Atlas Air 3591 NTSB Public Docket Opened
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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.
...
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.
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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
Past Training Notes (directly quoted from the NTSB Docket)
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.
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.
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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.
EDIT: Robert flew a Socata TB10 light, possibly no gliders.
Last edited by Euclideanplane; 20th Dec 2019 at 22:22.
SkyGod
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. 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.
Seen it in the simulator and in the aero plane.
It would appear to be a textbox example of the Dunning-Kruger Effect...
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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.
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TOGA in the 767 is pretty gentle, no need to panic and push the nose down 40 degrees with the throttles way up.
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The transcript made no mention of flaps 5.
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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.
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?
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.
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?
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
Captains that think only FOs can make mistakes.
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..
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.
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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
Past Training Notes (directly quoted from the NTSB Docket)
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.
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.
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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.
SOMATOGRAVIC ILLUSION WHILE IN IMC.
The remedy is aptitude and training. The former seem to have been a problem here.