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Passedv1
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Thu Jul 16, 2020 11:46 am

I agree with everything about the FO...but was the Captain asleep?
 
airhansa
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Thu Jul 16, 2020 12:12 pm

Basically he thought that he was in a stall and put his plane into a dive? What prevented him from recovering from the dive, or was he just too low?
 
mxaxai
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Thu Jul 16, 2020 12:17 pm

Passedv1 wrote:
I agree with everything about the FO...but was the Captain asleep?

From the AvHerald's notes on the press conference:
The captain was busy setting up the approach and communicating with ATC causing him to detect the airplane status with delay. Although the first officer's motions caught the attention of the captain the captain did not intervene. Delays are normal due to startle effect and surprise, the captain pulled on the control column but did not announce a control transfer.
...
The captain never really acknowledged anything was out of the ordinary. About 35 seconds after the onset of the upset the captain provided first control inputs on his column, the aircraft was already in steep high speed dive. ... There was a split of the elevators. ... There never was a transfer of control called, which could have made a difference to the outcome of the event.
...
The captain should have, in response to the invalid responses by the first officer, also disconnected the automation, announced "I have control" and return the aircraft back onto the intended profile. The captain would have had about 20 seconds to notice the mode changes before the aircraft significantly began to deviate from the intended profile, he may have had even some more seconds to recover the aircraft.

12. While the captain was setting up the approach and communicating with air traffic control, his attention was diverted from monitoring the airplane’s state and verifying that the flight was proceeding as planned, which delayed his recognition of and response to the first officer’s unexpected actions that placed the airplane in a dive.

13. The captain’s failure to command a positive transfer of control of the airplane as soon as he attempted to intervene on the controls enabled the first officer to continue to force the airplane into a steepening dive.

14. The captain’s degraded performance, which included his failure to assume positive control of the airplane and effectively arrest the airplane’s descent, resulted from the ambiguity, high stress, and short timeframe of the situation.

Basically, the captain did not expect the FO to give full nose down input in this situation and took several seconds to comprehend what was happening.
 
ATCtower
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Thu Jul 16, 2020 2:55 pm

It’s unfortunate and needs to be said...

Training isn’t what it used to be. Between unions sheltering the weak, the “nice guy” mentality, and general degradation of any accountability, things like this will happen more and more.

I don’t care if he was a “nice guy” he had no business whatsoever flying that aircraft and it sadly resulted in someone else’s death.
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Revelation
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Thu Jul 16, 2020 3:58 pm

mxaxai wrote:
n7371f wrote:
Well hopefully the downturn will allow these more fringe carriers to scrape off the mediocre pilots. The paper trail for the FO of resignations from clearly failing training and then failure to upgrade (yeah, Mesa!) should've been obvious to anyone.

The thing is, he was fully qualified, had a valid license and passed his checkrides. We can call him a bad pilot all day, but IMHO the system failed to detect and correct his shortcomings. It's now up to the FAA to create appropriate guidelines.

As the old joke goes:

Q: What do you call the person who graduates last in the class at medical school?
A: Doctor.
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Revelation
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Thu Jul 16, 2020 4:04 pm

mxaxai wrote:
Passedv1 wrote:
I agree with everything about the FO...but was the Captain asleep?

From the AvHerald's notes on the press conference:
The captain was busy setting up the approach and communicating with ATC causing him to detect the airplane status with delay. Although the first officer's motions caught the attention of the captain the captain did not intervene. Delays are normal due to startle effect and surprise, the captain pulled on the control column but did not announce a control transfer.
...
The captain never really acknowledged anything was out of the ordinary. About 35 seconds after the onset of the upset the captain provided first control inputs on his column, the aircraft was already in steep high speed dive. ... There was a split of the elevators. ... There never was a transfer of control called, which could have made a difference to the outcome of the event.
...
The captain should have, in response to the invalid responses by the first officer, also disconnected the automation, announced "I have control" and return the aircraft back onto the intended profile. The captain would have had about 20 seconds to notice the mode changes before the aircraft significantly began to deviate from the intended profile, he may have had even some more seconds to recover the aircraft.

12. While the captain was setting up the approach and communicating with air traffic control, his attention was diverted from monitoring the airplane’s state and verifying that the flight was proceeding as planned, which delayed his recognition of and response to the first officer’s unexpected actions that placed the airplane in a dive.

