Tuesday, January 10, 2023

Did Ethiopian Officials Use Boeing Problems to mask their own?

 I got this from a 3rd party source, it touched on something that I remember reading about a while ago, especially with 3rd world carriers, I recall reading somewhere "ICAO" commissioned a survey after the accident of "Bhoja Air" and the anonymous survey asked the pilots and First Officers about how they got their ratings and 1/3 of the pilots and FO's stated that they were encouraged to "offer incentives" to get help get their ratings and the results stunned the people that saw the report.  They expected a certain amount of "lubrication" I suppose, but to have that high of a percentage surprised them.   Now to have the Ethiopians throw the 737 under the bus(pardon the pun) and totally ignore indemic problems with their state airline shows a certain blindness and I recall that to own an airline is a big deal to a country, it is a prestige thing and to besmirch the airline is to besmirch the country and that just ain't done to the hand that feeds you.  As Londo Mollari said from Babylon 5 commented....


An aviation accident report is supposed to answer more questions than it raises, fostering lessons learned that often apply far beyond the specific chain of events at the center of the probe.

Here, Ethiopia’s final report on the March 2019 crash of Ethiopian Airlines Flight 302 (ET302) falls short. Ethiopian investigators do a thorough job detailing Boeing’s now well-documented—and accurate—737 MAX development missteps set the stage for two fatal accidents.


They do an even better job ignoring numerous red flags that point to major issues within government-owned Ethiopian Airlines’ flight training protocols and the country’s ability to conduct adequate safety oversight.

Two fatal 737-8 crashes—ET302 and Lion Air Flight 610, in October 2018—had similar accident sequences. A poorly designed system—the 737 MAX’s maneuvering characteristics augmentation system (MCAS)—activated erroneously, confusing and overwhelming the pilots. The one major difference: the ET302 crew had the benefit of specific instructions issued after the Lion Air accident that explained MCAS, warned of the Lion Air crash’s specific failure scenario, and provided instructions on how to counteract it.

Had the pilots followed that protocol, they probably would have saved the airplane—though the report says nothing of the sort. Instead, its probable-cause statement pins the accident solely on MCAS’s uncommanded, unneeded nose-down inputs. 

The NTSB, in comments on a draft of the ET302 final report released after the probe was completed, pulls no punches in assessing the Ethiopians’ analysis. 

Yes, NTSB concluded, MCAS “should be part of the probable cause for this accident.” But there is more to the story.

“We believe that the probable cause also needs to acknowledge that appropriate crew management of the event, per the procedures that existed at the time, would have allowed the crew to recover the airplane even when faced with the uncommanded nose-down inputs,” the U.S. agency wrote.

In their final report, Ethiopian investigators contend the crew was overwhelmed by a series of alerts and warnings triggered by the same problem—a faulty angle-of-attack sensor—that activated MCAS roughly 1 min., 30 sec. after takeoff. They also claim instructions from Boeing on how to counteract MCAS were confusing.

That may be true.

But it doesn’t explain why the pilots failed to execute routine checklists—or even acknowledge flight deck prompts—in response to several warnings triggered after takeoff but before the first MCAS activation. 

The final report is largely silent here, too. Instead, it claims two alerts on the pilots’ primary flight displays did not activate, despite overwhelming evidence to the contrary.

According to the French BEA investigation agency, damning parts of the cockpit voice recorder transcript were edited to help mask the pilots’ confusion and lack of basic crew resource management (CRM). 

“During this [initial flight] phase ... the coordination and the communication between the captain and the [first officer] were very limited and insufficient,” the BEA wrote in its own comments. “There was no discussion nor diagnosis with respect to the nature of the events on board. The situational awareness, problem solving, and decision making were therefore deeply impacted.”

BEA also agrees with the NTSB’s probable-cause analysis.

“The BEA believes that the crew’s inadequate actions and the insufficient [CRM] played a role in the chain of events that led to the accident, in particular during the first phase of the flight, before the first MCAS activation,” the agency wrote in its comments on the draft report.

“It is regrettable that the report does not include a thorough analysis of the reasons for the behaviors observed, in relation with their training, their experience and the company organization with regard to the training and knowledge acquisition principles,” BEA added.

Perhaps Ethiopian aviation safety officials have addressed these issues behind the scenes, getting to the bottom of why ET302’s pilots performed so poorly. Were they simply bad at their jobs, or—more likely—were they victims of inadequate training and safety oversight? And if it’s the latter, what has Ethiopian Airlines and the Ethiopian Civil Aviation Authority done to mitigate these risks?

The ET302 report touches on none of this. From an aviation safety improvement standpoint, that is truly regrettable.

 

3 comments:

  1. It's easier to condemn the manufacturer of an aircraft than to acknowledge a problem with training and safety. Suing the pilots is fruitless, third world politics make suing an important airline risky, and if all else fails, some money will be offered to make everyone go away.

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  2. If I remember correctly, there were some 'issues' with how many actual hours the FO had too... CRM IS important!

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  3. During the period of time between Lion Air and Ethiopian, the MCAS malfunction that destroyed the Lion Air and Ethiopian planes also occurred 8 times in North America divided between US and Canadian carriers that bought the Max. In every cases it was addressed so quickly it was a non event and a logbook writeup.nSeems years of sitting next to a Boeing trim wheel and knowing that if it goes full tilt more than four turns without a damn good reason , you hit the stab trim cut out switches and then figure things out. This wasn't reported on media channels etc due to political/economic expedient reasons. But makes more sense out of Ethiopian .

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