Ethiopian Airlines Boeing 737 MAX crash

[CatsEyes]

If the jet is as safe as Boeing was saying just a couple of weeks ago, I wonder if you loaded a 737-Max with Boeing owners, top execs, designers - and their families, whether they'd trust their lives to it?

 

[Toastie]

I’m going to go out on a limb here!

A lot of criticism is (rightly) being levelled at Boeing. What they (appear) to have done is inexcusable but for me, the question that needs asking is “why did they do it?” The unpalatable answer is “because they were allowed to”. In other words, Regulators the world over failed to regulate. Those who’ve read any of my previous posts on various threads will recognise my recurring theme!

Aviation is like the restaurant industry; you get on a plane expecting to get off safely at the other end in the same way as you go to a restaurant in the expectation you’re not going to get food poisoning. How the food is delivered, packaged, prepared, cooked and served is essentially a back room function we know little about, carried out by people we know little about but trust nevertheless. If we didn’t, we’d never get on a plane / go out for a meal. I could cite dozens of issues that’d make your hair curl and ensure you’d look into ferry travel but then the same probably applies to the merchant marine. It is only when an aircraft crashes or someone dies of food poisoning after eating out that these concerns get aired and people ask questions. How many newspaper articles have you read with headlines like “aircraft arrives safely despite crew being so tired their mental acuity was equivalent to having drunk 5 pints of beer” or “great meal had by all despite cockroaches infesting filthy kitchen”?

So how does this happen? Various regulators are charged with setting rules and enforcing them without fear or favour and without regard to the financial consequences an adverse decision might have on the people they are regulating. Both aviation and the restaurant trade are largely left to self regulate, “here are the rules, take action to remain within them”. It’s at this point that the two trades diverge. Food Standards and Environmental Health actively monitor compliance and take action where shortfalls are identified, they close restaurants and issue enforcement notices, they do it publicly. When was the last time you saw a “This airline is certified as 5 star for safety” sticker on the aeroplane door? There’s a reason for that, the Regulator doesn’t know and the reason it doesn’t know is because it doesn’t look, largely ignores those who tell it and fails to act on the evidence preferring to cite the evidence that all is well because aircraft aren’t crashing. And then one crashes. And another one. Then we have reactive measures put in place that largely ignore the central issue because that’d be tantamount to an admission of failure and that costs people their jobs. Never mind that this particular case has cost 346 people their lives. Wholly avoidably. The only reason they weren’t UK airframes was blind luck. To be fair to the airlines, they were told by the Authority that it was all fine, again, why would they question the organisation that supposedly sets the standard?

The above food agencies are well staffed and knowledgeable and take their work seriously. Crucially, they don’t charge those they’re inspecting.

The Civil Aviation Authority is understaffed, has lost most (?all) it’s technical expertise and is immediately conflicted by the simple fact it charges those it’s supposed to regulate for regulating them. There is a failure in regulatory oversight and regulatory capture as a result. The FAA are in the same boat. They handed much of the certification process to Boeing because they, the FAA didn’t have the time, resources, expertise or will to do it themselves. I’d bet my next pay cheque on the CAA simply rubber stamping the FAA certification process and so the problem arrived on these shores unchecked.

Let’s face it, how many of us paid for extra driving lessons to improve our skills beyond the basic skills required to pass the test? Why do insurers charge new drivers more and why are P plates all the rage? We know new drivers are more of a risk yet we endorse the above on the grounds of cost. Why pay more? Why would you expect Boeing and the airlines to do anything different?

It takes regulatory oversight to identify a problem, regulatory capture to accept it, regulatory governance to decide on a solution and enact it and lastly regulatory enforcement to ensure it’s complied with. The DVLA identified new drivers killing themselves on motorways as a problem, realised the reason why was motorway driving was not a teaching or testing requirement, made it so and you cannot now pass a driving test unless you prove competence in motorway driving.

And so on.

Unless you’re a National Aviation Authority that is unable or unwilling to exercise its authority.

 

[06FA56Paderborn]

Snip. They handed much of the certification process to Boeing because they, the FAA didn’t have the time, resources, expertise or will to do it themselves.

