Atlas Air Giant 3591 NTSB Interim Report
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- Опубліковано 6 вер 2024
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NTSB Interim Report:
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Aram Bedrosian
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As a non pilot myself ( and no desire to be so ), but interested in aviation safety, I’m constantly impressed with how well you explain these tragic events. I find your ‘unpolished’ delivery offers extreme credibility to what you are saying. You clearly know your topic and I am glad you take the time to explain things to non pilots like me. I’d happily have you as my pilot when you’re flying again... THANK YOU
As a former aerospace engineer, pilot and aircraft owner, I expected that I might have had something to add to this conversation --- but I don't. Such a great analysis. Thanks for spending your time on this, Mr. Browne.
My experience is that trusting the instruments requires a LEARNED trust in the in what the eyes see on the panel. Once I learned to trust the instruments I never felt a conflict with what my inner ear would have wanted to tell me.
I think you're right, and part of the problem is that the relaxed requirements applied to those pilots didn't require that mental and physical capability of those pilots, and that those pilots were themselves so uneducated in the ways of training the mind that they DID NOT HAVE THE CAPABILITY to think like you to align the instruments and body to function together.
I wonder if this is because your brain has mentally mapped what your inner ear feels to what you are seeing on the panel. You trust that panel with your life, and you trust it over your own senses. This probably helps with your brain effectively remapping the feelings in your inner ear to what your brain knows is actually going on via what your instruments and computers are telling you.
Your brain may even be using those instruments as new senses, becsuse these things will become so second nature to you as an experienced, quality pilot. You might not even think before you react, but you still react in the proper way because your mental maps and models are so powerful that it all becomes muscle memory. When you work with a new tool for the first time, it feels like a separate thing you're using. But the more you use it, eventually that tool becomes an extension of your own body. That yoke probably becomes an extension of your own body. The steering wheel in your car will be likewise.
I'm not a pilot or doctor, but I do know that your brain makes mental maps all the time. Every time you do even the most mundane thing that you don't even consciously think about, your brain very much is thinking about it. It's creating new pathways and reinforcing existing ones, and probably even removing old ones too as you learn more and stop doing things you used to do.
Itd be interesting to hear from someone who's actuslly qualified to comment, but I wonder if this is what might be going on.
I agree. Now with an instrument rating I prefer to fly on instruments. Looking outside is for sightseeing and emergency planning. But I remember one time climbing in hard IMC and engaging the autopilot to turn to my new ATC clearance. I glanced up to see the windshield completely gray for the fun of it. When I looked back down I was actually surprised that the attitude indicator was indicating the bank to the left that the autopilot was commanding. My inner ear was wrong, the instruments were right.
My first thought when I saw you'd released a new vid was that it's 45 minutes - pretty long compared to your normal videos. After watching it, the it felt like 15 minutes. You do such a great job of explaining and keeping it interesting Juan. Thank you sir.
As a navy A4d Skyhawk pilot 1959-64 I made 91 night Cat shots (307 total carrier landings) many with no horizon visible. No auto pilot in those planes. Even then we did not touch the stick on ANY cat shot until free of all the G forces from the Cat shot. You relied on the trim and thrust of the aircraft to get you safely airborne. MANY disorienting IMC flights in formation flying if you were not the lead pilot! During one 9 month cruise we lost 6 pilots from the 4 squadrons aboard of fighter type jet aircraft at night in IMC conditions.
New subject: Juan, I hope you are still on your way to getting your medical back. I suffered from the same progression of Prostate cancer to bone cancer as you have. A word of encouragement: I have been taking the same medication as you mentioned you are for 6 years now. I feel great at 84 years old and my many detailed physical tests indicate I could easily pass an FAA First Class physical. I'm sure , with a little practice, I could pass a Sim check in the Gulfstream type Aircraft which I flew all over the world for 28 years. How could they not let You
back in the seat?!!
I worked on the last seven A-4J Skyhawks in the Navy, squadron VC-8...thanks for your insight on your tour and thanks for your service, RIP to the pilots lost
In 1982, I got into a graveyard spiral in a 172. It was due to a very serious error in judgement. The visual world ended at the outer edges of the aircraft and my IAS was 147. When I realized something was wrong, I used the instruments to right the aircraft. Without them, I would have made a small hole in northern Arizona. It was a scary experience.
@@osakarose5612 You're definitely right. It was a combination of get-home-itis, inexperience, and temporary stupidity. Because the airspeed was 147, the plane was 25 mph above the maneuvering speed when I initiated the critical attitude recovery procedure. It took a lot of control to pull on the yoke gently in order to get it out of the dive without over-stressing the airframe. It was terrifying. To add to the unpleasantness of the situation, I was also lost. Overall, it was a day that I would wish on no one. I'll be the first to admit that I was a very poor pilot that day, and almost didn't live to see another one. I credit my survival to my flight instructor. Without his expert teaching, I'd be dead.
"The FO had a habit of flipping switches without explanation." Another one slips through the cracks.
I stopped subscribing to newspapers a number of years ago because I got tired of reading crap. Recently the same with TV news. However, I don’t mind at all sending money for this level of info. Many thanks! Great report!
As a professional avionics tech, I cannot repeat this often enough: WHEN THE ADI I INSTALLED IN YOUR AIRCRAFT SAYS YOU ARE FLYING LEVEL, BELIEVE IT!
It’s depressing how many stories I watch or read about how the pilot didn’t trust his instruments.
If you trust my work with your FMS, then trust my work with your basic instruments.
