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Published On: Tue, Jun 18th, 2019

Boeing and the battle over blame

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By Theo Leggett and Simon Browning

Standing in a muddy field on the edge of a small farm to the south of the Ethiopian capital Addis Ababa, it’s difficult to imagine that 157 men, women and children lost their lives here.
The landscape is vast, with rolling plains to the west that appear to go on forever. It’s broken up by small clusters of trees spread across the yellow-and-brown arable land.
Against a backdrop of undulating hills, there is a large, circular wooden fence.
Slim, single batons reaching about head height, stand up from the ground. Beyond it lies a crater some 27m (90ft) wide and 36.6m (120ft) long.
This is where, just over three months ago, Ethiopian Airlines Flight 302 nose-dived into the ground at 500mph, just six minutes after leaving Addis Ababa.
Mounds of earth are piled up where excavators have sifted through the wreckage.
Here in Hama Kuntuschule, where the local population still travels by horse and cart, people from 35 different countries as far away as Canada, China and the UK, lost their lives.
A small group of men walk towards us. One of them, Kelele, tells us that he was here on 10 March when the plane crashed.

Kelele
“The time was early morning and we were all in the house, taking our breakfast. No-one saw what happened at the time,” he says. “We just heard a sound. When we got out we just saw something burning and smoking.”
Almost immediately, the land was besieged by diggers, air crash investigators, government officials, men and women walking in lines combing through the debris and charred personal belongings.
And, of course, the families of the victims who had gathered to grieve.

The crash site in March 2019
It is a different sight today. It’s very quiet and the more obvious pieces of wreckage have been taken away. But debris remains, catching your eye wherever you turn. Scraps and shreds of fabric, a piece of leather – possibly the strap of a bag.
A small, square chunk of metal still bears the distinctive black, yellow and green paint of the Ethiopian Airlines livery. The process of being ripped from the fuselage has left it jagged and contorted.
Fragments of a honeycomb-like material, flecked with white paint, are scattered widely across the rich dark mud. It’s all that remains of the aircraft’s interior.

Debris from the crash
It’s hard to comprehend the violence of what happened here – that a brand new modern jet could be obliterated in an instant, that this place is a mass grave.
The victims’ families have long since left the site. Their memorials and floral tributes have been removed.

The crash site, June 2019
But the fate of flight ET302 has not been forgotten. It is still the subject of intense debate and concern, particularly in corridors of power in the US.
The plane was a new design – a 737 Max, an updated version of Boeing’s long-serving workhorse, the 737 – and the crash was the second accident involving that model in the space of just a few months.
Now Boeing is facing serious questions about the way in which the new plane was conceived and brought to market.
The US Department of Justice is reportedly carrying out a criminal inquiry. Numerous lawsuits have been launched against the aerospace giant by relatives of the crash victims.
Amid all of this, a great deal of attention has been focused on the pilots of the aircraft, the action they took during the fatal flight and whether the training they were given by their employer, Ethiopian Airlines, gave them the skills they needed to avert disaster.

Were the pilots to blame?
When the preliminary report was published after the crash, Ethiopian transport minister Dagmawit Moges appeared keen to exonerate Capt Yared Getachew and First Officer Ahmednur Mohammed Omar.
Yared was a relatively seasoned pilot, with more than 8,000 flying hours on his record, including some 1400 on 737s. His first officer, however, had just 361 hours, including 207 on Boeing 737s.
The Ethiopian government had taken charge of the investigation, which was helped by the relatively quick recovery and analysis of the aircraft’s flight recorders. It concluded that the crew had done nothing wrong.
“The crew performed all the procedures – repeatedly – provided by the manufacturer, but was not able to control the aircraft,” said Dagmawit .