13. The captain’s failure to command a positive transfer of control of the airplane as soon as he attempted to intervene on the controls enabled the first officer to continue to force the airplane into a steepening dive.

14. The captain’s degraded performance, which included his failure to assume positive control of the airplane and effectively arrest the airplane’s descent, resulted from the ambiguity, high stress, and short timeframe of the situation.

Basically, the captain did not expect the FO to give full nose down input in this situation and took several seconds to comprehend what was happening.

We'll never know, but it'd be interesting to know what would have happened had the CA taken the recommended steps promptly. Would have have said "you accidentally hit the TOGA switch, here's some tips to never do that again" and called it a day, or would he have written up the FO to try to get him removed?

One of the videos I watched (blancolario, Mentour, who knows) seemed to suggest this happened fairly often, to the point where pilots would give each other tips on how to avoid hitting the switch when moving the throttles. It wasn't clear if the airline was training to avoid these situations or if it was just an informal set of tips between pilots.

ATCtower wrote:
It’s unfortunate and needs to be said...

Training isn’t what it used to be. Between unions sheltering the weak, the “nice guy” mentality, and general degradation of any accountability, things like this will happen more and more.

I don’t care if he was a “nice guy” he had no business whatsoever flying that aircraft and it sadly resulted in someone else’s death.

Yet it's pretty clear he isn't the only one who has hit the TOGA by mistake and not dealt well with the aftermath so we can't just go with the "one bad apple" theory.
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n7371f
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Fri Jul 17, 2020 3:36 am

The FAA needs to finally get off its hands and get the damn pilot training database up and running. Darn thing was ordered after that Colgan Air captain pulled the way back on a stalling aircraft and his first officer without command retracted the flaps. The increased flight hours were a no brainer but this tragedy likely would've been averted as this f.o. never would've been hired.

mxaxai wrote:
n7371f wrote:
Well hopefully the downturn will allow these more fringe carriers to scrape off the mediocre pilots. The paper trail for the FO of resignations from clearly failing training and then failure to upgrade (yeah, Mesa!) should've been obvious to anyone.

The thing is, he was fully qualified, had a valid license and passed his checkrides. We can call him a bad pilot all day, but IMHO the system failed to detect and correct his shortcomings. It's now up to the FAA to create appropriate guidelines.
 
Passedv1
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Fri Jul 17, 2020 7:07 am

Hitting the TOGA switches by accident should not be a big deal, especially in a Boeing where you get immediate feedback with the movement of the thrust levers. This is going to be another one of those useless training events in a couple of years. Okay, pretend you accidentally hit the TOGA...

This accident is inexplicable on so many levels. They flew a perfectly good airplane straight into the ground in pretty good weather conditions. Wow.
 
spacecadet
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Fri Jul 17, 2020 10:56 am

Revelation wrote:
One of the videos I watched (blancolario, Mentour, who knows) seemed to suggest this happened fairly often, to the point where pilots would give each other tips on how to avoid hitting the switch when moving the throttles. It wasn't clear if the airline was training to avoid these situations or if it was just an informal set of tips between pilots.


I don't know where the TOGA switch exactly is in the 767, but in some planes there is definitely IMO kind of a hazard in where it's placed. In the E190, for example, the TOGA switch is under your thumb if you're holding the throttle a certain way, and the auto-throttle disconnect switch is under your thumb if you're holding the throttle a slightly different way. 99.99% of the time, any pilot's going to hit the correct switch. But it would be easy to momentarily forget on one out of a thousand approaches how you've got your hand positioned on the throttle and hit the wrong switch (whichever one you were trying to hit). It's not really SOP or common technique to look down at your hand before hitting either switch because you're generally concentrating in front of you at that point. Also, it's usually SOP (or at least technique) to have your thumb on the TOGA button on final approach, but it's not uncommon to disengage the A/T for some reason at that point too. So I'm surprised we don't hear about TOGA switches being pressed by accident more often.

My guess is that it does happen very occasionally and it's just caught immediately and rectified. In most situations, pressing the TOGA switch by mistake shouldn't really cause any problem if it's just fixed right away. Pilots make mistakes; they're human, and even moreso when dealing with a man-machine interface that isn't the greatest design. The Swiss cheese model hopefully catches those mistakes and rectifies them. But you're never going to have perfect pilots. Pilots aren't robots.