It does seem that lack of regulatory oversight is also part of the problem. However from my position whilst sat in the back of the aircraft I was under the impression that function (quoted from your informative post), is the core business of the FAA (and CAA), if they are not carrying out this process what are they doing and how does it contribute to flight safety?

 

[Lindermyer]

. I’d bet my next pay cheque on the CAA simply rubber stamping the FAA certification process and so the problem arrived on these shores unchecked.

Small (pedantic) point - surely it would be an EASA rubber stamp (Particularly since EASA regs are a rewrite of JARs in themselves a direct copy of the US FAA FARs**
CAA being limited these days to tasks on behalf of EASA with the exception of state aviation (eg Police helicopters).


**By Direct copy I mean scan edit some words and replace FAR with JAR - Undeniably so because when reading JAR 145 some page headers had been missed and still said FAR 145.

 

[Lardbeast]

I’m going to go out on a limb here!

A lot of criticism is (rightly) being levelled at Boeing. What they (appear) to have done is inexcusable but for me, the question that needs asking is “why did they do it?” The unpalatable answer is “because they were allowed to”. In other words, Regulators the world over failed to regulate. Those who’ve read any of my previous posts on various threads will recognise my recurring theme!

Aviation is like the restaurant industry; you get on a plane expecting to get off safely at the other end in the same way as you go to a restaurant in the expectation you’re not going to get food poisoning. How the food is delivered, packaged, prepared, cooked and served is essentially a back room function we know little about, carried out by people we know little about but trust nevertheless. If we didn’t, we’d never get on a plane / go out for a meal. I could cite dozens of issues that’d make your hair curl and ensure you’d look into ferry travel but then the same probably applies to the merchant marine. It is only when an aircraft crashes or someone dies of food poisoning after eating out that these concerns get aired and people ask questions. How many newspaper articles have you read with headlines like “aircraft arrives safely despite crew being so tired their mental acuity was equivalent to having drunk 5 pints of beer” or “great meal had by all despite cockroaches infesting filthy kitchen”?

So how does this happen? Various regulators are charged with setting rules and enforcing them without fear or favour and without regard to the financial consequences an adverse decision might have on the people they are regulating. Both aviation and the restaurant trade are largely left to self regulate, “here are the rules, take action to remain within them”. It’s at this point that the two trades diverge. Food Standards and Environmental Health actively monitor compliance and take action where shortfalls are identified, they close restaurants and issue enforcement notices, they do it publicly. When was the last time you saw a “This airline is certified as 5 star for safety” sticker on the aeroplane door? There’s a reason for that, the Regulator doesn’t know and the reason it doesn’t know is because it doesn’t look, largely ignores those who tell it and fails to act on the evidence preferring to cite the evidence that all is well because aircraft aren’t crashing. And then one crashes. And another one. Then we have reactive measures put in place that largely ignore the central issue because that’d be tantamount to an admission of failure and that costs people their jobs. Never mind that this particular case has cost 346 people their lives. Wholly avoidably. The only reason they weren’t UK airframes was blind luck. To be fair to the airlines, they were told by the Authority that it was all fine, again, why would they question the organisation that supposedly sets the standard?

The above food agencies are well staffed and knowledgeable and take their work seriously. Crucially, they don’t charge those they’re inspecting.

The Civil Aviation Authority is understaffed, has lost most (?all) it’s technical expertise and is immediately conflicted by the simple fact it charges those it’s supposed to regulate for regulating them. There is a failure in regulatory oversight and regulatory capture as a result. The FAA are in the same boat. They handed much of the certification process to Boeing because they, the FAA didn’t have the time, resources, expertise or will to do it themselves. I’d bet my next pay cheque on the CAA simply rubber stamping the FAA certification process and so the problem arrived on these shores unchecked.

Let’s face it, how many of us paid for extra driving lessons to improve our skills beyond the basic skills required to pass the test? Why do insurers charge new drivers more and why are P plates all the rage? We know new drivers are more of a risk yet we endorse the above on the grounds of cost. Why pay more? Why would you expect Boeing and the airlines to do anything different?

It takes regulatory oversight to identify a problem, regulatory capture to accept it, regulatory governance to decide on a solution and enact it and lastly regulatory enforcement to ensure it’s complied with. The DVLA identified new drivers killing themselves on motorways as a problem, realised the reason why was motorway driving was not a teaching or testing requirement, made it so and you cannot now pass a driving test unless you prove competence in motorway driving.

