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  • 58

Cockpit voice recorder of doomed Lion Air jet depicts pilots' frantic search for fix

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The pilots of a doomed Lion Air Boeing 737 MAX scoured a handbook as they struggled to understand why the jet was lurching downwards, but ran out of time before it hit the water, three people with knowledge of the cockpit voice recorder contents said. (uk.reuters.com) 기타...

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gcottay
It seems to me that skipping those expensive simulator hours was the critical error.
bbabis
Bill Babis 11
Yes, MCAS gets the blame but at the end of the day it was a basic trim malfunction.

1. Problem should not have happened.
2. Problems do happen.
3. Unqualified crew.

Lack of understanding leads to panic. Panic leads to fixation which leads to being overwhelmed.

[This poster has been suspended.]

afcjr1201
He has a great point but calling others fools is immature and childless and will not go well with fellow posters.
rawhp1
Don't be afraid to fly the airplane. Turn the MCAS off and LEAVE IT OFF.
erisajd
erisajd 1
the only way to turn it off is to pull the breaker. Behind you on the wall. Finding it might be a challenge if you don’t know its there since no one told you.

Also. There has been damn little information on how the system operates other than the highest level and contradictory information.
hlsjones
"the only way to turn it off is to pull the breaker" Totally untrue. Three different switches, any one of them would do it not to mention the 4th way, the breaker. The problem, as I see it, is everyone being "dumbed-down" and depending on computerized, read AI, systems instead of knowing and flying the airplane.
erisajd
erisajd 1
See my comment above.

The three alternatives you mention are just electronic disconnection of the system. Which did not work. The ONLY WAY to totally turn the system off is to pull the breaker.

Maybe then you can take out the nose down trim. Maybe.
hlsjones
What do you mean they din not work - they never even tried those fixes. This from the box.
SmittySmithsonite
Turning the stabilizer trim switches to the "cut out" position will allow the pilot to regain control - this cuts off the computer's ability to drive the trim full nose-down in response to bad data.

This is the most detailed explanation of the system I have yet to see: https://youtu.be/9Ts_AjU89Qk
erisajd
erisajd 0
Assuming the system was not working properly [which seems obvious giving its activation in both situations] then perhaps it would not let go - I have had several situations in my flying career where a trim system would not disengage from a flight cruise trim position - I have had to recycle the system back to an 'on' position and then trim the airplane for a new speed - let it maintain that speed and then disconnect again.

This system needs to be removed - not reprogrammed. There is NOTHING this system does that a pilot with a correct AOA indication cannot do manually and safely.. If the pitch is so serious that the aircraft needs this system, then is should not be certified.
SmittySmithsonite
I agree with you there - this system should NOT have been installed in this aircraft, or ANY aircraft to begin with.

From what I understand, had these foreign pilots known that they could've just thrown the stab trim switches, they'd still be alive, along with all the passengers. They were fighting nose-down trim, and had no idea how to disable that. It was Boeing's fault the pilots were unaware of this, even though I agree they definitely should've been more thoroughly trained on this new aircraft. The fact that Boeing didn't make the existence of this system known to anyone is criminal, IMO. I believe the only reason there weren't any crashes here in the USA, was the pilots here would throw those switches as part of their training - a seemingly runaway trim, throw the switches, disable auto trim, regain control. Who knows if this ever happened here. We only hear about when they crash.

Imagine the lawsuits if Ford or GM put a system like this in a vehicle, taking control of steering in response to a bad sensor input, veering the vehicle into oncoming traffic. People would be up in arms.
erisajd
erisajd -1
I disagree. You can disconnect the system by turning on the autopilot. Which DID NOT WORK.

The pilots turned off the autopilot and promptly started fighting the MCAS system.

The ONLY way to COMPLETELY disable the system electronically is to pull the breaker. Then. Maybe. The electric trim system will allow the pilots to reverse out nose down.

