Lionair 610 crash

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The AV Herald has obviously received some advice in order to ask these questions

Following the release of the preliminary report on Nov 28th 2018 The Aviation Herald issued a number of questions to the FAA (see below) and received the following reply, the spokesman explaining "We aren'’t going to answer your specific questions because the investigation is ongoing":

The Federal Aviation Administration continues to participate in the Indonesian government’s investigation into the crash of Lion Air Flight 610. The FAA issued an Emergency Airworthiness Directive (AD) on Nov. 7 ordering operators to revise the airplane flight manual (AFM) to give the flight crew horizontal stabilizer trim procedures to follow under certain conditions. The agency will take further action if findings from the accident investigation warrant.

The Aviation Herald had submitted following questions (two questions were forgotten but in the light of the reply above it can be assumed they would not have been addressed too):

With respect to the certification of the 737 MAX aircraft, in particular the MCAS system, I'd like to raise following questions:

- when was the certificate for the 737 MAX 8 requested, and when was the certification issued?

- what risk assessments were done within the certification procedures, in particular again with respect to the AoAs and MCAS?

- were the ADR (Air Data Reference) algorithms reviewed with respect to AoA?

- was the risk assessed that one of the AoA sensors could be damaged by a bird strike, hail strike or similiar and could show a substantially too high angle of attack?

- did the certification deem not necessary that an "AoA Disagree" message was to be introduced?

- Why was the MCAS permitted to operate on the base of a single AoA value showing too high angle of attacks? Why does the MCAS not consider the other AoA value?

- Was the risk assessed according to Boeing's last sentence in the notice to operators: "If the original elevated AOA condition persists, the MCAS function commands another incremental stabilizer nose down command according to current aircraft Mach number at actuation.", in particular what possibilities existed for that conditions to persist?

- what should the system response have been in case the AoA values disagree? How would the systems determine which value is plausible and which is erroneous? Is there any such check at all? Would MCAS not need to be prohibited if left and right AoA disagree?

- considering the scenario that happened to Airbus twice (the crash in Perignan and the Lufthansa A321 near Bilbao losing 4000 feet), that at least two AoA sensors froze in same positions during climb, was the risk of such a scenario on the 737s assessed, too?

- Did the certification consider a massive change in the function of the AoA when MCAS (as actor in the flight controls) was introduced in addition to stick shaker (monitoring only)?

- What is the reasoning behind the certification permitting to allow a system modify the aircraft's equilibrium (via trim) in manual flight in a way that the trim could run to the mechanical stop and thus overpower the elevator?

- Was the AoA input to the MCAS (or in general) ever being cross checked, e.g. by taking into account altitude, IAS, vertical speed to compute TAS via altitude, density and IAS and the angle of the airflow by computing the angle of the flight trajectory with TAS and vertical speed? Could such an crosschecking algorithm not even detect if two or more AoA sensors were frozen/faulty?

- is the FAA going to review the certification of the 737 MAX family (and perhaps previous 737 versions) following the findings by the KNKT so far?

- Russia's MAK revoked the certificate of airworthiness for the entire 737 family (from 737-100 to 737-900) three years ago claiming they found an issue in the pitch/altitude control system of the aircraft (suggesting that at least the Tatarstan crash in Kazan as well as the Flydubai crash in Rostov may have been the result of that weakness) but did not receive a satisfactory response by the FAA and Boeing, also see News: Russia suspends airworthiness certification for Boeing 737s, but does not prohibit operation of 737s. What was the issue they found?


The questions we forgot to add:

- How the certification deal with spurious faults and spurious functions, in particular during maintenance? The maintenance manuals define a test to be run, then list maintenance steps one by one, the test is to be repeated after each step. If the system is found to be working during the test the maintenance task aborts with the message "You have solved the issue", which may trigger a wrong analysis and premature end of troubleshooting without removing the fault if the test apparently works correctly by random chance.

- Why do the FIM procedures for airspeed disagree, altitude disagree, feel difference light, inexplicable stick shaker activation etc. not reference the possibility of an AoA issue although AoA has a crucial influence onto all these error conditions, thus not guiding the AME to verify proper action of this input in each of these error conditions?
 
So 2 pilots were able to manage with Cutoff switch to Off, but the second 2 pilots didnt. Why?
Probably the same reason why some people perform better under pressure than others. That human condition is notoriously difficult to fix. Maybe more training?, changes to selection criteria?
 
Following the release of the preliminary report on Nov 28th 2018 The Aviation Herald issued a number of questions to the FAA (see below) and received the following reply, the spokesman explaining "We aren'’t going to answer your specific questions because the investigation is ongoing":

Well at least they were refreshingly straight with their answer, as in "We are not going to answer your specific questions" , rather than dodging all over the place!
 
So 2 pilots were able to manage with Cutoff switch to Off, but the second 2 pilots didnt.

Well, they didn't crash, but the more I read, the less I like what they did too.

Why?
Probably the same reason why some people perform better under pressure than others. That human condition is notoriously difficult to fix. Maybe more training?, changes to selection criteria?

If you build a system that can be messed up, and run the exercise enough times, you'll have plenty of people get it wrong. You'll even have some who come up with very novel ways of doing so.

I'm not normally one who believes in fixing piloting issues by setting the engineers loose, as invariably, their solution comes with unintended consequences....as we're already seeing here. But, I think that the 737 has been allowed to grandfather far too much into the modern world. It is, in most ways, a very old aircraft, with a veneer of modernity tacked on. Old aircraft designs have a bit of, well, honesty about their designs..they don't have much sneaky behaviour. Very modern aircraft have their own issues, but in general their behaviour is now well understood. But, the MAX is neither, and we're seeing technology being employed to fix behaviour that simply would not be allowed to exist in the first place in a more modern design.
 
That 2 pilots would fly to a planned destination with an active stick shaker for the entire flight, auto trim off, autopilot off, 1 pan-pan and a NNC (non normal checklist that does not include Land ASAP at nearest suitable aerodrome), something is very bad - and it's not anyone or anything in isolation - its the system.

The question therefore is whether that system exists elsewhere. In Australia?
 
I recently travelled to Australia on MI but on the day did not have a new B738MAX, but an older B738.

Is it our aviators' view that one should not travel on these new aircraft until the FAA and other regulators issue their investigation report(s) or would that be an over the top reaction?

Would you travel on MI if it was a B738MAX as MI811 was this morning (9V-MBA) from SIN to CNS?
 
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Its a bit more complicated than that. I think its the overall (and complex it is) system that one has to scrutinise. However the average Joe traveller does not have visibility or understanding into such complex systems. Mostly decisions are made on price
 
I think certification questions are most certainly required. Once upon a time things had dynamic tests but now it seems desk top validation and verification is the way to go and without a doubt a way for manufactures to save money.



The AV Herald has obviously received some advice in order to ask these questions

Following the release of the preliminary report on Nov 28th 2018 The Aviation Herald issued a number of questions to the FAA (see below) and received the following reply, the spokesman explaining "We aren'’t going to answer your specific questions because the investigation is ongoing":

The Federal Aviation Administration continues to participate in the Indonesian government’s investigation into the crash of Lion Air Flight 610. The FAA issued an Emergency Airworthiness Directive (AD) on Nov. 7 ordering operators to revise the airplane flight manual (AFM) to give the flight crew horizontal stabilizer trim procedures to follow under certain conditions. The agency will take further action if findings from the accident investigation warrant.

The Aviation Herald had submitted following questions (two questions were forgotten but in the light of the reply above it can be assumed they would not have been addressed too):

With respect to the certification of the 737 MAX aircraft, in particular the MCAS system, I'd like to raise following questions:

- when was the certificate for the 737 MAX 8 requested, and when was the certification issued?

- what risk assessments were done within the certification procedures, in particular again with respect to the AoAs and MCAS?

- were the ADR (Air Data Reference) algorithms reviewed with respect to AoA?

- was the risk assessed that one of the AoA sensors could be damaged by a bird strike, hail strike or similiar and could show a substantially too high angle of attack?

- did the certification deem not necessary that an "AoA Disagree" message was to be introduced?

- Why was the MCAS permitted to operate on the base of a single AoA value showing too high angle of attacks? Why does the MCAS not consider the other AoA value?

- Was the risk assessed according to Boeing's last sentence in the notice to operators: "If the original elevated AOA condition persists, the MCAS function commands another incremental stabilizer nose down command according to current aircraft Mach number at actuation.", in particular what possibilities existed for that conditions to persist?

- what should the system response have been in case the AoA values disagree? How would the systems determine which value is plausible and which is erroneous? Is there any such check at all? Would MCAS not need to be prohibited if left and right AoA disagree?

- considering the scenario that happened to Airbus twice (the crash in Perignan and the Lufthansa A321 near Bilbao losing 4000 feet), that at least two AoA sensors froze in same positions during climb, was the risk of such a scenario on the 737s assessed, too?

- Did the certification consider a massive change in the function of the AoA when MCAS (as actor in the flight controls) was introduced in addition to stick shaker (monitoring only)?

- What is the reasoning behind the certification permitting to allow a system modify the aircraft's equilibrium (via trim) in manual flight in a way that the trim could run to the mechanical stop and thus overpower the elevator?

- Was the AoA input to the MCAS (or in general) ever being cross checked, e.g. by taking into account altitude, IAS, vertical speed to compute TAS via altitude, density and IAS and the angle of the airflow by computing the angle of the flight trajectory with TAS and vertical speed? Could such an crosschecking algorithm not even detect if two or more AoA sensors were frozen/faulty?

- is the FAA going to review the certification of the 737 MAX family (and perhaps previous 737 versions) following the findings by the KNKT so far?

- Russia's MAK revoked the certificate of airworthiness for the entire 737 family (from 737-100 to 737-900) three years ago claiming they found an issue in the pitch/altitude control system of the aircraft (suggesting that at least the Tatarstan crash in Kazan as well as the Flydubai crash in Rostov may have been the result of that weakness) but did not receive a satisfactory response by the FAA and Boeing, also see News: Russia suspends airworthiness certification for Boeing 737s, but does not prohibit operation of 737s. What was the issue they found?


The questions we forgot to add:

- How the certification deal with spurious faults and spurious functions, in particular during maintenance? The maintenance manuals define a test to be run, then list maintenance steps one by one, the test is to be repeated after each step. If the system is found to be working during the test the maintenance task aborts with the message "You have solved the issue", which may trigger a wrong analysis and premature end of troubleshooting without removing the fault if the test apparently works correctly by random chance.

- Why do the FIM procedures for airspeed disagree, altitude disagree, feel difference light, inexplicable stick shaker activation etc. not reference the possibility of an AoA issue although AoA has a crucial influence onto all these error conditions, thus not guiding the AME to verify proper action of this input in each of these error conditions?
 
The fact that the NNC didn’t have land at nearest suitable airport doesn’t worry me. In both the airspeed unreliable and runaway stabiliser malfunctions, the aircraft is still flyable. Just more crew coordination required. Now airmanship must come into play somewhere. Would I continue to destination with either of those malfunctions? It depends. Did I leave from an engineering port or non engineering? You need to be configured and established early to keep it stable. If the port I left from was a major international airport, then yeah I’d return.

As for what VA is going to do I’m not sure, but I dare say that any operator with Maxs will be watching this investigation closely. A couple of our Checkies have gone over to the US to develop an upper air work recovery program for the NG and the Max and started to develop cyclics for the Max. I guess we’ll know in 12months time.
 
What Im worried about when NNC does not say Land ASAP, some may be feel pressured to not divert at all and continue to planned destination.
 
What Im worried about when NNC does not say Land ASAP, some may be feel pressured to not divert at all and continue to planned destination.

Depends what the failure is. Some checklists don’t make any mention of landing at all. If you’ve got the aircraft under control then what’s the rush? Would I fly from SYD to MEL with an unreliable airspeed and/or runaway trim? No. But that depends. What if SYD had the weather it had yesterday but MEL was CAVOK? There has to be some sort of discretion and decision making left up to the pilots if the situation is under control.
 
As Aviator and JB have said a few times it’s the system that’s the concern with these types of airlines. Easy to blame pilots for everything but if the training system that they are apart of has holes in it, eventually those holes lineup with tragic consequences.

I think if people were to observe a QF/VA sim session and then observed one of the ‘usual suspects’ sim sessions they would probably have to pick their jaws up off the floor at how profoundly different they were. I think a lot of people care desperately about safety up until the point they have to pay for it.
 
So 2 pilots were able to manage with Cutoff switch to Off, but the second 2 pilots didnt. Why?
Probably the same reason why some people perform better under pressure than others. That human condition is notoriously difficult to fix. Maybe more training?, changes to selection criteria?

i think this is in the context of when the incident happened?

on take off - millions of things to look at - altitude also lower - meaning less time. i am not surprised that the flight crew would be overwhelmed. heck they would not even have time to consult the SOP manual? So on take-off - the plane was pushing the nose down - pilots were fighting to pull it up? And the pilots lost?.

in previous flights - i believe the errors happened on cruise at much higher altitude? so much better chance of fixing stuff.
 
in previous flights - i believe the errors happened on cruise at much higher altitude? so much better chance of fixing stuff.

They flicked the auto trim switch to off very early on - it was one of first things they did after noticing the autotrim pushing nose down. The events occurred during the climb out just like on the event flight.

If you look at Fig 7. The autotrim was switched off around 14:33. Cruise altitude didnt occur till later.

One didnt fight. They just flicked the switch - but flew the rest of the trip in a very abnormal config. The other didnt and fought the whole way down. A couple of little switches was the main difference.
 
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on take off - millions of things to look at - altitude also lower - meaning less time. i am not surprised that the flight crew would be overwhelmed. heck they would not even have time to consult the SOP manual? So on take-off - the plane was pushing the nose down - pilots were fighting to pull it up? And the pilots lost?.

in previous flights - i believe the errors happened on cruise at much higher altitude? so much better chance of fixing stuff.

Taking off, the flaps are extended, so, I don't think this system (MCAS) is active.

You don't consult any manuals for what are memory items. It just seems that the second crew never realised it was a runaway trim. If the trim isn't doing what you want, then it must be considered a runaway.

The lack of "land ASAP", etc, means nothing. Yes, perhaps it's an avenue for an unscrupulous operator, but it also means the crew can decide based on what they are seeing. I flew an A380 with a dual ADR failure for 5 hours, and past a number of airfields that we could have used, because the weather and time of day at those airfields was a consideration. Basically a night landing with low cloud was a lot less attractive than a longer flight to a day VMC landing.
 
think if people were to observe a QF/VA sim session and then observed one of the ‘usual suspects’ sim sessions they would probably have to pick their jaws up off the floor at how profoundly different they were.

What drives that in your opinion?
Culture? Inadequate sim supervisors? Regulation?

Surely it's in the airlines and aircraft manufacturers interest to ensure pilots are getting similar training.
 
One didnt fight. They just flicked the switch - but flew the rest of the trip in a very abnormal config. The other didnt and fought the whole way down. A couple of little switches was the main difference.

Abnormal, sure but the amount of trim needed to conduct a climb, cruise and descent is not as much as you think. You could still hand fly and trim as required. It gets a little more tricky once flaps start coming out and you’ll need your offsider to trim for you, but as I’ve said before not impossible just more coordination.
 
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