Amazon Air MIA Runway Excursion

[GypsyPilot]

Oh. I think your right. The guy on the radio had an accent so he would have been the PM. My bad. I wonder what the Capts past experience was in.

 

[BEEF SUPREME]

I read that Air21 went from 8 pilots to over 100 in an extremely short time.

 

[///AMG]

As a hip pocket reference, when on the ground with weight on wheels, one of our USAF Training Command IPs noted that with normal moderate braking on a variety of jets he flew both small and large, they on average lost about 20 lnots per 1000’. Thus, if you took the distance remaining board on the runway, and doubled it, you’d get a rough speed average reference for whether you’ll be able to stop or not. 6000 feet remaining / 6 board, multiple by two to get 12, add the zero, and 120 knots should be able to come to a complete stop from there with constant moderate braking. For a jet like the F-117 that had no flaps, no slats, no spoilers, and no speedbrakes, and relied fully on its drag chute; when that drag chute didn’t work and you had to get on the brakes and that’s all you had, a hip pocket easy formula like this would be handy to determine whether to begin braking, or cob the power in and accelerate for lift off again.

Not that it is entirely relevant since we don't have TR's or even good brakes, but maybe as a general sanity check as you mention. But the ROT you mention is exactly what we have always used in the F/A-18. 120 at the 6, 100 at the 5, 80 at the 4, and generally considered to be under control if at 60 by the 3 board. Braking as needed to intercept one of these checkpoints, and then generally moderate braking will get you the rest of the way. If you aren't 60 by the 3, its time for a G/A. Obviously once the buckets are out on transport cat airplanes, the G/A option disappears, unlike in our case in fighters.

Also holy f**** s****** that reads like a nightmare of passive PM and grossly incompetent PF. I don't care how tired you might be. Sounds like a continuous mandatory G/A starting at least by 500' (and my shop's standards), and probably as early as 1000'. Whatever the hell they thought they were doing once they actually crossed the threshold is like every no-no, crammed into one. High and fast, not configured by any reasonable altitude, still high and fast, second-guessing a G/A, not using any drag/stopping devices other than brakes. What an absolute ********show

 

[GypsyPilot]

Regarding fatigue and go arounds, I had a great sim instructor a few years ago (on the 767). When it came to the go around, he said click the go around switch and just sit on your hands until 3,000 ft.

The jet climbs out just fine with zero pilot input. The emphasis was that go arounds are not a hair on fire exercise, even if you’re brain dead from fatigue.

 

[Cherokee_Cruiser]

Regarding fatigue and go arounds, I had a great sim instructor a few years ago (on the 767). When it came to the go around, he said click the go around switch and just sit on your hands until 3,000 ft.

The jet climbs out just fine with zero pilot input. The emphasis was that go arounds are not a hair on fire exercise, even if you’re brain dead from fatigue.

Wasn’t a go around trigger what started the crash sequence of the other Amazon 767 crash?

Sometimes pilots just suck and muck up bad.

 

[phill1174]

I read that Air21 went from 8 pilots to over 100 in an extremely short time.

Yep when they got the Amazon contract. Idk what the experience level was since every other reputable company was hiring like gang busters at that time also.

 

[phill1174]

DCA26MA352.aspx

www.ntsb.gov

Approximate Time to End of CVR Recording (mm:ss)	Observation
06:02	A pilot called for flaps to be set to 1 degree.
04:18	The flight crew checked in with Miami tower and were cleared to land on runway 30.
02:53	A pilot called for flaps to be set to 5 degrees.
02:37	The flight crew lowered the landing gear.
02:14	A pilot called for flaps to be set to 15 degrees.
01:42	A pilot called for flaps to be set to 20 degrees, and the other pilot cautioned they were too fast. The other pilot made additional comments regarding the aircraft’s excessive speed throughout the remainder of the recording. There was not a consistent verbal response to the comments about speed.
01:23	Sounds consistent with autopilot disconnect.
01:12	Electronic “one thousand” callout.
01:04	Electronic “sink rate sink rate” callout.
00:58	Electronic “five hundred” callout.
00:57	Electronic “sink rate sink rate” callout.
00:54	Electronic “one hundred” callout.
00:50	Electronic “minimums” callout.
00:48	Electronic “too low terrain” callout. Annunciated four times.
00:41	A pilot called for flaps to be set to 30 degrees.
00:40	Electronic “forty” callout.
00:39	Electronic “too low terrain” callout.
00:36	Electronic “ten” callout.
00:31	Sounds similar to the aircraft touching down.
00:15	A pilot called for a go-around.
00:10	Sounds similar to the aircraft departing the paved surface.
00:00	The CVR recording ended.

