NTSB issues investigative update on B-767 runway excursion accident in Miami

Four words said by the pilot monitoring that any pilot flying will understand and react automatically to.

A big part of the monitoring pilot's job is noticing when things have gotten too far and taking over controls. This does very much include scenarios when the pilot flying has fallen to tunnel vision, subtle incapacitation, and the continuation/sunk cost fallacy.

I'm pretty sure it's FAA policy, but not 100% on that.

A bad bump on a commercial plane can be hundreds of thousands to millions in damage + downtime + inspection/repairs. And tens or hundreds of millions if you wreck a big plane. Companies may be evil, but most would still prefer you waste $2k in go around fuel than $200k because you decided to set it down badly or $20M+ because you drove their plane off the runway.

https://youtube.com/watch?v=Ccq30minme8

(not an aviation expert, just summarizing various bits and pieces I gathered from various YouTubers over the last days)

[0] https://en.wikipedia.org/wiki/Crew_resource_management

Is there evidence that PM ever called for a go around? I mean earlier, when it would have actually been possible, not 15 seconds before the end of the flight data recording.

From what I've heard, PM stated (repeatedly) that they were too high and/or too fast, and PF was not heard to respond.

> Having pilots fighting over the controls is not a situation anyone wants

Nor crashing and killing 5 people.

The training pilots go through to get type rated and to be allowed to fly by airlines is incredible. But knowledge is one thing, attitudes and behavior and truly taking safety to heart outside the sim is another. I bet this guy was slightly reckless in every model he's flown.

Another alternative is external social factors acting on the captain. Maybe he was distracted by personal issues. There again though, if you're not fit to fly that day, you call out.

It's almost the opposite. There is automatic monitoring for stable approach criteria (simplified: you must be at speed X with flaps selected etc by altitude Y). So this example would cause an automatic report from the aircraft to the airline, because they were too fast (not within stable approach criteria) and still continued the approach instead of going around.

However even in those cases it's not meant for punishment but for safety improvement. In most professional operations these reports are made anonymous, and only for example someone from a union committee gets to know who the crew were and could have a talk with them if necessary.

Part 121 Cargo and Part 135 Charter are ... another story. Quality of training and procedures vary a lot. Some are run about as well as the Part 121 Passenger operations. At others a go-around is a career-limiting move.

I do not know how 21Air operated - leave that to the NTSB to discover - but it would not surprise me whatsoever if Amazon leans heavily on their contracted ACMIs and yanks contracts for delays. A go-around means an extra 15 minutes (give or take) and Amazon cuts their logistics schedules razor thin so they don't have to pay for extra labor. A 15-20 minute delay in unloading the airplane can mean the sorting center staff and delivery trucks sit idle (though it wouldn't surprise me if they just stiff the delivery contractors for the wasted time).

This isn't necessarily done with ill intent - the middle managers at Amazon are just chasing their numbers and an operator that prioritizes safety will inevitably have worse on-time performance. As is often the case these days outsourcing / contracting can end up being a race to the bottom even if no one intends it that way. FedEx Ground is all contractors who bid on routes. If you ever wonder why the driver throws your package or leaves it in your driveway: they had to be the lowest bidder to get the contract and that means X deliveries per hour or they lose money. It just so happens that with air cargo operations this kind of pressure can easily lead to an accident.

However, I don't doubt shady operations might be doing this(more so if they aren't carrying passengers). They won't be around for long if they are caught doing this kind of nonsense and it causes an incident (or accident in this case).

Today there may be some rules (more than X go arounds because of weather, you have to divert, etc).

To be stabilized you must be lined up laterally (eg localizer captured) and on glide slope (vertically aligned). Airspeed must be Vref +/-10, final landing configuration (flaps, gear, etc), sink rate correct (<1000fpm), power set (not idle), and all checklists complete.

Typically the pilot monitoring should make a callout for this (eg "Approach") and the pilot flying responds ("stabilized" or "unstable, going around").