But. There is no confirmation of that yet either.
afcjr1201
Not true, where did you get that info?
RECOR10
RECOR10 0
Who cares, it is clear in the statement by erisaid that there is no confirmation.
erisajd
erisajd 0
confirmation is about whether disconnecting the MCAS will allow you to recover your nose down trim - not that the pilots fought the MCAS system after disconneting the AP - that confirmation is readily available
jazzguru
Why hasn't the FAA or Boeing or any responsible news service mentioned that this specific type of problem has happened previously? On March 17th and 22nd, the Smithsonian tv channel aired what happened on October 7, 2008 to Quantas flight 74 over the Indian Ocean at 37,000 feet. It was an Airbus A-330 with a former US Navy Top Gun pilot. This same problem happened to two additional Quantas A-330's. Also an Air Canada A320 in 2017 and a Malaysian L-1011 in 2005...all traced to the ADIRU (Air Data Inertial Reference Unit) which tagged altitude information to the flight control computer as angle-of-attack data leading the computer to think the plane was pitching up and going to stall and causing a nose down command.So these "attitude augmentation" systems have been around for many years in both Boeing and Airbus aircraft and experienced pilots should be aware of them. There should have been no loss of life if these two Asian airlines had experienced pilots instead of 200 hour boy wonders with mostly simulator training!!! GET OFF BOEING'S BACK!!!
mcalant
Why did Boeing feel the need to put this system on the airplane in the first place? Has there been that many accidents of transport category aircraft that were attributed to stalls that could've been prevented if an automated system such as this had been in place?

These aircraft are flown by professional pilots. Stick shakers were fine for decades. Let them just fly the damn airplane!!
I find it hard to believe that there were that many driving factors to substantiate the expense and complexity of putting this system on an airplane of this type.
erisajd
erisajd 2
from what I have heard the control forces were not linear with the thrust pushing the nose up faster than the controls would push it down so this system was added to ensure a linear feel to the flight controls. . .
KC3CDU
why did the FAA give Boeing so much wiggle room in the first place? if the FAA is understaffed, let's fix that. so much for safety. shame on boeing and the FAA.
tompaxy
Tom Pips 1
I think it's just the matter of bullshit, unnecessary technology permeating all aspects of our lives. Happens with everything trying to be "Smart" these days. Hell, happens with toasters connected to internet. Instead of mocking the companies that are basically telling them toasters are smarter then their users, people are buying that shit. You can imagine what they're doing in complex machines like airplanes. It's ideal playground for no life geeks trying to justify their existence. Smart toasters and idiots buying them are the reason this plane went down.

[This poster has been suspended.]

speshulk99
C'mon now, this "phenomenon" only occurs on a/c with MCAS.
bobkeeping
It always sounds good at the engineering meeting. But real life is different. Every tie someone does something for my "own good" I cringe and wait for the explosion. Goes double for government. My biggest plea is LEAVE ME ALONE. I'm only dangerous when provoked

Bob
akebonolove
Why is it so damn difficult for "experienced pilots" to just turn that *#*$! system off?
skye12
Because many pilots didn't even know that system existed. And it's not in the flight handbook.
hlsjones
To say that the manuals from Boeing don't mention the system is totally untrue. That system is one of the selling points for the aircraft.
Pilotcooky2
I agree. It’s one of the main feature of the 737 max. Pilots were aware of the system. I think that every pilot that has a rating for a specific aircraft should learn about every feature that particular aircraft has.
rlitterell
This forum sounds more like Facebook politics than an aviation forum.
bishops90
They all do these days, that's why I rarely visit anymore.
afcjr1201
I could not agree more not to mention the language that is also allowed
shenghaohan
Very typical tunnel vision... they didn’t notice the trim indicator had ran away. That said, the tiny trim indicator triangle is really hard to see especially when you are panicking and the plane is diving.
ssobol
In the 737 it is pretty obvious when the trim is moving there are two large spinning wheels and a distinctive noise. I'm pretty sure they knew the trim was running. They just didn't know why.
baingm
You don't have to know why. Why did they screw around with the QRH for nine minutes to handle an UNCOMMANDED/RUNAWAY TRIM scenario. It's a MEMORY ITEM! Some one also said they tried that and it didn't work. How you know. I've not seen anything indicating that.
tompaxy
Tom Pips 6
First, my heart is broken for the pilots and passengers, my condolences to their families. Now, correct me if I'm wrong, but this sounds like basic lack of seat of the pants flying experience (by that, I mean "without autopilot"). Also, it's just one of the many consequences of fucking computers, sensors, small robots and other gremlins interfering with common human sense and seat of the pants skills. It's all fine while it's fine, but let some freaking wire shoot low voltage and all hell breaks lose. Then, in panic, one has to go find that forgotten drawer where his basic, forgotten piloting skills lie. What they needed wasn't flight manual, they just needed to fly manually. And, everybody remotely familiar with flying your basic Cessna trainer knows it means one hand on the trim wheel almost all the time. Trimming is essential part of manipulating basic command surfaces of an airplane. But I'm not blaming pilots, I'm blaming Boeing and all those fucking "early adopting" idiots that feed us with needles technology with a spoon. I say, bring back the piloting to the pilots. I mean, could something be more useless than this supposed "selling point" of Boeing Max? How hard it is to push control column forward if the plane is indeed stalling? It's piloting 101. Why do we need fucking "system" to do that????
afcjr1201
tom there is no need for the language you used and unnecessary.
flightcan
Tom, flying is a complex activity. There are many failure modes and designers try to make the machine fix human errors that are bound to occur. Your comment is simplistic and doesn't consider the numerous crashes that have occurred due to stalls. The dash 8 crash in Buffalo comes to mind. If that plane was equipped with the same system the 737 MAX is, everyone on that plane would be alive today. Pilot pulled back on the throttle when the plane was already at minimum speed.

