Here’s What Was on the Record About Problems With the 737 Max ( www.theatlantic.com )

As mentioned in these two previous reports—a long one, and a short one—some things are known, and many things are not, about the horrific crash this past weekend outside Addis Ababa, in which all 157 people aboard a new-model Ethiopian Airlines 737 Max were killed.

  • One thing that’s known: This is the second crash of this kind of plane within the past five months, following the Lion Air crash in Indonesia last year.
  • One thing that’s not known: whether the two crashes are related, which would suggest a disastrous system flaw with the 737 Max and its software.

Just this afternoon—minutes ago as I type, four days after the Ethiopian crash— aviation authorities in the United States and Canada joined their counterparts in Europe and Asia in grounding the 737 Max fleet until more is known about whether the crashes are connected and whether there is something systematically wrong with the plane.

The FAA has grounded airliners before: for instance, the 787 Dreamliner soon after its introduction, in 2013, because of onboard lithium-battery fires, and the DC-10 in 1979, after a crash that killed 273 people and that remains the deadliest aviation accident in U.S. history. Both types of airlines were cleared relatively soon to fly again. (In the 787’s case, with a redesigned battery compartment, and for the DC-10, after an investigation said that the crash was not caused by any basic design flaws. The 787 is an ongoing commercial success, and the DC-10 remained in production until the late 1980s.)  

What will happen with the 737 Max? At this point, again, no one knows—or has said publicly. As a practical matter, grounding all Boeing 737s would have an enormous  effect on world air travel, since they’re the most popular airliners on Earth, with a production run of well over 10,000. Although more than 5,000 orders have been placed for the 737 Max series, only a few hundred of them have gone into service, fewer than 100 of them with U.S. carriers, and most airlines can cancel those Max flights without fundamentally disrupting their service.

Was the FAA right to act now? Was it right to wait as long as it did? The minute-by-minute choices that organizations and their leaders are making in real timeBoeing itself, the crash investigators from the U.S. and Europe, the FAA and other civil-aviation authorities, the airlines, and others—will be studied for a very long time, and will have enormous reputational (in addition to safety-related) consequences.

By which I mean: The astonishingly good safety record of the world’s commercial-air travel system over the past generation has earned most of its members the benefit of the doubt when it comes to safety judgments. Between 2010 and 2019, exactly one person died in a crash on a U.S. passenger airline. (That was the person killed aboard a Southwest flight in 2018, when an engine exploded and the debris hit her window.) Three other people died in a crash at San Francisco airport in 2013, when a captain flying for the Korean carrier Asiana badly misjudged a landing.

By comparison: Around 100 Americans die every day in car crashes, and a similar number from gunshots, and a larger number from opioids and other drugs. The culture of safety within commercial air travel is a real thing, and it is a credit to all components of the system: the aircraft companies, the airlines (yes, despite our grumblings as passengers), the dispatchers and air traffic controllers, the weather forecasters, the flight crews and ground-maintenance operators, and even the regulators.

Thus I have presumptively given the FAA the benefit of the doubt on its calls. But when this is over, we’ll know what factors the FAA was weighing these past few days. Was it right in resisting a panicky instant reaction? Or was it being politically, nationalistically, or commercially swayed? (That is, did it want to go improperly soft on America’s leading exporter, which also happens to be a major player in all D.C. lobbying wars?) No one knows this at the moment. We will know, at some point.

Every choice made by Boeing, the FAA, and others involved in this tragedy and drama will eventually become known. Awareness that any harmful incident will be painstakingly reconstructed is itself an important part of the aviation-safety culture. (Before considering a flight in dicey conditions in our little single-engine propeller plane, my wife, Deb, and I would sometimes ask ourselves: “How would this look in the NTSB report?” That is, if something went wrong, what would they say about “the danger signs the pilot ignored..” etc?)

Boeing, like Airbus, has earned trust for decades’ worth of safe decisions. The FAA, like most of its counterparts, has earned similar trust for its safety mindedness—despite endless grievances about aspects of FAA bureaucracy from pilots, airlines, and aircraft companies. If any of them is making the wrong choices now, the airline-safety culture will certainly recover—but their reputations and credibility might not, for a very long time.


