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class="ArticleLeadArt_root__nRSLU"><figure class="ArticleLeadFigure_root__Bj81R ArticleLeadFigure_standard__20Izv"><div class="ArticleLeadFigure_media__R1npW" data-flatplan-lead_figure_media="true"><picture><img alt="" class="Image_root__XxsOp ArticleLeadArt_image__HZS4B" sizes="(min-width: 976px) 976px, 100vw" srcSet="https://cdn.theatlantic.com/thumbor/8KUbgtcR5bWasakPYKNg7HVrwCk=/0x416:4000x2666/750x422/media/img/notes/2019/03/RTX6QYX5/original.jpg 750w, https://cdn.theatlantic.com/thumbor/NphH6sKvB6_sZgfVzeJE7HUg5Jk=/0x416:4000x2666/828x466/media/img/notes/2019/03/RTX6QYX5/original.jpg 828w, https://cdn.theatlantic.com/thumbor/2-BTnSOLnN-_nrKeBK_UreHdrq0=/0x416:4000x2666/960x540/media/img/notes/2019/03/RTX6QYX5/original.jpg 960w, https://cdn.theatlantic.com/thumbor/yVQaW7Wrnk8BdBY-4PJXbUflMKo=/0x416:4000x2666/976x549/media/img/notes/2019/03/RTX6QYX5/original.jpg 976w, 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class="EditorsNote_root__980OP" id="editors-note" data-flatplan-editors_note="true"><div class="EditorsNote_content__sKLpl"><span class="EditorsNote_label__kOb4u">Editor’s Note: </span><span>This article previously appeared in a different format as part of The Atlantic’s Notes section, retired in 2021.</span></div></section></div></header><div><section class="ArticleBody_root__2gF81" data-event-module="article body" data-flatplan-body="true"><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">As mentioned in two previous reports—a <a data-event-element="inline link" href="https://www.theatlantic.com/ideas/archive/2019/03/et302-boeing-737-max-8-blame/584572/">long one</a>, and a <a data-event-element="inline link" href="https://www.theatlantic.com/notes/2019/03/shorter-guide-ethiopian-air-tragedy-and-737-max-8/584620/">short one</a>—some things are known, and many 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.</p><div class="ArticleLegacyHtml_root__WFd2I ArticleLegacyHtml_standard__kC_zi"><ul class=""><li>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.</li> <li>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.</li></ul></div><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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. This is until more is known about whether the crashes are connected and whether there is something systematically wrong with the plane.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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 airliners 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 found 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.)</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">What will happen with the 737 Max? At this point, again, no one knows—or has said publicly. As a practical matter, grounding <em>all</em> 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 with U.S. carriers. Most airlines can cancel those Max flights without fundamentally disrupting their service.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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 time—Boeing 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.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">By which I mean: The <em>astonishingly good</em> safety record of the world’s commercial air-travel system over the past generation has earned most of the system’s members the benefit of the doubt on safety judgments. Between 2010 and 2019, exactly one person died in an accident on a U.S. passenger airline. (That was the person killed on 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 International Airport in 2013, when a captain flying for the Korean carrier Asiana badly misjudged a landing.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">By comparison: About 100 Americans die every <em>day</em> 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.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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, was it trying to go improperly soft on America’s leading exporter, which also happens to be a major player in all Washington, D.C., lobbying wars?) No one knows this at the moment. We will know, at some point.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">Every choice made by Boeing, the FAA, and others involved in this tragedy and drama will eventually become known. <em>Awareness</em> 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 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.?)</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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 from pilots, airlines, and aircraft companies about aspects of FAA bureaucracy. If either Boeing or the FAA is making the wrong choices now, the airline-safety culture will certainly recover—but their reputation and credibility might not, for a very long time.</p><hr class="ArticleLegacyHtml_root__WFd2I c-section-divider ArticleLegacyHtml_standard__kC_zi"/><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">While the fundamentals remain unknown, here are some relevant primary documents. They come from an underpublicized but extremely valuable part of the aviation-safety culture. This is a program called ASRS, or Aviation Safety Reporting System, which has been run by NASA <a data-event-element="inline link" href="https://www.nasa.gov/ames/feature/40-Years-of-Safer-Aviation-through-Reporting">since the 1970s</a>. 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. Nonpunitive.”</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">The ASRS system is based on the idea that anyone involved in aviation—pilots, controllers, ground staff, anyone—can file a report of situations that seemed worrisome, in confidence that <em>the information will not be used against them. </em>Pilots are conditioned to treat the FAA warily, and to make no admissions against interest that might be used again them. <em>What if I confess that I violated an altitude clearance or busted a no-fly zone, and they take away my certificate?</em> 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.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">Reports flow into NASA by the dozens each day; they’re put into a searchable public database (it’s <a data-event-element="inline link" href="https://asrs.arc.nasa.gov/overview/database.html">here</a>); and every month, NASA puts out a publication, <a data-event-element="inline link" href="https://asrs.arc.nasa.gov/publications/callback.html"><em>Callback</em></a>, listing the emerging trends.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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 percent of the reports are about “normal” aviation problems, which could have happened on any kind of airplane. In one, a captain confesses that he got no sleep in a noisy hotel 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 observes that the 737’s cockpit design let his flight manual slide down into an area that made it hard to retrieve during flight. And so on.