BREAKING: Boeing 767 cargo jet operated by Atlas Air has crashed in Texas

[3WE]

TOGA

Sorry, I'm too lazy to read between the lines.

How does accidentally hitting "TOGA" lead to someone initiating a low-altitude dive?

I won't say there's zero influence here, but I can't see how it is a primary contributing cause (unless you are making it primary in the time-sense)...but still primary in the time sense does not excuse relentless, deliberate dive inputs.

If the plane is trying to go around, but you are thinking "What's it doing now?", your control input should be to keep FDH attitudes and speeds, not initiating a dive.

One other lazy question (Gabieeee)- was there some "chirp" of a stall warning in this sequence?

Still flabbergasted...relentless push overs are about as bad as relentless pull ups...Heck, we even have the relentless right roll input on another thread (albeit a more valid situation, even though it's quite the testimony to the effects of relentlessness).

[Evan]

It sounds like the control layout is a bit problematic in that it's easy to hit the TOGA switch unintentionally when dealing with speed flaps.

The go levers seem to be a bit vulnerable. I wonder how often they are accidentally activated. I still favor a system such as that used by airbus where the thrust levers must be manually advanced to the go-around 'click' to activate the mode and then set to the desired power.

[Schwartz]

Outside the obvious solution of not allowing pilots who panic (i.e. start taking random actions when faced with unknowns) to fly, I get the impression there are a couple basic ergonomic problems.

It sounds like the control layout is a bit problematic in that it's easy to hit the TOGA switch unintentionally when dealing with speed flaps. I can imagine other scenarios where a sudden unexpected acceleration to maximum thrust might cause some safety issues.

The second question is if there is a clear indicator that the TOGA switch/button has been activated or do the pilots have to notice the thrust levers moving? That also could prevent a scenario like this at least allowing the other pilot to diagnose the situation quicker. It sounds like the captain didn't figure out the problem right away either.

[3WE]

True, just about 26 seconds from the point where the FO first touched the yoke to the ground.


Engines go from idle to TOGA, spool up and a rush of thrust kicks in with a lot of longitudinal acceleration involved, which pushes you back against the seat back, just as if you were tilted nose-up. That is the most basic and common somatogravuic illusion (confusing longitudinal acceleration with pitch) and is the cause, for example, of the well documented series of accidents where the pilots take off into total darkness (like onto a large body of water in a moonless night or into very low IMC), push down and crash.

The slight pitch up made by the AP when transitioning into the go-around possibly gave a rotational cue to the inner ear that they were pitching up, which was exaggerated by the brain when combined with the somatogravic illusion explained.

At this point the FO thought that they were aiming way too high and when he pushed forward on the column the plane entered a very low G state which feels like falling from the sky. The FO's brain then possibly combined his exaggerated nose-up perception with the falling sensation to fabricate the "stall" mental picture.

When the guy says “we’re stalling” it all kind of fits.

Also of note- the FIRST descent seems fast and the level off and little climb seems a tad aggressive which would make my flawed mind think towards a an accelerated, stall-prone pull up.

And, as Evan says, maybe this is combined with fatigued thinking and performance.

[Gabriel]

Well, yes but how is that different from any other go-around?

In that this one was unexpected and uncommanded (or better, accidentally and unnoticedly commanded)

From the NTSB findings:

The activation of the airplane’s go-around mode was unintended and unexpected by the pilots.

From the NTSB's public hearing:

The chair inquired whether it was correct the first officer perceived something like an 80 degrees pitch up as result of the unintended go around activation and how the somatogravic illusion could be overcome. The expert stated: "Well I think it is helpful that pilots know when to be on their guard like during an intentional go around and if they have practice with instrument flying. In this case I think the thing that was tricky they would not have expected a rapid acceleration at this time and they were unaware of the mode change and at a bit of disadvantage."

I think the real issue here was either extreme fatigue or mental instability. Plus somatogravic illusion.

I think that the NTSB kinda answered that too.

Quote from the public hearing:

Check airmen at Air Wisconsin, Mesa and Atlas reported that when the first officer was presented with an unexpected scenario, he would get flustered and could not respond to the system, he would become extremely anxious and push buttons without thinking about what he was doing just to be doing things.

The first officer's training record was "terrible".

If the FAA had done their job this pilot would not have been employed by Atlas Airlines and therefore this crash would not have happened.

And from the contributing factors:

- systemic deficiencies in the aviation select and performance measurement practices which failed to address the first officer's aptitude related deficiencies in maladaptive stress response
- the federal aviation administrations dragging failure to administer the pilot database in a sufficient robust timely manner.