The Swiss cheese model seems to have failed pretty hard here. As in most accidents, it seems like there were plenty of opportunities - right up to the end - to save this flight. The FO made at least two serious mistakes (pressing the TOGA button, and separately pitching down due to somatogravic illusion), neither of which were caught by the captain in time, and both of which should have been. Those were the last two slices of cheese, and unfortunately the holes just kept lining up. When I read that the captain didn't take control until 35 seconds after the upset, and then never announced a positive change of control, that's almost as unbelievable to me as what the FO did.
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HVN2HEL2LAX
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Fri Jul 17, 2020 3:46 pm

ATCtower wrote:
It’s unfortunate and needs to be said...

Training isn’t what it used to be. Between unions sheltering the weak, the “nice guy” mentality, and general degradation of any accountability, things like this will happen more and more.

I don’t care if he was a “nice guy” he had no business whatsoever flying that aircraft and it sadly resulted in someone else’s death.


If you're a Controller, you know that EXACT same thing is happening in your line of work.
 
HVN2HEL2LAX
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Fri Jul 17, 2020 3:47 pm

n7371f wrote:
The FAA needs to finally get off its hands and get the damn pilot training database up and running.


The FAA can't even figure it's own internal business. Don't expect anything. See the 737, see pilot training, see Air Traffic.
 
Lrockeagle
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Fri Jul 17, 2020 4:08 pm

I’m a little surprised Bitching Betty doesn’t yell that Go Around has been activated when the button is pushed.
Lrockeagle
15 years ago

I got $20 says AA takes their 787's with GE powerplants. Just a hunch. Any takers?
 
luv2cattlecall
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Fri Jul 17, 2020 4:43 pm

n7371f wrote:
The FAA needs to finally get off its hands and get the damn pilot training database up and running. Darn thing was ordered after that Colgan Air captain pulled the way back on a stalling aircraft and his first officer without command retracted the flaps. The increased flight hours were a no brainer but this tragedy likely would've been averted as this f.o. never would've been hired.

mxaxai wrote:
n7371f wrote:
Well hopefully the downturn will allow these more fringe carriers to scrape off the mediocre pilots. The paper trail for the FO of resignations from clearly failing training and then failure to upgrade (yeah, Mesa!) should've been obvious to anyone.

The thing is, he was fully qualified, had a valid license and passed his checkrides. We can call him a bad pilot all day, but IMHO the system failed to detect and correct his shortcomings. It's now up to the FAA to create appropriate guidelines.


How were the increased pilot hours a no brainier? I thought both those pilots had way more than the 1,500 hours anyway?
 
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proudavgeek
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Re: Giant 3591 Down in Trinity Bay, Texas

Fri Jul 17, 2020 5:26 pm

rufusmi wrote:
Aircraft is N1217A, a 26 year old 767 freighter operated by Atlas for Amazon


Amazon Cargo is not a good employer so far. Pilots have to work extra-long hours for a relatively less pay. So this is eventually bound to happen. And the airline is struggling to hold on to their current pilots and to bring new ones onboard..

https://qz.com/1763226/amazon-air-is-st ... to-pilots/

Hopefully, things turnaround soon for the pilots and airline.
 
Lrockeagle
Posts: 171
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Re: Giant 3591 Down in Trinity Bay, Texas

Fri Jul 17, 2020 6:34 pm

proudavgeek wrote:
rufusmi wrote:
Aircraft is N1217A, a 26 year old 767 freighter operated by Atlas for Amazon


Amazon Cargo is not a good employer so far. Pilots have to work extra-long hours for a relatively less pay. So this is eventually bound to happen. And the airline is struggling to hold on to their current pilots and to bring new ones onboard..

https://qz.com/1763226/amazon-air-is-st ... to-pilots/

Hopefully, things turnaround soon for the pilots and airline.

Unfortunately Covid has seen to it that most pilots are trying to hold any job they can right now
Lrockeagle
15 years ago

I got $20 says AA takes their 787's with GE powerplants. Just a hunch. Any takers?
 
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Revelation
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Fri Jul 17, 2020 6:35 pm

spacecadet wrote:
Revelation wrote:
One of the videos I watched (blancolario, Mentour, who knows) seemed to suggest this happened fairly often, to the point where pilots would give each other tips on how to avoid hitting the switch when moving the throttles. It wasn't clear if the airline was training to avoid these situations or if it was just an informal set of tips between pilots.


