Boeing crashes had earlier roots

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bmforre
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Boeing crashes had earlier roots

Post by bmforre » Tue Jan 21, 2020 10:00 am

NYTimes reports
After a Boeing 737 crashed near Amsterdam more than a decade ago, the Dutch investigators focused blame on the pilots for failing to react properly when an automated system malfunctioned and caused the plane to plummet into a field, killing nine people.

The fault was hardly the crew’s alone, however. Decisions by Boeing, including risky design choices and faulty safety assessments, also contributed to the accident on the Turkish Airlines flight. But the Dutch Safety Board either excluded or played down criticisms of the manufacturer in its final report after pushback from a team of Americans that included Boeing and federal safety officials, documents and interviews show.
In particular
A review by The New York Times of evidence from the 2009 accident, some of it previously confidential, reveals striking parallels with the recent crashes — and resistance by the team of Americans to a full airing of findings that later proved relevant to the Max.

In the 2009 and Max accidents, for example, the failure of a single sensor caused systems to misfire, with catastrophic results, and Boeing had not provided pilots with information that could have helped them react to the malfunction. The earlier accident “represents such a sentinel event that was never taken seriously,” said Sidney Dekker, an aviation safety expert who was commissioned by the Dutch Safety Board to analyze the crash.

Dr. Dekker’s study accused Boeing of trying to deflect attention from its own “design shortcomings” and other mistakes with “hardly credible” statements that admonished pilots to be more vigilant, according to a copy reviewed by The Times.

The study was never made public. The Dutch board backed away from plans to publish it, according to Dr. Dekker and another person with knowledge of its handling. A spokeswoman for the Dutch board said it was not common to publish expert studies and the decision on Dr. Dekker’s was made solely by the board.

At the same time, the Dutch board deleted or amended findings in its own accident report about issues with the plane when the same American team weighed in. The board also inserted statements, some nearly verbatim and without attribution, written by the Americans, who said that certain pilot errors had not been “properly emphasized.”

The muted criticism of Boeing after the 2009 accident fits within a broader pattern, brought to light since the Max tragedies, of the company benefiting from a light-touch approach by safety officials.

References to Dr. Dekker’s findings in the final report were brief, not clearly written and not sufficiently highlighted, according to multiple aviation safety experts with experience in crash investigations who read both documents.

One of them, David Woods, a professor at the Ohio State University who has served as a technical adviser to the Federal Aviation Administration, said the Turkish Airlines crash “should have woken everybody up.”
There's more and to me this seems frighteningly relevant to the later crashes.

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Pucksoppet
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Re: Boeing crashes had earlier roots

Post by Pucksoppet » Thu Jan 23, 2020 8:34 pm

There is a good thread on PPRuNe about this, which has buried in it a link to the suppressed report, which was published after the NYT article came out:

PPruNe thread: https://www.pprune.org/rumours-news/629 ... uried.html

Report: https://www.onderzoeksraad.nl/nl/media/ ... dekker.pdf

bmforre
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Re: Boeing crashes had earlier roots

Post by bmforre » Fri Jan 24, 2020 3:41 am

Thank you Pucksoppet.

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