https://dms.ntsb.gov/public/63000-63499/63168/631156.pdf

What’s the conclusion?

Doesn't look like there is one.

86 pages of nothing

All I got was they were dropping rapidly to 3000 and didn’t stop.

I blame gravity

The NTSB just opened the public docket.  You have to get into the documents and do some reading.  For some reason, the NTSB site is not working well today, but here is the link.

NTSB Docket/documents

The FO should have Never been in the seat.  Multiple training failures over his career.  He failed to disclose employment at two airlines where he had failed training, and lied about his employment history.  Failed upgrade at Mesa, twice.  Lots of remedial training at ATLAS.

Sounds like the TOGA paddles did get pushed accidentally, the FO freaked out, thought he was stalling, and drove it into the ground.

avhearald has some of the relevant stuff posted.  Linky to avhearald page

The relevant part of the CVR transcript:

The cockpit voice recorder group provided a transcipt, the last decisive minute reads (-1 captain, -2 first officer, -3 observer, HOT flight crew audio panel voice or sound source, CAM Cockpit Area Microphone voice or sound source, RDO Radio transmission from the aircraft, APR transmission from Houston Approach):

12:38:02.2 HOT-2 'kay flaps one.
12:38:04.8 CAM [Sound of mechanical click.]
12:38:05.1 HOT-2 thank you.
12:38:06.1 HOT-1 confirm. confirm.
12:38:07.3 HOT-2 execute.
12:38:08.7 HOT-1 LNAVs available.
12:38:09.9 HOT-2 LNAV is...
12:38:14.3 HOT-1 not on intercept heading.
12:38:15.0 HOT-2 no (your on/it's on) a heading right?
12:38:16.7 HOT-1 oh we're supposed to be on heading- yeah.
12:38:17.9 HOT-2 yeah.
12:38:31.1 CAM [Sound of click.]
12:38:35.1 APP Giant thirty-five ninety-one in about another eighteen miles or so we'll cut you due north(bound) for a base leg.
12:38:40.3 CAM [Sound of four beeps within a duration of .75 seconds at a frequency of 1200 Hz.]3
12:38:41.4 RDO-1 sounds good uh Giant thirty-five ninety-one.
12:38:43.6 APP it is severe clear on the other side of this stuff so you'll have no problem gettin' the airport *(either).
12:38:43.6 CAM-2 (oh)
12:38:44.0 CAM [Sound similar to a mechanical click.]
12:38:45.0 CAM-2 woah. [Spoken in elevated voice.]
12:38:45.9 CAM-2 (where's) my speed my speed [Spoken in elevated voice.]
12:38:46.9 CAM [Sound similar to louder mechanical click.]
12:38:47.3 RDO-1 okay.
12:38:47.9 CAM [Sound similar to multiple random thumping noises.]
12:38:48.0 HOT-2 we're stalling. [Spoken in elevated voice.]
12:38:50.5 HOT-2 stall. [Exclaimed.]
12:38:51.9 HOT-? #.
12:38:52.3 HOT-2 oh Lord have mercy myself. [Spoken in elevated voice.]
12:38:53.3 CAM [Sound similar to multiple random thumping noises.]
12:38:53.9 HOT-2 Lord have mercy. [Exclaimed.]
12:38:55.1 HOT-2 @Capt. [Spoken in elevated voice.]
12:38:55.7 HOT-1 what's goin' on?
12:38:56.0 HOT-2 (Lord)– [Spoken in elevated voice.]
12:38:56.3 CAM [Sound of 1000 Hz series of beeps with approximately .25 second spacing begin. Group could not determine if audible sound lasted until end of recording.] 4
12:38:56.4 HOT-2 @Capt. [Spoken in elevated voice.]
12:38:56.6 CAM-3 what's goin' on? [Spoken in an elevated voice.]
12:38:56.8 HOT-? [Sound of rapid breathing.]
12:38:57.4 HOT-2 @Capt-
12:38:58.1 CAM [Sound of quick series of four beeps at 1200 Hz.] 5
12:38:58.9 CAM [Sound of longer duration pulse tone about 1000 Hz, similar to Siren. Group could not determine if audible sounds lasted until end of recording.]
12:38:59.4 CAM-3 * pull up. [Shouted.]
12:39:00.9 HOT-2 [Unintelligible shout.]
12:39:02.0 HOT-? (oh God). [Shouted.]
12:39:02.0 HOT-2 Lord * * you have my soul. [Shouted.]
1239:03.9 END OF TRANSCRIPT END OF RECORDING

Jeeze.  