I don't know where the TOGA switch exactly is in the 767, but in some planes there is definitely IMO kind of a hazard in where it's placed. In the E190, for example, the TOGA switch is under your thumb if you're holding the throttle a certain way, and the auto-throttle disconnect switch is under your thumb if you're holding the throttle a slightly different way. 99.99% of the time, any pilot's going to hit the correct switch. But it would be easy to momentarily forget on one out of a thousand approaches how you've got your hand positioned on the throttle and hit the wrong switch (whichever one you were trying to hit). It's not really SOP or common technique to look down at your hand before hitting either switch because you're generally concentrating in front of you at that point. Also, it's usually SOP (or at least technique) to have your thumb on the TOGA button on final approach, but it's not uncommon to disengage the A/T for some reason at that point too. So I'm surprised we don't hear about TOGA switches being pressed by accident more often.

My guess is that it does happen very occasionally and it's just caught immediately and rectified. In most situations, pressing the TOGA switch by mistake shouldn't really cause any problem if it's just fixed right away. Pilots make mistakes; they're human, and even moreso when dealing with a man-machine interface that isn't the greatest design. The Swiss cheese model hopefully catches those mistakes and rectifies them. But you're never going to have perfect pilots. Pilots aren't robots.

The Swiss cheese model seems to have failed pretty hard here. As in most accidents, it seems like there were plenty of opportunities - right up to the end - to save this flight. The FO made at least two serious mistakes (pressing the TOGA button, and separately pitching down due to somatogravic illusion), neither of which were caught by the captain in time, and both of which should have been. Those were the last two slices of cheese, and unfortunately the holes just kept lining up. When I read that the captain didn't take control until 35 seconds after the upset, and then never announced a positive change of control, that's almost as unbelievable to me as what the FO did.

It was Blancolirio's video, and he shows where the switches are.

At the following timestamp he explains that lowering the flaps allows TOGA to operate and then shows where the TOGA switches are: https://www.youtube.com/watch?v=GR4xhTF-13g&t=13m53s

He then says the switches were activated following some "lateral movements" of the aircraft recorded by FDR, and says he's seen it happen before, and starts talking through how it can happen. The FO has to reach around the throttle to get to the speed brake control. The CA has to reach around the throttle to get to the flaps control. He describes bumping the TOGA paddles while doing this as "not uncommon" and he has time on 767 at AA so he speaks from experience. He says it's more common in turbulence and he says wearing a big watch can be an issue. He said the "last time" he witnessed this was a case where it happened in a 777.

He's just one person, but still, seems like it is a thing.
Wake up to find out that you are the eyes of the world
The heart has its beaches, its homeland and thoughts of its own
Wake now, discover that you are the song that the morning brings
The heart has its seasons, its evenings and songs of its own
 
SpectralK
Posts: 18
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Mon Aug 10, 2020 9:43 am

The final report was published a few days ago. It mostly just confirms what is already known:

The NTSB determines that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the pilot records database in a sufficiently robust and timely manner.


What is more interesting is the recommendations. The two big ones that stood out to me were the recommendation to create a searchable database for pilot training & employment history, and the recommendation to consider retrofitting airliners with the ground avoidance AI that's used on the F-16. That seems a bit unlikely for the immediate future since the tech is still new, but I can see it being rolled out on, say, the 767X if it ever gets developed.
 
trex8
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Mon Aug 10, 2020 1:52 pm

SpectralK wrote:
The final report was published a few days ago. It mostly just confirms what is already known:

The NTSB determines that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the pilot records database in a sufficiently robust and timely manner.


What is more interesting is the recommendations. The two big ones that stood out to me were the recommendation to create a searchable database for pilot training & employment history, and the recommendation to consider retrofitting airliners with the ground avoidance AI that's used on the F-16. That seems a bit unlikely for the immediate future since the tech is still new, but I can see it being rolled out on, say, the 767X if it ever gets developed.


Not sure which systems you are referring to but there are two types of "terrain avoidance" the F16 has . One Terprom has been around for 2 decades+ and essentially has a terrain database which helps prevent you flying into the ground by comparing your position with the database and surrounding terrain, the more recent one Auto GCAS actually automatically recovers you into safe level flight if you are likely to run into something.
 
SpectralK
Posts: 18
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Mon Aug 10, 2020 9:19 pm

trex8 wrote:
SpectralK wrote:
The final report was published a few days ago. It mostly just confirms what is already known:

The NTSB determines that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the pilot records database in a sufficiently robust and timely manner.