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">Below are <em>all</em> 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. I won’t annotate or parse them, but I offer them as the documentary supplement to what you’ll read about in the papers.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">The first four reports involve the aspect of the 737 Max software most in the news: its MCAS 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 overrode automated systems and took control of the plane themselves. Obviously none of these flights crashed.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">Here we go. Most readers will want to skip to “Narrative” and “Synopsis,” but I have left in all the other information just for the record:</p><hr class="ArticleLegacyHtml_root__WFd2I c-section-divider ArticleLegacyHtml_standard__kC_zi"/><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">1) From November 2018, <em>after</em> the Lion Air crash. ASRS summary: “B737MAX Captain reported an autopilot anomaly in which led to an undesired brief nose down situation.”</p><div class="ArticleLegacyHtml_root__WFd2I ArticleLegacyHtml_standard__kC_zi"><blockquote class=""><p><strong>ACN</strong>: 1597380</p> <p><strong>Time</strong> / Day</p> <p><strong>Date</strong> : 201811</p> <p><strong>Place</strong></p> <p>Locale Reference.ATC Facility : ZZZ.TRACON<br/> State Reference : US<br/> Altitude.MSL.Single Value : 2000</p> <p><strong>Environment</strong></p> <p>Weather Elements / Visibility : Rain<br/> Weather Elements / Visibility : Snow</p> <p><strong>Aircraft</strong></p> <p>Reference : X<br/> ATC / Advisory.TRACON : ZZZ<br/> Aircraft Operator : Air Carrier<br/> Make Model Name : B737-800<br/> Crew Size.Number Of Crew : 2<br/> Operating Under FAR Part : Part 121<br/> Flight Plan : IFR<br/> Mission : Passenger<br/> Nav In Use : FMS Or FMC<br/> Flight Phase : Climb<br/> Airspace.Class B : ZZZ</p> <p><strong>Component</strong></p> <p>Aircraft Component : Autoflight System<br/> Aircraft Reference : X<br/> <strong>Problem</strong> : Malfunctioning</p> <p><strong>Person</strong></p> <p>Reference : 1<br/> Location Of Person.Aircraft : X<br/> Location In Aircraft : Flight Deck<br/> Reporter Organization : Air Carrier<br/> Function.Flight Crew : Captain<br/> Function.Flight Crew : Pilot Flying<br/> Qualification.Flight Crew : Instrument<br/> Qualification.Flight Crew : Air Transport Pilot (ATP)<br/> Qualification.Flight Crew : Multiengine<br/> Experience.Flight Crew.Last 90 Days : 626<br/> ASRS Report Number.Accession Number : 1597380<br/> Human Factors : Human-Machine Interface<br/> Human Factors : Confusion</p> <p><strong>Events</strong></p> <p>Anomaly.Aircraft Equipment Problem : Less Severe<br/> Detector.Automation : Aircraft Other Automation<br/> Detector.Person : Flight Crew<br/> When Detected : In-flight<br/> Result.Flight Crew : FLC Overrode Automation<br/> Result.Flight Crew : Overcame Equipment Problem<br/> Result.Aircraft : Equipment Problem Dissipated</p> <p><strong>Assessments</strong></p> <p>Contributing Factors / Situations : Aircraft<br/> Contributing Factors / Situations : Human Factors<br/> Primary Problem : Aircraft</p> <p><strong>Narrative: 1</strong></p> <p>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.<br/> <br/> 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+.<br/> <br/> 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!"<br/> <br/> 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).<br/> <br/> 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.</p> <p><strong>Synopsis</strong></p> <p>B737MAX Captain reported an autopilot anomaly in which led to an undesired brief nose down situation.</p></blockquote></div><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true"></p><hr class="ArticleLegacyHtml_root__WFd2I c-section-divider ArticleLegacyHtml_standard__kC_zi"/><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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.”</p><div class="ArticleLegacyHtml_root__WFd2I ArticleLegacyHtml_standard__kC_zi"><blockquote class=""><p>ACN: 1597286</p> <p><strong>Time</strong> / Day</p> <p><strong>Date</strong> : 201811</p> <p><strong>Place</strong></p> <p>Locale Reference.Airport : ZZZ.Airport<br/> State Reference : US<br/> Altitude.MSL.Single Value : 2000</p> <p>Aircraft</p> <p>Reference : X<br/> ATC / Advisory.Tower : ZZZ<br/> Aircraft Operator : Air Carrier<br/> Make Model Name : B737-800<br/> Crew Size.Number Of Crew : 2<br/> Operating Under FAR Part : Part 121<br/> Flight Plan : IFR<br/> Mission : Passenger<br/> Nav In Use : FMS Or FMC<br/> Flight Phase : Takeoff<br/> Airspace.Class C : ZZZ</p> <p>Component</p> <p>Aircraft Component : Autopilot<br/> Aircraft Reference : X<br/> Problem : Malfunctioning</p> <p>Person</p> <p>Reference : 1<br/> Location Of Person.Aircraft : X<br/> Location In Aircraft : Flight Deck<br/> Reporter Organization : Air Carrier<br/> Function.Flight Crew : Pilot Not Flying<br/> Function.Flight Crew : First Officer<br/> Qualification.Flight Crew : Air Transport Pilot (ATP)<br/> Qualification.Flight Crew : Instrument<br/> Qualification.Flight Crew : Multiengine<br/> Experience.Flight Crew.Last 90 Days : 511<br/> ASRS Report Number.Accession Number : 1597286<br/> Analyst Callback : Attempted</p> <p>Events</p> <p>Anomaly.Aircraft Equipment Problem : Critical<br/> Detector.Person : Flight Crew<br/> When Detected : In-flight<br/> Result.Flight Crew : Regained Aircraft Control</p> <p>Assessments</p> <p>Contributing Factors / Situations : Aircraft<br/> Primary Problem : Aircraft</p> <p><strong>Narrative: 1</strong></p> <p>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.</p> <p><strong>Synopsis</strong></p> <p>B737 MAX First Officer reported that the aircraft pitched nose down after engaging autopilot on departure. Autopilot was disconnected and flight continued to destination.</p></blockquote></div><hr class="ArticleLegacyHtml_root__WFd2I c-section-divider ArticleLegacyHtml_standard__kC_zi"/><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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.’”</p><div class="ArticleLegacyHtml_root__WFd2I ArticleLegacyHtml_standard__kC_zi"><blockquote class=""><p>ACN: 1593021</p> <p><strong>Time</strong> / Day</p> <p><strong>Date</strong> : 201811</p> <p>Place</p> <p>Altitude.AGL.Single Value : 0</p> <p>Aircraft</p> <p>Reference : X<br/> Aircraft Operator : Air Carrier<br/> Make Model Name : B737 Next Generation Undifferentiated<br/> Crew Size.Number Of Crew : 2<br/> Operating Under FAR Part : Part 121<br/> Flight Plan : IFR<br/> Flight Phase : Parked</p> <p>Person</p> <p>Reference : 1<br/> Location Of Person.Aircraft : X<br/> Location In Aircraft : Flight Deck<br/> Reporter Organization : Air Carrier<br/> Function.Flight Crew : Captain<br/> Qualification.Flight Crew : Instrument<br/> Qualification.Flight Crew : Air Transport Pilot (ATP)<br/> Qualification.Flight Crew : Multiengine<br/> Experience.Flight Crew.Total : 21200<br/> Experience.Flight Crew.Last 90 Days : 178<br/> Experience.Flight Crew.Type : 3342<br/> ASRS Report Number.Accession Number : 1593021<br/> Human Factors : Training / Qualification<br/> Human Factors : Confusion</p> <p>Events</p> <p>Anomaly.Deviation - Procedural : Published Material / Policy<br/> Detector.Person : Flight Crew<br/> When Detected : Pre-flight<br/> Result.General : None Reported / Taken</p> <p>Assessments</p> <p>Contributing Factors / Situations : Company Policy<br/> Contributing Factors / Situations : Human Factors<br/> Contributing Factors / Situations : Manuals<br/> Contributing Factors / Situations : Procedure<br/> Primary Problem : Manuals</p> <p><strong>Narrative: 1</strong></p> <p>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.