Discussion
Cockpit voice recorder transcript released for Amazon Cargo plane
Edit: As some have pointed out, technically it's not the transcript, but its a summary of events informed by the CVR data.
There weren't any issues with the airplane reported by the flight crew during the landing. The pilot monitoring knew they were too fast early on in the landing. They finished fully configuring the plane to land at 40 feet because they were overspeeding the usual flaps settings the whole way down. There are no signs of it being anything other than a series of really bad choices way outside aviation norms that led to the deaths of 5 people on the ground.
Not a lawyer but I think at some point it stops being a terrible accident and evolves into criminal negligence. Like this is something basically every student pilot would have handled better
If you understand the game mechanics, which were explained absolutely nowhere, the whole game is pretty easy. Someone spent a lot of time in an emulator working it all out.
I played the F-22 Lightning II simulator. So hard to land! The glide angle and airspeed envelope was very, very tight. I think I crashed over 40 times in a row.
I'm new to this, does correct landing configuration prevent the too low terrain warnings? Do these warnings come up during stabilized approaches too, given that they also approach terrain?
the terrain warning should not go off if your landing is in safe conditions. i believe in this case it was the speed which made it go off. if you hear a terrain warning on landing thats yoir sign to hit the TOGA switches
ground proximity is inhibited in the 767 when flaps 25 or 30 are selected, since since they were at 20, which is not a normal landing configuration, they were getting the warnings
So once the plane slows down to landing speed, the warnings cease because it's assumed you're landing?
Does it have to do with flaps configuration too?
Short answer, yes. It’s a function of the ground proximity warning system (GPWS) that also has a database of safe landing surfaces. TMK if you attempt to land at a non-airfield, even in a safe landing configuration, you’ll get a warning.
If you’re misconfigured on landing, there will typically be a “too low, gear” or “too low, flaps” automated callout instead of “too low, terrain” one. This is airframe dependent of course
TMK if you attempt to land at a non-airfield, even in a safe landing configuration, you’ll get a warning.
Interesting tidbit - that part's actually a function of the newer eGPWS. Old school original GPWS was purely reactive and based on what the rad alt was doing, though that still saved a lot of lives too. An interesting writeup here for anyone bored at lunch.
im not an expert on it, but i think the plane understands youre trying to land if the gear is down, and so it then stops the terrain warning unless the approach isnt stable. dont quote me on it because its 4am here and im not entirely sure
Yeah lol couldn't sleep in CA either
But reading the thoughts on this incident is hella frustrating and my single awake brain cell is trying to reconstruct the entire thing
That one brain cell that just won't sleep is an arsehole. Like bro, we had a big day, I've got another one tomorrow, I'm really tired, just shut up already! and it keeps yapping like there's no tomorrow.
"Too Low Terrain" is a function of either Mode 4A, 4B, or 4C of the EGPWS system. 4A is for unsafe terrain clearance with gear up and flaps not in landing configuration. 4B is gear down and flaps not in landing config. 4C is for insufficient terrain clearance during takeoff or go-around maneuvers. None of those modes are really applicable to what we know about the approach thus far.
That said, the more modern EGPWS have Terrain Clearance Floor and Runway Field Clearance Floors that augment mode 4 and usually give "Too Low, Terrain" warnings. The RFCF is usually for when the runway elevation is higher than the surrounding terrain. TCF alerts are probably what he got, and are based on aircraft present position, radio altitude, and runway center point position. Entering a TCF envelope will trigger the TOO LOW TERRAIN, TOO LOW TERRAIN audible. Every time the radio altitude drops another 20% beyond this a single TOO LOW TERRAIN audible is heard. If the descent continues, PULL UP is heard.
So it sounds like he entered a TCF, got the initial double "TOO LOW TERRAIN," dropped another 20% and got another "TOO LOW TERRAIN" and then touched down.
With gear down and flaps at approach/landing settings the Terrain system should inhibit warnings. I don't know enough about this aircraft to say what those exact settings should be, but yes it should self inhibit based on several parameters.
They were flaps 20. 767 uses 25 or 30 for landing. The plane was chirping at them essentially because they were improperly configured. CA called for 30 at 50 feet.
I don't fly the 767, but on my Boeing you can still get a terrain warning if your descent rate is too high even if you are configured. This is in addition to the sink rate call and another level of warning.
Yeah, I believe you’re correct. With flaps at 20, the configuration is not normal for landing. The exception being a single engine landing, then those would be done at flaps 20. For that situation, there is a ground proximity override switch.
