A US reviewer initially lost us a lot of sales for our second edition taking offence at our piece on how a fabulously expensive US warship designed to fight World War III found itself larking around with Iranian gunboats and in the process shot down an Iranian airliner on a scheduled flight. (The loss of the Pan Am 747 over Lockerbie, Scotland, was just possibly a consequence of this.)
Interestingly, it was not so much the captain’s decision to fire that was the problem, but the circumstances, in that he was at the time chasing Iranian speedboats (mini-gunboats) with a billion dollar ship to claim combat experience when he shouldn’t have been.
In fact, our account was accurate, as Australia’s “60 Minutes” TV program confirmed.
The original all-in-one second edition of Air Crashes and Miracle Landings has a detailed account (See extract). [Note: Large print edition does not have detailed accounts of military actions.]
In early comments on the Boeing 737 MAX disasters Donald Trump tweeted that airliners were becoming too complicated (Click here).
The problem with that is that the 737 MAX in many respects is not a modern airliner. It is based on design work done in the 1960s and is not a fly-by-wire aircraft with an integrated control system.
The article to which we supply the “Click Here” link explains this.
There have been a number of fiery evacuations with passengers bringing their their hand luggage with each time everyone getting out, though sometimes injured.
In the Air France overrun at Montreal it was touch an go with one passenger blocking an aisle as he unpacked his bag. Passengers on the British Airways 777 that caught fire at Las Vegas had large bags, but fortunately the aircraft had only been half full.
The Sukhoi Superjet Crash in Moscow (Click Here) is an example of how dangerous taking your luggage can be for others. Perhaps part of the problem is that people exist in a bubble–say at the front of the aircraft in relative safety unaware of the severity the fire at the back or of the possibility that an explosion may engulf the whole aircraft in seconds.
There have been many suggestions regarding ways to stop people collecting their luggage including the locking of the overhead bins, though this would have to be automatic and have some facility to deal with a fire in the bin, say caused by a lithium battery. Ensuring passengers have essential items such as medication in a mini-bag would help. Confiscation of luggage taken in an evacuation might be a help but difficult to put into practice world-wide. Making passengers criminally liable for deaths or injuries would be difficult to prove in court.
Here is the end to our piece on the “Miracle on the Hudson” from our book Air Crashes and Miracle Landings:
Comparison with Ditching of Ethiopian Airliner
The media immediately contrasted Sully’s ditching and its perfect outcome with the imperfect one by Captain Leul Abate, the Ethiopian Airlines pilot who ditched his 767 off a beach, with one wing snagging the water and the aircraft spinning around before breaking up, with many lives lost. (A number of passengers were trapped due to premature inflation of their life vests causing them to float upward in the water-filled cabin.)
[Described earlier in this chapter.]
However, the two ditchings are not comparable:
1. Abate was coming down in the sea with waves;
2. A hijacker was grabbing at the controls;
3. With no fuel left, electrical power was only being provided by the ram air turbine (RAT), a wind-driven generator;
4. With only minimal electric power for the most basic instruments and controls, he could not use any flap and was therefore traveling much too fast, with the aircraft difficult to control.
However, like Sully he did well to come down somewhere where boats could come to the rescue of survivors.
A Very Close-run Thing
Only when one looks closely at the photos of the occupants of the A320 perched precariously on its wings does one realize what a close-run thing it was. The aircraft could have sunk deeper; there could have been jostling, with people falling into the water and dragging others with them.
Again, Sully did great—going twice up and down the cabin to check everyone was out and telling rescuers to first save those on the wings. But had the bird strike occurred a little earlier, with the aircraft not quite so high, he would not have been able to skirt the George Washington Bridge and come down at a shallow angle on the Hudson, let alone at a point where rescue craft were at hand.
It was a miracle—call it what you like—that Sully’s great feat was capped by the perfect rescue, thanks to an almost unbelievable combination of factors and, not least, diligence—and nothing went seriously wrong, as it so easily could have.
Boeing 737 MAX deliveries will surely regain momentum, though it may take time to get approvals from the various regulatory authorities now that the FAA has lost its sheen.