Flying by the seat of your pants sometimes just isn't practical (or possible) today under certain conditions. Combine that with improper instrument scan techniques and poor judgment can quickly turn your flight into a permanent one way trip.
@Jason Bowman Don't forget, reset cannon plug, ops check normal.
Dan as a retired avionics tech with 40 years service I must say you are probably over estimating your capability.
@@jayreiter268 yup
Why would a pilot go to the time and expense of getting an instrument rating on your ticket and then not rely on them, seems to miss the point a bit.
Nice work on a tough one Juan!
That fidgety switch pushin’ habit the FO has is a really bad sign. And anybody that would attempt to override the auto pilot without disconnecting it would get my hard attention.
When we first heard about this accident the buzz in the cockpits was a pilot suicide. With his omissions in employment history, deceitful behavior in gaining employment, coupled with a severe lack of ability, and finally repeatedly using the race card to maintain altitude in his career, we should be treating this first officer like the murderer he was.
This is beyond inept, it is criminal. And the system that allowed him to be in place should be held accountable.
RIP Sean.
Mark g not surprising a plane that has Amazon paint on the side would cheap it or cut corners with pilots.
ATC decided it was a good idea to make race more important than skill in hiring controllers, so this will only happen more often.
When I was D.O. in the FAR-135 air courier world (flying Cessna 210s and BE-58s), I established company policy that addressed check ride failures. Fail a check ride and you were removed from the line and sent back to training. When the IP felt you were ready you were scheduled for another ride. If you failed the ride a 2nd time, you had an option. You could resign as a pilot (basically quit), OR, you could return to training at your own expense. They usually quit after a 2nd failure. In my 10-yrs as D.O. only one paid to do additional training. He failed the third check ride attempt. A third failure was an automatic termination with no chance for rehire. Some thought the policy a bit on the harsh side. It is a much different perspective when you are running the company as opposed to flying for the company. It quickly becomes very clear that a sub-standard pilot has no business in a commercial flight operation. As always Juan, you are spot on with the analysis!
The good part is you had training as a specific activity. maybe even access to a sim, where you can learn what happens when it all goes wrong. I worked for a company where only the FO's to be promoted to left seat were sent for real training. Everyone else was stuck with whatever the pilot felt was worth his time. One guy actually said, "it is not my job to train anyone."
The bigger problem to solve though is making sure that what happened gets documented and reported so that the pilot can’t attempt to get hired somewhere else. In your case, letting them resign should also come with a report to the database as to why they resigned, due to the failure in training.
How the hell do you fail a C210 check ride?
@@josephking6515 I would guess the fail could be emergency gear extension. Some guys gloss over little details like that...
As a person who flew extensiverly for 16 months and infrequently before, about 450 flights total, and has followed aviation accidents, I would not want to be in an aircraft with a seat occupied by a 3 time check fail and definitely not one with 1 or 2 fails without remediation that can be evaluated as successful. I worry when I saw an airline is looking to train pilots, off the street, in 2 years to a commercial FO. I worry that these are not going to be real professional pilots. I am a computer/electronics geek, I have lived electronics since about the age of 10 and computers since 19 when i got my first look at one. I understand the guy or gal who saw a plane at 8 years and wanted to fly it and that was the focus from there. Although there are good career change pilots I see the firmer ones as better. It scares me to think that a guy with a masters in business going to commercial pilot in 2 years. Any technical profession needs inate ability, training, experience and that undefinable desire to do it.
Thank you for the thorough presentation and the links to the NTSB reports. Very much appreciated!
Juan you're so much better than the know nothing "eye candy" we get on the MSM
Eastern Woods oilers
A Boado has to work on a day to get my hair
The most trusted voice on the internet! Thank you Juan!
Wow. I am CDL. truck driver. Dot keeps my training records and employment for the last 10 years! no gaps allowed. never thought we were regulated more than airline pilots!
I'm told that your physical exam is more intense, also.
@@davef.2811 maybe so on the physical too. I just completed mine on the 8th of January. And the doctor was asking me about my teeth. And about every surgery I've ever had in my life. Had to also pick up 70 lb correctly. Push and pull with the resistance on my arms and my legs. Urine test, eye test, and the normal stuff listening to my lungs, checking it out my ears. Also check my reflection my knees made me walk on my toes forwards and backwards. And the top it off ask me about my mental health!
Mark Thompson What do you mean by “no gaps”? Do you mean unexplained gaps? Because sometimes you’re just out of work and have trouble landing a job in a bad market or medical issues.
@@JustinLHopkins yes no unexplained gaps.
I only see reasons to automate things.. Takes the direct human action away from the equation.
Outstanding analysis. As a former Air Force flight surgeon, I couldn't have explained the somatogravic illusion better. The Air Force back in my day had trainer simulators specifically designed to create the common illusions and force responses based on instruments.
Yup, I remember that training (USAF UPT in the mid '80's).
The real problem is worse than that. The word is the the first officer had a history of becoming alarmed and agitated, followed by punching random buttons on the panel. The dude wasn't really a pilot. He could go along for the ride if someone else was in charge of the airplane.
Wow, on the one hand fascinating, and on the other hand, very sad. Thanks, as always, for your thorough and detailed analysis.
This is one of several analyses of this crash that I've watched.
Everyone KNOWS why this plane crashed, and why that FO was in that seat.
But we can't talk about it. And we all know WHY we can't talk about it.
O brave new world
That has such people in't!
I don't KNOW why it crashed or WHY we can't talk about. Please talk about it.
This has got to be the most thorough and accurate analyses and recreation of an accident I have ever seen.
