning the trim back manually to a safe position.
Of course I speculate. I'm no expert but it looks like a lot of things had to go wrong and if any one of them had been absent from the beginning then we'd never have heard of this. I'm just seeing too much attention being on the use of a single AoA sensor when it seems to me that the critical failure was in allowing MCAS to set the trim so far and not being able to disable MCAS separately from disabling the power trim motors.
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Not necessarily superhuman strength, but certainly a lot of strength - a lot of pilots/co-pilots would not be able to physically manually correct the trim.
Knowing about MCAS would have saved the doomed pilots critical seconds as they tried to diagnose the problem with the trim - it could well have made a crucial difference to the outcome.
You've probably seen the Mentour simulator video already, but it might be interesting for other people:
https://www.youtube.com/watch?... [youtube.com]
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Knowing about MCAS would have saved the doomed pilots critical seconds as they tried to diagnose the problem with the trim - it could well have made a crucial difference to the outcome.
It may be impossible to tell if this would have made a difference.
You've probably seen the Mentour simulator video already, but it might be interesting for other people:
I had not watched that video before but I have watched many other videos from Mentour Pilot which have been very enlightening on the 737 MAX problems. I can certainly encourage others to watch his videos.
I can agree that pilots flying the 737 MAX should have received better training. As Mentour Pilot has pointed out in other videos the procedure for receiving certification across different 737 airframe variants can be as simple as getting s
Re:Pilots weren't paying attention (Score:4, Informative)
Minor correction, there was no breaker to turn MCAS off other than shutting down the entire flight computer. It's just that with the motors off, MCAS had no way to alter the trim (further). It would STILL be sending a dignal to change the trim, it's just that nothing would respond.
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"The problems with MCAS is in a class all its own. One major problem with the 737 MAX was that the MCAS and the power trim controls were on the same circuit breaker. If the MCAS set the trim too far then the manual trim control would have required superhuman strength to put back to a reasonable position. Turning the circuit on meant MCAS put the trim in a dangerous position, turning the circuit off meant there was no power to the motors needed to move the trim to a safe position. If the MCAS had limits on h
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"I'm not even sure if knowledge of the presence of MCAS was necessary to prevent these deadly crashes. Pilots would have to know how to deal with a failure of the power trim and I'm speculating that by disabling the power trim the pilots might still have been able to recover from the MCAS failure. If MCAS had not been able to put the trim to a point in which both control column input could not counteract, and where the forces on the trim were too much to overcome manually, then by disabling the power trim t
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It's not just that the pilots weren't paying attention. The operating procedures they were meant to follow required them to give up on that attempt to land and go around before the problem even happened because they were too far behind on their landing preparations, but they chose not to. This is a really bad idea which has caused a number of crashes over the years - unfortunately, pilots keep on doing it anyway since it saves time and works out fine so long as everything works and no-one makes a mistake, b
Boeing blame storming (Score:4, Interesting)
Re:Boeing blame storming (Score:5, Informative)
only the Long Island crash was attributed to a forward fuel tank explosion.
Center tank. It was the center tank, the one that forms the wing box.
It's bigger than my house.
I'm not defending Boeing, I think they're shit ever since they married that whore Douglas.
that is what needs to be looked at. How now they're all-for-profit while before that they were quite a bit more engineering-driven.
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Re:Boeing blame storming (Score:5, Informative)
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The engine falling off was due to improper maintenance procedures by the airline.
The cargo door failures were caused by a poorly designed door. In fact, the subcontractor that manufactured them had warned McDonnell Douglas of the problems but no action had been taken because it would interrupt the manufacturing schedules. Seems familiar doesn't it? In fact, a lot of people attribute Boeing's problems as starting when they merged with McDonnell Douglas.
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I think they should go further back and investigate all the 747 crashes also, many of which were blamed on cargo fires, or terrorists, while only the Long Island crash was attributed to a forward fuel tank explosion. It looks like Boeing may have a long history of crash investigation blame storming.