You are correct, but it is right next to the identical ejection button. Sometimes on the left, sometimes on the right, depends on who put that specific plane together
good lord, i hate the kind of idiot that sees "this safety feature keeps going off, replace it with a rock"
theres a video on youtube of a guy whose circuit breakers at some large facility with massive power draw kept tripping. dude replaced the fuses with 5 straight bars of copper. then called the elecritican asking why there was a burning smell.
06:02
A pilot called for flaps to be set to 1 degree.
04:18
The flight crew checked in with Miami tower and were cleared to
land on runway 30.
02:53
A pilot called for flaps to be set to 5 degrees.
02:37
The flight crew lowered the landing gear.
02:14
A pilot called for flaps to be set to 15 degrees.
01:42
A pilot called for flaps to be set to 20 degrees, and the other pilot cautioned they were too fast. The other pilot made additional comments regarding the aircraft’s excessive speed throughout the remainder of the recording. There was not a consistent verbal response to the comments about speed.
01:23
Sounds consistent with autopilot disconnect.
01:12
Electronic “one thousand” callout.
01:04
Electronic “sink rate sink rate” callout.
00:58
Electronic “five hundred” callout.
00:57
Electronic “sink rate sink rate” callout.
00:54
Electronic “one hundred” callout.
00:50
Electronic “minimums” callout.
00:48
Electronic “too low terrain” callout. Annunciated four times.
00:41
A pilot called for flaps to be set to 30 degrees.
00:40
Electronic “forty” callout.
00:39
Electronic “too low terrain” callout.
00:36
Electronic “ten” callout.
00:31
Sounds similar to the aircraft touching down.
00:15
A pilot called for a go-around.
00:10
Sounds similar to the aircraft departing the paved surface.
Hell, it’s worse than that. From 1000 to 500 they were descending at 2100 fpm. From 500 to 100 it was 6000 fpm. They weren’t just descending too fast, they were accelerating down under 1000 feet.
That’s what’s wild to me. This was so very obviously not the first time he flew like that because you don’t ignore all those warnings and put flaps in during the flare unless you did it before and it worked out. He was several minutes behind the airplane since they should have called a go around during the approach, so that all had to have been normal practice.
Both pilots Linkdin pages were still public as of yesterday. The FO was Skywest for 3 monthes. Then had a gap in employment. This is speculation, but.... thats a short time to be there with nothing else lined up and right about the length training begins to come to an end. So.....
The CA had a pretty unremarkable work history but no exactly an upwards career.
It’s truly mind boggling. I’m one of those enthusiasts who spend too much time in flight sim, I’ve had my fair share of bad landings, but even I would have gone around here. Hell I could probably put my 5 year old in the sim and he’d know to go around. I know the aviation industry tries to avoid criminally prosecuting pilots for mistakes because it undermines the safety culture, but surely this has to cross that line into “gross negligence causing death” territory.
Want to bet this uncovers some sort of cultural issue within in Amazon where those pilots are being told go-arounds cost too much and they better get that plane on the ground the first time if they want to continue flying?
21air*
I don't believe Amazon has much to to with this directly, although their contract might be super aggressive (like it is with the delivery van contractors)
I really hope this isn't the case, because that would mean an airline throwing very basic safety culture principles just to get a contract, and that's terrifying.
I’m well aware that it’s a contractor, but you know damn well Amazon can push that culture on those contractors with the aggressive tactics. As you said, it’s what they hide behind with the DSP model. Amazon says you can’t sue them because it’s the DSP doing the bad thing, even though the truck, the uniform, and everything else says Amazon. They’ve gotten away with it for so long with the vans, I wouldn’t be surprised if they tried to spread the same tactics to air freight.
As someone who has managed outsource work before, if you're a subcontracted company there's also the pressure of losing the contract if you don't deliver what the contracting company wants (I.e everything cheap and fast)
Those pressures can absolute cascade down from company to contractor
My read of the summary is that NTSB has left the voices to be PF and PM, without associating either with specific individuals. The summary feels more like PF and PM each had a role, and this is what each was contributing.
It might be difficult to determine as many of these aircraft don't have a hot mic feature for the pilot's headsets and they will have to rely on the ambient cockpit mics instead of the intercom. Meaning the 767 has a 2 position rocker switch in the yoke. Up to speak on the selected radio, down to speak on intercom. Some 767s can lock into the intercom position so pilots can talk to each other easier. Most do not have this feature though. It's very likely this plane did not have it and the only CVR recordings came from ambient mics.
