Atlas Air Flight 3591

[Vito]

TBro96,

   In hindsight, the location of the Go Around  switches could be placed in a different location. However, the fact that the 767 and 757 have been flying for millions of hours over 40 years with few  instances of pilots inadvertently engaging the GA switches should be testament of a good design. 

[StoleIt]

52 minutes ago, tbro96 said:

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.

Gotcha! Sorry for my tone to one or two of your questions...I assumed this was a master's level thesis/capstone and you were at least a commercial/military pilot (my selection bias stemming from the demographics of the normal posters on this site).

As for TOGA, I cannot think of a better place for it beyond the throttle. It needs to be somewhere immediately accessible using a hands on throttle/stick style approach.

Quote

"The NTSB concluded that the first officer most likely struck the go-around switch accidentally with his left wrist or his wristwatch while manipulating the nearby speedbrake lever and that neither pilot realized that the aircraft's automated flight mode had been changed." - FAA

Now where to put it on the throttle is a better discussion.

Just a quick google of 767 toga switch highlights the issue:

 

Now you can push for two types of remedies: Training and/or physically moving the switch. For obvious reasons, training is the quicker and cheaper method to fixing this problem. Train all crews and make it SOP to retract the speed brake by going on top/in front of the throttles. This eliminates the risk of hitting the TOGA.

Second, ask Boeing to physically move the switch. You can put the TOGA button in front of the throttles, behind but covered, etc, etc. Unlikely COA considering it'll cost a lot of operators a lot of time and money.

Finally, lets talk about why this crews unusual attitude recovery was subpar. Did the Captain call for transfer of aircraft control? Was the Captain late/untimely on taking over to recover? And, of course, all the drama associated with why the FO was even in that seat in the first place.

Quote

The NTSB recommended that pilots of the 767 and the similar Boeing 757 be trained to recognize and recover from inadvertent go-around mode actuation, but also concluded that available data suggested that such an actuation was a "rare and typically benign event." - NTSB

^ That is basically as blunt as the NTSB can get with calling out a crew member as completely at fault IMO.

[tbro96]

Don't worry about your tone. It is the internet after all, @StoleIt. I had come here originally just to ask about my chances of getting a guard slot interview, as I had just taken the AFOQT and then learned about this website. However, I've found that it's just an enjoyable forum to talk to people. This being my subject of formal education, I wanted to chime in.

I've seen that picture of how easy it is to hit the TOGA with your wrist, which is why I question its location in the first place. But you are most definitely correct in that it would cost a lot of money to change the location, and as with most things safety related, it can be dealt with pretty effectively with a little bit of training. I guess I may be a bit naïve, but I don't think the money matters if it saves lives in this situation. This type of thing isn't only possible in cargo aircraft holding a few pilots. It could happen in a commercial flight, too. 

As for the crew, its hard to say for me about how the pilots reacted. Screaming "lord take my soul" doesn't seem like quite the answer to me, though.

[CaptainMorgan]

Don't worry about your tone. It is the internet after all, [mention=405]StoleIt[/mention].
I've seen that picture of how easy it is to hit the TOGA with your wrist, which is why I question its location in the first place. But you are most definitely correct in that it would cost a lot of money to change the location, and as with most things safety related, it can be dealt with pretty effectively with a little bit of training. I guess I may be a bit naïve, but I don't think the money matters if it saves lives in this situation.

The plane has been flying for decades without this being a significant issue.


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[SocialD]

Having flown 6 different transport category aircraft (including the 75/76), I don't necessarily disagree that the G/A switch position is less than ideal.  However, this jet has been flown free of major incidents like this for decades.  Clearly the risk is easily mitigated by proper training/procedures.  The bigger issue here is the complete lack of airmanship, which based on the FOs record, doesn't sound like it should be all that shocking.  An inadvertent activation of the GA switches should have been a simple thing to recover from, AP/AT/FD - OFF, set known pitch/power setting, reestablish the automation at the level you want.  That's basic airmanship shit right there!  

 

Linked below is an outstanding video series (might have to click through the recommended videos to get them all...I think 6 videos total).  Very dated, but I feel most of his points are even more applicable today.  