A summary of select events captured on the FDR during the final few minutes of the FDR recording is provided below. All times are referenced relative to the end of the FDR recording. Note that the CVR and FDR times have not been precisely synchronized. The times and descriptions are preliminary and subject to change.

Approximate Time to End of FDR Recording (mm:ss)	Observation
00:30	The nose and right main gear touched down at a groundspeed of 158 knots.
00:23	The brakes were applied at a groundspeed of 146 knots.
00:19	The left main gear touched down at a groundspeed of 134 knots.
00:15	Brakes were released at a groundspeed of 120 knots and throttles were increased to a value consistent with go-around thrust.
00:11	The throttles were reduced to idle power and the brakes were re-applied. The groundspeed was 117 knots. The throttles remained at idle, and brakes remained applied until the end of the recording.
00:07	Recorded lateral, longitudinal, and vertical acceleration values changed markedly; the FDR data indicated a groundspeed of 96 knots.
00:00	The FDR recording ended. The final recorded groundspeed was 65 knots. There was no indication in the recorded data that speed brakes or thrust reversers were deployed.

Images are available on NTSB's Flickr

Yikes
Although 5 died it might be a saving grace they didn’t get a chance to go around. If the approach was that bad the go around might’ve left a smoking hole NW of the airport. They’re lucky this happened in the U.S. Depending on the country they’d be sitting in a jail cell.

 

[tcco94]

Are you sure? Flaps 30 speed is 170 on all of my airline's 767-300s. It is 162 on the 757-200 though so maybe you're thinking of that?

Yeah had that one gumped up, thank you for correcting me. Tried to delete that

 

[DE727UPS]

Regarding fatigue and go arounds, I had a great sim instructor a few years ago (on the 767). When it came to the go around, he said click the go around switch and just sit on your hands until 3,000 ft.

The jet climbs out just fine with zero pilot input. The emphasis was that go arounds are not a hair on fire exercise, even if you’re brain dead from fatigue.

That's true. It's a wonderful thing to watch. But when it doesn't do what you want for some reason, you need to be ready to push the thrust up and fly the airplane while possibly ignoring the FD.

 

[scooter2525]

Brand new Capt. New to the plane. New to the company. Wonder if he was thinking "man, is that how it is here? and didn't take command cause he was the new guy. I'll say UPS preached the "No fault go around" and the stabilized approach criteria. Standards that should be preached.

No pride
No pressure
No jeopardy
No hesitation
No fault

 

[jtrain609]

Yikes
Although 5 died it might be a saving grace they didn’t get a chance to go around. If the approach was that bad the go around might’ve left a smoking hole NW of the airport. They’re lucky this happened in the U.S. Depending on the country they’d be sitting in a jail cell.

This might be one of the rare situations in the United States where these guys could end up being criminally charged.

If there aren't mitigating circumstances, this is one of the most collosal • ups I've ever read about.

 

[rockman2343@aol.com]

Is it 7 dead now? Yikes

Maybe it was 5 and two critical. That might be how I got 7.

 

[GypsyPilot]

That's true. It's a wonderful thing to watch. But when it doesn't do what you want for some reason, you need to be ready to push the thrust up and fly the airplane while possibly ignoring the FD.

Absolutely, and that is part of the training and Go Around calls/check at Purple. But the point was to show that Go Arounds really shouldn’t be a big deal.

 

[luke3]

This might be one of the rare situations in the United States where these guys could end up being criminally charged.

If there aren't mitigating circumstances, this is one of the most collosal • ups I've ever read about.

As much as I agree that this was garbage tier flying and absolutely avoidable, I hope they don't get charged and the courts stay out of it.

I come from a country where a criminal investigation starts up together with the technical accident investigation as soon as there's an incident. Although Italy seems to be one of the worst offenders, many other European countries follow a similar playbook. They WILL find someone to place the blame on, and most of the time that person is the Captain. I've seen lives and careers ruined from small SOP deviations that got translated into negligence charges and even jail time. Then you wonder why everyone flies like robots there. I know this case is so egregious that as professionals we cannot stand to see innocent lives ended by such disregard for airmanship, but I don't want the camel's nose under the tent because it only gets much worse for everyone after that with very few benefits. I'll say based on Italian accident history many people got screwed by the courts and only a couple of outcome could be considered "justice" throughout my lifetime. I don't like those odds.

