Atlas 3591 NTSB Animation released

[Ryan A]

 

[Kenny Phillips]

Not the first time this sort of thing has happened, likely not the last.

 

[Ryan A]

So difficult to watch.

 

[FlyingElvii]

Some pretty damning conclusions:

“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,” the NTSB said, as reported by The Aviation Herald.

“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.”

"Moreover, the group believes that systemic deficiencies in the aviation industry’s selection and performance measurement practices also contributed to this incident. It also shares that the Federal Aviation Administration’s (FAA) failure to implement the pilot records database in a sufficiently robust and timely manner is a contributing factor.

The chair concluded that if the FAA had done its job, this pilot would not have been employed by Atlas. Subsequently, this accident would not have occurred."

The Co-pilot had multiple Sim Failures at Mesa and Atlas, and had washed out of two programs before landing at YV.

"The NTSB says that the first officer failed proficiency evaluations during his training at Atlas Air, which operates Amazon Air flights, and at his prior job at Mesa Airlines. He also washed out of training at two other airlines, which he concealed when he applied for work at Atlas, claiming that he had been doing freelance real estate work and taking college classes during that period of time."

After reading several articles on this, IMHO, the Pilot Shortage is as much to blame for this as anything else was. Airlines giving multiple chances to pilots they otherwise would never have hired, because no pilot meant no flying contract, especially at the bottom feeders. Good or bad, the end of the shortage means that operators can become pickier about who they hire.

 

[FlyingElvii]

I was wondering hw a guy like this could get through multiple systems, with all of the checks and balances, to even get to a 767, then I read this on ANet:

"The FO supposedly had a long history of suing employers based on being fired because of his race and lying on PRIA checks."

Political correctness kills, kiddies.

 

[hindsight2020]

check and balances....

Remember children, what Mr. Coppertone said back in the ancient history of 2009: ONE level of safety.

 

[dmspilot]

One of the airlines he washed out of is my current employer; an instructor had not nice things to say.

 

[SC777]

I don’t get it. I mean, I assume the FO didn’t even glance at his gauges?

 

[Bell206]

Abstract of the Final Report:
https://www.ntsb.gov/news/events/Documents/2020-DCA19MA086-BMG-abstract.pdf

 

[Ryan A]

I don’t get it. I mean, I assume the FO didn’t even glance at his gauges?

Sounds like no. Not even a stall horn or anything

 

[Larry in TN]

Sounds like no. Not even a stall horn or anything

There wouldn't be a stall horn. Transport jets have stick shakers.

The stick shakers (a separate one for each pilot's control column) physically vibrates the control column and, in doing so, makes a loud rattling sound. Each stick shaker is independent so if one fails (false positive) only the failed side will activate. If both systems detect the excessive AoA then both stick shakers activate.

But, yeah... They were nowhere near a stall. The F/O misinterpreted the pitch up and acceleration (auto-throttles going to G/A thrust) as an impending stall.

 

[Ryan A]

There wouldn't be a stall horn. Transport jets have stick shakers.

The stick shakers (a separate one for each pilot's control column) physically vibrates the control column and, in doing so, makes a loud rattling sound. Each stick shaker is independent so if one fails (false positive) only the failed side will activate. If both systems detect the excessive AoA then both stick shakers activate.

But, yeah... They were nowhere near a stall. The F/O misinterpreted the pitch up and acceleration (auto-throttles going to G/A thrust) as an impending stall.

Some jets have stall horns though - not the 767
A320:

MD80:

 

[Stan Cooper]

Very hard to watch...

 

[SC777]

There wouldn't be a stall horn. Transport jets have stick shakers.

The stick shakers (a separate one for each pilot's control column) physically vibrates the control column and, in doing so, makes a loud rattling sound. Each stick shaker is independent so if one fails (false positive) only the failed side will activate. If both systems detect the excessive AoA then both stick shakers activate.

