Yeah, I think most of us know that these things happen as a result of a series of events, usually 7 or more. In this case, it was 9 (I only listed 7 which I think was of interest - particularly first 2 below):
- the jet should have been grounded before departing on the fatal flight because of an earlier cockpit issue
- a crucial sensor - which had been bought from a repair shop in Florida - had not been properly tested
- first officer, who had performed poorly in training, struggled to run through a list of procedures that he should have had memorised.
- 31 pages were missing from the plane's maintenance log
- If the crew of the previous days flight had given a more detailed description of the problems they'd faced, the aircraft might never have taken off on its fatal flight
- if the captain, who'd successfully kept the plane in the air - despite the intervention of a rogue automated system he didn't understand - hadn't handed over to his less-capable first officer, disaster might still have been avoided.
- at the heart of that chain was MCAS - a control system that the pilots didn't know about, and which was vulnerable to a single sensor failure
- and more
https://www.bbc.com/news/business-50177788
Boeing 737 Max Lion Air crash caused by series of failures
Re: Boeing 737 Max Lion Air crash caused by series of failures
I've designed warships, submarines, rail vehicles..... and let me tell you the failure wasn't a series of faults but instead a failure in the design department.
The Captain and First officer are victims and should be treated and respected as such....
The Captain and First officer are victims and should be treated and respected as such....
"If anyone ever tells you anything about an aeroplane which is so bloody complicated you can't understand it, take it from me - it's all balls" - R J Mitchell
Re: Boeing 737 Max Lion Air crash caused by series of failures
bomber wrote:I've designed warships, submarines, rail vehicles..... and let me tell you the failure wasn't a series of faults but instead a failure in the design department.
I disagree; it's a series of events leading up to the end result. You can say ,"no such thing as 'if only' " but then again, some of chains have prcedures and guidelines that are already very specifically defined and detailed for airlines to follow. They did not do that.
Never mind the missing pages - what were they trying to hide?
Because if only one of these was intervened, the event would be entirely different. No.1 being pushing an already known unflayable aircraft into service without grounding it for thorough inspection. The notorious Indonesian air safety record rears its ugly head here.
bomber wrote:The Captain and First officer are victims and should be treated and respected as such....
This, I will agree - to a point. The pilots were simply unaware of such a system called MACS and untrained for it and the runaway elevator trim procedures.
Boeing is totally at fault here. At the same time, you certainly cannot guarantee your product is 100% safe, I think even Airbus will never put that on record. With something as complex as a modern airplane there is always something to be discovered. But that is why there are procedures and systems in place to prevent that as much as possible.
I am not trying to downplay Boeing's role both here and the Ethopian one . But add all the negligence into the mix you have the perfect storm.
Re: Boeing 737 Max Lion Air crash caused by series of failures
Actually, the no.1 thing is for Boeing pushing some weird characteristics augmentation thing onto their planes. But, had they not done that in the first place, this doesn't automatically solve the missing pages, pushign an (another) unflyable plane into service and not testing some second-hand new equipment. Those kinds of attitudes are very clearly asking for trouble. If not this MCAS fiasco, it's gonna be another one.
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