B767 Atlas Air/Prime Air crashed while approaching Houston


Dancrane ha detto:
È stato pubblicato il video, ed è impressionante, l’aereo va giù a 90 gradi.
Clicca per espandere...

Perdona il momento da puffo Quattrocchi, GP, ma per me non si puo' dire che sia venuto giu' di 90 gradi. Il video mostra l'aereo "di spalle". Potrebbe esserci stato anche un movimento in senso orizzontale che, dato l'angolo della ripresa, non possiamo vedere.

In ogni caso e' venuto giu' in picchiata come uno Stuka.
 
Sempre a spanne guardando un video di scarsa qualità, all'apparizione l'aereo sembra veloce, mentre in prossimità del suolo più lento. Questo vuol dire che si sta allontanando dal punto di ripresa, quindi con una traiettoria per nulla perpendicolare al terreno
 
13900 ha detto:
Perdona il momento da puffo Quattrocchi, GP, ma per me non si puo' dire che sia venuto giu' di 90 gradi. Il video mostra l'aereo "di spalle". Potrebbe esserci stato anche un movimento in senso orizzontale che, dato l'angolo della ripresa, non possiamo vedere.

In ogni caso e' venuto giu' in picchiata come uno Stuka.
Clicca per espandere...

cammellocane ha detto:
Sempre a spanne guardando un video di scarsa qualità, all'apparizione l'aereo sembra veloce, mentre in prossimità del suolo più lento. Questo vuol dire che si sta allontanando dal punto di ripresa, quindi con una traiettoria per nulla perpendicolare al terreno
Clicca per espandere...

Guardandolo bene sullo schermo del pc, in effetti, si ha l'impressione di un tentativo di planata (dal 6° secondo del video), sembra impattare quasi di pancia. Sul cellulare avevo avuto ben altra impressione.
 
Col muso di 15 gradi sotto l'orizzonte si può già dire che sei in "upset" (e con un liner ti caghi addosso..).
 
Fa decisamente impressione! Poveri cristi!


Inviato dal mio iPhone utilizzando Tapatalk
 
Quindi conferma il fatto che nel video si veda un tentativo di richiamata, congruente con un pitch che passa da -49° a -20°.
Ora c'è da capire cosa abbia causato il passaggio da un volo stabile ad uno con massima potenza, 4° a cabrare e successiva picchiata
 
Interpreto male io quel che è scritto da NTSB e riportato da AvH o sembra che l’aereo sia stato condotto intenzionalmente in picchiata?


Inviato dal mio iPhone utilizzando Tapatalk
 
Also, about this time, the FDR data indicated that some small vertical accelerations consistent with the airplane entering turbulence. Shortly after, when the airplane’s indicated airspeed was steady about 230 knots, the engines increased to maximum thrust, and the airplane pitch increased to about 4° nose up. The airplane then pitched nose down over the next 18 seconds to about 49° in response to nose-down elevator deflection. (Editorial Note: the sentence originally read: "and then rapidly pitched nose down to about 49° in response to column input." and was later edited by the NTSB). The stall warning (stick shaker) did not activate.
Clicca per espandere...

La NTSB ha modificato la loro iniziale dichiarazione, probabilmente una semplice svista
Sarebbe interessante sapere se il 767 ha anche i dati della control column registrati nel FDR
 
Voci che girano senza garanzia di veridicità. Bert Botta è un ex pilota TWA che ha concluso poi la carriera come pilota di jet privati.

Subject: Houston Amazon 767 Crash 23 Feb 19

From the net, courtesy of a reliable source.…

Just FYI… we’ve heard the full cockpit audio and seen the data. Here’s what really happened (name redacted to protect the innocent!):

During the approach, at about 6,000 FT (being flown by the first officer), the Captain reached around the throttle quadrant to extend the flaps to the next position after being called to do so by the first officer (pilot flying)… very normal.

In many aircraft including the 767, that’s a very odd/difficult repositioning of your hand (from the left seat, all the way around to the right side of the center console), and requires intimate familiarity and slow deliberate motion to do successfully.

Well in any case, it was not done so this time. The captain accidently hit the “go around” switch while bringing his hand around for the flaps, which brought both engines up to full power. In the landing configuration, as this aircraft was transitioning into, that obviously causes a vast increase in lift… and the first officer (pilot flying) used everything he had to force the nose back down.

