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The captain on Lion air's flight 610, re-trimmed the aircraft through 21 MCAS activations. The first officer, who was given control of the aircraft, got 5 more. Although it is speculated that neither pilot executed the required stabilizer trim procedure, the report does not specifically state whether or not that procedure was actually run. Source

The captain on Ethiopia Airlines flight 302, tried engaging the auto-pilot, on the faulty side as well, and despite that being the first step for the procedure, to disengage, he tried multiple times to do otherwise, then skipped over the second step, which was to disengage auto throttles, this allowed their airspeed to build up around 390. I’m sure this didn’t help the nose down force, but ultimately, they re-engaged the system which allowed MCAS to drive the nose down further. Boeing's CEO stated these failures to follow procedures is what led to the crash. Source

The question, then, is this: if the crashes each resulted from pilot error, why is Boeing under so much scrutiny?

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    $\begingroup$ This is largely opinion based (which is out of scope here) but news outlet are covering both sides of the story depending on where you look. Boeing a very large American company and their stock is a major market player. Many of the financial news outlets are covering the company because its having a tangible impact on the economy. $\endgroup$ – Dave Oct 23 '19 at 11:46
  • $\begingroup$ @Dave How can it be opinion based, when I got this from the reports, and not something I convinced myself? $\endgroup$ – Firefighter1 Oct 23 '19 at 11:47
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    $\begingroup$ mostly because of the line I have no problem with Boeing being faulted, why is everyone totally ignoring another issue people are not ignoring the issue, some are discussing it and why news outlets chose to report on and cover certain things is surely an opinion $\endgroup$ – Dave Oct 23 '19 at 11:50
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    $\begingroup$ This is both opinion based (why is a company receiving media attention) and borderline speculative (where it involves the two 737MAX crashes, which are the subject of ongoing investigations), so I foresee its closure in the near future. Or, as is customary in other parts of the net: inb4lock $\endgroup$ – AEhere supports Monica Oct 23 '19 at 12:02
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    $\begingroup$ @DeltaLima In my opinion this is till too much focused on the recent accidents, which are still under investigation. I vote to leave closed. $\endgroup$ – Bianfable Oct 24 '19 at 6:36
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In aviation (and other safety critical areas) it's not enough to just look at the first cause of an accident, you have to look at why that mistake was made, and why that thing happened, as far back up the chain as you can. Then you try to address all the problems.

So, when a pilot makes a mistake, it's tempting to say "the pilots was an idiot. Case closed." However, then you've got to wonder why the company employed idiots, and how many others are flying. That implies that there's something wrong with the pilot licencing and testing rules, and that has huge implications.

If we assume that these pilots weren't idiots, we have to ask why they made a mistake, because other good pilots could make the same mistake. Anyone who has played a computer game knows that mistakes are inevitable when you're under enough stress, just like a well built bridge will still break if it's overloaded.

You could conclude that they hadn't been trained well enough, which raises the question "Why?". Apparently the pilots did all the required training, so maybe the training was at fault. But it's not enough to just improve that piece of training, you've got to ask why again. Was it not checked? What else hasn't been checked properly? How do we know that any future training will be properly checked? Also, what incentive did the person writing the training have to miss things out, and does it apply elsewhere?

If you don't find and fix the root of a problem, it will continue to grow until it pops out somewhere else and causes another tragedy.

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    $\begingroup$ "Unfortunately Boeing and airbus can make great aircraft all they want, but malfunctions will still occur. And we just have to learn how to deal with them." This aircraft, and MCAS in particular, and the development process used to create MCAS, is clearly not "great". Believing that malfunctions will occur, and we just need to learn to deal with them actually has a formal term: "normalization of deviance". Aviation is (and should be) built to the highest standards, accepting malfunctions as "normal" is not appropriate. $\endgroup$ – abelenky Oct 23 '19 at 14:17
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    $\begingroup$ If the question gets closed, I hope you write another one to attach this nice answer to. $\endgroup$ – quiet flyer Oct 23 '19 at 15:38
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    $\begingroup$ @Firefighter1 This isn't just about a malfunction. Boeing found that the new airframe's behaviour did not meet the established safety norm (requirement?) that a commercial aircraft should be inherently stable, so they created the MCAS to compensate; which they believed would make the new airframe's behaviour as safe and intuitive as the old (proven) airframe. They believed it safe and intuitive enough that pilots were not informed during their training, and here we are with 2 fatal accidents. What other assumptions have they made that we are not aware of, and what more accidents await? $\endgroup$ – aerobot Oct 23 '19 at 16:05
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    $\begingroup$ @Firefighter1 I’m just saying that the malfunction has already existed, for decades now. I think this is where the misconception is. The MCAS is a new subsystem created for the 737 MAX series, to counteract a significant modification to the original 737 airframe. The modification should have invited scrutiny from the FAA, but did not, which is why the FAA's role/responsibilities/diligence have also been questioned. $\endgroup$ – aerobot Oct 23 '19 at 16:22
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    $\begingroup$ 737-MAX and MCAS were introduced in 2017 (production started in 2014). That is in no way "decades". No training was provided because (in theory) it worked the same. The checklists you are referring to are for runaway trim, which is the trim running continually. What actually happened was intermittent incorrect trim adjustment, and there currently is no checklist or training for that. $\endgroup$ – abelenky Oct 23 '19 at 17:02

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