<br/> <br/> 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.<br/> <br/> 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.<br/> <br/> The mechanic explained the light was part of a menu for maintenance use only on the ground.<br/> <br/> 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.<br/> <br/> 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.<br/> <br/> 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.<br/> <br/> 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.</p> <p><strong>Synopsis</strong></p> <p>B737MAX Captain reported confusion regarding switch function and display annunciations related to "poor training and even poorer documentation".</p></blockquote></div><hr class="ArticleLegacyHtml_root__WFd2I c-section-divider ArticleLegacyHtml_standard__kC_zi"/><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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.”</p><div class="ArticleLegacyHtml_root__WFd2I ArticleLegacyHtml_standard__kC_zi"><blockquote class=""><p>ACN: 1593017</p> <p><strong>Time</strong> / Day</p> <p><strong>Date</strong> : 201811</p> <p>Place</p> <p>Altitude.AGL.Single Value : 0</p> <p>Aircraft</p> <p>Reference : X<br/> Aircraft Operator : Air Carrier<br/> Make Model Name : B737 Next Generation Undifferentiated<br/> Flight Phase.Other</p> <p>Person</p> <p>Reference : 1<br/> Location Of Person.Aircraft : X<br/> Location In Aircraft : Flight Deck<br/> Reporter Organization : Air Carrier<br/> Function.Flight Crew : Captain<br/> Qualification.Flight Crew : Air Transport Pilot (ATP)<br/> ASRS Report Number.Accession Number : 1593017<br/> Human Factors : Confusion<br/> Human Factors : Training / Qualification</p> <p>Events</p> <p>Anomaly.Deviation - Procedural : Published Material / Policy<br/> Detector.Person : Flight Crew<br/> When Detected : Pre-flight<br/> Result.General : None Reported / Taken</p> <p>Assessments</p> <p>Contributing Factors / Situations : Aircraft<br/> Contributing Factors / Situations : Manuals<br/> Primary Problem : Manuals</p> <p><strong>Narrative: 1</strong></p> <p>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.<br/> <br/> 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.<br/> <br/> 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.<br/> <br/> 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.<br/> <br/> 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.<br/> <br/> 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.</p> <p><strong>Synopsis</strong></p> <p>B737MAX Captain expressed concern that some systems such as the MCAS are not fully described in the aircraft Flight Manual.</p></blockquote></div><hr class="ArticleLegacyHtml_root__WFd2I c-section-divider ArticleLegacyHtml_standard__kC_zi"/><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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 might 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.”</p><div class="ArticleLegacyHtml_root__WFd2I ArticleLegacyHtml_standard__kC_zi"><blockquote class=""><p>ACN: 1590012</p> <p><strong>Time</strong> / Day</p> <p><strong>Date</strong> : 201810<br/> Local Time Of Day : 0001-0600</p> <p>Place</p> <p>Locale Reference.Airport : ZZZ.Airport<br/> State Reference : US<br/> Altitude.AGL.Single Value : 1000</p> <p>Environment</p> <p>Light : Daylight</p> <p>Aircraft</p> <p>Reference : X<br/> ATC / Advisory.Tower : ZZZ<br/> Aircraft Operator : Air Carrier<br/> Make Model Name : B737-800<br/> Crew Size.Number Of Crew : 2<br/> Operating Under FAR Part : Part 121<br/> Flight Plan : IFR<br/> Mission : Passenger<br/> Flight Phase : Takeoff<br/> Airspace.Class C : ZZZ</p> <p>Component</p> <p>Aircraft Component : Autothrottle/Speed Control<br/> Aircraft Reference : X<br/> Problem : Improperly Operated</p> <p>Person</p> <p>Reference : 1<br/> Location Of Person.Aircraft : X<br/> Location In Aircraft : Flight Deck<br/> Reporter Organization : Air Carrier<br/> Function.Flight Crew : Pilot Flying<br/> Function.Flight Crew : Captain<br/> Qualification.Flight Crew : Multiengine<br/> Qualification.Flight Crew : Instrument<br/> Qualification.Flight Crew : Air Transport Pilot (ATP)<br/> Experience.Flight Crew.Last 90 Days : 419<br/> ASRS Report Number.Accession Number : 1590012<br/> Human Factors : Confusion</p> <p>Events</p> <p>Anomaly.Aircraft Equipment Problem : Less Severe<br/> Anomaly.Deviation - Speed : All Types<br/> Anomaly.Deviation - Procedural : Published Material / Policy<br/> Detector.Person : Flight Crew<br/> When Detected : In-flight<br/> Result.Flight Crew : Overcame Equipment Problem</p> <p>Assessments</p> <p>Contributing Factors / Situations : Aircraft<br/> Primary Problem : Aircraft</p> <p><strong>Narrative: 1</strong></p> <p>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.<br/> <br/> 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.</p> <p><strong>Synopsis</strong></p> <p>B737-MAX8 Captain reported the autothrottles failed to move to the commanded position during takeoff and climb.</p> <p> </p></blockquote></div><hr class="ArticleLegacyHtml_root__WFd2I c-section-divider ArticleLegacyHtml_standard__kC_zi"/><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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.”</p><div class="ArticleLegacyHtml_root__WFd2I ArticleLegacyHtml_standard__kC_zi"><blockquote class=""><p>ACN: 1555013</p> <p><strong>Time</strong> / Day</p> <p><strong>Date</strong> : 201806</p> <p>Place</p> <p>Locale Reference.Airport : ZZZ.Airport<br/> State Reference : US<br/> Altitude.AGL.Single Value : 0</p> <p>Aircraft</p> <p>Reference : X<br/> Aircraft Operator : Air Carrier<br/> Make Model Name : B737 Undifferentiated or Other Model<br/> Crew Size.Number Of Crew : 2<br/> Operating Under FAR Part : Part 121<br/> Flight Plan : IFR<br/> Mission : Passenger<br/> Nav In Use : FMS Or FMC<br/> Flight Phase : Parked</p> <p>Person</p> <p>Reference : 1<br/> Location Of Person.Aircraft : X<br/> Location In Aircraft : Flight Deck<br/> Reporter Organization : Air Carrier<br/> Function.Flight Crew : First Officer<br/> Function.Flight Crew : Pilot Not Flying<br/> Qualification.Flight Crew : Instrument<br/> Qualification.Flight Crew : Air Transport Pilot (ATP)<br/> Qualification.Flight Crew : Multiengine<br/> Experience.Flight Crew.Total : 10861<br/> Experience.Flight Crew.Type : 1660<br/> ASRS Report Number.Accession Number : 1555013<br/> Human Factors : Human-Machine Interface<br/> Human Factors : Training / Qualification</p> <p>Events</p> <p>Anomaly.Deviation - Procedural : Published Material / Policy<br/> Anomaly.Inflight Event / Encounter : Weather / Turbulence<br/> Detector.Person : Flight Crew<br/> When Detected : Pre-flight<br/> Result.General : None Reported / Taken</p> <p>Assessments</p> <p>Contributing Factors / Situations : Company Policy<br/> Contributing Factors / Situations : Human Factors<br/> Contributing Factors / Situations : Manuals<br/> Contributing Factors / Situations : Procedure<br/> Primary Problem : Company Policy</p> <p><strong>Narrative: 1</strong></p> <p>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.