And so on.

Unless you’re a National Aviation Authority that is unable or unwilling to exercise its authority.

Not to mention a lot of oversight is arse covering by the regulator to make sure no shit splashes back when it all goes wrong. Engineers sign away their lives and fill out reams of paperwork to assure the regulator they're doing it right, so much so that it entails a large proportion of their job.

At the same time, due to the loss of expertise, the regulator is often unable to assist and point them in the right direction when they run into technical problems. Inspectors going around hangars who are shit hot at the paperwork and will tear you a new one for an incorrectly filled in form, but unable to inform or answer questions regarding the tech side ofthe operation and barely know what they're looking at in some cases.

All they're capable of inspecting is the paperwork that covers the arse of the regulating authority. Be very afraid.

 

[Toastie]

It does seem that lack of regulatory oversight is also part of the problem. However from my position whilst sat in the back of the aircraft I was under the impression that function (quoted from your informative post), is the core business of the FAA (and CAA), if they are not carrying out this process what are they doing and how does it contribute to flight safety?

You are correct, it is a core responsibility. They’re not doing it (and much else besides). It doesn’t contribute to Flight Safety, arguably quite the opposite.

https://www.balpa.org/About/Files/M-Simkins-vs-Thomas-Cook-Airlines-Ltd-ET-Judgment.

Although the link refers to a different matter, it takes 40 pages to say an airline essentially tried to force a pilot to do something illegal, disciplined him when he refused and then lied / frigged the evidence when challenged.

They were challenged by the pilot, not the CAA who did nothing and refuse to acknowledge there’s even an issue.

 

[exbluejob]

I’m going to go out on a limb here!

A lot of criticism is (rightly) being levelled at Boeing. What they (appear) to have done is inexcusable but for me, the question that needs asking is “why did they do it?” The unpalatable answer is “because they were allowed to”. In other words, Regulators the world over failed to regulate. Those who’ve read any of my previous posts on various threads will recognise my recurring theme!

Aviation is like the restaurant industry; you get on a plane expecting to get off safely at the other end in the same way as you go to a restaurant in the expectation you’re not going to get food poisoning. How the food is delivered, packaged, prepared, cooked and served is essentially a back room function we know little about, carried out by people we know little about but trust nevertheless. If we didn’t, we’d never get on a plane / go out for a meal. I could cite dozens of issues that’d make your hair curl and ensure you’d look into ferry travel but then the same probably applies to the merchant marine. It is only when an aircraft crashes or someone dies of food poisoning after eating out that these concerns get aired and people ask questions. How many newspaper articles have you read with headlines like “aircraft arrives safely despite crew being so tired their mental acuity was equivalent to having drunk 5 pints of beer” or “great meal had by all despite cockroaches infesting filthy kitchen”?

So how does this happen? Various regulators are charged with setting rules and enforcing them without fear or favour and without regard to the financial consequences an adverse decision might have on the people they are regulating. Both aviation and the restaurant trade are largely left to self regulate, “here are the rules, take action to remain within them”. It’s at this point that the two trades diverge. Food Standards and Environmental Health actively monitor compliance and take action where shortfalls are identified, they close restaurants and issue enforcement notices, they do it publicly. When was the last time you saw a “This airline is certified as 5 star for safety” sticker on the aeroplane door? There’s a reason for that, the Regulator doesn’t know and the reason it doesn’t know is because it doesn’t look, largely ignores those who tell it and fails to act on the evidence preferring to cite the evidence that all is well because aircraft aren’t crashing. And then one crashes. And another one. Then we have reactive measures put in place that largely ignore the central issue because that’d be tantamount to an admission of failure and that costs people their jobs. Never mind that this particular case has cost 346 people their lives. Wholly avoidably. The only reason they weren’t UK airframes was blind luck. To be fair to the airlines, they were told by the Authority that it was all fine, again, why would they question the organisation that supposedly sets the standard?

The above food agencies are well staffed and knowledgeable and take their work seriously. Crucially, they don’t charge those they’re inspecting.