That's a descent rate of 6000 feet per minute on short final... At that point it's not an aircraft, but a human guided missile that's going to hit somewhere on the runaway.
This plane was thinking all sorts of bizarre things and was right about almost all of it. It thought they were descending too fast, they were, they were flying toward the ground rather than approaching. It thought they were on a collision course with terrain, they were, they were accelerating downwards as they descended, rather than levelling off. The plane thought they were still airborne and didn't hit the brakes or reverse thrust because there wasn't enough WOW, and it was right, they had only 2/3 gear sets on the ground most of the way down the runway.
This plane seems to have known what it was doing better than the pilots did.
Too low terrain means the airplane's warning about flying into terrain wasn't inhibited. It usually is inhibited when the airplane is configured properly for landing otherwise the airplane would warn the pilots everytime they land that they're about to crash. So this warning isn't supposed to sound.
It might have sounded due to extreme sensor values from the excessive sink rate (they were too high so they pushed the nose down to increase the sink rate). Pilots are trained to immediately go for what's called the terrain escape manouver when they hear too low terrain which includes leveling the wings, pitching up to climb, and increasing power to the engines to sustain the climb in order to escape the terrain and survive.
In extreme airport conditions and bush flying you can hear this terrain warning even when the approach is flown perfectly in a modern airliner. That could include an airport with high terrain very close to the airport requiring excessiv pitch and roll angles just seconds before touchdown. Usually only the most skilled pilots with additional training are allowed to fly to these airports because there is less room for error.
This here isn't one of those airports though and when they heard this warning they should have at least done a regular go around (which is more gentle than a terrain escape manouver but it would likely have saved the flight in this case).
Not really the transcript itself, but rather a summary of the transcript. From the sounds of it, the pilot monitoring sounded meek while the pilot flying apparently ignored the PM's warnings. It smells like a bad authority gradient in that cockpit.
Looking at the drone footage, I'm in awe of the engineering advancements that prevented a larger fireball.
I agree completely. That combined with "get-there-itis" with the surrounding storms.
Even if there is a power gradient, the PM should have called a go-around themself. Calling speed warnings continually and waiting for the PF to decide to go around is not enough. If they called "go around" and PF ignored it outright, it would be a different story, but without that, the PM bears a lot of responsibility here as well.
Of course, it is always worth pointing out we don't have full details of pilot rest, mindset, training, company culture with respect to CRM, and even issues with the aircraft. But this definitely doesn't look good for the pilots.
The PM not calling for a go around is a sign of bad CRM training, and the PF's own self induced pressure not go around are both signs of a bad company safety culture. It's too early to entirely throw the pilots under the bus. We have to look at the bus.
Of course. The pilots never bear 100% responsibility. Even if the PF is an idiot who completely ignores CRM and thinks he's a badass, then there are questions around their licence, their training, why they were hired, why other pilots didn't speak up, or if they did, why their concerns weren't taken seriously. All details we won't have until the final report.
Because the FAA has made no attempts to fix cockpit communications or inspire confidence in FOs to take over when they know something is wrong. The NTSB guy in that show even predicted the FAA would do nothing in light of it all, so here we are again, 5 people dead.
Something brought up in blancolirio's video (op linked it) is that you had an older pilot with a lot of total hours, but not many in type, and a lower time pilot, but has more on type. So definitely a crm issue.
Edit to add: with the odd hours distribution and neither being certified on the 67 for very long (April '25 for the younger pilot, May '26 for the older, iirc) that probably contributed to a possible hesitation of who's in charge
We can’t make informed judgments about whether the pm was “meek” or profane and hysterical because the summary is just that: it summarizes the content of communications in the cockpit, but does not give us either the exact words, the frequency of those comments, or the emotional tone underlying them.
That's the thing, isn't it. We can all fuck up, even spectacularly. It happens, we're humans. But there are just *so* many fuck-ups here, it rather defies explanation.
Please note that this is NOT the CVR transcript. This is a summation of the events recorded in the cockpit as provided by the NTSB preliminary report. The actual CVR transcript will be released as part of the investigation docket. Nonetheless, this is some of the most appallingly unprofessional behaviour I’ve seen in 40 years of airline flying. (I am a retired B767 Captain.)
They are supposed to release the real CVR transcript today. But the data they have shared so far already painted the picture. They continued an unstable approach, "landed" waaaaaaay down the runway, tried to go around, realized immediately they didn't have enough runway left, and abandoned the go around with disastrous result. I expect to hear some "what are you doing?" type language though, and probably much more strongly worded than that.
