Atlas Air 3591 NTSB Public Docket Opened

[Airbubba]

Docket opened for the February 2019 IAH B767 freighter crash.

NTSB News Release
National Transportation Safety Board Office of Public AffairsNTSB Opens Public Docket for Investigation of Atlas Air Flight 3591 Cargo Plane Crash12/19/2019WASHINGTON (Dec. 19, 2019) — The National Transportation Safety Board (https://www.ntsb.gov/Pages/default.aspx)opened the public docket Thursday as part of its ongoing investigation of the Feb. 23, 2019, Atlas Air flight 3591 crash into Trinity Bay, Texas.

The accident occurred when a Boeing 767-300 Atlas Air cargo jet entered a rapid descent from 6,200 feet and impacted a marshy bay area about 40 miles from Houston’s George Bush Intercontinental Airport. The two pilots and one non-revenue jumpseat pilot were fatally injured. The airplane was destroyed. The airplane was carrying cargo from Miami to Houston for Amazon.com Inc., and the US Postal Service.https://www.ntsb.gov/news/press-releases/PublishingImages/NR20191219-img.jpg (Graphic depiction of the descent of Atlas Air flight 3591 and the communication between air traffic control and the aircraft pilots on Feb. 23, 2019. NTSB Graphic)Graphic depiction of the descent of Atlas Air flight 3591 and the communication between air traffic control and the aircraft pilots on Feb. 23, 2019. NTSB Graphic)

The docket (https://u7061146.ct.sendgrid.net/wf/click?upn=G62jSYfZdO-2F12d8lSllQB4sEPPiTnAuGGPQQ7g2uqiQ-3D_0Wg9Nh1n4pGFtplDTkv8PtnY1rChQHh6guRbd111Ehukhxa-2B4y2qgQ76oS85hQZleB-2BOdZHoCjMlWAGTZUTa6BeDE7juUiaGexOxaHjQeW5P5q9DkXbaTc5F7-2FixUo9CoBY42OSpwbyuDmNPKJEijFzKBB84elxoyNZbStlyjNDyBAwRRuSM fVne497hqaGg5I51qeIU-2BRFv0KJyXvOQD3PPh32aN6uUIH9POYKTraPMW63-2B3HC05WLA9T0xiShHVP-2Bp0mQ7cfCdOipJhBYJ6S2EprkYh9ufOym2BDElhtHXeRX8FPHi-2FnNud-2B7oZ9H63BkLODnUWLuqgJRXX4427W1c5ziDbCxRcj6A7jsd3io-3D) includes more than 3,000 pages of factual reports that cover various aspects of the investigation, including operations, survival factors, human performance, air traffic control, aircraft performance, and includes the cockpit voice recorder transcript, sound spectrum study, and the flight data recorder information. The docket also includes interview transcripts, photographs, and other investigative materials.

The docket (https://u7061146.ct.sendgrid.net/wf/click?upn=G62jSYfZdO-2F12d8lSllQB4sEPPiTnAuGGPQQ7g2uqiQ-3D_0Wg9Nh1n4pGFtplDTkv8PtnY1rChQHh6guRbd111Ehukhxa-2B4y2qgQ76oS85hQZleB-2BOdZHoCjMlWAGTZUTa6BeDE7juUiaGexOxaHjQeW5P5q9DkXbaTc5F7-2FixUo9CoBY42OSpwbyuDmNPKJEijFzKBB84elxoyNZbStlyjNDyBAwRRuSM fVne497hqaGgmNZBinP-2F3KdPiID5D9ijiMhqDBq5Z73-2FHTbmWr08sEXhMfdbypc-2BsQPyflK6NY98yOlS1WGg4B5YiPMGB0gBw30jga5LldtVurn9aPlAi8oMb2 iTZbqmdOhj9zmrssWlNLmDOnqgadGjBx1cWK9oyfUURTRWEv3E7v02uDU4ok A-3D) contains only factual information collected by NTSB investigators; it does not provide the final report, analysis, findings, recommendations, or probable cause determinations. No conclusions about how or why the crash occurred should be drawn from the information within the docket. Analysis, findings, recommendations, and probable cause determinations related to the crash will be issued by the NTSB in a final report at a later date.

The public docket for this investigation is available online at: https://go.usa.gov/xp7gH (https://go.usa.gov/xp7gH)

Additional material may be added to the docket (https://u7061146.ct.sendgrid.net/wf/click?upn=G62jSYfZdO-2F12d8lSllQB4sEPPiTnAuGGPQQ7g2uqiQ-3D_0Wg9Nh1n4pGFtplDTkv8PtnY1rChQHh6guRbd111Ehukhxa-2B4y2qgQ76oS85hQZleB-2BOdZHoCjMlWAGTZUTa6BeDE7juUiaGexOxaHjQeW5P5q9DkXbaTc5F7-2FixUo9CoBY42OSpwbyuDmNPKJEijFzKBB84elxoyNZbStlyjNDyBAwRRuSM fVne497hqaGgFo6nVjf-2BDMRb5Mw-2BBp4JOoT35i2uMHfb8-2F399rn5NLuKHjpf4ZpDy0N56JUbMutGN2HSXidAxddNtaK15u-2F9EtMI9qROglGqmJ0WQkXd-2F5goNkojM2HD8vOaJSN46RCFbh6QmaKfmmnE31BMWR1dT5AieWwpcx4Zsmv JviU5nzo-3D) as it becomes available.


The link on the Commodore 64 server is a little slow to open right now. I've attached the CVR Report to this post.

[Paul852]

The link on the Commodore 64 server is a little slow to open right now. I've attached the CVR Report to this post.Showing your age a bit there! But thanks for the attachment.

Oh, and on a quick first skim-read, the authors might need to look up the difference between "silicon" and "silicone".

[Airbubba]

Information in the docket indicates that the FO had a history of multiple training failures and busted checkrides at Atlas, Mesa and Trans States and that he flunked out of initial training at Air Wisconsin and CommutAir. Some of these failures showed up in the PRIA (Pilot Records Improvement Act) report ordered for the Atlas job application but were not passed to the Atlas Director of Training before he did the job interview.

As I've observed in earlier threads, poor training performance and awful past employment history seem to be common findings in these freighter mishaps.

In several of these widebody freighter mishaps a crewmember with a very unsatisfactory employment and training history is revealed in the investigation.

In the 1995 FedEx 705 hijack attempt Auburn Calloway was unable to check out as aircraft commander in the Navy and had been fired by American and Flying Tigers before he was hired at FedEx.

RS, the copilot in the 2003 FedEx 647 MEM MD-10 crash had her ticket pulled a couple of times prior to the mishap due to training deficiencies. She also had other employment challenges including DUI's.

CB, captain on the 2013 UPS 1354 crash at BHM had been let go by TWA prior to his 1990 hiring by UPS. He had a history of repeated training failures including open book homestudy exams but was eventually able to upgrade to captain in 2009.

On a perhaps related note, freighters continue to crash at a much higher rate than pax aircraft at U.S. carriers. Is this due to less oversight? Or lower standards and a more challenging operating environment?

Will Atlas 3591 turn out to be yet another widebody freighter loss due to 'human factors'? Is a higher accident rate acceptable for cargo planes since the crashes cause 'no significant loss of life'?

In past years much of the discussion here was focused on the string of mishaps and hull losses at FedEx. As I posted in 2006:Quote:Originally Posted by Airbubba https://www.pprune.org/images/buttons/viewpost.gif (https://www.pprune.org/rumours-news/236665-fedex-off-runway-mem-post2746987.html#post2746987) (February 2006) >>by now FED EX must have one of the worst hull loss records in the industry!

Sadly, FedEx seems to have a widebody hull loss every two or three years. If they were a pax carrier there would be enormous adverse publicity and probably many casualties as well.

I've got friends over at FedEx who tell me the FAA has been all over their training for years now. Instead of annual AQP sim checks like most U.S. carriers, they are under a closely monitored old style six month program.

The pilot flying in the December 2003 MD-10 hard landing and fire at MEM had a history of busted checkrides before she was hired. In April, 1994 the feds pulled her ATP after an FAA inspector observed her performance. She took more training and got the ATP back and was hired by FedEx in 1996. At FedEx she had more checkride failures, a couple of DUI's and an altitude bust that set up the fateful Mad Dog line check back into MEM. Is it possible that "diversity" was promoted over performance in this case? A possibly similar precedent at FedEx was the overlooked poor employment history of Auburn Calloway who brutally attempted to hijack a FedEx DC-10 in MEM in 1994.

Traditionally, FedEx has had very high employment standards for the freight world, i.e. almost all pilots have college degrees (well, there are some Naval Academy graduates <g>) and many are like the founder, Fred Smith, ex-military aviators [I was later corrected on this point, FS was a Marine officer but not an aviator - Airbubba]. The company is consistently profitable and maintenance is excellent by most accounts.

Still, the mishaps and hull losses continue at what everyone agrees is an unacceptable rate...

[tdracer]

Will Atlas 3591 turn out to be yet another widebody freighter loss due to 'human factors'? Is a higher accident rate acceptable for cargo planes since the crashes cause 'no significant loss of life'?

Unfortunately, the first part is probably true, the second part is definitely true. The regulators have made a conscious decision to allow freight operators more risk - it's encoded in the regulations (and the FAA isn't alone here, EASA has similar differences). One blatant example is the rules for extended diversion time operations. The extended diversion time rules have been applied to passenger aircraft with more than two engines, while freight aircraft with more than two engines are specifically exempted.

[aa777888]

Reading the transcript of the CVR, and looking at the synopsis of the FDR data, is it ridiculous to consider that this might have been an intentional act?

[Check Airman]

Reading the transcript of the CVR, and looking at the synopsis of the FDR data, is it ridiculous to consider that this might have been an intentional act?

yes

10 characters

[aa777888]

Why do you think it is ridiculous?

[AviatorDave]

Reading the transcript of the CVR, and looking at the synopsis of the FDR data, is it ridiculous to consider that this might have been an intentional act?

What makes you consider this? To me, the transcript reveals startled pilots, completely caught by surprise and out of the loop until realizing the inevitable outcome.

[Check Airman]

Why do you think it is ridiculous?

What part of any of this would suggest a deliberate act?

[Mr Optimistic]

(pax) similarities with flydubai.

[Fogliner]

What part of any of this would suggest a deliberate act?
Last comments similar to other crashes proven to be intentional?

Eerily similar to Al-Batouti's while taking the plunge.

No doubt that aspect will be fully investigated.

Also non pertinent conversation has probably been redacted in the version released to the public.

fog

[Check Airman]

Last comments similar to other crashes proven to be intentional?

Eerily similar to Al-Batouti's while taking the plunge.

No doubt that aspect will be fully investigated.

Also non pertinent conversation has probably been redacted in the version released to the public.

fog

I read his last comments to be the utterances of a religious man that proved to be ineffective.

The report doesn’t mention anything about redaction. The only omissions are the standard ones made, presumably to edit out expletives.

[BFSGrad]

The "Records of Conversation" is an illuminating read.

[lomapaseo]

redacted material is often of conversations that are personal in nature and have no bearing on the operation of the aircraft other than the time it takes to say them. If there are any other reasons for redaction it is typical for the group to provide the reason.

Anything obviously significant would have ;leaked out by now anyway so give up on the conspiracies along these lines

[Check Airman]

redacted material is often of conversations that are personal in nature and have no bearing on the operation of the aircraft other than the time it takes to say them. If there are any other reasons for redaction it is typical for the group to provide the reason.

Anything obviously significant would have ;leaked out by now anyway so give up on the conspiracies along these lines

Thank you. I’m not sure where the tin foil hat brigade was trying to go.

[pattern_is_full]

Thank you. I’m not sure where the tin foil hat brigade was trying to go.

Misunderstanding of cultures, perhaps. I read the final recorded comments as a religious reaction to a horrible situation - "Oh, God, we're gonna die!" Not as an expression of religious intent.

On the whole, American Christians tend to view suicide as one of the worst sins, and never a passport into Heaven.

[Check Airman]

Well it’s certainly difficult to tell how any of us would react when we see that death is imminent. I’d like to think that I’d be fighting to the very end.

[Airbubba]

From the Airplane Performance Study in the docket:

Figure 3 highlights the descent during the last two minutes of the flight with select paraphrased CVR comments overlaid. The descent appears normal until about 1238:31 and approximately 6,300 ft pressure altitude when the go-around mode was activated using one of the Go-around (G/A) buttons on the throttle quadrant: see Figure 4. There was no mention of initiating a goaround by the flight crew on the cockpit voice recorder (CVR), and flight 3591 had been cleared to descend to 3,000 ft. (The normal load factor, an, in Figure 6 shows that the airplane encountered turbulence at approximately 1238:25, six seconds before the recorded flight mode transitioned to G/A. The turbulence was likely associated with the cold front mentioned earlier and included instrument meteorological conditions or IMC.)

The airplane Euler angles recorded on the FDR are shown in Figure 5. The airplane pitch attitude increased from about -1˚ airplane-nose-down (AND) before G/A was annunciated to approximately 4˚ airplane-nose-up (ANU) six seconds later at 1238:37. The airplane then pitched AND to about -49˚ over the next 18 seconds in response to an AND elevator input.

At 1238:48 and 1238:51, the pilot flying (the first officer in the right seat) made comments about the airplane stalling that were recorded on the CVR. However, Figure 6 shows the recorded airplane wing angle-of-attack and airspeed were below -15˚ and above 250 kt, respectively. This is well below the airplane’s wing stall angle-of-attack.

Figure 7 shows an elevator split between the left and right sides of the airplane: the left elevator is associated with the captain in the left seat, and the right elevator is associated with the first officer in the right seat. The elevator deflections are similar until about 1238:46. At that time, the first officer is heard asking a question about airspeed on the CVR, and the elevators begin to split: the captain begins to pull from 2˚ to 8˚ more ANU elevator than the first officer. The split continues until about 1238:56, about one second after the airplane would have broken out of the reported 3,500 ft cloud layer. Both the captain and the first officer subsequently commanded ANU elevator until impact. (The normal load factor recorded by the FDR in Figure 6 is greater than 4g right before impact.)



https://cimg4.ibsrv.net/gimg/pprune.org-vbulletin/1707x1158/figure_3_edit_7aaa5352c3a219276f234dfae03cf87ed302c6b9.jpg
It now appears that the 'leaked' info from months ago posted on earlier threads ago was from good sources.

Another perfectly good airplane flown into the ground/water due to 'human factors'? :ugh:

Subject: Houston Amazon 767 Crash 23 Feb 19

From the net, courtesy of a reliable source.… [i.e. Now, this is no s**t... - Airbubba]

Just FYI… we’ve heard the full cockpit audio and seen the data. Here’s... what really happened (name redacted to protect the innocent!):

During the approach, at about 6,000 FT (being flown by the first officer), the Captain reached around the throttle quadrant to extend the flaps to the next position after being called to do so by the first officer (pilot flying)… very normal.

In many aircraft including the 767, that’s a very odd/difficult repositioning of your hand (from the left seat, all the way around to the right side of the center console), and requires intimate familiarity and slow deliberate motion to do successfully.

Well in any case, it was not done so this time. The captain accidently hit the “go around” switch while bringing his hand around for the flaps, which brought both engines up to full power. In the landing configuration, as this aircraft was transitioning into, that obviously causes a vast increase in lift… and the first officer (pilot flying) used everything he had to force the nose back down.
Still not sure why that occurred, as the crew should have just “gone around” and tried it again when properly configured… but they did not. And that started in motion a chain of events that lead to tragedy.

As the First Officer over-rotated downward, again with the engines at full power, the aircraft quickly accelerated and approached something we’re all trained to handle (at least in good training environments)… an “upset recovery”, countered by NON-AUTOMATION and basic “stick and rudder skills”.

This captain however, in turn, grabbed the controls without using positive command (“I’ve got”, “My aircraft”, or anything normally done), and countered the F/O’s control input by completely hauling his control column full aft… remember, while the F/O is pushing full forward.

In the process of doing that, he broke the “shear pin” on his control column (a device/mechanical safety interlock used to separate a control column from the “innards” of the control architecture in the event one control column is doing something it should not)… and that occurred here.

The captain, a few seconds later, now accelerating downward out of the control envelope of the 767 (remember, all of this started at 6000 FT and probably took less time to get to the fatal point than it did to read this far), recognizes the has no control column and then asks the F/O to pull up, get the nose up, or something to that affect. It isn’t 100% clear what he says.
The F/O then tries to pull aft on his column (going from full forward to full aft), but isn’t getting the response he needs, because the aircraft is out of the envelope of controllability and the controls are “air-loaded” in position.

At about 2000 FT, eventually the trim motors are able to start overcoming the air-load, and the aircraft begins to attempt to arrest its rate of descent… but alas it’s far too little, far too late, and the aircraft impacts about 30-40 degrees nose down, with what is believed to be about 4-5000 FT / minute rate of descent.

All during this time the throttles aren’t touched until somewhere during that last few seconds of flight… which is believed to be what enabled the trim motors to start working. Unclear who does it, and no audio indicates who it was.

Just FYI… we’ve attempted in our 767 simulators to recover from the event with the exact same setup, and thus far we’ve only had success when starting at 8000’ or higher… meaning we are fully established in the “out of control” position at 8000’, recognize it by then, and initiate recovery starting at 8000’.

These guys started the whole thing at 6000’ and were much lower when a true recovery attempt was initiated. No chance, and just shows you how quickly you can get “out of the envelope” when you don’t follow procedure, try some completely erroneous recovery technique, and don’t have a clue what you’re doing.

So many things went wrong with crew coordination, basic flying skills, aircraft envelope awareness, basic procedures, and such… that this will likely go down as one of the absolute worst “pilot error” events ever.

It needs to have serious impact throughout the Amazon flying circus (and associated partnerships), and show people that Jeff Bezos’ attempt to push the envelope at lower cost, all things else be damned, doesn’t apply to aviation.

This accident no doubt was absolutely horrible, and three people lost their lives…one of them (the jumpseater) through absolutely no fault of his own. But making an approach into Houston, TX, it could have been so much worse. In another few miles, they would have been over major population centers and who knows what would have happened then.

Know your aircraft. Know your procedures. And for God sakes, just FLY! It’s not a video game!

Relayed by your PJP Editor
Bert Botta
Aviation Writer
PJPFBO Editor
Email: bert@privatejetpilots

The “thump” was the Jumpseater bouncing off the ceiling. The FO had a history of doing this. He was terminated from a previous airline according to a very reliable source. HR is in charge of all pilot hiring at atlas. They hit -4 g’s.

this from the boxes folks, heard the same thing from my insider connection, jumpseater thrown from under his unfastened belt, Captain sheared the control breakaway pulling so hard to override the FO who had his column forward, it is thought as flaps were called for, somehow the Capt inadvertently hit the TOGA levers, which then caused TOGA to activate when flaps "1" were selected, the pitch and startle factor caused the FO to aggressively move his controls nose down, with the captain fighting him to no avail, when the aircraft came clear of the clouds then the FO made some exclamation and began to pull back on the controls, but apparently not aggressively enough , I was not privy to the actual conversation on the CVR, this account was heavily redacted, might be a bit before all the story is heard, the word I heard used to describe it was "shocking"

my source dried up, refuses to talk about it...NOT an airplane issue is all thats being said

[UltraFan]

What is a "public docket"?

[Airbubba]

What is a "public docket"?

It's the records, interviews, CVR and FDR analyses and other documentation of evidence collected in an NTSB accident investigation.

From the media release in the first post on this thread:

The docket (https://u7061146.ct.sendgrid.net/wf/click?upn=G62jSYfZdO-2F12d8lSllQB4sEPPiTnAuGGPQQ7g2uqiQ-3D_0Wg9Nh1n4pGFtplDTkv8PtnY1rChQHh6guRbd111Ehukhxa-2B4y2qgQ76oS85hQZleB-2BOdZHoCjMlWAGTZUTa6BeDE7juUiaGexOxaHjQeW5P5q9DkXbaTc5F7-2FixUo9CoBY42OSpwbyuDmNPKJEijFzKBB84elxoyNZbStlyjNDyBAwRRuSM fVne497hqaGg5I51qeIU-2BRFv0KJyXvOQD3PPh32aN6uUIH9POYKTraPMW63-2B3HC05WLA9T0xiShHVP-2Bp0mQ7cfCdOipJhBYJ6S2EprkYh9ufOym2BDElhtHXeRX8FPHi-2FnNud-2B7oZ9H63BkLODnUWLuqgJRXX4427W1c5ziDbCxRcj6A7jsd3io-3D) includes more than 3,000 pages of factual reports that cover various aspects of the investigation, including operations, survival factors, human performance, air traffic control, aircraft performance, and includes the cockpit voice recorder transcript, sound spectrum study, and the flight data recorder information. The docket also includes interview transcripts, photographs, and other investigative materials.