<br/> <br/> 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).<br/> <br/> 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.<br/> <br/> I recommend the following to help crews w/ their introductory flight on the Max:<br/> Email notification the day before the flight (the email should include: Links - Training Video, PSOB and QRG and all relevant updates/FAQ's)<br/> 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.<br/> <br/> 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.</p> <p><strong>Synopsis</strong></p> <p>B737 MAX First Officer reported feeling unprepared for first flight in the MAX, citing inadequate training.</p> <p> </p></blockquote></div><hr class="ArticleLegacyHtml_root__WFd2I c-section-divider ArticleLegacyHtml_standard__kC_zi"/><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">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 database, I assume someone will let me know about them. We’ll see where the evidence leads.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">Here is another highly relevant offering for the day. It comes from J. Mac McClellan, a longtime writer and editor in the flying world, <a data-event-element="inline link" href="https://airfactsjournal.com/2019/03/can-boeing-trust-pilots/">at the <em>Air Facts</em> site</a>. He argues that Boeing may have been assuming that pilots would note any pitch anomaly, and override it if it occurred (as appears to have happened in the incidents involving U.S.-carrier pilots that were reported in ASRS). His whole article, about how airlines manage the complexities of automated and human flight guidance, is worth reading.</p><p class="ArticleParagraph_root__4mszW" data-flatplan-paragraph="true">In the article, called “Can Boeing Trust Pilots?,” McClellan writes:</p><div class="ArticleLegacyHtml_root__WFd2I ArticleLegacyHtml_standard__kC_zi"><blockquote class=""><p>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.</p> <p>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.</p> <p>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.</p> <p>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 ...</p> <p>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?</p></blockquote></div><div class="ArticleBody_divider__GpNxD" id="article-end"></div></section></div><div data-event-module="footer"><div class="ArticleWell_root__fueCa"><div data-event-module="author footer" class="ArticleFooter_authorFooter__5NsdY"><div class="SectionHeading_root__3GnqT"><h3 class="SectionHeading_heading__iNkek">About the Author</h3></div><div class="ArticleBio_root__ua8zj"><address id="article-writer-0" class="ArticleBio_author__6pDyl" data-event-element="author" data-event-position="1"><div class="ArticleBio_content__O0ZVF"><div class="ArticleBio_topContainer__QYRU4"><a class="ArticleBio_headshotContainer__Am2nR" href="https://www.theatlantic.com/author/james-fallows/" data-event-element="image" aria-label="Read more by James Fallows"><img alt="" loading="lazy" 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Fallows\",\"__typename\":\"Author\",\"id\":\"Author:316\",\"isFollowable\":false,\"biography\":{\"default\":\"\u003ca href=\\\"https://www.theatlantic.com/author/james-fallows/\\\" class=\\\"author-link\\\" data-label=\\\"https://www.theatlantic.com/author/james-fallows/\\\" data-action=\\\"click author - name\\\" \u003eJames Fallows\u003c/a\u003e is a contributing writer at \u003cem\u003eThe Atlantic \u003c/em\u003eand author of the newsletter \u003cem\u003e\u003ca href=\\\"https://fallows.substack.com/\\\"\u003eBreaking the News\u003c/a\u003e.\u003c/em\u003e\",\"__typename\":\"Biography\"},\"headshot\":{\"width\":120,\"height\":120,\"srcSet\":\"https://cdn.theatlantic.com/thumbor/C0Vnn1T_rUGEmvGosxygN_10HS0=/0x158:1594x1752/120x120/media/None/JFallowsHeadshotAtlanticSmall_grey/original.png, https://cdn.theatlantic.com/thumbor/Y_aEtrC8pDnzcfvtLq-Pje0FVpA=/0x158:1594x1752/240x240/media/None/JFallowsHeadshotAtlanticSmall_grey/original.png 2x\",\"url\":\"https://cdn.theatlantic.com/thumbor/C0Vnn1T_rUGEmvGosxygN_10HS0=/0x158:1594x1752/120x120/media/None/JFallowsHeadshotAtlanticSmall_grey/original.png\",\"__typename\":\"BasicImage\"},\"river\":{\"edges\":[{\"cursor\":\"MjAyMy0wMi0yMSAxODoxNjowOHw2NzMxNDY=\",\"node\":{\"id\":\"BlogArticle:673146\",\"title\":\"An Unlucky President, and a Lucky Man\",\"url\":\"https://www.theatlantic.com/ideas/archive/2023/02/jimmy-carter-accomplishments-james-fallows/673146/\",\"__typename\":\"BlogArticle\"},\"__typename\":\"PromoEdge\"},{\"cursor\":\"MjAyMi0wMy0wMyAxNDo1Nzo1NXw2MjQxNzQ=\",\"node\":{\"id\":\"BlogArticle:624174\",\"title\":\"Biden’s State of the Union Did Something New\",\"url\":\"https://www.theatlantic.com/ideas/archive/2022/03/was-bidens-state-union-speech-good/624174/\",\"__typename\":\"BlogArticle\"},\"__typename\":\"PromoEdge\"},{\"cursor\":\"MjAyMS0wOC0xMyAxODoyNzozNXw2MjE0MzI=\",\"node\":{\"id\":\"BlogArticle:621432\",\"title\":\"Will the U.S. Pass a Point of No Return?\",\"url\":\"https://www.theatlantic.com/ideas/archive/2021/08/will-us-pass-point-no-return/621432/\",\"__typename\":\"BlogArticle\"},\"__typename\":\"PromoEdge\"}],\"__typename\":\"RiverConnection\"},\"slug\":\"james-fallows\",\"socialMedia\":[{\"platform\":\"TWITTER\",\"url\":\"https://twitter.com/jamesfallows\",\"__typename\":\"SocialMedia\"}]}],\"authorContext\":null,\"categories\":[{\"slug\":\"notes\",\"__typename\":\"Category\"}],\"content\":[{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"As mentioned in two previous reports—a \u003ca data-event-element=\\\"inline link\\\" href=\\\"https://www.theatlantic.com/ideas/archive/2019/03/et302-boeing-737-max-8-blame/584572/\\\"\u003elong one\u003c/a\u003e, and a \u003ca data-event-element=\\\"inline link\\\" href=\\\"https://www.theatlantic.com/notes/2019/03/shorter-guide-ethiopian-air-tragedy-and-737-max-8/584620/\\\"\u003eshort one\u003c/a\u003e—some things are known, and many 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.\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"UL\",\"idAttr\":\"\",\"className\":\"\",\"style\":\"\",\"innerHtml\":\"\u003cli\u003eOne 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.\u003c/li\u003e \u003cli\u003eOne 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.\u003c/li\u003e\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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. This is until more is known about whether the crashes are connected and whether there is something systematically wrong with the plane.