This is the story of Atlas Air Flight 3591. On the 23rd of February 2019 an Atlas Air
767 was on its way from Miami international airport to the George Bush intercontinental
airport in houston. Atlas air is an alias for prime air that is
legally, they are known as Atlas air but their planes fly the prime air liveries. The plane took off from Miami and was cruising
on its way from Miami with no issues, the First officer was the one at the controls
and the captain was the one monitoring. At 12:34 pm CST the Houston terminal radar
approach controller informed the crew about the light to heavy rain in the plane's flight
path the controller told them to expect vectors around the weather system. The plane descended along its intended route
and at 12:36 pm the first officer exclaimed “ Okay I just had a … Your controls”
Something had caught the first officers attention and so he transferred control of the plane
to the captain. The captain acknowledges and says “My Control”. The first officer was having issues with the
electronic flight instrument displays. The first officer preses the EFI or electronic
flight instrument switch. That seemed to do the trick, the displays
were back up and running.The first officer, now the pilot monitoring, asked for vectors
west of the weather. As the plane descended the First officer asked
the captain to turn to 270 degrees and the controls were handed back to the pilot flying. As the plane flew on the captain was busy
programming the FMC or the flight management computer and the first officer was busy with
configuring the plane for landing at bush intercontinental, as part of this the first
officer set the flaps to 1. At 12:38 pm and with the plane at 6300 feet
the planes go around mode was somehow activated. Over the next 6 seconds with the go around
system activated the autopilot commanded a nose pitch up and the auto throttle commanded
go around power from the engines. But as all of this happened the crew remained
silent, no one made any attempt to disconnect override or counter the automation. At 12:38 pm the speed brakes that had been
extended to help the plane descend was retracted and the elevators moved in response to manual
input, someone was pushing the nose down. The nose down inputs grew and grew till the
plane was in a steep descent. The first officer says “Woah My speed my
speed we’re stalling”. The captain asks “what's going on?” A pilot in the jump seat says “pull up!”,
the elevator moved in response to manual input, they were trying to pull the plane out of
its dive. They commanded a nose up for 7 seconds but
it was too little too late the plane was already plummeting too quickly and there was nothing
that they could do, the 767 crashed into some marshy ground in trinity bay. Unfortunately all 3 souls onboard did not
make it. Now it was up to the investigators to figure
out how a 767 plummeted from the sky. They sifted through the data from the FDR,
they noticed a small 1.26g change in the plane as they penetrated the leading edge of the
cold front, now this signified a small bit of turbulence, a small bump that's about it. But strangely it was after this small bump
that the go around mode was activated. At this time the plane was at 6300 feet descending
down to 3000 feet and they were about 43 miles from their airport. It makes no sense for the pilots to activate
the go around mode in this phase of flight. This means that the go around mode was activated
unintentionally. To activate the go around mode on the 767
there are switches under the throttle quadrants, If you hit them the go around mode gets activated. During their descent ATC had asked them to
get down to 3000 feet. To descend as fast as they could the pilots
had deployed the speed brakes. Now as per Atlas Air policies when the speed
brakes are deployed, the pilot has to keep one hand on the speedbrake handle as a reminder
to retract the speedbrakes. The first officer who was the pilot flying
probably had his hand on the speedbrake lever. Investigators noticed that when pilots did
this their wrists were very close to the go around switches. If the pilot were to be wearing a watch on
their left wrist, there would not be a lot of space between the watch and the go around
switches themselves. So the light turbulence that the plane flew
through might have been enough to jostle the wrist of the first officer into the go around
switches, thereby triggering a go around. When this happened mode annunciator on their
displays would have shown GA, informing the pilots that the plane was now in go around
mode. At this point the correct course of action
would be to disarm the automation and to hand fly the plane into a safe configuration. But neither pilot says anything about the
go around mode or tries to disarm the autopilot or the auto throttle. No one in the cockpit had realized that the
mode of the airplane had changed to the go around mode. Control inputs from the First officer signified
that he felt like something was wrong. The speed brakes were retracted . As the plane
started to pitch up slightly but then nose down commands from the control columns started
to override the pitch up commands given by the autopilot. This caused the nose of the plane to start
dropping. This is when the first officer likely experienced
a somatogravic illusion. I briefly touched upon this in my fly dubai
981 video. The human body has multiple ways of determining
its orientation. The eyes are one. You can just look at the horizon and figure
out if youre pitching up or down, turning left or right and so on. But the body has other ways. The body has these Somatosensory structures. Im not a doctor but ill try to explain it
the best way that I can. These nerves are tree-like in shape and when
youre level and still, they’re erect the brain interprets this as being level. When you're pitched up these tree like structures
get pulled back due to gravity, Something similar happens when you experience acceleration. When youre being accelerated these nerves
get pulled back due to inertia and if you dont have external visual cues you might experience
