Federal Investigators Reportedly Suspect That Pilot Error Played A Role In The Fatal Amazon Air Cargo Crash

Atlas Air Flight 3591 black box. 

  • The Wall Street Journal reported that the National Transportation Safety Board (NTSB) is suspecting pilot error in the Atlas Air Flight 3591, which crashed on February 23 in Texas, killing all three on board.
  • The plane was carrying US Postal Service and Amazon cargo.
  • Several pilots told Business Insider that the pilot's actions that the NTSB reported happening were unusual.

Inspectors with the National Transportation Safety Board (NTSB) suspect that pilot error — not aircraft malfunctions — led to the deadly Atlas Air crash on February 23, The Wall Street Journal reported on Friday. All three people on board died in the crash.

The NTSB said on March 5 that the Boeing 767-300 cargo jet entered some turbulence shortly before the plane's crash landing. Then, the engines increased to maximum thrust, after which the airplane pitch turned slightly up. That "startled the cockpit crew," The Journal reported, citing several sources familiar with the details. The crew then tried to push the nose of the plane down. At a 49-degree angle, this caused an unusually steep descent, The Journal reported.

The NTSB said the plane accelerated to 495 mph as it dropped. The crew pulled the plane up to a 20-degree angle. Ultimately, in the last 18 seconds of the plane's descent, the crew lost control of the plane, the NTSB said. The plane then nosedived into a muddy bay some 30 miles southeast of Houston George Bush International Airport. An NTSB spokesman told The Associated Press that the agency is still investigating why the plane underwent a sharp change in pitch.

Read more: Pilots likely lost control of the plane carrying Amazon cargo before the crash killed all 3 on board, according to an initial review of the cockpit recording

Pilots told Business Insider that the actions taken during the flight were "perplexing" and not akin to typical flight maneuvers.

"I can't imagine," a pilot and former aviation-safety officer in the US military told Business Insider. "It sounds so off to me — totally counter to my instincts and training. I'd kick the autopilot and auto throttles off pretty darn fast."  "Obviously, going 49 degrees nose down is beyond a radical move," Todd Curtis, a former Boeing safety engineer who runs AirSafe.com, told The Associated Press. "That's not something an airplane should be doing, especially at that altitude." Robert Sumwalt, the NTSB's chairman, predicted it would take more than a year of work to determine the cause of the crash, Flying magazine reported."This seems to be very much a mystery," Sumwalt said, according to the magazine. "But the NTSB has 52 years of experience solving such mysteries, and I'm confident we will get to the bottom of this. "Atlas Air pilots Capt. Ricky Blakely and First Officer Conrad Jules Aska, as well as Mesa Airlines Capt. Sean Archuleta, who was riding in the jump seat, died in the crash.

"Our thoughts and prayers are with all those who have been affected," Bill Flynn, Atlas Air's CEO, said in a statement on February 24. "This is a sad time for all of us. Our team continues to work closely with the NTSB, the FAA and local authorities on the ground in Houston. We would like to commend the efforts of all of the first responders. We sincerely appreciate their efforts and support in the investigation."

Boeing Had Too Much Sway in Vetting Own Jets, FAA Was Told By Peter Robison and Alan Levin , March 17, 2019, 10:31 PM EDT Updated on March 18, 2019, 5:22 AM EDT

  • Company engineers cleared equipment at center of crash probe
  • Shares drop as U.S. agency examines certification of 737 Max

Boeing 737 Max Safety Certification Process Called Into Question

The FAA’s approval of Boeing’s 737 Max range is being investigated, according to the WSJ. Derek Wallbank reports.  FAA employees warned as early as seven years ago that Boeing Co. had too much sway over safety approvals of new aircraft, prompting an investigation by Department of Transportation auditors who confirmed the agency hadn’t done enough to “hold Boeing accountable.” The 2012 investigation also found that discord over Boeing’s treatment had created a “negative work environment” among Federal Aviation Administration employees who approve new and modified aircraft designs, with many of them saying they’d faced retaliation for speaking up. Their concerns pre-dated the 737 Max development. On Sunday night, a person familiar with the 737 Max said the Transportation Department’s Inspector General was examining the plane’s design certification before the second of two deadly crashes of the almost brand-new aircraft. Earlier Sunday, Ethiopia’s transport minister said flight-data recorders show “clear similarities” between the crashes of Ethiopian Airlines Flight 302 on March 10 and Lion Air Flight 610 last October.