Damn

Suicide, maybe?

I’ve been combing through the details today. What’s been the common consensus is only being affirmed

Training Incompetency and Failures
6/27/11 - Resigned from CommutAir for failing DHC-8 initial
8/13/12 - Resigned from Air Wisconsin for failing CRJ initial
4/22/14 - Failed EMB-145 Oral at Trans State Airlines
5/11/14 - Failed EMB-145 Type Rating at Trans States Airlines
5/17 - Failed EMB-175 Upgrade Attempt at Mesa Airlines
5/17 - Nearly failed FO Requal after failing upgrade attempt at Mesa Airlines
7/27/17 - Failed B-767 Oral at Atlas Air
8/1/17 - Unsat Judgement/Situational Awareness during DBS-1 at Atlas Air
8/5/17 - Failed DBS-5 at Atlas Air
8/11/17 - Almost Failed FFSI-1 at Atlas Air
8/31/17 - "Regression of Situational Awareness" during FFSI-3 at Atlas Air
9/22/17 - Failed B-767 Type Rating for "Very Low Situational Awareness", incomplete procedures, and exceeding limitations at Atlas Air

Past Training Notes
Air Wisconsin CRJ Initial Failure - "They were conducting the emergency procedure cabin altitude ... where they are at FL350 or so, and he gives the students a cabin altitude message requiring an emergency descent to 10,000 feet" ... "Conrad then goes to descend the simulator. He was not sure of Conrad's background, but instead of descending on the autopilot, Conrad disengaged the autopilot and abruptly pitched down well below horizon. They got stick shaker and overspeed alert together. He was not sure if it was an extreme nose down, but remembered that it was abrupt input on the controls"
Mesa Airlines ERJ-175 Upgrade Failure (Instructor 1) - "He had previously failed simulator lesson 2 with different instructor, and he had requested a different instructor. She was conducting his retraining for lesson 2. She said his performance was a "train wreck" and he performed very poorly in this lesson. In the briefing room he did well, and explained things well. However, in the simulator and something he wasn't expecting happened he got extremely flustered and could not respond appropriately to the situation." ... "When asked about her comment in her notes about Conrad's "lack of understanding of how unsafe he was," she said he was making very frantic mistakes, lots and lots of mistakes, and did a lot of things wrong but did not recognize this was a problem. He thought he was a good pilot never had any problems and thought he should be a captain. he could not evaluate himself and see that he did not have the right stuff."
Mesa Airlines ERJ-175 Upgrade Failure (Instructor 2) - "He first met Conrad Aska during a recurrent checking event in March 2016. That session went ok and nothing stood out. He did have some trouble with the stall series. The problems were with his attitude control, and he had a hard time getting the airplane back to level flight" ... "He said when Conrad would make a mistake in training he had an excuse for everything"

The quote that stands out the most to me in this second Mesa instructor interview is, "When asked if Conrad would get startled in the simulator, he said that during one stall recovery, Conrad pitched down about 40 degrees for recovery, then a pitch up about 20 degrees. His flight path was all over the place."

Wow those are some scary comments from the flight instructors

Wow.

Seems like the FO had no business being in the cockpit. Also interesting to see confirmation that TOGA may have accidentally been engaged. I recall that being suggested in one of the earlier threads. With mixed opinions on whether or not that was a reasonable theory.

Why was this guy still at the controls instead of handing out snacks in the cabin?
It seems like no matter what he was flying, he was an accident looking for a place to happen.  

And why did the captain not do anything?

With all of that failure, was he allowed to fly to meet the quota?

No room for error in a cockpit.

Oh man

This thread was harder to read than I expected coming in

That’s not “error”.  That’s criminal negligence putting him in any cockpit.  The guy had no sense of airmanship.  Sadly, I wonder how many more like him remain in cockpits of US carriers.

I’m not an aviator. But from the transcript, it seems there was only about 20 seconds from the “oh shit, something’s wrong” moment to the end of the transmission. So, I’m guessing he “did nothing” simply because there was no time to do anything once he realized they were in trouble.

The thread on this over at APC is quite revealing as well. According to one poster there may have been multiple attempts to let him (the FO) go at his various places of employment but that they were thwarted by a series of legal threats to sue for discrimination. Could be just hearsay, but take it for what it's worth

The copilot probably should have changed careers years ago. He seems to be a huge factor in this. The pilot should have taken over

Pilots like that are far more common than many people think.

