NTSB issues investigative update on B-767 runway excursion accident in Miami
ntsb.gov
ntsb.gov
- 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 time
- PM was concerned that the approach/descent was abnormal but kept his mouth shut as the more experienced captain was at the controls (Edit: apparently he did speak up but PF did not acknowledge)
- PM lowered the flaps much later than required (PF orders flaps lowered and PM executes, but flaps can only be lowered when aircraft goes below certain speed) and the flaps were lowered all the way as the plane crossed the runway threshold, which likely caused plane to "float" and overshoot even further
- Plane touched down too late, and left wheel even later, which likely precluded some braking mechanisms from activating (or the PF forgot to since was busy trying to put the thing down)
- PM finally said "too fast, go around" but PF ignored him (or likely did not hear)
- In these situations PM has the right (and obligation) to take over the controls and start go around by themselves, but he didn't, presumably because the Cap was driving
- PF finally panicked and started the go around procedure, bit realized it was too late almost as the front wheel exited the runway, idled the engines and reapplied the brakes.
So, yeah...
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.
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.
Four words said by the pilot monitoring that any pilot flying will understand and react automatically to.
PM finally said "too fast, go around" but PF ignored him (or likely did not hear)Still, the PM notified PF that they were going too fast many times during the approach. All warnings were ignored.
The reason I ask is, case in point, do you think the PM is going to be penalized in some way?
Also, you'll see that says "Crew" not just "Cockpit". Turns out that from the cockpit of an airliner you've not always got the best possible view of the problem. If the steward who has no idea how to fly a plane insists it's the right engine that is on fire, her input is valuable, from back where she's serving customers with coffee she can see the engines, the fire is on the right, whereas you're just looking at sensor outputs and you were maybe about to turn off the left engine.
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.
I'm pretty sure it's FAA policy, but not 100% on that.
But importantly, the first officer had almost a year more experience in the 767, which sets the stage for an almost textbook imbalance: having to speak up to someone senior to you, someone older and with more overall experience, but less direct experience in the airplane they are flying
Other comments talk about The Rehearsal Season 2, which is spot on. The FAA of course had dismissed the idea that there needed to be any special focus on training pilots to speak up, saying it's already under the umbrella of CRM (crew resource management)
This was exactly what season 2 of The Rehearsal was all about. It also had one of the most jaw-dropping IRL plot twists in its last episode. I highly recommend it.
It was really, really, really sloppy approach. And all could have been corrected just by executing go-around literally at any point in time up to 10 sec before he did. Both pilots still would have their careers, and those 5 people would still be alive.
(not an aviation expert, just summarizing various bits and pieces I gathered from various YouTubers over the last days)
As a passenger I had my first go around a few days ago, but we were 5km away from the runway.
The clouds had been very thick for awhile. The plane was making those weird low-and-slow vibes that it makes on final approach.
We popped out of the clouds and there was a highway with cars! A huge parking lot! (An airport, too? Certainly, but I didn't really see a runway or any runway-adjacent stuff.) To my inexpert eyes, we just looked to be impossibly low for our location.
The folks in the cockpit apparently didn't like what they saw with their eyes, either. In an instant, the engines roared as they simultaneously pointed the thing upwards. My little pea brain was very impressed by the immediacy of the forces on my body as we disappeared back into the clouds after what was at most just several seconds of visibility.
Anyway, it was very clear that there was no hesitation to the go-around. However that decision was reached, it was then simply executed.
The next attempt went very smoothly about ten minutes later.
(The go-around can be seen here, if anyone wants to have a look at some pretty lines and maps from ADS-B: https://planefinder.net/data/flight/NK630/history/5-48596475 )
When either pilot calls for a go-around, both are supposed to drop literally everything else, execute the go-around without delay or hesitation, and then pause to analyze the situation once ATC gives them a heading and altitude or holding pattern to regroup.
The only thing lost in a go-around is fuel and time. Any sane airline will never punish a call to go-around if done so in good faith.
Yes, it does. I can't speak universally but I would generally expect it to be a written rule, if not then at least it's the expectation.
