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Flight JT610: Update - 9 Nov 2018. 

Emergency AD link provided by Grant Brophy off twitter:

Grant Brophy
@airsafetyman
Emergency AD 2018-23-51: the Boeing Company Model 737-8 & 737-9 airplanes. https://t.co/37xroHOmIT #aircraft

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And for a good breakdown of the Boeing service bulletin please refer to this Air Current blog piece: https://theaircurrent.com/aviation-safet...air-crash/

Not even going to try and keep up with the constant stream of media coverage on JT610, especially now with the Boeing service bulletin and subsequent emergency FAA AD.

To say that this tragic accident and ongoing investigation is rapidly escalating would be an understatement - 

Anyway in the interest of trying to sort the wheat from the chaff I have picked out a copy of articles/blogs that have come out in recent days after some of the JT610 AAI developments.

First from Christine Negroni's Flying Lessons blog:

The Hidden Message in Boeing’s Lion Air Service Bulletin

November 8, 2018 / Share your comments... http://christinenegroni.com/the-hidden-m...n/#respond

(photo courtesy www.merdeka.com)

From the time the pilots retracted the flaps of the new Lion Air jetliner that flew as Flight 610, they were presented with anomalous readings, chaotic warnings and an airplane that was not flying as it should. This is what can be learned reading between the lines of the service bulletin Boeing sent to airlines operating the planemaker’s newest 737, the MAX.

The airplane crashed into the sea 13 minutes after taking off from Jakarta on October 29th killing 189 people. In the bulletin, Boeing says during the Lion Air crash investigation, it was determined that a faulty reading of the flight sensor measuring the plane’s angle of attack “can cause uncommanded nose down stabilizer trim movements” without the pilots’ input.

Further, the nose down maneuvers could last as long as 10 seconds and reoccur every 5 seconds even when the autopilot is turned off.  Boeing says “there will be no indication to the pilots that the stabilizer trim is activating.”  In response, pilots are told to disconnect the system controlling the position of the horizontal stabilizer.
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It is an indication that very early in the flight, possibly as soon as the flaps were retracted, (extended flaps inhibiting the stabilizer trim) the pilots of the brand new airliner were dealing with an unexpected loss of altitude, a problem the pilots may not have understood and from which they did not have sufficient time to diagnose and respond.

At American, which has sixteen MAX aircraft it its fleet, spokesman Ross Feinstein said the document reiterated “existing, well-established procedures for 737 MAX 8 pilots.” And some pilots to whom I spoke to agree, instances of uncommanded nose down can occur for reasons other than this faulty sensor and pilots are trained to deal with them.

“There has been training for a runaway stabilizer trim since the beginning of time. We train for it in the sim,” said Cort Tangeman, an airline pilot who flies the MAX. You can have a ground fault on the side of the motor and you have to know how to stop it.”



Many factors could have increased the difficulty of recovery for the Lion Air pilots;  including the lack of an indication that the plane was going nose down and a series of sensory alarms on the flight deck triggered by the erroneous information.

“There are so many hidden things in there and it’s only getting more complicated,” Tangeman said. “You can get a stick shaker and it has nothing to do with airspeed. That’s the confusing part of having data in an electronic airplane send information to the jet telling it to do stuff and telling you to do stuff that’s not right. You have to figure it out and the only way to figure that out is with experience, unfortunately.”

The pilots of Lion Air Flight 610 reportedly had five and six thousand hours of flight time, though it is not clear whether that was total accumulated time or time in the 737. But their time in the MAX had to be brief considering it came into the fleet just months earlier. It is possible that given the choice of trusting their own judgment or the information offered from their brand spanking new airplane, they opted to believe the airplane and its erroneous data.

One factor commands attention; the early onset of the problem. Automatically sending the airplane into a nose down orientation could have begun as soon as the crew retracted the flaps after takeoff. Looking at Flight 610’s flight profile from Flight Aware, two 737 pilots told me it had an unusual flight profile from the time of takeoff. Meaning that the pilots were burdened during a time of high workload and without the benefit of altitude and therefore time.