The docket (https://u7061146.ct.sendgrid.net/wf/click?upn=G62jSYfZdO-2F12d8lSllQB4sEPPiTnAuGGPQQ7g2uqiQ-3D_0Wg9Nh1n4pGFtplDTkv8PtnY1rChQHh6guRbd111Ehukhxa-2B4y2qgQ76oS85hQZleB-2BOdZHoCjMlWAGTZUTa6BeDE7juUiaGexOxaHjQeW5P5q9DkXbaTc5F7-2FixUo9CoBY42OSpwbyuDmNPKJEijFzKBB84elxoyNZbStlyjNDyBAwRRuSM fVne497hqaGgmNZBinP-2F3KdPiID5D9ijiMhqDBq5Z73-2FHTbmWr08sEXhMfdbypc-2BsQPyflK6NY98yOlS1WGg4B5YiPMGB0gBw30jga5LldtVurn9aPlAi8oMb2 iTZbqmdOhj9zmrssWlNLmDOnqgadGjBx1cWK9oyfUURTRWEv3E7v02uDU4ok A-3D) contains only factual information collected by NTSB investigators; it does not provide the final report, analysis, findings, recommendations, or probable cause determinations. No conclusions about how or why the crash occurred should be drawn from the information within the docket. Analysis, findings, recommendations, and probable cause determinations related to the crash will be issued by the NTSB in a final report at a later date.

[Beamr]

Wow, things went from perfect day to total loss in just 32 seconds :sad:
If I interpret this correctly (and add the Bert Botta quote to the equation), the captain realized what just happened but he couldn't do anything about it (no comms -> shear pin -> no control), and by the time FO got the hang of it, it was inevitably too late.
Actually: based on Bert Botta quote above, there was nothing they could've done anyway at the point captain grabbed the controls, due to lack of altitude.

[StudentPilot479]

Just a GA pilot here, but if the two yokes were going opposite ways, why does the captains yoke shear pin break and why not the shear pin on the first officer's yoke? Would it not make sense to assume that the captain is most likely more experienced and more apt to be making the proper (or desired) inputs over the first officer (except when training)?

Just as in this case, if the first officer makes an incorrect control movement that requires opposite correction by the captain, would it not make more sense for the system to lock out the first officer's yoke and leave control with the captain?

[AviatorDave]

Just a GA pilot here, but if the two yokes were going opposite ways, why does the captains yoke shear pin break and why not the shear pin on the first officer's yoke? Would it not make sense to assume that the captain is most likely more experienced and more apt to be making the proper (or desired) inputs over the first officer (except when training)?

Just as in this case, if the first officer makes an incorrect control movement that requires opposite correction by the captain, would it not make more sense for the system to lock out the first officer's yoke and leave control with the captain?

No, because the Captain is not always right, and on more than one occasion it was the FO who saved the day. Just imagine an incapacitation of the Captain. Reflecting a command gradient in the controllability of an airplane could easily do more harm than good.

[Check Airman]

To add to that, the Captain is not always more experienced (although, it is a general rule of thumb). In addition, the failure may be on the captain’s side.

Also, occasionally the PIC will be in the right seat.

[AviatorDave]

Given all that information now, and the fact that the FO had poor training records and washouts at Atlas and also with previous employers, what exactly is the point of the FO‘s family suing Amazon?

There seems to be no indication of any aircraft malfunction, caused by negligence and sloppy maintenance.

[dcoded]

Wait, why was GA mode activated?
And because of the acceleration perceived as a pitch up the FO pushed the nose down?
Why did the FO think the AC was stalling? Was this before or after the activation of GA?
confused here..

[Beamr]

Wait, why was GA mode activated? By accident apparently?
And because of the acceleration perceived as a pitch up the FO pushed the nose down? Apparently, yes
Why did the FO think the AC was stalling? Was this before or after the activation of GA? After, based on the combined timeline of CVR transcript and FDR data.

[Check Airman]

I’m also confused about the “stall” comment. The maximum pitch recorded after GA was annunciated was 5 deg ANU. His training records, and comments from prior trainers are interesting to read.

[bud leon]

Wow, things went from perfect day to total loss in just 32 seconds .

Actually I think things were not a perfect day for a while before the loss of control.

[Beamr]

Actually I think things were not a perfect day for a while before the loss of control.
Of course theres always room for debate on when the events started folding, I am looking at the moment of the unintentional GA command, 32 sec before impact.

[Jcb86]

STOP saying the yoke “shear pin” broke. For the love of god, the system doesn’t have a yoke shear pin, the system has shear rivets at the PCUs that power the elevator, and a force breakout mechanism between the two yokes. Nothing on this airplane broke. The entire control system worked how it was designed. There is a breakout mechanism between the two yokes, not a shear pin. It’s to mitigate a control jam. When a certain amount of opposite force is applied by fo or capt, you get an elevator split.

Additionally, only captains side column position is recorded on this bird. These older cargo planes only have to record 34 parameters. If you want to “see” what the fo was doing with his controls you would have to back it out from the amount of elevator split.

stop repeating this pilot rumor nonsense that a non existent shear pin broke and the jump seater hit the ceiling. None of this is in any of the factual reports released.

[Dogsofwar]

Just a GA pilot here, but if the two yokes were going opposite ways, why does the captains yoke shear pin break and why not the shear pin on the first officer's yoke? Would it not make sense to assume that the captain is most likely more experienced and more apt to be making the proper (or desired) inputs over the first officer (except when training)?

Just as in this case, if the first officer makes an incorrect control movement that requires opposite correction by the captain, would it not make more sense for the system to lock out the first officer's yoke and leave control with the captain?

when the shear pin breaks the control columns operate the elevators of there respective sides, so in this instance the FO’s elevator would have been deflected down whist the Capt who was pulling back would have deflected his upwards, once the fo realize what was actually happening he then was able to pull nose up on his!

[Airbubba]

Just a GA pilot here, but if the two yokes were going opposite ways, why does the captains yoke shear pin break and why not the shear pin on the first officer's yoke?

when the shear pin breaks the control columns operate the elevators of there respective sides, so in this instance the FO’s elevator would have been deflected down whist the Capt who was pulling back would have deflected his upwards, once the fo realize what was actually happening he then was able to pull nose up on his!


I don't believe there is any shear pin involved in a 767.

From my earlier post on a closed thread:

Here's a description of the B-763 control column operation with one side jammed from page 12 of the MS990 NTSB accident report:The captains and first officers control columns have authority to command full travel of the elevators under most flight conditions and normally work together as one system. However, the two sides of the system can be commanded independently because of override mechanisms at the control columns and aft quadrant. Therefore, if one side of the system becomes immobilized, control column inputs on the operational side can cause full travel of the nonfailed elevator. In addition, in many cases, control column inputs on the operational side can also result in nearly full travel of the elevator on the failed side through the override mechanisms. The elevator PCAs are installed with compressible links located between each bellcrank assembly and PCA input control rod to provide a means of isolating a jammed PCA, thus allowing the pilots to retain control of that elevator surface through its two remaining (unjammed) PCAs




https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/1199x878/b_763_elevator_a17404b1dbe94f111ae331c8c18341e43a641a02_eb0b f89184bd6b5160d603fdec41b16ef1d2590b.jpg

From the Performance Report in the recently released docket:

Figure 7 shows an elevator split between the left and right sides of the airplane: the left elevator is associated with the captain in the left seat, and the right elevator is associated with the first officer in the right seat. The elevator deflections are similar until about 1238:46. At that time, the first officer is heard asking a question about airspeed on the CVR, and the elevators begin to split: the captain begins to pull from 2˚ to 8˚ more ANU elevator than the first officer. The split continues until about 1238:56, about one second after the airplane would have broken out of the reported 3,500 ft cloud layer. Both the captain and the first officer subsequently commanded ANU elevator until impact. (The normal load factor recorded by the FDR in Figure 6 is greater than 4g right before impact.)

There was an earlier rumor of a -4g load factor on the pitchover, this was apparently a typo (or an exaggeration).

[Airbubba]

An article from Air Cargo News:

Atlas 767 crash: Go-around mode activated after mystery ‘click’

20 / 12 / 2019
By David Kaminski-Morrow - Flight Global

Investigators probing the fatal Atlas Air Boeing 767-300 freighter crash near Houston have been trying to ascertain whether a sound captured on the cockpit-voice recorder signifies the activation of the go-around switch immediately before the accident sequence.

The aircraft, which was flying on behalf of Amazon Air, suddenly entered a steep nose-down attitude and dived into Trinity Bay from around 6,000ft while preparing for an approach to Houston on February 23.

National Transportation Safety Board investigators have released detailed information on the cockpit-voice and flight-data recordings, as well as a spectral analysis of certain sounds in the cockpit.

Cockpit conversation indicates that the flight was progressing normally, with a call to start extending the flaps heard some 60s before the impact.

But just under 30s after this “flaps 1” call, and shortly after the jet encountered moderate turbulence, the recorder picks up the sound of a click, the origin of which has been of particular interest to the inquiry.

The time alignment of the click, it says, matched flight-data recorder information showing activation of the go-around mode.

Spectral analysis has been conducted to try to establish the likely source of the sound. Although the recording quality was poor, investigators have used filtering and detailed comparison with the double-click of a 767 go-around button being pushed and released to try to identify the noise.

The inquiry says the mysterious click on the cockpit recorder “shares a similar characteristic” to the go-around button activation, and that it “could potentially be associated” with the release portion of the double-click.

“However, it cannot be conclusively determined if it is the same sound due to the degraded quality of the [recording] at the time of the sound detection,” it stated.

Accompanying documentation, however, suggests the inquiry is convinced that a go-around switch on the throttle levers was triggered. The accident sequence developed rapidly afterwards.

Simultaneously with the click, the autoflight system entered go-around mode – which had been armed when the flaps were deployed – and the engine thrust began advancing to the go-around setting.

Flight-data recorder information shows the aircraft started pitching up and entered a shallow climb.

The 767’s control column moved to a forward deflection, with the pitch decreasing and the aircraft accelerating rapidly from 240kt.

Caution alarms began to sound, just 9s after the go-around mode engaged. The inquiry says the control column remained deflected forward for 10s and the aircraft transitioned from a shallow climb to a steep descent.

Five seconds after the alarm commenced, one of the pilots exclaimed, “Whoa”, and shortly afterwards, in an elevated voice: “Where’s my speed, my speed”. Three seconds later, a voice loudly declared: “We’re stalling.”

Flight-data recordings reveal that, during these remarks, the thrust levers were brought to idle for about 2s and then were advanced again to their previous power setting. The aircraft’s pitch rapidly declined and the jet experienced negative g-forces for nearly 11s.

Investigators have disclosed that the recording shows the right and left elevators were split – by 2° to 7° – for some 10s beginning around the point of the “we’re stalling” remark.

The aircraft continued to dive through 2,000ft altitude at which point the flight-data recorder showed the control column being moved full aft until the end of the recording.

Although pitch recovered from 50° nose-down to 16° nose-down, the dive could not be arrested in time and the aircraft struck the water at over 430kt. None of the three occupants survived.

Investigators have yet to draw conclusions over the circumstances and contributing factors to the accident.

Meanwhile, Atlas Air and Amazon.com Services are among the companies named in a lawsuit filed by the brother of one of the pilots, Elliott Aska, killed in the tragic B767 freighter accident earlier this year.


https://www.aircargonews.net/airlines/atlas-767-crash-go-around-mode-activated-after-mystery-click/

[Joejosh999]

With a sudden acceleration and small pitch up from TOGA, could that create illusion of a stall?

[wiggy]

With a sudden acceleration and small pitch up from TOGA, could that create illusion of a stall?

It might well lead to the sensation of a steep climb (cf. somatogravic illusion) but I don’t see how that sensation, in isolation, could lead a competent pilot to think the aircraft might be in a stall...

[Joejosh999]

Yeah. Also he was unsure of speed.

[Airbubba]

With a sudden acceleration and small pitch up from TOGA, could that create illusion of a stall?

Here's a discussion of a possible pitch illusion from the Airplane Performance Study posted above. I agree with wiggy, I'm not sure that would cause 'a competent pilot' to think the plane was in a stall. The Gulf Air 72 crash in Y2K sounds like a similar pitch over into the water after a sudden longitudinal acceleration as TOGA thrust was selected.


https://cimg4.ibsrv.net/gimg/pprune.org-vbulletin/1598x1085/disorientation_1_3db438894ea39df3adc7160a833584f1b76ab27e.jp g
https://cimg3.ibsrv.net/gimg/pprune.org-vbulletin/1520x1042/disorientation_2_4ff6b61f2a9d9e9df46c0ec5920bc9c5796f6e1e.jp g

[silverstrata]

Why did the FO think the AC was stalling? Was this before or after the activation of GA?
confused here..

Probably because he pushed zero or negative g. In the gliding world, they do a lot of training on the difference between zero g and a stall, but that is not always so in power flying. Zero g can be disorientating, if you have not felt it (and it cannot be simulated in a sim), and ab-initios can often react to zero g by pushing harder.

I liken this to AA587, where excessive rudder inputs were used, resulting in the vertical stabiliser tearing off. In a swept wing aircraft, an agg.ressive rudder input will result in a sharp roll, which could be mistaken for a stall and wing-drop. And the cure for a wing drp stall, is an agg,ressive opposite rudder input, which simply drops the other wing. And so you get a rudder-reversal, because of another misperception of a stall.

And AF447 is not dissimilar to these two incidents. And all caused by first officers, who seem to lack basic training in light aircraft.

It seems clear to me that ALL first officers should complete a two week gliding course, perhaps after their first year of commercial flying, where they can learn basic stick and rudder skills, and to correctly identify a stall and instinctively react to it. In the 21st century, we should not have first officers who...

Think that zero g at high speed is a stall.
Think that a wing drop at high speed is a stall.
Think that pulling 20 degrees of pitch at 35,000 ft is NOT a stall.

Silver

[Joejosh999]

Wasn’t 447 FO a glider pilot? Perhaps I mis-remember?...

[Check Airman]

Wasn’t 447 FO a glider pilot? Perhaps I mis-remember?...

That was the CA of the A320 that landed in the river.

[darkshadow]

Wow, the record of conversations is something else...

When asked about her comment in her notes about Conrad’s “lack of understanding of how unsafe he was,” she said he was making very frantic mistakes, lots and lots of mistakes, and did a lot of things wrong but did not recognize this was a problem. He thought he was a good pilot never had any problems and thought that he should be a captain. He could not evaluate himself and see that he did not have the right stuff.

...

When asked if the nature of his difficulty was lack of knowledge or skill, or just elevated
stress and anxiety, she said she thought it was mostly anxiety, but it was hard to say, and probably both. There were a few things that he did well, but they were things that he was expecting. Like for a single engine ILS he did good, but he also knew he was going to have to do that on pretty much every check in the simulator. For things he was unfamiliar with, it was a combination of the two (lack of knowledge or skill, or stress). When he did not know what to do, he became extremely anxious. She did not know if frantic was the right word, but he would start pushing a lot of buttons without thinking about what he was pushing, just to do something.

[Disso]

Long time lurker, first time poster, but this situation is just too frustrating to stay silent about.


It might well lead to the sensation of a steep climb (cf. somatogravic illusion) but I don’t see how that sensation, in isolation, could lead a competent pilot to think the aircraft might be in a stall...


The missing link that you're missing, and everyone else whom doesn't understand why the FO thought they were 'stalling,' is THIS:

SOMATOGRAVIC ILLUSION WHILE IN IMC.

The captain inadvertently hitting TOGA while they were IMC descending, causing an immediate and sudden pitch up and negative G while accelerating, imposed the Somatogravic Illusion effect upon the FO, whom suddenly got the erroneous perception that the aircraft was pitching up way past what it actually was. The hard sudden TOGA acceleration combined with IMC caused the FO to feel the aircraft was pitching up 30-40-50-60 degrees, and thus he freaked the hell out, and thought, in his degraded mental capacity state, that the aircraft *must* be stalling, if it was pitching up that much (subjectively in his mind). To him, 767, pitching up to the degree he FELT (erroneously subjectively) it was, would DEFINITELY must be stalling at that AOA state. This explains the max pitch down. Obviously, whether or not his reaction was reasonable, is a completely different point, because it was not.

There has been SEVERAL pilot error crashes lately that are DIRECTLY attributable to Somatogravic Illusion:
- FlyDubai 981
- Tatarstan Airlines 735
- Gulf Air 72
- Japanese F-35 pilot
- Countless more Military + Commercial + GA accidents/incidnets.

To the point of his unreasonable reaction to his perceived erroneous subjective assessment of high pitch, it is explained by this:

The FO, given his egregious history of abysmal flying capacity and ineptitude (which I will paste below), had a documented track record of overreacting in unreasonable, irrational ways to 'stalling' states of aircraft by pushing the nose forward past any remotely reasonable degree of 'recovery'. He was documented to freak the F out when startled in precisely THESE type of situations, as has been documented. He should have never been in the seat that fateful day, and didn't deserve to.

Clipped from another forum:

Training Incompetency and Failures

6/27/11 - Resigned from CommutAir for failing DHC-8 initial
8/13/12 - Resigned from Air Wisconsin for failing CRJ initial
4/22/14 - Failed EMB-145 Oral at Trans State Airlines
5/11/14 - Failed EMB-145 Type Rating at Trans States Airlines
5/17 - Failed EMB-175 Upgrade Attempt at Mesa Airlines
5/17 - Nearly failed FO Requal after failing upgrade attempt at Mesa Airlines
7/27/17 - Failed B-767 Oral at Atlas Air
8/1/17 - Unsat Judgement/Situational Awareness during FBS-1 at Atlas Air
8/5/17 - Failed DBS-5 at Atlas Air
8/11/17 - Almost Failed FFSI-1 at Atlas Air
8/31/17 - "Regression of Situational Awareness" during FFSI-3 at Atlas Air
9/22/17 - Failed B-767 Type Rating for "Very Low Situational Awareness", incomplete procedures, and exceeding limitations at Atlas Air


Past Training Notes (directly quoted from the NTSB Docket)

Air Wisconsin CRJ Initial Failure - "They were conducting the emergency procedure cabin altitude ... where they are at FL350 or so, and he gives the students a cabin altitude message requiring an emergency descent to 10,000 feet" ... "Conrad then goes to descend the simulator. He was not sure of Conrad's background, but instead of descending on the autopilot, Conrad disengaged the autopilot and abruptly pitched down well below horizon. They got stick shaker and overspeed alert together. He was not sure if it was an extreme nose down, but remembered that it was abrupt input on the controls"
Mesa Airlines ERJ-175 Upgrade Failure (Instructor 1) - "He had previously failed simulator lesson 2 with different instructor, and he had requested a different instructor. She was conducting his retraining for lesson 2. She said his performance was a "train wreck" and he performed very poorly in this lesson. In the briefing room he did well, and explained things well. However, in the simulator and something he wasn't expecting happened he got extremely flustered and could not respond appropriately to the situation." ... "When asked about her comment in her notes about Conrad's "lack of understanding of how unsafe he was," she said he was making very frantic mistakes, lots and lots of mistakes, and did a lot of things wrong but did not recognize this was a problem. He thought he was a good pilot never had any problems and thought he should be a captain. he could not evaluate himself and see that he did not have the right stuff."
Mesa Airlines ERJ-175 Upgrade Failure (Instructor 2) - "He first met Conrad Aska during a recurrent checking event in March 2016. That session went ok and nothing stood out. He did have some trouble with the stall series. The problems were with his attitude control, and he had a hard time getting the airplane back to level flight" ... "He said when Conrad would make a mistake in training he had an excuse for everything"


The quote that stands out the most to me in this second Mesa instructor interview is, "When asked if Conrad would get startled in the simulator, he said that during one stall recovery, Conrad pitched down about 40 degrees for recovery, then a pitch up about 20 degrees. His flight path was all over the place."

_____

Thus, massive take-aways from this incident thus far are:
- Somatogravic Illusion is a serious, fatal issue in aviation that needs to be taken seriously and reassessed, and new measures/training/tech needs to be implemented/considered/studied/introduced.
- The FO should NOT have been seated in that seat that fateful day, and Atlas should NOT have hired him, given his ABYSMAL history of sheer and utter ineptitude that was clearly documented.
- Atlas HR is at fault for hiring him given his abysmal past training history and ultimately needs to share a huge responsibility of negligence.
- ACMI training/hiring/qualification/etc needs to be looked at with increased scrutiny, once again
- This is a direct result of Amazon's push for profits over safety, and the repercussions this extends down through the entire process, endangering the lives of the pilots aboard the aircraft, and the world around the aircraft.
- Atlas also flies military charter pax, and it was just a stroke of dumb luck that this wasn't a flight of 250 soldiers that was flown directly into the ground into the center of the Houston city, causing hundreds of deaths, due to egregious sheer pilot error in response to Somatogravic Illusion while in IMC and poor hiring practices at Atlas HR and Amazon's push for maximizing profits.

[Euclideanplane]

Wasn’t 447 FO a glider pilot? Perhaps I mis-remember?...


2nd officer Pierre-Cedric Bonin definitely was a glider pilot. I am not sure about FO David Robert.
EDIT: Robert flew a Socata TB10 light, possibly no gliders.

[TowerDog]

. He thought he was a good pilot never had any problems and thought that he should be a captain. He could not evaluate himself and see that he did not have the right stuff.

Noticed the same thing about incompetent pilots: They have no idea they are useless and/or clueless.
Seen it in the simulator and in the aero plane. :yuk:

[RHSandLovingIt]

It would appear to be a textbox example of the Dunning-Kruger Effect (https://en.wikipedia.org/wiki/Dunning%E2%80%93Kruger_effect)...

[neville_nobody]

It would appear to be a textbox example of the Dunning-Kruger Effect (https://www.pprune.org/left=https://en.wikipedia.org/wiki/Dunning%E2%80%93Kruger_effect)...

More like HR not doing their job properly. The FO had so many fails he had no business being in an aeroplane. The guy failed at least 3 endorsements and a line check. If that isn't a red flag for HR then I don't know what is.

