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Posted

Just watched it on Netflix. Often times documentaries make things look worse than they are but this one got it mostly right. It documents the 737Max tragedy and Boeing's culpability in the  scandal. I have to say as a former LCA on the 737NG, I was a little skeptical, but as I learned more about MCAS and how it worked, I thought back then, "what the hey were they thinking". Now after watching this, it is much worse than I thought. There was real hubris and active deceit proven by documents. They have cockpit simulations as well as MS flight simulator visuals of both crashes which had me cursing out loud at the speed and deadliness of MCAS. Added to maniacal side of MCAS is that it was a single sensor system. One thing they failed to mention was the effect of the stab trim brake in conjunction with MCAS but that would have complicated the explanation without really changing the outcome.

It also documented the change in corporate culture at Boeing after the MD merger and I noticed that as well on some aircraft deliveries in which I participated. Boeing was always very meticulous in delivering a good airplane, then all of the sudden it was "take it, we'll pay you to fix it". One in particular resulted in coming home with a check still in my briefcase and no airplane. I knew Boeing was toast when 777 Program manager Phil Condit took over as CEO ( then he engineered the MD merger). The management coup de grace was Dennis Muilenburg who presided over the whole Max coverup was fired with a 62 million dollar parachute.

 

  • Like 6
Posted
2 hours ago, GeeBee said:

Just watched it 

I saw it advertised,  and I passed it by. I knew it would make me upset regardless of how slanted I felt the show was, or wasn't. 

  • Like 1
Posted

This thing has been coming for a long time. I note that when the MD-90 was certified it had a full authority hydraulic elevator, the DC-9/MD-80 used control tabs. A change in the motive force for the flight controls should require a new TCDS. The FAA let it slide because MD was broke. In addition, to my knowledge, no one has successfully landed an MD-80 or 90 in standby rudder. Everyone who has done it including the FAA test pilot went off the side of the runway. The FAA let it slide because the test pilot blamed his technique.

If there is any good that came out of the Max debacle is a more sober view of aircraft certification. As pilots, that helps us.

 

 

  • Like 3
Posted

My wife and I just watched it a couple days ago, I thought it was well done. 

43 minutes ago, Mcstealth said:

I saw it advertised,  and I passed it by. I knew it would make me upset regardless of how slanted I felt the show was, or wasn't. 

Yes, it was very upsetting.

  • Like 1
Posted

FWIW, American Greed did a whole episode on Boeing as well and covered much of the same stuff.

My exposure to the old Boeing was when I worked at Honeywell Air Transport developing the original avionics for the 777.   The professional engineering culture from Boeing and focus on quality and safety was very, very good.   The Boeing requirements flowed down into how we did the avionics with redundancy, formal verification techniques (which were very stringent), etc., etc.

I thought there was going to be trouble when the MD merger happened and they moved the HQ to Chicago.   That was the final stake in the removal of the soul of the old Boeing.

When the 737 Max crashes happened and it was starting to come out that there was reliance on a single sensor for a critical system I was thinking that that couldn't happen unless there had been a total paradigm shift in how Boeing did engineering, which I thought was unlikely.    Unfortunately, it was true, and there had been a total shift at Boeing which led to the issues.

It used to be "If it's not Boeing I'm not going", but over the years it became "If it's Boeing, I'm not going."    Sadly the transition has happened over such a long time that the former methodologies are long fogotten and buried.   It would take another decade or so to really get back to where they were if they really wanted to, but it doesn't appear that they want to.

 

  • Like 1
Posted

I’m looking forward to catching up…

There are several (not just) American Engineering disaster stories…

That have come out over the decades…

This is probably the most recent…

Engineering disaster… because there is an engineering person on the inside that knew what could happen… and wasn’t able to stand up and be heard….

 

Automotive companies are famous for these…

Ford flaming Pinto, Chevy side saddle fuel tank pick-up, Audi unintended acceleration 5000, GM ignition switches that wear easily, drop the key, turn off the engine, and airbag system, while the PIC becomes a passenger to the whole thing at highway speeds…

Boeing did it with Panache!  Training for a single sensor system… naaah… training costs too much…

Thanks for the reviews!