If this had happened and the captain had fought over the controls and still caused an accident, we’d be having a very different conversation. The FO would be lauded as a hero who fought to save the lives of those on the ground.
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.
Making the assumption the PM could have taken control cleanly if the power dynamic was so poor that they weren't able to demand a go-around seems iffy, typical stabilised approach gates are 500ft in VMC, with an aircraft travelling 3nm a minute, 40 seconds before touchdown.
But as I said, the human factors involved will be a huge focus of the accident investigation.
If anything, it would have been yet one more opportunity to avert catastrophe and perform a go-around. Pilots are trained for this, and it makes less than zero sense for a PM to fail to take the controls from a PF who is flying unsafely over some imagined fear of a battle for control while the plane jostles around hurtling toward the ground. The PM is obligated to do this by every written regulation.
If you have never actually been behind the controls of an aircraft, please just stop trying to confidently assert things about this subject.
If this site had a slogan, I think you just guessed it
That's a lot of assumptions.
> Having pilots fighting over the controls is not a situation anyone wants
Nor crashing and killing 5 people.
This pairing, considering past incidents with similar airframe vs. total hours disparity, really does look to be bad practice. You've got to acknowledge the human psychology. Part of it is probably the crazy pipeline over the past few years where people are racing to 1500 hours no matter how they log them, or they're getting on restricted certs with lower hours.
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.
That is not the reason this incident happened. This happened because the pilots continued to put it on the ground while ignoring at least a dozen clear and unambiguous indicators to abort the approach and go around.
Wow, The Rehearsal season 2 flashbacks. Although the show was mostly pure absurdity, the central claim of crisis in cockpit communications / lack of adequate FAA mandated training around interpersonal dynamics was spot on.
Generally, that's under the 'crew resource management' umbrella.
https://m.youtube.com/watch?v=bIFdbd6dmKg&t=275s (4min 35sec)
Anyway, this is the opening scene of Season 2 and it feels eerily spot on https://www.youtube.com/watch?v=UDu0b6nxMjY
I am a pilot; and although I don’t fly large transport category aircraft, this sort of procedural discipline makes all the difference no matter what you fly.
Given the level of negligence on display here I would not be remotely surprised if charges were filed against both pilots.
When you try to land with too much energy the airplane refuses. When you get within a wingspan or two of the ground then ground effect starts giving you more and more lift. That plus excess speed means the airplane simply will not come down.
To force it down you lower the nose but that can end up castering on the nose wheel, starting a PIO event (pilot-induced oscillation), or as in this case the left wing just refused to stop flying. The "quartering tailwind" is a red herring. The jet was well within its tailwind limits - most of the wind was crosswind at that point and the tailwind contribution wasn't anywhere near enough to explain what happened. When you get above glide slope things get worse as you now need to lose altitude but that increases your speed. Even if you get the speed under control if you come at the runway with a 1700-2500fpm descent rate inertia can slam you into the runway.
They were coming in with way too much speed. They leveled off and got above glide slope because they were trying to bleed off enough speed to get within flap speed - flaps give you more drag which they desperately needed.
I made the transition this year into a much higher performance airplane and even going from a Cessna 172 to an A36 TN Bonanza the difference is stark. You must be way further ahead of the airplane in the Bonanza or you will find yourself screaming into the airport at 170kts when your landing speed is more like 80kts. And discover you are above flap and gear extension speed with all power taken out - thus without a good way to slow down.
Transport category jets are that times 100. You absolutely cannot get behind the aircraft. You plan your descents. You begin them much earlier. You pull power earlier. You add drag before speed runs away.
Above all else when you're barreling in 40kts above landing speed you call a go-around and try it again. It is way too late to fix it.
This accident started 30 minutes before they touched the tarmac. A complete failure of planning, of execution, and of ADM (to admit the problem and go-around).
You fly an approach on airspeed and/or angle of attack, and on glideslope. Period. You're either there or you're correcting to get there, and you're correcting at a point that you don't need huge oh-my-God corrections in close. If you can't do that, sucks to be you, take your waveoff like a real man or woman, and next time suck less.
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.
