20 Seconds to Save It: How an Impulsive Pilot Caused a Fatal Crash Revised

hi everyone paul bertorelli for avweb just as i was editing the video you're about to see i got an email from a boeing 767 pilot friend of mine who related a story very similar to the one we're about to cover here he was the pnf that's the pilot not flying or pilot monitoring and while flying an approach into a major international airport he heard swearing from the first officer followed by an attention-getting pitch excursion he looked down for five seconds to make a frequency change when the airplane's automation suddenly did exactly what someone told it to do but which was nonetheless not desired by the time he re-entered the loop the fo had tweaked the desired selector and tamp things down my friend said it took about 20 seconds to figure things out and by then it was all over and that sort of thing probably happens oh a dozen times a day or at least it did before covet 19 dried up airline flying the point is automation in airplanes is great stuff but with homo the sap still in the loop it can cause machine assisted chaos the accident we'll review here is not an automation accident it's a lack of piloting skill accident aggravated by misused automation this week the ntsb held a sunshine hearing on its investigation into the crash of atlas air 3591 on a flight from miami to houston on february 23 2019. three crew members aboard that airplane were killed atlas air is a cargo airline and it's a contract hauler for amazon the flight was carrying freight into houston's bush airport cut right to the chase the summary is this the airplane crashed into trinity bay 40 miles southeast of houston while skirting the edge of convective weather and some turbulence it crashed into the shallow bay after entering a 46 degree nose down dive that accelerated from 225 knots to 433 knots in 30 seconds reaching a maximum vertical speed of 30 000 feet per minute here's how the ntsb reconstructed it we will show a short animation depicting the sequence of events note that the depictions are not necessarily identical to the airplane displays in this still frame you can see a simulated external view of the airplane the analog airspeed indicator with digits to aid clarity the main attitude director indicator including an airspeed tape display and artificial horizon and here is a representation of the flight mode annunciator display an analog altimeter also with digits added for clarity the control yoke position thrust levers the speed brake lever position a profile graph and select cockpit voice recorder transcript items this animation may be disturbing to some viewers who may wish to blank the screen for about 90 seconds the crew was setting up the approach procedure when the airplane encountered light turbulence shortly afterward the autopilot and auto throttles entered go around mode as the airplane was passing about 6300 feet there were no flight crew call outs consistent with the activation of the go around mode the airplane arrested descent and began a slight pitch up the thrust levers advanced and the speed brakes were retracted which could only be done manually the captain responded to a routine radio call while the first officer pushed forward on the column and made an expression about speed and exclaimed we're stalling there was no indication that the airplane actually stalled it was likely that the first officer was experiencing disorientation due to the somatographic illusion in which airplane acceleration results in a false nose high feeling the airplane reached a steep nose down attitude and high speed below about three thousand feet the airplane broke out of the clouds the controls moved to full nose up but it was too late before they impacted the bay the ntsb was unsparing in its analysis and concluded that the first officer inadvertently activated the airplane's go around mode and then due to spatial disorientation misinterpreted the airplane's attitude as nearing a stall and he sharply commanded nose down captain was slow to respond and by the time he did counter the first officer's pitch down it was too late to recover the airplane the aircraft was never near a stall condition much of the hearing was given over to discussion of the first officer's weak piloting skills and how he was able to conceal an unfavorable employment record from atlas when he was hired more on that later but first the clarification of terms transport aircraft equipped with autopilots that's basically all of them have what's called a go around mode even light aircraft autopilots sometimes have this capability in the 767 the switch for go around mode is on the throttles and when commanded the airplane smoothly pitches up about four or five degrees and the auto throttles advance to produce a 2000 foot per minute climb it is not an abrupt maneuver the ntsb believes the first officer accidentally bumped the go around button because he likely had his hand on the speed brake control which is located on the captain's side of the cockpit pedestal it requires an awkward reach and due to height turbulence the first officer's hand may have bumped the button at least that's the theory a veteran 767 training captain i know told me he doesn't see how this could happen and never saw it in decades of instructing but however it happened it's pretty clear that it did happen although the go around maneuver is not aggressive the acceleration may have been enough to induce a kind of spatial disorientation called somatographic illusion probably remember this from your instrument training and maybe even basic fight training human sense of balance is controlled by the inner ears vestibular system three semicircular canals sense accelerations in pitch yaw and roll within the vestibular labyrinth are two structures referred to as otolith organs these sense movements in the vertical and horizontal planes such as side to side or front to back head movement when an airplane pitches up in visual conditions the pilot properly senses this similarly if the otolith organ is subject to level acceleration outside visual