Best regards,

-a-

Posted (edited)
5 hours ago, carusoam said:

Engineering disaster… because there is an engineering person on the inside that knew what could happen… and wasn’t able to stand up and be heard….

Oh, he was heard, they just wrote him off as a nut job and not a team player! He didn't have the right vision of the project.

Edited by N201MKTurbo
  • Like 1
Posted
3 hours ago, N201MKTurbo said:

Oh, he was heard, they just wrote him off as a nut job and not a team player! He didn't have the right vision of the project.

The Challenger disaster was that way.   Engineering said do not launch, management said we need to make schedule.

Posted
4 minutes ago, EricJ said:

The Challenger disaster was that way.   Engineering said do not launch, management said we need to make schedule.

The museum in McMinnville OR has a set of SRB cases laying in a field behind the parking lot. Most people just figure they are some kind of sewer pipes. They still had the O-Rings on them. You can even touch them. 

  • Like 1
Posted
28 minutes ago, Eight8Victor said:

There needs to be a documentary made about big pharma. 
 

Do you have something specific in mind?

is there an engineering disaster in a pharma company?

 

Each pharma company looks like an engineering disaster on the inside…. :)
 

Or is the name big pharma incriminating enough?

One of the biggest opioid producers was a family owned company… not very big in terms of pharma…

 

note: the meds I use that allow me to fly…. They are made by companies that get captured in the big pharma cohort…

 

Big pharma has nice helicopters and a few jets…. And a few pilots on their payroll…

 

we might be drifting a bit off the aviation topic…

My fault… :)

-a-

Posted

There are at least three major documentaries on the Max and Boeing's strive to improve the bottom line. Interestingly, all three are in complete agreement with each other.

  • Like 1
Posted

I saw the documentary and thought it was fact-based.  If I understand the documentary right, Boeing initially intended for the "fix" to be some additional lines of code in the MCAS program.  Did the final fix include addition of one or more redundant AOA sensors? 

Posted
19 hours ago, Fly Boomer said:

I can't attest to the facts, but made-for-TV "documentaries" are created for profit by businesses.

How else do documentaries get made?

I only get to see the ones that are made by businesses…

Not all profitable documentaries are lies….

Any idea how much profit there is in documentaries about business mistakes?

Should good documentarians not get paid?

If they get paid, is their work not as good?

 

wait a sec… see the documentary on the subject delivered by PBS above… Frontline is somehow related to PBS… and technically PBS is a not for profit company…

 

Even if all the news was posted on YouTube… I wouldn’t be able to find it all… or it would be buried in the fake news that comes with it… how would I know the difference?


Summary-ish of this thread….

1) Businesses are bad…

2) Big pharma is bad…

3) Boeing is a whole lot worse than expected….  They did have a halo for quite some time!   :)
 

 

4) How are we on GE?  The engine maker first, then the rest of the company….  Jack Welsh retired in a timely fashion….

 

5) wait a sec….   Isn’t it the GE LEAP (?) engines what caused the need for the MCAS system in the first place?

6) If the PBS presentation is correct….

a) single sensor system was the deadly one…

b) sensor wasn’t calibrated properly, and improperly activated the MCAS system… (pilots not able to be aware of the failure)

c) MCAS is a bit tricky to turn off… requiring two switches to be off….  A smart SIC was able to do this… (seconds of delay are important)

d) Manual trim took more power to operate than humanly available… given the time they had to do it… (speed, and load, and design)

e) MCAS turns back on by itself…. (End of story…)

The powered trim runs very quickly….