I went through most of the comments before speaking and am amazed at the number of experienced transport pilots following you and agreeing with your analyses and contributing to it from their own experience.
You are simply amazing, Juan!
Juan, although not the cause of the accident, take a look at the maintenance records. Those displays and a few other things in that cockpit were replaced twice inside the space of about a month. Re: about his gaps in employment. He lied and told them he wasn’t working in the flying industry and instead said he was doing real estate work and I think also caring for his father, when in actuality he got hired and left two different flight companies and failed out of their training programs.
Quite scary. Thanks for clearing this up. My military training in simulators repeatedly put me through imc single pilot training. It's gold experience. As our ears do trick us again and again. Placing 100 faith in your instruments with logical constant reference keeps you and your aircraft safe.
Absolutely outstanding explanation! Thanks very much!
As a 28 thousand hour airline captain, with time on 747’s, 767’s, and 737’s, I found your summation to be excellent.
The CVR transcript is... umm, illuminating, (and disturbing)!
Thanks. (Hope you can get back to flying Juan.... if you haven’t already.)
I've flown on this series of aircraft as a passenger, if it's so easy to accidentally bump the switch why does Boeing not redesign the go around switches?
James Jackman because it’s usually a non-event when it happens. I have thought that an audio warning saying something like “Toga” or “Go Around” when they have been activated would be a good way to alert if somebody had bumped it though. Anyway the FOs response in this case was completely unpredictable and disproportionate, and more due to his lack of training rather then a design flaw with the aircraft. They need to be somewhere they can be easily accessed so it’s difficult to make them completely un-bumpable.
Ben D I have had the switch “bumped accidentally” maybe twice or three times in thousands of hours, and usually in turbulence. Of course it needs to be easy to activate intentionally.
Handled correctly, an accidental activation just isn’t an issue, any more than maybe accidentally hitting the turn indicator in your car.
FutureSystem738 More like accidentally activating the cruise control, if you ask me. This crash should change the attitude that inadvertently hitting the switch is "no big deal". A simple fix, like annunciation, or maybe requiring a one-second press to activate -- or even both -- should be considered.
Alex Curtis These are not mutually exclusive measures. And the PM (captain at the end, as I understand it) wasn't unqualified, yet he missed the GA activation too, as did both active crew members in Juan Brown's London 777 incident. Human interface factors can be cheap safety measures.
“Fly the airplane”. Your first and most important job as a pilot!
Juan you look so disappointed. Your empathy for the needless loss of life and dismay at the apparent avoidability of it all is there to see. But your professionalism in getting the facts conveyed is commendable and thoroughly appreciated. Thank you for all your hard work. I hope to see you PIC again soon.
Thanks Juan! I just wish we could get this much accuracy and detail from or normal news channels about anything. Love your channel.
Originally we were not required to keep a hand on the speed brake while it was deployed. This came about after American Airlines Flight 965 which crashed while descending into Cali. In their case they got off course in high mountainous terrain due to the incorrect NB being selected. They received a terrain warning and attempted to immediately execute an aggressive climb, however, in their haste they failed to stow the speed brake. The NTSB later determined that had they stowed the brake that they would have cleared the terrain. The drill in responding to a wind-shear or terrain warning was to hit TOGA, disconnect the autopilot, auto-throttles, and make sure the speed brake was stowed. The autopilot had a built in buffer so it was slower to respond than direct Pilot inputs. When this flight was asked to expedite their descent, ATC was trying to get them under the departures, rather than hold the departing aircraft down which would complicate handing them off to en-route controllers. I don't have the speed trace, but normally they would have been at 250kts below 10,000 feet. When asked to expedite their descent, if they slowed from 250kts to 210kts, their normal flap extension speed, this would have delayed their descent. Secondly leaving the autopilot, and auto-throttles engaged would again slow the start of the descent since the buffer effect would be in play. Had they selected 3000', FLCH, while staying at 250 kts., disconnected the autopilot and auto-throttles, and deployed the speed brake, they then would have been able to pitch to a lower angle of attack, thus most effectively complying with ATC's request. (FLCH) means flight level change, which normally gives a full power climb, or an idle descent.
Learning more about stuff thanks to Juan Brown.
Philip Housel It’s so fascinating between the human variables of flying and the variables of the myriad systems of the aircraft. Many, many integration possibilities.
I don't watch many UA-cam videos start to finish and certainly none 40 minutes long. But, I'm glued to Juan's start to finish. Keep up the good work.
Thanks Juan, another great summary. I had a chance to read some of the Atlas pilot interviews in regards to the F/O, and they were shocking. On one hand - the F/O, at times, showed great skill executing typically well trained scenarios (engine out ILS spproaches) and on the other hand, was completely inept dealing with "surprises". It seems like his reaction to the surprise of an un-intended TOGA actuation is right in line with his training experience. Should have been shown the door long ago.
The 767 is a stalwart, a dependable aircraft as close to perfect as any have ever been engineered. To see one so senselessly, even wantonly destroyed is a tragedy second only to the loss of lives.
Great report Juan! I especially liked the portion where you explained what one is supposed to do in the event of an inadvertent selection of TOGA, then you relating the experience you had arriving London.
I just read the transcript, the First officer sounded unstable or overwhelmed pretty much the whole time on approach.
lot's of excess, nervous chatter...
I think he was pretty much unstable and overwhelmed throughout his short career, which should have been terminated early.