The S.O.P. always seems to be 'Blame the pilot(s) first', no matter the airline, no matter the airplane. That should be investigated too.
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I think they should go further back and investigate all the 747 crashes also, many of which were blamed on cargo fires, or terrorists, while only the Long Island crash was attributed to a forward fuel tank explosion. It looks like Boeing may have a long history of crash investigation blame storming.
The S.O.P. always seems to be 'Blame the pilot(s) first', no matter the airline, no matter the airplane. That should be investigated too.
Well, normally the pilots are dead so blaming them makes for an convenient profit saving measure. I'm not saying it's fair, good or honourable but that's how corporate types think. There is a reason corporate executives are usually psychopaths.
Re:Boeing blame storming (Score:4, Insightful)
The S.O.P. always seems to be 'Blame the pilot(s) first', no matter the airline, no matter the airplane. That should be investigated too.
Every year there are millions of flights that take off and land safely, and only a half dozen or so of them ending in fatalities every decade. Of these millions of flights these same airlines, with the same aircraft, operate safely. The one unique variable is most often the pilot. Why would we not first investigate the pilots for a cause of any problems?
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The S.O.P. always seems to be 'Blame the pilot(s) first', no matter the airline, no matter the airplane. That should be investigated too.
Every year there are millions of flights that take off and land safely, and only a half dozen or so of them ending in fatalities every decade. Of these millions of flights these same airlines, with the same aircraft, operate safely. The one unique variable is most often the pilot. Why would we not first investigate the pilots for a cause of any problems?
Right. I forgot that electronic systems never fail. My bad.
Re:Boeing blame storming (Score:4, Insightful)
Why would we not first investigate the pilots for a cause of any problems?
Because it is a symptom of a bigger problem.
Boeing knew about the fatal problems with the 737 Max before the crashes, and hid the facts. With the crashes, they obscured evidence and instead blamed the pilots, until they were finally caught.
The FAA allowed this to happen because they put Boeing's profits ahead of safety - it's what they do. And it's not just Boeing that the FAA backs this way. I seriously doubt that it's just Boeing that repackages facts and evidence to divert attention from a faulty airplane, or the corporations that built them.
All of which makes Blaming The Pilots First a symptom of what has literally become deadly flaws in the FAA and the industry it is supposed to regulate.
Re:Boeing blame storming (Score:4, Insightful)
All of which makes Blaming The Pilots First a symptom of what has literally become deadly flaws in the FAA and the industry it is supposed to regulate.
I'll remember that the next time someone says we need to put the government in charge of something.
Indeed, people screw up. This was not just a fault of Boeing but of the government. We can shuffle around the blame but there is no perfect system which will remove human error.
Now, again, why should we look first into pilot error as a cause of any airplane crash? Because with the millions of flights every year this has been shown to be the most likely cause of failure in the most cases. Does this mean that's where we stop looking? Of course not. We start with the pilots but don't stop until satisfied that we've discovered the problem.
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...This was not just a fault of Boeing but of the government...
It was Boeing's fault. The FAA's fault was letting it happen.
Now, again, why should we look first into pilot error as a cause of any airplane crash? Because with the millions of flights every year this has been shown to be the most likely cause of failure in the most cases. Does this mean that's where we stop looking? Of course not. We start with the pilots but don't stop until satisfied that we've discovered the problem.
gTsiros below replies to this succinctly. But because I can't seem to shut up...
Boeing's coverup disaster is an indication that the game is rigged against pilots. Boeing blamed the pilots, even though they knew better. When foreign investigators found the fault lay with the 737 max, the Boeing president still tried to offload most of the blame onto the pilots. The world didn't buy it. There was evidence that the pilots weren't trained to deal
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All of which makes Blaming The Pilots First a symptom of what has literally become deadly flaws in the FAA and the industry it is supposed to regulate.
I have read somewhere that "blaming the pilots" is accepted standard practice, so airlines and manufacturers can not be sued for extra damage by the relatives of the victims.
