Lion Air pilots struggled against Boeing's 737 MAX flight-control system, black box data shows
Source: Seattle Times
A key instrument reading on Lion Air flight JT610 was faulty even as the pilots taxied out for takeoff. As soon as the Boeing 737 MAX was airborne, the captains control column began to shake as a stall warning.
And from the moment they retracted the wing flaps at about 3,000 feet, the two pilots struggled in a 10-minute tug of war against a new anti-stall flight-control system that relentlessly pushed the jets nose down 26 times before they lost control.
Though the pilots responded to each nose-down movement by pulling the nose up again, mysteriously they didnt do what the pilots on the previous days flight had done: simply switched off that flight-control system.
The detail is revealed in the black box flight-recorder data from the fatal Oct. 29 flight that killed 189 people and the prior days flight of the same jet, presented last Thursday to the Indonesian Parliament by the countrys National Transportation Safety Committee.
Read more: https://www.seattletimes.com/business/boeing-aerospace/black-box-data-reveals-lion-air-pilots-struggle-against-boeings-737-max-flight-control-system/
demsocialist
(202 posts)Just wondering why they didn't know the remedy??
cstanleytech
(26,282 posts)Those two are entirely a guess on my part though but regardless of the reason its still a tragedy.
RainCaster
(10,866 posts)This was a big screwup on Boeing's part.
groundloop
(11,518 posts)If pilots the day before had issues with the stall warning system the subsequent flight crew should have been given that information. And I'd chalk up their failure to turn that system off to lack of training.
Angleae
(4,482 posts)Stall warning is an automatic system (no "OFF" switch). You have to pull the circuit breakers and if you don't know where they are, it takes a while to find them, all while fighting the control column in the first place.
Major Nikon
(36,827 posts)So regardless of whatever changes Boeing made to this particular aircraft, the pilots should have known how and when to turn that system off.
Racerdog1
(808 posts)The previous flight, this same aircraft had issues. They supposedly had corrected the fault or thought they had. If the pilots checked the log, they would have known about the problem on the previous flight. As with all accidents, it is the details that get you in trouble.
SCVDem
(5,103 posts)The last great act of defiance!
Pilots need to understand the electronic/avionics system.
rickford66
(5,523 posts)If the sims out there are programmed correctly, this situation should occur if an AOA sensor fails. Unfortunately over the years we've seen many systems not fully simulated. These malfs are usually reproduced on a simulator soon after detected on an aircraft or in this case after the black box is recovered. This problem should be added to the training schedule if not already in it. Modern jets have so many sensors now that it's overwhelming to program each to fail. But a failed sensor should cause the sim to react exactly as the aircraft. Boeing knew about this bug, probably from their own simulator testing. Bugs like this are usually found well before boxes are certified. We used to find an occasional bug with Red Boxes (still in early testing) and Boeing would respond with their next s/w update. Some boxes have pins to set so the box "knows" it's in a simulator. This has been done in my experience when you can't simulate a sensor exactly as in the real world, cabin pressure for example. The customers decide what malfunctions they want, over and above those required by the FAA. After Russia shot down Korean Airlines back in the 80's, we had a couple requests to add it to their sims. Since there's no recovery from it, I put it down to sneaky flight instructors, but it was added to some. I'm up late and rambling on. I'm sorry the crew and passengers died for no reason, but others won't.
Eugene
(61,872 posts)Source: Washington Post
By Stanley Widianto, Ashley Halsey III and Aaron Gregg November 28 at 6:30 AM
JAKARTA, Indonesia A malfunctioning sensor and an automated response from the aircrafts software stymied pilots efforts to control a doomed Indonesian flight that went careening into the sea, according to a preliminary investigative report released Wednesday.
The report, which stops short of determining the cause of the crash or analyzing findings, chronicles the chaotic moments on the Lion Air flight before it crashed into the waters off the coast of Java last month, killing all 189 passengers and crew on board.
It details how sensors and other equipment were checked and fixed before the aircrafts final flight, but not the angle of attack sensor, which measures where the nose is pointing and was showing erroneous readings throughout the short time the plane was airborne.
With the sensor insisting the nose was too high, an automatic feature kicked in, sending the plane plummeting as the pilots wrestled to regain control. Unable to trust their readings, the pilots resorted to asking air traffic control what their speed and altitude were.
-snip-
Read more: https://www.washingtonpost.com/local/trafficandcommuting/report-on-airline-crash-that-killed-189-people-draws-few-conclusions/2018/11/27/a07b833c-f274-11e8-80d0-f7e1948d55f4_story.html
Eugene
(61,872 posts)Source: BBC
28 November 2018
Indonesian investigators have said the Lion Air plane that crashed last month killing 189 people was not airworthy and should have been grounded.
The Boeing 737 Max plane crashed into the Java Sea shortly after departing from Jakarta on 29 October.
A preliminary report has found technical problems had been reported on previous flights.
The 737 Max is a new version of Boeing's original 737 and has become its fastest selling plane.
