A Crash That Made Boeing Change Their System| Mayday: Air Disaster 

It’s a question we will never know

Because he knew the issue was the altimeter was broken.

Pilots need to train and follow the steps not hard

Because the "system warnings", such as they were, were woefully inadequate. Unless I'm mistaken, there was never an audible "Airspeed!" warning, as there obviously should have been, nor a properly visible warning like a flashing light. You know, something that might actually get your attention. You've got the slowly rising "barber pole", which is barely noticeable, and apparently you have a teeny tiny ultra-thin frame around the speed indicator that is about a millimeter thick and is almost invisible, and flashes imperceptibly from gray to white when the speed is too low. (White? Not red or orange? Since when is *_white_* an emergency color???) These design deficiencies also contributed to the Asiana Flight 214 crash at SFO in 2013, which was also the result of low airspeed. I used to think highly of Boeing, but in recent years I've really had to reconsider my opinion.

It's bonkers for a flight to have 3 pilots in the cockpit and not a single one paid attention to the instruments.. Especially considering the 3rd pilot was there specifically for that.. They did their final approach checklist/configuration too late, unsure as to why it was delayed. Possibly they were too comfortable and trusted the systems too much? Every pilot should always remember: Aviate, Navigate, Communicate. But, as far as the plane itself, everything in a plane has redundancy, taken with a grain of salt.. how come there was no connection between the radio alt and the first officers display?

Flawed design sounds 100% accurate. Imagine a car being produced with gauges showing sloppy readings.

@@S730SD "Yeah we understand the speedo gives you BS speeds, but you should be able to look out the window and figure it out :)"

It is a flawed design if you are fortunate to walk away , then you have the right to not fly an aircraft with such a flaw. May cost you money but you still have your life

@Opterongeek Which Warners are those? There was Jack Warner. Aside from producing films he appeared in films in the 1950s. He was in the 1951 version of "Scrooge," with Alistair Sim, that was based on Dickens's _A Christmas Carole._ Just a random factoid there for you. I am a font of useless info. Just ask and I will give you more. You never know when you might need them and trivia night or something. 😸🤯😁

Unsurprisingly there is a bit of a parallel here, coming from the nuclear power industry. The partial core meltdown that occurred at TMI, was due to a few primary factors. Without going into the engineering weeds, we'll just put it simply. The operators in the Control Room, released too much water from the primary coolant system and partially exposed the reactor core. This caused the still hot reactor core to overheat and begin to melt. A set of valves designed to keep the reactor coolant system from becoming over-pressurized, had a design flaw. They were notorious for sticking partially open after being operated, as seen by many routine tests of them. Also, the valves had a poor system for indicating their position in the Control Room, that was also seen on a number of occasions to indicate shut, when in fact they were just a little bit open still. The water from these valves when released was directed into a tank inside the Reactor Containment Building. For an unknown reason, the engineers designing this system only provided temperature gauges downstream of these valves. Other tanks in the plant were generally provided with some sort of level indication and most importantly the PRESSURE in the tank. During the accident sequence, the operators became concerned with overfilling the reactor coolant system and causing its pressure to increase, perhaps dangerously. They elected to open these valves to release the excess water in the system. Once the operators saw indications that the coolant levels were properly restored, they shut these valves. Unknown to them, a set of the valves failed to fully close, yet in the control room they indicated shut. The operators observed the downstream pressure indication and it seemingly returned to a near-normal temperature. The operator training program has intensive instruction in thermodynamics and the behavior of system pressure and temperatures during both normal and emergency conditions. However there was a flaw in the training manuals, and they did not provide an explanation for the relationship of pressure and temperature in this particular system. It's function was much different than other systems in the plant and therefore the indications during operation were also much different. This condition composed of these three or so factors, led to the real disaster. The parallel I see is that we have systems with known deficiencies, but instead of modifying their design and installing more adequate indications to the control room, they chose to rely on the operators identifying and reacting properly to the issues should they arise. Then DID and the poor SOBs in the Control Room relying on their flawed training didn't notice the loss of water for some hours, triggering the core partial meltdown.

If It's Boeing , I Ain't Going 😢

in this case you can't blame boeing honestly. they should've done better to improve it but in this case ethe 3 pilots should've seen it coming

@@jaomircourtar1501 I see two problems. The pilots were not fully aware that the captains radio altimeter controls the autothrottle Under normal circumstances. the pilot monitoring would be monitoring the instruments. He was under training for landing and no one was assigned the monitoring role. I would have expected the third pilot to have been assigned this role, but did his seating position give him a clear view of the instruments.???