[stilton]

So no one knows the real reason yet then

[4runner]

He saw the red overspeed ribbon drop to 250 when flaps were extended to 1. Toga was pushed without realizing before the flaps deployed. When the slats extended, toga engaged and pitched up. He mistook the overspeed cues to be a stall cue.

[TowerDog]

He saw the red overspeed ribbon drop to 250 when flaps were extended to 1. Toga was pushed without realizing before the flaps deployed. When the slats extended, toga engaged and pitched up. He mistook the overspeed cues to be a stall cue.

TOGA in the 767 is pretty gentle, no need to panic and push the nose down 40 degrees with the throttles way up.

[Check Airman]

He saw the red overspeed ribbon drop to 250 when flaps were extended to 1. Toga was pushed without realizing before the flaps deployed. When the slats extended, toga engaged and pitched up. He mistook the overspeed cues to be a stall cue.

I’m not following this line of reasoning. Does the flap 1 position only extend the TE devices, and GA engage only when the slats extend?

The transcript made no mention of flaps 5.

[oceancrosser]

I’m not following this line of reasoning. Does the flap 1 position only extend the TE devices, and GA engage only when the slats extend?

The transcript made no mention of flaps 5.

Flaps 1 is LE devices only. GA arms when the flaps are selected.

[Check Airman]

Flaps 1 is LE devices only. GA arms when the flaps are selected.

That was my understanding. I can’t follow what 4Runner is trying to get to.

On a closer reading of the factual report, I noticed this on page 10.

About 16 seconds after the Captain told ATC “OK,” the FDR stopped recording data with the airplane descending at an airspeed of about 433.5 knots and the autopilot engaged.

So during the whole episode, with split elevators and all, the AP remained engaged? Was it the AP that commanded the pitch down to 50 degrees?

They had recently (apparently) resolved an instrument problem. Is there a scenario where the ADI would be indicating a nose up pitch (leading the FO to believe they were in a stall) and the AP would aggressively command a nose down pitch?

I didn’t see where the report mentions which autopilot was engaged. Could the engaged autopilot somehow have been getting bad info that was not captured by the FDR, or noticed by the crew after they addressed the instrument problem?

[hans brinker]

Probably because he pushed zero or negative g. In the gliding world, they do a lot of training on the difference between zero g and a stall, but that is not always so in power flying. Zero g can be disorientating, if you have not felt it (and it cannot be simulated in a sim), and ab-initios can often react to zero g by pushing harder.

I liken this to AA587, where excessive rudder inputs were used, resulting in the vertical stabiliser tearing off. In a swept wing aircraft, an agg.ressive rudder input will result in a sharp roll, which could be mistaken for a stall and wing-drop. And the cure for a wing drp stall, is an agg,ressive opposite rudder input, which simply drops the other wing. And so you get a rudder-reversal, because of another misperception of a stall.

And AF447 is not dissimilar to these two incidents. And all caused by first officers, who seem to lack basic training in light aircraft.

It seems clear to me that ALL first officers should complete a two week gliding course, perhaps after their first year of commercial flying, where they can learn basic stick and rudder skills, and to correctly identify a stall and instinctively react to it. In the 21st century, we should not have first officers who...

Think that zero g at high speed is a stall.
Think that a wing drop at high speed is a stall.
Think that pulling 20 degrees of pitch at 35,000 ft is NOT a stall.

Silver



Another thing we should not have:
Captains that think only FOs can make mistakes.

[wiggy]

I didn’t see where the report mentions which autopilot was engaged. Could the engaged autopilot somehow have been getting bad info that was not captured by the FDR, or noticed by the crew after they addressed the instrument problem?

Interesting point..I can't access the full docket at the moment, probably my "IT", but from the CVR transcript the last reference I can see to the autopilot appears to be at a handover of control at:

12:36:19.2

HOT-2 "LNAV VNAV center autopilot".

I can't see any subsequent comment such as "sound of autopilot being disengaged"/s"sound of autopilot disconnect warning..

[deltahotel]

tdracer

i don’t understand your comment on regulation being less safe for freight operations cf pax.

rgds

[MarkerInbound]

The Part 117 flight and duty time regulations put in place after the Colgan crash in 2009 were not applied to cargo operations due to a cost/benefit analysis. UPS basically said it was cheaper to have a crash once a decade killing two pilots than apply the proposed limits to their operations.

[Bleve]

Good explanation of Somatogarvic Illusion here:

Somatogravic Illusion (http://aviationknowledge.wikidot.com/aviation:somatogravic-illusion)

[bud leon]

Long time lurker, first time poster, but this situation is just too frustrating to stay silent about.



The missing link that you're missing, and everyone else whom doesn't understand why the FO thought they were 'stalling,' is THIS:

SOMATOGRAVIC ILLUSION WHILE IN IMC.

The captain inadvertently hitting TOGA while they were IMC descending, causing an immediate and sudden pitch up and negative G while accelerating, imposed the Somatogravic Illusion effect upon the FO, whom suddenly got the erroneous perception that the aircraft was pitching up way past what it actually was. The hard sudden TOGA acceleration combined with IMC caused the FO to feel the aircraft was pitching up 30-40-50-60 degrees, and thus he freaked the hell out, and thought, in his degraded mental capacity state, that the aircraft *must* be stalling, if it was pitching up that much (subjectively in his mind). To him, 767, pitching up to the degree he FELT (erroneously subjectively) it was, would DEFINITELY must be stalling at that AOA state. This explains the max pitch down. Obviously, whether or not his reaction was reasonable, is a completely different point, because it was not.

There has been SEVERAL pilot error crashes lately that are DIRECTLY attributable to Somatogravic Illusion:
- FlyDubai 981
- Tatarstan Airlines 735
- Gulf Air 72
- Japanese F-35 pilot
- Countless more Military + Commercial + GA accidents/incidnets.

To the point of his unreasonable reaction to his perceived erroneous subjective assessment of high pitch, it is explained by this:

The FO, given his egregious history of abysmal flying capacity and ineptitude (which I will paste below), had a documented track record of overreacting in unreasonable, irrational ways to 'stalling' states of aircraft by pushing the nose forward past any remotely reasonable degree of 'recovery'. He was documented to freak the F out when startled in precisely THESE type of situations, as has been documented. He should have never been in the seat that fateful day, and didn't deserve to.

Clipped from another forum:

Training Incompetency and Failures

6/27/11 - Resigned from CommutAir for failing DHC-8 initial
8/13/12 - Resigned from Air Wisconsin for failing CRJ initial
4/22/14 - Failed EMB-145 Oral at Trans State Airlines
5/11/14 - Failed EMB-145 Type Rating at Trans States Airlines
5/17 - Failed EMB-175 Upgrade Attempt at Mesa Airlines
5/17 - Nearly failed FO Requal after failing upgrade attempt at Mesa Airlines
7/27/17 - Failed B-767 Oral at Atlas Air
8/1/17 - Unsat Judgement/Situational Awareness during FBS-1 at Atlas Air
8/5/17 - Failed DBS-5 at Atlas Air
8/11/17 - Almost Failed FFSI-1 at Atlas Air
8/31/17 - "Regression of Situational Awareness" during FFSI-3 at Atlas Air
9/22/17 - Failed B-767 Type Rating for "Very Low Situational Awareness", incomplete procedures, and exceeding limitations at Atlas Air


Past Training Notes (directly quoted from the NTSB Docket)

Air Wisconsin CRJ Initial Failure - "They were conducting the emergency procedure cabin altitude ... where they are at FL350 or so, and he gives the students a cabin altitude message requiring an emergency descent to 10,000 feet" ... "Conrad then goes to descend the simulator. He was not sure of Conrad's background, but instead of descending on the autopilot, Conrad disengaged the autopilot and abruptly pitched down well below horizon. They got stick shaker and overspeed alert together. He was not sure if it was an extreme nose down, but remembered that it was abrupt input on the controls"
Mesa Airlines ERJ-175 Upgrade Failure (Instructor 1) - "He had previously failed simulator lesson 2 with different instructor, and he had requested a different instructor. She was conducting his retraining for lesson 2. She said his performance was a "train wreck" and he performed very poorly in this lesson. In the briefing room he did well, and explained things well. However, in the simulator and something he wasn't expecting happened he got extremely flustered and could not respond appropriately to the situation." ... "When asked about her comment in her notes about Conrad's "lack of understanding of how unsafe he was," she said he was making very frantic mistakes, lots and lots of mistakes, and did a lot of things wrong but did not recognize this was a problem. He thought he was a good pilot never had any problems and thought he should be a captain. he could not evaluate himself and see that he did not have the right stuff."
Mesa Airlines ERJ-175 Upgrade Failure (Instructor 2) - "He first met Conrad Aska during a recurrent checking event in March 2016. That session went ok and nothing stood out. He did have some trouble with the stall series. The problems were with his attitude control, and he had a hard time getting the airplane back to level flight" ... "He said when Conrad would make a mistake in training he had an excuse for everything"


The quote that stands out the most to me in this second Mesa instructor interview is, "When asked if Conrad would get startled in the simulator, he said that during one stall recovery, Conrad pitched down about 40 degrees for recovery, then a pitch up about 20 degrees. His flight path was all over the place."

_____

Thus, massive take-aways from this incident thus far are:
- Somatogravic Illusion is a serious, fatal issue in aviation that needs to be taken seriously and reassessed, and new measures/training/tech needs to be implemented/considered/studied/introduced.
- The FO should NOT have been seated in that seat that fateful day, and Atlas should NOT have hired him, given his ABYSMAL history of sheer and utter ineptitude that was clearly documented.
- Atlas HR is at fault for hiring him given his abysmal past training history and ultimately needs to share a huge responsibility of negligence.
- ACMI training/hiring/qualification/etc needs to be looked at with increased scrutiny, once again
- This is a direct result of Amazon's push for profits over safety, and the repercussions this extends down through the entire process, endangering the lives of the pilots aboard the aircraft, and the world around the aircraft.
- Atlas also flies military charter pax, and it was just a stroke of dumb luck that this wasn't a flight of 250 soldiers that was flown directly into the ground into the center of the Houston city, causing hundreds of deaths, due to egregious sheer pilot error in response to Somatogravic Illusion while in IMC and poor hiring practices at Atlas HR and Amazon's push for maximizing profits.

You should chill out a bit.

[172_driver]

The missing link that you're missing, and everyone else whom doesn't understand why the FO thought they were 'stalling,' is THIS:

SOMATOGRAVIC ILLUSION WHILE IN IMC.

Pilots are aware of this, part of the job.

The remedy is aptitude and training. The former seem to have been a problem here.

[deltahotel]

Markerinbound

​​​​Thanks. Didn’t know that FAA allowed different rules for freight and pax.

dh

[wiggy]

Disso..

Long time lurker, first time poster, but this situation is just too frustrating to stay silent about.

"Quote:
Originally Posted by wiggy https://www.pprune.org/images/buttons/viewpost.gif (https://www.pprune.org/rumours-news/628156-atlas-air-3591-ntsb-public-docket-opened-post10644394.html#post10644394)
It might well lead to the sensation of a steep climb (cf. somatogravic illusion) but I don’t see how that sensation, in isolation, could lead a competent pilot to think the aircraft might be in a stall..."

The missing link that you're missing, and everyone else whom doesn't understand why the FO thought they were 'stalling,' is THIS:

SOMATOGRAVIC ILLUSION WHILE IN IMC.


Well actually no, I hadn't missed "somatogravic illusion", I'd merely chosen not to type it in bold characters..

If a trained pilot perceives a nose high pitch attitude and immediately equates that/verbalises it as a stall then I am in violent agreement with 172 driver.

[noalign]

On the CVR transcript, HOT-2 appears to mention the EFI source source select switch as though he has selected alternate. I believe he now is looking at output from the center symbol generator. A minute and a half later he's speaking as though he no longer has airspeed, perhaps there is no drawn airspeed.

Shouldn't the source inputs for the center symbol generator be the same source inputs for the center autopilot? The autopilot that appears to have been engaged throughout the entire flight?

[derjodel]

when the shear pin breaks the control columns operate the elevators of there respective sides, so in this instance the FO’s elevator would have been deflected down whist the Capt who was pulling back would have deflected his upwards, once the fo realize what was actually happening he then was able to pull nose up on his!

what’s the reasoning for elevator split?? I don’t see how it could end in a positive outcome.

[Check Airman]

On the CVR transcript, HOT-2 appears to mention the EFI source source select switch as though he has selected alternate. I believe he now is looking at output from the center symbol generator. A minute and a half later he's speaking as though he no longer has airspeed, perhaps there is no drawn airspeed.

Shouldn't the source inputs for the center symbol generator be the same source inputs for the center autopilot? The autopilot that appears to have been engaged throughout the entire flight?

I was thinking along the same lines earlier. Interesting that the AP remained engaged as well.

[Airbubba]

More like HR not doing their job properly. The FO had so many fails he had no business being in an aeroplane. The guy failed at least 3 endorsements and a line check. If that isn't a red flag for HR then I don't know what is.

The FO, given his egregious history of abysmal flying capacity and ineptitude (which I will paste below), had a documented track record of overreacting in unreasonable, irrational ways to 'stalling' states of aircraft by pushing the nose forward past any remotely reasonable degree of 'recovery'. He was documented to freak the F out when startled in precisely THESE type of situations, as has been documented. He should have never been in the seat that fateful day, and didn't deserve to.

Clipped from another forum:

Training Incompetency and Failures

6/27/11 - Resigned from CommutAir for failing DHC-8 initial
8/13/12 - Resigned from Air Wisconsin for failing CRJ initial
4/22/14 - Failed EMB-145 Oral at Trans State Airlines
5/11/14 - Failed EMB-145 Type Rating at Trans States Airlines
5/17 - Failed EMB-175 Upgrade Attempt at Mesa Airlines
5/17 - Nearly failed FO Requal after failing upgrade attempt at Mesa Airlines
7/27/17 - Failed B-767 Oral at Atlas Air
8/1/17 - Unsat Judgement/Situational Awareness during FBS-1 at Atlas Air
8/5/17 - Failed DBS-5 at Atlas Air
8/11/17 - Almost Failed FFSI-1 at Atlas Air
8/31/17 - "Regression of Situational Awareness" during FFSI-3 at Atlas Air
9/22/17 - Failed B-767 Type Rating for "Very Low Situational Awareness", incomplete procedures, and exceeding limitations at Atlas Air


Past Training Notes (directly quoted from the NTSB Docket)...

Will the NTSB address these multiple training failures with a call for higher employment standards for transport category pilots? Or will they call for even more remedial training for those folks who can't do the job?

The Part 117 flight and duty time regulations put in place after the Colgan crash in 2009 were not applied to cargo operations due to a cost/benefit analysis. UPS basically said it was cheaper to have a crash once a decade killing two pilots than apply the proposed limits to their operations.

Similarly, is an occasional crash just the price we pay for overlooking a horrible training record in an effort to embrace a broader workplace recruitment demographic?

Things seemed to tighten up around the training building at many places after the Colgan crash for those 'frequent flyers' in the sims who never passed their checkrides without a lot of additional instruction. 709 rides were given by the FAA and a few of the legacy problem children quietly negotiated non-contractual early retirements and cash settlements in lieu of company provided training to get their tickets back.

The 1996 Pilot Records Improvement Act (PRIA) was intended to flag imposters and folks with training issues prior to hiring. Unfortunately, the current custom seems to be to offer a pilot being terminated for cause a chance to resign to avoid further litigation. The union and in many cases gender and ethnic advocacy groups cut a deal with the company and nothing adverse shows up on the PRIA record.

[Capi_Cafre']

This report is the most eloquent commentary that I've read to date on the pilot shortage issue.

[svhar]

I flew the 757/767 for 15 years, 2 years in the RHS and the rest in the LHS. I just cannot imagine a scenario where someone could accidentally hit the go-around switches when selecting flaps.

[exeng]

Whilst under line training as a brand new F/O on the 737 I went to disconnect the A/T during an approach. Engines spooled up and flight director looked a bit odd so I shut the thrust levers and switched off the flight director - many chortles from the line trainer in the LH seat. In fairness we were in marginal VMC at the time.

I never repeated that trick and having spent some time in the LH seat on the 757 it would seem quite odd to manage an inadvertent operation of the TOGA switch on the 75 or 76. Even if one did I cannot imagine why one would not recognise what had transpired and act accordingly.


kind regards
Exeng

[Joejosh999]

I can’t help but think how awful this incident might have been if they were a couple miles closer and over heavily pop’d areas....it’s hard to feel grateful about anything here, but I guess that would be one thing.

[neilki]

Interesting point..I can't access the full docket at the moment, probably my "IT", but from the CVR transcript the last reference I can see to the autopilot appears to be at a handover of control at:

12:36:19.2

HOT-2 "LNAV VNAV center autopilot".

I can't see any subsequent comment such as "sound of autopilot being disengaged"/s"sound of autopilot disconnect warning..
While I cant speak to the EU, US Operators generally transfer Aircraft Control to the PM prior to the Approach Briefing. From a brief read of the CVR I assumed that's what happened here..

[neilki]

Will the NTSB address these multiple training failures with a call for higher employment standards for transport category pilots? Or will they call for even more remedial training for those folks who can't do the job?



Similarly, is an occasional crash just the price we pay for overlooking a horrible training record in an effort to embrace a broader workplace recruitment demographic?

Things seemed to tighten up around the training building at many places after the Colgan crash for those 'frequent flyers' in the sims who never passed their checkrides without a lot of additional instruction. 709 rides were given by the FAA and a few of the legacy problem children quietly negotiated non-contractual early retirements and cash settlements in lieu of company provided training to get their tickets back.

The 1996 Pilot Records Improvement Act (PRIA) was intended to flag imposters and folks with training issues prior to hiring. Unfortunately, the current custom seems to be to offer a pilot being terminated for cause a chance to resign to avoid further litigation. The union and in many cases gender and ethnic advocacy groups cut a deal with the company and nothing adverse shows up on the PRIA record.
@Airbubba
Always a privilege to join your conversations; I've interviewed at Atlas. I found them an extremely professional and diligent group. HR and Technical folks were very well tuned in, and they certainly were not so desperate pilots that, in my opinion they lowered their guard in any meaningful way. Less than half the qualified applicants that day got offers. they turned away a ME 777 CA and several experienced 121 skippers.
Their reputation is that they won't hire anyone with any training failures.
While I fly recognize this fellow wouldn't be suited to driving the hotel van to the overnight; my experience of the recruiting event was that the entire group was extremely professional. This is not. a cowboy outfit by any measure..

The union will generally not step in to New Hire Pilot training problems, and Atlas does wash out a good few during training, certainly on the 747.
With all that said however, there is enormous pressure on everyone in the US to increase diversity in the workplace, and as troubling as it is, that reality is unlikely to change..

[tdracer]

tdracer

i don’t understand your comment on regulation being less safe for freight operations cf pax.

rgds

There are the differences in the Extended Diversion Time Operations (aka ETOPS) that I referenced in the original post and the crew duty that Markerinbound noted, and I wouldn't be surprised if there are others.
Further, regulatory oversight - not just of operations, but of aircraft modifications (i.e. Supplemental Type Certificate changes) is more relaxed in the freighter world. Just one example - back in the 1990s UPS re-engined some 727 freighters with Rolls Tay engines via an STC. They had an incident where all three Tay engines flamed out at the same time (they managed to get them restarted and landed safely). Although the FAA initially came to Boeing, turns out Boeing had no involvement and had never even been contacted about the STC - it was a purely DER project. That would never have been allowed for a passenger aircraft.

[MechEngr]

what’s the reasoning for elevator split?? I don’t see how it could end in a positive outcome.

It appears to be if one side control column jammed, say if a mechanic lost a wrench or a bolt worked loose. Not so much if the pilots disagree on how best to fly the plane.

[Bratchewurst]

He was a sailplane pilot; not sure how much time though.

[slickcity]

I flew the 757/767 for 15 years, 2 years in the RHS and the rest in the LHS. I just cannot imagine a scenario where someone could accidentally hit the go-around switches when selecting flaps.


I have thousands of hours in both seats of the 757 and the 767. When the f/o is hand flying an approach and calls for flaps, the captain many times will reach behind the throttles and around to set the flaps. This avoids contacting the first officer’s hand while he/she is operating the throttles. But it also puts the captain’s wrist in close proximity to the go around switches. I can see this happening.

[Check Airman]

I have thousands of hours in both seats of the 757 and the 767. When the f/o is hand flying an approach and calls for flaps, the captain many times will reach behind the throttles and around to set the flaps. This avoids contacting the first officer’s hand while he/she is operating the throttles. But it also puts the captain’s wrist in close proximity to the go around switches. I can see this happening.

The FO didn’t call for flaps 5 though. What would the captain’s (or anyone else’s) hand be doing there?

[neilki]

The FO didn’t call for flaps 5 though. What would the captain’s (or anyone else’s) hand be doing there?

in expectation, coaching or ‘guarding the controls’ FAA speak...

[Airbubba]

I have thousands of hours in both seats of the 757 and the 767. When the f/o is hand flying an approach and calls for flaps, the captain many times will reach behind the throttles and around to set the flaps. This avoids contacting the first officer’s hand while he/she is operating the throttles. But it also puts the captain’s wrist in close proximity to the go around switches. I can see this happening.


The FO didn’t call for flaps 5 though. What would the captain’s (or anyone else’s) hand be doing there

The FO was apparently flying on autopilot and had called for flaps 1. There is a little pitch up on the '76 when you select flaps 1 (actually just the LE slats) but the autopilot should have handled that. But if those go-around switches or whatever they are called had been bumped I guess TOGA power would be selected when the flaps were 'out of the up position' (it's been a long time since I took the oral).