reference will confirm there's no pitch up but in instrument conditions the brain may interpret level acceleration as a pitch up moment possibly a rapid one this is somatographic illusion and it may have led the first officer to believe mistakenly that the aircraft was approaching stall angle of attack here's how the ntsb's david lawrence described it because the first officer was not effectively scanning his instruments interpreting the information they provided he experienced sensations which led him to incorrectly conclude that the airplane was stalling while the airplane was not in a stalled condition the first officer's aggressive nose-down inputs and his failure to disconnect the autopilot and auto thrust were contrary to his training and atlas air sops for both a stall recovery or an unintended automation change the first officer should have disconnected the automation and manually return the airplane to its original profile instead the first officer continued to make manual inputs that overrode the autopilot and forced the airplane into a steep dive that was unrecoverable the first officer's apparent struggles with impulsive action during training scenarios at multiple employers suggest that he had an inability to remain calm during stressful situations this trace from the airplane's flight data recorder shows how aggressively the first officer reacted this blue line depicts pitch green line is air speed and the purple line is altitude time is along the bottom scale from the initiation of the inadvertent go around here where the pitch up starts to impact was about 37 seconds go around power was reduced but not significantly pitch recovery starts 22 seconds after the go around command when the captain began reversing the first officer's nose down input but it was too late the aircraft impacted pitch down at about 16 degrees and at 433 knots the 767 has by the way what's called a split path elevator meaning the left and right elevators work independently of each other but the pitch up command has slightly less authority than the pitch down command not that it would have mattered much because of the captain's delayed response and the ntsb found that the captain's response was a factor in the accident cause from the hearing again here's david lawrence during the descent as the captain was acting as pilot monitoring and setting up the approach and communicating with air traffic control his attention was diverted from monitoring the airplane state and verifying that the airplane was proceeding as planned this delayed his recognition of and response to the first officer's unexpected actions to place the airplane in a dive as pilot in command the captain is directly responsible for and is the final authority on the operation of that aircraft despite having demonstrated an effective transfer of control several minutes earlier when the first officer had his display problem the captain failed to assume positive control away from the first officer and arrest the airplanes decent and instead began making manual control inputs simultaneously with the first officer that overrode the autopilot all the way to impact as you heard the ntsb was critical of the captain's failure to use proper transfer of control pilots are trained to verbalize handoff of aircraft control by some version of the phrase i have control or you have control in this case the captain failed to do that and simply input nose up commands without informing the first officer that he was assuming control however just a few minutes earlier the first officer had a minor problem with his display and the two pilots did exchange control with the proper verbal notification while the first officer corrected the problem also worth noting is that during the descent 40 miles from the airport the first officer called for flaps one that extends leading edge slats but not trailing flaps this is counter to atlas procedures and i'm told that it's unusual to select flats one that far from the airport furthermore flaps one enables the go around mode to be selected with flaps retracted go around mode is inhibited at the hearing ntsb vice chairman bruce landsberg asked how long the captain had to intervene after the pitch down and recover the aircraft do we have any estimate as to how long how much time the captain might have had to intervene before this uh became unrecoverable and an altitude or something like that that they might have been able to recover right i'll defer that to uh mr english uh yes uh vice chairman landsberg we uh while we don't know precisely the point where the airplane could be recoverable uh from the beginning of the anomaly where the go around mode was activated uh through to the point where the airplane still hadn't deviated from that 63 6000 foot altitude very much the captain had about 20 seconds or so to notice first the the uh inappropriate um the mode change and the level off which was one opportunity to intervene before the airplane started to become extreme and then uh if you remember where the throttles went back and forth that was about 20 seconds or so into the into the event and at that point the aircraft had not yet started the very steep descent and there was probably some amount of time after that um where still a correct intervention could have could have changed so roughly about 20 seconds they likely would have been able to recover maybe a little more but that's a good estimate yes okay good what happened in this accident is not difficult to understand but why it happened is a lot harder to grasp the bottom line is that a qualified and trained crew flew a perfectly air worthy airplane into a swampy bay but the ntsb was blunt about the first officer's lack of skill here's the ntsb's human factors expert dr william bramble the first officer's performance and training demonstrated that when given enough practice he was able to perform highly proceduralized actions but he became overwhelmed when confronted with novel complex or unexpected situations atlas instructors attributed his difficulties to external circumstances or low confidence however