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Freighter crash, Houston

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Fox3WheresMyBanana
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Re: Freighter crash, Houston

#101 Post by Fox3WheresMyBanana » Wed Mar 13, 2019 11:52 pm

Still might be the jumpseater falling forwards, or even a loadshift coming forward into the cockpit.
But, doesn't sounds good.

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Re: Freighter crash, Houston

#102 Post by Boac » Thu Mar 14, 2019 8:28 am

The apparent combination of nose-down controls and high power are puzzling and do not fit with a 'falling foward'.

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Re: Freighter crash, Houston

#103 Post by Pontius Navigator » Thu Mar 14, 2019 8:38 am

BOAC, the pitch up is consistent with increased power, but if throttle movement AND nose down were due to falling forward would there have been an initial pitch up!

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Re: Freighter crash, Houston

#104 Post by Boac » Thu Mar 14, 2019 8:52 am

PN - it is the dive that killed them, not the pitch up, so although it is a puzzling 'happening' (as to 'why') it is of less import than the subsequent.

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Re: Freighter crash, Houston

#105 Post by Fox3WheresMyBanana » Thu Mar 14, 2019 8:55 am

Given how the aircraft impacted, if they don't get something obvious off the CVR then this could be a very long investigation trying to identify the correct sequence of causes.

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Re: Freighter crash, Houston

#106 Post by Ex-Ascot » Thu Mar 14, 2019 9:11 am

Boac wrote:
Thu Mar 14, 2019 8:52 am
PN - it is the dive that killed them, not the pitch up, so although it is a puzzling 'happening' (as to 'why') it is of less import than the subsequent.
Sorry Boac, I disagree. The dive didn't kill them it was the sudden stop at the end of the dive wot did it. IMHO.
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Re: Freighter crash, Houston

#107 Post by Pontius Navigator » Thu Mar 14, 2019 9:14 am

Boac wrote:
Thu Mar 14, 2019 8:52 am
PN - it is the dive that killed them, not the pitch up, so although it is a puzzling 'happening' (as to 'why') it is of less import than the subsequent.
I was clumsy, what I was trying to say was a power and pitch up before nose down was not consistent with the single event of 'falling forward '.

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Re: Freighter crash, Houston

#108 Post by Boac » Thu Mar 14, 2019 9:18 am

Ex-A - yes, you are right..............

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Re: Freighter crash, Houston

#109 Post by Stoneboat » Sun Mar 17, 2019 7:47 pm


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Re: Freighter crash, Houston

#110 Post by Fox3WheresMyBanana » Sun Mar 17, 2019 8:51 pm

I see they've changed "column input" to "elevator deflection". One wonder whether the FDR measures both, and whether there's a discrepancy if it does. I would suspect from the change that it only measures elevator deflection, and somebody jumped the gun in assuming this meant column input. The 767 has no manual reversion linkage, so it's all FBW. The change to 20 nose down in the dive would seem to indicate at least one crew member is trying to pull out of the dive, but we don't even know if control column input is having any effect on the elevator at this point.
We seem to be none the wiser as to the cause from this extra info. The onset of turbulence has me slightly biased closer to a 'not a crew member's deliberate act' collection of causes.

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Re: Freighter crash, Houston

#111 Post by barkingmad » Mon Mar 25, 2019 10:26 am

Fox3, I trust when you mentioned FBW you were not referring to the 'bus' method of controlling the 'frame?

The various diagrams hawked around in T O P all seem to refer to big twangy guitar type control cable wires which accords with the age of the 767.

