Atlas Air Flight 3591

[TreeA10]

https://admiralcloudberg.medium.com/legacy-of-a-lie-the-crash-of-atlas-air-flight-3591-519a3a7bd6ec

[uhhello]

1 hour ago, TreeA10 said:

https://admiralcloudberg.medium.com/legacy-of-a-lie-the-crash-of-atlas-air-flight-3591-519a3a7bd6ec

And his family is suing others for THEIR failings...

[brickhistory]

One of the commenters after the article was making the same argument; it's not his fault...

[Danger41]

For the 767/other heavy drivers out there…is it possible to do it basically single pilot? You’ve got a copilot out to lunch…can you just tell him to sit on his hands and handle everything from the left seat?

[Prozac]

21 minutes ago, Danger41 said:

For the 767/other heavy drivers out there…is it possible to do it basically single pilot? You’ve got a copilot out to lunch…can you just tell him to sit on his hands and handle everything from the left seat?

From what I remember from the initial investigation, the shear pin connecting the yokes was broken when the Captain attempted to take control of the aircraft. To answer your question, yes, either seat can fly the aircraft & reach pretty much everything required to get yourself safely on the ground. But the designers didn’t account for fighting a large, adrenaline fueled adult male for control of the aircraft. Shitty situation for all involved & despite the conclusions of the well written article that was posted earlier, I believe the Atlas HR and training departments are being let off easy here. 

[TreeA10]

6 hours ago, Danger41 said:

For the 767/other heavy drivers out there…is it possible to do it basically single pilot? You’ve got a copilot out to lunch…can you just tell him to sit on his hands and handle everything from the left seat?

Yes, you can fly it single pilot if the other pilot isn't horrendously incompetent and keeps touching switches. Self induced problems were apparently a trend item with this guy. 

[tbro96]

Recently received my M.S. in Aviation Safety. My capstone project was on this flight and what went wrong. It's an incredibly shallow view to just label it as pilot error and be done with it. There were so many questionable things that happened here from the training of the pilot, the structure of Atlas Air, to the cockpit design itself. 

[uhhello]

37 minutes ago, tbro96 said:

Recently received my M.S. in Aviation Safety. My capstone project was on this flight and what went wrong. It's an incredibly shallow view to just label it as pilot error and be done with it. There were so many questionable things that happened here from the training of the pilot, the structure of Atlas Air, to the cockpit design itself. 

I don't think anyone is arguing that.  It's rarely down to a single pilot error.  In this case, the pilot error was pretty significant though.  Over and over again.  

[tbro96]

3 minutes ago, uhhello said:

I don't think anyone is arguing that.  It's rarely down to a single pilot error.  In this case, the pilot error was pretty significant though.  Over and over again.  

That article in particular really demonized the pilot, when I would personally say that the FAA, Atlas Air, and Boeing are more to blame. The fact that the FAA hasn't even come remotely close to finishing the PRIA mandated database should be a higher priority. Obviously the pilot shouldn't have decided not to disclose some information, but the blame lies more with the system (or lack thereof) to catch these situations before they occur. People in every industry will omit shortcomings in order to get a better job or get ahead, regardless of the morality of it and what the consequences of it could be. I guess my issue with this article lies in the tone and how it focuses so much on the pilot being incompetent, rather than all of the other pieces of what lead to the accident.

 

[Prozac]

2 hours ago, tbro96 said:

That article in particular really demonized the pilot, when I would personally say that the FAA, Atlas Air, and Boeing are more to blame. The fact that the FAA hasn't even come remotely close to finishing the PRIA mandated database should be a higher priority. Obviously the pilot shouldn't have decided not to disclose some information, but the blame lies more with the system (or lack thereof) to catch these situations before they occur. People in every industry will omit shortcomings in order to get a better job or get ahead, regardless of the morality of it and what the consequences of it could be. I guess my issue with this article lies in the tone and how it focuses so much on the pilot being incompetent, rather than all of the other pieces of what lead to the accident.

 

I think if your complete lack of skill and aptitude kills a couple of people who depend on you to operate with an assumed level of competence (with the potential for many, many more deaths.....imagine if the aircraft had gone down in a neighborhood or crowded city), you deserve a good chunk of the blame.  Multiple failures at several operators should be a clue that maybe this isn't the job for you.  At the end he seemed only too content to place his fate in the hands of his god.  I wonder if the other two people on the airplane shared his sentiments?  Sure, the FAA and Atlas are also complicit, but this dude deserves the criticism IMO.

