As in most general aviation accidents, airline crashes—what few there are these days—are often caused by human error; mistakes in judgment, ham-handed hand-eye coordination or mishandling of the ever-present automation. The errors are sometimes subtle, the result of complexities in the human/machine interface.
But there was nothing subtle about the crash of Atlas Air 3591, which the NTSB discussed in exhaustive detail last week and which is summarized in this week’s video. Although rated in the airplane, the first officer lacked the aviation aptitude to do his job and precipitated the crash by a panicked reaction to an inadvertent activation of the go-around mode. The NTSB believes the first officer experienced somatogravic illusion, that thing we always have to remember for written exams and then promptly forget.
Stipulating that this is true, his training record—a sad history of busted checkrides and frantic simulator sessions—suggests that if it hadn’t been vertigo, it eventually would have been something else. The NTSB repeatedly said the first officer, under stress, got flustered and reactive, often taking rapid action whether appropriate or not. Ask any airline pilot you know about weak sticks finding their way into the cockpit and you’ll hear that yes, it happens from time to time. And although the Atlas Air first officer might have been in the one percentile of low-aptitude, the industry is not shot through with this kind of incompetence. If it were, it would be raining Boeings and Airbuses.
A recently retired 767 training captain I know pointed out a subtle misjudgment the captain of 3591 arguably made. He reminds me that in the bad old days, captains used the first officer as a voice-activated gear switch, but in the enlightened world of crew resource management, it no longer works that way. Most captains let the first officer fly the airplane the way he wants to fly it, intervening only if the FO is about to do something ill-advised.
My friend said he would have nixed the Atlas Air FO’s decision to call for flaps 1 some 40 miles from the airport. At 230 knots that far from the destination, it just makes no sense to dirty up the airplane. Had the captain intervened, go-around mode would not have armed and would not have activated when the G/A switches were inadvertently pushed and the accident might not have happened. Or least not happened where it did. Later on, he might not have been distracted by a radio call and might have been more integrated into the loop to catch any errors. This is, after all, the underlying principle of pilot flying/pilot monitoring. And we know it works if everyone is paying attention.
But the slightest lapse can be fatal, as it was in this accident. When the captain looked up to re-engage his scan, he would have soon been weightless in the seat from the FO’s aggressive pitch down. The NTSB said research has repeatedly shown that the startle reflex in a novel situation requires many seconds to shake off—not five and not 10, either. The human brain just doesn’t work that fast. I don’t need a 767 type rating to surmise I couldn’t have recovered it any sooner. Could you? Aeronautical wisdom (and survival) flows from the ability to proactively steer yourself out of situations that require 10-second reactions.
You could tell from the tone of the hearing that the NTSB members were stunned that this pilot survived in aviation long enough to work for seven airlines and accumulate 5000 hours. He was not a low timer by any means, although he might have been the poster child for the cynical example of one hour, 5000 times.
NTSB chairman Robert Sumwalt, a pilot himself, all but seethed that the FAA hasn’t implemented the Pilot Records Database that would have given Atlas Air a more fine-grained glimpse into the FO’s poor training performance. Even in the go-go hiring of the last five years, he might not have made the cut.
That part might be about to change, too, with the appearance of “before COVID” and “after COVID.” NTSB’s David Lawrence used the phrase a couple of times to explain that prior to the pandemic and the aviation depression it has induced, airlines routinely hired pilots with known checkride busts. They had little choice in a hot pilot market.
Not anymore. With airlines poised to furlough thousands of pilots for an unknown period, they may be in a position to be more picky about new hires. Whether that has any impact on system safety is an unknown—I’d guess not much. But it might at least close the door to someone as unsuited for the job as the FO on Atlas Air 3591.
Dirtying up 40 miles from the airport… per my experience, common for the weaker pilots. Somehow, many seem to think that they “have to get ready to fly the approach” and to do so, need to configure really early. I’ve seen this little scenario start in the initial sim training and if not cut off by the instructor(s) continues out onto the line. I don’t know how an extra 10+ minutes flying with the flaps way down and the sneakers in the breeze gets one “ready” to fly the approach….
Unless approach or tower requests “min speed for spacing” I see no reason what-so-ever to start configuring more than 8 to 10 miles from touchdown. Flying around dirty like that does not alter any aviation skills and certainly does put a lot of extra, unnecessary fuel out the back of the engines and adds flying time to the aircraft, both of which are expenses incurred for the company.
