Maneuvering Characteristics Augmentation System
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The Maneuvering Characteristics Augmentation System (MCAS) is a flight stabilizing feature developed by
Boeing The Boeing Company () is an American multinational corporation that designs, manufactures, and sells airplanes, rotorcraft, rockets, satellites, telecommunications equipment, and missiles worldwide. The company also provides leasing and product ...
that became notorious for its role in two fatal accidents of the
737 MAX The Boeing 737 MAX is the fourth generation of the Boeing 737, a narrow-body airliner manufactured by Boeing Commercial Airplanes (BCA), a division of American company Boeing. It succeeds the Boeing 737 Next Generation (NG) and competes with th ...
, which killed all 346 passengers and crew among both flights. Systems similar to the Boeing 737 MCAS were previously included on the
Boeing 707 The Boeing 707 is an American, long-range, narrow-body airliner, the first jetliner developed and produced by Boeing Commercial Airplanes. Developed from the Boeing 367-80 prototype first flown in 1954, the initial first flew on December 20, ...
and
Boeing KC-46 The Boeing KC-46 Pegasus is an American military aerial refueling and strategic military transport aircraft developed by Boeing from its 767 jet airliner. In February 2011, the tanker was selected by the United States Air Force (USAF) as the w ...
, a 767 variant. On the 737 MAX, MCAS was intended to mimic the flight behavior of the previous generation of the series, the
Boeing 737 NG The Boeing 737 Next Generation, commonly abbreviated as 737NG, or 737 Next Gen, is a narrow-body aircraft powered by two jet engines and produced by Boeing Commercial Airplanes. Launched in 1993 as the third generation derivative of the Boeing ...
. During MAX flight tests, Boeing discovered that the position and larger size of the engines tended to push the nose up during certain maneuvers. Engineers decided to use MCAS to counter that tendency, since major structural redesign would have been prohibitively expensive and time-consuming. Boeing's goal was to have the MAX certified as another 737 version, which would appeal to airlines with the reduced cost of pilot training. The
Federal Aviation Administration The Federal Aviation Administration (FAA) is the largest transportation agency of the U.S. government and regulates all aspects of civil aviation in the country as well as over surrounding international waters. Its powers include air traffic m ...
(FAA) approved Boeing's request to remove a description of MCAS from the aircraft manual, leaving pilots unaware of the system when the airplane entered service in 2017. After the Lion Air crash in 2018, Boeing and the FAA, still not revealing MCAS, referred pilots to a revised checklist procedure that must be performed in case of a malfunction. Boeing then received many requests for more information and revealed the existence of MCAS in another message, and that it could intervene without pilot input. According to Boeing, MCAS was supposed to compensate for an excessive nose up angle by adjusting the
horizontal stabilizer A tailplane, also known as a horizontal stabiliser, is a small lifting surface located on the tail (empennage) behind the main lifting surfaces of a fixed-wing aircraft as well as other non-fixed-wing aircraft such as helicopters and gyroplan ...
before the aircraft would potentially stall. Boeing denied that MCAS was an anti- stall system, and stressed that it was intended to improve the handling of the aircraft. After the Ethiopian Airlines crash in 2019, Ethiopian authorities stated that the procedure did not enable the crew to prevent the accident, which occurred while a fix to MCAS was under development. Boeing admitted MCAS played a role in both accidents, when it acted on false data from a single
angle of attack In fluid dynamics, angle of attack (AOA, α, or \alpha) is the angle between a reference line on a body (often the chord line of an airfoil) and the vector representing the relative motion between the body and the fluid through which it is m ...
(AoA) sensor. In 2020, the FAA,
Transport Canada Transport Canada (french: Transports Canada) is the department within the Government of Canada responsible for developing regulations, policies and services of road, rail, marine and air transportation in Canada. It is part of the Transportati ...
, and
European Union Aviation Safety Agency The European Union Aviation Safety Agency (EASA) is an agency of the European Union (EU) with responsibility for civil aviation safety. It carries out certification, regulation and standardisation and also performs investigation and monitori ...
(EASA) evaluated flight test results with MCAS disabled, and suggested that the MAX might not have needed MCAS to conform to certification standards. Later that year, an FAA
Airworthiness Directive An Airworthiness Directive (commonly abbreviated as AD) is a notification to owners and operators of certified aircraft that a known safety deficiency with a particular model of aircraft, engine, avionics or other system exists and must be correct ...
approved design changes for each MAX aircraft, which would prevent MCAS activation unless both AoA sensors register similar readings, eliminate MCAS's ability to repeatedly activate, and allow pilots to override the system if necessary. The FAA began requiring all MAX pilots to undergo MCAS-related training in flight simulators by 2021.