Knee jerking - this went wrong - so we should not do that is very simplistic approach to over all safety. I think your comment has no value.
bdjam
Very sad - especially if a little more diligence from Boeing and the FAA could have prevented this.
chalet
chalet 4
Sorry to disagree Brian, Boeing pressured FAA to delegate the testing and issuance of seals of approval of most of these systems to Boeing personnel who in turn were pressured by their higher ups to approve everything ASAP. Just wait to see the multi million if not billion Dollars in fines, settlements, legal fees that both Boeing (mostly) and the FAA Will have to couoght up for derelict of duty.

[This comment has been downvoted. Show anyway.]

mweiserny
The blame goes to everyone involved - of course excluding the front line FAA teams and the people who fly and maintain extremely complicated aircraft. I am a RVN UH1 driver w/2500+ in time, and frankly a lot of the new electronic jargon goes right on past me! Sure, i'm old! But we need all the POLITICS OUT OF AVIATION COMPLETELY- both on the regulatory side and the business side. Our very lives are at stake, Congress dropped the ball for the last 30 years on funding the FAA properly, Using commercial aviation for Pork (aka the Charlotte Plant) and a host of others. Politicians are just too stupid to fly a plane (notice how few actually do?? You also only see a few pilots in politics, they're too smart.
D4D77
The problem with refusing to participate in politics is that you end up being controlled by your inferiors. 😕

[This comment has been downvoted. Show anyway.]

[This poster has been suspended.]

bdjam
The system may have been approved under the Obama administration, but the plane was certified during the trump administration. Boeing calls trump and asks that the plane not be grounded, high ranking Boeing officials become part of the administration and Nikki Haley becomes a Boeing board member. All of this with a overarching libertarian view point...sorry - there's enough smoke that there should be some fire detection going on. And it's not just Boeing, the FAA and the trump administration.

That said, the FAA never was able to effectively carry out it's mission of regulating and ensuring safety while promoting the airline industry. William mentioned that the MAX has become another DC-10 - the FAA was clearly negligent and it took the deaths of 346 people in France to get them to take action to fix the DC-10. Another 350 or so have died on the MAX and finally the FAA is doing something. Is 350 the magic number?

As an old software engineer, one of the first things we learn is that you NEVER allow the people who have developed software to test and certify it. Perfect way to let defects get into the final product - and that's without being negligent or malicious. If FAA isn't sufficiently staffed to quickly certify planes, they should take longer.

The ugly fact is that the blood of 350 people are on the hands of whomever committed these build/certification errors. The non-union Boeing shops are already known for delivering inferior products with lots of mistakes - that culture has apparently spilled over into Seattle too.

Finally, California isn't dying...and we are 100% Democrat. Just sayin
baingm
This is an AVIATION WEBSITE. Can't we knock of the stupid political crap for a while.

[This poster has been suspended.]

bdjam
Your prejudiced comments about San Francisco and Los Angeles are uncalled for.

Yeah, they grounded them. After everyone else did and people started cancelling their flights.

