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-   -   Atlas Air 767 down/Texas (https://www.pprune.org/rumours-news/618723-atlas-air-767-down-texas.html)

B2N2 13th Apr 2019 01:17


Originally Posted by 49d (Post 10446229)
Flaps down, 30 miles out?

If you look at the STAR they flew, two waypoints required a height of 6000’ and 7000’ respectively and both required a speed of 240kts which depending on weight would usually be “Flaps 1” which is leading edge slats only.

extreme P 13th Apr 2019 01:29


Originally Posted by B2N2 (Post 10446390)


If you look at the STAR they flew two waypoints required a height of 6000’ and 7000’ respectively and both required a speed of 240kts which depending on weight would usually be “Flaps 1” which is leading edge slats only.

I can't see a short domestic flight being at such a heavy weight on landing requiring flaps 1 at 240 kts. Likely 220 kts or less for minimum clean speed.

B2N2 13th Apr 2019 01:42

Well maybe they intended to slow down even further in anticipation of a high close in descent, or simply more of a buffer considering weather or expected turbulence.
In any case it appears flaps were selected.
Does not really matter what you or I think.

Airbubba 13th Apr 2019 02:07


Originally Posted by B2N2 (Post 10446390)


If you look at the STAR they flew, two waypoints required a height of 6000’ and 7000’ respectively and both required a speed of 240kts which depending on weight would usually be “Flaps 1” which is leading edge slats only.

The plane must have been pretty light to climb directly to FL400 out of MIA. I think most of us would fly 240 knots clean in a B-763 even at max landing weight.

Which STAR did they fly with GILLL in it?

Did they fly the LINKK ONE GIRLY TRANSITION? The next waypoint after GILLL has a 210 knot speed constraint, they were taken off the STAR on vectors but maybe the call was made for flaps 1 in anticipation of slowing with some stall margin for the bumps.

B2N2 13th Apr 2019 22:17

When they take you off a STAR it’s smart to keep altitude and speed constraints in the back of your mind as you may get cleared to a waypoint further down the line once clear of weather or slower/faster conflict traffic.
So even though they were on a vector they may have decided to slow to 210 and select flaps 1 as that was the constraint for the next waypoint.

49d 14th Apr 2019 00:23

wreckage should have shown, flaps, or led s in or out .i wonder how they would do with a 100kt overspeed...

aterpster 14th Apr 2019 00:28


Originally Posted by 49d (Post 10447004)
wreckage should have shown, flaps, or led s in or out .i wonder how they would do with a 100kt overspeed...

Probably a lot of data from the DFDR as well.

And, then, there is the DCVR.

Both of which the NTSB is holding back, unlike if these were a 767 with 200 souls, or so, on board.

747-8driver 19th Apr 2019 16:01

Texas Fishing Forum
Quite amazing if true.

hawkeye red 19th Apr 2019 16:16

747-8driver...rubbish article. If your throttles advance to the TO/GA mode without you wanting that, you just disconnect autothrottle. Simple and easy...

Airbubba 19th Apr 2019 16:23

Here's the post from the link above, the narrative is similar to other online versions supposedly leaked by someone privy to the CVR and FDR readouts.


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


Organfreak 19th Apr 2019 16:33


Originally Posted by hawkeye red (Post 10451370)
747-8driver...rubbish article. If your throttles advance to the TO/GA mode without you wanting that, you just disconnect autothrottle. Simple and easy...

Is it possible that they didn't realize that TOGA had engaged? (One would THINK not!)
:eek:

Meester proach 19th Apr 2019 18:52

Same narrative again .
TOGA isn’t full power , it’s 2000 FPM.

whats happens with the shear pin ? Do you get your respective elevator or both ?

flyingchanges 19th Apr 2019 19:01

Approaching 8 weeks with no prelim.

Old Boeing Driver 19th Apr 2019 20:53


Originally Posted by Meester proach (Post 10451461)
Same narrative again .
TOGA isn’t full power , it’s 2000 FPM.

whats happens with the shear pin ? Do you get your respective elevator or both ?

See post #691. There is not a shear pin as in earlier Boeing's. Either yoke would control both surfaces.