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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 airliners 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 found 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.)\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"What will happen with the 737 Max? At this point, again, no one knows—or has said publicly. As a practical matter, grounding \u003cem\u003eall\u003c/em\u003e 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 with U.S. carriers. Most airlines can cancel those Max flights without fundamentally disrupting their service.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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 time—Boeing 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.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"By which I mean: The \u003cem\u003eastonishingly good\u003c/em\u003e safety record of the world’s commercial air-travel system over the past generation has earned most of the system’s members the benefit of the doubt on safety judgments. Between 2010 and 2019, exactly one person died in an accident on a U.S. passenger airline. (That was the person killed on 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 International Airport in 2013, when a captain flying for the Korean carrier Asiana badly misjudged a landing.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"By comparison: About 100 Americans die every \u003cem\u003eday\u003c/em\u003e 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.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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, was it trying to go improperly soft on America’s leading exporter, which also happens to be a major player in all Washington, D.C., lobbying wars?) No one knows this at the moment. We will know, at some point.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"Every choice made by Boeing, the FAA, and others involved in this tragedy and drama will eventually become known. \u003cem\u003eAwareness\u003c/em\u003e 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 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.?)\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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 from pilots, airlines, and aircraft companies about aspects of FAA bureaucracy. If either Boeing or the FAA is making the wrong choices now, the airline-safety culture will certainly recover—but their reputation and credibility might not, for a very long time.\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"HR\",\"idAttr\":\"\",\"className\":\"c-section-divider\",\"style\":\"\",\"innerHtml\":\"\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"While the fundamentals remain unknown, here are some relevant primary documents. They come from an underpublicized but extremely valuable part of the aviation-safety culture. This is a program called ASRS, or Aviation Safety Reporting System, which has been run by NASA \u003ca data-event-element=\\\"inline link\\\" href=\\\"https://www.nasa.gov/ames/feature/40-Years-of-Safer-Aviation-through-Reporting\\\"\u003esince the 1970s\u003c/a\u003e. 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. Nonpunitive.”\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"The ASRS system is based on the idea that anyone involved in aviation—pilots, controllers, ground staff, anyone—can file a report of situations that seemed worrisome, in confidence that \u003cem\u003ethe information will not be used against them. \u003c/em\u003ePilots are conditioned to treat the FAA warily, and to make no admissions against interest that might be used again them. \u003cem\u003eWhat if I confess that I violated an altitude clearance or busted a no-fly zone, and they take away my certificate?\u003c/em\u003e 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.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"Reports flow into NASA by the dozens each day; they’re put into a searchable public database (it’s \u003ca data-event-element=\\\"inline link\\\" href=\\\"https://asrs.arc.nasa.gov/overview/database.html\\\"\u003ehere\u003c/a\u003e); and every month, NASA puts out a publication, \u003ca data-event-element=\\\"inline link\\\" href=\\\"https://asrs.arc.nasa.gov/publications/callback.html\\\"\u003e\u003cem\u003eCallback\u003c/em\u003e\u003c/a\u003e, listing the emerging trends.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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 percent of the reports are about “normal” aviation problems, which could have happened on any kind of airplane. In one, a captain confesses that he got no sleep in a noisy hotel 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 observes that the 737’s cockpit design let his flight manual slide down into an area that made it hard to retrieve during flight. And so on.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"Below are \u003cem\u003eall\u003c/em\u003e 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. I won’t annotate or parse them, but I offer them as the documentary supplement to what you’ll read about in the papers.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"The first four reports involve the aspect of the 737 Max software most in the news: its MCAS 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 overrode automated systems and took control of the plane themselves. Obviously none of these flights crashed.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"Here we go. Most readers will want to skip to “Narrative” and “Synopsis,” but I have left in all the other information just for the record:\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"HR\",\"idAttr\":\"\",\"className\":\"c-section-divider\",\"style\":\"\",\"innerHtml\":\"\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"1) From November 2018, \u003cem\u003eafter\u003c/em\u003e the Lion Air crash. ASRS summary: “B737MAX Captain reported an autopilot anomaly in which led to an undesired brief nose down situation.”