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Thread: 'Pilots are losing their basic flying skills,' some fear after Boeing 737 Max crashes

  1. #1

    Exclamation 'Pilots are losing their basic flying skills,' some fear after Boeing 737 Max crashes

    Expect the same thing from drivers, once we all become nothing but redundant meatsacks behind the wheel plopped in the seat of the self driving car.

    Already starting to happen, and crashes and fatalities are rising in part because of it.




    On autopilot: 'Pilots are losing their basic flying skills,' some fear after Boeing 737 Max crashes

    https://www.usatoday.com/story/news/...ty/1219147001/

    Chris Woodyard, USA TODAY Published 7:00 a.m. ET May 25, 2019

    The crew on the Ethiopian Airlines plane that crashed in March performed all procedures recommended by manufacturer Boeing.

    Automation has made planes safer and more efficient, but the crashes of two Boeing 737 Max jets is leading some to wonder if there is a dangerous flip side.

    While advanced autopilots and computers are now considered an integral part of any modern jetliner, many pilots worry that the systems are detracting from developing and maintaining their own abilities.

    "We’ve been talking about this in the industry for years. Pilots are losing their basic flying skills and there’s an overreliance on automation," said Les Westbrooks, an associate professor at Embry-Riddle Aeronautical University, after the latest 737 Max crash, an Ethiopian Airlines flight in March.

    That crash followed the crash of a Lion Air flight into the Java Sea five months earlier. The two accidents together killed a total of 346 passengers and crew. Boeing is redesigning a key computerized system in the plane, but questions are being raised about pilot actions as well.

    Appearing before a House subcommittee earlier this month, FAA acting administrator Daniel Elwell expressed concern that pilots in both jets appeared to have made mistakes in trying to deal with the emergencies.

    He said he was disturbed that, based on the flight data recorder, it appeared that pilots in both planes didn't properly deal with a stabilizer trim problem early despite the issues with Boeing's faulty onboard computer system.

    "You don't pull out a checklist. You memorize it and you are tested on it all the time," said Elwell, formerly an American Airlines pilot for 16 years.

    In the case of the Boeing 737 Max, a computerized system was installed to compensate for the jet's tendency to point its nose upward because of heavier engines that were placed farther forward on the wings. It was called the Maneuvering Characteristics Augmentation System (MCAS). But in the case of the Lion Air and Ethiopian Airlines crashes, pilots found themselves wrestling to keep the jetliner aloft as MCAS repeatedly switched on and pointed the nose toward the ground.

    The link to one of the 737 Max's automated systems raises "concerns about pilots' abilities to recognize and react to unexpected events," Transportation Department Inspector General Calvin Scovel wrote in prepared remarks for the subcommittee hearing.

    As for MCAS, training in it may become more common as more 737 Max simulators are rolled out. There are currently only 17 simulators for the 737 variant globally, said spokesman Paul Bergman. "We expect the number of Max simulators to more than double by year’s end," he said in an email.

    It wasn't just the two Boeing 737 Max crashes in which trouble with automation played a role. An Asiana Airlines airliner crashed short of the runway at San Francisco International Airport in 2013 because, an investigation found, the pilots didn't thoroughly understand how the plane's automated systems worked.

    Experts say automation has helped to make aviation one of the safest means of transportation. Because of advanced autopilot systems, for instance, aircraft save fuel by being able to fly in an optimal way. They can be landed in fog, a boon to travelers who no longer are diverted to other airports. The systems are so advanced that they can counteract bad judgments by pilots. Automated systems are switched on for about 90 percent of a typical airline trip, according to government estimates.

    But those same experts say pilots must not be simply monitors of a plane's automated systems but have the ability to step in with hands-on flying. Though every pilot must pass qualification exams for every type of plane they fly, the fear is they'll forget key skills at times when they need them the most.

    "Airlines don't teach pilots to fly. They teach procedures. Your basic core skills should be there before you get to the airline," said Bo Corby, director of standards and training for Future & Active Pilot Advisors, or FAPA, a career and financial advisory service.

    He said the focus for training many pilots these days is to teach them how to use the automated systems, deemphasizing basic flying skills. He said the time has come to revert to a system in which knowledge of core techniques becomes critical again.

    Another expert, veteran airline pilot John Cox, said it's clear that automation overall has made flying safer. The key is not to have an overdependency on it — "to be comfortable and capital of being able to fly the plane manually. That has been an industry challenge," he said.

    But Cox says there's more to the Ethiopian Airlines crash than just an automation issue. The pilots were confronted with a load of warnings in the cockpit, more than anyone could be reasonably expected handle, he said.

    "You hit a point called task saturation. You are taking in more information than you can process," Cox said. And with all those distractions, a person's cognitive ability to deal with them can drop by half.

    Thus, he said "automation dependence is not a cause, but it is a contributor" to the disaster.

    As a result, Cox said he, too, believes pilots need to strike balance between knowing the nuances of planes' automated systems while also maintaining their basic flying abilities.

    Trainers, Cox said, should "emphasize manual flying skills and not have a dependence on the computer, but use them as aids."
    Last edited by Anti Federalist; 05-26-2019 at 12:53 AM.
    Another mark of a tyrant is that he likes foreigners better than citizens, and lives with them and invites them to his table; for the one are enemies, but the Others enter into no rivalry with him. - Aristotle's Politics Book 5 Part 11



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  3. #2
    Fly by wire.. AI controls..

    Removal of human error.. and independence.

    "and the monkey pushes the button"
    Liberty is lost through complacency and a subservient mindset. When we accept or even welcome automobile checkpoints, random searches, mandatory identification cards, and paramilitary police in our streets, we have lost a vital part of our American heritage. America was born of protest, revolution, and mistrust of government. Subservient societies neither maintain nor deserve freedom for long.
    Ron Paul 2004

    Registered Ron Paul supporter # 2202
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  4. #3
    Do something Danke

  5. #4
    Quote Originally Posted by oyarde View Post
    I hope Danke isn't getting lazy and losing his edge.
    Never attempt to teach a pig to sing; it wastes your time and annoys the pig.

    Robert Heinlein

    Give a man an inch and right away he thinks he's a ruler

    Groucho Marx

    I love mankind…it’s people I can’t stand.

    Linus, from the Peanuts comic

    You cannot have liberty without morality and morality without faith

    Alexis de Torqueville

    Those who fail to learn from the past are condemned to repeat it.
    Those who learn from the past are condemned to watch everybody else repeat it

    A Zero Hedge comment

  6. #5
    Quote Originally Posted by Swordsmyth View Post
    I hope Danke isn't getting lazy and losing his edge.
    You mean like when he is goofing off taking selfies ?
    Do something Danke

  7. #6
    Quote Originally Posted by oyarde View Post
    You mean like when he is goofing off taking selfies ?
    Or inviting pretty passengers into the cockpit.
    Never attempt to teach a pig to sing; it wastes your time and annoys the pig.

    Robert Heinlein

    Give a man an inch and right away he thinks he's a ruler

    Groucho Marx

    I love mankind…it’s people I can’t stand.

    Linus, from the Peanuts comic

    You cannot have liberty without morality and morality without faith

    Alexis de Torqueville

    Those who fail to learn from the past are condemned to repeat it.
    Those who learn from the past are condemned to watch everybody else repeat it

    A Zero Hedge comment

  8. #7
    Quote Originally Posted by Swordsmyth View Post
    Or inviting pretty passengers into the cockpit.
    The way things are going, women will get more excited about dating the autopilot rather than the human one.
    ...

  9. #8
    Quote Originally Posted by RJB View Post
    The way things are going, women will get more excited about dating the autopilot rather than the human one.
    Do Something Danke.
    Never attempt to teach a pig to sing; it wastes your time and annoys the pig.

    Robert Heinlein

    Give a man an inch and right away he thinks he's a ruler

    Groucho Marx

    I love mankind…it’s people I can’t stand.

    Linus, from the Peanuts comic

    You cannot have liberty without morality and morality without faith

    Alexis de Torqueville

    Those who fail to learn from the past are condemned to repeat it.
    Those who learn from the past are condemned to watch everybody else repeat it

    A Zero Hedge comment



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  11. #9
    Eventually AIs are going to do everything for us and the human race will become even more lazy than it already is.
    "Perhaps one of the most important accomplishments of my administration is minding my own business."

    Calvin Coolidge

  12. #10
    Probably about the late 70's there was a video arcade game at the butcher . I had never played anything but pinball before . It was called Defender and I got pretty good at it . It was a flying / shooting game . Between that and knowing they let Danke fly I just knew I could fly an airplane when I bought one .
    Do something Danke

  13. #11
    Quote Originally Posted by Anti Globalist View Post
    Eventually AIs are going to do everything for us and the human race will become even more lazy than it already is.
    Unlikely. Is there such a thing as AI loyalty?

  14. #12
    Quote Originally Posted by oyarde View Post
    Probably about the late 70's there was a video arcade game at the butcher . I had never played anything but pinball before . It was called Defender and I got pretty good at it . It was a flying / shooting game . Between that and knowing they let Danke fly I just knew I could fly an airplane when I bought one .
    http://www.free80sarcade.com/defender.php
    "He's talkin' to his gut like it's a person!!" -me
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    "Paul said "the wave of the future" is a coalition of anti-authoritarian progressive Democrats and libertarian Republicans in Congress opposed to domestic surveillance, opposed to starting new wars and in favor of ending the so-called War on Drugs."

  15. #13
    Quote Originally Posted by Swordsmyth View Post
    I hope Danke isn't getting lazy and losing his edge.
    Have been for years now...
    Pfizer Macht Frei!

    Openly Straight Man, Danke, Awarded Top Rated Influencer. Community Standards Enforcer.


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  16. #14
    Quote Originally Posted by Danke View Post
    Have been for years now...
    I wanna fly with you some day...

    Another mark of a tyrant is that he likes foreigners better than citizens, and lives with them and invites them to his table; for the one are enemies, but the Others enter into no rivalry with him. - Aristotle's Politics Book 5 Part 11

  17. #15
    Quote Originally Posted by Anti Federalist View Post
    I wanna fly with you some day...

    I want to dogfight him some day:

    Never attempt to teach a pig to sing; it wastes your time and annoys the pig.

    Robert Heinlein

    Give a man an inch and right away he thinks he's a ruler

    Groucho Marx

    I love mankind…it’s people I can’t stand.

    Linus, from the Peanuts comic

    You cannot have liberty without morality and morality without faith

    Alexis de Torqueville

    Those who fail to learn from the past are condemned to repeat it.
    Those who learn from the past are condemned to watch everybody else repeat it

    A Zero Hedge comment

  18. #16
    What Really Brought Down the Boeing 737 Max?







    CreditCreditPhoto illustration by Matt Dorfman

    By William Langewiesche




    On Oct. 29, 2018, Lion Air Flight 610 taxied toward the runway at the main airport in Jakarta, Indonesia, carrying 189 people bound for Bangka Island, a short flight away. The airplane was the latest version of the Boeing 737, a gleaming new 737 Max that was delivered merely three months before. The captain was a 31-year-old Indian named Bhavye Suneja, who did his initial flight training at a small and now-defunct school in San Carlos, Calif., and opted for an entry-level job with Lion Air in 2011. Lion Air is an aggressive airline that dominates the rapidly expanding Indonesian market in low-cost air travel and is one of Boeing’s largest customers worldwide. It is known for hiring inexperienced pilots — most of them recent graduates of its own academy — and for paying them little and working them hard. Pilots like Suneja who come from the outside typically sign on in the hope of building hours and moving on to a better job. Lion Air gave him some simulator time and a uniform, put him into the co-pilot’s seat of a 737 and then made him a captain sooner than a more conventional airline would have. Nonetheless, by last Oct. 29, Suneja had accumulated 6,028 hours and 45 minutes of flight time, so he was no longer a neophyte. On the coming run, it would be his turn to do the flying.

    His co-pilot was an Indonesian 10 years his elder who went by the single name Harvino and had nearly the same flight experience. On this leg, he would handle the radio communications. No reference has been made to Harvino’s initial flight training. He had accumulated about 900 hours of flight time when he was hired by Lion Air. Like thousands of new pilots now meeting the demands for crews — especially those in developing countries with rapid airline growth — his experience with flying was scripted, bounded by checklists and cockpit mandates and dependent on autopilots. He had some rote knowledge of cockpit procedures as handed down from the big manufacturers, but he was weak in an essential quality known as airmanship. Sadly, his captain turned out to be weak in it, too.

    “Airmanship” is an anachronistic word, but it is applied without prejudice to women as well as men. Its full meaning is difficult to convey. It includes a visceral sense of navigation, an operational understanding of weather and weather information, the ability to form mental maps of traffic flows, fluency in the nuance of radio communications and, especially, a deep appreciation for the interplay between energy, inertia and wings. Airplanes are living things. The best pilots do not sit in cockpits so much as strap them on. The United States Navy manages to instill a sense of this in its fledgling fighter pilots by ramming them through rigorous classroom instruction and then requiring them to fly at bank angles without limits, including upside down. The same cannot be expected of airline pilots who never fly solo and whose entire experience consists of catering to passengers who flinch in mild turbulence, refer to “air pockets” in cocktail conversation and think they are near death if bank angles exceed 30 degrees. The problem exists for many American and European pilots, too. Unless they make extraordinary efforts — for instance, going out to fly aerobatics, fly sailplanes or wander among the airstrips of backcountry Idaho — they may never develop true airmanship no matter the length of their careers. The worst of them are intimidated by their airplanes and remain so until they retire or die. It is unfortunate that those who die in cockpits tend to take their passengers with them.

    It was a blue-sky morning in Jakarta, with a few clouds floating offshore to the north. The flight was assigned a standard departure route over the Java Sea. At 6:20 a.m., it was cleared for takeoff. To anyone observing the airplane externally, for instance from the control tower, the takeoff would have appeared ordinary as the Boeing lumbered down the runway and lifted into the air. The first external hint of trouble came about a minute later, after a departure controller cleared the flight for a climb to 27,000 feet. Harvino asked the controller to confirm the airplane’s current altitude as shown on the controller’s display. The request was unusual, and it went unexplained. The controller answered that he showed the altitude as 900 feet, and Harvino acknowledged him without comment as if he concurred.




    Twenty-five seconds later (a long interlude in flight), Harvino requested a clearance to “some holding point” where the airplane could linger in the sky. The request was surprising. The controller did not provide a holding point but asked about the nature of the problem. Harvino answered, “Flight-control problem.” He did not mention which kind, but before they die, pilots are rarely so descriptive. Harvino did not declare an emergency. The controller asked about their intended altitude. Harvino answered 5,000 feet, which was strangely low and to this day remains unexplained.

    Two and a half minutes after takeoff, as the airplane was climbing through 2,175 feet, it suddenly went into a violent 700-foot dive, rounding out of it at 1,475 feet and pulling into an uncertain climb. No turn was associated with the plunge, so the airplane’s problem seemed to be unrelated to roll control and the age-old menace of a spiral dive. Right from the start of the investigation, suspicions focused on Lion Air 610’s trim mechanism — and specifically on the possibility of a failure known as a runaway trim. Trim refers to an aerodynamic condition related to pitch — the nose-up-or-down attitude of an airplane in flight. It can be thought of as a balance point, or the nose attitude at which an airplane naturally rides when no up-or-down elevator-control deflections are applied. That is a slight simplification, but good enough. Trim is routinely adjusted in flight. In the Boeing 737, the adjustments are made by the use of thumb switches on the control wheels when the pilots are “hand flying” the airplane manually, as they would on takeoff and landing. The thumb switches control an electric mechanism that changes the angle of the horizontal stabilizer — the all-important tail surface that counteracts the natural pitching effects of the wings and provides the necessary aerodynamic balance for flight. In its functioning, the electric trim is smooth, powerful and usually well behaved. On occasion, however, it may start running on its own volition and prompt the airplane to nose up or down. That’s a runaway trim. Such failures are easily countered by the pilot — first by using the control column to give opposing elevator, then by flipping a couple of switches to shut off the electrics before reverting to a perfectly capable parallel system of manual trim. But it seemed that for some reason, the Lion Air crew might not have resorted to the simple solution.

    Lion Air 610 climbed to 5,000 feet and stayed there shakily for an additional six minutes. Soon it was out over open water. At some point, Harvino declared the crew’s intent to return to the Jakarta airport. Air-traffic control approved the return and later advised the crew to plan on Runway 25 Left, the one closest to their position. But nothing occurred as a result. The airplane kept flying away from the airport. Harvino asked the controller for the airplane’s speed across the ground. This was another unusual question, given that multiple independent indications of speed should have been available in the cockpit. The controller answered that the groundspeed was 322 knots (371 miles per hour). At that altitude, it was nearing the 737’s maximum engineered aerodynamic airspeed of approximately 340 knots. The airplane was flying unusually fast.

    It should have been obvious to air-traffic control that the pilots were struggling, but maybe because they had not declared an emergency, the controller continued to treat them routinely, repeatedly instructing them to maintain their chosen altitude of 5,000 feet and issuing multiple new compass headings to steer. Each new heading involved a banked turn, and each bank complicated the crew’s ability to keep the nose from dropping. It is hard to imagine what the controller was thinking. One of his headings steered the flight away from conflicting traffic, when instead it was the traffic that should have been steered away from the flight. Equally unfortunate was the acquiescence of Suneja and Harvino, who dutifully complied with every air-traffic control request.

    At 6:31 a.m., 11 minutes into the flight, Suneja got on the radio for the first time. He did not know their altitude, he told the controller, because all their altitude indicators were showing different values. This is unlikely and has never been explained. Perhaps reflecting the strain he felt, Suneja misidentified himself as Lion Air 650. Appropriately, the controller acknowledged Suneja’s transmission without quibbling and responded, “No restriction.” He meant that Suneja was cleared to fly at whatever altitude he chose. But apparently Suneja did not understand. A few seconds later, he unnecessarily asked the controller for a block clearance to all altitudes 3,000 feet above and below his current altitude for traffic avoidance. The controller, who had just heard Suneja say he did not know his altitude, asked him what altitude he wanted. Suneja answered, “Five thou.”