@KOB You are correct. Below 10,000' both in the climb and descent extraneous conversation in the cockpit is verboten - it is all serious business. One of the problems here is that the crew would normally pull out their charts and set up their navigation and flight instruments and brief for the expected arrival and approach prior to the top of descent. In this case they were being vectored off the arrival and at the same time being told to expedite their descent, all the while attempting to keep track of the developing weather situation. If the auto-flight systems were engaged then it would be normal for the flying Pilot to update the flight management computer, and the autopilot, while if the flying Pilot was hand flying then the non-flying Pilot would do so. Both Pilots would be required to verify the correct inputs. The B757 has dual FMS key boards and triple autopilots. It also appears that they were heavily reliant on their auto flight systems, otherwise they would have clicked them off to expedite the descent. Needless to say they would have been pretty busy. I too have a hard time buying the spacial orientation interpretation. Since both Pilots were not likely to simultaneously experience somatogravic effects one wonders why the Captain was so slow to intervene? Interesting, a full motion sim will use somewhat non- corollary motions to give the sensation of accelerating or descending.
tenpiloto Well, it was. In the worst possible way.
Great job as always Juan. Thank you.
Phew! That's a lot to get through. Thanks Juan for taking the time to train us.
Thanks for the great up date, on Atlas. Goes to show, Never confuse total hours with Flight Skills and performance (First Officer). All pilots are not created equal.
Lostcreek 1 I agree. Total flight hours is fairly meaningless. Flight Departments use 3rd grade math to determine the best pilot. Just pick the bigger number of flight hours.
@@raoulcruz4404 Thanks for comments. Both the Captain and First Officer per the NTSB had poor performance issues.
Thanks, Wait til the reports are released and pilots and airlines are covered in the Lion and Ethiopian crashes.
433.5 knots is just under 732 feet per second. Given the angle of 49° and altitude of 6,000 feet, the plane traveled ~9,145.5 feet until impact. That would take ~12.5 seconds.
That's about the time between when the FO first said "(where's) my speed my speed" and then the last thing said which was "Lord * * you have my soul." 3 seconds before they crashed someone yells "pull up" but of course by that time it's too late.
You're great at math! Never my strong subject. Thank you!
Good job with a very complicated and highly technical incident. I think you may have identified a trend that we need to be aware of, the decreased experience and education of pilots due to the pilot shortage. Keep up the good work Juan.
Amazing new info thanks! Pitch disorientation due to acceleration - first time I heard of this was the 1989 Metroliner crash in Terrace BC - in broken IFR pilot hit the throttles for go-around but then started flying by feel and pushed aircraft into the trees despite warnings from the FO that they were “descending”.
I watched this whole video, then read the last couple pages of the CVR transcript as i listened to your narrative of the event (switching back and forth with pauses and unplanned moments of reflection). Very chilling and sad. Thank you Juan. This is real education.
Great job. Thank you for putting the time required to research this accident. I flew for Expressjet when Rick B did and had Friends the remember him. RIP
He is sorely missed. Gone too soon
Very nice and thorough explanation. It's interesting how so many plane accidents are due to some sort of pilot mistake(s). Many of them have had poor performance....and I do believe the system fails as they try to make them pass (not terminate) or turn the blind eye..... Same stuff with the medical field.....there are more mistakes there..... Human nature and now the fear that you cannot terminate mediocre or dangerous performers.....
I've heard reliable sources put the figure at about 70% of all crashes are due to pilot error.
Fantastic thorough reporting.
Thank you for correcting my misconception for the overhead handle in my car as the "OH NO BAR." I've been using a "nautical" term.
IMO this has been the most interesting of all the recent accidents .
And now we have PIA 8303 which is the absolute most confounding accident! And it killed I think 130 people
wow, just wow. slipping through the cracks is one thing, yet that age thing also is interesting. For so many, it is more difficult to learn new stuff the older someone is, it's an age thing. I know it sounds so simple to ignore what your inner ear is saying and look at the ADI(or the many other abbreviations for it), yet I guess it comes back to that learning for the first time at an older age. Breaking instinctive reflexes can be so difficult.
It's also heartbreaking, even acknowledging that this is a unique accident, there are striking similarities to a few Seconds From Desaster episodes where the pilot lost track of situational awareness, ignoring the ADI and flew a perfectly good plane into the ground (directly or via a pilot induced stall). There has to be an effective way to break the instinctive reflex of going by the inner ear, and looking at the ADI when there is nothing outside the windows (that works regardless of age/mental-sharpness). sadly, maybe becoming a pilot at an older age just may not be a thing for 'everyone', after all not everyone can become an olympian (Olympic athlete).
Thanks for the fantastic Vid Juan and crew. This is what a documentary used to be like at one time. B)
Fluid intelligence (learning ability) peaks at age 25 and goes down from there. Crystallized intelligence (knowledge and "wisdom") gradually increase. AT pilots used to have to retire at 60. Later they realized that those guys at 60 (if they could pass their check rides) had so much crystallized intelligence (flying experience) that it would be a waste to throw that all away. It is a bit alarming the people are entering flying "ab initio" in their thirties and early forties. By then the expectation is that the person has mastered the art more or less, and has a highly developed intuitive understanding of things. Combining this with increasing automation is even more worrisome.
Then again, in 70 years the planes will fly themselves.
Sparky They have it on a lot of new airplanes. It’s a HUD. The Max has it. I’m sure Juan’s 777 has it. Gulfstream definitely has it. Do a quick Google search about them. It’s pretty awesome. Heck, even ForeFlight has synthetic vision. I can see through anything just by looking at my iPad. There’s all sorts of things out there to make it easier.
