Author Topic: NTSB Opens Pubic Docket on the Crash of Atlas (Amazon) 3591 (CVR Transcript)  (Read 1477 times)

Offline joeyb747

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The CVR Transcript paints a picture of confusion on the cockpit of the 767, and apparent spatial disorientation. Obviously, this is early in the investigation, and is by no means the final report on what caused the crash.

The F/O seemed to have an issue with his ADI/HSI, and handed control to the Captain. Once the situation seemed to be corrected, control was handed back the the F/O.

From the AvHerald article:

"According to recorded data, the FO then commented in the cockpit that he experienced a potential failure of his attitude director indicator/horizontal situation indicator (ADI/HSI) display information, and then made a comment about using the Electronic Flight Information (EFI) switch. This was followed by the Captain commenting on potentially getting the displays back.

At 1837:18Z, the controller instructed the GTI3591 to turn to a 270 heading, and the response to ATC was made by the Captain confirming the turn to heading 270 when the airplane was about 40 miles from IAH and descending through 8,500 feet. Shortly afterwards, according to recorded data, the Captain transferred controls of the airplane back to the FO, who became the PF and the Captain became the PM again. The crew then began setting up the approach into the airplane’s Flight Management Computer (FMC)."

While in cloud cover, the aircraft encountered turbulence. The G/A switch had been activated (accidentally?). There is no mention of initiating a go-around, or abandoning the approach, by either pilot on the CVR. Shortly after that, the F/O thought the aircraft was stalling, and pushed the nose down. The aircraft reached a nose-down angle of a terrifying -49 degrees and a speed of 433.5 knots was recorded by the FDR. Also, according to the FDR data, the Captain was pulling on his yoke, while the F/O was pushing on his. The F/O pulled his yoke back once the airplane broke out of the clouds at about 3,500 ft.

From the AvHerald article:

"The descent appears normal until about 1238:31 and approximately 6,300 ft pressure altitude when the go-around mode was activated using one of the Go-around (G/A) buttons on the throttle quadrant: see Figure 4. There was no mention of initiating a go-around by the flight crew on the cockpit voice recorder (CVR), and flight 3591 had been cleared to descend to 3,000 ft. (The normal load factor, an, in Figure 6 shows that the airplane encountered turbulence at approximately 1238:25, six seconds before the recorded flight mode transitioned to G/A. The turbulence was likely associated with the cold front mentioned earlier and included instrument meteorological conditions or IMC.)

The airplane pitch attitude increased from about -1˚ airplane-nose-down (AND) before G/A was annunciated to approximately 4˚ airplane-nose-up (ANU) six seconds later at 1238:37. The airplane then pitched AND to about -49˚ over the next 18 seconds in response to an AND elevator input.

At 1238:48 and 1238:51, the pilot flying (the first officer in the right seat) made comments about the airplane stalling that were recorded on the CVR. However, Figure 6 shows the recorded airplane wing angle-of-attack and airspeed were below -15˚ and above 250 kt, respectively. This is well below the airplane’s wing stall angle-of-attack.

Figure 7 shows an elevator split between the left and right sides of the airplane: the left elevator is associated with the captain in the left seat, and the right elevator is associated with the first officer in the right seat. The elevator deflections are similar until about 1238:46. At that time, the first officer is heard asking a question about airspeed on the CVR, and the elevators begin to split: the captain begins to pull from 2˚ to 8˚ more ANU elevator than the first officer. The split continues until about 1238:56, about one second after the airplane would have broken out of the reported 3,500 ft cloud layer. Both the captain and the first officer subsequently commanded ANU elevator until impact. (The normal load factor recorded by the FDR in Figure 6 is greater than 4g right before impact.)"

Here's 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.]


See also this article, which indicates a troubled training record: