That really is actually exactly what they did and are doing. When you don’t do tests because you are confident something will pass, that doesn’t change that you aren’t testing, and you are compromising quality on the basis of productivity. Here Boeing decided to go against the safe practice because that would have classified the plane as a different plane and incurred huge costs, but it would have increased safety and likely avoided the accidents.
They did compromise safety, they did so thinking that it wouldn’t matter because the overall safety would be good enough for no one to notice, but that gamble failed and others paid their lives to cover the bet.
If product A has passed testing and I made minor changes and made a product B if I can avoid running the whole battery of tests as if product B is brand new and not derivative then I totally will and Aerospace and Automotive operate like this all the time in every country in the world it's not poor practice.
Human factors design is nowhere near easy or settled science, not in iphone design nor in flight controls design.
Given.
The issue I keep coming back to is the flawed regard for human factors in MCAS. They paid enough attention to squeak by the artificial feel, but then completely ignored the fact that a pilot can't react or stay ahead of something on a plane that no one tells them even exists. Then when it became evident it might be a problem, they back pedaled, putting as much blame on the operators as they could.
They thought about it. They decided "Nah, they don't need to know." At some point the tech pilot even expressed concerns over the system, yet was still pressured to keep it out of the manual...why?
No one in good faith has anything to gain from that system's implementation details seeing the light of day. Unless of course, there was some other motivation, like avoiding the costs of compliance at some point.
The first of the 3 sets of pilots did this, and landed without incident.
The next set overrode MCAS successfully 25 times, inexplicably did not turn off the trim, did not override it the last time, and crashed.
The last set successfully countered MCAS twice, then turned off the trim. They did not follow the directions on Boeing's Flight Crew Operations Manual Bulletin: "Uncommanded Nose-Down Stabilizer Trim Due to Erroneous Angle Of Attack During Manual Flight Only", which the FAA turned into a mandatory emergency airworthiness directive.
-- Aviation Week, Aug 19, 2019
Extra pilot in cockpit. Not a CRM situation that's a given.
>The next set overrode MCAS successfully 25 times, inexplicably did not turn off the trim, did not override it the last time, and crashed.
They didn't know why the trim was kicking in in the first place, and the senior pilot was the one countering the trim. He handed it off to the junior pilot to sift through the manual, which ironically, would have been futile anyway as MCAS was dropped from the manual. The behavior did not present as a classic stabilizer runaway. Other pilots interviewed also pointed this out including in the Australian 60 minutes expose on the 737 MAX if I recall correctly, so I'm not sure that the same definition you're fond of is universally shared amongst pilots. Bad priming is also a human factor that is catastrophically lacking among other things not being taken into account.
Furthermore, if pilots were really held to account for knowing the hardware they're operating, they should have known the nature of the trim switch change between the 737 NG and MAX, and the consequences thereof; that wasn't included.
>The last set successfully countered MCAS twice, then turned off the trim. They did not follow the directions on Boeing's Flight Crew Operations Manual Bulletin: "Uncommanded Nose-Down Stabilizer Trim Due to Erroneous Angle Of Attack During Manual Flight Only", which the FAA turned into a mandatory emergency airworthiness directive.
They did follow it actually, but also notice the Note toward the end (see the appendix in the Ethiopian preliminary report. The line reads)
>Note: Initially higher control forces may be needed to overcome any stabilizer nose down trim already applied. Electric stabilizer trim can be used to neutralize control column pitch before moving the STAB TRIM CUTOUT switches to CUTOUT.
Now. There is something to be said for "Gee, did they read it", but considering the bloody thing includes a disclaimer that the AFM supersedes the bulletin due to not being approved by the FAA, the note being presented outside the main content of the directive, and the notification beeping issued in November, I don't have high hopes for the real effectiveness of the bulletin at clearly communicating the severity of the problem, something which simulator time would have made plain and obvious.
Then again, that's just me.
Unknown cause is symptomatic of runaway trim.
> The behavior did not present as a classic stabilizer runaway
How is runaway trim different from classic runaway trim? The trim was mysteriously turning on and trying to drive the nose into the ground. If that isn't runaway trim, I have no idea what runaway trim is.
BTW, I worked for 3 years on the Boeing 757 stabilizer trim gearbox. I know what runaway trim is. The cutoff switches are there as the last resort to stopping it, and they're prominently and conveniently on the center console for darn good reason.
> if pilots were really held to account for knowing the hardware they're operating
The point being, even if they knew what MCAS was, the corrective action is the exact same thing as in the instructions provided by Boeing, before and after the Lion Air crash.
> They did follow it actually
I'm glad you read it, but read it again. They did not follow it.
> clearly communicating the severity of the problem
Considering that it was an emergency mandatory notification, and the LA pilots had already crashed, I don't know how to harder communicate the severity. I'm not a pilot, but if I was a MAX pilot, I'd certainly not want to die the same way the LA pilots did, and I'd pay attention to an AD explaining how not to die.
But I do agree that evidently pilots needed more training to understand what to do about runaway trim, which they need to understand regardless of whether MCAS is causing the runaway trim or some other problem. There's a reason the runaway trim procedure is something that is a memory item, meaning pilots are supposed to know what to do about it without needing to consult the checklist. Training in this is clearly insufficient.
But it is still poor optics to rarely dog food your own products.
[1] https://qz.com/work/1169517/executives-are-dying-in-private-...
[2] https://fivethirtyeight.com/features/corporate-jets-commerci...
So it's really not a fair comparison and I wouldn't be surprised if they're functionally equivalent after taking into account all major variables.
But Boeing executives doesn't fly on these, since they're too large for even CEOs. Boeing executives fly on one of the three Boeing owned Bombardier Challenger 650s [1][2][3].
[0] https://en.wikipedia.org/wiki/Boeing_Business_Jet
[1] https://www.planelogger.com/Aircraft/Registration/N541BA/908...
[2] https://www.planelogger.com/Aircraft/Registration/N543BA/908...
[3] https://www.planelogger.com/Aircraft/Registration/N544BA/884...
The second part is key to me. Inadequate system safety analysis seemed to give them the green light in decisions to save money (or make more money with safety critical 'options'). It's not like they knew MCAS would have an out-sized chance of downing a plane. My guess is they didn't know what they didn't know and it led them to have overconfidence in their ability to properly gauge business/safety trade-offs
I mean, do you really not understand how that sort of thing is done? They ask 100 people and then edit it down to the 5 most extreme responses.
I'm from Charleston, where the plant is located, & I have several friends that work at Boeing in assembly and quality inspection. What you see in the video is exactly the same sentiment I've heard for years.
I was really writing about work travel though.