1583028: B737 MAX-8 Captain reported the engine fuel burn was higher than expected. Maintenance confirms that several 737-MAXs are burning fuel faster than expected.
1593699: ATIS sheet fell through the slot forward of the center pedestal and the blank off plate. We had Maintenance come out to remove it. We discovered 20 other ATIS sheets mixed into the wiring. The aircraft is only six months old. Severe potential fire hazard!
1538699: B737 MAX pilots reported flying through the final approach course and descending below published altitudes due to confusion with the new style instrument displays.
1603376: B737 Captain reported the flight recorder light was inoperative, which led to the discovery that the flight data recorder was not installed.
Can anyone anyone with more experience with this say whether this is normal for a new aircraft? I get that it's easy to forget parts of the assembly process, but how do you put an aircraft into service without verifying that all the parts (especially important parts like this one) are installed?
Wouldn't it fail preflight checklists? Depending on the country I'd have thought that's a "lose your license to operate" kinda deal??
Most likely, the part is pulled for maintenance and its not properly recorded. If its not properly recorded, the plane can be put back into service without the part that was removed.
Air Canada Flight 143 is an example of maintenance records not being kept properly. https://en.wikipedia.org/wiki/Gimli_Glider
1593017: B737MAX Captain expressed concern that some systems such as the MCAS are not fully described in the aircraft Flight Manual.
Edit: A CSV of all incidents that include "MAX" in their report text: https://pastebin.com/ezhffWRn
Nothing is more infuriating than a UI redesign to fix what's not broken.
[0] https://arstechnica.com/information-technology/2017/11/uss-m...
Some reporter is wondering around the international car expo, discussing with various car makers. Mercedes tells him "our car is the most air-tight ever produced. It scored 24 on the cat test!" The reporter wonders - "cat test? what is that?" ""Oh, it's a novel test! We put the cat in the car, closed all of the windows and doors, and 24 hours later it drew its last breath".
Impressed, the reporter moves on to Ferrari. They tell him the same story - most airtight car ever made! He asks them knowingly - "How did the cat test go?" to which they proudly reply - "Oh, very well, very well! We put the cat in the car, closed all of the windows and doors, 12 hours later the poor thing was dead".
Next he wonders to the Renault-Dacia stand. They also tell him about the air-tightness of their car, again he asks how the cat test went. The Dacia representative beams: "Oh, wonderful! We put the cat in the car, closed all of the windows and doors, and wherever its head poked out, we quickly plastered over".
<90s Saturn> The panel gaps shrink in warm weather. </90s Saturn>
In case anyone was wondering that was actually a thing with early plastic body panels. They eventually refined it to the point where the gaps don't change noticeably and now pretty much every car has some plastic body panels.
The oil, though, was interesting. The s-series engine had a design flaw with the oil control piston ring where it would get stuck in its groove due to carbon build-up. The engine would then start burning prodigious amounts of oil — mine burned 1 quart every 500 miles. I put the cheapest oil I could find in as a result and when I did a filter change I’d save the old oil to pour back into the engine (diluted — about 1 qt of old oil and 3 qts of new.). By the time I used up all of the old oil it was time to change filters again.
GM treated Saturn like a throwaway brand so they used them for a lot of R&D they didn't want to risk "important brands" over and consequently there's a bunch of random Saturn cars that have features that even some new cars don't have. My friend had one from the early 2000s that would vary radio volume with speed and window position.
A popular shade tree mechanic fix was to drill drain back holes in the oil control ring groove: https://m.youtube.com/watch?v=UrnblJ8VZtY
1565207 At cruise flight, our Wi-Fi stopped working. I then saw that I was unable to access the Pilot Mobile app. Since I do not routinely copy the flight plan to iBook or acrobat (we are not required to do this), I was unable to access the flight plan. I've lost Wi-Fi before but not had this problem. Maybe it's a 737max thing. My First Officer had a copy on iBook and airdropped it to me. Later we were able to restore the Wi-Fi and I could login to pilot mobile but the [flight plan] was not there anymore.
It's time we make radio with the ATC VoIP. Just run an asterisk on the plane.
2. Perhaps I'm misjudging, but the tone and perspective of pilot makes me worry for their approach and technical skills. Does not routinely copy to local device before takeoff? "Maybe it's a 737max thing"? Airdropping as a solution?
