Our view: What we've got here is a fail­ure to com­mu­ni­cate

USA TODAY International Edition - - OPINION -

“Know your air­plane, fly your air­plane” is a bedrock prin­ci­ple for pi­lots.

But pi­lots can’t know their air­plane if the maker fails to dis­close a new emergency fea­ture in its flight op­er­a­tions man­ual, as hap­pened with the Boe­ing 737 Max.

On Oct. 29, the fea­ture, known by the acro­nym MCAS, re­lent­lessly pushed down the nose of In­done­sia’s Lion Air Flight 610 more than 20 times be­fore the jet plunged into the Java Sea, killing all 189 on board.

Pi­lots strug­gled against the new sys­tem, which is de­signed to pre­vent a stall by au­to­mat­i­cally push­ing the nose down. Trag­i­cally, on Flight 610 it was ap­par­ently trig­gered by a sen­sor de­liv­er­ing a false read­ing.

The 737 Max, Boe­ing’s new­est ver­sion of the work­horse 737 se­ries, is flown by air­lines around the world, in­clud­ing Amer­i­can, South­west and United. Hun­dreds more are on or­der. Since the Lion Air crash, Amer­i­can and South­west pi­lots have com­plained about Boe­ing’s fail­ure to com­mu­ni­cate.

“The key to any emergency is iden­ti­fy­ing the sys­tem that is be­tray­ing you or failed,” says Den­nis Ta­jer, a vet­eran 737 cap­tain and spokesman for the Al­lied Pi­lots As­so­ci­a­tion, which rep­re­sents pi­lots at Amer­i­can. “We did not know about the sys­tem” un­til af­ter the Lion Air crash. It was not on pre­vi­ous ver­sions of the 737. Jon Weaks, pres­i­dent of the South­west Air­lines Pi­lots As­so­ci­a­tion, put it sim­ply: “We should have known the sys­tem ex­isted.”

With all the safety built into to­day’s jet­lin­ers, it typ­i­cally takes a cas­cad­ing se­ries of events to bring down a plane. Based on a pre­lim­i­nary re­port re­leased last week by In­done­sian au­thor­i­ties and ques­tions raised by safety experts, the final flight of Lion 610 is a text­book ex­am­ple of mul­ti­ple fail­ures.

In­ves­ti­ga­tors will need to get to the bot­tom of sev­eral is­sues in­volv­ing:

Boe­ing. A po­ten­tial de­sign or manufacturing flaw might have al­lowed a sin­gle sen­sor, with an er­ro­neous read­ing, to trig­ger MCAS — which stands for Ma­neu­ver­ing Char­ac­ter­is­tics Aug­men­ta­tion Sys­tem — and the nose-down move­ments. Two sen­sors on the jet were mea­sur­ing what’s known as an­gle of at­tack, “one giv­ing you an accurate read­ing, one in­ac­cu­rate,” says for­mer Na­tional Trans­porta­tion Safety Board Chair Mark Rosenker. “The prob­lem was the in­ac­cu­rate one ap­peared to take over.” He ques­tioned why a sin­gle mal­func­tion­ing sen­sor could cre­ate a sit­u­a­tion po­ten­tially lead­ing to a cat­a­strophic fail­ure. The answer might be that it shouldn’t.

Days af­ter the crash, Boe­ing is­sued a bul­letin telling 737 Max pi­lots to deal with er­ro­neous sen­sor data and nose­down move­ments by turn­ing off the au­to­matic sys­tem, in ac­cor­dance with “ex­ist­ing pro­ce­dures.” A Fed­eral Avi­a­tion Ad­min­is­tra­tion direc­tive fol­lowed, warn­ing that faulty read­ings could cause “difficulty con­trol­ling” the plane and “pos­si­ble im­pact with ter­rain.”

Lion Air. The day be­fore the crash, Lion Air main­te­nance re­placed the sen­sor on the same plane. But pi­lots got er­ro­neous read­ings on that flight and ex­pe­ri­enced a nearly iden­ti­cal prob­lem to the one on Flight 610. Was the sen­sor in­stalled prop­erly by com­pany crews? Based on the se­ri­ous prob­lems on Oct. 28, should the plane have been grounded be­fore the fa­tal flight?

Flight 610 pi­lots. On the Oct. 28 flight, pi­lots ini­tially re­acted to the nose-down move­ments the same way as pi­lots on Flight 610 the next day. When that didn’t work, they used two switches to cut off the sys­tem — a stan­dard emergency pro­ce­dure. Oddly, the pi­lots on Flight 610 failed to do the same thing. Per­haps, faced by an in­ac­cu­rate read­ing from a faulty sen­sor and a sys­tem they likely knew noth­ing about, they were con­fused in the emergency. Per­haps they were not well-trained.

The causes of the crash will be de­ter­mined by In­done­sian au­thor­i­ties and the U.S. Na­tional Trans­porta­tion Safety Board, which has an in­ter­est in keep­ing Amer­i­can fleets safe.

Boe­ing is­sued a state­ment as­sert­ing, “We are confident in the safety of the 737 MAX.” A com­pany spokesman added that the “func­tion per­formed by MCAS is ref­er­enced” in the flight man­ual, and “ex­ist­ing pro­ce­dures” to deal with it are doc­u­mented. The chair­man of the United Air­lines branch of the Air­line Pi­lots As­so­ci­a­tion echoed that state­ment, break­ing with two other unions and his own union lead­er­ship.

Backup sys­tems, what the in­dus­try calls re­dun­dancy, are de­signed to keep planes in the air if one com­po­nent fails. The ul­ti­mate safety back­ups are the pi­lots — who de­serve to know about ev­ery change on the air­craft they fly.

PRADITA UTAMA/EPA-EFE

In­done­sians re­cover Lion Air Flight 610’s data recorder Satur­day.

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