But, yeah... They were nowhere near a stall. The F/O misinterpreted the pitch up and acceleration (auto-throttles going to G/A thrust) as an impending stall.

I’m a 35hr student so don’t know s..t from shinola but when I’m doing unusual attitude recovery from under the hood (chin to chest, eyes closed) looking at the AI is the first thing I was taught to do. I assume that still applies at the ATP level??

 

[Tarheelpilot]

I’ll sum this up... the FO was an awful, substandard and unqualified pilot that lied about his experience and training history. He so entitled he leveraged his race in an attempt to prevent accountability for his sub standard performance.

so all of these questions about how 767’s annunciate stalls and whether or not basic airmanship still applies in jets are just a waste of time.

this was 100% pilot error due to gross incompetence.

If you’re questioning how such a dud made it all the way to a 767 cockpit you need to open your eyes. This is a direct result of our societal trends.

 

[DaleB]

I’m a 35hr student so don’t know s..t from shinola but when I’m doing unusual attitude recovery from under the hood (chin to chest, eyes closed) looking at the AI is the first thing I was taught to do. I assume that still applies at the ATP level??

You’d think, wouldn’t you?

I try really hard not to look at professionals doing their jobs and think, “Oh, even I could do that”. I do, however, occasionally say, “Hell, even I wouldn’t do that”.

 

[SC777]

I’ll sum this up... the FO was an awful, substandard and unqualified pilot that lied about his experience and training history. He so entitled he leveraged his race in an attempt to prevent accountability for his sub standard performance.

so all of these questions about how 767’s annunciate stalls and whether or not basic airmanship still applies in jets are just a waste of time.

this was 100% pilot error due to gross incompetence.

If you’re questioning how such a dud made it all the way to a 767 cockpit you need to open your eyes. This is a direct result of our societal trends.

I agree with you 100%. But where was the captain?

 

[Tarheelpilot]

I agree with you 100%. But where was the captain?

Well. He was next door pulling so hard on the yoke that he sheared the interconnect. Sounds like he panicked. Not the best performance in the left seat either. I’m not going to continue my thought... it’s headed to banning territory real quick and I just came back from a vacation because my jokes are apparently inappropriate.

I’ve already said enough.

 

[Larry in TN]

I assume that still applies at the ATP level??

It does. Read about the F/Os previous training failures and how he'd overreact and lock up on the controls.

 

[MFE]

I was wondering hw a guy like this could get through multiple systems, with all of the checks and balances, to even get to a 767, then I read this on ANet:

"The FO supposedly had a long history of suing employers based on being fired because of his race and lying on PRIA checks."

Political correctness kills, kiddies.

Oh no you didn't! Prior experience tells me a reprimand coming in 3..2..1..

 

[TrueCourse]

[was replying to SC777 upthread and didn’t have all the responses posted since last night]

The attitude indicator is a primary instrument that one would look at, yes, but baring a failure of it (which can happen and is trained for in the sim) what we have here is something else. He PUT himself into this situation due to failures outlined in the report, he didn’t see a simple unusual attitude and attempt a recovery. (As a side note, accelerations and decelerations can impact a gyro AI.)

What’s sobering is how quickly he put the plane in a situation that wasn’t recovered from. I still need to read in the report about the complaints he made about his flight instruments just prior to the accident. If there was some failed instrument providing erroneous information, that makes things more complicated than just him misinterpreting what he was feeling against what he was seeing.

What a tragedy. He should have never gotten most of the jobs he had. His performance during training should have washed him out.

 

[Bill]

If you’re questioning how such a dud made it all the way to a 767 cockpit you need to open your eyes. This is a direct result of our societal trends.

And only the first few raindrops of the hurricane on the horizon.

 

[TrueCourse]

The evaluation process doesn’t reject when it should reject. Even if there is trouble finding candidates you can still say “no, this one won’t work out”. So, “failure of an inferior selection and evaluation process influenced by a shortage of highly skilled candidates” is what I prefer to say. All parties drop the ball: hiring employer, pilot candidate, training, etc.