While the fundamentals remain unknown, here are some relevant primary documents. They come from an under-publicized but extremely valuable part of the aviation safety culture. This is a program called ASRS, for Aviation Safety Reporting System, which has been run by NASA since the 1970s. That it is run by NASA—and not the regulator bosses at the FAA—is a fundamental virtue of this system. Its motto is “Confidential. Voluntary. Non-Punitive.”

It’s based on the idea that anyone involved in aviation—pilots, controllers, ground staff, anyone—can file a narrative of situations that seemed worrisome, in confidence that the information will not be used against them. Pilots are conditioned to treat the FAA warily, and make no admissions-against-interest that could be used again you. “What if I confess that I violated an altitude clearance or busted a no-fly zone, and they take away my certificate?” But they’ve learned to trust NASA in handling this information, and using it to point out emerging safety problems. (I’ve filed half-a-dozen ASRS reports over the years, when I’ve made a mistake or seen someone else doing so.)

Reports flow into NASA by the dozens per day; they’re put into a searchable public database (it’s here); and every month NASA puts out a publication, Callback, listing the emerging trends.

I’ve searched just now for ASRS reports in the past year involving the 737. This past year covers the 737 Max’s introduction to airline fleets.

There are hundreds upon hundreds of these 737-related ASRS reports, amounting to more than 600,000 words total when I exported them to a text file. Significantly, at least 99% of the reports are about “normal” aviation problems, which could have happened in any kind of airplane. In one, a captain confesses that he got no sleep in a noisy hotel room the night before a flight, and nonetheless took command of a plane when he should have declared himself unfit. In another, a maintenance worker talks about an engine-start problem with a 737. In another, a pilot complains that a controller did not let him descend early enough to intercept the instrument-landing signal at a major airport. Another complains that the 737’s cockpit design let his flight manual slide down in an area that made it hard to retrieve during flight. And so on.

Below are all of the reports I could find that are related to possible runaway-trim problems with the new 737 Max. As a reminder, that is the presumed cause of the Indonesian Lion Air crash, and possibly a factor in the accident in Ethiopia. For the moment, I’m not going to provide a full annotation. Instead, I’m offering them in full, as a documentary supplement to what you’re read in the papers.

I won’t annotate or parse them, but I offer then as the documentary supplement to what you’ll read about in the papers.

The first four reports involve the aspect of the 737 Max software most in the news: its “EMACS” program that automatically lowers the nose of the plane, even if the pilot does not want the plane to descend. In these cases, it is worth noting, these U.S.-carrier pilots disabled or over-rode the system and took control of the planes themselves. Obviously none of these flights crashed.

Here we go. You’ll probably want to skip to “Narrative” and “Synopsis”:


1) From November, 2018, after the Lion Air crash.  ASRS summary: “B737MAX Captain reported an autopilot anomaly in which led to an undesired brief nose down situation.”

ACN: 1597380

Time / Day

Date : 201811

Place

Locale Reference.ATC Facility : ZZZ.TRACON
State Reference : US
Altitude.MSL.Single Value : 2000

Environment

Weather Elements / Visibility : Rain
Weather Elements / Visibility : Snow

Aircraft

Reference : X
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B737-800
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Climb
Airspace.Class B : ZZZ

Component

Aircraft Component : Autoflight System
Aircraft Reference : X
Problem : Malfunctioning

Person

Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Last 90 Days : 626
ASRS Report Number.Accession Number : 1597380
Human Factors : Human-Machine Interface
Human Factors : Confusion

Events

Anomaly.Aircraft Equipment Problem : Less Severe
Detector.Automation : Aircraft Other Automation
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : FLC Overrode Automation
Result.Flight Crew : Overcame Equipment Problem
Result.Aircraft : Equipment Problem Dissipated

Assessments

Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Aircraft

Narrative: 1

It was day three of six for me and day three with very good FO (First Officer). Well rested, great rapport and above average Crew coordination. Knew we had a MAX. It was my leg, normal Ops Brief, plus I briefed our concerns with the MAX issues, bulletin, MCAS, stab trim cutout response etc. I mentioned I would engage autopilot sooner than usual (I generally hand fly to at least above 10,000 ft.) to remove the possible MCAS threat.