Airbubba 19th Apr 2019 22:38

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://cimg3.ibsrv.net/gimg/pprune....e43a641a02.jpg
https://www.ntsb.gov/investigations/...ts/AAB0201.pdf

Bleve 20th Apr 2019 00:09

If TOGA thrust was inadvertently and unexpectedly applied, then the subsequent events have all the hallmarks of Somatogravic illusion. From:

Somatogravic Illusion - AviationKnowledge


...power is rapidly applied and the aircraft then accelerates rapidly ... As no visual cues exist, this generates a strong ‘tilt back’ sensation which the pilot interprets (incorrectly) as a rapid pitching up sensation. Despite this perception the aircraft may still actually be in a level attitude or only a slight climb ... This is the somatogravic illusion. The pilot will then push forward on the control column to control this (imaginary) climb thinking they are lowering the aircraft nose back to level flight, when in actual fact they are lowering the nose into a dive. As the aircraft nose lowers, the aircraft continues to accelerate, generating additional pitch up sensations, causing the pilot to lower the nose even further. Tragically, this illusion normal ends with the pilot commanding the aircraft into a high speed steep dive and contact with the ground quickly ensues.
Full Flight Simulators use this principle, except in reverse. Tilting of the simulator is used to simulate acceleration: tilt back = acceleration, tilt forward = deceleration.

If a rapid acceleration resulted in the F/O falling victim to this illusion, that would explain why he pushed full forward on the control column and also why he was unresponsive to the CPT's desperate attempts to get control of the aircraft. Having experienced this illusion once myself, I can tell you that it is overwhelming and results in almost total cognitive overload. The defence against it is awareness that it can happen and training in what to do if it does. In my training it was to 'Trust your Instruments'. ie Lock onto the AI and fly the attitude, regardless of what your body is screaming at you to do. And that struggle between doing what is right (fly the attitude) and what is wrong (push forward to counter the illusion) is all consuming - I doubt I would have been responsive to someone screaming at me either.

FIRESYSOK 20th Apr 2019 04:32

Trusting instruments without discrimination is deadly. Many instances of this have resulted in crashes and serious upsets as well.

A wiser reaction— and one you have to think about beforehand— is to ask yourself- is this real? Sim training should address instrument failure and force this thought process. At 6000’, you have the time to recover from a low speed condition without moving the column full forward. On liftoff you see a sudden, incredibly dwindling, or increasing airspeed...is it real? A quick crosscheck can prevent disaster.

Fatigue, training, natural ability...all factor in. No doubt, somatogravic illusion can make you ill and many have never experienced it first hand. Don’t forget there is another crew member to defer to if suddenly you’re overwhelmed. It can happen.

fox niner 20th Apr 2019 07:00

All this may be very true, but what was the last time the ntsb postponed or omitted to publish a preliminary report?
9-11?
Today is day 55. This is certainly going to be an interesting read.

aterpster 20th Apr 2019 13:29


Originally Posted by flyingchanges (Post 10451470)
Approaching 8 weeks with no prelim.

That shouts out something.

Dark Knight 21st Apr 2019 03:57

Re post 850 from a reliable source.

My thoughts.

Did not fly the 767 however, checking Captain Google images, the TOGA (Go Round) switches (as in most Boeings) are positioned such they require a premeditated, definite decision/action to trigger them.

I suggest it is almost impossible to do this when correctly selecting a flap reposition particularly should one have been properly trained: i.e. when selecting a flap reposition from the Left seat the hand always goes under the pilot flying (F/O's) arm. This prevents the Left seat pilot's arm getting in the way of the Pilot Flying (F/O) use of the thrust levers.
Further the hand/arm would not be anywhere near the TOGA switches.

Had for some reason TOGA had been initiated one would think autothrust would be immediately disconnected to maintain the required flight path/remain in control of the aircraft. Or is the required flight path was not able to be maintained a go round carried out.

This should be a fairly standard procedure which all training would demonstrate.

Airbubba 21st Apr 2019 04:58


Originally Posted by Dark Knight (Post 10452331)
I suggest it is almost impossible to do this when correctly selecting a flap reposition particularly should one have been properly trained: i.e. when selecting a flap reposition from the Left seat the hand always goes under the pilot flying (F/O's) arm. This prevents the Left seat pilot's arm getting in the way of the Pilot Flying (F/O) use of the thrust levers.
Further the hand/arm would not be anywhere near the TOGA switches.