Even in IFR weather, I would seldom start configuring the Classic Whale more than 2 or three miles from the glideslope. VFR, well, unless needed otherwise I flew visual approaches from any angle I could get and configure so as to be stable and configed NLT 500 agl. I certainly didn’t need the flying time required to fly 10 to 15 miles past the airfield then drag her tail feathers back dirty and slow. Saved, time, fuel, and was a better neighbor to those whiners that bought that cheap house under the approach and had the airport authority noise line on speed dial.
You forgot to mention PASSENGER DISCOMFORT!!!!! ughhhhhh
I probably would have but at Atlas all I flew was freight. Boxes don’t care.
Pilots that are inexperienced on type ie thinking about 100 things to do next, or lacking basic skills as seems to be the case here often do things early or out of sequence just to get it off the to do list. They need guidance and some rules of thumb from more experienced pilots as they move up the food chain. If they can’t seem to learn, then they should stick to flying as a hobby.
What isn’t discussed is the lack of experience in the industry – becoming more prevalent as the industry grows and senior pilots retire. Pilots are pipelined rapidly – I’m an Air Force vet, 20 plus at a legacy carrier, 12+ on the 767. I’m flying with FOs that flew a 1900 before this. Some are terrific (I don’t think I could make that transition!) some don’t understand what’s going on at a basic airplane handling level.
I had this happen to me. My reaction was nearly instant – AP off, AT off, FDs off – FLY THE JET. Many FOs have rarely done much hand flying especially in jets. This dependence on automation adds a layer when things go wrong – what’s the “machine” doing and what buttons do I push? The ability to connect your brain through your hands to the a/c is often the best immediate solution.
“…the industry is not shot through with this kind of incompetence. If it were, it would be raining Boeings and Airbuses.”
Not sure that we can justify that confidence with regard to certain foreign carriers.
My thoughts exactly.
In my 40 odd years in military and civilian(airline) flying I was the guy in the right seat on 4 occasions who saved the airplane from the inept Captain. In my early commercial training my instructor said “ announce your intention, take the airplane, fix the problem, talk about it on the ground.” He subsequently demonstrated what he meant when an aircraft delivery went sideways in an unsafe steep climb where the aircrafts regular pilot tried to kill us. The Captains in each case didn’t resist much( head up and locked and they knew it), didn’t try to burn me and didn’t thank me either.
Dang! I hate to see a guys that’s in the grave get hammered so hard. Does this poor guy deserve it? Maybe. However, I’ve been doing this for quite a few years and I remember the bad old days when manufacturers and other entities, who had an economic stake in protecting their pocketbooks, would yell pilot error every time there was a crash. I’d like to have a more in depth look at the training system that allowed this gentleman to get 5,000 hours but still not be able to keep control when things went a bit sideways.
Training is an ineffective remedy for lack of aptitude and talent.
Every now and then, you have to ask a wannabee: “Have you ever considered pursuing bowling?”
Yes, this guy deserves a really hard time. He killed two other people and destroyed a perfectly good airplane. The Captain deserves to be treated equally harshly. Both were clearly weak and were in a situation of their own making that was well above their ability for coping.
I’ll take your easy statement first: how much of that “5000” hours were “Parker Pen Time”? Likely a fair amount. At a company not to be named, there was an F/O that was inept at best. Said F/O was investigated by the Chief Pilot and a huge part of the time claimed on the application was never really flown. At least one of the planes allegedly flown never was. Unfortunately, “HR” got involved and the that inquiry was buried deep for fear of a lawsuit.
Your claim about companies claiming Pilot Error at every turn is a might exaggerated, don’t you think? Sure, maybe some small plane makers might have but not the “big four” over time. Every crash in history has someone saying the pilot screwed up and, to some point, maybe he or she did although not to the point of being the root cause. There just isn’t the evidence in existence to support your blanket accusation. More to the point: the pilot in command isn’t always blameless as you would appear to be asserting.
I’ve seen times when a guy builds time as an instructor then gets a job as an FO in something bigger than an Arrow and the transition is impossible.
We’ve had some of these pilots and during the first couple flights after initial training, we give them the empty legs and they’re way behind the airplane. We work with them and most catch up quickly.
However it becomes evident that one or two are just never going to get “it”.