 

[Kenny Phillips]

The evaluation process doesn’t reject when it should reject. Even if there is trouble finding candidates you can still say “no, this one won’t work out”. So, “failure of an inferior selection and evaluation process influenced by a shortage of highly skilled candidates” is what I prefer to say. All parties drop the ball: hiring employer, pilot candidate, training, etc.

In today's world, everyone gets a participation ribbon, and an ATP.

 

[Pugs]

The evaluation process doesn’t reject when it should reject. Even if there is trouble finding candidates you can still say “no, this one won’t work out”. So, “failure of an inferior selection and evaluation process influenced by a shortage of highly skilled candidates” is what I prefer to say. All parties drop the ball: hiring employer, pilot candidate, training, etc.

It's mind boggling that he was not weeded out in the simulator training. Perhaps my experience is different but that's where the really weird stuff is thrown at you to make sure your skills and knowledge are deep enough to be considered up to snuff. Good point about the staffing gaps but I sure hope that pressure to qualify isn't true.

 

[Bell206]

If you’re questioning how such a dud made it all the way to a 767 cockpit you need to open your eyes. This is a direct result of our societal trends.

And only the first few raindrops of the hurricane on the horizon.

Unfortunately, it's not just in the cockpit or with their employers. This storm is still brewing. Nothing like being over-qualified. As they say, red sky in the morning....
https://mslegal.org/press-releases/...s-racially-discriminatory-hiring-policies-­­/

 

[MFE]

Unfortunately, it's not just in the cockpit or with their employers. This storm is still brewing. Nothing like being over-qualified. As they say, red sky in the morning....
https://mslegal.org/press-releases/2500-aspiring-air-traffic-controllers-who-were-harmed-by-the-faas-racially-discriminatory-hiring-policies-/

Merely questioning if something like this were a possible contributor to the pilot's advancement despite documented deficiencies in his skillset was enough to get me censored here when the pilot's background first came to light.

 

[hindsight2020]

False dichotomy. Colgan 3407 demonstrated the same dynamic without having to get into the online ban game. Which is why I posted the reference to it back in post #6. The white knighting for employers here is a more interesting dynamic to me. Post #23 hit the nail pretty well. Plenty of blame to go around.

 

[Larry in TN]

There are regulatory procedures in affect to track training failures from one company to another. This pilot lied on subsequent applications to hide his previous failures. Atlas didn't request his training records from the airlines that he failed initial training because they didn't know he worked for them.

Everybody struggles in the simulator. Some days go really well but everyone has a day, or more, where nearly everything goes wrong. If you come back the next day, show progress, and eventually exceed the standards then you progress and pass. It is rarely a clear, black and white decision to identify someone who is unable to consistently exceed standards. This is especially true in airline training where you may only have a dozen, or so, simulator training events and often have those split up between several different instructors. At the end of the program--the checkride--he met the standards. His problem, which did show up in training, was he'd occasionally over-control and lock up on the controls. How do you know that the training he received after a "bad session" didn't correct the problem?

20/20 hindsight makes it easy to look back and find the warning signs that showed up again on the accident flight. They are not so obvious the first time through when you have an incomplete history, multiple instructors, and no knowledge of what will happen later.

 

[zaitcev]

I’m a 35hr student so don’t know s..t from shinola but when I’m doing unusual attitude recovery from under the hood (chin to chest, eyes closed) looking at the AI is the first thing I was taught to do. I assume that still applies at the ATP level??

Some people are subject to extremely strong illusions in this situation and they must be specifically trained to overcome it by using a higher brain function. I remember at least 2 similar crashes, a Gulf Air A320 into ocean some time around 2001, and a Tatarstan 737 in 2013. On both occasions PF was unable to overcome the illusion.