This does not smell off setting up for success... :<
Of course, it'll fail at some point, but it's not like they were cut off from the world, they could have radioed for the information if the copilot didn't have it, or something.
My experience with WiFi routers is the opposite. I will wire anything important.
I'd like to say an airplane might work better as a controlled environment than an office building, but probably not if you have 300 passengers in the back, half of whom have forgotten their MiFi devices running in their carryon.
You know if WiFi was so awesome, wifi routers wouldn't have wires in them!
Especially if (a) it’s not part of your extensive checklists, which would reasonably be expected to be included if it was important, and (b) you’ve lost WiFi in other planes before without losing your flight plan.
I.e the airlines could save money on training.
The main design constraint on that bird was that it should pass most of the old paperwork so that Boeing nor airlines would need to go through expensive training and quification.
Yet, they modified the plane quite a bit - but they could not modernize several systems since they would have to then go through rigorous and expensive testing. ..
Nobody seems to underline this fact.
I bet that's the actual reason they didn't put the automatic pitch modification system to any documentation - it would not fit on the description of "just old 737 nothing new here hop in".
Really? Everything I heard so far sounds like the 737 MAX has a few new, unusual or counter intuitive features that require extra training, and that training material skimped on training for that.
> "just old 737 nothing new here hop in"
Am I correct in understanding that was a blatant lie?
It does not sound to me like lying, more like a confusion of project constraints. I.e. "make the plane better but don't touch this and this and this arbitrary system".
"737.{0,20}max" (case insensitive) yields 20. [0]
[0] CSV output: https://pastebin.com/87N023cx
To build on what @ggm and @siwatanejo noted. The 737 debuted in 1967, so it is 52 years old now. The 737 MAX is 2 years old. In terms of number of issues per year since the aircraft was introduced the 737 is at ~15 incidents per year and the 737 MAX is at ~10/year. But as @ggm notes, it's important to look at when in the life cycle many of the non-MAX 737 incidents occurred.
Another way to look at this is by number of aircraft produced. The Boeing website[0] gives production numbers for various classes of the 737. In terms of incidence per number of aircraft delivered the non-max 737s have 0.082 incidents per delivered aircraft while the 737 MAX has 0.05 incidents per delivered aircraft.
Both of those suggest that the 737 MAX may not be any worse than the non-max 737s, but a more careful statistical analysis is probably necessary to draw strong conclusions.
[0] http://active.boeing.com/commercial/orders/displaystandardre...
The problem might not be with the plane per se but rather with Boeing rushing a bit and relying on the fact that “it basically the same plane but better so why would there be issues”.
"all new systems have bugs. this may not be unusual"
The 737 Max is an augmented version of the original.
I think @ams6110 is saying that it may not be fair to identify the 737MAX as a completely new plane, since the 737MAX can be identified as more of an evolution of the 737 rather than a new, from-scratch plane design.
"I had my first flight on the Max [to] ZZZ1. We found out we were scheduled to fly the aircraft on the way to the airport in the limo. We had a little time [to] review the essentials in the car. Otherwise we would have walked onto the plane cold.My post flight evaluation is that we lacked the knowledge to operate the aircraft in all weather and aircraft states safely.
The instrumentation is completely different - My scan was degraded, slow and labored having had no experience w/ the new ND (Navigation Display) and ADI (Attitude Director Indicator) presentations/format or functions (manipulation between the screens and systems pages were not provided in training materials. If they were, I had no recollection of that material).
We were unable to navigate to systems pages and lacked the knowledge of what systems information was available to us in the different phases of flight. Our weather radar competency was inadequate to safely navigate significant weather on that dark and stormy night. These are just a few issues that were not addressed in our training.
I recommend the following to help crews w/ their introductory flight on the Max:Email notification the day before the flight (the email should include: Links - Training Video, PSOB and QRG and all relevant updates/FAQ's)SME (Subject Matter Expert) Observer - the role of the SME is to introduce systems navigation, display management, answer general questions and provide standardized best practices to the next generation aircraft.Additionally, the SME will collect de-identified data to provide to the training department for analysis and dissemination to the line pilots regarding FAQs and know systems differences as well best practices in fly the new model aircraft."
[EDIT] Fixed ACN Number
I'd assume that when the 777's came out even pilots with experience on the 767 and other Boeing planes were still given ample training beforehand. The minor difference in the Max's model name disguises the seemingly large difference in their operation.
The determination to shoehorn what aerodynamically kind of is a new type of plane into the 737's type rating seems likely to be the root cause of these deaths.
Given that investigation in both accidents is still ongoing and all we know is wild speculation your conclusion is premature even though it finally may turn out to be true.
(Also, I don't agree that we only know "wild speculation" about the Lion Air crash. The investigators have told us much about the proximate cause of the crash, even though their final investigation is not yet complete.)
There may or may not be something inherently problematic about the way the MCAS works, but more thorough training would likely have lowered the chance of these accidents happening - having the same type rating was one of the root causes for the lacking training
It's a damning indictment of Boeing, and whichever authorities let them get away with it, that they pushed through an aircraft with a different pilot UI/UX knowing that pilots would then be under trained when using it: like someone said we train baristas better.
I've driven minibuses before and always ensure to get an hour of driving a new model before taking passengers.
That would seem to fall directly on the operator / carrier.
Boeing takes responsibility if the training manuals were not comprehensive. Aviation authorities take responsibility if they under-mandated training. But ultimately neither know a given carrier's scheduling and pilot allocation.
If the carrier was told by Boeing and the FAA that no additional training was needed, why would they use any different procedure.
At some point this falls back on nannyism. Either you have a functional company, where your employees are empowered to communicate internally, and your company does something about it... or you don't.
Boeing's job is to engineer the billion things required to keep an airplane flying. The government's job is to validate Boeing performed due diligence and mandate what training is required to the carriers. The carriers have a job too.
I wouldn't be surprised if Boeing pushed hard to have it same type certified. Why wouldn't they? Ultimately, regulatory agencies agreed. Maybe that was correct, maybe not.
But absolving the pilots' direct parent company of responsibility is bullshit. Aerospace is a different industry, but it's not that different vis what a healthy, functioning company does.
Ultimately Boeing and the airlines share responsibility for ensuring the training is adequate, thats why many airlines have lots of training that goes above and beyond what Boeing supplies.
Not that 90 minutes on a tablet constitutes a reasonable level of training though.
It's likely that people rewrote their memories of the event. It's also likely that the MCAS induced stresses on the plane caused a turbine flameout.
It wouldn't even be surprising if the aerodymanic stress had caused a breakup, though that doesn't seem to have happened judging by the crater.
Why would boeings shuffle around such critical human+machine interfaces?
That model name would’ve been worse. The 737-800 is very commonly abbreviated to 738 in the industry (739 being 737-900, 744 being the 747-400, etc).
(Yes, that sorta stuff annoys me ;) e.g. people talking about v2.04 of $project, when they really mean v0.204 - sure, I get it, but at some point the searchability for issues on the internet is going to be screwed!)
Are these changes not noticeable until you're in the air or should pilots have been refusing to take off in a plane they're not familiar with?
I'm not familiar with the plane and I'm not a pilot, but from reading the report it sounds like they were able to do the checks OK – but that took time.
It also sounds like the instrumentation displays on the plane very helpfully have modes and some kind of menu system. The references to stages of flight make it sound like these modes become available dynamically. So it seems quite probable that it isn't possible to actually navigate the screens in the air in the same way as on the ground.
Compare the 737 MAX8 cockpit [0] with the 737-800 cockpit [1] and the 737-300 cockpit [2]. Then consider that all of these planes are under the same type rating [3] – so a pilot trained on one of them is good for all of them.
There's also a lot of commercial pressure on pilots to not refuse to take off in a plane – which could lead to bizarre consequences like the airline questioning their competence for their current type rating.
[0] https://i.ytimg.com/vi/tCXPJkC7ZwI/maxresdefault.jpg
[1] https://drscdn.500px.org/photo/35641948/m%3D2048_k%3D1_a%3D1...
[2] https://magazin.lufthansa.com/content/uploads/2016/07/Boeing...
Maybe that’s just me
However, Boeing seems to have marketed this plane under the regulatory fiction that it was the same plane as the 737, and that therefore no retraining was needed.
https://titan-server.arc.nasa.gov/ASRSPublicQueryWizard/Quer...
