Lionair 610 crash

[jb747]

If you were a flying instructor, you probably remember just how hard it was to get some people to trim. And I guess he was taught not to be 'too' aggressive with the trim.

 

[flyer89]

Would the 2kt discrepancy at 80kts have been too little to be able to discern a ‘DISAGREE’ between the PNF calling it out and the PF confirming it?

 

[jb747]

Would the 2kt discrepancy at 80kts have been too little to be able to discern a ‘DISAGREE’ between the PNF calling it out and the PF confirming it?

Way too small. At that call, the bloke flying is 99% outside the aircraft, so he either has to transition to a quick look inside, or find the number and read it on the HUD. You're really only after a very gross check, the sort of thing that would show up if a mud wasp has blocked a probe.

 

[flyer89]

FO’s training record is interesting....

 

[VulpesVulpes]

Interesting change of tune in the comments here.

It's good to see the report acknowledge there is shared blame here. Boeing obviously goes without saying, but the pilots, lion air and the parts supplier are all contributors to this.

Many many people took a number 2 on the bed here. Lion air IMO are just as liable for releasing an unairworthy plane as Boeing for getting the design wrong.

If anything, Lion air contributed the most through 1, improper controls releasing an aircraft not ready for flight and 2, allowing the coughpit calamity that was the crew to exist.

Catastrophic disasters are a chain of events and removing only one of the failures would have made this a non newsworthy flight.

 

[oz_mark]

Catastrophic disasters are a chain of events and removing only one of the failures would have made this a non newsworthy flight.

Boeing's problem is that there have been two crashes - and one of the causes of this accident was implicated in the second.

 

[jb747]

Whilst neither training record is exactly flash, the reality is that Boeing have been pitching the aircraft as suitable for pilots like these. The fact that this system caught out two crews, with the second having at least an idea of the existence of MCAS is quite an indictment.

 

[Quickstatus]

One crew was able to successfully counteract erroneous MCAS and survived. However this sets up the pilots to a never ending cycle of trim correction. Cycles of Insufficient trim correction of MCAS becomes coughulative over time and eventually overwhelms the crew

And AoA disagree was omitted in the MAX but was enabled in previous 737 iterations. Pilots coming over from previous 737s did not know there was no AoA disagree on the MAX, and this is one reason the LionAir crew who survived did not point to AoA disagree in the maintenance write up. A warning light that does not come on is a significant indicator of a problem not occurring but the crew did not know that there was no warning light installed.

Systems that interface humans with machine have over time, been designed to improve that relationship or at least make that interface “user friendly”. In critical systems such as aircrafts, safer. It seems that Boeing just assumed that it would in the MAX.

 

[jb747]

I'm not convinced that an AoA disagree indication would have made any difference.

 

[AviatorInsight]

I'm not convinced that an AoA disagree indication would have made any difference.

I agree with that too.

And AoA disagree was omitted in the MAX but was enabled in previous 737 iterations. Pilots coming over from previous 737s did not know there was no AoA disagree on the MAX, and this is one reason the LionAir crew who survived did not point to AoA disagree in the maintenance write up. A warning light that does not come on is a significant indicator of a problem not occurring but the crew did not know that there was no warning light installed.

We don’t have the AoA indicator but still have the AoA disagree illumination on the PFD. All the checklist says is that there might be a discrepancy with the airspeed and/or altimeter. In which case go to the respective checklist. Yes, the one that the FO couldn’t find on the front cover of the QRH with all the other memory item checklists.

 

[Quickstatus]

I get the impression that there was not a lot of effective communication between the 2 pilots to try to resolve a chaotic situation. It seemed like each existed in their own little world and the little communication that existed did not add anything constructive.

I’m my world this is often an indication of a brain freeze where performance deteriorates to a basic “automaton” level and where higher analytic functions are missing. The one thing that seem to assist with solving the problem is communication - often coordinated by a Team Leader not tasked with anything else. In this case I think the Captain possibly tried to be that by giving the FO the flying duties but was not able to improve the collective problem solving ability of the flight deck.
It is easier in my world because pressing the big red button usually summons a lot of people - sometimes you can’t fit into the room and some people have to be dismissed from the red button call to make room. I get there is no such red button or people to parachute into a flight deck.

 

[oz_mark]

Certainly, the report reinforces my belief that LionAir is not an airline I want to use.

But none of that excuses what Boeing have done.

 

[MEL_Traveller]

But none of that excuses what Boeing have done.

I think that's right. As someone mentioned up-thread, if this was simply an issue of 'pilot error' or 'training', the plane wouldn't have been grounded for this long.

 

[jb747]

I get the impression that there was not a lot of effective communication between the 2 pilots to try to resolve a chaotic situation. It seemed like each existed in their own little world and the little communication that existed did not add anything constructive.

Actually this is one of the things I find amusing (for want of a better word) about proposals to have only one pilot on an aircraft, with another at some central base. If communication can break down over 1 metre, how will it go over a couple of thousand?