[This poster has been suspended.]

bdjam
There are issues with people living on the streets everywhere in this country. The non-democrats in the federal government have consistently voted against funding veterans' agencies and so many of those people living on the streets are people who have served our country. I never said we were perfect - I said we weren't dying. And we won't be - we will address the problems we have. Conservatives need to rejoin the human race and realize that the conditions they love to ridicule are only not being experienced by them through luck.

Now if you don't mind, I was interested in the 737 MAX discussion and you're a distraction.
waterfall925
+Taylor Beck the GOP ideologues in Congress were very busy during the Obama years as well. Which administration 737 MAX8 was approved under begs the question of the fuedalistic cutting of the FAA budget to the point that FAA oversight could not effectively function. The same fact is true for the companies that construct American warships...self-inspection, cost overruns, and not-finished ships putting out to sea. The salient fact is that the GOP IDEOLOGY DOES NOT work for the society as a whole.

[This poster has been suspended.]

waterfall925
Bad analogy, because the auto is not a mass transportation vehicle. I'm no Democrat. The Republican failure has been a consistent failure to support either national planning or a strong central government. The Democrats are just identity group vote bait.
afcjr1201
William THIS IS NOT THE RIGHT FORUM FOR YOU TO DEGRADE ANY LEGISLATED BODY. TAKE YOUR VIEWS AND HATE SPEECH TO THE CORRECT SOURCE, THIS IS AM AVIATION SITE NOT A POLITICAL FORUM.
waterfall925
it's not hate speech. People wonder why the FAA lpermitted Boeing to largely self-certify the 737 MAX 8, and the answer is they didn't have enough inspectors. Why not? Because the GOP=led Congresses have consistently cut their budget. So sometimes it DOES go back to the legislative process. But I still think the 737 MAX 8 is basically a safe airplane.
RECOR10
RECOR10 2
It is never a good idea to display your own ignorance in a public forum. Even when you are anonymous.
afcjr1201
same stupid mistake William you again brought in the GOP so.....

[This poster has been suspended.]

waterfall925
Afraid not. An automobile is inherently more safe than an airplane because it operates in only 2 dimensions, and it transports fewer people per unit than an airplane. For sure the average auto driver is not as competent in operating the vehicle as is an airplane pilot in operating an airplane.However, the airplane operates in 3 dimensions, is more complex in its operation, and transports more people per unit. Therefore we as a society have decided that we want a certification process for airplanes that is more rigorous than the relatively simple standards for auto tires, horns, brakes, etc. FAA inspectors do not oversee the construction of an airplane; they rather pass on airworthiness standards of parts and syatem designs, and then ultimately whether or not the entire airplane meets certification criteria. However, along the way Boeing was allowed to self-certify much of the design and materials testing because the FAA just didn't have enough inspectors. Is that just as safe? Maybe, but maybe not.
baingm
Bullshit.
RECOR10
RECOR10 -1
Your right. Land mines and snipers would be far more cost effective.
waterfall925
ha,ha...well we do need some sort of a virtual wall
waterfall925
i'm in El Paso, and the Wall is NOT needed
RECOR10
RECOR10 -4
I am not in ElPaso,,,a wall is BADLY needed. Maybe true patriots in El Paso should be part of the solution, not complacent fools. I am a fan of landmines and snipers (and no warnings) over a wall however.
waterfall925
Whatever. Now, getting back to the 737 MAX 8, it appears that the publicity damage is done, and it's the next DC-10. it's sad, because the airp[lane had a lot of promise.
waterfall925
MCAS is new technology, and so Boeing should have restricted initial sales of the 737 MAX 8 and 9 to U.S. carriers with seasoned pilots, and extensive expertise on the 737 airframe. When the sensor failed, or inappropriate activation of MCAS occurred , these pilots and maintenance crews in the U.S. knew wehat to do. Develop fixes and upgrade software. THEN Boeing could have sold the airplanes to foreign flag carriers who are procedure-thin and are only oriented to operating airplanes according to normal operating checklists.

