October 13, 2019
Closeup of the B737-MAX Stabilizer
Perhaps you believe you could have saved one or both of the MAX crashes.
Perhaps. But you have missed the point. The MAX is a betrayal of both you and your trade.
Where does the MAX story begin?
You could say back in 1997, with Boeing’s merger with/acquisition of the flawed McDonnell Douglas. The US government forced the merger. The necrotic tissue was brought indoors in Seattle, and it spread.
Or you could say it was in 2001, when Boeing moved its corporate headquarters to the Morton Salt building in Chicago, two-thirds of a continent away from the factory floor.
Or perhaps it was way back in 1967, when Southwest Airlines started up. That is also the year the B-737 first flew.
In any case, Southwest bought B-737’s and kept buying them. Only B-737’s.
All of these sub-stories are relevant to the story of the MAX. By the time Boeing management gave a green light to this latest variant of the B-737, in 2005, many pieces of the MAX story were already in place. Southwest had extracted a promise from Boeing that their pilots would not require simulator training. If they did have to transition in the simulator, the airline would receive a $1 million rebate per airplane.
Back in the windy city, the Boeing head shed was wowing Wall Street with numbers. Boeing stock was soaring.
But on the shop floor things were not so rosy. The B-777 – perhaps Boeing’s most successful airplane – had cost a lot to develop. For the B-787 Dreamliner, Boeing decided to contract out an unprecedented portion of the work, while meanwhile taking some very large technological steps. They offloaded risk (development, labour, taxes) to the subcontractors, meanwhile squeezing the latter’s margins.
The strategy of offloading risk while holding profits close should sound familiar. It worked like gangbusters on Wall Street.
Until it didn’t. In 2008, multiple too-big-to-fail companies were bailed out by the taxpayer.
Those of us who are long past retirement can remember Controls and Indicators. If you went on a Boeing course back in the day, you were exposed to a need-to-know philosophy. I flew the B-727 and didn’t know it had a (mechanical) trim brake. I flew the B-767 and didn’t know it had a stick pusher.
Another Boeing policy – which was more noticeable after the introduction of the A320 in 1988 – was trust the pilot. This is another way of saying if the airplane crashes, it is pilot error.
This is a perfect offloading of risk. I was aware of it for my entire airline career, and I accepted the beauty of the logic. If people die, it is the fault of the dead.
But all golden geese are eventually killed for their feathers and flesh. Just so pilots. New management has interpreted old bargains as certainty. Ruled by numbers, they seize small advantages as they appear before their eyes. The underlying risk has been neglected, offloaded, and forgotten.
Here, step by step, is the plucking of feathers and roasting of flesh. Yours.
Fatal crashes of the B-737 caused by a corner-cutting design (rudder actuator) were waved off as pilot error and then forgotten:
UAL 585, 03 march 1991, Colorado Springs. All 25 people on board died.
US Air 427, 08 September 1994, Pittsburgh. All 132 people on board died.
and perhaps Silk Air 185, 19 December 1997, Sumatra, (104 dead) and others. In these cases the cause was originally listed as pilot error.
Lessons that could have been learned from the DC-10 were ignored (DC-10 hydraulics and B-737 rudder cables are vulnerable to uncontained engine failures and other structural failures).
The Turkish airlines crash at Schiphol was caused by a single sensor (RA) feeding software in series (no parallel supervision or voting). Forgotten.
The B-767 was certified with a stick pusher. The MAX needs one.
The B-787 was grounded because of lithium ion battery fires. The subcontractor’s factory also burned down. (My Ryobi handsaw had built-in lithium ion battery protection with current and temperature sensing, and it cost less than $100. (It is unclear if Boeing’s contractor was even asked to develop a safety system for these batteries).
Designing the MAX
Follow me down the garden path as Boeing designs the MAX:
Oh, oh. The MAX has a negative stick force per G problem near the stall. Why not do like the B-767 and add stick pusher? Too late. Too expensive. But mainly, the B-737 has already flown for fifty years without one.
We’ll use the stab. Hey – we have already given questionable software access to the stab: trim brake, speed trim, and others – and we haven’t had any problems.
A stick pusher pushes the nose down. We’ll push the nose down with the stab. Same thing.
Except it Isn’t
It isn’t? No. Not even close. The stab is more powerful than the elevator. By using the stab you set up a situation where the airplane can seize control from the pilot.
No? Can full up elevator win against full nose-down trim or vice versa? Would you attempt takeoff with the stab in one of those positions? And what about the fact that MCAS can trim faster than you can? MCAS could use that advantage even above VMO. And did. It bunted beyond the negative G limit for the airplane.
And there are other problems not addressed in the certification and not flight tested:
stab jamming with with elevator counter-pressure
loss of pitch stability with elevator counter-pressure
elevator blowback at high speed
The first two became well-known in the industry after the Trans Canada Airlines crash at Ste. Thérèse. November 29, 1963. CF-TJN. The stab was full nose-down. The Final Report (typed on a typewriter) (http://publications.gc.ca/collections/collection_2016/bcp-pco/Z1-1964-3-eng.pdf) is now a must-read because of the MAX.
Three months later another DC-8 dove into Lake Pontchartrain north of New Orleans. Eastern Airlines. The trajectory was almost identical. It is likely that in both cases the Pitch Trim Compensator extended. Probably the pilots used nose-down trim to counter the 34 lb. nose-up pressure on the yoke. Then the loss of pitch stability and the dark night did the rest.
Boeing demonstrated ignorance of this history. After tests found the original MCAS design was inadequate to the task, MCAS was made much more powerful. They did not tell the FAA.