Captain Yared Getachew
However, this conclusion has been challenged by people who believe the pilots committed a series of errors.
The trigger for the accident – and the root cause of another crash involving a near-identical 737 Max off Indonesia last year – is thought to have been the failure of a system known as Manoeuvring Characteristics Augmentation System (MCAS).
What now seems apparent with the benefit of hindsight is that MCAS had design flaws. Boeing itself has indicated as much.
MCAS is a piece of flight control software designed to make the new plane easier and more familiar to fly for pilots who were already used to the previous generation of 737 – reducing the need for potentially costly extra training.
It was meant to curb a tendency for the nose of the aircraft to rise too much, when it was already pitched up at a steep angle. It used the stabilisers – the horizontal wings on the tail of the aircraft, which are normally used to keep the aircraft balanced – to produce a nose-down movement.
However, the system relied on data from a single sensor on the outside of the aircraft to determine the angle at which the aircraft was flying. The failure of that one sensor could lead to the system deploying at the wrong time – forcing the aircraft into a descent.
It appears to have done just that on both the Boeings that crashed, forcing the nose of the aircraft down when the pilots were attempting to gain height.
The system was also very powerful, able to produce significant stabiliser movements, and capable of overriding the crews’ own inputs as it activated again and again.
After the second crash, authorities around the world grounded the 737 Max.
Boeing is working on modifications to the software, and the design will not fly again until regulators are satisfied it is completely safe. But if the aircraft control systems themselves were faulty, why have attempts been made – by Boeing and some US politicians – to cast a share of the blame onto the crew of the stricken aircraft?
Among the fiercest critics of the crew’s actions in the US has been Congressman Sam Graves, himself a qualified pilot and Ranking Member of the Committee on Transportation and Infrastructure in the House of Representatives. The Missouri Republican thinks that the crew of ET302 could have saved their plane.

Congressman Sam Graves
He has been a vocal presence at hearings in Washington involving both the Federal Aviation Administration (FAA) and the National Transportation Safety Board as part of the inquiries and investigations surrounding the 737 Max.
In May, Graves insisted that “facts in the preliminary report reveal pilot error as a factor”. He went on to claim that “pilots trained in the US would have successfully been able to control this situation”.
That is a controversial view, but one based on the way in which the pilots reacted to the situation confronting them. Nor is he alone in his opinion which is widely reflected in statements made by others online and in the media.
Before the Lion Air crash off Indonesia – in which 189 people were killed – the very existence of MCAS was unknown to airlines buying the 737 Max, or to their flight crews. The acronym did not appear in the flight manual.
After the accident, however, Boeing published a bulletin in which it described the effects of an MCAS malfunction, and instructed pilots to follow a particular “non-normal checklist” designed to help them cope with uncontrolled stabiliser movements.
This checklist – which is meant to be memorised by flight crew – instructed them to flip switches on the centre console, to turn off the stabiliser electronics, then balance the aircraft using manual trim wheels beside the pilots’ knees.
The Ethiopian crew tried to follow this procedure. They turned off the electronics and attempted to “trim” the aircraft – to bring it back into level, balanced flight – using the hand controls. But the preliminary report suggests that they were physically unable to do so.
It appears the aircraft was simply going too fast, and the aerodynamic forces building up on the stabilisers were too strong for the pilots to overcome with muscle power. They turned the electronics back on and ultimately lost control altogether.
This is where Graves’ main criticisms come in. He points out that throughout the flight, the pilots failed to reduce power from the levels used immediately after take-off, allowing the plane to continue accelerating to the point where it was moving too quickly to be trimmed manually.
“Once they set those throttles to full power, they never retarded them,” he told the committee. “They accelerated right through the certified maximum speed… and just kept on accelerating.”
What went wrong inside Boeing’s cockpit?
During the same hearing, under questioning from Graves, the acting head of the FAA, Dan Elwell, appeared to agree with him.
“They did turn the [stabiliser trim switches] off, but they never controlled their airspeed,” he said.
“And then subsequently… they turned them back on. Both of those things are unfortunate.”
Srouce: BBC
Elwell went on to say: “I’ve never looked at an accident where there weren’t three or four or five links of a chain, any one of which, if it hadn’t gone wrong, the plane would have survived.”

That seemed to echo the words of Boeing’s Chief Executive Dennis Muilenburg, who told journalists in late April that both the Lion Air and Ethiopian Airlines accidents were the results of a “chain of events” of which MCAS was one link.

Such claims have gone down badly at Ethiopian Airlines headquarters in Addis Ababa, where the emotional impact of the crash is still felt very strongly.

In the ornate, wood-panelled boardroom, Chief Executive Tewolde Gebremariam remembers the day the plane went down.

Ethiopian Airlines CEO Tewolde Gebremariam

“I was at church at that time, at about 9am,” he says. “It was a big shock when they called and told me that ET302 had disappeared from radar. It was a tragic accident, a very, very tragic accident.”

It was the beginning, he says, of a very difficult period, particularly for staff at the company’s hub, where the crew of the stricken airliner worked and received their training.