    Suneja was shepherding 188 hapless souls through the sky, 189 if you include his own, and struggling with a confusing failure of some kind. Under stress, his performance had become abysmal. Right from the start — months before the cockpit voice recorder was found and listened to — his obsession with altitude clearances could only be explained as a pilot drowning in minutiae. “Five thou” was his final transmission. Twelve minutes into the flight, Lion Air 610 disappeared from radar.

    [Read highlights from The Times’s coverage of the 737 Max crashes and the fallout.]

    Airline crashes are rare, and rarer still are crashes that force the grounding of an entire fleet. Lion Air 610 was not immediately among them. But about four months later, on March 10, 2019, an equally new 737 Max flown by Ethiopian Airlines went down on departure from Addis Ababa with the loss of everyone aboard, and within a week all further flights of the 737 Max were stopped worldwide.

    After both accidents, the flight-data recordings indicated that the immediate culprit was a sensor failure tied to a new and obscure control function that was unique to the 737 Max: the Maneuvering Characteristics Augmentation System (MCAS). The system automatically applies double-speed impulses of nose-down trim, but only under circumstances so narrow that no regular airline pilot will ever experience its activation — unless a sensor fails. Boeing believed the system to be so innocuous, even if it malfunctioned, that the company did not inform pilots of its existence or include a description of it in the airplane’s flight manuals.

    The system in question is complicated, and we will return to it later, but for now it is enough to know that after the loss of Lion Air 610, the company suggested that the 737 Max was as safe as its predecessors. Its tone was uncharacteristically meek, but not for lack of conviction. The company seemed hesitant to point the finger at a prickly customer — Lion Air — that had several billion dollars’ worth of orders on the table and could withdraw them at any time. The dilemma is familiar to manufacturers after major accidents in which it is usually some pilot and not an airplane that has gone wrong. Nonetheless, Boeing’s reticence allowed a narrative to emerge: that the company had developed the system to elude regulators; that it was all about shortcuts and greed; that it had cynically gambled with the lives of the flying public; that the Lion Air pilots were overwhelmed by the failures of a hidden system they could not reasonably have been expected to resist; and that the design of the MCAS was unquestionably the cause of the accident.



    But none of this was quite true. The rush to lay blame was based in part on a poor understanding not just of the technicalities but also of Boeing’s commercial aviation culture. The Max’s creation took place in suburban Seattle among engineers and pilots of unquestionable if bland integrity, including supervising officials from the Federal Aviation Administration. Although Boeing’s designers were aware of timetables and competitive pressures, the mistakes they made were honest ones, or stupid ones, or maybe careless ones, but not a result of an intentional sacrifice of safety for gain. As always, there was a problem with like-mindedness and a reluctance by team players to stand out from the crowd. Even more pernicious was the F.A.A.’s longstanding delegation of regulatory authority to Boeing employees — a worry that is perennially available to chew on if you like and may indeed be related to the configuration of the troublesome system as it was installed. Nonetheless, in Seattle, at the level where such small choices are made, corruption, like cynicism, is rare.

    That is not meant as a blanket defense of Boeing. On the corporate level, the company is the worst sort of player — a corrosive agent that spreads money around Washington, pushes exotic weapons on Congress, toys with nuclear annihilation, sells all sorts of lesser instruments of death to oppressive regimes around the world and dangerously distorts American society in the ways that President Dwight D. Eisenhower warned against in his prescient 1961 farewell address. But hardly any of that matters in the story of the 737 Max. What sent an expensive new Boeing into the ocean on that beautiful, bright morning in Indonesia? It is understandable to look for a simple answer. Laying the blame on a poorly implemented system, even a complex one, made the accident relatively easy to understand and also provided for a material solution: Simply fix the system. But the focus on a single shoddy component — as the news media and government regulators have rushed to do — has obscured the larger forces that ultimately made these accidents possible.



    The paradox is that the failures of the 737 Max were really the product of an incredible success: a decades-long transformation of the whole business of flying, in which airplanes became so automated and accidents so rare that a cheap air-travel boom was able to take root around the world. Along the way, though, this system never managed to fully account for the unexpected: for the moment when technology fails and humans — a growing population of more than 300,000 airline pilots of variable and largely unpredictable skills — are required to intervene. In the drama of the 737 Max, it was the decisions made by four of those pilots, more than the failure of a single obscure component, that led to 346 deaths and the worldwide grounding of the entire fleet.

    If you were to choose a location in the developing world in which to witness the challenges facing airline safety — the ossification of regulations and in many places their creeping irrelevance to operations; the corruption of government inspectors; the corruption of political leaders and the press; the pressure on mechanics, dispatchers and flight crews to keep unsafe airplanes in the air; the discouragement, fatigue and low wages of many airline employees; the willingness of bankers and insurers to underwrite bare-bones operations at whatever risk to the public; the cynicism of investors who insist on treating air travel as just another business opportunity; and finally the eagerness of the manufacturers to sell their airplanes to any airline without restraint — you would be hard pressed to find a more significant place than Indonesia.

    The country began deregulating its airline industry in the late 1990s in the hope of providing for the sort of fast, low-cost travel that might help bind its islands together. No-frills newcomers who cared nothing for prestige rushed in to compete for the business of bargain-conscious passengers and undercut the flagship national airline, Garuda, in a booming domestic market that started growing at a rate second only to China’s. The free-for-all soon raised questions about how to manage safety. That is a polite way of putting it. A race to the bottom comes to mind.

    At the forefront of the boom was a streetwise Jakarta local named Rusdi Kirana, then 36, who came from a humble background, once sold typewriters for a living and became an airport freelancer hustling for scraps of opportunity among the passengers moving through the terminal buildings. Initially that meant wheeling suitcases to and from the curb, holding up name signs in the arrival flows or spotting people who might appreciate some friendly guidance. He was good at the hustle, but little else has been reported about his early work at the airport, except that in the 1990s he and his brother started what they called a travel agency. This was in a pre-electronic era, when the airlines issued paper tickets. In Jakarta, the airport terminals had become marketplaces where thousands of passengers in search of cheap flights hunted for last-minute discounts offered by airlines wanting to fill empty seats at any price. Kirana and his brother stepped in as middlemen, acquiring tickets by the fistful from airline clerks and scalping them to the crowds. The mechanics of the scheme remain murky, but even Garuda profited from Kirana’s hustle. No one complained.

    Kirana’s travel agency did not make him rich, but it apparently convinced him that a large, unexploited market existed in Indonesia for cheap flights, and that someday, because of the country’s island geography, air travel might be seen as routine by ordinary people. At the time, the industry remained regulated. Kirana seemed to believe that it was price rather than convenience that counted and that the trips would have to cost about the same as those by ferry and bus. To achieve that, he would have to use his own airplanes and control every aspect of the operation. More important than reducing costs, he would have to fill his airplanes to capacity and keep them flying. He would call the airline Lion Air. To save money, he sketched out the logo and uniforms himself. He approached the Transportation Ministry to inquire about licensing the airline and was laughed off and advised to set up a condom factory instead. But when the industry was deregulated shortly afterward, Kirana could not be denied. He leased a decrepit Boeing 737, and in June 2000, Lion Air started operations, offering low-cost flights on two of Indonesia’s most popular routes.

    Within five years, domestic passenger traffic doubled and then tripled. Lion Air’s fleet grew by even larger multiples as the airline gobbled up an increasing share of the market, and Kirana turned out to be a master of financial dealings. The public flocked to him even while reviling his airline for its poor on-time performance and, soon enough, for its safety record. He did not appear to care about the complaints that came in. One afternoon, he pointed to a trash can in his office and said to a businessman I know, “Here’s my complaints department.” People called him ruthless, but shrewd is a better description. Having given up at typewriter sales, he was determined to succeed at something else. He told the businessman that it is a mistake in an airline venture to get wrapped up in the romance and art of flying, because money is what counts. He may have been right, except that this approach reduces pilots to journeymen and ignores the role of airmanship in safety.

    The twist is that Kirana could have built his airline on the Airbus 320, an airplane that is less challenging to fly, but instead chose the equivalent Boeing 737, which counts on pilots as the last resort if something mechanical or otherwise goes wrong. I have been unable to speak to Kirana despite multiple attempts to reach him, so I do not know if he cares about these distinctions. For sure, though, he cares that once an airline makes a choice between Airbus and Boeing, changing manufacturers is expensive to do. Simulators, shop equipment, stocks of spare parts and training curriculums have to change. Kirana has become a major Airbus customer — but for other airlines he now controls. As for Lion Air, having begun with Boeing, it stuck with Boeing and by 2005 placed an order for up to 60 Next-Generation 737-900ERs. ER stands for extended range. The 900 is a 220-passenger airplane. The model was unpopular and had garnered not a single customer before Lion Air came along. The deal came close to $4 billion. This got Boeing’s attention.



    The deregulated Indonesian airline industry was also attracting attention, but not of the desirable kind. Accompanying the drastic expansion in traffic was a disproportionate rise in accidents. There were many contributing factors, mostly among the budget carriers but affecting Garuda as well: an onrush of inexperienced pilots willing to work long hours for low pay; discouragement among mechanics, ramp workers and dispatchers; pressure to keep airplanes flying despite component failures that should have grounded them; the falsification of cargo and passenger manifests; dual maintenance and flight logs; and corruption permeating the entire system, including even air-traffic control.
    In Jakarta, a graybeard captain, speaking to me on the condition of anonymity, described the attitude of the new owners toward their pilots. He said: “The pilots passed the check ride! They can fly the airplanes!” Also, in some owners’ view, the semiannual simulator training is wasteful because the simulators are costly to run and maintain, and while the pilots are playing around in them (while collecting their pay), they are not out producing revenue. Normally two pilots train in a simulator at a time, with an instructor seated behind them — so, three in the box. I was told that in Indonesian simulators, there are sometimes seven in there: two pilots flying, one instructing and four others standing up and logging the time.

    One Indonesian newcomer was a low-cost airline called Adam Air, which was a Lion Air competitor for several years. Its disregard of safety ran the gamut and resulted in the dispatch of shabby airplanes in the hands of beleaguered pilots. (Former Adam Air employees could not be reached for comment.) Many pilots quit out of disgust or fear. I know how it feels, because as a young man I flew for fly-by-night cargo operators in the United States and suffered most of the survivable failures known to pilot-kind — engine failure, engine fire, electrical failure, electrical fire, radio failure, radar failure, pressurization failure, wing-flap failure, landing-gear failure, gyroscopic failure, airspeed-indication failure, altimeter failure, anti-ice failure, personal (girlfriend) failure, tail-tin-canning lightning-strike failure and trim failures at least four times. By trim failures, I mean runaway trims. Our mechanics laughed about “pencil whipping” the airplanes into the air, and we agreed that the paperwork was a joke. The F.A.A. inspected it and never caught on. But we carried only freight. One winter night, one of our pilots died. He was taken down by a de-icing failure over high terrain inbound to Los Angeles, and none of us were surprised.

    But Adam Air carried unwitting passengers. Its president director was a wealthy young man named Adam Suherman, who lived in Los Angeles for a few years. One day, he went back to Jakarta and, with the help of family money, started an airline. It began flying in December 2003. One of its 737s — an airplane that had been around the block for 18 years and was leased from Wells Fargo — was written up by pilots for recurring defects 154 times over the final three months of 2006. The number was high because the defects were not fixed. By far the largest number of defects was related to discrepancies between the airplane’s two independent inertial reference systems, navigational and flight instrumentation drivers that are important to the safe completion of a flight.

    Speaking about Adam Air, Dave Carbaugh, a former Boeing test pilot and one of the world’s top aviators, who trained airline pilots throughout Asia, told me: “They kept dispatching a faulty aircraft. Eventually they ran into a crew that couldn’t handle it.” It happened on New Year’s Day in 2007. While flying through an area of bad weather at 35,000 feet, the crew noticed discrepancies between the navigational systems; while fiddling with a solution, they switched off the autopilot unintentionally and drifted into a bank that turned into an uncontrolled spiral dive, during which the descent rate exceeded 50,000 feet per minute and the airplane approached the speed of sound before the captain pulled the wings off in flight. All 102 occupants died in terror.



    Seven weeks later, another Adam Air 737 flew an erratic approach to the Surabaya airport among thunderstorms and made a landing so hard that its fuselage cracked and was badly bent, leaving the aft section drooping toward the pavement. No passengers were seriously injured, but the airplane had to be written off. The airline did not provide investigators with the identities of its pilots and was not forced to. Their training histories and qualifications therefore remain unknown. In 2008, Adam Air lost yet another 737 and was grounded by the Indonesian government. The airline declared bankruptcy and ceased operations. Adam Suherman faded from view. The more important point was that Adam Air no longer posed a threat to the flying public.



    By 2007, Garuda, the national airline, had a notoriously bad safety record. Two weeks after Adam Air’s bent-airplane episode in Surabaya, a Garuda captain at the controls of a 737 bound for another airport on the island of Java allowed the airplane to get too high on the approach and tried to resolve the problem by pointing the nose down and diving at the runway despite the co-pilot’s calls to abort the approach and circle around. The captain got the airplane going so fast that when he called for flaps to configure for landing, the co-pilot did not dare extend them for fear of structural damage and did not communicate his doubts to the captain. Investigators later criticized the co-pilot for poor teamwork, specifically for not taking control of the airplane, but short of clubbing the captain into submission, there wasn’t much he could do. The airplane landed long, touched down going 100 miles an hour too fast, bounced three times and went careering off the far end of the runway, slicing through an airport perimeter fence and sliding across a road, a ditch and an embankment before coming to rest in a rice paddy and bursting into flames. Because rescue vehicles could not cross the ditch, firefighters could not get their equipment close enough to suppress the flames effectively, and the fire burned for more than two hours. The captain and the co-pilot were not hurt, but 21 people died and others were severely injured.

    Garuda was the last straw. From 2003 to 2007, the Indonesian accident rate as measured by fatal flights per million departures had grown to be 15 times as high as the global average. The United States Embassy in Jakarta advised Americans to avoid travel on Indonesian airlines, though within Indonesia that was practically impossible to do. As usual, the numbers worked in favor of individual travelers: Even on the worst Indonesian airlines in the worst of times, the chances of being killed were minuscule. But for foreign governments that had become the self-anointed guardians of their citizens worldwide, the exposure was similar to that of the airplane manufacturers, though less consequential: Inevitably, accidents would continue to occur in Indonesia, and foreigners would die, and it would be hard for their officials to duck accountability unless the officials had registered concern in advance.

    In 2007, the European Union and the United States permanently banned all Indonesian airlines from their national territories. This was done for reasons of safety. The ban was largely symbolic, because the Indonesians were focused on their expanding regional markets and had no immediate plans to open such long-distance routes, but it signaled official disapproval of Indonesia’s regulatory capabilities and served as a public critique of a group of airlines, some of which were out of control. Residents of Europe and the United States generally did not know or care, but many of the ordinary Indonesians who had grown to hate their airlines were in favor of the ban simply as a form of punishment. Deregulation had transformed Indonesia into a complicated Wild East of flying, inhabited by consumers who were immune to prestige, just as Lion Air’s Kirana had predicted.

    The ban put Boeing and Airbus into a delicate position. They would now be selling airplanes to officially declared unsafe airlines that the American and European authorities expected would keep killing and injuring their passengers at a rate that would be unacceptable in the West. By 2007, the biggest of those airlines was Lion Air. That year, it placed a new order for 40 additional 737s, and Boeing happily agreed to fill it. In 2011, Lion Air returned to the table with what at the time was the largest commercial order in aviation history, a $22 billion deal for 230 units of the 737, including 201 units of the coming 737 Max. The deal was finalized during an Asean summit meeting in Bali that was attended by President Barack Obama. Photographs show Obama looking on approvingly as Kirana and a senior Boeing executive signed the contract. No mention was made in the associated news reports that Lion Air was considered to be a dangerous airline and that it was banned from the United States.

    Lion Air had been contributing to the casualties almost since its inception. By the time of the signing ceremony in Bali, it was responsible for 25 deaths, a larger number of injuries, five total hull losses and an unreported number of damaged airplanes. An old truth in aviation is that no pilot crashes an airplane who has not previously dinged an airplane somehow. Scratches and scrapes count. They are signs of a mind-set, and Lion Air had plenty of them, generally caused by rushed pushbacks from the gates in the company’s hurry to slap airplanes into the air. Kirana was once asked why Lion Air was experiencing so many accidents, and he answered sincerely that it was because of the large number of flights. Another question might have been why, despite so many crashes, the death toll was not higher. The answer was that all of Lion Air’s accidents happened during takeoffs and landings and therefore at relatively low speed, either on runways or in their immediate obstacle-free vicinities. These were the brief interludes when the airplanes were being flown by hand. The reason crashes never happened during other stages of flight is most likely that the autopilots were engaged.

    Boeing knew it had a problem. A widespread culture of corruption lay at the core, but that was beyond anyone’s ability to reform. Instead, Boeing decided to intervene at its own expense to raise standards at Lion Air and try to reduce its contributions to the accident rate. Both Boeing and Airbus had taken larger such actions before. Foremost were their epic interventions in China that gathered speed in the late 1980s and endured for years. At the start, civil aviation in China was a mess, with one of the highest accident rates in the world.

    Dave Carbaugh, the former Boeing test pilot, spent his first 10 years with the company traveling the globe to teach customers how to fly its airplanes. He mentioned the challenge of training pilots in Asia. “Those were the rote pilots,” he said, “the guys standing up in the back of a sim. They saw a runaway trim. They saw where and how it was handled in the curriculum — always on Sim Ride No. 3. And so on their Sim Ride No. 3, they handled it correctly, because they knew exactly when it was coming and what was going to happen. But did they get exposed anywhere else? Or did they discuss the issues involved? No. It was just a rote exercise. This is Step No. 25 of learning to fly a 737. Period.” I asked about China specifically. He said: “The Chinese? They were probably the worst.” He spent every other month in China for years. He said: “They saw flying from Beijing to Tianjin as 1,352 steps to do. Yet if they flew from Beijing to Guangzhou, it was 1,550 steps. And they didn’t connect the two. It would get so rote that they just wouldn’t deviate. I remember flying with a captain who would never divert no matter how many problems I gave him. I asked him, ‘How come?’ He said, ‘Because the checklist doesn’t say to divert.’ ”



    That changed over time. With the support of the Chinese government, which went so far as to delegate some regulatory functions to foreigners like Carbaugh, the manufacturers were able to instill a rigorous approach to safety in a small cadre of pilots and managers, who in turn were able to instill it in others. The effort was made not out of the goodness of the manufacturers’ hearts, but out of calculations related to risk and self-preservation. It is widely seen to have been a success. Today the Chinese airlines are some of the safest in the world.
    This was the history that Boeing had in mind 10 years ago when it decided to intervene with Lion Air. Carbaugh said: “Boeing spent a $#@!pot full of money trying to bring those folks up to Western standards. We could only do so much, but we knew we had to try. It was an extraordinary effort.” But it was not good enough. Lion Air continued to crash airplanes around runways as it had before. The Indonesian authorities lacked the political will to rein that in. It is no secret that Rusdi Kirana prioritized efficiency over regulation. Recently he made it clear that he also resented Boeing as being presumptuous and typically condescending. “They look down on my airline and my country,” he told Reuters. “They treat us as third-world.”

