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Kylee Evancho

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Aug 2, 2024, 10:36:51 PM8/2/24
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That brief mention in the manual, a copy of which was obtained by CBC News, has prompted some speculation that more details about the anti-stall computer system may have been included in previous drafts, but then left out of the final version.

"I think the fairly obvious conclusion is that a broader explanation of MCAS was included in an earlier edition of the manual, and somewhere along the way it ended up on the cutting room floor," said Judson Rollins, a New Zealand-based aviation consultant, who worked for three airlines and a plane manufacturer.

The operating manual mentions the term MCAS under the section entitled "Abbreviations," where the acronym is defined as "Maneuver Characteristics Augmentation System." That's the one and only reference to MCAS, which is suspected of playing a role in two recent crashes involving Max 8 planes in Indonesia and Ethiopia, which killed 346 people in total.

Raymond Hall, a former Air Canada pilot, said "it's very interesting" that the subject of MCAS was broached in the manual, but that "no follow-up" was done to explain it. Hall said that Boeing has historically been quite vigilant in making sure that all of its systems are laid out in clear terms, both in pilot training and in pilot manuals.

"The system is critical to the safety of the flight. And pilots ought to have known that it was there, ought to have been able to recognize it when it was implemented and ought to have been able to respond effectively," Hall said.

Dennis Tajer, an American Airlines pilot and spokesman for the Allied Pilots Association, told the Washington Post that during that meeting, executives said they didn't inform pilots about the MCAS because they didn't want to "inundate" them with too much information.

In an emailed response to CBC News, Boeing did not deny that there were no references to MCAS in the manual. But spokesman Paul Bergman said that the relevant functions of the system were "described" in the manual, and that "media reports that we intentionally withheld information about airplane functionality from our customers are simply untrue."

The Max, which came into service two years ago, features the new automated MCAS, which is meant to prevent an aerodynamic stall, which can cause a loss of lift, sending the plane downwards in an uncontrolled way.

This system is designed to force the plane to pitch down if it thinks the aircraft is about to stall. Reports suggest that in the Lion Air crash, the MCAS may have responded to a faulty sensor, leading it to think the plane was stalling, and causing the plane to lurch downwards. The pilots, unfamiliar with the MCAS system, may have been helpless to respond and unable to bring its nose back up.

The New York Times reported that in the final minutes of the Lion Air flight, the pilot handed the controls to his co-pilot and flipped through the pages of a technical manual, trying to figure out what was happening.

For the download version :
Download File Size : 90 Mb
The user is not allowed to print the document.
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On 23 April 2016 Virgin Australia Boeing 737-8FE VH-YIW was operating from Auckland, New Zealand to Faleolo Airport, Apia, Samoa. Unbeknown to the crew, the right engine nacelle made contact with the runway during the landing and been damaged. The damage was not detected for several days.

The Australian Transport Safety Bureau (ATSB) explain in their safety investigation report (issued 30 June 2020) that the aircraft was expected to depart on the return sector before the arrival of approaching Tropical Cyclone Amos (TC Amos).

The captain had a total of about 10,000 flying hours experience, c6,000 on type. The first officer had about 5,300 hours, c1,100 were on type. Both had operated to Apia many times, including at night and in rain.

The captain disconnected the autopilot at 260 ft and then inadvertently activated the take-off/go-around (TOGA) function. He immediately realised, corrected this action and then deactivated the auto throttle as originally planned.

At 0807UTC, the aircraft landed on the right main landing gear wheels first, followed by the nose wheels, then the left main gear wheels. Flight data indicated that the aircraft was not pitched nose-up to flare for landing before touchdown.

The crew taxied to the terminal and discussed the landing. While neither crew reported that it was a hard landing, the first officer considered it firmer than normal and consequently checked the landing data. Having only been informally shown how to access this information, the first officer recalled identifying the touchdown as 1.45 G landing with a 10 right roll. This alleviated his concerns of a hard landing and he communicated this to the captain.

In preparation for the return flight, the captain and the engineer both conducted independent external pre-flight aircraft inspections in the heavy weather conditions. During this time, the weather deteriorated further and the crew postponed the return flight until the next day.

Following the conduct of four sectors after the Apia landing, damage to the right engine nacelle was detected. Additional inspection identified lateral wear damage on the outer right landing gear tyre.

Runway shape and slope illusions: At a given altitude and distance from a runway, the slope of a runway will affect the amount of runway visible to a pilot. For a down-sloping runway such as Apia, this will result in less of the runway being visible. Pilots may perceive this lack of visibility as the flight path being below the correct approach path and as a result, the pilot may fly a higher-than-normal approach to achieve the runway visibility that would be present on a level runway. Both flight crew identified this runway as having a significant down slope, which increased the difficulty of landing at Samoa. They also reported heavy rain on approach, which did affect visibility. However, both crew had a high level of experience operating into this airport and did not report any issues relating to the slope or visibility of this approach.

Neither pilot reported the workload during the approach as being too high to manage. They briefed for the approach and were actively monitoring the weather conditions, and they addressed the increased requirements for radar scanning successfully. However, final approach is normally known as a period of high workload for pilots, particularly at night. In this case, the workload was further increased by the changing weather conditions. The difficulty in communications with the tower, the crosswind, manual control of the aircraft and the potential influence of fatigue also added to this workload.

During the post-event investigation, the operator found that flight crew were not specifically instructed on how to interpret this data. Consequently, the FO did not understand the limitations in how the data was displayed, which led the flight crew to believe the landing was within acceptable limits, and alleviated any concerns they may have had with the landing. As a result, the flight crew did not alert the maintenance engineer of an increased likelihood of a hard landing or possible runway contact with the airframe.

The operator has modified its training in relation to flight crew external inspections to include a specific visual inspection of the underside of engine nacelles, as per the procedure outlined in the flight crew operations manual. The operator has also modified the procedures for engineering external daily inspections to include a specific visual inspection of the underside of engine nacelles. International roaming on the Virgin Australia International fleet has been introduced to enable automatic downland of QAR data immediately after shutdown at all Australian and International Airports.

Aerossurance will be running training workshops at the EHA European Rotors VTOL Show and Safety Conference in Cologne in November 2020 on a) Safety Culture and Leadership and b) Contracting Aviation Services: An Introduction to the Basics.

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