-snip-
Read more: https://www.bbc.com/news/world-asia-46121127
turbinetree
(24,695 posts)The preliminary report into the Oct. 29 Lion Air flight 610 crash confirms that the pilots struggled with the automatic trim as it responded to faulty inputs, although they appear to have not activated the cut-out switch for this system.
The report by the Indonesian National Transportation Safety Committee details the maintenance timeline for the Boeing 737-8, which experienced similar issues on previous flights. It also outlines the sequence of events on the prior flight on Oct. 28, and flight data recorder [FDR] information and air-traffic control communications from the flight that crashed. All 189 passengers and crew were killed as the plane plunged into the sea shortly after takeoff from Jakarta.
While the report lists recommendations and actions that have already been taken, it also includes an additional recommendation related to pilot procedures. Boeing has issued a statement highlighting certain aspects of the report.
Before the prior flight on Oct. 28, the pilot discussed with the engineer the maintenance actions that had been performed including replacement of the AoA [angle of attack] sensor and had been tested accordingly, the report said. During this flight, the stick shaker activated during the rotation and remained active throughout the flight. The pilot noticed the IAS [indicated airspeed] disagree warning, and that the aircraft was automatically trimming aircraft nose down (AND).
After three automatic AND trim occurrences, the second-in-command (SIC) commented that the control column was too heavy to hold back, the report said. The pilot moved the STAB TRIM switches to CUT OUT and the SIC continued the flight with manual trim without auto-pilot until the end of the flight. Boeing introduced an automatic trim system known as the Maneuvering Characteristics Automation System on the 737 MAX.
After landing, the pilot informed the engineer about the problem and entered IAS and ALT disagree, and feel differential pressure, on the flight maintenance log. The engineer flushed the left pitot air data module (ADM) and static ADM to rectify the IAS and ALT disagree followed by an operations test on the ground, and was satisfied, the report said. The feel differential pressure was rectified by cleaning the electrical connector plug of the elevator feel computer. Tests on the ground found that the problem had been solved, the report said.
During the Oct. 29 flight, the FDR information showed a difference between left and right [AoA] of about 20 degrees and continued until the end of recording
during rotation the left control column stick shaker activated and continued for most of the flight. The FDR data also showed multiple attempts to manually trim up to counteract automatic trim down. The report does not indicate that the pilots cut out the automatic trim as the pilots on the previous flight had done.
While the cockpit voice recorder has not yet been located, records of communications with the ground show that the crew advised controllers of flight control problems and that they were flying the aircraft manually. The controller gave the crew a heading to return to the airport. The pilots also told the controller that the altitude of the aircraft could not be determined due to all aircraft instruments indicating different altitudes.
The last communications noted in the report started with the pilot asking the controller to block altitude 3,000 feet above and below for traffic avoidance. The controller then asked what altitude the pilot wanted, and the pilot responded with five thou. About 20 seconds later the FDR stopped recording, according to the report.
The report lists several actions, advisories and recommendations that have already been taken or issued by Lion Air, Indonesian authorities, the FAA, Boeing, and MRO provider Batam Aero Technic.
The committee acknowledges the safety actions taken by Lion Air since the crash and consider[s] that the safety actions were relevant to improve safety, however there still safety issues [that] remain to be considered.
One of these additional recommendations calls for Lion Air to ensure the implementation of a section of the operations manual that advises pilots to discontinue the flight when unairworthy mechanical, electrical, or structural conditions occur. The report notes the stick-shaker event on the prior Oct. 28 flight, and that this is considered as [an] un-airworthy condition and the flight [should] not be continued.
Another recommendation calls for better flight documentation since there was one more flight attendant on board than was listed on the weight and balance sheet.
In its statement released following the preliminary report, Boeing said it is taking every measure to fully understand all aspects of this accident, working closely with authorities.
Boeing noted that maintenance logs recorded problems related to airspeed and altitude on each of the four flights that occurred over the three days prior to Flight 610. The logs indicate that various maintenance procedures were performed, but issues related to airspeed and altitude continued on each successive flight.
The preliminary report does not include records as to the installation or calibration of the new [AoA] sensor, nor does the report indicate whether the sensor was new or refurbished, Boeing said.
Although the report states that the pilot on the Oct. 28 flight was satisfied by the information relayed by the engineer that the AOA sensor had been replaced and tested, during the flight the pilots again experienced problems with erroneous airspeed data, and also experienced automatic nose down trim.
Boeing highlights the fact that the pilots on the Oct. 28 flight turned off the stabilizer trim switches within minutes of experiencing the automatic nose down trim. They followed checklists as the appropriate procedure to address unintended horizontal stabilizer movement, regardless of source.
After landing, the pilot reported some of the issues both on the aircraft maintenance log and to engineering, Boeing said. The manufacturer also noted that the report states that the pilot ran the runaway stabilizer non-normal checklist, but it does not state that he communicated that fact in the maintenance documentation following that flight.
The report shows that shortly after taking off, the pilots on the Oct. 29 flight experienced issues with altitude and airspeed data that the pilots had previously experienced on the earlier flights, due to erroneous AoA data, Boeing said. However, unlike as is stated with respect to the prior flight, the report does not state whether the pilots performed the runaway stabilizer procedure or cut out the stabilizer trim switches.