Atlas Air 3591
Atlas Air 3591 was a Boeing-767 Freighter, operating as an Amazon
Prime delivery, flying from Miami, FL to Houston, TX on February 24,
2019. On board were the two pilots, and one jump-seater. As they
were nearing Houston, and making those descent and turning maneuvers
required to place themselves in sequence for landing, they suddenly
pitched down, and dove into the North end of Trinity Bay, hitting the
water at a very high speed and descent rate. All three men onboard
were killed.
Here
is what happened, as determined by the subsequent investigation. The
First-Officer was the Pilot-Flying as the Captain was the
Pilot-Monitoring. Air Traffic Control had encouraged them to increase
their descent rate, so to allow them to make a favorable turn upon
clearing a conflicting altitude. In normal fashion, the F/O extended
the wing spoilers for that purpose. Company policy required him to
keep his hands on the Spoiler handle (His left hand) while the
spoilers were deployed, as a
preventative to using that same hand to increase engine power without
first retracting the spoilers. The investigators determined that
while the F/O was reaching across the Thrust-levers
as he held
the Spoiler-lever, he inadvertently pressed the Go-Around button on
the left Thrust-lever.
That caused to auto-flight system to power-up and pitch-up the
aircraft, which was certainly an unexpected event for
him to cope with.
Ordinarily,
when the auto-flight system goes wonky and does the unexpected, the
savy pilot will quickly hit the Master-disconnect and revert to the
old fashioned stick, rudder, and power method of flying , and
thus maintain control.
Unfortunately, in the case of our poor overwhelmed F/O, he didn’t
know how. Really. He had been trained so thoroughly automation
dependent, and afforded virtually no opportunity to hand fly his
airplane, that he simply was unable to fly straight and level, even
though he was in the clear and not in a cloud.
Flying a complex aircraft by hand while using flight instruments to
determine acceptable and desired flight perimeters is a specific
skill which requires practiced hand-eye coordination. It requires a
specific eye muscle memory which the industry calls the “instrument
scan”. The instrument scan is a skill involving watching several
instrument indications in quick succession, so quickly in fact that
it is almost simultaneous, while processing that information within
one’s head, and applying the correct inputs to the flight controls
and power, resulting in the preferred flight condition.
The
instrument scan is a very different, and more complex scan than the
scan universally used today as our pilots simply follow the
Flight-director, as commanded by the Auto-flight system. The
Flight-director reduces the scan from several instrument sources to
one, which is within the Attitude Indicator., which is it’s raison
d’etre (reason to be). In other words, the Flight-director is
specifically designed to reduce the complexity of the instrument
scan, thus reducing the pilot’s efforts in determining what control
inputs are required. Reducing those efforts over time results in loss
of the scanning
skill. What happens when such a poor, hapless pilot is thrust into
the situation of needing a proficient instrument scan, while lacking
the skill, is a fixation. He stares at one instrument in a near
panic, searching for information, which is elsewhere, and fails to
properly control the aircraft. Perversely, his best friend, the
Flight-director, was lying to him in this case. The Go-around button
told the Flight-director to pitch the aircraft up, which he knew was
wrong, thus he simply did not know where go for the pitch information
he so desperately needed. Thus
it was that in frozen confusion, he simply grabbed the stick and
drove the airplane into the water because, for the life of him, he
didn’t know what else to do.
I
do not know why the captain sat there and allowed that event to
happen. Maybe he was just as confused. The NTSB, in their conclusion,
made a statement about “...flight crew training issues at Atlas Air
and across the US commercial aviation industry.”, and I was
involved in some special simulator training maneuvers in the
following year involving wing stalls, slow flight, and aircraft
controllablilty. I was still dismayed in that while those new
training modules were designed to combat the loss of control
accidents which we have been lately
seeing, I still believe that
the underlying cause is being ignored. Pilots must practice basic
aircraft control while using the basic instrument scan, which
requires them to turn off the automation and simply fly their
airplanes.
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