Warning: the author makes significant conclusions that are not corroborated by the NTSB. All of the commentary on the violation of the sterile cockpit rule and argument before departure are irrelevant to the actual cause, despite the author stating otherwise.
There are some great lessons to learn from this (better flight control handovers during emergency, double checking which engine failed, applying thrust to both engines when nothing else works). The violation of the sterile cockpit rule and the asshole nature of the captain were not factors here as determined by the NTSB.
The first officer gave him bad info and he accepted it. That is not a failure mode caused by being obstinate nor a “team player”.
The author explicitly points out the nonappearance of the captains rant within the NTSB report.
The author points out that NTSB report does allude to the captain's many instances of dubious judgment during the emergency.
The author also highlights the protracted diatribe spanning thirty minutes, transpiring even during the hallowed period of the "sterile cockpit," implying a discernible lack of concentration on the imminent mission.
The captain's unclear headspace became evident by his protracted tirade. He was likely mentally unfit for the task of captaining that day, and the rant was evidence of it.
> The captain's unclear headspace became evident by his protracted tirade. He was likely mentally unfit for the task of captaining that day, and the rant was evidence of it.
You jumped to the same conclusion the author did, which was that the rant was evidence of anything. Some people rant all of the time and sometimes it’s about sexist, racist, whatever things. It does not imply they are mentally unfit for captaining.
> All of the commentary on the violation of the sterile cockpit rule and argument before departure are irrelevant to the actual cause
Which is just as false a statement as it is to say "The violation of the sterile cockpit rule and argument before departure were a significant cause". The fact is, we don't know if it was, but it's not wrong to say that it might be.
Real life is rarely about evidence or not evidence, which is a categorical decision (in contrast to evidence in court, which can be circumstantial).
Some more context in addition to the sibling comment: The classical example is this. You want to test the effectiveness of two drugs A and B in some sort of clinical trial. You gather a lot of data and learn that drug A has an average effectiveness of 4.0, while drug B has 4.9 (more is better). You apply a statistical test and it tells you B is not significantly different from A.
Can you conclude that B is not better than A? You can't. The absence of evidence is not evidence of absence. There could be any number of reasons why we don't have significant evidence, e.g. because the experiment was done with a sample too small. B might be better than A, but there is no evidence it is.
The NTSB gathers a lot of data regarding the crash. The board looks at all the factors and deliberates whether they contributed to the crash. It determines that there is no significant evidence that the mental state of the pilot was relevant.
Can you conclude that the mental state was irrelevant? You can't. It's likely the pilot experienced stress but it is impossible to determine whether this stress was significant. It might well be, but there is no evidence it was.
Parent seems to think it was not a factor. But by relying on a flawed argument we will not find out why he actually thinks that way, ultimately leading to an unproductive discussion.
> The NTSB would have called it out if that were the case.
If there’s protracted conversation unrelated to the safe operation of flight, apparently agitated conversation, being conducted during a critical phase of flight, it seems odd that the official report would not mention what led the NTSB to exclude psychological factors and/or cockpit distractions as a contributing factor. But I don’t read these reports frequently; so maybe that’s not how they are structured. I imagined that they were structured like scientific papers where the conclusions typically anticipate reviewers’ critiques and dealt with them in advance. Then again, there’s no intent of peer review here.
> In the end, the NTSB declined to mention these conversations in its final report, *which is normal — most of the time, the agency doesn’t wade into pilots’ personal disputes*
> Some people rant all of the time and sometimes it’s about sexist, racist, whatever things. It does not imply they are mentally unfit for captaining.
Given the whole idea behind the sterile cockpit rule, I'd say this is clearly wrong. It's true that ranting about mysogynist murder fantasies is probably no worse from a safety perspective (albeit wildly more offensive) than other topics, but ranting about anything is just a no-go in the air. When you're flying the plane you're supposed to be talking about flying the plane, and nothing else.
It really seems like you and other posters here want this blog post to be some kind of woke tirade you need to rebutt. But that's not how most of us are reading it. They mysogyny is the evidence, not the crime. Really the article is pretty dry.
> Some people rant all of the time and sometimes it’s about sexist, racist, whatever things. It does not imply they are mentally unfit for captaining.