a feeling of being pitched up when youre not. If you can see the horizon the brain would
have been able to correct itself but without external visual stimuli that might not happen. With flight 3591 in the clouds it's entirely
possible that the FO experienced a sort of somatogravic illusion. With this he's convinced that the plane is
pitching up, when its not, now the first officer is commanding a nose down to counter a pitch
up that just isn't there. Before the go around happened the captain
was on the radio with Bush intercontinental setting the approach up. It was likely that he had his head down and
was looking at the FMC rather than looking at the instruments. This would have reduced his awareness of the
airplane and it would also explain why he didn't catch the go around mode change that
was displayed right in front of him. With his attention directed towards the FMC,
the captain was slow to respond to the situation that was developing in the cockpit. When the captain realized what was happening
he immediately grabbed the control column and pulled back but at this time the first
officer was pushing the nose down and the captain was pulling up. They split the elevators for about 10 seconds,
and during those 10 seconds the dive steepend. The plane would have broken through the clouds
at about 3000 feet and at that point both pilots would be on the same page, as they
could clearly see the orientation of their plane. From this point on both elevators were commanding
a nose up, but it was too late, they just did not have the time to recover. Had the captain just said I have control,
his nose up inputs would have started to correct the issue, but in that dive both crew members
had a drastically different view of what was happening. But wait there's more, the pilot in question
mis-reacted to a simple problem during a flight and that caused the plane to nose dive. The investigators looked at the history of
both the captain and the first officer and that's where they found something interesting. They looked at how atlas air had onboarded
the first officer. Atlas air first checked the First officers
minimum requirements they then went through his resume, and then after that there were
two interviews. But atlas relied on the honesty of the applicant
for the background check and the interview. But the first officer had not been 100% honest
with Atlas air and he had hidden a few of his past jobs and a few of his past training
failures. So when evaluating the First officer Atlas
air did not have a complete picture of his history. The first officer had worked at commutair
and air wisconsin in 2011 and 2012 respectively. He did not complete his initial training at
both companies. He was not required to disclose his employment
with Commutair due to a 5 year reporting window but he had to disclose his stint at air wisconsin. When the first officer applied to trans state
airlines in 2014 he did not disclose his job with air wisconsin. In addition to that the first officer did
not disclose his unsuccessful attempt to upgrade to a captain at mesa airlines. The NTSB came to the conclusions that the
first officer's omissions were an attempt on his part to conceal his history of performance
deficiencies. During his training the first officer displayed
very low situational awareness and that he overcontrolled the plane.The first officer's
simulator partner complained that they were being held back by the first officer's lack
of progress. Going back further the investigators talked
to his trainers from mesa airlines. The instructor said that the FO was able to
explain concepts in the briefing room and that hed fall apart in the simulator when
presented with a challenging situation. She said that he would start pressing buttons
just to be doing something. I'm going to quote the report for a bit “This
check airman described the FO’s piloting performance as among the worst he had ever
seen and noted that the FO tended to have an excuse for each of his poor performances,
such as blaming his simulator partner, his instructor, or the hotel”. Another person from air wisconsin said that
the FO made aggressive control inputs that triggered overspeed or stick shaker alerts. I'm going to leave it at that the first officer's
employment history is literally as long as this entire video. The next failure came at Atlas air the people
who went throught the first officers file saw that he had failed in his attempt to become
a captain at Mesa airlines but it was worded as “returning to FO '' which is quite ambiguous. More over the people who went over the file
were not pilots they were HR personnel. The investigators also found that the hiring
model that airlines were using was flawed as well. The system right now is called PRIA where
the hiring entity requests records from each previous employer. So if someone decides to leave an employer
off the hiring entity has no idea that they have an incomplete picture of the candidate. 10 years ago the FAA was asked to build a
centralized database for all of a pilots files called the pilot record database or the PRD. This has many benefits, the hiring agency
wouldn't have to wait around for files since its all electronic and it would be hard for
an applicant to hide previous jobs. Congress said that the PRD had to be up and
running by the 30th of april 2017. Its 2020 and it is being phased in right now. The PRD was developed in response to colgan
air 3407. A plane that dropped out of the sky cause
the pilot in control over controlled the plane, in that case the pilot also hid his employment
history from colgan air. That was in 2009. This accident is so similar to the korean
air crash that I recently covered both pilots put their planes into dives believing that
their planes were in danger. When they weren't. I guess history has a way of repeating itself.
https://www.khou.com/article/news/local/pilot-flying-atlas-air-jet-that-crashed-near-houston-had-history-of-panicking-during-training/285-dbea3573-5034-4641-87e2-d502104e9dff
Were they desperate for pilots because of Amazon? I'm surprised that Atlas didn't contact/follow up with Wisconsin for a reference.