“The entire company was grieving, for the loss of passengers, the loss of colleagues,” he says.

“But at the same time, we managed to operate all our flights, on that very day and on the subsequent days.”

The Ethiopian flag carrier is Africa’s largest airline. It operates more than 100 planes, and has a relatively young fleet, which includes state-of-the-art designs such as the Airbus A350 and Boeing’s 787.

Although it has existed in various forms since the 1940s, it likes to project itself as a highly professional, thoroughly modern operation. Far removed from the tired African stereotype of a disorganised outfit operating a handful of ageing airliners, it sees itself as an ambitious new standard-bearer for the continent.

It has a relatively strong safety record, although that was marred by the loss a 737 that crashed off the coast of Lebanon in 2010 – an accident that was blamed in official reports on errors by the crew.

So the fact that its training standards have been questioned by influential people such as Congressman Graves, and the idea that its pilots should bear some responsibility for the latest accident, has gone down badly.

The Ethiopian Airlines boss says the congressman is “severely misinformed, or doesn’t have the facts in his hands”.

When asked if there might be an agenda in the US to divert attention away from alleged failings by Boeing or the FAA, however, Tewolde strikes a more diplomatic note.

There have been “very, very few” criticisms, he insists, though he concedes they may come from people with “vested interests”. Nevertheless, he makes it clear where he feels the real blame for the accident lies.

“People who’ve made those comments should ask themselves, ‘Why on earth have they grounded 380 aircraft around the world?’ The facts speak for themselves.”

Grounded Ethiopian Airlines Boeing 737 Max 8

Out of control
Despite his assurances, the points made by Congressman Graves have prompted widespread debate about the actions of the pilots – particularly their apparent failure to reduce power.

They were struggling desperately to recover their aircraft. An “overspeed” warning was blaring in the cockpit. The strength of the aerodynamic forces building up was preventing them from taking the steps they needed to save the plane.

Yet they didn’t reduce thrust. It seems like an extraordinary oversight, but some aviation experts believe there may have been a very good reason why they didn’t touch the throttles.

They include one UK-based 737 training captain who is also a former accident investigator. Like many other working pilots who have expressed views about the two accidents, he prefers not to be identified.

He points to a particular handling characteristic of the aircraft – known as the pitch/power couple.

In simple terms, it means that when engine thrust is increased, the nose of the aircraft will push upwards. When it is reduced, the reverse will happen – the nose will pitch down. It is a powerful effect, but one that the crew can normally respond to using their controls almost without thinking.

But in the case of ET302, he argues, this effect left the pilots facing “an unsolvable conundrum”.

Why does thrust and pitch matter?
In the early stages of the flight, they were confronted with a rapidly developing situation as they struggled to gain height while trying to work out why the plane seemed to have a mind of its own.

By the time they began working through the procedure mandated by Boeing to disable the electronic stabiliser controls, they were already going too fast for the manual system to work.

Boeing recognises this can happen. Its flight manual for the 737 Max advises pilots to accelerate or decelerate to a point where the plane reaches a natural aerodynamic balance and the control surfaces can move more easily – a point known as the “in-trim speed”.

But doing that also presented a problem.

“At this point, the crew are already dealing with an aircraft that wants to pitch nose-down,” the training captain explains.

“It is also going too fast. The thought process may have been: ‘The answer to this would be to reduce thrust. But, if I reduce thrust I will immediately fall victim to the pitch/power couple, and the aircraft nose will pitch down even further.’”

In other words, the pilots were faced with a situation where they couldn’t control the aircraft unless they tried to slow down – but doing so could push it into a catastrophic dive.

It’s possible, then, that the crew didn’t reduce thrust because they simply didn’t dare to do so.

Capt Chris Brady, himself a pilot and the author of a technical website devoted to the Boeing 737, endorses this theory.

“In these circumstances, you’re really caught between a rock and a hard place,” he says.

“They may have wanted to reduce thrust, but when the aircraft is already very low and nose down as well, you’d have to have balls of steel to do so.”

There remains the question of why they didn’t adjust the throttles earlier.

Brady concedes that “with the benefit of 20/20 hindsight, it would have been better if they’d reduced thrust at an earlier stage.”

But early in the flight, the pilots were trying to gain height, and one of the control columns was shaking, usually a warning of an impending stall – a situation where the wings suddenly lose lift. Under those circumstances, Brady says, they would normally maintain a high level of thrust.