@@mg-by7uu it was pilot error, below 2000 feet HANDS ON THE CONTROLS

Yup, Boeing was right. One altimeter failed to indicate the altitude. Three pilots failed to monitor the airspeed. The airplane stalled due to insufficient airspeed. The airplane crashed. You think the airplane crashed because the altimeter failed. Obviously this stuff is too complicated for you to understand.

It's design by body count! 😱

Well, it least you only have a 1 in 30 million chance

Hahahha

Exactly what I think.

​​@@AccidentallyOnPurpose that statistic is a lie to keep people flying. It only takes one failure and hundreds gone.

Great idea having the computer parrot the changes back to the pilots, but there needs to be proof the changes were actually applied, no?

@@jp.1543 That's what the pilots are for. The normal procedure in the cockpit is: One pilot makes a configuration change and calls out that change, and the second pilot _verifies_ that the change was made, so there would be no difference in procedure aside from a clarification of whose responsibility it is to verify changes the computer makes. I'm honestly kind of surprised this isn't already how things operate.

From an automation perspective I'm surprised that no redundancy was built into this system. In the space shuttle as well as other aircraft, multiple CPU's are used as safety to protect against faults. In this case if the altimeters don't agree the computer should have allowed the pilots to select the functioning altimeter and have the computer ignore the faulty one. Of course they would also have to program a notification to ensure the plane didn't get stuck on this mode after repair, but it's surprised me with both altitude and airspeed that aircraft computers have only relied on the Captain's side.

@@jp.1543 Having the aircraft's electronics communicate verbally is not the same as an indicators on a panel or system alarms. A pilot can easily be overwhelmed by information and the computer should be seeking to distill the warnings into something the pilots can quickly and easily digest. In addition, when we give computers the 'smarts' to autonomously play with power settings we invite potential catastrophe - at the very least the computers should be clearly enunciating what they are doing to the pilot(s). Humans perform poorly when bombarded by information and having the aircraft make its own decisions, without properly and clearly informing the pilots, only compounds the problem. What is annoying, as a programmer and hardware designer, is that flight control systems could perform in a way that is far more compatible with how humans function.

@@TheLegoMasterMan100 ---- Hadn't thought of it before, but relative to the rest of the aircraft, a CPU is cheap. I don't know what they'd have to connect it to ... I think there are something like two miles of wiring in an airplane, maybe more.

Aaaaaah… What? Is this true? That’s awful 😣

​@@InspektoraDeFrutas I'd day this is definitely not true

I remember the news video the captain waving his hand. Surely he was badly injured but was alive. Contrary to the commentary in this video it took ages Dutch responders to arrive to crash site

The root cause is often irrelevant, and you should have remembered that; fixing the root cause is often expense when put next to a functioning workaround, and in this case, there was such a workaround. It only became an issue when the function of the workaround was compromised because of an incorrectly performed procedure. IT is a failed human endeavor.

no... we been landing planes in IMC for 50 years. radio altimeters are a new luxury... the root cause is the pilot monitoring, wasn't. there are reasons that there is a pilot monitoring, there is a reason you need to be stabilised on approach 1000ft AGL. they ignored all the warnings, didnt follow procedure and missed everything

@@PhycoKrusk expense? to get an altimeter to work reliably? in a supposedly super hitech airplane? an airplane that otherwise does not how high it's flying? Lets work around it? lol

​@@PhycoKruskAs a software engineer the last word I want to hear for an airplane is "workaround". We have a word for that: "hacky"

@@mg-by7uu I'm not disagreeing, but that's the nature of any highly computerized system; if something doesn't work right, someone will find a way to make it work, even if that doesn't actually correct the problem. _Every_ computerized system is like this, and they are like this because they have grown so large and so complex that it's basically impossible to actually fix anything; _everything_ is a workaround.

LoL, I totally agree. Episodes like this are some of the best ones.

Yes definitely, I concur my friend

Dozens and hundreds of people’s lives and eternities are at stake, and this is all a game and a captivating puzzle for you, fools?! I hope you won’t have to experience this, or your loved ones, for you to begin appreciating the immeasurable value of human life!!! This is not just a computer game. Wake the heck up! 🤯🫢⏰🚨⏰

@@InspektoraDeFrutas he never said anything about the people, of course this is above all a tragic event. What he said is that the episode was more interesting than the others.

Is Boeing flying the airplane or the pilot? When I drive my boat with the autopilot on, do you think I trust my life to that autopilot system? I know if one sensor failed, the damn boat would steer itself into the nearest rock jetty. Many boats has been lost due to autopilot systems. Do yo blame the pilots or captains or do you blame the boat?