Shares of the Chicago-based plane maker fell early Monday after Boeing Chief Executive Officer Dennis Muilenburg and FAA officials were forced to defend the quality of testing of the new aircraft, and the Wall Street Journal reported on a grand jury probe. The stock was trading at $371.99 in pre-market U.S. trading -- down 1.8 percent from Friday, and below any closing price since the Ethiopian Airlines disaster. A Seattle Times investigation found that the U.S. regulator delegated much of the safety assessment to Boeing and that the company in turn delivered an analysis with crucial flaws. Separately, a grand jury in Washington, D.C., issued a broad subpoena dated March 11 to at least one person involved in the development process of the 737 Max jets, the Wall Street Journal reported late Sunday. In recent years, the FAA has shifted more authority over the approval of new aircraft to the manufacturer itself, even allowing Boeing to choose many of the personnel who oversee tests and vouch for safety. Just in the past few months, Congress expanded the outsourcing arrangement even further. “It raises for me the question of whether the agency is properly funded, properly staffed and whether there has been enough independent oversight,” said Jim Hall, who was chairman of the National Transportation Safety Board from 1994 to 2001 and is now an aviation-safety consultant.

Outsourcing Safety

At least a portion of the flight-control software suspected in the 737 Max crashes was certified by one or more Boeing employees who worked in the outsourcing arrangement, according to one person familiar with the work who wasn’t authorized to speak about the matter. The Wall Street Journal first reported the inspector general’s latest inquiry. The watchdog is trying to assess whether the FAA used appropriate design standards and engineering analysis in approving the 737 Max’s anti-stall system, the newspaper said. Both Boeing and the Transportation Department declined to comment about that inquiry. In a statement on Sunday, the agency said its “aircraft certification processes are well established and have consistently produced safe aircraft designs,” adding that the “737 Max certification program followed the FAA’s standard certification process.”

The Ethiopian Airlines plane crashed minutes after it took off from Addis Ababa, killing all 157 people on board. The accident prompted most of the world to ground Boeing’s 737 Max 8 aircraft on safety concerns, coming on the heels of the October crash of a Max 8 operated by Indonesia’s Lion Air that killed 189 people. Much of the attention focused on a flight-control system that can automatically push a plane into a catastrophic nose dive if it malfunctions and pilots don’t react properly. In one of the most detailed descriptions yet of the relationship between Boeing and the FAA during the 737 Max’s certification, the Seattle Times quoted unnamed engineers who said the planemaker had understated the power of the flight-control software in a System Safety Analysis submitted to the FAA. The newspaper said the analysis also failed to account for how the system could reset itself each time a pilot responded -- in essence, gradually ratcheting the horizontal stabilizer into a dive position.

Software Fix

Boeing told the newspaper in a statement that the FAA had reviewed the company’s data and concluded the aircraft “met all certification and regulatory requirements.” The company, which is based in Chicago but designs and builds commercial jets in the Seattle area, said there are “some significant mischaracterizations” in the engineers’ comments. In a separate statement Sunday, Muilenburg reiterated the company’s sympathies for the affected families and support for the investigation into the flight-control system, known as the Maneuvering Characteristics Augmentation System. “While investigators continue to work to establish definitive conclusions, Boeing is finalizing its development of a previously announced software update and pilot training revision that will address the MCAS flight-control law’s behavior in response to erroneous sensor inputs,” Muilenburg said.