But the cause of a need to go around can be pilot error. There could be non-pilot error needs for a go around like when there is a runway incursion so the pilot is waved off. If a pilot makes a bad approach, would that not be pilot error? Not being a pilot, I'm not sure of the procedure. I'm assuming a 767 uses autopilot for the majority of the flight. I just have no insight on whether the pilot or the autopilot is responsible for the approach.
The industry does not treat a go around like an error. You'll only ever get questions when you don't go around while procedures clearly require it, like what seems to have happened in this case.
On autopilot use: The pilot is always responsible for the approach. You can definitely have an unstable approach on autopilot if you configure it wrong or ask it to do things that can't be done within the stable approach criteria. A common example is trying to slow down and descend at the same time, most jets can't really do that.
But "responsible" does not necessarily mean to blame in aviation. The industry as a whole follows the Just Culture principles (see: https://www.caa.co.uk/general-aviation/general-aviation-at-t... ) The purpose of a report is to learn from it and improve safety, not to blame the crew.
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).
If there is a company willing to bend rules to increase profits, I'd bet it'd be Amazon's retail side. Not via explicit punishment, because that'd be too easy to catch, but bonuses for timely arrivals, fuel efficiency, and so on.
Claiming that this company is making Aviation unsafe is a serious accusation, that requires evidence.
The incentive is to pick the lowest bid and that could be a company whose culture creates indirect pressure on pilots to be on time. All it takes is a dispatcher in a small company that is constantly irritated when things are late. Knowing that the other people are going to be angry with you for being late can make you hesitant to go around, causing exactly this type of accident.
Is this what happened? Probably not. Pilots get tunnel vision for any number of reasons.
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.
Instead they waited until they were about to go off the end with idle engines to try it - the one time it was too late to go around.
The further in advance you cut power, descend, and get your airspeed set, you’ll find you have plenty of time to go over your checklists, mentally rehearse, and get configured. By the time you’re touching down, the plane wants to be on the ground.
If you’re coming in high and fast, you have significantly abbreviated time. And you’re constantly fighting airspeed and altitude. If both are high, trying to lose one just increases the other. It’s a losing battle and one you’re fighting on an accelerated and accelerating time frame.
The interaction here is eerily similar to the pilot interactions preceding the 1997 Korean Air Flight 801 (B747) disaster in Guam [1]. It's not clear based on the NTSB update if the Captain was ignoring the First Officer or the other way around.
[1]: https://en.wikisource.org/wiki/Korean_Air_Flight_801_-_Aircr...
I don't know anything about flying. Is this normal? Doesn't sound like it, but I don't know why the pilots would not have used these things that sound useful.
Every single thing they could do wrong at, they did.
There are just too many ways to screw up for that ever to be the case.
For instance, they could also have been lined up to land on something other than the runway they were cleared to land on -- see Air Canada Flight 759, https://en.wikipedia.org/wiki/Air_Canada_Flight_759, which came within 14 feet of colliding with an aircraft on the taxiway they mistook for the runway..
Similarly, it isn't specified anywhere, but it took TEN FULL SECONDS of contact with the runway between first wheel down and last wheel down. Why didn't spoilers deploy and bring down the third wheel way faster than that? Do spoilers require all three wheels already down? Why, this is exactly what they are for!
There was also 7 seconds between first wheel touchdown and first application of brakes. That would seem to mean they were confused and autobrakes didn't function, but then the third wheel comes down, which should have let autobrakes and thrust reversers deploy, yet the aircraft only lost 14 knots in the 4 seconds between that event and the throttles being moved to go around. That is consistent with only the existing braking effort, which expended a similar speed in the previous 4 seconds. Brake performance may have been reduced by a slick runway maybe.
15 full seconds between first wheel touchdown and an actual decision to go around being executed. 3000 feet is a rather significant portion of any runway.
Really that's all that needs to be said at the moment. They had way too much energy[1], which anyone with flight sim or RC experience will recognize as a routine mistake when hand-flying.
The question is why all (all!) the layers of checklists and warnings and process and ATC direction somehow failed in combination to prevent. Yeah, they should have aborted for sure, but they didn't, and we won't know why for a good while yet.