“Unreliable airspeed tricks the airplane into thinking its stalling. It’s showing you are stalling on the airspeed indicator. You have to determine by what its really doing. And again, that takes a lot of experience,” Tangeman told me.[/size]
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This dilemma is likely to get closer scrutiny according to an American air safety investigator to whom I spoke but who wished to remain unidentified. Pointing to other accidents in which pilots failed to recognize bad data or mishandled an airplane in an auto recovery mode, this investigator said the Lion Air probe “should be part of a broader question about airplane design and pilot training and whether the procedures generated are predicated on basic assumptions on how pilots will react and interpret information.”

Assuming that pilots will be able to quickly diagnose and react appropriately to an unexpected event is nothing new. That’s what simulator training is for. What’s still a work in progress are effective methods for managing safety in the digital age – when the computer competes with the pilot for control of the flight.

“Does this whole system have one failure mode which could cause a cascading failure with a human component? It appears as if it does,” John Gadzinski, of Four Winds Aerospace Safety Corp and a Boeing 737 Max pilot told me in a discussion of the Boeing service bulletin.

“If that one failure mode can make the system work against its intended function,” which is to prevent the airplane from stalling, “then the whole system is working against the pilot.”

So while Boeing’s alert to airlines may be – as American says – a reiteration of procedures already taught to pilots, make no mistake, the logic that allows pilots to find themselves in a situation like Lion Air 610 is about more than the pilots. It’s about the airplane too.[/size]

Next from Jamie Freed via Reuters...  

After deadly Lion Air crash, new focus on torrid industry growth in Indonesia

Jamie Freed, Fanny Potkin

JAKARTA (Reuters) - In April 2013, a Lion Air Boeing 737 missed the runway on the Indonesian resort island of Bali in bad weather and plowed into the sea, cracking its fuselage open on the rocks.


A pilot of Lion Air Group leaves an aircraft simulator after a routine practice session at Angkasa Training Center near Jakarta, Indonesia, November 2, 2018. REUTERS/Willy Kurniawan

All 108 on board survived. But a September 2014 report by Indonesia’s air crash investigators highlighted errors and poor training, saying the 24-year-old co-pilot had failed to adhere to the “basic principles of jet aircraft flying.”

Lion Air, struggling to get off a European Union blacklist because of “unaddressed safety concerns,” asked Airbus, which supplies part of its fleet, to help improve training.

The EU removed the privately owned budget airline from the list in 2016 after it determined Lion Air met international safety standards. None of Indonesia’s roughly 100 airlines - most of them tiny - remain on the EU blacklist, with the last few coming off in June. All were banned in 2007; the national carrier, Garuda Indonesia, was the first to be removed in 2009.

The crash of a Lion Air jet on Oct. 29 into the sea off Jakarta has put a spotlight back on the airline’s safety record, although the cause remains undetermined. None of the aircraft’s 189 passengers and crew survived.

Lion Air’s latest crisis illustrates the challenge relatively new carriers face as they try to keep pace with unstoppable demand for air travel in developing nations while striving for standards that mature markets took decades to reach.

Retired air force chief of staff Chappy Hakim, an adviser to the transport ministry, told Reuters he avoided flying with Lion Air or other Indonesian airlines, with the exception of Garuda, which has not had a fatal crash since 2007.
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“I know Garuda,” he said of the national carrier. “The other airlines, I don’t believe they do the maintenance and training properly.” He declined to elaborate further.

Lion Air Managing Director Daniel Putut disputed any laxity in the airline’s safety culture, stressing that it conducted maintenance in accordance with manufacturer guidelines.

The Directorate General of Civil Aviation, the Indonesian aviation authority, did not respond to multiple requests for comment about Lion Air’s safety record.
Putut, a former pilot, also told Reuters during a visit to the airline’s training center near the Jakarta airport that it complied with all regulatory requirements.
He said Lion Air had worked hard to install an attitude of “zero tolerance” for accidents after the Bali crash, making last week’s disaster a painful eye-opener. Thousands of Lion Air flights have taken off and landed without serious incident since then.

“We are also looking into what went wrong - new aircraft, experienced crews, and we have applied the zero-tolerance culture, yet another accident happened,” Putut said. “But we still don’t know the cause, so we will wait for the investigation from NTSC (National Transportation Safety Committee).”

SAFETY CULTURE

Frank Caron, head of a risk consulting firm who served as Lion Air’s safety manager from 2009 to 2011 after insurance companies requested a foreign expert, said that at the time he was troubled by what he regarded as the airline’s attitude that accidents were inevitable.