The sad part is these are the folks most proud and happy to be a “professional” pilot with the epaulets and bumper stickers. Do they know deep down they are below the curve and believe they will get better or do they hide their lack of skill because it’s “always been their dream”?
My question is why hasn’t someone along the way suggested maybe they should think of a different career.
What is the best way to tell someone time is up?
Dan
Carriers select capable, qualified and current candidates. Training departments operate according to “train to proficiency.” Crews fly by AFM, GOM and QRCs. APDs and Line Check Pilots show the “non-compliant” the door.
Am I missing something?
On paper, anyway. In reality, carriers invest a lot of money in their pilots, and will generally do what they can to try and bring deficient pilots up to standards. After enough failures they usually do eventually show them the door, but sometimes a few pilots slip through. Happens in the GA world too – sometimes a deficient pilot will find an examiner who’s feeling generous and passes someone who really shouldn’t have passed. And it’s no different in any other industry either; there will always be some deficient workers who manage to slip through the cracks. It’s just that few industries have such deadly consequences as when a deficient pilot slips through.
Gary, you are correct, spot on correct. Some slip through. In the case of the inept F/O that I mentioned above, the individual in question was a complete enigma on the line. Some huge, scary error was going to be made almost every leg, the Captain just never knew what or when. Example, when assisted verbally a landing might be a thing of beauty. The very next leg, very similar runway and weather, the landing could very well make a Navy carrier-qual pilot wince (flare…Flare….FLARE..WHAM), you get the idea.
Yet, when sent to the sim or there for required training, the performance was pretty much always very acceptable. Not Bob Hoover smooth and steady, but at least meeting the standards. Reason: the sim profiles were always “fixed” and “known” so preparation required little or no thinking. The sim profiles never vary second to second like life out on the line.
Example: that F/O and I flew together for a month. Suffice it to say that we flew almost every day as it was special scheduling. Arriving at a European airport, empty, ferrying in, beautiful sunny VFR day no wind, the airplane ahead of us got real slow real early. Tower asked us to side step and land on the other runway. We were about 6-8 miles out at the time, entire area clearly in sight, F/O says sure, easy, runway in sight, while resetting the ILSs and Marker beacons the FE taps me on the shoulder and points out the front. We were beautifully lined up on the centerfield taxiway. We I pointed this out, F/O got totally flustered. (I was being very patient and very careful about how I said pretty much anything) Rest of the approach was not a thing of beauty and the landing… ouch. The aircraft had hardly got firmly on the ground and the F/O tried to give it to me as they were totally flumuxed. This aircraft had steering tillers on both sides and either pilot was expected to taxi to-from the blocks on their leg.
Folks, these pilots are out there and get through the system. One can only hope that they are held back as F/Os and that the company always schedules them with adequate Captains.
I wish it were that simple, but it’s not.
Definitely a tragic situation. If there is any bright spot to it was that the plane went into the bay. Five miles closer in to the airport and it probably would have impacted in a housing development or retail center.
” And although the Atlas Air first officer might have been in the one percentile of low-aptitude, the industry is not shot through with this kind of incompetence. If it were, it would be raining Boeings and Airbuses.”
Lion Air, Ethiopia Airlines, Atlas, Pakistani International Airlines (recent gear up touch and go and crash and burn), Lufthansa/Germanwings, several Russian, and middle east wrecks that gathers little press when an airliner dorks into an emerging or third world country seems to suggest not a deluge but it seems to be a steady light rain of Boeing, Airbus, and Ilyushin’s.
Once a pilot manages to get his airline wings, unless he ends his career as did this Atlas pilot, the current airline flying system seems pretty reluctant to flush out a consistent marginal performing pilot. Sort of an aviation “code of silence”. And judging from the comments thus far from active, current, and retired readers of Avweb, this is more of a problem than we truly want to admit. I am not suggesting that aviation as a whole is unsafe or unsat. Most GA, commercial and airline pilots/crew ( domestic and international) spend an enormous of time, energy, and funds to be the best they can be. But it is hard to ignore the numbers of accidents that were accumulating pre-Covid-19 with commercial travel at an all time high. While US airlines were flying with great safety on a national level, globally/internationally, it was not the same. Were we simply getting used to our collective aviation surroundings because of the increased demand for commercial aviation travel? Hard to say. But airliners were getting bent with some regularity.