The '76 and the '75 are supposed to throttle back to a 2000 foot per minute climb as the nose comes up on the go-around. However, if you try to keep the nose down the plane thinks it needs more power and doesn't throttle back in my experience. There are subtleties and nuances on 757/767 autoflight that in some cases seem to be specific to the engine manufacturer. tdracer probably knows a lot about this.

On the CVR transcript, HOT-2 appears to mention the EFI source source select switch as though he has selected alternate. I believe he now is looking at output from the center symbol generator. A minute and a half later he's speaking as though he no longer has airspeed, perhaps there is no drawn airspeed.

Shouldn't the source inputs for the center symbol generator be the same source inputs for the center autopilot? The autopilot that appears to have been engaged throughout the entire flight?

Did we figure out what instrument panel this freighter had? It was probably mentioned in the closed thread a few months ago but I can't seem to find it. Was it the legacy 767 panel with the round dial airspeed and Trinitron CRT screens? Or a flat screen mod done on the freighter conversion?

From the CVR transcript:

12:37:07.2 HOT-2 E-fy. [EFI button.]

12:37:08.5 HOT-? E-fy.

12:37:08.9 HOT-2 okay I got it back.

12:37:09.5 HOT-1 now it's back. [Sound of quick laugh.]

12:37:10.1 CAM [Sound of quick two beeps. Frequency not discernible.]

12:37:11.5 HOT-2 I press the E-fy button- it fixes everything.

Did the FO go to ALTN EFI? On the legacy panel it wouldn't affect his airspeed display it seems.

[Airbubba]

@Airbubba
Always a privilege to join your conversations; I've interviewed at Atlas. I found them an extremely professional and diligent group. HR and Technical folks were very well tuned in, and they certainly were not so desperate pilots that, in my opinion they lowered their guard in any meaningful way. Less than half the qualified applicants that day got offers. they turned away a ME 777 CA and several experienced 121 skippers.
Their reputation is that they won't hire anyone with any training failures.


I agree, Atlas training gets good reviews from the folks I've worked with who have passed through there.

The interviews in the Accident Docket give a lot of insight to the hiring process and training. The NTSB does the customary 'we're here to find the cause, not to assign blame' opener. And 'that FAA guy is here to help you, he can't pull your ticket for anything you say during the interview'.

Atlas Director of Human Resources Denise Borrelli's interview starting on page 534 of the 734 page file is interesting as she is asked how the FO's numerous training failures are somehow missed in the PRIA check and the job interview process. Was it just an oversight?

Did we figure out what instrument panel this freighter had? It was probably mentioned in the closed thread a few months ago but I can't seem to find it. Was it the legacy 767 panel with the round dial airspeed and Trinitron CRT screens? Or a flat screen mod done on the freighter conversion?

Looking at the interviews, it appears that the plane had the flat screen panel upgrade with the round dial airspeed still there as well. So, even with the loss of the EADI you would presumably still have airspeed indication on the dial.

Here's a link to the interview transcripts, I find the online docket interface with the MS Word table of contents to be a little, well, wonky.

https://dms.ntsb.gov/public/63000-63499/63168/631157.pdf

[4runner]

I flew the 757/767 for 15 years, 2 years in the RHS and the rest in the LHS. I just cannot imagine a scenario where someone could accidentally hit the go-around switches when selecting flaps.

I don’t have that many, but I am current and I can imagine the scenario. The Captain reaches behind the thrust levers to select the flap lever. His watch hits the TOGA paddle without realizing it. It doesn’t become active until flaps indicate 1. We just tried it in the sim last week. I can totally see it happening in the heat of battle with an FO that you’re focused on.

[tdracer]

Did we figure out what instrument panel this freighter had? It was probably mentioned in the closed thread a few months ago but I can't seem to find it. Was it the legacy 767 panel with the round dial airspeed and Trinitron CRT screens? Or a flat screen mod done on the freighter conversion?
Airbubba, I'm only aware of one 767 flat panel upgrade - it's the one that FedEx is getting on it's new build 767F where the six CRTs are replaced with 3 large(r) flat panels - done by an STC. I have some familiarity with the STC since they started implementing that STC in production before I retired (initially they'd take a new 767 with the CRTs, fly it somewhere to remove the CRTs and install the flat panel systems - obviously it was cheaper to just install the STC flat panels during production). If it's the same flat panel STC as FedEx is getting, the logic as to what gets displayed and where is unchanged - there are some interfacing electronics that convert the display inputs as needed for the flat panel instead of the CRTs. But the exact same information is being displayed as with the original CRTs. The standby instrumentation is also unchanged.
Afraid I can't help with the detailed autothrottle logic during a go-around.

[Check Airman]

The FO was apparently flying on autopilot and had called for flaps 1. There is a little pitch up on the '76 when you select flaps 1 (actually just the LE slats) but the autopilot should have handled that. But if those go-around switches or whatever they are called had been bumped I guess TOGA power would be selected when the flaps were 'out of the up position' (it's been a long time since I took the oral).

The '76 and the '75 are supposed to throttle back to a 2000 foot per minute climb as the nose comes up on the go-around. However, if you try to keep the nose down the plane thinks it needs more power and doesn't throttle back in my experience. There are subtleties and nuances on 757/767 autoflight that in some cases seem to be specific to the engine manufacturer. tdracer probably knows a lot about this.



Did we figure out what instrument panel this freighter had? It was probably mentioned in the closed thread a few months ago but I can't seem to find it. Was it the legacy 767 panel with the round dial airspeed and Trinitron CRT screens? Or a flat screen mod done on the freighter conversion?

From the CVR transcript:



Did the FO go to ALTN EFI? On the legacy panel it wouldn't affect his airspeed display it seems.

From the pictures in the report, it seemed the plane had the speed tape on the side of the ADI. I assume it’s representative.

[derjodel]

It appears to be if one side control column jammed, say if a mechanic lost a wrench or a bolt worked loose. Not so much if the pilots disagree on how best to fly the plane.

thanks, under mechanical failure it might indeed make sense.

but when pilots disagree (not uncommon in recent crashes!), it reduces the chances of survival from 50% (stronger wins) to 0% (no one wins)

seems like a design flaw to me. Final report might be interesting.

[tcasblue]

I agree, Atlas training gets good reviews from the folks I've worked with who have passed through there.

The interviews in the Accident Docket give a lot of insight to the hiring process and training. The NTSB does the customary 'we're here to find the cause, not to assign blame' opener. And 'that FAA guy is here to help you, he can't pull your ticket for anything you say during the interview'.

Atlas Director of Human Resources Denise Borrelli's interview starting on page 534 of the 734 page file is interesting as she is asked how the FO's numerous training failures are somehow missed in the PRIA check and the job interview process. Was it just an oversight?



Looking at the interviews, it appears that the plane had the flat screen panel upgrade with the round dial airspeed still there as well. So, even with the loss of the EADI you would presumably still have airspeed indication on the dial.

Here's a link to the interview transcripts, I find the online docket interface with the MS Word table of contents to be a little, well, wonky.

https://dms.ntsb.gov/public/63000-63499/63168/631157.pdf

Everybody be honest. Would you have let this person get hired if you knew his record?

If the NTSB is truly interested in aviation safety, they will not look the other way when it comes to investigating all possible reasons that this copilot was hired.

That includes affirmative action. Maybe that aspect of the investigation will show that it had nothing to do with him getting hired which would provide clarity but maybe it did get him hired. The families of the dead have a right to know along with the flying public.

[B2N2]

I don’t have that many, but I am current and I can imagine the scenario. The Captain reaches behind the thrust levers to select the flap lever. His watch hits the TOGA paddle without realizing it. It doesn’t become active until flaps indicate 1. We just tried it in the sim last week. I can totally see it happening in the heat of battle with an FO that you’re focused on.

Have you considered the FO triggering TOGA while stowing the speedbrake?

[misd-agin]

I have thousands of hours in both seats of the 757 and the 767. When the f/o is hand flying an approach and calls for flaps, the captain many times will reach behind the throttles and around to set the flaps. This avoids contacting the first officer’s hand while he/she is operating the throttles. But it also puts the captain’s wrist in close proximity to the go around switches. I can see this happening.


^^ x2. 10,000+ hrs on the 757/767. I can recall at least 3 incidents of inadvertently activating the G/A switches in 15,000+ hrs on Boeing's with G/A switches. 'Click, click' to deactivate the auto throttles is the rapid response.

It's typically a non event because the FO, with their hand on the throttles, feels an uncommanded forward movement and physically restrains the thrust levers while using the push buttons to disconnect the auto throttles.

[Airbubba]

^^ x2. 10,000+ hrs on the 757/767. I can recall at least 3 incidents of inadvertently activating the G/A switches in 15,000+ hrs on Boeing's with G/A switches. 'Click, click' to deactivate the auto throttles is the rapid response.

It's typically a non event because the FO, with their hand on the throttles, feels an uncommanded forward movement and physically restrains the thrust levers while using the push buttons to disconnect the auto throttles.

And, in my observation, even if you leave the autothrottles engaged it's easy to overpower the automation and pull the power back manually. At 6000 feet the plane hand flies just fine so if you went up off altitude just pop off the autopilot and ease back down. Would selecting FLCH also bring you back to the altitude in the window? It probably would but there may be some inhibit above 2500 feet RA with flaps out in G/A mode on alternate Thursdays etc. So just pop off the automation and make the plane do what you want then 'Autopilot Center to Command' to recover from the inadvertent go-around switch activation would be my suggestion.

Some folks would have their hands on the throttles at 6000 feet with the autothrottles and autopilot on, others would not. I've seen it done and taught both ways.

In the docket file of interviews starting on page 305 an Atlas FO recalls a possible earlier automation glitch incident with the accident aircraft.

3 Q. Okay. Tell me what it is you want to share with us. You had
4 some information about the accident airplane.

5 A. Well, I don't know if it does. The -- I had an incident
6 coming out of Stockton on -- and I'm not actually sure that it was
7 that date. I think I believe it is. It very well could be --
8 Q. What date are you talking about?
9 A. 11/2 of '18.
10 Q. Got it.

11 A. And I had a incident coming out of Stockton on one of our
12 aircraft. It was -- we departed there in the middle of the night
13 it was 0730Z VFR and normal departure. It was heading off
14 departure with a climb -- a left climbing turn to 7,000 feet and
15 when we went through 1,000 we engaged the center autopilot and
16 somewhere before 2,000 we got a Flight Director command full down,
17 nose down. And the airplane tried to start leveling off and I
18 disengaged the autopilot, hand flew it, we reset the autopilot in
19 the climb out and it was all systems were normal after that.
20 And we did not do an FTR on it. We just took it as a anomaly
21 of the autopilot and it reset and we just continued on.

22 And I can't say if Laz, the guy I was flying with, remembers
23 the incident, you know, if we could verify that that was one
24 hundred percent it but when I was looking through my logbook I was
25 like, “Oh, that's -- that tail number was on that flight.” So it
1 just kind of concerned me.

2 Q. Okay. So when it nosed over did you happen to notice what
3 the flight motor enunciator was telling you at the time?
4 A. I do not.

5 Q. Okay. And was it a hard over or was it just trying to level
6 off and kind of go to a normal reduced pitch?
7 A. No, it felt like it was pushing over and I'm sure that the
8 command bars being all the way as far down as they could go.

9 Q. Okay. And when you reengaged --
10 A. I wouldn't say it was so abrupt -- it wasn't so abrupt like
11 it was trying to push us out of our seats or anything but it was
12 definitely heading into a pretty good dive. But -- and, you know,
13 we kicked the autopilot off, we kept flying the airplane and, you
14 know, corrected it but it was, you know, very noticed, very
15 pronounced.

16 Q. Okay. When you reengaged the autopilot do you reengage that
17 second or the center autopilot?
18 A. Yes.
19 Q. Okay.
20 A. We reengaged the center autopilot.

21 Q. And anything happen after that?
22 A. No. It was Flight Director was all normal, everything was
23 normal. It flew all the way to CVG with no problems.
24 Q. Okay. Was this written up in the logbook?
25 A. I do not recall.
1 Q. Okay. Any irregularity reports or anything like that filed
2 in conjunction with this event?
3 A. No.

4 Q. Okay. And how certain are you that this was 1217 Alpha?
5 A. I would say really only talking about 80 percent. If Laz
6 cannot verify that he was on that and that was the -- then I would
7 have to look elsewhere but it was -- I'm about 80 percent sure
8 that that's what it was.

9 Q. Okay. You said earlier it was pushing over toward a dive.
10 It never got into a dive or did it actually start to descend?
11 A. It started to descend. We went -- it -- level come off
12 immediately and it started to descend down and we probably got a
13 little bit vertical descent and immediately kicked off and
14 reinitiated the climb.

15 Q. Yeah. I'm trying to visualize this so you turned the
16 autopilot on during the climb then it started to level off and
17 then it continued past the level off into a descent before you
18 disconnected the autopilot. Did I get that right?
19 A. Yes.

In the preamble to this interview conducted over the phone the FAA disclaimer mentioned in my earlier post is given.

19 MR. LAWRENCE: Okay. Oh, by the way, FAA is in the room
20 here. They're a representative on our group but they're not here
21 for certificate action or anything. It's just like a safety --
22 this is just a safety investigation, okay. Just to let you know.

23 MR. ANDREWS: Right.

24 MR. LAWRENCE: Okay. Cool.

[Check Airman]

And, in my observation, even if you leave the autothrottles engaged it's easy to overpower the automation and pull the power back manually. At 6000 feet the plane hand flies just fine so if you went up off altitude just pop off the autopilot and ease back down. Would selecting FLCH also bring you back to the altitude in the window? It probably would but there may be some inhibit above 2500 feet RA with flaps out in G/A mode on alternate Thursdays etc. So just pop off the automation and make the plane do what you want then 'Autopilot Center to Command' to recover from the inadvertent go-around switch activation would be my suggestion.

Some folks would have their hands on the throttles at 6000 feet with the autothrottles and autopilot on, others would not. I've seen it done and taught both ways.

In the docket file of interviews starting on page 305 an Atlas FO recalls a possible earlier automation glitch incident with the accident aircraft.



In the preamble to this interview conducted over the phone the FAA disclaimer mentioned in my earlier post is given.

Interesting find. That muddies the waters a lot. Also the fact that the AP was engaged the whole time. How does it stay engaged with all those stick forces? Does it not disengage after a certain level of force is applied?

[svhar]

G/A does not arm or engage by someone just looking at the switches or just by brushing them with their fingers or a watch, which is normally worn on the left arm, they need a firm touch. Even so, it should be a non event, autopilot off, autothrottle off and then back to normal.

[deltahotel]

Just press ALT HOLD

[4runner]

thanks, under mechanical failure it might indeed make sense.

but when pilots disagree (not uncommon in recent crashes!), it reduces the chances of survival from 50% (stronger wins) to 0% (no one wins)

seems like a design flaw to me. Final report might be interesting.

every transport category aircraft I’ve ever flown has some sort of elevator break away system installed. 4 different airplanes by 2 different manufacturers had this. A design flaw?????

[4runner]

Whilst under line training as a brand new F/O on the 737 I went to disconnect the A/T during an approach. Engines spooled up and flight director looked a bit odd so I shut the thrust levers and switched off the flight director - many chortles from the line trainer in the LH seat. In fairness we were in marginal VMC at the time.

I never repeated that trick and having spent some time in the LH seat on the 757 it would seem quite odd to manage an inadvertent operation of the TOGA switch on the 75 or 76. Even if one did I cannot imagine why one would not recognise what had transpired and act accordingly.


kind regards
Exeng

ive done the EXACT same thing in the 73, during an actual approach. The difference is our ability. The FO in question displayed irrational reactions to non normal scenarios throughout his career. He saw the check board and mistook it for a stall and not max speed.

[derjodel]

every transport category aircraft I’ve ever flown has some sort of elevator break away system installed. 4 different airplanes by 2 different manufacturers had this. A design flaw?????

You did not address my reasoning at all, and simply stating the fact that other types use the same design does not refute the argument.

think about it. It’s guaranteed to cause a crash in case of yoke fight (pilot disagreement)

[Australopithecus]

You did not address my reasoning at all, and simply stating the fact that other types use the same design does not refute the argument.

think about it. It’s guaranteed to cause a crash in case of yoke fight (pilot disagreement)


It can happen in an Airbus too, btw. The first autopilot disconnect switch pressed and held overrides the opposite sidestick*. All of these features have to assume two rational, competent pilots. Its up to vetting, hiring and training to ensure that assumption remains valid

* Although, on edit, the Airbus architecture does allow for a subsequent dueling disconnect button fight..

[AlexGG]

derjodel, probably the reason for shear pins is that the probability of mechanical failure somewhere in the system is higher (or is considered higher) than the probability of pilots having a duel on control sticks.

[TyroleanCondor]

Having flown the 767 and the 747 I wonder about the inconsistent architecture of the TO/GA switch vs. A/T Disconnect.
Pressing the switch which disconnects autothrottle on the 747 would activate the TO/GA mode on a 767!

[infrequentflyer789]

derjodel, probably the reason for shear pins is that the probability of mechanical failure somewhere in the system is higher (or is considered higher) than the probability of pilots having a duel on control sticks.

More likely, I think, the reason is that the shear pins (or whatever) can (or may, with some probability) effectively mitigate a failure elsewhere.

There is no mechanical/automated system that can cope with the two pilots fighting each other on the controls. Either the pilot who is correct disables (or persuades to desist) the other one, in time to recover, or the ground will intervene and end it.

Two of anything is only for redundancy if one bails out (figuratively or literally), in case of disagreement two is the worst number to have - voting is inevitable tie. Three physical pilots isn't really going to fit in today's aircraft, but in the future we may be able to have a third synthetic pilot, whose job will be: in the event of disagreement, determine which is the errant pilot and remove them from the control path. Pilots or AOA vanes, take your pick - two is not enough to resolve a disagreement.

[derjodel]

It can happen in an Airbus too, btw. The first autopilot disconnect switch pressed and held overrides the opposite sidestick*. All of these features have to assume two rational, competent pilots. Its up to vetting, hiring and training to ensure that assumption remains valid

* Although, on edit, the Airbus architecture does allow for a subsequent dueling disconnect button fight..

"All of these features have to assume two rational, competent pilots."

I believe that is a problem. All designs assume "rational, competent pilots". But what is really a "rational, competent pilot"? Whenever something goes wrong, airplane makers are quick to blame the pilots. Presumably, because they didn't act "rationally and with competence". There are many examples, AF447, both MAC crashes etc.

However, I said it before and I'l say it again, there is no real measure of level of "rationality and competence". There is just a binary term, called "licensed pilot'. Since airplanes are meant to be flown by licensed pilots (whatever their level of competency is), either airplanes should be made such that any licensed pilot could safely fly them, or the license itself needs to be redefined and pass criteria should be severely stricter and should include reactions under stress (remember, the "rational" part). The question is, how does one test that without putting the candidate in real danger. Altough eliminating unsuitable candidates by darwin method would work quite well (and this forum is full of pilots so sure in themselves they would not mind to take such test), I'm not sure that's actually going to happen any time soon.

Going back to the design, the whole system is built around the premise of "2 rational, competent pilots". I believe it would be much more appropriate to require that the airplane must be able to fly safely with two parallel, independent systems in command. The fact that these systems are of biological nature should not play any role in the design.

Now just start thinking if the current cockpit design meets safety criteria. If it does, it should not matter if the "systems" in command are biological or not.

But the assumption that biological systems are flawless and the design can make shortcuts it would not with non-biologic systems is, IMO, a major flaw. Recently we've seen many crashes due to this design:
- AF447: biological system identified stall correctly, applied incorrect procedure, the other biological system was not able to monitor flying system's stick commands and was unable to correct. A perfectly flying airplane crashed as a result
- Germanwings: one biological system was temporarily unavailable due to maintenance, the other biological system malfunctioned, prevented access to the controls, and crashed the airplane
- Atlas air: biological system incorrectly identified acceleration due to (uncommanded?) TOGA as stall, and over applied stall recovery procedure; the other biological system correctly asses the situation and applied the right proceudre, which resulted in a yoke duel between the two piloting systems, however, the surface control system was not designed for such duels and broke off (a feature designed to prevent another type of problem), leading to each piloting system controlling only half of the elevator

Now read both of the above scenarios and think of the self-flying planes. Would you fly (as a passenger) on a plane which was designed in the same way, for two AI pilots? If not, why do you insist it's a good design for biological pilots? Try to view the situation without your inherent bias. Ask people who know nothing about airplanes (and don't depend on your salary) what they think of it...

