Federal Democratic Republic of Ethiopia
Ministry of Transport
Aircraft Accident Investigation Bureau
Aircraft Accident Investigation Preliminary Report
Ethiopian Airlines Group
B737-8 (MAX) Registered ET-AVJ
28 NM South East of Addis Ababa, Bole International Airport
March 10, 2019
Report No. AI-01/19 [not dated but released: 5.April.2019]
Before I jump into the report, I wish people would follow the long-established and proven rules. Making public pronouncements without the official report are fraught with risk, and those risks were realized . . . at least for those of us who follow aircraft accidents.
As I read the official preliminary report, I see several rather disappointing observations that are not addressed in the preliminary report. Not least of which, pilots (or perhaps I should say, most pilots) are taught very early in their training, and it is repeatedly and consistently reinforced, to fly the aircraft first and foremost. Then, deal with any system problems, as you are able. Second, like a caution light or abnormal indication before V1 (takeoff rejection speed), a flight control problem will NOT be improved by increasing airspeed; it will ONLY be made worse. Third, the accident aircraft had two (2) Angle Of Attack (AOA) sensors installed, one on either side of the aircraft. The preliminary report findings mentions the significant mis-compare between AOA-L (74.5º) & AOA-R (15.3º) shortly after takeoff; however, the report does not mention the potential control complications associated with such a large mis-compare. Further, the preliminary report does not address the Maneuvering Characteristics Augmentation System (MCAS), or whether the AOA sensor input was single or dual, or where the AOA input to the MCAS or how that might affect aircraft control? Lastly, I find it a little disturbing that the first officer (co-pilot) has 361 total flight hours, 207 hours in type; that does not mean he was a bad pilot, but he had a rather thin experience base.
The FDR & CVR data are quite enlightening. I am grateful for the preliminary report. However, I have one major (if not paramount) disagreement with the official and public speculatory findings. The last of the preliminary findings from the official report states: “The crew performed runaway stabilizer checklist and put the stab trim cutout switch to cutout position and confirmed that the manual trim operation was not working.” Based on the checklist excerpts attached, I would agree. However, there is no mention whatsoever about the No.1 Pilot Axiom of Flight, rarely written in checklists – fly the aircraft first. Why did they allow airspeed to continue increasing when they first became aware of a serious flight control problem? Why did they leave both throttles at the takeoff / climbout N1 thrust setting? Why couldn’t they manually trim after the electric stabilizer trim cutout was activated? There are far more questions yet to be answered. Based on this official preliminary report, it is wrong to excoriate Boeing—the pilots are NOT absolved. To me, the pilots appear to have flown the checklist rather than the aircraft. Boeing still has an awful lot of questions to answer; yet, I am NOT convinced the root causal factors belong to Boeing alone. Let us all be very careful with our accusations or condemnations of Boeing.
-- According to the Wall Street Journaland unnamed U.S. officials, the administration is preparing to designate Iran’s Islamic Revolutionary Guard Corps as a foreign terrorist organization—an action long overdue in my humble opinion. If the administration follows through with this action, it will likely increase tensions with the IRI [813] significantly, and unfortunately, take another few steps closer to violence.
House Ways and Means Committee Chairman Representative Richard Edmund Neal of Massachusetts formally requested six year’s worth of the BIC's tax returns, setting up what is likely to become a protracted legal conflict. The law often cited for such action is the RevenueAct of 1924 [PL 68-176; 43 Stat. 253; 2.6.1924] [885], and specifically, § 257 that states tax returns are to be considered public records. The BIC broke with prevailing custom since President Nixon that presidents and presidential candidates voluntarily released their tax returns to reassure We, the People, they were not indebted to anyone that might present a conflict of interest, among other concerns. The BIC has routinely thumbed his nose at custom, tradition, practice and evolved standards; this instance is no different. I expect the BIC will order his army of personal lawyers to stonewall this request in perpetuity, or as long as possible. Based on his character flaws, I suspect the BIC will even defy the Supreme Court in this matter, if it goes that far. He does not want to be exposed as a fraud.
The BIC occasionally gets positive news he can brag about even though he does not deserve to do so. He is the duly elected leader of this Grand Republic and he gets to take credit. The Labor Department announced nonfarm employment increased a seasonally adjusted 196,000 in March. Average hourly wages for private-sector workers grew 3.2% from a year earlier. The unemployment rate held steady at 3.8% last month, just above a 49-year low of 3.7% touched last fall. The unemployment rate is in the range of full employment, although, since I became aware of the notion, I have understood that full employment level was considered to be 3.2.% unemployment. Historically, the lowest rate achieved in the United States was 1.2% in 1944. The labor market remains a source of strength for the economy.
Homeland Security Secretary Kirstjen Michele Nielsen tendered her resignation to the BIC on Sunday, after the BIC suddenly decided to drop the nomination of Ronald Donato Vitiello to be Director, U.S. Immigration and Customs Enforcement (ICE). The chaos surrounding the BIC continues to boil unabated.
Comments and contributions from Update no.899:
Comment to the Blog:
“Your Henry Miller quote (‘We do not talk, we bludgeon one another . . .’) is apt to many conversations but is at least an over-generalization.
“As an observer at the most ordinary level, I will ask two more questions about the MCAS on those planes. (1) Was there no redundant sensor that might have functioned correctly? (2) Why were the pilots unable to detect and correct the system’s failure?
“I already brought up the airplane regulatory question. This relates to the larger ‘free market’ issues of privatization and self-regulation/regulatory capture.
“The UK is in deep trouble with Brexit, and their ‘leaders’ show no sign of coming to their collective senses. It’s a good bet the people know better, but the elected officials cling to their entrenched positions for no sane reason.
“Attorney General Barr has stated, under pressure, that he will forward a redacted version of the Mueller Report to Congress within a few weeks. I’m betting the redactions will protect the guilty. The Clintons are noting the irony that the report on his sex life was published in full, not redacted and in graphic detail. On another of your points, my college courses included one on ‘crisis communication.’ The use of the word ‘collusion’ allows all and sundry to avoid the correct term ‘obstruction of justice.’ Those are not synonyms under the law. In some future court case, they can say they didn’t lie about Chump’s obstruction of justice.
“The Wall Street Journal is the voice of capitalist wealth. We can safely discount its informational value and ignore its opinion.
“Mitch McConnell (R-Ky), the Senate Majority Leader, is single-handedly preventing us from holding Chump accountable and is otherwise harming the United States. He is also running for re-election this year. The leadership of the Democratic Party is quietly playing along with much of this harm, against the wishes of their own base and some of their elected officials.
“I live in a State afflicted with gerrymandering. I certainly agree with you on that.”
My response to the Blog:
I just liked the two quotes—nothing more.
To your appropriate Qs regarding the B737-MAX8 accidents:
1.) Re: “Was there no redundant sensor that might have functioned correctly?” I am not and I do not have a definitive, official source (yet); however, it is my understanding from my sources that both accident aircraft were capable of dual AOA sensors, but the operator chose not to pay extra for the second sensor, thus they were in a single sensor configuration when the accident occurred. If this information is accurate and true, as I have written before, I cannot believe any competent flight control engineer or DER would approve of such a system. All sensors fail or output erroneous data from time to time, no matter how expensive those sensors are. It is unusual for a fairly simple sensor like an AOA device to malfunction or fail so early in operation, but it happens. So, this issue—single versus redundant AOA sensor(s)—raises a number of other far more impactful issues: A.) certification, B.) pilot training, and C.) documentation, i.e., was the system properly explained to the pilots & maintainers?
2.) Re: “Why were the pilots unable to detect and correct the system’s failure?” This Q is more difficult to answer. I have not yet seen the transcripts of the CVR downloads in either event, or the correlation between the CVR & FDR data, to gain a look-see as to what the crew was doing in those fateful seconds once the upset sequence began. My guess, they were probably stunned by the initiation and confused as to what was happening. I fear the pilots fell victim to saturation with the system rather than every pilots primary axiom—fly the aircraft first. There are more than a few reasons attitude upsets can occur. As reported in a number of usually reliable sources, a prior event with the LionAir aircraft was quickly resolved by a deadheading jump-seat pilot, who knew enough to switch off the MCAS. If officially validated, that information raises more questions about training and post-event maintenance to troubleshoot and resolve the cause.
The more I learn about these two accidents the more I am left with one salient question: how on God’s little green Earth did Boeing get into this situation? Boeing has always been an industry-leading, conservative, engineering company. How and why did all that history get overcome? So many questions; so few answers.