[This poster has been suspended.]

waterfall925
mcas is a new system within the b737 family, but you're right, the same concept has been around on the airbus and fbw
mbrews
mbrews -3
On two tragic occasions, 737 MAX MCAS scheme has acted as MECHANISM to CRASH AIRCRAFT SUDDENLY
jaxonboy
Sorry for the loss of passengers and crew. The immediate cause of the crash is the failure of the port attitude sensor. I believe boeing is going to make standard the software utilization of both port and starboard attitude sensors. If they deviate, the MCAS will disengage.
cyberbiker
It is a shame financial liability issues delay release of preliminary info from the voice recorder of Ethiopian Flight 302. It would be interesting to hear the dialog in light of yesterday’s announcement by the Ethiopiann Aviation Authority that the crew did everything right.
C79492001
Why don't they let pilots fly anymore? That is what they are trained to do. The equipment should be a backup, not the pilot in command. Spoken from a non pilot of anything but a car.
augerin
....man, this forum has become a joke...
flyerh
flyerh 1
How stupid to use the language you used. It only shows a lack of vocabulary. I concur with your sentiment but not the language.
jptq63
jptq63 1
Who / what company makes the MCAS sensor? And why (postulating from the Lion Air crash) would is seems this sensor is failing often (i.e. reported this sensor replace multiple time on a new aircraft)? If in error, please correct.
chalet
chalet 1
Did the stick shakers operate correctly on both of the doomed aicraft Lion Air and Ethiopian.
erisajd
erisajd 1
why would they? They got correct information - the airplanes were not near stall . . .
akebonolove
Can somebody pls answer this question? Why can you not just simply turn off MCAS? Or do some idiots here prefer to argue about LA/SF dems/reps?
baingm
STAB TRIM switches OFF!
gcottay
That would have been great but only if the pilots knew that MCAS could be the problem. Sim hours would have saved lives.
baingm
If the trim wheels are moving for no apparent reason, especially if they are turning in the direction to trim down, and the nose is going down it's an uncommanded / runaway trim issue. Manual trim is then available by manually turning the trim wheels. I'm not saying the MCAS isn't an issue but if the correct procedure is followed there wouldn't have been a catastrophe. The symptom was a trim problem regardless of what was causing it. The crew flying the airplane the previous flight did exactly that ....turned off the stab trim switches, trimmed manually and landed safely. There is obviously an issue with MCAS and the 737 MAX (should be multiple inputs to MCAS, not a single AOA input, but it need not be fatal is the proper procedures are applied.
skye12
No excuse for not having a complete and comprehensive flight manual. None.

And farming out certification responsibilities to the manufacturer? That's nuts.
rickg30
Auto pilot off, stab trim off. Problem solved. And put the 727 manual trim wheel back in the cockpit!
ssobol
737 has the same trim wheel system as the 727.

[This poster has been suspended.]