Weather was about 1000 OVC drizzle, temperature dropping and an occasional snow flake. I double checked with an additional personal walkaround just prior to push; a few drops of water on the aircraft but clean aircraft, no deice required. Strong crosswind and I asked Tug Driver to push a little more tail east so as not to have slow/hung start gusts 30+.

Wind and mechanical turbulence was noted. Careful engine warm times, normal flaps 5 takeoff in strong (appeared almost direct) crosswind. Departure was normal. Takeoff and climb in light to moderate turbulence. After flaps 1 to “up” and above clean “MASI up speed” with LNAV engaged I looked at and engaged A Autopilot. As I was returning to my PFD (Primary Flight Display) PM (Pilot Monitoring) called “DESCENDING” followed by almost an immediate: “DONT SINK DONT SINK!”

I immediately disconnected AP (Autopilot) (it WAS engaged as we got full horn etc.) and resumed climb. Now, I would generally assume it was my automation error, i.e., aircraft was trying to acquire a miss-commanded speed/no autothrottles, crossing restriction etc., but frankly neither of us could find an inappropriate setup error (not to say there wasn’t one).

With the concerns with the MAX 8 nose down stuff, we both thought it appropriate to bring it to your attention. We discussed issue at length over the course of the return to ZZZ. Best guess from me is airspeed fluctuation due to mechanical shear/frontal passage that overwhelmed automation temporarily or something incorrectly setup in MCP (Mode Control Panel). PM’s callout on “descending” was particularly quick and welcome as I was just coming back to my display after looking away. System and procedures coupled with CRM (Resource Management) trapped and mitigated issue.

Synopsis

B737MAX Captain reported an autopilot anomaly in which led to an undesired brief nose down situation.


2) From November, 2018, also after Lion Air. ASRS summary: “B737 MAX First Officer reported that the aircraft pitched nose down after engaging autopilot on departure. Autopilot was disconnected and flight continued to destination.”

ACN: 1597286

Time / Day

Date : 201811

Place

Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.MSL.Single Value : 2000

Aircraft

Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B737-800
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Takeoff
Airspace.Class C : ZZZ

Component

Aircraft Component : Autopilot
Aircraft Reference : X
Problem : Malfunctioning

Person

Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Last 90 Days : 511
ASRS Report Number.Accession Number : 1597286
Analyst Callback : Attempted

Events

Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Regained Aircraft Control

Assessments

Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft

Narrative: 1

Day 3 of 3 departing in a MAX 8 after a long overnight. I was well rested and had discussed the recent MAX 8 MCAS guidance with the Captain. On departure, we had strong crosswinds (gusts > 30 knots) directly off the right wing, however, no LLWS or Micro-burst activity was reported at the field. After verifying LNAV, selecting gear and flaps up, I set “UP” speed. The aircraft accelerated normally and the Captain engaged the “A” autopilot after reaching set speed. Within two to three seconds the aircraft pitched nose down bringing the VSI to approximately 1,200 to 1,500 FPM. I called “descending” just prior to the GPWS sounding “don’t sink, don’t sink.” The Captain immediately disconnected the autopilot and pitched into a climb. The remainder of the flight was uneventful. We discussed the departure at length and I reviewed in my mind our automation setup and flight profile but can’t think of any reason the aircraft would pitch nose down so aggressively.

Synopsis

B737 MAX First Officer reported that the aircraft pitched nose down after engaging autopilot on departure. Autopilot was disconnected and flight continued to destination.