Had for some reason TOGA had been initiated one would think autothrust would be immediately disconnected to maintain the required flight path/remain in control of the aircraft. Or is the required flight path was not able to be maintained a go round carried out.

This should be a fairly standard procedure which all training would demonstrate.

No offense but are you an Ozmate FO perhaps? :confused: I've flown with a couple who had similar detailed ideas of the 'right' way to do things in the cockpit. One guy told me that I was folding the paperwork the wrong way. Maybe he was right...

Can you find any reference for this 'standard procedure' for your, uh, reach around?

Some FO's would have their hands on the throttles at 6000 feet with autoflight engaged, others would not in my experience. These are not TOGA switches, they are go-around switches on the B-763. I agree that clicking off the autothrottle and pulling back the thrust levers would be a simple way of handling the initial miscue. Or, selecting FLCH since 6000 is in the altitude window would automatically pull back the power and bring you back on altitude.

extreme P 21st Apr 2019 07:47


Originally Posted by Dark Knight (Post 10452331)
Re post 850 from a reliable source.

My thoughts.

Did not fly the 767 however, checking Captain Google images, the TOGA (Go Round) switches (as in most Boeings) are positioned such they require a premeditated, definite decision/action to trigger them.

I suggest it is almost impossible to do this when correctly selecting a flap reposition particularly should one have been properly trained: i.e. when selecting a flap reposition from the Left seat the hand always goes under the pilot flying (F/O's) arm. This prevents the Left seat pilot's arm getting in the way of the Pilot Flying (F/O) use of the thrust levers.
Further the hand/arm would not be anywhere near the TOGA switches.

Had for some reason TOGA had been initiated one would think autothrust would be immediately disconnected to maintain the required flight path/remain in control of the aircraft. Or is the required flight path was not able to be maintained a go round carried out.

This should be a fairly standard procedure which all training would demonstrate.

What do you recommend for a "go round" at 6000' when flying a STAR?

misd-agin 21st Apr 2019 13:31

The 767 Go-Around switches are in a different position than the one's on the 737NG and 777. The 737NG and 777 are forward of your hand and are activated by your finger tips. On the 767, if you let your throttle hand thumb relax and lower, it's in about the right position to engage the Go-Around switch. I've unintentionally engaged the Go-Around on both designs (767 and 777). It didn't happen on the 737 because the buttons are smaller and harder to move.
Maybe I'm a klutz but things get bumped.

gearlever 21st Apr 2019 14:27

TOGA switches 767


https://cimg5.ibsrv.net/gimg/pprune....d7b0c60518.jpg

IcePack 21st Apr 2019 17:07

On the 767/757 I was told the go around switches were palm switches. Seemed to work for me.

Meester proach 22nd Apr 2019 09:48

Actually preferred them in that position to the 78 reach over and down, seemed easier to find .

6PapaWhishey 23rd Apr 2019 23:23

NTSB Preliminary Report published
 
Says nothing that wasn't known within a week of the mishap. I'm a noob, so can't post the URL.

Jumbo744 24th Apr 2019 13:36


Originally Posted by Dark Knight (Post 10452331)
Re post 850 from a reliable source.

My thoughts.

Did not fly the 767 however, checking Captain Google images, the TOGA (Go Round) switches (as in most Boeings) are positioned such they require a premeditated, definite decision/action to trigger them.

I suggest it is almost impossible to do this when correctly selecting a flap reposition particularly should one have been properly trained: i.e. when selecting a flap reposition from the Left seat the hand always goes under the pilot flying (F/O's) arm. This prevents the Left seat pilot's arm getting in the way of the Pilot Flying (F/O) use of the thrust levers.
Further the hand/arm would not be anywhere near the TOGA switches.

Had for some reason TOGA had been initiated one would think autothrust would be immediately disconnected to maintain the required flight path/remain in control of the aircraft. Or is the required flight path was not able to be maintained a go round carried out.

This should be a fairly standard procedure which all training would demonstrate.


Where do you get these statements from? Who said there was a standard procedure for moving the flap lever? Just making this up? And also, how do you perform a go around at 6000 feet on a STAR? Do you know the definition of a Go-Around? On a Boeing, if you ever need to stop your descent on an arrival and need to climb back up, the easiest and smoothest way would be to set a higher altitude on the MCP and use Level Change. Unless you are about to hit something, you won't use TOGA at this point.

