FAA proposes draft B-737 Max Training only for US carriers & registered aircraft only

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The FAA has released a flight standardisation boardreport relating to B-737 Max pilot training. Soon after, an addendum was issued too. While FAA has clearly stated that the training required in the FSB is mandated for US air carriers & US registered aircrafts, other aviation authorities must take their own action for the return of the B-737 Max.Question, will the Indian regulator follow a systematic process of change management and not be rushed into the re-entry process? Will the FSB report adopted in toto and will the regulators draft training requirements be put out for public comments?
The key highlights are quoted below from the FAA website as of 7th Oct 2020:While this is an important step, several key milestones remain:Final Design Documentation and Technical Advisory Board (TAB) Report – The FAA will review Boeing’s final design documentation to evaluate compliance with all FAA regulations. The multi-agency TAB will also review the final Boeing submission and issue a f…

NTSB Board Meeting: Atlas Air Flight 3591 Cargo Plane Crash highlights systemic failure

NTSB Board Meeting: Atlas Air Flight 3591 Cargo Plane Crash highlights systemic failure

Atlas Air


NTSB Board Meeting: Atlas Air Flight 3591

The National Transportation Safety Board determined during a public board meeting held Tuesday that Atlas Air flight 3591 crashed in Trinity Bay, Texas, because of the first officer’s inappropriate response to an inadvertent activation of the airplane’s go-around mode, resulting in his spatial disorientation that led him to place the airplane in a steep descent from which the crew did not recover.

The key highlights were:
  • The NTSB concluded the first officer likely experienced a pitch-up somatogravic illusion.
  • The NTSB also determined the captain’s failure to adequately monitor the airplane’s flightpath and to assume positive control of the airplane to effectively intervene contributed to the crash.
  • “The first officer in this accident deliberately concealed his history of performance deficiencies, which limited Atlas Air’s ability to fully evaluate his aptitude and competency as a pilot,” said NTSB Chairman Robert Sumwalt.
In my opinion, selection of pilot and training remains the key highlight in the investigation process. The industry was under pressure to meet with the operational requirements of keeping the aircraft's manned. The holes in the safety net are plenty and the pilots and other staff who form the process of selection and training. The blame game begins but like every investigation recommendation, there has to be a commitment from the top policy makers.


Brief of the board meeting

The accident happened Feb. 23, 2019, when the Atlas Air Boeing 767 cargo jet entered a rapid descent from about 6,000 feet and impacted a marshy bay about 40 miles from Houston’s George Bush Intercontinental Airport. The captain, first officer and a non-revenue, jumpseat pilot, died in the crash. The airplane – which was carrying cargo from Miami to Houston for Amazon.com Services LLC., and the US Postal Service – was destroyed. The first officer was the pilot flying the airplane at the time of the accident.

The NTSB also determined the captain’s failure to adequately monitor the airplane’s flightpath and to assume positive control of the airplane to effectively intervene contributed to the crash. Also cited as a contributing factor is the aviation industry’s selection and performance measurement practices that failed to address the first officer’s aptitude related deficiencies and maladaptive stress response.

The NTSB concluded the first officer likely experienced a pitch-up somatogravic illusion – a specific kind of spatial disorientation in which forward acceleration is misinterpreted as the airplane pitching up – as the airplane accelerated due to the inadvertent activation of the go-around mode, which prompted the first officer to push forward on the elevator control column. The first officer subsequently believed the airplane was stalling and continued to push the control column forward, exacerbating the airplane’s dive. However, no cues consistent with an aerodynamic stall —such as stick shaker activation, stall warning annunciations, nose-high pitch indications or low airspeed indications—were present. Additionally, the NTSB’s airplane performance study found the airplane’s airspeed and angle of attack were not consistent with having been at or near a nose-high stalled condition. The first officer’s response was contrary to standard procedures and training for responding to a stall. Graphic depicting of the descent of Atlas Air flight 3591 before final impact on Feb. 23, 2019. (Graphic depicting of the descent of Atlas Air flight 3591 before final impact on Feb. 23, 2019. NTSB Graphic)

The NTSB concluded that while the captain, as the pilot monitoring, was setting up the approach to Houston 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. This delayed his recognition of, and his response to, the first officer’s unexpected actions that placed the plane in a dive.


Investigators also concluded 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. While the first officer took deliberate actions to conceal his history of performance deficiencies, Atlas’ reliance on designated agents to review pilot background records and to flag significant concerns was inappropriate and resulted in the company’s failure to evaluate the first officer’s unsuccessful attempt to upgrade to captain at his previous employer. Additionally, the NTSB found that had the FAA met the deadline and complied with the requirements for implementing the pilot records database as stated in Section 203 of the Airline Safety and Federal Aviation Administration Extension Act of 2010, the pilot records database would have provided hiring employers relevant information about the first officer’s employment history and long history of training performance deficiencies. “The first officer in this accident deliberately concealed his history of performance deficiencies, which limited Atlas Air’s ability to fully evaluate his aptitude and competency as a pilot,” said NTSB Chairman Robert Sumwalt. “Therefore, today we are recommending that the pilot records database include all background information necessary for a complete evaluation of a pilot’s competency and proficiency.” An abstract of the final report, which includes the findings, probable cause, and all safety recommendations, is available at https://go.usa.gov/xfbcb. Links to the accident docket and other publicly released information about this investigation are available at https://go.usa.gov/xfTNs. The final report for the investigation of the accident is expected to post to the NTSB website in the next few weeks.

Comments

  1. If a pilot says the aircraft is stalling it means that he is looking at either AOA indicator or the ASI or may be stall warnings. It is obvious that the stall warnings have not sounded. Difficult to believe that Somatogravic illusion caused the FO to push the nose down so hard. If we calculate mathematically may be the amount of pitch up (false) perceived by the FO could have been 2 or 3 degrees which is not enough to startle him so much. Is it possible that he may be confused with the altimeter and ASI. I never heard any transport pilot getting disoriented with this pitch up illusion. Another aspect which is hotly being debated is the proposal of having video recorders inside the cockpit. I think it will be a brilliant idea as far as understanding the accidents is concerned.

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  2. The expert has testified that the somatogravic illusion have the first officer a pitch up sensation of +80 degrees. This is from the NTSB hearing.

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  3. Somatogravic illusion is not a new discovery. Time and again it seems to affect incompetent pilots who violate basic rule of instrument flying. In instrument conditions they induce extreme flight control input without referring to instruments. Human factors are a guide to the wise to guard against but unfortunately it's just an obituary for the incompetent.

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