3) Also November, 2018. This is not about the automatic controls but about 737 Max documentation in general. ASRS summary: “B737MAX Captain reported confusion regarding switch function and display annunciations related to ‘poor training and even poorer documentation’”

ACN: 1593021

Time / Day

Date : 201811

Place

Altitude.AGL.Single Value : 0

Aircraft

Reference : X
Aircraft Operator : Air Carrier
Make Model Name : B737 Next Generation Undifferentiated
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Flight Phase : Parked

Person

Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 21200
Experience.Flight Crew.Last 90 Days : 178
Experience.Flight Crew.Type : 3342
ASRS Report Number.Accession Number : 1593021
Human Factors : Training / Qualification
Human Factors : Confusion

Events

Anomaly.Deviation – Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : Pre-flight
Result.General : None Reported / Taken

Assessments

Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Manuals
Contributing Factors / Situations : Procedure
Primary Problem : Manuals

Narrative: 1

This was the first flight on a Max for both pilots. Unfamiliarity with flight deck displays led to confusion about display annunciations and switch function. The Flight Manual does not address at least one annunciation, or the controls for the display—or if it does, neither pilot could find the explanation. I have spent literally days looking for an explanation, could not find one, and that is why I wrote this report. It shouldn’t be this hard to figure out what I’m looking at.

On the First Officer side ND, on the ground only, there is a MAINT annunciation. We both saw it, couldn’t find any immediate explanation for it on the ground, and didn’t address it until airborne. I researched the FM (Flight Manual) for an explanation, accomplishing a word search of the term MAINT. There are only two references I could find: the overhead MAINT light (a no go item) and the CDS MAINT light (a QRH item). There is no explanation of the ND MAINT annunciation.

We spent the entire hour flight trying to find the meaning of this annunciation and came up empty handed. We determined to check it out once we landed (if the light came on again). Sure enough, after parking, the MAINT annunciation came back on the ND display. We called Maintenance to check out the light. We waited to make an ELB entry, unsure if one was required. Turned out, an ELB entry was not required.

The mechanic explained the light was part of a menu for maintenance use only on the ground.

In addition, there are two selector knobs that are under-explained (i.e., not explained) in the manual, and we were uncertain what their purpose was. One is under the Fuel Flow switch and the other under the MFD/ENG TFR display switch. These knobs don’t seem to work in flight. The First Officer offered to hit the SEL function in flight, to test it out, but I thought something irreversible or undesirable might happen (not knowing what we were actually selecting), so we did not try it out in flight. The mechanic later explained SEL on the First Officer side was used on the ground by maintenance to toggle between the maintenance functions. I forgot to ask what my side did, and still don’t know.

Finally, in the Captain’s preflight procedure in the bulletin, it says, “Selector… C”. What selector is this referring to? Is this the same selector under the Fuel Flow switch, (which is shown in the MAX panels on the L position, as if that is the normal position?) This is very poorly explained. I have no idea what switch the preflight is talking about, nor do I understand even now what this switch does.

I think this entire setup needs to be thoroughly explained to pilots. How can a Captain not know what switch is meant during a preflight setup? Poor training and even poorer documentation, that is how.

It is not reassuring when a light cannot be explained or understood by the pilots, even after referencing their flight manuals. It is especially concerning when every other MAINT annunciation means something bad. I envision some delayed departures as conscientious pilots try to resolve the meaning of the MAINT annunciation and which switches are referred to in the setup.

Synopsis

B737MAX Captain reported confusion regarding switch function and display annunciations related to “poor training and even poorer documentation”.


4) This is the harshest-judgment report, in which the captain condemns Boeing for the insufficiency of the documentation. ASRS summary: “B737MAX Captain expressed concern that some systems such as the MCAS are not fully described in the aircraft Flight Manual.”

ACN: 1593017

Time / Day

Date : 201811

Place

Altitude.AGL.Single Value : 0

Aircraft

Reference : X
Aircraft Operator : Air Carrier
Make Model Name : B737 Next Generation Undifferentiated
Flight Phase.Other

Person

Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 1593017
Human Factors : Confusion
Human Factors : Training / Qualification

Events

Anomaly.Deviation – Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : Pre-flight
Result.General : None Reported / Taken

Assessments

Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Manuals
Primary Problem : Manuals

Narrative: 1

The recently released 737 MAX8 Emergency Airworthiness Directive directs pilots how to deal with a known issue, but it does nothing to address the systems issues with the AOA system.