[BashiChuni]

Rumor was he threatened to sue for discrimination when he was brought into the CPO office and talked to about his poor performance. Sad for all players involved. 

[tac airlifter]

2 hours ago, tbro96 said:

That article in particular really demonized the pilot, when I would personally say that the FAA, Atlas Air, and Boeing are more to blame. 

Bro, the CP flew the aircraft into the ground because he sucked.  Despite any other culture/system failures, what can you add to the incident which contravenes my first sentence?

Copy every accident has a chain, but this level of incompetence was a crash waiting to happen.  I don’t like being a dick, but we shouldn’t be afraid to call a spade a spade.  That dude was terrible, and stories like this help reinforce the importance of IPs & EPs holding the standard.  That’s the single change which could have prevented this.  

[Prozac]

1 minute ago, BashiChuni said:

Rumor was he threatened to sue for discrimination when he was brought into the CPO office and talked to about his poor performance. Sad for all players involved. 

I’ve heard the same thing from several sources. I was hesitant to bring that up because I’ve not seen it substantiated, but it certainly adds another element if true. I’m generally for airlines increasing diversity. I understand the means to that end are controversial & I don’t intend to start that particular argument. The one thing we should all agree on though is that there must be a minimum level of acceptable performance for everyone. Maybe this accident will move the needle a bit in convincing airlines, judges, and maybe even lawyers that, regardless of minority status, airlines need the ability to weed out people who can’t meet the standards. 

[BashiChuni]

The Air Force has not learned from this lesson unfortunately And is constantly pushing student pilots thru UPT (reinstating SPs who fail their 89 rides) and letting ticking time bombs graduate and spread all throughout the service. 
 

don’t be surprised to see situations like this in the future. 

[tbro96]

8 minutes ago, tac airlifter said:

Bro, the CP flew the aircraft into the ground because he sucked.  Despite any other culture/system failures, what can you add to the incident which contravenes my first sentence?

Copy every accident has a chain, but this level of incompetence was a crash waiting to happen.  I don’t like being a dick, but we shouldn’t be afraid to call a spade a spade.  That dude was terrible, and stories like this help reinforce the importance of IPs & EPs holding the standard.  That’s the single change which could have prevented this.  

If we take out all of the other failures and only leave the one where he "sucked" then obviously there are no other reasons? I'm not saying he wasn't a bad pilot or that he has NO blame. I'm saying that there are many other entities and people at fault for letting the sucky pilot through. The mindset of "pilot error" being the main cause is a slippery slope and even when it is a contributing factor, we as an industry cannot accept that as a widely accepted scapegoat. I believe we're all on the same page with the fact that what he did by withholding information was wrong. However, where is this disdain toward whoever was in charge of putting him on the pilot watch program? Why didn't they have him go through the training again if there was a two week hiatus in his training before the exam and he had all of his home issues and the hurricane stress? His obvious lack of quality airmanship would have been caught then and there. These are all questions that I feel have answers that would be much more indicative to why this happened than focusing on the fact the pilot was sub-par.

[StoleIt]

8 hours ago, tbro96 said:

Recently received my M.S. in Aviation Safety. My capstone project was on this flight and what went wrong. It's an incredibly shallow view to just label it as pilot error and be done with it. There were so many questionable things that happened here from the training of the pilot, the structure of Atlas Air, to the cockpit design itself. 

Curious, what in particular were the issues with the cockpit?

[jazzdude]

Bro, the CP flew the aircraft into the ground because he sucked.  Despite any other culture/system failures, what can you add to the incident which contravenes my first sentence?
Copy every accident has a chain, but this level of incompetence was a crash waiting to happen.  I don’t like being a dick, but we shouldn’t be afraid to call a spade a spade.  That dude was terrible, and stories like this help reinforce the importance of IPs & EPs holding the standard.  That’s the single change which could have prevented this.  

The dude sucked, but if that's where you leave it, it opens the door for this kind of thing to happen again.