Background

In the 1960s, a basic pitch control system to avoid stalling was installed in the Boeing 707. Later, a similar system, in this case specifically called MCAS, was implemented on the
Boeing KC-46 Pegasus The Boeing KC-46 Pegasus is an American military aerial refueling and strategic military transport aircraft developed by Boeing from its Boeing 767, 767 jet airliner. In February 2011, the tanker was selected by the United States Air Force (US ...
military aerial refueling tanker. The KC-46, which is based on the
Boeing 767 The Boeing 767 is an American wide-body aircraft developed and manufactured by Boeing Commercial Airplanes. The aircraft was launched as the 7X7 program on July 14, 1978, the prototype first flew on September 26, 1981, and it was certified on ...
, requires MCAS because the weight and balance shifts when the tanker redistributes and offloads fuel. On that aircraft, the MCAS is overriden and disengaged when a pilot makes a stick input. Another MCAS implementation was installed on the 737 MAX, adding a feature that had not been present on previous versions of the 737. The original Boeing 737-100 and -200 used the long and narrow
Pratt & Whitney JT8D The Pratt & Whitney JT8D is a low-bypass (0.96 to 1) turbofan engine introduced by Pratt & Whitney in February 1963 with the inaugural flight of the Boeing 727. It was a modification of the Pratt & Whitney J52 turbojet engine which powered th ...
engine, which fit entirely under the wing and enabled a relatively low ground clearance. In the late 1960s, when the aircraft was introduced, its low-to-the-ground design was beneficial, allowing easier boarding from optional on-board
airstair An airstair is a set of steps built into an aircraft so that passengers may board and alight the aircraft. The stairs are often built into a clamshell-style door on the aircraft. Airstairs eliminate the need for passengers to use a mobile st ...
s and hand-loading of baggage into holds. But as airports were modernized with
jet bridge A jet bridge (also termed jetway, jetwalk, airgate, gangway, aerobridge/airbridge, skybridge, finger, airtube, expedited suspended passenger entry system (E-SPES), or its official industry name passenger boarding bridge (PBB)) is an enclosed, ...
s and mechanized baggage handling, the design was less necessary, and the low ground clearance would prove to be a design constraint for Boeing engineers. For the 737 Classic and 737 Next Generation (737NG) variants, Boeing switched to the
CFM56 The CFM International CFM56 (U.S. military designation F108) series is a Franco-American family of high-bypass turbofan aircraft engines made by CFM International (CFMI), with a thrust range of . CFMI is a 50–50 joint-owned company of Safran ...
engine, which was a more efficient
high bypass turbofan The turbofan or fanjet is a type of airbreathing jet engine that is widely used in aircraft engine, aircraft propulsion. The word "turbofan" is a portmanteau of "turbine" and "fan": the ''turbo'' portion refers to a gas turbine engine which ac ...
, but consequently was much larger in circumference. Because the 737s wings were closer to the ground than in previous applications for the CFM56, several modifications were made including mounting the engine forward of the wing and mounting engine accessories to the sides, giving the engine nacelle a distinctive flat-bottomed shape. These modifications also limited the bypass ratio compared to versions of the CFM56 used on other aircraft. In 2013, CFM introduced its LEAP series of engines that were 16% more efficient by using even higher bypass ratios. To enable it to be fitted to the 737, the engine was attached to a pylon that held it further forward from the wing and higher off the ground. The new engine installation changed the aircraft handling characteristics. To make the 737 MAX perform similarly to its immediate predecessor, the 737NG, Boeing added the (MCAS)
flight control law A flight control mode or flight control law is a computer software algorithm that transforms the movement of the yoke or joystick, made by an aircraft pilot, into movements of the aircraft control surfaces. The control surface movements depend ...
. When a single
angle of attack In fluid dynamics, angle of attack (AOA, α, or \alpha) is the angle between a reference line on a body (often the chord line of an airfoil) and the vector representing the relative motion between the body and the fluid through which it is m ...
(AoA) sensor indicated that the angle was too high, MCAS would trim the horizontal stabilizer in the nose-down direction. This was necessary to meet Boeing's internal objective of minimizing training requirements for pilots already qualified on the 737NG. However, the MAX would have met certification standards even without MCAS, according to both the FAA and EASA. The presence of MCAS in Boeing 737 MAX was intentionally omitted from the pilot handbook.


The role of MCAS in accidents

For flights ET 302 and JT 610, investigators determined that MCAS was triggered by falsely high AoA inputs, as if the plane had pitched up excessively. On both flights, shortly after takeoff, MCAS repeatedly actuated the
horizontal stabilizer A tailplane, also known as a horizontal stabiliser, is a small lifting surface located on the tail (empennage) behind the main lifting surfaces of a fixed-wing aircraft as well as other non-fixed-wing aircraft such as helicopters and gyroplan ...
trim Trim or TRIM may refer to: Cutting * Cutting or trimming small pieces off something to remove them ** Book trimming, a stage of the publishing process ** Pruning, trimming as a form of pruning often used on trees Decoration * Trim (sewing), or ...
motor to push down the airplane nose. Satellite data for the flights showed that the planes struggled to gain altitude. Pilots reported difficulty controlling the airplane and asked to return to the airport. The implementation of MCAS has been found to disrupt autopilot operations. On March 11, 2019, after China had grounded the aircraft, Boeing published some details of new system requirements for the MCAS software and for the cockpit displays, which it began implementing in the wake of the prior accident five months earlier: * If the two AoA sensors disagree with the flaps retracted, MCAS will not activate and an indicator will alert the pilots. * If MCAS is activated in non-normal conditions, it will only "provide one input for each elevated AoA event." * Flight crew will be able to counteract MCAS by pulling back on the column. On March 27, Daniel Elwell, the acting administrator of the FAA, testified before the Senate Committee on Commerce, Science, and Transportation, saying that on January 21, "Boeing submitted a proposed MCAS software enhancement to the FAA for certification. ... the FAA has tested this enhancement to the 737 MAX flight control system in both the simulator and the aircraft. The testing, which was conducted by FAA flight test engineers and flight test pilots, included aerodynamic stall situations and recovery procedures." After a series of delays, the updated MCAS software was released to the FAA in May 2019. On May 16, Boeing announced that the completed software update was awaiting approval from the FAA. The flight software underwent 360 hours of testing on 207 flights. Boeing also updated existing crew procedures. On April 4, 2019, Boeing publicly acknowledged that MCAS played a role in both accidents.


Purpose of MCAS and the stabilizer trim system

The FAA and Boeing both disputed media reports describing MCAS as an anti-stall system, which Boeing asserted it is distinctly not. The aircraft had to perform well in a low-speed stall test. The "considers that the /MCAS and elevator feel shift (EFS) functions could be considered as stall identification systems or stall protection systems, depending on the natural (unaugmented) stall characteristics of the aircraft". The JATR said, "MCAS used the stabilizer to change the column force feel, not trim the aircraft. This is a case of using the control surface in a new way that the regulations never accounted for and should have required an issue paper for further analysis by the FAA. If the FAA technical staff had been fully aware of the details of the MCAS function, the JATR team believes the agency likely would have required an issue paper for using the stabilizer in a way that it had not previously been used; this ight haveidentified the potential for the stabilizer to overpower the elevator."


