Two Boeing 737 Max crashes fewer than five months apart led to a worldwide grounding of the aircraft type for nearly two years. Tragically, 346 people died in the two crashes. Investigators concluded that a poorly designed flight control system and a single faulty sensor contributed to each crash. Today, the story of the 737 Max has reignited a debate on the depth and adequacy of pilot training.
A recent AirlineRatings article by Geoffrey Thomas reviewed the Netflix documentary Downfall: The Case Against Boeing, along with John Leahy. Thomas, an award-winning aviation journalist, and Leahy, an airline safety and training expert with more than 30,000 flight hours, highlighted potential lessons from the Boeing 737 Max accidents.
Surprisingly, Leahy identified the decline in pilot training as a root cause. Beyond the emotional scenes of grieving family members, he pointed out the documentary’s goal: seeking truth without emotion.
Training and Skill Decline
The decline in training, according to Leahy, began sometime around 2005. Earlier generations of pilots trained on “classic” jetliners, such as the Boeing 707 and 737, were rigorously trained on flight control failures, such as jammed stabilizers or a runaway trim. Today, training in full-flight simulators barely touches on these scenarios.
Rightly so, Boeing has been criticized for not including information on the maneuvering characteristics augmentation system (MCAS) in flight manuals or training. But it did not require “in-depth systems” knowledge, according to Leahy, since it was a memory item—no different than the established runaway trim procedure.
“It was a memory item—meant to be applied from memory,” said Leahy. “If training was a root cause,” he added, “then simply fixing MCAS is like putting a band-aid over a deep wound.”
He asked a rhetorical question: “Can a trained pilot still be startled or overwhelmed after several minutes?” Leahy rebutted, based on his 40 years of flight training experience, “I would argue, not if they are trained properly.”
He concluded, “The two 737 Max crashes should have never happened. The 737 is a superb aircraft. But it’s one that demands proper training.” In a telling remark, Leahy said, “You cannot automate your way out of inadequate training. And if you keep ignoring this lesson, the next failure may come from a completely different system, but with the same tragic result.”
According to Thomas, these views are largely supported by many experts, including Greg Feith and John Goglia, who explored the 737 Max crashes in a recent Flight Safety Detectives episode.
Lion Air: A Checkered Past and a Near Miss
The first of the two 737 Max crashes occurred on Oct. 29, 2018. That aircraft was operated by Lion Air, a low-cost airline based in Indonesia. The second crash involved an Ethiopian Airlines flight on March 10, 2019.
Omitted from the documentary were details on Lion Air’s regulatory history, maintenance practices, or a prior flight with the accident aircraft that had the exact same failure, but with a different outcome. Based on reports, Lion Air was banned from operating in Europe until 2017 by the European Union Aviation Safety Agency (EASA). The agency cited safety concerns and prohibited operations.
Despite these concerns, Lion Air charted an aggressive growth strategy by ordering more than 200 Boeing 737 Maxs in 2011. At the time, this was the second-largest order for aircraft in aviation history. Two years later, the airline made a significant Airbus aircraft order.
Another factor missing from the documentary was the issues identified with Lion Air’s maintenance division. As reported, for weeks, the accident aircraft was dispatched with airspeed system faults. A day prior to the crash, the angle of attack (AOA) sensor was replaced with a faulty unit that failed the post-installation test, yet the aircraft continued to fly.
On the day prior to the crash, the same aircraft, flown by a different flight crew, experienced an identical MCAS failure and did not crash. During this event, after takeoff, the stick shaker inadvertently activated (based on the faulty AOA sensor), and upon flap retraction, the MCAS system “fired off” and began to trim the nose of the aircraft down. According to reports, the crew diagnosed the problem as a Runaway Stabilizer Trim and applied the appropriate non-normal procedure, which included, “from memory,” turning the STAB TRIM switch to CUT OFF. Two hours later, the aircraft landed safely.
Reports indicate that a cockpit jumpseat occupant identified the problem and resolved it successfully. Unfortunately, one day later, the accident flight crew was unaware of the previous failure and faced the exact same problem. This time, the aircraft crashed into the Java Sea, killing everyone onboard.
Personal Experience
From my experience, flight training changed dramatically with the introduction of highly automated aircraft decades ago.
Herein lies the real root cause of the 737 Max crashes: it’s two-fold.
Manufacturers (not only Boeing) simplify training by relying on aircraft automation to sell aircraft globally; this approach is misguided.
Secondly, operators are cheap.
Bottom line: An airline’s training organization is continually under financial pressure to cram more content in a very tight footprint (the time spent on training); rarely is this footprint expanded. Thus, to Leahy’s point, there is a skill decline and deficit. It’s largely a self-inflicted wound by industry.
Like Leahy, I’d flown many classic airliners, including the Boeing 727 and 747 and Douglas DC-8. Flight control failures such as runaway stabilizers and other basics, such as Dutch roll demonstrations, were all a part of training in those simulator sessions.
In addition, there was great emphasis on in-depth aircraft systems knowledge. Training took place in a classroom, often taught by professional flight engineers. A typical oral exam question required a very detailed response. The examiner may ask, “You’re a fuel molecule: take me from the fuel truck, through the fuel system, powerplant, and out the exhaust section.” While excessive, it made the student learn the fuel system.
Fast forward to my training in the Boeing 747-400. Everything changed. The aircraft systems manuals were stripped of detailed descriptions of aircraft systems and replaced with brief descriptions of indicators, lights, and switches. Most importantly, the human instructor and the meaningful dialogue and discussion were replaced by computer-based training programs.
Simulator training has also changed. Less flying, more interactions with the flight management systems (to include unrealistic route modifications), automation, and more adherence to reading the quick reference handbook as a script (with less diagnosis of systems malfunctions).
During training, my simulator partner and I would joke, “Monkey see, monkey do,” and now, as a reward, “a banana should drop out of the ceiling.”
Captain Leahy is on target with his assessment of pilot training. As he said, “You cannot cut corners on pilot training.” There is a decline in skills in pilots, and yes, it began long before the 737 Max crashes. It is a global threat many decades in the making.