Furthermore, the signature feature of the MCAS failure that downed the Lion Air flight was runaway trim, and there is no indication in this report that the crew had to take any action to stop it by disabling MCAS (setting STAB TRIM CUTOUT to CUTOUT, the documented procedure for doing so), or to restore the correct trim manually (as far as I know, it would not revert to the correct setting simply because MCAS was disabled.)
As far as I am aware (totally a layperson), there have been potentially only 3 potential 737-MAX MCAS trim issue occurrences:
1. The Lion Air flight prior to the fatal lion air flight
2. The Lion air flight which crashed
3. The Ethiopian flight which crashed
Of course I don't think any of those 3 are absolutely confirmed, but I do think it seems likely the three had MCAS trim related issues. If the success rate for pilots dealing with this issue just 1 in 3, does that say anything regarding the MCAS issue difficulty/complexity or the skill/training of pilots?
The latest crash certainly looks suspicious, but we don't really know yet, and the Lion Air crash occurred before the details about how MCAS could behave on sensor failure had been revealed. One would certainly hope that after this was revealed, all Max-8 pilots would be well prepared to recognize the situation and handle it, which might suggest that there is something more (or different) about this case (which could be worse news for Boeing).
Far from certain, becaus Boeing is selling and the companies indeed treat it as "the same plane like old" even if it obviously isn't:
For obvious reasons, pilots tend to take a keen interest in matters of aviation safety, so I wonder if this was not simply a repeat of the Lion Air crash (which, as I said elsewhere, might be even worse news for Boeing.)
[1] https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf...
Day 3 of 3 departing in a MAX 8 after a long overnight. I was well rested and had discussed the recent MAX 8 MCAS guidance with the Captain. On departure, we had strong crosswinds (gusts > 30 knots) directly off the right wing, however, no LLWS or Micro-burst activity was reported at the field. After verifying LNAV, selecting gear and flaps up, I set "UP" speed. The aircraft accelerated normally and the Captain engaged the "A" autopilot after reaching set speed. Within two to three seconds the aircraft pitched nose down bringing the VSI to approximately 1,200 to 1,500 FPM. I called "descending" just prior to the GPWS sounding "don't sink, don't sink." The Captain immediately disconnected the autopilot and pitched into a climb. The remainder of the flight was uneventful. We discussed the departure at length and I reviewed in my mind our automation setup and flight profile but can't think of any reason the aircraft would pitch nose down so aggressively.
This sounds very similar to the MCAS problems on the other flights, and these pilots were aware of MCAS (this is post Lion Air).
I have not read in detail yet about the proposed update to MCAS they are working on
ACN: 1597286
"Day 3 of 3 departing in a MAX 8 after a long overnight. I was well rested and had discussed the recent MAX 8 MCAS guidance with the Captain. On departure, we had strong crosswinds (gusts > 30 knots) directly off the right wing, however, no LLWS or Micro-burst activity was reported at the field. After verifying LNAV, selecting gear and flaps up, I set "UP" speed. The aircraft accelerated normally and the Captain engaged the "A" autopilot after reaching set speed. Within two to three seconds the aircraft pitched nose down bringing the VSI to approximately 1,200 to 1,500 FPM. I called "descending" just prior to the GPWS sounding "don't sink, don't sink." The Captain immediately disconnected the autopilot and pitched into a climb. The remainder of the flight was uneventful. We discussed the departure at length and I reviewed in my mind our automation setup and flight profile but can't think of any reason the aircraft would pitch nose down so aggressively."
ACN: 1597380
"It was day three of six for me and day three with very good FO (First Officer). Well rested, great rapport and above average Crew coordination. Knew we had a MAX. It was my leg, normal Ops Brief, plus I briefed our concerns with the MAX issues, bulletin, MCAS, stab trim cutout response etc. I mentioned I would engage autopilot sooner than usual (I generally hand fly to at least above 10,000 ft.) to remove the possible MCAS threat.
Weather was about 1000 OVC drizzle, temperature dropping and an occasional snow flake. I double checked with an additional personal walkaround just prior to push; a few drops of water on the aircraft but clean aircraft, no deice required. Strong crosswind and I asked Tug Driver to push a little more tail east so as not to have slow/hung start gusts 30+.