The "minimums" callout is to verify that you can see the runway sufficiently to land. The exact requirements vary - a Category I ILS you can go down to 200ft without seeing the runway. A Category IIIb ILS is 50ft. Technically Category IIIc allows 0 so has no decision height and requires no "minimums" callout but I don't know of anyone crazy enough to allow this - you wouldn't be able to taxi off the runway with zero visibility.

The stabilized approach gate is a performance & configuration check. Is the aircraft configured for landing and on the correct performance profile with the expected automatic guidance?

Minimums callout (DA/MDA) is a visibility check. Can we see the runway to whatever degree our approach requires?

btw: If you are curious the various ILS categories impose performance and redundancy requirements on both aircraft and the airport ground equipment. Things like backup transmitters, self-monitoring to catch drift, battery backups, etc.

They hit the ground at 158 knots. 767-300ER rotates at 130 to 160 knots. Given it had burned through its fuel, at the moment they touched down they could have immediately taken back off and gone around.

Given the pilots braked at 146 kts, released at 120 kts to throttle up for G-A, then four seconds later ditched the G-A and re-applied brakes, this sounds like they got stuck between going around and committing to the landing and never quite did either.

The comments here during the 737 MAX MCAS thing were fucking wild. So many randoms spitting out confidently incorrect nonsense.

You get what you incentivize. The point of the number in the top right is to incentivize. This kind of contribution is what this place is built for.

The more egregious thing to me though is ignoring the GPWS callouts on approach because they were chasing the glideslope. If you can't maintain a stable approach, you need to go around, it's the first thing you learn.

You expect this behaviour from a first-timer in the sim, not a commercial cargo pilot.

Literally 5 consecutive minutes of making 100s of wrong decisions snatching defeat from the jaws of victory.

According to news reports, a magistrate judge at OSHA has been sandbagging an investigation into retaliatory firings by this airline (of pilots who reported unsafe practices with maintenance, CRM, training, scheduling, everything). I wonder if the NTSB will include that judge in the investigation. It seems like he or she has a lot to answer for.

https://www.cbsnews.com/news/miami-plane-crash-21-air-safety...

This tends to be something we see in most incidents, because the cases where someone makes the right choice at one of the points tend to not become incidents.

An interesting thought is that the more obviously bad/incompetent/terrible decisions or (in)actions were involved in an incident, the better it is, because it means more things had to go wrong for a disaster to occur (more slices of cheese in the Swiss Cheese model).

You're correct. When they first annunciate G-A, they've missed the chance. (They almost certainly had enough airspeed to G-A even after touching down, though.)

My question is whether throttling up for G-A at 00:15 is what caused the overshoot to extend out of the airport (versus if they'd committed to braking). This will come down to runway conditions, braking performance and the throttle responsse of their engines.

Not 15 seconds before the crash, 15 seconds before the end of the recording. Then overran the runway 10 seconds before the end of the recording, then started crashing into objects 7 seconds before the end of the recording.

Thrust was reduced back to idle 11 seconds before the end of the recording, so just before departing the runway.

- a) Flying an unacceptably sloppy approach that put them on short final going that fast, high, and overpowered. Professionalism is being on airspeed and/or angle of attack and on glidepath . . . no excuses.

- b) Responding to a) by trying to force the jet onto the runway, when any aircrew member with half a brain should understand how badly you're going to float in ground effect when you're that fast and that overpowered. And what that's going to in turn do to your spoilers and thrust reversers that depend on weight-on-wheels before activating. Professionalism is recognizing a botched approach, swallowing your ego, and taking it the hell around.

- c) The pilot not flying sitting there like a coward and not taking the controls from the pilot flying. If someone hits a go-around criterion and isn't going around, YOU TAKE THE CONTROLS AND EXECUTE ONE. Professionalism is proper crew coordination and proper assertiveness in the cockpit.

This whole thing seems to just boil down to a complete failure of airmanship and a complete failure of professionalism all around. If I'd done that or allowed my pilot to do that, I'd expect to have had my wings pulled. If the investigation reveals more, I'll change my mind. But it ain't looking good.

