Profits 1st, Safety 2nd? Pt 2

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Message 2016618 - Posted: 25 Oct 2019, 20:16:03 UTC - in response to Message 2016593.  
Last modified: 25 Oct 2019, 20:17:08 UTC

[...]
A series of failures led to the Lion Air tragedy.
"If one of the nine [failures] hadn't occurred, maybe the accident wouldn't have occurred."

For so many things to be so badly wrong, that strongly suggests that for Lion Air at least, their passengers have been flying on a "Wing and a Prayer"...

How much of that story is repeated for other airlines?

How much of that is by design by Boeing?


Note that 'corrupt non-maintenance' cannot be directly a Boeing fault but such scenarios can be a problem due to the design... For example in the world of electronics and computer systems, there are a lot of "self-test" systems used to improve reliability and to reduce trouble-shooting and maintenance costs.


All just my humble personal opinion as always...

All in our only one world,
Martin
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Message 2016650 - Posted: 25 Oct 2019, 22:26:03 UTC - in response to Message 2016617.  

Didn't Boeing tell the Airline, don't fly with a broken sensor?

Kind of like, don't operate without brakes.
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Message 2016651 - Posted: 25 Oct 2019, 22:31:11 UTC - in response to Message 2016618.  

How much of that story is repeated for other airlines?

99%. Just like bus companies who don't fix their equipment.

It is called deferred maintenance. Kills, airplanes, buses, chemical plants, etc.
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Message 2016688 - Posted: 26 Oct 2019, 8:43:05 UTC

Agreed, but you miss a key point.
The aircraft was fitted with TWO sensors, but was only using one of them. There was no cross checking by the aircraft that the two sensors were giving sensibly similar readings until sometime after take-off. And unlike our cars brakes the crew NOTHING about MCAS because Boeing hadn't told them, via the Boeing supplied training material, that MCAS existed.
The key thing is that the aircraft was fitted with two AoA sensors, but only used one of them at a time to feed into MCAS and didn't do any "sanity checking" of the output of the active sensor with the non-active one. Now that has nothing to do with the undoubtedly poor maintenance but every thing to do with the failure of the design processes used by Boeing and the assurance process by both Boeing and the FAA.
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Message 2016689 - Posted: 26 Oct 2019, 8:44:11 UTC

Commenting on the latest fire, Governor Gavin Newsom said on Friday that PG&E "simply did not do their job". He condemned "years and years of greed, years and years of mismanagement in the utilities".
The news sent share prices of PG&E tumbling on Friday, as investors feared the company might be held responsible for the Kincade Fire.
The company is already seeking bankruptcy protection as it faces lawsuits over last year's deadly Camp Fire. It was found to have been sparked by ageing equipment owned by PG&E.
Gotta love "profits 1st"
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Message 2016693 - Posted: 26 Oct 2019, 10:14:12 UTC - in response to Message 2016689.  

Commenting on the latest fire, Governor Gavin Newsom said on Friday that PG&E "simply did not do their job". He condemned "years and years of greed, years and years of mismanagement in the utilities".
The news sent share prices of PG&E tumbling on Friday, as investors feared the company might be held responsible for the Kincade Fire.
The company is already seeking bankruptcy protection as it faces lawsuits over last year's deadly Camp Fire. It was found to have been sparked by ageing equipment owned by PG&E.
Gotta love "profits 1st"
Private excess, public squalor.
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Message 2016719 - Posted: 26 Oct 2019, 14:23:45 UTC - in response to Message 2016688.  

Rob, which crash are you talking about? The other one I think. This one the FDR has bad readings as the plane taxied. When Boeing said don't fly unless working, why do you attempt to fly it?
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Message 2016721 - Posted: 26 Oct 2019, 14:28:55 UTC - in response to Message 2016719.  

Rob, which crash are you talking about? The other one I think. This one the FDR has bad readings as the plane taxied. When Boeing said don't fly unless working, why do you attempt to fly it?
Because it's expensive to taxi back to the hanger and offload the passengers.

And you don't assume that your choice is between expense and fatality.
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Message 2016726 - Posted: 26 Oct 2019, 14:57:36 UTC - in response to Message 2016721.  

Because it's expensive to taxi back to the hanger and offload the passengers.
Finally someone has stated the real cause, airline greed.
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Message 2016731 - Posted: 26 Oct 2019, 15:44:05 UTC - in response to Message 2016689.  

Commenting on the latest fire, Governor Gavin Newsom said on Friday that PG&E "simply did not do their job". He condemned "years and years of greed, years and years of mismanagement in the utilities".
The news sent share prices of PG&E tumbling on Friday, as investors feared the company might be held responsible for the Kincade Fire.
The company is already seeking bankruptcy protection as it faces lawsuits over last year's deadly Camp Fire. It was found to have been sparked by ageing equipment owned by PG&E.
Gotta love "profits 1st"

That is a silly statement concerning greed. The power companies are regulated public utilities. The public utility commision sets the rates based upon the costs and a "reasonable profit margin." If the costs go up due to maintenance they will be passed onto the consumers and not reduce the profits. At least the way it works in my state and I assume the same is true in California and everywhere else in this country.
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Message 2016742 - Posted: 26 Oct 2019, 17:22:25 UTC - in response to Message 2016726.  