[blind pew]

An interesting thread which is perhaps getting to the root of the problem which is a lack of understanding of how diverse human responses are to sensory overload.
My first introduction was with Tony Farrell doing a test of unusual attitudes under the hood on limited panel where he took control as I was about to tail slide the PA28.
https://www.hampshirechronicle.co.uk/news/16335591.death-of-tony-farrell-one-of-the-last-pilots-of-world-war-two-bomber-command
Thats the man in question ex mosquitoes DFC and unlike many of my instructors he allowed students to take a flying machine to its limits. My senses were so overloaded that nearly 50 years on I haven't a clue as to our attitudes.
Shortly afterwards I had a chop test with Duff Mitchell who also had a DFC..only aircraft flying as weather was P poor..again under the hood and a practice GCA which I landed from whilst still wearing the head gear..cross wind and turbulence but it taught me to forget sensory perception.
Fast forward 25 years which included teaching limited aerobatics, a lot of spinning and mountain gliding including being knocked semi concious; I did an AFF and jumped out of an aircraft at 12,000ft..had no recollection of a falling sensation and found it frankly boring.
I was then asked to find out how a colleague had died; he had 25 years of airliners, a similar amount of hang gliders but like myself at that time around a year paragliding. He had a collapse at 200ft agl and was looking up at his wing when he hit the ground instead of throwing his reserve. A few years later I had a similar series of collapses and lost over 1,000ft in seconds whilst looking up at the wing. My senses told me I had lost around 100ft.
The next year I carried out a SIV course at Annecy with Flyeo and its boss Fabio; a small, quietly spoken young frenchman. He taught me more in two hours about how the muscles and senses act with acceleration than what I had learnt in my flying career.
From that I can understand how PF in AF 447 apparently kept back pressure on the stick.
Yesterday arrived the latest addition of Cross Country magazine which includes a study of paraglider pilots deploying their reserve parachute on a zip wire. Scientifically carried out with prior attempted sensory overload before the pilots were released. The technique was to delay their release whilst carrying out an oral reasoning task plus an "unusual" physical upset. The reserve deployments were delayed and sometimes completely erroneous.
I had one emergency smoke training in a DC9 mock up where I had to find a baby; not only a claustrophobic mask/ dense smoke but the sounds of a baby crying which disorientated me.
I failed miserably as I did in the hypoxia exercise carried out in the decompression chamber at Portsmouth.

The industry has bought two crew operation, advanced simulator use at the expense of real flying and packaged the product up with automatics and checklists..this accident won't be the last that is blamed on pilot error!

As to GA button, a mate who was the chief trainer on the 400 hit it when he went to take the auto throttle out on short final. His copilot said he caught three of the levers but with an outer at full chat the 74 did something he hadn't seen before. It was written up in an air safety report.

[misd-agin]

Read CKA Peavley's interview. He busted him at Atlas on his 767 type rating ride. The checkride started out bad, Peavley thought perhaps due to nerves with the FAA observing, but it got worse. He finally stopped the ride early and the FO was stunned. There's a complete disconnect when you think your performance is acceptable and the CKA stops the ride because it's completely unacceptable. Peavley was asked what he thought - "I thought he should be in a different profession."

When it appears that you have more 121 busts than 'passed on first attempts' the industry needs to do a better job documenting this. Maybe a national database for busts that employers can access?

[aterpster]

Read CKA Peavley's interview. He busted him at Atlas on his 767 type rating ride. The checkride started out bad, Peavley thought perhaps due to nerves with the FAA observing, but it got worse. He finally stopped the ride early and the FO was stunned. There's a complete disconnect when you think your performance is acceptable and the CKA stops the ride because it's completely unacceptable. Peavley was asked what he thought - "I thought he should be in a different profession."

When it appears that you have more 121 busts than 'passed on first attempts' the industry needs to do a better job documenting this. Maybe a national database for busts that employers can access?
I would think those busts would be, or should be, reported to FAA's Airman Certification Branch.

[Check Airman]

Read CKA Peavley's interview. He busted him at Atlas on his 767 type rating ride. The checkride started out bad, Peavley thought perhaps due to nerves with the FAA observing, but it got worse. He finally stopped the ride early and the FO was stunned. There's a complete disconnect when you think your performance is acceptable and the CKA stops the ride because it's completely unacceptable. Peavley was asked what he thought - "I thought he should be in a different profession."

When it appears that you have more 121 busts than 'passed on first attempts' the industry needs to do a better job documenting this. Maybe a national database for busts that employers can access?

This came from Colgan. Still not fully implemented though.

https://www.faa.gov/regulations_policies/pilot_records_database/

[mnttech]

This came from Colgan. Still not fully implemented though.
https://www.faa.gov/regulations_policies/pilot_records_database/
One small little word....
"All part 119 certificate holders and fractional ownerships can register to access the PRD and evaluate the available FAA data for each individual pilot candidate prior to making a hiring decision."
Change the can to shall and this might not have happened.

[Ripper3785]

blancolirio analysis here -

youtube.com/watch?v=GR4xhTF-13g

[Airbubba]

The Miami Herald reports that a couple of the training managers involved in the hiring of FO Conrad Aska have suddenly 'retired'.

Is a draft of the final report now being circulated among the 'parties' for response perhaps?

From the article below:

The documents also show that Atlas hired Aska despite his repeated training failures at other airlines.“If I had that information at the time we would not have offered him a position,” Anderson told investigators about Aska.

Carlson, the senior vice president for flight operations, agreed with the captain’s assessment. “I worry about quotas on the flight deck,” he said, according to the recording obtained by the Miami Herald. “I’m not oblivious to any of that. ...

I doubt that the NTSB will address the touchy issue of possibly adjusted hiring and training standards to promote a more diverse and inclusive workplace. Still, the question of why someone with so many training failures would continue to be hired at other airlines seems to be too obvious to be ignored. Will this be dismissed as the result of a puzzling chain of unexplained administrative oversights?

Top Atlas Air flight training directors retire as government crash investigation looms

Miami Herald

By Taylor Dolven

February 22, 2020 06:30 AM

Nearly one year after Miami International Airport’s largest cargo airline Atlas Air crashed a plane killing three pilots, two top directors of the company’s training program in Miami suddenly retired this week.

Fleet captain Joe Diedrich and training director Scott Anderson abruptly left the company Tuesday. An internal email titled “Miami Training Center: Organizational Update” from senior vice president Jeff Carlson announced their departures as retirements. The shakeup comes as the National Transportation Safety Board’s final report about the fatal Feb. 23, 2019, crash is pending and the company reported a deep earnings loss for 2019.

The Atlas Air Flight 3591 crash happened as Diedrich was head of the Boeing 767 training program and Anderson was overseeing procedures, training and standards for the entire airline.

After departing Miami, the plane full of Amazon shipments suddenly increased in power and pitched upward about 40 miles outside Houston, likely in reaction to an activation of the go-around switches. Thirty seconds later, the plane nosedived 6,000 feet down into Trinity Bay, killing three people: captain Ricky Blakely, 60, of Indiana; first officer Conrad Jules Aska, 44, of Miami; and Mesa Air pilot Sean Archuleta, 36, of Texas, who was riding as a passenger on the flight.

Government crash investigators (https://www.miamiherald.com/news/business/tourism-cruises/article238587338.html) released a trove of documents in December showing that Blakely failed his proficiency test on the Boeing 767 in 2015 and was placed in a monitoring program “as a result of [his] repetitive need for additional training.” Blakely was removed from the monitoring program in February 2017. The documents also show that Atlas hired Aska despite his repeated training failures at other airlines.

“If I had that information at the time we would not have offered him a position,” Anderson told investigators about Aska. At the time of the crash, Blakely had worked for Atlas since September 2015 and had 11,000 hours of flying time, 1,250 hours on the 767. Aska had worked for Atlas since July 2017 and had 5,000 hours of flying time, 520 hours on the 767.

Atlas Air did not respond to requests for comment about the training directors’ retirements.

A Miami Herald investigation found that pilots for Atlas Air repeatedly warned company executives (https://www.miamiherald.com/news/business/tourism-cruises/article230569724.html) in the years leading up to the 2019 crash that if they did not bolster the training program and hire pilots with more experience, a plane was going to crash. At a meeting with executives in Miami in 2017, a pilot who had been with the company for two decades described an “erosion of level of experience in the cockpit.”

Carlson, the senior vice president for flight operations, agreed with the captain’s assessment. “I worry about quotas on the flight deck,” he said, according to the recording obtained by the Miami Herald. “I’m not oblivious to any of that. ... We know experience level decreases over time. That’s a challenge for this group. ... Regardless of the experience, the bar never changes. And I just want to make sure that sticks in the back of your mind.”

Since the crash, former CEO of the company William Flynn stepped down, (https://www.miamiherald.com/news/business/tourism-cruises/article232243242.html) and chief operating officer John Dietrich ascended to the role in January. On Wednesday, one day after the training directors’ departures, Dietrich announced a $293.1 million net loss for Atlas Air in 2019 and said the company has taken five of its Boeing 747 planes out of service due to a “softer market.” In 2018, the company reported a profit of $270.6 million.

Atlas Air Worldwide Holdings, formed in 2001, is the parent company of four cargo airlines — Atlas Air, Polar Air, Southern Air and Titan Aviation Leasing. Since 2010, the company’s fleet has grown from 29 planes to 123, boosted by contracts with Amazon and the U.S. Department of Defense.

In its interim report on the crash released in December, the NTSB found that total average flying time for new hires at Atlas Air and Southern Air dropped to around 5,600 hours in 2018, compared to 7,303 hours in 2015. Two-thirds of pilots have been with the company for less than five years. The FAA requires that new hires have at least 1,500 hours.

https://www.miamiherald.com/news/business/tourism-cruises/article240510511.html

[pattern_is_full]

NTSB to hold virtual board meeting July 14, 2020 - per Aviation Herald. Meeting will be webcast.

[XPMorten]

https://www.youtube.com/watch?v=gV1Qi45dm5w

[Ray_Y]

Sorry, I chose to remove my contribution to this site.

[Meester proach]

Might as well wait till 14/7 and see if some conclusive answers are forthcoming

[Check Airman]

Ray_Y

I’m interested.

[Ray_Y]

I won't continue trying to post. Content removed. Sorry & bye

[42...]

silverstrata

If you dont have these stick and rudder skills before you get to jets, you should never get there. It should be some pre hire evaluation.

[Meester proach]

I’m not sure you are telling us something we don’t know.

Pressed TOGA, fought the aircraft, crashed ?

[Airbubba]

If you dont have these stick and rudder skills before you get to jets, you should never get there. It should be some pre hire evaluation.

And why, oh why would this guy keep getting hired as a pilot after so many training failures? :confused:

The search for answers continues...

[Airbubba]

NTSB virtual board meeting tomorrow morning.

MEDIA ADVISORY: Fatal Atlas Air Flight 3591 Cargo Plane Crash Subject of Board Meeting7/13/2020​WASHINGTON (July 13, 2020) — The National Transportation Safety Board (https://www.ntsb.gov/Pages/default.aspx)is scheduled to hold a board meeting July 14, 2020, 9:30 a.m. (EDT), to determine the probable cause of the Feb. 23, 2019, Atlas Air flight 3591 crash into Trinity Bay, Texas.

The accident happened when the Atlas Air Boeing 767 cargo jet entered a rapid descent from about 6,000 feet and impacted a marshy bay about 40 miles from Houston’s George Bush Intercontinental Airport. The two pilots and one non-revenue, jumpseat pilot were fatally injured. The airplane, which was carrying cargo from Miami to Houston for Amazon.com Inc., and the US Postal Service, was destroyed.

In keeping with established Federal and local social distancing guidelines to prevent the spread of the coronavirus, while also ensuring the NTSB’s compliance with the Government in the Sunshine Act, the board meeting for this investigation will be webcast to the public, with the board members and investigative staff meeting virtually. There will be no physical gathering to facilitate the board meeting.

WHO: NTSB investigative staff and board members (https://www.ntsb.gov/about/board/Pages/default.aspx)

WHAT: A Webcast, virtual board meeting.

WHEN: Tuesday, July 14, 2020, 9:30 a.m. (EDT).

HOW: The board meeting will be webcast only, there will not be a public gathering of NTSB investigative staff or board members. A link to other webcast will be available shortly before the start of the meeting at NTSB Live (http://ntsb.windrosemedia.com/).

MEDIA AVAILABILITY: The Chairman of the NTSB, Robert Sumwalt (https://www.ntsb.gov/news/speeches/RSumwalt/Pages/bio_sumwalt.aspx), is scheduled to hold a virtual media briefing at 2 p.m. (EDT) to answer questions about Tuesday’s board meeting and the NTSB’s investigation of the crash.

The virtual media briefing will be conducted using Microsoft Teams Live Event. Journalists who RSVP to [email protected] receive an email with the attendee link and information about how the briefing will be conducted. A recording of the briefing will be made available via the NTSB’s YouTube channel as soon as practicable.

[Old Boeing Driver]

Sorry. missed this thread. From the NTSB earlier today.

https://youtu.be/GsSNr5DR840

[Airbubba]

The NTSB is going to press for cameras in the cockpit again according to remarks made in the hearing today.

[Zeffy]

Links to presentations:

https://www.ntsb.gov/news/events/Pages/2020-DCA19MA086-BMG.aspx

[Airbubba]

NTSB abstract of the upcoming Atlas 3591 accident report.

NATIONAL TRANSPORTATION SAFETY BOARD Virtual Meeting of July 14, 2020 (Information subject to editing)

Rapid Descent and Crash into Water, Atlas Air Inc. Flight 3591 Boeing 767-375BCF, N1217A Trinity Bay, Texas February 23, 2019 DCA19MA086

This is a synopsis from the NTSB’s report and does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations. NTSB staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing to reflect changes adopted during the Board meeting.
Executive Summary

On February 23, 2019, at 1239 central standard time, Atlas Air Inc. (Atlas) flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level (msl) and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer (FO), and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations (CFR) Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport (MIA), Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH.

The accident flight’s departure from MIA, en route cruise, and initial descent toward IAH were uneventful. As the flight descended toward the airport, the flight crew extended the speedbrakes, lowered the slats, and began setting up the flight management computer for the approach. The FO was the pilot flying, the captain was the pilot monitoring, and the autopilot and autothrottle were engaged and remained engaged for the remainder of the flight.
Analysis of the available weather information determined that, about 1238:25, the airplane was beginning to penetrate the leading edge of a cold front, within which associated windshear and instrument meteorological conditions (as the flight continued) were likely. Flight data recorder data indicated that, during the time, aircraft load factors consistent with the airplane encountering light turbulence were recorded and, at 1238:31, the airplane’s go-around mode was activated. At the time, the accident flight was about 40 miles from IAH and descending through about 6,300 ft msl toward the target altitude of 3,000 ft msl. This location and phase of flight were inconsistent with any scenario in which a pilot would intentionally select go-around mode, and neither pilot made a go-around callout to indicate intentional activation.

Within seconds of go-around mode activation, manual elevator control inputs overrode the autopilot and eventually forced the airplane into a steep dive from which the crew did not recover. Only 32 seconds elapsed between the go-around mode activation and the airplane’s ground impact.

The investigation evaluated the following safety issues:

• Inadvertent activation of the go-around mode. The investigation determined a likely scenario to explain how the go-around mode became activated. However, a review of the available data suggests that inadvertent activation of the go-around mode on Boeing 767-series airplanes may be a rare and typically benign event.
• Flight crew performance. The investigation examined the factors that influenced the FO’s incorrect response following the unexpected mode change and the captain’s delayed awareness of and ineffective response to the situation.
• Atlas’ evaluation of the FO. The FO failed to disclose to Atlas some of the training difficulties he experienced at former employers, and Atlas’ records review did not identify the FO’s past training failure at one former employer, which may have affected how Atlas evaluated him during the hiring process and during training.
• Industry pilot hiring process deficiencies. Limitations in the background records retrieval process places hiring operators (like Atlas when considering the FO’s application) at a disadvantage when trying to obtain a complete training history on a pilot applicant. Also, the circumstances of this accident highlighted a need for improved pilot selection and performance measurement methods.
• Awareness information for Boeing 767 and 757 pilots. Although there were no other known events involving inadvertent activation of the go-around mode on a Boeing 767-series airplane, pilots of Boeing 767- and 757-series airplanes (which share a similar go-around switch design) could benefit from understanding the circumstances of this accident.
• Adaptations of automatic ground collision avoidance technology. The US military has successfully equipped some fighter airplanes with an automatic ground collision avoidance system that has prevented the loss of several aircraft and saved lives. Research into adapting such technology for lower-performance, less-maneuverable airplanes could have relevance for civil transport-category airplanes.
• Cockpit image recorders. Certain aspects of the circumstances of this accident could be better known with improved information about flight crew actions, possibly leading to additional safety recommendations for preventing similar accidents.

Findings

1. None of the following were factors in this accident: (1) the captain’s and the first officer’s certifications and qualifications; (2) air traffic control services; (3) the condition and maintenance of airplane structures, powerplants, and systems; and (4) airplane weight and balance.
2. There was insufficient information to determine whether the flight crewmembers were fatigued at the time of the accident, and no available evidence suggested impairment due to any medical condition, alcohol, or other impairing drugs.
3. Whatever electronic flight instrument system display anomaly the first officer (FO) experienced was resolved to both crewmembers’ satisfaction (by the FO’s cycling of the electronic flight instrument switch) before the events related to the accident sequence occurred.
4. The activation of the airplane’s go-around mode was unintended and unexpected by the pilots and occurred when the flight was encountering light turbulence and likely instrument meteorological conditions associated with its penetration of the leading edge of a cold front.
5. Presuming that the first officer (FO) was holding the speedbrake lever as expected in accordance with Atlas Air Inc.’s procedure, the inadvertent activation of the goaround mode likely resulted from unintended contact between the FO’s left wrist or watch and the left go-around switch due to turbulence-induced loads that moved his arm.
6. Despite the presence of the go-around mode indications on the flight mode annunciator and other cues that indicated that the airplane had transitioned to an automated flight path that differed from what the crew had been expecting, neither the first officer nor the captain were aware that the airplane’s automated flight mode had changed.
7. Given that the first officer (FO) was the pilot flying and had not verbalized any problem to the captain or initiated a positive transfer of airplane control, the manual forward elevator control column inputs that were applied seconds after the inadvertent activation of the go-around mode were likely made by the FO.
8. The first officer likely experienced a pitch-up somatogravic illusion as the airplane accelerated due to the inadvertent activation of the go-around mode, which prompted him to push forward on the elevator control column.
9. Although compelling sensory illusions, stress, and startle response can adversely affect the performance of any pilot, the first officer had fundamental weaknesses in his flying aptitude and stress response that further degraded his ability to accurately assess the airplane’s state and respond with appropriate procedures after the inadvertent activation of the go-around mode.
10. Had the Federal Aviation Administration met the deadline and complied with the requirements for implementing the pilot records database (PRD) as stated in Section 203 of the Airline Safety and Federal Aviation Administration Extension Act of 2010, the PRD would have provided hiring employers relevant information about the first officer’s employment history and training performance deficiencies.
11. The first officer’s long history of training performance difficulties and his tendency to respond impulsively and inappropriately when faced with an unexpected event during training scenarios at multiple employers suggest an inability to remain calm during stressful situations—a tendency that may have exacerbated his aptituderelated performance difficulties.
12. While the captain was setting up the approach and communicating with air traffic control, his attention was diverted from monitoring the airplane’s state and verifying that the flight was proceeding as planned, which delayed his recognition of and response to the first officer’s unexpected actions that placed the airplane in a dive.
13. The captain’s failure to command a positive transfer of control of the airplane as soon as he attempted to intervene on the controls enabled the first officer to continue to force the airplane into a steepening dive.
14. The captain’s degraded performance, which included his failure to assume positive control of the airplane and effectively arrest the airplane’s descent, resulted from the ambiguity, high stress, and short timeframe of the situation.
15. The first officer’s repeated uses of incomplete and inaccurate information about his employment history on resumes and applications were deliberate attempts to conceal his history of performance deficiencies and deprived Atlas Air Inc. and at least one other former employer of the opportunity to fully evaluate his aptitude and competency as a pilot.
16. Atlas Air Inc.’s human resources personnel’s reliance on designated agents to review pilot background records and flag significant items of concern was inappropriate and resulted in the company’s failure to evaluate the first officer’s unsuccessful attempt to upgrade to captain at his previous employer.
17. Operators that rely on designated agents or human resources personnel for initial review of records obtained under the Pilot Records Improvement Act should include flight operations subject matter experts early in the records review process.
18. The manual process by which Pilot Records Improvement Act records are obtained could preclude a hiring operator from obtaining all background records for a pilot applicant who fails to disclose a previous employer due to either deception or having resigned before being considered fully employed, such as after starting but not completing initial training.
19. The establishment of a confidential voluntary data clearinghouse to share deidentified pilot selection data among airlines about the utility of different methods for predicting pilot success in training and on the job would benefit the safety of the flying public.
20. All pilots of Boeing 767- and 757-series airplanes (which share a similar go-around switch design) could benefit from an awareness of the circumstances of this accident that likely led to the inadvertent activation of the go-around mode.
21. The Department of Defense has developed approaches to automatic ground collision avoidance system technology for fighter airplanes that, if successfully adapted for use in lower-performance, less-maneuverable airplanes, could serve as a model for the development of similar installations in civil transport-category airplanes that could dramatically reduce terrain collision accidents involving pilot spatial disorientation.
22. An expanded data recorder that records the position of various knobs, switches, flight controls, and information from electronic displays, as specified in amendment 43 to the recorder standards of the International Civil Aviation Organization, would not have provided pertinent information about the flight crew’s actions.
23. A flight deck image recording system compliant with Technical Standard Order TSO-C176a, “Cockpit Image Recorder Equipment,” would have provided relevant information about the data available to the flight crew and the flight crew’s actions during the accident flight.
Probable Cause

The NTSB determines that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the Pilot Records Database in a sufficiently robust and timely manner.