MCAS (Maneuvering Characteristics Augmentation System) is implemented on the 737 MAX to enhance pitch characteristics with flaps UP and at elevated angles of attack. The MCAS function commands nose down stabilizer to enhance pitch characteristics during steep turns with elevated load factors and during flaps up flight at airspeeds approaching stall. MCAS is activated without pilot input and only operates in manual, flaps up flight. The system is designed to allow the flight crew to use column trim switch or stabilizer aisle stand cutout switches to override MCAS input. The function is commanded by the Flight Control computer using input data from sensors and other airplane systems.

The MCAS function becomes active when the airplane Angle of Attack exceeds a threshold based on airspeed and altitude. Stabilizer incremental commands are limited to 2.5 degrees and are provided at a rate of 0.27 degrees per second. The magnitude of the stabilizer input is lower at high Mach number and greater at low Mach numbers. The function is reset once angle of attack falls below the Angle of Attack threshold or if manual stabilizer commands are provided by the flight crew. If the original elevated AOA condition persists, the MCAS function commands another incremental stabilizer nose down command according to current aircraft Mach number at actuation.

This description is not currently in the 737 Flight Manual Part 2, nor the Boeing FCOM, though it will be added to them soon. This communication highlights that an entire system is not described in our Flight Manual. This system is now the subject of an AD.

I think it is unconscionable that a manufacturer, the FAA, and the airlines would have pilots flying an airplane without adequately training, or even providing available resources and sufficient documentation to understand the highly complex systems that differentiate this aircraft from prior models. The fact that this airplane requires such jury rigging to fly is a red flag. Now we know the systems employed are error prone–even if the pilots aren’t sure what those systems are, what redundancies are in place, and failure modes.

I am left to wonder: what else don’t I know? The Flight Manual is inadequate and almost criminally insufficient. All airlines that operate the MAX must insist that Boeing incorporate ALL systems in their manuals.

Synopsis

B737MAX Captain expressed concern that some systems such as the MCAS are not fully described in the aircraft Flight Manual.


5) This is from October, 2018, presumably before the Lion Air crash at the end of the month. It involves automatic thrust control, which also may have been involved in the Lion Air crash.  ASRS summary: “B737-MAX8 Captain reported the autothrottles failed to move to the commanded position during takeoff and climb.”

ACN: 1590012

Time / Day

Date : 201810
Local Time Of Day : 0001-0600

Place

Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 1000

Environment

Light : Daylight

Aircraft

Reference : X
ATC / Advisory.Tower : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : B737-800
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Flight Phase : Takeoff
Airspace.Class C : ZZZ

Component

Aircraft Component : Autothrottle/Speed Control
Aircraft Reference : X
Problem : Improperly Operated

Person

Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Captain
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Experience.Flight Crew.Last 90 Days : 419
ASRS Report Number.Accession Number : 1590012
Human Factors : Confusion

Events

Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.Deviation – Speed : All Types
Anomaly.Deviation – Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Overcame Equipment Problem

Assessments

Contributing Factors / Situations : Aircraft
Primary Problem : Aircraft

Narrative: 1

After 1000 feet I noticed a decrease in aircraft performance. I picked up that the autothrottles were not moving to commanded position even though they were engaged. I’m sure they were set properly for takeoff but not sure when the discrepancy took place. My scan wasn’t as well developed since I’ve only flown the MAX once before. I manually positioned the thrust levers ASAP. This resolved the threat, we were able to increase speed to clean up and continue the climb to 3000 feet.

Shortly afterwards I heard about the (other carrier) accident and am wondering if any other crews have experienced similar incidents with the autothrottle system on the MAX? Or I may have made a possible flying mistake which is more likely. The FO (First Officer) was still on his first month and was not able to identify whether it was the aircraft or me that was in error.

Synopsis

B737-MAX8 Captain reported the autothrottles failed to move to the commanded position during takeoff and climb.

  


6) From June, 2018, one of the early crews to  fly a 737 Max complains about feeling unprepared to handle its displays and controls. ASRS summary: “B737 MAX First Officer reported feeling unprepared for first flight in the MAX, citing inadequate training.”