Thank you for posting this great video. It's definitely a wake up call to everyone in the industry. I have approximately 15 years of flying experience and also started young in this business. I would like to respond to your closing comments regarding the pilot shortage and recent influx of career changers in the cockpit. I think it should be said that years of flight experience or hours in a logbook does not necessarily equate to a competent pilot. We always "hope" that the incompetent ones will get weeded out sooner rather than later but that's obviously not always the case.
love the flight deck pic's, some of the best times in my 72 years were on the deck of the USS America during the 6 Day War..................................................at 17 years old....thanks
I am a firm believer in mandatory verbal FMA call outs when they occur. I used to not be but this SOP drives home to both crew members any change of FMA/aircraft mode. If mandated procedure, it becomes second nature and you are always keyed in to what mode the a/c is in as well as eventual absolute
understanding of the a/c and autopilot modes.
Juan, your explanations of the above keeps my mind current as I hope to fly GA airplanes during the cold winters in the Northeast U.S. Just following your mental instructions helps me keep my mental flight requirements current.
Thank you so much Juan. Replacing the Flight Engineer, Navigator, Radio Operator with computers saved a lot of capital and salaries. But it reduced the number of eyes, on an integrated flight deck. A reminder I learned from my Dad that flew the B-307 on schedule.
Thanks Juan. I am a VLJ driver and viewing your videos is always an excellent investment in my time.
Having flown over the last 40 years, I was very curious about this odd accident. Excellent presentation. Nice work and I'm sure it is appreciated by many. The NTSB does an incredible job and hats off to those folks.
I don't get how he assumed they were in a stall if there was no stick shaker active, that alone should have made him check the artificial horizon and rethink the situation. If only the captain had declared control he might've saved it.
Somatogravic Illusion can be overpowering.
@@osakarose5612 Agreed. Most difficult are actions against feels and instinct.
Read the NTSB interviews with the people who trained him. He apparently freaked out whenever something unexpected happened.
@@blancolirio, I know sailing across the Pacific, you can suffer the illusion that the boat is sinking even though nothing is wrong.
That illusion or spatial disorientation can be very strong as Juan said. Think of the famous Flight 19 Avengers. The command pilot was convinced he was over the Keys to the point he said , the sun is in the wrong place.
This really chokes me up. They had clear indications of what was wrong and knew how to fix it, if they worked through it. Turning off auto-pilot is so standard when things pile up. Thank you Juan! I really needed this. I thought it would have been an unworkable situation. It unfortunately was not.
Once again you had me glued to my computer for 40 plus minutes! Thank you again.
I had vertigo once, while working on an F4, Wild Weasel. I had to work on the radio in the back seat. As I was quickly lowering myself head first I swung my head to make sure I didn’t hit any ejection seat cables. At that moment I felt the aircraft tilt on its side, I instantly realized it was vertigo. I climbed slowly back out and set on the ground trying not to throw up. THIS FEELS COMPLETELY REAL! Later I was an aircrew member on AWACS planes and EC-135’s retiring with over 8000 hours of flying time. I also have around a 150 hours of Cessna flying, but luckily never suffered from vertigo again. All I can say is trust your instruments, trust your instruments, and trust your instruments!!!!!
Juan, fantastic breakdown and glad you included the links. I’m so upset at times, this being one, with people working beyond their talent levels. This time it was fatal. Thanks again.
When I was in the US Army I was a passenger in a UH-1 'Huey' helicopter flying in the vicinity of Tokyo, Japan. We were flying at about 1,500' AGL. It was winter time and a very cloudy day. Suddenly we flew into a low cloud blank and the visibility was zero, nothing but gray-white all around us. I had heard about the spatial disorientation in such a situation, but I had never experienced it. I had no idea if we were ascending, descending, right side up, upside down or level. I was completely disoriented and it was a very strange feeling to say the least. Of course the pilots were experienced, calmly flying on instruments and after a few minutes we came out of the cloud and everything was fine. But after that I have a complete understanding of what you described in this video, and I can see how an inexperienced pilot could start to panic, and react inappropriately in such a situation.
Thanks for your great explanation of this accident. Your videos are very good and I enjoy watching and learning from them.
Your very thorough breakdown of the NTSB’s report with explanations based on your own piloting/A&P experience makes your channel a must watch for all pilots and aviation enthusiasts interested in industry safety. I was totally captivated!! Thanks Juan very much and keep ‘em coming!!
Juan. I am hoping the FAA and NTSB watches your videos and Dan Gryders. You have different styles and focus but you both bring out things that could help make aviation safer, him general, you more commercial. The Idaho crash that killed a female pilot was one i watched you and Dan. Both were great.
Trust your instruments, aircraft configuration and power settings.
40 years ago i went to bed at 2 am after consuming 4 beers with my FO for a scheduled departure at 3:00 pm with a very high ranking VIP. At 9:00 am we are awaken and told we would depart at 10:00 am. We were flying a twin turbine aircraft.
We took off on time from a mountainous area. WE were IFR. For the next 25 minutes my head was telling me I was in a climb, I was in steep banking turns and also upside down. I did what was the right thing, continue to monitor my ADI's and stdby indicator and power settings until clear of clouds. Of course, I had a hangover. I never forgot that terrible day and never repeated that foolish mistake of drinking while on any possible flight status. Spacial disorientation is a killer.