Wind and mechanical turbulence was noted. Careful engine warm times, normal flaps 5 takeoff in strong (appeared almost direct) crosswind. Departure was normal. Takeoff and climb in light to moderate turbulence. After flaps 1 to "up" and above clean "MASI up speed" with LNAV engaged I looked at and engaged A Autopilot. As I was returning to my PFD (Primary Flight Display) PM (Pilot Monitoring) called "DESCENDING" followed by almost an immediate: "DONT SINK DONT SINK!"
I immediately disconnected AP (Autopilot) (it WAS engaged as we got full horn etc.) and resumed climb. Now, I would generally assume it was my automation error, i.e., aircraft was trying to acquire a miss-commanded speed/no autothrottles, crossing restriction etc., but frankly neither of us could find an inappropriate setup error (not to say there wasn't one).
With the concerns with the MAX 8 nose down stuff, we both thought it appropriate to bring it to your attention. We discussed issue at length over the course of the return to ZZZ. Best guess from me is airspeed fluctuation due to mechanical shear/frontal passage that overwhelmed automation temporarily or something incorrectly setup in MCP (Mode Control Panel). PM's callout on "descending" was particularly quick and welcome as I was just coming back to my display after looking away. System and procedures coupled with CRM (Resource Management) trapped and mitigated issue."
ACN: 1593017
"The recently released 737 MAX8 Emergency Airworthiness Directive directs pilots how to deal with a known issue, but it does nothing to address the systems issues with the AOA system.
MCAS (Maneuvering Characteristics Augmentation System) is implemented on the 737 MAX to enhance pitch characteristics with flaps UP and at elevated angles of attack. The MCAS function commands nose down stabilizer to enhance pitch characteristics during steep turns with elevated load factors and during flaps up flight at airspeeds approaching stall. MCAS is activated without pilot input and only operates in manual, flaps up flight. The system is designed to allow the flight crew to use column trim switch or stabilizer aisle stand cutout switches to override MCAS input. The function is commanded by the Flight Control computer using input data from sensors and other airplane systems.
The MCAS function becomes active when the airplane Angle of Attack exceeds a threshold based on airspeed and altitude. Stabilizer incremental commands are limited to 2.5 degrees and are provided at a rate of 0.27 degrees per second. The magnitude of the stabilizer input is lower at high Mach number and greater at low Mach numbers. The function is reset once angle of attack falls below the Angle of Attack threshold or if manual stabilizer commands are provided by the flight crew. If the original elevated AOA condition persists, the MCAS function commands another incremental stabilizer nose down command according to current aircraft Mach number at actuation.
This description is not currently in the 737 Flight Manual Part 2, nor the Boeing FCOM, though it will be added to them soon. This communication highlights that an entire system is not described in our Flight Manual. This system is now the subject of an AD.
I think it is unconscionable that a manufacturer, the FAA, and the airlines would have pilots flying an airplane without adequately training, or even providing available resources and sufficient documentation to understand the highly complex systems that differentiate this aircraft from prior models. The fact that this airplane requires such jury rigging to fly is a red flag. Now we know the systems employed are error prone--even if the pilots aren't sure what those systems are, what redundancies are in place, and failure modes.
I am left to wonder: what else don't I know? The Flight Manual is inadequate and almost criminally insufficient. All airlines that operate the MAX must insist that Boeing incorporate ALL systems in their manuals."
(1) The third report says that MCAS only operates in manual flight. The second report appears to confirm that since the pilot says he engaged autopilot sooner than usual to remove the possible MCAS threat.
(2) However, both the first and second reports describe uncommanded pitch down events while in autopilot. That means there is another problem in addition to the MCAS issue, since the latter should not be engaged at all when in autopilot. (If the root problem is an unreliable angle of attack sensor, that would explain both issues, since the AoA sensor would be used by the autopilot as well as by the MCAS.)
(3) We have an aircraft type that is known to have repeated uncommanded pitch down events while in autopilot, and it's still flying. Unfortunately, we already have other aircraft types (from Airbus, not Boeing) that have the same known issue that have not been grounded either. So the system as a whole simply seems to accept the risk of this happening without warning, and hoping that pilots will be able to respond as these pilots did (well done to them) and avoid an actual incident.