Because it's expensive to taxi back to the hanger and offload the passengers.
Finally someone has stated the real cause, airline greed.
And you ignore the unwarranted assumption that Boeing will sell you a safe brand-new plane.
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Message 2016745 - Posted: 26 Oct 2019, 17:39:43 UTC - in response to Message 2016719.  

Lion air....
The thing is the aircraft was presented to the flight crew as being air-worthy, so the flight crew acted on the apparent safety of the aircraft. The flight crew do not see the "raw" FDR data in real-time, but they do get visual and audible warnings if they are available, and in the case of Lion Air 610 it would appear the appropriate warnings were not available to them for some reason or other.

The fact that the maintenance had not been undertaken correctly was a secondary cause of that crash. If that sensor had failed during the actual take-off the result would have been exactly the same. BOEING DID NOT DESIGN THE MCAS SYSTEM CORRECTLY IS THE PRIME CAUSE OF THE CRASH.

It is well worth reading the report and not just the summaries in the media - sections 3, 4 and 5 cover the conclusions & recommendations, and make very sorry reading. Perhaps one of the easiest parts to read is section 3.2 "Contributory Factors", nine are listed, only two of which are not "attributable" to Boeing.

Having "officially" received a copy of the report, I now have 14days to read and comment, plus produce some guidance derived from the underlying causes.
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Message 2016779 - Posted: 26 Oct 2019, 23:18:20 UTC - in response to Message 2016745.  

Lion air....
The thing is the aircraft was presented to the flight crew as being air-worthy, so the flight crew acted on the apparent safety of the aircraft. The flight crew do not see the "raw" FDR data in real-time, but they do get visual and audible warnings if they are available, and in the case of Lion Air 610 it would appear the appropriate warnings were not available to them for some reason or other.

The fact that the maintenance had not been undertaken correctly was a secondary cause of that crash. If that sensor had failed during the actual take-off the result would have been exactly the same. BOEING DID NOT DESIGN THE MCAS SYSTEM CORRECTLY IS THE PRIME CAUSE OF THE CRASH.

It is well worth reading the report and not just the summaries in the media - sections 3, 4 and 5 cover the conclusions & recommendations, and make very sorry reading. Perhaps one of the easiest parts to read is section 3.2 "Contributory Factors", nine are listed, only two of which are not "attributable" to Boeing.

Having "officially" received a copy of the report, I now have 14days to read and comment, plus produce some guidance derived from the underlying causes.

Boeing's first fault is saying do not fly if an AOA sensor is failed and not providing an easy method to test if they are operating. Per the report that sounds like a software bug. Seems the AOA disagree was supposed to be on all aircraft, but a bug only put it on aircraft if they ordered a AOA display function.

"If that sensor had failed during the actual take-off the result would have been exactly the same." If it was operating the result would have been a safe flight. However it was already failed. Report indicates it was installed in a failed condition and the post install test would have spotted it, a test which was required to be done.

Looks like there is a phrase that applies to all the human factors in this. Get-home-itis. Every one of the human failures seems to point to people who wanted to be done with their job and go home. Not willing to complete their task and make sure of the result. Maintenance, pilot training, air-frame design, certification, you name it. Good Enough for Government work.

"Perhaps one of the easiest parts to read is section 3.2 "Contributory Factors", nine are listed, only two of which are not "attributable" to Boeing.", I read 3.2 to say 1 through 5 as Boeing, 6 through 9 as not Boeing.
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Message 2016783 - Posted: 26 Oct 2019, 23:35:51 UTC - in response to Message 2016779.  

"If that sensor had failed during the actual take-off the result would have been exactly the same." If it was operating the result would have been a safe flight.
Pitiful excuse to absolve Boeing. WHERE was the redundancy? Wasn't MCAS only "accepting" the data from 1 sensor?
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Message 2016846 - Posted: 27 Oct 2019, 10:36:13 UTC

Time to take a look at "The F.A.A. Reauthorization Act of 2018".

Boeing Shaped a Law to Its Liking
Weeks Later, a 737 Max Crashed.

The government has been handing over more responsibility to manufacturers for years. The new law makes it even harder for regulators to review Boeing’s work.

In a stark warning as the bill was being written, the Federal Aviation Administration said that it would “not be in the best interest of safety.”
A labor group representing agency inspectors raised concerns that the rules would turn the F.A.A. into a “rubber stamp” that would only be able to intervene after a plane crashed “and people are killed,” according to internal union documents

President Trump signed the F.A.A. Reauthorization Act of 2018 into law last October. Most of the attention on the legislation had been on a failed Republican effort to privatize the air traffic control system.Credit...Official White House Photo by Joyce N. Boghosia[/b]
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Message 2016874 - Posted: 27 Oct 2019, 17:29:44 UTC

Garry, too many crossings out on my bit of paper - yes there are six of nine attributable to Boeing, not 8 of nine.