Recommendations

New Recommendations

As a result of its investigation, the NTSB makes the following six new safety recommendations:

To the Federal Aviation Administration:
1. Inform Title 14 Code of Federal Regulations Part 119 certificate holders, air tour operators, fractional ownership programs, corporate flight departments, and governmental entities conducting public aircraft operations about the hiring process vulnerabilities identified in this accident, and revise advisory circular 120-68H, “Pilot Records Improvement Act and Pilot Records Database,” to emphasize that operators should include flight operations subject matter experts early in the records review process and ensure that significant training issues are identified and fully evaluated.
2. Implement the pilot records database and ensure that it includes all industry records for all training started by a pilot as part of the employment process for any Title 14 Code of Federal Regulations Part 119 certificate holder, air tour operator, fractional ownership program, corporate flight department, or governmental entity conducting public aircraft operations regardless of the pilot’s employment status and whether the training was completed.
3. Ensure that industry records maintained in the pilot records database are searchable by a pilot’s certificate number to enable a hiring operator to obtain all background records for a pilot reported by all previous employers.
4. Establish a confidential voluntary data clearinghouse of deidentified pilot selection data that can be used to conduct studies useful for identifying effective, scientifically based pilot selection strategies. This program should be modeled after programs like Aviation Safety Information and Analysis Sharing and Flight Operations Quality Assurance.
5. Issue a safety alert for operators to inform pilots and operators of Boeing 767- and 757-series airplanes about the circumstances of this accident and alert them that, due to the close proximity of the speedbrake lever to the left go-around mode switch, it is possible to inadvertently activate the go-around mode when manipulating or holding the speedbrake lever as a result of unintended contact between the hand or wrist and the go-around switch.
6. Convene a panel of aircraft performance, human factors, and aircraft operations experts to study the benefits and risks of adapting military automatic ground collision avoidance system technology for use in civil transport-category airplanes and make public a report on the committee’s findings.

Previously Issued Recommendations Reiterated in this Report As a result of this investigation, the NTSB reiterates the following safety recommendations to the Federal Aviation Administration:

To the Federal Aviation Administration:
Require that all existing aircraft operated under Title 14 Code of Federal Regulations (CFR) Part 121 or 135 and currently required to have a cockpit voice recorder and a flight data recorder be retrofitted with a crash-protected cockpit image recording system compliant with Technical Standard Order TSO-C176a, “Cockpit Image Recorder Equipment,” TSO-C176a or equivalent. The cockpit image recorder should be equipped with an independent power source consistent with that required for cockpit voice recorders in 14 CFR 25.1457. (A-15-7)
Require that all newly manufactured aircraft operated under Title 14 Code of Federal Regulations (CFR) Part 121 or 135 and required to have a cockpit voice recorder and a flight data recorder also be equipped with a crash-protected cockpit image recording system compliant with Technical Standard Order TSO-C176a, “Cockpit Image Recorder Equipment,” or equivalent. The cockpit image recorder should be equipped with an independent power source consistent with that required for cockpit voice recorders in 14 CFR 25.1457. (A-15-8)
Previously Issued Recommendations Reiterated and Classified in The Report As a result of its investigation, the NTSB reiterates and classifies the following four safety recommendations:

To the Federal Aviation Administration:
Require all Part 121 and 135 air carriers to obtain any notices of disapproval for flight checks for certificates and ratings for all pilot applicants and evaluate this information before making a hiring decision. (A-05-1) Classified “Open—Unacceptable Response” Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to document and retain electronic and/or paper records of pilot training and checking events in sufficient detail so that the carrier and its principal operations inspector can fully assess a pilot’s entire training performance. (A-10-17) Classified “Open—Unacceptable Response” Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to provide the training records requested in Safety Recommendation A-10-17 to hiring employers to fulfill their requirement under the Pilot Records Improvement Act. (A-10-19) Classified “Open—Unacceptable Response” Develop a process for verifying, validating, auditing, and amending pilot training records at 14 Code of Federal Regulations Part 121, 135, and 91K operators to guarantee the accuracy and completeness of the records. (A-10-20) Classified “Open—Unacceptable Response”

[Check Airman]

They seem to be able to manage just fine without the cameras.

[aterpster]

They can always express their fantasies during a hearing.

[alf5071h]

Technical aspects which I may have missed in previous posts.

In the 767, to what extent does the autopilot / auto trim respond to pilot override with stick input.
Will the auto trim oppose inappropriate pilot stick input and trim in the opposite direction.
What is the auto trim datum in GA mode - speed.

Was the ATH engaged, Did the thrust increase with GA selection.
What thrust change, if any, might be seen if GA mode is selected but the ATH not engaged.

Does the FDR record stick position directly, or is this inferred fom the elevator psition.

[A320LGW]

Unfortunately what they will never 'report' is that this was a diversity hire, not one on merit.

Will all operators commit to hiring solely based on merit or do we need another incident of this type and more pain with the potential loss of hundreds of lives? I personally don't give a rat's backside about the ethnic background of the person sat next to me, though I care for everything that they were hired on merit and ability.

[Contact Approach]

Could not agree more.

[Check Airman]

Was the Colgan Dash 8 CA also hired because of his skin pigmentation, and not merit?

[Ray_Y]

Looked at part of the hearing.
1. They almost ruled out a repetitive issue with PF display. Furthermore Artificial Horizon was unaffected, and apart from speed tape, F/O could still use conventional speed gauge or stby instruments. IF that happened again it could further irritate IMHO, but looks like it didn't happen.
2. The EFIS momentarily switched to alternate was not recorded on the FDR. I had assumed such looking at the recording resolution of this parameter
3. Yes, there's not much left to defend the First Officer
4. The Cpt contributed with late and lonely action
5. I was not aware of FAA missing deadlines by congress. The hearing contained somehow harsh critics for FAA taking decades to complete safety improvements like Pilot Records Database.
6. The same will happen regarding Image Recorders/CCTV?

Let's still not forget, this is "only" Cargo Operations. Lower count of potential victims.
And having this very Pilot been rejected on Cargo Airlines, he would possibly continue with crop dusters. Even lower count of potential victims like cows in a barn. Still ...

[Airbubba]

Unfortunately what they will never 'report' is that this was a diversity hire, not one on merit.

Will all operators commit to hiring solely based on merit or do we need another incident of this type and more pain with the potential loss of hundreds of lives?

Hiring on merit is considered unfair to groups who do poorly on tests of technical aptitude. You are correct, the word 'diversity' will not be mentioned in the final NTSB report.

As with some other U.S. freighter mishaps, the pilot flying in the Atlas Air 3591 crash had an abysmal training history.

Aska, who was 44, joined Atlas Air in 2017 from the regional airline Mesa, where he had failed to win promotion to captain an Embraer 175 regional jet after being given an unsatisfactory rating in two flight simulator sessions.

Two Mesa captains who evaluated Aska told NTSB that he would get flustered when he encountered unexpected situations in training. Capt. Leigh Lawless said he would “make frantic mistakes,” and would “start pushing a lot of buttons without thinking about what he was pushing.”

Aska failed to finish training at two other U.S. airlines. He left Air Wisconsin after four months of training to be a first officer of a Bombardier CRJ regional jet. The NTSB says he cited personal reasons.

In 2011, he resigned after a month at CommutAir due to “lack of progress in training” to become first officer of a De Havilland Canada Dash 8 regional turboprop, the report says.

Aska failed to list his stints at Air Wisconsin and CommutAir on his employment application, and according to Atlas Air’s director of training, the airline was not aware of it. With that information “we would not have offered him a position,” the NTSB quotes the executive as saying.

After the 2009 Colgan Air crash, Congress required the Federal Aviation Administration to set up a clearinghouse including FAA and employer records on pilots to aid carriers in vetting them, but it has yet to complete the process.

After joining Atlas Air in July 2017, Aska’s training to pilot a 767 did not go smoothly. He was required to undergo 4.5 hours of remedial instruction before he could take an oral exam, and then he was held back for four additional hours of remedial training on a fixed-base simulator before he was allowed to proceed to training on a full-flight simulator, which has motion systems to better replicate the feel of flying.

After two sessions, a fellow student he was paired with complained that Aska was holding him back, and his instructors decided to restart his full flight simulator training from the beginning.

He failed his practical 767 type rating examination, the NTSB says, “due to unsatisfactory performance in crew resource management, threat and error management, non-precision approaches, steep turns and judgment.”

After remedial training he passed, but an NTSB operational factors report questions why Atlas Air didn’t put him in an FAA-mandated, six-month proficiency watch program for remedial training and tracking. Atlas Air’s fleet captain for the 747 and 767 told NTSB investigators that he chalked up the pilot’s poor performance to nervousness, and considering the gaps in his training and family issues he was experiencing, decided to just keep an eye on his performance.


https://www.forbes.com/sites/jeremybogaisky/2019/12/19/pilot-of-doomed-amazon-air-flight-had-poor-training-record-seemed-confused-before-crash-ntsb-report-suggests/#248dec779cc5

[Commander Taco]

Hi Bubba,

And I can think of a few (as I’m sure any of us with a training background can) with “issues” who were not diversity hires and somehow “made it” to the line. Nevertheless, the record above points to a particularly egregious lack of the requisite skill sets.

Cheers.

[Check Airman]

Airbubba

I'll pose the same question to you as Contact Approach and A320LGW . Was the Colgan Dash 8 Captain also a diversity hire?

[A320LGW]

This thread is about the Atlas 767 crash, what relevance does the Colgan air crash have? Whether the colgan captain was hired on diversity or not does not take away from the fact that this guy was, all avenues that allow people who are not up to the job into the job must be closed and 'diversity' points is one of those avenues, this whataboutery solves nothing.

[A320LGW]

Airbubba

The bit about the partner complaining about their progress being held back due to the pilot in question struck a chord with me, I have had this exact same experience. I complained and was told there was nothing that could be done (my partner was literally landing nosewheel into the grass and we were spending whole sessions repositioning at 3 mile finals). It's incredible what can be accepted. Any hope of doing important stuff in preparation for the skills test went out the window, in the name of CRM ... we couldn't even fly straight without being in a nosedive of some sort, it got so bad the instructor had to lean over to her side and put his hand over her's (airbus) and control the sidestick with her. The writing was on the wall but was not accepted, is this turning into an issue across the board?

[Check Airman]

The Colgan crash was similar to this in that a pilot with a checkered background was able to progress by concealing that background. That eventually lead to a crash. I don’t recall that being summed up to the fact that he was a diversity hire. Why’s that the assumption here?

[Airbubba]

The bit about the partner complaining about their progress being held back due to the pilot in question struck a chord with me, I have had this exact same experience. I complained and was told there was nothing that could be done (my partner was literally landing nosewheel into the grass and we were spending whole sessions repositioning at 3 mile finals). It's incredible what can be accepted.

Every U.S. training department seems to have a small group of 'frequent fliers' who repeatedly bust their rides but somehow get passed eventually. I got paired with one of those folks years ago as an FO on a reserve callout for a sim session. She was under some special monitoring by the feds (double secret probation) so an FAA guy was observing on the sim jumpseat.

'Just do your job and don't worry.' the instructor briefed me when I arrived at the training building. It was back in the days where almost every engine failure on takeoff in the sim was the classic V1 cut. As expected, she went off the side of the runway, then cartwheeled and next rolled inverted on the first three tries. She finally got a very wobbly climb out and I prompted her slightly on the gear and flaps. The maneuver was deemed complete. I did some approaches, a V1 cut and a reject and her PNF stuff was fine. The session was complete, they thanked me for the sim support and said I didn't need to stick around for the debrief.

A couple of decades later I flew a trip with another FO who had been recently paired with the same captain for AQP training. She had her customary performance issues and busted the ride as usual. However, this time with crew concept, the FO was busted as well for not taking command of the sim when she couldn't keep it upright.

The pilot flying in the UPS 1394 BHM A306 crash had a similar training history revealed in the docket documents. He took several attempts to upgrade to captain, some documented and perhaps some not according to the 'incomplete' training records. He had been hired by UPS after flunking out of initial training at TWA.

The FedEx 647 crash at MEM and the FedEx MEM 705 hijacking uncovered similar cases of pilots with unusually bad training and employment records hired to fly large freighters.

Airbubba

I'll pose the same question to you as Contact Approach and A320LGW . Was the Colgan Dash 8 Captain also a diversity hire?

Nope and I doubt that he would have been hired at Atlas, UPS or FedEx with his weak training record.

[Check Airman]

Nope and I doubt that he would have been hired at Atlas, UPS or FedEx with his weak training record.

What makes you think he would not have been hired at Atlas, and what gives you reason to believe the GTI FO was a diversity hire? Was it mentioned at any point in the documentation? If I've missed it, would you be kind enough to correct my oversight?

[Airbubba]

What makes you think he would not have been hired at Atlas?

The Colgan pilot flying had a history of training failures.

I've interviewed at Atlas. I found them an extremely professional and diligent group. HR and Technical folks were very well tuned in, and they certainly were not so desperate pilots that, in my opinion they lowered their guard in any meaningful way. Less than half the qualified applicants that day got offers. they turned away a ME 777 CA and several experienced 121 skippers.
Their reputation is that they won't hire anyone with any training failures.

[…] and what gives you reason to believe the GTI FO was a diversity hire? Was it mentioned at any point in the documentation

Just a hunch I suppose.

And why, oh why would this guy keep getting hired as a pilot after so many training failures? :confused:

The search for answers continues...

[Check Airman]

Heck of a hunch. FYI the quote "Their reputation is that they won't hire anyone with any training failures" was from Dec 2019. The crash occurred in February 2019. I know people at GTI who are senior and junior to the FO in question who've had training failures. Your hunch doesn't seem to be correct in this case.

[parkfell]

Coming late into this discussion......

Clearly he wasn’t up to it in multi crew flying, but were his basic flight training records for CPL / IR ever revealed?
It is invariably the case that his ability in flying light aircraft translates directly into more complex multi crew operations.

Within the first 20 hours of ab initial training, his flight instructors would know with certainty that he lacked the aptitude.
They will be reading the accident report with a certain sense of “if only we had terminated the training, he simply wasn’t up to it”.

Citing personal / private / family issues is often the standard excuse for failure to perform.
Clearly it doesn’t help ( if true?)
Harsh as it may be, resolve these issues, and then return once a clear focused mind is achievable.

The clue will lie in the ab initio training files. I would put money on it.

[Check Airman]

I tend to agree with you parkfell but I don’t recall seeing anything about prior history. The other question I have is why it took the CA so long to realise what was happening.

[A320LGW]

I do feel for the captain in this instance, he probably had no idea what the FO was capable of and trusted his skills as a professional who was certified to occupy that seat and manage the aircraft whilst he saw to some of his PNF duties, this given trust came back to bit him in the worst way.

[Airbubba]

Your hunch doesn't seem to be correct in this case.

Really? So he was hired for his ability on merit? I think the record clearly indicates otherwise.

From earlier in this thread:


The FO, given his egregious history of abysmal flying capacity and ineptitude (which I will paste below), had a documented track record of overreacting in unreasonable, irrational ways to 'stalling' states of aircraft by pushing the nose forward past any remotely reasonable degree of 'recovery'. He was documented to freak the F out when startled in precisely THESE type of situations, as has been documented. He should have never been in the seat that fateful day, and didn't deserve to .

Training Incompetency and Failures

6/27/11 - [b]Resigned from CommutAir for failing DHC-8 initial
8/13/12 - Resigned from Air Wisconsin for failing CRJ initial
4/22/14 - Failed EMB-145 Oral at Trans State Airlines
5/11/14 - Failed EMB-145 Type Rating at Trans States Airlines
5/17 - Failed EMB-175 Upgrade Attempt at Mesa Airlines
5/17 - Nearly failed FO Requal after failing upgrade attempt at Mesa Airlines
7/27/17 - Failed B-767 Oral at Atlas Air
8/1/17 - Unsat Judgement/Situational Awareness during FBS-1 at Atlas Air
8/5/17 - Failed DBS-5 at Atlas Air
8/11/17 - Almost Failed FFSI-1 at Atlas Air
8/31/17 - "Regression of Situational Awareness" during FFSI-3 at Atlas Air
9/22/17 - Failed B-767 Type Rating for "Very Low Situational Awareness", incomplete procedures, and exceeding limitations at Atlas Air


Past Training Notes (directly quoted from the NTSB Docket)

Air Wisconsin CRJ Initial Failure - "They were conducting the emergency procedure cabin altitude ... where they are at FL350 or so, and he gives the students a cabin altitude message requiring an emergency descent to 10,000 feet" ... "Conrad then goes to descend the simulator. He was not sure of Conrad's background, but instead of descending on the autopilot, Conrad disengaged the autopilot and abruptly pitched down well below horizon. They got stick shaker and overspeed alert together. He was not sure if it was an extreme nose down, but remembered that it was abrupt input on the controls"
Mesa Airlines ERJ-175 Upgrade Failure (Instructor 1) - "He had previously failed simulator lesson 2 with different instructor, and he had requested a different instructor. She was conducting his retraining for lesson 2. She said his performance was a "train wreck" and he performed very poorly in this lesson. In the briefing room he did well, and explained things well. However, in the simulator and something he wasn't expecting happened he got extremely flustered and could not respond appropriately to the situation." ... "When asked about her comment in her notes about Conrad's "lack of understanding of how unsafe he was," she said he was making very frantic mistakes, lots and lots of mistakes, and did a lot of things wrong but did not recognize this was a problem. He thought he was a good pilot never had any problems and thought he should be a captain. he could not evaluate himself and see that he did not have the right stuff."
Mesa Airlines ERJ-175 Upgrade Failure (Instructor 2) - "He first met Conrad Aska during a recurrent checking event in March 2016. That session went ok and nothing stood out. He did have some trouble with the stall series. The problems were with his attitude control, and he had a hard time getting the airplane back to level flight" ... "He said when Conrad would make a mistake in training he had an excuse for everything"


The quote that stands out the most to me in this second Mesa instructor interview is, "When asked if Conrad would get startled in the simulator, he said that during one stall recovery, Conrad pitched down about 40 degrees for recovery, then a pitch up about 20 degrees. His flight path was all over the place."


As I mused here earlier:

Will the NTSB address these multiple training failures with a call for higher employment standards for transport category pilots? Or will they call for even more remedial training for those folks who can't do the job?

Similarly, is an occasional crash just the price we pay for overlooking a horrible training record in an effort to embrace a broader workplace recruitment demographic?

Things seemed to tighten up around the training building at many places after the Colgan crash for those 'frequent flyers' in the sims who never passed their checkrides without a lot of additional instruction. 709 rides were given by the FAA and a few of the legacy problem children quietly negotiated non-contractual early retirements and cash settlements in lieu of company provided training to get their tickets back.

The 1996 Pilot Records Improvement Act (PRIA) was intended to flag imposters and folks with training issues prior to hiring. Unfortunately, the current custom seems to be to offer a pilot being terminated for cause a chance to resign to avoid further litigation. The union and in many cases gender and ethnic advocacy groups cut a deal with the company and nothing adverse shows up on the PRIA record.

The FO's family has sued claiming that the plane and his Atlas training did not prevent the crash.

The surviving family of Aska, who died at 44, claims in a new lawsuit that negligence from Atlas Air and Amazon, as well as Florida-based companies F&E Aircraft Maintenance and Flightstar Aircraft Services, "directly and proximately caused the death" of the pilot. The family is suing the four companies in a lawsuit filed on Sept. 19 in the 11th Circuit Court for the State of Florida.

Atlas Air, which is contracted to fly Amazon Air's planes along with air cargo company ATSG, employed Aska. The company, according to the federal suit, "owed a duty to the decedent to maintain and use the subject aircraft with the highest degree of care, including a nondelegable duty to ensure its airworthiness, and to exercise the highest degree of care to prevent injury of any kind."

The airline also failed to ensure pilots were well-trained or well-rested, the suit states. The lawsuit claims that Amazon also played a role in those actions.


https://www.businessinsider.com/amazon-atlas-air-fatal-crash-pilots-sue-2019-9

Anyway, I expect that the NTSB will be mystified as to why such a horrible training record was repeatedly overlooked by multiple employers. And, until a freighter hits a city, there will be 'no significant loss of life' in these mishaps with good aircraft and poor pilots.

[Toryu]

Funny how this hasn't turned into multiple thread-pages of rambling about how in a Boeing the captain cold see the yoke move or how he could guide with tactile feedback.
I guess we call all agree on there being too many people flying airliners these days, who have no business sitting at the pointy end of those vehicles.

Hopefully the covid-standdown can do something to purge the bad apples.

[OvertHawk]

Nope!

It will purge the expensive apples and the cheaper ones will be retained regardless of how good they are!

So it will, in fact, result in a higher percentage of bad apples amongst what's left.

Plus they'll be out of practice and under more stress than normal.

But I'm sure that it will all be fine!

[parkfell]

As I mused here earlier:
The FO's family has sued claiming that the plane and his Atlas training did not prevent the crash.


The US legal system does seem somewhat bizarre at times.

The UK equivalent would be to say that they owed a “Duty of Care” to him, and given his appalling airline training record ( treat him as ‘Egg shells’ ) his prospects of a career as as airline pilot should have been brought to an end. By whom and when...? Hindsight is a wonderful thing.

Using the US legal logic, I would have thought the family lawyers would also take aim at the flight school(s) who allowed him to progress and achieve his CPL/IR.
Perhaps even at the FAA and the examiner as well for licence issue?

His flight school training records will be very revealing; of that I am certain.

[Ray_Y]

The US legal system does seem somewhat bizarre at times.

Agree. On the other hand, if the family is in financial trouble since then, I accept them seeking for a good settlement, and then ...

