Atlas Air 3591 NTSB Public Docket Opened

[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
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]

Originally Posted by Dogsofwar

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]

Originally Posted by 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?

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

[Airbubba]

Originally Posted by neville_nobody

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.

Originally Posted by Disso

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?

Originally Posted by 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.

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]

Svhar

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]

Approach Brief

Originally Posted by wiggy

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]

Originally Posted by Airbubba

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]

Originally Posted by deltahotel

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]

Originally Posted by derjodel

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]

Could happen

Originally Posted by 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.

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]

Originally Posted by slickcity

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]

Originally Posted by Check Airman

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]

Originally Posted by slickcity

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.

Originally Posted by Check Airman

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.

Originally Posted by 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?

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]

Originally Posted by neilki

@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?

Originally Posted by Airbubba

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/63000-63...168/631157.pdf