ACN: 1555013

Time / Day

Date : 201806

Place

Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0

Aircraft

Reference : X
Aircraft Operator : Air Carrier
Make Model Name : B737 Undifferentiated or Other Model
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Mission : Passenger
Nav In Use : FMS Or FMC
Flight Phase : Parked

Person

Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : First Officer
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Instrument
Qualification.Flight Crew : Air Transport Pilot (ATP)
Qualification.Flight Crew : Multiengine
Experience.Flight Crew.Total : 10861
Experience.Flight Crew.Type : 1660
ASRS Report Number.Accession Number : 1555013
Human Factors : Human-Machine Interface
Human Factors : Training / Qualification

Events

Anomaly.Deviation – Procedural : Published Material / Policy
Anomaly.Inflight Event / Encounter : Weather / Turbulence
Detector.Person : Flight Crew
When Detected : Pre-flight
Result.General : None Reported / Taken

Assessments

Contributing Factors / Situations : Company Policy
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Manuals
Contributing Factors / Situations : Procedure
Primary Problem : Company Policy

Narrative: 1

I had my first flight on the Max [to] ZZZ1. We found out we were scheduled to fly the aircraft on the way to the airport in the limo. We had a little time [to] review the essentials in the car. Otherwise we would have walked onto the plane cold.

My post flight evaluation is that we lacked the knowledge to operate the aircraft in all weather and aircraft states safely. The instrumentation is completely different – My scan was degraded, slow and labored having had no experience w/ the new ND (Navigation Display) and ADI (Attitude Director Indicator) presentations/format or functions (manipulation between the screens and systems pages were not provided in training materials. If they were, I had no recollection of that material).

We were unable to navigate to systems pages and lacked the knowledge of what systems information was available to us in the different phases of flight. Our weather radar competency was inadequate to safely navigate significant weather on that dark and stormy night. These are just a few issues that were not addressed in our training.

I recommend the following to help crews w/ their introductory flight on the Max:
Email notification the day before the flight (the email should include: Links – Training Video, PSOB and QRG and all relevant updates/FAQ’s)
SME (Subject Matter Expert) Observer – the role of the SME is to introduce systems navigation, display management, answer general questions and provide standardized best practices to the next generation aircraft.

Additionally, the SME will collect de-identified data to provide to the training department for analysis and dissemination to the line pilots regarding FAQs and know systems differences as well best practices in fly the new model aircraft.

Synopsis

B737 MAX First Officer reported feeling unprepared for first flight in the MAX, citing inadequate training.

  


That’s what is on the record, from U.S. pilots, about this plane. If I’ve missed any relevant 737 Max reports among the many thousands in the ASRS data base, I assume someone will let me know about them. We’ll see where the evidence leads.

Here is another highly relevant offering for the day. It comes from J. Mac McClellan, very long-time writer and editor in the flying world, at the Air Facts site. He argues that Boeing may have been assuming that pilots would note any pitch anomaly, and over-ride it if it occurred (as appears to have happened in the incidents reported in ASRS). His whole article is worth reading, about how airlines with manage the complexities of automated and human flight guidance.

In an article called “Can Boeing Trust Pilots?” McClellan writes:

What’s critical to the current, mostly uninformed discussion is that the 737 MAX system is not triply redundant. In other words, it can be expected to fail more frequently than one in a billion flights, which is the certification standard for flight critical systems and structures.

What Boeing is doing is using the age-old concept of using the human pilots as a critical element of the system… In all airplanes I know of, the recovery is—including the 737 MAX—to shut off the system using buttons on the control wheel then a switch, or sometimes circuit breaker to make a positive disconnect.

Though the pitch system in the MAX is somewhat new, the pilot actions after a failure are exactly the same as would be for a runaway trim in any 737 built since the 1960s. As pilots we really don’t need to know why the trim is running away, but we must know, and practice, how to disable it.

Boeing is now faced with the difficult task of explaining to the media why pilots must know how to intervene after a system failure. And also to explain that airplanes have been built and certified this way for many decades. Pilots have been the last line of defense when things go wrong…

But airline accidents have become so rare I’m not sure what is still acceptable to the flying public. When Boeing says truthfully and accurately that pilots need only do what they have been trained to do for decades when a system fails, is that enough to satisfy the flying public and the media frenzy?

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