Now that Covid-19 has completely changed commercial aviation into something we have no idea what commercial aviation travel will actually look like in the next 2-5 years, the $64,000 question might be…who will stay and who will go?. Will the best be in the cockpit? Or will the marginal one’s rise to the top because of furlough’s, pay cuts, airline restructuring, airline collapses followed with a slew of smaller start ups driving out the current crop of largely fine aviators? Are the airlines going to buy new Max’s, getting rid of their inefficient airplanes or will it go the other way, keeping older airplanes, with considerable but aging automation, being flown by relatively less experienced or lower performing pilots that potentially remain in the new Covid-19 normal?
Great article, Paul!
36 years at a major carrier; a retirement gig flying in some nasty places; 26000 hours; Instructor Captain.
Yes; there are “weak sticks” in the industry.
Every carrier has its’ “Bottom Gun”, or “Cementhead”; known to all line pilots.
Recent research tells us that the less competent someone is, the better they think they are; true in many cases.
Some training departments judge success by the quality of “button” pushing, not the overall ability of the candidate.
Some characters are not bad in ground school, but the real world baffles them. Line Indoctrination Captains are the ones who deal with it, the Line Captains suffer it if the candidate is pushed onto the line.
It isn’t only problems in the right seat; there are a very few in the Left Seat who are behind the curve.
Many First Officers have saved the day for these guys repeatedly.
There are also management types who have no competence in the real world. They have learned how to weasel their way into management positions, but have no real world skills, although they may hold the type rating.
Flying with any of the characters above is an exercise in single pilot operations; complicated by the necessity to manage the impediment in the other seat.
Get away from the major carriers, and the picture changes; there are some at the lower levels of the industry for good reason; they have risen to their level of incompetence.
I dealt with a couple of such types in a retirement gig on a large turboprop.
I was given a First Officer to work with, who supposedly had Convair Captain time; he was hopeless.
You could never be sure what he would do. He finally failed the first six month re-qual training session, to the great relief of all concerned.
Another type was a Captain who was toxic; a couple of them in fact.
First flight with one; no green gear light on one side. “It’s OK, it’s down.” was the comment.
I said I would go check the visual indicator; “It’s OK; the Flight Attendant can check”.
Said Flight Attendant responded that she had no idea how to check. (She was smart; she knew this “Captain was out to lunch)
I went back, checked the visual indicator and all was fine.
I suggested I change the bulb; the “Captain” said; “That is a maintenance function” “We’re not allowed to touch it”.
So; we landed safely, called maintenance who said; “Change the Bulb”. The Captain said she didn’t know how (although it was covered in training), so I did it, made the entry and we proceeded.
The point is, those who are over their head often compensate with bluster if they are in the Left Seat.
Watch out for these types!
Disappointing to see this. An article full of counterfactual reasoning and hindsight bias describing things that didn’t happen. Would be much better to read something that describes what did actually happen and more importantly, why (not much in the NTSB report either to be fair.)
Jane, it would appear that you are either very inexperienced or wish not to see reality. It is crystal clear from the NTSB report that the F/O in the Atlas crash was a weak stick. The NTSB report bears that out with their remarks about his training record. The Captain wasn’t a whole lot better. He clearly bumped one of the G-A switches, common, and not a big deal, but it doesn’t appear that he took any action to correct the situation either. The report is correct, on a Boeing like the 767 going from min thrust to G-A thrust will most definitely make the nose go up, seriously up. The F/O let it then tried to recover very ineptly as he must have had everyone off their seats against the straps. Unless you are trying to evade AAA or the fighters, there is absolutely no reason to ever have the nose that far down in a big airplane.
Now, I am clueless about your experience, qualifications, or abilities and that is fine as I am not questioning them. However, there are several tales here, two of my own, exemplifying the point about weak pilots squeezing through the system. There are plenty of weak, inept drivers on the highway every day, why wouldn’t there be weak, inept pilots in the sky?
jane G you disagree with the article, seem to know what did not happen and what did happen, and you are critical of the NTSB all in general terms. Can you be specific?
Well not disappointing. This a forum to speak freely I hope. That seems to be under attack in these times!! Naturally we will “arm chair quarterback”. That’s what we do and we also try to learn from it–most of the time. In my opinion this was kind of the perfect storm Why? Captain and F/O were weak players. Never mind the fact the F/O falsified his records. Why did all the companies he worked for kick the can down the road? Maybe to avoid a law suit? Look what is happening now in today’s climate on race 🤔. Maybe the Capt. had upgrade issues. Combine to the two and bad things may happen. Equal opportunity does not always equate to outcome of equality. In our profession you can loose your life over that.