Getting after the "why" the pilot sucked is the more important and harder question to answer to prevent something like this from happening again. They were flying in an environment that is regulated and controlled: there are supposed to be several players of safeguards to remove bad pilots from flying (for an air transport carrier) and being a danger to the public.

Poor sq or company culture can be a factor (i.e. IPs/EPs/LCAs not holding the standard), and that needs to be examined and fixed if needed as well.

Things like FOQA and ASAP are important as well to identify issues before they become problems, whether it's bad operational procedures/guidance or poor aircraft design.

I don't think anyone would argue the mishap copilot doesn't deserve blame, but there's a lot of blame that is deserved elsewhere as well.

[jonlbs]

4 hours ago, BashiChuni said:

don’t be surprised to see situations like this in the future. 

Can't really speak to the Military side, but for the Civilian side, I truly (sadly) believe it is only a matter of time. Regionals are where it will happen first. The need for Captains is just so insane that bad ones are going to skirt by. What used to be a washout is now going to get hand held just a little more and make it thru. Only time before they pass and get paired with a shit FO and the wrong circumstances.

The problem might matriculate to the Major's as they lose the ability to be as selective as well. Don't get me wrong there are solid training programs with good dudes in place but I just don't see it holding up forever with the business pressure.

Business considerations > Safety considerations. Sounds oddly familiar.

[tac airlifter]

4 hours ago, tbro96 said:

If we take out all of the other failures and only leave the one where he "sucked" then obviously there are no other reasons? I'm not saying he wasn't a bad pilot or that he has NO blame. I'm saying that there are many other entities and people at fault for letting the sucky pilot through. The mindset of "pilot error" being the main cause is a slippery slope and even when it is a contributing factor, we as an industry cannot accept that as a widely accepted scapegoat. I believe we're all on the same page with the fact that what he did by withholding information was wrong. However, where is this disdain toward whoever was in charge of putting him on the pilot watch program? Why didn't they have him go through the training again if there was a two week hiatus in his training before the exam and he had all of his home issues and the hurricane stress? His obvious lack of quality airmanship would have been caught then and there. These are all questions that I feel have answers that would be much more indicative to why this happened than focusing on the fact the pilot was sub-par.

I’ll buy 90% of what you said above.  But I do not ascribe to your earlier  viewpoint that primary responsibility for an act so blatantly bad rests with entities other than the person who did it.  
 

You and jazzdude mention multiple contributing factors that should all be examined and rectified. Concur.  But causal on this accident is pretty obvious: dude flew it straight into the ground.  It’s necessary to state it so bluntly (because I’m not a fan of throwing spears at fellow aviators who made mistakes) to reinforce the importance of holding standards. Thank goodness so many flight evaluators had documented his behavior and poor performance; had HR caught it he may not have been allowed at the controls.

I will also mention a thank you to the original poster. These are great discussions for a bunch of professionals to have, and much more useful than Covid and political discussions to me personally. Cheers🥃

[jazzdude]

I’ll buy 90% of what you said above.  But I do not ascribe to your earlier  viewpoint that primary responsibility for an act so blatantly bad rests with entities other than the person who did it.  
 
You and jazzdude mention multiple contributing factors that should all be examined and rectified. Concur.  But causal on this accident is pretty obvious: dude flew it straight into the ground.  It’s necessary to state it so bluntly (because I’m not a fan of throwing spears at fellow aviators who made mistakes) to reinforce the importance of holding standards. Thank goodness so many flight evaluators had documented his behavior and poor performance; had HR caught it he may not have been allowed at the controls.
I will also mention a thank you to the original poster. These are great discussions for a bunch of professionals to have, and much more useful than Covid and political discussions to me personally. Cheers

Agree it's great discussion!

One of the limitations of the AF safety system is it looks to assign blame (even though it's always talked about as not assigning blame, labeling factors as causal and contributing assigns blame). It looks for what went wrong and establishes a chain of events leading to a mishap, and that one individual can break the mishap chain. That approach is fine for all individual chain of events, but largely misses problems that tend to not consist of individuals (i.e. organizational problems).

Another safety paradigm that is starting to gain some traction is to look for what goes right rather than what went wrong ("safety II" if you want to read more into it). Basically, any system is prone to errors that could lead to mishaps, but the people in the system make small corrections that together keep the system safe.