Still not sure why that occurred, as the crew should have just “gone around” and tried it again when properly configured… but they did not. And that started in motion a chain of events that lead to tragedy.

As the First Officer over-rotated downward, again with the engines at full power, the aircraft quickly accelerated and approached something we’re all trained to handle (at least in good training environments)… an “upset recovery”, countered by NON-AUTOMATION and basic “stick and rudder skills”.

This captain however, in turn, grabbed the controls without using positive command (“I’ve got”, “My aircraft”, or anything normally done), and countered the F/O’s control input by completely hauling his control column full aft… remember, while the F/O is pushing full forward.

In the process of doing that, he broke the “shear pin” on his control column (a device/mechanical safety interlock used to separate a control column from the “innards” of the control architecture in the event one control column is doing something it should not)… and that occurred here.

The captain, a few seconds later, now accelerating downward out of the control envelope of the 767 (remember, all of this started at 6000 FT and probably took less time to get to the fatal point than it did to read this far), recognizes the has no control column and then asks the F/O to pull up, get the nose up, or something to that affect. It isn’t 100% clear what he says.

The F/O then tries to pull aft on his column (going from full forward to full aft), but isn’t getting the response he needs, because the aircraft is out of the envelope of controllability and the controls are “air-loaded” in position.

At about 2000 FT, eventually the trim motors are able to start overcoming the air-load, and the aircraft begins to attempt to arrest its rate of descent… but alas it’s far too little, far too late, and the aircraft impacts about 30-40 degrees nose down, with what is believed to be about 4-5000 FT / minute rate of descent.

All during this time the throttles aren’t touched until somewhere during that last few seconds of flight… which is believed to be what enabled the trim motors to start working. Unclear who does it, and no audio indicates who it was.

Just FYI… we’ve attempted in our 767 simulators to recover from the event with the exact same setup, and thus far we’ve only had success when starting at 8000’ or higher… meaning we are fully established in the “out of control” position at 8000’, recognize it by then, and initiate recovery starting at 8000’.

These guys started the whole thing at 6000’ and were much lower when a true recovery attempt was initiated. No chance, and just shows you how quickly you can get “out of the envelope” when you don’t follow procedure, try some completely erroneous recovery technique, and don’t have a clue what you’re doing.

So many things went wrong with crew coordination, basic flying skills, aircraft envelope awareness, basic procedures, and such… that this will likely go down as one of the absolute worst “pilot error” events ever.

It needs to have serious impact throughout the Amazon flying circus (and associated partnerships), and show people that Jeff Bezos’ attempt to push the envelope at lower cost, all things else be damned, doesn’t apply to aviation.

This accident no doubt was absolutely horrible, and three people lost their lives…one of them (the jumpseater) through absolutely no fault of his own. But making an approach into Houston, TX, it could have been so much worse. In another few miles, they would have been over major population centers and who knows what would have happened then.

Know your aircraft. Know your procedures. And for God sakes, just FLY! It’s not a video game!

Relayed by your PJP Editor
Bert Botta
Aviation Writer
PJPFBO Editor
Email: bert@privatejetpilots
Clicca per espandere...


Credo sia utile poter visualizzare i pulsanti TOGA del 767 per capire come possa essere successo.

GoAround-Switches-1200.jpg
 
Spectre of pitch-up illusion emerges in Atlas 767 crash probe

Investigators have alluded to the possibility that an Atlas Air Boeing 767-300 freighter pilot experienced somatogravic illusion before the aircraft entered a fatal dive on approach to Houston.
The aircraft had been descending through cloud at 6,000ft when its go-around mode activated and its engine thrust increased, causing the aircraft to accelerate into a shallow climb.
US National Transportation Safety Board documentation states that the go-around mode was activated “using one of the go-around buttons on the throttle quadrant” – although it does not indicate why the button was pressed.
“There was no mention of initiating a go-around by the flight crew on the cockpit voice recorder,” says the NTSB in an aircraft performance analysis.
Cockpit-voice recordings reveal that the first officer – who was flying – remarked, “We’re stalling”, about 17s after the go-around mode activation.
But the inquiry analysis contradicts this perception. The wing’s angle-of-attack was below -15°, it points out, while the aircraft’s airspeed was above 250kt.
“This is well below the [aircraft’s] wing stall angle-of-attack,” the analysis adds.

