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Started By
Message
re: 767 cargo plane crash outside Houston
Posted on 3/12/19 at 1:14 pm to AUTimbo
Posted on 3/12/19 at 1:14 pm to AUTimbo
NTSB issues investigative update on the Feb. 23, 2019, Atlas Air flight 3591
quote:
On February 23, 2019, at 1239 central standard time, Atlas Air flight 3591, a Boeing 767-375BCF, N1217A, entered a rapid descent from 6,000 ft and impacted a marshy bay area about 40 miles southeast of George Bush Intercontinental Airport (KIAH), Houston, Texas. The two pilots and one nonrevenue jumpseat pilot were fatally injured. The airplane was destroyed and highly fragmented. The airplane was operated as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight, which originated from Miami International Airport (KMIA), Miami, Florida, and was destined for KIAH.
The NTSB launched a go-team consisting of an investigator-in-charge from the major investigations division and specialists in structures, systems, powerplants, air traffic control (ATC), and meteorology. Specialists in operations, human factors, maintenance records, and flight recorders supported the investigation from other locations.
Parties to the investigation include the Federal Aviation Administration (FAA), Atlas Air, General Electric (GE) Aviation, Boeing, the International Brotherhood of Teamsters, and the National Air Traffic Controllers Association. The investigative team was also assisted by numerous other federal, state, and local law enforcement and public safety agencies.
The wreckage was situated in a shallow muddy swamp area, and the main debris field was oriented east to west and about 350 yards long by about 200 yards wide (figure 1). One engine and some landing gear components were found beyond the main debris field to the west. Less dense components and a large portion of the cargo floated southward and were recovered up to 20 miles away. The wreckage was highly fragmented and resting in the soft mud in 1-3 ft of water. Recovery of the wreckage was very difficult in the swampy conditions because visibility in the water was poor and the muddy bottom could not support heavy equipment. Airboats, barges, and amphibious equipment was brought in to search for the recorders and retreive the wreckage.
quote:
About 12:38, the controller informed the pilots that they would be past the area of weather in about 18 miles, that they could expect a turn to the north for a base leg to the approach to runway 26L, and that weather was clear west of the precipitation area. The pilots responded, “sounds good” and “ok.” At this time, radar and ADS-B returns indicated the airplane levelled briefly at 6,200 ft and then began a slight climb to 6,300 ft.
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 and then rapidly pitched nose down to about 49° in response to column input. The stall warning (stick shaker) did not activate.
FDR, radar, and ADS-B data indicated that the airplane entered a rapid descent on a heading of 270°, reaching an airspeed of about 430 knots. A security camera video (figure 4) captured the airplane in a steep, generally wings-level attitude until impact with the swamp. FDR data indicated that the airplane gradually pitched up to about 20 degrees nose down during the descent.
quote:
A cockpit voice recorder (CVR) group was convened and will complete a transcript of the entire event. The CVR transcript will be released when the public docket is opened. Other groups include operations/human factors, ATC, weather, structures, systems, powerplants, and maintenance records. Further groups may be formed as the investigation progresses.
This post was edited on 3/12/19 at 1:18 pm
2
Posted on 3/13/19 at 2:03 pm to When in Rome
LINK
This commercial pilot's interpretation does a good job addressing the facts that were released by the NTSB yesterday.
This commercial pilot's interpretation does a good job addressing the facts that were released by the NTSB yesterday.
Posted on 3/13/19 at 2:06 pm to When in Rome
The video certainly made me question if this wasn't an intentional act.
Posted on 3/13/19 at 2:10 pm to RogerTheShrubber
If it was intentional and suicide thank God he crashed in the bay and not in a populated area. Lots of people in Baytown and those refineries ahead of him.