What is more interesting is the recommendations. The two big ones that stood out to me were the recommendation to create a searchable database for pilot training & employment history, and the recommendation to consider retrofitting airliners with the ground avoidance AI that's used on the F-16. That seems a bit unlikely for the immediate future since the tech is still new, but I can see it being rolled out on, say, the 767X if it ever gets developed.


Not sure which systems you are referring to but there are two types of "terrain avoidance" the F16 has . One Terprom has been around for 2 decades+ and essentially has a terrain database which helps prevent you flying into the ground by comparing your position with the database and surrounding terrain, the more recent one Auto GCAS actually automatically recovers you into safe level flight if you are likely to run into something.


I was referring to the Auto GCAS. It's section 2.6.2 on the report. I'm not too knowledgeable about military aviation, but they made it sound like it was a new system that could be adapted for civilian use in the future with further research.
 
Antarius
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Mon Aug 10, 2020 10:00 pm

SpectralK wrote:
The two big ones that stood out to me were the recommendation to create a searchable database for pilot training & employment history


Long overdue for this to happen. It has been recommended before and is quite absurd that it still is not present.
2020: SFO DFW IAH HOU CLT MEX BIS MIA GUA ORD DTW LGA BOS LHR DUB BFS BHD STN OAK PHL ISP JFK SJC DEN SJU LAS TXL GDL
 
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trinidadeG
Posts: 223
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Thu Aug 20, 2020 3:32 am

Atlas 767 probe sees potential to adapt military terrain-escape system - Flight Global

Loss of an Atlas Air Boeing 767-300F in Texas last year has led investigators to highlight the potential for adapting military automatic ground collision-avoidance technology to civil aircraft.

The aircraft dived into a lake after failing to recover from an excessive pitch-down input by the first officer, in response to the inadvertent activation of go-around thrust.
 
LCDFlight
Posts: 563
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Thu Aug 20, 2020 3:45 am

SpectralK wrote:
The final report was published a few days ago. It mostly just confirms what is already known:

The NTSB determines that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the pilot records database in a sufficiently robust and timely manner.


What is more interesting is the recommendations. The two big ones that stood out to me were the recommendation to create a searchable database for pilot training & employment history, and the recommendation to consider retrofitting airliners with the ground avoidance AI that's used on the F-16. That seems a bit unlikely for the immediate future since the tech is still new, but I can see it being rolled out on, say, the 767X if it ever gets developed.


Amateur here, but. An aircraft that already has envelope protection could add terrain avoidance as a software layer. Admittedly, it would introduce new failure modes and new problems, very hard to do well, but fairly easy to do crudely. Just any steering that irrevocably would go into terrain would be declared invalid.

Also, the hiring and training process that allowed that guy into the cockpit was not valid. If the plane itself is supposed to figure out that he was not a legit pilot, maybe we should question why the FAA and the airline could not.
 
TheWorm123
Posts: 256
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Re: Atlas Air 3591 Down in Trinity Bay, Texas

Thu Aug 20, 2020 3:46 pm

LCDFlight wrote:
Amateur here, but. An aircraft that already has envelope protection could add terrain avoidance as a software layer. Admittedly, it would introduce new failure modes and new problems, very hard to do well, but fairly easy to do crudely. Just any steering that irrevocably would go into terrain would be declared invalid.

Isn’t that just describing envelope protection on fly by wire?
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mxaxai
Posts: 1897
Joined: Sat Jun 18, 2016 7:29 am

Re: Atlas Air 3591 Down in Trinity Bay, Texas

Thu Aug 20, 2020 4:07 pm

TheWorm123 wrote:
LCDFlight wrote:
Amateur here, but. An aircraft that already has envelope protection could add terrain avoidance as a software layer. Admittedly, it would introduce new failure modes and new problems, very hard to do well, but fairly easy to do crudely. Just any steering that irrevocably would go into terrain would be declared invalid.

Isn’t that just describing envelope protection on fly by wire?

Not quite. Traditional envelope protection is only for parameters like angle of attack, bank angle, g-limit, or overspeed. These are all measured aboard the aircraft. EGPWS exists to help avoid CFIT (and uses external terrain data) but it's just a warning. It's right in the name Ground Proximity Warning System. You can still fly the aircraft into the ground, as demonstrated by quite a few pilots. You would have to link these two into an active terrain avoidance system, perhaps similar to the terrain following systems on some military aircraft.

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