That would be even worse: If the captain consistently disregards their training by engaging in unnecessary conversations during designated sterile cockpit periods, it indicates a consistent lack of suitability for the position of captaining an airplane.
There have been some very smart racists in the past. Depending on your definition of racism, it could even include Nobel prize winners from the last century.
> “These are the kind of women you don’t wanna get married to,” he said. “You know, some men, they lose their temper and the next thing you know, the wife is dead, you know… they start punching them and kicking them, and they lost their minds, you know… they kill the woman… it’s the woman who can drive you to do crazy stuff, you know?”
My guess is that the NTSB wants to focus on causes that they can issue guidance for, rather than assign blame. Sure, the captain's state of mind most likely contributed to the incident, but it also revealed a couple of issues that warranted new guidance, which is a big part of what the reports are for.
The NTSB should have issued guidance that if the pilot or copilot is in a distraught emotional state, takeoff should not happen. And it is the responsibility of the other to abort takeoff.
This is organizationally hard to do within an airline. But it is easy to do if regulators back it up, and the questionable state is backed up by dialog during the "sterile cockpit".
No, this is absolutely incorrect. The NTSB focuses on the cause, regardless of whether or not guidance can be issued based on it.
The guidance itself will be focused on relevance, but the root cause is never tainted that way. If the NTSB thought the rant had absolutely anything to do with this, they would have mentioned it.
> The captain's unclear headspace became evident by his protracted tirade. He was likely mentally unfit for the task of captaining that day, and the rant was evidence of it.
Reading through the article, that's not the feel I get. As presented by the article, the captain state of mind did had an effect, he was not at 100% of its mental capacities.
But reading through the CVR transcript, the communication between the first officer and captain was good, and the crew did fly the plane from take-off up until the end which implies that the breach of the "sterile cockpit" rule before take-off did not had any major effect. They were fully focused on the task of flying immediately before and during the emergency.
They simply both made mistakes/bad judgement calls.
In fairness, the captain did make more mistakes, and some of these mistakes maybe may have been avoided if he was in a different state of mind. But at the same time he was placed in a situation where these mistakes could occur and become catastrophic (very old and unreliable plane lacking maintenance and ways to easily troubleshoot an engine failure).
In my opinion, he, or any other pilot could have made the same mistakes even in a right state of mind. It's also an unreasonable assumption that pilots will always operate at 100% of their capacity.
The question of whether the CVR recording demonstrates good communication is something of a red herring. As the article and NTSB report make clear, the crew deviated significantly from the correct procedure, which should have led to the unambiguous identification of the working engine. While the crew were not arguing, cockpit discipline had still broken down, with the result that the pilots talked themselves into believing that they had a double engine failure.
The deviations started with the captain struggling with an overloaded radio channel, which should have been cut short by squawking 7700. Th article notes that the controller was a woman. Was that an issue in what followed? It’s a possibly-relevant factor that we will never get a certain answer to.
No one is assuming that pilots will always operate at 100% capacity, which is one of the reasons for having procedures intended to catch common errors.
Would the 30min discussion during cargo loading count against the sterile cockpit rule? Obviously the ground is less than 10,000 ft but surely there's a point in time that defines the "start" of the flight when the rule goes into effect.
Most of the pre-flight work on a plane on the ground is safety critical, with rules around them written in the blood of somebody who wasn't paying enough attention and missed them.
Paying attention to things like weight checks, fuel checks, and systems bringup should take priority over gossip.
Imagine if your prod system was on fire, and while waiting for a diagnostic query to run, you talk your coworkers ear off about how you really dislike working with another coworker. It's just not the time to do that. Every single flight requires your attention, and letting things become routine is called "normalization of deviance" and is step one to an event that kills people.
It's not a transcription of the NTSB report. This is a post on a dedicated and reasonably well-thought-of aviation safety blog. I think it's reasonable to expect some editorializing and be expected to weigh the arguments on their merits.
The NTSB is great. They're not the final word on anything in particular.
It’s an armchair analyst injecting their pet peeves into an otherwise narrated report of what the NTSB found.
It’s disingenuous to do a publication the final report and cause of a crash and blend in your own views without big disclaimers that they aren’t supported.
It’s no different than the author focusing on the ethnicity or religion of the pilots or even the phases of the moon and planets. There is what the NTSB said, and what the author pulled out of his ass. They are unfortunately blended together and pretty severely conflict in this case.
