On Jun 11th 2020 the NTSB announced a (virtual) board meeting on Jul 14th 2020 to determine the probable causes of the crash. The board meeting was webcast on schedule and has concluded by now.
The chair reported opening the meeting: "The first officer was the pilot flying at the flight had its initial descent there was nothing unusual at that point but as it encountered black turbulence a go around was activated it was an aborted landing. It was unusual to be activated so far from the airport or initial descent in addition neither pilot made the call around and manual over rode the pilot and put it in a dive where the crew did not recover The airplane crashed into a shallow marshy area at Trinity Bay. The captain the first officer and a non-revenue pilot riding on the jump seat lost their lives."
The chair continued to say: "The crew-related issues we will discuss today are not to highlight individual deficiencies, but rather, to raise attention to a possibly systemic issue that needs to be addressed so that others do not have to go through what these family members have experienced."
The first officer had a display issue and temporarily transferred control to the captain until he sorted the problem using the EFI switch.
The speedbrakes were extended for the descent, it was procedure to guard the speed brake handle for speed brake retraction upon reaching the target altitude. The hand of the first officer was very close to the go-around switches while guarding the speed brake handle.
The aircraft pitched up, the engines spooled up and the speed brakes retracted which can only be done manually. Bill English, investigator in charge said (most likely referring to the first officer and not the captain as he spoke): "The captain responded to the call and pushed forward and made an expression of speed and said we're stalling. There was no indication that the airplane was stalling. He was experiencing disorientation because of somatogravic illusion." The aircraft reached a nose down attitude, at about 3 thousand feet it broke out of the clouds, full nose up input occurred but were too late to prevent impact in the bay.
The human factors expert stated: "When he was using the speed brakes standard operating procedures (SOP) require his hand require on the speed brake handle to retract the speed brakes at selected altitude and increase in thrust. Holding the thrust close to the left go around switch so that very little upward arm movement would be needed to make contact with the switch. The go around mode was unintended. The first officer was not effected in scanning these instruments he had sensations to incorrectly concludes the airplane was stalling. It was not in a stalled condition. First officer provided nose down input and failed to disengage the autopilot. The first officer should have disconnected the automation and recovered the airplane. His inputs however overrode the autopilot and forced the aircraft into a steep dive that was unrecoverable. The first officer during training actions at multiple employers showed an inability to remain calm during stressful situations."
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 first officer's training record was "terrible".
The board members currently discuss the hiring processes and how information flow between former employer(s) and hiring employer is at the current and what improvements could be made.
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. The left elevator (which is the only one recorded on the FDR) was pulled while it was reasonable to assume the right hand control column still was pushed forward causing left and right elevators to move differently. Left and right elevator are connected via a spring load, so it there is no control force on the left column, both elevators follow the right column (and vice versa). A short time later the right elevator joined the movement of the left control column so it can be assumed the first officer ceased his nose down control input (when the aircraft broke out of clouds). There never was a transfer of control called, which could have made a difference to the outcome of the event.
The chair stated in summary to the discussion about the hiring processes: "I intend to offer an amendment to add the FAA as a contributing factor. That the FAA's failure to implement the pilots record database in timely manner when we get to that point. ... The FAA has dragged their feet on implementing a sufficient pilot record database."
The vice chair rose this question: "I think we're starting to find that mf as the flight was approaching the area of turbulence the first officer called for mrap flap extension it lowers the aircraft and Boeing and Atlas remind that they not be extended until you are closer to the airport. Had the flaps not been extended my understanding that the go around modes woo not have been able to be activated is that correct?" which received an affirmative reply by the aircraft systems expert. Stick shaker and stick pusher never operated, the pitch angles were never indicative of a stall.
The human factors expert responded to a related question by the vice chair, initially when the go around mode was activated it triggered the thrust to increase over a couple of seconds. The preceiption of the changing inertia and the force of gravity causes the perceived angle to shift and that caused the first officer feeling like the plane was pitching up more than 4 to 5 degrees."
Check airmen at Air Wisconsin, Mesa and Atlas reported that when the first officer was presented with an unexpected scenario, he would get flustered and could not respond to the system, he would become extremely anxious and push buttons without thinking about what he was doing just to be doing things. This pattern, observed by three check airmen, also surfaced during the accident flight in the sense "in an inconsistency in a stressful situation do anything."