Description


Background

The Maneuvering Characteristics Augmentation System (MCAS) is a
flight control law A flight control mode or flight control law is a computer software algorithm that transforms the movement of the yoke or joystick, made by an aircraft pilot, into movements of the aircraft control surfaces. The control surface movements depend ...
built into the
Boeing 737 MAX The Boeing 737 MAX is the fourth generation of the Boeing 737, a narrow-body aircraft, narrow-body airliner manufactured by Boeing Commercial Airplanes (BCA), a division of American company Boeing. It succeeds the Boeing 737 Next Generation (NG ...
's flight control computer, designed to help the aircraft emulate the handling characteristics of the earlier
Boeing 737 Next Generation The Boeing 737 Next Generation, commonly abbreviated as 737NG, or 737 Next Gen, is a narrow-body aircraft powered by Twinjet, two jet engines and produced by Boeing Commercial Airplanes. Launched in 1993 as the third generation derivative of th ...
. According to an international Civil Aviation Authorities team review (JATR) commissioned by the FAA, MCAS may be a stall identification or protection system, depending on the natural (unaugmented) stall characteristics of the aircraft. Boeing considered MCAS part of the flight control system, and elected to not describe it in the flight manual or in training materials, based on the fundamental design philosophy of retaining commonality with the
737NG The Boeing 737 Next Generation, commonly abbreviated as 737NG, or 737 Next Gen, is a narrow-body aircraft powered by two jet engines and produced by Boeing Commercial Airplanes. Launched in 1993 as the third generation derivative of the Boein ...
. Minimizing the functional differences between the Boeing 737 MAX and Next Generation aircraft variants allowed both variants to share the same
type rating A type rating is an authorization entered on or associated with a pilot licence and forming part thereof, stating pilot's privileges or limitations pertaining to certain aircraft type. Such qualification requires additional training beyond the s ...
. Thus, airlines can save money by employing and training one pool of pilots to fly both variants of the Boeing 737 interchangeably. When activated, MCAS directly engages the
horizontal stabilizer A tailplane, also known as a horizontal stabiliser, is a small lifting surface located on the tail (empennage) behind the main lifting surfaces of a fixed-wing aircraft as well as other non-fixed-wing aircraft such as helicopters and gyroplan ...
, thus is distinct from an anti-stall device, such as
stick pusher A stick pusher is a device installed in some fixed-wing aircraft to prevent the aircraft from entering an aerodynamic stall. Some large fixed-wing aircraft display poor post-stall handling characteristics or are vulnerable to deep stall. To preven ...
, which physically moves the pilot's control column forward and engages the airplane's
elevators An elevator or lift is a cable-assisted, hydraulic cylinder-assisted, or roller-track assisted machine that vertically transports people or freight between floors, levels, or decks of a building, vessel, or other structure. They are ...
when the airplane is approaching a stall. Boeing's former CEO
Dennis Muilenburg Dennis A. Muilenburg (born 1964) is an American engineer, business executive, and the former president and chief executive officer (CEO) of The Boeing Company, a multinational aerospace and defense company. He was CEO from 2015 to 2019, when h ...
said " CAShas been reported or described as an anti-stall system, which it is not. It's a system that's designed to provide handling qualities for the pilot that meet pilot preferences." The 737 MAX's larger CFM LEAP-1B engines are fitted farther forward and higher up than in previous models. The aerodynamic effect of its
nacelle A nacelle ( ) is a "streamlined body, sized according to what it contains", such as an engine, fuel, or equipment on an aircraft. When attached by a pylon entirely outside the airframe, it is sometimes called a pod, in which case it is attached ...
s contributes to the aircraft's tendency to
pitch up In aerodynamics, pitch-up is an uncommanded nose-upwards rotation of an aircraft. It is an undesirable characteristic that has been observed mostly in experimental swept-wing aircraft at high subsonic Mach numbers or high angle of attack. History ...
at high
angles of attack In fluid dynamics, angle of attack (AOA, α, or \alpha) is the angle between a reference line on a body (often the chord line of an airfoil) and the vector representing the relative motion between the body and the fluid through which it is m ...
(AOA). The MCAS is intended to compensate in such cases, modeling the pitching behavior of previous models, and meet a certain certification requirement, in order to enhance handling characteristics and thus minimizing the need for significant pilot retraining. The software code for the MCAS function and the computer for executing the software are built to Boeing's specifications by Collins Aerospace, formerly Rockwell Collins. As an automated corrective measure, the MCAS was given full authority to bring the aircraft nose down, and could not be overridden by pilot resistance against the control wheel as on previous versions of the 737. Following the Lion Air accident, Boeing issued an Operations Manual Bulletin (OMB) on November 6, 2018, to outline the many indications and effects resulting from erroneous AOA data and provided instructions to turn off the motorized trim system for the remainder of the flight, and trim manually instead. Until Boeing supplemented the manuals and training, pilots were unaware of the existence of MCAS due to its omission from the crew manual and no coverage in training. Boeing first publicly named and revealed the existence of MCAS on the 737 MAX in a message to airline operators and other aviation interests on November 10, 2018, twelve days after the Lion Air crash.


Safety engineering and human factors

As with any other equipment on board an aircraft, the FAA approves a functional "design assurance level" corresponding to the consequences of a failure, using the
SAE International SAE International, formerly named the Society of Automotive Engineers, is a United States-based, globally active professional association and standards developing organization for engineering professionals in various industries. SAE Internatio ...
standards
ARP4754 ARP4754, Aerospace Recommended Practice (ARP) ARP4754A (''Guidelines For Development Of Civil Aircraft and Systems''), is a guideline from SAE International, dealing with the development processes which support certification of Aircraft systems, ad ...
and
ARP4761 ARP4761, Guidelines and Methods for Conducting the Safety Assessment Process on Civil Airborne Systems and Equipment is an Aerospace Recommended Practice from SAE International. In conjunction with ARP4754, ARP4761 is used to demonstrate complian ...
. MCAS was designated a "hazardous failure" system. This classification corresponds to failures causing "a large reduction in safety margins" or "serious or fatal injury to a relatively small number of the occupants", but nothing "catastrophic". The MCAS was designed with the assumption, approved by FAA, that pilots would react to an unexpected activation within three seconds.