getasset.aspx


It flags the possibility that the first officer misperceived the aircraft’s acceleration as a sharp pitch upwards – a phenomenon known as somatogravic illusion, which occurs when visual cues to differentiate the two sensations are absent.
The analysis compares the 767’s actual pitch with the apparent pitch which the first officer might have experienced according to a mathematical calculation.
It indicates that, although the control column was pushed forward and the aircraft transitioned from the shallow climb to a steep dive, the pilot could have erroneously perceived that the jet was pitching upwards at an alarming 40° and even momentarily at 60-80°.
“If the change is interpreted as the result of a climb, the pilot will input nose-down elevator in response,” says the analysis.
“For this reason, it is important that pilots develop an effective instrument scan in [instrument meteorological conditions].”
Flight-data recorder information showed an elevator split emerged as the aircraft entered the dive, with the captain applying nose-up input.
This split continued for several second but ceased about 1s after the aircraft would have broken out of the 3,500ft cloud layer – at which point both pilots would have been able to see that the jet was diving steeply.
Both subsequently pulled on the control columns but were not able to recover the aircraft sufficiently to avoid its impact with Trinity Bay. None of the three occupants survived the 23 February crash.
Cirium/FG
 
Mandrake ha detto:
Riesumo il thread perchè è uscito il rapporto finale NTSB. I trascorsi precedenti del F/O fanno impressione, una delle tante raccomandazioni è il miglioramento dei processi di selezione e check del personale navigante.

Clicca per espandere...

Copio e incollo dal report (grazie!).

Probable Cause
The NTSB determines that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the pilot records database in a sufficiently robust and timely manner.
Clicca per espandere...

1.2.2.1 Training History at Atlas
The FO completed Atlas basic indoctrination training on July 7, 2017, and Boeing 767 ground school on July 22, 2017. On July 27, 2017, he was not recommended for his Boeing 767 type-rating oral examination due to his need for remedial training in takeoff and landing performance and airplane systems. He completed 4.5 hours of remedial training, which included takeoff and landing performance and aircraft systems, then passed the oral examination on July 29, 2017. The FO was recommended to begin Boeing 767 fixed-base simulator training the next day. After completing five fixed-base simulator training sessions, the FO was not recommended to proceed to full-flight simulator training due to his difficulty in completing normal procedures. The FO received one 4-hour remedial training session then completed fixed-base training on August 8, 2017.

According to the fleet captain, the FO began full-flight simulator training for the Boeing 767 on August 10, 2017, and, after two sessions, the FO’s simulator partner complained that he was being held back by the FO. The fleet captain said that, at the time, Atlas did not have the available seat support to continue the FO’s full-flight simulator training and decided to restart it from the beginning on August 27, 2017.

By September 3, 2017, the FO had completed his sixth full-flight simulator training session when the effects of a hurricane forced Atlas to shut down all training for several days. The FO’s training resumed on September 19, 2017. On September 22, 2017, the FO failed his practical Boeing 767 type-rating examination due to unsatisfactory performance in CRM, threat and error management, nonprecision approaches, steep turns, and judgment. During a postaccident interview, the Atlas check airman who was the FO’s examiner said the FO was very nervous, had “very low” situational awareness, overcontrolled the airplane, did not work well with the other pilot, omitted an emergency checklist during an abnormal event, and exceeded a flap speed. The examiner said the FO was not thinking ahead, and, when he realized that he needed to do something, he often did something inappropriate, like push the wrong button. The examiner said the FO’s performance was so poor that he worried that the FO would be unable to “mentally recover” enough to complete the course.

The FO received remedial training on September 25, 2017, and he passed the type-rating checkride the next day. During a postaccident interview, the Atlas instructor who performed the FO’s remedial training (who was not the same person as the checkride examiner) said he thought the FO had a confidence problem and described the remedial training as a “great training session.” The FO was not placed in the PWP.13 Between October 26 and November 22, 2017, the FO received 53 hours of initial operating experience on the Boeing 767 and, by January 24, 2018, had completed 116 hours of Boeing 767 flight time. He completed recurrent line-oriented flight training on February 17, 2018, and January 7, 2019.