\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"BLOCKQUOTE\",\"idAttr\":\"\",\"className\":\"\",\"style\":\"\",\"innerHtml\":\"\u003cp\u003e\u003cstrong\u003eACN\u003c/strong\u003e: 1597380\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e / Day\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eDate\u003c/strong\u003e : 201811\u003c/p\u003e \u003cp\u003e\u003cstrong\u003ePlace\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eLocale Reference.ATC Facility : ZZZ.TRACON\u003cbr/\u003e State Reference : US\u003cbr/\u003e Altitude.MSL.Single Value : 2000\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eEnvironment\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eWeather Elements / Visibility : Rain\u003cbr/\u003e Weather Elements / Visibility : Snow\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eAircraft\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eReference : X\u003cbr/\u003e ATC / Advisory.TRACON : ZZZ\u003cbr/\u003e Aircraft Operator : Air Carrier\u003cbr/\u003e Make Model Name : B737-800\u003cbr/\u003e Crew Size.Number Of Crew : 2\u003cbr/\u003e Operating Under FAR Part : Part 121\u003cbr/\u003e Flight Plan : IFR\u003cbr/\u003e Mission : Passenger\u003cbr/\u003e Nav In Use : FMS Or FMC\u003cbr/\u003e Flight Phase : Climb\u003cbr/\u003e Airspace.Class B : ZZZ\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eComponent\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eAircraft Component : Autoflight System\u003cbr/\u003e Aircraft Reference : X\u003cbr/\u003e \u003cstrong\u003eProblem\u003c/strong\u003e : Malfunctioning\u003c/p\u003e \u003cp\u003e\u003cstrong\u003ePerson\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eReference : 1\u003cbr/\u003e Location Of Person.Aircraft : X\u003cbr/\u003e Location In Aircraft : Flight Deck\u003cbr/\u003e Reporter Organization : Air Carrier\u003cbr/\u003e Function.Flight Crew : Captain\u003cbr/\u003e Function.Flight Crew : Pilot Flying\u003cbr/\u003e Qualification.Flight Crew : Instrument\u003cbr/\u003e Qualification.Flight Crew : Air Transport Pilot (ATP)\u003cbr/\u003e Qualification.Flight Crew : Multiengine\u003cbr/\u003e Experience.Flight Crew.Last 90 Days : 626\u003cbr/\u003e ASRS Report Number.Accession Number : 1597380\u003cbr/\u003e Human Factors : Human-Machine Interface\u003cbr/\u003e Human Factors : Confusion\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eEvents\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eAnomaly.Aircraft Equipment Problem : Less Severe\u003cbr/\u003e Detector.Automation : Aircraft Other Automation\u003cbr/\u003e Detector.Person : Flight Crew\u003cbr/\u003e When Detected : In-flight\u003cbr/\u003e Result.Flight Crew : FLC Overrode Automation\u003cbr/\u003e Result.Flight Crew : Overcame Equipment Problem\u003cbr/\u003e Result.Aircraft : Equipment Problem Dissipated\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eAssessments\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eContributing Factors / Situations : Aircraft\u003cbr/\u003e Contributing Factors / Situations : Human Factors\u003cbr/\u003e Primary Problem : Aircraft\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eNarrative: 1\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eIt 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.\u003cbr/\u003e \u003cbr/\u003e 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+.\u003cbr/\u003e \u003cbr/\u003e 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!\\\"\u003cbr/\u003e \u003cbr/\u003e 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).\u003cbr/\u003e \u003cbr/\u003e 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.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eSynopsis\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eB737MAX Captain reported an autopilot anomaly in which led to an undesired brief nose down situation.\u003c/p\u003e\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"HR\",\"idAttr\":\"\",\"className\":\"c-section-divider\",\"style\":\"\",\"innerHtml\":\"\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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.”\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"BLOCKQUOTE\",\"idAttr\":\"\",\"className\":\"\",\"style\":\"\",\"innerHtml\":\"\u003cp\u003eACN: 1597286\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e / Day\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eDate\u003c/strong\u003e : 201811\u003c/p\u003e \u003cp\u003e\u003cstrong\u003ePlace\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eLocale Reference.Airport : ZZZ.Airport\u003cbr/\u003e State Reference : US\u003cbr/\u003e Altitude.MSL.Single Value : 2000\u003c/p\u003e \u003cp\u003eAircraft\u003c/p\u003e \u003cp\u003eReference : X\u003cbr/\u003e ATC / Advisory.Tower : ZZZ\u003cbr/\u003e Aircraft Operator : Air Carrier\u003cbr/\u003e Make Model Name : B737-800\u003cbr/\u003e Crew Size.Number Of Crew : 2\u003cbr/\u003e Operating Under FAR Part : Part 121\u003cbr/\u003e Flight Plan : IFR\u003cbr/\u003e Mission : Passenger\u003cbr/\u003e Nav In Use : FMS Or FMC\u003cbr/\u003e Flight Phase : Takeoff\u003cbr/\u003e Airspace.Class C : ZZZ\u003c/p\u003e \u003cp\u003eComponent\u003c/p\u003e \u003cp\u003eAircraft Component : Autopilot\u003cbr/\u003e Aircraft Reference : X\u003cbr/\u003e Problem : Malfunctioning\u003c/p\u003e \u003cp\u003ePerson\u003c/p\u003e \u003cp\u003eReference : 1\u003cbr/\u003e Location Of Person.Aircraft : X\u003cbr/\u003e Location In Aircraft : Flight Deck\u003cbr/\u003e Reporter Organization : Air Carrier\u003cbr/\u003e Function.Flight Crew : Pilot Not Flying\u003cbr/\u003e Function.Flight Crew : First Officer\u003cbr/\u003e Qualification.Flight Crew : Air Transport Pilot (ATP)\u003cbr/\u003e Qualification.Flight Crew : Instrument\u003cbr/\u003e Qualification.Flight Crew : Multiengine\u003cbr/\u003e Experience.Flight Crew.Last 90 Days : 511\u003cbr/\u003e ASRS Report Number.Accession Number : 1597286\u003cbr/\u003e Analyst Callback : Attempted\u003c/p\u003e \u003cp\u003eEvents\u003c/p\u003e \u003cp\u003eAnomaly.Aircraft Equipment Problem : Critical\u003cbr/\u003e Detector.Person : Flight Crew\u003cbr/\u003e When Detected : In-flight\u003cbr/\u003e Result.Flight Crew : Regained Aircraft Control\u003c/p\u003e \u003cp\u003eAssessments\u003c/p\u003e \u003cp\u003eContributing Factors / Situations : Aircraft\u003cbr/\u003e Primary Problem : Aircraft\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eNarrative: 1\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eDay 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 \u0026gt; 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.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eSynopsis\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eB737 MAX First Officer reported that the aircraft pitched nose down after engaging autopilot on departure. Autopilot was disconnected and flight continued to destination.\u003c/p\u003e\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"HR\",\"idAttr\":\"\",\"className\":\"c-section-divider\",\"style\":\"\",\"innerHtml\":\"\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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.’”