Airlines, in particular low-cost-carriers, have put so much investment in the 737 and are not in the main going to move to Airbus, even though they may suggest the possibility to get better terms from Boeing. In fact, Airbus would not be able to ramp up production very significantly.
Parallels with the DC-10
However, there are some parallels with the sad history of the McDonnell Douglas DC-10. Design was rushed in order to compete with the Lockheed’s L1011 TriStar.
In 1972, a DC-10 flying along the border between the US and Canada almost crashed when it became almost uncontrollable when a cargo hold door blew out with the result that the pressure differential between the passenger cabin and the hold caused the cabin floor to buckle.
The hydraulic lines and cables to the tail were attached to the underside and damage to these was what was making the aircraft difficult to control. Fortunately the floor had been reinforced to support a piano for an inaugural event and the pilots were left with just enough control to bring the aircraft back to the airport with good airmanship, adjusting the power of the low-slung engines to raise and lower the nose.
Within three weeks of the Detroit/Windsor scare, the NTSB made two urgent recommendations:
1. Modification of the DC-10 door-locking mechanism so that it is physically impossible to bring the vent-flap-locking handle to its stowed position without the C-latch locking pins being fully engaged.
2. Vents (holes) should be incorporated in cabin floors to greatly relieve sudden pressure differentials, such as those caused by the opening of a cargo hold door in flight.
The Gentleman’s Agreement
The NTSB could only advise. It was up to the FAA to make these two modifications mandatory.
Just when the FAA was about to issue an airworthiness directive (AD) making interim and long-term solutions mandatory for all US operators of the DC-10 (which foreign operators would have followed), discussions between the FAA administrator and the president of the Douglas division of McDonnell Douglas led to the senior FAA technical staff being overruled. Douglas and the FAA were no doubt being subjected to pleading from US airlines, who would not want to take their aircraft out of service in the peak summer season. So, the FAA did not issue that airworthiness directive. Instead, McDonnell Douglas almost immediately issued recommendations, in particular the installation of a “lock mechanism viewing window.”
This gentleman’s agreement between the FAA administrator and McDonnell Douglas’s Douglas division president sufficed to prevent a repeat accident in the United States, but not to prevent a DC-10 crashing after taking off from Paris for London with the loss of 345 lives.
The FAA hurriedly made the measures the NTSB had recommended mandatory. These included floor vents. Passengers are safer now thanks to that.
The DC-10 was only grounded when a DC-10 taking off from Chicago lost an engine and crashed.
Further to this, the public lost confidence in the DC-10 and sales petered out. This was unfair as the engine had fallen off because maintenance workers had contrary to instructions used a fork lift to remove the engine and in so doing had damage the pylon. In fact, the DC-10 albeit in limited numbers flew safely for airlines for many years.
If the max were to similarly have a terrible accident in the US sometime in the future, one that was not Boeing’s fault, the public’s refusal to fly on it could, however unfairly, be a serious problem for Boeing and not least those low-cost-carriers.
This crash where a new version the 737 came down on a motorway just short of the diversion airport after the captain had shut down the good engine in the belief–based on his knowledge of the previous version–that the smoke must be coming from that one.
Furthermore, the pilots had felt the vibration and aircraft shudder, but did not refer to the engine vibration indicators clearly showing which engine had the problem because they had got out of the habit of doing so because the ones in the previous version were unreliable. This was not true for those in the new version of the 737.
When the problem engine failed completely they were too low on their approach to the airport and going too slowly to restart the good engine.
Extract from Air Crashes and Miracle Landings (85 Cases):
In total, forty-seven passengers perished, sixty-seven passengers and seven crew members were seriously injured, and four passengers and one crew member had slight or no injuries. Though considered the classic case of what not to do, there were a number of contributory factors to what came to be called the Kegworth Air Disaster, in view of its proximity to the village of that name. These include the following:
Safety expert Professor Peter Ladkin says this is the only case he is aware of where a “false positive” features in an air accident. That is to say the mistaken corrective action (shutting down the good engine) seemed to be solving the problem, thus making the pilots think they had done the right thing. This is unlike in medicine, where the long period of time over which recovery or improvement of the patient for any unrelated reason can be attributed to action by the doctor or surgeon means such false positives are well known.