Thanks Juan for making this a major point of your briefing. And to think these days we read of pilots showing up for flights that are under the influence is crazy and should be fired. OH WAIT! We're short of pilots! That's no excuse.
gary grant Years ago, the Navy did an experiment with drinking and flying. They put Navy pilots in the sim and gradually got them intoxicated. A few actually did better with a small amount of alcohol. All of them did their worst performance with a hangover.
gary grant Years ago, the Navy did an experiment with drinking and flying. They put Navy pilots in the sim and gradually got them intoxicated. A few actually did better with a small amount of alcohol. All of them did their worst performance with a hangover.
Thank you sir for your analysis of this tragedy. I appreciate the hours you've spent going through all the reports, etc., digesting the facts.
I live east of Houston Intercontinental (IAH). I remember being impressed by how brief & violent the cold front passage was just before the crash. In my neighborhood, quite a few large tree limbs were torn off by wind gusts. There were no tornadoes reported, but the wind gusts seemed to approach that strength for several minutes. It struck me as really odd weather for that time of year. So at the time I suspected the cold front would be a major contributor to the accident; but the facts indicate otherwise.
Thanks again for explaining all this so clearly.
Again .... Great analysis. One comment. The hand off stick carrier problem may be more related to mass and accelerations and muscle tension than inner ear. When the pilot is exposed to launch accelerations, and then suddenly those accelerations are removed, the entire body jerks forward. If the arm and hand are connected to the stick, it will be pushed forward too. No ear problem, just mass and accelerations
Extremely well worded, extremely well investigated and reported back. Those of us who enjoy this detailed information cannot obtain it elsewhere...so we DO truly get excited when a title such as this arrives in the email box! Thank you!
Having flown for a major US carrier, on the B-767-200 & 400 series for over 10 years, and about 6 years flying the B-777-200, I have never experienced an accidental engagement of the TOGA buttons. Maybe I'm just lucky? Great video and description. I have witnessed a few people get "washed out" of training, but it is rare. The airlines have such good training programs today that if you apply yourself and have the ability, you should pass the multiple check rides that we all face. I would rather stick needles in my eyes than go to the sim!
This is why I love desktop flight sims or all flight sims for that matter, because it allows you to hop into an aircraft that you are not fully trained and prepared to fly and in turn creates the opportunity to fall into a precarious situation unexpectedly which then can show someone who’s learning about flight just how quickly it can go all wrong. The reason I say this is because I did something very similar where I hit the to/ga button by accident and my reaction was turn off auto throttle turn off autopilot and manually reduce the throttles but the airplane wouldn’t give it to me. It stayed at toga thrust, and by the time I figured out that it was because I had forgotten to turn off the flight directors to fully reset everything I was already at VMO
Once again thank you for your thorough and factual explanation. Very sad story, thank God they didn't have 150 trusting passengers sitting behind them.
great analysis & insight from your point of view, I must say you do these so well. maybe your next job is NTSB iinvestigator.
Thanks again for such a clear & concise report as i'm not an airline pilot but can follow your explanation easily.
One of the best explanations of a tragic aviation event I have read. Many thanks.
This CVR transcript makes me really affected. It is an outstanding example of how quickly and unexpectedly death can come. Shortly before they died the FO chatted with the Jumpseater about aviation career opportunities. It was the routine of everyday life for them nearly to the end. They haven´t realised the danger until the very last moments of their lives. It is a very sad document, especially when you´re reading the last words of the FO.
unfortunately for them, the FO was an idiot
@@Hazza4257 The FO was an incompetent Pilot who hadn´t basic abilities necessary to work in this profession as we now know. He should have switched to another profession, allthough this would have ended his "Being-a-Pilot"-Dream of his Life. But you know something like this always when you readed the Final Report. I made my statement three years ago on the basis of the Preliminary Report and what Juan told about it.
I just heard the best explanation of how important training check rides are
Like I have told others, this man knows his stuff. Thank you for this detailed analysis. Your insights into this "pilot's world" are fascinating. As you have pointed out in the past, maybe the lack of pilot training and monitoring contributed to this accident. I must say, it is shocking that this lack of skill by seemingly qualified, capable pilots keep coming up in these incidents. As automated as these cockpits have become, it still takes the skills of airmanship to fly these modern aircraft.
Haunting circumstances. I recall an fatal C-130H crash of the 440 AW in Honduras when I was an Air Force Reserve member. The AC was, unfortunately, one who slipped through the cracks of both a major U.S. Air carrier and the military. Crew pairing decisions, heavy load and a challenging approach to Tegucigalpa added up to a disaster. These types of "perfect storm" scenarios make us shake our heads in hindsight, wondering why we didn't see it coming. Thank you, Juan, for your insightful and particular care in reviewing these tragic air mishaps.
Excellent presentation Juan. After reading the FO's training record, I would not have much confidence in his capability under perfect conditions, much less stress. The two things that stood out to me were the several comments about his poor judgement and his on-going lack of knowledge of procedures in virtually every phase of operation. In my Air Force days (Vietnam era), this is going to get you washed out of pilot training ASAP or removed from flying status if it occurs after you report to your operational squadron. I am really surprised that Atlas continued to tolerate it, but as you said, perhaps the civilian world has adapted a lower standard in the face of pilot shortages at that time.
You mentioned middle aged folks deciding they want to be Airline pilots and after getting their ratings are being hired. My experience is totally different from a former time. I had around 1800 hours when my 5 year hitch was up. Pilot training, a year in Vietnam flying AC-47's, and two years in B-52's where I was upgraded to aircraft commander after six months. Of my B-52 time, 80% of it was flying out of Guam and Thailand for eleven months until the end of the war in early 73. I got out in March, 73 and had already applied to several airlines. I had an interview with Delta in June and was notified that there was a class starting in October 73. The Yom Kippur war kicked off on Oct 6 and the Arabs placed an embargo on oil. Prices went from $3 a barrel to $12. Oregon banned Christmas and politicians called for national gasoline rationing. Pilots became baggage handlers. Needless to say, there was no hiring of new pilots. I could have pursued it in terms of using my GI bill to get ratings, but the situation was very unpredictable and other opportunities presented themselves.