Technology readiness

The MCAS design parameters originally envisioned automated corrective actions to be taken in cases of high AoA and
g-force The gravitational force equivalent, or, more commonly, g-force, is a measurement of the type of force per unit mass – typically acceleration – that causes a perception of weight, with a g-force of 1 g (not gram in mass measure ...
s beyond normal flight conditions.
Test pilot A test pilot is an aircraft pilot with additional training to fly and evaluate experimental, newly produced and modified aircraft with specific maneuvers, known as flight test techniques.Stinton, Darrol. ''Flying Qualities and Flight Testing ...
s routinely push aircraft to such extremes, as the FAA requires airplanes to perform as expected. Before the MCAS, test pilot Ray Craig determined the plane did not fly smoothly, in part due to the larger engines. Craig would have preferred an
aerodynamic Aerodynamics, from grc, ἀήρ ''aero'' (air) + grc, δυναμική (dynamics), is the study of the motion of air, particularly when affected by a solid object, such as an airplane wing. It involves topics covered in the field of fluid dyn ...
solution, but Boeing decided to implement a control law in software. According to a news report in the ''Wall Street Journal'', engineers who had worked on the
KC-46A Pegasus The Boeing KC-46 Pegasus is an American military aerial refueling and strategic military transport aircraft developed by Boeing from its 767 jet airliner. In February 2011, the tanker was selected by the United States Air Force (USAF) as the w ...
tanker, which includes an MCAS function, suggested MCAS to the design team. With the MCAS implemented, new test pilot Ed Wilson said the "MAX wasn't handling well when nearing stalls at low speeds" and recommended MCAS to apply across a broader range of flight conditions. This required the MCAS to function under normal g-forces and, at stalling speeds, deflect the vertical trim more rapidly and to a greater extent—but now it reads a single AoA sensor, creating a
single point of failure A single point of failure (SPOF) is a part of a system that, if it fails, will stop the entire system from working. SPOFs are undesirable in any system with a goal of high availability or reliability, be it a business practice, software appl ...
that allowed false data to trigger MCAS to pitch the nose downward and force the aircraft into a dive. "Inadvertently, the door was now opened to serious system misbehavior during the busy and stressful moments right after takeoff", said Jenkins of ''
The Wall Street Journal ''The Wall Street Journal'' is an American business-focused, international daily newspaper based in New York City, with international editions also available in Chinese and Japanese. The ''Journal'', along with its Asian editions, is published ...
''. The FAA did not conduct a safety analysis on the changes. It had already approved the previous version of MCAS, and the agency's rules did not require it to take a second look because the changes did not affect how the plane operated in extreme situations. The Joint Authorities Technical Review found the technology unprecedented: "If the FAA technical staff had been fully aware of the details of the MCAS function, the JATR team believes the agency likely would have required an issue paper for using the stabilizer in a way that it had not previously been used. MCAS used the stabilizer to change the column force feel, not trim the aircraft. This is a case of using the control surface in a new way that the regulations never accounted for and should have required an issue paper for further analysis by the FAA. If an issue paper had been required, the JATR team believes it likely would have identified the potential for the stabilizer to overpower the elevator." In November 2019, Jim Marko, a manager of aircraft integration and safety assessment at
Transport Canada Transport Canada (french: Transports Canada) is the department within the Government of Canada responsible for developing regulations, policies and services of road, rail, marine and air transportation in Canada. It is part of the Transportati ...
aviation regulator's National Aircraft Certification Branch questioned the readiness of MCAS. Because new problems kept emerging, he suggested to his peers at FAA, ANAC and EASA to consider the safety benefits of removing MCAS from the MAX.


Scrutiny

The MCAS came under scrutiny following the fatal crashes of
Lion Air Flight 610 Lion Air Flight 610 was a scheduled domestic passenger flight from Soekarno–Hatta International Airport, Jakarta to Depati Amir Airport, Pangkal Pinang in Indonesia. On 29 October 2018, the Boeing 737 MAX operating the route crashed into th ...
and
Ethiopian Airlines Flight 302 Ethiopian Airlines Flight 302 was a scheduled international passenger flight from Addis Ababa Bole International Airport in Ethiopia to Jomo Kenyatta International Airport in Nairobi, Kenya. On 10 March 2019, the Boeing 737 MAX 8 aircraft ...
soon after takeoff. The Boeing 737 MAX global fleet was grounded by all airlines and operators, and a number of functional issues were raised. The MCAS deflects the horizontal stabilizer four times farther than was stated in the initial safety analysis document. Due to the amount of trim the system applies to the horizontal stabilizer, aerodynamic forces resist pilot control effort to raise the nose. As long as the faulty AOA readings persist, a human pilot "can quickly become exhausted trying to pull the column back". In addition, switches for the horizontal stabilizer trim assist now serve a shared purpose of turning off automated systems such as MCAS as well as the trim buttons on the yoke, whereas in previous 737 models each could be switched off independently. In simulator sessions, pilots were stunned by the substantial effort needed to manually crank the trim wheel out of its nose down setting when the trim assist was deactivated. Boeing CEO
Dennis Muilenburg Dennis A. Muilenburg (born 1964) is an American engineer, business executive, and the former president and chief executive officer (CEO) of The Boeing Company, a multinational aerospace and defense company. He was CEO from 2015 to 2019, when h ...
has stated that there was "no surprise, or gap, or unknown here or something that somehow slipped through a certification process." On April 29, 2019, he stated the design of the aircraft was not flawed and reiterated that it was designed per Boeing's standards. In a May 29 interview with CBS, Boeing admitted that it had botched the software implementation and lamented the poor communications. On September 26, the
National Transportation Safety Board The National Transportation Safety Board (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incid ...
criticized Boeing's inadequate testing of the 737 MAX, and pointed out that Boeing made erroneous assumptions on pilots' response to alerts in 737 MAX, triggered by activation of MCAS due to a faulty signal from an angle-of-attack sensor. The Joint Authorities Technical Review (JATR), a team commissioned by the FAA for 737 MAX investigation, concluded that FAA failed to properly review MCAS. Boeing failed to provide adequate and updated technical information regarding the MCAS system to FAA during Boeing 737 Max certification process, and had not carried out a thorough verification by
stress-testing Stress testing (sometimes called torture testing) is a form of deliberately intense or thorough testing used to determine the stability of a given system, critical infrastructure or entity. It involves testing beyond normal operational capacity, ...
of the MCAS system. On October 18, Boeing turned over a discussion from 2016 between two employees that revealed prior issues with the MCAS system. Boeing's own internal design guidelines related to the 737 MAX's development stated that the system should "not have any objectionable interaction with the piloting of the airplane" and "not interfere with dive recovery". The operation of MCAS violated those.