 

[Pilot Fighter]

Are there 767’s that don’t have auto-land capability? Would AP have laughed at the crew if they tried to select out of the envelope, too high and too fast? Anybody know the constraints of the system?

Is this a case where captain was reliant on automation and was incapable of hand-flying an approach and landing?

So many questions.

 

[jtrain609]

As much as I agree that this was garbage tier flying and absolutely avoidable, I hope they don't get charged and the courts stay out of it.

I come from a country where a criminal investigation starts up together with the technical accident investigation as soon as there's an incident. Although Italy seems to be one of the worst offenders, many other European countries follow a similar playbook. They WILL find someone to place the blame on, and most of the time that person is the Captain. I've seen lives and careers ruined from small SOP deviations that got translated into negligence charges and even jail time. Then you wonder why everyone flies like robots there. I know this case is so egregious that as professionals we cannot stand to see innocent lives ended by such disregard for airmanship, but I don't want the camel's nose under the tent because it only gets much worse for everyone after that with very few benefits. I'll say based on Italian accident history many people got screwed by the courts and only a couple of outcome could be considered "justice" throughout my lifetime. I don't like those odds.

I don't disagree with you. I think it's inappropriate in almost all cases to criminally prosecute pilots. It does not lead to better and safer outcomes, and it certainly doesn't support a just safety culture. Additionally, pilots don't normally survive when they make mistakes this large.

However.

This is, without question in my mind, wanton disregard that has resulted in involuntary manslaughter. The Florida statute states, in applicable part:

782.07 Manslaughter; aggravated manslaughter of an elderly person or disabled adult; aggravated manslaughter of a child; aggravated manslaughter of an officer, a firefighter, an emergency medical technician, or a paramedic.

(1) The killing of a human being by the act, procurement, or culpable negligence of another, without lawful justification according to the provisions of chapter 776 and in cases in which such killing shall not be excusable homicide or murder, according to the provisions of this chapter, is manslaughter, a felony of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.

Culpable negligence is explained as:

Specifically, culpable negligence is conduct that so grossly and recklessly disregards the safety of others that it is as though he or she had intentionally caused the injuries at issue.

https://www.thefowlerlawgroup.com/blog/2015/august/criminal-liability-for-culpable-negligence-in-fl/

The conduct of this crew was outrageous.

As always, we'll need to wait for the NTSB final to know all the details, but this looks egregious.

 

[BlueMoon]

Are there 767’s that don’t have auto-land capability? Would AP have laughed at the crew if they tried to select out of the envelope, too high and too fast? Anybody know the constraints of the system?

Is this a case where captain was reliant on automation and was incapable of hand-flying an approach and landing?

So many questions.

have to be on Localizer and GS for it to engage at a minimum. Pilot controls the airspeed through the mcp and configuration , so it isn’t going to save a bad approach

Also anutolands are pretty rote in my experience. Fly loc and gs, pull power at x height, raise pitch attitude X amount. Decrab at X altitude, Wait for wow and then derotate at a standard rate. They can range from smooth to bangers.

In 11 years of flying airplanes with auto land I have seen it used 5 times. 3 were tests and 2 were actually needed.

 

[Pilot Fighter]

have to be on Localizer and GS for it to engage at a minimum. Pilot controls the airspeed through the mcp and configuration , so it isn’t going to save an bad approach

Also anutolands are pretty rote in my experience. Fly loc and gs, pull power at x height, raise pitch attitude X amount. Decrab at X altitude, Wait for wow and then derotate at a standard rate. They can range from smooth to bangers.

Thanks. Just wondering how somebody capable of this cluster• could survive a thousand hours. Was thinking he was hooked on AL and clueless without it.

 

[sweeps]

Optimized for what class of aircraft?

MAX 11

 

[Soul Brotha']

Any 76/75 drivers answer this for me. Is there not an aural warning if the correct flap setting is not set in the approach config. On LeBus we get a “Too low flaps”
I still can’t fathom how/why they added flaps damn near in the flare.