I wonder how he didn't get fired after 5 fails and an "almost fail" in only 2 months at atlas?  However he avoided getting fired this guy seems like a champion shitbag!

I didn't read the details, but I wonder if atlas followed their own policies about dealing with shitbags?

what was the captain's problem

he said nothing on that transcript after what ever happened happened

all the captain said was "what's going on"

WTF?

what were the random thumping noises? Hail?

It seems like this was wx related to me, maybe big hail strikes ( multiple random thumps ) after they lost airspeed indication with 'my speed my speed" from the FO that was flying  Then "stalling"

Captain saying  "whats going on" could be indicative of conflicting speed and altitude information

"stalling" could be because  the pitot tube ices over or taken out by hail and airspeed indication was decreasing and FO thought they were stalling, captain is confused as to what is going on.

My educated guess based on wx and comm is loss of reliable airspeed and hail damage due to thunder storms and loss of control of aircraft due to low SA and incorrect flight control inputs due to thinking airspeed was low

I have actually had loss of a pitot tube and bogus altitude, descent rate and airspeed indications. But quickly cross checked the other 2 sets of instruments and picked the 2 that agreed with each other and called them good and it was a non-issue but was very confusing for about 5 secs until I figured out what was going on, but we also had effective descriptive and directive comm in the cockpit

The comm these guys had sucked

(In my opinion)the lawsuits should bankrupt Atlas.....it was criminal negligence

These types of accidents will become more common as the bottom feeders struggle to find pilots.  Delta, united and Southwest will hire close to 3,000 pilots next year.....lower tier operators will be sucking air.

Sad. I work with someone that was in sim training with him at an airline that let him go. He was a train wreck that was arrogant and abusive to other students, and would bring up race at every turn.

while the FO may have been a train wreck, the captain did not seem to be any better

He appears to have said nothing but "what is going on" and there is no indication of him figuring it out, being directive or taking the aircraft. He lost control of the cockpit.  They did not even talk about what was happening

Their CRM sucked, and their comm
sucked,

Sorry mach, maybe I'm out of my element here but you seem to believe problems outside the cockpit rather than inside were the cause of this mishap.

I think the random thumping noises were shit in the cockpit hitting the ceiling from the egregious nose dive.

I also wonder what was going on in the Capt's mind, but I doubt we will ever know.  Probably heads down performing some other task.

Poor jump seater.  Sounds like he recognized what was going on, albeit way too late and without any chance to be able to do anything productive to save the aircraft.

Those are good points could very well be.

In my scenario I certainly think there were problems in the cockpit also

This is from the FDR specialists report.

The aircraft descended and reached 10,000 ft at about 12:36:35 CST. Immediately before reaching 10,000 ft the captain’s radio mic was keyed, consistent with speaking on the radio, and the autopilot lateral mode changed from LNAV to Heading Select at 12:36:27. About 30 seconds later, the autopilot vertical mode was changed from VNAV to Flight Level Changeand the MCP altitude selection was changed from 7,000 ft to 3,000 ft in this time3.

After  the  autopilot  mode  change,  the  speedbrake  handle was  extended  and  the  rate  of  descent  increased.  For  the  next  minute,  the  aircraft  descended  steadily  and  flaps  wereselected from up to position 1 at 12:38:04. The autoflight go around modes were armed at the time the flaps began to move into position.

At about 12:38:26 at an altitude of about 6,500 ft, triaxial acceleration magnitudes increased, consistent with the aircraft entering light to moderate turbulence. At 12:38:31 the autoflight system entered go around mode, the engines began advancing to go around thrust setting, the control column, which had been neutral, moved slightly aft and elevator deflected up, the aircraft pitch began to increase, and altitude stopped descending and began to climb. At 12:38:37   the   speedbrake   handle   was   retracted and   the   engines   approached   their   commanded go around power settings.