As far as hitting the TOGA switches accidentally, stranger things have happened, and it is possible.

Meester proach 24th Apr 2019 14:35

[QUOTE=6PapaWhishey;10454240]Says nothing that wasn't known within a week of the mishap. I'm a noob, so can't post the URL.[/QUO

Cant see anything new on NTSB site after March .

6PapaWhishey 24th Apr 2019 14:55

Cant see anything new on NTSB site after March .
[/QUOTE]

Here's the text from the report:

" On February 23, 2019, at 1239 central standard time, Atlas Air flight 3591, a Boeing 767-375BCF, N1217A, entered a rapid descent from 6,000 ft and impacted a marshy bay area about 40 miles southeast of George Bush Intercontinental Airport (KIAH), Houston, Texas. The two pilots and one nonrevenue jumpseat pilot were fatally injured. The airplane was destroyed and highly fragmented. The airplane was operated as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight, which originated from Miami International Airport (KMIA), Miami, Florida, and was destined for KIAH."

The report can be found in the " Accident Synopses - by month" page of the NTSB site.

Paul852 24th Apr 2019 15:02

Here you go (it's more or less content-free): https://app.ntsb.gov/pdfgenerator/Re...=HTML&IType=MA

PerPurumTonantes 24th Apr 2019 15:14


Originally Posted by Paul852 (Post 10454651)
Here you go (it's more or less content-free): https://app.ntsb.gov/pdfgenerator/Re...=HTML&IType=MA

That's not a "report". It's a piece of paper generated because someone felt they had to generate a piece of paper. No information after this long lends more weight to the rumours earlier in this thread.

testpanel 24th Apr 2019 15:17

Well, we all knew that.
Nothing new.
Time for the ntsb to come up with some real investigating news!

armchairpilot94116 24th Apr 2019 16:12

https://ocw.mit.edu/ans7870/16/16.63...3JF12_A300.pdf

hitting the TOGA accidentally has resulted in crashes and near crashes before as in CI 140 Nagoya accident A300-600

Lonewolf_50 24th Apr 2019 21:33


Originally Posted by testpanel (Post 10454665)
Time for the ntsb to come up with some real investigating news!

What's your hurry?
If they are being meticulous, and it takes time, where's the problem?

lomapaseo 24th Apr 2019 21:46


Originally Posted by armchairpilot94116 (Post 10454713)
https://ocw.mit.edu/ans7870/16/16.63...3JF12_A300.pdf

hitting the TOGA accidentally has resulted in crashes and near crashes before as in CI 140 Nagoya accident A300-600


I don't recall TOGA being the precipitator. I do recall the screaming call as they fell in a stall of "power Power"

They hit the ground flat with little forward speed

The CI crash in Tapei was involved with too much power, precip a stall on a canceled approach

Lonewolf_50 24th Apr 2019 21:53

loma, I know very little about 767: if one accidentally hits TOGA, can not then pull the power back by hand? (Or otherwise disengage it?)

Meester proach 24th Apr 2019 23:17


Originally Posted by Lonewolf_50 (Post 10455031)
loma, I know very little about 767: if one accidentally hits TOGA, can not then pull the power back by hand? (Or otherwise disengage it?)


Of course.

b1lanc 25th Apr 2019 00:36


Originally Posted by lomapaseo (Post 10455019)
I don't recall TOGA being the precipitator. I do recall the screaming call as they fell in a stall of "power Power"

They hit the ground flat with little forward speed

The CI crash in Tapei was involved with too much power, precip a stall on a canceled approach

VanderBurgh confirmed TOGA switch as precipitator in his video that includes runaway stab. You can choose to believe his information or not.

armchairpilot94116 25th Apr 2019 01:36


Originally Posted by lomapaseo (Post 10455019)
I don't recall TOGA being the precipitator. I do recall the screaming call as they fell in a stall of "power Power"

They hit the ground flat with little forward speed

The CI crash in Tapei was involved with too much power, precip a stall on a canceled approach

i was in Taipei when that one went down
will have to find the accident report
memory fades but remember they were a bit high on the approach and did late go around with full load sans the fuel burn from Bali and stalled at low altitude into apartments

pilot fatigue was mentioned as a big
factor Power applied too late for successful go around it seems or the AOA too high

the accident happened at night


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