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 At 12:38:37 the speedbrake handle was retracted and the engines approached their commanded go around power settings.”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.
So the cause of the accident was a shortage of qualified pilots?
Yep. And the 1500 hour rule has been a contributing factor to the shortage.
“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.”
Good lord that is a lot of things to fail on. This organization has a lot to answer for.
The Performance Study in the docket provides some excellent additional information. As do the simulator study photos.
It is too simple to cite the amount of hours as a qualification for the capabilities of a pilot. A well trained, soundly educated and properly selected individual does not need to have x-thousands (or hundreds) of hours to be a qualified crew member. It all depends on the environment in which an individual pilot accumulates the experience. The fact that an individual -as in this case- might have required some extra training is meaningless unles placed in the proper context.
There are some pilots, for whom all of the training in the world will not result in an acceptable level of performance. Anyone who tells you otherwise probably is in the business of selling pilot training.
my point… That is why the FAA 1500hr rule has no bearing on this event. Properly educated, trained and selected pilots should not be judged on the thickness of their logbook alone. And an operator that relaxes their training and checking standards for staffing reasons is taking the wrong turn. I know of operators with first-officers in the right seat of f.e. E190’s or B737’s/A320’s with excellent safety records because they invest in proper training…
I think the point of the 1500hr rule being a factor is that it is unnecessarily excluding some otherwise potentially excellent pilots from getting jobs in aviation. It’s not enough to just have the desire to get an aviation job; you also have to have the time, money, and opportunity. And it’s easy enough to see how the more money you have, the more likely you’re also able to make the time and find the opportunity, even if your skills aren’t necessarily at the requisite level.
Whether it is pilot training or crew rest,or hiring, the real problem here is Atlas Air wants to make money and is willing to compromise on safety. Atlas Air is not the only carrier that makes compromises. The copilot obviously was being pushed thru a program he could not master. I have seen compromises like this for 40 years including Navy training. Ultimately it ends up in an accident and people die.
WOW! That was quite a maneuver, from GA pitch to 50 degrees nose down, all while still at GA power. Must have been some negative G’s involved. There’s a lot more to this than what’s in this article.
The article states the following:
“… the first officer, once again flying, cued the 767’s go-around system.”
“… the captain realized the severity of the situation, began trying to correct the dive, then finally pulled the control column to the aft stop”
What information in the docket indicates that it was the FO that cued the go-around system? That it was the captain that pulled the control column aft?
To introduce myself, I am an ex USAF C 141 Aircraft Commander with abt 5,000 hours in command. I have an ATP, with type ratings in L-300 and Lears, and an FE rating in turbojets. I live in Houston, so this accident was well-reported here. I was very puzzled for a long time about what had happened. Since there were thunderstorms in the area, I sort of assumed they had fatally encountered a cell. Yesterday I got curious and did some research about the crash, and found out what had happened. Apparently the FO was an immigrant from some Caribbean island, and had been fired from two previous flying jobs due to lousy flying. He got hired by Atlas because he lied on his job application about his previous troubles. This accident is a prime example of what can happen when someone with poor flying instincts gets turned loose in a high performance aircraft. The only other incident of which I am aware that was similar to this was the crash of that Air France A-330 in the South Pacific when the idiot 3rd pilot had a pitot tube icing incident that caused the airspeed to rapidly increase. The guy pulled the nose up 30 degrees, and the A/S kept on rapidlyincreasing, so he just kept up the back pressure until the aircraft stalled and fell into the water. In both cases the pilots seemed to have no idea how to do an instrument cross check and accurately evaluate the flight condition of the aircraft. In the case of the Air France situation, the first thing I would have done is look at the TAS and ground speed from the inertial or GPS. No increase, no actual problem–but there was an obvious IAS problem. Both pilots seemed blissfully unaware of how an aircraft reacts in a given situation. The Air France dope apparently wasn’t a bit concerned about how an aircraft could possibly be rapidly accelerating with the nose up 30 degrees. The same thing applies to the Atlas Air FO, when he couldn’t put 2 and 2 together, look at the airspeed, and deduce that they obviously weren’t stalled. The USAF had a simple evaluation procedure for all in-flight problems : 1. Maintain aircraft control. 2. Analyze the situation. 3. Take proper action. Brief, and it covers everything. I don’t indict all low time pilots because of these two accidents, but it’s scary to me that pilots as weak as those two could still keep their jobs.