This is a technical profession that has measurable performance standards. There is an artistic component to flying all airplanes, also. Bob Hoover. Many are not artistic in their flying or judgment. Airlines strive to have a demonstrably high minimum standard. But on any given day some pilots will perform at the low end of a high standard. Those that routinely demonstrate poor judgement and substandard performance should be fired. Regardless of gender or race or any other distraction. Competence is blind to all of this. AH! There’s the rub. Congress, law firms, HR departments and unions all interfere with flight departments. We can all argue the methodology of getting from identifying incompetence to dismissal but after a fair review they must be dismissed.
AGREE !
As someone who has never flown as a profession, and likely never will, just a few questions. Hopefully the comment section here can preserve anonymity if needed. First, how is it handled when the ineptness of the person in the other seat is discovered? Is there a standardized way for the information get to decision-makers? Or, as Brian H. mentioned a six-month requal training session, is someone’s inadequate performance only caught in recurrent training situations? Nobody wants to be a rat, but nobody wants to see anyone (or themselves) get hurt because of an individual’s incompetence. Is there a level of incompetence that would demand immediate attention by management?
Thanks in advance.
I can only comment on the pt135/91K world. Chris K, depending on the company (I have flown for 4), there is no real “standardized” way of reporting issues. My current company just had a candidate fail FO IOE (initial operating experience) and that person was let go, even though he passed the sim check ride. Sometimes an upgrade candidate can’t pass IOE even after passing check rides. Not all pt135 outfits use the IOE step, they just throw a new person into the right seat after passing the check ride. In that case the captain is stuck with dealing with any issues that may come up. All of the examples I brought up makes the job of company check and IOE Captains that much tougher. A lot of small companies use training providers as check airman so it is possible to pass the airplane check ride in sim and still not do well in the airplane. Although seniority still plays a big part, it is almost impossible to upgrade without some kind of recommendation from captains that FO has flown with. Part of most captain positions I have been associated with is to evaluate the FO he/she is flying with and report any issues to the chief pilot. Depending on the competence of the captain it can be a way for FO’s to bring up issues about the captain. Unfortunately in most cases unless a client complains about the flight the last resort a crew member has is to flat out refuse to fly with other assigned crew member. In a unionized company or pt121 companies I can’t comment.
Thirteen year retired airline pilot from a major carrier. I’ve seen weak captains and co-pilots and wondered how they managed to stay onboard. As a former ALPA member, I suspect that may have contributed to their longevity.
I watched the accident video presentation and fortunately the odds of two weak crew members on the same flight is exceedingly rare.
Training documentation is a multi-blade sword. I was giving an upgrade PC check ride in a 757 sim with a candidate who was completely unprepared. His performance was abysmal. After about 1 hour I called it quits and explained that everyone has bad days, etc. he could try again the next day, or have another check airman administer the ride if he thought there might be friction between us. I explained that this day would be documented as training. He agreed to the following day after a very lengthy debriefing.
The next day was just as bad. Not only was he totally unprepared, but his attitude was worse. Ended up downing him explaining that there would be no document of failure for the ride. It was just training. I didn’t want his “unblemished” trading records to be affected. Turns out the training department was unaware of his previous failures at another airline.
Did a first officer PC and he went on his way.
Three months later I get a certified letter from his attorney with a personal lawsuit at me. Because I hadn’t “failed” him on the PC he therefore must have passed. I made a phone call to him explaining that I was trying to help him. Instead, because of the lawsuit I would have to retroactively fail him and pink slip him. He finally rescinds the lawsuit.
The performance he displayed was un fathomable. I think it was the worst performance I had seen in many years of training/checking. His attitude just made everything that much worse.
One might be surprised that the aptitude of some crew members can be so bad, but unfortunately they are still flying.
The First Officer had a long long history of failed checkrides. Why the FAA did not pull his license years ago is beyond me. Some of the comments written describing his inept skills in the simulator during evaluations are mind boggling. Nope. No sympathy here. I fault the FAA together with the evaluators who kept letting him slide time after time. I hope the family of the unsuspecting jump seat rider who died at his hands gets a hold of this guys training record and sues the FAA, evaluators and airlines who kept ignoring the fact that this idiot could not fly, period.