The newspaper also quoted unnamed FAA technical experts who said managers prodded them to speed up the certification process as development of the Max was nine months behind that of rival Airbus SE’s A320neo. The FAA has let technical experts at aircraft makers act as its representatives to perform certain tests and approve some parts for decades. The FAA expanded the scope of that program in 2005 to address concerns about adequately keeping pace with its workload. Known as Organization Designation Authorization, or ODA, it let Boeing and other manufacturers choose the employees who approve design work on the agency’s behalf. Previously, the FAA approved each appointment. Under the new approach, which was fully implemented in 2009, the ODA representatives are still under U.S. legal requirements and the FAA has the authority to oversee them and request that their management be changed.

Anonymous Faxes

In 2012, a special investigator of the Office of Inspector General at the Department of Transportation sent a memo to the FAA’s audit chief warning him of concerns voiced by agency employees about the new process. Some allegations were made in anonymous faxes sent to the inspector general’s office, and the office followed up by interviewing employees in the FAA’s Transport Airplane Directorate. “Our investigation substantiated employee allegations that TAD and FAA headquarters managers have not always supported TAD employee efforts to hold Boeing accountable and this has created a negative atmosphere within the TAD,” according to the June 22, 2012, report sent to the FAA. (The memo was made available later in a public records request and appears now on a website operated by

governmentattic.org, which warehouses government documents. A spokesman for the inspector general’s office confirmed its authenticity.) The employees told the investigators that managers had overturned a recommendation by staff to remove the administrator Boeing had chosen for the program and “had not adequately addressed employees’ concerns” about potential conflicts of interest, the memo said. The employees, it said, viewed this as evidence of management having “too close a relationship with Boeing officials.” Despite those concerns, as well as others raised in a subsequent report by the inspector general, Congress has embraced the program as a way to improve the FAA’s efficiency. President Donald Trump signed into law a change on Oct. 5. It allows manufacturers to request that the FAA eliminate limitations on how company representatives certify “low and medium risk” items, giving them even more authority over their own products. The agency doesn’t have the budget to do every test, and “the use of designees is absolutely necessary,” said Steve Wallace, the former head of accident investigations at the FAA. “For the most part, it works extremely well. There is a very high degree of integrity in the system.”

Dreamliner Fires

But the program was also at issue in the FAA’s 2013 grounding of Boeing’s 787 Dreamliner after two fires of battery packs. Boeing’s designated engineering representatives oversaw tests of the battery packs. A 2015 report by the Department of Transportation’s inspector general, requested by U.S. Representative Peter DeFazio, found the FAA lacked “an effective staffing model” and “risk-based oversight process” over the ODA program. DeFazio, an Oregon Democrat, now heads the House transportation and infrastructure committee, and has said he will conduct a “rigorous investigation” to make sure the FAA is protecting safety. Hall, the former NTSB chairman, said the agency’s move to shift power to the manufacturers contributed to the unusual situation in which two of Boeing’s newly introduced aircraft were grounded in a period of six years. Before the Dreamliner, the FAA hadn’t grounded a model since 1979. “When I was chairman of the NTSB, my single most important job was who we hired,” Hall said. “Do we have in the federal government the level of funding and expertise we need? Are we attracting the kind of young, smart minds that continue to uphold our reputation in the aviation area?” As the investigation continues, mourners marched in the hundreds past the Library of Parliament in Addis Ababa to Selassie Cathedral for a funeral service Sunday, wearing black or the sea-green uniforms of Ethiopian Airlines and carrying photos of the dead. After a priest read the victims’ names aloud, people carried empty coffins from the cathedral to a graveyard. All that was heard was sobbing, wailing and chanting. — With assistance by Margaret Newkirk, Nizar Manek, Michael Sasso, and Rita Devlin

Flawed Analysis, Failed Oversight: How Boeing and FAA Certified

The Suspect 737 MAX

Flight Control System.