The Civil Aviation Authority is understaffed, has lost most (?all) it’s technical expertise and is immediately conflicted by the simple fact it charges those it’s supposed to regulate for regulating them. There is a failure in regulatory oversight and regulatory capture as a result. The FAA are in the same boat. They handed much of the certification process to Boeing because they, the FAA didn’t have the time, resources, expertise or will to do it themselves. I’d bet my next pay cheque on the CAA simply rubber stamping the FAA certification process and so the problem arrived on these shores unchecked.

Let’s face it, how many of us paid for extra driving lessons to improve our skills beyond the basic skills required to pass the test? Why do insurers charge new drivers more and why are P plates all the rage? We know new drivers are more of a risk yet we endorse the above on the grounds of cost. Why pay more? Why would you expect Boeing and the airlines to do anything different?

It takes regulatory oversight to identify a problem, regulatory capture to accept it, regulatory governance to decide on a solution and enact it and lastly regulatory enforcement to ensure it’s complied with. The DVLA identified new drivers killing themselves on motorways as a problem, realised the reason why was motorway driving was not a teaching or testing requirement, made it so and you cannot now pass a driving test unless you prove competence in motorway driving.

And so on.

Unless you’re a National Aviation Authority that is unable or unwilling to exercise its authority.

I have been following, with interest, your views on aircraft regulation. In ATC things are very different. Yes each country has it's own regulator (In Europe EASA sits above that) but, in general, they do not give 'approval' for changes to procedures, new systems etc. What you get is a LONO (Letter of no objection). The reason being that the various ANSPs (Air Navigation Service Providers, in UK mainly NATS) have to satisfy the people that provide the service (the controllers) that it's safe.
We follow the EASA guidelines and the EUROCAE standards, write safety cases etc. However if the controllers are not happy using whatever the new 'thing' is then they won't use it.

 

[Toastie]

Small (pedantic) point - surely it would be an EASA rubber stamp (Particularly since EASA regs are a rewrite of JARs in themselves a direct copy of the US FAA FARs**
CAA being limited these days to tasks on behalf of EASA with the exception of state aviation (eg Police helicopters).


**By Direct copy I mean scan edit some words and replace FAR with JAR - Undeniably so because when reading JAR 145 some page headers had been missed and still said FAR 145.

Yes in terms of setting the regulation, no in terms of policing it. Essentially the rules have EASA written at the top and the responsibility for oversight and enforcement is devolved to the National Aviation Authorities, the CAA in the U.K.

Not to mention a lot of oversight is arse covering by the regulator to make sure no shit splashes back when it all goes wrong. Engineers sign away their lives and fill out reams of paperwork to assure the regulator they're doing it right, so much so that it entails a large proportion of their job.

At the same time, due to the loss of expertise, the regulator is often unable to assist and point them in the right direction when they run into technical problems. Inspectors going around hangars who are shit hot at the paperwork and will tear you a new one for an incorrectly filled in form, but unable to inform or answer questions regarding the tech side ofthe operation and barely know what they're looking at in some cases.

Which is the other side of the same problem. With the advent of EASA the CAA was stripped to a husk. There is zero expertise any more, the place is full of bureaucrats who endlessly debate the meaning of words in what are actually pretty simple rule sets. The result is endless shades of grey that are exploited.

The CAA used to be an Authority in every sense of the word; you went to them for the definitive answer, black or white. Now we have all that devolved to those who are supposed to be being regulated and they’re now given endless latitude in the shades of grey interpretation of the black and white rules.

It’s the crux of the MAX issue IMHO, the Regulator devolved the act of regulation to those they were supposed to regulate, Boeing, and gave them endless shades of grey to manoeuvre within.

 

[Toastie]

I have been following, with interest, your views on aircraft regulation. In ATC things are very different. Yes each country has it's own regulator (In Europe EASA sits above that) but, in general, they do not give 'approval' for changes to procedures, new systems etc. What you get is a LONO (Letter of no objection). The reason being that the various ANSPs (Air Navigation Service Providers, in UK mainly NATS) have to satisfy the people that provide the service (the controllers) that it's safe.
We follow the EASA guidelines and the EUROCAE standards, write safety cases etc. However if the controllers are not happy using whatever the new 'thing' is then they won't use it.

See the link to the Tribunal above......