So for this mishap, we would expect a competent pilot to recognize that TOGA was inadvertently engaged, and to reconfigure the flight director and recover from any spatial disorientation by transiting to their instruments. Post flight, the pilot could fill out an ASAP documenting inadvertent TOGA, which could initiate a trend leading to a cockpit redesign or procedure change if it's determined that inadvertent TOGA is a frequently realized hazard/issue. Alternatively, FOQA analysis could see inadvertent TOGA trends.

We'd also see that pilot hiring relies on accurate job history. Generally, pilots will be truthful on their resume since if they aren't and are caught, they'll be blacklisted from that airline. But without a system like a fully implemented PRIA program, it trusts pilots to be honest or airline HRs to do a lot of digging into applicants to verify employment. It's something we take for granted in the AF, since we have our FEF that follows us every time we change assignments that documents our history. (Sidebar- is the AMC philosophy of Q3/Q1 to "document" a deviation that in ACC might be a "there I was" lessons learned brief to the sq good or bad?)

[Beaker16]

1 hour ago, jazzdude said:

(Sidebar- is the AMC philosophy of Q3/Q1 to "document" a deviation that in ACC might be a "there I was" lessons learned brief to the sq good or bad?)

I think a justifying a Q3 with "documenting" a discrepancy is asinine. If we banish folks for smaller mistakes, it creates a culture of non-reporting and non-accountability. The ultimate goal is to debrief every sortie and preform to a higher standard during the next hack. 

Every aircrew member should be on their game every time they step, meet Q1 standards and discuss with the dudes and dudettes when they were exceeded. I get there are black and white standards in MDS Vol 2s. As tac mentioned it takes a strong core of line IP/EPs to holistically uphold those standards and foster a Squadron and intern community that fosters development.

For example, I previously violated my MDS V3 by accomplishing a mission event under a training LAA (1000AGL vs 1000MSL). It was as an honest mistake that we overlooked. Before we did it we discussed COAs as a crew, accomplished an inflight terrain analysis and pressed. It ultimately lead to no downgrades, and we passed a emphasis point that LAAs are easily misattributed, specifically when operating close to sea level. Since then I've heard three stories with a eerily similar root causes that weren't discussed. 

[Vito]

TBro96,

  As a 767 Pilot, I too would like to know your rationale for the comment blaming Boeing for cockpit design. This accident has parallels to the Max debacle. People blaming Boeing for 99% of the problem, when pilots who didn’t have a clue are held blameless, not to mention he outright lied about his background.

Edited April 20, 2022 by Vito

[tbro96]

Lots of discussion since yesterday! This is awesome!

I'm going to attach the CAST Analysis I performed (With a partner. I can't take all of the credit. I have removed names and dates as well.) for my M.S. to this post. CAST is a Causal Analysis using Systems Theory. CAST is a newer way to look at accident investigations that is gaining in popularity that attempts to look in more depth at all of the components and how they work together. Disclaimer it's 30 pages long.

@Vito as far as Boeing, I don't believe that the issues with the cockpit design are at the same level as the Max debacle. It is more of a "How can we improve the design?" rather than a "Boeing knew and decided not to do anything about it."

 

Atlas Air 3591 CAST Analysis.pdf

[StoleIt]

46 minutes ago, tbro96 said:

Lots of discussion since yesterday! This is awesome!

I'm going to attach the CAST Analysis I performed (With a partner. I can't take all of the credit. I have removed names and dates as well.) for my M.S. to this post. CAST is a Causal Analysis using Systems Theory. CAST is a newer way to look at accident investigations that is gaining in popularity that attempts to look in more depth at all of the components and how they work together. Disclaimer it's 30 pages long.

@Vito as far as Boeing, I don't believe that the issues with the cockpit design are at the same level as the Max debacle. It is more of a "How can we improve the design?" rather than a "Boeing knew and decided not to do anything about it."

 

Atlas Air 3591 CAST Analysis.pdf 211.06 kB · 4 downloads

Just browsing through your report. Some good stuff in there...but I am curious you and your writing partners background. A lot of your "Why did this happen? This needs to be answered to explain why the events occurred" questions at the beginning are a little alarming if you and your writing partner need to ask.