BUT the key thing is had Boeing not gone down the non-redundant path for the use of sensors for MCAS the maintenance errors and the flight crew errors would not have been critical. The initialisation checks after installing the replacement would probably have flagged up that there was an error in the data, the flight crew would have be alerted that the AoA sensors didn't agree.

The discussion about the faults & repairs on the AoA sensors does get somewhat confusing - there are two talked about, the one that was removed from the plane on Oct 28 (serial 21401) and the one which replaced it (serial 14488 - which went down with the plane, and has not been recovered).
To sum up:
21401 misbehaved badly on a previous flight, and was removed on 28 Oct. It went off for repair/investigation 5 Nov, but nothing happened until it was sent on via the NTSB to Collins (the OEM) for investigation. Some significant faults were found. This unit played no "active" part in the crash as it was sitting somewhere on the ground.
14488 replaced 21401 on 28 Oct. Nothing identifiable has been found (hardly surprising given its location and speed of impact - the CVR and FDR were recovered and both are designed to survive crashes, but both showed signs that they had bee involved in a high speed impact). 14488 had its vane replaced in 2017, records from the repairer indicate that it had passed its (bench?) test. It then sat in stores for about a year before replacing 21401. The post installation tests were not properly recorded, and the "short form" test was undertaken - this test is really just to prove that the sensor gives "sensible" data at the mid-point and extremities of its range, this is possibly OK for a known good sensor (only possibly, not probably). This sensor did two flights, one not being used, and the final (crash) flight where it was the active AoA.

There were faults in the way the AoA unit exchange was recorded, but it still boils down to a design that was going to fail in this manner at some time or other.
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Message 2016918 - Posted: 27 Oct 2019, 23:38:30 UTC - in response to Message 2016874.  

Rob, If I read the report correctly they went to the shop that repaired the unit that was installed at the time of the crash, pulled out the logs and found they used a meter that potentially had a setting that would show pass when it should show fail if the meter switch was in the incorrect position. Then they went to the manufacturer and did the same test, several times, and found, yes it would show pass when it should show fail. I believe they also showed that it was extremely likely that the "resolvers" would have moved in the repair process of the unit on the plane and the unit would need re-calibration to fix the zero point. While they don't have the unit from the bottom of the sea floor, they did have FDR from the previous flight, when it wasn't the side in control of MCAS showing it was biased from accelerating for takeoff to landing. Essentially proof that it was bad when put on the aircraft. I believe I also read they did a test, with a known incorrectly calibrated sensor, of the short form or alternate test and showed that a incorrectly calibrated sensor would show a fail for that test. Since the results of that test on the crash aircraft were not recorded as required and the mechanic involved sent in pictures of a different aircraft attempting to show he did the test, it leaves an impression of consciousness of guilt.
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Message 2016951 - Posted: 28 Oct 2019, 7:39:44 UTC

Two things, first, and I think we both agree here, ground maintenance did a poor job in recording what they, or didn't, do. Second, Collins possibly used a duff instrument to test (and calibrate?) the AoA. If the latter is the case I hope that there will be an official call for calibration of all AoA maintained around the world, and across all aircraft types affected (the same core part is, I understand, fitted to more types than just the B737MAX).
All this however deflects from the fact that Boeing only used the data from one of two AoA at a time to drive MCAS, and didn't use redundant data to show that one or other of the AoA was giving invalid data. And this despite the recovered FDR clearly showed a big difference in AoA between the two on the previous flight where 14488 was "isolated from control".
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Message 2016954 - Posted: 28 Oct 2019, 8:16:57 UTC

Continuing reading the Lion Air crash. Section 2.5.1.4 has this little gem:
(2.5.1.4 is a long section. and these are the last few lines - describing actions of the flight crew of the penultimate flight of PK-LQP, aka flight LNI610)

The flight crew of LNI043 eventually observed and recognized the un-commanded stabilizer movement and moved the stabilizer trim cutout switches to the cutout position. Stopping the stabilizer movement enabled the flight crew to continue the flight using manual trim wheel to control stabilizer position. On that flight, stabilizer cutout was used to counter the repetitive MCAS-commanded stabilizer.
The aircraft design should not have allowed this situation. The flight crew should have been provided with information and alerts to help them understand the system and know how to resolve potential issues. Flight crew procedures and training should be appropriate. The aircraft should have included the intended AOA DISAGREE alert message functionally, which was installed on 737 NG aircraft. Boeing and the FAA should ensure that new and changed aircraft design are properly described, analyzed, and certified.


Ouch - I didn't realise until I read this that one of the things that may have prevented this crash was installed on B737NG, but not on B737MAX - an AoA disagree indicator.
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Message 2016955 - Posted: 28 Oct 2019, 9:18:24 UTC - in response to Message 2016954.  

There was some concern by the US Air Force over the KC-46A Pegasus but that went quiet when they realised that pulling back the yoke disabled MCAS as designed into that aircraft. The KC-46A Pegasus uses both AOA sensors.

http://www.airforcemag.com/Features/Pages/2019/March%202019/USAF-Reviewing-Training-After-MAX-8-Crashes-KC-46-Uses-Similar-MCAS-System.aspx
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Message boards : Politics : Profits 1st, Safety 2nd? Pt 2


 
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