The FO completed his most recent recurrent ground school training on July 7, 2018, and completed his most recent recurrent simulator proficiency check the next day. In both instances, he was graded satisfactory/complete on unusual attitudes, upset recovery maneuvers, and a takeoff stall recovery.
Clicca per espandere...

1.2.2.2 Certificate History and Previous Employment
FAA records for the FO showed no reports of any previous aviation accidents or incidents. Records for the FO’s pilot certificates showed the following notices of disapproval (and subsequent certificate issuances after he passed retests):
• ATP Boeing 767, practical test failure (September 22, 2017): Takeoff and departure phase, in-flight maneuvers. Certificate issued 4 days later.
• ATP Embraer ERJ145, practical test failure (May 11, 2014): Nonprecision approaches, navigation procedures. Certificate issued the next day with a PIC limitation. The limitation was removed on September 30, 2014.
• ATP Embraer ERJ145, oral examination failure (April 22, 2014): Retest completed 4 days later.

The FO’s previous employment included the following:
• Mesa Airlines (February 2015 until July 2017, when he was hired by Atlas): Embraer ERJ175 FO, unsuccessfully attempted to upgrade to captain in May 2017 and resigned (citing “career growth”) to accept a position with Atlas.
• Trans States Airlines (March to September 2014): Embraer ERJ145 FO, failed an oral examination for the Embraer ERJ145 in April (then successfully retested) and failed Embraer ERJ145 ATP checkride in May (then successfully received his certificate). He was graded unsatisfactory on a line check in August and resigned citing personal reasons.
• Charter Air Transport (February 2013 to March 2014): Embraer EMB120 FO.
• Air Wisconsin Airlines (April to August 2012): Did not complete FO initial training for Canadair Regional Jet and resigned citing personal reasons.
• CommutAir (May to June 2011): Did not complete FO initial training for de Havilland DHC-8 and resigned citing “lack of progress in training.”
• Air Turks and Caicos (June 2008 to June 2010): Embraer EMB120 FO until furloughed.

When the FO applied for a job at Atlas, he did not disclose that he had worked for Air Wisconsin and CommutAir or that he did not complete initial training at either airline. He also did not disclose to Trans States Airlines when he applied for a job there that he had previously worked for and did not complete initial training at Air Wisconsin. Investigative interviews with instructors who evaluated the FO at two of his previous employers provided insight into the FO’s training performance at those airlines.

According to one check airman at Mesa Airlines, the FO could explain things well in the briefing room and performed some expected tasks well in the simulator. However, when presented with something unexpected in the simulator, the FO would get extremely flustered and could not respond appropriately to the situation. She said that when the FO did not know what to do, he became extremely anxious and would start pushing a lot of buttons without thinking about what he was pushing, just to be doing something. She noted that the FO lacked an understanding of how unsafe his actions were, and he could not see why he should not be upgraded to a captain.

Another check airman at Mesa said the FO’s stick and rudder skills were weak, and he also struggled with basic flight management system tasks. 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. A third check airman at Mesa said that the FO had weak situational awareness, did not realize what was going on with the airplane at times, and had difficulty staying ahead of the airplane. She said the FO was completely unaware that he lacked skills, unwilling to accept feedback, and unhappy with her about his failure to upgrade to captain.

An instructor who taught cockpit procedures on the flight training devices at Air Wisconsin Airlines recalled that during one emergency procedures training scenario, the FO made abrupt control inputs that triggered the stick shaker and overspeed alerts. The instructor said that instead of staying engaged in the scenario and addressing the problem with his training partner, the FO just stopped what he was doing and turned around and looked at the instructor. The instructor found this reaction highly unusual.
Clicca per espandere...
 
Succede anche in Europa, nel 2017 era accaduto un tailstrike ad un 757 Jet2 per "incorrect pitch position during landing" e anche qui il PF (F/O) aveva dei trascorsi abbastanza burrascosi con diversi additional trainings e Line training checks.
 
Quello che è sconvolgente è il "Sistema".
Un pilota con così scarse attidudini al mestiere doveva già essere fermato da anni, invece oggi bocciava un esame faceva 2 ore di "ripetizioni" e il giorno dopo passava l'esame, davvero incredibile, sia che succeda in USA o in qualsiasi parte del mondo, in questo caso la FAA penso abbia serie responsabilità.

Saluti Marco
 
  • Like
Reactions: Farfallina
Devi accedere o registrarti per rispondere qui.


Top Bottom