 

[Harry Clampers]

If the jet is as safe as Boeing was saying just a couple of weeks ago, I wonder if you loaded a 737-Max with Boeing owners, top execs, designers - and their families, whether they'd trust their lives to it?

A similar question was asked of the Board of Airbus Helicopters after the grounding of their EC225 following another gearbox self-destruction.

 

[Toastie]

A similar question was asked of the Board of Airbus Helicopters after the grounding of their EC225 following another gearbox self-destruction.

And is being asked of the Glasgow night club helicopter accident. I’m not at liberty to discuss the details of that because the case is ongoing but Airbus have hired a staggeringly expensive legal team to shift the onus of the questions away from the allegedly poorly designed fuel control system which is alleged to be a human factors nightmare and on to the poor standard of Piloting.

Poor design becomes poorly certified design becomes pilot error.

Is there an echo in here?

 

[Harry Clampers]

And is being asked of the Glasgow night club helicopter accident. I’m not at liberty to discuss the details of that because the case is ongoing but Airbus have hired a staggeringly expensive legal team to shift the onus of the questions away from the allegedly poorly designed fuel control system which is alleged to be a human factors nightmare and on to the poor standard of Piloting.

Poor design becomes poorly certified design becomes pilot error.

Is there an echo in here?

A task made simpler in the absence of surviving aircrew. I have a particular interest in the crash of G-WNSB, as a dear friend failed to escape the cabin after the pilots allowed the cab to get into an unrecoverable situation off a relatively benign approach.

 

[Toastie]

Thinking on this more, another example is grapes!

Boeing designed the MCAS system into the aircraft with the very best of intentions, stopping aircraft falling out of the sky but the execution of the plan was flawed.

Parents were giving small children grapes with the very best of intentions, getting fruit into their kids. And then kids started choking on them.

Or the tragic case a few years back where a young mum decided that gravy dinners for her baby were a better and cheaper alternative to shop bought baby food. She used a lot of gravy to purée the meals not realising the gravy powder had lethally high salt levels for a baby.

Neither of these cases were deliberate acts of malice but both, particularly the gravy case could have been avoided by equipping people with an understanding of possible unforeseen and undesirable outcomes.

It’s a fine line I know, dangerously close to the Nanny State but the assumption that you can put something new in the market or posit a new idea and everyone will see all the risks is an incorrect one. It’s the role of the Regulator to identify those risks or at least require the manufacturer to do so and then to ensure the risk is promulgated.

Granted, difficult with grapes!

 

[Toastie]

A task made simpler in the absence of surviving aircrew. I have a particular interest in the crash of G-WNSB, as a dear friend failed to escape the cabin after the pilots allowed the cab to get into an unrecoverable situation off a relatively benign approach.

Aircraft Accident Report AAR 1/2016 - G-WNSB, 23 August 2013

The causal factors are reasonably clear but look at the casual factors. 3 of the 4 were down to poor procedures, not poorly executed procedures. Approval of procedures is a regulatory function. Why were poor procedures in place that allowed the crew or in fact required the crew to get into that situation in the first place?

And my condolences on the loss of your friend.

 

[Harry Clampers]

Aircraft Accident Report AAR 1/2016 - G-WNSB, 23 August 2013

The causal factors are reasonably clear but look at the casual factors. 3 of the 4 were down to poor procedures, not poorly executed procedures. Approval of procedures is a regulatory function. Why were poor procedures in place that allowed the crew or in fact required the crew to get into that situation in the first place?

And my condolences on the loss of your friend.

Thanks. It was a Friday afternoon, marginal weather forecast for Aberdeen, so they planned on a fuel-stop at Sumburgh for a possible diversion to Edinburgh. The cloudbase at Sumburgh precluded a precision approach, hence they elected a cross-wind procedural approach over open water, running-in at MDH to the MAP, during which they allowed the airspeed to decay to the point where VRS should have been considered. Over-reliance on automation? Speed governed by the AP? Yes, I know that the SOP was and still is to make maximum use of automated systems, but this seems to be at the expense of raw handling skills. The relatively inexperienced co-pilot seemed content to let the commander's judgement over-rule his misgivings, so it's as much a human-factors issue as one of blindly following company procedure. Both looking for approach lights as they reached MAP, neither noticing the speed wash-off and the nose-up attitude increase. It's possible that they spotted a cloud-break and turned downwind straight into VRS.