\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"BLOCKQUOTE\",\"idAttr\":\"\",\"className\":\"\",\"style\":\"\",\"innerHtml\":\"\u003cp\u003eACN: 1593021\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e / Day\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eDate\u003c/strong\u003e : 201811\u003c/p\u003e \u003cp\u003ePlace\u003c/p\u003e \u003cp\u003eAltitude.AGL.Single Value : 0\u003c/p\u003e \u003cp\u003eAircraft\u003c/p\u003e \u003cp\u003eReference : X\u003cbr/\u003e Aircraft Operator : Air Carrier\u003cbr/\u003e Make Model Name : B737 Next Generation Undifferentiated\u003cbr/\u003e Crew Size.Number Of Crew : 2\u003cbr/\u003e Operating Under FAR Part : Part 121\u003cbr/\u003e Flight Plan : IFR\u003cbr/\u003e Flight Phase : Parked\u003c/p\u003e \u003cp\u003ePerson\u003c/p\u003e \u003cp\u003eReference : 1\u003cbr/\u003e Location Of Person.Aircraft : X\u003cbr/\u003e Location In Aircraft : Flight Deck\u003cbr/\u003e Reporter Organization : Air Carrier\u003cbr/\u003e Function.Flight Crew : Captain\u003cbr/\u003e Qualification.Flight Crew : Instrument\u003cbr/\u003e Qualification.Flight Crew : Air Transport Pilot (ATP)\u003cbr/\u003e Qualification.Flight Crew : Multiengine\u003cbr/\u003e Experience.Flight Crew.Total : 21200\u003cbr/\u003e Experience.Flight Crew.Last 90 Days : 178\u003cbr/\u003e Experience.Flight Crew.Type : 3342\u003cbr/\u003e ASRS Report Number.Accession Number : 1593021\u003cbr/\u003e Human Factors : Training / Qualification\u003cbr/\u003e Human Factors : Confusion\u003c/p\u003e \u003cp\u003eEvents\u003c/p\u003e \u003cp\u003eAnomaly.Deviation - Procedural : Published Material / Policy\u003cbr/\u003e Detector.Person : Flight Crew\u003cbr/\u003e When Detected : Pre-flight\u003cbr/\u003e Result.General : None Reported / Taken\u003c/p\u003e \u003cp\u003eAssessments\u003c/p\u003e \u003cp\u003eContributing Factors / Situations : Company Policy\u003cbr/\u003e Contributing Factors / Situations : Human Factors\u003cbr/\u003e Contributing Factors / Situations : Manuals\u003cbr/\u003e Contributing Factors / Situations : Procedure\u003cbr/\u003e Primary Problem : Manuals\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eNarrative: 1\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eThis 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e The mechanic explained the light was part of a menu for maintenance use only on the ground.\u003cbr/\u003e \u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eSynopsis\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eB737MAX Captain reported confusion regarding switch function and display annunciations related to \\\"poor training and even poorer documentation\\\".\u003c/p\u003e\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"HR\",\"idAttr\":\"\",\"className\":\"c-section-divider\",\"style\":\"\",\"innerHtml\":\"\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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.”\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"BLOCKQUOTE\",\"idAttr\":\"\",\"className\":\"\",\"style\":\"\",\"innerHtml\":\"\u003cp\u003eACN: 1593017\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e / Day\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eDate\u003c/strong\u003e : 201811\u003c/p\u003e \u003cp\u003ePlace\u003c/p\u003e \u003cp\u003eAltitude.AGL.Single Value : 0\u003c/p\u003e \u003cp\u003eAircraft\u003c/p\u003e \u003cp\u003eReference : X\u003cbr/\u003e Aircraft Operator : Air Carrier\u003cbr/\u003e Make Model Name : B737 Next Generation Undifferentiated\u003cbr/\u003e Flight Phase.Other\u003c/p\u003e \u003cp\u003ePerson\u003c/p\u003e \u003cp\u003eReference : 1\u003cbr/\u003e Location Of Person.Aircraft : X\u003cbr/\u003e Location In Aircraft : Flight Deck\u003cbr/\u003e Reporter Organization : Air Carrier\u003cbr/\u003e Function.Flight Crew : Captain\u003cbr/\u003e Qualification.Flight Crew : Air Transport Pilot (ATP)\u003cbr/\u003e ASRS Report Number.Accession Number : 1593017\u003cbr/\u003e Human Factors : Confusion\u003cbr/\u003e Human Factors : Training / Qualification\u003c/p\u003e \u003cp\u003eEvents\u003c/p\u003e \u003cp\u003eAnomaly.Deviation - Procedural : Published Material / Policy\u003cbr/\u003e Detector.Person : Flight Crew\u003cbr/\u003e When Detected : Pre-flight\u003cbr/\u003e Result.General : None Reported / Taken\u003c/p\u003e \u003cp\u003eAssessments\u003c/p\u003e \u003cp\u003eContributing Factors / Situations : Aircraft\u003cbr/\u003e Contributing Factors / Situations : Manuals\u003cbr/\u003e Primary Problem : Manuals\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eNarrative: 1\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eThe 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eSynopsis\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eB737MAX Captain expressed concern that some systems such as the MCAS are not fully described in the aircraft Flight Manual.\u003c/p\u003e\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"HR\",\"idAttr\":\"\",\"className\":\"c-section-divider\",\"style\":\"\",\"innerHtml\":\"\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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 might 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.”\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"BLOCKQUOTE\",\"idAttr\":\"\",\"className\":\"\",\"style\":\"\",\"innerHtml\":\"\u003cp\u003eACN: 1590012\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e / Day\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eDate\u003c/strong\u003e : 201810\u003cbr/\u003e Local Time Of Day : 0001-0600\u003c/p\u003e \u003cp\u003ePlace\u003c/p\u003e \u003cp\u003eLocale Reference.Airport : ZZZ.Airport\u003cbr/\u003e State Reference : US\u003cbr/\u003e Altitude.AGL.Single Value : 1000\u003c/p\u003e \u003cp\u003eEnvironment\u003c/p\u003e \u003cp\u003eLight : Daylight\u003c/p\u003e \u003cp\u003eAircraft\u003c/p\u003e \u003cp\u003eReference : X\u003cbr/\u003e ATC / Advisory.Tower : ZZZ\u003cbr/\u003e Aircraft Operator : Air Carrier\u003cbr/\u003e Make Model Name : B737-800\u003cbr/\u003e Crew Size.Number Of Crew : 2\u003cbr/\u003e Operating Under FAR Part : Part 121\u003cbr/\u003e Flight Plan : IFR\u003cbr/\u003e Mission : Passenger\u003cbr/\u003e Flight Phase : Takeoff\u003cbr/\u003e Airspace.Class C : ZZZ\u003c/p\u003e \u003cp\u003eComponent\u003c/p\u003e \u003cp\u003eAircraft Component : Autothrottle/Speed Control\u003cbr/\u003e Aircraft Reference : X\u003cbr/\u003e Problem : Improperly Operated\u003c/p\u003e \u003cp\u003ePerson\u003c/p\u003e \u003cp\u003eReference : 1\u003cbr/\u003e Location Of Person.Aircraft : X\u003cbr/\u003e Location In Aircraft : Flight Deck\u003cbr/\u003e Reporter Organization : Air Carrier\u003cbr/\u003e Function.Flight Crew : Pilot Flying\u003cbr/\u003e Function.Flight Crew : Captain\u003cbr/\u003e Qualification.Flight Crew : Multiengine\u003cbr/\u003e Qualification.Flight Crew : Instrument\u003cbr/\u003e Qualification.Flight Crew : Air Transport Pilot (ATP)\u003cbr/\u003e Experience.Flight Crew.Last 90 Days : 419\u003cbr/\u003e ASRS Report Number.Accession Number : 1590012\u003cbr/\u003e Human Factors : Confusion\u003c/p\u003e \u003cp\u003eEvents\u003c/p\u003e \u003cp\u003eAnomaly.Aircraft Equipment Problem : Less Severe\u003cbr/\u003e Anomaly.Deviation - Speed : All Types\u003cbr/\u003e Anomaly.Deviation - Procedural : Published Material / Policy\u003cbr/\u003e Detector.Person : Flight Crew\u003cbr/\u003e When Detected : In-flight\u003cbr/\u003e Result.Flight Crew : Overcame Equipment Problem\u003c/p\u003e \u003cp\u003eAssessments\u003c/p\u003e \u003cp\u003eContributing Factors / Situations : Aircraft\u003cbr/\u003e Primary Problem : Aircraft\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eNarrative: 1\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eAfter 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eSynopsis\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eB737-MAX8 Captain reported the autothrottles failed to move to the commanded position during takeoff and climb.