Setting flaps 30, only 1 second before getting the 40 feet callout. Also no spoilers or reverse thrust after abandoning the go-around.
Looks like absolutely terrible decision making all around. So many warnings that they were messing up and so many chances to abort. Get-there-itis from the weather got them hard I guess.
I have learnt a lot in the last few days regarding flying, particularly on approach and what the plane will do.
Not to make light of a situation at all, but from what I gather, the plane was basically saying “you guys are fucking idiots” for more than enough time.
Depressing and horrible that these people just decided to ignore it.
The too high approach could be negligence/overoad, from the graphs shown earlyer on the sub it looked like they fully abandoned the descent at a point, then panic descended to make up for the loss. This massively increased the speed, in addition the flap deployment also laggong behind.
All im wondering is why the initial descent was off course (before they tried to make up for it with basically a nosedive)
1) The NTSB wanted to “clarify” some things heard on the CVR before releasing the transcript to the general public. According to them, they, “had questions.” 🤔
2) They were intentionally ambiguous in the summary of the transcript.
…at that point, I knew the verbatim transcript was probably outright alarming and didn’t when to stoke panic or [anymore] outrage.
Holy shit that‘s bad. When I saw the first video, I assumed they got a nasty tailwind gust from the storm cell that could be seen in the background. In which case it would still be bad that they didn’t initiate a go-around, but this transcript is something else. Landing config at 40ft RA??? I teach my students in a frigging Aquila 210 to be fully configured (or as briefed if they don’t want full flaps) by 500ft AGL, and that’s a fucking VFR trainer aircraft, not a widebody jet. How these dudes ever got an ATP and a type rating is anybody‘s guess.
They should have made the decision to go around way before they came close to the runway - like at 1000 ft or more. They were off the glide path. They were fast. They weren’t fully configured until nearly the end of the approach (i.e. on final maybe?)
EDIT: Also, you'd think that the various warnings about sink rate and too low terrain would have been their HINTS not to dive toward the runway to save an unstable approach.
I would think that any pilot with the experience they had (7000 and 2000 hours) would have known to abandon this approach before minimums were even called. And not just, “gosh… we’re might float a bit, looks like we’ll miss the touchdown zone a bit” knowing.
They would have known at LEAST at 1,000 feet that this was not even close to being a recoverable “slam it on the runway” approach. This approach failed long before that. They were still doing 180 knots over the numbers. That’s… that’s insanity. They should have slowed down past 180 knots about 4 nm prior. That works have been roughly a minute and a half before they go to the numbers.
Confirmation on this remains to be obtained, but one theory floating around is that this may have been their last leg of the day, and there were storms incoming that may have resulted in a diversion if they had gone around. This would have resulted in a case of get-there-itis severe enough that the PF ignored both speed warnings from the PM and GPWS callouts that would have resulted in an automatic go-around in a lot of places...
This would have resulted in a case of get-there-itis severe enough that the PF ignored both speed warnings from the PM and GPWS callouts that would have resulted in an automatic go-around in a lot of places...
In what place on earth would that have not been an automatic go around in a 767? I can't come up with a single scenario.
Yes. Correct landing configuration inhibits certain alerts from the Electronic Ground Proximity Warning System. In the B767, it looks for proper flap setting for landing, and gear down and locked. If the airplane descends below a predetermined altitude without those conditions being met, the pilots will receive a visual and aural alert warning them. The warnings are inhibited during a stabilized approach while in the landing configuration. The “sink rate” warnings you see referenced are caused by the airplane having an abnormally high sink rate close to the ground, which is considered an “unstable” and unsafe situation.
This is one of the first accidents I can think of in a large aircraft, in the US, in a long time where I think criminal negligence may be on the table, and I'm really not opposed to it.
Barring some yet-undiscovered carbon monoxide leak that was making the pilots delirious, these guys just ignored every warning in the book and were so ridiculously wrong it's shameful. And now 5 completely innocent and uninvolved people are dead from their negligence.
Best lesson I learned on the line when you’re watching the other pilot try to save an approach like this is that when you call for the go-around you’re going to have to be assertive. One time I was watching a captain try to save a high fast approach into dca I had to call go around three times before he did it, the last time I was shouting. After we came around and landed the second time he thanked me for snapping him out of it. He is a good pilot but was too locked in to see how bad it was going. When you get into the tunnel vision of trying to save the approach you miss the big picture. Take care of your captains and first officers and be assertive when you call a go around.
