NTSB Recreation of Final Moments of Atlas Air 3591

"ttyymmnn" (ttyymmnn) 07/15/2020 at 14:18 • Filed to: wingspan, Planelopnik

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On February 23, 2019, Atlas Air 3591 nosedived into Trinity Bay in Texas, killing the three pilots onboard. The National Transportation Safety Board, which released its !!!error: Indecipherable SUB-paragraph formatting!!! yesterday, suggests the likelihood that the first officer, Jules Aska, experienced !!!error: Indecipherable SUB-paragraph formatting!!! , where an increase of speed with no visual cues can lead a pilot to believe they are going up steeply. There was nothing wrong with the aircraft. The PIC simply pushed the nose down into the ground after the TOGA was triggered.

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 following is taken from the YouTube comments, and while I can’t independently verify this, it is in line with other things I have read about the FO, Jules Aska.

Investigators also found that Aska, 44, had a problematic employment and training history prior to his hiring at Atlas in 2017. He joined the freight operation from Mesa Airlines, which he left after failing two flight simulator checkouts for promotion to captain on the Embraer 175 regional jet. One Mesa captain who evaluated him told the NTSB that Aska would “make frantic mistakes [and] start pushing a lot of buttons without thinking about what he was pushing.” Earlier in his flying career, Aska had been briefly employed by regional airlines Air Wisconsin and Commutair but had left after four months and one month, respectively, due to failure to satisfactorily complete training at both carriers. He did not list his time with those airlines when applying at Atlas, the NTSB noted. Aska also failed his initial checkride at Atlas, due to what company pilots told the NTSB was “unsatisfactory performance in crew resource management, threat and error management, non-precision approaches, steep turns, and judgment.” He ultimately passed the checkride after more remedial training, with the chief pilot at Atlas telling investigators he’d chalked up the first officer’s previous difficulties to nerves and family issues.

Just Jeepin' > ttyymmnn 07/15/2020 at 14:27

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make frantic mistakes [and] start pushing a lot of buttons without thinking about what he was pushing 

I’ve worked with people like that in IT. Very stressful even in a relatively low-risk environment; I can’t imagine why someone like that would slip through the hiring process to fly an airplane.

For Sweden > ttyymmnn 07/15/2020 at 14:28

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I’m going to have “Read the instruments ” engraved on my tombstone.

CarsofFortLangley - Oppo Forever > ttyymmnn 07/15/2020 at 14:31

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“ start pushing a lot of buttons without thinking about what he was pushing.”

Nice! Good to know my flight sim strategy is employed by real pilots

Rusty Vandura - www.tinyurl.com/keepoppo > For Sweden 07/15/2020 at 14:33

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I suspect your actual epitaph will be something much more ironic.

ttyymmnn > CarsofFortLangley - Oppo Forever 07/15/2020 at 14:38

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Your flight sim training was probably enough to get you hired before the Covid.

Rusty Vandura - www.tinyurl.com/keepoppo > ttyymmnn 07/15/2020 at 14:38

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Oof.

For Sweden > Just Jeepin' 07/15/2020 at 14:39

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The pilot shortage was an odd time.

ttyymmnn > Rusty Vandura - www.tinyurl.com/keepoppo 07/15/2020 at 14:39

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Indeed.

CarsofFortLangley - Oppo Forever > ttyymmnn 07/15/2020 at 14:44

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If about to crash, Alt+Tab out.

Highlander-Datsuns are Forever > ttyymmnn 07/15/2020 at 14:45

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I got the radio! But how is flying the plane?

CarsofFortLangley - Oppo Forever > ttyymmnn 07/15/2020 at 14:46

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“Lord…you have my soul,” Aska yelled, a second before the high-speed impact covered the Texas bay with debris, reports TIME magazine.

Top 10 things you don’t want the pilot to say

Exage03040 @ opposite-lock.com > Just Jeepin' 07/15/2020 at 14:46

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I think the issue is that we like to believe that people can overcome this reaction (experience, practice and such). Realistically I think it’s built in part of the panic fight response and it’s difficult to break . The whole throw everything at the wall and see what sticks.

The only actual way to solve it for a person such as would be continuous drills and training more than the typical operator   but then you get into the whole robot mode of following the SOP to the T and they can’t adapt or problem solve which is essential for senior crew . Especially if they misinterpret or incorrectly diagnose faults.

This is such a strange case of an incorrectly diagnosed fault, all the instruments were reading good and yet they went nose down because of a ‘ feeling’ . Tragic.

ttyymmnn > CarsofFortLangley - Oppo Forever 07/15/2020 at 14:46

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Gone > ttyymmnn 07/15/2020 at 14:48

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His evals/history read as though he should have been bounced from the industry. Holy shit.

TheRealBicycleBuck > ttyymmnn 07/15/2020 at 14:50

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Always trust the instruments first. The butt dyno can be fooled in an airplane.

RacinBob > ttyymmnn 07/15/2020 at 14:51

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https://www.thesun.co.uk/news/10591631/pilot-last-words-amazon-prime-cargo-crash-texas/

Boy that is generous by the NTSB to call it a mistake.  If you look at the transcript, it sounds like a suicide. Aska is the co-pilot who washed out of several other jobs.

