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[B25]

RH, totally agree. Its a no brainer.

[Paphitis]

Yes it is completely possible that the Pilots did not read the Flight Manual.

I don’t know many that do. The damn thing is unreadable and it isn’t easily read. That is one aspect. Also the reason why we have Standard Operation Procedures, a Flight Operations Manual for each type and a QRH. Those are mandatory reading and more pilot friendly.

It’s not the pilots fault for not reading the AFM.

However, if the company did not issue a procedure in the Flight Ops Manual and QRH and were not aware of it, then that is another matter.

Secondly it is completely possible that Ethiopian did not update their FOM (Flight Ops Manual) and more importantly the Quick Reference Handbook which is the go to in any Emergency. The QRH has 2 sections.

Section 1 at the front are the Emergency Procedures, and section 2 are the Abnormal Procedures (such as no Flap Landings or Gear Retract Inop)

At the front are critical Emergency Procedures for every possible scenario you can think off. Trim runaway should be in the first 15 procedures and at the top are the Memory Items. Below the memory items are the non memory checks and check lists. Each procedure has a quick tab for immediate access and they are colour coded too.

Boeing issued a procedure which is all they had to do. No one accused them for not having a procedure. What they have been accused of is not providing training material for a new system known as MCAS and also they have been accused of defective software. They have accepted both these things on the chin and have cooperated with the authorities and the investigation team.

Boeing issued this Air Directive in 2018: this procedure was published in the AFM.

https://cimg0.ibsrv.net/gimg/pprune.org ... c4cb07.jpg

If that was not replicated by Ethiopian in their FOM and QRH or if the pilots were not aware of it because the airline did not update their SOPs then that too is a very significant factor. Another factor among many more we do not know of yet.

[Paphitis]

RH, totally agree. Its a no brainer.

A no brainer hey.

Well that is a very stupid statement. I have been studying airline accidents for 20 plus years and I have not known one where there are not MANY factors involved culminating in an accident. It takes months for an investigation to complete its due process. According to ICAO rules, the investigators are given a month for a preliminary report and 12 months to conclude. Most however take 2 to 3 years. I know of some that took 6 years. It’s a very complex process and the system or process is also complex.

There could be up to 20 factors, if not more.

For instance, they have not analyzed or released information from the FDR yet or looked into the pilots training. They look at every facet you can think of including maintenance.

Saying that Boeing is 100% responsible is something you will not have Boeing admit to or the investigation team accuse. Boeing will never admit total responsiblility or liability. This you can guarantee.

The investigation team will come up with factors. It will not lay blame on Boeing. That isn’t allowed. After the factors are released it will turn into a shit fight between lawyers of Boeing and Ethiopian and also lawyers representing the families in a class action. Boeing already accepted some responsibility and will pay some compensation but they will never accept total culpability, unless the Federal Courts in the USA enforce it which they will not. The courts can only look at the factors handed by the international investigation.

[Robin Hood]

Yes it is completely possible that the Pilots did not read the Flight Manual.

I don’t know many that do. The damn thing is unreadable and it isn’t easily read. That is one aspect. Also the reason why we have Standard Operation Procedures, a Flight Operations Manual for each type and a QRH. Those are mandatory reading and more pilot friendly.

It’s not the pilots fault for not reading the AFM.

However, if the company did not issue a procedure in the Flight Ops Manual and QRH and were not aware of it, then that is another matter.

Secondly it is completely possible that Ethiopian did not update their FOM (Flight Ops Manual) and more importantly the Quick Reference Handbook which is the go to in any Emergency. The QRH has 2 sections.

Section 1 at the front are the Emergency Procedures, and section 2 are the Abnormal Procedures (such as no Flap Landings or Gear Retract Inop)

At the front are critical Emergency Procedures for every possible scenario you can think off. Trim runaway should be in the first 15 procedures and at the top are the Memory Items. Below the memory items are the non memory checks and check lists. Each procedure has a quick tab for immediate access and they are colour coded too.

Boeing issued a procedure which is all they had to do. No one accused them for not having a procedure. What they have been accused of is not providing training material for a new system known as MCAS and also they have been accused of defective software. They have accepted both these things on the chin and have cooperated with the authorities and the investigation team.

Boeing issued this Air Directive in 2018: this procedure was published in the AFM.

https://cimg0.ibsrv.net/gimg/pprune.org ... c4cb07.jpg

If that was not replicated by Ethiopian in their FOM and QRH or if the pilots were not aware of it because the airline did not update their SOPs then that too is a very significant factor. Another factor among many more we do not know of yet.

But none of this shit was required until MCAS failed!!!!! Why do you find that so hard to understand. The MCAS failure WAS the cause, none of your contributing factors will change that ....... the contributory factors can only be considered after that event!

If the MCAS failed then MCAS was the cause ....... if the elevator fell off ..... then it was the elevator that was the cause ....... if a bomb blew the elevator off .... then the bomb was the cause. The first event is always the cause; you ask why did t happen? So you look into the cause first and THEN the other factors.

[Robin Hood]

RH, totally agree. Its a no brainer.

A no brainer hey.

Well that is a very stupid statement. I have been studying airline accidents for 20 plus years and I have not known one where there are not MANY factors involved culminating in an accident. It takes months for an investigation to complete its due process. According to ICAO rules, the investigators are given a month for a preliminary report and 12 months to conclude. Most however take 2 to 3 years. I know of some that took 6 years. It’s a very complex process and the system or process is also complex.

There could be up to 20 factors, if not more.

For instance, they have not analyzed or released information from the FDR yet or looked into the pilots training. They look at every facet you can think of including maintenance.

Saying that Boeing is 100% responsible is something you will not have Boeing admit to or the investigation team accuse. Boeing will never admit total responsiblility or liability. This you can guarantee.

The investigation team will come up with factors. It will not lay blame on Boeing. That isn’t allowed. After the factors are released it will turn into a shit fight between lawyers of Boeing and Ethiopian and also lawyers representing the families in a class action. Boeing already accepted some responsibility and will pay some compensation but they will never accept total culpability, unless the Federal Courts in the USA enforce it which they will not. The courts can only look at the factors handed by the international investigation.

That is all nothing but your opinion! No brainer .... correct ...... MCAS failed!!

When MCAS is shown officially to have failed .... mechanically/electrically/hydraulic or in the design or software ...... it will be Boeings fault! BUT ...... when it gets to awarding blame, Boeing will settle out-of-court and any settlement will contain a no-liability clause. What will get Boeing off the hook ......... is not their innocence but employing a very expensive team of smart assed Lawyers!


"It will not lay blame on Boeing. That isn’t allowed." Rule 1: When you are the exceptional Nation you are never in the wrong ....... and if you are ........ Rule 1 applies.

[Paphitis]

It's not my opinion. It is what is happening with the investigation and the process at large. It is what happens with all investigations (they don't lay blame). There are a no blame culture here and ICAO (UN) will enforce that to the end even with regard to Boeing.

Boeing or any business is not going to admit full liability. No one expects them to either. Whether you like it or not. They have accepted what parts they are responsible for - faulty MCAS software and inadequate training and there may be more than that that will come out later but that is all. And they didn't have to do that. they only did it to protect their brand and reputation because it would not have looked good if they were flippantly disregarding the obvious.

There will be other factors that they are NOT responsible or culpable for.

For instance, they issued an Air Directive in 2018 which if Ethiopian followed, would have likely avoided this accident. So the investigation is going to look at how well this procedure was complied with, if at all. They are also going to look at whether Ethiopian complied with this Air Directive and had updated manuals.

If they didn't, then these are factors which contributed to the crash as well. The same rules apply to Ethiopian with regard to this investigation. The investigation can not lay blame against Ethiopian either. They can only publish contributory factors in an non biased and independent manner.

And there could be many more. For instance, they might talk about the experience level of the First Officer. They might not. It will depend on how well they followed their procedures. Maybe their were failings at a company level. If the procedures were not followed, then they will establish the reasons why they were not followed.

It is complete stupidity to believe Boeing is going to accept liability and take 100% of the blame before the conclusion of the investigation. Even after the conclusion of the investigation they won't do that. They are going to battle it out with their team of lawyers guaranteed. And their lawyers will NOT allow Boeing to admit anything. They will take it down the wire to the US Federal Courts.

A major focus will be how well Ethiopian complied with the following procedure:

https://cimg0.ibsrv.net/gimg/pprune.org ... c4cb07.jpg

The bits about the MCAS and the training material has already been established and will be part of the final report. The question is, what else will be in the report.