But I could be wrong as 4+ decades in aviation and too much brain solvent consumed during that time has definitely taken its toll!! :O3

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Re: Freighter crash, Houston

#112 Post by Fox3WheresMyBanana » Sun Mar 31, 2019 2:11 am

Thanks, Barking, I was in error; the original reference I read said it was all FBW, but I've now checked elsewhere and the first fully FBW airliner was the A320 two years later. The 767 does indeed have, as my basic flying ground instructor used to say, "a suitable system of wires, levers, pulleys and bell cranks"

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Re: Freighter crash, Houston

#113 Post by Alisoncc » Sun Mar 31, 2019 4:17 am

Fox3WheresMyBanana wrote:
Sun Mar 31, 2019 2:11 am
The 767 does indeed have, as my basic flying ground instructor used to say, "a suitable system of wires, levers, pulleys and bell cranks"
The onset of turbulence has me slightly biased closer to a 'not a crew member's deliberate act' collection of causes.
Whilst I haven't played at being a LAME for many a year, keeping foreign objects clear of control runs is still etched into my brain. Anything so deposited could quite likely shift during turbulence, causing the undoing of this aircraft.
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Re: Freighter crash, Houston

#114 Post by TheGreenGoblin » Wed Jul 22, 2020 10:59 am

NTSB Abstract
During the NTSB’s probe into the February 2019 crash of an Atlas Air Boeing 767 into a marshy area in Trinity Bay, Texas, the board determined the crew lost control of the airplane as it approached Houston’s George Bush Intercontinental Airport (IAH). The accident, an all-cargo flight, killed both pilots and also took the life of another airline pilot who was riding along in the jump seat.

The first officer was acting as the pilot flying on the leg to Houston that originated in Miami, Florida. As the heavy jet approached KIAH, the crew deployed the speed brakes and leading edge slats to increase the rate of descent. The captain was the pilot monitoring, though the Boeing’s autopilot and autothrottle system were engaged throughout the approach. Standard company procedure says the flying pilot should guard the speed brakes to ensure they are retracted when power is added to maintain level flight. The NTSB said the crew encountered light turbulence as they penetrated a deck of clouds associated with a cold front approaching Houston and continued the flight on solid instruments.

About 30 seconds prior to impact, as the aircraft descended through 6,300 feet headed to 3,000 feet, the flight data recorder indicated the go-around button was activated, possibly by the FO’s wrist while retracting the speedbrakes. The captain was distracted with other duties preparing for the approach. Activating the go-around button made the autopilot assume the crew wanted to climb and caused the command bars on the flight director to indicate the increase in nose pitch. Within a few seconds of the go-around mode’s activation, the first officer—believing the pitch up indicated the aircraft was stalling—shoved the control wheel forward.

The NTSB says, “Within seconds of go-around mode activation, manual elevator control inputs overrode the autopilot and eventually forced the airplane into a steep dive from which the crew did not recover. Only 32 seconds elapsed between the go-around mode activation and the airplane’s ground impact.” None of the flight data recorder information indicated the aircraft was anywhere near a stall at the time of the first officer’s reaction. The Board also cited the Atlas captain for failing to closely supervise the FO and also his failure to assume command of the aircraft when things began heading south.


The NTSB says, “Despite the presence of the go-around mode indications on the flight mode annunciator and other cues that indicated that the airplane had transitioned to an automated flight path that differed from what the crew had been expecting, neither the first officer nor the captain were aware that the airplane’s automated flight mode had changed.” Neither pilot communicated anything about the change with the other. The Board believes “the first officer likely experienced a pitch-up somatogravic illusion as the airplane accelerated due to the inadvertent activation of the go-around mode, which prompted him to push forward on the elevator control column.” A somatogravic illusion, also referred to as a vestibular or false sensation, can occur when no clear horizon is present, as in this case when the aircraft had just entered the clouds. The NTSB’s video recreation of the sequence of events during the final moments of Atlas Air 3591 and the Board’s abstract of the investigation offer a look at what probably happened in the cockpit.

Skybrary says, “The vestibular organs are part of the human body’s mechanism for achieving posture and stability. Changes in linear acceleration, angular acceleration and vertical acceleration (gravity) which occur as a result of flight control inputs, made to accomplish a change in the flight path, are detected by the vestibular system and may create either or both of these illusions. Whilst there are many situations in which these illusions can occur, one of the most likely, and certainly the most dangerous, is when the positive changes in acceleration, which accompany the initiation of a go around or the transition to initial climb after takeoff, are occurring. In both cases, the consequences can rapidly lead to CFIT if the condition is not recognized or to a [loss of control] if the situation is recognized but the complexities of recovery are mishandled.”