Children of the Magenta

[disgruntledemployee]

Retro install 737 "thrust levers"* where the G/A button is on top. Cost category - MX, $$$$$.

or

Put your arm on top of the "thrust levers"* while using the speed brake from the right seat, removing the threat of inadvertent G/A switch engagement.  Bonus, one can feel the throttles, er, I mean "thrust levers" move at level off/power up and stow the brakes.  Training, $

or

Don't hire people that should not be flying.  High startle, low SA, overreacts with a crazy ivan vs a trained maneuver.  Hiring, free; or Training, $ for starting and washing them out.

* Boeing and its use of weird terms for airplane things.

[Prozac]

7 hours ago, disgruntledemployee said:

Put your arm on top of the "thrust levers"* while using the speed brake from the right seat, removing the threat of inadvertent G/A switch engagement.  Bonus, one can feel the throttles, er, I mean "thrust levers" move at level off/power up and stow the brakes.  Training, $

I’ve always instinctively used this technique. Feels far more natural/less awkward than the reach-around method (giggidy), & has the added benefit of reminding you that the throttles are supposed to be at idle when the boards are out.  

[HuggyU2]

The issue isn't the TOGA switch location.  Instead, I ask "why do I have to reach all the way over to the left side of the center panel to get to the speed brake?"  Why can't there be one on the FO's side?

Boeing simply won't move it to a better place. It's like that on all four Boeings I've flown. 

[TheNewGazmo]

The issue isn't the TOGA switch location.  Instead, I ask "why do I have to reach all the way over to the left side of the center panel to get to the speed brake?"  Why can't there be one on the FO's side?
Boeing simply won't move it to a better place. It's like that on all four Boeings I've flown. 

It is like that in EVERY jet I have flown from Boeing, to Airbus to Embraer. Must be a standard.

[AirGuardianC141747]

On 4/20/2022 at 3:16 PM, SocialD said:

An inadvertent activation of the GA switches should have been a simple thing to recover from, AP/AT/FD - OFF, set known pitch/power setting, reestablish the automation at the level you want.  That's basic airmanship shit right there!  

 

Linked below is an outstanding video series (might have to click through the recommended videos to get them all...I think 6 videos total).  Very dated, but I feel most of his points are even more applicable today.  

Children of the Magenta

Bottom line like SocialD stated and many others - If the aircraft is not doing what is required or what you want, turn OFF the automation. All of it if need be. Fly your aircraft! Valid videos.

*Previously we weren’t allowed to hand-fly specific departures ever. Now we are allowed if the crew agrees and amount of busy-work/congestion is manageable. Slap automation on when required; otherwise, maintain your proficiency as best you can. It’s not easy in the Heavy world when we fly long legs (1 maybe 2, rarely 3) with 3 or 4 pilots on a routine basis. Must keep vigilant.

Edited April 23, 2022 by AirGuardianC141747

[Danger41]

Similar note I saw when I was DO at a deployed site and all we had at the time for precision recovery was a PAR. Nobody ever flew those and most guys would couple an ILS or at least fly with the aid of a flight director. Since that wasn’t an option, I directed the folks to fly those for practice (and for the PAR team to practice before it was needed). It was ugly. However, a couple reps and guys were right back in the groove. 
 

Flip side of that…I almost always fly precision approaches with no automation or flight director for practice. One time I made a series of idiotic choices before diverting to no shit mins and had one chance before emergency fuel and I’m hand flying it with no automation for no reason. Copilot asked if I’d like that and I sheepishly said that was probably a good idea. We hit mins and saw nothing…we got cleared the approach one minute before the field (Tallahassee) closed and went back to pilot controlled lighting (weren’t on tower yet to hear that). I probably set some kind of human performance record for most radio transmit actuations in 3 seconds but we got there thanks to the automation. Good times.
 

 

[HuggyU2]

On 4/22/2022 at 7:56 PM, TheNewGazmo said:

It is like that in EVERY jet I have flown from Boeing, to Airbus to Embraer. Must be a standard.

On the Airbus 319/320/321, it is only about 5" left of the center of the console. 

And it is well aft of the throttles, which allows both pilots to use it without the throttles interfering. 
 

Much better design. 

Edited April 24, 2022 by HuggyU2