 

f) internal documents and emails are known to become public… write them as if they will become public… :)

g) there is plenty of slant given in the presentation….  There was a design problem, it wasn’t handled properly, then the cover story was near criminal….

h) As far as the engineering failure goes…. enough of the facts are public record that got shared by news outlets over time…. I hope I have them correctly laid out here …

 

For a long time… GE and Boeing were great companies for engineers…. They will be again some day…  :)

 

PP thoughts only, trying to understand as many details as possible….  :)
 

Runaway trim is a really important Mooney challenge…
 

Best regards,

-a-

  • Like 1
Posted
1 hour ago, Eight8Victor said:

Yes, but I would get a strike if I mentioned it here.

Probably have to go to PharmaSpace for that conversation… :)
 

There is an interesting internet board for everything…. The pharma ones are interesting… because pharma sales is really interesting…

 

Things have changed a lot over the last decade and more….

prior to that… sales people carried actual drug product in their cars… and handed them out to Dr.’s offices without a whole lot of accounting of who was giving and who was receiving…

A lot of assuming that people were doing the right thing…

A sales guy would set up a nice golf outing for the Dr…and friends… just to have a few minutes to push the agenda…

Things deteriorated to ‘paying’ the doctor with outings… for the sale of the product…. And the sales guy never showed…

 

Suddenly things changed… no free samples carried by sales people… no more free outings…. No cheesy flashlights with drug product logos on them…

 

Marketing ethics got redefined in short order…

Mostly because somebody produced an embarrassing exposé of how the aged system worked…

 

The FDA and FAA are very similar in how they work, and how they are structured…. EPA is also very similar…

 

The easy part… is pointing out the failures….

The hard part… knowing how to make improvements…. Then executing…. :)
 

Going into a factory under consent decree…. Is like running into a fire…. Be ready to work smartly!   
 

PP thoughts only, not a government genius…

Best regards,

-a-

Posted

Drug companies still give out free samples and you can rest assured that there is excellent accounting.

When I was a medical student my family medicine preceptor worked closely with one of the drug reps. One day he told me clinic was cancelled and we were going to drive around with the drug rep and visit various practices because the rep wasn’t allowed to talk about “off label” uses of a drug, but he was. The rep has listings of EVERY provider at every practice, which drugs they prescribed (their drugs or their competitor’s) and other statistics about each prescriber as well as a strategy for how to motivate the “stragglers.”

Fortunately, in my field we don’t really have to deal with them as they don’t waste their efforts on people who prescribe drugs with zero refills. Although I do miss my Levitra pen.

 

  • Haha 1
Posted

Boeing definitely screwed the pooch. 

But don't forget......the first accident happened after an airplane with a unreported deficiency was put in service.  Then, Boeing was essentially denied access to flight recorder data for a month.  They did distribute a bulletin after that accident regarding cockpit indications and procedures.  Ethiopia Air had received that bulletin.

During the Ethiopia accident the stick shaker went off - and the pilots changed the configuration of the airplane (retracted flaps) - this enabled the MCAS to behave badly.  Even then, all they had to do was use the electric trim button under their thumb - it overrides the trim commands which come from the autopilot.  You can even see it in the plots.

On the 737 the autopilot trim is about half the rate of manual electric trim.

I believe these to be facts. 

 

Posted (edited)
2 hours ago, skykrawler said:

all they had to do was use the electric trim button under their thumb - it overrides the trim commands which come from the autopilot.  You can even see it in the plots.

I believe these to be facts. 

I believe your correct, the real issue in my opinion is the abysmal understanding / training of complex aircraft systems, particularly flight control systems by Airline pilots in General, but more to the point places like Ethiopia etc the level of training and understanding is so bad they shouldn’t be flying people, but they are. The reliance on automation is scary.

Boeing should never have built an unstable aircraft and never resorted to electronic magic to fix it, to say nothing about a single sensor to drive the thing, but the bottom line is they did, and a pilot who was trained and understood what was going on would have saved the aircraft. But Boeing did, and the pilots had no idea what to do, so everyone died.

My training is Military, and there you had to have every emergency procedure memorized and every limitation memorized as well as being able to sit down and discuss each system down to the “I am a drop of hydraulic fluid level”. Before you say those aircraft weren’t as complex as Airliners you would be wrong, to say nothing of all the weapons systems limitations and employment etc.