his long history of significant performance difficulties is indicative of low aviation aptitude to mitigate the risk of hiring pilots with unsuitable characteristics airlines need a systematic scientifically based approach to pilot selection that assesses relevant pilot characteristics and collects enhanced pilot performance data to validate selection measures and establish appropriate cutoff scores airlines would benefit from a collaborative effort that allows them to pool data and share best practices in this area staff has proposed a recommendation that the faa established a clearinghouse of pilot selection data to help operators improve and validate pilot selection strategies the first officer's lack of aptitude according to the ntsb was abundantly clear he had worked at six airlines and had check ride bus oral or line check failures at four of them ntsb chairman robert sumwalt asked staff member david lawrence about this captain lawrence i want to ask you a question here i looked at at the some of the comments from from mesa airlines as well as atlas as it related to the first officer and i want to see if you see a trend here at mesa the czech airman said that when the first officer was presented with something unexpected in the simulator the first officer would get extremely flustered and could not respond appropriately to the situation when he didn't know what to do he would become extremely anxious and would start pushing a lot of buttons without thinking about what he was pushing just to be doing something and an atlas when he busted his first check right there the examiner told the ntsb that when the first officer realized that he needed to do something he often did something inappropriate like push the wrong button there here's two different airlines talking about the same person and they're using almost exactly the same verbiage would you say that this this behavior that was described at each of these airlines was seen in this accident flight we saw the same similarities and in fact it wasn't just atlas it was uh air wisconsin a czech airman from air wisconsin had the same um identical concerns the czech airman that provided his upgrade training at mesa said the same thing that uh atlas was so there was a consistency that this pilot tended to do things in a stressful situation just do anything anything and start pushing buttons and it was consistent through all these airlines so how did it get this far hiring processes of all kinds consisted of a series of filters to weed out unsuited candidates airline pilots have to actually walk the walk with a pre-hire simulator check and even after hire they have a probationary period and careful monitoring through ioe or initial operational experience as is required by the faa atlas has an in-house quality control system called proficiency watch it's designed to identify problem pilots for remedial training if this first officer had problems at atlas he wasn't placed in the proficiency watch program according to the ntsb but rather had his operational experience period extended larger issue according to the ntsb is that atlas did not know about all of the first officer's problems at the other airlines for two reasons one as is not uncommon the airline used an outside designated agent for initial hiring review and that agency wasn't experienced in aviation but was basically a records retriever and reviewer and the records available to them under what's called the pilot record improvement act were limited and allowed the first officer to hide some of his employment history under the newly proposed pilot records database program the faa is supposed to set up a system whereby the faa allows airlines to share pilot data the ntsb somewhat could barely contain his impatience with faa foot dragging on implementing this thank you for bringing up the points that you just made about the failure of the faa to move in a timely manner i intend to offer an amendment when we get to this point to add the faa as a contributing factor that the faa's failure to implement the pilot records database in a sufficiently in a sufficient and timely manner i intend to offer that as an amendment when we get to that point the pilot record database has ignited quite a bit of opposition from industry trade groups mainly related to the way the faa wants to implement it and the ntsb did indeed add the faa's inaction on the prd as a factor in this accident but the probable cause here should be obvious it was the first officer's inadvertent activation of go around mode followed by an inappropriate response once he did contributing was the captain's failure to monitor the aircraft situation and to properly transfer control authority to resolve it before i go a few words about somatographic illusion we will likely never know if that actually happened here or if the first officer was just too inept to handle the airplane i looked at 10 years worth of general aviation accidents and somatographic illusion is listed as causal or contributory 23 times in accidents every one of them fatal again these are best guesses since there's no way to know what was going on inside the pilot's head as instructors we try to induce spatial disorientation and training my method is to put the pilot under the hood with eyes closed and looking in his lap then either island douche rapid maneuvering or have the pilot do it followed by recovering on instruments in years of doing this i have not even once succeeded in creating somatographic illusion or even vertigo that's not to say i don't think it can happen but that the way we train it doesn't appear to make it happen either way the cure is a good disciplined instrument scan centered on the attitude indicator if the nose is down and air speed is increasing level the wings first then pitch the nose up to level flight if the speed is decreasing lower the nose first to gain some energy then level the wings this is not complicated stuff but if you never do it or you don't do it regularly in training it could be a smoking crater in your future for avweb i'm paul bergarelli thanks for watching