Worse, the software for MCAS was a quick and dirty contract job, performed by people who were neither pilots nor aerodynamic engineers.
The bottom line is that none of these functions with access to the stab – trim brake, speed trim, MCAS, and others – is flight control software. Single channel systems cannot be so called.
Boeing is now caught in liar’s corner. Yes, they got certification, but the FAA doesn’t know how deadly MCAS is because Boeing didn’t tell them.
And they can’t tell the pilots that in order to allow MCAS to operate unimpeded, they have also disabled the trim brake and changed the stab cutout switches, removing the possibility of disabling software access to the stab while retaining their own.
They can’t even tell the pilots MCAS exists, because that would require transitional simulator training, and that would mean a $1 million penalty to Boeing for each aircraft destined for Southwest.
Our airlines may not be any help. Southwest pilots have brought a $115 million lawsuit against Boeing for loss of wages. (The Seattle Times of October 9, 2019, In scathing lawsuit, Southwest pilots’ union says Boeing 737MAX was unsafe). However, Southwest has said in response to the lawsuit:
“As our CEO Gary Kelly has previously stated, All Southwest Employees have been impacted by the Max grounding, and it is our intent to allocate, as appropriate, any compensation received from a Boeing business settlement with all Employees via Profit Sharing.”
Translation: even though 346 people have died, there is still profit in this airplane for all of us. Come back to work and fly it, and we’ll pay you for your trouble.
The Pilot Trap
There is another, much more insidious lie. It was inserted into our collective aviation consciousness not by Boeing, but by an institutional investor. This investment company owns more Boeing stock than anyone else. In April of this year, they paid for an Article by Don McGregor and Vaughn Cordle, The Boeing 737 MAX 8 Crashes: The Case For Pilot Error. Since this article was published (April 9, 2019), many pilots have taken the bait:
Yes, I am a good pilot. Unlike many (third world) amateurs, I could have saved those MAX’s.
That is exactly what Boeing (and maybe your airline) wants you to think.
The lie was reinforced dramatically by William Langewiesche’s article in the New York Times Magazine of September 18, 2019, What Really Bought Down the Boeing B737 Max?.
Fortunately, another important article was published on the same day in the New Republic. It is called Crash Course: How Boeing’s Managerial Revolution Created the B737 Max Disaster, and is by Maureen Tkacik.
This second article is worth a read, especially if you are beginning to doubt that the MAX crashes were pilot error.
Captain Chesley (Sully) Sullenberger wrote a letter to the editor in response to the Langewiesche article. It was published in the New York Times Magazine of October 13, 2019. I can’t find a link to it, so here is is, verbatim:
Letters to the Editor,
New York Times Magazine,
Re: What Really Brought Down the Boeing 737 Max?
October 13, 2019
William Langewiesche draws the conclusion that the pilots are primarily to blame for the fatal crashes of Lion Air 610 and Ethiopian flight 302. In resurrecting this age-old aviation canard, Langewiesche minimizes the fatal design flaws and certification failures that precipitated those tragedies, and still pose a threat to the flying public. I have long stated, as he does note, that pilots must be capable of absolute mastery of the aircraft and the situation at all times, a concept pilots call “airmanship”. Inadequate pilot training and insufficient pilot experience are problems worldwide, but they do not excuse the fatally flawed design of the Maneuvering Characteristics Augmentation System that was a death trap. As one of the few pilots who have lived to tell about being in the left seat of an airliner when things went horribly wrong, with seconds to react, I know a thing or two about overcoming an unimagined crisis. I am also one of the few who have flown a Boeing 737 MAX Level D full-motion simulator, replicating both accident flights multiple times. I know firsthand the challenges the pilots on the doomed accident flights faced, and how wrong it is to blame them for not being able to compensate for such a pernicious and deadly design. These emergencies did not present as a classic runaway stabilizer problem, but initially as ambiguous unreliable airspeed and altitude situations, masking the M.C.A.S. The M.C.A.S. design should never have been approved – not by Boeing, and not by the Federal Aviation Administration. The National Transportation Safety Board has found that Boeing made faulty assumptions both about the capability of the aircraft design to withstand damage or failure, and the level of human performance possible once the failures began to cascade. Where Boeing failed, the F.A.A. should have stepped in to regulate, but it failed to do so. Lessons from accidents are bought in blood, and we must seek all the answers to prevent the next one. We need to fix all the flaws in the current system – corporate governance, regulatory oversight, aircraft maintenance, and, yes, pilot training and experience. Only then can we assure the safety of everyone who flies. (my emphasis)
Capt. Chesley (Sully) Sullenberger
Sully set me on fire. I spent the rest of that Sunday (October 13, 2019) writing this piece. I cannot overstate the comfort I felt when someone of his stature in our trade was willing to speak out – and be heard, at least by a few.
I kept a diary as the slow-reveal played out during the month after the second crash. It is long, but if you are interested it is on my site stilllearningtofly.org, under Investigating the Investigations. It was written not just for professional pilots, but for everyone who travels. It is called The Max Mess: Diary of Disaster.
Would I fly the MAX? Would I fly in the MAX? Would I want my loved ones to fly in the MAX? Would I want anyone to fly in the MAX?
No. Not unless they fix it, either with a stick pusher or with proper flight control software, with triple sensors and independent parallel multichannel software. Or just forget all the software and make the stab larger.
I know this is the real world and that a proper fix is unlikely. But that doesn’t change the facts.
Boeing betrayed us.