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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

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”.

BoxFour 3y ago
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.
- halestock 3y ago
  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.
  - kortilla 3y ago
    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.
    - halestock 3y ago
      Ah okay, that sounds a lot more reasonable.
  - btilly 3y ago
    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".
- kortilla 3y ago
  > 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. The NTSB would have called it out if that were the case. They did not. For an example of where they would, look at this flight: https://en.wikipedia.org/wiki/Eastern_Air_Lines_Flight_212 https://en.wikipedia.org/wiki/Eastern_Air_Lines_Flight_212
  - brightlancer 3y ago
    > The NTSB would have called it out if that were the case. Should have called it out if they had enough evidence to support it, but absence of evidence is not evidence of absence. (Mine is not a defense of the article.)
    - Pyramus 3y ago
      > absence of evidence is not evidence of absence. Exactly. It's a significant cognitive bias / logical fallacy that's very easy to fall for leading to wrong conclusions. The not-inclusion of factor A for lack of evidence is not evidence of A not being a factor.
      - refurb 3y ago
        But that’s a silly way to look at things, because you could say it about anything - it tells you nothing. “I had bad diarrhea before getting into a car accident. There is no evidence it contributed, but that’s not proof it wasn’t a factor”
        spuz 3y ago
        The point we're responding to is this: > 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.
- kakwa_ 3y ago
  > 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.
  - mannykannot 3y ago
    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.
- matt-attack 3y ago
  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.
  - mrguyorama 3y ago
    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.
ajross 3y ago
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.
- kortilla 3y ago
  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.
  - giraffe_lady 3y ago
    [flagged]
    - kortilla 3y ago
      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.
  - spuz 3y ago
    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.
- flaminHotSpeedo 3y ago

BoxFour 3y ago

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.

halestock 3y ago
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.
- kortilla 3y ago
  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.
  - halestock 3y ago
    Ah okay, that sounds a lot more reasonable.
- btilly 3y ago
  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".
kortilla 3y ago
> 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. The NTSB would have called it out if that were the case. They did not. For an example of where they would, look at this flight: https://en.wikipedia.org/wiki/Eastern_Air_Lines_Flight_212 https://en.wikipedia.org/wiki/Eastern_Air_Lines_Flight_212
- brightlancer 3y ago
  > The NTSB would have called it out if that were the case. Should have called it out if they had enough evidence to support it, but absence of evidence is not evidence of absence. (Mine is not a defense of the article.)
  - Pyramus 3y ago
    > absence of evidence is not evidence of absence. Exactly. It's a significant cognitive bias / logical fallacy that's very easy to fall for leading to wrong conclusions. The not-inclusion of factor A for lack of evidence is not evidence of A not being a factor.
    - refurb 3y ago
      But that’s a silly way to look at things, because you could say it about anything - it tells you nothing. “I had bad diarrhea before getting into a car accident. There is no evidence it contributed, but that’s not proof it wasn’t a factor”
      - spuz 3y ago
        The point we're responding to is this: > 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.
kakwa_ 3y ago
> 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.
- mannykannot 3y ago
  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.
matt-attack 3y ago
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.
- mrguyorama 3y ago
  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.

ajross 3y ago

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.

kortilla 3y ago
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.
- giraffe_lady 3y ago
  [flagged]
  - kortilla 3y ago
    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.
- spuz 3y ago
  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.
flaminHotSpeedo 3y ago