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"HR\",\"idAttr\":\"\",\"className\":\"c-section-divider\",\"style\":\"\",\"innerHtml\":\"\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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.”\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"BLOCKQUOTE\",\"idAttr\":\"\",\"className\":\"\",\"style\":\"\",\"innerHtml\":\"\u003cp\u003eACN: 1555013\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e / Day\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eDate\u003c/strong\u003e : 201806\u003c/p\u003e \u003cp\u003ePlace\u003c/p\u003e \u003cp\u003eLocale Reference.Airport : ZZZ.Airport\u003cbr/\u003e State Reference : US\u003cbr/\u003e Altitude.AGL.Single Value : 0\u003c/p\u003e \u003cp\u003eAircraft\u003c/p\u003e \u003cp\u003eReference : X\u003cbr/\u003e Aircraft Operator : Air Carrier\u003cbr/\u003e Make Model Name : B737 Undifferentiated or Other Model\u003cbr/\u003e Crew Size.Number Of Crew : 2\u003cbr/\u003e Operating Under FAR Part : Part 121\u003cbr/\u003e Flight Plan : IFR\u003cbr/\u003e Mission : Passenger\u003cbr/\u003e Nav In Use : FMS Or FMC\u003cbr/\u003e Flight Phase : Parked\u003c/p\u003e \u003cp\u003ePerson\u003c/p\u003e \u003cp\u003eReference : 1\u003cbr/\u003e Location Of Person.Aircraft : X\u003cbr/\u003e Location In Aircraft : Flight Deck\u003cbr/\u003e Reporter Organization : Air Carrier\u003cbr/\u003e Function.Flight Crew : First Officer\u003cbr/\u003e Function.Flight Crew : Pilot Not Flying\u003cbr/\u003e Qualification.Flight Crew : Instrument\u003cbr/\u003e Qualification.Flight Crew : Air Transport Pilot (ATP)\u003cbr/\u003e Qualification.Flight Crew : Multiengine\u003cbr/\u003e Experience.Flight Crew.Total : 10861\u003cbr/\u003e Experience.Flight Crew.Type : 1660\u003cbr/\u003e ASRS Report Number.Accession Number : 1555013\u003cbr/\u003e Human Factors : Human-Machine Interface\u003cbr/\u003e Human Factors : Training / Qualification\u003c/p\u003e \u003cp\u003eEvents\u003c/p\u003e \u003cp\u003eAnomaly.Deviation - Procedural : Published Material / Policy\u003cbr/\u003e Anomaly.Inflight Event / Encounter : Weather / Turbulence\u003cbr/\u003e Detector.Person : Flight Crew\u003cbr/\u003e When Detected : Pre-flight\u003cbr/\u003e Result.General : None Reported / Taken\u003c/p\u003e \u003cp\u003eAssessments\u003c/p\u003e \u003cp\u003eContributing Factors / Situations : Company Policy\u003cbr/\u003e Contributing Factors / Situations : Human Factors\u003cbr/\u003e Contributing Factors / Situations : Manuals\u003cbr/\u003e Contributing Factors / Situations : Procedure\u003cbr/\u003e Primary Problem : Company Policy\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eNarrative: 1\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eI 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.\u003cbr/\u003e \u003cbr/\u003e 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).\u003cbr/\u003e \u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e I recommend the following to help crews w/ their introductory flight on the Max:\u003cbr/\u003e Email notification the day before the flight (the email should include: Links - Training Video, PSOB and QRG and all relevant updates/FAQ's)\u003cbr/\u003e 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.\u003cbr/\u003e \u003cbr/\u003e 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.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eSynopsis\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eB737 MAX First Officer reported feeling unprepared for first flight in the MAX, citing inadequate training.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"HR\",\"idAttr\":\"\",\"className\":\"c-section-divider\",\"style\":\"\",\"innerHtml\":\"\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"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 database, I assume someone will let me know about them. We’ll see where the evidence leads.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"Here is another highly relevant offering for the day. It comes from J. Mac McClellan, a longtime writer and editor in the flying world, \u003ca data-event-element=\\\"inline link\\\" href=\\\"https://airfactsjournal.com/2019/03/can-boeing-trust-pilots/\\\"\u003eat the \u003cem\u003eAir Facts\u003c/em\u003e site\u003c/a\u003e. He argues that Boeing may have been assuming that pilots would note any pitch anomaly, and override it if it occurred (as appears to have happened in the incidents involving U.S.-carrier pilots that were reported in ASRS). His whole article, about how airlines manage the complexities of automated and human flight guidance, is worth reading.\"},{\"__typename\":\"ArticleParagraphContent\",\"subtype\":null,\"idAttr\":\"\",\"innerHtml\":\"In the article, called “Can Boeing Trust Pilots?,” McClellan writes:\"},{\"__typename\":\"ArticleLegacyHtml\",\"tagName\":\"BLOCKQUOTE\",\"idAttr\":\"\",\"className\":\"\",\"style\":\"\",\"innerHtml\":\"\u003cp\u003eWhat’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.\u003c/p\u003e \u003cp\u003eWhat 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.\u003c/p\u003e \u003cp\u003eThough 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.\u003c/p\u003e \u003cp\u003eBoeing 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 ...\u003c/p\u003e \u003cp\u003eBut 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?\u003c/p\u003e\"}],\"editorialProject\":null,\"primaryCategory\":{\"__typename\":\"Channel\",\"displayName\":\"Ideas\",\"url\":\"https://www.theatlantic.com/ideas/\",\"slug\":\"ideas\"},\"primaryChannel\":{\"slug\":\"ideas\",\"__typename\":\"Channel\",\"displayName\":\"Ideas\"},\"reviews\":[],\"embeds\":[],\"preview\":null,\"tags\":[],\"layout\":\"standard\",\"secondaryByline\":\"\",\"dek\":\"\",\"url\":\"https://www.theatlantic.com/ideas/archive/2019/03/heres-what-was-on-the-record-about-problems-with-the-737-max/622213/\",\"shareText\":\"Pilots can file ASRS reports about problems they encounter. @JamesFallows compiles the complaints related to possible runaway-trim issues in the Boeing 737 Max over the past year:\",\"shareTitle\":\"Here’s What Was on the Record About Problems With the 737 Max\",\"title\":\"Here’s What Was on the Record About Problems With the 737 Max\",\"datePublished\":\"2019-03-13T20:47:51Z\",\"audio\":null,\"hasAudioRights\":null,\"editorsNote\":{\"content\":\"This article previously appeared in a different format as part of The Atlantic’s Notes section, retired in 2021.\",\"datePublished\":null,\"__typename\":\"EditorsNote\"},\"leadArt\":{\"__typename\":\"LeadArtImage\",\"image\":{\"url\":\"https://cdn.theatlantic.com/thumbor/2-BTnSOLnN-_nrKeBK_UreHdrq0=/0x416:4000x2666/960x540/media/img/notes/2019/03/RTX6QYX5/original.jpg\",\"width\":960,\"height\":540,\"srcSet\":\"https://cdn.theatlantic.com/thumbor/8KUbgtcR5bWasakPYKNg7HVrwCk=/0x416:4000x2666/750x422/media/img/notes/2019/03/RTX6QYX5/original.jpg 750w, https://cdn.theatlantic.com/thumbor/NphH6sKvB6_sZgfVzeJE7HUg5Jk=/0x416:4000x2666/828x466/media/img/notes/2019/03/RTX6QYX5/original.jpg 828w, 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