    It was perhaps inevitable that the relationship between Boeing and Lion Air would prove fractious. Boeing became the world’s pre-eminent commercial airplane manufacturer in part because it developed a coherent design philosophy that relied on pilots’ airmanship as the last line of defense. It made sense in an era when airplanes were vulnerable to weather and prone to failures and pilots intervened regularly to keep airplanes from crashing. By the 1980s, however, the situation had evolved. It became apparent that because of engineering improvements, very few accidents were caused by airplanes anymore, and almost all resulted from pilot error. This occurred at a time when airlines were being deregulated, discount carriers were springing up, major new markets were beginning to appear in developing countries, pilots’ unions were being busted, pilots’ salaries were in steep decline and airmanship globally was being eroded by an increasing reliance on cockpit automation, production-line training and a rote approach to flying.

    In the face of these changes, Boeing clung resolutely to its pilot-centric designs, but in Toulouse, France, the relative newcomers at the European consortium called Airbus were not nearly as shy. Led by an outspoken former military test pilot turned chief engineer named Bernard Ziegler, Airbus decided to take on Boeing by creating a robotic new airplane that would address the accelerating decline in airmanship and require minimal piloting skills largely by using digital flight controls to reduce pilot workload, iron out undesirable handling characteristics and build in pilot-proof protections against errors like aerodynamic stalls, excessive banks and spiral dives. The idea was that it would no longer be necessary to protect the public from airplanes if Airbus could get airplanes to protect themselves from pilots.

    The approach was diametrically opposed to Boeing’s. Ziegler announced that he was going to build an airplane that even his concierge could fly. The implicit insult won him the enmity of some French airline pilots, who then as now thought highly of themselves. Ziegler told me he received death threats and lived under police protection for a while. But his efforts led to the smartest airplane ever built, a single-aisle medium-range “fly-by-wire” masterpiece called the A320 that entered the global market in 1988, led the way to all other Airbus models since and has been locked into a seesaw battle with Boeing’s relatively conventional 737s for the past 30 years.

    You might think that the 737 would have grown increasingly disadvantaged given the New World qualities of the A320, but in my estimation pilots have managed to crash the 320 at about the same rate, largely because of confusion over automation. In other more positive ways, the 737 and A320 were closely matched: same payloads and performance, same operating costs, same potential for profit-making. That threatened to change in 2010 when Airbus introduced a version of the 320 called the Neo (for “new engine option”) that offered large improvements in fuel efficiency, range and payload. The following year, American Airlines warned that it might abandon Boeing and buy hundreds of the new Airbus models. Boeing responded with a rush program to re-engineer the 737, modify the wings and make other changes to improve the performance of the airplane and give it some perceptible advantage over the A320Neo.



    The rush took five years to complete. Boeing called the result the Max. To keep costs down, as with all previous iterations, the redesign had to lie within the original 1968 F.A.A. certification of the type and not be treated officially as a new airplane. Airbus had similar requirements for the Neo. In its marketing literature comparing the Max to the earlier Next-Generation 737, Boeing wrote: “same pilot type rating, same ground handling, same maintenance program, same flight simulators, same reliability.” Equally important was that it had to have the same flying characteristics. This was a regulatory necessity if the Max was to escape onerous reclassification as a new airplane. And there was a problem. Boeing test pilots discovered that the Max had unusual stall characteristics when the wing flaps were up and the engines were thrusting.



    Aerodynamic stalls are central to the Boeing 737 saga, so let’s explore them briefly now. Airplanes fly because their wings greet the oncoming air at a positive angle, known as an angle of attack. The faster an airplane flies, the lower the angle of attack needs to be to generate the necessary lift. Conversely, the slower an airplane flies, the greater the angle of attack needs to be. But at some point, the angle of attack becomes too great for the oncoming air to negotiate smoothly. As the airplane approaches that critical angle, the first event is a stall warning in the cockpit. In the 737, it is a rattling “stick shaker” that vibrates the control columns and is meant as an urgent warning to lower the nose. If the pilot does not respond, the airflow starts to boil across the top of the wings, sometimes causing buffets that shake the airplane, before separating from the wings conclusively at the moment of the stall. At that point, the wings’ effectiveness is hugely degraded, roll control becomes difficult and the nose drops unavoidably in what is known as a G-break, so called because it may be felt as a brief lessening of the normal (unaccelerated) 1-G pull of gravity.

    The nose drop can be drastic, typically about 30 degrees in a classic 737. Now fully stalled, the airplane enters into a precipitous, low-airspeed descent — a condition referred to as mushing that if left unattended will lead to a catastrophic impact with the ground. The event does not take long. In June 2009, when an Air France crew stalled a twin-aisle Airbus 330 on a night flight from Rio de Janeiro to Paris, the descent required merely three minutes and 30 seconds from 38,000 feet to the ocean’s surface. Start to finish, that was an exercise in poor airmanship. Investigators later determined that the Air France flight — a heavy jet stalling at absurdly high angles of attack — passed the point of possible recovery as it mushed down through 12,000 feet. After that, it was just as a co-pilot said before pancaking into the Atlantic: “[Expletive], we’re dead.”

    The Max’s stall characteristics, which indirectly bear on the accidents, have been widely reported as being an unusual tendency to pitch up when the airplane is flown at high angles of attack, in realms beyond the stick shaker where airline pilots never go. But pitching up into a stall is a characteristic of all jets with underslung engines, and the tendency in the Max, though slightly stronger than in previous 737s, was probably not sufficiently different to rouse the F.A.A. during the airplane’s testing and certification process. Rather, it was an entirely new characteristic that caused regulatory concern. During stall testing in the Max, the area of buffet was found to be unusually wide, and the G-break, when it occurred, was unusually mild. More important, within the buffet zone as the airplane approached the stall, the control forces — the necessary backpressure on the control column — did not increase in a conventional linear manner as they had in previous 737s and as certification standards required. As a mild behavioral quirk, this was a remote concern, and it occurred in an area of the flight envelope where airline pilots never go. But if the Max was to avoid designation as an entirely new model, the control-force problem needed to be addressed.

    Some at Boeing argued for an aerodynamic fix, but the modifications would have been slow and expensive, and Boeing was in a hurry. Its solution was to create synthetic control forces by cooking up a new automated system known as the MCAS to roll in a burst of double-speed nose-down stabilizer trim at just the right moment, calculated largely by angle of attack. There were two other conditions for MCAS activation: the wing flaps had to be up and the autopilot off. The logic of those conditions is clear, but not worth the digression here. After some initial tweaking, the system produced control forces that closely mimicked those of the earlier 737 models, allowing the Max to avoid onerous recertification. Indeed, on initial impulse the artificial forces were so realistic that Boeing convinced itself (and the F.A.A.) that there was no need to even introduce the MCAS to the airplane’s future pilots. The omission meant that the possibility of a false positive in cruising flight — a pushover occurring where it naturally would not — would likewise not be addressed. Boeing believed that in the worst case, a false positive would present as a mere runaway trim, a problem any pilot would know how to handle. The 737 features two prominent toggle switches on the center pedestal whose sole purpose is to deal with such an event — a pilot simply switches them off to disengage the electric trim. They are known as trim cutout switches. They are big and fat and right behind the throttles. There is not a 737 pilot in the world who is unaware of them. Boeing assumed that if necessary, 737 Max pilots would flip them much as previous generations of 737 pilots had. It would be at most a 30-second event. This turned out to be an obsolete assumption.


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  20. #17
    It took several months and the slow and reluctant release of investigative findings before the inside story of the tragedy of Lion Air 610 could be told. That story actually starts three days before the accident, when the same airplane — under different flight numbers and Lion Air crews — experienced errors in airspeed and altitude indications on the captain’s (left side) flight display that weren’t properly addressed. Those indications are driven by a combination of sensors on the surface of the airplane. A set of independent duplicate sensors drive the co-pilot’s (right side) display. A third standby system provides additional independent backup and allows for intuitive troubleshooting when any one of the three systems fails: If two indications agree and the third one does not, the odd one out is obviously the one to ignore. This sort of arrangement helps to explain why flying a Boeing is not normally an intellectual challenge. Furthermore, the airplane provides an alert when airspeed or altitude indications disagree.

    All the faulty indications on that airplane were only ever on the captain’s side. The respective crews wrote them up repeatedly. During intervals on the ground, the airline’s technicians ran built-in tests, got coded responses and did plug-out plug-in reboot attempts of the mindless sort performed at automotive service centers. None of it worked here, but the technicians kept zeroing the fault messages and approving the airplane for flight. Two days before the final flight, the airplane was in Bali, and technicians did more of the same.

    Additionally, in response to an error message indicating possible failures in angle-of-attack information, they replaced the angle-of-attack vane on the nose of the airplane on the captain’s side. Angle-of-attack vanes are exposed to the winds and are vulnerable to impact, ice and wear. The replacement vane put onto this airplane in Bali was older than the airplane itself. It was a used part that had been provided by a shop in Miramar, Fla., and shipped to Lion Air one year before. In the maintenance log in Bali, the company technicians documented replacing the angle-of-attack vane and testing it. They wrote, “Installation test and heater test result good.”




    I had some doubts whether these tests were really run, and I mentioned these doubts to John Goglia, a no-nonsense Bostonian who spent 35 years as an airline mechanic and an additional nine years as a board member of the competent crash-investigation unit of the United States government, the National Transportation Safety Board. Goglia has followed the investigations surrounding the 737 Max closely. Speaking of the Lion Air mechanics, he said: “They’re full of $#@!. They suspected they found the problem in Bali. So they replaced one problem with another — a dubious unit from Cockroach Corner in Miami. Cockroach Corner is the source of tons of suspected unapproved parts. Many of those repair stations in Miami are junk peddlers.” And the Lion Air mechanics? He said: “They didn’t finish, whatever the log says. They didn’t do an adequate check of the systems.” If they had, in Goglia’s view, they would have seen that the unit was faulty.

    According to the official narrative, which — discounting its omissions — seems to be mostly true, when a fresh crew arrived to take the next run, a night flight 600 miles west to Jakarta, a technician showed the new captain the maintenance log and explained that the angle-of-attack sensor on the left side had been replaced. The captain informed the co-pilot and said that he himself would do the flying. They would have a hitchhiker in the cockpit, sitting on the jump seat just behind them. He was an off-duty pilot and, according to one Indonesian pilot I spoke to, a 737 Max captain for a Lion Air subsidiary. For mysterious reasons, this man was not mentioned in subsequent Indonesian accounts. When I asked a senior investigator about the omission, he explained that it was because the investigators had been busy. Only recently and reluctantly have the Indonesians acknowledged the third pilot’s presence, though, as it happened, he played an important role.
    None of the Bali crew have been named, and access to them has been blocked. The airplane took off at 10:20 p.m. with 189 people aboard, or 190 if the ghost in the cockpit is included. Immediately after liftoff, the captain’s airspeed indication failed, airspeed-disagreement and altitude-disagreement warnings appeared on his flight display and his stick shaker began to rattle the controls in warning of an imminent stall.

    The Bali captain was enough of an airman to realize that he was dealing with an information failure only — not an actual stall. No direct mention has been made of this, but he must have immediately identified the replacement angle-of-attack vane on his side as the likely culprit. The co-pilot’s stick shaker had not activated. The second angle-of-attack sensor was functioning correctly. The captain held the airplane steady in the climb, confirmed that the right-side indications crosschecked with the standby instruments and transferred the flying to the co-pilot with instructions to follow a regular schedule of flap retractions and retrim the airplane as normal. The handoff was well done. The stick shaker continued to rattle, but that was merely an annoyance.

    But then there was a change. What had been an information failure suddenly turned into a flight-control one. Soon after the flaps were retracted, the airplane developed a mind of its own and rolled in a fast burst of nose-down trim. Apparently, this caused such a lurch that back in the cabin some passengers started praying. It was just the MCAS kicking in, because the three conditions necessary to trigger it had combined: The flaps were up, the autopilot was off and the captain’s angle-of-attack sensor was showing a stall.

    One of Boeing’s bewildering failures in the MCAS design is that despite the existence of two independent angle-of-attack sensors, the system did not require agreement between them to conclude that a stall had occurred. Inside the cockpit, none of the pilots knew any of this or had ever heard of the MCAS. To them the event must have looked like a runaway trim, much as Boeing had expected. But there were two differences that may have confused them. The first was the severity of the pitch-down trim, which ran twice as fast as a regular runaway — hence the praying in the cabin. The second was that it lasted about only 10 seconds, then stopped for five seconds, then started again. The pattern repeated and would have kept repeating to the limits of nose-down trim, an extreme imbalance never approached in regular flight. This is another of Boeing’s bewildering failures — the implementation of an automated nose-down input meant to make for an authentic control feel but allowed to keep at it again and again while throwing the airplane wildly out of trim. No one I spoke to from Boeing, Airbus or the N.T.S.B. could explain the reasoning here.

    MCAS trimming can be thwarted and even overpowered by counter-trimming with the sustained use of the thumb switches on the control yokes, but in the confusion of the encounter in Bali, the counter-trimming went only so far. After three MCAS impulses, the co-pilot said that his control column had grown so heavy that he could hardly hold the nose up. They were about six minutes into the flight and still on the runway heading. The captain formally declared a condition of urgency by making a “pan-pan” call to air-traffic control. He reported an instrument failure and asked to continue flying straight ahead. The controller approved the request and asked if the crew wanted to return to the airport. The captain answered, “Stand by.” Over the next two minutes, while the co-pilot fought to maintain control of the airplane, the captain went wandering through the checklists trying to figure out what to do.



    Finally the ghost in the jump seat intervened. It is impossible to know if he was a better airman than the pilots in the front or simply had the advantage of an overview. Either way, he recommended the obvious — shutting off the electric trim by flipping the cutout switches. The captain flipped the switches, the trim stopped running away and the MCAS was disabled. It was that easy.

    With the captain’s stick shaker continuing to rattle and the trim switches set to the off (cutout) position, the crew flew to Jakarta without further issue, adjusting trim as sometimes necessary by use of the manual trim wheels mounted on both sides of the central pedestal, and landed just before midnight. Investigators do not seem to have explored why the pilots required nearly five minutes to handle what normally might have been a 30-second adventure, or why they required a cockpit guest to provide the solution. Such questions were overshadowed by the subsequent failures of the accident crew on Flight 610.

    After pulling up to the gate in Jakarta, the Bali captain informed a company mechanic about “the aircraft problem” and in the maintenance log noted only three anomalies — the captain’s airspeed and altitude indication errors and the illumination of a warning light related to a system known as Feel Differential Pressure. That was it. Apparently the captain noted nothing about the failure of the newly installed angle-of-attack sensor, or the activation of the stick shaker, or the runaway trim, or the current position of the trim cutout switches. If true, it was hard to conclude anything other than that this was severe and grotesque negligence. Dave Carbaugh, the former Boeing test pilot, had the most charitable view of the matter. “I suspect that the pilot wrote what you see in the log, and he verbally told maintenance that, ‘Hey, the trim was running down, and we had to use the stabilizer cutout switches, and we flew the airplane back manually,’ ” he said. “And maintenance took no action on that, because the airplane had made it back to Jakarta. They just checked the fault messages and cleared them and called it a day. That’s my best guess. They were just hellbent to release that airplane.”

    According to the written record, the mechanics responded to the captain’s reports by flushing out a couple of air-data units, cleaning an electrical plug and declaring success after running some ground tests. Given the scope of the night’s events, the report was so off-base that I questioned whether any of the recorded maintenance had even taken place. I was not the only one with questions. John Goglia, with his vast knowledge, shared my concerns. Falsified maintenance records? They are as common as they are difficult to discern. One reason for them is that no one expects a pilot to go out and crash the next day. Goglia said: “They say they flushed the pitot-static in an 800-hour airplane? That’s a sure sign right there.” About the Bali crew, he said: “They pull up to the gate. They had a stick shaker. The No. 1 culprit is the angle-of-attack vane. But they don’t say anything? The trim switches are off. They leave the airplane. The next morning, the accident crew comes out. They go through the checklist. Those two switches are still off? They turn them on? What’s not known is who did that. The first officer? He didn’t know what he was doing? He didn’t tell the captain?”

    It is hard to believe that any pilot entering that cockpit could have been so sloppy. But one thing is obvious: Throughout the subsequent fatal flight, neither member of the accident crew gave those switches a thought.

    The Lion Air 610 accident crew — Capt. Bhavye Suneja and his co-pilot, First Officer Harvino — arrived at the airport before dawn to prepare for the flight. Each had been through pro forma runaway-trim training in Lion Air simulators (hint: watch for it in Sim Ride No. 3), but they had never heard of the MCAS and had no way of guessing from the maintenance log that none of the airplane’s recent failures had been resolved, that some of the entries might have been fraudulent, that serious failures had occurred on the previous flight that had not been recorded or addressed or that the angle-of-attack sensor on the captain’s side was a slapped-on unit from Cockroach Corner that was 20 degrees out of whack. Instead, they thought they had a healthy airplane, and a nice new one, too.



    That much can be discerned by a close study of the flight data that have been parsed out, as well as from glimpses into the cockpit provided by certain summaries of the audio recordings. Suneja was at the controls. Everything seemed fine during the takeoff roll, but as soon as he hauled back on his control column and the airplane lifted off, the angle-of-attack sensor went haywire, the stick shaker began to rattle the left-side controls and Suneja lost reliable indications of airspeed and altitude on his flight display. In other words, the airplane misbehaved exactly as it had the night before. Once again, everything was fine on the co-pilot’s side. Suneja, however, did not turn the flying over to Harvino but retained it for himself, despite the vibrations of the controls in his hands.