The first officer could have disconnected the automation by pushing two buttons, one for the autopilot and another one for the autothrust, then he could have flown the aircraft conventionally in manual control and returned it onto the intended profile. 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.
The chair inquired whether it was correct the first officer perceived something like an 80 degrees pitch up as result of the unintended go around activation and how the somatogravic illusion could be overcome. The expert stated: "Well I think it is helpful that pilots know when to be on their guard like during an intentional go around and if they have practice with instrument flying. In this case I think the thing that was tricky they would not have expected a rapid acceleration at this time and they were unaware of the mode change and at a bit of disadvantage."
The topic of video surveillance in the cockpit was brought up, the relevant expert stated: "it would be tremendously helpful for the air carriers and the training environment to actually see how pilots are operating within the cockpit and this is not intended to be something you see on the evening news. We have been careful in the use of CVR to my knowledge there has never been an accidental release of internal cockpit recordings. We do transcripts but that's about it. And I'm a little disappointed in terms of people saying it is privacy in other modes of transportation in trucking and buses and railroad cabs they are all using image recorders to help to manage the safety aspect. So I guess I'm having difficulty in understanding and I've heard concerns it could be used in some area for criminal use and I think there could be way that's could be managed but I'm curious if there are any other objections besides we don't want people to see what is going on in the cockpit."
The NTSB is not aware of any training regarding somatogravic illusions provided to the first officer. The FAA does not require any physical type of sensory illusions, there is only a theoretic lesson very early into the instrument rating. In summary there is no requirement for a specific training to sensory illusions like black hole, somatogravic illusion etc. The FAA database of 10 years (2009-2018) contain 219 accidents with 400 fatalities caused by spatial disorientation (though most of them happened in general aviation).
23 findings were adopted by the investigation (subject to publication in writing by NTSB).
The NTSB board concludes the probable cause of the accident was (subject to publication in writing by NTSB):
The probable cause of this accident was the inappropriate response by the first officer as a pilot flying to inadvertently activating the go around mode which led to spatial disorientation and nose down input that placed the airplane in a deep dive which the crew did not recover from.
Contributing to the accident were:
- the captain's failure to adequately monitor the flight path and assume a control of the aircraft to intervene and
- systemic deficiencies in the aviation select and performance measurement practices which failed to address the first officer's aptitude related deficiencies in maladaptive stress response
- the federal aviation administrations dragging failure to administer the pilot database in a sufficient robust timely manner.
The chair concludes: "I think we're on target if the FAA had done their job this pilot would not have been employed by Atlas Airlines and therefore this crash would not have happened."
The investigation proposes 6 safety recommendations and reiterated a number of safety recommendations that were issued 15 years ago.
The actual final report will be released in due time (a couple of weeks estimated).
Later Jul 14th 2020 the NTSB released an abstract stating following findings and probable causes in writing:
Findings
1. None of the following were factors in this accident: (1) the captains and the first officers certifications and qualifications; (2) air traffic control services; (3) the condition and maintenance of airplane structures, powerplants, and systems; and (4) airplane weight and balance.
2. There was insufficient information to determine whether the flight crewmembers were fatigued at the time of the accident, and no available evidence suggested impairment due to any medical condition, alcohol, or other impairing drugs.
3. Whatever electronic flight instrument system display anomaly the first officer (FO) experienced was resolved to both crewmembers satisfaction (by the FOs cycling of the electronic flight instrument switch) before the events related to the accident sequence occurred.
4. The activation of the airplanes go-around mode was unintended and unexpected by the pilots and occurred when the flight was encountering light turbulence and likely instrument meteorological conditions associated with its penetration of the leading edge of a cold front.
5. Presuming that the first officer (FO) was holding the speedbrake lever as expected in accordance with Atlas Air Inc.s procedure, the inadvertent activation of the goaround mode likely resulted from unintended contact between the FOs left wrist or watch and the left go-around switch due to turbulence-induced loads that moved his arm.
6. Despite the presence of the go-around mode indications on the flight mode annunciator and other cues that indicated that the airplane had transitioned to an automated flight path that differed from what the crew had been expecting, neither the first officer nor the captain were aware that the airplanes automated flight mode had changed.