National Transportation Safety Board

On September 26, 2019, the
National Transportation Safety Board The National Transportation Safety Board (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incid ...
(NTSB) released the results of its review of potential lapses in the design and approval of the 737 MAX. * The NTSB report concludes that assumptions "that Boeing used in its functional hazard assessment of uncommanded MCAS function for the 737 MAX did not adequately consider and account for the impact that multiple flight deck alerts and indications could have on pilots' responses to the hazard". When Boeing induced a stabilizer trim input that simulated the stabilizer moving consistent with the MCAS function,
the specific failure modes that could lead to unintended MCAS activation (such as an erroneous high AOA input to the MCAS) were not simulated as part of these functional hazard assessment validation tests. As a result, additional flight deck effects (such as IAS DISAGREE and ALT DISAGREE alerts and stick shaker activation) resulting from the same underlying failure (for example, erroneous AOA) were not simulated and were not in the stabilizer trim safety assessment report reviewed by the NTSB."
The NTSB questioned the long-held industry and FAA practice of assuming the nearly instantaneous responses of highly trained test pilots as opposed to pilots of all levels of experience to verify
human factors Human factors and ergonomics (commonly referred to as human factors) is the application of psychological and physiological principles to the engineering and design of products, processes, and systems. Four primary goals of human factors learnin ...
in aircraft safety. The NTSB expressed concerns that the process used to evaluate the original design needs improvement because that process is still in use to certify current and future aircraft and system designs. The FAA could, for example, randomly sample pools from the worldwide pilot community to obtain a more representative assessment of cockpit situations.


Supporting systems

The updates proposed by Boeing focus mostly on MCAS software. In particular, there have been no public statements regarding reverting the functionality of the stabilizer trim cutout switches to pre-MAX configuration. A veteran software engineer and experienced pilot suggested that software changes may not be enough to counter the 737 MAX's engine placement. The ''
Seattle Times ''The Seattle Times'' is a daily newspaper serving Seattle, Washington, United States. It was founded in 1891 and has been owned by the Blethen family since 1896. ''The Seattle Times'' has the largest circulation of any newspaper in Washington st ...
'' noted that while the new software fix Boeing proposed "will likely prevent this situation recurring, if the preliminary investigation confirms that the Ethiopian pilots did cut off the automatic flight-control system, this is still a nightmarish outcome for Boeing and the FAA. It would suggest the emergency procedure laid out by Boeing and passed along by the FAA after the Lion Air crash is wholly inadequate and failed the Ethiopian flight crew." Boeing and the FAA decided that the AoA display and an AoA disagree light, which signals if the sensors give different readings, were not critical features for safe operation. Boeing charged extra for the addition of the AoA indicator to the primary display. In November 2017, Boeing engineers discovered that the standard AoA disagree light cannot independently function without the optional AoA indicator software, a problem affecting 80% of the global fleet that had not ordered the option. The software remedy was scheduled to coincide with the roll out of the elongated 737 MAX 10 in 2020, only to be accelerated by the Lion Air accident. Furthermore, the problem had not been disclosed to the FAA until 13 months after the fact. Although it is unclear whether the indicator could have changed the outcome for the ill-fated flights, American Airlines said the disagree indicator provided the assurance in continued operations of the airplane. "As it turned out, that wasn't true."


Runaway stabilizer and manual trim

In February 2016, the EASA certified the MAX with the expectation that pilot procedures and training would clearly explain unusual situations in which the seldom used manual trim wheel would be required to trim the plane, i.e. adjust the angle of the nose; however, the original flight manual did not mention those situations. The EASA certification document referred to simulations whereby the electric thumb switches were ineffective to properly trim the MAX under certain conditions. The EASA document said that after flight testing, because the thumb switches could not always control trim on their own, the FAA was concerned by whether the 737 MAX system complied with regulations. The American Airlines flight manual contains a similar notice regarding the thumb switches but does not specify conditions where the manual wheel may be needed. Boeing's CEO Muilenburg, when asked about the non-disclosure of MCAS, cited the "runaway stabilizer trim" procedure as part of the training manual. He added that Boeing's bulletin pointed to that existing flight procedure. Boeing views the "runaway stabilizer trim" checklist as a memory item for pilots. Mike Sinnett, vice president and general manager for the Boeing New Mid-Market Airplane (NMA) since July 2019, repeatedly described the procedure as a "memory item". However, some airlines view it as an item for the quick reference card. The FAA issued a recommendation about memory items in an Advisory Circular, ''Standard Operating Procedures and Pilot Monitoring Duties for Flight Deck Crewmembers'': "Memory items should be avoided whenever possible. If the procedure must include memory items, they should be clearly identified, emphasized in training, less than three items, and should not contain conditional decision steps." In November 2018, Boeing told airlines that MCAS could not be overcome by pulling back on the control column to stop a runaway trim as on previous generation 737s. Nevertheless, confusion continued: the safety committee of a major U.S. airline misled its pilots by telling that the MCAS could be overcome by "applying opposite control-column input to activate the column cutout switches". Former pilot and
CBS CBS Broadcasting Inc., commonly shortened to CBS, the abbreviation of its former legal name Columbia Broadcasting System, is an American commercial broadcast television and radio network serving as the flagship property of the CBS Entertainm ...
aviation & safety expert
Chesley Sullenberger Chesley Burnett "Sully" Sullenberger III (born January 23, 1951) is a retired American fighter pilot, diplomat, and airline pilot best known for his heroism as captain of US Airways Flight 1549 that he ditched in the Hudson River in 2009 a ...
testified, "The logic was that if MCAS activated, it had to be because it was needed, and pulling back on the control wheel shouldn't stop it." In October, Sullenberger wrote, "These emergencies did not present as a classic runaway stabilizer problem, but initially as ambiguous unreliable airspeed and altitude situations, masking MCAS." In a legal complaint against Boeing, the Southwest Airlines Pilot Association states:
An MCAS failure is not like a runaway stabilizer. A runaway stabilizer has continuous un-commanded movement of the tail, whereas MCAS is not continuous and pilots (theoretically) can counter the nose-down movement, after which MCAS would move the aircraft tail down again. Moreover, unlike runaway stabilizer, MCAS disables the control column response that 737 pilots have grown accustomed to and relied upon in earlier generations of 737 aircraft.