Is it formal for the FO to be pilot flying on takeoff? - Yes, generally 50% of the legs.

Could this cause complacency in the pilots? - No, acft data burst messages back to dispatch is 100% invisible. Just like datalink while oceanic. It actually significantly alleviates pilot workload.

Is it appropriate to talk about while flying? - Good think you didn't hear what we normally talk about.

Is the FO allowed to monitor radios independent of Captain oversight? - That is an alarming question to not know the answer to.

Is it normal for captain to go make everyone coffee? - Granted I have FA's for that sort of thing...but sounds like a great Capt.

Could light chop have been severe in the vicinity of rain showers? - By definition...no light chop cannot be severe.

Should the plane be configured for a go around? - A go around can occur in any configuration. Slightly more frowned upon up in the flight levels, but I've been told to G/A or had approach clearance cancelled well before I was in landing configuration.

Etc etc.

 

Why was there not a better indication that go around mode had been activated? There is...the FMA's cycle and the big obvious one is the throttles advance to GA N1. I've had plenty of C-17 turned 737 pilots I fly with TOGA instead of A/T disconnect due to negative transfer. Each one has been competent enough to hold the throttles back instead of letting them advance to GA N1...then say ooops...then proceed to correctly disconnect the A/T. A question you never appeared to ask was why didn't this accident pilot do that?

Contributing Control Action: Improperly designed go around mode ergonomics that make it easy to accidentally turn on. - Making it harder to hit TOGA is NOT the answer. TOGA should be easy to turn on otherwise you will get a lot more airplanes slamming into the ground in an unsafe situation.

 

Any who, just my $.02 as a student of Human Factors Engineering. Congrats on completing your capstone!

[tbro96]

44 minutes ago, StoleIt said:

Just browsing through your report. Some good stuff in there...but I am curious you and your writing partners background. A lot of your "Why did this happen? This needs to be answered to explain why the events occurred" questions at the beginning are a little alarming if you and your writing partner need to ask.

Is it formal for the FO to be pilot flying on takeoff? - Yes, generally 50% of the legs.

Could this cause complacency in the pilots? - No, acft data burst messages back to dispatch is 100% invisible. Just like datalink while oceanic. It actually significantly alleviates pilot workload.

Is it appropriate to talk about while flying? - Good think you didn't hear what we normally talk about.

Is the FO allowed to monitor radios independent of Captain oversight? - That is an alarming question to not know the answer to.

Is it normal for captain to go make everyone coffee? - Granted I have FA's for that sort of thing...but sounds like a great Capt.

Could light chop have been severe in the vicinity of rain showers? - By definition...no light chop cannot be severe.

Should the plane be configured for a go around? - A go around can occur in any configuration. Slightly more frowned upon up in the flight levels, but I've been told to G/A or had approach clearance cancelled well before I was in landing configuration.

Etc etc.

 

Why was there not a better indication that go around mode had been activated? There is...the FMA's cycle and the big obvious one is the throttles advance to GA N1. I've had plenty of C-17 turned 737 pilots I fly with TOGA instead of A/T disconnect due to negative transfer. Each one has been competent enough to hold the throttles back instead of letting them advance to GA N1...then say ooops...then proceed to correctly disconnect the A/T. A question you never appeared to ask was why didn't this accident pilot do that?

Contributing Control Action: Improperly designed go around mode ergonomics that make it easy to accidentally turn on. - Making it harder to hit TOGA is NOT the answer. TOGA should be easy to turn on otherwise you will get a lot more airplanes slamming into the ground in an unsafe situation.

 

Any who, just my $.02 as a student of Human Factors Engineering. Congrats on completing your capstone!

Thank you. We were both students/student pilots. We do not have experience flying with the big boys yet, so a lot of the things that you would consider "obvious" for someone with more experience are not obvious to us. This was not a thesis to earn the degree, just a project in one of our last semester classes. 

I think this thread is a really cool way to dive deeper into this topic for me, as I am now working in a safety role, and seeing the different viewpoints of the subject is important. Especially views from other pilots that have flown in the aircraft.

As for TOGA, I wouldn't say it needs to be harder to hit. It needs to be placed somewhere that it is *less likely* to be accidentally hit. However I am not an engineer so it's quite possible that it currently IS in that spot.