    In the aftermath of the accident, it turned out that a warning light indicating disagreement between the two angle-of-attack sensors was absent from the airplane because it was being offered on the Max only as part of an optional angle-of-attack instrumentation package. On previous models, the light had come as standard equipment. The change was a result of an error somewhere in the bowels of Boeing. Critics have since loudly blamed it for the difficulty in countering the MCAS when the system receives false indications of a stall. But the truth is that the MCAS is easy to counter — just flip the famous switches to kill it. Furthermore, when you have a maintenance log that shows the replacement of an angle-of-attack sensor two days before and then you have an associated stick shaker rattling away while the other stick shaker remains quiet, you do not need an idiot light to tell you what is going on. At any rate, the recognition of an angle-of-attack disagreement — however pilots do or do not come to it — has no bearing on this accident, so we will move on.

    With the stick shaker sounding off, Suneja might have chosen to discontinue the trip and immediately return for a landing. Instead, two minutes after takeoff, Harvino asked air-traffic control for clearance to proceed to “some holding point” where he and Suneja could figure things out. The mood in the cockpit was calm. When Harvino mentioned a “flight-control problem,” he was wrong. They had a stick shaker sounding off and some unreliable indications, but the still-unknown MCAS had not yet engaged because the wing flaps remained extended. The only control problem they had was some hand-flown sloppiness from Suneja, who allowed a minor drift-down to occur before continuing with the climb.

    In reaction to the drift-down, the controller asked them what altitude they wanted, and Harvino opted for 5,000 feet. It was a poorly considered level that turned into a murderous one as the pilots tied themselves to it under circumstances that changed. I spoke to a heavy-jet pilot with global experience who said that had he been flying that 737, he would have scratched for all the altitude he could get — probably 20,000 feet — and after the first few vectors would have ignored air-traffic control and “pointed the damned airplane toward Nevada.” He meant he would have pared down to the essentials and sought to buy time.

    As the airplane climbed through 2,150 feet, Harvino retracted the wing flaps, and the MCAS kicked in for the first time, ambushing Suneja with its 10 seconds of double-fast nose-down trim and resulting in the 700-foot plunge seen on radar by the controller. Suneja countered by using his thumb switch to apply a burst of nose-up trim as he hauled back on the control column and returned the airplane to its climb. Adding to the workload, the controller chose this moment to issue the first needless turn and to formally clear the flight to 5,000 feet. Harvino dutifully responded. Suneja then ordered him to put the wing flaps back down to where they had been. It was the best move of the morning and seems to have been based on a rule of thumb that if you do something in a cockpit and are rewarded by some unwanted event, do not waste time wondering what the connection is — undo that something you just did.

    Suneja knew they had experienced some kind of runaway trim, but now with the flaps extended (and therefore with the unknown MCAS neutralized) it did not happen again. This would have been a good time to quit and go home. Instead, Suneja leveled at 5,000 and 30 seconds later ordered the flaps retracted. He may have made that choice because the airplane was flying at aerodynamic speeds in excess of 300 knots, which is not only fast for that altitude but also at least 50 knots faster than the maximum flap speed and enough to generate a loud overspeed clacker in the cockpit. He did not know about the MCAS, it’s true, but he had just experienced a violent runaway trim after flap retraction, and you might think he would have had the wherewithal to leave the flaps alone and throttle back to slow or, alternatively, pull into a climb to achieve the same result while also buying time. But no, he stuck obediently to 5,000 feet, left the throttles forward and retracted the flaps.

    This time he was ready when the MCAS engaged, and he managed to avoid a dive by counter-trimming and hanging tight. The surprise was that after the assault ended, the MCAS paused and came at him again and again. In the right seat, Harvino was fumbling through checklists with increasing desperation, trying to figure out which one might apply. Over in the left seat, Suneja was confronting a rabid dog. The MCAS was fast and relentless. Suneja could have disabled it at any time with the flip of the two trim cutout switches, but this apparently never came to mind, and he had no ghost in the jump seat to offer the advice. The fight continued for the next five minutes, during which time the MCAS mounted more than 20 attacks and began to prevail.



    As a reminder, the horizontal stabilizer is the large tail surface that can be angled down or up by the trimming mechanisms to change the airplane’s pitch; the “elevators” are the hinged control surfaces mounted behind it and are manipulated by the use of primary controls to adjust the pitch. Normally, these two movable surfaces function in agreement to the same end — nose-up elevator, nose-up trim; nose-down elevator, nose-down trim. But the relationship reverses with a runaway. In the unusual case in which a pilot does not switch off the electric trim, the elevator has to be used against the runaway stabilizer to keep an airplane from getting out of control. By certification standards, the elevator will succeed at this at all aerodynamic speeds up to the maximum, which, again, is approximately 340 knots in the 737. The catch is that as the airspeed increases, so does the power of the stabilizer in relation to the elevators. The slope becomes slippery toward the end. If an inattentive crew allows a runaway trim to drop the nose too far below the horizon and the crew reacts with full up elevator, the nose will rise as certification standards require, but it may remain below the horizon for a period sufficient to allow the airspeed to continue to increase and bust right through the maximum speed, at which point recovery becomes impossible if you don’t lay into the electric trim.


    The story is complicated because the counter-trim that Suneja had been thumbing to beat back the dog was working, and with greater effect at higher speeds, to the point that full nose-down trim would have been avoidable even if the cutout switches were not thrown, so long as the pilots stayed in the fight. But panic was growing in the cockpit. What little the Indonesian investigators have said about the voice recordings, they have described that much. The air-traffic control record shows the same. Suddenly it was the captain, Suneja, who was on the radio, and his transmissions made little sense. Apparently he had taken over the desperate search through the checklists and handed the flying to Harvino. This was a mistake, because Harvino was in no condition to fend off the MCAS attacks. He gave a few feeble inputs of nose-up trim with his thumb switch and began calling on God for a miracle. The MCAS ignored his entreaties and pitched the airplane into a steepening dive at airspeeds that quickly exceeded the engineered limits. Harvino stopped even trying to thumb the trim. Suneja hauled his control column all the way back, giving full up elevator to no avail. The nose dropped farther as the stabilizer prevailed. The crew of an offshore oil platform saw the airplane in a nearly vertical dive before it hit the water.

    The MCAS as it was designed and implemented was a big mistake. It remains unclear exactly what went wrong at Boeing — who decided what, and why — but a small collective breakdown had obviously occurred, and the F.A.A. had gone along for the ride. Nonetheless, the lethargy of the company’s initial response to the loss of Lion Air 610 seemed rooted less in fear or feelings of remorse than in genuine incredulity that these two pilots had been so incompetent as to plunge into the sea because of what amounted to a runaway trim. Eight days after the accident, Boeing issued a worldwide bulletin for 737 Max pilots in which it continued to avoid mention of the MCAS but emphasized longstanding procedures provided in the “Runaway Stabilizer Non Normal Checklist (NNC).” The company was willing to leave its communications to that. Privately, it would start working on a fix for the MCAS. Meanwhile, even after the accident, there still seemed to the company to be no reason to burden pilots with descriptions of the system.

    One day later, however, the F.A.A. repeated the same information in the form of an “Emergency Airworthiness Directive,” a regulatory mandate to change the airplane’s flight manual. That same day, the Indonesians followed suit, as did the rest of the world. “Emergency” is a riveting word, and it provided the urgency that Boeing had lacked. Requests for information started flooding into Seattle. Two days later, Boeing finally came forward. Under the title “Boeing Correspondence: Multi Operator Messages,” it sent a two-paragraph email that named the MCAS for the first time.

    Events would soon show that the situation was far worse than Boeing realized — to the extent that disseminating full descriptions of the MCAS was not sufficient to keep another accident from happening. But for what it’s worth, if asked at the time, I would have agreed with the company. It seemed highly unlikely that Lion Air’s mistakes would be repeated anytime soon. In my own flying life, each of the four trim runaways I have experienced has been at most a 10-second problem — eight seconds to be surprised, and two seconds to flip the electric trim off. Who could be confused? When I mentioned this to Larry Rockliff, a former Canadian military and Airbus test pilot, he shrugged me off. “Look,” he said, “we know as a fact that half of airline pilots graduated in the bottom half of their class.”

    If only they were so easy to rank. Bernard Ziegler, the founding father of the Airbus fly-by-wire designs, once told me that the company ran tests and found that 90 percent of airline pilots believed that they could extract maximum performance from an airplane during emergency pull-ups away from the ground, but that only 10 percent actually could. Rockliff said, “More like 0.1 percent.” The Airbus answer was to automate the pull-ups and let computers do the job. Boeing’s answer was to continue to rely on pilots.



    This spring, I drove an hour west of the Jakarta airport to a compound known as Lion City. There, 2,500 flight attendants live in dormitories and batches of pilot recruits sit through up to six months of initial ground school before moving on to four to five months of flight training in Cessna 172s, followed by guaranteed jobs as co-pilots for the Lion Air Group. The pedagogical approach is that of a production line, with no accommodation for creativity or the unexpected. The tuition is $60,000. About 150 to 200 students pass through every year. The completion rate for the flight training is an astonishing 95 percent. When I asked how the completion rate could be so high, the head of training explained that it is because of aptitude testing at the start. For instance, applicants must have graduated from high school. In other words, when it comes to predicting the competence of its pilots, Lion Air has achieved the clairvoyance that has long eluded Boeing and Airbus, both of which have spent decades in that pursuit without finding good answers.

    At Lion City, I stood in front of a class of buzz-cut clean-shaven young recruits in white uniform shirts and narrow black neckties — the new checklist children of global aviation. At a loss for words, I said, “Congratulations.” Dutifully and in perfect unison they answered, “Thank you, sir.” The visit was an education for me. Boeing is aware of this academy and feeder facilities just like it all over the world. The situation is evidently grave. I left Lion City struck that Boeing has not reacted with greater urgency to the larger problems now faced.
    The second accident occurred when Ethiopian Airlines Flight 302,a 737 Max bound for Nairobi with 157 people aboard, hit the ground near Addis Ababa in a screaming dive. The airplane was captained by a 29-year-old pilot named Yared Getachew, who had graduated from the airline’s production-line academy 10 years before and had accumulated 8,122 hours of flight time. His co-pilot was a 25-year-old named Ahmed Nur Mohammod Nur, who had graduated from the academy just a few months before and had started serving as a 737 co-pilot when he had merely 154 hours of flight time. Since then, he had gained another 207 hours.

    Both men were aware of the Lion Air tragedy. They had been briefed on the MCAS system and knew the basics: that it provided repetitive 10-second bursts of nose-down trim, that it could be held at bay through vigorous use of the control yoke thumb switches to counter-trim, that it would not activate if the flaps were down or the autopilot was on, that it could be deactivated by shutting off the electric trim through use of the now-famous cutout switches on the center pedestal and that afterward the airplane could be trimmed using the manual trim wheel.

    The airplane rolled down the runway at 8:38 a.m. with a standard takeoff flap setting and Getachew at the controls. Immediately after liftoff, the angle-of-attack measurement on his side failed, setting off his stick shaker and distorting his indications of airspeed and altitude. It is not known why the angle-of-attack measurement failed. The vane on that side seemed to be the original unit. As in Indonesia, all indications on the co-pilot’s side were evidently correct because they crosschecked to the standby instruments and were not accompanied by a stick shaker. Airmanship 101. The situation was obvious enough for almost any pilot. Roughly one minute after takeoff and 1,000 feet above the ground, they engaged the autopilot on the captain’s side. The choice to use the captain’s side was strange because the instrument failure was clearly on that side, but the autopilot gracefully agreed to help. The airplane wobbled a bit, perhaps because the captain’s air data was confusing.

    A few seconds later, air-traffic control cleared the flight to 34,000 feet. Despite the troubles in the cockpit, the co-pilot, Mohammod, acknowledged the clearance, changed the autopilot mode, dialed in the target altitude and selected a climb airspeed of 238 knots, apparently because he was flying by rote. Similarly, Getachew took this moment to be really dumb: Despite the activation of his stick shaker and the likelihood that it related to erroneous angle-of-attack measurements on his side, despite knowing what had occurred in Indonesia, despite the information he had received about the MCAS and despite the need to return to the airport, he ordered Mohammod to raise the flaps. Mohammod did, and five seconds later the autopilot disengaged, perhaps because the captain’s indications became even more erratic than before. Getachew instructed Mohammod to advise air-traffic control that they were having flight-control problems, even though until then the only problem they had experienced was with instruments and their indications.

    Getachew had neglected to throttle back from the full takeoff thrust setting. And now the MCAS kicked in. It gave a nine-second nose-down burst that stopped the climb and forced the airplane into a slight descent. Because of the descent, a ground-proximity “DON’T SINK” warning sounded. Getachew pulled the nose up. The MCAS kicked in again. Three more ground-proximity warnings sounded. Getachew asked for help with the nose-up trim, a request that did not make sense because the dual use of electric thumb switches is no more powerful than a single use. Mohammod said: “Stab trim cutout! Stab trim cutout!” And Getachew concurred. Mohammod flipped the switches. That should have ended the story, but it didn’t.



    The airplane was now so far out of trim that Getachew had to hold his control column halfway back (meaning half up-elevator) to keep the nose from dropping. It was urgent to retrim the airplane using the manual trim wheel. But there was a big problem: The pilots had still not throttled back from takeoff thrust, and the airplane now in level flight was going extremely fast, at least 25 knots faster than the maximum operating speed of 340 knots, and was rapidly accelerating into realms beyond the flight-testing range. The excessive speed was amply clear in the cockpit, where an overspeed clacker was sounding off, but neither pilot thought to reduce the thrust and slow. The flight-data recorder later showed that the throttles remained at a takeoff setting until the end.

    The speed, meanwhile, was producing such large aerodynamic forces on the tail that the manual trim wheel lacked the mechanical power to overcome them, and the trim was essentially locked into the position where the MCAS had left it — not fully nose-down, but dangerously out of whack. The only way to retrim the airplane at these speeds would be to use the much more powerful electric mechanism associated with the thumb switches, which, however, would require the pilots first to flip the cutout switches back to “normal,” exposing the airplane to further attacks from the MCAS.










    But something slightly different occurred. On Getachew’s orders, Mohammod flipped the cutout switches to reactivate the electric trim, but apparently less to use the thumb switch — Getachew gave it only two halfhearted tries — than to activate the autopilot as a way of disabling the MCAS. The record shows four attempts in rapid succession to engage the autopilot, all of which were refused because autopilots are not recovery devices and will not engage if they sense pressures on the control column — meaning that an airplane is being flown out of trim.

    This airplane had heavy pressures on the controls — remember, Getachew was muscling his control column halfway back. Now, in apparent desperation to persuade the autopilot to engage, Getachew did the unthinkable and released his pressure on the control column. The column snapped forward, and the airplane responded by violently pitching down, 20 degrees below the horizon. Just then, with the stick shaker still rattling, the MCAS kicked in and achieved full nose-down trim, doubling the angle of the dive. As the speed shot through 450 knots, the pilots hauled back on their control columns to no effect. Six minutes after takeoff, the airplane hit the ground doing approximately 600 miles an hour. It buried itself into a 30-foot-deep crater in farmland about 32 miles southeast of the airport. Within a week, the Boeing 737 Max was grounded worldwide.

    The formal investigations continue today, and you might hope that their findings would lead to a more complete understanding of the accidents. Each appears to comply with guidelines laid out in a document known as Annex 13 that is disseminated by the International Civil Aviation Organization, a United Nations agency. Each is led by government officials of the countries where the airplanes crashed — Indonesia and Ethiopia — and joined, respectively, by Lion Air and Ethiopian Airlines, by Boeing as the airplane’s builder and by the N.T.S.B. as investigators from the country of the airplanes’ manufacture. Australian and French investigators have been involved, too.
    Knowledgeable observers, however, are skeptical that the investigations can proceed unimpeded. Dennis Jones, a retired N.T.S.B. investigator with a long career of international experience, suggested to me diplomatically that Annex 13 is a typical United Nations construct that does not necessarily accommodate national and political variations in intent to get at the truth no matter where it may lie. He was speaking specifically about Malaysia’s investigation into the mysterious disappearance of Flight 370, the Malaysia Airlines Boeing 777 lost in 2014, a case to which he was assigned. He came away from it impressed by some of the Malaysian investigators because of their efforts to explore the evidence despite powerful political constraints.



    The process in Jakarta has been similarly problematic. The official investigation is proceeding under the gaze of Lion Air’s founder, Rusdi Kirana, who has acquired political power and wealth. According to sources familiar with both investigations, Boeing and the N.T.S.B. have been largely excluded and denied access to such basic evidence as the complete flight-data recordings and the audio from the cockpit. A representative from the Indonesian investigation rebuts this claim and said that all parties have “access to all investigation data.” Important leads, meanwhile, are not being pursued, entire angles are being overlooked and the release of information to the public has been unusually restricted. This is occurring in a country where assumptions are widespread that regulators, investigators and reporters alike are on Lion Air’s payroll.

    This year, two New York Times reporters, Hannah Beech and Muktita Suhartono, spoke to a former investigator who said that after a previous Lion Air accident, an airline employee tried to hand over a black garbage bag full of cash. The surprise was that the investigator did not accept it. Beech and Suhartono wrote: “Such payments from Lion Air were common because transportation-safety officials were poorly paid, former investigators said. A former high-level Lion Air employee confirmed that when he worked at the company, clandestine payments to government investigators, even for restaurants and prostitutes, were routine.” I admired the reporters’ restraint in their use of the past tense. It is not clear that anything has changed.

    In the case of the Ethiopian investigation, we have an airline and an investigative body that historically have not been able to isolate themselves from the country’s dysfunctional political life. Carbaugh mentioned to me that he was serving as Boeing’s chief pilot of safety in 2010 when an Ethiopian crew lost control of a 737 NG, the predecessor of the Max, killing all 90 people aboard. The airplane had just departed from Beirut. The subsequent investigation was led by a brilliant Lebanese airline pilot named Mohammed Aziz, who after nearly two years of obstructionism and obfuscations by the Ethiopians produced a report laying the blame squarely on the pilots, who had overshot assigned compass headings left and right, overbanked repeatedly, stalled twice and, for lack of airmanship, entered a lethal high-G spiral dive.