“Safety is much more than running concepts and procedures,” he said. “Safety is a spirit, a state of mind, a way of thinking, an attitude in the daily aspects of an operational life. And that is precisely what Lion never got. They would say, ‘The airline has 250 flights a day, it is not abnormal that you have accidents.’”

For example, after the 2013 Bali crash, Lion Air co-founder Rusdi Kirana told local media who asked about the airline’s safety record: “If we are seen to have many accidents, it’s because of our frequency of flights.”

Caron claimed he left Lion Air after some of his safety recommendations were not implemented. Lion Air’s chief executive declined to comment on Caron’s account of his departure or his other assertions.

Indonesian accident investigators made four recommendations after the Bali crash, including that Lion Air should “ensure that all pilots must be competent in hand flying” and teach proper cockpit coordination.

They also urged the aviation authority to ensure all airlines under its control did the same.

Putut said Lion Air embraced those recommendations.

Between the Bali crash and the one last week, Lion Air had three non-fatal accidents, including one in April in which a 737 skidded off a runway, according to Flight Safety Foundation’s Aviation Safety Network database.

Since it began operating 18 years ago, Lion Air has seen a total of eight planes damaged beyond repair in accidents, two of which killed a combined 214 people, according to the Aviation Safety Network database.

During the same period, five jets from its chief rival, the national carrier Garuda Indonesia (GIAA.JK), were damaged beyond repair, and two accidents killed a combined 22 people, according to the database. Garuda declined to comment about its safety record.

Since the 2013 Bali crash, Lion Air has sought to improve safety by gaining European Aviation Safety Agency (EASA) certification for its pilot training and maintenance facilities.

EASA certifies its training center to instruct other airlines’ pilots on A320 simulators and is seeking the same approvals for 737 jets and ATR72 turboprops, said Audy L Punuh, Lion Air’s Angkasa Pilot Training Organisation Director.

RAPID GROWTH

Lion Air has expanded quickly since it started flying in 2000, overtaking national carrier Garuda by capturing more than half of the domestic market and establishing offshoots in Thailand and Malaysia.
It has ridden a wave of aviation growth in Indonesia, where air travel has become critical for the economy.

Domestic air traffic more than tripled in Indonesia over the past decade as prosperity and low fares made flying affordable for more people.

With 129 million passengers in 2017, the Southeast Asian country was already the world’s 10th-largest aviation market and is projected to continue growing.

That growth has been accompanied by an air-accident rate that was twice the global average in 2017 and consistently higher than Indonesia’s neighbors in the Association of Southeast Asian Nations, according to the United Nations’ aviation agency.

Indonesian pilots are allowed to fly a maximum of 110 hours a month, which is more than the 100 hours in most other countries.

Last year seven commercial planes were damaged beyond repair around the world, according to Boeing data; two were in Indonesia, wrecked in non-fatal accidents involving Sriwijaya Air and Tri M.G. Airlines.

LATEST CRASH

Flight JT610 took off from Jakarta at 6:20 a.m. on Oct. 29, bound for Bangka island, off Sumatra, and plunged into the sea 13 minutes later. Just before the crash, the pilot asked to return to the airport.

The aircraft flew erratically on its previous flight and its airspeed readings were unreliable, according to an accident investigator and a flight tracking website.

Investigators on Monday said the flight data recorder from the downed jet showed an airspeed indicator had been damaged during its final four flights, raising questions about maintenance and mechanical problems.

Boeing said on Wednesday it had issued a bulletin to airlines reminding pilots about what it described as existing procedures for handling erroneous data from sensors.

The Federal Aviation Administration later issued a directive calling for revisions to “operating procedures of the airplane flight manual.”
It is too early for regulators to decide whether to reconsider the decision to remove Lion Air from the EU blacklist, EU Ambassador to Indonesia Vincent Guerend told Reuters.

“The European Commission continues to monitor the situation on a regular basis,” he said. “It is still too early to have any conclusive views on the causes of the accident.” 

(This story fixes typo in name of Lion Air’s Angkasa Pilot Training Organisation Director) 

Reporting by Jamie Freed, Fanny Potkin, Jessica Damiana, Cindy Silviana, Fathin Ungku, Ed Davies, Gayatri Suroyo and Tabita Diela in Jakarta and Tim Hepher in Hong Kong; Editing by John Chalmers and Gerry Doyle
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MTF...P2