One thing that may make it worse is if the pilot does not realize that he, too, is vulnerable to the illusion, or being normally resistant is not equipped to counter an unexpectedly strong onset. I had to learn it from experience, unfortunately, although I'm still alive.

 

[flyingcheesehead]

If you’re questioning how such a dud made it all the way to a 767 cockpit you need to open your eyes. This is a direct result of our societal trends.

"Societal trends"??? Presumably you mean he got a pass because of his race?

Come on, open YOUR eyes. With the pilot shortage, they'd hire anyone, and give them multiple chances. Clearly the captain wasn't exactly 89th Airlift Wing material either.

 

[3393RP]

"Societal trends"??? Presumably you mean he got a pass because of his race?

I felt he was commenting on the "everyone gets a trophy, it's mean to fail someone" culture. Of course, perhaps you should open your eyes, because race and gender play a significant part in decision making in today's world. It's undeniable.

 

[MauleSkinner]

At the end of the program--the checkride--he met the standards.

This is one of the advantages and disadvantages of our system.

it’s an advantage because a bad day in training doesn’t really count against you.

it’s a disadvantage because it allows truly unqualified pilots to be trained merely to pass the test.

 

[Kenny Phillips]

I'm all in for training to proficiency. Check rides not needed. Fly until you can do the job, then do the job.

 

[MauleSkinner]

I'm all in for training to proficiency. Check rides not needed. Fly until you can do the job, then do the job.

So a step less than what got this guy into the cockpit of a 767?

 

[Doc Holliday]

The company culture is the greatest failure here.

Supply and demand set the market place. When other operators realize the supply is low (on pilots) they raise the pay to attract the best.

Also, other operators realize the purpose of two crew members who are competent and qualified with regards to the safety and efficiency of their operation.

Also, other operators set standards of training and line operations and adhere to those standards.

So when crew members are considered a “necessary evil” that cuts into the bottom line, and first officers are looked at as seat warmers, and when the job is offered at subpar wages, should anyone be surprised that the applicants will not necessarily be the best?

 

[Larry in TN]

Supply and demand set the market place. When other operators realize the supply is low (on pilots) they raise the pay to attract the best.

Yet, when Atlas hired the accident F/O, they were struggling to attract applicants yet they were engaged in a draw-out contract battle with their pilots. Low training pay, a low 50hr montly guarantee for the first year, and a sub-par hourly rate as compared to other 767 operators. Not a good combination.

 

[Let'sgoflying!]

The NTSB says this airplane crashed (RIP both pilots and passenger) because the FO succumbed to somatogravic illusion (SI).
You might think this won't happen to you because you are on the lookout for it, you trained for it, you are a better imc stick, you did better in flight testing, maybe you have better trained stereocilia and otoliths etc....but can you be sure?
Anyone have first hand experience with SI?
I think all of us can be taken by surprise by this, and other illusions.

 

[Doc Holliday]

The NTSB says this airplane crashed (RIP both pilots and passenger) because the FO succumbed to somatogravic illusion (SI).
You might think this won't happen to you because you are on the lookout for it, you trained for it, you are a better imc stick, you did better in flight testing, maybe you have better trained stereocilia and otoliths etc....but can you be sure?
Anyone have first hand experience with SI?
I think all of us can be taken by surprise by this, and other illusions.

In 40+ years of professional flying, and instructing, I’ve never seen it.

 

[MauleSkinner]

The NTSB says this airplane crashed (RIP both pilots and passenger) because the FO succumbed to somatogravic illusion (SI).
You might think this won't happen to you because you are on the lookout for it, you trained for it, you are a better imc stick, you did better in flight testing, maybe you have better trained stereocilia and otoliths etc....but can you be sure?
Anyone have first hand experience with SI?
I think all of us can be taken by surprise by this, and other illusions.

I’m sure we can all be taken by surprise. But I’m also sure that a competent pilot at the level he was theoretically at would be able to deal with it in a far less fatal manner.