[1] Which can just as easily mean "too high" as "too fast", c.f. the sink rate warnings in the logs which would be consistent with trying to squeeze the airplane down onto the runway. But again we won't know without more data.
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.
Ah, literally the worst thing you can ever do, the in-between. Either go or stop, never do the indecisive middle route. If in doubt, default to stopping, though in this case of course the default is to go-around.
Although... it's probably going to end up the case, as is usual, that were they truly committed to landing and started braking hard right away, they would have ended up fine enough. Indecisiveness kills.
I recently learned that you wash/soak the salt off before consuming it. So, are you talking pre or post wash? ;)
Here's a neat video of an accurate reproduction, including a taste test after sitting "in a ship hold" for 7 months! https://www.youtube.com/watch?v=2tWQpJ8kR5U
https://www.reddit.com/r/aviation/comments/1w9jsrb/put_toget...
I'm not a pilot but from my understanding there's a lot of failsafes to ensure things that slow the plane down only trigger when the plane is actually on the ground. Considering that the left gear touched down at 0:19 and pilot called for TOGA at 0:15 they didn't stand a chance.
The pilot flying appears to have been dead set on landing on the first try no matter the cost and the first officer did not intervene as he should have.
They got incredibly lucky and both survived, however likely will never be behind the controls ever again.
Not deploying thrust reversers is normal, not all situations require them. But brakes are terrible when the wings are still flying, so spoilers (if armed as they should) automatically deploy when all wheel sensors report the aircraft is on the ground, so that there will be more weight on the wheels and the brakes can work properly.
If the culture allows for it, yes.
On final my instructor was talking about the next approach. I heard the words 'go around' and immediately executed one. He realized that (1) that conversation was unnecessary at that phase of the flight and (2) to not use those words unless he wants me to immediately go around :)
After soloing, I sometimes report that I had to go around because I didn't like how the approach or landing was looking like. I got praised for it every time.
So yes, it's all culture.
A supportive culture encourages you to declare early at the first sign you feel something isn't right.
The fact you're struggling to decide means it should be declared but you feel some negative force if ends up not as serious as you think.
A supportive culture will work with you and if necessary down grade the priority if it can wait until a regular release cycle.
It's the same rot that set into Telstra https://news.ycombinator.com/item?id=49534127
Greg Feith covered this well on one of the Mayday episodes, he put an American Airlines' manager on the stand during the NTSB investigation.
What were the company rules for pilots flying near thunderstorms?
When asked the question, he basically responded that he just didn't want his pilots flying into that type of weather. Our pilots are forbidden to enter or depart a terminal area blanketed by thunderstorms.
Well, that's a very subjective call for a pilot. Pilots need boundaries. You have to set limits.
If there's convective activity, that is thunderstorm activity, that's within five nautical miles of the airport, there's lightning, there's wind shear... don't go there.
Production incidents are comparatively trivial, irrelevant issues.
>> 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 of the recording.
So they decided to go-around (i.e. do not land and climb immediately, going full thrust), then 4 seconds later changed their mind and went back to power idle and brakes (unclear how speed didn't increase).
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), guessing those 4 seconds contributed to the disaster by a lot.
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 and approximate how much thrust the engines were producing during that time, which was about 15,000 lbf (vs ~120,000 lbf max thrust for a 767-300er) which reduced how quickly they were decelerating by... Maybe a few % or so. But they didn't start accelerating yet. They would have in another second or two, however.
I'll agree that they should have gone around far earlier; getting non-spurious GPWS callouts on final because you're trying to dive and find the glideslope is... Crazy, and configuring landing flaps over the numbers is also crazy, and so is landing 10-20kts faster than the highest possible Vref value for the type, and everything else. But that's fairly obvious...
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.
The comments here during the 737 MAX MCAS thing were fucking wild. So many randoms spitting out confidently incorrect nonsense.
Maybe that helps explain some of the fraction of HN that loves LLMs: they found their soulmates.
The trim motors only have 2 speeds - on and off.
It actually causes me stress because a) I need to prevent myself from posting corrections and b) from knowing that these people are everywhere and are posting fud about trains or something
Coined by Michael Crichton (the famous author).