Like most things in life, timing and luck matters. I've since fortunately had a successful business career, owned a Bonanza and am now semi-retired to Montana.
Juan, once again a fantastic explanation of the NTSB report on the Atlas accident. Last year when you made your first video on the accident your ideas of what went wrong were right on. That is attributable to your experience flying this type airplane. What was not known is the FO's issues which obviously was the major cause. I look forward to each of your videos and learn something from each one.
Thanks for a great report. I never knew why navy pilots hang on to the handles on take off from an aircraft carrier.
Very interesting! I'm a former Boeing Flight Controls engineer; lots of that hardware looked really familiar despite 10 years of retirement. Kind of surprised at the inadvertent GoAround activation on the 767; I had to work on fixes for quite a few of those on 747 and 777. The switch location is very different.
Wow ! Busting out of the clouds, 49 degrees nose down and 400 plus knots. That kind of lays it all out. How they got there, I think you described well.
As a retired customer service airline career of thirty-five years I'd had no desire to learn to fly personally. But have always taken an informaitonal interest in flying requirements and techniques. I appreciate your reporting and evaluation of airline accidents and commerical airline issues. Thank you and pray your health allows you to return to actvie status. God Bless.
Wow! Juan, that was an absolutely riveting account of the accident, with some really insightful commentary about pilot training and spatial disorientation. Thanks so much.
I am the pilot training (AQP) data analyst for a US regional airline over the statistical analysis of pilot proficiency data, and you wouldn't believe the stuff we see these days. The upgrade time (time to go from copilot to captain) went from about 12 years to 6 months in just 3 years. We've also hired street captains in limited situations. I would expect we'll continue to see things like these on our way to the bottom. Now, where is that bottom? I don't think anyone knows.
diegus012 A while back there was a Jetstream 41(?) accident near RDU. The captain was a recent upgrade from FO. He remarked to others some time before the fatal accident that he didn’t feel ready to be captain.
“On the way to the bottom “. Yep we think we are getting smarter and more sophisticated.
Wow. Remember all this and you can impress your ground school instructor. Juan, this was awesome. And of course if all pilots were this good 737max would all be flying. Which is why I support you.
Just one thing I would like to add and it is something I teach on the 76 if an inadvertent activation of the G/A mode occurs, you can of course disconnect the A/P and do it the way you described but it is a lot easier and with less drama just to hit the ALT HLD switch, from there you can go to any lateral or vertical mode you want! I like easy, easy works for me!
Agree.
Have you had a chance to look at the FDR traces?
what mode do the AT's assume? Once the plane is in an undesirable state, it's time to "Fly the plane" and reduce the level of automation to a point of certainty.
@@blancolirio When you hit ALT HLD the AP will level off and the AT will go to SPD. The AP is holding Altitude and the AT is holding the selected airspeed. I understand the point about "Fly the Plane". Sometimes easy works, especially if it was just an indavenent mode selection. But I agree 100% if you don't like what the automation is doing, disengage and hand fly it.
@@blancolirio I'm not disagreeing with the technique you described! You can always just disconnect everything and just fly it! But that in it self also brings a higher level of complication doesn't it? This particular captain was dealing with an F/O that was not following any sort of SOP'S At that point I wouldn't want to become the PF while handflying, you would have to dedicate your total attention just to fly the A/C and the capacity of supervising him would greatly reduce. I agree with Bob Teter that if the G/A mode is activated by mistake just pressing the ALT HLD button immediately stops the climbing and acceleration tendency of the G/A mode and holds the altitude and speed at the time you pressed the switch! Simple and effective!
Juan, Thank you so much!!.
Your in depth detailed explanations, both, about the plane’s systems, and piloting, are just incredible!!.
In it, there is a so much knowledge, experience and know how of great piloting and aviator!!.That is adorable 🙏. Well done!!!. Wish I had the chance to fly with you in my Cessna.
Looking forward for each and every video of your’s.
I'd watch 45 min of Juan over 45 45 min of "mayday" any day! Thank you, very informative.
I like them all. "Mayday" is fascinating for the recreations of what happened inside the plane. "Air crash investigation" is fascinating for what you learn about how they work out the answers to what happened. The Flight Channel and Allec Joshua Ibay are fascinating because of their simulator recreations of the flights. They're all good!
Very well presented, lots of information to get out there. I’m a retired corporate pilot, retired at the age of 62 with 22k hrs in my book. I’m also a licensed A and P mech. 40 plus years.
What I’m seeing is pilots relying too much on computers and not having the basic flying skills needed. Would that have averted this crash, maybe, maybe not, but if your hand flying you get a better feel of what’s happen to your aircraft. Just my option for what’s it’s worth, not much.
Your experience is very valuable. I have watched a couple of The Flight Channel videos about Qantas flights with A380s where the computer went haywire because of faulty sensors and the pilots had to struggle to get control of their planes and land them safely. One was awarded a medal for his skills. Also, I am reminded of the Winnipeg "glider" incident, which much like the Miracle on the Hudson, where the pilots were experienced with flying gliders so when they lost all engines, they treated the jet as just another glider and made a safe landing. It still surprises me that pilots today don't seem to get enough training in manual flying, like most people don't know how to drive a manual-transmission car. I guess it's because too many people expect the technology to always work.