There was none of this light is flashing, pull out the book and look up what that means and read me the procedure stuff.

The difference was the Military doesn’t have to turn a profit, then can spend millions of dollars on training per pilot yearly.

Since deregulation way back in the 70’s the Airlines have been slipping slowly to become the Greyhound bus, that along with the heavy reliance of automation and you end up with an airline crew that can stall an airplane all the way down from the flight levels and never figure out what’s wrong before impacting the Ocean and everyone dies.

Edited by A64Pilot
  • Like 1
Posted
3 hours ago, A64Pilot said:

I believe your correct, the real issue in my opinion is the abysmal understanding / training of complex aircraft systems, particularly flight control systems by Airline pilots in General, but more to the point places like Ethiopia etc the level of training and understanding is so bad they shouldn’t be flying people, but they are. The reliance on automation is scary.

Boeing should never have built an unstable aircraft and never resorted to electronic magic to fix it, to say nothing about a single sensor to drive the thing, but the bottom line is they did, and a pilot who was trained and understood what was going on would have saved the aircraft. But Boeing did, and the pilots had no idea what to do, so everyone died.

My training is Military, and there you had to have every emergency procedure memorized and every limitation memorized as well as being able to sit down and discuss each system down to the “I am a drop of hydraulic fluid level”. Before you say those aircraft weren’t as complex as Airliners you would be wrong, to say nothing of all the weapons systems limitations and employment etc.

There was none of this light is flashing, pull out the book and look up what that means and read me the procedure stuff.

The difference was the Military doesn’t have to turn a profit, then can spend millions of dollars on training per pilot yearly.

Since deregulation way back in the 70’s the Airlines have been slipping slowly to become the Greyhound bus, that along with the heavy reliance of automation and you end up with an airline crew that can stall an airplane all the way down from the flight levels and never figure out what’s wrong before impacting the Ocean and everyone dies.


i think the ire comes from…

In one case…

the pilots new the problem…

Turned off the MCAS… 

while hand trimming…

The MCAS came back on automatically… driving the nose further down…

 

What’s not really clear…

1) The developed world bought the same system….

2) But paid extra for the multi sensor add on…. Replete with error checking…

3) if the sensors of the more complex system are all mis calibrated the same way the crashed planes were… expect the same thing to happen… (?)

 

 

The real bummer…

1) The black box data wasn’t shared very openly… very slow to get data shared…

2) The sensors are reported as being calibrated incorrectly… not broken or somehow disabled…

3) the training that was needed/required/important was a maintenance procedure… 

4) the focus on the pilots not getting training…. (Great story, sells papers…)

5) The basic issue…  the single sensor can be miscalibrated

6) The pilots got handed a few things…

  • a sensor generating bad data… 
  • an MCAS system that turns itself back on…after being turned off.
  • a mechanical trim system that is hard to physically use… in the available time…

7) unclear if a multi sensor system can be mis calibrated the same systematic way…

 

The rabbit hole…

1) Selling machines into the developing world…

2) Lowest cost machinery in their ‘stripper’ models…

3) Trying to build the new planes to operate the same way as the old planes… missed the single sensor mis calibration…

4) Avoiding any additional expensive training… needs to be proven possible….

5) Systems training doesn’t always need full simulator training does it?  If I want to deactivate a bad AP… I just turn it off… a new to me AP may take a few minutes of Transition Training delivered via a zoom (or similar training available back in the day) meeting… PowerPoint and books always have worked…

 

Going forward…

1) technology can improve safety…

2) needs to be turned off after failure…

3) Plane needs to be flyable with the automation turned off…

4) Pre-flight is the procedure where all systems get checked for their readiness prior to flight occurring….

 

Final thought… (?)

1) How did a bad calibration of a single sensor system not get identified during the pre-flight?

2) What is different today to make this situation better?

 

PP thoughts only, not an automations engineer…

Best regards,

-a-

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