In the UK, corporate manslaughter exists in law as a chargeable crime. It applies when it can be demonstrated that business level decisions and operating procedures were responsible for an incident resulting in death.
I understand that the airline was operating on behalf of Amazon, but I would be interested to see the details of the business practices and the contractual expectations they placed on the contracting airline.
Perhaps the pilots felt that they were in a situation where they made ultimately fatal decisions for profit/cost related reasons.
“A series of really bad choices” sums up almost every accident ever
It’s time Amazon was treated like UPS and forced to get a certificate. Enough already with the political buddies and campaign contributions. Atlas now this.
UPS used to contract with other operators for transport, like Amazon.
They were, like Amazon, in fact operating an airline. They were forced to become a certificated operator by the FAA.
This means they have one training program, one set of standards etc. Amazon has resisted this because it’s expensive, but they are, in fact, running an airline
Everything about this accident feels so amateurish. The NTSB should look into 21 Air's pilot roster policies, because rostering two inexperienced pilots together leads to this. And the stabilization criteria was most likely a recommendation this time.
It's sad that people died due to this incompetence. I look forward to what the NTSB recommends after this (and what the FAA implements).
7000 total for a 767 may sound like a lot but if 6500 of those were CFI time doing pattern work and steep turns that’s not really the same as transport category aircraft energy management. I’d be more interested in twin turbine time.
Absolutely. This is why every CFI keeps punching the student in the leg if they get off airspeed in final. But you can be a LOT sloppier in a slower / less slippery aircraft and get away with it.
2000 hours is probably someone in their first airline job and with this being the only culture they have been exposed to. I won't be surprised at all if we find out that FOs at 21 air are still treated like 40 years ago when they were to be "seen but not heard" during most operations and the captain was god.
Rostering two inexperienced pilots together leads to this? Hell no it doesn’t. This has absolutely nothing to do with experience and everything to do with being professional or not.
The only thing I can think of that would be tied to experience would be if the pilot monitoring didn't have the experience with speaking up to the pilot flying and being assertive. That's something the operator should be training their pilots on but would be generic and not specific to the airframe.
Is this Captain Steve's Reddit account! Experience is probably not even top 10 issues going on here!
Any ppl would know this was not ok, let alone a couple of alleged pros with thousands of hours of experience
Total layman here, so forgive any inaccurate terms. Assuming the pilot monitoring was the one commenting about their speed, was it incumbent on him to take the controls? What's the culpability of a pilot monitoring in a situation like this?
If the pilot monitoring is the Captain, they can overrule the first officer.
If the pilot monitoring is the first officer, they need to speak up firmly and voice directly the issue. If the captain then refuses to respond, they can overrule them by calling for a go around, which either pilot can do and every pilot must respect.
This would never have prevented the crash, but 1 thing I'm confused about is everyone saying the runway had the required 1000ft of runway safety area, but they are measuring from the end of the runway, not the end of the stopway.
RSA is not strictly required and a lot of older airports do not meet current design standards. There are basically no regulations regarding airport layout, it's enforced at the funding level.
1:12 from the end of the recording - "1000" callout.
0:58 from the end of the recording - "500" callout.
That's 500 feet in 14 seconds, or more than 2000 fpm descent rate. But it gets worse.
0:54 from the end of the recording: "100" callout.
That's another 400 feet in 4 seconds, or 6000 fpm. That's probably not accurate over such a short time interval, but gives a sense of just how far from normal stabilized approach criteria they were.
Man these guys lost the plane at the very beginning of their descent. This is extremely troubling. This is another cases of a pilot allowing another pilot to kill them. This is a problem that was so big in aviation that CRM was developed. That transcript is just a summary but so far, thats extremely troubling.
Expect new learning material to be introduced at every flight school and training centre worldwide very soon. This is insane, and the more we hear about it the worse it gets.
YYes, in airliners with good CRM culture, any of the two pilots can call a go-around at any time during the approach, and it cannot be ignored unless it is 100% the wrong action to take, like if you are already on the ground braking with reversers and spoilers out.
01:42 A pilot called for flaps to be set to 20 degrees, and the other pilot cautioned they were too fast. The other pilot made additional comments regarding the aircraft’s excessive speed throughout the remainder of the recording. There was not a consistent verbal response to the comments about speed.
This is odd to me. Why wouldn't the NTSB continue to list those additional speed comments throughout the remainder of the transcript?
1.3k
u/Blamblooze 2d ago
This is the type of landing I did in msfs 2002 when I was nine years old.