The cessation of the vibrations was one thing, but to confirm things by saying that the smoke disappeared when the pilots shut down the number two engine was, with hindsight, rather dubious thinking, since smoke would not normally disappear immediately.
Engine instrument system (EIS) difficult to read
Before the introduction of two-man flight crews, the primary instruments, showing the performance of the engines were in front of the pilots, and the secondary instruments, indicating the condition of the engines, such as oil temperature and pressure and vibration, were in front of the flight engineer. However, with the sidelining of the flight engineer, these secondary instruments had to be in front of the pilots.
In the earlier version of the aircraft, the B737-300, this was done by having traditional cockpit dials with mechanical hands, as in traditional clocks, there being two panels side by side, one with the main flying instruments, and the other showing the condition of the engines. These earlier ones with needles were easy to read at a glance.
However, as anything mechanical is liable to go wrong and anyway requires costly maintenance, LEDs were used instead of mechanical hands. However, rather than redesigning the panels to take full advantage of the virtues of an electronic display, the designers wanted to maintain the same general layout so pilots could switch from one model of the aircraft to another without expensive recertification.
In reality, LEDs could not simulate the previous clocklike hands, because those available at that time could not be bunched up at the center of the dials to look like a continuous line. Instead, the designers placed three rather pathetic-looking LEDs at intervals around the perimeter of the dials.
These could still be read by pilots with good eyesight when looking for a particular reading but made comparison and noticing anything unusual more difficult. In addition, Boeing had reduced the size of the secondary engine display relative to that for the primary display instruments.
The captain and first officer had very little experience (twenty-three and fifty-three hours respectively) on the 737-400 version, and the airline did not yet have a simulator where they could have practiced using the new engine information system (EIS), with its diodes. In addition, the captain said his considerable experience with other aircraft had led him to distrust vibration readings in general, and he did not include them in his usual scan of the instruments. His conversion training had not included instruction that technical improvements meant that spurious vibration readings were very unlikely.
Training and checklists
In the training of the BMA 737 pilots, the need to think or check things out before taking precipitous action was stressed, but as already mentioned there had not been training on a flight simulator with the new hybrid EIS display. There was a checklist for what to do in case of vibration from the engines and one for what to do when smoke occurred, but not one for when they happened simultaneously.
At the time pilots at BMA had not been made fully aware that there was no need to shut down engines completely because of vibration, nor that engine fans which are vibrating or not properly aligned could have their fan tips touching the rubber seals on the periphery and that this could produce smoke and a smell of burning but did not mean the engine was on fire. Thus, as the investigators said, the situation was outside the pilots’ experience and training.
Workload and stress: Fear of fire
In many emergencies, airlines usually insist that captains take control. Captains also tend to take control in difficult situations when it is not quite an emergency. Doing something physical makes the captain feel he is coping and relieves stress. The trouble with this is that the captain is concentrating on the physical task of flying the aircraft, or, as in the case of SQ006 at Taipei, maneuvering it over the slippery taxiway in bad visibility and heavy rain, and misses the larger picture.
The flight data recorder (FDR) revealed that when the captain disengaged the autopilot, the aircraft yawed sixteen degrees to the left, a sign that the left engine was producing less power than the one on the right, but he did not seem to notice, as he did nothing to correct it. The fact that the first officer reported to ATC early on that they had an “emergency situation like an engine fire” shows they were concerned about fire, even though up to then none of the engine fire alarms had triggered.
It is an interesting psychological point that a smell can instantly transport one mentally to a certain place, and the shaking of the aircraft followed by the smell of burning may have caused the pilots to react more instinctively and precipitously than they would have done in the event of a fire-warning light coming on. Anyway, a fire warning would have immediately indicated which engine had the problem.
The official report made the additional point that having another pilot take over the handling of the aircraft—as PF (pilot flying)—meant monitoring of the instruments was less consistent than it might have been.
