The USA National Transport Safety Board released the abstract of the final report of Atlas Air flight 3591 which crashed in Trinity Bay, Texas on 23 Feb 2019. The First Officer has been blamed for the accident but it is a systemic failure which has been highlighted many times.

Blame the First Officer

1. The report has squarely blamed the First Officer for an inappropriate response to inadvertent activation of the aeroplane’s go-around mode, resulting in the spatial disorientation that led him to place the aeroplane in a steep descent from which the crew did not recover.
2. Further, the report blames the First Officer’s repeated uses of incomplete and inaccurate information about his employment history on resumes and applications were deliberate attempts to conceal his history of performance deficiencies and deprived Atlas Air Inc. and at least one other former employer of the opportunity to fully evaluate his aptitude and competency as a pilot.
3. The first officer’s long history of training performance difficulties and his tendency to respond impulsively and inappropriately when faced with an unexpected event during training scenarios at multiple employers suggest an inability to remain calm during stressful situations—a tendency that may have exacerbated his aptitude related performance difficulties.

Objective of the investigation

The sole objective of the investigation of an accident or incident as per ICAO Annex-13, shall be the prevention of accidents and incidents. It is, not the purpose of this activity to apportion blame or liability.

Any judicial or administrative proceedings to apportion blame or liability shall be separate from any investigation conducted under the provisions of Annex 13.

What is blame?

Theoretical and sociological examination of placing blame reveals that it consists of three elements.

1. Blame is placed only if a capable addressee of norms is present (personhood),
2. if this person was in the time of offending competent enough to question a norm (competence), and
3. if this person actually communicated a negation of this norm (message).

The First Officer was hired at Atlas Air having undergone a selection process despite being aware of the fact that he had failed his previous command upgrade. This indicates that Atlas Air was satisfied that the First Officer met with their expectations.

Under this assumption that the First Officer was competent to handle all situations, the First Officer is blameworthy. Unfortunately, the objective of the report is not to apportion blame on anyone but to determine the probable cause & prevent accidents.

Contradiction

The investigation finds that the First Officer had a long history of performance difficulties with respect to unexpected events. The inference is that the First Officer was incompetent in the eyes of the investigators to handle unexpected events since he was unable to remain calm.

If the First Officer was incompetent, then his actions on the fateful day were consistent with his personality. Why blame the person, then?

Standards division

Every pilot involved in an accident is a competent and thorough professional. This is the reason that companies hire them, train and check them. It is only after an accident that facts about their previous performance are revealed through other than the formal channel. The role of the selectors and examiners responsible for standards must be questioned.

mindFly analysis

The investigation must look at all aspects especially the important gates where the errors could have been trapped. The AirCanada overflight of the taxiway at SFO revealed that the First Officer who was the PM had failed his command upgrade twice with situational awareness and CRM being deficient. Surprisingly, when he re-qualified for the right seat, the deficiencies magically disappeared and the reports were fine.

A contributory reason for what could have been the worst air disaster is the failure of the human aspect in AQP training and checking methodology to prevent the incident. It is a clear failure of the examiners in upholding the standards and biases in training.

While the NTSB has recommended cockpit imaging to make their jobs easier, there is no provision to use better technology in order to eleminate the instructor bias or use flight simulator date more effectively.

Introduction of artificial intelligence will eliminate this and replace the trainer and the bias from the system.

The trainer is the lacunae in the system and it is a systemic failure not just the First Officer’s as has been highlighted.