The two tragic crashes of Boeing ’s best - selling 737 Max planes increasingly look to be caused in part bya malfunctioning automate scheme — and the pilots’lack of trainingaround how to address with it — that was designed to keep the aircraft from stalling out . The final reports are n’t in yet , but thesimilaritiesbetween the crashes in Indonesia and Ethiopia that together killed 346 people , andthe log of complaints from other pilots about the system , all point to trouble with the Maneuvering Characteristics Augmentation System , or MCAS .
In short , a combination of an unfamiliar , potentially faulty mechanisation system and a gang that was not adequately informed in how to operate or overthrow that organisation probably lead to both crashes , according to preliminary findings . One thing that ’s striking about this is that it ’s incisively the hazardous scenario that a top air guard prediction grouping has warned of for over a decennium .
In 2004 , the Future Aviation Safety Team ( FAST ) , a group first convened in 1999 by a consortium of international escape regulators and co - chaired by Brian E. Smith of NASA Ames Research Center , published a account on“Increasing Reliance on Flight Deck Automation”—a trend that was already afoot . harmonise to FAST , the report had “ two main conclusions ” :
a ) that there will be problems with maintaining “ hand - on ” currentness due to future progress in flight of steps pack of cards mechanization and
b ) that stress and fatigue duty will increase rapidly when the trajectory bunch does not empathise what flight deck mechanisation is asking the aircraft to do .
The account term this “ mechanization surprise , ” and it accurately discover what appear to have happened to the pilots attempting to overcome the MCAS system to keep their Boeing Max planes from going down . ( ‘ mechanization surprise ’ is such a potent and useful condition , it ’s one that can be applied to how we get confounded and overwhelmed by unfamiliar automated systems more generally . )
fundamentally , because the newfangled 737 Max 8 woodworking plane have engines that sit further forward on the wing than previous models , they’reprone to stalling easily if pilots tilted the nozzle too high — so the MCAS automatically recoil in to lower the nose . In the Indonesia clang , battling an MCAS that was reply to erroneous sensing element data , the pilot film push to keep the olfactory organ up , manually push it up 21 metre only to have the figurer system push it back down after every discipline — MCAS , it seems , ultimately downed the plane into the Java Sea . So far , the flying data point from the Ethiopia crash indicates a similar pattern .
Now , it is possible to override the MCAS autopilot organization , but Boeing apparentlydid not disclose how the new automation worked to airplane pilot , in what seems to be an effort to sustain the same “ type military rank ” of plane — even as itwithheld information about the hazards it pose — which helped the ship’s company avoid legion hours of pricy pilot light grooming .
So in both Indonesia and Ethiopia — and on flights that pilots logged complaints about that problem but did not crash — pilot light were subjected to mechanization surprise . The unfamiliar system kick in , mistakenly , in the case of the Lion Air flight in Indonesia , and they did not have the tools or noesis to override it in metre .
For 20 year , FAST has worked on identifyingdozens of Areas of Change(AoCs ) in the aviation field of operations , which crop from “ novel cockpit and cabin surveillance and recording system ” to “ Global organizational theoretical account ” to “ raw hypersonic aircraft ” to our “ Reliance on mechanisation abide a complex air transit arrangement , ” and researching them deep to understand how they stand up to impact passenger and pilot safety .
In the case of the 50 - page “ increase Reliance on Flight Deck Automation”study , according to FAST , the “ data came from a pilot view among more than 190 respondent , with a mean of 10,000 flying hour and 20 years in the business enterprise . ”
The top five hazards FAST identified with emerging sovereign flight organization were :
flight of stairs crew expend inordinate time in a monitoring role potentially compromise their ability to intervene when necessary
Failure of the flight of steps crew to stay mindful of mechanization mode and aircraft energy State Department
Unfamiliar modes of aircraft mechanization may result in a perfectly normal flying aircraft suddenly taking on characteristics that the pilot film has seldom or never previously meet
Latent flaws in the show or primary flight of stairs controller system may go undetected , because not enough man - in - the - loop testing is do
Pilots may not be adequately trained to empathize the doctrine of the mechanisation design when the functionality is being automatically degraded in exceptional position for reasons know only to the software
Each of the hazards I bolded above — i.e. , all but the first — all seem to have befall the two Boeing MAX flights that ended in annihilating crashes .
FAST continued to study the mechanization AoC as it develop , and in 2016 , in a report call “ Aviation Safety Concerns for the Future , ” the source drop a line that “ Although the increasing reliance on trajectory deck of cards automation has been a major component in the current lucky base hit platter of westerly commercial aviation , the abuse / misapprehension of automation has been implicate in certain high - profile accidents . ”
They look back on at least five flights where crash were attributable to mechanisation surprisal , like Air France Flight 447 , where confusion over both an automated control stick and a electronic computer scheme that intervened with misinformation at a crucial minute contributed to a dramatic crashthat killed all 228 passengers onboardthe Airbus A330 - 200 plane . ( Interestingly , at the time of that crash , Boeing was publicly resistant to employ too much mechanization . While Airbus used control stick that cowcatcher could promptly programme and spillage — leaving them in what can come along to copilot to be a neutral place , which is one of the source of discombobulation in the 447 crash — Boeing still used easily identifiable“old - fashion ” leversthat resembled their mechanical forbear , and worsen to bosom “ auto - strangulation ” in its cockpits as Airbus did .
“ In each of the fortuity listed in Table II mechanisation surprises lead the crews aside from appropriate action , ” the FAST report card explains . “ It is yet unclear whether revised breeding – for example , worried recovery grooming , new procedures or design change can prevent the occurrence of such cases in the future , because we do not fully understand human determination devising in unusual billet , ” before calling for further enquiry into behavior around automated systems .
As loyal points out , automate systems have improved safety in a great issue of ways , and have likely prevented a salutary many accident — but that ’s no exculpation for ignoring the hazards that rise by bringing new automatise systems onboard . Especially hazards that were explicitly pointed out by aviation safety groups with a large public footprint over a decade ago . Yet this keeps happening — Boeing ’s Max plane are only the recent and perhaps peculiarly rank example .
Ultimately , 346 people have lose their lives plain due , in part , to automation surprise . But if Boeing had done its preparation , andhadn’t cut cornersto keep costs down , there ’s a undecomposed chance there would have been no such shock . And mayhap , no fatalities .
I ’ve reached out to the FAA for input on whether they ’re aware of the FAST reputation and its recommendations and will update if I hear back . Thanks toHugh MacMillanfor the tip .
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