What you are doing is speculating and assuming and also over simplifying what is an extremely complex process. The media too, fixate on a very small part of the total picture. If it was that simple there would be no need for any further investigation. They will just publish the 2 factors - MCAS and lack of training and be done with it but that is not what these Crash Investigators do. They spend months and years deliberating on every minute detail possible.

For example, most of the general public are under the misconception that Boeing did not issue a procedure for MCAS failure and trim runaway. Whilst they didn't issue one in the very beginning, they did actually issue an Air Directive in 2018 (see link above). Most of the media have not reported this. Only a very few high end broadsheet outlets have - such as Washington Post and New York Times.

[Robin Hood]

It seems that you are not clever enough to realise the obvious that if MCAS had not failed then nothing you have quoted would be of any relevance.

When you clearly identify what caused the crash ..... THEN and only then can you investigate whether there were other factors that could have prevented the outcome. But no matter how many other factors you expound ..... it was MCAS failure that was the primary cause of the accident. What you are trying to do is consider 'double' jeopardy' i.e. a primary failure .... followed by another failure, as a consideration.

That scenario in industry is covered by dual systems or even three ..... certainly in the Nuclear Industry. The same, as I understand it, is done on the control systems on commercial aircraft. The parallel control systems vote by considering 2 out of 3 sensors and assumes you do not get two identical failures on identical systems at the same time. Which seems reasonable?

If MCAS was considered as a crucial safety function then .... IMO ..... the same should apply, as it appears it was likely a failure of the only sensor on that system. It should not have required operator intervention to make any corrections. So in that case poor design would be a contributing factor .......... not the cause.

You are clouding the issue with other factors that were contributory after the event not the cause!

There was only one cause ...... MCAS FAILED There can be no other conclusion based on what has been released to date!

[Paphitis]

Everything is relevant.

No one is denying the MCAS failed, but there was also a published procedure for this, so yes, the accident must have been avoidable.

The investigation team will look at all the data, and also ascertain whether the procedure was complied with or whether Ethiopian updated its procedures.

This Air Directive was issued by Boeing for exactly this contingency in mind, total MCAS failure and trim runaway. It would have been tested in the simulator hundreds of times, and the investigators will do more testing as well. Most of the general public still can not comprehend the fact hat this Air Directive was issued by Boeing.

https://cimg0.ibsrv.net/gimg/pprune.org ... c4cb07.jpg

The reason why it is relevant is because if for some reason the procedure was not complied with, then it is actually this that caused the accident. MCAS failure was just a trigger. BUT, and I must stress this. The investigation team is not exactly going to come out and say that Ethiopian's non-compliance caused the crash because that is laying blame squarely at one party. They will not say Boeing is to blame either. they are just going to conclude with contributory factors:

a)
b)
c)
d) and so on.

In the end, the investigation can come up with many reasons and contributory factors, aside from what we already know about the MCAS and lack of training material.

What caused the accident could also be an incorrect configuration. For instance, MCAS only operates whilst in the climb with more than 15 degrees of flap. If they were past their Acceleration Altitude and leveled off and raised the flaps, and disengaged their Stab Trim, they could have returned to their departure aerodrome and be alive. There are many unanswered questions.

Never quite as simple as saying MCAS failed or there was an engine failure or whatever the case may be. What happened afterwards is also important.

There are many things that will be looked at, including whether Boeing properly communicated the above little life-saving tidbit to operators. If they did not, then again they are up shit creek even more.

[Londonrake]

When you are the exceptional Nation you are never in the wrong

I think that comment says far more about the poster than the subject. Which it seems, ultimately, is not at all his point.

[Kikapu]

If and when the MAX takes to the skies again with billions of dollar in litigation for Boeing to pay out in out of court settlements for no guilt accepted, this may not save the MAX, or dare I say, to save Boeing from financial ruins if Boeing wants to stand by the MAX. At the moment the MAX is “damaged goods” product with the flying public, and should the flying public accept the MAX to fly with again, the next time the MAX suffers another MCAS related crash, the flying public and regulators will not forgive Boeing and the company will be as good as dead. Boeing needs to think hard to do away with the MAX right now and take their loss or risk losing the whole company with another MAX crash. Boeing can turn the B-757 design into their new MAX planes with it’s large engines and retire the B-737 MAX 8&9 models for good. Playing Russian Roulette is no way to run a company.