Stabilizer cutoff switches re-wiring

In May 2019, ''
The Seattle Times ''The Seattle Times'' is a daily newspaper serving Seattle, Washington, United States. It was founded in 1891 and has been owned by the Blethen family since 1896. ''The Seattle Times'' has the largest circulation of any newspaper in Washington (s ...
'' reported that the two stabilizer cutoff switches, located on the center console, operate differently on the MAX than on the earlier 737 NG. On previous aircraft, one cutoff switch deactivates the thumb buttons on the control yoke that pilots use to move the horizontal stabilizer; the other cutoff switch disables automatic control of the horizontal stabilizer by autopilot or /MCAS. On the MAX, both switches are wired in series and perform the same function: they cut off all electric power to the stabilizer, both from the yoke buttons and from an automatic system. Thus, on previous aircraft it is possible to disable automatic control of the stabilizer yet to employ electric power assist by operating the yoke switches. On the MAX, with all power to the stabilizer cut, pilots have no choice but to use the mechanical trim wheel in the center console. However, as pilots pull on the 737 controls to raise the nose of the aircraft, aerodynamic forces on the elevator create an opposing force, effectively paralyzing the jackscrew mechanism that moves the stabilizer. It becomes very difficult for pilots to hand crank the trim wheel. The problem was encountered on earlier 737 versions, and a "roller coaster" emergency technique for handling the flight condition was documented in 1982 for the 737-200 but did not appear in training documentation for later versions (including the MAX).


Manual trim stiffness

In the early 1980s a problem was found with the 737-200 model. When the elevator operated to raise or lower the nose, it set up a strong force on the trim jackscrew that opposed any corrective force from the control systems. When attempting to correct an unwanted deflection using the manual trim wheel, exerting enough hand force to overcome the force exerted by the elevator became increasingly difficult as speed and deflection increased and the jack screw effectively jammed in place.Jon Ostrower;
Vestigial design issue clouds 737 Max crash investigations
, ''The Air Current'', April 4, 2019. (retrieved November 21, 2019)
A workaround was developed called the "roller coaster" technique. Counter-intuitively, to correct an excessive deflection causing a dive the pilot first pushes the nose down further, before easing back to gently raise the nose again. During this easing back period, the elevator deflection reduces or even reverses, its force on the jackscrew does likewise and the manual trim eases up. The workaround was included in the pilot's emergency procedures and in the training schedule. However while the 737 MAX has a similar jackscrew mechanism the "roller coaster" technique has been dropped from the pilot information. During the events leading to the two MAX crashes, the stiffness of the manual trim wheel repeatedly prevented manual trim adjustment to correct the MCAS-induced nose-down pitching. The issue has been brought to the notice of the DoJ criminal inquiry into the 737 MAX crashes. In simulator tests of
Ethiopian Airlines Flight 302 Ethiopian Airlines Flight 302 was a scheduled international passenger flight from Addis Ababa Bole International Airport in Ethiopia to Jomo Kenyatta International Airport in Nairobi, Kenya. On 10 March 2019, the Boeing 737 MAX 8 aircraft ...
flight scenario, the trim wheel was "impossible" to move when one of the pilots would instinctively pull up from the nosedives. It takes 15 turns to manually trim the aircraft one degree, and up to 40 turns to bring the trim back to neutral from the nose down position caused by MCAS.


Horizontal stabilizer actuator

The horizontal stabilizer is fitted with a conventional
elevator An elevator or lift is a wire rope, cable-assisted, hydraulic cylinder-assisted, or roller-track assisted machine that vertically transports people or freight between floors, levels, or deck (building), decks of a building, watercraft, ...
for flight control. However, it is itself all-moving about a single pivot and can be
trimmed ''Trimmed'' is a 1922 American silent Western film directed by Harry A. Pollard and featuring Hoot Gibson. It is not known whether the film currently survives, and it may be a lost film. Cast * Hoot Gibson as Dale Garland * Patsy Ruth Miller ...
to adjust its angle. The trim is actuated via a
jackscrew A jackscrew, or screw jack, is a type of jack that is operated by turning a leadscrew. It is commonly used to lift moderately and heavy weights, such as vehicles; to raise and lower the horizontal stabilizers of aircraft; and as adjustable suppo ...
mechanism.


Slippage concern

Sylvain Alarie and Gilles Primeau, experts on the horizontal stabilizers, observed anomalies in the data from the aircraft data recorders: a progressive shift of 0.2 degrees of the horizontal stabilizer, before the crash. "It may not seem like much, but it is an order of magnitude higher than what is normally allowed when designing systems like these", says Gilles Primeau. They say that the movements are easily observable, and disallowed according to Regulation 395A. These anomalies raise fundamental questions about this jack screw, which controls the horizontal stabilizer since the beginning of the 737 models, first certified in 1967. These slips are particularly visible on flight ET302: "While there is no MCAS command, and no control of the pilots, we see a movement of the jack screw which controls the horizontal stabilizer, we see a slip. And at the very end of the flight, the jack screw starts to slide again with an increase in the speed of the plane and its dive," says Alarie. Since its original design, the 737 has become 61% heavier, 24% longer, and 40% wider, and its engines twice as powerful. These experts are concerned that the loads on the jack screw have potentially increased since the creation of the 737. By regulations, the controls must be designed for 125% of the foreseeable loads. These experts have raised concerns about the motors possibly overheating in April 2019.


MCAS circumvention for ferry flights

During the groundings, special flights to reposition MAX aircraft to storage locations, as per 14 CFR § 21.197, flew at lower
altitude Altitude or height (also sometimes known as depth) is a distance measurement, usually in the vertical or "up" direction, between a reference datum and a point or object. The exact definition and reference datum varies according to the context ...
and with flaps extended to circumvent MCAS activation, rather than using the recovery procedure after the fact. Such flights required a certain pilot qualification as well as permission from corresponding regulators, and with no other cabin crew or passengers.