The DER system is not self-regulation. I can assure you the system in general is a carefully supervised system. And yet, the unofficial, public information suggests something failed in that system at Boeing. Nonetheless, your concerns and apprehensions are valid and warranted. Those of us who have lived in that world share your concerns and apprehensions.
Re: Brexit. You clearly expressed by feelings as well. This is a tragedy of the first-order and an indictment of those charged with representing the British people in Her Majesty’s Government. My opinion is beginning to grow that perhaps the only way out is for the Queen to beg indulgence by the EU for a year extension, and then dissolve Parliament to force a new general election in hopes of finding better representation—a major event, but no less serious than Brexit without an agreement.
Excellent assessment of the Mueller Report situation. I have been impressed with Barr as a person, but he is a compromised attorney general. I am not able to imagine how Congress can or will accept his redactions as a consequence. The capability and facilities exist and operate for selected members of Congress to view highly classified material. The same system should be sufficient for viewing the un-redacted report. How the administration takes the next few steps may well head us into a serious constitutional crisis? I hope they tread lightly. I am not confident given the BIC’s penchant for self-protection, self-aggrandizement, and willingness to obstruct justice (put his thumb on the scale).
I held the Wall Street Journal to a higher journalistic standard until now. They have fallen and succumbed to the seduction of political bias.
McConnell’s harming of this Grand Republic, its foundation principles, and our form of governance began long before the BIC became POTUS, e.g., not least of which was his singular stonewalling of President Obama’s Supreme Court nomination. We can only hope the voting residents of Kentucky see the greater good when it comes time to vote next year.
You are not alone. Most states suffer the affliction, which is precisely why the Supreme Court can and should weigh in.
My very best wishes to all. Take care of yourselves and each other.
Cheers,
Cap :-)
2 comments:
The House Judiciary Committee's subpoena of the Mueller report will surely bring about an interesting legal battle. It will be necessary if we want to know what Mueller found, though. I read a New York Times article on what the Attorney General could/might redact from his submission. That article led me to expect AG Barr's submission to me more of an omission.
Your aircraft crash analysis goes far beyond my background.
The Ways and Means Committee's request for Chump's tax returns sets up a battle as fascinating to lawyers as the Max 8 crashes are to you. That battle may or may not continue for years. Should we see the returns, important facts will be revealed. In addition to the potential for conflicts of interest and criminal behavior that might be shown by those returns, Chump's tax avoidance strategies, legal or not, ought to draw wide interest.
Stand by for further developments on the economy. Everything Chump touches turns to garbage. He's sort of a reverse King Midas.
I have begun to wonder which temporary service is providing White House officials. I want to avoid hiring on with that one.
Good morning to you, Calvin,
As always, thank you so much for your contribution.
Re: Mueller Report. I share the same concern. As much as I want to read the whole, un-redacted report, I recognize, understand and acknowledge the requirement for redaction . . . too many among us would abuse the unfiltered information. Rules are rules for a reason. However, the Executive cannot have unilateral authority in such matters, especially when POTUS is a principal object of potential criminal conduct. Congress, even if necessary restricted access to the Gang of Eight, must read the un-redacted version, and the Special Counsel must testify before Congress. I believe Mueller passed judgment regarding obstruction of justice expecting Congress to decide that task, not the Attorney General. We do not know (yet) whether he found criminal obstruction of justice due to the Attorney General’s public position of “the King can do no wrong.”
I am also fascinated with the law . . . not just aircraft accidents. I am fascinated by a lot of things: history, science, physics, economics, photography, space, ad infinitum. You noted 26 USC §6103(f)(1), which is the current, specific, applicable law in this instance. The genesis of that law was the Revenue Act of 1924, with the current language growing from Internal Revenue Code of 1954 [PL 83-591; 68 Stat. 730; 16.8.1954], i.e., there is a long history in the law. Yet, the law gives Congress access to tax returns . . . not We, the People. The BIC is not a private citizen; he is a public employee at the highest level, and therein lies the salient difference.
Oh, I do agree; all of the BIC’s chest-beating has been for the short term, make-me-look-good-now objective, and certainly and emphatically not for the long term good, e.g., the grotesque inflation of the national debt. Reverse King Midas indeed!
Good point. Chaos may work in the BIC’s biz of marketing and labeling, but it is most definitely does NOT work in government or commerce. I was convinced long ago that the BIC has no understanding or appreciation for stability; he probably does not know what the word means.
“That’s just my opinion, but I could be wrong.”
Cheers,
Cap
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