By Dominic Gates, Seattle Times Aerospace Reporter Originally published March 17, 2019 6:00 am

Federal Aviation Administration managers pushed its engineers to delegate wide responsibility for assessing the safety of the 737 MAX to Boeing itself. But safety engineers familiar with the documents shared details that show the analysis included crucial flaws. As Boeing hustled in 2015 to catch up to Airbus and certify its new 737 MAX, Federal Aviation Administration (FAA) managers pushed the agency’s safety engineers to delegate safety assessments to Boeing itself, and to speedily approve the resulting analysis. But the original safety analysis that Boeing delivered to the FAA for a new flight control system on the MAX — a report used to certify the plane as safe to fly — had several crucial flaws. That flight control system, called MCAS (Maneuvering Characteristics Augmentation System), is now under scrutiny after two crashes of the jet in less than five months resulted in Wednesday’s FAA order to ground the plane.  Current and former engineers directly involved with the evaluations or familiar with the document shared details of Boeing’s “System Safety Analysis” of MCAS, which The Seattle Times confirmed.

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The safety analysis:

  • Understated the power of the new flight control system, which was designed to swivel the horizontal tail to push the nose of the plane down to avert a stall. When the planes later entered service, MCAS was capable of moving the tail more than four times farther than was stated in the initial safety analysis document.
  • Failed to account for how the system could reset itself each time a pilot responded, thereby missing the potential impact of the system repeatedly pushing the airplane’s nose downward.
  • Assessed a failure of the system as one level below “catastrophic.” But even that “hazardous” danger level should have precluded activation of the system based on input from a single sensor — and yet that’s how it was designed.

The people who spoke to The Seattle Times and shared details of the safety analysis all spoke on condition of anonymity to protect their jobs at the FAA and other aviation organizations. Both Boeing and the FAA were informed of the specifics of this story and were asked for responses 11 days ago, before the second crash of a 737 MAX last Sunday. Late Friday, the FAA said it followed its standard certification process on the MAX. Citing a busy week, a spokesman said the agency was “unable to delve into any detailed inquiries.” Boeing responded Saturday with a statement that “the FAA considered the final configuration and operating parameters of MCAS during MAX certification, and concluded that it met all certification and regulatory requirements.” Adding that it is “unable to comment … because of the ongoing investigation” into the crashes, Boeing did not respond directly to the detailed description of the flaws in MCAS certification, beyond saying that “there are some significant mischaracterizations.” Several technical experts inside the FAA said October’s Lion Air crash, where the MCAS has been clearly implicated by investigators in Indonesia, is only the latest indicator that the agency’s delegation of airplane certification has gone too far, and that it’s inappropriate for Boeing employees to have so much authority over safety analyses of Boeing jets.  “We need to make sure the FAA is much more engaged in failure assessments and the assumptions that go into them,” said one FAA safety engineer.

Certifying a new flight control system: Going against a long Boeing tradition of giving the pilot complete control of the aircraft, the MAX’s new MCAS automatic flight control system was designed to act in the background, without pilot input.  It was needed because the MAX’s much larger engines had to be placed farther forward on the wing, changing the airframe’s aerodynamic lift. Designed to activate automatically only in the extreme flight situation of a high-speed stall, this extra kick downward of the nose would make the plane feel the same to a pilot as the older-model 737s.

Boeing engineers authorized to work on behalf of the FAA developed the System Safety Analysis for MCAS, a document which in turn was shared with foreign air-safety regulators in Europe, Canada and  elsewhere in the world. The document, “developed to ensure the safe operation of the 737 MAX,” concluded that the system complied with all applicable FAA regulations. Yet black box data retrieved after the Lion Air crash indicates that a single faulty sensor — a vane on the outside of the fuselage that measures the plane’s “angle of attack,” the angle between the airflow and the wing — triggered MCAS multiple times during the deadly flight, initiating a tug of war as the system repeatedly pushed the nose of the plane down and the pilots wrestled with the controls to pull it back up, before the final crash. On Wednesday, when announcing the grounding of the 737 MAX, the FAA cited similarities in the flight trajectory of the Lion Air flight and the crash of Ethiopian Airlines Flight 302 last Sunday.

