A systematic failure.
THE CROSSCHECK
A recent FAA Safety Alert for Operators makes me ask a question. How much care and competence should aircraft designers expect from the pilots who will fly their new designs? SAFO 21006, issued on Oct. 20, 2021, sounds like it is addressing a design problem. It warns pilots of the possibility of inadvertently triggering the go-around mode in Boeing 757s and 767s. Is design really the problem? The chances of the inadvertent triggering of a take-off/go-around (TOGA) switch causing an accident are remote, but it did, in fact, happen. An Atlas Air Boeing 767 freighter mysteriously pitched over and dove into the swamps of Trinity Bay, Texas on Feb. 23, 2019, and it took the NTSB 17 months to figure out why.
The first officer (FO) brushed the TOGA switch on the aft end of the left thrust lever while holding the speed brake lever, and this triggered the chain of events that resulted in the accident.
NTSB
When you eliminate all the most likely causes of such an event, you have to start looking at the unlikely causes.
Two NTSB investigators, experts in operations and human performance, led a small team in a flight simulator study that re-created the accident scenario based on the recorded data. It was then they realized what happened. Incredibly, the pilot in the right seat of the accident airplane did not realize that he himself had triggered the rapid increase in thrust. He misinterpreted the rapid pitch up as a stall, and he then forced the airplane into the fatal dive. The captain didn’t realize what was happening until it was too late. The FO’s background was revealing. He had shown serious training and performance deficiencies at four airlines before arriving at Atlas. At two regional airlines, he never finished initial training, and at two more he failed multiple check rides. One check airman said that when he didn’t know what to do, he became extremely anxious and would start pushing a lot of buttons without thinking about what he was pushing, just to do something. How did a pilot with this lack of emotional self-control get and keep a job as a commercial pilot? I think it was a failure of the pilot hiring, training and checking system. Too often pilots are hired because of a good smile, a firm handshake, a dishonest resume and a shortage of better-qualified candidates. Too often captains and check airmen are reluctant to deliver the bad news to a struggling pilot. As NTSB board member Michael Graham said, “I had the unpleasant job of informing a few pilots their career was over because of a lack of airmanship skills, unsafe acts, poor judgment or a constant lack of situational awareness. Each time it pained me, but it was required to protect the pilot and the operation.” The protection of the system Graham is talking about was the goal of the Airline Safety and Federal Aviation Administration Extension Act of 2010, which was, in turn, an outgrowth of the Colgan 3407 accident. That accident, along with 10 others over 30 years, prompted the need for the highly unpopular Pilot Records Database (PRD) run by the FAA. I understand why so many commercial operators are unhappy about the new hiring and record-keeping requirements of the PRD, but it’s a consequence of too many accidents resulting from too little hiring and training oversight. The “V” shaped recovery from the Covid 19 pandemic has generated a cornucopia of new pilot jobs. With every period of rapid growth in the industry comes the pressure of shortages of experienced pilots, and we are seeing that now. Now, more than ever, airlines, commercial operators, chief pilots, captains and training departments are going to have to scrutinize all pilots and set a high standard of performance. We will keep adding automatic features to aircraft. The question is, will those features be tools to better serve the pilot or a protection against mistakes that a pilot should never make? Are we going to make manufacturers effectively put training wheels on commercial jets and turboprops, or are we going to insist that operators and pilots demonstrate a high level of care and competence in flight operations? I think you know the answer.
—A former military, corporate and airline pilot, Roger Cox was also a senior investigator at the NTSB. He writes about aviation safety issues.