7. Given that the first officer (FO) was the pilot flying and had not verbalized any problem to the captain or initiated a positive transfer of airplane control, the manual forward elevator control column inputs that were applied seconds after the inadvertent activation of the go-around mode were likely made by the FO.
8. The first officer likely experienced a pitch-up somatogravic illusion as the airplane accelerated due to the inadvertent activation of the go-around mode, which prompted him to push forward on the elevator control column.
9. Although compelling sensory illusions, stress, and startle response can adversely affect the performance of any pilot, the first officer had fundamental weaknesses in his flying aptitude and stress response that further degraded his ability to accurately assess the airplanes state and respond with appropriate procedures after the inadvertent activation of the go-around mode.
10. Had the Federal Aviation Administration met the deadline and complied with the requirements for implementing the pilot records database (PRD) as stated in Section 203 of the Airline Safety and Federal Aviation Administration Extension Act of 2010, the PRD would have provided hiring employers relevant information about the first officers employment history and training performance deficiencies.
11. The first officers long history of training performance difficulties and his tendency to respond impulsively and inappropriately when faced with an unexpected event during training scenarios at multiple employers suggest an inability to remain calm during stressful situationsa tendency that may have exacerbated his aptituderelated performance difficulties.
12. While the captain was setting up the approach and communicating with air traffic control, his attention was diverted from monitoring the airplanes state and verifying that the flight was proceeding as planned, which delayed his recognition of and response to the first officers unexpected actions that placed the airplane in a dive.
13. The captains 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 captains degraded performance, which included his failure to assume positive control of the airplane and effectively arrest the airplanes descent, resulted from the ambiguity, high stress, and short timeframe of the situation.
15. The first officers repeated uses of incomplete and inaccurate information about his employment history on resumes and applications were deliberate attempts to conceal his history of performance deficiencies and deprived Atlas Air Inc. and at least one other former employer of the opportunity to fully evaluate his aptitude and competency as a pilot.
16. Atlas Air Inc.s human resources personnels reliance on designated agents to review pilot background records and flag significant items of concern was inappropriate and resulted in the companys failure to evaluate the first officers unsuccessful attempt to upgrade to captain at his previous employer.
17. Operators that rely on designated agents or human resources personnel for initial review of records obtained under the Pilot Records Improvement Act should include flight operations subject matter experts early in the records review process.
18. The manual process by which Pilot Records Improvement Act records are obtained could preclude a hiring operator from obtaining all background records for a pilot applicant who fails to disclose a previous employer due to either deception or having resigned before being considered fully employed, such as after starting but not completing initial training.
19. The establishment of a confidential voluntary data clearinghouse to share deidentified pilot selection data among airlines about the utility of different methods for predicting pilot success in training and on the job would benefit the safety of the flying public.
20. All pilots of Boeing 767- and 757-series airplanes (which share a similar go-around switch design) could benefit from an awareness of the circumstances of this accident that likely led to the inadvertent activation of the go-around mode.
21. The Department of Defense has developed approaches to automatic ground collision avoidance system technology for fighter airplanes that, if successfully adapted for use in lower-performance, less-maneuverable airplanes, could serve as a model for the development of similar installations in civil transport-category airplanes that could dramatically reduce terrain collision accidents involving pilot spatial disorientation.
22. An expanded data recorder that records the position of various knobs, switches, flight controls, and information from electronic displays, as specified in amendment 43 to the recorder standards of the International Civil Aviation Organization, would not have provided pertinent information about the flight crews actions.
23. A flight deck image recording system compliant with Technical Standard Order TSO-C176a, Cockpit Image Recorder Equipment, would have provided relevant information about the data available to the flight crew and the flight crews actions during the accident flight.
Probable Cause
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 captains failure to adequately monitor the airplanes flightpath and assume positive control of the airplane to effectively intervene.
Also contributing were systemic deficiencies in the aviation industrys selection and performance measurement practices, which failed to address the first officers aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administrations failure to implement the Pilot Records Database in a sufficiently robust and timely manner.
NTSB Animation of accident sequence (Video: NTSB):
| https://www.youtube.com/watch?v=GsSNr5DR840 |