Channel: AVweb

Views: 240,326

Rating: 4.9233074 out of 5

Keywords:

Id: uEWXYizNKf0

Length: 21min 9sec (1269 seconds)

Published: Tue Jul 21 2020

Reddit Comments

[u/KaJuNator]

Well, time for Congress to step in and raise the ATP minimums to (reaches into my hat) 2,835 hours. That should solve all the problems! You can never be too safe!

[u/SlipAerP]

Sometimes it’s unbelievable how pilots with so many check ride failures and poor check ride reviews are able to hold such desirable jobs, I have a feeling things will change because of this crash. Airlines and the FAA will make previous pilot check ride failures more public. Several check ride examiners stated that the FO panicked during stressful situations and became overwhelmed with anxiety during simulated emergencies. They stated that he would press random buttons and make random control inputs during stressful situations.

This situation also reminds me of the Learjet that crashed going in Teterboro New Jersey, the first officer scored so poorly on his simulator rides that he wasn’t even qualified to be pilot flying, he had a history of failing his private pilot check ride twice, and crashing on takeoff during simulator training sessions.

[u/sq_lp]

I looked to see if someone posted the unrevised version within the last day or so and I couldn't find it so I wanted to post this one. The NSTB animation was posted a week ago but this video adds a lot more information about the accident as a whole. Revised reasoning as per description if you are curious

This is a revised version of a previously uploaded video. It clarifies the position of the go around button and corrects errors in the somatogravic illusion section.

AVweb puts out a great video again. Does a great job breaking it down for those student pilots out there who are unsure of the terminology or how automation works on transport category aircraft.

This is once again one of those accidents that could have been avoided well before the aircraft EVER took to the skies

[u/el_lobo_crazy]

The creation of a clearing house of pilot performance database is an interesting idea. I wonder if it will include checkride failures all the way from PPL to your airline career?

[u/FlipDetector]

This is why I’m giving up my PPL learning journey if I get diagnosed with ADHD. I’ll have my evaluation in a few weeks. I’ll still have lessons everywhere I’m travelling but I could never live the Pilots’ life and have lazer focus all the time. I just learned this recently about myself but the love of flying already changed my life. I changed to a well paying but harder IT job to get my funds for the PPL and stopped drinking alcohol completely last year.

[u/Santos_Dumont]

In the government contracting world this is how this happens:

Sr. Architect bill rate: $225/hr.
HR: we found this dude that will do it for $20/hr!
Hiring Manager: Margin!
SVP: I’m skiing Aspen with my bonus this qtr!