Angle of Attack (AoA)

As per Boeing technical description: "the
Angle of Attack In fluid dynamics, angle of attack (AOA, α, or \alpha) is the angle between a reference line on a body (often the chord line of an airfoil) and the vector representing the relative motion between the body and the fluid through which it is m ...
(AoA) is an aerodynamic parameter that is key to understanding the limits of airplane performance. Recent accidents and incidents have resulted in new flight crew training programs, which in turn have raised interest in AoA in commercial aviation. Awareness of AOA is vitally important as the airplane nears stall." *
Chesley Sullenberger Chesley Burnett "Sully" Sullenberger III (born January 23, 1951) is a retired American fighter pilot, diplomat, and airline pilot best known for his heroism as captain of US Airways Flight 1549 that he ditched in the Hudson River in 2009 a ...
said AoA indicators might have helped in these two crashes. "It is ironic that most modern aircraft measure (angle of attack) and that information is often used in many aircraft systems, but it is not displayed to pilots. Instead, pilots must infer (angle of attack) from other parameters, deducing it indirectly."


AoA sensors

Though there are two sensors on the MAX only one of them is used at a time to trigger MCAS activation on the 737 MAX. Any fault in this sensor, perhaps due to physical damage, creates a single point failure: the flight control system lacks any basis for rejecting its input as faulty information. Reports of a single point of failure were not always acknowledged by Boeing. Addressing American Airlines pilots, Boeing vice-president Mike Sinnett contradicted reports that the MCAS had a single-point failure, because the pilots themselves are the backup. Reporter Useem said in
The Atlantic ''The Atlantic'' is an American magazine and multi-platform publisher. It features articles in the fields of politics, foreign affairs, business and the economy, culture and the arts, technology, and science. It was founded in 1857 in Boston, ...
it was "showing both a misunderstanding of the term and a sharp break from Boeing's long-standing practice of having multiple backups for every flight system". Problems with the AoA sensor had been reported in over 200 incident reports submitted to the FAA; however, Boeing did not flight test a scenario in which it malfunctioned. The sensors themselves are under scrutiny. Sensors on the Lion air aircraft were supplied by United Technologies' Rosemount Aerospace. In September 2019, the EASA said it prefers triple-redundant AoA sensors rather than the dual redundancy in Boeing's proposed upgrade to the MAX. Installation of a third sensor could be expensive and take a long time. The change, if mandated, could be extended to thousands of older model 737s in service around the world. A former professor at Embry-Riddle Aeronautical University, Andrew Kornecki, who is an expert in redundancy systems, said operating with one or two sensors "would be fine if all the pilots were sufficiently trained in how to assess and handle the plane in the event of a problem". But, he would much prefer building the plane with three sensors, as Airbus does.


AoA Disagree alert

In November 2017, after several months of MAX deliveries, Boeing discovered that the ''AoA Disagree'' message, which is indicative of potential sensor mismatch on the
primary flight display A primary flight display or PFD is a modern aircraft instrument dedicated to flight information. Much like multi-function displays, primary flight displays are built around a Liquid-crystal display or CRT display device. Representations of ol ...
, was unintentionally disabled. Clint Balog, a professor at Embry-Riddle Aeronautical University, said after the Lion Air crash: "In retrospect, clearly it would have been wise to include the warning as standard equipment and fully inform and train operators on MCAS". According to Bjorn Fehrm, Aeronautical and Economic Analyst at Leeham News and Analysis, "A major contributor to the ultimate loss of JT610 is the missing AoA DISAGREE display on the pilots' displays." The software depended on the presence of the visual indicator software, a paid option that was not selected by most airlines. For example, Air Canada, American Airlines and Westjet had purchased the disagree alert, while Air Canada and American Airlines also purchased, in addition, the AoA value indicator, and Lion Air had neither. Boeing had determined that the defect was not critical to aircraft safety or operation, and an internal safety review board (SRB) corroborated Boeing's prior assessment and its initial plan to update the aircraft in 2020. Boeing did not disclose the defect to the FAA until November 2018, in the wake of the Lion Air crash. Consequently, Southwest had announced to pilots that its entire fleet of MAX 8 aircraft will receive the optional upgrades. In March 2019, after the second accident of Ethiopian Airlines Flight 302, a Boeing representative told '' Inc.'' magazine, "Customers have been informed that AoA Disagree alert will become a standard feature on the 737 MAX. It can be retrofitted on previously delivered airplanes." On May 5, 2019, ''
The Wall Street Journal ''The Wall Street Journal'' is an American business-focused, international daily newspaper based in New York City, with international editions also available in Chinese and Japanese. The ''Journal'', along with its Asian editions, is published ...
'' reported that Boeing had known of existing problems with the flight control system a year before the Lion Air accident. Boeing defended that "Neither the angle of attack indicator nor the AoA Disagree alert are necessary for the safe operation of the airplane." Boeing recognized that the defective software was not implemented to their specifications as a "standard, standalone feature." Boeing stated, "...MAX production aircraft will have an activated and operable AoA Disagree alert and an optional angle of attack indicator. All customers with previously delivered MAX airplanes will have the ability to activate the AoA Disagree alert." Boeing CEO Muilenburg said the company's communication about the alert "was not consistent. And that's unacceptable."


Visual AoA indicator

Boeing published an article in ''Aero'' magazine about AoA systems, "Operational use of Angle of Attack on modern commercial jet planes": Boeing announced a change in policy in the Frequently Asked Questions ( FAQ) about the MAX corrective work, "With the software update, customers are not charged for the AoA Disagree feature or their selection of the AoA indicator option." In 1996, the NTSB issued Safety Recommendation A-96-094.
TO THE FEDERAL AVIATION ADMINISTRATION (FAA): ''Require that all transport-category aircraft present pilots with angle-of-attack info in a visual format, and that all air carriers train their pilots to use the info to obtain maximum possible airplane climb performance.''
The NTSB also stated about another accident in 1997, that "a display of angle of attack on the flight deck would have maintained the flightcrew's awareness of the stall condition and it would have provided direct indication of the pitch attitudes required for recovery throughout the attempted stall recovery sequence." The NTSB also believed that the accident may have been prevented if a direct indication of AoA was presented to the flightcrew (NTSB, 1997)."