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I have read somewhere that "blaming the pilots" is accepted standard practice, so airlines and manufacturers can not be sued for extra damage by the relatives of the victims.
I do believe you're on to something there.
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You mean the pilot that has been flying year after year without incident, just like the planes?
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You mean the pilot that has been flying year after year without incident, just like the planes?
No, I mean that when an accident does occur, keeping an open mind is not what happens. To steal a line from Leonard Cohen, the game is rigged.
In general, I'm in awe of airplanes, their underlying technology, the black box, the inspections, the properly signed off logbook. The Before Takeoff Checklist is pure genius - I wish doctors and hospitals had such a checklist.
When an accident occurs, the inspectors should have such a checklist. It might be a bothersome nuisance that adds to their workload. And jus
Re: Boeing blame storming (Score:2)
It has been many years since the Surgical Safety Checklist was first introduced. Gawande wrote a book about it
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Making the pilot the go-to fault isn't keeping an open mind, it's blaming the dead so the living don't have to do anything.
The plane should be examined first since if it has a problem, there is something that can be done that will make future flights safer. If the pilot did make an error, we have to ask why. The answer may be that he was drunk and stupid, but it may be that something in the way the controls are laid out or the way the automation interacts with the pilot that tends to induce errors.
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> The one unique variable is most often the pilot
right, because a plane flying can be accurately modeled as a neutron moving through vacuum... piloted by a human.
nothing effecting its behavior, except the pilot
none of its properties ever changing
next time you try sounding scientific, make sure to use actual scientific thinking, not just a phrase you imagine somehow fits
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Because that's not good engineering. You start with no assumptions and don't favour any particular theory over another. You consider every possible way that the failure could have happened and investigate every available bit of evidence.
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This is bullshit. Have you ever read an NTSB report? They almost always list multiple factors that acted together to bring the plane down. Frequently, one of those factors is the pilot(s). The reason pilot error is often listed as a factor in a crash is because pilot error is a very common factor in a crash.
It's not in anybody's interest, least of all the manufacturer's, to hide lethal engineering flaws in an airframe because, sooner or later, they will get found out. If your aircraft keep crashing, you can
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You must be quite the patriot if you think giving a free pass to a company to build unsafe planes is good only because it is from your country.
Let's hope your family doesn't end up dead in one of those mass graves, because even the most ardent patriotism copes poorly with such a loss.
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Considering that a tank can only "explode" if you mix air/oxygen into the fuel ...
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A normal day for me on the Internet of 2020:
If that nightmare of a user experience is a normal day on the internet for you then maybe you need to limit your exposure to it. As in the old joke...
Patient: "Doc, it hurts when I do this."
Doctor: "Then don't do that any more."
One thing that was pointed out to me once was that the world is designed to be navigated by 99% of the population. This means, as an example, you don't have to be an average driver to get from point A to point B safely. It means you have to be just slightly better of a driver th
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Why shouldn't they? Is there any particular reason that the Dutch should coordinate with, for example, you, Putin, Donald or Boris or Angela what to put in an investigation?
What part of the MH17 investigation exactly displeased you? Be as specific as possible.
Boeing needs FAR better management. My opinion. (Score:4, Informative)
You can download "Internal Boeing communications about the 737 Max [nyt.com]". (PDF file, 35 megabytes) Quote from the next story: The PDF file is "117 pages of damning internal communications".
I Honestly Don’t Trust Many People at Boeing: A Broken Culture Exposed [nytimes.com]. (New York Times, Jan. 13, 2020)
It seems to me that Boeing will need perhaps at least 3 years to improve, and that will happen only if Boeing finds a CEO who is extremely technically capable and, at the same time, extremely socially capable.
Ouch (Score:2)
I can't imagine morale at Boeing is very high right now.
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Killing hundreds of people through negligence can have that affect on you.
Dr Woods at OSU (Score:2)