    The report was passed around for comment before publication. The French, Americans and Lebanese all agreed that it was complete. Ethiopia vociferously disagreed. Shortly before the report was to be released in 2012, Carbaugh stopped by Addis Ababa to demonstrate a new 787 Dreamliner, four of which the airline had ordered. He told me that a senior official from Ethiopian Airlines asked him to come to his office for a private talk. According to Carbaugh, the official said: “The report is coming out. Boeing has influence over the N.T.S.B. and the Lebanese. You need to get them to change the findings. They need to say that an Israeli shoot-down or a bomb was a possible cause of the accident.”

    Carbaugh told me that he answered: “Sir, here’s the data. Here’s what it says. Here’s what happened. Eyewitnesses who saw a flash, that was probably the landing lights coming out of the bottom of the clouds. There was no Israeli missile, no explosion, no lightning strike. That’s not what happened. The facts speak for themselves. Boeing works on behest of the N.T.S.B. on a technical basis. We don’t control the outcome.”

    The official was incredulous and mentioned the airline’s relationship with Boeing. He insisted that the report be changed.
    Carbaugh wasn’t going to argue. “We can’t,” he said.

    The Ethiopian Airlines Flight 302 investigation currently underway may look from a distance like an Annex 13 effort, but it is riddled with furtiveness and fear. One example can stand for much of the rest: After the cockpit voice recorder was dug out of the wreckage, it was shielded from the N.T.S.B. and whisked to Paris. There, for reasons unknown, French accident investigators agreed to download its contents in private onto a drive for an immediate return to Addis Ababa, where the information remains mostly locked away today and has been withheld in full form from any outside observers.



    It is a forlorn hope, but you might wish that investigators like those in Indonesia and Ethiopia would someday have the self-confidence to pursue full and transparent investigations and release all the raw data associated with the accidents. When I mentioned this to Carbaugh, he said: “I think the information will never get released. Too damning. And if they don’t want to release the information, they won’t. And the U.N. and I.C.A.O. probably won’t have the gumption to demand that they do.” He thought for a moment and said, “Oh, they may do it years down the road, when nobody gives a $#@! anymore.” I said it is hard to believe that such a moment will come. Sounding resigned, if not fatigued, he said, “Yeah, but that’s the way it goes.”

    The 737 Max remains grounded under impossibly close scrutiny, and any suggestion that this might be an overreaction, or that ulterior motives might be at play, or that the Indonesian and Ethiopian investigations might be inadequate, is dismissed summarily. To top it off, while the technical fixes to the MCAS have been accomplished, other barely related imperfections have been discovered and added to the airplane’s woes. All signs are that the reintroduction of the 737 Max will be exceedingly difficult because of political and bureaucratic obstacles that are formidable and widespread. Who in a position of authority will say to the public that the airplane is safe?

    I would if I were in such a position. What we had in the two downed airplanes was a textbook failure of airmanship. In broad daylight, these pilots couldn’t decipher a variant of a simple runaway trim, and they ended up flying too fast at low altitude, neglecting to throttle back and leading their passengers over an aerodynamic edge into oblivion. They were the deciding factor here — not the MCAS, not the Max. Furthermore, it is certain that thousands of similar crews are at work around the world, enduring as rote pilots and apparently safe, but only so long as conditions are routine. Airbus has gone further than Boeing in acknowledging this reality with its robotic designs, though thereby, unintentionally, steepening the very decline it has tried to address. Boeing is aware of the decline, but until now — even after these two accidents — it has been reluctant to break with its traditional pilot-centric views. That needs to change, and someday it probably will; in the end Boeing will have no choice but to swallow its pride and follow the Airbus lead.

    These broader implications, however, have been lost in the noise. After President Trump weighed in on the basis of no perceptible knowledge, and the F.A.A. was forced to retreat from its initial defense of the airplane, Boeing had to accept a public onslaught. The onslaught has included congressional hearings, federal investigations, calls for the criminal prosecution of Boeing executives, revelations by whistle-blowers, attacks in the news media, the exploitation of personal tragedy and the construction of a whole new economic sector built around perceptions of the company’s liability. Boeing has grown largely silent, perhaps as much at the request of its sales force as of its lawyers. To point fingers at important clients would risk alienating not only those airlines but others who have been conditioned to buy its airplanes, no matter how incompetent their pilots may be.



    William Langewiesche is a newly named writer at large for the magazine. He is a former national correspondent for The Atlantic and international correspondent for Vanity Fair, where he covered a wide variety of subjects throughout the world. He grew up in aviation and got his start as a pilot before turning to journalism. This is his first article for the magazine.






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  21. #18
    Interesting article.

    That story actually starts three days before the accident, when the same airplane — under different flight numbers and Lion Air crews — experienced errors in airspeed and altitude indications on the captain’s (left side) flight display that weren’t properly addressed. Those indications are driven by a combination of sensors on the surface of the airplane. A set of independent duplicate sensors drive the co-pilot’s (right side) display. A third standby system provides additional independent backup and allows for intuitive troubleshooting when any one of the three systems fails: If two indications agree and the third one does not, the odd one out is obviously the one to ignore.
    ...
    It was just the MCAS kicking in, because the three conditions necessary to trigger it had combined: The flaps were up, the autopilot was off and the captain’s angle-of-attack sensor was showing a stall.

    One of Boeing’s bewildering failures in the MCAS design is that despite the existence of two independent angle-of-attack sensors, the system did not require agreement between them to conclude that a stall had occurred.
    So MCAS utilized only the pilot’s indicator, and did not check against the backups. That was a key Boeing failure, which led to at least one of the crashes where the pilot’s indicators were failing.

    Finally the ghost in the jump seat intervened. It is impossible to know if he was a better airman than the pilots in the front or simply had the advantage of an overview. Either way, he recommended the obvious — shutting off the electric trim by flipping the cutout switches. The captain flipped the switches, the trim stopped running away and the MCAS was disabled. It was that easy.
    ...
    After pulling up to the gate in Jakarta, the Bali captain informed a company mechanic about “the aircraft problem” and in the maintenance log noted only three anomalies — the captain’s airspeed and altitude indication errors and the illumination of a warning light related to a system known as Feel Differential Pressure. That was it. Apparently the captain noted nothing about the failure of the newly installed angle-of-attack sensor, or the activation of the stick shaker, or the runaway trim, or the current position of the trim cutout switches. If true, it was hard to conclude anything other than that this was severe and grotesque negligence. Dave Carbaugh, the former Boeing test pilot, had the most charitable view of the matter. “I suspect that the pilot wrote what you see in the log, and he verbally told maintenance that, ‘Hey, the trim was running down, and we had to use the stabilizer cutout switches, and we flew the airplane back manually,’ ” he said. “And maintenance took no action on that, because the airplane had made it back to Jakarta. They just checked the fault messages and cleared them and called it a day. That’s my best guess. They were just hellbent to release that airplane.”
    I would suspect some human nature at play in addition to the clusterf*ck going on with maintenance. The pilot probably did not want to admit or document that a jump-seat passenger had saved his ass.

    He almost silently passed the plane on to the next unsuspecting pilots, who had no one to save them.
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  22. #19
    Boeing clung resolutely to its pilot-centric designs, but in Toulouse, France, the relative newcomers at the European consortium called Airbus were not nearly as shy. Led by an outspoken former military test pilot turned chief engineer named Bernard Ziegler, Airbus decided to take on Boeing by creating a robotic new airplane that would address the accelerating decline in airmanship and require minimal piloting skills largely by using digital flight controls to reduce pilot workload, iron out undesirable handling characteristics and build in pilot-proof protections against errors like aerodynamic stalls, excessive banks and spiral dives. The idea was that it would no longer be necessary to protect the public from airplanes if Airbus could get airplanes to protect themselves from pilots.

    The approach was diametrically opposed to Boeing’s. Ziegler announced that he was going to build an airplane that even his concierge could fly. The implicit insult won him the enmity of some French airline pilots, who then as now thought highly of themselves. Ziegler told me he received death threats and lived under police protection for a while. But his efforts led to the smartest airplane ever built, a single-aisle medium-range “fly-by-wire” masterpiece called the A320 that entered the global market in 1988, led the way to all other Airbus models since and has been locked into a seesaw battle with Boeing’s relatively conventional 737s for the past 30 years.

    You might think that the 737 would have grown increasingly disadvantaged given the New World qualities of the A320, but in my estimation pilots have managed to crash the 320 at about the same rate, largely because of confusion over automation.
    Interesting. A philosophy difference between Boeing and Airbus. Which leads me to check which brand of aircraft was involved in the infamous crash at San Francisco by Asian pilots who apparently couldn’t land in a visual mode.

    Asiana Airlines Flight 214 was a scheduled transpacific passenger flight from Incheon International Airport near Seoul, South Korea, to San Francisco International Airport in the United States. On the morning of 6 July 2013, the Boeing 777-200ER crashed on final approach into San Francisco International Airport. Of the 307 people on board, three died; another 187 were injured, 49 of them seriously.
    ...
    The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's mismanagement of the airplane's descent during the visual approach, the pilot flying's unintended deactivation of automatic airspeed control, the flight crew's inadequate monitoring of airspeed, and the flight crew's delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing's documentation and Asiana's pilot training, which increased the likelihood of mode error; (2) the flight crew's nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the pilot flying's inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot's inadequate supervision of the pilot flying; and (5) flight crew fatigue, which likely degraded their performance.
    ...
    The Boeing 777-200ER, registration HL7742,[8] was powered by two Pratt and Whitney PW4090 engines.[4][22] It was delivered new to Asiana Airlines on 7 March 2006,[23][24] and at the time of the crash had accumulated 37,120 flight hours and 5,388 (takeoff-and-landing) cycles.[1]:20

    The Boeing 777 has a good reputation for safety.[25] This was its first fatal accident, second crash (after British Airways Flight 38), and third hull loss since the 777 began operating commercially in 1995.[26]
    ...
    https://en.m.wikipedia.org/wiki/Asia...nes_Flight_214
    Last edited by Brian4Liberty; 09-20-2019 at 12:42 PM.
    "Foreign aid is taking money from the poor people of a rich country, and giving it to the rich people of a poor country." - Ron Paul
    "Beware the Military-Industrial-Financial-Pharma-Corporate-Internet-Media-Government Complex." - B4L update of General Dwight D. Eisenhower
    "Debt is the drug, Wall St. Banksters are the dealers, and politicians are the addicts." - B4L
    "Totally free immigration? I've never taken that position. I believe in national sovereignty." - Ron Paul

    Proponent of real science.
    The views and opinions expressed here are solely my own, and do not represent this forum or any other entities or persons.

  23. #20
    Quote Originally Posted by RJB View Post
    The way things are going, women will get more excited about dating the autopilot rather than the human one.

    Last edited by sam1952; 09-20-2019 at 02:42 PM.
    "Nobody wins in a Dairy Challenge" ~ Kenny Rogers, RIP


    "When a man who is honestly mistaken hears the truth, he will either quit being mistaken, or cease to be honest." ~ anonymous


    “The fate of all mankind I see
    Is in the hands of fools” ~ King Crimson

  24. #21
    “Airmanship” is an anachronistic word
    So is seamanship, but it means the same thing, roughly.

    Its full meaning is difficult to convey. It includes a visceral sense of navigation, an operational understanding of weather and weather information, the ability to form mental maps of traffic flows, fluency in the nuance of radio communications and, especially, a deep appreciation for the interplay between energy, inertia and wings. Airplanes are living things. The best pilots do not sit in cockpits so much as strap them on. The United States Navy manages to instill a sense of this in its fledgling fighter pilots by ramming them through rigorous classroom instruction and then requiring them to fly at bank angles without limits, including upside down. The same cannot be expected of airline pilots who never fly solo and whose entire experience consists of catering to passengers who flinch in mild turbulence, refer to “air pockets” in cocktail conversation and think they are near death if bank angles exceed 30 degrees. The problem exists for many American and European pilots, too. Unless they make extraordinary efforts — for instance, going out to fly aerobatics, fly sailplanes or wander among the airstrips of backcountry Idaho — they may never develop true airmanship no matter the length of their careers. The worst of them are intimidated by their airplanes and remain so until they retire or die. It is unfortunate that those who die in cockpits tend to take their passengers with them.
    This is how you could have a licensed master of vessels of unlimited tonnage, who can't steer a dingy.
    Last edited by Anti Federalist; 09-20-2019 at 04:34 PM.
    Another mark of a tyrant is that he likes foreigners better than citizens, and lives with them and invites them to his table; for the one are enemies, but the Others enter into no rivalry with him. - Aristotle's Politics Book 5 Part 11

  25. #22
    This turned out to be an obsolete assumption
    I'm putting that phrase in my pocket for future reference.
    Another mark of a tyrant is that he likes foreigners better than citizens, and lives with them and invites them to his table; for the one are enemies, but the Others enter into no rivalry with him. - Aristotle's Politics Book 5 Part 11

  26. #23
    @Danke - what say you?

    So here's a lefty broad's take on things.

    I'm sure that managerial revolution included diversity and committee thinking.

    If a bunch of hard assed, buzz cut, white men in black skinny ties were calling the shots, she'd be screaming blue murder.


    Crash Course: How Boeing's Managerial Revolution Created the 737 Max Disaster

    https://newrepublic.com/article/1549...=pocket-newtab

    By Maureen Tkacik

    September 18, 2019

    Nearly two decades before Boeing’s MCAS system crashed two of the plane-maker’s brand-new 737 MAX jets, Stan Sorscher knew his company’s increasingly toxic mode of operating would create a disaster of some kind. A long and proud “safety culture” was rapidly being replaced, he argued, with “a culture of financial bull$#@!, a culture of groupthink.”


    Sorscher, a physicist who’d worked at Boeing more than two decades and had led negotiations there for the engineers’ union, had become obsessed with management culture. He said he didn’t previously imagine Boeing’s brave new managerial caste creating a problem as dumb and glaringly obvious as MCAS (or the Maneuvering Characteristics Augmentation System, as a handful of software wizards had dubbed it). Mostly he worried about shriveling market share driving sales and head count into the ground, the things that keep post-industrial American labor leaders up at night. On some level, though, he saw it all coming; he even demonstrated how the costs of a grounded plane would dwarf the short-term savings achieved from the latest outsourcing binge in one of his reports that no one read back in 2002.*

    Sorscher had spent the early aughts campaigning to preserve the company’s estimable engineering legacy. He had mountains of evidence to support his position, mostly acquired via Boeing’s 1997 acquisition of McDonnell Douglas, a dysfunctional firm with a dilapidated aircraft plant in Long Beach and a CEO who liked to use what he called the “Hollywood model” for dealing with engineers: Hire them for a few months when project deadlines are nigh, fire them when you need to make numbers. In 2000, Boeing’s engineers staged a 40-day strike over the McDonnell deal’s fallout; while they won major material concessions from management, they lost the culture war. They also inherited a notoriously dysfunctional product line from the corner-cutting market gurus at McDonnell.


    And while Boeing’s engineers toiled to get McDonnell’s lemon planes into the sky, their own hopes of designing a new plane to compete with Airbus, Boeing’s only global market rival, were shriveling. Under the sway of all the naysayers who had called out the folly of the McDonnell deal, the board had adopted a hard-line “never again” posture toward ambitious new planes. Boeing’s leaders began crying “crocodile tears,” Sorscher claimed, about the development costs of 1995’s 777, even though some industry insiders estimate that it became the most profitable plane of all time. The premise behind this complaining was silly, Sorscher contended in PowerPoint presentations and a Harvard Business School-style case study on the topic. A return to the “problem-solving” culture and managerial structure of yore, he explained over and over again to anyone who would listen, was the only sensible way to generate shareholder value. But when he brought that message on the road, he rarely elicited much more than an eye roll. “I’m not buying it,” was a common response. Occasionally, though, someone in the audience was outright mean, like the Wall Street analyst who cut him off mid-sentence:


    “Look, I get it. What you’re telling me is that your business is different. That you’re special. Well, listen: Everybody thinks his business is different, because everybody is the same. Nobody. Is. Different.”


    And indeed, that would appear to be the real moral of this story: Airplane manufacturing is no different from mortgage lending or insulin distribution or make-believe blood analyzing software—another cash cow for the one percent, bound inexorably for the slaughterhouse. In the now infamous debacle of the Boeing 737 MAX, the company produced a plane outfitted with a half-assed bit of software programmed to override all pilot input and nosedive when a little vane on the side of the fuselage told it the nose was pitching up. The vane was also not terribly reliable, possibly due to assembly line lapses reported by a whistle-blower, and when the plane processed the bad data it received, it promptly dove into the sea.

    Must-reads.
    5 days a week.

    It is understood, now more than ever, that capitalism does half-assed things like that, especially in concert with computer software and oblivious regulators: AIG famously told investors it was hard for management to contemplate “a scenario within any kind of realm of reason that would see us losing one dollar in any of those transactions” that would, a few months later, lose the firm well over $100 billion—but hey, the risk management algorithms had been wrong. A couple of years later, a single JP Morgan trader lost $6 billion because someone had programmed one of the cells in the bank’s risk management spreadsheet to divide two numbers by their sum instead of their average. Boeing was not, of course, a hedge fund: It was way better, a stock that had more than doubled since the Trump inauguration, outperforming the Dow in the 22 months before Lion Air 610 plunged into the Java Sea.


    And so there was something unsettlingly familiar when the world first learned of MCAS in November, about two weeks after the system’s unthinkable stupidity drove the two-month-old plane and all 189 people on it to a horrific death. It smacked of the sort of screwup a 23-year-old intern might have made—and indeed, much of the software on the MAX had been engineered by recent grads of Indian software-coding academies making as little as $9 an hour, part of Boeing management’s endless war on the unions that once represented more than half its employees. Down in South Carolina, a nonunion Boeing assembly line that opened in 2011 had for years churned out scores of whistle-blower complaints and wrongful termination lawsuits packed with scenes wherein quality-control documents were regularly forged, employees who enforced standards were sabotaged, and planes were routinely delivered to airlines with loose screws, scratched windows, and random debris everywhere. The MCAS crash was just the latest installment in a broader pattern so thoroughly ingrained in the business news cycle that the muckraking finance blog Naked Capitalism titled its first post about MCAS “Boeing, Crapification and the Lion Air Crash.”