Up until the onset of the vibration, the first officer had been flying the aircraft and would have been concentrating on the main instruments, not the engine vibration indicator, it being the role of the PNF (pilot not flying; in this case the captain, who did not believe in scanning vibration readings) to do the general monitoring. The captain must have thought the first officer had good reason to say it was the right engine that was giving trouble.
5. Unfortunate timing.
The pilots did not have the height or speed to restart the good engine, and not enough height to choose a flat place to land. Had the airport been farther away, they would have had found the problems with the number one engine when still high enough to restart the other one.
Passengers and three cabin crew knew
Passengers at the rear who had seen the “sparks” from the left engine when the initial trouble occurred were somewhat perplexed when the captain said he had shut down the right engine but did not inform the cabin crew because the captain sounded supremely confident.
The three members of the cabin crew who had also seen the sparks apparently did not notice the captain saying the right engine had been shut down. They knew the purpose of the announcement was to reassure the passengers and were no doubt extremely busy with their own duties as they got ready for the unexpected landing.
A retired British Airways flight attendant has suggested to the author that the failure to pick up on the captain’s mistake might have come about because cabin staff themselves often get confused about left and right, as they face backwards when addressing the passengers.
Just after shutdown of the number two engine, the captain called the flight service manager (FSM) to the flight deck to tell him to clear things for landing, and at the same time asked him, “Did you get smoke in the cabin back there?” He got the reply “We did. Yes.”
This perhaps only confirmed the captain’s mistaken view that the right-hand engine must have been at fault. The FSM departed but returned a minute later to say the passengers were panicky, and it was only then that the captain announced to the passengers that a little trouble with the right engine had produced some smoke, but it would be okay, as they had shut it down, and would be landing about ten minutes thereafter.
The Mentour Aviation YouTube videos, site, and Apps have gone from strength to strength, explaining to wannabe pilots and thousands of others all aspects of flying down to minor details such as why pilots pause for a moment at medium thrust before engaging takeoff thrust on departure.
They gave the impression MentourPilot was working as captain on a small airline based in Spain flying Boeing 737s.
It came as a nice surprise that on a flight to holiday in Thailand with his young son on Qatar Airways where the first leg to the Middle East was on the Airbus A350 and the second on the Boeing 787 MentourPilot dared say that he liked both aircraft but if anything he preferred the Airbus A350, perhaps because of the slightly wider diameter of the cabin. He was not saying anything that would deter people flying on the 787.
Sadly this was followed by a video saying that flying the route the opposite way starting with the 787 made him think differently. That was OK, but the rehashing and rehashing of features such as the auto-darkening windows seemed over the top.
I would not have thought any more about this blip except that he took down a video on the 737 MAX after a few hours not realizing the impact it would have when linked to Leeham News and his collaboration with its Bjorn Fehrm. The big boys had taken notice.
The written post remains and we had A LINK to it in our previous post (a video) entitled “Boeing between A Rock and A Hard Place” explaining grandfathering and the danger of a reprogrammed MAX crashing if MCAS failed to function if too many precautions against it not doing so when not needed.
There are many comments on the above Leeham News post which says MentourPilot took down the video on the advice of a colleague and not due to pressure from his airline. (MentourPilot said the same about his colleague) in a subsequent post of his.
Seeing how his subsequent coverage of the MAX is so over the top in favor of Boeing and the future MAX I decided to look further.
Far from working for a small airline operating out of Spain, MentourPilot is working at a Spanish base of the largest low-cost carrier in Europe. One that only flies Boeing 737s and has 110 orders for the MAX 200, a high-capacity version of the MAX 8, with options on 100 more! While the airline would be careful about applying direct pressure, the esteemed colleague who who exerted so much influence, might have been subject to it and anyway neither would have wanted to kill the goose that lays the golden egg.
As an employee of such an airline it would be difficult for him to suggest that grandfathering has perhaps gone too far in the case of the 737 and that Boeing did not really want to go for the MAX in the first place.
Even so, to use his signature word, he usually does a “fantastic” job.