It does seem to me that the author has injected their own theory of the state of mind of the crew, but in what way does this theory conflict with the NTSB's account? I agree that if there was evidence that the state of mind of the crew was a significant factor in the cause of the accident that they would have mentioned it, but this simply means they did not find sufficient evidence for this theory, not that the theory is incorrect.
Him, the topic here is aviation safety and this particular incident. I didn’t add any analysis of the cause of the incident. The author made conclusions up whole cloth.
The NTSB is great precisely because they deal in facts.
This article does not, yet presents speculation as fact, without critical context that the NTSB certainly considered.
Facts are important because you can learn from them, speculation about human behavior is sensationalist bullshit because you can't prove it and can't reliably prevent human error in the first place.
For example: only a handful of 372's were ever ETOPS certified and I'm pretty sure this plane was not one of them. Should airframes with lower reliability like that even be allowed to operate in areas like Hawaii in the first place? Clearly these pilots weren't prepared to handle the situation, what needs to happen (and what the NTSB aims to do) is to avoid putting any other pilots in the same situation, from a holistic perspective
Well, in this case it was undeniably human behavior that crashed the plane: if the pilots would have, at any point during the flight except at the very end, realized that they were trying to fly using the damaged engine, and switched to the other engine instead, they probably could have salvaged the situation. So I think a psychological analysis of why this didn't happen is warranted, and the story about another copilot refusing to fly with the pilot because of his disregard for procedures is relevant context, even if the NTSB didn't mention it.
No, you don't know that. I'm just not sure why people are trying to read things into the narrative that simply no known.
The captain rather demonstrated proper CRM by delegating aviating to the co-pilot while he communicated with tower control. He also trusted the judgment of the fist officer as to which engine was out, although the information he was given was wrong.
The other pilot was told by the chief pilot to not fly with the captain.
Also, see this quote:
> “This is the way we work when I am with her, you know, you have to yell at her to force her to do things.”
This is ignoring the paid-in-blood lessons of the worst aviation accident in history (Tenerife) that could have been avoided if the captain listened to his crew. Crewmembers should always feel free to speak up in safetry critical situations. You don't "force them to do things".
I don't think this contributed to this particular incident because both pilots agreed on the wrong engine but it is very valid criticism IMO.
My original intent mentioning ETOPS was supposed to be a point about wild speculation being detrimental to reporting and recommendations, unfortunately the point got lost in a copy paste mistake while rearranging my comment.
ETOPS absolutely _could_ have made the difference here. Either by avoiding the engine failure in the first place my way of more strict maintenance requirements, or potentially by setting the expectation that the aircraft can operate with a single engine and causing the pilots to rethink which engine was underperforming.
But just like the original article, speculation like that is not practical for an NTSB report
Yes, really. The pilots checked flaps/gear multiple times trying to diagnose the speed & altitude issues. The article says the pilots assumed that was the expected performance of the old engines, but I haven't read the transcripts to see if that's another speculation/editorialization by the author. Theorizing that better expectations for single engine performance could have avoided the crash is no more of a leap than what the author made.
The point of ETOPS is to ensure that pilots can continue to operate the plane on a single engine, and that the likelihood of dual engine failure is vanishingly small. It explicitly requires manageable pilot workload (which was cited by the NTSB as a failure/contributor to this crash), and is implemented in part through more rigorous maintenance and inspection.
You're right that ETOPS would not be required for a flight like this but aside from the notable flight envelope difference (since ETOPS focuses on engine failure while cruising far from airports) the considerations for ETOPS are very similar to considerations that would go into prevention this crash in the future.
Pretty sure your point about 737-200 ETOPS certification is also not present in the NTSB report. Why is it OK for you to pontificate but not the linked author?
I meant to have a point that if you grab at tenuous connections every report would speculate to the point of uselessness, but that got lost to a cut and paste mistake while rearranging the comment.
There are some great lessons to learn from this (better flight control handovers during emergency, double checking which engine failed, applying thrust to both engines when nothing else works). The violation of the sterile cockpit rule and the asshole nature of the captain were not factors here as determined by the NTSB.
The first officer gave him bad info and he accepted it. That is not a failure mode caused by being obstinate nor a “team player”.