Inside the flight simulator
Ethiopian Airlines rejects any suggestion that its training standards fall short. Tewolde says the company has invested more than $500,000,000 (£396,000,000) on its Aviation Academy over the past five years

Within the academy, rows of flight simulators sit in two vast hangars. Large, unwieldy-looking boxes on stilts, they sway and swerve as they replicate the movements of giant airliners.

These simulators cost millions of dollars each. The company has one for each of the large airliners in its fleet, including the Boeing 787 Dreamliner, the Airbus A350 – and the 737 Max.

The latter is something of a rarity. There are still relatively few in service, and this is the only one in Africa. It started operating in January.

Boeing 737 Max simulator

Because the Max was designed to be very similar to the previous generation of 737, pilots have been able to move from one model to the other without needing specific simulator training. Instead, they were allowed to make the transition after a relatively short computer-based course.

Many carriers that already use the 737 Max – including American Airlines, for example – have yet to acquire a dedicated simulator.

Inside Ethiopian Airlines’ machine Training Pilot Nathan Elias and his trainee first officer simulate an emergency. A warning blares out, and large, heavy control wheels by their knees start spinning rapidly.

They adjust the throttles and flick a couple of switches. The wheels by their knees stop moving on their own, and the first officer uses a handle to crank them back to their previous position. The plane returns to an even keel.

Cockpit
This is the procedure specified by Boeing for dealing with uncontrolled stabiliser movements – the same procedure it says should be used in the event of an MCAS failure. On this occasion it is carried out with a minimum of fuss.

But Capt Elias says that the emergency faced by the pilots of ET302 would have been very different. He believes they may simply have become overwhelmed by the situation.

On that plane, the pilots were faced with a shaking control column warning them of a possible stall. Due to the sensor failure, some instruments were giving unreliable readings. Warnings would have been sounding. And all of this began when the aircraft was just a few hundred feet off the ground.

Yet one thing the simulator cannot yet do is replicate the circumstances of that accident or the previous crash off Indonesia. In late May, Boeing admitted that software provided to simulator operators was flawed, and incapable of reproducing some flight conditions, including the failures experienced by ET302.

Lawsuits
It’s worth remembering that the Ethiopian Airlines crash was the second of two major accidents involving the new 737 Max. The first occurred when a Lion Air jet fell into the sea off Indonesia on 29 October last year.

Although preliminary reports have pointed the finger at MCAS in both cases, there is an important difference. Until the Lion Air plane went down, 737 Max pilots around the world were unaware that the system existed.

It was intended to operate behind the scenes – an invisible aid to the crew. By the time of the ET302 accident, however, Boeing had published details of how the system worked and what pilots should do if it went wrong.

They did attempt to follow that procedure – but because of the speed they were going, were unable to complete the process.

One question, then, is whether Boeing did enough in the wake of the first crash to ensure its design was actually safe to operate. Another – asked by the likes of Congressman Graves – is whether the crew themselves were sufficiently competent to carry it out.

The relatives of those who died are trying to find ways to come to terms with what happened.

Among them is Paul Njoroge, a Canadian resident who lost his wife, three young children and mother-in-law when ET302 went down.

Paul Njoroge (with microphone) at a memorial service. Nakuru, Kenya

“I see other people moving on with their lives, with their children, and I know I am not like them,” he says. “I think of my wife and children every moment.

“At first I could not live, I could not eat, I could not talk to people,” he says, his voice breaking as we speak on the phone.

He says that sometimes he wishes that he, too, had died on the aircraft.

Boeing is now facing a number of lawsuits from relatives of victims, among them the family of Jonathan Seex, who was the chief executive of restaurant business The Tamarind Group, as well as the widow of Anthony Ngare, a journalist working for the UN cultural agency Unesco.

These two lawsuits both make a serious accusation against Boeing. They claim “shortly after Flight 610 crashed… Boeing knew that hundreds of Max 8 aircraft were still in use carrying passengers all over the globe, which presented a substantial risk that a similar incident could occur without appropriate and immediate intervention…

“Despite this knowledge and the gravity of the risks presented to passengers…Boeing consciously and intentionally failed to act, and/or acted without the urgency commensurate with the risk of harm presented by its defective and dangerous aircraft.”