sgbelverta
When you're diving down toward the ground at 350+ mph from a low altitude, the thing that will save you is muscle memory. Forget a manual. Your hands just need to know what to do. Several runs in a simulator would have really helped
666adt
I've read that at least with regard to Ethiopian Airlines, their simulator wasn't equipped to simulate MCAS issues, AND, regardless, their pilot of the doomed flight hadn't trained on the MAX 8 simulator, anyway.
E1craZ4life
They'd need to know what those even are. I certainly don't.
Highflyer1950
Funny thing Ed, is that these trim cut out switches are on every model B737 and a runaway trim is a pilot memory item to this issue?
E1craZ4life
That seemed to be the case with XL Airways Flight 888T.
Highflyer1950
Well in that one, the Airbus A-320 was on a test flight and because the crew were denied airspace clearance to conduct their testing they decided to test the stall warning systems at an altitude of 3,000’ instead od 10,000’! Two of the three AOA sensors were faulty due to I believe water contamination prior to painting and they froze. This left the single functioning AOA system to correctly indicate a stall but the computer is designed to disregard a single input as erroneous. Bottom line is the crew failed to recognize an impending stall and initiate manual recovery but also started the whole at too low an altitude. Sorry for the lengthy post.
E1craZ4life
They might have recovered by adjusting the elevator trim, but that wasn't attempted before impact either because they forgot that was an option or didn't know that the inputs they did execute wouldn't be enough.
Highflyer1950
Which is why you never adjust the trim when below 1.3 VSo in any aircraft., plus you don’t forget how to recover from a stall. “Didn’t know” is an extremely poor excuse....remember they were on a “test” flight. Only an airline with limited understanding would hand over an aircraft out of maintenance requiring a test flight to an unqualifid crew. Proof is in their actions.
E1craZ4life
They were making efforts to recover from the stall, but in that case, they also needed to adjust the elevator trim in addition to sidestick forward and increased engine power in order to recover from the stall.
Highflyer1950
I’m still trying to figure out what you are saying here Ed? 1. The crew was attempting an approach to stall at too low an altitude in order to check the stall protections! 2. In the landing configuration the pitch trim is in Direct Law (no auto trim available). 3. If they trimmed below VSo ( not supposed to do that) then the aircraft stalled, with the elevator in the full up position. 4. Full nose down stick with the pilot using nose down pitch trim as well the crew could have recovered from the stall even with engines at idle if they had been at the proper altitude. They were not qualified to do a test flight.
perleyc
Sad is the word..these conversations. Never comment on these types of conversations, but there are a lot of snowflakes. Amazing how old are the snowflakes. Gotta find the reason for the failure, and the fix in politics. Is it the GOP, or is it MoveOn.org. Maybe Bernie, or AOC could get on top on this problem. GEEZ! I bet some here would slip out a fart, now realizing they’ve actually crapped their pants, find the cause external. Could it be GOP!!!!
chalet
chalet 0
Lets call a spade a spade. Boeing created a Frankenstein of an aircraft by placing an extremely good design up to the -500 series on a hard diet of steroids and top it all off they jumped extremely important design review and approval stages to get them out to customers. They are going to pay hell for their arrogance.
waterfall925
"Pull Trim fuse,Press autopilot disconnect " was the answer. MCAS not triple redundant. Lion at fault and Brit Reuters reporter can't spell "maneuver."
Highflyer1950
MCAS only operates when flying the aircraft manually, not on autopilot. No CB to pull, just turn off both Trim Cut-out switches located on centre pedestal.
waterfall925
+Highflyer1950 You're right, and thank you for correcting me. Also available was a brute force movement of the manual trim wheel while flying manually. Now I'm wondering 1) . Why the pilots didn't know what you know, and 2) . if engaging the autopilot was not an additional option, and 3)If there were too many distracting annunciators and alarms going off for the pilots to properly concentrate?
erisajd
erisajd 2
If you.have control system problems it is counter intuitive to engage the autopilot. Most pilots are taught to not use an autopilot with control system problems.
666adt
This account seems to say the opposite, that the MCAS system was operating during autopilot:

"After flaps 1 to "up" and above clean "MASI up speed" with LNAV engaged I looked at and engaged A Autopilot. As I was returning to my PFD (Primary Flight Display) PM (Pilot Monitoring) called "DESCENDING" followed by almost an immediate: "DONT SINK DONT SINK!"

I immediately disconnected AP (Autopilot) (it WAS engaged as we got full horn etc.) and resumed climb."

From https://www.theatlantic.com/notes/2019/03/heres-what-was-on-the-record-about-problems-with-the-737-max/584791/?fbclid=IwAR2RCoR2yi-KBU2VvKwxOeMt_BZCqseuC040RIXx0AcmHh2dym09Nnfx6cY

Or is that account talking about something else?
nasdisco
Chris B 8
Brit Reuters reporter spells it correctly according to the way they spell in the UK.
waterfall925
+Chris B yes, but the UK spells a number of words incorrectly. For example, they spell "U.S." as "US," and they also drive on the wrong side of the road. Of course, I'm just poking a bit of fun at them. It is their language, after all, and I'm sure they could point to any number of assaults we Yanks perpetrate on the English language. Now if the UK would only drive on the right side of the road....
VivPike
Viv Pike 0
The Brits DO drive on the right side of the road. It is you Americans who drive on the WRONG side of the road.
666adt
Driving on the right, not left, side of the road is the much more common practice around the world.
rhirsch
I do believe that Boeing has lost its way. And I blame it entirely on management. The culture from the top has poisoned the culture from build a better mousetrap to build it as fast as you can for a cheap as you can and we'll fix it in the field. I can think of at least 2 other big projects that are in trouble and they are the, KC-46A PEGASUS and CST-100 STARLINER. Lastly the companies greed in trying to block the Bombardier CS100 is now the A220-100, while the CS300 has been renamed the A220-300 claiming it would hurt their 737 salce, Ha look who is hurting 737 sales.

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