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What Really Brought Down the Boeing 737 Max?

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What Really Brought Down the Boeing 737 Max?

In 2007, Garuda, the national airline, had a notoriously poor safety record. Two weeks after the Adam Air folded plane episode in Surabaya, a Garuda captain at the controls of a 737 bound for another airport on the island of Java allowed the plane to get very high on approach and tried to solve the problem by pointing its nose down. and plunging into the runway despite the co-pilot's pleas to abort the approach and turn around. The captain made the plane run so fast that when he asked the flaps to be set for landing, the co-pilot dared not extend them for fear of structural damage and did not report his doubts to the captain. Investigators later criticized the co-pilot for bad teamwork, specifically for not taking control of the plane, but before hitting the captain in the finish, there was not much he could do. The plane landed long, landed at 100 miles per hour very fast, jumped three times and exited the other side of the runway, cutting a perimeter fence at the airport and sliding down a road, a ditch and a landfill before resting. on a rice paddy and bursting into flames. Because rescue vehicles could not cross the ditch, firefighters could not get their equipment close enough to effectively suppress the flames, and the fire burned for more than two hours. The captain and co-pilot were not injured, but 21 people died and others were seriously injured.

Garuda was the last straw. From 2003 to 2007, the accident rate in Indonesia, measured by fatal flights per million departures, grew 15 times more than the global average. The US Embassy in Jakarta advised Americans to avoid travel on Indonesian airlines, although in Indonesia this was virtually impossible. As usual, the numbers worked for individual travelers: even on Indonesia's worst airlines at the worst times, the chances of being killed were slim. But for foreign governments who became the self-anointed guardians of their citizens around the world, the exposure was similar to that of aircraft manufacturers, though less consequential: inevitably, accidents would continue to occur in Indonesia, and foreigners would die, and would die. It will be difficult for your employees to avoid accountability unless employees have raised concerns in advance.

In 2007, the European Union and the United States permanently banned all Indonesian airlines from their national territories. This was done for security reasons. The ban was largely symbolic because Indonesians were focused on expanding their regional markets and had no immediate plans to open long-haul routes, but signaled an official disapproval of Indonesia's regulatory capabilities and served as public criticism for a group of companies. some of which were out of control. Residents of Europe and the United States generally did not know or care, but many of the ordinary Indonesians who came to hate their airlines were in favor of prohibition simply as a form of punishment. Deregulation has turned Indonesia into a tricky flying east, inhabited by prestigious immune consumers, just as Lion Air's Kirana had predicted.

The ban placed Boeing and Airbus in a delicate position. Now they were selling airplanes to officially declared insecure airlines that US and European authorities expected to continue killing and injuring their passengers at a rate that would be unacceptable in the West. In 2007, the largest of these airlines was Lion Air. That year, it reordered an additional 40 737s, and Boeing was happy to serve it. In 2011, Lion Air returned to the table with what was then the largest commercial order in aviation history, a $ 22 billion deal to 230 737 units, including 201 units of the next 737 max. The deal was finalized during an Asean summit in Bali, attended by President Barack Obama. Photographs show Obama looking approvingly as Kirana and a senior Boeing executive signed the contract. No mention was made in the associated reports that Lion Air was considered a dangerous airline and was banned from the United States.

Lion Air had been contributing to casualties almost from the beginning. At the time of the signing ceremony in Bali, he was responsible for 25 deaths, more injuries, five total hull losses and an unreported number of damaged aircraft. An old truth in aviation is that no pilot crashes into a plane that he had not previously forgotten about. Scratches and scratches count. They are signs of a mindset, and Lion Air had many of them, usually caused by sudden gates from the gates in the company's rush to launch airplanes. Kirana was once asked why Lion Air was suffering so many accidents and he sincerely answered that it was because of the large number of flights. Another question may have been why, despite so many accidents, the death toll was not higher. The answer was that all Lion Air crashes occurred during takeoffs and landings, and thus at relatively low speeds, on runways or unobstructed surroundings. These were the brief interludes when the planes were being piloted manually. The reason accidents never occurred during other stages of the flight is that autopilots are more likely to be engaged.

Boeing knew it had a problem. A pervasive culture of corruption was at the center, but it was beyond anyone's ability to reform. Instead, Boeing decided to intervene at its own expense to raise standards at Lion Air and try to lower its accident rate contributions. Both Boeing and Airbus had taken larger measures before. First, it was the epic interventions in China that gained speed in the late 1980s and lasted years. In the beginning, civil aviation in China was a mess, with one of the highest accident rates in the world.

Dave Carbaugh, a former Boeing test pilot, spent his first 10 years at the company traveling the world to teach customers how to fly their aircraft. He mentioned the challenge of training pilots in Asia. “These were the routine pilots,” he said, “the guys standing behind a simulator. They saw a fleeing garrison. They saw where and how it was dealt with in the curriculum – always on Sim Ride No. 3. And so on Sim Ride No. 3, they treated him correctly, because they knew exactly when he was coming and what was going to happen. But were they exposed elsewhere? Or did they discuss the issues involved? No. It was just a routine exercise. This is step 25 of learning to fly a 737. End point. ”I asked specifically about China. He said, “The Chinese? They were probably the worst. ”He spent every month in China for years. He said: “They saw the flight from Beijing to Tianjin as 1,352 steps to take. However, if they flew from Beijing to Guangzhou, there were 1,550 steps. And they didn't connect the two. It would be so bad that they just wouldn't go astray. I remember flying with a captain who would never deflect no matter how many problems I gave him. I asked him: "What do you mean?" He said, "Because the checklist doesn't say to deviate." "

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