... I would have thought the family lawyers would also take aim at the flight school(s) who allowed him to progress and achieve his CPL/IR.

... Amazon is the most wealthy party in this constellation. A Flight School seems to be less "attactive".

[A320LGW]

Surely if anybody is to sue it would be the captain’s family?

He was entirely failed by the company in that they provided him with a colleague who’s poor skill (that was assessed as being adequate by somebody in Atlas) actually killed him. Don’t we all trust that the person sitting beside us is of a certain standard? Don’t companies have a duty of care to provide us with colleagues who meet set requirements? Was the captain a line training captain in which case some requirements were waived? I found no mention of this.

[Toryu]

Nope!

It will purge the expensive apples and the cheaper ones will be retained regardless of how good they are!

So it will, in fact, result in a higher percentage of bad apples amongst what's left.

Plus they'll be out of practice and under more stress than normal.

But I'm sure that it will all be fine!

I'm afraid you'll be correct.

[WillowRun 6-3]

parkfell, certainly there are odd and even inexplicable (sometimes) things about the law courts and overall legal system, in the U.S. Still, I'd want to read the complaint in this case (assuming it's been filed) before trying to say anything useful with regard to the most significant question in the largest context relevant here: what claims and what plan of attack is best calculated to reach into, or at least toward, the deep pocket (Amazon)? Of course serving the client's interests is the central question but that's just the root; there are lots of branches.

As a side note, ordinarily in litigation the discovery process is dull, drab and boring. But once in a while really juicy, even captivating stuff is known to be "out there"....a 'train wreck', I read somewhere? Hmm, could that be tied to the Railway Labor Act, which governs airline labor relations?

[Midland63]

I'm just an slf so do you mind if I interject to ask a question to see if I've followed this right?

The theory is that GA was commanded accidentally and somatogravic illusion caused the PF to interpret the forward acceleration as upward acceleration causing him to respond by pitching the a/c down. And the PM didn't rescue that error in time.

Is that roughly it?

Thanks

[Uplinker]

Surely if anybody is to sue it would be the captain’s family?

He was entirely failed by the company in that they provided him with a colleague who’s poor skill (that was assessed as being adequate by somebody in Atlas) actually killed him.

Well perhaps, but why did the Captain not take control? It seems that the Captain just sat there and watched the F/O dive and crash the plane? I have to say that, from the CVR transcript, both these pilots do not sound to be exactly on top of things generally. There is 8 seconds after GA is pressed before Captain says anything, and even then it is "what's going on?"

If the F/O had been perfectly competent but had had a seizure or other such rapid onset medical issue, the Capt would have had to take control, so why not in this case?

[WillowRun 6-3]

Though without hitting the law books to see if my recollection suffers from a gap, I do not recall any case law precedent for one pilot's surviving family members suing based on a theory of failure to provide a competent second pilot. Maybe such a precedent does exist (I'm doubtful).

This is equivocal because it indulges patience of qualified posters enough to be a lawyer on this forum in the first place. So without something more definite to work from, no comment on possible legal theories for such putative claims.

[Check Airman]

Uplinker

Agreed. Last I checked, two pilots were required.

[ehwatezedoing]

Uplinker

Assuming the Captain would have recovered relatively quickly the onset, then what?
What about the F/O, given another life extension under the cover of "More training!?"
Or finally fired?

I know, insight is a wonderful thing.

[parkfell]

Without putting too fine a point on it, Aska was less than honest when disclosing his “track record”.
Why might that be? I don’t think you need to have a particularly high IQ to work that one out.

So based on ‘incomplete information’ a decision was taken to hire him.

Q: had full and complete disclosure occurred, would he have been hired?
Clearly this omission must be regarded as at least a chink in the armour of the family’s case?

Despite his shortcomings and repeat / additional training he did complete the course as prescribed by the FAA, the Regulatory body. So by definition, his training was regarded as adequate by the Regulator otherwise he would not have been permitted to operate.
As tragic as it was on that fateful day, he had been adequately trained.
As to why he took that particular course of action is something the psychologists will need to ponder.

If any family needs to feel aggrieved, it is that of the Captain and the other crew on board.

I presume that company “death in service” benefit exists.

As someone who has attended two Fatal Accident Inquiries in Scotland, (The rest of the UK have Inquests) as a witness (aircraft crashes) and a subsequent High Court action, the law, conducted by non aviators, can be an interesting process to observe.

[Meester proach]

I guess that the captain just wasn’t quick enough, this went from minor to catastrophe pretty fast.

[A320LGW]

Uplinker

The captain was talking to ATC at this point, perhaps writing something down? Looking at his chart? (There appears to be minor confusion about whether they are on HDG or LNAV), could have been looking at navaids to adjust? Anyhow after the FO does yank the controls forward, the captain does respond by pulling up - but the FO countered throughout, right until the end when yelling from the jumpseat appeared to make him stop.

There is always startle factor etc, however that does not justify the fact that the causal factor of this incident was an incompetent pilot nosediving an aircraft to the ground. If I were the captain’s family I would want answers anyway.

[OldSowBreath]

I have been a trial attorney in Texas for 40 years this year. I know nothing about flying but for what I’ve learned from the good pilots here. But I do know the courtroom. This is how it will go down: The estates of the three deceased will sue the other estates. All estates will sue Atlas, Amazon and Boeing, and probably a host of others. It’s all about insurance. The case will never go to trial, and it won’t be a decision made by Atlas, Amazon or Boeing, et al. The insurers will settle it out of court and probably during court ordered mediation. Ninety-three percent, if not more, of cases settle out of court now. Arguments will be made back and forth by the lawyers as to culpability and percentages of negligence, but it will boil down to dollars and who you have hired as your attorney. And this city (Houston) has a plethora of tort attorneys that you wouldn’t want your worst enemy to meet in a courtroom. Trust me on this.

[Check Airman]

A320LGW

I’ll accept that the CA may have been distracted by something else, but he wouldn’t have been writing for very long. Isn’t this the accident where the pushover was well into the negative g’s?

If I’m not mistaken, and it is, the CA would have noticed immediately. The question is, why did it take him so long to realise the pitch and the control column position were inappropriate?

[A320LGW]

I suppose this from the report may partially explain why:

“The captain was busy setting up the approach and communicating with ATC causing him to detect the airplane status with delay. Although the first officer's motions caught the attention of the captain the captain did not intervene. Delays are normal due to startle effect and surprise, the captain pulled on the control column but did not announce a control transfer.“

[Uplinker]

A320LGW "If I were the captain’s family I would want answers anyway."

Fair enough. I am not exclusively blaming the Captain, it seems that both pilots were culpable. However, the Captain was the PM, and he was........the captain. So he had two reasons to be monitoring his F/O, and Capt appeared to react slowly in this case, (though it is not very clear to me).

When reading a chart or inputting data, I still glance at the PFD every 10 seconds or so - either mine or his; whichever is closest to my eye-line at the time, and it is rarely out of my peripheral vision. (As we do by checking a car rear-view mirror every 10s or so when driving). In addition, if there was a sudden pitch change, or a sudden change in engine thrust while my eyes were down, I would instantly look up to see what was happening. Ditto if I was making a radio call.

I am curious though, how it is known that the F/O was pushing the yoke and the Captain was pulling? The two are mechanically joined with a shear pin, so would move together until the pin broke, (as happened I believe). Are there force sensors on each yoke to record who was pushing or pulling, and if so how do they work when the shear pin is in?

It also seems to say in the report that the Captain accidentally pressed the TOGA switch. How is it known who pressed the switch?

[Ray_Y]

...Are there force sensors on each yoke to record who was pushing or pulling, and if so how do they work when the shear pin is in?

The FDR file in the public docket only contains Control Column Left (Pitch Control), Elev L and Elev R. All values in Degrees, no forces. So roughly assume Ctrl Left=Ctrl Right before the split, after that you need to guess from the ELEV R what the First Officer did. I was close to provide a higher resolution Graph of the final seconds, but it's difficult.


It also seems to say in the report that the Captain accidentally pressed the TOGA switch. How is it known who pressed the switch?
I remember from the hearing the most probable scenario was the F/O guarding the SPD BRK Lever as per procedure, bringing his hand+wrist close to one of the TOGA switches. Then 5-1 seconds before G/A mode those light turbulences affected the aircraft. Means they don't really "know". It's very likely to be related to the "turbulence", it's not known who touched it.

[Ray_Y]

I have been a trial attorney in Texas for 40 years this year. ...
The case will never go to trial, and it won’t be a decision made by Atlas, Amazon or Boeing, et al. The insurers will settle it out of court and probably during court ordered mediation. ...
Thank you. Your post surfaced late due to your status as new user.
Means it's important to address the wealthy ones who are able to shoulder their share of payment - or is it just the insurances that pay?

[Ray_Y]

I’ll accept that the CA may have been distracted by something else, but he wouldn’t have been writing for very long. Isn’t this the accident where the pushover was well into the negative g’s?

If I’m not mistaken, and it is, the CA would have noticed immediately. The question is, why did it take him so long to realise the pitch and the control column position were inappropriate?

A combined timeline from all sources could help judging. I can't recall all, is this sequence close to reality?
Assumed: Both miss the FMA announced G/A
The pitch up is quite gentle, short after light turbulences
The engines spooling up are the first real alarming surprise
The CPT was busy constructing an answer for ATC and transmit it?
He wants to get an overview, but now the bloke right of him mentiones speed. He compares what he sees with what the other calls out and can't find a connection. This consumes time.
He wants to summarize and maybe act, but then bloke right of him now mentiones "we're stalling". Another seconds wasted in getting an idea. And what's those forces suddenly?
No wonder if there's a delay in response. And they didn't have that much time until they were doomed.
Final bad is, the CPT not only acted late, but lonely. Last chance gone.

EDIT: Alright, 4 timestamps:
12:38:31 G/A
12:38:37 N1>50%
12:38:47 Pitch going Through -20° ,
12:38:50 Pitch ~-40; 290KN, at this increasing Speed & current Power they were most probably doomed here

Fill the gaps with the other events

[OldSowBreath]

Thank you. Your post surfaced late due to your status as new user.
Means it's important to address the wealthy ones who are able to shoulder their share of payment - or is it just the insurances that pay?

The wealthy ones, if not self-insured, will pay out through their primary and umbrella insurance policies. Often, big self-insureds will hire an insurance company and their lawyers simply to handle the negotiations. Today, almost all cases are settled within policy limits. We've gotten attuned to the quick, guaranteed payment of an agreed settlement, as opposed to trying a case that will take years to get through the trial and appellate level, and then trying to seize and sell the assets of the liable parties. I don't see any reason these cases won't settle within policy limits. As you are sure to know, all settlements will be confidential, but between the attorneys, the amounts and percentages of the pay-outs will give them them an idea as to culpability between the parties.

Last night, I got to thinking, and there are probably ten or more defendants who will be sued in addition to the big three. I don't know if Boeing makes its own in-flight cockpit instrumentation, or if that is subbed out to someone like Honeywell, TI, Garmin, etc., etc., but if so, they will be potential defendants.

[alf5071h]

Check A, A320, re #158 '… the CA would have noticed immediately. The question is, why did it take him so long to realise the pitch and the control column position were inappropriate?'

Rephrasing the question #158 with stick-force (trimmed state vs 'pitch') as the key 'awareness' parameter (poor flying technique, training or aptitude) would provide an alternative view of the crews actions.

Opposed to what the pilot 'saw', what was 'felt' and acted on; particularly with respect to configuration change - flap, airbrake, change / reversal of thrust, and speed. In addition, any change from overpowering / CWS function from the autopilot / auto trim ( if it remained engaged ).

If the pilot erroneously used stick force as a key 'awareness' datum, then the rapid and unexpected change in operating configuration (control force is out-of-phase with that required) could result in inappropriate control input opposed to what we, (with hindsight and normal attitude reference), would expect. Thus the CA had to re-establish the situation from an unexpected attitude, control, feel, condition. P2 presents a severely out of trim aircraft to CA, and continues to make inputs - crew use different datums.

View the simulated video of events, without pitch attitude, replace with with stick force - true value has to be calculated from FDR parameters and aircraft type characteristics. How would we fly with our eyes closed.

[misd-agin]

The pitch up after clicking G/A is noticeable. Seat of the pants sensations. Acceleration, positive G's, throttles advancing, engines spooling up (less obvious).

Vertigo issues come into play with advancing thrust and pitch up.

[Ray_Y]

Then have a look at this, regarding positive g's related to the turbulence before. This is from FDR data, 20 seconds around the GA mode activation
The A/P G/A mode recordings have an 1 sample per second interval, so I marked the 1 second time range where the mode must have activated
The vertical accel had 8 samples per second.
The pitch was constant at -1.4 for the last 4 seconds up to 12:38:31.6

https://cimg3.ibsrv.net/gimg/pprune.org-vbulletin/1184x622/atlas_air_crash_accel_vert_aae883968170d5f1ab11bd868570aab38 4ad0959.jpg

(Analysis and Graph Intellectual Property with me)

I'm not saying the CPT behaved perfectly. But the Vertical Acceleration wasn't that clear.

[parkfell]

.......Last night, I got to thinking, and there are probably ten or more defendants who will be sued in addition to the big three....

Might the family lawyers attempt to sue the FAA for issuing him with a licence and/or Boeing type rating?

Now that would set an interesting precedent.....?

[Uplinker]

Uplinker

Assuming the Captain would have recovered relatively quickly the upset then what?
What about the F/O, given another life extension under the cover of "More training!?"
Or finally fired?.......

Yes, exactly. It would appear that within a normal routine flight and the framework of the SOPs, this F/O could operate a B767. However, when things became non-normal, or unexpected, he couldn't, and his instinctive inputs to the flight controls were massively inappropriate. He appeared to have almost no SA and no instrument scan, or appreciation of what his primary instruments actually told him.

So yes; had the flight not crashed, the captain should have sent a formal report or a private word to the chief pilot: "F/O xxx reacted and behaved in a very strange way to an unexpected event. I think you need to look at F/O xxx very carefully, and you should probably check his reactions to such events and other upsets - unbriefed - in the SIM. Over to you".

[parkfell]

.......... However, when things became non-normal, or unexpected, he couldn't, and his instinctive inputs to the flight controls were massively inappropriate. He appeared to have almost no SA and no instrument scan, or appreciation of what his primary instruments actually told him........

A question for those familiar with FAA / NTSB protocols:

Will the FO’s FAA medical records etc be subject to scrutiny with disclosure of any relevant aspects?

[Ray_Y]

Digging in the NTSB docket ...File #36! I quote segments from accident flight CVR:

Between approximately 10:54:48 and approximately 11:04:38, the captain gave the first officer advice on material and study strategies for future captain upgrade training.

Around 11:07:28, the first officer was briefly audible reading items consistent with training material.

Around 11:09:33, the first officer and the jumpseater began a conversation regarding aviation career related topics. The conversation topic changed to discuss how the first officer transitioned to the 767 airframe around 11:13:48. Comparisons were made to previous airplanes, the first officer discussed the transition being “not hard” and that “the box [Flight Management System (FMS)] is easy.”

Around 11:21:48, the first officer discussed the jumpseater’s new job at a different airline. The first officer and the jumpseater discussed upgrade opportunities, basing, scheduling and salaries at different carriers.

??:??:?? The three personnel continued to discuss the aviation industry and upgrade opportunities. The first officer made favorable comments about upgrade opportunities and the lifestyle of his current employment when speaking to the jumpseater.

[WillowRun 6-3]

Case No. 3:19-cv-00170, U.S. District Court for the Southern District of Texas, filed mid-May 2019, dismissed upon a confidential settlement (after referral to a Magistrate Judge) in mid-May 2020. Plaintiff was surviving family member of the jumpseater, Sean Archuleta, as administratrix of his estate and as next friend of two minors. Two heavy-hitter aviation litigators were involved in the case (Mary Schiavo (Pl), Andrew Harakas (D)). The court documents (available on the court's website) contain an interesting item: the release of claims includes a list of related parties, which in turn includes "George Bush Intercontinental Airport, the Federal Aviation Administration, or any other airport or aviation authorities, . . ." (emphasis added).

Not that it would keep a lawsuit by the survivors of the captain from trying what would be the novel theory of negligence or other legal responsibility for the FO's - bluntly stated - gross incompetence, asserted against other than his employer (and the chain of related entities -- and in the Texas federal court case, the lists of related entities are pretty substantial). But so far no trace has been found of any lawsuit by the captain's survivors. Maybe I missed it, somewhere.

The lawsuit by the FO's survivors was filed in Sept. 2019 in the 11th Circuit Court for the State of Florida. Not sure whether any electronic access is available to court files (or any other status information about the case).

[OldSowBreath]

Boeing will already be sued, but yes, that is an allegation the estate could make. Whether it goes anywhere would remain to be seen.

FAA will either have sovereign immunity or at least partial sovereign immunity, which would require the government's permission to sue.

All attorneys' mantra - "Plead like Hell, prove what you can."

[megan]

AVweb's Paul Bertorelli raises a a couple of interesting points, one being Atlas had extended the FO's line flying introduction due lack of progress.

https://www.youtube.com/watch?time_continue=1263&v=uEWXYizNKf0&feature=emb_title

[parkfell]

This addition line training comes as no surprise. Does the source specify how many additional sectors were required?
The line training file will probably be no more than confirmation that the FO was ‘slow to learn’, together with inappropriate responses to situations.

Just why he ‘pushed’ the control column on that fateful day....?
I just wonder if there any clues during the initial stalling exercises in basic training to explain it?

The NTSB really need to explore his training from day 1 PPL / basic training if important lessons are to be learnt.
And his occupation prior to pilot training?
The clues are out there. They need to be found.

[Check Airman]

Just why he ‘pushed’ the control column on that fateful day....?
I just wonder if there any clues during the initial stalling exercises in basic training to explain it?

Hard to say for sure, but the interviews of the instructors he worked with at previous airlines (linked in the original thread, I think) don't paint a rosy picture.

[Ray_Y]

Ok, I found some time to play with Excel, learned how to master the 54,5 average samples per second timeline and combine parameters. Would someone please crosscheck, cause I had worked a lot with formatting the data and correlate events. Source is the public docket at NTSB, file number 66 containing reformatted FDR data as csv file.

Some had interest in the elevator split.I tried to determine the start and end of it. Here the two Elevator parameters in degree, starting 10 seconds before G/A and ending with the last recorded data.
Note that left and right Elevator were recorded alternating with half a second offset, so you can't precisely compare both at the same time.
12:38:44 there might have been a first and short elevator split.
3 seconds later there's a definite split, confirmed in the report.

https://cimg4.ibsrv.net/gimg/pprune.org-vbulletin/1098x680/atlas_air_crash_elevlr_e33a60f78e46d2d10cf9ba31de9fd458fdd97 800.jpg

Then I added 2 parameters, Control Column Left in Degrees (the only one recorded)
And Horizontal Stab Trim Units (Scale right of diagram).

Controls:
Seems as if the CPT held the Column at -4°, while the F/O broke off by pushing.
After 3 seconds CPT reduced to like neutral. He didn't pull, but was he feeling force from the spring connection mechanism between the 2 systems?
After another 7 seconds both pilots pulled almost simultaniously.

Trim:
Interesting. Dunno 767. Is that A/P's revenge (hasn't been disengaged) or is that pilot trim?

https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/1160x682/atlas_air_crash_elevcolumntrim_db2a888b8dd5173b189aa9c16abac 05aa761711a.jpg

(Graphs and Analysis my property, all rights with me)

[Ray_Y]

Those are the G/A switches in the 767.
(Source: Video of the NTSB Board Hearing)
https://cimg2.ibsrv.net/gimg/pprune.org-vbulletin/1331x660/atlas_air_crash_ga_switches_1_6e694f8aef8441d590507116a90512 60e98617ba.jpg
https://cimg9.ibsrv.net/gimg/pprune.org-vbulletin/923x678/atlas_air_crash_ga_switches_2_91d779a81096ede27237b189c5eecb e8860602ff.jpg
https://cimg5.ibsrv.net/gimg/pprune.org-vbulletin/866x653/atlas_air_crash_ga_switches_3_52d356ea9725fbd6b9e92aabd77350 4729e95be2.jpg

[megan]

Just why he ‘pushed’ the control column on that fateful day....If he thought they were stalling you could explain it, even though it may have been an incorrect response, but why did he think they were stalling? That's the one needing an answer to me.

[testpanel]

A simple 757/767 driver here....

Not suggesting/concluding anything, but WHY was the pilot guarding the speed brake?
Wasn't it because the speed brake does not auto-stow when advancing the thrust levers (e.g. on a G/A)?

Have not searched enough but i think after the AA-965 crash in Cali, most/all 757/767 operators world-wide (were told by Boeing?? to) guard the speed brake when extended (since it does not auto stow, compared to, for example an "old" Fokker 70/100 that does auto stow)

Not defending nor attacking anybody, just think out loud...(and very fortunate this pilot was not working in my company......)

RIP

[StopStart]

The brake was out as they were descending so I assume that was why he was guarding it. The brakes were manually retracted as G/A was "initiated". Watch the Youtube vid in the post above - about 3:35 onwards.

[alf5071h]

Ray, interesting charts, #177.

Concentrating on the 'certainly split' region, then this is coincident with change of stab trim.
As you note, which part of the system is driving the trim; which direction - presumably nose down.

