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

ntsb.gov

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

#131

Earlier quoted context omitted.

> unclear how speed didn't increase How can you comment as if you are knowledgeable enough about aviation to speak on this with authority, but you aren't aware that turbofan engines don't have instant throttle response and need time (up to 8 seconds) to spool up? I think a little more restraint is warranted in something like this if you don't know something that basic. You can actually do the math to work backwards a…

> How can you comment as if you are knowledgeable enough about aviation to speak on this with authority, but you aren't aware that ... This is par for the course for HN; smart people applying first-principle thinking on unfamiliar domains for about a minute, which confirms the biases of other outsiders who vote the plausible, but not-quite-right comments to the top.

This sounds about right to me, so I upvoted.

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

#132

So many mistakes. A notable part is this: >> CVR: 00:15 A pilot called for a go-around. >> FDR: 00:15 Brakes were released at a groundspeed of 120 knots and throttles were increased to a value consistent with go-around thrust. >> FDR: 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 o…

> While they were still late in calling a go-around (they should have done it before being anywhere close to touching down due to their unstable approach) Barring a massive tailwind, they had enough groundspeed to go around at touchdown (158 kts). I think we'll find throttling to G-A and then aborting the G-A caused the crash. If they'd committed to landing they at least wouldn't have overshot with that much energy.…

> I think we'll find throttling to G-A and then aborting the G-A caused the crash.

Not even a chance.

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

#133

Earlier quoted context omitted.

> unclear how speed didn't increase How can you comment as if you are knowledgeable enough about aviation to speak on this with authority, but you aren't aware that turbofan engines don't have instant throttle response and need time (up to 8 seconds) to spool up? I think a little more restraint is warranted in something like this if you don't know something that basic. You can actually do the math to work backwards a…

> How can you comment as if you are knowledgeable enough about aviation to speak on this with authority, but you aren't aware that ... This is par for the course for HN; smart people applying first-principle thinking on unfamiliar domains for about a minute, which confirms the biases of other outsiders who vote the plausible, but not-quite-right comments to the top.

HN is particularly notorious for armchair aviation experts. I am an aerospace engineer having worked in airworthiness & certification as well as maintenance/repair/overhaul on multiple different aircraft types both fixed and rotary. I mention this only to establish my bona fides as someone who knows their shit:

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

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

#134
post #89

So many mistakes. A notable part is this: >> CVR: 00:15 A pilot called for a go-around. >> FDR: 00:15 Brakes were released at a groundspeed of 120 knots and throttles were increased to a value consistent with go-around thrust. >> FDR: 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 o…

The go-around decision was far too late. Remember the engines need significant time to spool up. The decision to cancel the go-around was correct (conditional on the preceding series of terrible decisions).

They were over takeoff velocity at that point and could have bounced up in the air and waited for the thrust to come. Would have been sketchy but better than what did happen.

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

#136

A few observations to add context (partially stolen from PPRuNe): - Pilot Flying (PF) was the Captain, 55 yo (presumably) more experienced pilot, who only got certified to fly that type (B767) in May - Pilot Monitoring (PM) was a 38 yo first officer, also not very experienced on B767 - PF made a number of mistakes, going too high, too fast (partially because he was descending too fast), not catching the glidescope on…

This is the spitting image of old pre-CRM thinking:

If I try to force the captain to go around, (or follow procedures or whatever), then i am exceeding my authority and will probably be fired. Some cultures have this sort of mentality a lot stronger than others, and it has zero place in the modern cockpit.

While a captain can pull rank, they really should only ever do it with respect to the first officer if: an inexperienced first officer is trying to insist on something dangerous or forbidden by law or policy, or if the captain fully understands an FO's concerns, is fully accounting for them, and as the person ultimately responsible for safety, has determined from experience and training that the current action is safer than alternatives, and would explain but cannot explain right now for workload/emergency status reasons.

That's it, the only two reasons.

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

#137

Earlier quoted context omitted.

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

Notably, none of those allegations from the fired former chief(!) pilot actively suing the company while appealing his rejected OSHA case touch on in-flight procedures. If any of those are true, it will be very bad for the carrier, but they are not related to any of the failures being reported on.

> ...but they are not related to any of the failures being reported on.

If pilots weren't being given enough rest time, as alleged, you don't believe that might affect decision-making in the cockpit?

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

#138

Earlier quoted context omitted.

I think the real question is why didn't the pilots do a go around. I bet there are underlying pressures from the airlines and/or amazon to not do a go around to avoid schedule delays or fuel costs.

This is based on my understanding from several pilots who have weighted in. The cockpit voice recorder transcript has the copilot repeatedly saying "we're coming in too fast" but the pilot never clearly acknolwedges. The copilot ought to have been more assertive and said "We need to go around. NOW." The pilot shouldn't have needed that. He should have made the call himself, but even if he was unsure, once his copilot…

> Neither of them will ever fly again

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.

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

#139
post #18

Earlier quoted context omitted.

Private pilot here. No, I'm quite sure very few of you here would have made the same mistake as evidenced by the fact that literally hundreds of thousands of aircraft land successfully every day, many of them under much more adverse conditions. This is not a oh-it-could-have-happened-to-anyone kind of screwup, this is a did-this-guy-really-go-through-basic-pilot-training kind of screwup.

I’m not a manned pilot, but have my part 107 and have spent a few thousand hours flying combat flight sims - ~150kts in a cargo aircraft, four seconds from departing the runway, seems like the worst possible time to abort a touch-and-go. Then consider the numerous automated audio warnings and the copilot suggesting a go-around, and it seems pretty ridiculous to me. Don’t get me wrong - if I had to land that plane, I’…

They could have “aborted” at almost any time prior to when they did. And even that may have been fine if they had stuck with it.

A decent rule of thumb in aviation (and life…) is that you’re allowed to change your mind once. Waffling kills more people than switching to a bad decision does.

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

#140

The NTSB confirmed that while the pilot applied the physical wheel brakes, the Flight Data Recorder (FDR) showed zero evidence that the speed brakes/spoilers ever extended. They also overshot the runway; I think those were the key mistakes that caused the accident. https://www.wisn.com/article/amazon-cargo-plane-black-box-mi...

No, the left main was not on the ground after touchdown for some time. The aircraft will not auto-deploy the spoilers nor autobrake until it senses weight on weels. It also locks out the thrust reversers. All for obvious reasons. The left wing was lifting because they came in way too fast. 30-40 knots above final approach speed. That's why they landed so flat - if they had assumed correct flare AoA the airplane would…

Seeing a 767 wheelbarrow down a runway is so surreal. Brings back fond memories of scaring CFIs in a 172.
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