Aircraft accidents attributed to pilots reacting to these “seat of their pants” illusions have occurred in both commercial and general aviation operations. Another significant Part 121 loss took place in May 2010, as an Afriqiyah Airways Airbus A330 began a go-around in daylight from a non-precision approach at Tripoli. The crew also reacted to what they felt was happening rather than what their instruments indicated. The aircraft rapidly descended into the ground and was destroyed by impact forces and fire. All but one of the 104 occupants were killed.
https://www.flyingmag.com/story/news/at ... -reaction/
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Re: Freighter crash, Houston

#115 Post by TheGreenGoblin » Wed Jul 22, 2020 11:00 am

While sensory illusions, stress, and startle response can adversely affect the performance of any pilot, the investigation revealed that in this case, the first officer of Atlas Air 3591 had earlier demonstrated fundamental weaknesses in his flying abilities and his response to stress that would have made it even more difficult for him to accurately assess the airplane’s state and respond with appropriate procedures after the inadvertent activation of the go-around mode.

In written comments found in the NTSB Docket on this accident related to remedial training session prior to the first officer taking his Boeing 767 type rating checkride, the instructor said the pilot’s, “Situational awareness was lacking. Procedures were incorrect. [Aircraft] Limitations were exceeded. Judgment was poor, CRM skills were poor. Steep turns exceeded all PTS limits. Non-precision procedures non-existent and a totally unstable approach resulted. Didn’t work well with pilot monitoring during in-flight emergency. Lack of confidence and tunnel vision were definite contributing factors.”

Additional evidence indicated the first officer had a long history of training performance difficulties as well as a tendency to respond impulsively and inappropriately when faced with an unexpected event during training scenarios at a number of different employers. The Board believes this indicated an inability to remain calm during stressful situations. The 1996 Pilot Record Improvement Act system was originally created in order to make it difficult for an applicant to be hired at a company without the hiring company being aware of those training issues. This accident showed the record system has no fallback when an applicant either lies or simply omits critical information from their application.

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Re: Freighter crash, Houston

#116 Post by Boac » Wed Jul 22, 2020 11:04 am

In view of the length of time the Captain took to react to the extreme control input by the F/O, I seriously wonder if he was in his seat at the time.

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Re: Freighter crash, Houston

#117 Post by barkingmad » Wed Jul 22, 2020 12:46 pm

“caused the command bars on the flight director to indicate the increase in nose pitch.”

I never did like nor trust FD bars after long years of flying raw old fashioned AHs.

The implication here is he saw the bars going north and pushed south to ‘correct’ as the movement of the bars requiring a nose up pitch is not necessarily an actual NU pitch action.

So his SA was obviously compromised bigtime by the unexpected but inevitable result of the TOGA being initiated.

It’s neither the first nor the last accident where the articulate bonobo chimp with the control column (of whom I was one!) has got “out of phase” with the automatics.

Just thinking aloud, not advocating major changes in APFDS management, but hat and coat are at the ready in case...

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Re: Freighter crash, Houston

#118 Post by AtomKraft » Sat Jul 25, 2020 7:03 am

How did that idiot get into that seat?
I realise the Capt. gets a share of the blame for not intervening, but nobody should have had to fly with anyone with that level of ability.

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Re: Freighter crash, Houston

#119 Post by TheGreenGoblin » Sun Aug 02, 2020 6:38 am

Some comment from Paul Bertorelli on Avweb...

A good detailed overview of the ATSB summary here... including their report briefing...



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Re: Freighter crash, Houston

#120 Post by Boac » Sun Aug 02, 2020 7:23 am

Notwithstanding the problems with the F/O, as I have said before, the Captain's performance baffles me. He seemed to be completely divorced from the operation of the aircraft. I have queried whether he was actually in his seat or not at the time of the upset, as that could explain the lack of action. Presumably there is post-crash evidence, but I have not seen it. The CVR should also give a clue.

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