Pilot trim switch input, but it is not clear if the AP was disengaged.
Or the AP, auto trim, unlikely re the stick deflection; but if so the direction should be consistent with the selected mode, which was …
Or AP overridden by stick deflection; is this CWS mode, and if so what would the trim be expected to do. Perhaps minimise the stick force as a 'follow up' trim function; but then why does the trim not stop / reverse when the sticks are reversed. The stick 'reversal' is coincident with the split region, where trim reversal might be expected, but with a split, which stick has priority.

Much of the above depends on the stick force felt by the pilot, which is affected by the elevator and trim positions and their relative position in feeding back the feel force.
We don't know what the pilots felt nor how that might have influenced their perception.

[Ray_Y]

Just why he ‘pushed’ the control column on that fateful day....?
I just wonder if there any clues during the initial stalling exercises in basic training to explain it?

If he thought they were stalling you could explain it, even though it may have been an incorrect response, but why did he think they were stalling? That's the one needing an answer to me.

12:38:38 The Ctrl Col was first pushed ~7s after the GA and 1s after N1 increased thru 50%. We can assume this was the F/O
... then eased back for short time before applying more push to -2.5° Elevator
12:38:42 further pushed to -7° Elevator. That's 12/13s after G/A
12:38:46 FO shouts "my speed", that's 8s after the first push
12:38:48 FO shouts "we're stalling", 10s after first push

It's simple, and just needs looking at the report again.

He (or both) was hit by Somatogravic Illusion. Consistent with the thrust increase.
The apparent pitch up was calculated with ~20° at 12:38:42 and 80° at 12:38:46 in the report.
He was not the first commercial pilot to react with pushing down. He did as far as producing 0...-1g
I bet he was partially blind and deaf now, well, overwhelmed. That was especially a problem for him! From then on don't take his calls for real. Did he really believe in a stall?
If you believe you're up to 80°, you can guess your speed is gone very quick
If you feel g-force of 0 or -1, you can think that you're falling
Regarding "speed", it's not 100% ruled out the speed tape on EFIS was affected from another breakdown. NTSB however found it very unlikely. Or he confused overspeed range with something different.

The hearing mentioned some hundereds pilots known to have been affected by somatographic illusion, MOst of them in Gereral Aviation,
The hearing discussed how that effect is dealt with in trainings

[Ray_Y]

Concentrating on the 'certainly split' region, then this is coincident with change of stab trim.
As you note, which part of the system is driving the trim; which direction - presumably nose down.

Pilot trim switch input, but it is not clear if the AP was disengaged.
Or the AP, auto trim, unlikely re the stick deflection; but if so the direction should be consistent with the selected mode, which was …
Or AP overridden by stick deflection; is this CWS mode, and if so what would the trim be expected to do. Perhaps minimise the stick force as a 'follow up' trim function; but then why does the trim not stop / reverse when the sticks are reversed. The stick 'reversal' is coincident with the split region, where trim reversal might be expected, but with a split, which stick has priority.

We don't know what the pilots felt nor how that might have influenced their perception.

A/P C was NEVER off since cruise until end of record
After G/A, A/P was in G/A P mode and G/A R mode (pitch and roll)
The final seconds it changed from G/A P mode to ALT and ALT HOLD mode, that was somewhere at 3000ft (guess what was dialed in into MCP)
The FDR data does not mention CWS. I don't know the 767 and its behaviour with manual overriding the G/A mode

TRIM changed from ~5 to ~4 Units, that is towards nose down. I believe it followed colums with some delay. Again, I hav no knowledge of 767.

"Stick force": add the forces once the split between CPT and F/O took place. I don't know if it's just a momentary breakout force or if the split produces permanent forces.

[testpanel]

Ok, i will try again in more simple terms....

Why, why, does the speed brake does NOT "stow" when thrust levers advance? Because both conditions does not make sense!

Regarding the seconds and somatographic illusion this person should never be in a flight deck

[Ray_Y]

Regarding speed brake I repeat

I remember from the hearing the most probable scenario was the F/O guarding the SPD BRK Lever as per procedure, bringing his hand+wrist close to one of the TOGA switches.

It was procedure, and in fact they were retracted some time after G/A. This made the scenario very likely, but NTSB can't really know.

Touching the extended speed brakes lever is a good practice not to forget it. Happened too often in the past. Simple as that,

[Ray_Y]

Regarding the seconds and somatographic illusion this person should never be in a flight deck

Issue is, how can you prevent somat. illus. from happening? This person yes, he already showed having issues with overpitch even without. But there's no test, it can't be fully simulated. NTSB want's to improve the future, did they address this at the end? Can't remember.

[parkfell]

......He was not the first commercial pilot to react with pushing down. He did as far as producing 0...-1g. I bet he was partially blind and deaf now, well, overwhelmed. That was especially a problem for him!......

Whilst GA will find it harder to create a training program to prevent a repeat of “pushing down”, the airlines will need to design a program to really mitigate this threat.

The data from this tragic event needs to part of the UPRT simulator program and certainty part of any command training and recurrence training yearly.

Prospective employers minds will clearly be concentrated by this tragic event, and improve the Due Diligence process before hiring new pilots.
I would suggest that the process starts from day 1 of flying, even if this is for PPL issue, prior to any thoughts of professional flying.

[Ray_Y]

We still need to see his basic training records, I would suggest?
I think investigation is completed. And then there's this remark at "findings" ... nothing of the following were factors ... training and certification of crew (from memory)

And no safety reccom to address the issue of somat. illus.by training, simulation, right?

Rather a device/automation that shall prevent such CFIT in future, as it seems to work in military aircraft.

[alf5071h]

Ray, et al,
There is no need to invoke an illusion to account for the pilot's nose-down action.

Consider the inadvertent GA mode, not recognised; aircraft starts to pitch up and thrust increases.
The pilot's objective is to continue the descent; the pilot 'naturaly' pushes forward on the stick (opposing the GA pitchup stick force), forgetting that the AP is still engaged; i.e. overpowers the AP without disengaging.

An unknown factor is the mechanism of AP / auto trim movement in this condition. Either:

- Overpowering a normal pitch mode, the trim could react to oppose the pilot stick input, but not necessarily for GA mode.

- If the 767 (this version) enters CWS mode with overpower, then trim follow-up action is more likely; the trim movement and direction aids the pilots stick input.

Thus the erroneous nose down stick input could have been a subconscious, automatic, or startle response to the unseen GA mode, which was then aided by nose down trim.

Does the 767 have a CWS mode, is this activated by overpowering the AP ?
What would the trim do when overpowering the AP, particularly in CWS mode if fitted and activated ?

'Rather a device/automation that shall prevent such CFIT in future, as it seems to work in military aircraft.'
Already tested as a proposal for EGPWS auto pull up for obstacle / unauthorised location (after 9/11); rejected due to civil certification requirements. Also that AP 'muscle' is usually much less than the human input - pilots can override the AP - back to square 1; what happens if the AP is owerpowered.

[misd-agin]

Ok, i will try again in more simple terms....

Why, why, does the speed brake does NOT "stow" when thrust levers advance? Because both conditions does not make sense!

Regarding the seconds and somatographic illusion this person should never be in a flight deck

AFAIR Airbus' speed brakes don't retract either. Instead it gives you and ECAM alert.

Why don't they? No idea. We'd have to be back to the later 1970's or early 1980's to ask why it was designed and certified that way. Perhaps it was "one step too far" for the parties involved in transitioning to the modern glass cockpits? Now we accept glass cockpits but there were significant trainings issues training pilots coming off of 'round dial gauges' to 'glass' /FMC cockpits.

[misd-agin]

The hearing mentioned some hundereds pilots known to have been affected by somatographic illusion, MOst of them in Gereral Aviation,
The hearing discussed how that effect is dealt with in trainings

Friend flew F-15's. Beating up the pattern, light, at the end of a sortie was fun. IMC? G/A in IMC? "I'd just retract the speedbrake and gear. That was enough performance to go-around and reduced the chance of getting vertigo." Imagine being surrounded by a canopy with fantastic visibility. A terrible downside is the 'Star Wars' effect on approach in low visibility. The approach lights go under you and then a split second later flash by across the complete canopy. Add n the acceleration on takeoff (burner), or a G/A around MIL power per SOP's, and vertigo is a real threat.

Deploying squadron overseas had the last departure 'lose his radios' and returned to base. Low IMC using a/c radar in trail departure procedures. So the other aircraft continued. On landing they were told that the last guy had crashed. Investigation was vertigo and pushed over...staying in burner to rejoin quicker? Distracted by radar? Somatogravic illusion.

Vertigo is a real threat if fighters, even in VMC. I think the F-15 record is 12 G's pulling out of a dive after getting vertigo while dog fighting in VMC. Late 1980's out of Langley AFB. A funny moment in his video briefing on what happened - F-4 flashes across the screen. Based on his perception on his attitude the F-4 would be climbing vertically - "if I'd seen that I would have realized I had vertigo. F-4's don't go straight up like that." That always had the viewers laugh...except the F-4 guys?

"

[Ray_Y]

4 submissions of investigation parties published in the NTSB dockets today

dms.ntsb.gov Public docket (https://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=63168&CFID=3041421&CFTOKEN=9eb7f19d5413e33d-334C8CF1-0FB6-0B0B-EFEC7294646BA690)

https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/661x426/atlas_air_crash_docket_screenie_kopie_25c8cb81218d9a20eba973 f13885724e4698c212.jpg

[Ray_Y]

There you have some answers! One of the last 4 files

INTERNATIONAL BROTHERHOOD OF TEAMSTERS Submission:

(...)

1. Autopilot Does Not Disconnect
Discussions with Boeing’s Air Safety Investigation team revealed that the autopilot system is designed such that control column input force that overrides a single channel autopilot servo on the 767-300 will not result in autopilot disconnect, but rather an illumination of the autopilot caution light. A review of the Boeing 767 manual reveals no notes or cautions to this effect. However, in the simulator training environment the built-in protections of simulator control loading will disconnect the autopilot and release the control columns when excessive force is applied during a maneuver or malfunction of the simulator control loading.

The IBT investigators believe this difference has the potential for a ‘negative learning’ transfer from the simulator training environment to actual line flying. While it did not appear to have a direct impact on the accident, the Boeing 767 manuals should be corrected to highlight this system architecture difference for all operators.

2. EFI Switch and Symbol Generator Malfunction
Investigators have been unable to determine the exact failure scenario that required the rapid transfer of controls back and forth between the First Officer and the Captain. Based on a review of the CVR, it appears there may have been a right symbol generator failure of the First Officer’s EFIS59 screens. Selecting the EFI switch to ALTN60 mode would have sourced the center symbol generators. Since this EFI switching event occurred so close to the final upset event, it is possible that the First Officer may have mistrusted his EFIS screen readings and relied instead on sensory input as to aircraft attitude. This EFI/symbol generator event should not have affected the round-dial (analog) airspeed indicators on either pilot’s instrument panel or the backup ISFD in the center left panel for airspeed/attitude crosschecking purposes.

(...)

EDIT: And read their recommendations.

[Ray_Y]

ATLAS AIR Submission:

1.2.2.1 Atlas Air Stall Recovery Guidance
...
1.3.2 Personnel Info > F/O
Employment History
...

3.3 Safety Recommendations
1. To the FAA: Require air carriers to implement ground and simulator training to recognize spatial disorientation/somatogravic illusion induced by sudden unexpected acceleration.
2. To Boeing: Make the activation of the go-around mode more conspicuous to the crew, including an aural alert.
3. To the FAA: Require air carriers to implement training programs related to recognizing inadvertent activation of go-around mode.
4. To the FAA: Implement Congress’s 2010 mandate to establish an electronic database for pilot records.
5. Reiterate, to the FAA: Develop a process for verifying, validating, auditing, and amending pilot training records at 14 Code of Federal Regulations Part 121, 135, and 91K operators to guarantee the accuracy and completeness of the records. (A10-20).

And many more to read

[Uplinker]

Testpanel: Why, why, does the speed brake does NOT "stow" when thrust levers advance?
AFAIR Airbus' speed brakes don't retract either. Instead it gives you and ECAM alert.

Why don't they? No idea. We'd have to be back to the later 1970's or early 1980's to ask why it was designed and certified that way. Perhaps it was "one step too far" for the parties involved in transitioning to the modern glass cockpits? Now we accept glass cockpits but there were significant trainings issues training pilots coming off of 'round dial gauges' to 'glass' /FMC cockpits.

Airbus FBW speed brakes DO automatically retract : if the thrust levers are set above MCT. (TOGA gate is above MCT gate, obviously).

From A320 FCOM: (my bold)

Speedbrake extension is inhibited, if:

SEC1 and SEC3 both have faults, or

An elevator (L or R) has a fault, or

Angle-of-attack protection is active, or

Flaps are in configuration 3 or FULL, or

Thrust levers above MCT position, or

Alpha Floor activation.


If an inhibition occurs when the speedbrakes are extended, they automatically retract and remain retracted until the inhibition condition disappears and the pilots reset the lever. (The speedbrakes can be extended again, 10 s or more after the lever is reset).

In my opinion Airbus significantly improved aircraft design in many areas, including removing the 'external' TOGA switches to avoid accidental operation and re-siting the speed brake and flap levers away from the thrust levers.

[alf5071h]

Ray, #193, #194
Very informative links and a great contribution in identifying explanatory text; thank you. From one set of answers there are more questions.

"Overpowering aircraft auto-flight system does not disconnect the autopilot; this is incorrectly represented in the simulator."

Your question #177 about trim activation and direction of stab movement remains open.
From your chart, trim movement is correlated with stick displacement ('certainly split' region), possibly because auto-trim runs to reduce stick force as it would to reduce autopilot servo load (because the autopilot/auto-trim is still engaged)
If so the nose down pitch change from the erroneous forward stick would be aided by stab trim such that the recovery nose up pull is most disadvantaged by the need for more force to pull up *. Subsequently, stab trim tracks the nose up stick input, but too late.

The remaining question is why the pilot pushed forward at the time. The Boeing view suggest mis-assessed stall condition, my previous - the mindset of intended descent, or other views of illusion; we don't and cannot know for sure.

However, what we can learn is if the 767 AP is overpowered, the the auto-trim moving the stab to reduce stick force to help the pilot can be a disadvantage if the control direction has to be reversed.
Also that the simulator does not replicate this hazard.

* shadow of 737 MAX

[FlightDetent]

If so the nose down pitch change from the erroneous forward stick would be aided by stab trim such that the recovery nose up pull is most disadvantaged by the need for more force to pull up *.

- - - - - - - - - - - - -

* shadow of 737 MAX Sir, I am afraid your credibility took a large one below the waterline with that asterisked remark. My first reaction to reading it was " you could not make this up" but then you actually did.

Yes, I get it that once trimmed down it is harder to pull up, but that make-believe similarity above - - - like seriously bro' WTF? [/grumpy .... exits the stage via the trap-door

[Ray_Y]

...what we can learn is if the 767 AP is overpowered, the the auto-trim moving the stab to reduce stick force to help the pilot...
So this one's for you
A simple 757/767 driver here....
I asked myself if this is a sort of CWS function in the 76, a leftover from former Boeing aircraft. Anyway, if you deflect Column to pitch, as A/P would do, the trim will follow with a delay, as A/P would do, well, rather that's what a still active A/P does, right?

I see a 5 second delay in the FDR, when trim starts to follow control input. And yes, when trim followed nose-down then ...

...the recovery nose up pull is most disadvantaged by the need for more force to pull up

As a side note, I briefly thought of the Ethopian MAX trim as well, like you. I just wouldn't mention it, cause it had not much negative effect:

Ethopian suffered from large Trim down, combined with increasing airspeed. The result was eventual complete loss of pilot elevator authority, impossible to counter trim.

This ATLAS flight had eventually added 1 Trim Unit nose down, also combined with increasing airspeed. Had it not been G/A with trim up before, they'd ended with like +3.8 units. BUT: at the end they were able to pull +4g. So loss of control authority wasn't a factor.

[Ray_Y]

INTERNATIONAL BROTHERHOOD OF TEAMSTERS Submission


There's so much to read in that, I recommend to anybody interested. The other one is Atlas Air Submission. GE had nothing to suggest, and Boeing 's answer is underwhelming.

After reading few of these party's answers, I wonder if NTSB will also pickup these safety improvements:

Add the problem of Somatographic Illusion into training, simulation, enhance simulators fidelity to this (I think it's time!)
Install 767-400 Throttles into older types, those having TOGA switches moved away
Add G/A aural clues (I don't like that one really, more clutter)
Prevent G/A by more logic (With different throttles this is unnecessary IMHO)

[Ray_Y]

Any more questions with respect to FDR data? I'm able to dig out Graphs better now, but soon this fresh knowledge will fade again,

[alf5071h]

Ray, again thank you.

You are in the engine room doing the hard work, identifying aspects which could form the dots of information; its up to others how they put the dots together to clarify the overall picture.

Even with more focus on the pilot's action, any view would only be speculative; yet there are several recently identified technical issues which would benefit from a NTSB review.

We might never know why the pilots reacted as they did, but the operational environment could be improved; inadvertent GA switching, annunciation, AP overpower characteristic - why no disengagement / trim protection and annunciation, representativeness of simulators.

Re simulator training for illusions; the types of illusion being considered involve acceleration - linear or angular. AFAIR there are no training simulators capable of generating sustained acceleration.

[alf5071h]

A theme in this thread is a belief that FDR visualisations alone will provide understanding of the crews perception and thence behaviour.

Tactile senses contribute to pilots awareness - stick force has been overlooked, and thence the 'feel' of the aircraft including significant trim /AP inputs experienced by the crew were not considered.
Without evidence of the stick forces, the ability and time required for recovery is unknown, excepting that in this instance its appears insufficient. Stick force might be calculated from the FDR, however the erroneous assumption that the AP disengaged, but did not, would complicate the process, particularly for any trim contribution to stick force - direction and magnitude.

Re #198

* an attention getting * comment, yes; a reminder of the need for trim awareness and its powerful control function.

A similarity with … No, just a 'shadow'.

For the philosophical, how might we perceive the unseen - look for the shadows.

;)

[FlightDetent]

If you linked to Rostov - a rather appropriate choice - would you do that by saying akin to the NG? That's my shadow ... of a doubt. :ok:

[Ray_Y]

Re simulator training for illusions; the types of illusion being considered involve acceleration - linear or angular. AFAIR there are no training simulators capable of generating sustained acceleration.
Currently yes. But there's always room for improvement. And it's for safety reasons, so they should gather those few engineers, that remained in this world, and get it done
Well, maybe would work even with existing technology. Full FS are about fooling the senses. If you let them prepare a special illusion session, it might come as close as necessary to give the trainees an idea. And then tell them "it's similar, but can even be much stronger".

[Ray_Y]

alf5071h

Yes, I somehow agree. There's one thing to mention.

I focus more on understanding with perspective to improve, identify bad habits and bad tech - like Transport Safety boards
Many other focus more on understanding to judge. Morals, Blame Game, who's the "bad boy", who's the victim, the evil company. Court Room time.

I don't see much to change, improve with respect to control forces, sensations or what you mention those poor souls experienced. So that's again to judge, isn't it? ;)

[Zeffy]

NTSB Final (https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2002.pdf)


https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/1540x2000/screen_shot_2020_08_05_at_2_14_30_pm_a7b2c5bbf22a363297f5c63 79b2e4e35a58be7fd.png

[Ray_Y]

Somehow I'm a bit surprised that NTSB does not at all recommend anything regarding Somatographic Illusion. Not even suggesting to make the community aware or consider refresh knowledge.

NTSB cares to addess "all pilots ... 767/757... awareness of the circumstances of this accident that likely led to the inadvertent activation of the go-around mode.". That's more important?

Rest of suggestions are fine.

[deltahotel]

I guess they didn’t consider it a causal factor. SI is when a strong horizontal acceleration fools the otoliths into believing there is a pitch up. In a GA there is no horizontal acceleration and the pitch up is real.

[_Benjamin_]

Ten years and counting. That’s the amount of time that the FAA has taken to implement
a sufficiently robust Pilot Records Database (PRD), as mandated by Congress.

Seems there needs to be a tighter leash on the FAA.

[Spooky 2]

So does EASA have anything equivalent to a PRIA report?

[oceancrosser]

Probably would be illegal in the EU for privacy reasons. I am actually amazed that Americans seem all for a central database on pilots training records that pretty much anyone could access. Weird. Sound like something out of the USSR...

[Check Airman]

If you ever fill out the paperwork, you’d see why. My understanding is that it won’t be open to the public though. It’s just an overview of your training, and when changing companies, the pilot would give the new company access to (presumably all of) the records. Assume it’ll be something like read-only access to a folder.

[wrench1]

oceancrosser

FYI: access is pretty restricted. It's not a free for all on the info. The link below gives a history and other info.
https://www.faa.gov/pilots/lic_cert/pria/

[apstraining]

There has been a pretty good discussion here of Somotagravic Illusion, but there is another aspect that is often underappreciated in flight simulation, and that is the psychological component. In this case it helps to explain the gross over reaction on the part of the FO. Simulators are great in the normal flight envelope, where the brain is working much the same as it would in flight. But the brain works differently in an upset, when a bunch of hormones (cortisol, adrenaline) get dumped into the system and the training platform isn't bolted to the floor. Doing on-aircraft UPRT it is interesting to watch competent, reliable pilots in the normal domain do some pretty interesting stuff that I don't see in the simulator when confronted with an actual upset in flight. The slang terminology is an "amygdala hijack" and you just can't generate that level of surprise or startle in a simulator.