A330 has figured in the incidents, but AFAIK the flight control software and angle of attack sensors that are implicated in those incidents are the same in all of the Airbus models.
> They never quite figured out the root cause of the un-commanded dives
Yes, they did. Read the "Conclusion" under the "Final Report" section. The "design limitation" they're referring to is that, first, the autopilot is not driven by an average or majority vote of the three angle of attack sensors, but by one of them only (which one depends on whether the captain or first officer's position engaged the autopilot), and second, the other two angle of attack sensor inputs are not used to check the sensor that is driving the autopilot, so if that sensor gives faulty input (the "multiple spikes" described), the faulty input is allowed to trigger uncommanded events such as the violent pitch down that happened on Quantas Flight 72.
What should happen is that the input from all three angle of attack sensors should be combined: as long as all three of them are within some tolerance, the average of the three becomes the angle of attack used to drive the autopilot. If one goes out of tolerance compared to the other two, its input is discarded until it comes back into tolerance (so "multiple spikes" from one sensor would simply be ignored). If it takes too long for the one sensor to come back into tolerance compared to the other two, that sensor gets ignored for the remainder of the flight and the pilots get notified. If it gets to a point where no two of the sensors are within tolerance of each other, the autopilot gets disengaged and a big red light goes on in the cockpit. I am unable to understand why that is not how the system is designed, but the investigation reports make clear that it isn't.
From the reports:
Synopsis
B737MAX Captain reported an autopilot anomaly in which led to an undesired brief nose down situation.
Synopsis
B737 MAX First Officer reported that the aircraft pitched nose down after engaging autopilot on departure. Autopilot was disconnected and flight continued to destination.
Regardless of the usual tone, I find this particular paragraph a fairly terrifying indictment of cockpit human factors across the board. Apparently it's not unusual for aircraft behave unusually with the pilots not understanding why - and the poor pilots "generally" blame themselves!
Aircraft have many states, and there is a lot of information to process to fly an aircraft, even in normal flight. When situations develop in real time, it takes a lot of mental horsepower to understand the situation and react appropriately. Despite all this, aviation is safer than driving a car.
It is one of the reasons I find aviation to be inspiring. Conscientious humans have mastered this unforgiving domain through effort and power of will. When you talk to a real pilot, there are certain mannerisms that they share that tend to show that the practice of flying really makes you a thoughtful person.
"The fact that this airplane requires such jury rigging to fly is a red flag"
I'm wildly speculating here, but since wing loading is also a factor in calculating the angle of attack at which a potential stall condition could occur, I'm also wondering if it relies on the accuracy of the weight and balance the pilots enter into the flight computer. Pilots have missentered such critical information before.
But I know that for instance there are plenty of alarms warning the pilots about the proximity to terrain.
Besides, there were excellent visibility conditions at the time of the accident so, even if the autopilot were able to drive the plane into ground, the pilots would have realized that not only by seeing the other instruments but looking through the window as well.
The available radar data also shows there's been a struggle to keep the airplane flying. An autopilot-controlled flight into terrain wouldn't show such pattern.
The MAX family has more powerful engines, and they are a bit projected ahead under the wings. This makes the plane susceptible to point its nose up during full throttle, which could lead to a stall.
This system shouldn't be confused with the regular autopilot. It plays a completely different role and, the way it's designed, it should engage only under very specific conditions.
1. There have been 865 737 related ASRS reports since 1/1/2018
2. I don't know how to quickly separate out 737-MAX reports from the non 737-MAX reports, as the ASRS database doesn't include 737-MAX as an airplane type! From scanning, I can say that there are more than five MAX related reports, though.
[1] All 865 737 reports since 1/1/2018
CSV - http://s000.tinyupload.com/index.php?file_id=546686797940621...
DOC - http://s000.tinyupload.com/index.php?file_id=726497188798253...
[2] Airplane model filter with no MAX option: https://imgur.com/a/09rRtzX
[3] ASRS database: https://titan-server.arc.nasa.gov/ASRSPublicQueryWizard/Quer...
[4] Document linked in the article with plane models listed under 737-800 or 737-Next Generation Undifferentiated https://www.documentcloud.org/documents/5766398-ASRS-Reports...