[Peetwo]

NTSB v ATSB - Like chalk and cheese?? 

In regards to the ongoing investigations and inquiries into the Boeing 737-MAX, I note the following press statement from the NTSB 2 days ago (NB: report/recommendations link at the bottom of the page): 

 NTSB Issues 7 Safety Recommendations to FAA related to Ongoing Lion Air, Ethiopian Airlines Crash Investigations
9/26/2019
WASHINGTON (Sept. 26, 2019) — The National Transportation Safety Board issued seven safety recommendations Thursday to the Federal Aviation Administration, calling upon the agency to address concerns about how multiple alerts and indications are considered when making assumptions as part of design safety assessments. 

Aviation Safety Recommendation Report 19-01 was issued Thursday stemming from the  NTSB’s ongoing support under International Civil Aviation Organization Annex 13 to Indonesia’s Komite Nasional Keselamatan Transportasi (KNKT) investigation of the Oct. 29, 2018, crash of Lion Air flight 610 in the Java Sea and the Aircraft Accident Investigation Bureau of Ethiopia’s investigation of the crash of Ethiopian Airlines flight 302 near Ejere, Ethiopia. All passengers and crew  on board both aircraft – 346 people in all – died in the accidents. Both crashes involved a Boeing 737 MAX airplane.

The seven safety recommendations issued to the FAA are derived from the NTSB’s examination of the safety assessments conducted as part of the original design of Boeing’s Maneuvering Characteristics Augmentation System (MCAS) on the 737 MAX and are issued out of the NTSB’s concern that the process needs improvement given its ongoing use in certifying current and future aircraft and system designs.

“We saw in these two accidents that the crews did not react in the ways Boeing and the FAA assumed they would,” said NTSB Chairman Robert Sumwalt. “Those assumptions were used in the design of the airplane and we have found a gap between the assumptions used to certify the MAX and the real-world experiences of these crews, where pilots were faced with multiple alarms and alerts at the same time. It is important to note that our safety recommendation report addresses that issue and does not analyze the actions of the pilots involved in the Lion Air and Ethiopian Airlines accidents. That analysis is part of the ongoing accident investigations by the respective authorities.”

The NTSB notes in the report that it is concerned that the accident pilots’ responses to unintended MCAS operation were not consistent with the underlying assumptions about pilot recognition and response that were used for flight control system functional hazard assessments as part of the Boeing 737 MAX design.

The NTSB’s report further notes that FAA guidance allows such assumptions to be made in certification analyses without providing clear direction about the consideration of multiple, flight-deck alerts and indications in evaluating pilot recognition and response. The NTSB’s report states that more robust tools and methods need to be used for validating assumptions about pilot response to airplane failures in safety assessments developed as part of the U.S. design certification process.

The seven recommendations issued to the FAA urge action in three areas to improve flight safety:

• Ensure system safety assessments for the 737 MAX (and other transport-category airplanes) that used certain assumptions about pilot response to uncommanded flight control inputs, consider the effect of alerts and indications on pilot response and address any gaps in design, procedures, and/or training.
  
• Develop and incorporate the use of robust tools and methods for validating assumptions about pilot response to airplane failures as part of design certification.
  
• Incorporate system diagnostic tools to improve the prioritization of and more clearly present failure indications to pilots to improve the timeliness and effectiveness of their response.
  

NTSB investigators continue to assist the KNKT and AAIB in their ongoing investigations. The NTSB has full access to information from the flight recorders, consistent with standards and recommended practices for the NTSB’s participation in foreign investigations. 

The KNKT’s accident report is expected to be released in the coming months, and their analysis of the Lion Air accident may generate additional findings and recommendations.

Aviation Safety Recommendation Report 19-01 is available online at https://go.usa.gov/xVv7P.