    But not everyone viewed the crash with such a jaundiced eye—it was, after all, the world’s first self-hijacking plane. Pilots were particularly stunned, because MCAS had been a big secret, largely kept from Boeing’s own test pilots, mentioned only once in the glossary of the plane’s 1,600-page manual, left entirely out of the 56-minute iPad refresher course that some 737-certified pilots took for MAX certification, and—in a last-minute edit—removed from the November 7 emergency airworthiness directive the Federal Aviation Administration had issued two weeks after the Lion Air crash, ostensibly to “remind” pilots of the protocol for responding to a “runaway stabilizer.” Most pilots first heard about MCAS from their unions, which had in turn gotten wind of the software from a supplementary bulletin Boeing sent airlines to accompany the airworthiness directive. Outraged, they took to message boards, and a few called veteran aerospace reporters like The Seattle Times’ Dominic Gates, The Wall Street Journal’s Andy Pasztor, and Sean Broderick at Aviation Week—who in turn interviewed engineers who seemed equally shocked. Other pilots, like Ethiopian Airlines instructor Bernd Kai von Hoesslin, vented to their own corporate management, pleading for more resources to train people on the scary new planes—just weeks before von Hoesslin’s carrier would suffer its own MAX-engineered mass tragedy.


    It went without saying that MCAS was an honest mistake, but the secrecy shrouding the program’s very existence told you it wasn’t a 100 percent honest honest mistake. The story of the secrecy begins with the universally beloved, unusually labor-friendly, strangely not-evil Southwest Airlines. (When the carrier’s beloved co-founder Herb Kelleher died in January, Ralph Nader wrote a fawning obituary about the old friend, a “many splendored human being,” who had founded his favorite airline; Nader would soon lose a grandniece to MCAS.) On something of a lark, Boeing had given Kelleher a sweet no-money-down deal on his first four 737s in 1971, and Kelleher repaid the favor by buying more than 1,000 737s over the next 50 years—and zero of any other plane. According to a recent lawsuit against Southwest and Boeing, the airline had rewarded this loyalty with an unwritten but zealously enforced “handshake” agreement, dating back to the 1990s, that Boeing would not sell any planes for less than Southwest was paying, or Boeing would send Southwest a rebate check. And in exchange for that guarantee, Southwest reliably swooped in with big orders and/or accelerated payments after accidents, stock price plunges, or both; the same lawsuit claims that, after September 11, the airline formed an off–balance-sheet slush fund to bail out Boeing during unanticipated shortfalls, and lent other airlines its own planes when Boeing production fell behind, all while it waited patiently for its order deliveries to be filled at a time when it was convenient for Boeing. As the carriers became more profitable in the twenty-first century, more of them followed Southwest’s lead and helped Boeing make its numbers, with United Airlines and Alaska Airlines pitching in during fourth-quarter 2015, alongside Southwest, to make payments not due until 2016. Those partnerships were but one numbers-smoothing mechanism in a diversified tool kit Boeing had assembled over the previous generation for making its complex and volatile business more palatable to Wall Street, and while not entirely kosher and not at all sustainable, they were by far the least destructive tool in the kit—until Southwest called in the favor on its orders for the MAX.


    Southwest always had a lot to say about projected modifications to the 737, and Kelleher’s team mostly wanted as few technical modifications as possible. With the MAX, they upped the ante: According to Rick Ludtke, a former Boeing employee, Boeing agreed to rebate Southwest $1 million for every MAX it bought, if the FAA required level-D simulator training for the carrier’s pilots.


    To whoever agreed to this, the rebate probably seemed like a predictably quixotic demand of the airline that had quixotically chosen to fly just one plane model, exclusively and eternally, where every other airline flew ten. Simulator training for Southwest’s 9,000 pilots would have been a pain, but hardly ruinous; aviation industry analyst Kit Darby said it would cost about $2,000 a head. It was also unlikely: The FAA had three levels of “differences” training that wouldn’t have necessarily required simulators. But the No Sim Edict would haunt the program; it basically required any change significant enough for designers to worry about to be concealed, suppressed, or relegated to a footnote that would then be redacted from the final version of the MAX. And that was a predicament, because for every other airline buying the MAX, the selling point was a major difference from the last generation of 737: unprecedented fuel efficiency in line with the new Airbus A320neo.


    The MAX and the Neo derived their fuel efficiency from the same source: massive “LEAP” engines manufactured by CFM, a 50-50 joint venture of GE and the French conglomerate Safran. The engines’ fans were 20 inches—or just over 40 percent larger in diameter than the original 737 Pratt & Whitneys, and the engines themselves weighed in at approximately 6,120 pounds, about twice the weight of the original engines. The planes were also considerably longer, heavier, and wider of wingspan. What they couldn’t be, without redesigning the landing gear and really jeopardizing the grandfathered FAA certification, was taller, and that was a problem. The engines were too big to tuck into their original spot underneath the wings, so engineers mounted them slightly forward, just in front of the wings.


    This alteration created a shift in the plane’s center of gravity pronounced enough that it raised a red flag when the MAX was still just a model plane about the size of an eagle, running tests in a wind tunnel. The model kept botching certain extreme maneuvers, because the plane’s new aerodynamic profile was dragging its tail down and causing its nose to pitch up. So the engineers devised a software fix called MCAS, which pushed the nose down in response to an obscure set of circumstances in conjunction with the “speed trim system,” which Boeing had devised in the 1980s to smooth takeoffs. Once the 737 MAX materialized as a real-life plane about four years later, however, test pilots discovered new realms in which the plane was more stall-prone than its predecessors. So Boeing modified MCAS to turn down the nose of the plane whenever an angle-of-attack (AOA) sensor detected a stall, regardless of the speed. That involved giving the system more power and removing a safeguard, but not, in any formal or genuine way, running its modifications by the FAA, which might have had reservations with two critical traits of the revamped system: Firstly, that there are two AOA sensors on a 737, but only one, fatefully, was programmed to trigger MCAS. The former Boeing engineer Ludtke and an anonymous whistle-blower interviewed by 60 Minutes Australia both have a simple explanation for this: Any program coded to take data from both sensors would have had to account for the possibility the sensors might disagree with each other and devise a contingency for reconciling the mixed signals. Whatever that contingency, it would have involved some kind of cockpit alert, which would in turn have required additional training—probably not level-D training, but no one wanted to risk that. So the system was programmed to turn the nose down at the feedback of a single (and somewhat flimsy) sensor. And, for still unknown and truly mysterious reasons, it was programmed to nosedive again five seconds later, and again five seconds after that, over and over ad literal nauseam.


    And then, just for good measure, a Boeing technical pilot emailed the FAA and casually asked that the reference to the software be deleted from the pilot manual.


    No more than a handful of people in the world knew MCAS even existed before it became infamous.

    So no more than a handful of people in the world knew MCAS even existed before it became infamous. Here, a generation after Boeing’s initial lurch into financialization, was the entirely predictable outcome of the byzantine process by which investment capital becomes completely abstracted from basic protocols of production and oversight: a flight-correction system that was essentially jerry-built to crash a plane. “If you’re looking for an example of late stage capitalism or whatever you want to call it,” said longtime aerospace consultant Richard Aboulafia, “it’s a pretty good one.”


    The 737 MAX sailed through its FAA certification flight tests in just over a year. The plane was actually early, which was a good thing from an investor’s standpoint, since Boeing’s last new plane, the 787, had been three years late. Of course, the MAX wasn’t really a new plane, just an “upgrade” of the old 737 that had the benefit of carrying roughly two and a half times as many passengers about three times as far as the original 737. 


    In its early aftermath, Lion Air 610’s fatal crash conformed too much to well-worn stereotypes about Indonesian safety standards to seem, at least to layman observers, like anything more significant than a cautionary tale about honeymooning in Bali. As it happened, the MAX flight directly before the crash had started nosediving right after takeoff, too. The pilots turned it up, but it dove down again and again, so the crew flew manually the whole way to Jakarta, where a passenger told the television reporters everyone on board had spent the whole ride “reciting every prayer” they knew. But all the pilots reported in a routine maintenance log that the plane’s speed trim system was “running to the wrong direction,” and that the air speed and altitude sensors were off. “Nothing about how, oh by the way, this plane is possessed by demons?” joked Aboulafia.


    And so all the early hot takes about the crash concerned Indonesia’s spotty safety record and Lion Air’s even-less-distinguished one. The plane dove into the Java Sea early in the morning on a Monday, 14 hours before the market opened and sent Boeing’s stock down almost $30. But the price shot right back up again on Tuesday. “It looked like an anomaly,” said David Calhoun, the private-equity executive who leads Boeing’s board of directors, and whose shares in the company appreciated in value by $2 million between the two 737 MAX crashes.

    There aren’t any pilots on the Boeing board, and the only engineer in the C-suites is CEO Dennis Muilenburg—and pilots and engineers were the ones who found the crash unnerving.

    Of course, there aren’t any pilots on the Boeing board, and the only engineer in the C-suites is CEO Dennis Muilenburg—and pilots and engineers were the ones who found the crash unnerving. “Boeing is the type of place where all you have to say is ‘427’ or ‘Turkish 981,’ and everyone knows immediately what you’re talking about,” said Sorscher. Preliminary satellite data showed that the plane dove just after takeoff, then recovered—and then dove again, and recovered again, and dove again, over and over. It wasn’t the usual flight path of a pilot who’d lost control of a plane. Twenty-two times the demons had violently jerked down the nose, and 22 times the pilot had corrected with equivalent force. “I get so mad at Boeing trying to tar this captain when he was actually the most proficient pilot of all of them,” said Bjorn Fehrm, a former Swedish air force pilot whose technical blog on the aviation web site Leeham News is a 737 MAX must-read. “He was mastering this wild animal—22 times and he kept it in check!”


    What was this wild animal that kept dunking down the nose of the plane? There is a scene in the first episode of a five-part 1996 PBS series on the making of the 777, Boeing’s first plane to employ “fly-by-wire” technology, in which an engineer discusses the company’s philosophy of computer-assisted aviation:


    One of the things that we do in the basic design is the pilot always has the ultimate authority of control. There’s no computer on the airplane that he cannot override, or turn off if the ultimate comes, but, in terms of any of our features, even those that are built to prevent the airplane from stalling, which is the lowest speed you can fly and beyond which you would lose the control. We don’t inhibit that totally; we make it difficult, but if something in the box should inappropriately think that it’s stalling when it isn’t, the pilot can say, this is wrong and he can override it. That’s a fundamental difference in philosophy that we have versus some of the competition.


    Pilots are familiar with this philosophy. It’s one of the things that makes flying a Boeing different from flying an Airbus. On the 1997 update of the 737, Southwest had requested that Boeing make special changes in its cockpit design because the carrier’s pilots were more comfortable with analog displays. The Lion Air pilot was certain he could turn off whatever was trying to crash his plane, so he temporarily handed over the controls to his co-pilot and scanned the manual. Ninety seconds later, everyone was dead. The co-pilot, said Fehrm, “was not prepared for the powerful beast of MCAS.”


    As it happened, the beast would strike again, four months later, with the crash of Ethiopian Airlines Flight 302 outside Addis Ababa, claiming 157 more lives in conditions nearly identical to the Lion Air catastrophe. The Boeing MAX body count now stood at 346, and once the scope of the horror became fully evident, the FAA had Boeing’s MAX fleet grounded, initially intending to return the planes to service within a few weeks. That’s since become months, and the fleet’s return may not ultimately happen until sometime next year. What has pitched up nicely since its initial nosedive is Boeing’s stock price, which as The New Republic went to press was right about where it stood a year ago, despite company projections of some $8 billion to settle wrongful death suits from the MAX debacle. The true financial cost could be much bigger for Boeing, if more carriers follow in the footsteps of Rostec, the Russian government conglomerate whose aircraft leasing arm sued Boeing in August to cancel its orders of the plane and return its deposit plus interest. That could prompt already pessimistic credit-rating agencies to downgrade Boeing’s debt, which could put Boeing in a serious cash crunch. But until anything really, really catastrophic happens, investors seem ready to buy all of Boeing’s dips—rather like MCAS in reverse. That’s in no small part because they know the company has developed fail-safe systems for smoothing earnings, beating expectations and jacking up demand for its shares with a precision that rivals any jet that rolled off the assembly line in Boeing’s heyday.

    An investigator with the U.S. National Transportation and Safety Board (NTSB) looks over debris at the crash site of Ethiopian Airlines Flight ET 302 on March 12, 2019 in Bishoftu, Ethiopia.Jemal Countess/Getty

    You can say that a fatal design flaw killed all these people, but that’s actually just another way of saying that money did. It’s hard to square the Boeing behind that powerful beast with the subject of the awe-inspiring PBS series. With the crippling recession of the early ’90s an ever-present source of stress for Boeing managers back then, the company nevertheless marshaled $5 billion and 10,000 employees—5,000 engineers and 5,000 machinists, split into a few dozen “design-build” teams inspired by Japanese manufacturing practices—to develop the 777. Roughly $2 billion to $3 billion, in an era of rock-bottom interest rates and record airline profits, was detailed to the 737 MAX.


    There was one unmistakable harbinger of what was to come at Boeing in the saga of the GE90—an all-new, ultra-efficient engine inspired by a NASA project that General Electric’s pioneering chief of aviation Brian Rowe developed exclusively for the new plane. Market watchers referred to the development of jet engines, which make up 20 percent of an airplane’s purchase price, as GE’s “crown jewel,” because the margins were high once the company had eaten the ten-figure cost of developing and testing one. But in 1993, GE’s notorious downsizing CEO Jack Welch—by then well on his way to becoming the most grotesquely lionized character in American business—abruptly fired Rowe, along with several thousand other aviation engineers. The results were predictable: The engines failed their tests, often in spectacular fashion, replete with smoke and flames, over and over and over again. Things deteriorated to the point that the FAA sent Boeing a “letter of discontinuance” directing the company to cease flight tests until GE got its act together. A shrunken staff of engineers, working overtime to implement decisions by colleagues who had long since been laid off, finally got the engines approved more than a year past their scheduled delivery dates, and malfunctions continued to plague the engines for years thereafter.


    Less than two years later, a layoff-happy Welch protégé named Harry Stonecipher, McDonnell Douglas’s former CEO, grabbed the reins at Boeing, and the same dysfunction took hold in Seattle.


    The line on Stonecipher was that he had “bought Boeing with Boeing’s money.” Indeed, Boeing didn’t ultimately get much for the $13 billion it spent on McDonnell Douglas, which had almost gone under a few years earlier. But the McDonnell board loved Stonecipher for engineering the McDonnell buyout, and Boeing’s came to love him as well. This was in no small part because Stonecipher cast himself as the savior of Boeing and knew just how to exploit a bad situation to get his way. When he arrived in Seattle, an unwieldy new computer system was conspiring with a sudden spike in orders and a clueless new workforce hired to fill them to wreak havoc on production. Factory managers pleaded with Stonecipher to marshal resources to fix things, but he ignored them until things got so bad they had to halt the assembly lines—at which point he began what The Seattle Times called a “cultural revolution.”


    The first suitably Maoist edict of the new era was a ban on the term “family,” which had first been rolled out as managerial precept at a 1998 Boeing retreat. (This move was cribbed from Jack Welch, who famously detested “loyalty” as a concept among his subordinates.) The new idea for describing intracorporate interdependence was “team.”


    Stonecipher’s other big cultural transformation was focused on maligning and marginalizing engineers as a class, and airplanes as a business. “You can make a lot of money going out of business” was something he liked to say. Welch had been famous for transferring upper managers from, say, GE’s locomotives division one year over to plastics the next, and to jet engines after that. Stonecipher wanted Boeing’s upper management to view planes with that same cold detachment, to not, as then-chief financial officer Debbie Hopkins explained in a 2000 Bloomberg interview, “get overly focused on the box”—i.e., the airplane.


    No one at Boeing really knew what had hit them after the McDonnell merger. Stan Sorscher was at a family reunion when he started putting the pieces together. He’d been talking (OK, ranting) to his Uncle Sidney, a gentle and brilliant man widely considered to possess the brightest mind to have ever emerged out of Flint, Michigan, about the depraved new managerial culture that had taken hold of his company, when Uncle Sidney cut him off, looked him straight in the eye, and, with a kind of precision and clarity Sorscher had only ever seen in “like, Nobel Prize-winning physicists,” told his nephew:
 


    You are in a mature industry that is no longer innovative; it’s a commodity business. The last great innovation capable of driving major growth in aviation was the jet engine back in the 1950s, and every technological advance since has been incremental. And so the emphasis of the business is going to switch away from engineering and toward supply-chain management. Because every mature company has to isolate which parts of its business add value, and delegate the more commoditylike things to the supply chain. The more you look to the market for pricing signals, the more the role of the engineer will shrink.


    
Sidney Davidson was a pioneering University of Chicago accounting professor who viewed his profession, in the words of one of his textbook titles, as “the language of business.” And while he was wrong, Sorscher knew, about airplane manufacturing, his glib analysis was compelling in large part because fin de sičcle Boeing was being devoured by the trendy accounting standards of the day. The new model for measuring long-term profitability in corporate America had boldly eclipsed the old Warren Buffett-style metrics like earnings and operating margins. Companies with traditional earnings fell out of favor—now, businesses that weren’t overcapitalized tech start-ups clamored to position themselves as turnaround stories. Boeing was telling its own version of this story, with the aid of another Stonecipher initiative that naysayers dubbed “the cult of RONA,” or return on net assets.


    Theoretically, return on net assets, which was called “residual income” at GE, is a quantification of how efficiently a company is using its factories, warehouses, office buildings, storefronts, and other elements of its physical plant. Theoretically, the metric can be used to make the case that a factory would be better served by shutting down and converting to condos and Amazon warehouses—or that a fighter jet factory and a fuel tanker factory would be better off consolidating production lines into one, or (depending on the year that a company is in the airplane manufacturing business) it can be worth more dead than alive. In reality, all you had to do to make RONA go up instantaneously, no matter what, was to sell off your assets indiscriminately, and outsource whatever functions they used to serve to other strategic points along the “supply chain.”