Investigators also found the Ethiopian plane’s jackscrew, a part that moves the horizontal tail of the aircraft, and it indicated that the jet’s horizontal tail was in an unusual position — with MCAS as one possible reason for that. Investigators are working to determine if MCAS could be the cause of both crashes. More:


Video :Ethiopian 737-8 Max UPDATE 15 March 2019 - Click Here:


No survivors after Ethiopian Airlines flight to Nairobi crashes shortly after takeoff March 10, 2019, 4:53 AM EDT / Updated March 10, 2019, 9:02 AM EDT By Yuliya Talmazan and Associated Press

The Boeing 737 is believed to have crashed early on Sunday with 149 passengers and eight crew members aboard, the airline said. Ethiopian Airlines plane crashes shortly after takeoff, killing all 157 on board . An Ethiopian Airlines flight carrying 157 people crashed shortly after takeoff Sunday morning from Addis Ababa.

The airline confirmed there were no survivors among what it believed were 149 passengers and eight crew members who were destined for the Kenyan capital Nairobi. Eight Americans were among the dead, the Ethiopian Airlines CEO and Kenya's transport minister said. The airline's CEO expressed his "profound sympathy and condolences to the families and loved ones of passengers and crew who lost their lives in this tragic accident" in a Facebook statement.


A statement by the Ethiopian prime minister's office on Sunday offered its "deepest condolences" to the families of those on board.Kenya's President Uhuru Kenyatta also tweeted that he was saddened by the news of the crash.  "My prayers go to all the families and associates of those on board," Kenyatta said. Authorities earlier said 32 Kenyans and nine Ethiopians were killed. They later confirmed the plane was carrying passengers from more than 30 countries. Those include 18 Canadians; eight each from China, the United States and Italy and seven each from France and Britain. There were no immediate details on what caused the crash of the Boeing 737 Max 8 plane, which was new and had been delivered to the airline in November, but Swedish flight-tracking website flightradar24 said the plane "had unstable vertical speed" after take-off. People look at the scene of the Ethiopian Airlines crash near the town of Bishoftu, southeast of Addis Ababa, on March 10, 2019.Tiksa Negeri / Reuters

Boeing said in a statement that a technical team is prepared to provide assistance to Ethiopian Airlines at the request and under the direction of the U.S. National Transportation Safety Board. "Boeing is deeply saddened to learn of the passing of the passengers and crew on Ethiopian Airlines Flight 302," it said. "We extend our heartfelt sympathies to the families and loved ones of the passengers and crew on board and stand ready to support the Ethiopian Airlines team." The NTSB later said it would send four people to assist in the aftermath of the crash. In October, another Boeing 737 Max 8 plunged into the Java Sea just minutes after taking off from Jakarta, Indonesia's capital, killing all 189 people on board. The Addis Ababa-Nairobi route links East Africa's two largest economic powers and is popular with tourists making their way to safari and other destinations. Sunburned travelers and tour groups crowd the Addis Ababa airport's waiting areas, along with businessmen from China and elsewhere.

At the airport in Nairobi, worried families gathered. "I came to the airport to receive my brother but I have been told there is a problem," Agnes Muilu said. "I just pray that he is safe or he was not on it." Family members of victims react to the news of a plane crash in Addis Ababa, Ethiopia, on March 10, 2019.Mulugeta Ayene / APThe last deadly crash of an Ethiopian Airlines passenger plane was in 2010, when the plane crashed minutes after takeoff from Beirut, killing all 90 people on board. The state-owned airline, widely considered the best-managed airline in Africa, calls itself Africa's largest carrier and has ambitions of becoming the gateway to the continent.Sunday's crash comes as the country's reformist prime minister, Abiy Ahmed, has vowed to open up the airline and other sectors to foreign investment in a major transformation of the state-centered economy. Ethiopian Airlines has been expanding assertively, recently opening a route to Moscow and in January inaugurating a new passenger terminal in Addis Ababa to triple capacity. Speaking at the inauguration, the prime minister challenged the airline to build a new "Airport City" terminal in Bishoftu — where Sunday's crash occurred.


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