Posted on 3/13/19 at 2:20 pm to TxWadingFool
Thanks for sharing 
that pilot didn’t specifically mention anything about it being an intentional act, but he pretty much went through every other speculative scenario and shut them down, and then he finished by saying that they need to figure out why the engines went full thrust and what moved the control column so far forward so suddenly to cause the plane to nosedive. He tried to get a comment from the NTSB re: whether the plane was in autopilot or manual when this occurred, and they chose not to comment.
that pilot didn’t specifically mention anything about it being an intentional act, but he pretty much went through every other speculative scenario and shut them down, and then he finished by saying that they need to figure out why the engines went full thrust and what moved the control column so far forward so suddenly to cause the plane to nosedive. He tried to get a comment from the NTSB re: whether the plane was in autopilot or manual when this occurred, and they chose not to comment. 
Posted on 3/13/19 at 2:31 pm to TxWadingFool
That was good. He ruled out most of the possible causes. The voice recorder will be telling I think. Damn
Posted on 6/19/19 at 12:36 pm to tigerpimpbot
Bump for some new info I read on another site,
"Just? FYI… we’ve heard the full cockpit audio and seen the data. Here’s what really happened (name redacted please to protect the innocent!):
During the appro?ach, 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/non-spazzy (technical term!)/deliberate motion to do successfully.
Well in any case, it was not done so this time. The captain accidentally hit the “go around” switch while bringing his hand around for the flaps, which brought bo?th 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” then 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”. T?his 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.
Oh by the way, the throttles aren’t touched until somewhere during that la?st 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 ho?w 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 fa?ult 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?!?????"
"Just? FYI… we’ve heard the full cockpit audio and seen the data. Here’s what really happened (name redacted please to protect the innocent!):
During the appro?ach, 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/non-spazzy (technical term!)/deliberate motion to do successfully.
Well in any case, it was not done so this time. The captain accidentally hit the “go around” switch while bringing his hand around for the flaps, which brought bo?th 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” then 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”. T?his 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.
Oh by the way, the throttles aren’t touched until somewhere during that la?st 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 ho?w 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 fa?ult 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?!?????"
Posted on 6/19/19 at 12:40 pm to Tbonepatron
Hope there was a soccer ball and ice skates on board.
Posted on 6/19/19 at 12:44 pm to TxWadingFool
quote:
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 ho?w 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.
meh, it's been a while since I've flown the 76, but I've got about 5000 hours in it, that all sounds a little far fetched to me, not saying it couldn't have happened that way, but I cut my teeth flying John Wayne jets and I just don't see that, current gen pilots who've never had anything but glass and automation? maybe more likely I suppose
Posted on 6/19/19 at 12:47 pm to 777Tiger
When I fly, I hope my pilot is someone like you.
Posted on 6/19/19 at 12:57 pm to chinhoyang
quote:
When I fly, I hope my pilot is someone like you.
gracias chin
Posted on 6/19/19 at 12:59 pm to chinhoyang
quote:
When I fly, I hope my pilot is someone like you.
You know he let Pan Am 759 take off right before him sitting on the Tarmac. He even thought it was a bad idea and didn't stop em.
And you liked Johnny Jones.
frick both you guys.
Jusssss Kiddin about that last part.
This post was edited on 6/19/19 at 1:00 pm
Posted on 6/19/19 at 1:00 pm to mikelbr
quote:
He even thought it was a bad idea and didn't stop em
they were senior to me!?!?
Posted on 6/19/19 at 2:16 pm to 777Tiger
quote:
they were senior to me!?!?
I'm just giving you a hard time. It was an awful tragedy for sure but your fault, buddy.
I think I told you my uncle lives in that neighborhood(he didn't live there in 1982) so it's on my mind often when we go over there.
This post was edited on 6/19/19 at 2:17 pm
Posted on 6/19/19 at 2:20 pm to mikelbr
quote:
I'm just giving you a hard time.
I know
quote:
It was an awful tragedy for sure
yes it was, a lot of the wind shear
knowledge, detections systems, and escape procedures were developed as a result of that crash and DAL191 at DFW a few years later
Posted on 6/20/19 at 9:38 am to 777Tiger
How does a stick shear off? I’ve never heard of that happening and seems like it shouldn’t? Surprised human strength could do it?
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