    The McDonnell Douglas engineers had seen it all before: In the name of RONA, Stonecipher’s team had driven the last nail in the coffin of McDonnell’s flailing commercial jet business by trying to outsource everything but design, final assembly, and flight testing and sales of the MD-11. In 2001, one McDonnell engineer wrote a scathing critique of the metric and its inevitable result, “Out-sourced Profits,” that went viral on Boeing’s intranet server. But Wall Street analysts dismissed the paper as a “rant,” and so the whole process was fated to begin anew under Stonecipher’s watch at Boeing.


    Abuzz with new ideas about factories to sell and components to outsource, Boeing was hemorrhaging market share to Airbus, and even the newest Jack Welch protégé on the board, James McNerney, was pushing for a new plane. Stonecipher and John McDonnell, who seemed almost irrationally intent on the Salieri-style project of seeing Boeing fail at the enterprise that had done in his own family business, issued what Sorscher called a “medieval” ultimatum: Develop the plane for less than 40 percent of what the 777 had cost to develop 13 years earlier, and build each plane out of the gate for less than 60 percent of the 777’s unit costs in 2003. The board ultimately approved a development budget, estimated by those in the industry to be $7 billion, for a project labeled at the time as the 7E7—later to be known as the 787—but that figure came with a huge asterisk, because managers promised the board they would require subcontractors to foot the majority of costs. As former Boeing Commercial Airplanes president Alan Mulally explained it to a friend of Sorscher’s one day in the parking lot before he quit in 2006: “In the old days, you would go to the board and ask for X amount of money, and they’d counter with Y amount of money, and then you’d settle on a number, and that’s what you’d use to develop the plane. These days, you go to the board, and they say, ‘Here’s the budget for this airplane, and we’ll be taking this piece of it off the top, and you get what’s left; don’t $#@! up.’”


    It’s difficult to convey the extent to which the 787 was $#@!ed up. Pitched as a high-tech, vastly more efficient sequel to the 777, the plane was in every way the inverse of its predecessor. It debuted three years behind schedule, tens of billions over budget, and was grounded 14 months after its maiden voyage, following a rash of mysterious lithium ion battery fires. This was a surprise only because the batteries were the last thing anyone (with the exception of Boeing’s battery team) thought would ground the 787 Dreamliner. (As for those battery specialists, there’s a fantastic 2014 Al-Jazeera English documentary recounting how the subcontractors tasked with manufacturing the 787’s battery chargers struggled to meet Boeing’s specifications and ended up burning down an entire 10,000-square-foot plant in the worst chemical fire in the history of Tucson, Arizona.)


    The whole 787 project had been ludicrously understaffed from the outset, remembered former flight controls engineer Peter Lemme: “Literally where there had been 20 engineers, there was now one.” Boeing deliberately subcontracted the components without designing them. The general manager of the program, Mike Bair, promised that, once finished, the parts would quickly “snap together” like Legos. This was an unintentionally funny spin on the design of the 777: For that plane, the project managers wanted the aircraft to be as easy to assemble as Fisher-Price toys. And unlike the 787, the 777 was completed with such precision that it was the first Boeing jet that didn’t need its kinks worked out on an expensive physical mock-up plane. The very first 777 off the assembly line was airworthy.


    With the 787, very much by contrast, nothing seemed to fit. There was a gap between the flight deck and the fuselage; the wing didn’t attach securely to the body of the plane. Far more troubling, it turned out that most of the parts Boeing workers were expected to “snap together,” from the wings to the smoke detectors, lacked tubes and electrical wiring. Even the fuselage was an empty husk. In the end, much of the plane’s real design happened on the assembly line, and Boeing had to write off three separate mock-ups that were too much like science projects to pass off as airworthy planes. In the end, the Dreamliner cost no less than $30 billion, and probably closer to $50 billion. From 2004 to 2008, the year the plane was scheduled to hit the market, Boeing plowed $16 billion into dividends and share repurchases—only ceasing when the plane officially blew its deadline, even though, as Sorscher bitterly recalled, “anyone could have told you that plane was going to blow its deadline.”


    In an ordinary context, it’s hard to imagine how The Harry Stonecipher Way—by that point being carried out by James McNerney, the Harvard MBA and GE veteran who had pushed the board to approve the plane to begin with—could survive such a traumatizing, spectacular hellward spiral as the one that the 787 had plunged Boeing into. But the project’s dysfunction came to light amid far graver trouble signs in the American economy, circa 2008—during the same volatile spring on Wall Street that saw the Bear Stearns bailout. By the time test flights began to suggest fundamental problems with the plane’s architecture, it was 2009, and America was in the depths of the worst recession since the 1930s. Investors, voters, and regulators had all become inured to that sort of thing. So McNerney held on to his job for the long haul, ultimately raking in about $250 million in compensation at Boeing. In one of his final acts, he restored the company’s stock buyback program, six months after the FAA lifted the grounding of the 787. Between 2013 and 2019, Boeing would spend more than $43 billion buying its own stock, and an additional $17.4 billion on dividends.


    Nor have the company’s recent MAX woes altered its basic financial outlook. Two months after the Lion Air crash, the board authorized the company to plow yet another $20 billion into buying its own stock. If you wondered where they got the nerve, well, GE spent $24 billion on its own stock in 2016 and 2017 alone. The Boeing board is now led by David Calhoun, still another Jack Welch protégé, with nothing but an accounting B.S. from Virginia Tech, who had run four GE divisions by the time he turned 49—something of a real-life version of Jack Donaghy, the swashbuckling GE hired gun played by Alec Baldwin on 30 Rock. Calhoun was the runner-up for the CEO job in 2005, when McNerney nabbed it, and he’s a shoo-in for the post when and if the board finally decides to can Dennis Muilenburg, a lifelong Boeing employee and engineer now shouldering the challenge of managing through the aftermath of the MAX fiasco. Asked by The Washington Post to comment on the company’s failure to ground the MAX when it first learned of the sinister suicide software that had killed 189 people, a coolly indignant Calhoun doubled down. “I don’t regret that judgment. And I don’t think we got it wrong at that time and that place.” Translation: It’s easier to lie about something when you can’t be bothered to understand it.


    Indeed, most of Boeing’s response to the MAX disasters has involved disseminating a kind of misinformation and doubt that makes the crashes look more complex than they really are. First Boeing issued, then instructed the FAA to circulate, a terse directive to the aviation community essentially copying-and-pasting the 737 flight manual’s instructions for handling a runaway stabilizer—a rare (but terrifying, and well-understood) situation in which the plane’s horizontal stabilizer doesn’t respond to a pilot’s commands. Then, when the airlines informed pilots about MCAS, they dispatched executives to talk pilots off the ledge about the deadly software—explaining, in the words of a Boeing vice president Mike Sinnett to the American Airlines pilots’ union, that Boeing simply didn’t want to “overload the crews with information that’s unnecessary.” Sinnett also suggested that an MCAS malfunction would never happen to American pilots, because the AOA “Disagree” light, an optional feature for which American had paid extra to outfit its fleet, would alert the crew before takeoff that the plane’s angle-of-attack sensors were contradicting each other and that the plane was not airworthy.


    That part turned out to be a lie. (The plane needed to be at least 400 feet in the air to activate the Disagree light—at which point the pilots, already preoccupied with getting the plane in the air, would only have a few seconds to turn it around.) But the idea that some safety feature existed that would have saved American planes perpetuated the fiction that an MCAS crash couldn’t have happened in a civilized country, even if its pilots were ill-informed enough to fail to remember the runaway stabilizer checklist.


    And that’s why, come March 2019, Peter Lemme, a former Boeing flight controls engineer who publishes a very technical aviation blog called Satcom Guru, could not bring himself to believe that when Ethiopian Flight 302 drilled into the ground near the resort town of Bishoftu, this incident could possibly be related to the Lion crash. “It can’t be MCAS, it just can’t be,” he thought. Lemme had met his wife working on pitch augmentation controls for the 757 and 767 aircraft; he’s also been one of the company’s now much-maligned “designated engineering representatives,” to whom the FAA delegates so much of its oversight. It went against everything he’d seen in 40 years in the business to think that two crashes four months apart had been caused by something so specific and inane. When the FAA grounded the MAX before even analyzing the preliminary black box data on the crashes, he assailed the move on Twitter. Clearly Boeing had made some serious mistakes, but it seemed implausible that the media wasn’t oversimplifying them—and moreover, every pilot in the world knew how to respond to an MCAS error. They had the checklist!


    But by the end of March, Lemme and his fellow aviation blogger Bjorn Fehrm, working occasionally in concert with the anonymous but very pilot-famous Mentour Pilot, a 737 captain and “type rating examiner” with half a million YouTube subscribers, had solved at least one mystery: The Ethiopian pilots had followed the Boeing checklist. They had switched the stabilizer trim cutout switches to the “cutout” position and attempted to turn the nose of the plane back up using the manual crank—they just couldn’t. In accordance with the prescribed fix for an alert they were getting on the flight control computer, the pilots had been flying extremely fast, and above the speeds of about 265 miles per hour at which the manual trim wheel became unbearably heavy. This issue wasn’t specific to the MAX; it was a well-known bug in the 737 generally. The Mentour Pilot had noticed the problem in his day job evaluating the final flight simulator exams of hundreds of would-be 737 pilots. He had even filmed a terrifying video in which he attempted to implement the MCAS override checklist in a simulator to demonstrate the system failure. And as Lemme had detailed on his blog, the predicament was compounded by the ways in which Boeing had and hadn’t tweaked the plane through its various iterations—shrinking the size of the cranks, adding augmentations but never moving to a full fly-by-wire electronic flight control system, introducing a somewhat questionable function called “speed trim” in the ’80s that paved the way for MCAS, consolidating certain controls on the MAX, and all the while purging a lot of pertinent information from the official 737 literature over the years.

    Representative Angie Craig, D-Minnesota, talks with Paul Njoroge (right) and Michael Stumo, who both lost family members in the crash of Ethiopian Airlines Flight 302, at a hearing of the House Transportation and Infrastructure Subcommittee on Aviation. Tom Williams/CQ Roll Call/Getty

    The upshot was that Boeing had not only outfitted the MAX with a deadly piece of software; it had also taken the additional step of instructing pilots to respond to an erroneous activation of the software by literally attempting the impossible. MCAS alone had taken twelve minutes to down Lion Air 610; in the Ethiopian crash, the MCAS software, overridden by pilots hitting the cutout switches as per Boeing’s instructions, had cut that time line in half. Lemme had seen a lot of stupidity from his old employer over the years, but he found this whole mess “frankly stunning.”


    Lemme was on the brink of going public with his analysis of the manual crank fail when a federal agent showed up at his door with a subpoena demanding all his electronic correspondence. He was dumbfounded that the feds wanted talk to someone who hadn’t worked at Boeing in 22 years, and a little concerned that the criminal probe would “chill the open dialogue” he considered foundational to a functional safety culture, but he chose to take it all as a positive sign authorities were casting an “unusually wide net” in their hunt for the perpetrators of MCAS and the deadly obfuscation surrounding it. Lemme called Dominic Gates at The Seattle Times and posted his analysis the next day, tweeting for context a link to the Mentour Pilot video, in which he and a co-pilot use the full force of their bodies to move the crank about a degree or two before turning off the camera. It was a sanitized but still deeply unnerving reenactment of what the Ethiopian pilots experienced.


    “There was this micro tidal wave of people coming forward because they felt it was safe to come out of the woods,” remembered Dennis Tajer, spokesman for the American Airlines pilots’ union, of the weeks following the Ethiopian crash, when pilots and engineers alike shed their qualms and unloaded on the company whose “toxic culture of fear and intimidation” they blamed for the crash. But the fear and intimidation would start to surface again: Mentour Pilot took down his video, explaining in a livestream that he shouldn’t have taken such liberties amid an “ongoing investigation.”


    But the bigger picture was becoming clearer: Boeing had manufactured a self-hijacking plane, and in a display of grotesque cowardice, it had chosen to disseminate to pilots a checklist for counteracting the self-destruct mechanism that had killed them even faster. The Seattle Times deemed it “a nightmarish outcome for Boeing and the FAA.”


    But as the nightmare drags on, the clarity of things has dimmed a bit. We have learned that there were other problems with the MAX—esoteric and exponentially less comprehensible than the MCAS nosedives—as well as problems that dated back to earlier generations of corner-cutting, but troubles that the company and the agency are genuinely trying to fix. We have learned that the FAA certified the plane despite its professed belief that the plane “does not meet” its own safety standards due to the elevated possibility of one of its massive new engines destroying the single set of cables controlling the rudder, if it were to break apart in midair. (The FAA is not mandating repairs to the cables.)


    We have also learned that no one at FAA wanted to work on the MAX certification—to the point that one of the engineers who did take a job on the effort told The New York Times he joked that he was high on drugs when he agreed to the assignment. We have learned that Indian coders engineered much of the software powering the MAX in offshore coding sweatshops as part of a campaign to make inroads in Airbus-dominated India, where one airline proceeded to order $22 billion worth of Boeing jets in 2017. We have learned as well that Patrick Shanahan, the former Boeing executive and acting defense secretary whom President Trump nominated and then withdrew from consideration for the job, probably hit his ex-wife.


    But, as it generally goes when a corporate malefactor is caught doing something wrong, we have also unlearned some things about Boeing and the MAX. Starting almost immediately after the Ethiopian crash, Daniel Elwell and Sam Graves, respectively the then-acting FAA chief and the ranking Republican on the House Transportation and Infrastructure Committee, led a coordinated campaign to blame the dead pilots for crashing the planes. The crux of their argument was that there was nothing to see here—that correct execution of the runaway stabilizer checklist would have saved all 346 lives, and that the real scandal behind the two crashes was a regime of lax foreign pilot training standards. Graves proceeded, in the storied tradition of congressional grandstanding, to call for the Department of Transportation to launch an investigation into this manifest nonissue.


    The pilot errorists took their primary talking points from a blog post titled “The Boeing 737 Max 8 Crashes: The Case for Pilot Error,” written by two pilots and published on a site called Seeking Alpha. According to The Seattle Times, the post in question had been commissioned by one of Boeing’s institutional shareholders; and the error-narrative picked up additional bursts of momentum by aggregating random little scooplets turned up in the media’s voracious focus on the MAX soap opera. The Wall Street Journal, in particular, homed in laserlike on matters of pilot behavior—even managing to transform the impossibility of manual flight under the conditions of the Ethiopian crash into a story about the FAA’s new concern that “female” pilots might lack the physical strength to fly the old-fashioned way.

    Another mark of a tyrant is that he likes foreigners better than citizens, and lives with them and invites them to his table; for the one are enemies, but the Others enter into no rivalry with him. - Aristotle's Politics Book 5 Part 11

  27. #24
    What had been a tidy fable about good and greed, up there with OxyContin and the Ford Pinto, one of the simplest ever told about the perils of following orders from investor-managers, was gradually dissolving into incoherence and uncertainty. Planes piled up in Victorville, California, where an out-of-the-way airport charges $2,000 a month to park a plane in the bone-dry Inland Empire’s corrosion-proof desert. Graves went on Fox News or Fox Business every few days, and he insisted in one representative appearance, “It’s not the plane I’m concerned about; I think the plane is very safe. We need to concentrate on the pilot ... being trained [for] the aircraft, and being able to fly a plane and not just fly the computer.”


    The House Aviation Subcommittee held regular hearings. The lawmakers on Graves’s side of the aisle showed up ready for information war, and the panel’s majority members were best embodied by subcommittee Chairman Rick Larsen, an ex-lobbyist New Democrat who delivered an opening statement of head-scratching insipidness: “As I have said before, if the public does not feel safe about flying then they won’t fly; if they don’t fly, airlines don’t need to buy airplanes; if they don’t need to buy airplanes, then airplanes don’t need to be built; and if there is no need to build airplanes, then there will be no jobs in aviation.”


    The Republican minority was spearheaded by Graves’s colleague Paul Mitchell, a two-term congressman from Michigan who sharpened his knives and summoned all his righteous indignation for a showdown with Dan Carey, the outgoing president of the Allied Pilots Association, the American Airlines pilots’ union:


    Captain Carey, you made more than a few headlines by releasing portions of an apparently secret recording made in November.... Who made that recording, sir?


    Did the APA board of directors authorize that or know in advance you were making the recording? Did you tell Boeing officials that you were making that recording prior to the meeting or subsequent to that?... Are you aware that—I’m sure you are—in April you issued a press release fully confident in the 737 MAX’s capabilities?


    What’s the value [of releasing a secret recording] to the system or the families?... Explain to me what warranted that, sir!


    Carey had, in fact, recorded a meeting seven months earlier with Boeing executive Mike Sinnett—the now-infamous gathering at which Sinnett had falsely assured pilots that a failure of the MCAS was a near zero probability event, and that in any case an MCAS breakdown would never happen in the United States, because most airlines had paid extra to activate their “AOA Disagree” lights on the cockpits. Boeing had a history of deflecting blame on to dead pilots, even back in the pre-Stonecipher era, when a malfunctioning rudder on an earlier generation of 737s caused a string of crashes and near-misses in the 1990s, while Boeing and its surrogates promulgated a range of alternative theories about pilots inexplicably (or intentionally) jamming the controls.


    Carey could feel the MCAS story veering into similar territory, so he recorded the meeting in case another once-in-a-lifetime MCAS fail occurred—as it indeed did. Had you wandered into the congressional hearing without knowing an extra 157 people were now dead as a result, you’d have assumed Dan Carey, a pilot and labor leader whose small effort to check the power of a corporate behemoth had been rewarded with a lost reelection campaign two weeks earlier, was in fact the most unscrupulous character in the whole sordid affair. (His interrogator, Mitchell, for the record, is a probable centimillionaire who made his fortune selling a chain of predatory for-profit junior colleges to a private-equity firm and his political reputation challenging Rick Snyder, Michigan’s water-poisoning, austerity-besotted governor from the right.)