@@ahndeux Either the Pilot or the plane can be at fault, or even both combined. Human, being imperfect will eventually make mistakes and shouldn't be expected to cover for a known mechanical fault that could be prevented. I don't think it's right for manufacturers of any type of vehicle to place blame on issues caused by known mechanical failures that shouldn't exist. Sure sometimes human pilots make dumb mistakes but expecting humans to never mess up, will cause deaths. -In summary, manufacturers shouldn't be allowed to forward blame to pilots for the "manufacturers" known problems. In this situation Boeing would say 9 of 10 pilots caught the issue in time, and this time the pilot was at fault. But Just because pilots catch an issue doesn't make the issue OK. I'm not singling out Boeing, all aircraft manufactures have pushed aircraft to the production line and blamed the user for mishandling. I'm actually a fan of Boeing and hate Airbus joystick control and greater automation. I think the pilots needs more control ability. Despite how great Boeing has been, they have recently been letting safety slip.

@@mrdan2898 Wait a minute. Its not a design failure. The radar altimeter is known to have failed so it gave bad data. A system that was designed to take in inputs to automate the control of an airplane is being fed KNOWINGLY BAD data. How is this related to blaming the pilots by the aircraft manufacturer? In reality, pilots should FLY the airplanes manually and not rely on AUTOMATED SYSTEMS which are prone to failures or respond incorrectly due to bad data. The real SAFETY issue it he pilots has been relying too much on autopilots and other automated flying software and that is a MISTAKE.

@@ahndeux I agree with you that Pilots rely on automation too much as a result often forget how to manually fly the plane when issues arris. That's a known issue. Supposedly the airlines touch up, retrain pilots but I don't have any confidence in this.

@@mrdan2898 Almost every accident shown in these videos are because pilots are depending too much on software and automated system as opposed to flying the airplane itself. If your life depends on these systems, you better know how it works and which sensors it uses to run the systems.

When you're flying in an airplane going at 300+ knots per hour, every issue is dangerous. However, the main issue I see is that pilots are depending more and more on autopilot systems without understanding how it works. If drive a boat and it has an autopilot, I would like to understand how it gets the data and how the sensors are used to move the boat for me. If any of those sensors go down, I would like to know so I can shut down the system. Its the same with airplanes. Its become so complicated that pilots don't even know how it works or where it gets the data for the sensors. If any of those sensors go down, it would be good to know you can't rely on the system. The fact that the pilot kept turning off the warning horn tells you he had no idea what that sensor would do to the automated system. Its like driving a car and you get an engine light come on. Instead of trying to figure out the cause, you just reset your car ODB system so it doesn't show you the engine light. Seriously, that is practically what the pilots did.

Has *any* airplane manufacturer?

This comment's foreshadowing is quite ominous. Made after two 737-MAX 8 crashes, but before the MAX 9 door plug blowout & reports of many loose bolts on other MAX 9 planes; and before the nose gear tire spotted rolling along the runway by a fellow pilot.

@@dexterpoindexter3583 it's not ominous if the problems keep getting ignored, it's just fucking inevitable

@@monty58 Absolutely right. And sad, dangerous, & it seems very tricky to fix properly. Yet the _comment_ was ominous. Maybe omens always foretell some inevitable events. (How can we be sure they're inevitable, in general - not just in industry?) But they still feel eerie, spooky, scary & otherworldly. Until you know the basis they're founded on (sometimes that's possible): then they can become wise.

Neither does Airbus.

It's human nature... "It's not my fault"...

​@@hhds113neither did Douglas, Lockheed, Convair, etc.

did they not say in this video that they concluded that a major part was due to the altimeter bug?

But surviving pilots/crew carry guilt forever

Heh, and the microscope, and the audio mixing console that looks like it's better suited for a concert, than listening to a CVR...

There’s only one radio altimeter, and a barometric one. They just feed different displays. If they disagree then any automation that relies on either sensor should likewise be disabled accompanied by a visual/audio warning. Why you’d continue running any automated process after it was known that a sensor failed is beyond me. The single AOA sensor feeding MCAS with the Max was a political decision not an engineering one. If they’d used 2 sensors then it would’ve required manual reconciliation in case of failure, which would’ve necessitated training the pilots specifically for the Max, in which case pilots couldn’t just use their old type rating, in which case they’d lose out on money.

My thoughts exactly. It's utterly baffling how such obvious design oversights make it into production.

@@JohnnyUtah488 Read my comment above. It wasn’t an oversight. It was a deliberate decision designed to meet the commercial objectives of the program.