At 12:38:40 a Master Caution was recorded along with Autopilot Caution. The control column was had  moved  to  be  deflected forward  at  the  time,  pitch  was  decreasing,  and  airspeed  began  to  accelerate  rapidly  from  240  knots.  Autoflight  systems  remained  in  Go  Around  modes  and  the  aircraft  continued  a  shallow  climb  for  a  short  time  before  entering  a  rapid  descent. Control column remained deflected forward for the next 10 seconds.At 12:38:46 the throttles were brought to idle for about 2 seconds then readvanced to the previous power setting. At this point the aircraft pitch was rapidly decreasing and vertical g became negative for nearly 11 seconds. At 12:38:47 a split between left and right elevators was noted ranging between 2 to 7 degrees split until 12:38:57. The aircraft Overspeed and Master  Warning  alerts  were recorded  at  12:38:55 with  airspeed  increasing  beyond  350  knots.

At 12:38:57, altitude crossed through 3,000 ft and the autothrottle switched out of go around mode  and  engine  TRA  began  to  decrease.  12:38:58 with  altitude  at  about  2,000  ft,  the control column moved to the aft stop until the end of the recording. Aircraft pitch was about 50  degrees  nose  down.  Vertical acceleration  went  from  0 g  to  4.2  g  and  pitch  increased  rapidly  until  its  final  recorded  position  of  16  degrees  nose  down  at  12:39:03.  The  final recorded airspeed was 433.5 kts.

It honestly sounds like they crashed a perfectly good aircraft for reasons I still cant figure out.

holy shit

and none if that was talked about at all

so I was wrong about the possible scenario but right about their CRM and comm sucked, worse that I thought

https://www.forbes.com/sites/jeremybogaisky/2019/12/19/pilot-of-doomed-amazon-air-flight-had-poor-training-record-seemed-confused-before-crash-ntsb-report-suggests/

Even worse.

This conflicts what what I thought was stalling it into the ground. Can someone explain what they mean by the split in elevators? Does each side have separate controls or are they referring to commanded pitch by each seat?

The elevators would have split because of the two control yokes being pushed in opposite directions.

Clearly they were in moderate and possibly even severe turbulence (1.7G of acceleration) and the aircraft was upset. No initiation of proper stall recovery in a timley fashion, coupled with the engagement of go around mode compounding the problem, and not enough altitude to recover all combined for the loss of an airframe.

In many cases, where its only a "cargo" flight, that crashes into the water and does not kill anyone on the ground, lawsuits are not brought against the carrier.

Beyond the piloting errors/failures, this portion was particularly mind boggling...

“After the 2009 Colgan Air crash, Congress required the Federal Aviation Administration to set up a clearinghouse including FAA and employer records on pilots to aid carriers in vetting them, but it has yet to complete the process.”

So the FO lied about/omitted portions of his work history. Presumably, because he knew he wouldn’t get a job if his poor performance and failures were known. That’s egregious enough.

But what’s more ridiculous is that the FAA set out to stop pilots from hiding their histories; and couldn’t manage to get the program working after 10 fucking years!

Oh, and in spite of the FO having no business being in the cockpit, his brother is suing Atlas .

Jesus what a tragedy. I really feel for the jumpseater.

Why in the fuck would any company out there hire someone that couldn't make it through upgrade.

What a shit show.

Yep. And the greatest tragedy was hiring this worthless POS.
Attached File

Either that, or the company lacking the intestinal fortitude to fire the jack hole once he repeatedly proved himself incompetent. Apparently, the race card is powerful thing. Seems he was more interested in studying the Bible than studying for his profession. I hope HR departments across this nation take note of this blunder and make every effort to not repeat it.

I was impressed by what United did for his family.

How do you, as an aviator, not self-evaluate and remove yourself from the problem?

Reading that CVR transcript I can’t shake the suicide angle.

In this case of  what appears to be negligence on behalf of the carrier.....I bet they will be several lawsuits, and rightfully so.

I hope the lawsuit is painful enough that they fear that more than a incompetent pilot discrimination lawsuit.

It was an interesting choice of words by the FO at the end...wasn’t it?

Terrifying, absolutely terrifying.

Initially, I’d thought the same. Considered they may have even “translated” what was said in the report. But, from the obit it appears he was a Christian. Still could be suicide. But likely rules out the snackbar angle.

Yes it is, but it might have been the last words of an incompetent pilot, who happens to have been a
believer in that few moments of resignation knowing nothing can be done prior to impact to save himself
from the mess he had created.

He was from the Caribbean I believe.  There's a chance the phrases he was using is just his country's form of "ah shit" or "what the fuck".

My point exactly. We all use the language slightly differently, huge difference between what is transcribed here and allah akbuar screams in other intentional crashes.

The most incompetent pilots in my experience have no clue as to their inability.