 

[ancienturion]

At the same time, due to the loss of expertise, the regulator is often unable to assist and point them in the right direction when they run into technical problems. Inspectors going around hangars who are shit hot at the paperwork and will tear you a new one for an incorrectly filled in form, but unable to inform or answer questions regarding the tech side ofthe operation and barely know what they're looking at in some cases.

Surely all that makes some sort of case for having specialist regulators for various aspects. Could such be obtained by use of older/retired people from the trade?

 

[Toastie]

Surely all that makes some sort of case for having specialist regulators for various aspects. Could such be obtained by use of older/retired people from the trade?

That’s what used to happen and at least notionally, still does. There are any number of retired specialists in the various departments of the CAA (or at least retired from active duty). CAA Ops Inspectors still fly with the various airlines occasionally but only with that particular airline’s Training Captains. The problem is not so much with the guys on the front line, it’s more to do with policy and policy makers who give them direction. The various heads of the CAA over the years have included a world class yachtsman and a champion athlete. The current board is heavy on those with regulatory experience in things like utilities but only 2 have any real experience as aviation professionals. The Chair is essentially a political appointee, currently Dame Deidre Hutton.

The problem is that these people are great at ticking off water companies for high bills or the post office for late deliveries but none of them have sat half way across the Atlantic or in an ATC Centre or in a gloomy hangar at 0300 and experienced the front line of aviation; they’re all from a business background used to dealing with business people at arms length.

A classic example is their Aviation Medicine branch. I had a heart problem and the hoops I had to jump through to tick off the CAA boxes to get my licence back were old hat 20 years ago according to my cardiologist, some were no longer relevant having been superseded by medical advances and one was downright discredited, the cardiologist (when you Google him he makes the top 5 in the world) didn’t even have the kit to do the test any more, it went in the skip years ago.

Businesses of all types are now run by an unholy alliance of accountants and HR bods, long gone are the days of people with practical experiences of the function of that business and therefore an understanding of the implications of their decisions being involved, and with it has gone any hope of a business being able to regulate itself in anything other than costs. The Regulators are yet to wake up to that.

 

[Lardbeast]

...they’re now given endless latitude in the shades of grey interpretation of the black and white rules...

Until it splashes back on the regulator, in which case all the arse covering documents signing away your rights and enforcing culpability miraculously appear.

SACAA pretty much gutted of competent engineers and now staffed by desk jockeys and arse covering bureaucrats. No chance of any advice re patching ceconite or which AN bolt to use in a situation but they'll have your head for not crossing the tees and dotting the ies on the avalanche of paperwork they hold up to justify their existence (paperwork they require be generated by already overworked engineers and others in the industry).

You now have a situation where inadequate attention is paid to work on the shop floor to allow that attention to be spent on mostly pointless documentation.

 

[Le_addeur_noir]

Yes in terms of setting the regulation, no in terms of policing it. Essentially the rules have EASA written at the top and the responsibility for oversight and enforcement is devolved to the National Aviation Authorities, the CAA in the U.K.



Which is the other side of the same problem. With the advent of EASA the CAA was stripped to a husk. There is zero expertise any more, the place is full of bureaucrats who endlessly debate the meaning of words in what are actually pretty simple rule sets. The result is endless shades of grey that are exploited.

The CAA used to be an Authority in every sense of the word; you went to them for the definitive answer, black or white. Now we have all that devolved to those who are supposed to be being regulated and they’re now given endless latitude in the shades of grey interpretation of the black and white rules.

It’s the crux of the MAX issue IMHO, the Regulator devolved the act of regulation to those they were supposed to regulate, Boeing, and gave them endless shades of grey to manoeuvre within.

Has not the CAA over the last couple of decades morphed from the highly-respected Civil Aviation Authority to the much derided Cnuts Against Aviation?.

The CAA was respected by many up to the 1980/1990s, which is why many of out ex colonies use (or used) CAA standards in their own certification processes.

 

[Le_addeur_noir]

Boeing cuts 737 production,

Boeing cuts 737 production after Max crashes