Boeing did a poo (and had plenty of good reasons to, though safety was not one of them), but they fixed it. I don't get why every still hates on the 737 MAX - it's a great plane.

100%!!!!!! Can’t blame the pilots for a fault in the design

HAHA YOU NEW ON THIS PLANET?

It's Boeing again!! It is really suspicious that most of these deaths are caused by Boeing. Boeing killed every whisleblower who speaks against them. Something disturbing about Boeing, it's like it was made with many dysfunctional problems as part of the depopulation plan!!!!

@@liukang3545 why?

"60% of the time, it works every time."

I think he means that the pressure altimeter isn't 100% accurate compared to the radio altimeter

​​@@NobleSuitGThe plane literally...crashed...because of the inaccurate radio/radar altimeter readings. That's what this whole episode was about. But sure, it's 100% accurate😂

Can confirm: My car starts 100% of the time it starts correctly.

What he's trying to say is that the pressure altimeter is approximating the altitude and will never tell you how far above ground you are except flying above the sea, where as the radio altimeter will tell you exactly how many feet above ground level you are if it is operable.

Exactly… if you have to listen to pull up over and over again, why not add throttle down! :)

Yes it should say throttle down or throttle up if needed. But at the same time there have been instances where there has been other computer malfunctions and it's telling them to do one thing such as pull up low terrain and there's not even terrain. So what do they do about that then??

When you’re in landing mode, airspeed is supposed to be low.

There is a shaker on the flight control column to tell the pilots of things like this.... This flaw was KNOWN to exist on several of the 800 series 737's.... Those planes s hould have been grounded.... Until Boeing and Rockwell/Collins identified & repaired the problems... According to this video, Boeing and Rockwell-Collins did not feel that the inop radio altimeter was a bad enough problem to ground these planes.... I thought that the Radio altimeters are serious enough items to be on the MEL's....

Both air speed and altitude

And with all the boeing news coming out these days, having 3 boeing engineers being victims adds some layers 😂

Look at all the airbus “fly by wire” issues

@@CheddarCheeseBandit examples please?

@@aspiringcaptain Yup. This is the second (or third?) Mayday I've seen where the autopilot's malfunction caused/played a role in crashing the plane, and all of them have been Boeing... Despite the fact that Airbus is meant to be the one relying more on automation...

@@Metoobie it's more poor training that causes the problems

Well in this case it was a pilot error. 😂😂

Maybe they should go back to the days of having a flight engineer to monitor all the increasingly complex systems and let the pilots concentrate on flying the plane.

@@johncantwell8216 Now that's a suggestion worth considering.

​@@johncantwell8216 Another trained hand in the cockpit to take workload off the pilots would help. But that would also be another salary for the airlines to pay, so I doubt flight engineers will return. The Air Force still uses them on many planes for a reason.

You are right about the F/E's not returning: in addition to their salaries and cost of training, a row of seats would have to be removed to accommodate their workstation. Maybe better air-to-ground telemetry could be developed so the status of the onboard systems could be more accurately monitored from the ground, and the pilots advised in real time on how to deal with certain problems.@@lawv804

@@lawv804 your likely correct. And passengers may end up paying the price in human lives that airlines are unwilling to pay in currency

😅

Most are Boeing engineering!!! Hmmm !!!

In this case, it wasn’t an archaic system, although it could have been better.

Boeing be like - this is an amusement park ride, enter at your own risk.

Why watch when you can be part of one?

@@NoReply28 Yeah, imagine me on TV. No thank you. If I were involved in a plane crash, I’d either want to be dead or someone they don’t interview

I just did that. It was intriguing. Flight was fine.

I already did it as well. 😂😂😂

​@@sharoncassell9358That would be fun! I used to always joke about that. Like "Hey, let's watch a plane crash movie while flying aboard an airplane!" Awesome!

We need more female commercial pilots!

There are women who can ride Harleys & fly planes very well, but if you drive enuf you will find the majority of women cannot even drive a car let alone ride a MC or fly a plane. They just dont have the aptitude. And its frustrating! We are THE FEW.

@@Userxyz-z2d Why are you all being sexist about this!? For goodness sakes people's lives were lost here! Have some decency!

@@Userxyz-z2d The internalized misogyny here is pathetic. Do better.

@@christinajackson6309 All you ladies belong in the kitchen and keeping the house clean.

What I find weird is that the manufacturers had the foresight to install independent altimeters in case one of them malfunctions, yet didn't consider that one of them could be feeding false information to the computer. Pilots should be able to choose what altimeter the computer is receiving data from.

The airplane is not a bomb. It doesn't "blow up" on any impact. Pieces will fly off, but its due to the inertia and momentum of the airplane.