And from the NTSB's findings

Although compelling sensory illusions, stress, and startle response can adversely affect the performance of any pilot, the first officer had fundamental weaknesses in his flying aptitude and stress response that further degraded his ability to accurately assess the airplane’s state and respond with appropriate procedures after the inadvertent activation of the go-around mode.

Had the Federal Aviation Administration met the deadline and complied with the requirements for implementing the pilot records database (PRD) as stated in Section 203 of the Airline Safety and Federal Aviation Administration Extension Act of 2010, the PRD would have provided hiring employers relevant information about the first officer’s employment history and training performance deficiencies.

The first officer’s long history of training performance difficulties and his tendency to respond impulsively and inappropriately when faced with an unexpected event during training scenarios at multiple employers suggest an inability to remain calm during stressful situations—a tendency that may have exacerbated his aptituderelated performance difficulties.

[Evan]

True, just about 26 seconds from the point where the FO first touched the yoke to the ground.


Engines go from idle to TOGA, spool up and a rush of thrust kicks in with a lot of longitudinal acceleration involved, which pushes you back against the seat back, just as if you were tilted nose-up.

Well, yes but how is that different from any other go-around?

I think the real issue here was either extreme fatigue or mental instability. Plus somatogravic illusion.

[Gabriel]

That happened much more quickly that I imagined.

True, just about 26 seconds from the point where the FO first touched the yoke to the ground.

I don't understand where the strong somatogravic illusion would come from. The go-around change in g-force doesn't seem to be unusual and the F/O reacts at least a few seconds after that.

Engines go from idle to TOGA, spool up and a rush of thrust kicks in with a lot of longitudinal acceleration involved, which pushes you back against the seat back, just as if you were tilted nose-up. That is the most basic and common somatogravuic illusion (confusing longitudinal acceleration with pitch) and is the cause, for example, of the well documented series of accidents where the pilots take off into total darkness (like onto a large body of water in a moonless night or into very low IMC), push down and crash.

The slight pitch up made by the AP when transitioning into the go-around possibly gave a rotational cue to the inner ear that they were pitching up, which was exaggerated by the brain when combined with the somatogravic illusion explained.

At this point the FO thought that they were aiming way too high and when he pushed forward on the column the plane entered a very low G state which feels like falling from the sky. The FO's brain then possibly combined his exaggerated nose-up perception with the falling sensation to fabricate the "stall" mental picture.

[Evan]

AVH's report on the NTSB's public hearing:

http://avherald.com/h?article=4c497c3c/0001&opt=0

NTSB's annimation:
https://www.youtube.com/watch?v=GsSNr5DR840

That happened much more quickly that I imagined. I don't understand where the strong somatogravic illusion would come from. The go-around change in g-force doesn't seem to be unusual and the F/O reacts at least a few seconds after that.

[Gabriel]

AVH's report on the NTSB's public hearing:

http://avherald.com/h?article=4c497c3c/0001&opt=0

NTSB's annimation:

https://www.youtube.com/watch?v=GsSNr5DR840

[Schwartz]

AVHerald comments on the new Public Docket released for this flight. Lots of data, not a lot of answers:

https://avherald.com/h?article=4c497c3c/0000&opt=0

[Gabriel]

THAT it's 2 months old is a bit newsworthy.

It is and it was. We already discussed it here.

[3WE]

That's more than 2 months old.

THAT it's 2 months old is a bit newsworthy.

[Gabriel]

The NTSB has downloaded the CVR and issued preliminary information.
https://www.ntsb.gov/news/press-rele...r20190305.aspx

That's more than 2 months old.

[Highkeas]

The NTSB has downloaded the CVR and issued preliminary information.

https://www.ntsb.gov/news/press-releases/Pages/mr20190305.aspx

[Evan]

Nevertheless, this is all still rumor and yes, I remember the suicide deal where somehow or other the 767 went into "split elevator" mode...

The left column controls the left elevator. The right controls the right elevator. They run separate cables through entirely different parts of the fuselage. The columns are linked via a torque tube under the cockpit, and the two sides of the torque tube are connected via a spring mechanism that is designed to breakout if a large differential force is applied. This is all done to prevent a single column/elevator control circuit jam from prohibiting pitch control. But if both columns are forcefully moved in opposite directions, you can get into a split elevator situation. AFAIK this basic set-up is common to all the non-fbw Boeings, including the older 737's via a retrofit.

I don't see any scenario in which the right column could be broken by pilot force against the left. It makes no sense.