So you,me and OP will likely miss a lot of nuance when discussing jets - after all, reality has a lot of detail. Stating the existence of blindspots is not condescension, having blindspots does not make one inferior.
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.
I'm curious - are commercial pilots reprimanded for doing a go-round after messing up the approach?
However I will say that the majority of unstable approaches (97%!!) do continue to landing: https://flightsafety.org/wp-content/uploads/2017/03/Go-aroun...
...but I think that most of these unstable approaches are likely marginally unstable and only in one dimension. This landing was so far outside the realm of normal it's actually mind boggling that it actually happened. Pilots are trained to immediately go around without questioning it if many of the things that happened on this flight occur (such as not being in landing configuration well before touching down!)
I'm a pilot, and I don't fly turbofans/jets. Not claiming any "authority", but qualified to comment... It's not "something that basic" unless you fly in that category, there's a lot more to aviation experience than knowing a fact about an engine you don't use. (But hey, congrats to you that you know it!)
> I think a little more restraint is warranted in something like this..
More restraint than saying "unclear <i.e. to me> why ...", an exact statement about what I didn't know, which harms no one and led to several informative explanations by people who know (most of them in good spirit)?
This is what good conversation is about.
...
Anyway, the point I was making holds and is this:
Orthogonal to whether they could/should have gone around at that point, and given that they stayed on the ground after all, it may turn out that that 4 seconds of indecision (instead of pure deceleration) may have directly contributed to the fatalities at the end of the crash.
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. If they'd decided to G-A even at 00:15, they may have been well within margin to take back off.
Should have had a better approach; should have gone around before they even touched the ground; conditional on the bad approach and first touch, they should have gone around after the initial touch 50% down the runway. But they made the wrong choices at all of those points.
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.
Well also, at what time point did all the tires finally make simultaneous firm contact with the ground? Ie were they going slow enough for braking performance to even matter?
Not even a chance.
Large high-bypass turbofan engines take several seconds to spool up from idle (as they would be on landing) to full thrust. The 4 seconds that the thrust levers spent in the full thrust position in this accident was not long enough.
Sadly if they had made the call earlier they were going so fast they were basically at rotation speed when they touched down so could have just pulled back and gotten into the air.
They landed flat (and the left wing refused to come down) because they tried to force the plane onto the runway. That just doesn't work. The wings are creating too much lift when you're that fast.
Disclosure: Pilot but not ATP or Jet rated.
If so, it’s tight… but i feel like they should have made it if they had stuck to that plan. They commanded full power 15 seconds before the crash, and were pretty close to (if not slightly above) their stall speed (depends on load). I suspect they just needed another 10-20 knots and enough energy to climb.
- 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.
And the other pilot is another Amazon driver riding shotgun as required by law.
“As required by law” is a synonym for “as bad as is still legal.”
YMMV though, I'm not an ATP.
Airplanes don't pay any attention to excuses. The only way to fly is do it perfectly, every time.
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.
They aborted the go-around attempt because they were literally at the end of the runway; Probably because they thought it would be "safer" to run off the end without the engines rapidly reaching full thrust.
How sure are you? Could it actually happen that way 95% of the time, which means they don’t crash and we never hear about it? Likely a pilot gets disciplined for the other errors and nobody else cares? This exact thing could happen 20 times with everything turning up relatively ok and we only heard about it because they didn’t make that final call correctly either.
To be clear I’m not an aviator, just an armchair statistician with an interest in aviation
This concept is called normalization of deviance and is the cause of a lot of accidents in aviation and other fields.
What the outcome of the discussion was that it depends on the culture and training of the organisation. It could be possible that it does happen like this 95% of the time with no crash in that specific organisation.
Prime Air crash: 10+ mandatory go-around triggers were ignored [video] - https://news.ycombinator.com/item?id=49650689 - September 2026
I would not be referencing him as a good source.
Airlines in the US do not pressure pilots to avoid go arounds. Pilots in the US do not delegate life or death decisions to ops, especially since the FAA legally holds them accountable for that. All pilots are aware that they are responsible for the decision to go around or not.
Any airline found to be pressuring pilots to avoid go arounds would be in a world of pain with the FAA.