Njoroge is among the relatives taking legal action against Boeing.

“I would like to see Boeing and the FAA unequivocally take responsibility for the deaths of 346 people, on the two planes, instead of shifting the blame onto the pilots,” he says.

He believes the actions of the FAA and Boeing so far have displayed “a deep level of arrogance, of hubris”.

“If they were to take ownership and responsibility for what happened, that to me would be everything.”

Boeing will not comment on the specific allegations contained in the lawsuits. In a statement, it says: “Boeing extends our heartfelt condolences and sympathies to the families and loved ones of those onboard Ethiopian Airlines Flight 302 and Lion Air Flight 610. As the investigations continue, Boeing is cooperating fully with the investigating authorities.”

Within the pilot community, meanwhile, there is clearly anger at what some see as attempts to move responsibility away from the manufacturer, and on to the crew of the crashed plane.

“With all due to the pride in training and experience we have here in the US, it should not be used as a platform to vilify non-US pilots,” says Capt Dennis Tajer, spokesman for the Allied Pilots Association, a union representing 15,000 crew at American Airlines.

“Blaming dead pilots, blaming non-US pilots, the suggestion that somehow they’re not of equal skill and training is professionally insulting, and just not the way we do business,” he says.

“Clearly the match and the gasoline were the MCAS system.”

He claims any attempt to suggest otherwise is “disingenuous at best, and trying to distract from the real cause of the tragedies”.

It is important to remember that investigations into the loss of ET302 are still under way, and the final report may well give much fuller details about what the pilots were or were not able to do.

It is also worth acknowledging that many aviation accidents in the past have often involved a combination of technical failure and human error – and there is no question that the possibility of human error needs to be looked into thoroughly.

Grounded Boeing 737 Max 8
Grounded. Parked up. Going nowhere.
In a far corner at the end of the runway at Addis Ababa Airport is a huge maintenance area. Three enormous hangars are filled with jets from Ethiopian Airlines and other carriers that serve this region. Engineers are carrying out critical safety inspections and maintenance procedures.

Parked up in front of the smallest hangar are four Boeing 737 Max 8s. The planes were grounded immediately after the crash and they’ve been stashed away from public view ever since.

The cockpit windows are covered with silver reflective film to protect the electronic units inside from the harsh Ethiopian sunlight.

On the exit doors, bright pink signs with black print read: “DO NOT OPEN”.

Plane door
Huge red plastic sleeves cover the engines. The sensor instruments just under the cockpit have also been covered over. Four jets that would usually have so much power and speed look strangely forlorn and rigid.

Grounded planes
Mesfin Tasew, the company’s chief operating officer, explains that the grounded planes are under what’s known as “preservation maintenance”.

The engines, he says, have to be run once a week, and covered up the rest of the time, to prevent any foreign objects getting inside.

Ethiopian Airlines Chief Operating Officer Mesfin Tasew

Keeping aircraft like these on the ground is a costly process. Tasew explains that under normal circumstances they would be ferrying passengers twice a day on routes to other African countries, as well as operating services to India and the Middle East.

Having to do without them means a great deal of lost revenue. The airline is still making repayments on money it borrowed to buy the planes, as well as having to fund the maintenance programme while they are on the ground. All told, it’s costing the airline millions of dollars every week.

Other carriers with similar grounded planes have already admitted that costs are mounting up as a result.

Airlines are very keen to see the 737 Max cleared to fly as soon as possible, because it was designed to be fuel-efficient, and cheap to operate.

As Mesfin puts it, “We need this plane.”

Nevertheless, safety has to come first. It’s still not clear when the plane will be allowed back in the air. The solutions put forward by Boeing need to be approved by the FAA first of all, while regulators elsewhere may decide to take a tough line before they give their own approvals. Ultimately, however, the 737 Max will fly again.

Tewolde Gebremariam says that Ethiopian Airlines will have to be thoroughly convinced that the aircraft is truly safe before flights can be resumed.

It will not be the first airline to put the plane back into the air, he says, but the last.

Mourners visit the crash site of Ethiopian Airlines Flight ET302

Credits
Authors: Theo Leggett and Simon Browning

Digital producer: James Percy

Photos: Simon Browning, Neil Drake, Getty, Reuters

Video: China Central Television

Graphics: Lilly Huynh, Tom Housden, Gerry Fletcher, Salim Qurashi

Editor: Kathryn Westcott

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