    I was sitting in the room as this happened, my first time in the Rayburn building since the immediate aftermath of the 2008 financial crisis, and I am almost embarrassed to report how painful it was to listen to Mitchell and company shamelessly gaslight everyone, just as Congress’s hard-right true believers had done when they fingered ACORN as the perpetrator of the 2008 meltdown, or Iraq as a key culprit in 9/11 before that. Men like these had told far bigger lies for far bigger and scarier clients to far more destructive ends. And far more successfully: Regardless of what happens in the criminal case, there have been more than 60 lawsuits filed against Boeing over the MAX. No one who knows anything about anything believes Boeing is anywhere close to being out of the woods, and some who know a lot think the road ahead could lead to bankruptcy court.


    But it’s also true that no one who knew anything about anything thought it was a good idea to slash research and development spending, lay off half the engineers, or subcontract whole chunks of a plane without designing it first. It hardly mattered. “It was two camps of managers, the Boeing Boy Scouts and the ‘hunter killer assassins,’” remembered Cynthia Cole, a former Boeing engineer who led the Society of Professional Engineering Employees in Aerospace (SPEEA) during the 787 saga. “How do you merge those two management philosophies? The hunter killer assassins will destroy the Boy Scouts. That’s what happens.” 


    That’s what happened on an exponentially more ruinous scale in mortgage lending and pharmaceutical sales and at General Electric, which over the past decade has spent more than $50 billion buying back its own stock even as its staggering insurance business losses threaten to bankrupt the company. (And none of this has diminished GE’s zeal for deindustrialization, which has disemboweled places like Fort Wayne and Erie and Schenectady and put tens of thousands of people out of work, both permanently and on furlough.) It’s what happens to every well-intentioned half-measure to mitigate the catastrophic effects of climate change. 


    None of these things had to be ideological wars, said Cole, a lifelong conservative who now chairs the King County Republican Party in Washington state and first joined the union—membership in SPEEA had been voluntary when she joined—because not a few months into her first engineering job she had watched a space shuttle land in a control room full of engineers who had built the shuttle. The shuttle bounced, there was a massive collective intake of air, and one of her colleagues let it slip that the landing gear wasn’t strong enough to withstand certain weather conditions, and that if she wanted to keep her job she’d keep her mouth shut about it; she was laid off a few months later. “I thought to myself, oh my gosh! This happens in the movies.”


    She had no idea then how sick she would get of watching the same movie.


    But a month later, back in the same room on a biblically hot day, a son of Kenyan farmers restored a bit of moral clarity to proceedings: “As an investment professional, allow me to inform Congress as to how Boeing has viewed this whole crisis.” Noting that the stock had surged from $140 four years earlier to $446 right before the crash that had killed his wife, and his son, four-year-old daughter, nine-month-old daughter, and mother-in-law, Paul Njoroge laid out the sequence of 737 MAX orders, ten-figure stock buybacks, and dividend hikes that had dealt out this horrible fate to his family.


    “One hundred and eighty-nine lives were lost, and executives at Boeing cared more about its stock price than preventing such a tragedy from occurring again.”

    “Could that be the reason Boeing did not feel obliged to ground the MAX even after the second crash of the Boeing 737 MAX?” he asked. “Back to my very essential question, why wasn’t the MAX 8 grounded in November after the first crash in the Java Sea? One hundred and eighty-nine lives were lost, and executives at Boeing cared more about its stock price than preventing such a tragedy from occurring again,” and so had begun “a pattern of behavior blaming innocent pilots.”


    “I am empty,” he told the committee. “My life has no meaning.” He had met his wife studying finance at the University of Nairobi. The family had been spread across Bermuda, where Paul worked as an investment manager at Butterfield Bank, and Ontario, where his wife and children were settling down. Paul was expected to join them later. The distance had been hell, and he had never even had a girlfriend before her; his family was literally everything, he explained, and every single one of them was gone. “I have nightmares about how they must have clung to their mother, crying, seeing the fright in their eyes as they sat there helplessly. It is difficult for me to think of anything but the horror they must have felt.”


    After his testimony, a dead-eyed Njoroge stood in the hallway for nearly three hours, granting interviews to the dozens of journalists who needed exclusive footage to anchor their packages. He told me he wasn’t surprised that Boeing’s stock hadn’t suffered more since the company had killed his family. He would never buy it himself, of course, but even now it would be hard to justify leaving it out of a client’s portfolio.
    Another mark of a tyrant is that he likes foreigners better than citizens, and lives with them and invites them to his table; for the one are enemies, but the Others enter into no rivalry with him. - Aristotle's Politics Book 5 Part 11



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  29. #25
    I refuse to become a redundant meat sack while a self driving car drives me around.
    "Perhaps one of the most important accomplishments of my administration is minding my own business."

    Calvin Coolidge

  30. #26
    Ya, Boeing screwed up big time. But I hope I would not have reacted the way those 4 pilots did. And I do think we have better pilots in the US than most other places. So chances are the faulty AOA vane on the 737 Max would not have resulted in crashes here.
    Pfizer Macht Frei!

    Openly Straight Man, Danke, Awarded Top Rated Influencer. Community Standards Enforcer.


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  31. #27
    Quote Originally Posted by Danke View Post
    Ya, Boeing screwed up big time. But I hope I would not have reacted the way those 4 pilots did. And I do think we have better pilots in the US than most other places. So chances are the faulty AOA vane on the 737 Max would not have resulted in crashes here.
    This baffles me to no end, and we've had some serious marine incidents that were very similar:

    It was the best move of the morning and seems to have been based on a rule of thumb that if you do something in a cockpit and are rewarded by some unwanted event, do not waste time wondering what the connection is — undo that something you just did.
    But yet, he went right back to attempting to engage the autopilot and raise flaps, putting himself right back into the same fire.

    You have runaway controls that threaten the airworthiness of the plane (or seaworthiness of the vessel) when engaging "X", you have no idea why "X" is behaving this way, then keep your goddam meat nuggets away from "X", take manual control, slow down, declare an emergency and get back down.
    Another mark of a tyrant is that he likes foreigners better than citizens, and lives with them and invites them to his table; for the one are enemies, but the Others enter into no rivalry with him. - Aristotle's Politics Book 5 Part 11

  32. #28


    • Airline went into records after Max crash, engineer says


      ,Associated PressOctober 7, 2019














      1 / 9
      Boeing Plane Ethiopian Whistleblower

      In this photo taken Monday, Sept. 23, 2019, Yonas Yeshanew, who resigned as Ethiopian Airline's chief engineer this summer and is seeking asylum in the U.S., listens to a reporter's question during an interview in Seattle area. Yeshanew says in a whistleblower complaint filed with regulators that the carrier went into the maintenance records on a Boeing 737 Max jet a day after it crashed this year, a breach he contends was part of a pattern of corruption that included fabricating documents, signing off on shoddy repairs and even beating those who got out of line. (AP Photo/Elaine Thompson)



      SEATTLE (AP) — Ethiopian Airlines' former chief engineer says in a whistleblower complaint filed with regulators that the carrier went into the maintenance records on a Boeing 737 Max jet a day after it crashed this year, a breach he contends was part of a pattern of corruption that included fabricating documents, signing off on shoddy repairs and even beating those who got out of line.

      Yonas Yeshanew, who resigned this summer and is seeking asylum in the U.S., said that while it is unclear what, if anything, in the records was altered, the decision to go into them at all when they should have been sealed reflects a government-owned airline with few boundaries and plenty to hide.

      "The brutal fact shall be exposed ... Ethiopian Airlines is pursuing the vision of expansion, growth and profitability by compromising safety," Yeshanew said in his report, which he gave to The Associated Press after sending it last month to the U.S. Federal Aviation Administration and other international air safety agencies.

      Yeshanew's criticism of Ethiopian's maintenance practices, backed by three other former employees who spoke to AP, makes him the latest voice urging investigators to take a closer look at potential human factors in the Max saga and not just focus on Boeing's faulty anti-stall system, which has been blamed in two crashes in four months.

      It's not a coincidence, he said, that Ethiopian saw one of its Max planes go down when many other airlines that fly the plane suffered no such tragedy.

      Ethiopian Airlines portrayed Yeshanew as a disgruntled former employee and categorically denied his allegations, which paint a blistering counterpoint to the perception of the airline as one of Africa's most successful companies and a source of national pride.
      Yeshanew alleged in his report and interviews with AP that Ethiopian is growing too fast and struggling to keep planes in the air now that it is carrying 11 million passengers a year, four times what it was handling a decade ago, including flights to Los Angeles, Chicago, Washington and Newark, New Jersey. He said mechanics are overworked and pressed to take shortcuts to get planes cleared for takeoff, while pilots are flying on too little rest and not enough training.

      And he produced an FAA audit from three years ago that found, among dozens of other problems, that nearly all of the 82 mechanics, inspectors and supervisors whose files were reviewed lacked the minimum requirements for doing their jobs.
      Yeshanew included emails showing he urged top executives for years to end a practice at the airline of signing off on maintenance and repair jobs that he asserts were done incompletely, incorrectly or not at all. He said he stepped up his efforts following the Oct. 29, 2018, crash of a Lion Air Boeing 737 Max in Indonesia that killed all 189 people on board. One email Yeshanew sent to CEO Tewolde Gebremariam urged him to "personally intervene" to stop mechanics from falsifying records.
      Those pleas were ignored, he said. And after the March 10, 2019, nosedive crash of an Ethiopian Boeing 737 Max outside Addis Ababa that killed all 157 people on board, Yeshanew said it was clear the mindset had not changed.

      Yeshanew said in an interview that on the day after the crash, Ethiopian's Chief Operating Officer Mesfin Tasew openly agonized that the airline could get blamed because of its maintenance "issues" and "violations," and he ordered that records on the downed Max plane be checked for "mistakes."

      "We pray to God that this will not point to our fault," Yeshanew quoted the COO as saying.
      That same day, Yeshanew said in his report, someone logged into the computerized maintenance record-keeping system, specifically on the records from the downed plane that detailed a flight-control problem — "a roll to the right" — that pilots had reported three months earlier. Yeshanew included in his report a screenshot of a directory of the records related to the problem that showed a final entry that was time-stamped March 11.

      Yeshanew said he didn't know what was in the records previously or if they were changed, only that the records were left to say that tests had been done and the issue had been resolved. While he doubted that the flight-control problem brought the plane down, he said any changes to the records would call into question the actual condition of the airplane at the time of the crash as well as the integrity of the airline as a whole.

      Aviation experts say that after a crash, maintenance records — specifically, log books and task cards containing notes by pilots and fixes by mechanics — are required by international air safety regulators to be immediately sealed off, and any attempt to manipulate them is a serious violation tantamount to trampling on a crime scene.

      "If there is an accusation that you went into records, it means you're hiding something, you have something to hide," said John Goglia, a former member of the U.S. National Transportation Safety Board and an expert in aircraft maintenance.

      In its response to AP, Ethiopian denied a history of tampering and shoddy maintenance, and denied its COO or anyone else ordered someone to change the maintenance records on the downed 737 Max. It said that as soon as the accident happened, those documents were sealed, stored in a secure place and delivered to Ethiopia's Aircraft Accident Investigation Bureau. It added that while "a technician tried to see the aircraft records," its review found no data was changed or updated.

      Ethiopian is Africa's biggest airline, is profitable and is one of only a few on the continent that have passed the tests necessary to allow their planes to fly into Europe and North America, with a relatively good safety record.

      The company confirmed Yeshanew served as director of aircraft engineering and planning but said he was demoted because of a "serious weaknesses in leadership, discipline and poor integrity."

      "He is a disgruntled ex-employee who fabricated a false story about Ethiopian Airlines, partly to revenge for his demotion while working in Ethiopian, and partly to probably develop a case to secure asylum in the USA," the airline said in an email to AP. "We would like to confirm once more that all his allegations are false and baseless."

      Yeshanew and his attorney, Darryl Levitt, said that he was never demoted and, in fact, his steady rise through the ranks over a 12-year career at Ethiopian continued even into this year when he was tapped to oversee a new venture making aircraft parts and investigate two pilots who botched a landing in Uganda and nearly skidded into Lake Victoria. Yeshanew said his recommendations after that incident — fewer inexperienced pilots in cockpits and better training — went unheeded.
      Yeshanew also attached internal emails to the report that he contends show faulty paperwork and repairs, and investigations from parts suppliers that point to similar errors, including ones that led to two cockpit windows shattering in flight, a de-icing mechanism burning, and missing or incorrect bolts on key sensors.

      "I personally saw that many task cards are signed without even doing what is written in the instruction," Yeshanew wrote to COO Tasew in 2017. "Such violations may even result in a serious safety issue."

      Others have made similar claims. In 2015, an anonymous employee told an FAA safety hotline that mechanics often cleared planes for takeoff with "unresolved" mechanical issues. It was unclear if the complaint led to any action by the FAA or the airline.
      Three other former Ethiopian employees made such allegations to AP, including one who provided documents that he said show faulty repairs and paperwork errors stretching back years, and another who said mechanics felt they had no choice but to "pencil whip it" — industry jargon for signing off on repairs never done.

      "They would actually lie about it," said Franz Rasmussen, who flew for the airline for two years before leaving in 2016. "There was a philosophy: You can't ground an airplane — it's go, go, go."

      Among the allegations in Yeshanew's report is that Ethiopian maintains a jail-like detention center on the grounds of its Addis Ababa headquarters that it used to interrogate, intimidate and sometimes beat up employees who got out of line. Yeshanew said he knows of at least two mechanics beaten up in the past three years after falling out of favor with the company, and he feared the same fate awaited him.

      Yeshanew said in the report and later interviews with AP that he was taken to the single-story, dirt-floored detention center in July on suspicion he was talking to news organizations, and after 10 hours of questioning was told he would be thrown into jail "like all the other persons before" him if he didn't keep quiet. He took that as a threat of torture.

      "If you are in jail, it means you'll be beaten, you will be tortured," he told AP. "There is no difference in the current political system of Ethiopia."

      Four days later, Yeshanew fled to the U.S. with this wife and two children and settled in the Seattle area.
      A former spokesman for the airline union, Bekele Dumecha, told AP that he met with more than a dozen workers over six years who had been beaten at the same detention center, including one of the alleged victims identified by Yeshanew. Dumecha said he saw that person an hour after he was released, bruised and staggering.

      "He couldn't walk properly," said Dumecha, who is now living in Minnesota and also seeking asylum. "He was mentally and physically destroyed."

      Human Rights Watch said in an April report that torture in jails and "unmarked detention centers" have long been a "serious and underreported problem" in Ethiopia, and its former researcher there said he personally interviewed three airline workers who alleged they were tortured by the government, the most recent three years ago.

      "It was all about ensuring the positive image of the company and the country is kept intact," said HRW researcher Felix Horne. "Many people who tried to speak out against government-controlled companies were inevitably thrown in prison and beaten up."
      In its statement, Ethiopian Airlines denied that a detention center for torture exists and offered to show an AP reporter around the grounds. But after AP sought such a tour this past week, Ethiopian officials said it would take several weeks to arrange.

      Yeshanew's allegations are the latest to cast a light on factors other than what has become the overriding focus of the Max crash investigations — a system on the plane called MCAS, for Maneuvering Characteristics Augmentation System, that automatically pushes the plane's nose down when it is at risk of stalling.

      Preliminary reports indicate it misfired in both fatal crashes, with pilots losing control of the planes as they fought against it. Regulators have grounded nearly 400 737 Max planes while Boeing tries to fix the problem.

      Another whistleblower from Ethiopian, veteran pilot Bernd Kai von Hoesslin, told the AP in May that after Indonesia's Lion Air crash, he pleaded with Ethiopian's top executives to give pilots better training on the Max, predicting that if pilots are not sufficiently drilled on Boeing's protocols for how to disable the autopilot system in the event of a misfire, "it will be a crash for sure."

      Ethiopian has said the pilots followed all the steps Boeing laid out. But the preliminary report on the crash showed they deviated from the directives and made other mistakes, notably flying the plane at an unusually high speed and inexplicably reactivating the anti-stall system shortly after manually overriding it. Six minutes into the Max flight, the plane with passengers from nearly a dozen countries cratered into the ground about 40 miles from the airport.

      For the 39-year-old Yeshanew, the decision to become a whistleblower has come at a heavy price. He is leaving behind relatives and a job that he called "the dream of my life," one with prestige and a big enough salary for him to buy a three-story house. He is not sure of what kind of job he can get in the U.S., or if he will even be granted asylum.

      Ultimately, he said, he has dreams of returning to his native Ethiopia and even going back to work at Ethiopian Airlines.
      "I have to reveal the truth, the reality to the world, so that the airline will be fixed," he said, "because it can't continue like what it is doing now."

























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  33. #29
    Boeing Pilots Detected 737 Max Flight Control Glitch 2 Years Before Deadly Crash
    October 18, 2019

    New evidence indicates that Boeing pilots knew about "egregious" problems with the 737 Max airplane three years ago, but federal regulators were not told about them.

    Investigators say the plane's new flight control system, called MCAS, is at least partially to blame for 737 Max crashes in Indonesia in 2018 and Ethiopia this year that killed 346 people. Acting on data from a single, faulty angle-of-attack sensor, MCAS repeatedly forced both planes into nosedives as the pilots struggled, but failed to regain control.

    The pilots in the Lion Air plane that crashed in Indonesia last October did not know MCAS existed, as Boeing did not disclose any information about it in pilot manuals or in training material.

    Newly revealed instant messages sent between Boeing's then-chief technical pilot for the 737, Mark Forkner, and another technical pilot, Patrik Gustavsson, in November 2016 indicate that Forkner experienced similar problems with MCAS during a test session in a flight simulator.

    In a transcript obtained by NPR, Forkner writes that "there are still some real fundamental issues" with the system that he says Boeing engineers and test pilots "claim that they are aware of."

    As the two pilots banter back and forth in the messages, Forkner says the system is "running rampant in the sim on me," then adding, "I'm leveling off at like 4000 ft, 230 knots and the plane is trimming itself like crazy."

    Forkner calls the problem "egregious" and writes that he had "basically lied to the regulators (unknowingly)" before experiencing the glitch, when he had told the FAA that MCAS was safe and did not need to be included in pilot manuals.

    Later emails, also newly disclosed, show Forkner still telling the FAA that MCAS didn't need to be covered in the manuals.
    ...
    More: https://www.npr.org/2019/10/18/77145...ore-deadly-cra
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