The Atlas Air 767 that plummeted into the wetlands short of a Houston airport in February was under a control tug-of-war between crew members prior to impact. According to the NTSB Public Docket released this week, the first officer of the 767 was convinced the aircraft, being flown for Amazon Prime, was in a stalled condition and forced the nose down before the captain recognized the situation and, too late, tried to counteract him.
Earlier in the flight, the first officer was concerned that he had an instrument error and handed control back to the captain, but later in the approach sequence, believing the instrument indications were correct, he took over from the captain. The airplane slammed into the ground at high speed, resulting in three fatalities—the active flight crew and a jumpseater.
The NTSB’s release of factual data, which does not include an official cause or make specific recommendations, includes both transcripts of the cockpit voice recorder and data from the flight data recorder. According to that data, while on approach and soon after encountering turbulence, the first officer, once again flying, cued the 767’s go-around system. This commands the autothrottles to increase power to maintain a 2000-foot-per-minute climb rate. The Boeing duly responded and climbed briefly. According to the FDR review, “At about 12:38:26 at an altitude of about 6,500 ft, triaxial acceleration magnitudes increased, consistent with the aircraft entering light to moderate turbulence. At 12:38:31 the autoflight system entered go around mode, the engines began advancing to go around thrust setting, the control column, which had been neutral, moved slightly aft and elevator deflected up, the aircraft pitch began to increase, and altitude stopped descending and began to climb. At 12:38:37 the speedbrake handle was retracted and the engines approached their commanded go around power settings.”
Nine seconds later, the first officer said, “whoa … (where’s) my speed … we’re stalling.” The flight data reveals that the “control column … had moved to be deflected forward at the time, pitch was decreasing, and airspeed began to accelerate rapidly from 240 knots. Autoflight systems remained in Go Around modes and the aircraft continued a shallow climb for a short time before entering a rapid descent. Control column remained deflected forward for the next 10 seconds.”
The 767 accelerated rapidly with go-around power applied and it’s believed the captain realized the severity of the situation, began trying to correct the dive, then finally pulled the control column to the aft stop at about 2000 feet. Pitch attitude was then at 50 degrees nose down. Pitch attitude rose rapidly, with the final recorded attitude of 16 degrees nose down, the freighter now traveling at more than 400 knots and pulling more than 4 Gs in the maneuver.
The NTSB documentation paints a picture of a copilot who struggled through his 767 training with Atlas Air. He required 4.5 hours of remedial training before being recommended for the oral examination, then was not recommended to continue to full-motion simulator training after five sessions in a non-motion sim. Another round of remedial training allowed the FO to move ahead in training. During his training in the full-motion simulator, his sim partner complained that he was “being held back by the FO.” About a month later, the first officer “failed his practical B-767 type rating examination due to unsatisfactory performance in crew resource management (CRM), threat and error management (TEM), non-precision approaches, steep turns, and judgment.” A few days later, he received more remedial training and passed his checkride. Many smaller, growing airlines have been criticized for trying to move pilots through the system too quickly in an effort to meet staffing demands.
Speaking to Forbes, an Atlas Air spokesperson said, “Atlas pilot training includes multiple reviews, evaluations and proficiency checks to comply with FAA regulations. We continually evaluate all training and hiring procedures, and in addition, in the aftermath of Flight 3591, we enhanced training for our employees and expanded background checks for all candidates.”
The NTSB’s final report is expected sometime in 2020.