On cargo flights in particular timing and fuel usage are less critical than passenger flights, and a go around doesn't affect either much.
Pressure to avoid go arounds would also be incredibly counter productive since go arounds exist to preserve life and property. Pilots do go arounds to avoid costly incidents.
You are correct that the question is why they didn't do a go around, but I would bet a large sum of money that airline pressure to avoid go arounds was not a factor.
> 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."
Since the lavatory is not on the Minimum Equipment List, it would cost 30 minutes of paperwork to update the maintenance log and declare it inoperative.
Depends on how much of a psychopath the person doing the cost-benefit analysis is I suppose.
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.
If pilots weren't being given enough rest time, as alleged, you don't believe that might affect decision-making in the cockpit?
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.
Sure there have been plenty of incidents. Can you point to one in the US, with pilots flying big planes, that hasn't led to regulatory change?
Its worth pointing out that pilots are almost always paid by flight hour. In other words, they get paid more to go around.
That one did lead to major regulatory changes. It wasn't in the US though but there was an American plane involved (which was not to blame)
Note: Both planes were American. One of the carriers was not. NTSB gets involved whenever it is a US carrier OR manufacturer, so they have a ton more data than just US carrier incidents.
Has timeliness based performance reviews ever been reported at any US carrier in the past half century?
Similar to farmers working in the fields - they didn't walk all the way back to the farmhouse if they had to pee.
That I've heard, with the insane pace of work that Amazon tries to force 'em to maintain, 3,600,000 milliseconds per hour, the job would be very little better if they somehow had 5-star resort bathrooms folded into hyperspace inside their trucks.
Take a look at Southwest's safety record. I believe they have 1 fatality due to an air incident in their history due to an uncontained engine failure that was not related to maintenance.
Also this was Amazon, not Southwest.
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 called that he should have done the right thing.
Neither of them will ever fly again. The only question now is if either of them will go to prison. There's already a civil wrongful death lawsuit against them.
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.
The thing that amazes me about this is the timeline here:
00:30 The nose and right main gear touched down at a groundspeed of 158 knots.
...
00:19 The left main gear touched down at a groundspeed of 134 knots.
00:15 A pilot called for a go-around.
11 seconds and 24 knots after the nose touched down and then the left main finally also touched down? Wow. Then 4 seconds after all that the go-around. It is one thing to hold the nose off for that long, but a main mount?!
When you take resource consumption out of the equation, you are more free to make lower-risk decisions.
From the reporting and commenting on this incident, that is not the impression I'm getting. This wasn't one bad call after getting half way down the runway, this was a continuous stream of bad decision making for the entire approach, with the copilot suggesting the pilot go around too.
Also: this kind of incident is very rare, so obviously, the vast majority of pilots don't make this mistake.
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.
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.
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?
When aircraft got significantly faster, heavier, and larger with the advent of jet airliners, it became less of a noise issue and more of a safety issue. You can tell people to put up with noise, you can't tell them to put up with a huge airplane falling out of the sky onto their homes.
Anyway, Mentour Pilot has a 2.5 minute short coverage, and the long form one is indeed something to look forward to.
From the timeline, one pilot knew they were too fast 90 seconds before touchdown.
Not their first fuck up rodeo.
What I don't understand from his analysis though was early on he said the tail wind increased a minute before landing which is too quick to have communicated. If that's true, we need to get better about this. A minute to send a message is ages. It should be automatic between the airport and the aircraft.
https://www.wisn.com/article/amazon-cargo-plane-black-box-mi...
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 have flown away from the runway.
This is the definition of trying to "horse it onto the runway".
Disclosure: Pilot on small GA aircraft but not ATP and not jet rated so YMMV. FWIW small airplanes are the same: if you're too fast they don't want to land. Bad things happen when you try to force them.
While I agree the obvious course of action would be a go-around, a manual override for when you know doing the stupid thing is the least unsafe thing to do would be handy.
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?
ABS does not ensure the shortest possible braking distance. It ensures you have steering control and your wheels don’t lock up.
If you are on a dry road on a hot day, you might get a shorter braking distance by disabling ABS and slamming the brakes hard.
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.
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.