@@ahndeux Airplane fuel is very flammable

@@alex15095 And set up to not mist. KAM, Kerosene - AntiMisting. The product of an extensive R&D campaign in the sixties or seventies. Like gasoline, it's not the liquid that goes boom, it's the gas.

Yeah when you intercept it. They never intercepted the ils. Did you not watch the same video we did?

Equipment can fail, that's OK. What is not so state of the art is an airplane that relies solely on one sensor and expecting the pilots to catch that and correct it.

He he. At the time of the accident, the 737 was 42 years old, albeit the 737-800 had avionics and other updates. At the time of writing (2024), the 737 is 57 years old, still flowing the design principles of the 1960's. Boeing still believes it is state of the art,

the mergerign with MD and what affects many companies today. corperate heads wantign the quick buck rather then long term investment

@@Revkorsoon they will merge with Uranus!

DEI?

​@@fiddlermargieUm,NO.The pilots were all white. As most on these airplane disaster channels. Try again,bud.

Accountants

Um, she didn't say "more training" at all. She said, "So what we have to do is design automation to work with people in a way that keeps them more actively, cognitively involved and in the loop, and not just monitoring a piece of automation to say, 'Is it doing what it's supposed to be doing?'" Also, maneuvering was not an issue in this case, it was about failing to monitor the progress of the flight.

today's young pilots don't know what to do with the airplane when their precious computers go out.

Unless you don’t have trained licenced Engineers with enough experience …. the world is running out of these responsible men because off ? Reducing Maintenance Costs 😮

Not in an ideal situation but doesn't save this from any sort of liability..

Or better yet, dont fly at all ! Let Boeing and other companies keep making planes, without having any passengers. I mean i know some people cant do without flying, but those of us who can avoid it, can do our bit, to stop these monsters companies and airlines.

Who cares

@@Kylecamp420 You may someday! 😘🤭🙄🤣😂

GOBBLESS!!!

​@Kyle ask yourself that same

Yeah but what if the cruise control disables your brakes? To be honest, it also largely disables your steering wheel. And it happens just as you start braking for a red light. p.s.: Airliner's auto pilots are a good thing. There is a bias because we dont know how many times and how many lives have been saved by the auto pilot correcting the pilot, or from a pilot error on some routine maneuverers. Just like self driving cars. I dont like the idea of the car driving for me. But I really like the idea of the car driving other people's car around me.

In case of overspeed or approaching stall speed, not only should the flag show up but also an audible sound. That is the case on Airbus, I'm not sure for Boeing but they sure need to add it if they haven't!

Test bench connect and computer says LRU is o.k. 😂 , tell me how many times did you get a “serviceable” LRU back on the shelf … 😅

Another short but succint one, that was passed to me by an F-4 USAF pilot in SE Asia. "When the thrusties quit, ALL the lifties jump off" and #2- Always beware of altitude to avoid encounters with Cumulus Granite formations.

Pretty sure the ground does not have the capability of reaching up and doing anything

Size matters....

When a pilot is incapacitated with spatial disorientation that leads into the evil graveyard spiral and you're accelerating down, the ground can come up and bite real fast.

​@@csn6234 oh yes it does

And Uranus is becoming too tight

They did in the last season

@@JayJayAviationwhere is the link ?

@@luisfernando5998 what

Especially when the pilot is dead

The pilots should also understand how the plane gathers the information it uses to execute an automatic landing, and how it depends on which instruments.

@@fiddlermargie the plane shouldn't rely upon the input of a single sensor to make decisions when the other two inputs indicated the plane wasn't on the ground. This is the same thing that happened with a single non-redundant AoA sensor taking out the Max 8 flights. There was enough data for the computers to make the right decision.

Yup

Ok pilot

segun...unfamiliar system error...apart from the couple of thousand times it had already occurred which no-one thought to mention to all the Boeing 737 pilots..."oh by the way your plane altimeter might malfunction be warned and prepared etc"...I guess it wasn't important enough..."if we get a few thousand more complaints..we'll send a memo"

Also they didnt have anything to work with. No altitude, no time. Last moment crash.

It's not a crazy idea because it would give pilots a clear view of the outside in case visibility is a problem.

Good luck getting that to work fast enough to actually be of any use. The plane crash isn't going to wait until everything is uploaded to a cloud.

The Pilot Unions do not want that !

I mean.. is he just supposed to stay airborne forever?

That wasn't an issue he didn't pay attention to the airspeed. All three didn't!

Probably no one at Boeing wanted to die by a hit man.

But the captain wasn’t flying the plane here. He was ignoring warnings and not taking control when he needed to.