Effective communication in a coughpit, especially when things are busy, uses all sorts of modes. As often as not, you'll learn something simply by watching what the other guy is doing. Management of a coughpit, is not something that comes naturally to all pilots, but it is the difference between the great captains, and the also rans. Making a coughpit work when you have highly experienced crews is one thing, but there are all sorts of variations on the theme that can make it go from easy, to very hard work indeed. And the issues aren't always in any given seat.

The cacophony of alarms and warnings that would have been going on is not being given sufficient credence by those who haven't experienced it either. You have simultaneous loud alarms, that may actually be telling you opposite things, added to pages of EICAS messages, it makes for an interesting environment.

Sitting in your own bubble is sometimes the only way to do things. Tasks are generally split up, so that one person is actually flying the aircraft, whilst the other is taking care of everything else. You need to stop, and come together every now and then, to keep the mental model on the same page, but tasks need to be logically split up.

Looking at this event, the captain was the pilot flying, and whilst he was having a fairly hard time of it, with MCAS repeatedly activating, he was trimming sufficiently to at least keep up. He'd have had momentary periods when he could try to manage the FO, but they would have been in the MCAS inactivity times, which, as we now know, are only a few seconds long. His ability to keep track of what the FO was doing, or otherwise, would have been quite limited. At some point though, he seems to have decided that the FO was not up to the task of supporting him, and has decided to reverse the roles. Sadly the FO was even less able to handle the task of actually flying. So, whilst they were unable to dig themselves out of the hole, it was a hole that was dug by Boeing.

 

[Quickstatus]

Sitting in your own bubble is sometimes the only way to do things. Tasks are generally split up, so that one person is actually flying the aircraft, whilst the other is taking care of everything else. You need to stop, and come together every now and then, to keep the mental model on the same page, but tasks need to be logically split up.

Yes in my world, the tasks are split up such that each task is very specific and repetitive, but someone else has the overall task of the team leader who provides the focus and direction, - keeping everyone on the same page and does not perform any other tasks.
It must be difficult enough being Pilot flying and also in overall command.

So, whilst they were unable to dig themselves out of the hole, it was a hole that was dug by Boeing.

Effectively they had to be Boeing Test pilots, but test pilots would have been told about MCAS.

Alarms

Where can pilots get additional resources from to help deal with bad situations like this. RdeC had 4 other pilots with him, I can get 15 people turn up in minutes. Sometimes there are additional pilots for long range missions. But a 2 pilots in a never before encountered scenario even in a sim?.

The crew that flicked the Stab Cutoff. Why did they do that and lived and no one else did? Why do some people perform better than others in a chaotic, terrifying environment.

 

[jb747]

Yes in my world, the tasks are split up such that each task is very specific and repetitive, but someone else has the overall task of the team leader who provides the focus and direction, - keeping everyone on the same page and does not perform any other tasks.
It must be difficult enough being Pilot flying and also in overall command.

Which is why it's often best to give the flying to the FO, and to sort the problems out yourself. But, that firstly assumes a reasonable flying standard from the FO, and also that flight control is not the actual issue. In QF30 I let the FO fly all of the descent. He was doing a perfectly good job, and it left me to try to work out what was actually going on.

Effectively they had to be Boeing Test pilots, but test pilots would have been told about MCAS.

I think you'll find that Boeing never actually tested the scenario of a mad MCAS, deciding that the odds of it happening were minuscule. After the events, when it was looked at (in the sims), they used up many thousands of feet, far more than was actually available.

To handle it, you literally need to know immediately that it's the problem, and not one of the other things that's setting off alarms. Not many times does the aircraft give you advance notice.

Where can pilots get additional resources from to help deal with bad situations like this. RdeC had 4 other pilots with him, I can get 15 people turn up in minutes. Sometimes there are additional pilots for long range missions. But a 2 pilots in a never before encountered scenario even in a sim?

Extra resources are rarely going to be of any help whatsoever. Very few aviation events aren't over within a few minutes. Trying to bring some remote person up to speed, would be little more than huge waste of time. All of this presumes that the crew have some reasonable level of competency. FOs who have only a couple of hundred hours in real aircraft (and who would never have seen a real problem) are always going to be limited in how much help they can offer. People who don't know memory items are of zero value.

RdC basically had an engine failure in a four engined aircraft. Whilst there were lots of system failures to be looked at, none of them were ever resolved, though the time they used gave them a better picture of the issues. His FO was extremely good (and is now a management Captain). I see no reason why any two of the people in the coughpit would not have effectively resolved the issues. Also the autopilots remained engaged, which unloads the PF dramatically.

The crew that flicked the Stab Cutoff. Why did they do that and lived and no one else did? Why do some people perform better than others in a chaotic, terrifying environment.

Turning off the stab power will mean that the only way to move the trim is via the trim wheel, which we've not been told is unusable at high speed. So, you must turn the stab power off at a point where the aircraft is basically in trim, not at some extreme value. If you do so when more or less in trim, the aircraft will be flyable. But, if you do it when way outside of the norm, then all you've done is remove your own ability to fix the issue, even if only for a few seconds.