This is the Washington Post article link summarising that report and subsequent statements by the NTSB Chairman Robert Sumwalt: 

NTSB cites competing pilot warnings and flawed safety assumptions on Boeing 737 Max

The company assumed the feature in certain circumstances could pose a “major” hazard, but not a “catastrophic” one, according to the NTSB. Boeing underestimated the risk and overestimated pilots’ ability to handle any problems with the feature.

“Their assumptions were inaccurate, and did not portray how reality actually played out,” NTSB Chairman Robert L. Sumwalt said in an interview.

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The Federal Aviation Administration should require Boeing to make a more rigorous analysis of how its warning systems might overwhelm pilots, the NTSB said. The safety board also said the same problem could affect other passenger planes beyond the Max and recommended that the FAA address such shortcomings broadly.

“They’re getting all these different alerts. That’s the actual scenario that never got evaluated in the simulator,” said Dana Schulze, director of the NTSB’s Office of Aviation Safety.


The FAA should require that safety assessments consider the effect of multiple alerts, she said.

“Clearly, if the underlying process has a deficiency, it’s going to affect more than just potentially one aircraft,” she added. “What we’re not saying is that there’s broadly a safety issue in all these airplanes. We’re saying, ‘This is an opportunity to improve the process to ensure that the human aspect is considered,’ ” Schulze said.

Now compare that to this load of drivel from the Hooded Canary and his aviary...  

ATSB investigation highlights risks of community service flights

“The community could reasonably expect that community service flights would have a level of safety at least commensurate with other private operations, if not higher. However, this investigation has shown that those conducted for Angel Flight are actually less safe than other private operations, let alone charter and scheduled airline flying,” Commissioner Hood said.

ATSB issues recommendations for improved aircraft design tolerance to inadvertent dual control inputs

“What this report seeks to achieve is to influence further incremental safety improvements,” ATSB Chief Commissioner Greg Hood said.


“This serious incident demonstrates aircraft and aircraft systems need to be designed in anticipation of and tolerant to foreseeable inadvertent pilot actions.

“Further, when identified, aviation safety regulators and aircraft manufacturers need to address previously unforeseen aircraft design consequences during the operational life of an aircraft type.”

P2 comment: Note that HVH states that this was a 'serious incident', in actual fact this categorised under both the ICAO and ATSB standards as an 'accident' due to the flight attendant incurring a serious injury ie broken leg.   

And the HVH on the importance of checklists - FDS...

Yet there the DFO sits with...



Ref: Airports - Buy two, get one free.


And from sometimes Executive Director of Aviation Safety...

 

Next going back to the REAL world of AAI, I noted the following excellent podcast links of World-renowned aviation-industry consultants and former NTSB investigators John Goglia and Greg Feith. who have 100 years of worldwide aviation safety experience between them.

 

Flight Safety Detectives
Leisure:Aviation

The Flight Safety Detectives Takeoff
2019-08-23 Download

Episode 1
 
Why would two guys with 100 years of flight safety experience between them want to dive back into the politics, the technology, the human factors and other aspects of the worldwide aviation industry? Because, often, it's a matter of life and death and billions of dollars are at stake. 

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Flight Safety Detectives
Leisure:Aviation

The Aftermath, Causes and Results of the Deadly Lion Air Crash
2019-09-18 Download

Episode 2
 
"That was a brand new airplane. If they had a problem, why didn't they go back to Boeing for a brand new part?"

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Flight Safety Detectives
Leisure:Aviation

Who's Accountable and What Caused the Ethiopian Airlines Crash?
2019-09-18 Download

Episode 3
 
"In the US we have the NTSB which is an independent investigative authority.  Ethiopia does not have that. How is it that that they are going to be held accountable?" 

 
 Now compare that to this absolute load of waffle and horse pooh audio from the Hooded Canary and his executive A-Team at the recent Senate Angel Flight embuggerance inquiry...  

(From about 1hr 2min)

 Ref: https://auntypru.com/forum/showthread.ph...7#pid10577


Hmm...no further comment required me thinks?? 


MTF?- Undoubtedly...P2