Some pilots relying not so much as "too much on computers;" however, relying on them with too little systems knowledge behind those the magic of those computers. Their lack of understanding those systems is just as dangerous of a lack of flying skill. But I agree; those that rely heavily on automation see a degradation of basic stick and rudder skills.
Keep it up Juan, we GA pilots and certainly many others are constantly learning from you. As much in depth explanations as well as fundamental information as possible is always highly appreciated.
Just finished watching the video in its entirety. Thank you so much Juan 👍👍.
ive been in a go around once and the sound of the engines powering up is quite obvious (along with the somatogravic illusion). incredible that the two pilots didnt seem to hear the engines spool up or even look at their EFIS.
Dang Juan! What an excellent presentation! I have been waiting on this one brother! You did not disappoint! I had posted on one of your earlier videos about this one. I am an old A&P mech, who works for Boeing here in Houston. I live just a couple of miles from this crash site on the bay. It was a sad day. More sad now that I know the details. Thanks for what you do man!
Superb presentation! i am a big fan and am very grateful for you taking the time to thoroughly explain this to us non-aviators
Sterling work, especially over the last few days. Thanks Juan
A fine presentation of a tragic accident. Lots of human failures along the "error chain" both in the cockpit and at Atlas and the FAA. So sad.
Juan, great report! Thank you very much for taking the time to read the NTSB public docket. We can only hope that as a result of this investigation and videos like yours that the airline industry becomes safer. My condolences to the families of the pilots and the passenger. Again, thank you!
Juan, thank for your presentation, I was technician in this particular aircraft some time before it was withdrawn from passenger service and converted to freighter. Thanks for your explanation, and your approach and carefulness on description about crew behaivor in this fatal accident.
Another" home run" Juan!! You up to .406 like T Williams now!! Amazing report.thank you sir for everything you teach us about aviation in your videos!
Juan, Thank you for this very thorough breakdown of this accident. I was once on an aircraft, weighing in at over 580,000 lbs, just before landing, and while both acting pilots were on totally different INUs and ADIs, neither of them believed what the ADI was displaying to them! The aircraft stalled, then rolled right to 93*. The aircraft stalled again and rolled over onto the left wing, at close to 90*, before the right seater was able to recover the aircraft!! In this "WE NEARLY BOUGHT THE FARM" experience, the aircraft was not properly configured for the selected approach speed, which ultimately lead to this mishap. Flight deck crews, need to constantly back each other up, and not just blatantly read off items on a checklist. Force yourself to look at each configuration item on the checklist! It may save your life one day. thank you
The fundamental truth of any work is that experience costs money. If you don't want to pay out money, you cannot hire experience. In this case, experience means putting in the requisite time to develop a rock solid instrument scan, and an unshakeable trust in what the instruments are saying, either in aircraft or simulators. The illusion that Juan described is one of a set of common illusions that you must ignore, replacing them, or maybe more pointedly, overriding them, with the visual input you are taking into your brain from the panel. One thing you can do that will help you ignore these feelings is to look at your attitude indicator, and mentally extend out the lines to the left and right....imagine that the AI is MUCH larger, and then focus on that extended line like it is a real horizon, and note that even if you think you are pitching UP, the AI will tell you that you are NOT. This level of instrument trust does not happen overnight. It takes many long hours of practice. I can tell you that it has probably saved my life in actual IMC.
Juan, it seems unusual with two pilots having fifteen thousand hours and four clear signs indicating 'GA" that they should have noticed the gauges while working together...many thanks for bringing clarity from the FAA MuBoJumbo ...
Juan, as always your crash analysis seems to be thorough and spot on with one exception in this case. Although I am confident your intent was to be fair and unbiased, I believe we are only human and for any of us it is extremely difficult to not put a slant on our reporting
One of the discussion threads seems to be pretty heated and IMO I think your reporting contributed to it. As you presented most of the facts of this crash you only spent 14 seconds out of 40 minutes (at time 40:56), talking about “One hiccup in the captain’s trading record”. What was the nature of this “hiccup”? Was it a failure or additional training? What was the procedure or area of difficulty?
Therefore it seems natural that many folks are focused on blaming the crash entirely on the FO. In fairness, you could have spent more time discussing the fact that the captain as PIC (pilot-in-command) has the sole responsibility to insure the safe operation of the flight. Therefore, I believe we should also ask the following questions. Although the pitch attitude reached minus 49 degrees, this change in pitch occurred over an 18 second period.. 1) why did the captain not recognize this pitch change? 2) why did the captain not react to this change in pitch? 3) why did the captain not take over sooner? 4) why did the captain not state, “ I have the aircraft”?
If you had spent more time on the captain’s deficiencies more folks could see that both pilot’s should more evenly share responsibly for this terrible crash.
RIP to all three occupants!!! My condolences to their family and friends.
Juan, please keep up the great reporting!
r4444m Good points about the captain. CRM seemed nonexistent. Perhaps the Atlas air training program is a bit lacking?
Amazing summary. Thanks Juan for breaking it down for us viewers.
Very thorough and detailed, thanks so much for explaining as I was completely confused by this accident.
@blancolirio This spacial confusion you discuss reminds me of a knee jerk tendency that I had for some years re riding motorcycles. It happens when your eyes are focused on a danger and one inadvertently steers towards it making it worse. It's just human nature and one needs to be literally trained out of it. Terrific video.