The transcript of the pilots’ last words before the Amazon Prime cargo plane plummeted 6200 feet

Blakely: It is severe clear on the other side of this stuff so you’ll have no problem gettin’ to the airport

Aska: (oh)

[Sound similar to a mechanical click is heard]

Aska: Whoa [Spoken in an elevated voice]

Aska: My speed. My speed [Spoken in an elevated voice]

[Sound similar to louder mechanical click is heard]

Blakely: Okay

[Sound similar to multiple random thumping noises]

Aska: ‘We’re stalling [Spoken in an elevated voice]

Aska: Stall [Exclaimed]

Aska: Oh Lord have mercy on myself [Spoken in elevated voice]

[Sound similar to multiple random thumping noises]

Aska: Lord have mercy [Exclaimed]

Aska: Captain [Spoken in an elevated voice]

Blakely: What’s going on?

Aska: Lord [Spoken in elevated voice]

[Sound of 1000HZ series of beeps with approximately .25 spacing being. It’s not clear if it lasted until the end of the recording]

Aska: Captain [Spoken in an elevated voice]

Archuleta: What’s going on? [Spoken in an elevated voice]

Unknown: [Sound of rapid breathing]

Aska: Captain

[Sound of quick series of four beeps followed by a pulse tone, similar to a siren]

Archuleta: Pull up [Shouted]

Aska: [Unitellligbable shout]

Unknown: Oh God [Shouted]

Aska: Lord you have my soul

- Source: National Transport Safety Board

ttyymmnn > Gone 07/15/2020 at 14:54

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He was hired at a time of rapid growth when pilots were in high demand, and there may also be an undercurrent social promotion at play. Interestingly, Aska’s brother sued Amazon and Atlas   over the crash. I’m guessing that this finding pretty much torpedoes his case.

ttyymmnn > TheRealBicycleBuck 07/15/2020 at 15:02

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Yet there are so many cases of pilots not doing that. I’m reminded of the tragic case during the Desert Storm where an AH-64 gunner hit two US vehicles at nigh t with Hellfire missiles . He had location information on where the enemy was located, he identified two targets, but didn’t believe the instruments, which told him he was not where he thought he was. He was also the Apache battalion commander, and he may have had an itchy trigger finger. The synopsis of this report paints a pretty grim picture, and sounds like the mission was lead by a commander who was just itching to put a notch in his belt.

https://www.govinfo.gov/content/pkg/GAOREPORTS-OSI-93-4/html/GAOREPORTS-OSI-93-4.htm

ttyymmnn > RacinBob 07/15/2020 at 15:03

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Nah, I think the guy just freaked out and his brain shut down. He asked for forgiveness when he realized that they were all going to die.

ClassicDatsunDebate > ttyymmnn 07/15/2020 at 15:04

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ooo...I’ve got a new burn: “Aptitude related deficiencies” 

ttyymmnn > ClassicDatsunDebate 07/15/2020 at 15:05

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Which I think just means, “You dumb.”

Gone > ttyymmnn 07/15/2020 at 15:05

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Interesting. Rapid growth of “x” usually leads to no-so-good results. I’d agree that the case should be done for.

ClassicDatsunDebate > ttyymmnn 07/15/2020 at 15:08

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yes but as a Canadian, I seek out higher-brow burns.

f86sabre > ttyymmnn 07/15/2020 at 15:10

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Sounds like many holes in the cheese aligned here.  Glad to hear a reasonable evaluation of what happened. 

user314 > CarsofFortLangley - Oppo Forever 07/15/2020 at 15:12

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Yeah, much as I wanted to learn how to fly, time on the FS95 sims in HS disabused me of the idea. 

Only Vespas... > ttyymmnn 07/15/2020 at 15:42

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Well, before the virus the airlines were desperate for pilots. Now, with so many pilots hanging out in the kitchen, perhaps airlines can afford to be choosy.

ttyymmnn > Only Vespas... 07/15/2020 at 15:44

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By the looks of it, they will be able to afford it for a long time. It looks like Delta played the strongest hand and will avoid mass furloughs through buyouts, but the others are going to be cutting tons of jobs soon.

Ash78, voting early and often > For Sweden 07/15/2020 at 15:44

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My grandpa (flying from 1952-2008) always said — about flying, driving, life — always believe what you see, not what you feel.

RacinBob > ttyymmnn 07/15/2020 at 16:49

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Man that is a tough one to swallow though. If not suicide, he has a panic disorder inconsistent with continued life while flying. This was the instruments the moment he rammed the controls forward. Note he never heard a stall warning or experienced a stick shaker, he just rammed it forward. 

This is it 7 seconds after he pushed down.

If he got that freaked to not look or understand his instruments , how did he ever live through solo and instrument flight training? Panic disorder or suicide I think is a better explanation .

ttyymmnn > RacinBob 07/15/2020 at 16:51

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One Mesa captain who evaluated him told the NTSB that Aska would “make frantic mistakes [and] start pushing a lot of buttons without thinking about what he was pushing.”

I think that’s all you really need to know.

RacinBob > ttyymmnn 07/15/2020 at 23:56

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Ok panic disorder inconsistent with life.