Flight computer architecture

In early April 2019, Boeing reported a problem with software affecting flaps and other flight-control hardware, unrelated to MCAS; classified as critical to flight safety, the FAA has ordered Boeing to fix the problem correspondingly. In October 2019, the EASA has suggested to conduct more testing on proposed revisions to flight-control computers due to its concerns about portions of proposed fixes to MCAS. The necessary changes to improve redundancy between the two flight control computers have proved more complex and time-consuming than the fixes for the original MCAS issue, delaying any re-introduction to service beyond the date originally envisaged. In January 2020, new software issues were discovered, affecting monitoring of the flight computer start-up process and verifying readiness for flight. In April 2020, Boeing identified new risks where the trim system might unintentionally command nose down during flight or prematurely disconnect the autopilot.


Microprocessor stress testing

The MAX systems are integrated in the "e-cab" test flight deck, a simulator built for developing the MAX. In June 2019, "in a special Boeing simulator that is designed for engineering reviews," FAA pilots performed a
stress testing Stress testing (sometimes called torture testing) is a form of deliberately intense or thorough testing used to determine the stability of a given system, critical infrastructure or entity. It involves testing beyond normal operational capacity, ...
scenarioan abnormal condition identified through FMEA after the MCAS update was implementedfor evaluating the effect of a fault in a microprocessor: as expected from the scenario, the horizontal stabilizer pointed the nose downward. Although the test pilot ultimately recovered control, the system was slow to respond to the proper runaway stabilizer checklist steps. Boeing initially classified this as a "major" hazard, and the FAA upgraded it to a much more severe "catastrophic" rating. Boeing stated that the issue can be fixed in software. The software change will not be ready for evaluation until at least September 2019. EASA director
Patrick Ky The European Union Aviation Safety Agency (EASA) is an agency of the European Union (EU) with responsibility for civil aviation safety. It carries out Type certificate, certification, regulation and standardisation and also performs investiga ...
said that retrofitting additional hardware is an option to be considered. The test scenario simulated an event toggling five bits in the flight control computer. The bits represent status flags such as whether MCAS is active, or whether the tail trim motor is energized. Engineers were able to simulate
single event upset A single-event upset (SEU), also known as a single-event error (SEE), is a change of state caused by one single ionizing particle (ions, electrons, photons...) striking a sensitive node in a live micro-electronic device, such as in a microprocesso ...
s and artificially induce MCAS activation by manipulating these signals. Such a fault occurs when memory bits change from 0 to 1 or vice versa, which is something that can be caused by cosmic rays striking the microprocessor. The failure scenario was known before the MAX entered service in 2017: it had been assessed in a safety analysis when the plane was certified. Boeing had concluded that pilots could perform a procedure to shut off the motor driving the stabilizer to overcome the nose-down movement. The scenario also affects
737NG The Boeing 737 Next Generation, commonly abbreviated as 737NG, or 737 Next Gen, is a narrow-body aircraft powered by two jet engines and produced by Boeing Commercial Airplanes. Launched in 1993 as the third generation derivative of the Boein ...
aircraft, though it presents less risk than on the MAX; on the NG, moving the
yoke A yoke is a wooden beam sometimes used between a pair of oxen or other animals to enable them to pull together on a load when working in pairs, as oxen usually do; some yokes are fitted to individual animals. There are several types of yoke, us ...
counters any uncommanded stabilizer input, but this function is bypassed on the MAX to avoid negating the purpose of MCAS. Boeing also said that it agreed with additional requirements that the FAA required it to fulfill, and added that it was working toward resolving the safety risk. It will not offer the MAX for certification until all requirements have been satisfied. Early news reports were inaccurate in attributing the problem to an
80286 The Intel 80286 (also marketed as the iAPX 286 and often called Intel 286) is a 16-bit microprocessor that was introduced on February 1, 1982. It was the first 8086-based CPU with separate, non-multiplexed address and data buses and also the fi ...
microprocessor overwhelmed with data, though as of April 2020 the concern remains that the MCAS software is overloading the 737 MAX's computers.


Computer redundancy

, the two flight control computers of Boeing 737 never cross-checked each other's operations; i.e., each was a single non-redundant channel. This lack of robustness existed since the early implementation and persisted for decades. The updated flight control system will use both flight control computers and compare their outputs. This switch to a
fail-safe In engineering, a fail-safe is a design feature or practice that in the event of a specific type of failure, inherently responds in a way that will cause minimal or no harm to other equipment, to the environment or to people. Unlike inherent safe ...
two-channel redundant system, with each computer using an independent set of sensors, is a radical change from the architecture used on 737s since the introduction on the older model 737-300 in the 1980s. Up to the MAX in its prior-to-grounding-version, the system alternates between computers after each flight. The two computers' architecture allowed switching in-flight if the operating computer failed, thus increasing availability. In the revised architecture, Boeing required the two computers to monitor each other so that each one can vet the other.


Trim system malfunction indicator

In January 2020, during flight testing, Boeing discovered a problem with an indicator light; the defect was traced to the "redesign of the two flight computers that control the 737 MAX to make them more resilient to failure". The indicator, which signals a problem with the trim system, can remain on longer than intended by design.


Updates for return to service

In November 2020, an Airworthiness Directive required corrective actions to the airplane's flight control laws (embodied in the Speed Trim System software):
* The new flight control laws now require inputs from both AOA sensors in order to activate MCAS. They also compare the inputs from the two sensors, and if those inputs differ significantly (greater than 5.5 degrees for a specified period of time), will disable the Speed Trim System (STS), which includes MCAS, for the remainder of the flight and provide a corresponding indication of that deactivation on the flight deck. * The new flight control laws now permit only one activation of MCAS per sensed high-AOA event, and limit the magnitude of any MCAS command to move the horizontal stabilizer such that the resulting position of the stabilizer will preserve the flightcrew's ability to control the airplane's pitch by using only the control column. This means the pilot will have sufficient control authority without the need to make electric or manual stabilizer trim inputs. * The new flight control laws also include Flight Control Computer (FCC) integrity monitoring of each FCC's performance and cross-FCC monitoring, which detects and stops erroneous FCC-generated stabilizer trim commands (including MCAS)


References


External links

* * *


Further reading

* * * * Design of a pitch stability augmentation system. * * {{Boeing Boeing Engineering failures Flight control systems Software bugs