> The Amazon Prime Air Boeing 767 cargo plane that crashed off a Miami runway on Sunday, killing five people, was operated by a North Carolina company that has been accused by past employees of violating safety regulations, legal documents reveal.

There's a lot in the article, but this allegation is worth highlighting:

> Seuring's attorney, Michael Anello, told the judge that another 21 Air pilot, Johnny Salmonson, "was being pressured to fly in periods of time that were too short to comply with the proper amounts of rest, and that implicated safety. The layovers were too short."

There have been accidents around the world where pilots were trying to save fuel, get off work at a normal time instead of 2 hours extra holding, not wanting to divert and not be home, try to get on the ground so they don’t go over their max hours for the day, etc.

Yes it’s counterproductive. *It happens*. External or internal, it happens.

Construction companies in the US do not pressure employees to get shit done. Construction workers do not delegate the decisions to work in sketchy circumstances, especially since OSHA holds them accountable for all that.

See how silly that sounds?

They cook up the rules to be all compliant and whatnot and then everyone breaks them a little pretty often and in tasteful ways in order to actually get the job done. If you get caught or screw up, it's on you.

I assume this sort of pressure happens a lot less with pilots because of the cost of screw ups but there's still probably some implied pressure there.

Why do you say this so confidently? Aviation generally does not have a culture of taking future employment away from people proximate to accidents.

Seems likely the FO will be fine. The CA will have some hard questions to answer.

It'll be interesting to see the outcome of the NTSB investigation, they're usually quite thorough.

Don’t get me wrong - if I had to land that plane, I’d likely have overrun the runway too. I’m not saying it’s easy, only that it appears to me that they were operating well outside the documented parameters that are the pilot’s responsibility to know.

I just looked it up, and a 767’s Vref is 122-165kts, with Vref at max weight at 144kts. They touched down at 158kts, nose down. The approach was ~35kts over speed, they were above the glide slope, and not bleeding speed fast enough to sink - so they dropped the nose.

From what I can see, they were screwed the moment they touched down - the last moment they had a reasonable opportunity to abort was when they decided to drop the nose and commit instead.

Those are a few situations when a trained individual could make a series of bad decisions. More so if they were forced into the situation (flying) despite raising objections. It has happened to other 21 Air pilots in the past - when they objected to flying but were forced, so who knows?

Absolutely does not absolve this individual of the incident. It’s a burden they’ll have to bear for the rest of their lives. But it could help explain why?

They'd have needed the mental bandwidth to notice on the EICAS display that the spoilers weren't deploying to even know to manually trigger them. Given how far behind they were noticing that would be highly unlikely. Under high stress you revert to your training or habits and manual spoiler deployment is just not something you need to do.

Their bank angle (for lack of a better term) was probably not enough to notice unless they had the mental bandwidth to pay close attention.

This is a common thing in these sorts of accidents: if you have the mental bandwidth to deal with these problems you'd have been properly setting yourself up for landing 30 minutes before you started and you wouldn't be in this mess to begin with.

This also represents a safety margin during normal flights: If everything is done by-the-book and going well then you are calm, collected, and you have the mental resources available to do quick instrument scans after touching down and potentially notice spoilers did not deploy - and you have the extra runway to account for the few seconds of delay it takes to notice then manually deploy them.

Plus even in this case it wouldn't have saved them, it was too fast too far, plus Im sure there would be some unpleasantness if both engines went full reverse while one landing gear was still not on the ground, thats gonna be some yaw right there :p . Its kinda like saying what if I need to override ABS?

Deploying the spoilers manually would have brought the wheels down and that could have allowed thrust reverser deployment.

Note that it took them 7 seconds between first wheel touching down and first application of the brakes, which they were doing manually. If they had applied spoilers at the same time, they still only had 10 seconds of runway left. I think this still would have been a runway overrun even in that case.

https://www.youtube.com/watch?v=qDCezFdr_Ws